A Gluten-Free Diet, Not an Appropriate Choice without a Medical Diagnosis

Celiac disease and nonceliac enteropathies

PURPOSE OF REVIEW

This review highlights recent research in the field of celiac disease.

RECENT FINDINGS

Epidemiological studies continue to identify celiac disease-associated diseases such as inflammatory arthritis, irritable bowel syndrome, and cardiovascular disease. Recently published consensus guidelines provide recommendations for the long-term management and monitoring of patients with celiac disease. There are multiple pharmaceutical therapies for celiac disease under investigation, and recent phase I and phase II trials are reviewed here. Finally, a recent trial of patients with nonceliac gluten sensitivity demonstrates a significant nocebo effect in this condition.

SUMMARY

Recent advances in celiac disease include the development of new clinical guidelines as well as promising new therapeutics. Continued high-quality research is needed to improve the outcomes of patients with celiac disease and nonceliac enteropathies.

Beyond the gluten-free diet: Innovations in celiac disease therapeutics

Celiac disease (CD) is an autoimmune disorder exacerbated by the ingestion of gluten in genetically susceptible individuals, leading to intestinal inflammation and damage. This chronic disease affects approximately 1% of the world’s population and is a growing health challenge due to its increasing prevalence. The development of CD is a complex interaction between genetic predispositions and environmental factors, especially gluten, culminating in a dysregulated immune response. The only effective treatment at present is a strict, lifelong gluten-free diet. However, adherence to this diet is challenging and often incomplete, so research into alternative therapies has intensified. Recent advances in understanding the molecular and immunological aspects of CD have spearheaded the development of novel pharmacologic strategies that should provide more effective and manageable treatment options. This review examines the latest innovations in CD therapies. The focus is on drugs in advanced clinical phases and targeting specific signaling pathways critical to the disease pathogenesis. We discuss both quantitative strategies such as enzymatic degradation of gluten, and qualitative approaches including immunomodulation and induction of gluten tolerance. Innovative treatments currently under investigation include transglutaminase inhibitors, which prevent the modification of gluten peptides, and nanoparticle-based therapies to recalibrate the immune response. These new therapies not only promise to improve patient outcomes but are also expected to improve quality of life by reducing the burden of dietary restrictions. The integration of these new therapies could revolutionize the treatment of CD and shift the paradigm from strict dietary restrictions to a more flexible and patient-friendly therapeutic approach. This review provides a comprehensive overview of the future prospects of CD treatment and emphasizes the importance of continued research and multidisciplinary collaboration to integrate these advances into standard clinical practice.

Impact of gluten intake on clinical outcomes in patients with chronic inflammatory diseases initiating biologics: Secondary analysis of the prospective multicentre BELIEVE cohort study

Chronic inflammatory diseases (CIDs) pose a growing healthcare challenge, with a substantial proportion of patients showing inadequate response to biological treatment. There is renewed interest in dietary changes to optimize treatment regimens, with a growing body of evidence suggesting beneficial effects with adherence to a gluten-free diet. This study compared the likelihood of achieving clinical response to biological treatment after 14-16 weeks in patients with CID with high versus low-to-medium gluten intake. Secondary outcomes of interest included changes in disease activity, health-related quality of life and C-reactive protein. The study was a multicentre prospective cohort of 193 participants with a CID diagnosis (i.e. Crohn's Disease, Ulcerative Colitis, Rheumatoid Arthritis, Axial Spondyloarthritis, Psoriatic Arthritis or Psoriasis) who initiated biological treatment between 2017 and 2020. Participants were stratified based on their habitual gluten intake: the upper 33.3% (high gluten intake) and the remaining 66.6% (low-to-medium gluten intake). The proportion of patients achieving clinical response to biological treatment after 14-16 weeks was compared using logistic regression models. The median gluten intake differed significantly between groups (12.5 g/day vs. 5.9 g/day, standardized mean difference = 1.399). In total, 108 (56%) achieved clinical response to treatment, with no difference between 35 (55%) in the high gluten group and 73 (57%) in the medium-to-low gluten group (OR = 0.96 [0.51-1.79], p = 0.897). No differences were found with secondary outcomes. In conclusion, this study found no association between gluten intake and response to biological treatment in patients with CID.

Clinical outcomes of potential coeliac disease: a systematic review and meta-analysis

OBJECTIVE

Potential coeliac disease (PCD) is characterised by positive serological and genetic markers of coeliac disease with architecturally preserved duodenal mucosa. The clinical outcomes and rates of progression to overt coeliac disease in patients with PCD remain uncertain. In this systematic review and meta-analysis, we aimed to evaluate the clinical outcomes of patients with PCD.

DESIGN

We searched Medline, Embase, Scopus and Cochrane Library from 1991 through May 2024 to identify studies evaluating the clinical outcomes of patients with PCD. The progression rates to villous atrophy, seroconversion and response to a gluten-free diet (GFD) were analysed. A random-effect meta-analysis was performed, and the results were reported as pooled proportions with 95% CIs.

