What are the dietary recommendations for individuals with gluten sensitivity?

Dietary Recommendations for Gluten Sensitivity

A strict gluten-free diet is the only effective treatment for individuals with gluten sensitivity, requiring complete avoidance of all products containing wheat, barley, and rye proteins for the duration of their lives. 1

Core Dietary Guidelines

Foods to Strictly Avoid

• All products containing wheat, barley, and rye proteins 1
• Hybrids of these grains, such as kamut and triticale 1
• Foods with potential cross-contamination (processed in facilities that also process gluten-containing foods)

Foods That Are Safe

• Rice, corn, and potatoes (traditional substitutes) 1
• Nutrient-dense alternative grains: buckwheat, amaranth, quinoa, millet, and sorghum 2
• Naturally gluten-free foods (fresh fruits, vegetables, unprocessed meats, fish, eggs, dairy, legumes, nuts, and seeds) 3

Special Considerations for Oats

The inclusion of oats in a gluten-free diet remains controversial:

• Multiple studies suggest oats can be safely included in the gluten-free diet for most individuals 1
• Oats can increase intake of iron, dietary fiber, thiamin, and zinc 1
• However, commercial oats often have unacceptably high levels of cross-contamination, with contamination varying widely even within the same product 1
• Some individuals may have an exaggerated sensitivity to oats unrelated to celiac disease 1

Recommendation: If including oats, use only certified gluten-free oats and introduce them slowly while monitoring for adverse reactions 1, 2

Nutritional Considerations

Many gluten-free products are low in essential nutrients and few are fortified, leading to potential deficiencies 2, 4:

• Patients with newly diagnosed gluten sensitivity should undergo testing for micronutrient deficiencies, particularly:

  • Iron
  • Folic acid
  • Vitamin D
  • Vitamin B12 1, 2
  • Calcium, zinc, magnesium, and fiber 2

• Focus on a balanced diet rich in naturally gluten-free foods rather than processed gluten-free products 3

• Choose whole grain gluten-free options when possible to maintain adequate fiber intake 3

Implementation and Monitoring

1. Professional Guidance: Patients should be referred to a registered dietitian for a nutritional assessment and counseling about implementing a gluten-free diet 1, 3

2. Regular Monitoring:

   • Combination of history and serology to monitor adherence 1
   • Verification that clinical abnormalities detected on initial laboratory investigations have normalized 1
   • Regular follow-up to ensure nutritional adequacy and assess for complications 1
   • Special attention to normal growth and development in children 1

3. If Symptoms Persist:

   • Consider non-responsive celiac disease if symptoms persist despite adherence to a gluten-free diet for 4-6 weeks 2
   • Evaluate for other conditions like microscopic colitis, small intestinal bacterial overgrowth, exocrine pancreatic insufficiency, lactose intolerance, or thyroid dysfunction 2
   • Consider FODMAP sensitivity and potential trial of low FODMAP diet under dietitian supervision 2

Common Pitfalls and Caveats

1. Hidden Gluten Sources:

   • Medications and supplements may contain gluten as fillers
   • Processed foods often contain hidden gluten in additives, flavorings, or stabilizers
   • Cross-contamination during food preparation is common 3

2. Dietary Balance:

   • Avoid excessive focus on processed gluten-free products, which may be high in sugar, fat, and calories 3
   • Weight gain is common after starting a gluten-free diet and may require attention for those already overweight 3

3. Psychological Impact:

   • Hypervigilance about the diet can negatively impact quality of life 3
   • Social isolation from avoiding dining out can affect mental wellbeing 3

4. Wheat Starch Controversy:

   • Some countries allow wheat starch in "gluten-free" products, but the safety threshold is not definitively established 5
   • In the United States, complete avoidance of wheat starch is generally recommended 5

The gluten-free diet should be maintained for life in individuals with confirmed celiac disease. For those with non-celiac gluten sensitivity, the diet should be followed as long as symptoms persist with gluten consumption 2, 4.