Vitamin D and K status influences bone mineral density and bone accrual in children and adolescents with celiac disease

Nutrition Assessment and Management in Celiac Disease

Celiac disease (CeD) is the most common immune condition affecting the gastrointestinal tract; it is triggered by gluten and the only available treatment is a strict gluten-free diet (GFD). Therefore, for patients with CeD, adopting a GFD is not a lifestyle choice. The major problem is that a GFD is restrictive and, like all restrictive diets, it has the potential for adverse nutritional outcomes, especially if adopted for a long term. It is well known that GFD can be nutritionally inadequate and is frequently associated with vitamin and mineral deficiencies; it is also associated with excessive sugar and fat intake, particularly when gluten-free substitutes are consumed. Consequently, people with CeD are affected by higher rates of overweight and obesity and metabolic complications, such as fatty liver and cardiovascular disease. Therefore, assessment of nutritional status and diet quality at diagnosis and while on a long-term GFD is key in the management of CeD. This narrative review addresses nutritional considerations in CeD and management of common challenges associated with a GFD.

Relationship between vitamin D levels and pediatric celiac disease: a systematic review and meta-analysis

BACKGROUND

The relationship between Vitamin D levels and pediatric celiac disease (CD) remains controversial. In this study, we conducted a systematic review and meta-analysis to examine the relationship between Vitamin D and pediatric CD.

METHODS

We screened relevant studies from PubMed, EMBASE, and Web of Science published in English from January 1, 2000, to August 1, 2023. The included studies were assessed according to the STROBE checklist. Heterogeneity was quantified by Cochran's Q test and the I2 statistic. Publication bias was estimated by Begg's test and Egger's test. Meta-regression was used to detect potential sources of heterogeneity.

RESULTS

A total of 26 studies were included in the meta-analysis. Nineteen articles compared 25(OH)D3 levels between CD patients and control groups, average 25-hydroxyvitamin D3 [25(OH)D3 or calcidiol], and 1,25-dihydroxyvitamin D3 [1,25(OH)2D3 or calcitriol] levels, as the main forms of Vitamin D, there was a significant difference in CD patients and healthy controls (weighted mean difference (WMD) = - 5.77, 95% confidence interval (CI) = [- 10.86, - 0.69] nmol/L). Meanwhile, eleven articles reported the numbers of patients and controls with Vitamin D deficiency, there was a significant difference in the incidence of 25(OH)D3 deficiency between CD patients and healthy controls (odds ratio 2.20, 95% CI= [1.19, 4.08]). Nine articles reported changes in 25(OH)D3 levels before and after administering a GFD in patients with CD, the result of this study revealed the increase of 25(OH)D3 levels in CD patients after a gluten-free diet (GFD) (WMD = - 6.74, 95% CI = [- 9.78, - 3.70] nmol/L).

CONCLUSIONS

Vitamin D levels in pediatric CD patients were lower than in healthy controls, and 25(OH)D3 deficiency was more prevalent in CD patients. We found that 25(OH)D3 levels were elevated in CD patients after GFD, which is consistent with previous research. Further well-designed, longitudinal, prospective cohort studies focusing on the role of Vitamin D in the pathogenesis of CD are therefore needed.

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

BACKGROUND

Celiac disease (CD) is associated with malabsorption and consequential nutritional deficiencies. Patients with CD must follow a gluten-free diet (GFD), which is also associated with nutrient deficiencies. Despite the clinical significance, consensus is lacking on the pattern and frequency of nutrient deficiencies in CD and the usefulness of assessment during follow-up. The aim was to investigate the presence of micronutrient and protein deficiencies in pediatric patients with CD after starting a GFD and receiving standard clinical care, taking disease activity into account.

METHODS

This single center retrospective chart review aimed to map the occurrence of nutrient deficiencies, determined in serum samples derived during follow-up in an expertise center for pediatric CD. Serological micronutrient levels were determined during routine clinical visits up until 10 years in children with CD on a GFD.

RESULTS

The data of 130 children with CD was included. When pooling the measurements between 3 months and 10 years after GFD initiation, a deficiency in iron, ferritin, vitamin D, vitamin B12, folate and zinc was present in 33%, 21,9%, 21,1%, 2,4%, 4,3% and 8,1% of measurements, respectively. No hypocalcemia or vitamin B6 deficiency was found.

CONCLUSION

The prevalence of deficiency varies amongst nutrients in children following a GFD, a high prevalence of some nutrient deficiencies is noteworthy. This study highlights the necessity to structurally investigate the risk of developing nutrient deficiencies while following a GFD. Knowledge of the risk to develop deficiencies can contribute to achieving a more evidence based approach in the management and follow-up of CD in children.

Formula Milk Supplementation and Bone Acquisition in 4-6 Years Chinese Children: A 12-Month Cluster-Randomized Controlled Trial

Dairy foods are crucial for adequate calcium intake in young children, but scarce data are available on the effects of formula milk on bone acquisition. This cluster-randomized controlled trial investigated the effects of the supplementation of formula milk on bone health in rural children accustomed to a low-calcium diet between September 2021 and September 2022. We recruited 196 healthy children aged 4-6 years from two kindergartens in Huining County, Northwest China. A class-based randomization was used to assign them to receive 60 g of formula milk powder containing 720 mg calcium and 4.5 µg vitamin D or 20-30 g of bread per day for 12 months, respectively. Bone mineral density (BMD) and bone mineral content (BMC) at the left forearm and calcaneus, bone biomarkers, bone-related hormones/growth factors, and body measures were determined at baseline, 6, and 12 months. A total of 174 children completed the trial and were included in the analysis. Compared with the control group, formula milk intervention showed significant extra increments in BMD (3.77% and 6.66%) and BMC (4.55% and 5.76%) at the left forearm at 6th and 12th months post-intervention (all p < 0.001), respectively. Similar trends were observed in BMD (2.83%) and BMC (2.38%) in the left calcaneus at 6 months (p < 0.05). The milk intervention (vs. control) also showed significant changes in the serum concentrations of osteocalcin level (-7.59%, p = 0.012), 25-hydroxy-vitamin-D (+5.54%, p = 0.001), parathyroid hormone concentration (-15.22%, p = 0.003), and insulin-like growth factor 1 (+8.36%, p = 0.014). The percentage increases in height were 0.34%, 0.45%, and 0.42% higher in the milk group than in the control group after 3-, 6-, and 9-month intervention, respectively (p < 0.05). In summary, formula milk supplementation enhances bone acquisition at the left forearm in young Chinese children.

