Does C-section Increase Risk of Celiac Disease? Probably Not

Using data from the prospective TEDDY (The Environmental Determinants for Diabetes in the Young) from 2004-2010, a recent study (S Koletzko et al. JPGN 2018; 66: 417-24) has shown that cesarean section is not associated with an increased risk of celiac disease (CD) or celiac disease autoimmunity (CDA). TEDDY participants are at increased risk for CD and type 1 diabetes (T1D) based on HLA-risk genotypes.

Key findings:

  • Of the 6087 singletons, 1600 (26%) were born via C-section
  • C-section was associated with a lower risk for CDA (HR 0.85) and a lower risk of CD (HR 0.75)

My take: While environmental factors are likely to be responsible for increasing incidence of CD, C-section compared to vaginal delivery does not appear to be a risk factor.

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Amber Cove, Dominican Republic


Oats OK in Celiac Disease

A recent double-blind, randomized, placebo-controlled trial (E Lionetti et al. J Pediatr 2018; 194: 116-22) examined the effect of adding oats to the diets of 79 children and compared this to a control group of 98 children; all participants had biopsy-proven celiac disease (CD).


  • “A large body of evidence has so far suggested that the consumption of pure oats is safe in the vast majority of patients with celiac disease.”
  • Still concerns persist.  In addition, the purity of oats cannot always be guaranteed.
  • Previous studies were limited by small sample sizes, short follow-up, limited details regarding oat used, and lack of detail about cross-contamination.

This study sought to remedy prior trial deficiencies and examined clinical indices,  serology, and intestinal permeability after 6, 9 and 15 months.

Key finding:

  • There were no statistically significant clinical, serologic, or intestinal permeability variables when comparing the oat group to the control group.

My take: Oats, free of cross contaminants, are safe to incorporate into a gluten-free diet for CD.

Canyon Rim

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

How Gluten Free is a Gluten-Free Diet?

A recent analysis (JA Syage et al.The American Journal of Clinical Nutrition, Volume 107, Issue 2, 1 February 2018, Pages 201–207, (Thanks to Kipp Ellsworth for this reference) of 259 patients with celiac disease (~75% pediatric) showed that a large number with ongoing gluten ingestion based on urine and stool tests of gluten excretion.

Results: The average inadvertent exposure to gluten by CD individuals on a GFD was estimated to be ∼150–400 (mean) and ∼100–150 (median) mg/d using the stool test and ∼300–400 (mean) and ∼150 (median) mg/d using the urine test. The analyses of the latiglutenase data for CD individuals with moderate to severe symptoms indicate that patients ingested significantly >200 mg/d of gluten.

My take (borrowed from authors): These surrogate biomarkers of gluten ingestion indicate that many individuals following a GFD regularly consume sufficient gluten to trigger symptoms and perpetuate intestinal histologic damage.

Free link to full article: Determination of gluten consumption in celiac disease patients on a gluten-free diet

Despite signs like these, a lot of individuals veer off the path.

Never Too Old for Celiac Disease

A recent article (P Collin et al. AP&T 2018; 47: 563-72) reviews the presentation of celiac disease in later years (Thanks to Ben Gold for this reference).

Key findings:

  • Approximately 25% of celiac diagnoses are made at age ≥60 years
  • ~4% of celiac diagnoses are made at age ≥80 years
  • About 60% of individuals with celiac disease remain undetected
  • Adherence with gluten free diet results in “resolution of symptoms and improvement in laboratory indices…in over 90% of patients”

This review also focuses on specific related problems besides epidemiology: malabsorption, dermatitis herpetifromis, bone mineral density and fractures, autoimmune disease, heart disease, neurological disturbances, and malignancy.

Bright Angel Trail

“Is There a Downside to Going Gluten-Free if You’re Healthy?” Yes

From NY Times: Is There a Downside to Going Gluten-Free if You’re Healthy?

Yes. This short commentary explains a lot of reasons why going gluten-free is not a great idea for healthy individuals.

