January/February 2013

Celiac Disease in Older Adults

By Ronni Alicea, RD, CSG, MBA
Aging Well
Vol. 6 No. 1 P. 16

It’s not unusual for older adults to be diagnosed with previously unrecognized celiac disease. Physicians must become familiar with the important aspects of identifying and treating the condition.

The understanding of celiac disease has undergone substantial medical advances, and gluten intolerance is now recognized as a legitimate dietary concern. Celiac disease is a digestive condition triggered by eating the protein gluten, which is primarily found in breads, pasta, pizza crust, cookies, and other foods containing wheat, barley, or rye. Eating gluten-containing foods produces an immune reaction in the small intestines, causing damage to the inner surfaces and an inability to absorb nutrients.

Combined with the media touting a gluten-free diet as the secret to health and large gluten-free food sections in most supermarkets, the designation of “gluten free” has elicited a healthy dose of interest and skepticism. Although it was once relegated to pediatric gastroenterology journals, most healthcare practitioners have addressed celiac disease in their specialty areas. This article discusses when to suspect celiac disease and how to address nutrition issues for mature people managing gluten-free diets, which is the only treatment available at this time. Combined with growing knowledge of nutrition and aging well, understanding the nuances of a gluten-free lifestyle will help restore and/or maintain nutritional well-being. 

Prevalence and Diagnosis
An estimated 1% of the American population has celiac disease, with diverse heritages at particular risk. Gluten intolerance is less well defined and treated as a metabolic disorder similar to lactose maldigestion.

Physicians are now exploring options when a patient’s Clostridium difficile (C diff) panel is negative and unexpected osteopenia presents with adequate dietary calcium and vitamin D along with Hashimoto’s thyroiditis. The American Gastroenterology Association’s position paper on the diagnosis and management of celiac disease recommends expanding celiac disease testing consideration beyond just the usual symptoms of weight loss and diarrhea. Populations at high risk of developing celiac disease include those suffering conditions such as refractory iron deficiency anemia, cerebellar ataxia, recurrent migraine, Sjögren’s syndrome, and type 1 diabetes mellitus. 

Research shows that mature adults may experience seroconversion after previous negative testing for celiac disease. Diagnosis criteria are now under discussion among celiac specialists globally. Currently, a diagnosis is made by combining a positive serology of a celiac panel ELISA test and response to the gluten-free diet with the gold standard small-bowel biopsy. (A comprehensive list of testing information is available from the Celiac Sprue Association at www.csaceliacs.info/celiac_centers.jsp.)

Defining a Gluten-Free Diet
A cereal chemist will correctly state that all grains contain gluten. The medical community defines gluten as the storage protein found in the wheat family: triticum, rye, and barley. The triticum family includes names that may have mistakenly been thought of as gluten free. Gluten-free diets should not include spelt and durum wheat, which may be in the form of semolina flour or bulgur. Additionally, einkorn, emmer (also known as farro), and Khorason wheat (commonly sold as kamut in North America) should be avoided. Some wheat-free advocates eat these grains with impunity, but they contain the protein sequence toxic to people with celiac disease.

Oats are off limits because of high levels of wheat contamination unless the oats are specifically grown, harvested, stored, and milled away from wheat, rye, and barley. The mantra to remember is that wheat free does not mean gluten free, and a product label should expressly state “gluten-free oats.”

With respect to potential medication interaction, although it occurs infrequently, excipients may contain wheat starch with low levels of gliadin, the protein fraction of wheat known to cause the autoimmune response in people with celiac disease. The website GlutenFreeDrugs.com updates the gluten content status of many over-the-counter and prescription medications.

Medications also may cause symptoms consistent with celiac disease. Recently olmesartan (Benicar) has been shown to cause classic gastrointestinal distress along with altered intestinal biopsies and negative serology that resolved when the medication was changed.

The immediate goals for those with celiac disease are to normalize bowel function, stabilize weight, and correct anemias. For patients with diabetes, it is important to monitor blood sugars carefully, as carbohydrate and medication absorption may change.

