Celiac disease in normal-weight and overweight children: clinical features and growth outcomes following a gluten-free diet

Follow-up of Celiac Disease

Currently, the only effective treatment for celiac disease is complete removal of gluten from the diet. However, patients need to follow a strict gluten-free diet that results in symptomatic, serologic, and histologic remission in most patients. Histologic remission is usually complete in children, but recovery is slower and more frequently incomplete in adults. When remission has been achieved, yearly follow-up is recommended for adults, children, and adolescents. This article deals with conventional strategies used in order to follow-up patients on treatment and aiming to obtain the best clinical outcome.

Low Rates of Screening for Celiac Disease Among Family Members

BACKGROUND & AIMS

Given the increased morbidity and potential mortality of celiac disease, guidelines recommend screening high-risk individuals, including first-degree relatives of patients. We assessed how commonly celiac disease testing occurs in these individuals and identified factors that influence testing.

METHODS

Relatives of 2081 patients with biopsy-diagnosed celiac disease and followed up at Columbia University Medical Center were identified using relationship inference from the electronic health record-a validated method that uses emergency contact information to identify familial relationships. We manually abstracted data from each record and performed univariate and multivariate analyses to identify factors associated with testing relatives for celiac disease.

RESULTS

Of 539 relatives identified, 212 (39.3%) were tested for celiac disease, including 50.4% (193 of 383) of first-degree relatives and 71.5% (118 of 165) of symptomatic first-degree relatives. Of the 383 first-degree relatives, only 116 (30.3%) had a documented family history of celiac disease. On multivariate analysis, testing was more likely in adults (odds ratio [OR], for 18-39 y vs younger than 18 y, 2.27; 95% CI, 1.12-4.58); relatives being seen by a gastroenterologist (OR, 15.16; 95% CI, 7.72-29.80); relatives with symptoms (OR, 3.69; 95% CI, 2.11-6.47); first-degree relatives of a patient with celiac disease (OR, 4.90, 95% CI, 2.34-10.25); and relatives with a documented family history of celiac disease (OR, 11.9, 95% CI, 5.56-25.48).

CONCLUSIONS

By using an algorithm to identify relatives of patients with celiac disease, we found that nearly 30% of symptomatic first-degree relatives of patients with celiac disease have not received the tests recommended by guidelines. Health care providers should implement strategies to identify and screen patients at increased risk for celiac disease, including methods to ensure adequate documentation of family medical history.

Gluten-Free Diet: Gaps and Needs for a Healthier Diet

The gluten-free diet (GFD) is currently the only effective treatment in remitting the symptoms of coeliac disease (CD), a chronic systemic autoimmune disorder caused by a permanent intolerance to gluten proteins in genetically susceptible individuals. The diet entails the substitution of gluten-containing products with gluten-free-rendered products. However, over recent decades the nutritional profile of gluten-free (GF) food products has been increasingly questioned within the scientific community. The aim of this paper is to review the nutritional profile of gluten-free-rendered products currently available on the market, and discuss the possible relationship thereof with the nutritional status of coeliac patients on a GFD. Key inadequacies of currently available GF products are low protein content and a high fat and salt content. More adequate levels of dietary fiber and sugar than in the past have been reported. Population studies confirmed the above mentioned inadequacies. Further efforts are required to conceive adoptable interventions for product development and reformulation in order to achieve compliance with nutritional recommendations.

Growth changes after gluteen free diet in pediatric celiac patients: a literature-review

BACKGROUND

Celiac disease is an auto-immune disorder characterized by clinical manifestations that appear in genetically predisposed subjects after gluten ingestion. In the last years, there has been a progressive change in clinical manifestations. Our aim was to evaluate the nutritional status of children with celiac disease at diagnosis and how the gluten-free diet (GFD) influences their growth.

METHODS

A search on PubMed/Medline was performed using "celiac disease", "body mass index" and "children" as key words.  Medline, Scopus, PubMed publisher and Google Scholar were searched as well.  We selected clinical studies describing the nutritional status of patients before and after GFD using indicators like height, weight, BMI, skeletal age.  We excluded papers referred to adult population or in which other diseases were related to celiac disease. Also literature-reviews were excluded.

RESULTS

From 1999 to 2018, 10 studies were found. Overall, 1383 patients in pediatric age were evaluated for their nutritional status at diagnosis of celiac disease and after a variable period from 1 to 17 years of GFD. Indicators considered were height, weight, BMI and skeletal age.

CONCLUSIONS

the nutritional status of celiac patients at diagnosis is variable including an increasing number of overweight and obese. GFD has a beneficial impact on growth changes determining a correction of BMI distribution towards a Gaussian shape.

The Relationship between Body Composition and a Gluten Free Diet in Children with Celiac Disease

The primary and proven therapy, in cases of celiac disease (CD), is a rigorous gluten-free diet (GFD). However, there are reports of its negative effects in the form of nutritional deficiencies, obesity, and adverse changes in body composition. The study aimed to assess the impact of a GFD on the body composition of children with CD. In a case-controlled study (n = 41; mean age 10.81 y; SD = 3.96) children with CD, in various stages of treatment, underwent medical assessment. The control group consisted of healthy children and adolescents, strictly matched for gender and age in a 1:1 case-control manner. More than half of the examined children (n = 26) followed a GFD. CD children had significantly higher mean values of the fat free mass (FFM% = 80.68 vs. 76.66, p = 0.015), and total body water (TBW% = 65.22 vs. 60.47, p = 0.012), and lower mean values of the fat mass (FM% = 19.32 vs. 23.34, p = 0.015). Children who were on a GFD presented slightly higher, but not statistically significant, mean values of FM and FFM, than children who did not follow dietary recommendations (FM [kg] = 7.48 vs. 5.24, p = 0.064; FM% = 20.81 vs. 16.73, p = 0.087; FFM [kg] = 28.19 vs. 22.62, p = 0.110). After minimum one year of a GFD, CD children showed significantly higher values of FFM [kg] (p = 0.001), muscle mass (MM) [kg] (p < 0.001), TBW [L] (p < 0.001) and body cell mass (BCM) [kg] (p < 0.001). Furthermore, CD children who were on a GFD presented a significantly higher increase in weight (p = 0.034) and body mass index (BMI) (p = 0.021). The children adhering to a GFD demonstrate a tendency towards higher indices of selected body composition components.

