Socio-economic characteristics in children with coeliac disease

COVID-19-Related Food Insecurity Among Households with Dietary Restrictions: A National Survey

Background

Food insecurity dramatically increased because of the COVID-19 pandemic; however, little is known about pandemic-related food insecurity in households with dietary restrictions.

Objective

To examine pre-pandemic rates of and pandemic-related change in food insecurity among households with and without dietary restrictions.

Methods

A cross-sectional, panel-based survey of 3200 U.S. women was conducted in April 2020. Pre-pandemic food insecurity and early pandemic-related change in food insecurity were assessed using the adapted Hunger Vital Sign. Weighted, multivariate logistic regression was used to model the odds of pre-pandemic food insecurity and the odds of incident or worsening pandemic-related food insecurity among households with and without dietary restrictions. In models predicting pandemic-related outcomes, interaction effects between race/ethnicity and dietary restrictions were examined.

Results

Before the COVID-19 pandemic, households with self-reported food allergy (adjusted odds ratio [aOR]: 1.5, 95% confidence interval [CI]: 1.2-1.9), celiac disease (aOR: 2.3, 95% CI: 1.4-3.5), or both (aOR: 2.1, 95% CI: 1.2-3.6) were significantly more likely to be food insecure than households without restrictions. Households with dietary restrictions were also significantly more likely to experience incident or worsening food insecurity during the early pandemic (food allergy: aOR: 1.6, 95% CI: 1.3-2.1) (celiac disease: aOR: 2.3, 95% CI: 1.5-3.5) (both: aOR: 2.0, 95% CI: 1.2-3.4). Race/ethnicity was not a significant moderator of the relationship between dietary restrictions and pandemic-related food insecurity.

Conclusion

Households with dietary restrictions were more likely to experience both pre-pandemic and pandemic-related incident or worsening food insecurity than households without restrictions. Clinical care for patients with dietary restrictions requires attention to food insecurity.

Coeliac disease: beyond genetic susceptibility and gluten. A narrative review

Coeliac disease (CD) is an immune-mediated disorder triggered by the ingestion of gluten in genetically susceptible individuals. However, only a small proportion of subjects harbouring CD-related genetic risk develop the disease. Among the environmental factors that may influence CD risk, pre- and perinatal factors, delivery methods, parental lifestyle, infant feeding practices, seasonality, dietary factors, drug use, childhood infections and variability in gut microbiota are those most widely studied regarding the risk to develop CD. Although for many of these external factors the exact mechanism of action is unknown, most of them are thought to act by disrupting the intestinal barrier, facilitating contact between potential antigens and the immune system effector cells. Management of CD is relatively easy in patients with a definite diagnosis and requires a strict, lifelong, gluten-free diet. Better knowledge of environmental exposures apart from gluten can facilitate understanding of the pathogenesis of the disorder and the wide heterogeneity of its clinical spectrum. The purpose of this review is to discuss current knowledge on environmental CD risk factors, as well as possible interaction between them, on the grounds of the reliable scientific evidence available. Key messages The risk of developing CD is influenced not only by gluten ingestion but also by a number of environmental factors including childhood infections and variability in gut microbiota, pre- and perinatal factors, infant feeding practices, delivery methods, parental lifestyle, seasonality, dietary factors and drug use, acting mainly by disrupting intestinal permeability. Better knowledge of exposure to these factors can facilitate their identification, and subsequent elimination, in the individual patient.

Ethnic differences in coeliac disease autoimmunity in childhood: the Generation R Study

OBJECTIVE

The aim was to identify whether ethnic differences in coeliac disease autoimmunity (CDA) in children at 6 years of age exist, and when present, to evaluate how these differences may be explained by sociodemographic and environmental factors.

DESIGN

This study was embedded within a multi-ethnic population-based prospective cohort study.

