Dietary therapy consists of the consistent elimination of foods containing gluten. Thus, foods made from or containing wheat, rye, barley, and oats must be avoided. Furthermore, the treatment should include the reduced absorption of vital substances (micronutrients) caused by damage to the intestinal villi and mucosa of the small intestine. Gluten is contained as a food additive in many types of cereals, in foods made from cereals, and in quite a few finished products. For this reason, in addition to their gluten-free diet, Spruekranke must make sure to meet their increased nutrient and vital substance needs (macro- and micronutrients) especially fat-soluble vitamins, vitamin B9, B12, iron, copper, selenium and zinc through other foods with high nutrient and vital substance density (macro- and micronutrients). Gluten-free foods include, but are not limited to, pure products made from starch, flour, soybeans, vegetables, potatoes, fruits, milk, meat, fish, and gluten-free grains and their flours. If people with gluten-induced enteropathy strictly avoid cereal protein in their diet, the mucosal cells as well as the villi of the intestinal wall increasingly regenerate and the typical symptoms disappear within a few days to several weeks. The improvement in the function of the intestinal mucosa and villi is accompanied by a higher absorption of nutrients and vital substances (macro- and micronutrients). If sprue sufferers do not show significant improvements within eight weeks, unconscious or even conscious dietary errors are often the cause. Those affected should bear in mind that some foods, such as wheat starch, may still contain traces of gluten. Such small amounts of gluten are already sufficient in cases of pronounced intolerance to maintain damage to the intestinal mucosa and villi and prevent regeneration. Cereals containing gluten to be strictly avoided in sprue sufferers:
- Wheat
- Rye
- Oats
- Barley
- Spelt (type of wheat)
- Kamut (type of wheat)
- Einkorn (type of wheat)
- Emmer (type of wheat)
- Triticale (wheat-rye cross)
- Green spelt unripe harvested spelt, einkorn or emmer
- All foods made from these grains, such as flour, bread, pastries, breadcrumbs, pasta, cereals, sauces and others.
- Wild rice
Dietary recommendations for gluten-induced enteropathy:
- In addition to gluten-containing cereals and foods made from cereals, ready-made products should also be avoided, as gluten is often used as an emulsifier, stabilizer or binder
- Gluten does not have to be labeled as a food additive and can therefore also be found in industrially produced foods and canned foods!
- Pure products from starch, flour, soybeans, chestnuts, vegetables, potatoes, fruit, all legumes, milk and dairy products, meat, fish, eggs, oils and fats, South American grains quinoa, amaranth.
- Gluten-free grains and their flours, such as buckwheat, corn, corn flour, rice (not wild rice), rice flour, millet, potato flour.
- All foods made specifically for a gluten-free diet, such as gluten-free bread, pastries, pasta and other imprint gluten-free.
- Pure wheat starch very sensitive patients should avoid them, because they still react even to the traces of gluten in pure wheat starch
Until the intestinal villi are largely regenerated:
- Reduce fat intake
- Avoid lactose to a large extent consume low-lactose milk and dairy products
- Avoid fruits and vegetables rich in oxalic acid, such as beet, parsley, rhubarb, spinach, beet, Swiss chard
- Due to the renunciation of quite a few foods must be paid attention to an adequate supply of nutrients and vital substances (macro- and micronutrients)
Oxalic acid-rich fruits and vegetables spinach, beet, chard and rhubarb should be avoided, especially in the early phase of dietary therapy. Excessive oxalate concentrations promote kidney as well as urinary stone formation. In addition, oxalic acid inhibits the absorption of calcium by forming, together with the mineral inside the intestine, a calcium oxalate that is difficult for the human digestive system to dissolve.Apart from this, the need for calcium is significantly increased in those affected due to reduced absorption and insufficient intake via milk and dairy products. In case of delayed recovery of the resorption problem as well as to improve the energy balance and alleviate the fat diarrhea, usual dietary fat consisting of predominantly long-chain triglycerides should be partially replaced by medium-chain triglycerides (MCT fats1). Importance of MCT fats1 in the dietary management of steatorrhea and enteral protein loss syndrome:
- MCTs are cleaved more rapidly in the small intestine than LCT fats2 under the influence of the pancreatic enzyme lipase.
