Download Nutritional Management of the Gluten-Free Diet

Weighing in on the
Gluten-Free Diet
Melinda Dennis, MS, RDN
Nutrition Coordinator, Celiac Center
Beth Israel Deaconess Medical Center
Boston MA, USA
www.celiacnow.org
Disclosures
Co-author of Real Life with Celiac Disease:
Troubleshooting and Thriving Gluten-Free. AGA Press, 2010.
www.RealLifewithCeliacDisease.com
Today’s Objectives
 Review how celiac disease (CD) and the quality of the
gluten-free diet (GFD) impact nutritional status
 Review general healthy dietary advice for the GFD
 Specify recommended nutritional management of the
patient with CD
Initiation and lifelong
maintenance of the GFD
remains the cornerstone
of therapy in CD.
CD’s Impact on Health
Severity of nutritional deficiency is affected
by at least 5 factors1
 Length of time with active, undiagnosed
CD1,2
 Extent and location of damage1,2
 Degree of malabsorption of nutrients1,2
 Medications that block absorption or
increase demand of nutrients
 Quality of GFD
1. Saturni. Nutrients 2010; 2. Garcia-Manzanares. Nutr Clin Prac 2011
Newly Diagnosed: Vitamin & Mineral
Deficiencies and Weight Concerns
• 80 newly diagnosed CD adult patients (42.8 +/- 15.1 years)
• 24 healthy Dutch controls
Vitamin A: 7.5%
46% decreased iron stores
Vitamin B6: 14.5%
32% anemia
Folic acid: 20%
17% malnourished
Vitamin B12: 19%
22% women underweight
Zinc: 67%
29% men & women overweight
• Vitamin deficiencies were barely seen in healthy controls w/ exception of Vitamin
B12.
Wierdsma. Nutrients Oct 2013
Vitamin & Mineral Deficiencies in
CD and GFD
Low in Blood Work AND Diet
Additionally Low in Diet
 Iron (Ferritin in blood work)
 Phosphorus
 Vitamin D
 Fiber
 B vitamins
 Calcium, Magnesium
 Zinc
Saturni. Nutrients 2010; Theethira Expert Rev Gastroenterol Hepatol 2014; Barton. Gastroenterol Clin N Am
2007; Dahele Am J Gastroenterol 2001; Halfdanarson Blood 2007; Tikkakoski Scand J Gastroenterol 2007;
Chakravarthi Indian J Gastroenterol 2012; Lerner. Clin Rev Allergy Immunol 2012; See. Nutr Clin Prac 2006;
ADA (now Academy of Nutrition and Dietetics[AND]) Evidence Analysis Library: Celiac Disease 2011; Thompson. J Hum
Dietet 2005; Hallert. Aliment Pharmacol Ther 2002; Thompson. JADA (now AND) 1999. Garcia Manzanares. Nutr Clin Prac
2011
Imbalance of the GFD
 “Following a diet based on gluten-free products could
suppose a nutritional imbalance for celiac patients as well as
non celiac patients who follow a diet that includes many
gluten-free related foodstuffs.”(1)
for special medical purposes should
 “Foods
contain nutrients at the levels found in the
foods they are intended to replace.”(2)
1. Miranda. Plant Foods Hum Nutr 2014
2. Pelligrini J Sci Food Agric 2015
Nutritional Quality of the GFD
Study Team
Conclusions
Lee, 2009
US
38% meals/snacks had no grain; (rice 44%) Adding
whole GF grains improved protein, iron, calcium and
fiber content
Kinsey, 2007
UK
Patients w/ CD consumed less calcium, vitamin D,
calories, fat, and fiber than recommended, and more
protein
Thompson, 2005
US
Women meeting needs: 46% fiber; 21% grains; 31%
calcium; 44% iron
Men: 88% fiber; 63% grains; 63% calcium; 100% iron
Hallert, 2002
Sweden
Daily intakes of folate and vitamin B-12 were lower in
patients with CD; some nutritional deficiencies have
been seen after treatment with the GFD for ~10 years
Hopman, 2006
Netherlands
Lower fiber and iron intake and higher saturated fat
intake than recommended but comparable to general
population
Negative Factors Affecting
Quality of GF Products
STARCHES
KEY NUTRIENTS
FAT, TRANS FAT
FIBER
CALORIES
ENRICHED/FORTIFIED
SUGAR
PRODUCTS
COST
Miranda. Plant Foods Hum Nutr 2014; Kupper Gastroenterol 2005; Thompson. J Hum Nutr Dietet
2005; Lee. J Hum Nutr Diet 2009;Thompson J Am Diet Assoc (now AND) 2000; Shepherd J Hum
Nutr Diet 2012; Pelligrini J Sci Food Agric 2015
Comparison of GF and
Gluten-Containing Flours
White
Rice
Flour
Tapioca
Starch
Cornstarch Potato
Starch
Enriched
White
Flour
Whole
Wheat
Flour
Protein (g)
9.4
0
0.3
0.2
12.9
15.9
Fiber (g)
3.8
0
1.2
0
3.4
12.8
Carbohydrate
(g)
127
106
117
158
95
86
Iron (mg)
0.6
0
0.6
2.9
5.8
4.3
Calcium (mg)
16
28
3
19
19
41
Zinc (mg)
1.3
N/A
0.1
N/A
0.9
3.1
Magnesium
(mg)
55
N/A
4
N/A
28
164
Thiamin (mg)
0.22
N/A
0
0
0.98
0.6
Riboflavin (mg)
0.03
N/A
0
0
0.62
0.2
Folate (mcg)
6
N/A
0
N/A
364
53
Courtesy of: Gluten-Free Diet: The Definitive Resource Guide by Shelley Case, RD, 2015 (in press).
