Gastroenterology · Medical Literature
Physical Activity in Patients with Celiac Disease: A Systematic Review.
Abstract
Objectives: Celiac disease (CD) is an immune-mediated disorder triggered by gluten ingestion. Although a gluten-free diet (GFD) is the only effective treatment, patients may still experience inflammation, nutritional imbalances, and reduced quality of life. Physical activity (PA) has demonstrated anti-inflammatory benefits; however, its role in CD management remains unclear. This systematic review aimed to synthesize evidence on the associations of PA and the outcomes of exercise interventions in individuals with CD, focusing on metabolic, nutritional, clinical, and functional outcomes. Methods: Following PRISMA guidelines, we included peer-reviewed observational and experimental studies assessing PA in individuals with CD across all age groups, without language or date restrictions. Searches were conducted in PubMed, Scopus, Web of Science, EMBASE, and SPORTDiscus. The risk of bias was evaluated using JBI and Cochrane RoB 2 tools. Results: Fourteen studies (17 publications) were included, the vast majority of which were cross-sectional, along with one quasi-experimental study and two randomized controlled trial cohorts reported across five publications. Data from these predominantly observational studies suggested possible, yet inconsistent, links between higher PA levels and better profiles in body composition, inflammatory and oxidative markers, quality of life, and psychological outcomes. Positive associations were also observed in some studies regarding gastrointestinal symptoms and adherence to the GFD. However, findings on metabolic markers and bone mineral density were inconsistent and linked to dietary factors. Conclusions: While PA represents a potential adjunct in the comprehensive management of CD, particularly in relation to functional and inflammatory outcomes. However, the current evidence remains highly preliminary, limited, and inconsistent, which restricts the strength of any definitive conclusions. Therefore, high-quality, longitudinal studies and well-designed clinical trials are needed to confirm its long-term benefits, especially in the pediatric population, and to establish specific recommendations.
Clinical relevance
Celiac disease affects a significant subset of the population and, despite strict adherence to a gluten-free diet, patients frequently continue to experience systemic inflammation, nutritional deficiencies, reduced bone mineral density, and impaired quality of life — representing an unmet therapeutic gap. This systematic review is clinically timely as it is the first to synthesize evidence across all age groups on the role of physical activity as a potential adjunct to GFD in CD management. Gastroenterologists and dietitians managing CD patients need to understand the current evidence base — and its limitations — before incorporating exercise counseling into routine clinical recommendations.
Key findings
1. Fourteen studies (reported across 17 publications) met inclusion criteria; the evidence base was predominantly observational (largely cross-sectional), with only one quasi-experimental study and two RCT cohorts reported across five publications, reflecting a critically immature literature. 2. Higher levels of physical activity were associated with more favorable body composition profiles in a subset of studies, though the magnitude of effect and specific anthropometric parameters were inconsistent across the included observational reports. 3. Some studies observed positive associations between greater physical activity and improved inflammatory and oxidative stress markers, suggesting a potential anti-inflammatory adjunct role for exercise in CD beyond GFD alone, but findings were not uniform. 4. Psychological outcomes and health-related quality of life showed positive associations with higher physical activity levels in a portion of the included studies, though effect sizes and instruments used varied across reports. 5. Associations between physical activity and gastrointestinal symptom burden, as well as GFD adherence, were positive in some studies, but the directionality and causality cannot be established given the cross-sectional design of the majority of included studies. 6. Findings on metabolic markers and bone mineral density were explicitly inconsistent across studies and appeared confounded by dietary factors, precluding any conclusions regarding the independent effect of physical activity on skeletal health in CD.
Practice implications
At present, the evidence is insufficient to support specific, evidence-based exercise prescriptions (type, frequency, intensity, or duration) for patients with celiac disease, and clinicians should communicate this uncertainty clearly rather than extrapolating from general population guidelines. Physical activity may be cautiously encouraged as part of a comprehensive, individualized management plan — particularly for CD patients with residual inflammatory burden, poor quality of life, or psychological comorbidities — while ensuring nutritional adequacy (especially calcium, vitamin D, and iron) to mitigate theoretical risks of exercise-related deficiency exacerbation. High-quality, longitudinal RCTs are urgently needed, with particular priority given to the pediatric CD population and to outcomes including bone mineral density, mucosal healing, and GFD adherence, before definitive clinical practice recommendations can be established.