Quality of Life and Nutritional Parameters of Celiac Patients in Mar Del Plata, Argentina

Introduction

The gluten-free diet (GFD) is the only treatment indicated in celiac disease (CD) [1, 2]. The GFD includes foods that naturally do not contain gluten and those foods that by their preparation are indicated as GF. Some studies report that GFD is associated with some nutritional deficiencies due to the exclusion of cereals that contain gluten and provide vitamins and minerals. The changes that occur due to the influence of a GFD lead to a lower content in the intake of fibers, vitamins and minerals with the consequent decrease in serum concentration of folate, iron, calcium, magnesium, vitamin B12 and ferritin [3]. In our country, some studies reported nutritional deficiencies in celiac children under treatment but studies in adults are scarce [4].

Strict compliance to GFD may be affected by several factors. Some authors point out that the cost, the low availability of GF foods in social events and the low mood could influence the adherence to DLG [5]. Consequently, celiac patients may show different degrees of adherence to treatment. Food is an important part of a person's life, not only because it contributes to the well-being in their health but also because it collaborates in the style and quality of life. Previous studies on the impact of celiac disease and GFD on health-related quality of life (HRQOL) have yielded conflicting results, some research showed a decrease in HRQOL in celiac disease and other results estimated that it was comparable to that of the general population Our aims were to evaluate the nutritional status of celiac people in Mar del Plata by determining the serum concentration of micronutrients, identify the factors that are associated with adherence to the gluten- free diet (DLG) and evaluate the quality of life in that group of patients [6].

Materials and Methods

Type of study: Descriptive, qualitative-quantitative, cross- sectional. Sample: not probabilistic for convenience.

Results

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Serum nutritional markers showed some deficiencies. Thus, 6.7% and 7.7% of patients with high and low adherence respectively had low serum iron concentration and only 7.0% of patients with low adherence had low serum vitamin B12 concentration.

46.4% of people with celiac disease showed a low serum folate concentration, with the most widespread deficiency in those patients who reported high adherence (53.8%) compared to those with low adherence (33.3%). These results indicated that patients who follow a strict GFD have a higher prevalence of folate deficiency compared to those with low level of adherence to diet (Figure 2).

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No significant differences were found in the mean serum concentration of folate, magnesium, iron and vitamin B12 between both groups, high and low adhesion (p> 0.05) (Table 2). The mean concentrations of folate, magnesium, iron and vitamin B12 were within the normal ranges for patients with high and low adherence.

No patient had low albumin levels and only 3.6% of CD patients had low serum ceruloplasmin levels.

The factor questionnaire did not show a significant association between the presence of symptoms and the level of adherence to the GFD (p=1,000), 84% of patients responded that they had positive symptoms (abdominal pain, discomfort, diarrhea, others), but only 32% of the total said that these symptoms influenced the will to comply with the diet. Half of the population felt depressed and 64% of them said that this feeling negatively influenced their adherence behavior, however, this factor was not significantly associated with adherence to the GFD (p = 0.445).

Costs of gluten free foods

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No 29%

YES 71%

Only 11% of the patients responded that they do not have family support to be able to comply with the treatment and 46% of CD patients who have family support considered that family and social events, represent an obstacle in the fulfillment of the diet due to the great offer of gluten-free foods. This situation was significantly associated with the worst adherence to the gluten-free diet (p=0.026, p <0.05).

Another barrier in treatment is represented by the lack of availability of gluten-free foods in the market (for 64% of respondents), and two-thirds of the population (71%), considered that the cost of these foods also has a negative impact (Figure 3). However, these factors were not significantly associated with adherence to the GFD (p = 0.705 and p = 0.670 respectively). No person assumed physical impossibilities that prevented him from preparing his own meals, but 39% said he had difficulty doing them for several reasons: not having adequate physical space, kitchen items, lack of time, variety of recipes, lack of will.

Influence of lack of product offer in the market yes

36% no

64% Figure 3: Percentage of answers reported of some items of factor questionnaire.

domain of body pain shows values below 50 in all age ranges and in both genders, being lower in the age range between 18 and 40 years (21.9 to 28.7) and in women (24.0 to 27.1). For the Mental Component Summary (SCM), the values were above 50 and in energy and vitality, they were lower than 50 in the range of 18 to 40- year-old group (37.5± 25.2) and in women (41.7 ±28.8).

Table 3: Mean values, standard deviation and 95 % confidence interval of the domains of the SF12 questionnaire by age and gender. *Data are presented as mean ±SD and confidence interval (95 %). Physical component summary (PCS) included physical functioning (PF), physical role (PR), pain (P), and general health (GH). Mental component summary (MCS) included social functioning (SF), energy/vitality (E/V), emotional role (ER) and mental health (MH) years old (Table 4).

