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Nutritional Considerations and Health Issues of a Gluten-Free Diet

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A special issue of Nutrients (ISSN 2072-6643). This special issue belongs to the section "Nutrition and Public Health".

Deadline for manuscript submissions: closed (25 August 2023) | Viewed by 21162

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Special Issue Editors

Dr. Abdulbaqi Al-Toma

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Guest Editor

Department of Gastroenterology and Hepatology, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
Interests: gastroenterology; celiac disease; gluten related disorders; non-celiac gluten allergy; refractory celiac disease; nutrition; small bowel enteroscopy

Prof. Dr. Chris JJ Mulder

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Guest Editor

Department of Gastroenterology and Hepatology, VU University Medical Centre, 1081 HV Amsterdam, The Netherlands
Interests: celiac disease; refractory celiac disease; gluten related disorders; non-celiac gluten allergy

Special Issue Information

Dear Colleagues,

Celiac disease (CeD) is a systemic disease that causes chronic enteropathy of the small intestine and develops through an inadequate immune response to gluten in genetically predisposed individuals. To date, the only effective treatment is a gluten-free diet that essentially relies on the consumption of naturally gluten-free foods and gluten-free dietary products. Several patients have difficulty controlling their diet, and therefore, regularly consume sufficient gluten to trigger symptoms. Furthermore, an inadequately balanced gluten-free diet can increase the risk of obesity, negatively affect glucose and lipid metabolism, and increase the risk of metabolic syndrome. Therefore, adequate nutritional counseling is necessary for patients diagnosed with CeD in order to prevent and treat the components of metabolic syndrome.

Emerging therapeutic options for CeD are based on the removal of toxic gluten peptides, the modulation of intestinal permeability, or the restoration of the gut microbiota. These treatment options have shown encouraging preliminary results in clinical trials. If successful, these novel approaches raise the possibility of reintroducing gluten, in amounts to be determined, into the diets of patients with CeD.

The planned Special Issue will include research and reviews from the most recognized names research topics related to a gluten-free diet, which means that only well-established data will be presented. We are also aiming to cover new and challenging topics within the Special Issue.

Dr. Abdulbaqi Al-Toma
Prof. Dr. Chris JJ Mulder
Guest Editors

Manuscript Submission Information

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Keywords

celiac disease
gluten free diet
nutritional deficiencies
bone mineral density
dietary therapy for celiac disease
malabsorption
metabolic syndrome
non-dietary therapy

Published Papers (7 papers)

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Research

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10 pages, 856 KiB

Open AccessArticle

Evaluation of a Single Determination of Gluten Immunogenic Peptides in Urine from Unaware Celiac Patients to Monitor Gluten-Free Diet Adherence

by Vincenza Lombardo, Alice Scricciolo, Andrea Costantino, Luca Elli, Giorgia Legnani, Ángel Cebolla, Luisa Doneda, Federica Mascaretti, Maurizio Vecchi and Leda Roncoroni

Nutrients 2023, 15(5), 1259; https://doi.org/10.3390/nu15051259 - 02 Mar 2023

Cited by 2 | Viewed by 1745

Abstract

Introduction and aim: Usually, adherence to the gluten-free diet (GFD) in celiac patients is indirectly assessed through serological analysis, questionnaires, or invasive methods such as intestinal biopsy. The detection of gluten immunogenic peptides in urine (urinary gluten immunogenic peptides—uGIP) is a novel technique that directly evaluates the ingestion of gluten. The aim of this study was to evaluate the clinical efficacy of uGIP in the follow-up of celiac disease (CD). Methods: From April 2019 to February 2020, CD patients reporting complete adherence to the GFD were prospectively enrolled but were unaware of the reason for the tests. Urinary GIP, the celiac dietary adherence test (CDAT), symptomatic visual analog scales (VAS), and tissue transglutaminase antibodies (tTGA) titres were evaluated. Duodenal histology and capsule endoscopy (CE) were performed when indicated. Results: A total of 280 patients were enrolled. Thirty-two (11.4%) had a positive uGIP test (uGIP+). uGIP+ patients did not show significant differences in demographic parameters, CDAT, or VAS scores. The tTGA+ titre was not related to the positivity of uGIP (14.4% vs. 10.9% in patients with tTGA+ and tTGA−). Regarding histology, 66.7% of the GIP+ patients had atrophy compared to 32.7% of the GIP patients (p-value 0.01). However, the presence of atrophy did not correlate with tTGA. Mucosal atrophy was detected in 29 (47.5%) out of 61 patients by CE. With this method, no noticeable dependence on uGIP results (24 GIP− vs. 5 GIP+) was observed. Conclusions: The single uGIP test was positive in 11% of CD cases referring a correct GFD adherence. Furthermore, uGIP results significantly correlated with the duodenal biopsy, formerly considered the gold standard for assessing CD activity. Full article

