Celiac Disease: Predictors of Compliance With a Gluten-free Diet in Adolescents and Young Adults
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Journal of Pediatric Gastroenterology and Nutrition
49:1–8 # 2009 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
Celiac Disease: Predictors of Compliance With a Gluten-free
Diet in Adolescents and Young Adults
Simona Errichiello, yOscar Esposito, yRaffaella Di Mase, yMaria Erminia Camarca,
yClelia Natale, yMaria Giovanna Limongelli, yCaterina Marano, yAnna Coruzzo,
yMaria Lombardo, yPietro Strisciuglio, and yLuigi Greco
Department of Pediatrics, University of Magna Graecia, Catanzaro, and {Department of Paediatrics and European
Laboratory for the Investigation of Food-Induced Disease, University of Naples ‘‘Federico II,’’ Naples, Italy
ABSTRACT
Aims: To identify risk as well as protective factors related to was above the 97th percentile in 20 of 204 (9.8%). Diet
compliance with the gluten-free diet in a cohort of teenagers compliance did not seem to influence the weight and height.
with celiac disease (CD). One hundred eleven of 150 good compliers (74%) and 31of 54
Patients and Methods: Two hundred four patients with CD (57.4%) poor compliers were asymptomatic. Most patients
(European Society for Pediatric Gastroenterology, Hepatology, reported good family relationships (88.7%), social
and Nutrition criteria) older than or equal to 13 years and residents relationships (91.2%), and school integration (88.2%).
of Campania (southern Italy) were enrolled in the study. Patients Alternatively, 54% of patients reported some limitation in
underwent clinical examination and blood sampling, and were their social life. Compliance was good in patients who
interviewed about school performance, social relationships, reported excellent school integration (83%) and social
family integration, smoking habit, and compliance with a relationships (81%).
gluten-free diet. Anti-tissue transglutaminase antibodies were Conclusion: Optimal school integration significantly
assayed with an enzyme-linked immunosorbent assay. contributes to the likelihood of good compliance. A better
Results: One hundred fifty of 204 (73.5%) reported no dietary understanding within the school environment about CD-
transgressions, and 54 of 204 (26.5%) reported occasional or related issues could improve motivation to adhere to a
frequent transgressions. During the previous month 29 of 54 gluten-free diet. JPGN 49:000–000, 2009. Key Words:
(53.7%) poor compliers ate from 0.001 to 1 g of gluten per day, Celiac disease—Diet compliance—Quality of life—Gluten
14 (25.9%) from 1 to 5 g, and 11 (20.4%) more than 5 g. The intake. # 2009 by European Society for Pediatric
daily intake of gluten was significantly related to anti-tissue Gastroenterology, Hepatology, and Nutrition and North
transglutaminase antibodies (x2 ¼ 38.872, P ¼ 0.000). Height American Society for Pediatric Gastroenterology, Hepatology,
was below the third percentile in 19 of 204 (9.3%), and weight and Nutrition
The increasingly early recognition of celiac disease the outcome of patients once they have been diagnosed.
(CD) has resulted in an increase in the prevalence of the Patients’ adherence to a gluten-free diet ranges from
disease from 1:1000 (1) to 1:100 (2–4), which matches the extremely poor (6,7) to satisfactory (8–11). Long-term
figure forecasted by Magazzù et al (5) more than 12 years compliance to a gluten-free diet in CD is an increasing
ago. Most doctors now recognize and diagnose CD in challenge given the impressive increase in diagnosis, but it
atypical cases and in apparently healthy individuals as well will increase even more when self-managed diagnosis is
as in openly symptomatic subjects. Less is known about available through the point-of-care test (12).
Children are mostly fed by parents. Consequently,
Received May 29, 2008; final revision received December 18, 2008;
good compliance in young children is related to familial
Address correspondence and reprint requests to Oscar Esposito, awareness about the disease. However, problems arise in
Department of Paediatrics, University of Naples ‘‘Federico II,’’ Via the case of teenagers. Children who have long accepted a
S. Pansini 5, 80131 Naples, Italy (e-mail: oscaresp80@hotmail.com; gluten-free diet often rebel during adolescence, and a
ydongre@unina.it). sizeable proportion will stop their gluten-free diet. Social
This work was supported by European Laboratory for the Investi-
gation of Food-Induced Diseases and Italian Ministry of Instruction, integration, self-esteem, and school achievements are at
University and Research. risk in teenagers with CD and are likely to generate more
The authors report no conflicts of interest. problems than clinical complaints.
