Enteric-Release Budesonide May Be Useful in the Management of Non-Responsive Celiac Disease.

BACKGROUND: Non-responsive celiac disease (NRCD) has many aetiologies, including gluten exposure. Budesonide may be used for refractory celiac disease (RCD) and celiac crisis. AIMS: We reviewed the effectiveness of budesonide to induce clinical and histologic response in NRCD with villous atrophy (VA). METHODS: Case series of adult cases with NRCD and VA prescribed budesonide at two celiac centers. Clinical variables and mucosal recovery (i.e., normal villous architecture within 1 year of treatment) were evaluated. RESULTS: Forty-two cases [77% female, median age 45.0 (IQR 28.3-60.0) years] were included. Most common symptoms were diarrhea (64%) and abdominal pain (62%). Budesonide was initiated at 9 mg (83%) for a median duration of 16.0 weeks (IQR 6.8-25.0 weeks). In total, 57% exhibited a clinical response, positively associated with diarrhea (adjusted OR 6.08 95% CI 1.04-35.47) and negatively with fatigue (adjusted OR 0.18 95% CI 0.03-0.98). Clinical response was higher among those with dietitian counseling prior to budesonide (n = 29, 70 vs. 23%, p < 0.01). Mucosal recovery was observed in 11/24 with follow-up duodenal biopsies. There was no association between clinical response and mucosal recovery, and 79% of clinical responders had a symptomatic relapse. RCD (48%) and chronic gluten exposure (24%) were the main suspected aetiologies of NRCD. Most individuals without a clinical response subsequently received an IBS-related diagnosis. CONCLUSIONS: Budesonide may be effective to induce clinical response in NRCD presenting with diarrhea and VA, but clinical recurrence and lack of mucosal recovery are frequent after tapering. Other diagnoses, including coexisting IBS, may be considered in non-responders to budesonide therapy.

Gluten and FODMAPS-Sense of a Restriction/When Is Restriction Necessary?

Gluten-free diet (GFD) is enjoying increasingly popularity, although gluten-free products are considerably more expensive. GFD is absolutely necessary for patients with celiac disease, as in this case even minor amounts of gluten can lead to the destruction of the intestinal mucosa. In addition, GFD is currently the best therapy to improve clinical symptoms of patients with non-celiac gluten sensitivity (NCGS), although the diet may not be as strict as that for patients with celiac disease. Beside gluten, other wheat components such as oligosaccharides and amylase trypsin inhibitors are discussed as triggers of NCGS in this review. An overlap between gastrointestinal symptoms in NCGS and irritable bowel syndrome (IBS) is described. Patients with NCGS attribute their symptoms to the consumption of gluten, while patients with IBS rarely describe gluten as a trigger. Recently, several studies have demonstrated that the introduction of a low FODMAP (fermentable oligo-, di-, monosaccharides, and polyols) diet reduced gastrointestinal symptoms in patients with IBS and this diet is suggested as the first choice of therapy in IBS. However, a low FODMAP diet also eliminates prebiotica and may negatively influence the gut microbiota. For this reason, the diet should be liberalized after symptom improvement. There is no evidence that a GFD is healthier than the standard diet. In contrast, GFD often is accompanied by nutritional deficiencies, mainly minerals and vitamins. Therefore, GFD and low FODMAP diets are not recommended for healthy subjects. Since wheat contains fructans belonging to FODMAPs), a GFD is not only gluten-free but also has less FODMAPs. Thus, symptom improvement cannot be correctly correlated with the reduction of either one or the other.

Análisis de menús sin gluten de comedores escolares en granada capital y área metropolitana: ¿son equilibrados? / Analysis of the gluten-free menus served in school canteens: are they balanced?

Introducción y objetivos: analizar el perfil alimentario y el valor nutricional de los menús adaptados para celiacos ofertados en los comedores de los centros escolares de Granada capital y área metropolitana. Material y métodos: estudio descriptivo en el que se han analizado los menús adaptados para niños celiacos de 41 centros escolares, cinco con cocina propia y 36 abastecidos por catering. La participación de los centros fue voluntaria, una vez fueron informados de las características y objetivos del estudio. Se recogió información a través de las fichas técnicas de los platos elaborados con la cantidad de cada alimento, además de las marcas de los productos sin gluten utilizados. Se analizaron menús de cuatro semanas en cuanto a distribución de raciones, energía, macro y micronutrientes para el grupo de 10 a 12 años, obteniendo valores medios y desviación estándar de 31 parámetros. Se utilizaron el programa Odimet y la base de datos CeliacBase. Se usó el programa estadístico IBM SPSS 22.0. Resultados: la pasta sin gluten fue la base del primer plato en el 31,7% de los menús analizados. En el segundo plato, la carne fue el constituyente principal. En todos los menús se ofertaba, al menos, una ración diaria de verdura. El 80% de los menús no alcanzaron la ingesta energética recomendada, aunque la distribución de macronutrientes fue adecuada. La cantidad media de fibra y de hidratos de carbono totales fue superior a lo recomendado. La cantidad de calcio y vitamina D no alcanzó la ingesta recomendada. Destaca un elevado consumo de sodio, que duplica la cantidad recomendada para la comida del mediodía. Conclusiones: los menús escolares adaptados para niños celiacos se ajustan a las recomendaciones, aunque deberían limitar la ingesta semanal de carne y presentan exceso de azúcares totales y sal

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

Metabolic interventions in Autism Spectrum Disorder.

