Gluten-free Research Articles

Dietary assessments in individuals living with coeliac disease: key considerations.

Coeliac disease (CeD) is a type of enteropathy characterised by an immune-mediated reaction to ingested gluten, resulting in impaired absorption of nutrients and symptoms such as bloating, abdominal cramping and diarrhoea. Currently, the only treatment for CeD is adherence to a gluten-free diet (GFD). The latest draft guidance from the US Food and Drug Administration recommends that dietitians experienced in CeD management evaluate patients during the screening and treatment period of CeD clinical trials to assess adherence to a GFD. However, there are currently no standardised guidelines on dietary assessment of patients with CeD on a GFD and there is a lack of widespread availability of expertise in this field. Based on the findings of a literature review conducted between April and September 2023, this article provides an overview of key points to consider in the nutritional and dietary assessment of patients with CeD who are following a GFD, with particular focus on the clinical trial setting. Based on a consensus from dietitians and gastroenterologists experienced in treating patients with CeD, we present specific recommendations for registered dietitians who manage patients with CeD. We also describe the development of a simplified tool for assessment of adherence to a GFD, the Gluten-Free Adherence Survey, based on these recommendations. These guidelines cover nutritional and dietary assessment of patients with CeD, physical assessments, intake of oats, environmental considerations and the disease burden.

The influence of celiac disease on fertility and pregnancy: an Italian survey.

Celiac disease (CD) is an inflammatory enteropathy that has been associated to obstetric and gynecological disorders. However, it is still not adequately tested by gynecologists due to the misconception that it is solely a gastrointestinal disease. This underestimation requires the development of targeted interventions. This study aims to evaluate the association between CD and obstetric/gynecological complications, highlight the importance of informing patients about CD manifestations, and assess the patient satisfaction with the information provided by healthcare professionals on the disease. A digital survey was administered to celiac women via the Italian Celiac Association's website. We analyzed 493 questionnaires. Obstetric and gynecological disorders led to the diagnosis of CD in 11.7% of interviewed. The study revealed that untreated CD patients are more predisposed to miscarriages (41.8% vs 34% before/after diagnosis, respectively, p = 0.111), anemia in pregnancy (71.4% vs 40.4% before/after diagnosis, respectively, p < 0.001) and the risk of low birth weight (newborns weighing < 1500g were 4.0% before and 1.1% after the gluten-free diet, p = 0.028). Women with CD, both before and after gluten-free diet, had higher infertility rates (about 19%) than the general population. Additionally, 73% of interviewees were dissatisfied with the information they received from health professionals about the reproductive implications of CD. Our research contributes to a deeper understanding of the intersection between CD and reproductive outcomes, highlighting the main obstetric and gynecological problems related to it. It emphasizes the importance of patient's perspective and the need for greater awareness about celiac disease from healthcare workers.

Availability and cost of gluten-free products in Algeria

PurposeA strict gluten-free diet (GFD) is the only effective treatment for coeliac disease (CD), which has an increasing prevalence. However, the limited availability and high price of gluten-free products (GFPs) compared to their gluten-containing counterparts (GCCs) are still among the factors that may influence compliance with a strict GFD. The purpose of this study is to assess the availability and price of GFPs in retail stores in a major Algerian city and investigate how they compare to GCCs.Design/methodology/approachWe performed a cross-sectional study that targets a representative number of supermarkets and grocery stores in Constantine (Algeria). All available GFPs as well as their GCCs were recorded. The price per 100 g was recorded for each product.FindingsAmong the 285 visited stores, only 25.4% of them sold GFPs, which were more available at supermarkets than at grocery stores. The category “gluten-free pasta and couscous” was the most represented (43.8%). A total of 64 GFPs were observed across 285 stores investigated, and their price was two to six times higher than that of their GCCs.Originality/valueThis study showed the limited availability and diversity and higher price of processed GFPs in Algeria. This negatively influences compliance with GFD as well as the quality of life of patients with CD. Furthermore, the findings prompt the national government to provide financial support to coeliac individuals.

