The impact of a gluten-free diet on adults with coeliac disease: results of a national survey

Adherence to the Gluten-Free Diet Role as a Mediating and Moderating of the Relationship between Food Insecurity and Health-Related Quality of Life in Adults with Celiac Disease: Cross-Sectional Study

This cross-sectional study aimed to estimate the relationship between food insecurity (FI) and health-related quality of life (HRQoL) in patients with celiac disease (CD) and assess whether this relationship is mediated or moderated by adherence to the gluten-free diet (GFD). The results of 1162 samples of patients diagnosed with CD showed that 8.3% of individuals who have a combined score of less than 13 exhibited excellent or very good adherence to the GFD. Furthermore, moderate and fair to poor adherence to the GFD was demonstrated, respectively and 71.9% of the patients had poor HRQoL levels. A significant and moderate positive correlation between FI and GFD adherence (r = 0.489) was found, indicating that 24% of the variance in FI is shared with GFD adherence. The patients' gender, marital status, and monthly income made statistically significant contributions to the prediction (p < 0.05). Females had significantly lower HRQoL scores than males (B = -4.619, 95% CL: -6.08, -3.16) after holding all other variables constant. In conclusion, FI is mediated by GFD adherence to HRQoL. Moreover, a significant total effect relation was found between HRQoL and both FI and GFD adherence, suggesting that lowering symptoms and complications associated with CD may reduce the impact of FI on HRQoL.

Global Approach to Follow-Up of Celiac Disease

Celiac disease, an autoimmune disorder induced by the ingestion of gluten, affects approximately 1.4% of the population. Gluten damages the villi of the small intestine, producing symptoms such as abdominal pain, bloating and a subsequent loss of nutrient absorption, causing destabilization of the nutritional status. Moreover, gluten can trigger extra intestinal symptoms, such as asthma or dermatitis, but also mental disorders such as depression or anxiety. Moreover, people suffering from celiac disease sometimes feel misunderstood by society, mainly due to the lack of knowledge about the disease and the gluten-free diet. Thus, the treatment and follow-up of patients with celiac disease should be approached from different perspectives, such as the following: (1) a clinical perspective: symptomatology and dietary adherence monitorization; (2) nutritional assessment: dietary balance achievement; (3) psychological assistance: mental disorders avoidance; and (4) social inclusion: educating society about celiac disease in order to avoid isolation of those with celiac disease. The aim of this narrative review is to gain deep insight into the different strategies that currently exist in order to work on each of these perspectives and to clarify how the complete approach of celiac disease follow-up should be undertaken so that the optimum quality of life of this collective is reached.

Barriers at various levels of human ecosystem for maintaining adherence to gluten free diet in adult patients with celiac disease

INTRODUCTION

While lifelong and strict adherence to gluten-free diet (GFD) is essential for the successful treatment of celiac disease (CeD), only 30-50% of patients are able to maintain a good adherence to GFD. We determined factors influencing the adherence to GFD at various ecological levels including intra-personal, inter-personal, organizational, community and system-based levels in adult patients with CeD.

METHODS

A questionnaire to assess the adherence was developed and it was administered in the CeD clinic to patients with CeD on GFD for >1 year. Adherence to GFD was assessed in a subset of patients (n = 320) using Celiac Disease Adherence Test (CDAT).

RESULTS

Overall, 978 patients [median age: 29 years; females: 592] with CeD on GFD were recruited. They reported many barriers to adherence to GFD including intra-personal barriers such as lack of knowledge about GFD (19%), inadequate financial resources (27.2%) and lack of self-motivation/confidence (55.3%); inter-personal barriers such as intake of gluten-containing food upon forceful insistence of friends/family (23.4%); organizational barriers such as high cost (70.8%) and non-availability of GF-food products (48.6%); community-based barriers like consumption of gluten-containing food at religious occasions/festivals (11.1%) and social occasions (27.2%); and system-based barriers such as non-referral to dietitian for counseling (21.9%). As per CDAT, 204 (63.7%), 73(22.8%) and 43(13.4%) patients had good, average, and poor adherence to GFD, respectively. On multivariable analysis, occasional consumption of gluten, non-availability of GF-food while dining out and coercing by family and friends for consumption of GC-food were found to have highest odds for poor adherence to GFD.

CONCLUSIONS

Non-referral to a dietitian for counseling, irregular follow-up visits, unavailability of flour mill, non-supportive family/friends, high cost and limited availability of GF-food are the most common barriers to adherence to GFD. There is a need to create infrastructure and develop strategies to overcome these diverse barriers at various levels of ecosystem and thereby facilitate better adherence to GFD.

Gluten-Free Diet and Other Celiac Disease Therapies: Current Understanding and Emerging Strategies

A lifelong gluten-free diet (GFD) is the only treatment for celiac disease and other gluten-related disorders. Nevertheless, strict adherence to the GFD is often challenging due to concerns about social isolation, risk of gluten contaminations, high cost, poor quality and the taste of gluten-free products. Moreover, although the GFD is effective in achieving mucosal healing, it may lead to dietary imbalances due to nutrient deficiencies over a long period of time. To overcome these issues, several gluten-free wheat flours have been developed to create products that closely resemble their gluten-containing counterparts. Furthermore, given the critical importance of adhering to the GFD, it becomes essential to promote adherence and monitor possible voluntary or involuntary transgressions. Various methods, including clinical assessment, questionnaires, serology for celiac disease, duodenal biopsies and the detection of Gluten Immunogenic Peptides (GIPs) are employed for this purpose, but none are considered entirely satisfactory. Since adherence to the GFD poses challenges, alternative therapies should be implemented in the coming years to improve treatment efficacy and the quality of life of patients with celiac disease. The aim of this narrative review is to explore current knowledge of the GFD and investigate its future perspectives, focusing on technology advancements, follow-up strategies and insights into a rapidly changing future.

Assessment of dietary patterns in celiac disease patients using factor analysis method and their relationship with dietary intakes and body mass index

BACKGROUND/OBJECTIVES

Celiac disease (CD) is a systemic and autoimmune enteropathy of the gastrointestinal tract with malabsorption characteristics. The only effective treatment for CD is adhere strictly to a gluten-free diet (GFD) throughout life. We evaluated the dietary patterns in celiac disease patients and their association with dietary intakes and anthropometric measurements in Iran.

SUBJECTS/METHODS

This is a case-control study on 182 participants who were referred to the Khuzestan Celiac Association, Iran. Nutritional information was collected using a validated 147-item semi-quantitative food frequency questionnaire (FFQ). The software Stata (StataCorp, Version 14.0) was used to analyze the data. Principal component analysis (PCA) was used to obtain participants' dietary patterns.

RESULTS

A significant relationship was observed between age and body mass index (BMI) across quartiles of the healthy dietary pattern score (P < 0.001, P = 0.001, and P = 0.001, respectively), indicating that as age and BMI increased, participants demonstrated greater adherence to the healthy dietary pattern. Individuals with the highest adherence to the healthy dietary pattern had the lowest odds ratio for celiac disease (CD) (Q1: reference; Q2: 1.96, 95% CI: 0.84-4.55; Q3: 0.61, 95% CI: 0.27-1.42; Q4: 0.10, 95% CI: 0.03-0.33, P trend < 0.001), and this association remained significant after adjusting for BMI (adjusted P trend = 0.003) and energy intake (adjusted P trend < 0.001). Moreover, there was a significant association between the lowest odds ratio for CD and the highest adherence to the unhealthy dietary pattern after adjustment for energy intake (Q1: reference; Q2: 0.38, 95% CI: 0.13-1.12; Q3: 0.21, 95% CI: 0.06-0.71; Q4: 0.07, 95% CI: 0.02-0.29, adjusted P trend < 0.001). Additionally, a significant association was observed between the odds ratio for CD and the mixed dietary pattern score (Q1: reference; Q2: 6.01, 95% CI: 2.29-15.72; Q3: 2.47, 95% CI: 0.93-6.55; Q4: 4.84, 95% CI: 1.84-12.66, P trend = 0.02), and this association remained significant after adjustment for energy intake (adjusted P trend < 0.001).

