Impact of gluten-free diet on cardiovascular risk factors. A retrospective analysis in a large cohort of coeliac patients

Guidelines for best practices in monitoring established coeliac disease in adult patients

Coeliac disease (CeD) is an immunological disease triggered by the consumption of gluten contained in food in individuals with a genetic predisposition. Diagnosis is based on the presence of small bowel mucosal atrophy and circulating autoantibodies (anti-type 2 transglutaminase antibodies). After diagnosis, patients follow a strict, life-long gluten-free diet. Although the criteria for diagnosis of this disease are well defined, the monitoring phase has been studied less and there is a lack of specific guidelines for this phase. To develop a set of clinical guidelines for CeD monitoring, we followed the Grading of Recommendations Assessment, Development and Evaluation methodology. Statements and recommendations with the level of evidence were developed and approved by the working group, which comprised gastroenterologists, pathologists, dieticians and biostatisticians. The proposed guidelines, endorsed by the North American and European coeliac disease scientific societies, make recommendations for best practices in monitoring patients with CeD based on the available evidence. The evidence level is low for many topics, suggesting that further research in specific aspects of CeD would be valuable. In conclusion, the present guidelines support clinicians in improving CeD treatment and follow-up and highlight novel issues that should be considered in future studies.

Celiac Disease and Cardiovascular Risk: A Retrospective Case-Control Study

Background: The association of celiac disease (CD) with premature atherosclerosis, including increased carotid artery intima-media thickness and cardiovascular disease (CVD), is controversial. The aim of this study was to investigate this relationship. Methods: Clinical records of patients from Northern Sardinia referred to the Gastroenterology section of the Department of Medicine, University of Sassari, Italy, were analyzed. Unadjusted and adjusted odds ratios (ORs) for CVD with their 95% confidence intervals (CIs) were calculated according to established risk factors, including age, sex, diabetes, dyslipidemia, overweight/obesity, blood hypertension, and cigarette smoking, as well as a possible risk factor such as H. pylori infection. Results: In a total of 8495 patients (mean age 52.1 ± 17.3 years; 64.7% females), 2504 reported a diagnosis of CVD and 632 of CD. Logistic regression analysis showed a significantly reduced risk of CVD among patients with CD (OR 0.30, 95% CI 0.22–0.41). Moreover, the long duration of the gluten-free diet (GFD) was able to lower the risk of CVD in celiac patients. Finally, CD significantly decreased the frequency of carotid plaques (11.8% vs. 40.1%, p < 0.001). Conclusions. Our retrospective study demonstrated that CD reduces the risk of CVD in general and more specifically of carotid lesions after adjusting for potential confounders, especially in those on GFD for a long time.

Risk of obesity during a gluten-free diet in pediatric and adult patients with celiac disease: a systematic review with meta-analysis

CONTEXT

Obesity is a significant risk factor for many pathological conditions. Whether a gluten-free diet (GFD) is a risk factor for overweight or obesity remains controversial.

OBJECTIVE

The primary aim of this study was to assess the prevalence of body mass index (BMI) categories at disease presentation and the variation in BMI category from underweight/normal to overweight/obese and vice versa during a GFD.

DATA SOURCES

PubMed, Scopus, and Web of Science databases were searched through February 2021 for retrospective, cross-sectional, and prospective studies reporting BMI categories at disease diagnosis and during a GFD.

DATA EXTRACTION

Data were extracted by 2 reviewers independently. Disagreements were resolved by consensus; a third reviewer was consulted, if necessary. Risk of bias was assessed with the Cochrane ROBINS-I tool.

DATA ANALYSIS

Subgroup analysis based on age (pediatric/adult patients), study design (prospective, cross-sectional, retrospective), and duration of GFD was performed.. Forty-five studies were selected (7959 patients with celiac disease and 20 524 healthy controls). The mean BMI of celiac patients at presentation was significantly lower than that of controls (P < 0.001). During a GFD, the mean BMI increased significantly (mean difference = 1.14 kg/m2 [95%CI, 0.68-1.60 kg/m2]; I2 = 82.8%; P < 0.001), but only 9% of patients (95%CI, 7%-12%; I2 = 80.0%) changed from the underweight/normal BMI category to the overweight/obese category, while 20% (95%CI, 11%-29%; I2 = 85.8%) moved into a lower BMI category.

CONCLUSION

Most celiac patients had a normal BMI at presentation, although the mean BMI was significantly lower than that of controls. A GFD does not increase the risk of becoming overweight/obese, especially in children. The quality of several studies was suboptimal, with moderate or high overall risk of bias and heterogeneity.

Comparison of early atherosclerosis markers in children with Celiac disease and their healthy peers

Purpose: We aimed to evaluate carotid intima-media thickness (cIMT) and epicardial adipose tissue thickness (EATT) concurrently as early atherosclerotic markers in pediatric patients with Celiac disease. Materials and Methods: Patients with Celiac disease (n=54) and healthy peers (n=54) aged 5-18 years were enrolled in this cross-sectional study. Patients who followed gluten free diet at least the past 12 months were included. Anthropometric and biochemical measurements were performed. cIMT and EATT were measured by echocardiography and compared between the patient and control groups. Results: Body mass index (17.4±3.0 vs. 18.4±3.1 kg/m2), blood pressure (systolic: 100 (85-120) vs. 100 (80-100) mmHg; diastolic: 60 (40-90) vs. 70 (40-90) mmHg), and lipid profile (total cholesterol: 144.6±30.2 vs. 150.8±22.6 mg/dL; triglycerides: 71.5 (27-178) vs. 92.5 (34-203) mg/dL) were not different between the patient and control groups, while there were significant differences in cIMT and EATT. The patient group had higher cIMT (0.50±0.07 vs. 0.45±0.04 mm) and EATT (5.68±0.90 vs. 4.22±0.76 mm) than the control group. The risk of vitamin D insufficiency was 2.68 times higher in the patient group (95% CI=1.19-6.03). Conclusions: Children with Celiac disease had higher cIMT and EATT than healthy peers. cIMT and/or EATT measurements by echocardiography may present as a reliable and easy method to investigate subclinical atherosclerosis in children with Celiac disease.

