The prevalence of celiac disease in average-risk and at-risk Western European populations: a systematic review

Clinical presentation and factors associated with gluten exposure in children with celiac disease

OBJECTIVES

The prevalence of celiac disease (CeD) is increasing, yet it is still underdiagnosed, in part because of its heterogeneous presentation. Diagnostic criteria are evolving and management with strict adherence to a gluten-free diet is challenging for many. We aimed to characterize the clinical presentation of CeD among a large multicenter cohort of pediatric patients and to identify factors associated with gluten-free diet adherence.

METHODS

Patients with CeD aged 0-18 years were recruited from 11 United States health centers. Parents completed surveys about gluten-free diet adherence and patient electronic health records were reviewed. Logistic regression analyses were performed to identify risk factors associated with gluten exposure.

RESULTS

Charts were reviewed for 460 children with a median age of 6.4 years. Abdominal pain was reported in 57% of the cohort, but diverse symptoms were identified. Parent surveys were completed for 455 participants. Sixty-five (14%) participants were at high risk for gluten exposure based on parental reports of weekly or daily gluten exposure or eating gluten by choice in the past year. Participants under the age of 5 years had a lower risk of gluten exposure, while participants without repeat serology testing 18 months after initial diagnosis were at higher risk of gluten exposure.

CONCLUSIONS

In a large, multicenter cohort of pediatric CeD patients, clinical presentation is highly variable, necessitating a high index of suspicion to make a diagnosis. Parent surveys indicate that 14% of patients are at high risk of gluten exposure, with patient age and lack of close follow-up associated with gluten-free diet adherence.

Long-Term Cost-Effectiveness of Case Finding and Mass Screening for Celiac Disease in Children

BACKGROUND & AIMS

Celiac disease (CD) is a common yet underdiagnosed autoimmune disease with substantial long-term consequences. High-accuracy point-of-care tests for CD antibodies conducted at youth primary health care centers may enable earlier identification of CD, but evidence about the cost-effectiveness of such strategies is lacking. We estimated the long-term cost-effectiveness of active case finding and mass screening compared with clinical detection in the Netherlands.

METHODS

A decision tree and Markov model were used to simulate a cohort of 3-year-old children with CD according to each strategy, taking into account their impact on long-term costs (from a societal perspective) and quality-adjusted life-years (QALYs). Model parameters incorporated data from the GLUTENSCREEN project, the Dutch Celiac Society, the Dutch Pediatric Surveillance Unit, and published sources. The primary outcome was the incremental cost-effectiveness ratio (ICER) between strategies.

RESULTS

Mass screening produced 7.46 more QALYs and was €28,635 more costly compared with current care (ICER: €3841 per QALY), and case finding produced 4.33 more QALYs and was €15,585 more costly compared with current care (ICER: €3603 per QALY). At a willingness to pay of €20,000 per QALY, both strategies were highly cost-effective compared with current care. Scenario analyses indicated that mass screening is likely the optimal strategy, unless no benefit in detecting asymptomatic cases is assumed.

CONCLUSIONS

An earlier identification of CD through screening or case finding in children using a point-of-care tests leads to improved health outcomes and is cost-effective in the long-term compared with current care. If the feasibility and acceptability of the proposed strategies are successful, implementation in Dutch regular care is needed.

HLA Genotyping in Children With Celiac Disease Allows to Establish the Risk of Developing Type 1 Diabetes

INTRODUCTION

Celiac disease (CD) and type 1 diabetes (T1D) often co-occur and share genetic components in the human leukocyte antigen (HLA) class II region. We aimed to study the usefulness of HLA genotyping in predicting the risk of developing T1D in patients with CD and the temporal relationship between these diseases.

METHODS

A cohort of 1,886 Sardinian patients, including 822 with CD, 1,064 with T1D, and 627 controls, underwent HLA class II typing. Seventy-six of 822 patients with CD were also affected by T1D (CD-T1D), and their HLA genotypes were analyzed for specific HLA associations with CD, T1D, and controls.

RESULTS

High-risk HLA-DQ genotypes, including HLA-DQ2.5/DQ8, -DQ2.5/DQ2.5, and -DQ2.5/DQ2.3, were strongly associated with CD-T1D with frequencies of 34.5%, 15.9%, and 18.8%, respectively. Conversely, certain HLA genotypes associated with CD seemed to confer protection against T1D development. Therefore, HLA genotyping allows for the identification of those patients with CD who might develop T1D. The frequency of patients with CD preceding T1D is higher in younger children than older ones, with implications for the early childhood approach to diabetes prevention.

DISCUSSION

CD is a condition for future T1D development, and specific HLA genotypes can predict this risk. Early screening for celiac autoimmunity and subsequent HLA typing in CD children could help identify those at high risk of T1D, allowing for proactive interventions and immunotherapies to preserve β-cell function. These findings may support the re-evaluation of HLA typing in children with CD.

A Deep Learning-Based Approach to Estimate Paneth Cell Granule Area in Celiac Disease

CONTEXT.—

Changes in Paneth cell numbers can be associated with chronic inflammatory diseases of the gastrointestinal tract. So far, no consensus has been achieved on the number of Paneth cells and their relevance to celiac disease (CD).

OBJECTIVES.—

To compare crypt and Paneth cell granule areas between patients with CD and those without CD (non-CD) using an artificial intelligence-based solution.

DESIGN.—

Hematoxylin-eosin-stained sections of duodenal biopsies from 349 patients at the McGill University Health Centre were analyzed. Of these, 185 had a history of CD and 164 were controls. Slides were digitized, and NoCodeSeg, a code-free workflow using open-source software (QuPath, DeepMIB), was implemented to train deep learning models to segment crypts and Paneth cell granules. The total area of the entire analyzed tissue, epithelium, crypts, and Paneth cell granules was documented for all slides, and comparisons were performed.

RESULTS.—

A mean intersection-over-union score of 88.76% and 91.30% was achieved for crypt areas and Paneth cell granule segmentations, respectively. On normalization to total tissue area, the crypt to total tissue area in CD was increased and the Paneth cell granule area to total tissue area decreased when compared to non-CD controls.

CONCLUSIONS.—

Crypt hyperplasia was confirmed in CD compared to non-CD controls. The area of Paneth cell granules, an indirect measure of Paneth cell function, decreased with increasing severity of CD. More importantly, our study analyzed complete hematoxylin-eosin slide sections using an efficient and easy to use coding-free artificial intelligence workflow.

Experiences and perceptions of people with celiac disease, food allergies and food intolerance when dining out

Introduction

Eating out is a common practice in modern society. Celiac disease (CeD) and food allergy (FA) are among the most common conditions responsible for adverse reactions to food. Despite their different origins, both require treatment with restrictive diets (avoidance of gluten and/or specific allergens) and this results posing similar challenges when eating out. Our objective was to learn about the experiences/perceptions of consumers with CeD and FA when dining out, as well as the challenges they face in food service environments.

Methods

An ad hoc questionnaire was used to record consumer perceptions, food service characteristics and resulting adverse reactions.

Results

377 individuals living in Santiago, Chile, provided complete information and were analyzed (160 CeD, 105 FA). 301 participants (79.8%) declared eating out, 33.6% reported experiencing an adverse reaction at least once while eating out. 94.4% of the 377 participants believed that the serving staff had little or no knowledge about his/her condition. Consumers reporting symptoms as severe adverse reactions were more common among celiac than allergic patients (p < 0.001).

Discussion

The study showed no significant differences based on consumer-related characteristics (p:NS). The consequences of eating out did not vary based on individual's data, including diagnosis, age, frequency of eating out, adverse reactions experienced, or intensity. These findings suggest that the most important determinants of risk associated with eating out are characteristics of the food service, like availability of information, staff training, and establishment's facilities like equipment available, exclusive utensils for customers with special dietary needs and kitchen and bathrooms organization.