CONCLUSIONS

The findings of the present study indicate that individuals who adhere to healthy dietary patterns have a lower incidence of celiac disease.

Study Protocol for a Controlled Trial of Nutrition Education Intervention about Celiac Disease in Primary School: ZELIAKIDE Project

The only treatment for celiac disease (CD) is a strict and lifelong gluten-free diet (GFD), which must be safe and nutritionally balanced. Avoiding gluten brings difficulties with following the diet and can affect the social life of people with CD. The Zeliakide Project is a nutrition education program aimed at increasing the knowledge of the general population about healthy diets, CD and GFD, and, therefore, to improve the social inclusion and quality of life of people with CD. It is a one-month intervention program, two-armed cluster, non-randomised and controlled trial, conducted among 10-12-year-old children. Pre- and post-intervention evaluation and 1 month follow-up will be carried out to assess the effectiveness of the program. It is based on competencies and their respective learning outcomes. The teaching methodology chosen is a STEAM methodology: inquiry-based learning (IBL). A teaching unit has been created to develop the project, which, in the future, will be useful for the self-application of the program. This study will provide a valid and useful tool to achieve changes in the diet at the school level and will help to promote the social inclusion of people with CD. Moreover, it will enforce the STEAM competences of children.

Experiences and difficulties for primary caretakers of children with celiac disease - A qualitative study

BACKGROUND

The purpose of this study was to understand the experiences of primary caretakers (PCTs) with a child diagnosed with celiac disease (CeD). There is paucity of research in understanding the experiences of PCTs of children with CeD in India.

METHODS

Purposive sampling was used to select PCTs of CeD-affected children from a tertiary hospital in New Delhi. Ten PCTs took part in the investigation. To gather the data, semi-structured interviews were held with participants. Hindi was used to administer the interviews.

RESULTS

The current study focused on the difficulties and worries PCTs experience in managing CeD. The main themes and sub-themes that emerged from the data were diagnosis of CeD (misdiagnosis of CeD, late diagnosis of CeD, feelings at the time of diagnosis, help from a doctor/nutritionist at the time of diagnosis); characteristics of CeD (CeD as a new disease, CeD as an allergy); attitude towards wheat (wheat as a poison, ignorance regarding negative effect of wheat); influence of significant others (making fun of the child, queries from others are a source of worry, non-acceptance of celiac disease by others and pressure to give gluten to the child); issues in following gluten-free diet (GFD) (fear of cross-contamination, distrust on GFD available outside home, GFD is expensive, making GFD is difficult, joint family, non-adherence to GFD, making non-GFD along with GFD); effect of CeD (financial effect of CeD, effect on physical and mental health of the child and PCT, effect on social life, change in family dynamics, eating restrictions); management of CeD (GFD for the whole family to manage CeD, family support to manage CeD, adhering to GFD, early diagnosis); and concerns (future marital concern for the child, cure of CeD, proper physical growth).

CONCLUSION

The current study gave an understanding of how PCTs dealt with a child's CeD. The difficulties and worries of caretakers should be taken into consideration and appropriate recommendations made to lessen the strain of managing the child's CeD and the daily obstacles associated with it.

Experiences with Gluten-Free Bread: A Qualitative Study Amongst People with Coeliac Disease Participating in a Randomised Controlled Trial

BACKGROUND

Whole-grain bread can be an important source of fibre for people with coeliac disease (CeD) who must adhere to a gluten-free diet and avoid consuming wheat, rye and barley. Gluten-free bread frequently has a lower nutritional quality and different texture relative to gluten-containing counterparts.

OBJECTIVE

The aim was to investigate experiences with gluten-free bread amongst people with CeD prior to and during a randomised controlled trial (RCT).

DESIGN

We conducted individual interviews with 10 people with CeD participating in a RCT that aimed to investigate the effects of fibre-rich gluten-free products on metabolic regulation in people with CeD compared with benchmark gluten-free products. Five participants were in the control group (benchmark gluten-free bread) and five participants in the intervention group (fibre-rich gluten-free bread). The fibre-rich gluten free bread was formulated and prepared by the project group. The benchmark gluten-free bread was commercially available. The RCT lasted for four weeks. Interviews were conducted digitally between October 2021 and January 2022 and were thematically analysed.

RESULTS

Participants in both groups appeared to avoid bread prior to the study, primarily due to the poor taste and chewy consistency of the available bread in food stores and bakeries. Participants preferred the fibre-rich intervention bread as opposed to the available bread in the food market. However, participants had to become accustomed to eating the fibre-rich whole-grain bread during the study, since they avoided eating store-bought bread that they experienced chewy and not filling.

CONCLUSIONS

Participants asked for fibre-rich gluten-free bread products that are satiating and have a good texture. Palatable gluten-free bread products might be an important source of fibre for people with CeD.

Gluten-Free Product Recalls and Their Impact on Consumer Trust

The range of gluten-free food products available to consumers is steadily expanding. In recent years, recalls of food products have highlighted the importance of accurate labeling of food products for the presence of wheat, other gluten-containing cereals, or gluten itself as refined ingredient. The purpose of this study was to gain more insights into recent food recalls related to undeclared gluten/wheat contamination and consumer experiences with these recalls. Recalls of products triggered by gluten contamination are relatively scarce and are not often triggered by a consumer complaint. The impact of these recalls on consumer trust was evaluated through an online survey that was distributed among supporters of Celiac Canada (CCA) and covered (i) strategies to adhere to a gluten-free diet, (ii) experiences with gluten-free recalls and their impact on consumer trust, and (iii) demographic information. Consumer concern regarding gluten-free product recalls is significant, but the concern regarding recalls is not heightened after experiencing a recall. Companies pursuing transparency in the process, identification of the source of contamination, and mitigation strategies going forward are likely to retain consumer trust in their product and brand. Based on the survey results, further efforts focusing on consumer education regarding interpreting nutrient labels, identifying sources of information on product recalls, and understanding procedures to follow upon suspected gluten contamination of a gluten-free product are recommended.

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.

Health utilities and willingness to pay in adult patients with coeliac disease in Hungary

BACKGROUND

Coeliac disease (CD) is a life-long food-related disorder with a global prevalence of approximately 1%. Patients with CD often experience reduced health-related quality of life that could improve with a strict adherence to a gluten-free diet (GFD).

OBJECTIVES

To obtain visual analogue scale (VAS), time trade-off (TTO) and willingness-to-pay (WTP) values amongst patients with CD.

METHODS

In 2020-2021, a cross-sectional online survey was conducted amongst 312 adult CD patients in Hungary. Patients completed the Gastrointestinal Symptom Rating Scale (GSRS) and evaluated their current health and three hypothetical health state vignettes defined based on dietary adherence using VAS, conventional 10-year TTO and WTP. Multivariate regressions were used to explore the effect of patients' demographic and clinical characteristics on utility and WTP values.

RESULTS

Mean VAS values for current health and 'CD with strict adherence to GFD', 'CD with loose adherence to GFD' and 'CD without GFD' hypothetical health states were 79.69 ± 18.52, 85.36 ± 16.18, 62.44 ± 19.91 and 36.69 ± 25.83, respectively. Corresponding mean TTO utilities were: 0.90 ± 0.19, 0.91 ± 0.20, 0.87 ± 0.23 and 0.76 ± 0.29. Mean annual WTP values for returning to full health were: €845 ± 1077, €648 ± 1002, €862 ± 1135 and €1251 ± 1496. Older age at diagnosis, male sex, more severe gastrointestinal symptoms (GSRS) and having comorbidities were associated with lower VAS and TTO or higher WTP values for current own health (p < 0.05).

CONCLUSION

This is the first study to report TTO utilities for CD health states. Strict adherence to the GFD may result in substantial health gains in symptomatic patients. Utilities and WTP results can be used to estimate benefits of GFD in cost-utility and cost-benefit analyses.

