|
 
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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 1
| Issue : 1 | Page : 3-6 |
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Diet in celiac disease
Swapan Kumar Paul1, Amrita Ghosh2, Ranabir Pal1, Shrayan Pal3
1 Department of Community Medicine, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
2 Department of Biochemistry, Medical College, Kolkata, West Bengal, India
3 Department of Dermatology Venereology and Leprosy, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
| Date of Submission | 23-Nov-2020 |
| Date of Acceptance | 09-Dec-2020 |
| Date of Web Publication | 31-Dec-2020 |
Correspondence Address:
Dr. Swapan Kumar Paul
Assistant Professor, Department of Community Medicine, MGM Medical College and LSK Hospital Kishanganj Bihar
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jascp.jascp_6_20
Celiac disease is an autoimmune disease triggered by presence of gluten in diet which precipitates symptomsof celiac disease causing malnutrition. A narrative review on diet in Celiac diseasewas taken up, which was very much required for health care providers in day-to-day clinical care. Thirty six research studies were identified from 105 potentially relevant articles. Studies were selected on: firstly; all protocols of celiac disease among published literature were meticulously searched. Secondly, nutritional considerations about celiac disease were explored from relevant articles, Thirdly, published reports from apex bodies of global importance like World Health Organization (WHO), Centre for disease control (CDC), Atlanta USA and others were given due weightage for their multi-authored authenticity. In this review the correlation between celiac disease and gluten free diets have been discussed with prognosis, complications, and clinical outcomes of patients reported by different research groups. In spite of substantial growth in healthcare, no researchers have yet suggested any other management except elimination of gluten from diet of celiac disease cases. Though there is abundant literature on celiac disease about its aetiology, signs and symptoms and diet models, there is no specific treatment and management protocol available, other than gluten free diet. Researchers have to do further studies to suggest treatment modalities.
Keywords: Celiac disease, compliance, diet
How to cite this article:
Paul SK, Ghosh A, Pal R, Pal S. Diet in celiac disease. J Appl Sci Clin Pract 2020;1:3-6 |
| Introduction | |  |
Celiac disease is an autoimmune disease, where in presence of gluten present in cereals like wheat, barley, rye triggers reaction in finger like projections called villi in small intestine, which gets inflamed and starts flattening and may lead even to complete disappearance, resulting in erratic absorption followed by malnutrition. At present there is no specific treatment except total elimination of food items containing gluten. Once diagnosed, Celiac disease is there to stay for entire life period. Its symptoms range from mild to severe, changing over time. Even having the disease, some people do not show symptoms. Celiac disease is a treatable disorder and the intestinal damage from celiac disease is reversible, and the therapy does not involve shots, pills or surgery.These grains are used in such items as breads, cereals, pasta, pizza, cakes, pies, and cookies and as added ingredients to many processed food items.After diagnosing a case of celiac disease and with subsequent nutritional advice from physician many run straight to the grocery store to stock up on gluten-free (GF) products but in spite of spending hours, land up with only a small bag of groceries and no idea of what to do. They may experience, what is called “Celiac Meltdown”![1]
About 1% of population are affected by Celiac disease, which is triggered by gliadin, a protein in gluten, found in variety of everyday cereals like wheat, barley, rye and rarely in oats. Symptoms of celiac disease are chronic diarrhoea, fatigue resulting in weight loss. Gluten precipitates symptoms of celiac disease and if it is not eliminated from the diet, the intestinal villi gets inflamed and starts flattening and may lead even to complete disappearance, resulting in erratic absorption of nutrients from small intestine ultimately causing malnutrition.[2],[3]
In the above scenario, a narrative review was taken up, which was very much required for a concerted all round application for on diet in Celiac disease.
