Skip to main content

Advertisement

SpringerLink
Log in

Celiac disease: understanding the gluten-free diet

  • Review
  • Published:
European Journal of Nutrition Aims and scope Submit manuscript

Abstract

Purpose

The only effective and safe treatment of celiac disease (CD) continues being strict exclusion of gluten for life, the so-called gluten-free diet (GFD). Although this treatment is highly successful, following strict GFD poses difficulties to patients in family, social and working contexts, deteriorating his/her quality of life. We aimed to review main characteristics of GFD with special emphasis on factors that may interfere with adherence to it.

Methods

We conducted a search of various databases, such as PubMed, Google Scholar, Embase, and Scielo, with focus on key words such as “gluten-free diet”, “celiac disease”, “gluten” and “gluten-free diet adherence”. Available literature has not reached definitive conclusions on the exact amount of gluten that is harmless to celiac patients, although international agreements establish cutoff points for gluten-free products and advise the use of clinical assessment to tailor the diet according to individual needs. Following GFD must include eliminating gluten as ingredient as well as hidden component and potential cross contamination in foods. There are numerous grains to substitute wheat but composition of most gluten-free products tends to include only a small number of them, especially rice. The diet must be not only free of gluten but also healthy to avoid nutrient, vitamins and minerals deficiencies or excess. Overweight/obesity frequency has increased among celiac patients so weight gain deserves attention during follow up. Nutritional education by a trained nutritionist is of great relevance to achieve long-term satisfactory health status and good compliance.

Conclusions

A balanced GFD should be based on a combination of naturally gluten-free foods and certified processed gluten-free products. How to measure and improve adherence to GFD is still controversial and deserves further study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Green PH, Lebwohl B, Greywoode R (2015) Celiac disease. J Allergy Clin Immunol 135(5):1099–1106. doi:10.1016/j.jaci.2015.01.044

    Article  CAS  Google Scholar 

  2. Schuppan D, Zimmer KP (2013) The diagnosis and treatment of celiac disease. Dtsch Arztebl Int 110(49):835–846. doi:10.3238/arztebl.2013.0835

    Google Scholar 

  3. Accomando S, Cataldo F (2004) The global village of celiac disease. Dig Liver Dis 36(7):492–498. doi:10.1016/j.dld.2004.01.026

    Article  CAS  Google Scholar 

  4. Leffler DA, Schuppan D (2010) Update on serologic testing in celiac disease. Am J Gastroenterol 105(12):2520–2524. doi:10.1038/ajg.2010.276

    Article  Google Scholar 

  5. Catassi C, Ratsch IM, Gandolfi L, Pratesi R, Fabiani E, El Asmar R, Frijia M, Bearzi I, Vizzoni L (1999) Why is coeliac disease endemic in the people of the Sahara? Lancet 354(9179):647–648

    Article  CAS  Google Scholar 

  6. Ciacci C, Cirillo M, Cavallaro R, Mazzacca G (2002) Long-term follow-up of celiac adults on gluten-free diet: prevalence and correlates of intestinal damage. Digestion 66(3):178–185. doi:10.1159/000066757

    Article  CAS  Google Scholar 

  7. Ludvigsson JF, Montgomery SM, Ekbom A, Brandt L, Granath F (2009) Small-intestinal histopathology and mortality risk in celiac disease. JAMA 302(11):1171–1178. doi:10.1001/jama.2009.1320

    Article  CAS  Google Scholar 

  8. Lee A, Newman JM (2003) Celiac diet: its impact on quality of life. J Am Diet Assoc 103(11):1533–1535. doi:10.1016/S0002-8223(03)01233-1

    Article  Google Scholar 

  9. Parnell ND, Ciclitira PJ (1999) Review article: coeliac disease and its management. Aliment Pharmacol Ther 13(1):1–13

    Article  CAS  Google Scholar 

  10. Hallert C, Grant C, Grehn S, Granno C, Hulten S, Midhagen G, Strom M, Svensson H, Valdimarsson T (2002) Evidence of poor vitamin status in coeliac patients on a gluten-free diet for 10 years. Aliment Pharmacol Ther 16(7):1333–1339

    Article  CAS  Google Scholar 

  11. Kupper C (2005) Dietary guidelines and implementation for celiac disease. Gastroenterology 128(4 Suppl 1):S121–S127

    Article  CAS  Google Scholar 

  12. Thompson T, Dennis M, Higgins LA, Lee AR, Sharrett MK (2005) Gluten-free diet survey: are Americans with coeliac disease consuming recommended amounts of fibre, iron, calcium and grain foods? J Hum Nutr Diet 18(3):163–169. doi:10.1111/j.1365-277X.2005.00607.x

    Article  CAS  Google Scholar 

  13. Saturni L, Ferretti G, Bacchetti T (2010) The gluten-free diet: safety and nutritional quality. Nutrients 2(1):16–34. doi:10.3390/nu20100016

