Celiac disease and non-celiac gluten sensitivity

Celiac Disease in Children with Functional Constipation: A School-Based Multicity Study

OBJECTIVE

To determine whether children in the community with functional constipation have increased prevalence of celiac disease.

STUDY DESIGN

Between April 4, 2015, and April 25, 2017, we enrolled 1809 children from 5 schools in Colombia and screened them for functional gastrointestinal disorders (FGIDs), including functional constipation, using questionnaires recommended in the Rome III/IV criteria. We matched children with functional constipation with healthy controls without a FGID and tested them for celiac disease with tissue transglutaminase (tTG)-Immunoglobulin A (IgA) and total IgA screening. In those who tested positive for tTG-IgA, we performed HLA genotyping and endoscopy to obtain 4 duodenal biopsy specimens for classification of celiac disease using the Marsh criteria. Analysis of statistical significance between groups of children with and without functional constipation was done using a 2-tailed Fisher exact test.

RESULTS

Patients diagnosed with functional constipation (n = 203) were matched with 419 healthy controls without FGIDs. The overall prevalence of celiac disease in the entire cohort was 0.6%. Of those with functional constipation, 1 (0.5%) was diagnosed with celiac disease, and 3 (0.7%) of the control patients without FGIDs had celiac disease (P = .743).

CONCLUSIONS

The prevalence of celiac disease in our cohort was similar to worldwide estimates. The prevalence of celiac disease in schoolchildren with functional constipation in Colombia is similar to those without FGIDs. Thus, routine testing of schoolchildren with functional constipation for celiac disease is not indicated.

Long-term Consequences of Undiagnosed Celiac Seropositivity

INTRODUCTION

Diagnosed celiac disease (CD) is associated with lymphoproliferative malignancy and gastrointestinal cancer, but little is known about the long-term consequences of undiagnosed CD. We aimed to investigate long-term consequences of undiagnosed CD for mortality and incidence of cancer and other chronic diseases.

METHODS

We screened biobank serum samples for immunoglobulin (Ig) A and IgG tissue transglutaminase (TTG) and IgG deamidated gliadin peptide in a study of 8 population-based cohort studies comprising 16,776 participants examined during 1976-2012 and followed with >99% complete follow-up in Danish nationwide registries until December 31, 2017, regarding vital status and incidence of diseases. Undiagnosed CD was defined as antibody positivity (IgA-TTG or IgG-TTG ≥ 7 U/mL and/or IgG deamidated gliadin peptide ≥ 10 U/mL) in individuals without a diagnosis of CD recorded in the National Patient Register. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated by Cox regression analyses with age as the underlying time scale.

RESULTS

The prevalence of undiagnosed CD was 1.0% with no statistically significant increase over time. Undiagnosed CD was associated with increased risk of cancer overall (HR, 1.57; 95% CI, 1.16-2.11), gastrointestinal cancer (HR, 2.33; 95% CI, 1.35-4.04), cancer of the uterus (HR, 3.95; 95% CI, 1.46-10.69), breast cancer (HR, 1.98; 95% CI, 1.02-3.82), head and neck cancer (HR, 3.12; 95% CI, 1.15-8.43), and cardiovascular disease (HR, 1.37; 95% CI, 1.01-1.85). We found no statistically significant association between undiagnosed CD and mortality (HR, 1.19; 95% CI, 0.87-1.61).

DISCUSSION

Undiagnosed CD was associated with increased risk of cardiovascular disease and cancer suggesting that untreated CD has serious long-term health consequences not only affecting the gastrointestinal tract (see Visual Abstract, Supplementary Digital Content, http://links.lww.com/AJG/B566).

Gluten consumption may contribute to worldwide obesity prevalence

Gluten consumption has been controversially associated with obesity in previous studies. We sought to examine this association at the worldwide level.

Country specific data were obtained from 168 countries. Scatter plots, bivariate, partial correlation and multiple linear regression models were used to explore and compare the coincidence between obesity prevalence and consumption of gluten, non-gluten cereal protein and total cereal protein respectively. The established risk factors of obesity: caloric intake, sedentary lifestyle, urbanization, socioeconomic status, meat protein intake and sugar consumption were included in analyses as potential confounders. The 168 countries were also stratified into developing and developed country groupings for further examination of the relationships.

Worldwide, bivariate correlation analyses revealed that the strength and direction of correlations between all variables (independent, dependent and potential confounders) were at similar levels. Obesity prevalence was positively correlated to gluten consumption but was negatively correlated to consumption of non-gluten cereal protein, and was in almost nil correlation to total cereal protein consumption. These relationships were similar across all countries (n= 168), developed country grouping (N=44) and developing country grouping (n=124). When caloric intake, Gross Domestic Product at Purchasing Power Parity, sedentary lifestyle and urbanization were kept statistically constant in the partial correlation analysis, obesity was significantly correlated to gluten consumption in all countries, developed country grouping and developing country grouping, and was significantly but inversely and weakly correlated to non-gluten cereal protein in all countries and developing countries, and was in almost nil correlation to total cereal protein in all country groupings. Globally, stepwise multiple regression analysis, when all the independent variables and potential confounding factors were included, selected consumption of sugar as the variable having the greatest influence on obesity with R2 = 0.510, while gluten was placed second increasing R2 to 0.596. Gluten consumption may have been emerging as an inconspicuous, but significant cause of obesity. While Westernization has driven the diet patterns worldwide to incorporate more gluten crops, obesity prevalence projection methods may estimate future obesity rates poorly if gluten consumption is not considered.

Mathematical Modeling of Autoimmune Diseases

The human organism is a very complex system. To be in good health, its components must function properly. One of the most important systems of an organism is the immune system. It protects the body from the harmful effects of various external and internal agents. Sometimes, however, the immune system starts attacking its own healthy cells, tissues and organs. Then autoimmune diseases arise. They are widespread in recent decades. There is evidence that often autoimmune responses occur due to viral infections. In this paper, a new mathematical model of a general autoimmune disease is proposed. It describes the interactions between viral particles and host cells. The model is formulated by using integro-differential equations of Boltzmann type. This approach is typical for the nonequilibrium statistical mechanics. A preliminary qualitative and quantitative analysis of the model is presented.

Gluten Degrading Enzymes for Treatment of Celiac Disease

Celiac disease (CeD) affects about 1% of most world populations. It presents a wide spectrum of clinical manifestations, ranging from minor symptoms to mild or severe malabsorption, and it may be associated with a wide variety of autoimmune diseases. CeD is triggered and maintained by the ingestion of gluten proteins from wheat and related grains. Gluten peptides that resist gastrointestinal digestion are antigenically presented to gluten specific T cells in the intestinal mucosa via HLA-DQ2 or HLA-DQ8, the necessary genetic predisposition for CeD. To date, there is no effective or approved treatment for CeD other than a strict adherence to a gluten-free diet, which is difficult to maintain in professional or social environments. Moreover, many patients with CeD have active disease despite diet adherence due to a high sensitivity to traces of gluten. Therefore, safe pharmacological treatments that complement the gluten-free diet are urgently needed. Oral enzyme therapy, employing gluten-degrading enzymes, is a promising therapeutic approach. A prerequisite is that such enzymes are active under gastro-duodenal conditions, quickly neutralize the T cell activating gluten peptides and are safe for human consumption. Several enzymes including prolyl endopeptidases, cysteine proteases and subtilisins can cleave the human digestion-resistant gluten peptides in vitro and in vivo. Examples are several prolyl endopeptidases from bacterial sources, subtilisins from Rothia bacteria that are natural oral colonizers and synthetic enzymes with optimized gluten-degrading activities. Without exception, these enzymes must cleave the otherwise unusual glutamine and proline-rich domains characteristic of antigenic gluten peptides. Moreover, they should be stable and active in both the acidic environment of the stomach and under near neutral pH in the duodenum. This review focuses on those enzymes that have been characterized and evaluated for the treatment of CeD, discussing their origin and activities, their clinical evaluation and challenges for therapeutic application. Novel developments include strategies like enteric coating and genetic modification to increase enzyme stability in the digestive tract.

