Limited availability and higher cost of gluten-free foods

Life Challenges and Quality of Life of People Living With Coeliac Disease: Time of Diagnosis Matters

BACKGROUND

Previous studies have examined the quality of life of patients with coeliac disease. There is a lack of understanding about potential changes in emotional responses and life challenges after diagnosis. This exploratory study aimed to evaluate the emotional impact, life challenges and quality of life in people living with coeliac disease in Germany.

METHODS

An online survey was conducted among patients with coeliac disease to assess difficulties in implementing a gluten-free diet in daily life activities, including food shopping and preparation, and eating away from home, as well as additional costs of time and money. Furthermore, the questionnaire assessed the time of diagnosis, emotions felt after diagnosis and today, compliance regarding the gluten-free diet and sociodemographic data. Participants were recruited in 2022 via social media, newsletters and websites. Out of 1286 participants who had taken part in the survey, 766 met the inclusion criteria and were included in the data analysis.

RESULTS

The majority of the respondents (aged 18-83 years) were female (93%) and almost 50% were diagnosed more than 5 years ago. Negative emotion ratings related to the disease were associated with age at the time of diagnosis and years passed since diagnosis. While compliance was high with 89% of respondents strictly adhering to the gluten-free diet, patients with coeliac disease reported mainly life challenges in social situations involving food such as out-of-home consumption in restaurants, at work and while travelling. These challenges appear to persist over time.

CONCLUSIONS

Negative emotions and difficulties in implementing a gluten-free diet are negatively impacting individuals with coeliac disease, particularly in the first months after diagnosis. Particularly adolescents and young adults appear to be negatively impacted. The study emphasises the need to improve the quality of life in all impacted areas through better guidance and improved training of health professionals as well as food providers outside of home and through psychological counselling in the first year of diagnosis to better help individuals improve their quality of life.

Gluten-free and conventional breads and pastas sold in Southern Brazil: a comparative study on cost, nutritional composition and ingredients

A gluten-free diet is the only treatment for patients with coeliac disease, who report dissatisfaction with the availability and variety of products, especially bread and pasta. The aim was to compare availability, cost, nutritional composition and ingredients of gluten-free and conventional bread and pasta products. Census of breads and pastas available in online commerce belonging to the third largest supermarket chain in southern Brazil. Information was collected at supermarket's and brand's websites. One hundred and fourteen products were analysed (n = 37 breads and n = 77 pastas): 32.4% (n = 12) gluten-free breads and 18.2% (n = 14) gluten-free pastas. Both gluten-free breads and pastas were significantly more expensive when compared to gluten-containing breads and pastas. Gluten-free breads have higher fat content, gluten-free pastas have higher content of sodium and ingredients. Gluten-free breads and pastas are less available, more expensive and have lower nutritional value compared to conventional versions.

Prevalence and etiologies of non-responsive celiac disease: A systematic review and meta-analysis

BACKGROUND AND AIM

Non-responsive celiac disease (NRCD) is defined as ongoing symptoms despite 6-12 months of gluten-free diet (GFD), the only known treatment for celiac disease (CeD). There is inconsistency in studies describing the proportion of patients having NRCD and its various causes among patients with CeD. We therefore conducted a systematic review and meta-analysis to determine the prevalence and causes of NRCD.

METHODS

The PubMed, Embase, Cochrane Library, Scopus, and Web of Science databases were searched for original studies reporting the proportion of patients with persistent symptoms after ≥ 6 months of GFD. Studies reporting the etiologies of NRCD were also identified. The systematic review was conducted as per the Meta-analysis of Observational Studies in Epidemiology guidelines. Statistical analysis was performed in STATA.

RESULTS

Of 2965 search results, nine studies met the inclusion and exclusion criteria. Five studies (n = 4414) reported data on prevalence, and seven studies (n = 790) reported the causes of NRCD. The pooled prevalence of NRCD was 22% (95% confidence interval, 11-35%). Among patients with NRCD, inadvertent exposure to gluten was the most common cause (33%), followed by functional gastrointestinal disorders including irritable bowel syndrome in 16%. Refractory CeD type II along with its premalignant and malignant sequelae was observed in 7% of patients with NRCD.

CONCLUSION

One in five patients with CeD may not respond to GFD and would likely be classified as NRCD. Inadvertent gluten exposure was the cause of ongoing symptoms in one-third of patients with NRCD. Improving adherence to GFD along with developing novel therapeutics to mitigate symptoms due to ongoing gluten exposure is critical.

Gluten-free Diet, a Friend or a Foe, an American Perspective

Gluten proteins in cereal grains are often considered unsafe for health. Indeed, the dissemination of misinformation through various sources has led to a widespread misconception that the consumption of gluten by healthy individuals results in adverse health consequences and contributes to obesity. In recent years, many health-conscious consumers have started reducing or avoiding gluten consumption without a medical recommendation. Consequently, the adoption of gluten-free diets has expanded significantly. This study compared 39 gluten-free products and their gluten-containing counterparts for energy, sugar, dietary fiber content, and price. We found that, on average, gluten-free products available to United States consumers contained significantly less protein and more sugar and calories. Furthermore, on average, gluten-free products are more expensive than gluten-containing products. Our finding may serve as a guide for dietitians, nutritionists, and legislators in introducing a gluten-free prescription list for individuals with celiac disease, wheat allergy, and non-celiac wheat sensitivity.

Food insecurity impacts diet quality and adherence to the gluten-free diet in youth with celiac disease

OBJECTIVES

Celiac disease (CD) is an autoimmune gastrointestinal disorder that requires a strict lifelong gluten-free diet (GFD). Gluten-free (GF) foods are more expensive and less readily accessible than gluten-containing foods, contributing to an increased risk for food insecurity (FI). The study aimed to determine associations between GF-FI, sociodemographic risk factors and child dietary adherence and diet quality (DQ).

METHODS

A 26-item, cross-country online survey was administered through social media to parents of children with CD on the GFD. The survey elicited household and CD child sociodemographic and clinical characteristics (e.g., duration of CD), measures of household FI, child DQ and GFD adherence, and parents' concerns related to GF food. Household GF-FI was evaluated using the validated Hunger Vital Sign™ and the US Department of Agriculture Six-Item Short Form Household Food Security Survey Module.

RESULTS

GF-FI occurred in 47% of households with children with CD with >30% reporting low to very low food security. Sociodemographic risk factors identified included lower income, renters, rural residency, single-parental households, and having children with additional dietary restrictions (p < 0.001). Regardless of FI status, a majority of households reported experiencing significantly higher GF food expenditure. GF-FI was associated with reduced adherence to the GFD, increased consumption of processed GF food, and lower intakes of fresh fruits and vegetables and GF grains among children with CD (p < 0.05).

CONCLUSIONS

GF-FI is prevalent in this multiethnic cohort of households with CD children and is associated with worsening DQ and GFD adherence. Policy interventions are urgently needed to address GF-FI.

