The Naturopathic Management of Coeliac Disease: A Case Report

Abstract:

 

Introduction

This case study examines the application of naturopathic treatments, in a 34-year-old female, presenting with coeliac disease. As the main treatment for coeliac disease is immediate and permanent exclusion of gluten-containing foods, the aim of this report is to investigate whether potential exists for naturopathic therapies to aid in reducing risk of associated complications and significantly improving self-management of the disease.

Method

The treatment was implemented over a 14-week period, consisting of eight appointments in total; the initial consultation, a wellness plan presentation and six follow-up appointments thereafter. Two clinical patient-related outcome measures were used to document quantitative data, as reported by the client, this includes a Measure Yourself Medical Outcome Profile version 2 (MYMOP2) and Well-Being Questionnaire 36-Item Short Form Survey (SF-36). These were completed before treatment had commenced and at the third and sixth follow up sessions. Qualitative data was gathered through documentation of the client’s narrative during each appointment.

Results

MYMOP2 and SF-36 outcome measures showed clinically significant improvements from baseline over the course of the treatment. Clinical symptoms of coeliac disease had reduced in frequency or severity, as perceived by the client, by the end of the treatment.

Conclusion

A naturopathic approach was shown to be useful in the management of coeliac disease. Further research is required to assess the effectiveness of naturopathic medicine on this condition.

Key words

Coeliac disease, autoimmune disease, gastrointestinal, digestive health, naturopathic medicine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Introduction:

 

The prevalence of Coeliac disease (or gluten-sensitive enteropathy) in New Zealand (NZ) is similar to that of other industrialised countries, with 1% of the general population diagnosed (Tanpowpong et al., 2011). This highlights a significant public health issue in NZ and the importance for early detection and long-term management strategies.

Coeliac disease now affects 1% of most populations around the world, making it one of the most common genetically determined diseases in humans (Rubio-Tapia & Murray, 2010).

This case report examines naturopathic treatment of Coeliac disease, to investigate how a naturopathic approach may improve long-term management and self-efficacy of coeliac disease, in order to reduce severity of symptoms and associated complications.

 

The pathogenesis of coeliac disease is complex, involving dietary, genetic and immunological factors (Craft & Gordon, 2015). Coeliac disease originates as a result of a combined action involving adaptive and innate immunity (Setty, Hormaza, Guandalini, 2008). Exposure to gluten causes a T-cell mediated autoimmune injury to intestinal epithelial cells in genetically susceptible individuals. The major pathophysiological characteristics of coeliac disease are atrophy and flattening of villi in the duodenum and jejunum of the small intestine (Craft & Gordon, 2015).

Destruction of gastrointestinal mucosal cells causes inflammation, leading to water and electrolytes to be secreted resulting in watery diarrhoea, bloating and abdominal pain (Craft & Gordon, 2015; Ludvigsson et al., 2013). Loss of villi decreases the absorbent surface area of the intestines, allowing food to pass through more quickly, reducing the absorption of nutrients including essential fatty acids, B vitamins, and minerals (Fasano & Catassi, 2012; Craft & Gordon, 2015). The secretion of intestinal hormones may be diminished, therefore secretion of bile and pancreatic enzymes decrease, further contributing to malabsorption, fatty stools (steatorrhoea) and alterations in bowel motility (Ludvigsson et al., 2013; Craft & Gordon, 2015).

Treatment is based on the immediate and permanent exclusion of gluten containing foods from the diet (Ludvigsson et al., 2013). As gluten can be found in a wide variety of foods, patient education is crucial for successful long-term management of the disease. Patients may require supplementation of fat-soluble vitamins and minerals to treat deficiencies associated with malabsorption (Craft & Gordon, 2015; Pizzorno & Murray, 2013). Naturopathic treatment of coeliac disease is based on preventing gluten contamination through client education, removal of other possible aggravating factors from the diet and healing the gastrointestinal (GI) epithelium to encourage the regrowth of intestinal villi, to improve absorption of nutrients (Pizzorno & Murray, 2013; Hechtman, 2012). Further more herbal medicine and nutritional interventions can help improve digestion and modulate bowel function (Braun & Cohen, 2015; Hechtman, 2012).