Reliability, Validity, and Transcultural Adaptation of New Persian Version of Celiac Disease Quality of Life Questionnaire

Background: Health-related quality of life (HRQOL) assessment in patients with celiac disease (CD) leads to understanding the impact of the CD and interventions on the individual and society. The aim of this study was transcultural adaptation and evaluation of the reliability and validity of the standardized questionnaire of celiac disease quality of life (CD-QOL) in the Persian language in southwest Iran. Methods:150 adults with CD were randomly selected from the celiac clinic and Fars Celiac Registry to complete the New Persian version of the CD-QOL questionnaire. Transcultural adaptation of the questionnaire was conducted by a four-step procedure. The internal consistency of the CD-QOL subscales and convergent and discriminant validity were assessed using Cronbach's alpha coefficient and Spearman's correlation, respectively. Construct validity was evaluated by exploratory and confirmatory factor analysis. Results: All domains of the CD-QOL questionnaire had acceptable internal consistency, showing excellent reliability. The scaling success rates for convergent and discriminant validity were also within an acceptable range (87-100%). In the factor analysis model, similar to the original English version, four factors were extracted characterizing the patients' answers (limitations, dysphoria, health concerns, and inadequate treatment). Conclusion: Our Persian version of the CD-QOL questionnaire had high reliability and validity and could be used in clinical practice assessing the CD-specific HRQOL in the Iranian population.

A Comprehensive Review of the Neurological Manifestations of Celiac Disease and Its Treatment

Celiac disease (CD) is a common chronic inflammatory disorder occurring in genetically predisposed individuals secondary to gluten ingestion. CD usually presents with gastrointestinal symptoms such as pain, bloating, flatulence, and constipation or diarrhea. However, individuals can present in a nonclassical manner with only extraintestinal symptoms. The neurological manifestations of CD include ataxia, cognitive impairment, epilepsy, headache, and neuropathy. A lifelong gluten-free diet is the current recommended treatment for CD. This review discusses the relevant neurological manifestations associated with CD and the novel therapeutics. Further research is required to get a better understanding of the underlying pathophysiology of the neurological manifestations associated with CD. Clinicians should keep CD in the differential diagnosis in individuals presenting with neurological dysfunction of unknown cause.

Safety Assessment of Foods and Drinks Consumed by People on a Gluten-Free Diet

Naturally gluten-free foods and processed foods that do not contain information about the potential presence of gluten in them pose a hypothetical threat to people with food allergies and celiac disease. Patients who should follow a strict gluten-free diet do not always do so. Therefore, the aim of this research was to analyze certified “gluten-free” and naturally gluten-free products without labeled “may contain gluten” information in terms of their content of gluten proteins. The enzyme immunoassay AgraQuant Gluten G12 ELISA test kit was used for the analysis. Of all the products used in the research, only 5.8% were found to contain gluten above 20 ppm. Only one product labeled “gluten-free” was contaminated with gluten at 79.3 ppm (cider cake). In addition, our research also examined the gluten content of commercial beers containing barley malt not labeled as “gluten-free”. Research has shown that 60% of samples are not safe for those on a strict gluten-free diet. Our research clearly shows that many manufacturers, although they do not monitor their products for the presence of gluten in them, offer safe products, although they cannot be recommended in a gluten-free diet. Therefore, there is a strong need to increase the frequency of testing by food manufacturers for the presence of gluten in their products, so that the number of products approved for people on a gluten-free diet continues to increase.

Evaluation of a paediatric gluten-free food guide by children and youth with coeliac disease, their parents and health care professionals

There are currently no universal evidence-based nutrition guidelines that address the gluten-free (GF) diet for children/youth (4-18 years). A GF food guide was created to help children/youth with coeliac disease (CD) and their families navigate the complexities of following a GF diet. Guide formation was based on pre-guide stakeholder consultations and an evaluation of nutrient intake and dietary patterns. The study objective was to conduct an evaluation on guide content, layout, feasibility and dissemination strategies from end-stakeholder users (children/youth with CD, parents/caregivers and health care professionals). This is a cross-sectional study using a multi-method approach of virtual focus groups and an online survey to conduct stakeholder evaluations. Stakeholders included children/youth (4-18 years), their parents/caregivers in the coeliac community (n 273) and health care professionals (n 80) with both paediatric and CD experience from across Canada. Thematic analysis was performed on focus group responses and open-ended survey questions until thematic saturation was achieved. χ² and Fisher's exact statistical analyses were performed on demographic and close-ended survey questions. Stakeholders positively perceived the guide for content, layout, feasibility, ethnicity and usability. Stakeholders found the material visually appealing and engaging with belief that it could effectively be used in multi-ethnic community and clinical-based settings. Guide revisions were made in response to stakeholder consultations to improve food selection (e.g. child-friendly foods), language (e.g. clarity) and layout (e.g. organisation). The evaluation by end-stakeholders provided practical and patient-focused feedback on the guide to enable successful uptake in community and clinical-based settings.

Referral for Dietary Intervention in Celiac Disease Is Low among Gastroenterologists and Primary Care Providers

BACKGROUND

Strict adherence to a gluten-free diet is the only known effective treatment for celiac disease currently. Multiple organizations recommend follow-up with a dietitian and guideline-directed management after diagnosis. Few studies have evaluated follow-up post diagnosis. However, these do not include a systematic process for monitoring dietary referral among celiac disease patients. We sought to evaluate and compare the frequency of early dietary referral and guideline-directed preventive care and management for celiac disease patients managed by gastroenterologists and primary care providers.

METHODS

A retrospective chart review of celiac disease patients receiving care at a single tertiary care facility. Our primary outcome was to compare the frequency of dietary intervention between gastroenterologists and primary care providers in an outpatient setting after initial diagnosis. Multivariate analysis was performed to determine associated factors for referral for dietary intervention and recommended follow-up lab work.

RESULTS

261 patients were included in the study, 81.6% were followed by gastroenterologist and only 51% were seen by a dietitian. Patients following up with gastroenterologists had higher odds of referral for dietary intervention on multivariate analysis (OR 3.29, p value <0.003). Only 16% of all patients completed appropriate guideline-directed follow-up care.

CONCLUSIONS

Dietary intervention and follow-up of preventive care lab work were low in celiac disease patients. There is an opportunity for further education of both primary care providers and gastroenterologists on the importance of early dietary referral and appropriate medical management at follow-up.

Quality of Life in Teenagers and Adults With Coeliac Disease: From Newly Spanish Coeliac Disease Questionnaire Validation to Assessment in a Population-Based Study

Background

Coeliac disease (CD) is an immune-mediated systemic disorder elicited by the ingestion of gluten in genetically predisposed individuals. Gluten restriction in CD sufferers leads to numerous limitations in various aspects of daily life and can significantly impact the quality-of-life (QoL). The specific and widely used Coeliac Disease Questionnaire (CDQ) is an excellent tool to evaluate QoL in patients with CD, assessing physical, psychological, and social domains. This questionnaire is unavailable in Spain. Therefore, our study is the first to translate, culturally adapt, validate, and apply the Spanish version of CDQ to a representative sample of Spanish teenagers and adults with CD.

Methods

A total of 153 CD participants with biopsy-proven and self-reported gluten-free adherence were included in the cross-sectional study, which included four stages: (1) translation and retranslation of the French CDQ version into Spanish; (2) cultural adaptation and semantic evaluation; (3) CDQ validation through the internal consistency determination and reproducibility of the QoL; and (4) application of the questionnaire to Spanish teenagers and adults with CD and estimation of QoL using EQ-5D.

Results

The internal consistency and test–retest reliability of the Spanish CDQ were satisfactory and no ceiling or floor effects were detected. Significant correlations were identified between the CDQ scales, and the instrument for validation covering similar dimensions of the QoL was identified. The mean CDQ total score was 131.03 ± 24.1, and the social domain had the highest rating. There was no correlation between the time spent on a gluten-free diet and QoL. A significantly higher QoL score was reported among males and adolescents in the 15–17 age groups.