(This article belongs to the Special Issue Nutritional Considerations and Health Issues of a Gluten-Free Diet)

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12 pages, 731 KiB

Open AccessArticle

Dietary Acid Load in Gluten-Free Diets: Results from a Cross-Sectional Study

by Maximilian Andreas Storz, Alvaro Luis Ronco and Mauro Lombardo

Nutrients 2022, 14(15), 3067; https://doi.org/10.3390/nu14153067 - 26 Jul 2022

Cited by 3 | Viewed by 1565

Abstract

The gluten-free diet (GFD) ensures improvement of clinical symptoms in the vast majority of celiac disease (CD) patients. Despite stable CD rates in many countries, an increasing number of healthy individuals are adopting gluten-free diets, believing that this diet is an inherently healthier choice. The health effects of gluten-free diets are controversial, and a recent study added to the debate by reporting a lower acidogenic potential of this diet. The effects of the GFD on potential renal acid load (PRAL) and net endogenous acid production (NEAP)—two important markers of dietary acid load (DAL)—are poorly understood, and have never been examined in a Western population. Using cross-sectional data from the National Health and Nutrition Examination Surveys, we estimated DAL in U.S. individuals reporting a GFD and contrasted the results to the general U.S. population consuming gluten and denying special diets. The GFD was associated with significantly lower crude DAL scores, and after adjustments for confounders in multivariate regression, the results remain significant. Yet, our study could not confirm the reported alkalizing properties of the GFD. Although overall DAL scores were significantly lower in the GFD group, they were comparable to Western diets producing 50–75 mEq of acid per day. Full article

(This article belongs to the Special Issue Nutritional Considerations and Health Issues of a Gluten-Free Diet)

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Review

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25 pages, 1906 KiB

Open AccessReview

The Gluten-Free Diet for Celiac Disease: Critical Insights to Better Understand Clinical Outcomes

by Edurne Simón, Marta Molero-Luis, Ricardo Fueyo-Díaz, Cristian Costas-Batlle, Paula Crespo-Escobar and Miguel A. Montoro-Huguet

Nutrients 2023, 15(18), 4013; https://doi.org/10.3390/nu15184013 - 16 Sep 2023

Viewed by 4498

Abstract

The gluten-free diet (GFD) remains a complex paradigm in managing celiac disease (CeD) in children and adults, and there are many reasons why GFD adherence should be strict to improve outcomes. However, this is a challenging task for patients, since they need to have access to quality healthcare resources that facilitate optimal GFD adherence. Understanding the strengths and weaknesses of the GFD, tackling coexisting nutritional deficiencies, and dealing with complex situations, such as seronegative CeD or non-responsive CeD, all require the involvement of a multidisciplinary team. The short- and long-term follow-up of CeD patients should preferably be performed by a combined Gastroenterology and Nutrition service with well-defined quality standards and the multidisciplinary involvement of physicians, nurses, dietitians, and psychologists. Nutritional advice and counseling by an experienced dietitian can reduce the costs associated with long-term follow-up of CeD patients. Likewise, psychological interventions may be essential in specific scenarios where implementing and sustaining a lifelong GFD can cause a significant psychological burden for patients. This manuscript aims to provide guidelines to improve clinical practice in the follow-up and monitoring of CeD patients and provide information on the nutritional risks of an ill-advised GFD. Clinicians, biochemists, food technologists, dietitians, and psychologists with a global view of the disease have been involved in its writing. Full article

