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Celiac DiseaseCeliac Disease (CD) Guideline (2009)

Celiac Disease

CD: Major Recommendations (2009)Recommendations

Recommendations are categorized in terms of either conditional or imperative statements. While conditional statements clearlydefine a specific situation, imperative statements are broadly applicable to the target population and do not impose restraints ontheir application.

Conditional recommendations are presented in an if/then format, such that:

If CONDITION then ACTION(S) because REASON(S)

Fulfillment of the condition triggers one or more guideline-specified actions. In contrast, imperative recommendations includeterms such as “require, ” “must, ” and “should, ” and do not contain conditional text that would limit their applicability to specifiedcircumstances.

Resources Available with Each Recommendation

In addition to the recommendation statement and strength rating, you will find on each recommendation page:

A brief narrative summary of the evidence analyzed to reach the recommendationA statement of justification, or reason for the strength of the recommendationDetailed information on the evidence supporting the recommendations and background narrative (available in theSupporting Evidence section toward the bottom of each recommendation page)A reference list at the end of each recommendation page that includes all the sources used in the evidence analysis forthe particular recommendation (each reference is hyperlinked to a summary of the article analyzed in the evidenceanalysis).

Below, you will find a list of the Celiac Disease Recommendations organized by the steps in ADA's Nutrition Care Process. To seethe Recommendation Summary, just click on the recommendation title.

Celiac Disease (CD) Major Recommendations

CD: Medical Nutrition Therapy

Nutrition Assessment

CD: Assessment of Food/Nutrition-Related History

CD: Assessment of Factors Affecting Quality of Life

CD: Bone Density Screening

CD: Assessment of Biochemical Data and Results of Medical Procedures

CD: Assessment of Gastrointestinal Symptoms

CD: Assessment of Other Disease States

Nutrition Intervention

CD: Inclusion of Gluten-Free Oats

Inclusion of Gluten-Free Oats as Tolerated

CD: Meeting Nutritional Needs

Consumption of Whole/Enriched Gluten-Free Grains and ProductsAddition of Multivitamin and Mineral Supplements

CD: Calcium/Vitamin D for Reduced Bone Density

CD: Iron Supplementation for Iron Deficiency Anemia

CD: Gluten-free Dietary Pattern

CD: Provide Resources and Education on Label Reading

CD: Education on Food Cross-Contamination

CD: Coordination of Care

Nutrition Monitoring and Evaluation

CD: Monitoring and Evaluation of Dietary Compliance

CD: Monitoring and Evaluation of Factors Affecting Quality of Life

CD: Monitoring and Evaluation of Gastrointestinal Symptoms


© 2015 Academy of Nutrition and Dietetics (A.N.D.), Evidence Analysis Library. Printed on: 12/16/15 - from:http://www.andeal.org

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Recommendations SummaryCD: Medical Nutrition Therapy 2009

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels(Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use thehyperlinks in the Supporting Evidence Section below.

Recommendation(s) CD: Medical Nutrition Therapy

Medical nutrition therapy (MNT) provided by a registered dietitian is strongly recommended for individuals with celiacdisease. Consultation with a registered dietitian as part of a team-based approach results in improved self-management.

Rating: ConsensusImperative

Risks/Harms of Implementing This Recommendation

None.

Conditions of Application

None specified.

Potential Costs Associated with Application

Although costs of MNT sessions and reimbursement vary, MNT sessions are essential for improved outcomes.

Recommendation Narrative

The National Institutes of Health Consensus Development Conference Statement identified six elements requiredfor the management of celiac disease:

Consultation with a skilled dietitianEducation about the diseaseLifelong adherence to a gluten-free dietIdentification and treatment of nutritional deficienciesAccess to an advocacy groupContinuous long-term follow-up by a multi-disciplinary team.

Recommendation Strength Rationale

The ADA Celiac Disease Work Group concurs with the National Institutes of Health Consensus DevelopmentConference Statement.

Minority Opinions

Consensus reached.

Supporting Evidence The recommendations were created from the evidence analysis on the following questions. To see detail of the evidenceanalysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

References References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

National Institutes of Health Consensus Development Conference on Celiac Disease. Consensus DevelopmentConference Statement, June 28-30, 2004. Available at http://consensus.nih.gov/2004/2004CeliacDisease118html.htm.