    Article  CAS  Google Scholar 

  14. La Vieille S, Dubois S, Hayward S, Koerner TB (2014) Estimated levels of gluten incidentally present in a Canadian gluten-free diet. Nutrients 6(2):881–896. doi:10.3390/nu6020881

    Article  CAS  Google Scholar 

  15. Catassi C, Bai JC, Bonaz B, Bouma G, Calabro A, Carroccio A, Castillejo G, Ciacci C, Cristofori F, Dolinsek J, Francavilla R, Elli L, Green P, Holtmeier W, Koehler P, Koletzko S, Meinhold C, Sanders D, Schumann M, Schuppan D, Ullrich R, Vecsei A, Volta U, Zevallos V, Sapone A, Fasano A (2013) Non-celiac gluten sensitivity: the new frontier of gluten related disorders. Nutrients 5(10):3839–3853. doi:10.3390/nu5103839

    Article  CAS  Google Scholar 

  16. Ludvigsson JF, Leffler DA, Bai JC, Biagi F, Fasano A, Green PH, Hadjivassiliou M, Kaukinen K, Kelly CP, Leonard JN, Lundin KE, Murray JA, Sanders DS, Walker MM, Zingone F, Ciacci C (2013) The Oslo definitions for coeliac disease and related terms. Gut 62(1):43–52. doi:10.1136/gutjnl-2011-301346

    Article  Google Scholar 

  17. Fasano A, Sapone A, Zevallos V, Schuppan D (2015) Nonceliac gluten sensitivity. Gastroenterology 148(6):1195–1204. doi:10.1053/j.gastro.2014.12.049

    Article  CAS  Google Scholar 

  18. Ontiveros N, Lopez-Gallardo JA, Vergara-Jimenez MJ, Cabrera-Chavez F (2015) Self-reported prevalence of symptomatic adverse reactions to gluten and adherence to gluten-free diet in an Adult Mexican Population. Nutrients 7(7):6000–6015. doi:10.3390/nu7075267

    Article  Google Scholar 

  19. Volta U, Bardella MT, Calabro A, Troncone R, Corazza GR, Study Group for Non-Celiac Gluten S (2014) An Italian prospective multicenter survey on patients suspected of having non-celiac gluten sensitivity. BMC Med 12:85. doi:10.1186/1741-7015-12-85

    Article  Google Scholar 

  20. Sapone A, Bai JC, Ciacci C, Dolinsek J, Green PH, Hadjivassiliou M, Kaukinen K, Rostami K, Sanders DS, Schumann M, Ullrich R, Villalta D, Volta U, Catassi C, Fasano A (2012) Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Med 10:13. doi:10.1186/1741-7015-10-13

    Article  Google Scholar 

  21. Lebwohl B, Ludvigsson JF, Green PH (2015) Celiac disease and non-celiac gluten sensitivity. BMJ 351:h4347. doi:10.1136/bmj.h4347

    Article  CAS  Google Scholar 

  22. Inomata N (2009) Wheat allergy. Curr Opin Allergy Clin Immunol 9(3):238–243. doi:10.1097/ACI.0b013e32832aa5bc

    Article  CAS  Google Scholar 

  23. Jones SM, Magnolfi CF, Cooke SK, Sampson HA (1995) Immunologic cross-reactivity among cereal grains and grasses in children with food hypersensitivity. J Allergy Clin Immunol 96(3):341–351

    Article  CAS  Google Scholar 

  24. Matricardi PM, Bockelbrink A, Beyer K, Keil T, Niggemann B, Gruber C, Wahn U, Lau S (2008) Primary versus secondary immunoglobulin E sensitization to soy and wheat in the Multi-Centre Allergy Study cohort. Clin Exp Allergy J Br Soc Allergy Clin Immunol 38(3):493–500. doi:10.1111/j.1365-2222.2007.02912.x

    Article  CAS  Google Scholar 

  25. Tatham AS, Shewry PR (2008) Allergens to wheat and related cereals. Clin Exp Allergy J Br Soc Allergy Clin Immunol 38(11):1712–1726. doi:10.1111/j.1365-2222.2008.03101.x

    CAS  Google Scholar 

  26. Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG (2014) A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology 146(1):67–75 e65. doi:10.1053/j.gastro.2013.09.046

    Article  CAS  Google Scholar 

  27. Lis DM, Stellingwerff T, Shing CM, Ahuja KD, Fell JW (2015) Exploring the popularity, experiences, and beliefs surrounding gluten-free diets in nonceliac athletes. Int J Sport Nutr Exerc Metab 25(1):37–45. doi:10.1123/ijsnem.2013-0247

