Study Sessions

By Van Waffle

Until now, doctors have no had clear guidelines on follow-up care for kids with celiac disease. A panel of North American experts has attempted to address this by recommending best practices to manage children with the disease.

Guidelines were based on an extensive review of existing research. The panel of seven experts considered the data supporting each guideline, graded the evidence, took their individual experiences treating patients into account and voted anonymously whether to recommend the guideline as a best practice. The panel reached consensus on 24 of 25 questions, voting unanimously on 15.

The guidelines cover six areas of concern, including bone health, blood problems, endocrine disorders, liver health, nutritional concerns and diagnostic testing for celiac disease. They indicate which tests and counseling doctors should undertake when a patient is newly diagnosed with celiac disease and in subsequent follow-up.

Some of the guidelines that received unanimous support included testing for immunoglobin A anti-tissue transglutaminase (tTG) as part of initial diagnosis, screening diagnosed patients for anemia and thyroid disease, providing access to an experienced dietitian, recommending multivitamin supplements and repeat tTG testing to monitor compliance with a gluten-free diet.

Snyder J, Butzner JD, DeFelice AR, Fasano A, Guandalini S, Liu E and Newton KP, “Evidence-informed expert recommendations for the management of celiac disease in children,” Pediatrics, Sept 2016, doi:10.1542/peds.2015-3147.

By Van Waffle

Celiac disease commonly imposes a burden on patients’ partners, according to new research from Columbia University. Previous research has found celiac disease imposes a reduced quality of life similar to that of other severe chronic diseases. However, this was the first to study impact on loved ones.

The study surveyed 94 patients and their partners at the university’s celiac disease center. Sixteen percent of patients reported poor quality of life, while 37 percent of partners reported mild to moderate burden, 23 percent reported poor relationship satisfaction and 12 percent reported poor sexual satisfaction.

The study did not use a control group of people unaffected by celiac disease for comparison. However, the partner burden was significantly higher than normal, according to surveys in previous research. The authors recommend healthcare workers try to include partners in the counseling process when caring for people with celiac disease.

Roy A, Minaya M, Monegro M, Fleming J, Wong RK, Lewis S, Lebwohl B and Green PH, “Partner burden: a common entity in celiac disease,” Digestive Disease and Sciences, Apr 28 2016 [Epub ahead of print].

By Van Waffle

A study from Northern Italy has confirmed that celiac disease may be associated with autoimmune hypothyroidism and type 1 diabetes. People with celiac disease are 4.6 times more likely to be diagnosed with autoimmune hypothyroidism. They also face a marginal 2.5 times increased risk for type 1 diabetes.

The study, supported by the University of Padua, collected data on 1,215 child and young adult patients with celiac disease born between 1989 and 2011, and compared them with the general population. While previous studies have found type 1 diabetes patients have an increased risk for celiac disease, few like this one have shown the reverse is also true. Other studies have also associated celiac disease with hypothyroidism. However, this latest research provides stronger evidence because it identified all celiac disease patients from a region during a given time period.

The reason for the association remains uncertain, but experts suspect a shared genetic background. Almost all people with celiac disease have the human leukocyte antigen-DQ2 or -DQ8 gene, which occur at more than the usual frequency in people with autoimmune hypothyroidism or type 1 diabetes.

Canova C, Pitter G, Ludvigsson JF, Romor P, Zanier L, Zanotti R and Simonato L, “Celiac disease and risk of autoimmune disorders: a population-based matched birth cohort study,” The Journal of Pediatrics, July 2016, doi:10.1016/j.jpeds.2016.02.058.

By Van Waffle

A study from Dartmouth College in New Hampshire found that rice cereal and other rice-containing foods contribute to arsenic exposure in infants.

The study collected data on 759 children whose mothers enrolled during pregnancy in the New Hampshire Birth Cohort Study from 2011 to 2014. Researchers interviewed parents about children’s food intake during the first year of life.

The analysis separated out infants who ate fish and seafood, which also contain arsenic. Among infants who didn’t consume seafood, those who ate rice and rice-containing products had more arsenic in their urine than children who did not eat rice.

The authors recommend minimizing arsenic exposure during early childhood development.

Karagas MR, Punshon T, Sayarath V, Jackson BP, Folt CL and Cottingham KL, Association of rice and rice-product consumption with arsenic exposure early in life,” JAMA Pediatrics, June 2016, doi:10.1001/jamapediatrics.2016.0120.

