A gluten-free diet for asymptomatic patients with coeliac disease

The tip of the iceberg? @ Wikipedia 

Today I'd like to focus on the paper by Kalle Kurppa and colleagues [1] and their suggestion that: "GFDs [gluten-free diets] benefit asymptomatic EMA-positive [endomysial antibody] patients" with coeliac (celiac) disease in mind.

Asymptomatic, when it comes to a condition like coeliac disease (CD) - an autoimmune condition linked to the consumption of gluten - is not necessarily all that surprising given the numbers of cases where the words 'clinically silent' are used [2]. Indeed, the term 'coeliac iceberg' [3] is something I remember from my very earliest reading about CD reflective of the quite large numbers of people walking around with the serological and/or histopathological markers of the condition yet not seemingly experiencing the more classical signs of the disease or at least not severe enough to seek medical advice.

The Kurppa paper concluded that even in those cases where clinically silent is a feature of someones CD, the adoption of a gluten-free diet should still be considered. If anything because outside of changes (improvements) to the serological marker measures and any gastrointestinal (GI) symptoms: "The GFD group also had reduced indigestion (P=.006), reflux (P=.05), and anxiety (P=.025), and better health, based on the visual analog scale (P=.017), than the gluten-containing diet group".

Reduced anxiety eh? Well, obviously I don't want to make too much of a meal of this one even though that previous Catassi 'iceberg' study [3] talked about "decreased psychophysical well-being" as being part and parcel of "low-grade intensity illness". What I will however draw to your attention are two potentially important things:

The possible 'autism' connection. 
I doubt that readers will remember my post a while back on the paper by Jonas Ludvigsson and colleagues [4] talking about a sort of not-quite-coeliac-disease condition seemingly present in some children diagnosed with an autism spectrum disorder (ASD). Ludvigsson et al concluded that: "there was a markedly increased risk of ASDs in individuals with normal mucosa but a positive CD serologic test result". Ergo, not coeliac disease (CD) but something perhaps along the lines of a non-coeliac gluten sensitivity (NCGS). Tagged on to the the paper by Giacomo Caio [5] (open-access here), I'm wondering whether the Kurppa results might indeed hold some research promise when applied to at least some diagnosed as being on the autism spectrum perhaps with those CD serological markers? Particularly given that something like anxiety, when it occurs comorbid, can be absolutely disabling for some on the autism spectrum (see here) alongside other mention of a possible link between things like anxiety and GI issues with autism in mind (see here). Just thinkin' out loud.

Gluten exposure and feelings of depression?
The paper by Simone Peters and colleagues [6] talked about in another post (see here) might also fit with some of the Kurppa findings. I know I'm probably stretching things a little bit here but the Peters finding of that gluten ingestion "induced current feelings of depression" specifically in cases of "self-reported non-coeliac gluten sensitivity (NCGS)" may be related. Again with the speculating machine in full operation, I do wonder if the relationship between psychological health and wellbeing seemingly linked to CD or NCGS might hint at some shared mechanisms between the two states?

As per my blogging caveats - no medical or clinical advice given or intended - I'm not suggesting anything above and beyond what the Kurppa findings reported. There are also quite a few other potential explanations for the results they got insofar as not just what was excluded from the diet (gluten) but what might have also been added to the diet too also affecting health and wellbeing [7]. What I would perhaps champion however is a research agenda further tuned to the potential role that gluten may have on psychological health and wellbeing bearing in mind what gluten-free might have to cover [8]. As per the review paper by Genuis & Lobo [9] talked about in a previous post (see here), whether this important foodstuff might have much more to answer for than just CD. Oh, and then there are the results from Volta and colleagues [10] to also consider...

Music to close. Don't you worry child...

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[1] Kurppa K. et al. Benefits of a Gluten-free diet for Asymptomatic Patients with Serologic Markers of Celiac Disease. Gastroenterology. 2014 May 13. pii: S0016-5085(14)00609-X.

[2] Tursi A. et al. Prevalence and clinical presentation of subclinical/silent celiac disease in adults: an analysis on a 12-year observation. Hepatogastroenterology. 2001 Mar-Apr;48(38):462-4.

[3] Catassi C. et al. The coeliac iceberg in Italy. A multicentre antigliadin antibodies screening for coeliac disease in school-age subjects. Acta Paediatr Suppl. 1996 May;412:29-35.

[4] Ludvigsson JF. et al. A nationwide study of the association between celiac disease and the risk of autistic spectrum disorders. JAMA Psychiatry. 2013 Nov;70(11):1224-30.

[5] Caio G. et al. Effect of gluten free diet on immune response to gliadin in patients with non-celiac gluten sensitivity. BMC Gastroenterol. 2014 Feb 13;14:26.

[6] Peters SL. et al. Randomised clinical trial: gluten may cause depression in subjects with non-coeliac gluten sensitivity - an exploratory clinical study. Aliment Pharmacol Ther. 2014 May;39(10):1104-12.

[7] Gautam M. et al. Role of antioxidants in generalised anxiety disorder and depression. Indian J Psychiatry. 2012 Jul;54(3):244-7.

[8] Sjöberg V. et al. Noncontaminated dietary oats may hamper normalization of the intestinal immune status in childhood celiac disease. Clin Transl Gastroenterol. 2014 Jun 26;5:e58.

[9] Genuis SJ. & Lobo RA. Gluten Sensitivity Presenting as a Neuropsychiatric Disorder. Gastroenterol Res Pract. 2014;2014:293206.

[10] Volta U. et al. An Italian prospective multicenter survey on patients suspected of having non-celiac gluten sensitivity. BMC Medicine 2014, 12:85

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Kurppa K, Paavola A, Collin P, Sievänen H, Laurila K, Huhtala H, Päivi Saavalainen, Mäki M, & Kaukinen K (2014). Benefits of a Gluten-free diet for Asymptomatic Patients with Serologic Markers of Celiac Disease. Gastroenterology PMID: 24837306