Gluten-free Diet In Celiac Patients Research Articles

Compliance and Attitudes towards the Gluten-Free Diet in Celiac Patients in Italy: What Has Changed after a Decade?

This study aims were (i) to describe Italian celiac patients who agreed to participate in the latest web survey and their attitudes toward the GF diet (compliance, perceived limitations, and worries) and (ii) to compare the answers given by the 2011 and 2022 responders. The self-administered questionnaire was distributed through the Italian Coeliac Association channels (link on social media, websites, and newsletters) to all of the celiac patients willing to participate in 2011 and 2022 (2427 and 3529 responders who answered the same questions, respectively). Descriptive analyses and the Pearson's chi-squared test were performed. The responders were 1 to 84 years old and mainly female. The prevalence of adherent patients in 2022 was 91%, with the highest value (94%) in children (≤10 years old) and adolescents (15-17 years old). Overall, young adults were the most worried group. About a decade after the first survey, we observed a decreasing prevalence of transgression events (-5%) and (at least) occasional temptation (-17%), a decreasing prevalence of health-related and general worries, but an increasing prevalence of social life withdrawal. In conclusion, it is important to periodically monitor celiac patients' compliance and attitudes towards the gluten-free diet. As also highlighted in international guidelines, a reorganization of the diagnosis/follow-up visits, including an expert dietary consultation, is needed.

Factors Associated With Adherence to a Gluten-Free Diet in Celiac Patients Diagnosed in Childhood as Compared to Adulthood.

Past studies have reported differences between pediatric and adult celiac disease patients. We aimed to compare factors associated with adherence to a gluten-free diet between these groups. An anonymous online questionnaire was sent via the Israeli Celiac Association and social networks to celiac patients. The Biagi questionnaire was used to assess dietary adherence. A total of 445 subjects participated. Mean age was 25.7 ± 17.5 years and 71.9% were female. Subjects were divided into six groups according to age at diagnosis: younger than 6 years (134 patients, 30.7%), 6-12 (79 patients, 18.1%), 12-18 (41 patients, 9.4%), 18-30 (81 patients, 18.5%), 30-45 (79 patients, 18.1%), and 45 years and above (23 patients, 5.3%). There were several significant differences between childhood- and adulthood-diagnosed patients. Pediatric patients were less likely to be noncompliant with a gluten-free diet (3.7% vs. 9.4%, p < .001). They were also more frequently followed by a gastroenterologist ( p < .001), a dietitian ( p < .001), and participated in a celiac support group ( p = .002). In logistic regression analyses, longer duration of disease was associated with poor compliance. In conclusion, pediatric-diagnosed celiac patients are more adherent to a gluten-free diet than those diagnosed in adulthood, with better social support and nutritional follow-up possibly contributing.

Adherence to a gluten-free diet in celiac disease patients from Paraguay

Introduction and aimThe treatment for celiac disease is a gluten-free diet that should be strictly and permanently carried out. Our aims were to determine adherence to the gluten-free diet and the risk factors for non-adherence. Materials and methodsAn observational, cross-sectional, comparative study was conducted. It included individuals of both sexes and of any age that presented with celiac disease, lived in Paraguay from January to April 2021, and agreed to participate in the survey. Incomplete questionnaires were excluded. Non-probabilistic convenience sampling was utilized. Adherence was measured using the Leffler questionnaire. The study was approved by the Ethics Committee of the Universidad Privada del Este. ResultsThe sample consisted of 371 respondents, 322 (87%) of whom were adults, with a mean age of 38 ± 12 years, and 49 (13%) of whom were children and adolescents, with a mean age of 10 ± 5 years. Female sex was predominant (85%). Adherence to the gluten-free diet was detected in 59% of the adults and 73% of the children and adolescents. The factors significantly associated with adherence included belonging to the child and adolescent age group and having had the diagnosis for a longer time: 9 ± 8 years for the adherence group and 7 ± 8 years for the non-adherence group. ConclusionsThe present study demonstrated the frequency of adherence to the gluten-free diet in celiac patients in Paraguay. Psychologic and nutritional support is recommended for individuals with celiac disease that do not adhere to their treatment.

