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Nutritional Deficiency in Celiac Disease: Current Perspective

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

Deadline for manuscript submissions: closed (9 July 2021) | Viewed by 70704

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Dr. Anil K. Verma

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Division of Gastroenterology, McMaster University Medical Centre, Hamilton, ON, Canada
Interests: celiac disease; gluten contamination; HLA-DQ distribution; other gluten related disorders
Special Issues, Collections and Topics in MDPI journals

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Dear Colleagues,

Adherence to a strict gluten-free diet is the only effective treatment, to date, for celiac disease, with absolute regression in celiac-associated symptoms. A gluten-free diet is also recommended in other gluten-related disorders. Gluten is a mixture of storage proteins found in wheat and related grains that contains certain immune-potent fragments (prolamins), which are enough to inflict a toxic effect in the intestinal mucosa by triggering an immunological response in genetically susceptible individuals. However, gluten is a vital source, not only of protein, but also of various macro- and micronutrients. Banishment of gluten from the diet causes an alteration in the level of macro and micronutrients that eventually leads to nutritional imbalances, both in adult and pediatric celiac disease individuals.

Naturally gluten-free (grains, fruits, vegetables, etc.) and processed gluten-free products (commercial products) are advised as substitutes for gluten-containing food to patients affected with celiac disease and other gluten-related disorders. Although gluten-free products are enriched with nutrients however, they do not fulfill the required amount of nutrition; whereas gluten-containing products do. It is reported that gluten-free products contain a low amount of needed micronutrients (iron, folate, and vitamin B), fiber, and a higher amount of carbohydrates and lipids compared to gluten-containing products.

In recent years, nutritional complications have been reported in patients with celiac disease, which is a serious health issue, especially in growing children, that requires immediate action. For this Special Issue, we invite articles related to the nutritional aspects of celiac disease and other gluten-related disorders.

Dr. Anil K. Verma
Guest Editor

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Keywords

Celiac Disease
Gluten
Gluten-Related Disorders
Nutritional Deficiency
Gluten-Free Products
Nutritional Imbalance

Published Papers (13 papers)

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Editorial

Jump to: Research, Review

4 pages, 209 KiB

Open AccessEditorial

Nutritional Deficiencies in Celiac Disease: Current Perspectives

by Anil K. Verma

Nutrients 2021, 13(12), 4476; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13124476 - 15 Dec 2021

Cited by 5 | Viewed by 2912

Abstract

Gluten-induced T-cell-mediated immune response damages the villous structure that significantly affects the functioning of the small intestinal mucosa [...] Full article

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

Research

Jump to: Editorial, Review

16 pages, 1358 KiB

Open AccessArticle

TMPRSS6 rs855791 Polymorphism Status in Children with Celiac Disease and Anemia

by Klaudia Urbaszek, Natalia Drabińska, Anna Szaflarska-Popławska and Elżbieta Jarocka-Cyrta

Nutrients 2021, 13(8), 2782; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13082782 - 13 Aug 2021

Cited by 5 | Viewed by 3100

Abstract

Celiac disease (CD) is an autoimmune chronic inflammatory disease occurring in genetically predisposed individuals in response to the intake of gluten. Clinical presentation can be heterogeneous. Iron-deficient anemia (IDA) is one of the most common extra-intestinal manifestations of CD. Although IDA usually reverts with a gluten-free diet (GFD), some patients show persistent IDA, the mechanisms of which are poorly understood. Recent studies suggest an association between the rs855791 polymorphism in the TMPRSS6 gene and persistent IDA in adults with CD. The current study aimed to assess the potential link between rs855791 and persistent IDA in pediatric patients with CD. The study included 106 children diagnosed with CD between 2015 and 2019. Clinical and blood parameters (including blood count, serum iron) were collected at diagnosis and after ≥12 months of GFD, and the rs855791 genotype was assessed for each patient. IDA was present at diagnosis in 25 patients (23.6%); only three (3%) had persistent IDA after GFD. The prevalence of rs855791 genotypes was 9% (n = 10) for TT, 53% (n = 56) for CT, and 38% (n = 40) for CC. There was a tendency toward a higher proportion of the T allele in patients with IDA and lower hemoglobin in the TT genotype but without statistical significance. An association between rs855791 and persistent IDA was not observed. These findings suggest that persistent IDA is uncommon in pediatric patients with CD. The prevalence of rs855791 in children with CD is reported for the first time. Full article

