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Macedo L, Catarino M, Festas C, Alves P. Vulnerability in Children with Celiac Disease: Findings from a Scoping Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:729. [PMID: 38929308 PMCID: PMC11201835 DOI: 10.3390/children11060729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
(1) Background: The scientific literature highlights that children diagnosed with celiac disease (CD) are at a heightened risk of experiencing physical, psychological, and social challenges, impacting their overall healthy childhood development. However, there remains a lack of a clear understanding regarding the factors that contribute to this vulnerability. The purpose of this study is to analyze and map the evidence on the sociopsychosomatic vulnerability of these children and identify gaps in this topic. (2) Methods: Following Joanna Briggs Institute's guidelines for scoping reviews, we executed a detailed search of key electronic databases and explored the grey literature to capture a broad spectrum of studies. Our focus was on identifying research that looked into the multiple dimensions of vulnerability-physical, psychological, and social-in children with CD. We included a diverse range of study designs as well as systematic reviews, ensuring a comprehensive analysis. The selection process was stringent, utilizing clearly defined inclusion and exclusion criteria. (3) Results: We identified 61 studies that met our inclusion criteria. The review highlighted significant adverse health outcomes in children with CD and elucidated various individual and environmental determinants that influenced these vulnerabilities. It also underscored the lack of assessment tools to evaluate the risk of health problems in this population. (4) Conclusions: The findings underscore a critical need for further research to deepen our understanding of the vulnerabilities associated with CD in children. Developing targeted assessment tools will be crucial in stratifying health risks and enhancing care strategies for this vulnerable population.
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Affiliation(s)
- Lúcia Macedo
- Âncora Community Care Unit, Gaia and Espinho Local Health Unit, 4430-037 Gaia, Portugal
- Institute of Health Sciences (ICS), Universidade Católica Portuguesa, 4169-005 Porto, Portugal; (C.F.); (P.A.)
- Center for Interdisciplinary Research in Health (CIIS), Institute of Health Sciences (ICS), Universidade Católica Portuguesa, 4169-005 Porto, Portugal;
| | - Marta Catarino
- Center for Interdisciplinary Research in Health (CIIS), Institute of Health Sciences (ICS), Universidade Católica Portuguesa, 4169-005 Porto, Portugal;
- Health Department, Polytechnic Institute of Beja, 7800-111 Beja, Portugal
- Institute of Health Sciences (ICS), Universidade Católica Portuguesa, 1649-023 Lisboa, Portugal
| | - Constança Festas
- Institute of Health Sciences (ICS), Universidade Católica Portuguesa, 4169-005 Porto, Portugal; (C.F.); (P.A.)
- Center for Interdisciplinary Research in Health (CIIS), Institute of Health Sciences (ICS), Universidade Católica Portuguesa, 4169-005 Porto, Portugal;
| | - Paulo Alves
- Institute of Health Sciences (ICS), Universidade Católica Portuguesa, 4169-005 Porto, Portugal; (C.F.); (P.A.)
- Center for Interdisciplinary Research in Health (CIIS), Institute of Health Sciences (ICS), Universidade Católica Portuguesa, 4169-005 Porto, Portugal;
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Luque V, Crespo-Escobar P, Hård Af Segerstad EM, Koltai T, Norsa L, Roman E, Vreugdenhil A, Fueyo-Díaz R, Ribes-Koninckx C. Gluten-free diet for pediatric patients with coeliac disease: A position paper from the ESPGHAN gastroenterology committee, special interest group in coeliac disease. J Pediatr Gastroenterol Nutr 2024; 78:973-995. [PMID: 38291739 DOI: 10.1002/jpn3.12079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 02/01/2024]
Abstract
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.
