Nutritional Deficiencies in Children with Celiac Disease Resulting from a Gluten-Free Diet: A Systematic Review

Sorghum (Sorghum vulgare): an ancient grain, a novel choice for a healthy gluten-free diet

Celiac disease (CD) is an autoimmune disease related to gluten consumption. To date, the only effective therapy that can reverse symptoms and prevent complications is the gluten-free diet (GFD), which is challenging to maintain and has potential health risks. Identifying foods that can help diversify the GFD and that best match the nutritional needs of people with CD may improve the health and quality of life of celiac patients. This review, conducted through a non-systematic search of the available literature, aims to gather the most recent research on nutritional issues in CD and GFD. Moreover, it highlights how sorghum characteristics could provide health benefits to CD patients that counteract the nutritional problems due to CD and the nutritional consequences of GFD acceptance. Sorghum contains a wide variety of bioactive compounds, such as flavones and tannins, that have shown anti-inflammatory activity in preclinical studies. They can also regulate blood sugar levels and lower cholesterol to reduce the effects of common chronic diseases such as metabolic and cardiovascular diseases. Because it is gluten-free, its use in making foods for celiac patients is increasing, especially in the United States. In conclusion, sorghum is a fascinating grain with nutritional properties and health benefits for supplementing GFD. However, only one study confirms the short-term safety of sorghum inclusion in the GFD, and further long-term studies with a large sample are needed.

Enrichment of vegan gluten-free pasta with basil seeds: Cooking quality, nutritional and antioxidant properties

The germinated clove basil (Ocimum gratissimum) and sweet basil (Ocimum basilicum) seeds being a potent source of dietary fibre, minerals and antioxidants are utilized as functional ingredients for the enrichment of gluten-free pasta. The germinated clove basil seed and sweet basil seed incorporated pastas with acceptable sensory scores were developed by substituting 30% and 15% of gluten-free flour respectively. Basil seed pastas exhibited lesser cooking time (7-8 min), cooking loss (6%) and similar texture as that of control. The clove basil seed pasta exhibited better cooking quality, nutritional and antioxidant properties than the sweet basil seed pasta due to higher level of basil seed flour substitution. Consumption of one serving of clove basil seed pasta (75 g) could meet the dietary fibre (49%, 58%), protein (15%, 17%), magnesium (18%, 21%), phosphorus (22%, 22%), manganese (28%, 28%) and copper (28%, 28%) daily requirements of sedentary adult men and women, respectively.

Nutrition Assessment and Management in Celiac Disease

Celiac disease (CeD) is the most common immune condition affecting the gastrointestinal tract; it is triggered by gluten and the only available treatment is a strict gluten-free diet (GFD). Therefore, for patients with CeD, adopting a GFD is not a lifestyle choice. The major problem is that a GFD is restrictive and, like all restrictive diets, it has the potential for adverse nutritional outcomes, especially if adopted for a long term. It is well known that GFD can be nutritionally inadequate and is frequently associated with vitamin and mineral deficiencies; it is also associated with excessive sugar and fat intake, particularly when gluten-free substitutes are consumed. Consequently, people with CeD are affected by higher rates of overweight and obesity and metabolic complications, such as fatty liver and cardiovascular disease. Therefore, assessment of nutritional status and diet quality at diagnosis and while on a long-term GFD is key in the management of CeD. This narrative review addresses nutritional considerations in CeD and management of common challenges associated with a GFD.

Gluten-free diet for pediatric patients with coeliac disease: A position paper from the ESPGHAN gastroenterology committee, special interest group in coeliac disease

BACKGROUND AND OBJECTIVE

Coeliac disease is a chronic, immune-mediated disorder for which the only treatment consists of lifelong strict adherence to gluten-free diet (GFD). However, there is a lack of evidence-based guidelines on the GFD dietary management of coeliac disease. This position paper, led by the Special Interest Group in coeliac disease of the European Society of Pediatric, Gastroenterology Hepatology, and Nutrition, supported by the Nutrition Committee and the Allied Health Professionals Committee, aims to present evidence-based recommendations on the GFD as well as how to support dietary adherence.

METHODS

A wide literature search was performed using the MeSH Terms: "diet, gluten free," "gluten-free diet," "diets, gluten-free," "gluten free diet," and "coeliac disease" in Pubmed until November 8th, 2022.

RESULTS

The manuscript provides an overview of the definition of the GFD, regulations as basis to define the term "gluten-free," which foods are naturally gluten-free and gluten-containing. Moreover, it provides recommendations and educational tips and infographics on suitable food substitutes, the importance of reading food labels, risk of gluten cross-contact at home and in public settings, nutritional considerations as well as factors associated to dietary adherence based on available evidence, or otherwise clinical expertise.

CONCLUSIONS

This position paper provides guidance and recommendations to support children with coeliac disease to safely adhere to a GFD.

Celiac disease and depressive disorders as nutritional implications related to common factors - A comprehensive review

Celiac disease (CD) is an immune-mediated disease affecting the small intestine. The only treatment strategy for CD is the gluten-free diet (GFD). One of the more common mental disorders in CD patients is major depressive disorder (MDD). The influence of GFD on the occurrence of MDD symptoms in patients with CD will be evaluated. This diet often reduces nutritional deficiencies in these patients and also helps to reduce depressive symptoms. Both disease entities are often dominated by the same deficiencies of nutrients such as iron, zinc, selenium, iodine, or B and D vitamins. Deficiencies of particular components in CD can favor MDD and vice versa. Gluten can adversely affect the mental state of patients without CD. Also, intestinal microbiota may play an important role in the described process. This work aims to comprehensively assess the common factors involved in the pathomechanisms of MDD and CD, with particular emphasis on nutrient imbalances. Given the complexity of both disease entities, and the many common links, more research related to improving mental health in these patients and the implementation of a GFD would need to be conducted, but it appears to be a viable pathway to improving the quality of life and health of people struggling with CD and MDD. Therefore, probiotics, micronutrients, macronutrients, and vitamin supplements are recommended to reduce the risk of MDD, given that they may alleviate the symptoms of both these disease entities. In turn, in patients with MDD, it is worth considering testing for CD.

Gluten-free wafer formulation: Development, characterisation and addition of flavourings with antioxidant capacity

The incidence of celiac disease is increasing, therefore the demand for gluten-free products that also satisfy the nutritional requirements of celiac individuals is rising. Thus, the objective of the present work was to develop a gluten-free nutritionally balanced wafer formulation with a high content of antioxidants. First, the animal fat used in the traditional formulation was successfully replaced by high oleic sunflower. Second, the antioxidant content of several flavourings (cinnamon/honey/anise/vanilla) was measured and their addition to a gluten-free wafer formulation was evaluated. Third, multivariate statistical tools were used to select the formulation that properly mimicked the characteristics of a gluten-containing wafer. According to the results, anise and cinnamon were the most suitable flavourings to prepare gluten-free wafers, and the sensory analysis concluded that these formulations were highly acceptable (means>6.7 on the hedonic scale). Finally, the storage time analysis indicated that the texture of the gluten-free wafers was more susceptible to water absorption than gluten-containing wafers. Besides, cinnamon wafers presented a higher bioaccessible antioxidant capacity than anise wafers (43.5 ± 0.1 mg Trolox/g and 18.8 ± 0.9 mg Trolox/g respectively) (p < 0.05), which remained stable for four months. This indicates that during its shelf life, the product could be consumed with its beneficial effects intact.