| Gluten-Free Foods | | |
Gluten is the specific chemical entity that has binding property to keep grains organized and responsible for the shape of the foodsconsumed by us. Cutting out gluten from diet is not only difficult but achallenging task, fortunately, many naturally gluten-free foods are available, which are healthy and delicious. It will be farsighted health and cost-effective approach will be to select foods basically from the naturally gluten-free food groups, which include: Fruits; Vegetables; Meat and poultry; Fish and seafood; Dairy; Beans, legumes, and nuts. In addition there are Gluten-free grains and starches available: Amaranth, Arrowroot, Corn, Flax, Millet, Potato, Quinoa, Rice, Sago, Sorghum, Soya, Tapioca etc.[4]
A person is having bad reaction to gluten doesn't mean that he/she has celiac disease; there are many other reasons wherein people might react to wheat and/or gluten. Now it is clear that Non-Celiac Gluten Sensitivity is also there. Similarly wheat allergy andFODMAPsensitivity is also observed. As such all the three mentioned above may mimic just like celiac disease.[5]
The signs and symptoms of celiac disease may vary from person to person. There will not be any symptom in the mildest form. However, even if there are no symptoms, absorption of nutrients will be hampered, that can be confirmed by blood tests e.g., there may be low blood count due to decreased iron absorption.A person with celiac disease may have following symptoms: abdominal discomfort, excessive gas, constipation, diarrhoeaand/or bloating, weight loss etc. In addition they may have other signs and symptoms caused by vitamin and micronutrient deficiencies.Also if not treated celiac disease may have: Iron deficiency anaemia; osteopenia or osteoporosis; diabetes mellitus; hypothyroidism; herpetiformis (type of skin disease); nervous system disorders; liver disease etc. The only treatment at present available for celiac disease is complete elimination of gluten from diet, which will help in halting any additional damage to their gut mucosa, but will actually not fix the pre-existing damage. In a studyin celiac disease cases (on gluten free diet) it was observed that after 2 years of the diet, 66% of the cases still had some kind of injury to their gut lining and after 5 years, 34% still had injury to the gut mucosa, but it was seen that many compliant patients still had persistent gut problems comprising up to 30%, known as non-responsive Celiac Disease (symptoms donot respond to gluten elimination).
| Celiac Disease Complications | | |
In the cases of delayed diagnosis or no diagnosis, with continued consumption of gluten in the diet, nutrient deficiency and other morbidities like iron deficiency anaemia, decreased bone density, unintentional weight loss, folate and vitamin B12 deficiency etc., will be precipitated.[1] Many cases of celiac disease may present only with anaemia, even when they are diagnosed late.[2],[3]
In about 10% cases of celiac disease still havecontinuing symptoms, in spite adhering to a strict gluten-free diet, known as 'Nonresponsive Celiac Disease'.This may be due to a variety of reasons fromintolerances to food items like fructosemalabsorption, food allergies, bacterial overgrowth in the small intestine or conditions viz. pancreatic exocrine insufficiency, irritable bowel syndrome, microscopic colitis, or refractory celiac disease. However, the most common cause is on-going, often inadvertent, gluten ingestion. Due to unknown reasons, in some cases, symptoms initially improve with gluten free diet but again return; these may have, what is called asRefractory Celiac Disease. For treatment of these cases steroids can be tried. People with refractory celiac disease not responding to steroid therapy may have ulcerative jejunitis withmultiple non-healing ulcers in small intestine that may require surgery to remove the ulcerated area.Less commonly lymphoma can also occur, which can usually be prevented by gluten elimination.Among skin conditions, commonest is dermatitis herpetiformis, which is characterized by intensely itchy, raised, fluid-filled areas on the skin, usually located on the elbows, knees, buttocks, lower back, face, neck, trunk, and occasionally within the mouth with severe itching and burning. Skin eruption slowly improves after eliminating gluten from the diet. Requires tabletdapsone orally along with gluten elimination.[6],[7]
| Diagnosis | | |
This is done mainly by signs and symptoms, aided by blood tests to detectantigliadin antibodies (AGA); endomysial antibodies (EmA); anti-tissue transglutaminase antibodies (TTG). Though, series of endoscopic biopsy of small intestinal lining is the most accurate test for celiac disease.Conditions that have similar symptoms to celiac disease include: pancreatic insufficiency; Crohn's disease of the small intestine; irritable bowel syndrome (IBS);small intestinal overgrowth of bacteria; gluten sensitivity, all have similar symptoms.[8],[9]
| Indications of Gluten Free Diet | | |
The gluten-free diet is mainly essential for treating celiac disease, wherein gluten, present in variety of everyday cereals like wheat, barley, rye and many other food items, triggers immune system activity that damages the finger like projections in small intestine causingmal-absorption of nutrients from food.[10]
Nonceliac gluten sensitivity
Causes similar signs and symptoms as in celiac disease, including abdominal pain, bloating, diarrhoea, constipation, “foggy brain,” rash or headache, even without any visible damage to the tissues of the small intestine. Researches have shown that the immune system plays a role.