SETTING AND PATIENTS

4442 six-year-old children born between 2002 and 2006 were included. Information on ethnicity, environmental and lifestyle characteristics was assessed by questionnaires. Ethnicity was categorised into Western (Dutch, European, Indonesian, American, Oceanian) and non-Western (Turkish, Moroccan, Cape Verdean, Antillean, Surinamese). Serum transglutaminase type 2 antibody (TG2A) levels were measured with fluorescence enzyme immunoassay. Serum IgG levels against cytomegalovirus (CMV) were measured by ELISA.

MAIN OUTCOME MEASURES

TG2A positivity was defined as TG2A ≥7 U/mL, strong TG2A positivity as TG2A ≥10 upper limit normal (70 U/mL).

RESULTS

Of 4442 children, 60 (1.4%) children were TG2A positive, of whom 31 were strong positive. 66% of children were Western, 33% non-Western. Western ethnicity, high socioeconomic position and daycare attendance were positively associated with strong TG2A positivity (odds ratio (OR) 6.85 (1.62 to 28.8) p<0.01, OR 3.70 (1.40 to 9.82) p<0.01, OR 3.90 (1.38 to 11.0) p=0.01 resp.), whereas CMV seropositivity was inversely related to strong TG2A positivity (OR 0.32 (0.12 to 0.84) p=0.02). Together, these factors explained up to 47% (-67 to -17; p=0.02) of the ethnic differences in TG2A positivity between Western and non-Western children.

CONCLUSIONS

Ethnic differences in children with CDA are present in childhood. Socioeconomic position, daycare attendance and CMV seropositivity partly explained these differences, which may serve as targets for prevention strategies for CDA.

The association between socioeconomic status and the symptoms at diagnosis of celiac disease: a retrospective cohort study

BACKGROUND

There are little data on patient factors that impact diagnosis rates of celiac disease. This study aims to evaluate the association between patient socioeconomic status and the symptoms at diagnosis of celiac disease.

METHODS

A total of 872 patients with biopsy-proven celiac disease were categorized based on the presence or absence of (1) diarrhea and (2) any gastrointestinal symptoms at diagnosis. Univariate and multivariate analyses were used to assess the association between socioeconomic status and symptoms.

RESULTS

Patients without diarrhea at presentation had a higher mean per capita income (US$34,469 versus US$32,237, p = 0.02), and patients without any gastrointestinal symptoms had a higher mean per capita income (US$36,738 versus US$31,758, p < 0.01) compared with patients having such symptoms. On multivariable analysis adjusting for sex, age, autoimmune or psychiatric comorbidities, and income, per capita income remained a significant predictor of diagnosis without gastrointestinal symptoms (odds ratio: 1.71, 95% confidence interval: 1.17-2.50, p < 0.01), and it showed a trend towards significance in diagnosis without diarrhea (odds ratio: 1.40, 95% confidence interval: 0.98-2.02, p = 0.06).

CONCLUSIONS

Patients with nonclassical symptoms of celiac disease are less likely to be diagnosed if they are of lower socioeconomic status. Celiac disease may be under-recognized in this population due to socioeconomic factors that possibly include lower rates of health-seeking behavior and access to healthcare.

Socioeconomic variation in the incidence of childhood coeliac disease in the UK

BACKGROUND

Serological studies indicate that evidence of coeliac disease (CD) exists in about 1% of all children, but we lack estimates of current diagnostic patterns among children and how they vary by socioeconomic group.

METHODS

We identified all children aged 0-18 years between 1993 and 2012 who were registered with general practices across the UK that contribute to a large population-based general practice database. The incidence of CD was evaluated in each quintile of the Townsend index of deprivation and stratified by age, sex, country and calendar year.

RESULTS

Among 2,063,421 children, we identified 1247 CD diagnoses, corresponding to an overall CD incidence of 11.9 per 100,000 person-years, which was similar across the UK countries and higher in girls than in boys. We found a gradient of CD diagnosis across socioeconomic groups, with the rate of diagnosis being 80% higher in children from the least-deprived areas than in those from the most-deprived areas (incident rate ratio 1.80, 95% CI 1.45 to 2.22). This pattern held for both boys and girls and across all ages. Across all four countries of the UK, we found similar associations between CD and socioeconomic status. While CD incidence up to age 2 remained stable over the study period, diagnoses at older ages have almost tripled over the past 20 years.

