Subclinical nutritional deficiency in treated coeliac disease and nutritional content of the gluten free diet

Abstract

Patients with coeliac disease are started on a gluten free diet at the time of diagnosis, but after a varying period of follow-up are often discharged from outpatient and dietary follow-up. We have studied the nutritional status and dietary intake of 54 patients with treated coeliac disease diagnosed in adult life.Each patient was paired with a healthy age and sex matched control. There was no difference in height in patients compared to controls, but a greater proportion of patients (15%) than controls (4%) had weight below the UK population lower 5th percentile (xz test P< 0.05). Triceps skinfold thickness was 102% of age and sex matched mean reference values, but mid-arm circumference and arm muscle circumference were below reference mean values (93.1% and 91.5% of reference values, respectively). Haemoglobin, mean corpuscular volume, red cell folate and 25 hydroxyvitamin D were all in the normal range.A strict gluten free diet was followed by 78% of patients; 22% had occasional gluten intake. Seventy-four per cent considered that they had reduced their intake of bread since commencing a gluten free diet. In 48% of patients, average daily intake of energy was less than the estimated average requirement, and in more than one-third of patients the intake of iron, copper, magnesium, retinol and folic acid was less than the relevant reference nutrient intake (RNI). In more than 10% of patients, average daily intake of calcium, zinc or vitamin Bs was less than the RNI. Vitamin D intake was lower than the RNI in four of five patients older than 65 years.

A dietary survey to determine if patients with coeliac disease are meeting current healthy eating guidelines and how their diet compares to that of the British general population

“…This survey has highlighted the potential nutritional inadequacies in the GFD that may be contributing to the nutritional deficiencies that have been identified in patients with CD in previous studies (Bode et al, 1991;Varkonyi et al, 1992;McFarlane et al, 1995;Thompson, 1997Thompson, , 2000Grehn et al, 2001;Hallert et al, 2002). These nutritional inadequacies could be increasing patient's risk of osteomalacia, osteoporosis and bowel problems.…”

“…It fulfils the need for a more up-to-date assessment of the dietary intake of patients with CD. Only one other survey has compared the intake of this group to the general British population (McFarlane et al, 1995).…”

“…A good clinical response is usually seen with the GFD; however, a number of authors have reported evidence of persisting nutritional deficiencies (Bardella et al, 1985;Collins et al, 1986;Bode et al, 1991;Varkonyi et al, 1992;McFarlane et al, 1995;Thompson, 1997Thompson, , 2000Grehn et al, 2001;Hallert et al, 2002). Often the continued ingestion of small amounts of gluten is held responsible for this.…”

“…Little research has been carried out on the nutritional adequacy of the GFD in terms of macronutrients, and authors have arrived at conflicting results (Table 1) (Bjorkman et al, 1985;Collins et al, 1986;Kemppainen et al, 1995;McFarlane et al, 1995;Bardella et al, 2000;Capristo et al, 2000;Grehn et al, 2001). Bjorkman et al (1985) and Bardella et al (2000) found that the GFD resulted in a significant decrease in mean energy intake and significantly lower total daily intake of energy than controls, whereas Kemppainen et al (1995) found intakes of energy were significantly greater in patients with CD compared to the controls (Po0.05).…”

“…Since the study by McFarlane et al (1995) was published, the variety of GFP has increased, palatability has improved and products have become more widely available in supermarkets, health food shops and over the Internet. More prescription products are being fortified with iron, calcium and non-starch polysaccharide (NSP).…”