Dietary management of irritable bowel syndrome: considerations, challenges, and solutions

Diet is a cornerstone in the management of irritable bowel syndrome (IBS). There is evidence of efficacy across the spectrum of dietary management strategies, including some supplements (eg, specific fibres), foods, and whole diets (eg, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [known as the low-FODMAP diet]). Whole-diet interventions, in particular those that restrict intake, can be challenging to deliver effectively and safely. Factors to consider include patient demographics, food cost and availability, and the acceptability of dietary management and its impact on food-related quality of life. There is concern regarding a potential role of restrictive whole-diet interventions in eating disorder risk. Optimal approaches to delivering dietary management in the health-care setting are unclear. The aim of this Review is to summarise the clinical evidence for the dietary management of IBS; to discuss the challenges, burdens, and risks of dietary management; and to propose how these challenges, burdens, and risks should be mitigated and minimised in clinical practice.

A gluten-free diet for endometriosis patients lacks evidence to recommend it

Endometriosis is an estrogen-dependent chronic disease characterized by the presence of endometriumlike tissue outside the uterus and is often associated with symptoms, such as dysmenorrhea, dysuria, dyschezia, chronic pelvic pain, and infertility. Moreover, women diagnosed with endometriosis can report gastrointestinal symptoms, including bloating, constipation or diarrhea, and abdominal cramping, which can be associated with irritable bowel syndrome and can result in the misdiagnosis of endometriosis as irritable bowel syndrome at first. Treatment usually involves hormonal therapy, pain management, surgery, and/or assisted reproductive techniques in case of infertility. Nonetheless, these treatment methods can be insufficient for alleviating symptoms or can have unacceptable side effects, leading to noncompliance. Therefore, women often apply self-management strategies, including dietary interventions. One of the diets frequently suggested as a tool to manage endometriosis-related symptoms on social media and patient forums is a gluten-free diet. Although a gluten-free diet has been proven effective in managing nonceliac wheat sensitivity or celiac disease, its effectiveness in endometriosis remains uncertain. The Nurses' Health Study II found it unlikely that gluten intake was a strong factor in endometriosis etiology and symptomatology. To the best of our knowledge, the most frequently cited and sole published intervention study on the efficacy of a gluten-free diet for endometriosis has several important limiting factors, including the absence of a control group. In addition, gluten consumption is highly susceptible to a placebo effect and a nocebo effect, where women might experience symptom relief after eliminating gluten and return of symptoms after they consume gluten again, solely because they believe that gluten is bad for them. Despite the inverse association between body mass index and endometriosis and between a gluten-free diet and increased body mass index, this is an association, and no causality was proven. In addition, other factors should be taken into consideration. Of note, a gluten-free diet is expensive, has limited availability, and has a significant effect on quality of life. Moreover, without proper dietary guidance, it may adversely affect the gastrointestinal microbiome. Therefore, scientifically substantiated advice regarding the use of a gluten-free diet for endometriosis-related symptoms is currently not available, and a gluten-free diet should be discouraged unless there is an additional diagnosis of nonceliac wheat sensitivity or celiac disease.

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.

Vulnerability in Children with Celiac Disease: Findings from a Scoping Review

(1) Background: The scientific literature highlights that children diagnosed with celiac disease (CD) are at a heightened risk of experiencing physical, psychological, and social challenges, impacting their overall healthy childhood development. However, there remains a lack of a clear understanding regarding the factors that contribute to this vulnerability. The purpose of this study is to analyze and map the evidence on the sociopsychosomatic vulnerability of these children and identify gaps in this topic. (2) Methods: Following Joanna Briggs Institute's guidelines for scoping reviews, we executed a detailed search of key electronic databases and explored the grey literature to capture a broad spectrum of studies. Our focus was on identifying research that looked into the multiple dimensions of vulnerability-physical, psychological, and social-in children with CD. We included a diverse range of study designs as well as systematic reviews, ensuring a comprehensive analysis. The selection process was stringent, utilizing clearly defined inclusion and exclusion criteria. (3) Results: We identified 61 studies that met our inclusion criteria. The review highlighted significant adverse health outcomes in children with CD and elucidated various individual and environmental determinants that influenced these vulnerabilities. It also underscored the lack of assessment tools to evaluate the risk of health problems in this population. (4) Conclusions: The findings underscore a critical need for further research to deepen our understanding of the vulnerabilities associated with CD in children. Developing targeted assessment tools will be crucial in stratifying health risks and enhancing care strategies for this vulnerable population.

Investigation of cost and availability of gluten-free food in Jeddah, KSA

Objective

The prevalence of celiac disease (CD) in KSA is progressively increasing. Consistent adherence to a gluten-free (GF) diet is the only effective CD treatment. The availability and cost of GF food are important factors in adherence to a GFD. The objective of this study was to investigate the cost and availability of GF food in a sample of local stores and supermarkets across Jeddah province in KSA.

Method

Eleven supermarkets in Jeddah, KSA, ranging from high budget/quality supermarkets to low-budget stores, were visited. Eight food categories were evaluated, including flour, breakfast cereals, breads, pastas, and snacks (e.g., biscuits, cookies, snack bars, and chips). The availability and cost of GF and gluten containing (GC) items within these food categories were recorded. Each item included in these food categories was counted, and the overall average price was calculated.

Results

A total of 233 GF and 24 GC products were found. Supermarket 1 had the highest availability of GF foods (n = 90), followed by supermarket 2 (n = 34), supermarket 3 (n = 30), supermarket 4 (n = 23), supermarket 5 (n = 21), supermarket 6 (n = 18), supermarket 7 (n = 9), and supermarket 8 (n = 8). The median price per 100 g was significantly greater for GF than GC products (p < 0.05). The cost of GF products was significantly higher than that of GC products (p < 0.05); consequently, GF foods were twice as expensive as their GC counterparts.

Conclusion

The availability of GF products was limited, and GF products were more expensive than standard GC products. High cost and limited availability are major roadblocks to GFD adherence among people with CD. Governmental organizations must cooperate with healthcare providers and food industries to ensure that GF foods are widely available and affordable for people with CD, to minimize financial pressure and improve health quality.

Gluten-free diet for pediatric patients with coeliac disease: A position paper from the ESPGHAN gastroenterology committee, special interest group in coeliac disease

BACKGROUND AND OBJECTIVE

Coeliac disease is a chronic, immune-mediated disorder for which the only treatment consists of lifelong strict adherence to gluten-free diet (GFD). However, there is a lack of evidence-based guidelines on the GFD dietary management of coeliac disease. This position paper, led by the Special Interest Group in coeliac disease of the European Society of Pediatric, Gastroenterology Hepatology, and Nutrition, supported by the Nutrition Committee and the Allied Health Professionals Committee, aims to present evidence-based recommendations on the GFD as well as how to support dietary adherence.

METHODS

A wide literature search was performed using the MeSH Terms: "diet, gluten free," "gluten-free diet," "diets, gluten-free," "gluten free diet," and "coeliac disease" in Pubmed until November 8th, 2022.