Despite the gluten-free diet being so effective, there is a growing demand for alternative treatment options (Setty, Hormaza, Guandalini, 2008). The aim of this case report is to outline the process and outcomes of 8 naturopathic treatment sessions, which included a range of dietary, lifestyle and herbal medicine interventions.

This case study is intended to provide direction for, and contribute to, the evidence base for naturopathic treatment and management of coeliac disease.

Case Presentation:

Client Profile

The client, a 34-year-old, female, employed as a funding manager for youth social justice, diagnosed with coeliac disease by a GP via tissue transglutaminase (TTG) serology approximately 5 years ago.

No treatment was given at the initial diagnosis. After diagnosis the client has followed a gluten-free diet, although may occasionally be exposed to gluten from a café. She has used slippery elm powder with beneficial results. She has seen other naturopaths in the past, who recommended probiotics, multivitamins and herbal fluid extracts. The client has used this same treatment regime prescribed by the naturopath each time her symptoms are exacerbated.

At the initial consultation the client was suffering from flatulence, bloating, cramping in left and right lower quadrants, and nausea, which are worse after each meal. The client gets alternating diarrhoea and constipation with gluten consumption. The client rated her most frequently passed type of stool as a type three on the Bristol stool chart. The client is a smoker of approximately 12 ‘roll-your-own’ cigarettes per day. At the initial consultation the client was attending a one-hour yoga class each week.

Both of the client’s parents are intolerant to lactose and gluten. The client was hospitalised for 5 weeks at 3-years-old due to lead poisoning, as her parents were sanding lead-based paint from their family home. The client stated she is lactose intolerant, which was “diagnosed at a very young age”.

On examination there was no abdominal mass or pain felt. On auscultation, low to medium pitched gurgles were heard every 3 seconds in all four quadrants. Hyperactive sounds are commonly heard with diarrhea or in conditions such as gastroenteritis (Jarvis, 2012).

Naturopathic Assessment

 

The client stated coeliac disease had impacted her “diet” and her “body is in a state of inflammation constantly”, “tiredness and malabsorption” also “make the day longer”. At the time of diagnosis, the client was under considerable stress due to completion of a bachelor’s degree and family issues.

Furthermore, the client stated she was “allergic” to her mothers “breast milk” as a baby, and when “put on a dairy based formula” she “reacted” and given non-dairy based formula thereafter.

The client did not seem comfortable talking about her bowel habits and was vague on the topic.

The client experienced two traumatic experiences at the start of the year including a house fire and car accident, which affected her both physically and mentally. The client felt as though emotional stress exacerbated her symptoms. The client rated her stress on the day of the consultation as an 8/10 stating, it could “easily be a 12, if I let it go”.

 

A one-day diet recall was conducted at the initial consultation, Foodworks (2015) analysis of this showed vitamin A, calcium, iron and iodine intake were below the recommended daily intake (RDI). Further more, the client’s diet was low in fiber, fresh fruit, whole grains and water. The client’s dietary recall also included dairy (as milk in her morning coffee), of which she is intolerant to.

Nutrient	RDI/ Adequate intake (AI) per day	Intake per day
Vitamin A	700mcg (Ministry of Health (MoH) NZ, 2017).	469mcg or, 67% of RDI
Iodine	150mcg (MoH NZ, 2017)	132 mcg or, 88% of RDI
Calcium	1000mg (MoH NZ, 2017)	904mg or, 90% of RDI
Iron	18mg (MoH NZ, 2017)	14.3mg or, 80% of RDI
Fiber	25g (AI) (MoH NZ, 2017)	23g
Water	2.8L (AI) (MoH, 2017)	1L

Table 1: One-day diet recall foodworks analysis

Desired outcomes for the client included improving energy and figuring out what was the cause of her coeliac symptoms, as she believes she was completely avoiding gluten.

