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The Gluten-Free Diet: Use in Digestive Disease Management

  • Carolyn NewberryEmail author
Obesity and Nutrition (O Pickett-Blakely, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Obesity and Nutrition

Abstract

Purpose of Review

Gluten is a commonly ingested polymeric protein found in wheat, barley, and rye that has gained recent notoriety because of its relationship to disease and health. Avoidance of gluten is appropriate in patients with a diagnosed gluten–related disorder and may have treatment implications in other diseases of the digestive tract. This review highlights current knowledge of gluten related disorders and the use of a gluten-free diet in gastrointestinal disease management.

Recent Findings

Gluten-free diets should be used in patients with a diagnosed gluten–related disorder including celiac disease, non-celiac gluten sensitivity, and wheat-sensitive eosinophilic esophagitis. Use of this diet in management of other digestive conditions including gastroesophageal reflux disease, irritable bowel syndrome, and inflammatory bowel disease is controversial and not currently supported by the literature.

Summary

This review provides a framework for classifying gluten-related disorders in terms of pathogenesis, understanding the literature that supports dietary avoidance in modulation of gastrointestinal disease, and identifies limitations of dietary restriction in patients.

Keywords

Gluten Gluten-related disorders Diet Nutrition 

Notes

Author Contributions

Carolyn Newberry, MD was involved in the manuscript research, preparation, and final approval of the manuscript.

