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Luque V, Crespo-Escobar P, Hård Af Segerstad EM, Koltai T, Norsa L, Roman E, Vreugdenhil A, Fueyo-Díaz R, Ribes-Koninckx C. Gluten-free diet for pediatric patients with coeliac disease: A position paper from the ESPGHAN gastroenterology committee, special interest group in coeliac disease. J Pediatr Gastroenterol Nutr 2024; 78:973-995. [PMID: 38291739 DOI: 10.1002/jpn3.12079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 02/01/2024]
Abstract
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.
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Affiliation(s)
- Veronica Luque
- Serra Húnter, Universitat Rovira i Virgili, Reus, Spain
- Paediatric Nutrition and Development Research Unit, IISPV, Reus, Spain
| | - Paula Crespo-Escobar
- Health Sciences Department, ADVISE Research Group, Miguel de Cervantes European University, Valladolid, Spain
- Nutrition and Dietetics Unit, Hospital Recoletas Campo Grande, Valladolid, Spain
| | - Elin M Hård Af Segerstad
- Paediatric Department, Skane University Hospital, Malmoe, Sweden
- Department of Clinical Sciences, Celiac Disease and Diabetes Unit, Faculty of Medicine, Lund University, Malmoe, Sweden
| | - Tunde Koltai
- Direction Board, Association of European Coeliac Societies, Brussels, Belgium
| | - Lorenzo Norsa
- Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Enriqueta Roman
- Paediatric Gastroenterology and Nutrition, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Anita Vreugdenhil
- Department of Pediatrics, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ricardo Fueyo-Díaz
- Department of Psychology and Sociology, Aragonese Primary Care Research Group (GAIAP, B21_20R), University of Zaragoza, Zaragoza, Spain
| | - Carmen Ribes-Koninckx
- Paediatric Gastroenterology, Hepatology and Nutrition, La Fe University Hospital & La Fe Research Institute, Valencia, Spain
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Belpınar A, Dağ YS, Arıcıoğlu Sülün A, Yayan EH, Varol Fİ. The effect of anxiety and depression levels of children with celiac disease on quality of life. J Pediatr Nurs 2023; 73:e260-e265. [PMID: 37805380 DOI: 10.1016/j.pedn.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/24/2023] [Accepted: 09/24/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE This study was conducted to examine the effect of anxiety and depression levels on quality of life in children with celiac disease. DESIGN AND METHOD This descriptive and correlational study was conducted with 98 children diagnosed with celiac disease who applied to the pediatric outpatient clinic of a university hospital in Eastern Anatolia between September 2021 and August 2022. Data were collected using the State-Trait Anxiety Scale, Depression Scale, and Quality of Life Scale through face-to-face interviews conducted by the researchers. Percentage distribution, mean, independent samples t-test, Pearson correlation analysis and regression analysis were used to analyze the data. RESULTS It was found that 62% of the participant children were female and their mean age was 11.69 ± 4.15 years. The mean scores of state anxiety, trait anxiety, depression and quality of life of children with celiac disease were 42.46 ± 5.42 (high), 43.83 ± 7.08 (high), 23.37 ± 4.79 (high) and 43.67 ± 19.67 (low), respectively. Regression analysis revealed that anxiety had a statistically significant relationship with quality of life. CONCLUSIONS It was found that children with celiac disease experienced high levels of depression and anxiety along with physical functionality and psychosocial health problems and this negatively affected their quality of life. It is recommended that children with celiac disease should be followed up and supported psychosocially. PRACTICE IMPLICATIONS That healthcare professionals can contribute to reducing the depression and axienty and improving the quality of life by strengthening the social support systems of childrens with celiac disease.
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Affiliation(s)
- Ayşe Belpınar
- Department of Medical Services and Techniques, Health Assistance Vocational School, Yozgat Bozok University, Yozgat, Turkey.
| | - Yeliz Suna Dağ
- Pediatric Nursing Department, Faculty of Health Sciences, Fırat University, Elazığ, Turkey
| | - Ayşe Arıcıoğlu Sülün
- Pediatric Nursing Department, Faculty of Health Sciences, Ordu University, Ordu, Turkey
| | - Emriye Hilal Yayan
- Pediatric Nursing Department Faculty of Nursing, İnönü University, Malatya, Turkey
| | - Fatma İlknur Varol
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, Inonu University, Malatya, Turkey
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Vázquez-Polo M, Navarro V, Larretxi I, Perez-Junkera G, Lasa A, Matias S, Simon E, Churruca I. Uncovering the Concerns and Needs of Individuals with Celiac Disease: A Cross-Sectional Study. Nutrients 2023; 15:3681. [PMID: 37686713 PMCID: PMC10490089 DOI: 10.3390/nu15173681] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
The treatment for celiac disease (CD) involves a strict gluten-free diet, which can be challenging and lead to questions for patients. Pinpointing these uncertainties can enable the creation of efficient educational resources. In this study, a questionnaire was specifically designed to gain insights into the knowledge, concerns, and needs of individuals with CD and their supporters. The questionnaire was distributed through the Instagram social network and received adequate responses from 300 participants, 258 (86%) being female and 152 (50.7%) falling in the age range of 25-44 years. The concerns of individuals with celiac disease and celiac supporters were rated on a 1-4 scale, with a mean score of 3.5 indicating significant concern. A total of 255 (85%) of all participants expressed that their principal concern was the social limitations they faced, such as difficulties in eating out and sharing food with others. Every participant evaluated their overall disease knowledge, averaging at 2.92 out of 4, indicating a reasonable level of awareness. When asked if they believed that improving general knowledge about CD in the general population would enhance their quality of life, the vast majority responded affirmatively. This finding underscores the importance of not only educating individuals with CD but also reaching out to the wider population, especially those who have a direct impact on the daily lives of individuals with CD, such as family members, friends, and food service providers.
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Affiliation(s)
- Maialen Vázquez-Polo
- Gluten 3S Research Group, Department of Nutrition and Food Science, Faculty of Pharmacy, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (M.V.-P.); (I.L.); (G.P.-J.); (A.L.); (S.M.); (E.S.); (I.C.)
- Bioaraba, Nutrition and Food Safety Group, 01009 Vitoria-Gasteiz, Spain
| | - Virginia Navarro
- Gluten 3S Research Group, Department of Nutrition and Food Science, Faculty of Pharmacy, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (M.V.-P.); (I.L.); (G.P.-J.); (A.L.); (S.M.); (E.S.); (I.C.)
- Bioaraba, Nutrition and Food Safety Group, 01009 Vitoria-Gasteiz, Spain
| | - Idoia Larretxi
- Gluten 3S Research Group, Department of Nutrition and Food Science, Faculty of Pharmacy, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (M.V.-P.); (I.L.); (G.P.-J.); (A.L.); (S.M.); (E.S.); (I.C.)
- Bioaraba, Nutrition and Food Safety Group, 01009 Vitoria-Gasteiz, Spain
- Centro Integral de Atención a Mayores San Prudencio, 01006 Vitoria-Gasteiz, Spain
| | - Gesala Perez-Junkera
- Gluten 3S Research Group, Department of Nutrition and Food Science, Faculty of Pharmacy, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (M.V.-P.); (I.L.); (G.P.-J.); (A.L.); (S.M.); (E.S.); (I.C.)