RESULTS

The manuscript provides an overview of the definition of the GFD, regulations as basis to define the term "gluten-free," which foods are naturally gluten-free and gluten-containing. Moreover, it provides recommendations and educational tips and infographics on suitable food substitutes, the importance of reading food labels, risk of gluten cross-contact at home and in public settings, nutritional considerations as well as factors associated to dietary adherence based on available evidence, or otherwise clinical expertise.

CONCLUSIONS

This position paper provides guidance and recommendations to support children with coeliac disease to safely adhere to a GFD.

Relationship between vitamin D levels and pediatric celiac disease: a systematic review and meta-analysis

BACKGROUND

The relationship between Vitamin D levels and pediatric celiac disease (CD) remains controversial. In this study, we conducted a systematic review and meta-analysis to examine the relationship between Vitamin D and pediatric CD.

METHODS

We screened relevant studies from PubMed, EMBASE, and Web of Science published in English from January 1, 2000, to August 1, 2023. The included studies were assessed according to the STROBE checklist. Heterogeneity was quantified by Cochran's Q test and the I2 statistic. Publication bias was estimated by Begg's test and Egger's test. Meta-regression was used to detect potential sources of heterogeneity.

RESULTS

A total of 26 studies were included in the meta-analysis. Nineteen articles compared 25(OH)D3 levels between CD patients and control groups, average 25-hydroxyvitamin D3 [25(OH)D3 or calcidiol], and 1,25-dihydroxyvitamin D3 [1,25(OH)2D3 or calcitriol] levels, as the main forms of Vitamin D, there was a significant difference in CD patients and healthy controls (weighted mean difference (WMD) = - 5.77, 95% confidence interval (CI) = [- 10.86, - 0.69] nmol/L). Meanwhile, eleven articles reported the numbers of patients and controls with Vitamin D deficiency, there was a significant difference in the incidence of 25(OH)D3 deficiency between CD patients and healthy controls (odds ratio 2.20, 95% CI= [1.19, 4.08]). Nine articles reported changes in 25(OH)D3 levels before and after administering a GFD in patients with CD, the result of this study revealed the increase of 25(OH)D3 levels in CD patients after a gluten-free diet (GFD) (WMD = - 6.74, 95% CI = [- 9.78, - 3.70] nmol/L).

CONCLUSIONS

Vitamin D levels in pediatric CD patients were lower than in healthy controls, and 25(OH)D3 deficiency was more prevalent in CD patients. We found that 25(OH)D3 levels were elevated in CD patients after GFD, which is consistent with previous research. Further well-designed, longitudinal, prospective cohort studies focusing on the role of Vitamin D in the pathogenesis of CD are therefore needed.

The financial impact on people with coeliac disease of withdrawing gluten-free food from prescriptions in England: findings from a cross-sectional survey

BACKGROUND

A lifelong gluten-free diet is the only treatment for coeliac disease. The cost and availability of gluten-free substitute food (GFSF) remain challenging. Some local areas in England have stopped gluten-free prescriptions for coeliac disease. The aim of this paper is to present the quantitative findings of the financial impact of prescription withdrawal on people with coeliac disease.

METHODS

A cross-sectional survey with adults in England who reported having been diagnosed with coeliac disease by a health professional. The postal survey was distributed by Coeliac UK to their members in 13 prescribing and 13 non-prescribing local areas that were matched for geographical location and level of deprivation. Additionally, an advertisement for the survey was placed on social media. The questionnaire contained items on the availability and use of prescriptions; the weekly amount spent on GFSF; amount of specific GFSF bought; affordability of GFSF; demographics and health-related variables. Data were analysed by descriptive statistics, analysis of variance and regression analysis.

RESULTS

Of the 1697 participants, 809 resided in areas that provided prescriptions and 888 in non-prescribing areas. Participants self-report of their prescription did not always match the local area prescription policy. There was no statistically significant difference between prescribing and non-prescribing areas in how easy or difficult participants found it to obtain GFSF (p = 0.644) and its availability in various locations. Participants in non-prescribing areas purchased most types of GFSF items in statistically significantly higher quantities and thereby spent an additional £11.32/month on GFSF items than participants in prescribing areas (p < 0.001). While taking into account the self-reported prescription status, the amount increased to £14.09/month (p < 0.001). Although affordability to buy GFSF did not differ based on local area prescription policy or self-reported prescription status, it was dependent on equivalised annual income. However, affordability did not influence spending on GFSF. Regression analysis indicated that males and households with additional members with coeliac disease spent more on GFSF.

CONCLUSIONS

The study has highlighted that gluten-free prescription withdrawal can have financial implications for people with coeliac disease. Any future changes to the prescription policy of GFSF should consider the impact on the population, especially lower income households.

Specificity Enhancement of Glutenase Bga1903 toward Celiac Disease-Eliciting Pro-Immunogenic Peptides via Active-Site Modification

Celiac disease is an autoimmune disease triggered by oral ingestion of gluten, with certain gluten residues resistant to digestive tract enzymes. Within the duodenum, the remaining peptides incite immunogenic responses, including the generation of autoantibodies and inflammation, leading to irreversible damage. Our previous exploration unveiled a glutenase called Bga1903 derived from the Gram-negative bacterium Burkholderia gladioli. The cleavage pattern of Bga1903 indicates its moderate ability to mitigate the toxicity of pro-immunogenic peptides. The crystal structure of Bga1903, along with the identification of subsites within its active site, was determined. To improve its substrate specificity toward prevalent motifs like QPQ within gluten peptides, the active site of Bga1903 underwent site-directed mutagenesis according to structural insights and enzymatic kinetics. Among the double-site mutants, E380Q/S387L exhibits an approximately 34-fold increase in its specificity constant toward the QPQ sequence, favoring glutamines at the P1 and P3 positions compared to the wild type. The increased specificity of E380Q/S387L not only enhances its ability to break down pro-immunogenic peptides but also positions this enzyme variant as a promising candidate for oral therapy for celiac disease.

Mapping the knowledge structure of a gluten-free diet: a global perspective

Background

A gluten-free diet (GFD) has become one of the most popular eating plans and is essential for managing gluten-related medical conditions, signs, and symptoms. Therefore, we performed a bibliometric analysis of the scientific literature on the GFD to describe the research landscape.

Methods

The Scopus database was searched for publications on the GFD from 1952 to 2021. A bibliometric analysis of the data was performed. VOSviewer software was used to perform visualization analysis, co-occurrence analysis, and publication trends in GFD.

Results

A total of 3,258 publications were retrieved. In terms of publications, Italy (n = 468, 14.36%) led in the number of publications, followed by the USA (n = 398, 12.22%) and Spain (n = 274, 8.41%). The retrieved documents earned an average of 22.89 citations per document, for a total of 74,560 citations. Since 2001, there has been a gradual growth in the number of articles published, going from 23 to more than 370 in 2021. Using the mapping terms in the title/abstract a minimum of 50 times, 291 terms were divided into two main clusters: ‘adherence to a gluten-free diet in celiac disease’ and ‘improvement of the nutritional and sensory quality of gluten-free products.’