Intestinal mRNA expression analysis of polarity-related genes identified the discriminatory ability of CRB3 as a diagnostic marker for celiac disease

BACKGROUND

Celiac disease (CD) is a chronic autoimmune disorder characterized by an abnormal immune response to gluten, a protein found in wheat, barley, and rye. It is well established that the integrity of epithelial tight junctions (TJs) and adherens junctions (AJs) plays a crucial role in the pathogenesis of CD. These junctional complexes contribute to the apical-basal polarity of the intestinal epithelial cells, which is crucial for their proper functioning.

METHODS

Sixty CD subjects, and 50 controls were enrolled in the current study. Mucosal samples were obtained from the distal duodenum, total RNA was extracted and complementary DNA was synthesized. The relative expression levels of the desired genes were evaluated by quantitative real-time polymerase chain reaction based on ΔΔCt method. The gene-gene interaction network was also constructed using GeneMANIA.

RESULTS

CRB3 (p = .0005), LKB1 (p < .0001), and SCRIB (p = .0005) had lower expression in CD patients compared to controls, while PRKCZ expression did not differ between groups (p > .05). CRB3 represented a significant diagnostic value for differentiating CD patients from the control group (p = .02).

CONCLUSION

The aim of the current study was to evaluate the changes in the mRNA expression levels of SCRIB, PRKCZ, LKB1, and CRB3 genes in the small intestinal biopsy samples of CD patients in comparison to the healthy control subjects. Our data uncover the importance of polarity-related genes (especially CRB3) in CD pahtomechanism, that may facilitate the planning of the future studies looking for finding innovative diagnostic and therapeutic strategies for CD.

Standardizing Randomized Controlled Trials in Celiac Disease: An International Multidisciplinary Appropriateness Study

BACKGROUND & AIMS

There is a need to develop safe and effective pharmacologic options for the treatment of celiac disease (CeD); however, consensus on the appropriate design and configuration of randomized controlled trials (RCTs) in this population is lacking.

METHODS

A 2-round modified Research and Development/University of California Los Angeles Appropriateness Method study was conducted. Eighteen gastroenterologists (adult and pediatric) and gastrointestinal pathologists voted on statements pertaining to the configuration of CeD RCTs, inclusion and exclusion criteria, gluten challenge, and trial outcomes. Two RCT designs were considered, representing the following distinct clinical scenarios for which pharmacotherapy may be used: trials incorporating a gluten challenge to simulate exposure; and trials evaluating reversal of histologic changes, despite attempted adherence to a gluten-free diet. Each statement was rated as appropriate, uncertain, or inappropriate, using a 9-point Likert scale.

RESULTS

For trials evaluating prevention of relapse after gluten challenge, participants adherent to a gluten-free diet for 12 months or more with normal or near-normal-sized villi should be enrolled. Gluten challenge should be FODMAPS (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) free, and efficacy evaluated using histology with a secondary patient-reported outcome measure. For trials evaluating reversal of villus atrophy, the panel voted it appropriate to enroll participants with a baseline villus height to crypt depth ratio ≤2 and measure efficacy using a primary histologic end point. Guidance for measuring histologic, endoscopic, and patient-reported outcomes in adult and pediatric patients with CeD are provided, along with recommendations regarding the merits and limitations of different end points.

CONCLUSIONS

We developed standardized recommendations for clinical trial design, eligibility criteria, outcome measures, gluten challenge, and disease evaluations for RCTs in patients with CeD.

From ancient crop to modern superfood: Exploring the history, diversity, characteristics, technological applications, and culinary uses of Peruvian fava beans

The search for plant-based superfoods has shown that many regional populations already have these foods in their diet, with significant potential for production and marketing. This critical review intends to show the history, diversity, characteristics, and uses, emphasizing their significance in traditional diets and potential in the food industry of Peruvian fava beans. As a valuable plant-based protein source, fava beans offer essential micronutrients and have diverse culinary applications. Innovative food industry applications include plant-based meat alternatives, fortified gluten-free products, and a natural color, protein, and fiber source in extruded foods. Key studies have highlighted the successful incorporation of fava beans into various food products, improving their nutritional properties, though some studies also point to limitations in their sensory acceptance. Further research is needed to understand the bioactive components, health effects, and techno-functional characteristics of beans. Challenges facing cultivating and consuming fava beans in Peru include adapting to climate change, enhancing productivity and quality, and promoting consumption and added value. Addressing these challenges involves developing climate-resilient varieties, optimizing agricultural practices, and providing access to resources and financing. In conclusion, this review highlights the promising prospects of Peruvian fava beans as a sustainable, nutritionally rich, and versatile ingredient in the food industry. By harnessing their potential and overcoming challenges, Peruvian fava beans can transition from an ancient crop to a modern superfood, inspiring a global shift towards sustainable and nutritionally balanced diets, aiding the fight against malnutrition, and enriching culinary traditions worldwide.

How Many Hungarian Consumers Choose Lactose- and Gluten-Free Food Products Even When They Do Not Necessarily Need to?

The popularity of "free-from" food products (FFFPs), which exclude several ingredients such as lactose, gluten, or sugar, is increasing globally. However, experts agree that avoiding these ingredients without medical reasons can lead to nutritional deficiencies. A representative consumer survey was conducted in Hungary (n = 1002); it focused on behaviors related to FFFPs, particularly lactose- and gluten-free products. This study revealed that consumers often consider "free-from" claims during shopping. Lactose- and gluten-free foods were popular, even among those without specific dietary needs. A distinct "free-from consumer group" (7.8% of the sample, predominantly women) was identified, who consume both lactose- and gluten-free foods frequently. However, only 15.4% of the group had medical reasons for their preference, such as lactose intolerance or gluten sensitivity. The majority (75.6%) chose these products without medical justification, relying on self-diagnosis, through the involvement of family members, or the belief that they were healthier. This consumer group accounts for nearly 6% of Hungary's adult population, exceeding 470,000 individuals. Extrapolating these figures to other European countries suggests that 25-30 million EU citizens might be in a similar situation, highlighting the need for improved health education and awareness-raising campaigns to prevent imbalanced nutrition and foster the recognition and treatment of real health problems.

Development of Functional Gluten-Free Sourdough Bread with Pseudocereals and Enriched with Moringa oleifera

Celiac patients tend to have an unbalanced diet, because gluten-free products typically contain a high amount of fats and carbohydrates and a low amount of proteins, minerals, and dietary fiber. This research focused on the development of gluten-free functional breads using pseudocereals, psyllium, and gluten-free sourdough to replace commercial yeast, fortifying them with Moringa oleifera. Six different gluten-free breads were made with sourdough: three control breads differentiated by sourdough (quinoa, amaranth, and brown rice) and three breads enriched with moringa leaf differentiated by sourdough. The antioxidant capacity, phenolic compounds, nutritional composition, physicochemical parameters (color, pH, and acidity), folate content, amino acid profile, reducing sugars, mineral composition, mineral bioaccessibility, fatty acid profile, and sensory acceptability were evaluated. A commercial gluten-free (COM) bread was included in these analyses. Compared with COM bread, the reformulated breads were found to have better nutritional properties. Moringa leaf increased the nutritional properties of bread, and highlighted the QM (quinoa/moringa) bread as having increased protein, fiber, sucrose, glucose, maltose, phenylalanine, and cysteine. The AM (amaranth/moringa) bread was also shown to have a higher total folate content, antioxidant capacity, phenolic compounds, 9t,11t-C18:2 (CLA), and 9t-C18:1. Reformulated breads enriched with moringa could meet nutritional requirements and provide health benefits to people with celiac disease.