    Article  Google Scholar 

  28. Markets and Markets (2015) Gluten-free products market by type, sales channel and geography: global trends and forecasts to 2018. http://www.marketsandmarkets.com/Market-Reports/gluten-free-products-market-738.html. Accessed Jan 2016

  29. Greco L (1997) From the neolithic revolution to gluten intolerance: benefits and problems associated with the cultivation of wheat. J Pediatr Gastroenterol Nutr 24(5):S14–S16 (discussion S16-17)

    Article  CAS  Google Scholar 

  30. van den Broeck HC, van Herpen TW, Schuit C, Salentijn EM, Dekking L, Bosch D, Hamer RJ, Smulders MJ, Gilissen LJ, van der Meer IM (2009) Removing celiac disease-related gluten proteins from bread wheat while retaining technological properties: a study with Chinese Spring deletion lines. BMC Plant Biol 9:41. doi:10.1186/1471-2229-9-41

    Article  CAS  Google Scholar 

  31. Ang S, Kogulanathan J, Morris GA, Kok MS, Shewry PR, Tatham AS, Adams GG, Rowe AJ, Harding SE (2010) Structure and heterogeneity of gliadin: a hydrodynamic evaluation. Eur Biophys J 39(2):255–261. doi:10.1007/s00249-009-0529-7

    Article  CAS  Google Scholar 

  32. Frisoni M, Corazza GR, Lafiandra D, De Ambrogio E, Filipponi C, Bonvicini F, Borasio E, Porceddu E, Gasbarrini G (1995) Wheat deficient in gliadins: promising tool for treatment of coeliac disease. Gut 36(3):375–378

    Article  CAS  Google Scholar 

  33. Spaenij-Dekking L, Kooy-Winkelaar Y, van Veelen P, Drijfhout JW, Jonker H, van Soest L, Smulders MJ, Bosch D, Gilissen LJ, Koning F (2005) Natural variation in toxicity of wheat: potential for selection of nontoxic varieties for celiac disease patients. Gastroenterology 129(3):797–806. doi:10.1053/j.gastro.2005.06.017

    Article  CAS  Google Scholar 

  34. Carroccio A, Di Prima L, Noto D, Fayer F, Ambrosiano G, Villanacci V, Lammers K, Lafiandra D, De Ambrogio E, Di Fede G, Iacono G, Pogna N (2011) Searching for wheat plants with low toxicity in celiac disease: between direct toxicity and immunologic activation. Dig Liver Dis 43(1):34–39. doi:10.1016/j.dld.2010.05.005

    Article  Google Scholar 

  35. Parada A, Araya M (2010) History of gluten and its effects on celiac disease. Rev Med Chil 138(10):1319–1325. doi:10.4067/S0034-98872010001100018

    Article  CAS  Google Scholar 

  36. Mitea C, Salentijn EM, van Veelen P, Goryunova SV, van der Meer IM, van den Broeck HC, Mujico JR, Montserrat V, Gilissen LJ, Drijfhout JW, Dekking L, Koning F, Smulders MJ (2010) A universal approach to eliminate antigenic properties of alpha-gliadin peptides in celiac disease. PLoS One 5(12):e15637. doi:10.1371/journal.pone.0015637

    Article  CAS  Google Scholar 

  37. Auricchio S, De Ritis G, De Vincenzi M, Occorsio P, Silano V (1982) Effects of gliadin-derived peptides from bread and durum wheats on small intestine cultures from rat fetus and coeliac children. Pediatr Res 16(12):1004–1010

    Article  CAS  Google Scholar 

  38. Kagnoff MF (2007) Celiac disease: pathogenesis of a model immunogenetic disease. J Clin Invest 117(1):41–49. doi:10.1172/JCI30253

    Article  CAS  Google Scholar 

  39. Rescigno M, Urbano M, Valzasina B, Francolini M, Rotta G, Bonasio R, Granucci F, Kraehenbuhl JP, Ricciardi-Castagnoli P (2001) Dendritic cells express tight junction proteins and penetrate gut epithelial monolayers to sample bacteria. Nat Immunol 2(4):361–367. doi:10.1038/86373

    Article  CAS  Google Scholar 

  40. Ciccocioppo R, Di Sabatino A, Parroni R, D’Alo S, Pistoia MA, Doglioni C, Cifone MG, Corazza GR (2000) Cytolytic mechanisms of intraepithelial lymphocytes in coeliac disease (CoD). Clin Exp Immunol 120(2):235–240

    Article  CAS  Google Scholar 

  41. Di Sabatino A, Ciccocioppo R, Cupelli F, Cinque B, Millimaggi D, Clarkson MM, Paulli M, Cifone MG, Corazza GR (2006) Epithelium derived interleukin 15 regulates intraepithelial lymphocyte Th1 cytokine production, cytotoxicity, and survival in coeliac disease. Gut 55(4):469–477. doi:10.1136/gut.2005.068684