Persistent organic pollutant exposure and celiac disease: A pilot study

Celiac disease affects approximately 1% of the population worldwide. Little is known about environmental factors that may modulate risk in genetically susceptible populations. Persistent organic pollutants (POPs) are known endocrine disruptors and, given the interplay between the endocrine and immune systems, are plausible contributors to celiac disease. The current study aims to elucidate the association between POPs and celiac disease. We conducted a single-site pilot study of 88 patients recruited from NYU Langone's Hassenfeld Children's Hospital outpatient clinic, 30 of which were subsequently diagnosed with celiac disease using standard serology and duodenal biopsy examination. Polybrominated diphenyl ether (PBDEs), perfluoroalkyl substances (PFASs), and p,p'-dichlorodiphenyldichloroethylene (DDE) and HLA-DQ genotype category were measured in blood serum and whole blood, respectively. Multivariable logistic regressions were used to obtain odds ratios for celiac disease associated with serum POP concentrations. Controlling for sex, race, age, BMI, and genetic susceptibility score, patients with higher serum DDE concentrations had 2-fold higher odds of celiac disease (95% CI: 1.08, 3.84). After stratifying by sex, we found higher odds of celiac disease in females with serum concentrations of DDE (OR = 13.0, 95% CI = 1.54, 110), PFOS (OR = 12.8, 95% CI = 1.17, 141), perfluorooctanoic acid (OR = 20.6, 95% CI = 1.13, 375) and in males with serum BDE153, a PBDE congener (OR = 2.28, 95% CI = 1.01, 5.18). This is the first study to report on celiac disease with POP exposure in children. These findings raise further questions of how environmental chemicals may affect autoimmunity in genetically susceptible individuals.

Irritable Bowel Syndrome and Gluten-Related Disorders

Background: Irritable bowel syndrome (IBS) is frequently associated with celiac disease (CD) and nonceliac gluten/wheat sensitivity (NCGS/NCWS), but epidemiological and pathophysiological aspects are still unclear. Furthermore, a gluten-free diet (GFD) can positively influence IBS symptoms. Methods: A comprehensive online search for IBS related to CD, NCGS and GFD was made using the Pubmed, Medline and Cochrane databases. Results: Although a systematic screening for CD in IBS is not recommended, CD prevalence can be increased in diarrhea-predominant IBS patients. On the other hand, IBS symptoms can be persistent in treated CD patients, and their prevalence tends to decrease on a GFD. IBS symptoms may overlap and be similar to those associated to nonceliac gluten and/or wheat sensitivity. Increased gut permeability could explain the gluten/wheat effects in IBS patients. Finally, a GFD could improve symptoms in a subgroup of IBS patients. Conclusions: The possible interplay between IBS and gluten-related disorders represents a scientifically and clinically challenging issue. Further studies are needed to confirm these data and better clarify the involved pathophysiological mechanisms.

Patterns of Marijuana Use Among Patients With Celiac Disease in the United States: A Population-based Analysis of the NHANES Survey

BACKGROUND

Marijuana use has been assessed in patients with chronic gastrointestinal disorders and may contribute to either symptoms or palliation. Use in those with celiac disease (CD) has not been assessed. Our aim was to evaluate patterns of marijuana use in a large population-based survey among patients with CD, people who avoid gluten (PWAG), and controls.

STUDY

We analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2014. χ tests and multivariable logistic regression were used to compare participants with CD and PWAG to controls regarding the use of marijuana.

RESULTS

Among respondents who reported ever using marijuana (overall 59.1%), routine (at-least monthly) marijuana use was reported by 46% of controls versus 6% of participants with diagnosed CD (P=0.005) and 66% undiagnosed CD as identified on serology (P=0.098) and 51% of PWAG (P=0.536). Subjects with diagnosed CD had lower odds of routine marijuana use compared with controls (odds ratio, 0.08; 95% confidence interval, 0.01-0.73), whereas participants with undiagnosed CD had increased odds of routine use (odds ratio, 2.26; 95% confidence interval, 0.83-6.13), which remained elevated even after adjusting for age, sex, race/ethnicity, health insurance status, alcohol, tobacco use, educational level, and poverty/income ratio.

CONCLUSIONS

In all groups, marijuana use was high. Although there were no differences among subjects with CD, PWAG, and controls who ever used marijuana, subjects with diagnosed CD appear to have decreased routine use of marijuana when compared with controls and PWAG. Those with undiagnosed CD have significantly higher rates of regular use. Future research should focus on the utilization of marijuana as it may contribute to further understanding of symptoms and treatments.

Concepts and Instruments for Patient-Reported Outcome Assessment in Celiac Disease: Literature Review and Experts' Perspectives

BACKGROUND

In diseases where there is a large subjective component, such as celiac disease (CD), patient reported-outcomes (PRO) endpoints are highly relevant. However, there is a gap in knowledge about which PRO endpoints and instruments should be used for clinical trials for treatment of celiac disease.

OBJECTIVES

To identify patient-centered symptom, impact, and health-related quality of life (HRQoL) concepts in CD and relevant PRO instruments, and to gather expert input on concepts and instruments to inform selection of PRO endpoints for use in clinical trials of new CD treatments.

METHODS

A targeted literature review was conducted to identify symptom, impact, and HRQoL concepts, including those captured in PROs further reviewed against U.S. Food and Drug Administration standards for development and validation as endpoints. US and European clinicians, payers, and a patient advocate (n = 21) were interviewed to assess the identified concepts' relative importance in measuring treatment benefit and to gauge the value of potential PROs as endpoints for market access/reimbursement.

RESULTS

Thirty-four published studies were identified: 27 elucidated patient-centered concepts and 7 detailed the development or validation of PRO instruments. The Celiac Disease Symptom Diary and Celiac Disease Patient Reported Outcome instrument were deemed most appropriate for use as endpoints; however, each had limitations related to conceptual coverage, evidence for measurement properties, and feasibility for use in clinical trials. Experts reported gastrointestinal symptoms as most important to treat, with extra-intestinal symptoms burdensome from the patient perspective as well. Payers emphasized measuring both frequency and severity of symptoms and targeting patients nonresponsive to the gluten-free diet for treatment.

CONCLUSIONS

With emerging treatment options for CD, further work is needed to operationalize PRO symptom endpoints that are meaningful to patients, valued by payers, and acceptable to regulators in demonstrating efficacy.

A Comparative Study of Modern and Heirloom Wheat on Indicators of Gastrointestinal Health

Wheat consumption has declined amid growing concerns about gluten-sensitivity. To determine if genetic manipulation of wheat contributes to systemic and localized gut inflammation, we compared the effects of the modern variety Gallagher and a blend of two heirloom varieties, Turkey and Kharkof, on measures of gut inflammation, structural characteristics, and barrier integrity under normal and Western diet (WD) conditions in C57BL/6 mice. Indicators of gut inflammation, including lymphocyte infiltration and cytokine expression, were largely unaffected by WD or wheat, although WD elevated interferon-γ (Ifng) and heirloom varieties modestly reduced interleukin-17 (Il17) in the context of WD. WD negatively affected jejunal villi structure, while the modern variety improved villi structure in the ileum. Relative mRNA and tight junction proteins and serum lipopolysaccharide binding protein were unaltered by WD or wheat. These findings indicate that the modern variety did not compromise barrier function or contribute to gut inflammation compared to its heirloom predecessor.

