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

Review Article: Novel Enzyme Therapy Design for Gluten Peptide Digestion Through Exopeptidase Supplementation

BACKGROUND

Dietary peptides are increasingly linked to inflammatory gastrointestinal diseases, exemplified by coeliac disease. Coeliac disease is caused by an acquired immune response to proline- and glutamine-rich gluten peptides, which bottleneck proteolysis and provide substrates for immune recognition. Enzyme therapies aim to eliminate gluten immunogenic peptides as an adjunct to gluten-free diet.

AIMS

To investigate overlooked aspects of enzyme development given difficulties in translating preclinical efficacy into clinical benefit.

METHODS

We assessed mode-of-action, target organ and drug delivery in the context of digestive physiology and motility for gluten-digesting enzymes on the market or in development until 1 December 2024.

RESULTS

Most enzymes were gastric endopeptidases specific for proline or glutamine residues. Gastric enzymes may achieve poor enzyme-substrate exposure due to limited mixing and rapid emptying of water-soluble particles. Moreover, endopeptidases cleave proteins/peptides into shorter peptides but do not systematically cleave protein into absorbable fractions. Natural digestive physiology provides thorough mixing at the intestinal brush border, which produces exopeptidases necessary to fully digest proline-rich peptides. Despite reduced activity in patients with coeliac disease, exopeptidases remain underexplored as therapeutic agents. Given limited substrate scope and end-to-end digestion, exopeptidases are ineffective as single agents, requiring functional combinations. Furthermore, vulnerability to gastric acid requires stabilisation or formulation for rapid enteric release.

CONCLUSIONS

Enzymes should be stabilised throughout the gastrointestinal tract including the small intestine. Exopeptidases perform a critical function by systematically generating absorbable fractions, warranting future investigation as therapeutic agents. Sensitive and translational biomarkers are needed to better assess enzyme efficacy in real-meal conditions.

Long-term laboratory follow-up is essential in pediatric patients with celiac

OBJECTIVES

Celiac disease (CeD) requires long-term follow. The role of laboratory testing other than celiac serology during follow up is unclear. We aimed to determine which laboratory tests are required during follow up based on the prevalence of abnormal tests and timing of abnormalities appearance.

METHODS

Retrospective chart-review of children diagnosed with CeD between 1999 and 2018 was conducted. Demographic, clinical and laboratory data were recorded from diagnosis and during follow-up.

RESULTS

The cohort included 500 children with CeD [59.8% females, median(IQR) age at diagnosis 5.7(3.7-8.9) years]. Mean follow-up time was 5.5 years (range 1.5-16.2). The most frequently abnormal laboratory tests at time of diagnosis were low ferritin (64.3%), vitamin D (33.6%), zinc (29.9%), hemoglobin (29.2%), and folate (14.7%). In 74 (14.8%) patients, anemia developed only during follow up, while in another 46 patients, anemia resolved after diagnosis and reappeared later (after a mean ± SD 2.8 ± 2.1 years from CeD diagnosis, for the entire group). Abnormal values that developed during follow up were low folate in 40 patients (3.9 ± 2.6 years), and abnormal liver enzymes in 18 patients (3.1 ± 2.7 years). Elevated TSH during follow-up was observed in 14/280 (5%) patients, after a mean ± SD of 2.2 ± 1.6 years from diagnosis. Patients diagnosed as teenagers (12-18 years) had shorter intervals to reappearance of anemia and folate deficiency.

CONCLUSIONS

Multiple laboratory abnormalities may occur in pediatric patients with CeD, both at diagnosis and during long-term follow-up. We suggest continued monitoring of hemoglobin, ferritin, folate, liver, and thyroid function in addition to celiac serology during follow-up of CeD.

Short- and Long-Term Nutritional Status in Children and Adolescents with Celiac Disease Following a Gluten-Free Diet: A Systematic Review

BACKGROUND/OBJECTIVES

Numerous studies have highlighted the nutritional imbalances that are commonly observed in children and adolescents diagnosed with celiac disease (CD) who follow a gluten-free diet (GFD). However, the development and timeline of these nutritional deficiencies remain unclear. The aim of the present study is to investigate the short-term (≥6 months to <12 months) and long-term (≥12 months) association between adherence to a GFD and nutrient intake as well as micronutrient blood status in children and adolescents aged from 0 to 18 years with CD.

