Gluten-free Research Articles

Children with celiac disease, diagnosed with or without biopsy, present similar adherence to gluten-free diet and serology decline.

Rate of TTG decline did not differ between CeD patients diagnosed with and without biopsy, suggesting that, at least in short term, no biopsy approach may not change patients' adherence and families' attitude towards treatment. • Based on current guidelines, there is a rise in the incidence of pediatric celiac disease (CeD) diagnosis without an intestinal biopsy. • There is insufficient data regarding patients' adherence to treatment, including pattern of serology decline, based on the method of CeD diagnosis. • Children with CeD have similar baseline characteristics, including presence or absence of symptoms, whether diagnosed with or without biopsies. • During 18-month follow-up, the rate of celiac serology decline, and the reported adherence to treatment, do not differ between patients diagnosed based on biopsy or no biopsy approaches.

Volumetric Analysis of Motor Cortex and Basal Ganglia in Pediatric Celiac Disease Patients Using volBrain: Implications for Neurological Dysfunction-Preliminary Results

Background/Objectives: Celiac disease (CD) is a common immune-mediated, chronic systemic disorder that is treated with a strict, life-long gluten-free diet (GFD). In addition to gastrointestinal manifestations, CD also presents with a variety of extraintestinal symptoms, including significant neurological and neuropsychiatric symptoms. Among these neurological manifestations, motor dysfunctions are particularly notable. The aim of this study is to investigate the potential volumetric differences in brain structures, particularly the motor cortex and basal ganglia, between pediatric CD patients and healthy controls using the volBrain software AssemblyNet version 1.0. Methods: This prospective study included pediatric patients with CD who complained of neurological symptoms and were scheduled for brain magnetic resonance imaging (MRI). All children had been previously diagnosed with CD and their adherence to GFD was evaluated using the Biagi score. Brain MRIs were performed on all included patients to obtain volumetry at the onset of the disease. For volumetric and segmentation data, the volBrain software was used. Results: In total, 12 pediatric patients with CD were included, with a median duration of a GFD of 5.3 years at the time of the MRI examination. There were no statistically significant differences between patients compliant with the GFD and those non-compliant in terms of age or duration of GFD. Volumetric analysis revealed deviations in all patients analyzed, which involved either a decrease or increase in the volume of the structures studied. Conclusion: Despite the limited number of patients in this study, the initial findings support previously described neurological manifestations in patients with CD. Newly developed MRI tools have the potential to enable a more detailed analysis of disease progression and its impact on the motor cortex.

Current Strategies to Modify the Functional Properties of Proteins Extracted from Pumpkin Seeds: A Comprehensive Review

The functional properties of pumpkin seed proteins remain unutilized in numerous food and industrial applications. Several current approaches aim to improve the functional properties of pumpkin seed proteins, allowing their innovative potential to develop and modify significantly. Several strategies can be implemented to alter the functional properties of proteins isolated from pumpkin seeds. The first is enzymatic hydrolysis, regardless of whether, proteases may free peptide binding and profoundly impact the protein structure and functionality. Thermal treatment can include heating and cooling to replace protein conformation and increase solubility, emulsification, and gelation properties. Chemical modification techniques, including acylation and glycation, can also be used to improve stability, viscosity, and foaming ability. Functional properties and, where possible, ingredients with many applications may include exceptional possibilities for proteins modified in food preparations, such as dairy replacements, plant-based meat analogues, and free gluten that have an outstanding aspect, satisfactory quality, and nutritional profiles. As multiple different proteins act as precursors of active peptides, they can also be used to generate bio-specific foods. This review briefly provides information about various types of protein extraction techniques and functional properties that are modified by different types of processing technologies.

Finding of celiac disease during the study of Kimura disease in a Caucasian male.