Increased risk of nonalcoholic fatty liver disease in patients with coeliac disease on a gluten-free diet: beyond traditional metabolic factors

BACKGROUND

A gluten-free diet (GFD) is known to be associated with altered macronutrient intake and metabolic syndrome. Nonalcoholic fatty liver disease (NAFLD) is the hepatic hallmark of metabolic syndrome. The risk of NAFLD in patients with coeliac disease (CD) adhering to a GFD remains to be fully investigated; in particular, data from real-life clinical settings are lacking.

AIM

To assess the prevalence and relative risk of NAFLD in CD patients treated with a GFD.

METHODS

Case-control study, with prospective enrolment of CD outpatients following a GFD and controls. Patients were matched for demographic characteristics (age and gender) and metabolic risk factors (overweight, diabetes mellitus, total cholesterol, and triglycerides) using a 1:1 ratio. NAFLD was diagnosed according to the European Association for the Study of the Liver criteria.

RESULTS

202 CD patients and 202 controls were compared. The raw prevalence of NAFLD was 34.7% and 21.8% in the CD and control group, respectively (P = 0.006). Binary logistic regression confirmed an increased risk of NAFLD in the CD group (adjusted odds ratio = 2.90, 95% confidence interval: 1.64-5.15, P < 0.001). Additionally, the relative risk for NAFLD was notably higher in non-overweight CD patients (adjusted odds ratio = 5.71, 95% confidence interval: 2.30-14.19, P < 0.001).

CONCLUSIONS

More than one-third of CD patients adhering to a GFD had concurrent NAFLD, accounting for a three-fold increased risk compared to the general population. Dietary advice provided using a patient-tailored approach should assist CD patients with NAFLD in achieving an appropriate nutritional intake whilst reducing the risk of long-term liver-related events.

Physiolgic hypercortisolism at onset of celiac disease in a girl: A case report

RATIONALE

Celiac disease (CD) is an autoimmune disorder induced by dietary gluten in genetically predisposed subjects. Activation of the hypothalamic-pituitary-axis (HPA) can occur in patients with CD; however, this condition has never been described in overweight/obese CD children.

PATIENT CONCERNS

A 12-year-old girl with CD was admitted with mild acanthosis nigricans of the armpits, groin and neck. Recently, extra fat appeared around the neck, and moon face was observed. The abdomen was globular and meteoric, treatable and not aching. She weighed 64 kilos (75°-97° percentile) and was 146 centimeters tall (3°-25° percentile) with a body mass index of 30 kg/mq. Laboratory tests revealed hypertriglyceridemia and positive anti-transglutaminase IgA. Cortisoluria was determined. Serum ACTH was normal.

DIAGNOSES

This paper reports a case of a girl with CD in which both obesity and activation of HPA activity were noted.

INTERVENTIONS

During follow-up, anti-transglutaminase IgA increased to 201.5 UI/mL. The patient was positive for anti-endomysium antibodies, and the HLA DQ2 haplotype was identified, confirming a diagnosis of CD.

OUTCOMES

Despite a gluten-free diet, obesity and hyperadrenalism persisted, and anti-transglutaminase antibodies remained elevated. In addition, high cortisoluria persisted. A high-dose suppression dexamethasone test (8 mg) produced negative results with a morning cortisol value of 1 ng/mL, suggesting the diagnosis of pseudo-Cushing's syndrome.

LESSONS

This case highlights that the first manifestation of CD could be being overweight, and this finding seems to support the need to prescribe laboratory tests for CD not only to children with failure to thrive, as commonly recommended, but also to those with increased body weight.

Frequency of overweight/obesity among a group of children with celiac disease in Iran

Introduction

A small number of overweight and obese children with celiac disease (CD) has been reported.

Aim

To estimate the prevalence of obesity, underweight and normal weight in a group of Iranian pediatric patients.

Material and methods

In a retrospective study from 2007 to 2015, 225 children less than 18 years old with biopsy-proven CD were enrolled. Data collected included demographic characteristics, clinical presentation, antibody titers and severity of small-bowel mucosal damage. Body mass index (BMI) profile of subjects was calculated based on the age and gender percentile at presentation.

Results

The mean ± standard deviation (SD) for age was 7.4 ±3.8 and 62% of patients were female. Fifty-four percent of patients presented with a normal BMI, 43% were underweight, and the remaining patients (3.5%) were overweight/obese. The mean age of underweight and normal weight patients was higher than that of obese/overweight patients. Mean ± SD of TTG titer was higher in overweight/obese and normal weight children compared to underweight subjects. The majority of patients (195/225) had severe enteropathy compatible with Marsh III on duodenal biopsy. Most of the children had gastrointestinal (GI) and extra-intestinal manifestations on presentation. There was no association between severity of histological disease and BMI for age. Five out of eight cases in the obese/overweight group had an index case with CD in their family.

Conclusions

This study highlights the importance of considering celiac disease in children regardless of their BMI. Failure to diagnose CD in children leads to unnecessary diagnostic delays and long-term adverse health consequences.

Obesogenic habits among children and their families in response to initiation of gluten-free diet

Initiation of a lifelong, gluten-free diet (GFD) in children with celiac disease (CD) influences the child's life in many ways. The aim of this study was to assess the influence of GFD on the child and his/her family's eating habits and lifestyle behaviors. To study this, we asked children and their parents completed the Family Eating and Activity Habits Questionnaire (FEAHQ) at the time of diagnosis of CD and at least 6 months after initiation of GFD and a questionnaires assessing symptoms related to CD and adherence to the GFD diet. We analyzed questionnaires from 40 children with CD and their families. There were 21 females, ranging in age from 4 to 15.7 years (median age 7.4 years±2.8 years). The control group comprised 15 healthy children. After initiation of GFD the family ate more junk food including snacks and candies (p = 0.05), with the significant change reported by children and fathers (p = 0.001 and 0.03 respectively). All family members in the control group had significantly less snacks. Parents and children reported a significant increase in obesogenic eating styles, such as eating from the cooking pot and eating while doing other activities (mothers, p = 0.001; fathers, 0.02; and children, 0.02 respectively).