(This article belongs to the Special Issue Nutritional Considerations and Health Issues of a Gluten-Free Diet)

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17 pages, 752 KiB

Open AccessReview

Follow-Up of Celiac Disease in Adults: “When, What, Who, and Where”

by Chris J. J. Mulder, Luca Elli, Benjamin Lebwohl, Govind K. Makharia, Kamran Rostami, Alberto Rubio-Tapia, Michael Schumann, Jason Tye-Din, Jonas Zeitz and Abdulbaqi Al-Toma

Nutrients 2023, 15(9), 2048; https://doi.org/10.3390/nu15092048 - 24 Apr 2023

Cited by 8 | Viewed by 4042

Abstract

For patients with celiac disease (CeD), a lifelong gluten-free diet is not a voluntary lifestyle choice—it is a necessity. The key end points in clinical follow-up are symptom resolution, the normalization of weight, prevention of overweight, seroconversion, and negation or minimization of increased long-term morbidity. For the latter, a surrogate endpoint is mucosal healing, which means the normalization of histology to Marsh 0–1. Ideally, celiac follow-up care includes a multidisciplinary approach, effective referral processes, improved access that leverages technological advances, and following guidelines with the identification of measurable quality indicators, ideally informed by evidence-based research. Face-to-face CeD care and telemedicine are considered the standards for this process, although published data are insufficient. Guidelines and statements on diagnosis are readily available. However, data are lacking on optimal clinic visit intervals and outcomes and quality indicators such as improvement of symptoms, function and quality of life, survival and disease control, and how to most effectively use healthcare resources. The results of future research should provide the basis for general recommendations for evidence-based standards of quality of care in CeD. Full article

(This article belongs to the Special Issue Nutritional Considerations and Health Issues of a Gluten-Free Diet)

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16 pages, 314 KiB

Open AccessReview

Gluten-Free Diet in Co-Existent Celiac Disease and Type 1 Diabetes Mellitus: Is It Detrimental or Beneficial to Glycemic Control, Vascular Complications, and Quality of Life?

by Ingo Eland, Lars Klieverik, Abbas Ali Mansour and Abdulbaqi Al-Toma

Nutrients 2023, 15(1), 199; https://doi.org/10.3390/nu15010199 - 30 Dec 2022

Cited by 4 | Viewed by 3327

Abstract

Celiac disease (CeD) is associated with type 1 diabetes mellitus (T1DM), and both have the same genetic background. Most patients with T1DM who develop CeD are either asymptomatic or have mild CeD-related gastrointestinal symptoms. Therefore, children affected by T1DM should undergo screening for asymptomatic CeD. The aim of this review is to highlight the influence of a gluten-free diet (GFD) on glycemic control, growth rate, microvascular complications, and quality of life in patients with T1DM and CeD. PubMed, Google Scholar, Web of Science, and Cochrane Central databases were searched. Reports reviewed were those published from 1969 to 2022 that focused on the interplay of T1DM and CeD and examined the effect of diet on glycemic control, growth rate, and quality of life. The most challenging aspect for a child with T1DM and CeD is that most GFD foods have a high glycemic index, while low glycemic index foods are recommended for T1DM. Interestingly, dietary therapy for CeD could improve the elevated HbA1c levels. Avoiding gluten added to a diabetic dietary regimen in T1DM patients might impose practical limitations and lead to important restrictions in the lifestyle of a young patient. Consequently, non-adherence to GFD in patients with T1DM and CeD is common. GFD in patients with T1DM and CeD seems to lower the incidence of micro- and macrovascular complications, but this requires further investigation. It seems that adherence to GFD in young patients with T1DM and CeD leads to regular growth and a stable body mass index without any negative effect on HbA1c or insulin requirements. Furthermore, the lipid profile and quality of life seem to have improved with the introduction of GFD. Full article

(This article belongs to the Special Issue Nutritional Considerations and Health Issues of a Gluten-Free Diet)

