Coeliac disease and the gluten-free diet: a review of the burdens; factors associated with adherence and impact on health-related quality of life, with specific focus on adolescence.

Adherence and non-adherence to a gluten-free diet (GFD) may impact negatively on health-related quality of life (HRQoL). Understanding the factors that influence compliance could help inform management and also guide support. With a particular focus on adolescence, this narrative review critiques current literature on the burdens associated with following a GFD and the factors associated with adherence. Studies highlight a variety of burdens faced by individuals with coeliac disease, including the cost, access and availability of gluten-free (GF) foods, as well as the dilemmas experienced when eating out, travelling and socialising with friends. A number of studies report that adolescents face stigmatisation and feel isolated in social situations and at school. Additional burdens that are highlighted are a lack of knowledge regarding CD and GFD difficulties in interpreting food labels, as well as dissatisfaction with the organoleptic properties of GF foods. Factors associated with poor adherence in adolescence include older age, an absence of immediate symptoms, difficulties eating out and poor palatability of GF foods. Conversely, better emotional support and stronger organisation skills have been associated with superior adherence. Significant associations have been reported between HRQoL measures and adherence, although the findings are inconsistent. Limitations in research methodologies exist and data are restricted to just a few countries. Further research specific to adolescence is required to identify independent predictors of adherence.

A study of fluid provision and consumption in elderly patients in a long-stay rehabilitation hospital.

BACKGROUND: Adequate hydration is key to good clinical care and essential for preventing problems in elderly patients such as constipation, pressure sores and confusion. The present study aimed to evaluate fluid provision and consumption in elderly patients against current standards for Scottish hospitals. METHODS: A service evaluation, of fluid provision and consumption over 24 h by elderly orthopaedic rehabilitation patients in a long-stay hospital in Scotland was conducted. Fluids provided and consumed from trolley services, those at meal times and beverages from jugs of water were measured. The average fluid content of a jug, cup and glass on each ward was determined. Each jug of water provided was recorded, as was the acceptance of hot and cold drinks offered. Intake was determined by measuring the leftover water in each jug when these were refreshed and any leftover liquid in patients' cups deducted from that provided. Observations were made with respect to the presentation and encouragement of fluids. RESULTS: Fifty-eight patients (12 males, 46 female, aged ≥65 years) were monitored, of whom 56 were provided with more than the recommended minimum fluid per day [mean (SEM) = 2379 (82) mL]; however, mean intake was lower than recommended [mean (SEM) = 1302 (60) mL; P = 0.002]. Provision of drinks from a trolley service [mean (SEM) = 956 (44) mL] was less than fluid from jugs [mean (SEM) = 1398 (54) mL; P = 0.002]; however, the consumption of drinks from the trolley was greater [77% consumed, mean (SEM) = 770 (46) mL] than from jugs [41% mean (SEM) = 514 (36) mL; P < 0.001]. CONCLUSIONS: Patients consumed significantly more fluid from individual beverages than jugs. Consideration of the method of fluid provision is important with respect to influencing fluid intakes.

A dietary survey to determine if patients with coeliac disease are meeting current healthy eating guidelines and how their diet compares to that of the British general population.

OBJECTIVES: To assess the dietary intake of people with coeliac disease (CD) and to determine if they are meeting the current dietary reference values (DRVs). To compare dietary intakes of people with CD to the dietary intake of the general population. The nutritional contribution of gluten-free products (GFPs) and current purchasing trends was also evaluated. SUBJECTS/METHODS: 106 patients were invited to participate via post. Three-day food diary to assess intake and a short simple questionnaire that looked at purchasing trends of GFP. RESULTS: Forty-nine patients returned the food diary and 48 returned the questionnaire. Patients were found to have a low intake of energy, non-starch polysaccharides (NSPs), vitamin D and calcium. They were obtaining a significantly lower proportion of energy from fat and a significantly higher proportion of energy from protein than the DRVs (P<0.05). Intake was comparable to the general population for most nutrients, except they had a significantly greater intake of protein, a lower intake of fat and a significantly lower intake of vitamin D (P<0.05). Specialist GFP, especially those obtained on prescription, were an important source of energy, carbohydrate, NSP, calcium and iron. CONCLUSIONS: Patients with CD are at risk of having an inadequate intake of calcium, NSP and vitamin D. Specialist GFP, which were obtained on prescription, helped patients get a balanced diet and without these patients would be at an increased risk of many deficiencies.