CONCLUSIONS

Our study shows that initiation of GFD in children with CD leads to changes in eating habits and staple food eating that may lead to a more obesogenic environment. Care givers, pediatricians, gastroenterologists, and dieticians alike should be aware of these implications and educate families towards a healthier lifestyle and diet beyond the GFD itself. What's Known: • Gluten-free diet has been shown to affect various psychosocial aspects of children with celiac disease. • Obesity and celiac are associated. What is New: • Initiation of gluten-free diet led to increased eating of junk food both in the patient and his/her family. • After initiation of GFD pro-obesogenic eating habits is increased.

The pre-treatment characteristics and evaluation of the effects of recombinant human growth hormone therapy in children with growth hormone deficiency and celiac disease or inflammatory bowel disease

The aim of the study

was to investigate the coincidence of growth hormone deficiency (GHD) and celiac disease (CD) or inflammatory bowel disease (IBD) in patients referred for short stature, and to evaluate the baseline anthropometric parameters and the effectiveness of recombinant human growth hormone (rhGH) therapy in the first year in those patients (GHD+CD/IBD subgroup) in comparison to patients with GHD without CD or IBD (GHD-CD/IBD subgroup).

Material and methods

The study was retrospective and included 2196 short patients (height SDS [Standard Deviation Score] ≤ –1.2). 1454 patients had height SDS ≤ –2. Twenty-nine patients suffered from CD or IBD. GHD was confirmed in 419 patients with height SDS ≤ –2. The coexistence of GHD and CD or IBD was found in seven patients (GHD+CD/IBD subgroup).

Results

At baseline the GHD-CD/IBD subgroup did not differ significantly in chronological age, height SDS, height velocity (HV) before rhGH therapy, body weight SDS, and body mass index SDS from the GHD+CD/IBD subgroup. The improvement in height SDS within the first year of rhGH therapy was higher in the GHD+CD/IBD subgroup than in the GHD-CD/IBD subgroup and the difference was statistically significant (p<0.05). HV in the first year of rhGH therapy was also significantly higher in the GHD+CD/IBD subgroup than in the GHD-CD/IBD subgroup (p < 0.05).

Conclusions

In patients with chronic inflammatory disorders of the gastrointestinal tract, especially celiac disease, coexisting with GHD, rhGH therapy could be effective and should be administered together with therapy of primary gastrointestinal disease.

Biomarkers of cardiometabolic health and nutritional status in individuals with positive celiac disease serology

BACKGROUND

Celiac disease (CD) is an autoimmune disorder characterized by damage to the intestinal mucosa and nutrient malabsorption in severe cases. However, it remains unclear whether nutrient deficiencies and other adverse health effects are prevalent in individuals with positive CD serology identified through screening studies.

OBJECTIVE

The objective was to determine whether biomarkers of cardiometabolic health and nutritional status differ between those with positive and negative CD serology identified in a screening study of Canadian adults.

METHODS

Participants ( n=2832) were from the Toronto Nutrigenomics and Health Study and the Toronto Healthy Diet Study. Individuals were screened for CD-specific anti-tissue transglutaminase autoantibodies. Lipid profiles as well as concentrations of six carotenoids (α-carotene, β-carotene, β-cryptoxanthin, lutein, lycopene, and zeaxanthin), three tocopherols (α-tocopherol, δ-tocopherol, and γ-tocopherol), retinol, ascorbic acid, and 25-hydroxyvitamin D were cross-sectionally compared between those with positive and negative CD serology using general linear mixed models.

RESULTS

Individuals with positive CD serology ( n=23) had significantly lower levels of HDL-cholesterol ( p=0.008) and apolipoprotein-AI ( p=0.02), a higher ratio of total cholesterol to HDL-cholesterol ( p=0.006), and a higher apolipoprotein-B/AI ratio ( p=0.03) than those with negative CD serology. Positive CD serology was also associated with significantly lower concentrations of retinol ( p=0.006) in fully adjusted models. Those with positive CD serology had lower serum 25-hydroxyvitamin D in unadjusted models ( p=0.01), but not in fully adjusted models ( p=0.08).

CONCLUSIONS

Individuals with undiagnosed CD may have unfavorable lipid profiles and be at elevated risk for inadequacy of certain fat-soluble vitamins, but not widespread nutrient deficiencies.

Rate and determinants of non-adherence to a gluten-free diet and nutritional status assessment in children and adolescents with celiac disease in a tertiary Brazilian referral center: a cross-sectional and retrospective study

Background

Compliance with a gluten-free diet (GFD) is difficult at all ages but particularly for teenagers due to social, cultural, economic, and practical pressures. The multidisciplinary team responsible for the treatment of patients with celiac disease and give support to their parents plays a special role on strengthening GFD and assessing the nutritional and physical health.

Methods

A cross-sectional and retrospective study including patients under 20 years of age, with biopsy-confirmed CD, followed regularly at the Department of Pediatrics, Division of Gastroenterology, Hospital das Clínicas, University of Sao Paulo, School of Medicine, Sao Paulo, Brazil, were surveyed using a questionnaire and serologic test applied between November 2011 and February 2012. A retrospective chart review of these patients was performed to collect the anthropometric data along with the results of the serologic test performed at the time of diagnosis and after at least 1 year of treatment with a GFD.

Results

We evaluated 35 patients aged between 2.4 and 19.9 years. Of these 68.6% were female, 88.6% had the typical form of the disease and 51.4% had other comorbidities. The mean age at diagnosis was 5.4 years. Despite dietary guidance, 20% reported non-adherence to the diet. Most children recovered the weight and height deficit after 5 years of treatment, and in some children, excessive weight gain became a concern.

