harvard medical school celiac research program

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The Celiac Disease Genomic Environmental Microbiome and Metabolomic Study

Cdgemm: studio sulla malattia celiaca.

Benvenuto! CDGEMM sta per Celiac Disease Genomic Environmental Microbiome and Metabolomic Study (Studio Genomico Ambientale Microbiomico e Metabolomico nella Malattia Celiaca) e recluta bambini che hanno un parente di primo grado con celiachia.

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Gut Microbiota in Infants: First Results from the CDGEMM Study

The CDGEMM Study is currently recruiting infants in the womb or aged up to 6 months who have a first-degree relative (parent or sibling) with celiac disease.

For general questions about the CDGEMM study, email [email protected] . To enroll, or inquire about enrollment, please contact a participating center nearest you.

For study updates and more information from the Center for Celiac Research and Treatment , visit us on social media! You can also find details about the CDGEMM study on clinicaltrials.gov and on the Mass General Brigham clinical trials registration page .

Interested in sharing information about CDGEMM in your healthcare setting?

This flyer can be posted or distributed freely to any interested care providers or potential participants. Thank you for helping to spread the word about CDGEMM!

Meet the Team

Alessio Fasano, MD
Maureen Leonard, MD
Mark A. Salvatore, MD
Martha Pacetti, RN, MSN, CPNP
Pam Cureton, RD, LDN
Gloria Serena, PhD
Victoria Kenyon, Clinical Research Coordinator

As of February 2021, the CDGEMM Study has enrolled 235 infants in the United States and 266 in Italy for a total of 501 infants. Check out our recent newsletters below for additional updates on study progress.

February 2018 (PDF)
August 2017 (PDF)
January 2017 (PDF)

Got Comments? CDGEMM participants and care providers are encouraged to submit comments or concerns about the study through this anonymous portal . We love to hear your feedback!

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harvard medical school celiac research program

Maureen Leonard, M.D., MMSc

Research interests, research narrative.

Dr. Leonard’s research is focused on predicting and preventing celiac disease through precision medicine. Precision medicine is an emerging approach to disease prevention and treatment that takes into account individual variability in genes, environment, and lifestyle.

Her current work includes identifying biomarkers that can predict intestinal healing in patients with celiac disease, building translational models capable of predicting autoimmune disease in high-risk individuals and working on the NIH-funded Celiac Disease: Genomic Environment Microbiome and Metabolomic Study (CDGEMM).

Dr. Leonard currently holds funding from the NIH (K23DK122127) and was previously funded by the Thrasher Research Fund, the Nutrition Obesity Research Center at Harvard, and the NIH (FDK109620A).

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World J Gastroenterol
v.27(20); 2021 May 28

Understanding celiac disease monitoring patterns and outcomes after diagnosis: A multinational, retrospective chart review study

Knut ea lundin.

K.G. Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo 0450, Norway

Department of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo 0372, Norway

Ciaran P Kelly

Celiac Center Beth Israel Deaconess Medical Center, Celiac Research Program Harvard Medical School, Boston, MA 02115, United States

David S Sanders

Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2TN, United Kingdom

Kristina Chen

Takeda Pharmaceuticals International Co., Cambridge, MA 02139, United States

Sheena Kayaniyil

Real World Evidence Strategy and Analytics, ICON plc., Toronto, ON L7N 3G2, Canada

Real World Evidence Strategy and Analytics, ICON plc., Vancouver, BC V6B 1P1, Canada

Rajvi J Wani

Caitlin barrett, shakira yoosuf, ellen s pettersen, robert sambrook, daniel a leffler.

Takeda Pharmaceuticals International Co., Cambridge, MA 02139, United States. [email protected]

Corresponding author: Daniel A Leffler, MD, Doctor, Takeda Pharmaceuticals International Co., 40 Landsdowne Street, Cambridge, MA 02139, United States. [email protected]

Associated Data

Data are available upon request from the corresponding author.

Long-term outcomes and monitoring patterns in real-world practice are largely unknown among patients with celiac disease.

To understand patterns of follow-up and management of patients with celiac disease, and to characterize symptoms and villous atrophy after diagnosis.

A retrospective chart review study was performed using medical chart data of patients diagnosed with celiac disease. Three gastroenterology referral centers, with substantial expertise in celiac disease, participated in the United Kingdom, United States, and Norway. Demographic and clinical data were collected from medical charts. Descriptive analyses were conducted on patients with biopsy-confirmed celiac disease, diagnosed between 2008 and 2012, with at least one follow-up visit before December 31, 2017. Patient demographic and clinical characteristics, biopsy/serology tests and results, symptoms, and comorbidities were captured at diagnosis and for each clinic visit occurring within the study period ( i.e. , before the study end date of December 31, 2017).

A total of 300 patients were included in this study [72% female; mean age at diagnosis: 38.9 years, standard deviation (SD) 17.2]. Patients were followed-up for a mean of 29.9 mo (SD 22.1) and there were, on average, three follow-up visits per patient during the study period. Over two-thirds (68.4%) of patients were recorded as having ongoing gastrointestinal symptoms and 11.0% had ongoing symptoms and enteropathy during follow-up. Approximately 80% of patients were referred to a dietician at least once during the follow-up period. Half (50.0%) of the patients underwent at least one follow-up duodenal biopsy and 36.6% had continued villous atrophy. Patterns of monitoring varied between sites. Biopsies were conducted more frequently in Norway and patients in the United States had a longer follow-up duration.

This real-world study demonstrates variable follow-up of patients with celiac disease despite most patients continuing to have abnormal histology and symptoms after diagnosis.

Core Tip: Inadequately managed celiac disease can lead to health complications. However, there are limited published data on real-world monitoring and outcomes for patients with celiac disease. In this real-world study, country/site-specific differences in the routine monitoring of patients after diagnosis were evident, including differences in the frequency of follow-up biopsy. A large proportion of patients continued to have villous atrophy and symptoms after diagnosis and, therefore, there is a continued need for more routine follow-up assessments, including mucosal assessments of celiac disease activity.

INTRODUCTION

Celiac disease is a chronic, immune-mediated disorder that affects genetically susceptible individuals. The only accepted current standard of care for celiac disease is a life-long gluten-free diet (GFD). Previous studies have reported that adherence rates to a GFD range between 42% and 91%[ 1 , 2 ]. Inadequately managed celiac disease can lead to health complications such as malnutrition, osteoporosis, neurologic complaints, and lymphoma[ 2 ]. It has been hypothesized that long-term management and regular follow-up of patients with celiac disease will improve adherence to a GFD, and improve disease outcomes including mucosal healing and symptom resolution. For this reason, long-term management and regular follow-up of patients with celiac disease are advocated by current practice guidelines[ 3 , 4 ], yet it is unclear how these are actually implemented in practice. It is understood, however, that practice patterns vary widely both between countries and between practices.