Celiac Disease in Moroccan Children: Diagnostic Characteristics and Determinants of Diagnosis Delay

Advances in the field of celiac disease have led to a better understanding of the disease, but it remains underdiagnosed and poses a daily challenge to clinicians to make a timely diagnosis. This study aims to analyze and describe diagnosis characteristics, diagnosis delay, and the factors influencing this delay in Moroccan children. Our study included 324 children diagnosed during the study period from January 01, 2010, to December 30, 2019, at the Department of Pediatrics, Hassan II University Hospital in Fez, Morocco. Data were collected using a collection grid and then analyzed using SPSS 26 software (IBM Corp., Armonk, NY). The results showed a female predominance (n=197, 60.8%), with a diagnosis age of 73.8±46.8 months. The mean age onset of symptoms was 51.3±41.2 months, and the diagnosis delay was 22.2±22.6 months, with only 32.7% (n=106) diagnosed less than 12 months after symptom onset. The most common consultation reason was diarrhea (n=149, 46%) and growth delay (n=105, 32.4%) and 50.5% (n=98) of parents consulted a pediatrician first. The three clinical, serologic, and histologic criteria made it possible to agree on the diagnosis, with the clinical profile dominated by the digestive form at 84.9% (n=279), serologic with the presence of IgA transglutaminase antibodies (95.7%; n=310), and histologic with villous atrophy at 91.7% (n=297). Unfortunately, 14.8% (n=48) of the children were diagnosed with a celiac crisis. The multivariate logistic regression analysis showed that as symptoms onset age increased, so did the risk of late diagnosis (OR=0.96, 95% CI: 0.94 to 0.97, p<0.001). Age of diagnosis was also associated with delayed diagnosis (OR=19.68, 95% CI: 8.77 to 44.15, p<0.001). The combination of these variables and the diagnosis delay argues in favor of adopting a diagnosis strategy that includes raising awareness among healthcare professionals of the need to identify typical and atypical cases early in order to reduce the adverse effects of late diagnosis and the complications that can result. This methodology for improving diagnoses may also unearth previously unknown aspects of celiac disease in Moroccan children.

Accuracy of Serological Screening for the Diagnosis of Celiac Disease in Type 1 Diabetes Children

Background and Objectives: Patients with type 1 diabetes (T1D) are considered at high-risk for developing celiac disease (CD). The purpose of our study was to determine the prevalence of CD among children who were followed in our unit for T1D using the latest ESPGHAN guidelines, and avoiding intestinal biopsies in some of the children. Materials and Methods: We performed a prospective monocentric study, which included 663 T1D children between June 2014 and June 2016. We considered CD according to serological (tissue transglutaminase (TGAs) and endomysium antibodies) results. Children were included either at the time of T1D diagnosis or during their follow up. We looked for clinical and biochemical signs of CD, and for T1D characteristics. Results: The children's ages ranged from 11 months to 18 years. CD was confirmed in 32 out of 663 patients with T1D, with a prevalence of 4.8%. CD was excluded in 619 children and remained uncertain for 12 children, who had positive TGAs without the required criteria. We found that 95% of T1D children express HLA-DQ2 and/or -DQ8, which was 2.4 times higher than in the general population. Conclusions: An intestinal biopsy could be avoided to confirm CD in the majority of T1D children. Silent forms of CD are frequent and screening is recommended for all patients. Importantly, repeated TGA assessment is required in HLA genetically predisposed T1D patients, while it is unnecessary in the 5% who are HLA-DQ2 and -DQ8 negative.

Follow-Up of Celiac Disease in Adults: "When, What, Who, and Where"

For patients with celiac disease (CeD), a lifelong gluten-free diet is not a voluntary lifestyle choice-it is a necessity. The key end points in clinical follow-up are symptom resolution, the normalization of weight, prevention of overweight, seroconversion, and negation or minimization of increased long-term morbidity. For the latter, a surrogate endpoint is mucosal healing, which means the normalization of histology to Marsh 0-1. Ideally, celiac follow-up care includes a multidisciplinary approach, effective referral processes, improved access that leverages technological advances, and following guidelines with the identification of measurable quality indicators, ideally informed by evidence-based research. Face-to-face CeD care and telemedicine are considered the standards for this process, although published data are insufficient. Guidelines and statements on diagnosis are readily available. However, data are lacking on optimal clinic visit intervals and outcomes and quality indicators such as improvement of symptoms, function and quality of life, survival and disease control, and how to most effectively use healthcare resources. The results of future research should provide the basis for general recommendations for evidence-based standards of quality of care in CeD.

High Frequency of Glucose-6-Phosphate Dehydrogenase Deficiency in Patients Diagnosed with Celiac Disease

Celiac disease (CD) is characterized by a proinflammatory state associated with the production of reactive oxygen species, i.e., a condition of oxidative stress. In this study, we tested the hypothesis that the inherited deficiency of glucose-6-phosphate dehydrogenase (G6PD), by causing impaired antioxidant defense, may increase the risk of CD.

METHODS

A retrospective monocentric case-control study was performed using the clinical records of 8338 outpatients (64.6% women) scheduled for upper endoscopy between 2002 and 2021 in Northern Sardinia. Overall, 627 were found to have CD (7.5%), and 1027 resulted to be G6PD-deficiency carriers (12.3%). Since randomization was impractical, the potential covariates imbalance between cases and controls was minimized using a 1:2 propensity-score-matched (PSM) analysis.

RESULTS

Overall, G6PD deficiency was associated with increased risk of CD (odds ratio (OR) 1.50; 95% confidence interval (CI) 1.19-1.90). The PSM procedure identified 1027 G6PD-deficient and 2054 normal patients. Logistic regression including the propensity score detected for G6PD deficiency an OR of 1.48 (95%CI 1.13-1.95; p = 0.004).

CONCLUSIONS

Our findings show that the enzyme defect was significantly and positively associated with CD, in line with the pro-oxidant impact of the enzyme defect observed in animal models and humans.

Development and external validation of a clinical prediction model to aid coeliac disease diagnosis in primary care: An observational study

BACKGROUND

Coeliac disease (CD) affects approximately 1% of the population, although only a fraction of patients are diagnosed. Our objective was to develop diagnostic prediction models to help decide who should be offered testing for CD in primary care.

METHODS

Logistic regression models were developed in Clinical Practice Research Datalink (CPRD) GOLD (between Sep 9, 1987 and Apr 4, 2021, n=107,075) and externally validated in CPRD Aurum (between Jan 1, 1995 and Jan 15, 2021, n=227,915), two UK primary care databases, using (and controlling for) 1:4 nested case-control designs. Candidate predictors included symptoms and chronic conditions identified in current guidelines and using a systematic review of the literature. We used elastic-net regression to further refine the models.

FINDINGS

The prediction model included 24, 24, and 21 predictors for children, women, and men, respectively. For children, the strongest predictors were type 1 diabetes, Turner syndrome, IgA deficiency, or first-degree relatives with CD. For women and men, these were anaemia and first-degree relatives. In the development dataset, the models showed good discrimination with a c-statistic of 0·84 (95% CI 0·83-0·84) in children, 0·77 (0·77-0·78) in women, and 0·81 (0·81-0·82) in men. External validation discrimination was lower, potentially because 'first-degree relative' was not recorded in the dataset used for validation. Model calibration was poor, tending to overestimate CD risk in all three groups in both datasets.

INTERPRETATION

These prediction models could help identify individuals with an increased risk of CD in relatively low prevalence populations such as primary care. Offering a serological test to these patients could increase case finding for CD. However, this involves offering tests to more people than is currently done. Further work is needed in prospective cohorts to refine and confirm the models and assess clinical and cost effectiveness.

FUNDING

National Institute for Health Research Health Technology Assessment Programme (grant number NIHR129020).

Structural bases of T cell antigen receptor recognition in celiac disease

Celiac disease (CeD) is a human leukocyte antigen (HLA)-linked autoimmune-like disorder that is triggered by the ingestion of gluten or related storage proteins. The majority of CeD patients are HLA-DQ2.5⁺, with the remainder being either HLA-DQ8⁺ or HLA-DQ2.2⁺. Structural studies have shown how deamidation of gluten epitopes engenders binding to HLA-DQ2.5/8, which then triggers an aberrant CD4⁺ T cell response. HLA tetramer studies, combined with structural investigations, have demonstrated that repeated patterns of TCR usage underpins the immune response to some HLADQ2.5/8 restricted gluten epitopes, with distinct TCR motifs representing common landing pads atop the HLA-gluten complexes. Structural studies have provided insight into TCR specificity and cross-reactivity towards gluten epitopes, as well as cross-reactivity to bacterial homologues of gluten epitopes, suggesting that environmental factors may directly play a role in CeD pathogenesis. Collectively, structural immunology-based studies in the CeD axis may lead to new therapeutics/diagnostics to treat CeD, and also serve as an exemplar for other T cell mediated autoimmune diseases.

