Appropriate nutrient supplementation in celiac disease

Celiac Disease: Beyond Diet and Food Awareness

Celiac disease is attributable to a combination of genetic predisposition and exposure to dietary gluten, with immune system involvement. The incidence is increasing globally, and the societal economic burden of celiac disease stretches beyond the cost of gluten-free food. This enteropathy that affects the small intestine has been related to different disorders and comorbidities. Thus, the implications of suffering from this disease are multidimensional and need further consideration. Celiac disease is a serious condition that remains under-recognized, resulting in an increased need for programs for better management. This review aims to summarize the current evidence regarding celiac diseases, with special emphasis on clinical implications, diagnosis, dietary management, socioeconomical aspects, and future perspectives.

Exploring the Impact of Folic Acid Supplementation and Vitamin B12 Deficiency on Maternal and Fetal Outcomes in Pregnant Women with Celiac Disease

Background: Celiac disease is a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten, affecting approximately 1% of the global population and two million Americans. An increasing number of studies have identified a link between celiac disease and adverse maternal and fetal outcomes during pregnancy and after birth. Additionally, both celiac disease and pregnancy are associated with an increased risk for nutrient deficiencies, specifically vitamin B12 and folate. Methods: This review examines the current literature related to the folate trap and vitamin B12 deficiency in patients with celiac disease and pregnant women independently and provides rationale for future research to explore the relationship between the folate-to-12 ratio in pregnant women with celiac disease. Results: Deficiencies in vitamin B12 are linked with several negative maternal and fetal health outcomes including pre-eclampsia, gestational diabetes, spontaneous abortion/miscarriage, preterm birth, neural tube defects, intrauterine growth restriction, and low gestational age and birthweight. Conclusions: Folic acid supplementation is widely recommended during pregnancy, but complementary vitamin B12 supplementation is not standard. Physicians should consider celiac disease screening during pregnancy as well as vitamin B12 supplementation.

Growth Stunting and Nutritional Deficiencies among Children and Adolescents with Celiac Disease in Kuwait: A Case-Control Study

BACKGROUND/OBJECTIVES

This study aimed to assess the nutritional status of children and adolescents with celiac disease (CD) in Kuwait and investigate the nutritional deficiencies and sociodemographic factors associated with growth stunting in this population.

METHODS

This case-control study included 77 CD patients aged 3-18 years diagnosed with CD using IgA anti-tissue transglutaminase and duodenal biopsy and 33 healthy controls. Nutritional status was evaluated based on demographic and clinical characteristics, anthropometric measurements, and biochemical parameters. Univariate and multivariate logistic regression models were used to determine the association between CD and growth stunting.

RESULTS

Approximately one-third (31%) of children with CD had stunted growth, 20.8% had a low body mass index for their age, and 5.2% had both growth stunting and wasting. Children with CD had higher odds of iron-deficiency anemia, vitamin D deficiency, anemia, and lower socioeconomic status. They were also younger and had decreased serum levels of vitamin D compared to the controls. These factors were all significantly associated with an increased risk of CD, collectively explaining over 50% of the risk. For growth stunting, lower education status among mothers, family income, and serum ferritin were identified as risk factors.

CONCLUSIONS

A significant proportion of children and adolescents with CD had malnutrition, overt deficiencies, and impaired growth despite coherence with a gluten-free diet.

RECOMMENDATION

Routine monitoring and targeted nutritional interventions are recommended for children and adolescents with CD to address malnutrition and growth stunting. Addressing socioeconomic disparities and enhancing maternal education may also help mitigate the risk factors.

The Impact of a Gluten-Free Diet on Pregnant Women with Celiac Disease: Do We Need a Guideline to Manage Their Health?

A healthy and balanced diet is a critical requirement for pregnant women as it directly influences both the mother’s and infant’s health. Poor maternal nutrition can lead to pregnancy-related complications with undesirable effects on the fetus. This requirement is equally important for pregnant women with celiac disease (CD) who are already on a gluten-free diet (GFD). Although the GFD is the sole treatment option for CD, it still presents some challenges and confusion for celiac women who wish to conceive. Poorly managed CD has been linked to miscarriages, preterm labor, low birth weight, and stillbirths. Current CD guidelines primarily focus on screening, diagnosis, treatment, and management but lack an evidence-based approach to determine appropriate energy requirements, recommended weight gain during pregnancy, target macronutrient distribution from the diet, the recommended intake of vitamins and minerals from diet and/or supplementation, timing for starting supplementation, and advised portions of gluten-free foods during pregnancy. We recommend and call for the development of such guidelines and/or authoritative papers in the future.

Gluten-containing flours and gluten-free flours as a source of calcium, magnesium, iron and zinc

Wheat flour is widely used in Poland for the preparation of bread, pasta and other foods. Due to the increasing number of people diagnosed with diet-related diseases, consumer awareness of health-promoting issues and interest in gluten-free products (GFP). There is a dynamic development of the market for these foods with high quality and nutritional value and minerals that benefit human health and prevent deficiencies in patients on a gluten-free diet. The aim of this study was to determine the content of minerals: Ca, Fe, Mg and Zn in flours using the ICP-OES method. The mineral composition of selected GF flours available on the Polish market was analysed. It was tested how they supplement the mineral requirements compared to gluten-containing flours. It was found that these products can be a valuable source of essential minerals, which are often in short supply, especially in patients with gastrointestinal disorders. As our study has shown, flours from the GFP group are a good source of essential minerals, especially in the case of chia and flax flours, as well as buckwheat, amaranth, quinoa, lupin or almonds flours.