RESULTS

Seventeen studies comprising 1010 patients with PCD were included in the final analyses. The pooled prevalence of PCD among patients with suspected coeliac disease was 16% (95% CI 10% to 22%). The duration of follow-up in most of the studies was at least 1 year, with follow-up periods within individual studies ranging from 5 months to 13 years. During follow-up, 33% (95% CI 18% to 48%; I2=96.4%) of patients with PCD on a gluten-containing diet developed villous atrophy, and 33% (95% CI 17% to 48%; I2=93.0%) had normalisation of serology. Among those who adhered to a GFD, 88% (95% CI 79% to 97%; I2=93.2%) reported symptomatic improvement.

CONCLUSION

Almost a third of patients with PCD develop villous atrophy over time, whereas a similar proportion experience normalisation of serology despite a gluten-containing diet. Most symptomatic patients benefit from a GFD. These findings highlight the importance of structured follow-up and individualised management for patients with PCD.

Yield of Gluten Challenge in Patients on Self-Prescribed Gluten-Free Diets

BACKGROUND

Patients on a gluten-free diet (GFD) whose celiac disease (CD) status is unknown may undergo gluten challenge (GC) to clarify their diagnosis. Though this is an established diagnostic practice, the proportion of patients undergoing GC who are diagnosed with CD is unknown.

AIMS

We aimed to analyze which factors were predictive of having CD in a cohort of patients who underwent GC followed by upper endoscopy with duodenal biopsy.

METHODS

We identified adult patients at a CD referral center who had been on a GFD and then underwent GC to determine a diagnosis of CD during the years spanning 2006 to 2020. We compared those patients found to have CD (defined as villus atrophy/Marsh 3) on duodenal biopsy with those who did not, using the chi square and Fischer exact tests.

RESULTS

We identified 206 patients who underwent GC. Of these 206, 30 (14%) were diagnosed with CD based on post-GC duodenal biopsy. 176 of the 206 (85%) patients reported various gastrointestinal symptoms, including bloating (39%), though these were more common in those without CD (any GI symptoms: 89% vs 67%, p 0.004; bloating: 43% vs 20%, p 0.019). Serology values, when normalized, including pre- and post-challenge TTG IgA (37% vs 1.7%, p 0.001; 23% versus 2.3%, p 0.001), DGP IgG and IgA (57% vs 2.8%, p 0.001; 37% vs 6.2%, p 0.001) were higher in the group of patients with CD.

CONCLUSION

Among patients undergoing GC for diagnostic purposes, only 14% had evidence of villus atrophy corresponding with CD on duodenal biopsy. The presence of any elevated pre-challenge serology was associated with CD. Bloating in combination with low serologies may help risk stratify patients as being less likely to have CD upon GC.

Effects of gluten on dyspeptic symptoms: a systematic review and meta-analysis of clinical trials

CONTEXT

Research on the effects of gluten on dyspeptic symptoms has shown conflicting results.

OBJECTIVE

The aim of this systematic review and meta-analysis of clinical trials was to assess the effects of gluten on dyspeptic symptoms.

DATA SOURCES

A systematic search of the PubMed, ISI Web of Science, Scopus, Cochrane, and Embase online databases was performed up to May 2022.

DATA EXTRACTION

Randomized controlled trials (RCTs) and non-RCTs that examined the impact of a gluten-free diet, a low-gluten diet, or a gluten challenge on dyspeptic symptoms, including early satiety, epigastric pain, bloating, and nausea, were selected independently by 2 authors. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework was used to assess the certainty of the evidence. Results were pooled using a random-effects model and expressed as weighted mean differences (WMDs) and 95%CIs.

DATA ANALYSIS

Of the 7641 citations retrieved, 27 articles (18 RCTs and 9 non-RCTs) were included in the systematic review. Of those, 5 RCTs were eligible for the meta-analysis. The pooled results indicated that gluten challenge significantly increased the severity of bloating (WMD = 0.67; 95%CI, 0.37-0.97; I2 = 81.8%; n = 6), early satiety (WMD = 0.91; 95%CI, 0.58-1.23; I2 = 27.2%; n = 5), and epigastric pain (WMD = 0.46; 95%CI, 0.17-0.75; I2 = 65.8%; n = 6). However, the effect of gluten challenge on the severity of nausea (WMD = 0.13; 95%CI, -0.17 to 0.43; I2 = 0.0%, n = 5) was nonsignificant.

CONCLUSION

Gluten challenge significantly worsened dyspeptic symptoms, including bloating, early satiety, and epigastric pain, but did not affect nausea. These findings suggest that gluten restriction could be efficient in reducing dyspeptic symptoms. Well-designed large RCTs recruiting homogenous groups of patients with functional dyspepsia are needed to clarify the effectiveness of gluten restriction on dyspeptic symptoms.

Myths and Facts about Food Intolerance: A Narrative Review

Most adverse reactions to food are patient self-reported and not based on validated tests but nevertheless lead to dietary restrictions, with patients believing that these restrictions will improve their symptoms and quality of life. We aimed to clarify the myths and reality of common food intolerances, giving clinicians a guide on diagnosing and treating these cases. We performed a narrative review of the latest evidence on the widespread food intolerances reported by our patients, giving indications on the clinical presentations, possible tests, and dietary suggestions, and underlining the myths and reality. While lactose intolerance and hereditary fructose intolerance are based on well-defined mechanisms and have validated diagnostic tests, non-coeliac gluten sensitivity and fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) intolerance are mainly based on patients' reports. Others, like non-hereditary fructose, sorbitol, and histamine intolerance, still need more evidence and often cause unnecessary dietary restrictions. Finally, the main outcome of the present review is that the medical community should work to reduce the spread of unvalidated tests, the leading cause of the problematic management of our patients.

