Coeliac disease is a strong risk factor for Gastro-oesophageal reflux disease while a gluten free diet is protective: a systematic review and meta-analysis

Background

Gastro-oesophageal reflux disease (GORD) mechanisms are well described, but the aetiology is uncertain. Coeliac disease (CD), a gluten enteropathy with increased duodenal eosinophils overlaps with GORD. Functional dyspepsia is a condition where duodenal eosinophilia is featured, and a 6-fold increased risk of incident GORD has been observed. Perturbations of the duodenum can alter proximal gastric and oesophageal motor function. We performed a systematic review and meta-analysis assessing the association between CD and GORD.

Methods

A systematic search of studies reporting the association of GORD and CD was conducted. CD was defined by combined serological and histological parameters. GORD was defined based on classical symptoms, oesophagitis (endoscopic or histologic) or abnormal 24-h pH monitoring; studies reporting oesophageal motility abnormalities linked with GORD were also included. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random-effects model.

Findings

31 papers were included. Individuals with CD on a gluten containing diet were 3 times more likely to have GORD than controls (OR: 3.37, 95% CI: 2.09-5.44), and over 10 times more likely when compared to those on a gluten free diet (GFD) (OR: 10.20, 95% CI: 6.49-16.04). Endoscopic oesophagitis was significantly associated with CD (OR: 4.96; 95% CI: 2.22-11.06). One year of a GFD in CD and GORD was more efficacious in preventing GORD symptom relapse than treatment with 8 weeks of PPI in non-CD GORD patients (OR: 0.18, 95% CI: 0.08-0.36). Paediatric CD patients were more likely to develop GORD (OR: 3.29, 95% CI: 1.46-7.43), compared to adult CD patients (OR: 2.55, 95% CI: 1.65-3.93).

Interpretation

CD is strongly associated with GORD but there was high heterogeneity. More convincingly, a GFD substantially improves GORD symptoms, suggesting a role for duodenal inflammation and dietary antigens in the aetiology of a subset with GORD. Ruling out CD in patients with GORD may be beneficial.

Funding

The study was supported by an Investigator Grant from the NHMRC to Dr. Talley.

Celiac disease: Hope for new treatments beyond a gluten-free diet

BACKGROUND & AIMS

Celiac disease (CD) is a chronic inflammatory disease of the small intestine induced and maintained by gluten ingestion in susceptible individuals. Current treatment consists of strict adherence to a lifelong gluten-free diet (GFD) which is considered safe and effective in the large majority of patients. However, since adherence to a GFD is difficult and has a negative impact on quality of life, an increasing interest in other treatment options has emerged. Moreover, in some individuals a GFD is not sufficiently effective, necessitating alternative treatments.

METHODS

By performing a systematic search, we constructed a detailed narrative review. Only treatment options considered relevant and conducted in a phase I, II or III clinical trial were included.

RESULTS

Based on the pathophysiology of CD, four major therapeutic approaches can be distinguished: firstly, by focusing on intraluminal gluten detoxification before absorption occurs, secondly, by modulating intestinal permeability and preventing paracellular uptake, thirdly, by enhancing immunological tolerance to gluten and finally, by regulating gluten auto-immunity.

CONCLUSIONS

Despite significant efforts, no treatment has yet completed a phase III clinical trial. Future studies will likely focus on the use of supplemental drugs in conjunction to a GFD, with ALV003 and ZED-1227 currently being the most promising therapeutic options.

Fecal calprotectin levels in patients with non-celiac wheat sensitivity: a proof of concept

Some data suggest the existence of intestinal inflammation in patients with non-celiac wheat sensitivity (NCWS). We aimed to verify whether fecal calprotectin (FCP), a marker of intestinal inflammation, could be used to confirm this inflammatory status and to test its diagnostic performance in differentiating NCWS from irritable bowel syndrome/functional dyspepsia (IBS/FD). We conducted a multicenter study, comparing NCWS patients, diagnosed by a double-blind placebo-controlled wheat challenge, with IBS/FD subjects. In the retrospective phase, FCP values were analyzed to define the prevalence of its positivity and its role as a NCWS diagnostic biomarker. In the prospective phase we tested the effects of a strict 6-month wheat-free diet (WFD) on FCP values. 31.3% (n = 63/201) of NCWS patients had above normal FCP values (NCWS FCP +), whereas all IBS/FD patients proved negative (P = 0.0001). FCP using a cut-off value > 41 µg/g showed a 58.6% sensitivity and a 98.0% specificity (AUC 0.755, 95% C.I. 0.702-0.837) in distinguishing NCWS from IBS/FD patients. Of the 63 NCWS FCP+, 65.1% had negative FCP values after ≥ 6 months of WFD, with a significant reduction in FCP values (P < 0.0001). All NCWS FCP- subjects still preserved negative FCP values after ≥ 6 months of WFD. Our study showed that FCP can be a useful but supplementary diagnostic marker for differentiating between NCWS and IBS/FD. Strict WFD adherence reduced FCP values, normalizing them in 65.1% of NCWS FCP + subjects. These data suggest the existence of two NCWS subgroups: NCWS FCP + characterized by a probable predominantly inflammatory/immunologic pattern and NCWS FCP- featuring non-immuno-mediated etiopathogenetic mechanisms. (Registration number NCT01762579).

Investigation of cost and availability of gluten-free food in Jeddah, KSA

Objective

The prevalence of celiac disease (CD) in KSA is progressively increasing. Consistent adherence to a gluten-free (GF) diet is the only effective CD treatment. The availability and cost of GF food are important factors in adherence to a GFD. The objective of this study was to investigate the cost and availability of GF food in a sample of local stores and supermarkets across Jeddah province in KSA.

Method

Eleven supermarkets in Jeddah, KSA, ranging from high budget/quality supermarkets to low-budget stores, were visited. Eight food categories were evaluated, including flour, breakfast cereals, breads, pastas, and snacks (e.g., biscuits, cookies, snack bars, and chips). The availability and cost of GF and gluten containing (GC) items within these food categories were recorded. Each item included in these food categories was counted, and the overall average price was calculated.

Results

A total of 233 GF and 24 GC products were found. Supermarket 1 had the highest availability of GF foods (n = 90), followed by supermarket 2 (n = 34), supermarket 3 (n = 30), supermarket 4 (n = 23), supermarket 5 (n = 21), supermarket 6 (n = 18), supermarket 7 (n = 9), and supermarket 8 (n = 8). The median price per 100 g was significantly greater for GF than GC products (p < 0.05). The cost of GF products was significantly higher than that of GC products (p < 0.05); consequently, GF foods were twice as expensive as their GC counterparts.

Conclusion

The availability of GF products was limited, and GF products were more expensive than standard GC products. High cost and limited availability are major roadblocks to GFD adherence among people with CD. Governmental organizations must cooperate with healthcare providers and food industries to ensure that GF foods are widely available and affordable for people with CD, to minimize financial pressure and improve health quality.

Popular Diets and Skin Effects: A Narrative Review

Numerous diets for losing weight, building strength, and managing a range of cardiovascular, neurologic, and skin diseases have become popular in recent years. The ketogenic diet and intermittent fasting in particular have shown promising results in clinical and sports medicine. The Mediterranean diet, in turn, is widely recognized for its numerous health benefits. Also popular are the paleo diet and vegan and gluten-free diets. Positive effects on inflammatory conditions, such as psoriasis, atopic dermatitis, hidradenitis suppurativa, and acne, have been observed in patients who practice intermittent fasting or follow ketogenic or Mediterranean diets. This last choice may also protect against certain skin cancers. We review the role of several popular diets in the management of skin disorders.

[Translated article] Popular Diets and Skin Effects: A Narrative Review

Numerous diets for losing weight, building strength, and managing a range of cardiovascular, neurologic, and skin diseases have become popular in recent years. The ketogenic diet and intermittent fasting in particular have shown promising results in clinical and sports medicine. The Mediterranean diet, in turn, is widely recognized for its numerous health benefits. Also popular are the paleo diet and vegan and gluten-free diets. Positive effects on inflammatory conditions, such as psoriasis, atopic dermatitis, hidradenitis suppurativa, and acne, have been observed in patients who practice intermittent fasting or follow ketogenic or Mediterranean diets. This last choice may also protect against certain skin cancers. We review the role of several popular diets in the management of skin disorders.

Obsessive-Compulsive Symptomatology and Disgust Propensity in Disordered Eating Behaviors of Adolescents with Celiac Disease

BACKGROUND

Considering the importance of underlying psychopathological mechanisms that mediate maladaptive eating behaviors in celiac disease (CD) in the determination of cognitive-behavioral therapeutic approaches, we investigated the impact of obsessive-compulsive symptomatology and disgust propensity on disordered eating attitudes (DEA) and poor gluten-free diet (GFD) compliance in adolescents with CD.

METHOD

Adolescents with biopsy-proven CD (n = 148, aged 12-18 years) were compared with age- and sex-matched controls (n = 104) in terms of eating attitudes/behaviors, obsessive-compulsive symptoms, and disgust propensity, as well as depression and anxiety to rule out depression- and anxiety-related covariates. The clinical implications associated with poor GFD compliance were determined using between-subgroup analysis. Multivariate linear regression and multiple logistic regression were used to identify predictors of DEA and GFD noncompliance, respectively.