Given that celiac disease is a chronic disorder, it is important to understand real-world, long-term outcomes and routine monitoring practices; however, there are few published data in these areas. Therefore, the aims of this multinational study were twofold. First, to understand, in real-world clinical practice, patterns of patient follow-up and management and how these practices vary by country. The second aim was to characterize patient outcomes, specifically related to ongoing symptoms and ongoing villous atrophy after diagnosis. Together, these data may be helpful in informing clinical practice, studies, and interventions aimed at improving celiac disease outcomes, and for quality improvement initiatives.

MATERIALS AND METHODS

A retrospective chart review study was conducted using medical chart data of patients diagnosed with celiac disease. Three large gastroenterology centers with substantial expertise in celiac disease participated, capturing patients in the United Kingdom, the United States, and Norway. Each site contributed 100 patients. Ethics approval was obtained before data collection commenced.

Patients were eligible if they had biopsy-confirmed celiac disease[ 3 , 5 , 6 ], were diagnosed between 2008 and 2012, and had at least one follow-up visit before 31 December 2017. This study period was selected to allow for at least five years of follow-up after diagnosis. Patients were excluded if they had initiated a GFD before receiving a diagnosis of celiac disease.

Using the database of patients at each site, the assigned staff at each center identified eligible patients by first looking at the date of diagnosis. The data abstractor reviewed and identified eligible patients who were diagnosed in December 2012, and then continued review of eligibility for patients consecutively backwards from that date (back to a diagnosis date in 2008). After examining the date of diagnosis, other inclusion/exclusion criteria were assessed to verify patient eligibility for the study. All three sites were explicitly asked to follow the same approach regarding selection of consecutive patients to avoid selection bias. The assigned staff at each site responsible for data abstraction then entered de-identified data for eligible patients into a custom electronic case report form. All data collected were based on the patient’s pre-existing medical record. No direct personal identifiers were attached to the abstracted data. Data describing patient demographic and clinical characteristics, biopsy/serology tests and results, symptoms, and comorbidities were captured at diagnosis and for each clinic visit occurring within the study period ( i.e., before the study end date of December 31, 2017).

In terms of diagnostic testing, available serology results were collected, including tissue transglutaminase-immunoglobulin (Ig) A, IgA endomysial antibody, total serum IgA, deamidated gliadin peptide (DGP) IgA, DGP IgG, and DGP IgA-IgG. As not all pathology reports across sites utilized Marsh-Oberhuber classification, a descriptive assessment of biopsy results was recorded as follows: normal, increased intraepithelial lymphocytes only, mild/partial villous atrophy, subtotal villous atrophy, total/complete atrophy, and other.

Data are summarized by descriptive statistics [mean, standard deviation (SD), median, and interquartile range for continuous variables, and number and percentage for categorical variables]. Gastrointestinal symptoms and extraintestinal comorbidities/ complications (termed extraintestinal manifestations) are described at diagnosis and during study follow-up.

The presence of symptoms during the follow-up period was characterized specifically for patients who had a symptom at diagnosis and a record of symptoms at least once during follow-up. For each patient, the duration of the follow-up period was calculated as the time from diagnosis to the last follow-up visit within the study period. The mean number of visits per patient and the number of follow-up visits per patient with biopsy data were summarized overall and by country.

Following the classification proposed by Kurien et al [ 2 ], subsets of study patients with available symptom (defined as diarrhea, abdominal pain, abdominal distention, poor appetite, weight loss, tiredness/lethargy, brain fog, malabsorption and/or bloating) and biopsy data were grouped into four main disease states at diagnosis and at each follow-up visit: class 1 (no symptoms and normal duodenal histology); class 2 (no symptoms and abnormal duodenal histology); class 3 (symptoms and normal duodenal histology); class 4 (symptoms and abnormal duodenal histology). This classification provides an intuitive framework for assessing celiac disease outcomes and may help to identify patients with the highest risk of complications. In addition, biopsy results reported as mild/partial/subtotal/total/complete villous atrophy were considered as abnormal histology; all other findings were considered normal for this classification. Those with ‘other’ biopsy findings were excluded in the classification.

Analyses were based on available data. Descriptive statistics were restricted to the subset of patients for whom data were available, with relevant denominator information provided in the results. All analyses were conducted in SAS 9.4.

A total of 300 patients with celiac disease were included in this study, comprising 100 patients from each of the three participating gastroenterology referral centers in the United Kingdom, the United States, and Norway. Table Table1 1 presents the demographic and clinical characteristics of included patients at diagnosis.

Demographic and clinical characteristics of patients at diagnosis, by country

EGD: Esophagogastroduodenoscopy; IQR: Interquartile range; SD: Standard deviation.

Patients were, on average, 39 years of age at diagnosis, with 24 patients (8%) less than 18 years of age; there were 216 females in the study (72.0%). The study populations across the three sites were quite similar with respect to age, gender, and ethnicity distributions (Table (Table1). 1 ). Gastrointestinal symptoms were the most common reason leading to diagnosis. There was a significantly greater proportion of patients in the United Kingdom (57.0%, n = 57) who presented with extraintestinal manifestations at diagnosis compared with patients in the United States (17.0%) and Norway (17.0%) ( P < 0.0001). Nutritional deficiency was the most commonly reported extraintestinal manifestation in the United States and Norway, whereas in the United Kingdom anemia was most frequently documented at diagnosis (Table (Table2). 2 ). Almost all ( n = 299, 99.7%) patients had an esophagogastroduodenoscopy (EGD) conducted at diagnosis, and two patients (0.7%) had an enteroscopy. Overall, 90.7% ( n = 272) of patients had serologic testing concurrently with biopsy, and these findings were similar across patients at the three sites. Biopsy results are presented in Table Table1. 1 . Serology results at diagnosis and during the follow-up period are presented in Supplemental Table 1 .

Presentation of gastrointestinal and extraintestinal manifestations at diagnosis and at follow-up visits, by country

The types of gastrointestinal and extraintestinal manifestations and associated conditions at diagnosis and during follow-up were similar across sites and are presented in Table Table2. 2 . At diagnosis, 256 patients (85.3%) and 228 patients (76.0%) had at least one gastrointestinal or extraintestinal manifestation, respectively. The most common symptoms across all sites were diarrhea, abdominal pain and bloating and the most common laboratory findings included nutrient deficiencies, anemia and low bone mineral density. Interestingly, both weight loss and weight gain were more commonly reported in the United States compared to the United Kingdom and Norway. There were 147 patients (49.0%) who presented with diarrhea, 124 (41.3%) who presented with abdominal pain, and 90 (30.0%) who presented with bloating. In addition, 104 patients (34.7%) had documentation of a nutritional deficiency, and 34 patients (11.3%) presented with another autoimmune disease, in addition to celiac disease, at diagnosis. During follow-up, diarrhea [ n = 100 (33.3%)], abdominal pain [ n = 93 (31.0%)], and bloating [ n = 76 (25.3%)] continued to be the most frequently reported gastrointestinal symptoms. Of the 256 patients who had gastrointestinal symptoms at diagnosis, 175 (68.4%) had at least one visit reporting gastrointestinal symptoms during the follow-up period.

