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Vegetarian Diet and Coeliac Disease

Carlo Catassi, Giulia Naspi Catassi, Clinica Pediatrica, Università Politecnica delle Marche, Ancona, Italy
 
It is a well-known fact that the vegetarian diet excludes all types of fish and meat, while the vegan diet also excludes all other foodstuffs originating from animals, such as dairy products and eggs. According to the Eurispes research institute there were 4.2 million vegetarians and vegans in Italy in 2014 (7.1% of the population), which corresponds to an increase of 15% compared with the previous year. Most people who choose to follow a vegetarian or vegan lifestyle do so because of the health benefits, for ethical and religious reasons, or because of environmental protection and economic factors. There has also been an increase in the number of people with specific dietary requirements who decide to adopt a vegetarian/vegan diet, including children and teenagers as well as adults suffering from coeliac disease.
One and the same person adhering to two different diets (vegetarian/vegan diet and gluten-free diet) at the same time poses special problems. Is it possible for children to follow a gluten-free diet and at the same time a vegetarian or vegan diet? Which foodstuffs can be used in a diet with such “double" restrictions? Are there any nutritional risks, which must be taken into account when following a gluten-free diet and a vegan/vegetarian diet at the same time? This article aims to provide concise answers to these questions with particular focus on the dietary requirements of children.
 
Advantages and limits of a vegetarian/vegan diet
 
Many studies have shown the potential advantages of a vegetarian diet. The health benefits of vegetarian and vegan nutrition regimes can be summarised as follows: (a) a reduced risk of overweight, dyslipidaemia, metabolic syndrome, type II diabetes, high blood pressure and ischemic cardiomyopathy; (b) a reduced risk of neoplasms in general and in particular of the gastrointestinal tract and the prostate; (c) lower mortality, notably due to cardiovascular diseases and neoplasms. These advantages are underlined by the fact that vegetarians have a life expectancy which is 1.5–2.4 years longer than that of the non-vegetarian population.
 
On the other hand, a vegetarian/vegan lifestyle also brings with it certain risks, which should not be overlooked. Vegetarian diets first and foremost lack vitamin B12, which can be found almost exclusively in animal-based foodstuffs. This shortage also applies, albeit to a lesser extent, to iron. The even stricter vegan diet lacks calories, protein (meat-based protein is superior to plant-based protein), fat (in particular due to the lack of omega-3 fatty acids, also known as docosahexaenoic acid = DHA and eicosapentaenoic acid = EPA), zinc, calcium and certain vitamins (A and D). Furthermore, vegetarians and vegans run the risk of consuming too much fibre (> 0.5 g/kg/day), which could lead to an excessive reduction of calorie density and could hinder the absorption of mineral nutrients.
 
Nutritional aspects of a gluten-free diet
 
Sufferers of coeliac disease follow a gluten-free diet, which excludes all products derived from wheat, barley and rye. Gluten represents the main source of protein in these cereals. However, the fact that this protein is missing in a gluten-free diet does not have a negative impact on the overall protein consumption since gluten is of very low biological quality, particularly due to the lack of lysine. The gluten which is missing in a gluten-free diet can be easily replaced using products based on proteins which are not toxic for sufferers of coeliac disease (maize, rice) or other plant proteins (such as legumes). As wheat is one of the main components of the Mediterranean diet, eliminating it can lead to a shortage of other nutrients, in particular fibres, calcium, iron and folic acids. Prior to diagnoses, intestinal malabsorption in sufferers of coeliac disease can also contribute to these (albeit negligible) deficiency symptoms.
 
Tips for sufferers of coeliac disease who want to follow a vegetarian/vegan diet
 
Although there are no reasons why a child (or adult) on a gluten-free diet should not follow a vegetarian/vegan diet, it must be emphasised that persons wishing to adhere to a “double” diet must pay attention to certain factors set out below.
 
Persons with coeliac disease wishing to follow a vegan diet must ensure that they consume enough foodstuffs with a high calorie density, such as gluten-free cereals and pseudo-cereals, jams, dried fruits and virgin olive oil. Furthermore, due to the low digestibility of plant proteins, it is recommended that they should increase their daily consumption of protein by 30–35% for children up to two years of age, by 20–30% for children up to six years of age, and by 15% for children over six years of age compared to the recommended daily amount of protein for non-vegetarians. The most important sources of plant-based protein are legumes and cereals (of course gluten-free for sufferers of coeliac disease). The most important vitamin B12 sources for vegetarians/vegans is enriched foodstuffs, for example soya-based dishes. Due to the limited bioavailability of iron contained in plants, vegetarians and vegans should increase their iron consumption by 80%. It is also important to know that foodstuffs with a high concentration of vitamin C promote the absorption of iron, while other plant-based elements (phytic acid, tannins and fibres) limit its absorption. The use of iron-enriched foodstuffs may be recommendable during periods of fast growth. When it comes to zinc there is the same problem of low bioavailability, in particular in combination with a high consumption of phytic acid (found in large quantities in wholegrain cereals and legumes). Therefore, a 50% increase in zinc consumption is recommended compared to the normal recommended daily amount. The foodstuffs with the highest concentration of zinc are legumes, dried fruits, cheese and fermented soya products. Vegetarians receive enough calcium as milk and diary products contain large quantities of calcium. Vegans, however, often do not have enough calcium in their diet. Therefore, it is advisable to consume calcium-enriched foodstuffs, such as soya products, or to use foodstuffs which naturally contain a high concentration of calcium, such as leaf vegetables, cabbages and almonds.
Some foodstuffs with a high concentration of fat, such as nuts, oilseeds (sunflower, pumpkin, sesame, linseed, poppy), avocado, soya products and plant oils play an important role in the vegan diet. It is important that vegans consume enough alpha linolenic acid (ALA, ω-3), which is found in foodstuffs such as linseeds, nuts and soya products, as well as oils with low levels of linoleic acid (ω-6), such as extra virgin olive oil.
Although exposing children with light skin to the sun for short periods is enough to prevent vitamin D shortage, vegans sometimes receive too little vitamin D. This problem can be solved by consuming enriched foodstuffs (dishes based on soya or rice) or by using food supplements. A meat-free diet will always lack vitamin A, but this shortage can be prevented by increasing the consumption of foodstuffs with high levels of carotene (pro-vitamin A). Such foodstuffs include fruits and orange or yellow-coloured vegetables as well as leaf vegetables.
 
The problem of gluten contamination
 
Sufferers of coeliac disease must ensure that the foodstuffs they consume are not contaminated with gluten. Unfortunately, some foodstuffs often consumed by vegetarians/vegans (such as soya, legumes and oilseeds) have a high risk of being contaminated with gluten. Therefore, gluten-intolerance sufferers should pay special attention when selecting these products and make sure that the packaging contains a seal of approval certifying that they are gluten-free.
 
Conclusions
 
The vegetarian or vegan diet is by all means an option for children or adults who suffer from gluten intolerance and must, therefore, avoid consuming gluten. When it comes to choosing foodstuffs, sufferers of gluten intolerance should follow the recommendations given in this article and plan their diet carefully. They must at all times ensure that the foodstuffs they consume have not been contaminated with gluten.
 
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