Quick Links

Recommendations SummaryCD: Assessment of Food/Nutrition-Related History 2009

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels


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Recommendation(s) CD: Assessment of Food/Nutrition-Related History

The registered dietitian (RD) should assess the food and nutrition-related history of individuals with celiac disease,including (but not limited to) the following:

Food and nutrient intake (e.g., diet history, diet experience and macronutrient or micronutrient intake, specificallycalcium, iron, vitamin B complex and vitamin D)Medication and herbal supplement use Knowledge, beliefs or attitudes (e.g., readiness to change nutrition-related behaviors)Behavior (e.g., social network) Factors affecting access to food and food and nutrition-related supplies (e.g., safe food and meal availability).

Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutritionintervention. Intake of gluten results may result in gastrointestinal symptoms, malabsorption and villous atrophy.

Rating: StrongImperative


None.


None specified.


Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT sessions are essentialfor improved outcomes.


Several studies report that individuals who are compliant with a gluten-free dietary pattern havesubstantial improvement in villous atrophy; however, mucosal abnormalities may persist in someindividualsNormalization of abnormalities may occur within one year, but generally takes longer, depending on theseverity of villous atrophy, level of dietary compliance and age at diagnosis (Dickey et al, 2000; Kaukinenet al, 2002; Lee et al, 2003; Abrams et al, 2004)One study indicated that recovery in children may progress faster and more completely than in adults(Wahab et al, 2002)Several studies report that improvement in villous atrophy is not dependent on the type of gluten-freedietary pattern; however, villous atrophy is significantly associated with dietary compliance (Janatuinen etal, 1995; Kemppainen et al, 1998; Kaukinen et al, 1999; Selby et al, 1999; Lohiniemi et al, 2000;Janatuinen et al, 2000; Ciacci et al, 2002; Janatuinen et al, 2002; Peraaho et al, 2003; Hogberg et al,2004; Peraaho et al, 2004; Baudon et al, 2005; Ciacci et al, 2005)Further research is needed to determine the factors involved with the persistence of mucosal abnormalitiesin those adhering to a gluten-free dietary patternSeveral studies have reported that people with celiac disease are more likely to experience gastrointestinalsymptoms such as diarrhea, constipation, abdominal pain and bloating, nausea or vomiting, reduced gutmotility, delayed gastric emptying and prolonged transit time than healthy controls (Cucchiara et al,1995; Usai et al, 1995; Chiarioni et al, 1997; Fine et al, 1997; Benini et al, 2001; Cuomo et al, 2003;Midhagen et al, 2003; Tursi et al, 2003; Murray et al, 2004; Hopper et al, 2005; Viljamaa et al, 2005;Casellas et al, 2006)Compliance with a gluten-free diet reduces the prevalence of these symptomsFurther evaluation of persistent gastrointestinal symptoms in some persons with celiac disease isrecommended. Evidence is limited regarding the effect of a gluten-free dietary pattern on indigestion,dysphagia and reflux; additional research is needed in these areas.


Both conclusion statements received Grade II.

Minority Opinions

Consensus reached.


What is the long-term effectiveness in people with celiac disease of following a gluten-free dietary pattern on villousatrophy?


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What is the long-term effectiveness in people with celiac disease of following a gluten-free dietary pattern ongastrointestinal symptoms?

References Abrams JA, Diamond B, Rotterdam H, Green PHR. Seronegative celiac disease: increased prevalence with lesserdegrees of villous atrophy. Digestive Diseases and Sciences 2004;49(4):546-550.

Baudon JJ, Chevalier J, Boccon-Gibod L, Le Bars MA, Johanet C, Cosnes J. Outcome of infants with celiac disease. Gastroenterol Clin Biol 2005;29:1097-1102.

Ciacci C, Cirillo M, Cavallaro R, Mazzacca G. Long-term follow-up of celiac adults on gluten-free diet: prevalenceand correlates of intestinal damage. Digestion 2002; 66(3): 178-185.

Ciacci C, Iovino P, Amoruso D, Siniscalchi M, Tortora R, Di Gilio A, Fusco M, Mazzacca G. Grown-up celiacchildren: the effects of only a few years on a gluten-free diet in childhood. Aliment Pharmacol Ther 2005; 21(4):421-429.