Effects of a gluten-reduced or gluten-free diet for the primary prevention of cardiovascular disease

BACKGROUND

Cardiovascular diseases (CVD) are a major cause of disability and the leading cause of death worldwide. To reduce mortality and morbidity, prevention strategies such as following an optimal diet are crucial. In recent years, low-gluten and gluten-free diets have gained strong popularity in the general population. However, study results on the benefits of a gluten-reduced or gluten-free diet are conflicting, and it is unclear whether a gluten-reduced diet has an effect on the primary prevention of CVD.

OBJECTIVES

To determine the effects of a gluten-reduced or gluten-free diet for the primary prevention of CVD in the general population.

SEARCH METHODS

We systematically searched CENTRAL, MEDLINE, Embase, CINAHL and Web of Science up to June 2021 without language restrictions or restrictions regarding publication status. Additionally, we searched ClinicalTrials.gov for ongoing or unpublished trials and checked reference lists of included studies as well as relevant systematic reviews for additional studies.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs), such as prospective cohort studies, comparing a low-gluten or gluten-free diet or providing advice to decrease gluten consumption with no intervention, diet as usual, or a reference gluten-intake category. The population of interest comprised adults from the general population, including those at increased risk for CVD (primary prevention). We excluded cluster-RCTs, case-control studies, studies focusing on participants with a previous myocardial infarction and/or stroke, participants who have undergone a revascularisation procedure as well as participants with angina or angiographically-defined coronary heart disease, with a confirmed diagnosis of coeliac disease or with type 1 diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility of studies in a two-step procedure following Cochrane methods. Risk of bias (RoB) was assessed using the Cochrane risk of bias tool (RoB2) and the 'Risk Of Bias In Non-randomised Studies - of Interventions' (ROBINS-I) tool, and the certainty of evidence was rated using the GRADE approach.

MAIN RESULTS

One RCT and three NRSIs (with an observational design reporting data on four cohorts: Health Professionals Follow-up Study (HPFS), Nurses' Health Study (NHS-I), NHS-II, UK Biobank) met the inclusion criteria. The RCT was conducted in Italy (60 participants, mean age 41 ± 12.1 years), two NRSIs (three cohorts, HPFS, NHS-I, NHS II) were conducted across the USA (269,282 health professionals aged 24 to 75 years) and one NRSI (Biobank cohort) was conducted across the UK (159,265 participants aged 49 to 62 years). Two NRSIs reported that the lowest gluten intake ranged between 0.0 g/day and 3.4 g/day and the highest gluten intake between 6.2 g/day and 38.4 g/day. The NRSI reporting data from the UK Biobank referred to a median gluten intake of 8.5 g/day with an interquartile range from 5.1 g/day to 12.4 g/day without providing low- and high-intake categories. Cardiovascular mortality From a total of 269,282 participants, 3364 (1.3%) died due to cardiovascular events during 26 years of follow-up. Low-certainty evidence may show no association between gluten intake and cardiovascular mortality (adjusted hazard ratio (HR) for low- versus high-gluten intake 1.00, 95% confidence interval (CI) 0.95 to 1.06; 2 NRSIs (3 cohorts)). All-cause mortality From a total of 159,265 participants, 6259 (3.9%) died during 11.1 years of follow-up. Very low-certainty evidence suggested that it is unclear whether gluten intake is associated with all-cause mortality (adjusted HR for low vs high gluten intake 1.00, 95% CI 0.99 to 1.01; 1 NRSI (1 cohort)). Myocardial infarction  From a total of 110,017 participants, 4243 (3.9%) participants developed non-fatal myocardial infarction within 26 years. Low-certainty evidence suggested that gluten intake may not be associated with the development of non-fatal myocardial infarction (adjusted HR for low versus high gluten intake 0.99, 95% CI 0.89 to 1.10; 1 NRSI (2 cohorts)). Lowering gluten intake by 5 g/day also showed no association on the primary prevention of non-fatal and fatal myocardial infarction (composite endpoint) in linear dose-response meta-analyses (adjusted HR 1.02, 95% CI 0.98 to 1.06; 1 NRSI (2 cohorts)). Coronary risk factors  Type 2 diabetes From a total of 202,114 participants, 15,947 (8.0%) developed type 2 diabetes after a follow-up between 22 and 28 years. There was low-certainty evidence that a lower compared with a higher gluten intake may be associated with a slightly increased risk to develop type 2 diabetes (adjusted HR 1.14, 95% CI 1.07 to 1.22; 1 NRSI (3 cohorts)). Furthermore, lowering gluten intake by 5 g/day may be associated with a slightly increased risk to develop type 2 diabetes in linear dose-response meta-analyses (adjusted HR 1.12, 95% CI 1.08 to 1.16; 1 NRSI (3 cohorts)). Blood pressure, low-density lipoprotein level, body mass index (BMI) After six months of follow-up, very low-certainty evidence suggested that it is unclear whether gluten intake affects systolic blood pressure (mean difference (MD) -6.9, 95% CI -17.1 to 3.3 mmHg). There was also no difference between the interventions for diastolic blood pressure (MD -0.8, 95% CI -5.9 to 4.3 mmHg), low-density lipoprotein levels (MD -0.1, 95% CI -0.5 to 0.3 mmol/L) and BMI (MD -0.1, 95% CI -3.3 to 3.1 kg/m²).  No study reported data on adverse events or on other outcomes. Funding sources did not appear to have distorted the results in any of the studies.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggested that it is unclear whether gluten intake is associated with all-cause mortality. Our findings also indicate that low-certainty evidence may show little or no association between gluten intake and cardiovascular mortality and non-fatal myocardial infarction. Low-certainty evidence suggested that a lower compared with a higher gluten intake may be associated with a slightly increased risk to develop type 2 diabetes - a major cardiovascular risk factor. For other cardiovascular risk factors it is unclear whether there is a difference between a gluten-free and normal diet. Given the limited findings from this review predominantly based on observational studies, no recommendations for practice can be made.

Management of coeliac disease patients after the confirmation of diagnosis in Central Europe

BACKGROUND

Recently published paediatric guidelines for diagnosing coeliac disease do not include recommendations on the follow-up of coeliac disease patients.

GOAL

The aim of this study was to assess the management practices and experience of coeliac disease patients with their follow-up appointments in Central Europe.

STUDY

Gastroenterologists and coeliac disease patients in five Central European countries were asked to complete the web-based questionnaire focusing on coeliac disease management practices.

RESULTS

Answers from 147 gastroenterologists and 2041 coeliac disease patients were available for the analysis. More than half of the gastroenterologists (58.5%) schedule the first follow-up visit within 3 months after the diagnosis. At follow-up, tissue transglutaminase antibodies are checked in almost all patients (95.9%). Approximately two-thirds (60.7%) of gastroenterologists refer all of their patients to the dietitian at diagnosis. Similarly, 42.8% of coeliac disease patients reported that they had not been appointed to a dietitian. Almost one-third of coeliac disease patients (30.8%) reported that they had no follow-up appointments with gastroenterologist at all.

CONCLUSIONS

Follow-up of coeliac disease patients is suboptimal in Central Europe. Many patients are not followed regularly. A lot of patients are not referred to a dietitian. The recommendations on the optimal follow-up of coeliac disease patients are needed in order to improve patient care.

Perineal cutaneous basal cell carcinomas in patients with familial seronegative celiac disease: Report of three cases

The etiopathogenesis of basal cell carcinoma (BCC) arising in the perineum is unclear. We report BCC arising in the perineum of three longstanding untreated celiac disease (CD) patients. CD is an autoimmune enteropathy due to hypersensitivity to consumed gluten. Patients can present with gastrointestinal symptoms including diarrhea and weight loss, as well as fatigue, iron-deficiency anemia, vitamin D deficiency, depression, and unexplained hypocalcemia. As a result, CD often goes undiagnosed for many years before a diagnosis is made.

