Coeliac Disease (CD) is a permanent gluten intolerance, whose pathogenesis involves multiple factors including genetics and environment. CD has different representations and non-specific symptoms such as diarrhea, bloating, pain, flatulence and constipation may sometimes be misleading. Once diagnosed of CD, patients must adhere to Gluten Free Diet, which consists in the lifelong avoidance of gluten containing foods and of those naturally gluten free but at risk of contamination. This dietary approach is considered the only therapy in order to avoid symptoms exacerbation and to reduce the digestive mucosa inflammation, which has been related to higher risks of lymphoproliferative malignancy and other immunological disorders. However, being on a Gluten Free Diet is not as resolving as it may seem since it has several criticalities. First of all, excluding gluten means limiting food variety so that coeliac patients may have unbalanced intake of several nutrients and develop clinical or subclinical deficiencies. This can be due to scarce attention to qualitative and quantitative composition of diets and poor information about gluten-containing foods, which only patient-tailored dietetic protocol and long-term follow-up can achieve. Secondly, Gluten Free Diet may not result in complete remission of mucosal damage or in resolution of symptoms. Unintentional contamination of gluten or poor adherence to diet are the main culprits of the incomplete mucosal healing but other triggers may be involved. Recent research has focused on the role of FODMAPs in changing gut microbiota and on the improvement of Irritable Bowel Syndrome (IBS) symptoms after their dietary avoidance or reduction. Since CD and IBS may share many clinical presentations, further studies are needed to evaluate if a subgroup of CD patients whose symptoms are not improved by Gluten Free Diet could benefit from a new therapeutic approach consisting in both gluten/wheat and FODMAPs avoidance.
References
[1]
American College of Gastroenterology (2013) Clinical Guidelines: Diagnosis and Management of Coeliac Disease. American Journal of Gastroenterology, 108, 656-676. http://dx.doi.org/10.1038/ajg.2013.79
[2]
Bai, J.C., Ciacci, C., Corazza, G.R., Fried, M., Olano, C., Rostami-Nejad, M., González, A., Green, P., Gutierrez-Achury, J., Schultz, M., Verdú, E., Barada, K., Gibson, P., Koletzko, S., Coton, T., Mulder, C., Makharia, G. and LeMair, A. (2016) World Gastroenterology Organisation Global Guidelines: Celiac Disease. http://www.worldgastroenterology.org/guidelines/global-guidelines/celiac-disease/celiac- disease-english#Ref013
[3]
Hooper, L.V., Littman, D.R. and Macpherson, A.J. (2012) Interactions between the Microbiota and the Immune System. Science, 336, 1268-1273. http://dx.doi.org/10.1126/science.1223490
[4]
Taus, M., Busni, D., Fumelli, D., Paci, A., Nicolai, G. and Nicolai, A. (2015) Inflammatory Bowel Diseases: What Do We Still Need to Investigate? Open Journal of Gastroenterology, 5, 146-154. http://dx.doi.org/10.4236/ojgas.2015.510024
[5]
De Palma, G., Nadal, I., Collado, M.C. and Sanz, Y. (2009) Effects of a Gluten-Free Diet on Gut Microbiota and Immune Function in Healthy Adult Human Subjects. British Journal of Nutrition, 102, 1154-1160. http://dx.doi.org/10.1017/S0007114509371767
[6]
Brottveit, M. and Lundin, K.E. (2008) Cancer Risk in Coeliac Disease. Tidsskrift for Den norske legeforening, 128, 2312-2315.
