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Recommendations Summary

CD: Routine Nutrition Assessment

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: Routine Nutrition Assessment

    In individuals newly diagnosed with celiac disease, it is reasonable that a registered dietitian nutritionist or an international equivalent conduct a comprehensive initial nutrition assessment and evaluates individual ability (including but not limited to access to gluten-free food, socioeconomic barriers, label and menu reading, food preparation, and avoidance of cross-contact skills) and willingness to implement a gluten-free diet, the only available treatment for celiac disease. Follow-up assessments should be individualized according to individual response to treatment, changes in ability or willingness to continue treatment, and signs and symptoms related to celiac disease.

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

      There are no obvious risks or harms associated with these recommendations. 

    • Conditions of Application

      Nutrition assessment methods should be conducted by individuals trained to perform the respective method. Routine nutrition screening of individuals with celiac disease should occur to allow for the identification and further assessment and treatment of nutritional concerns.

      Although costs of nutrition assessment sessions and reimbursement vary,  assessment of nutritional status are essential for improved outcomes.

      Implementation Considerations

      Refer to Nutrition Care Manual for Nutrition Assessment related education materials: https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=22684&lv3=274049&ncm_toc_id=274049&ncm_heading=& 

    • Potential Costs Associated with Application

      • Cost of equipment, supplies and staff are factors in conducting laboratory tests and medical procedures.
      • Insurance coverage may vary.
      • Although costs of medical nutrition therapy sessions and reimbursement vary, medical nutrition therapy sessions are essential for improved outcomes.

    • Recommendation Narrative

      The effect of adherence to a gluten-free diet (GFD) on nutrition-related laboratory measures among patients with celiac disease is inconclusive. While Kahramanoglu et al, 2019 found that celiac disease patients who were non-compliant with a GFD had significantly lower levels of serum ferritin, there were no differences in other laboratory measures (hemoglobin, leukocytes, MCV, glucose, AST, ALT, B12 and total protein). Similarly, Valerio et al, 2008, concluded that there were no differences in HbA1c, serum calcium, phosphorus or alkaline phosphatase between compliant and non-compliant groups. 

      There was no effect of adherence to a GFD on dietary intake among patients with celiac disease, according to Blazina et al, 2010 and Valerio et al, 2008. Blazina et al, 2010 concluded that, among children and adolescents with celiac disease, there was no difference in calcium intake as a percentage of DACH reference value between those who followed a strict GFD and those who did not, as measured by a presence of endomysium antibodies. The same authors concluded that there was no difference between groups in energy intake. Valerio et al, 2008 also concluded that there was no difference in calcium intake between groups of adolescents with celiac disease and type 1 diabetes who were compliant with a GFD and non-compliant with a GFD.

      The effect of adherence to a GFD on anthropometrics among patients with celiac disease is inconclusive. Wagner et al, 2008 found that, among adolescents with celiac disease, those who followed a strict GFD had a significantly lower BMI in comparison to those with frequent or infrequent nonadherence, demonstrating that those with strict compliance were more apt to fall in the “underweight” category. Kabbani et al, 2012 concluded that, in comparison to adults with poor GFD adherence, those with good adherence had a significantly lower mean BMI, both at initial assessment and at follow-up (mean 39.5 months), which was classified in the “healthy” category. While Wiech et al, 2018 found no difference in indicators of body composition, height, weight or BMI between groups of children and adolescents who were compliant to a GFD or non-compliant at presentation, among a subset of the group that was followed and evaluated after 17.2 months, there was a significant increase in weight gain and BMI towards the “healthy” category among the compliant group in comparison to the noncompliant group. Comba et al, 2018; Heyman et al, 2009; and Valerio et al, 2008 all compared height among children or adolescents who were compliant or non-compliant to a GFD and found no significant differences between groups. Comba et al, 2018 and Valerio et al, 2018 compared BMI between groups and found no significant differences, and Heyman et al, 2009 assessed weight gain between groups and also noted no significant differences. Additionally, Hopman et al, 2007 assessed BMI between groups of adults who followed a strict, non-strict or no GFD and found no differences between groups. 