The duration of follow-up and average number of follow-up visits for the overall study population and by country are presented in Table Table3. 3 . Patients were followed up for a mean of 29.9 mo (SD: 22.1) and there were, on average, three follow-up visits per patient during the study period. Patients from the United States site had the longest follow-up duration during the study period (mean: 38.7 mo), compared with the United Kingdom and Norway sites (mean: 26.5 and 24.5 mo, respectively; P < 0.0001). Overall referral patterns to other specialists were captured, indicating that approximately 80% of patients were referred to a dietician at least once during the follow-up period. Details on the last-recorded follow-up with the patient indicated that almost half (48%) of all patients had a follow-up appointment scheduled. Some were discharged (approximately 10%) or were referred to another specialist (approximately 19%), otherwise, the last follow-up decision was recorded as ‘unknown’ or ‘other’.

Descriptive characteristics of follow-up visits and endoscopies during the follow-up period, overall and by country

For unknown diagnosis days and months, the day was imputed to the 15 th , and the month was imputed to June.

IQR: Interquartile range; SD: Standard deviation.

After EGD, bone densitometry was the next most frequently reported procedure during follow-up, performed in 89 patients (29.7%) from the overall study population. Bone densitometry was performed at least once in 45 United States patients (45.0%) during the follow-up period, compared with patients who received this procedure in the United Kingdom and Norway [ n = 22 (22.0%) for both United Kingdom and Norway patients; P < 0.001]. As this procedure is not performed in the gastroenterology unit, the results of these tests were not routinely available.

A summary of endoscopies with duodenal biopsy performed during the follow-up period, overall and by country, is also presented in Table Table3. 3 . Of the 300 patients included in this study, 150 (50.0%) had at least one endoscopy with duodenal biopsy during the follow-up period. Of these 150 patients, 116 (77.3%) had a single follow-up endoscopy with biopsy during the follow-up period and most (14.7%, n = 22/150) of the remaining 34 patients had two follow-up endoscopies. A significantly higher proportion of Norway patients received a follow-up biopsy (82.0%, n = 82) compared with patients in the United Kingdom (42.0%, n = 42) and United States (26.0%, n = 26) ( P < 0.0001).

The proportion of patients in the four disease state classes at diagnosis and at last follow-up with available data within the study period are presented in Figure Figure1. 1 . Of patients in classes 2 or 4 at diagnosis ( n = 295) and who had a follow-up biopsy ( n = 150), 53 (36.6%) continued to have villous atrophy (classes 2 or 4) at their last follow-up visit with biopsy data. The proportions were similar for the United Kingdom, United States, and Norway sites, where 39.0% ( n = 16), 40.0% ( n = 10), and 34.6% ( n = 27) of patients, respectively, remained in classes 2 or 4 based on the last available biopsy data within the study period.

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Number of patients grouped into the four disease state classes at diagnosis and at last follow-up with available biopsy data. Class 1: no symptoms and normal duodenal histology; Class 2: No symptoms and abnormal duodenal histology; Class 3: Symptoms and normal duodenal histology; Class 4: Symptoms and abnormal duodenal histology. 1 Patients with biopsy result indicated as ‘other’ in the data collection form were excluded from this classification.

Overall, there were 54 patients who were in class 1 (no symptoms and normal duodenal histology) by the last follow-up visit with biopsy data. Of the patients with data available for the classification at diagnosis and at the last follow-up, the proportion of patients in class 1 during the follow-up period was slightly higher in Norwegian patients [ n = 34 (43.6%)] compared with patients from the United Kingdom [ n = 12 (29.3%)] and the United States [ n = 8 (32.0%)].

This real-world study characterizes patients with celiac disease over time, and provides insight into routine monitoring practices from three large referral centers in the United Kingdom, the United States, and Norway. The majority of patients were female, which is consistent with other reports on the demographics of the celiac disease patient population[ 7 , 8 ]. Patients were followed for a mean of 29.9 mo (median 25 mo) and there were, on average, three follow-up visits per patient. Over two thirds of patients had a documentation of gastrointestinal symptoms during the follow-up period, which may indicate inadequate control of celiac disease despite patients being on a GFD. In addition, the fact that a higher proportion of patients from the United Kingdom site presented with extraintestinal manifestations at diagnosis, compared with patients from the United States and Norway sites, indicates that differences may exist in diagnostic or referral practices between different countries. This is particularly true for the United Kingdom site, which was known to see a greater number of patients with neurological manifestations of celiac disease. It is therefore likely that the differences in extraintestinal manifestations at diagnosis between the countries are due to a combination of referral bias and ascertainment bias at the individual sites, such that some manifestations may be evaluated more frequently at some sites than others.

While the study did collect information on extraintestinal manifestations, including liver abnormalities, it did not specifically assess metabolic disorders of patients with celiac disease. Given that an increased risk of non-alcoholic fatty liver disease in patients with celiac disease on a GFD has been reported[ 9 ], it would be valuable for future long-term studies to examine such metabolic disorders in this patient population. Country/site-specific differences were also evident in the routine monitoring of patients after diagnosis. While the United States patients had the longest follow-up duration within the study period, compared with Norwegian and United Kingdom patients, a higher proportion of Norwegian patients received a follow-up biopsy, indicating differences in diagnostic or referral practices across the different sites/countries that may not necessarily be reflective of differences in national guidelines.

In this study, half of patients received at least one follow-up biopsy after diagnosis within the study period, with significant variability between sites. While there is currently no consistent recommendation to perform routine follow-up biopsy on all patients, recent European guidelines suggest a follow-up biopsy in adults one to two years after diagnosis and after starting a GFD to assess mucosal healing, as treatment of ongoing mucosal injury is less well defined and depends on likely etiology[ 3 ].