Dickey W, Hughes DF, McMillan SA. Disappearance of endomysial antibodies in treated celiac disease does notindicate histological recovery. Am J Gastroenterol 2000; 95(3): 712-714.

Hogberg L, Laurin P, Falth-Magnusson K, Grant C, Grodzinsky E, Jansson G, Ascher H, Browaldh L, Hammersjo JA,Lindberg E, Myrdal U, Stenhammar L. Oats to children with newly diagnosed celiac disease: a randomized doubleblind study. Gut 2004; 53:649-654.

Janatuinen EK, Kemppainen TA, Julkunen RJK, Kosma VM, Maki M, Heikkinen M, Uusitupa MIJ. No harm from fiveyear ingestion of oats in celiac disease. Gut 2002; 50: 332-335.

Janatuinen EK, Kemppainen TA, Pikkarainen PH, Holm KH, Kosma VM, Uusitupa MIJ, Maki M, Julkunen RJK. Lack ofcellular and humoral immunological responses to oats in adults with celiac disease. Gut 2000; 46: 327-331.

Janatuinen EK, Pikkarainen PH, Kemppainen TA, Kosma VM, Jarvinen RMK, Uusitupa MIJ, Julkunen RJK. Acomparison of diets with and without oats in adults with celiac disease. N Engl J Med 1995; 333: 1033-7.

Kaukinen K, Collin P, Holm K, Rantala I, Vuolteenaho N, Reunala T, Maki M. Wheat starch-containing gluten-freeflour products in the treatment of coeliac disease and dermatitis herpetiformis. A long-term follow-up study. Scand J Gastroenterol 1999; 34: 163-169.

Kaukinen K, Sulkanen S, Maki M, Collin P. IgA-class transglutaminase antibodies in evaluating the efficacy ofgluten-free diet in celiac disease. Eur J Gastroenterol Hepatol 2002; 14(3): 311-315.

Kemppainen TA, Kosma VM, Janatuinen EK, Julkunen RJ, Pikkarainen PH, Uusitupa MI. Nutritional status of newlydiagnosed celiac disease patients before and after the institution of a celiac disease diet - association with thegrade of mucosal villous atrophy. Am J Clin Nutr 1998; 67(3): 482-487.

Lee SK, Lo W, Memeo L, Rotterdam H, Green PH. Duodenal histology in patients with celiac disease aftertreatment with a gluten-free diet. Gastrointest Endosc 2003; 57(2): 187-191.

Lohiniemi S, Maki M, Kaukinen K, Laippala P, Collin P. Gastrointestinal symptoms rating scale in coeliac diseasepatients on wheat starch-based gluten-free diets. Scand J Gastroenterol 2000; 35:947-949.

Peraaho M, Kaukinen K, Paasikivi K, Sievanen H, Lohiniemi S, Maki M, Collin P. Wheat-starch-based gluten-freeproducts in the treatment of newly detected coeliac disease: Prospective and randomized study. AlimentPharmacol Ther 2003; 17:587-594.

Peraaho M, Kaukinen K, Mustalahti K, Vuolteenaho N, Maki M, Laippala P, Collin P. Effect of an oats-containinggluten-free diet on symptoms and quality of life in celiac disease. A randomized study. Scand J Gastroenterol 2004; 39:27-31.

Selby WS, Painter D, Collins A, Faulkner-Hogg KB, Loblay RH. Persistent mucosal abnormalities in coeliac diseaseare not related to the ingestion of trace amounts of gluten. Scand J Gastroenterol 1999; 34: 909-914.

Wahab PJ, Meijer JWR, Mulder CJJ. Histologic follow-up of people with celiac disease on a gluten-free diet: slowand incomplete recovery. Am J Clin Pathol 2002; 118(3): 459-463.

Benini L, Sembenini C, Salandini L, Dall'O E, Bonfante F, Vantini I. Gastric emptying of realistic meals with andwithout gluten in patients with celiac disease. Effect of jejunal mucosal recovery. Scand J Gastroenterol2001;36(10):1044-1048.

Casellas F, Lopez Vivancos J, Malagelada JR. Current epidemiology and accessibility to diet compliance in adultceliac disease. Rev Esp Enferm Dig 2006;98(6):408-419.

