Episode 2: The Intersection of Celiac Disease and Inflammatory Bowel Disease

[00:00:00] Vanessa Weisbrod: Welcome to Raising Celiac, a podcast dedicated to raising the standard of education, awareness, and research on celiac disease and related autoimmune conditions. I’m Vanessa Weisbrod the education director of the Celiac program at Boston Children’s Hospital, and [00:00:15] each month on the podcast, we will invite leading experts to dive into a condition related to celiac

[00:00:20] And look at how it impacts a patient family, the latest research and offer suggestions for health providers to manage these complex cases. Every episode of the [00:00:30] Raising Celiac podcast is accredited by the Boston Children’s Hospital Continuing Education Department for 0.5 AMA PRA category one credits for Physicians.

[00:00:39] 0.5 Contact Hour for Nurses, 0.5 ACE CE Continuing [00:00:45] Education Credits for Social Workers, and 0.5 CEUs for Registered Dieticians. To claim your credits for listening to today’s episode, please visit dme.childrenshospital.org/raisingceliac. Let’s get started with this month’s Raising Celiac patient story.[00:01:00]

[00:01:00] Janis Arnold: Eliza led a very normal childhood and with the exception of needing glasses at an early age, had few medical concerns. It wasn’t until she was in her mid-twenties when she started trying to have a child that she found herself visiting the doctor on a very frequent [00:01:15] basis. Eliza and her husband had no trouble getting pregnant

[00:01:19] staying pregnant was the issue five times in a row she miscarried between eight and 19 weeks. Fertility specialists couldn’t seem to explain the issues and [00:01:30] recommended that they just keep trying, so they did. After nearly 10 years of trying, Eliza and her husband welcomed a premature, but very beautiful and healthy baby girl.

[00:01:42] Vanessa Weisbrod: Over the last decade, several research [00:01:45] studies have garnered conflicting results when looking at the link between celiac disease and fertility issues. Some research has shown that women with undiagnosed celiac may struggle with fertility. While others have found that there is no increased risk of infertility, it is [00:02:00] unclear if nutritional concerns like mal absorption that occurs with untreated celiac disease, may cause reproductive issues, or if the immune system may be the culprit.

[00:02:11] Janis Arnold: Fast forward two years, Eliza thought that she was [00:02:15] exhausted all the time because she was a working mom of an energetic toddler and constantly on the go. Her stomach hurt many days a week and she had lost quite a bit of weight even though she wasn’t trying to. Every morning she had diarrhea. She had to go at [00:02:30] least three times before she could leave the house. When she got on the scale and it read 90 pounds, she knew she needed to see a doctor. She scheduled a visit with her primary care and had lots of labs done. She was severely anemic, deficient in vitamin [00:02:45] B12 and had a tissue transaminase antibody level that was more than 10 times the upper limit of. She was scheduled for a visit with a gastroenterologist within two weeks and underwent an endoscopy that showed total villous atrophy, [00:03:00] a clear indication she had celiac disease. As Eliza started doing research on celiac disease, it made perfect sense. But what she wasn’t expecting to learn is that her prior struggles with pregnancy could have been related to celiac disease. [00:03:15] With this knowledge in hand, she felt hopeful. She would feel better. And would be able to start trying to give her daughter a sibling.

[00:03:25] Vanessa Weisbrod: It’s well established that patients with celiac disease often have problems absorbing [00:03:30] calcium, iron, folate, and other vitamins and minerals. This can lead to iron deficiency, anemia, and low bone density. The good news is that most often these deficiencies correct once on a strict gluten-free diet and the gut heals. Most patients feel better quite [00:03:45] quickly, though some can take more than a year or two to fully respond to the gluten-free.

[00:03:51] Janis Arnold: Eliza went on a gluten-free diet and felt a little better. She was very strict about her diet and never cheated even when she really wanted a bite of a [00:04:00] soft and chewy gluten containing bagel while on a family trip to New York, Despite her vigilance with a gluten-free diet, two years after her diagnosis, she still didn’t feel well, and the daily diarrhea was severely impacting her quality of life. [00:04:15] She was feeling antsy because she really wanted a second child, but her health just wasn’t strong enough to endure the physical demands of a pregnancy. She headed back to the gastroenterologist. After a round of blood work, stool tests and a colonoscopy, [00:04:30] Eliza found herself with a second diagnosis of ulcerative colitis.