Conclusion

The newly Spanish CDQ is an appropriate tool to assess the QoL of the teenager and adult patients with CD. This study highlights the importance of identifying the affected scales to address actions to reduce the impact of the gluten-free diet burden of the coeliac patients and maintain public health regulations that support patients with chronic diseases such as CD.

Compliance with Gluten Free Diet Is Associated with Better Quality of Life in Celiac Disease

The quality of life (QOL) of patients with celiac disease (CD) can be altered by both symptoms of the disease and by the restrictions of the gluten-free diet (GFD). The objective was to determine the factors associated with better QOL in a large cohort of CD patients. A link to an online survey was sent to the members of the French Association of Gluten Intolerant People (AFDIAG). The French-Celiac Disease Questionnaire (F-CDQ), scoring from 0 to 100, was used to measure the QOL. Other data collected were sociodemographic characteristics, information on CD, purchasing and consumption habits of gluten-free products, and a self-assessment scale (ranging from 0 to 10) to determine the compliance with the GFD. Among the 907 CD patients who returned the questionnaire, 787 were analyzed (638 women (81%); median age: 49 years; 71% with self-assessed GFD compliance > 8). Their median F-CDQ was 73 (range: 59−82). In multivariate analysis, the main factors associated with a better quality of life were the long duration of the GFD, good compliance with the GFD, and the number of follow-up visits. Compliance with and duration of the GFD are associated with a better quality of life in patients with CD. Taking this into consideration would offset its restrictive aspect and improve its adherence.

The costs of celiac disease: a contingent valuation in Switzerland

This paper proposes a first monetary measure of the private costs of celiac disease, including intangible costs (physical symptoms, logistical constraints, etc.) in Switzerland. This auto-immune disease damages the intestine when patients ingest gluten. The only treatment currently available is a gluten-free diet, which implies great nutritional constraints. To get a monetary equivalent of the costs borne by celiac patients, we used a contingent valuation. The scenario suggested to celiac patients a treatment in form of a daily pill, which would allow them to eat normally and avoid any physical pain from celiac disease. Mean Willingness To Pay (WTP) for the treatment is found to be around CHF 87 (approx. USD 87) per month. WTP is positively influenced by direct and indirect costs of the disease. Oppositely, individuals, who find the gluten-free diet healthier are willing to pay less. Finally, unlike symptoms before diagnostic, the current presence or intensity of physical symptoms are found to be insignificant. The latter result can be explained by the fact that, individuals facing stronger symptoms are more likely to adhere strictly to the GFD and hence to reduce their frequency.

The Gluten-Free Diet for Celiac Disease and Beyond

The gluten-free diet (GFD) has gained popularity beyond its main medical indication as the treatment for gluten-induced immune-mediated disorders such as celiac disease (CD), dermatitis herpetiformis, gluten ataxia, wheat allergy, and non-celiac gluten sensitivity. However, the diet carries some disadvantages such as elevated costs, nutritional deficiencies, and social and psychological barriers. The present work aims to review indications, proven benefits, and adverse events of a gluten-free diet. Close follow-up with patients following the diet is recommended. More data is needed to assess the effectiveness of the diet in managing mental and cognitive disorders and to establish a connection between the brain and gluten.

Barriers of Adherence to a Gluten-Free Diet in Iranian Adults With Celiac Disease

This cross-sectional study aimed to evaluate and classify barriers to adherence to the gluten-free diet in 137 Iranian adults with celiac disease. We used a 23-point Likert questionnaire and exploratory factor analysis to identify and classify the barriers. Adherence to gluten-free diet was assessed by measuring the serum level of anti-tTG-IgA. The correlation between the barriers and adherence to gluten-free diet was assessed using logistic regression. A total of 117 subjects completed the study. Seven factors were extracted: "gluten-free diet restrictions," "self-awareness and social awareness," "psychological barriers," "education," "situational barriers and gatherings," "lack of access/labeling," and "cost." There was a significant correlation between the situational barriers and gatherings and nonadherence to the diet in the adjusted model (odds ratio = 1.63; 95% confidence interval [1.03, 2.54], p = .03). Nutritionists and physicians should consider these barriers when consulting patients with celiac disease.

The influence of a gluten-free diet on health-related quality of life in individuals with celiac disease

Background

Adherence to a gluten-free diet (GFD) and food insecurity (FI) may influence health-related quality of life (HRQOL) in individuals with celiac disease (CD). This study aimed to investigate the association between adherence to a GFD, FI, and HRQOL in individuals with CD.

Methods

This cross-sectional study included 97 adults (mean age: 34 ± 9 years) diagnosed with CD. The participants were on a GFD for more than 6 months. Sociodemographic characteristics and medical history were assessed. Adherence to a GFD, FI, and HRQOL were assessed using validated questionnaires.

Results

Most participants (73%) adhered to a GFD, and 62% were experiencing FI. Individuals with CD faced difficulty in accessing GF foods due to the high cost (90%) and limited availability (79%). The mean overall HRQOL score was 60. Scores on the physical and mental health domains were 69 and 47, respectively. Adherence to a GFD was significantly associated with FI (P = 0.02), while there was no association between adherence to a GFD and HRQOL measures (P > 0.05). Participants facing FI had lower scores in emotional well-being and mental health domains, and overall HRQOL (P < 0.05).

Conclusions

The findings of the present study demonstrate that FI influences adherence to a GFD, and that FI is associated with HRQOL in terms of both emotional well-being and mental health.

Dietary Changes Among Breastfeeding Mothers

BACKGROUND

Breastfeeding mothers have been avoiding foods in their diet based on ancient beliefs that it can prevent/reduce unsettled infant crying-fussing behavior.

RESEARCH AIMS

This study aimed to explore (1) the prevalence of maternal dietary changes during the postpartum period; (2) the demographic and infant feeding differences between women who made dietary changes and those who did not; (3) the reasons for dietary change; and (4) what specific foods were avoided.

METHODS

A prospective, cross-sectional 2-group comparison using an online survey mixed-methods design was advertised via social media and Australian websites. Anonymous volunteers who were presently breastfeeding or had breastfed for any length of time in the past were eligible.

RESULTS

Of 1,262 participants, 966 (77%) avoided foods/beverages in their diet. The most commonly avoided beverages were alcohol (79%) and coffee (44%), and the most commonly avoided foods were chili (22%), milk-chocolate (22%), cabbage (20%), onion (20%), and garlic (16%). Reasons for dietary avoidance related to baby being unsettled (31%), baby having wind/gas (29%), colic (11%), and crying (10%). Of 245 participants who removed dairy, 80 (33%) did not substitute with calcium-rich alternatives. Food and beverage avoidance commenced as early as 1 week postpartum and continued until mean (SD) infant age of 9 (5) months.

CONCLUSIONS

It is commonplace for breastfeeding mothers to avoid foods and beverages for reasons associated with infantile colic. Of major concern is the duration of food avoidance during a time of increased nutritional requirements. This information may assist in improving the nutritional support given to breastfeeding mothers.

Systematic review: Exploration of the impact of psychosocial factors on quality of life in adults living with coeliac disease

BACKGROUND

Individuals living with coeliac disease generally experience a remission of symptoms after adopting the gluten-free diet but often report substantial treatment burden and ongoing quality of life issues. Psychosocial factors have been suggested to play a significant role in post-diagnosis quality of life but have yet to be systematically reviewed.

AIM

To review the evidence for psychosocial factors associated with quality of life in adult coeliac disease cohorts.

METHODS

Studies were identified via systematic searches of eight databases (MEDLINE, Embase, Emcare, PsycINFO, Ovid Nursing, CINAHL, Informit Health Collection, Cochrane Library) in May 2019.