Conclusions

Over the past six decades, there has been a growing need for gluten-free bakery products and a noticeable increase in related publications. This study indicates that the “improvement of the nutritional and sensory quality of gluten-free products” will remain a hotspot in this research field for upcoming years.

The Nutritional Quality of Gluten-Free versus Non-Gluten-Free Pre-Packaged Foods and Beverages Sold in Hong Kong

INTRODUCTION

The consumption of gluten-free foods has continued to increase in recent years. Given their higher intake among individuals both with and without a medically diagnosed gluten allergy or sensitivity, it is important to understand how the nutritional quality of these foods compares against non-gluten-free foods. As such, we aimed to compare the nutritional quality of gluten-free and non-gluten-free pre-packaged foods sold in Hong Kong.

METHODS

Data from 18,292 pre-packaged food and beverage items in the 2019 FoodSwitch Hong Kong database were used. These products were categorized as (1) "declared gluten-free"; (2) "gluten-free by ingredient or naturally gluten-free"; and (3) "non-gluten-free" according to information presented on the package. One-way ANOVA was used to compare the differences in the Australian Health Star Rating (HSR), energy, protein, fibre, total fat, saturated fat, trans-fat, carbohydrates, sugars, and sodium content between products in different gluten categories, overall and by major food category (e.g., bread and bakery products) and region of origin (e.g., America, Europe).

RESULTS

Products declared gluten-free (mean ± SD: 2.9 ± 1.3; n = 7%) had statistically significantly higher HSR than those gluten-free by ingredient or naturally gluten-free (2.7 ± 1.4; n = 51.9%) and non-gluten-free (2.2 ± 1.4; n = 41.2%) (all pairwise comparisons p < 0.001). Overall, non-gluten-free products have higher energy, protein, saturated fat, trans-fat, free sugar and sodium, and less fibre compared with products in the other two gluten categories. Similar differences were observed across major food groups and by region of origin.

CONCLUSIONS

Non-gluten-free products sold in Hong Kong were generally less healthy than gluten-free products (regardless of the presence of gluten-free declaration). Consumers should be better educated on how to identify gluten-free foods, given that many gluten-free foods do not declare this information on the label.

Gluten-free diet adherence in children with screening-detected celiac disease using a prospective birth cohort study

BACKGROUND

Celiac disease has an increasing incidence worldwide and is treated with lifelong adherence to a gluten-free diet. We aimed to describe gluten-free diet adherence rates in children with screening-identified celiac disease, determine adherence-related factors, and compare adherence to food records in a multinational prospective birth cohort study.

METHODS

Children in The Environmental Determinants of Diabetes in the Young study with celiac disease were included. Subjects had at least annual measurement of adherence (parent-report) and completed 3-day food records. Descriptive statistics, t-tests, Kruskal-Wallis tests and multivariable logistic and linear regression were employed.

RESULTS

Two hundred ninety (73%) and 199 (67%) of subjects were always adherent to a gluten-free diet at 2 and 5 years post celiac disease diagnosis respectively. The percentage of children with variable adherence increased from 1% at 2 years to 15% at 5 years. Children with a first-degree relative with celiac disease were more likely to be adherent to the gluten-free diet. Gluten intake on food records could not differentiate adherent from nonadherent subjects. Adherent children from the United States had more gluten intake based on food records than European children (P < .001 and P = .007 at 2 and 5 years respectively).

CONCLUSION

Approximately three-quarters of children with screening-identified celiac disease remain strictly adherent to a gluten-free diet over time. There are no identifiable features associated with adherence aside from having a first-degree relative with celiac disease. Despite good parent-reported adherence, children from the United States have more gluten intake when assessed by food records. Studies on markers of gluten-free diet adherence, sources of gluten exposure (particularly in the United States), and effects of adherence on mucosal healing are needed.

Optimization of a novel, gluten-free bread's formulation based on chickpea, carob and rice flours using response surface design

This study aimed to develop nutritious, gluten-free bread with high quality characteristics using a mixture of chickpea, carob and rice flours as substitutes of wheat flour. To optimize the bread formulation, a Box-Behnken experimental design was conducted to evaluate the effect of the corresponding flour blend addition, proofing time and water amount addition on the physicochemical, technological and sensory properties of the obtained formulated bread. The optimized formulation was calculated to contain 70% of mixture flour and 100% of water, with a proofing time of 40 minutes. This formulation produced bread with greater specific volume ( 3.73 ± 0.37 cm3/g) and less baking loss ( 22.98 ± 0.94 % ) than those of control (+) bread ( 2.93 ± 0.21 cm3/g and 31.65 ± 0.72 % , respectively). Findings proved that the mixture flour based on chickpeas, carob and rice represents a good alternative to make gluten-free bread with acceptable baking properties.

The gluten-free diet challenge in adults with coeliac disease: the Hellenic survey

Objective

The only available treatment for coeliac disease (CD) is a lifelong strict gluten-free diet (GFD), which can be extremely challenging. Τhe aim of the present study was to gain an insight into patients' perceptions regarding the GFD, in relation to difficulties experienced, disease-specific symptoms, adherence level, and information sources used.

Methods

Two hundred ninety CD patients (247 women and 43 men) aged 18-74 years, completed a self-administered questionnaire.

Results

Self-rated dietary adherence was high in 65.5%, moderate in 27.5% and poor in 6.9% of the patients. The main difficulties encountered were the high cost and limited availability of GF foods and meals in markets and restaurants. The main source of information concerning CD and GFD was the internet, and the most useful source was the Coeliac Society. Dietary adherence correlated positively with Coeliac Society membership and awareness of the monthly CD allowance.

Conclusion

Α substantial proportion of patients did not adhere to a strict GFD. Patients were not adequately followed-up.

Innovation

A self-administered questionnaire was used to explore the practical challenges of a GFD in an understudied population, Greek adult coeliac patients. The results highlighted the need for dietitians with expertise on CD.

Food Insecurity Negatively Impacts Gluten Avoidance and Nutritional Intake in Patients With Celiac Disease

BACKGROUND

Food insecurity is a major public health challenge. For patients with celiac disease (CeD), food insecurity may be particularly detrimental as it threatens the cornerstone of their treatment: adoption of a gluten-free diet (GFD). We aimed to characterize the prevalence of food insecurity in patients with CeD and evaluate its impact on GFD adoption and nutritional intake.

METHODS

We analyzed data from patients with CeD participating in the US National Health and Nutrition Examination Survey (NHANES) from 2009 to 2014. Food insecurity was defined using the US Department of Agriculture 18-Item Standard Food Security Survey Module. Survey-weighted logistic regression was used to assess differences in demographic characteristics of CeD patients living with food insecurity and the impact of food security on GFD adoption. Multivariable survey-weighted linear regression was used to evaluate the effect of food insecurity on nutritional intake of macronutrients and micronutrients.