Evaluation of the Relationship Between Carotid Intima Media Thickness and Dietary Compliance in Pediatric Celiac Patients: A Single-Center Pilot Study

OBJECTIVES

This study aimed to show the relationship between gluten-free diet (GFD) compliance in Celiac Disease (CD) and early atherosclerotic findings in pediatric patients and to test the effectiveness of carotid-intima-media-thickness (cIMT) to possibly predict long-term compliance to the GFD.

METHODS

Patients from 6 to 18 years of age with a diagnosis of CD confirmed by endoscopic duodenal biopsy who were followed at our hospital's pediatric gastroenterology outpatient clinic between November 2020 and May 2021 were evaluated in this single-center, prospective study. The study patients were divided into two groups according to GFD compliance. Serologic and biochemical tests were conducted routinely during the follow-up period. cIMT was measured using ultrasound for both groups.

RESULTS

A total of 80 patients (GFD-non-compliant: n = 35, GFD-compliant: n = 45) were evaluated. No significant differences were observed between the groups in terms of demographic data and pathology results. The mean cIMT value was 0.44 ± 0.028 mm for the GFD-compliant group and 0.54 ± 0.036 mm for the GFD-non-compliant group, with a statistically significant between-group difference (P < .001). The receiver operating characteristic curve analysis showed an area under the curve of 0.992 (95% confidence interval [CI]: 0.978-1, P < .001) for discrimination of the groups. In addition, a cutoff value of 0.486 mm for cIMT showed 96% (95% CI: 0.83-0.99) sensitivity and 94% (95% CI: 0.79-0.99) specificity for distinguishing GFD-compliant patients from non-GFD-compliant patients.

CONCLUSION

In this study, the relationship between long-term GFD compliance and cIMT was demonstrated in CD. Currently used by some authors for the assessment of preclinical atherosclerosis, cIMT can also be used as a long-term indicator of dietary compliance as well as cardiovascular risk.

Effects of Gluten-free Diet on Lipid Profile Risk Factors in Celiac Children

Many studies raise concerns about the nutritional consequences of gluten-free diet. It has been documented that gluten-free (GF) foods have a higher glycemic index, saturated fats, and lower content of micronutrients determining important health implications. In this retrospective study, we evaluated the change in cardiometabolic risk factors in prepubertal celiac children in remission following different gluten-free diet regimes. Patients using processed GF foods showed a significant increase over time for standard deviation score-total cholesterol, standard deviation score-low density lipoprotein cholesterol, and fasting glycemia. These alterations were not confirmed in patients using naturally GF foods. Therefore, processed GF foods might promote unfavorable alterations of metabolic parameters, especially those associated with increased risk of cardiovascular diseases. Supervision of a dietitian and medical practitioner is recommended to ensure nutritional adequacy and monitoring of cardiovascular risk factors in this population.

S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology (EADV)

INTRODUCTION

Dermatitis herpetiformis (DH) is a chronic, pruritic, gluten-induced skin disorder characterized by subepidermal granular IgA deposition and a variable degree of enteropathy identical to that seen in coeliac disease. So far, there has been no European consensus about the management of DH.

METHODS

The guidelines were created by small subgroups of a guideline committee consisting of 26 specialists from various medical fields and one patients' representative. The members of the committee then discussed the guidelines and voted for the final version at two consensus meetings. The guidelines were developed under the support of the European Academy of Dermatology and Venereology (EADV) and in collaboration with the European Dermatology Forum (EDF).

RESULTS

The guidelines summarize evidence-based and expert-based recommendations (S2 level) for the management of DH (see Appendix).

CONCLUSION

These guidelines will improve the quality of management of DH and support dermatologists in their diagnostic and therapeutic decisions.

Multidimensional Disadvantages of a Gluten-Free Diet in Celiac Disease: A Narrative Review

A gluten-free diet is the mainstay method of treatment and the prevention of celiac disease complications. However, an inadequately balanced gluten-free diet can increase the risk of obesity, negatively affect glucose and lipid metabolism, and increase the risk of the metabolic syndrome. Therefore, an adequate nutritional counselling is necessary for patients diagnosed with celiac disease in order to prevent and treat the components of the metabolic syndrome.

Determination and Comparison of the Lipid Profile and Sodium Content of Gluten-Free and Gluten-Containing Breads from the Spanish Market

The objective is to verify if gluten-free (GF) and gluten-containing (G) breads differ in their sodium content and lipid profile. Samples of GF (n = 20) and G (n = 14) sliced white sandwich bread of commercial brands most frequently consumed in Spain were collected. The fatty acid (FA) composition and the contents of sodium, fat, cholesterol and phytosterols were determined. Sodium, fat and cholesterol contents were significantly higher in GF bread. The FA composition also differed, while G breads declared in most instances the use of sunflower oil as fat ingredient and presented a higher polyunsaturated FA percentage; GF breads declared a wide variety of fats and oils as ingredients (coconut, palm, olive, sunflower, etc.) which was reflected in their FA profile. Cholesterol content was higher in GF bread because five samples declared the use of whole egg, while G samples did not include any egg product in their formulas. Phytosterol content was higher in G bread but its variability was greater in GF bread. In conclusion, nutritional quality of GF bread varied depending on the ingredients used and might be lower than that of G bread. However, these differences in composition could be reduced or eliminated through changes in the formulation of GF bread. Moreover, the comparison of the results obtained in our laboratory for fat and salt content with the declared contents on the labels showed a much higher deviation for GF samples and it can be concluded that the quality of the nutritional information declared was lower in GF samples.

