2023+营养和饮食学会循证实践指南：乳糜泻.（英文版pdf

FROM THE ACADEMYCeliac Disease:An Academy of Nutrition andDietetics Evidence-Based Nutrition PracticeGuidelineJoann M.McDermid,PhD,MSc,RDN,FAND;M.Angie Almond,MEd,RDN,LDN,FAND;Kristen M.Roberts,PhD,RDN,LD,FASPEN,FAND;Emily M.Germer,MBA,MPH,RDN,LDN;Marilyn G.Geller,MSPH;Theresa A.Taylor,MS,RDN,LD;Rachel C.Sinley,PhD,MPH,RDN;Deepa Handu,PhD,RDNABSTRACTCeliac disease is an autoimmune disorder in which the immune system of genetically susceptible individuals elicits a reaction to glutencausing small intestine damage.If left undiagnosed and untreated,the resulting nutrition malabsorption can lead to anemia,bonedisease,growth faltering,or other consequences.The condition is lifelong and lacks a cure;the only treatment is lifelong adherence to agluten-free diet(GFD).This diet is challenging to follow and adversely influences quality of life;however,it is essential to ensure in-testinal recovery and prevent future negative health consequences.The Academy of Nutrition and Dietetics convened an expert panelcomplemented by a celiac disease patient advocate to evaluate evidence for six topics,including medical nutrition therapy;the GFD;oatconsumption;micronutrients;pro-/prebiotics;and the low fermentable oligosaccharides,disaccharides,monosaccharides,and polyolsdiet.This publication outlines the Academy of Nutrition and Dietetics Evidence Analysis Library methods used to complete the sys-tematic review and guideline development,and summarizes the recommendations and supporting evidence.The guidelines affirm thatall individuals with celiac disease should follow a GFD(1C,Imperative)that may include gluten-free oats in adults(2D,Conditional).Children should follow a nutritionally adequate GFD that supports healthy growth and development(Consensus,Imperative)and doesnot unnecessarily restrict gluten-free oats(Consensus,Conditional).The guidelines indicate nutritional care should include routinenutritional assessment(Consensus,Imperative)and medical nutrition therapy(Consensus,Imperative).At this time,the guidelines donot support a recommendation for the addition of the low fermentable oligosaccharides,disaccharides,monosaccharides,and polyolsdiet(2C,Conditional);prebiotic or probiotic supplementation(2D,Conditional);or micronutrient supplementation(in the absence ofnutritional deficiency)(Consensus,Conditional).The 2021 Celiac Disease Evidence-Based Nutrition Guideline will assist registereddietitian nutritionists in providing appropriate evidence-based medical nutrition therapy to support people with celiac disease inachieving and maintaining nutritional health and avoiding adverse celiac disease consequences throughout their lives.J Acad Nutr Diet.2023;123(12):1793-1807.Supplementarymaterials:Tables 2 and 3 and the Figure areavailable at www.jandonline.orgCELIAC DISEASE IS AN AUTOIM-mune condition characterizedby immune-mediated damageto the small intestine that oc-curs following gluten consumption ingeneticallysusceptibleindividuals.The factors that lead to the develop-ment of subclinical or overt celiac dis-easeingeneticallysusceptibleindividuals are unknown.Once celiacdisease manifests,there is no cureand it remains a lifelong medical con-dition.Currently,the only approvedtreatment is the total avoidance ofgluten that is present in foods,bever-ages,andmedications.Giventheubiquitous nature of gluten in fooditems in most dietary patterns,totallifelongdietaryadherenceischal-lenging for any person living with thecondition,as well as those who prepareand share meals with them.Medicalnutrition therapy(MNT)provided by aregistered dietitian nutritionist or in-ternational equivalent(RDN)is neededat celiac disease diagnosis and there-aftertoprovidesupporttowardachieving and maintaining lifelong die-taryadherencetoanutritionallyadequate gluten-free diet(GFD).Ensuring that celiac disease-specificMNT is based on current evidence iscritical as our understanding of celiacdisease progresses and the nature of aGFD changes.With that in mind,TheAcademy of Nutrition and Dietetics(Academy)Evidence Analysis Center(EAC)conductedascopingreview(Cheng and colleagues1)and a sys-tematic review of the literature toguide the development of evidence-basedpracticeguidelinesforin-dividuals diagnosed with celiac dis-ease.This guideline is intended toinform the practice of clinicians work-ing with people diagnosed with celiacdisease,includingRDNsprovidingMNT.Like all guidelines,the goal is toprovide evidence-based guidance thatmust be appropriately combined withclinical judgment that best meets theneeds of individual patients.GUIDELINE OBJECTIVE,SCOPE,AND TARGET USERSGuideline ObjectiveThe purpose of this guideline was toprovide evidence-based recommenda-tions for RDNs delivering MNT to in-dividualswithceliacdiseaseandpeople who share in their food acqui-sition,preparation,and consumption.The focus of this guideline was on2212-2672/Copyright 2023 by theAcademy of Nutrition and Dietetics.https:/doi.org/10.1016/j.jand.2023.07.018 2023 by