Management—the gluten-free diet
Once you diagnose celiac disease, assess the patient’s nutritional intake, test his or her bone mineral density (BMD), and address deficiencies. Iron, folate, vitamin B12, zinc, copper, calcium, and vitamin D status are particularly important, observes Dr. Murray.
The primary—and usually the only—long-term treatment for celiac disease is strict adherence to a gluten-free diet (GFD), a regimen in which wheat, rye, and barley products are rigorously excluded. “Celiac disease has become common enough that family physicians need to be comfortable monitoring the GFD,” he says.
The Technical Review cites data indicating that adherence to a GFD reduces the risk of NHL, in some studies bringing it down to that of the general population. Physical parameters, including BMD, body weight, and fat and lean mass, have also been shown to improve. The GFD appears to have a positive effect on nutritional and biochemical status, including resolution of IDA.
Patient education is key in fostering compliance with this challenging diet. “It is reasonable to suggest that interventions designed to improve knowledge about celiac disease as well as about the GFD” and the “outcomes of untreated celiac disease” are likely to improve compliance, the Position Statement notes.
The assistance of a registered dietitian is invaluable, both in designing a diet and monitoring patient adherence to it. “I recommend physicians identify one or two dietitians in their community with expertise in celiac disease,” Dr. Murray says. Local celiac disease groups can be important resources for practical information and emotional support. (Check the Web sites of such organizations as the Celiac Disease Foundation and the Celiac Sprue Association.)
“When speaking with patients, the important thing is for the doctor to be positive,” Dr. Murray says. “If he transmits the attitude, ‘I could never follow this diet,’ it sets up the patient for failure.” Expressions of interest and empathy are important for promoting the therapeutic alliance and adherence.
The Position Statement recommends regular evaluations to assess compliance with the GFD and to detect and manage lapses and difficulties. Beyond symptomatic improvement, repeated serologic testing after six months can help assess histologic resolution and adherence to treatment (although, as the authors point out, these tests are not sensitive to minor transient dietary transgressions).
Continuing or relapsing symptoms are usually the result of deliberate nonadherence or inadvertent gluten consumption on the part of the patient. If these have been ruled out, the possibility of separate or associated illness, such as irritable bowel syndrome, pancreatic insufficiency, or microscopic colitis, needs to be explored.
True refractory celiac disease, in which intestinal atrophy fails to respond in a patient who has been compliant with the GFD, requires referral to a gastroenterologist.
The AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease was published in Gastroenterology (2006;131:1977-1980). The American Gastroenterological Association (AGA) Institute Technical Review on the Diagnosis and Management of Celiac Disease was published in the same issue of Gastroenterology (2006:131:1981-2002).