RESULTS

Overall, 15.9% (95% confidence interval: 10.6%, 23.1%) of patients with CeD in the United States [weighted N=2.9 million (95% confidence interval: 2.2, 3.5 million)] are food insecure. Food insecure patients with CeD were disproportionately younger, poorly educated, nonwhite, living in poverty, and were significantly less likely to adopt a GFD (24.1% vs. 67.9%, P =0.02). Food insecurity was associated with significantly lower consumption of protein, carbohydrates, fat, and most vitamins and minerals.

CONCLUSIONS

One in 6 patients with CeD are food insecure, negatively impacting GFD adoption and the ability to meet recommended daily intake of most micronutrients. Less than one quarter of food insecure CeD patients adhere to a GFD.

Coexisting Type 1 Diabetes, Persistent Symptoms, and Financial Issues Associate With Poorer Adherence to a Gluten-Free Diet in Celiac Disease After Transition From Pediatrics to Adult Care

Purpose

We evaluated adherence to a gluten-free diet and associated factors in adult celiac disease patients diagnosed in childhood.

Methods

Comprehensive medical data on 955 pediatric celiac disease patients was collected and study questionnaires sent to 559 who were now adults. All variables were compared between strictly adherent and non-adherent patients.

Results

Altogether 237 adults (median age 27 years, 69% women) responded to the questionnaires a median of 18 (range 3-51) years after the childhood diagnosis. Altogether 78% were reportedly adherent and 22% non-adherent. The non-adherent patients had more concomitant type 1 diabetes (18% vs. 4%, p = 0.003), whereas the groups did not differ in demographic data or clinical and histological features at diagnosis, or in short-term dietary adherence. In adulthood, non-adherent patients found gluten-free diet more challenging (39% vs. 17%, p < 0.001) and had higher prevalence (39% vs. 19%, p = 0.004) and severity of symptoms. The main motivation factors for dietary adherence were attempts to avoid symptoms and complications, but these were considered less important and price of gluten-free products more important among non-adherent patients. Adherent and non-adherent patients did not differ in socioeconomic or lifestyle factors, comorbidities other than type 1 diabetes, self-reported general health, health concerns, follow-up, or in quality of life.

Conclusion

Most originally pediatric celiac disease patients reported strict dietary adherence in adulthood. However, particularly those with concomitant type 1 diabetes, persistent symptoms or financial issues may require attention during the transition from pediatric to adult care.

A Cross-Sectional Study of Celiac Disease Awareness in the Food Industry in the Western Region of Saudi Arabia

Background

The only treatment available for celiac disease (CD), an autoimmune disease, is a gluten-free diet. Restaurant personnel have major roles in understanding the possible risks to consumers with CD, ensuring the availability of and preparing gluten-free foods. We attempted to evaluate the awareness and knowledge of CD among chefs, cooks, restaurant personnel, and owners and assess the availability of gluten-free diet options in the western region of Saudi Arabia.

Methods

A cross-sectional, questionnaire-based study was conducted in 126 restaurants based in Makkah al-Mukarramah and Jeddah cities. The chefs and owners of the restaurants were interviewed face-to-face to collect data knowledge about CD, gluten sensitivity, food containing gluten, serving gluten-free food, intention to add gluten-free options in the future, and circumstances related to serving gluten-free food.

Result

Our study showed that 17.5% and 51.6% of the participants had heard about CD and gluten sensitivity, respectively, and 34.1% checked a right answer of gluten-containing food with a mean of 0.68 (±1.02). About 17.5% of the participating restaurants serve gluten-free meal options (mean: 0.63±1.57), 14.7% had protocols for the preparation of gluten-free food, 7.1% displayed signs or notices that they sell gluten-free products, and 50.8% disclosed an intention to add gluten-free options in the future. Furthermore, 82.5% of gluten-free options were more expensive. Education level, being a trained chef, and experience years were significantly associated with awareness about CD or gluten sensitivity (p<0.05).

Conclusion

There is a general lack of awareness of CD, and most restaurants lack gluten-free options. We recommend adding more gluten-free food options for patients with CD.

A Tomato Pomace Enriched Gluten-Free Ready-to-Cook Snack’s Nutritional Profile, Quality, and Shelf Life Evaluation

Attempts were undertaken to design a quick ready-to-cook gluten-free snack utilizing finger millet and potato flour (50:50) as well as tomato pomace due to the restricted availability of gluten-free snack goods in the Indian market. The nutritional content of the food and its general acceptability, cooking characteristics, and storage stability were all tested. The addition of tomato pomace had a distinct influence on the product’s color and hardness. Additionally, it resulted in a significant reduction in the amount of oil used, cooking loss, and frying time required. With a high acceptance level, the snack supplemented with 10% tomato pomace was determined to be the most optimal formulation. When the same substance was subjected to FTIR analysis, it was discovered that it retained all the important functional groups required for sustaining antioxidant activity. It also displayed high storage stability, a desirable overall acceptance score, and a very promising nutritional profile, all of which would benefit the product’s end users.

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.

Determinants of health-related quality of life in patients with celiac disease: a structural equation modeling

Background

We aimed to investigate the determinants of Health-related quality of life (HRQOL) in Iranian patients with celiac disease (CD) using the structural equation modeling (SEM).

Methods

In the present cross-sectional study, a total of 170 adult patients with CD were recruited. The information regarding adherence to diet, symptom severity, and HRQOL were collected using the celiac disease adherence test (CDAT), gastrointestinal symptom rating scale (GSRS), and SF-36 questionnaire respectively. Association between various studied variables and HRQOL was assessed using SEM. The standardized regression weights were used to assess total, direct and indirect effects. The model fit indices were used to assess the “goodness of fit” between the hypothesized models.

Results

The mean age of participants was 37.57 ± 9.59 years. The results of SEM indicated that the overall fit of our model was acceptable. Adherence to the diet, GSRS score, occupation, and education level was significantly related to PCS of SF-36; and adherence to the diet, GSRS score, and education level were significantly correlated with MCS of SF-36. The analysis of indirect associations indicated that only adherence to diet indirectly via GSRS score was significantly associated with PCS and MCS of SF-36.

Conclusion

In adult patients with celiac disease, HRQOL was associated with age, education, adherence to GFD, and GSRS score. Additionally, occupation and disease duration were associated with HRQOL only in women and men respectively.

