A systematic literature review on the nutritional adequacy of a typical gluten-free diet with particular reference to iron, calcium, folate and B vitamins Dr G Robins Dr A Akobeng Ms N McGough Ms E Merrikin Ms E Kirk September 2008 1 Contents Page Number Glossary of terms 4-7 1.0 Executive Summary 1.1 Rationale 8 1.2 Aims and Objectives 9 1.3 Methodology 10 1.4 Results 10 1.5 Conclusion 11 1.6 Significance of findings 11 2.0 Introduction and Background 2.1 Epidemiology 12 2.2 Coeliac disease 12 2.2.1 Diagnosis 12 2.2.2 Complications 14 2.2.3 Associated conditions 16 2.2.4 Treatment: the gluten-free diet 17 2.2.5 Nutritional requirements in coeliac disease 19 2.3 Review of current literature 19 2.4 Rationale for research 21 2.5 Aims and Objectives 22 3.0 Methodology 3.1 Search process 23 3.1.1 Search for published studies 23 3.1.2 Hand searching 25 3.1.3 Identification of unpublished studies 26 3.1.4 Conclusion of search process 28 3.2 Summary of search 29 2 3.3 Inclusion and exclusion criteria 30 3.4 Data extraction 31 3.5 Data presentation 32 4.0 Results 4.1 Summary 32 5.0 Discussion 5.1 Study appraisal 33 5.1.1 Study type 33 5.1.2 Sample size 33 5.1.3 Sourcing 33 5.1.4 Confounding factors 34 5.1.5 Exclusion and inclusion criteria 35 5.1.6 Non participation 36 5.1.7 Measures 36 5.1.8 Overall methodological process of studies 36 5.2 Discussion of findings 36 5.3 Conclusions 40 5.4 Recommendations 5.4.1 For practice 40 5.4.2 For research 41 6.0 References 42 7.0 Appendices A Summary of search for published studies A1-5 B Number of articles appearing in journals A6 C Second search including search term ‘nutritional status’ A7-12 D List of key institutions and organisations contacted A13 E Papers included in the review A14 F Excluded papers A15-16 G Collation of data extraction tools A17-49 H Summary of Results A50 3 Glossary of Terms ACBS (ACBS): the Advisory Committee on Borderline Substances (ACBS) was set up to advise GPs on prescription of products that are not drugs or medical devices. The Committee is an advisory Non-Departmental Public Body (NDPB), non-statutory and UK-wide. The ACBS reviews information for applications for products to be prescribed at NHS expense. Adaptive immune system: A system of highly specialised, systemic cells and processes that eliminate or prevent potential disease causing agents. The adaptive immune response provides the immune system with the ability to recognise and remember specific pathogens and to mount repeated responses each time the pathogen is encountered. Addison’s disease: an autoimmune disease caused by inadequate secretion of corticosteroid hormones from the adrenal glands. Symptoms include weakness, loss of energy, low blood pressure, and dark pigmentation of the skin. The disease is treated with corticosteroid therapy. Ataxia: the shaky movements and unsteady gait that result from the brain’s failure to regulate the body’s posture and the strength and direction of limb movements. Autoimmune condition: a condition where the body’s own immune system attacks its own tissues. In coeliac disease the trigger for the autoimmune response is eating gluten, and as a result of this complex immune response the lining of the small bowel becomes damaged. Bias: is a term used to describe a tendency or preference towards a particular perspective or result, especially when the tendency interferes with the ability to be impartial or objective. Biopsy: the removal of a small piece of tissue for analysis. Bone mineral density: A measure that is used to assess the strength of bones. Coeliac UK: leading Charity working to improve the lives of those with coeliac disease and dermatitis herpetiformis. With 85,000 Members, it is the largest organisation of its type in the world. 4 Confounding factor: A variable which is related to one or more of the variables defined in a study. Confounding factors may mask an actual association or falsely demonstrate an apparent association between study variables, when in fact no real relationship exists. If confounding factors are not measured and considered, bias may result in the conclusion of the study. Endomysial antibodies: One of the antibody blood tests that is used in screening process for coeliac disease. Endosperm: is the nutritive tissue produced in the seeds of flowering plants. It surrounds the embryo and contains a mixture or starch, oils and protein. Epithelium: the lining issue that covers the external surface of hollow structures (in this instance the small bowel). Gastroenterologist: Specialist medical consultant working in the field of gastroenterology. Haemolytic anaemia: a type of anaemia resulting from the breakdown of red blood cells. Homocysteine: an amino