Comparison of Different Hydrocolloids on the Novel Development of Muffins from "Purple Yam" (Dioscorea alata) Flour in Sensory, Textural, and Nutritional Aspects

Hydrocolloids can act as gluten substitutes to form the structural equivalents of the gluten network in gluten-free bakery products. "Purple yam" (Dioscorea alata) is one of the underutilized yams in Sri Lanka with high nutritional potential. The overall objective of this study was to develop gluten-free muffins using "Purple yam" (Dioscorea alata) flour with hydrocolloids (pectin, xanthan gum, and guar gum) and investigate the nutritional composition and selected properties of the muffins. The texture profiles of gluten-free muffins were analyzed through the following parameters: hardness, adhesiveness, cohesiveness, etc. The chromameter values were obtained and sensory evaluations for gluten-free muffins were carried out. The highest moisture content was recorded in pectin-incorporated muffins (17.70 ± 0.50%). The protein content of all three types of muffins was around 5%. The highest fat content was recorded in pectin-incorporated muffins (19.26 ± 0.51%). The ash content of all three types of muffins was around 2%. Potassium was the most predominant element found in each muffin. The hardness of guar gum-incorporated muffin (6379.3 ± 135.9 g) was greater than that of the pectin-incorporated one (6082.3 ± 23.4 g). Xanthan gum-incorporated muffins had significantly decreased cohesiveness (0.19 ± 0.04). The highest springiness was obtained in pectin-incorporated muffin (37.13 ± 1.61 mm). The descending order of the chewiness of muffin is pectin - added > xanthan gum - added > guar gum - added sample. According to the sensory evaluation, pectin-incorporated muffin was the best as it had obtained the highest sum of ranks for appearance, color, taste, after taste, and overall acceptability.

Plant-Based Dietary Practices and Socioeconomic Factors That Influence Anemia in India

While rates of malnutrition have declined over the last decade in India due to successful government interventions, the prevalence of anemia remains high. Staple foods provide almost 70% of the daily iron intake. As staple foods are a rich source of phytate, this ingested iron is poorly absorbed. Currently, 59% of children below 3 years of age, 50% of expectant mothers and 53% of women aged 15-19 years are anemic. The most common intervention strategy has been through the use of iron supplements. While the compliance has been low and supplies irregular, such high rates of anemia cannot be explained by iron deficiency alone. This review attempts to fit dietary and cooking practices, field-level diagnostics, cultural beliefs and constraints in implementation of management strategies into a larger picture scenario to offer insights as to why anemia continues to plague India. Since the rural Indian diet is predominantly vegetarian, we also review dietary factors that influence non-heme iron absorption. As a reference point, we also contrast anemia-related trends in India to the U.S.A. Thus, this review is an effort to convey a holistic evaluation while providing approaches to address this public health crisis.

Presence of high-risk HLA genotype is the most important individual risk factor for coeliac disease among at-risk relatives

BACKGROUND

Family screening has been advocated as a means to reduce the major underdiagnosis of coeliac disease. However, the precise risk of the disease in relatives and the impact of patient- and relative-related individual factors remain obscure.

AIMS

To investigate the individual risk of coeliac disease among patients' relatives.

METHODS

Altogether 2943 relatives of 624 index patients were assessed for the presence of previous coeliac disease diagnosis, or were screened for the disease. Coeliac disease-associated human leucocyte antigen (HLA) genotype was determined from all participants. The association between individual factors and new screening positivity was assessed by logistic regression.

RESULTS

There were 229 previously diagnosed non-index relatives with coeliac disease and 2714 non-affected (2067 first-degree, 647 more distant) relatives. Of these 2714 relatives, 129 (4.8%) were screening-positive (first-degree 5.1%, second-degree 3.6%, more distant 3.5%). The combined prevalence of the previously diagnosed and now detected cases in relatives was 12.2% (6.3% clinically detected, 5.9% screen-detected). In univariate analysis, age <18 years at diagnosis (odds ratio 1.60, 95% CI 1.04-2.45) in index, and age 41-60 years (1.73, 1.10-2.73), being a sibling (1.65, 1.06-2.59) and having the high-risk genotype (3.22, 2.01-5.15 DQ2.5/2.5 or DQ2.5/2.2 vs other risk alleles) in relatives were associated with screening positivity. Only high-risk HLA remained significant (2.94, 1.80-4.78) in multivariable analysis.

CONCLUSIONS

Unrecognised coeliac disease was common among at-risk relatives even in a country with an active case-finding policy, and also in relatives more distant than first-degree. The presence of a high-risk genotype was the most important predictor for screening positivity. ClinicalTrials.gov identifier NCT03136731.

Making a Confident Diagnosis of Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is among the most common diagnoses made by medical providers and its symptoms are common causes for health care consultation. IBS is characterized by abdominal pain associated with abnormal stool consistency and/or frequency and is widely considered a diagnosis of exclusion, despite abundant evidence contradicting such an approach. A positive diagnosis is achieved through application of symptom-based clinical criteria, careful history and physical examination, evaluation for alarm sign/symptoms, and judicious use of diagnostic testing. This article reviews the symptom-based criteria for IBS and utility of diagnostic tests commonly included in the evaluation of IBS symptoms.

Trends in iron deficiency anemia research 2001-2020: A bibliometric analysis

BACKGROUND

Iron deficiency anemia has a worldwide impact on individual health and national and international economies, with an estimated one-third of the world population being iron deficient.

AIM

To evaluate the iron deficiency literature published between 2001-2020 with an emphasis on: (1) Identification of collaborative research networks most active in this field; (2) Research topics of greatest importance; and (3) Analysis of the most-cited papers published between 2001-2020 and the most cited papers in 5-year intervals during this period to assess for emerging trends in research in this area.

METHODS

A search of Clarivate Analytics World of Science Core Collection was performed for the topic “iron deficiency anemia”, limited to document type (article or review), language (English), and time span (2001-2020). The following data were extracted from these articles: Year of publication, journal, study design, country of first author, and number of citations. The metadata derived from the search were used to identify publication trends in iron deficiency anemia research and their distribution in countries/regions and institutions. Network visualization by VOSviewer (Leiden University) was performed to identify international collaborative groups and research hotspots.

RESULTS

The search identified 4828 publications. Three international collaborative networks were identified: United States, Canada, and India; Turkey, China, and Japan; and England and other European countries. Five research areas were hotspots: Epidemiologic aspects of iron deficiency anemia, biochemical aspects of iron deficiency anemia, clinical evaluation of causes of iron deficiency anemia, causes of iron deficiency anemia, and bioavailability of dietary iron. Subset analysis of the top-10 overall cited papers, and the top-10 cited papers for each 5-year increment beginning in 2001 showed that the largest number of highly cited papers were from the field of epidemiology, the smallest number from the field of bioavailability of dietary iron.

CONCLUSION

The literature on iron deficiency anemia has a high citation rate compared to studies of other topics using similar methodology and is heavily biased toward studies from the United States and epidemiologic studies.

High Protein Substitutes for Gluten in Gluten-Free Bread

Gluten-free products have come into the market in order to alleviate health problems such as celiac disease. In this review, recent advances in gluten-free bread are described along with plant-based gluten-free proteins. A comparison with animal-based gluten-free proteins is made reporting on different high protein sources of animal origin. Sea microorganisms- and insect-based proteins are also mentioned, and the optimization of the structure of gluten-free bread with added high protein sources is highlighted along with protein digestibility issues. The latter is an issue for consideration that can be manipulated by a careful design of the mixture in terms of phenolic compounds, soluble carbohydrates and fibres, but also the baking process itself. Additionally, the presence of enzymes and different hydrocolloids are key factors controlling quality features of the final product.

Accuracy of Screening Tests for Celiac Disease in Asymptomatic Patients With Type 1 Diabetes

INTRODUCTION

To evaluate the diagnostic performance of celiac serologic tests in asymptomatic patients with type 1 diabetes (T1D).

METHODS

Patients with T1D asymptomatic for celiac disease were prospectively screened with immunoglobulin A anti-tissue transglutaminase. Test characteristics were calculated and optimal cutoffs for a positive screen determined.

RESULTS

Two thousand three hundred fifty-three patients were screened and 101 proceeded to biopsy. The positive predictive value of immunoglobulin A anti-tissue transglutaminase at the assay referenced upper limit of normal (30CU) was 85.9%, and the sensitivity and specificity were 100% and 38%, respectively.

DISCUSSION

Thresholds extrapolated from the general population for the diagnostic evaluation of celiac disease are not suitable for use in asymptomatic T1D patients. Population-specific screening cutoffs are required.

Systematic review and meta-analysis: the incidence and prevalence of paediatric coeliac disease across Europe

BACKGROUND

Coeliac disease is one of the most prevalent immune-mediated gastrointestinal disorders in children.

AIM

To review the incidence and prevalence of paediatric coeliac disease, and their trends, regionally across Europe, overall and according to age at diagnosis.