Fat-soluble vitamin and phytochemical metabolites: Production, gastrointestinal absorption, and health effects

Consumption of diets rich in fruits and vegetables, which provide some fat-soluble vitamins and many phytochemicals, is associated with a lower risk of developing certain degenerative diseases. It is well accepted that not only the parent compounds, but also their derivatives formed upon enzymatic or nonenzymatic transformations, can produce protective biological effects. These derivatives can be formed during food storage, processing, or cooking. They can also be formed in the lumen of the upper digestive tract during digestion, or via metabolism by microbiota in the colon. This review compiles the known metabolites of fat-soluble vitamins and fat-soluble phytochemicals (FSV and FSP) that have been identified in food and in the human digestive tract, or could potentially be present based on the known reactivity of the parent compounds in normal or pathological conditions, or following surgical interventions of the digestive tract or consumption of xenobiotics known to impair lipid absorption. It also covers the very limited data available on the bioavailability (absorption, intestinal mucosa metabolism) and summarizes their effects on health. Notably, despite great interest in identifying bioactive derivatives of FSV and FSP, studying their absorption, and probing their putative health effects, much research remains to be conducted to understand and capitalize on the potential of these molecules to preserve health.

Studies on the synergistic Interplay of Vitamin D and K for Improving Bone and Cardiovascular Health

Nutrients perform their roles either directly or through interaction with other nutrients inside our body. The nature of interactions between nutrients can be synergistic, which brings about maximum benefit to the host, or antagonistic, i.e., one nutrient affects the uptake and availability of other nutrients in the body. These interactions need to be critically analysed and acknowledged to harness their positive health benefits. Combining nutrients having a synergistic effect may help in lowering the threat of cardiovascular ailment, osteoporosis, and other health issues. This study aims to qualitatively review the information that is currently available upon the synergistic effects of co-supplementing Vitamin D and K on bone and cardiovascular health among various age groups. The methodology followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A structured search of two databases-PubMed and Google Scholar—was carried out, and articles were identified that focused upon the dual supplementation of Vitamin D and K, which has been shown to improve bone and cardiovascular health among users. The search was restricted to the English language, conducted, and published between 2006 and 2021. Overall, 12 studies involving 8216 participants were included in the qualitative analysis. Among these, 5 were randomized controlled trials, 6 were observational studies, and 1 was interventional studies. The results were interpreted based on improved bone health by assessing the progress in Bone Mineral Content (BMC), lower extremity function, Bone Mineral Density (BMD), and bone turnover. In contrast, improvement in cardiovascular health was recorded based on the Carotid Intima-media Thickness (CIMT), arterial stiffness, high systolic and diastolic blood pressure, and the structure of the heart. Out of a total 12 studies, 11 studies showed that Vitamin D work in synergy with Vitamin K and also has a significant role in improving bone fractures, low BMD, and cardiovascular disorders. Further research and clinical trials on these Vitamins in different age groups and disease conditions are warranted.

Effect of a gluten-free diet on bone mineral density in children and adolescents with celiac disease: Systematic review and meta-analysis

Studies suggest an association between a gluten-free diet (GFD) and bone health in celiac disease (CD). However, the evidence on this relationship in children and adolescents is limited. Thus, this systematic review and meta-analysis aimed to analyze the effect of GFD on the bone health and anthropometric profile of children and adolescents with CD. Five databases were searched up to January, 2022 to identify relevant studies. The studies' methodological quality was evaluated using two scales. The Hedge's g standardized mean differences (SMD) with 95% confidence intervals were estimated using a random-effects model. The GRADE approach was used to assess the quality of evidence. Twenty-eight studies were included in the final review. GFD increased bone mineral content (BMC) (SMD = 0.39; 95%CI = 0.16, 0.62) and bone mineral density (BMD) (SMD = 0.29; 95%CI = 0.10, 0.47) in CD individuals. Difference in mean BMC and BMD between children and adolescents with CD versus healthy individuals was -0.49 (95%CI = -0.76, -0.22) and -0.47 (SMD = -95%CI = -0.72, -0.22), respectively. There was no difference in BMI and body fat among celiac children and adolescents versus healthy controls. In conclusion, GFD was associated with higher BMC and BMD in children and adolescents with CD.

The Crosstalk between Vitamin D and Pediatric Digestive Disorders

Vitamin D is a cyclopentane polyhydrophenanthrene compound involved mainly in bone health and calcium metabolism but also autophagy, modulation of the gut microbiota, cell proliferation, immune functions and intestinal barrier integrity. The sources of vitamin D include sunlight, diet and vitamin D supplements. Vitamin D3, the most effective vitamin D isoform is produced in the human epidermis as a result of sunlight exposure. Vitamin D undergoes two hydroxylation reactions in the liver and kidney to reach its active form, 1,25-dihydroxyvitamin D. Recent studies highlighted a complex spectrum of roles regarding the wellbeing of the gastrointestinal tract. Based on its antimicrobial effect, it was recently indicated that vitamin D supplementation in addition to standard eradication therapy might enhance H. pylori eradication rates. Moreover, it was suggested that low levels of vitamin D might also be involved in the acquisition of H. pylori infection. In terms of celiac disease, the negative effects of vitamin D deficiency might begin even during intrauterine life in the setting of maternal deficiency. Moreover, vitamin D is strongly related to the integrity of the gut barrier, which represents the core of the pathophysiology of celiac disease onset, in addition to being correlated with the histological findings of disease severity. The relationship between vitamin D and cystic fibrosis is supported by the involvement of this micronutrient in preserving lung function by clearing airway inflammation and preventing pathogen airway colonization. Moreover, this micronutrient might exert anticatabolic effects in CF patients. Inflammatory bowel disease patients also experience major benefits if they have a sufficient level of circulating vitamin D, proving its involvement in both induction and remission in these patients. The findings regarding the relationship between vitamin D, food allergies, diarrhea and constipation remain controversial, but vitamin D levels should be monitored in these patients in order to avoid hypo- and hypervitaminosis. Further studies are required to fill the remaining gaps in term of the complex impact of vitamin D on gastrointestinal homeostasis.

ESPGHAN Position Paper on Management and Follow-up of Children and Adolescents With Celiac Disease

OBJECTIVES

To gather the current evidence and to offer recommendations for follow-up and management.

METHODS

The Special Interest Group on Celiac Diseases of the European Society of Paediatric Gastroenterology Hepatology and Nutrition formulated ten questions considered to be essential for follow-up care. A literature search (January 2010-March 2020) was performed in PubMed or Medline. Relevant publications were identified and potentially eligible studies were assessed. Statements and recommendations were developed and discussed by all coauthors. Recommendations were voted upon: joint agreement was set as at least 85%.