RESULTS

In adolescents with CD, DEA was remarkably associated with obsessive-compulsive symptom severity and disgust propensity, especially in contamination and core disgust sub-dimensions. Obsessionality and disgust propensity were independent predictors of DEA, of which the obsessive-compulsive symptom severity was the most decisive predictor of DEA. Higher DEA severity and lower body mass index were independent predictors of poor GFD compliance.

CONCLUSION

Higher obsessionality, accompanied by disgust-related evaluative conditioning processes, may contribute to constructing a cognitive network consisting of hypervigilance and catastrophic interpretations towards benign somatic stimulations, food-related preoccupations, and avoidant behaviors in the disordered eating of adolescents with CD. The reciprocal relationship between lifelong GFD and DEA, mediated by obsessionality and disgust propensity, was supported by current findings that could guide clinicians in the management of maladaptive eating behaviors in adolescents with CD.

Celiac disease symptom profiles and their relationship to gluten-free diet adherence, mental health, and quality of life

BACKGROUND

A subgroup of adults with celiac disease experience persistent gastrointestinal and extraintestinal symptoms, which vary between individuals and the cause(s) for which are often unclear.

METHODS

The present observational study sought to elucidate patterns of persistent symptoms and the relationship between those patterns and gluten-free diet adherence, psychiatric symptoms, and various aspects of quality of life (QOL) in an online sample of adults with celiac disease. U.S. adults with self-reported, biopsy-confirmed celiac disease (N = 523; Mage = 40.3 years; 88% women; 93.5% White) voluntarily completed questionnaires as part of the iCureCeliac® research network: (a) Celiac Symptoms Index (CSI) for physical symptoms and subjective health; (b) Celiac Dietary Adherence Test for gluten-free diet adherence; (c) PROMIS-29, SF-36, and Celiac Disease Quality of Life Survey for psychiatric symptoms and QOL. Symptom profiles were derived using latent profile analysis and profile differences were examined using auxiliary analyses.

RESULTS

Latent profile analysis of CSI items determined a four-profile solution fit best. Profiles were characterized by: (1) little to no symptoms and excellent subjective health (37% of sample); (2) infrequent symptoms and good subjective health (33%); (3) occasional symptoms and fair to poor subjective health (24%); (4) frequent to constant symptoms and fair to poor subjective health (6%). Profiles 2 and 3 reported moderate overall symptomology though Profile 2 reported relatively greater extraintestinal symptoms and Profile 3 reported relatively greater gastrointestinal symptoms, physical pain, and worse subjective health. Profiles differed on anxiety and depression symptoms, limitations due to physical and emotional health, social functioning, and sleep, but not clinical characteristics, gluten-free diet adherence, or QOL. Despite Profile 3's moderate symptom burden and low subjective health as reported on the CSI, Profile 3 reported the lowest psychiatric symptoms and highest quality of life on standardized measures.

CONCLUSIONS

Adults with celiac disease reported variable patterns of persistent symptoms, symptom severity, and subjective health. Lack of profile differences in gluten-free diet adherence suggests that adjunctive dietary or medical assessment and intervention may be warranted. Lower persistent symptom burden did not necessarily translate to better mental health and QOL, suggesting that behavioral intervention may be helpful even for those with lower celiac symptom burden.

Experiences and difficulties for primary caretakers of children with celiac disease - A qualitative study

BACKGROUND

The purpose of this study was to understand the experiences of primary caretakers (PCTs) with a child diagnosed with celiac disease (CeD). There is paucity of research in understanding the experiences of PCTs of children with CeD in India.

METHODS

Purposive sampling was used to select PCTs of CeD-affected children from a tertiary hospital in New Delhi. Ten PCTs took part in the investigation. To gather the data, semi-structured interviews were held with participants. Hindi was used to administer the interviews.

RESULTS

The current study focused on the difficulties and worries PCTs experience in managing CeD. The main themes and sub-themes that emerged from the data were diagnosis of CeD (misdiagnosis of CeD, late diagnosis of CeD, feelings at the time of diagnosis, help from a doctor/nutritionist at the time of diagnosis); characteristics of CeD (CeD as a new disease, CeD as an allergy); attitude towards wheat (wheat as a poison, ignorance regarding negative effect of wheat); influence of significant others (making fun of the child, queries from others are a source of worry, non-acceptance of celiac disease by others and pressure to give gluten to the child); issues in following gluten-free diet (GFD) (fear of cross-contamination, distrust on GFD available outside home, GFD is expensive, making GFD is difficult, joint family, non-adherence to GFD, making non-GFD along with GFD); effect of CeD (financial effect of CeD, effect on physical and mental health of the child and PCT, effect on social life, change in family dynamics, eating restrictions); management of CeD (GFD for the whole family to manage CeD, family support to manage CeD, adhering to GFD, early diagnosis); and concerns (future marital concern for the child, cure of CeD, proper physical growth).

CONCLUSION

The current study gave an understanding of how PCTs dealt with a child's CeD. The difficulties and worries of caretakers should be taken into consideration and appropriate recommendations made to lessen the strain of managing the child's CeD and the daily obstacles associated with it.

Impact of Gluten-free Diet on Anthropometric Indicators in Individuals With and Without Celiac Disease: A Systematic Review and Meta-analysis

PURPOSE

Previous studies have found that a gluten-free diet (GFD) may have improve obesity-related factors. For this reason, we conducted a systematic review and meta-analysis to investigate the effect of a GFD on anthropometric indicators.

METHODS

We performed a systematic search in databases from inception until July 12, 2022. We included all relevant articles that evaluate efficacy of a GFD on anthropometric indicators in patients with and without celiac disease (CD). Random-effects models were applied to combine the data. The main outcomes were then analyzed using weight mean differences (WMDs) and 95% CIs.

FINDINGS

A total of 27 articles met the eligible criteria and were included. Pooled results from the random-effects model indicated that the GFD has no significant effect on any of the factors of anthropometry, including weight (WMD, 1.20 kg; 95% CI, -1.16 to 3.55 kg; P = 0.319), body mass index (WMD, 0.70 kg/m2; 95% CI, -0.45 to 1.84 kg/m2; P = 0.233), waist circumference (WMD, 0.92 cm; 95% CI, -1.34 to 3.17 cm; P = 0.497), and body fat (WMD, 1.02%; 95% CI, -0.38% to 2.42%; P = 0.153). The subgroup results indicated that after implementation of a GFD significant increased weight and body fat occurred in patients with compared with without CD. In addition, the effect of this diet on the increase of BMI and body fat in the intervention of more than 48 weeks was significantly higher.

IMPLICATIONS

The results of the present study indicate that a GFD can have a significant and beneficial effect on weight and body fat in patients with CD.

Effects of different dietary interventions in multiple sclerosis: a systematic review of evidence from 2018 to 2022

BACKGROUND

Nutrition is an important risk factor for both Multiple sclerosis (MS) development and post-diagnosis disease prognosis. However, it is important to evaluate the diet as a whole instead of considering the effects of nutrients individually.

AIMS

In this systematic review, it was aimed to evaluate the effect of different dietary interventions in MS patients and to determine the most appropriate dietary model for this group.

METHODS

The search was carried out between February 2022 and March 2022 in three different databases, 'PubMed', 'Web of Science' and 'The Cochrane Library' over the university access network. After the search for the determined keywords, a total of 269 studies conducted between 2018 and 2022 were identified, but only 17 of them were found to be suitable for inclusion criteria.

RESULTS AND CONCLUSION

Although there are studies reporting positive health outcomes for energy-restricted/intermittent fasting diets, ketogenic diet, and modified paleolithic diet, these diets may not be applicable diets in the long-term as they may cause deficiencies of various nutrients. No current study was found for low-fat diets, gluten-free diet and Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet applied to individuals with MS. The Mediterranean diet, on the other hand, is more recommendable than other diet models due to the positive health results reported in long-term studies and the absence of any side effects. However, more studies are needed to reach a definite conclusion.

Knowledge of and behaviors toward a gluten-free diet among women at a health sciences university

Purpose

Gluten-free diets have gained popularity worldwide. However, little information is available regarding the knowledge of, and behaviors toward, this diet among adults in KSA. This study was aimed at addressing this knowledge gap.

Methods

A cross-sectional survey was conducted in 352 women at a health sciences university in KSA.

Results

Eleven percent of participants had followed a gluten-free diet at least once, 70% of whom had voluntarily tried this diet without a confirmed medical diagnosis. The main source of information regarding this diet was the internet and social media. Additionally, followers of this diet had moderate knowledge of gluten and its products yet higher knowledge than that of non-followers (65% vs 56%, P = .0055). Following a GFD was associated with an age of 25 years or older, higher education, and being employed. Although 56% of participants reported following this diet 75% or more of the time, the average calculated adherence score was low. Although 95% of the followers indicated changes in their lifestyle and social life, 71% felt better after following this diet, and only 2.6% felt worse. This self-reported results were confirmed by a calculated average quality of life score of 1.3, indicating a good quality of life after following this diet.

