Celiac Disease (CD) continues to require a strict lifetime gluten-free diet (GFD) to maintain healthy status. Many studies have assessed the GFD nutritional adequacy in their cohorts, but an overall picture in adults and children would offer a lifetime vision to identify actionable areas of change. We aimed at assessing the nutrient intakes of adult and pediatric CD patients following a GFD diet and identifying potential areas of improvement. Systematic review was carried out across PubMed, Scopus and Scholar up to October 2022, including full-text studies that assessed the nutrient intakes of CD patients on GFD, in terms of macro- and/or micronutrients (absolute or percentage daily average). Random-effect meta-analysis and univariable meta-regression were applied to obtain pooled estimates for proportions and influencing variables on the outcome, respectively. Thirty-eight studies with a total of 2114 patients were included. Overall, the daily energy intake was 1995 (CI 1884–2106) Kcal with 47.8% (CI 45.7–49.8%) from carbohydrates, 15.5% (CI 14.8–16.2%) from proteins, and 35.8% (CI 34.5–37.0%) from fats. Of total fats, 13.2% (CI 12.4–14.0%) were saturated fats. Teenagers had the highest consumption of fats (94.9, CI 54.8–134.9 g/day), and adults presented insufficient dietary fiber intake (18.9 g, CI 16.5–21.4 g). Calcium, magnesium, and iron intakes were particularly insufficient in adolescence, whereas vitamin D was insufficient in all age groups. In conclusion, GFD may expose CD patients to high fat and low essential micronutrient intakes. Given GFD is a lifelong therapy, to prevent the occurrence of diseases (e.g. cardiovascular or bone disorders) dietary intakes need to be assessed on long-term follow-ups.
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Caio G, Volta U, Sapone A, Leffler DA, Catassi C, Fasano A. Coeliac disease: a comprehensive current review. BMC Med. 2019;17. https://doi.org/10.1186/s12916-019-1380-z.
Vasagar B, Cox J, Herion JT, Ivanoff E. World epidemiology of non-coeliac gluten sensitivity. Minerva Gastroenterol Dietol. 2017;63:5–15. https://doi.org/10.23736/s1121-421x.16.02338-z.
Vici G, Belli L, Biondi M, Polzonetti V. Gluten free diet and nutrient deficiencies: a review. Clin Nutr. 2016;35:1236–41. https://doi.org/10.1016/j.clnu.2016.05.002.
Melini V, Melini F. Gluten-free diet: gaps and needs for a healthier diet. Nutrients. 2019;11. https://doi.org/10.3390/nu11010170.
Martin J, Geisel T, Maresch C, Krieger K, Stein J. Inadequate nutrient intake in patients with coeliac disease: results from a German dietary survey. Digestion. 2013;87:240–6. https://doi.org/10.1159/000348850.
Shepherd SJ, Gibson PR. Nutritional inadequacies of the gluten-free diet in both recently-diagnosed and long-term patients with coeliac disease. J Hum Nutr Diet J Br Diet Assoc. 2013;26:349–58. https://doi.org/10.1111/jhn.12018.
Wild D, Robins GG, Burley VJ, Howdle PD. Evidence of high sugar intake, and low fibre and mineral intake, in the gluten-free diet. Aliment Pharm Ther. 2010;32:573–81. https://doi.org/10.1111/j.1365-2036.2010.04386.x.
Jones AL. The gluten-free diet: fad or necessity? Diabetes Spectr Publ Am Diabetes Assoc. 2017;30:118–23. https://doi.org/10.2337/ds16-0022.
Niland B, Cash BD. Health benefits and adverse effects of a gluten-free diet in non–coeliac disease patients. Gastroenterol Hepatol. 2018;14:82–91.
Potter MDE, Brienesse SC, Walker MM, Boyle A, Talley NJ. Effect of the gluten-free diet on cardiovascular risk factors in patients with coeliac disease: a systematic review. J Gastroenterol Hepatol. 2018;33:781–91. https://doi.org/10.1111/jgh.14039.
Moher D, Liberati A, Tetzlaff J, Altam DG,PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264–9, W64.
Wells G, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2011; http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
EFSA (European Food Safety Authority). Dietary reference values for nutrients summary report 2017—EFSA Supporting Publications-Wiley Online Library. 2017;e1521:98 pp. https://doi.org/10.2903/sp.efsa.2017.e15121.
U.S. Dept of Agricoltureand U.S. Dept of Health and Human Services. Dietary guidelines for Americans, 2020-2025 and online materials|Dietary Guidelines for Americans. https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials.
R Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2020.
Viechtbauer W. Conducting meta-analyses in R with the metafor Package. J Stat Softw. 2010;36:1–48. https://doi.org/10.18637/jss.v036.i03.