Celiac disease and depressive disorders as nutritional implications related to common factors - A comprehensive review

Celiac disease (CD) is an immune-mediated disease affecting the small intestine. The only treatment strategy for CD is the gluten-free diet (GFD). One of the more common mental disorders in CD patients is major depressive disorder (MDD). The influence of GFD on the occurrence of MDD symptoms in patients with CD will be evaluated. This diet often reduces nutritional deficiencies in these patients and also helps to reduce depressive symptoms. Both disease entities are often dominated by the same deficiencies of nutrients such as iron, zinc, selenium, iodine, or B and D vitamins. Deficiencies of particular components in CD can favor MDD and vice versa. Gluten can adversely affect the mental state of patients without CD. Also, intestinal microbiota may play an important role in the described process. This work aims to comprehensively assess the common factors involved in the pathomechanisms of MDD and CD, with particular emphasis on nutrient imbalances. Given the complexity of both disease entities, and the many common links, more research related to improving mental health in these patients and the implementation of a GFD would need to be conducted, but it appears to be a viable pathway to improving the quality of life and health of people struggling with CD and MDD. Therefore, probiotics, micronutrients, macronutrients, and vitamin supplements are recommended to reduce the risk of MDD, given that they may alleviate the symptoms of both these disease entities. In turn, in patients with MDD, it is worth considering testing for CD.

Status of vitamins and minerals in children with screening-identified celiac disease: A case-control study

OBJECTIVES

Micronutrient deficiencies characterize classical "late-diagnosed" celiac disease (CeD). This study aimed to identify the prevalence of micronutrient deficiencies among children with "early-diagnosed" screening-identified CeD to determine the clinical value of routine testing for deficiencies in those patients.

METHODS

A case-control study was conducted on screening-identified CeD patients diagnosed during a mass screening study (84 patients, mean age 11.3 ± 2.6 years). The controls (443 children, mean age 10.8 ± 2.5 years) were negative for celiac disease serological screening. Hemoglobin, serum levels of iron, ferritin, folate, vitamin B12, vitamin A, vitamin E, 25-OH vitamin D, zinc, and selenium were measured.

RESULTS

The mean serum levels of hemoglobin, iron, ferritin, vitamin D, zinc, copper, and selenium were significantly lower in CeD patients than in healthy controls (hemoglobin 12.56 vs. 13.02 g/dL [p = 0.04]; iron 10.61 vs. 17.6 µmol/L [p < 0.001], ferritin 25.7 vs. 48.3 µg/L [p < 0.001], vitamin D 29.1 vs. 37.5 nmol/L, zinc 11.9 vs. 21.7 µmol/L, copper 18.9 vs. 32.5 µmol/L, selenium 1.04 vs. 1.36 µmol/L; p < 0.001). Patients with celiac and severe intestinal damage (Marsh IIIb and IIIc) had significantly lower serum ferritin and vitamin A levels than patients with mild intestinal damage (Marsh II and IIIa) (ferritin 15 vs. 22 µg/L, p < 0.025; vitamin A 0.85 vs. 1.35 µmol/L, p = 0.007).

CONCLUSION

Micronutrient deficiencies are still detectable in "early-diagnosed" screening-identified CeD cases, a clinically relevant result that strongly supports efforts for screening and early diagnosis of CeD.

Trends in Nutrition and Andean Food for People with Celiac Disease: A review study

Celiac disease is characterized by nutritional imbalances due to intestinal inflammation caused by gluten, which hinders the absorption of essential nutrients. Iron deficiency anemia is common, as well as the lack of vitamins and minerals, some of which are reversed with a gluten-free diet. Andean foods constitute an option in the diet of celiac patients due to their high nutritional quality in proteins, carbohydrates, vitamins, minerals, and fiber, which are generally deficient nutrients. Studies suggest that products such as quinoa, corn, and rice can be viable substitutes in baking, extruded products, and beverages, offering nutritious and acceptable options. However, despite the positive trend towards including these foods in the diet of people with CD, challenges are identified, such as nutritional education to promote their consumption. In conclusion, it is suggested that Andean nutrition and food offer valuable options for people with CD, but effective strategies are needed to integrate them into patients' diets

Iron, vitamins and minerals status in pediatric patients with celiac diseaseand non celiac gluten sensitivity prior to diagnosis and three months later

AIM

Pathologies associated with gluten intake are increasingly prevalent. Diagnosis of celiac disease (CD) or non-celiac gluten sensitivity (NCGS) is based on compatible clinical alterations and in case of CD on compatible serology or intestinal biopsy. The aim was to determine the values of iron, vitamins and minerals ^{prior to diagnosis and to verify whether a gluten-free diet treatment can cause the normalization of these parameters both in patients diagnosed with celiac disease and gluten sensitivity.} METHODS: ^{Retrospective} observational study from November 2016 to November 2021. 101 celiac patients and 26 with NCGS were included, all under 18 years of age. Levels of Fe, Na+ , K+ , Cl-, Ferritin, Ca2 + , P, Vitamin B12, Vitamin D and Transferrin were determined, following the quality standards of the Hospital Clínico San Carlos laboratory. Statistical software IBM SPSS Statistics v.26 was used.

RESULTS

Calcium levels in celiac patients follow a positive trend after 3 months of gluten-free diet. Ferritin levels in patients with NCGS increased in a statistically significant way (p < 0.017).

