Gastrointestinal symptoms and well-being of adults living on a gluten-free diet: a case for nursing in celiac disease. Gastroenterol Nurs. 2009;32:196-201. [PMID: 19506436 DOI: 10.1097/SGA.0b013e3181a85e7b]

Guidelines of the Italian societies of gastroenterology on the diagnosis and management of coeliac disease and dermatitis herpetiformis

INTRODUCTION

Coeliac disease and dermatitis herpetiformis are immune-mediated diseases triggered by the consumption of gluten in genetically predisposed individuals. These guidelines were developed to provide general practitioners, paediatricians, gastroenterologists, and other clinicians with an overview on the diagnosis, management and follow-up of coeliac patients and those with dermatitis herpetiformis.

METHODS

Guidelines were developed by the Italian Societies of Gastroenterology. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists and a paediatrician with expertise in this field.

RESULTS

These guidelines provide a practical guidance for the diagnosis, management and follow-up of coeliac patients and dermatitis herpetiformis in children and adults, both in primary care and in specialist settings. We developed four sections on diagnosis, gluten-free diet, follow-up and risk of complications in adults, one section focused on diagnosis and follow-up in children and one on the diagnosis and management of dermatitis herpetiformis.

CONCLUSIONS

These guidelines may support clinicians to improve the diagnosis and management of patients with coeliac disease.

Evaluation of Daily Lives of Children and Adolescents with Celiac Disease and Nursing Approaches

The incidence of celiac disease has been increasing in recent years. Celiac disease is an autoimmune enteropathy that emerges mostly in the childhood period. This disorder is a chronic condition of the small intestine due to gluten intake in individuals with genetic predisposition. In the treatment of celiac disease, gluten-free diet therapy is applied. However, the adaptation process to the diet may create difficulties for patients. Compliance with diet is much more difficult among patients with celiac disease in childhood and adolescence than in adult patients. Children and adolescents face distinct difficulties in their homes, at school, and in their social lives. Besides following dietary treatment, children and adolescents living with celiac disease need peer support to manage their daily routines. In this article, we aimed to discuss the problems experienced by children and adolescents living with celiac disease and nursing approaches to these problems.

Women's Experience With Celiac Disease: A Phenomenological Study

The purpose of this qualitative study was to explore the lived experience of women who have been diagnosed with celiac disease. Celiac disease is a multisystem autoimmune disease and affects approximately 1% of the population. In addition, celiac disease is seen 1-2 times more often in women and they tend to have more severe disease and treatment burden. Quantitative research has been completed on celiac disease, but there remains a gap related to the implications of the disease from a qualitative perspective. The research tradition used for this qualitative study was phenomenology. Interviews were audio-recorded using a developed questionnaire. Saturation of the data occurred after 12 participant interviews. Following the analysis, 5 themes resulted: (a) Who am I? (b) medical aspects; (c) challenges; (d) daily living; and (e) facing the challenges. There remains a gap in the education, support, advocacy, and follow-up care of this population.

Nutrition Assessment, Interventions, and Monitoring for Patients with Celiac Disease: An Evidence Analysis Center Scoping Review

The objectives of this scoping review were to identify and characterize studies examining nutrition assessment, interventions, and measures to monitor gluten-free diet (GFD) adherence/compliance in patients with celiac disease (CD). An electronic literature search of four databases (Cochrane Database for systematic reviews, CINAHL, Embase, and Ovid MEDLINE) was conducted to identify articles examining nutrition care in CD individuals. Except for narrative review, grey literature, and case study/report, all types of peer-reviewed articles published between January 2007 and August 2018 were eligible. There were a total of 10,823 records; 10,368 were excluded during the first round of screening due to irrelevancy and/or duplication. Of the 455 full-text articles that were assessed, 292 met the criteria and were included. Most of the studies were observational studies (n=212), followed by experimental trials (n=50), evidence-based practice guideline (EBPG)/report/statement (n=16), and systematic review (SR) (n=14). Nine original studies examined assessment, focusing mainly on different tools/ways to assess GFD adherence. The majority of the included original articles (n=235) were in the nutrition intervention category with GFD, oats, and prebiotics/probiotics as the top-three most studied interventions. There were eight SRs on GFD and five on oats. One SR and 21 original studies investigated the effectiveness of different measures to monitor GFD adherence/compliance. Although recent CD EBPGs were identified, different methods with varying levels of rigor, in terms of literature search and assessment of evidence strength, were used. Based on this scoping review, interventions focused on gluten-free diet and oats have been significantly covered by either SRs or EBPGs. Studies related to prebiotics/probiotics and education program/counseling focused interventions, as well as assessment, in CD patients have increased in recent years. Thus, it might be beneficial to conduct SRs/EBPGs focused on these topics to guide practitioners.