We present the case of a 27-year-old man, with no previous diseases, who was referred to the Department of Otorhinolaryngology in May 2023 for a 2-cm right submandibular lymphadenopathy of two month's evolution. He did not report fever or night sweats, and no oral or genital ulcers were observed. He presented eosinophilia in the analysis performed and a maculopapular exanthema on the left leg and malleolus areas, which was initially treated with topical antibiotic and corticosteroids. A soft tissue ultrasound revealed two right laterocervical lymphadenopathies at levels I and II. Given the suspicion of a primary hematological tumor, a PET-CT scan was conducted to complete the study, which revealed hypermetabolic laterocervical bilateral lymphadenopaties. In June 2023, a programmed cervicotomy was conducted, with complete excision of the right main lymphadenopathy in the Ib region, which showed a histological result of reactive lymphadenitis with intense eosinophilia, vascular proliferation, and fibrosis. These findings suggest Kimura disease as the first possibility. Due to sporadic episodes of choking that were not associated with specific food, persistent elevated IgE levels and eosinophilia in peripheral blood tests, and skin alterations, the study was completed with a gastroscopy to rule out the presence of eosinophilic esophagitis, which showed erosive duodenitis, with villous shortening and increased lymphoplasmacytic cellularity of the lamina propria, findings consistent with celiac disease, which was afterwards confirmed with the presence of positive anti-endomysial and transglutaminase antibodies, and the presence of HLA-DQ8 positive in homozygosis in the genetic study. The patient started systemic treatment with corticosteroids and gluten-free diet, which he continues to take at present.

Can flow cytometry be a key in the difficult diagnosis of coeliac disease?

We present the clinical case of a 39-year-old woman with a medical history of juvenile idiopathic arthritis and uveitis, evaluated for abdominal pain and distension, difficulty gaining weight, and diarrhea. Blood tests were requested, including antibodies which were negative and common genetic markers, showing positivity for HLA DQ 7.5. A gastroscopy with duodenal biopsies revealed findings consistent with stage 3b of the modified Marsh classification. Due to diagnostic uncertainty, an IEL study was performed, showing a characteristic CD pattern, leading to the initiation of a strict gluten-free diet (GFD). During follow-up, the patient showed partial improvement, with persistent digestive symptoms. A repeat endoscopic study revealed persistent atrophy, but refractory disease type 2 was ruled out. During a flare of rheumatologic disease, Tocilizumab was initiated by Rheumatology, resulting in improvement of duodenal atrophy.

Use of Carbohydrate (CHO), Gluten-Free, and FODMAP-Free Diets to Prevent Gastrointestinal Symptoms in Endurance Athletes: A Systematic Review

Background: Gastrointestinal symptoms (GISs) can affect the performance of endurance athletes (EAs). This study aims to analyze the efficacy of carbohydrate (CHO), gluten-free, and low-mono-saccharide and polyol (FODMAP) diets in preventing GISs in adult EAs of both sexes. Methods: A systematic search was conducted prior to 30 June 2024 in accordance with the PRISMA statement. We searched for original studies from the last eight years, in English or Spanish, that looked at the effect of CHO, gluten-free, or FODMAP diets on the GISs of EAs. In PubMed, the MeSH (medical subject heading) categories were used. The search was repeated in EBSCO, Google Scholar, and Web of Science. The inclusion criteria were determined using the PICOS framework and the risk of bias in each paper was assessed using the PEDro scale quality criteria checklist (systematic review registration: INPLASY202490080). Results: Of 289 articles identified, only 3.5% met the eligibility criteria. All studies found that GISs are common in EAs. We found that 60% of the articles used an experimental method; moreover, based on 80% of the articles, following a bowel training diet, like CHO, reduced fiber and dairy products, or a low-FODMAP diet, has the potential to reduce gastrointestinal symptoms and improve the athletic performance of EA. Conclusions: We found that low-FODMAP diets, gut training with CHO intake, and decreased fiber and dairy intake may have favorable effects in preventing GISs. No studies support a gluten-free diet in reducing GISs in EAs.

Access to gluten-free foods for people with coeliac disease in New Zealand.