Teff: Its applicability in various food uses and potential as a key component in gluten-free food formulations—An overview of existing literature research

In recent years, there has been a significant increase in demand for gluten-free foods. This rise can be attributed to a growing number of individuals opting for gluten-free diets due to factors such as gluten sensitivity and celiac disease. Interest in teff has also increased markedly due to its high protein content, balanced amino acid composition, and rich nutrient contents including fiber, iron, and calcium, along with its gluten-free nature. Additionally, teff exhibits positive functional properties that contribute to improving texture, moisture retention, and shelf life in gluten-free products. Its mild flavor profile allows for versatile applications across a spectrum of culinary applications, enhancing the sensory appeal and taste of gluten-free offerings. This makes it a suitable alternative to wheat and other grains in food applications for individuals with celiac disease. Overall, integrating teff into gluten-free formulations presents an attractive opportunity to enhance the nutritional quality, sensory experience, and market competitiveness of gluten-free products, catering to the diverse needs and preferences of consumers seeking gluten-free alternatives for health, dietary, or lifestyle reasons. Further research and innovation in teff-based product development are crucial to fully unlock its potential and promote inclusive, sustainable growth in the gluten-free food sector. Therefore, these attributes underscore teff's promising role in the global food and beverage industries.

The Influence of an Anti-Inflammatory Gluten-Free Diet with EPA and DHA on the Involvement of Maresin and Resolvins in Hashimoto’s Disease

The potential modulation of thyroid inflammatory conditions via a gluten-free diet has been suggested after establishing a link between Hashimoto’s thyroiditis (HT) and celiac disease. However, the majority of targeted studies in this field do not support the general recommendation of prescribing a gluten-free diet (GFD) for all HT patients. This study aims to analyze data regarding the impact of a GFD supplemented with eicosapentaenoic (EPA) and docosahexaenoic acid (DHA), along with vegetables, on the course of inflammation involving long-chain fatty acid mediators. The study cohort consisted of 39 Caucasian female patients with autoimmune HT. Metabolite separations were performed using a liquid chromatograph with a DAD detector. Absorption peaks were read at 210 nm for resolvin E1, protectin DX, and maresin 1 and at 302 nm for resolvin D1. The introduction of a gluten-free diet completed with omega-3, including EPA and DHA, may contribute to a reduction in the inflammatory state in HT patients. This effect is supported by the elevation in the levels of anti-inflammatory mediators derived from long-chain fatty acids with anti-inflammatory properties but not by eliminating gluten. Significant statistical changes in the levels of all derivatives were observed before and after the implementation of the diet. It is worth noting that this effect was not observed in anti-TPO and anti-TG levels. The induction of anti-inflammatory changes can be achieved by supplementing the diet with EPA, DHA and vegetables with increased anti-inflammatory potential.

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

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

Case Report: Ocular paroxysmal non-epileptic events as the presenting sign of celiac disease in children: a case series

IntroductionNeurologic manifestations may be presenting signs of celiac disease (CD). Pediatric-onset paroxysmal non-epileptic events (PNEEs) are not included among them.Cases presentationWe report the case of two children who presented with ocular PNEEs in association with mild symptoms evocative for CD, who were subsequently diagnosed with CD and experienced regression of PNEEs on a gluten-free diet. Data from 12 patients undergoing neurological evaluation in 2019–2023 for ocular PNEEs were reviewed: 3 (25%) had a subsequent diagnosis of CD.ConclusionsOcular PNEEs could be a presenting manifestation of CD. In the diagnostic work-up of PNEEs, screening for CD could be included, both to avoid unnecessary tests and to promptly start a gluten-free diet, which might lead to a favorable clinical response.

