一旦患者被诊断患有乳糜泻，应建议其避免食用所有含有小麦、黑麦、大麦和斯佩耳特小麦的食品。National Digestive Diseases Information Clearinghouse: celiac diseaseNational Celiac Association 理论上燕麦不会导致乳糜泻，但许多燕麦制品被小麦污染，且少数乳糜泻患者可能对燕麦不耐受。 有大量证据表明，未被小麦或大麦污染的燕麦对绝大多数乳糜泻患者是安全的。[148]Holm K, Maki M, Vuolteenaho N, et al. Oats in the treatment of childhood coeliac disease: a 2-year controlled trial and a long-term clinical follow-up study. Aliment Pharmacol Ther. 2006 May 15;23(10):1463-72.http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2006.02908.x/fullhttp://www.ncbi.nlm.nih.gov/pubmed/16669961?tool=bestpractice.com[149]Hogberg L, Laurin P, Falth-Magnusson K, et al. Oats to children with newly diagnosed coeliac disease: a randomised double blind study. Gut. 2004 May;53(5):649-54.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774046/http://www.ncbi.nlm.nih.gov/pubmed/15082581?tool=bestpractice.com[150]Garsed K, Scott BB. Can oats be taken in a gluten-free diet? A systematic review. Scand J Gastroenterol. 2007 Feb;42(2):171-8.http://www.ncbi.nlm.nih.gov/pubmed/17327936?tool=bestpractice.com然而，部分患者可能很敏感。[151]Pinto-Sánchez MI, Causada-Calo N, Bercik P, et al. Safety of adding oats to a gluten-free diet for patients with celiac disease: systematic review and meta-analysis of clinical and observational studies. Gastroenterology. 2017 Aug;153(2):395-409;e3.https://www.gastrojournal.org/article/S0016-5085(17)35474-4/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F28431885%2Fhttp://www.ncbi.nlm.nih.gov/pubmed/28431885?tool=bestpractice.com 美国胃肠病学院指南建议在乳糜泻患者的饮食中加入无麸质燕麦。[73]Chaudrey KH. ACG guideline: diagnosis and management of celiac disease. Am J Gastroenterol. 2023;118(1):23.http://www.ncbi.nlm.nih.gov/pubmed/36602833?tool=bestpractice.com在北美，一些食品生产商依照“纯度认证协议（Purity Protocol）”运作，包括使用尽量减少麸质的工艺流程来收获、运输、储存、加工和生产燕麦。[152]Allred LK, Kupper C, Iverson G, et al. Definition of the “Purity Protocol” for producing gluten-free oats. Cereal Chem. (2017) 94:377–9.https://onlinelibrary.wiley.com/doi/epdf/10.1094/CCHEM-01-17-0017-VO 在某些国家/地区，不建议将燕麦作为无麸质饮食的一部分，并且在推荐燕麦之前，应先查阅当地指南。
无麸质饮食的要求非常高，尤其是在开始阶段，故强烈推荐将患者转诊至擅于管理乳糜泻患者的营养师，并介绍给本地的支持性/倡议性团体。应宽慰患者，坚持无麸质饮食是一项挑战，早期出现错误和调整困难都是常见的。可提高无麸质饮食总体依从性的因素包括：增进对饮食的了解、加入乳糜泻组织、加强教育，以及提升自我调节效力。[195]Abu-Janb N, Jaana M. Facilitators and barriers to adherence to gluten-free diet among adults with celiac disease: a systematic review. J Hum Nutr Diet. 2020 Dec;33(6):786-810.http://www.ncbi.nlm.nih.gov/pubmed/32348008?tool=bestpractice.com 因为乳糜泻患者可能面临饮食失调的风险，可以建议咨询相应治疗专家。[196]Peters JE, Basnayake C, Hebbard GS, et al. Prevalence of disordered eating in adults with gastrointestinal disorders: a systematic review. Neurogastroenterol Motil. 2022 Aug;34(8):e14278.http://www.ncbi.nlm.nih.gov/pubmed/34618988?tool=bestpractice.com
隐藏的麸质来源
在理想情况下，“无麸质饮食”应排除所有含麸质的食物。然而，尽管采取了严格的饮食调整，但至少 1/3 的乳糜泻患者暴露于麸质。[197]Wieser H, Segura V, Ruiz-Carnicer Á, et al. Food safety and cross-contamination of gluten-free products: a narrative review. Nutrients. 2021 Jun 29;13(7):2244.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8308338/http://www.ncbi.nlm.nih.gov/pubmed/34210037?tool=bestpractice.com 许多经过认证的天然无麸质食品都容易受到污染，且麸质含量高于食品法典委员会标准 118-1979 设定的 20 mg/kg 阈值。[198]Food and Agriculture Orgnaisation of the United Nations. Standard for foods for special dietary use for person intolerant to gluten. 2008 [internet publication].https://www.fao.org/fao-who-codexalimentarius/sh-proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FStandards%252FCXS%2B118-1979%252FCXS_118e_2015.pdf[199]Gibert A, Kruizinga AG, Neuhold S, et al. Might gluten traces in wheat substitutes pose a risk in patients with celiac disease? A population-based probabilistic approach to risk estimation. Am J Clin Nutr. 2013 Jan;97(1):109-16.https://www.sciencedirect.com/science/article/pii/S0002916523053790?via%3Dihubhttp://www.ncbi.nlm.nih.gov/pubmed/23193005?tool=bestpractice.com[200]Sharma GM, Pereira M, Williams KM. Gluten detection in foods available in the United States - a market survey. Food Chem. 2015 Feb 15;169:120-6.http://www.ncbi.nlm.nih.gov/pubmed/25236206?tool=bestpractice.com[201]Koerner TB, Cleroux C, Poirier C, et al. Gluten contamination of naturally gluten-free flours and starches used by Canadians with celiac disease. Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2013;30(12):2017-21.http://www.ncbi.nlm.nih.gov/pubmed/24124879?tool=bestpractice.com 不恰当的标签、社交限制以及生食或熟食和药物中普遍存在的麸质蛋白也可能导致意外接触麸质。此外，餐厅用餐、食用复合食品以及使用含有隐藏麸质的口腔卫生用品和化妆品可能会无意中接触麸质。[202]Lerner BA, Phan Vo LT, Yates S, et al. Detection of gluten in gluten-free labeled restaurant food: analysis of crowd-sourced data. Am J Gastroenterol. 2019 May;114(5):792-7.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502671/http://www.ncbi.nlm.nih.gov/pubmed/30920417?tool=bestpractice.com[203]Falcomer AL, Santos Araújo L, Farage P, et al. Gluten contamination in food services and industry: A systematic review. Crit Rev Food Sci Nutr. 2020;60(3):479-93.http://www.ncbi.nlm.nih.gov/pubmed/30582343?tool=bestpractice.com[204]Verma AK, Lionetti E, Gatti S, et al. Contribution of oral hygiene and cosmetics on contamination of gluten-free diet: do celiac customers need to worry about? J Pediatr Gastroenterol Nutr. 2019 Jan;68(1):26-9.http://www.ncbi.nlm.nih.gov/pubmed/30119098?tool=bestpractice.com 使用单独的生产和加工区域对含麸质和无麸质产品进行加工可成为这个问题的一种可能的解决办法。[205]Demirkesen I, Ozkaya B. Recent strategies for tackling the problems in gluten-free diet and products. Crit Rev Food Sci Nutr. 2022;62(3):571-97.http://www.ncbi.nlm.nih.gov/pubmed/32981341?tool=bestpractice.com
