The only treatment for celiac disease, at present, is a strictly gluten-free diet for life. No foods or medications containing gluten from wheat, rye, or barley or their derivatives can be taken, as even small quantities of gluten may be harmful.
- Removal of gluten (with a reduction to below 20 mg gluten intake per day) from the diet of celiac disease patients will result in symptomatic, serologic, and histological remission in most patients.
- Approximately 70% of patients report an improvement in symptoms within 2 weeks of starting the gluten-free diet.
- Growth and development in children return to normal with adherence to a gluten-free diet. Many complications of the disease are preventable with a gluten-free diet.
- With strict dietary adherence, the titer of celiac disease–specific antibodies normalizes.
- Although the villous changes start to improve within months after the start of a gluten-free diet, complete histological resolution may take years and may not be achieved in every patient.
- There is evidence that a lack of histological resolution may be dependent on persistent consumption of gluten.
The safe limit of gluten intake varies from patient to patient and has been considered to be 10–100 mg/day, although a subsequent study indicated that the upper limit should be no more than 50 mg/day.
Gluten-free diet. Not allowed in a gluten-free diet.
Grains, starches, and flours not permitted in a gluten-free diet:
- Durum flour
- Einkorn (Triticum monococcum)*
- Emmer (Triticum dicoccum)*
- Kamut™ (Khorasan wheat)*
- Any item with wheat, barley, or rye in its name
* Varieties of wheat
- Malt, malt extract, malt flavoring, malt syrup
- Oats, oat bran, oat syrup — not labeled as gluten-free
- Gluten, gluten flour
- Graham flour
- Semolina (durum wheat)*
- Spelt (dinkel wheat, Triticum spelta)
- Wheat germ, wheat starch, wheat bran
Pure oats free of contamination are available in some countries, and these are allowed in certain quantities. Although many studies have indicated that a moderate amount of oats can safety be eaten by patients with celiac disease, there are concerns regarding the contamination of oats with wheat and barley during processing.
Allowed in a gluten-free diet.
Gluten-free grains, flours, and starches that are allowed in a gluten-free diet:
- Bean flours
- Garbanzo beans
- Montina flour (Indian rice grass)
- Nut flour and nut meals
- Oats (uncontaminated, labeled as gluten-free)
- Potato flour, potato starch
- Rice, all forms (brown, white, sweet, wild, jasmine, basmati, glutinous rice, polished rice, rice bran)
- Sorghum flour
- Soy flour
- Teff flour
Although these gluten-free grains, flours, and starches are allowed in a GFD, there are concerns regarding cross-contamination with wheat and barley. Starches and flours should therefore be analyzed for gluten content before permitted use in diets for celiac disease patients. Some countries periodically publish updated lists of gluten-free products on the Internet. Foods on the list have been analyzed for gluten content.
Other foods for a basic gluten-free diet.
- All fresh meats and gluten-free preserved meat
- Legumes: lentils, chickpeas (garbanzo beans), peas, beans, nuts, seeds —packaged, not loose
- Fruits (fresh, frozen, canned) and plain fruit juices
- Vegetables (fresh, frozen, canned) and plain vegetable juices
- Liquid vegetable oils
Miscellaneous items allowed in a gluten-free diet.
Sweets: honey, corn syrup, sugar (brown and white)
Snack foods: plain popcorn, nuts, plain pickles, olives, gluten-free potato chips (potato crisps)
Condiments: natural herbs, pure black pepper, vinegars (apple, grape, or wine)
Cooking and food preparation: patients should be instructed not to contaminate gluten-free food — e.g., using separate cooking utensils, cooking surfaces, and toasters.
The majority of industrially produced foods contain nonallowable ingredients — attention to labeling is important, and available lists should be checked for allowable foodstuffs. It is very important to access a support group.
A gluten-free diet is low in fiber.
Patients should be advised to eat a high-fiber diet supplemented with whole-grain rice, maize, potatoes, and ample vegetables. Any dietary deficiencies such as iron, folic acid, calcium and (very rarely) vitamin B12 should be corrected.
- Assess the patient’s current nutritional status.
- Identify macronutrient and/or micronutrient intake and detect deficiencies and/or excesses. It is important that patients with celiac disease consume a well-balanced diet including vitamins, calcium, and fibers, with specialist consultation.
- Analyze eating habits and potential factors affecting access to the diet.
- Provide information and initiate the gluten-free diet.
- Provide dietary education.
- Monitor and evaluate dietary compliance and reinforce alimentary counseling.
Patients who are unable to adhere to the diet may require support with psychological counseling.
Source: World Gastroenterology Organisation Global Guidelines Celiac Disease/ 2016.