    Article  CAS  Google Scholar 

  42. Salvati VM, Mazzarella G, Gianfrani C, Levings MK, Stefanile R, De Giulio B, Iaquinto G, Giardullo N, Auricchio S, Roncarolo MG, Troncone R (2005) Recombinant human interleukin 10 suppresses gliadin dependent T cell activation in ex vivo cultured coeliac intestinal mucosa. Gut 54(1):46–53. doi:10.1136/gut.2003.023150

    Article  CAS  Google Scholar 

  43. Burgess SJ, Maasho K, Masilamani M, Narayanan S, Borrego F, Coligan JE (2008) The NKG2D receptor: immunobiology and clinical implications. Immunol Res 40(1):18–34. doi:10.1007/s12026-007-0060-9

    Article  CAS  Google Scholar 

  44. Meresse B, Chen Z, Ciszewski C, Tretiakova M, Bhagat G, Krausz TN, Raulet DH, Lanier LL, Groh V, Spies T, Ebert EC, Green PH, Jabri B (2004) Coordinated induction by IL15 of a TCR-independent NKG2D signaling pathway converts CTL into lymphokine-activated killer cells in celiac disease. Immunity 21(3):357–366. doi:10.1016/j.immuni.2004.06.020

    Article  CAS  Google Scholar 

  45. Pagliari D, Cianci R, Frosali S, Landolfi R, Cammarota G, Newton EE, Pandolfi F (2013) The role of IL-15 in gastrointestinal diseases: a bridge between innate and adaptive immune response. Cytokine Growth Factor Rev 24(5):455–466. doi:10.1016/j.cytogfr.2013.05.004

    Article  CAS  Google Scholar 

  46. Hue S, Mention JJ, Monteiro RC, Zhang S, Cellier C, Schmitz J, Verkarre V, Fodil N, Bahram S, Cerf-Bensussan N, Caillat-Zucman S (2004) A direct role for NKG2D/MICA interaction in villous atrophy during celiac disease. Immunity 21(3):367–377. doi:10.1016/j.immuni.2004.06.018

    Article  Google Scholar 

  47. Maiuri L, Ciacci C, Auricchio S, Brown V, Quaratino S, Londei M (2000) Interleukin 15 mediates epithelial changes in celiac disease. Gastroenterology 119(4):996–1006

    Article  CAS  Google Scholar 

  48. Benahmed M, Meresse B, Arnulf B, Barbe U, Mention JJ, Verkarre V, Allez M, Cellier C, Hermine O, Cerf-Bensussan N (2007) Inhibition of TGF-beta signaling by IL-15: a new role for IL-15 in the loss of immune homeostasis in celiac disease. Gastroenterology 132(3):994–1008. doi:10.1053/j.gastro.2006.12.025

    Article  CAS  Google Scholar 

  49. Meresse B, Verdier J, Cerf-Bensussan N (2008) The cytokine interleukin 21: a new player in coeliac disease? Gut 57(7):879–881. doi:10.1136/gut.2007.141994

    Article  CAS  Google Scholar 

  50. Daum S, Bauer U, Foss HD, Schuppan D, Stein H, Riecken EO, Ullrich R (1999) Increased expression of mRNA for matrix metalloproteinases-1 and -3 and tissue inhibitor of metalloproteinases-1 in intestinal biopsy specimens from patients with coeliac disease. Gut 44(1):17–25

    Article  CAS  Google Scholar 

  51. Junker Y, Zeissig S, Kim SJ, Barisani D, Wieser H, Leffler DA, Zevallos V, Libermann TA, Dillon S, Freitag TL, Kelly CP, Schuppan D (2012) Wheat amylase trypsin inhibitors drive intestinal inflammation via activation of toll-like receptor 4. J Exp Med 209(13):2395–2408. doi:10.1084/jem.20102660

    Article  CAS  Google Scholar 

  52. Hopper AD, Cross SS, Hurlstone DP, McAlindon ME, Lobo AJ, Hadjivassiliou M, Sloan ME, Dixon S, Sanders DS (2007) Pre-endoscopy serological testing for coeliac disease: evaluation of a clinical decision tool. BMJ 334(7596):729. doi:10.1136/bmj.39133.668681.BE

    Article  Google Scholar 

  53. Oberhuber G, Granditsch G, Vogelsang H (1999) The histopathology of coeliac disease: time for a standardized report scheme for pathologists. Eur J Gastroenterol Hepatol 11(10):1185–1194

    Article  CAS  Google Scholar 

  54. Ludvigsson JF, Green PH (2011) Clinical management of coeliac disease. J Intern Med 269(6):560–571. doi:10.1111/j.1365-2796.2011.02379.x

