Celiachia a 360°: dalla Medicina alle Scienze Sociali

e alla Tecnologia Alimentare Firenze, Palazzo dei Congressi

29-31 Marzo 2012

Sessione B, Sabato 31 Marzo 2012

Celiachia: oltre la Sicurezza Alimentare, Ristorazione fuori Casa e Qualità

Aspetti Metabolici dell’Alimentazione senza Glutine

Umberto VoltaResp. SSO Malattia Celiaca

Dipartimento di Malattie dell’Apparato Digerente e Medicina Interna, Azienda Ospedaliero-Universitaria , Bologna

Gluten-free diet is the only effectivetreatment for coeliac disease

▲Disappearance of intestinal and extra-intestinal symptoms▲Normalization of duodenal histology ▲Antibody disappearance▲Prevention of auto-immune disorders ▲Protection against complication (refractory CD, intestinal lymphoma)

LIGHTS SHADES

▲Minerals and vitamins deficiency▲Psychological problems▲Metabolic Abnorm.▲Increased cardiovascular risk

Gluten-free Diet (GFD)

• Gluten proteins do not have a high biological value since they do not contain some essential amino acids. The exclusion of gluten-containing foods from the diet does not represent a problem from a nutritional point of view.

• However, GFD can be responsible of psychologycal and social problems considering the relevant role of cereals and gluten-containing foods in our alimentary life-style and culture

• A life-long strict GFD implies a positive awareness of a radical life-style change with a careful participation in the choices of the new alimentary regimen for a correct and balanced nutrition

Nutritional deficiencies in coeliac disease

B1

B2

B6

B12

Folic acid

Other Vitamins

B12

Folic acid

B1, B2

Folic acid

B1, B2, B6

B12

Folic acid

Zn

Mg

Vitamin D

Calcium

Iron

Fiber

Proteins

Long-term GFD (8-12 anni)b

Gluten-free productsa

GFDaAt diagnosisa

a: Thomson et al 2000; b: Hallert et al 2002

Nutritional intake in young coeliac disease (CD) patients with a strict compliance with GFD

• Young CD patients with a strict compliance with GFDoften showed an inadequate nutritional intake

• Fiber and iron intakes were significantly lower and thesaturated fat intake was significantly higher thanrecommended but comparable with the general population

• Better medical and dietary support is necessary to preventlong-term complications and to achieve an ongoingsatisfying management in the group of young patients withCD

Hopman E et al, JPGN 2006

as low as possible

Gluten-free diet and metabolic abnormalities

� In coeliac disease on a GFDclinical experience andliterature data showthat a number of patients tend tooverweight up to obesity

� The development of overweight can be explained by thenormalization of intestinal absorption due to the regrowthof duodenal villi and to the high content of lipids of somedietary commercial products

Kupper C, Gastroenterology 2005

High fat content of gluten-free commercial products

• Bread substitutes (slice toasted, crackers, breadsticks)4 fat content from 1.5% a 20%4 caloric intake from 353 a 466 kcal per 100 grams4 rarely reported fat saturated content4 most of products contain “oils and/or

vegetable margarines”

• Sweets, biscuits/wafers and snacks4 fat content from 5% to 30%4 caloric intake from 300 to 550 kcal per 100 grams4 most of products contain “oils and/or vegetables

margarines (oils of palm/coconut palm)”

The Gluten -Free Diet (GFD): a Nutritional Risk Factor for

Adolescents with Celiac Disease?

Mariani P., J Pediatric Gastroenterol Nutr 1998

1. Adolescent celiacs in GFD usually had a highdietary intake in fat and proteins and a poor intake incarbohydrates.

2. The prevalence of overweight and obesity washigher in adolescents celiacs following a strict GFDthan in those with a partial compliance with GFD andcontrols on a gluten containing diet.

How does feeding change by following a GFD regimen?

• Both children and adults on GFDchange their dietcomposition by a lower intake of carbohydrates and ahigher amount of fat and proteins in comparison with thegeneral population:�The intake of gluten-free dietary bread substitutes such

as thin breadsticks and snacks with a high fat contentof poor quality is usually high in celiacs

�Gluten-free bread, pasta and pizza are less appetizingthan the same gluten-containing foods and for thisreason their intake is usually lower in celiacscontributing to the lowintake of carbohydrates

�Celiacs tend to eat more meat, eggs, milk and cheesewith a higher intake of proteins compared with the nonceliac general population

1. Mariani P, J Pediatr Gastroenterol Nutr; 2. Bardella MT, Am J Clin Nutr 2000

Why do celiacs increase their weight after starting GFD?

� Nutrient absorption improves following the normalizationof small intestinal mucosa.

� Coeliacs reach satiety sensation after a higher caloric intakedue to the reduced fiber content of GFD.

� Coeliacs do not increase their caloric consumption keepingunchanged their physical activity.

� A bad choice of gluten-free commercial foods can cause asignificant increase of fat and caloric intake, i.e. thereplacement of bread with thin breadsticks or salt snacksdo increase fat content from2 to 10-14 g and the caloriccontent of 90 kcal per 100 g of the product.