19 pages, 382 KiB

Open AccessReview

The Dietary and Non-Dietary Management of Osteoporosis in Adult-Onset Celiac Disease: Current Status and Practical Guidance

by Abdulbaqi Al-Toma, Amin Herman, Willem F. Lems and Chris J. J. Mulder

Nutrients 2022, 14(21), 4554; https://doi.org/10.3390/nu14214554 - 28 Oct 2022

Cited by 4 | Viewed by 2686

Abstract

Impaired bone mineral density (BMD) is a frequent complication of adult-onset celiac disease (CeD). This is usually due to malabsorption of nutrients, changes in bone metabolism in association with inflammation, and to a lesser extent, decreased overall physical health and mobility. This review aims to highlight the current status concerning surveillance, prevention, and treatment strategies for bone disease in CeD. A practical guidance on these matters is suggested. The available published research on the prevention and treatment of decreased BMD in relation to CeD is scarce. In general, publications were based on expert opinions or extrapolation from studies on postmenopausal women or inflammatory bowel disease. Optimal dietary treatment and an adequate supply of calcium and vitamin D are the cornerstones for the reduction in fracture risk in patients with CeD. In adults with low BMD or fragility fractures, CeD needs to be considered and specifically approached. When osteoporosis is documented, start treatment with an antiresorptive agent; these agents are proven to result in a long-term reduction in fracture risk in high-risk individuals. However, there are some important differences between the management of male and female patients, particularly premenopausal women, that need to be addressed. In patients with persisting diarrhea and malabsorption, parenteral medications may be preferable. Future research specifically focusing on celiac disease and the associated disorders in bone mineralization is mandatory to provide evidence-based recommendations in this field. Full article

(This article belongs to the Special Issue Nutritional Considerations and Health Issues of a Gluten-Free Diet)

Other

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12 pages, 4574 KiB

Open AccessSystematic Review

Systematic Review and Dose-Response Meta-Analysis on the Relationship between Different Gluten Doses and Risk of Coeliac Disease Relapse

by Mohammad Rostami-Nejad, Nastaran Asri, Meysam Olfatifar, Babak Khorsand, Hamidreza Houri and Kamran Rostami

Nutrients 2023, 15(6), 1390; https://doi.org/10.3390/nu15061390 - 14 Mar 2023

Cited by 5 | Viewed by 2164

Abstract

Gluten proteins are known as immunological triggers for inflammation resulting in mucosal lesions in patients with coeliac disease (CD). Adherence to a strict gluten-free diet (GFD) is currently known as the only effective treatment for CD. In this study, we performed a systematic review and dose-response meta-analysis on data from previous studies to investigate the association between different gluten doses administered and the risk of CD relapse. Electronic databases were systematically searched to retrieve studies that investigated the response of CD patients to different amounts of gluten intake and evaluated the clinical, serologic, and/or histologic evidence to recognize disease relapse. Study-specific relative risks (RRs) were combined using a random effects model. A total of 440 identified published papers were screened, of which 7 records were selected following full-text reviewing and eligibility assessment for dose-response meta-analysis. According to our analysis, the risk of CD relapse is estimated to be 0.2% (RR: 1.002; 95% CI: 1.001 to 1.004) following the consumption of 6 mg gluten/day, which was increased to 7% (RR: 1.07; 95% CI: 1.03 to 1.10), 50% (RR: 1.50; 95% CI: 1.23 to 1.82), 80% (RR: 1.80; 95% CI: 1.36 to 2.38), and 100% (RR: 2.00; 95% CI: 1.43 to 2.78) by the daily intake of 150, 881, 1276, and 1505 mg gluten, respectively. Although good adherence to a GFD can adequately control CD-related symptoms, disease relapse might happen even with a very low dose of gluten, and the duration of exposure to gluten is also an important matter. The current literature has substantial limitations, such as relying on the data from just a few countries that were different in terms of the amount of gluten administered, the duration of the challenge, etc. Therefore, more randomized clinical trials using a standardized gluten challenge protocol are needed to confirm the findings of the present study. Full article

(This article belongs to the Special Issue Nutritional Considerations and Health Issues of a Gluten-Free Diet)

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