Survey-Based Study on Food Insecurity During COVID-19 for Households With Children on a Prescribed Gluten-Free Diet

Dietary assessments in individuals living with coeliac disease: key considerations

BACKGROUND

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 The latest draft guidance from the US Food and Drug Administration recommends that dietitians experienced in CeD management evaluate patients during the screening and treatment period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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

These guidelines cover nutritional and dietary assessment of patients with CeD, physical assessments, intake of oats, environmental considerations and the disease burden.

Food insecurity in a diverse community pediatric gastroenterology clinic: Screening strategies and insights

OBJECTIVES

We aimed to evaluate the prevalence of food insecurity (FI) in the community pediatric gastroenterology (GI) subspecialty clinic at Texas Children's Hospital (TCH) West Campus and to assess the utilization of services through our partnership with a local food bank.

METHODS

From July 1, 2023, to February 29, 2024, all patients seen in the pediatric GI clinic at TCH West Campus were screened for FI using the validated Hunger Vital Sign tool and given the opportunity to consult with a local food bank representative. A retrospective chart review was then performed on patients who completed the implemented FI screening process.

RESULTS

13.4% of the total patients screened positive for FI. Hispanic patients (p < 0.0001), patients with the preferred language of Spanish (p < 0.0001), those enrolled in Medicaid or Children's Health Insurance Program (p < 0.0001), and patients with obesity (body mass index ≥ 30.0, p = 0.0003) were more likely to screen positive for FI. Poor weight gain/failure to thrive and steatotic liver disease were significantly more common in those with FI (p < 0.0001 and p = 0.0003, respectively), while celiac disease, abdominal pain, and blood in stool were more common in those without FI (p = 0.0003, 0.0475, and 0.0404, respectively). As a result of our implemented FI screening process, 68.4% of those screening positive opted for resource referral, with 50.7% successfully receiving assistance in combating FI.

CONCLUSIONS

Identifying the potential impact of FI in common pediatric GI conditions calls for proactive screening and more holistic, patient-centered approaches in clinical practice.

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

OBJECTIVES

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).

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Identifying parentally perceived barriers for children with celiac disease to participate in elementary school meal programs

Several states have recently enacted laws permanently granting all public school students access to free breakfast and lunch. However, children with dietary restrictions, such as celiac disease (CeD), may encounter barriers to participation in these meal programs. We surveyed caregivers of school-aged children with CeD to study barriers to universal school meals. More than half of the children with CeD did not participate in school meal programs due to concerns about the cafeteria's ability to prepare gluten-free (GF) meals safely. Moreover, among those who were food insecure and GF food insecure, 50% had never consumed free school lunch and breakfast. Parental perception of nutritional quality, communication regarding GF options, and safety of school kitchens emerged as common obstacles to participation in these programs. Addressing these concerns is paramount to ensuring equitable access to nutritious meals for all students.

Food insecurity and other barriers to adherence to a gluten-free diet in individuals with coeliac disease and non-coeliac gluten sensitivity in the Netherlands: a mixed-methods study

OBJECTIVES

To determine the prevalence of food insecurity among individuals with coeliac disease (CeD) and non-coeliac gluten sensitivity (NCGS) in the Netherlands and explore its association with diet quality and other barriers to adherence to a gluten-free diet.

DESIGN

Mixed-method design comprising a survey and semistructured interviews.

SETTING

An online survey was distributed through social media accounts and the newsletter of the Dutch Association for Celiac Disease. Community-dwelling patients were surveyed and interviewed between June and November 2023.

PARTICIPANTS AND OUTCOME MEASURES

In total 548 adults with CeD and NCGS in the Netherlands who adhered to a gluten-free diet completed the survey including questions related to demographics, household food insecurity, financial stress and diet quality. Regression analyses were conducted to assess associations between food insecurity and diet quality, and between food insecurity and perceived difficulty of gluten-free eating and cooking. Additionally, semistructured interviews with eight food insecure adults with CeD were conducted.