CONCLUSIONS

Children living in less socioeconomically deprived areas in the UK are more likely to be diagnosed with CD. Increased implementation of diagnostic guidelines could result in better case identification in more-deprived areas.

Neighborhood conditions and celiac disease risk among children in Sweden

Aim: To investigate celiac disease (CD) clustering at different geographical levels and to examine the association between neighborhood demographic and socioeconomic conditions and the risk of neighborhood CD. Methods: We included 2080 children diagnosed with CD between 1998 and 2003, identified from 43 of the 47 reporting hospitals in Sweden. A total of 8036 small area market statistics (SAMS) areas were included; these were nested in 253 municipalities that were further nested into eight ‘nomenclature of territorial units for statistics’ (NUTS) 2 regions. We performed multilevel logistic regression analyses. Results: We found the highest geographical variation in CD incidence at the municipality level, compared to the region level. The probability of having CD increased in the statistical areas of (SAMS) areas with higher average annual work income, with an odds ratio (OR) of 2.24 and 95% CI of 1.76–2.85. Reduced CD risk in neighborhoods was associated with higher average age (OR 0.96; 95% CI 0.95–0.97), higher proportion of residents with a university education (OR 0.98; 95% CI 0.97–0.99), and higher level of industrial and commercial activity (OR 0.59; 95% CI 0.44–0.82). We found no significant association between CD risk and population density, proportion of Nordic to non-Nordic inhabitants, nor share of the population with only a compulsory education. Conclusions: Neighborhood composition influences CD risk. This is one of the first attempts to identify factors explaining geographical variation in CD.

Rising incidence of celiac disease in the Netherlands; an analysis of temporal trends from 1995 to 2010

OBJECTIVE

According to screening studies, celiac disease (CD) is prevalent in Western Europe. Actual prevalence tends to be much lower. The width of this actual gap is determined by the balance between disease symptoms and the "case-finding" capabilities of the healthcare system. Therefore, we conducted a nationwide study to determine the temporal trends in the incidence in the Netherlands including a focus on demographic aspects.

MATERIALS AND METHODS

We performed a nationwide search in the Dutch Pathology Registry (PALGA) to identify all biopsy-proven cases of CD in five different years between 1995 and 2010. Furthermore, demographic profiles and socioeconomic status (SES) of patients were studied.

RESULTS

The overall incidence of CD increased from 2.72 (confidence interval [CI] 2.46-2.99) in 1995 to 6.65 (CI 6.27-7.06) per 100,000 inhabitants in 2010. No significant regional differences were noticed. In men, rates increased from 2.28 (CI 1.95-2.65) to 4.71 (CI 4.25-5.20) per 100,000 in 2010. In women, the increase was from 3.27 (CI 2.88-3.70) to 8.66 (CI 8.04-9.31) per 100,000 in 2010. A trend toward leveling of incidence was observed from 2008 to 2010. Patients diagnosed during childhood live in areas with a higher SES compared with patients diagnosed at adult age.

CONCLUSION

The incidence of biopsy-proven CD in the Netherlands increased almost threefold between 1995 and 2010. In areas with a higher SES, relatively more children were diagnosed.

Association of maternal education, early infections, and antibiotic use with celiac disease: a population-based birth cohort study in northeastern Italy

We conducted a population-based birth cohort study of approximately 203,000 babies born in northeastern Italy (1989-2012) to investigate perinatal variables, early infections leading to hospital admission, and antibiotic use in the first 12 months of life as possible risk factors for celiac disease (CD). Incident CD cases were identified from pathology reports, hospital discharge records, and exemptions from prescription charges for clinical tests. Multivariate Poisson regression models were fitted to estimate incidence rate ratios (IRRs). A total of 1,227 children had CD; CD was histopathologically confirmed in 866 (71%). Female sex, maternal age, and high maternal educational level were found to be significantly associated with CD. Gastrointestinal infections were strongly associated with a subsequent diagnosis of CD (IRR = 2.04, 95% confidence interval (CI): 1.30, 3.22). Antibiotic use was significantly associated with CD onset (IRR = 1.24, 95% CI: 1.07, 1.43), with a dose-response relationship for number of courses (P-trend < 0.01). Cephalosporin use strongly increased the risk of CD (IRR = 1.42, 95% CI: 1.18, 1.73). Use of antibiotics (supported by the dose-response relationship) and gastrointestinal infections in the first year of life may facilitate the early onset of CD by altering intestinal microflora and the gut mucosal barrier. Perinatal factors, including cesarean section, had little influence on the risk of childhood CD.