Challenges of Monitoring the Gluten-Free Diet Adherence in the Management and Follow-Up of Patients with Celiac Disease

Celiac disease (CD) is a chronic gluten-responsive immune mediated enteropathy and is treated with a gluten-free diet (GFD). However, a strict diet for life is not easy due to the ubiquitous nature of gluten. This review aims at examining available evidence on the degree of adherence to a GFD, the methods to assess it, and the barriers to its implementation. The methods for monitoring the adherence to a GFD are comprised of a dietary questionnaire, celiac serology, or clinical symptoms; however, none of these methods generate either a direct or an accurate measure of dietary adherence. A promising advancement is the development of tests that measure gluten immunogenic peptides in stools and urine. Causes of adherence/non-adherence to a GFD are numerous and multifactorial. Inadvertent dietary non-adherence is more frequent than intentional non-adherence. Cross-contamination of gluten-free products with gluten is a major cause of inadvertent non-adherence, while the limited availability, high costs, and poor quality of certified gluten-free products are responsible for intentionally breaking a GFD. Therefore, several studies in the last decade have indicated that many patients with CD who follow a GFD still have difficulty controlling their diet and, therefore, regularly consume enough gluten to trigger symptoms and damage the small intestine.

Cost, Nutritional Content and Number of Gluten-Free Staple Foods Available in Winnipeg, Manitoba, Canada

Data has indicated that gluten-free (GF) foods are more expensive and have lower nutritional value than their gluten-containing (GC) counterparts. The aim of the present study was to compare the cost and nutrient content between GF and GC staple foods and determine whether the number and price of GF staple foods differed based on type of store or location within Winnipeg, Canada. Twelve grocery stores (2 chain stores/quadrant;1 local store/quadrant) in the four quadrants (northwest, northeast, southwest, southeast) of Winnipeg were visited to identify GF staple products (bread, flour, cereal, pasta) along with a GC comparator. A total of 819 GF products along with GC comparators were identified. The median cost of GF products ($1.50/100 g) was 131 % greater than that of GC ($0.65/100 g) (p < 0.0001). The greatest difference in cost was between GF and GC flour, with the least difference occurring between GF and GC cereal. GF products were 58, 36 and 100 % lower in iron, protein and saturated fat (p < 0.0001) than their GC comparators, respectively. The number of GF staple products was 370 % higher (p < 0.007) at chain stores than at local stores, whereas store location did not significantly affect the number of GF products available. The greatest difference in number of different GF foods based on store type was for cereals, with the least being for flours. These results confirm that GF staple foods are more expensive and have lower nutritional value (mainly due to lower iron and protein content) compared to GC foods.

A comprehensive investigation of gluten free bread dough rheology, proving and baking performance and bread qualities by response surface design and principal component analysis

Contribution of methylcellulose (MC), psyllium seed husk powder (PSY), and water addition level to gluten free bread quality and correlations between dough rheological properties and bread qualities were investigated by response surface design and principal component analysis. The generalised Maxwell model was applied to estimate the relaxation frequency of gluten free doughs. The addition of PSY has a complex influence on pasting viscosity at high temperature and an additional peak was observed. MC significantly influenced dough extensibility and work of adhesion, which are good predictors of bread volume and textural properties. Other rheological responses are less significantly correlated to specific volume, but they are sensitive to formulation variations, reflect dough structures and stability, related to proving behaviours, and correlated to loaf concavity. An inappropriate combination of water and hydrocolloids might lead to problems such as low stability of doughs, overexpansion, and weak crumb structure at high water addition levels, or, in contrast, high rigidity of dough, a trap of excessive air during mixing, and restrained gas cell expansion with high hydrocolloid addition and low water addition.

The Level of Processing, Nutritional Composition and Prices of Canadian Packaged Foods and Beverages with and without Gluten-Free Claims

Little is known about the healthfulness and cost of gluten-free (GF) foods, relative to non-GF alternatives, in Canada. This study compared the extent of processing, nutritional composition and prices of Canadian products with and without GF claims. Data were sourced from the University of Toronto Food Label Information Program (FLIP) 2013 (n = 15,285) and 2017 (n = 17,337) databases. Logistic regression models examined the association of NOVA processing category with GF claims. Calorie/nutrient contents per 100 g (or mL) were compared between GF and non-GF products. Generalized linear models compared adjusted mean prices per 100 g (or mL) of products with and without GF claims. The prevalence of GF claims increased from 7.1% in 2013 to 15.0% in 2017. GF claims appeared on 17.0% of ultra-processed foods, which were more likely to bear GF claims products than less-processed categories. Median calories and sodium were significantly higher in GF products; no significant differences were observed for saturated fat or sugars. Compared to non-GF products, adjusted mean prices of GF products were higher for 10 food categories, lower for six categories and not significantly different for six categories. Overall, GF claims are becoming increasingly prevalent in Canada; however, they are often less healthful and more expensive than non-GF alternatives, disadvantaging consumers following GF diets.

Current and emerging therapies for coeliac disease

Coeliac disease is a common enteropathy that occurs in genetically susceptible individuals in response to the ingestion of gluten proteins present in wheat, rye and barley. Currently, the only available treatment for the condition is a strict, life-long gluten-free diet that, despite being safe and often effective, is associated with several challenges. Due to the high cost, particularly restrictive nature and perception of decreased quality of life associated with the diet, some patients are continuously exposed to gluten, which prevents an adequate disease control. Moreover, a subgroup of patients does not respond to the diet adequately, and healing of the small-bowel mucosa can be incomplete. Thus, there is a need for alternative treatment forms. The increasingly understood pathogenetic process of coeliac disease has enabled the identification of various targets for future therapies. Multiple investigational therapies ranging from tolerogenic to immunological approaches are in the pipeline, and several drug candidates have entered phase II/III clinical trials. This Review gives a broad overview of the different investigative treatment modalities for coeliac disease and summarizes the latest advances in this field.

Celiac Disease Causes Epithelial Disruption and Regulatory T Cell Recruitment in the Oral Mucosa

Celiac disease (CD) is a chronic autoimmune disease characterized by an immune-triggered enteropathy upon gluten intake. The only current treatment available is lifelong Gluten Free Diet (GFD). Several extraintestinal manifestations have been described in CD, some affecting the oral mucosa. Thus, we hypothesized that oral mucosa could potentially be a target for novel biomarkers and an administration route for CD treatment. Six de novo diagnosed and seven CD patients under GFD for at least 1 year were recruited. Non-celiac subjects (n = 8) were recruited as control group. Two biopsies of the cheek lining were taken from each subject for mRNA analysis and immunohistochemical characterization. We observed a significant decrease in the expression of epithelial junction proteins in all CD patients, indicating that oral mucosa barrier integrity is compromised. FoxP3+ population was greatly increased in CD patients, suggesting that Tregs are recruited to the damaged mucosa, even after avoidance of gluten. Amphiregulin mRNA levels from Peripheral Blood Mononuclear Cells (PBMCs) and epithelial damage in the oral mucosa correlated with Treg infiltration in all the experimental groups, suggesting that recruited Tregs might display a “repair” phenotype. Based on these results, we propose that oral mucosa is altered in CD and, as such, might have diagnostic potential. Furthermore, due to its tolerogenic nature, it could be an important target for oral immunotherapy.

