A prospective, longitudinal study of the long-term effect of treatment on bone density in children with celiac disease

Fracture risk among children and adolescents with celiac disease: a nationwide cohort study

BACKGROUND

Metabolic bone disease is a common manifestation of celiac disease (CD). We aimed to assess fracture risk among children and adolescents with CD compared with a matched group.

METHODS

This registry-based cohort study included 2372 children with CD who were matched 1:5 to 11,860 children without CD. Demographic and clinical data were obtained from the electronic database of Meuhedet, a health maintenance organization. Fracture events at ages 1-18 years were identified by coded diagnoses.

RESULTS

The overall fracture incidence rate was 256 per 10,000 patient-years (PY) in the CD group and 165 per 10,000 PY in the comparison group (p < 0.001). The hazard ratio (HR) to have a fracture was 1.57 (95% CI 1.43-1.73, p < 0.001) for the CD group compared to the matched group. The HR for multiple fractures was 1.67 (95% CI 1.38-2.01, p < 0.001). Analysis of the pre- and post-diagnosis periods separately showed that the HR for fractures in the pre-diagnosis period was 1.64 (95% CI 1.42-1.88, p < 0.001) for the CD group compared to the matched group, and 1.52 (95% CI 1.26-1.71, p < 0.001) in the period from diagnosis to the end of the follow-up period.

CONCLUSIONS

Children with CD had increased fracture risk both preceding and following the diagnosis of CD.

IMPACT

One manifestation of celiac disease (CD) is metabolic bone disease, including osteoporosis and impaired bone mineralization. We found increased fracture risk among children with CD, both preceding the CD diagnosis and during the years following the diagnosis. Recognition of the high risk of fractures in this population may help promote prevention. Further studies are needed to evaluate changes in bone quantity and quality after initiation of a gluten-free diet, and to identify those at risk for persistent metabolic bone disease.

[Celiac disease]

Celiac disease is a frequent auto-immune disease characterized by villous atrophy related to gluten intake in patients with genetic susceptiblity. Patients do not present symptoms in the majority of cases. Presence of the disease must be investigated in case of digestive symptoms or presence of auto-immune disease. Diagnosis is based on anti-transglutaminase antibody and dudodenal biospies. The only available treatment is gluten-free diet. Associated auto-immune diseases must be investigated, especially thyroiditis. Complications related to nutritional deficiency must be accounted for also.

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.

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.

Guidelines of the Italian societies of gastroenterology on the diagnosis and management of coeliac disease and dermatitis herpetiformis

INTRODUCTION

Coeliac disease and dermatitis herpetiformis are immune-mediated diseases triggered by the consumption of gluten in genetically predisposed individuals. These guidelines were developed to provide general practitioners, paediatricians, gastroenterologists, and other clinicians with an overview on the diagnosis, management and follow-up of coeliac patients and those with dermatitis herpetiformis.

METHODS

Guidelines were developed by the Italian Societies of Gastroenterology. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists and a paediatrician with expertise in this field.

RESULTS

These guidelines provide a practical guidance for the diagnosis, management and follow-up of coeliac patients and dermatitis herpetiformis in children and adults, both in primary care and in specialist settings. We developed four sections on diagnosis, gluten-free diet, follow-up and risk of complications in adults, one section focused on diagnosis and follow-up in children and one on the diagnosis and management of dermatitis herpetiformis.

CONCLUSIONS

These guidelines may support clinicians to improve the diagnosis and management of patients with coeliac disease.

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).

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.

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.

Alterations of Inflammatory and Matrix Production Indices in Celiac Disease With Low Bone Mass on Long-term Gluten-free Diet

BACKGROUND

A clinically meaningful impairment of bone mass secondary to malabsorption is frequent in untreated celiac disease. In adult patients, a rigorous gluten-free diet (GFD) significantly improves, but does not always normalize, bone mineral density (BMD). The reason for this marginal response is unclear. Accordingly, we evaluated the role of both local and systemic factors for bone loss in celiac patients on long-term GFD.

STUDY

In a prospective cohort, 22 patients with low lumbar and/or femoral BMD and 22 with normal BMD underwent bone and mineral metabolism evaluation: we tested calcium, phosphate, parathyroid hormone, and vitamin D; telopeptide of type I collagen, a bone resorption index; propeptide of type I procollagen, a bone neoformation index; receptor antagonist of NF-kB ligand, an osteoclast-stimulating factor; osteoprotegerin (OPG), a decoy receptor for RANKL. Sunlight exposure and physical exercise were measured.

RESULTS

Patients with bone loss showed prevalently osteopenia, severe osteoporosis was rare. In comparison with normal BMD patients, they showed higher serum OPG, telopeptide, and lower serum propeptide, suggesting an increased bone turnover. Lumbar T-score was negatively correlated with OPG, telopeptide and RANKL and positively with propeptide. Propeptide was negatively correlated with OPG and telopeptide. OPG was positively correlated with telopeptide.

CONCLUSIONS

The persistent activation of inflammation should be considered the main pathophysiological mechanism for bone defect in celiac disease patients with bone loss on long-term GFD. High levels of OPG, an attempt at protective mechanism, and low levels of propeptide of type I procollagen, reflecting an insufficient matrix production, characterize this subgroup of patients.

Neutrophil-to-Lymphocyte Ratio, Mediterranean Diet, and Bone Health in Coeliac Disease Patients: A Pilot Study

Neutrophil-to-lymphocyte ratio (NLR) has been proposed as a bone loss index in postmenopausal women and as a marker of inflammation in coeliac patients. The aims of this work were to evaluate the effect of gluten-free diet (GFD) on NLR retrospectively and study the relationship between NLR and Mediterranean diet adherence and selected food groups (fruits, vegetables, red meat, potatoes, and unrefined and refined cereals). Adult individuals (n = 50), who had been on a strict GFD by at least 6 months, were recruited. The degree of adherence to the Mediterranean diet was calculated with two different scores: the Mediterranean Diet Score (MDS-14), assessed through the validated 14-item questionnaire of the PREDIMED study, and the MEDScore (Score-55) proposed by Panagiotakos. The latter includes the consumption of unrefined cereals (UC). High percentages of osteopenia and osteoporosis were found within the recruited subjects, who furnished the reports of bone mineral density (BMD), in particular in postmenopausal (Post-M) women. Recent NLR was higher in subjects with osteoporosis compared to osteopenia and normal BMD. However, retrospective analysis showed both increase and decrease in NLR after GFD, with no significant differences between Marsh grade, anemia, and BMD status. Moreover, premenopausal previous pregnancy (Pre-MPP) and Post-M had higher NLR at diagnosis compared to Men and premenopausal (Pre-M), but higher differences were observed in recent NLR between Pre-MPP and Men only. Chocolate consumption was associated with lower recent NLR, whereas the latter was correlated with Score-55, but not with MDS-14. Moreover, refined cereal consumption was correlated with recent NLR. Although large prospective studies are needed in order to clarify the relationship between UC and NLR in coeliac patients, in this pilot study, we have investigated for the first time the relationship between NLR, dietary habit, and osteoporosis in coeliac disease.