Gluten Detection Methods and Their Critical Role in Assuring Safe Diets for Celiac Patients

Celiac disease, wheat sensitivity, and allergy represent three different reactions, which may occur in genetically predisposed individuals on the ingestion of wheat and derived products with various manifestations. Improvements in the disease diagnostics and understanding of disease etiology unveiled that these disorders are widespread around the globe affecting about 7% of the population. The only known treatment so far is a life-long gluten-free diet, which is almost impossible to follow because of the contamination of allegedly "gluten-free" products. Accidental contamination of inherently gluten-free products could take place at any level from field to shelf because of the ubiquity of these proteins/grains. Gluten contamination of allegedly "gluten-free" products is a constant threat to celiac patients and a major health concern. Several detection procedures have been proposed to determine the level of contamination in products for celiac patients. The present article aims to review the advantages and disadvantages of different gluten detection methods, with emphasis on the recent technology that allows identification of the immunogenic-gluten peptides without the use of antibodies. The possibility to detect gluten contamination by different approaches with similar or better detection efficiency in different raw and processed foods will guarantee the safety of the foods for celiac patients.

ADOLESCENT GLUTEN INTAKE: POPULATION-BASED STUDY IN A BRAZILIAN CITY

Objective:

To estimate the prevalence of gluten intake according to demographic, socioeconomic, and health-related behavioral variables in adolescents.

Methods:

This is a population-based cross-sectional study with a two-stage cluster sampling, conducted in Campinas, São Paulo, in 2008-2009. Foods containing gluten were identified using a 24-hour Recall. We calculated the prevalence and adjusted prevalence ratios with multiple Poisson regression.

Results:

The study had a sample of 924 adolescents aged 10 to 19 years. Among the foods assessed, 26.9% (confidence interval of 95% - 95%CI 25.3-28.6) contained gluten. We found a higher prevalence of gluten intake in younger individuals (10 to 14 years), as well as in subgroups of adolescents who had a higher number of household appliances, attended school, consumed fewer beans and vegetables during the week (<4 times), and whose head of the family had better education level (≥12 years of schooling). The main food sources of gluten in their diet were: bread, cakes, and cereals (30.2%), chocolate milk (14%), chicken nuggets (12.3%), and cookies (11%).

Conclusions:

The results of the study show the epidemiological profile associated with gluten intake in adolescents and could support actions aimed at promoting healthy eating habits and preventing gluten-related diseases.

High-Protein Nutritious Flatbreads and an Option for Gluten-Sensitive Individuals

Whole grain quinoa and wheat, high-protein vegetable flatbreads were evaluated by tasters and a physical analysis was conducted. The objective was to produce nutritious, tasty gluten-free (quinoa) as well as gluten-containing (wheat) flatbreads. Flatbreads were Quinoa Peanut Oilcake Broccoli (QPCBROC), Wheat Peanut Oilcake Broccoli (WPCBROC), Quinoa Peanut Oilcake Beets (QPCBEET) and Wheat Peanut Oilcake Beets (WPCBEET). Peanut Oilcake would increase protein and add value to this farm byproduct. Bile acid binding broccoli and beets with cholesterol-lowering potential were used. Tasters preferred QPCBROC flatbreads for all sensory parameters. Acceptance of flatbreads was QPCBROC (83%), WPCBROC (70%), QPCBEET (78%) and WPCBEET (69%); these values were statistically similar. The objective of ≥25% protein content was exceeded by 5–8% and that of ≥70% acceptance was adequately achieved. These flatbreads were low in fat (5–6%) and contained essential minerals (4%) with only ≤1% added salt. Porosity and expansion data suggest that these flatbreads would take up relatively little shelf space. These flatbreads require only three ingredients and can be made in a household kitchen or by commercial production. These flatbreads offer a nutritious, tasty choice for all, and quinoa flatbreads offer an option for gluten-sensitive individuals.

The Gluten-Free Diet: Use in Digestive Disease Management

PURPOSE OF REVIEW

Gluten is a commonly ingested polymeric protein found in wheat, barley, and rye that has gained recent notoriety because of its relationship to disease and health. Avoidance of gluten is appropriate in patients with a diagnosed gluten-related disorder and may have treatment implications in other diseases of the digestive tract. This review highlights current knowledge of gluten related disorders and the use of a gluten-free diet in gastrointestinal disease management.

RECENT FINDINGS

Gluten-free diets should be used in patients with a diagnosed gluten-related disorder including celiac disease, non-celiac gluten sensitivity, and wheat-sensitive eosinophilic esophagitis. Use of this diet in management of other digestive conditions including gastroesophageal reflux disease, irritable bowel syndrome, and inflammatory bowel disease is controversial and not currently supported by the literature. This review provides a framework for classifying gluten-related disorders in terms of pathogenesis, understanding the literature that supports dietary avoidance in modulation of gastrointestinal disease, and identifies limitations of dietary restriction in patients.

Mathematical Analysis of an Autoimmune Diseases Model: Kinetic Approach

A new mathematical model of a general autoimmune disease is presented. Basic information about autoimmune diseases is given and illustrated with examples. The model is developed by using ideas from the kinetic theory describing individuals expressing certain functions. The modeled problem is formulated by ordinary and partial equations involving a variable for a functional state. Numerical results are presented and discussed from a medical view point.

Celiac Disease Autoimmunity and Emotional and Behavioral Problems in Childhood

BACKGROUND AND OBJECTIVES

Celiac disease (CeD) is associated with psychopathology in children. It is unknown whether this association is present in children with celiac disease autoimmunity (CDA) identified by screening. We examined the associations between subclinical CDA and emotional and behavioral problems in children without previous CeD diagnosis.

METHODS

In a population-based cohort study of 3715 children (median age: 6 years), blood titers of tissue transglutaminase autoantibodies were analyzed. CDA was defined as a measurement of tissue transglutaminase autoantibodies ≥7 U/mL (n = 51). Children with previous CeD diagnosis or children on a gluten-free diet, were excluded. The Child Behavior Checklist (CBCL) was filled in by parents and was used to assess behavioral and emotional problems of children at a median age of 5.9 years. Multiple linear regression models were applied to evaluate the cross-sectional associations between CDA and CBCL scores. Sensitivity analyses were done in a subgroup of children who were seropositive carrying the HLA antigen risk alleles for CeD.

RESULTS

In basic models, CDA was not associated with emotional and behavioral problems on the CBCL scales. After adjustment for confounders, CDA was significantly associated with anxiety problems (β = .29; 95% confidence interval 0.02 to 0.55; P = .02). After exclusion of children who did not carry the HLA-DQ2 and/or HLA-DQ8 risk alleles (n = 4), CDA was additionally associated with oppositional defiant problems (β = .35; 95% confidence interval 0.02 to 0.69). Associations were not explained by gastrointestinal complaints.

CONCLUSIONS

Our results reveal that CDA, especially combined with the HLA-DQ2 and HLA-DQ8 risk alleles, is associated with anxiety problems and oppositional defiant problems. Further research should be used to establish whether behavioral problems are a reflection of subclinical CeD.

Toward New Paradigms in the Follow Up of Adult Patients With Celiac Disease on a Gluten-Free Diet

Gluten free diet is the only available treatment for celiac disease (CeD). Patients with CeD who do not adhere to a strict gluten-free diet (GFD) have been found to have complications involving nutritional deficiencies, increased risk of bone fractures, increased risk of mortality, and certain types of cancers. Complete removal of gluten from the diet in a patient with CeD often results in symptomatic, serologic, and histologic remission. However, strict compliance with the diet is challenging. Long-term follow-up care is needed to assure treatment compliance and positive health outcomes. Monitoring celiac specific serology, nutrient deficiencies, bone mineral density, and assessment of GFD compliance have been recommended in clinical practice. However, there is no consensus on which specific tests and how often they should be performed during the follow up. Here, we have performed a review of the literature on current strategies to follow up patients with CeD. There are new tools for monitoring adherence to the GFD which could change some paradigms in following up treated patients.

