Management: The Gluten-Free Diet

The only currently available management option is a life-long strict adherence to a gluten-free diet (GFD).

A gluten-free diet is a diet that excludes all products containing gluten. In other words, all products made from the flours of wheat, barley, rye and, in many countries (due to frequent cross-contamination), oats.

The main challenge to a total adherence to a gluten-free diet is that grains, or their by-products, are widely used in the food industry and are present in numerous food and household products. Modern diets are increasingly enriched with gluten, which is also used as an additive to processed foods, household items (cosmetics, toothpaste and lipstick) and as an excipient in oral medications. Gluten is the second most common food ingredient after sugar and, in some countries, is present in up to 80% of foodstuff.

Even manufactured “gluten-free” products can contain small amounts of gluten, may be difficult to find, tend to be less flavorful and are more expensive than regular gluten containing products. In addition, labeling of food and household products is deficient in many countries.

Finally, there is no available objective tool for patients to monitor gluten consumption.

For all these reasons, celiac sufferers are regularly exposed to gluten contamination.

The Burden of the Gluten-Free Diet (GFD)

Celiac disease is the only common autoimmune disorder with no approved medication. The only available strategy for the management of celiac disease patients is a lifelong total avoidance of gluten. While simple in theory, the ubiquity of gluten in foodstuffs, medications, household substances, cosmetics, and gluten-free items makes total avoidance of gluten difficult – if not impossible.

As few as 50 milligrams a day (a few bread crumbs) triggers the disease. For comparison, a normal diet contains more than 10 grams per day. Thus, the only currently available management option of a GFD presents both a considerable challenge and substantial burden for patients. A study found the burden of celiac disease and a GFD on patient quality of life was ranked second only to end-stage renal disease – a condition that requires multiple, weekly dialysis treatments. This illustrates the very high burden of celiac disease on patients.

Catassi C; Fabiani E; Iacono G, D’Agate C, Francavilla R, Biagi F et al. A prospective, double blind, placebo controlled trial to establish a safe gluten threshold for patients with celiac disease. Am J Clin Nutr 2007; 85:160-166.

Shah S, Akbari M, Vanga R, et al.Patient perception of treatment burden is high in celiac disease compared with other common conditions. Am J Gastroenterol 2014; 109:1304-1311.