Dietary compliance in Iranian children and adolescents with celiac disease

Predictive factors of health related quality of life in children and adolescents with celiac disease: An Italian multicenter study on behalf of the SIGENP

BACKGROUND

In pediatric patients, celiac disease (CD) may influence the health-related quality of life (HRQoL).

AIMS

The study aimed to assess HRQoL and further characterise the clinical factors associated with reduced HRQoL, in a large multicenter pediatric cohort with CD.

METHODS

The disease-specific questionnaire CD Dutch Questionnaire (CDDUX) and the generic questionnaire Paediatric Quality of Life Inventory (PedsQL) were used to assess the HRQoL. Clinical and sociodemographic characteristics were analyzed, univariate and multivariate analysis were conducted.

RESULTS

Eleven different Italian pediatric centers and 871 families were involved. Mean age at interview was 12.9 ± 2.9 years. The mean total CDDUX score of CD patients was 47.1 ± 18.8, revealing a neutral HRQoL (47.1 ± 18.8), and a good to very good HRQoL according to the PedsQL (81.4 ± 12.6), parents indicated lower scores (p = 0.03) with both questionnaires (CDDUX 45.1 ± 18.6 and PedsQL 79.9 ± 14.5). Patients with lower HRQoL were mainly female, living in Northern Italy, with lower parent's education level and non-biopsy diagnosis of CD. In multivariate analysis, the main predictor of lower CDDUX score was non-biopsy diagnosis.

CONCLUSIONS

The HRQoL in a large cohort of Italian children is reported as neutral-good. This indicates a high level of adaptive behaviors in response to the daily challenges of CD. Parents tend to underestimate their children's HRQoL. Specific clinical factors, including non-biopsy diagnosis, may be associated to lower HRQoL.

Transcultural adaptation to Spain of the CDPQOL questionnaire specific for coeliac children

This study aimed to translate, cross-culturally adapt, and validate the CDPQOL questionnaire, a coeliac disease (CD)-specific paediatric health-related quality of life (HRQoL) instrument (CDPQOL), in Spanish children with CD. The CDPQOL questionnaire has two versions for children aged 8-12 and 13-18. Translation and linguistic validation were performed following an international consensus process. Internal consistency was calculated using Cronbach's alpha and McDonald's omega coefficients, and convergent validity was assessed with average variance extracted (AVE). Confirmatory factor analysis (CFA) and exploratory factor analysis (EFA), when necessary, were carried out to assess the construct validity. A total of 235 children were included. In the 8-12 age group, a change in the distribution of items to a new structure of three dimensions (negative emotions, food feelings and social interaction) was required. In this new model, CFA supported the fit of the model (χ2/gl = 1.79, RMSEA = 0.077 (IC 95% 0.05-0.100), CFI = 0.969, TLI 0.960, SRMR = 0.081) and Cronbach's alpha and McDonald's omega coefficients were > 0.7 in all three dimensions. In the 13-18 age group, CFA showed that all fit indexes were acceptable (χ2/gl = 1.702, RMSEA = 0.102 (IC 95% 0.077-0.127), p < 0.001, CFI = 0.956, TLI = 0.947, SRMR = 0.103) and Cronbach's alpha and McDonald's omega coefficients were > 0.7 in all three dimensions, except for uncertainty dimension.    Conclusions: The Spanish version of the CDPQOL questionnaire is a useful instrument to assess quality of life in coeliac children whose native language was Spanish spoken in Spain, with changes in item distribution in the younger age group questionnaire. What is Known: • The first specific questionnaire for coeliac children, Dutch Coeliac Disease Questionnaire (CDDUX), which focuses on diet, was translated into Spanish and validated allowing to evaluate the HRQoL of Spanish coeliac children. • Spanish Children and parents feel the disease had no substantial negative impacts on patient HRQoL using this questionnaire, similar to that observed with other countries. What is New: • The age specific for CD children (CDPQOL) was elaborated in the USA and focuses on other aspects not evaluated by CDDUX such as emotional and social issues related to living with CD. • The CDPQOL was translated into Spanish and validated allowing it to be used to assess Spanish coeliac children's QoL.

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.

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.

Health-related quality of life in children with coeliac disease and in their families: A long-term follow-up study

OBJECTIVES

The aim of the study was to assess long-term health-related quality of life (HRQoL) in children and adolescents with coeliac disease (CD), and their parents.

METHODS

We re-evaluated prospectively the HRQoL and clinical characteristics of 80 families, assessed 5 years earlier, using a disease-specific questionnaire, the CD Dutch Questionnaire (CDDUX), and a generic questionnaire, the Paediatric Quality of Life Inventory (PedsQL).

