Celiac disease: evaluation of the diagnosis and dietary compliance in Canadian children

Maintaining a gluten-free diet is associated with quality of life in youths with type 1 diabetes and celiac disease

AIM

Conflicting findings have been reported on whether in youths, the double diagnosis of type 1 diabetes (T1D) and celiac disease (CD) substantially impacts quality of life QoL, compared to subjects with T1D only.

METHODS

In this study, 86 youths with double diagnosis and their parents were compared to 167 subjects with T1D only. QoL was assessed through the KINDL questionnaire. Anti-tissue transglutaminase antibodies and dietary interviews evaluated the degree of maintaining a gluten-free diet (GFD).

RESULTS

We found that having CD in addition to T1D has little effect on overall QoL. However, analysis of the degree of maintaining GFD revealed significantly lower total QoL scores in groups with T1D + CD not strictly maintaining GFD compared to T1D only (p = 0.0014). The multivariable linear regression model confirmed the importance of maintaining GFD on QoL in subjects (p = 0.0066) and parents (p = 0.023).

CONCLUSION

The coexistence of T1D and CD and the adoption of a GFD resulted in poor QoL levels, as in youth as in their parents, when difficulties implementing the GFD are present. Psychological support should consider the importance of maintaining GFD not only to prevent potential complications in the future but also to improve actual QoL in different subdomains.

Gluten-free diet for pediatric patients with coeliac disease: A position paper from the ESPGHAN gastroenterology committee, special interest group in coeliac disease

BACKGROUND AND OBJECTIVE

Coeliac disease is a chronic, immune-mediated disorder for which the only treatment consists of lifelong strict adherence to gluten-free diet (GFD). However, there is a lack of evidence-based guidelines on the GFD dietary management of coeliac disease. This position paper, led by the Special Interest Group in coeliac disease of the European Society of Pediatric, Gastroenterology Hepatology, and Nutrition, supported by the Nutrition Committee and the Allied Health Professionals Committee, aims to present evidence-based recommendations on the GFD as well as how to support dietary adherence.

METHODS

A wide literature search was performed using the MeSH Terms: "diet, gluten free," "gluten-free diet," "diets, gluten-free," "gluten free diet," and "coeliac disease" in Pubmed until November 8th, 2022.

RESULTS

The manuscript provides an overview of the definition of the GFD, regulations as basis to define the term "gluten-free," which foods are naturally gluten-free and gluten-containing. Moreover, it provides recommendations and educational tips and infographics on suitable food substitutes, the importance of reading food labels, risk of gluten cross-contact at home and in public settings, nutritional considerations as well as factors associated to dietary adherence based on available evidence, or otherwise clinical expertise.

CONCLUSIONS

This position paper provides guidance and recommendations to support children with coeliac disease to safely adhere to a GFD.

Diagnostic Delay of Celiac Disease in Childhood

Importance

The extent and factors associated with risk of diagnostic delay in pediatric celiac disease (CD) are poorly understood.

Objectives

To investigate the diagnostic delay of CD in childhood, and to assess factors associated with this delay.

Design, Setting, and Participants

Multicenter, retrospective, cross-sectional study (2010-2019) of pediatric (aged 0-18 years) patients with CD from 13 pediatric tertiary referral centers in Italy. Data were analyzed from January to June 2023.

Main Outcomes and Measures

The overall diagnostic delay (ie, the time lapse occurring from the first symptoms or clinical data indicative of CD and the definitive diagnosis), further split into preconsultation and postconsultation diagnostic delay, were described. Univariable and multivariable linear regression models for factors associated with diagnostic delay were fitted. Factors associated with extreme diagnostic delay (ie, 1.5 × 75th percentile) and misdiagnosis were assessed.

Results

A total of 3171 patients with CD were included. The mean (SD) age was 6.2 (3.9) years; 2010 patients (63.4%) were female; and 10 patients (0.3%) were Asian, 41 (1.3%) were Northern African, and 3115 (98.3%) were White. The median (IQR) overall diagnostic delay was 5 (2-11) months, and preconsultation and postconsultation diagnostic delay were 2 (0-6) months and 1 (0-3) month, respectively. The median (IQR) extreme overall diagnostic delay (586 cases [18.5%]) was 11 (5-131) months, and the preconsultation and postconsultation delays were 6 (2-120) and 3 (1-131) months, respectively. Patients who had a first diagnosis when aged less than 3 years (650 patients [20.5%]) showed a shorter diagnostic delay, both overall (median [IQR], 4 [1-7] months for patients aged less than 3 years vs 5 [2-12] months for others) and postconsultation (median [IQR], 1 [0-2] month for patients aged less than 3 years vs 2 [0-4] months for others). A shorter delay was registered in male patients, both overall (median [IQR], 4 [1-10] months for male patients vs 5 [2-12] months for female patients) and preconsultation (median [IQR], 1 [0-6] month for male patients vs 2 [0-6] months for female patients). Family history of CD was associated with lower preconsultation delay (odds ratio [OR], 0.59; 95% CI, 0.47-0.74) and lower overall extreme diagnostic delay (OR, 0.75; 95% CI, 0.56-0.99). Neurological symptoms (78 patients [21.5%]; OR, 1.35; 95% CI, 1.03-1.78), gastroesophageal reflux (9 patients [28.1%]; OR, 1.87; 95% CI, 1.02-3.42), and failure to thrive (215 patients [22.6%]; OR, 1.62; 95% CI, 1.31-2.00) showed a more frequent extreme diagnostic delay. A previous misdiagnosis (124 patients [4.0%]) was more frequently associated with gastroesophageal reflux disease, diarrhea, bloating, abdominal pain, constipation, fatigue, osteopenia, and villous atrophy (Marsh 3 classification).

Conclusions and Relevance

In this cross-sectional study of pediatric CD, the diagnostic delay was rather short. Some factors associated with risk for longer diagnostic delay and misdiagnosis emerged, and these should be addressed in future studies.

Celiac Disease in Moroccan Children: Diagnostic Characteristics and Determinants of Diagnosis Delay

Advances in the field of celiac disease have led to a better understanding of the disease, but it remains underdiagnosed and poses a daily challenge to clinicians to make a timely diagnosis. This study aims to analyze and describe diagnosis characteristics, diagnosis delay, and the factors influencing this delay in Moroccan children. Our study included 324 children diagnosed during the study period from January 01, 2010, to December 30, 2019, at the Department of Pediatrics, Hassan II University Hospital in Fez, Morocco. Data were collected using a collection grid and then analyzed using SPSS 26 software (IBM Corp., Armonk, NY). The results showed a female predominance (n=197, 60.8%), with a diagnosis age of 73.8±46.8 months. The mean age onset of symptoms was 51.3±41.2 months, and the diagnosis delay was 22.2±22.6 months, with only 32.7% (n=106) diagnosed less than 12 months after symptom onset. The most common consultation reason was diarrhea (n=149, 46%) and growth delay (n=105, 32.4%) and 50.5% (n=98) of parents consulted a pediatrician first. The three clinical, serologic, and histologic criteria made it possible to agree on the diagnosis, with the clinical profile dominated by the digestive form at 84.9% (n=279), serologic with the presence of IgA transglutaminase antibodies (95.7%; n=310), and histologic with villous atrophy at 91.7% (n=297). Unfortunately, 14.8% (n=48) of the children were diagnosed with a celiac crisis. The multivariate logistic regression analysis showed that as symptoms onset age increased, so did the risk of late diagnosis (OR=0.96, 95% CI: 0.94 to 0.97, p<0.001). Age of diagnosis was also associated with delayed diagnosis (OR=19.68, 95% CI: 8.77 to 44.15, p<0.001). The combination of these variables and the diagnosis delay argues in favor of adopting a diagnosis strategy that includes raising awareness among healthcare professionals of the need to identify typical and atypical cases early in order to reduce the adverse effects of late diagnosis and the complications that can result. This methodology for improving diagnoses may also unearth previously unknown aspects of celiac disease in Moroccan children.

A Clinical Investigation on ADHD-Traits in Childhood Celiac Disease

OBJECTIVE

There are no definitive results about either the presence of exact comorbidity between celiac disease (CD) and attention-deficit/hyperactivity disorders (ADHD) or etiology. We intend to screen ADHD-related cognitive and behavioral traits in children with biopsy-proven CD and investigate the possible association of these traits with certain vitamin levels, body-mass index, and gluten-free diet (GFD) compliance.