Adherence to a gluten-free diet in celiac disease patients from Paraguay

INTRODUCTION AND AIM

The treatment for celiac disease is a gluten-free diet that should be strictly and permanently carried out. Our aims were to determine adherence to the gluten-free diet and the risk factors for non-adherence.

MATERIALS AND METHODS

An observational, cross-sectional, comparative study was conducted. It included individuals of both sexes and of any age that presented with celiac disease, lived in Paraguay from January to April 2021, and agreed to participate in the survey. Incomplete questionnaires were excluded. Non-probabilistic convenience sampling was utilized. Adherence was measured using the Leffler questionnaire. The study was approved by the Ethics Committee of the Universidad Privada del Este.

RESULTS

The sample consisted of 371 respondents, 322 (87%) of whom were adults, with a mean age of 38 ± 12 years, and 49 (13%) of whom were children and adolescents, with a mean age of 10 ± 5 years. Female sex was predominant (85%). Adherence to the gluten-free diet was detected in 59% of the adults and 73% of the children and adolescents. The factors significantly associated with adherence included belonging to the child and adolescent age group and having had the diagnosis for a longer time: 9 ± 8 years for the adherence group and 7 ± 8 years for the non-adherence group.

CONCLUSIONS

The present study demonstrated the frequency of adherence to the gluten-free diet in celiac patients in Paraguay. Psychologic and nutritional support is recommended for individuals with celiac disease that do not adhere to their treatment.

A prospective pilot study of a gluten-free diet for primary sclerosing cholangitis and associated colitis

BACKGROUND

Primary sclerosing cholangitis (PSC) is a progressive bile duct disease associated with inflammatory bowel disease (PSC-IBD).

AIM

To investigate whether patients with PSC-IBD benefit from a gluten-free and amylase trypsin inhibitor (ATI)-free diet (GFD).

METHODS

We performed a prospective clinical pilot study administering an eight-week GFD. The primary outcomes were colonic inflammation assessed by proctosigmoidoscopy, and liver stiffness (surrogate for fibrosis, inflammation and cholestasis) measured by transient elastography before and after GFD. Amongst the secondary (exploratory) outcomes were colonic mucosal and serum cytokine/chemokine changes, the intestinal microbiome and transcriptome dynamics, and shifts in serum markers of hepatic fibrogenesis.

RESULTS

Fifteen patients with PSC-IBD completed the study. The study did not meet its primary outcome: the endoscopic score and liver stiffness remained unchanged. However, the expression of pro-inflammatory mucosal cytokines and chemokines such as IL6, IL8, CCL2, and TNFα was significantly down-regulated. Two critical markers of liver fibrosis and matrix remodelling, thrombospondin-2 and -4, decreased significantly. The microbiota composition changed slightly, including a decrease in the pathogen Romboutsia ilealis. The intestinal transcriptome indicated a gut barrier improvement. Pruritus, fatigue, overall well-being, faecal calprotectin levels, and serum alkaline phosphatase did not change significantly.

CONCLUSIONS

This study did not demonstrate a clinical improvement with short-term GFD in patients with PSC-IBD. However, a gluten/ATI-free diet may improve biomarkers of intestinal inflammation and barrier function in these patients with associated changes in the enteric microbiota. Further investigation of the therapeutic potential of the GFD in PSC-IBD is warranted.

The gluten-free diet challenge in adults with coeliac disease: the Hellenic survey

Objective

The only available treatment for coeliac disease (CD) is a lifelong strict gluten-free diet (GFD), which can be extremely challenging. Τhe aim of the present study was to gain an insight into patients' perceptions regarding the GFD, in relation to difficulties experienced, disease-specific symptoms, adherence level, and information sources used.

Methods

Two hundred ninety CD patients (247 women and 43 men) aged 18-74 years, completed a self-administered questionnaire.

Results

Self-rated dietary adherence was high in 65.5%, moderate in 27.5% and poor in 6.9% of the patients. The main difficulties encountered were the high cost and limited availability of GF foods and meals in markets and restaurants. The main source of information concerning CD and GFD was the internet, and the most useful source was the Coeliac Society. Dietary adherence correlated positively with Coeliac Society membership and awareness of the monthly CD allowance.

Conclusion

Α substantial proportion of patients did not adhere to a strict GFD. Patients were not adequately followed-up.

Innovation

A self-administered questionnaire was used to explore the practical challenges of a GFD in an understudied population, Greek adult coeliac patients. The results highlighted the need for dietitians with expertise on CD.