Development of oat malt production technology using plasma-chemically activated aqueous solutions

The object of the study was oat malt production. The result of the presented study is the development of a technology for gluten-free oat malt production using cold plasma-treated technological solutions. The material for the study was oat grain. The main technological task is to obtain high-quality oat malt, which, in turn, will be suitable for producing gluten-free beverages and highly nutritious foods. The expediency of using cold plasma-treated aqueous solutions as an activator of the oat malting process and an effective disinfectant of the technological process and the finished product (oat malt) was experimentally proved. It was confirmed that using cold plasma-treated aqueous solutions can accelerate the oat germination process: the germination energy increased by 6–14 %; germination capacity by 2–10 %. The moisture content of oats when moistened increases by 6–37 %. Analysis of the amylolytic enzymatic activity showed a dynamic increase of 17.6 %. The result was the breakdown of carbohydrates. Thus, the amount of starch decreased by 2.4 %, fiber did not undergo significant changes, and the content of simple sugars increased by 2.3 %. The proteolytic activity of oat malt increased by 18.1 %. An increase in the amount of amino acids in the experimental samples was noted. The total amount of amino acids is 793 mg/100 g of product higher than in the control (i.e. by 3 %). There was also an increase in the content of vitamins B (B1, B2), as well as vitamin C, the content of which increased by 5.6 %. Disinfecting properties of cold plasma-treated aqueous solutions in relation to oat malt were noted. The innovative technology of oat malt production can be implemented in the industrial production of gluten-free malts for the brewing industry and for producing gluten-free foods.

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

Celiac disease (CD) is an autoimmune gastrointestinal disorder that requires a strict lifelong gluten-free diet (GFD). Gluten-free (GF) foods are more expensive and less readily accessible than gluten-containing foods, contributing to an increased risk for food insecurity (FI). The study aimed to determine associations between GF-FI, sociodemographic risk factors and child dietary adherence and diet quality (DQ). A 26-item, cross-country online survey was administered through social media to parents of children with CD on the GFD. The survey elicited household and CD child sociodemographic and clinical characteristics (e.g., duration of CD), measures of household FI, child DQ and GFD adherence, and parents' concerns related to GF food. Household GF-FI was evaluated using the validated Hunger Vital Sign™ and the US Department of Agriculture Six-Item Short Form Household Food Security Survey Module. GF-FI occurred in 47% of households with children with CD with >30% reporting low to very low food security. Sociodemographic risk factors identified included lower income, renters, rural residency, single-parental households, and having children with additional dietary restrictions (p < 0.001). Regardless of FI status, a majority of households reported experiencing significantly higher GF food expenditure. GF-FI was associated with reduced adherence to the GFD, increased consumption of processed GF food, and lower intakes of fresh fruits and vegetables and GF grains among children with CD (p < 0.05). GF-FI is prevalent in this multiethnic cohort of households with CD children and is associated with worsening DQ and GFD adherence. Policy interventions are urgently needed to address GF-FI.

When toxicity is not just from gluten: a systematic review on financial toxicity and celiac disease

Abstract Background With an incidence of up to ∼2% globally, Celiac Disease (CD) is probably one of the most life-long common chronic conditions. Although ‘Financial toxicity’ (FT) has been mainly linked to oncology, significant financial burdens have been described across all healthcare domains, even in CD and to the unexpected economic effort resulting from illness and the need for treatments. This study aimed to investigate the potential relationship between CD and FT. Methods A systematic literature review was performed according to the PRISMA Statement 2020 guidelines. The search query queried the following databases: PubMed, Scopus, CINAHL and APA PsycInfo. No time and study design limits were included. Results 105 articles were found, and 25 were included in the review. The main results revealed that CD impacts physical health and imposes a significant financial burden on patients and their families. FT in CD is primarily due to the high costs of diagnosis, lifestyle changes, and expenses for gluten-free foods. Several studies highlighted the scarce adherence to the therapeutic diet due to the cost of food and poor acceptance of CD. Furthermore, since 2007, there has been increased attention to the difficulty of finding gluten-free products and their expensive fees. All these aspects, even for low-income countries, were faced differently globally, as documented by the heterogeneity of government subsidy policies highlighting the health inequity. Conclusions Considering the prevalence, a comprehensive health assessment with a global health approach should consider clinical, social, and economic aspects. This regard could improve the quality of life for CD patients and ensure fair and personalised access to care, regardless of their geographical location or financial situation. This review has highlighted the fragmentation of resources available internationally, underlining the relevance from a public health point of view. Key messages • Celiac Disease is one of the most common life-long disorders, and financial toxicity is an aspect that should be taken into account also from a public health point of view to ensure health equity. • The gluten-free diet represents an important therapeutic choice in CD; the related expensive fees could increase scarce adherence and worse health outcomes.