- Bioaraba, Nutrition and Food Safety Group, 01009 Vitoria-Gasteiz, Spain
| | - Arrate Lasa
- Gluten 3S Research Group, Department of Nutrition and Food Science, Faculty of Pharmacy, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (M.V.-P.); (I.L.); (G.P.-J.); (A.L.); (S.M.); (E.S.); (I.C.)
- Bioaraba, Nutrition and Food Safety Group, 01009 Vitoria-Gasteiz, Spain
| | - Silvia Matias
- Gluten 3S Research Group, Department of Nutrition and Food Science, Faculty of Pharmacy, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (M.V.-P.); (I.L.); (G.P.-J.); (A.L.); (S.M.); (E.S.); (I.C.)
- Bioaraba, Nutrition and Food Safety Group, 01009 Vitoria-Gasteiz, Spain
| | - Edurne Simon
- Gluten 3S Research Group, Department of Nutrition and Food Science, Faculty of Pharmacy, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (M.V.-P.); (I.L.); (G.P.-J.); (A.L.); (S.M.); (E.S.); (I.C.)
- Bioaraba, Nutrition and Food Safety Group, 01009 Vitoria-Gasteiz, Spain
| | - Itziar Churruca
- Gluten 3S Research Group, Department of Nutrition and Food Science, Faculty of Pharmacy, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (M.V.-P.); (I.L.); (G.P.-J.); (A.L.); (S.M.); (E.S.); (I.C.)
- Bioaraba, Nutrition and Food Safety Group, 01009 Vitoria-Gasteiz, Spain
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Cadenhead JW, Martínez-Steele E, Contento I, Kushi LH, Lee AR, Nguyen TTT, Lebwohl B, Green PHR, Wolf RL. Diet quality, ultra-processed food consumption, and quality of life in a cross-sectional cohort of adults and teens with celiac disease. J Hum Nutr Diet 2023; 36:1144-1158. [PMID: 36653177 DOI: 10.1111/jhn.13137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 01/03/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Coeliac disease (CeD), a common autoimmune condition, requires strict adherence to a gluten-free diet (GFD). Adherence to the GFD has been associated with quality of life (QOL). However, there may be other diet-related concerns, such as overall diet patterns, including diet quality or ultra-processed food (UPF) consumption, possibly associated with QOL among people with CeD following a GFD that have not been examined. METHODS Diet quality was determined based on 24-h diet recalls of a cross-sectional prospectively recruited sample of 80 participants (50 adults and 30 teens) with biopsy-confirmed CeD ('Study Sample') using the Healthy Eating Index and Alternate Mediterranean Diet score. The amount of UPF consumed was assessed using Nova, a food processing classification system. QOL was measured using Celiac Disease-Specific Quality of Life (CDQOL) and Celiac Disease Pediatric-Specific Quality of Life (CDPQOL). The Study Sample's diet patterns were compared with National Health and Nutrition Examination Survey (NHANES) groups (25 adults reporting prior CeD and GFD; 51 adults with new CeD and no GFD; 15,777 adults and 2296 teens without CeD). The relationship of the Study Sample's diet patterns with CDQOL/CDPQOL was assessed using analysis of covariance. RESULTS The Study Sample's diet patterns were suboptimal but generally favourable compared with all NHANES groups. Compared to Study Adults with the highest tertile of UPF, those with the lowest tertile had significantly higher CDQOL (mean: 67.6 vs. 78.3, p < 0.001). Compared to Study Teens with the lowest tertile of AMED, those with the highest tertile had significantly higher CDPQOL (mean: 67.0 vs. 79.9, p < 0.01). CONCLUSIONS Maintaining high diet quality and minimising UPF may be important for CeD-specific QOL among individuals with CeD maintaining a GFD.
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Affiliation(s)
- Jennifer W Cadenhead
- Department of Health & Behavior Studies, Program in Nutrition Teachers College, Columbia University, New York, NY, USA
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Euridice Martínez-Steele
- Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil
- Center for Epidemiological Studies in Health and Nutrition, University of São Paulo, São Paulo, Brazil
| | - Isobel Contento
- Department of Health & Behavior Studies, Program in Nutrition Teachers College, Columbia University, New York, NY, USA
| | - Lawrence H Kushi
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Anne R Lee
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Thanh Thanh T Nguyen
- Department of Health & Behavior Studies, Program in Nutrition Teachers College, Columbia University, New York, NY, USA
| | - Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
| | - Peter H R Green
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Randi L Wolf
- Department of Health & Behavior Studies, Program in Nutrition Teachers College, Columbia University, New York, NY, USA
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Gholmie Y, Lee AR, Satherley RM, Schebendach J, Zybert P, Green PHR, Lebwohl B, Wolf R. Maladaptive Food Attitudes and Behaviors in Individuals with Celiac Disease and Their Association with Quality of Life. Dig Dis Sci 2023:10.1007/s10620-023-07912-6. [PMID: 37024737 PMCID: PMC10079145 DOI: 10.1007/s10620-023-07912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 03/02/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The only treatment for celiac disease (CeD) is strict lifelong adherence to a gluten-free diet (GFD). In some individuals the demands of a GFD may contribute to maladaptive eating attitudes and behaviors that impair quality of life (QOL). The Celiac Disease Food Attitudes and Behaviors (CD-FAB) is an easily administered and scored 11-item tool querying potentially maladaptive food attitudes and behaviors resulting from beliefs around gluten exposures and food safety. OBJECTIVES To assess the usefulness of the CD-FAB in establishing the presence of maladaptive food attitudes and behaviors among adults with CeD and to explore the relationship between these attitudes and behaviors and other factors including QOL, anxiety, depression, CeD symptoms and personality traits. METHODS The study is a cross-sectional pilot of 50 adults (mean age 29.6 years) with biopsy-proven CeD who followed a GFD for at least one year and had no self-reported eating disorder diagnosis. High scores on the CD-FAB tool suggest higher disordered eating attitudes and beliefs. RESULTS Compared to lower scores (mean 20.2), higher (worse) CD-FAB scores (mean 54.5) were positively associated with recency of diagnosis, number of CeD-related gastrointestinal symptoms, and the personality trait of neuroticism. Higher CD-FAB scores were statistically and clinically significantly associated with diminished QOL (p < 0.001). The relationship with anxiety and depression was less clear but trended in the expected direction. CONCLUSION The CD-FAB may be a useful tool for dietitians who wish to monitor maladaptive food attitudes and behaviors among their CeD patients, especially in the first-year post-diagnosis.
