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Recommendations Summary

CD: Gluten-Free Diet (2021)

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.


  • Recommendation(s)

    CD: Gluten-Free Dietary Pattern

    For all individuals with celiac disease, the registered dietitian nutritionist or an international equivalent should recommend following a gluten-free dietary pattern and adherence to this dietary pattern to improve gastrointestinal health and symptoms, quality of life, quality of dietary intake, maintenance or achievement of a normal body mass index or weight, and improvement in celiac disease-related antibodies, inflammatory and immunological indicators.

    Rating: Level 1(C)
    Imperative

    CD: Gluten-Free Dietary Pattern for Growth and Development

    In children with celiac disease, the registered dietitian nutritionist or an international equivalent should recommend a nutritionally adequate gluten-free dietary pattern to achieve and maintain appropriate growth and development.

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

      The gluten-free dietary pattern does not eliminate any food group, however, the extent that gluten is naturally (wheat, rye, barley, triticale) or incorporated into processed foods intentionally (e.g., an added ingredient) or unintentionally (e.g., cross-contact through the manufacturing or production processes) is widespread. Given the ubiquitous presence of gluten in many foods common in the United States, individuals may be at nutritional risk if they eliminate staple or commonly consumed foods without identifying a suitable alternative.

      Consuming a gluten-free dietary pattern prior to the diagnosis of celiac disease is confirmed may result in inaccurate diagnostic test results.

      Consuming a gluten-free diet may result in inappropriate stigmatization, anxiety or apprehension in children or adults in school, workplace, social and travel situations that may negatively impact quality of life.

    • Conditions of Application

      Refer to the Nutrition Care Manual for Client Education documents for Education on Gluten-Free Nutrition Therapy, Label reading tips, and healthy eating tips.

      Implementation Considerations:

      • Refer to the Nutrition Care Manual for tips on gluten-free dietary patterns and education materials to help plan meals. https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=162
      • Consuming whole grain and nutrient fortified gluten-free grains and products such as brown rice, wild rice, buckwheat, quinoa, amaranth, millet, sorghum, teff and others or iron or other nutrient-fortified cereals to promote consumption of nutrient-dense foods.
      • By using resources in the Nutrition Care Manual to help develop good quality knowledge of food budgeting/purchasing practices, food preparation skills and equipment, combined with the motivation to prepare meals at home, the gluten-free diet can be comparable in financial cost. 
      • Guide budget-aware clients to plan meals in advance as preparing economical gluten-free meals requires less reliance on convenience items or organic/specialty items prepared with gluten-free modifications (e.g., more food items must be prepared from scratch). 
      • If a population has access to and consumes foods according to the Dietary Guidelines for Americans, then the need for supplementation with a gluten-free diet is decreased.

    • Potential Costs Associated with Application

      A gluten-free diet is the only treatment for celiac disease, therefore the net benefits of essential medical nutrition therapy sessions that are essential for improved outcomes cannot be measured as a cost factor for nutritional status evaluation.

      Complete elimination of gluten from the diet is challenging for many individuals, and education and guidance on successfully implementing and maintaining this dietary change by a registered dietitian nutritionist or equivalent is recommended. The direct cost to the individual for initial and follow-up consultations varies according to insurance coverage and may be a barrier for some. While a gluten-free diet is theoretically possible to follow on any food budget, the additional financial cost of gluten-free versions of staple foods (e.g., bread, certified gluten-free flours, oats and others) and gluten-free versions of time-saving common convenience foods (e.g., deli, frozen, canned and packaged foods) are burdensome for some individuals. While the consumer marketplace for gluten-free foods has expanded in recent years, physical access to gluten-free foods is not universal throughout the United States and the additional costs of shipping gluten-free versions is important to consider in the overall costs associated with implementing the gluten-free diet.

    • Recommendation Narrative

      A total of twenty-four studies were examined that explored the effects of a gluten-free diet (GFD), compared to a control, on nutrition-related outcomes in patients with celiac disease. One positive observational study (Kahramanoglu et al, 2019) two neutral-quality RCTs (Catassi et al, 2007; Kurppa et al, 2014), seventeen neutral-quality observational studies (Balamtelkin et al, 2012; Bassotti et al, 2008; Casellas et al, 2008; Cheng et al, 2010; Forchielli et al, 2015; Hogberg et al, 2009; Ioannou et al, 2011; Karadas et al, 2016; Kautto et al, 2016; Korpimaki et al, 2011; Koskinen et al, 2010; Laine et al, 2018; Margoni et al, 2012; Pludowski et al, 2007; Rajpoot et al, 2015; Sun et al, 2009; Van Koppen et al, 2009) and four negative quality observational studies (Collado et al, 2009; De Palma et al, 2010; Ferretti et al, 2012; Szymczak et al, 2012) were included. Three included studies were conducted in Turkey, four were conducted in Finland, four were conducted in Italy, three were conducted in Spain, two in Sweden and two in Greece, and two studies were conducted in Poland. One study each was conducted in India, England, the Netherlands and the United States. Twelve studies included adults with celiac disease and twelve studies included children or adolescents with celiac disease as their target population. Sample sizes of participants analyzed ranged from 10 to 369 per group (some studies included additional participant groups not considered for this review). All intervention groups investigated, at least in part, the effect of a GFD, compared to a control, on nutrition-related outcomes among patients with celiac disease. 