Gluten ataxia
An autoimmune disorder, affecting nerve tissues, causing problems with muscle control and voluntary muscle movement.
Wheat allergy
Similar to other allergies, this is also result of the immune system mistaking gluten for disease-causing agent (virus or bacteria).
It is understood that a gut damaged by celiac disease cannot be managed by a gluten-free diet alone; it requires inclusion of: increased high fibre, vitamin-and-mineral-containing fruits, and vegetables also, to support the growth of good bacteria and inhibit inflammatory molecules. Alongside, intake of refined grains, sugars, and gluten-free processed products, that feeds bad bacteria and worsen dysbiosis, to be reduced. We have to think of inclusion of some naturally fermented foods and probiotic sources, or supplements in the diet to support the growth of good bacteria. Inclusion of herbs and spices like Garlic, ginger, turmeric, thyme, cinnamon, and basil will cool the inflammatory process in the gut. This can be further boosted by including fish oil, walnuts, flax, and olive-oil, tea and bone broth in the diet. Pathogenic bacterial overgrowth can be reduced by reducing stress.[11]
| Paleo Diet | | |
A strict gluten-free diet can prevent further damage to the gut in a celiac disease case but this may not solve all the problems, which may be of non-celiac origin causing similar symptoms. That's where, diet called as Paleo is helpful in healing damage caused due to celiac disease, and also address non-celiac problems that might be aggravating the symptoms. Paleo consists of nutrient-dense foods, supplying: Iron and Vitamin B12:liver, red meat, egg yolk, shellfishetc; fruits and vegetables: the carotenoids (in red/orange foods like tomatoes and carrots) and Vitamin C. Vitamin D: sunshine, fattyfresh-water fish. Calcium: collard greens, other dark green leafy vegetables, bone-in fish, and dairy if patient can tolerate it. Absorption tip: Vitamin K2. Only grass-fed butter contains Vitamin K2; Folate: spinach and other dark green leafy vegetables; it is advisable to take these items as uncooked or raw since folate is rapidly biodegradable and breaks down easily with cooking.[8],[12]
Of late, gluten-free diet has gained immense popularity, not only among celiac disease patients but also in the normal people without any gluten-related medical conditions due to the belief that the diet is a healthier alternative compared to regular diet getting benefits e.g., improving health, weight loss and increased energy. At present, there is little clinical evidence about health benefits in general populationbecause; almost all researches on gluten free diet have been conducted on people with celiac disease.Elimination of gluten from diet may also change the overall intake of fibre, vitamins and other nutrients causing adverse effect on health.Foods manufacturing transnational business houses haveput hand-in-gloves with media and celebrities in an onslaught of campaignin favour of gluten-free foods over gluten-containing foods for reasons better known to them. In the downstream effects to choose gluten-free foods the search engines including“Google search” were flooded with key word 'Gluten-free diet' between 2005 and 2015 as a misdirected crazy inquest in search of healthy foods. Thoughgluten-free diet is crucial as the mainstay in the management ofCeliac disease and achieved the popularity, consumers in particular without celiac disease should be made cautious not to consume this diet in persons without Celiac disease. Research group from Australiaobserved that the nutritivevalue of gluten-free foods was not superior to gluten-containing foods and any nutritional advantage was not found in gluten-free foods. Consumers should be aware of evidence-based disadvantages or advantages of gluten rather than biased information through the media and be smart enough to consume gluten-free foods according to the appropriate needs. For this purpose, nutrition experts should be involved in raising the consumer awareness and likewise appropriate standards and regulations at the government-level are required.[13]
| FODMAP Dietary Advice | | |