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Affiliation(s)
- Yara Gholmie
- Program in Nutrition, Department of Health & Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, New York, NY, 10027, USA.
| | - Anne R Lee
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, 180 Fort Washington Avenue, Suite 934, Harkness Pavilion, New York, NY, 10032, USA
| | - Rose-Marie Satherley
- Department of Psychological Interventions, School of Psychology, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Janet Schebendach
- Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Patricia Zybert
- Department of Health & Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, New York, NY, 10027, USA
| | - Peter H R Green
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, 180 Fort Washington Avenue, Suite 934, Harkness Pavilion, New York, NY, 10032, USA
| | - Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University Irving Medical Center, 180 Fort Washington Avenue, Suite 934, Harkness Pavilion, New York, NY, 10032, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, 722 West 168th St., New York, NY, 10032, USA
| | - Randi Wolf
- Program in Nutrition, Department of Health & Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, New York, NY, 10027, USA
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Dalton J, Castellanos DC. The Exploration of the Eating Experience in Adults with Celiac Disease: A Phenomenological Qualitative Study. J Acad Nutr Diet 2023; 123:593-601. [PMID: 36028163 DOI: 10.1016/j.jand.2022.08.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The adjustment to a strict gluten-free diet for adults diagnosed with celiac disease (CD) may lead to changes in the eating experience affecting the physical, social, and emotional states. OBJECTIVE Through the application of the Social Cognitive Transition Model of Adjustment, the aim of the study was to explore the adjustment in the eating experience in adults recently diagnosed with CD and transitioning to a gluten-free diet. DESIGN This was a qualitative phenomenological study conducted using semistructured interviews. PARTICIPANTS AND SETTING Seventeen adults from the midwestern United States who were diagnosed with CD between 6 months and 5 years before the study were recruited using social media CD sites and snowball sampling. Participants completed a semistructured interview on Zoom and the Celiac Disease Adherence Test and CeliacQ-7 questionnaires from May to November 2020. STATISTICA ANALYSES PERFORMED Two trained qualitative researchers engaged in four steps to reduce and contextualize the data: horizontilization, reduction and elimination, clustering and thematizing, and composition of textural description. During analysis, the Social Cognitive Transition Model of Adjustment was incorporated for organization of themes and text description. RESULTS There was moderate to high dietary adherence in 14 of 17 participants and quality of life scores ranged from 19 to 43 (median = 33). Five themes emerged aligning with Social Cognitive Transition Model of Adjustment, describing the adjustment in pre- and postdiagnosis eating experience and the coping and behaviors enacted during adjustment to a gluten-free diet. CONCLUSIONS In individuals with CD, moving beyond problem solving and identifying psychosocial and emotional attributes in the adoption of a gluten-free diet need to be considered to promote maintenance of quality of life and dietary adherence.
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Affiliation(s)
- Jennifer Dalton
- Health and Sport Science, University of Dayton, Dayton, Ohio.
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Staller K, Abber SR, Burton Murray H. The intersection between eating disorders and gastrointestinal disorders: a narrative review and practical guide. Lancet Gastroenterol Hepatol 2023; 8:565-578. [PMID: 36868254 DOI: 10.1016/s2468-1253(22)00351-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 03/04/2023]
Abstract
Eating disorders include a spectrum of disordered thinking patterns and behaviours around eating. There is increasing recognition of the bi-directional relationship between eating disorders and gastrointestinal disease. Gastrointestinal symptoms and structural issues might arise from eating disorders, and gastrointestinal disease might be a risk factor for eating disorder development. Cross-sectional research suggests that individuals with eating disorders are disproportionately represented among people seeking care for gastrointestinal symptoms, with avoidant-restrictive food intake disorder in particular garnering attention for high rates among individuals with functional gastrointestinal disorders. This Review aims to describe the research to date on the relationship between gastrointestinal disorders and eating disorders, highlight research gaps, and provide brief, practical guidance for the gastroenterology provider in detecting, potentially preventing, and treating gastrointestinal symptoms in eating disorders.
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Affiliation(s)
- Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Sophie R Abber
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Helen Burton Murray
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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Examining the Psychosocial Well-Being of Children and Adolescents With Coeliac Disease: A Systematic Review. J Pediatr Gastroenterol Nutr 2023; 76:e1-e14. [PMID: 36573999 DOI: 10.1097/mpg.0000000000003652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This review aimed to synthesize the available literature regarding the psychosocial well-being of children and adolescents with coeliac disease (CD). Research on psychosocial well-being outcomes in children and adolescents with CD under the age of 18 were identified through a systematic search in the PsychInfo, Medline, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases in July 2021. Outcomes, including health-related quality of life (HRQOL), psychological adjustment, mental health, and social functioning were examined. Changes in outcomes over time and the geographic representation of the included studies were also analyzed. A total of 43 studies were included. Mixed results were found in the domain of HRQOL and mental health. Both challenges with psychological adjustment and adaptive coping strategies were identified. Social functioning was found to be an area of difficulty for children and adolescents with CD. However, there was high heterogeneity in methodology and participant characteristics between studies. This review concluded there were mixed findings regarding the HRQOL and mental health of young people with CD. However, CD and the gluten-free diet initiates a need for psychological adjustment and impacts on social functioning. The review highlights the need for the integration of physical and psychosocial care, and further research to determine the most appropriate screening measures, and the most efficacious psychological interventions for this group. Future research should continue examining changes in psychosocial outcomes over time given the increase in the availability of gluten-free foods and changes in food labeling policies.
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Annan SF, Higgins LA, Jelleryd E, Hannon T, Rose S, Salis S, Baptista J, Chinchilla P, Marcovecchio ML. ISPAD Clinical Practice Consensus Guidelines 2022: Nutritional management in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1297-1321. [PMID: 36468223 DOI: 10.1111/pedi.13429] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 12/07/2022] Open
Affiliation(s)
- S Francesca Annan
- Paediatric Division, University College London Hospitals, London, UK
| | - Laurie A Higgins
- Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Elisabeth Jelleryd
- Medical Unit Clinical Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | - Tamara Hannon
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Shelley Rose
- Diabetes & Endocrinology Service, MidCentral District Health Board, Palmerston North, New Zealand
| | - Sheryl Salis
- Department of Nutrition, Nurture Health Solutions, Mumbai, India
| | | | - Paula Chinchilla
- Women's and Children's Department, London North West Healthcare NHS Trust, London, UK
| | - Maria Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Aswani-Omprakash T, Shah ND. Sociocultural Considerations for Food-Related Quality of Life in Inflammatory Bowel Disease. Gastroenterol Clin North Am 2022; 51:885-895. [PMID: 36376002 DOI: 10.1016/j.gtc.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The prevalence of inflammatory bowel disease (IBD) is increasing substantially in non-White races and ethnicities in the United States. As a part of promoting quality of life in patients with IBD, the optimization of food-related quality of life (FRQoL) is also indicated. It is known that the practices of food avoidance and restrictive eating are associated with a reduced FRQoL in IBD. Gaining insight into sociocultural influences on FRQoL will aid in the provision of culturally competent interventions to improve FRQoL in patients with IBD.
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Affiliation(s)
- Tina Aswani-Omprakash
- Mount Sinai Icahn School of Medicine, New York, NY 10029, USA; South Asian IBD Alliance, New York, NY 10021, USA. https://twitter.com/@ownyourcrohns
| | - Neha D Shah
- South Asian IBD Alliance, New York, NY 10021, USA; Colitis and Crohn's Disease Center, University of California, San Francisco, CA 94115, USA; Neha Shah Nutrition, San Francisco, CA 94105, USA.