  1. Often, a gluten-free diet incorporates more fat, more sugar, more salt and less fiber –all bad for your health.  A gluten-free diet can increase the risk of weight gain, type 2 diabetes, and cardiovascular disease.
  2. A gluten-free diet may make definitive testing for celiac disease inaccurate after more than a few weeks.
  3. “While much has been written in books and online sources about the purported benefits of avoiding gluten, such as weight loss, cognitive well-being and overall wellness, these claims are not supported by evidence….Though some patients with irritable bowel syndrome, or I.B.S., may see symptoms improve after cutting out gluten-containing foods, research suggests it’s likely to be a result of something other than gluten.”

My take (borrowed): “There’s no reason for someone who feels well to start a gluten-free diet to promote wellness,” said Dr. Benjamin Lebwohl, director of clinical research at the Celiac Disease Center at Columbia University. “It is not an intrinsically wellness-promoting diet.”

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Does Celiac Disease Increase the Likelihood of Clostridium difficile infections?

Thanks to Mike Hart for the following reference:  Risk of Clostridium difficile in patients with Celiac Disease: A Population-Based Study B Lebwohl et al. AJG 2017; doi:10.1038/ajg.2017.400



Patients with celiac disease are at increased risk for infections such as tuberculosis, influenza, and pneumococcal pneumonia. However, little is known about the incidence of Clostridium difficile infection (CDI) in patients with celiac disease.


We identified patients with celiac disease based on intestinal biopsies submitted to all pathology departments in Sweden over a 39-year period (from July 1969 through February 2008). We compared risk of CDI (based on stratified Cox proportional hazards models) among patients with celiac disease vs. without celiac disease (controls) matched by age, sex, and calendar period.


We identified 28,339 patients with celiac disease and 141,588 controls; neither group had a history of CDI. The incidence of CDI was 56/100,000 person-years among patients with celiac disease and 26/100,000 person-years among controls, yielding an overall hazard ratio (HR) of 2.01 (95% confidence interval (CI), 1.64–2.47; P<0.0001). The risk of CDI was highest in the first 12 months after diagnosis of celiac disease (HR, 5.20; 95% CI, 2.81–9.62; P<0.0001), but remained high, compared to that of controls, 1–5 years after diagnosis (HR, 1.85; 95% CI, 1.22–2.81; P=0.004). Among 493 patients with CDI, antibiotic data were available for 251; there were no significant differences in prior exposures to antibiotics between patients with celiac disease and controls.


In a large population-based cohort study, patients with celiac disease had significantly higher incidence of CDI than controls. This finding is consistent with prior findings of higher rates of other infections in patients with celiac disease, and suggests the possibility of altered gut immunity and/or microbial composition in patients with celiac disease.

Silver Bridge crossing Colorado River. Part of Grand Canyon’s Bright Angel Trail.

#NASPGHAN17 Celiac Disease and Mucosal Healing

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Celiac disease: treat to target! Where should we aim and how do we get there?

Ivor Hill  Nationwide Children’s Hospital

Key point:

  • Dr. Hill asserted that long-term outcomes are related to ongoing intestinal inflammation and thus our goal should be mucosal healing rather than normalized symptoms/normalized serology

At this lecture, I asked Dr. Hill what he would recommend for an asymptomatic pediatric patient with ongoing intestinal inflammation who was strictly adherent to a gluten-free diet, who had no other recognizable diseases, and who had normalized their serology on treatment.  His response was that in adults that ~50% of patients improve with better attention to diet.  Thus, currently besides further dietary scrutiny, it is unclear what should be done in the pediatric population should one find ongoing mucosal disease in an asymptomatic adherent patient.

My take: Until prospective pediatric studies are published to determine the frequency of ongoing intestinal inflammation in those on a strictly GFD in asymptomatic patients and until we have additional management options, it does not make sense to look for mucosal healing.  “Don’t hunt what you cannot kill.”

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.