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Affiliation(s)
- Veronica Luque
- Serra Húnter, Universitat Rovira i Virgili, Reus, Spain
- Paediatric Nutrition and Development Research Unit, IISPV, Reus, Spain
| | - Paula Crespo-Escobar
- Health Sciences Department, ADVISE Research Group, Miguel de Cervantes European University, Valladolid, Spain
- Nutrition and Dietetics Unit, Hospital Recoletas Campo Grande, Valladolid, Spain
| | - Elin M Hård Af Segerstad
- Paediatric Department, Skane University Hospital, Malmoe, Sweden
- Department of Clinical Sciences, Celiac Disease and Diabetes Unit, Faculty of Medicine, Lund University, Malmoe, Sweden
| | - Tunde Koltai
- Direction Board, Association of European Coeliac Societies, Brussels, Belgium
| | - Lorenzo Norsa
- Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Enriqueta Roman
- Paediatric Gastroenterology and Nutrition, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Anita Vreugdenhil
- Department of Pediatrics, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ricardo Fueyo-Díaz
- Department of Psychology and Sociology, Aragonese Primary Care Research Group (GAIAP, B21_20R), University of Zaragoza, Zaragoza, Spain
| | - Carmen Ribes-Koninckx
- Paediatric Gastroenterology, Hepatology and Nutrition, La Fe University Hospital & La Fe Research Institute, Valencia, Spain
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Baseer KAA, Mohammed AE, Elwafa AMA, Sakhr HM. Prevalence of celiac-related antibodies and its impact on metabolic control in Egyptian children with type 1 diabetes mellitus. BMC Pediatr 2024; 24:99. [PMID: 38317100 PMCID: PMC10840212 DOI: 10.1186/s12887-024-04575-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/18/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVE The simultaneous presence of celiac disease and type 1 diabetes (T1DM) is coupled with more hazards of comorbidities and complications. This current study aimed to screen for celiac disease in Egyptian children with type 1 diabetes and evaluate its impact on glycemic control. METHODS A cross-sectional study was verified with 200 Egyptian children diagnosed with T1DM and having a diabetic duration of less than five years. Testing for anti-tissue transglutaminase IgA (tTG-IgA), anti-tissue transglutaminase IgG (tTG-IgG), anti-Endomysial IgA (EMA), and Hb A1c levels were done. RESULTS The serological screening revealed that 11 cases (5.5%) tested positive; 8 children with T1DM (4.0%) showed tTG-IgA antibodies ≥ 10 times the upper limit of normal (ULN) with at least one symptom; and 3 cases (1.5%) had levels between 20 and 50 IU/ml (considering a cut-off point of 10 U/ML for positive results). Intestinal biopsy was performed for these three cases, with one case detected to have subtotal villous atrophy, resulting in an overall prevalence of celiac disease in T1DM as 4.5%. Children with positive screening exhibited a higher insulin dose, a higher HbA1c, an increased frequency of hypoglycemic attacks, and recurrent DKA compared to negative cases. A negative correlation was detected between tTG-IgA antibodies with height Z score and hemoglobin level, while a positive correlation was found between tTG-IgA antibodies and HbA1c level. CONCLUSION Undiagnosed celiac disease in children with T1DM negatively impacted metabolic control and affected their general health.
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Affiliation(s)
| | - Abdallah E Mohammed
- Department of Clinical Pathology, Faculty of Medicine, South Valley University, Qena, Egypt
| | | | - Hala M Sakhr
- Department of Pediatrics, Faculty of Medicine, South Valley University, Qena, Egypt.
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Tauschi R, Eurén A, Vuorela N, Koskimaa S, Huhtala H, Kaukinen K, Kivelä L, Kurppa K. Association of concomitant autoimmunity with the disease features and long-term treatment and health outcomes in Celiac disease. Front Med (Lausanne) 2022; 9:1055135. [PMID: 36465913 PMCID: PMC9709120 DOI: 10.3389/fmed.2022.1055135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/01/2022] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Celiac disease (CeD) is often accompanied by other autoimmune diseases (AID). However, the association of co-existing autoimmunity with the presentation and treatment success in CeD is unclear. We investigated these issues with a large and well-defined cohort of Finnish patients. METHODS Adult CeD patients (n = 806) were collected from multiple heath care sites via nationwide recruitment. They were interviewed, underwent measurement of CeD autoantibodies, and filled out questionnaires to ascertain quality of life (PGWB) and gastrointestinal symptoms (GSRS) after a median of 9.7 years on a gluten-free diet. Data were supplemented retrospectively from patient records. The results were compared between CeD patients with and without a coexisting AID. RESULTS Altogether 185 patients had CeD+AID and 621 had CeD only. At CeD diagnosis, patients with CeD+AID were older (median 42 vs. 36 years, p = 0.010) and had more joint symptoms (9.1 vs. 4.2%, p = 0.011), whereas the groups were comparable in sex, family history of CeD, other presenting symptoms, proportion of screen-detected subjects, and severity of duodenal lesion. During follow-up on gluten-free diet, CeD+AID patients experienced poorer general health (median score 12 vs. 14, p < 0.001) in PGWB, more overall gastrointestinal symptoms (2.1 vs. 1.9, p = 0.001), and constipation (2.0 vs. 1.7, p < 0.001) in GSRS, whereas there was no difference in histological and serological recovery, dietary adherence, use of gluten-free oats, smoking, and presence of regular follow-up. CONCLUSIONS Co-existing AID was not significantly associated with the baseline features or with most long-term outcomes in CeD. However, the increased prevalence of gastrointestinal symptoms and reduced poorer self-perceived health during treatment indicates these patients' need for special support.