RESULTS

Publications (n = 2775) were identified and 164 were included. Using evidence or expert opinion, 37 recommendations were formulated on: The need to perform follow-up, its frequency and what should be assessed, how to assess adherence to the gluten-free diet, when to expect catch-up growth, how to treat anemia, how to approach persistent high serum levels of antibodies against tissue-transglutaminase, the indication to perform biopsies, assessment of quality of life, management of children with unclear diagnosis for which a gluten-challenge is indicated, children with associated type 1 diabetes or IgA deficiency, cases of potential celiac disease, which professionals should perform follow-up, how to improve the communication to patients and their parents/caregivers and transition from pediatric to adult health care.

CONCLUSIONS

We offer recommendations to improve follow-up of children and adolescents with celiac disease and highlight gaps that should be investigated to further improve management.

Evaluation of a paediatric gluten-free food guide by children and youth with coeliac disease, their parents and health care professionals

There are currently no universal evidence-based nutrition guidelines that address the gluten-free (GF) diet for children/youth (4-18 years). A GF food guide was created to help children/youth with coeliac disease (CD) and their families navigate the complexities of following a GF diet. Guide formation was based on pre-guide stakeholder consultations and an evaluation of nutrient intake and dietary patterns. The study objective was to conduct an evaluation on guide content, layout, feasibility and dissemination strategies from end-stakeholder users (children/youth with CD, parents/caregivers and health care professionals). This is a cross-sectional study using a multi-method approach of virtual focus groups and an online survey to conduct stakeholder evaluations. Stakeholders included children/youth (4-18 years), their parents/caregivers in the coeliac community (n 273) and health care professionals (n 80) with both paediatric and CD experience from across Canada. Thematic analysis was performed on focus group responses and open-ended survey questions until thematic saturation was achieved. χ² and Fisher's exact statistical analyses were performed on demographic and close-ended survey questions. Stakeholders positively perceived the guide for content, layout, feasibility, ethnicity and usability. Stakeholders found the material visually appealing and engaging with belief that it could effectively be used in multi-ethnic community and clinical-based settings. Guide revisions were made in response to stakeholder consultations to improve food selection (e.g. child-friendly foods), language (e.g. clarity) and layout (e.g. organisation). The evaluation by end-stakeholders provided practical and patient-focused feedback on the guide to enable successful uptake in community and clinical-based settings.

Effects of vitamin D on bone density in healthy children: A systematic review

Skeletal growth and bone health are very important in children. The effective role of vitamin D in bone mineral density has been observed in children and adolescents. This systematic review study evaluated the effects of vitamin D on bone density in healthy children with the help of valid databases and the website of clinical trials. The results of experimental, clinical, retrospective, prospective, double-blind, and randomized studies were used. Articles that appropriately covered the topic and had the proper content structure were selected for this review. Out of a total of 132 articles, finally, 13 articles were selected based on inclusion and exclusion criteria for further study, the results of which show the association between serum levels of vitamin D and bone mineral density and health. However, in some articles, the relationship between other influential variables such as age and nutrition on bone density in children was identified. In general, the current systematic review demonstrates the role of vitamin D on bone density in healthy children, so that in children studied, vitamin D is at different levels and complications related to bone density are observed in many children. It is recommended that more clinical and longitudinal studies be performed to further understand the role of vitamin D levels in bone health in children.

Follow-up practices for children and adolescents with celiac disease: results of an international survey

Adequate follow-up in celiac disease is important to improve dietary compliance and treat disease-related symptoms and possible complications. However, data on the follow-up of celiac children is scarce. We aimed to assess current pediatric celiac follow-up practices across Europe. Pediatricians and pediatric gastroenterologists from 35 countries in Europe, Israel, Turkey, and Russia completed an anonymous survey which comprised a 52-item questionnaire developed by the ESPGHAN Special Interest Group on Celiac Disease. A total of 911 physicians, the majority of whom exclusively worked in pediatric care (83%) and academic institutions (60%), completed the questionnaire. Mean age and mean experience with celiac care were 48.7 years (± 10.6) and 15.7 years (± 9.9), respectively. The vast majority (≥ 92%) always assessed anthropometry, dietary adherence, and tissue-transglutaminase IgA-antibodies at every visit, with the first visit being between 3 and 6 months after diagnosis. Other parameters (% always tested) were as follows: complete blood count (60%), iron status (48%), liver enzymes (42%), thyroid function (38%), and vitamin D (26%). Quality of life was never assessed by 35% of the responding physicians. Transition to adult care was mostly completed via a written transition report (37%) or no formal transition at all (27%).Conclusions: Follow-up of celiac children and adolescents in Europe may be improved, especially regarding a more rational use of (laboratory) tests, dietary and QoL assessment, and transition to adult care. Evidence-based advice from international scientific societies is needed. What is Known: • Follow-up in celiac disease is important to treat disease-related symptoms, improve dietary compliance, and prevent possible complications. • There is a lack of consensus about the appropriate follow-up. What is New: • Almost all European physicians assess anthropometry, tissue-transglutaminase IgA-antibodies, and dietary adherence at every visit, but there are large variations in other follow-up aspects. • Follow-up could be improved by a more rational use of (laboratory) tests, increased intention to dietary compliance, and quality of life together with transition programs to adult care.

Gluten-Free Diet: Nutritional Strategies to Improve Eating Habits in Children with Celiac Disease: A Prospective, Single-arm Intervention Study

Background: Elimination of gluten-containing cereals and consumption of ultra-processed gluten-free foods might cause an unbalanced diet, deficient in fiber and rich in sugar and fat, circumstances that may predispose celiac children to chronic constipation. Aim: to evaluate if counseling with a registered dietitian (RD) was capable of improving eating and bowel habits in a celiac pediatric population. Methods: Dietetic, lipid profile and stool modifications were analyzed, comparing baseline assessments with those twelve months after receiving heathy eating and nutrition education sessions. At both time points, 3-day food records, a bowel habit record and a lipid panel were conducted. Calculated relative intake of macro- and micro-nutrients were compared with current recommendations by the European Food Safety Authority (EFSA). Student’s paired t-test, McNemar test, Mandasky test and Pearson correlation tests were used. Results: Seventy-two subjects (58.3% girls) with a mean (standard deviation (SD)) age of 10.2 (3.4) years were included. Baseline diets were imbalanced in macronutrient composition. Significant improvements were observed in their compliance with dietary reference values (DRVs), where 50% of the subjects met fat requirements after the education and 67% and 49% with those of carbohydrates and fiber, respectively (p < 0.001). Celiac children decreased red meat and ultra-processed foods consumption (p < 0.001) and increased fruits and vegetables intake (p < 0.001), leading to a reduction in saturated fat (p < 0.001) and sugar intake (p < 0.001). Furthermore, 92% of the patients achieved a normal bowel habit, including absence of hard stools in 80% of children constipated at baseline (p < 0.001). Conclusions: RD-led nutrition education is able to improve eating patterns in children with celiac disease (CD).