    Article  CAS  Google Scholar 

  55. do Nascimento AB, Fiates GM, Dos Anjos A, Teixeira E (2013) Analysis of ingredient lists of commercially available gluten-free and gluten-containing food products using the text mining technique. Int J Food Sci Nutr 64(2):217–222. doi:10.3109/09637486.2012.718744

    Article  CAS  Google Scholar 

  56. Santos V, Benassi M, Visentainer J, Matioli G (2010) Quinoa and flaxseed: potential ingredients in the production of bread with functional quality. Braz Arch Biol Tech 53(4):981–986

    Article  CAS  Google Scholar 

  57. Rahaie S, Gharibzahedi SM, Razavi SH, Jafari SM (2014) Recent developments on new formulations based on nutrient-dense ingredients for the production of healthy-functional bread: a review. J Food Sci Technol 51(11):2896–2906. doi:10.1007/s13197-012-0833-6

    Article  CAS  Google Scholar 

  58. Alvarez-Jubete L, Arendt EK, Gallagher E (2009) Nutritive value and chemical composition of pseudocereals as gluten-free ingredients. Int J Food Sci Nutr 60(Suppl 4):240–257. doi:10.1080/09637480902950597

    Article  CAS  Google Scholar 

  59. Schuppan D, Junker Y, Barisani D (2009) Celiac disease: from pathogenesis to novel therapies. Gastroenterology 137(6):1912–1933. doi:10.1053/j.gastro.2009.09.008

    Article  CAS  Google Scholar 

  60. Mukherjee R, Kelly CP, Schuppan D (2012) Nondietary therapies for celiac disease. Gastrointest Endosc Clin N Am 22(4):811–831. doi:10.1016/j.giec.2012.09.001

    Article  Google Scholar 

  61. Nasr I, Leffler DA, Ciclitira PJ (2012) Management of celiac disease. Gastrointest Endosc Clin N Am 22(4):695–704. doi:10.1016/j.giec.2012.07.012

    Article  Google Scholar 

  62. Lundin KE, Nilsen EM, Scott HG, Loberg EM, Gjoen A, Bratlie J, Skar V, Mendez E, Lovik A, Kett K (2003) Oats induced villous atrophy in coeliac disease. Gut 52(11):1649–1652

    Article  CAS  Google Scholar 

  63. Chartrand LJ, Russo PA, Duhaime AG, Seidman EG (1997) Wheat starch intolerance in patients with celiac disease. J Am Diet Assoc 97(6):612–618. doi:10.1016/S0002-8223(97)00156-9

    Article  CAS  Google Scholar 

  64. Peraaho M, Kaukinen K, Paasikivi K, Sievanen H, Lohiniemi S, Maki M, Collin P (2003) Wheat-starch-based gluten-free products in the treatment of newly detected coeliac disease: prospective and randomized study. Aliment Pharmacol Ther 17(4):587–594. doi:10.1046/j.1365-2036.2003.01425.x

    Article  CAS  Google Scholar 

  65. Collin P, Thorell L, Kaukinen K, Maki M (2004) The safe threshold for gluten contamination in gluten-free products. Can trace amounts be accepted in the treatment of coeliac disease? Aliment Pharmacol Ther 19(12):1277–1283. doi:10.1111/j.1365-2036.2004.01961.xAPT1961

    Article  CAS  Google Scholar 

  66. Akobeng AK, Thomas AG (2008) Systematic review: tolerable amount of gluten for people with coeliac disease. Aliment Pharmacol Ther 27(11):1044–1052. doi:10.1111/j.1365-2036.2008.03669.x

    Article  CAS  Google Scholar 

  67. Hischenhuber C, Crevel R, Jarry B, Maki M, Moneret-Vautrin DA, Romano A, Troncone R, Ward R (2006) Review article: safe amounts of gluten for patients with wheat allergy or coeliac disease. Aliment Pharmacol Ther 23(5):559–575. doi:10.1111/j.1365-2036.2006.02768.x

    Article  CAS  Google Scholar 

  68. Ciclitira PJ, Ellis HJ, Fagg NL (1984) Evaluation of a gluten free product containing wheat gliadin in patients with coeliac disease. Br Med J (Clin Res Ed) 289(6437):83

    Article  CAS  Google Scholar 

  69. Kaukinen K, Collin P, Holm K, Rantala I, Vuolteenaho N, Reunala T, Maki M (1999) Wheat starch-containing gluten-free flour products in the treatment of coeliac disease and dermatitis herpetiformis. A long-term follow-up study. Scand J Gastroenterol 34(2):163–169

    Article  CAS  Google Scholar 

  70. Catassi C, Rossini M, Ratsch IM, Bearzi I, Santinelli A, Castagnani R, Pisani E, Coppa GV, Giorgi PL (1993) Dose dependent effects of protracted ingestion of small amounts of gliadin in coeliac disease children: a clinical and jejunal morphometric study. Gut 34(11):1515–1519

    Article  CAS  Google Scholar 

  71. Catassi C, Fabiani E, Iacono G, D’Agate C, Francavilla R, Biagi F, Volta U, Accomando S, Picarelli A, De Vitis I, Pianelli G, Gesuita R, Carle F, Mandolesi A, Bearzi I, Fasano A (2007) A prospective, double-blind, placebo-controlled trial to establish a safe gluten threshold for patients with celiac disease. Am J Clin Nutr 85(1):160–166.

