TRAINING TABLE
DEBRA WEIN, MS, RD, LDN, NSCA-CPT,*D AND
MEGAN MIRAGLIA MS, RD, LDN
GLUTEN INTOLERANCE AND THE ATHLETE
Living a gluten-free lifestyle is growing in prevalence both
across the United States and around the world. Special care and
consideration should be taken for the athlete with celiac disease or
observing a gluten-free diet to ensure that adequate nutrients and
energy are consumed to achieve peak performance and prevent
physical complications.
Celiac disease affects approximately 0.6 – 1% of the population
worldwide and is common in developing countries that are
becoming more exposed to the westernized, processed diet
(3). Women are 1.5 – 2 times more at risk than men, and that
risk is amplified in those who have a first-degree relative with
celiac disease, type I diabetes, Hashimoto’s thyroiditis, or other
autoimmune diseases (3). As awareness increases around celiac
disease, gluten intolerance, and wheat allergies, so does research
around better methods of diagnosis, treatment, and product
development to accommodate affected individuals. Celiac disease
is a hereditary, systemic immune-mediated disorder triggered
by dietary gluten that leads to damage of the intestinal tract
and consequently malabsorption of nutrients (3,5). The offender,
gluten (or gliadin), is a protein complex found in wheat, rye, and
barley that gives rise to bread during the baking process (3).
SYMPTOMS AND COMPLICATIONS
Individuals with celiac disease may experience a broad range of
symptoms. Consumption of gluten produces an inflammatory
response in the intestinal tract that may ultimately result in
damage to the small intestinal mucosa causing the villi to flatten
and atrophy (5). This reduces the colon’s ability to absorb proper
nutrients leading to potential nutrient deficiencies that may affect
not only the digestive tract, but also the blood, bones, brain,
nervous system, and skin (5).
Athletes need to be aware of both short-term and long-term
symptoms and complications that may affect their performance
now and later in life. Gluten sensitivity, also known as non-celiac
gluten intolerance, is characterized by fatigue, headaches, and
gastrointestinal distress such as gas, bloating, and diarrhea (4). On
a more severe scale, those with celiac disease may experience any
of the above symptoms in addition to iron deficiency, weight loss,
short stature, reduced bone mineral density, or skin conditions
(3). Complications related to untreated celiac disease include
osteoporosis, impaired splenic function, neurological disorders,
infertility, ulcerative jejunoileitis, or cancer (3). On the other hand,
those with gluten intolerance or a wheat allergy do not need to
worry about any coexisting conditions or long-term complications
outside of the symptoms. For a better comparison of the three
conditions, please refer to Table 1.
DIAGNOSIS
Diagnosing celiac disease and gluten intolerance can come with
some degree of uncertainty (3). First, assess an athlete’s past
medical and nutrition history including questions regarding
fatigue, energy level, exercise tolerance, and gastrointestinal
symptoms such as diarrhea, bloating, and abdominal pain (5).
Additionally, collection of information about stress fractures,
anemia, and signs and symptoms around gluten-containing
foods should be obtained prior to a detailed physical exam. In
diagnosis workup for an athlete, it is important to test for common
ailments such as electrolyte abnormalities from eating disorders,
iron-deficiency anemia, mononucleosis, vitamin D deficiency,
food allergies, thyroid, or Lyme disease (5). Currently, the most
common blood serum test to screen for celiac disease is the
measurement of IgA anti-tissue transglutaminase antibodies due
to the high levels of sensitivity and specificity (6). If there is a
positive blood serum test, an upper endoscopy and duodenal
biopsy that look for damage to the intestinal lining are used to
confirm celiac disease. Catassi recommends that four of the five
should be present to accurately diagnose celiac disease: typical
symptoms, positive IgA class antibodies serum celiac disease
test, HLA-DQ2 or DQ8 genotypes, celiac enteropathy (damage to
intestine via biopsy), and response to a gluten-free diet (1).
NUTRITIONAL CONCERNS
Newly diagnosed athletes may experience iron-deficiency anemia
and need to focus on consuming gluten-free iron-rich foods and/
or an iron supplement (5). A gluten-free multivitamin is beneficial
to support nutritional needs. Lactose intolerance and calcium
deficiency are also commonly reported and the athlete should
aim to include non-dairy, calcium-rich sources such as broccoli,
spinach, fortified-orange juice, and fish, as dairy may be difficult
to tolerate while the intestinal tract is healing. Grains such as
amaranth, quinoa, and teff are high in calcium and offer crucial B
vitamins, protein, and fiber. Other nutrients commonly lacking in
the diet of an athlete with celiac disease include vitamin B12, folic
acid, zinc, and copper.
LIFESTYLE MANAGEMENT
Following a gluten-free diet is the only known treatment of
celiac disease and may require a multi-disciplinary approach to
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