An association between crypt apoptotic bodies and mucosal flattening in celiac disease patients exposed to dietary gluten

BACKGROUND

Celiac disease (CD) is characterized histologically by inflammation and villous atrophy. Villous atrophy is thought to result from a disruption of epithelial cellular proliferation and death. Epithelial cells in intestinal mucosa normally proliferate in the crypts and migrate towards the lumen, eventually dying. Apoptotic bodies in crypts are usually abnormal and are associated with certain disease states. The presence of crypt apoptosis in celiac disease has not been thoroughly examined by routine histologic assessment of crypt apoptotic body count (ABC).

METHODS

We quantified the ABC in duodenal biopsies from celiac patients before and after initiation of a gluten-free diet (GFD). We examined twenty-three duodenal biopsies from adult patients with celiac disease at diagnosis and following GFD and determined the maximum ABC in 10 consecutive crypts. Fourteen biopsies from heartburn patients served as controls.

RESULTS

Mean duration between paired biopsies was 2.9 (0.5-8.5) years. Mean maximum ABC in active celiac disease was 5.44 per crypt and decreased to 2.60 with GFD (p = <.0001). The mean maximum ABC in controls was 1.79, lower than both active celiac disease and GFD (p = <.0001 and p = .019 respectively). Flat lesions with total villous atrophy (mean: 6.44) showed a higher ABC compared to non-flat lesions (mean: 4.87); p = .04.

CONCLUSIONS

Crypt ABC is markedly elevated in active celiac disease and decreases significantly with GFD, however it does not achieve normalcy. Total villous atrophy is associated with a higher ABC than all other lesions. Crypt apoptosis is likely a significant contributor to villous atrophy in celiac disease and can be appreciated by routine histologic examination.

Gluten Intake and Risk of Celiac Disease: Long-Term Follow-up of an At-Risk Birth Cohort

OBJECTIVES

To determine the association between the amount of gluten intake in childhood and later celiac disease (CD), for which data are currently scarce.

METHODS

The prospective Diabetes Autoimmunity Study in the Young cohort includes 1875 at-risk children with annual estimates of gluten intake (grams/d) from age 1 year. From 1993 through January 2017, 161 children, using repeated tissue transglutaminase (tTGA) screening, were identified with CD autoimmunity (CDA) and persistent tTGA positivity; of these children, 85 fulfilled CD criteria of biopsy-verified histopathology or persistently high tTGA levels. Cox regression, modeling gluten intake between ages 1 and 2 years (i.e., in 1-year-olds), and joint modeling of cumulative gluten intake throughout childhood were used to estimate hazard ratios adjusted for confounders (aHR).

RESULTS

Children in the highest third of gluten intake between the ages of 1 and 2 years had a 2-fold greater hazard of CDA (aHR 2.17; 95% confidence interval [CI], 1.22-3.88; P value = 0.01) and CD (aHR 1.96; 95% CI, 0.90-4.24; P value = 0.09) than those in the lowest third. The risk of developing CDA increased by 5% per daily gram increase in gluten intake (aHR 1.05; 95% CI, 1.00-1.09; P value = 0.04) in 1-year-olds. The association between gluten intake in 1-year-olds and later CDA or CD did not differ by the child's human leukocyte antigen genotype. The incidence of CD increased with increased cumulative gluten intake throughout childhood (e.g., aHR 1.15 per SD increase in cumulative gluten intake at age 6; 95% CI, 1.00-1.32; P value = 0.04).

DISCUSSION

Gluten intake in 1-year-olds is associated with the future onset of CDA and CD in children at risk for the disease.

Going Against the Grains: Gluten-Free Diets in Patients Without Celiac Disease-Worthwhile or Not?

While the gluten-free diet (GFD) is the only known effective therapy for celiac disease, in recent years it has become increasingly popular in the USA and worldwide, with many believing it to be more "healthful" and others claiming that it has beneficial effects for health conditions, many extraintestinal, other than celiac disease. This review examines the evidence for use of the GFD in patients without celiac disease who self-report intestinal and/or extraintestinal symptoms (non-celiac gluten sensitivity), as well as for enhancement of athletic performance and treatment of autism, rheumatoid arthritis, and psychiatric disorders. Overall, the evidence for use of GFDs in conditions other than celiac disease is poor. Though non-celiac gluten sensitivity may ultimately emerge as a biomarker-defined condition, a large proportion of patients with apparent non-celiac gluten sensitivity have, after careful investigation, an alternative diagnosis. In light of this, and coupled with the potential physical and psychological harms associated with the avoidance of gluten, initiating a GFD should not be encouraged for people who have these other conditions or are seeking physical/athletic enhancement.

The impact of diagnosis on health-related quality of life in people with coeliac disease: a UK population-based longitudinal perspective

Background

Before diagnosis, people with coeliac disease suffer reduced quality of life, which improves substantially after the disease has been diagnosed. Delayed diagnosis is common. The aim of this study was to assess changes over time in prevalence of coeliac disease symptoms/associated medical conditions, time to diagnosis, quality of life and its determinants before and after diagnosis in the United Kingdom.

Methods

A postal questionnaire was designed in 2015 and sent to 4000 individuals with diagnosed coeliac disease, requesting information on respondents’ socio-demographic and clinical characteristics, and their quality of life pre- and post-diagnosis using the EQ-5D instrument. Data were analysed and compared with results from a survey conducted in 2006 using descriptive analyses, univariate and multivariable regression methods.

Results

The survey response rate was 40%. Sixty-five percent of respondents reported at least 4 symptoms pre-diagnosis, a significant reduction by 13 percentage points (95% CI: -16.9, − 9.4; p-value: < 0.001) compared to 2006. Pre-diagnosis mean duration of symptoms was 12.8 years (SD: 15.3), a non-significant reduction of 0.6 years (95% CI: -2, 0.8; p-value: 0.426) compared to 2006. There was a significant improvement of 0.20 (95% CI: 0.18, 0.22; p-value: < 0.001) in quality of life from pre- (0.65) to post-diagnosis (0.85). Pre-diagnosis values were significantly higher by 0.09 (95% CI: 0.06, 0.12; p-value: < 0.001) than in 2006. Number of symptoms and low income were associated with decreased quality of life.

Conclusions

Undiagnosed coeliac disease is associated with a substantial decrement in quality of life. Time to diagnosis has not significantly shortened over the decade 2006–2015, but symptoms are less severe when diagnosis occurs. Harmonising clinical guidelines for intensified active case finding will help improve quality of life of people with coeliac disease.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-0980-6) contains supplementary material, which is available to authorized users.

Promotion of Testing for Celiac Disease and the Gluten-Free Diet Among Complementary and Alternative Medicine Practitioners

INTRODUCTION

We identified the frequency and assessed the validity of marketing claims made by American chiropractors, naturopaths, homeopaths, acupuncturists, and integrative medicine practitioners relating to the diagnosis and treatment of celiac disease and nonceliac gluten sensitivity (NCGS), both of which have increased in prevalence in recent years.

METHODS

We performed a cross-sectional study analyzing websites of practitioners from 10 cities in the United States and analyzed the websites for any mention of celiac or NCGS as well as specific claims of ability to diagnose, ability to treat, and treatment efficacy. We classified treatments promoted as true, false, or unproven, as assessed independently by 2 authors.