Zinc Deficiency and Therapeutic Value of Zinc Supplementation in Pediatric Gastrointestinal Diseases

The benefits of zinc in treating certain gastrointestinal (GI) diseases have been recognized for over two decades. This review aims to explore zinc deficiency (ZD) and the potential therapeutic value and safety of zinc supplementation in pediatric GI diseases. A systematic review of published articles on ZD and zinc as adjuvant treatments for GI diseases was conducted using various databases. Children with inflammatory bowel disease (IBD), celiac disease, and those receiving long-term proton pump inhibitor treatments are particularly susceptible to ZD. ZD in children with celiac disease and IBD is attributed to insufficient intake, reduced absorption, and increased intestinal loss as a result of the inflammatory process. Zinc plays a crucial role in maintaining the integrity of the gastric mucosa and exerts a gastroprotective action against gastric lesions. Although considerable evidence supports the use of zinc as adjuvant therapy for certain GI diseases in adults, its use is unspecified in children except for infectious diarrhea. Current evidence suggests that zinc supplementation with well-documented dosages helps reduce the duration of diarrhea in children with acute or persistent diarrhea, while there are no specific guidelines for zinc supplementation in children with IBD and celiac disease. Zinc supplementation appears to be beneficial in peptic ulcer disease or gastroesophageal reflux disease. The available evidence highlights the need for intervention programs to enhance zinc status and reduce the morbidity of certain GI diseases in children.

Diet quality, ultra-processed food consumption, and quality of life in a cross-sectional cohort of adults and teens with celiac disease

BACKGROUND

Coeliac disease (CeD), a common autoimmune condition, requires strict adherence to a gluten-free diet (GFD). Adherence to the GFD has been associated with quality of life (QOL). However, there may be other diet-related concerns, such as overall diet patterns, including diet quality or ultra-processed food (UPF) consumption, possibly associated with QOL among people with CeD following a GFD that have not been examined.

METHODS

Diet quality was determined based on 24-h diet recalls of a cross-sectional prospectively recruited sample of 80 participants (50 adults and 30 teens) with biopsy-confirmed CeD ('Study Sample') using the Healthy Eating Index and Alternate Mediterranean Diet score. The amount of UPF consumed was assessed using Nova, a food processing classification system. QOL was measured using Celiac Disease-Specific Quality of Life (CDQOL) and Celiac Disease Pediatric-Specific Quality of Life (CDPQOL). The Study Sample's diet patterns were compared with National Health and Nutrition Examination Survey (NHANES) groups (25 adults reporting prior CeD and GFD; 51 adults with new CeD and no GFD; 15,777 adults and 2296 teens without CeD). The relationship of the Study Sample's diet patterns with CDQOL/CDPQOL was assessed using analysis of covariance.

RESULTS

The Study Sample's diet patterns were suboptimal but generally favourable compared with all NHANES groups. Compared to Study Adults with the highest tertile of UPF, those with the lowest tertile had significantly higher CDQOL (mean: 67.6 vs. 78.3, p < 0.001). Compared to Study Teens with the lowest tertile of AMED, those with the highest tertile had significantly higher CDPQOL (mean: 67.0 vs. 79.9, p < 0.01).

CONCLUSIONS

Maintaining high diet quality and minimising UPF may be important for CeD-specific QOL among individuals with CeD maintaining a GFD.

Nutrient deficiencies in children with celiac disease during long term follow-up

BACKGROUND

Celiac disease (CD) is associated with malabsorption and consequential nutritional deficiencies. Patients with CD must follow a gluten-free diet (GFD), which is also associated with nutrient deficiencies. Despite the clinical significance, consensus is lacking on the pattern and frequency of nutrient deficiencies in CD and the usefulness of assessment during follow-up. The aim was to investigate the presence of micronutrient and protein deficiencies in pediatric patients with CD after starting a GFD and receiving standard clinical care, taking disease activity into account.

METHODS

This single center retrospective chart review aimed to map the occurrence of nutrient deficiencies, determined in serum samples derived during follow-up in an expertise center for pediatric CD. Serological micronutrient levels were determined during routine clinical visits up until 10 years in children with CD on a GFD.

RESULTS

The data of 130 children with CD was included. When pooling the measurements between 3 months and 10 years after GFD initiation, a deficiency in iron, ferritin, vitamin D, vitamin B12, folate and zinc was present in 33%, 21,9%, 21,1%, 2,4%, 4,3% and 8,1% of measurements, respectively. No hypocalcemia or vitamin B6 deficiency was found.

CONCLUSION

The prevalence of deficiency varies amongst nutrients in children following a GFD, a high prevalence of some nutrient deficiencies is noteworthy. This study highlights the necessity to structurally investigate the risk of developing nutrient deficiencies while following a GFD. Knowledge of the risk to develop deficiencies can contribute to achieving a more evidence based approach in the management and follow-up of CD in children.

The Importance of an Early Evaluation after Establishing a Gluten-Free Diet in Children with Celiac Disease

A gluten-free diet (GFD) is the only treatment available for celiac disease (CD); hence, it is important to ensure correct adherence to the diet and adequate monitoring of the diet. The present study aims to assess the importance of an early follow-up of celiac patients after diagnosis of the disease, identify the role of stool gluten immunogenic peptides (GIPs) in the assessment of GFD adherence, and analyze possible nutritional imbalances or deficiencies in the GFD. This is a cross-sectional study carried out in pediatric patients with newly diagnosed CD in a tertiary hospital in Spain. Of the 61 patients included, 14% had positive stool GIPS at 4 months after CD diagnosis, Among them, 88% had negative stool GIPS at 9 months after diagnosis, following dietary advice. We found nutritional deficiencies in the GFD, such as vitamin D (with only 27% of patients with adequate intakes), folate, calcium, magnesium, and fiber. Similarly, we found imbalances: excess protein and fat intakes and a high percentage of total daily energy intake came from ultra-processed foods (UPF). These findings emphasize the importance of early follow-up of children after diagnosis of CD. It is also crucial to identify patients with poor GFD compliance based on stool GIPS and analyze GFD nutritional imbalances and deficits. Our findings may contribute to the development of specific strategies for the early follow-up of patients with CD, including appropriate nutritional counselling.

Nutritional Considerations in Celiac Disease and Non-Celiac Gluten/Wheat Sensitivity

A gluten-free diet (GFD) is the only available treatment for celiac disease (CeD), and it may also improve symptoms in non-celiac gluten/wheat sensitivity (NCGWS). In CeD, gluten triggers an immune reaction leading to enteropathy, malabsorption, and symptoms; in NCGWS, the mechanism leading to symptoms is unknown, and neither wheat nor gluten triggers enteropathy or malabsorption. A strict GFD is, therefore, necessary for CeD, but a gluten-restricted diet (GRD) may suffice to achieve symptom control for NCGWS. Regardless of this distinction, the risk of malnutrition and macro- and micronutrient deficiencies is increased by the adoption of a GFD or GRD. Thus, patients with CeD or NCGWS should undergo nutritional assessment and subsequent monitoring, based on evidence-based tools, under the care of a multidisciplinary team involving physicians and dietitians, for the long-term management of their nutrition. This review gives an overview of available nutrition assessment tools and considerations for the nutritional management of CeD and NCGWS populations.