Compliance with Ethical Standards

Conflict of Interest

Carolyn Newberry declares the she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Guandalini S, Gokhale R. Update on immunologic basis of celiac disease. Curr Opin Gastroenterol. 2002;18(1):95–100 Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=n&CSC=Y&PAGE=fulltext&D=ovft&AN=00001574-200201000-00017.PubMedCrossRefGoogle Scholar
  2. 2.
    Kim H, Patel KG, Orosz E, et al. Time trends in the prevalence of celiac disease and gluten-free diet in the US population: results from the national health and nutrition examination surveys 2009-2014. JAMA Int Med. 2016;176(11):1716–7. Available from.  https://doi.org/10.1001/jamainternmed.2016.5254.CrossRefGoogle Scholar
  3. 3.
    Stamnaes J, Sollid LM. Celiac disease: autoimmunity in response to food antigen. Semin Immunol. 2015;27(5):343–52 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S104453231500072X.PubMedCrossRefGoogle Scholar
  4. 4.
    Cebolla Á, Moreno ML, Coto L, Sousa C. Gluten immunogenic peptides as standard for the evaluation of potential harmful prolamin content in food and human specimen. Nutrients. 2018;10(12):1927 Available from: https://www.ncbi.nlm.nih.gov/pubmed/30563126.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Real A, Comino I, de Lorenzo L, et al. Molecular and immunological characterization of gluten proteins isolated from oat cultivars that differ in toxicity for celiac disease. PLoS One. 2012;7(12):e48365 Available from: https://www.ncbi.nlm.nih.gov/pubmed/23284616.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Graveland A, Bosveld P, Lichtendonk WJ, et al. A model for the molecular structure of the glutenins from wheat flour. J Cereal Sci. 1985;3(1):1–16 Available from: https://www.sciencedirect.com/science/article/pii/S0733521085800291.CrossRefGoogle Scholar
  7. 7.
    Kagnoff MF. Celiac Disease Pathogenesis of a model immunogenetic disease. J Clin Invest. 2007;117(1):41–9 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1716218/.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Pietzak M. Celiac disease, wheat allergy, and gluten sensitivity. J Parenter Enteral Nutr. 2012;36(1_suppl):75S Available from: https://journals.sagepub.com/doi/full/10.1177/0148607111426276.CrossRefGoogle Scholar
  9. 9.
    •• Sapone A, Bai J, Ciacci C, et al. Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Medicine. 2012;10:13 Available from: https://search.datacite.org/works/10.7916/D8PR7TBW. This consensus statement defines current classification of gluten related disorders based on pathogenesis of disease.
  10. 10.
    Cianferoni A. Wheat allergy: diagnosis and management. J Asthma Allergy. 2016;9:13–25 Available from: https://www.ncbi.nlm.nih.gov/pubmed/26889090.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Reed CC, Dellon ES. Eosinophilic esophagitis. Med Clin of N Amer. 2019;103(1):29–42 Available from: https://www.sciencedirect.com/science/article/pii/S0025712518301007.CrossRefGoogle Scholar
  12. 12.
    Leonard MM, Sapone A, Catassi C, et al. Celiac disease and nonceliac gluten sensitivity: A review. JAMA. 2017;318(7):647–56. Available from.  https://doi.org/10.1001/jama.2017.9730.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Kim SM, Mayassi T, Jabri B. Innate immunity: actuating the gears of celiac disease pathogenesis. Best Prac Res: Clin Gastroenterol. 2015;29(3):425–35 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S1521691815000554.CrossRefGoogle Scholar
  14. 14.
    Bolotin D, Petronic-Rosic V. Dermatitis herpetiformis. J Am Acad Dermatol. 2010;64(6):1017–24 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S0190962210021225.CrossRefGoogle Scholar
  15. 15.
    Rubio-Tapia A, Hill ID, Kelly CP, et al. ACG clinical guidelines: diagnosis and management of celiac disease. Amer J Gastroenterol. 2013;108(5):656–76 Available from: https://www.ncbi.nlm.nih.gov/pubmed/23609613.CrossRefGoogle Scholar
  16. 16.
    Hadjivassiliou M, Boscolo S, Davies-Jones GAB, et al. The humoral response in the pathogenesis of gluten ataxia. Neurology. 2002;58(8):1221–6 Available from: https://www.ncbi.nlm.nih.gov/pubmed/11971090.PubMedCrossRefGoogle Scholar
  17. 17.
    Hadjivassiliou M, Davies-Jones GAB, Sanders DS, et al. Dietary treatment of gluten ataxia. J Neurol, Neurosurg & Psych. 2003;74(9):1221–4. Available from.  https://doi.org/10.1136/jnnp.74.9.1221.CrossRefGoogle Scholar
  18. 18.
    Hollon J, Puppa EL, Greenwald B, et al. Effect of gliadin on permeability of intestinal biopsy explants from celiac disease patients and patients with non-celiac gluten sensitivity. Nutrients. 2015;7(3):1565–76 Available from: https://www.ncbi.nlm.nih.gov/pubmed/25734566.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Matuchansky C. Gluten-free diet and irritable bowel syndrome–diarrhea. Gastroenterol. 2013;145(3):692–3 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S0016508513009992.CrossRefGoogle Scholar
