American Dietetic Association Evidence-Based Practice Guideline Celiac Disease

The American Dietetic Association has published a new evidence-based nutrition practice guideline for registered dietitians on nutrition care for patients with celiac disease. The guideline is available through the ADA’s Evidence Analysis Library which analyzes and summarizes results of the best available research and offers recommendations for RDs in treating clients and patients.

ADA members, including an expert workgroup and trained analysts, extensively examined the research to develop a series of recommendations and treatment algorithms which accurately summarize this body of evidence. The intent of ADA’s guidelines is to support the integration of evidence-based dietetics practice and improve the quality of care.

Celiac Disease
Within this guideline are nutrition recommendations related to celiac disease on topics including:

  • Medical nutrition therapy
  • Bone density screening
  • Gastrointestinal symptoms
  • Gluten-free dietary pattern
  • Consumption of whole/enriched gluten-free grains and products
  • Addition of multivitamin and mineral supplement
  • Calcium/vitamin D for reduced bone density
  • Monitoring and evaluation of dietary compliance

Executive Summary of Recommendations

ADA members and Evidence Analysis Library (EAL) subscribers may access the recommendations along with the Guideline Overview and evidence analysis supporting these recommendations under via Major Recommendations

Screening and Referral

CD: Medical Nutrition Therapy

Medical nutrition therapy (MNT) provided by a registered dietitian is strongly recommended for individuals with celiac disease. Consultation with a registered dietitian as part of a team-based approach results in improved self-management.

Nutrition Assessment

CD: Assessment of Food/Nutrition-Related History

The registered dietitian (RD) should assess the food and nutrition-related history of individuals with celiac disease, including (but not limited to) the following:

  • Food and nutrient intake (e.g., diet history, diet experience and macronutrient or micronutrient intake, specifically calcium, iron, vitamin B complex and vitamin D)
  • Medication and herbal supplement use
  • Knowledge, beliefs or attitudes (e.g., readiness to change nutrition-related behaviors)
  • Behavior (e.g., social network)
  • Factors affecting access to food and food and nutrition-related supplies (e.g., safe food and meal availability).

Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition intervention. Intake of gluten results may result in gastrointestinal symptoms, malabsorption and villous atrophy.

CD: Assess Biochemical Data and Results of Medical Procedures

The registered dietitian (RD) should assess the biochemical data and review the results of medical procedures in individuals with celiac disease, regardless of presentation and clinical symptoms, including (but not limited to) the following:

  • Gastrointestinal profile [e.g., intestinal biopsy (or skin biopsy in the case of dermatitis herpetiformis) and celiac antibodies]
  • Nutritional anemia profile (e.g., folate, ferritin and vitamin B12)
  • Vitamin profile (e.g., thiamin, vitamin B6 and 25-hydroxy vitamin D)
  • Mineral profile (e.g., copper and zinc)
  • Lipid profile
  • Electrolyte and renal profile.

Untreated celiac disease results in villous atrophy and malabsorption. The use of effective techniques to assess nutritional status is essential to prevention and treatment of malnutrition and the presence of iron deficiency anemia.

CD: Bone Density Screening

The registered dietitian (RD) should recommend bone density screening for adults with celiac disease within the first year. Clinical trials and cross-sectional studies have reported reduced bone mineral content and bone mineral density in untreated adults with celiac disease.

CD: Assess Factors Affecting Quality of Life

The registered dietitian (RD) should assess the factors affecting the quality of life of individuals with celiac disease when completing a comprehensive client history, which includes a medical history (e.g., gastrointestinal, immune, neurological and psychological) and social history (e.g., socioeconomic factors, religion, social and medical support and daily stress level). Individuals with celiac disease may not attain the same level of quality of life as the general population, due to social inconveniences of following a gluten-free dietary pattern.

CD: Assess Gastrointestinal Symptoms

The registered dietitian (RD) should assess gastrointestinal symptoms (such as type, frequency and volume of bowel function; abdominal pain and bloating; nausea or vomiting; reduced gut motility and delayed gastric emptying) in individuals with celiac disease. Several studies have reported that people with celiac disease (treated and untreated) are more likely to experience gastrointestinal symptoms than are healthy control subjects.

CD: Assessment of Other Disease States

The registered dietitian (RD) should assess for the presence of other disease states, such as thyroid conditions, other autoimmune and endocrinologic disorders and diabetes, when implementing medical nutrition therapy (MNT). Identification of all nutritional issues is optimal to integrate MNT for individuals with celiac disease into overall disease management.

Nutrition Intervention

CD: Gluten-Free Dietary Pattern

The registered dietitian (RD) should advise and educate individuals with celiac disease to be compliant with a gluten-free dietary pattern. Research on individuals with celiac disease reports that long-term compliance with a gluten-free dietary pattern improves outcomes related to bone density, iron deficiency anemia, villous atrophy, gastrointestinal and neurological symptoms, pregnancy outcomes and quality of life.