      The effect of adherence to a GFD on indicators of quality of life among patients with celiac disease is unclear. In Casellas et al, 2015, the Celiac Disease Quality of Life questionnaire (CD-QOL) and EuroQoL-5D questionnaires were used to assess multiple dimensions of QoL among adult patients with celiac disease and signficiantly higher scores were reported in both scales by the compliant group in comparison to the non-compliant groups. In Wagner et al, 2008, the Inventory of Life Quality in Children and Adolescents (ILC) and the Berner Subjective Well-being Inventory (BFW) were used to assess QoL among pediatric patients. There were significant between-group differences in ILC global scores, with higher scores indicating more impairment of QoL in the groups with non-adherence. On the BFW scales, those in the adherent group scored significantly higher in the well-being scale than those in the non-adherent groups and significantly lower in the ill-being scale. Barratt et al, 2011; Hopman et al, 2009 and Usai et al, 2007 all administered the Short-Form 36-Item Health Survey (SF-36) to adults to assess QoL between groups with varying GFD adherence. While Usai et al, 2007 noted that the strict GFD group obtained higher scores on multiple domains, Barratt et al, 2011 and Hopman et al, 2009 concluded there was no impact on GFD across SF-36 domains. Van Hees et al, 2013 reported on symptoms of depression and anxiety among adults with celiac disease using the Hospital Anxiety and Depression scale and noted no differences in symptoms between adherence groups. Chauhan et al, 2010 reported on QoL among children with celiac disease using the Pediatric Symptom Checklist Scores and noted no difference between adherence groups, although between-group difference was not reported. Esenyl et al, 2014 administered multiple scales to both children with celiac disease and their parents to assess depression and anxiety levels between GFD compliant and non-compliant groups, while there were no significant differences between the children, the parents of children who were non-compliant reported significantly higher levels of anxiety in comparison to the parents of children who were compliant with the GFD.

      The current evidence suggests that there is no effect of adherence to a GFD on indicators of gastrointestinal health and gastrointestinal symptoms among patients with celiac disease. While Barratt et al, 2013 found that adult patients who identified as non-adhering to a GFD reported significantly higher rates of fatigue, itchy skin and bloating in comparison to their fully adherent counterparts, there were no significant differences in rates of self-reported abdominal pain, diarrhea, nausea or flatulence. On the contrary, Norsa et al, 2018 concluded that, in comparison to adults in the groups that were non-adherent or discontinued GFD, the adults in the GFD adherent group had a higher percentage of self-reported GI symptoms as the primary reason for scheduling an endoscopy. Kabbani et al, 2012 concluded that there were no differences in self-reported gastrointestinal symptoms between the group of adult patients that was compliant vs. non-compliant to a GFD. Hopman et al, 2007 and Usai et al, 2007 used the GSRS and IBS-TS scales, respectively to assess gastrointestinal symptoms between groups of adult patients who followed a strict vs. partial GFD and found no significant difference. 

      Adherence to a GFD has a potential positive effect on indicators of bone metabolism among patients with celiac disease. Four studies (Blazina et al, 2010; Heyman et al, 2009; Usta et al, 2014; Valerio et al, 2008) noted significant differences in measures of bone mineral density between groups of pediatric patients with different adherence levels to a GFD, with those reporting strict compliance exhibiting a higher average bone mineral density score than those with lower compliance. Of note, while Usta et al, 2014 concluded that, after 2 years on a GFD, children who were compliant to a GFD had higher bone mineral density z-scores than the non-compliant group, this finding was reversed at the five-year mark. Additionally, while serum TSH scores were significantly higher in the non-compliant group of adult patients with celiac disease in comparison to the compliant group in Kahramanoglu et al, 2019, self-reported cases of osteoporosis were significantly higher among adult patients who reported following a strict GFD in comparison to those who reported not following a strict GFD in Hopman et al, 2007.

      Adherence to a GFD has a potential effect on celiac disease-related antibodies, inflammatory and immunological indicators among patients with celiac disease. Hopman et al, 2007; Kahramanoglu et al, 2019 and Wagner et al, 2008 all reported on the impact of adherence to a GFD on celiac disease-related antibodies. All three studies noted a significant difference in anti-gliadin antibodies between groups with varying adherence. Hopman et al, 2007 noted a significant difference in the number of adult patients with positive IgA-EMA between groups who followed a strict GFD in comparison to those who followed a non-strict or no GFD, with the fewest number in the strict GFD group. Kahramanoglu et al, 2019 concluded that thymic stromal lymphopoietin, IgA anti-tTG and IgG anti-tTG levels were significantly higher in the noncompliant group of adult patients in comparison to the compliant group of adult patients. Finally, Wagner et al, 2008 reported that, among adolescents with varying levels of GFD adherence, there were more positive anti-gliadin antibody cases in the last blood checkup in patients with frequent non-adherence than in patients who were fully compliant to the GFD.

    • Recommendation Strength Rationale

      The recommendations regarding frequency of assessment are based on Consensus/Expert Opinion.

    • Minority Opinions

      Consensus reached.