RESULTS

Of 500 clinics identified, 178 (35.6%) made a claim regarding celiac disease, NCGS, or a gluten-free diet. Naturopath clinic websites have the highest rates of advertising at least one of diagnosis, treatment, or efficacy for celiac disease (40%), followed by integrative medicine clinics (36%), homeopaths (20%), acupuncturists (14%), and chiropractors (12%). Integrative medicine clinics have the highest rates of advertising at least one of diagnosis, treatment, or efficacy for NCGS (45%), followed by naturopaths (37%), homeopaths (14%), chiropractors (14%), and acupuncturists (10%). A geographic analysis yielded no significant variation in marketing rates among clinics from different cities. Of 232 marketing claims made by these complementary and alternative medicine (CAM) clinic websites, 138 (59.5%) were either false or unproven.

DISCUSSION

A significant number of CAM clinics advertise diagnostic techniques or treatments for celiac disease or NCGS. Many claims are either false or unproven, thus warranting a need for increased regulation of CAM advertising to protect the public.

MPGN Type 3 Associated with Pemphigus Herpetiformis Mimicking PGNMID and Dermatitis Herpetiformis

A 45-year-old man suffering from dermal blistering disease with proteinuria and hematuria underwent renal biopsy. The renal biopsy specimen suggested proliferative glomerulonephritis with monoclonal IgG deposits under routine light, immunofluorescence and electron microscopy. The staining for IgG subclasses (IgG1 and IgG2) and κ/λ light chain indicated secondary immune complex type MPGN type 3. The patient had been diagnosed as having dermatitis herpetiformis (DH), a phenotype of gluten hypersensitivity prior to the appearance of the renal abnormality. Although common autoantibodies might be related to the pathogenesis of disorders in the skin and kidney, DH is mainly driven by IgA autoantibody, while MPGN is induced by IgG immune complexes. IgA was not observed in the glomeruli by immunofluorescence. Neither the examination for DH specific autoantibodies nor HLA-DQB1 genotype supported the diagnosis of DH. Reassessment of the skin biopsy record revealed that the blister was localized in the epidermis, suggesting pemphigus herpetiformis by IgG class anti-epidermal autoantibody, which also affected the renal disorder.

Identifying True Celiac Disease and Wheat Allergy in the Era of Fashion Driven Gluten-Free Diets

BACKGROUND

Diagnosing both celiac disease (CD) and wheat allergy (WA) might be challenging due to the increasingly popular gluten-free diets.

OBJECTIVES

This study investigates the value of anti-tissue transglutaminase IgA (tTGIgA) and wheat-specific IgE (WIgE), and identifies clinical and serological features associated with CD and WA.

METHOD

Serological markers of autoimmunity and allergy along with medical charts of patients assessed for tTGIgA and WIgE between 2010 and 2016 were evaluated.

RESULTS

During the last years, an increasing number of patients have been tested for tTGIgA, while the number of positive results decreased linearly. Among the 2,965 patients included, 128 patients showed at least once a positive tTGIgA. All patients with tTGIgA levels higher than the 12-fold upper normal limit had CD. The ratio of tTGIgA/total IgA did not perform better as a diagnostic test for CD compared to tTGIgA. tTGIgA and anti-nuclear antibodies were significantly associated. WA was only rarely investigated, particularly in adults. However, positive WIgE were found in nearly 50% of the cases. WIgE and tTGIgA values were negatively correlated.

CONCLUSIONS

tTGIgA were increasingly tested, while the rate of positive results decreased in recent years, possibly reflecting the impact of current alimentary trends on clinical practice. Associated autoimmune disease was frequently found in CD. High levels of tTGIgA accurately predicted CD diagnosis. WA was rarely investigated and deserves more attention, in particular in children with atopic background. WA does not seem to be associated with CD.

Low Rates of Screening for Celiac Disease Among Family Members

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic Literature Review of the Economic Burden of Celiac Disease

BACKGROUND

The prevalence of celiac disease (CD) has rapidly increased over recent decades, but costs related to CD remain poorly quantified.

OBJECTIVE

This systematic review assessed the economic burden of CD in North America and Europe.

METHODS

MEDLINE, EMBASE, EconLit, and the Cochrane Library databases were systematically searched to identify English-language literature from 2007 to 2018 that assessed costs, cost effectiveness, and health resource utilization for CD.

RESULTS

Forty-nine studies met the inclusion criteria, of which 28 (57.1%) addressed costs of testing and diagnosis; 33 (67.3%) were from Europe. The cost per positive CD diagnosis of testing patients already undergoing esophagogastroduodenoscopy for other indications ranged from 1300 Canadian dollars ($Can) in Canada (2016 value) to €44,712 in the Netherlands (2013 value). Adding the CD test was cost effective when it combined diagnostic modalities (e.g., serology and biopsy). Direct annual excess costs to a US payer per diagnosed CD patient totaled $US6000 (2013 value) more than for a person without CD, chiefly due to outpatient care. Hospitalizations, emergency visits, and medication use were more common with CD. After initiating a gluten-free diet (GFD), patients visited primary care providers less often, used more medications, and missed fewer days from school and work.

CONCLUSIONS

Most of the few available economic studies of CD assess testing and diagnosis costs, especially in Europe. Methods of testing generally are considered cost effective when they combine diagnostic modalities in symptomatic patients. Most costs to a payer of managing CD derive from outpatient care. Following GFD initiation, patients lose fewer days from work and school than pretreatment.

Dietary Gluten Intake and Risk of Microscopic Colitis Among US Women without Celiac Disease: A Prospective Cohort Study

OBJECTIVE

Microscopic colitis is a common cause of chronic watery diarrhea among the elderly. Although the prevalence of celiac disease appears to be higher in patients with microscopic colitis, the relationship between dietary gluten intake and risk of microscopic colitis among individuals without celiac disease has not been explored.

METHODS

We conducted a prospective study of 160,744 US women without celiac disease enrolled in the Nurses' Health Study (NHS) and the NHSII. Dietary gluten intake was estimated using validated food frequency questionnaires every 4 years. Microscopic colitis was confirmed through medical records review. We used Cox proportional hazard modeling to estimate the multivariable-adjusted hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

We documented 219 incident cases of microscopic colitis over more than 20 years of follow-up encompassing 3,716,718 person-years (crude incidence rate: 5.9/100,000 person-years) in NHS and NHSII. Dietary gluten intake was not associated with risk of microscopic colitis (Ptrend = 0.88). Compared to individuals in the lowest quintile of energy-adjusted gluten intake, the adjusted HR of microscopic colitis was 1.18 (95% CI: 0.77-1.78) for the middle quintile and 1.03 (95% CI: 0.67-1.58) for the highest quintile. Additional adjustment for primary dietary sources of gluten including refined and whole grains did not materially alter the effect estimates (All Ptrend ≥ 0.69). The null association did not differ according to lymphocytic or collagenous subtypes (Pheterogeneity = 0.72) and was not modified by age, smoking status, or body mass index (All Pinteraction ≥ 0.17).

CONCLUSIONS

Dietary gluten intake during adulthood was not associated with risk of microscopic colitis among women without celiac disease.