  20. 20.
    Roque V, Camilleri MI, Smyrk M, et al. A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: effects on bowel frequency and intestinal function. Gastroenterol. 2013;144(5):911.e3 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S0016508513001352.Google Scholar
  21. 21.
    Lebwohl B, Ludvigsson J, Green PH. Celiac disease and non-celiac gluten sensitivity. BMJ. 2015;351:h4347 Available from: htps://www.bmj.com/content/351/bmj.h4347.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Bardella MT, Fredella C, Prampolini L. Body composition and dietary intakes in adult celiac disease patients consuming a strict gluten-free diet. Amer J Clini Nutr. 2000;72(4):937–9 Available from: https://www.ncbi.nlm.nih.gov/pubmed/11010934.CrossRefGoogle Scholar
  23. 23.
    Kupper C. Dietary guidelines and implementation for celiac disease. Gastroenterol. 2005;128(4):S127 Available from: https://www.sciencedirect.com/science/article/pii/S0016508505001939.CrossRefGoogle Scholar
  24. 24.
    Nachman F, Sugai E, Vázquez H, et al. Serological tests for celiac disease as indicators of long-term compliance with the gluten-free diet. Eur J Gastroenterol Hepatol. 2011;23(6):473–80 Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=n&CSC=Y&PAGE=fulltext&D=ovft&AN=00042737-201106000-00005.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Malamut G, Murray J, Cellier C. Refractory celiac disease. Gastrointest Endosc Clin N Am. 2012;22(4):759–72 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S1052515712000992.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Cash BD, Rubenstein JH, Young PE, et al. The prevalence of celiac disease among patients with non-constipated irritable bowel syndrome is similar to controls. Gastroenterology. 2011;141(4):1187–93 Available from: https://www.ncbi.nlm.nih.gov/pubmed/21762658.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    •• Biesiekierski JR, Peters SL, Newnham ED, et al. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterol. 2013;145(2):328.e3 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S0016508513007026. This article discusses the potential overlap between symptoms induced by gluten and FODMAP ingestion by double blind crossover trial.CrossRefGoogle Scholar
  28. 28.
    Dellon ES, Gonsalves N, Hirano I. ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Amer J Gastroenterol. 2013;108(5):679–92 Available from: https://www.ncbi.nlm.nih.gov/pubmed/23567357.CrossRefGoogle Scholar
  29. 29.
    Warners MJ, Vlieg-Boerstra BJ, Bredenoord AJ. Elimination and elemental diet therapy in eosinophilic oesophagitis. Best Prac Res: Clin Gastroenterol. 2015;29(5):793–803 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S1521691815000980.CrossRefGoogle Scholar
  30. 30.
    Kagalwalla AF, Sentongo TA, Ritz S. Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2006;4(9):1097–102 Available from:.PubMedCrossRefGoogle Scholar
  31. 31.
    Molina-Infante J, Lucendo AJ. Dietary therapy for eosinophilic esophagitis. J Allergy Clin Immunol. 2018;142(1):41–7 Available from: https://www.sciencedirect.com/science/article/pii/S0091674918303208.PubMedCrossRefGoogle Scholar
  32. 32.
    Gonsalves N, Yang G-Y, Doerfler B, et al. Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterol. 2012;142(7):1459.e1 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S0016508512003095.CrossRefGoogle Scholar
  33. 33.
    Kagalwalla A, Shah A, Li B, et al. Identification of specific foods responsible for inflammation in children with eosinophilic esophagitis successfully treated with empiric elimination diet. J Ped Gastroenterol Nut. 2011;53(2):145–9 Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=n&CSC=Y&PAGE=fulltext&D=ovft&AN=00005176-201108000-00006.CrossRefGoogle Scholar
  34. 34.
    Doerfler B, Bryce P, Hirano I, et al. Practical approach to implementing dietary therapy in adults with eosinophilic esophagitis: the chicago experience. Dis Esophagus. 2015;28(1):42–58 Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/dote.12175.PubMedCrossRefGoogle Scholar
  35. 35.
    Kliewer K, Venter C, Cassin A, et al. Should wheat, barley, rye, and/or gluten be avoided in a 6-food elimination diet? J Allergy Clin Immunol. 2015;137(4):1011–4 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S0091674915017261.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Vakil N, van Zanten Sander V, Kahrilas P, et al. The montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Amer J Gastroenterol. 2006;101(8):1900–20. Available from.  https://doi.org/10.1111/j.1572-0241.2006.00630.x.CrossRefGoogle Scholar
  37. 37.