METHODS

Systematic review and meta-analysis from January 1, 1950 to December 31, 2019, based on PubMed, CINAHL and the Cochrane Library, searches of grey literature and websites and hand searching of reference lists. A total of 127 eligible studies were included.

RESULTS

The prevalence of previously undiagnosed coeliac disease from screening surveys (histology based) ranged from 0.10% to 3.03% (median = 0.70%), with a significantly increasing annual trend (P = 0.029). Prevalence since 2000 was significantly higher in northern Europe (1.60%) than in eastern (0.98%), southern (0.69%) and western (0.60%) Europe. Large increases in the incidence of diagnosed coeliac disease across Europe have reached 50 per 100 000 person-years in Scandinavia, Finland and Spain. The median age at diagnosis increased from 1.9 years before 1990 to 7.6 since 2000. Larger increases in incidence were found in older age groups than in infants and ages <5 years.

CONCLUSIONS

Paediatric coeliac disease incidence and prevalence have risen across Europe and appear highest in Scandinavia, Finland and Spain. The most recent evidence shows large increases in incidence in most regions, but stabilisation in some (notably Sweden and Finland). Sharp increases in the age at diagnosis may reflect increases in milder and asymptomatic cases diagnosed since reliable serology testing became widely used, through endomysial antibodies after 1990 and tissue transglutaminase antibodies around 2000.

The Top 100 Cited Papers in the Field of Iron Deficiency in Humans: A Bibliometric Study

Worldwide, iron deficiency is a common form of micronutrient deficiency with a high individual and societal cost. There are considerable knowledge and practice gaps in the diagnosis and treatment of iron deficiency. Bibliometric analysis examines the published body of knowledge of a subject in an objective fashion. The Web of Science Core Collection was searched to retrieve the 100 most cited papers on the topic of iron deficiency, and the key metrics of each paper were extracted. A keyword study was performed using VOSviewer 1.6.10 software, which provided a visual mapping of the network of keyword cooccurrences. The papers were published between 1964 and 2017 and were cited an average of 636 times. They were contributed by authors from 119 different countries/regions, with the largest contributing country being the United States. 29 institutions contributed at least 6 publications each, and 4 researchers authored or coauthored at least 5 papers. Keyword analysis suggests that the most cited topics could be grouped into 4 categories: (1) epidemiologic research of the global burden of iron deficiency, (2) clinical aspects of iron deficiency anemia, (3) iron metabolism, and (4) the impact of iron deficiency on children. Identification of the most impactful studies in the field of iron deficiency may be helpful to practitioners interested in improving their knowledge base. Compared to bibliometric studies performed on other topics, the medical literature of iron deficiency is mature, as evidenced by the high citation rate of the top 100 papers. Despite the high worldwide prevalence of iron deficiency, the top cited papers are dominated by a relatively small number of countries and institutions. Interestingly, however, the most cited authors in this study do not overlap with the most cited institutions.

Iron Deficiency Anemia in Celiac Disease

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

Celiac disease: Understandings in diagnostic, nutritional, and medicinal aspects

Celiac disease (CD) is characterized by clinical polymorphism, with classic, asymptomatic or oligosymptomatic, and extra-intestinal forms, which may lead to diagnostic delay and exposure to serious complications. CD is a multidisciplinary health concern involving general medicine, pediatric, and adult gastroenterology, among other disciplines. Immunology and pathology laboratories have a fundamental role in diagnosing and monitoring CD. The diagnosis consists of serological testing based on IgA anti-transglutaminase (TG2) antibodies combined with IgA quantification to rule out IgA deficiency, a potential misleading factor of CD diagnosis. Positive TG2 serology should be corroborated by anti-endomysium antibody testing before considering an intestinal biopsy. Owing to multiple differential diagnoses, celiac disease cannot be confirmed based on serological positivity alone, nor on isolated villous atrophy. In children with classical signs or even when asymptomatic, with high levels of CD-linked markers and positive HLA DQ2 and/or DQ8 molecules, the current trend is to confirm the diagnosis on basis of the non-systematic use of the biopsy, which remains obligatory in adults. The main challenge in managing CD is the implementation and compliance with a gluten-free diet (GFD). This explains the key role of the dietitian and the active participation of patients and their families throughout the disease-management process. The presence of the gluten in several forms of medicine requires the sensitization of physicians when prescribing, and particularly when dispensing gluten-containing formulations by pharmacists. This underlines the importance of the contribution of the pharmacist in the care of patients with CD within the framework of close collaboration with physicians and nutritionists.

Celiac Disease and Obesity: Is Bariatric Surgery an Option?

Celiac disease is an immune-mediated enteropathy associated with malabsorptive syndrome and fat-soluble vitamin deficiencies. Celiac disease affects 1% of individuals but is largely underdiagnosed, as its multifaceted clinical presentations create challenging diagnostic scenarios. With the rise of the obesity epidemic, doctors are increasingly seeing celiac disease patients with overweight or obesity, which raises the question of bariatric surgery. However, few studies so far have investigated bariatric surgery in this patient population. Here, we provide a comprehensive review of the literature on celiac disease, its nutritional consequences and complications, and we discuss the possible impact of bariatric surgery on weight loss, nutritional deficiencies, response to gluten-free diet, and long-term post-operative complications. We also review the effect of bariatric surgery on the incidence of celiac disease.

Posterior Tibial Tendinopathy and Osteopenia as Primary Symptoms of Celiac Disease: A Case Report

This case report describes posterior tibial tendon (PTT) tendinopathy, valgus deformity with tenosynovitis, and osteopenia at the medial malleolus as the primary symptoms of a young patient with celiac disease (CD) without gastrointestinal symptoms. CD is an autoimmune condition that is a chronic inflammatory disorder of the small intestine triggered by ingestion of gluten in individuals with a particular genetic background. Without typical gastrointestinal symptoms, CD patients are often misdiagnosed or undiagnosed. The patient was diagnosed with CD by duodenal biopsy. He underwent a surgical procedure, including medial displacement calcaneal osteotomy, tenosynovectomy of the PTT and flexor digitorum longus (FDL), FDL transfer to the navicular for a pes planovalgus deformity, and drilling of the medial malleolus for a stress reaction. The mechanism of the PTT tear and associated heel valgus deformity was assumed to be related to the fact that his heel alignment on the affected side changed gradually from normal to valgus and pes planus owing to CD and mechanical stress, because his normal-side heel alignment was neutral before surgery and at final follow-up. His operated ankle was pain-free, with full range of motion, 1.5 years after surgery. The patient was able to restart running and exercise gradually. Foot and ankle specialists should consider the possibility of CD in patients presenting with a PTT tear without injury or trauma and osteopenia with no obvious reason.

Family socio-economic status and childhood coeliac disease seem to be unrelated-A cross-sectional screening study

Aim

The aim of our study was to examine whether there is a difference in coeliac disease prevalence in regard to parents' education level and occupation, and whether this differs between screened and clinically diagnosed children at the age of 12 years.

Methods

The study, Exploring the Iceberg of Celiacs in Sweden (ETICS), was a school‐based screening study of 12‐year‐old children that was undertaken during the school years 2005/2006 and 2009/2010. Data on parental education and occupation were reported from parents of the children. Specifically, by parents of 10 710 children without coeliac disease, 88 children diagnosed with coeliac disease through clinical care, and 231 who were diagnosed during the study.

Results

There were no statistically significant associations between occupation and coeliac disease for either the clinically detected (prevalence ratio 1.16; confidence interval 0.76‐1.76) or screening‐detected coeliac disease cases (prevalence ratio 0.86; confidence interval 0.66‐1.12) in comparison with children with no coeliac disease. Also, there were no statistically significant associations for parental education and coeliac disease diagnosis.

Conclusion

There was no apparent relationship between coeliac disease and socio‐economic position. Using parents' socio‐economic status as a tool to help identify children more likely to have coeliac disease is not recommended.

Gluten intake and metabolic health: conflicting findings from the UK Biobank

PURPOSE

The impact of gluten intake on metabolic health in subjects without celiac disease is unclear. The present study aimed to assess the association between gluten intake and body fat percentage (primary objective), as well as a broad set of metabolic health markers.

METHODS

Gluten intake was estimated in 39,927 participants of the UK Biobank who completed a dietary questionnaire for assessment of previous 24-h dietary intakes. Multiple linear regression analyses were performed between gluten intake and markers of metabolic health with Holm adjustment for multiple comparisons.