� Rarely celiacs are advised to make more frequent theirphysical activity taking in account of the newalimentaryregimen.

Total caloric intake: division in macronutrients, and iron, calciumand fiber intakes of adolescents with celiac disease and control

subjects compared with reference values

Mariani P, et al. JPGN 1998

Total number of consumptions and daily frequency of consumption for each kind of food by patients with celiac disease consuming a gluten-free diet (group 1A) and in those consuming

a gluten-containing diet (group 1B)

Mariani P, et al JPGN 1998

Mean age at diagnosis 6 yrs, follow-up 4 yrs:after GFD overweight

percentage doubled (from 11% to 21%) P=0.03

0

10

20

30

40

50

60

70

80

90

low weight normal overweight obesity

Body Mass Index (BMI) (kg/m2) in 240 (F/M 3:1) coeliacs at onset and 1 year after GFD

Coeliac Disease Unit, St.Orsola-Malpighi HospitalUniversity of Bologna (Resp. Prof. U. Volta)

BMI<18.5

%

BMI18.5-24.9

BMI25.0-29.9

BMI>30.0

CD onset

1 year GFD

15% overweight or with obesity after

1 year of GFD

05

101520253035404550

cholesterol tryglic. glucose

Metabolic abnormalities in 240 consecutive coeliacs at onset and 1 year after GFD

Coeliac Disease Unit St.Orsola-Malpighi HospitalUniversity of Bologna (Resp. Prof. U. Volta)

%

CD onset

GFD 1 year

↑↑↑↑ ↑↑↑↑ ↑↑↑↑

0

5

10

15

20

25

30

35

40

atdiagnosis

6 monthsof GFD

24 monthsof GFD

Prevalence of hypertransaminasaemia in 240 coeliac patients at diagnosis anf after 6 and 24 months of GFD

Coeliac Disease Unit, St. Orsola-Malpighi HospitalUniversity of Bologna (Resp. U. Volta)

%

(ultrasound consistent with liver steatosis)

GUIDELINES FOR THE DIAGNOSIS AND

FOLLOW -UP OF COELIAC DISEASEby

National Scientific Committee of the Italian Association of Coeliac Disease

(CSN A.I.C)U. Volta (coordinator), A. Calabrò, C. Catassi, I. De Vitis, P.

Lionetti, S. Martelossi, A. Picarelli, R. Troncone

in cooperation with the Italian Health Ministery

(published in the Official Gazette of the Italian Republic on February 7th 2008)

Follow-up GuidelinesIndications for monitoring

(Official Gazette of Italian Republic February 7th, 2008)

� Verification of the compliance with thediet

� Development of autoimmune disorders� Metabolic alterations� Neoplastic (lymphoma) and non-

neoplastic (refractory coeliac disease,ulcerative jejunum ileitis, collagenoussprue) complications

Follow-up of coeliac disease(Official Gazette of Italian Republic, February 7th 2008)

First evaluation 6 months after the diagnosis andthen yearly by means of:

• Medical examination and dietary interview• Blood absorption tests (ferritin, blood count

and other routine tests)• tTGA of IgA class (IgGclass if IgAdeficiency)TSH, anti-TPO, anti-TG

• Metabolic tests (cholesterol, HDL, tryglicerides,glucose, transaminases)

Metabolic abnormalities in coeliac disease (CD) after gluten-free diet (GFD)

CSN-AIC investigation in 109 CD Centers

109 CD Centers55 Pediatric

54 Adult

Overweight orobesity

5% childhood CD15% adult CD

↑Cholesterol5% childhood CD

15% adult CD

Availability of dieticians in 50%

of CD centers

Celiachia Notizie 2006

Glycaemic index (GI) of GF foods

Food Calculated GI

White bread 100

GF biscuit 83 ± 14

GF pasta 77 ± 18

GF white bread 114 ± 21

GF fibre bread 109 ± 13

Food Calculated GI

White bread 100

GF biscuit NT

GF pasta 255

GF white bread 230

GF fibre bread NT

Packer SC, Diabet Med 2000 Berti C, Eur J Nutr 2004

In general GI of GF products seems to be slightly higherthan that of the corresponding gluten-containing foods

Total intake of gluten-free products in European countries

Gibert A, EJGH 2006

1. PA: Hypertension

2. COL: ↑↑↑↑ Cholesterol

3. FA: Atrial fibrillation

4. IMA: Acute myocardial infarction

5. Ictus

Data collected from the “General Practice Research Database” (8.000.000 patients followed by GP in UK): 3590 pts with coeliac disea ses and 17925 controls

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

PA COL FA IMA ICTUS

HR

Advantages of naturally gluten free cereals for coeliac diet

Rice

Corn

Buckwheat

Teef

Millet

Soy

1. High content of vitamins, mineral salts and fiber

2. Prevention of metabolic abnormalities induced by gluten-free commercial products

3. By-pass of the possible (even very rare) wheat allergy in celiac patients

Lee AR, J Hum Nutr Diet 2009

Corn flour

carbohydrates

proteins

lipids

Farina di frumento (Triticum aestivum)

carbohydrates

proteins

lipids

Edibile part (%) 100H2O (g) 12.5Proteins (g) 8.7Lipids (g) 2.7Carbohydrates 80.8Kcal. 362.0