Nutrient intakes in adult and pediatric coeliac disease patients on gluten-free diet: a systematic review and meta-analysis

Celiac Disease (CD) continues to require a strict lifetime gluten-free diet (GFD) to maintain healthy status. Many studies have assessed the GFD nutritional adequacy in their cohorts, but an overall picture in adults and children would offer a lifetime vision to identify actionable areas of change. We aimed at assessing the nutrient intakes of adult and pediatric CD patients following a GFD diet and identifying potential areas of improvement. Systematic review was carried out across PubMed, Scopus and Scholar up to October 2022, including full-text studies that assessed the nutrient intakes of CD patients on GFD, in terms of macro- and/or micronutrients (absolute or percentage daily average). Random-effect meta-analysis and univariable meta-regression were applied to obtain pooled estimates for proportions and influencing variables on the outcome, respectively. Thirty-eight studies with a total of 2114 patients were included. Overall, the daily energy intake was 1995 (CI 1884-2106) Kcal with 47.8% (CI 45.7-49.8%) from carbohydrates, 15.5% (CI 14.8-16.2%) from proteins, and 35.8% (CI 34.5-37.0%) from fats. Of total fats, 13.2% (CI 12.4-14.0%) were saturated fats. Teenagers had the highest consumption of fats (94.9, CI 54.8-134.9 g/day), and adults presented insufficient dietary fiber intake (18.9 g, CI 16.5-21.4 g). Calcium, magnesium, and iron intakes were particularly insufficient in adolescence, whereas vitamin D was insufficient in all age groups. In conclusion, GFD may expose CD patients to high fat and low essential micronutrient intakes. Given GFD is a lifelong therapy, to prevent the occurrence of diseases (e.g. cardiovascular or bone disorders) dietary intakes need to be assessed on long-term follow-ups.

The Effect of a Gluten-Free Diet on Vitamin D Metabolism in Celiac Disease: The State of the Art

Celiac disease is a chronic autoimmune disorder involving the small intestine, characterized by villous atrophy, crypt hyperplasia and an increase in intraepithelial lymphocytes. Due to both calcium malabsorption and immune activation, a high prevalence of bone mass derangement is evident in this condition, regardless of the presence of overt malabsorption. Alterations of mineral metabolism are also frequently described, and in this review, the modifications of serum levels of vitamin D are analyzed, according to the available literature on this topic. In untreated patients, secondary hyperparathyroidism is responsible for the hyperconversion of 25-vitamin D into 1,25-vitamin D making mandatory the determination of serum levels of both vitamin metabolites to avoid a wrong diagnosis of vitamin D deficit. A gluten-free diet allows for a normalization of bone and mineral metabolism, reverting these abnormalities and raising some doubts on the need for vitamin supplementation in all the patients. Data available do not support this wide indication, and a complete evaluation of bone and mineral metabolism should be performed to select patients who need this therapeutic approach.

Assessment of iron status and iron deficiency anemia in patients with celiac, a single center experience

Aim

This study aimed to assess the status of iron stores and the frequency of iron deficiency anemia in Celiac disease (CD) patients referred to the Golestan Research Center of Gastroenterology and Hepatology, Gorgan, Iran.

Background

Studies have shown that nutritional deficiencies affect 20-38% of patients with CD due to malabsorption and as a result of a gluten-free diet.

Methods

In this study, 59 out of 100 CD patients were assessed. The presence and severity of anemia were determined using the concentration of serum hemoglobin according to WHO criteria. The status of body iron stores was also assessed based on serum ferritin levels.

Results

Mean and SD of age, duration of disease, serum hemoglobin, ferritin, TIBC, and serum iron were 39.9±11.9 years, 69.8±45.4 months, 12.6±1.99 g/dl, 54.3±55.3 mg/dL, 365.9±49.1 μg/dL, and 84.1±37.1 μg/dL, respectively. 68.42% had no anemia, 19.3% had mild anemia, 8.77% had moderate anemia, and 3.51% had severe anemia. 25.42% of patients had depleted iron stores, 71.19% had normal iron stores, and 3.39% were exposed to iron overload. There was a statistically significant correlation between serum hemoglobin and the duration of disease diagnosis (P=0.037, r=0.302).

Conclusion

In this study, 31.58% of CD patients on a gluten-free diet had some degree of anemia. In addition, 25.42% of patients had depleted iron stores. These results suggest that CD patients should be evaluated for iron status, even with a gluten-free diet.

The gut microbiome: an overview of current trends and risks for paediatric populations

PURPOSE OF REVIEW

Gut health is an increasingly popular topic of discussion among scientists and the general population alike. As interest surrounding the gut microbiome grows, the accessibility to misinformation and unfounded gut health trends to youth is likely to emerge as a public health concern. The purpose of this review is to provide paediatricians with current information about the gut microbiome, as well as explanations and possible risks of the multitude of gut health trends that adolescents may be exposed to.

RECENT FINDINGS

The gut microbiome is implicated in overall health by playing roles in digestion, immunity and mental health. Novel microbiome-related therapies, such as faecal microbiota transplants, and the gut-brain link show the therapeutic potential of the gut microbiome. However, unproven dietary fads and trends on social media are rampant as well, such as ginger juice shots. In addition, paediatric supplements meant to target gut health are unregulated, yet are highly marketed. Improperly applying these trends and diets may result in risks of malnutrition and body image issues for impressionable children.

SUMMARY

Increased familiarity regarding the types of gut health trends and diets among young people will allow paediatricians to more effectively advise their patients about potential risks and good gut health practices. Paediatricians and caregivers serve as role models and educators with regard to children's perceptions and management of their gut and overall health.

Gluten-Free Product Contribution to Energy and Macronutrient Intakes in Spanish Children and Adolescents with Celiac Disease

Gluten-free products (GFP) are a good choice for the replacement of cereals when following a gluten-free diet due to celiac disease (CD). However, commercial GFP are made with highly refined flours and may contain more fat, sugar, and salt, and less fiber and micronutrients than gluten-containing analogues, thus challenging the nutritional adequacy of the diet. The aim of this study is to assess the contribution of GFP to the diets of children and adolescents with CD. Food intakes were assessed in a cross-sectional study on 70 children and adolescents with CD (aged four to 18, 50% females), using three 24-h dietary records. GFP consumption reached 165 g a day and comprised mostly bread and fine bakery ware, followed by pasta. GFP contributed with a high percentage (>25%) to total energy, carbohydrates, fiber, and salt daily intakes and, to a lesser extent (<20%), to fat (including saturated fat), sugars and protein. Contribution of homemade products was testimonial. GFP contribution to total energy intake is significant and, consequently, relevant to the nutritional adequacy of the diet. Children and adolescents with CD could benefit from fat, saturated fat, and salt reduction, and fiber enrichment of processed GFP.

Food Insecurity Negatively Impacts Gluten Avoidance and Nutritional Intake in Patients With Celiac Disease

BACKGROUND

Food insecurity is a major public health challenge. For patients with celiac disease (CeD), food insecurity may be particularly detrimental as it threatens the cornerstone of their treatment: adoption of a gluten-free diet (GFD). We aimed to characterize the prevalence of food insecurity in patients with CeD and evaluate its impact on GFD adoption and nutritional intake.

METHODS

We analyzed data from patients with CeD participating in the US National Health and Nutrition Examination Survey (NHANES) from 2009 to 2014. Food insecurity was defined using the US Department of Agriculture 18-Item Standard Food Security Survey Module. Survey-weighted logistic regression was used to assess differences in demographic characteristics of CeD patients living with food insecurity and the impact of food security on GFD adoption. Multivariable survey-weighted linear regression was used to evaluate the effect of food insecurity on nutritional intake of macronutrients and micronutrients.