Lower limb fracture, cognitive impairment and risk of subsequent malnutrition: a prospective evaluation of dietary energy and protein intake on an orthopaedic ward.

OBJECTIVE: To report the dietary energy and protein intake of undernourished older adults (with and without cognitive impairment) admitted to hospital following a lower limb fracture and to determine whether dietary intakes met estimated requirements. DESIGN: An observational study of a sequential sample. SETTING: The orthopaedic ward of a South Australian metropolitan teaching hospital. SUBJECTS: Sixty-eight patients aged > or =70 years screened as undernourished and admitted to hospital following lower limb fracture (50% cognitively impaired) provided 3 to 5 days of dietary data. MAJOR OUTCOME METHODS: Dietary energy and protein intake. METHODS: Dietary assessment using plate waste methodology and snack record charts commenced within 6 days postinjury and continued for up to five consecutive days or until discharge. Estimated resting energy requirements were calculated and adjusted for activity equivalent to bed rest and physiological stress. Protein requirements were calculated as 1 g/kg/day. Cognition was assessed using the Short Portable Mental Status Questionnaire. RESULTS: Cognitively impaired participants and those without cognitive impairment consumed, mean (95% CI) respectively, 3661 kJ/day (3201, 4121) versus 4208 kJ/day (3798, 4619) and 38 g (33, 44) versus 47 g (41, 52) protein/day. Cognitively impaired participants consumed mean (95% CI) 48% (43, 53) of estimated total energy expenditure and 78% (69, 87) of estimated protein requirements. CONCLUSIONS: Orthopaedic fracture patients at greatest nutritional risk, including those with cognitive impairment, do not achieve estimated energy or protein requirements from diet alone. Effective methods of achieving requirements in this vulnerable group are needed before improvements in outcomes will be observed.

Australian Longitudinal Study of Ageing: prospective evaluation of anthropometric indices in terms of four year mortality in community-living older adults.

The Australian Longitudinal Study of Ageing (ALSA) aims to identify factors that contribute to & predict the health & social well-being of older Australians. Analyses were performed to determine the predictive value of anthropometric measurements in older Australians for four-year mortality. Weight, height, skinfolds (triceps, abdominal, supra-spinale, sub-scapular, medial calf, and front thigh) & girth (arm, waist, hip, calf) measurements were performed on a randomly selected community-living sample of 772 men & 624 women aged>70 years. Waist: Hip, % weight loss, corrected-arm-muscle area (CAMA) & BMI were calculated. These measures were categorised into quartiles & also according to commonly adopted definitions of nutritional status. Cox regression analysis was undertaken to assess the predictive value of the independent anthropometric variables for four-year mortality, adjusting for potential confounders (age, gender, marital status, smoking, alcohol status, self-rated health, basic activities of daily living & co-morbidity). Risk of four-year mortality increased with weight loss >10% over two years (HR=2.53, CI=1.37-4.67) & CAMA <21.4cm2(M) & <21.6cm2(F) (HR=1.93, CI=1.03-3.60) independent of confounding variables. These results confirm that selected anthropometric indices (weight loss, CAMA) independently increase the risk of four-year mortality & highlights their potential use in the nutrition screening and assessment of community-living older adults.

Evaluation of micronutrient intakes of older Australians: The National Nutrition Survey--1995.

PURPOSE: To determine the proportion of Australian adults >65 years with nutrient intakes less than 70% of the current national RDIs and investigate associated differences in both diet quality and quantity. METHOD: Intake data were collected as part of the National Nutrition Survey 1995 representing all areas of Australia. Dietary intake of 1960 (902 males) adults >65 years was assessed using a structured 24-hour diet recall. Intakes of 12 micronutrients were compared with current Australian recommended dietary intakes (RDIs) and assessed as > RDI, < RDI but > 70% RDI, and < 70% RDI. RESULTS: Intakes of vitamin A, magnesium, potassium and calcium were < 70% RDI in 12-24% males and 14-61% females. In addition 10% and 43% females had low intakes of folate and zinc respectively. None of the participants had intakes of niacin or vitamin C < 70% RDI, and few males had low thiamin intakes. Specific nutrient density and energy intake (kJ/kg) were significantly less in those with intakes < 70% RDI for eight of the 12 nutrients studied. CONCLUSIONS: In general the low nutrient intakes reported here can be attributed to diets of poor quality, in terms of low nutrient density, and quantity of food eaten. Age-specific targeted nutrition promotion strategies are required to improve overall health of older Australians.