Nutritional, physicochemical, and sensorial characterisation of quinoa-millet enriched gluten-free functional cookies

AbstractThe demand for gluten-free food products is expected to grow in the coming years. Quinoa's versatility allows it to replace traditional grains and adds high nutritional value to grain blends and processed food items. The present study was designed to prepare and evaluate gluten-free cookies by substituting rice with quinoa and keeping pearl and foxtail millet constant. A significant increase in protein (8.0–13.2 g/100 g), crude fibre (2.9–6.2%), ash (0.5–1.7%), and hardness (928.9–1736.9 g) was observed with increasing quinoa supplementation. A positive correlation of crude fibre with protein, hardness, and fracturability was observed at P ≤ 5%. Organoleptic evaluation indicated that cookies with 30% quinoa were overall accepted by the consumer. Also, these cookies had lower acid and peroxide values, thus, had longer shelf-lives. This is the first report for the use of quinoa with the mixture of rice and millet, which could be a decent alternative ingredient for gluten-free cookies formulations.

Development of the celiac disease symptom diary version 2.1© (CDSD 2.1©) patient-reported outcome measure.

For patients with celiac disease (CeD), the only current management option is adherence to a strict gluten-free diet (GFD); however, many patients on a GFD continue to experience symptoms with asignificant impact on quality of life. Potential new treatments for CeD are under development and a validated patient-reported outcome measure is required to evaluate their utility in clinical trials. The purpose of this article is to provide a history of the development of the Celiac Disease Symptom Diary (CDSD) 2.1© for use in clinical trials. Qualitative and quantitative studies were conducted from 2010 to 2021, including concept elicitation and cognitive debriefing interviews with adult and adolescent participants with CeD (N = 93) diagnosed via biopsy and/or serology and input from eight interviews with CeD clinical experts. During these studies, different iterations of the CDSD were presented to the US Food and Drug Administration and the European Medicines Agency, and modifications were made in line with their feedback. These studies ultimately led to the development of CDSD 2.1©, a daily diary which focuses on key symptoms of CeD (abdominal pain, bloating, diarrhea, nausea and tiredness). This patient-reported outcome measure was readily understood by adult and adolescent participants with CeD and content validity was demonstrated in both populations. CDSD 2.1© is a content-valid patient-reported outcome measure developed in accordance with best practices and regulatory guidance. A thorough exploration of the psychometric properties of CDSD 2.1© for both adult and adolescent participants with CeDis ongoing to support utilization in clinical trials.

Higher cost of gluten-free products compared to gluten-containing equivalents is mainly attributed to staple foods.

The high cost of gluten-free products (GFPs) is being discussed as a potential barrier to adherence to a gluten-free diet, rendering monitoring of their pricing an ongoing demand in a market subject to continuous fluctuations. The current study aimed to assess the current pricing status of GFPs in the Greek retail market, with a focus on differences between staple and non-staple foods. The retail price and packaging weight of all available GFPs and their gluten-containing (GCPs) counterparts of a GFP-shopping basket (formulated based on the results of a preceding online survey) were recorded by visiting one store of the five most popular reported supermarket chains. The food categories were grouped into staple (e.g. breads, pasta and flours) and non-staple (e.g. chips, sweets and sauces) foods. Adjusting for supermarket chain and product type, a quantile mixed regression model was applied to assess the extent to which median product price (per 100 g) differed between GFPs and GCPs. The unique products recorded were 1058 (of which 408 GFPs), with a total of 2165 retail price recordings. While the overall median price/100 g of GFPs was not found to be significantly different from that of GCPs, the median price of staple GFPs was estimated to be higher than staple GCPs (+€1.03 [95% CI: €0.93; €1.13] per 100 g), whilst that of non-staple GFPs was slightly lower (-€0.20 [95% CI: -€0.37; -€0.02] per 100 g). In conclusion, the persisting higher cost of staple GFPs suggests the need for ongoing financial support for people with coeliac disease.