Differential diagnosis

 

Small intestinal bacterial overgrowth (SIBO): Symptoms of flatulence, bloating, steatorrhea, nausea, diarrhoea and constipation are commonly seen in alterations in SIBO (Gasbarrini et al., 2007; Bures et al., 2010). This is due to the incomplete digestion of food in the gastrointestinal tract, which ferments, leading to excess production of gas and consequent bloating (Hechtman, 2012; Pizzorno and Murray, 2013).

 

Crohn’s disease: symptoms of abdominal pain, cramping, tiredness, malabsorption, alternating constipation and diarrhoea are commonly seen in Crohn’s disease (Craft & Gordon, 2015).

 

Food intolerance: symptoms of flatulence, bloating, nausea, loose stools and constipation can be indicative of a food intolerance (Sampson, 2004).

 

Lead toxicity: may cause gastrointestinal symptoms (e.g. diahorrea, constipation and stomach pains) (Ministry of Health NZ, 2017a).

 

Treatment plan:

The treatment plan consisted of naturopathic goals, three S.M.A.R.T (Specific, measurable, agreed upon, realistic and time-based) goals (Doran, 1981) and herbal formula prescribed at the second appointment after the initial consultation. Additional goals and a supplement were prescribed at follow-up appointments. All the above were discussed and assessed with necessary changes made, using shared decision making with the client.

Naturopathic goals

The primary intent of the naturopathic treatment was to reduce the symptoms experienced through educating the client on long-term management strategies and reducing inflammation in the gastrointestinal tract associated with coeliac disease. This aimed to improve health-related quality of life and reduce the risk of associated complications for the client (Ludvigsson et al., 2013; Hechtman, 2012). Naturopathic goals implemented throughout the treatment included:

Help reduce symptoms associated with coeliac disease

Educate the client on stress management techniques

Assess for and eliminate food intolerances.

Correct possible nutrient inadequacies.

Increase rate of exercise.

Increase water consumption

Educate the client on prevention and self-management strategies for coeliac disease.

S.M.A.R.T goals

Goal	Rationale
“For the next two weeks I will consume one serving of anti-inflammatory foods in one meal each day.”	Anti-inflammatory foods contain phytochemicals, found to have antioxidant, anti-inflammatory and immune enhancing properties (Zhang & Tsao, 2016; Hechtman, 2012). To help reduce/prevent inflammation within the body.
“For the next two weeks I will consume one serving of fiber containing foods each day.”	Improves transit time, maintains colonic functioning and increases protection from oxidative stress (de Vries, Miller & Verbeke, 2015; Flint, Scott, Louis & Duncan, 2012).
“For the next week I will keep a food, stress and symptom diary.“	To gain an understanding of the client’s nutritional health, stress levels and if there is any association with her symptoms (Hechtman, 2014; Braun & Cohen, 2015).

Table 2: S.M.A.R.T goals

Nutritional recommendations

Nutritional interventions were prescribed at follow-up appointments and were based on correcting nutritional inadequacies, eliminating possible aggravating factors from the diet and reducing inflammation within the GIT.

Intervention	Rationale
Increase water consumption to 1.5L per day	Client was consuming approximately 750mL per day, this goal aimed to improve physical and cognitive function and optimise hydration for consistency of stools (Hechtman, 2012; Maughan, 2003).
Eliminate sources of dairy from diet	Analysis of the 7-day food diary identified dairy in diet. The client was lactose intolerant as a child this goal aimed to eliminate possible sources of aggravators causing her symptoms. It is recommended to remove dairy from the diet in coeliac disease until intestinal structure and function return to normal (Pizzorno & Murray, 2013; Perlmutter, 2013). Interestingly, research shows breastfed babies have a decreased risk of developing coeliac disease (Ivarsson et al., 2013). A further reduction in risk was seen in babies who continued to breast feed after the introduction of gluten into the diet (Pizzorno & Murray, 2013; Ivarsson et al., 2013). The introduction of cow’s milk is also thought to be a major etiological factor to gluten ntolerance (Pizzorno & Murray, 2013).
Introduce bone broths into diet	Contains amino acids, collagen, minerals and gelatin, which aid in protecting and healing the digestive tract, this may help to protect and repair damage caused in the GIT by coeliac disease (Siebecker, 2004).
Breakfast smoothie Including Slippery elm	To encourage the client to eat a more sustainable breakfast. The client was consuming a gluten-free ‘breakfast’ muesli bar and coffee for breakfast prior to this goal being implemented. The client had used slippery elm powder in the past finding it had a beneficial result on her symptoms. She was encouraged to add slippery elm into her breakfast smoothies. Slippery elm contains mucilage giving it a demulcent action (Watts & Rousseau, 2012). This action has beneficial effects on gastric inflammation and irritations, by coating the mucous membrane in a protective gel-like barrier, preventing further damage from stomach acid (Hawrelak & Myers, 2010). This also provides an anti-inflammatory effect which aids in soothing and healing of mucous membranes (Morton, 1990).