Daily oligofructose-enriched inulin intake impacts bone turnover markers but not the cytokine profile in pediatric patients with celiac disease on a gluten-free diet: Results of a randomised, placebo-controlled pilot study

BACKGROUND

Bone metabolism disturbances are commonly observed in patients with newly diagnosed celiac disease (CD). The only available treatment for CD-the intake of a gluten-free diet (GFD)-has been found to be insufficient in effectively improving bone health in some patients. Therefore, there is an urgent need to modify the GFD so as to allow for the provision of all the necessary nutrients and improved absorption. Prebiotics intake reportedly improves the absorption of bone-related vitamin D and calcium as well as bone metabolism. The effect of prebiotic intake on bone health in CD patients has not been studied yet. This study aimed to evaluate the effect of oligofructose-enriched inulin intake on bone metabolism and immune response in children with CD on a GFD.

METHODS

A total of 34 children with CD were randomised into two groups receiving 10 g of oligofructose-enriched inulin (Synergy 1) or a placebo (maltodextrin) for three months, together with a strict GFD. The children's bone metabolism marker levels and cytokine profiles were analysed before and after the intervention.

RESULTS

After supplementation, the concentration of osteocalcin increased significantly in children receiving Synergy 1, while the concentration of bone alkaline phosphatase increased in both groups, independent of supplementation. After the intervention, the level of pyridinoline increased significantly in the placebo group, resulting in a concentration that was two times higher than that in the Synergy 1 group, in which it remained stable. Moreover, the plasma concentrations of N-terminal telopeptides of type I collagen decreased in both the groups, whereas the tartrate-resistant acid phosphatase 5b level increased particularly in the Synergy 1 group. The intervention did not lead to immunological response changes.

CONCLUSIONS

The proposed supplementation beneficially altered bone metabolism, through increased bone formation rates and decreased bone resorption process rates. Supplementation of GFD with prebiotic oligofructose-enriched inulin may be a promising auxiliary therapy for bone metabolism improvements in children with CD.

Nutritional Consideration in Celiac Disease and Nonceliac Gluten Sensitivity

Celiac disease is an autoimmune disorder due to the inflammatory response to gluten in genetically predisposed individuals. It causes an enteropathy associated with several nutritional complications. Strict compliance to a gluten-free diet (GFD) is the current primary therapy. Nonceliac gluten sensitivity (NCGS) is a condition in which gluten ingestion leads to systemic symptoms but is not associated with small bowel atrophy or abnormal celiac serologies. A GFD heals celiac disease enteropathy and improves symptoms in NCGS. However, a long-term GFD can be associated with nutritional deficiencies and requires monitoring and guidance.

Rate and determinants of non-adherence to a gluten-free diet and nutritional status assessment in children and adolescents with celiac disease in a tertiary Brazilian referral center: a cross-sectional and retrospective study

Background

Compliance with a gluten-free diet (GFD) is difficult at all ages but particularly for teenagers due to social, cultural, economic, and practical pressures. The multidisciplinary team responsible for the treatment of patients with celiac disease and give support to their parents plays a special role on strengthening GFD and assessing the nutritional and physical health.

Methods

A cross-sectional and retrospective study including patients under 20 years of age, with biopsy-confirmed CD, followed regularly at the Department of Pediatrics, Division of Gastroenterology, Hospital das Clínicas, University of Sao Paulo, School of Medicine, Sao Paulo, Brazil, were surveyed using a questionnaire and serologic test applied between November 2011 and February 2012. A retrospective chart review of these patients was performed to collect the anthropometric data along with the results of the serologic test performed at the time of diagnosis and after at least 1 year of treatment with a GFD.

Results

We evaluated 35 patients aged between 2.4 and 19.9 years. Of these 68.6% were female, 88.6% had the typical form of the disease and 51.4% had other comorbidities. The mean age at diagnosis was 5.4 years. Despite dietary guidance, 20% reported non-adherence to the diet. Most children recovered the weight and height deficit after 5 years of treatment, and in some children, excessive weight gain became a concern.

Conclusion

The majority of transgressions occurred intentionally at home or at parties. There was a risk of excessive weight gain, especially in the first two years of treatment. More alternatives and easier access to low cost gluten-free foods, increasing the discussion about the benefits of adhering to a GFD among patients, families, and the general population, besides the acquisition of self-management skills, are crucial to fostering independent children and adolescents who have the knowledge and tools to manage life with CD.

Electronic supplementary material

The online version of this article (10.1186/s12876-018-0740-z) contains supplementary material, which is available to authorized users.

Reduced Bone Mineral Density in Children With Screening-detected Celiac Disease

OBJECTIVES

The aim of the study was to assess whether bone mass and metabolism are impaired in genetically at-risk children with screening-detected celiac disease.

METHODS

Included were 71 children with screening-detected celiac disease diagnosed at 10.0 ± 0.7 (mean ± standard deviation) years and 142 matched controls and 30 children with screening-detected celiac disease diagnosed at 3.3 ± 0.4 years of age presently on a gluten-free diet for 6.9 ± 1.1 years and 60 matched controls. All participants were assessed for bone mineral density (BMD) of total body and spine by dual x-ray absorptiometry, serum 25(OH) vitamin D3, parathyroid hormone (PTH), interleukin (IL)-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-15, interferon gamma, and tumor necrosis factor alpha.

RESULTS

At diagnosis, screening-detected celiac disease children as compared to controls had a mean -0.03 g/cm reduced BMD of both total body and spine (P = 0.009 and P = 0.005, respectively), a mean -11.4 nmol/L lower level of 25(OH) vitamin D3 (P < 0.001), and a mean +1.0 pmol/L higher PTH level (P < 0.001). Systemic levels of the cytokines IL-1β, IL-6, IL-8, IL-10, IL-12p70, IL-13, and tumor necrosis factor alpha were all increased in screening-detected celiac disease as compared to controls (P < 0.001). No difference in BMD, 25(OH) vitamin D3, PTH, and cytokine levels were detected in children on a gluten-free diet compared with controls.