Significant improvement in bone mineral density in pediatric celiac disease: even at six months with gluten-free diet

OBJECTIVES

Patients with celiac disease had significantly decreased bone mineral density even in patients with no gastrointestinal symptoms. Only few bone studies are available on pediatric patients with celiac disease.

METHODS

Forty-six patients underwent measurement of areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry (DXA) before the initiation of gluten-free diet. Anthropometric, laboratory and DXA measurements at baseline and at sixth month of the treatment were compared.

RESULTS

The frequency of low aBMD Z-score (≤-1 SDS) in both or any site was found to be 78.2% in this study. Of 16 patients with an aBMD Z-score of <-2 SDS five gained more than 1 SDS, and one gained more than 2 SDS. Nine of 20 patients with an aBMD Z-score of <-1 SDS completely normalized.

CONCLUSIONS

The results of the study showed that low BMD is common in children with celiac disease at the time of diagnosis and could improve in a short period of six months with a strict gluten-free diet and adequate supplementation of calcium and vitamin D.

Celiac Disease and Bone Health in Children and Adolescents: A Systematic Review and Meta-Analysis

CONTEXT

Celiac disease is characterized by deficits in bone mineral accrual and longitudinal growth.

OBJECTIVE

The purpose of this study was to determine the differences in bone health and stature among children and adolescents with celiac disease versus healthy controls.

DATA SOURCES

Articles published before February 27, 2018 were located using searches of the Physical Education Index (n = 186), PubMed (n = 180), Scopus (n = 3), SPORTDiscus (n = 3), and Web of Science (n = 4).

STUDY SELECTION

Bone mineral content (BMC) and areal bone mineral density (aBMD) were assessed via dual-energy X-ray absorptiometry, and height was measured using a stadiometer.

DATA EXTRACTION

Effect sizes (ES) were calculated as follows: the mean difference of the celiac disease group and healthy control group, divided by the pooled standard deviation. The inverse variance weight was used to calculate the overall mean ES. Random-effects models were used to aggregate a mean ES, 95% confidence intervals (CIs) and to identify potential moderators.

RESULTS

The results of 30 effects gathered from 12 studies published between 1996 and 2017 indicated BMC (ES = -0.54, 95% CI: -0.69 to -0.40; p < 0.0001) and aBMD (ES = 0.72, 95% CI: -0.96 to -0.47; p < 0.0001) were lower in youth with celiac disease.

LIMITATIONS

These results were limited to only cross-sectional and baseline data from longitudinal studies reporting BMC and BMD, however did not assess changes in bone health over time.

CONCLUSION

Children and adolescents with celiac disease have suboptimal bone health and shorter stature.

Narrative Review: Nutrient Deficiencies in Adults and Children with Treated and Untreated Celiac Disease

Nutrient deficiencies are well recognized as secondary consequences of celiac disease (CD) and closely related to the clinical presentation of affected patients. Despite their clinical significance, consensus is lacking on the pattern and frequency of nutrient deficiencies in CD, the usefulness of their assessment at the time of diagnosis and during follow-up. This review aims to provide an overview of nutrient deficiencies among pediatric and adult CD patients at diagnosis and on a gluten-free diet (GFD), and their potential causes in CD. Secondly, we review their impact on CD management strategies including the potential of nutrient supplementation. A search of Medline, Pubmed and Embase until January 2019 was performed. Despite a high variability between the reported deficiencies, we noted that nutrient deficiencies occur frequently in children and adults with CD at diagnosis and during treatment with a GFD. Both inadequate dietary intake and/or diminished uptake due to intestinal dysfunction contribute to nutrient deficiencies. Most deficiencies can be restored with (long-term) treatment with a GFD and/or supplementation. However, some of them persist while others may become even more prominent during GFD. Our results indicate a lack of comprehensive evidence on the clinical efficacy of nutrient supplementation in CD management highlighting the need for further studies.

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.

Should We Assess Vitamin D Status in Pediatric Patients With Celiac Disease?

OBJECTIVES

Screening for vitamin D status in celiac disease (CD) has been recommended but the literature provides varying support. We sought to assess the vitamin D status in newly diagnosed children with CD and in a non-CD control population and relate them to vitamin D intake.

METHODS

In a cross-sectional study, serum 25-hydroxyvitamin D (25-OHD) levels were drawn in children with newly diagnosed CD and compared with pediatric outpatients with functional abdominal complaints. Anthropometric data as well as vitamin D intake based on milk and multivitamin ingestion were collected.

RESULTS

Thirty-eight newly diagnosed CD patients (10.4 ± 3.0 years old; 50% girls) and 82 controls (11.2 ± 4.2 years old; 58.5% girls) were studied. Both groups were similar except for average daily D intake and BMI. There was no statistical difference in mean 25-OHD levels between CD (26.4 ± 8.0 ng/mL) and controls (23.5 ± 8.2 ng/mL) [P ≤ 0.07]. Both groups had high percentages of suboptimal D status (65.8% CD and 79.3% controls). 25-OHD levels significantly correlated with age (r = -0.262; P < 0.0038) and estimated vitamin D intake (r = 0.361; P < 0.0001).

CONCLUSIONS

No significant difference in 25-OHD levels was noted between newly diagnosed CD and controls, but inadequate 25-OHD levels were common in both. 25-OHD levels were highly associated with vitamin D intake demonstrating similar vitamin D absorption between patients and controls. As CD is associated with bone disease and D status is frequently low, efforts at optimizing D, such as screening levels at diagnosis need to be conducted.

Linear growth of children with celiac disease after the first two years on gluten- free diet: a controlled study

