Abstracts
Has Coeliac Disease Increased in Frequency?
Many Nutritional Therapists are becoming aware that the incidence of Coeliac Disease (CD) is increasing in frequency, but by what sort of levels?
To answer this question a comparison was undertaken over a 50 year period. The study group looked at the incidence of undiagnosed CD and its likely hood of future health complications.[1]
A previous study in 2005 had noted that Children identified with CD, but never put on a gluten-free diet, as adults have a significantly higher percentage of auto-immune disorders, higher BMI, osteoporosis, dental enamel defects, alcohol intake, cigarette smoking, sexual habits and lower neo-natal weight in their children with subsequent shorter breast-feeding time.[2]
The finding allows the hypothesis that even a short period of GFD in childhood exerts a sort of protective effect from gluten induced diseases.
The implications are that if the incidence of CD is increasing then the presentation of patients with often complex multifactoral symptoms may in fact be reflecting a growing reactivity to gluten and an increased immune related disease pattern.
The 2009 study included 9,133 healthy young adults from a USA Air Force Base (sera were collected between 1948 and 1954) and 12,768 gender-matched subjects from 2 recent cohorts from Olmsted County, Minnesota, with either similar years of birth (n = 5558) or age at sampling (n = 7210) to that of the Air Force cohort.
Samples using sera were tested for tissue transglutaminase and, if abnormal, for endomysial antibodies. Survival was measured during a follow-up period of 45 years in the Air Force cohort. The prevalence of undiagnosed CD between the Air Force cohort and recent cohorts was compared.
Results
Of 9,133 persons from the Air Force cohort, only 14 (0.2%) had undiagnosed CD. In this cohort, during 45 years of follow-up, all-cause mortality was greater in persons with undiagnosed CD than among those who were seronegative (hazard ratio = 3.9; 95% confidence interval, 2.0-7.5; P < .001).
Undiagnosed CD was found in 68 (0.9%) of the Olmsted group with similar age at sampling and 46 (0.8%) persons with similar years of birth.
The rate of undiagnosed CD was 4.5-fold and 4-fold greater in the recent cohorts, respectively, than in the Air Force cohort (both P < or = .0001).
Conclusions
During 45 years of follow-up, undiagnosed CD was associated with a nearly 4-fold increased risk of death. The prevalence of undiagnosed CD seems to have increased dramatically in the United States during the past 50 years.
This 400% increase in incidence of undiagnosed CD is a dramatic growth and strongly suggests that other nations including the UK who follow a similar dietary intake and lifestyle patterns to those of the United States may also have had similar increases. Coeliac disease is now known to be a common condition that affects approximately 1 in every 100 people in the UK. Women are two to three times more likely to develop coeliac disease than men.[3]
Are you considering this diagnosis in your patients and do you know the best test to determine their diagnosis? The current opinion is that IgA antitissue transglutaminase antibodies and IgA antiendomysial antibodies have high sensitivity and specificity for diagnosing coeliac disease, as described in a former post.
References
[1] Rubio-Tapia A, Kyle RA, Kaplan EL, Johnson DR, Page W, Erdtmann F, Brantner TL, Kim WR, Phelps TK, Lahr BD, Zinsmeister AR, Melton LJ 3rd, Murray JA. Increased prevalence and mortality in undiagnosed celiac disease. Gastroenterology. 2009 Jul;137(1):88-93. Epub 2009 Apr 10. View Abstract
[2] Ciacci C, Iovino P, Amoruso D, Siniscalchi M, Tortora R, Di Gilio A, Fusco M, Mazzacca G. Grown-up coeliac children: the effects of only a few years on a gluten-free diet in childhood. Aliment Pharmacol Ther. 2005 Feb 15;21(4):421-9. View Full Paper
[3] West J, Logan RF, Hill PG, Lloyd A, Lewis S, Hubbard R, Reader R, Holmes GK, Khaw KT. Seroprevalence, correlates, and characteristics of undetected coeliac disease in England. Gut. 2003 Jul;52(7):960-5. View Full Paper
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Dr’s Make Blood Pressure Soar!
In the ever increasing fight against vascular disease and related health problems the role of the silent marker – Blood Pressure has always been regarded as a sentinel sign. The levels determined to be safe have been adjusted over the years to try and develop a public and medical policy towards compression of risk. Therefore nurses and Dr’s perform clinic blood pressure tests to look for indications of different states of hypertension. This study from the BMJ indicates who and how, has significant effects on results/intervention.[1]
Clinic blood pressure measurements taken by doctors were considerably higher than those taken by trained staff and therefore gave inappropriate estimates of ambulatory thresholds.1
It is already known that ambulatory blood pressure observed over 24 hours is significantly lower than clinic blood pressure, measured at a one off event, even in patients with moderate and severe hypertension. The disparity between both methods also increases with increasing clinic blood pressure values raising questions about the validity of relying on clinical evaluation alone.[2]
There are a number of factors that affect blood pressure, from Vit D status to menopause but what if one of the most dramatic is simply from white coat hypertension – magnified by the Dr actually taking the test. What if the effect of this is so great that many patients may well have been prescribed anti-hypertensive medication incorrectly?
