In November 2018, Dr Schär welcomed international experts to their Headquarters for the 4th Expert Meeting on Gluten-Related Disorders. Here we bring you two abstracts from presentations by Benjamin Lebwohl and Anil Verma highlighting current clinical discussions relating to a gluten-free diet and celiac patient management.
Gluten-Free Diet: How Strict is Too Strict?
Evaluating Adherence with Dietetic Interviews
Benjamin Lebwohl
The gluten-free diet is the only proven therapy for celiac disease at this time, but adherence to the diet varies between individuals, and within the individual patient over time. This has posed a challenge to investigators who seek to quantify adherence as an outcome or covariate in studies that evaluate interventions. Validated adherence scales for adherence to the gluten-free diet include the Coeliac Disease Adherence Test (CDAT), the Gluten-Free Eating Assessment Tool (GF-EAT), and the Biagi score.
Though each of these scores considers adherence as a unidimensional measure in which greater adherence is the desirable outcome, in recent years it has become clear that strict adherence may come at a cost in terms of anxiety and reduced quality-of-life related to hypervigilance. Though mucosal healing on follow-up biopsy is generally regarded as a desirable endpoint, patients with this finding appear to be at increased risk of a new diagnosis of anxiety, underscoring the link between strict adherence and its toll on mental health. The Celiac Disease Food Attitudes and Behaviors Scale (CD-FAB) is a newly developed measure of the impact of the gluten-free diet on attitudes, behaviors, and quality of life.
Recent studies have also explored the phenomenon of falsely identifying items as unsafe for people on a gluten-free diet. This phenomenon is likely exacerbated by the use of internet sites and forums that contain misinformation regarding gluten-free items such as coffee and maltodextrin. Such misinformation may foster excessive restriction by individuals and may even pose a detriment to public health: there is a prevalent belief (more common in those with non-celiac gluten sensitivity than those with celiac disease) that the influenza vaccine contains gluten, a belief without any factual basis. It has also been documented that individuals with non-celiac gluten sensitivity are more likely to have additional food restrictions (such as dairy, soy, and eggs), compared to those with celiac disease. Despite the concern about the consequences of excessive restriction, there is some evidence supporting additional restriction for select cases. For example, the gluten contamination elimination diet (“Fasano diet”), a more restrictive mode of gluten avoidance, has been assessed in the short-term for people with celiac disease and ongoing symptoms and villus atrophy. This diet has been shown to result in healed villi in a case series. Future studies should focus on strategies to maximize strict adherence to the gluten-free diet that is not overly restrictive and is compatible with a high quality of life.
Gluten contamination in Gluten-free products
Anil K Verma1, Elena Lionetti2, Simona Gatti2, Chiara Monachesi1, Tiziana Galeazzi1, Elisa Franceschini2, Giulia Naspi Catassi2, Carlo Catassi 2,3
1.Celiac Disease Research Laboratory, Department of Pediatrics, Marche Polytechnic University, 60123, Ancona, Italy. 2.Department of Pediatrics, Marche Polytechnic University, 60123, Ancona, Italy. 3.The Division of Pediatric Gastroenterology and Nutrition and Center for Celiac Research, Mass General Hospital for Children, Boston, MA 02114, USA.
Introduction: A strict and lifelong gluten-free diet is the only available treatment for celiac disease. Continuous ingestion of traces of gluten (10-50 mg daily) is capable of damaging the integrity of small intestinal mucosa. Gluten contamination in gluten-free food products has been frequently documented in different countries. However, the status of gluten contamination in Italian gluten-free food products was not known. Apart from food production, gluten is used in a wide range of industries in different forms, such as oral hygiene products and cosmetics. Although many of such products are not directly ingested, some amounts can inadvertently be swallowed. Until date, very little is known about the effect of continuous unintentional gluten exposure to such non-food products as well as its consequence on intestinal integrity. In two different studies, we have investigated the gluten level in gluten-free food products and oral hygiene products and cosmetics in Italy.
Methodology: Overall, a total of 200 commercially available gluten-free food products (including naturally gluten-free =107 and labeled as gluten-free food products=93) and 66 oral hygiene and cosmetics products (toothpastes=37; dental tablets=2; mouthwashes=5; lip-balms=10; lipsticks =12) were collected from different Italian supermarkets, pharmacies and cosmetics shops, between 2016 and 2018. Gluten content level was determined by the R5 ELISA method approved by EU regulations. Products tested with gluten level < 20 ppm were considered as gluten-free.
Results: In the first study, out of 200 gluten-free food products, 182 (91%) were tested with gluten level <20 ppm (gluten-free), while 18 (9%) products were tested with gluten level >20 ppm. These 18 contaminated products mostly belonged to oats, buckwheat, and lentil-based items with gluten level exclusively in the range of low gluten content (20-100 ppm). No gluten contamination was found in certified (crossed ear symbol) gluten-free products. In the second study, out of 66 oral hygiene and cosmetics, 62 products (94%) were found gluten-free, while 4 (6%) (toothpastes=3; lipsticks=1) showed gluten level >20 ppm. None of the selected products had ingredient derived from wheat, barley, or rye.
Conclusions: Gluten contamination in either naturally or labeled gluten-free products marketed in Italy is uncommon and usually mild on a quantitative basis. A program of systematic sampling of gluten-free food is needed to promptly disclose at-risk products. Gluten contamination is currently not an issue in a wide array of cosmetic and oral hygiene products that are commonly on the market. However, it is recommended to manufacturers to report the information ‘‘gluten-free’’ or ‘‘may contain traces of gluten’’ on the package and celiac consumers are advised to look for the product information.