Adherencia a la dieta sin gluten en celíacos del Paraguay

Introduction and aimThe treatment for celiac disease is a gluten-free diet that should be strictly and permanently carried out. Our aims were to determine adherence to the gluten-free diet and the risk factors for non-adherence. Materials and methodsAn observational, cross-sectional, comparative study was conducted. It included individuals of both sexes and of any age that presented with celiac disease, lived in Paraguay from January to April 2021, and agreed to participate in the survey. Incomplete questionnaires were excluded. Non-probabilistic convenience sampling was utilized. Adherence was measured using the Leffler questionnaire. The study was approved by the Ethics Committee of the Universidad Privada del Este. ResultsThe sample consisted of 371 respondents, 322 (87%) of whom were adults, with a mean age of 38±12 years, and 49 (13%) of whom were children and adolescents, with a mean age of 10±5 years. Female sex was predominant (85%). Adherence to the gluten-free diet was detected in 59% of the adults and 73% of the children and adolescents. The factors significantly associated with adherence included belonging to the child and adolescent age group and having had the diagnosis for a longer time: 9±8 years for the adherence group and 7±8 years for the non-adherence group. ConclusionsThe present study demonstrated the frequency of adherence to the gluten-free diet in celiac patients in Paraguay. Psychologic and nutritional support is recommended for individuals with celiac disease that do not adhere to their treatment.

The GLU-10: a validated ten-point score to identify poorly instructed celiac patients in need of dietary interventions.

A standard tool to assess patients' knowledge about gluten and the gluten-free diet (GFD) is lacking. We aimed to develop and validate a questionnaire to assess GFD knowledge. A 10-point questionnaire (GLU10) covering different aspects of knowledge about gluten content in food/non-food products and the gluten-free living was developed. To validate this questionnaire, it was administered to adult celiac patients already instructed on gluten and the GFD and non-celiac controls. Patients were prospectively recruited at our Gastroenterology Outpatient Clinic between August 2020 and February 2021. One hundred and six patients (52 celiac patients and 54 controls) participated in the validation phase. Celiac patients scored significantly higher than controls on the GLU10 Questionnaire (median 6 points vs. 2 points, P<0.001). Higher self-reported knowledge of the GFD was related to a higher score (P<0.001). ROC curve confirmed the ability of the GLU10 Questionnaire to discriminate between subjects with good and poor GFD knowledge (AUC=0.94, 95% CI: 0.90-0.98). A score of 5 was identified as the best cut-off (sensitivity 80.8%, specificity 94.4%). On multivariable logistic regression analysis, being a celiac patient (P<0.001) and having a university degree (P=0.04) were associated to a high GLU10 Score (≥5). GLU10 is the first validated questionnaire for assessing knowledge of a GFD in celiac patients and the general population.

Difficulties Assessing Adherence to Gluten-free Diet in Celiac Patients

To date the only efficient treatment of celiac disease is a lifelong gluten-free diet (GFD), which involves relevant lifestyle changes. Numerous methods measure adherence to GFD, but none is completely reliable. The aim of the study was to compare three frequently used methods to measure adherence to GFD and study factors that influence adherence to GFD. Eighty-one celiac patients 15 years or older, on GFD were evaluated by dietitian interview, a Celiac Dietary Adherence Test (CDAT) and blood antitransglutaminase antibodies (tTG). Factors influencing adherence were assessed by an ad-hoc questionnaire following WHO criteria. Adherent and non-adherent patients were classified in the same category in 44.4% of cases (n=36), (non-adherent=35.8% and adherent= 8.6%). In general, methods identified better non-adherent than adherent individuals. Among the 5 realms defined by WHO, when tTG (positive/negative) defined adherence, logistic regression identified ten significant variables (information about disease, income, education, cost of gluten-free products, eating in restaurants, time on GFD, symptoms at diagnosis, number of symptoms at time of diagnosis, other chronic diseases present, allergy/food intolerance plus a chronic disease and CD). Using the interview as reference, two variables were significant (self-perception of knowledge of the GFD, and presence of gastrointestinal symptoms when gluten is consumed). Results illustrate the difficulties of measuring both adherence to GFD and the factors that influences it. Further studies should explore new markers able to measure the amount of gluten necessary to activate autoantibodies production and the time they take to stop their production once the patient stops gluten ingestion.