METHOD

A total of 85 children with biopsy-proven CD (the ages of 8-18 years) were compared with age and sex-matched 72 healthy controls in terms of demographics, psychiatric symptoms, certain vitamin levels, and anthropometric measurements.

RESULTS

ADHD-like cognitive issues, such as inattention and learning difficulties, as well as psychosomatic symptoms and poor prosocial behavior, were all associated with GFD noncompliance in childhood CD.

CONCLUSION

Untreated CD may predispose to ADHD-resembling symptoms. Physicians should be aware of the probability of ADHD misdiagnosing due to ADHD-resembling cognitive and behavioral traits in untreated CD.

Promoting Effective Self-Management of the Gluten-Free Diet: Children's and Adolescents' Self-Generated Do's and Don'ts

Celiac disease (CD) is a chronic health condition treated by managing a lifelong, strict, and demanding gluten-free diet. Managing the diet entails effective use of self-management skills. This study aimed to explore self-generated procedures children and adolescents with CD in Israel perform when participating in food-related activities considering their self-management skills and health requirements. Participants included children and adolescents with CD, aged 8 to 18 years, that had been diagnosed more than 6 months prior to the study. Parents completed a demographic questionnaire and reported their child's constancy in adherence to the diet. Children and adolescents were asked to share the things they do themselves to prepare for participating in the various activities. Responses were qualitatively analyzed, and common themes were identified and categorized using directed analysis. Participants were 126 children and adolescents (M_age = 12.33 yr, SD = 2.85), 67.5% of whom had been diagnosed more than 3 yr prior to the study. Based on parents' reports, almost all (97.6%) participants "always adhered" to the diet. A total of 10 categories were defined from the qualitative responses describing 125 do and don't actions used by the children and adolescents to self-manage their diet. The do and don't actions encompass cognitive planning far beyond the mere act of avoiding gluten. These actions can serve as an initial database of suggested strategies to support acquiring independent self-management. Understanding the cognitive complexity of routinely carrying out the diet while actively participating in everyday activities can assist health professionals in building support and intervention programs, promoting effective self-management, and facilitating optimal adherence to the diet.

The impact of gluten-free diet on growth, metabolic control and quality of life in youth with type 1 diabetes and celiac disease: A systematic review

AIMS

To evaluate the impact of gluten free diet (GFD) on growth, metabolic control and quality of life in children and adolescents with type 1 diabetes (T1D) and celiac disease (CD).

METHODS

A systematic search was performed including studies published in the last 15 years. PICOS framework was used in the selection process and evidence was assessed using the GRADE system.

RESULTS

Overall, studies comparing youth with T1D + CD on GFD to those with T1D only, showed no significant differences in growth parameters, HbA1c, number of episodes of hypoglycemia, total daily insulin doses. Studies assessing the effect of GFD introduction showed stable BMI and HbA1c. Only two studies assessed QoL of life, which was not different between T1D + CD vs T1D only youth, as well as pre- and post-CD diagnosis and introduction of GFD.

CONCLUSION

This systematic review, including only studies of moderate-high evidence quality level and reporting data on objectively assessed adherence to GFD, highlights that adherence to GFD in youth with T1D + CD leads to regular growth, stable BMI, without any negative effect on HbA1c and insulin requirements. Although assessed in few studies, lipid profile and QoL improved with the introduction of GFD.

Rotavirus vaccination is not associated with incident celiac disease or autoimmune thyroid disease in a national cohort of privately insured children

Rotavirus infection is a potential trigger for autoimmune diseases, and previous reports note associations between rotavirus vaccination and type 1 diabetes. In this report, we examine the association between rotavirus vaccination and autoimmune diseases associated with type 1 diabetes: celiac disease and autoimmune thyroiditis. We conducted a retrospective cohort study using de-identified claims data (Optum Clinformatics^® Data Mart). Eligible infants were born between 2001 and 2018 and continuously enrolled from birth for at least 365 days (n = 2,109,225). Twenty-nine percent (n = 613,295) of infants were born prior to the introduction of rotavirus vaccine in 2006; 32% (n = 684,214) were eligible for the vaccine but were not vaccinated; 9.6% (n = 202,016) received partial vaccination, and 28.9% received full vaccination (n = 609,700). There were 1379 cases of celiac disease and 1000 cases of autoimmune thyroiditis. Children who were born prior to the introduction of rotavirus vaccine in 2006 had lower risk of celiac disease compared to unvaccinated children born after 2006 (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.59, 0.85). However, children who were partially vaccinated (HR 0.90, 95% CI 0.73, 1.11) or fully vaccinated (HR 1.03, 95% CI 0.88, 1.21) had similar risk to eligible, unvaccinated children. Risk of autoimmune thyroiditis was similar by vaccination status. We conclude that rotavirus vaccination is not associated with increased or decreased risk for celiac disease or autoimmune thyroiditis.

Review article: Becoming and being coeliac-special considerations for childhood, adolescence and beyond

Classically considered a disease of early childhood characterised by malabsorption and failure to thrive, coeliac disease is now recognised to arise in genetically susceptible individuals at any age. Although permissive HLA genotypes are the strongest predictor of coeliac disease, they are not sufficient. Several prospective cohort studies enrolling genetically at-risk infants have investigated the role of potential triggers of coeliac disease autoimmunity, such as timing of gluten introduction, viral infections and dietary patterns. Much less is known about triggers of coeliac disease in adulthood. Better understanding of factors leading to coeliac disease may be helpful in the management of those with potential coeliac disease (elevated serum celiac antibodies without villous atrophy in the small intestine), many of whom initiate a gluten-free diet without demonstration of villous atrophy. There are a range of clinical presentations of celiac disease in childhood and patterns of coeliac serology, including fluctuation and spontaneous reversion on a gluten-containing diet, vary. There is a current debate over best strategies to manage adults and children with potential coeliac disease to avoid over-treatment and under-treatment. Childhood and adolescence carry unique issues pertaining to the diagnosis and management of coeliac disease, and include nutrition and growth, rescreening, repeat biopsy, dietary adherence concerns and transition to adult care. In conclusion, while coeliac disease has similar pathogenesis and general clinical manifestations in paediatric and adult populations, diagnostic and management approaches need to adapt to the developmental stages.

Evaluation of a paediatric gluten-free food guide by children and youth with coeliac disease, their parents and health care professionals

There are currently no universal evidence-based nutrition guidelines that address the gluten-free (GF) diet for children/youth (4-18 years). A GF food guide was created to help children/youth with coeliac disease (CD) and their families navigate the complexities of following a GF diet. Guide formation was based on pre-guide stakeholder consultations and an evaluation of nutrient intake and dietary patterns. The study objective was to conduct an evaluation on guide content, layout, feasibility and dissemination strategies from end-stakeholder users (children/youth with CD, parents/caregivers and health care professionals). This is a cross-sectional study using a multi-method approach of virtual focus groups and an online survey to conduct stakeholder evaluations. Stakeholders included children/youth (4-18 years), their parents/caregivers in the coeliac community (n 273) and health care professionals (n 80) with both paediatric and CD experience from across Canada. Thematic analysis was performed on focus group responses and open-ended survey questions until thematic saturation was achieved. χ² and Fisher's exact statistical analyses were performed on demographic and close-ended survey questions. Stakeholders positively perceived the guide for content, layout, feasibility, ethnicity and usability. Stakeholders found the material visually appealing and engaging with belief that it could effectively be used in multi-ethnic community and clinical-based settings. Guide revisions were made in response to stakeholder consultations to improve food selection (e.g. child-friendly foods), language (e.g. clarity) and layout (e.g. organisation). The evaluation by end-stakeholders provided practical and patient-focused feedback on the guide to enable successful uptake in community and clinical-based settings.