Conclusion

This study indicated moderate knowledge and low adherence to a gluten-free diet among followers. This finding may be attributable to the high percentage of followers without a confirmed medical condition, or to the social and lifestyle changes faced by followers of GFDs. Educational programs should be introduced to the public to increase awareness of gluten-free foods and diets.

Causal relationships between dietary habits and five major mental disorders: A two-sample Mendelian randomization study

OBJECTIVE

To explore the causal relationship between dietary habits and five major mental disorders using the two-sample Mendelian randomization (MR) analysis.

METHODS

This study was based on the summary data of the genome-wide association study (GWAS) on diet and five major mental disorders in the European population. The genetic locus data of five major mental disorders (mania, bipolar disorder, manic depression, depression, schizophrenia) from those who never eat eggs, dairy, wheat, and sugar were used. Two-sample MR analysis was conducted to evaluate the causal relationship between diet and five major mental disorders.

RESULTS

This study revealed a causal relationship between "Never eat Wheat products" and all five types of mental disorders (mania, bipolar disorder, manic depression, depression, schizophrenia), demonstrating a significant negative correlation (P < 0.05). However, no significant causal relationship was observed between "Never eat Sugar or foods/drinks containing sugar" and any of the five mental disorders (P > 0.05). Furthermore, the study found that the statement "Never eat eggs, dairy, wheat, sugar: I eat all of the above" had a causal relationship with mania, bipolar disorder, and manic depression, showing a significant positive correlation (P < 0.05). However, this statement did not exhibit a significant causal relationship with depression and schizophrenia (P > 0.05).

CONCLUSION

There was a negative correlation between never eating wheat products and the five mental disorders (mania, bipolar disorder, manic depression, depression, schizophrenia), indicating that never eating wheat products may reduce the risk of mental disorders.

Effects of the supplementation with a multispecies probiotic on clinical and laboratory recovery of children with newly diagnosed celiac disease: A randomized, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy of a multispecies probiotic on clinical and laboratory recovery of children with celiac disease (CeD) at diagnosis.

METHODS

Children with newly diagnosed CeD entered a randomized double-blind placebo-controlled trial. A gluten-free diet (GFD) plus a multispecies probiotic or placebo were administered for 12 weeks. Growth, laboratory, and clinical parameters were recorded at enrollment, after 3 and 6 months of follow-up.

RESULTS

Overall, 96 children completed the study: 49 in group A (placebo) and 47 in group B (probiotic). A significant increase of BMI-Z score was found in both groups after 3 and 6 months of treatment (p < 0.001), however the increase of BMI-Z score was significantly higher and faster in Group B than in Group A. Other clinical and laboratory parameters improved in both groups after 3 and 6 months (p<0.001), but no difference was found between the groups and a comparable time trend was observed in both groups.

CONCLUSIONS

Treatment with a multispecies probiotic induced a higher and faster increase of BMI in children with newly diagnosed CeD. The mechanism of this positive effect remains to be elucidated.

Impact of probiotics on gut microbiota composition and clinical symptoms of coeliac disease patients following gluten-free diet

Coeliac disease (CD) is associated with alterations in gut microbiota composition. This study evaluated the effects of probiotics on gut microbiota composition and clinical symptoms of treated CD patients. In this double-blind, placebo-controlled trial study, 31 CD patients that were randomly classified as probiotics (n = 15) and placebo (n = 16) groups received 109 colony-forming units/capsule for 12 weeks. Fecal samples were collected before and after probiotics, or placebo administration and the changes in intestinal microbiota were assessed by quantitative real-time PCR. Probiotic administration improved the patients' clinical symptoms when compared to the placebo group. Fatigue score was significantly reduced by the intake of probiotic supplements (P = 0.02). Except for Staphylococcus spp., the relative abundances of Bacteroidetes, Lactobacillus spp., Bifidobacterium spp., Clostridium cluster I, Enterobacteriaceae, and Firmicutes were higher in probiotics group. Accordingly, a 12-week multi-strain probiotic treatment regimen may modify the composition of intestinal microbiota and improve GI symptoms in CD patients.

Adherence to a gluten-free diet in celiac disease patients from Paraguay

INTRODUCTION AND AIM

The treatment for celiac disease is a gluten-free diet that should be strictly and permanently carried out. Our aims were to determine adherence to the gluten-free diet and the risk factors for non-adherence.

MATERIALS AND METHODS

An observational, cross-sectional, comparative study was conducted. It included individuals of both sexes and of any age that presented with celiac disease, lived in Paraguay from January to April 2021, and agreed to participate in the survey. Incomplete questionnaires were excluded. Non-probabilistic convenience sampling was utilized. Adherence was measured using the Leffler questionnaire. The study was approved by the Ethics Committee of the Universidad Privada del Este.

RESULTS

The sample consisted of 371 respondents, 322 (87%) of whom were adults, with a mean age of 38 ± 12 years, and 49 (13%) of whom were children and adolescents, with a mean age of 10 ± 5 years. Female sex was predominant (85%). Adherence to the gluten-free diet was detected in 59% of the adults and 73% of the children and adolescents. The factors significantly associated with adherence included belonging to the child and adolescent age group and having had the diagnosis for a longer time: 9 ± 8 years for the adherence group and 7 ± 8 years for the non-adherence group.

CONCLUSIONS

The present study demonstrated the frequency of adherence to the gluten-free diet in celiac patients in Paraguay. Psychologic and nutritional support is recommended for individuals with celiac disease that do not adhere to their treatment.

Metabolic control, adherence to the gluten-free diet and quality of life among patients with type 1 diabetes and celiac disease

AIMS

In this cross-sectional study, we aimed to evaluate metabolic control, adherence to a gluten-free diet (GFD), and quality of life (QoL) in individuals with type 1 diabetes (T1D) and celiac disease (CD).

METHODS

We targeted individuals with T1D and CD at a major tertiary hospital in Saudi Arabia. We gathered retrospective data from medical records and prospectively assessed glycemic control using HbA1c and ambulatory glucose metrics, adherence to a GFD using the Celiac Dietary Adherence Test (CDAT), and QoL using the Celiac Disease Quality of Life survey (CD-QoL).

RESULTS

Forty-eight out of 1095 patients screened (4.38%) were included. Mean age and HbA1c were 21.3 (± 6.6) and 8.3% (± 0.8%). The average time in range% and above range% were 38.5 (range 24-68) and 29.6 (± 7.4). The median hypoglycemic events/month was 8, with a median duration of 80 min. The median overall CDAT and CD-QoL scores were 20.5 and 54. No significant correlations were observed between glucose management indicator (GMI), % in target, and CDAT/CD-QoL scores (all p > 0.05).

CONCLUSIONS

No significant effect of GFD on QoL or glycemic control was observed. Further prospective studies are warranted to establish solid evidence of the impact of GFD on individuals with T1D and CD.

Gluten Sensitivity Underlying Resistant "Laryngopharyngeal Reflux" Symptoms and Signs

INTRODUCTION

Laryngopharyngeal reflux (LPR) is one of the most common conditions encountered in otolaryngology. Gluten sensitivity may mimic the signs and symptoms of LPR or act as an aggravating cofactor with LPR. Gluten sensitivity and food intolerance also have been implicated as conditions that may be associated specifically with LPR symptoms and signs resistant to traditional medical treatment. Medical management of LPR may be insufficient to control symptoms and laryngeal signs of reflux, constituting resistant LPR. Eliminating gluten from the diet could provide symptomatic relief to patients with gluten sensitivity and LPR that is not controlled adequately by current regimens. The purpose of our study was to investigate the relationship between gluten sensitivity and LPR. We aimed to evaluate reflux finding score (RFS) improvement following elimination of gluten from the diet in patients with resistant LPR who had positive blood tests associated with gluten sensitivity. Symptom improvement was also assessed following dietary gluten elimination. Lastly, we aimed to identify predictors for a positive response to a gluten-free diet.

METHODS

Adult patients who underwent gluten sensitivity testing for treatment-resistant LPR symptoms and/or signs were included. Patients with ≥1 positive test were advised to begin a therapeutic trial of a gluten-free diet. Subjects who chose not to trial a gluten-free diet or tested negative for gluten sensitivity markers served as controls. RFS was the primary outcome measure.

RESULTS

One hundred ninety-seven patients were included; 81 trialed a gluten-free diet. Subjects who trialed the gluten-free diet were significantly more likely to demonstrate objective improvement in RFS (77.14% vs 43.88%), and report subjective improvement (55.41% vs 25.77%) than those who did not. RFS had decreased significantly from baseline at 1-3, 3-6, 6-12, and >12-month interval follow-up examinations in subjects who trialed a gluten-free diet. Comparison between subjects who trialed the gluten-free diet, tested positive for a gluten sensitivity marker but did not trial the gluten-free diet, and subjects who were negative for all gluten sensitivity markers revealed that a gluten-free diet was associated with a significantly greater percent improvement in RFS compared to controls at 1-3, 6-12, and >12-months.

CONCLUSION

Gluten sensitivity can mimic or aggravate LPR. A gluten-free diet should be considered for patients with resistant LPR, especially if blood test abnormalities that suggest gluten sensitivity are identified. The diet should be maintained for a minimum of three months to demonstrate objective improvement using RFS.

