A major pediatric nutrition review reveals why going gluten-free is lifesaving for some children, but a potential health risk for others when adopted without medical guidance.
Study: Gluten-related nutritional challenges in pediatric subjects: treatment and beyond. Image credit: aleksandr talancev/Shutterstock.com
A recent review in the journal Frontiers in Nutrition addresses the management of these conditions in children with an emphasis on holistic health, including growth, neurodevelopment, metabolic health, and psychosocial well-being. Gluten-related disorders like celiac disease (CD) may require lifelong avoidance of gluten, or even of wheat, but at the potential cost of nutritional imbalance and other health risks.
Introduction
Gluten-free diets have become increasingly popular among the general population, often adopted without clear medical guidance, such as a diagnosed gluten-related disorder.
Gluten-related disorders include sensitivity to gluten (celiac disease, CD), wheat allergy (WA), and non-celiac gluten sensitivity (NCGS). Despite significant overlap in their signs and symptoms, they involve different pathways and exhibit distinct diagnostic features, requiring different management approaches.
In all three conditions, a gluten-free diet represents the primary dietary approach to management. In such cases, convenience often dictates the use of processed foods that are gluten-free. These are usually calorie-dense, increasing cardiometabolic risk. They are also likely to be deficient in essential nutrients.
As a result of all these factors, children on a gluten-free diet may have abnormal growth and neurological development. Similar risks apply to individuals who unnecessarily adopt a gluten-free diet. The current study examined the distinctions between the three disorders while investigating the potential adverse effects of a gluten-free diet.
Celiac disease
CD affects about 1 % of the world’s population. Its current rising rates may indicate better awareness and diagnostic tools, as well as a marked change in eating habits. However, many people continue to go undiagnosed.
The spectrum of CD varies from silent or asymptomatic forms to classic gut symptoms (chronic diarrhea, bloating, abdominal pain, weight loss, constipation) or extraintestinal symptoms (short stature, stunted growth, iron deficiency anemia, osteoporosis, peripheral neuropathy, reproductive impairment). In addition, some individuals have type 1 diabetes, autoimmune thyroid disease, Down or Turner syndrome, or selective IgA deficiency. Many have a first-degree family history of CD.
CD is an autoimmune condition triggered by exposure to wheat, barley, and rye, all of which contain gluten. In genetically predisposed individuals, the immune system reacts to deamidated peptides released from gluten digestion. These peptides are presented to CD4 lymphocytes by HLA-DQ2 and HLA-DQ8 molecules. This induces inflammation of the intestinal mucosa, with atrophy of the villi.
Diagnosis is based on a combination of symptoms and blood tests, with an intestinal biopsy used when needed. All testing should be done while the person is still eating foods that contain gluten. In symptomatic children with very high antibody levels confirmed on repeat testing, a biopsy may not be required. The absence of the HLA-DQ2 and DQ8 alleles practically rules out CD, but tests for this are not routinely performed.
Wheat allergy
WA is not an autoimmune condition, but rather a food allergy. It is caused by acute hypersensitivity mediated by IgE reactivity to wheat antigens such as albumins, globulins, gliadins, and glutenins. This leads to the activation of mast cells and basophils, resulting in the release of histamine and other inflammatory substances. However, non-IgE mechanisms may also be involved in some cases.
WA can present in a variety of ways, including immediate allergic reactions, wheat-dependent exercise-induced anaphylaxis (WDEIA), occupational asthma or rhinitis (“baker’s asthma”), and hives. Gastrointestinal symptoms in IgE-mediated reactions may include nausea, vomiting, and abdominal pain, often accompanied by hives, angioedema, and, in severe cases, anaphylaxis.
Non-IgE-mediated wheat allergy manifests with delayed vomiting and diarrhea, and abdominal pain. It is more common in children.
Diagnosis depends on clinical history and skin tests, such as the skin prick test and serum-specific IgE tests. In doubtful cases, the oral food challenge test is a useful benchmark.
WA requires the exclusion of wheat. Other cereals are generally tolerated, except in cases of cross-reactivity, are excluded. Patient education is key, and rescue medication should always be on hand, particularly in those at risk of anaphylaxis.
Non-celiac gluten sensitivity
NCGS presents with gut and extraintestinal symptoms related to gluten sensitivity, but without autoimmune or IgE-mediated immunological features. It presents with abdominal pain, bloating, diarrhea, and constipation, as well as fatigue, headache, brain fog, and myalgia. Minus the characteristic features of either WA or CD, it may resemble irritable bowel syndrome (IBS).
A gluten-free diet relieves the symptoms, with recurrence on reintroduction. Some NCGS patients do tolerate small amounts of gluten, unlike those with CD.
NCGS is diagnosed based on symptom improvement after gluten is removed from the diet, followed by symptom recurrence when gluten is reintroduced. However, it can be difficult to distinguish NCGS from irritable bowel syndrome, as some patients with IBS also report symptom relief on a gluten-free diet, underscoring the need for careful diagnostic evaluation.
NCGS is traced to innate rather than adaptive immunity, reacting to naturally occurring wheat proteins, such as amylase-trypsin inhibitors (ATIs), which activate the toll-like receptor 4 (TLR4), triggering intestinal inflammation. Fermentable sugars in the FODMAP group, especially wheat fructans, may also play a role.
The gluten-free diet
A gluten-free diet is sometimes essential, but it can be challenging to maintain adequate nutrition. Dietary quality is lowered with a non-medically indicated gluten-free diet.
Processed gluten-free foods may be protein- and fiber-deficient, yet energy-dense, and contain excessive amounts of saturated fat and sugar. Without fortification, there is a potential for multiple nutritional deficiencies of minerals, such as iron, calcium, magnesium, and zinc; vitamins, including folate, B12, and D; and dietary fiber, as well as gut dysbiosis.
Some of these disadvantages may be mitigated by incorporating multiple naturally gluten-free foods, such as pseudocereals, quinoa, buckwheat, and amaranth, as well as legumes, fruits, and vegetables. Fortified gluten-free foods should be preferred, and dietary supervision is highly recommended to minimize adverse cardiometabolic effects, especially in children and adolescents with ongoing growth requirements.
A gluten-free diet may help patients with CD lose weight, but regular consumption of gluten-free snacks may increase it. Unnecessarily strict dietary control may trigger eating disorders (as high as 9 % in one study), with adolescents and females appearing to be at higher risk. Their symptoms resemble those of CD, such as abdominal pain, vomiting, tiredness, and weight loss. This may delay their diagnosis.
Conclusions
A gluten-free diet “may present nutritional challenges, particularly when followed without medical necessity.”
Healthcare providers need to make the correct diagnosis, exclude similar-appearing conditions, and advise on a healthy diet. Diligent long-term follow-up is essential to ensure that all necessary nutrients are present, to monitor metabolic and psychological well-being, while minimizing the nutritional and cardiometabolic risks associated with unnecessary or poorly balanced gluten-free diets.
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