Metabolic interventions including special diets and supplements are commonly used in Autism Spectrum Disorder (ASD). Yet little is known about how these interventions, typically initiated by caregivers, may affect metabolic function or the core symptoms of ASD. This review examines possible direct and indirect roles for metabolism in the core symptoms of ASD as well as evidence for metabolic dysfunction and nutritional deficiencies. We also discuss some of the most popular diets and supplements used in our patient population and suggest strategies for discussing the utility of these interventions with patients, families, and caregivers.

Experiences of coeliac disease in a changing gluten-free landscape.

BACKGROUND: Coeliac disease is an autoimmune disorder triggered by the ingestion of gluten. In recent years, there has been considerable increase in the availability of gluten-free products in North America. The present study investigated how the recent proliferation of the gluten-free industry has affected individuals living with coeliac disease, with a primary focus on their social lives and relationships. METHODS: Interpretive phenomenology was utilised for study design and analysis. Semi-structured interviews were conducted with 17 adults diagnosed with coeliac disease in Calgary, Alberta. Interviews were audio recorded and then transcribed for analysis. RESULTS: People living with coeliac disease experience the growth of the gluten-free industry as a 'double-edged sword'. Although they are grateful for more palatable gluten-free options, they are increasingly faced with misunderstandings about the severity of coeliac disease as a result of many noncoeliac disease individuals subscribing to the gluten-free diet. This 'double-edged sword' made certain types of social situations more easily manageable (e.g. more gluten-free options available at restaurants), whereas others produced distress (e.g. increased risk of inadvertently consuming gluten). Participants also felt they may be perceived or even perceived themselves differently (e.g. felt high maintenance). To help mitigate these social ramifications of following the gluten-free diet, participants utilised various strategies. CONCLUSIONS: The sole medical recommendation of a gluten-free diet fails to acknowledge the ongoing difficulties those with coeliac disease can endure in the current gluten-free landscape. Recommendations beyond the gluten-free diet are advisable to alleviate many of the indirect burdens revealed in the present study.

Breve revisión sobre controversias en la sensibilidad al gluten / trigo no celíaca. Respuestas prácticas a preguntas frecuentes / No disponible

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Marco socioantropológico de la enfermedad celíaca y sensibilidad al gluten; presente y futuro / No disponible

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Consideraciones analíticas en la determinación de gluten en alimentos / No disponible

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Alimentos libres de gluten y nutrición: situación actual de los pacientes celíacos, necesidades destacadas, retos futuros / No disponible

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Anxiety after coeliac disease diagnosis predicts mucosal healing: a population-based study.

BACKGROUND: Coeliac disease has been linked to anxiety and depression. However, their association with mucosal healing is unknown. AIM: To examine the relationship between anxiety, depression and mucosal healing in coeliac disease. METHODS: Between 1969 and 2008, we collected data on all small intestinal biopsies with villous atrophy from Sweden's 28 pathology departments. We restricted our cohort to individuals with data on follow-up biopsy (either persistent villous atrophy [n = 3317] or mucosal healing [n = 4331]). Through Cox regression, we estimated hazard ratios (HRs) for anxiety or depression. RESULTS: During follow-up, 123 (2.8/1000 person-years) individuals with mucosal healing had developed anxiety, compared to 94 (2.1/1000 person-years) with persistent villous atrophy. Mucosal healing was hence associated with a higher risk of future anxiety (HR = 1.49; 95% CI = 1.12-1.96). Similarly, 167 (3.8/1000 person-years) individuals with mucosal healing developed depression, compared to 148 (3.3/1000 person-years) with persistent villous atrophy, corresponding to a HR of 1.25 (95% CI = 0.99-1.59). Mucosal healing was more common in individuals with prior diagnoses of anxiety or depression before follow-up biopsy. Anxiety diagnosed between diagnostic and follow-up biopsy for coeliac disease was associated with an almost nine-fold increased chance of mucosal healing (odds ratio = 8.94; 95%CI = 2.03-39.27). CONCLUSION: Anxiety and depression are more common in coeliac disease patients with mucosal healing, both before and after follow-up biopsy, an association potentially mediated through more vigilant compliance with a gluten-free diet. This finding raises concern that achieving the goal of mucosal healing may come at a cost of an increased risk of mood disorders.

