192 Troncone SarnoGFD is well established, so that possible adverse
reactions can be readily identified by a strict clin-
ical follow-up.
There is a general consensus that all CD pa-
tients should be treated with a GFD irrespective
of the presence of symptoms. However, while it is
relatively easy to assess the health improvement
after treatment of CD in patients with clinical
symptoms of the disease, it proves difficult in
persons with asymptomatic CD. A high rate of
osteoporosis/osteopenia (60%) was observed in
asymptomatic patients with villous atrophy; this
finding suggests that, in CD, clinical tolerance
does not ref lect tolerance to gluten and that, in
silent cases, the increased risk of osteoporosis
substantiates the need for a GFD. There are no
guidelines concerning the need for a GFD in sub-
jects with ‘potential’ CD (patients with positive
CD-associated serology but without enteropa-
thy). Most of the ‘potential’ cases are left on glu-
ten-containing diet and strictly monitored for the
appearance of complications. While a risk of os-
teoporosis also for this group of patients has been
repor ted in t he past [7] , no significant differences
have recent ly been fou nd bet ween CD pat ients on
a long-term GFD and ‘latent’ patients (patients
with a clear previous diagnosis of CD and no
clinical/histological relapse after a long period of
GFD) as far as biological tests of malabsorption
and the overall nutritional status, including bone
mass density, are concerned. Similarly, we did not
observe any major nutritional problem in our co-
hort of potential CD subjects [8].
Compliance with GFD
It is important that an experienced dietician with
specific expertise in CD counseling educates the
family and the child about dietary restrictions. An
expert dietician should be consulted in order to
evaluate the patient’s current nutritional status,
to assess macronutrient and/or micronutrient in-
take, to detect deficiencies, to educate the patient
to the GFD and to monitor dietary compliance.
Compliance with a GFD can be difficult, especial-
ly in adolescents [9]. It is recommended that chil-
dren with CD be monitored with periodic visits
for assessment of symptoms, growth, physical
status and adherence to GFD. Periodic measure-
ments of tissue TG antibody levels to document
reductions in antibody titers can be helpful as in-
direct evidence of adherence to a GFD, although
they are inaccurate in detecting slight dietary
transgressions. Recently, methods based on the
detection of a 33-mer gliadin peptide in feces have
been proposed to assess compliance with the
GFD [10].Limits
More information is needed on the daily gluten
amount that may be tolerated by CD patients. The
data available so far seem to suggest that, although
individual variability makes it difficult to set a
universal threshold, this should be set below 50
mg/day, a level unlikely to cause significant histo-
logical abnormalities. The regulations on the
composition and labeling of food suitable for CD
patients have recently changed. In 2008, the Co-
dex Alimentarius revised the previous standard
indicating 2 thresholds: 20 ppm for products to be
labeled gluten free and 100 ppm for products with
very low gluten content. The 20-ppm threshold is
considered a safe option for CD patients, consid-
ering the overall consumption of gluten-free
products [11].Alternative TherapiesBreeding programs and transgenic technology
may lead to the production of wheat that is devoid
of biologically active peptide sequences. Recently,
new, alternative approaches to GFD have been in-
vestigated ( table 2 ) [12]. As gliadin peptides are
highly resistant to digestive processing, prolyl en-
dopeptidase produced by probiotic microorgan-
isms has been shown to promote digestion of gli-
adin. Clinical trials have already started. Other
approaches include restoring intestinal permea-Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 190–194
DOI: 10.1159/000367874