RESULTS

Overall, 15.9% (95% confidence interval: 10.6%, 23.1%) of patients with CeD in the United States [weighted N=2.9 million (95% confidence interval: 2.2, 3.5 million)] are food insecure. Food insecure patients with CeD were disproportionately younger, poorly educated, nonwhite, living in poverty, and were significantly less likely to adopt a GFD (24.1% vs. 67.9%, P =0.02). Food insecurity was associated with significantly lower consumption of protein, carbohydrates, fat, and most vitamins and minerals.

CONCLUSIONS

One in 6 patients with CeD are food insecure, negatively impacting GFD adoption and the ability to meet recommended daily intake of most micronutrients. Less than one quarter of food insecure CeD patients adhere to a GFD.

Quinoa Snack Production at an Industrial Level: Effect of Extrusion and Baking on Digestibility, Bioactive, Rheological, and Physical Properties

This research aimed to produce gluten-free snacks on a pilot scale from quinoa flour. These snacks experienced an extrusion process, followed by baking. The effects of these technological processes on carbohydrate and protein digestibility, extractable phenolic compounds (EPP), hydrolyzable phenolic compounds (HPP), antioxidant capacity, and physical properties were evaluated in raw quinoa flour and extruded snacks. Extrusion increased digestible starch (RDS) from 7.33 g/100 g bs to 77.33 g /100 g bs. Resistant starch (RS) showed a variation of 2 g/100 g bs. It is noteworthy that protein digestibility increased up to 94.58 g/100 bs after extrusion and baking. These processes increased HPP content, while EPP and carotenoid content decreased. The samples showed significant differences (p < 0.05) in the antioxidant properties determined through the DPPH and ABTS methods. Values of 19.72 ± 0.81 µmol T/g were observed in snacks and 13.16 ± 0.2 µmol T/g in raw flour, but a reduction of up to 16.10 ± 0.68 µmol T/g was observed during baking. The baking process reduced the work of crispness (Wcr) from 0.79 to 0.23 N.mm, while the saturation (C*) was higher in baked ones, showing higher color intensity. The baking process did not influence the viscosity profile. The results in this study respond to the growing interest of the food industry to satisfy consumer demand for new, healthy, and expanded gluten-free snacks with bioactive compounds.

Quality of Diet of Patients with Coeliac Disease in Comparison to Healthy Children

A lifelong strict gluten-free diet is the only available treatment for patients with coeliac disease (CD). As with any restrictive diet, it may potentially lead to nutritional deficits. Seventy-six patients with CD (mean age 9.0 ± 4.3 years, 57% female) and 590 healthy controls (HC) (mean age 9.9 ± 0.1 years, 54% female) were recruited and requested to keep a 3-day food record (3DFR). In HC patients, anthropometric data were determined at the time when 3DFRs were collected. In CD patients, anthropometric data were determined at two time points: at diagnosis and at the time of 3DFRs collection. Intake of energy, macronutrients, and micronutrients was determined using PRODI expert 6.9 software and expressed as a percentage of recommended daily intake. In CD patients, all measured anthropometric measures (body weight (BW), body height (BH), and body mass index (BMI) z-scores) increased significantly after the mean duration of 34.1 months of a GFD. Overall, CD patients had significantly lower BW and BH z-scores compared to healthy controls. Patients with CD were generally more compliant with the recommended dietary intakes of macronutrients and some micronutrients, as compared to HC. Three participants were not compliant with the GFD; 42.1% of participants took oral nutritional supplements at the start of their GFD. Our study showed that patients with CD have better compliance with dietary recommendations compared to healthy controls, showing that a well-balanced GFD diet can provide necessary macro- and micronutrients.

Nutritional Imbalances in Polish Children with Coeliac Disease on a Strict Gluten-Free Diet

Currently, the only treatment for coeliac disease (CD) is a strict, lifelong gluten-free diet (GFD); however, their completeness with regard to energy and macro- and micronutrients remains poorly understood. Paediatric studies are often limited by a low quality and a lack of controls, and their findings should be interpreted with caution. The aim of the present study was to evaluate nutritional imbalances in children with CD on a strict GFD. Methods: A single-centre prospective cohort study was conducted. A total of 48 children with CD (33 girls, mean age 11.8 ± 3.68 years) on a strict GFD (mean duration 5.02 ± 3.87 years) were compared with 50 non-coeliac subjects (26 girls, mean age 10.2 ± 3.97 years). In both groups, anthropometric measurements (body height, weight and BMI) and laboratory tests (haemoglobin level, calcium and magnesium serum concentration, folic acid, vitamin B1, B2, B6 and B12 level) were checked. Additionally, in coeliac subjects, a 3-day food record for energy and macro- and micronutrient intake assessment were determined, and the values were compared to those in non-CD participants and the dietary reference intake (DRI) standards. Results: The CD children were more likely to demonstrate significantly lower serum vitamin B1 and folic acid levels compared to controls (p = 0.01 and p = 0.002, respectively). Although mean serum calcium values were within normal ranges, they were significantly lower in CD subjects than controls (p = 0.01). Mean calcium, folic acid and vitamin D intake was below the dietary recommendations in the CD group (69.9%, 71.2% and 68.9% DRI, respectively) but did not differ significantly between CD and non-coeliac subjects. In turn, the mean supply of proteins and carbohydrates in the CD group substantially exceeded the recommended levels (190.3% and 189.4% DRI, respectively) but was similar to controls. A significantly higher number of CD children were classified as underweight, and a significantly lower number as overweight or obese, compared with controls (p < 0.001). Conclusion: Although children with CD receive nutritional education at diagnosis, a GFD often does not provide a balanced set of macro- and micronutrients. This is mainly due to unhealthy dietary habits, as commonly observed in the general population. Children with CD should be informed that while their diet should be free of gluten, it should nevertheless cover all their nutrition requirements in the long term.

Nutritional Status of Saudi Children with Celiac Disease Following the Ministry of Health’s Gluten-Free Diet Program

This study aimed to evaluate the nutritional status of Saudi children with celiac disease (CD) who followed the Ministry of Health’s gluten-free diet (GFD) program. This study involved 66 children with CD (29 boys and 37 girls) from 5 hospitals belonging to the Ministry of Health. Socioeconomic characteristics were obtained using a structured questionnaire. Anthropometric indices were measured using a body composition analyzer. Dietary intake was assessed using three 24 h dietary records. The biochemical parameters were determined in the hospitals’ laboratories. According to the findings, the majority of respondents had ages ranging from 10 to 13 years, a father and mother with a university education, a high family income, and 5 to 7 family members. Carbohydrates and protein intake for both genders were significantly higher than the DRI’s recommended dietary intake. However, the majority of nutrients consumed were at levels significantly lower than the DRI. Both genders had normal anthropometric indices, with girls having at significantly higher indices than boys. The biochemical parameters of both genders were comparable and within the normal range, except for vitamin D, which was below the normal range. The most important factors influencing nutritional status were age for both genders, and family income and number of family members for boys. In conclusion, data obtained for nutrient intake, anthropometric indicators, body composition, and biochemical analysis indicated that CD children following the Ministry of Health GFD program have a generally good nutritional status.