RESULTS

After a 10-year follow-up, there was no significant change in the total CDDUX and PedsQL scores in children and their parents when compared to the evaluation conducted 5 years earlier. The total CDDUX score reflected a neutral QoL, while for the generic PedsQL was good-very good. The only significant decrease after 5 years was the PedsQL subdomain Emotional functioning. Patients who admitted voluntarily eating gluten reported lower score in CDDUX Diet. Lower scores in subdomain "Physical functioning" (PedsQL) were reported in patients with positivity of TTG or associated diseases.

CONCLUSIONS

The CDDUX score indicated a consistently stable and neutral QoL perception among coeliac patients and caregivers, even after 10-year postdiagnosis, suggesting minimal fluctuations in the impact of CD on disease-specific health domains over time. Furthermore, the consistently good PedsQL score could be a reflection of the resilience of coeliac families in coping with this chronic condition. Gluten-free diet compliance was confirmed to be determinant of HRQoL in the long term. The study confirms the importance of extending surveillance on these patients, possibly using different questionnaires, to assess QoL from different perspectives.

Predictors of Compliance to Gluten-Free Diet in Children with Celiac Disease

Background: Celiac disease (CD) is a common autoimmune disorder that presents intestinal and extra-intestinal symptoms. It is also associated with cardiovascular diseases and malignancies, and mortality risk. The only way to control the disease is to follow a strict gluten-free diet (GFD) for the rest of life. Objectives: This survey aimed to investigate GFD non-adherence and causes in the pediatric setting. Methods: In this study, 187 children aged between 2.5 to 14 years old with a confirmed diagnosis of CD at least for a year were studied using a questionnaire-based interview in a census study between 2018 to 2019 in a referral center in southern Iran. Results: About 40% of children adhered to a GFD poorly. This group significantly complained of more symptoms than the group with high adherence. Improper access was the most important cause of non-adherence to a GFD. The mean current weight and at the time of diagnosis as well as the mean current BMI and at the time of diagnosis in the non-adherent group were significantly lower than the adherent group. However, IgA anti-transglutaminase antibodies and histopathologic examination did not change remarkably. Furthermore, no significant relationship was found between following a GFD and age, age at the time of diagnosis, gender, and parental educational status. Conclusions: According to our results, inaccessibility, high costs, and lack of food labeling were the primary reasons for non-adherence to GDF. Therefore, to increase compliance, easy access to GFD with proper food labeling and suitable price should be implemented.

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.

Assessing Health-Related Quality of Life in Children with Coeliac Disease: The Italian Version of CDDUX

We aimed to assess Health-Related Quality of Life (HRQoL) of Italian children and their parents with coeliac disease (CD) using the Coeliac Disease Dutch Questionnaire (CDDUX). The CDDUX underwent a cross-cultural adaptation in a multi-step process, according to international guidelines. A total of 224 children aged between 8–18 years and their parents were prospectively recruited. Cronbach α coefficient was determined as a measure of internal consistency of the questionnaire and inter-children/parent reliability by intraclass correlation coefficient. Univariate and bivariate regression models were used to evaluate correlations between clinical variables and children and parents subclasses of CDDUX and overall mean Paediatric Quality of Life Inventory (PedsQL). The Italian CDDUX proved to be valid and reliable, mean CDDUX total score revealing a neutral evaluation of the quality of life in children 52.6 ± 17.2 and parents 49.5 ± 17.9 (p = 0.07) with strong correlation with PedsQL. The only clinical variable which appeared to affect significantly quality of life both in children and parents was the lower age. A comparison with our results showed remarkable differences in the HRQoL of populations of various nationalities. The Italian version of the CDDUX questionnaire is a simple and reliable tool for assessing the HRQoL in children and adolescents with CD.

Factors Affecting Compliance to a Gluten-Free Diet in Pediatric Populations with Celiac Disease

Celiac disease (CD) is a multisystemic autoimmune disorder triggered by gluten, and the only known remedy available for this malady is a gluten-free diet (GFD). Therefore, we performed a systematic review to correlate the influence of different factors in compliance to a GFD. We searched PubMed database, from inception to April 2019. As inclusion criteria we considered population under 18 years, confirmed diagnosis of CD without related comorbidities and the study objective being the factors affecting compliance to a GFD. The variables compared were age, parent's education level, parental knowledge about CD, family type, celiac association membership, quality of life, and perception of difficulties in maintaining a GFD. We identified 1,414 articles, 35 articles were eligible for full text assessment and 12 were included in the study since they studied similar variables. Our work has found some limitations namely a variety of methods to assess GFD compliance, a limiting definition of compliance, a parental bias in data, an absence of standardization in age categories, and a majority of studies being observational in their nature. Age as well as parental knowledge of CD and family type are key factors in pediatric GFD compliance. Nevertheless environmental, social, and family factors were also related with compliance. Further studies are needed to fully disclose the causality relation between these factors and compliance.