acid. Raised levels of homocysteine in the blood can be associated with increased cardiovascular disease risk. Innate immune system: provides immediate defence against infection, and comprises cells and mechanisms that defend the host from infection by other organisms, in a non-specific way. The cells of the innate immune system recognise and respond to disease in a generic way, but do not confer long-lasting specific immunity. Infiltration: the abnormal entry of a substance into a cell or tissue. Lamina propria: thin layer of connective tissue found below the lining of the epithelium. LRNI (Lower Reference Nutrient Intake): the amount of a nutrient that is sufficient for only a small number of people who have low nutritional requirements (2.5%).The majority of the people in the population need more than the LRNI. 5 Malabsorption: when absorption of one or more substances and nutrients by the small intestine is reduced. Marsh Classification: an accepted categorisation of mucosal damage seen in coeliac disease. Neurological: describes medical conditions affecting the nervous system (brain, spinal cord and all peripheral nerves). Non-Hodgkin’s Lymphoma: a malignant tumour of the lymph nodes. Odds Ratio (OR): is a measure of a given association. A value of 1.0 means there is no relationship between the variables being studied. The size of a relationship is measured by the difference (either above or below) 1.0. An OR of less than 1.0 indicates a negative association, while an OR greater than 1.0 indicated a positive relation. Oesphageal cancer: cancer affecting the cells of the oesophagus (gullet/food pipe). Oropharyngeal cancer: oral cancer affecting the part of the pharynx (throat) containing the tonsils. Osteoporosis: loss of bone minerals (calcium) resulting in thin bones that are brittle and have an increase risk of fracture. Peptide: the building block of protein (a sequence of two or more amino acids). Primary Biliary Cirrhosis (PBC): an autoimmune disease resulting in disordered liver function tests where the bile ducts in the liver are attacked by the body's own immune system. Symptoms include extreme tiredness, poor appetite, nausea, diarrhoea, joint or bone pain. In some cases there are no symptoms. Peripheral neuropathy: disease of the peripheral nerves causing weakness and numbness in the hands and feet. Reference Nutrient Intake (RNI): the RNI is the amount of a nutrient that is enough to ensure that the nutritional needs of nearly all the population (97.5%) are being met. 6 Relative risk (RR) is the risk of developing a disease relative to exposure. Relative risk is a ratio of the probability of the disease developing in the exposed group versus a non-exposed group. Sensitivity: is a statistical measure of the reliability of a screening test based on the proportion of people with a specific test (the higher the sensitivity the fewer false negatives). Serological test: a test which is normally carried out on blood serum (the liquid component of blood). Specificity: measures the proportion of people free from a disease who react negatively to the test i.e. the higher the specificity the fewer the false positives. Sjogren’s syndrome: an autoimmune disease affecting the salivary and lacrimal glands resulting in dry mouth and eyes. Thyroid: an endocrine gland situated at the base of the neck which regulates the body’s metabolic rate. Tissue transglutaminase: an enzyme used in antibody blood test used to screen for coeliac disease. Type 1 diabetes: an autoimmune disease where islet cells in the pancreas stop producing insulin. Those with Type 1 diabetes need to have injections of insulin to control blood glucose levels. Villous atrophy: typical mucosal damage seen in coeliac disease. 7 1.0 Executive Summary 1.1 Rationale Coeliac disease (CD) is a life-long autoimmune condition affecting 1 percent of the population in the UK.1, 2 To date, the only effective treatment for CD is strict adherence to a gluten-free (GF) diet. A GF diet is restrictive as it involves eliminating wheat flour and its associated staple products including bread, pasta and cereals from the diet. Ranges of GF substitute foods have been developed based on GF cereals such as maize (corn) and rice. The GF diet can be made up in a variety of different ways, but generally incorporates GF substitute products e.g. GF breads and flours in place of standard products. In the UK, people with medically diagnosed CD may access some of their GF substitute foods on prescription. The foods on prescription are generally staples in the diet such as bread and pasta rather than foods which can be considered luxury items, such as confectionery. The GF foods that are prescribable are agreed by