Edible part (%) 100H2O (g) 14.2Proteins (g) 11.5Lipids (g) 1.0Carbohydrates 76.2Kcal. 341,0

Caloric value and chemical composition of corn vs wheat flour

Comparison between various cereals suitable for celiacs: Chemical compositionper 100 grams of edible part

Corn Rice Buckwheat

Proteins(g) 8.7 7.3 12.4

Lipids(g) 2.7 0.5 3.3

Carbohydrates 80.8 87.0 62.5

Starch(g) 72.1 79.1 0

Fiber(g) 3.1 1.0 6.0

Vitamin A(µg) 67.0 0 0

Kcal. 362 360 314

Functional symptoms of gastro-enteric tract linked to ingestion of gluten-free commercial products

• Functional symptoms (vomiting, bloating, alterations ofbowel habits) are attributable to the presence ofpreservatives and additives in gluten-free commercialproducts.

• Patients complaining of these symptoms have benefitfrom the replacement of gluten-free commercial productswith naturally gluten-free cereals such as corn, rice,buckwheat, teef (decrease of symptoms from61% to17%)

Hopman E, Scand J Gastroenterol 2008

Alimentary Educational Course for Coeliac Disease Coeliac Disease Unit, St.Orsola-Malpighi Hospital University of Bologna

� Detailed information on GFD � Cereals and flours to be avoided and allowed� Guidelines on the correct alimentary approach � Nutritional aspects (intake of iron, calcium, vitamin D, vitamin B

group, fiber)� To read and understand food labels, cross-contamination of foods,

cuisine recipes� To eat gluten-free at restaurants and during travels � Commercially available gluten-free products

� General principles on the healthy food intake� Caloric balance – Weight monitoring – Nutritional principles� Food pyramid � Labels of food

� Physical activity and energetic balance� GFD and psycho-social aspects

Use sparingly fats, oils and sweets

2-3 servings of milk, yogurt and cheese; 2-3 servings of meat, poultry, dry beans, eggs and nuts group

3-5 servings of vegetables and 2-4 of fruit

At least 6 servings of carbohydrates (gluten-free bread and pasta, rice, corn, buckwheat, soy)

Food Pyramid for People with Coeliac Disease

Nutritional plan for celiacs

� Diet does not take into account only the absence of gluten

� It must be highlighted the importance of caloric content, fiber intake, fat and characteristics of fat used

� Celiacs must be informed on nutritional content of gluten-free commercial foods and on the importance of checking the labels of gluten-free foods

� Celiacs must acquire the capacity to make appropriate alimentary choices.

� It must be stressed the important role of physical activity for maintaining a good state of health.

� Alimentary Educational Program is the best way for making the celiacs able of performing autonomously appropriate choices for their alimentation.

What must celiacs check on labels of gluten free commercial products?

� Caloric content

� Fat content

� Kind of fat � saturated/unsaturated

� absence of hydrogenate fat

� “fat/vegetable oils” (palm and coconut palm oils, which are vegetable oils of poor quality at high content of saturated fat)

� Vegetable margarines

� Fiber content

� Preservatives/additives

Regulations CE 41/2009 on commercial products for people with gluten intolerance

(in force from January 1st 2012)

Kind of products

Gluten <20ppm

Gluten 21-100 ppm

Gluten >100ppm

Dietetic

products

Very low

gluten content

Not allowed

for celiacs

Products for all people

Without

gluten It may contain traces of

gluten

EU Regulations on labelling of commercial products n.1169/2011, November 22, 2011

Nutritional labelling with detailed information (to be app liedwithin 5 years) : from the Big 4 (energy –Kcal-, proteins,carbohydrates, fat) to the Big 8 (energy –Kcal-, proteins,carbohydrates, sugars, fat, saturated fat, fiber, sodium)

The commitment of gluten free manufacturers

for celiacs’ information

• In order to help celiacs to make healthier choices in thefood they eat, gluten-free food manufacturers are applyingnutritional information (the “Big 8”) on the packaging oftheir food products included in list of gluten-freecommercial products

• Moreover, manufacturers are trying to increase the offerand the nutritional and palatable quality of gluten-freecommercial products, useful tools for increasing thecompliance with GFDand a lifelong good health of celiacsthrough a safe alimentation

Take home message• A number of coeliac patients on a strict GFD tend to develop

overweight and obesity due to an excessive intake of some gluten freeproducts at high lipid content.

• Metabolic abnormalities (↑ cholesterol,↑ triglycerides,↑ glucose,↑transaminases) are observed in this subgroup of coeliac patients. Acareful follow-up of these patients is mandatory.

• To prevent the development of metabolic syndrome in CD pts aneducational program with detailed information on the composition ofgluten-free commercial foods, general principles of the healthy foodintake, physical activity and energetic balance, and psycho-socialaspects (excessive fear of contamination resulting in exclusive intakeof gluten-free commercials products) is recommended.

• EU regulations on nutritional labelling of commercial products andthe increased commitment of gluten-free manufacturers will guaranteea better quality of commercial products for coeliac patients in nextyears.