Involvement of gliadin, a component of wheat gluten, in increased intestinal permeability leading to non-steroidal anti-inflammatory drug-induced small-intestinal damage

Gliadin, a component of wheat gluten known to be an important factor in the etiology of celiac disease, is related to several other diseases through its enhancing effect on intestinal paracellular permeability. We investigated the significance of gliadin in non-steroidal anti-inflammatory drug (NSAID)-induced small-intestinal damage in mice. 7-week-old C57BL/6 male mice were divided into the following groups: standard diet group, in which mice were fed with wheat-containing standard rodent diet (CE-2); gluten-free diet group, in which mice were fed with gluten-free diet (AIN-76A); and gliadin-administered group, in which mice fed with gluten-free diet were administered with gliadin (~250 mg/kg BW). Each group was subdivided into negative, healthy control group and NSAID-treated group. To some mice fed with gluten-free diet and administered with gliadin, epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor was administered for clarification of the significance of EGFR in NSAID-induced small intestinal damage and intestinal permeability. In mice fed with a gluten-free diet, indomethacin or diclofenac induced very mild mucosal damage in the small intestine compared with that in mice fed with a wheat-containing standard diet. Gliadin exacerbated the NSAID-induced small-intestinal damage in mice fed with a gluten-free diet. With the administration of indomethacin, MPO activity, a marker of neutrophil infiltration into the mucosa and mRNA expression level of tumor necrosis factor α and interleukin-1β in the small intestine were higher in the gliadin-administered mice. Gliadin increased the intestinal paracellular permeability without indomethacin administration (4.3-fold) and further increased the permeability after indomethacin administration (2.1-fold). Gliadin induced phosphorylation of epidermal growth factor receptor (EGFR) in small-intestinal tissues, and erlotinib (an EGFR tyrosine kinase inhibitor) attenuated the indomethacin-induced intestinal damage and permeability exacerbated by gliadin, accompanied by inhibition of EGFR phosphorylation. These results suggest that gliadin plays an important role in the induction and exacerbation of NSAID-induced small-intestinal damage, and that increase in intestinal permeability via the EGFR signalling pathway is involved in its mechanism.

Evolving Therapy for Celiac Disease

Gluten is known to be the main triggering factor for celiac disease (CeD), an immune-mediated disorder. CeD is therefore managed using a strict and lifelong gluten-free diet (GFD), the only effective treatment available currently. However, the GFD is restrictive. Hence, efforts are being made to explore alternative therapies. Based on their mechanisms of action on various molecular targets involved in the pathogenesis of CeD, these therapies may be classified into one of the following five broad approaches. The first approach focuses on decreasing the immunogenic content of gluten, using strategies like genetically modified wheat, intra-intestinal gluten digestion using glutenases, microwave thermal treatment of hydrated wheat kernels, and gluten pretreatment with either bacterial/ fungal derived endopeptidases or microbial transglutaminase. The second approach involves sequestering gluten in the gut lumen before it is digested into immunogenic peptides and absorbed, using binder drugs like polymer p(HEMA-co-SS), single chain fragment variable (scFv), and anti- gluten antibody AGY. The third approach aims to prevent uptake of digested gluten through intestinal epithelial tight junctions, using a zonulin antagonist. The fourth approach involves tissue transglutaminase (tTG) inhibitors to prevent the enhancement of immunogenicity of digested gluten by the intestinal tTG enzyme. The fifth approach seeks to prevent downstream immune activation after uptake of gluten immunogenic peptides through the intestinal mucosal epithelial layer. Examples include HLA-DQ2 blockers that prevent presentation of gluten derived- antigens by dendritic cells to T cells, immune- tolerizing therapies like the vaccine Nexvax2 and TIMP-Glia, cathepsin inhibitors, immunosuppressants like corticosteroids, azathioprine etc., and anti-cytokine agents targeting TNF-α and interleukin-15. Apart from these approaches, research is being done to evaluate the effectiveness of probiotics/prebiotics, helminth therapy using Necator americanus, low FODMAP diet, and pancreatic enzyme supplementation in CeD symptom control; however, the mechanisms by which they play a beneficial role in CeD are yet to be clearly established. Overall, although many therapies being explored are still in the pre-clinical phase, some like the zonulin antagonist, immune tolerizing therapies and glutenases have reached phase II/III clinical trials. While these potential options appear exciting, currently they may at best be used to supplement rather than supplant the GFD.

Extra-Intestinal Manifestations of Coeliac Disease in Children: Clinical Features and Mechanisms

Celiac disease (CD) is a systemic autoimmune disease due to a dysregulated mucosal immune response to gluten and related prolamines in genetically predisposed individuals. It is a common disorder affecting ~1% of the general population, its incidence is steadily increasing. Changes in the clinical presentation have become evident since the 80s with the recognition of extra-intestinal symptoms like short stature, iron deficiency anemia, altered bone metabolism, elevation of liver enzymes, neurological problems. Recent studies have shown that the overall prevalence of extra-intestinal manifestations is similar between pediatric and adult population; however, the prevalence of specific manifestations and rate of improvement differ in the two age groups. For instance, clinical response in children occurs much faster than in adults. Moreover, an early diagnosis is decisive for a better prognosis. The pathogenesis of extra-intestinal manifestations has not been fully elucidated yet. Two main mechanisms have been advanced: the first related to the malabsorption consequent to mucosal damage, the latter associated with a sustained autoimmune response. Importantly, since extra-intestinal manifestations dominate the clinical presentation of over half of patients, a careful case-finding strategy, together with a more liberal use of serological tools, is crucial to improve the detection rate of CD.

Mechanisms by which gut microorganisms influence food sensitivities

Finely tuned mechanisms enable the gastrointestinal tract to break down dietary components into nutrients without mounting, in the majority of cases, a dysregulated immune or functional host response. However, adverse reactions to food have been steadily increasing, and evidence suggests that this process is environmental. Adverse food reactions can be divided according to their underlying pathophysiology into food intolerances, when, for instance, there is deficiency of a host enzyme required to digest the food component, and food sensitivities, when immune mechanisms are involved. In this Review, we discuss the clinical and experimental evidence for enteric infections and/or alterations in the gut microbiota in inciting food sensitivity. We focus on mechanisms by which microorganisms might provide direct pro-inflammatory signals to the host promoting breakdown of oral tolerance to food antigens or indirect pathways that involve the metabolism of protein antigens and other dietary components by gut microorganisms. Better understanding of these mechanisms will help in the development of preventive and therapeutic strategies for food sensitivities.

The Dietary Intervention of Transgenic Low-Gliadin Wheat Bread in Patients with Non-Celiac Gluten Sensitivity (NCGS) Showed No Differences with Gluten Free Diet (GFD) but Provides Better Gut Microbiota Profile

The study evaluated the symptoms, acceptance, and digestibility of bread made from transgenic low-gliadin wheat, in comparison with gluten free bread, in Non-coeliac gluten sensitivity (NCGS) patients, considering clinical/sensory parameters and gut microbiota composition. This study was performed in two phases of seven days each, comprising a basal phase with gluten free bread and an E82 phase with low-gliadin bread. Gastrointestinal clinical symptoms were evaluated using the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire, and stool samples were collected for gluten immunogenic peptides (GIP) determination and the extraction of gut microbial DNA. For the basal and E82 phases, seven and five patients, respectively, showed undetectable GIPs content. The bacterial 16S rRNA gene V1-V2 hypervariable regions were sequenced using the Illumina MiSeq platform and downstream analysis was done using a Quantitative Insights into Microbial Ecology (QIIME) pipeline. No significant differences in the GSRS questionnaires were observed between the two phases. However, we observed a significantly lower abundance of some gut genera Oscillospira, Dorea, Blautia, Bacteroides, Coprococcus, and Collinsella, and a significantly higher abundance of Roseburia and Faecalibacterium genera during the E82 phase compared with the basal phase. The consumption of low-gliadin bread E82 by NCGS subjects induced potentially positive changes in the gut microbiota composition, increasing the butyrate-producing bacteria and favoring a microbial profile that is suggested to have a key role in the maintenance or improvement of gut permeability.

The association of celiac disease and allergic disease in a general adult population

Background

The relationship between allergy and celiac disease (CD) is not clear.

Objective

The objective of this article is to investigate the association of CD and CD antibody positivity with hay fever, asthma and immunoglobulin (Ig)E sensitization in a general adult population.