Chiarioni G, Bassotti G, Germani U, Battaglia E, Brentegani MT, Morelli A, Vantini I. Gluten-free diet normalizesmouth-to-cecum transit of a caloric meal in adult patients with celiac disease. Dig Dis Sci1997;42(10):2100-2105.

Cucchiara S, Bassotti G, Castellucci G, Minella R, Betti C, Fusaro C, Morelli A, Bertotto A, Auricchio S. Uppergastrointestinal motor abnormalities in children with active celiac disease. J Pediatr Gastroenterol Nutr1995;21(4):435-442.

Cuomo A, Romano M, Rocco A, Budillon G, Del Vecchio Blanco C, Nardone G. Reflux esophagitis in adult celiacdisease: beneficial effect of gluten-free diet. Gut 2003;52:514-517.

Fine KD, Meyer RL, Lee EL. The prevalence and causes of chronic diarrhea in patients with celiac sprue treatedwith a gluten-free diet. Gastroenterology 1997;112(6):1830-1838.

Hopper AD, Leeds JS, Hurlstone DP, Hadjivassiliou M, Drew K, Sanders DS. Are lower gastrointestinalinvestigations necessary in patients with celiac disease? Eur J Gastroenterol Hepatol 2005;17(6):617-21.

Midhagen G, Hallert C. High rate of gastrointestinal symptoms in celiac patients living on a gluten-free diet:


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controlled study. Am J Gastroenterol 2003;98(9):2023-2026.

Murray JA, Watson T, Clearman B, Mitros F. Effect of a gluten-free diet on gastrointestinal symptoms in celiacdisease. Am J Clin Nutr 2004; 79: 669-673.

Tursi A, Brandimarte G, Giorgetti G. High prevalence of small intestinal bacterial overgrowth in celiac patientswith persistence of gastrointestinal symptoms after gluten withdrawal. Am J Gastroenterol 2003;98(4):839-843.

Usai P, Bassotti G, Usai Satta P, Cherchi MV, Plesa A, Boy F, Morelli A, Balestrieri A. Oesophageal motility in adultceliac disease. Neurogastroenterol Motil 1995;7(4):239-244.

Viljamaa M, Collin P, Huhtala H, Sievanen H, Maki M, Kaukinen K. Is coeliac disease screening in risk groupsjustified? A fourteen-year follow-up with special focus on compliance and quality of life. Aliment Pharmacol Ther2005;22(4):317-24.

References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

National Institutes of Health. National Institutes of Health Consensus Development Conference Statement: CeliacDisease. Available at: http://consensus.nih.gov/2004/2004CeliacDisease118html.htm.


Quick Links

Recommendations SummaryCD: Assessment of Factors Affecting Quality of Life 2009


Recommendation(s) CD: Assess Factors Affecting Quality of Life

The registered dietitian (RD) should assess the factors affecting the quality of life of individuals with celiac disease whencompleting a comprehensive client history, which includes a medical history (e.g., gastrointestinal, immune, neurologicaland psychological) and social history (e.g., socioeconomic factors, religion, social and medical support and daily stresslevel). Individuals with celiac disease may not attain the same level of quality of life as the general population, due tosocial inconveniences of following a gluten-free dietary pattern.

Rating: StrongImperative


None.


None specified.


Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT sessions are essentialfor improved outcomes.


Individuals with celiac disease demonstrate improved quality of life after compliance with a gluten-freedietary pattern for at least one year (Hallert et al, 1998; Green et al, 2001; Hallert et al, 2002; Mustalahtiet al, 2002; Hallert et al, 2003; Johnston et al, 2004; Viljamaa et al, 2005)Those who have been symptom-detected rather than screen-detected demonstrated greater improvementin quality of lifeIndividuals with celiac disease may not attain the same level of quality of life as the general population,due to social inconveniences of following a gluten-free dietary pattern; these issues are reported morefrequently by women than men (Ciacci et al, 2002; Usai et al, 2002; Ciacci et al, 2003; Fera et al, 2003;Lee and Newman, 2003; Rashid et al, 2005; Zarkadas et al, 2006)Those with persistent gastrointestinal symptoms, despite adherence to a gluten-free dietary pattern, alsodid not attain quality of life comparable to the general populationSeveral studies have reported that people with celiac disease (treated and untreated) are more likely toexperience gastrointestinal symptoms such as diarrhea, constipation, abdominal pain and bloating, nauseaor vomiting, reduced gut motility and delayed gastric emptying than healthy controls (Cucchiara et al,1995; Usai et al, 1995; Chiarioni et al, 1997; Fine et al, 1997; Benini et al, 2001; Cuomo et al, 2003;Midhagen et al, 2003; Tursi et al, 2003; Murray et al, 2004; Hopper et al, 2005; Viljamaa et al, 2005;Casellas et al, 2006)


file:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmhttp://consensus.nih.gov/2004/2004CeliacDisease118html.htmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfmfile:/E:/InetWeb/WebSiteRoot/andeal.org/print_queue.cfm

Compliance with a gluten-free diet reduces the prevalence of these symptomsFurther evaluation of persistent gastrointestinal symptoms in some persons with celiac disease isrecommended. Evidence is limited regarding the effect of a gluten-free dietary pattern on indigestion,dysphagia and reflux; additional research is needed in these areas.Several studies have reported that people with celiac disease are more likely to experience neurologicalsymptoms such as depression, cerebellar ataxia, headaches and migraines, and neuropathy than healthycontrols (Bushara et al, 2001; Hadjivassiliou et al, 2001; Kieslich et al, 2001; Volta et al, 2002; Gabrielliet al, 2003; Luostarinen et al, 2003; Zelnik et al, 2004; Briani et al, 2005; Ihara et al, 2006)Early diagnosis and compliance with a gluten-free dietary pattern may reduce the prevalence of symptomsrelated to cerebellar ataxia, headaches and migrainesSix studies report that compliance with a gluten-free dietary pattern has not been shown to have an effecton depressive symptoms (Ciacci et al, 1998; Addolorato et al, 2001; Cicarelli et al, 2003; Addolorato etal, 2004; Siniscalchi et al, 2005). One study suggests that this may relate more to family history ofdepression (Pynnonen et al, 2004).Evidence is less conclusive and limited regarding the effect of a gluten-free dietary pattern on epilepsy,anxiety, regional cerebral perfusion, hypotonia, learning disorders and disruptive behavior disorders;additional research is needed in these areas.Clinical trials and cross-sectional studies have reported reduced bone mineral content and bone mineraldensity in untreated children, adolescents and adults with celiac disease; both of these parametersimprove significantly with compliance to a gluten-free dietary pattern for at least one yearCompliance with dietary treatment initiated during childhood or adolescence allows achievement of anormal bone mineralization (Rea et al, 1996; Scotta et al, 1997; Mora et al, 1998; De Lorenzo et al,1999; Kalayci et al, 2001; Mora et al, 2001; Szathmari et al, 2001; Carbone et al, 2003; Kavak et al,2003; Sdepanian et al, 2003; Barera et al, 2004; Hartman et al, 2004; Tau et al, 2006)However, studies in untreated adults have shown that a gluten-free dietary pattern improves but may notnormalize bone mineral density; successful treatment depends on the age at diagnosis, as patients whodo not receive treatment in childhood and adolescence may never reach peak bone mass (Corazza et al,1995; McFarlane et al, 1995; Molteni et al, 1995; Walters et al, 1995; Corazza et al, 1996; McFarlane etal, 1996; Valdimarsson et al, 1996; Bai et al, 1997; Ciacci et al, 1997; Kemppainen et al, 1999; Mora etal, 1999; Bardella et al, 2000; Sategna-Guidetti et al, 2000; Valdimarsson et al, 2000; Vazquez et al,2000; O'Leary et al, 2004; Pazianas et al, 2005; Viljamaa et al, 2005)Further studies are needed regarding the effects of calcium and vitamin D supplementation on bonemineral content and bone mineral density, as well as hormone replacement therapy for post-menopausalwomen (McFarlane et al, 1995; Pistorius et al, 1995; Walters et al, 1995; Bai et al, 1997;Sategna-Guidetti et al, 2000)For most children and adults with celiac disease, studies report that compliance with a gluten-free dietarypattern results in significant improvements in hematological parameters including serum hemoglobin, iron,ferritin, mean corpuscular volume, mean corpuscular hemoglobin and red cell distribution width (Rea et al,1996; Annibale et al, 2001; Mitchell and Robinson, 2002; Kapur et al, 2003; Patwari et al, 2003; O'Learyet al, 2004; Rashid et al, 2005; Masjedizadeh et al, 2006; Poddar et al, 2006)Recovery of anemia (normalization of hemoglobin concentrations) generally occurs within six months,while recovery from iron deficiency (normalization of ferritin concentrations) may take longer than oneyear. Iron supplementation in the form of a multivitamin with iron or additional therapeutic doses of ironmay be necessary to achieve normal values of these hematological variables within these time periods.Several studies report that individuals who are compliant with a gluten-free dietary pattern havesubstantial improvement in villous atrophy. However, mucosal abnormalities may persist in someindividuals.Normalization of abnormalities may occur within one year, but generally takes longer, depending on theseverity of villous atrophy, level of dietary compliance and age at diagnosis (Dickey et al, 2000; Kaukinenet al, 2002; Lee et al, 2003; Abrams et al, 2004)One study indicated that recovery in children may progress faster and more completely than in adults(Wahab et al, 2002)Several studies report that improvement in villous atrophy is not dependent on the type of gluten-freedietary pattern; however, villous atrophy is significantly associated with dietary compliance (Janatuinen etal, 1995; Kemppainen et al, 1998; Kaukinen et al, 1999; Selby et al, 1999; Lohiniemi et al, 2000;Janatuinen et al, 2000; Ciacci et al, 2002; Janatuinen et al, 2002; Peraaho et al, 2003; Hogberg et al,2004; Peraaho et al, 2004; Baudon et al, 2005; Ciacci et al, 2005)Further research is needed to determine the factors involved with the persistence of mucosal abnormalitiesin those adhering to a gluten-free dietary patternSeveral cohort and case-control studies have reported that women with undiagnosed or untreated celiacdisease have an increased risk of spontaneous abortion and miscarriage, low birth weight and small forgestational age newborns, stillbirth, perinatal disease and mortality, low Apgar scores, delayed menarcheand early menopause, premature delivery, intrauterine growth retardation, breech presentation andCesarean delivery, while compliance with a gluten-free dietary pattern results in risks similar to those ofhealthy controls (Ciacci et al, 1996; Sher et al, 1996; Smecuol et al, 1996; Norgard et al, 1999;Martinelli et al, 2000; Greco et al, 2004; Kotze, 2004; Ciacci et al, 2005; Ludvigsson et al, 2005; Sheineret al, 2005; Tata et al, 2005) Despite the increased risks of complications, the overall number of pregnancies does not appear to beinfluenced by celiac disease Evidence is limited in the areas of fertility, breast-feeding duration, threatened abortion, secondaryamenorrhea and labor induction; further research is needed in these areas.