    Ness-Jensen E, Hveem K, El-Serag H, et al. Lifestyle intervention in gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2016;14(2):175 Available from: http://kipublications.ki.se/Default.aspx?queryparsed=id:132991735.PubMedCrossRefGoogle Scholar
  38. 38.
    MacFarlane NG. Digestion and absorption. Anesth Int Care Med. 2018;19(3):125–7 Available from: https://www.sciencedirect.com/science/article/pii/S1472029918300018.CrossRefGoogle Scholar
  39. 39.
    Piche T, des Varannes SB, Sacher-Huvelin S, Holst JJ, et al. Colonic fermentation influences lower esophageal sphincter function in gastroesophageal reflux disease. Gastroenterol. 2003;124(4):894–902 Available from: https://www.sciencedirect.com/science/article/pii/S0016508503000738.CrossRefGoogle Scholar
  40. 40.
    Morozov S, Isakov V, Konovalova M. Fiber-enriched diet helps to control symptoms and improves esophageal motility in patients with non-erosive gastroesophageal reflux disease. World J Gastroenterol. 2018;24(21):2291–9 Available from: https://www.ncbi.nlm.nih.gov/pubmed/29881238.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    DiSilvestro RA, Verbruggen MA, Offutt EJ. Anti-heartburn effects of a fenugreek fiber product. Phytotherapy Res. 2011;25(1):88–91 Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/ptr.3229.CrossRefGoogle Scholar
  42. 42.
    Usai P, Manca R, Cuomo R, et al. Effect of gluten-free diet on preventing recurrence of gastroesophageal reflux disease–related symptoms in adult celiac patients with nonerosive reflux disease. J Gastroenterol Hepatol. 2008;23(9):1368–72 Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1440-1746.2008.05507.x.PubMedCrossRefGoogle Scholar
  43. 43.
    Zhang Y-Z, Li Y-Y. Inflammatory bowel disease: pathogenesis. World J Gastroenterol. 2014;20(1):91–9 Available from: https://www.wjgnet.com/1007-9327/full/v20/i1/91.htm.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Hou JK, Bincy AB, El-Serag H. Dietary intake and risk of developing inflammatory bowel disease: a systematic review of the literature. Am J Gastroenterol. 2011;106(4):563–73 Available from: https://www.ncbi.nlm.nih.gov/pubmed/21468064.CrossRefGoogle Scholar
  45. 45.
    Limketkai BN, Iheozor-Ejiofor Z, Gjuladin-Hellon T, et al. Dietary interventions for induction and maintenance of remission in inflammatory bowel disease. Cochrane Database Syst Rev. 2019;2:CD012839 Available from: https://www.ncbi.nlm.nih.gov/pubmed/30736095.PubMedGoogle Scholar
  46. 46.
    Herfarth HH, Martin CF, Sandler RS, et al. Prevalence of a gluten-free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases. Inflamm Bowel Dis. 2014;20(7):1994–7 Available from: https://www.ncbi.nlm.nih.gov/pubmed/24865778.CrossRefGoogle Scholar
  47. 47.
    Limketkai BN, Sepulveda R, Hing T, et al. Prevalence and factors associated with gluten sensitivity in inflammatory bowel disease. Scand J Gastroenterol. 2018;53(2):147–51 Available from: http://www.tandfonline.com/doi/abs/10.1080/00365521.2017.1409364.PubMedCrossRefGoogle Scholar
  48. 48.
    Singh J, Whelan K. Limited availability and higher cost of gluten-free foods. J Human Nutr Diet. 2011;24(5):479–86 Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-277X.2011.01160.x.CrossRefGoogle Scholar
  49. 49.
    Allen B, Orfila C. The availability and nutritional adequacy of gluten-free bread and pasta. Nutrients. 2018;10(10):1370 Available from: https://www.ncbi.nlm.nih.gov/pubmed/30257431.PubMedCentralCrossRefPubMedGoogle Scholar
  50. 50.
    Shepherd SJ, Gibson PR. Nutritional inadequacies of the gluten-free diet in both recently-diagnosed and long-term patients with coeliac disease. J Hum Nutr Diet. 2013;26(4):349–58 Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/jhn.12018.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Vici G, Belli L, Biondi M, et al. Gluten free diet and nutrient deficiencies: a review. Clin Nutr. 2016;35(6):1236–41 Available from: https://www.clinicalkey.es/playcontent/1-s2.0-S0261561416300887.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Thompson T. Folate, Iron and dietary fiber contents of the GFD. J Amer Diet Assoc. 2000;100(11):1389–96 Available from: https://www.researchgate.net/publication/12223715_Folate_Iron_and_Dietary_Fiber_Contents_of_the_Gluten-free_Diet.CrossRefGoogle Scholar
  53. 53.
    Thompson T. Thiamine, riboflavin, and niacin contents of the GFD. J Am Diet Assoc. 1999;99(7):858–62 Available from: https://linkinghub.elsevier.com/retrieve/pii/S0002822399002059.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Newberry C, McKnight L, Sarav M, et al. Going gluten free: the history and nutritional implications of today’s most popular diet. Curr Gastroenterol Rep. 2017;19(11):1–8 Available from: https://www.ncbi.nlm.nih.gov/pubmed/28948465.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of GastroenterologyWeill Cornell Medical CenterNew YorkUSA

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