Evolution of bone densitometry parameters and risk of fracture in coeliac disease: a 10-year perspective

BACKGROUND

Metabolic bone disease is frequently found in patients with coeliac disease (CD). Despite its high prevalence, international guidelines are partially discordant about its management due to the lack of long-term data.

METHODS

We retrospectively evaluated a large dataset of prospectively collected data of CD patients assessing the variation of DXA parameters and estimated fracture risk according to the FRAX® score in a 10-year follow-up. Incident fractures are reported, and the predictive ability of the FRAX® score is verified.

RESULTS

We identified 107 patients with low bone density (BMD) at the diagnosis of CD and a 10-year follow-up. After improving at the first follow-up, T-scores slowly reduced over time but with no clinically relevant differences between the first and last examination (lumbar spine: from - 2.07 to - 2.07, p = 1.000; femoral neck: from - 1.37 to - 1.55, p = 0.006). Patients with osteoporosis at the index measurement had more marked fluctuations than those with osteopenia; the latter group also showed minimal modifications of the FRAX® score over time. Six incident major fragility fractures occurred, with a good predictive ability of the FRAX® (AUC 0.826).

CONCLUSION

Adult CD patients with osteopenia and no risk factors had substantially stable DXA parameters and fracture risk during a 10-year follow-up. A dilated interval between follow-up DXA for these patients could be considered to reduce diagnosis-related time and costs, maintaining a 2-year interval for patients with osteoporosis or risk factors.

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.

Updates in the diagnosis and management of coeliac disease

Coeliac disease is a common autoimmune disorder induced by ingesting gluten, the protein component of wheat, barley, and rye. It is estimated that one-in-hundred people worldwide have coeliac disease, of whom the majority remain undiagnosed. Coeliac disease is characterized by a wide range of gastrointestinal and extraintestinal symptoms but can also present asymptomatically. Diagnosing coeliac disease depends on the concordance of clinical, serological and histopathological data. However, the diagnosis can be challenging and frequently overlooked. Undiagnosed coeliac disease is associated with an increased risk of complications and detrimental effects on quality of life. Early diagnosis and treatment of coeliac disease are necessary to reduce the risk of long-term complications.

Clinical features, treatment, and outcomes of celiac-associated arthritis: a retrospective cohort study

BACKGROUND

Although arthritis is recognized as an extra-intestinal manifestation of celiac disease, little is known about the clinical course and outcomes of pediatric celiac-associated arthritis. This study describes clinical characteristics, treatments, and outcomes of children with celiac-associated arthritis.

METHODS

This was a retrospective cohort study of children with celiac disease seen in pediatric rheumatology clinic between 2004 and 2021 for joint complaints. Data was abstracted from electronic health records. Patient demographics and clinical manifestations were evaluated using standard descriptive statistics. Physician- and patient-reported outcomes were evaluated at the index visit, 6-month follow-up, and last recorded visit, and were compared using Wilcoxon signed-rank tests.

RESULTS

Twenty-nine patients with celiac disease were evaluated for joint complaints, and 13 were diagnosed with arthritis. Their mean age was 8.9 years (SD 5.9), and 61.5% were female. Celiac disease diagnosis was made before arthritis diagnosis in only 2 cases (15.4%). Initial testing that led to the celiac disease diagnosis was obtained by the rheumatologist in 6 cases (46.2%). Only 8 patients (61.5%) had concomitant GI symptoms, and of these, 3 patients had BMI z-scores <-1.64 and 1 had impaired linear growth. Arthritis presentation was most often oligoarticular (76.9%) and asymmetric (84.6%). Most cases required systemic therapy (n = 11, 84.6%) with DMARDs, biologics, or both. Of the 10 patients who required systemic therapy and reported compliance with the gluten-free diet, 3 (30%) were able to stop systemic medications. Two of 3 patients who cleared celiac serologies came off systemic medications. Statistically significant improvement was noted in the number of joints involved (p = 0.02) and physician global assessment of disease activity (p = 0.03) between the index and final visit.

CONCLUSIONS

Rheumatologists play an important role in the identification of celiac disease, as arthritis was the presenting symptom in most cases and was not always associated with GI symptoms or poor growth. The arthritis was most often oligoarticular and asymmetric. Most children required systemic therapy. The gluten-free diet may not be sufficient to manage arthritis, but antibody clearance may be an indicator of higher likelihood of disease control off medications. Outcomes are promising with a combination of diet and medical therapy.

Perceived barriers to gluten-free diet adherence by people with celiac disease in Greece

Background

In people with celiac disease (CD), many factors affect adherence to a gluten-free diet (GFD), and these may well differ among countries. In Greece, such data for the adult population are lacking. Thus, the present study aimed to explore the perceived barriers to compliance with a GFD that are faced by people with CD living in Greece, also taking into account the impact of the COVID-19 pandemic.

Methods

Nineteen adults (14 females) with biopsy-proven CD, mean age 39±9 years and median time on GFD 7 (Q1-Q3: 4-10) years, participated in 4 focus groups, conducted through a video conference platform during the period October 2020 to March 2021. Data analysis followed the qualitative research methodology.

Results

Eating outside the home was reported as the domain where most difficulties were faced: these were related to a lack of confidence in finding safe gluten-free food and to the lack of social awareness about CD/GFD. All participants highlighted the high cost of gluten-free products, which was mostly managed by receiving state financial support. Regarding healthcare, the vast majority of participants reported little contact with dietitians and no follow up. The COVID-19 pandemic eased the burden of eating out, as staying at home and allocating more time to cooking was experienced as a positive effect, although the shift to online food retailing impacted food variability.

Conclusion

The main impediment to GFD adherence seems to stem from low social awareness, while the involvement of dietitians in the healthcare of people with CD warrants further investigation.

Health utilities and willingness to pay in adult patients with coeliac disease in Hungary

BACKGROUND

Coeliac disease (CD) is a life-long food-related disorder with a global prevalence of approximately 1%. Patients with CD often experience reduced health-related quality of life that could improve with a strict adherence to a gluten-free diet (GFD).

OBJECTIVES

To obtain visual analogue scale (VAS), time trade-off (TTO) and willingness-to-pay (WTP) values amongst patients with CD.

METHODS

In 2020-2021, a cross-sectional online survey was conducted amongst 312 adult CD patients in Hungary. Patients completed the Gastrointestinal Symptom Rating Scale (GSRS) and evaluated their current health and three hypothetical health state vignettes defined based on dietary adherence using VAS, conventional 10-year TTO and WTP. Multivariate regressions were used to explore the effect of patients' demographic and clinical characteristics on utility and WTP values.

RESULTS

Mean VAS values for current health and 'CD with strict adherence to GFD', 'CD with loose adherence to GFD' and 'CD without GFD' hypothetical health states were 79.69 ± 18.52, 85.36 ± 16.18, 62.44 ± 19.91 and 36.69 ± 25.83, respectively. Corresponding mean TTO utilities were: 0.90 ± 0.19, 0.91 ± 0.20, 0.87 ± 0.23 and 0.76 ± 0.29. Mean annual WTP values for returning to full health were: €845 ± 1077, €648 ± 1002, €862 ± 1135 and €1251 ± 1496. Older age at diagnosis, male sex, more severe gastrointestinal symptoms (GSRS) and having comorbidities were associated with lower VAS and TTO or higher WTP values for current own health (p < 0.05).

CONCLUSION

This is the first study to report TTO utilities for CD health states. Strict adherence to the GFD may result in substantial health gains in symptomatic patients. Utilities and WTP results can be used to estimate benefits of GFD in cost-utility and cost-benefit analyses.

Pancytopenia in celiac disease-A case series of 20 children

Pancytopenia in children with celiac disease (CeD) is postulated to be due to nutritional deficiency such as vitamin B12, folate and copper or an autoimmune process resulting in aplastic anemia with hypoplastic marrow. In the present case series, we report the profile and explore the etiology of pancytopenia among children with CeD. There are only a few case reports of pancytopenia in children with CeD. We enrolled newly diagnosed cases of CeD and pancytopenia presenting in the celiac disease clinic over three years. Detailed evaluation was carried out for the cause of pancytopenia. We followed up on the cases for compliance and response to gluten-free diet at three months, six months and 12 months. Twenty patients were eligible for inclusion. They were divided into two groups: one with aplastic anemia with hypoplastic marrow labeled as Gp CeD-AA and the other with megaloblastic/nutritional anemia labeled as Gp CeD-MA. Patients in Gp CeD-MA presented with classical symptoms of CeD as recurrent diarrhea, abdomen distension, pallor and poor weight gain. They had none or just one transfusion requirement and had an early and complete recovery from pancytopenia. Patients in Gp CeD-AA presented with atypical symptoms such as epistaxis, short stature, fever, pallor and weakness. They had a multiple blood transfusion requirement and had delayed and partial recovery from pancytopenia. Pancytopenia is not a disease in itself but is the presentation of an underlying disease. It can occur due to various coexisting disorders in children with CeD, which can be as simple as nutritional deficiencies to as complex as an autoimmune process or malignancy. CeD should be included in the differential diagnosis of aplastic anemia as CeD and aplastic anemia both have a similar pathological process involving T cell destruction of tissues.