RESULTS

Median gluten intake was 9.7 g/day (male: 11.7 g/day; female: 8.2 g/day; p < 0.0001). In multiple linear regression analysis, association between gluten intake and percentage body fat was negative in males (β = - 0.028, p = 0.0020) and positive in females (β = 0.025, p = 0.0028). Furthermore, gluten intake was a negative predictor of total cholesterol (male: β = - 0.031, p = 0.0154; female: β = - 0.050, p < 0.0001), high-density lipoprotein cholesterol (male: β = - 0.052, p < 0.0001; female: β = - 0.068, p < 0.0001), and glomerular filtration rate (sexes combined: β = - 0.031, p < 0.0001) in both sexes. In females only, gluten intake was positively associated with waist circumference (β = 0.041, p < 0.0001), waist-to-height ratio (β = 0.040, p < 0.0001), as well as body mass index (β = 0.043, p < 0.0001), and negatively related to low-density lipoprotein cholesterol (β = - 0.035, p = 0.0011). A positive association between gluten intake and triglycerides was observed in males only (β = 0.043, p = 0.0001).

CONCLUSION

This study indicates that gluten intake is associated with markers of metabolic health. However, all associations are weak and not clinically meaningful. Limiting gluten intake is unlikely to provide metabolic health benefits for a population in total.

The Knowledge About Celiac Disease Among Healthcare Professionals and Patients in Central Europe

OBJECTIVES

Celiac disease (CD) remains undiagnosed for a long time in many adult and pediatric patients. We assessed the knowledge about CD among healthcare professionals (HCPs) and CD patients in Central Europe (CE).

METHODS

HCPs and CD patients from 5 CE countries were asked to complete the web-based questionnaire about CD. The questions were divided into subsections on epidemiology, clinical presentation, diagnostics, treatment, and follow-up. Achieved scores of different specialists managing patients with CD were compared and regional differences in patients' knowledge were analyzed.

RESULTS

Questionnaire was completed by 1381 HCPs and 2262 CD patients or their caregivers from Croatia, Hungary, Germany, Italy, and Slovenia. Mean score achieved by HCPs was 50.9%, and by CD patients 56.4%. Pediatric gastroenterologists scored the highest (69.4%; P < 0.001). There were significant differences in knowledge of patients from different CE regions with German participants scoring the highest (58.3%). Members of CD societies scored higher compared with nonmembers (mean score 58% vs 53.2%; P < 0.001) and patients diagnosed less than 5 years ago scored higher compared with those diagnosed more than 10 years ago (mean score 57.3% vs 54.6%; P < 0.001).

CONCLUSIONS

The knowledge about CD among HCPs and CD patients is not satisfactory. Further awareness-raising and learning activities are needed to improve HCPs' knowledge and to minimize the number of unrecognized patients and unnecessary diagnostic delays. Patients should be better informed about their disease to reach higher compliance with the gluten-free diet.

Clinical Presentation in Children With Coeliac Disease in Central Europe

OBJECTIVES

During the past decades, there has been a shift in the clinical presentation of coeliac disease (CD) to nonclassical, oligosymptomatic, and asymptomatic forms. We assessed clinical presentation of CD in children and adolescents in Central Europe.

METHODS

Paediatric gastroenterologists in 5 countries retrospectively reported data of their patients diagnosed with CD. Clinical presentation was analyzed and the differences among very young (<3 years) and older children and adolescents were studied.

RESULTS

Data from 653 children and adolescents (median age 7 years 2 months; 63.9% girls) from Croatia, Germany, Hungary, Italy, and Slovenia were available for the analysis. One fifth (N = 134) of all children were asymptomatic. In symptomatic children, the most common leading symptom was abdominal pain (33.3%), followed by growth retardation (13.7%) and diarrhoea (13.3%). The majority of symptomatic children (47.6%; N = 247) were polysymptomatic. Abdominal pain was the most common symptom in polysymptomatic (66.4%) as well as in monosymptomatic children (29.7%). Comparing clinical presentation of CD in very young children (younger than 3 years) with older children (3 years or older), we found that symptoms and signs of malabsorption were significantly more common in younger (P < 0.001), whereas abdominal pain and asymptomatic presentation were more common in older children and adolescents (both P < 0.001).

CONCLUSION

In children with CD, abdominal pain has become the most common symptom. However, in younger children, symptoms of malabsorption are still seen frequently. This raises a question about the underlying mechanism of observed change in clinical presentation in favour of nonclassical presentation and asymptomatic disease at certain age.

Nutritional quality and costs of gluten-free products: a case-control study of food products on the Norwegian marked

Background

Celiac disease is a chronic autoimmune disease triggered by gluten exposure in genetically predisposed individuals. A life-long intake of a gluten-free (GF) diet is required for its management. Wheat, rye and barley are eliminated in a GF diet and the nutritional adequacy of the diet has been questioned. In Norway, cereals and bread constitute a key role of the diet and are the main source of fiber intake. Gluten restrictions may therefore offer important implications for nutrient adequacy especially linked to fiber intake in people with celiac disease.

Objective

The aim of the study was to investigate the nutritional quality and price of GF products and compare with gluten-containing counterparts available at instead of in the Norwegian market.

Design

The macronutrient content of 423 unique GF products were compared with 337 equivalents with gluten. All products were selected from grocery stores and web-based shops, with the aim of including as many GF products as possible. Listed macronutrients content and price in 11 different food categories were compared to gluten-containing counterparts with Wilcoxon signed rank test.

Results

The GF products contained less protein and fiber, and higher content of saturated fat, carbohydrate and salt compared to the gluten-containing products. The total amount of fat was not different between the groups. A similar pattern was found within several of the food categories. More gluten-containing products met the nutrition claim "high in fiber" (fiber > 6 g/100 g) compared to the GF products. The price of the GF products was higher; ranging from 46%-443% more expensive than the gluten-containing products.

Conclusion

GF products are less nutritious and have a higher price compared to equivalent gluten-containing products. Knowing that an unhealthy diet is the most important risk factor for developing non-communicable diseases, the nutritional quality of a GF diet needs to be addressed and should be improved.

Gluten Intake and All-Cause and Cause-Specific Mortality: Prospective Findings from the UK Biobank

BACKGROUND

Gluten has been linked to adverse effects on metabolic and vascular health.

OBJECTIVES

The present study determines the association between dietary gluten intake and all-cause (primary objective), as well as cause-specific, mortality in people without celiac disease.

METHODS

Gluten intake was estimated in 159,265 participants of the UK Biobank which is a large multicenter, prospective cohort study initiated in 2006. Cox proportional hazard regression models were used and HRs were determined for all-cause and cause-specific mortality. All models were adjusted for confounders and multiple testing.

RESULTS

Median (IQR) age was 57 (49-62) y with 52.1% of participants being female. Gluten intake was 8.5 (5.1-12.4) g/d with significantly higher consumption in males [10.0 (6.3-14.1) g/d] than in females [7.2 (4.6-10.7) g/d] (P < 0.0001). During a median follow-up of 11.1 (10.6-11.9) y and 1.8 million person-years, 6259 deaths occurred. Gluten intake was not significantly associated with all-cause mortality after adjusting for confounders (HR: 1.00; 95% CI: 1.00, 1.01; P = 0.59). Dietary gluten was not significantly associated with cancer (HR: 1.00; 95% CI: 1.00, 1.01; raw P = 0.24) or noncancer (HR: 1.00; 95% CI: 0.99, 1.01; raw P = 0.56) mortality. However, gluten intake was positively associated with ischemic heart disease mortality (HR: 1.02; 95% CI: 1.01, 1.04; raw P = 0.003, Holm-adjusted P = 0.04).

CONCLUSIONS

Gluten intake is not significantly associated with all-cause and cancer mortality in adults without celiac disease. The findings support the hypothesis that limiting gluten intake is unlikely to provide significant overall survival benefits on a population level. The positive association between gluten intake and ischemic heart disease mortality requires further study.

The Gluten Gene: Unlocking the Understanding of Gluten Sensitivity and Intolerance

Wheat flour is one of the most important food ingredients containing several essential nutrients including proteins. Gluten is one of the major protein components of wheat consisted of glutenin (encoded on chromosome 1) and gliadin (encoded on chromosome 1 and 6) and there are around hundred genes encoding it in wheat. Gluten proteins have the ability of eliciting the pathogenic immune responses and hypersensitivity reactions in susceptible individuals called “gluten-related disorders (GRDs)”, which include celiac disease (CD), wheat allergy (WA), and non-celiac gluten sensitivity (NCGS). Currently removing gluten from the diet is the only effective treatment for mentioned GRDs and studies for the appropriate and alternative therapeutic approaches are ongoing. Accordingly, several genetic studies have focused on breeding wheat with low immunological properties through gene editing methods. The present review considers genetic characteristics of gluten protein components, focusing on their role in the incidence of gluten-related diseases, and genetic modifications conducted to produce wheat with less immunological properties.

