Educating Patients About Risk of Celiac Disease Nutritional Deficiencies While on Gluten-Free Diet
Celiac disease and gluten sensitivity are so well-known—and gluten-free products have become so widely available—that vast numbers of people decide to follow the diet without seeking a diagnosis. This decision seems harmless, but it could have unexpected long-term consequences in the form of nutritional deficiencies and comorbidities.
Pharmacists need a working knowledge of the nutritional risks faced by patients following a gluten-free diet—risks that arise whether or not they have celiac disease. You can use this information to protect patients’ health and to raise awareness, which in turn brings your services and supplemental products you may carry into the limelight.
Celiac Disease vs Non-Celiac Gluten Sensitivity vs Wheat Allergy
When counseling patients about gluten-free diets, you’ll need to know the differences between the three clinical conditions associated with gluten ingestion:1
- Autoimmune disorder triggered by gluten, which consists of gliadin and glutenin proteins found in wheat, rye, barley and crossbreed grains like triticale.
- Gluten causes intestinal inflammation, leading to verifiable damage of the villi.
- Genetic predisposition—strong association with HLA class II genes.2
- Symptoms may be intestinal or extraintestinal and range from asymptomatic to severe:3
- Classic GI symptoms – abdominal pain, diarrhea, constipation, bloating
- Extraintestinal symptoms – joint pain, skin rash, fatigue, foggy brain, anemia, depression, peripheral neuropathy and hormonal disorders (to name just a few)
- Children – Present with classic GI symptoms, growth problems and failure to thrive, but up to 61 percent of children only have musculoskeletal symptoms such as delayed teething, osteopenia and arthritis.
- Adults – Most common sign is iron deficiency anemia that doesn’t respond to iron therapy.
- Immunoglobulin E-mediated entity triggered by wheat proteins—gluten is only one type of protein in wheat.
- Symptom onset within minutes to several hours.
- Mild to severe symptoms – rashes, hives, itching, swelling, trouble breathing, loss of consciousness, anaphylaxis.
Non-celiac gluten sensitivity:
- Pathogenesis and epidemiology unknown—no known association with HLA genes
- No intestinal damage on endoscopy or histology.
- Symptoms – same as celiac disease.
- Diagnosis currently based on ruling out celiac disease and wheat allergy while establishing cause-effect relationship between gluten consumption and symptoms.4
- Emerging research suggests involvement of wheat-based proteins called amylase-trypsin inhibitors (ATIs), which make up about 4 percent of wheat proteins and can trigger immune responses in the gut.5
The Scoop on Mandatory and Voluntary Gluten-Free Diets
Until medical therapy is available, there’s only one treatment for celiac disease: patients must avoid all sources of gluten because it only takes a miniscule amount to trigger damaging inflammation. Patients with a wheat allergy must avoid all forms of wheat, which may be stricter than a gluten-free diet.
People with non-celiac gluten sensitivity need to avoid gluten and/or ATIs, which are found in the same foods. Some researchers have suggested that “non-celiac gluten sensitivity” may actually be caused by poorly absorbed carbohydrates known as FODMAPs—fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. For now, advise patients that much research must be done before they’ll have solid answers about gluten sensitivity.
People who choose to follow a gluten-free diet without a medical diagnosis may be trying to relieve symptoms similar to celiac disease. The diet may help them feel better, but that relief comes at the risk of masking underlying disease, which increases their chance for developing celiac-related comorbidities such as autoimmune disease, osteoporosis, and liver disorders.
About half of voluntary gluten-free followers believe it’s healthier than a standard diet. Some use it for weight loss, even though gluten-free products have the same—and often more—calories. Others hope it will improve energy and performance. However, the only proof of such benefits comes by word-of-mouth from diet followers and from the testimony of athletes and celebrities.
A few statistics demonstrate just how popular the gluten-free diet has become:6
- Prevalence of celiac disease is estimated to be 1 percent.
- Prevalence of celiac disease has remained stable—the number of people following a gluten-free diet has more than tripled.
- 1 in 5 Americans have eliminated or reduced gluten in their diet.
