Celiac Disease

CD: Executive Summary of Recommendations (2009)

Executive Summary of Recommendations

Below are the major recommendations and ratings for the Academy of Nutrition and Dietetics Celiac Disease (CD) Evidence-Based Nutrition Practice Guideline. More details is available to Academy members and EAL subscibers by clicking Major Recommendations  from the menu bar on the left.

For a description of the Academy Recommendation Rating Scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence) and an explanation of the type of Recommendation (Imperative, Conditional), click here.

The CD Recommendations are listed below. [Note: If you mouse-over underlined acronyms and terms, a definition will pop up.]

  • Screening and Referral
    CD: Medical Nutrition Therapy
    Medical nutrition therapy (Medical nutrition therapy) 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. 
    Consensus
    Imperative
  • 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.
    Strong
    Imperative
    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.
    Strong
    Imperative
    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.
    Strong
    Conditional
    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. 
    Strong
    Imperative
    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. 
    Strong
    Imperative
    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 (Medical nutrition therapy). Identification of all nutritional issues is optimal to integrate Medical nutrition therapy for individuals with celiac disease into overall disease management.
    Consensus
    Imperative
  • 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. 
    Strong
    Imperative
    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.
    Strong
    Imperative
    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.
    Strong
    Conditional
    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. 
    Fair
    Conditional
    CD: Calcium/Vitamin D for Reduced Bone Density
    For Adult 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 Adult with untreated celiac disease have shown that a gluten-free dietary pattern improves, but may not normalize bone mineral density.
    Strong
    Conditional
    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. 
    Strong
    Conditional
    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 Medical nutrition therapy for individuals with celiac disease into overall disease management.
    Consensus
    Imperative
    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.
    Consensus
    Imperative
    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 Medical nutrition therapy for individuals with celiac disease into overall disease management.
    Consensus
    Imperative
  • 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.
    Strong
    Imperative
    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.
    Strong
    Imperative
    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.
    Fair
    Imperative