Impact of adherence to gluten-free diet in paediatric celiac patients on optical coherence tomography findings: Ocular imaging based study

OBJECTIVE

This study aims to measure choroidal thickness, retinal nerve fiber layer thickness, GCC thickness, and foveal thickness by optical coherence tomography and to investigate whether there is a difference between celiac patients who adhere to the gluten-free diet and who do not.

MATERIALS AND METHODS

A total of 68 eyes of 34 pediatric patients diagnosed with celiac disease were included in the study. Celiac patients were divided into two groups those who adhere to the gluten-free diet and those who do not. Fourteen patients who adhere to the gluten-free diet and 20 patients who do not adhere to the gluten-free diet were included in the study. Choroidal thickness, GCC, RNFL, and foveal thickness of all subjects were measured and recorded using an optical coherence tomography device.

RESULTS

The mean choroidal thickness of the dieting and non-diet groups was 249.05 ± 25.60 and 244.18 ± 33.50 µm, respectively. The mean GCC thickness of the dieting and non-diet groups was 96.56 ± 6.26 and 93.83 ± 5.62 µm, respectively. The mean RNFL thickness of the dieting and non-diet groups was 108.83 ± 9.97 and 103.20 ± 9.74 µm, respectively. The mean foveal thickness of the dieting and non-diet groups was 259.25 ± 33.60 and 261.92 ± 32.94 µm, respectively. There was not a statistically significant difference between the dieting group and the non-diet group in terms of choroidal, GCC, RNFL and foveal thicknesses (p = 0.635, p = 0.207, p = 0.117, p = 0.820, respectively).

CONCLUSION

In conclusion, the present study states that adhering to a gluten-free diet does not make any difference in choroidal, GCC, RNFL, and foveal thicknesses in pediatric celiac patients.

Role of Serology, Dietary Assessment, and Fecal Gluten Immunogenic Peptides for Predicting Histologic Recovery in Children with Celiac Disease

BACKGROUND

A strict lifelong gluten-free diet (GFD) remains the only treatment of celiac disease (CD). Adherence to gluten-free diet is best reflected by mucosal healing. Noninvasive tools capable of predicting mucosal recovery in CD patients need to be identified.

AIMS

To compare the ability of various modalities used to assess compliance to GFD, for predicting persistent mucosal damage in children with CD.

METHODS

A prospective, single-center, observational study on children with CD on a GFD was conducted between January 2020 and April 2021. Children with CD on GFD were consecutively enrolled and various modalities used to assess adherence to GFD were compared.

RESULTS

One hundred and fifty children (Mean age 12.2 ± 3.6 years, 58% Boys) on GFD (Mean duration 6 ± 3.1 years) were enrolled in the study. Persistent mucosal damage was seen in 88% of the enrolled. Fecal gluten immunogenic peptide (GIP) was positive in 87.8% (129/147). Antibodies to tissue transglutaminase (TGA-IgA) and/or deamidated gliadin peptide (DGP) were positive in 32% (48/150) whereas antibody to synthetic neoepitopes of TGA-IgA was positive in 24.8% (37/149). Non-compliance as assessed by local questionnaire, Biagi score, and dietitian detailed interview were 62.7%, 60%, and 75.3%, respectively. Serology had the highest specificity (83%) and fecal GIP had the highest sensitivity (89%). On logistic regression analysis, only non-compliance by Biagi score predicted poor mucosal recovery.

CONCLUSION

Fecal GIP may be sensitive to detect only "one-point dietary transgression." None of the existing modalities used to assess compliance to GFD accurately predict persistent mucosal damage. A subset of patients may develop gluten tolerance.

Extra-intestinal manifestations of Celiac disease in children: their prevalence and association with human leukocyte antigens and pathological and laboratory evaluations

BACKGROUND

Celiac disease (CD) is an autoimmune disease caused by gluten intake. Traditionally CD was believed to be a disease of the gut, although a wide range of extra-intestinal manifestations (EIM) was recognized. The exact prevalence of EIM and the associated risk factors have not been well studied.

AIM

We aimed to assess the prevalence of EIM in children with CD and their association with human leukocyte antigen (HLA) typing, and pathological and laboratory indices.

METHOD

We conducted a cross-sectional study on children and adolescents with a definite diagnosis of CD. They were followed in the main Celiac Clinic of Southern Iran.

RESULTS

We included 204 children who were visited between 2012 and 2017. Nearly 85% of them were positive for HLA-DQ2 and 40.6% for HLA-DQ8. The most prevalent intestinal complaints reported were abdominal pain (42.6%) and chronic constipation (19.1%). Failure-to-thrive (32.7%), iron deficiency anemia (25%), short stature (20.5%), and eczema (18.6%) were the most common EIMs. However, failure-to-thrive and short stature were presented at significantly younger ages, whereas those patients with concomitant type 1 diabetes mellitus (DM) were significantly older. We also found significant relationships between autoimmune thyroid disease and HLA-DQ5, and the presence of headaches with HLA-DQ7. The prevalence of HLA types of DQ2, DQ8, DQ6, and DQ7 significantly varied among different Marsh groups. Patients who were positive for HLA-DQ8, were significantly older, taller, and weightier. No significant association was found between HLA types and any of the gastrointestinal symptoms, anti-tTG and compliance to gluten free diet. Moreover, there were no statistically significant differences detected between the presence of each individual EIM, the level of IgA anti-tTG, sex, and Marsh typing.

CONCLUSION

This study highlights the presence of EIM in CD and their associated factors. We show the potential role of HLA typing in some EIMs, which may shed light for future studies.

Changes in the gut bacteriome upon gluten-free diet intervention do not mediate beta cell preservation

AIMS/HYPOTHESIS

We previously detected indications that beta cell function is protected by gluten-free diet (GFD) introduced shortly after the onset of childhood type 1 diabetes. The present aim was to assess whether GFD was associated with changes in the gut bacteriome composition and in its functional capacity, and whether such changes mediated the observed effects of GFD on beta cell function.

METHODS

Forty-five children (aged 10.2 ± 3.3 years) were recruited into a self-selected intervention trial primarily focused on determining the role of GFD on beta cell preservation ( ClinicalTrials.gov NCT02867436). Stool samples were collected prior to the dietary intervention and then at 3-month intervals. A total of 128 samples from the GFD group and 112 from the control group were analysed for bacteriome 16S rDNA community profiles, the bacteriome functional capacity was predicted using PICRUSt2 and actual gut metabolome profiles measured using NMR. Intestinal permeability was assessed using serum zonulin concentrations at 1, 6 and 12 months and lactulose/mannitol tests at the end of intervention. Dietary questionnaires were used to ensure that the dietary intervention did not result in differences in energy or nutrient intake.

RESULTS

The bacteriome community composition changed during the intervention with GFD: of abundant genera, a 3.3-fold decrease was noted for Bifidobacterium genus (adjusted p=1.4 × 10^-4 in a DESeq2 model, p=0.026 in generalised estimating equations model), whereas a 2.4-fold increase was observed in Roseburia (adjusted p=0.02 in DESeq2 model, p=0.002 in generalised estimating equations model). The within-sample (alpha) diversity did not change, and there was no statistically significant clustering of GFD samples in the ordination graphs of beta diversity. Neither of the genera changes upon GFD intervention showed any association with the pace of beta cell loss (p>0.50), but of the remaining taxa, several genera of Bacteroidaceae family yielded suggestive signals. The faecal metabolome profile ordination correlated with that of bacteriomes but did not associate with GFD or categories of beta cell preservation. There was no indication of changes in gut permeability.

CONCLUSIONS/INTERPRETATION

The bacteriome reacted to GFD, but the changes were unrelated to the pace of beta cell capacity loss. The previously observed moderately protective effect of GFD is therefore mediated through other pathways.

Long-term follow-up in patients with coeliac disease in the pandemic-era: a view from Sheffield the NHS England national centre for adult coeliac disease

Aim

To explore patients' follow-up preferences.

Background

Optimal follow-up strategies for patients with coeliac disease remain a subject of debate. Research suggests patients' prefer review by dietitians with a doctor available as required.

Methods

Patients with coeliac disease under review at our centre, completed a questionnaire assessing their views on what makes follow-up useful based on specific criteria. Bloods tests, symptoms review, dietary assessment, opportunity to ask questions and reassurance. Patients' preferences between follow-up with a hospital doctor, a hospital dietitian, a hospital dietitian with a doctor available, a general practitioner, no follow-up or access when needed were also evaluated.

Results

138 adult patients completed the questionnaire, 80% of patients reported following a strict gluten free diet (mean diagnosis was 7.2 years). Overall, 60% found their follow-up to be 'very useful' valuing their review of blood tests and symptoms (71%) reassurance (60%) and opportunity to ask questions (58%). Follow-up by a dietitian with a doctor available was the most preferred option of review (p<0.001) except when compared to hospital doctor (p=0.75). Novel modalities of follow-up such as telephone and video reviews were regarded as of equal value to face-to-face appointments (65% and 62% respectively). Digital applications were significantly less preferable (38%, p<0.001).