Evaluation of a paediatric gluten-free food guide by children and youth with coeliac disease, their parents and health care professionals

There are currently no universal evidence-based nutrition guidelines that address the gluten-free (GF) diet for children/youth (4-18 years). A GF food guide was created to help children/youth with coeliac disease (CD) and their families navigate the complexities of following a GF diet. Guide formation was based on pre-guide stakeholder consultations and an evaluation of nutrient intake and dietary patterns. The study objective was to conduct an evaluation on guide content, layout, feasibility and dissemination strategies from end-stakeholder users (children/youth with CD, parents/caregivers and health care professionals). This is a cross-sectional study using a multi-method approach of virtual focus groups and an online survey to conduct stakeholder evaluations. Stakeholders included children/youth (4-18 years), their parents/caregivers in the coeliac community (n 273) and health care professionals (n 80) with both paediatric and CD experience from across Canada. Thematic analysis was performed on focus group responses and open-ended survey questions until thematic saturation was achieved. χ² and Fisher's exact statistical analyses were performed on demographic and close-ended survey questions. Stakeholders positively perceived the guide for content, layout, feasibility, ethnicity and usability. Stakeholders found the material visually appealing and engaging with belief that it could effectively be used in multi-ethnic community and clinical-based settings. Guide revisions were made in response to stakeholder consultations to improve food selection (e.g. child-friendly foods), language (e.g. clarity) and layout (e.g. organisation). The evaluation by end-stakeholders provided practical and patient-focused feedback on the guide to enable successful uptake in community and clinical-based settings.

Gluten-free bakery products: Ingredients and processes

There is an increasing demand for gluten-free products around the world because certain groups of people, which have increased in the last decades, need to eliminate gluten from their diet. A growing number of people consider gluten-free products to be healthier. However, making gluten-free products such as bread is a technological challenge due to the important role of the gluten network in their development. However, other products, such as cakes and cookies usually made with wheat flour, can easily be made with gluten-free starches or flours since gluten does not play an essential role in their production. To replace wheat flour in these elaborations it is necessary to resort to gluten-free starches and/or flours and to gluten substitutes. Additionally, it can be convenient to incorporate other ingredients such as proteins, fibers, sugars or oils, as well as to modify their quantities in wheat flour formulations. Regarding gluten-free flours, it will also be necessary to know the parameters that influence their functionality in order to obtain regular products. These problems have originated a lower availability of gluten-free products which have a worse texture and are less tasty and more expensive than their homologues with gluten. These problems have been partially solved thanks to research on these types of products, their ingredients and their production methods. In recent years, studies about the nutritional improvement of these products have increased. This chapter delves into the main ingredients used in the production of gluten-free products, the processes for making gluten-free breads, cakes and cookies, and the nutritional quality of these products.

Review on pediatric coeliac disease from a clinical perspective

Coeliac disease is an immune-mediated condition characterized by chronic inflammation of the small bowel with villous atrophy driven by gluten ingestion in genetically predisposed individuals. It occurs frequently in both children and adults, affecting 1-4% of the population. The disease is associated with both gastrointestinal and extra-intestinal symptoms related to malabsorption and/or immune activation, and autoantibodies to tissue transglutaminase. Removal of gluten from the diet results in resolution of symptoms and enteropathy in the majority of patients. A good diagnostic work-up is important to avoid unnecessary restrictive diets in children. In this review on pediatric coeliac disease, we address epidemiology including predisposing environmental factors and possible preventive strategies, as well as the clinical presentation, diagnosis and follow-up. What is Known: •Primary prevention of coeliac disease is not possible; however, secondary prevention by targeting high-risk groups is recommended. •The diagnosis is safe without duodenal biopsies if specific conditions are met, also in asymptomatic children. What is New: •HLA-DQ typing is not routinely required for the diagnosis, whereas it can rule out coeliac disease if HLA-DQ2 and HLA-DQ8 are absent. •Follow-up could be improved by a more rational use of (laboratory) tests, increased intention to dietary compliance and quality of life.

Review article: therapeutic targets for the pharmacologic management of coeliac disease-the future beyond a gluten-free diet

BACKGROUND

Coeliac disease (CeD) is an immune-mediated small bowel enteropathy resulting from dietary gluten exposure. Presently, the only effective treatment is adoption of a gluten-free diet (GFD), although strict adherence is challenging to maintain, and inadvertent gluten exposures are inevitable for most patients. Hence, there is substantial interest in drug development in CeD and multiple novel therapies are under investigation.

AIMS

To review existing and upcoming clinical trial programmes for pharmacologic agents for CeD.

METHODS

A narrative review was performed, informed by a search of MEDLINE, Embase, the Cochrane CENTRAL Library and clinicaltrials.gov.

RESULTS

We summarise the pathophysiology of CeD and the specific steps that are potentially amenable to pharmacologic treatment. We evaluate the evidence supporting existing and future drug targets, including trials of peptidases, gluten sequestrants, tight junction regulators, anti-transglutaminase 2 therapies, immune tolerizing agents, advanced biologics and small molecules, and microbiome-targeted strategies. We highlight unique considerations for conducting CeD trials, including identifying appropriate study populations, assessing results in the context of a gluten challenge, and interpreting CeD-specific clinical and histologic outcomes. Understanding these factors is crucial for accurately appraising the evidence. Finally, we outline what the future of CeD therapy may hold with the introduction of pharmacotherapies.

CONCLUSIONS

There is a need for pharmacologic options for CeD, either used adjunctively with a GFD for accidental or intentional gluten exposures or for refractory disease. Multiple promising agents are in development, and these trials are likely to lead to approvals for the first generation of pharmacologic agents for CeD within the next 5 years.

Healthy Eating and Diets: Fad or Rad?

One of the top chronic diseases in the United States is pediatric obesity. As such, many pediatricians will have conversations with patients and families regarding the health effects of this disease process. This article will provide a broad overview of many of the popular diets as well as evidence for their effectiveness. Lastly, recommendations for healthy eating and nutritional counseling with patients and families will be discussed. [Pediatr Ann. 2022;51(3):e88-e92.].

Vitamin D deficiency in young children with iron deficiency in Misan province, Iraq

This study aimed to assess vitamin D status and its association with iron status in young Iraqi children. A total of 95 infants and toddlers with iron deficiency (ages ranging from 6 to 24 months) and an equal number of 95 healthy subjects with normal hemoglobin (Hb) and sufficient ferritin level with matching age were included as a control group. A specially designed questionnaire was used to collect data. The cases were classified into iron deficiency (ID) and iron deficiency anemia (IDA) according to hemoglobin and ferritin levels. The cases and control groups were subdivided into vitamin insufficiency (VDI), vitamin D deficiency (VDD), and vitamin D sufficiency groups according to 25-hydroxyvitamin D [25(OH)D] levels. Young children with IDA have significantly lower serum levels of 25(OH) D compared with ID and control groups (p<0.05). According to iron status, VDI and VDD were present in 20% and 70% of IDA, 25.7% and 60%of ID, and 26.3% and 30.5% of control groups, respectively, with a significant difference in vitamin D level (p<0.05) among studied groups. A significant positive correlation (p=0.000) was found between serum ferritin level and 25(OH) D level in studied patients. Young children with severe iron deficiency have a higher prevalence of vitamin D deficiency, and there was a significant positive correlation between serum ferritin level and 25(OH) D levels among studied children.