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Coburn S, Germone M, McGarva J, Taft T. Psychological Considerations for Food Intolerances: Celiac Sprue, Eosinophilic Esophagitis, and Non-Celiac Gluten Sensitivity. Gastroenterol Clin North Am 2022; 51:753-764. [PMID: 36375994 PMCID: PMC10581356 DOI: 10.1016/j.gtc.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Several chronic digestive conditions are physiologically based on food intolerance, including celiac disease, nonceliac gluten sensitivity, and eosinophilic esophagitis. Patients are expected to follow medically prescribed diets to eliminate identified food triggers to control symptoms. However, the psychological impacts of these dietary approaches are largely unaddressed in clinical practice. Hypervigilance and anxiety regarding food and symptoms, and disordered eating, may emerge and negatively affect outcomes. Clinicians working with pediatric and adult populations with food intolerances should be aware of these psychological comorbidities, and equally emphasize effective ways to help patients manage the mental and physical aspects of their condition.
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Affiliation(s)
- Shayna Coburn
- Children's National Hospital 111 Michigan Avenue NW, Center for Translational Research, 6th Flr Main, Washington, DC 20010, USA
| | - Monique Germone
- Departments of Psychiatry and Pediatrics, University of Colorado Anschutz Medical Campus, Digestive Health Institute, Children's Hospital Colorado, 13123 E. 16th Ave., B130, Aurora, CO 80045, USA
| | - Josie McGarva
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street Suite 1400, Chicago, IL 60611, USA
| | - Tiffany Taft
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street Suite 1400, Chicago, IL 60611, USA.
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12
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Chang D, O’Shea D, Therrien A, Silvester JA. Review article: Becoming and being coeliac-special considerations for childhood, adolescence and beyond. Aliment Pharmacol Ther 2022; 56 Suppl 1:S73-S85. [PMID: 35815825 PMCID: PMC9441244 DOI: 10.1111/apt.16851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/10/2022] [Accepted: 02/13/2022] [Indexed: 12/09/2022]
Abstract
Classically considered a disease of early childhood characterised by malabsorption and failure to thrive, coeliac disease is now recognised to arise in genetically susceptible individuals at any age. Although permissive HLA genotypes are the strongest predictor of coeliac disease, they are not sufficient. Several prospective cohort studies enrolling genetically at-risk infants have investigated the role of potential triggers of coeliac disease autoimmunity, such as timing of gluten introduction, viral infections and dietary patterns. Much less is known about triggers of coeliac disease in adulthood. Better understanding of factors leading to coeliac disease may be helpful in the management of those with potential coeliac disease (elevated serum celiac antibodies without villous atrophy in the small intestine), many of whom initiate a gluten-free diet without demonstration of villous atrophy. There are a range of clinical presentations of celiac disease in childhood and patterns of coeliac serology, including fluctuation and spontaneous reversion on a gluten-containing diet, vary. There is a current debate over best strategies to manage adults and children with potential coeliac disease to avoid over-treatment and under-treatment. Childhood and adolescence carry unique issues pertaining to the diagnosis and management of coeliac disease, and include nutrition and growth, rescreening, repeat biopsy, dietary adherence concerns and transition to adult care. In conclusion, while coeliac disease has similar pathogenesis and general clinical manifestations in paediatric and adult populations, diagnostic and management approaches need to adapt to the developmental stages.
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Affiliation(s)
- Denis Chang
- 1. Boston Children’s Hospital, Boston, MA,2. Harvard Celiac Research Program, Harvard Medical School, Boston, MA
| | - Delia O’Shea
- 1. Boston Children’s Hospital, Boston, MA,2. Harvard Celiac Research Program, Harvard Medical School, Boston, MA
| | - Amelie Therrien
- 2. Harvard Celiac Research Program, Harvard Medical School, Boston, MA,3. Beth Israel Deaconess Medical Center, Boston, MA
| | - Jocelyn A Silvester
- 1. Boston Children’s Hospital, Boston, MA,2. Harvard Celiac Research Program, Harvard Medical School, Boston, MA,3. Beth Israel Deaconess Medical Center, Boston, MA
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13
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Lee AR. Review article: Dietary management of coeliac disease. Aliment Pharmacol Ther 2022; 56 Suppl 1:S38-S48. [PMID: 35815831 DOI: 10.1111/apt.16974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/23/2021] [Accepted: 05/03/2022] [Indexed: 12/09/2022]
Abstract
As the gluten-free diet is currently the only treatment for coeliac disease and one that needs to applied in the long term, this review aims to explore the various issues confronting an individual and discuss the importance of ongoing dietary management. The process of dietary counselling has shifted from one that focuses on just foods to avoid to one that evaluates the multiple life factors (social, cultural, environmental, biological) that affect the individual's food choices and dietary behaviour. The nutritional quality of a gluten-free diet continues to affect vitamin, mineral and weight status of individuals with coeliac disease. There are many barriers to dietary adherence including increased cost and limited availability of gluten-free products, as well as the negative impact on an individual's social domain of quality of life. Therefore, assessment, education and counselling by a coeliac specialist dietitian should be the cornerstone of dietary management.
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Affiliation(s)
- Anne R Lee
- Celiac Disease Center, Columbia University Irving Medical Center, New York City, New York, USA
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14
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Crawley C, Savino N, Halby C, Sander SD, Andersen AN, Arumugam M, Murray J, Christensen R, Husby S. The effect of gluten in adolescents and young adults with gastrointestinal symptoms: a blinded randomised cross-over trial. Aliment Pharmacol Ther 2022; 55:1116-1127. [PMID: 35352373 PMCID: PMC9313792 DOI: 10.1111/apt.16914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/17/2021] [Accepted: 03/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The popularity of the gluten-free diet and sales of gluten-free products have increased immensely. AIMS To investigate whether gluten induces gastrointestinal symptoms, measured by self-reported questionnaires, as well as mental health symptoms in adolescents from a population-based cohort. METHODS The eligible participants (n = 273) were recruited from a population-based cohort of 1266 adolescents and had at least four different gastrointestinal symptoms. Phase one (n = 54) was a run-in phase where the participants lived gluten-free for 2 weeks. If they improved they continued to phase 2 (n = 33), a blinded randomised cross-over trial. Participants were blindly randomised either to start with 7 days of gluten, eating two granola bars containing 10 g of gluten or to 7 days on placebo, eating two granola bars without gluten, followed by the reverse and separated by a 7-day washout period. The effects of the intervention on gastrointestinal symptoms and mental health symptoms were assessed. RESULTS In total, 54/273 participants entered the run-in phase and 35 were eligible for randomization. A total of 33 were randomised and 32 completed the trial. The median age was 20.3 (IQR 19.2-20.9) and 32/33 participants were females. Compared with a placebo, gluten did not induce gastrointestinal symptoms. The difference in the average VAS was -0.01 (95% confidence interval -2.07 to 2.05). Nor did we find a difference in the outcomes measuring mental health. CONCLUSION Compared with placebo, adding gluten to the diet did not induce gastrointestinal symptoms or worsened mental health in adolescents recruited from a population-based cohort. The trial registration number is NCT04639921.