The grouping of patients into four disease state classes in this study allows for examination of the persistence of celiac disease symptoms as well as mucosal recovery/healing. Patients in this study with ongoing mucosal injury likely represent a combination of ongoing gluten exposure, slow recovery post diagnosis, and refractory celiac disease. Analysis of specific etiologies of ongoing villous atrophy, however, is outside the scope of this manuscript. Study results indicated that 36.6% of patients overall had presence of villous atrophy (classes 2 or 4) at the last follow-up visit with available biopsy data, with similar findings across sites. While it is unclear how many of these patients would progress to histologic remission given longer follow-up, these data suggest that a substantial proportion of patients may not be achieving therapeutic goals, even at specialized celiac disease centers. Furthermore, it is important to note that among those with at least one follow-up visit only half of patients had a follow-up biopsy to examine mucosal recovery. While the proportion of patients with persistent villous atrophy may be partially related to referral bias, the inclusion of patients diagnosed only at tertiary centers should have mitigated this. Conversely, patients who are not followed up or who receive care at less well-equipped centers may have even higher rates of inadequate disease control.

The reasons for the variability in follow-up, both within and between centers, are unclear. However, it seems that many of the patients in this study were either not continuing to see their gastroenterologist or not having a follow-up biopsy, which would limit the ability to assess continued presence of symptoms and villous atrophy. Yet, previous studies reported that having a follow-up biopsy did not impact long-term outcomes when compared with those who did not have a follow-up biopsy, possibly due to lack of effective interventions to address ongoing villous atrophy [ 10 , 11 ].

Potential country differences in healthcare policies may also be at play here. Indeed one previous study conducted in Norway reported that only 6% of patients had prevalence of villous atrophy after a median follow-up of 8.1 years[ 10 ]. The authors of this Norwegian study indicated that this may be partially driven by the fact that, in Norway, patients diagnosed with celiac disease automatically qualify for a reimbursement to cover the extra costs associated with following a GFD. In another study, from Australia, rates of mucosal remission and response were 50% and 85% at one and five years, respectively[ 12 ]. In addition, Pekki et al [ 11 ] reported that 42% ( n = 200) of the 476 patients examined in Finland, who had a repeat biopsy, continued to have atrophy after one year of follow-up[ 11 ]. In yet another study from Finland, the authors reported that 96% ( n = 177) of patients had villous recovery after a mean of 11 years of follow-up while adhering to a GFD[ 13 ]. The present study, however, did not find a large difference by country for the proportion of patients with continued presence of villous atrophy during follow-up.

Strengths of this study are the inclusion of patients with biopsy-proven celiac disease, the multinational sample, and the use of consecutively diagnosed patients, which should have reduced selection bias. However, future research may be warranted to examine whether patterns of care are different in community-based compared with tertiary centers, and whether there are potential differences in outcomes for patients diagnosed by serology alone and followed up in general practice. Given that the sites in this study were large gastroenterology referral centers, it is anticipated that they should be reflective of practice patterns in similar centers within the countries studied, and where there were commonalities between the centers, these are likely generalizable. However, as this cannot be tested, it is also likely that the selected sites may not be truly representative of the country, and these findings would need to be confirmed by further research within each country. In addition, patterns of care are reflective of those in gastroenterology referral centers, and may be more rigorous than patterns of care in general practice.

Limitations of this study include the lack of information regarding adherence to a GFD, as this information is often not readily available in patient charts, although most patients (approximately 80%) were referred to a dietician at least once during the follow-up period. Future studies may be able to assess GFD adherence objectively through the presence of gluten immunogenic peptides in the urine[ 14 ]. There is also the possibility that variation in pathology assessment and reporting may influence inter center results; although, good interobserver agreement for the detection of villous atrophy has been reported[ 15 ]. In addition, the majority of patients included in this study were diagnosed on the basis of symptoms, with approximately 12% diagnosed by screening alone. While asymptomatic patients may have different outcomes, related in part to GFD adherence, the current study was not designed to address this. However, it would be valuable for future studies to consider and compare outcomes based on whether diagnosis was based on asymptomatic vs symptomatic disease.

Further, it is unclear what proportion of patients in this study were diagnosed elsewhere and referred to one of the participating gastroenterology centers owing to lack of healing. This may have resulted in a higher proportion of patients with villous atrophy compared with a community setting. In addition, this study captured patient visits to the gastroenterologist only, and any continued management with another healthcare provider ( e.g., general practitioner, dietician) was not captured. Therefore, the results of this study are reflective of follow-up and outcomes for patients with celiac disease as per their management by the gastroenterologist. While it is expected that most patients will continue to be managed by a gastroenterologist, particularly if they continue to experience symptoms and have no evidence of mucosal healing, management by a general practitioner or other specialist ( e.g., dietician) may occur in parallel. In addition, given that the inclusion criteria required selection of patients with at least one follow-up visit within the study period, to report on follow-up patterns and outcomes, the study is unable to provide information on patients who did not return to the gastroenterologist for a follow-up visit during the study period. Further, comparisons made between sites/countries relied on standard parameters assessed across sites including celiac serologies (but heterogeneous in the frequency of retesting), symptoms assessment, GFD adherence and nutritional values. However, differences across the sites and the standard of practice would largely be the driver of follow-up endoscopy/biopsy, and the authors recognize this limitation in adequately comparing outcomes across patients.

There is a lack of clarity in guidelines on types of clinicians who are most appropriate to administer follow-up care and management for patients with celiac disease, and this may be especially important given increasing activity of non-traditional practitioners. Results from a patient survey indicated that 27% of patients had not visited a healthcare provider about celiac disease over the past five years, with almost half of these patients reporting that they felt that they were managing their celiac disease effectively on their own[ 16 ]. Therefore, despite the present study focusing specifically on management by gastroenterologists, it may be that some patients choose to manage celiac disease on their own and do not return for regularly scheduled visits.

This study provides valuable insight into the monitoring patterns and outcomes of patients with celiac disease managed at large referral centers in real-world practice. Overall, the monitoring of patients, including the rate of follow-up biopsy, varied across the participating sites, with a higher proportion of Norwegian patients receiving a follow-up biopsy compared with patients in the United Kingdom and United States. Differences were also observed in the presentation of extraintestinal manifestations at diagnosis across the sites. In addition, the study results indicate that a large proportion of patients continue to have villous atrophy and continue to experience symptoms after diagnosis; a finding that was consistent across sites. Pharmacological management may be required for patients who are adherent to a GFD but who still experience symptoms and mucosal injury.

In general, patients are not routinely monitored for the outcome of a GFD on symptoms, which may have an impact on intestinal health and can be a burden to patients. Overall, these data suggest that more routine follow-up assessment of celiac disease activity is needed. The inconsistent rates of mucosal assessment may be of concern, especially as many patients do not achieve histological remission. Novel, less invasive measures for assessment of ongoing villous atrophy, in combination with adjunctive pharmacologic therapy, may be needed to improve outcomes in patients with celiac disease.

ARTICLE HIGHLIGHTS

Research background.

Long-term outcomes and monitoring patterns for patients with celiac disease in the real world are unknown.