Of late, there is growing interest regarding the role of FODMAPs (Fermentable Oligo-, Di-, and Mono-saccharides And Polyols) is getting the limelight.This is particularly advised to change gut microbiota and to improve symptoms. Since CD and IBS have close clinical presentations, we propose clinical practice guidelines by further researchwhether we need to evaluate for IBS in case of CD and vice-versa. Benefits of therapeutic trial with Gluten Free Diet in CD and benefit from a new therapeutic approach consisting in both gluten/wheat and FODMAPs avoidance may usher new vistas of this impasse.[14]
| Celiac Disease in India | | |
Once perceived as a “Western” phenomenon, celiac disease is making its presence felt in India too. In 2015, a multi-centre study by AIIMS Delhi with 23,000 subjects found that0.6 per cent (1 in 160) had celiac disease. It was more common in the northern part of India, i.e., one in 90 (1.2 per cent) as compared to north eastern (0.8 per cent) and the southern part it was 1 in 1,000 (0.1 per cent), whereas globally, about 40 to 60 million people suffer from the disease.In the study of 2015, it was found that the incidence of celiac disease was more common in north and north eastern states because their diet contained more wheat, however, B.S. Ramakrishna, director, Institute of Gastroenterology, SIMS hospital, Chennai, found that “new world wheat” could be responsible for the rising incidence of celiac disease. During last century, agricultural revolution has brought new variety of wheat that is now grown all over the world.[15],[16],[17],[18]
| Conclusions | | |
Celiac disease is congenital and permanent gluten intolerance and the pathogenesis of this entity involves manifold factors including genotype and phenotypes depend on assorted environmental risk correlatesculminating in the common gastrointestinalpresentations. Till datesingle most importantintervention is the stringentexclusion of gluten containing food items and nutrient stuffs from diet irrespective of presence or absence of acute or chronic co-morbidities to circumvent exacerbation of clinical featuresoriginating from inflammation of the gastrointestinal mucosa leading to genesis of lympho-proliferative malignancy and immunological disorders. It is most unfortunate observation that by exclusion of gluten from diet disturbsvariant taste and satiety factors from spectrum in the diet and nutrition arena.
Further, this limitation of dietary optionsmay even lead to uneven intake of natural macronutrients and micronutrients which may precipitateovert and subclinical deficiency sign and symptoms. Tailor-made dietary counselling of the celiac disease patients and their caregivers can only solve this and advices needed with options as well as choices from naturally available gluten free food items with long-term lifelong follow-up is the only way out for this chronic disease.
How to diagnose an individual with celiac disease?
Many individual feel uncomfortable after consuming foods containing gluten; most severe cases are confirmed by diagnostic algorithm. With a high index of suspicion, the health care provider can diagnose by screening of first degree relatives of known celiac disease patients (above 3 years), persons with auto-immune and genetic disorders, even with atypical extra-intestinal clinical features, overweight.[8],[9],[19],[20],[21],[22]
Do's and Donot's after being diagnosed individual with celiac disease?
Switch on to 'Living without gluten' philosophy of life if anyone is diagnosed with celiac disease and cultivate mindset to accept life-long guidance of healthcare provider and support groups within and outside family and peers. Celiac disease cases should consume domestic well-balanced diet item from fruits, green leafy vegetables, rice, and potatoes without additives or seasonings; clearly labelled 'gluten-free' items; may need fibre, iron, and calcium supplementation; for non-vegetarians meat, fish etc., animal proteins; items prepared from flour of rice, soy, potato etc., instead of wheat flour and moderate amounts of oats are safe; be sure to consume gluten-free foods while eating out.[10],[11],[13],[23]
Acknowledgement
We are thankful to our authority to permit us to conduct the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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