CONCLUSION

Calcium in the CD group increases its values after the establishment of a gluten-free diet as treatment, as well as ferritin in patients with NCGS. No significant changes were found in the rest of the analyzed parameters. This could be ^{due to the precocity of the diagnosis thanks to a rapid clinical suspicion that determines few analytical alterations.}

Anti-tissue transglutaminase antibodies (TG2A) positivity and the risk of vitamin D deficiency among children - a cross-sectional study in the generation R cohort

BACKGROUND

Suboptimal vitamin D status is common in people with celiac disease (CeD), a disease that can be characterized by the presence of serum anti-tissue transglutaminase antibodies (TG2A) (i.e., TG2A positivity). To date, it remains unclear whether childhood TG2A positivity is associated with vitamin D status and how this potential association can be explained by other factors than malabsorption only, since vitamin D is mainly derived from exposure to sunlight. The aim of our study was therefore to assess whether childhood TG2A positivity is associated with vitamin D concentrations, and if so, to what extent this association can be explained by sociodemographic and lifestyle factors.

METHODS

This cross-sectional study was embedded in the Generation R Study, a population-based prospective cohort. We measured serum anti-tissue transglutaminase antibodies (TG2A) concentrations and serum 25-hydroxyvitamin D (25(OH)D) concentrations of 3994 children (median age of 5.9 years). Children with serum TG2A concentrations ≥ 7 U/mL were considered TG2A positive. To examine associations between TG2A positivity and 25(OH)D concentrations, we performed multivariable linear regression, adjusted for sociodemographic and lifestyle factors.

RESULTS

Vitamin D deficiency (serum 25(OH)D < 50 nmol/L) was found in 17 out of 54 TG2A positive children (31.5%), as compared to 1182 out of 3940 TG2A negative children (30.0%). Furthermore, TG2A positivity was not associated with 25(OH)D concentrations (β -2.20; 95% CI -9.72;5.33 for TG2A positive vs. TG2A negative children), and this did not change after adjustment for confounders (β -1.73, 95% CI -8.31;4.85).

CONCLUSIONS

Our findings suggest there is no association between TG2A positivity and suboptimal vitamin D status in the general pediatric population. However, the overall prevalence of vitamin D deficiency in both populations was high, suggesting that screening for vitamin D deficiency among children, regardless of TG2A positivity, would be beneficial to ensure early dietary intervention if needed.

Osteoporosis and Celiac Disease: Updates and Hidden Pitfalls

Celiac disease (CD) is an autoimmune disorder caused by gluten ingestion in genetically predisposed individuals. In addition to the typical gastrointestinal symptoms (e.g., diarrhea, bloating, and chronic abdominal pain), CD may also present with a broad spectrum of manifestations, including low bone mineral density (BMD) and osteoporosis. The etiopathology of bone lesions in CD is multifactorial and other conditions, rather than mineral and vitamin D malabsorption, may affect skeletal health, especially those related to the endocrine system. Here, we describe CD-induced osteoporosis in an attempt to enlighten new and less-known aspects, such as the influence of the intestinal microbiome and sex-related differences on bone health. This review describes the role of CD in the development of skeletal alterations to provide physicians with an updated overview on this debated topic and to improve the management of osteoporosis in CD.

Textural characteristics and color analyses of 3D printed gluten-free pizza dough and crust

A new methodology was developed to print pizza dough with a gluten free flour blend or commercial gluten whole wheat flour using extrusion-based 3-D printing technology. Their physical properties were compared to commercially available pizza dough and crust. The optimized nozzle size, print speed, ingredient flow speed, and line thickness for the 3-D printing of pizza dough were: 0.04 cm, 800 cm/minutes, 1.8, and 0.34 cm, respectively. The printed gluten-free pizza dough required 120 min of fermentation to obtain a comparable color and textural profile (P < 0.05) to that of the gluten whole wheat flour dough fermented for 60 min. The 3-D printed gluten free, whole-wheat pizza and commercially available wheat flour dough and standard crusts demonstrated identical Δ E ab ∗ values of 0.14 and 0.13, respectively with brownness index (BI) values of 1.47 and 1.62, respectively. Textural profile analysis (TPA) of 3-D printed gluten free and whole wheat pizza dough, crust and the commercial standard wheat flour pizza dough and crust demonstrated significant (P < 0.05) correlations in terms of hardness, fracturability, adhesiveness, springiness, cohesiveness, chewiness, and resilience. An optimized method was developed to prepare gluten-free pizza dough and crust with similar functional properties to that of gluten whole wheat flour dough and crust.

Evaluation of Serum Levels of Copper and Zinc in Patients with Celiac Disease Seropositivity: Findings from the National Health and Nutrition Examination Survey

Celiac disease is a multisystem immune based disorder, caused by an immune-mediated reaction to ingested gluten with increasing prevalence in the USA. Celiac disease can cause a wide variety of symptoms, including gastrointestinal symptoms (diarrhea, abdominal distention, or abdominal pain), which may affect absorption of many nutritional components. All patients with celiac disease should remain on a strict and lifelong gluten-free diet, which are often low in certain trace elements such as zinc. On the other hand, zinc and copper as the essential trace elements have been hypothesized to help maintain optimum function of the immune system. Then, this study aims to examine the association between celiac disease seropositivity and serum zinc and copper levels. A nationally representative sample from National Health and Nutrition Examination Survey (2011-2014) was analyzed. Celiac disease seropositivity was determined using the tissue transglutaminase IgA antibody test (IgA-TTG). Multivariable linear regression models were performed with celiac disease seropositivity as a predictor and serum zinc and copper levels as outcome. The present study included 4732 participants (1398 children aged 6-19 years and 3334 adults aged ≥ 20 years). The weighted prevalence of celiac disease seropositivity was higher (11.6/1000) among children aged 6-19 years compared to that (6.3/1000) among adults aged ≥ 20 years. In the stratified analysis by age, the multivariable linear regression analysis revealed that among children aged 6-19 years, celiac disease seropositivity was associated with 5.32 (95% CI, - 9.71 to - 0.92) μg/dL lower serum zinc level, but not associated with serum copper level. However, the association between celiac disease seropositivity and serum zinc level was not statistically significant among adults aged 20 years or older. Future prospective studies are warranted to confirm these findings.