Dietary Acid Load in Gluten-Free Diets: Results from a Cross-Sectional Study

The gluten-free diet (GFD) ensures improvement of clinical symptoms in the vast majority of celiac disease (CD) patients. Despite stable CD rates in many countries, an increasing number of healthy individuals are adopting gluten-free diets, believing that this diet is an inherently healthier choice. The health effects of gluten-free diets are controversial, and a recent study added to the debate by reporting a lower acidogenic potential of this diet. The effects of the GFD on potential renal acid load (PRAL) and net endogenous acid production (NEAP)—two important markers of dietary acid load (DAL)—are poorly understood, and have never been examined in a Western population. Using cross-sectional data from the National Health and Nutrition Examination Surveys, we estimated DAL in U.S. individuals reporting a GFD and contrasted the results to the general U.S. population consuming gluten and denying special diets. The GFD was associated with significantly lower crude DAL scores, and after adjustments for confounders in multivariate regression, the results remain significant. Yet, our study could not confirm the reported alkalizing properties of the GFD. Although overall DAL scores were significantly lower in the GFD group, they were comparable to Western diets producing 50–75 mEq of acid per day.

Population-based screening for celiac disease reveals that the majority of patients are undiagnosed and improve on a gluten-free diet

The impact of a gluten-free diet (GFD) on screen-detected celiac disease (CD) is currently ambiguous. We aimed to identify the population-based prevalence of undiagnosed adult CD and examine the impact of a GFD on screen-detected CD. In total, 12,981 adults participated in a population-based health study in Tromsø, Norway. Participants with increased levels of anti-tissue transglutaminase-2 IgA or anti-deamidated gliadin peptide IgG were invited to undergo gastroduodenoscopy with both histological and immunohistochemical examination of small-bowel biopsies. The prevalence of previously diagnosed CD was 0.37%. Additionally, the prevalence of previously undiagnosed CD was 1.10%. Thus, 1.47% of the population had CD, of whom 75% were previously undiagnosed. A GFD resulted in significant improvements in overall gastrointestinal symptoms, diarrhea, and health-related quality of life, with reduced abdominal discomfort (76%) and improved levels of energy (58%). The large majority of patients with adult CD were undiagnosed and benefited from a GFD with reduced gastrointestinal symptoms and improved health-related quality of life. In clinical practice, there should be a low threshold for CD testing even in the absence of abdominal complaints because most adult patients appear to consider their symptoms a part of their normal state and therefore remain untested and undiagnosed.Trial registration: Clinical Trials. Gov Identifier: NCT01695681.

How Diet and Physical Activity Modulate Gut Microbiota: Evidence, and Perspectives

Gut microbiota plays a significant role in the maintenance of physiological homeostasis, contributing to human health. Nevertheless, some factors (sex, age, lifestyle, physical activity, drug-based therapies, diet, etc.) affect its composition and functionality, linked to pathologies and immunological diseases. Concerning diet, it interacts with microorganisms, leading to beneficial or detrimental outcomes for the health of host. On the other hand, physical activity is known to be useful for preventing and, sometimes, treating several diseases of cardiovascular, neuroendocrine, respiratory, and muscular systems. This paper focuses on diet and physical activity presenting the current knowledge about how different diets (Western, ketogenic, vegan, gluten free, Mediterranean) as well as different types of exercise (intensive, endurance, aerobic) could shape gut microbiota.

Effects of green coffee bean flour fortification on the chemical and nutritional properties of gluten-free cake

The objective of this study was the application of green coffee bean flour in gluten-free cakes with different percentages (4, 8 and 15% (w/w)), to evaluate the optimal value for fortification, and the products were characterized based on their centesimal composition and bioactive compounds (caffeine and total phenolic compounds). Significant differences (p ≤ 0.05) were observed in the content of lipids, total dietary fiber, insoluble fiber, energy values, sodium, caffeine, and total phenolics, mainly in the product in which 15% (w/w) green coffee bean flour was added. Caffeine content was only detected and quantified in products with > 8% (w/w) green coffee bean flour, whereas the total phenolic content was detected and quantified in products with > 4% (w/w) green coffee bean flour. Thus, fortification of these products with 15% green coffee bean flour promoted a higher content of total dietary fiber and lower content of lipids, calories, sodium, and increased bioactive compounds. Thus, green coffee bean flour is an excellent alternative for the production of innovative foods.

Review article: therapeutic targets for the pharmacologic management of coeliac disease-the future beyond a gluten-free diet

BACKGROUND

Coeliac disease (CeD) is an immune-mediated small bowel enteropathy resulting from dietary gluten exposure. Presently, the only effective treatment is adoption of a gluten-free diet (GFD), although strict adherence is challenging to maintain, and inadvertent gluten exposures are inevitable for most patients. Hence, there is substantial interest in drug development in CeD and multiple novel therapies are under investigation.

AIMS

To review existing and upcoming clinical trial programmes for pharmacologic agents for CeD.

METHODS

A narrative review was performed, informed by a search of MEDLINE, Embase, the Cochrane CENTRAL Library and clinicaltrials.gov.

RESULTS

We summarise the pathophysiology of CeD and the specific steps that are potentially amenable to pharmacologic treatment. We evaluate the evidence supporting existing and future drug targets, including trials of peptidases, gluten sequestrants, tight junction regulators, anti-transglutaminase 2 therapies, immune tolerizing agents, advanced biologics and small molecules, and microbiome-targeted strategies. We highlight unique considerations for conducting CeD trials, including identifying appropriate study populations, assessing results in the context of a gluten challenge, and interpreting CeD-specific clinical and histologic outcomes. Understanding these factors is crucial for accurately appraising the evidence. Finally, we outline what the future of CeD therapy may hold with the introduction of pharmacotherapies.