CONCLUSIONS

Children with screening-detected celiac disease have reduced BMD, lower levels of vitamin D3, higher levels of PTH, and signs of systemic inflammation compared with controls. These differences were not found in celiac disease children on a gluten-free diet, indicating that children with screening-detected celiac disease benefit from an early diagnosis and treatment.

Bone Mineral Density in Celiac Disease

OBJECTIVES

To study bone mineral density (BMD) and standard serum biochemical indices among newly diagnosed and already diagnosed cases of Celiac Disease (CD) on gluten free diet for at least one year.

METHODS

This hospital based analytic, observational study was done at a tertiary care centre, from April 2013 through June 2014. Thirty six children (20 females) with untreated CD at diagnosis (Group A) and 36 age and sex matched children on gluten-free diet for at least one year (Group B) were studied. Serum measurements of biochemical bone health indices and BMD, assessed by dual X-ray absorptiometry, were obtained.

RESULTS

BMD Z-score was significantly low in newly diagnosed celiac patients. Patients on gluten free diet had higher BMD Z-score as compared to newly diagnosed patients (-2.02 vs. -0.65 respectively, p < 0.001). BMD Z-score was high in GI symptom patients as compared to non-GI symptom patients (-0.46+/-0.89 vs. - 0.88 = +/-0.94) in Group B. In female patients BMD Z-score was comparatively low as compared to male patients in both groups but difference was not significant. In Group A the mean serum calcium level was lower than the patients in Group B (8.72 + 0.73 vs. 9.34 + 0.65, p < 0.001). S. calcium levels were not correlated with bone mineral density (BMD) in both groups (P value >0.05).

CONCLUSIONS

Children with CD are at risk for reduced BMD. Strict gluten-free diet significantly improves bone mineralization. Early diagnosis and treatment of celiac disease during childhood may protect CD patients from osteoporosis.

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.

Update on Bone Health in Pediatric Chronic Disease

Children and adolescents with chronic disease are predisposed to impaired bone health. Pediatric illness, including type 1 diabetes mellitus, celiac disease, and cystic fibrosis, have significant risk of low bone mineralization and fracture due to underlying inflammation, malabsorption, lack of physical activity, and delayed puberty. Dual-energy x-ray absorptiometry is the primary imaging method to assess bone health in this population. The purpose of this review is to update readers about the assessment and management of bone health in children with common pediatric chronic illnesses and review recent advances in the prevention and treatment of impaired bone health.

Primary care management of celiac disease

: Celiac disease is an autoimmune disorder with genetic predisposition that affects as many as 1 in 100 individuals. Treatment is a lifelong, strict adherence to a gluten-free diet. Management by a primary care provider may lead to increased adherence and can minimize effects of nonadherence to the diet.

Appropriate nutrient supplementation in celiac disease

Reduced levels of iron, folate, vitamin B12, vitamin D, zinc, and magnesium are common in untreated celiac disease (CD) patients probably due to loss of brush border proteins and enzymes needed for the absorption of these nutrients. In the majority of patients, removal of gluten from the diet leads to histological recovery and normalization of iron, vitamin, and mineral levels. Iron deficiency anemia is the most common extra-intestinal sign of CD and usually resolves with adherence to a gluten-free diet. However, deficiencies of both folate and vitamin B12 may persist in some patients on a gluten-free diet, thus requiring vitamin supplementation to improve subjective health status. Similarly, exclusion of gluten from the diet does not always normalize bone mineral density; in these cases, supplementation of vitamin D and calcium is recommended. Resolution of mucosal inflammation may not be sufficient to abrogate magnesium deficiency. Since gluten-free cereal products have a lower magnesium content as compared with gluten-containing counterparts, a magnesium-enriched diet should be encouraged in CD patients. In this article we discuss the frequency and clinical relevance of nutrient deficiency in CD and whether and when nutrient supplementation is needed.

PREVALENCE OF CELIAC DISEASE IN CHILDREN WITH EPILEPSY

ContextNeurological symptoms have been well-documented in patients with celiac disease, nevertheless, the presumption of a greater prevalence of epilepsy in celiac patients remains controversial.ObjectivesTo determine the frequency of celiac disease in children and adolescents with idiopathic or cryptogenic epilepsy.MethodsA cross-sectional study. One hundred pediatric patients with non-symptomatic epilepsy were followed-up at two public pediatric neurology clinics in Salvador, Bahia, Brazil. Screening for celiac disease was performed by serial measurements of IgA anti-transglutaminase and IgA anti-endomysium antibodies, followed by bowel biopsy in positive cases. HLA DQ02 and DQ08 were investigated in seropositive individuals, assessing the type of seizures, the number of antiepileptic drugs used and the presence gastrointestinal symptoms.ResultsThree (3.0%) patients tested anti-tTG-positive, two with normal duodenal mucosa (Marsh 0) and one with intraepithelial infiltrate (Marsh I). No villous atrophy of the duodenal mucosa (Marsh III) celiac disease was found. Two patients tested positive for HLA DQ02; none were DQ08 positive.ConclusionThe present study failed to prove the association between celiac disease and epilepsy.

Bone mass and mineral metabolism alterations in adult celiac disease: pathophysiology and clinical approach

Osteoporosis affects many patients with celiac disease (CD), representing the consequence of calcium malabsorption and persistent activation of mucosal inflammation. A slight increase of fracture risk is evident in this condition, particularly in those with overt malabsorption and in postmenopausal state. The adoption of a correct gluten-free diet (GFD) improves bone derangement, but is not able to normalize bone mass in all the patients. Biomarkers effective in the prediction of bone response to gluten-free diet are not yet available and the indications of guidelines are still imperfect and debated. In this review, the pathophysiology of bone loss is correlated to clinical aspects, defining an alternative proposal of management for this condition.

