Unnecessary gluten-free diets can endanger children

Unnecessary gluten-free diets can endanger children

A comprehensive pediatric nutrition study shows why the gluten-free diet is life-saving for some children but poses a potential health risk for others when introduced without medical guidance.

Study: Gluten-Related Dietary Problems in Pediatric Subjects: Treatment and Beyond. Photo credit: aleksandr talancev/Shutterstock.com

A recent review in the magazineLimits in nutritionaddresses the treatment of these disorders in children with a focus on holistic health, including growth, neurological development, metabolic health and psychosocial well-being. Gluten-related diseases such as celiac disease (celiac disease) may require a lifelong avoidance of gluten or even wheat, but at the expense of nutritional imbalance and other health risks.

introduction

Gluten-free diets are becoming increasingly popular among the general population and are often followed without clear medical guidance, for example when a gluten-related disorder has been diagnosed.

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 signaling pathways and have different diagnostic features, requiring different treatment approaches.

For all three conditions, a gluten-free diet represents the primary dietary approach to treatment. In such cases, convenience often requires the use of processed foods that are gluten-free. These are usually high in calories and increase cardiometabolic risk. It is also likely that they are deficient in essential nutrients.

Due to all of these factors, children on a gluten-free diet may experience abnormal growth and neurological development. Similar risks exist for people who eat a gluten-free diet unnecessarily. The current study examined the differences between the three conditions while also examining the possible adverse effects of a gluten-free diet.

Celiac disease

Celiac disease affects approximately 1% of the world's population. The current rising rates could indicate better awareness and diagnostic tools, as well as a significant change in eating habits. However, for many people the diagnosis remains unrecognized.

The spectrum of CD ranges from silent or asymptomatic forms to classic intestinal symptoms (chronic diarrhea, bloating, abdominal pain, weight loss, constipation) or extraintestinal symptoms (short stature, growth disorders, iron deficiency anemia, osteoporosis, peripheral neuropathy, reproductive dysfunction). In addition, some people have type 1 diabetes, autoimmune thyroid disease, Down or Turner syndrome, or selective IgA deficiency. Many have a first-degree family history of celiac disease.

Celiac disease is an autoimmune disease caused by exposure to wheat, barley and rye, all of which contain gluten. In genetically predisposed individuals, the immune system responds to deamidated peptides released during gluten digestion. These peptides are presented to CD4 lymphocytes by HLA-DQ2 and HLA-DQ8 molecules. This leads to inflammation of the intestinal mucosa with atrophy of the villi.

Diagnosis is based on a combination of symptoms and blood tests, and an intestinal biopsy is also performed if necessary. All tests should be done while the person is still eating foods containing gluten. Symptomatic children with very high antibody levels confirmed on repeat testing may not require a biopsy. The absence of the HLA-DQ2 and DQ8 alleles virtually excludes celiac disease, but testing for this is not routinely performed.

Wheat allergy

WA is not an autoimmune disease, but a food allergy. It is caused by acute hypersensitivity caused by IgE reactivity to wheat antigens such as albumins, globulins, gliadins and glutenins. This leads to the activation of mast cells and basophils, which leads to the release of histamine and other inflammatory substances. However, in some cases non-IgE mechanisms may also be involved.

WA can occur 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 of IgE-mediated reactions may include nausea, vomiting, and abdominal pain, often accompanied by hives, angioedema, and, in severe cases, anaphylaxis.

A non-IgE-mediated wheat allergy manifests itself as delayed vomiting and diarrhea as well as abdominal pain. It is more common in children.

Diagnosis depends on medical history and skin tests such as prick test and serum-specific IgE tests. In cases of doubt, the oral food challenge test is a useful benchmark.

WA requires the exclusion of wheat. Other types of grain are generally tolerated, except in the case of cross-reactivity, and are excluded. Patient education is critical and emergency medications should always be on hand, especially for patients at risk of anaphylaxis.

Non-celiac gluten sensitivity

In NCGS, intestinal and extraintestinal symptoms associated with gluten sensitivity occur, but without autoimmune or IgE-mediated immunological features. It manifests as abdominal pain, bloating, diarrhea, and constipation, as well as fatigue, headache, brain fog, and myalgia. Without the characteristic features of WA or CD, it may resemble irritable bowel syndrome (IBS).

A gluten-free diet alleviates symptoms that recur upon reintroduction. Some NCGS patients can tolerate small amounts of gluten, unlike those with celiac disease.

NCGS is diagnosed on the basis of symptom improvement after gluten is removed from the diet, followed by recurrence of symptoms when gluten is reintroduced. However, it can be difficult to distinguish NCGS from irritable bowel syndrome because some patients with irritable bowel syndrome also report relief of symptoms on a gluten-free diet, highlighting the need for careful diagnostic evaluation.

Due to innate rather than adaptive immunity, NCGS responds to naturally occurring wheat proteins such as amylase-trypsin inhibitors (ATIs), which activate Toll-like receptor 4 (TLR4) and trigger intestinal inflammation. Fermentable sugars from the FODMAP group, particularly wheat fructans, could also play a role.

The gluten-free diet

A gluten-free diet is sometimes essential, but maintaining adequate nutrition can be difficult. When a gluten-free diet is not medically indicated, the quality of the diet is compromised.

Processed gluten-free foods may be deficient in protein and fiber but are still energy-dense and contain excessive saturated fat and sugar. Without fortification, there is the possibility of multiple nutrient deficiencies in minerals such as iron, calcium, magnesium and zinc; vitamins, including folic acid, B12 and D; and fiber as well as intestinal dysbiosis.

Some of these disadvantages can be mitigated by including several naturally gluten-free foods such as pseudograins, quinoa, buckwheat and amaranth, as well as legumes, fruits and vegetables. Fortified gluten-free foods should be preferred and nutritional monitoring is strongly recommended to minimize adverse cardiometabolic effects, particularly in children and adolescents with continued growth demands.

A gluten-free diet can help patients with celiac disease lose weight, but regularly consuming gluten-free snacks can lead to weight gain. Unnecessarily strict dietary control can trigger eating disorders (up to 9% in one study), with adolescents and women appearing to be at higher risk. Its symptoms are similar to those of CD, such as abdominal pain, vomiting, fatigue and weight loss. This may delay their diagnosis.

Conclusions

A gluten-free diet “can pose nutritional challenges, especially when followed without medical necessity.”

Healthcare providers must make the correct diagnosis, rule out similar illnesses and advise on a healthy diet. Careful long-term follow-up is essential to ensure 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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