By Van Waffle

Digestive enzymes of the fly-eating pitcher plant show promise as a treatment for celiac disease. They can break down gluten proteins into smaller, non-damaging particles, as revealed in an international study by scientists in Austria, Canada, the Czech Republic and France.

Researchers fed gluten treated with normal digestive enzymes to gluten-sensitive mice. Their intestinal lining became inflamed. However, when the gluten was also treated with pitcher plant enzymes, no inflammation occurred.

Enzyme therapies are not new. Other digestive aids exist on the market. However, medical research has found them ineffective at protecting celiac disease patients against the damage caused by gluten. The pitcher plant enzymes distinguish themselves by performing well at low concentrations: one part enzyme to 12,000 parts gluten. This would allow a small yet effective amount to be consumed along with any meal.

The effect depends on two different enzymes working together. This study identifies a formerly unknown catalyst called neprosin, which collaborates with another enzyme, nepenthesin.

Clinical studies will be needed to show whether their anti-inflammatory action against gluten can translate to humans. If so, this combination of enzymes could potentially assist or even replace a gluten-free diet in treating celiac disease.

It took 100 plants with about 1,000 individual pitchers six months to produce 1.3 gallons of digestive fluid for this study.

Rey M, Yang M, Lee L, Zhang Y, Sheff JG, Sensen CW, Mrazek H, Halada P, Man P, McCarville JL, Verdu EF and Schriemer DC, “Addressing proteolytic efficiency in enzymatic degradation therapy for celiac disease,” Scientific Reports, Aug 2 2016, doi:10.1038/srep30980.

By Van Waffle

People with celiac disease are more likely to visit the doctor with headache complaints, according to a large population study by U.S. and Swedish researchers. It identified 26,638 Swedish celiac disease patients and matched each with up to five controls for comparison. The celiac disease patients made 66% more headache-related health-care visits. The most common diagnosis was migraine.

The risk for headache visits declined over time after diagnosis but remained higher than normal. The study didn’t track adherence to the gluten-free diet, so no conclusion could be reached on its benefits.

The study also found an elevated headache risk in people who had intestinal inflammation but no tissue damage associated with celiac disease and in people with normal intestinal tissue but elevated blood antibodies associated with celiac disease. These findings support evidence that autoimmunity and inflammation associated with celiac disease can lead to headaches. More research is needed to explain why.

Lebwohl B, Roy A, Alaedini A, Green PHR, Ludvigsson JF, “Risk of headache-related healthcare visits in patients with celiac disease: a population-based observational study,” Headache, 12 Mar 2016, doi:10.1111/head.12784 [Epub ahead of print].

By Van Waffle

Start small and don’t wait too long: That’s the takeaway advice from two recent studies on introducing gluten to children, particularly those at risk for celiac disease.

One international team found high gluten intake before age 2 increases the risk in children who are genetically predisposed. The study drew from 15 years of follow-up data on 48,000 newborn Swedish children. In Sweden children traditionally eat more cereals than those in other European countries or the United States.

Parents of children in the study reported the children’s daily food consumption up to 24 months of age. From this group, researchers identified 146 children diagnosed with celiac disease by intestinal biopsy. Each of these individuals were matched and compared with three children (a total of 436) of the same age, sex and genetic type who did not acquire the disease.

Comparing diets, the study found no difference based on how long breastfeeding lasted or at what age gluten was first introduced to the child. However children who ate more than 5 grams of gluten per day were more likely to develop celiac disease than those who ate less than 3.4 grams per day.

This doesn’t prove eating too much gluten actually triggers celiac disease. However the authors suggest their findings “may have consequence for future infant feeding recommendations.” Further research in other countries is needed to confirm these findings.

Aronsson CA, Lee H-L, Koletsko S, Uusitalo U, Yang J, Virtanen SM, Liu E, Lernmark Å, Norris JM, Agardh D and the TEDDY Study Group, “Effects of gluten intake on risk of celiac disease: a case-control study on a Swedish birth cohort,” Clinical Gastroenterology and Hepatology, Nov 25 2015; doi:10.1016/j.cgh.2015.09.030 [Epub ahead of print].

By Van Waffle

In a clinical trial, one of the potential drugs to treat celiac disease reduced persistent symptoms in people already following a gluten-free diet. The trial involved 342 adults at 74 health care sites across North America.

Previous research suggested that larazotide acetate prevents a “leaky gut,” so gluten doesn’t reach underlying tissue and cause inflammation. In studies of patients being challenged with gluten, the drug reduced symptoms and celiac
disease antibodies.