The Role of Pseudocereals in Celiac Disease: Reducing Nutritional Deficiencies to Improve Well-Being and Health

Celiac disease or gluten-dependent enteropathy is a chronic autoimmune pathology triggered by dietary gluten in genetic predisposed individuals, mediated by transglutaminase 2 IgA autoantibodies and associated with a deteriorating immune and inflammatory response. This leads to intestinal villous atrophy, impairing the intestinal mucosa structure and function of secretion, digestion, and absorption. The result is macro- and micronutrient deficiency, including fat soluble vitamins and minerals, and a consequent nutritional status depletion. A lifelong gluten-free diet is the only available treatment for celiac patients in order to assure normal intestinal mucosa and remission of gastrointestinal symptoms. However, a gluten-free diet can itself cause other nutritional deficiencies due to its restrictive nature regarding gluten-containing cereals. A group of gluten-free cereals, known as pseudocereals, is increasingly recognized as valuable options for gluten-free diets due to their high nutritional value. Amaranth, quinoa, millet, and buckwheat are examples of gluten-free nutrient-dense grains that can be used as alternatives to the conventional gluten-containing grains and improve the variety and nutritional quality of the celiac diet. Current work reviews the nutritional pitfalls of a gluten-free diet and analyses how pseudocereals can contribute to revert those deficiencies and optimize the nutritional value of this mandatory diet for the celiac population.

Nutritional Deficiencies in Vegetarian, Gluten-Free, and Ketogenic Diets

Previously, medical diets, including the ketogenic and gluten-free diets, were rare outside of their target population. Subspecialists more familiar with risks and benefits often managed nutrition and any associated shortcomings. With more patients electively following a gluten-free or ketogenic diet for nonmedical needs, as well as the increasing prevalence of vegetarian diets, general pediatricians are seeing more followers of restrictive diets with general well-child care. Increasingly, general pediatricians can be the first provider to witness presenting signs or symptoms of associated nutritional deficiencies. This article reviews signs and symptoms of possible nutrient deficiencies seen with the vegetarian, ketogenic, and gluten-free diets.

Gluten-Free Diet in Childhood Difficult-to-Treat Nephrotic Syndrome: A Pilot Feasibility Study

Introduction

Minimal change disease in childhood can follow a frequently relapsing or steroid-dependent course in up to 40% of cases. Second-line immunosuppressive medications that are used to manage these patients are associated with significant adverse effects. There is a need for safer alternative treatments for difficult-to-treat nephrotic syndrome. Therefore, we conducted an open-label feasibility study to assess the safety and efficacy of a gluten-free diet as treatment for pediatric patients with difficult-to-treat nephrotic syndrome. As a second aim, we sought to determine if the plasma zonulin concentration can identify those who are more likely to respond to this intervention.

Methods

Seventeen patients were placed on a gluten-free diet for 6 months. A positive response was defined as a 50% reduction in the relapse rate compared to the preceding 6 months or the ability to discontinue 1 immunosuppressive drug.

Results

Five (29%) participants had a positive response to the dietary intervention. The gluten-free diet was well tolerated with no clinical or laboratory adverse events. Plasma zonulin concentration was elevated in patients who failed to benefit from the gluten-free diet.

Discussion/Conclusion

A gluten-free diet may be a useful adjunctive intervention for patients with difficult-to-treat nephrotic syndrome that can be implemented prior to resorting to second-line immunosuppressive therapy. Development of the plasma zonulin level as a biomarker to predict efficacy would facilitate rational use of a gluten-free diet in the management of nephrotic syndrome.

Nutrition in Patients with Lactose Malabsorption, Celiac Disease, and Related Disorders

Lactose malabsorption (LM), celiac disease (CD), non-celiac gluten sensitivity (NCGS), and irritable bowel syndrome (IBS) are conditions associated with food triggers, improvement after withdrawal, treatment with dietary restriction, and subsequent nutritional detriments. LM occurs when there is incomplete hydrolysis of lactose due to lactase deficiency and frequently produces abdominal symptoms; therefore, it can cause lactose intolerance (LI). A lactose-restricted diet is frequently recommended, although it can potentially lead to nutrient deficiencies. Furthermore, lactose is an essential component of fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) and is subsequently associated with intolerance to these compounds, especially in IBS. LM commonly presents in CD. Nutritional deficits are common in CD and can continue even on a gluten-free diet (GFD). Conditions triggered by gluten are known as gluten-related disorders (GRDs), including CD, wheat allergy, and NCGS. IBS can also be associated with a gluten sensitivity. A GFD is the treatment for CD, GRDs, and gluten sensitive IBS, although compliance with this restricted diet can be difficult. Strict dietary therapies can have a negative effect on quality of life. This review aims to provide an overview of the difficult nutritional elements of these disorders, which are critical for medical providers to recognize when managing these patients.

Evaluation of the Utility of Amino Acid Citrulline as a Surrogate Metabolomic Biomarker for the Diagnosis of Celiac Disease

Introduction

Citrulline is regarded as a biomarker for celiac disease (CD). Its utility for assessment and evaluation of additive predictive value for latent, potential CD and first degree relatives (FDRs) needs exploration.

Method

Consecutive 558 index cases diagnosed as per European Society for Pediatric Gastroenterology and Nutrition (ESPGHAN) 2012 guidelines and their 1565 FDRs were evaluated over five and half year period. Serology negative FDRs at initial visit and follow ups were served as controls. HLA typing for DQ2 and DQ8 genotypes, along with plasma and dried blood spot (DBS) filter paper citrulline were evaluated.

Results

Median plasma citrulline values were 20.1 and 37.33 µMol/l in cases and controls (P < .001). Cut off values for Marsh grade 3a, 3b, and 3c were 35.0, 32.8, 25.26 µMol/l in CD patients and 36.51, 30.10, 25.26 µMol/l in biopsy proven FDR. Increasing trends of plasma citrulline levels with decreasing tTG-IgA levels were observed on follow up. Low plasma citrulline levels were observed with HLA DQ 2.5 genotype (P < .05). Agreement between DBS and plasma citrulline was 94.8%.

Conclusion

Citrulline is a good surrogate biomarker for identification of histopathological grade of damage, extent of mucosal recovery and has negative correlation with tTG-IgA. It identifies the silent and latent phase of CD. DBS citrulline provides adequate information and can be used for monitoring CD patients at remote locations.

The Gluten-Free Diet for Celiac Disease and Beyond

The gluten-free diet (GFD) has gained popularity beyond its main medical indication as the treatment for gluten-induced immune-mediated disorders such as celiac disease (CD), dermatitis herpetiformis, gluten ataxia, wheat allergy, and non-celiac gluten sensitivity. However, the diet carries some disadvantages such as elevated costs, nutritional deficiencies, and social and psychological barriers. The present work aims to review indications, proven benefits, and adverse events of a gluten-free diet. Close follow-up with patients following the diet is recommended. More data is needed to assess the effectiveness of the diet in managing mental and cognitive disorders and to establish a connection between the brain and gluten.

Nutritional Imbalances in Adult Celiac Patients Following a Gluten-Free Diet

Celiac disease (CD) is a chronic autoimmune disorder of the small intestine, whose only effective treatment is a gluten-free diet (GFD). It is characterized by the atrophy of the intestinal villi that leads to altered nutrient absorption. This study describes the nutritional imbalances which may be found in adults with CD following a GFD. During the first year of treatment, deficiencies will overcome as the intestinal mucosa recovers. Thus, biochemical data will show this progression, together with the decrease in symptoms. In contrast, in the long term, when a strict GFD is followed and mucosal recovery is achieved, analyzing nutrient intake makes more sense. Macronutrient consumption is characterized by its low complex carbohydrate and fiber intakes, and high fat (especially SFA) and sugar intakes. This profile has been related to the consumption of GFP and their nutritional composition, in addition to unbalanced dietary habits. The most notable deficiencies in micronutrients are usually those of iron, calcium and magnesium and vitamin D, E and some of group B. It is necessary to follow up patients with CD and to promote nutritional education among them, since it could help not only to achieve a gluten free but also a balanced diet.