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Affiliation(s)
- Caecilie Crawley
- Hans Christian Andersen Children’s HospitalOdense University HospitalOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Nadia Savino
- Hans Christian Andersen Children’s HospitalOdense University HospitalOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Cecilie Halby
- Hans Christian Andersen Children’s HospitalOdense University HospitalOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | | | | | - Manimozhiyan Arumugam
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark,Department of Gastroenterology and HepatologyOdense University HospitalOdenseDenmark
| | - Joseph Murray
- Division of Gastroenterology and Hepatology, Department of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Robin Christensen
- Section for Biostatistics and Evidence‐Based Research, the Parker InstituteBispebjerg and Frederiksberg HospitalCopenhagenDenmark,Research Unit of Rheumatology, Department of Clinical ResearchUniversity of Southern Denmark, Odense University HospitalOdenseDenmark
| | - Steffen Husby
- Hans Christian Andersen Children’s HospitalOdense University HospitalOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
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15
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The global burden of coeliac disease: opportunities and challenges. Nat Rev Gastroenterol Hepatol 2022; 19:313-327. [PMID: 34980921 DOI: 10.1038/s41575-021-00552-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 02/06/2023]
Abstract
Coeliac disease is a systemic disorder characterized by immune-mediated enteropathy, which is caused by gluten ingestion in genetically susceptible individuals. The clinical presentation of coeliac disease is highly variable and ranges from malabsorption through solely extra-intestinal manifestations to asymptomatic. As a result, the majority of patients with coeliac disease remain undiagnosed, misdiagnosed or experience a substantial delay in diagnosis. Coeliac disease is diagnosed by a combination of serological findings of disease-related antibodies and histological evidence of villous abnormalities in duodenal biopsy samples. However, variability in histological grading and in the diagnostic performance of some commercially available serological tests remains unacceptably high and confirmatory assays are not readily available in many parts of the world. Currently, the only effective treatment for coeliac disease is a lifelong, strict, gluten-free diet. However, many barriers impede patients' adherence to this diet, including lack of widespread availability, high cost, cross-contamination and its overall restrictive nature. Routine follow-up is necessary to ensure adherence to a gluten-free diet but considerable variation is evident in follow-up protocols and the optimal disease management strategy is not clear. However, these challenges in the diagnosis and management of coeliac disease suggest opportunities for future research.
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16
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Wessels M, Dolinsek J, Castillejo G, Donat E, Riznik P, Roca M, Valitutti F, Veenvliet A, Mearin ML. Follow-up practices for children and adolescents with celiac disease: results of an international survey. Eur J Pediatr 2022; 181:1213-1220. [PMID: 34817672 DOI: 10.1007/s00431-021-04318-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
Adequate follow-up in celiac disease is important to improve dietary compliance and treat disease-related symptoms and possible complications. However, data on the follow-up of celiac children is scarce. We aimed to assess current pediatric celiac follow-up practices across Europe. Pediatricians and pediatric gastroenterologists from 35 countries in Europe, Israel, Turkey, and Russia completed an anonymous survey which comprised a 52-item questionnaire developed by the ESPGHAN Special Interest Group on Celiac Disease. A total of 911 physicians, the majority of whom exclusively worked in pediatric care (83%) and academic institutions (60%), completed the questionnaire. Mean age and mean experience with celiac care were 48.7 years (± 10.6) and 15.7 years (± 9.9), respectively. The vast majority (≥ 92%) always assessed anthropometry, dietary adherence, and tissue-transglutaminase IgA-antibodies at every visit, with the first visit being between 3 and 6 months after diagnosis. Other parameters (% always tested) were as follows: complete blood count (60%), iron status (48%), liver enzymes (42%), thyroid function (38%), and vitamin D (26%). Quality of life was never assessed by 35% of the responding physicians. Transition to adult care was mostly completed via a written transition report (37%) or no formal transition at all (27%).Conclusions: Follow-up of celiac children and adolescents in Europe may be improved, especially regarding a more rational use of (laboratory) tests, dietary and QoL assessment, and transition to adult care. Evidence-based advice from international scientific societies is needed. What is Known: • Follow-up in celiac disease is important to treat disease-related symptoms, improve dietary compliance, and prevent possible complications. • There is a lack of consensus about the appropriate follow-up. What is New: • Almost all European physicians assess anthropometry, tissue-transglutaminase IgA-antibodies, and dietary adherence at every visit, but there are large variations in other follow-up aspects. • Follow-up could be improved by a more rational use of (laboratory) tests, increased intention to dietary compliance, and quality of life together with transition programs to adult care.
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Affiliation(s)
- Margreet Wessels
- Department of Pediatrics, Rijnstate Hospital Arnhem, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands.
| | - Jernej Dolinsek
- Department of Pediatrics, Gastroenterology, Hepatology and Nutrition Unit, University Medical Centre Maribor, Maribor, Slovenia.,Department of Pediatrics, Medical Faculty, University Medical Centre Maribor, Maribor, Slovenia
| | - Gemma Castillejo
- Pediatric Gastroenterology Unit, Hospital Universitario Sant Joan de Reus, Reus, Spain
| | - Ester Donat
- Pediatric Gastroenterology and Hepatology Unit, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Petra Riznik
- Department of Pediatrics, Gastroenterology, Hepatology and Nutrition Unit, University Medical Centre Maribor, Maribor, Slovenia
| | - Maria Roca
- Celiac Disease and Digestive Immunopathology Unit, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | | | - Anne Veenvliet
- Department of Pediatrics, Rijnstate Hospital Arnhem, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - M Luisa Mearin
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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17
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Dietary Behavior and Risk of Orthorexia in Women with Celiac Disease. Nutrients 2022; 14:nu14040904. [PMID: 35215554 PMCID: PMC8879910 DOI: 10.3390/nu14040904] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 02/04/2023] Open
Abstract
Evidence points to a link between celiac disease and eating disorders. Although with the current limited knowledge, orthorexia cannot be formally recognized as an eating disorder, some features are similar. This study is the first to examine individuals with celiac disease in terms of the prevalence of risk of orthorexia. Participants were 123 females diagnosed with celiac disease. The standardized ORTO-15 questionnaire was used to assess the risk of orthorexia. In this study, eating habits and physical activity were assessed. The effect of celiac disease on diet was self-assessed on a 5-point scale. Taking a score of 40 on the ORTO-15 test as the cut-off point, a risk of orthorexia was found in 71% of individuals with celiac disease, but only in 32% when the cut-off point was set at 35. There was a positive correlation between age and ORTO-15 test scores (rho = 0.30). In the group with orthorexia risk, meals were more often self-prepared (94%) compared to those without risk of orthorexia (78%) (p = 0.006). Individuals at risk for orthorexia were less likely to pay attention to the caloric content of food (46%) relative to those without risk of orthorexia (69%) (p = 0.001). For 64% of those at risk for orthorexia vs. 8% without risk had the thought of food that worried them (p = 0.001). Given the survey instrument for assessing the prevalence of orthorexia and the overlap between eating behaviors in celiac disease and orthorexia, the prevalence of orthorexia in celiac disease cannot be clearly established. Therefore, future research should focus on using other research tools to confirm the presence of orthorexia in celiac disease.