Weight of Patients with CD at
Diagnosis
 About one-half of the adult population in western countries
is overweight or obese.
 Mean body mass index is increasing.
 Similar trend in CD
 4-5% underweight
 40% overweight at diagnosis
 Obesity is increasingly seen as part of the initial presentation
of CD.
Ukkola. Eur J Int Med 2012; Tucker. J Gastrointesin Live Dis 2012; Dickey. Am J Gastroenterol 2006;
Sonti et al Gastro and Hepatology 2012
Effect of GFD on BMI on Patients with
Newly Diagnosed CD
Country
Subjects
Results
Ireland
Dickey, 2006
371 patients; BMI at diagnosis
and 2 years later
81% gained weight after 2 years
(including 82% of initially
overweight patients)
United States
Cheng, 2010
369 patients; BMI at diagnosis
and after 2.8 years
66% of underweight gained
weight; 54% of overweight and
47% obese lost weight; GFD had
beneficial effect on BMI
United States
Kabbani, 2012
679 patients; BMI at diagnosis
and after almost 3 years
21% normal or high BMI at
study entry rose by 2 points
(15.8% moved from normal or
low BMI to overweight; 22%
overweight at diagnosis gained
weight); majority remained in
same BMI category
Finland
Ukkola, 2012
698 patients; BMI at diagnosis
and 1 year later
BMI improved similarly in
screen and symptom detected
patients on GFD;
overweight/obese lost and
underweight gained
Weight Gain on the GFD
Overall, patients with CD on a GF diet tend to gain weight.
 A few theories:
 Symptom resolution PLUS better absorption of food with SAME




caloric intake = WEIGHT GAIN
Used to eating large portions of food
GF diet is NOT inherently healthy
Whole healthcare team needs to address risk of weight gain
Dietitian: diet and lifestyle (exercise) counseling
Sonti Gastro Hepatol 2012; Kabbani Aliment Pharmacol 2012;
See. Nutr Clin Prac 2006; Tucker Gastrointestin Live Dis 2012; Dickey Am J
Gastroenterol 2006; Valletta Eur J Clin Nutr 2010
Key Elements in the Management
of CD
 Consultation with a skilled dietitian
 Education about the disease
 Lifelong adherence to a gluten-free diet
 Identification and treatment of nutritional deficiencies
 Access to an advocacy group
 Continuous long-term follow-up by a multidisciplinary team
NIH Consensus Development Conference on Celiac Disease, 2004
Enhancing Nutrition of the
GFD



Select naturally GF foods.
Emphasize the quality of the GFD (especially for women) as it concerns
FIBER, IRON, and CALCIUM.
Consume whole or enriched LABELED gluten-free grains and products
such as brown rice, wild rice, buckwheat, quinoa, amaranth, millet,
sorghum, teff, etc.




Choose 6-11 servings (depending on calories) of GF grain foods daily,
especially whole or enriched.
At least half of the grain servings each day should come from whole grain
sources.
3 servings/day (oats, brown rice, quinoa) positively impacts the nutrient
profile (fiber, thiamin, riboflavin, niacin, folate and iron) of the grain portion
of the diet and is less costly.
Select enriched/fortified GF products, (especially B vitamins thiamin, riboflavin and niacin) during pregnancy and lactation.