Thromboembolic complications and cardiovascular events associated with celiac disease

Celiac disease (CD) is a chronic intestinal immune-mediated disease occurring in genetically susceptible individuals who are exposed to gluten. Although it primarily affects the small intestine, CD has been associated with a wide spectrum of extraintestinal manifestations, including thromboembolism and cardiovascular events. The risk of ischemic stroke, myocardial infarction, and thromboembolism, such as deep vein thrombosis and pulmonary embolism, is higher in patients with CD, while there is accumulating evidence that gluten-free diet in CD patients decreases the risk of these complications. The pathogenetic mechanism of increasing hypercoagulability in CD is multifactorial and involves hyperhomocysteinemia due to malabsorption of vitamins B12, B6, and folic acid; endothelial dysfunction; acceleration of atherosclerosis; chronic inflammation; thrombocytosis; and thrombophilia. Therefore, in cases of thromboembolic complications and cardiovascular disease of obscure etiology, clinicians' awareness of possible celiac disease is warranted.

Nutrition Assessment, Interventions, and Monitoring for Patients with Celiac Disease: An Evidence Analysis Center Scoping Review

The objectives of this scoping review were to identify and characterize studies examining nutrition assessment, interventions, and measures to monitor gluten-free diet (GFD) adherence/compliance in patients with celiac disease (CD). An electronic literature search of four databases (Cochrane Database for systematic reviews, CINAHL, Embase, and Ovid MEDLINE) was conducted to identify articles examining nutrition care in CD individuals. Except for narrative review, grey literature, and case study/report, all types of peer-reviewed articles published between January 2007 and August 2018 were eligible. There were a total of 10,823 records; 10,368 were excluded during the first round of screening due to irrelevancy and/or duplication. Of the 455 full-text articles that were assessed, 292 met the criteria and were included. Most of the studies were observational studies (n=212), followed by experimental trials (n=50), evidence-based practice guideline (EBPG)/report/statement (n=16), and systematic review (SR) (n=14). Nine original studies examined assessment, focusing mainly on different tools/ways to assess GFD adherence. The majority of the included original articles (n=235) were in the nutrition intervention category with GFD, oats, and prebiotics/probiotics as the top-three most studied interventions. There were eight SRs on GFD and five on oats. One SR and 21 original studies investigated the effectiveness of different measures to monitor GFD adherence/compliance. Although recent CD EBPGs were identified, different methods with varying levels of rigor, in terms of literature search and assessment of evidence strength, were used. Based on this scoping review, interventions focused on gluten-free diet and oats have been significantly covered by either SRs or EBPGs. Studies related to prebiotics/probiotics and education program/counseling focused interventions, as well as assessment, in CD patients have increased in recent years. Thus, it might be beneficial to conduct SRs/EBPGs focused on these topics to guide practitioners.

Incidence and prevalence of self-reported non-coeliac wheat sensitivity and gluten avoidance in Australia

OBJECTIVES

To determine the incidence of self-reported non-coeliac wheat sensitivity (SR-NCWS) and factors associated with its onset and resolution; to describe the prevalence of factors associated with gluten avoidance.

DESIGN

Longitudinal cohort study; analysis of responses to self-administered validated questionnaires (Digestive Health and Wellbeing surveys, 2015 and 2018).

SETTING, PARTICIPANTS

Subset of an adult population sample randomly selected in 2015 from the electoral rolls for the Newcastle and Gosford regions of New South Wales.

MAIN OUTCOME MEASURES

Prevalence of SR-NCWS (2015, 2018) and incidence and resolution of SR-NCWS, each by demographic and medical factors; prevalence of gluten avoidance and reasons for gluten avoidance (2018).

RESULTS

1322 of 2185 eligible participants completed the 2018 survey (response rate, 60.5%). The prevalence of SR-NCWS was similar in 2015 (13.8%; 95% CI, 12.0-15.8%) and 2018 (13.9%; 95% CI, 12.1-15.9%); 69 of 1301 respondents (5.3%) reported developing new onset (incident) SR-NCWS between 2015 and 2018 (incidence, 1.8% per year). Incident SR-NCWS was significantly associated with a diagnosis of functional dyspepsia, and negatively associated with being male or older. Gluten avoidance was reported in 2018 by 24.2% of respondents (20.5% partial, 3.8% complete avoidance); general health was the most frequent reason for avoidance (168 of 316 avoiders, 53%). All 13 participants with coeliac disease, 56 of 138 with irritable bowel syndrome (41%), and 69 of 237 with functional dyspepsia (29%) avoided dietary gluten.

CONCLUSIONS

The prevalence of SR-NCWS was similar in 2015 and 2018. Baseline (2015) and incident SR-NCWS (2018) were each associated with functional gastrointestinal disorders. The number of people avoiding dietary gluten exceeds that of people with coeliac disease or SR-NCWS, and general health considerations and abdominal symptoms are the most frequently reported reasons for avoidance.

Insights in the Evaluation of Gluten Dietary Avoidance in Healthy Subjects

Background: The amount of healthy subjects adopting a gluten-free diet (GFD) for nonmedical reasons actually surpasses the numbers of those who are dealing with a permanent gluten-related disorder.Objective: The study aimed to better clarify the interactions between a GFD and physical and psychological well-being.Methods: Sixty healthy subjects with normal weight were enrolled. Thirty subjects (15 female) were submitted to a normocaloric GFD and considered as the experimental group (EG), and 30 subjects (15 female) were submitted to a normocaloric diet (CG) for 6 months. The hematochemical and psychological parameters before and after the diet were recorded.Results: Significant improvement was demonstrated in red blood count, hemoglobin, total cholesterol, and high-density lipoprotein parameters in the EG after the gluten-free diet. However, a significant increase of α-amylase pancreatic activity and reduction of vitamin B12 and magnesium levels in the EG were observed. Regarding the psychological parameters, the GFD significantly improved scores assessing body satisfaction, but increased social insecurity.Conclusions: The study is the first to consider significant modulation in hematochemical parameters as well as psychological ones by gluten avoidance in healthy individuals. Although these subjects were not characterized by intestinal mucosa damage, some of the effects were similar to those observed in celiac disease patients who began to adhere to a GFD.