It is already recognised that the adverse effects of NSAID’s can include hypertension, leading to adverse drug related prescription therapy, rather than physiological prescription.[3] Yet single spikes in systolic blood pressure previously thought to be a benign event if overall BP was within normal bounds has now been identified as an increased risk for stroke development.[4]
This further implies that a progressive ambulatory approach will provide a more accurate blood pressure analysis than a single clinical reading as the risk for over prescription will now rise in light of the implications for stroke management.1
Current Leels of Blood Pressure as of 2010 for determination of risk
Comment
The risks of untreated hypertension are well established and treatment recommendations have undergone significant periods of review and reflection over the last 10 years. The use of medications can be lifesaving and at times provide dramatic benefits. Many patients however, do not respond well to the medication either in terms of limited BP reduction benefit, or reaction to the medication and others simply wish to explore alternative strategies.
Hypertension is a major risk factor for cardiovascular morbidity and mortality. Blood pressure measurements taken in the clinic or office provide limited information about the true blood pressure load, and measurements taken elsewhere are often needed to best guide the diagnosis and treatment of hypertension.1
Lifestyle changes can have significant effects of hypertension and are low risk interventions, albeit difficult to manage complete compliance in many cases. Dr Marc Houston a cardiologist has published a paper on the effects of a supplement programme on the resolution of hyperlipidemia a condition often found in coexistance with hypertension and presents some early data with a compelling outcome for clinical strategy where medication is unsuited or unwanted. This paper and other relevant information can be found in the lecture pack provided by Michael Ash from his presentation at the 2010 CAM conference on a Nutritional Therpaist approach to CVD using evidence based strategies and treatments.
Other lifestyle strategies have demonstrated improvement in blood pressure levels and represent a practical long term strategy.[5]
References
[1] Head GA, Mihailidou AS, Duggan KA, Beilin LJ, Berry N, Brown MA, Bune AJ, Cowley D, Chalmers JP, Howe PR, Hodgson J, Ludbrook J, Mangoni AA, McGrath BP, Nelson MR, Sharman JE, Stowasser M. Definition of ambulatory blood pressure targets for diagnosis and treatment of hypertension in relation to clinic blood pressure: prospective cohort study. BMJ. 2010 Apr 14;340:c1104. doi: 10.1136/bmj.c1104. View Full Paper
[2] Bur A, Herkner H, Vlcek M, Woisetschläger C, Derhaschnig U, Hirschl MM. Classification of blood pressure levels by ambulatory blood pressure in hypertension. Hypertension. 2002 Dec;40(6):817-22. View Abstract
[3] Rochon PA, Gurwitz JH. Drug therapy. Lancet. 1995 Jul 1;346(8966):32-6. Review. View Abstract
[4] Rothwell PM, Howard SC, Dolan E, O’Brien E, Dobson JE, Dahlöf B, Sever PS, Poulter NR Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet. 2010 Mar 13;375(9718):895-905. View Abstract
[5] Fleet JC. DASH without the dash (of salt) can lower blood pressure. Nutr Rev. 2001 Sep;59(9):291-3. Review. View Abstract
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Resveratrol Adds Another Benefit
Ulcerative colitis is a nonspecific inflammatory disorder characterised by oxidative and nitrosative stress, leucocyte infiltration and upregulation of inflammatory mediators. Resveratrol is a polyphenolic compound found in grapes and wine, with multiple pharmacological actions, mainly anti-inflammatory, antioxidant, antitumour and immunomodulatory activities.
Inflammatory bowel disease is a recognised as a chronic pathology by uncontrolled inflammation of the intestinal mucosa which can affect part of the gastrointestinal tract, with causes including genetic factors, immune deregulation, barrier dysfunction, and a loss of immune tolerance toward the enteric flora.
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Atishoo – that’s D’ one!
Vitamin D Vs Influenza A
Lets face it, right now we are still recovering from the various revelations about the novel variant H1N1 or swine flu non event (in terms of pandemic effects) to be looking to see if we can manage the more common seasonal influenza. Plus spring is in the air and we all know that colds and the flu viruses seem to be less vigorous during the time of the year we actually see the sun!
However a rather neat randomised trial to see if Vitamin D supplementation had any prevention effect in school children adds further weight to the evolving understanding of its innate immune activation potential.[1]
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Drink? – Mines 1.5 Litres Of Your Finest H2O
Water as an essential nutrient: the physiological basis of hydration
There are many times when the decision to say we need ‘8 glasses of water’ a day just pops out. But what is the evidence for this, do we need more or less? Obviously climate, activity, age and availability of fluids are all going to have an effect, and what about if we drink too much and suffer hyperhydration leading to hyponatraemia (a disturbance of the salts in the blood) in which the sodium (Natrium in Latin) concentration in the plasma is lower than normal (hypo in Greek), specifically below 135 mEq/L)?