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18
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Satherley RM, Lerigo F, Higgs S, Howard R. An interpretative phenomenological analysis of the development and maintenance of gluten-related distress and unhelpful eating and lifestyle patterns in coeliac disease. Br J Health Psychol 2022; 27:1026-1042. [PMID: 35170152 PMCID: PMC9544439 DOI: 10.1111/bjhp.12588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 02/03/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Estimates indicate that individuals with coeliac disease are more likely to experience disordered eating and impaired well-being than healthy controls, but less is known about the mechanisms by which these factors are related. The aim of this study was to understand experiences of coeliac disease and influence on subsequent unhelpful eating and lifestyle patterns. METHODS An online focus group discussion, hosted through a synchronous chat log, with adults living with coeliac disease was conducted. Seven individuals discussed their condition, lifestyle, and dietary changes post-diagnosis. Discussions were analysed using an interpretative phenomenological approach, a technique that enables new practical or research insight into health conditions based upon participants' experiences of their condition. RESULTS Three themes were identified: (i) Nobody knew what was happening to my body; (ii) I am so afraid of being 'glutened' that it is central to my thoughts and anxieties; and (iii) I am frightened but I can keep myself safe by being a 'good' coeliac. These appeared to contribute to participant distress or unhelpful eating or lifestyle behaviours. Participants appeared to develop severe anxiety around gluten, and implausible beliefs around diet and lifestyle management that appear to initiate and maintain unhelpful eating behaviours and maladaptive lifestyles changes, that contribute to distress. CONCLUSIONS Extending current knowledge, we propose a novel cognitive perspective on the development and maintenance of disordered eating in coeliac disease. Implications for how health providers can better support individuals with coeliac disease, and the role of dietary management, anxiety, and gastrointestinal symptoms in the development of disordered eating are discussed.
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Affiliation(s)
- Rose-Marie Satherley
- Department of Psychological Interventions, School of Psychology, University of Surrey, Guildford, UK
| | - Fiona Lerigo
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, UK
| | - Suzanne Higgs
- School of Psychology, University of Birmingham, Edgbaston, UK
| | - Ruth Howard
- School of Psychology, University of Birmingham, Edgbaston, UK
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19
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Simons M, Taft TH, Doerfler B, Ruddy JS, Bollipo S, Nightingale S, Siau K, van Tilburg MAL. Narrative review: Risk of eating disorders and nutritional deficiencies with dietary therapies for irritable bowel syndrome. Neurogastroenterol Motil 2022; 34:e14188. [PMID: 34254719 DOI: 10.1111/nmo.14188] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/20/2021] [Accepted: 05/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Dietary treatments are growing in popularity as interventions for chronic digestive conditions. Patients with irritable bowel syndrome (IBS) often change their eating behaviors to mitigate symptoms. This can occur under the direction of their physician, a dietitian, or be self-directed. Poorly implemented and monitored diet treatments occur frequently with considerable risks for negative consequences. We aim to review the literature related to dietary treatments and risks associated with nutritional deficiencies and disordered eating. METHODS Searches were conducted from June to December 2020 on PubMed, MEDLINE, EMBASE, DARE and the Cochrane Database of Systematic Reviews using relevant keywords based on the Patient, Intervention, Comparator and Outcome (PICO) format. Studies included both adult and pediatric populations. Results are synthesized into a narrative review. RESULTS While dietary approaches are efficacious in many research studies, their translation to clinical practice has been less clear. Patients with IBS are at risk for nutritional deficiencies, disordered eating, increased anxiety, and decreases in quality of life in both adult and pediatric groups. CONCLUSIONS Physicians prescribing dietary treatment for IBS should be aware of nutritional and psychological risks and implement mitigation measures. These include using a combination of brief, validated questionnaires and clinical history, and collaboration with registered dietitians and/or psychologists. Recommendations for clinical decisions are provided.
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Affiliation(s)
- Madison Simons
- Division of Gastroenterology & Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Tiffany H Taft
- Division of Gastroenterology & Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Bethany Doerfler
- Division of Gastroenterology & Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Steven Bollipo
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Scott Nightingale
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Keith Siau
- The Dudley Group, NHS Foundation Trust, Dudley, UK
| | - Miranda A L van Tilburg
- College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC, USA.,Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,School of Social Work, University of Washington, Seattle, WA, USA
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20
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Lee AR, Lebwohl B, Lebovits J, Wolf RL, Ciaccio EJ, Green PHR. Factors Associated with Maladaptive Eating Behaviors, Social Anxiety, and Quality of Life in Adults with Celiac Disease. Nutrients 2021; 13:4494. [PMID: 34960046 PMCID: PMC8708489 DOI: 10.3390/nu13124494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 01/05/2023] Open
Abstract
A gluten-free diet (GFD), which is the only treatment for celiac disease (CeD), is challenging and associated with higher levels of anxiety, disordered eating, and lower quality of life (QOL). We examined various demographic and health factors associated with social anxiety, eating attitudes and behaviors, and QOL. Demographics and health characteristics, QOL, eating attitudes and behaviors, and social anxiety of adults with CeD were acquired using validated measures. The mean scores for QOL, SAQ, and CDFAB were compared across various demographic groups using the Z statistical test. The mean QOL score was 57.8, which is in the moderate range. The social anxiety mean scores were high: 78.82, with 9% meeting the clinical cutoff for social anxiety disorder. Those on a GFD for a short duration had significantly higher SAQ scores (worse anxiety), higher CDFAB scores (worse eating attitudes and behavior), and lower QOL scores. Those aged 23-35 years had lower QOL scores (p < 0.003) and higher SAQ scores (p < 0.003). Being single (p < 0.001) and female (p = 0.026) were associated with higher SAQ scores. These findings suggest that the development of targeted interventions to maximize QOL and healthy eating behaviors as well as to minimize anxiety is imperative for some adults with CeD.
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Affiliation(s)
- Anne R. Lee
- Celiac Disease Center, Columbia University Irving Medical Center, New York, NY 10032, USA; (B.L.); (J.L.); (E.J.C.); (P.H.R.G.)
| | - Benjamin Lebwohl
- Celiac Disease Center, Columbia University Irving Medical Center, New York, NY 10032, USA; (B.L.); (J.L.); (E.J.C.); (P.H.R.G.)
| | - Jessica Lebovits
- Celiac Disease Center, Columbia University Irving Medical Center, New York, NY 10032, USA; (B.L.); (J.L.); (E.J.C.); (P.H.R.G.)
| | - Randi L. Wolf
- Teachers College, Columbia University, New York, NY 10027, USA;
| | - Edward J. Ciaccio
- Celiac Disease Center, Columbia University Irving Medical Center, New York, NY 10032, USA; (B.L.); (J.L.); (E.J.C.); (P.H.R.G.)
| | - Peter H. R. Green
- Celiac Disease Center, Columbia University Irving Medical Center, New York, NY 10032, USA; (B.L.); (J.L.); (E.J.C.); (P.H.R.G.)