The Effect of Gluten-free Diet on Cardiovascular Risk Factors in Newly Diagnosed Pediatric Celiac Disease Patients

OBJECTIVES

Although gluten-free diet (GFD) is the only proven therapy for celiac disease (CD), its effect on cardiovascular disease (CVD) risk factors is still unclear. Our aim was to determine whether adherence to GFD affects CVD risk factors among newly diagnosed pediatric CD subjects.

METHODS

We prospectively enrolled pediatric subjects undergoing upper gastrointestinal endoscopy for suspected CD. We collected anthropometric and laboratory parameters related to CVD risk factors at the time of CD diagnosis and 1 year after initiation of a GFD and evaluated changes in CVD risk factors. Paired t tests or Wilcoxon nonparametric tests were used, each when appropriate.

RESULTS

One hundred ten newly diagnosed CD pediatric subjects were included in the analysis. There were 64 (58.2%) girls and the mean age at diagnosis was 6.8 ± 3.4 years. Median body mass index z scores (P = 0.84), rates of underweight or overweight (P = 0.32), and rates of elevated blood pressure (P = 0.78) remained unchanged. Although median fasting insulin levels increased (1.9 vs 5.4 μU/mL, P < 0.001), insulin resistance as measured by homeostatic model assessment did not increase after 1 year of GFD (P = 0.16). Although rates of dyslipidemia remained unchanged, median high-density lipoprotein levels increased on GFD (47 vs 51 mg/dL, P < 0.001).

CONCLUSIONS

In this pediatric CD cohort, GFD for 1 year was not associated with increased CVD risk factors. The long-term significance of these mild changes is yet to be determined.

Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico

Celiac disease, celiac sprue, or gluten-sensitive enteropathy, is a generalized autoimmune disease characterized by chronic inflammation and atrophy of the small bowel mucosa. It is caused by dietary exposure to gluten and affects genetically predisposed individuals. In Mexico, at least 800,000 are estimated to possibly have the disease, prompting the Asociación Mexicana de Gastroenterología to summon a multidisciplinary group of experts to develop the "Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico" and establish recommendations for the medical community, its patients, and the general population. The participating medical professionals were divided into three working groups and were given the selected bibliographic material by the coordinators (ART, LUD, JMRT), who proposed the statements that were discussed and voted upon in three sessions: two voting rounds were carried out electronically and one at a face-to-face meeting. Thirty-nine statements were accepted, and once approved, were developed and revised by the coordinators, and their final version was approved by all the participants. It was emphasized in the document that epidemiology and risk factors associated with celiac disease (first-degree relatives, autoimmune diseases, high-risk populations) in Mexico are similar to those described in other parts of the world. Standards for diagnosing the disease and its appropriate treatment in the Mexican patient were established. The guidelines also highlighted the fact that a strict gluten-free diet is essential only in persons with confirmed celiac disease, and that the role of gluten is still a subject of debate in relation to nonceliac, gluten-sensitive patients.

Anti-High-Density Lipoprotein Antibodies and Antioxidant Dysfunction in Immune-Driven Diseases

Introduction

Impaired high-density lipoprotein (HDL) levels and antioxidant functionality of HDL, mainly attributed to a decreased paraoxonase-1 (PON1) functionality, have been described in autoimmune conditions. In this setting, a role for humoral response in cardiovascular disease is emerging. This study evaluates the role of immunoglobulin G (IgG) antibodies against HDL and disease-related autoantibodies on HDL dysfunction in immune-driven diseases.

Methods

Serum IgG anti-HDL antibodies, PON1 activity, and total antioxidant capacity (TAC) were quantified in 381 patients with different immune-driven diseases [18 mixed connective tissue disease (MCTD), 35 primary Sjögren syndrome (pSS), 38 systemic sclerosis (SSc), 33 ANCA-associated vasculitis (AAV), 60 diabetes mellitus 1, 29 autoimmune B12 deficiency/pernicious anemia, 29 primary biliary cirrhosis, 46 IBD/Crohn, 54 IBD/UC, and 39 celiac disease (CD)] and 138 healthy controls.

Results

IgG anti-HDL antibodies were increased in MCTD, pSS, AAV, and inflammatory bowel disease (IBD) [Crohn and ulcerative colitis (UC)], even after correcting for total IgG levels, but not in organ-specific autoimmune diseases. Anti-HDL antibodies were negatively associated with PON1 activity in MCTD (r = −0.767, p < 0.001) and AAV (r = −0.478, p = 0.005), whereas both anti-HDL and anti-neutrophil cytoplasm antibod levels were related to an impaired PON1 activity and TAC in IBD/UC. In SSc, anti-centromere antibodies correlated PON1 activity. anti-Saccharomyces cerevisiae antibodies levels were negatively associated with PON1 activity (r = −0.257, p = 0.012) and PON1/TAC ratio (r = −0.261, p = 0.009) in IBD/Crohn. HDL dysfunction in CD was only related to anti-transglutaminase levels.

Conclusion

IgG anti-HDL antibodies and HDL dysfunction are common hallmarks of systemic autoimmunity. Anti-HDL and disease-related autoantibodies account for the HDL antioxidant dysfunction in immune-driven conditions, mainly in systemic autoimmune disorders.

Proton pump inhibitors as risk factor for metabolic syndrome and hepatic steatosis in coeliac disease patients on gluten-free diet

BACKGROUND

Recent research has shown that patients with coeliac disease (CD) are at risk of developing metabolic syndrome (MS) and hepatic steatosis (HS) after commencing a gluten-free diet (GFD). This study aimed to evaluate the predictive factors for MS and HS in CD after 1 year of GFD.

