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    Mucosal Recovery and Mortality in Adults With Celiac Disease Following a Gluten-Free Diet


    Jefferson Adams
    Mucosal Recovery and Mortality in Adults With Celiac Disease Following a Gluten-Free Diet
    Image Caption: New research on mucosal recovery and CD.

    Celiac.com 02/23/2011 - In most adults with celiac disease, clinical symptoms disappear with a gluten-free diet. However, the exact effects of a gluten-free diet on rates of mucosal recovery in adults with celiac disease is less certain.

    A group of clinicians recently set out to assess rates of mucosal recovery under a gluten-free diet in adults with celiac disease, and to gauge the clinical prospects of ongoing mucosal damage in celiac patients who follow a gluten-free diet.

    The study group included Alberto Rubio-Tapia, MD; Mussarat W. Rahim, MBBS; Jacalyn A. See, MS, RD, LD; Brian D. Lahr, MS; Tsung-Teh Wu, MD; and Joseph A. Murray, MD.

    Each patient in the study had biopsy-proven celiac disease, and was assessed at the Mayo Clinic. Also, each patient received duodenal biopsies at diagnosis. After beginning a gluten-free diet, each patient had at least one follow-up intestinal biopsy to assess mucosal recovery.

    The study team focused on mucosal recovery and overall mortality. Of 381 adult patients with biopsy-proven celiac disease, a total of 241 (175 women - 73%) had both a diagnostic and follow-up biopsy available for re-review.

    Using the Kaplan–Meier rate of confirmed mucosal recovery to assess these 241 patients, the study group found that 34% of the patients enjoyed mucosal recovery at 2 years after diagnosis (95% with a confidence interval (CI): 27–40 % ), and 66% of patients enjoyed mucosal recovery at 5 years (95% CI: 58–74 % ).

    More than 80% of patients showed some clinical response to the gluten-free diet, but clinical response was not a reliable marker of mucosal recovery ( P = 0.7). Serological response was, by far, the best marker for confirmed mucosal recovery ( P = 0.01).

    Patients who complied poorly with a gluten-free diet ( P < 0.01), those with severe celiac disease defined by diarrhea and weight loss ( P < 0.001), and those with total villous atrophy at diagnosis ( P < 0.001) had high rates of persistent mucosal damage.

    With adjustments for gender and age, patients who experienced confirmed mucosal recovery had lower mortality rates overall (hazard ratio = 0.13, 95 % CI: 0.02 – 1.06, P = 0.06).

    One of the most important findings from this study was that a large number of adults with celiac disease have no mucosal recovery, even after treatment with a gluten free diet.

    Compared to those patients who suffered persistent damage, patients who experienced confirmed mucosal recovery had lower rates of mortality independent of age and gender.

    The group notes that systematic follow-up via intestinal biopsy may be advisable for adults with celiac disease.

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  • About Me

    Jefferson Adams earned his B.A. and M.F.A. at Arizona State University, and has authored more than 2,000 articles on celiac disease. His coursework includes studies in biology, anatomy, medicine, and science. He previously served as Health News Examiner for Examiner.com, and provided health and medical content for Sharecare.com.

    Jefferson has spoken about celiac disease to the media, including an appearance on the KQED radio show Forum, and is the editor of the book Dangerous Grains by James Braly, MD and Ron Hoggan, MA.