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.

An updated overview on celiac disease: from immuno-pathogenesis and immuno-genetics to therapeutic implications

INTRODUCTION

Celiac disease (CD) is an autoimmune enteropathy triggered by ingestion of gluten. While presenting many similarities with other autoimmune diseases, celiac disease is unique in that the external trigger, gluten, and the genetic background necessary for disease development (HLA DQ2/DQ8) are well described. The prevalence of celiac disease is dramatically increasing over the years and new epidemiologic data show changes regarding age of onset and symptoms. A better understanding of CD-pathogenesis is fundamental to highlight the reasons of this rise of celiac diagnoses.

AREAS COVERED

In this review we describe CD-pathogenesis by dissecting all the components necessary to lose tolerance to gluten (ingestion of gluten, genetic predisposition, loss of barrier function and immune response). Additionally, we also highlight the role that microbiome plays in celiac disease as well as new proposed therapies and experimental tools.

EXPERT OPINION

Prevalence of autoimmune diseases is increasing around the world. As a result, modern society is strongly impacted by a social and economic burden. Given the unique characteristics of celiac disease, a better understanding of its pathogenesis and the factors that contribute to it may shed light on other autoimmune diseases for which external trigger and genetic background are not known.

Prevalence of celiac disease in low and high risk population in Asia-Pacific region: a systematic review and meta-analysis

This systematic review and meta-analysis study was conducted to estimate the pooled prevalence of CD in low and high risk groups in this region. Following keywords were searched in the Medline, PubMed, Scopus, Web of Science and Cochrane database according to the MeSH terms; celiac disease, prevalence, high risk population and Asian-Pacific region. Prevalence studies published from January 1991 to March 2018 were selected. Prevalence of CD with 95% confidence interval (CI) was calculated using STATA software, version 14. The pooled sero-prevalence of CD among low risk group in Asia-Pacific region was 1.2% (95% CI 0.8-1.7%) in 96,099 individuals based on positive anti-tissue transglutaminase (anti-t-TG Ab) and/or anti-endomysial antibodies (EMA). The pooled prevalence of biopsy proven CD in Asia-Pacific among high and low risk groups was 4.3% (95% CI 3.3-5.5%) and 0.61% (95% CI 0.4-0.8%) in 10,719 and 70,344 subjects, respectively. In addition, the pooled sero-prevalence and prevalence of CD in general population was significantly higher in children compared with adults and it was significantly greater in female vs. male (P < 0.05). Our results suggest high risk individuals of CD are key group that should be specifically targeted for prevention and control measures, and screening may prove to have an optimal cost-benefit ratio.

The Prevalence of Celiac Disease in a Fracture Liaison Service Population

Celiac disease (CD) is a known risk factor for osteoporosis and fractures. The prevalence of CD in patients with a recent fracture is unknown. We therefore systematically screened patients at a fracture liaison service (FLS) to study the prevalence of CD. Patients with a recent fracture aged ≥ 50 years were invited to VieCuri Medical Center's FLS. In FLS attendees, bone mineral density (BMD) and laboratory evaluation for metabolic bone disorders and serological screening for CD was systematically evaluated. If serologic testing for CD was positive, duodenal biopsies were performed to confirm the diagnosis CD. Data were collected in 1042 consecutive FLS attendees. Median age was 66 years (Interquartile range (IQR) 15), 27.6% had a major and 6.9% a hip fracture, 26.4% had osteoporosis and 50.8% osteopenia. Prevalent vertebral fractures were found in 29.1%. CD was already diagnosed in two patients (0.19%), one still had a positive serology. Three other patients (0.29%) had a positive serology for CD (one with gastro-intestinal complaints). In two of them, CD was confirmed by duodenal histology (0.19%) and one refused further evaluation. The prevalence of biopsy-proven CD was therefore 0.38% (4/1042) of which 0.19% (2/1042) was newly diagnosed. The prevalence of CD in patients with a recent fracture at the FLS was 0.38% and within the range of reported prevalences in the Western-European population (0.33-1.5%). Newly diagnosed CD was only found in 0.19%. Therefore, standard screening for CD in FLS patients is not recommended.

Celiac Disease Screening for High-Risk Groups: Are We Doing It Right?

Celiac disease (CD) is an immune-mediated enteropathy triggered by dietary ingestion of gluten in genetically susceptible patients. CD is often diagnosed by a "case-finding" approach of symptomatic patients. In recent times, the diagnostic paradigm has shifted to investigate patients who may be asymptomatic, but are at high risk of developing CD due to shared genetic susceptibilities. These high-risk groups include first-degree relatives of CD patients and patients with Type 1 diabetes mellitus, autoimmune thyroid disease, Down's syndrome, and Turner syndrome. Moreover, CD is often diagnosed as the cause of iron deficiency anemia or unexplained chronic diarrhea. Although screening for CD with serological tests is not recommended for the general population, it should be considered in these special populations. In this review, we explore screening for CD among high-risk groups in light of recent research and development in the CD arena.

The development of the gluten free healthy food basket in Cyprus. Is it affordable among low-income adults diagnosed with celiac disease?

BACKGROUND

Gluten free (GF) diets are not only restrictive but also costly. The main aim of this study was to evaluate the acceptability, cost and affordability of a Gluten Free Healthy Food Basket (GFHFB) and further examine whether low-income Cypriots diagnosed with celiac disease (CD) experience food stress.

METHODS

GFΗFBs were constructed for adult women and adult men (±40 years) diagnosed with CD. Feasibility and acceptability was tested through three focus groups. Affordability was defined as the cost of the GFΗFB as a percentage of the Guaranteed Minimum Income (GMI).

RESULTS

The GFΗFB was 33.6 and 47 euros/month more expensive compared to the HB (Healthy Basket) for women and men, respectively. The total budget for GF-manufactured products were 27.81 and 28.5% of the total food budget, for women and men, respectively. For low-income people receiving the GMI, the proportion of income that would need to be spent on the GFHFB ranges from around 42 to 60%.

CONCLUSIONS

The GFΗFB is costly and not affordable among low-income Cypriots diagnosed with CD; thus, they are likely to suffer from food stress. As such, the risk of reducing their adherence to a GF diet is high and thus compromises their long-term health.

The association of anti-gliadin and anti-transglutaminase antibodies and chronic plaque psoriasis in Indian patients: Preliminary results of a descriptive cross-sectional study

BACKGROUND

Gluten sensitivity among psoriasis patients and its association with gender, age, disease duration and severity of psoriasis are under studied in Indians.

OBJECTIVE

To examine association among serum levels of anti-tTG and anti-gliadin antibodies and clinical features including gender, age, duration and severity of psoriasis.

METHODS

Serum levels of anti-transglutaminase and anti-gliadin antibodies were measured quantitatively in 80 (M:F 57:23) psoriasis patients aged 15 to 83 years and matched healthy subjects.

RESULTS

Forty-five (56.3%) patients were aged ≥41years, duration of disease was >5years in 43(53.8%) patients, and 22 (27.5%) patients had moderate-to-severe psoriasis. Two (2.5%) patients had arthritis and elevated serum anti-gliadin antibody. Significantly more patients than controls had elevated serum anti-gliadin antibody (67.5% vs. 2.5%) and anti-transglutaminase antibody levels (62.5% vs. 0%). Two patients, each with mild and moderate-to-severe psoriasis, had highly elevated serum anti-gliadin antibody and symptoms akin to coeliac disease. Except for a longer duration of psoriasis in patients with elevated anti-gliadin antibodies, there was no statistically significant difference in gender, age, and severity of psoriasis when compared with patients having normal levels.

CONCLUSION

Significant elevation of serum anti-transglutaminase and anti-gliadin antibodies levels is noted in psoriasis patients reflecting a possible link. However, results need careful interpretation for any significance of gluten sensitivity in pathogenesis of psoriasis/arthritis or as a stand-alone risk factor for chronicity/severity of psoriasis or whether gluten-free diet will be ameliorating. Small number of subjects, cross-sectional study design, lack of pathological/endoscopic diagnosis and follow-up are study limitations.

