Over the last years, coeliac disease has undergone significant developments not only from a diagnostic perspective, but also from clinical and nutritional standpoints. Alongside the classic issues related to malabsorption, the scientific literature is beginning to highlight an increasingly relevant aspect in clinical practice: the relationship between coeliac disease and metabolic health, particularly in paediatric patients.

A recent review published in Frontiers in Nutrition analyses precisely this link, emphasising that the nutritional management of coeliac patients must now consider not only gluten exclusion, but also the correct balance of nutrients and the overall quality of the diet in order to reduce the risk of developing alterations in metabolic pathways (1).

Coeliac disease is not merely an autoimmune enteropathy: it can be considered a systemic disorder with metabolic repercussions. Exposure to gluten triggers, in fact, a series of changes common to other metabolic disorders:

Taken together, these factors act synergistically, through intestinal damage, immune activation and nutritional deficiencies, to amplify the inflammatory and metabolic pathways shared with metabolic syndrome, highlighting the importance of active nutritional and metabolic monitoring in patients with coeliac disease.

A gluten-free diet is the cornerstone of coeliac disease treatment and is the only therapeutic tool available to clinicians capable of bringing about clinical improvement in patients. However, a gluten-free diet should be designed whilst also taking overall nutritional balance into account. In particular, a diet that is nutritionally unbalanced may result in excessive calorie intake or reduced intake of fibre and micronutrients, factors that could increase the risk of developing metabolic disorders such as dyslipidaemia, insulin resistance and visceral adiposity.

For this reason, the authors recommend that nutritional counselling should be guided by a gluten-free Mediterranean model that takes into account:

• dietary variety;
• proper distribution of macronutrients;
• adequate consumption of pulses, fruit and vegetables
• adequate fibre intake;
• consumption of naturally gluten-free foods.

In addition to dietary composition, a significant role is attributed to the education of patients and carers, with the aim of guiding them in reading labels and understanding the implications of cross-contamination.

For paediatric patients, a personalised nutritional strategy is recommended, which also takes into account specific energy requirements in relation to growth rate, stage of development and monitoring of micronutrients.

Finally, the involvement of a dietitian and a multidisciplinary team is highlighted as a key element in ensuring personalised and sustainable long-term management.