Health-related quality of life is not impaired in children with undetected as well as diagnosed celiac disease: a large population based cross-sectional study

Background

Knowledge regarding the health-related quality of life (HRQoL) of children with celiac disease remains limited and inconclusive. We investigated the HRQoL of three groups of 12-year-olds with: i) undetected celiac disease ii) clinically diagnosed celiac disease, and iii) without celiac disease.

Methods

A school-based cross-sectional multicenter screening study invited 18 325 children, whereof 68% consented to participate. Participants provided a blood sample, which was later analyzed for anti-tissue-tranglutaminase antibodies, and alongside filled in a questionnaire. When anti-tissue-tranglutaminase antibodies were elevated, a small intestinal biopsy verified the screening-detected celiac disease diagnosis. Self-reported HRQoL was measured using Kidscreen, a generic 52 items instrument with proven reliability and validity. Scores were linearly transformed into a 0–100 scale with higher values indicating better HRQoL. Mean values with standard deviations (mean ± SD) were compared, and uni- and multivariate logistic regression models tested the odds of a low HRQoL among children with undetected or diagnosed celiac disease, respectively.

Results

Children with undetected celiac disease (n = 238) reported similar HRQoL as children without celiac disease (n = 12 037) (83.0 ± 11.0 vs. 82.5 ± 11.3, P = 0.51), and also similar HRQoL (82.2 ± 12.2, P = 0.28) to that of children with diagnosed celiac disease (n = 90), of whom 92% were adherent to treatment. Having undetected celiac disease did not increase the odds of low overall HRQoL, independent of sex, area of residence, study year and occurrence of gastrointestinal symptoms (adjusted odds ratio 0.77, 95% CI 0.54-1.10). Comparable results were seen for diagnosed celiac disease cases (adjusted odds ratio 1.11, 95% CI 0.67-1.85).

Conclusion

Children with undetected celiac disease reported comparable HRQoL as their peers with diagnosed celiac disease, and those without celiac disease, when reporting prior to receiving the diagnosis through screening. Thus, children with celiac disease, both untreated and diagnosed, perceive their HRQoL as unimpaired by their disease.

Socioeconomic position and education in patients with coeliac disease

BACKGROUND AND AIM

Socioeconomic position and education are strongly associated with several chronic diseases, but their relation to coeliac disease is unclear. We examined educational level and socioeconomic position in patients with coeliac disease.

METHODS

We identified 29,096 patients with coeliac disease through biopsy reports (defined as Marsh 3: villous atrophy) from all Swedish pathology departments (n=28). Age- and sex-matched controls were randomly sampled from the Swedish Total Population Register (n=145,090). Data on level of education and socioeconomic position were obtained from the Swedish Education Register and the Occupational Register. We calculated odds ratios for the risk of having coeliac disease based on socioeconomic position according to the European Socioeconomic Classification (9 levels) and education.

RESULTS

Compared to individuals with high socioeconomic position (level 1 of 9) coeliac disease was less common in the lowest socioeconomic stratum (routine occupations=level 9 of 9: adjusted odds ratio=0.89; 95% confidence interval=0.84-0.94) but not less common in individuals with moderately low socioeconomic position: (level 7/9: adjusted odds ratio=0.96; 95% confidence interval=0.91-1.02; and level 8/9: adjusted odds ratio=0.99; 95% confidence interval=0.93-1.05). Coeliac disease was not associated with educational level.

CONCLUSIONS

In conclusion, diagnosed coeliac disease was slightly less common in individuals with low socioeconomic position but not associated with educational level. Coeliac disease may be unrecognised in individuals of low socioeconomic position.