Intraepithelial lymphocyte immunophenotype: a useful tool in the diagnosis of celiac disease.

According to new ESPGHAN guidelines, gluten challenge is considered necessary when there is doubt about the initial diagnosis of celiac disease (CD). The main aim of this study was to quantify intraepithelial lymphocyte (IEL) immunophenotype on celiac patients on gluten-containing diet (GCD) compared to those on gluten-free diet (GFD). Another aim was to evaluate the clinical utility of IELs in the CD diagnosis, especially in selected patients on GFD where diagnostic uncertainty remains. IEL immunophenotype (TCRγδ and NK-like IELs) were studied by flow cytometry in 111 children with CD (81 children with CD on GCD and 30 celiac patients on GFD) and a control group (10 children). Duration of GFD was 5.4±1.6years. TCRγδ IELs in celiac patients receiving a GCD or GFD were significantly higher (p<0.001) than in the control group. NK-like IELs in patients receiving a GCD or GFD were significantly lower than in the control group (p<0.001). We observed a permanent decrease of NK-like IELs and an increment of TCRγδ IELs after following an adequate establishment and compliance of a long-term GFD in celiac patients. Recognition of IELs changes in the intestinal mucosa on celiac patients after long-term establishment of a GFD could constitute a useful tool for CD diagnosis in various situations: in which there is doubt about the initial diagnosis and repeat biopsy is necessary (avoiding the need of gluten challenges), and in those patients with symptoms/signs suggestive of CD who maintain a low gluten diet.

Fecal Gluten Peptides Reveal Limitations of Serological Tests and Food Questionnaires for Monitoring Gluten-Free Diet in Celiac Disease Patients.

Objectives:Treatment for celiac disease (CD) is a lifelong strict gluten-free diet (GFD). Patients should be followed-up with dietary interviews and serology as CD markers to ensure adherence to the diet. However, none of these methods offer an accurate measure of dietary compliance. Our aim was to evaluate the measurement of gluten immunogenic peptides (GIP) in stools as a marker of GFD adherence in CD patients and compare it with traditional methods of GFD monitoring.Methods:We performed a prospective, nonrandomized, multicenter study including 188 CD patients on GFD and 84 healthy controls. Subjects were given a dietary questionnaire and fecal GIP quantified by enzyme-linked immunosorbent assay (ELISA). Serological anti-tissue transglutaminase (anti-tTG) IgA and anti-deamidated gliadin peptide (anti-DGP) IgA antibodies were measured simultaneously.Results:Of the 188 celiac patients, 56 (29.8%) had detectable GIP levels in stools. There was significant association between age and GIP in stools that revealed increasing dietary transgressions with advancing age (39.2% in subjects ≥13 years old) and with gender in certain age groups (60% in men ≥13 years old). No association was found between fecal GIP and dietary questionnaire or anti-tTG antibodies. However, association was detected between GIP and anti-DGP antibodies, although 46 of the 53 GIP stool-positive patients were negative for anti-DGP.Conclusions:Detection of gluten peptides in stools reveals limitations of traditional methods for monitoring GFD in celiac patients. The GIP ELISA enables direct and quantitative assessment of gluten exposure early after ingestion and could aid in the diagnosis and clinical management of nonresponsive CD and refractory CD. Trial registration number NCT02711397.