ACG clinical guidelines: diagnosis and management of celiac disease

This guideline presents recommendations for the diagnosis and management of patients with celiac disease. Celiac disease is an immune-based reaction to dietary gluten (storage protein for wheat, barley, and rye) that primarily affects the small intestine in those with a genetic predisposition and resolves with exclusion of gluten from the diet. There has been a substantial increase in the prevalence of celiac disease over the last 50 years and an increase in the rate of diagnosis in the last 10 years. Celiac disease can present with many symptoms, including typical gastrointestinal symptoms (e.g., diarrhea, steatorrhea, weight loss, bloating, flatulence, abdominal pain) and also non-gastrointestinal abnormalities (e.g., abnormal liver function tests, iron deficiency anemia, bone disease, skin disorders, and many other protean manifestations). Indeed, many individuals with celiac disease may have no symptoms at all. Celiac disease is usually detected by serologic testing of celiac-specific antibodies. The diagnosis is confirmed by duodenal mucosal biopsies. Both serology and biopsy should be performed on a gluten-containing diet. The treatment for celiac disease is primarily a gluten-free diet (GFD), which requires significant patient education, motivation, and follow-up. Non-responsive celiac disease occurs frequently, particularly in those diagnosed in adulthood. Persistent or recurring symptoms should lead to a review of the patient's original diagnosis to exclude alternative diagnoses, a review of the GFD to ensure there is no obvious gluten contamination, and serologic testing to confirm adherence with the GFD. In addition, evaluation for disorders associated with celiac disease that could cause persistent symptoms, such as microscopic colitis, pancreatic exocrine dysfunction, and complications of celiac disease, such as enteropathy-associated lymphoma or refractory celiac disease, should be entertained. Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice. Given the incomplete response of many patients to a GFD-free diet as well as the difficulty of adherence to the GFD over the long term, development of new effective therapies for symptom control and reversal of inflammation and organ damage are needed. The prevalence of celiac disease is increasing worldwide and many patients with celiac disease remain undiagnosed, highlighting the need for improved strategies in the future for the optimal detection of patients.

Evaluation and management of skeletal health in celiac disease: position statement

OBJECTIVE

To review the evaluation and management of skeletal health in patients with celiac disease (CD), and to make recommendations on screening, diagnosis, treatment and follow-up of low bone mineral density (BMD) in CD patients.

METHODS

A multidisciplinary team developed clinically relevant questions for review. An electronic search of the literature was conducted using the MEDLINE and EMBASE databases from 1996 to 2010. All original studies, reviews and guidelines, both pediatric and adult, were included. A document summarizing the results of the review and proposed recommendations was prepared and underwent multiple revisions until consensus was reached.

RESULTS

At diagnosis, approximately one-third of adult CD patients have osteoporosis, one-third have osteopenia and one-third have normal BMD. Children with CD have low bone mass at diagnosis. Adult and pediatric CD patients are at increased risk of fractures.

DISCUSSION

For adults, serum calcium, albumin, 25(OH) vitamin D3, parathyroid hormone and 24 h urine calcium testing should be performed at diagnosis; patients with 'classic' CD and those at risk for osteoporosis should undergo a dual x-ray absorptiometry scan. An abnormal baseline dual x-ray absorptiometry scan should be repeated one to two years after initiation of a gluten-free diet (GFD). For children, BMD should be assessed one year after diagnosis if GFD adherence is not strict. A GFD is the most important treatment for bone loss. Supplemental antiresorptives may be justified in those who remain at high fracture risk (eg, postmenopausal women, older men) after implementation of a GFD.

CONCLUSION

Current evidence does not support the screening of all CD patients for low BMD at diagnosis. Follow-up BMD assessment should be performed one to two years after initiation of a GFD.

Leonardo da Vinci meets celiac disease

BACKGROUND AND AIM

Leonardo da Vinci's face symmetry derives from 3 equal craniofacial segments: trichion-nasion (tn), which represents the superior third of the face, nasion-subnasal (ns) that is the medium third of the face, and subnasal-gnathion (sg) that is the length of the lower third of the face. It has been reported that adult subjects with celiac disease (CD) can be identified on the basis of a greater extension of the forehead in comparison to the medium third of the face, with a high tn/ns ratio. The aim of the present study was to investigate the correlation between facial asymmetry and CD in childhood and adulthood.

METHODS

We studied 126 biopsy-proven patients with CD (76 children and 50 adults) and 102 healthy controls (43 children and 59 adults). Their faces were photographed; the pictures were edited using a software program to calculate the facial segments.

RESULTS

The tn length was significantly different between adult celiac and adult controls (7.43 ± 1.46 cm vs 6.38 ± 1.73 cm, P = 0.001). The cutoff of 6.5 cm tn, derived from receiver operating characteristic curve analysis, identified 43 of 50 patients (sensitivity 86%), but 34 of 59 controls were positive (specificity 54.2%). The positive predictive value was 56%; however, the tn/ns ratio was not significantly different between celiacs and controls. Neither the tn length nor the tn/ns ratio in celiacs correlated to the time of gluten exposure.

CONCLUSIONS

Adults, but not children, with celiac disease show a forehead extension significantly greater than controls, but this test's specificity appears too low to be used in the screening of CD.

Growth and metabolic control in patients with type 1 diabetes and celiac disease: a longitudinal observational case-control study

BACKGROUND

The occurrence of celiac disease (CD) in patients with type 1 diabetes (T1D) is increasing.

OBJECTIVE

To determine the effect of CD on growth and glycemic control in patients with T1D, and the effects of adherence to gluten-free diet (GFD) on these parameters.

PATIENTS AND METHODS

A longitudinal retrospective case-control design was used. The medical files of 68 patients with T1D and duodenal-biopsy-confirmed CD were reviewed for data on weight, height, hemoglobin A1c (HbA1c), frequency of diabetic ketoacidosis (DKA), and severe hypoglycemic events before and after diagnosis and treatment of CD. Findings were compared with 131 patients with T1D only matched for age, gender, and duration of diabetes.

RESULTS

CD was diagnosed in 5.5% of all patients with T1D attending our center during the study period; 26% of the patients with CD were symptomatic. There were no significant differences in glycemic control or frequency of severe hypoglycemia or DKA events between the study and control groups. Body mass index-standard deviation score (SDS), height-SDS, and HbA1c values were marginally but not significantly higher in the control than the study group and similar in subjects with CD with good or fair/poor adherence to a GFD throughout follow-up.

CONCLUSIONS

Patients with T1D and CD treated with GFD have growth and measures of metabolic control similar to those with T1D without CD. The decision whether asymptomatic celiac patients should be put on a GFD or only symptomatic patients has to be weighed against possible short- and long-term consequences of no intervention, and should be based on more evidence from larger randomized studies.

Coeliac disease in Type 1 diabetes from 1990 to 2009: higher incidence in young children after longer diabetes duration

AIMS

To determine the incidence of coeliac disease in young people with Type 1 diabetes and to examine the effect of age at diabetes onset and disease duration.