Conclusion

The majority of transgressions occurred intentionally at home or at parties. There was a risk of excessive weight gain, especially in the first two years of treatment. More alternatives and easier access to low cost gluten-free foods, increasing the discussion about the benefits of adhering to a GFD among patients, families, and the general population, besides the acquisition of self-management skills, are crucial to fostering independent children and adolescents who have the knowledge and tools to manage life with CD.

Electronic supplementary material

The online version of this article (10.1186/s12876-018-0740-z) contains supplementary material, which is available to authorized users.

Increasing Incidence and Altered Presentation in a Population-based Study of Pediatric Celiac Disease in North America

OBJECTIVES

Celiac disease (CD) is a common immune-mediated disorder that affects up to 1% of the general population. Recent reports suggest that the incidence of CD has reached a plateau in many countries. We aim to study the incidence and altered presentation of childhood CD in a well-defined population.

METHODS

Using the Rochester Epidemiology Project, we retrospectively reviewed Mayo Clinic and Olmsted Medical Center medical records from January 1994 to December 2014. We identified all CD cases of patients ages 18 years or younger at the time of diagnosis. Incidence rates were calculated by adjusting for age, sex, and calendar year and standardizing to the 2010 US white population.

RESULTS

We identified 100 patients with CD. Incidence of CD has increased from 8.1 per 100,000 person-years (2000-2002) to 21.5 per 100,000 person-years (2011-2014). There was an increase in CD prevalence in children from 2010 (0.10%) to 2014 (0.17%). Thirty-four patients (34%) presented with classical CD symptoms, 43 (43%) had nonclassical CD, and 23 (23%) were diagnosed by screening asymptomatic high-risk patients. Thirty-six patients (36%) had complete villous atrophy, 51 (51%) had partial atrophy, and 11 (11%) had increased intraepithelial lymphocytes. Two patients were diagnosed without biopsy. Most patients (67%) had a normal body mass index, 17% were overweight/obese, and only 9% were underweight.

CONCLUSIONS

Both incidence and prevalence of CD have continued to increase in children during the past 15 years in Olmsted County, Minnesota. Clinical and pathologic presentations of CD are changing over time (more nonclassical and asymptomatic cases are emerging).

Cardiometabolic risk factors in children with celiac disease on a gluten-free diet

Celiac disease (CD) is an immune-mediated systemic condition evoked by gluten and related prolamines in genetically predisposed subjects. It is characterised by a variable combination of gluten-dependent clinical symptoms, CD-specific antibodies, HLA-DQ2 and HLA-DQ8 haplotypes, and enteropathy. The only therapy of CD consists of a life-long gluten free diet (GFD). Strict GFD adherence results in full clinical, serological and histological remission, avoiding long-term complications in CD patients. However, this diet is not without problems. Gluten free products have high levels of lipids, sugar and salt to improve food palatability and consistency, and subjects with CD show an excessive consumption of hypercaloric and hyperlipidic foods to compensate dietetic restriction. GFD may therefore have a negative impact on cardiometabolic risk factors such as obesity, serum lipid levels, insulin resistance, metabolic syndrome, and atherosclerosis. In adults, some studies have suggested that GFD have a beneficial effect on cardiovascular profile, whereas others have shown an atherogenic effect of GFD. In children, very few studies are available on the issue. Thus, the aim of the present narrative review was to analyze the current clinical evidence on the impact of GFD on cardiometabolic risk factors in children with CD.

Evidence-Informed Expert Recommendations for the Management of Celiac Disease in Children

Although the need for effective long-term follow-up for patients with celiac disease (CD) has been recognized by many expert groups, published practice guidelines have not provided a clear approach for the optimal management of these patients. In an attempt to provide a thoughtful and practical approach for managing these patients, a group of experts in pediatric CD performed a critical review of the available literature in 6 categories associated with CD to develop a set of best practices by using evidence-based data and expert opinion. The 6 categories included the following: bone health, hematologic issues, endocrine problems, liver disease, nutritional issues, and testing. Evidence was assessed by using standardized criteria for evaluating the quality of the data, grade of evidence, and strength of conclusions. Over 600 publications were reviewed, and 172 were chosen for inclusion. The thorough review of the results demonstrated that the quality of the data available was often insufficient to provide unequivocal best practices. However, using the available data and the clinical experience of the panel, a practical framework for the management of children with CD was created. These recommendations were developed by our expert panel and do not necessarily reflect the policy of the American Academy of Pediatrics. The potential usefulness of these best practices is underscored by the fact that consensus, measured by the outcome of anonymous voting, was reached by the panel for 24 of the 25 questions. We hope that these best practices may be useful to the pediatric gastroenterology and larger general pediatric communities.

Dietary compliance in Iranian children and adolescents with celiac disease

INTRODUCTION

Celiac disease (CD) is caused due to intake of gluten, a protein component in wheat, barley, and rye. The only treatment currently available for CD is strict lifetime adherence to a gluten-free diet (GFD) which is a diet that excludes wheat, barley, and rye. There is limited information on barriers to following a GFD. The present study aimed to investigate the compliance with a GFD, barriers to compliance, and the impact of compliance on the quality of life (QOL) in Iranian children and adolescents suffering from CD.

METHODS

In this cross-sectional study, a total of 65 known cases of CD (both males and females), diagnosed in Namazi Hospital, a large referral center in south of Iran, selected by census were studied in 2014. Dietary compliance was assessed using a questionnaire. A disease-specific QOL questionnaire for children with CD (the celiac disease DUX [CDDUX]) was used. Comparisons between categorical variables were performed using chi-square test.

RESULTS

Sixty-five patients, 38 females (58.5%) and 27 (41.5%) males, were surveyed. Mean (± standard deviation [SD]) age of the respondents was 11.3 (±3.8) years. Dietary compliance was reported by 35 (53.8%) patients. The mean (± SD) CDDUX score was higher in dietary-compliant patients (33.5 [±19.4] vs 26.7 [±13.6], respectively, P=0.23). The score of CDDUX in parents of patients in dietary-compliant group was more than the noncompliant patients (28.1 [±13.5] vs 22.1 [±14], respectively, P=0.1). Barriers to noncompliance were poor or unavailability (100%), high cost (96.9%), insufficient labeling (84.6%), poor palatability (76.9%), and no information (69.23%).