[7]
Lebwohl, B., Granath, F., Ekbom, A., Smedby, K.E., Murray, J.A., Neugut, A.I., Green, P.H. and Ludvigsson, J.F. (2013) Mucosal Healing and Risk for Lymphoproliferative Malignancy in Celiac Disease: A Population-Based Cohort Study. Annals of Internal Medicine, 159, 169-175. http://dx.doi.org/10.7326/0003-4819-159-3-201308060-00006
[8]
Ohlund, K., Olsson, C., Hernell, O. and Ohlund, I. (2010) Dietary Shortcomings in Children on a Gluten Free Diet. Journal of Human Nutrition and Dietetics, 23, 294-300. http://dx.doi.org/10.1111/j.1365-277X.2010.01060.x
[9]
Rajpoot, P., Sharma, A., Harikrishnan, S., Baruah, B.J., Ahuja, V. and Makharia, G.K. (2015) Adherence to Gluten-Free Diet and Barriers to Adherence in Patients with Celiac Disease. Indian Journal of Gastroenterology, 34, 380-386. http://dx.doi.org/10.1007/s12664-015-0607-y
[10]
Ciacci, C., Ciclitira, P., Hadjivassiliou, M., Kaukinen, K., Ludvigsson, J.F., McGough, N., Sanders, D.S., Woodward, J., Leonard, J.N. and Swift, G.L. (2015) The Gluten-Free Diet and Its Current Application in Coeliac Disease and Dermatitis Herpetiformis. United European Gastroenterology Journal, 3, 121-135. http://dx.doi.org/10.1177/2050640614559263
[11]
Medina, M., De Palma, G., Ribes-Koninckx, C., Calabuig, M. and Sanz, Y. (2008) Bifidobacterium Strains Suppress in Vitro the Pro-Inflammatory Milieu Triggered by the Large Intestinal Microbiota of Celiac Patients. Journal of Inflammation, 5, 19. http://dx.doi.org/10.1186/1476-9255-5-19
[12]
Lanzini, A., Lanzarotto, F., Villanacci, V., Mora, A., Bertolazzi, S., Turini, D., Carella, G., Malagoli, A., Ferrante, G., Cesana, B.M. and Ricci, C. (2009) Complete Recovery of Intestinal Mucosa Occurs Very Rarely in Adult Coeliac Patients Despite Adherence to Gluten-Free Diet. Alimentary Pharmacology & Therapeutics, 29, 1299-308. http://dx.doi.org/10.1111/j.1365-2036.2009.03992.x
[13]
Ludvigsson, J.F., Bai, J.C., Biagi, F., Card, T.R., Ciacci, C., Ciclitira, P.J., Green, P.H., Hadjivassiliou, M., Holdoway, A., van Heel, D.A., Kaukinen, K., Leffler, D.A., Leonard, J.N., Lundin, K.E., McGough, N., Davidson, M., Murray, J.A., Swift, G.L., Walker, M.M., Zingone, F. and Sanders, D.S. (2014) BSG Coeliac Disease Guidelines Development Group; British Society of Gastroenterology. Diagnosis and Management of Adult Coeliac Disease: Guidelines from the British Society of Gastroenterology. Gut, 63, 1210-1228. http://dx.doi.org/10.1136/gutjnl-2013-306578
[14]
Silvester, J.A., Graff, L.A., Rigaux, L., Walker, J.R. and Duerksen, D.R. (2016) Symptomatic Suspected Gluten Exposure Is Common among Patients with Coeliac Disease on a Gluten-Free Diet. Alimentary Pharmacology and Therapeutics, 44, 541-651. http://dx.doi.org/10.1111/apt.13725
[15]
MacCulloch, K. and Rashid, M. (2014) Factors Affecting Adherence to a Gluten-Free Diet in Children with Celiac Disease. Paediatrics and Child Health, 19, 305-309.
[16]
Shah, S., Akbari, M., Vanga, R., Kelly, P.C., Hansen, J., Theethira, T., Tariq, S., Dennis, M. and Leffler, D.A. (2014) Patient Perception of Treatment Burden Is High in Celiac Disease Compared to Other Common Conditions. American Journal of Gastroenterology, 109, 1304-1311. http://dx.doi.org/10.1038/ajg.2014.29
[17]
Codex Alimentarius Standard (2015) Codex Standard for Foods for Special Dietary Use for Persons Intolerant to Gluten. http://www.codexalimentarius.org/input/download/standards/291/CXS_118e_2015.pdf
[18]
Kemppainen, T., Uusitupa, M., Janatuinen, E., Jarvinen, R., Julkunen, R. and Pikkarainen, P. (1995) Intakes of Nutrients and Nutritional Status in Coeliac Patients. Scandinavian Journal of Gastroenterology, 30, 575-579. http://dx.doi.org/10.3109/00365529509089792
[19]
Wild, D., Robins, G.G., Burley, V.J. and Howdle, P.D. (2010) Evidence of High Sugar Intake, and Low Fibre and Mineral Intake, in the Gluten-Free Diet. Alimentary Pharmacology & Therapeutics, 32, 573-581. http://dx.doi.org/10.1111/j.1365-2036.2010.04386.x
[20]
Myszkowska-Ryciak, J., Szymanska, J., Harton, A. and Gajewska, D. (2010) Evidence of High Fat and Sugar Intake and Low Fibre and Selected Minerals Intake in Adult Female Coeliac Patients. Journal of Pre-Clinical and Clinical Research, 4, 112-115.