RESULTS

Fourteen studies were included involving 3372 participants (80.2% female, mean age = 46.4 years). Symptoms of depression and anxiety were the most examined psychosocial factors across all studies. Quality of life was differentially associated with psychological distress, illness perceptions, coping, and attitudes/behaviours regarding food and the gluten-free diet.

CONCLUSION

Several psychosocial factors are associated with quality of life in adults living with coeliac disease. Current evidence suggests these factors are interrelated and may influence quality of life directly, via reduced psychological well-being, and indirectly, via reduced adherence to the gluten-free diet. Future research is needed to examine these processes concurrently, with the aim of elucidating the psychosocial mechanisms underlying post-diagnosis well-being and identifying potential targets for psychosocial intervention.

Patient Perspectives of Living with Coeliac Disease and Accessing Dietetic Services in Rural Australia: A Qualitative Study

Adapting to living with coeliac disease requires individuals to learn about and follow a strict gluten-free diet. Utilising a qualitative inductive approach, this study aimed to explore the perspectives of adults diagnosed with coeliac disease who have accessed dietetic services in a rural outpatient setting. A purposive sample of adults with coeliac disease who had accessed dietetic services from two rural dietetic outpatient clinics were recruited. Semi-structured interviews were conducted by telephone. Data were thematically analysed. Six participants were recruited and interviewed. Three key themes emerged: (i) optimising individualised support and services, (ii) adapting to a gluten-free diet in a rural context, and (iii) managing a gluten-free diet within the context of interpersonal relationships. Key issues identified in the rural context were access to specialist services and the increased cost of gluten-free food in more remote areas. The findings of this study have highlighted the difficulties associated with coeliac disease management and how dietetic consultation has the potential to influence confidence in management and improve lifestyle outcomes. Further qualitative research is required to expand on the findings of this study and inform future dietetic practice that meets the expectations and individual needs of people with coeliac disease in rural settings.

Predictors of adherence to a gluten-free diet in celiac disease: Do knowledge, attitudes, experiences, symptoms, and quality of life play a role?

OBJECTIVES

This study aimed to identify the relationship between adherence to a gluten-free diet (GFD) and demographic characteristics, knowledge, attitudes, and beliefs regarding celiac disease (CD) and GFD, experiences of following a GFD, symptoms, and quality of life (QoL).

METHODS

Patients with CD were recruited from outpatient clinics. Adherence to GFD was assessed using the CD adherence test (CDAT) and GFD score (GFD-S). Knowledge, attitudes, experiences, symptoms, and QoL were assessed using existing questionnaires. A multivariate logistic regression was performed.

RESULTS

Overall, 116 patients with CD were included (48 ± 16 y; 70% female). Based on the CDAT, 58 patients (50%) were adequate adherers, but 86 patients (74%) were adequate adherers according to GFD-S. When adherence was measured using the CDAT, being female was associated with lower odds of adherence (odds ratio [OR]: 0.36; P = 0.028), and better emotional wellbeing was associated with higher odds of adherence (OR: 1.19; P < 0.001). When adherence was measured using GFD-S, membership in a support group (OR: 6.17; P = 0.002), stronger beliefs about the chronicity of CD (OR: 1.15; P = 0.059), and weaker beliefs on accident/chance causing CD (OR: 1.94; P = 0.05) were associated with greater odds of adherence. Difficulties when eating with family/friends (OR: 0.98; P = 0.005) and weaker beliefs on immunity causing CD (OR: 0.77; P = 0.031) were associated with lower odds of adherence.

CONCLUSIONS

The association between gender, attending support groups, attitudes, experiences, and QoL with adherence to a GFD should be considered by health care professionals managing patients with CD.

Nutritional considerations of a paediatric gluten-free food guide for coeliac disease

The gluten-free (GF) diet is the only treatment for coeliac disease (CD). While the GF diet can be nutritious, increased reliance on processed and packaged GF foods can result in higher fat/sugar and lower micronutrient intake in children with CD. Currently, there are no evidence-based nutrition guidelines that address the GF diet. The objective of this cross-sectional study was to describe the methodological considerations in forming a GF food guide for Canadian children and youth (4–18 years) with CD. Food guide development occurred in three phases: (1) evaluation of nutrient intake and dietary patterns of children on the GF diet, (2) pre-guide stakeholder consultations with 151 health care professionals and 383 community end users and (3) development of 1260 GF diet simulations that addressed cultural preferences and food traditions, diet patterns and diet quality. Stakeholder feedback identified nutrient intake and food literacy as important topics for guide content. Except for vitamin D, the diet simulations met 100 % macronutrient and micronutrient requirements for age–sex. The paediatric GF plate model recommends intake of >50 % fruits and vegetables (FV), <25 % grains and 25 % protein foods with a stronger emphasis on plant-based sources. Vitamin D-fortified fluid milk/unsweetened plant-based alternatives and other rich sources are important to optimise vitamin D intake. The GF food guide can help children consume a nutritiously adequate GF diet and inform policy makers regarding the need for nutrition guidelines in paediatric CD.

Multidimensional Disadvantages of a Gluten-Free Diet in Celiac Disease: A Narrative Review

A gluten-free diet is the mainstay method of treatment and the prevention of celiac disease complications. However, an inadequately balanced gluten-free diet can increase the risk of obesity, negatively affect glucose and lipid metabolism, and increase the risk of the metabolic syndrome. Therefore, an adequate nutritional counselling is necessary for patients diagnosed with celiac disease in order to prevent and treat the components of the metabolic syndrome.

Differences Between Familial and Sporadic Celiac Disease

BACKGROUND

It is not known if genetic background, characteristics at diagnosis, physical and psychological well-being, and adherence to a gluten-free diet are comparable between patients with familial or sporadic celiac disease. These issues were investigated in a follow-up study.

METHODS

Altogether 1064 patients were analyzed for celiac disease-associated serology, predisposing HLA-DQ, and non-HLA genotypes. Medical data were collected from patient records and supplementary interviews. Current symptoms and quality of life were further evaluated with the Gastrointestinal Symptom Rating Scale (GSRS), the Psychological General Well-Being questionnaire (PGWB), and Short Form 36 (SF-36) questionnaires.

RESULTS

Familial and sporadic groups differed (P < 0.001) in the reason for diagnosis and clinical presentation at diagnosis, familial patients being more often screen-detected (26% vs. 2%, P < 0.001) and having less often gastrointestinal (49% vs. 69%) and severe symptoms (47% vs. 65%). The groups were comparable in terms of histological damage, frequency of malabsorption, comorbidities, childhood diagnoses, and short-term treatment response. At the time of the study, familial cases reported fewer symptoms (21% vs. 30%, P = 0.004) and lower prevalence of all (78% vs. 86%, P = 0.007), neurological (10% vs. 15%, P = 0.013), and dermatological (9% vs. 17%, P = 0.001) comorbidities. Dietary adherence and GSRS scores were comparable, but familial cases had better quality of life according to PGWB and SF-36. High-risk genotype HLA-DQ2.5/DQ2.5 was more frequent among familial cases, and four non-HLA SNPs were associated with familial celiac disease.

CONCLUSIONS

Despite the greater proportion of high-risk genotypes, familial cases had milder symptoms at presentation than did sporadic cases. Worse experience of symptoms and poorer quality of life in sporadic disease indicate a need for intensified support.

Experiences of managing a gluten-free diet on multiple levels of society: a qualitative study

Background

Coeliac disease (CD) is an immune-mediated enteropathy against dietary gluten. The treatment for CD is a strict life-long gluten-free (GF) diet, which has a profound effect on a person’s life. In recent years, there has been an increase in the availability of gluten-free products. This study investigates how people with CD experience and manage a GF diet.

Methods

Semi-structured, individual interviews were conducted in different areas of Norway. The analysis was guided by Interpretative Phenomenological Analysis. Participants with CD (n = 12) varied in terms of gender, age, family composition and time since diagnosed.

