National survey evaluating the provision of gastroenterology dietetic services in England.

Aims: The aim of the study was to assess the provision of dietetic services for coeliac disease (CD), irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Methods: Hospitals within all National Health Service trusts in England were approached (n=209). A custom-designed web-based questionnaire was circulated via contact methods of email, post or telephone. Individuals/teams with knowledge of gastrointestinal (GI) dietetic services within their trust were invited to complete. Results: 76% of trusts (n=158) provided GI dietetic services, with responses received from 78% of these trusts (n=123). The median number of dietitians per 100 000 population was 3.64 (range 0.15-16.60), which differed significantly between regions (p=0.03). The most common individual consultation time for patients with CD, IBS and IBD was 15-30 min (43%, 44% and 54%, respectively). GI dietetic services were delivered both via individual and group counselling, with individual counselling being the more frequent delivery method available (93% individual vs 34% group). A significant proportion of trusts did not deliver any specialist dietetic clinics for CD, IBS and IBD (49% (n=60), 50% (n=61) and 72% (n=88), respectively). Conclusion: There is an inequity of GI dietetic services across England, with regional differences in the level of provision and extent of specialist care. Allocated time for clinics appears to be insufficient compared with time advocated in the literature. Group clinics are becoming a more common method of dietetic service delivery for CD and IBS. National guidance on GI dietetic service delivery is required to ensure equity of dietetic services across England.

Early recognition of coeliac disease through community pharmacies: a proof of concept study.

Setting Fifteen community pharmacies in the UK. Objective Proof of concept study to test the use of community pharmacies for active case finding of patients with coeliac disease. Methods Customers accessing over-the counter and prescription medicines indicated in the treatment of possible symptoms of coeliac disease over a 6 month period were offered a free point of care test. All patients were given advice regarding the test results and those who tested positive were advised to make an appointment with their general practitioner. Patients and pharmacists involved in service provision were asked to complete a satisfaction survey. Pharmacists were additionally invited to undertake interviews to better understand their views on the service. Main outcome measures Feasibility of service, acceptability to stakeholders and proportion testing positive for coeliac disease. Results Of the 551 individuals tested, 52 (9.4 %) tested positive. 277 (50.3 %) were tested for accessing irritable bowel syndrome treatment, 142 (25.8 %) due to presenting for diarrhoea. The proportion of patients testing positive with different symptoms or for different treatments were similar. Of 43 customers who returned the satisfaction survey, all would recommend the service to others, believing the community pharmacy to be a suitable location. Community pharmacists believed that it enabled them to improve relationships with their customers and that medical practices were receptive to the service. Conclusion This proof of concept study has shown that community pharmacies using a point of care test can effectively recognise and refer patients for confirmatory coeliac disease testing with high levels of customer and service provider satisfaction.

Catering Gluten-Free When Simultaneously Using Wheat Flour.

A European law on gluten-free (GF) labeling came into force in 2012, covering foods sold prepacked and in food service establishments, and a similar U.S. Food and Drug Administration (FDA) regulation covers GF labeling from August 2014. Gluten is found in the grains wheat, rye, and barley. A common source of gluten in the kitchen is wheat flour. This research aimed to determine variables that have a significant effect on gluten contamination in commercial kitchens when wheat flour is in use and to establish controls necessary to assure GF production. A pilot study was used to test the following hypotheses: (i) increasing duration of exposure to wheat flour would increase gluten contamination, (ii) increasing distance between the site of preparation and the site of wheat flour would reduce gluten contamination, (iii) the use of a ventilation hood would decrease gluten contamination, and (iv) the use of a barrier segregating the site of preparation of a GF meal and the use of wheat flour would decrease gluten contamination. Petri dishes containing GF rice pudding were placed in three directions at increasing distances (0.5 to 2 m) from a site of wheat flour use. A barrier was in place between a third of samples and the site of wheat flour. After wheat flour was handled for 0.5 and 4.0 h, petri dishes were sealed and the contents were analyzed for gluten. The experiment was duplicated with the ventilation hood on and off. The pilot study revealed that a distance of 2 m from the use of wheat flour was required to control gluten contamination at ≤20 ppm if wheat flour had been in use for 4.0 h. The identified control of distance was tested in five different study sites. In each of the study sites, a test meal was prepared a minimum of 2 m away from the site of wheat flour use. Although kitchens vary and must be considered individually, the established control of a minimum 2 m distance, along with good hygiene practices, was found to be effective in preparing GF meals at all five study sites.