An Evaluation of Nutritional Status and Problems with Dietary Compliance in Polish Patients with Celiac Disease

Celiac disease (CD, enteropathy) is a genetic autoimmune disease (abnormal immune response that attacks healthy tissues) associated with gluten intolerance. The aim of this study was to evaluate and monitor the nutritional status of CD patients, explore the problems associated with diet planning and dietary adherence among children and adults, and assess the impact of these factors on the persistence of CD symptoms. This study was carried out as part of the project entitled “A gluten-free diet without obstacles—eating well and healthy” (POWR 03.01.00-00-T153/18), conducted in Lublin Voivodeship. The study involved 87 persons, including 23 children younger than 18. At the beginning of the study and after nine months, all adult participants (older than 18) were subjected to a body composition analysis with the SECA mBCA 515 analyzer. During the project, the participants attended three consultations with a dietician. During each visit, the subjects’ body weight, nutritional status and diets were evaluated; their diets were modified, and problems relating to dietary adherence were resolved. The initial body composition analysis revealed a risk of sarcopenic obesity in 30% of adult participants, in particular in women (p = 0.003) older than 45 (p = 0.001). The risk of being underweight was diagnosed in 25% of the subjects, in particular, in women younger than 35 (p = 0.0023) and in participants who had been affected by short stature and underweight in childhood, i.e., before CD diagnosis (p = 0.0024). The analysis demonstrated that patients with gastrointestinal symptoms (abdominal pain, diarrhea, vomiting) of CD were significantly more likely to avoid even accidental exposure to gluten and were more likely to strictly follow GFD recommendations (1.97; 95CI:1.56–2.12, p = 0.0001) and safety guidelines when preparing meals at home (1.76; 95CI: 1.34–192, p = 0.0023). Parents, in particular, parents of toddlers and preschoolers who are at significantly higher risk of CD, adhered strictly to dietary guidelines and did not allow for any exceptions when preparing meals (1.88; 95CI: 1.53–2.09, p = 0.001). Persons at risk of malnutrition were also far less likely to deliberately choose gluten-containing foods (0.74; 95CI: 0.53–0.91, p = 0.021), in particular, patients with Marsh type 3a and 3b classification (p = 0.01) and persons whose intestinal histology scores did not fully improve after switching to a GFD. An assessment of the effectiveness of diet therapy based on the phase angle revealed that dietary recommendations had a positive impact on patients who had been recently diagnosed with CD. In all age groups, the main problem was accidental exposure to gluten, in particular in foods that were not labeled with the crossed grain symbol. A comparative analysis of CDAT questionnaires revealed that dietary advice on eating out significantly improved adherence to a GFD and reduced the frequency of unintentional gluten exposure in all age groups.

Structural validation and dyadic child-parent measurement invariance of the celiac disease quality of life questionnaire

OBJECTIVE

The celiac disease quality of life questionnaire (CDDUX) is used widely in numerous languages worldwide. However, it's structural and construct validity and child-parent invariance had not been thoroughly examined. The objective of this study was to examine the psychometric properties of the 12-item CDDUX and the extent to which it meets the acceptable requirements of reliability and structural and convergent validity, as well as its child-parent invariance.

METHODS

In this cross-sectional study, 126 dyads of children aged 8-18 years and their parents completed the Hebrew version self-report and parent-proxy report CDDUX. Recently developed methods to examine psychometric properties and to measure invariance of dyadic samples were used while properly accounting for nonindependence in measurement patterns.

RESULTS

A three-factor structure, each with sufficient internal consistency, is confirmed for both children and parents. Removing a single indicator of the diet subscale resulted in full configural (χ2(181) = 202.277, P > 0.05, RMSEA = 0.026) and metric (χ2(189) = 209.543, P > 0.05, RMSEA = 0.043) invariance of the measure between children and parents. However, this occurred only in partial-scalar (χ2(198) = 229.813, P > 0.05, RMSEA = 0.031) and uniqueness invariance, which is nevertheless sufficient for meaningful comparison between the groups.

CONCLUSION

Overall, with minor modifications, the Hebrew version of the CDDUX was found to be a valid measure of children's celiac-related quality of life when measured across children's self-reports and parent-proxy reports. The CDDUX provides meaningful measurement and allows child-parent comparison.

Barriers of Adherence to a Gluten-Free Diet in Iranian Adults With Celiac Disease

This cross-sectional study aimed to evaluate and classify barriers to adherence to the gluten-free diet in 137 Iranian adults with celiac disease. We used a 23-point Likert questionnaire and exploratory factor analysis to identify and classify the barriers. Adherence to gluten-free diet was assessed by measuring the serum level of anti-tTG-IgA. The correlation between the barriers and adherence to gluten-free diet was assessed using logistic regression. A total of 117 subjects completed the study. Seven factors were extracted: "gluten-free diet restrictions," "self-awareness and social awareness," "psychological barriers," "education," "situational barriers and gatherings," "lack of access/labeling," and "cost." There was a significant correlation between the situational barriers and gatherings and nonadherence to the diet in the adjusted model (odds ratio = 1.63; 95% confidence interval [1.03, 2.54], p = .03). Nutritionists and physicians should consider these barriers when consulting patients with celiac disease.

Celiac disease in children: A review of the literature

Celiac disease is an immune-mediated systemic disease triggered by intake of gluten in genetically susceptible individuals. The prevalence of celiac disease in the general population is estimated to be 1% in the world. Its prevalence differs depending on geographical and ethnic variations. The prevalence of celiac disease has increased significantly in the last 30 years due to the increased knowledge and awareness of physicians and the widespread use of highly sensitive and specific diagnostic tests for celiac disease. Despite increased awareness and knowledge about celiac disease, up to 95% of celiac patients still remain undiagnosed. The presentations of celiac disease have significantly changed in the last few decades. Classical symptoms of celiac disease occur in a minority of celiac patients, while older children have either minimal or atypical symptoms. Serologic tests for celiac disease should be done in patients with unexplained chronic or intermittent diarrhea, failure to thrive, weight loss, delayed puberty, short stature, amenorrhea, iron deficiency anemia, nausea, vomiting, chronic abdominal pain, abdominal distension, chronic constipation, recurrent aphthous stomatitis, and abnormal liver enzyme elevation, and in children who belong to specific groups at risk. Early diagnosis of celiac disease is very important to prevent long-term complications. Currently, the only effective treatment is a lifelong gluten-free diet. In this review, we will discuss the epidemiology, clinical findings, diagnostic tests, and treatment of celiac disease in the light of the latest literature.

The Experience of a Gluten-free Diet in Children with Type 1 Diabetes and Celiac Disease

Objective

This study examined overall self-reported adherence to gluten-free diet (GFD) in children with type 1 diabetes and celiac disease (T1DCD) compared to children with celiac disease (CD). Secondary objectives included gaining insight into self-reported symptoms, barriers to adherence, and experience of a GFD between groups.

Methods

Children &lt;18 years old who had been seen at BC Children’s Hospital for T1DCD or CD were invited to participate in a web-based questionnaire and medical record review.

Results

A total of 26 children with T1DCD and 46 children with CD participated in the study. The groups’ demographics and symptoms of CD were similar; however, a greater proportion of those with T1DCD were asymptomatic at diagnosis (T1DCD 27%; CD 7%; P = 0.016). Overall adherence to a GFD was high in both groups (T1DCD 92%; CD 100%; P = 0.38) but those with T1DCD reported a significantly less positive effect on their health (P = 0.006) and a significantly greater negative effect on activities from a GFD (P = 0.03). Children with T1DCD reported more significant barriers to eating gluten-free at home and at restaurants, specifically with social pressure, cost and taste compared to those with CD only.

Conclusion

Children with T1DCD face specific barriers in adherence that are more impactful compared with children living with CD. These children are more often asymptomatic at diagnosis, and they go on to experience different impacts of a GFD spanning across home and social settings. Given the complexity of having a dual diagnosis, CD care should be tailored specifically to children living with T1DCD.

Impact of a Gluten-Free Diet on Quality of Life and Health Perception in Patients With Type 1 Diabetes and Asymptomatic Celiac Disease

CONTEXT

Celiac disease (CD) is a common comorbidity seen in patients with type 1 diabetes (T1D) and is frequently asymptomatic. As chronic conditions requiring significant lifestyle changes, there are limited reports assessing changes in health-related quality of life (HRQoL) during transition to a gluten-free diet (GFD) in patients with T1D who are asymptomatic for CD.

OBJECTIVE

This work aims to prospectively assess HRQoL and health perception in children and adults with T1D and asymptomatic CD after random assignment to GFD vs usual diet.