Results

The analysis revealed challenges for a GF diet at the individual, interpersonal, community and policy levels. At the individual level, the participants explained that it took time to gain knowledge about a GF diet, and they expressed uncertainty about the healthiness of a GF diet. At the interpersonal level, the feeling of being different and the fear of gluten contamination were barriers to the enjoyment of social meals. At the community level, the participants asked for a wider selection of tastier GF products to purchase and increased knowledge about CD among those who prepare and sell GF foods. At the policy level, the participants asked for political action to make GF products more affordable.

Conclusions

This study indicates that people with CD should be given information about how to manage a GF diet right after being diagnosed with CD. The food industry should be encouraged to produce healthy and tasty GF products.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s40795-020-00390-3.

Measurement of Inter-Individual Variability in Assessing the Quality of Life in Respondents with Celiac Disease

Quality of life of Celiac Disease (CD) patients is affected by constraints in their physical, social and emotional behaviour. Our objective is to assess differences in two relevant dimensions of the Celiac Quality of Life (CQoL) scale, Limitations due to the disease and Dysphoria (i.e., feelings of depression and discomfort), in relation to the perceived social support and some individual and disease-related characteristics. The paper exploits suitable unidimensional Item Response Theory (IRT) models to individually analyse the two mentioned dimensions of the CQoL and Multidimensional Latent Class IRT models for ordinal polytomous items in order to detect sub-populations of CD patients that are homogenous with respect to the perceived CQoL. The latter methods allow to address patients with similar characteristics to the same treatment, performing at the same time a more tailored overture to health promotion programmes. The analysis extracts the relevant patterns and relations among CD patients, disentangling respondents receiving CD diagnosis in adolescence or adult age rather than in childhood (the first perceive high levels of Limitations and Dysphoria), patients with high perceived social support, a factor influencing in a positive way motivation to engage in management of CD-related distress and psychological well-being, and participants who are married or cohabiting. The latter report higher latent trait levels.

Quality-of-Life Evaluation in Coeliac Patients on a Gluten-Free Diet

The treatment for coeliac disease (CD) has a considerable psychological impact on patients, which may vary depending on subjects and clinical characteristics. The aim of this study was to describe the quality of life (QoL) in CD patients during follow-up, evaluating which factors can influence it. Patients with CD who consecutively visited the outpatient clinic of CD Unit of the University Hospital of Padua from January to September 2019 were enrolled. Demographics and clinical information were collected, and all patients were asked to answer the CD-QoL and Biagi’s validated questionnaires. Student’s t-test and chi-square test were used to compare the continuous and categorical variables, respectively. One hundred patients were enrolled (86 females, mean age at test ± SD: 39.73 ± 13.51; mean age at diagnosis ± SD: 33.09 ± 12.92), with 61% of them having been diagnosed with CD within the previous 5 years. At the time of diagnosis, 43 CD patients reported classical CD presentation, 32 non-classical features, 16 only anaemia and 9 were asymptomatic. The mean CD-QoL value was overall high (80.54 ± 11.91). We found that the “health concerns” subscale score was significantly lower in subjects aged more than 35 years compared to younger subjects (p = 0.03). We also observed that the CD-QoL score in gluten-free diet (GFD)-adherent patients tended to be higher compared to subjects who were non-compliant, with a significantly higher percentage of patients with low score for the “dysphoria” subscale (p = 0.05). This study showed an overall good QoL in subjects on a GFD. However, subjects older and non-compliant to GFD appear to experience more health concerns and suffer from dysphoria, respectively.

Evaluation of Quality of Life of Adult Patients with Celiac Disease in Argentina: From Questionnaire Validation to Assessment

This cross-sectional study aimed to translate, culturally adapt, validate, and apply a Celiac Disease Quality of Life (CD-QoL) questionnaire to a representative sample of Argentina’s celiac population. A previously developed and validated questionnaire (Celiac Disease Questionnaire: CDQ) was chosen as a tool for assessing the health-related quality of Life (HRQoL) of adult celiac patients in Argentina. Therefore, the study was performed in four stages: (a) translation and re-translation of the CDQ to Argentinian-Spanish language; (b) cultural adaptation and semantic evaluation; based on the Delphi method (c) validation of the CDQ by applying it to a representative sample of Argentinian celiac patients; (d) statistical analysis of the data. The result of stages (a) and (b) was a translated and culturally adapted an Argentinian-Spanish version of the CDQ, which was generated after reaching consensus between the corresponding four (phase a) and 10 (phase b) professionals involved in the different phases of this process. Among them, we can cite bilingual healthcare professionals with extensive experience in research and celiac disease, celiac patients, gastroenterologists, general practitioners, dieticians, and psychologists. The resulting CDQ proved to be an appropriate measuring tool to assess the HRQoL of Argentinian celiac patients confirmed by a good fit in the confirmatory factor validity analysis (RMSEA < 0.001 and χ² = 267.325, df = 313, p = 0.971) and high values of internal consistency (Cronbach’s alpha > 0.7). A total of 191 participants accessed the questionnaire, and 171 individuals from 20 out of 23 Argentinian states completed the questionnaire. There was no correlation between higher educational level nor marital status with QoL. Individuals on a strict gluten-free diet (GFD) and those who do not take antidepressants showed higher QoL. Male gender also presented better HRQoL. There was no correlation between differences in HRQoL and age of the respondent, age at diagnosis, symptoms at diagnosis, or having other chronic diseases. However, a significantly higher score of HRQoL was reported among those individuals who disclosed having knowledge of CD related national regulations and benefits. This study highlights the importance of maintaining current public health regulations that support chronic disease patients, such as celiac patients.

Celiac Dietary Adherence Test and Standardized Dietician Evaluation in Assessment of Adherence to a Gluten-Free Diet in Patients with Celiac Disease

Adherence to a gluten-free diet (GFD) is currently the mainstay of treatment strategy for celiac disease (CD). The aim of our study was measuring a GFD adherence in CD patients using two newly validated methods of dietary assessment-Standardized Dietician Evaluation (SDE) and the Celiac Dietary Adherence Test (CDAT). Ninety-two adults with CD were evaluated by a registered dietitian with extensive experience with the use of SDE and CDAT. Duodenal biopsy was performed and blood was drawn for serum anti-endomysial, anti-deamidated gliadin peptide and anti-tissue transglutaminase antibodies in forty four of those patients. The results of CDAT and SDE were very convergent, but SDE scores better correlated with serologic and histologic findings. As many as 24-52% of study participants did not adhere well enough to a GFD. Insufficient adherence to a GFD in CD patients is still a significant problem. The knowledge about gluten content in food ingredients and additives is very low among adults with CD. SDE is the most accurate method in assessing compliance with a GFD and is especially helpful in determining hidden sources of gluten. The CDAT may be a fast tool for screening for a GFD adherence in CD patients.

Facilitators and barriers to adherence to gluten-free diet among adults with celiac disease: a systematic review

BACKGROUND

Coeliac disease (CD) is a chronic, autoimmune disease that prevents individuals from processing gluten, leading to adverse health effects. People with CD should adhere to a gluten-free diet (GFD); however, adherence rates are well below optimal in adults with CD, ranging between 42% and 91%. To date, limited evidence is available on the nature and magnitude of factors that affect adherence to GFD. The present study aimed to develop a systematic review that critically appraises and synthesises evidence on facilitators and barriers that affect adherence to GFD among adults with CD.

METHODS

Four databases were searched (Ovid Medline, CINAHL, PsychInfo and Embase) using variant keywords to identify empirical studies meeting the inclusion/exclusion criteria. A coding scheme was developed to extract relevant information from each article.

RESULTS

Forty articles were included. Grounded in the bioecological theory of development, we synthesised the facilitators and barriers in the literature into a social ecological model with multiple levels: system, community, organisational, interpersonal and individual. The studies varied by design and level of evidence; only one randomised trial was identified. The most significant facilitators include (% of studies): increased education (22.5%); increased knowledge of a GFD (20%); increased intention/self-regulatory efficacy (17.5%); and coeliac association membership (12.5%). The most significant barriers include: lower knowledge of CD (35%); restaurant/supermarket shopping (30%); poor patient education from practitioner (17.5%); and low intention/motivation to adhere to a GFD (17.5%).