CONCLUSION

Approximately half of the patients with CD reported dietary compliance. Poor or unavailability was found to be the most important barrier contributing to noncompliance. The QOL was better in compliant patients. Proposed strategies to improve compliance are greater availability of gluten-free products, better food labeling, and better education about the diet and condition.

The overweight: a rare presentation of celiac disease

We describe the nutritional status of a cohort of celiac disease (CD) children at presentation and during follow-up on gluten-free diet (GFD). Two Italian centers (Rome and Bari) prospectively enrolled 445 biopsy-confirmed CD children, diagnosed between 2009 and 2013. Body Mass Index was used as a measure of nutritional status according to Italian growth charts of Cacciari. The overweight/obese subject was 7.8% at onset and did not significantly increase during follow-up (9.8% at final assessment). The prevalence of overweight/obesity was significantly higher among males than females. Furthermore, overweight/obesity children as compared with those with normal weight were significantly older and had significantly lower levels of tTG antibodies. This study shows that some CD children are obese/overweight at diagnosis; therefore, overweight/obesity can be considered a rare but a possible mode of CD presentation. Thus, CD diagnosis must be considered even in overweight/obese children where this diagnosis can be easily missed.

The clinical presentation of coeliac disease in 1030 Swedish children: Changing features over the past four decades

BACKGROUND

The features of paediatric coeliac disease have changed in recent decades. We hypothesised that the age at diagnosis might continue to increase, whereas the severity of symptoms should decrease.

METHODS

In the present study, filed data on 1030 paediatric patients diagnosed with coeliac disease between 1973 and 2013 were analysed. The information available covered 99.8% of small bowel biopsies and included information on sex, age and clinical symptoms.

RESULTS

The age at diagnosis increased significantly, from a mean of 2.2 years during the first 10 years to 8.2 years in recent years. The proportion of children with severe symptoms declined from 92.8% to 78%, as did the proportion of biopsies characterised by severe pathology. In recent years, the monosymptomatic form of coeliac disease has been more common, and the number of patients detected at screening has increased. The frequency of patients with gastrointestinal symptoms, extra-intestinal symptoms, and failure to thrive and/or short stature at presentation decreased.

CONCLUSIONS

The mean age of newly diagnosed patients has increased over the last 15 years. Currently, coeliac disease shows a less severe picture in terms of symptoms and intestinal pathology. Younger children suffer primarily from gastrointestinal symptoms and growth failure, and adolescents from extra-intestinal manifestations.

Patients with celiac disease may have normal weight or may even be overweight

BACKGROUND

It is believed that patients with celiac disease (CeD) are likely to be underweight. Data from west suggest that 8% to 40% of them can be overweight or obese. We reviewed data on body mass index (BMI) of our patients with CeD and derived the correlations between BMI and other disease characteristics.

METHODS

We retrospectively studied case records of 210 adolescent and adult patients with CeD at the Celiac Disease Clinic. We classified BMI as underweight, normal weight, overweight, and obese based on the Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians for those with age >18 years and revised Indian Association of Pediatrics BMI-for-age charts for those between 12 and 18 years.

RESULTS

Of 210 patients, 76 (36.2%) were underweight, 115 (54.8%) were normal weight, 13 (6.2%) were overweight, and 6 (2.9%) were obese. There was no difference in the proportion of underweight between male and female patients with CeD. The mean age of underweight patients was similar to those having normal or overweight. There was no difference in the mean duration of symptoms; frequencies of diarrhea, anorexia, and weakness; anemia; titer of anti-tissue transglutaminase antibody; and severity of villous atrophy in those with underweight or normal weight or overweight.

CONCLUSIONS

In our practice, only one third of patients with CeD had low BMI. A diagnosis of CeD should not be excluded if patient has normal or high BMI.

Celiac disease and non-celiac gluten sensitivity

Celiac disease is a multisystem immune based disorder that is triggered by the ingestion of gluten in genetically susceptible individuals. The prevalence of celiac disease has risen in recent decades and is currently about 1% in most Western populations. The reason for this rise is unknown, although environmental factors related to the hygiene hypothesis are suspected. The pathophysiology of celiac disease involves both the innate and adaptive immune response to dietary gluten. Clinical features are diverse and include gastrointestinal symptoms, metabolic bone disease, infertility, and many other manifestations. Although a gluten-free diet is effective in most patients, this diet can be burdensome and can limit quality of life; consequently, non-dietary therapies are at various stages of development. This review also covers non-celiac gluten sensitivity. The pathophysiology of this clinical phenotype is poorly understood, but it is a cause of increasing interest in gluten-free diets in the general population.

Extraintestinal manifestations of coeliac disease

Coeliac disease is a common disorder that can arise at any age and typically presents with a broad spectrum of symptoms. The disease is thought to be underdiagnosed, in part owing to the fact that coeliac disease is often characterized by associated conditions and extraintestinal manifestations that can misdirect and impede diagnosis. Some of these manifestations are direct consequences of autoimmunity, such as dermatitis herpetiformis or gluten ataxia, whereas others are indirectly related to inflammation and/or malabsorption including anaemia, osteoporosis, short stature and delayed puberty. Any organ from the central nervous system to joints, liver or teeth can be affected. In some cases, extraintestinal symptoms are the only clinical manifestations of coeliac disease or occur in conjunction with diarrhoea and malabsorptive symptoms. An increased awareness among medical practitioners of the variety of extraintestinal manifestations of coeliac disease is essential to improve diagnosis and treatment.