METHODS

Patients with T1D aged 8 to 45 years without CD symptoms were serologically screened for CD, with positive results confirmed with intestinal biopsy. Participants were randomly assigned in an open-label fashion to a GFD or gluten-containing diet (GCD) for 12 months. Generic and diabetes-specific HRQoL and self-perceived wellness (SPW) were assessed longitudinally.

RESULTS

A total of 2387 T1D patients were serologically screened. CD was biopsy-confirmed in 82 patients and 51 participants were randomly assigned to a GFD (N = 27) or GCD (N = 24). Excellent adherence to the assigned diets was observed. Overall, no changes in generic (P = .73) or diabetes-specific HRQoL (P = .30), or SPW (P = .41) were observed between groups over 12 months. Hemoglobin A1c (HbA1c) and gastrointestinal symptoms were consistent predictors of HRQoL and SPW.

CONCLUSION

HRQoL and SPW were not significantly affected by the adoption of a GFD over 12 months, but worsened with symptom onset and increased HbA1c. Our findings indicate that transition to a GFD can be made successfully in this population without adversely affecting quality of life.

Celiac disease: Understandings in diagnostic, nutritional, and medicinal aspects

Celiac disease (CD) is characterized by clinical polymorphism, with classic, asymptomatic or oligosymptomatic, and extra-intestinal forms, which may lead to diagnostic delay and exposure to serious complications. CD is a multidisciplinary health concern involving general medicine, pediatric, and adult gastroenterology, among other disciplines. Immunology and pathology laboratories have a fundamental role in diagnosing and monitoring CD. The diagnosis consists of serological testing based on IgA anti-transglutaminase (TG2) antibodies combined with IgA quantification to rule out IgA deficiency, a potential misleading factor of CD diagnosis. Positive TG2 serology should be corroborated by anti-endomysium antibody testing before considering an intestinal biopsy. Owing to multiple differential diagnoses, celiac disease cannot be confirmed based on serological positivity alone, nor on isolated villous atrophy. In children with classical signs or even when asymptomatic, with high levels of CD-linked markers and positive HLA DQ2 and/or DQ8 molecules, the current trend is to confirm the diagnosis on basis of the non-systematic use of the biopsy, which remains obligatory in adults. The main challenge in managing CD is the implementation and compliance with a gluten-free diet (GFD). This explains the key role of the dietitian and the active participation of patients and their families throughout the disease-management process. The presence of the gluten in several forms of medicine requires the sensitization of physicians when prescribing, and particularly when dispensing gluten-containing formulations by pharmacists. This underlines the importance of the contribution of the pharmacist in the care of patients with CD within the framework of close collaboration with physicians and nutritionists.

The Knowledge About Celiac Disease Among Healthcare Professionals and Patients in Central Europe

OBJECTIVES

Celiac disease (CD) remains undiagnosed for a long time in many adult and pediatric patients. We assessed the knowledge about CD among healthcare professionals (HCPs) and CD patients in Central Europe (CE).

METHODS

HCPs and CD patients from 5 CE countries were asked to complete the web-based questionnaire about CD. The questions were divided into subsections on epidemiology, clinical presentation, diagnostics, treatment, and follow-up. Achieved scores of different specialists managing patients with CD were compared and regional differences in patients' knowledge were analyzed.

RESULTS

Questionnaire was completed by 1381 HCPs and 2262 CD patients or their caregivers from Croatia, Hungary, Germany, Italy, and Slovenia. Mean score achieved by HCPs was 50.9%, and by CD patients 56.4%. Pediatric gastroenterologists scored the highest (69.4%; P < 0.001). There were significant differences in knowledge of patients from different CE regions with German participants scoring the highest (58.3%). Members of CD societies scored higher compared with nonmembers (mean score 58% vs 53.2%; P < 0.001) and patients diagnosed less than 5 years ago scored higher compared with those diagnosed more than 10 years ago (mean score 57.3% vs 54.6%; P < 0.001).

CONCLUSIONS

The knowledge about CD among HCPs and CD patients is not satisfactory. Further awareness-raising and learning activities are needed to improve HCPs' knowledge and to minimize the number of unrecognized patients and unnecessary diagnostic delays. Patients should be better informed about their disease to reach higher compliance with the gluten-free diet.

The Healthy Gluten-Free Diet: Practical Tips to Prevent Metabolic Disorders and Nutritional Deficiencies in Celiac Patients

The gluten-free diet (GFD) is the cornerstone treatment for coeliac disease (CD). However, a healthy GFD is more complex than the only exclusion of gluten-containing foods. Most celiac patients do not receive nutritional advice and tend to consume industrial gluten-free products (GFPs), which often lack fiber, vitamins, and other micronutrients while being rich in saturated fats and refined sugars. This review focuses on the main potential metabolic disorders and nutritional deficiencies in CD patients at diagnosis and dissects the main nutritional and metabolic issues due to a non-balanced GFD. Nutritional tips to achieve an adequate dietary approach in CD are provided. We also compared the main nutritional components of naturally gluten-free cereals (including pseudocereals) to give an exhaustive overview of the possible healthy alternatives to processed GFPs. Clinicians and dietitians should be systematically involved in the diagnosis of CD to monitor the appropriateness of GFD and the patient’s nutritional status over time.

Morphological evaluation of bulb and distal duodenal biopsies in pediatric celiac disease with clinical and serological correlation

Background and Aims

An early correct diagnosis of celiac disease (CD) is fundamental to reversal of symptoms and prevention of complications in pediatric patients. Our aim was to evaluate the role of duodenal bulb biopsy by studying the degree of mucosal damage in the duodenal bulb (D1) and second part of the duodenum (D2) and correlating the findings with serum IgA anti-tTG levels.

Settings and Design

Pediatric patients (age <18 years) with clinical suspicion of CD and positive IgA anti-tTG titers were consecutively enrolled over a period of one year. Demographic variables, anthropometry, clinical history, laboratory values and endoscopic findings were studied. Endoscopic biopsies obtained from D1 and D2 were evaluated and assigned histopathologic grades that were correlated with serology.

Statistical Analysis Used

Descriptive statistics were employed.

Results

A total of 37 clinically suspected cases of pediatric CD were studied. The mean age was 6.7 years and the M:F ratio was 1:1.3. Thirty-two (32) children had varying degrees of growth impairment. Eight (8) children had only extra-intestinal symptoms. Thirty (30) children were anemic, hypoalbuminemia was seen in five (5) children while transaminitis was seen in two (2) children. IgA anti-tTG >300 U/ml was associated with Marsh-Oberhuber Grade 3 morphology at atleast one site.

Conclusions

Low positive serology values should be confirmed by histopathology. Biopsies should be taken even in the absence of endoscopic abnormality. Additional D1 biopsies placed in a separate container can increase the diagnostic yield.

Evaluation of Daily Lives of Children and Adolescents with Celiac Disease and Nursing Approaches

The incidence of celiac disease has been increasing in recent years. Celiac disease is an autoimmune enteropathy that emerges mostly in the childhood period. This disorder is a chronic condition of the small intestine due to gluten intake in individuals with genetic predisposition. In the treatment of celiac disease, gluten-free diet therapy is applied. However, the adaptation process to the diet may create difficulties for patients. Compliance with diet is much more difficult among patients with celiac disease in childhood and adolescence than in adult patients. Children and adolescents face distinct difficulties in their homes, at school, and in their social lives. Besides following dietary treatment, children and adolescents living with celiac disease need peer support to manage their daily routines. In this article, we aimed to discuss the problems experienced by children and adolescents living with celiac disease and nursing approaches to these problems.

Health-related quality of life using specific and generic questionnaires in Spanish coeliac children

Background

We aimed to compare the perception of health-related quality of life (HRQOL) and related factors in Spanish coeliac children and their parents, using two questionnaires, the generic KIDSCREEN-52 and the specific the Celiac Disease DUX (CDDUX), and to assess the correlation between them.

Methods

Coeliac children, aged 8-18, who are members of the Madrid Coeliac Association (MCA) and their parents, answered the Spanish version of the CDDUX and KIDSCREEN-52 questionnaires via e-mail. CDDUX was answered by 266 children and 428 parents and KIDSCREEN-52 by 255 children and 387 parents. Linear regression models were fitted to evaluate the association of demographic and clinical factors with HRQOL scores. CDDUX scores were compared with the subjective perception of health status assessed by the first question of KIDSCREEN-52. The correlation between the questionnaires was analysed.