    CAS  Google Scholar 

  72. Leffler D, Schuppan D, Pallav K, Najarian R, Goldsmith JD, Hansen J, Kabbani T, Dennis M, Kelly CP (2013) Kinetics of the histological, serological and symptomatic responses to gluten challenge in adults with coeliac disease. Gut 62(7):996–1004. doi:10.1136/gutjnl-2012-302196

    Article  CAS  Google Scholar 

  73. Food and Drug Administration (2011) Health hazard assessment for gluten exposure in individuals with celiac disease: determination of tolerable daily intake levels and levels of concern for gluten. Office of Food Safety/Center of Food Safety and Applied Nutrition, Food and Drug Administration, USA

    Google Scholar 

  74. Food and Agriculture Organization/World Health Organization (FAO/WHO) (2008) Codex Committee on Nutrition and Foods for Special Dietary Uses. Codex standard for foods for special dietary use for persons intolerant to gluten. World Health Organization, Rome

  75. Minister of Justice Canada (2015) Food and drug regulations. C.R.C., c. 870. B part. Foods. Foods for special dietary use

  76. Food and Drug Administration (2013) Food labeling: gluten-free labeling of foods. Final Rule 78(150):47154–47179

    Google Scholar 

  77. Ministerio de Salud Argentina (2015) Directrices para la Autorización de un Alimento Libre de Gluten. Programa Federal de control de Alimentos. Conal, Acta 106, Abril 14, 2015. Buenos Aires, Argentina

  78. Food Standards in Australia and New Zealand (2012) Nutrition information user guide to standard 1.2.8, Nutrition information requirements. Part B, Nutrition Claims, Australia

  79. Instituto de Salud Pública (1997) Reglamento Sanitario de los Alimentos (RSA), Articulos 516–518. ISP, Santiago

    Google Scholar 

  80. Gibert A, Espadaler M, Angel Canela M, Sanchez A, Vaque C, Rafecas M (2006) Consumption of gluten-free products: should the threshold value for trace amounts of gluten be at 20, 100 or 200 p.p.m.? Eur J Gastroenterol Hepatol 18(11):1187–1195. doi:10.1097/01.meg.0000236884.21343.e4

    Article  CAS  Google Scholar 

  81. Gibert A, Kruizinga AG, Neuhold S, Houben GF, Canela MA, Fasano A, Catassi C (2012) Might gluten traces in wheat substitutes pose a risk in patients with celiac disease? A population-based probabilistic approach to risk estimation. Am J Clin Nutr 97(1):109–116. doi:10.3945/ajcn.112.047985

    Article  CAS  Google Scholar 

  82. Theethira TG, Dennis M (2015) Celiac disease and the gluten-free diet: consequences and recommendations for improvement. Dig Dis 33(2):175–182. doi:10.1159/000369504

    Article  Google Scholar 

  83. Diamanti A, Capriati T, Basso MS, Panetta F, Di Ciommo Laurora VM, Bellucci F, Cristofori F, Francavilla R (2014) Celiac disease and overweight in children: an update. Nutrients 6(1):207–220. doi:10.3390/nu6010207

    Article  Google Scholar 

  84. Mariani P, Viti MG, Montuori M, La Vecchia A, Cipolletta E, Calvani L, Bonamico M (1998) The gluten-free diet: a nutritional risk factor for adolescents with celiac disease? J Pediatr Gastroenterol Nutr 27(5):519–523

    Article  CAS  Google Scholar 

  85. Wild D, Robins GG, Burley VJ, Howdle PD (2010) Evidence of high sugar intake, and low fibre and mineral intake, in the gluten-free diet. Aliment Pharmacol Ther 32(4):573–581. doi:10.1111/j.1365-2036.2010.04386.x

    Article  CAS  Google Scholar 

  86. Norsa L, Shamir R, Zevit N, Verduci E, Hartman C, Ghisleni D, Riva E, Giovannini M (2013) Cardiovascular disease risk factor profiles in children with celiac disease on gluten-free diets. World J Gastroenterol 19(34):5658–5664. doi:10.3748/wjg.v19.i34.5658

    Article  Google Scholar 

  87. Kabbani TA, Goldberg A, Kelly CP, Pallav K, Tariq S, Peer A, Hansen J, Dennis M, Leffler DA (2012) Body mass index and the risk of obesity in coeliac disease treated with the gluten-free diet. Aliment Pharmacol Ther 35(6):723–729. doi:10.1111/j.1365-2036.2012.05001.x

