Coeliac disease (CD) and other dietary restrictions- which nutrients are at risk?

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1 Coeliac disease (CD) and other dietary restrictions- which nutrients are at risk? Chloe Hall, RD BSc MSc Community Dietitian, Spokesperson for the British Dietetic Association and advisor for the IBS Network

2 What is Coeliac disease (CD)? Chronic inflammatory condition of the Small intestine Heightened immune response to gluten Effects 1 in 100 people (Coeliac UK 2017) Symptoms include: diarrhoea and/or constipation, nausea/vomiting, anaemia, tiredness, mouth ulcers, skin rash, depression, unintentional weight loss, neurological Treated with a gluten free diet

3 What are the nutritional implications of Coeliac Disease? Low ferritin, folate or vitamin B12 may occur in up to 50% at diagnosis May reduce bone mineral density Increased need for calcium than the general population- 1000mg/day No increased need for any other nutrient

4 Nutritional adequacy of a Gluten free (GF) diet Lower protein content (Fry et al, 2018; Allen and Orfila 2018) One study showed lower intakes of magnesium, iron, zinc, manganese, selenium and folate (Wild et al, 2010) Higher fibre and fat (Allen and Orfila 2018) At risk of inadequate intake of Calcium and Vitamin D (Kinsey et al, 2008)

5 The Availability and Nutritional Adequacy of Gluten-Free bread and Pasta (Allen and Orfila 2018) 28% of GF breads were fortified with calcium carbonate and iron and only 5% of the total GF breads were fortified with all four fortification minerals, in addition to folic acid and riboflavin. 2 out of 14 GF manufacturers fortified their products

6 Additional restrictions and the 1) Lactose Intolerance implications Associated with undiagnosed coeliac disease Usually temporary If avoiding dairy products can reduce calcium intake if not well planned

7 Additional restrictions and the implications 2) Vegan and vegetarian diets Can meet requirements if well planned Ensure adequate protein Vitamin D & calcium Iodine, Vitamin B12 and Omega 3 fats

8 Additional restrictions and the implications 4) Irritable Bowel Syndrome (IBS)/Low FODMAP 20 23% of treated CD patients fulfil the Rome III criteria for IBS and also suffer from various functional gastrointestinal symptoms (O Leary et al, 2002) Low FODMAP may increase general wellbeing, reduce abdominal pain and improve faecal consistency in those with CD with persistent gastro symptoms (Roncoroni et al, 2018)

9 Additional nutritional considerations with low FODMAPs and CD Lower calcium intake with low FODMAP (Staudacher et al, 2012) Affects gut bacteria (Staudacher et al, 2012) Research limited to dietitian-led approach, therefore may be further dietary inadequacies without appropriate guidance/information

10 Further support with nutritional intake in CD Registered Dietitian Coeliac UK apps Coeliac UK food and drink directory

11 Conclusion The diet needs to be well planned to be nutritionally adequate Food fortification to the same level as standard products would contribute to vitamin and mineral intake. Annual reviews should continue to be undertaken to assess nutritional intake and identify any dietary inadequacies and address these.

12 References Fry L., Madden A. M. & Fallaize R. (2018) An investigation into the nutritional composition and cost of gluten-free versus regular food products in the UK. J Hum Nutr Diet. 31, Wild D, Robins G, Burley V et al. (2010) Evidence of high sugar intake, and low fibre and mineral intake, in the gluten-free diet. Aliment Pharmacol Ther 32, Allen B and Orfila C. (2018) The Availability and Nutritional Adequacy of Gluten-Free Bread and Pasta. Nutrients Kinsey L., Burden ST and Bannerman E (2008) A dietary survey to determine if patients with coeliac disease are meeting current healthy eating guidelines and how their diet compares to that of the British general population. European Journal of Clinican Nutrition O Leary, C.; Wieneke, P.; Buckley, S.; O Regan, P.; Cronin, C.C.; Quigley, E.M.M.; Shanahan, F. Celiac disease and irritable bowel-type symptoms. Am. J. Gastroenterol. 2002, 97, Roncoroni L., Bascuñán K.A., Doneda L., Scricciolo A., Lombardo V., Branchi F., Ferretti F., Dell Osso B, Montanari V., Bardella M.T. and Elli L. (2018) A Low FODMAP Gluten-Free Diet Improves Functional Gastrointestinal Disorders and Overall Mental Health of Celiac Disease Patients: A Randomized Controlled Trial Nutrients. 10, 1023 Staudacher H.M., Lomer M.C., Anderson J.L. et al. Fermentable Carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. Journal of nutrition. 2012; 142: