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

Background: In people with celiac disease (CD), many factors affect adherence to a gluten-free diet (GFD), and these may well differ among countries. In Greece, such data for the adult population are lacking. Thus, the present study aimed to explore the perceived barriers to compliance with a GFD that are faced by people with CD living in Greece, also taking into account the impact of the COVID-19 pandemic. Methods: Nineteen adults (14 females) with biopsy-proven CD, mean age 39±9 years and median time on GFD 7 (Q1-Q3: 4-10) years, participated in 4 focus groups, conducted through a video conference platform during the period October 2020 to March 2021. Data analysis followed the qualitative research methodology. Results: Eating outside the home was reported as the domain where most difficulties were faced: these were related to a lack of confidence in finding safe gluten-free food and to the lack of social awareness about CD/GFD. All participants highlighted the high cost of gluten-free products, which was mostly managed by receiving state financial support. Regarding healthcare, the vast majority of participants reported little contact with dietitians and no follow up. The COVID-19 pandemic eased the burden of eating out, as staying at home and allocating more time to cooking was experienced as a positive effect, although the shift to online food retailing impacted food variability. Conclusion: The main impediment to GFD adherence seems to stem from low social awareness, while the involvement of dietitians in the healthcare of people with CD warrants further investigation.

Celiac Disease and the Gluten Free Diet during the COVID-19 Pandemic: Experiences of Children and Parents.

The COVID-19 pandemic perturbed the everyday life of children and those with chronic illnesses, along with the lives of their families. Patients with celiac disease (CD) follow a strict gluten-free diet (GFD), and gluten ingestion is associated with negative health outcomes. The aim of this study was to investigate the experiences of children with CD and their families concerning their GFD, symptoms and CD management during the first period of the COVID-19 pandemic. A cross-sectional questionnaire-based study was performed including 37 Dutch pediatric patients with CD, along with their parents. The majority reported good compliance to the GFD and stated that the diet was easier to follow during the pandemic, mainly due to eating more meals in the home. Some discovered a greater variety of GF products by utilizing online shopping, potentially increasing the financial burden of the GFD. Concerning general dietary habits, 21.6% reported a healthier eating pattern, in contrast to 37.8% and 10.8% who consumed more unhealthy snacks and fewer fruits and vegetables, respectively, than normal during the pandemic. The natural experiment of the COVID-19 pandemic provides valuable information regarding the management of pediatric CD. Education on healthy dietary patterns is important, especially for children with restrictive diets, and the findings of this study show that there is room for improvement in this respect, regardless of the current pandemic.

The Influence of SARS-CoV-2 Pandemic on the Diagnosis of Celiac Disease and Clinical Practice in Pediatric Gastroenterology.

Celiac disease (CD) has a high prevalence but remains largely underdiagnosed. Although extensive studies have confirmed that children with CD do not have an increased risk of severe COVID-19, public health regulations associated with the SARS-CoV-2 pandemic may have exacerbated this problem. The aim of this study was to assess the effect of SARS-CoV-2 on the number of new-onset CD cases. Additionally, the role of SARS-CoV-2 in autoimmune diseases and its influence on clinical practice in pediatric gastroenterology were briefly reviewed. We described the data from the hospital electronic registry of new-onset CD, during the COVID-19 pandemic and 2 years before. A total of 423 children were diagnosed with CD between March 2018 and February 2022: 228 in the 2-year pre-COVID-19 period and 195 during the pandemic. The number of patients during the COVID-19 pandemic was 14.5% lower than in the previous years. The quarterly comparison of CD diagnoses showed a reduction in all quarters. A reduction in diagnoses during the lockdown and in the following months was evident and not compensated thereafter. This is the first study to evaluate the impact of SARS-CoV-2 on the diagnosis of CD in children. Further studies are necessary to improve the system of biopsy-sparing diagnosis and to evaluate the effect of the diagnostic delay. Special attention should be given to the implementation of telemedicine services.