Vitamins and Minerals
Research indicates that without careful planning, gluten-free diets may lack key nutrients. Physicians should not assume that people who have lived gluten free for years are in a good nutritional state. In addition, it has been found that with long-standing celiac disease, mucosal damage in the intestines may not heal efficiently. This key finding is important when addressing diet planning and nutrition supplements. Incomplete villous healing can affect the intestine’s ability to absorb nutrients. A careful clinical assessment is necessary even when the diet history seems adequate.

Watch the status of iron, magnesium, calcium, and vitamin D along with the B vitamin family. The goal is to remove the toxin (gluten) while providing for nutrient repletion. Gluten-free flours are not required to be enriched with thiamin, riboflavin, niacin, folic acid, or iron as wheat flours are. Vitamin B12 is a concern because the medications a patient has used for symptom relief prior to diagnosis may alter its absorption. Fiber can also present a challenge since traditional fiber boosters such as bran cereals and most oatmeal are off limits. 

A multivitamin with mineral supplementation is generally recommended, with several nutrients available in sublingual delivery systems, bypassing the need for healthy villi. Most commercial vitamin supplements are gluten free, but ingredients should always be examined. New formulas touting phytonutrients may contain wheatgrass, which has a controversial gluten-free status. If label reading is daunting due to small print, mail order companies dedicated to gluten-free supplements, such as Country-life.com and Freedavitamins.com, offer safe gluten-free products. Most medical nutritional beverage supplements are gluten free, with the exclusion of malt flavors because of the barley content.

Gluten-Free Grains, Pseudograins, and Seeds
Well-balanced diets have variety and contain whole grains. Wheat provides an energy source, protein, vitamins, and minerals along with fiber. Gluten-free substitutes most often include high-glycemic rice, corn, tapioca, and potato flours in addition to nut flours. Encourage patients to select whole grain brown rice and try alternate grains such as amaranth, buckwheat, millet, quinoa, sorghum, and teff. Practitioners doing diet planning and who need specific nutrient content of grains often rely on a comprehensive resource: Gluten-Free Diet by Shelly Case, RD.

Gluten-free news recently highlighted a preliminary study of quinoa that found two of 15 species tested in vitro contained the protein sequence known to trigger celiac disease. Quinoa continues to be recommended for the gluten-free diet at this time. Ongoing studies will continue to determine whether the prolamine content is significant.

Diet for a Lifetime
In most cases, eliminating gluten from the digestive tract will stop the autoimmune process. To monitor dietary compliance, add a celiac panel to the annual serology. If a marker is elevated, determine whether the patient has willingly and knowingly eaten gluten-containing foods or whether the problem is one of dietary ignorance or noncompliance by others, for example, those who prepare meals. The goal is normal tissue transglutaminase antibodies to assure there’s no intestinal inflammation.

Gluten-free foods may be contaminated along the food chain from growing to processing. Currently, the FDA does not regulate the term “gluten free,” with only advisory guidelines for manufacturers. There are third-party auditing agencies to assure products are indeed gluten free. Passing the Gluten Free Certification Organization audit allows an icon to be placed on the label, providing peace of mind for consumers.

Strongly encourage patients with celiac disease to contact a support organization. There are more than 500 groups that conduct local meetings. Networking with others with celiac disease will reduce the social isolation that may arise for elderly patients managing the condition. Resources include the Celiac Disease Foundation (www.celiac.org), Celiac Sprue Association (www.csaceliacs.info), and Gluten Intolerance Group (www.gluten.net).

Case Study
Linda, 63, was admitted to a subacute facility with syncope and collapse, pneumonia, anemia, and a history of celiac disease. She was ordered a gluten-free diet. Her height was 4 ft 11 inches, and her weight was 135 lbs with a BMI of 27. The admission goal was to return home at her previous level of activities of daily living with assistance for food preparation.