Mood Disorders and Gluten: It's Not All in Your Mind! A Systematic Review with Meta-Analysis

Gluten elimination may represent an effective treatment strategy for mood disorders in individuals with gluten-related disorders. However, the directionality of the relationship remains unclear. We performed a systematic review of prospective studies for effects of gluten on mood symptoms in patients with or without gluten-related disorders. Six electronic databases (CINAHL, PsycINFO, Medline, Web of Science, Scopus and Cochrane Library) were searched, from inception to 8 August 2018, for prospective studies published in English. Meta-analyses with random-effects were performed. Three randomised-controlled trials and 10 longitudinal studies comprising 1139 participants fit the inclusion criteria. A gluten-free diet (GFD) significantly improved pooled depressive symptom scores in GFD-treated patients (Standardised Mean Difference (SMD) -0.37, 95% confidence interval (CI) -0.55 to -0.20; p < 0.0001), with no difference in mean scores between patients and healthy controls after one year (SMD 0.01, 95% CI -0.18 to 0.20, p = 0.94). There was a tendency towards worsening symptoms for non-coeliac gluten sensitive patients during a blinded gluten challenge vs. placebo (SMD 0.21, 95% CI -0.58 to 0.15; p = 0.25). Our review supports the association between mood disorders and gluten intake in susceptible individuals. The effects of a GFD on mood in subjects without gluten-related disorders should be considered in future research.

Effect of comprehensive nursing intervention on gastrointestinal function recovery in patients after cardiac surgery

AIM: To explore the effect of comprehensive nursing intervention on gastrointestinal function in patients after cardiac surgery.

METHODS: Ninety-five patients who underwent cardiac surgery were enrolled, including 40 cases as a control group who received traditional nursing and 55 cases as a study group who received comprehensive nursing care. The levels of motilin, the rate of gastric emptying, postoperative gastrointestinal functional recovery, and postoperative appetite were compared.

RESULTS: The levels of motilin for the two groups after intervention were significantly higher than those before intervention (675.26 ng/L ± 312.08 ng/L vs 343.51 ng/L ± 203.26 ng/L, 468.77 ng/L ± 211.85 ng/L vs 345.37 ng/L ± 210.08 ng/L, P < 0.05). The levels of motilin and the 24- and 72-h gastric emptying rates for the study group were significantly higher than those for the control group (675.26 ng/L ± 312.08 ng/L vs 468.77 ng/L ± 211.85 ng/L, 45.57% ± 16.85% vs 20.86% ± 15.97%, 51.26% ± 17.85% vs 31.77% ± 16.33%, P < 0.05). The times to first anal exhaust and defecation and the incidence of abdominal distension for the study group were significantly lower than those for the control group (28.33 h ± 1.96 h vs 34.12 h ± 1.80 h, 56.79 h ± 11.75 h vs 87.19 h ± 12.77 h, 10.91% vs 50.00%, P < 0.05). The rate of good appetite for the study group was significantly higher than that for the control group (56.36% vs 20.00%, P < 0.05).

CONCLUSION: Comprehensive nursing intervention can improve gastrointestinal motility, gastric emptying and the levels of gastrin, and accelerate postoperative gastrointestinal functional recovery in patients after cardiac surgery.

Internalizing the threat of risk--a qualitative study about adolescents' experience living with screening-detected celiac disease 5 years after diagnosis

BACKGROUND

Mass screening could identify those with unrecognized celiac disease (CD), but the experience of being detected through screening and living with screening-detected CD should be explored before considering this as acceptable intervention. For this study we invited screening-detected adolescents to describe their experience living with screening-detected CD five years after diagnosis with the aim to explore how their perceptions, practices, and beliefs evolved.

METHODS

Adolescents who were diagnosed through a population-based CD screening were invited to write narratives after being diagnosed. Of 153 adolescents who were eventually diagnosed through the screening, 91 wrote narratives one year after diagnosis and 72 five years after diagnosis. A qualitative content analysis resulted in a theme and categories that describe the experience living with screening-detected CD five years after diagnosis.