CONCLUSIONS

Improving knowledge of a GFD, becoming a member of a coeliac association, and improving practitioners' abilities to educate patients on CD will create opportunities for improved adherence to GFD among adults with CD.

Concepts and Instruments for Patient-Reported Outcome Assessment in Celiac Disease: Literature Review and Experts' Perspectives

BACKGROUND

In diseases where there is a large subjective component, such as celiac disease (CD), patient reported-outcomes (PRO) endpoints are highly relevant. However, there is a gap in knowledge about which PRO endpoints and instruments should be used for clinical trials for treatment of celiac disease.

OBJECTIVES

To identify patient-centered symptom, impact, and health-related quality of life (HRQoL) concepts in CD and relevant PRO instruments, and to gather expert input on concepts and instruments to inform selection of PRO endpoints for use in clinical trials of new CD treatments.

METHODS

A targeted literature review was conducted to identify symptom, impact, and HRQoL concepts, including those captured in PROs further reviewed against U.S. Food and Drug Administration standards for development and validation as endpoints. US and European clinicians, payers, and a patient advocate (n = 21) were interviewed to assess the identified concepts' relative importance in measuring treatment benefit and to gauge the value of potential PROs as endpoints for market access/reimbursement.

RESULTS

Thirty-four published studies were identified: 27 elucidated patient-centered concepts and 7 detailed the development or validation of PRO instruments. The Celiac Disease Symptom Diary and Celiac Disease Patient Reported Outcome instrument were deemed most appropriate for use as endpoints; however, each had limitations related to conceptual coverage, evidence for measurement properties, and feasibility for use in clinical trials. Experts reported gastrointestinal symptoms as most important to treat, with extra-intestinal symptoms burdensome from the patient perspective as well. Payers emphasized measuring both frequency and severity of symptoms and targeting patients nonresponsive to the gluten-free diet for treatment.

CONCLUSIONS

With emerging treatment options for CD, further work is needed to operationalize PRO symptom endpoints that are meaningful to patients, valued by payers, and acceptable to regulators in demonstrating efficacy.

Are gluten-free food staples accessible to all patients with coeliac disease?

INTRODUCTION

Within England the removal of prescribed gluten-free (GF) foods from many Clinical Commissioning Groups has resulted in a greater reliance on commercially available GF food by adults and children with coeliac disease (CD). High cost and limited availability of GF foods are associated with poorer dietary adherence in people with CD.

AIM

To assess if the rise in popularity of GF diets globally has improved the cost or availability of cereal-based GF foods over the past 6 years.

DESIGN

Observational study where data were collected on cereal-based GF foods from 50 stores and 10 internet retailers. The number of GF foods within each food category and the cost per 100 g of GF and gluten-containing (GC) foods were compared by store type.

RESULTS

GF food availability has increased in premium stores and online. The majority (82%) of GF food categories were significantly more expensive online compared with regular supermarkets. On average, GF breads were 400% more expensive compared with GC breads (p<0.001); no narrowing in cost difference over time observed. Convenience stores did not stock any GF bread nor GF pasta and only one of the budget supermarkets stocked them, similar to data reported 6 years ago.

CONCLUSIONS

GF food availability has increased, predominately in premium markets. The GF food desert within convenience and budget stores will continue to disproportionately impact poor socioeconomic cohorts, the elderly and physically disabled. A lack of accessibility to GF foods impacts GF dietary adherence, increasing related comorbidities and healthcare costs.

Compliance with gluten-free diet in a selected group of celiac children in the Slovak Republic

OBJECTIVE

Celiac disease (CD) is a chronic long-term disease with autoimmune disorder connected to an allergic reaction to the molecule of gluten. CD is manifested in persons who are genetically predisposed. The only therapy for CD is a strong gluten-free (GF) diet. The aim of our study was to follow the adherence to the gluten-free diet in the selected group of parents and caregivers of children with CD, and to compare factors influencing the adherence to GF diet and therefore influencing also clinical symptoms of CD. We compared and examined important food-related activities as well, by using a personal questionnaire in the group of CD children's parents or caregivers.

METHODS

We designed a cross-sectional study; 325 parents or caregivers of children with CD were recruited in the sample. CD was confirmed by the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) criteria. The anonymous questionnaires were collected at summer camps within period data 2012-2016 and followed factors which might have an influence on compliance with GF diet, according to parents' opinions.

RESULTS

Adherence to GF diet was statistically significantly higher among girls compared to boys. Parents' questionnaires confirmed that younger group of children and children with the family history of CD had statistically higher compliance with GF diet. Parents with higher education confirmed better adherence to GF diet, statistical analyses confirmed higher adherence in mother´s education compared to father's education. Duration of CD, socio-demographic factors of parents - age of parent, gender of parent, and residency were not statistically significant in terms of compliance with the diet.

CONCLUSIONS

Our study confirmed important factors influencing adherence to the GF diet, which are connected to the symptoms and consequences of CD. The assessment of parents' opinions and burden on the families of children with celiac disease should be also reflected in the evaluation of patient's status. Important is also the role of parents in order to facilitate and support clinical interventions and prevention of CD.

Adults following a gluten-free diet report little dietary guidance in a pilot survey exploring relationships between dietary knowledge, management, and adherence in Nova Scotia, Canada

The strict nature of a gluten-free diet (GFD) poses a challenge for patient adherence and for clinicians to provide comprehensive client-centered care. Evidence on the relationship between nutrition knowledge, food skills, dietary management, and adherence can guide healthcare professionals counseling patients following this diet. In this explanatory pilot study, a province-wide survey (phase I) with 68 community-dwelling Nova Scotians following a GFD was conducted to investigate relationships between personal, social, and health care factors and dietary adherence using a mixed-methods approach. A sub-sample of 19 survey respondents were interviewed (phase II) to explore contextual experiences related to GFD knowledge, food skills, dietary management, and adherence using a food literacy lens. Here, we report findings from phase I, in which 37 participants with self-reported celiac disease (CD) and 31 participants reporting non-celiac reasons for wheat restriction (NCWR) completed a detailed 41-item online questionnaire. Self-reported data combined for both CD and NCWR respondents showed 76% perceived their health status as good to excellent. Most (62%) reported not receiving GFD advice from a health professional. Respondents with higher frequency of intentional consumption of gluten were more likely to have fewer correct answers to a food label quiz (ρ = -0.44; P = .0002). Most participants (75%) made at least one error in identifying gluten-free and gluten-containing foods, which may lead to unintentional gluten consumption and/or unnecessarily restricting safe foods. Findings from this exploratory study suggest patients may lack adequate referrals and support within the health care system and the community, adding to individual challenges of GFD adherence.

Identifying and improving adherence to the gluten-free diet in people with coeliac disease

Coeliac disease (CD) is an autoimmune gastrointestinal disorder whereby the ingestion of gluten, a storage protein found in wheat, barley and rye, causes damage to intestinal mucosa with resultant malabsorption, increased risk of anaemia and osteoporosis. Worldwide estimates suggest 1% of the population have CD. With no cure, the only treatment is a gluten-free diet (GFD). Adhering to a GFD can be very challenging; it requires knowledge, motivation and modified behaviours. Assessing adherence to a GFD is methodologically challenging. This review aims to provide an overview of the literature reporting adherence to a GFD in people with CD and the methodological challenges encountered. From six studies it has been reported that rates of adherence to a GFD range between 45 and 90% in patients of different ethnicities with CD. GF dietary adherence can be influenced by age at diagnosis, coexisting depression, symptoms on ingestion of gluten, nutrition counselling, knowledge of GF foods, understanding of food labels, cost and availability of GF foods, receiving GF foods on prescription and membership of a coeliac society. To date only five intervention studies in adults with CD have been undertaken to improve GF dietary adherence. These have included dietary and psychological counselling, and the use of online training programmes, apps, text messages and telephonic clinics. Future interventions should include people of all ethnicities, consider patient convenience and the cost-effectiveness for the healthcare environment.