Conclusion statements received Grades I and II.

Minority Opinions

Consensus reached.


What is the long-term effectiveness in people with celiac disease of following a gluten-free dietary pattern on quality of


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life?

What is the long-term effectiveness in people with celiac disease of following a gluten-free dietary pattern on neurologicalsymptoms?

What is the long-term effectiveness in people with celiac disease of following a gluten-free dietary pattern ongastrointestinal symptoms?

What is the long-term effectiveness in people with celiac disease of following a gluten-free dietary pattern on bonedensity?

What is the long-term effectiveness in people with celiac disease of following a gluten-free dietary pattern onhematological variables related to iron deficiency anemia?

What is the long-term effectiveness in people with celiac disease of following a gluten-free dietary pattern on villousatrophy?

What is the long-term effectiveness in women with undiagnosed or untreated celiac disease following a gluten-freedietary pattern on pregnancy outcomes?

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Undiagnosed coeliac disease does not appear to be associated with unfavorable outcome of pregnancy. Gut2004; 53:149-151.

Kotze LMS. Gynecologic and obstetric findings related to nutritional status and adherence to a gluten-free diet inBrazilian patients with celiac disease. J Clin Gastroenterol 2004;38(7):567-574.

Ludvigsson JF, Montgomery SM, Ekbom A. Celiac disease and risk of adverse fetal outcome: a population-basedcohort study. Gastroenterology 2005; 129(2):454-463.

Martinelli P, Troncone R, Paparo F, Torre P, Trapanese E, Fasano C, Lamberti A, Budillon G, Nardone G, Greco L. Coeliac disease and unfavourable outcome of pregnancy. Gut 2000; 46: 332-335.