Table 3: Nutritional recommendations

After analysis of the clients 7-day food diary, a supplement was prescribed at the forth appointment, which aimed to replenish inadequate supply of iron.

Supplement/Ingredient

Rationale

Clinicians Iron Boost Capsule Iron              24mg Ascorbic acid 50mg Vitamin B12 50mg Folic acid 300mcg

This supplement includes enough of each of these nutrients to provide the client with her RDI (MoH NZ, 2017). The clients 7-day food diary showed she was consuming 46% of the recommended daily intake of iron (NRV ref) Inadequate supply of iron is associated with low energy and mood fluctuations (Gropper, 2012). Furthermore, conditions associated with reduced transit time and diarrhoea cause reduce iron absorption and increase iron loss (Gropper, 2012). Vitamin C improved the absorption of iron in the GIT (Lane & Richardson, 2014). Vitamin C also has antioxidant activity to reduce oxidative stress (Gropper, 2012). B12 and folate are more likely to be deficient in those with coeliac disease due to malabsorption of nutrients and quickened transit time (Dahele & Ghosh, 2001).

Table 4: Iron supplement

Lifestyle Interventions

Lifestyle interventions were prescribed at follow-up appointments and aimed to reduce severity of symptoms through decreasing stress and improving health related quality of life.

Intervention	Rationale
Attending 2 yoga classes per week	Increase frequency of exercise. Regular yoga practice has a positive effects on oxidative stress and sympathetic nervous system activation (Penman, Cohen, Stevens  & Jackson, 2012). Evidence is emerging that yoga may have beneficial effects on gastrointestinal conditions such as coeliac disease (Penman, Cohen, Stevens & Jackson, 2012).
Abdominal massage	May help relieve symptoms of constipation and abdominal pain through improving bowel motility, promoting blood flow to the GIT and improved healing of the GI mucous membrane (Ernst, 1999; Pizzorno & Murray, 2013).

Table 5: Lifestyle Interventions

Herbal intervention

An herbal medicine intervention was presented at the second appointment and taken throughout the treatment. This provided choleretic, cholegogue, antioxidant, heatoprotective, adaptogenic, anti-inflammatory, anti-spasmodic and spasmolytic actions. This aimed to improve digestive function, reduce oxidative damage, inflammation and stress to decrease symptoms severity and long-term complications of coeliac disease. Further information on the herbal intervention can be seen in Table 6.