1
Copyright © 2008 by Lippincott Williams & Wilkins.Unauthorized reproduction of this article is prohibited.2 ERRICHIELLO ET AL.
Quality of life is a major part of care. A study of self- TABLE 1. Baseline data of the study cohort
rated quality of life in adults with CD did not reveal any
Variable n %
major problems (13), but teenagers may well feel dif-
ferently. In an attempt to shed light on this issue, we Age 13.00–18.99 y 127 62.2
evaluated the global well-being (health, education, and Age 19.00–25.99 y 64 31.4
social integration) of teenagers with CD with the aim of Age 26.00–30.00 y 13 6.4
Women 127 62
identifying predictors of good adherence to a gluten- Men 77 38
free diet. Women/men ratio 1.65
The objective of the study was to evaluate a cohort of Age at diagnosis 13 y 30 14.7
factors related to compliance with the gluten-free diet. Classic symptoms at diagnosis 156 76.5
Atypical symptoms at diagnosis 16 7.8
Diagnosis by screening 32 15.7
Patients with health problems in last 30 days 62 30.2
PATIENTS AND METHODS
Two hundred four patients (127 women and 77 men, sex
ratio 1.65:1), from the Campania region (southern Italy) were
consecutively admitted to this cross-sectional study on the basis The questionnaire was administered after a 2-day training
of age between 13 and 30 years, CD diagnosed according to session of the investigators (qualified S.E., O.E., R.D.M.,
European Society for Pediatric Gastroenterology, Hepatology, M.E.C., C.N., and M.G.L.). We evaluated family and social
and Nutrition revised criteria (14), and willingness to cooperate. integration, integration within the school environment, and
Patients were divided into 2 groups: those diagnosed as children sexual life, on visual analogue scales rated 0 to 25 ranging
(younger than 13 years) and those diagnosed as teenagers (older from poor to excellent. Social integration was investigated
than 13 years). Table 1 shows the baseline data of this cohort. through the description of the daily life of the patients including
Each patient underwent a complete clinical check-up and number of outings, participation in social events, number of
199 of them underwent a blood sampling. Tissue transgluta- friends, and play activities. Feeling of self-constraint related to
minase was assayed with an enzyme-linked immunosorbent the gluten-free diet was also investigated. Smoking habit and
assay. school performance concluded the interview.
An already standardized self-administered questionnaire The second section, related to food habits, was managed by 2
modified by our previous study (13) was used throughout dieticians (A.C. and M.L.). Patients were questioned about their
(Fig. 1). A psychologist working with our team adapted the diet in the previous day, using a standardized 1-day recall form,
form from internationally validated references (15–20). and about the total amount of gluten-containing foods ingested
Family integration:
First name: _____ Last name:____ Date of birth:_____ Sex: M/F 5 10 15 20 25
Address: ________Phone: _______
Poor Average Sufficient Good Excellent
School:____________ Achievement: ______Job: __
School integration:
Age at diagnosis:_______Year: ______ N° of biopsies: ____
5 10 15 20 25
Date of last biopsy:_____Other CD cases in family _________
Symptoms at diagnosis: Poor Average Sufficient Good Excellent
Screening Asymptomatic Diarrhoea Failure to thrive Anaemia Social relationship:
Abdominal pain Other: ____ 5 10 15 20 25
Associated diseases:
Diabetes Thyroid disease IBD Other: _______________ Poor Average Sufficient Good Excellent
How is your sexual life?
Weight: Kg _______ pct° ______ Height: cm ______ pct°_____ 5 10 15 20 25
Health status: ______________________
Symptoms in the last 30 days:___________________________
Poor Average Sufficient Good Excellent
tTG IgA: ________ Date: ____________ Your partner knows about your disease: yes no
Do you feel that gluten intolerance makes you different?
Yes no sometimes
What did you eat yesterday?
Do you smoke? Yes no Number of cigarettes/day: ________
Gluten-free food Brand Amount
Breakfast Compliance to diet in the last 30 days:
Snack
5 10 15 20 25
Poor Average Sufficient Good Excellent
Lunch
Snack What type of product with gluten did you eat in the last 30 days?
(with quantity)_______________________________________
Dinner
Occasional transgressions (≤2/month)
Other snacks Frequent transgressions (>2/month)
FIG. 1. A sample of how the questionnaire was formulated.
