SERUM ZINC, COPPER AND IRON STATUS OF CHILDREN WITH NEWLY DIAGNOSED CELIAC DISEASE ON 3 MONTHS OF GLUTEN FREE DIET WITH OR WITHOUT FOUR WEEKS OF ZINC SUPPLEMENTS - A RANDOMIZED CONTROLLED
TRIAL
PROTOCOL FOR SUBMISSION OF THESIS TO
UNIVERSITY OF DELHI
FOR THE DEGREE OF
DOCTOR OF MEDICINE
(M.D. PEDIATRICS)
Dr . Kanika Negi
Lady Hardinge Medical College and Associated Hospitals
New Delhi- 110001
(2012-2014)
PROTOCOL FOR THE PLAN OF SUBMISSION OF THESIS FOR
THE AWARD OF DEGREE OF DOCTOR OF MEDICINE (PEDIATRICS)
UNIVERSITY OF DELHI, SESSION 2012-2015
Title of Thesis / : / “SERUM ZINC, COPPER AND IRON STATUS OF CHILDREN WITH NEWLY DIAGNOSED CELIAC DISEASE ON 3 MONTHS OF GLUTEN FREE DIET WITH OR WITHOUT FOUR WEEKS OF ZINC SUPPLEMENTS-A RANDOMIZED CONTROLLED TRIAL”Name of the Institution / : / LADY HARDINGE MEDICAL COLLEGE AND ASSOCIATED HOSPITALS, NEW DELHI.
SIGNATURE
Name of the Candidate / : / Dr. KANIKA NEGI
SIGNATURE
Name of the Supervisor / : / Dr. PRAVEEN KUMAR
Professor, Dept. of Pediatrics
LHMC & Associated Hospitals,
New Delhi
SIGNATURE
Name of the
Co-Supervisor
/ : / Dr. MONISHA CHOUDHARY
Director-Professor, Dept. of Pathology
LHMC & Associated Hospitals,
New Delhi
SIGNATURE
Head of the Department
SIGNATURE / :
/ DR S. ANEJA
Director-Professor & Head
Dept. of Pediatrics
LHMC & Associated Hospitals,New Delhi.
Head of the Institution / : / Dr. ATUL MURARI
Director
LHMC & Associated Hospitals,
New Delhi
CERTIFICATE FROM THE INSTITUTION
We hereby declare that to the best of our knowledge no study has been carried out on the thesis topic “SERUM ZINC, COPPER AND IRON STATUS OF CHILDREN WITH NEWLY DIAGNOSED CELIAC DISEASE ON 3 MONTHS OF GLUTEN FREE DIET WITH OR WITHOUT FOUR WEEKS OF ZINC SUPPLEMENTS-A RANDOMIZED CONTROLLED TRIAL” over the past 5 years in the Delhi University.
PLACE: New Delhi Signature:
DATE : Name of Candidate: Dr. Kanika Negi
PG Student (Pediatrics)
Signature:
Name of Supervisor: Dr. Praveen Kumar
Professor, Dept. of Pediatrics
LHMC & Associated Hospitals,
New Delhi.
Signature:
Name of Co-Supervisor: Dr. Monisha Choudhary
Director-Prof, Dept of Pathology
LHMC & Associated Hospitals, New Delhi.
LADY HARDINGE MEDICAL COLLEGE & SMT. S.K. HOSPITAL, NEW DELHI.
UNDERTAKING
I/We agree to abide by the ethical guidelines for biomedical research on human subjects (As per the ICMR guidelines) while conducting the research project being submitted for Ethical Committee consideration:
1. Project is considered to be absolutely essential for the advancement of knowledge and for the benefit of all.
2. Only subjects, who volunteer for the project will be included. Their informed consent shall be obtained prior to commencement of the research project, and subjects will be kept fully appraised of all the consequences.
3. Privacy and confidentiality of the subjects shall be maintained and without the consent of the subject no disclosure will be made.
4. Proper precautions shall be taken so as to minimize the risk and prevent irreversible adverse effects.
5. Research will be conducted by the professionally competent persons.
6. Research will be conducted in a fair, honest, impartial and transparent manner.
Researcher will be accountable for maintaining proper records.
7. Research will be conducted keeping in view the public interest at large.
8. Research reports, materials and data will be preserved (as per institutional guidelines).
9. Result of research will be made known through scientific publications.
10. Professional and moral responsibilities will be of the researchers, directly or indirectly connected with the research.
11. Only those drugs which are approved by the Drug Controller of India for a specific purpose will be used in the research project.