      A total of seventeen studies in nineteen papers were examined that explored the effects of adherence to a GFD, on nutrition-related outcomes in patients with celiac disease. Two positive observational studies (Kahramanoglu et al, 2019; Norsa et al, 2018) twelve neutral-quality observational (Blazina et al, 2010; Casellas et al, 2015; Comba et al, 2018; Heyman et al, 2009; Hopman et al, 2007/ 2009; Kabbani et al, 2012; Usai et al, 2014; Valerio et al, 2008; Van Hees et al, 2013; Wagner et al, 2008; Wiech et al, 2018) and three negative quality observational studies (Barratt et al, 2011/2013; Chauhan et al, 2010; Esenyel et al, 2014) were included. Four included studies were conducted in Turkey, three were conducted in Italy, and three were conducted in the Netherlands.  One study each was conducted in India, the United Kingdom, Slovenia, Spain, India, Germany, Poland, and the United States. Nine studies included adults with celiac disease and nine studies included children or adolescents with celiac disease as their target population. Sample sizes of participants analyzed ranged from 8-1136 per group (some studies included additional participant groups not considered for this review). All intervention groups investigated, at least in part, the effect of adherence to a GFD on nutrition-related outcomes among patients with celiac disease. 

      The effect of a gluten-free diet, compared to a control, on nutrition-related laboratory measures is inconclusive. While five observational studies noted improvements in measures including HDL cholesterol, zinc, serum ferritin, albumin, hemoglobin, AST and ALT with a GFD, one additional observational study and a randomized controlled trial noted no differences in laboratory measures.

      There is limited evidence to suggest that a gluten-free diet, compared to a control, may have a positive effect on dietary intake among patients with celiac disease. One study in children demonstrated that those who followed a GFD consumed fewer saturated fatty acids than those on a gluten-containing diet. An additional study among adolescents showed that those on a GFD consumed more vegetables, poultry and bread than those on a gluten-containing diet.

      The effects of a gluten-free diet, compared to a control, on anthropometrics among patients with celiac disease are unclear. While two studies with children and one study with adults with celiac disease noted improvements in either weight or BMI among groups that were on a GFD in comparison to a control, five studies noted no difference in either BMI or weight between groups.

      There is evidence to suggest that a gluten-free diet, compared to a control, may have a positive effect on quality of life among patients with celiac disease.

      There is evidence to suggest that a gluten-free diet, compared to a control, may have a positive effect on indicators of gastrointestinal health and gastrointestinal symptoms among patients with celiac disease. Eight studies noted improvements in gastrointestinal symptoms and indicators of gastrointestinal health with a GFD, while four studies noted conflicting evidence.

      The effect of a gluten-free diet, compared to a control, on indicators of bone metabolism is inconclusive. Three observational studies found that groups who consumed a GFD had higher bone mineral density than the control group, while one observational study and one RCT found no evidence of difference between groups.

      A gluten-free diet, compared to a control, has a positive effect on celiac disease-related antibodies, inflammatory and immunological indicators among patients with celiac disease. Five studies concluded that a GFD resulted in improvement in markers of antibodies and inflammation compared to a control.

      The effect of adherence to a gluten-free diet on nutrition-related laboratory measures is inconclusive. While one observational study noted that non-compliant adult patients with celiac disease had lower serum ferritin than compliant patients, the same study and an additional observational study with pediatric patients noted no differences in other laboratory measures, including calcium, hemoglobin, leukocytes, MCV, glucose, AST, ALT, albumin, B12 and total protein.

      There is no evidence to suggest that adherence to a gluten-free diet affects dietary intake of calcium or total energy intake among pediatric patients with celiac disease.

      The effects of adherence to a gluten-free diet on anthropometrics among patients with celiac disease are unclear. While one study in children showed lower BMI values towards underweight among those following a strict GFD in comparison to those with frequent nonadherence, another study with children showed that those who complied with a GFD experienced increases in BMI associated with a normal BMI value in comparison to those who were non-compliant. In a study with adults, compliance with a GFD was associated with a lower BMI in the normal category in comparison to those with poor compliance, whose mean was in the overweight category. Four additional observational studies noted no difference in BMI between adherence groups.

      The effect of adherence to a gluten-free diet on indicators of quality of life among pediatric and adult patients with celiac disease is unclear. There is conflicting observational evidence on the role a gluten-free diet may play in improving measures of quality of life.

      There is no evidence to suggest that adherence to a gluten-free diet affects self-reported indicators of gastrointestinal health and gastrointestinal symptoms among patients with celiac disease. While one observational study noted improvements among adults in self-reported gastrointestinal symptoms with adherence to a gluten-free diet, four other studies in adults provided conflicting evidence.

      Adherence to a gluten-free diet may have a positive effect on indicators of bone metabolism among patients with celiac disease. Four observational studies in pediatric patients found that those who adhered to a GFD had higher bone mineral density than groups with poor adherence.

      Adherence to a gluten-free diet may have a positive effect on celiac disease-related antibodies, inflammatory and immunological indicators among patients with celiac disease. Three observational studies (two in adults and one in youths) concluded that non-adherence to a GFD resulted in significantly more cases of positive celiac-disease antibodies in comparison to GFD adherence.

    • Recommendation Strength Rationale

      The evidence supporting the recommendation is based on Grade III /Grade C evidence. 

    • Minority Opinions

      Consensus reached.