Barriers to Compliance to Gluten-free Diet in Celiac Disease: The Role of Depression and Motivation

Purpose: Gluten-free diet (GFD) is the cornerstone of treatment in celiac disease (CD). Compliance to GFD is often compromised by psychosocial factors as well as emotional (e.g., depression, anxiety), cognitive (e.g., perceived competence), and interpersonal (quality of patient-physician relationship) characteristics. Drawing from a social psychological theory of motivation called Self Determination Theory (SDT) (Deci and Ryan, 1985, 1991), we assessed the relative magnitude of the relationship between these psychosocial processes and compliance to GFD in a sample of patients with CD. Methods: Subjects included members of the Western New York Gluten-Free Diet Support Group who completed a testing battery, including the Celiac Dietary Adherence Test (CDAT), the Depression Anxiety Stress Scale (DASS), the Celiac Disease Quality of Life scale (CD-QOL), and the Celiac Symptom Index (CSI). The assessment also included SDT measures that were found to influence motivation in a range of chronic conditions. These variables included the Perceived Competence for CD Scale (PCS), measuring feelings of competence to comply with GFD, the Treatment Self-Regulation Questionnaire (TSRQ-CD), assessing autonomous versus controlled motivation, and the Health Care Climate Questionnaire (HCCQ-CD), measuring perceptions of physician autonomy supportiveness. Statistical analysis included Pearson correlations to measure linear relationships and hierarchical linear regression to determine predictors of noncompliance. Results: Of 500 members who received questionnaires, 190 completed the questionnaires. We report data from the first 100 questionnaires. As hypothesized, there was a significant correlation between non-compliance and depression (r=0.58, p<0.001), and to a lesser extent to anxiety (r=0.41, p<0.001) and stress (r=0.44, p<0.001). Non-compliance also correlated strongly with reduced perceived competence (r=-0.67, p<0.001) and disease severity (r=0.66, p< 0.001). Moderate correlations were found between compliance and autonomous motivation (r=-.43, p<0.001) as well as quality of life (r=0.46, p<0.001). In the final model of the regression analysis, significant independent predictors of noncompliance were perceived competence (β=-0.45, t=-0.4.90, p<0.001) and depression (β=0.28, t=2.80, p<0.01). Conclusion: Compliance to GFD in celiac patients is associated with psychological distress, particularly depression, as well as motivation factors including perceived competence and autonomous motivation. Non-compliance is associated with increased disease severity and reduced quality of life. These preliminary findings highlight barriers to compliance that, if addressed, can optimize the therapeutic value of GFD for this challenging disease.

Refractory celiac disease: from bench to bedside

Refractory celiac disease is defined by the persistence of symptoms of malnutrition and intestinal villous atrophy for more than 6-12 months despite strict gluten-free diet in celiac patients. Diagnosis of this rare condition is made after excluding other causes of chronic small intestinal inflammation and villous atrophy and inadvertent intake of gluten. Over the past 15 years, multidisciplinary approaches have been developed to assess the mechanism of resistance to the diet, and two distinct entities have been delineated. Type II refractory celiac disease (RCD) can be defined as a low-grade intraepithelial lymphoma. RCD II is characterised by a massive accumulation of abnormal IEL that display an aberrant hybrid NK/T cell phenotype, contain clonal T cell rearrangement(s) and can mediate a cytolytic attack of the gut epithelium. This condition has a severe prognosis, largely due to the frequent transformation of RCDII IEL into overt aggressive enteropathy-type-associated T cell lymphoma. In contrast, in type I RCD, intestinal lymphocytes have a normal phenotype, and this generally milder condition remains often difficult to differentiate from uncomplicated CD except for the resistance to gluten-free diet (GFD). Several mechanisms may underlie resistance to gluten. Herein, we review the distinctive characteristics of RCD I and RCD II, the mechanisms underlying the onset of resistance to GFD, the risk of developing high grade lymphoma and possible clues to improve their treatment.

