Celiac Sprue: Nutritional Considerations

Nutritional adjustments are essential to the management of this disorder. The key aspects of treatment are as follows:

Gluten–free Diet

A gluten–free diet eliminates wheat, barley, rye, and other gluten–containing foods. Patients should consult with an experienced dietitian to identify these foods and ensure adequate nutrient balance.

Although gluten is also found in oats, some studies suggest that pure oat flour can be tolerated without disease recurrence. Thus, once the disease has become quiescent, many gastroenterologists will introduce oats to the diet (less than 2 g/day), and patients may eventually be able to tolerate 40 to 60 grams per day. However, some patients are sensitive to oats, a sensitivity confirmed by the presence of oat–specific intestinal T cells. Further caution regarding oats is justified by the fact that commercial oat products may be contaminated with other gluten–containing grains.¹

Patients should be aware that 100% gluten avoidance is impossible. Even naturally gluten–free products may contain 20 to 200 mg gluten/kg. Evidence supports setting the threshold for gluten–contamination at 100 mg/kg; the intake of gluten–free flour up to 300 g/day provides 30 mg of gluten, which is within the range found to allow for mucosal recovery in clinical and challenge studies.²

Addressing Nutrient Deficiencies

Celiac disease patients’ diets and gluten–free products are often low in B vitamins, calcium, vitamin D, iron, zinc, magnesium, and fiber. Consequently, newly diagnosed or inadequately treated patients often have low bone–mineral density, low fiber intake, and micronutrient deficiencies, despite increased obesity in this population.³

The prevalence of vitamin B–complex deficiency is between 5% and 7% of persons with undiagnosed celiac disease, compared with 1% to 2% in a control population.⁴ About 5% of patients diagnosed with iron and/or folate deficiency were found to have histologically confirmed celiac disease after endoscopy and biopsy.⁵ In patients following a gluten–free diet for 10 years, blood levels of folate were low in 37%, and blood levels of vitamin B6 were low in 20%.⁶ Between 20% and 40% of untreated celiac patients appear to have poor vitamin B₁₂ status.^7,8

Nutritional deficiencies of fat–soluble vitamins, occurring as a result of malabsorption, are not uncommon. Cases of myopathy and vitamin D deficiency in celiac disease have been reported, and low levels of vitamin E have been implicated in neurologic complications of celiac disease. Vitamin E supplementation and a gluten–free diet reverse the resulting myopathy.⁹ Malabsorption of vitamin K in untreated celiac disease may also prolong the prothrombin time, requiring parenteral administration of this vitamin.10

Orders

Gluten–free diet.

Nutrition consultation to assist patient with diet changes, with outpatient follow–up as needed.  

What to Tell the Family

The importance of complete abstinence from gluten–containing foods should be stressed to all family members. Careful reading of labels on food products is imperative. A diet based on unprocessed or minimally processed foods is required.