Atherosclerotic Risk Factors in Children with Celiac Disease

Results

We found significantly lower concentrations of total cholesterol, lipoprotein LDL-C, apolipoproteins A1 and B, as well as hCRP in all children with CD. We showed decreased level (<5 ng/mL) of folic acid among 46% of children treated for >5 years. Moreover, we showed significant decrease of folic acid level already after 1 year of a GFD (12 vs. 5.6 ng/mL; p < 0.001). We also found significant negative correlation of z-score body mass index (BMI) with HDL and APOA1 level (r = −0.33; p = 0.015 and r = −0.28; p = 0.038, respectively) and modest positive correlation of z-score BMI with atherogenic factor of total cholesterol-HDL ratio and LDL-HDL ratio (r = 0.40; p = 0.002 and r = 0.36; p = 0.006, respectively). Analysis of physical activity showed an increase in the insulin levels with inactivity (r = 0.36; p = 0.0025). We also found positive correlation of the sleep duration with the adiponectin level (r = 0.41; p = 0.011).

Conclusions

In children with CD treated with a GFD, decreased level of folic acid together with increased BMI, sedentary behavior, and an improper lipid profile may predispose them to atherosclerosis in the long run. This data suggests the need of further studies to determine the need for metabolic cardiovascular risk screening in children with CD.

Diagnostic values of duodenal endoscopic markers in paediatric coeliac patients

BACKGROUND AND STUDY AIMS

The recognition of suggestive endoscopic markers in the duodenum during open access endoscopy can help identifying patients who are likely to develop coeliac disease (CD). This study aims to determine the diagnostic accuracy of duodenal endoscopic markers for the diagnosis of CD.

PATIENTS AND METHODS

All children (0-15 years) who underwent oesophagogastroduodenoscopy (EGD) for any reason suggestive of CD at the paediatric department of Al-Assad University Hospital in Latakia, Syria during a 4-year period (from January 2010 to December 2013) were retrospectively included, in the study; this yielded a consecutive cohort without selection bias. The relevant data were obtained from the patients' files. Four duodenal endoscopic markers, including scalloping, reduction of duodenal folds, nodular mucosal pattern, and scattered white spots, were evaluated.

RESULTS

During the study period, 504 children underwent EGD of whom 123 (24.4%) were ultimately diagnosed with CD. At least one marker was observed in 200/504 children (39.6%) and the diagnostic values were as follows: Sensitivity (91%), specificity (76%), positive predictive value (56%), and negative predictive value (97%). Scalloping had the highest sensitivity and specificity of 89% and 96%, respectively.

CONCLUSION

Careful examination of the second and third parts of the duodenum during endoscopy can be helpful in identifying CD. Scalloping is the most common endoscopic marker, and the high NPV values of endoscopic markers should be interpreted cautiously, as the diagnosis of CD can be missed.

The Pros and Cons of Using Oat in a Gluten-Free Diet for Celiac Patients

A therapeutic gluten-free diet often has nutritional limitations. Nutritional qualities such as high protein content, the presence of biologically active and beneficial substances (fiber, beta-glucans, polyunsaturated fatty acids, essential amino acids, antioxidants, vitamins, and minerals), and tolerance by the majority of celiac patients make oat popular for use in gluten-free diet. The health risk of long-time consumption of oat by celiac patients is a matter of debate. The introduction of oat into the diet is only recommended for celiac patients in remission. Furthermore, not every variety of oat is also appropriate for a gluten-free diet. The risk of sensitization and an adverse immunologically mediated reaction is a real threat in some celiac patients. Several unsolved issues still exist which include the following: (1) determination of the susceptibility markers for the subgroup of celiac patients who are at risk because they do not tolerate dietary oat, (2) identification of suitable varieties of oat and estimating the safe dose of oat for the diet, and (3) optimization of methods for detecting the gliadin contamination in raw oat used in a gluten-free diet.

Nutritional Status in Spanish Children and Adolescents with Celiac Disease on a Gluten Free Diet Compared to Non-Celiac Disease Controls

Patients who follow a gluten-free diet (GFD) may be prone to nutritional deficiencies, due to food restriction and consumption of gluten-free products. The aim was to assess nutritional status in celiac children and adolescents on a long-term GFD. A cross-sectional age and gender-matched study in 70 celiac and 67 non-celiac volunteers was conducted, using dietary, anthropometric, biochemical parameters, and assessing bone mineral density and physical activity. Adequacy of vitamin D intake to recommendations was very low, in both groups, and intakes for calcium and magnesium were significantly lower in celiac volunteers. Celiac children and adolescents may have a higher risk of iron and folate deficiencies. Both groups followed a high-lipid, high-protein, low fiber diet. Median vitamin D plasma levels fell below reference values, in celiac and non-celiac participants, and were significantly lower in celiac girls. Other biochemical parameters were within normal ranges. Anthropometry and bone mineral density were similar within groups. With the exception of some slightly lower intakes, children and adolescents following a GFD appear to follow the same trends as healthy individuals on a normal diet. No effect of food restriction or gluten-free product consumption was observed.

Diagnostic Delays in Children With Coeliac Disease in the Central European Region

OBJECTIVES

Coeliac disease (CD) is a systemic autoimmune disorder affecting about 1% of the population. Many patients remain undiagnosed or are diagnosed with substantial delay. We assessed diagnostic delays in symptomatic CD children in Central Europe (CE).

METHODS

Paediatric gastroenterologists in 5 CE countries retrospectively reported data of their patients diagnosed in 2016. Age at first CD-related symptom(s), first visit to paediatric gastroenterologist and confirmed diagnosis were used to determine diagnostic delays.

RESULTS

Data from 393 children (65% girls, median age 7 years, range 7 months to 18.5 years) from Croatia, Hungary, Germany, Italy, and Slovenia were analysed. Median duration from first symptom(s) to visit to paediatric gastroenterologist was 5 months (range 0-10 years; preschool 4 months, school-aged 5 months), and further duration until final diagnosis was 1 month (range 0-5 years) with significant regional differences (P < 0.001). Median diagnostic delay was 6 months (range 0-10 years; preschool 5 months, school-aged 7 months). Type of clinical presentation had little, however, significant effect on delays. Reduced body mass in delays longer than 3 years compared with delays shorter than 1 year was found (z score -0.93 vs -0.39, P < 0.05).

CONCLUSIONS

Time from first symptoms to CD diagnosis in children in 5 CE countries is slightly shorter compared with few other small paediatric studies, and significantly shorter than reported for adults. Nevertheless, delays of more than 3 years in 6.6% of children are worrisome. Raising awareness about the variable symptoms and implementation of reliable diagnostic tools will further reduce diagnostic delays.

ASSOCIATIONS OF IL-6 -174G>C AND IL-10 -1082A>G POLYMORPHISMS WITH SUSCEPTIBILITY TO CELIAC DISEASE: EVIDENCE FROM A META-ANALYSIS AND LITERATURE REVIEW

BACKGROUND

There has been little evidence to suggest that the IL-6 -174G>C and IL-10 -1082A>G polymorphisms are significantly associated with susceptibility to celiac disease. Thus, we performed the present meta-analysis to explore the potential association between these polymorphisms and celiac disease risk.

METHODS

Eligible studies were searched in PubMed, Medline, Embase, Web of Science and CNKI database up to April 20, 2019. Odds ratios with 95% confidence interval were calculated to assess the potential associations. Moreover, we performed the heterogeneity, sensitivity, and publication bias tests to clarify and validate the pooled results.

RESULTS

Overall, nine case-control studies involving five studies with 737 cases and 1,338 control on IL-6 -174G>C polymorphism and four studies with 923 cases and 864 controls on IL-10 -1082A>G polymorphism were selected. The pooled ORs showed that the IL-6 -174G>C and IL-10 -1082A>G polymorphisms were not significantly associated with increased risk of celiac disease under all five genetic models. There was no publication bias.

CONCLUSION

To the best of our knowledge, this is the first meta-analysis summarizing all of the available studies on the association of IL-6 -174G>C and IL-10 -1082A>G polymorphisms with celiac disease. Our results suggest that the IL-6 -174G>C and IL-10 -1082A>G polymorphisms may not be associated with increased risk of celiac disease. Moreover, large and well-designed studies are needed to fully describe the association of IL-6 -174G>C and IL-10 -1082A>G polymorphisms with celiac disease.