A Gluten Free Diet in the Management of Epilepsy in People with Coeliac Disease or Gluten Sensitivity

The aim of this review was to assess the effects of a gluten free diet (GFD) in the management of epilepsy in people with coeliac disease (CD) or gluten sensitivity (GS). A systematic approach was used to undertake a literature review. Five electronic databases (PubMed;Scopus;Google Scholar;Cochrane Epilepsy Group specialised register;Cochrane Register of Controlled Trails (CENTRAL) via the Cochrane Register of Online Trials) were searched using predetermined relevant search terms. In total, 668 articles were identified. Duplicates were removed and predefined inclusion and exclusion criteria were applied, and a PRISMA flow chart was produced. Data was extracted using Covidence software. Twelve studies on Epilepsy and CD involving a total of 70 participants were selected for analysis;narrative synthesis was used owing to the small sample sizes in the selected studies. None of the 12 studies meeting inclusion criteria investigated gluten sensitivity and epilepsy. All the included studies support a link between epilepsy and CD. GFD was effective in 44 out of 70 participants across the studies in terms of a reduction of seizures, reduction of antiepileptic drugs (AEDs) or normalisation of EEG pattern. A total of 44 participants showed a reduction in seizures (across eight studies) and complete cessation of seizures was reported in 22 participants. In general, the earlier the GFD is implemented after the onset of seizures, the better the likelihood of the GFD being successful in supporting control of seizures. Mechanisms linking gluten with epilepsy are not fully understood;possible hypotheses include gluten mediated toxicity, immune-induced cortical damage and malabsorption. Evidence suggests the effectiveness of a GFD in supporting the management of epilepsy in patients with CD, although the quality of evidence is low. There appears to be a growing number of neurologists who are prepared to advocate the use of a GFD. A multidisciplinary approaches and further research are recommended. It could be argued that when balancing potential treatments such as AEDs or surgery, a GFD has a low likelihood of harm. © 2020 by the authors.

Utilization of a Hospital-Based Food Pantry and Associated Nutrition Education and Cooking Program for Patients with Celiac Disease

Objective: Food insecurity impacts 1 out of 6 patients with celiac disease (CD) in the United States, and rates have increased during the COVID-19 pandemic. This is particularly concerning for vulnerable populations who require specialized medical diets. State and federal resource programs do not account for the increased cost of gluten-free (GF) foods, and food pantries do not address overall health issues that often come with food insecurity. Our project aimed to provide GF food to food insecure families through a hospital-based food pantry and offer dietitian-led cooking classes to improve dietary quality and nutrition knowledge. Method(s): To address barriers to food access, Boston Children's Hospital (BCH) opened a food pantry, the Family Food Connections (FFC), in the Jamaica Plain neighborhood of Boston. FFC offers weekly food supplies to BCH patient families and community members. GF food bags are available for those who request them. Monthly virtual cooking classes led by a registered dietitian are offered free of charge to families with and without CD. All classes are held via Zoom with simultaneous translation services available in Spanish. Classes feature naturally GF recipes, and provide instructions on scratch cooking, nutrition education, and use of ingredients found in the food packages. The recipes are designed to include seasonal ingredients and are used as a platform to teach about nutrition related topics. Classes also serve as an open forum for families to ask nutrition and meal preparation related questions to the dietitian instructor. Metrics on pantry usage and class attendance were collected using Zoom analytics tools and REDCap. Result(s): Utilization of both the food pantry and cooking classes increased monthly. During the first six months of operation, an average of 500 families per week visited the FFC for food packages, totaling over 5,000 unique family visits. Of these families, 122 indicated needing all gluten-free food (64) or some gluten-free food (58). As of May 2022, 34 families attended the live virtual cooking classes, and 628 families viewed the recorded sessions. Survey questionnaire responses were limited to date (N=11) but did indicate that families previously had never attended a cooking class due to a lack of time, or they were not aware that classes were available. Conclusion(s): Initial utilization of the FFC, GF food packages, and accompanying cooking classes revealed a significant demand for the provision of GF food as well as a GF focused cooking and nutrition education program. The classes allow for processing nutrition education through non-intentional learning, and provide an opportunity to improve health and quality of life for all who attend, regardless of dietary restrictions. Future studies will evaluate changes in health outcomes, quality of life, cooking habits, and GF diet knowledge.

Celiac Disease and Food Banks in Colorado during the Covid-19 Pandemic

Background: In Colorado, food insecurity affects about 10% of patients with celiac disease and is associated with decreased adherence to gluten-free diet. With the COVID-19 pandemic, demand for gluten-free foods from food banks increased. We sought to assess the availability of gluten-free foods at food banks in Colorado during the pandemic. Method(s): Food banks in Colorado were asked to complete a survey about general understanding of celiac disease and identifying perceived barriers to providing gluten-free foods to people with celiac disease and food insecurity. In-person visits with additional predefined questions for the director were planned. Result(s): Of the 63 food banks contacted, 27 (43%) responded and 15 (24%) completed questionnaires (Table). Some in the Denver Metro area reported no barriers as they felt well equipped with resources and information related to celiac disease. The most common barrier reported was access to gluten-free foods from both donors and from mass suppliers. The next most common barriers were volunteer training and lack of celiac community advocacy about need. Of 16 providing written responses, 8 requested written resources and 3 indicated a separate area for those with food restrictions and adequate supply of gluten-free foods. Only one food bank was visited. The others were inaccessible due to lack of resources or capacity due to the pandemic or lack of communication. The food bank visited was Integrated Family Community Services, a social service whose mission is to alleviate hunger and empower people to make health adjustments. This food bank works with hospitals and the community to support low-income families in Englewood CO, an area with population at high risk of food insecurity. The director at this food bank reported knowing what celiac disease and gluten-free are, as well as trying to provide food for those with specific food restrictions. Prior to COVID, recipients could select the food items they wanted, and gluten-free pastas, flours, breads were separated, as were low glycemic foods for those with diabetes and low sodium foods for those with hypertension. However, due to COVID restrictions, this was no longer possible;volunteers put together pre-made boxes, but not gluten-free boxes. Conclusion(s): During the COVID-19 pandemic, demand for gluten-free food items increased;however, not only was there diminished supply of gluten-free foods to food banks by large and small donors, food banks also were reduced in their capacity to sort and deliver the gluten-free foods to those in need. In addition, there was little awareness of the need for gluten-free donations and the need for volunteers at the food banks. Food insecurity is a contributing factor in adverse health outcomes for celiac disease. Discussion(s): Food insecurity is common, impacting 10%-20% of families with celiac disease and is associated with rural communities, reduced adherence to the gluten-free diet, and the burden of the higher cost of gluten-free foods on low income families. Recognizing the impact on social determinants of health, the US Preventive Services Task Force is developing a research agenda for food insecurity. Strategies celiac centers could adapt to improve access include 1) focused advocacy to increase donations to food banks by gluten-free food producers, 2) creation of areas within food pantries for special dietary needs, 3) provide expert dietitian support to food banks, 4) develop written resources about gluten-free foods, labelling and recipes for food banks, and 5) improve staffing by promoting volunteering. Limitations of this study include low participation rate by food pantries, inability to visit more than one pantry during this study, and extrapolation of findings to other areas outside Colorado. Future directions could include studies to increase health care systems awareness of and screening for food insecurity (demand side), as well as partnering with food banks and gluten free food manufacturers and suppliers to enhance the availability of these foods (supply side) and then assess any impact on health outcomes. (Table Presented).

Impact of demographic profile on nutritional labelling usage by working women population of Varanasi, India

Nutritional labelling is the nutritional description of the food on the label to help the consumer in food selection. The present study aimed to assess the knowledge, attitude and practices adopted by the subjects and correlate them to have a better understanding of their nutritional background. Nutrition labels are a prominent first-glance article that needs to be very catchy and easy to interpret. The organizations responsible for formulating the rules and regulations must keep them updated and devise new formats of the display to enhance the usage of food labels up to the maximum possible level. A cross-sectional research study on 100 working women of Varanasi, aged between 20-50 years was conducted through a self-structured questionnaire to evaluate their KAP level. In view of the COVID-19 pandemic, the questionnaire was administered to the respondents through the online medium using Google forms. It can be inferred from the study that 58 % of the total respondents surveyed were aware of the labels, 61% of them had a positive attitude towards its usage but only 52% practised healthy shopping more often. About 70% of the participants preferred back-of-pack labelling rather than front-of-pack because the former provides elaborative information. The factors like qualification and occupation of women participants had negative associations with the satisfaction of the display format. The women having knowledge regarding traffic light labelling showed a positive association with the usefulness of the same. The average practice percentage adopted by the consumers had a negative association with factors like qualification, income, and occupation. The need for simplifying the display format and providing basic nutrition information to the population is highlighted in this study.

RISK PERCEPTION AND KNOWLEDGE OF COVID-19 IN PATIENTS WITH CELIAC DISEASE

Background: Celiac disease (CeD) has been associated with an increased risk of respiratory infections, however, we recently demonstrated that the odds of contracting COVID-19 in patients with CeD is similar to that of the general population. Due to this discrepancy, how patients with CeD perceive their risk may differ from their actual risk. Aims: The aim of this study was to investigate the risk perceptions for contracting COVID-19 in patients with CeD and to determine the factors that may influence their perceptions. Methods: We distributed a survey throughout 10 countries between March and June 2020 and collected data on demographics, diet, COVID-19 testing, and risk perceptions of COVID-19 in patients with CeD. Participants were recruited through various celiac associations, clinic visits, and social media. Risk perception was assessed by asking individuals whether they believe patients with CeD are at an increased risk of contracting COVID-19 compared to the general population. Logistic regression was used to determine the influencing factors associated with COVID-19 risk perception, such as age, sex, adherence to a gluten-free diet (GFD), and comorbidities such as cardiac/respiratory conditions and diabetes. Data was presented as adjusted odds ratios (aORs). Results: A total of 10,737 participants with CeD completed the survey. From them, 6,019 (56.1%) patients with CeD perceived they were at a higher risk or were unsure if they were at a higher risk of contracting COVID-19 compared to the non-CeD population. A greater proportion of patients with CeD had high levels of COVID-19 risk perceptions when compared to infections in general (56.1% vs 26.7%;p<0.0001). Consequently, 28.8% reported taking extra COVID-19 precautions as a result of their CeD. Members of celiac associations had lower rates of perceiving an increased risk of COVID-19 when compared to non-members (49.5% vs 57.4%, p<0.0001). Older age (aOR: 0.9;95% CI: 0.9 to 1, p<0.001), male sex (aOR: 0.85;95% CI: 0.76 to 0.94, p=0.001), and strict adherence to a GFD (aOR: 0.89;95% CI 0.82 to 0.97, p=0.007) were associated with a lower perception of COVID-19 risk. Meanwhile, the presence of comorbidities was associated with a higher perception of COVID-19 risk (aOR: 1.34;95% CI: 1.20 to 1.51, p<0.001). Conclusions: Overall, a large proportion of patients with CeD, particularly females, those with comorbidities, or those not adhering to a strict GFD, believed they were or were unsure if they were at a higher risk of contracting COVID-19 due to their condition. As high levels of risk perception may increase an individual's pandemic-related stress and contribute to negative mental health consequences, healthcare providers should maintain consistent communication with the celiac community and provide them with evidence-based recommendations.

Does a Gluten-Free Diet Affect BMI and Glycosylated Hemoglobin in Children and Adolescents with Type 1 Diabetes and Asymptomatic Celiac Disease? A Meta-Analysis and Systematic Review.

Background: Children diagnosed with type 1 diabetes mellitus (T1DM) are more prone to having celiac disease (CD) than the normal population. Moreover, patients with this dual diagnosis who are also on a diabetic and gluten-free diet (GFD) risk faltering growth and uncontrolled blood glucose levels. This review aims to assess the efficacy and effectiveness of managing patients with T1DM screened for CD with GFD to prevent complications associated with these chronic pathologies in childhood and adulthood. Materials and Methods: We abided by the PRISMA guidelines in this meta-analysis and used multiple databases and search engines. We included case-control studies. The primary outcomes were changes in the standard deviation score, body mass index (SDS BMI), and glycosylated hemoglobin (HA1C) after being on a GFD for at least twelve months. Results: The pooled data from the six studies included showed that there was neither a statistically significant difference in the mean SDS BMI (-0.28 (95% CI -0.75, 0.42)) (p = 0.24) nor in the mean of HA1C (mean -0.07 (95% CI -0.44, 0.30)) (p = 0.36) for the same group. HDL cholesterol improved significantly in patients on a strict GFD (p < 0.01). Conclusions: In children with T1DM and asymptomatic CD, being on a GFD had no significant effect on BMI or HA1C. However, it can have a protective effect on the other complications found in both chronic pathologies.

PATIENTS WITH CELIAC DISEASE HAVE NO INCREASED RATE OF ADVERSE EVENTS AFTER COVID-19 VACCINE ADMINISTRATION COMPARED WITH NON-CELIAC CONTROLS

Background: A recent study showed that CeD patients have greater hesitancy in receiving the COVID-19 vaccine, mainly due to fear of adverse events. It is unclear if the rate of adverse events post-vaccine administration is higher in CeD compared to non-celiac population. Aims: To assess the prevalence of adverse events related to COVID-19 vaccine administration in patients with CeD compared to non-CeD controls, and to explore factors that predict the risk of adverse events related to COVID-19 vaccine. Methods: This is a preliminary analysis of an ongoing study conducted at McMaster Adult Celiac Disease Clinic. We collected data prospectively in a cohort of adult patients with a diagnosis of CeD attending our clinic and compared with non-CeD controls (university personnel). CeD diagnosis was based on serology, biopsy, and HLA DQ2/DQ8 in discrepant cases. Data collected included demographics, CeD activity through serology, adherence to the gluten-free diet (GFD), prior COVID-19 infection, vaccine type and status, and any adverse events. Mild adverse events were classified as pain at the site, fatigue, fever/chills, nausea, headaches. Severe adverse events included anaphylaxis, thrombosis, myocarditis/pericarditis, and hospitalization or emergency visits due to vaccination. Data were expressed as median [IQR] for continuous variables and n/N (%) for categorical variables. Mann-Whitney U test and Fisher exact test were performed using SPSS (v26, IBM Corp) to assess differences between groups and logistic regression to assess predictors of adverse events. Results: An interim analysis was performed in 53 patients with CeD (25% male;median age of 34[25] years) and 46 controls (37% male;median age of 41[22] years). There were no differences in sex between CeD and controls, however, controls were older than CeD (p=0.04). Fifty-five % of CeD patients were strictly adherent with a GFD. There was no difference in the rate of COVID-19 infection between CeD and controls. All CeD patients and controls reported receiving two doses of COVID-19 vaccines. Eighty-three % of CeD received the same vaccine type in both doses, and 17% mixed vaccines vs 81% and 19% respectively for controls. There were no severe adverse events reported by CeD or controls. The most common mild adverse events reported in CeD and controls included pain at the injection site (27% vs 64%;p <0.001) and fatigue (11% vs 46%;p<0.001). Celiac activity, age, sex, or vaccine type did not predict adverse events in CeD patients for either dose. Conclusions: In this preliminary analysis, administration of COVID-19 vaccines did not lead to severe adverse and less mild adverse reactions in patients with CeD compared to non-CeD controls. These results should be confirmed in a larger population, and ideally, in a future multicentre study involving pediatric and adult populations from different countries.

FOOD INSECURITY INCREASES THE ODDS OF INTENTIONAL GLUTEN EXPOSURE

Background: Food insecurity, defined as lack of consistent access to enough food for an active, healthy life was projected to affect 1 in 6 children in the United States in 2021. Market basket studies have consistently found that gluten-free (GF) foods are more expensive than their gluten-containing counterparts. We conducted an anonymous survey to determine the prevalence of food insecurity in households with children on a gluten-free diet (GFD) and how it can impact a child's adherence to a GFD. Methods: An anonymous electronic survey was distributed through celiac support groups, national celiac organization newsletters, and social media from March to May 2021. Survey items included demographic and medical information. Food insecurity risk before and during the COVID-19 pandemic was evaluated using the validated adapted Hunger Vital Signs Screener modified with “glutenfree food” to each screening question. Results: The 413 households with children on a GFD that completed the survey primarily self-identified as white (86%, 354). All 10 zip-code regions in the United States were represented. Most had a household income > $80000, resided in a mortgaged home, and were relatively well-educated. The most common reason for a GFD was celiac disease (CD) (92%, 378), and 72% (266) had been on a GFD for >2 years. All households noted a decrease in availability of GF foods during the pandemic (p<0.001). Pre-pandemic, 21% (86) of the households with at least one child following a GFD screened positive for food insecurity. When asked specifically about GF foods, 23% (94) of the households screened positive. Both food insecurity (25%, 104) and GF food insecurity (28%, 116) increased during the pandemic. Both before and during the COVID- 19 pandemic, 5% (19) of the households who were food secure screened positive for GF food insecurity. In one of ten households, individuals on a GFD ate gluten because there were no GF options available. Gluten ingestion due to unavailability of GF foods was higher in households who screened positive for food insecurity (aOR=5) or GF food insecurity (aOR=7). Gluten was eaten before and during the COVID-19 pandemic with a significant increase during the pandemic(p<0.001). Conclusions: Using a nationwide survey, we found that both overall and GF food insecurity have increased for households with children on a GFD. Rates of reported intentional gluten consumption because no GF options were available increased from 1 in 20 households to 1 in 10 households. Food insecurity increased the odds of a household member on a GFD eating gluten on purpose/intentionally. Food insecurity is an underrecognized risk to our celiac patients. Gastroenterologists should incorporate food insecurity screening into their practice for patients on a GFD, especially in the setting of celiac symptom exacerbation.(Figure Presented)Food Insecurity, Intentional Gluten Ingestion and Gluten-Free Food Availability (n=413) (a) Food and Gluten-Free Food Insecurity in Households with Children on a Gluten-Free Diet was measured by screening patients via the validated and adapted Hunger Vital Signs Screener. There was no significant difference in food insecurity before and during the pandemic. (b) Intentional Gluten Ingestion due to Unavailability of Gluten-Free Foods before and during pandemic was compared with test of proportions showing a significant difference (p value < 0.05) (c) Gluten-Free Food availability before the pandemic and (d) Gluten-Free Food availability during the pandemic showed decreasing availability of gluten free foods.

Effects of a gluten-reduced or gluten-free diet for the primary prevention of Cardiovascular disease

Background: Cardiovascular diseases (CVD) are a major cause of disability and the leading cause of death worldwide. To reduce mortality and morbidity, prevention strategies such as following an optimal diet are crucial. In recent years, low-gluten and gluten-free diets have gained strong popularity in the general population. However, study results on the benefits of a gluten-reduced or gluten-free diet are conflicting, and it is unclear whether a gluten-reduced diet has an effect on the primary prevention of CVD. Objectives: To determine the effects of a gluten-reduced or gluten-free diet for the primary prevention of CVD in the general population. Search methods: We systematically searched CENTRAL, MEDLINE, Embase, CINAHL and Web of Science up to June 2021 without language restrictions or restrictions regarding publication status. Additionally, we searched ClinicalTrials.gov for ongoing or unpublished trials and checked reference lists of included studies as well as relevant systematic reviews for additional studies. Selection criteria: We planned to include randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs), such as prospective cohort studies, comparing a low-gluten or gluten-free diet or providing advice to decrease gluten consumption with no intervention, diet as usual, or a reference gluten-intake category. The population of interest comprised adults from the general population, including those at increased risk for CVD (primary prevention). We excluded cluster-RCTs, case-control studies, studies focusing on participants with a previous myocardial infarction and/or stroke, participants who have undergone a revascularisation procedure as well as participants with angina or angiographically-defined coronary heart disease, with a confirmed diagnosis of coeliac disease or with type 1 diabetes. Data collection and analysis: Two review authors independently assessed eligibility of studies in a two-step procedure following Cochrane methods. Risk of bias (RoB) was assessed using the Cochrane risk of bias tool (RoB2) and the 'Risk Of Bias In Non-randomised Studies - of Interventions' (ROBINS-I) tool, and the certainty of evidence was rated using the GRADE approach. Main results: One RCT and three NRSIs (with an observational design reporting data on four cohorts: Health Professionals Follow-up Study (HPFS), Nurses' Health Study (NHS-I), NHS-II, UK Biobank) met the inclusion criteria. The RCT was conducted in Italy (60 participants, mean age 41 +or- 12.1 years), two NRSIs (three cohorts, HPFS, NHS-I, NHS II) were conducted across the USA (269,282 health professionals aged 24 to 75 years) and one NRSI (Biobank cohort) was conducted across the UK (159,265 participants aged 49 to 62 years). Two NRSIs reported that the lowest gluten intake ranged between 0.0 g/day and 3.4 g/day and the highest gluten intake between 6.2 g/day and 38.4 g/day. The NRSI reporting data from the UK Biobank referred to a median gluten intake of 8.5 g/day with an interquartile range from 5.1 g/day to 12.4 g/day without providing low-and high-intake categories. Cardiovascular mortality: From a total of 269,282 participants, 3364 (1.3%) died due to cardiovascular events during 26 years of follow-up. Low-certainty evidence may show no association between gluten intake and cardiovascular mortality (adjusted hazard ratio (HR) for low- versus high-gluten intake 1.00, 95% confidence interval (CI) 0.95 to 1.06;2 NRSIs (3 cohorts)). All-cause mortality: From a total of 159,265 participants, 6259 (3.9%) died during 11.1 years of follow-up. Very low-certainty evidence suggested that it is unclear whether gluten intake is associated with all-cause mortality (adjusted HR for low vs high gluten intake 1.00, 95% CI 0.99 to 1.01;1 NRSI (1 cohort)). Myocardial infarction: From a total of 110,017 participants, 4243 (3.9%) participants developed non-fatal myocardial infarction within 26 years. Low-certainty evidence suggested that gluten intake may not be associated with the development of non-fatal myocardial infarction (adjust

Maintaining, Managing, and Tele-Monitoring a Nutritionally Adequate Mediterranean Gluten-Free Diet and Proper Lifestyle in Adult Patients