METHODS

A systematic review was conducted in PubMed and Scopus for observational studies published up to June 2024.

RESULTS

A total of 15 studies (case-control, cross-sectional, and prospective studies) with 2004 children and adolescents were included. Their quality was assessed using the ROBINS-E tool. Despite the lack of high-quality data and the heterogeneity of the methods used in the included studies, the results of the cross-sectional/case-control studies show that, in the short term, children and adolescents with CD consumed excessive amounts of protein and carbohydrates compared to controls. After long-term adherence to a GFD, significant changes in the diets of children and adolescents with CD persisted. Fat intake was higher, while protein intake remained excessive compared to controls. Based on prospective studies, vitamin C and iodine intake improved both in the short and long term after adherence to a GFD. However, most other nutrients either remain inadequate or continue to decline, indicating that it is difficult to meet nutrient requirements despite dietary adjustments.

CONCLUSIONS

Gaps in adherence to dietary recommendations appear to be widespread in children and adolescents with CD, emphasizing the need for improved diet quality and regular monitoring.

Coeliac disease: complications and comorbidities

Coeliac disease is an autoimmune disease characterized by small intestinal villus atrophy and inflammation upon exposure to gluten. It has a global prevalence of approximately 1%. Although the gluten-free diet can be an effective treatment, this diet is burdensome with practical difficulties and frequent inadvertent gluten exposure. Moreover, there are a variety of potential complications and comorbidities of coeliac disease that might be related to malabsorption and/or chronic immune activation. Overall, individuals with coeliac disease have increased mortality compared with the general population, underscoring the severity of this common disease. Comorbidities and complications that have been associated with coeliac disease include poor growth, reproductive complications, kidney and liver diseases, respiratory disease (such as pneumonia) and infections (including sepsis). Furthermore, coeliac disease has been linked to other autoimmune disease and psychiatric disease, as well as certain cancers. Data suggest that mucosal healing on a gluten-free diet might protect against some, but not all, of these complications. In this Review, we present absolute and relative risks of coeliac-associated disorders. We discuss underlying mechanisms, the role of the gluten-free diet and mucosal healing, as well as implications for follow-up and non-dietary treatment of coeliac disease.

Rational application of the ESPGHAN 2022 recommendations for the follow-up of the paediatric coeliac patient: consensus document of scientific societies (SEGHNP, AEPAP, SEPEAP, SEEC, AEG, SEPD, SEMFYC, SEMG and SEMERGEN)

Coeliac disease is a common condition for which the only current treatment is a gluten-free diet. Adherence to this diet is not always easy and is associated with a reduction in quality of life for the patient and their family. Non-adherence is associated with complications of varying severity. The lack of control at the outpatient care level in a high percentage of these patients evinces the need to improve follow-up protocols and the approach to care delivery with coordination of paediatric gastroenterology units (PGU) and primary care paediatricians. With this aim in mind, the present document was developed by consensus to offer a set of recommendations adapted to our region, based on the recent recommendations published by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), and with participation of the pertinent scientific societies, including those concerning the adult population, for the management and follow-up of adolescents and the transition to adult care.

Growth Stunting and Nutritional Deficiencies among Children and Adolescents with Celiac Disease in Kuwait: A Case-Control Study

BACKGROUND/OBJECTIVES

This study aimed to assess the nutritional status of children and adolescents with celiac disease (CD) in Kuwait and investigate the nutritional deficiencies and sociodemographic factors associated with growth stunting in this population.

METHODS

This case-control study included 77 CD patients aged 3-18 years diagnosed with CD using IgA anti-tissue transglutaminase and duodenal biopsy and 33 healthy controls. Nutritional status was evaluated based on demographic and clinical characteristics, anthropometric measurements, and biochemical parameters. Univariate and multivariate logistic regression models were used to determine the association between CD and growth stunting.