Results

We found that the main factors that negatively affected HRQOL were having social or economic difficulties associated with following the diet and having transgression-related symptoms. The maximum correlation between the questionnaires was 0.309 and − 0.254 in parents and children respectively.

Conclusions

Although there is a poor correlation between the two questionnaires, both agreed that the main concerns of the respondents were related to the social and economic difficulties of following the diet. It would be interesting to use both types of questionnaires in order to perform a more complete assessment of HRQOL in coeliac children.

Trial registration

Not applicable.

An Overview of International Guidelines Focusing on the Long-Term Management of Coeliac Disease

Coeliac disease (CD) is an autoimmune disorder characterised by, but not isolated to, intestinal enteropathy in response to exposure to gluten in predisposed individuals. The mainstay of the management of CD is a strict, lifelong gluten free diet (GFD). Although numerous publications have focused on pathways to guide the diagnosis of CD, recommendations for the care of patients after diagnosis are less well established. This manuscript aimed to review the available published guidelines focusing on the ongoing management and follow-up of patients after diagnosis with CD and commencement of a GFD. All available guidelines recommend strict adherence to a GFD with most recommending an annual review by a specialist clinician, focusing on symptoms, adherence and growth. In addition to monitoring micronutrient status, some guidelines suggest monitoring bone mineral density in at-risk groups and screening for other autoimmune disorders. The benefit of multi-disciplinary input was outlined in many guidelines, in particular, the involvement of a specialist dietitian to provide nutritional counselling and support. While the available guidelines provide key messages, they highlight a lack of strong evidence and some inconsistences. Further evidence is required to support high quality, best-practice management strategies that will optimise the outcomes of patients with CD.

The development of the gluten free healthy food basket in Cyprus. Is it affordable among low-income adults diagnosed with celiac disease?

BACKGROUND

Gluten free (GF) diets are not only restrictive but also costly. The main aim of this study was to evaluate the acceptability, cost and affordability of a Gluten Free Healthy Food Basket (GFHFB) and further examine whether low-income Cypriots diagnosed with celiac disease (CD) experience food stress.

METHODS

GFΗFBs were constructed for adult women and adult men (±40 years) diagnosed with CD. Feasibility and acceptability was tested through three focus groups. Affordability was defined as the cost of the GFΗFB as a percentage of the Guaranteed Minimum Income (GMI).

RESULTS

The GFΗFB was 33.6 and 47 euros/month more expensive compared to the HB (Healthy Basket) for women and men, respectively. The total budget for GF-manufactured products were 27.81 and 28.5% of the total food budget, for women and men, respectively. For low-income people receiving the GMI, the proportion of income that would need to be spent on the GFHFB ranges from around 42 to 60%.

CONCLUSIONS

The GFΗFB is costly and not affordable among low-income Cypriots diagnosed with CD; thus, they are likely to suffer from food stress. As such, the risk of reducing their adherence to a GF diet is high and thus compromises their long-term health.

Examining core self-management skills among adolescents with celiac disease

A strict gluten-free diet is the only treatment for celiac disease, and it is especially challenging among adolescents. Participation in food-related activities and self-managing the chronic health condition involve use of cognitive skills. This cross-sectional study examined how executive functions might be associated with participation in food-related activities. Adolescents aged 12-18 years (N = 65; M_age = 14.67) with celiac were interviewed about participation, and their parents completed an executive function questionnaire. Poorer participation significantly correlated with poorer executive abilities. Identifying executive function profiles may contribute to understanding and advancing resourceful daily functioning and participation in daily food-related activities.

Mental Health Disorders and Psychosocial Distress in Pediatric Celiac Disease

OBJECTIVES

Celiac disease (CeD) has been associated with increased mental health disorders (MHD) and psychosocial distress in children, which may complicate treatment with the gluten-free diet (GFD). This single-center cross-sectional study examined psychological comorbidities in children with CeD to assess psychological needs in CeD care.

METHODS

Participants were 73 parents (95% mothers) of children (ages 3-18) attending a multidisciplinary celiac disease clinic. Parents completed electronic surveys about their child's MHD history, psychological symptoms, and GFD experiences. Rates of MHD were calculated and compared with National Institute of Mental Health population-level data. Differences in psychosocial symptoms and GFD experiences were examined based on child age, time since CeD diagnosis, and MHD.

RESULTS

Thirty-four percentage of children had at least 1 MHD; anxiety disorders (16%, P < 0.001) and attention-deficit/hyperactivity disorder (ADHD; 16%, P = 0.01) were more common than general population rates. More than 1 quarter of parents reported current child psychosocial distress (28%-39%), and approximately half reported parent stress (51%) and financial burden (46%) associated with the GFD. Parents of children with new CeD diagnoses reported lower confidence in the GFD (P < 0.01) but MHD, stress, and financial burden did not differ by time since CeD diagnosis. Children with MHD had more anxiety, anger, overall distress, and parent distress than those without MHD (Ps < .05).

CONCLUSIONS

Comorbid CeD and MHD was common and was associated with increased child and parent psychosocial distress. Our findings emphasize the importance of psychological screening and services to assess for and treat comorbid MHD and to mitigate psychosocial distress associated with the GFD.

Rate, Risk Factors, and Outcomes of Nonadherence in Pediatric Patients With Celiac Disease: A Systematic Review

BACKGROUND AND AIMS

The only treatment for celiac disease is strict adherence to a gluten-free diet (GFD). We performed a systematic review to investigate the rate of adherence to a GFD in children with celiac disease, risk factors that affect adherence, and outcomes of non-adherence.

METHODS

We searched PubMed, Cochrane Library, EBSCO, and Scopus for studies through January 2019. We included observational studies of ≥50 children diagnosed with celiac disease and recommended for placement on a GFD. We collected data on adherence assessment (self-report, serology tests, structured dietary interview, biopsies, or assays for gluten immunogenic peptides), risk factors, and outcomes related to adherence. Findings were presented with medians, range, and a narrative synthesis.

RESULTS

We identified 703 studies; of these, 167 were eligible for full-text assessment and 49 were included in the final analysis, comprising 7850 children. Rates of adherence to a GFD ranged from 23% to 98%. Comparable rates (median rates of adherence, 75%-87%) were found irrespective of how assessments were performed. Adolescents were at risk of non-adherence and children whose parents had good knowledge about celiac disease adhered more strictly. Non-adherence associated with patient growth, symptoms, and quality of life.

CONCLUSION

In a systematic review of 49 studies of children with celiac disease, we found substantial variation in adherence to a GFD among patients. Rate of adherence was not associated with method of adherence measurement, so all methods appear to be useful, with lack of consensus on the ideal metric. Studies are needed to determine the best method to ensure adherence and effects on long-term health.

A Single Institution's Experience of Primary Headache in Children With Celiac Disease

BACKGROUND

Few studies exist examining the frequency of primary headache in children with celiac disease and the impact of a gluten-free diet on primary headache symptomology. This study explores characteristics and frequency of headaches in children with celiac disease and response to gluten-free diet at a single institution.

METHODS

Medical records were reviewed for children with celiac disease confirmed by the presence of elevated tissue transglutaminase IgA levels and histologic changes consistent with the diagnosis of celiac disease on small bowel biopsy. Eligible participants were contacted via letter for participation in a phone survey regarding headaches. Phone interviews were conducted 2 weeks after notification and lasted approximately 10 minutes. Headaches were classified according to ICHD-3 criteria.

RESULTS

247 eligible patients or their families were contacted. A total of 132 (53.44%) agreed to participate. One participant was excluded due to insufficient information provided. Overall, 51 of 131 participants had recurrent headache defined as at least 1 episode per month (39%, 95% confidence interval [CI]: 31%-47%) and 33 had migraine with or without aura (25%, 95% CI: 18%-33%). Twenty-eight had frequent tension-type headache (22%, 95% CI: 15%-29%). Thirty-two participants noted headaches before a confirmed diagnosis of celiac disease. Twenty-two of 32 participants (68.75%) noticed decreased headache frequency or intensity, or both, after starting the gluten-free diet.

