Gluten-Free Diet: From Development to Assessment of a Check-List Designed for the Prevention of Gluten Cross-Contamination in Food Services

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.

Application of checklist-based nursing care process in patients undergoing intervention for coronary chronic total occlusions: a quasi-randomized study

BACKGROUND

Coronary chronic total occlusion (CTO) interventions are more complex than general percutaneous coronary intervention (PCI) procedures. However, only a few nursing methods are specifically applied to patients undergoing CTO interventions. And the conventional nursing effect is not ideal, urgent need to explore more effective nursing methods. The checklist is a simple and effective tool for error management and performance improvement that has been widely used in many fields. But there have been no reports of the checklist being used to improve care for CTO patients.

OBJECTIVE

This study aimed to investigate the effectiveness of a checklist-based nursing care process in patients undergoing Coronary chronic total occlusion (CTO) interventions, including duration of care, patient anxiety, improved patient satisfaction, and occurrence of adverse events.

METHODS

A total of 120 CTO patients undergoing percutaneous coronary intervention (PCI) were selected at our hospital and divided into an intervention group (n = 60, adopted the checklist-based nursing care process for patient care) and a control group (n = 60, adopted nursing care according to the existing workflow) according to different nursing interventions. After surgery, the nurse in charge of the patient completed the nursing according to the "List of postoperative care for CTO patients" filled in by the patient within 24 h after surgery, conducted a doctor satisfaction survey, recorded adverse events, and completed the postoperative Self-Rating Anxiety Scale (SAS) score and patient satisfaction survey before the patient was discharged. Subsequently, the Qc team checks the completion of the patient's checklist for safety and the completion of the questionnaire. Finally, the differences between the two groups in preoperative nursing time, incidence of adverse events caused by nurses' omission or inadequate guidance, patient anxiety, and doctor and patient satisfaction were compared.

RESULTS

The intervention grouphad significantly shorter preoperative nursing care time and significantly lower the total number of adverse events than the control group (P < 0.05).The postoperative Self-Rating Anxiety Scale (SAS) score of the intervention group was significantly lower than that of the control group (P < 0.05).The satisfaction of doctors and patients in the intervention groupwas significantly higher than that in the control group (P < 0.05).

CONCLUSION

The application of the checklist-based nursing care process in patients with CTO intervention can significantly reduce the preoperative nursing care time, reduce patient anxiety, improve patients' and doctors' satisfaction with nursing care, and effectively reduce the occurrence of adverse events caused by nurses' omissions or inadequate instructions.

TRIAL REGISTRATION

The protocol of the trial was registered retrospectively of Chinese Clinical Trial Registry (registration number ChiCTR2200056804, reg date17/02/2022).

Amorphophallus konjac: A Novel Alternative Flour on Gluten-Free Bread

The demand for gluten-free products is rising, but their production with similar quality as their gluten counterparts is challenging. This study aimed to develop gluten-free bread samples using different concentrations of Amorphophallus konjac flour (0%, 12.5%, 25%, 37.5%, and 50% of the total flour content) and to evaluate their nutritional and physicochemical properties. Proteins, lipids, carbohydrates, moisture, ash content, fibers, resistant starch, firmness, specific volume, and color were evaluated using official methods. Protein varied from 2.95% to 4.94%, the energy value from 347.93 to 133.55 kcal/100 g, dietary fiber from 8.19 to 17.90%, and resistant starch from 0.67% to 0.75% on wet basis. The addition of konjac flour positively influenced the specific volume. Higher concentrations of konjac flour in the formulations led to lower calories of the bread due to the significant addition of water to the dough. The bread samples with konjac showed high fiber content due to the composition of the flour. They had lower levels of carbohydrates, which can positively influence the glycemic index. Konjac flour provided dough mold, growth, and better texture for gluten-free bread. The best formulations were prepared in concentrations up to 37.5% konjac. The 50% konjac bread showed slightly reduced specific volume and pale color.

Glycemic Index of Gluten-Free Bread and Their Main Ingredients: A Systematic Review and Meta-Analysis

This study aimed to perform a systematic review and meta-analysis of the glycemic index (GI) of gluten-free bread (GFB) and its main ingredients. The systematic review followed PRISMA guidelines, using seven electronic databases (PubMed, EMBASE, Scopus, Science Direct, Web of Science, gray literature research with Google Scholar, and patents with Google Patent tool), from inception to November 2020. Eighteen studies met the inclusion criteria evaluating 132 GFB samples. Five articles tested GI in vivo, eleven in vitro; and two studies tested both methods. The analysis showed that 60.7% (95% CI: 40.2-78.1%) of the samples presented high glycemic indexes, evidencing a high glycemic profile for GFB. Only 18.2% (95% CI: 11.7-27.2%) of the bread samples presented in the studies were classified as a low GI. Meta-analysis presented moderate/low heterogenicity between studies (I2 = 61% and <1% for both high and low GIs) and reinforced the proportion of high GIs. Lower GIs were found in formulations based on Colocasia esculenta flour or enriched with fiber, yogurt and curd cheese, sourdough, psyllium, hydrocolloids, enzymes, fructans, and resistant starch, highlighting the efficacy of these ingredients to lower GFBs' GI. GFB tends to present high GI, impacting the development of chronic diseases when consumed.

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.