Herb & Plant Family	Part used	Source	Ratio	Therapeutic range	Dose prescribed	Actions	Rationale
Schisandra chinensis, Schisandra (Schisandra-ceae) Phytomed, 2017).	fruit Phytomed, 2017).	China Phytomed, 2017).	1:2 Phytomed, 2017).	25-60ml per week Phytomed, 2017).	40ml 1000mg per 5 ml dose Phytomed, 2017).	Anti-inflammatory Antioxidant Hepatoprot-ective Adaptogen (Braun & Cohen, 2015).	Schisandrin shows anti-inflammatory effects through significantly decreasing nitric oxide and prostaglandin production by inhibiting COX-2 expression (Guo et al., 2008). Lignans (schisandrins) exhibit antioxidant activity (Leong et al., 2016; Alok et al., 2014). Lignans also exhibit hepatoprotective effects (Cheng et al., 2013; Pu et al., 2012). Exhibits adaptogenic action, increasing resistance to physical and emotional stressors, helpful for stress management (Braun & Cohen, 2015).
Cynara scolymus, Globe artichoke (Asteraceae) Phytomed, 2017).	leaf Phytomed, 2017).	New Zealand/ France Phytomed, 2017).	1:2 Phytomed, 2017).	15-35ml per week Phytomed, 2017).	20ml 500mg per 5 ml dose	Choleretic Cholegogue Spasmolytic (Braun & Cohen, 2015; Fisher, 2009).	Stimulates bile production and secretion, beneficial in both constipation and diarrhoea (Marakis et al, 2002). Helpful for improving digestive function (Braun & Cohen, 2015). German Commission E. approved for dyspepsia and as a spasmolytic (Braun & Choen, 2015).
Vaccinium myrtillus, Bilberry (Ericaceae) Phytomed, 2017).	Berr-ies Phytomed, 2017).	Albania/ Bosnia/ Kosovo Phytomed, 2017).	1:1 Phytomed, 2017).	20-40ml per week Phytomed, 2017).	20ml 1000mg per 5 ml dose	Antioxidant Anti-inflammatory (Braun & Cohen, 2015).	Anthocyanins in Bilberry have superoxide radicle scavenging properties and the ability to amplify endogenous antioxidant systems within the body (Valentová, Ulrichová, Cvak, & Šimánek, 2007; Milbury, Graf, Curran-Celentano & Blumberg, 2007). Bilberry displays anti-inflammatory properties associated with its antioxidant actions, which have been proven in human trials (Karlsen et al., 2010; Braun & Cohen, 2015).
Melissa officinalis, Lemonbalm (Lamiaceae) Phytomed, 2017).	herb Phytomed, 2017).	Germany/Austria/ Croatia/ United States of America/ Poland Phytomed, 2017).	1:2 Phytomed, 2017).	20-45ml per week (Phytomed, 2017).	20ml 500mg per 5 ml dose	Anti-inflammatory Antioxidant Antispasmodic (Braun & Cohen, 2015; Fisher, 2009).	Rosmarinic acid and Eugenol content has shown to inhibit inflammatory processes (Birdane, Buyukokuroglu, Birdane, Cemek, & Yavuz, 2007) Demonstrated antioxidant activity (Kamdem et al., 2013; Dastmalchi et al., 2008). Volatile oils and citral have demonstrated spasmolytic activity in mice (Sadraei, Ghannadi & Malekshahi, 2003). Lemon balm may delay gastric emptying, improving absorption of nutrients and frequency of diarrhea (Braun & Cohen, 2015).

Table 6: Herbal formulation intervention

Methods:

Treatment took place over 14 weeks, consisting of eight consultations – an initial consultation, a wellness plan presentation and six follow up sessions. Two client-centred patient reported outcome measures were used. Measure yourself Medical Outcome Profile version 2 (MYMOP2) (Paterson, 2017) and Well-Being Questionnaire 36-Item Short Form Survey (SF-36) (RAND Health, 2017), were utilized throughout the treatment plan. These were completed before treatment had begun, and at the third and sixth follow up sessions.

 

Results:

 

SMART Goals

The client had attempted incorporation of fiber and anti-inflammatory foods into her diet by the first follow up.

The 7-day food, stress and symptom diary was returned and analysed via Foodworks (2015). By the second follow up a dietary supplement was prescribed to correct nutritional inadequacies.

Nutrient	RDI/ AI per day	Intake
Calcium	1000mg (MoH NZ, 2017)	638mg or, 64% of RDI
Iron	18mg (MoH NZ, 2017)	10.68mg or, 59% of RDI
Zinc	8mg (MoH NZ, 2017)	6.8mg or, 86% of RDI
Potassium	460-920mg (AI) (MoH NZ, 2017)	2234mg
Fibre	25g (AI) (MoH NZ, 2017)	22.6g
Water	2.8L (AI) (MoH, 2017)	1.45L

Table 7: 7-day food diary foodworks analysis

The client was requested to do a second 7-day food, stress and symptom diary at the fifth follow-up. The client lost the template provided and returned to the sixth follow-up with a 7-day food diary without portion sizes and symptoms or stress experienced, making it virtually incomparable to the first. Therefore, no secondary food works analysis was conducted.