- Due to their better water solubility, the small intestine can absorb MCT fats more easily
- The presence of bile salts is not required for the absorption of MCTs
- MCT fats can still be exploited both in the absence and deficiency of lipase and bile salts inside the intestine, respectively
- The small intestine has a greater absorption capacity for MCT than for LCT.
- Binding of MCT fats to the transport lipoproteins chylomicrons is not necessary, because medium-chain fatty acids are removed via portal blood and not via intestinal lymph
- Due to the removal with the portal blood, the lymphatic pressure does not increase during the absorption of MCT and there is less lymph leakage into the intestine, reducing intestinal protein loss increase in plasma proteins
- When long-chain fatty acids are absorbed, on the other hand, the lymphatic pressure increases and thus the passage of lymph into the intestine lymphatic congestion leads to a high loss of plasma proteins
- MCT are oxidized faster in the tissue than LCT
- Medium-chain triglycerides reduce water loss with stool by low stimulation of gallbladder contraction, resulting in a low bile salt concentration inside the intestine Reduction of chologenic diarrhea
- MCT fats improve the overall nutritional status
Substitution of LCT by MCT subsequently leads to the reduction of fat excretion in the stool alleviation of steathorroe and enteric protein loss syndrome. MCT fatty acids are available in the form of MCT margarine is not suitable for frying and MCT cooking oils (usable as cooking fat). The transition to medium-chain triglycerides should be gradual, otherwise pain in the abdomen, vomiting and headaches may occur Increasing the daily amount of MCT from day to day by about 10 grams until the final daily amount of 100-150 grams is reached. MCT fats are heat labile and should not be heated for too long and never above 70°C. In addition, care should be taken to cover the requirements of fat-soluble vitamins A, D, E and K and essential fatty acids such as omega-3 and omega-6 compounds. When MCTs are administered, fat-soluble vitamins are sufficiently absorbed. In the course of the disease or during therapy, gluten tolerance may improve, especially during puberty. Under these circumstances, the diet no longer needs to be strictly adhered to. As a rule, however, foods containing gluten should not be consumed, since sprue patients are at high risk of developing malignant tumors of the mouth, pharynx, and esophagus, as well as cancers of the lymphatic tissue, more frequently than healthy individuals if the dietary treatment is not adhered to. In a large proportion of patients, dermatitis herpetiformis Duhring (Duhring’s disease) is associated with villous atrophy of the small intestine. This highly itchy skin disease, accompanied by nodules and vesicles, regresses in the long term on a gluten-free diet, although it can take up to two years for the skin lesions to heal completely. The majority of patients experience a significant improvement after six to twelve months. In rare cases, sprue sufferers exhibit the damage to the intestinal mucosa and villi as well as the typical symptoms, but show no improvement during the gluten-free diet. Such patients are more likely to respond to hormones from the adrenal cortex glucocorticoids. Otherwise, they only respond to a gluten-free diet if other protein-rich foods eggs, poultry or milk are avoided.If people with indigenous sprue have low concentrations of the critical vital substances (micronutrients) due to non-compliance with the gluten-free diet, still existing absorption disorders, and a low intake of nutrients and vital substances (macro- and micronutrients) through the diet, vital substance deficiency symptoms occur in addition to the typical symptoms. 1 MCT = fats with medium-chain fatty acids; their digestion and absorption is faster and independent of bile acids, which is why they are preferred for diseases of the pancreas and intestines. 2 LCT = fats with long-chain fatty acids; they are absorbed directly into the body’s fat depots without much conversion and are released from them only very slowly. They are also known by the term hidden fats.