A strict gluten-free (GF) diet is the current mainstay of treatment for coeliac disease (CD). A limited range of GF foods are available on prescription for those with CD. GF foods purchased in shops are typically more expensive than gluten-containing equivalents. This study sought to understand how New Zealanders with CD obtain GF products and the changes associated with this. Coeliac New Zealand members were asked to complete an anonymous electronic survey in June 2023. Although 24% of the 522 respondents had accessed GF foods on prescription in the past, only 2% currently used the service. One-third of the respondents were unaware of the service. Cost and limited product range were the key reasons for not accessing prescriptions. Most non-prescription GF foods were purchased from a supermarket, with 54% spending over $50 per week on GF foods. Most respondents (90%) would prefer a discount card to purchase GF products. Preferences regarding the prescription service would be to collect products from a local shop (84%) or a pharmacy (42%). This study indicates a very low uptake of GF products on prescription, with awareness, cost, product range and convenience limiting use of the service. Most respondents would prefer financial support for discounted GF products.

Exploring the link between celiac disease and obesity: a potential role of gut microbiome.

In today's age, celiac disease (CD) is no longer solely characterized by chronic diarrhea in a malnourished child. Obesity is gradually being acknowledged as part of CD's clinical course. Both conditions have been linked to alterations of gut microbiome. Given the difficulty of strict gluten-free diet adherence, there is a need for less restrictive adjunctive therapies. We aimed to investigate the prevalence of obesity in patients diagnosed with CD with the goal of developing new therapeutic approaches. Baseline data from the National Institute of Health's All of Us Research Program, was used to evaluate the relationship between CD and obesity. A retrospective cohort study was conducted where groups of individuals with CD and without CD were matched by age range and health surveys. Statistical analysis with odds ratios (OR) with 95% confidence intervals (CI) were reported. The prevalence of obesity was 32.6% in the CD group compared to 18.4% in the control group (OR, 2.111; 95% CI, 1.914-2.328; P< 0.0001). Women accounted for a greater population of patients with CD and obesity. The largest percentage of patients with CD and obesity were older than 65 years. The highest percentage of individuals in both the experimental and control groups were white, followed by African Americans. Our data shows a significant association between CD and increased prevalence of obesity. These results warrant further investigation into microbial changes and dietary exposures that affect the pathogenesis of both diseases.

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.

Improvement of Gluten-Free Sponge Cake with A Combination of Chia Seed Flour and Millet Flour

Background: Celiac disease is an autoimmune disorder in which the patient is permanently intolerant to proteins containing gluten, and the only treatment is to use a gluten-free diet. The present study is designed to investigate physicochemical, antioxidant activity, textural, and sensory properties attributes of developed gluten-free sponge cake containing chia seed (Salvia hispanica L.) flour (CHF) along with millet (Panicum miliaceum) and corn flour. Methods: The cake was produced using CHF (4, 8, 12, 16%; w/w) with the replacement of millet flour (MF), and 50% corn flour (CF) was used equally in all the samples. Results: Applied CHF significantly increased moisture, ash, protein, and fat content of gluten-free cakes (P&lt;0.05). Replacement of CHF with MF reduced specific volume (using colza grains) and porosity (using image processing method) by 64% and 76%, respectively. Texture analysis showed an increase in hardness in all the three-storage times with the addition of CHF. Color measurement indicated that CHF significantly reduced the amount of a*, and L* values of the crusts. Radical scavenging activity by DPPH was improved in a dose-dependent manner (P&lt;0.05). The lowest amount of CHF in cake formula had the highest score in sensory evaluation with verbal hedonic scale. Conclusion: Based on the results, the samples containing 4% CHF, 46% MF, and 50% CF had the most desirable texture and palatability with reasonable radical scavenging activity among developed gluten-free sponge cakes.

