Gluten-Related Disorders and Gluten Free Diet Plan

Assessment and Plan: Gluten and Gluten-related disorder

• The incidence of gluten-related disorders including celiac disease is on the rise and should be included as a possible cause of a chronic gastrointestinal condition or extraintestinal condition. Proper diagnosis may be complicated and is best accomplished by the primary care physician and gastroenterologist.

• Gluten-related disorder signs and symptoms:
  • In those with a gluten related disorder, gluten causes inflammation and antibody production in the bowels which results in diarrhea and poor absorption of nutrients. Gluten disorder symptoms can be severe with diarrhea and weight loss, or mild with nausea, abdominal pain and bloating.
  • Gastrointestinal signs and symptoms: diarrhea, constipation, abdominal bloating, malodorous stool, abdominal pain, tongue soreness, burning, redness or atrophy, elevated liver function tests, microscopic colitis, pancreatic exocrine dysfunction
  • Extraintestinal signs and symptoms: bone demineralization, osteoporosis, joint pains, weight gain, weight loss, enamel defects, apthous stomatitis, lower birth weights, poor childhood weight gain, hypocalcemia, fatigue, weakness, dry skin, blistering rash, eczema, iron deficiency anemia, infertility, depression, neuropathy or numbness of the extremities, cerebellar ataxia, epilepsy, dementia, and headaches.

• Gluten-related disorder screening and diagnosis:
  • According to Rubio-Tapia A et al, the following patients should be evaluated for celiac disease (4):
    • Signs, symptoms, or lab testing showing evidence of malabsorption.
    • Signs, symptoms, or lab testing concerning for celiac disease who are candidates for treatment once diagnosed.
    • Signs, symptoms, or lab testing concerning for celiac disease who have a first degree relative with the condition.
    • It may be appropriate to screen patients without any symptoms who have a first degree relative with celiac disease.
    • Unknown cause of elevated liver function tests should be evaluated for celiac disease.
    • Diabetes mellitus type 1 patients with gastrointestinal signs, symptoms, or lab testing concerning for celiac disease.
  • Diagnosis of celiac disease:
    • Celiac disease may have non-specific symptoms, which requires a diagnostic approach to distinguish it from other gastrointestinal conditions. This is best accomplished by a primary care physician and gastroenterologist. Testing should ideally be done while on a diet containing gluten.
    • The initial test is immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody in patients over 2 years old. If this serology is positive, the patient should proceed to an endoscopic small bowel biopsy of the duodenum. Genetic testing is also available which determines susceptibility of the patient to celiac disease.
    • Additional testing of routine complete blood count may show anemia and nutrient testing might reveal vitamin and mineral deficiencies. Basic metabolic panel may show electrolyte abnormalities related to malabsorption. Liver function tests may be elevated.
  • Genetic test for celiac disease:
    • Genetic testing for risk of celiac disease may be done once in a persons lifetime using blood or a swab from the inside of the cheek. About 95% of individuals with celiac disease have the HLA DQ2 gene and about 5% of individuals with celiac disease have the HLA DQ8 gene. These 2 genes are present in up to 40% of the population. However, only 3% of these individuals with the genes will develop celiac disease. If the individual does not have these genes, celiac disease is extremely unlikely.

• Disorders affected by gluten:
  • Autism and a gluten-free diet:
    • Diets free of gluten and casein have some evidence of benefit in autism. Research suggests that abnormal levels of peptides by excessive opioid activity caused by the ingestion of gluten and casein may play a role in autism.
    • In as little as 2 weeks, autistic children changed to a gluten-free diet have shown improvements in social isolation, eye contact, speech, learning skills, hyperactivity, stereotypical activity, panic attacks, self-mutilation, total autistic trait score (measured by the Diagnosis of Psychotic Behavior in Children [DIPAB]), nonverbal communication, stereotypy, social interactions, normalizing of behavior, language skills after 1 year, language skills after 4 years, social interaction, play based creativity, motor abilities, decrease in urine peptide levels (UPL), decrease in urinary metal concentrations, and behavioral improvements (6).
    • A Cochrane Database Systematic Review described research showing a reduction of autistic traits, but a benefit in cognitive skills, linguistic ability and motor ability was not seen (8). Additional research showed that only parents saw some improvement of symptoms by their children on this diet. (7)
  • Schizophrenia and gluten: Some schizophrenia patients have improvement of symptoms on a gluten-free diet. Cascella, NG et al found that testing for a specific type of transglutaminase autoantibody may be useful to identify patients who might respond (10).
  • Gluten and bone mineral density:
    • All patients with celiac disease should undergo bone mineral density scans.
    • Osteoporosis appears to occur early in the course of celiac disease, and patients without symptoms at the time of diagnosis had a bone mineral density of over 1 standard deviation below normal (12).
  • Gluten and tooth enamel defects: Dentists have an important role in identifying patients with celiac disease.
    • Enamel defects may be the only sign of celiac disease and are found in about 85% of patients with celiac disease at the time of diagnosis (13).
    • Children with enamel defects should be screened for celiac disease, especially if hypocalcemia and poor weight gain is present (14).
  • Gluten and recurrent apthous stomatitis: A high rate of patients with recurrent apthous stomatitis and celiac disease respond well to treatment with a gluten-free diet. These patients with recurrent apthous stomatitis should be screened for celiac disease (15).
  • Gluten and depression:
    • Patients who self-reported non-celiac gluten sensitivity given a short term challenge with 16 grams of gluten, 16 grams of whey protein, or placebo daily for 3 days found that gluten induced feelings of depression compared to whey or placebo (16).
    • Celiac disease patients with a better adherence to a gluten-free diet over the long term had a lower risk of developing symptoms of depression (17).

• The dillemma of diagnosing gluten related disorders
  • Gluten antibody testing, this will help diagnose gluten related disorder if symptoms are related to gluten. If gluten disorder is present, the symptoms will get better with eliminating all sources of gluten. One can consider eliminating gluten to see if symptoms get better. However, if this testing is done after eliminating gluten, the antibody levels will decrease and the test will not be accurate.

• Eating a gluten-free diet plan for gluten-related disorders:
  • Even small amounts over 1-2 grams of residual gluten in the diet are known to contribute to the celiac disease processv(inflammation due to gluten). Gluten sensitive individuals are able to tolerate up to 5 grams of gluten without symptoms of sensitivity. The general guideline is that anything containing wheat contains gluten.
  • Dietary counseling is based on support of the patient in the major lifestyle change of a gluten-free diet for life best accomplished by a qualified dietitian.
  • Education is necessary to avoid all foods containing wheat, rye, barley (including all types of beer), and oats. Avoid these gluten containing foods.
  • Distilled alcohol beverages and wine are generally free of gluten.
  • Gluten containing foods should be substituted with the following gluten free foods (Yes, these foods are OK to eat):
    • Grains including rice, corn, quinoa, soy, and buckwheat
    • Acceptable flours include tapioca, rice, potato, corn, and coconut
    • Meats without coatings or additives which include beef, bacon, pork, chicken, and turkey.
    • Fish and shellfish without coatings or additives.
    • Fresh or frozen fruit without additives.
    • Nuts and seeds
    • Vegetables, beans, herbs, spices, and coconut.
    • Gluten free pasta is available containing rice, quinoa, and corn
  • Pay special attention to labels for retail and processed foods and avoid those with labels which include gluten, wheat protein, and vital wheat protein as ingredients.
  • Oat consumption is controversial, with research showing that oats may provoke gluten related disorder, while other research has supported oats as generally safe to consume