Gluten Unraveled: Latest Insights on Terminology, Diagnosis, Pathophysiology, Dietary Strategies, and Intestinal Microbiota Modulations—A Decade in Review

A decade of research on gluten-related disorders (GRDs) is reviewed in this study, with a particular emphasis on celiac disease (CD) and non-celiac gluten sensitivity (NCGS). GRDs are triggered by the ingestion of gluten and gluten-like proteins found in wheat, barley, and rye. These proteins lead to intestinal damage in celiac disease, an autoimmune condition characterized by villous atrophy and a variety of gastrointestinal and extraintestinal symptoms. More enigmatic and less understood, NCGS involves symptoms similar to CD but without the immunological reaction or intestinal damage. Recent years have seen advances in the understanding of GRDs, particularly in connection to how intestinal microbiota influences disease progression and patient outcomes. The gluten-free diet (GFD) is still the standard therapy recommended for GRDs despite significant challenges, as discussed in this article. Precise diagnostic methods, patient education and dietary counseling are critical for improving patients’ quality of life. The purpose of this review is to provide a more clear and up-to-date understanding of GRDs, and to help further research on this important topic.

Unlocking the Potential of Teff for Sustainable, Gluten-Free Diets and Unravelling Its Production Challenges to Address Global Food and Nutrition Security: A Review

Sustainable diets, as defined by the Food and Agriculture Organisation, aim to be nutritionally adequate, safe, and healthy, while optimising natural and human resources. Teff (Eragrostis tef), a gluten-free grain primarily grown in Ethiopia, has emerged as a key contender in this context. Widely regarded as a “supergrain”, teff offers an outstanding nutrition profile, making it an excellent choice for people with gluten-related disorders. Rich with protein, essential amino acids, polyunsaturated fats, and fibre, and abundant in minerals like calcium and iron, teff rivals other popular grains like quinoa and durum wheat in promoting human health. Beyond its nutritional benefits, teff is a hardy crop that thrives in diverse climates, tolerating both drought and waterlogged conditions. Due to its resilience and rich nutrient content, teff holds the potential to address nine of the 17 United Nations’ Sustainable Development Goals (SDGs), including SDG 1 (no poverty), SDG 2 (zero hunger), and SDG 3 (good health and wellbeing), which are tied to improving food and nutrition security. However, teff production in Ethiopia faces significant issues. Traditional farming practices, insufficient storage infrastructure, and food safety challenges, including adulteration, hinder teff’s full potential. This review explores teff’s dual role as a nutritious, sustainable food source and outlines the key challenges in its production to conclude on what needs to be done for its adoption as a golden crop to address global food and nutrition security.

Psychological flexibility and celiac disease in adolescents: Understanding adherence and well-being for enhanced care. A rapid narrative review

Abstract Background Psychological flexibility (PF) has been approached as a mediator between health conditions and outcomes by promoting positive responses and healthier behavior repertoires. Purpose This rapid narrative review examines studies exploring the role of PF in influencing celiac disease outcomes among adolescents, with a particular focus on adherence to dietary management practices. Method Online databases were searched for studies exploring possible connections between PF, celiac manifestation, and management presented by adolescents. Selected articles have entered the analysis to highlight whether PF mediates or affects celiac-related outcomes in adolescents. Conclusions Adolescents demonstrate a greater capacity to organize their daily routines effectively while adhering to gluten-free diets. However, the emphasis on PF can significantly impact their social interactions. Although there is much research to be conducted on this possible connection, there are still primary assumptions that support the idea that PF can also be a factor in helping adolescents with celiac disease navigate the challenges of their illness and maintain a quality of life. Healthcare professionals can find value in incorporating elements from supporting therapies, health literacy programs, and health promotion strategies. Furthermore, insights from the review suggest the importance of standardizing interventions and measurements including counseling practices at the primary care level.