[00:04:36] Vanessa Weisbrod: Ulcerative colitis is a type of inflammatory bowel disease in which the inner lining of the colon and rectum become inflamed. Inflammation [00:04:45] usually begins in the rectum and lower large intestine and spreads upward, potentially involving the entire colon. Ulcerative colitis causes diarrhea and frequent emptying of the colon as cells on the surface of the colon die and fall. Ulcers form leading to [00:05:00] puss, mucus and bleeding. Ulcerative colitis may occur at any age, but is most common in older children and young adults, and may run in some families. Like celiac disease. Ulcerative colitis is a chronic autoimmune disease where the body mistakenly [00:05:15] attacks itself. Similarly, to celiac, it may be triggered by a combination of genetic and environmental factors, but for Eliza, which came first, did one autoimmune disease cause the other? Should she have been tested for more at the time of her celiac diagnosis? [00:05:30] And did these two conditions play a role in her struggles to stay pregnant? We’ll discuss this and more on today’s episode of Raising Celiac.

[00:05:38] Vanessa Weisbrod: Today we talk about celiac disease and IBD with Dr. Maria Ines Pinto-Sanchez. Dr. Pinto [00:05:45] Sanchez is a gastroenterologist at McMaster University in Hamilton Health Sciences. She is the director of the Celiac clinic at McMaster University and provides nutritional support for the Home Perinatal Nutrition Program in Intestinal Failure Clinic. Her [00:06:00] clinical and research. To include the diagnosis and treatment of different gastrointestinal conditions with a focus on celiac disease and gluten related disorders. She recently authored a paper on the Association of Celiac Disease and Inflammatory Bowel Disease, which she’s going to tell us [00:06:15] more about today. On a personal note, I get to work with her on educational programming for the Society for the Study of Celiac Disease and honored she is joining us today. Welcome Dr. Pinto-Sanchez to Raising Celiac.

[00:06:27] Dr. Pinto-Sanchez: Thank you very much, Vanessa, for inviting me, and I [00:06:30] think it’s fantastic that you’re doing this podcast to educate people and raise awareness about celiac disease.

[00:06:35] Vanessa Weisbrod: Thank you. We are very excited about it. So, before we talk about Eliza’s story, I want to talk about the similarities and differences between celiac disease and inflammatory bowel [00:06:45] disease. Can you tell our listeners how they are alike and how they are different?

[00:06:49] Dr. Pinto-Sanchez: Absolutely. So, both inflammatory bowel disease and Celiac disease are considered chronic, which is long term, inflammatory conditions, and both involve the immune [00:07:00] system. So, and both of them affect the gut. However, there are some differences between IBD and celiac disease, celiac disease is characterized by inflammation, so you can see inflammation in the gut. But ulcers, having ulcers, which you describe [00:07:15] already for these patients are not quite common. It’s very, very rare to find ulcers in celiac disease. And also celiac disease affects the small bowel and mainly the very first parts of the small bowel. So, um, uh, so this is different from inflammatory bowel disease. [00:07:30] In the opposite hand, IBD or inflammatory bowel disease involve two main conditions and that one of them is ulcerative colitis, which Eliza has been diagnosed with. And um, this ulcerative colitis [00:07:45] affects mainly the colon, which is a large bowel. And the second one, which is Crohn’s Disease, can affect any part of and both of them, they produce such inflammation and lead to ulcers. So these are the [00:08:00] differences between celiac and IBD. And as you will see, uh, they can share symptoms in common that when you do the endoscopy, you can differentiate most of the times both of them. And another important aspect is that celiac disease is a genetic [00:08:15] condition, and that means that it has a strong genetic predisposition. And that’s why it runs in families and that’s why it’s so common to find another celiac in a family. However, in IBD believe whether there are some genes involved and there are some family [00:08:30] preposition is not as strong as in celiac.

[00:08:32] Vanessa Weisbrod: Great. So Eliza stuck to a very strict gluten-free diet, or at least she claimed to. How do you assess if the continuing symptoms are related to ongoing gluten exposures or potentially a different disease [00:08:45] process?

[00:08:45] Dr. Pinto-Sanchez: So the first thing that we do, is to have  dietician education and assessment. And this is because we can identify sometimes by interviewing the patient,  situations that can expose people to[00:09:00] to gluten, and then we can correct. And then we do have other objective measures and some of them, they’re not perfect. For example, TTG antibodies or celiac markers, and we do that to determine if the person has been exposed. So mostly if they [00:09:15] have their celiac is active, which is related. Secondary to gluten exposure. Um, the problem is that these markers are not very accurate to determine exposure, especially if it is very occasional.