Gluten-free diet attenuates the impact of exogenous vitamin D on thyroid autoimmunity in young women with autoimmune thyroiditis: a pilot study

Although both exogenous vitamin D and a gluten-free diet were found to reduce thyroid antibody titers, no study investigated interactions between gluten intake and vitamin D status in patients with autoimmune thyroid disorders. The aim of the present study was to assess whether the gluten-free diet determines the effect of vitamin D treatment on thyroid autoimmunity and thyroid function in young women with autoimmune (Hashimoto's) thyroiditis. The study compared two groups of euthyroid premenopausal women with this disorder, matched for thyroid antibody titers: 31 women with non-celiac gluten sensitivity complying for at least 12 months with the gluten-free diet and 31 unaffected sisters of women with non-celiac gluten sensitivity remaining without any dietary intervention. Plasma titers of thyroid peroxidase and thyroglobulin antibodies, as well as plasma concentrations of thyrotropin, free thyroid hormones, prolactin, 25-hydroxyvitamin D and high-sensitive C-reactive protein were measured at entry and after a six-month follow-up. Moreover, at both time points, the structure parameters of thyroid homeostasis were assessed. Although exogenous vitamin D decreased titers of thyroid peroxidase and thyroglobulin antibodies and increased 25-hydroxyvitamin D levels in each treatment group, this effect was less pronounced in patients on the gluten-free diet than in patients not following any dietary recommendations. Only in the latter group of patients, vitamin D increased SPINA-GT. Treatment-induced changes in thyroid peroxidase and thyroglobulin antibodies correlated with the impact of treatment on 25-hydroxyvitamin D levels. The obtained results suggest that gluten-free diet may impair beneficial effects of exogenous vitamin D in individuals with Hashimoto's thyroiditis.

The Dietary and Non-Dietary Management of Osteoporosis in Adult-Onset Celiac Disease: Current Status and Practical Guidance

Impaired bone mineral density (BMD) is a frequent complication of adult-onset celiac disease (CeD). This is usually due to malabsorption of nutrients, changes in bone metabolism in association with inflammation, and to a lesser extent, decreased overall physical health and mobility. This review aims to highlight the current status concerning surveillance, prevention, and treatment strategies for bone disease in CeD. A practical guidance on these matters is suggested. The available published research on the prevention and treatment of decreased BMD in relation to CeD is scarce. In general, publications were based on expert opinions or extrapolation from studies on postmenopausal women or inflammatory bowel disease. Optimal dietary treatment and an adequate supply of calcium and vitamin D are the cornerstones for the reduction in fracture risk in patients with CeD. In adults with low BMD or fragility fractures, CeD needs to be considered and specifically approached. When osteoporosis is documented, start treatment with an antiresorptive agent; these agents are proven to result in a long-term reduction in fracture risk in high-risk individuals. However, there are some important differences between the management of male and female patients, particularly premenopausal women, that need to be addressed. In patients with persisting diarrhea and malabsorption, parenteral medications may be preferable. Future research specifically focusing on celiac disease and the associated disorders in bone mineralization is mandatory to provide evidence-based recommendations in this field.

Anemia Etiology and the Response to a Gluten-Free Diet in Untreated Patients With Celiac Disease: A 2-Year Follow-Up

INTRODUCTION

Anemia and micronutrient deficiencies are common in newly diagnosed patients with celiac disease (CeD). We aim to determine the prevalence and etiology of anemia in a cohort of patients with CeD in the United States and examine the effect of a gluten-free diet (GFD) on the laboratory parameters related to anemia in CeD.

METHODS

We analyzed a prospectively collected cohort of adults with biopsy-proven CeD followed in a specialized CeD center between January 2000 and June 2016. We used the level of hemoglobin (Hb) and micronutrients suggested by the World Health Organization to establish the diagnosis of anemia or deficiencies. Demographic data and laboratory parameters related to anemia and micronutrients were recorded at the time of diagnosis and on a GFD. A celiac expert nutritionist or gastroenterologist evaluated all patients.

RESULTS

In 572 patients with laboratory evaluation before starting a GFD, approximately 25% presented with anemia at the time of diagnosis of CeD. Iron deficiency was present in 50.8% of the cohort and in 78.8% of the patients with anemia. Within the anemic population, 84.4% of female patients as compared with 58.3% of male patients ( P = 0.02) showed iron deficiency. Folate deficiency (23.2%), vitamin B12 deficiency (11%), and anemia of chronic diseases (7.8%) were also part of both sexes' anemia etiology. Of the initially anemic patients, 81% and 89% normalized their Hb levels within 1 year and 2 years of beginning a GFD, respectively. All patients received appropriate supplementation when needed.

DISCUSSION

Approximately 25% of individuals have anemia at CeD diagnosis. The anemia etiology included iron deficiency, vitamin deficiencies, and anemia of chronic diseases. Most of the patients will normalize their Hb levels and the anemia laboratory parameters 1 year after starting a strict GFD.

The Crosstalk between Vitamin D and Pediatric Digestive Disorders

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

The Impact of Zinc and Zinc Homeostasis on the Intestinal Mucosal Barrier and Intestinal Diseases

Zinc is an essential trace element for living organisms, and zinc homeostasis is essential for the maintenance of the normal physiological functions of cells and organisms. The intestine is the main location for zinc absorption and excretion, while zinc and zinc homeostasis is also of great significance to the structure and function of the intestinal mucosal barrier. Zinc excess or deficiency and zinc homeostatic imbalance are all associated with many intestinal diseases, such as IBD (inflammatory bowel disease), IBS (irritable bowel syndrome), and CRC (colorectal cancer). In this review, we describe the role of zinc and zinc homeostasis in the intestinal mucosal barrier and the relevance of zinc homeostasis to gastrointestinal diseases.