the Academy of Nutrition and Dietetics.JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS1793nutrition-relatedinterventionsandoutcomes that inform nutrition-relatedpractice for people with celiac disease.The primary goals being to promote theachievementandmaintenanceofoptimal health,growth,and develop-ment;topreventandtreatceliacdisease-associatedmalabsorptionormalnutrition that may lead to comor-bidities such as anemia,osteopenia,orosteoporosis;andtoimprovethequality of life for people following theGFD after celiac disease diagnosis andthroughout their lives.Guideline ScopeTheresultsofthescopingreviewrevealed that existing evidence-basednutritionguidelinesforindividualswith celiac disease did not focus onMNT or guidelines to help RDNs pri-marily working with clients in theUnited States.Therefore,in this newguideline,the expert workgroup panelfocused on the effectiveness of the pri-mary nutrition intervention,the GFD,including gluten-free oat consumptionand micronutrient supplementation.Italso considered newer nutrition in-terventions utilized in other gastroin-testinal conditions as possible adjuvantdietaryinterventions,includingpre-biotics/probiotics and the low ferment-ableoligosaccharides,disaccharides,monosaccharides,andpolyols(low-FODMAP)diet.METHODSSupporting Systematic ReviewTo inform the current evidence-basedpractice guidelines,a systematic re-view was conducted to examine theeffectiveness of the primary nutritionintervention,theGFD,alongwithreconsideringgluten-freeoatcon-sumption and micronutrient supple-mentation and adding adjuvant dietaryinterventions like prebiotics/probioticsand the low-FODMAP diet.The methodsused to conduct the systematic reviewweretheAcademysprocess2andCochraneCollaborationsGradingofRecommendations Assessment,Devel-opmentandEvaluation(GRADE)methods,3with adherence to the stan-dards of Preferred Reporting Items forSystematic Reviews and Meta-analysischecklist.4Specific methods for theseguidelines and supporting systematicreview are briefly described here,withfurther details available on the EvidenceAnalysis Library(EAL)website(https:/www.andeal.org/).Systematic Review ProcessSummaryQuestion Development,LiteratureSearch,and Study Selection.Thequestionsreviewedin this guideline andsupporting systematic review are listedin Table 1.The expert panel followedthe EAC process for conducting thesystematicreview.Thepopulation,intervention/exposure,comparison/control,and outcome format for ques-tions,eligibility criteria,and search planfor this systematic review were regis-teredapriorionthePROSPEROdatabase5(CRD42020169998)(Chengandcol-leagues1).A comprehensive search ofdatabases,including(MEDLINE(Ovid),Embase(Ovid),CochraneCENTRAL(Ovid),CINAHL(EBSCO),and Web ofScience,PsycINFO)was conducted by amedical librarian.Details of the searchplanandsearchtermsaresummarizedinTable 2(available at www.jandonline.org).Results of the systematic searchesand screening results are presentedusing the Preferred Reporting ItemsforSystematicReviewsandMeta-Analysis in the Figure(available atwww.jandonline.org).Study Quality Assessment.Risk ofepidemiological biaswasconsideredforeach study and was assessed by twoindependent reviewers using the Qual-ity Criteria Checklist,the Academysonline risk of bias tool.The questions ofthe Quality Criteria Checklist are basedon constructs and risk of bias domainsidentified by the Cochrane Collabora-tion,including selection,performance,detection,attrition,and reporting bia-ses.Any discrepancies between the tworeviewers were resolved by consensus,and if unable to reach consensus,byincluding athirdindependent reviewer.Table 1.Intervention research question(RQ)list for celiac disease systematic reviewSubtopicQuestionMNTa/nutrition counselingRQ 1:In patients with celiac disease,how does MNT/nutrition counseling provided by a RDNbor international equivalent,compared with a control,influence nutrition-related outcomes?Adjuvant prebiotic/probioticsupplementationRQ 2:In patients with celiac disease,what are the effects of prebiotics/probiotics,comparedwith a control,on nutrition-related outcomes?Adjuvant low-FODMAPcdietRQ 3:In patients with celiac disease,what are the effects of low-FODMAP diet,compared witha control,on nutrition-related outcomes?Gluten-free dietRQ 4:In patients with celiac disease,what are the effects of gluten-free diet,compared with acontrol,on nutrition-related outcomes?Oat consumptionRQ 5:In patients with celiac disease,what are the effects of oats,compared with a control,onnutrition-related outcomes?Micronutrient supplementationRQ 6:In patients with celiac disease,what are the effects of supplements(eg,calcium,iron,Bvitamins,zinc,copper,multivitamin),compared with a control,on nutrition-relatedoutcomes?aMNT medical nutrition therapy.bRDN registered dietitian nutritionist.cFODMAP fermentable oligosaccharides,disaccharides,monosaccharides,and polyols.FROM THE ACADEMY1794JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICSDecember 2023 Volume 123 Number 12Data