METHODS

This was a clinic-based observational cohort study of 4379 people aged ≤ 18 years (49% male) between 1990 and 2009 from Sydney, Australia. Screening for coeliac disease was performed at diagnosis and 1-2 yearly using anti-endomysial and/or anti-tissue transglutaminase immunoglobulin A (IgA) antibodies. Coeliac disease was diagnosed by small bowel biopsy based on Marsh score ≥ III.

RESULTS

Coeliac disease was confirmed by biopsy in 185; of these, 61 (33%) were endomysial or tissue transglutaminase IgA antibody-positive at diabetes diagnosis. Mean age at diabetes onset was 6.6 ± 4.0 vs. 8.4 ± 4.1 years in those without coeliac disease (P < 0.001). Mean incidence was 7.7 per 1000 person years (95% CI 6.6-8.9) over 20 years. Incidence was higher in children aged < 5 years at diabetes diagnosis (10.4 per 1000 person years) vs. ≥ 5 years (6.4 per 1000), incidence rate ratio 1.6 (95% CI 1.2-2.2, P = 0.002). Coeliac disease was diagnosed after 2, 5 and 10 years of diabetes in 45, 78 and 94% of cases, respectively. Median time to coeliac disease diagnosis was longer in children aged < 5 years at diabetes onset (3.3 years) compared with older children (0.7 years, P < 0.001).

CONCLUSIONS

Coeliac disease is common in young people with Type 1 diabetes; the risk is greatest with diabetes onset < 5 years, but after longer diabetes duration. Screening for coeliac disease should be performed at diabetes diagnosis and for at least 10 years in young children.

Celiac disease in children and adolescents: special considerations

Although there are many commonalities between adult and pediatric celiac disease (CD), special considerations must be taken into account when working with children and adolescents. In this patient population, there are unique aspects of the epidemiology, pathogenesis, presentation, diagnosis, and management of CD. In terms of management, early and timely recognition of CD can maximize childhood and adolescent development and prevent complications. This requires insight into the unique presentations of CD in the pediatric population. Furthermore, health care providers must use proper screening methods and continue surveillance of at-risk individuals throughout childhood. Potential interventions for primary prevention of CD in children, although not completely understood, may offer some benefit. The goals of this article are to discuss in detail these special considerations when dealing with pediatric CD.

Bone health in children with celiac disease assessed by dual x-ray absorptiometry: effect of gluten-free diet and predictive value of serum biochemical indices

OBJECTIVES

In the present study, we aimed to assess bone status and the effect of gluten-free diet (GFD) in children with celiac disease (CD), and to evaluate the predictive value of standard serum biochemical indices in the diagnosis of bone mineral density (BMD) disturbances.

METHODS

Forty-five children at the time of diagnosis of CD (group A, 77.8% girls) and 36 children receiving GFD for >2 years (group B, 75% girls) were included. Sixteen children in group A were reexamined 12 months after initiation of GFD. Serum measurements of biochemical bone health indices and BMD, assessed by dual x-ray absorptiometry, were obtained.

RESULTS

Patients after 1 year of receiving GFD had higher BMD z scores compared with baseline (-1.45 ± 0.28 vs -0.61 ± 0.25, respectively, P = 0.004). BMD z scores were significantly lower than expected for the normal population, after 1 (P = 0.03) or at least 2 (P < 0.001) years of receiving GFD. In group B, BMD z score was positively correlated with 25-hydroxy vitamin D levels (P = 0.009). In the repeated measurements group, 25-hydroxy vitamin D differed between pre- and post-GFD (P = 0.018). No biochemical index was capable of predicting an abnormal BMD z score (receiver operating characteristic curve analysis, all of the areas under the curve <0.66).

CONCLUSIONS

GFD has a beneficial effect on bone health. Two years receiving diet do not ensure normalization. Biochemical markers are not indicative of BMD disturbances. Dual x-ray absorptiometry should be included in the standard management of children with CD.

[Gluten-free diet for children]

Children with celiac disease do not share the same risks as adults, and should have an adapted diet and a prolonged follow-up until adulthood. The following indications seem reasonable: in symptomatic children and adults, gluten free diet during several years in children and for the entire life in adults; in children becoming "silent", without any clinical or biological signs of malnutrition, discussion of coming back to normal diet, under the condition a strict follow-up and restarting gluten free diet at age of 25 and/or in case of pregnancy, to prevent the complications of celiac disease in adulthood; prolonged follow-up for adolescents and young adults returned to a "latent" disease.

Bone mineral densitometry findings of children with newly diagnosed celiac disease

Objective: The effect of Celiac Disease (CD) on children’s bone is the decrease in bone mineral density (BMD). Osteoporosis is a consequence of this decrease and usually manifests in adult ages. Studies in CD patients generally show that bone density of these patients can be different at the same ages for the same duration of disease. The aim of this study is to investigate the relationship between age and bone mineral density of CD patients at first diagnosis.

Material and Methods: Ninety one patients (M/F: 36/55; age range: 3-16; mean age: 9.6±3.5) with diagnosis of CD were included in the study. BMD survey from L1-L4 lumbar spine and total hip of the patients was evaluated at presentation. We evaluated the patients in 3 groups according to their ages: Group 1: pre-school (3-7 years old), Group 2: elementary school (8-11 years old) and Group 3: adolescent (12-16 years old). Results were compared using Student’s t test and correlation analysis.

Results: The mean disease duration of the patients was 16.4±16.3 months. Mean height and weight of the patients were 124.8±17.9 cm and 27±9.3 kg, respectively and height and weight of 37 patients were in ≤ 3. percentile according to age. The BMD values of both lumbar spine and total hip and Z-scores of lumbar region were in mild correlation with age (r>0.5). There was significant difference between mean ages of patients with low bone mass for chronological age and normal bone densitometry values (p<0.05). There were 27, 36 and 28 patients in Group 1, Group 2 and Group 3, respectively. The difference between mean BMD values of these groups were statistically significant (p<0.05). The mean values of lumbar Z- scores of patients were -1.08±1.27, -1.42±1, -1.86±1.14, respectively for these three groups.

Conclusion: Bone mineral densities of CD patients in childhood were lower in elder children at the time of diagnosis. This confirms the opinion that the diagnosis at earlier age results better treatment chance before bone mineral loss appears in CD patients.

Conflict of interest:None declared.

Celiac autoimmunity in children with type 1 diabetes: a two-year follow-up

OBJECTIVE

To determine the benefits of screening for celiac autoimmunity via immunoglobulin A transglutaminase autoantibodies (TG) in children with type 1 diabetes (T1D).