Nutrient intake differs among persons with celiac disease and gluten-related disorders in the United States

Persons with celiac disease (CD) may develop nutritional deficiencies, while individuals following a gluten-free diet (GFD) may lack essential nutrients. We examined nutrient intake from diet and supplements among persons with CD and GFD in the cross-sectional National Health and Nutrition Examination Survey, 2009-2014. Among 15,610 participants 20 years and older, we identified CD based on positive serology for immunoglobulin A against tissue transglutaminase, health care provider diagnosis, and adherence to a GFD. People without CD avoiding gluten (PWAG) adhered to a GFD without a diagnosis of CD. Two 24-h recalls assessed nutrient intake from diet and supplements. Compared to participants without CD or PWAG, persons with diagnosed CD had lower intake of total energy, carbohydrates, fat, and saturated and monounsaturated fatty acids. In contrast, persons with undiagnosed CD and positive serology had higher intake of those nutrients, sugar, and protein. Total carbohydrate and sugar intake was lower among PWAG. Persons with diagnosed CD had higher vitamin A and E intake, while those with undiagnosed CD had increased intake of calcium, phosphorus, magnesium, iron, zinc, copper, sodium, potassium, vitamin A, alpha-carotene, folic acid, and choline. Higher micronutrient intake with undiagnosed CD was observed more at high latitudes. PWAG had higher beta-carotene and lutein/zeaxanthin and lower folic acid intake. In the U.S. population over a 6-year period, total energy and macronutrient intake was decreased among persons with diagnosed CD, while intake of total energy, macronutrients, and multiple micronutrients was increased among persons with undiagnosed CD. Nutriomics studies of multiple analytes measured simultaneously across affected persons and populations are needed to inform screening for malabsorption and treatment strategies.

The Role of Pseudocereals in Celiac Disease: Reducing Nutritional Deficiencies to Improve Well-Being and Health

Celiac disease or gluten-dependent enteropathy is a chronic autoimmune pathology triggered by dietary gluten in genetic predisposed individuals, mediated by transglutaminase 2 IgA autoantibodies and associated with a deteriorating immune and inflammatory response. This leads to intestinal villous atrophy, impairing the intestinal mucosa structure and function of secretion, digestion, and absorption. The result is macro- and micronutrient deficiency, including fat soluble vitamins and minerals, and a consequent nutritional status depletion. A lifelong gluten-free diet is the only available treatment for celiac patients in order to assure normal intestinal mucosa and remission of gastrointestinal symptoms. However, a gluten-free diet can itself cause other nutritional deficiencies due to its restrictive nature regarding gluten-containing cereals. A group of gluten-free cereals, known as pseudocereals, is increasingly recognized as valuable options for gluten-free diets due to their high nutritional value. Amaranth, quinoa, millet, and buckwheat are examples of gluten-free nutrient-dense grains that can be used as alternatives to the conventional gluten-containing grains and improve the variety and nutritional quality of the celiac diet. Current work reviews the nutritional pitfalls of a gluten-free diet and analyses how pseudocereals can contribute to revert those deficiencies and optimize the nutritional value of this mandatory diet for the celiac population.

Nutritional Imbalances in Adult Celiac Patients Following a Gluten-Free Diet

Celiac disease (CD) is a chronic autoimmune disorder of the small intestine, whose only effective treatment is a gluten-free diet (GFD). It is characterized by the atrophy of the intestinal villi that leads to altered nutrient absorption. This study describes the nutritional imbalances which may be found in adults with CD following a GFD. During the first year of treatment, deficiencies will overcome as the intestinal mucosa recovers. Thus, biochemical data will show this progression, together with the decrease in symptoms. In contrast, in the long term, when a strict GFD is followed and mucosal recovery is achieved, analyzing nutrient intake makes more sense. Macronutrient consumption is characterized by its low complex carbohydrate and fiber intakes, and high fat (especially SFA) and sugar intakes. This profile has been related to the consumption of GFP and their nutritional composition, in addition to unbalanced dietary habits. The most notable deficiencies in micronutrients are usually those of iron, calcium and magnesium and vitamin D, E and some of group B. It is necessary to follow up patients with CD and to promote nutritional education among them, since it could help not only to achieve a gluten free but also a balanced diet.

The Modification of the Gut Microbiota via Selected Specific Diets in Patients with Crohn's Disease

Gastrointestinal symptoms in Crohn’s disease (CD) are common and affect the quality of life of patients; consequently, a growing number of studies have been published on diet interventions in this group. The role of the gut microbiota in the pathogenesis and the progression of inflammatory bowel diseases (IBD), including CD, has been widely discussed. Mainly, a decreased abundance of Firmicutes, species of the Bifidobacterium genus, and the Faecalibacterium prausnitzii species as well as a reduced general diversity have been described. In this review article, we summarize available data on the influence of reduction diets on the microbiome of patients with CD. One of the most frequently used elimination diets in CD patients is the low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) diet. Although many papers show it may reduce abdominal pain, diarrhea, or bloating, it also reduces the intake of prebiotic substances, which can negatively affect the gut microbiota composition, decreasing the abundance of Bifidobacterium species and Faecalibacterium prausnitzii. Other elimination diets used by IBD patients, such as lactose-free or gluten-free diets, have also been shown to disturb the microbial diversity. On the other hand, CDED (Crohn’s disease exclusion diet) with partial enteral nutrition not only induces the remission of CD but also has a positive influence on the microbiota. The impact of diet interventions on the microbiota and, potentially, on the future course of the disease should be considered when nutritional guidelines for IBD patients are designed. Dietetic recommendations should be based not only on the regulation of the symptoms but also on the long-term development of the disease.