Norgard B, Fonager K, Sorensen HT, Olsen J. Birth outcomes of women with celiac disease: a nationwidehistorical cohort study. Am J Gastroenterol 1999;94(9):2435-2440.

Sheiner E, Peleg R, Levy A. Pregnancy outcome of patients with known celiac disease. Eur J Obstet GynecolReprod Biol 2005; Nov 22, Epub.

Sher KS, Mayberry JF. Female fertility, obstetric and gynaecological history in celiac disease: a case controlstudy. Acta Paediatr Suppl 1996; 412: 76-77.

Smecuol E, Maurino E, Vazquez H, Pedreira S, Niveloni S, Mazure R, Boerr L, Bai JC. Gynaecological and obstetricdisorders in celiac disease: frequent clinical onset during pregnancy or the puerperium. Eur J GastroenterolHepatol 1996; 8(1): 63-89.

Tata LJ, Card TR, Logan RFA, Hubbard RB, Smith CJP, West J. Fertility and pregnancy-related events in womenwith celiac disease: a population-based cohort study. Gastroenterology 2005; 128(4):849-855.


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Recommendations SummaryCD: Bone Density Screening 2009


Recommendation(s) CD: Bone Density Screening

The registered dietitian (RD) should recommend bone density screening for adults with celiac disease within the firstyear. Clinical trials and cross-sectional studies have reported reduced bone mineral content and bone mineral density inuntreated adults with celiac disease.

Rating: StrongConditional


Bone density screening may be contraindicated in pregnancy.


This recommendation applies to adult men and women with celiac disease.


Cost of equipment, supplies and staff are factors in bone density screeningInsurance coverage for screening may varyAlthough costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT sessions areessential for improved outcomes.


Clinical trials and cross-sectional studies have reported reduced bone mineral content and bone mineraldensity in untreated children, adolescents and adults with celiac disease; both of these parametersimprove significantly with compliance to a gluten-free dietary pattern for at least one yearCompliance with dietary treatment initiated during childhood or adolescence allows achievement of anormal bone mineralization (Rea et al, 1996; Scotta et al, 1997; Mora et al, 1998; De Lorenzo et al,1999; Kalayci et al, 2001; Mora et al, 2001; Szathmari et al, 2001; Carbone et al, 2003; Kavak et al,2003; Sdepanian et al, 2003; Barera et al, 2004; Hartman et al, 2004; Tau et al, 2006)Studies in untreated adults have shown that a gluten-free dietary pattern improves but may not normalizebone mineral density; successful treatment depends on the age at diagnosis, as patients who do notreceive treatment in childhood and adolescence may never reach peak bone mass (Corazza et al, 1995;


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McFarlane et al, 1995; Molteni et al, 1995; Walters et al, 1995; Corazza et al, 1996; McFarlane et al,1996; Valdimarsson et al, 1996; Bai et al, 1997; Ciacci et al, 1997; Kemppainen et al, 1999; Mora et al,1999; Bardella et al, 2000; Sategna-Guidetti et al, 2000; Valdimarsson et al, 2000; Vazquez et al, 2000;O'Leary et al, 2004; Pazianas et al, 2005; Viljamaa et al, 2005)Further studies are needed regarding the effects of calcium and vitamin D supplementation on bonemineral content and bone mineral density, as well as hormone replacement therapy for post-menopausalwomen (McFarlane et al, 1995; Pistorius et al, 1995; Walters et al, 1995; Bai et al, 1997;Sategna-Guidetti et al, 2000).


Conclusion statement received Grade I.

Minority Opinions

Consensus reached.


What is the long-term effectiveness in people with celiac disease of following a gluten-free dietary pattern on bonedensity?

References Bai JC, Gonzalez D, Mautalen C, Mazure R, Pedreira S, Vazquez H, Smecuol E, Siccardi A, Cataldi M, Niveloni S,Boerr LA, Maurino E. Long-term effect of gluten restriction on bone mineral density of patients with celiacdisease. Aliment Pharmacol Ther. 1997;11:157-164.

Bardella MT, Fredella C, Prampolini L, Molteni N, Giunta AM, Bianchi PA. Body composition and dietary intakes inadult celiac disease patients consuming a strict gluten-free diet. Am J Clin Nutr. 2000; 72: 937-939.