Enfermedad celíaca: quién sabe dónde / Celiac disease: who knows where

La celiaquía puede considerarse (como antes la sífilis) "la gran simuladora". Una enfermedad prevalente con nuevos matices y diferentes formas de presentación, incluyendo la silente. En relación con la ingesta de cereales están apareciendo otras enfermedades no celíacas, pero que mejoran al retirar el trigo. En este artículo se hace una actualización de la celiaquía y de las enfermedades relacionadas con la ingesta de cereales

Celiac disease can be considered "the great pretender" (as syphilis some years ago). A prevalent disease with different presentations, including silent ones. In relation to diet with cereals, other non-celiac diseases are appearing, that also improve removing wheat. The fact that it's being diagnosed in adults, adds complexity because protocols are somehow different than protocols in children. New data about celiac disease and other syndromes related to cereals help clarify practical management

Past, present and future: The strength of plant-based dairy substitutes based on gluten-free raw materials.

Plant-based foods are gaining popularity and the market is developing fast. This trend is based on several factors, like the change of lifestyle, interest in alternative diets, and the increasing awareness about sustainable production of food and especially proteins. Plant-based dairy substitutes can serve as an option to traditional food products, meeting many of these interests. However, the market is in its infancy and needs to progress. Trends show, that the market will change from being focused on mainly soya, almond and rice-based products, due to their unsustainable farming, and nutritional concerns, like genetic modification and low protein content. The market is likely to shift towards alternative plants to meet consumers' needs and desire for healthy, flavourful and intriguing products. In this regard, the aspect of allergy-free, like gluten-free products gain in importance. Research studies are approaching the nutritional quality of plant-based dairy substitutes, such as improving the protein quality and glycaemic properties. Furthermore, the application of these products or plant proteins as functional ingredients or substitutes for cow's milk in dairy products like cheese and yoghurt are disseminated. However, there is still a need for much more diversified studies in order to overcome stability, textural, nutritional and sensory problems.

Trends, geographical variation and factors associated with prescribing of gluten-free foods in English primary care: a cross-sectional study.

OBJECTIVES: There is substantial disagreement about whether gluten-free foods should be prescribed on the National Health Service. We aim to describe time trends, variation and factors associated with prescribing gluten-free foods in England. SETTING: English primary care. PARTICIPANTS: English general practices. PRIMARY AND SECONDARY OUTCOME MEASURES: We described long-term national trends in gluten-free prescribing, and practice and Clinical Commissioning Group (CCG) level monthly variation in the rate of gluten-free prescribing (per 1000 patients) over time. We used a mixed-effect Poisson regression model to determine factors associated with gluten-free prescribing rate. RESULTS: There were 1.3 million gluten-free prescriptions between July 2016 and June 2017, down from 1.8 million in 2012/2013, with a corresponding cost reduction from £25.4 million to £18.7 million. There was substantial variation in prescribing rates among practices (range 0 to 148 prescriptions per 1000 patients, IQR 7.3-31.8), driven in part by substantial variation at the CCG level, likely due to differences in prescribing policy. Practices in the most deprived quintile of deprivation score had a lower prescribing rate than those in the highest quintile (incidence rate ratio 0.89, 95% CI 0.87 to 0.91). This is potentially a reflection of the lower rate of diagnosed coeliac disease in more deprived populations. CONCLUSION: Gluten-free prescribing is in a state of flux, with substantial clinically unwarranted variation between practices and CCGs.

Latiglutenase Improves Symptoms in Seropositive Celiac Disease Patients While on a Gluten-Free Diet.

BACKGROUND AND AIMS: Celiac disease (CD) is a widespread condition triggered by dietary gluten and treated with a lifelong gluten-free diet (GFD); however, inadvertent exposure to gluten can result in episodic symptoms. A previous trial of latiglutenase (clinicaltrials.gov; NCT01917630), an orally administered mixture of two recombinant gluten-specific proteases, was undertaken in symptomatic subjects with persistent injury. The primary endpoint for histologic improvement was not met, presumably due to a trial effect. In this post hoc analysis, we investigated the efficacy of latiglutenase for reducing symptoms in subgroups of the study participants based on their seropositivity. METHODS: The study involved symptomatic CD patients following a GFD for at least one year prior to randomization. Patients were treated for 12 weeks with latiglutenase or placebo. Of 398 completed patients, 173 (43%) were seropositive at baseline. Symptoms were recorded daily, and weekly symptom scores were compiled. p values were calculated by analysis of covariance. RESULTS: A statistically significant, dose-dependent reduction was detected in the severity and frequency of symptoms in seropositive but not seronegative patients. The severity of abdominal pain and bloating was reduced by 58 and 44%, respectively, in the cohort receiving the highest latiglutenase dose (900 mg, n = 14) relative to placebo (n = 54). Symptom improvement increased from week 6 to week 12. There was also a trend toward greater symptom improvement with greater baseline symptom severity. CONCLUSIONS: Seropositive CD patients show symptomatic improvement from latiglutenase taken with meals and would benefit from the availability of this treatment.