Vitamin D deficiency negatively affects both the intestinal epithelial integrity and bone metabolism in children with Celiac disease

BACKGROUND AND AIM

We aim to evaluate serum vitamin D levels, vitamin D receptor (VDR) expression in the intestinal epithelium, and their relation with epithelial barrier proteins and bone metabolism in children with Celiac disease (CD).

METHODS

Immunostaining for VDR, Claudin-2 and E-cadherin was performed in duodenal samples of the patients with CD and controls. H-score [∑Pi(I+1)] where I is the intensity score and Pi is the corresponding percentage of stained cells was calculated for each samples. The clinic, laboratory and histopathological findings were compared between patients and controls.

RESULTS

Thirty-six patients with CD and age and sex matched 36 controls were enrolled. 25-OH vitamin D levels were significantly lower in the patient group compared to the control group. The mean bone mineral density (BMD) value was significantly lower in patients with vitamin D deficiency compared to patients with normal vitamin D level. H-scores for both VDR and Claudin-2 were significantly lower in patient group when compared to the control group. H-scores for VDR, Claudin-2 and E-cadherin were significantly lower in patients with vitamin D deficiency compared to patients with normal vitamin D level. There were positive correlations between 25-OH vitamin D level and H-scores for VDR, E-cadherin and Claudin-2 in patient group.

CONCLUSIONS

Our findings showed that vitamin D deficiency is common among children with CD. Expression of VDR and epithelial barrier proteins Claudin-2 and E-cadherin which have important roles in paracellular pathway, was decreased in children with CD in correlation with histological findings of disease severity. Furthermore, deficiency of vitamin D was related to decreased expression of VDR and epithelial barrier proteins E-cadherin and Claudin-2. These findings indicate that paracellular pathway structures responsible for calcium absorption are disturbed in CD which is aggravated by vitamin D deficiency.

Expanded Role of a Dietitian in Monitoring a Gluten-Free Diet in Patients with Celiac Disease: Implications for Clinical Practice

Access to a registered dietitian experienced in celiac disease (CD) is still limited, and consultation when available focuses primarily on the elimination of gluten from the diet. Thus, the aim of this study was to evaluate the nutritional value of a gluten-free diet (GFD) in adult CD patients before, and one year after, the standard dietary education. The study included 72 CD patients on a GFD and 30 healthy controls. The dietary intake of both groups was assessed through a 3-day food diary, while adherence to a GFD in celiac subjects was assessed using Standardized Dietician Evaluation (SDE). Subsequently, all CD patients received detailed education on gluten sources, and 48 of them participated in a one-year follow-up. Results: Comparison with the control group showed that consumption of plant protein in CD patients was significantly lower, whereas fat and calories were higher. At baseline, only 62% of CD patients adhered to a GFD, but the standard dietary education successfully improved it. However, the nutritional value of a GFD after one year did not change, except for a reduced sodium intake. The CD subjects still did not consume enough calcium, iron, vitamin D, folic acid or fiber. In conclusion, while the standard dietary education improved GFD adherence, it did not significantly alter its nutritional value. Therefore, it is necessary to increase the role of a dietitian in the treatment of CD.

Knowledge of Medical Students and Medical Professionals Regarding Nutritional Deficiencies in Patients with Celiac Disease

A gluten-free diet provides relief from symptoms for patients with celiac disease, although there is still a risk of nutritional deficiencies. These patients can potentially consume an excessive amount of fat and insufficient amounts of fiber, iron, vitamin D, and calcium. This study aimed to assess the knowledge of medical students and healthcare professionals in Poland regarding nutritional deficiencies and the prevention of such deficiencies in patients with celiac disease who are on a gluten-free diet. Of the 430 survey participants, 46% did not realize the risk of nutritional deficiencies in patients with celiac disease. The knowledge of the participants was lowest regarding the risk of being overweight or obese. Among the healthcare professionals, an acceptable level of correct answers was provided by only 37% of individuals and was highest for the dietitians’ group. Our results demonstrate the need to improve the education of healthcare professionals concerning nutrition in patients with celiac disease.

Celiac Disease and the Thyroid: Highlighting the Roles of Vitamin D and Iron

Celiac disease (CD) and autoimmune thyroid diseases (AITD) like Hashimoto’s thyroiditis (HT) and Graves’ disease (GD) frequently coexist, entailing numerous potential impacts on diagnostic and therapeutic approaches. Possible correlations might exist through gut microbiota, regulating the immune system and inflammatory responses, promoting autoimmune diseases, as well as shared cytokines in pathogenesis pathways, cross-reacting antibodies or malabsorption of micronutrients that are essential for the thyroid like iron or vitamin D. Vitamin D deficiency is a common finding in patients with AITD, but might protect from autoimmunity by wielding immunoregulatory and tolerogenic impacts. Additionally, vitamin D is assumed to be involved in the onset and progression of CD, presumably plays a substantial protective role for intestinal mucosa and affects the thyroid via its immunomodulatory effects. Iron is an essential micronutrient for the thyroid gland needed for effective iodine utilization by the iron-dependent enzyme thyroid iodine peroxidase (TPO). Despite being crucial for thyroid hormone synthesis, iron deficiency (ID) is a common finding in patients with hypothyroidism like HT and is frequently found in patients with CD. A literature research was conducted to examine the interplay between CD, AITD, vitamin D and iron deficiency. This narrative review highlights the relevant correlation of the two disease entities CD and AITD, their reciprocal impact and possible therapeutic options that should be further explored by future studies.

Iron Deficiency Anemia in Celiac Disease

The iron absorption process developsmainly in the proximal duodenum. This portion of the intestine is typically destroyed in celiac disease (CD), resulting in a reduction in absorption of iron and subsequent iron deficiency anemia (IDA). In fact, the most frequent extra-intestinal manifestation (EIM) of CD is IDA, with a prevalence between 12 and 82% (in relation with the various reports) in patients with new CD diagnosis. The primary treatment of CD is the gluten-free diet (GFD), which is associated with adequate management of IDA, if present. Iron replacement treatment historically has been based on oral products containing ferrous sulphate (FS). However, the absorption of FS is limited in patients with active CD and unpredictable in patients on a GFD. Furthermore, a poor tolerability of this kind of ferrous is particularly frequent in patients with CD or with other inflammatory bowel diseases. Normalization from anemic state typically occurs after at least 6 months of GFD, but the process can take up to 2 years for iron stores to replenish.

Magnesium: Biochemistry, Nutrition, Detection, and Social Impact of Diseases Linked to Its Deficiency

Magnesium plays an important role in many physiological functions. Habitually low intakes of magnesium and in general the deficiency of this micronutrient induce changes in biochemical pathways that can increase the risk of illness and, in particular, chronic degenerative diseases. The assessment of magnesium status is consequently of great importance, however, its evaluation is difficult. The measurement of serum magnesium concentration is the most commonly used and readily available method for assessing magnesium status, even if serum levels have no reliable correlation with total body magnesium levels or concentrations in specific tissues. Therefore, this review offers an overview of recent insights into magnesium from multiple perspectives. Starting from a biochemical point of view, it aims at highlighting the risk due to insufficient uptake (frequently due to the low content of magnesium in the modern western diet), at suggesting strategies to reach the recommended dietary reference values, and at focusing on the importance of detecting physiological or pathological levels of magnesium in various body districts, in order to counteract the social impact of diseases linked to magnesium deficiency.