Conclusion

Follow-up by a dietitian with a doctor available as needed was the most preferred follow-up method. However, in this study follow-up by a dietitian with doctor available and hospital doctor alone was statistically equivalent. Many patients consider telephone and video follow-up of equal value to face-to-face reviews.

Celiac disease and upper secondary school achievement in Sweden A retrospective cohort study

BACKGROUND

Both undiagnosed celiac disease and some chronic childhood diseases are associated with lower academic achievement. However, there is little knowledge of achievements in those diagnosed with celiac disease. Our aim was to investigate school achievements in upper secondary school among Swedish adolescents with celiac disease.

METHODS

We performed a retrospective cohort study using register data. We analyzed choice of upper secondary school program, completion of upper secondary school including achievements of basic eligibility for college/university, and final grade in individuals with celiac disease diagnosed before 15 years of age, born 1991-97. We compared with the Swedish population of the same birth years. Analyses were adjusted for sex, year of birth, living region at 17 years of age, and parental education as well as income.

RESULTS

The cohort included 734 074 individuals, whereof 3 257 (62% females) with celiac disease. There was no significant difference in choice of upper secondary school program. No significant difference was found in completion or achieving basic eligibility for college/university in adjusted analyses. The mean final grade in the celiac disease group was 13.34 (standard deviation 4.85) compared to 12.78 (standard deviation 5.01) in the reference population (p < 0.001), out of a maximum of 20. The effect of celiac disease on final grade remained in adjusted analyses (p = 0.012).

CONCLUSIONS

We found that diagnosed celiac disease does not negatively affect school achievements in upper secondary school. This finding suggests the diagnosis, treatment and follow-up programs of celiac disease could reverse potential deleterious academic processes.

Cerebellar Symptoms in Gluten Sensitivity: a Systematic Review of the Effect of a Gluten-Free Diet on Brain Imaging

Cerebellar manifestations have been described in patients with gluten sensitivity (GS)-related disorders. A better understanding of the neurological manifestations of GS requires the use of neuroimaging techniques. We performed a systematic review on neuroimaging findings in GS patients with cerebellar symptoms. We also included a specific search on neuroimaging findings in GS patients with cerebellar manifestations on a gluten-free diet (GFD). PubMed, Embase, and Bireme were systematically searched to identify studies assessing neuroimaging features of adults with cerebellar manifestations and GS with or without enteropathy on a GFD. Ten studies with a total of 222 adult-GS patients were included. Magnetic resonance imaging was used in 100% of the studies. Cerebellar atrophy was evaluated in 7 studies and observed in 63% of the patients. White matter abnormalities were described in 2 studies. Single-photon emission computed tomography was used in 2 studies, and decreased cerebellar perfusion was detected in 92% of the included patients. No study employed nuclear medicine after the start of GFD. Magnetic resonance spectroscopy (MRS) was performed in 2 studies before and after GFD. An increase in the Naa/Cr ratio in cerebellar vermis was seen in 98% of the cases on a strict GFD. Cerebellar atrophy was found to be a prevalent condition in GS patients. MRS demonstrated to be useful in the follow-up of GS patients with cerebellar manifestations on a GFD. Prospective studies using nuclear medicine imaging are needed to study brain changes in GS patients on a GFD.

High Prevalence of Functional Gastrointestinal Disorders in Celiac Patients with Persistent Symptoms on a Gluten-Free Diet: A 20-Year Follow-Up Study

BACKGROUND

Ongoing symptoms in treated celiac disease (CD) are frequent and are commonly thought of as being due to infractions to a gluten-free diet (GFD) or complications.

AIMS

To study the etiology and natural history of clinically relevant events (CREs) throughout follow-up and identify predictors thereof to guide follow-up.

METHODS

CREs (symptoms/signs requiring diagnostic/therapeutic interventions) occurring in celiac patients between January-2000 and May-2021 were retrospectively collected between June and September 2021 and analysed.

RESULTS

One-hundred-and-eighty-nine adult patients (133 F, age at diagnosis 36 ± 13 years, median follow-up 103 months, IQR 54-156) were enrolled. CREs were very common (88/189, 47%), but hardly due to poor GFD adherence (4%) or complications (2%). Interestingly, leading etiologies were functional gastrointestinal disorders (30%), reflux disease (18%) and micronutrient deficiencies (10%). Age at diagnosis ≥ 45 years (HR 1.68, 95%CI 1.05-2.69, p = 0.03) and classical pattern of CD (HR 1.63, 95%CI 1.04-2.54, p = 0.03) were predictors of CREs on a multivariable Cox model. At 5 years, 46% of classical patients ≥ 45 years old at diagnosis were event-free, while this was 62% for non-classical/silent ≥ 45 years, 60% for classical < 45 years, and 80% for non-classical/silent < 45 years.

CONCLUSIONS

CREs occurred in almost half of CD patients during follow-up, with functional disorders being very common. New follow-up strategies for adult CD may be developed based on age and clinical pattern at diagnosis.

What are the clinical consequences of 'potential' coeliac disease?

BACKGROUND

There is limited data on the clinical consequences of potential coeliac disease (PCD).

AIM

To compare the presentation of PCD with coeliac disease (CD).

METHODS

A retrospective study of adult PCD patients (>18 years) was performed. Presenting manifestations, serology and HLA-DQ genotyping were compared to an age-at-diagnosis and sex-matched CD cohort.

RESULTS

The PCD cohort comprised 84 patients (median age 37 years, 63% female). The majority of PCD patients were symptomatic at presentation (PCD 91.7% versus CD cohort 94.0%, p = 0.55). In total, 79.8% and 76.2% of the PCD and CD cohorts respectively reported ≥1 gastrointestinal symptoms at presentation (p = 0.58). Extraintestinal presentation was less common in PCD than CD (65.5% versus 79.8% respectively, p = 0.038). PCD patients had fewer haematinic deficiencies than those with CD (iron 21.4% versus 41.7%, p = 0.005, vitamin D 14.3% versus 27.4%, p = 0.037 and folate deficiency 7.1% versus 28.6%, p= <0.001.) Post-diagnosis, 67.5% of the PCD patients chose a GFD. One-third of the patients who continued to eat gluten developed villous atrophy.

CONCLUSION

The presentation of PCD and CD differ; however, mild enteropathy does not necessarily equate to mild symptoms. The GFD appears to be advantageous in symptomatic PCD.

Quality of life of Moroccan patients with celiac disease: Arabic translation, cross-cultural adaptation, and validation of the celiac disease questionnaire

BACKGROUND AND STUDY AIMS

Celiac disease (CD) management is based on a lifelong gluten-free diet (GFD) that affects the quality of life (QoL) of patients with CD. Specific instruments have been used to evaluate this QoL, such as the CD-Questionnaire (CD-Q). This study aimed to translate, validate, and cross-culturally adapt the CD-Q in an Arabic version and then apply it to evaluate the QoL of Moroccan adult patients with CD.

PATIENTS AND METHODS

The Moroccan version of the CD-Q (M-CD-Q) was administered to 150 patients with CD, and 112 of them completed it. The reproducibility and reliability of the M-CD-Q were studied by the intraclass coefficient (ICC) and Cronbach's α, respectively. Parametric and nonparametric tests, confirmatory factor analysis, and Spearman correlation were used for the statistical analysis performed by SPSS, and the goodness-of-fit test was determined using SPSS AMOS.

RESULTS

No difficulties were found during the translation and cultural adaptation of the CD-Q. Cronbach's α showed good internal consistency. The retest showed excellent reproducibility (ICC > 0.4). The study of the psychometric properties of the M-CD-Q showed good acceptance, zero ceiling effect, and floor effect. The model fit was good [(root mean square error of approximation = 0.075 (<0.08) and χ2 = 509.04, p < 0.001]. The total scores showed a neutral QoL. This QoL was worse in the worries subscale, which is related to gluten-free products. The GFD did not improve the QoL of the examined samples.

CONCLUSION

The M-CD-Q is the first reliable and adapted instrument in an Arab country for the evaluation of QoL in patients with CD. CD negatively influences this QoL, especially items related to gluten-free products.

Gluten-free diet attenuates the impact of exogenous vitamin D on thyroid autoimmunity in young women with autoimmune thyroiditis: a pilot study

Although both exogenous vitamin D and a gluten-free diet were found to reduce thyroid antibody titers, no study investigated interactions between gluten intake and vitamin D status in patients with autoimmune thyroid disorders. The aim of the present study was to assess whether the gluten-free diet determines the effect of vitamin D treatment on thyroid autoimmunity and thyroid function in young women with autoimmune (Hashimoto's) thyroiditis. The study compared two groups of euthyroid premenopausal women with this disorder, matched for thyroid antibody titers: 31 women with non-celiac gluten sensitivity complying for at least 12 months with the gluten-free diet and 31 unaffected sisters of women with non-celiac gluten sensitivity remaining without any dietary intervention. Plasma titers of thyroid peroxidase and thyroglobulin antibodies, as well as plasma concentrations of thyrotropin, free thyroid hormones, prolactin, 25-hydroxyvitamin D and high-sensitive C-reactive protein were measured at entry and after a six-month follow-up. Moreover, at both time points, the structure parameters of thyroid homeostasis were assessed. Although exogenous vitamin D decreased titers of thyroid peroxidase and thyroglobulin antibodies and increased 25-hydroxyvitamin D levels in each treatment group, this effect was less pronounced in patients on the gluten-free diet than in patients not following any dietary recommendations. Only in the latter group of patients, vitamin D increased SPINA-GT. Treatment-induced changes in thyroid peroxidase and thyroglobulin antibodies correlated with the impact of treatment on 25-hydroxyvitamin D levels. The obtained results suggest that gluten-free diet may impair beneficial effects of exogenous vitamin D in individuals with Hashimoto's thyroiditis.