Practical insights into gluten-free diets

Coeliac disease is a global disease, and the only currently available treatment is a gluten-free diet (GFD). Although conceptually simple, the diet changes are substantial and have a profound effect on a patient's life. Untreated coeliac disease is associated with complications, including excess mortality, most of which can be avoided with a strict GFD. However, there are many barriers, including availability, cost and safety of gluten-free foods, and gluten cross-contamination. The GFD can be restrictive in social situations, leading to poor quality of life and, ultimately, nonadherence. As the number of patients with coeliac disease increases worldwide, clinicians need to be aware of the challenges patients face. Heightened awareness by physicians, dietitians and other providers can help maximize successful treatment, improve outcomes, and reduce health-care costs and disease burden. Routine follow-up is necessary to reinforce the need for a GFD, provide social and emotional support, and achieve mucosal healing, leading to reduced risk of complications. Unfortunately, there is wide variation in follow-up practices. The objective of this Review is to increase awareness of the challenges, management and follow-up of patients with coeliac disease to help them achieve GFD adherence and prevent complications whilst preserving their quality of life.

FTO Polymorphism rs9939609 Contributes to Weight Changes in Children With Celiac Disease on Gluten-Free Diet

OBJECTIVES

Studies of adults and children with celiac disease have reported an increased risk of overweight during gluten-free diet (GFD). The fat mass and obesity-associated gene (FTO) variant rs9939609 has been associated with increased risk of developing obesity in children and adults.

METHODS

In our study, we analyzed the effect of this variant on weight gain in a cohort of 280 children with celiac disease on GFD.

RESULTS

We found that after a mean follow-up time of 3.0 years on GFD, FTO polymorphism influenced significantly the mean change in body mass index z score (P = 0.01).

CONCLUSIONS

We conclude that the FTO gene contributes to determine weight changes in children with celiac disease on GFD.

Celiac disease

This review will focus on the pathogenesis, clinical manifestations, diagnosis, and management of celiac disease (CD). Given an increasing awareness of gluten-related disorders, medical professionals of all varieties are encountering patients with a diagnosis of CD or who are thought to have food intolerance to gluten. The prevalence of CD among the general population is estimated to be 1% in Western nations, and there is growing evidence for underdiagnosis of the disease, especially in non-Western nations that were traditionally believed to be unaffected. The development of serologic markers specific to CD has revolutionized the ability both to diagnose and monitor patients with the disease. Additionally, understanding of the clinical presentations of CD has undergone a major shift over the past half century. Although it is well understood that CD develops in genetically predisposed subjects exposed to gluten, the extent of other environmental factors in the pathogenesis of the disease is an area of continued research. Currently, the main therapeutic intervention for CD is a gluten-free diet; however, novel nondietary agents are under active investigation. Future areas of research should also help us understand the relationship of CD to other gluten-related disorders.

Increased risk of non-alcoholic fatty liver disease after diagnosis of celiac disease

BACKGROUND & AIMS

Non-alcoholic fatty liver disease is a common cause of chronic liver disease. Celiac disease alters intestinal permeability and treatment with a gluten-free diet often causes weight gain, but so far there are few reports of non-alcoholic fatty liver disease in patients with celiac disease.

METHODS

Population-based cohort study. We compared the risk of non-alcoholic fatty liver disease diagnosed from 1997 to 2009 in individuals with celiac disease (n = 26,816) to matched reference individuals (n = 130,051). Patients with any liver disease prior to celiac disease were excluded, as were individuals with a lifetime diagnosis of alcohol-related disorder to minimize misclassification of non-alcoholic fatty liver disease. Cox regression estimated hazard ratios for non-alcoholic fatty liver disease were determined.

RESULTS

During 246,559 person-years of follow-up, 53 individuals with celiac disease had a diagnosis of non-alcoholic fatty liver disease (21/100,000 person-years). In comparison, we identified 85 reference individuals diagnosed with non-alcoholic fatty liver disease during 1,488,413 person-years (6/100,000 person-years). This corresponded to a hazard ratio of 2.8 (95% CI 2.0-3.8), with the highest risk estimates seen in children (HR = 4.6; 95% CI 2.3-9.1). The risk increase in the first year after celiac disease diagnosis was 13.3 (95% CI 3.5-50.3) but remained significantly elevated even beyond 15 years after the diagnosis of celiac disease (HR = 2.5; 95% CI 1.0-5.9).

CONCLUSION

Individuals with celiac disease are at increased risk of non-alcoholic fatty liver disease compared to the general population. Excess risks were highest in the first year after celiac disease diagnosis, but persisted through 15 years after diagnosis with celiac disease.

Obesity and gastrointestinal disorders in children

Obesity in children has become a global pandemic during the last decade. Recent studies have reported an association between obesity and functional gastrointestinal (GI) disorders. In addition, obesity is also becoming increasingly recognized at diagnosis of organic GI diseases such as celiac disease and inflammatory bowel disease. An awareness of all possible complications and associations of obesity by the practicing physician is crucial to provide comprehensive care to obese children. This article reviews the present data on the association between obesity and various common GI disorders. The possible mechanisms and the clinical significance of this association are also discussed.

Coeliac disease screening among a large cohort of overweight/obese children

Coeliac disease (CD) is a chronic, gluten-dependent enteropathy with a prevalence of approximately 1% in Western countries. Up to now, CD has been described only in sporadic cases of obesity. Our study aimed to evaluate retrospectively CD prevalence in a large series of overweight/obese children and adolescents. Among the 1527 overweight/obese children and adolescents consecutively evaluated, 17 (7 boys, 1.11%) were positive for serology and showed villous atrophy. In all of the patients with CD a well-balanced gluten-free diet was started, and a loss of weight rapidly obtained. Our study demonstrates that CD prevalence in overweight/obese children is similar to the general paediatric population in Italy.

Changing face and clinical features of celiac disease in children

BACKGROUND

The aim of this study was to analyze and compare the epidemiological and presenting features, clinical patterns, and complications of celiac disease (CD) in children.

METHODS

The clinical charts of children with CD were retrospectively analyzed. Data for children who presented during the first time period (January 2005-October 2008; group 1) were compared to those of children who presented during the second time period (November 2008-April 2012; group 2).