J Pediatr Gastroenterol Nutr, Vol. 00, No. 00, Month 2009
Copyright © 2008 by Lippincott Williams & Wilkins.Unauthorized reproduction of this article is prohibited.COELIAC DISEASE COMPLIANCE WITH GLUTEN-FREE DIET 3
in the last 30 days, using a visual list of gluten-containing items
30
available to this range of population. The daily gluten intake
was estimated summing the total amount of gluten-containing 25
foods ingested in the previous 30 days. The total protein intake 20
was computed and gluten estimated by multiplying by a factor 15
%
of 0.8 g of gluten per gram of vegetable protein (21). 10
5
Statistical Methods 0
97
Data were analyzed with the SPSS statistical package ver- Centiles
sion 11 (SPSS Inc, Chicago, IL). Continuous variables were
screened for normal distribution and transformed to reduce Observed Expected
skewness, when required. Mann-Whitney and Kruskal-Wallis
nonparametric tests were used to compare percentages in
addition to the x2 test. We used logistic regression analysis FIG. 2. Height percentile distribution.
to estimate predictors of adherence to the gluten-free diet.
Multivariate analysis was carried out with dietary compliance
as dependent variable, and sex, age, familial interaction, school
performance, school integration, and social integration had at least 1 associated disease (Table 2). There was no
as factors. major health complaint in the cohort. None of the girls
had ever been pregnant.
RESULTS
Symptoms at Diagnosis and Health Status Growth Outcome
At diagnosis, 32 patients (15.7%) reported no health Figures 2 and 3 show the distribution of height and
complaints; they were diagnosed by family screening. weight in the whole group. Nineteen patients (9.3%) had
Of the remaining 172 patients, 112 (27.5%) reported height below the third percentile for sex and age and 25
recurrent diarrhea, 89 (21.8%) failure to thrive and/or (12.2%) had height between the third and the 10th
pubertal delay, 41 (10%) weakness and/or anemia, percentile for sex and age. According to the growth
31 (7.6%) vomiting, 19 (4.7%) recurrent abdominal pain, standards we expected, among the 204 patients, 7 to
8 (2.0%) abdominal distensions, 8 (2.0%) headache be below the third percentile and 14 between the third and
or neurological disturbances, 7 skin disease (1.7%), 10th percentile; there is a significant excess of short
2 gastritis (0.5%), 2 (0.5%) constipation, and 2 (0.5%) stature (Wilcoxon test P ¼ 0.042) (22,23). As expected,
hypertransaminasemia. Point prevalence (previous weight was below the third percentile in 7 patients (3.4%)
30 days) of clinical complaints was evaluated by history and between the third and the 10th percentile in 18
taking (Table 2). Thirty-one of the 204 patients (15.2%) patients (8.8%). Weight was above the 75th percentile
in 47 patients (23%). Weight excess (>97th percentile)
was observed in 20 (9.8%) patients. Height and weight
TABLE 2. Symptoms in last 30 days and associated diseases
Symptom n %
Recurrent abdominal pain 21 10.3
Constipation 10 4.9 30
Diarrhea 9 4.4
Failure to thrive 7 3.5 25
Headache/neurological disturbances 9 4.4 20
Skin diseases 6 2.9
15
%
No symptoms 142 69.6
Total 204 100 10
Associated diseases 5
Diabetes mellitus type 1 12 5.9
0
Thyroid diseases 8 3.9
97
Other endocrine disturbances 4 2
Skin diseases 3 1.5 Centiles
Down syndrome 3 1.5
Chronic inflammatory bowel diseases 1 0.5 Observed Expected
No associated diseases 173 84.8
Total 204 100
FIG. 3. Weight percentiles.
J Pediatr Gastroenterol Nutr, Vol. 00, No. 00, Month 2009
Copyright © 2008 by Lippincott Williams & Wilkins.Unauthorized reproduction of this article is prohibited.4 ERRICHIELLO ET AL.
percentiles were not related to age at diagnosis or to the 45
interval from first symptoms to diagnosis. 40
35
30
% tTg pos
25
Educational Achievements 20
15
10
After grouping the patients by age, we analyzed the 5
number that passed the school level expected for their 0
0 0.001--1 1.001--5 5.001--80
age. We compared these data with the regional statistics
x 2 = 38.872 P = 0.000; r = 0.391 Gluten: grams/day
of school performance: 13% of our patients stopped at the
primary or secondary level against 53% of the regional 25
reference, 16% at high school against 24.4%, and 3% at 20
university level against 10.8% of the regional reference
tTg titers
15
(24) (x2 ¼ 5.33, P ¼ 0.07) showed no difference. Bad compliers
10
Good compliers
5
Self-rated Social Integration
0
0 20 40 60 80 100 120 140 160
A total of 181 (88.7%) patients reported good family
Tested patients
integration, 186 (91.2%) reported good social relation-
ships, and 180 reported (88.2%) good school integ- FIG. 4. Ingested gluten and positive anti-tissue transglutaminase
rations. On the contrary, 110 (53.9%) felt that CD antibodies.
occasionally or often limited their social life.