Gluten content in labeled and unlabeled gluten-free food products used by patients with celiac disease

OBJECTIVE

Gluten-free (GF) diet is the only reliable treatment for patients with celiac disease (CeD), but data on the extent of gluten contamination in GF food available in India is scanty. We evaluated gluten content in labeled, imported, and non-labeled GF food products currently available in the Indian market.

METHODS

Overall, 794 processed and commercially available packaged GF products (labeled GF (n = 360), imported GF (n = 80), and non-labeled/naturally GF (n = 354)) were collected from supermarkets of National Capital Region of India. Those unavailable in stores were purchased from e-commerce sites or directly from the manufacturers. Gluten level in them was determined by Ridascreen Gliadin sandwich R5 enzyme-linked immunosorbent assay (R-Biopharm AG, Germany). As per Codex Alimentarius and Food Safety and Standard Authority of India, "gluten free" labeled products must not contain > 20 mg/kg of gluten.

RESULTS

Overall, 10.1% of 794 GF products including 38 (10.8%) of 360 labeled and 42 (11.8%) of 354 non-labeled/naturally GF food products had gluten content > 20 mg/kg (range: 24.43-355 and 23.2-463.8 mg/kg, respectively). None of the imported GF products had gluten more than the recommended limits. Contaminated products most commonly belonged to cereal and their products (flours, coarse grains, pasta/macaroni, snack foods) pulse flours, spices, and bakery items.

CONCLUSIONS

A substantial proportion (10.1%) of GF food products (both labeled and non-labeled) available in India have gluten content greater than the prescribed limits of <20 mg/kg. Physicians, dietitians, support group, and patients with CeD should be made aware of this fact and regulatory bodies should ensure quality assurance.

Evaluation of Gluten-Free Diet Efficacy for Improving Quality of Life of Patients with Celiac Disease

Background: As the only effective treatment of celiac disease (CD) is a lifelong commitment to a gluten-free diet (GFD), this study was designed to evaluate the efficacy of GFD in the quality of life (QOL) of patients with CD to persuade them for strict commitment. Methods: In a cross-sectional study, the QOL of CD patients registered in the celiac society of Khuzestan province was evaluated and compared before and at least one year after commencing GFD using the QOL SF-36 questionnaire. Results: Overall, 200 CD patients (66 males and 134 females) were evaluated. The average age of male and female participants was 26.3 and 30.34 years, respectively (61% between 20 and 60-years-old). After GFD, complaints such as bloating (P = 0.001), abdominal pain (P = 0.001), diarrhea (P = 0.001), nausea (P = 0.001), vomiting (P = 0.03), reflux and regurgitation (P = 0.025), anorexia (P = 0.001), fatigue (P = 0.001), headache (P = 0.008), oral aphthous lesions (P = 0.014), weight loss (P = 0.001), and bone pain (P = 0.005) significantly improved while other symptoms such as muscular pain (P = 0.157), dermatitis (P = 0.083), and numbness (P = 0.317) did not show any major improvement. The average scores of QOL before and after GFD were 0.74 and 3.41, respectively, which demonstrated significant improvement (P = 0.001). This improvement was even seen among cases with sub-optimal compliance (average QOL score 3.28, P = 0.001). Conclusion: A gluten-free diet could significantly improve the quality of life of patients with celiac disease, and they should be encouraged as much as possible to be committed to this regimen.

Impact of Corona Virus Disease 2019 pandemic on adherence to gluten-free diet in Indian patients with celiac disease

AIMS

Lockdown and restricted mobility due to the pandemic of corona virus disease  2019 (COVID-19) has severely affected the continuity of healthcare of patients with acute and chronic diseases. We evaluated the impact of COVID-19 on the adherence to gluten-free diet (GFD), symptom control, and quality of life (QOL) in patients with celiac disease (CeD).

METHODS

A questionnaire, consisting of both ad-hoc and validated questions, was created after review of literature, group discussions, and expert meetings. Standardized questionnaires namely CeD adherence test (CDAT), celiac symptom index score, and CeD-related QOL were used. The web-based questionnaire was sent to 3130 patients via social media and 452 responses (14.4%) were received. Also, additional 68 patients (not available on any social media application) were interviewed telephonically by a trained dietitian.

RESULTS

Overall, 505 patients (females: 318; mean age: 24.1±14.2 years) were included. While only 6.7% (n = 34) had poor compliance to GFD (CDAT > 17) before COVID-19 pandemic, it almost doubled to 12.6% (n = 64) during the COVID-19 pandemic times (p = 0.02). Furthermore, 4.9% (n = 25) of patients were diagnosed contacting  COVID-19. Interestingly, 73.2% (n = 370) patients preferred online appointment than physical appointment. Most common difficulties faced during lockdown period were high delivery charges for getting gluten-free (GF) food at home (54.4%), increased prices of regular GF food (43.1%), and travelling long distance to arrange GF food (44.9%).

CONCLUSIONS

The COVID-19 pandemic has substantially affected the adherence, symptom control, and QOL in patients with CeD, attributable to unavailability, shortage of money, and heightened cost of GF food. The pandemic has offered an opportunity to practice teleconsultation approach for patients with CeD.

Factors associated with non adherence to a gluten free diet in adult with celiac disease: A survey assessed by BIAGI score

INTRODUCTION

The cornerstone of the recommended treatment for Celiac disease (CeD) is a lifelong strict gluten-free diet (GFD). We aimed to identify prospectively the demographic, clinical, social and psychological profile associated with non-adherence to a GFD in adult CeD patients in Israel.

METHODS

An anonymous online questionnaire was sent via the Israeli Celiac association and through social networks. Only CeD patients≥18 years old were included. Socio-demographic, laboratory and clinical data as well as anxiety and depression scores were reported. Adherence to a GFD was assessed by a Biagi questionnaire.

RESULTS

In total, 301 patients completed the questionnaire with a mean age of 37.5±14.9 years, 79.2% female. The most common presenting symptoms were: anemia (59.7%), abdominal pain (50.8%) and diarrhea (42.8%). According to the Biagi score, 82% of patients were found to be high adherent to a GFD (Biagi 3-4) and 18% were low adherent to a GFD (Biagi-0-2). Univariate analysis revealed that low adherence was associated with: younger age at the time of diagnosis (P<0.001), longer duration of disease (P=0.011) non academic education (P=0.011), below average income (P=0.018), smoking (P<0.001) and no gastroenterology follow up (P=0.038). However, in multivariate analysis, only a young age at diagnosis and smoking were significantly associated with non-adherence to a GFD (OR 0.924, 3.48, P-value<0.001, 0.029, respectively). In further analysis, we identified that age 20 is the best cutoff value to discriminate between those with high adherence and those with low adherence.

CONCLUSIONS

Young age, smoking, long disease duration, no academic education, low income and no gastroenterology follow-up were found to be associated with low adherence to GFD rate in a univariate analysis, however only the first two were found to be significant in the multivariate analysis. Additional intervention strategies might improve adherence and reduce future complications with a better quality of life.