Research motivation

Long-term management and regular follow-up of patients with celiac disease is thought to improve adherence to a gluten-free diet, improve mucosal healing, and symptom resolution. However, it is unclear how patients with celiac disease are managed in routine clinical practice. There is anecdotal evidence suggesting that practice patterns vary widely both between countries and between practices.

Research objectives

To understand real-world clinical practice, patterns of patient follow-up and management, and to characterize patient outcomes related to symptoms and villous atrophy after diagnosis.

Research methods

A retrospective observational study was performed using medical chart data of patients from three gastroenterology referral centers in the United Kingdom, United States, and Norway for patients diagnosed with celiac disease between 2008-2012.

Research results

300 patients were followed for a median of 25 mo. During follow-up, 68.4% of patients were recorded as having ongoing gastrointestinal symptoms and 11.0% had ongoing symptoms and enteropathy. 50.0% of patients underwent at least one follow-up duodenal biopsy and 36.6% had continued villous atrophy. Patterns of monitoring varied between sites.

Research conclusions

This real-world study demonstrates variable follow-up of patients with celiac disease even as most patients continue to have abnormal histology and symptoms after diagnosis.

Research perspectives

These data suggest that more routine follow-up assessment of celiac disease activity is needed. Novel and less invasive measures to assess ongoing villous atrophy, used in combination with adjunctive pharmacologic therapy, may be needed to improve outcomes in patients with celiac disease.

Institutional review board statement: Ethics approval was obtained before data collection commenced at each site (Beth Israel Deaconess Medical Center 09/11/2018; Health Research Authority 19/11/2018; and Regional Committees for Medical and Health Research Ethics 05/06/2018).

Informed consent statement: A waiver of consent was approved for the United States site; the other sites had collected patient consent for research with their patient database.

Conflict-of-interest statement: KEA Lundin has served as a speaker/consultant/advisory board member for Amyra Biotech AG, Bioniz Therapeutics, Chugai Pharmaceutical, Dr. Falk Pharma GMBH, Immusant Therapeutics, and Interexon Actobiotics. CP Kelly has served as a consultant/advisory board member for Aptalis, Cour Pharma, Glutenostics, ImmunogenX, Innovate, Janssen, Kanyos, Takeda Pharmaceuticals, Merck, and Theravance; CP Kelly has received a grant from Aptalis; S Kayaniyil, S Wang, RJ Wani, and R Sambrook are salaried employees of ICON, which received research funds from Takeda Pharmaceuticals for conducting the study and preparation of the manuscript for publication. K Chen was a salaried employee of Takeda Pharmaceuticals at the time of study. DA Leffler is a salaried employee of Takeda Pharmaceuticals; CP Kelly owns shares in Cour Pharma and Glutenostics; DS Sanders, C Barrett, S Yoosuf, and ES Pettersen have no conflicts of interest to declare.

STROBE statement: The authors have read the STROBE Statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement – checklist of items.

Manuscript source: Unsolicited manuscript

Peer-review started: November 12, 2020

First decision: January 23, 2021

Article in press: April 28, 2021

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: Canada

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): B

Grade C (Good): C

Grade D (Fair): D

Grade E (Poor): 0

P-Reviewer: Aufiero VR, Kroupa R, Vorobjova T S-Editor: Fan JR L-Editor: A P-Editor: Ma YJ

Contributor Information

Knut EA Lundin, K.G. Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo 0450, Norway. Department of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo 0372, Norway.

Ciaran P Kelly, Celiac Center Beth Israel Deaconess Medical Center, Celiac Research Program Harvard Medical School, Boston, MA 02115, United States.

David S Sanders, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2TN, United Kingdom.

Kristina Chen, Takeda Pharmaceuticals International Co., Cambridge, MA 02139, United States.

Sheena Kayaniyil, Real World Evidence Strategy and Analytics, ICON plc., Toronto, ON L7N 3G2, Canada.

Sisi Wang, Real World Evidence Strategy and Analytics, ICON plc., Vancouver, BC V6B 1P1, Canada.

Rajvi J Wani, Real World Evidence Strategy and Analytics, ICON plc., Toronto, ON L7N 3G2, Canada.

Caitlin Barrett, Celiac Center Beth Israel Deaconess Medical Center, Celiac Research Program Harvard Medical School, Boston, MA 02115, United States.

Shakira Yoosuf, Celiac Center Beth Israel Deaconess Medical Center, Celiac Research Program Harvard Medical School, Boston, MA 02115, United States.

Ellen S Pettersen, Department of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo 0372, Norway.

Robert Sambrook, Real World Evidence Strategy and Analytics, ICON plc., Vancouver, BC V6B 1P1, Canada.

Daniel A Leffler, Takeda Pharmaceuticals International Co., Cambridge, MA 02139, United States. [email protected] .

Data sharing statement

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From the Experts: All Things Celiac

The National Celiac Association and the Harvard Medical School Celiac Education & Research Program are co-hosting a series of 75-minute virtual meetings. Speakers present on selected topics for 60 minutes, followed by a 15-minute question-and-answer period.

For live technical support during the webinars, please call 857-282-6470 or email: digitalmedia@partners.org

Please note: These are educational webinars, and no information is intended for diagnosis or treatment of any medical condition. Please seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Getting the Most from your Gluten-Free Diet: Adaptations, Budgeting and Access for All

Join us for the combined Harvard Medical School Celiac Research & Education Program and the National Celiac Association’s Spring 2024 “Ask the Experts ” webinar. Speakers will present on selected topics for 60 minutes, followed by 15 minutes for Q&A, on Thursday, May 30, 2024, from 1- 2:15 pm ET.

Lauren Fiechtner, MD, MPh , Director of Nutrition, Division of Gastroenterology and Nutrition, Mass General for Children; Assistant Professor of Pediatrics, Harvard Medical School; and Senior Health and Research Advisor, Greater Boston Food Bank, will discuss the increased risk of food insecurity and its clinical presentation in children and adolescents on special diets, such as celiac disease, and highlight current work being done to improve access to food assistance programs. Soran R. Bozorg, MD, who is pursuing a PhD in Epidemiology and Health Economics at Karolinska Institutet in Sweden, will discuss the effects of the high cost of the gluten-free diet and the general economic burden to individuals with celiac disease and societies worldwide. Carla Carter , OTR/L, Director of Outreach and Programming with the National Celiac Association, will address fighting hunger in the nationwide gluten-free population and how individuals can cleverly adapt to a gluten-free diet in cost-effective ways, touching on food access, shopping, storing and preparing gluten-free food.

Chris Rich , Executive Director of the National Celiac Association, will introduce the webinar, which will be moderated by Vanessa Weisbrod, Chief Education and Community Engagement Officer for the Celiac Disease Foundation. A Q&A session will follow the presentations; please submit general questions when you register or during the webinar on the Zoom platform.

