Celiac disease: past, present, and future challenges: dedicated to the memory of our friend and colleague, Prof David Branski (1944-2013)

From Struggle to Strength: A Multicentric Study on How Public Policies for Celiac Disease Transform Lives

This multicenter study aims to assess the impact of public policies (PPs) on the health-related quality of life (HRQoL) of individuals with celiac disease (CD) using the Celiac Disease Questionnaire (CDQ) and PPs for Celiac Disease Score (PPCDS). This cross-sectional exploratory study was conducted in four stages: first, standardizing data from countries using the CDQ; second, analyzing PPs aimed at CD patients; third, statistically examining these data; and fourth, associating HRQoL indicators with corresponding PPs. This study analyzed 15 CDQ assessments from 12 countries from 2007 to 2023. It found that comprehensive PPs positively correlated with HRQoL outcomes (Spearman correlation of 0.358). However, policies specifically targeting gluten-free meals and certification did not significantly improve HRQoL individually, suggesting they may be more effective when implemented together. Additionally, specialized health services did not notably reduce gastrointestinal symptoms, underscoring the necessity for improved patient education to enhance the effectiveness of these services. This study concludes that implementing and rigorously monitoring regulations to support CD patients is crucial for enhancing their HRQoL.

Quality of Life Perception among Portuguese Celiac Patients: A Cross-Sectional Study Using the Celiac Disease Questionnaire (CDQ)

The aim of this study is to assess Portuguese celiac patients' quality of life (QoL) perception. A cross-sectional study was performed with a non-probability convenience sample of Portuguese celiac patients using an online self-administered celiac disease quality of life questionnaire (CDQ), previously validated for the Portuguese population. The final sample comprised 234 celiac patients, which included the following: primarily women (69.2%); aged between 18 and 49 years old (56.4%); with a partner (60.6%); with a high educational level (58.9%-graduated or post-graduated); following a gluten-free diet (GFD) (55.1%); and not using antidepressants (93.1%). The Portuguese CDQ presented good reliability and responsiveness in this sample of Portuguese celiac patients. In general, the CDQ in Portugal was affected by age at diagnosis (p = 0.017), educational level (p = 0.005), and compliance with GFD (p = 0.034). The emotion domain was affected only by using antidepressants (p = 0.036). The social domain was affected by gender (females had lower rates, p = 0.016), age at diagnosis (p = 0.009), educational level (p = 0.000), and compliance with a GFD (p = 0.002). The worries domain did not differ according to socioeconomic data. The symptoms domain was affected by compliance with GFD (p = 0.000), age at diagnosis (p = 0.000), and educational level (p = 0.014). Data on celiac QoL is essential to support the formulation and implementation of strategies to minimize the issues suffered by celiac patients, lowering their physical, emotional, and social burden. Additionally, data on Portuguese celiac disease patients using the CDQ will allow future comparative research among celiac populations from different countries.

Worldwide public policies for celiac disease: are patients well assisted?

OBJECTIVES

To evaluate public policies (PP) to celiac disease (CD) patients and classify countries regarding the level of assistance provided by the Public Policies for Celiac Disease Score.

METHODS

Countries were scored from 0 to 6 according to the existence of PP regarding industrial food and meal regulations, health service support, food allowance/financial incentive, gluten-free (GF) food certification, and CD associations. Subsequently, countries were allocated to continents. In total, 192 countries are registered as members of the World Health Organization.

RESULTS

The European continent (score 3.63) is the most advanced in CD patient care, followed by South America (2.86), North America (1.05), Asia (0.53), Oceania (0.5), and Africa (0.27). Industrial food regulations were the most frequent PP (40.6%). 15.6% of the countries display regulations for meals; 13.5% have health service support; 13.5% have policies of food allowance/financial incentive; 19.3% have GF certification; and 34.4% have celiac associations.

CONCLUSIONS

Policies regarding GF meals and food safety certification, health service support, and financial incentives need improvement to ensure correct treatment and reduce the diseases' financial burden for celiac patients and governments.