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21
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Lebwohl B, Haggård L, Emilsson L, Söderling J, Roelstraete B, Butwicka A, Green PHR, Ludvigsson JF. Psychiatric Disorders in Patients With a Diagnosis of Celiac Disease During Childhood From 1973 to 2016. Clin Gastroenterol Hepatol 2021; 19:2093-2101.e13. [PMID: 32801012 DOI: 10.1016/j.cgh.2020.08.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/29/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Few studies have explored the link between childhood celiac disease and long-term psychiatric comorbidities. We performed a population-based cohort study of associations between childhood celiac disease and psychiatric disorders and investigated whether risk persists into adulthood. METHODS We performed a nationwide study in Sweden using data from the Epidemiology Strengthened by histoPathology Reports in Sweden cohort. In this cohort, 19,186 children with a diagnosis of biopsy-verified celiac disease from 1973 through 2016 were identified from Sweden's 28 pathology departments. Each patient was matched with as many as 5 reference children (controls, n = 94,249). Data on psychiatric disorders were obtained from the patient register. We used Cox proportional modeling to estimate hazard ratios (HRs). RESULTS During a median follow-up period of 12.3 years, 3174 children (16.5%) with celiac disease received a new diagnosis of a psychiatric disorder, compared with 13,286 controls (14.1%). Corresponding incidence rates were 12.2 per 1000 person-years (95% CI, 11.8-12.7) vs 10.3 per 1000 person-years (95% Cl, 10.2-10.5). Childhood celiac disease was associated with a 19% increase in risk of any psychiatric disorder (95% CI, 1.14-1.23); the increase in risk was observed in all childhood age groups. The highest HRs were seen in the first year after celiac diagnosis (HR, 1.70; 95% CI, 1.41-2.05). The risk increase persisted into adulthood (age, >18 y: HR, 1.11; 95% CI, 1.04-1.17). We found increased risks of mood disorders (HR, 1.20; 95% CI, 1.12-1.28), anxiety disorders (HR, 1.12; 95% CI, 1.06-1.19), eating disorders (HR, 1.34; 95% CI, 1.18-1.51), attention deficit hyperactivity disorder (HR, 1.29; 95% CI, 1.20-1.39), and autism spectrum disorder (HR, 1.47; 95% CI, 1.32-1.64). We found no statistically significant risk increase for psychotic disorders, psychoactive substance misuse, behavioral disorders, personality disorders, suicide attempt, or suicide. Celiac disease also was linked to an increased use of psychiatric drugs (HR, 1.34; 95% CI, 1.24-1.43). A conditional logistic regression found that psychiatric disorders also were more common before a diagnosis of celiac disease (odds ratio, 1.56; 95% CI, 1.39-1.76). CONCLUSIONS Childhood celiac disease is associated with an increased risk of subsequent psychiatric disorders, which persists into adulthood. Mental health surveillance should be integral in the care of celiac disease.
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Affiliation(s)
- Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University Medical Center, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Linnea Haggård
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Louise Emilsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway; Vårdcentralen Årjäng, Centre for Clinical Research, County Council of Värmland, Värmland, Sweden; Faculty of Medicine and Health, Örebro, Sweden
| | - Jonas Söderling
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Bjorn Roelstraete
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Agnieszka Butwicka
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Child and Adolescent Psychiatry Stockholm, Stockholm Health Care Services, Stockholm, Sweden; Department of Child Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jonas F Ludvigsson
- Celiac Disease Center, Department of Medicine, Columbia University Medical Center, New York, New York; Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden.
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22
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Abstract
There are several online tools, books, and applications available to enhance the application of nutrition interventions for gastroenterologists and patients with gastrointestinal (GI) disorders. Nutritional health may be compromised in GI patients because of the nature of the disease impacting use of nutritional substrates or reducing oral intake. Protein-calorie malnutrition can result from insufficient intake, malabsorption of nutrients, and increased energy expenditure, all of which can occur in certain GI conditions. Eating disorders and disordered eating, and food insecurity, also impact nutritional status. Therapeutic nutrition interventions should be implemented with guidance of a registered dietitian with expertise in their application.
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Affiliation(s)
- Kate Scarlata
- For a Digestive Peace of Mind, LLC, 11 Pine Street, Medway, MA 02053, USA.
| | - Emily Haller
- Division of Gastroenterology, Michigan Medicine, University of Michigan, 3912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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23
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[Analysis of health-related quality life in celiac patients]. NUTR HOSP 2021; 38:715-721. [PMID: 34030447 DOI: 10.20960/nh.03538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Introduction: treatment of celiac disease is gluten-free diet for life. This can impact the quality of life (QoL) of patients. Objectives:the aim of this study was to evaluate the QoL and the factors with an impact on QoL in a sample of children with celiac disease. Methods and materials: a descriptive observational study. QoL was evaluated using the Celiac Disease Dux Questionnaire (CDDUX). Adherence to gluten-free diet was assessed with the Celiac Dietary Adherence Test (CDAT) and the presence of gluten immunogenic peptides (GIP) in the stools. Sociodemographic and clinical data were collected, and an ad-hoc survey was developed. Results: eighty patients were included. Median CDDUX score was 44.04 points (QoL: "neutral"). Subscale scores included: "communication", 58.3 points ("neutral"); "having CD", 25 points ("Bad"); and "diet", 41.6 points ("neutral"). QoL was worse among patients with celiac relatives (the result of the survey was "bad" vs. "neutral" with p = 0.02) and among those who found unsatisfactory the somatosensory characteristics and the price of gluten-free food (the result of the survey was "bad" vs. "neutral" with p = 0.02). Those who found unsatisfactory the texture of these food reported a worse QoL ("bad" vs. "neutral", p = 0.009). Those who reported eating outside the home as a transgression inducer reported a "bad" QoL; those who did not, reported a "neutral" QoL (p = 0.03). Conclusions: celiac patients report a "neutral" QoL. A poorer QoL was related to having celiac relatives, finding gluten-free food unsatisfactory, and considering eating outside the home as an inducer factor for transgressions.
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Asri N, Rostami-Nejad M, Rezaei-Tavirani M, Razzaghi M, Asadzadeh-Aghdaei H, Zali MR. Novel Therapeutic Strategies for Celiac Disease. Middle East J Dig Dis 2020; 12:229-237. [PMID: 33564379 PMCID: PMC7859609 DOI: 10.34172/mejdd.2020.187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/08/2020] [Indexed: 12/18/2022] Open
Abstract
Celiac disease (CeD) is a widespread autoimmune enteropathy caused by dietary gluten peptides in genetically susceptible individuals, which includes a range of intestinal and extraintestinal manifestations. Currently, there is no effective treatment for CeD other than strict adherence to a gluten-free diet (GFD). However, persistent or frequent symptoms and also partial villus atrophy were observed in some patients with CeD due to intentional or inadvertent gluten exposure during the use of GFD. It means that GFD alone is not enough to control CeD symptoms and long-term complications. Accordingly, new therapeutic approaches for CeD treatment such as gluten proteolysis, removing gluten from the digestive tract, promoting tight junction assembly, inhibiting intestinal tissue transglutaminase 2, using probiotics, and developing immunotherapeutic methods have been proposed through different strategies. This review focused on discussing the novel therapeutic strategies for CeD management.