CONCLUSIONS

There is a need for pharmacologic options for CeD, either used adjunctively with a GFD for accidental or intentional gluten exposures or for refractory disease. Multiple promising agents are in development, and these trials are likely to lead to approvals for the first generation of pharmacologic agents for CeD within the next 5 years.

Effect of the addition of high-temperature water on the properties of batter and bread made from gluten-free rice flour

Increasing number of individuals worldwide are consuming gluten-free products, for example, bread, for health and other reasons. However, gluten-free products are currently expensive and/or their preparation involves the use of specialist machinery or food additives. In this study, we focused on the thickening effect of starch gelatinization and attempted to develop a novel method for gluten-free rice flour bread production without the use of additives. We aimed to determine the effect of adding high-temperature water to gluten-free rice flour on the properties of the resulting batter, primarily gelatinization. The water was tested at temperatures between 50 and 80°C, in 2°C increments. For comparison, control bread from gluten-free rice flour was made using cold (5°C) water. The addition of water at a temperature between 66 and 70°C significantly improved the specific volume and firmness of bread (p < 0.05, Dunnett's test; compared with control). Additionally, maintaining the gelatinization temperature of the bread batter for approximately 1-10 s and the degree of gelatinization of batter, approximately 5%-10%, were crucial for obtaining good-quality bread. Further, the addition of water at a temperature above 78°C adversely affected the bread-making properties. This simple method developed for making high-quality bread from gluten-free rice flour will make gluten-free bread products more widely available to and acceptable by the consumers. PRACTICAL APPLICATION: Currently, making high-quality bread from gluten-free rice flour involves the use of food additives or special rice flour. Here, we present a simple method for producing high-quality bread by manipulating the temperature of water added during the preparation of rice flour batter. We optimized the method by analyzing the gelatinization properties of the batter and determined the optimal water temperature suitable for bread making. This method yields high-quality gluten-free bread and is cost-effective and simple to implement.

Maternal folic acid and multivitamin supplementation: International clinical evidence with considerations for the prevention of folate-sensitive birth defects

More evidence is available for maternal intake, absorption, distribution, tissue specific concentrations, and pregnancy outcomes with folic acid (fortification/supplementation) during preconception - first trimester. This Quality Improvement prevention review used expert guidelines/opinions, systematic reviews, randomized control trials/controlled clinical trials, and observational case control/case series studies, published in English, from 1990 to August 2021. Optimization for an oral maternal folic acid supplementation is difficult because it relies on folic acid dose, type of folate supplement, bio-availability of the folate from foods, timing of supplementation initiation, maternal metabolism/genetic factors, and many other factors. There is continued use of high dose pre-food fortification 'RCT evidenced-based' folic acid supplementation for NTD recurrence pregnancy prevention. Innovation requires preconception and pregnancy use of 'carbon one nutrient' supplements (folic acid, vitamin B12, B6, choline), using the appropriate evidence, need to be considered. The consideration and adoption of directed personalized approaches for maternal complex risk could use serum folate testing for supplementation dosing choice. Routine daily folic acid dosing for low-risk women should consider a multivitamin with 0.4 mg of folic acid starting 3 months prior to conception until completion of breastfeeding. Routine folic acid dosing or preconception measurement of maternal serum folate (after 4-6 weeks of folate supplementation) could be considered for maternal complex risk group with genetic/medical/surgical co-morbidities. These new approaches for folic acid oral supplementation are required to optimize benefit (decreasing folate sensitive congenital anomalies; childhood morbidity) and minimizing potential maternal and childhood risk.

Association between Self-Reported Gluten Avoidance and Irritable Bowel Syndrome: Findings of the NutriNet-Santé Study

Self-management of irritable bowel syndrome (IBS) is increasingly focusing on exclusion diets. In particular; patients are showing a significant interest in the gluten-free diet for the treatment of IBS. However; the lack of scientific evidence prevents the establishment of clear dietary guidelines and attention is needed as dietary restriction can lead to potentially adverse effects. This cross-sectional study aims to explore the practice of gluten avoidance in participants identified with IBS in a large cohort of non-celiac French adults. The population included 15,103 participants of the NutriNet-Santé study who completed a functional gastrointestinal disorder questionnaire based on the Rome III criteria to identify IBS in 2013 and a food avoidance questionnaire in 2016. Data on diet and anthropometric and sociodemographic characteristics were collected. Multivariate logistic regression models were used to compare the avoidance of gluten between IBS and non-IBS participants. Participants were mainly women (73.4%) and the mean age in this population was 55.8 ± 13.2 years. Among these individuals, 804 (5.4%) participants were identified as IBS cases. Among them, the prevalence of gluten avoidance was estimated at 14.8%, of which 3.0% reported total avoidance; versus 8.8% and 1.6% in non-IBS participants. After adjustments; gluten avoidance was higher in IBS participants compared to their non-IBS counterparts: (OR = 1.86; 95%CI = 1.21, 2.85) for total and (OR = 1.71; 95%CI = 1.36, 2.14) for partial avoidance. Participants identified with IBS were more associated with gluten avoidance than non-IBS participants. Further studies are needed to explore the long-term consequences of dietary interventions and to provide consistent dietary guidance connected to patient perception.

