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.