[00:09:26] And that’s why there is a novel test also that you can detect [00:09:30] gluten in stool. Like gluten is not gluten itself is the reaction or, or antibodies produced when people are supposed to gluten. So these are the very tiny parts after gluten digestion and these two tests or urine tests [00:09:45] to detect gluten can be done at home.

[00:09:47] So most of the times we do, we progress, you know, dietician, do blood work, and then we advise people to get these tests to self-assess gluten [00:10:00] exposure. If all these tests are negative. Then, uh, then we, we need to look for other reasons, right? Um, to see if, uh, you know, this person is experiencing symptoms that is not related to[00:10:15]

[00:10:16] Vanessa Weisbrod: How do you counsel a patient like Eliza on the importance of sticking to a gluten-free diet when it doesn’t seem to be helping their symptoms?

[00:10:24] Dr. Pinto-Sanchez: this is a real, real situation and is very challenging for everybody. And, um, it’s very [00:10:30] important that we discuss with our patient that. always correlate with the CEL a activity, right? So patients with celiac disease can have significant amount of inflammation in their gut and not much symptoms. Or not perceived symptoms.

[00:10:44] And then in the [00:10:45] opposite hand, they can have a lot of symptoms and not very much inflammation in the gut. But the truth is that the only way of getting their celiac disease under good control is to be completely, completely away of. [00:11:00] And that’s why we recommend patients to explain this after explaining this is to strongly recommend to adult, you know, like a strict term for diet.

[00:11:10] So then they can heal.

[00:11:13] Vanessa Weisbrod: So your group at McMaster recently [00:11:15] published a study in the Journal Gastroenterology that establishes a connection between Celiac and IBD. Can you tell her listeners about this study? What did you look at and what did you find?

[00:11:24] Dr. Pinto-Sanchez: Absolutely. That was very exciting. And, and this is, we did that. That [00:11:30] study is a bit. We look into the association between celiac and IBD because, um, there has been always, and many, many, uh, studies evaluating this association and there has been controversies in those results.

[00:11:43] And that’s why what [00:11:45] we did, um, in order to approach, when you have a lot of studies there out there and then there are controversies. The next step is to, um, is to look and pull all these studies. And this is what we did. We did a systematic review with meta analysis, which is, uh, [00:12:00] pulling all these studies together to get information on whether celiac is most associated with IBD. And this is not just pulling, it requires an, uh, you know, like a very rigorous technique, uh, knowledge and how [00:12:15] to do this properly and how to set up protocol in advance, set up criteria. Not every single study that is out there, we qualify right then.

[00:12:25] After pulling [00:12:30] 64 studies we determined that there is a ninefold increased risk of having IBD in celiac disease. If so, if patient has celiac disease, it has nine times more chances of getting [00:12:45] IBD and most frequently Crohn’s disease. And in the opposite hand, if you have IBD, it is fourfold increase or four times more frequent to have celiac disease than someone that doesn’t have celiac disease.

[00:12:59] [00:13:00] So in both ends there is an increased risk of having the other condition if you’ve been diagnosed with it previous. And more recently I was invited also to collaborate with prestigious colleagues, you know, from Sweden and Columbia University [00:13:15] and to analyze database, from all people from Sweden that have been diagnosed with celiac disease and also IBD and that were like over hundred 60,000 people.

[00:13:27] And, um, The same [00:13:30] results came in that large, very, very large study. Um, there, there was an increased risk of IBD in celiac disease and vice versa. And another important finding from that study that the latest that was recently published, is that the [00:13:45] diagnosis of, IBD in celiac disease is usually done within a year.

[00:13:49] So it is, it’s pretty quick, relatively right. So those are important findings, but still, you know, we have questions [00:14:00] that require more for research.

[00:14:03] Vanessa Weisbrod: So for these you, it’s a quick, you know, diagnosis of the second condition. Are these patients coming back and saying that they’re still symptomatic despite the treatments that they’re being on? Or how is it happening so quickly?[00:14:15]

[00:14:15] Dr. Pinto-Sanchez: Yes. So usually most of the time patients when they are diagnosed with a celiac disease and they started gluten-free diet, similar to what happened to Eliza.

[00:14:24] Um, they start, they’re doing the diet very strict and they see dietician. There is no [00:14:30] cross-contamination. That’s the first thing that we do. And then if they persist with symptom, we start other investigations. And one of the investigations involve a stool test, uh, uh, or, uh, blood work. Ultimately colonoscopy to rule out inflammatory [00:14:45] bowel disease.

