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Practical insights into gluten-free diets

Key Points

  • Education, support and follow-up are key to successful management of coeliac disease

  • Poor quality of life can lead to nonadherence and poor control of coeliac disease

  • Resources for management of coeliac disease have improved in developed countries, but are lacking in developing countries

  • Strict adherence to a gluten-free diet is necessary for mucosal healing and prevention of complications

  • Ongoing gluten ingestion (primarily inadvertent) is the leading cause of nonresponsive coeliac disease

  • Certain subsets of patients might need more intense or individualized attention (management strategies)

Abstract

Coeliac disease is a global disease, and the only currently available treatment is a gluten-free diet (GFD). Although conceptually simple, the diet changes are substantial and have a profound effect on a patient's life. Untreated coeliac disease is associated with complications, including excess mortality, most of which can be avoided with a strict GFD. However, there are many barriers, including availability, cost and safety of gluten-free foods, and gluten cross-contamination. The GFD can be restrictive in social situations, leading to poor quality of life and, ultimately, nonadherence. As the number of patients with coeliac disease increases worldwide, clinicians need to be aware of the challenges patients face. Heightened awareness by physicians, dietitians and other providers can help maximize successful treatment, improve outcomes, and reduce health-care costs and disease burden. Routine follow-up is necessary to reinforce the need for a GFD, provide social and emotional support, and achieve mucosal healing, leading to reduced risk of complications. Unfortunately, there is wide variation in follow-up practices. The objective of this Review is to increase awareness of the challenges, management and follow-up of patients with coeliac disease to help them achieve GFD adherence and prevent complications whilst preserving their quality of life.

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Figure 1: Role of registered dietitian.
Figure 2: Factors influencing quality of life in coeliac disease.
Figure 3: Diagnostic approach to nonresponsive coeliac disease.

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Acknowledgements

The authors wish to thank D. I. Frank for her expert assistance in the preparation of this manuscript.

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Supplementary information

Supplementary Figure 1

Ongoing small bowel atrophy in adults with coeliac disease despite a GFD. (DOCX 72 kb)

Supplementary Table 1

Follow-up strategies for management of coeliac disease. (DOCX 28 kb)

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See, J., Kaukinen, K., Makharia, G. et al. Practical insights into gluten-free diets. Nat Rev Gastroenterol Hepatol 12, 580–591 (2015). https://doi.org/10.1038/nrgastro.2015.156

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