METHODS

All consecutive newly diagnosed CD patients were enrolled. We prospectively collected data about BMI; waist circumference; blood pressure; cholesterol; triglycerides, glucose and insulin blood levels; insulin resistance (through the homeostatic model assessment HOMA-IR) and treatment with proton pump inhibitors (PPI). Diagnosis of MS was made in accordance with current guidelines and HS was diagnosed by ultrasonography. The prevalence of MS and HS was re-assessed after 1 year of GFD. A logistic regression analysis was performed to identify risk factors for MS and HS occurrence after 1 year of GFD.

RESULTS

Of 301 patients with newly diagnosed CD, 4.3% met criteria for diagnosis of MS and 25.9% presented with HS at the time of CD diagnosis; 99 subjects (32.8%) had long-term exposure to PPI during the study period. After 1 year, 72 (23.9%) patients had developed MS (4.3 vs 23.9%; p < 0.001, OR 6.9) and 112 (37.2%) had developed HS (25.9 vs 37.2%; p < 0.01, OR 1.69). At multivariate analysis, high BMI at diagnosis (OR 10.8; p < 0.001) and PPI exposure (OR 22.9; p < 0.001) were the only factors associated with the occurrence of MS; HOMA-IR (OR 9.7; p < 0.001) and PPI exposure (OR 9.2; p < 0.001) were the only factors associated with the occurrence of HS.

CONCLUSIONS

PPI exposure adds further risk of occurrence of MS and HS for patients with CD on GFD. The use of PPI in patients with CD on GFD should be limited to strict indications.

Effect of the gluten-free diet on cardiovascular risk factors in patients with coeliac disease: A systematic review

BACKGROUND AND AIMS

A gluten-free diet (GFD), the mainstay of treatment for celiac disease, is being increasingly adopted by people without this condition. The long-term health effects of this diet, apart from its beneficial effect on enteropathy in celiac disease, are unclear. Concerns exist that the GFD may result in micronutrient deficiencies, increased exposure to toxins such as arsenic, and an increased cardiovascular risk. This systematic review addresses the effect of the GFD on several modifiable cardiovascular risk factors.

METHODS

A systematic search of the literature addressing the GFD and blood pressure, glycaemia, body mass index, waist circumference, and serum lipids in patients before and after adoption of a GFD was conducted using the MEDLINE, EMBASE, PSYCInfo, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases. Two authors performed abstract and full text screening, and quality assessment.

RESULTS

A total of 5372 articles were identified, from which 27 were included. Lack of control groups in all but one study prevented meta-analysis of results. Overall study quality was low and restricted to patients with celiac disease. Consistent findings across studies included an increase in total cholesterol, high density lipoprotein, fasting glycaemia, and body mass index (while remaining within the healthy weight range). Significant changes in low density lipoprotein, triglycerides, and blood pressure were not consistently reported.

CONCLUSIONS

A GFD alters certain cardiovascular risk factors in patients with celiac disease, but the overall effect on cardiovascular risk is unclear. Further studies are warranted.

The influence of gluten-free bakery products consumption on selected anthropometric parameters

The aim of the study was to evaluate the effect of a short-term consumption (six weeks) of gluten-free bakery products on the anthropometric parameters. The study group was composed of volunteers from the general population and consisted of 30 healthy adults. The amount of bakery product was determined as follows: women consumed 150 - 200 grams per day; men 200 - 250 grams per day. Anthropometric measurements were made by using InBody 720, we received data such as body weight, Body Mass Index (BMI) and Waist-to-Hip Ratio (WHR), which we evaluated the presence of overweight and obesity in the monitored groups. We also observed visceral fat area (VFA). We found out that the 6-week consumption of gluten-free bread and bakery products showed a significant reduction in body weight and BMI (p <0.01), but also to a significant increase in VFA (p <0.05). By the impact of consumption we recorded the increase of body weight and BMI in 70% of participants (in 30% there was slight increase), decrease of WHR in 33% (increase in 43%) and decrease of VFA in 43% (increase in 57%). For other participants, the values remained unchanged. Two months after the termination of the consumption of gluten-free products we found out the increase of body weight and BMI, WHR remained unchanged, however in the case of VFA showed significant increase of values. We can summarize that dietary habits play a crucial role in the development of overweight and obesity and the consumption of bread and bakery products can also affect it. However, the overall effect of bread and bakery consumption on the development of overweight depends on many factors, such as the composition of the bread and bakery products and the presence of gluten.

Non-coeliac gluten or wheat sensitivity: emerging disease or misdiagnosis?

Non-coeliac gluten or wheat sensitivity (NCG/WS) is a condition characterised by adverse gastrointestinal and/or extra-intestinal symptoms associated with the ingestion of gluten- or wheat-containing foods, in the absence of coeliac disease or wheat allergy. Up to one in 100 people in Australia may have coeliac disease but many more report adverse gastrointestinal and/or extra-intestinal symptoms after eating wheat products. In the absence of validated biomarkers, a diagnosis of NCG/WS can only be made by a double-blind, placebo-controlled, dietary crossover challenge with gluten, which is difficult to apply in clinical practice. Of people self-reporting gluten or wheat sensitivity, only a small proportion (16%) will have reproducible symptoms after a blinded gluten challenge of gluten versus placebo in a crossover dietary trial and fulfil the current consensus criteria for a diagnosis of NCG/WS. A wide range of symptoms are associated with NCG/WS, including gastrointestinal, neurological, psychiatric, rheumatological and dermatological complaints. The pathogenesis of NCG/WS is not well understood, but the innate immune system has been implicated, and there is overlap with coeliac disease and the functional gastrointestinal disorders (irritable bowel syndrome and functional dyspepsia). Identification of NCG/WS is important as gluten-free diets carry risks, are socially restricting and are costlier than regular diets.