The gluten-free diet (GFD) is a restrictive diet. In many cases, it must be permanent and strict, and it may be associated with both nutritional deficiencies and excesses, which can be prevented by following a healthy, natural Mediterranean GFD (Med-GFD). In this paper, we describe the importance of the Mediterranean diet, the correct intake of vitamins and minerals, and how they may play an important protective role against chronic or degenerative conditions. Herewith, we analyze different aspects that influence the ability to maintain a correct and balanced Med-GFD, which may contribute to the health status of patients, including a conscious use of gluten-free products to maintain a healthy lifestyle. Monitoring the Med-GFD remains a pivotal issue: to evaluate the presence of gluten peptides in urine, it could be important to introduce point-of-care testing, an efficient method for GFD self-monitoring (immunochromatographic technique), together with online nutritional questionnaires. Indeed, medical care via telemedicine can provide practical indications aimed at supporting patients and doctors. A natural Med-GFD can ensure the correct intake of nutrients and could be important for patients affected by gluten-related disorders, helping them to maintain a correct and healthy lifestyle.

Diagnosis of coeliac disease by flow cytometry of intraepithelial lymphocytes: a new 'gold' standard?

Objective: The analysis of intraepithelial lymphocytes (IELs) by flow cytometry of duodenal biopsies-the 'IEL' lymphogram-has been proposed as a diagnostic test for coeliac disease. However, its clinical applicability has been limited due to variability in methods and definitions. This study set out to define useful parameters for the application of the IEL lymphogram to the diagnosis of coeliac disease. Design: Flow cytometry was performed on 117 sets of duodenal biopsies in 107 adult patients with active coeliac disease, long-term coeliac disease on a gluten free diet and a control group. The initial 95 samples were used for hypothesis generation for the subsequent samples comprising 12 patients with coeliac disease and 10 controls. Results: Rather than using single linear cut-offs for CD3 and T-cell receptor γδ (TCRγδ)+ve IELs, a discriminant function was identified as %CD3+ve IELs+2x(%TCRγδ+IELs)>100. This differentiated coeliac disease from control biopsies in the hypothesis generating group. These results were replicated in the validation group and found to be independent of histology in patients on long-term gluten free diet up to 12 years (combined sensitivity, 98.5%; specificity, 97.7%). Conclusions: Flow cytometric analysis of IELs is a highly sensitive and specific adjunct to serology and histological examination for the diagnosis of coeliac disease, even in individuals with coeliac disease following a gluten free diet who exhibit normal duodenal histology.

AN INTERNATIONAL REPORTING REGISTRY OF PATIENTS WITH CELIAC DISEASE AND COVID-19: INITIAL RESULTS FROM SECURE-CELIAC

Background: As the COVID-19 pandemic continues, there are questions about whether patients with celiac disease (CD) are at increased risk for severe outcomes. Prior studies have shown that patients with CD have a higher risk of developing zoster and complications from influenza and pneumococcal pneumonia, risks that persist after adoption of the gluten free diet. To study the outcomes of COVID-19 in patients with celiac disease, we created a secure, online, de-identified adult and pediatric reporting registry. Methods: The SECURECeliac registry (www.covidceliac.org) was established on March 31, 2020 and promoted via physician email lists, national societies, and word-of-mouth. Clinicians worldwide are encouraged to report all cases of COVID-19 in patients with celiac disease, regardless of severity. (Only confirmed cases of COVID-19, either through viral PCR swab or serology testing, are eligible to be reported in the registry.) Clinicians were counseled to report confirmed cases only after a minimum of 7 days and sufficient time had passed to observe the disease course through resolution of acute illness or death. A choropleth map to illustrate geographic differences in reported cases of COVID-19 in those with CD was created using QGIS and an interactive online website was created using ARCGIS to visualize current data by time, country, age, sex, hospitalizations, and deaths. Results: Between March 31, 2020 and November 20, 2020, there have been 84 cases of COVID-19 reported in patients with celiac disease. Countries across five continents are represented in the registry: Asia, Australia, Europe, North America and South America (Figure 1). 86% of patients (N = 72) did not require hospitalization for COVID-19 while 14% did (N = 12). 1% of patients (N = 1) required ICU-level care while 1% of patients (N = 1) died from COVID-19. Patients who were hospitalized tended to be older (45.8y vs 39.4y, p= 0.2) and have at least one comorbidity (50.0% vs 31.9%, p= 0.3). Patients who were hospitalized were also less likely to adhere to a strict gluten-free diet (41.7% vs 65.3%, p=0.2). Patients with gastrointestinal symptoms were more likely to be hospitalized (66.7% vs 31.9%, p = 0.03). An online dashboard with interactive map displaying the current global distribution of patients with CD and COVID-19 is found here: www.covidceliac.org/map Conclusions: Preliminary data from the SECURECeliac registry does not suggest increased risk of severe outcomes in patients with celiac disease who contract COVID-19. Gastrointestinal symptoms were associated with hospitalization for COVID-19. The registry remains open for clinicians to contribute to this reporting system so as to better define the impact of COVID-19 on patients with celiac disease and how factors such as age, comorbidities, and treatments impact COVID-19 outcomes.(Image Presented)(Table Presented)

