CD: Meeting Nutritional Needs 2009
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
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.
Risks/Harms of Implementing This Recommendation
- Regarding the Consumption of Whole/Enriched Gluten-Free Grains and Products recommendation, individuals who are newly diagnosed or unaccustomed to a higher fiber diet may need to introduce gluten-free whole grains and products gradually into their gluten-free dietary pattern
- The Consumption of Whole/Enriched Gluten-Free Grains and Products recommendation may be contraindicated in individuals who are on a fiber-restricted diet
- Regarding the Addition of Multivitamin and Mineral Supplement recommendation, consumption of nutrients exceeding the upper limit of the Dietary Reference Intakes (DRIs) may lead to adverse conditions.
Conditions of Application
- Regarding the Consumption of Whole/Enriched Gluten-Free Grains and Products recommendation, refer to the recommendation on Education on Food Cross-Contamination available at ada.portalxm.com/eal/template.cfm
- The Addition of Multivitamin and Mineral Supplement recommendation applies to individuals when usual food intake shows nutritional inadequacies that cannot be alleviated through improved eating habits
- Regarding the Addition of Multivitamin and Mineral Supplement recommendation, refer to the recommendation on Provide Resources and Education on Label Reading available at ada.portalxm.com/eal/template.cfm.
Potential Costs Associated with Application
- Specially manufactured whole and enriched gluten-free grains and products may be costly
- Although costs of medical nutrition therapy (MNT) sessions and reimbursements vary, MNT sessions are essential for improved outcomes.
- For newly diagnosed children and adults with celiac disease, studies report that compliance with a gluten-free dietary pattern results in significant improvements in nutritional laboratory values such as serum hemoglobin, iron, zinc and calcium as a result of intestinal healing and improved absorption (Rea et al, 1996; Smecuol et al, 1997; Kemppainen et al, 1998; De Lorenzo et al, 1999; Bardella et al, 2000; Dahele and Ghosh, 2001; Hallert et al, 2002; Dickey and Kearney, 2006)
- However, adherence to the gluten-free dietary pattern may result in a diet that is high in fat and low in carbohydrates and fiber, as well as low in iron, folate, niacin, vitamin B12, calcium, phosphorus and zinc (Capristo et al, 1997; Smecuol et al, 1997; Mariani et al, 1998; Bardella et al, 2000; Grehn et al, 2001; Hallert et al, 2002; Thompson et al, 2005; Hopman et al, 2006).
Recommendation Strength Rationale
Conclusion statement was given Grade II.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
Bardella MT, Fredella C, Prampolini L, Molteni N, Giunta AM, Bianchi PA. Body composition and dietary intakes in adult celiac disease patients consuming a strict gluten-free diet. Am J Clin Nutr. 2000; 72: 937-939.
Capristo E, Mingrone G, Addolorato G, Greco AV, Corazza GR, Gasbarrini G. Differences in metabolic variables between adult celiac patients at diagnosis and patients on a gluten-free diet. Scand J Gastronenterol 1997;32(12):1222-9.
Dahele A, Ghosh S. Vitamin B12 deficiency in untreated celiac disease. Am J Gastroenterol 2001;96(3):745-750.
De Lorenzo A, Di Campli C, Andreoli A, Sasso GF, Bonamico M, Gasbarrini A. Assessment of body composition by bioelectrical impedance in adolescent patients with celiac disease. Am J Gastroenterol 1999 Oct; 94(10): 2951-2955.
Dickey W, Kearney N. Overweight in celiac disease: prevalence, clinical characteristics, and effect of a gluten-free diet. Am J Gastroenterology 2006;101:2356-2359.
Grehn S, Fridell K, Lilliecreutz M, Hallert C. Dietary habits of Swedish adult celiac patients treated by a gluten-free diet for 10 years. Scand J Nutrition 2001;45:178-182.
Hallert C, Grant C, Grehn S, Granno C, Hulten S, Midhagen G, Strom M, Svensson H, Valdimarsson T. Evidence of poor vitamin status in celiac patients on a gluten-free diet for 10 years. Aliment Pharmacol Ther 2002;16:1333-1339.
Hopman EGD, le Cessie S, von Blomberg BME, Mearin ML. Nutritional management of the gluten-free diet in young people with celiac disease in the Netherlands. J Pediatr Gastroenterol Nutr 2006;43:102-108.
Kemppainen TA, Kosma VM, Janatuinen EK, Julkunen RJ, Pikkarainen PH, Uusitupa MI. Nutritional status of newly diagnosed celiac disease patients before and after the institution of a celiac disease diet - association with the grade of mucosal villous atrophy. Am J Clin Nutr 1998; 67(3): 482-487.
Mariani P, Viti MG, Montuori M, La Vecchia A, Cipolletta E, Calvani L, Bonamico M. The gluten-free diet: a nutritional risk factor for adolescents with celiac disease? J Pediatr Gastroenterol Nutr 1998;27:519-523.
Rea F, Polito C, Marotta A, Di Toro A, Iovene A, Collini R, Rea L, Sessa G. Restoration of body composition in celiac children after one year of gluten-free diet. J of Pediatric Gastroenterology and Nutrition 1996; 23: 408-412.
Smecuol E, Gonzalez D, Mautalen C, Siccardi A, Cataldi M, Niveloni S, Mazure R, Vazquez H, Pedreira S, Soifer G, Boerr LA, Maurino E, Bai JC. Longitudinal study on the effect of treatment on body composition and anthropometry of celiac disease patients. Am J Gastroenterol 1997;92(4):639-43.
Thompson T, Dennis M, Higgins LA, Lee AR, Sharrett MK. Gluten-free diet survey: are Americans with celiac disease consuming recommended amounts of fibre, iron, calcium, and grain foods? J Hum Nutr Diet 2005;18(3):163-9.
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
- Dietay Reference Intakes: The update to the Recommended Dietary Allowances (RDAs) daily intake levels for micronutrients and macronutrients. Available at the Institutes of Medicine Web site at http://www.iom.edu/CMS/3788/33354/33915.aspx
- Lee AR, Ng DL, Zivin J, Green P. Economic burden of a gluten-free diet. Journal of Human Nutrition and Dietetics 2007; 20(5): 423-430.