RESULTS

The overall theme--Internalizing the threat of risk--illustrates that being detected through screening and the internalized threat of future health complications have impacted how these adolescents felt about the diagnosis, coped with the gluten-free diet (GFD), and thought about CD screening. This theme is supported by four categories: maintaining an imposed disease identity describes how they continued to define their diagnosis in relation to the screening. They also expressed moving from forced food changes to adapted diet routines by describing habits, routines, coping strategies, and the financial burden of the GFD. They had enduring beliefs of being spared negative consequences, however, even after five years, some doubted they had CD and worried that being detected and eating a GFD might not be beneficial, i.e. continuing to fear it is "all in vain".

CONCLUSIONS

There was maintenance and evolution in the perceptions, practices, and beliefs of the adolescents after five years. Some have adjusted to the disease and adapted new habits and coping strategies to deal with the GFD, while others still doubt they have CD or that being detected was beneficial. The transition to adapting to the disease and GFD is ongoing, illustrating the importance of providing ongoing support for those with screening-detected CD as they adjust to this chronic disease and the GFD.

Everyday life for women with celiac disease

The aim of this research was to explore how women with celiac disease experience everyday life. It is important that healthcare professionals understand what it is like to live with a chronic illness, and also the factors that affect the lives of women who have celiac disease. The study has a qualitative approach and the data were collected using interviews with 16 women. A conventional content analysis was used for the subjective interpretation of the qualitative interviews. Three main themes emerged in the analysis: illness trajectory and treatment, socializing with others, and feelings of loneliness and worry. The findings indicate that living with celiac disease affects the person's entire life from the past, in the present, and into the future, especially when daily routines must be altered. The women expressed a sense of loneliness and invisibility, especially when socializing with others. The diet could be a friend, enemy, obstacle, or opportunity in terms of enjoying a good life. Supporting women diagnosed with celiac disease appears to be a major task for healthcare professionals. Such professionals need to pay attention to women's symptoms, worries, and their feeling of being invisible.

Usefulness of the organ culture system when villous height/crypt depth ratio, intraepithelial lymphocyte count, or serum antibody tests are not diagnostic for celiac disease

The existence of mild forms of celiac disease (CD) can make the histology-based diagnosis difficult to reach. Since anti-endomysium (EMA) and anti-tissue transglutaminase (anti-tTG) are detectable in culture supernatants of duodenal biopsies from CD patients, our aim was to assess if this system can support the histology in the diagnostic work-up. A total of 559 suspected CD patients underwent serum EMA/anti-tTG detection, upper endoscopy with duodenal biopsy sampling, histologic analysis, and organ culture to detect EMA/anti-tTG in supernatants. A subgroup of 30 patients with organ culture positive results were put on a gluten-free diet (GFD). Their gluten-dependency was evaluated by the psychological general well-being and beck depression inventory indexes. Statistical analysis was performed by Cohen k inter-test, Friedman test, and Dunn multiple comparison. Two hundred forty-one out of 559 (43.1%) patients showed intestinal villous atrophy, whereas serum and organ culture EMA/anti-tTG were positive in 293/559 (52.4%) and 334/559 (59.7%) patients, respectively. The strength of agreement resulted good for serology vs histology (k = 0.730), good for organ culture vs histology (k = 0.662), and very good for serology vs organ culture (k = 0.852). After 12 months of GFD, psychological general well-being index significantly increased, and beck depression inventory index significantly decreased (P < 0.001 for each one). Data highlight the organ culture system as a useful tool to assist the histology in diagnosing CD, mainly in cases without villous atrophy or in seronegative patients. The marked improvement in quality of life after a GFD further supports the reliability of this system in diagnosing CD.

Coeliac disease--women's experiences in everyday life

AIMS AND OBJECTIVES

To describe what life is like as a woman living with coeliac disease.

BACKGROUND

The therapy for coeliac disease is a gluten-free diet, and if sufferers keep strictly to this, it is suggested that they will stay well. However, previous studies point out that people who are treated for coeliac disease, particularly women, experience various kinds of inconvenience in relation to having coeliac disease and to being treated with gluten-free diet.

DESIGN

A qualitative research design was chosen.

METHODS

A phenomenological approach as devised by Giorgi was used. Tape-recorded qualitative interviews with a total of 15 women who were being treated for coeliac disease were conducted in 2008 in Sweden.

RESULTS

The results demonstrated that coeliac disease can influence women's lives in different ways. The general structure of being a woman with coeliac disease was described as a striving towards a normalised lifeworld. Three conditions necessary to achieve a normalised life were described, namely being secure, being in control and being seen and included.

CONCLUSION

Understanding factors affecting the ability to live with coeliac disease as normally as possible can help caregivers, and others, to support these women in their aims.