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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13 pages, 1043 KiB

Open AccessArticle

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

by Katarzyna Gładyś, Jolanta Dardzińska, Marek Guzek, Krystian Adrych, Zdzisław Kochan and Sylwia Małgorzewicz

Nutrients 2021, 13(6), 1859; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13061859 - 29 May 2021

Cited by 14 | Viewed by 3843

Abstract

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

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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11 pages, 264 KiB

Open AccessArticle

Pandemic Effects and Gluten-Free Diet: An Adherence and Mental Health Problem

by Karla A. Bascuñán, Juan Manuel Rodríguez, Carla Osben, Alan Fernández, Carlos Sepúlveda and Magdalena Araya

Nutrients 2021, 13(6), 1822; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13061822 - 27 May 2021

Cited by 10 | Viewed by 4012

Abstract

The COVID-19 pandemic has been present for many months, influencing diets such as the gluten-free diet (GFD), which implies daily challenges even in non-pandemic conditions. Persons following the GFD were invited to answer online ad hoc and validated questionnaires characterizing self-perceptions of the pandemic, current clinical condition, dietary characteristics, adherence to GFD, anxiety, and depression. Of 331 participants, 87% experienced shortage and higher cost of food and 14.8% lost their jobs. Symptoms increased in 29% and 36.6% failed to obtain medical help. Although 52.3% increased food preparation at home and purchased alternative foodstuffs, 53.8% had consumed gluten-containing foods. The Health Eating Index was intermediate/“needs improvement” (mean 65.6 ± 13.3 points); in 49.9% (perception) and 44.4% (questionnaire), adherence was “bad”. Anxiety and depression scores were above the cutoff in 28% and 40.4%, respectively. Adherence and mental health were strongly related. The likelihood of poor adherence was 2.3 times higher (p < 0.004) in participants declaring that pandemic altered GFD. Those suffering depressive symptoms were 1.3 times more likely to have poor adherence (p < 0.000). Depression and faulty GFD (mandatory for treatment) appear, affecting a high proportion of participants, suggesting that support measures aimed at these aspects would help improve the health condition of people that maintain GFD. Comparisons of data currently appearing in the literature available should be cautious because not only cultural aspects but conditions and timing of data collection are most variable. Full article

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

7 pages, 371 KiB

Open AccessArticle

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

by Łukasz Dembiński, Artur Mazur, Mariusz Dąbrowski, Teresa Jackowska and Aleksandra Banaszkiewicz

Nutrients 2021, 13(6), 1771; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13061771 - 22 May 2021

Cited by 6 | Viewed by 3031

Abstract

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

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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23 pages, 1116 KiB

Open AccessArticle

Nutritional Status in Spanish Adults with Celiac Disease Following a Long-Term Gluten-Free Diet Is Similar to Non-Celiac

by Catalina Ballestero-Fernández, Gregorio Varela-Moreiras, Natalia Úbeda and Elena Alonso-Aperte

Nutrients 2021, 13(5), 1626; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13051626 - 12 May 2021

Cited by 18 | Viewed by 3708

Abstract

The only available treatment for celiac disease is life-long gluten exclusion. We conducted a cross-sectional age- and gender-matched study in 64 celiac adults on a long-term (>1 year) gluten-free diet and 74 non-celiac volunteers from Spain, using dietary, anthropometric, and biochemical parameters, as well as assessing bone mineral density and physical activity. Celiac adults had deficient intake (below 2/3 of the recommended intake) for folates, vitamin E, and iodine and low intake of calcium (below 80% of the recommended intake). Iron intake was also below 2/3 of the recommended intake in celiac women. Vitamin D intake was extremely low, and 34% of celiac patients had moderately deficient plasma levels. According to bone mineral density, celiac women may be more prone to osteopenia and osteoporosis. However, we found a perfectly analogous nutritional status scenario in celiac as compared to healthy volunteers, with the dietary deviations found being similar to those of the Spanish population, i.e., both groups followed a high-lipid, high-protein, and low-carbohydrate diet. Values for biochemical parameters were found within the reference ranges. Celiac disease had no influence on body weight, but body fat in celiac patients tended to be higher. According to our results, vitamin D, calcium, folates, vitamin E, iodine, and iron nutritional status should be specifically assessed and monitored in the celiac population. Full article