Discussion

This study aimed to assess the effect of GFD on the micronutrient status, on the quality of life and to evaluate the factors that influence the GFD adherence of adults with CD.

Although no significance differences (p>0.05) were found in the mean serum concentrations of folate, magnesium, iron and vitamin B12 between high and low adherence group, almost 46.4 % of CD patients showed low serum folate concentration (<3.1 ng/ml). The deficiency of serum folate was more widespread in those patients who reported high adherence (53.8%) than in those with low adherence (33.3 %). The current observation showed that those patients who follow a strict GFD, have more frequently low serum folate concentration. These results show that the intake of GFD can accentuate nutritional deficiencies that may already be present in patients with CD. Previous reports have shown folate deficiencies in subjects with newly diagnosed disease and even in adults detected by screening [10, 11].

CD patients should be advised on the nutritional quality of gluten free food, taking into account that some inadequacies of dietary intake, such as deficient intake of folate, may be originated in the food choice, in addition to inherent deficiencies in GFD. The prevalence of folate deficiency among the celiac patients was quite different from that reported of women of the same range of age in Argentina (53.8 % vs 4 %, celiac patients and adult women, respectively) [12]. Though the sample size is small, these results were in agreement with previous studies that show low folic acid intake in celiac patients when compared with the general population [2, 13].

The prevalence of serum vitamin B12 is quite similar to the general population. In Argentina, 49% of pregnant women and 12% of adult women presented low serum vitamin B12 [12]. We observed that 6.6 % of celiac patients have low serum concentration of vitamin B12 (<187 pg/ml).

The prevalence of anemia (14.2%) was in the range of different studies that reported anemia between 12% to 69 % of newly diagnosed patients with CD (hemoglobin concentration < 12 g%) [14]. No differences were observed in the percentage of CD patients with serum iron deficiency (Fe concentration: 65-180 ng/ml) between the group of low and high adherence (6.7 % vs 7.7 %).

Many factors have been assessed through the factors’s questionnaire, only difficulty to follow GFD during social events, when dining out, presented significant association (p=0.026, p <0.05). The lack of information in the composition of food in restaurant or social meetings could be a negatively influence [15]. The percentage of patients (47 %) that reported high adherence to the diet was quite lower than those observed by us in a previous work (72.3%; unpublished results); this situation showed some kind of deterioration in the compliance to GFD.

The patients tend to overestimate the level of adherence to GFD, 64 % of patients answered that they follow strictly the treatment in contrast to only 47 % of the same group that expert nutritionists ranked as high adherent. No association was found between the level of adherence to GFD and the serum micronutrients concentration.

54% of patients report eating corn-based foods 3 or more times a week, while in a previous survey only 2.6 to 7.4% of general student population consumes cornmeal [9].

The evaluation of quality of life was acceptable for the PCS (63.5±17.0) but the perception of physical (21.9±28.7) pain and general health perception (34.3±22.0) indicated deterioration especially in the age range of 18 to 40 years. Previous surveys have reported low score of the emotional dimension in the group of CD patients under GFD treatment [16]. The MCS (55.5±19.0) was acceptable. We observed the lowest scores of the emotional role (43.5±44.8) in the group older than 41 years, and the vitality and energy component (37.5±25.2) indicated worsening especially in the age range of 18 to 40 years.

In previous studies, the evidence suggests that the level of compliance to diet is not related to the status of quality of life, although some studies have reported some kind of associations in some domains (perception of health) [17]. In our study, no association was observed between MCS domain and the level adherence to GFD (p:0.594 >0.05).

Conclusions

The low serum level of folate in both groups of patients, those who adhere to the diet and those who don’t, shows the need to increase the consumption of this micronutrient, it is important to consume the appropriate amounts of foods rich in folic acid, such as green leafy vegetables, such as arugula, spinach, endive, lettuce, chard.

Recommendations for dietary supplementation should be reviewed to take these deficiencies into account and to improve the nutritional quality of GF food products and hence the health of CD patients adhering to the GFD.

The health and quality of life of people with celiac disease could be get better with the increment of offer of gluten-free foods in restaurants, markets and food supply locations.

Strategies to disseminate information about this disease in the population are necessary and education programs should be included both for patients and for the medical team and the people who process food.

Conflicts of Interest

The authors declare no conflict of interest

Acknowledgments

The authors thank the National University of Mar del Plata (Proyecto CEN-005-2016). They thank the Argentine Celiac Association, Mar del Plata branch, for their collaboration in the call for patients who participated in this project.