CONCLUSION

This study suggests that at least one-third of children and adolescents with celiac disease have recurrent headaches at the time of diagnosis. A gluten-free diet led to improved headache symptomology in a significant number of these patients.

Current Evidence in the Diagnosis and Treatment of Children With Celiac Disease

Recent statistics report that 3 million people, or 1% of the population in the United States (U.S.), are affected by celiac disease (CD). In addition, in the U.S., as many as 1 in 80 children is affected with CD. However, CD can be challenging to diagnose and many children are not correctly diagnosed or live without a diagnosis for several years. Symptoms, if present, are often nonspecific and may be common manifestations of many pediatric illnesses. The purpose of this review is to examine the current evidence regarding incidence, pathophysiology, diagnosis, and treatment of a child with CD. Clinical implications for nurses caring for children and families are discussed.

Celiac Dietary Adherence Test simplifies Determining Adherence to a Gluten-free Diet in Swedish Adolescents

OBJECTIVES

The aims of the study were to ascertain whether the Celiac Dietary Adherence Test (CDAT) could contribute in determining adherence to a gluten-free diet in patients with celiac disease and to evaluate the diet adherence and well being of a study population 5 years after a celiac disease screening known as "Exploring the Iceberg of Celiacs in Sweden."

METHODS

Through the screening, 90 adolescents (born 1997) were diagnosed with biopsy-proven celiac disease at 12 years of age. Of them, 70 (78%) came to a 5-year follow-up where anti-tissue transglutaminase antibodies 2 was tested and a questionnaire was filled in, including CDAT, which consists of 7 questions related to adherence. Nonparametrical tests were used to determine associations between adherence measures.

RESULTS

Among the adolescents, 86% were adherent to a gluten-free diet 5 years after screening, 38% reported their general well being as excellent, 50% very well, and 12% well. Statistically significant associations were seen between anti-tissue transglutaminase antibodies 2 and the CDAT score (P = 0.033), and the self-reported adherence question and the CDAT score (P < 0.001).

CONCLUSIONS

The screening-detected adolescents reported a high level of well being and adherence to a gluten-free diet 5 years after screening. We conclude that the CDAT can be used in clinical practice as an estimation of adherence to a gluten-free diet. It would be most suitable to use in conjunction with currently used adherence measures, but can also be used as a stand-alone method when others are not accessible.

Effect of gluten-free diet and compliance on quality of life in pediatric celiac disease patients

Background

Quality of life (QOL) in children with celiac disease (CD) has been sparsely studied.

Aims

We aimed to study QOL in pediatric CD and the effect of a gluten‐free diet (GFD) in a North Indian population.

Methods

QOL was assessed at baseline and 6 months after GFD using a pediatric symptom checklist (PSC) score. The effect of GFD was assessed using a CD‐specific questionnaire on domains such as dietary compliance, parental behavior and perceptions, children's feeling, and difficulty identifying gluten‐free foods.

Results

A total of 60 CD children (age 6.03 ± 0. 42 years, range: 2–12 years, M:F 2:1) were prospectively enrolled. The median PSC score at baseline was 11.5 (2–35), which showed a statistically significant improvement after GFD to 2.5 (0–34) (P < 0.001). Significant concerns regarding specific domains emerged: difficulty in maintaining GFD 26.2%, at school 14.3%, at parties 43.2%, poor taste 11.4%, special diet a burden 28.5%, felt left out at school or friend's home 40.9%, felt different from other kids 40.9%, felt embarrassed to bring GFD to parties 54.6%, felt angry about following a special diet 56.8%, felt not invited out for meals because of CD 13.6%, and difficulty determining if food available was gluten free in 75%.

Conclusion

GFD has a significant impact on emotional, behavioral, and psychosocial domains in children with CD. Proper labeling of commercially available food items, counseling, and patient support groups are the need of the hour.

Diagnostic Delays in Children With Coeliac Disease in the Central European Region

OBJECTIVES

Coeliac disease (CD) is a systemic autoimmune disorder affecting about 1% of the population. Many patients remain undiagnosed or are diagnosed with substantial delay. We assessed diagnostic delays in symptomatic CD children in Central Europe (CE).

METHODS

Paediatric gastroenterologists in 5 CE countries retrospectively reported data of their patients diagnosed in 2016. Age at first CD-related symptom(s), first visit to paediatric gastroenterologist and confirmed diagnosis were used to determine diagnostic delays.

RESULTS

Data from 393 children (65% girls, median age 7 years, range 7 months to 18.5 years) from Croatia, Hungary, Germany, Italy, and Slovenia were analysed. Median duration from first symptom(s) to visit to paediatric gastroenterologist was 5 months (range 0-10 years; preschool 4 months, school-aged 5 months), and further duration until final diagnosis was 1 month (range 0-5 years) with significant regional differences (P < 0.001). Median diagnostic delay was 6 months (range 0-10 years; preschool 5 months, school-aged 7 months). Type of clinical presentation had little, however, significant effect on delays. Reduced body mass in delays longer than 3 years compared with delays shorter than 1 year was found (z score -0.93 vs -0.39, P < 0.05).

CONCLUSIONS

Time from first symptoms to CD diagnosis in children in 5 CE countries is slightly shorter compared with few other small paediatric studies, and significantly shorter than reported for adults. Nevertheless, delays of more than 3 years in 6.6% of children are worrisome. Raising awareness about the variable symptoms and implementation of reliable diagnostic tools will further reduce diagnostic delays.

Nutritional Status in Spanish Children and Adolescents with Celiac Disease on a Gluten Free Diet Compared to Non-Celiac Disease Controls

Patients who follow a gluten-free diet (GFD) may be prone to nutritional deficiencies, due to food restriction and consumption of gluten-free products. The aim was to assess nutritional status in celiac children and adolescents on a long-term GFD. A cross-sectional age and gender-matched study in 70 celiac and 67 non-celiac volunteers was conducted, using dietary, anthropometric, biochemical parameters, and assessing bone mineral density and physical activity. Adequacy of vitamin D intake to recommendations was very low, in both groups, and intakes for calcium and magnesium were significantly lower in celiac volunteers. Celiac children and adolescents may have a higher risk of iron and folate deficiencies. Both groups followed a high-lipid, high-protein, low fiber diet. Median vitamin D plasma levels fell below reference values, in celiac and non-celiac participants, and were significantly lower in celiac girls. Other biochemical parameters were within normal ranges. Anthropometry and bone mineral density were similar within groups. With the exception of some slightly lower intakes, children and adolescents following a GFD appear to follow the same trends as healthy individuals on a normal diet. No effect of food restriction or gluten-free product consumption was observed.

Linear growth of children with celiac disease after the first two years on gluten- free diet: a controlled study

Background: Celiac disease (CD) is a lifelong disorder with gluten-induced manifestations in different organs especially growth. Gluten free diet (GFD) is required to achieve remission and prevent abnormal growth. Study reports on growth of children with celiac disease on long-term GFD are not consistent. Objective: We evaluated the effect of GFD on growth of children with the classical form of CD (diagnosed by serology and small intestine mucosal biopsy) on log-term GFD (>2 years). Methods: We studied growth parameters (weight gain/day, BMI and BMI-SDS, height growth velocity, Ht-SDS) and lab data in 30 prepubertal children, aged 7.4±2.6 years, with CD, who were on GFD since the age of 3.2±1.6 years of age (>2 years on GFD) for duration of 1 year. The anthropometric data of 30 randomly selected normal, age and sex matched, children were used as control. Lab investigations of CD children included complete blood count (CBC), renal and liver functions (aspartate transaminase - AST, alanine aminotransferase - ALT, and alkaline phosphatase- ALP, serum albumin, fasting blood glucose, vitamin D, and thyroid function and antibodies. Results: The weight gain per day was on average or above, for age and sex, in 27 children and below average in 3. Two out of those 3 children had slow linear growth (decreased Ht-SDS by -0.56 and -0.1, over one year). BMI-SDS was normal in 26/30 patients (>-1.5). BMI-SD changed from -0.36±1.1 to -0.33±1.1 during the year of treatment. BMI-SDS decreased in 9 children during the follow up period that was explained by their fast-linear growth (increased Ht-SDS) in seven of them. The Ht-SDS was <-2 in four out of 30 children at the beginning of the study (2 years after being on GFD) and in 2 children after a year of follow-up (catch-up growth). Ht-SDS remained normal or increased in 28/30 children during the year of treatment (-0.38 ±1.2 to -0.22±1.1), with a positive trend: 0.15±0.4 SDS. Only one patient crossed down 1 Ht-SDS during the year of follow up, with low weight gain/day and decreased BMI-SDS that can be explained by poor compliance with GFD. Ht-SDS and BMI-SDS increased significantly in the CD group versus controls during the year of follow-up. All patients had normal serum albumin, liver enzyme and hemoglobin levels. 33.3% of patients had low serum ferritin level and 33.3% had a vitamin D deficiency. Conclusions: Most of our children with CD grew normally both in height and weight during GFD. Significant catch-up growth occurred in some of them after 2 years of being on GFD. Those with low BMI-SDS and/or Ht-SDS needed further management, including reinforcement on the importance of GFD and investigations on factors affecting growth pattern. Measuring weight gain /day appears to be a sensitive indicator for monitoring growth in these children. Vitamin D and iron status should be monitored, and deficiencies corrected. (www.actabiomedica.it)