Linda had a mental deficit and could not live independently. She could only parrot the gluten-free diet order. She could not question foods presented to her at mealtime. Her primary caregiver, a niece, stated that she prepared Linda’s meals and had followed the gluten-free diet for 20 years. The niece did not follow a gluten-free diet but believed Linda ate only allowed food. However, both received weekly communion at church. (Communion wafers are wheat based.)

The niece revealed that Linda displayed a good appetite, and her diet included a variety of foods. Linda ate plainly prepared protein, rice, gluten-free pasta and breads, potatoes, fruits, and vegetables. Although Linda was lactose intolerant, she could eat hard cheese and yogurt. Her favorite cereal was Kellogg’s Rice Krispies with Lactaid milk. (Many puffed wheat-free grain cereals contain barley malt, a gluten-containing grain.)

Linda’s diet was not gluten free despite the inclusion of gluten-free breads and pasta. Her nutrient absorption would have been impacted because of uncontrolled celiac disease. The lactose intolerance may have been secondary to gluten in the diet and resolved when a gluten-free diet was followed correctly.

Linda was admitted to subacute rehab for deconditioning posthospitalization for syncope and collapse with subsequent pneumonia treatment. The comorbid celiac disease was diagnosed 20 years prior and was believed to be controlled by following a gluten-free diet as prescribed. She frequently missed rehab sessions because of fatigue and persistent diarrhea. Weight loss did not occur. Diarrhea persisted after antibiotic therapy concluded. A stool sample for C diff was ordered along with a request for the pharmacy staff to check Linda’s medications for gluten. A note in Linda’s transfer records mentioned a benign pancreatic cyst. The physician reviewed pancreatic function.

The C diff test was negative; the pharmacy medication review revealed no gluten-containing excipients; and all of Linda’s snacks were gluten free. But the evening cook was toasting gluten-free bread in the rotary toaster. Crumbs from gluten-containing bread had contaminated the facility’s gluten-free diet preparation. After extensive education of foodservice staff, all traces of gluten were eliminated from Linda’s diet and she returned home, having successfully participated in rehabilitation though the length of stay beyond the usual for the primary diagnosis.

Linda’s niece received diet education to assure that going forward Linda’s diet was indeed gluten free and contact information for dietary resources.

Helping Older Adults
Socioeconomic concerns and living arrangements impact aging well with celiac disease and gluten intolerance. Whereas the American Disabilities Act protects some people, programs administered by the Older American Act for adult food security and socialization often do not have the infrastructure to provide dedicated gluten-free meals. An Internet search may find local meal delivery, and some community senior locations have subsidized meals from services specializing in gluten-free meals.

Assisted-living facilities have been known to decline admission to patients with celiac disease or provide inadequate nutrition by counseling residents against eat gluten-containing items rather than purchasing and providing gluten-free alternatives and staples. Planning is paramount for elders’ living arrangements, with thorough vetting of the meal service expectation. Encourage patients to have their room and board contracts modified concerning gluten-free foods and avoid a verbal concession that’s often disputed with staff changes. It is not unreasonable for items such as gluten-free breads and gravy to be purchased by residential facilities. Even gluten-free pizza is available in most distribution centers for food service. 

Older adults diagnosed with celiac disease and/or their caregivers will benefit from expert dietary consultation from a knowledgeable registered dietitian. The Academy of Nutrition and Dietetics has a search function to find dietitians at www.eatright.org.

Because misconceptions of diet liberalization can impact patients’ quality of life and expectations for health, understanding the nuances of celiac disease will allow better management of aging celiac patients. It is important to note that there are times when a gluten-free diet is not practical, even with confirmed celiac disease. Healthcare professionals and family members can determine the pros and cons of diet management. Although no cure is available, several treatments, from pills to vaccines, are on the horizon.

— Ronni Alicea, RD, CSG, MBA, a consultant in central New Jersey, maintains a blog at http://matureceliac.blogspot.com.