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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10 pages, 291 KiB

Open AccessArticle

by Ana Luísa Falcomer, Priscila Farage, Cláudia B. Pratesi, Riccardo Pratesi, Lenora Gandolfi, Eduardo Yoshio Nakano, António Raposo and Renata Puppin Zandonadi

Nutrients 2021, 13(5), 1582; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13051582 - 09 May 2021

Cited by 10 | Viewed by 2791

Abstract

Since the end of 2019, the world has been facing an unpredicted COVID-19 pandemic with consequences for the economy, environment, society, and health. The COVID-19 pandemic has increased the risk of death, bringing unbearable psychological pressure upon people worldwide. For celiac patients, the pandemic may represent an additional burden concerning the inherent aspects of celiac disease (CD) that compromise these individuals’ quality of life (QoL). Therefore, the objective of this study was to evaluate Brazilian celiac patients’ QoL during the course of the COVID-19 pandemic caused by its outbreak and rapid spread and subsequent restrictive measures in addition to the dietary restrictions and other burdens caused by CD. This country-wide cross-sectional study was conducted using a self-administered instrument previously validated in Brazilian–Portuguese to investigate the QoL of individuals with CD. Data collected through the online self-administration of the Brazilian version of the celiac disease quality of life questionnaire (CDQ) comprised 674 CD individuals’ responses. Although pandemics have historically posed a challenge for Brazilian population, this period was not associated with a negative impact on Brazilian CD individuals’ QoL. During the pandemic, the QoL of Brazilian’s with CD was more affected by gastrointestinal aspects than emotions and social aspects and worries. Gender, age, marital status, having (or not) children, occupation, and a positive test for COVID-19 did not affect CD individuals’ QoL. However, the study revealed a larger burden and diminished QoL for individuals not following a gluten-free diet and those using antidepressants. Additional research is necessary to verify how the length of the pandemic will affect celiac individuals and then compare those outcomes compare to the COVID-19 period and after. Full article

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

10 pages, 1088 KiB

Open AccessFeature PaperArticle

Iodine Absorption in Celiac Children: A Longitudinal Pilot Study

by Maurizio Delvecchio, Francesca Bizzoco, Rosa Lapolla, Antonia Gentile, Cinzia Carrozza, Michele Barone, Simonetta Simonetti, Paola Giordano, Vanessa Nadia Dargenio, Fernanda Cristofori and Ruggiero Francavilla

Nutrients 2021, 13(3), 808; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13030808 - 01 Mar 2021

Cited by 6 | Viewed by 3197

Abstract

Background: non-autoimmune thyroid disorder is a common finding in celiac patients, more frequent than in the general population. An impairment of iodine absorption has been hypothesized, but it has never been investigated so far. We aimed to evaluate the iodine absorption in children and adolescents with newly diagnosed celiac disease. Methods: 36 consecutive celiac patients (age 7.4 years, range 2.4–14.5 years) before starting a gluten-free diet (GFD) were enrolled. We assayed the urinary iodine concentration (UIC) in a 24-h urine sample, at baseline (T0) after 3 (T1) and 12 months (T2) of GFD. Results: UIC at T0 was 64 μg/L (IQR 45–93.25 μg/L) with an iodine deficiency rate of 77.8%. UIC was not different according to histological damage, clinical presentation (typical vs atypical); we found no correlation with the thyroid function tests and auxological parameters. UIC was not statistically different at T1 (76 μg/L) and T2 (89 μg/L) vs T0. UIC at T2 was similar between patients with positive and negative anti-transglutaminase antibodies at T2. No patients presented overt hypothyroidism during the study. Conclusions: We found that iodine absorption in celiac children is impaired compared to the general population; it increases slightly, but not significantly, during the GFD. We should regularly reinforce the need for a proper iodine intake in celiac disease patients to reduce iodine deficiency risk. Full article

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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13 pages, 726 KiB

Open AccessArticle

Influence of Ultra-Processed Foods Consumption on Redox Status and Inflammatory Signaling in Young Celiac Patients

by Teresa Nestares, Rafael Martín-Masot, Marta Flor-Alemany, Antonela Bonavita, José Maldonado and Virginia A. Aparicio