Synthesis and Grading theEvidence.For all identified outcomesreported in the included studies,anarrative synthesis of evidence wasconducted.Duetoinsufficientandinconsistent data reported for all prioriquestions/outcomes included,a meta-analysis was unable to be conducted.Instead,conclusion statements weredeveloped for each population,inter-vention/exposure,comparison/control,andoutcomeformatquestionandassigned a grade to reflect strength ofevidence.GRADE tables were generatedfor each outcome of interest usingGRADEPro and demonstrated how thestrength of evidence was derived.Evi-dence for each outcome of interest wasgraded as high(A),moderate(B),low(C),or very low(D),as described inTable 3(available at www.jandonine.org).Study characteristics tables for allincluded studies and GRADE tables canbe found on EAL website(https:/www.andeal.org/topic.cfm?menu5279).Expert Panel Selection Process.Tolimit the potential for personal bias orconflicts of interest and to recruit in-dividuals with relevant expertise,theWork Group Selection Subcommittee ofthe Academy Council on Research fol-lowedatransparentprocessofselectingan expert panel to help provide subjectmatterclinicalandresearchexpertisetoconduct the systematic review anddevelop recommendations.The expertpanel consisted of six US-credentialedRDNs with extensive experience inadultand/orpediatricMNT and/orresearch for individuals with celiac dis-ease.In addition,the parent of an indi-vidual with celiac disease served aspatientadvocate.Allexpertpanelmembers and the patient advocateparticipated in each step of the sys-tematic review and guideline develop-ment.Supporting members of the teamconsisted of aresearchmethodologist,amedical librarian,a project manager,alead analyst,as well as trained evidenceanalysts.Theteamhadregularvirtual meetings to develop researchquestions,screen studies,analyze evi-dence,voteandgradeconclusionstatements,and formulate and discussrecommendations.Guideline Development.The expertpanel followed the EAC and GRADEprocesses in the development of thisguideline.For each systematic reviewtopic,expertpanelmemberscompletedGRADEsevidence-to-decision(EtD)framework,6,7whichhelps to balance benefits and harms,certainty of evidence,importance ofoutcomes,resource use,equity,patientvalues,acceptabilityandfeasibilitybased on available evidence,and clin-ical expertise to develop recommen-dations.In situations where evidencewas unavailable to develop recom-mendations,consensusstatementsweredevelopedbasedonclinicalexpertiseandwiththegoalofachieving better outcomes for clientsnoting that all clinical practice de-cisionsshouldbeindividualizedtoeach specific client.The expert panelvoted on approving each recommen-dationandratedrecommendationsbased on the strength of evidence/confidence in findings and balance offactors considered in EtD framework.For each recommendation,the expertpanel and patient advocate providedimplementationconsiderations,po-tential risks and harms,condition ofapplication,costs,and rationale for therecommendation.Abbreviatedsup-porting evidence for each recommen-dation is included in this article,withthe complete version provided on theEAL website(https:/www.andeal.org/topic.cfm?menu5279).The grading of the recommendationstatements is based on certainty ofevidence(ranging from high A to verylow D)as well a clinical expertise andconsideration of client values and otherEtD framework components.Recom-mendations rated as Level 1 are strongand generally applicable to majority ofthe target population.Recommenda-tions rated as Level 2 may be of lowercertainty of evidence and are consid-ered weaker recommendations.External Peer-Review Process.Theceliac disease guidelines underwent apeer-reviewed process by an externalreview performed by 10 people withexpertise in providing celiac diseasecare.These experts used the Appraisalof Guidelines for Research and Evalua-tion II tool to assess the quality ofguidelinereporting.Basedonthefeedback from the external reviewers,the expert panel,patient advocate,andprojectmanagerrevisedtheguidelines and accompanying text,andthe expert panel voted and unani-mously approved all modifications.Anexecutive summary of the recommen-dations is provided in Table 4.Guideline Updates.Academy guide-lines are reviewed every 5 years whenascopingreviewisconductedtoexamine the need for new and revisedrecommendations based on existingevidence.The Academy Council onResearchevaluatesandprioritizesresearch topics based on the results ofthe scoping reviews and current Acad-emy member needs.RECOMMENDATIONSTATEMENTS AND SUPPORTINGEVIDENCEDetailedevidencesupportingtheserecommendations can be found on theEAL website(https:/www.andeal.org/topic.cfm?menu5279&cat5991).1.Recommendation for RoutineNutrition Assessment1.0.In individuals newly diagnosed withceliac disease,it is reasonable that aregistered dietitian nutritionist or an in-ternationalequivalentconductacomprehensive initial nutrition assess-ment and evaluates individual ability(including but not limited t