[00:14:47] Vanessa Weisbrod: Great. So the data establishes this link, but how should gastroenterologists use this information in their everyday clinical practices?

[00:14:56] Dr. Pinto-Sanchez: So once we do the studies, and once we do [00:15:00] this, this meta-analysis, those are usually used for to develop guidelines, right? So this is one way of reaching, other colleagues, uh, but it is very important that not only gastroenterologists, but all clinicians are aware of this [00:15:15] association and. They consider, and this is because if they’re aware of the association, they should consider investigating for celiac disease in someone that has IBD and is not responding to the treatment or vice versa.

[00:15:28] We have celiac disease and [00:15:30] is not responding to gluten for diet and have per symptoms to investigate for IBD as well because again, it is more frequent than in the general.

[00:15:39] Vanessa Weisbrod: Is the treatment for either condition modified based on having the dual diagnosis?

[00:15:44] Dr. Pinto-Sanchez: [00:15:45] So that’s interesting question and there are no many research studies on that, but, um, let’s say that at first it will see that exist. Uh, Should follow it. Look trigger lymph for diet anyways. Right. And if they’re diagnosed with, with [00:16:00] IVD on a top of a disease, more likely they’re, this person is going to be prescribed with additional treatment, which can involve depending on the location of the disease, like ANS or can involve like, you know, like a tablet for Pecos or [00:16:15] Anti-flammatory or immunosuppressants or intravenous medications.

[00:16:17] So there are a big variety of medications related to the severity of the disease. On the opposite hand, if a IBD is diagnosed and a person is doing all this treatment and has [00:16:30] persistence symptoms or, or is diagnosed with CEL disease, very likely this person is going to start cancer diet. And one of the thing, um, um, uh, it’s important is that the glutenin free diet is not, it shouldn’t be prescribed to all, only to [00:16:45] those that are diagnosed with disease.

[00:16:48] The Global Autoimmune Institute works to empower solutions in the diagnosis and treatment of autoimmune diseases. Through research, education, and awareness, while supporting [00:17:00] multidisciplinary approaches to health, we are thrilled to support the production of this educational.

[00:17:07] Vanessa Weisbrod: So thinking about Eliza’s story and the diagnosis of celiac disease, should additional screening for IBD have been done at the time of [00:17:15] celiac diagnosis, or was the high tissue transaminase level a reason to only do the small B small bowel biopsy?

[00:17:22] Dr. Pinto-Sanchez: Yeah, so that’s a very good question. So we acknowledge that there is an association, however, not everyone with celiac disease will have IBD or vice, [00:17:30] right? So at this time is unclear whether, which, you know, we should screen for IBDD in everyone, with celiac. Feel like this isn’t everyone with IBD. So what we do right [00:17:45] now, and I think until we have more information, is to check for IBD only if symptoms persist despite the very strict diet, or in the opposite hand is to screen for it. This is if person continues with let’s say, diarrhea, load and extension or gastrointestinal symptoms despite [00:18:00] doing different medication for IBD and especially sometimes the IBD is less active and then they have still symptoms and then diagnosed with say like, is this later? And the TtG is tricky because it can be high also [00:18:15] people with IBD without being celiac. So, it’s important to, to dig deeper in the diagnosis, to obtain the, you know, endoscopy, small bowel biopsy, and trying to, to characterize very well whether this is associated still like this or is [00:18:30] just elevated, mildly elevated because of a secondary to cross reaction to the.

[00:18:36] Vanessa Weisbrod: So how would a gastroenterologist make a decision to test for one the other, or both at the same time with a new patient?

[00:18:44] Dr. Pinto-Sanchez: So [00:18:45] it is challenges sometimes this is because, uh, there is a high variability how doctors, uh, you know, determine me, which test to order and not always follow guidelines and they’re not always guidelines available for everything. So, [00:19:00] The truth is that most of the time doctors will be guided by symptoms and, um, as part of a general blood work.

[00:19:06] is so common that, you know, if someone has diarrhea, low to distension, abdominal pain, of course they are not limited to those symptoms, but it’s a [00:19:15] low threshold to, to check for ttg and if a person has diarrhea, abdominal pain. Those are common symptoms also for IBD and especially now in Canada, and well, US two.