    Article  CAS  Google Scholar 

  88. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA (2013) ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol 108(5):656–676. doi:10.1038/ajg.2013.79ajg201379

    Article  CAS  Google Scholar 

  89. Dickey W, Kearney N (2006) Overweight in celiac disease: prevalence, clinical characteristics, and effect of a gluten-free diet. Am J Gastroenterol 101(10):2356–2359. doi:10.1111/j.1572-0241.2006.00750.x

    Article  CAS  Google Scholar 

  90. Botero-Lopez JE, Araya M, Parada A, Mendez MA, Pizarro F, Espinosa N, Canales P, Alarcon T (2011) Micronutrient deficiencies in patients with typical and atypical celiac disease. J Pediatr Gastroenterol Nutr 53(3):265–270. doi:10.1097/MPG.0b013e3181f988fc

    Article  CAS  Google Scholar 

  91. McGough N, Cummings JH (2005) Coeliac disease: a diverse clinical syndrome caused by intolerance of wheat, barley and rye. Proc Nutr Soc 64(4):434–450. doi:10.1079/PNS2005461

    Article  CAS  Google Scholar 

  92. Dahele A, Ghosh S (2001) Vitamin B12 deficiency in untreated celiac disease. Am J Gastroenterol 96(3):745–750. doi:10.1111/j.1572-0241.2001.03616.x

    Article  CAS  Google Scholar 

  93. Oyarzún A, Nakash T, Ayala J, Lucero Y, Araya M (2015) Following gluten free diet: less available, higher cost and poor nutritional profile of gluten-free school snacks. Int J Celiac Dis 3(3):102–107

    Article  Google Scholar 

  94. Wierdsma NJ, van Bokhorst-de van der Schueren MA, Berkenpas M, Mulder CJ, van Bodegraven AA (2013) Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients. Nutrients 5(10):3975–3992. doi:10.3390/nu5103975

    Article  CAS  Google Scholar 

  95. Salazar Quero JC, Espin Jaime B, Rodriguez Martinez A, Arguelles Martin F, Garcia Jimenez R, Rubio Murillo M, Pizarro Martin A (2015) Nutritional assessment of gluten-free diet. Is gluten-free diet deficient in some nutrient? An Pediatr (Barc) 83(1):33–39. doi:10.1016/j.anpedi.2014.08.011

    Article  CAS  Google Scholar 

  96. See J, Murray JA (2006) Gluten-free diet: the medical and nutrition management of celiac disease. Nutr Clin Pract 21(1):1–15. doi: 10.1177/011542650602100101

    Article  Google Scholar 

  97. Koerner TB, Cleroux C, Poirier C, Cantin I, La Vieille S, Hayward S, Dubois S (2013) Gluten contamination of naturally gluten-free flours and starches used by Canadians with celiac disease. Food Addit Contam Part A Chem Anal Control Expo Risk Assess 30(12):2017–2021. doi:10.1080/19440049.2013.840744

    Article  CAS  Google Scholar 

  98. Crowe JP, Falini NP (2001) Gluten in pharmaceutical products. Am J Health Syst Pharm 58(5):396–401

    CAS  Google Scholar 

  99. Leffler DA, Dennis M, Edwards George JB, Jamma S, Magge S, Cook EF, Schuppan D, Kelly CP (2009) A simple validated gluten-free diet adherence survey for adults with celiac disease. Clin Gastroenterol Hepatol 7(5):530–536, 536 e531–532. doi:10.1016/j.cgh.2008.12.032

  100. Vahedi K, Mascart F, Mary JY, Laberenne JE, Bouhnik Y, Morin MC, Ocmant A, Velly C, Colombel JF, Matuchansky C (2003) Reliability of antitransglutaminase antibodies as predictors of gluten-free diet compliance in adult celiac disease. Am J Gastroenterol 98(5):1079–1087. doi:10.1111/j.1572-0241.2003.07284.x

    Article  CAS  Google Scholar 

  101. Hall NJ, Rubin G, Charnock A (2009) Systematic review: adherence to a gluten-free diet in adult patients with coeliac disease. Aliment Pharmacol Ther 30(4):315–330. doi:10.1111/j.1365-2036.2009.04053.x

    Article  CAS  Google Scholar 

  102. Biagi F, Bianchi PI, Marchese A, Trotta L, Vattiato C, Balduzzi D, Brusco G, Andrealli A, Cisaro F, Astegiano M, Pellegrino S, Magazzu G, Klersy C, Corazza GR (2012) A score that verifies adherence to a gluten-free diet: a cross-sectional, multicentre validation in real clinical life. Br J Nutr 108(10):1884–1888. doi:10.1017/S0007114511007367