RESULTS

Group 1 and 2 consisted of 96 and 95 children, respectively. There were no differences in gender distribution, weight, or height z-scores between the two groups. Mean age at the time of diagnosis in group 2 (9.3 ± 4.5 years) was significantly higher than in group 1 (6.9 ± 3.9 years; P < 0.001). Non-classical presentation was more frequent in group 2 (P = 0.01). Associated disorders were observed in 49 children (25.7%) overall. There were significantly more children with type 1 diabetes mellitus in group 2 (P = 0.030). In all, 11 patients (5.8%) were overweight (either obese or at risk of obesity) at presentation. Isolated short stature was the presenting feature in 15 children (7.9%) overall, but was more frequently observed in group 2 (P = 0.003). In total, 15 patients (7.9%) presented with refractory iron deficiency anemia; the frequency was similar in both groups. Dual-energy X-ray absorptiometry was performed in 102 patients, and 82 (80.4%) had metabolic bone disease (MBD).

CONCLUSION

The mode of presentation and clinical features of CD in childhood continue to change. Of note, a substantial percentage of patients were overweight at presentation. MBD is a frequent complication, necessitating routine evaluation.

Celiac disease in children: is it a problem in Kuwait?

Background

Celiac disease (CD) is a chronic inflammatory disease of the small intestine triggered by gluten ingestion. The objective of this study is to describe our experience with CD children in Kuwait.

Methods

The records of children with CD seen in the pediatric gastroenterology unit between February 1998 and December 2010 were retrospectively reviewed. Patients were referred because of symptoms or positive CD antibody screening of a high-risk group (type 1 diabetes and Down syndrome).

Results

Forty-seven patients were diagnosed: 53% were symptomatic and 47% were identified by screening. The median age at diagnosis was 66 (range 7–189) months. All cases were biopsy-proven except one. The symptomatic patients were significantly younger than those identified following screening (P<0.004). In the whole group, 66% were females and 77% were Kuwaitis; 9% had a positive family history of CD. The estimated cumulative incidence was 6.9/10⁵. The median duration of symptoms before diagnosis was 8.5 (range 2–54) months. Failure to thrive was the most common presenting complaint (72%) followed by diarrhea (64%) and abdominal distension (56%). Atypical manifestations were seen in 60% of patients. Underweight and short stature were confirmed in 19% and 17% of patients, respectively. Overweight and obesity were detected in 14% and 6%, respectively. CD serology was based on a combination of antiendomysial and antigliadin antibodies. The median follow up was 24 (range 12–144) months. All patients were commenced on a gluten free diet, but good compliance was only achieved in 78%.

Conclusion

The low frequency of childhood CD in Kuwait could probably be attributed to either an underestimation of the atypical presentations or failure of proper screening. Also, adherence to a gluten free diet is a major problem in our population.

Body mass index is not a reliable tool in predicting celiac disease in children

Background

Untreated celiac disease is traditionally believed to be associated with malabsorption and underweight. However, studies describing body mass index (BMI) in individuals at the time of diagnosis have shown contradictory results. We investigated the differences in weight, height, and BMI in 12- year-old children with screening-detected celiac disease compared to their healthy peers.

Methods

In a population-based screening study of 12,632 12-year-old children, blood samples were analyzed for markers of celiac disease. Children with elevated markers were referred for a small bowel biopsy. Weight and height were measured in 239 out of 242 children with screening-detected celiac disease (57.3% girls) and in 12,227 children without celiac disease (48.5% girls). BMI was categorized according to the International Obesity Task Force. Age- and sex-specific cut-off points for underweight, normal weight, and overweight were used.

Results

Children with celiac disease weighed less and were shorter than their peers (median weight 45.2 kg, interquartile range (IQR) 40.2–52.2 kg vs. 47.0 kg, IQR 41.1–54.4 kg, respectively, p = 0.01; median height 156.5 cm, IQR 151.0–162.0 cm vs. 157.5 cm, IQR 152.0–163.0 cm, respectively, p = 0.04). In comparing those with celiac disease to their healthy peers, 4.2% vs. 5.2% were underweight, 82.0% vs. 72.8% were normal weight, and 13.8% vs. 21.9% were overweight, respectively. There was no association between being underweight and the risk of having undiagnosed celiac disease (Odds ratio (OR) 1.3, 95% CI 0.7–2.4), but the risk was significantly lower among overweight children (OR 0.56, 95% CI 0.4–0.8). Median BMI was slightly lower among the children with screening-detected celiac disease compared to their healthy peers (18.6 kg/m², IQR 17.1–19.8 kg/m² vs. 18.8 kg/m², IQR 17.2–21.1 kg/m², respectively, p = 0.05), but most of the celiac disease cases had a normal BMI.

Conclusions

At a population level, children with celiac disease weigh less, are shorter, and have a lower BMI compared to their peers without celiac disease, and this emphasizes the importance of early recognition and treatment of the condition. However, at an individual level, growth parameters are not reliable in establishing the diagnosis.

Celiac disease and overweight in children: an update

The clinical presentation of celiac disease in children is very variable and differs with age. The prevalence of atypical presentations of celiac disease has increased over the past 2 decades. Several studies in adults and children with celiac disease indicate that obesity/overweight at disease onset is not unusual. In addition, there is a trend towards the development of overweight/obesity in celiac patients who strictly comply with a gluten-free diet. However, the pathogenesis and clinical implications of the coexistence of classic malabsorption (e.g., celiac disease) and overweight/obesity remain unclear. This review investigated the causes and main clinical factors associated with overweight/obesity at the diagnosis of celiac disease and clarified whether gluten withdrawal affects the current trends of the nutritional status of celiac disease patients.