[21]
Mijatov, M.A. and Micetic-Turk, D. (2016) Dietary Intake in Adult Female Coeliac Disease Patients in Slovenia. Zdravstveno Varstvo, 11, 86-93.
[22]
Valente, F.X., Campos, T., Do, N., de Sousa Moraes, L.F., Hermsdorff, H.H., Cardoso, L., Pinheiro-Sant’Ana, H.M., Gilberti, F.A. and Peluzi Mdo, C. (2015) B Vitamins Related to Homocysteine Metabolism in Adults Celiac Disease Patients: A Cross-Sectional Study. Nutrition Journal, 14, 110. http://dx.doi.org/10.1186/s12937-015-0099-8
[23]
Abenavoli, L., Delibasic, M., Peta, V., Turkulov, V., De Lorenzo, A. and Medic-Stojanoska, M. (2015) Nutritional Profile of Adult Patients with Celiac Disease. European Review for Medical and Pharmacological Sciences, 19, 4285-4292.
[24]
Van Hees, N.J., Giltay, E.J., Tielemans, S.M., Geleijnse, J.M., Puvill, T., Janssen, N. and van der Does, W. (2015) Essential Amino Acids in the Gluten-Free Diet and Serum in Relation to Depression in Patients with Celiac Disease. PLoS ONE, 10, e0122619. http://dx.doi.org/10.1371/journal.pone.0122619
[25]
Missbach, B., Schwingshackl, L., Billmann, M.A., Hickelsberger, M., Bauer, G. and Konig, J. (2015) Gluten-Free Food Database: The Nutritional Quality and Cost of Packaged Gluten-Free Foods. PeerJ, 3, e1337. http://dx.doi.org/10.7717/peerj.1337
[26]
Wu, J.H., Neal, B., Trevena, H., Crino, M., Stuart-Smith, W., Faulkner-Hogg, K., Yu Louie, J.C. and Dunford, E. (2015) Are Gluten-Free Foods Healthier than Non-Gluten-Free Foods? An Evaluation of Supermarket Products in Australia. British Journal of Nutrition, 114, 448-454. http://dx.doi.org/10.1017/S0007114515002056
[27]
Aranda, E.A. and Araya, M. (2016) Treating Coeliac Disease. How Do We Measure Adherence to the Gluten-Free Diet? Revista Chilena de Pediatría, Epub.
[28]
Lee, A.R., Ng, D.L., Dave, E., Ciaccio, E.J. and Green, P.H. (2009) The Effect of Substituting Alternative Grains in the Diet on the Nutritional Profile of the Gluten-Free Diet. Journal of Human Nutrition and Dietetics, 22, 359-363. http://dx.doi.org/10.1111/j.1365-277X.2009.00970.x
[29]
Rybicka, I., Krawczyk, M., Stanisz, E. and Gliszczyńska-Swiglo, A. (2015) Selenium in Gluten-Free Products. Plant Foods for Human Nutrition, 70, 128-134. http://dx.doi.org/10.1007/s11130-015-0467-8
[30]
Godoy, R., Caliari, M., Soares Soares, M.J., Nunes, S., Benassi De Toledo, M. and Costa Garcia, M. (2015) Quinoa and Rice Co-Products Gluten Free-Cereals: Physical, Chemical, Microbiological and Sensory Qualities. Journal of Food and Nutrition Research, 3, 599-606.