ESPEN guideline on hospital nutrition

In hospitals through Europe and worldwide, the practices regarding hospital diets are very heterogeneous. Hospital diets are rarely prescribed by physicians, and sometimes the choices of diets are based on arbitrary reasons. Often prescriptions are made independently from the evaluation of nutritional status, and without taking into account the nutritional status. Therapeutic diets (low salt, gluten-free, texture and consistency modified, …) are associated with decreased energy delivery (i.e. underfeeding) and increased risk of malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) proposes here evidence-based recommendations regarding the organization of food catering, the prescriptions and indications of diets, as well as monitoring of food intake at hospital, rehabilitation center, and nursing home, all of these by taking into account the patient perspectives. We propose a systematic approach to adapt the hospital food to the nutritional status and potential food allergy or intolerances. Particular conditions such as patients with dysphagia, older patients, gastrointestinal diseases, abdominal surgery, diabetes, and obesity, are discussed to guide the practitioner toward the best evidence based therapy. The terminology of the different useful diets is defined. The general objectives are to increase the awareness of physicians, dietitians, nurses, kitchen managers, and stakeholders towards the pivotal role of hospital food in hospital care, to contribute to patient safety within nutritional care, to improve coverage of nutritional needs by hospital food, and reduce the risk of malnutrition and its related complications.

Gluten-Free Diet Reduces Diet Quality and Increases Inflammatory Potential in Non-Celiac Healthy Women

AIM

Gluten-free diets (GFDs) have gained popularity in the general population. Nonetheless, controlled studies are necessary before decisions can be made to promote GFDs. We aimed to evaluate the effects of gluten intake on body weight, body composition, and resting energy expenditure and observe the changes in nutrient intake caused by GFDs.

METHODS

Twenty-three women were kept on a GFD for six weeks and received muffins with 20 g of gluten isolate (gluten period) or muffins without gluten (gluten-free period) in a crossover, single-blind, non-randomized trial. Gastrointestinal symptoms, food frequency questionnaires, body composition, and resting energy expenditure were assessed before the study (habitual or usual diet) and in the third and sixth weeks. Food intake was recorded daily for six weeks.

RESULTS

Gastrointestinal symptoms, resting energy expenditure, and body weight and composition were similar during the gluten period and gluten-free period. When the diet of the gluten-free period was compared with the habitual diet, we found an increase in the intake of fat and sodium and a reduction in the intake of fiber and vitamins B1, B6, B12, and folate. The nutrient imbalance caused by a GFD led to an increase in the dietary inflammatory index, thus suggesting that this type of diet has high inflammatory potential.

CONCLUSION

Gluten intake (20 g/day) did not alter body composition and resting energy expenditure in healthy women without caloric restriction in the diet for a short period (three weeks). However, a GFD led to changes in the composition of the diet, which worsened the quality of the diet and increased its inflammatory potential.

"The Gluten-Free Diet and Its Relationship with Metabolic Syndrome: Dietary Friend or Foe?"

PURPOSE OF REVIEW

Celiac disease (CD) is a prevalent digestive illness as well as a budding area of research in the field of gastroenterology. While investigations are underway to find new and improved pharmacological therapies for CD, the gluten-free diet (GFD) remains the only option to effectively manage the condition.

RECENT FINDINGS

While the GFD is recommended for patients diagnosed with CD and other gluten-related conditions, studies show the number of individuals on the GFD surpasses the projected number of patients with these medical indications (1). The implications of widespread adoption of this dietary approach are still being determined, with many patients believing this diet will improve overall health and cardiovascular risk. This review analyzes the relationship between a GFD and metabolic syndrome in both non-celiac and celiac patients, concluding that although the diet may slightly improve overall cardiac risk factors, weight, and/or insulin resistance, its use in the absence of a gluten-related disorder is controversial.

The Relationship between Bodyweight Status and Weight Perception Explains Differences in Calories Ordered in a Food Choice Exercise

Understanding food choice is critical to be able to address the rise in obesity rates around the globe. In this paper, we examine the relationship between measured (BMI, using self-reported height and weight) and perceived weight status with the number of calories ordered in a controlled online food choice exercise. A total of 1044 participants completed an online food choice exercise in which they selected ingredients for a sandwich from five categories: meat/protein, cheese, spread/dressing, bread, and vegetables. We examine the number of calories ordered by participants and use linear regression to study the relationship of BMI category relative to self-reported perceived weight status with calories ordered. As a comparison to previous literature, we also examine the relationship between relative weight status and self-reported dieting behavior using logistic regression. We find that participants perceiving themselves to have a higher BMI than their BMI calculated using height and weight ordered significantly fewer calories and were more likely to report dieting than participants who perceived themselves to have a lower BMI than their calculated BMI. The relationship between perceived weight status and measured weight status explains behavior in a food choice task. Understanding how people perceive their weight may help design effective health messages.