Background: Celiac disease (CD) is a lifelong disorder with gluten-induced manifestations in different organs especially growth. Gluten free diet (GFD) is required to achieve remission and prevent abnormal growth. Study reports on growth of children with celiac disease on long-term GFD are not consistent. Objective: We evaluated the effect of GFD on growth of children with the classical form of CD (diagnosed by serology and small intestine mucosal biopsy) on log-term GFD (>2 years). Methods: We studied growth parameters (weight gain/day, BMI and BMI-SDS, height growth velocity, Ht-SDS) and lab data in 30 prepubertal children, aged 7.4±2.6 years, with CD, who were on GFD since the age of 3.2±1.6 years of age (>2 years on GFD) for duration of 1 year. The anthropometric data of 30 randomly selected normal, age and sex matched, children were used as control. Lab investigations of CD children included complete blood count (CBC), renal and liver functions (aspartate transaminase - AST, alanine aminotransferase - ALT, and alkaline phosphatase- ALP, serum albumin, fasting blood glucose, vitamin D, and thyroid function and antibodies. Results: The weight gain per day was on average or above, for age and sex, in 27 children and below average in 3. Two out of those 3 children had slow linear growth (decreased Ht-SDS by -0.56 and -0.1, over one year). BMI-SDS was normal in 26/30 patients (>-1.5). BMI-SD changed from -0.36±1.1 to -0.33±1.1 during the year of treatment. BMI-SDS decreased in 9 children during the follow up period that was explained by their fast-linear growth (increased Ht-SDS) in seven of them. The Ht-SDS was <-2 in four out of 30 children at the beginning of the study (2 years after being on GFD) and in 2 children after a year of follow-up (catch-up growth). Ht-SDS remained normal or increased in 28/30 children during the year of treatment (-0.38 ±1.2 to -0.22±1.1), with a positive trend: 0.15±0.4 SDS. Only one patient crossed down 1 Ht-SDS during the year of follow up, with low weight gain/day and decreased BMI-SDS that can be explained by poor compliance with GFD. Ht-SDS and BMI-SDS increased significantly in the CD group versus controls during the year of follow-up. All patients had normal serum albumin, liver enzyme and hemoglobin levels. 33.3% of patients had low serum ferritin level and 33.3% had a vitamin D deficiency. Conclusions: Most of our children with CD grew normally both in height and weight during GFD. Significant catch-up growth occurred in some of them after 2 years of being on GFD. Those with low BMI-SDS and/or Ht-SDS needed further management, including reinforcement on the importance of GFD and investigations on factors affecting growth pattern. Measuring weight gain /day appears to be a sensitive indicator for monitoring growth in these children. Vitamin D and iron status should be monitored, and deficiencies corrected. (www.actabiomedica.it)

[Analysis of the gluten-free menus served in school canteens: are they balanced?]

Introduction

Introduction and objectives: the alimentary profile and the nutritional value of the menus adapted for coeliacs in the dining halls of the schools of Granada capital and Metropolitan Area. Material and methods: descriptive study in which we analyzed the menus adapted for children from 41 schools, 5 with their own kitchen and 36 supplied by catering. The information is recognized through the technical sheets of the dishes made with the quantity of each food, in addition to the brands of the gluten-free products. The four-week menus will be analyzed in terms of the distribution of rations, energy, macro and micronutrients for the age group of 10 to 12 years, obtaining average values and standard deviation of 31 parameters. The Odimet program and the CeliacBase database are used. The data will be analyzed using the IBM SPSS 22.0 statistical program. Results: gluten-free pasta was the basis of the first course in 31.7% of the menus analyzed. In the second dish, the meat was the main constituent. In all the menus, at least one daily vegetable ration was offered. 80% of the menus did not reach the recommended energy intake, although the distribution of macronutrients was adequate. The average amount of fiber and total carbohydrates was higher than recommended. The amount of calcium and vitamin has not been recommended. It emphasizes a high consumption of sodium, which doubles the amount recommended for the midday meal. Conclusions: school menus adapted for children conform to the recommendations, although they should be limited to intake.

Nutritional Deficiencies in Children with Celiac Disease Resulting from a Gluten-Free Diet: A Systematic Review

BACKGROUND

A strictly gluten-free diet (GFD) is the basis for managing celiac disease (CD). Numerous studies have reported nutritional deficiencies/imbalances ascribable to a GFD. The aim of this review is to describe nutritional deficiencies observed in children with celiac disease on a GFD, to discuss the clinical consequences related to these nutritional imbalances, and to identify strategies that may be adopted to treat them.

METHODS

We reviewed the MEDLINE and EMBASE databases between January 1998 and January 2019.

RESULTS

Children are, regardless of whether they are on a gluten-free diet or not, at risk of consuming too much fat and insufficient fiber, iron, vitamin D, and calcium. These imbalances may be exacerbated when children are on a gluten-free diet. In particular, the intake of folate, magnesium, zinc, and foods with a high glycemic index in children with CD who are on a GFD is significantly altered.

CONCLUSIONS

Therapeutic protocols should include nutritional education to help teach subjects affected by disorders such as CD the importance of labels, the choice of foods, and the combination of macro- and micronutrients. Children with CD on a GFD should be encouraged to rotate pseudo-cereals, consume gluten-free commercial products that have been fortified or enriched, and use foods that are local and naturally gluten-free.

Micronutrients Dietary Supplementation Advices for Celiac Patients on Long-Term Gluten-Free Diet with Good Compliance: A Review

Background and objective: Often micronutrient deficiencies cannot be detected when patient is already following a long-term gluten-free diet with good compliance (LTGFDWGC). The aim of this narrative review is to evaluate the most recent literature that considers blood micronutrient deficiencies in LTGFDWGC subjects, in order to prepare dietary supplementation advice (DSA). Materials and methods: A research strategy was planned on PubMed by defining the following keywords: celiac disease, vitamin B12, iron, folic acid, and vitamin D. Results: This review included 73 studies. The few studies on micronutrient circulating levels in long-term gluten-free diet (LTGFD) patients over 2 years with good compliance demonstrated that deficiency was detected in up to: 30% of subjects for vitamin B12 (DSA: 1000 mcg/day until level is normal, then 500 mcg), 40% for iron (325 mg/day), 20% for folic acid (1 mg/day for 3 months, followed by 400–800 mcg/day), 25% for vitamin D (1000 UI/day or more-based serum level or 50,000 UI/week if level is <20 ng/mL), 40% for zinc (25–40 mg/day), 3.6% of children for calcium (1000–1500 mg/day), 20% for magnesium (200–300 mg/day); no data is available in adults for magnesium. Conclusions: If integration with diet is not enough, starting with supplements may be the correct way, after evaluating the initial blood level to determine the right dosage of supplementation.

Prevalence of and Risk Factors for Low Bone Mineral Density in Children With Celiac Disease

BACKGROUND & AIMS

Celiac disease can reduce bone mineral density. We sought to determine the prevalence and risk factors for low areal bone mineral density (aBMD) in children with celiac disease.

METHODS

We performed a retrospective cohort study of 673 children with celiac disease (63% female; median age at diagnosis, 10.6 y; interquartile range, 7.8-13.9) who underwent dual x-ray absorptiometry (DXA) from 2009 through 2016 at the Children's Hospital of Philadelphia. We collected demographic, clinical, and laboratory data from medical records. We performed logistic regression analysis to identify factors associated with low (Z less than -2) lumbar spine aBMD Z (aBMD-Z) scores at initial and subsequent tests.