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Affiliation(s)
- Riku Tauschi
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anna Eurén
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Nina Vuorela
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Sara Koskimaa
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Laura Kivelä
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Children's Hospital, and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kalle Kurppa
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
- The University Consortium of Seinäjoki, Seinäjoki, Finland
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Mozzillo E, Franceschi R, Di Candia F, Rosanio FM, Leonardi L, Fedi L, Rosà V, Cauvin V, Franzese A, Loredana Marcovecchio M. 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. Diabetes Res Clin Pract 2022; 191:110032. [PMID: 35934174 DOI: 10.1016/j.diabres.2022.110032] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/06/2022] [Accepted: 08/01/2022] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Enza Mozzillo
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
| | - Roberto Franceschi
- Pediatric Diabetology Unit, Pediatric Department, S. Chiara General Hospital, Trento, Italy.
| | - Francesca Di Candia
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
| | - Francesco Maria Rosanio
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
| | - Letizia Leonardi
- Pediatric Diabetology Unit, Pediatric Department, S. Chiara General Hospital, Trento, Italy
| | - Ludovica Fedi
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
| | - Valentina Rosà
- Pediatric Diabetology Unit, Pediatric Department, S. Chiara General Hospital, Trento, Italy
| | - Vittoria Cauvin
- Department of Translational Medical Science, Section of Pediatrics, Regional Center of Pediatric Diabetes, Federico II University of Naples, Naples, Italy
| | - Adriana Franzese
- Pediatric Diabetology Unit, Pediatric Department, S. Chiara General Hospital, Trento, Italy
| | - M Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Kamrath C, Tittel SR, Dunstheimer D, Fröhlich-Reiterer E, Freff M, Böttcher C, Scheffler N, Lenze S, Gericke E, Thiele S, Holl RW. Early vs late histological confirmation of coeliac disease in children with new-onset type 1 diabetes. Diabetologia 2022; 65:1108-1118. [PMID: 35488926 PMCID: PMC9174128 DOI: 10.1007/s00125-022-05701-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/11/2022] [Indexed: 11/26/2022]
Abstract
AIM Screening for coeliac disease in asymptomatic children with new-onset type 1 diabetes is controversial. The aim of this study was to analyse whether the confirmation of coeliac disease in children with new-onset type 1 diabetes and positive screening results can be postponed. METHODS This was a multicentre population-based cohort study based on the German/Austrian/Swiss/Luxembourgian Prospective Diabetes Follow-up Registry (Diabetes Patienten Verlaufsdokumentation [DPV]). Participants aged ≤18 years diagnosed with type 1 diabetes between 1995 and June 2021 and with elevated IgA tissue transglutaminase antibodies (anti-tTGA) at diabetes onset on screening for coeliac disease were included. We compared outcomes of participants with a diabetes duration of more than 1 year between those in whom coeliac disease was confirmed histologically within the first 6 months and those in whom coeliac disease was confirmed between 6 and 36 months after diabetes diagnosis. RESULTS Of 92,278 children and adolescents with a diagnosis of type 1 diabetes, 26,952 (29.2%) had documented anti-tTGA data at diabetes onset. Of these, 2340 (8.7%) had an elevated anti-tTGA level. Individuals who screened positive were younger (median age 9.0 vs 9.8 years, p<0.001) and more often female (53.1% vs 44.4%, p<0.001). A total of 533 participants (22.8% of those who screened positive) had a documented biopsy, of whom 444 had documented histological confirmation of coeliac disease. Of 411 participants with biopsy-proven coeliac disease within the first 36 months of diabetes and follow-up data, histological confirmation was performed in 264 (64.2%) within the first 6 months and in 147 (35.8%) between 6 and 36 months after diabetes onset. At follow-up (median diabetes duration 5.3 years and 5.1 years, respectively), estimated median HbA1c levels (62.8 mmol/mol vs 62.2 mmol/mol [7.9% vs 7.8%]), cardiovascular risk markers (lipids, rate of microalbuminuria, blood pressure), rates of acute diabetes complications (diabetic ketoacidosis, severe hypoglycaemia) and the proportions of participants reaching anti-tTGA levels within the normal range did not differ between groups. Participants with delayed histological confirmation of coeliac disease showed no negative effects on growth or weight gain during the observation period. CONCLUSIONS Our study suggests that the histological confirmation of coeliac disease in asymptomatic individuals with new-onset type 1 diabetes could be postponed.