Gluten cross-contact from common food practices and preparations

Patients with celiac disease continue to be exposed to gluten despite efforts to maintain a gluten-free diet (GFD). Gluten exposure in those with celiac disease leads to pathological changes in the small intestine that may or may not be associated with gastrointestinal distress. While several studies have investigated a GFD, little is known about sources of gluten contamination that prevent proper maintenance of such a diet by celiac patients. In this study, we investigate common food practices that could lead to gluten cross-contact. Three different practices were examined for gluten cross-contact: gluten-free foods fried in a fryer also used for gluten containing foods, gluten-free bread toasted in a toaster also used for gluten-containing bread, and popular sandwich spreads applied with a knife used on gluten-containing bread (mayonnaise, jam, and peanut butter). We used the ALLER-TEK™ Gluten ELISA test kit and the sandwich ELISA RIDASCREEN Gliadin test kit, which is endorsed for determination of gluten content and used for the evaluation of food cross-contact. Using both kits gave the advantage of using the 401.2 antibody as well as the better established R5 antibody, providing increased confidence in our results. We found these practices resulted in small amounts of gluten cross-contact, although the majority of the results (93.6%) showed no significant cross-contact. Mayonnaise and peanut butter samples were contaminated with gluten above the limit designated by the FDA as gluten-free <20 kg/mg (ppm).

Chemical Composition and Glycemic Index of Gluten-Free Bread Commercialized in Brazil

Nowadays, the world is experiencing an increased demand for gluten-free products associated with the high prevalence of gluten-related disorders (GRD). As this market thrives, bread stands out as the most demanded and consumed product, highlighting the need to evaluate its nutritional quality. In this sense, this cross-sectional study aimed to assess the ingredients, chemical composition, and glycemic index of gluten-free bread (GFB) commercialized nationwide in Brazil. The labels were analyzed according to their ingredients and composition. In addition, centesimal composition analysis (moisture, carbohydrates, protein, ash, lipid, and fiber) was performed using the official methods, as well as the in vivo glycemic index. Significant differences between manufacturing lots of each brand and between different gluten-free bread samples were found. There is a mismatch from what is stipulated by the Brazilian legislation between analytical data and the data described on sample labels. Samples showed predominantly refined starch and high glycemic index profile. Most samples (75%, n = 6) of the non-whole gluten-free bread (n = 8) presented high glycemic index (GI). From four whole food/multigrain gluten-free bread samples, three of them (75%) presented medium GI. However, two samples presented GI near the value to be considered high. The results suggest a lack of production control, impairing the gluten-free nutritional label as a reliable information source and tool for dietary control. Therefore, it is necessary to standardize the process of gluten-free bread production and labeling, as well as to improve the nutritional characteristics of these products, aiming the give accurate information to consumers and provide a healthier product beyond the sensory characteristics.

Measuring Quality of Life in Parents or Caregivers of Children and Adolescents with Celiac Disease: Development and Content Validation of the Questionnaire

Celiac disease (CD) is an autoimmune disorder triggered by the ingestion of gluten and affects approximately 1% of the global population. Currently, the only treatment available is lifelong strict adherence to a gluten-free diet (GFD). Chronic diseases such as CD affect patients and their family members’ quality of life (QoL); particularly parents and caregivers who play an essential role in the child’s care and treatment. A higher level of psychological distress has been found in the parents of children with chronic ailments due to limited control over the child’s daily activities and the child’s illness. In this context, the validation of a specific questionnaire of QoL is a valuable tool to evaluate the difficulties faced by parents or caregivers of children with this chronic illness. A specific questionnaire for this population can elucidate the reasons for stress in their daily lives as well as the physical, mental, emotional, and social impact caused by CD. Therefore, this study aimed to develop and validate a specific questionnaire to evaluate the QoL of parents and caregivers of children and adolescents with CD. Overall results showed that a higher family income resulted in a higher score of the worries domain. In addition, having another illness besides CD decreased the QoL (except in the worries domain). The other variables studied did not present a statistically significant impact on the QoL, which was shown to be low in all aspects. Knowledge of the QoL is important to help implement effective strategies to improve celiac patients’ quality of life and reduce their physical, emotional, and social burden.

Gluten contamination in food services and industry: A systematic review

Gluten-related disorders (GRD) affects approximately 10% of the general population. The only treatment for GRD is still so far is the lifelong complete exclusion of gluten from the daily diet. The correct information about the presence/absence of gluten in food is very important to this group. The present study aimed to evaluate the prevalence of gluten contamination in gluten-free industrial and non-industrial products. In this systematic review, 24 cross-sectional studies were analyzed. The authors developed specific search strategies for Science Direct, Scopus, Web of Science, Google Scholar and ProQuest Dissertations & Theses Global. The authors evaluated the methodological quality of the included studies using criteria from Meta-analysis of Statistics Assessment and Review Instrument (MASTARI). We performed the statistical meta-analysis by metafor package of R program. 95.83% (n = 23) of the studies presented positive results for contamination (over 20 ppm). In industrial food products, studies showed a contamination prevalence of 13.2% (95% CI: 10.8%-15.7%). In non-industrial food products, studies showed a contamination prevalence of 41.5% (95% CI: 16.6%-66.4%). Despite the non-industrial products presented higher contamination prevalence than the industrial products, the difference was not significant (p = 0.072). The findings indicate cross-contamination in industrialized and non-industrialized products. As expected, industrial products labeled as gluten-free showed a lower percentage of gluten-contamination than non-industrialized. Despite that, any contaminated sample found in this group present greater relevance than non-labeled foods. It indicates that foods labeled as "gluten-free" should not be considered safe for patients with GRD since information on the label regarding the presence/absence of gluten is unreliable. Therefore, any gluten-contamination in products labeled as gluten-free is a serious problem to whom present GRD. Further studies are needed to estimate gluten cross-contamination in food service meals and industry better.