Pediatric and adult celiac disease: similarities and differences

Differences between children and adults in celiac disease (CD) presentation and epidemiology are reviewed here. Clinical manifestations, histological changes, serology, and response to gluten-free diet are similar. Differences exist in epidemiology, type of clinical presentations, coexisting diseases, complications, and association with obesity. CD is two to five times more common in children than in adults. Classical CD with gastrointestinal symptoms is more common in children whereas nonclassical CD dominates in adults. A gene dose phenomenon (double-dose HLA-DQB1 02 allele) is postulated to be responsible for this difference. Coexisting autoimmune diseases like diabetes mellitus type 1, Sjogren's syndrome, and dermatitis herpetiformis are more common in adults than in children (42 % vs. 5 %). The association of overweight/obesity and CD is stronger in adults than in children (22.5 % vs. 14 %). Besides poor compliance, pancreatic insufficiency, bacterial overgrowth, lactose intolerance, irritable bowel syndrome, lymphocytic colitis, and microscopic colitis are considered responsible for nonresponsive CD in adults but not in children. Complications like refractory sprue and small intestinal neoplasms are seen exclusively in adults. Existing diagnostic criteria (modified ESPGHAN) are not suitable for diagnosing CD in adults as the majority of cases are either nonclassical or subclinical CD.

Prevalence of gluten-free diet adherence among individuals without celiac disease in the USA: results from the Continuous National Health and Nutrition Examination Survey 2009-2010

OBJECTIVES

Clinical inference suggests the prevalence of non-celiac gluten sensitivity is substantially higher than that of celiac disease in the USA. Unfortunately, there are currently no data supporting these claims. The authors analyzed nationally representative data to estimate the prevalence of adherence to a gluten-free diet among participants without celiac disease and also to characterize the demographics and general health status of these participants.

STUDY DESIGN AND SETTING

The Continuous National Health and Nutrition Examination Survey (NHANES) 2009-2010 enrolled 7762 individuals representing the civilian, non-institutionalized, US population free of celiac disease. Participants responded to interviewer administered questionnaires regarding current adherence to a gluten-free diet. Prevalence estimates were computed using SAS survey procedures.

RESULTS

There were 49 individuals who reported current adherence to a gluten-free diet reflecting a weighted prevalence of 0.548% (95% CI 0.206-0.889). The prevalence of a gluten-free diet was higher in females (0.58%) than males (0.37%), although this was not statistically significant (p = 0.34). Participants reporting a gluten-free diet were older (46.6 vs. 40.5 years, p = 0.005), had higher high-density lipoprotein, lower iron and lower body mass index.

CONCLUSIONS

The estimated national prevalence of non-celiac gluten sensitivity is 0.548%, approximately half that of celiac disease. Future studies are merited in order to better understand the population burden of non-celiac gluten sensitivity.

Changes of body mass index in celiac children on a gluten-free diet

BACKGROUND AND AIM

Studies of adults and children with celiac disease (CD) performed mostly in tertiary care centers have reported an increased risk of overweight during gluten-free diet (GFD). We measured body mass index (BMI) of CD children followed by family pediatricians in order to estimate prevalence of underweight and overweight at diagnosis and to describe BMI changes during GFD.

METHODS AND RESULTS

We compared 150 CD children (age range 2-16 yrs) under GFD from a median (IQR) time of 4.4 (4.2) years with 288 healthy children matched for gender and age. We also evaluated retrospectively BMI changes between CD diagnosis and the current evaluation. The median (IQR) BMI of CD patients was significantly lower than that of controls [-0.38 (1.46) vs. 0.09 (1.18) SDS, p < 0.0001, Italian reference data]. Using the International Obesity Task Force classifications, CD children were less frequently overweight or obese (12% vs. 23.3%, p = 0.014) and more frequently underweight (16% vs. 4.5%, p < 0.001) than controls. During GFD, there was a marked decrease of number of underweight subjects (13 vs. 27) and a minimal increase of number of overweight subjects (9 vs. 6) (p < 0.001).

CONCLUSIONS

The frequency of overweight and obesity at diagnosis of CD and during GFD in children followed by family pediatricians is substantially lower than that reported in tertiary care centers. On the other hand, the high frequency of underweight at diagnosis confirms the need of careful personalized nutritional management.

Should intussusception in children prompt screening for celiac disease?

OBJECTIVES

An association between adult celiac disease (CD) and intussusceptions (ISs) has been described. Although more common among children, intussusception has not been linked with childhood CD aside from isolated case reports. Our aim was to investigate the frequency of IS among children with CD.

METHODS

A patient database containing children with biopsy-proven CD was reviewed, in addition to radiology records contained in a hospital-maintained clinical data repository.

RESULTS

Of 254 children with biopsy-proven CD and complete records available for review, abdominal imaging was performed in 21%, mainly because of abdominal pain. Among children with CD, 1.2% experienced an IS <9 months before their diagnosis with CD. Among children seen at our institution in the same time period, 0.07% experienced an IS. The majority of those children with CD who were found to have IS had no evidence of nutritional deficit at the time of IS. IS was not identified in any children with CD who had been treated with a gluten-free diet.

CONCLUSIONS

IS was far more common among children in our cohort with untreated CD than in the general pediatric population simultaneously seen at our center. The diagnosis of CD should be considered in children with IS, even in the absence of signs of nutritional compromise.

Presentation of celiac disease

The mode of presentation of patients with celiac disease has changed dramatically over the recent decades, with diarrheal or classic presentations becoming less common. This trend is most markedly seen in children, whose main presentations include recurrent abdominal pain, growth issues, and screening groups at risk. Among adults, presentations include diarrhea, anemia, osteoporosis, and recognition at endoscopy performed for gastroesophageal reflux disease, as well as screening. The groups most commonly screened include family members of patients with celiac disease, Down syndrome, and autoimmune diseases.

Epidemiology and clinical presentations of celiac disease

Evidence of the prevalence of celiac disease comes from serological screening studies. These have revealed that celiac disease is common, occurring in about 1 % of the population worldwide. There are some countries with higher prevalence rates such as Finland and others with lower rates, for example Germany. The disease is found in most continents and appears to be increasing. Most people with the disease are not currently diagnosed though women are diagnosed more frequently than men. The mode of presentation has changed both in children and adults with diarrhea and a malabsorption syndrome becoming less common. Abdominal pain and growth issues are major modes of presentation in children, while anemia, osteoporosis, and recognition at endoscopy performed for GERD are seen as modes of presentation in adults. Screening of at risk groups is a major mode of presentation for both adults and children.