RESULTS

The time between diagnosis of celiac disease and first DXA was 0 days (interquartile range, -11 to 31 d). The mean aBMD-Z score at the children's initial scan was -0.4 ± 1.2; 46 children had aBMD-Z scores less than -2 (6.8%; 95% CI, 5.2%-9.0%). Those who had a second DXA analysis (n = 108; 16.0%) had a significant increase in aBMD-Z score (mean change, 0.29; P = .0005). Higher body mass index (BMI) was associated with lower odds of a low aBMD-Z score at the initial DXA analysis (odds ratio, 0.46, 95% CI, 0.35-0.50). BMI-Z scores greater than -0.4 identified children with a low aBMD-Z at their initial DXA analysis with a 95% negative predictive value.

CONCLUSIONS

Approximately 7% of subjects with celiac disease had a low aBMD-Z score, determined by DXA, at the time of diagnosis; this value was nearly 3-fold higher than expected from a population of children of this age and sex distribution. BMI-Z scores could be used to identify children with celiac disease at risk for low BMD who should receive DXA screening.

Gluten-Free Diet: Gaps and Needs for a Healthier Diet

The gluten-free diet (GFD) is currently the only effective treatment in remitting the symptoms of coeliac disease (CD), a chronic systemic autoimmune disorder caused by a permanent intolerance to gluten proteins in genetically susceptible individuals. The diet entails the substitution of gluten-containing products with gluten-free-rendered products. However, over recent decades the nutritional profile of gluten-free (GF) food products has been increasingly questioned within the scientific community. The aim of this paper is to review the nutritional profile of gluten-free-rendered products currently available on the market, and discuss the possible relationship thereof with the nutritional status of coeliac patients on a GFD. Key inadequacies of currently available GF products are low protein content and a high fat and salt content. More adequate levels of dietary fiber and sugar than in the past have been reported. Population studies confirmed the above mentioned inadequacies. Further efforts are required to conceive adoptable interventions for product development and reformulation in order to achieve compliance with nutritional recommendations.

Beneficial Effect of Oligofructose-Enriched Inulin on Vitamin D and E Status in Children with Celiac Disease on a Long-Term Gluten-Free Diet: A Preliminary Randomized, Placebo-Controlled Nutritional Intervention Study

Prebiotics have been shown to improve absorption of some nutrients, including vitamins. This pilot study evaluated the effect of the prebiotic oligofructose-enriched inulin (Synergy 1) on fat-soluble vitamins status, parathormone, and calcium-related elements in pediatric celiac disease (CD) patients (n = 34) on a strict gluten-free diet (GFD). Participants were randomized into a group receiving 10 g of Synergy 1 or placebo (maltodextrin) together with a GFD. At baseline and after 3 months of intervention, 25-hydroxyvitamin D [25(OH)D], parathormone, vitamin E and A, calcium, phosphate, magnesium, total protein, and albumin were determined. Concentration of 25(OH)D increased significantly (p < 0.05) by 42% in CD patients receiving Synergy 1 in GFD, whereas no change was observed in placebo. Vitamin D status reached an optimal level in 46% of patients receiving Synergy 1. No significant difference in parathormone, calcium, and phosphate levels was observed. Concentration of vitamin E increased significantly (p < 0.05) by 19% in patients receiving Synergy 1, but not in the placebo. Vitamin A levels were not changed. Supplementation of GFD with Synergy 1 improved vitamin D and vitamin E status in children and adolescents with CD and could be considered a novel complementary method of management of fat-soluble vitamins deficiency in pediatric CD patients.

Bone mineral density and vitamin K status in children with celiac disease: Is there a relation?

BACKGROUND/AIMS

To investigate bone mineral density (BMD) in children with celiac disease (CD) and to evaluate the association between vitamin K levels and osteoporosis.

MATERIALS AND METHODS

Children with CD and age- and sex-matched healthy control subjects were prospectively included in the study. BMD was measured, and serum anti-tissue transglutaminase IgA, ferritin, folate, vitamin B12, 25-hydroxy vitamin D and K2, calcium, phosphate, alkaline phosphatase, and parathormone were assayed in all subjects.

RESULTS

Overall, 72 patients (mean age 11.69±3 years, 59.7% female) and 30 healthy subjects (mean age 12.27±2.12 years, 63.3% female) were enrolled. The mean BMD Z score of the celiac group was significantly lower than that of the control group (-1.23±1.07 vs. -0.35±1.04, p=0.001). Vitamin D and K2 values did not differ significantly between the two groups (p > 0.05). BMD was positively correlated with vitamin D (r=0.198, p=0.001) and negatively with PTH (r=-0.397, p=0.002).

CONCLUSION

The BMD of celiac patients was lower than that of the control subjects. There was no difference in terms of vitamin D and K2 levels between the two groups. Further studies investigating the level and effect of vitamin K on bone in CD are needed.

Fat soluble vitamin levels in children with newly diagnosed celiac disease, a case control study

Background

In children diagnosed with celiac disease, fat soluble vitamin levels were aimed to be evaluated and it was intended to determine whether fat soluble vitamin levels were needed to be assessed routinely in these patients during diagnosis.

Methods

Between May 2015–May 2016, diagnosis symptoms of celiac patients (CD) in newly diagnosed pediatric group were questioned, fat soluble vitamin levels simultaneous with intestinal biopsies were evaluated. Vitamin levels were compared with those of healthy control group.

Results

A total of 52 patients involving 27 female (51.9%), 25 male (48.1%); and a total of 50 healthy control group including 25 female (50%), 25 male (50%) were evaluated. The average age of patients was 9 ± 4.3 years, and their average weight was determined as 16.2 ± 6.3 kg. Growth retardation was the most frequent symptom in our patients (61.5%). Abdominal pain (51.9%) and diarrhea (11.5%) are among the other most commonly seen symptoms. In the histological examination of patients, Marsh 3B n = 23 (45.1%) was mostly established. Vitamin A and vitamin D levels of patients were determined significantly lower compared to those of control group. Vitamin A and vitamin D deficiencies were identified significantly higher compared to those of healthy control group. Vitamin D insufficiency was observed in 48 patients (92.3%) and vitamin D deficiency was determined in 32 (61.5%) out of 48. Vitamin A deficiency was established in 17 (32.7%) patients. Vitamin E and vitamin K1 deficiency were determined in no patients. In the healthy control group, vitamin D deficiency was seen in 2 (4%) patients, vitamin D insufficiency was determined in 9 (18%) patients. Other vitamin levels were identified at normal levels in the healthy group.

Conclusions

In newly diagnosed children with CD, a significant lowness was established in vitamin D and A. The evaluation of vitamin A and D levels will be helpful in the course of diagnosis in these patients.