Intussusception in children with celiac disease

ABSTRACT Celiac disease (CD) is a chronic illness. Blood testing for tissue transglutaminase antibodies is the initial screening test for the diagnosis of CD, and upper gastrointestinal endoscopy and duodenal/jejunal biopsy are used to confirm CD. Intussusception (IS) is the process in which a proximal segment of the bowel invaginates through the lumen of a distal segment. The association between pediatric IS and CD has been described but is still not widely recognized. Herein, we report a case of IS as the first manifestation of CD in a child. A 3-year-old girl presented to the emergency department with a 1-week history of marked abdominal distention and lethargy, but there was no history of fever, bleeding per rectum, or jaundice. A second-degree relative had a family history of CD. Clinical examination: The patient was a lethargic child with pale conjunctiva and bilateral lower limb edema. She was a febrile and had a normal hemodynamic status. The adipose tissue was diminished throughout the patient’s body; her weight was 8 kg (&lt;5% weight percentile for girls), and her height was 81 cm (&lt;5% height percentile for girls). Laboratory results included the following: Hb of 9 g/dL, serum ferritin of 10 ng/mL (30–400 ng/mL), normal liver function test results except for hypoalbuminemia at 21 g/L (35–52 g/L), and low blood cholesterol of 0.94 g/L (1.54–2.01 g/L). The patient’s blood sugar level was 98 mg/dL, and her renal function test results were normal, with negative septic screening. Abdominal radiography revealed several air–fluid levels, suggestive of an obstruction in the small bowel. Abdominal ultrasonography revealed typical features confirming the diagnosis of IS. Abdominal computed tomography demonstrated an enteroenteric IS with no other signs of organic causes, such as lymphoma or other tumors. Based on the high index of suspicion of CD, a workup confirmed the diagnosis. A gluten-free diet [A1] was started during the hospital course, and the patient improved dramatically regarding her symptoms and was discharged home. In conclusion, this case highlights the association between IS and CD. Intussusception is an emergency condition and usually idiopathic. However, in atypical or recurrent typical presentations underlying causes, we should do proper investigations to initiate appropriate management. [A1]Abbreviations are generally avoided for terms that are not repeated in the text. In this case, this abbreviation is not used elsewhere in the Abstract. Hence, I have deleted the abbreviation. Categories: Pediatrics, Gastroenterology.

FOXP3 expression in duodenal mucosa: Unique role in pathogenesis and differential diagnosis of celiac disease

Forkhead box protein P3 (FOXP3) positive regulatory T lymphocytes are indispensable in the inflammatory homeostasis of the gastrointestinal tract and represent a significant subset of regulatory cells in inflammatory, autoimmune, and neoplastic conditions. This study aimed to elucidate the potential of FOXP3 expression in diagnosing and pathogenesis of celiac disease (CD) by comparing duodenal biopsies of CD cases with non-CD ones, some of which had increased intraepithelial lymphocytes (IELs). Two hundred sixty-one duodenal tissues of patients who applied to adult gastroenterology were reevaluated for immunohistochemical analysis. After excluding patients on a gluten-free diet (n = 44), the CD (n = 97) and non-CD (n = 120) groups were divided based on clinical complaints that could be associated with CD (intestinal or extraintestinal), serologic and histologic findings. The specific threshold was determined by receiver operating characteristic (ROC) analysis, and its relationship with CD diagnosis and clinicopathological data was evaluated. ROC analysis offered a “>14” cut-off value for diagnosing CD, for which AUC (Area Under The Curve): 0.968, p < 0.0001, sensitivity: 92.8, specificity: 91.7, positive and negative predictive values were 90 % and 94 %, respectively. High FOXP3 expression was associated with higher IEL, diagnosis of CD, more severe histologic (higher Marsh score) and endoscopic (scalloping) findings, and higher anti-tissue transglutaminase and anti-endomysium IgA titers (p < 0.001). It also correlates with IEL in CD patients and is unaffected by the increase in IEL and the presence of gastric Helicobacter Pylori in the non-CD group. FOXP3 is a sensitive and specific marker for diagnosing CD despite inflammatory conditions resulting from non-CD causes.

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.

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.