The Gluten Free Diet's Impact on Growth in Children with Celiac Disease in Two Different Countries

The effects of gluten free diet (GFD) on body mass index (BMI) and growth parameters in pediatric patients with celiac disease (CD) and their dependence on different socio-cultural environments are poorly known. We conducted an international retrospective study on celiac patients diagnosed at the University of Verona, Italy, and at the University of Chicago, Chicago, IL, USA, as underweight. A total of 140 celiac children and 140 controls (mean age 8.4 years) were enrolled in Chicago; 125 celiac children and 125 controls (mean age 7.3 years, NS) in Verona. At time of diagnosis, Italian celiac children had a weight slightly lower (p = 0.060) and a BMI z-score significantly (p < 0.001) lower than their American counterparts. On GFD, Italian celiac children showed an increased prevalence of both underweight (19%) as well as overweight (9%), while American children showed a decrease prevalence of overweight/obese. We concluded that while the GFD had a similar impact on growth of celiac children in both countries, the BMI z-score rose more in American than in Italian celiac children. Additionally, in Italy, there was an alarming increase in the proportion of celiac children becoming underweight. We speculate that lifestyle and cultural differences may explain the observed variations.

Accidental Gluten Contamination in Traditional Lunch Meals from Food Services in Brasilia, Brazil

This study aimed to evaluate the occurrence of gluten contamination in naturally gluten-free meals from food services in the Federal District, Brazil. This is an exploratory cross-sectional quantitative study in which a total of 180 samples of naturally gluten-free dishes were collected from 60 food services in Brazil. The enzyme-linked immunosorbent assay was used for the quantification of gluten. As established by the Codex Alimentarius, the threshold of 20 ppm of gluten was considered as the accepted upper gluten level for gluten-free food. A total of 2.8% (95% CI: 0.3-5.2%) gluten contamination was found in the samples. Among the 60 food services, 6.7% (95% CI: 2.7-10.6%) displayed at least one contaminated food in our sample. The occurrence of gluten contamination in naturally gluten-free preparations was uncommon and low on a quantitative basis.

Gluten contamination in food services and industry: A systematic review

Gluten-related disorders (GRD) affects approximately 10% of the general population. The only treatment for GRD is still so far is the lifelong complete exclusion of gluten from the daily diet. The correct information about the presence/absence of gluten in food is very important to this group. The present study aimed to evaluate the prevalence of gluten contamination in gluten-free industrial and non-industrial products. In this systematic review, 24 cross-sectional studies were analyzed. The authors developed specific search strategies for Science Direct, Scopus, Web of Science, Google Scholar and ProQuest Dissertations & Theses Global. The authors evaluated the methodological quality of the included studies using criteria from Meta-analysis of Statistics Assessment and Review Instrument (MASTARI). We performed the statistical meta-analysis by metafor package of R program. 95.83% (n = 23) of the studies presented positive results for contamination (over 20 ppm). In industrial food products, studies showed a contamination prevalence of 13.2% (95% CI: 10.8%-15.7%). In non-industrial food products, studies showed a contamination prevalence of 41.5% (95% CI: 16.6%-66.4%). Despite the non-industrial products presented higher contamination prevalence than the industrial products, the difference was not significant (p = 0.072). The findings indicate cross-contamination in industrialized and non-industrialized products. As expected, industrial products labeled as gluten-free showed a lower percentage of gluten-contamination than non-industrialized. Despite that, any contaminated sample found in this group present greater relevance than non-labeled foods. It indicates that foods labeled as "gluten-free" should not be considered safe for patients with GRD since information on the label regarding the presence/absence of gluten is unreliable. Therefore, any gluten-contamination in products labeled as gluten-free is a serious problem to whom present GRD. Further studies are needed to estimate gluten cross-contamination in food service meals and industry better.

Quality of Life of Celiac Patients in Brazil: Questionnaire Translation, Cultural Adaptation and Validation

(1) Background: Celiac disease (CD) is a common autoimmune disorder. The manifestations of the disease and the obligatory life-long gluten-free diet (GFD) are associated with the impairment of patients’ quality of life. Therefore, the present study aimed to translate, culturally adapt and validate a celiac disease quality of life (CD-QoL) questionnaire and apply it to a representative number of Brazilian CD patients. (2) Methods: A cross-cultural Brazilian-Portuguese version of the CD-QoL was developed according to revised international guidelines. The questionnaire was administered to 450 celiac patients. The reliability, reproducibility and validity were studied. (3) Results: The Brazilian CD-QoL questionnaire presents valid measures of reproducibility and internal consistency. Early diagnosis is related to higher scores of Brazilian CD-QoL social, sub- and total scale. There was a positive correlation between higher education level and higher QoL. Individuals with partners tend to have a better emotional subscale of QoL. CD-patients who follow a strict GFD have highest QoL scale values. Men scored higher than women on the CD-QoL. All results were statistically significant except for the gastrointestinal subscale. (4) Conclusions: Brazilian CD-QoL allows comparative research between different celiac populations in the world. QoL research will help in the development of effective strategies to improve Brazilian celiac patients’ quality of life.