CD: Consumption of Whole/Enriched Gluten-Free Grains and Products

The registered dietitian (RD) should advise individuals with celiac disease to consume whole or enriched gluten-free grains and products such as brown rice, wild rice, buckwheat, quinoa, amaranth, millet, sorghum, teff, etc. Research reports that adherence to the gluten-free dietary pattern may result in a diet that is low in carbohydrates, iron, folate, niacin, zinc and fiber.
CD: Addition of Multivitamin and Mineral Supplement

If usual food intake shows nutritional inadequacies that cannot be alleviated through improved eating habits, the RD should advise individuals with celiac disease to consume a daily gluten-free age- and sex-specific multivitamin and mineral supplement. Research reports that adherence to the gluten-free dietary pattern may result in a diet that is low in iron, folate, niacin, vitamin B12, calcium, phosphorus and zinc.

CD: Inclusion of Gluten-Free Oats as Tolerated

The registered dietitian (RD) should advise individuals with celiac disease who enjoy and can tolerate gluten-free oats to gradually include them in their gluten-free dietary pattern. Research on individuals with celiac disease reports that incorporating oats uncontaminated with wheat, barley or rye at intake levels of approximately 50g dry oats per day is generally safe and improves compliance with the gluten-free dietary pattern.

CD: Calcium/Vitamin D for Reduced Bone Density

For adults with reduced bone density or reduced serum levels of 25-hydroxyvitamin D, the registered dietitian (RD) should advise the consumption of additional calcium and vitamin D through food or gluten-free supplements. Studies in adults with untreated celiac disease have shown that a gluten-free dietary pattern improves, but may not normalize bone mineral density.

CD: Iron Supplementation for Iron Deficiency Anemia

For individuals with iron deficiency anemia and celiac disease, the registered dietitian (RD) should advise the consumption of a daily gluten-free multivitamin with iron or additional individualized therapeutic doses of iron. Studies report that iron supplementation may be necessary to achieve normal values of hematological parameters.

CD: Provide Resources and Education on Label Reading

The registered dietitian (RD) should provide resources and educate individuals with celiac disease about reviewing the ingredients on labels of food and supplements, using current publications, including those from the United States Food and Drug Administration, for identification and avoidance of sources of gluten, namely wheat, rye, barley, malt and oats (unless oats are gluten-free). Education about the disease is optimal to integrate MNT for individuals with celiac disease into overall disease management.

CD: Coordination of Care

The registered dietitian (RD) should implement medical nutrition therapy (MNT) and coordinate nutrition care with a team of clinical professionals. Depending on the coexisting conditions of the individual with celiac disease, consultation with gastroenterologists, endocrinologists, allergists, dermatologists, hepatologists, pharmacists, social workers, etc., may be warranted. An interdisciplinary team approach is optimal to integrate MNT for individuals with celiac disease into overall disease management.

CD: Education on Food Cross-Contamination

The registered dietitian (RD) should educate individuals with celiac disease regarding cross-contamination in gluten-free food preparation within manufacturing plants, restaurants and home kitchens. Education about the disease is optimal to integrate MNT for individuals with celiac disease into overall disease management.

Nutrition Monitoring and Evaluation

CD: Monitoring and Evaluation of Dietary Compliance

The registered dietitian (RD) should monitor the following to evaluate dietary compliance:

  • Gluten-free dietary pattern
  • Antibody levels
  • Potential exposure to cross-contamination
  • Hidden sources of gluten in foods, medications and supplements.

Intake of gluten may result in gastrointestinal symptoms, malabsorption and villous atrophy.

CD: Monitoring and Evaluation of Factors Affecting Quality of Life

The registered dietitian (RD), at every encounter, should monitor and evaluate the factors affecting the quality of life of individuals with celiac disease, reviewing changes in client status, which includes medical status (e.g., gastrointestinal, immune, neurological and psychological) and social status (e.g., socioeconomic factors, religion, social and medical support and daily stress level). Individuals with celiac disease may not attain the same level of quality of life as the general population, due to social inconveniences of following a gluten-free dietary pattern.

CD: Monitoring and Evaluation of Gastrointestinal Symptoms

The registered dietitian (RD), after ruling out gluten exposure, should monitor and evaluate persistent gastrointestinal symptoms in individuals with celiac disease, such as bloating, gas, constipation and diarrhea, as there may be other potential causes, such as leaky gut, lactose, fructose and carbohydrate intolerances, bacterial overgrowth, refractory sprue, related cancers, and other gastrointestinal diseases and conditions. Several studies have reported that people with celiac disease (treated and untreated) are more likely to experience gastrointestinal symptoms than healthy controls; compliance with a gluten-free diet reduces but may not eliminate these symptoms.

Evidence-based Nutrition Practice Guideline on Celiac Disease published on June 23, 2009 at (http://www.adaevidencelibrary.com/topic.cfm?cat=3677) and copyrighted by the American Dietetic Association.

Disclaimers

Evidence-based Nutrition Practice Guidelines are intended to serve as a synthesis of the best evidence available to inform registered dietitians as they individualize nutrition care for their clients. Guidelines are provided with the express understanding that they do not establish or specify particular standards of care, whether legal, medical or other.

Evidence-based Nutrition Practice Guidelines are intended to summarize best available research as a decision tool for ADA members.

No endorsement by the American Dietetic Association of any brand-name product or service is intended or should be inferred from a Guideline or from any of its components (including Question, Evidence Summary, Conclusion Statement, Conclusion Statement Grade, Recommendation or Recommendation Rating).