Nutritional interventions

Water consumption increased to “1.25L-1.5L” per day by the third follow up.

The client reported successfully having had a breakfast smoothie each day for breakfast by the second follow-up appointment. At the third follow-up the client had, had “three breakfast smoothies in the last couple of weeks”.

The herbal formula and dietary supplement were taken throughout the treatment as advised.

A dairy elimination goal was then attempted. The client removed some sources of dairy from her diet (such as cheese) but not others (such as milk in coffee) by the end of treatment.

The benefits of bone broth consumption were discussed at the seventh appointment and had been successfully incorporated into two meals per week by the end of treatment.

Lifestyle interventions

The client reported having attended two yoga classes each week by the third follow up appointment, and at the forth follow up had also attended a “cardio class” and had been “sailing”.

Abdominal massage was recommended at the final appointment therefore, no assessment of the progress of this goal was made.

MYMOP2

MYMOP2 questionnaires were completed at the initial consultation, mid way through the treatment (third follow-up) and at the end of the treatment (sixth follow-up) (Paterson, 2017). The client chose “Low energy due to coeliac disease” as ‘Symptom one’, and “Gym attendance due to low energy” as the ‘Activity’ and, scored these on a Likert scale of 6 ‘as bad as it could be’ to 0 ‘as good as it could be’. The scores can be seen in figure 1: MYMOP2 scores.

Figure 1: MYMOP2 scores.

SF-36

SF-36 questionnaires were completed at the second appointment and third and sixth follow up appointments by the client (RAND Health, 2017). The average score of the eight different categories (physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional wellbeing, social functioning, pain and general health) can be seen in figure 2: SF-36 scores.

Figure 2: SF-36 Scores

Discussion:

An evidence based approach to each goal was taken, while shared decision making and motivational interviewing techniques were used to match the client to the trans-theoretical stages of change (Gold, 2013; Elwyn, Edwards, Kinnersley & Grol, 2000). Treatment was tailored to the main health concerns of low energy and identifying other possible causative factors for the client’s symptoms. According to the integrative model a patient-centred, individualized approach, including nutritional counselling, and self-management education was designed to meet the client’s personal needs (Dusek, 2016). This aimed to reduce symptoms through education surrounding long-term management strategies and reducing inflammation in the gastrointestinal tract; to improve health-related quality of life and reduce the risk of associated complications for the client (Ludvigsson et al., 2013; Hechtman, 2012).

Overall results indicate the treatment was effective and objectives were mostly achieved. Lifestyle and nutritional education improved self-efficacy and long-term management of stress and coeliac disease. This is reflected in centred patient reported outcome measures (figure 1 and 2).

MYMOP2 and SF-36 results indicated improvements in health related quality of life and severity of symptoms experienced (Figue 1 and 2). MYMOP2 results showed statistically significant improvements in “low energy due to coeliac disease” between the initial consultation and third follow-up (Paterson, 2017). Results showed there was no clinically significant changes between the third and sixth follow-ups (Figure 1). This may be due to increased stress experienced due to work commitments at this time.

SF-36 results perceived by the client showed statistically significant improvements, when compared to baseline, in all areas by the sixth follow-up (Figure 2) (RAND Health, 2017). Role limitations due to physical health, physical functioning and energy/fatigue categories showed positive changes by the third follow up appointment. Role limitations due to emotional problems decreased dramatically between the third and sixth follow-ups. The supplement prescribed may have helped improve the client’s energy and emotional wellbeing as Inadequate supply of iron is associated with low energy and mood fluctuations (Vaucher, Druais, Waldvogel, & Favrat, 2012; Gropper, 2012; Hechtman, 2012). Improvements in physical areas may be due to the client’s recovery from the car accident experienced prior to the initial consultation.

