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Folate levels should be checked at diagnosis and annual follow-up visits. Unlike their gluten-containing counterparts, gluten-free foods are not fortified with folate. Women of childbearing age must be especially mindful of adequate folate levels and intake due to the importance of folate to the developing fetus.
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The connection between bone health and celiac disease has been well documented [ 15 ]. Bone mineral density is related to inflammation from active disease as well as poor absorption. Calcium and vitamin D are absorbed in the duodenum. Clinicians should check hydroxy-vitamin-D and in adults obtain a bone mineral density test at diagnosis, to determine baseline bone health and need for supplementation.
The bone mineral density test should be repeated within a year if the patient is found to have osteopenia or osteoporosis [ 15 ]. Bone density increases over time on the gluten-free diet, and especially rapidly in children; as the risk is reduced with good dietary adherence and reduction in intestinal villous atrophy [ 17 ]. Ideally, between the diet and supplements, adult patients with celiac disease should have a calcium intake of at least mg per day [ 18 ].
Many patients experience lactose intolerance which leads to gas and bloating that may overlap symptoms of celiac disease. Lactose intolerance may occur if villi are damaged, as lactase enzymes are in the brush border at the tips of the villi; but often improves with intestinal healing. Patients who suffer from gas, bloating, and diarrhea at diagnosis should be advised to avoid lactose to reduce symptoms [ 9 ].
Often after several weeks to months on a gluten-free diet, lactose containing products can be reintroduced without overt symptoms of intolerance. The medical treatment for celiac disease is a life-long avoidance of gluten-containing foods. G luten is found in wheat gliadin , rye hordein , barley secalin , and derivatives of these grains. Oats are not included in this group, but must be regarded with caution, due to risks of cross-contamination. The first step in managing the gluten-free diet is to understand which foods contain wheat, rye, and barley so they can be eliminated from the diet, and intestinal healing can begin.
Fresh foods, without any processing or additives, from fruit, vegetables, dairy products, fish, and meat, meat alternative food groups are all naturally gluten-free. The diet is complicated and confusing, with misinformation traveling over the Internet and bewildering patients. Oats are a significant source of vitamins, minerals, and heart healthy soluble fiber.
This prompted recommendations to only consume oats labelled as gluten-free, as the manufacturers follow a purity protocol to reduce the risk of cross contamination. The purity protocol involves frequent sampling of gluten-free oats in the field, during shipment, processing and in storage facilities to reduce the risk of cross-contamination [ 20 ]. The FDA set a gluten limit of less than 20 parts per million ppm in foods that carry the label gluten-free [ 21 ].
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According to a study by Catassi, 50 mg of gluten introduced daily induced villous damage over three months [ 24 ]. This study provided evidence for avoidance of minute amounts of gluten, with the cut-off of 10 mg gluten daily [ 24 , 25 ]. One would need to eat more than a pound of food g tested at 20 ppm of gluten to achieve 10 mg gluten in a day. Gluten exposure from cross-contamination may lead to ongoing disease activity, and is of concern.
Considering risk of cross-contamination, it is recommended to avoid grains and flours from bulk bins, and to purchase flours and grains labeled gluten-free [ 11 ]. Condiment containers that allow use of spoons or other utensils may be at risk of cross-contamination in shared kitchens. Deli slicers, cutting boards, toasters, and colanders are risks of cross-contamination in shared kitchens.
A gluten-free diet has become easier to follow with the explosion of gluten-free products and increasing options available when eating out. A major concern is eating out; as the establishment may have best intentions in mind but there is often cross-contamination. Despite a gluten-free menu, many restaurants do not follow strict guidelines to avoid cross-contamination.
If the wait staff of a restaurant does not communicate closely with the kitchen; this poses risks as the gluten-free order may not be high priority, or overlooked. Fortunately, chefs have become more aware of the gluten-free diet and concerns regarding cross-contamination over the past decade [ 26 ]. Proper gluten-free diet education and counseling by an expert RD is necessary to aid in adherence to the gluten-free diet. After the initial visit, the patient should have access to a RD to answer questions as he or she learns to navigate the gluten-free diet.
Such access would ideally include follow-up visits, phone calls, as well as analysis of food logs to ensure compliance and understanding of the diet. Not all insurance carriers cover visits with a RD. It is advisable for patients to check insurance coverage before the visit to avoid billing issues. Misinformation online can lead to anxiety, confusion, and overwhelm the patient. Important areas to focus on include cross-contamination in the home, frequency and locations of eating out, and products purchased that may be cross-contaminated.
The RD can direct patients to reputable information sources. Ludvigsson has four steps to assess diet adherence: dietetic review, serum antibodies, clinical assessment of symptoms and follow-up biopsy [ 27 ]. This test is unable to evaluate gluten content in foods with hydrolyzed proteins or fermented products. An example is the issue arising with gluten-removed beers. These beers are barley based, and are treated with enzymes that break the proteins at the amino acid proline. Therefore, no safe or accurate test is available to deem a gluten-removed beer safe for consumption [ 28 ].