RESULTS

The prevalence of food insecurity was 23.2%, with 10.4% reporting very low food security. Very low food insecurity was associated with poorer diet quality (β=-5.5; 95% CI=-9.2 to -1.9; p=0.003). Food insecurity was associated with heightened perceived barriers across multiple themes. In age, income and education adjusted models, compared with food secure participants, low food secure participants were more likely to experience difficulty regarding skills (OR=2.5; 95% CI=1.5 to 4.3; p≤0.001), social circumstances (OR=2.6; 95% CI=1.1 to 6.4; p=0.038), resources (OR=2.5; 95% CI=1.5 to 4.4; p=0.001) and naturally gluten-free products (OR=1.8; 95% CI=1.0 to 3.1; p=0.045) in gluten-free eating and cooking. Participants with very low food security were more likely to experience difficulty regarding skills (OR=4.4; 95% CI=2.4 to 8.1; p≤0.001) and resources (OR=4.2; 95% CI=2.3 to 7.8; p<0.001) in gluten-free eating and cooking. The qualitative analysis provided a deeper understanding of these challenges, including employed strategies to manage costs and insights into the mental burden associated with adhering to a gluten-free diet.

CONCLUSION

These findings indicate that food insecurity is prevalent among Dutch people with CeD and NCGS, with potential impact on diet quality and adherence to a gluten-free diet. It further provided insight into perceived barriers to adhering to a gluten-free diet among this target population. These challenges should be taken into account by clinicians and policy makers.

Utilizing Telemedicine Applications in Celiac Disease and Other Gluten-Free-Diet-Dependent Conditions: Insights from the COVID-19 Pandemic

BACKGROUND

Globally, approximately 1.4% of people have celiac disease (CD), induced by gluten sensitivity. If left untreated, it causes small intestinal inflammation and villous atrophy, which can result in failure to thrive, anemia, osteoporosis, malabsorption, and even malignancy. The only treatment option available is a gluten-free diet (GFD). Few studies have looked at the role and perception of telehealth in relation to CD and selective nutrition both before and after the COVID-19 pandemic.

AIM

Our goal was to screen and investigate the research conducted both before and after the COVID-19 pandemic concerning the utilization of telehealth applications and solutions in CD and other GFD-dependent circumstances.

METHODS

We employed a narrative review approach to explore articles that were published in scholarly journals or organizations between the years 2000 and 2024. Only English-language publications were included. PubMed and Google Scholar searches were mainly conducted using the following keywords: telemedicine, telehealth, telecare, eHealth, m-health, COVID-19, SARS-CoV-2, celiac disease, and gluten-free diet (GFD). Manual searches of the references in the acquired literature were also carried out, along with the authors' own personal contributions of their knowledge and proficiency in this field.

RESULTS

Only a few studies conducted prior to the COVID-19 outbreak examined the viewpoints and experiences of adult patients with CD with relation to in-person clinic visits, as well as other options such as telehealth. The majority of patients believed that phone consultations were appropriate and beneficial. Video conferencing and telemedicine became more popular during the COVID-19 pandemic, demonstrating the effectiveness of using these technologies for CD on a global basis. In recent years, urine assays for gluten identification have become accessible for use at home. These tests could be helpful for CD monitoring with telemedicine assistance.

CONCLUSIONS

The extended knowledge gathered from the COVID-19 pandemic is expected to complement pre-COVID-19 data supporting the usefulness of telemedicine even after the emergent pandemic, encouraging its wider adoption in standard clinical practice. The monitoring and follow-up of CD patients and other GFD-dependent conditions can greatly benefit from telemedicine.

Food insecurity screening practices in a pediatric gastroenterology population

Food insecurity is a rising concern for US households and leads to adverse child health outcomes. Pediatric gastroenterology providers are uniquely equipped to help guide families experiencing this challenge given their specialized training in nutritional support and dietary therapy for disease management. Hence, this study aimed to evaluate food insecurity screening practices from the perspectives of patient caregivers and healthcare providers in a tertiary pediatric gastroenterology practice. A survey was administered to 1279 caregivers and 121 providers. Of the 248 completed caregiver responses, 10%-15% reported being asked about food insecurity. Among the 36 healthcare provider responses, 53% expressed comfort in conducting food insecurity screening but only 14% routinely screened. The most cited barrier to screening was the lack of readily available patient resources. Further research is imperative to address these screening barriers and assess the impact of food insecurity screening and interventions on pediatric gastrointestinal health outcomes.

Coronavirus disease 2019 and gastrointestinal disorders in children

During the past 3 years, the coronavirus disease 2019 (COVID-19) pandemic has had a great impact on people all over the world. However, it has become evident that disease manifestations and severity differ across age groups. Most children have a milder disease course than adults but possibly more pronounced gastrointestinal (GI) symptoms. Given the child's developing immune system, the impact of COVID-19 on disease development may differ compared to adults. This study reviews the potential bi-directional relationship between COVID-19 and GI diseases in children, focusing on common pediatric conditions such as functional GI disorders (FGID), celiac disease (CeD), and inflammatory bowel disease (IBD). Children with GI diseases, in general, and CeD and IBD, in particular, do not seem to have an increased risk of severe COVID-19, including risks of hospitalization, critical care need, and death. While infections are considered candidate environmental factors in both CeD and IBD pathogenesis, and specific infectious agents are known triggers for FGID, there is still not sufficient evidence to implicate COVID-19 in the development of either of these diseases. However, given the scarcity of data and the possible latency period between environmental triggers and disease development, future investigations in this field are warranted.