Cross-sectional and prospective studies of nutritional indices after percutaneous gastrostomy.

OBJECTIVE: Formal monitoring of nutritional status may be lacking in many patients after gastrostomy. We aimed to study nutritional assessment and its problems in patients after gastrostomy in a cross-sectional study, assess prospectively the changes in nutritional status of patients at 1 month and 6 months after gastrostomy placement, and determine the prognostic value of nutritional indices assessed at the time of gastrostomy placement. DESIGN: We used cross-sectional and prospective cohorts. The subjects were institutional and community patients receiving percutaneous gastrostomy in a teaching hospital. METHOD: We studied patients living in the community and in long-term care institutions after gastrostomy. In the cross-sectional study, we observed all individuals who received a percutaneous gastrostomy from the Gastrointestinal Unit, Western General Hospital, Edinburgh from January 1994 to December 1996. In the prospective study, we observed consecutive referrals of patients to the Gastrointestinal Unit for percutaneous gastrostomy from March 1997 to June 1998. Nutritional status was assessed using: weight (kg), height or stature estimated from knee-height (m), mid-upper arm circumference and triceps skinfold thickness. Body mass index, arm-muscle circumference and corrected arm-muscle area were calculated. A blood sample was taken to assess micronutrient status. RESULTS: In the cross-sectional study, 215 patients were identified who had received a percutaneous gastrostomy during the 3-year period 1994-1996. The weight and height measurements obtained in patients after gastrostomy were not as successful as upper-arm anthropometry. Of the 55 who were alive, traceable and agreed to take part in the study, 8% were under-nourished by corrected arm-muscle area at a median of 16 months after gastrostomy placement, whilst 57% had biochemical evidence of macro- or micronutrient deficiency. In the prospective study, 54 out of 87 patients referred for percutaneous gastrostomy agreed to participate. Using corrected arm-muscle area, 14% of patients were under-nourished at the time of gastrostomy placement. Changes in nutritional status at 1 month and 6 months post gastrostomy were mixed across the patient groups. Patients with a depleted corrected arm-muscle area 21.6 cm2 (log-rank test 9.05; P = 0.003, relative risk 4.7). All patients in whom corrected arm-muscle area had increased at the 1-month follow-up survived to 6 months post gastrostomy. CONCLUSIONS: Assessment of nutritional status may be difficult in gastrostomy-fed patients. Upper-arm anthropometry is more often successful than other assessment methods and gives prognostic information.

Altered subjective appetite parameters in Crohn's disease patients.

BACKGROUND AND AIM: Altered appetite and early satiety may promote anorexia associated with Crohn's disease. The aim of this study was to assess the impact of disease activity on subjective appetite parameters in Crohn's disease patients. METHODS: Seventeen patients with Crohn's disease and 15 healthy controls (8 M: 7 F, 34 (20-35) years) were studied. Subjects rated their hunger, desire to eat, fullness and level of satiety using visual analogue scales after an overnight fast. Subjects were reassessed after ingestion of 500 and 1000 ml water. Anthropometry was used to determine percentage body fat. Serum leptin & TNF- alpha levels were assessed using immunoassay. Disease activity was determined using the Harvey-Bradshaw index. RESULTS: Hunger ratings for active Crohn's disease patients were significantly lower than controls at baseline (P<0.05). Desire to eat was lower in patients with active Crohn's disease than controls both at baseline (95% CI, 0.3 mm, 40.7 mm) and after ingestion of 500 ml water (95% CI, 1.25 mm, 51.9 mm) (P<0.05). Serum leptin concentrations were significantly associated with percent body fat (r=0.57;P<0.001) and, after correcting for body fat status, tended to be higher in patients with active Crohn's disease (mean 0.9 ng/ml/% body fat; SD 0.8 ng/ml/% body fat) compared with either patients with inactive disease (mean 0.4 ng/ml/% body fat; SD 0.3 ng/ml/% body fat) or healthy controls (mean 0.3 ng/ml/% body fat; SD 0.2 ng/ml/% body fat) (P=0.15, ns). Appetite parameters and serum leptin concentrations showed no significant correlation. CONCLUSIONS: Subjective appetite parameters were altered in patients with active Crohn's disease. At baseline, patients with active Crohn's disease were less hungry than healthy controls and had less desire to eat. After ingestion of 500 ml of water, desire to eat was significantly less in patients with active disease as compared with healthy controls. Serum leptin concentration corrected for percent body fat tended to be higher in patients with active Crohn's disease compared with inactive Crohn's disease and healthy controls, but the differences did not reach statistical significance.

A cross-sectional and longitudinal study of health-related quality of life after percutaneous gastrostomy.

OBJECTIVE: Although gastrostomy feeding tends to have fewer interruptions than naso-gastric feeding and is cosmetically more acceptable; there is little information on health-related quality of life (HRQoL) in these patients. This study aimed to measure the health-related quality of life of patients after gastrostomy placement. DESIGN: Cross-sectional and prospective cohorts. SETTING: Institutional and community-dwelling patients receiving nutritional support via a gastrostomy. PARTICIPANTS: For the cross-sectional cohort, all individuals who have received a percutaneous gastrostomy from our unit (January 1994-December 1996) were included; 55 of the 102 patients who were still living agreed to follow-up assessment. For the prospective cohort, all patients referred to our unit for percutaneous gastrostomy (March 1997-June 1998) were eligible to participate; 54 of 88 patients (62%) consented and were recruited. METHODS AND OUTCOME MEASURES: A cross-sectional assessment of patient outcome and health-related quality of life using SF-36, the Hospital Anxiety and Depression Scale and a disease-specific questionnaire (PEG-Qu) was carried out in patients in primary health care after receiving a gastrostomy. These assessments, plus the Modified Rankin Scale, were performed on patients studied at the time of gastrostomy placement, and after 1, 6 and 12 months of follow-up. RESULTS: HRQoL questionnaires could be answered in less than half the patients. An overall rating of the effect of the gastrostomy on the patients' and carers' HRQoL showed a positive effect in 55% and 80%, respectively. A positive impression of the gastrostomy by the patient did not necessarily reflect an improvement in their nutritional status. Assessment of HRQoL in a cohort of gastrostomy patients showed deficiencies in the physical domain but not mental function (anxiety or depression), energy or health perception. Neither physical function nor level of cognition at time of gastrostomy placement appear to be able to predict patient survival. Nutritional outcome was not related to HRQoL outcome. CONCLUSION: The majority of patients and carers rate gastrostomy positively. Patients who were 75 years or older had a poorer survival compared to younger patients, but gender, physical or cognitive function had no predictive value on survival.

Division of Listeria monocytogenes serovar 1/2a strains into two groups by PCR and restriction enzyme analysis.

Altogether, 100 strains of Listeria monocytogenes serovar 1/2a isolated from humans, animals, food, and the environment were typed by a combination of PCR and restriction enzyme analysis (REA). A PCR product of 2,916 bp, containing the downstream end of the gene inlA (955 bp), the space between inlA and inlB (85 bp), and 1,876 bp of the gene inlB, was cleaved with the enzyme AluI, and the fragments generated were separated by gel electrophoresis. By this method two different cleavage patterns were obtained. Seventy of the 100 strains shared one restriction profile, and the remaining 30 strains shared the second one. No relation was found between the types differentiated by PCR-REA and the origins of the strains.

Listeria monocytogenes subtypes associated with mortality among fallow deer (Dama dama).

Different subtypes of Listeria monocytogenes were isolated from various animal and environmental samples during an episode of increased mortality on a fallow deer (Dama dama) farm. During a 4-wk period, six fallow deer died, including four does, one fawn, and one adult buck. Prior to death, one of the does had exhibited central nervous system signs characteristic of listeriosis. Postmortem examination of the six deer showed no histologic changes typical of listeriosis, although inflammatory changes were present in several organs. Different subtypes of L. monocytogenes were isolated from brain samples from six deer, from fodder and soil from the deer feeding area, and from faces of some healthy animals on the farm. Listeria monocytogenes, which was frequently isolated in the environment of the farm, was considered the probable major cause of mortality in these fallow deer.

Comparison of PCR-based DNA fingerprinting techniques for the identification of Listeria species and their use for atypical Listeria isolates.

Four PCR-based DNA fingerprinting techniques were compared for their ability to identify at the species level a heterogeneous collection of isolates belonging to the six valid Listeria species. 16S rDNA-RFLP analysis identified all species and 16S rDNA-SSCP analysis identified almost all species. Also, isolates with unusual biochemical characteristics and/or unusual antigenic composition could be identified correctly. rRNA-intracistronic length polymorphism analysis suffered from high intraspecific variability, a limited number of fragments per profile, and small length differences between the spacers of different species. tRNA-intergenic length polymorphism analysis resulted in identification of all isolates but one, when fluorescent DNA capillary electrophoresis was used such that fragment length differences of 1 bp could be resolved. The four techniques yielded comparable results relevant to the taxonomy of Listeria. They all indicate a high degree of genetic relatedness between L. innocua and L. welshimeri, homogeneity of L. grayi, distinct but clear relatedness of L. grayi to the other Listeria species, a clear distinction between the two subspecies of L. ivanovii, and a clear distinction between Listeria isolates and isolates from closely related taxa or from species which are phenotypically difficult to distinguish from Listeria. New sequence determination of the 16S rRNA gene was necessary to obtain sequences in accordance with the findings of 16S rDNA-RFLP analysis.

Evaluation of validity of British anthropometric reference data for assessing nutritional state of elderly people in Edinburgh: cross sectional study.

OBJECTIVES: To evaluate the appropriateness of two sets of commonly used anthropometric reference data for nutritional assessment of elderly people. DESIGN: Cross sectional study. SETTING: Two general practices in Edinburgh. SUBJECTS: 200 independently living men and women aged 75 or over randomly recruited from the age and sex register of the practices. MAIN OUTCOME MEASURES: Weight (kg), knee height (cm), demispan (cm), mid-upper arm circumference (cm), triceps skinfold thickness (mm), arm muscle circumference (cm) body mass index (kg/m2), and demiquet (kg/m2) in men and mindex (kg/m) in women. RESULTS: Men and women in Edinburgh were significantly shorter than those in measured for the Nottingham reference data (demispan 0.79 v 0.80 (P < 0.05) for men and 0.72 v 0.73 (P < 0.01) for women). Comparison with data from South Wales showed that men and women from Edinburgh had significantly greater mid-upper arm circumference, triceps skinfold thickness, and arm muscle circumference. No one fell below the 10th centile of the South Wales data (the commonly used out off point for determining malnutrition) for these measures. CONCLUSIONS: Both sets of reference data commonly used in Britain may be inappropriate for nutritional screening of elderly people in Edinburgh. Contemporary reference data appropriate for the whole of Britain need to be developed, and in the longer term biologically or clinically defined criteria for undernutrition should be established.

Typing of Austrian Listeria monocytogenes isolates by automated laser fluorescence analysis of randomly amplified polymorphic DNA.

We used automated laser fluorescence analysis of randomly amplified polymorphic DNA (RAPD-Alfa) to study the epidemiology of listeriosis in western Austria. There were no discrepancies between RAPD-Alfa patterns and serotypes found in 18 food isolates and 18 clinical isolates. The results of our study suggest that the food isolates typed were not at the origin of the human cases in western Austria. Using RAPD-Alfa, it was possible to link 9 out of 16 "sporadic" Listeria infections (mother-child cases counted as one) to the occurrence of other cases. Our results underline the necessity of epidemiological clarification of listeriosis cases as a prerequisite for specific preventive measures by public health services (e.g. confiscation of contaminated food products, issue of public warnings). To establish the chain of infection, more is needed than just speciation of bacteria in incriminated food products. Automated laser fluorescence analysis of randomly amplified polymorphic DNA seems a suitable, easy and rapid method for the typing of Listeria monocytogenes strains.

Typing Listeria monocytogenes isolates from fish products and human listeriosis cases.

Seventy-two Listeria monocytogenes isolates originating from 10 different fish products of 12 producers and 47 isolates from human listeriosis cases were typed by serotyping and multilocus enzyme electrophoresis. Seventy-five of these isolates were further subtyped by restriction analysis of genomic DNA with the enzyme XhoI and by pulsed-field gel electrophoresis using the enzymes ApaI and SmaI. The results show that several L. monocytogenes clones identified by multilocus enzyme electrophoresis are frequently found in fish products of different origins. One of these clones is the same as another previously shown to be frequently associated with meat and meat products. The epidemic-associated electrophoretic type 1 was only rarely found in fish products. No association was found between any type of fish product and a particular lineage of L. monocytogenes. Both long-term persistence of a strain and simultaneous presence of several clearly distinct strains in the products of single producers were observed. The comparison of L. monocytogenes isolates from human clinical listeriosis cases in Switzerland and those from imported fish products by use of multilocus enzyme electrophoresis showed that they do not form two clearly distinct lineages but nevertheless belong to two separate populations. None of the 48 subtypes distinguished by the combination of all four typing methods could be found in both populations of human origin and those of fish origin.

Serotyping of 80 strains from the WHO multicentre international typing study of Listeria monocytogenes.

Serotyping was carried out on 80 coded strains, distribute to all laboratories taking part in the WHO L. monocytogenes multicenter subtyping study. All six laboratories used the method recommended by their coordinator. All 80 strains were typeable. There was complete agreement between the six laboratories on 49 (61.3%) strains (21 serovar 1/2a and 28 serovar 4b strains) which in turn were identical to the expected serovars, known only after decoding. The intralaboratory reproducibility carried out on 11 duplicate strains, ranged from 82 to 100%, with a medium value of 91%. Reproducibility of serotyping L. monocytogenes strains according to serovar varied from 33.3 to 100% for serotypes 3b and 1/2a, respectively, with serovar 4b (x) being incorrectly identified in all six laboratories. Serotyping of L. monocytogenes is easy and simple and is a useful prerequisite for other finer and more discriminatory typing methods. Problems may however, be encountered mainly with the flagellar antigenic factors. There is a need, therefore, for preparing antisera of good quality from which efficient antigenic factors can be obtained.

Subtyping Listeria monocytogenes isolates genetically related to the Swiss epidemic clone.

Macrorestriction analysis by pulsed-field gel electrophoresis was used to assess the diversity of strains within the epidemic-associated electrophoretic type 1 (ET1) clone of Listeria monocytogenes. For this purpose, a total of 144 isolates from Switzerland shown by multilocus enzyme electrophoresis to belong to the ET1 were examined. These isolates were subtyped by macrorestriction analysis using the enzymes ApaI and SmaI and field inversion gel electrophoresis. Among these 144 isolates, 45 were isolated in human listeriosis cases of the postepidemic period of 1988 to 1993 and 44 were isolated in animal listeriosis cases of the same period. Forty-seven isolates were from the epidemic period of 1983 to 1987, and eight additional isolates were from cattle from two different farms. Twenty-nine different subtypes could be identified among the 144 isolates tested. Five major subtypes were found more frequently than the others during the postepidemic period, both in humans and in animals. Two of these subtypes had been previously implicated in outbreaks of listeriosis, thus suggesting that particular pulsed-field gel electrophoresis subtypes may be frequently associated with disease in humans and animals. Two of these frequent subtypes were also suspected to be related to small clusters of listeriosis cases during the postepidemic period. The results obtained by typing epidemiologically related isolates from different animals within the same farms and from different body sites of a given patient confirmed the potential of macrorestriction analysis for epidemiological studies restricted to short periods of time and to small number of isolates. The analysis of 47 isolates related to the Swiss listeriosis epidemic period of 1983 to 1987 and the use of Southern blotting and hybridization experiments show that the interpretation of relatedness between isolates presenting slightly different macrorestriction patterns may be more complex than commonly accepted. In such cases, careful interpretation of the potential molecular mechanisms leading to the differences observed between patterns is necessary.