Paediatric Patients with Coeliac Disease on a Gluten-Free Diet: Nutritional Adequacy and Macro- and Micronutrient Imbalances

PURPOSE OF REVIEW

A strict, lifelong gluten-free diet is the cornerstone for management of coeliac disease. Elimination of gluten from the diet may be associated with nutritional imbalance; however, the completeness of this diet in energy and macro- and micronutrients in children is not well described. Understanding the nutritional adequacy of the gluten-free diet in children during this critical period of growth and development when dietary intake is strongly influential is important.

RECENT FINDINGS

Children, regardless of whether they have eliminated gluten from their diet, have a tendency to consume excess fat and insufficient fibre, iron, vitamin D and calcium, compared to recommendations. In the context of a gluten-free diet, these imbalances may be worsened or have more significant consequences. Paediatric studies have demonstrated that intakes of folate, magnesium, zinc and selenium may decrease on a gluten-free diet. Nutritional inadequacies may be risks of a gluten-free diet in a paediatric population. The potential implications of these inadequacies, both short and long term, remain unclear and warrant further investigation and clarification.

How to improve the gluten-free diet: The state of the art from a food science perspective

The celiac disease is the most common food intolerance and its prevalence is increasing. Consequently, use of gluten-free diet has expanded, notwithstanding consumption as therapy for other gluten-related disorders or by wellbeing people without any medical prescription. Even the therapeutic efficiency has undoubtedly proven, several drawbacks mainly regarding the compliance, nutritional deficits and related diseases, and the alteration of the intestinal microbiota have described in the literature. Food science has been considered as one of the primary area of intervention to limit or eliminate such drawbacks. Efforts have approached shelf life, rheology and palatability aspects but more recently have mainly focused to improve the nutritional features of the gluten-free diet, and to propose dietary alternatives. The sourdough fermentation has shown the most promising results, also including a biotechnology strategy that has allowed the complete degradation of gluten prior to consumption.

Vitamin D Status and Bone Mineral Density is Influenced by Vitamin D Supplementation and Vitamin K1 Intake in Adults with Diabetes and Chronic Kidney Disease

PURPOSE

Patients with diabetes (DM) and chronic kidney disease (CKD) are at increased risk for suboptimal bone health. The study objective was to investigate the relationships between vitamin D (vitD), vitamin K1 (vitK₁), and calcium intake with bone mineral density (BMD) and vitamin D status in an ambulatory population with DM and CKD.

METHODS

Adults (age 18-80 years; n = 62) with DM and CKD (stages 1-4) were recruited from the Northern Alberta Renal Program. Primary outcome variables included vitD, vitK₁, and calcium intake; serum 25(OH)D, 1,25(OH)₂D; and BMD as measured by dual X-ray absorptiometry. Statistical significance was determined at P < 0.05.

RESULTS

Participants met the estimated average requirement or adequate intake for vitD, vitK₁, and calcium intake in 73% (n = 45), 66% (n = 39), and 52% (n = 31), respectively, with a combined intake of micronutrient supplementation and diet. Participants had serum 25(OH)D concentrations ≥75 nmol/L (n = 41), normal BMDs (n = 48), and 66% (n = 41/62) were taking vitD supplements (>1000 IU/D). BMD was positively influenced by serum 25(OH)D. However, serum 25(OH) ≥100 nmol/L was associated with lower BMD (absolute and T-scores) for whole-body and spine (P ≤ 0.05). VitK₁ intake (≥200 μg/day) was associated with higher whole-body and femoral-neck BMDs (absoluteand T-scores; P ≤ 0.05).

CONCLUSION

VitD status and BMD in adults with DM and CKD was influenced by vitD supplementation and vitK₁ intake.

Evidence-Informed Expert Recommendations for the Management of Celiac Disease in Children

Although the need for effective long-term follow-up for patients with celiac disease (CD) has been recognized by many expert groups, published practice guidelines have not provided a clear approach for the optimal management of these patients. In an attempt to provide a thoughtful and practical approach for managing these patients, a group of experts in pediatric CD performed a critical review of the available literature in 6 categories associated with CD to develop a set of best practices by using evidence-based data and expert opinion. The 6 categories included the following: bone health, hematologic issues, endocrine problems, liver disease, nutritional issues, and testing. Evidence was assessed by using standardized criteria for evaluating the quality of the data, grade of evidence, and strength of conclusions. Over 600 publications were reviewed, and 172 were chosen for inclusion. The thorough review of the results demonstrated that the quality of the data available was often insufficient to provide unequivocal best practices. However, using the available data and the clinical experience of the panel, a practical framework for the management of children with CD was created. These recommendations were developed by our expert panel and do not necessarily reflect the policy of the American Academy of Pediatrics. The potential usefulness of these best practices is underscored by the fact that consensus, measured by the outcome of anonymous voting, was reached by the panel for 24 of the 25 questions. We hope that these best practices may be useful to the pediatric gastroenterology and larger general pediatric communities.

Parental Health Beliefs, Socio-demographics, and Healthcare Recommendations Influence Micronutrient Supplementation in Youth with Celiac Disease

To identify parental influences affecting micronutrient supplementation in children and adolescents (2–18 years of age) with Celiac Disease (CD), a multi-method (survey, focus groups) study was conducted. A 35-item questionnaire consisting of open- and closed-ended questions was launched nationally via Canadian Celiac Association internet sites. Five focus groups were conducted using a semi-structured interview guide. The survey and semi-structured interview guide content was vetted for face and content validity. Thematic analyses were conducted on the focus group content and open-ended survey questions, and χ2 and Fischer’s exact analysis were performed on closed-ended survey data. Survey respondents were predominantly mothers (97%) of female children (80 F, 49 M) between the ages of 9–12 (31%) with CD, residing in western provinces (55%) with a combined family income ≥$100 000/year (63%). Seventy-seven percent of parental respondent’s children or adolescents consumed micronutrient supplements, for 1–5 years (52%), 7 days a week (65%), as both multi-vitamin and single vitamin preparations (40%). Parental influences on child micronutrient use included health beliefs and knowledge, parental supplement use, supplement characteristics, age of child (above or below 13 years), household routines, and provincial residential status (P < 0.05). Parents relied on health professional recommendation (69%; MD, RD) and the internet (21%) as sources of information regarding child micronutrient supplementation. Parental health beliefs and knowledge, socio-demographic factors, and practitioner recommendation influence micronutrient supplement use in children and adolescents with CD.