Gluten-Free Diet in Prisons in Poland: Nutrient Contents and Implementation of Dietary Reference Intake Standards

The gluten-free diet (GFD) requires special attention from nutritionists due to the potential risk of nutrient deficiencies in its users. This risk may be greater when this type of nutrition is implemented in prisons due to the limited possibilities of external control, a low catering budget for meals, and insufficiently defined recommendations regulating nutrition for prisoners. The aim of the present study was to assess the nutritional value of GFD and regular diet meals served in some Polish prisons and to compare the values to the dietary reference intake (DRI) standards. Using a specialized computer program, 7-day menus of both types of diet provided in 10 prisons were analyzed. The percentage coverage of the DRI was calculated based on the recommendations of the Polish National Food and Nutrition Institute. GFD was characterized by lower average contents of energy and 11 out of 14 essential nutrients, i.e., protein, carbohydrates, dietary fiber, starch, ash, sodium, calcium, iron, zinc, folate, and vitamin B12. The average content of phosphorus, niacin, and riboflavin in the gluten-free diet was higher than that in the regular diet. It was shown that the meals in GFD and the regular diet did not provide the recommended amounts of calcium (38 and 44% DRI, respectively), vitamin D (29 and 30% DRI), vitamin C (86 and 76% DRI), and folate (51 and 56% DRI). In turn, the supply of sodium, phosphorus, copper, and vitamins A and B6 substantially exceeded the recommended levels. The results indicate a need for greater quality control of GFD meals served in catering facilities. It is also necessary to develop legal provisions that will regulate more specifically the nutrition for prisoners in terms of an adequate supply of minerals and vitamins.

Celiac Disease and Non-celiac Wheat Sensitivity: State of Art of Non-dietary Therapies

Gluten related disorders (GRD), which include celiac disease, non-celiac wheat sensitivity and wheat allergy are heterogeneous conditions triggered by ingestion of gluten-containing grains. Together, their prevalence is estimated to be ~5% in the general population, however, in the last years the number of diagnoses has been rapidly increasing. To this day, the gold standard treatment for these disorders is the complete removal of gluten-containing grains from the diet. Although this therapy results effective in the majority of patients, up to 30% of individuals affected by GRD continue to present persistent symptoms. In addition, gluten-free diet has been shown to have poor nutritional quality and to cause a socio-economic burden in patients' quality of life. In order to respond to these issues, the scientific community has been focusing on finding additional and adjuvant non-dietary therapies. In this review, we focus on two main gluten related disorders, celiac disease and non-celiac wheat sensitivity. We delineate the actual knowledge about potential treatments and their relative efficacy in pre-clinical and clinical trials.

Evaluating the Dietary Intakes of Energy, Macronutrients, Sugar, Fiber, and Micronutrients in Children With Celiac Disease

OBJECTIVES

Children with celiac disease (CD) follow a lifelong gluten-free diet. This restrictive diet may be associated with nutritional compromise. Our objectives were, therefore, to evaluate the dietary composition (energy, macronutrients and micronutrients, and fiber) in children with CD compared with healthy controls (HC) and relationship between dietary composition and socioeconomic status.

METHODS

This cross-sectional, case-control study recruited children with CD ages 2 to 18 years and HC matched for age, sex, and socioeconomic status. Clinical, sociodemographic, and dietary information were collected. A false discovery rate correction was applied to the P-value for multiple comparisons (q-value).

RESULTS

Sixty-five CD children were matched with 65 HC (mean [SD] age: 10.2 [3.6] vs 10.1 [3.7] years, P = 0.96). Compared with HC, CD children had higher intakes of energy (2413.2 [489.9] vs 2190.8 (593.5) kcal/day, P = 0.02), total fat (818.1 ± 180.9 vs 714.3 ± 212.2 kcal/day, q = 0.018), and subtypes of fat (saturated, polyunsaturated, and monounsaturated). There were no differences in other macronutrients, sugar, micronutrients, or fiber between CD and HC, and no difference in dietary intake among CD between socioeconomic disadvantage versus advantage. Children with CD had lower weight z-scores (-0.06 [1.05] vs 0.47 [0.96], P = 0.003) and body mass index (BMI) z-scores (-0.02 [0.88] vs 0.41 [1.09], P = 0.02) than HC.

CONCLUSIONS

Children with CD had higher calorie and fat intake compared with HC. Despite this, CD children had lower weight and BMI z-scores compared with HC.

Sensory Profile of Rice-Based Snack (Nuroongji) Prepared from Rice with Different Levels of Milling Degree

Nuroongji is a traditional rice-based snack that is widely consumed in Korea, but there is no reported comprehensive sensory characterization of this popular snack. The objective of this study was to conduct a sensory analysis of Nuroongji made with rice with different degrees of milling. Four different types of Nuroongji samples according to the degree of milling were prepared in the lab and subjected to physiochemical analysis. Descriptive sensory analysis was conducted by a trained panel (n = 8), and a consumer acceptance test was conducted using college students (n = 70). A sensory lexicon describing the flavor and texture characteristics of Nuroongji was developed: it included roasted brown rice, burnt, buckwheat, rice powder, glutinous rice power, and floral. The following texture attributes were evaluated in triplicate: hardness of particles, irregularity of particles, degree of coagulation, number of chews, and residual mouthfeel. Significant differences in flavor and mouthfeel attributes were observed between the Nuroongji samples according to the degree of milling (p < 0.05). Nuroongji made with white rice (N1) had a higher hardness value and less sweetness compared to other samples (p < 0.05). Texture- and mouthfeel-related attributes such as cohesiveness of the mass, irregularity of the surface, and astringency were identified as important characteristics that drive consumer acceptance of Nuroongji products. Findings from this study can provide Nuroongji product developers a valuable insight to extend their market by reformulating the product to be appealing to young consumers.

The development of the gluten free healthy food basket in Cyprus. Is it affordable among low-income adults diagnosed with celiac disease?

BACKGROUND

Gluten free (GF) diets are not only restrictive but also costly. The main aim of this study was to evaluate the acceptability, cost and affordability of a Gluten Free Healthy Food Basket (GFHFB) and further examine whether low-income Cypriots diagnosed with celiac disease (CD) experience food stress.

METHODS

GFΗFBs were constructed for adult women and adult men (±40 years) diagnosed with CD. Feasibility and acceptability was tested through three focus groups. Affordability was defined as the cost of the GFΗFB as a percentage of the Guaranteed Minimum Income (GMI).

RESULTS

The GFΗFB was 33.6 and 47 euros/month more expensive compared to the HB (Healthy Basket) for women and men, respectively. The total budget for GF-manufactured products were 27.81 and 28.5% of the total food budget, for women and men, respectively. For low-income people receiving the GMI, the proportion of income that would need to be spent on the GFHFB ranges from around 42 to 60%.

CONCLUSIONS

The GFΗFB is costly and not affordable among low-income Cypriots diagnosed with CD; thus, they are likely to suffer from food stress. As such, the risk of reducing their adherence to a GF diet is high and thus compromises their long-term health.