|Nutritional Care: The Clinical Diet|
The gluten-free diet means all packaged foods must be scrutinized before they are used. Ingredient labels read carefully reveal basic ingredients. Evaluate whether gliadin-containing grains may be added as a derivative when the food is processed or prepared.
Glucose syrup, hydrolyzed vegetable protein (HVP) and other ingredients when derived from wheat must declare wheat on the label.
Cereal products that can be used as substitutes are sweet rice flour, corn flour, cornmeal, potato flour, rice flour, soybean flour, tapioca flour and tapioca starch, and arrowroot starch. During the first few weeks of gluten elimination, the diet may be supplemented with vitamins and minerals and may need to be high in protein in order to cure deficiencies and replenish nutrient stores. These needs may not exist, supplementation is best defined through prescription by the monitoring physician.
Both the immediate and long-term effects of the gluten-free diet have been clinically dramatic. Any relapses are usually due to dietary indiscretions and promptly subside when gluten is again removed from the diet. For the celiac patient, there is no possibility to consider that "only a little bit may not hurt." One molecule of gluten may be just as bad as 10,000.
Just because the person with celiac disease is free of symptoms after eating gluten does not mean that there is no villi damage. There usually is, although it may take weeks or months to develop. It has been observed that if adults go on and off a gluten-free diet a number of times, they may reach a stage at which they do not respond to a gluten-free diet. In extreme cases, the patient may move on to a secondary condition of refractory celiac disease.
Some patients with untreated celiac disease develop aggravation of their symptoms after ingestion of milk or milk products. The probable cause of milk intolerance is lactase deficiency secondary to the reduced number of and damage to the intestinal absorptive cells that produce lactase at the tips of the villli. Milk and milk products develop milk tolerance as intestinal structure and function appears normal after gluten withdrawal.
If the disease has been severe, patients may need supplements in addition to the gluten-free diet. Anemic patients may need to receive iron, folate and/or vitamin B-12, depending upon the type and nature of the anemia. Vitamin K may be given there is purpura, bleeding or prolonged prothrombin time. Electrolyte and fluid replacement may be needed with patients with symptoms of dehydration from severe diarrhea. Calcium and vitamin D administration under physician monitoring may be necessary to correct osteomalacia. A multiple vitamin-mineral supplement should be taken regularly by nontropical sprue patients who continue to have malabsorption. Celiac patients who are self-directed regarding the use of vitamins and food supplements are often ill-advised and misdirected; the complexity of the subliminal absorption problem represented in celiac disease is best handled with the monitoring of a physician who has access to the clinical evaluation, history and dietary needs of the patient involved.
Prognosis. In children a gluten-free diet almost always results in a return to normal absorption; however, this is not always so in adults. Even though they gain relief with a gluten-free diet, some adults still continue to have intestinal abnormalities as revealed by biopsy. Likewise, persons with celiac disease who eat gluten but do not have clinical symptoms still show damage to intestinal villi. One does not outgrow nontropical sprue (celiac disease). There is still destruction of villi upon gluten ingestion, even thought clinical symptoms may abate for months or years or into later life.
Several research reports and individual case histories suggest an increased incidence of malignant disease in adults with celiac disease than in the general population. Gastrointestinal carcinomas and lymphomas seem to be the most common types of cancers reported. The true increase in the incidence is not known at this time. It is believed that strict adherence to the clinical gluten-free diet reduces the incidence of intestinal lymphoma and other malignancies in celiac disease patients, however, additional case studies and research follow-up are needed to further define the diet/cancer relationship.
Original by:Leon H. Rottmann, Ph.D., Professor Emeritus, University of Nebraska-Lincoln
CSA Library Series
CSA Library Series is a collection of articles that pertain to celiac disease and dermatitis herpetiformis. Most of these articles have appeared in CSA’s quarterly newsletter, Lifeline, which all CSA members receive. Historic articles included in these resources may or may not include updated notes. Updated information indicated in red type. Articles represent the work of the author.