Cardiovascular involvement in celiac disease

Celiac disease (CD) is an autoimmune response to ingestion of gluten protein, which is found in wheat, rye, and barley grains, and results in both small intestinal manifestations, including villous atrophy, as well as systemic manifestations. The main treatment for the disease is a gluten-free diet (GFD), which typically results in the restoration of the small intestinal villi, and restoration of other affected organ systems, to their normal functioning. In an increasing number of recently published studies, there has been great interest in the occurrence of alterations in the cardiovascular system in untreated CD. Herein, published studies in which CD and cardiovascular terms appear in the title of the study were reviewed. The publications were categorized into one of several types: (1) articles (including cohort and case-control studies); (2) reviews and meta-analyses; (3) case studies (one to three patient reports); (4) letters; (5) editorials; and (6) abstracts (used when no full-length work had been published). The studies were subdivided as either heart or vascular studies, and were further characterized by the particular condition that was evident in conjunction with CD. Publication information was determined using the Google Scholar search tool. For each publication, its type and year of publication were tabulated. Salient information from each article was then compiled. It was determined that there has been a sharp increase in the number of CD - cardiovascular studies since 2000. Most of the publications are either of the type "article" or "case study". The largest number of documents published concerned CD in conjunction with cardiomyopathy (33 studies), and there have also been substantial numbers of studies published on CD and thrombosis (27), cardiovascular risk (17), atherosclerosis (13), stroke (12), arterial function (11), and ischemic heart disease (11). Based on the published research, it can be concluded that many types of cardiovascular issues can occur in untreated CD patients, but that most tend to resolve on a GFD, often in conjunction with the healing of small intestinal villous atrophy. However, in some cases the alterations are irreversible, underscoring the need for CD screening and treatment when cardiovascular issues arise of unknown etiology.

Cardiometabolic risk factors in children with celiac disease on a gluten-free diet

Celiac disease (CD) is an immune-mediated systemic condition evoked by gluten and related prolamines in genetically predisposed subjects. It is characterised by a variable combination of gluten-dependent clinical symptoms, CD-specific antibodies, HLA-DQ2 and HLA-DQ8 haplotypes, and enteropathy. The only therapy of CD consists of a life-long gluten free diet (GFD). Strict GFD adherence results in full clinical, serological and histological remission, avoiding long-term complications in CD patients. However, this diet is not without problems. Gluten free products have high levels of lipids, sugar and salt to improve food palatability and consistency, and subjects with CD show an excessive consumption of hypercaloric and hyperlipidic foods to compensate dietetic restriction. GFD may therefore have a negative impact on cardiometabolic risk factors such as obesity, serum lipid levels, insulin resistance, metabolic syndrome, and atherosclerosis. In adults, some studies have suggested that GFD have a beneficial effect on cardiovascular profile, whereas others have shown an atherogenic effect of GFD. In children, very few studies are available on the issue. Thus, the aim of the present narrative review was to analyze the current clinical evidence on the impact of GFD on cardiometabolic risk factors in children with CD.

Cardiovascular Risk Factors in Adolescents With Celiac Disease: A Cross-sectional Population-Based Study

BACKGROUND

Recent data have shown that adults with celiac disease (CD) may have a higher prevalence of risk factors for cardiovascular disease (CVD) compared with the general population. Thus, we aimed to investigate the association of CD with CVD risk factors at late adolescence in a cross-sectional population-based study.

METHODS

A total of 2,001,353 Jewish Israeli adolescents who underwent a general health examination at median age of 17.1 years from 1988 to 2015 were included. Covariate data included demographic measures, blood pressure (BP), resting heart rate, and risk factors associated with CVD.

RESULTS

Overall, 10,566 cases of CD were identified (0.53%). Multivariate analysis showed that mean diastolic BP was significantly lower in subjects with CD (men: 72.0±8.7 vs 70.4 ± 8.5, P < 0.0001; women: 70.0 ± 8.3 vs 69.0 ± 8.2, P < 0.0001), whereas systolic BP did not differ between groups. Resting heart rate was higher in CD cases (an absolute difference of 0.4 beats per minute, P < 0.0001). The proportions of overweight and obese subjects were significantly lower in CD cases. Noninsulin-dependent diabetes mellitus (relative risk [RR], 4.1; 95% confidence interval [CI] 2.8-5.7), hypercoagulability (RR, 2.6; 95% CI 1.5-4.5), and hyperlipidemia (RR, 1.9; 95% CI 1.2-3) were significantly more common in subjects with CD.

CONCLUSIONS

At the age of 17 years, the prevalence of risk factors for CVD is higher in subjects with CD compared with the general population. There is, however, neither increase in BP nor increase in overweight and obesity rates.

Trending Cardiovascular Nutrition Controversies

The potential cardiovascular benefits of several trending foods and dietary patterns are still incompletely understood, and nutritional science continues to evolve. However, in the meantime, a number of controversial dietary patterns, foods, and nutrients have received significant media exposure and are mired by hype. This review addresses some of the more popular foods and dietary patterns that are promoted for cardiovascular health to provide clinicians with accurate information for patient discussions in the clinical setting.

Obesity and Cardiovascular Risk in Adults With Celiac Disease

BACKGROUND

Patients with celiac disease (CD) may be at an increased risk of cardiovascular disease (CVD), yet CVD risk factors are not well defined in CD. The validated Framingham Heart Study 10-year general CVD risk score (FRS) that incorporates traditional CVD risk factors including body mass index (BMI) has not been previously studied in CD patients.

AIMS

To compare BMI and FRS in CD patients with population-based controls.

METHODS

Biopsy-proven CD patients were ascertained retrospectively and data on BMI, systolic blood pressure, hypertension, smoking status, and diabetes were obtained at initial and follow-up visits. FRS was calculated and compared with 4 matched general population non-CD controls from the 2009 to 2010 National Health and Nutrition Examination Survey (NHANES).