Daily Life Restrictions are Common and Associated with Health Concerns and Dietary Challenges in Adult Celiac Disease Patients Diagnosed in Childhood

The prevalence and associated factors of daily life restrictions due to a gluten-free diet in adult celiac disease patients diagnosed in childhood are poorly known. We investigated these issues by collecting the medical data of 955 pediatric patients and sending questionnaires evaluating various health outcomes to the 559 patients who had reached adulthood. Of the 231 respondents, 46% reported everyday life restrictions caused by dietary treatment. Compared with those without restrictions, they more often had anemia at diagnosis (37% vs. 22%, p = 0.014), but the groups were comparable in other diagnostic features. In adulthood, patients with restrictions reported more overall symptoms (32% vs. 17%, p = 0.006), although the symptoms measured with the Gastrointestinal Symptom Rating Scale questionnaire were comparable. Despite strict dietary adherence in both groups, the experience of restrictions was associated with dietary challenges (34% vs. 9%, p < 0.001), health concerns (22% vs. 13%, p = 0.050), and lower vitality scores in the Psychological General Well-Being questionnaire. The groups did not differ in their current age, socioeconomic status, family history of celiac disease, general health or health-related lifestyle, the presence of co-morbidities, or regular follow up. Our results encourage healthcare professionals to discuss the possible health concerns and dietary challenges with patients to avoid unnecessary daily life restrictions, especially when young patients start to take responsibility for their treatment.

Compliance with gluten-free diet in a selected group of celiac children in the Slovak Republic

OBJECTIVE

Celiac disease (CD) is a chronic long-term disease with autoimmune disorder connected to an allergic reaction to the molecule of gluten. CD is manifested in persons who are genetically predisposed. The only therapy for CD is a strong gluten-free (GF) diet. The aim of our study was to follow the adherence to the gluten-free diet in the selected group of parents and caregivers of children with CD, and to compare factors influencing the adherence to GF diet and therefore influencing also clinical symptoms of CD. We compared and examined important food-related activities as well, by using a personal questionnaire in the group of CD children's parents or caregivers.

METHODS

We designed a cross-sectional study; 325 parents or caregivers of children with CD were recruited in the sample. CD was confirmed by the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) criteria. The anonymous questionnaires were collected at summer camps within period data 2012-2016 and followed factors which might have an influence on compliance with GF diet, according to parents' opinions.

RESULTS

Adherence to GF diet was statistically significantly higher among girls compared to boys. Parents' questionnaires confirmed that younger group of children and children with the family history of CD had statistically higher compliance with GF diet. Parents with higher education confirmed better adherence to GF diet, statistical analyses confirmed higher adherence in mother´s education compared to father's education. Duration of CD, socio-demographic factors of parents - age of parent, gender of parent, and residency were not statistically significant in terms of compliance with the diet.

CONCLUSIONS

Our study confirmed important factors influencing adherence to the GF diet, which are connected to the symptoms and consequences of CD. The assessment of parents' opinions and burden on the families of children with celiac disease should be also reflected in the evaluation of patient's status. Important is also the role of parents in order to facilitate and support clinical interventions and prevention of CD.

Extraintestinal manifestations were common in children with coeliac disease and were more prevalent in patients with more severe clinical and histological presentation

AIM

This study investigated the prevalence of extraintestinal manifestations (EIM) in paediatric coeliac disease and their associations with other disease features.

METHODS

Researchers at the University of Tampere, Finland, compared EIM in 511 children diagnosed with coeliac disease from 2003 to 2014 and 180 diagnosed with functional gastrointestinal disorders from 2007 to 2013. Disease severity and dietary responses were also compared between coeliac children diagnosed by screening (n = 146) or because of EIM (n = 116) or gastrointestinal symptoms (n = 249).

RESULTS

Coeliac patients had more EIM (62%) than those with functional disorders (33%). The most common EIM in coeliac children were poor growth (27%) and anaemia (18%). Children with coeliac disease often showed fatigue (8%) and symptoms affecting the skin (15%), nervous system (9%) and joints (6%). Coeliac patients with EIM as their main clinical presentation had more severe symptoms and histological damage at diagnosis than those with gastrointestinal presentation and screen-detected cases. The subgroups did not differ with regard to other clinical and laboratory parameters and dietary adherence. Concomitant EIM were also common in children diagnosed because of gastrointestinal presentation (60%) and by screening (37%).

CONCLUSION

EIM were common in coeliac disease and associated with more severe clinical and histological presentation.

Improving gluten free diet adherence by youth with celiac disease

INTRODUCTION

Celiac disease (CD) is a gluten-triggered autoimmune disorder of the small intestine, which can occur in genetically susceptible individuals at any age. A strict life-long gluten free diet (GFD) is the only medically approved treatment, and non-adherence is associated with significant morbidity. However, gluten use is widespread, complicating efforts to follow the diet. Youth with CD are especially challenged with dietary adherence, as they strive for peer acceptance and personal autonomy in the context of managing a chronic disease.

METHODS

A scoping review was conducted to identify mechanisms to assist youth with remaining gluten free.

RESULTS

There is a paucity of literature regarding best approaches to improve diet adherence by youth, however, lessons can also be learned by borrowing ideas from self-management approaches of other chronic diseases. Several mechanisms for improving GFD adherence among youth are identified, including regular engagement of the youth with CD and their family with an experienced multidisciplinary team, electronic tool utilization and awareness of accurate resources for self-guided education and resources.

CONCLUSIONS

Improvement in GFD adherence by youth is achievable and may influence long-term health outcomes.

Examination of Executive Function and Social Phobia Among Female College-Aged Students With Celiac Disease

Celiac disease (CD) is a T-cell mediated genetically inherited autoimmune disease affecting approximately 1% of the population. Research suggests that CD impacts executive functioning (EF) and social phobia (SP). However, most of the literature in this area focuses on age groups outside of the traditional college age range and has never measured EF and SP together. This descriptive study compared traditional age female college students with CD to age- and sex-matched college students without CD on measures of EF and SP. Participants completed the Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A), the Social Anxiety Questionnaire for Adults-Short Form (SAQ-A30), and a demographic questionnaire. Results indicated that participants with CD reported lower grade point averages; scored lower on BRIEF-A measures of working memory, planning/organization, and organization of materials; and scored higher on SAQ-A30 measures involving interactions with the opposite sex and strangers. Implications for nursing practice are discussed. [Journal of Psychosocial Nursing and Mental Health Services, 57(2), 25-34.].

The Gluten Free Diet: Assessing Adherence in a Pediatric Celiac Disease Population

Background

A strict, lifelong, gluten-free diet (GFD) remains the sole treatment for celiac disease (CD). The assessment of adherence to the GFD in pediatric studies is often based on self-report and visual analogue scales which lack proven validity. We sought to compare parental-report of GFD adherence to expert registered dietitian (RD) assessments, the best available standard.

Methods

Parents of children with biopsy-proven CD scored their adherence to the GFD on a five-point Likert scale similar to that used in previous pediatric CD studies. Each family was then evaluated by an RD expert in CD management who conducted a comprehensive and standardized assessment and scored the family's adherence. The agreement between parents and the RD was assessed using paired t test and intraclass correlation coefficient (ICC) based on their scores.