Methods

A total of 2297 individuals were screened for CD antibodies and underwent allergy testing. CD antibody-positive participants were invited to undergo clinical evaluation including biopsies. Additionally, biobank blood samples from four population-based studies (6423, 973, 1718 and 1101 participants) with data on IgE sensitization to inhalant allergens were screened for CD antibodies. CD antibody-positive participants were screened for serum IgE against food allergens in three biobank studies. CD-antibody positivity was defined as IgA or IgG tissue transglutaminase ≥7 U/ml and/or IgG deamidated gliadin peptide ≥10 U/ml.

Results

The nine participants (0.4%) diagnosed with CD had significantly higher prevalence of IgE sensitization to wheat and dust mites. The prevalence of CD antibody positivity was 0.8% (18/2297), and these participants had a significantly higher prevalence of IgE sensitization to food allergens (Fx5), egg, dust mites and mugwort. In the biobank studies, the prevalence of CD antibody positivity was 0.8% to 1.2%. One study showed a positive association between CD antibody positivity and IgE sensitization for dog, horse and food allergens.

Conclusion

We found a possible association of CD and IgE sensitization to some food and inhalant allergens in the Health2006 study. In further studies, however, we could not consistently replicate these associations.

Use of a Gluten-Free Diet in Schizophrenia: A Systematic Review

We performed a systematic review of the literature to determine whether adherence to a gluten-free diet (GFD) leads to improved outcomes for patients with schizophrenia. We searched the AMED (Allied and Complementary Medicine; 1985-June 2016), MEDLINE (1946-June 2016), and Embase (1980-2016 week 24) databases using the terms "wheat" or "glutenin" or "gliadin" or "gluten" AND "schizophrenia." A total of 9 studies met the inclusion criteria for this review: 1 randomized controlled trial, 7 crossover studies, and 1 open-label pilot study. Six of the included studies demonstrated beneficial effects including improved functioning and decreased symptom severity after the course of a GFD, whereas 3 studies found no benefits. All of the included studies found that a GFD is well tolerated and can be adhered to by patients with schizophrenia. The findings of this systematic review should be interpreted with caution due to limitations inherent to nonrandomized trials, as well as the heterogeneity in the study design and the length of the GFD applied in each study. Publication bias is another potential limitation. Further research is required to examine the biomarkers of gluten sensitivity and inflammation to effectively target those patients with schizophrenia who will benefit most from this dietary intervention.

Anxiety after coeliac disease diagnosis predicts mucosal healing: a population-based study

BACKGROUND

Coeliac disease has been linked to anxiety and depression. However, their association with mucosal healing is unknown.

AIM

To examine the relationship between anxiety, depression and mucosal healing in coeliac disease.

METHODS

Between 1969 and 2008, we collected data on all small intestinal biopsies with villous atrophy from Sweden's 28 pathology departments. We restricted our cohort to individuals with data on follow-up biopsy (either persistent villous atrophy [n = 3317] or mucosal healing [n = 4331]). Through Cox regression, we estimated hazard ratios (HRs) for anxiety or depression.

RESULTS

During follow-up, 123 (2.8/1000 person-years) individuals with mucosal healing had developed anxiety, compared to 94 (2.1/1000 person-years) with persistent villous atrophy. Mucosal healing was hence associated with a higher risk of future anxiety (HR = 1.49; 95% CI = 1.12-1.96). Similarly, 167 (3.8/1000 person-years) individuals with mucosal healing developed depression, compared to 148 (3.3/1000 person-years) with persistent villous atrophy, corresponding to a HR of 1.25 (95% CI = 0.99-1.59). Mucosal healing was more common in individuals with prior diagnoses of anxiety or depression before follow-up biopsy. Anxiety diagnosed between diagnostic and follow-up biopsy for coeliac disease was associated with an almost nine-fold increased chance of mucosal healing (odds ratio = 8.94; 95%CI = 2.03-39.27).

CONCLUSION

Anxiety and depression are more common in coeliac disease patients with mucosal healing, both before and after follow-up biopsy, an association potentially mediated through more vigilant compliance with a gluten-free diet. This finding raises concern that achieving the goal of mucosal healing may come at a cost of an increased risk of mood disorders.

Gluten-Free Snacks Based on Brown Rice and Amaranth Flour with Incorporation of Cactus Pear Peel Powder: Physical, Nutritional, and Sensorial Properties

An agroindustrial by-product (cactus pear peel) and whole grains flour (brown rice and amaranth) were used to present a gluten-free snack proposal. The effect of 5% (F1), 7% (F2), and 10% (F3) substitution of brown-rice flour for yellow cactus pear peel powder (Opuntia ficus-indica) on the snack physical, sensorial, and nutritional properties was evaluated. In addition, 20% of amaranth flour (Amaranthus caudatus) was used for all formulations. As the percentage of substitution increased, the a⁎ value increased, while the L⁎ decreased. The control snacks presented higher hardness, while the snacks with 10% substitution presented a greater crispness. The sensorial properties (overall liking, colour, crispness, and oiliness) reported that the samples containing cactus pear peel powder were the most accepted. The fat content decreased as the substitution percentage increased. The F3 formulation presented the best physical and sensorial properties and when compared with other commercial snack brands, it presented low fat and an adequate protein and fibre content. Therefore, snacks based on brown rice, amaranth, and cactus pear by-product could be considered as a good option of gluten-free product, contributing to reducing the lack of gluten-free products on the markets.

In Situ Gluten-Chitosan Interlocked Self-Assembled Supramolecular Architecture Reduces T-Cell-Mediated Immune Response to Gluten in Celiac Disease

SCOPE

The prevalence of celiac disease has increased since the last half of the 20th century and is now about 1% in most western populations. At present, people who suffer from celiac disease have to follow a gluten-exclusion diet throughout their lives. Compliance to this restrictive diet is demanding and the development of alternative strategies has become urgent.

METHODS AND RESULTS

In this context, it is found that the biocompatible aminopolysaccharide chitosan imposes a different gluten reorganization after gluten redox reaction producing in situ mechanically interlocked supramolecular assemblies between gluten and chitosan. These new structures result in the decrease of gluten digestibility, tissue transglutaminase deamidation activity, and interferon-γ production in intestinal T cell lines generated from biopsy specimens of celiac disease patients.

CONCLUSION

Overall, the results demonstrate the potential of this research avenue to celiac disease is problematic, as the reorganization of gluten proteins to a novel supramolecular architecture shows a positive impact on known pathogenesis mechanisms of the disease. At present, the only therapy for celiac disease is adherence to a gluten-free diet. Here, it is shown that chitosan-imposed gluten reorganization to an interlocked self-assembled supramolecular architecture reduces gluten digestibility, R5-reactivity, tissue transglutaminase deamidation activity, and its capacity to stimulate a T-cell-mediated immune response in celiac disease.

Gluten intake and risk of type 2 diabetes in three large prospective cohort studies of US men and women

AIMS/HYPOTHESIS

We investigated the association between gluten intake and long-term type 2 diabetes risk among Americans.

METHODS

We followed women from the Nurses' Health Study (NHS, n = 71,602, 1984-2012) and NHS II (n = 88,604, 1991-2013) and men from the Health Professionals Follow-Up Study (HPFS, n = 41,908, 1986-2012). Gluten intake was estimated using a validated food frequency questionnaire every 2-4 years. Incident type 2 diabetes was defined as self-reported physician-diagnosed diabetes confirmed using a supplementary questionnaire.

RESULT

Gluten intake was strongly correlated with intakes of carbohydrate components, especially refined grains, starch and cereal fibre (Spearman correlation coefficients >0.6). During 4.24 million years of follow-up, 15,947 people were confirmed to have type 2 diabetes. After multivariate adjustment, pooled HRs and 95% CIs for type 2 diabetes, from low to high gluten quintiles, were (p_trend < 0.001): 1 (reference); 0.89 (0.85, 0.93); 0.84 (0.80, 0.88); 0.78 (0.74, 0.82) and 0.80 (0.76, 0.84). The association was slightly weakened after further adjusting for cereal fibre, with pooled HRs (95% CIs) of (p_trend < 0.001): 1 (reference); 0.91 (0.87, 0.96); 0.88 (0.83, 0.93); 0.83 (0.78, 0.88) and 0.87 (0.81, 0.93). Dose-response analysis supported a largely linear inverse relationship between gluten intake up to 12 g/day and type 2 diabetes. The association between gluten intake and type 2 diabetes was stronger when intake of added bran was also higher (p_interaction = 0.02).