Diet and irritable bowel syndrome: an update from a UK consensus meeting

There has been a renewed interest in the role of dietary therapies to manage irritable bowel syndrome (IBS), with diet high on the agenda for patients. Currently, interest has focussed on the use of traditional dietary advice (TDA), a gluten-free diet (GFD) and the low FODMAP diet (LFD). A consensus meeting was held to assess the role of these dietary therapies in IBS, in Sheffield, United Kingdom.Evidence for TDA is from case control studies and clinical experience. Randomised controlled trials (RCT) have demonstrated the benefit of soluble fibre in IBS. No studies have assessed TDA in comparison to a habitual or sham diet. There have been a number of RCTs demonstrating the efficacy of a GFD at short-term follow-up, with a lack of long-term outcomes. Whilst gluten may lead to symptom generation in IBS, other components of wheat may also play an important role, with recent interest in the role of fructans, wheat germ agglutinins, as well as alpha amylase trypsin inhibitors. There is good evidence for the use of a LFD at short-term follow-up, with emerging evidence demonstrating its efficacy at long-term follow-up. There is overlap between the LFD and GFD with IBS patients self-initiating gluten or wheat reduction as part of their LFD. Currently, there is a lack of evidence to suggest superiority of one diet over another, although TDA is more acceptable to patients.In view of this evidence, our consensus group recommends that dietary therapies for IBS should be offered by dietitians who first assess dietary triggers and then tailor the intervention according to patient choice. Given the lack of dietetic services, novel approaches such as employing group clinics and online webinars may maximise capacity and accessibility for patients. Further research is also required to assess the comparative efficacy of dietary therapies to other management strategies available to manage IBS.

Bi-directional Relationship Between Celiac Disease and Liver Chemistries: A Systematic Review and Meta-Analysis

AIMS

Previous studies have reported conflicting results regarding prevalence of elevated LC (2-70%) in celiac disease (CD). This systematic review and meta-analysis assessed the prevalence of elevated LC at time of CD diagnosis and associated response to GFD. We also report the prevalence of CD in patients with unexplained elevation of LC.

METHODS

Studies assessing LC (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in CD patients were eligible. Studies with < 50 cases or in pediatric populations were excluded.

RESULTS

In total, 20 studies assessing prevalence of elevated LC in 4,265 participants with newly diagnosed CD (mean age = 35.6 ± 6.5 years, 69.8% female) were included. Pooled prevalence of elevated LC was 18.7% (95% CI 13.8-24.8; I2 = 95%). Normalization of elevated LC was seen in 83.1% (95% CI 73.4-89.7; I2 = 79%, 11 studies) of patients after GFD. On meta-regression, age at CD diagnosis, gender, and Marsh grading were not associated with elevated LC. Among 979 participants (7 studies) with unexplained elevation of LC, pooled seroprevalence and biopsy-proven CD was 6.4% (95% CI 2.9-10.3, I2 = 71%) and 4.5% (95% CI 2.6-7.7, I2 = 67%), respectively.

CONCLUSION

Elevated LC are seen in approximately one-fifth of patients at CD diagnosis with majority normalizing after GFD. Age, gender, and degree of intestinal damage are not predictive of elevated LC. In the appropriate clinical scenario, liver tests should be serially monitored in CD reserving workup for additional causes after a trial of GFD. Patients with unexplained elevation of liver tests should be screened for celiac disease.

The Effect of Gluten-Free Diet Duration on Body Mass Index of Iranian Patients with Celiac Disease

Background: A gluten-free diet (GFD) is the only effective treatment of celiac disease (CD) that is associated with body mass index (BMI) changes. This study aimed to determine how GFD duration affects the BMI of Iranian patients with CD. Methods: In this prospective study, 215 patients with CD, who were on a GFD, were categorized into three groups according to the duration of compliance to GFD: 1. patients with less than 6 months of diet, 2. Patients who had a diet for 6 months to 2 years, and 3. patients with more than 2 years of diet. The BMI changes were assessed before and after adherence to the GFD. Results: Most patients' weight remains in the same BMI category during different courses of GFD adherence. Patients who were underweight showed significant changes in their BMI following the diet in less than 6 months (P=0.033) and more than 2 years (P<0.001), and the number of weight gain cases increased over time. Conclusion: There is a need for careful, updated, and personalized nutrition management of patients with CD in different periods of the diet. Conducting similar studies with larger sample sizes in different regions can lead to providing expert dietary counseling for patients with CD.

Newly Diagnosed Celiac Disease and Bone Health in Young Adults: A Systematic Literature Review

Celiac disease (CD), a gluten-induced autoimmune disease, is associated with low bone mineral density (BMD) among children. Unfortunately, it is often diagnosed in adulthood, which may lead to an increased risk of fragile bones. The aim of this systematic review was to report on BMD status among young adults newly diagnosed with CD, and to examine the effect of a gluten-free diet (GFD), nutritional supplements, such as vitamin D, or antiresorptive medications on BMD recovery. Databases searched were Medline, Embase, and Cochrane Library up to July 2nd, 2020. Both observational studies and clinical trials were considered, if patients were newly diagnosed and between 20 and 35 years of age and reported on BMD. We critically appraised the identified studies using ROBINS-I and summarized the findings narratively. Out of 3991 references, we identified 3 eligible studies: one cross-sectional study and two longitudinal studies. In total, 188 patients were included, and the study population consisted primarily of women with an age range between 29 and 37 years old. Compared to healthy controls, our target population had lower BMD. Moreover, a strict GFD may increase BMD during a follow-up period of up to 5 years. Newly diagnosed CD patients aged 20-35 years are at risk of lower BMD. Therefore, it may be crucial to assess BMD at time of diagnosis in young women. Whether the results can be extrapolated to young men is unknown. While strict GFD may improve BMD over time, there is a lack of robust evidence to demonstrate that nutritional supplements or antiresorptive agents are beneficial in the prevention of fragile bones in this age group.

Gluten contamination in labelled gluten-free, naturally gluten-free and meals in food services in low-, middle- and high-income countries: a systematic review and meta-analysis

The gluten-free diet is based on the consumption of foods without gluten, which aims to manage celiac disease. The concern of celiac patients is that these foods should be safe. However, gluten contamination can affect these foods. The objectives of this review and meta-analysis were first, to identify articles that detected gluten contamination in gluten-free foods using validated methods. Second, to quantify the overall prevalence of gluten contamination of naturally gluten-free foods, labelled gluten-free products, and meals prepared in food services. Third, to highlight the influence of the country's income and the period of study on this prevalence. The studies were identified in Scopus, Science Direct, Web of Science, PubMed, and Google Scholar. Forty articles were included according to PRISMA guidelines. The statistical meta-analysis was performed using MedCalc 19 software. The results show that in the gluten-free foods analysed, the overall prevalence of gluten contamination was estimated at 15.12% (95% CI: 9.56%-21.70%), with more than 20 mg/kg of gluten. Naturally gluten-free foods were significantly more contaminated than labelled gluten-free products and than meals in food services (28.32%; 9.52%; 4.66% respectively; p < 0.001). Moreover, it was noticed that oats were the most contaminated food. In addition, the prevalence of gluten contamination has significantly decreased over time. The majority of the studies were carried out in upper-middle-income and high-income countries, while only one study was conducted in lower-middle income countries. Therefore, it is necessary to implement preventive actions to reduce gluten contamination, ensuring safe gluten-free foods for celiac patients, including low-income countries.

Adherence to the Mediterranean diet is linked to reduced psychopathology in female celiac disease patients

Celiac disease (CD) is a chronic enteropathy, affecting approximately 1% of the population worldwide with a higher prevalence in women. Recent studies demonstrate that CD is associated with an increased prevalence of psychopathology. The present study was undertaken to investigate the relationship between adherence to the Mediterranean Diet (MD) and psychopathological symptoms among CD patients, since the MD is a physical and mental health protective dietary regimen, which can easily be rendered gluten-free. A total of 134 CD patients (28 males and 106 females) were included in the study. Psychopathology was evaluated with the Symptom Checklist-90-Revised (SCL-90-R), and MD adherence was calculated using the Mediterranean Dietary Serving Score (MDSS). As regards psychopathological symptoms, female patients presented with statistically significant higher depression and anxiety than males. The majority of patients (64.9%) had low adherence to the MD (MDSS <14) with a mean score of 9.44 ± 3.26 and 9.14 ± 3.07 for men and women, respectively, out of a total of 24 points. High MD adherence was observed in 35.7% of the male and 34.9% of the female patients, with a mean score of 16.40 ± 2.63 and 16.35 ± 2.12, respectively. Interestingly, MD adherence was inversely associated with the intensity of several psychopathological symptoms in female patients, which represented the majority of the sample. The results of the study underline the need to encourage CD patients to adapt to a Mediterranean-style GFD.