RESULTS

Approximately one-third (31%) of children with CD had stunted growth, 20.8% had a low body mass index for their age, and 5.2% had both growth stunting and wasting. Children with CD had higher odds of iron-deficiency anemia, vitamin D deficiency, anemia, and lower socioeconomic status. They were also younger and had decreased serum levels of vitamin D compared to the controls. These factors were all significantly associated with an increased risk of CD, collectively explaining over 50% of the risk. For growth stunting, lower education status among mothers, family income, and serum ferritin were identified as risk factors.

CONCLUSIONS

A significant proportion of children and adolescents with CD had malnutrition, overt deficiencies, and impaired growth despite coherence with a gluten-free diet.

RECOMMENDATION

Routine monitoring and targeted nutritional interventions are recommended for children and adolescents with CD to address malnutrition and growth stunting. Addressing socioeconomic disparities and enhancing maternal education may also help mitigate the risk factors.

Serum anti-mullerian hormone, sex hormone, and nutrient levels in reproductive age women with celiac disease

PURPOSE

This study aimed to investigate the changes in serum Anti-Müllerian Hormone (AMH) levels, sex hormone levels, follicle-stimulating hormone (FSH)/luteinizing hormone (LH) ratio in patients with celiac disease (CeD), and their correlation with clinical characteristics and nutrient levels.

METHODS

This cross-sectional study collected clinical and biochemical data from a total of 67 females diagnosed with CeD and 67 healthy females within the reproductive age range of 18-44 years. The study was conducted at a tertiary hospital between September 2016 and January 2024. Both groups underwent comprehensive clinical and laboratory assessments. Serum levels of AMH and sex hormones were quantified using chemiluminescence immunoassay, and their associations with CeD clinical features and nutrient levels were thoroughly analyzed.

RESULTS

The study included 67 patients and 67 controls with a mean age of 36.7±7.6 years. No statistically significant differences were found between the two groups in mean age, BMI, FSH, LH, E2, P levels, FSH/LH, menstrual irregularities, abortions history, parity, and gravidity (all P>0.05). However, AMH, T, FER, FA, Zn, and Se levels were significantly lower, and PRL levels were higher in the CeD group (all P<0.05). Spearman's correlation analysis showed that AMH levels were negatively correlated with age, tTG level, disease duration, and Marsh grading (P<0.05).

CONCLUSIONS

This study highlights the association between impaired ovarian function in CeD patients and disease severity and nutrient levels. Early detection and intervention for ovarian function abnormalities are imperative to enhance fertility potential in CeD patients.

Evaluation of Sourdough Bread and Its Potential Use in Support of the Treatment of Chronic Non-Communicable Diseases

Gastrointestinal disorders dysregulate the biochemical environment of the gastrointestinal tract by altering pH conditions during the gastric phase of digestion or by reducing the secretion of pancreatin during the intestinal part of the process. Ingested functional food could therefore lose some of its health-promoting potential apart from its nutritional value. In this work, we aimed to manufacture bread marked by decreased gluten content, using a commercial or laboratory sourdough, that could be appropriate for patients afflicted with wheat allergy, hypertension and pancreatic malfunctions. A reference sample (no sourdough) was prepared alongside wheat and wheat-rye bread samples-produced with either commercial or laboratory sourdough (L. plantarum BS, L. brevis 1269, L. sanfranciscensis 20663). We measured the QQQPP allergen content (ELISA) in bread extracts digested in vitro and determined how these extracted components affect the level of active angiotensin and alpha amylase (spectrophotometry). We then elucidated how these properties changed when physiological digestion conditions (pH and pancreatin activity) were disturbed to mimic gastric hyperacidity, hypochlorhydria or exocrine pancreatic insufficiency. The key finding was that every tested type of bread produced with laboratory sourdough exhibited pronounced angiotensin-converting enzyme inhibition. The effect was preserved even in dysregulated digestive conditions. The use of laboratory sourdough prevented an increase in allergenicity when pancreatin was restricted as opposed to the commercial sourdough, which surpassed the reference sample reading at 50% pancreatin. No statistically consistent link was reported when the inhibition of alpha amylase was assayed. In conclusion, functional bread manufactured with sourdough composed of L. plantarum BS, L. brevis 1269, and L. sanfranciscensis 20663 was shown to be potentially capable of contributing to the treatment against hypertension as evidenced by in vitro research. It was also moderately safer with regard to its allergenicity.