Symptoms of Functional Intestinal Disorders Are Common in Patients with Celiac Disease Following Transition to a Gluten-Free Diet.

BACKGROUND: Celiac disease and functional intestinal disorders may overlap, yet the natural history of functional symptoms in patients with celiac disease is unknown. AIM: To investigate the prevalence of irritable bowel syndrome (IBS), functional dyspepsia (FD), and functional bloating (FB) symptoms among patients with celiac disease at diagnosis and during the first year of a gluten-free diet. METHODS: Adults with a new diagnosis of celiac disease were surveyed at baseline, 6 months and 1 year using standardized measures for intestinal symptoms [Rome III diagnostic questionnaire and celiac symptom index (CSI)] and gluten-free diet adherence [gluten-free eating assessment tool (GF-EAT) and celiac diet adherence test]. RESULTS: At diagnosis, two-thirds fulfilled Rome III diagnostic questionnaire symptom criteria for IBS (52%), functional dyspepsia (27%), and/or functional bloating (9%). One year post-diagnosis, there was high adherence to a gluten-free diet as 93% reported gluten exposure less than once per month on the GF-EAT and only 8% had ongoing celiac disease symptoms (CSI score >45). The rates of those meeting IBS (22%) and functional dyspepsia (8%) symptom criteria both decreased significantly on a gluten-free diet. The prevalence of functional symptoms (any of IBS, FD or FB) at 1 year was 47%. CONCLUSIONS: Long-term follow-up of patients with celiac disease is necessary because many patients with celiac disease who are adherent to a gluten-free diet have persistent gastrointestinal symptoms.

Obesity, Metabolic Syndrome, and Cardiovascular Risk in Gluten-Free Followers Without Celiac Disease in the United States: Results from the National Health and Nutrition Examination Survey 2009-2014.

BACKGROUND: Despite unclear benefits of gluten-free diets (GFD) in the general population, gluten-free followers without medical indications are driving the market. Few studies have investigated health benefits of GFD in the general population. AIMS: To estimate metabolic and cardiovascular disease (CVD) risk profiles among gluten-free followers without celiac disease (CD). METHODS: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2009-2014. There were 13,523 persons without CD who had GFD information. People with known CVD were excluded. We compared gluten-free followers without CD and the general population by selective metabolic and CVD risk profiles using survey-weighted generalized logistic regression. RESULTS: There were 155 gluten-free followers without CD and CVD, corresponding to a weighted prevalence of 1.3% (3.2 million Americans). Gluten-free followers tended to be women and have a smaller waist circumference and higher HDL cholesterol. They also had a lower BMI with a borderline p value (0.053) and significant self-reported weight loss (-1.33 kg) over one year. Moreover, gluten-free followers were more likely to consider their weight appropriate. There was no statistical difference by age, smoking, hypertension, total cholesterol, triglyceride cholesterol, HbA1c, or fasting glucose. Despite a lower probability of having metabolic syndrome (33.0 vs 38.5%) and lower 10-year CVD risk score (4.52 vs 5.70%) in gluten-free followers, there was no statistical difference. CONCLUSIONS: Although being on a GFD may be beneficial in weight management, there was no significant difference in terms of prevalence of metabolic syndrome and CVD risk score in gluten-free followers without CD.

Celiac crisis in adults: a case report and review of the literature focusing in the prevention of refeeding syndrome

Introduction: Celiac crisis is a life-threatening complication of celiac disease that is rarely described in adults. Case report: We report the case of a 31-year-old man with celiac crisis as a first manifestation of celiac disease. The patient presented with severe diarrhea, metabolic acidosis, and electrolyte disturbances accompanied by electrocardiographic alterations. A satisfactory clinical response was obtained after the correction of electrolyte abnormalities, hydration, and nutritional support with a gluten-free diet according to recommendations for patients at high risk of refeeding syndrome. Discussion: Celiac crisis generally occurs in patients with no previous diagnosis of celiac disease. The physician should therefore be aware of this diagnosis and consider celiac crisis in cases of unexplained intense secretory diarrhea, metabolic acidosis and severe electrolyte alterations in adults. The risk of refeeding syndrome should be assessed when a gluten-free diet is introduced and treatment of celiac crisis should include prevention and management of this possible complication (AU)

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Tempters and Gluten-Free Diet.

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