Gluten-free Diet (0.001–1 g/day) and medium (1.001–5 g/day) gluten
intake, we found 24 of 28 (85.7%) and 9 of 14
One hundred fifty (73.5%) patients declared they (64.2%) with negative tTG, whereas 4 of 28 (14.3%)
adhered completely to a gluten-free regimen. Fifty-four and 5 of 14 (35.7%) had positive tTG, respectively
(26.5%) reported occasional (less than or equal to (x2 ¼ 54.663, P ¼ 0.000). As shown in Figure 4, the
2/month) or frequent (>2/month) lapses from the diet. amount of gluten ingested daily was significantly related
There was no difference in compliance between males to the percentage of patients with increased tTG serum
and females or among age groups. Dietary compliance levels (x2 ¼ 38.872, P ¼ 0.000, r ¼ 0.391); in the lower
did not affect current weight and height. The interview part of the figure individual tTG titers are shown for the
dietary enquiry revealed that 29 of the 54 (53.7%) poor 2 groups.
compliers had assumed a quantity of gluten from 0.001 to
1 g/day, 14 of them (25.9%) from 1 to 5 g/day, and Compliance to a Gluten-free Diet and Health
11 (20.4%) >5 g/day during the last month. Types
of food eaten in transgressions are pizza in 15 of 54 One hundred eleven of the 150 patients who declared
(27.8%), snacks or/and sweets in 11 of 54 (20.4%), bread good compliance (74%) and 31 of the 54 poor compliers
in 10 of 54 (18.5%), and 18 of 54 (33.3%) ate several (57.4%) had no health complaints. Conversely, health
gluten-containing foods. complaints were more frequent among bad compliers
(23 of 54) than among good compliers (39 of 150)
Compliance to a Gluten-free Diet and Serology (x2 ¼ 6.025, P ¼ 0.014). Table 4 shows the symptoms
we identified in these 2 groups of patients and their
Not all ‘‘poor compliers’’ were identified by a serum correlation with daily gluten intake. As shown, the
anti-tissue transglutaminase antibodies (tTG) assay, and a percentage of patients with symptoms was significantly
large proportion of bad compliers tested had negative related to the amount of ingested gluten daily
tTG (Table 3). Among patients with high gluten intake (x2 ¼ 9.117, P ¼ 0.028).
(>5 g/day) 7 of 11 (63.6%) had negative tTG and 4 of 11
(36.4%) had positive tTG. Among patients with little Serology and Health
Among 182 patients with negative tTG, 127 (70%) had
TABLE 3. Dietary compliance and tissue transglutaminase
no health complaints, whereas 55 (30%) reported several
Positive Negative Total symptoms: 18 (9.8%) had recurrent abdominal pain, 9
(4.9%) had diarrhea, 9 (4.9%) had constipation, 9 (4.9%)
Good compliance 4 (2.7%) 142 (97.3%) 146 (100%)
Bad compliance 13 (30.2%) 40 (69.8%) 53 (100%)
had headache or neurological disturbances, 5 (2.7%) had
failure to thrive, and 5 (2.7%) had skin diseases. Of the
x2 ¼ 32.988, P ¼ 0.000. remaining 17 patients having positive tTG, 10 (58.8%)
J Pediatr Gastroenterol Nutr, Vol. 00, No. 00, Month 2009
Copyright © 2008 by Lippincott Williams & Wilkins.Unauthorized reproduction of this article is prohibited.COELIAC DISEASE COMPLIANCE WITH GLUTEN-FREE DIET 5
TABLE 4. Symptoms in last 30 days and compliance
Bad compliers
Good compliers Gluten (g/day)
Symptom No gluten (%) 0.001–1 (%) 1.001–5 (%) >5 (%)
Recurrent abdominal pain 12 (8.1) 6 (20.6) 1 (7.1) 2 (18.2)
Constipation 7 (4.7) 2 (6.9) 1 (7.1) 0 (0)
Diarrhoea 5 (3.3) 2 (6.9) 0 (0) 2 (18.2)
Failure to thrive 4 (2.6) 2 (6.8) 0 (0) 1 (9.1)
Headache/neurological disturbances 6 (4) 2 (6.9) 1 (7.1) 0 (0)
Skin diseases 5 (3.3) 0 (0) 1 (7.1) 0 (0)
No symptoms 111 (74) 15 (51.7) 10 (71.4) 6 (54.5)
Total 150 (100) 29 (100) 14 (100) 11 (100)
x2 ¼ 9.117, P ¼ 0.028.