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    Scott Adams
    The following Medline abstract describes a unique study that was done on the quality of life of two groups of people with celiac disease: One that was diagnosed as the result of having symptoms, and the other which had little or no symptoms and whose diagnosis was reached via screen-detection. Both groups were treated for one year with a gluten-free diet, and were then studied to determine their overall response, including their psychological response. Here is the abstract:
    Eff Clin Pract 2002 May-Jun;5(3):105-13
    Mustalahti K, Lohiniemi S, Collin P, Vuolteenaho N, Laippala P, Maki M.
    Department of Pediatrics, Tampere University Hospital, Finland.
    CONTEXT: Since the advent of serologic testing for celiac disease, most persons who receive a diagnosis of celiac disease have few or no symptoms. Although pathologic changes of celiac disease resolve on a gluten-free diet, how a gluten-free diet affects the quality of life for patients with screen-detected celiac disease is unclear.
    OBJECTIVE: To evaluate the effect of a gluten-free diet on the quality of life of patients with screen-detected celiac disease.
    DESIGN: Prospective study of patients before and 1 year after initiating a gluten-free diet.
    PARTICIPANTS: 19 patients with screen-detected celiac disease (found by serologically testing first-degree relatives of celiac patients) and 21 consecutive patients with symptom-detected disease. In all cases, celiac diagnosis was confirmed by finding villous atrophy and crypt hyperplasia on small-bowel biopsy.
    INTERVENTION: Gluten-free diet (explained during a single physician visit). MAIN OUTCOME
    MEASURES: Gastrointestinal Symptoms Rating Scale (GSRS), in which scores range from 0 to 6 (higher scores represent worse symptoms); and quality of life measured with the Psychological General Well-Being Questionnaire (PGWB). Scores range from 22 to 132 (higher scores mean greater well-being).
    RESULTS: At baseline, patients with symptom-detected celiac disease had poorer quality of life and more gastrointestinal symptoms than those with screen-detected celiac disease. Reported compliance with the gluten-free diet was good. All mucosal lesions of the small bowel had resolved at the follow-up biopsy. After 1 year of following the diet, quality of life for patients with screen-detected disease significantly improved (mean PGWB score increased from 108 to 114; P
    CONCLUSIONS: Gluten-free diet was associated with improved quality of life for patients with symptom-detected celiac disease and patients with screen-detected celiac disease. Concerns about the burden of a gluten-free diet, at least over the short term, may be unfounded.
    PMID: 12088289


    Jefferson Adams
    Celiac.com 06/18/2009 - According to the results of a recent study, complete recovery of intestinal mucosa occurs very rarely in patients with celiac disease, despite adherence to a gluten-free diet.
    Generally, when people with celiac disease go on a gluten-free diet, they can expect to enjoy some healing of small intestinal mucosa. However, new data casts doubt over how much of this benefit is experienced in adult celiac patients.
    In order to analyze the factors that influence histological outcome of a gluten-free diet in a large cohort of adult celiac patients, a team of researchers reviewed data on 465 consecutive celiac patients studied before and during the gluten-free diet.
    The team was made up of A. Lanzini, F. Lanzarotto, V. Villanacci, A. Mora, S. Bertolazzi, D. Turini, G. Carella, A. Malagoli, G. Ferrante, B.M. Cesana, and C. Ricci. The researchers made duodenal biopsies of subjects at diagnosis, and classified results. They found 11 cases of Marsh I, 25 cases of Marsh II, and 429 cases of Marsh III.
    After an average of 16 months on a gluten-free diet, 38 patients (8%) showed histological ‘normalization’, 300 patients (65%) showed  ‘remission’ with persistent intraepithelial lymphocytosis, 121 patients (26%) remained unchanged, while 6 patients (1%) showed ‘deterioration’.* Celiac disease-related blood tests were negative in 83% of patients with Marsh III lesion during the gluten-free diet.
    Researchers independently associated male gender and adherence to a gluten-free diet with histological ‘normalization’ and ‘remission’. There seemed to be no association between persistence of intraepithelial lymphocytosis and human lymphocyte antigen gene dose, or with Helicobacter pylori infection.
    From these results, the research team concluded that complete normalization of duodenal lesions is exceptionally rare in cases of adult celiac disease despite adherence to a gluten-free diet,  disappearance of symptoms, and  negative blood tests for celiac disease.
    Aliment Pharmacol Ther 29, 1299–1308
    *Author's note: Could such deterioration be due to undetected exposure to gluten over time?