Penagini Nutrients 2013; Thompson JADA (now AND) 1999; Shepherd JHND 2012; Thompson JADA (now AND)
2000; Lee JHND 2009. American Diet Assoc (now AND) EAL Celiac Disease Toolkit 2011. USDA Dietary
Guidelines for Americans 2010
Gluten-Free Whole Pseudo/Grains,
Seeds & Legumes
GRAINS/SEEDS
BEANS & LEGUMES
Amaranth
Black Beans
Buckwheat
Edamame (fresh soybeans in pod)
Brown rice
Garbanzo beans (chickpeas)
Corn
Lentils
Flax seed
Lima beans
Millet
Peas
Oats (specially labeled gluten-free)
Pinto beans
Popcorn
Soybeans
Quinoa
Kidney beans
Sorghum
Black-eyed peas
Teff
Butter beans
Wild rice
Adapted with permission: Higgins, L. Whole Grains=Nutritional Gold. In Real Life with
Celiac Disease. Dennis, M, Leffler D., eds. AGA Press, Bethesda, MD, 2010.
Specific Nutrient Content of
Whole GF Pseudo/Grains
Flours
Fiber (gm)
Folate (mcg)
Calcium (mg)
Iron (mg)
Amaranth
12.9
158
307
14.69
Buckwheat
groats
16.9
69
28
4.05
Millet
17.0
170
16
6.02
Quinoa
11.9
313
80
7.77
Sorghum
12.1
38
54
8.45
Wheat flour,
whole-grain
14.6
53
41
4.66
245
422
5.84
Wheat flour,
3.4
white enriched
USDA National Nutrient Database, http://www.nal.usda.gov/fnic/foodcomp/search/index.html
B Vitamins Content of
Whole GF Pseudo/Grains
Flours
Thiamine (B1)
(mg)
Riboflavin (B2) Niacin (B3)
(mg)
(mg)
B6 (mg)
Amaranth
0.22
0.39
1.78
1.14
Buckwheat
groats
0.37
0.44
8.42
0.579
Millet
0.84
0.58
9.44
0.77
Quinoa
0.62
0.54
2.58
0.88
Sorghum
0.46
0.27
5.6
1.13
Teff
0.75
0.52
6.49
0.93
Wheat flour,
whole-grain
0.54
0.26
7.6
0.41
Wheat flour,
0.84
white enriched
0.52
7.3
0.06
USDA National Nutrient Database,
http://www.nal.usda.gov/fnic/foodcomp/search/index.html
Gluten Contamination of Grains, Seeds,
and Flours in the U.S: A Pilot Study
 22 inherently gluten-free
grains, seeds, and flours
not labeled GF were
analyzed for gluten
 Samples were
homogenized and tested
in duplicate using R5 ELISA
assay
22 Samples
13 (59%)
Contained <5 ppm
2 (9%)
Contained mean
levels (8.5-<20
ppm)
7 (32%)
Contained mean
levels ≥20 ppm
Thompson T, Lee A, Grace T. JADA (now AND), 2010. Study
funded in part by Schar USA.
Enhancing Nutrition of the GFD
(cont’d)
 Base daily energy requirements on age, gender, and physical activity.
 Increase NON-grain food sources of iron & B vitamins (folic acid),
particularly for pregnant and nursing females, children and adolescents.
 Select 3 servings/day (varies by need) of lowfat or nonfat dairy, or
calcium and vitamin D fortified, non-dairy foods.
 Limit total fat to 20-35% (variable); sat fat to <10% and trans fat limited
to <1% (as little as possible) of total daily caloric intake*
 Take GF vitamin/mineral, iron, calcium and vitamin D supplements, as
recommended.
 Pay special attention to GF labeling in your country or when traveling
abroad.
Penagini Nutrients 2013; Thompson 2005; Thompson JADA (now AND)2000; See.
Nutr Clin Prac 2006.; * USDA Dietary Guidelines for Americans 2010
Calcium/Vitamin D for Reduced
Bone Density
“For adults with reduced bone density or reduced serum levels
of 25 OHD, the RD should advise the consumption of additional
calcium and vitamin D through food or gluten-free
supplements. Studies in adults with untreated celiac disease
have shown that a gluten-free dietary pattern improves, but
may not normalize bone density. [Strong, conditional]”
American Dietetic Assoc (now AND). Evidence Analysis Library Celiac
Disease Toolkit, 2011
Multivitamin/Mineral
Recommendation
“If usual food intake shows nutritional inadequacies that
cannot be alleviated through improved eating habits, the
dietitian should advise individuals with CD to consume a daily
gluten-free age- and sex-specific multivitamin/mineral
supplement. [Strong, conditional]”
American Dietetic Assoc. (now AND) Evidence Analysis Library Celiac Disease Toolkit, 2011;
Kupper. Gastroenterol 2005; Thompson JHND 2005
Recommended CD Labs
 CBC (hemoglobin,
hematocrit, etc.)