    Article  CAS  Google Scholar 

  103. Comino I, Real A, Vivas S, Siglez MA, Caminero A, Nistal E, Casqueiro J, Rodriguez-Herrera A, Cebolla A, Sousa C (2012) Monitoring of gluten-free diet compliance in celiac patients by assessment of gliadin 33-mer equivalent epitopes in feces. Am J Clin Nutr 95(3):670–677. doi:10.3945/ajcn.111.026708

    Article  CAS  Google Scholar 

  104. Moron B, Bethune MT, Comino I, Manyani H, Ferragud M, Lopez MC, Cebolla A, Khosla C, Sousa C (2008) Toward the assessment of food toxicity for celiac patients: characterization of monoclonal antibodies to a main immunogenic gluten peptide. PLoS One 3(5):e2294. doi:10.1371/journal.pone.0002294

    Article  CAS  Google Scholar 

  105. Moron B, Cebolla A, Manyani H, Alvarez-Maqueda M, Megias M, Thomas Mdel C, Lopez MC, Sousa C (2008) Sensitive detection of cereal fractions that are toxic to celiac disease patients by using monoclonal antibodies to a main immunogenic wheat peptide. Am J Clin Nutr 87(2):405–414.

    CAS  Google Scholar 

  106. Moreno ML, Cebolla A, Munoz-Suano A, Carrillo-Carrion C, Comino I, Pizarro A, Leon F, Rodriguez-Herrera A, Sousa C (2015) Detection of gluten immunogenic peptides in the urine of patients with coeliac disease reveals transgressions in the gluten-free diet and incomplete mucosal healing. Gut. doi:10.1136/gutjnl-2015-310148

    Google Scholar 

  107. Di Sabatino A, Corazza GR (2009) Coeliac disease. Lancet 373(9673):1480–1493. doi:10.1016/S0140-6736(09)60254-3

    Article  Google Scholar 

  108. Hallert C, Granno C, Grant C, Hulten S, Midhagen G, Strom M, Svensson H, Valdimarsson T, Wickstrom T (1998) Quality of life of adult coeliac patients treated for 10 years. Scand J Gastroenterol 33(9):933–938

    Article  CAS  Google Scholar 

  109. Vilagut G, Ferrer M, Rajmil L, Rebollo P, Permanyer-Miralda G, Quintana JM, Santed R, Valderas JM, Ribera A, Domingo-Salvany A, Alonso J (2005) The Spanish version of the Short Form 36 Health Survey: a decade of experience and new developments. Gac Sanit 19(2):135–150. doi: 10.1590/S0213-91112005000200007

    Article  Google Scholar 

  110. Hauser W, Gold J, Stein J, Caspary WF, Stallmach A (2006) Health-related quality of life in adult coeliac disease in Germany: results of a national survey. Eur J Gastroenterol Hepatol 18(7):747–754. doi:10.1097/01.meg.0000221855.19201.e8

    Article  Google Scholar 

  111. Zarkadas M, Cranney A, Case S, Molloy M, Switzer C, Graham ID, Butzner JD, Rashid M, Warren RE, Burrows V (2006) The impact of a gluten-free diet on adults with coeliac disease: results of a national survey. J Hum Nutr Diet 19(1):41–49. doi:10.1111/j.1365-277X.2006.00659.x

    Article  CAS  Google Scholar 

  112. Nachman F, Maurino E, Vazquez H, Sfoggia C, Gonzalez A, Gonzalez V, Plancer del Campo M, Smecuol E, Niveloni S, Sugai E, Mazure R, Cabanne A, Bai JC (2009) Quality of life in celiac disease patients: prospective analysis on the importance of clinical severity at diagnosis and the impact of treatment. Dig Liver Dis 41(1):15–25. doi:10.1016/j.dld.2008.05.011

    Article  CAS  Google Scholar 

  113. Sverker A, Hensing G, Hallert C (2005) ‘Controlled by food’- lived experiences of coeliac disease. J Hum Nutr Diet 18(3):171–180. doi:10.1111/j.1365-277X.2005.00591.x

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Nutrition, Faculty of Medicine, University of Chile, Av. Independencia 1027, Independencia, Santiago, Chile

    Karla A. Bascuñán

  2. Laboratory of Gastroenterology, Institute of Nutrition and Food Technology, INTA, University of Chile, Independencia, Chile

    María Catalina Vespa & Magdalena Araya

Authors
  1. Karla A. Bascuñán
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. María Catalina Vespa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Magdalena Araya
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Karla A. Bascuñán.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bascuñán, K.A., Vespa, M.C. & Araya, M. Celiac disease: understanding the gluten-free diet. Eur J Nutr 56, 449–459 (2017). https://doi.org/10.1007/s00394-016-1238-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00394-016-1238-5

Keywords

Search

Navigation