STUDY DESIGN

We followed up 79 screening-identified TG+ and 56 matched TG- children with T1D for 2 years to evaluate growth, bone mineral density, nutritional status, and diabetes control. TG+ subjects self-selected to gluten-free or gluten-containing diet.

RESULTS

Of the initial cohort, 80% were available for reexamination after 2 years. TG+ subjects had consistently lower weight z-scores and higher urine N-telopeptides than TG- subjects, but similar measures of bone density and diabetes outcomes. TG+ children who remained on a gluten-containing diet had lower insulin-like growth factor binding protein 3 z-scores compared with TG+ subjects who reported following a gluten-free diet. Children who continued with high TG index throughout the study had lower bone mineral density z-scores, ferritin, and vitamin D 25OH levels, compared with the TG- group.

CONCLUSIONS

No significant adverse outcomes were identified in children with T1D with screening-identified TG+ who delay therapy with a gluten-free diet for 2 years. Children with persistently high levels of TG may be at greater risk. The optimal timing of screening and treatment for celiac disease in children with T1D requires further investigation.

Bone mineral density and importance of strict gluten-free diet in children and adolescents with celiac disease

OBJECTIVES

Low bone mineral density (BMD) is common in children and adolescents with celiac disease. Strict gluten-free diet (GFD) improves bone mineralization, even in 1 year. The effect of occasional gluten intake is not known. The aims of this study were to compare BMD and prevalence of low BMD in children and adolescents on strict and not strict GFD.

METHODS

We measured BMD in 55 children and adolescents (strict GFD) with negative endomysium antibodies (EMA) in the last 2 years and in 19 (not strict GFD) with positive EMA at the time of the study. Lumbar, left hip and total body BMD were measured by dual-energy X-ray absorptiometry. Four-day weighted dietary protocols were obtained by means of a self-completed questionnaire of total food and beverage intake. Energy and calcium intake were calculated using nutrition data software. EMA, tissue transglutaminase antibodies, serum calcium, phosphate, 25-hydroxy vitamin D, intact parathormone, albumin, urea and creatinine levels were determined in all patients.

RESULTS

BMD in patients on strict GFD was significantly higher than in patients on not strict GFD (lumbar p=0.01; total body p=0.005). There were significantly more patients with total body BMD below -1.0 in not strictly compliant group (71% compared to 38%; p=0.03). Calcium intake and vitamin D levels were below recommendations in both groups.

CONCLUSION

Children and adolescents on not strict GFD are at increased risk for low BMD. We therefore recommend that BMD should be evaluated in patients with positive EMA. In addition, patients on strict GFD are at risk for low BMD because of low calcium intake or vitamin D deficiency. Therefore, strict GFD with recommended calcium intake and vitamin D supplementation during winter and spring should be encouraged in all children and adolescents with celiac disease.

Celiac disease without villous atrophy in children: a prospective study

OBJECTIVE

To establish whether children who are endomysial antibody (EmA) positive and have normal small-bowel mucosal villous morphology are truly gluten-sensitive and may benefit from early treatment with a gluten-free diet.

STUDY DESIGN

Children who were EmA positive with normal small-bowel mucosal villi were compared with children who were seropositive with villous atrophy by using several markers of untreated celiac disease. Thereafter, children with normal villous structure either continued on a normal diet or were placed on a gluten-free diet and re-investigated after 1 year. Seventeen children who were seronegative served as control subjects for baseline investigations.

RESULTS

Normal villous morphology was noted in 17 children who were EmA positive, and villous atrophy was noted in 42 children who were EmA positive. These children were comparable in all measured variables regardless of the degree of enteropathy, but differed significantly from the seronegative control subjects. During the dietary intervention, in children who were EmA positive with normal villi, the disease was exacerbated in children who continued gluten consumption, whereas in all children who started the gluten-free diet, both the gastrointestinal symptoms and abnormal antibodies disappeared.

CONCLUSIONS

The study provided evidence that children who are EmA positive have a celiac-type disorder and benefit from early treatment despite normal mucosal structure, indicating that the diagnostic criteria for celiac disease should be re-evaluated.

Inflammatory bowel diseases, celiac disease, and bone

The article summarizes the current knowledge on the pathogenesis, clinical aspects and treatment of bone problems in the major inflammatory bowel diseases (Crohn's disease and ulcerative colitis) and celiac disease. It presents the physiological relationship between intestine and bone as well as the alterations determined by disease-disrupted intestinal integrity. Two hypotheses about the pathogenetic mechanisms of bone metabolism derangements and bone loss are discussed: the classical one, that indicates calcium malabsorption as the main culprit, and the new one, that emphasizes the role of inflammation. The article summarizes the available epidemiological data about osteopenia/osteoporosis and fragility fractures in these chronic intestinal diseases and presents the state-of-the-art treatment options.

Celiac disease and pediatric type 1 diabetes: diagnostic and treatment dilemmas

Despite the advent of sensitive and specific serologic testing, routine screening for celiac disease (CD) in diabetic populations may not be universal practice, and many clinicians struggle to find the optimal approach to managing CD in pediatric Type 1 diabetes (T1D) patients. While some clinicians advocate screening for CD in all patients with T1D, others are unsure whether this is warranted. The diagnosis of patients who present with symptomatic CD, including malabsorption and obvious pathology upon biopsy, remains straightforward, with improvements noted on a gluten-free diet. Many patients identified by screening, however, tend to be asymptomatic. Evidence is inconclusive as to whether the benefits of screening and potentially treating asymptomatic individuals outweigh the harms of managing a population already burdened with a serious illness. This review focuses on current knowledge of CD in children and youth with T1D, highlighting important elements of the disease's pathophysiology, epidemiology, clinical presentation, and diagnostic challenges.

Metabolic osteopathy in celiac disease: importance of a gluten-free diet

Reduced bone mineral density (BMD) is frequently found in individuals with untreated celiac disease (CD), possibly due to calcium and vitamin D malabsorption, release of pro-inflammatory cytokines, and misbalanced bone remodeling. A gluten-free diet (GFD) promotes a rapid increase in BMD that leads to complete recovery of bone mineralization in children. Children may attain normal peak bone mass if the diagnosis is made and treatment is given before puberty, thereby preventing osteoporosis in later life. A GFD improves, but rarely normalizes, BMD in patients diagnosed with CD in adulthood. In some cases, nutritional supplementation may be necessary. More information on therapeutic alternatives is needed.

Celiac disease: presentation of 109 children

PURPOSE

The clinical features of patients with celiac disease (CD) are variable. In the present study, clinical and laboratory features of 109 patients with CD were retrospectively evaluated.