    Jefferson Adams
    Celiac.com 01/25/20010 - Women with celiac disease face greater risks for adverse pregnancy outcomes. A team of researchers recently set out to examine the effects of treated and untreated maternal celiac disease on infant birthweight and preterm birth. Among their findings are that expectant mothers with celiac disease face a higher risk of underweight and early-term birth than those without celiac disease.
    The research team included A.S. Khashan, T.B. Henriksen, P.B. Mortensen, R. McNamee, F.P. McCarthy, M.G. Pedersen and L.C. Kenny. They are affiliated variously with the Anu Research Centre of the Department of Obstetrics and Gynecology at the University College Cork at Cork University Maternity Hospital in Ireland, the Perinatal Epidemiology Research Unit in the Department of Paediatrics at Aarhus University Hospital, the National Centre for Register-based Research at the University of Aarhus, Denmark, and the Biostatistics Group, University of Manchester, Manchester, UK.
    For their data, they used a population-based cohort study of all live births in Denmark between 1 January 1979 and 31 December 2004. During that period, 836,241 mothers gave birth to a total of 1,504,342 babies. Mothers with diagnosed celiac disease gave birth to 1105 of those babies, while 346 were born to women with undiagnosed celiac disease.
    The team considered mothers with diagnosed celiac disease to be following a gluten free diet, and those with undiagnosed celiac disease to be on a gluten-inclusive diet. The team measured outcomes based on birthweight, small for gestational age (SGA: birthweight <10th centile), very small for gestational age (VSGA: birthweight <5th centile) and preterm birth. They then compared the results for the treated and untreated celiac disease mothers with those of a celiac-free reference group.
    The research team found that mothers with untreated celiac disease gave birth to smaller babies [difference = –98 g (95% CI: –130, –67)], with a higher risk of SGA [OR = 1.31 (95% CI: 1.06, 1.63)], VSGA [OR = 1.54 (95% CI: 1.17, 2.03)] and early birth [OR = 1.33 (95% CI: 1.02, 1.72)] compared with women with no celiac disease.
    The good news is that mothers with treated celiac disease showed no increased risk of reduced mean birthweight, or of delivering SGA and VSGA infants or preterm birth compared with mothers with no celiac disease.
    From the results, the research team concluded that untreated maternal celiac disease increases the risk of low birthweight, SGA and VSGA, and preterm birth.
    Diagnosis and treatment of maternal celiac disease with a gluten-free diet seems to return the birthweight and preterm birth rate to one comparable to women without celiac disease.
    This study drives home the importance of expectant mothers with celiac disease maintaining a gluten-free diet to promote a healthy delivery.
    Source: Human Reproduction, doi:10.1093/humrep/dep409


    Jefferson Adams
    Can Online Intervention Help Improve Gluten-free Diet Adherence in Adults with Celiac Disease?
    Celiac.com 05/08/2013 - A team of researchers recently set out to test determine if an interactive online intervention might help to improve gluten free diet adherence in adults with celiac disease.
    The research team included Kirby Sainsbury BA/BEd, DCP (candidate), Barbara Mullan PhD and Louise Sharpe PhD. They are affiliated with the School of Psychology, and the Clinical Psychology Unit at the University of Sydney in Sydney, New South Wales, Australia
    For their controlled trial, the researchers recruited 189 adults with biopsy-confirmed celiac disease. They randomly assigned 101 adults to receive the intervention, and 88 adults to a wait-list control condition.
    They retrieved post-intervention data for 70 intervention subjects and 64 wait-list participants, along with three month follow-up data for 46 of 50 who completed the intervention period.
    The team first measured overall gluten-free diet adherence, then measured gluten-free diet knowledge, quality of life and psychological symptoms.
    The researchers based their results on intention-to-treat analysis, which bases their calculations on initial treatment assignment and not on the treatment eventually received.
    ITT analysis helps avoid various misleading factors that can color intervention research, such as non-random attrition of participants from the study or crossover.
    Overall, the intervention group showed strong improvement in gluten-free diet adherence, and gluten-free diet knowledge following the treatment period compared to the wait-list control group.
    However, changes in knowledge had no effect on adherence. These improvements continued through the 3-month’ follow-up period.
    The results show that the online intervention program helped improve adherence to a gluten-free diet for people with celiac disease. Such a program can be developed into a valuable resource for celiacs who are struggling with gluten-free diet adherence.
    Source:
     Am J Gastroenterol advance online publication 5 March 2013;

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