Perceived barriers to gluten-free diet adherence by people with celiac disease in Greece

Background

In people with celiac disease (CD), many factors affect adherence to a gluten-free diet (GFD), and these may well differ among countries. In Greece, such data for the adult population are lacking. Thus, the present study aimed to explore the perceived barriers to compliance with a GFD that are faced by people with CD living in Greece, also taking into account the impact of the COVID-19 pandemic.

Methods

Nineteen adults (14 females) with biopsy-proven CD, mean age 39±9 years and median time on GFD 7 (Q1-Q3: 4-10) years, participated in 4 focus groups, conducted through a video conference platform during the period October 2020 to March 2021. Data analysis followed the qualitative research methodology.

Results

Eating outside the home was reported as the domain where most difficulties were faced: these were related to a lack of confidence in finding safe gluten-free food and to the lack of social awareness about CD/GFD. All participants highlighted the high cost of gluten-free products, which was mostly managed by receiving state financial support. Regarding healthcare, the vast majority of participants reported little contact with dietitians and no follow up. The COVID-19 pandemic eased the burden of eating out, as staying at home and allocating more time to cooking was experienced as a positive effect, although the shift to online food retailing impacted food variability.

Conclusion

The main impediment to GFD adherence seems to stem from low social awareness, while the involvement of dietitians in the healthcare of people with CD warrants further investigation.

COVID-19 and celiac disease: a review

The aim of this review is to broadly cover how the COVID-19 pandemic has affected individuals with celiac disease, including perceived risk, risk of contraction or severe infection, considerations regarding vaccination, access to gluten-free food during the pandemic, and possible long-term changes to the practice of celiac disease management spurred by the pandemic. While initially there was increased perceived risk about COVID-19 in the celiac disease population, studies have found that individuals with celiac disease are not at an increased risk of contracting or having a severe course compared to the general population. There is not yet evidence that COVID-19 infection will lead to an increase in celiac disease incidence, though more research on this topic with longer-term follow-up is necessary to make this determination. Limited access to in-person visits led to an increase in telemedicine, which was adopted swiftly by this patient population and may offer improved access in the long term. In summary, individuals with celiac disease do not appear to be at an increased risk of contracting COVID-19 or having a more severe disease course.

Increased Risk of Hospitalization in Celiac Disease With COVID-19 Infection Is Mitigated by Vaccination

BACKGROUND

We sought to describe clinical characteristics of celiac disease (CD) patients infected with coronavirus disease 2019 (COVID-19) and estimate hospitalization risk, intensive care unit (ICU) requirement, mortality, and thrombosis, and the impact of vaccination on these outcomes.

METHODS

We performed a single-center, retrospective cohort study comparing biopsy-proven CD patients with a matched sample of non-CD (referent) patients diagnosed with COVID-19 between March 2020 and January 2022. Matching ensured 2 referent patients for every 1 CD patient by age, sex, ethnicity, and COVID-19 diagnosis date. We also adjusted for general and celiac-specific comorbidity. The primary outcome was hospitalization. Secondary outcomes included ICU requirement, mortality, and thrombosis. We also compared these outcomes between vaccinated and unvaccinated individuals.

RESULTS

We included 330 patients: 110 with CD (mean age 47 years, 83% female) and 220 matched referents. Hospitalization occurred in 27 CD patients (24%) and 25 referent patients (11%) (hazard ratio, 2.10; 95% confidence interval, 1.21-3.65; P = .009). Vaccination was associated with significantly decreased risk of hospitalization (hazard ratio, 0.53; 95% confidence interval, 0.31-0.93; P = .026). Four unvaccinated CD patients and 2 unvaccinated referent patients required ICU. No mortality occurred among CD patients, and 2 referent patients died. No thrombosis occurred in either group.

CONCLUSIONS

CD patients with COVID-19 have a higher risk of hospitalization compared with non-CD referents. This risk is mitigated by vaccination in CD patients as it is in non-CD referents. ICU requirement occurred only in unvaccinated CD patients, and no CD patient died. Vaccination against COVID-19 should be strongly recommended in patients with CD as it is for non-CD patients in the general population.