MATERIALS AND METHODS

In all cases, diagnosis of CD was made by European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) criteria and clinical and laboratory findings, including hematological and biochemical analyses, immunoglobulin levels, autoantibodies [antinucler antibody (ANA), antidouble stranded DNA (dsDNA), antimitochondrial antibody (AMA), anti-smooth muscle antibody (ASMA), liver kidney antibody (LKM-1), anti thyroid peroxidase (TPO), anti thyroglobulin (Tg)], bone mineral density (BMD), and electroencephalogram were evaluated. The type of CD was recorded.

RESULTS

Of 109 patients with CD, 66 (60.6%) were classical type, 41 (37.6%) were atypical type and 2 (1.8%) were silent type. The mean age was 8.81 +/- 4.63 years and the most common symptom was diarrhea (53.2%) followed by failure to thrive, short stature, and abdominal pain. Paleness (40.4%), underweight (34.8%), and short stature (31.2%) were the most common findings. Iron deficinecy anemia (81.6%), zinc deficiency (64.1%), prolonged prothrombin time (35.8%), and elevated transaminase levels (24.7%) were the most common laboratory findings. Eight percent of patients had at least 1 autoantibody, and 28 of 52 patients had low BMD. Four of 38 patients had abnormalty in electroencephalograms. The prevalance of selective immunoglobulin (Ig) A deficiency was 9.1%. Histocompatibility antigen HLA-DQ and/or DQ8 genotypes were found in 91% of patients. Abdominal distention, iron deficiency, prolonged prothrombine time, hypoalbuminemia, and elevated transaminase levels were more significantly frequent in the classical type than atypical type (p < 0.005).

CONCLUSION

Although classical CD was seen in most patients in the present study, clinical variability of the condition should be kept in mind.

Prevalence of low bone mineral density in children and adolescents with celiac disease under treatment

CONTEXT AND OBJECTIVE

Low bone mineral density may be a finding among children and adolescents with celiac disease, including those undergoing treatment with a gluten-free diet, but the data are contradictory. The aim of this study was to determine the frequency of bone mineral density abnormalities in patients on a gluten-free diet, considering age at diagnosis and duration of dietary treatment.

DESIGN AND SETTING

Cross-sectional prevalence study at the Pediatric Gastroenterology Outpatient Clinic of Instituto Materno Infantil Professor Fernando Figueira.

METHODS

Thirty-one patients over five years of age with celiac disease and on a gluten-free diet were enrolled. Bone mineral density (in g/cm(2)) was measured in the lumbar spine and whole body using bone densitometry and categorized using the criteria of the International Society for Clinical Densitometry, i.e. low bone mineral density for chronological age < -2.0 Z-scores. Age at diagnosis and duration of dietary treatment were confirmed according to the date of starting the gluten-free diet.

RESULTS

Low bone density for chronological age was present in 3/31 patients in the lumbar spine and 1/31 in the whole body (also with lumbar spine abnormality). At diagnosis, three patients with low bone mineral density for the chronological age were more than 7.6 years old. These patients had been on a gluten-free diet for six and seven months and 3.4 years.

CONCLUSION

Pediatric patients with celiac disease on long-term treatment are at risk of low bone mineral density. Early diagnosis and long periods of gluten-free diet are directly implicated in bone density normalization.

Gastrointestinal symptoms in children with type 1 diabetes screened for celiac disease

BACKGROUND

The association between celiac disease (CD) and type 1 diabetes mellitus (DM) is recognized. Most cases of CD in patients with DM are reported to be asymptomatic.

OBJECTIVES

The objectives of this study were to (1) compare and audit our practice with the published standards for screening for CD in children with DM, (2) characterize the children with DM and biopsy-confirmed CD, in terms of growth and gastrointestinal symptoms, and compare them with children with DM and negative celiac serology, and (3) document the effects of a gluten-free diet (GFD) after 1 year of gastrointestinal symptoms, growth, and insulin requirement.

METHOD

We performed a retrospective case-note review of 22 children with DM, positive celiac serology +/- biopsy-confirmed CD, and 50 children with DM and negative celiac serology.

RESULTS

Twenty-two children (3.9% of the total diabetic population) had positive celiac serology on screening, with 17 (3%) having biopsy-confirmed CD. Ninety-four percent of the children had standardized celiac serology testing. At diagnosis of CD, 13 of the 17 biopsy-positive children (76.4%) had > or =1 gastrointestinal symptom. The frequency of gastrointestinal symptoms in negative celiac serology diabetic children was 6% (3 of 50) (P < .0005). Symptoms resolved in all children after introduction of a GFD. A significant improvement in weight SD score (P = .008) and BMI SD score (P = .02) was noted in those compliant with a GFD after 1 year.

CONCLUSIONS

Children with DM and CD have a higher frequency of gastrointestinal symptoms than their diabetic peers with negative celiac serology and are not truly asymptomatic. Institution of a GFD has a positive effect on nutritional status and symptom resolution in the short-term.

Coeliac disease

Coeliac disease is a chronic inflammatory disorder of the small bowel induced in genetically susceptible people by the irritant gluten and possibly other environmental cofactors. The disorder is characterised by a diverse clinical heterogeneity that ranges from asymptomatic to severely symptomatic, and it manifests with frank malabsorption, an increased morbidity attributable to the frequent association with autoimmune disorders and increased mortality resulting from the emergence of T-cell clonal proliferations that predispose the patient to enteropathy-type T-cell lymphoma. Our understanding of the molecular basis for this disorder has improved and enabled the identification of targets for new therapies, although a strict gluten-free diet remains the mainstay of safe and effective treatment. In this Seminar we critically reassess the clinical and diagnostic aspects of this disease and new perspectives in its pathogenesis and treatment.

Bone mineral content deficits of the spine and whole body in children at time of diagnosis with celiac disease

BACKGROUND

The aim of this study was to determine whether children with celiac disease (CD) have deficits in spine (SP) and whole body (WB) bone mineral content (BMC) at time of diagnosis, and whether the deficits are related to altered growth and body composition. The secondary aim was to examine the effect of histological grade on BMC.

PATIENTS AND METHODS

A retrospective study of children who had undergone a dual energy x-ray absorptiometry scan at the time of diagnosis with CD between October 1, 2003, and June 15, 2006, were compared with a healthy reference sample of similar age and race from the same geographic region in the United States. SP and WB BMC were expressed as sex-specific z scores relative to age and relative to height to assess differences in the CD group versus controls. Pearson correlation, t tests, and analysis of variance were performed to determine predictors of BMC.