RESULTS

Of 258 total CD patients, 38.3% were overweight or obese compared with 69.8% of controls (P<0.001). In total, 174 CD patients met the inclusion criteria for FRS calculation. Of these, the median FRS was lower in CD patients compared with controls (3.9 vs. 4.2; P=0.011). In CD patients, tobacco use was significantly lower (P<0.001), whereas systolic blood pressure was significantly higher (P<0.01) than controls.

CONCLUSIONS

Global CVD risk is lower among patients with CD compared with population controls. Lower BMI and tobacco use among CD patients could account for this difference. These results suggest that factors other than those measured by FRS could contribute to the increased risk of CVD in CD observed in some studies.

B vitamins related to homocysteine metabolism in adults celiac disease patients: a cross-sectional study

BACKGROUND

The only treatment for celiac disease is the gluten-free diet. Few studies have assessed the nutritional adequacy of this diet, especially of B vitamins related to homocysteine metabolism. The aim of this study was to assess the nutritional status and serum concentrations of B vitamins involved in homocysteine metabolism, and to determine whether the dietary intake of these vitamins are meeting Dietary Reference Intakes in celiac patients.

METHODS

A cross-sectional study enrolled a total of 20 celiac patients (36.3 ± 13.7 years old; 65% women), following strict gluten-free diet (GFD) and 39 healthy controls matched by sex and age. The dietary intake was assessed by 3-day food records, and serum concentrations of homocysteine and vitamins B6, B12, and folate were determined after overnight fasting. Comparisons between the two groups were performed by Student's t test or Mann-Whitney U-test, for continuous variables. Pearson's chi-square test or Fisher's exact test was used for categorical variables. An alpha level of 5% were considered significant.

RESULTS

Celiac patients had lower serum folate concentrations (7.7 ± 3.5 ng/mL, P < 0.05) than controls. All celiac patients had folate intake below the Estimated Average Requirement (EAR) (130.8 ± 53.6 μg/d). However, only a small proportion of celiac patients had hyperhomocysteinemia.

CONCLUSIONS

Celiac patients treated with GFD presented inadequacy of dietary folate intake and low-serum concentrations of folate, suggesting that more attention should be given to the quality of the nutrients offered by the GFD, as it constitutes a lifelong treatment.

Increased arterial stiffness and its relationship with inflammation, insulin, and insulin resistance in celiac disease

OBJECTIVE

Celiac disease (CD) is a lifelong, chronic, immune-mediated, inflammatory small bowel disorder, precipitated by exposure to dietary gluten and related proteins in genetically predisposed individuals. Recent studies have shed new light on the importance of inflammation in the pathogenesis of arterial stiffness. The aim of this study was to evaluate arterial stiffness using pulse wave velocity (PWV) in adult CD patients without cardiovascular risk factors in comparison with a control group.

PATIENTS AND METHODS

A total of 58 patients with CD without cardiovascular risk factors and age-matched and sex-matched healthy controls were enrolled in the study. All patients completed a standard questionnaire form, and various laboratory parameters were assessed. Vascular measurements, including PWV, were carried out using a Mobil-O-Graph 24-h pulse wave analysis monitor, an automatic oscillometric device.

RESULTS

Although cardiovascular risk factors, such as low-density lipoprotein cholesterol and triglyceride, were significantly lower (P<0.05) in celiac patients than in controls, the erythrocyte sedimentation rate, C-reactive protein, insulin, homeostasis model assessment of insulin resistance, homocysteine, and 24 h, day, and night PWV values were higher in patients with CD than in controls (P<0.05). A multiple linear regression analysis showed that PWV was correlated positively with age and the duration of CD.

CONCLUSION

This study found increased arterial stiffness, homocysteine, erythrocyte sedimentation rate, C-reactive protein, insulin, and homeostasis model assessment of insulin resistance in patients with CD and provides evidence for the potential contribution of these parameters and inflammation toward arterial stiffening, independent of conventional cardiovascular risk factors.

Celiac Disease and Type 1 Diabetes in Adults: Is This a High-Risk Group for Screening?

The association between celiac disease (CD), an autoimmune condition involving intestinal inflammation related to gluten ingestion, and type 1 diabetes has long been recognized. CD prevalence rates 4 to 6 times greater in adults with type 1 diabetes than in the general population. Much of the existing literature focuses on important implications related to the impact of a gluten-free diet on short-term outcomes in metabolic control and quality of life. Canadian Diabetes Association guidelines recommend targeted CD screening in patients with type 1 diabetes who have classic symptoms, such as abdominal pain, bloating, diarrhea, unexplained weight loss or labile metabolic control; however, a significant proportion (40% to 60%) of patients may have mild or absent symptoms. Recent evidence suggests that adult patients with both conditions are at higher risk for diabetes microvascular comorbidities, increased mortality and impaired bone health if the CD is untreated. The purpose of this review is to describe the association between CD and type 1 diabetes and to summarize recent literature that evaluates risks in patients with both conditions.

Gluten-Free Diet and Lipid Profile in Children With Celiac Disease: Comparison With General Population Standards

OBJECTIVES

A gluten-free diet (GFD) may carry high energy and fat load. We verified lipid profile and dietary indicators cross-sectionally and prospectively in patients with celiac disease (CD).

METHODS

In any consecutive child receiving a GFD (group 1) or newly diagnosed as having CD (group 2), total cholesterol (TC), triglycerides (TG), high-density lipoprotein (HDL) cholesterol, blood pressure (BP), anthropometric data, physical activity, and a 24-hour food diary were collected during follow-up visits (yearly in group 1 and during the first year of GFD in group 2).