[00:19:26] The rates of IBD are high and are increasing, right? [00:19:30] So there is a low threshold to, to test for, to order a stool test, which is qualify, cal protectin, or a CRP. You know, like a, in blood work, it’s very low threshold to do that. So most doctors are doing this when patient has [00:19:45] symptoms and if DTG becomes positive, as I mentioned, is important because TTG only, especially when it’s not in a very high.

[00:19:54] Not a hundred percent specific for celiac. So it’s important to dig deeper there and proceed with further [00:20:00] a test. For example, doing an endoscopy to obtain biopsies and see if this is celiac. Um, and again, if the person has more lower symptoms and diarrheas to liquid or her blood, very likely they’re going to order colonoscopy as well.

[00:20:13] So again, it’s [00:20:15] mostly guided by symptoms, but again, symptoms are not a hundred percent specific. So is this challenging for every.

[00:20:21] Vanessa Weisbrod: So I know behind the scenes you’re becoming the guideline queen. Maybe, um, this will become a guideline that you’ll create someday.

[00:20:28] Dr. Pinto-Sanchez: Oh my God. [00:20:30] are not that, that easy. That’s why there are not many many guidelines there.

[00:20:37] Vanessa Weisbrod: So this might be hard to answer, but do you think that all patients diagnosed with celiac or IBD should be tested for the other at the point of diagnosis?[00:20:45]

[00:20:45] Dr. Pinto-Sanchez: Yes, It’s, you know, it’s important to, I, I will say, to clarify that we don’t have enough information. Make a recommendation at this moment. And again, we need to assess all this. And, and it’s not just the frequency. What will determine [00:21:00] recommendations. So we need more studies. So see it not only the association, but what will happen if someone is diagnosed with celiac, how they would respond, uh, concomitant to IBD, What are the consequences of treating nont?

[00:21:11] Treating, um, what are the risk of doing, you know, [00:21:15] like additional treatment versus not treating. So, You know, we need more information on outcomes, uh, and how people will react to these conditions but not, we are not ready to test for everyone.[00:21:30]

[00:21:32] Vanessa Weisbrod: So while we probably can’t answer the question, which came first, is there a way to prevent developing a related condition or predicting if someone will get one if they already have celiac disease?

[00:21:42] Dr. Pinto-Sanchez: That’s another area to invest. [00:21:45] Very, very interesting question that unfortunately we don’t have the data to, to, to say what is the chicken, what is the, the act, um, um, in, in, in that study, Most people with, uh, IBD, uh, proof, [00:22:00] see like the. Develop earlier, but again, I think it’s is very difficult to, to pretty, which is the first and how to prevent that.

[00:22:10] We don’t have yet that information.

[00:22:12] Vanessa Weisbrod: I think that’s a question that we have to study in [00:22:15] so many of these autoimmune diseases that are linked. You know, I feel like we talk about all the time, which came first, Type one diabetes or celiac disease. You know, we don’t know the answer. The same with thyroid conditions and celiac disease. So I think there’s just a lot of unanswered questions in our [00:22:30] field.

[00:22:31] Dr. Pinto-Sanchez: Definitely, absolutely a hundred percent agree with you.

[00:22:35] Vanessa Weisbrod: So Eliza now has a beautiful little girl. Knowing that mom has two genetically mediated autoimmune diseases, what testing should her daughter have, if anything? [00:22:45] Or what should she tell doctors to ensure early intervention if she develops symptoms?

[00:22:50] Dr. Pinto-Sanchez: So, what is recommended in Celia Disease is. Screen first degree family members, which includes children, parents, siblings. [00:23:00] And uh, the reason for doing this is because first degree family member, including children, are the highest risk population for S disease.

[00:23:08] There is no other high risk population than first degree family members. It could be, the risk could be up to 15 times [00:23:15] about, you know, compared to someone that doesn’t have a per family member. So it’s a very high risk and that’s why what we recommend is to screen for celiac disease. and most of the time it’s independently of the symptoms.

[00:23:26] And, and this is because, um, celiac [00:23:30] disease can manifest in so many ways that we cannot tell one specific symptom or two specific symptoms. To be aware of. Um, so, uh, what, when to start screening children that ask a question that many of our patients ask. Um, usually what is [00:23:45] recommended is, you know, if a pa, if, if the children is doing well and is there is no urgency to do a test, is to wait until they are after two and a half or three years, because that’s a time when the antibodies are.