Please note: This is an educational webinar, and no information is intended for diagnosis or treatment of any medical condition. Please seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Continuing Education Units (CEUs): This course (220323-RSS) is approved by the Boston Children’s Hospital’s Continuing Education Department for 1.25 AMA PRA Category 1 Credits ™ for physicians, 1.25 contact hours for nurses, 1.25 ACE CE continuing education credits for social workers, and 1.25 CEUs for Registered Dietitians. Instructions for claiming credits will be made available during the webinar and transcripts will be available within 30 days.

Is it Celiac Disease and Something Else, or Something Else Entirely? SIBO, IBS, and Other Intestinal Disorders

Recorded February 29, 2024

Other than active celiac disease due to gluten exposure, there are many reasons for ongoing symptoms, including food intolerances, small intestinal bacterial overgrowth (SIBO), diet changes, co-existing or inflammatory diseases, and diseases that are unrelated to celiac disease. Amelie Therrien, MD, MSc , expert celiac gastroenterologist at the Celiac Center at Beth Israel Deaconess Medical Center, reviewed some of these conditions as well as celiac mimickers (conditions other than celiac disease that damage the small intestine and/or elevate tissue transglutaminase). Registered dietitian Christy Moran, MS, RD , discussed the existing evidence for diet therapies to address the commonly seen irritable bowel syndrome and SIBO. The most promising clinical drug trials to address ongoing symptoms in patients with celiac disease were highlighted by Jocelyn Silvester, MD, PhD , Director of Research for the Celiac Disease Program at Boston Children’s Hospital.

Chris Rich , executive director of the National Celiac Association, introduced the webinar. Katherine Olshan, MD , expert celiac gastroenterologist at the Center for Celiac Research and Treatment at Mass General for Children moderated. A Q&A session followed the presentations.

View this video!

Building a Strong Foundation: Celiac Disease and Bone Health

Recorded November 2023

Bone health is a crucial topic for both children and adults with celiac disease, as bone can be adversely affected due to the inflammatory process and malabsorption of key nutrients. Deborah Mitchell, MD , pediatric endocrinologist at Mass General for Children (MGfC), and Julio C. Bai, MD , adult gastroenterologist and Professor Emeritus of Medicine at the Research Institute of Universidad del Salvador in Buenos Aires, addressed the prevalence and types of bone disease in the adult and pediatric celiac populations, testing methods, and treatment options, including lifestyle modifications for bone health. Katarina Mollo, MEd, RDN, LDN , clinical dietitian at the Center for Celiac Research and Treatment at MGfC, discussed the importance of the gluten-free diet and the use of supplements, where appropriate.

Chris Rich , CEO and executive director of the National Celiac Association, introduced the webinar, which was moderated by Daniel Leffler, MD, expert celiac gastroenterologist at the Celiac Center at Beth Israel Deaconess Medical Center. A Q&A session followed the presentations.

Close Connections in Autoimmunity: Thyroid Disorders and Celiac Disease

Recorded October 2023

Thyroid disease and celiac disease are closely linked as two autoimmune diseases and commonly occur together. Two experts in the endocrinology field presented current findings and guidance to address challenges for adults and children who are managing both conditions. Ari Wassner, MD , Medical Director of the Thyroid Center at Boston Children’s Hospital, covered epidemiology, incidence, and screening of thyroid disease and celiac disease in children and adults and share newest research in the thyroid field. James Hennessey, MD , Director of Clinical Endocrinology at Beth Israel Deaconess Medical Center, addressed the impact of celiac disease on patients with thyroid disease, potential long-term complications and treatment strategies.

Giuseppe Barbesino, MD , of the Mass General Endocrinology Unit/Thyroid Associates, moderated the session. Lee Graham , executive director of the National Celiac Association, introduced the webinar. A Q&A followed the presentations.

Unbalanced Eating: The Spectrum of Eating Disorders with Gluten-Related Conditions

Recorded April 2023

Research shows that disordered eating patterns are more common in people with gluten-related conditions. Three experts presented current findings and guidance on both conditions. Elana Bern, MD, MPH , co-director of the Avoidant/Restrictive Food Intake (ARFID) Clinic at Boston Children’s Hospital, covered screening, diagnosis, and medical care of eating-disordered behavior, including ARFID, in gluten-related disorders. Rose-Marie Satherley, PhD , a lecturer in Clinical Psychology at the University of Surrey, discussed the intersection between diet-controlled conditions and disordered eating. Registered dietitian Janelle Smith, MS, RDN, CEDS , from UCLA’s Division of Digestive Diseases, covered nutritional concerns in restrictive eating patterns in patients with digestive disorders.

Melinda Dennis, MS, RD, LDN , nutrition coordinator at the Celiac Center at Beth Israel Deaconess Medical Center, moderated. Lee Graham , executive director of the National Celiac Association, introduced the webinar. A Q&A session followed.

Living Well with Celiac Disease and Diabetes Mellitus

Recorded February 2023

Together Caitlin Colling, MD , adult endocrinologist at MassGeneral for Children (MGfC), and Janaki Vakharia, MD , senior combined adult and pediatric endocrinology fellow at MGH and MGfC, covered the importance of screening and diagnosis of Type 1 diabetes in the celiac population and the medical care of diabetes in pediatrics, young adults, and adults. Registered Dietitian Sharon Weston, MS, RD, LDN, CSP, FAND, from the Celiac Disease Program at Boston Children’s Hospital, addressed nutritional concerns and challenges of adhering to the gluten-free diet while managing diabetes effectively.

Lee Graham , executive director of the National Celiac Association, introduced the webinar, which was moderated by Ciarán P. Kelly, MD, medical director of the Celiac Center at Beth Israel Deaconess Medical Center. A Q&A session followed the presentations.

Diagnosing and Predicting Celiac Disease: Clinical Pearls from International Celiac Disease Symposium 2022

Recorded November 2022

During our second Fall 2022 “Ask the Experts” webinar, three clinicians presented updates on diagnosing and predicting celiac disease, including developments from the 2022 International Celiac Disease Symposium in Sorrento, Italy.

Denis Chang, MD, MS , pediatric gastroenterologist at Boston Children’s Hospital (BCH), focused on the clinical challenges of diagnosis and the array of consumer testing kits for celiac disease and genetic information. Amelie Therrien, MD , gastroenterologist at Beth Israel Deaconess Medical Center, examined diagnostic alternatives to the current tool of endoscopy with biopsy. Focusing on the prevention of celiac disease, clinical director of the Center for Celiac Research and Treatment at MassGeneral for Children Maureen Leonard, MD, MMSc , presented findings on the gut microbiome and other areas of research.

Lee Graham , executive director of the National Celiac Association, introduced the webinar, which was moderated by Dascha Weir, MD , associate director of the Celiac Disease Program at BCH. A Q&A session followed the presentations.