Enhancement of Corn Flour with Carob Bean for Innovative Gluten-Free Extruded Products

The aim of this work is to study new, extruded products based on corn flour enriched with carob bean and the evaluation of its functional quality to develop novel gluten-free food products. Five samples based on corn flour with added carob bean flour (5 to 12.5%) were formulated. Extrusion was performed using a single-screw laboratory extruder at pilot plant scale. Extrusion parameters such as color and carbohydrate content (fiber, sucrose, and starch) were evaluated. Carob bean addition led to an increase in starch, soluble fiber, and insoluble fiber. Texture parameters related to hardness (crunchiness) were significantly reduced with the addition of CB (p &lt; 0.05), detectable from a 5% addition of CB and not significant with more CB content. Samples became browner with the addition of CB; however, when the concentrations of CB are high (&gt;5%) no major differences in color were observed. The extrusion process reduced the content of soluble and insoluble fiber, and sucrose in all formulated samples. Extruded samples with 5–7.5% CB seem to be the best formulation in terms of fiber content, color, and texture parameters. These innovative gluten-free foods could be considered as a source of fiber, and a healthier alternative to some commercially available snacks.

Celiac disease in the aspect of comorbidity: facets and boundaries

Celiac disease poses a serious diagnostic problem due to significant clinical polymorphism with a high frequency of atypical forms. The problem of comorbidity for celiac disease is relevant due to the possible involvement of almost all organs and systems in the pathological process. In this regard, the question arises of which symptoms are a manifestation of the disease, which are complications, and which symptoms are associated with comorbid conditions. The clinical polymorphism of celiac disease is obviously associated with damage to many organs in this disease. They all have a common starting point - an immunopathological process leading to malabsorption and secondary metabolic disorders, which are essentially a manifestation of the disease, but not complications, as is sometimes interpreted. A complication can be considered the oncological consequences of the disease, which develop after prolonged non-compliance of a gluten-free diet. The combination of celiac disease with associated diseases, primarily autoimmune diseases, should be considered as a manifestation of comorbidity.

Dual modification of starch: Synergistic effects of ozonation and pulsed electric fields on structural, rheological, and functional attributes

Study evaluated the influence of ozonization (O3) time combined with pulsed electric fields (PEF) on the modification of bean starch structure. O₃ was used at a concentration of 0.045 g/L for 60 min (Oz1) and 120 min (Oz2) both individually and in combination with 30 kV/cm (P30). Carbonyl content was higher than the carboxyl content, especially with prolonged treatment times (Oz2), indicating partial oxidation. Additionally, higher levels of amylose and degrees of polymerization (DP ≥ 37 and DP 25–36) were observed in the oxidized starches, with significant changes only when combined with PEF. The main morphological and structural modifications included the presence of agglomerates, partial gelatinization, reduced crystallinity, and lower IR1047/1022 in the granules treated with PEF + O3. Oxidized starches exhibited higher solubility, resulting in lower values for rheological parameters, with PEF + 2 h of O3 (Oz2P) standing out. It can be used as prebiotics, controlled release agents and a texturizer for gluten-free foods.

The frequency of HLA-DQ7 in patients at risk of coeliac disease: A haplotype to be reckoned with for screening?

HLA-DQ2 and -DQ8 carriers are genetically predisposed to develop coeliac disease (CD). Testing negative for HLA-DQ2/DQ8 has a high negative predictive value. Full HLA-DQ genotyping as well as tests only typing for HLA-DQ2/DQ8 are therefore used for screening at-risk populations. However, HLA-DQ7 positive and HLA-DQ2/DQ8 negative CD patients have been described in various populations. In this study we examine the relevance for HLA-DQ7 typing in a large at-risk CD population.The HLA-DQ status of all paediatric and adult patients at-risk of CD that were typed in a tertiary medical centre laboratory between 2012 and 2016 (n = 3983) was obtained. HLA-DQ7 (HLA-DQB1*03:01) positive and HLA-DQ2/DQ8 negative patients were selected. We gathered information on serology, histology and dietary status, and CD diagnosis.In total, 489/3983 patients were HLA-DQ7-positive and HLA-DQ2/DQ8 negative, and after exclusion (missing data on diet or serology/histology), 325 were included. Only one adult patient was diagnosed with CD, based on a duodenal biopsy and a clinical response to a gluten-free diet. Homozygosity was observed in 14.8 %.Based on the current cohort additional typing of HLA-DQ7 does not seem relevant for screening at-risk populations for CD in the Netherlands. It should be considered in patients with a high suspicion of CD.