Celiac Disease and the Thyroid: Highlighting the Roles of Vitamin D and Iron

Celiac disease (CD) and autoimmune thyroid diseases (AITD) like Hashimoto’s thyroiditis (HT) and Graves’ disease (GD) frequently coexist, entailing numerous potential impacts on diagnostic and therapeutic approaches. Possible correlations might exist through gut microbiota, regulating the immune system and inflammatory responses, promoting autoimmune diseases, as well as shared cytokines in pathogenesis pathways, cross-reacting antibodies or malabsorption of micronutrients that are essential for the thyroid like iron or vitamin D. Vitamin D deficiency is a common finding in patients with AITD, but might protect from autoimmunity by wielding immunoregulatory and tolerogenic impacts. Additionally, vitamin D is assumed to be involved in the onset and progression of CD, presumably plays a substantial protective role for intestinal mucosa and affects the thyroid via its immunomodulatory effects. Iron is an essential micronutrient for the thyroid gland needed for effective iodine utilization by the iron-dependent enzyme thyroid iodine peroxidase (TPO). Despite being crucial for thyroid hormone synthesis, iron deficiency (ID) is a common finding in patients with hypothyroidism like HT and is frequently found in patients with CD. A literature research was conducted to examine the interplay between CD, AITD, vitamin D and iron deficiency. This narrative review highlights the relevant correlation of the two disease entities CD and AITD, their reciprocal impact and possible therapeutic options that should be further explored by future studies.

Dietary nutrition for neurological disease therapy: Current status and future directions

Adequate food intake and relative abundance of dietary nutrients have undisputed effects on the brain function. There is now substantial evidence that dietary nutrition aids in the prevention and remediation of neurologic symptoms in diverse pathological conditions. The newly described influences of dietary factors on the alterations of mitochondrial dysfunction, epigenetic modification and neuroinflammation are important mechanisms that are responsible for the action of nutrients on the brain health. In this review, we discuss the state of evidence supporting that distinct dietary interventions including dietary supplement and dietary restriction have the ability to tackle neurological disorders using Alzheimer's disease, Parkinson's disease, stroke, epilepsy, traumatic brain injury, amyotrophic lateral sclerosis, Huntington's disease and multiple sclerosis as examples. Additionally, it is also highlighting that diverse potential mechanisms such as metabolic control, epigenetic modification, neuroinflammation and gut-brain axis are of utmost importance for nutrient supply to the risk of neurologic condition and therapeutic response. Finally, we also highlight the novel concept that dietary nutrient intervention reshapes metabolism-epigenetics-immunity cycle to remediate brain dysfunction. Targeting metabolism-epigenetics-immunity network will delineate a new blueprint for combating neurological weaknesses.

Celiac Disease and Obesity: Is Bariatric Surgery an Option?

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

The Healthy Gluten-Free Diet: Practical Tips to Prevent Metabolic Disorders and Nutritional Deficiencies in Celiac Patients

The gluten-free diet (GFD) is the cornerstone treatment for coeliac disease (CD). However, a healthy GFD is more complex than the only exclusion of gluten-containing foods. Most celiac patients do not receive nutritional advice and tend to consume industrial gluten-free products (GFPs), which often lack fiber, vitamins, and other micronutrients while being rich in saturated fats and refined sugars. This review focuses on the main potential metabolic disorders and nutritional deficiencies in CD patients at diagnosis and dissects the main nutritional and metabolic issues due to a non-balanced GFD. Nutritional tips to achieve an adequate dietary approach in CD are provided. We also compared the main nutritional components of naturally gluten-free cereals (including pseudocereals) to give an exhaustive overview of the possible healthy alternatives to processed GFPs. Clinicians and dietitians should be systematically involved in the diagnosis of CD to monitor the appropriateness of GFD and the patient’s nutritional status over time.

Magnesium: Biochemistry, Nutrition, Detection, and Social Impact of Diseases Linked to Its Deficiency

Magnesium plays an important role in many physiological functions. Habitually low intakes of magnesium and in general the deficiency of this micronutrient induce changes in biochemical pathways that can increase the risk of illness and, in particular, chronic degenerative diseases. The assessment of magnesium status is consequently of great importance, however, its evaluation is difficult. The measurement of serum magnesium concentration is the most commonly used and readily available method for assessing magnesium status, even if serum levels have no reliable correlation with total body magnesium levels or concentrations in specific tissues. Therefore, this review offers an overview of recent insights into magnesium from multiple perspectives. Starting from a biochemical point of view, it aims at highlighting the risk due to insufficient uptake (frequently due to the low content of magnesium in the modern western diet), at suggesting strategies to reach the recommended dietary reference values, and at focusing on the importance of detecting physiological or pathological levels of magnesium in various body districts, in order to counteract the social impact of diseases linked to magnesium deficiency.