Revisiting the risk of celiac disease in children born small for gestational age: a sibling design perspective

OBJECTIVE

An association between small for gestational age (SGA) and risk for celiac disease (CD) in childhood has previously been reported. However, this association may reflect residual confounding by genetic or environmental factors. For example, presence of subclinical CD in the mother might be a common cause of both SGA and CD in the offspring. We investigate whether SGA is causally associated with CD before age six years by applying both conventional population-based regression models and sibling analysis that investigates the association in siblings discordant for SGA.

MATERIAL AND METHODS

Using the Swedish Medical Birth Registry, we identified all singleton children born in Sweden during 1987-1993 (792,401). Of these we included 681,954 children in the study and identified 2641 cases of CD using the Swedish National In-Hospital Registry. We applied both conventional Cox regression analysis and a quasi-experimental sibling design that to some extent simulates a counterfactual situation of exposure, reducing possible confounding effects of genetic and shared environmental factors.

RESULTS

We identified an increased risk of CD in both boys (hazard ratio (HR) 1.70, 95% confidence interval (CI) 1.25-2.32) and girls (HR 1.30, 95% CI 0.99-1.70) using conventional Cox regression models. Using sibling analysis, the association between SGA and CD was confirmed in boys (HR 4.23, 95% CI 1.19-15.04) but not in girls (HR 1.00, 95% CI 0.45-2.20).

CONCLUSIONS

Our results support a causal association between SGA and CD risk in boys but not in girls, although the mechanisms underlying this difference are still unclear.

Coeliac disease in children: a social epidemiological study in Sweden

AIM

Little is known on the possible existence of socioeconomic and geographical differences in early coeliac disease (CD) risk. Therefore, we investigated these aspects in children before age two.

METHODS

Linking the Swedish Medical Birth Registry to several other national registries, we identified all singletons born in Sweden from 1987 to 1993 (n = 792,401) and followed them until 2 years of age to identify cases of CD. Applying multilevel logistic regression analysis, we investigated the association between socioeconomic position (SEP) and CD in children and also whether a possible geographical variation in CD risk was explained by individual characteristics.

RESULTS

Low SEP was associated with CD in boys OR 1.37 (95% CI 1.03-1.82), but not in girls OR 0.87 (95% CI 0.68-1.12). We found a considerable geographical variation in disease risk (i.e. intra-municipality correlation ≈ 10%) that was not explained by individual characteristics.

CONCLUSIONS

Low SEP is associated with CD in boys but not in girls. Also, CD appears to be conditioned by geographical area of residence. While our study represents an innovative contribution to the epidemiology of CD in children, the reasons for the observed geographical and socioeconomic differences could be speculated but are still unknown.

Perinatal risk factors and coeliac disease in children and young adults: a record linkage study

BACKGROUND

Little is known about perinatal risk factors and coeliac disease.

AIM

To investigate the relationship between perinatal risk factors and subsequent coeliac disease among offspring.

METHODS

Record linked abstracts of birth registrations, maternity, in-patient and day case records in a defined population of southern England.

RESULTS

Using univariate analysis, coeliac disease in the child was associated with maternal coeliac disease (odds ratio = 20.6; 95% CI = 5.04-84.0; based on two cases in both mother and child) and with social class, year of birth, maternal smoking and parity. Multivariate analysis confirmed an increased risk of coeliac disease of 3.79 (95% CI = 1.85-7.79) for classes IV and V compared with I and II, an increased risk of 1.92 (1.06-3.49) for births during 1975-1979 compared with 1970-1974 and an increased risk of 1.80 (1.05-3.09) for 'subsequent' compared with 'first' births. Smoking during pregnancy was no longer associated with coeliac disease. Because numbers were small, maternal coeliac disease was excluded from the multivariate analysis.

CONCLUSIONS

This study shows increased risks of coeliac disease for manual social classes, births during the late 1970s and 'subsequent' births. Overall, perinatal risk factors seem to have a limited role in the aetiology of coeliac disease in children and young adults.