ADA’S GUIDELINES HELP DIETITIANS HELP YOU

     What should you expect from a dietitian in your treatment for celiac disease or gluten intolerance? In the last newsmagazine, an article about the American Dietetic Association discussed the formation of practice guidelines for dietitians in the treatment of people with celiac disease or gluten intolerance. A plan is now in place, thanks to the ADA and input from the Dietitians in Gluten Intolerance Diseases, for the assessment, treatment and monitoring the nutritional status of people with celiac disease.
     The importance of this work is that for the first time, guidelines based on evidence are available for dietitians and health care practitioners on the management of celiac disease. These guidelines are universal and critical to standards of practice for celiac disease, which will help to improve the celiac consumer’s perception of dietitians.
Evidence-based Nutrition Practice Guideline on Celiac Disease was published on May 2009 at Evidence Analysis Library (http://www.adaevidencelibrary.com/) and copyrighted by the American Dietetic Association.
     These are the nutritional guidelines and monitoring you should expect during a visit with a dietitian.

Nutritional Guidelines

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.

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.

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.

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.

Supplement your diet naturally
IRON: Meat, legumes, and dark vegetables

Food tip: Make baked beans with blackstrap molasses or use amaranth flour in baked products
B VITAMINS: Legumes, meat, dairy, eggs, fruits and vegetables, and shellfish

Food tip: Try a spinach salad topped with fresh strawberries
Food tip: Combine scrambled eggs in a corn tortilla with salsa
Food tip: Try chicken stir fry with broccoli, asparagus, and mushrooms over brown rice
CALCIUM: Dairy, firm tofu, canned fish with bones, spinach, and dark leafy greens

Food tip: Enjoy a teff wrap with canned salmon and cream cheese
ZINC: Oysters, beef, dark turkey meat, ricotta cheese, and pecans
Food tip: Serve buckwheat pancakes made with ricotta cheese and topped with pecans
FIBER: Fruits and vegetables, legumes, and gluten-free grains (brown rice, teff, buckwheat and quinoa)
Food tip: Plain yogurt mixed with fresh fruit and gluten-free oatmeal makes a great snack. (Always add more water when you add more fiber. Jyr)  

       —Compiled by Jamie Hunter, dietetic intern, Bastyr University

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.

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.

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.

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.

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.

Monitoring
     And how should a dietitian monitor your progress on the gluten-free diet? These are some standards according to the new guidelines.

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.

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). People with celiac disease may not attain the same level of quality of life as the general population, due to social inconveniences of following a GF diet.

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. 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 GF diet reduces but may not eliminate these symptoms.