were asymptomatic, whereas 7 (41.2%) had health com- school performance and those with sufficient to average
plaints: 3 had (17.6%) recurrent abdominal pain, 2 had performance. However, people with excellent school
(11.7%) failure to thrive, 1 had (5.8%) constipation, and integration adhered to the diet better than those with
1 had (5.8%) skin diseases. There is no statistical corre- bad or sufficient school integration. About half of the
lation between tTG and symptoms (x2 ¼ 19.824, patients with poor school integration did not adhere to the
P ¼ 0.707). diet. A good social relationship was significantly related
to dietary compliance. People without feelings of self-
Compliance to a Gluten-free Diet and Social constraint complied better with the diet than those with
Integration occasional or persistent feelings of self-constraint. There
were no differences among sex or age groups.
Table 5 shows the relation between compliance to a Nonsmokers had significantly better dietary compli-
gluten-free diet and social integration. Family integration ance than smokers in the age group 19 to 26 years,
did not affect compliance, and similarly, there was no whereas there were no differences in the other age groups
difference in compliance between patients with good (Table 6).
TABLE 5. Dietary compliance and quality of life
Diet
Quality of life Good compliance (%) Bad compliance (%)
Family integration
x2 ¼ 0.9, P ¼ 0.3 Average/sufficient 15 (65.2) 8 (34.8)
Good/excellent 135 (74.6) 46 (25.4)
School achievement
x2 ¼ 0.6, P ¼ 0.4 Average/sufficient 63 (70.8) 26 (29.2)
Good/excellent 87 (75.7) 28 (24.3)
School integration
x2 ¼ 11.1, P ¼ 0.004 Bad 13 (54.2) 11 (45.8)
Sufficient/good 47 (66.2) 24 (33.8)
Excellent 90 (82.6) 19 (17.4)
Social relationship
x2 ¼ 9.6, P ¼ 0.008 Bad 11 (61.1) 7 (38.9)
Sufficient/good 39 (61.9) 24 (38.1)
Excellent 100 (81.3) 23 (18.7)
Feeling of self-constraint
x2 ¼ 8.7, P ¼ 0.012 Yes 32 (61.5) 20 (38.5)
No 78 (83) 16 (17)
Sometimes 40 (69) 18 (31)
Psychosexual relationship
x2 ¼ 0.185, P ¼ 0.667 Average 42 (72.4) 16 (27.6)
Excellent 89 (75.4) 29 (24.6)
J Pediatr Gastroenterol Nutr, Vol. 00, No. 00, Month 2009
Copyright © 2008 by Lippincott Williams & Wilkins.Unauthorized reproduction of this article is prohibited.6 ERRICHIELLO ET AL.
TABLE 6. Dietary compliance and smoke in the different age groups
Diet
Age groups (y) Good compliance (%) Bad compliance (%) Total
14–18 Smokers 17 (77.3) 5 (22.7) 22
x2 ¼ 0.19, P ¼ 0.662 Nonsmokers 72 (72.7) 27 (27.3) 99
19–26 Smokers 15 (50) 15 (50) 30
x2 ¼ 11.16, P ¼ 0.001 Nonsmokers 30 (88.2) 4 (11.8) 34
>26 Smokers 3 (50) 3 (50) 6
x2 ¼ 4.55, P ¼ 0.33 Nonsmokers 7 (100) 0 (0) 7
Similarly, psychosexual relationships were unrelated awareness of the ‘‘celiac condition’’ within our commu-
to adherence to the diet (Table 5). Twenty-four of 144 nities, the second (sometimes crucially important) is the
patients (16.7%) with a stable partner did not tell their excessive tone of dietary prescriptions given by doctors,
partner they suffered from CD. dieticians, and patients’ groups. The patient can become
obsessed with the fear of traces of gluten in canteens and
Multivariate Analysis restaurants or in common foods and snacks that are not
made with gluten-containing flours. Most patients are not
All of the variables that concern family, school, and aware that ‘‘100 parts per million’’ means 100 mg of
social interaction are related. Therefore, these cannot be gluten protein per million milligrams (1 kg) and thus
individually used as independent predictors of a good or 10 mg/100 g of flour, a trace amount that has never been
poor compliance with the diet. To select the best pre- shown to be toxic (25–27).