Supervisor : Investigator:
Dr. Praveen Kumar Dr Kanika Negi
Professor, Dept. of Pediatrics PG Student (Pediatrics)
Co-Supervisor
Dr. Monisha Choudhury
Director-Prof , Dept. of Pathology
CONSENT FORM
I, ______, S/D/of ______, R/o______hereby declare that I give my informed consent in the thesis entitled ““SERUM ZINC, COPPER AND IRON STATUS OF CHILDREN WITH NEWLY DIAGNOSED CELIAC DISEASE ON 3 MONTHS OF GLUTEN FREE DIET WITH OR WITHOUT FOUR WEEKS OF ZINC SUPPLEMENTS-A RANDOMIZED CONTROLLED TRIAL”” which will be used to treat me/my relative.
Dr. Kanika Negi has informed me to my full satisfaction in language I understand about the purpose, nature of the treatment and various laboratory investigations for the study to be carried out. I have been informed about the duration of the study and instructions to be followed during this study period. I have been informed that blood investigations will be carried out at the start and at the end of three months of study and I give my consent for it. I will also followup at two – four week interval during this study period. I understand that the treatment is known to be effective in the treatment of the disorder. I realize that this is being done for the sake of knowing the relative merits of this procedure and I give my full consent for the same. I have also been explained the side effects of the treatment to be used. I give full consent for being enrolled in the above study and I reserve my rights to withdraw from the study whenever I wish without prejudice of my rights to undergo treatment at Kalawati Saran Children Hospital, New Delhi.
Patient/Patient’s relative Signature
or thumb impression :
Name: Date :
We have witnessed that the patient signed the above form in the presence of his/her freewill after understanding its contents.
Signature of Witness: Signature of the Investigation
Name: Name:
Designation:
INTRODUCTION
Celiac disease (CD), also known as Gluten Sensitive Enteropathy is a reversible autoimmune enteropathy caused by permanent sensitivity to gluten in wheat and related proteins in barley and rye. It has genetic basis, associated with presence of specific HLA alleles that encode for DQ2 & DQ81.From India, CD was first reported in 1966, in children by Walia et al and in adults by Misra et al2. Many of the subsequent reports on CD are from North-West India (Punjab, Haryana, Delhi, Rajasthan, Uttar Pradesh) where wheat is the staple cereal in the diet 3. Celiac disease now has emerged as most common cause of chronic diarrhea in north & central India 4.
CD predominantly affects the proximal small intestine and is characterized by partial or total villous atrophy of mucosa 5. The small intestine has a central role in maintaining nutrients like zinc, copper and iron, vitamin B12 and folic acid homeostasis. In patients with CD, zinc deficiency may result from a cumulative loss of insoluble zinc complexes with fat and phosphate, exudation of zinc protein complexes into the intestinal lumen and massive loss of intestinal secretions or impaired zinc absorption because of damaged intestinal epithelial cell membrane. Some of the symptoms of CD (e.g. anorexia and reduced growth rate) may be related, in part, to zinc deficiency.
Solomons et al. found that conditioned zinc deficiency may develop in patients with celiac sprue, zinc therapy greatly enhances the healing of both the intestinal and skin lesions 6. In recent years zinc has emerged as a very important micronutrient for maintaining the integrity of intestinal mucosa, immunity and growth in children 7. However, the effect of Zinc therapy on iron is not consisitent8,9.Studies also have shown that although rise in plasma Zinc is better in zinc supplemented group, it is also satisfactory in children on GFD without supplementation 10.Comparative data about the effects of GFD with or without zinc supplementation on intestinal mucosal healing and normalization of plasma zinc and other micronutrient levels is scanty. With these backgrounds we are proposing to evaluate the effects of GFD with or without zinc supplementation on plasma zinc, copper and iron levels in newly diagnosed CD patients.
TITLE:
Serum zinc ,copper and iron status of children with newly diagnosed celiac disease on 3months of gluten free diet with or without four weeks of zinc supplements-A randomized controlled trial.
RESEARCH QUESTION
Do children(<18yrs) with newly diagnosed celiac disease receiving GFD and four weeks of zinc supplementation have higher rise in mean serum zinc, copper and better iron status at 3 months after diagnosis as compared to children receiving only GFD ?
HYPOTHESIS
Children (<18yrs) with newly diagnosed celiac disease receiving GFD and four weeks of zinc supplementation will have 10% higher increase in serum zinc as compared to children receiving GFD alone and higher proportion of children (<18yrs) with celiac disease receiving GFD and four weeks of zinc supplementation will have normal serum zinc, copper and iron status as compared to children receiving GFD alone.
AIMS AND OBJECTIVES
PRIMARY
1. To compare mean rise of serum zinc at 3 months after diagnosis in children with Celiac disease receiving GFD and four weeks of zinc supplementation as compared to children on GFD without zinc supplements.
SECONDARY
1. To compare the proportion of children with normal serum zinc level at 3 months after diagnosis in children with Celiac disease receiving GFD and four weeks of zinc supplementation as compared to children on GFD without zinc supplements.