[Analysis of health-related quality life in celiac patients]

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.

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

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

Health-related quality of life using specific and generic questionnaires in Spanish coeliac children

Background

We aimed to compare the perception of health-related quality of life (HRQOL) and related factors in Spanish coeliac children and their parents, using two questionnaires, the generic KIDSCREEN-52 and the specific the Celiac Disease DUX (CDDUX), and to assess the correlation between them.

Methods

Coeliac children, aged 8-18, who are members of the Madrid Coeliac Association (MCA) and their parents, answered the Spanish version of the CDDUX and KIDSCREEN-52 questionnaires via e-mail. CDDUX was answered by 266 children and 428 parents and KIDSCREEN-52 by 255 children and 387 parents. Linear regression models were fitted to evaluate the association of demographic and clinical factors with HRQOL scores. CDDUX scores were compared with the subjective perception of health status assessed by the first question of KIDSCREEN-52. The correlation between the questionnaires was analysed.

Results

We found that the main factors that negatively affected HRQOL were having social or economic difficulties associated with following the diet and having transgression-related symptoms. The maximum correlation between the questionnaires was 0.309 and − 0.254 in parents and children respectively.

Conclusions

Although there is a poor correlation between the two questionnaires, both agreed that the main concerns of the respondents were related to the social and economic difficulties of following the diet. It would be interesting to use both types of questionnaires in order to perform a more complete assessment of HRQOL in coeliac children.

Trial registration

Not applicable.

Systematic Review With Meta-analysis of the Health-related Quality of Life in Children With Celiac Disease

OBJECTIVES

The aim of this article is to systematically review and meta-analyze the published data on the comparison of the health-related quality of life (HRQOL) in children and adolescents with celiac disease (CD) and healthy children. Moreover, the meta-analysis was performed to compare the parent proxy-report and child self-report of HRQOL.

METHODS

The databases of PubMed, Embase, Scopus, and Cochrane library were searched from inception to April 2019 to identify observational studies that evaluated the HRQOL in children with CD. Studies comparing the HRQOL in celiac patients and healthy children, and also comparing the parent's proxy-report and child self-report of HRQOL were included. Comprehensive meta-analysis software was used for statistical analysis.

RESULTS

Through our systematic search, 26 articles met our predefined inclusion criteria. The result of our meta-analysis on studies using the PedsQL questionnaire showed that the total score of HRQOL was not significantly different between celiac patients and healthy controls (SMD (95% confidence interval; CI]: -0.11[-0.45 to 0.23], P = 0.52). The result of our meta-analysis showed that the parents reported the child's diet and communication scores lower than that of children. Only 4 out of 11 studies showed a significant correlation between HRQOL and gluten-free diet (GFD) compliance and 2 of 4 studies showed a significant negative association between HRQOL and age at diagnosis.

CONCLUSIONS

The results of the present study showed that there was no significant difference between children with CD and healthy controls regarding HRQOL. Moreover, the parental perception of their children's HRQOL was lower than the children's perception.

Rate, Risk Factors, and Outcomes of Nonadherence in Pediatric Patients With Celiac Disease: A Systematic Review

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Topical Review: Adherence Interventions for Youth on Gluten-Free Diets

Objective

To summarize gluten-free diet (GFD) nonadherence risk factors, nonadherence rates, and current intervention research within an integrative framework and to develop a research agenda for the development and implementation of evidence-based GFD adherence interventions.

Methods

Topical review of literature published since 2008 investigating GFD adherence in pediatric samples.

Results

Reviews of pediatric studies indicate GFD nonadherence rates ranging from 19 to 56%. There are few evidence-based, published pediatric GFD adherence interventions. Novel assessments of GFD adherence are promising but require further study. Nonmodifiable and modifiable factors within individual, family, community, and health systems domains must be considered when developing future interventions. Clinical implications are discussed.

Conclusions

Avenues for future research include development and refinement of adherence assessment tools and development of evidence-based GFD adherence interventions. Novel technologies (e.g., GFD mobile applications) require empirical study but present exciting opportunities for adherence intervention.

Challenges in gluten-free diet in coeliac disease: Prague consensus

BACKGROUND

New treatments in coeliac disease are being vigorously pursued to either replace or facilitate the difficult-tofollow gluten-free diet.

DESIGN

The present review intends to summarise the challenges in gluten-free diet adherence during the transitional period, as reflected in the last Prague consensus, published in 2016.

RESULTS

The honourable panel members recommended that dietary adherence and the consequences of nonadherence represent key components for discussion in the transitional period setting.

CONCLUSIONS

There are numerous difficulties in adhering to gluten withdrawal, but the transition period from adolescence to young adulthood is considered a fragile and high-risk period for intentional and unintentional gluten intake.