dictors, we carried out a multivariate analysis with Compliance to a gluten-free diet among adolescents
dietary compliance as dependent variable, and sex, has traditionally been reported poor in several studies.
age, familial interaction, school performance, school Kumar et al (6) reported that up to 44% do not comply
integration, and social integration as predictors. Only with the diet. Many of these youngsters had a gluten-free
school integration significantly contributed to the like- diet at home, but were consuming gluten-containing
lihood of good or poor compliance (Wald statistics ¼ foods in social meals. Teenagers go out for pizza or
10.83, P < 0.001, odds ratio 0.44). For each degree of sandwiches frequently; they use pizza as a snack also at
improved school integration, we have about 56% less school. Similarly, it has been widely accepted that a
transgression from the gluten-free diet. None of the significant proportion of adult patients do not adhere
other variables contributed significantly (>10%) to the to a gluten-free diet (28). Compliance with a gluten-free
increase in the log likelihood. diet in Campania is regarded by the patients and the
family as a major deprivation from food in general, which
DISCUSSION is understood as pasta and bread. In a different scenario, a
‘‘happy celiac world’’ has been reported recently by Roos
For many years, physicians have focused on the diag- et al (29,30) suggesting that different medical manage-
nosis and molecular and cellular markers of CD, with ment may eventually lead to different ‘‘care’’ of the
scarce attention being given to the care and well-being of patient. This is one of the major reasons for this study
the patient. Indeed the ratio of, articles devoted to CD and our special care toward adolescents. Since 1979, we
diagnosis versus those dealing with the care of patients is have provided, through the National Health Service, a
>10:1. By a PubMed search (key word ‘‘celiac disease’’), complete supply (valuable at s200/month), of gluten-
we found only 28 articles (9%) analyzing the patients’ free pasta, pizza, and snacks. In Campania the Celiac
treatment and 227 (75%) focused on the diagnosis on a Society set up in 1999 a factory of freshly baked gluten-
random sample of 300 articles published in the last free products that is free to patients.
3 years. In our study, 53 of 204 (26%) teenagers with CD had
Whereas young children with CD usually adhere to a occasional transgressions to the diet, but only 1 of 4 of
gluten-free diet because of parental influence, the situ- them had positive tTG (Table 3). Our group as well as
ation is more complex in adolescents with CD. Indeed, other groups have analyzed the relation between serology
they frequently reject parental advice; school and social and compliance to the diet, since the time when only anti-
environments are their daily scenario; they are exposed to gliadin antibodies were available (31). Unfortunately,
the comments of their peers, and not infrequently they anti-transglutaminase antibodies are related to mucosal
choose to restrict social relations to easy ones. Many damage (32) and this may come late after prolonged
factors contribute to the self-perceived restriction on the dietary transgression, so sensitivity in patients with mod-
social life of these youngsters. The first is the limited erate transgression is low (33). We are indeed been
J Pediatr Gastroenterol Nutr, Vol. 00, No. 00, Month 2009
Copyright © 2008 by Lippincott Williams & Wilkins.Unauthorized reproduction of this article is prohibited.COELIAC DISEASE COMPLIANCE WITH GLUTEN-FREE DIET 7
impressed by the relation, shown in Figure 4, between the care of patients; most of them will cope satisfactorily
amount of gluten ingested and tTG. We did not expect to with a gluten-free diet, but others will not. Our data
find such a significant relation, because the vast majority suggest that patients who feel limited in their social
of our patients do substantially adhere to a gluten-free expression, especially those with poor school integration,
diet. tend to be noncompliers. Perhaps one may envisage
As shown, in this study there is no strict relation caregivers (doctors included) setting up a bridge of
between gluten ingestion and actual health status with communication with the school environment with the
symptoms: 39 of 150 compliers do experience minor aim of promoting a reasonable integration of the adoles-
symptoms as bad compliers do. We have no straight cent affected by CD into the educational domain. Patient
explanation, but point prevalence of any cohort of indi- tailored intervention is likely to help those most likely to
viduals will produce a list of symptoms of the kind shown fail to comply with a gluten-free diet.
in Table 4.
According to Ciacci et al (34), even a short period of Acknowledgments: We thank the patients and their families.
gluten-free diet in childhood may produce a significant We are grateful to Jean Ann Gilder for editing the text.
difference in the health status and performance of adult
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