[31]
Galli, G., Esposito, G., Lahner, E., et al. (2014) Histological Recovery and Gluten-Free Diet Adherence: A Prospective 1-Year Follow-Up Study of Adult Patients with Coeliac Disease. Alimentary Pharmacology & Therapeutics, 40, 639-647. http://dx.doi.org/10.1111/apt.12893
[32]
Sanz, Y. (2015) Microbiome and Gluten. Annals of Nutrition and Metabolism, 67, 28-41. http://dx.doi.org/10.1159/000440991
[33]
Wacklin, P., Laurikka, P., Lindfors, K., Collin, P., Salmi, T., Lahdeaho, M.L., Saavalainen, P., Maki, M., Matto, J., Kurppa, K. and Kaukinen, K. (2014) Altered Duodenal Microbiota Composition in Coeliac Disease Patients Suffering from Persistent Symptoms on a Long-Term Gluten-Free Diet. American Journal of Gastroenterology, 109, 1933-1941. http://dx.doi.org/10.1038/ajg.2014.355
[34]
De Giorgio, R., Volta, U. and Gibson, P.R. (2016) Sensitivity to Wheat, Gluten and FODMAPs in IBS: Facts or Fiction? Gut, 65, 169-178. http://dx.doi.org/10.1136/gutjnl-2015-309757
[35]
Dugum, M., Barco, K. and Garg, S. (2016) Managing Irritable Bowel Syndrome: The Low-FODMAP Diet. Cleveland Clinic Journal of Medicine, 83, 655-662.
[36]
Maagaard, L., Ankersen, D.V., Végh, Z., Burisch, J., Jensen, L., Pedersen, N. and Munk-holm, P. (2016) Follow-Up of Patients with Functional Bowel Symptoms Treated with a low FODMAP Diet. World Journal of Gastroenterology, 22, 4009-4019. http://dx.doi.org/10.3748/wjg.v22.i15.4009
[37]
Laatikainen, R., Koskenpato, J., Hongisto, S.-M., Loponen, J., Poussa, T., Hillila, M. and Korpela, R. (2016) Randomised Clinical Trial: Low-FODMAP Rye Bread vs. Regular Rye Bread to Relieve the Symptoms of Irritable Bowel Syndrome. Alimentary Pharmacology & Therapeutics, 44, 460-470. http://dx.doi.org/10.1111/apt.13726
[38]
Iacovou, M., Tan, V., Muir, J.G. and Gibson, P.R. (2015) The Low FODMAP Diet and Its Application in East and Southeast Asia. Journal of Neurogastroenterology and Motility, 21, 459-470. http://dx.doi.org/10.5056/jnm15111
[39]
Pérez y López, N., Torres-López, E. and Zamarripa-Dorsey, F. (2015) Respuesta clínica en pacientes mexicanos con syndrome de intestino irritable tratados con dieta baja en carbohidratos fermentables (FODMAP). Revista de Gastroenterología de México, 80, 180-185. http://dx.doi.org/10.1016/j.rgmx.2015.06.008
[40]
Halmos, E.P., Christophersen, C.T., Bird, A.R., Shepherd, S.J., Gibson, P.R. and Muir, J.G. (2015) Diets That Differ in Their FODMAP Content Alter the Colonic Luminal Microenvironment. Gut, 64, 93-100. http://dx.doi.org/10.1136/gutjnl-2014-307264
[41]
Staudacher, H.M., Lomer, M.C., Anderson, J.L., et al. (2012) Fermentable Carbohydrate Restriction Reduces Luminal Bifidobacteria and Gastrointestinal Symptoms in Patients with Irritable Bowel Syndrome. Journal of Nutrition, 142, 1510-1518. http://dx.doi.org/10.3945/jn.112.159285
[42]
Halmos, E.P., et al. (2016) Consistent Prebiotic Effect on Gut Microbiota with Altered FODMAP Intake in Patients with Crohn’s Disease: A Randomised, Controlled Cross-Over Trial of Well-Defined Diets. Clinical and Translational Gastroenterology, 7, e164. http://dx.doi.org/10.1038/ctg.2016.22
[43]
Ong, D.K., Mitchell, S.B., Barrett, J.S., et al. (2010) Manipulation of Dietary Short Chain Carbohydrates Alters the Pattern of Gas Production and Genesis of Symptoms in Irritable Bowel Syndrome. Journal of Gastroenterology and Hepatology, 25, 1366-1373. http://dx.doi.org/10.1111/j.1440-1746.2010.06370.x
[44]
Monash University Website. http://www.med.monash.edu/cecs/gastro/fodmap/diet-updates/