Barera G, Beccio S, Proverbio MC, Mora S. Longitudinal changes in bone metabolism and bone mineral content inchildren with celiac disease during consumption of a gluten-free diet. Am J Clin Nutr. 2004; 79: 148-154.

Carbone MC, Pitzalis G, Ferri M, Nenna R, Thanasi E, Andreoli A, De Lorenzo A, Bonamico M. Body composition incoeliac disease adolescents on a gluten-free diet: a longitudinal study. Acta Diabetol 2003; 40: S171-173.

Ciacci C, Maurelli L, Klain M, Savino G, Salvatore M, Mazzacca G, Cirillo M. Effect of dietary treatment on bonemineral density in adults with celiac disease: factors predicting response. Am J Gastroenterology 1997; 92(6):992-996.

Corazza GR, Di Sario A, Cecchetti L, Tarozzi C, Corrao G, Bernardi M, Gasbarrini G. Bone mass and metabolism inpatients with celiac disease. Gastroenterology 1995; 109(1): 122-128.

Corazza GR, Di Sario A, Cecchetti L, Jorizzo RA, Di Stefano M, Minguzzi L, Brusco G, Bernardi M, Gasbarrini G. Influence of pattern of clinical presentation and of gluten-free diet on bone mass and metabolism in adult celiacdisease. Bone 1996; 18(6): 525-530.

De Lorenzo A, Di Campli C, Andreoli A, Sasso GF, Bonamico M, Gasbarrini A. Assessment of body composition bybioelectrical impedance in adolescent patients with celiac disease. Am J Gastroenterol 1999 Oct; 94(10):2951-2955.

Hartman C, Hino B, Lerner A, Eshach-Adiv O, Berkowitz D, Shaoul R, Pacht A, Rozenthal E, Tamir A, Shamaly H,Shamir R. Bone quantitative ultrasound and bone mineral density in children with celiac disease. JPGN2004;39:504-510.

Kalayci AG, Kansu A, Girgin N, Kucuk O, Aras G. Bone mineral density and importance of a gluten-free diet inpatients with celiac disease in childhood. Pediatrics 2001; 108(5): E89.

Kavak US, Yuce A, Kocak N, Demir H, Saltik IN, Gurakan F, Ozen H. Bone mineral density in children withuntreated and treated celiac disease. J Pediatr Gastroenterol Nutr 2003 Oct; 37(4): 434-436.

Kemppainen T, Kroger H, Janatuinen E, Arnala I, Lamberg-Allardt C, Karkkainen M, Kosma VM, Julkunen R,Jurvelin J, Alhava E, Uusitupa M. Bone recovery after a gluten-free diet: a 5-year follow-up study. Bone 1999;25: 355-360.

McFarlane XA, Bhalla AK, Reeves DE, Morgan LM, Robertson DAF. Osteoporosis in treated adult celiac disease. Gut 1995; 36: 710-714.

McFarlane XA, Bhalla AK, Robertson DAF. Effect of a gluten-free diet on osteopenia in adults with newlydiagnosed celiac disease. Gut 1996; 39: 180-184.

Molteni N, Bardella MT, Vezzoli G, Pozzoli E, Bianchi P. Intestinal calcium absorption as shown by stablestrontium test in celiac disease before and after gluten-free diet. Am J Gastroenterol 1995; 90: 2025-2028.

Mora S, Barera G, Ricotti A, Weber G, Bianchi C, Chiumello G. Reversal of low bone density with a gluten-freediet in children and adolescents with celiac disease. Am J Clin Nutr 1998; 67: 477-481.

Mora S, Barera G, Beccio S, Proverbio MC, Weber G, Bianchi C, Chiumello G. Bone density and bone metabolismare normal after long-term gluten-free diet in young celiac patients. Am J Gastroenterol 1999; 94: 398-403.

Mora S, Barera G, Beccio S, Menni L, Proverbio MC, Bianchi C, Chiumello G. A prospective, longitudinal study ofthe long-term effect of treatment on bone density in children with celiac disease. J Pediatr 2001; 139: 516-521.


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celiac diseasediagnosed celiac disease patients before and after the institution of a celiac disease...

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