the Advisory Committee on Borderline Substances (ACBS). There is no specific evidence base that compares the nutritional composition of GF substitute foods to standard products. The nutrient composition of wheat flour is covered by legislation, (The Bread and Flour Regulations, 1998)3; wheat flour is fortified with the minerals calcium and iron, and the B vitamins thiamin and nicotinic acid. For GF substitute products, this is not the case. GF substitute products may provide an ideal vehicle for additional nutrients to a potentially at risk group. However, the concept of fortification or enrichment of the necessary GF flours requires careful thought in terms of the perceived benefits to the consumer, health benefits to the population or a specific group of the population and marketing benefits to the food industry. Current practices in the UK regarding addition of nutrients to GF staple foods are variable. In addition, it is necessary to consider the specific dietetic issues with regard to the GF diet including potential propensity to lower calcium intake, calcium malabsorption of the coeliac 8 population and other specific nutritional deficiencies such as folate deficiency, iron deficiency and Bvitamin deficiency. 1.2 Aims and Objectives The aims of this research project were: - to produce a report which informs the Food Standard Agency (FSA) regarding the current status of evidence on the nutritional adequacy of the GF diet and its impact on nutritional status. - to inform the FSA for future policy development and strategies to minimise any negative effect of the GF diet per se on nutritional intake for people with CD. Due to the complexity of the composition of the GF diet, variability in consumer choice and access to GF substitute products, a range of policy options may have to be considered, if the evidence is suggestive of nutritional inadequacy. The objectives of the project were to: - perform a structured systematic literature review on the nutritional adequacy of a typical GF diet with particular reference to iron, calcium, folate and B vitamins by identifying, grading and reviewing the literature currently available. Both published and unpublished data are included in this review, so long as the inclusion and exclusion criteria were met. - produce a report summarising the state of scientific evidence and with recommendations on strategies to address any issues around nutritional adequacy of a GF diet that the review has identified (including fortification of GF substitute products). 9 1.3 Methodology This systematic literature review searched a series of databases, followed by hand searching of reference lists and a thorough search for unpublished research. All first authors of identified papers, established leaders in the field of CD, key professional bodies and their affiliated groups, CD related organisations and manufacturers of GF products were contacted as part of this search process. A quality assessment was carried out by two independent reviewers in order to grade the evidence. Each paper was assessed for the risk of bias by using checklists and a grading system as recommended by Scottish Intercollegiate Guidelines Network (SIGN).4 Bias may be introduced into a study in a number of ways. Factors that were considered included sample size, method of recruitment of participants, analysis of dietary intake, inclusion and exclusion criteria, whether potential confounding factors had been addressed and likely author bias. Identifying the sources of bias is important in order to try and estimate what effect it could have on the findings of a study. 1.4 Results There were eleven papers included in this systematic review; these consisted of ten case- control studies and one cohort. Ten of the papers were published studies and one case- control study was unpublished (it is unlikely that this work will be published until 2009). A summary of the baseline results for included studies can be found in Appendix H. The main sources of plausible bias in the included papers were: Recall/measurement bias: The methods used to assess dietary intake may not produce a true representation of dietary intake over the course of the study period. It is well established that, subconsciously or otherwise, self-recorded diet histories can often lead to an underreporting of nutritional intake. 5 Ascertainment/selection bias: The details regarding the selection of participants should be stated as part of the methodology. In some studies, participants may be recruited through national associations or patient groups, so by definition are a well “motivated” group. They may therefore be more likely to adhere to the GF diet, be better informed, and may have a 10