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Affiliation(s)
- Nastaran Asri
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mostafa Rezaei-Tavirani
- Proteomics Research Center, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Razzaghi
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Asadzadeh-Aghdaei
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Gładyś K, Dardzińska J, Guzek M, Adrych K, Małgorzewicz S. Celiac Dietary Adherence Test and Standardized Dietician Evaluation in Assessment of Adherence to a Gluten-Free Diet in Patients with Celiac Disease. Nutrients 2020; 12:nu12082300. [PMID: 32751809 PMCID: PMC7468751 DOI: 10.3390/nu12082300] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Katarzyna Gładyś
- Department of Clinical Nutrition, Medical University of Gdansk, Dębinki St. 7, 80-211 Gdańsk, Poland; (K.G.); (S.M.)
| | - Jolanta Dardzińska
- Department of Clinical Nutrition, Medical University of Gdansk, Dębinki St. 7, 80-211 Gdańsk, Poland; (K.G.); (S.M.)
- Correspondence: ; Tel.: +48-58-349-2723
| | - Marek Guzek
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Dębinki St. 7, 80-211 Gdańsk, Poland; (M.G.); (K.A.)
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Dębinki St. 7, 80-211 Gdańsk, Poland; (M.G.); (K.A.)
| | - Sylwia Małgorzewicz
- Department of Clinical Nutrition, Medical University of Gdansk, Dębinki St. 7, 80-211 Gdańsk, Poland; (K.G.); (S.M.)
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26
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Myléus A, Reilly NR, Green PHR. Rate, Risk Factors, and Outcomes of Nonadherence in Pediatric Patients With Celiac Disease: A Systematic Review. Clin Gastroenterol Hepatol 2020; 18:562-573. [PMID: 31173891 DOI: 10.1016/j.cgh.2019.05.046] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/21/2019] [Accepted: 05/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The only treatment for celiac disease is strict adherence to a gluten-free diet (GFD). We performed a systematic review to investigate the rate of adherence to a GFD in children with celiac disease, risk factors that affect adherence, and outcomes of non-adherence. METHODS We searched PubMed, Cochrane Library, EBSCO, and Scopus for studies through January 2019. We included observational studies of ≥50 children diagnosed with celiac disease and recommended for placement on a GFD. We collected data on adherence assessment (self-report, serology tests, structured dietary interview, biopsies, or assays for gluten immunogenic peptides), risk factors, and outcomes related to adherence. Findings were presented with medians, range, and a narrative synthesis. RESULTS We identified 703 studies; of these, 167 were eligible for full-text assessment and 49 were included in the final analysis, comprising 7850 children. Rates of adherence to a GFD ranged from 23% to 98%. Comparable rates (median rates of adherence, 75%-87%) were found irrespective of how assessments were performed. Adolescents were at risk of non-adherence and children whose parents had good knowledge about celiac disease adhered more strictly. Non-adherence associated with patient growth, symptoms, and quality of life. CONCLUSION In a systematic review of 49 studies of children with celiac disease, we found substantial variation in adherence to a GFD among patients. Rate of adherence was not associated with method of adherence measurement, so all methods appear to be useful, with lack of consensus on the ideal metric. Studies are needed to determine the best method to ensure adherence and effects on long-term health.
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Affiliation(s)
- Anna Myléus
- Division of Family Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
| | - Norelle R Reilly
- Department of Pediatrics, Celiac Disease Center, Columbia University College of Physicians and Surgeons, Columbia University, New York, New York; Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, Columbia University, New York, New York
| | - Peter H R Green
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, Columbia University, New York, New York
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Osorio CE, Wen N, Mejías JH, Mitchell S, von Wettstein D, Rustgi S. Directed-Mutagenesis of Flavobacterium meningosepticum Prolyl-Oligopeptidase and a Glutamine-Specific Endopeptidase From Barley. Front Nutr 2020; 7:11. [PMID: 32133368 PMCID: PMC7040222 DOI: 10.3389/fnut.2020.00011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/28/2020] [Indexed: 12/12/2022] Open
Abstract
Wheat gluten proteins are the known cause of celiac disease. The repetitive tracts of proline and glutamine residues in these proteins make them exceptionally resilient to digestion in the gastrointestinal tract. These indigested peptides trigger immune reactions in susceptible individuals, which could be either an allergic reaction or celiac disease. Gluten exclusion diet is the only approved remedy for such disorders. Recently, a combination of a glutamine specific endoprotease from barley (EP-B2), and a prolyl endopeptidase from Flavobacterium meningosepticum (Fm-PEP), when expressed in the wheat endosperm, were shown to reasonably detoxify immunogenic gluten peptides under simulated gastrointestinal conditions. However useful, these "glutenases" are limited in application due to their denaturation at high temperatures, which most of the food processes require. Variants of these enzymes from thermophilic organisms exist, but cannot be applied directly due to their optimum activity at temperatures higher than 37°C. Though, these enzymes can serve as a reference to guide the evolution of peptidases of mesophilic origin toward thermostability. Therefore, a sequence guided site-saturation mutagenesis approach was used here to introduce mutations in the genes encoding Fm-PEP and EP-B2. A thermostable variant of Fm-PEP capable of surviving temperatures up to 90°C and EP-B2 variant with a thermostability of up 60°C were identified using this approach. However, the level of thermostability achieved is not sufficient; the present study has provided evidence that the thermostability of glutenases can be improved. And this pilot study has paved the way for more detailed structural studies in the future to obtain variants of Fm-PEP and EP-B2 that can survive temperatures ~100°C to allow their packing in grains and use of such grains in the food industry.
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Affiliation(s)
- Claudia E. Osorio
- Department of Crop and Soil Sciences, Washington State University, Pullman, WA, United States
- Agriaquaculture Nutritional Genomic Center, Temuco, Chile
| | - Nuan Wen
- Department of Crop and Soil Sciences, Washington State University, Pullman, WA, United States
| | - Jaime H. Mejías
- Centro Regional de Investigación Carillanca, Instituto de Investigaciones Agropecuarias INIA, Temuco, Chile
| | - Shannon Mitchell
- Department of Biological Systems Engineering, Washington State University, Pullman, WA, United States
| | - Diter von Wettstein
- Department of Crop and Soil Sciences, Washington State University, Pullman, WA, United States
| | - Sachin Rustgi
- Department of Crop and Soil Sciences, Washington State University, Pullman, WA, United States
- Department of Plant and Environmental Sciences, Clemson University Pee Dee Research and Education Center, Florence, SC, United States
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Green PHR, Guandalini S. When Is Celiac Disease Celiac Disease? Gastroenterology 2019; 157:293-294. [PMID: 31260660 DOI: 10.1053/j.gastro.2019.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 06/07/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Peter H R Green
- Celiac Disease Center, Columbia University Medical Center, New York, New York.
| | - Stefano Guandalini
- Celiac Disease Center, University of Chicago, Chicago, Illinois; Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, Illinois
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