Nutrients 2021, 13(1), 156; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13010156 - 06 Jan 2021

Cited by 17 | Viewed by 3318

Abstract

The current study was designed to assess the influence of consumption of ultra-processed (UPF) on oxidative/antioxidant balance and evoked inflammatory signaling in young patients with celiac disease (CD). The study included 85 children. The celiac group (n = 53) included children with CD with a long (>18 months, n = 17) or recent (<18 months, n = 36) adherence to a gluten-free diet (GFD). The control group (n = 32) included healthy children with a significantly lower consumption of UPF compared to the CD group, both expressed as kcal/day (p = 0.043) and as percentage of daily energy intake (p = 0.023). Among children with CD, the group with the lowest consumption of UPF (below the 50% of daily energy intake) had a greater Mediterranean diet (MD) adherence and higher moderate physical activity levels. In addition, CD children with the lowest consumption of UPF had healthier redox (lower soluble superoxide dismutase-1 and 15-F2t-isoprostanes) and inflammatory profiles (lower macrophage inflammatory protein-1α) compared to the group with the highest consumption of UPF (all, p < 0.05) regardless of the time on a GFD. These findings highlight the importance of a correct monitoring of the GFD. An unbalanced GFD with high consumption of UPF and an unhealthy pattern with less physical activity and worse adherence to MD results in a worse inflammatory profile, which could act as a parallel pathway that could have important consequences on the pathophysiology of the disease. Full article

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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Review

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31 pages, 1814 KiB

Open AccessReview

Iron Deficiency in Celiac Disease: Prevalence, Health Impact, and Clinical Management

by Miguel A. Montoro-Huguet, Santos Santolaria-Piedrafita, Pablo Cañamares-Orbis and José Antonio García-Erce

Nutrients 2021, 13(10), 3437; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13103437 - 28 Sep 2021

Cited by 19 | Viewed by 9762

Abstract

Iron is an essential nutrient to life and is required for erythropoiesis, oxidative, metabolism, and enzymatic activities. It is a cofactor for mitochondrial respiratory chain enzymes, the citric acid cycle, and DNA synthesis, and it promotes the growth of immune system cells. Thus, iron deficiency (ID) leads to deleterious effects on the overall health of individuals, causing significant morbidity. Iron deficiency anemia (IDA) is the most recognized type of anemia in patients with celiac disease (CD) and may be present in over half of patients at the time of diagnosis. Folate and vitamin B12 malabsorption, nutritional deficiencies, inflammation, blood loss, development of refractory CD, and concomitant Heliobacter pylori infection are other causes of anemia in such patients. The decision to replenish iron stores and the route of administration (oral or intravenous) are controversial due, in part, to questions surrounding the optimal formulation and route of administration. This paper provides an algorithm based on the severity of symptoms; its impact on the health-related quality of life (HRQL); the tolerance and efficiency of oral iron; and other factors that predict a poor response to oral iron, such as the severity of histological damage, poor adherence to GFD, and blood loss due to mucosal lesions. Full article

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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17 pages, 376 KiB

Open AccessReview

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

by Aner Cardo, Itziar Churruca, Arrate Lasa, Virginia Navarro, Maialen Vázquez-Polo, Gesala Perez-Junkera and Idoia Larretxi

Nutrients 2021, 13(8), 2877; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13082877 - 21 Aug 2021

Cited by 47 | Viewed by 11072

Abstract

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

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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13 pages, 5323 KiB

Open AccessReview

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

by Christina Starchl, Mario Scherkl and Karin Amrein

Nutrients 2021, 13(6), 1755; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13061755 - 21 May 2021

Cited by 15 | Viewed by 8106

Abstract

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

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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11 pages, 258 KiB

Open AccessReview

Iron Deficiency Anemia in Celiac Disease

by Valentina Talarico, Laura Giancotti, Giuseppe Antonio Mazza, Roberto Miniero and Marco Bertini

Nutrients 2021, 13(5), 1695; https://0-doi-org.brum.beds.ac.uk/10.3390/nu13051695 - 17 May 2021

Cited by 29 | Viewed by 9229

Abstract

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

(This article belongs to the Special Issue Nutritional Deficiency in Celiac Disease: Current Perspective)

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