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

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

Over-processed meat and bone meal and phytase effects on broilers challenged with subclinical necrotic enteritis: Part 3. Bone mineralization and litter quality

This study was conducted to determine the effect of necrotic enteritis (NE), phytase level and meat and bone meal (MBM) processing on bone mineralization of broilers and litter quality. Ross 308 male broiler chicks (n = 768) were allotted to 48 pens with 16 birds each. There were 8 dietary treatments in a 2 × 2 × 2 factorial arrangement. Factors were NE challenge (no or yes), phytase level (500 or 5,000 FTU/kg), and MBM (as-received or over-processed). Half of the birds were challenged with field strains of Eimeria spp. at d 9 and 10⁸ CFU per mL of Clostridium perfringens strain EHE-NE18 on d 14 and 15. The middle toe, tibia and femur of 2 birds per pen were excised at d 16 and 29 for determination of ash, breaking strength (BS) and bone mineralization. At d 42, all were assessed for hock burns and litter was scored and assessed for dry matter (DM). At d 16, challenged birds had lower toe ash (P < 0.01), femur ash (P < 0.001), tibia ash (P < 0.001) and tibial BS (P < 0.001) than unchallenged birds. At d 16, challenged birds fed high phytase and over-processed MBM had higher toe Mn than those fed low phytase and as-received MBM. At d 29 unchallenged birds fed high phytase and as-received MBM had a higher toe Mn than those fed over-processed MBM. At d 16, a phytase × MBM interaction was detected for femur Zn concentration (P < 0.05), where a higher level of Zn was observed in the high phytase group fed over-processed MBM. At d 16, tibial Ca (P < 0.05) and P (P < 0.05) were lower in the challenged whereas the femur K (P < 0.001), Mn (P < 0.01) and Na (P < 0.001) were higher in the challenged at d 16. At d 42, challenged birds had higher litter DM (P = 0.058) and fewer hock burns than those unchallenged (P < 0.05). In conclusion, NE impaired bone traits but high phytase and over-processed MBM increased bone mineral contents. Cases of hock burns may be lower under NE incidences due to lower livability of birds reducing litter wetness.

All Things Gluten: A Review

Gluten is a common dietary component with a complex protein structure. It forms incomplete products of digestion, which have the potential to mount an immune response in genetically predisposed individuals, resulting in celiac disease. It also has been linked with nonceliac gluten sensitivity and irritable bowel syndrome due to wheat allergy. A gluten-free diet is an effective treatment of these conditions; however, it can lead to micronutrient and mineral deficiencies and a macronutrient imbalance with higher sugar and lipid intake. Recent popularity has led to greater availability, but increasing cost, of commercially available gluten-free products.

Neuroimmunogastroenterology: At the Interface of Neuroimmunology and Gastroenterology

The central nervous system (CNS) is an important regulator of the gastrointestinal tract, and CNS dysfunction can result in significant and disabling gastrointestinal symptom manifestation. For patients with neuroimmunologic and neuroinflammatory conditions, the recognition of gastrointestinal symptoms is under-appreciated, yet the gastrointestinal manifestations have a dramatic impact on quality of life. The current treatment strategies, often employed independently by the neurologist and gastroenterologist, raise the question of whether such patients are being treated optimally when siloed in one specialty. Neuroimmunogastroenterology lies at the borderlands of medical specialties, and there are few resources to guide neurologists in this area. Here, we provide an overview highlighting the potential mechanisms of crosstalk between immune-mediated neurological disorders and gastrointestinal dysfunction.

Facilitators and barriers to adherence to gluten-free diet among adults with celiac disease: a systematic review

BACKGROUND

Coeliac disease (CD) is a chronic, autoimmune disease that prevents individuals from processing gluten, leading to adverse health effects. People with CD should adhere to a gluten-free diet (GFD); however, adherence rates are well below optimal in adults with CD, ranging between 42% and 91%. To date, limited evidence is available on the nature and magnitude of factors that affect adherence to GFD. The present study aimed to develop a systematic review that critically appraises and synthesises evidence on facilitators and barriers that affect adherence to GFD among adults with CD.

METHODS

Four databases were searched (Ovid Medline, CINAHL, PsychInfo and Embase) using variant keywords to identify empirical studies meeting the inclusion/exclusion criteria. A coding scheme was developed to extract relevant information from each article.

RESULTS

Forty articles were included. Grounded in the bioecological theory of development, we synthesised the facilitators and barriers in the literature into a social ecological model with multiple levels: system, community, organisational, interpersonal and individual. The studies varied by design and level of evidence; only one randomised trial was identified. The most significant facilitators include (% of studies): increased education (22.5%); increased knowledge of a GFD (20%); increased intention/self-regulatory efficacy (17.5%); and coeliac association membership (12.5%). The most significant barriers include: lower knowledge of CD (35%); restaurant/supermarket shopping (30%); poor patient education from practitioner (17.5%); and low intention/motivation to adhere to a GFD (17.5%).

CONCLUSIONS

Improving knowledge of a GFD, becoming a member of a coeliac association, and improving practitioners' abilities to educate patients on CD will create opportunities for improved adherence to GFD among adults with CD.

Possible Role of Vitamin D in Celiac Disease Onset

Beside skeletal system maintenance and protection, possible extra-calcium roles of vitamin D have been recently described. In particular, studies have investigated possible roles of vitamin D as a key modulator of inflammation and immune mechanisms and of the intestinal mucosa barrier. In this regard, vitamin D has been considered as a factor that affects different conditions such as immune-mediated diseases. The new emerging role of vitamin D and its involvement in immune modulation has led it to be considered as a possible key factor involved in celiac disease (CD) onset. CD is a chronic immune-mediated enteropathy of the small intestine that is triggered by dietary gluten protein exposure in individuals who are genetically predisposed. However, along with gluten, other environmental factors are also involved in CD onset. The renewed interest in a molecule that offers great possibilities for new roles has led to an increase in studies, although there remains a lack of studies aimed at contextualizing the role of vitamin D on CD. This review aims to define the possible role of vitamin D in CD onset as it is presently understood, taking into account potential links among vitamin D, the immune system and CD.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An Innovative Effective Nutritional Therapy for Vitamin D Deficiency in Children with Celiac Disease