CONCLUSIONS/INTERPRETATION

Gluten intake is inversely associated with type 2 diabetes risk among largely healthy US men and women. Limiting gluten in the diet is associated with lower intake of cereal fibre and possibly other beneficial nutrients that contribute to good health.

Regional and National Variations in Reasons for Gluten Avoidance

BACKGROUND

Although studies have assessed the prevalence of celiac disease (CD), less is known about the prevalence of gluten avoidance because of nonceliac gluten sensitivity (GS). The avoidance of foods other than gluten is also understudied in these 2 groups.

METHODS

Participants visiting a web site for information about a newly developed portable gluten detection device (Nima) were instructed to complete questions about food and gluten avoidance patterns. We assessed the relative proportion of CD and GS across world regions and United States (US) regions and determined the distribution of food avoidance patterns.

RESULTS

CD was reported in 6474 respondents and GS in 2597 respondents. Within the United States, the majority of avoiders of gluten reported having CD (69.8%), with the highest ratio of CD to GS in the Northeast (CD: 74.3%; GS: 25.7%) and the lowest in the West (CD: 67.1%; GS: 32.9%) (P<0.0001). Compared with the United States, all other countries had lower proportions of GS, with the lowest in Argentina (CD: 94.7%; GS: 5.3%; P<0.0001). Food avoidances other than gluten were reported by 25% of respondents, with avoidance in all categories more common in GS than CD (P<0.0001).

CONCLUSION

There is a significant difference in the relative rates of CD and GS within the United States and worldwide. Food avoidance other than gluten seems to be a more common component of GS than CD. Future research should focus on the causes of these international and US regional differences and the significance of other food avoidances.

Systematic review with meta-analysis: the prevalence of coeliac disease in patients with osteoporosis

BACKGROUND

Earlier studies have produced highly varying risk estimates for the prevalence of coeliac disease (CD) in osteoporosis.

AIMS

To investigate the prevalence of CD among individuals with osteoporosis.

METHODS

We conducted a systematic review of articles published in PubMed, Medline or EMBASE through May 2017 to identify studies looking at prevalence of CD in patients with osteoporosis. Search terms included "coeliac disease" combined with "fractures", "bone disease", "bone density", "densitometry", "osteoporos*", "osteomal*", "osteodys" or "dexa" or "dxa" or "skelet". Non-English papers with English-language abstracts were included. We used fixed-effects inverse variance-weighted models, and tested heterogeneity through subgroup analysis as well as through meta-regression.

RESULTS

We identified eight relevant studies, comprising data from 3188 individuals with osteoporosis. Of these, 59 individuals (1.9%) had CD. A weighted pooled analysis demonstrated biopsy-confirmed CD in 1.6% (95% CI = 1.1%-2.0%) of individuals with osteoporosis. The heterogeneity was moderate (I²  = 40.1%), and influenced by the underlying CD prevalence in the general population. After adding four studies (n = 814) with CD defined as positive tissue transglutaminase or endomysial antibodies, the pooled prevalence was comparable (1.6%; 95% CI = 1.2%-2.0%).

CONCLUSIONS

About 1 in 62 individuals with osteoporosis, or 1.6%, have biopsy-verified CD. This prevalence is comparable to that in the general population. These findings argue against routinely screening patients with osteoporosis for CD, which is contrary to current guideline recommendations. Additional studies are needed to determine the true utility of such screening programs.

Autoantibodies in the Extraintestinal Manifestations of Celiac Disease

Increased antibody reactivity towards self-antigens is often indicative of a disruption of homeostatic immune pathways in the body. In celiac disease, an autoimmune enteropathy triggered by the ingestion of gluten from wheat and related cereals in genetically predisposed individuals, autoantibody reactivity to transglutaminase 2 is reflective of the pathogenic role of the enzyme in driving the associated inflammatory immune response. Autoantibody reactivity to transglutaminase 2 closely corresponds with the gluten intake and clinical presentation in affected patients, serving as a highly useful biomarker in the diagnosis of celiac disease. In addition to gastrointestinal symptoms, celiac disease is associated with a number of extraintestinal manifestations, including those affecting skin, bones, and the nervous system. Investigations of these manifestations in celiac disease have identified a number of associated immune abnormalities, including B cell reactivity towards various autoantigens, such as transglutaminase 3, transglutaminase 6, synapsin I, gangliosides, and collagen. Clinical relevance, pathogenic potential, mechanism of development, and diagnostic and prognostic value of the various identified autoantibody reactivities continue to be subjects of investigation and will be reviewed here.

Outcome measures in coeliac disease trials: the Tampere recommendations

OBJECTIVE

A gluten-free diet is the only treatment option of coeliac disease, but recently an increasing number of trials have begun to explore alternative treatment strategies. We aimed to review the literature on coeliac disease therapeutic trials and issue recommendations for outcome measures.

DESIGN

Based on a literature review of 10 062 references, we (17 researchers and 2 patient representatives from 10 countries) reviewed the use and suitability of both clinical and non-clinical outcome measures. We then made expert-based recommendations for use of these outcomes in coeliac disease trials and identified areas where research is needed.

RESULTS

We comment on the use of histology, serology, clinical outcome assessment (including patient-reported outcomes), quality of life and immunological tools including gluten immunogenic peptides for trials in coeliac disease.

CONCLUSION

Careful evaluation and reporting of outcome measures will increase transparency and comparability of coeliac disease therapeutic trials, and will benefit patients, healthcare and the pharmaceutical industry.

Prevalence of Celiac Disease in Patients With Iron Deficiency Anemia-A Systematic Review With Meta-analysis

BACKGROUND & AIMS

Anemia is common in patients with celiac disease (CD) and a frequent mode of presentation. Guidelines recommend screening patients with iron-deficiency anemia (IDA) for CD. However, the reported prevalence of CD in patients with IDA varies. We performed a systematic review to determine the prevalence of biopsy-verified CD in patients with IDA.

METHODS

We performed a systematic review of articles published in PubMed Medline or EMBASE through July 2017 for the term "celiac disease" combined with "anemia" or "iron deficiency." We used fixed-effects inverse variance-weighted models to measure the pooled prevalence of CD. Meta-regression was used to assess subgroup heterogeneity.

RESULTS

We identified 18 studies composed of 2998 patients with IDA for inclusion in our analysis. Studies originated from the United Kingdom, United States, Italy, Turkey, Iran, and Israel. The crude unweighted prevalence of CD was 4.8% (n = 143). Using a weighted pooled analysis, we found a prevalence of biopsy-confirmed CD of 3.2% (95% confidence interval = 2.6-3.9) in patients with IDA. However, heterogeneity was high (I2 = 67.7%). The prevalence of CD was not significantly higher in studies with a mean participant age older or younger than 18 years or in studies with a mixed-sex vs female-predominant (≥60%) population. On meta-regression, year of publication, female proportion, age at CD testing, and prevalence in the general population were not associated with the prevalence of CD in patients with IDA. In the 8 studies fulfilling all our quality criteria, the pooled prevalence of CD was 5.5% (95% confidence interval = 4.1-6.9).

CONCLUSIONS

In a systematic review and meta-analysis, we found that approximately 1 in 31 patients with IDA have histologic evidence of CD. This prevalence value justifies the practice of testing patients with IDA for CD.