Advancing Celiac Research Through Patient Participation and Industry Partnership

Recorded September 2022

Patients, clinicians, scientists and industry partners all contribute to the research effort to find treatment alternatives to the gluten-free diet. Speakers will present the latest research and talk about the importance of patient participation in clinical trials.

Daniel Leffler, MD, MS, AGAF , gastroenterologist at Beth Israel Deaconess Medical Center and senior medical director at Takeda Pharmaceuticals, joined Francisco Leon, MD, PhD , chief scientific officer and co-founder of Provention Bio, to present a research update on emerging technologies to diagnose and monitor celiac disease and alternative treatments in their experimental stages. Jocelyn Silvester, MD, PhD , pediatric gastroenterologist at Boston Children’s Hospital, talked about the use of gluten in clinical trials.

Lee Graham , executive director of the National Celiac Association, introduced the webinar, was moderated by Alessio Fasano, MD , pediatric gastroenterologist and director of the Center for Celiac Research and Treatment at Mass General for Children. A Q&A session followed the presentations.

Elite and Everyday Athletes with Celiac Disease: Eating for Fitness at All Ages

Recorded May 2022

Whether you’re an elite athlete, a weekend competitor, or you enjoy an evening stroll, leading an active healthy life is important for everyone, including those with celiac disease. Board-certified sports dietitian Mary Ellen Kelly, MS, RD, CSSD, LDN , and Tara McCarthy, MS, RDN, LD , Clinical Nutrition Supervisor at the Celiac Disease Program at Boston Children’s Hospital, talked about fueling our bodies throughout the day and eating the right foods to sustain us through physical activity. Concerning signs of celiac disease in pediatric patients, such as repeat injuries, fractures, and low bone density, were addressed. Caroline Johnson , a Division 1 distance runner at Lafayette University living with celiac disease, shared her experience managing the gluten-free diet while competing at the college level.

Lee Graham , executive director of the NCA, introduced the webinar, and Samuel A. Frank, MD , a neurologist at Beth Israel Deaconess Medical Center and Associate Professor of Neurology at Harvard Medical School, moderated the session. A Q&A session followed the presentations.

Aging Well with Celiac Disease

Recorded April 2022

What are the specific medical needs and concerns of a person living with celiac disease as they age? What nutritional deficiencies are more common in the older adult and how can we address them? How shall we approach long-term care for the best outcome? Joseph Murray, MD , expert celiac gastroenterologist and Professor of Medicine, Mayo Clinic College of Medicine and Science, and Katarina Mollo, MEd, RD, LDN , Director of Education for the National Celiac Association delved into critical questions that affect each and every person living with celiac disease.

Lee Graham , executive director of the NCA, introduced the webinar, and Ciarán P. Kelly, MD , Director of the Celiac Center at Beth Israel Deaconess Medical Center, moderated the session. A Q&A session followed the presentations.

Living with COVID-19: Celiac Disease, Autoimmunity, and Hyperinflammation

Recorded March 2022

Will the pandemic ever end? And what are the long-term effects (if any) for someone living with celiac disease or another autoimmune disorder? What COVID-19 treatments are safe for people with celiac disease and are all masks safe for people with gluten-related disorders?

Two expert authors and clinicians with decades of experience answered new questions about COVID-19, celiac disease and autoimmunity: Alessio Fasano, MD , Director of the Center for Celiac Research and Treatment at Massachusetts General Hospital in Boston, Massachusetts; and Dr. Steven Plogsted, BS, PharmD, BCNSP, CNSC, FASPEN, Clinical Pharmacy Specialist (retired) at Nationwide Children’s Hospital in Columbus, Ohio.

Lee Graham , executive director of the NCA, introduced the webinar, and Dan Leffler, MD, MS, a gastroenterologist and co-founder of the Celiac Center at Beth Israel Deaconess Medical Center, moderated the session. A Q&A session followed the presentations.

Celiac Disease and Your Reproductive Health

Recorded February 2022

Are you pregnant, thinking about starting a family, or caring for an infant?

How does celiac disease—treated or untreated—affect the reproductive health of both women and men? Fertility, pregnancy, and childbirth are some of the topics addressed by Maureen Leonard, MD , from the Center for Celiac Research and Treatment, Massachusetts General Hospital, and Amelie Therrien, MD , and Marcela Banegas, MD , from the Celiac Center at Beth Israel Deaconess Medical Center (BIDMC). They reviewed the latest data on celiac-related symptoms and the impact on the quality of life in patients with celiac disease during pregnancy and how genetics might contribute to the development of celiac disease.

Lee Graham , executive director of the NCA, introduced the webinar, and Dascha Weir, MD , Clinical Director of the Celiac Disease Program at Boston Children’s Hospital, moderated the session. A Q&A session followed the presentations.

Open Mic: Ask the Docs and Dietitian

Recorded December 2021

In this special Q&A webinar, experts spent 75 minutes answering your general questions on celiac disease and gluten-related disorders.

Our expert speaker panel included Denis Chang, MD , pediatric gastroenterologist in the Division of Gastroenterology and Nutrition at Boston Children’s Hospital; Rupa Mukherjee, MD , attending gastroenterologist in the Celiac Center at Beth Israel Deaconess Medical Center; and Pam Cureton, RD, LDN , registered dietitian with the Center for Celiac Research and Treatment at MassGeneral Hospital for Children (MGHfC) and the University of Maryland. Lee Graham , executive director of the NCA, introduced the webinar, and Mark Salvatore, MD , pediatric gastroenterologist at MGHfC, moderated the session.

Beginnings and Endings: Gluten-Free Holiday Appetizers and Desserts

Recorded November 2021

Executive Chef Denise Herrera from Burtons Grill & Bar and Lee Graham , Executive Director of the National Celiac Association, cooked up some new gluten-free holiday favorites. The theme was Beginning and Endings, with starters of butternut squash soup topped with rum buttercream and chives, an antipasti board, and smoked trout dip with homemade crackers. Featured desserts were butterscotch pudding with cookies and chocolate whoopie pies with raspberry cream. Suggestions included substitutions for lactose-free and other dietary needs.

Click here to view the recipes.

Dermatology and Celiac Disease: Did Gluten Cause this Rash?

Recorded October 2021

A range of dermatological features have been associated with celiac disease and gluten-related disorders, including Dermatitis Herpetiformis, eczema and psoriasis, to name a few. Attendees learned about the connection between the largest organ in our body and celiac disease and non-celiac gluten sensitivity in children and adults. “Celiac Disease and Your Skin” was presented by Channi Silence, MS , a research fellow at Massachusetts General Hospital under the mentorship of Shadi Kourosh, MD, MPH , board certified dermatologist and Assistant Professor of Dermatology at Harvard Medical School. Dr. Kourosh answered the Q & A along with Sophie Delano, MD , Instructor of Dermatology at Harvard Medical School, who presented “Recognizing & Treating Cutaneous Symptoms of Pediatric Celiac Disease.”