Nutritional and functional properties of certain gluten-free raw materials

Since the adherence to the gluten-free diet in celiac patients affects the consumption from the grain food group, questions have been raised about the effects of such diet on calcium, iron, and fiber intake, as well as total carbohydrate and grain food consumption. Therefore, in the framework of this research, eleven types of nutritionally valuable gluten-free raw materials were proposed for consumption in gluten-free diet. They were investigated considering their macronutritive composition, different starch classes, the contents of essential minerals, dietary fiber, and polyphenols, as well as their antioxidant activity. The results were compared to the values obtained with wheat flour that was used as the reference raw material indicating that, in many aspects, the gluten-free raw materials mentioned can be considered as nutritionally more valuable in comparison to wheat flour. Especially satisfying results were obtained regarding the contents of proteins, dietary fiber, polyphenols, iron, and calcium. Therefore, the raw materials investigated can be recommended as desirable components that may contribute to the diversity, functionality, and nutritional quality of gluten-free diet.

S2030 Circulating Hematopoietic Stem Cells and Dynamics of Intestinal Regeneration Following Gluten-Free Diet in Celiac Patients

Purpose: Celiac crisis is a life-threatening syndrome where celiac disease presents with profuse diarrhea and severe metabolic disturbances. Celiac crisis in adults is believed to be uncommon and is not well documented. However, it is likely that many patients with celiac crisis are not definitively diagnosed. In order to improve awareness and to facilitate diagnosis, we reviewed cases of celiac crisis seen at Beth Israel Deaconess Medical Center in Boston, MA and Mayo Clinic in Rochester, MN. These data were used to identify presenting features, formulate diagnostic criteria for celiac crisis in adults and develop treatment strategies. Methods: We reviewed cases of biopsy proven celiac disease in the last 5 years. Celiac crisis was defined as acute onset or rapid progression of gastrointestinal symptoms attributable to celiac disease requiring hospitalization and/or parenteral nutrition along with at least 2 of the 7 factors listed below: 1.Signs of severe dehydration including hemodynamic instability or orthostasis 2.Neurologic dysfunction 3.Renal dysfunction: creatinine >2.0 4.Metabolic acidosis: pH 10 lbs Results: Twelve patients met the above criteria. Of these, 8 were women and 4 were men. 11 developed celiac crisis prior to diagnosis of celiac disease. IgA tissue transglutaminase titer was available for 11 patients. Of these, one had IgA deficiency, and all of the others had elevated tTG, eight with levels greater than 4 times the normal limits. Biopsies of the duodenum in all patients were consistent with a Marsh 3 score. HLA type was available for 10, of which 9 were positive for DQ2 and 1 for DQ8. Patients presented with severe dehydration, renal dysfunction, and electrolyte disturbances, of which hypocalemia was most common. All patients required hospitalization and intravenous fluids and five required parenteral nutrition. Six patients required corticosteroids. All patients had a rapid clinical response to gluten free diet. Conclusion: Celiac crisis is associated with high morbidity and although rarely described, does occur in adults, often without a clear precipitating factor. Patients presentingwith severe unexplained diarrhea and malabsorption should be tested for celiac disease and treatment with systemic steroids or oral budesonide considered. Nutritional support is often required in the short term but most patients ultimately respond to gluten avoidance. We are hopeful that our delineation of formal diagnostic criteria for celiac crisis will aid in identification and management of these patients.

Antigliadin antibodies detected by enzyme-linked immunosorbent assay as a marker of childhood celiac disease

Using an enzyme-linked immunosorbent assay (ELISA) assay, we studied the sera of 17 patients with celiac disease and 114 control subjects for the levels of IgG and IgA antigliadin antibodies. As a group, the patients with celiac disease had significantly higher levels of antigliadin antibodies of both IgG and IgA classes (p less than or equal to 0.001). However, there was a significant overlap of values, resulting in respective sensitivities and specificities of 88% and 90% for IgG antigliadin antibodies, and 73% and 65% for IgA antigliadin antibodies. The combined use of both IgG and IgA antigliadin antibody levels produced a sensitivity of 86% and a specificity of 90%. A gluten-free diet in celiac patients did not seem to affect these results. We conclude that the antigliadin antibody ELISA assay cannot be used as a definitive diagnostic test for celiac disease. The small-bowel biopsy remains the principal diagnostic method; the ELISA assay should, at best, be considered a screening test for this disease.