IMPACT OF A SARS-COV2 INFECTION IN PATIENTS WITH CELIAC DISEASE

Objective. No data are available on the effects of SARS-CoV2 infection in patients with celiac disease (CD) in terms of development of related symptoms and antibodies. We aimed to investigate the impact of SARS-CoV2 infection in CD. Design. During lockdown (March-May 2020), celiac patients living in Milano were interviewed about the development of COVID-19 resembling symptoms, adherence to an anti-virus lifestyle and gluten-free diet (GFD), and were asked to reply to a stress questionnaire. The development of anti SARSCoV2 IgG and IgA (anti RBD and N proteins) and the expression of duodenal ACE2 receptor were also investigated. Whenever available, duodenal histology, anti-tissue transglutaminase IgA (tTGA), immunologic comorbidities and GFD adherence were analyzed as possible risk factors. Results. 362 celiac patients have been interviewed and 42 (11%) reported COVID-19 resembling symptoms. The presence of symptoms was not influenced by positivity of tTGA, presence of duodenal atrophy or adherence to GFD. 37% of symptomatic patients showed anti SARS-CoV2 Immunoglobulins (Ig). Globally, 18% of celiac patients had anti SARS-CoV2 Ig vs 25% of non-celiac controls (p=0.18). Levels of anti RBD IgG/IgA and anti N IgG did not differ from non-celiac controls. Celiac patients had significantly lower levels of anti N IgA. ACE2 receptor was detected in the non-atrophic duodenal mucosa of celiac patients;atrophy was associated with a weaker expression of ACE2 receptor. Conclusion. CD patients show an anti SARS-CoV2 Ig positivity/profile similar to non-celiac controls, except for anti-N IgA. Main celiac biomarkers and adherence to the GFD do not influence the development of different antibody profiles.

Impact of Corona Virus Disease 2019 pandemic on adherence to gluten-free diet in Indian patients with celiac disease.

AIMS: Lockdown and restricted mobility due to the pandemic of corona virus disease  2019 (COVID-19) has severely affected the continuity of healthcare of patients with acute and chronic diseases. We evaluated the impact of COVID-19 on the adherence to gluten-free diet (GFD), symptom control, and quality of life (QOL) in patients with celiac disease (CeD). METHODS: A questionnaire, consisting of both ad-hoc and validated questions, was created after review of literature, group discussions, and expert meetings. Standardized questionnaires namely CeD adherence test (CDAT), celiac symptom index score, and CeD-related QOL were used. The web-based questionnaire was sent to 3130 patients via social media and 452 responses (14.4%) were received. Also, additional 68 patients (not available on any social media application) were interviewed telephonically by a trained dietitian. RESULTS: Overall, 505 patients (females: 318; mean age: 24.1±14.2 years) were included. While only 6.7% (n = 34) had poor compliance to GFD (CDAT > 17) before COVID-19 pandemic, it almost doubled to 12.6% (n = 64) during the COVID-19 pandemic times (p = 0.02). Furthermore, 4.9% (n = 25) of patients were diagnosed contacting  COVID-19. Interestingly, 73.2% (n = 370) patients preferred online appointment than physical appointment. Most common difficulties faced during lockdown period were high delivery charges for getting gluten-free (GF) food at home (54.4%), increased prices of regular GF food (43.1%), and travelling long distance to arrange GF food (44.9%). CONCLUSIONS: The COVID-19 pandemic has substantially affected the adherence, symptom control, and QOL in patients with CeD, attributable to unavailability, shortage of money, and heightened cost of GF food. The pandemic has offered an opportunity to practice teleconsultation approach for patients with CeD.