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Affiliation(s)
- Clemens Kamrath
- Division of Paediatric Endocrinology and Diabetology, Centre of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany.
| | - Sascha R Tittel
- Institute of Epidemiology and Medical Biometry (ZIBMT), Ulm University, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Desiree Dunstheimer
- Division of Paediatric Endocrinology and Diabetology, Centre of Child and Adolescent Medicine, University Children's Hospital Augsburg, Augsburg, Germany
| | - Elke Fröhlich-Reiterer
- Department of Paediatrics and Adolescent Medicine, Division of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Markus Freff
- Darmstädter Kinderkliniken Prinzessin Margaret, Darmstadt, Germany
| | - Claudia Böttcher
- Paediatric Endocrinology and Diabetology, University Children's Hospital, University of Bern, Bern, Switzerland
| | - Nadine Scheffler
- Centre for Paediatrics and Adolescent Medicine, Neonatology and Paediatric Intensive Care, Clinic Itzehoe, Itzehoe, Germany
| | - Stefanie Lenze
- Centre of Diabetes, Department of Paediatrics, Sana Klinikum Berlin Lichtenberg, Berlin, Germany
| | - Elke Gericke
- Centre of Child and Adolescent Medicine, Mathias-Spital Rheine, Rheine, Germany
| | - Susanne Thiele
- Centre of Diabetes, Hospital of Child and Adolescent Medicine, St Vincenz Hospital, Paderborn, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry (ZIBMT), Ulm University, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
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Kivelä L, Eurén A, Repo M, Huhtala H, Kaukinen K, Kurppa K. Coexisting Type 1 Diabetes, Persistent Symptoms, and Financial Issues Associate With Poorer Adherence to a Gluten-Free Diet in Celiac Disease After Transition From Pediatrics to Adult Care. Front Nutr 2022; 9:883220. [PMID: 35719146 PMCID: PMC9200750 DOI: 10.3389/fnut.2022.883220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose We evaluated adherence to a gluten-free diet and associated factors in adult celiac disease patients diagnosed in childhood. Methods Comprehensive medical data on 955 pediatric celiac disease patients was collected and study questionnaires sent to 559 who were now adults. All variables were compared between strictly adherent and non-adherent patients. Results Altogether 237 adults (median age 27 years, 69% women) responded to the questionnaires a median of 18 (range 3-51) years after the childhood diagnosis. Altogether 78% were reportedly adherent and 22% non-adherent. The non-adherent patients had more concomitant type 1 diabetes (18% vs. 4%, p = 0.003), whereas the groups did not differ in demographic data or clinical and histological features at diagnosis, or in short-term dietary adherence. In adulthood, non-adherent patients found gluten-free diet more challenging (39% vs. 17%, p < 0.001) and had higher prevalence (39% vs. 19%, p = 0.004) and severity of symptoms. The main motivation factors for dietary adherence were attempts to avoid symptoms and complications, but these were considered less important and price of gluten-free products more important among non-adherent patients. Adherent and non-adherent patients did not differ in socioeconomic or lifestyle factors, comorbidities other than type 1 diabetes, self-reported general health, health concerns, follow-up, or in quality of life. Conclusion Most originally pediatric celiac disease patients reported strict dietary adherence in adulthood. However, particularly those with concomitant type 1 diabetes, persistent symptoms or financial issues may require attention during the transition from pediatric to adult care.
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Affiliation(s)
- Laura Kivelä
- Celiac Disease Research Center, Tampere University, Tampere, Finland.,Tampere Centre for Child, Adolescent and Maternal Health Research, Tampere University and Department of Pediatrics, Tampere University Hospital, Tampere, Finland.,Children's Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anna Eurén
- Celiac Disease Research Center, Tampere University, Tampere, Finland.,Tampere Centre for Child, Adolescent and Maternal Health Research, Tampere University and Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Marleena Repo
- Celiac Disease Research Center, Tampere University, Tampere, Finland.,Tampere Centre for Child, Adolescent and Maternal Health Research, Tampere University and Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Tampere University, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Kalle Kurppa
- Celiac Disease Research Center, Tampere University, Tampere, Finland.,Tampere Centre for Child, Adolescent and Maternal Health Research, Tampere University and Department of Pediatrics, Tampere University Hospital, Tampere, Finland.,The University Consortium of Seinäjoki and Department of Pediatrics, Seinäjoki Central Hospital, Seinäjoki, Finland
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