Hopefully the future will bring advances with testing. It is advised to only consume gluten-free beers and avoid gluten-removed beer until an appropriate test is developed to ensure safety. Only a handful of studies have been done to assess gluten content in foods that are labelled gluten-free. In the past year, three studies had varying results. One study analyzing U. A recent study found a four-fold increase in mercury blood levels in celiac patients following a gluten-free diet [ 33 ].
This study took into account amalgam fillings which contain mercury, as well as seafood intake; which did not correlate with blood and urine samples of mercury. Mercury is primarily absorbed in the duodenum.
This outcome could be due to an altered response to mercury exposure, with a predisposition to accumulate it. Further studies are needed to clarify the concern of mercury in celiac disease and inspire guidelines for the surveillance of mercury in food. Rice is a main staple in the diet of many with celiac disease. Consumption of plain rice and convenience foods processed with rice has skyrocketed. These include rice crackers, rice milk, rice flours, rice noodles, which further increases the average intake.
However, most varieties of rice have been shown to contain high levels of inorganic arsenic, a carcinogen [ 34 ].
Grain Foods Foundation research finds gluten avoidance alive and well
This may pose concerns due to large volumes of rice consumed by those following a gluten-free diet. Large doses of arsenic are life threatening, but small doses may increase risk of heart disease, diabetes, and cancer [ 34 ]. In , the Food and Drug Administration FDA conducted an analysis of rice-based foods to determine levels of arsenic. Varying levels of arsenic were found in the foods tested.
This furthers the importance of a diet with varied grains, an important consideration that could simply be overlooked in those who do not see a RD at diagnosis.
Corn has long been a staple in the typical gluten-free diet. Similar to rice, corn is one of the predominant gluten-free options in convenience foods, including corn tortillas, chips, or other baked foods or snacks. Corn has been found to contain high levels of mycotoxins, specifically fumonisins [ 36 ]. It was specifically high in extruded corn products, including polenta, but lower in corn flour or corn porridge [ 37 ]. Approximately The conditions corn sustains during the growth in fields, storage and processing allows for fumonisins to fester.
This is yet another reason to support a varied diet, a restrictive diet could prove hazardous. A study in Spain found a significant decrease in lactobacillus and bifidobacterium, and fecal short chain fatty acids in celiac patients on a gluten-free diet for 2 years [ 39 ]. There was a reduction in the diversity of healthy bacteria in 5 of 11 treated celiac patients, although 6 of 11 had similar microbiota compared to healthy controls [ 39 ]. Another recent study found a decrease in lactobacillus in pediatric celiac disease patients following a gluten-free diet [ 40 ].
Further studies are warranted to determine if probiotics or prebiotics may be of benefit to increase beneficial bacteria in celiac disease. Gluten is versatile, as it provides a variety of functions in foods. When gluten is removed, the product is denser. Sugar and fat are often added to provide a similar mouthfeel, which can result in higher calories. A recent study in Spain analyzed the nutritional content of gluten-free and gluten-containing products, which revealed significant differences. Gluten-free products contained more fat, predominantly saturated fat, more sodium, and less fiber and protein than gluten-containing counterparts [ 41 ].
Recent utilization of bean and nut flours, which aid in the texture, composition and nutritivevalueof gluten-free foods, has made some gluten-free products quite similar to their gluten-containing counterparts [ 42 ] and may aid in reducing the effect of weight gain on a gluten-free diet.
Shepherd et al. Those following a gluten-free diet consumed inadequate fiber and folate, with higher fat and sugar content of gluten-free foods [ 43 ]. Further attention should be paid to the importance of fortification of gluten-free foods to mimic gluten-containing counterparts.
This reflects the general population with respect to overweight and obesity [ 45 ]. Metabolic syndrome is a cluster of risk factors for cardiovascular disease and type 2 diabetes, and encompasses abdominal obesity, high blood pressure, dyslipidemia and impaired glucose regulation [ 46 ]. The researchers suggest an in-depth nutrition assessment and follow-up with a RD to help prevent weight gain and shifts in metabolism.
Cheng notes this further emphasizes the importance and impact of RDs in gluten-free diet adherence and quality of life. At diagnosis, In a study at the Cleveland Clinic, there was a two-fold increase in coronary artery disease in celiac disease versus non-celiac disease patients [ 52 ].
This is of interest because systemic inflammation, as well as a healed small bowel, may result in elevated cholesterol levels. After initiation of a strict gluten-contamination elimination diet, there were significant changes. Eleven of 14 subjects experienced resolution of symptoms, and were able to return to a normal gluten-free diet without issues. Five of six patients with Marsh 3 lesions on biopsy had resolution of symptoms and were no longer considered to have refractory celiac disease RCD.
If a strict gluten-free diet does not resolve symptoms, it is important to consider a consultation with a RD to rule out obvious or inadvertent sources of gluten. If antibody levels are improving or normal but symptoms persist, consider other reasons for persistent symptoms.