Celiac disease in patients with systemic lupus erythematosus

Objectives

Celiac disease (CD) is one of the most common chronic diseases. Celiac disease has been associated with several autoimmune disorders, but the association with systemic lupus erythematosus (SLE) as a systemic autoimmune disease is still controversial. In this study, we aimed to determine the prevalence of biopsy-proven CD in patients with SLE, and to determine the clinical symptoms and laboratory data in these patients.

Material and methods

In a cross-sectional study, SLE patients at a referral clinic were evaluated for gastrointestinal symptoms between March and December 2016. Patients were evaluated by a gastroenterologist, and upper gastrointestinal endoscopy with intestinal biopsy was performed if deemed necessary. The clinical symptoms, laboratory data, and endoscopy results were recorded and compared between groups.

Results

In total, 130 patients were evaluated in this study. Gastrointestinal symptoms were present in 40% of the patients. Endoscopy was performed in all SLE patients with gastrointestinal symptoms. Four patients (3%) were diagnosed as having CD based on biopsy results and response to a gluten-free diet. Anti-endomysium antibody (AEA) was found to be 100% sensitive and 99.2% specific for the diagnosis of CD in SLE patients, and anti-gliadin antibody (AGA) had a 50% sensitivity and 98% specificity. Patients with comorbid CD and SLE were significantly more likely to have diarrhea, abdominal pain, nausea/vomiting, recurrent oral aphthosis, and anemia.

Conclusions

The results of this study suggest that a significant association is present between CD and SLE. We found a prevalence of 3% for biopsy-proven CD in patients with SLE, which is five times the prevalence of CD in the general population.

The Evolving Landscape of Biomarkers in Celiac Disease: Leading the Way to Clinical Development

Celiac disease is a common immune-mediated disease characterized by abnormal T-cell responses to gluten. For many patients, symptoms and intestinal damage can be controlled by a gluten-free diet, but, for some, this approach is not enough, and celiac disease progresses, with serious medical consequences. Multiple therapies are now under development, increasing the need for biomarkers that allow identification of specific patient populations and monitoring of therapeutic activity and durability. The advantage of identifying biomarkers in celiac disease is that the underlying pathways driving disease are well characterized and the histological, cellular, and serological changes with gluten response have been defined in gluten challenge studies. However, there is room for improvement. Biomarkers that measure histological changes require duodenal biopsies and are invasive. Less invasive peripheral blood cell and cytokine biomarkers are transient and dependent upon gluten challenge. Here, we discuss established biomarkers and new approaches for biomarkers that may overcome current limitations.

Berrios J. Tiger Nut (Cyperus esculentus) as a Functional Ingredient in Gluten-Free Extruded Snacks

Tiger nut (TN) is a nutritious source of gluten-free flour, used generally in healthy beverages, but its incorporation in gluten-free extruded snacks has not been explored. TN flour was blended at different concentrations (up to 70%) with rice flour and soluble fiber, for the development of gluten-free snacks on a twin-screw extruder. The effect of TN inclusion in the formulations was evaluated on relevant physiochemical characteristics of the snacks. Viscoamylograph of the raw formulations showed that TN addition increased (p < 0.01) onset temperature and delayed peak viscosity. In the extruded flours, TN contributed to limit the starch degradation during extrusion. Diameter, expansion ratio, true density, and total pore volume of the extrudates were reduced (pf < 0.01) by the increased TN content in the formulations, while bulk density rose. The surfaces of the extruded snacks were modified by the increasing inclusion of TN in substitution of rice in the formulations. Extrudates containing 10% TN showed the best overall texture profile. Moreover, TN addition enhanced the ash and protein content of the snacks and increased their total antioxidant activity. This study demonstrated that incorporation of 10% TN flour into rice-based formulation was suitable for making gluten-free snacks with acceptable physical properties.

Probiotics, Prebiotics and Other Dietary Supplements for Gut Microbiota Modulation in Celiac Disease Patients

To date, the only available treatment for celiac disease (CD) patients is a life-lasting gluten-free diet (GFD). Lack of adherence to the GFD leads to a significant risk of adverse health consequences. Food cross-contamination, nutritional imbalances, and persistent gastrointestinal symptoms are the main concerns related to GFD. Moreover, despite rigid compliance to GFD, patients struggle in achieving a full restoring of the gut microbiota, which plays a role in the nutritive compounds processing, and absorption. Pivotal studies on the supplementation of GFD with probiotics, such as Bifidobacterium and Lactobacilli, reported a potential to restore gut microbiota composition and to pre-digest gluten in the intestinal lumen, reducing the inflammation associated with gluten intake, the intestinal permeability, and the cytokine and antibody production. These findings could explain an improvement in symptoms and quality of life in patients treated with GFD and probiotics. On the other hand, the inclusion of prebiotics in GFD could also be easy to administer and cost-effective as an adjunctive treatment for CD, having the power to stimulate the growth of potentially health-promoting bacteria strains. However, evidence regarding the use of prebiotics and probiotics in patients with CD is still insufficient to justify their use in clinical practice.