The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis.

BACKGROUND: A gluten-free diet (GFD) is currently the only available therapy for coeliac disease (CD). OBJECTIVES: We aim to review the literature on the GFD, the gluten content in naturally gluten-free (GF) and commercially available GF food, standards and legislation concerning the gluten content of foods, and the vitamins and mineral content of a GFD. METHODS: We carried out a PubMed search for the following terms: Gluten, GFD and food, education, vitamins, minerals, calcium, Codex wheat starch and oats. Relevant papers were reviewed and for each topic a consensus among the authors was obtained. CONCLUSION: Patients with CD should avoid gluten and maintain a balanced diet to ensure an adequate intake of nutrients, vitamins, fibre and calcium. A GFD improves symptoms in most patients with CD. The practicalities of this however, are difficult, as (i) many processed foods are contaminated with gluten, (ii) staple GF foods are not widely available, and (iii) the GF substitutes are often expensive. Furthermore, (iv) the restrictions of the diet may adversely affect social interactions and quality of life. The inclusion of oats and wheat starch in the diet remains controversial.

Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology.

A multidisciplinary panel of 18 physicians and 3 non-physicians from eight countries (Sweden, UK, Argentina, Australia, Italy, Finland, Norway and the USA) reviewed the literature on diagnosis and management of adult coeliac disease (CD). This paper presents the recommendations of the British Society of Gastroenterology. Areas of controversies were explored through phone meetings and web surveys. Nine working groups examined the following areas of CD diagnosis and management: classification of CD; genetics and immunology; diagnostics; serology and endoscopy; follow-up; gluten-free diet; refractory CD and malignancies; quality of life; novel treatments; patient support; and screening for CD.

Coeliac disease: a diverse clinical syndrome caused by intolerance of wheat, barley and rye.

Coeliac disease is a lifelong intolerance to the gluten found in wheat, barley and rye, and some patients are also sensitive to oats. The disease is genetically determined, with 10% of the first-degree relatives affected and 75% of monozygotic twins being concordant. Of the patients with coeliac disease 95% are human leucocyte antigen (HLA)-DQ2 or HLA-DQ8 positive. Characteristically, the jejunal mucosa becomes damaged by a T-cell-mediated autoimmune response that is thought to be initiated by a 33-mer peptide fragment in A2 gliadin, and patients with this disorder have raised levels of anti-endomysium and tissue transglutaminase antibodies in their blood. Coeliac disease is the major diagnosable food intolerance and, with the advent of a simple blood test for case finding, prevalence rates are thought to be approximately 1:100. Classically, the condition presented with malabsorption and failure to thrive in infancy, but this picture has now been overtaken by the much more common presentation in adults, usually with non-specific symptoms such as tiredness and anaemia, disturbance in bowel habit or following low-impact bone fractures. Small intestinal biopsy is necessary for diagnosis and shows a characteristically flat appearance with crypt hypoplasia and infiltration of the epithelium with lymphocytes. Diet is the key to management and a gluten-free diet effectively cures the condition. However, this commitment is lifelong and many aisles in the supermarket are effectively closed to individuals with coeliac disease. Compliance can be monitored by measuring antibodies in blood, which revert to negative after 6-9 months. Patients with minor symptoms, who are found incidentally to have coeliac disease, often ask whether it is necessary to adhere to the diet. Current advice is that dietary adherence is necessary to avoid the long-term complications, which are, principally, osteoporosis and small bowel lymphoma. However, risk of these complications diminishes very considerably in patients who are on a gluten-free diet.