The client saw improvements in her energy by the third follow-up (Figure 1 and 2). This also had a positive effect on the client’s gym attendance and physical activity level at the third follow-up (figure 1). After a discussion with the client about her Foodworks (2015) analysis results she accepted a prescription for Clinicians iron boost capsules at the second follow-up. At the third follow up the client reported “improved energy” and “feel happier”, which she attributed to the supplement.

After attempting to incorporate anti-inflammatory and fiber containing foods into her diet the client wanted to “combine” these foods into a “breakfast smoothie” each morning. This then remained as one of her goals up to the fifth follow-up. At the second follow-up the client stated she was “starting to feel like I actually want breakfast in the morning”, and may indicate improvements in onset of hunger and morning digestive function (Kaczmarek, Thompson & Holscher, 2017; Chen et al., 2014; Hechtman, 2012). This may also have positive effects on enzymatic release and absorption of nutrients for the client (Chen et al., 2014).

Inconsistent bowel movements were absent by the second follow up and remained “regular’ for the client, as a type 3-4 on the Bristol stool chart, throughout the rest of the treatment. Incorporation of fiber-containing foods and herbal formulation are likely to have played a part in this (de Vries, Miller & Verbeke, 2015; Marakis et al, 2002; Braun & Cohen, 2015). Symptoms of bloating and flatulence reduced in frequency from after each meal at the initial consult, to only after evening meals at the forth follow-up.

Water consumption gradually improved over several weeks, the client was drinking between 1.25L-1.5L per day at the third follow-up appointment. She believed it “may heave helped in reducing constipation”.  Epidemiological evidence indicates an association between lower fluid intake and constipation (Boilesen, Tahan, Dias, Melli, & Morais, 2017; Lee & Kim, 2017). Furthermore, inadequate water consumption has been linked to poor cognitive performance and altered mood (Masento, Golightly, Field, Butler & van Reekum, 2014). This may also link to improvements seen in energy and emotional wellbeing (Figure 2).

A discussion with the client took place in the third follow up about the importance of dairy elimination in lactose intolerance and coeliac disease (Szilagyi, Galiatsatos & Xue, 2016; Pizzorno and Murray, 2013). At the final appointment the client had not successfully removed all sources of dairy from her diet. Practitioner empathy and ongoing support through the therapeutic relationship may, over time, encourage the client to choose to make these changes (Price, Mercer & McPherson, 2006).

The client took the herbal formula as directed throughout the course of the treatment. At the first follow up she stated she felt “a bit better mentally” going on to say “I think that’s the herbs”. This may be the effect of Schisandra’s adaptogenic actions on the client (Natural Medicine database, 2017; Braun & Cohen, 2015). At the third follow up the client stated she had experienced less “cramping” in the last week, and that the “herbs have helped with this”. This may be due to the spasmolytic activity of Globe Artichoke and the antispasmodic activity of Lemon balm (Braun & Cohen, 2015; Sadraei, Ghannadi & Malekshahi, 2003). Bilberry has shown gastro-protective and anti-inflammatory effects on the intestinal mucosa and may have also helped reduce frequency and severity of the client’s symptoms (Biedermann et al., 2013; Roth et al., 2016)

Abdominal massage was recommended at the final appointment as a self-management technique to reduce severity of symptoms such as cramping and promote blood flow to the area (Ernst, 1999; Hechtman, 2012). The client did not want to address tobacco consumption, and continues to consume dairy in her diet. She likely remains at the pre-contemplative stage, as set out in the trans-theoretical model of change (Prochaska & DiClemente, 1983; Gold, 2013).

As exemplified in this case, education is crucial to efficacious long-term management of coeliac disease and individual preferences need to be catered for to make lasting changes.

Conclusion

This case study has demonstrated that naturopathic management is valuable in improving health related quality of life and long term management of coeliac disease. Through this patient-centred, integrative approach, a personalised treatment plan addressed the client’s desired outcomes, personal requirements, health complaints, and naturopathic considerations of the case. Despite the gluten-free diet being so effective, there is a growing demand for alternative treatment options. This case report offers a potential base for further research to assess the effectiveness of naturopathic treatment on coeliac disease.

 

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