RESULTS

Forty-four children (mean age 10.6 +/- 3.4 years; 77% female, 96% white) with CD were evaluated and compared with 338 healthy children. Children with CD were shorter than children of similar age and sex. SP and WB BMC for age z scores were significantly lower in the CD group compared with controls. When adjusted for height, significant deficits in WB BMC persisted in patients with CD. Low SP and WB BMC correlated with advanced histological grade in CD. Low body mass index correlated with low WB BMC in CD.

CONCLUSIONS

Newly diagnosed children with CD may benefit from screening for low bone mineral content. Patients with low body mass index and those with advanced histological damage (Marsh grade IIIc) particularly may be at risk for osteopenia.

Treatment regimen adherence in pediatric gastroenterology

OBJECTIVE

To review and critically evaluate the extant research pertaining to adherence in pediatric gastroenterological diseases, particularly inflammatory bowel disease and celiac disease, and to provide recommendations for future research development.

MATERIALS AND METHODS

A literature search with no date restriction was conducted using PubMed and PsychInfo electronic databases and bibliographies of relevant articles.

RESULTS

Adherence rates in inflammatory bowel disease and celiac disease range considerably from 16% to 62% and 5% to 70%, respectively, across treatments and assessment method; nonadherence frequency was generally not reported. Measures used to assess adherence included self-report, interview, diet record, and bioassay methods, and each measure demonstrated strengths and limitations. Limited evidence suggests that adherence in both disease populations is related to patient and family behavioral factors and that nonadherence is related to poor disease outcome. Treatment outcome research for nonadherence is scant in the current literature.

CONCLUSIONS

Future research should focus on refining assessment method, examining adherence and concomitant behavioral factors longitudinally, testing theoretical models of adherence, and developing efficacious treatments for nonadherence.

Celiac disease and the endocrinologist: a diagnostic opportunity

OBJECTIVE

To review the association of celiac disease and various endocrine disorders and present the related clinical experience of a 3-physician adult endocrinology practice.

METHODS

We provide an overview of the pertinent literature, discuss the clinical manifestations, genetics, and pathogenesis of celiac disease, and describe our clinical experience during a 5-year period.

RESULTS

Celiac disease has been associated with numerous disorders, including several conditions treated by endocrinologists-type 1 diabetes mellitus, autoimmune thyroid disease, Addison disease, osteomalacia, secondary hyperparathyroidism, vitamin D or iron deficiency, fertility problems, hypogonadism in men, and autoimmune hypopituitarism. After our clinical awareness was raised about these potential comorbidities, 18 patients were newly diagnosed with celiac disease in our clinical practice during a 5-year interval. All patients had been referred for endocrine evaluation or were undergoing follow-up for ongoing management of endocrine disorders. When a "celiac-associated" endocrine disorder coexists with other factors associated with celiac disease, we recommend performance of IgA class antibody testing, and either antiendomysial or anti-tissue transglutaminase antibodies provide high specificity and sensitivity for the diagnosis of celiac disease.

CONCLUSION

Endocrinologists have an opportunity to diagnose celiac disease, a relatively common disorder with profound clinical implications that can often be associated with various endocrinopathies.

Bone metabolism in celiac disease

OBJECTIVE

To investigate the prevalence of both calcium metabolism alterations and bone defects in children with celiac disease (CD).

STUDY DESIGN

We studied 54 untreated patients with CD (mean age, 7 years). We compared the serum concentration of calcium, magnesium, 25(OH)vitamin D3, alkaline phosphatase, and parathyroid hormone (PTH) of patients with CD with those of 60 healthy children. Children with CD with 2 laboratory alterations underwent DEXA examination, which was evaluated after 6 months of a gluten-free diet (GFD).

RESULTS

The calcium and the 25(OH)vitamin D3 levels were lower in children with CD than in control subjects, and the PTH level was higher in children with CD than in control subjects (P < .001). Hyperparathyroidism was found in 29 children with CD. Twenty patients tested positive for 2 laboratory alterations, and 10 of them were osteopenic. After 6 months of GFD calcium, 25(OH)vit.D3 and PTH levels normalized, with the improvement of bone mineral density.

CONCLUSIONS

Calcium metabolism defects are common in untreated children with CD, and they returned to normal after GFD. A detailed, time-consuming, and expensive study of bone metabolism is not necessary in children with CD shortly exposed to gluten who follow the GFD.

The influence of gluten free diet on quantitative ultrasound of proximal phalanxes in children and adolescents with type 1 diabetes mellitus and celiac disease

A reduced bone mineral density has been reported in patients with untreated celiac disease (CD) as well as in patients with poorly controlled type 1 diabetes mellitus (T1DM). The aim of this study was to evaluate the bone mineral status by phalangeal quantitative ultrasound in 52 children and adolescents with both diseases (mean age 13.3+/-4.9 years). As a control group 50 patients with T1DM and no CD (age 12.2+/-4.0 years) were studied. The following bone parameters, amplitude-dependent speed of sound (AD-SoS) and bone transmission time (BTT) were considered and expressed as z score. Compliance to gluten free diet and long term glycemic control (mean of four determinations of HbA1c in the last year) were also assessed. The lowest mean AD-SoS z score values were found in patients with T1DM and CD, who reported transgressions to gluten free diet and exhibited positivity for serum anti-tissue transglutaminase antibodies (tTG) and/or endomysial antibodies (EmA), compared with patients with occasional transgressions but negative for anti-tTG and/or -EmA, patients strictly adherent to the diet, and patients who suffered only from diabetes (ANOVA p=0.021). No difference was found between patients with diabetes alone and patients with both diseases strictly adherent to gluten free diet. Prevalence of osteopenia (z AD-SoS values <-2 SD) was higher in patients with T1DM and CD and poor compliance to the diet (45.5%) compared with patients with T1DM (8%) or patients with both diseases strictly compliant to diet (12.9%) (p=0.015). A negative correlation between Ad-SoS z score and HbA1c (r -0.236, p=0.036) was found when patients with T1DM and patients with T1DM and CD, who strictly adhere to the diet, were pooled. In conclusion the quality of bone as assessed by phalangeal ultrasound in patients with T1DM and CD, who strictly adhere to gluten free diet, is similar to that found in T1DM patients. A higher prevalence of osteopenia is present in patients with both diseases who reported habitual transgressions to gluten free diet. The gluten free diet, as well as the optimization of glycemic control, plays an important role in preventing the osteopenic status caused by the clustering of these two chronic diseases.