Fatigue as an Extra-Intestinal Manifestation of Celiac Disease: A Systematic Review

Celiac disease may present with a range of different symptoms, including abdominal problems in a broader sense, iron deficiency and “constant tiredness”. All of these symptoms should consequently lead the clinicians to consider celiac disease as a potential etiopathogenetic cause. Although the pathophysiology of celiac disease is well documented, the actual mechanisms for disease presentation(s) are less well understood. We here address the topic of fatigue in celiac disease. A systematic literature search identified 298 papers of which five met the criteria for full evaluation. None of the reviewed papers were of high quality and had several methodological weaknesses. We conclude that there is an unmet need to study the contributing factors and management of fatigue in celiac disease.

Headache Associated with Coeliac Disease: A Systematic Review and Meta-Analysis

Objective: The aim of this systematic review was to explore the relationship between coeliac disease (CD) and headache. The objectives were to establish the prevalence of each entity amongst the other, to explore the role of gluten free diet (GFD), and to describe the imaging findings in those affected by headaches associated with CD. Methodology: A systematic computer-based literature search was conducted on the PubMed database. Information regarding study type, population size, the age group included, prevalence of CD amongst those with headache and vice versa, imaging results, the nature of headache, and response to GFD. Results: In total, 40 articles published between 1987 and 2017 qualified for inclusion in this review. The mean pooled prevalence of headache amongst those with CD was 26% (95% CI 19.5–33.9%) in adult populations and 18.3% (95% CI 10.4–30.2%) in paediatric populations. The headaches are most often migraine-like. In children with idiopathic headache, the prevalence of CD is 2.4% (95% CI 1.5–3.7%), whereas data for adult populations is presently unavailable. Brain imaging can be normal, although, cerebral calcifications on CT, white matter abnormalities on MRI and deranged regional cerebral blood flow on SPECT can be present. GFD appears to be an effective management for headache in the context of CD, leading to total resolution of headaches in up to 75% of patients. Conclusions: There is an increased prevalence of CD amongst idiopathic headache and vice versa. Therefore, patients with headache of unknown origin should be screened for CD, as such patients may symptomatically benefit from a GFD.

Social and Emotional Fears and Worries Influencing the Quality of Life of Female Celiac Disease Patients Following a Gluten-Free Diet

The gluten-free diet is effective in the majority of celiac disease (CD) patients, but it is burdensome and may influence quality of life (QoL). The aim of the study was to analyze the social and emotional fears and worries influencing the QoL of female CD patients following a gluten-free (GF) diet, as well as to indicate the sociodemographic interfering factors. The study was conducted on a group of 251 female CD patients, while emotional, social and worries subscales of the Celiac Disease Questionnaire (CDQ) were applied, as well as purchase-related emotions and behaviors were assessed. Respondents declaring worse economic status obtained significantly lower scores in the emotional, social and worries subscales of the CDQ than respondents declaring better economic status, while for other factors (CD duration, GFD adherence, BMI, place of residence and educational level) no significant association was stated in the multi-factor analysis. Moreover, respondents declaring worse economic status more often declared that a bad mood affected their purchase decisions than did respondents declaring better economic status. It was stated, that the economic status of CD patient could be one of the most important factors influencing their social and emotional fears and worries. It may be supposed that low economic status may lead some CD patients to choose to relieve stress by purchasing GF products instead of other products.

A Review on the Gluten-Free Diet: Technological and Nutritional Challenges

Consumers, food manufacturers and health professionals are uniquely influenced by the growing popularity of the gluten-free diet. Consumer expectations have urged the food industry to continuously adjust and improve the formulations and processing techniques used in gluten-free product manufacturing. Health experts have been interested in the nutritional adequacy of the diet, as well as its effectiveness in managing gluten-related disorders and other conditions. In this review, we aim to provide a clear picture of the current motivations behind the use of gluten-free diets, as well as the technological and nutritional challenges of the diet as a whole. Alternative starches and flours, hydrocolloids, and fiber sources were found to play a complex role in mimicking the functional and sensory effects of gluten in gluten-free products. However, the quality of gluten-free alternatives is often still inferior to the gluten-containing products. Furthermore, the gluten-free diet has demonstrated benefits in managing some gluten-related disorders, though nutritional imbalances have been reported. As there is limited evidence supporting the use of the gluten-free diet beyond its role in managing gluten-related disorders, consumers are urged to be mindful of the sensorial limitations and nutritional inadequacies of the diet despite ongoing strategies to improve them.

Health-related quality of life in Spanish coeliac children using the generic KIDSCREEN-52 questionnaire

The aim of this study is to assess the impact of coeliac disease (CD) on health-related quality of life (HRQOL) using the generic KIDSCREEN-52 questionnaire in a group of Spanish children aged 8-18 years and their parents. For this cross-sectional study, coeliac children in the targeted age range, who are members of the Madrid Coeliac Association (MCA), were invited to participate. The Spanish version of the generic KIDSCREEN-52 questionnaire was administered via e-mail. Scores (on a scale from 1 to 100) were expressed as the mean and standard deviation (SD). Demographic and clinical variables related to HRQOL were also assessed. The questionnaire was completed by 434 children and/or their parents. Respondents gave scores of over 50 to seven quality of life domains. Mean scores were significantly higher in children than in their parents for six out of ten domains. In contrast, parents awarded significantly higher scores to the "social support and peers" domain than children did. Significantly lower QOL scores were reported by girls, children aged 16-18 years, children older than 7 years at the time of CD diagnosis, and respondents who did not adhere to the prescribed diet or had difficulty in doing so.

CONCLUSION

Overall, the KIDSCREEN-52 questionnaire revealed that CD had no substantial negative impacts on the children's QOL. However, some concerns from the children's perspective were identified, such as issues regarding relationships with their peers. These issues will need to be addressed in order to improve QOL in children with CD. What is Known: • According to the Spanish version of the specific CDDUX, parents and children felt CD had no substantial negative impacts on their HRQOL. What is New: • According to the generic KIDSCREEN-52 questionnaire, QOL in Spanish coeliac children does not seem to be negatively affected by the disease in most general aspects of life. • Parents have a worse perception of their children's HRQOL than their children themselves.

Quality of life in coeliac disease: item reduction, scale development and psychometric evaluation of the Coeliac Disease Assessment Questionnaire (CDAQ)

BACKGROUND

A better understanding of coeliac disease can be achieved by assessing health-related quality of life alongside clinical factors. Existing patient-reported outcome measures (PROMs) evaluating quality of life in coeliac disease have not been developed in accordance with the US Food and Drug Administration guidelines.

AIM

To develop a PROM in accordance with best practice guidelines, capturing all aspects of quality of life important to adults with coeliac disease.

METHODS

Candidate items for the Coeliac Disease Assessment Questionnaire (CDAQ) were refined through item appraisal, expert review, cognitive interviews, and a translatability assessment. A cross-sectional survey determined further item reduction and the CDAQ's structure. The final CDAQ was administered alongside the Short Form Health Survey Version 2 (SF?36v2) in a second survey to assess construct validity and test-retest reliability.

RESULTS

Pre-testing the 64 candidate items revealed a range of issues which guided their refinement and reduction, resulting in the final CDAQ with 32 items representing 5 subscales: stigma (eight items), dietary burden (eight items), symptoms (five items), social isolation (five items), and worries and concerns (six items). Cronbach's alpha ranged between 0.82 and 0.88 for all domains. Further results showed CDAQ scores were more strongly correlated with the SF-36v2's mental health dimensions, as expected. Intraclass correlation coefficients ranged from 0.79 to 0.89.

CONCLUSION

The CDAQ is a reliable and valid coeliac-specific measure that captures all aspects of quality of life important to adults with coeliac disease. Further work is underway to assess the CDAQ's responsiveness to change.