Results

One hundred twenty-two children and their families participated in the study, with a median of 32 months on a GFD. Excellent adherence (score 5 out of 5) was attributed to 60.5% of the sample by the RD. The parents scored adherence higher than the RD by an average difference of 0.41 scale points (95% CI, 0.28-0.54; P < 0.001). The agreement between parents and the registered dietitian was poor (ICC = 0.21).

Conclusion

Reliance on self-report through Likert scales for GFD adherence overestimates adherence and misses opportunities for patient and family education. Approximately 40% of children with CD have ongoing gluten exposure, highlighting the need for regular assessment by an RD expert in the GFD to identify education and counselling needs for children with CD.

Headache Associated with Coeliac Disease: A Systematic Review and Meta-Analysis

Objective: The aim of this systematic review was to explore the relationship between coeliac disease (CD) and headache. The objectives were to establish the prevalence of each entity amongst the other, to explore the role of gluten free diet (GFD), and to describe the imaging findings in those affected by headaches associated with CD. Methodology: A systematic computer-based literature search was conducted on the PubMed database. Information regarding study type, population size, the age group included, prevalence of CD amongst those with headache and vice versa, imaging results, the nature of headache, and response to GFD. Results: In total, 40 articles published between 1987 and 2017 qualified for inclusion in this review. The mean pooled prevalence of headache amongst those with CD was 26% (95% CI 19.5–33.9%) in adult populations and 18.3% (95% CI 10.4–30.2%) in paediatric populations. The headaches are most often migraine-like. In children with idiopathic headache, the prevalence of CD is 2.4% (95% CI 1.5–3.7%), whereas data for adult populations is presently unavailable. Brain imaging can be normal, although, cerebral calcifications on CT, white matter abnormalities on MRI and deranged regional cerebral blood flow on SPECT can be present. GFD appears to be an effective management for headache in the context of CD, leading to total resolution of headaches in up to 75% of patients. Conclusions: There is an increased prevalence of CD amongst idiopathic headache and vice versa. Therefore, patients with headache of unknown origin should be screened for CD, as such patients may symptomatically benefit from a GFD.

Extraintestinal Manifestations of Celiac Disease: Early Detection for Better Long-Term Outcomes

Population-based screening studies have shown celiac disease to be one of the most common chronic gastrointestinal diseases. Nevertheless, because of the diverse clinical presentation, the great majority of patients remain unrecognized. Particularly difficult to identify are the multifaceted extraintestinal symptoms that may appear at variable ages. Although the pathogenesis and long-term outcome of these manifestations are still poorly established, there is some evidence that unrecognized celiac disease predisposes to severe complications if not diagnosed and prevented with an early-initiated gluten-free diet. Therefore, it is of utmost importance that physicians of different disciplines learn to recognize celiac disease in individuals with non-gastrointestinal symptoms. In the future, more studies are needed to clarify the factors affecting development and prognosis of the extraintestinal manifestations.

The Nutritional Quality of Gluten-Free Products for Children

OBJECTIVES

To examine the nutritional quality of gluten-free (GF) products specifically marketed for children.

METHODS

All child-targeted food products were purchased from 2 major supermarket chains in Calgary, Alberta, Canada. Using the Pan American Health Organization Nutrient Profile Model, the nutritional quality of products with a GF claim was compared with those without such a claim. A secondary analysis further compared the nutrient profile of child-targeted GF products to their product "equivalents."

RESULTS

Overall, child-targeted GF products had lower levels of sodium, total fat, and saturated fat but also had less protein and a similar percentage of calories from sugar compared with child-targeted products without a GF claim. According to the Pan American Health Organization criteria, both GF products and "regular" products designed for children can be classified as having poor nutritional quality (88% vs 97%; P < .001). When analyzed in light of their product equivalents without a GF claim, both had similarly high levels of sugar (79% vs 81%; P < .001).

CONCLUSIONS

GF supermarket foods that are targeted at children are not nutritionally superior to regular child-targeted foods and may be of greater potential concern because of their sugar content. The health halo often attributed to the GF label is not warranted, and parents who substitute GF products for their product equivalents (assuming GF products to be healthier) are mistaken. Parents of children with gluten intolerance and/or sensitivity, along with parents who purchase GF products for other health reasons, need to carefully assess product labels when making purchases.

Creation of Experience-based Celiac Benchmarks: The First Step in Pretransition Self-management Assessment

OBJECTIVES

Transition planning for children with chronic disease includes the development of independence in many self-management tasks. Conditions that depend on diet have distinct skill sets not well assessed by the traditional transition-readiness tools. There has been literature that describes age-appropriate skill acquisition for diabetes and food allergy patients. There are, however, no age-appropriate benchmarks established for celiac disease (CD).

METHODS

CD experts (including physician, nurse, dietician, social worker, patient, and parent) created a list of celiac-related tasks, which formed the basis of the survey. Patients with CD, and their parents, were recruited from outpatient celiac clinic and support groups, and invited to report the age each task was mastered.

RESULTS

Respondents included 204 patients and 155 parents. Mean age was 12 years (standard deviation 4.6) with average of 4 years since diagnosis. The earliest tasks were mastered by a median age of 8 years, such as recognizing GF as gluten-free, eating safely in a shared space and recognizing basic unsafe foods. Describing the effects of eating gluten or explaining CD to a friend or stranger occurred around age 10. Asking about gluten-free preparation in a restaurant, and identifying gluten-free medications or vitamins was mastered around age 12, whereas tasks involved with safe domestic travel or assessing risk in a job environment occurred between 14 and 16. The interquartile range was about 4 years for each question. No significant difference seen between patient and parent reports.

CONCLUSIONS

This novel patient-centered celiac skill list may improve anticipatory guidance and accelerate self-management skills.

A Toddler With Treatment-Resistant Iron Deficiency Anemia

A 19-month-old girl with a history of asthma and atopic dermatitis presented to her pediatrician because of parental concerns of pallor and fatigue. On dietary history, it was discovered that she was a picky eater and consumed 26 oz of homogenous milk daily. Her physical examination was unremarkable aside from pallor, and both her height and weight plotted between the 50th and 75th percentile for age. Therefore, she was investigated for iron deficiency anemia and indeed her blood work was consistent. Despite appropriate iron supplementation and dietary milk restriction, there was no improvement in her hemoglobin or iron studies. Our expert panel examines the case and offers a differential diagnosis for a child presenting with treatment-resistant iron deficiency anemia.

Adherence to the Gluten-free Diet and Health-related Quality of Life in an Ethnically Diverse Pediatric Population With Celiac Disease

OBJECTIVES

Celiac disease (CD) is an autoimmune disease that requires lifelong adherence to a gluten-free diet (GFD). Adherence to the GFD in childhood may be poor and adversely influence health-related quality of life (HRQOL). The study purpose was to determine sociodemographic and socioeconomic factors influencing adherence to the GFD and HRQOL in a multiethnic cohort of youth with CD.

METHODS

A multisite (Edmonton, Hamilton, Toronto) study examining child-parent HRQOL in youth with CD (n = 243) and/or mild gastrointestinal complaints (GI-CON; n = 148) was conducted. Sociodemographic (age, child-parental age/education/ethnicity/place of birth), anthropometric (weight, height, body mass index), disease (diagnosis, age at diagnosis, duration, Marsh score, serology), household characteristics (income, family size, region, number of children/total household size), HRQOL (Peds TM/KINDL and Celiac Disease DUX), GI Complaints (PedsQL: Gastrointestinal Symptom Scale) and gluten intake were measured.

RESULTS

Younger age (<10 years), non-Caucasian ethnicity (parent/child), and presence of GI symptoms were associated with the highest rates of adherence to the GFD in CD children (P < 0.05). CD children (parent/child) had higher HRQOL (average, composite domains) than GI-CON (P < 0.05), but CD children were comparable to healthy children. Lack of GI symptoms, non-Caucasian ethnicity and age (<10 years) were associated with increased HRQOL in composite/average domains for CD (P < 0.05).

CONCLUSIONS

Child-parent perceptions of HRQOL in a multiethnic population with CD are comparable to healthy reference populations, but significantly higher than in parent/child GI-CON. Adherence to the GFD in ethnically diverse youth with CD was related to GI symptoms, age of the child, and ethnicity of the parent-child.