RESULTS

In group 1 (132 girls, 73 boys, 10.7 ± 4.2 years), TC (P = 0.006), TG (P = 0.014), and HDL (P = 0.019) were significantly higher in girls than in boys. Compared with the general pediatric population, group 1 girls had higher TC, TG, HDL, and low-density lipoprotein; group 1 boys had lower TC, TG, and low-density lipoprotein and higher HDL. TC was significantly and positively affected by age, sex, and time receiving GFD, whereas HDL was significantly and positively affected by body mass index, diastolic BP, and sex; TG was negatively affected by diastolic BP. Compared with recommendations, group 1 children introduced less calories, iron, and calcium; one-third more sodium; similar amounts of fiber; and twice as many proteins. In group 2 (20 girls, 10 boys, 8.6 ± 3.55 years), TC did not change over time and TG diminished, whereas HDL, blood glucose, and body mass index increased; saturated fats and caloric intake were below recommendations, whereas proteins were excessively introduced. Fibers were optimal. HDL was inversely correlated to calories and saturated fat (R² = 80, P = 0.011).

CONCLUSIONS

Lipid profiles of children with CD differ across sexes and from reference population. GFD, being unexpectedly appropriate in fibers and fat proportion, may be a contributor.

Preventing complications in celiac disease: our experience with managing adult celiac disease

Celiac disease is, as we know it, rather than being a rare and incurable disease until the 1950's, both quite common in screening studies and readily treatable. Three conditions are triggered by gluten consumption: celiac disease, the skin rash dermatitis herpetiformis and gluten ataxia. We describe our follow up for out clinic management, as evidence based data about such an approach are lacking in current literature. No food, beverages or medications containing any amount of gluten can be taken. Compliance is often difficult especially when patients are asymptomatic. We control a cohort, in daily practice, of over 700 adult patients. The majority of patients manage the diet without any problems. We describe our follow up in general, for serology, laboratory and histology. Forty percent of our newly diagnosed celiac patients do have a BMI over 25 kg/m(2). An appropriate attitude for this problem is lacking. The problem of slowly weaning off Dapsone over 5-10 years in DH is recognized. The bone density is checked in all newly diagnosed celiac patients. We control, if necessary, by telephone and lab controls done in local cities and see our patients only every two years face-to-face for follow up. The main question is if the adherence to a GFD, quality of life and prevention of complications is improved by visiting a dedicated celiac clinic. We hope to standardize this attitude on evidence data in the years to come.

The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis

BACKGROUND

A gluten-free diet (GFD) is currently the only available therapy for coeliac disease (CD).

OBJECTIVES

We aim to review the literature on the GFD, the gluten content in naturally gluten-free (GF) and commercially available GF food, standards and legislation concerning the gluten content of foods, and the vitamins and mineral content of a GFD.

METHODS

We carried out a PubMed search for the following terms: Gluten, GFD and food, education, vitamins, minerals, calcium, Codex wheat starch and oats. Relevant papers were reviewed and for each topic a consensus among the authors was obtained.

CONCLUSION

Patients with CD should avoid gluten and maintain a balanced diet to ensure an adequate intake of nutrients, vitamins, fibre and calcium. A GFD improves symptoms in most patients with CD. The practicalities of this however, are difficult, as (i) many processed foods are contaminated with gluten, (ii) staple GF foods are not widely available, and (iii) the GF substitutes are often expensive. Furthermore, (iv) the restrictions of the diet may adversely affect social interactions and quality of life. The inclusion of oats and wheat starch in the diet remains controversial.

Long term follow up of celiac disease-is atherosclerosis a problem?

Celiac disease (CD) is a lifelong condition and it often involves impaired nutrition, wide spectrum of symptoms and it requires constant dietetic treatment. The impact of the gluten-free diet on patients’ nutritional status and on the other biochemical parameters is being widely investigated. In this article we looked into particular risk factors that might lead to increased prevalence of atherosclerosis in CD patients, including nutritional status, gluten-free diet, lipids profile and concomitant disease—type 1 diabetes mellitus. Here, we present the current data and research on these risk factors of atherosclerosis with respect to celiac disease.

Factors that contribute to hypertransaminasemia in patients with celiac disease or functional gastrointestinal syndromes

BACKGROUND & AIMS

Transaminasemia develops via different pathways in patients with celiac disease; no information is available on risk factors specifically attributable to celiac disease.

METHODS

We analyzed data collected from consecutive patients referred from January 1997 through December 2009 to the celiac disease clinic at the Spedali Civili of Brescia, Italy. We assessed the factors affecting hypertransaminasemia in 683 patients with celiac disease (based on serologic and biopsy analysis, cohort A; 34 ± 14 years of age) and 304 with functional syndromes (cohort B; 37 ± 13 years of age).

RESULTS

Hypertransaminasemia was detected in 138 patients in cohort A (20%). It was associated with malabsorption (odds ratio [OR], 2.22; P = .004), diarrhea (OR, 1.72; P = .005), and increasing severity of mucosal lesion (Marsh-Oberhuber class; OR, 1.46; P = .001) but not with body mass index (BMI) or the serum level of tissue-transglutaminase antibodies (tTG). Hypertransaminasemia was detected in 22 patients in cohort B (7%) and was associated with the World Health Organization's BMI categories (OR, 7.9; P < .001). In subsets of patients studied with the same analytical method (313 of cohort A and 188 of cohort B), the level of tTG was significantly higher in cohort A at baseline (25.2 ± 16.9 U/L aspartate aminotransferase [AST]) than in cohort B (20.6 ± 9.9 U/L AST, P < .0001) and was related to BMI in cohort B (P = .0012) but not cohort A. When patients were placed on gluten-free diets, the levels of AST decreased from 25.2 ± 16.9 U/L to 19.9 ± 6.6 U/L (P < .0001), independently of the changes of duodenal histology and tTG and correlated with BMI (P = .0007); the prevalence of hypertransaminasemia decreased from 13% to 4%.

CONCLUSIONS

Patients with celiac disease have a higher prevalence of hypertransaminasemia than controls (patients with functional syndromes). Hypertransaminasemia is related to the severity of the duodenal lesion and malabsorption but not BMI. By contrast, there was a positive correlation between the levels of AST and BMI in controls; this relationship was restored when patients with celiac disease were placed on gluten-free diets.