Gastrointestinal Symptoms and Feeding Problems and Their Associations with Dietary Interventions, Food Supplement Use, and Behavioral Characteristics in a Sample of Children and Adolescents with Autism Spectrum Disorders

Autism spectrum disorders (ASD) are characterized by impairments in social interaction, communication, and restricted, stereotyped behavior. Gastrointestinal (GI), nutritional, and feeding problems are often reported in ASD. We investigated the prevalence of GI symptoms, food selectivity, and mealtime difficulties, and their associations with dietary interventions, food supplement use, and behavioral characteristics in a sample involving 247 participants with ASD and 267 controls aged 2-18 years. Data were collected by a questionnaire. GI symptoms were observed in 88.9% of children and adolescents with ASD, more often in girls than in boys. High rates of food selectivity (69.1%) and mealtime problems (64.3%) were found. Food supplements were used by 66.7% of individuals, mainly vitamins/minerals, probiotics, and omega-3 fatty acids. In the ASD sample, 21.2% of subjects followed a diet, mostly based on gluten and milk restriction, including individuals exhibiting food selectivity. Frequency of GI symptoms, food selectivity, and mealtime problems correlated weakly, but significantly with behavioral characteristics in the ASD group, but not with food supplement use. The study demonstrated that higher frequency of GI symptoms, food selectivity, and mealtime problems are a common problem in pre-schoolers, schoolchildren, and adolescents with ASD, and together with dietary modification, they are significantly associated with ASD.

Gluten hypersensitivities and their impact on the production of gluten-free beer

This article consists of a study of the literature and an assessment of available data on the production of gluten-free beer and its constituents. The article shows how the FAO/WHO Codex Alimentarius Commission for Nutrition and Foods for Special Dietary Uses defines celiac disease, gluten-free products, and gluten-free beer. It describes diet-dependent diseases, which require a gluten-free diet, and groups of potential consumers of gluten-free beer. This article describes the use of oats as a raw material for the production of brewing malt and its usefulness in the production of beer. It specifies how the technological process of standard beer production needs to be modified so that the product meets the requirements of patients with celiac disease. The article also provides an overview of literature data on the production of gluten-free beer from pseudocereal malts, such as sorghum malt, buckwheat malt, amaranth malt, and quinoa malt.

Amino Acid Profiles and Compositions of Different Cultivars of Panicum miliaceum L

Abstract

Amino acids are valuable nutrients, responsible for a variety of tasks in the human body. A favourable amino acid profile in gluten-free crops, such as millet, can thus be beneficial for human health, which is why 35 proso millet (Panicum miliaceum L.) samples, comprising 23 whole and 12 dehulled, were investigated regarding their amino acid profiles and compositions using acidic hydrolysis and ion-exchange chromatography with ninhydrin derivatization and subsequent detection with photometry. Results for amino acid compositions were compared with gluten-containing wheat and other gluten-free cereals. Furthermore, gained values were put in contrast to estimated essential amino acid requirements for adult humans. The study was able to show that cultivars of proso millet differ and that dehulling does not significantly influence the amino acid compositions. Furthermore, the results display that Panicum miliaceum L. holds more essential amino acids than other gluten-free grains and exhibits high amounts of leucine and alanine. The methionine content differs greatly between samples, which means that choosing certain cultivars is important to ensure a high content. The most abundant amino acids in proso millet grains are glutamic acid/glutamine (2.13 ± 0.34 g per 100 g), alanine (1.06 ± 0.18 g per 100 g) and leucine (1.36 ± 0.24 g per 100 g).

Graphic abstract

Global and local diet popularity rankings, their secular trends, and seasonal variation in Google Trends data

OBJECTIVES

The Internet has become the main source of health-related information including nutrition. The aim of this study was to rank the most popular diets among Google users globally and regionally in addition to secular and seasonal trends in the years 2004 to 2019.

METHODS

We used Google Trends (GT) to identify and analyze course over time and regional interest of 47 topics related to diets. We analyzed secular trends using the Seasonal Mann-Kendall test and seasonal variation using time-series decomposition. The topic "Mediterranean diet" (MedD) was used as a benchmark. We calculated the interest of all topics in proportion to the relative search volume (RSV) of MedD.

RESULTS

Globally, Google users were particularly interested in veganism (19.54 times higher than MedD), vegetarianism (15.09 times higher than MedD), and gluten-free diet (11.11 times higher than MedD). Veganism was the most frequently searched diet type in 23 countries followed by vegetarianism (14), ketogenic diet (7), and low-carbohydrate diet (7). Whereas an increase of RSV over time was observed for 23 diets, a decrease was noted for 20. The most dynamic increase was found for FODMAP (6.12 RSV/year), gluten-free diet (5.95 RSV/year), and raw veganism (5.72 RSV/year). Sharp declines concerned negative-calorie food (-4.34 RSV/year), macrobiotic diet (-3.89 RSV/year), and cabbage soup diet (-3.50 RSV/year). The interest in most diets falls in December but peaks in January.

CONCLUSION

Veganism, vegetarianism, and gluten-free diet attract the largest public interest globally. Both secular trends and seasonal variation shape the ever-changing landscape of diet popularity. GT holds promise as a valuable tool in local and international nutrition research.