Often ridiculed, the minimum volume per day has been contentious, with many commentators settling on 8 full 8oz glasses of water, and other suggesting that any fluid intake that hydrates will suffice.
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Alzheimers Postponed by Diet!
If Alzheimer’s is a disease related to adverse inflammatory responses over time, could one of the largest and most regular antigenic burden – our foods have a significant impact on risk of development. What level of conviction would we as humans looking at a future of declining cognitive function require to moderate our food selection.
The journal Archives of Neurology in April 2010 published a paper looking at the role of a protective diet over time on the risk of Alzheimer’s development in northern Manhattan, New York.[1]
As humans we are prone to wide food selection and isolated or synergistic combination become complex. To try and resolve a methodological error risk, this group used an alternative strategy called dietary pattern analysis.[2] Instead of looking at individual nutrients or foods, pattern analysis examines the effects of overall diet.
A group of 2,148 older adults (age 65 and older) without dementia living in New York were selected. They provided information about their diets and were assessed for the development of dementia every 1.5 years for an average of four years. Several dietary patterns were identified with varying levels of seven nutrients previously shown to be associated with Alzheimer’s disease risk:
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Multi Vitamin/Mineral Supplement Promotes Weight Loss in Women
Multi Vitamins are considered by many to be little more than colourful contributors to urine flow that reflect a gullible individuals need to add capital to the water course. I have addressed the major complications with this facile comment in a previous commentary.
A paper out in the March 2010 International Journal of Obesity[1] throws added weight to the triage theory of Prof Bruce Ames,[2] when additional nutrients were added to the dietary intake of obese Chinese females. It is already understood that obesity contributes to reduced bioavailability of minerals and vitamins and certainly contributes to reduced blood concentrations.
The team of researchers based at Harbin Medical University in China recruited 96 Chinese women with an average body mass index of 28kg/m2 and aged between 18-55 for the 6 month study.
Three groups were randomly set up, with one getting a multivimin, the next calcium only (162mg) and the last placebo. The results were compelling; the multivimin group had reduced body weight, body mass index, fat mass, total cholesterol and LDL cholesterol. On the positive side, they had an increased level of resting energy expenditure and HDL levels also increased. They also found reduced waist size and better breathing.
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Vit D Deficiency = Fat Legs For Young Women!
It’s hard to ignore, it really appears there is a genuine epidemic (occurrence of a disease or disorder in a population at a frequency higher than that expected in a given time period) in progress, and its not H1N1 Flu.
An excellently developed study published in the March 2010 Journal of Clinical Endocrinology and Metabolism found a depressingly high 59% of study subjects had too little Vitamin D in their blood (</=29 ng/ml).[1] Nearly a quarter of the group had serious deficiencies (less than 20 ng/ml) of this important vitamin. Even the sufficient (>/=30 ng/ml) was only 41% and if we were to apply the generally regarded 50ng/ml as the base line for sufficiency, the numbers would decline even further. Since Vitamin D insufficiency is linked to increased body fat, decreased muscle strength and a range of disorders, this is a serious health issue.
The 90 young women in this group aged between 16-22yrs of age had an increased level of fatty tissue when their Vit D levels were low. Abnormal levels of Vitamin D are associated with a whole spectrum of diseases, including cancer, osteoporosis and diabetes, as well as cardiovascular and autoimmune disorders.
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Gluten May be Causing Your Brain Problems!
An interesting paper published in the Sept 2008 Annals of Neurology described a ‘new to science’ brain aggravating enzyme, triggered by reactivity to gluten, but acting independently of other coeliac symptoms.[1]
Most clinicians understand that overt gluten reactivity is classified under coeliac disease and the the classic constellation of symptoms and signs characterising malabsorptive syndrome is a readily recognised manifestation of coeliac disease. Frank malabsorptive symptoms include steatorrhea, weight loss or failure to thrive, bloating, and flatulence, with multiple deficiency states. More common but more difficult to recognise, however, are the other diverse ways in which coeliac disease presents.
Coeliac disease may also mimic many common clinical entities. These atypical modes of presentation include deficiencies of single micronutrients; nonspecific gastrointestinal complaints such as bloating, abdominal pain, diarrhoea, constipation, flatulence, secondary lactose intolerance, and dyspepsia; and non-gastrointestinal complaints such as fatigue, depression, arthralgia, milk intolerance, osteomalacia or osteoporosis, and iron deficiency anaemia.
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IBS Relief and Probiotics – They do Work
Probiotics are widely consumed and the widespread advertising is often not really justified by the evidence. Many products were never studied as such and some companies use studies performed with other (and different) products for advertising.
In the March edition of GUT a systematic review on the randomised control trials (RCT) undertaken so far suggests that many are of good quality.[1], they determine that meta-analysis is impossible due to the various strains, phenotypes and genome vary greatly.[2] As a consequence and as stressed by the FAO/WHO joint report the benefits of one probiotic ‘cannot be extrapolated to other probiotic strains without experimentation.[3] However there tend to be properties consistent with different groups, from which strain specific organisms may be extracted.
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