2. To compare the proportion of children with normal serum copper and iron status at 3 months after diagnosis in children with Celiac disease receiving GFD and four weeks of zinc supplementation as compared to children on GFD without zinc supplements.
3. To compare weight gain at 3 months after diagnosis in children with Celiac disease receiving GFD and four weeks of zinc supplementation as compared to children on GFD without zinc supplements.
REVIEW OF LITERATURE
Celiac disease (CD) also known as Celiac sprue or Gluten Sensitive Enteropathy is an auto-immune gastrointestinal disorder triggered by the ingestion of wheat, barley and rye in genetically susceptible persons and characterized by chronic inflammation of the small intestine. Grains and genes are the two basic elements in the pathogenesis of celiac disease. The gliadin fraction of Gluten found in cereals triggers a T cell mediated immune response initiating a damaging inflammatory process in the lining of small intestine that blunts or destroys intestinal villi reducing the surface area for absorption, limiting absorption of nutrients 11.
Epidemiology of Celiac Disease
A few decades ago, celiac disease was considered an uncommon disorder, present mainly in Europe. From India, CD was first reported in 1966, in children by Walia et al and in adults by Musra et al12. Many of the subsequent reports on CD are from North West India (Punjab, Haryana, Delhi, Rajasthan, Uttar Pradesh) where wheat is the staple cereal in the diet. There are limited data on prevalence of CD from India 13-16.
Celiac Disease: Clinical presentation and micronutrient deficiency
Classically, children with celiac disease children present within first 2 years of life with failure to thrive, chronic diarrhea, vomiting abdominal distension, muscle wasting, anemia and irritability. Occasionally there is constipation, rectal prolapse or intussusceptions. The onset of symptoms is gradual and follows the introduction of cereals into the diet; patients with severe, untreated celiac spruce may present with short stature, delayed puberty, iron and folic acid deficiency with anemia and rickets 17.
Most of the Indian studies have also reported a delayed diagnosis of CD 18, which could be due to delayed weaning, a late introduction of gluten, delayed referral and lack of awareness about the disease. Due to delayed diagnosis most of the children have moderate to severe malnutrition and anemia. It is also postulated that they will have co-existent other micronutrient deficiencies.
Zinc Deficiency And Health Implications:
It has been known for many years that zinc deficiency in experimental animal’s results in atrophy of thymic and lymphoid tissue. The deprivation ofzinc, caused by malnutrition or disease, strongly affects immune cell functions, causing higher frequency of infections. Among other effects, an increased production of reactive oxygen species (ROS) and proinflammatory cytokines has been observed inzinc-deficient patients 19.
Zinc supplementation trials carried out among children have produced variable results, depending on the specific outcomes considered and the initial characteristics of the children who were enrolled. In a meta-analyses to study the health benefits of zinc supplementation it was found that zinc supplementation reduced the incidence of diarrhea by approximately 20%, and reduced the incidence of acute lower respiratory tract infections by approximately 15%. Zinc supplementation had a marginal 6% impact on overall child mortality, but there was an 18% reduction in deaths among zinc-supplemented children older than 12 months of age. Zinc supplementation increased linear growth and weight gain by a small, but highly significant, amount. The interventions yielded a consistent, moderately large increase in mean serum zinc concentrations, and they had no significant adverse effects on indicators of iron and copper status20.
MICRONUTRIENT DEFICIENCIES IN CELIAC DISEASE:
In a recently conducted cross-sectional study among 109 individuals deficiency of micronutrients was found both in typical as well as in typical cases 21. In patients with CD, zinc deficiency may result from a cumulative loss of insoluble zinc complexes with fat and phosphate, exudation of zinc protein complexes into the intestinal lumen and massive loss of intestinal secretions or impaired zinc absorption because of damaged intestinal epithelial cell membrane.
In another study the nutritional status and micronutrient levels of 22 children aged 2 to 14 years diagnosed as Celiac disease on the basis of typical intestinal biopsy findings were studied before and after GFD. 15 healthy children served as controls. Anthropometric measurements and serum Zinc Copper Magnesium and Iron along with albumin were done for both patients and controls initially and repeated after 6 months while patients were receiving strict GFD and controls receiving normal diet. There was a statistically significant increase in serum zinc, iron and magnesium levels (p value< 0.05) while serum copper and albumin did not show any significant rise after Gluten free diet. The authors concluded that celiac children receiving strict Gluten free diet and showing good clinical response probably do not need mineral supplementation 22.
Singhal et al in another study evaluated serum zinc level at inclusion and zinc supplementation for 3 months. The serum zinc levels of newly diagnosed CD cases (0.64+/-0.34 microg/mL) versus controls (0.94+/-0.14 microg/mL) were significantly lower (95% CI -0.44 to -1.4). No significant difference in serum zinc was seen with increasing grades of villous atrophy. The study has limitation of small sample size and comparison of supplemented group with controls and old cases 23.