Children with celiac disease (CD) are susceptible to reduced bone mineral density (BMD). Our target is to assess the severity of vitamin D deficiency in CD children on a gluten-free diet (GFD), and to evaluate the effectiveness of adding an innovative GF meal, on the clinical and bone biochemical indices of CD patients. 50 CD children who were diagnosed and followed up at Pediatric gastroenterology clinic, Specialized pediatric hospital, Cairo University; by serology and biopsy of the duodenum were included in this prospective study. CD children were on GFD for at least one year. As a control group, 40 healthy children were enrolled. Thorough clinical examination, anthropometric assessment, a complete history and 24 hours dietary recall were done for all the participants in this work. We introduced our innovative GF meal to CD patients twice/day, for 3 consecutive months. Venous blood samples were withdrawn from patients at the study beginning and after 3 months for detection of serum vitamin D, calcium, phosphorous and alkaline phosphatase levels. The anthropometric measurements, serum vitamin D, and calcium were markedly decreased in CD children than that of controls. In CD patients, a significant increase in anthropometric parameters, vitamin D and calcium were found. While there was a significant decline of serum alkaline phosphatase, and a slight decrease in serum phosphorus at the study end. The innovative gluten-free prepared meal confirmed to be of high nutritional value in the management of vitamin D deficiency and improvement of bone indices in CD patient.

Micronutrient Analysis of Gluten-Free Products: Their Low Content Is Not Involved in Gluten-Free Diet Imbalance in a Cohort of Celiac Children and Adolescent

Data about the nutritional composition of gluten-free products (GFP) are still limited. Most studies are based on ingredient and nutrition information described on the food label. However, analytical determination is considered the gold standard for compositional analysis of food. Micronutrient analytical content differences were observed in a selection of GF breads, flakes and pasta, when compared with their respective gluten-containing counterparts. In general terms, lower iron, piridoxin, riboflavin, thiamin, niacin, folate, manganese and vitamin B5 can be underlined. Variations in biotin and vitamin E content differed among groups. In order to clarify the potential contribution of the GFP to the gluten-free diet's (GFD) micronutrient shortages, analytical data were used to evaluate GFD in a cohort of celiac children and adolescent. Participants did not reach recommendations for vitamin A, vitamin E, folic acid, vitamin D, biotin, iodine, and copper. It does not seem that the lower micronutrient content of the analyzed GFP groups contributed to the micronutrient deficits detected in GFD in this cohort, whose diet was not balanced. Nevertheless, GFP fortification for folate and biotin is proposed to prevent the deficiencies observed in GFD, at least in the case of pediatric celiac disease.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Role of Dietary Gluten in Development of Celiac Disease and Type I Diabetes: Management Beyond Gluten-Free Diet

Gluten triggers Celiac Disease (CD) and type I diabetes in genetically predisposed population of human leukocyte antigen DQ2/DQ8+ and associates with disorders such as schizophrenia and autism. Application of a strict gluten-free diet is the only well-established treatment for patients with CD, whereas the treatment for patients with celiac type I diabetes may be depend on the timing and frequency of the diet. The application of a gluten-free diet in patients with CD may contribute to the development of metabolic syndrome and nonalcoholic fatty liver disease and may also lead to a high glycemic index, low fiber diet and micronutrient deficiencies. The alteration of copper bioavailability (deficient, excess or aberrant coordination) may contribute to the onset and progress of related pathologies. Therefore, nutrient intake of patients on a gluten-free diet should be the focus of future researches. Other gluten-based therapies have been rising with interest such as enzymatic pretreatment of gluten, oral enzyme supplements to digest dietary gluten, gluten removal by breeding wheat varieties with reduced or deleted gluten toxicity, the development of polymeric binders to suppress gluten induced pathology.

Gastrointestinal Malabsorption of Thyroxine

Levothyroxine, a largely prescribed drug with a narrow therapeutic index, is often a lifelong treatment. The therapeutic efficacy of T4 may be marred by behavioral, pharmacologic, and pathologic issues acting as interfering factors. Despite a continuous search for an optimal T4 treatment, a significant number of patients fail to show a complete chemical and/or clinical response to this reference dose of T4. Gastrointestinal malabsorption of oral T4 represents an emerging cause of refractory hypothyroidism and may be more frequent than previously reputed. In this review, we examine the pharmacologic features of T4 preparations and their linkage with the intestinal absorption of the hormone. We have stressed the major biochemical and pharmacologic characteristics of T4 and its interaction with the putative transporter at the intestinal level. We have examined the interfering role of nutrients, foods, and drugs on T4 absorption at the gastric and intestinal levels. The impact of gastrointestinal disorders on T4 treatment efficacy has been also analyzed, in keeping with the site of action and the interfering mechanisms. Based on the evidence obtained from the literature, we also propose a schematic diagnostic workup for the most frequent and often hidden gastrointestinal diseases impairing T4 absorption.

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

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

Bread Enrichment with Oilseeds. A Review

The use of oilseeds in bakery products has gained popularity in recent years, both for their organoleptic and nutritional characteristics. The aim of this work is to provide an overview of the studies centered on the use of oilseeds (flaxseed, chia, sunflower, pumpkin, sesame and poppyseed) in breads and other bakery products. This review highlights the effect of oilseeds on the mechanical and physical properties of bread according to the enrichment level, origin and way of addition (whole, crushed, oil or mucilage). In general, the incorporation of oilseeds improves the nutritional profile of bakery products with and without gluten, and provides several health benefits. Mucilages of oilseeds can also act as a fat replacer thanks to their properties. The incorporation of oilseeds modifies the rheology of the doughs, the volume of the products and their texture, affecting their organoleptic characteristics and their acceptability. Nevertheless, these changes will depend on the type of seed used, as well as on the method of addition.