Vitamin D deficiency in patients with intestinal malabsorption syndromes--think in and outside the gut

There is a very high prevalence of vitamin D deficiency, which is defined by a serum level of 25-hydroxyvitamin D [25(OH)D] of lower than 20 ng/mL, in all populations of the world. Unfortunately, the prevalence of vitamin D deficiency in patients with intestinal malabsorption syndromes, including cystic fibrosis (CF), celiac disease (CD), short bowel syndrome and inflammatory bowel disease (IBD), is higher than that in the general population, indicating the presence of disease-specific causative factors. In this review, we aimed to present clinical findings to highlight the roles of insufficient exposure to sunlight and inflammation in the development of vitamin D deficiency in patients with intestinal malabsorption syndromes. Furthermore, we aimed to present experimental evidence that supported a role of vitamin D deficiency in the pathogenesis of IBD. Finally, we reviewed clinical intervention strategies aiming to normalize vitamin D status in and even to improve the conditions of patients and to discuss certain issues that needed to be addressed in future research.

Assessing Nutritional Quality and Adherence to the Gluten-free Diet in Children and Adolescents with Celiac Disease

PURPOSE

Little is known regarding nutritional adequacy of the gluten free diet (GFD) in children and adolescents with celiac disease (CD). The study aim was to examine macro- and micronutrient intake in children with CD.

METHODS

A cross-sectional study was conducted in children and adolescents (4-18 years of age) with CD (n = 32) and healthy controls (n = 32). Macro- and micronutrient intake, and glycemic index (GI) and glycemic load (GL) intake was assessed using validated measures. Diet quality was assessed using the Canadian Healthy Eating Index (HEI-C) and the Alberta Nutrition Guidelines. Values are shown as mean ± SE.

RESULTS

Age (10.4 ± 0.7 years vs 8.7 ± 0.7 years; P = 0.06), weight-for-age z score (P = 0.27), and height-for-age z score (P = 0.23) were not different between groups. CD children consumed more fibre (15.9 ± 1.2 g per day(CD) vs 10.8 ± 0.8 g per day (controls); P < 0.001), had higher GI (CD: 54 ± 2 vs 48 ± 1; P < 0.01) and GL (CD: 118 ± 8 vs 93 ± 7; P = 0.02), and lower folate (146.7 ± 15.3 (CD) vs 245.4 ± 21.8 µg per day (controls); P < 0.001) than controls. No differences in HEI-C scores (≤ and > 80) were observed between groups (P > 0.05).

CONCLUSION

Children with CD had high intakes of fibre, GI, and GL and lower intakes of folate. This has implications for dietary counselling in this population.

Increased risk for vitamin d deficiency in obese children with both celiac disease and type 1 diabetes

Background. It is unknown whether the coexistence of type 1 diabetes (T1D) and celiac disease (CD) increases the risk for vitamin D deficiency. Aims. To determine the vitamin D status and the risk for vitamin D deficiency in prepubertal children with both T1D and CD compared to controls, TID, and CD. Subjects and Methods. Characteristics of 62 prepubertal children of age 2–13 y with either CD + T1D (n = 22, 9.9 ± 3.1 y), CD only (n = 18, 8.9 ± 3.3 y), or T1D only (n = 22, 10.1 ± 2.8 y) were compared to 49 controls of the age of 8.0 ± 2.6 years. Vitamin D deficiency was defined as 25(OH)D < 50 nmol/L, overweight as BMI of >85th but <95th percentile, and obesity as BMI > 95th percentile. Results. The 4 groups had no difference in 25(OH)D (ANOVA P = 0.123) before stratification into normal-weight versus overweight/obese subtypes. Following stratification, 25(OH)D differed significantly between the subgroups (F_(3,98) = 10.109, ANOVA P < 0.001). Post-hoc analysis showed a significantly lower 25(OH)D in the overweight/obese CD + T1D compared to the overweight/obese controls (P = 0.039) and the overweight/obese CD (P = 0.003). Subjects with CD + T1D were 3 times more likely to be vitamin D deficient (OR = 3.1 [0.8–11.9], P = 0.098), compared to controls. Conclusions. The coexistence of T1D and CD in overweight/obese prepubertal children may be associated with lower vitamin D concentration.

Is it necessary to assess for fat-soluble vitamin deficiencies in pediatric patients with newly diagnosed celiac disease?

BACKGROUND

The purpose of this study was to identify the frequency of fat-soluble vitamin deficiencies in children with celiac disease (CD) and to determine the value of routine testing for these deficiencies.

METHODS

We conducted a retrospective medical record review of patients with a confirmed diagnosis of CD and fat-soluble vitamin levels measured at diagnosis between 1995 and 2012 at Mayo Clinic. Patients' demographics, fat-soluble vitamin levels, and pertinent clinical factors at the time of diagnosis were collected.

RESULTS

Eighty-three patients were included in the final analysis: 51 girls and 32 boys, with an average age at diagnosis of 12.8 years in girls and 13.0 years in boys. The most commonly reported symptoms were abdominal pain in 49 patients and diarrhea in 30 patients. Family history of CD was reported in 32 patients. Average vitamin levels for vitamin E, 25-hydroxyvitamin D (25 (OH) D), and vitamin A were 7.5 mg/L, 32.8 ng/mL, and 334.5 μg/dL, respectively. No patients had vitamin A deficiency, 2 patients had vitamin E deficiency, and 9 patients had mild-to-moderate vitamin D deficiency (none had severe deficiency). Both patients with vitamin E deficiency were symptomatic and had complete villous atrophy. Thirty-one patients had insufficiency of 25 (OH) D, which was less than the reported frequency of vitamin D insufficiency in the general pediatric population in the United States in 2004. None of the patients were receiving vitamin supplements at the time of diagnosis.

CONCLUSIONS

Fat-soluble vitamin deficiencies are uncommon in children with new diagnosis of CD. Routine measuring of fat-soluble vitamins levels may not be necessary.

Bone mineralization in celiac disease

Evidence indicates a well-established relationship between low bone mineral density (BMD) and celiac disease (CD), but data on the pathogenesis of bone derangement in this setting are still inconclusive. In patients with symptomatic CD, low BMD appears to be directly related to the intestinal malabsorption. Adherence to a strict gluten-free diet (GFD) will reverse the histological changes in the intestine and also the biochemical evidence of calcium malabsorption, resulting in rapid increase of BMD. Nevertheless, GFD improves BMD but does not normalize it in all patients, even after the recovery of intestinal mucosa. Other mechanisms of bone injury than calcium and vitamin D malabsorption are thought to be involved, such as proinflammatory cytokines, parathyroid function abnormalities, and misbalanced bone remodeling factors, most of all represented by the receptor activator of nuclear factor B/receptor activator of nuclear factor B-ligand/osteoprotegerin system. By means of dual-energy X-ray absorptiometry (DXA), it is now rapid and easy to obtain semiquantitative values of BMD. However, the question is still open about who and when submit to DXA evaluation in CD, in order to estimate risk of fractures. Furthermore, additional information on the role of nutritional supplements and alternative therapies is needed.