RELEVANCE TO CLINICAL PRACTICE

Nurses should help women to adopt facilitating thoughts in relation to the disease and, in so doing, help them to select appropriate coping strategies.

Quality of life in adult celiac disease in a mountain area of northeast Italy

The aim of this study was to evaluate the health-related quality of life in patients diagnosed as having celiac disease and to study the factors involved in its impairment of quality of life. We conducted a cross-sectional study in a randomized sample of patients with celiac disease by administering the Celiac Disease Questionnaire distributed by mail. The association between the quality of life and sociodemographic and clinical variables was verified by means of a stepwise multiple regression model. One hundred ninety-one questionnaires were returned (participation rate = 63.66%), and 187 were analyzed. Women comprised 78.61% of the participants, and the median age was 36 years, 10 months. The mean summary total score in the Celiac Disease Questionnaire was 154.53 (possible range 1-196; higher scores equate with higher quality of life), and the score was lower in the subscale of emotion. Women scored significantly lower than men. Participants with the symptomatic disease scored significantly lower than the nearly asymptomatic patients in the total score and in all the subscales. Symptomatic patients need interventions for improving their quality of life, in particular psychological support.

Does a Coeliac School increase psychological well-being in women suffering from coeliac disease, living on a gluten-free diet?

AIM AND OBJECTIVE

To assess the effects of an active method of patient education on the psychological well-being of women with coeliac disease in remission.

BACKGROUND

Despite remission with a gluten-free diet, adults with coeliac disease and especially women experience a subjective poor health. Self-management education seems to be promising tool to help patients suffering from coeliac disease to cope with their disorder.

DESIGN

A randomised controlled trial.

METHODS

A total of 106 women, ≥ 20 years, with confirmed coeliac disease, who had been on a gluten-free diet for a minimum of five years. The intervention group (n = 54) underwent a 10-session educational programme, 'Coeliac School', based on problem-based learning. The controls (n = 52) received information regarding coeliac disease sent home on a regular basis. The primary outcomes were psychological general well-being measured with a validated questionnaire.

RESULTS

Participants in the Coeliac School reported a significant improvement in psychological well-being at 10 weeks, whereas the controls given usual care reported a worsening in psychological well-being. After six months, a significant improvement remained for the index of vitality.

CONCLUSIONS

Patient education increased psychological well-being in women with coeliac disease. There is a need to refine the methods of patient education to make the effects of well-being more pronounced over time.

RELEVANCE TO CLINICAL PRACTICE

Patient education using problem-based learning promotes self-management in coeliac disease by improving the well-being of patients who have been struggling with the gluten-free diet for years.

Celiac disease and health-related quality of life

Celiac disease is a particularly common life-long disorder with a prevalence of approximately 1-2% in Western populations. In recent years the health-related quality of life has become an important issue in this context, and most studies carried out so far have shown diminished quality of life in untreated patients compared with healthy controls. Furthermore, there has generally been a beneficial response to treatment with a gluten-free diet. However, the majority of trials have been carried out among adults with gastrointestinal disease, while in fact several extraintestinal and atypical forms of celiac disease might be even more common than the classical disorder. In addition, only a small proportion of these studies have been conducted among children. This article highlights the studies of health-related quality of life and celiac disease conducted to date. Particular attention is paid to the extraintestinal and atypical forms of the disorder.

Swedish women with coeliac disease in remission use more health care services than other women: a controlled study

OBJECTIVE

To examine whether the perceived poor outcome of dietary treatment makes Swedish women with coeliac disease (CD) prone to use more health care services than other women.

MATERIAL AND METHODS

The health care consumption over 36 consecutive months was examined for 137 Swedish women aged 20-80 years with CD in remission after living on a gluten-free diet for a median of 4 years (range 1-8 years). Comparisons were made with the health care consumption of 411 women in the general population matched for age and residence.

RESULTS

The results show that women with CD use health care services annually a median of 5.0 times (range 0-76) that is more than female controls 3.6 (0-311) (p < 0.05) mainly in primary care and for complaints related to mental and behavioral disorders (ICD F), diseases of the digestive system (ICD K) and diseases of the musculoskeletal system and connective tissue (ICD M).

CONCLUSIONS

Women with CD used health care services in keeping with studies indicating reduced health-related quality of life of people with this condition. The results provide evidence that women with CD in remission suffer from co-morbidities that may signal a need for a multidisciplinary follow-up of subjects with CD in Sweden.