This latest trial was first to test the drug in patients who had been following a gluten-free diet for at least 12 months but continued to experience symptoms. Participants randomly received a placebo, 0.5 mg, 1 mg or 2 mg of larazotide acetate three times daily.

More than one quarter of participants reported voluntarily eating gluten during the 20-week study, while more than half reported accidental exposure. They reported severity of various symptoms daily.

Patients receiving 0.5 mg showed improvement on the drug, reporting 26 percent fewer days with symptoms, averaging 1.73 days per week versus 2.38 days for patients on placebo. The same group also reported less severe symptoms. Patients with the most symptoms reported the most improvement.

Meanwhile patients in the groups receiving 1 or 2 mg reported no change in symptoms. Why higher doses are ineffective remains unclear, but this has been observed in similar drugs.

As a requirement for the study, candidates had to test positive for celiac disease antibodies so these levels could be monitored by blood tests. However most participants started with antibodies in a healthy or normal range. While the drug did not reduce patients’ antibodies in blood tests, it prevented any increase when they were exposed to gluten. More research is needed to investigate possible longer-term improvement.

The authors concluded larazotide deserves further study. It could also help people with other autoimmune diseases involving gut permeability, including Crohn’s disease, multiple sclerosis and type I diabetes.

Leffler DA, Kelly CP, Green PH, Fedorak RN, DiMarino A, Perrow W, Rasmussen H, Wang C, Bercik P, Bachir NM and Jurray JA, “Larazotide acetate for persistent symptoms of celiac disease despite a gluten-free diet: a randomized controlled trial,” Gastroenterology, Jun 2014;148(7): 1311–9.e6, doi:10.1053/j.gastro.2015.02.008.

By Van Waffle

Italian researchers have found that the season in which a child is born influences the development of celiac disease in young children, with babies born in the summer having a greater risk.

Celiac disease is known to be triggered by some environmental factor, possibly viral infection. The authors suggest summer babies may be at risk if they’re weaned and introduced to gluten during flu season.

The study collected data on all 596 children diagnosed with celiac disease through two Italian hospitals between 2003 and 2010. National statistics provided a comparison of all infants born in the same two cities during that period. Twenty-eight percent of children with celiac disease compared to 23 percent of children overall were born in summer.

This is the first study to investigate seasonal effect in southern Europe. Previous Swedish studies also found an increased summer risk. In the Boston area a 2013 study found an increased risk for spring births among boys only.

The authors suggest potential causes such as heat stress during pregnancy and a child’s exposure to viruses in winter, when summer babies are likely to be weaned and begin eating gluten-containing cereal. Although recent research dismissed hopes that the age when infants are introduced to gluten could reduce their risk for
celiac disease, those studies didn’t consider birth season. Since viral infections have been linked to celiac disease, this study suggests it’s better to avoid introducing gluten during flu season to babies with a family history of the disorder.

Capriati T, Francavilla R, Castellaneta S, Ferretti F and Diamanti A, “Impact of the birth’s season on the development of celiac disease in Italy,” European Journal of Pediatrics, Jul 5, 2015, doi:10.1007/s00431-015-2589-2.

We cannot live on grains alone because they do not contain enough amino acids, the building blocks that make protein. There are 20 kinds of amino acids. Our bodies naturally make some of these acids and get the rest from food.

Meat provides all the protein we need, but many people wish to eliminate or reduce their meat consumption for ethical, financial, environmental or health reasons. No single plant food contains all the essential amino acids to manufacture protein, so we can get enough only by combining them.

One of the most important amino acids we need is lysine. It’s scarce in wheat, corn, rice, oats, sorghum and millet protein. However, all these crops contain other essential amino acids, such as methionine. Other plant foods, including beans, are rich in lysine but have little methionine. These foods complement one another, with one providing amino acids the other lacks, to provide complete protein.

When people in early civilizations started growing grains for nutrition, nobody knew anything about protein. But they learned what foods to eat by using trial and error. Traditional diets evolved by combining complementary proteins. For example, corn and beans became staples in Mexico, and Indian people relied on rice and dal.

The gluten-free diet has brought attention to some interesting alternatives to the familiar grains. Amaranth, quinoa and buckwheat contain a high proportion of lysine, and amaranth is unusually high in many essential amino acids. This is good news for avid bakers going gluten free. They’re already experts at blending flours to achieve the right flavors and textures. Using amaranth, quinoa, buckwheat and legume (bean or chickpea) flour can also help round out the protein content to make these recipes more nutritious.