Common Pitfalls in Implementing a Gluten-Free Diet

Educational Objectives

The goal of this program is to improve the management of celiac disease. After hearing and assimilating this program, the clinician will be better able to:

1. Recommend appropriate dietary restrictions for patients with celiac disease.

Summary

Barriers to management of celiac disease (CeD) management: lack of access to a skilled dietician for gastrointestinal (GI) diseases; misinformation on the gluten-free diet; resumed consumption of gluten during adulthood among patients diagnosed with CeD as children; lack of long-term follow-up

Gluten: the protein portion of wheat, rye, and barley that imparts a crunchy or flaky texture; helps to retain moisture and fat and helps extend protein; CeD is triggered by the ingestion of gluten

Initial recommendations: may include multivitamin supplements to counter potential nutritional imbalances in patients new to a gluten-free (GF) diet; check ferritin and iron studies (for signs of anemia), bone mineral density, and levels of vitamins D and B₁₂; patients with CeD should be cautious about probiotics (may contain traces of gluten); a GF diet may lack fiber, B vitamins, iron, calcium, and zinc

Challenges associated with major dietary change: require coping skills; patients must find a balance (ie, remain vigilant about their GF diet without affecting quality of life); anxiety and fatigue increase with increasing vigilance (Wolf et al [2018])

Symptoms associated with CeD: include brain fog, migraines, headaches, neuropathy, and joint pain; these may improve with a GF diet

Persistence of elevated serologies and symptoms: time to clear the antibody varies among individuals; assess for inadvertent ingestion (eg, cross-contact) and deviations from the GF diet; in patients with persistent fatigue, factors may include a high-fat diet, increased caffeine intake, high stress levels, and poor sleep patterns; treat specific GI symptoms

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP): as wheat, rye, and barley are high-FODMAP foods, patients without CeD may have reduced GI symptoms with a GF diet

Lactose intolerance: some patients with CeD lose lactase enzymes (present in the tips of the villi); instead of complete avoidance of dairy, patients may take a lactase pill prior to consuming high-lactose foods (eg, milk, ice cream, cottage cheese) or consume lactose-free foods (eg, butter, hard cheese)

Low-FODMAP diet for gas and bloating: a high-FODMAP diet containing lactose and large amounts of fructose (eg, corn syrup, apples, peaches) can create gas, pull water into the gut, and be difficult to metabolize; a low-FODMAP diet need not be permanent (patients should identify foods that trigger their symptoms; these may be subsequently reintroduced)

GF products: the Food Allergen Labeling and Consumer Protection Act of 2004 requires that foods containing major food allergens be included in the ingredient list, in parentheses, eg, (wheat) or after the word “contains”; educate patients to avoid, eg, meats that are premarinated in multiple ingredients; the Gluten-Free Certification Organization tests these products at various stages to ensure that they have <20 ppm/kg of gluten (required to be considered GF; Catassi et al (2007) found that 50 mg of gluten introduced daily induced villous damage (blunting) over 3 mo in CeD

Oats: updated guidelines suggest that the consumption of oats is safe for most patients with CeD, but oats may be immunogenic in a subset; a study found that 22% of individuals with CeD had an immunogenic response to the avenin protein in oats; oats are highly contaminated (14%) vs regular GF foods (5%)

Cross-contamination in the kitchen: Thompson et al (2021) found that 25% of fry orders had >20 ppm of gluten; avoidance of shared fryers, toasters, and strainers is recommended to prevent cross-contact; the risk for cross-contamination may be mitigated by washing with water alone (Weisbrod et al [2020]); airborne gluten — more study is needed; distance from a stand mixer was found to be a factor in measurements of gluten in the air; air quality rapidly improves by 41 min

Maladaptive eating: ≈80% of the patients have social anxiety related to the GF diet, which impacts their overall and dating lives (Lebovits et al [2022])

Readings

Catassi C, Fabiani E, Iacono G, et al. A prospective, double-blind, placebo-controlled trial to establish a safe gluten threshold for patients with celiac disease. Am J Clin Nutr. 2007;85(1):160-166. doi:10.1093/ajcn/85.1.160; Facioni MS, Raspini B, Pivari F, et al. Nutritional management of lactose intolerance: the importance of diet and food labelling. J Transl Med. 2020;18(1):260. Published 2020 Jun 26. doi:10.1186/s12967-020-02429-2; Food and Drug Administration, HHS. Food labeling: gluten-free labeling of foods. Final rule. Fed Regist. 2013;78(150):47154-47179; Hoffmanová I, Sánchez D, Szczepanková A, Tlaskalová-Hogenová H. The pros and cons of using oat in a gluten-free diet for celiac patients. Nutrients. 2019;11(10):2345. Published 2019 Oct 2. doi:10.3390/nu11102345; Lebovits J, Lee AR, Ciaccio EJ, et al. Impact of celiac disease on dating. Dig Dis Sci. 2022;67(11):5158-5167. doi:10.1007/s10620-022-07548-y; Thompson T, Lyons TB, Keller A, et al. Gluten-free foods cooked in shared fryers with wheat: A pilot study assessing gluten cross contact. Front Nutr. 2021;8:652039. Published 2021 Mar 23. doi:10.3389/fnut.2021.652039; Wolf RL, Lebwohl B, Lee AR, et al. Hypervigilance to a gluten-free diet and decreased quality of life in teenagers and adults with celiac disease [published correction appears in Dig Dis Sci. 2018 Apr 11;:]. Dig Dis Sci. 2018;63(6):1438-1448. doi:10.1007/s10620-018-4936-4.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Ms. Welstead was recorded at the 25th Annual Women in Digestive Diseases: At the Forefront, held on March 4, 2023, in Chicago, IL, and presented by University of Chicago Medicine. For information on upcoming CME activities from this presenter, please visit cme.uchicago.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

GE372203

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.