Larretxi I, Simon E, Benjumea L, Miranda J, Bustamante MA, Lasa A, et al. Gluten-free-rendered products contribute to imbalanced diets in children and adolescents with coeliac disease. Eur J Nutr. 2019;58:775–83. https://doi.org/10.1007/s00394-018-1685-2.
Van Rossum C, Fransen H, Verkaik-Kloosterman J, Buurma-Rethans EJM, Ocke MC. Dutch National Food Consumption Survey 2007-2010: diet of children and adults aged 7 to 69 years. RIVM Rapp. 2011;350050006:148.
Babio N, Alcázar M, Castillejo G, Recasens M, Martínez-Cerezo F, Gutiérrez-Pensado V, et al. Patients with coeliac disease reported higher consumption of added sugar and total fat than healthy individuals. J Pediatr Gastroenterol Nutr. 2017;64:63–9. https://doi.org/10.1097/MPG.0000000000001251.
Ballestero Fernández C, Varela-Moreiras G, Úbeda N, Alonso-Aperte E. Nutritional status in Spanish children and adolescents with coeliac disease on a gluten free diet compared to non-coeliac disease controls. Nutrients. 2019;11. https://doi.org/10.3390/nu11102329.
Daniels SR, Pratt CA, Hayman LL. Reduction of risk for cardiovascular disease in children and adolescents. Circulation. 2011;124:1673–86. https://doi.org/10.1161/CIRCULATIONAHA.110.016170.
McFarlane XA, Marsham J, Reeves D, Bhalla AK, Robertson DAF. Subclinical nutritional deficiency in treated coeliac disease and nutritional content of the gluten free diet. J Hum Nutr Diet. 1995;8:231–7. https://doi.org/10.1111/j.1365-277X.1995.tb00316.x.
Quarpong W, Card TR, West J, Solaymani-Dodaran M, Logan RFA, Grainge MJ. Mortality in people with coeliac disease: long-term follow-up from a Scottish cohort. UEGJ. 2019;7:377–87. https://doi.org/10.1177/2050640618814662.
Grzymisławska M, Puch E, Zawada A, Grzymisławski M. Do nutritional behaviors depend on biological sex and cultural gender? Adv Clin Exp Med. 2020;29:165–72. https://doi.org/10.17219/acem/111817.
Kautto E, Rydén PJ, Ivarsson A, Olsson C, Norström F, Högberg L, et al. What happens to food choices when a gluten-free diet is required? A prospective longitudinal population-based study among Swedish adolescent with coeliac disease and their peers. J Nutr Sci. 2014;3:e2. https://doi.org/10.1017/jns.2013.24.
Cardo A, Churruca I, Lasa A, Navarro V, Vázquez-Polo M, Perez-Junkera G, et al. Nutritional imbalances in adult celiac patients following a gluten-free diet. Nutrients. 2021;13:2877. https://doi.org/10.3390/nu13082877.
Di Nardo G, Villa MP, Conti L, Ranucci G, Pacchiarotti C, Principessa L, et al. Nutritional deficiencies in children with celiac disease resulting from a gluten-free diet: a systematic review. Nutrients. 2019;11:1588. https://doi.org/10.3390/nu11071588.
Caeiro C, Pragosa C, Carreira Cruz M, Pereira CD, Gonçalves Pereira S. The role of pseudocereals in celiac disease: reducing nutritional deficiencies to improve well-being and health. J Nutr Metab. 2022. https://doi.org/10.1155/2022/8502169.
WW Jamieson JA, Gill K, Fisher S, English M. Development of a Canadian food composition database of gluten-free products. Foods. 2022;11:2215. https://doi.org/10.3390/foods11152215.
Macêdo MIP, Albuquerque MDFM, Tahan S, de MoraisIs MB. Is there any association between overweight, physical activity, fat and fiber intake with functional constipation in adolescents? Scand J Gastroenterol. 2020;55:414–20. https://doi.org/10.1080/00365521.2020.1749878.
Slavin JL. Position of the American Dietetic Association: health implications of dietary fiber. J Am Diet Assoc. 2008;108:1716–31. https://doi.org/10.1016/j.jada.2008.08.007.
Bailey ADL, Fulgoni III VL, Shah N, Patterson AC, Gutierrez-Orozco F, Mathews RS, et al. Nutrient intake adequacy from food and beverage intake of US children aged 1-6 years from NHANES 2001-2016. Nutrients. 2021;13. https://doi.org/10.3390/nu13030827.
U.S. Dept of Agriculture - Economic Research Service. Food Availability and consumption Data System. 2012. https://www.ers.usda.gov/data-products/food-availability-per-capita-data-system/.
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Gessaroli, M., Frazzoni, L., Sikandar, U. et al. Nutrient intakes in adult and pediatric coeliac disease patients on gluten-free diet: a systematic review and meta-analysis. Eur J Clin Nutr (2023). https://doi.org/10.1038/s41430-023-01280-0