[00:23:57] The immune system is fully developed and they can [00:24:00] produce the antibodies. Otherwise, if we do it too earlier, then they will not have the possibility of, of developing antibodies. And then the test may come. False negative, however, is again, it’s if the children is highly symptomatic, it may require other tests and [00:24:15] that we recommend to consult with their family doctor or the pediatrician, um, to see what other tests, uh, this patient may benefit to rule out.

[00:24:23] Celia, this is in the children and however, in I v. The opposite end. There is no [00:24:30] recommendations to screen for everyone in the family as the As. As I mentioned, the genetic praise position is not that strong as in Celia. So screening for IBD, it will be based on symptoms. The patient is symptomatic mostly.[00:24:45]

[00:24:45] Vanessa Weisbrod: Is there any reason for Eliza to preventatively put her child on a gluten-free diet?

[00:24:51] Dr. Pinto-Sanchez: So we recommends against that And, and this is because what happens is without, uh, [00:25:00] knowing that, that the person is Celia, then the glu diet can lead to more risk and benefits. So it’s important to, um, that if, if, uh, you know, the children is symptomatic or is to do. The [00:25:15] test first and to rule out celiac and see whether an endoscopy is needed.

[00:25:19] Um, again, we’ve just published another study on the high risk of nutrient deficiencies related to gluten diet, and it, it’s 60% of people on a gluten-free diet have deficiencies, [00:25:30] and that’s not minor. So it’s important to emphasize that we need to recommend gluten-free free diet only to those who really need it and will produce more benefit.

[00:25:41] Vanessa Weisbrod: Absolutely. And to still see a dietician with your on a gluten-free [00:25:45] diet, all the.

[00:25:46] Dr. Pinto-Sanchez: Definitely, and that’s not only because of if the person needs to be very strict to guide how to do a strict diet, but also to guide how to do nutritional adequate.

[00:25:57] Vanessa Weisbrod: Absolutely. [00:26:00] So what do you see as the future for patients with both Celiac and IBD? Are there screening or therapeutic interventions in the pipeline that could help this patient population?

[00:26:09] Dr. Pinto-Sanchez: I see gluten-free diet can help controlling symptoms in people with IBD as well. And, [00:26:15] there are many medications prescribed with IBD. For example, corticosteroids, immunosuppress and that, you know, biologic that are, have been studying some people with diseases and may help controlling, you know, uh, [00:26:30] celiac disease is. therefore, I, what I think is treating one condition will help with the management of the other condition. And, um, in addition, when you treat someone with Celiac, this disease on a gluten-free diet, and you [00:26:45] have, you know, a gut healing, one of the things that I predict that will happen also, that medication will absorb better.

[00:26:51] So you may, that may help by treating celiac also, not only with symptom. Controlling the IBD as well by getting more [00:27:00] medication in their system. Uh, so I, I think it’s again, it’s very, very important to treat both conditions appropriately if they’re diagnosed,

[00:27:12] Vanessa Weisbrod: Thank you so much, Dr. Pinto-Sanchez for all of the [00:27:15] wisdom you shared today.

[00:27:16] Dr. Pinto-Sanchez: Thank you very much, Vanessa.

[00:27:17] Vanessa Weisbrod: Now, let’s find out where Eliza is today.

[00:27:20] Janis Arnold: Eliza’s journey to diagnose both celiac disease and ulcerative colitis was a long one, filled with many challenging days. Today, Eliza feels [00:27:30] stronger and healthier than she was 10 years ago. She has tried different treatments for her I B D, including budesonide and Remicade, and always sticks to a gluten-free diet.

[00:27:40] She is now a mom to two daughters who bring her so much. in her [00:27:45] own words. I never imagined I would have two GI diseases, but I’m grateful to my medical team for getting me to a place where I can be an active part of my kids’ lives and enjoy our adventures as a family. But I still never leave home without [00:28:00] Imodium in my purse.

[00:28:01] Thanks for listening to this episode of Raising Celiac. Special thanks to the generous contribution from the Global Autoimmune Institute to make this podcast possible. A reminder to all physicians, nurses, and social workers and dieticians. To claim your continuing [00:28:15] education credits. For listening to today’s episode, please visit dme.childrenshospital.org/raisingceliac and complete the short survey attached to this episode.

[00:28:25] If you like what you heard, be sure to write a review, like and subscribe wherever you get your podcast. [00:28:30] For more information, check us out on social at Boston Children’s Celiac on TikTok, at Children’s Celiac, on Twitter, or at Celiac Kids Connection on Instagram. Join us next month when we discuss the relationship between celiac disease and type one diabetes.

[00:28:44] Have a [00:28:45] great month.