 25 OH Vitamin D
 Vitamin B12
 Folate (regional)
 Iron and Ferritin
 Zinc
As Needed
Calcium,
Magnesium,
PTH
Fat soluble
vitamins: A, E, K
Folate
Lipids
Other B vitamins
Selenium,
Copper
 IgA-TTG and/or DGP
 TSH
Courtesy of Celiac Center, Beth Israel Deaconess Medical Center, Boston MA 2015
Recommended Nutritional
Management of CD in Adults
Nutrient
Epidemiology
Testing Recs
Treatment Recs
Iron
Deficiency in 28-50%
patients at diagnosis;
one of the most
common
extraintestinal
manifestations
Serum iron and
ferritin at diagnosis;
repeat every 3-6
months until ferritin
normal; then every 12 yrs or for symptoms
Iron (325mg) 1-3
tablets based on
initial ferritin until
iron restored; IV iron
for severe
symptomatic iron
deficiency anemia or
intolerance of oral
iron
Vitamin D
Low levels in 20-66%
patients at diagnosis,
even in high sunshine
areas
25 OHD level at
diagnosis; every 3
mos until normal;
every 1-2 yrs or for
symptoms
1000IU or more/day
based on 25 OHD
level; 50,000IU/week
if levels <20ng/mL
Folic acid
Deficiency in 18-42%
patients at diagnosis;
deficiency rare in No.
America
Serum folate at
diagnosis in at-risk;
check all women
planning pregnancy
Folic acid 1mg/day x 3
months; once
diarrhea improves
400-800mcg/day
Theethira. Expert Rev Gastroenterol Hepatol 2014
Recommended Nutritional
Management of CD in Adults
Nutrient
Epidemiology
Testing Recs
Treatment Recs
Vitamin B12
Deficiency 8-41% in
patients at diagnosis;
suspected secondary to
SIBO
Serum B12 at diagnosis;
then every 1-2 yrs or for
symptoms
1000mcg orally until
normal; then daily
multivitamin/mineral
(MVM)
Zinc
Deficiency in 54-67%
patients at diagnosis;
most commonly
deficient trace mineral
Serum zinc at diagnosis; Zinc supplement 25repeat every 3 mos until 40mg/day until normal;
normal; every 1-2 yrs or then MVM
for symptoms
Calcium
>50% patients consume
less than RDI of calcium
Regular dietary
assessment by RD
1200-1500mg/day*
[* Depends on
individual]
Dietary Fiber
Deficient intake of GFD
causes constipation;
deficiency in both
genders in Europe and
US
Regular dietary
assessment by RD
25-35g/day based on
age and gender;
encourage “alternative
grains” w/ high fiber
and adequate water
MONITOR for overdosing of iron, calcium, vit D, B3, B6, and fat soluble
vitamins.
Theethira. Expert Rev Gastroenterol Hepatol 2014
Recommended CD Post-diagnosis
Follow-up with a Registered Dietitian
Nutritionist (RDN)
 Visit #1 (45-90 minutes)
 Visit #2 (45-90 minutes) 2- 4 weeks later
 Visit #3 (30-45 minutes) 6 months after diagnosis
 Annually thereafter
 Varies widely across the country;
dependent on many factors
Celiac Disease Toolkit. American Dietetics Association (now AND), 2011
Heal and Support the Gut
Eat whole,
unprocessed
food as much
as possible.
EAT
GLUTEN
FREE.
Prioritize
exercise &
social
connections.
.
Space regular
meals and
snacks.
Drink
fresh
water.
Take
appropriate
GF
supplements,
as directed by
healthcare
provider.
Summary
The GF population needs more foods…
 High in fiber, B vitamins, iron
 Nutrient rich
 Low in added sugar
 Uncontaminated by gluten
 Naturally low in fat & sodium
 Reasonably priced
 And free of major allergens
Academy of Nutrition and
Dietetics (AND) -Resources
 Medical Nutrition Practice Group; Dietitians in Gluten
Intolerance Diseases (DIGID): www.mnpgdpg.org
 Evidence Analysis Library (EAL) on CD:
www.adaevidencelibrary.com
 Celiac Disease Toolkit: Companion to AND’s Evidence-Based
Nutrition Practice Guideline
 Coming Soon! Online Certificate of Training from the Center
for Professional Development:
Treating Gluten Related Disorders