CSA Library Series is a collection of articles that pertain to celiac disease and dermatitis herpetiformis. Most of these articles have appeared in CSA’s quarterly newsletter, Lifeline, which all CSA members receive. Historic articles included in these resources may or may not include updated notes. Updated information indicated in red type. Articles represent the work of the author.

Nutritional Care: The Clinical Diet

Leon H. Rottmann, Ph.D., Professor Emeritus, University of Nebraska-Lincoln
Excerpted from CSA Handbook, Ist Edition
Lifeline, Winter 1995, Vol XIII, No 1, pp 1-2

Treatment for nontropical sprue includes correcting the nutritional malfunction of the small bowel and the deficiency states. Removal of gluten from the diet results in the histological appearance of the intestinal mucosa returning to the normal state. Those conditions represent the need for the clinical gluten-free diet for nontropical sprue (celiac sprue) patients.

Gluten-Free Diet. A specific diet that omits the glutamine-bound fraction of protein (glutenin and gliadin) is the clinical treatment of choice for nontropical sprue. In this diet wheat, rye, barley and oats are excluded, since they all contain large amounts of this protein fraction. Buckwheat and millet are also excluded because of lack of reliable information about their glutamine content.

[Please see updated information on buckwheat and millet.]

The gluten-free diet means that all bakery products and packaged foods must be scrutinized before they are used. Labels must be read carefully because, besides being a basic ingredient, gliadin-containing grains may be added as a derivative when the food is processed or prepared. For example, hydrolyzed vegetable protein may be made from soy or corn, or it may be made from mixtures of wheat, corn and soy. Thus, the need to know the content of hydrolyzed vegetable protein (HVP) before ingestion by celiac patients.

Cereal products that can be used as substitutes are corn flour, cornmeal, potato flour, rice flour, soybean flour, tapioca flour and tapioca starch, and arrowroot starch. During the first few weeks of gluten restriction, the diet may be supplemented with vitamins and minerals and may need to be high in protein in order to cure deficiencies and replenish nutrient stores. These needs may not exist, supplementation is best defined through prescription by the monitoring physician.

Both the immediate and long-term effects of the gluten-free diet have been clinically satisfactory. Any relapses are usually due to dietary indiscretions and promptly subside when gluten is again removed from the diet. For the celiac patient, there is no possibility to consider that "only a little bit may not hurt." One molecule of gluten may be just as bad as 10,000.

Just because the person with celiac sprue is free of symptoms after eating gluten does not mean that there is no villi damage. There usually is, although it may take weeks or months to develop. It has been observed that if adults go on and off a gluten-free diet a number of times, they may reach a stage at which they do not respond to a gluten-free diet. In extreme cases, the patient may move on to a secondary condition of refractory sprue.

Some patients with untreated celiac sprue develop aggravation of their symptoms after ingestion of milk or milk products. The probable cause of milk intolerance is lactase deficiency secondary to the reduced number of and damage to the intestinal absorptive cells that produce lactase. Milk and milk products develop milk tolerance as intestinal structure and function appears normal after gluten withdrawal.

If the disease has been severe, patients may need supplements in addition to the gluten-free diet. Anemic patients may need to receive iron, folate and/or vitamin B-12, depending upon the type and nature of the anemia. Vitamin K may be given there is purpura, bleeding or prolonged prothrombin time. Electrolyte and fluid replacement may be needed with patients with symptoms of dehydration from severe diarrhea. Calcium and vitamin D administration under physician monitoring may be necessary to correct osteomalacia. A multiple vitamin-mineral supplement should be taken regularly by nontropical sprue patients who continue to have malabsorption. Celiac sprue patients who are self-directed regarding the use of vitamins and food supplements are often ill-advised and misdirected; the complexity of the malabsorption problem represented in sprue is best handled with the monitoring of a physician who has access to the clinical evaluation, history and dietary needs of the patient involved.

Prognosis. In children a gluten-free diet almost always results in a return to normal absorption; however, this is not always so in adults. Even though they gain relief with a gluten-free diet, some adults still continue to have intestinal abnormalities as revealed by biopsy. Likewise, persons with celiac sprue who eat gluten but do not have clinical symptoms still show damage to intestinal villi. One does not outgrow nontropical sprue (celiac disease). There is still destruction of villi upon gluten ingestion, even thought clinical symptoms may abate for months or years or into later life.

Several research reports and individual case histories suggest an increased incidence of malignant disease in adults with celiac sprue than in the general population. Gastrointestinal carcinomas and lymphomas seem to be the most common types of cancers reported. The true increase in the incidence is not known at this time. It is believed that strict adherence to the clinical gluten-free diet reduces the incidence of intestinal lymphoma and other malignancies in celiac sprue patients, however, additional case studies and research follow-up are needed to further define the diet/cancer relationship.