Iron deficiency and supplementation in heart failure

Non-anaemic iron deficiency (NAID) is a strategic target in cardiovascular medicine because of its association with a range of adverse effects in various conditions. Endeavours to tackle NAID in heart failure have yielded mixed results, exposing knowledge gaps in how best to define 'iron deficiency' and the handling of iron therapies by the body. To address these gaps, we harness the latest understanding of the mechanisms of iron homeostasis outside the erythron and integrate clinical and preclinical lines of evidence. The emerging picture is that current definitions of iron deficiency do not assimilate the multiple influences at play in patients with heart failure and, consequently, fail to identify those with a truly unmet need for iron. Additionally, current iron supplementation therapies benefit only certain patients with heart failure, reflecting differences in the nature of the unmet need for iron and the modifying effects of anaemia and inflammation on the handling of iron therapies by the body. Building on these insights, we identify untapped opportunities in the management of NAID, including the refinement of current approaches and the development of novel strategies. Lessons learned from NAID in cardiovascular disease could ultimately translate into benefits for patients with other chronic conditions such as chronic kidney disease, chronic obstructive pulmonary disease and cancer.

Vitamin D: An Essential Nutrient in the Dual Relationship between Autoimmune Thyroid Diseases and Celiac Disease-A Comprehensive Review

Autoimmune thyroid diseases (AITD) are among the most frequent autoimmune disorders, with a multifactorial etiology in which both genetic and environmental determinants are probably involved. Celiac disease (CeD) also represents a public concern, given its increasing prevalence due to the recent improvement of screening programs, leading to the detection of silent subtypes. The two conditions may be closely associated due to common risk factors, including genetic setting, changes in the composition and diversity of the gut microbiota, and deficiency of nutrients like vitamin D. This comprehensive review discussed the current evidence on the pivotal role of vitamin D in modulating both gut microbiota dysbiosis and immune system dysfunction, shedding light on the possible relevance of an adequate intake of this nutrient in the primary prevention of AITD and CeD. While future technology-based strategies for proper vitamin D supplementation could be attractive in the context of personalized medicine, several issues remain to be defined, including standardized assays for vitamin D determination, timely recommendations on vitamin D intake for immune system functioning, and longitudinal studies and randomized controlled trials to definitely establish a causal relationship between serum vitamin D levels and the onset of AITD and CeD.

Celiac disease - a pluripathological model in pediatric practice

Being defined as an autoimmune, chronic pathology, frequently encountered in any age group, but especially in pediatrics, celiac disease (also called gluten enteropathy), is gaining more and more ground in terms of diagnosis, but also interest in research. The data from the literature of the last decades attest the chameleonic way of its presentation, there may be both classic onset symptoms and atypical symptoms. Given the impact played by celiac disease, especially in the optimal growth and development of children, the current narrative review aims to highlight the atypical presentation methods, intended to guide the clinician towards the inclusion of the pathology in the differential diagnosis scheme. To these we add the summary presentation of the general data and therapeutic lines regarding the underlying condition and the existing comorbidities. In order to place the related information up to date, we performed a literature review of the recent articles published in international databases. We bring forward the current theories and approaches regarding both classic celiac disease and its atypical manifestations. Among these we note mainly constitutional, skin or mucous, bone, neuro-psychic, renal, reproductive injuries, but also disorders of biological constants and association with multiple autoimmunities. Knowing and correlating them with celiac disease is the key to optimal management of patients, thus reducing the subsequent burden of the disease.