- 10 years ago there were no commercially produced gluten-free products available—in 2015 gluten-free products sold in conventional grocery stores accounted for $2.79 billion in sales in the US.7
Nutrient Shortages at Time of Celiac Diagnosis
Since intestinal damage results in malabsorption, patients with celiac disease often have nutritional deficiencies at the time of diagnosis. The nutrients most affected by celiac disease before the start of a gluten-free diet include:8
- Iron – About half of newly diagnosed celiac patients have iron-deficiency anemia.
- Calcium – Is poorly absorbed in untreated celiac disease, leading to osteopenia and osteoporosis.
- Zinc – As many as 67 percent of adult patients are low in zinc.
- Folic acid – 20 percent of patients have a deficiency in folic acid.
- Vitamin B12 – 19 percent have low stores of vitamin B12.
- Vitamin B6 – Nearly 15 percent are low in B6.
- Vitamin A – About 7.5 percent had deficient levels of vitamin A.
Nutritional Deficiencies During a Gluten-Free Diet
The potential for nutrient deficiencies due to a gluten-free diet will be news for many of your patients. The actual risk they face depends on their overall diet and the gluten-free products they choose. Gluten-free alternatives mix various combinations of ingredients in an effort to develop end products with similar texture and taste to their wheat-based counterparts. The amount of each ingredient used in the mix determines nutritional quality.
Some of the most common alternative ingredients include white rice flour, brown rice flour, sorghum flour, millet flour, tapioca starch, potato starch and a variety of bean flours. Brown rice flour has about the same nutrients as whole-wheat flour; by comparison, white rice flour (a favorite due to its texture and mild flavor) has two to five times less. Bean flours have a better nutrient profile, but their unique flavors often need to be diluted so they may represent a small percentage of the overall mix.
Commercially prepared gluten-free products generally contain less iron, folate, and other B vitamins.9 They’re also not consistently enriched or fortified, which is why processed wheat flour is higher in nutrients. Adults following a gluten-free diet typically lack the following nutrients:
- Vitamin D
- Vitamin B12
A well-planned diet that includes whole foods naturally free of gluten—chicken, fish, meat, vegetables, and fruits—and nutrient-rich pseudograins such as amaranth and quinoa can prevent nutrient deficiencies, but many patients may need to consider supplements to fill in any gaps.
Pharmacist Intervention Improves Nutritional Status
Whether the diet is voluntary or mandatory, people tend to focus on the gluten content of foods; they often don’t realize that they also need to focus on nutrients and that gluten-free doesn’t automatically provide a better-balanced diet. Don’t hesitate to set-up an educational display in your pharmacy and, if you don’t already offer supplements, consider stocking high-quality brands to fill the needs of a gluten-free diet. Even if you’re not comfortable giving nutritional advice, you can raise awareness and recommend that patients consult a registered dietitian. Any intervention you offer stands to improve the nutritional status and overall health of customers and patients on a gluten-free diet.
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- “Taking the Temperature of Celiac Disease,” November 2016, http://www.gastroendonews.com/Expert-Roundtable/Article/10-16/Taking-the-Temperature-of-Celiac-Disease/38126 ↩
- “Genetics of Celiac Disease,” November 2016, http://emedicine.medscape.com/article/1790189-overview ↩
- “Symptoms of Celiac Disease,” accessed December 2016, http://www.cureceliacdisease.org/symptoms/ ↩
- “Medication and Supplement Use in Celiac Disease,” December 2014, https://www.uspharmacist.com/article/medication-and-supplement-use-in-celiac-disease ↩
- “New Study Links Protein in Wheat to the Inflammation of Chronic Health Conditions,” October 2016, https://www.ueg.eu/press/releases/ueg-press-release/article/new-study-links-protein-in-wheat-to-the-inflammation-of-chronic-health-conditions/ ↩
- “The Most Popular Diet Ever: Why Going Gluten-Free is Risky,” November 2016, http://www.medscape.com/viewarticle/870954#vp_1 ↩
- “Statistics and Facts on the Gluten-Free Foods Market in the United States,” accessed December 2016, https://www.statista.com/topics/2067/gluten-free-foods-market/ ↩
- “Vitamin and Mineral Deficiencies Are Highly Prevalent in Newly Diagnosed Celiac Disease Patients,” October 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3820055/ ↩
- “Gluten-Free Diet in Children: An Approach to a Nutritionally Adequate and Balanced Diet,” November 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3847748/ ↩