Q: When I was first diagnosed with celiac disease, I asked my doctor if I should see a dietitian. He did not see the need and said I could find information on the Internet. My 6-month follow-up lab work shows that my antibody levels are down but not back to normal, and I still have symptoms. Would it help to see a dietitian now?
A. The only treatment for celiac disease is a strict, lifelong gluten-free diet. The Internet can be a wonderful help but can also be a source of confusion and misinformation. The National Institutes of Health consensus statement on the management of celiac disease advises consulting with a skilled dietitian. The Academy of Nutrition and Dietetics Evidence Based Nutrition Practice Guideline for celiac disease says medical nutrition therapy provided by a registered dietitian is strongly recommended for individuals with celiac disease.
A consultation would include:
- An assessment to determine a nutritional plan. This includes the review of nutritional anemias, vitamin deficiencies, and other factors affecting quality of life. It would also include an assessment of gastrointestinal symptoms as well as others related to celiac disease and the conditions it sometimes causes.
- Nutritional advice and education on how to follow a gluten-free diet. A registered dietitian would advise you on gluten-free meal plans, the consumption of whole and enriched gluten-free grains, the addition of multivitamins and mineral supplements (calcium, Vitamin D, iron) and how to read labels to determine if a food is gluten free. In addition, he or she would provide you with reliable sources of further information.
- Monitoring and evaluation of follow-up lab work and a dietary questionnaire to determine if you are complying with a gluten-free diet.
You should consult with a dietitian to look for any sources of gluten inadvertently getting into your diet. A dietitian will also be able to help determine if your current symptoms are related to other dietary intolerances such as lactose or fructose. In addition, a review of your diet will indicate if you are receiving important nutrients and essential vitamin/minerals.
Q: I did seek the help of a dietitian when I was diagnosed, but she did not seem familiar with celiac disease or the gluten-free diet. How do I find a dietitian who can help me?
A. Within the medical profession, many health care providers have chosen to specialize in a concentrated area of practice. Just as your primary care physician relies on specialists for further evaluation and treatment of specific diseases, the same holds true for dietitians. We all have an excellent background in nutrition assessment and treatment; some diseases need more in-depth skill. I specialize in celiac disease and other gluten-related disorders and would be helpful in managing those patients. However, I would not be the one to treat and manage renal transplant patients. I would refer a patient to my colleagues who specialize in those areas.
There are a number of resources to help find a dietitian knowledgeable about celiac disease. The Dietitians in Gluten Intolerance Disorders have a resource list of celiac centers and dietitians who specialize in gluten-related disorders that is available at mnpgdpg.org (click on DIGID Resources). Tricia Thompson’s website, glutenfreedietitian.com, provides a list of dietitians who specialize in gluten-related illness, listed by state, under “Resources.” The Academy of Nutrition and Dietetics (eatright.org) will also help you find a dietitian by specialty and zip code.
Q. I have been following a gluten-free diet for two years and my symptoms have improved, but I worry that I am not getting a balanced diet. I recently read an article that vitamin/mineral supplements are not helpful and can even be harmful. Should I be taking a supplement?
A. This is an example of why is it so important to work with your dietitian to evaluate your diet and assess whether you may need a supplement and what kind.
First and foremost, essential nutrients should come from the foods we eat by including a wide variety of foods from each of the basic food groups (dairy, lean protein, fruits and vegetables, whole grains and healthy fats/oils). That said, few of us eat a perfectly balanced diet every day, and on occasion our daily vitamin consumption is less than stellar. As a result it can be a good idea to take a daily vitamin and/or other needed supplement.
The gluten-free diet can be low in iron, calcium, magnesium, vitamin D, zinc, folate and other B vitamins. A general gluten-free multivitamin/mineral supplement that supplies no more than the recommended daily allowance (RDA) or daily value (DV) of the B vitamins plus minerals (no mega or high-potency brands) will fill in the gaps. Overdoing certain vitamins can lead to toxic levels causing harm. If you are already eating the recommended amount of a nutrient, you may not get any further health benefit from taking a supplement. In some cases, supplements and fortified foods may actually cause you to exceed safe levels of nutrients.
For more detailed information about supplements, see GF Vitamin Guide: Food is the Best Source but Supplements May be Needed.
The NIH Office of Dietary Supplements has a series of vitamin and mineral fact sheets that provide scientifically based overviews of a number of vitamins and minerals.
Webmd.com also provides sound information.
Q. Does insurance usually cover a consultation with a dietitian?
A. Insurance coverage will vary greatly depending on the insurance company and the specific plan. It is best to check with your insurance provider for the coverage details and to see if you have to select a dietitian from a pre-approved list. If coverage is denied, you can ask for a letter of necessity from your physician and dietitian to appeal the decision to deny coverage. Also, it may be covered under your pre-tax health care spending account.
Q. If not, how much would it cost me to see a dietitian?
A. This is also variable. Some dietitians’ services are included in the physician’s bill and are not charged separately. Others charge by the session or time increments if seen without a physician’s visit. Exact fees and billing procedures need to be discussed at the time the appointment is made. Most hospital-based outpatient services, including medical nutrition therapy, can be prorated if payment is an issue.
Q. How does a dietitian treat gluten sensitivity?
A. Non-celiac gluten sensitivity also requires a strict gluten-free diet, and a knowledgeable dietitian would provide treatment to be sure the diet is nutritionally sound and effective.
Pam Cureton is a clinical and research dietitian specializing in the treatment of celiac disease. She currently works with Alessio Fasano, M.D., at the Center for Celiac Research & Treatment at Massachusetts General Hospital and the University of Maryland celiac disease clinic. Cureton’s recurring column answers readers’ questions about managing the gluten-free diet. Send yours to [email protected].