The effect of expectancy versus actual gluten intake on gastrointestinal and extra-intestinal symptoms in non-coeliac gluten sensitivity: a randomised, double-blind, placebo-controlled, international, multicentre study

BACKGROUND

Many individuals without coeliac disease or wheat allergy reduce their gluten intake because they believe that gluten causes their gastrointestinal symptoms. Symptoms could be affected by negative expectancy. Therefore, we aimed to investigate the effects of expectancy versus actual gluten intake on symptoms in people with non-coeliac gluten sensitivity (NCGS).

METHODS

This randomised, double-blind, placebo-controlled, international, multicentre study was done at the University of Leeds (Leeds, UK), Maastricht University (Maastricht, the Netherlands), and Wageningen University and Research (Wageningen, the Netherlands). People aged 18-70 years with self-reported NCGS (ie, gastrointestinal symptoms within 8 h of gluten consumption) without coeliac disease and wheat allergy were recruited. Participants had to follow a gluten-free or gluten-restricted diet for at least 1 week before (and throughout) study participation and had to be asymptomatic or mildly symptomatic (overall gastrointestinal symptom score ≤30 mm on the Visual Analogue Scale [VAS]) while on the diet. Participants were randomly assigned (1:1:1:1; blocks of eight; stratified by site and gender) to one of four groups based on the expectation to consume gluten-containing (E+) or gluten-free (E-) oat bread for breakfast and lunch (two slices each) and actual intake of gluten-containing (G+) or gluten-free (G-) oat bread. Participants, investigators, and those assessing outcomes were masked to the actual gluten assignment, and participants were also masked to the expectancy part of the study. The primary outcome was overall gastrointestinal symptom score on the VAS, which was measured at and corrected for baseline (before breakfast) and hourly for 8 h, with lunch served after 4 h, and analysed per-protocol. Safety analysis included all participants incorporated in the per-protocol analysis. The study is registered at ClinicalTrials.gov, NCT05779358, and has ended.

FINDINGS

Between Oct 19, 2018, and Feb 14, 2022, 165 people were screened and 84 were randomly assigned to E+G+ (n=21), E+G- (n=21), E-G+ (n=20), or E-G- (n=22). One person in the E+G+ group was excluded due to not following test day instructions, leaving 83 participants in the per-protocol analysis. Median age was 27·0 years (IQR 21·0-45·0), 71 (86%) of 83 people were women, and 12 (14%) were men. Mean overall gastrointestinal symptom score was significantly higher for E+G+ (16·6 mm [95% CI 13·1 to 20·0]) than for E-G+ (6·9 mm [3·5 to 10·4]; difference 9·6 mm [95% CI 3·0 to 16·2], p=0·0010) and E-G- (7·4 mm [4·2 to 10·7]; difference 9·1 mm [2·7 to 15·6], p=0·0016), but not for E+G- (11·7 mm [8·3 to 15·1]; difference 4·9 mm [-1·7 to 11·5], p=0·28). There was no difference between E+G- and E-G+ (difference 4·7 mm [-1·8 to 11·3], p=0·33), E+G- and E-G- (difference 4·2 mm [-2·2 to 10·7], p=0·47), and E-G+ and E-G- (difference -0·5 mm [-7·0 to 5·9], p=1·0). Adverse events were reported by two participants in the E+G- group (itching jaw [n=1]; feeling lightheaded and stomach rumbling [n=1]) and one participant in the E-G+ group (vomiting).

INTERPRETATION

The combination of expectancy and actual gluten intake had the largest effect on gastrointestinal symptoms, reflecting a nocebo effect, although an additional effect of gluten cannot be ruled out. Our results necessitate further research into the possible involvement of the gut-brain interaction in NCGS.

FUNDING

Government of the Netherlands Topsector Agri & Food Top Consortium for Knowledge and Innovation, AB Mauri Global Bakery Ingredients, Baking Industry Research Trust, Borgesius-Albert Heijn, CSM Innovation Centre, the International Maize and Wheat Improvement Center (CIMMYT), DSM Food Specialties, Fazer, Healthgrain Forum, the International Association for Cereal Science and Technology, the International Wheat Gluten Association, Lantmännen, Mondelez International, Nederlands Bakkerij Centrum, Nutrition & Santé, Puratos, Rademaker, Sonneveld Group, and Zeelandia HJ Doeleman.