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AAP National Conference: Should your patient be on a gluten-free diet? :

October 25, 2016

It seems everyone is going gluten-free these days.

Once reserved for just a few conditions like celiac disease (CD), the diet now is touted as an antidote for a range of disorders from irritable bowel syndrome (IBS) to autism. Many people also are shunning gluten simply because they believe they will be healthier without it.

“If you had asked me 20 years ago, when I first started doing research on CD, I would have never imagined that the gluten-free diet would go mainstream,” said Michelle Pietzak, M.D., a pediatric gastroenterologist and assistant professor of clinical pediatrics at the University of Southern California Keck School of Medicine.

But like your mother told you, just because everyone is doing it, doesn’t make it right.

Dr. Pietzak discussed when the diet should and should not be used during a session titled “Don’t Just 'Try' a Gluten-Free Diet: It May Not Be Celiac Disease.”

“Many physicians think the gluten-free diet is a fad; it’s not,” she said. “It’s medical nutritional therapy for a specific group of patients,” she said.

That group includes patients with CD, an immune-mediated enteropathy whereby there is an immune response to the gliadin portion of wheat and related alcohol-soluble proteins found in grains, particularly wheat, rye and barley, Dr. Pietzak explained.

“You do not need to have GI symptoms to have CD,” she said. “Many children present with iron deficiency anemia, short stature and delayed puberty without GI symptoms.”

Screening for the disease is done by measuring specific antibodies. Patients who screen positive should be referred to a gastroenterologist for an endoscopic biopsy to confirm the diagnosis.

“Many patients (with CD) get mislabeled as having other diseases, such as IBS, lactose intolerance or hypochondria before getting the diagnosis,” she said.

For those diagnosed with CD, a gluten-free diet is the only proven treatment that results in improvements in symptomatology and small bowel histology, according to an article Dr. Pietzak wrote titled “Celiac Disease, Wheat Allergy, and Gluten Sensitivity: When Gluten Free Is Not a Fad” (JPEN J Parenter Enteral Nutr. 2012;36:68S-75S).

Steering clear of gluten also might help those with wheat allergy. The immune responses in wheat allergy are directed at three types of gliadins, Dr. Pietzak said. The IgE response to the insoluble gliadin leads to a specific constellation of symptoms.

More controversial is gluten sensitivity, also called “non-celiac gluten sensitivity (NCGS)” or “wheat intolerance syndrome.” There is no specific test for NCGS. It occurs in individuals who do not have CD or wheat allergy but have gastrointestinal or extra-intestinal symptoms after ingesting gluten or wheat-containing foods. A gluten-free diet may improve symptoms.

“It is important for patients and health care practitioners to understand the differences between these conditions, even though they may all respond to a GFD (gluten-free diet),” Dr. Pietzak wrote in the article.

Those with CD, for example, often have other autoimmune conditions such as thyroid disease, diabetes and liver disease; nutritional deficiencies; and increased risk for osteoporosis, fractures and cancers.

Finally, despite the fact that gluten-free foods are now a multibillion-dollar industry, eliminating gluten from one’s diet is not an easy task.

“The gluten-free diet is very restrictive and difficult to do in a child without the assistance of a registered dietitian,” Dr. Pietzak said. “In addition, people on a gluten-free diet often don’t get enough fiber, folic acid and other trace minerals and vitamins in their diet.”

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