Comparison of dietary acid load score between celiac patients and healthy population

Background and aims

In the present study, we assessed the dietary acid load in adult celiac patients and compared it with that of the healthy population to provide more specific dietary recommendations for celiac patients.

Methods

This study was a cross-sectional study that included 130 celiac patients and 462 Non-celiac participants. The 80-item semi-quantitative food frequency questionnaire was used to obtain dietary data. Based on the dietary data, the dietary acid load (DAL), Potential renal net acid load (PRAL), and net endogenous acid production (NEAP) were calculated.

Results

The mean PRAL value is negative in the celiac group but positive in the general population. There was a significant difference in the PRAL score between celiac patients and the general population (p < 0.001). The mean NEAP and DAL score were significantly lower in the celiac group compared with the healthy population (P < 0.001). There were no significant differences between gluten-free diet adherents and non-adherents regarding the PRAL, NEAP, and DAL values (P > 0.05).

Conclusion

We showed that the patients with celiac disease had a significantly less acidogenic diet compared with that of the general population. So, following dies low in gluten may be associated with less acid production spacially in populations at risk of acid/base imbalance.

Current guidelines for the management of celiac disease: A systematic review with comparative analysis

BACKGROUND

Wheat and other gluten-containing grains are widely consumed, providing approximately 50% of the caloric intake in both industrialised and developing countries. The widespread diffusion of gluten-containing diets has rapidly led to a sharp increase in celiac disease prevalence. This condition was thought to be very rare outside Europe and relatively ignored by health professionals and the global media. However, in recent years, the discovery of important diagnostic and pathogenic milestones has led to the emergence of celiac disease (CD) from obscurity to global prominence. These modifications have prompted experts worldwide to identify effective strategies for the diagnosis and follow-up of CD. Different scientific societies, mainly from Europe and America, have proposed guidelines based on CD's most recent evidence.

AIM

To identify the most recent scientific guidelines on CD, aiming to find and critically analyse the main differences.

METHODS

We performed a database search on PubMed selecting papers published between January 2010 and January 2021 in the English language. PubMed was lastly accessed on 1 March 2021.

RESULTS

We distinguished guidelines from 7 different scientific societies whose reputation is worldwide recognized and representative of the clinical practice in different geographical regions. Differences were noted in the possibility of a no-biopsy diagnosis, HLA testing, follow-up protocols, and procedures.

CONCLUSION

We found a relatively high concordance between the guidelines for CD. Important modifications have occurred in the last years, especially about the possibility of a no-biopsy diagnosis in children. Other modifications are expected in the next future and will probably involve the extension of the non-invasive diagnosis to the adult population and the follow-up modalities.

Family ties: the impact of celiac disease on children and caregivers

PURPOSE

To evaluate the impact of celiac disease (CD) and the gluten-free diet (GFD) on the health-related quality of life (HRQoL) in children with CD in the United States using validated measures. We hypothesize that CD negatively impacts the child and caregivers' HRQoL.

METHODS

Participants included children with a confirmed diagnosis of CD and their caregivers (n = 246) seen in a CD multidisciplinary clinic. Caregivers completed the Pediatric Quality of Life (PedsQL) parent-proxy scale to report on their child's HRQoL and the Family Impact Module (FIM), which assesses the impact of caring for a child with a chronic illness. Their children completed the age-appropriate PedsQL. PedsQL and FIM results were compared to published data for children with gastroenterological conditions and a healthy cohort using non-parametric tests.

RESULTS

Children with CD reported significantly lower HRQoL than reports from healthy controls across all PedsQL domains (P < 0.001, Cohen d = 0.8), and lower compared to children with other organic gastrointestinal conditions in Social Functioning (P < 0.001, Cohen d = 0.5) and overall Psychosocial Functioning (P < 0.001, Cohen d = 0.3) domains. Results from the caregiver's report on their own HRQoL were significantly worse than that reported by historical controls in the domains of Communication (P < 0.001, Cohen d = 0.3) and Worry (P < 0.001, Cohen d = 0.8), yet similar on all other domains.

CONCLUSIONS

In our population, CD is associated with low HRQoL scores for both children and their caregivers. Screening children and families for HRQoL can identify patients and families in need of additional support in this higher-risk population.

Quality of life of Moroccan children with celiac disease: Arabic translation and validation of a specific celiac disease instrument

PURPOSE

Gluten-free diet (GFD) is a lonely lifelong management for patients with celiac disease (CD), which may affect their quality of life (QoL). This can be evaluated by generic or specific instruments. We aimed to translate, validate and cross-culturally adapt a specific-CD instrument to Moroccan-Arabic version (M-CD-DUX), and then apply it to evaluate the QoL of Moroccan celiac children.

DESIGN AND METHODS

CD-DUX instrument was translated and culturally adapted, and preliminarily evaluated on 15 children and their proxies. The reproducibility and internal consistency of M-CD-DUX were measured by intra-class coefficient (ICC) and Cronbach α tests respectively. The statistical analysis of data consisted was conducted using SPSS, and the Goodness-of-Fit test was measured by SPSS AMOS.

RESULTS

The reliability of M-CD-DUX instrument showed a good internal consistency and reproducibility. The psychometric properties of M-CD-DUX were acceptable, and the instrument's Model fit was good [(Root Mean Square Error of Approximation = 0.062; χ2 = 603.08, p < 0.001]. M-CD-DUX was completed by 52 celiac children and their proxies. It showed a worse QoL for all items and subscales, and no difference was observed between the QoL of celiac children already under GFD and those recently diagnosed.

CONCLUSION

M-CD-DUX was the first reliable and adapted instrument used to evaluate the QoL of celiac children in an Arab country, emphasizing a negative impact of CD on their QoL.

PRACTICE IMPLICATIONS

Therefore, improving their QoL requires to make gluten-free products available to them at an appropriate price as well as a good integration into society.

Long-Term Adherence to a Gluten-Free Diet and Quality of Life of Celiac Patients After Transition to an Adult Referral Center

BACKGROUND

Modalities for the transition to adult care of celiac patients diagnosed during childhood/adolescence and their impact on long-term adherence to a gluten-free diet (GFD-A), quality of life (QOL) and maintenance of follow-up in adulthood are unknown.

AIMS

To evaluate whether timing of transition affects long-term GFD-A, QOL, and continuity of follow-up in adulthood and to identify predictors of long-term GFD-A.

METHODS

Clinical and demographic data about pediatric care and adult follow-up at our center were retrospectively collected from clinical notes of celiac patients diagnosed during childhood/adolescence and then referred to our tertiary center. QOL and adult long-term GFD-A were prospectively evaluated with validated questionnaires. These parameters were studied by means of univariate and multivariate statistical analysis.

RESULTS

183 patients (130F, mean age at diagnosis 7.6 ± 5.8 years) were enrolled. Median age at transition to adult care was 20 years (IQR 17-25). There was no relationship between age at transition to adult care, long-term GFD-A, QOL, and continuity of follow-up. GFD-A tended to improve overall from pediatric care to adult referral (OR 2.92, 95% CI 1.13-7.87, p = 0.02) and also throughout adult follow-up (OR 9.0, 95% CI 4.2-19.7, p < 0.01). On multivariable logistic regression analysis, classical symptoms at diagnosis of celiac disease (p = 0.02) and good GFD-A at adult referral (p < 0.01) predicted good long-term GFD-A, while being lost to follow-up predicted poorer long-term GFD-A (p = 0.02).

CONCLUSIONS

Clinical characteristics can guide development of personalized strategies for implementing long-term GFD-A and ensure maintenance of regular follow-up in celiac patients diagnosed in childhood/adolescence and transitioning to adult care.

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.

Association between celiac disease and vitiligo: A review of the literature

Celiac disease (CD) is an autoimmune intestinal disease caused by the intake of gluten-containing cereals and their products by individuals with genetic susceptibility genes. Vitiligo is a commonly acquired depigmentation of the skin; its clinical manifestation are skin patches caused by localized or generalized melanin deficiency. Both diseases have similar global incidence rates (approximately 1%) and are associated to similar diseases, including autoimmune bullous disease, inflammatory bowel disease, autoimmune thyroiditis, autoimmune gastritis, and type 1 diabetes. The relationship between CD and vitiligo has been reported in several studies, but their conclusions are inconsistent. Further, it has also been reported that a gluten-free diet (GFD) can improve the symptoms of immune-related skin diseases such as vitiligo. In this mini-review, we summarize and review the literature on the relationship between CD and vitiligo, assess the therapeutic significance of GFD for patients with vitiligo, and explore their possible physiopathology. We are hopeful that the information summarized here will assist physicians who treat patients with CD or vitiligo, thereby improving the prognosis.