Lee Graham , executive director of the NCA, introduced the webinar and Alessio Fasano, MD , founder and director of the Center for Celiac Research and Treatment at Massachusetts General Hospital, moderated the session.

The Intersection of Neurology and Celiac Disease

Recorded September 2021

A range of neuropsychological features have been associated with celiac disease, including headaches, ataxia (coordination problems), peripheral neuropathy (numbness, tingling or pain from nerve damage), cognitive challenges, and "brain fog," to name a few.

Samuel Frank, MD, a neurologist at Beth Israel Deaconess Medical Center and Associate Professor of Neurology at Harvard Medical School, and Benny Kerzner, MD, medical director of the Celiac Disease Program at Children's National Hospital, led the discussion. Attendees learned about the connection between our nervous system and celiac disease in pediatric and adult patients as well as non-celiac gluten sensitivity.

Lee Graham, executive director of NCA, introduced the webinar, and Alan Leichtner, MD, pediatric gastroenterologist in the Boston Children's Hospital (BCH) Celiac Disease Program and Chief Education Officer and Director of the Department of Education at BCH, moderated the session.

Research Roundup: Promising Novel Therapies for Celiac Disease

Recorded May 2021

Three expert gastroenterologists demystified the complexities of clinical drug trials in gastrointestinal diseases and presented the latest research in medical therapies for celiac disease.

Jocelyn Silvester, MD, PhD, from Boston Children's Hospital; Amelie Therrien, MD, from the Celiac Center at Beth Israel Deaconness Medical Center (BIDMC); and Alessio Fasano, MD, from the Center for Celiac Research and Treatment, Massachusetts General Hospital, included highlights on current research for evidence-based medical treatments for celiac disease.

Lee Graham , executive director of NCA, introduced the webinar, and Ciarán Kelly, MD , medical director of the Celiac Center at BIDMC, moderated the session.

Gluten-Free Farm to Table: Delicious, Nutritious and Affordable Options for Whole Food

Recorded April 2021

Straight from a farm’s greenhouse on Cape Cod, registered dietitian Nicole Cormier introduced us to this spring’s highlighted seasonal produce found at your local farmers’ markets along with simple, unique ways to prepare them. Nicole shared how local and seasonally grown food benefits your own microbiome and our environment and how to create your own kitchen or outdoor herb garden featuring easy to grow medicinal and culinary herbs.

Chef and former food editor of Bon Appétit , Kristine Kidd demonstrated easy cooking techniques for three delicious and nutrient-rich grains, enhanced with vegetables, fruits, and herbs that add diversity and flavor to the gluten-free diet. After learning these simple techniques, you’ll be cooking an endless variety of easy, elegant and gluten-free meals with the confidence of a backyard garden gourmet chef.

Lee Graham , Executive Director of the National Celiac Association, introduced the webinar and Melinda Dennis, MS, RDN, LD , Nutrition Coordinator of the Celiac Center at Beth Israel Deaconess Medical Center, moderated the session.

Read the Q&A from this webinar!

View Nicole Cormier, RD, LDN's recipes here

View Kristine Kidd's recipes here

Get the Facts on COVID-19 Vaccines and Celiac Disease

Recorded March 2021

Addressing the COVID-19 pandemic requires understanding variations in the human immune system, how different groups are affected by the virus, and how we can leverage science to develop targeted vaccines to protect us.

Dr. Ofer Levy , Director of the Precisions Vaccine Program in the Division of Infectious Diseases at Boston Children's Hospital, and Dr. Lael Yonker , pediatric pulmonologist and co-founder of the Pediatric COVID-19 Biorepository at Massachusetts General Hospital, led the discussion to help attendees understand what is known about the COVID-19 virus today and how new developments will help to contain community spread of the virus.

View this video!

Click here to read the Q&A from this webinar.

More Than Celiac Disease: Managing Multiple Autoimmune Conditions

Recorded February 2021

Managing celiac disease presents unique medical, emotional and social challenges; having more than one autoimmune disease in an individual or family requires additional coping skills.

On February 11th, Dr. Edwin Liu , Director of the Colorado Center for Celiac Disease, and Janis Arnold, MSW, LICSW , licensed social worker at Boston Children’s Hospital presented a compelling session on science and social support.

A New Perspective: The Psychology of Dealing with a Chronic Disease

Recorded December 2020

Optimum health for people with celiac disease includes good mental health. Sarah Ballou, PhD , director of Gastrointestinal Psychology Services at Beth Israel Deaconess Medical Center, discussed what is known and still unknown about mental health conditions among children and adults with celiac disease and how celiac disease affects health-related quality of life at diagnosis and after starting the gluten-free diet.

Mary Shull, MD , pediatric gastroenterologist at Children’s Hospital Colorado, shared how gastrointestinal psychology treatment, including cognitive behavioral therapy, is used in celiac disease as well as hands-on breathing techniques that can help common gastrointestinal symptoms.

How Good Nutrition Feeds Our Bodies and Minds

Recorded November 2020

Celiac disease dietitians Tara McCarthy, MS, RDN, LDN , of Boston Children’s Hospital; Pam Cureton, RDN, LDN , of Massachusetts General Hospital; and Melinda Dennis, MS, RDN, LDN, of Beth Israel Deaconess Medical Center showcased the nuances of gluten-free food labeling and highlighted important nutrients, explained how to optimize the gluten-free diet when faced with other food restrictions, and shared tips on how to enhance your diet and lifestyle for optimal digestion and health.

Cooking Gluten Free with Demonstrations and Holiday Inspirations

Recorded October 2020

Denise Herrera , Executive Chef and VP of Food and Beverage for Burtons Grill and Bar, shared cooking skills and tips on using gluten-free bread products to create holiday food favorites, including crab-stuffed mushrooms, versatile soup stock and herbed croutons, holiday gravy, and bread pudding. Lee Graham , Executive Director of NCA, co-hosted with Chef Herrera.

View the recipes!

From the Experts: Latest Guidance on COVID-19 and Celiac Disease

Recorded September 2020

Dr. Jonathan Li , director of the Harvard University Virology Specialty Laboratory, presented "An Update on the COVID-19 Pandemic" and Dr. Alessio Fasano , director of the Center for Celiac Research and Treatment at Massachusetts General Hospital presented "Impact of COVID-19 on Celiac Patients." The Q&A moderator was Dr. Alan Leichtner , director of the Celiac Disease Research Program at Boston Children’s Hospital.

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Gluten-Free Community Calendar

Celiac Webinar: Harvard Medical School Celiac Research Program and the National Celiac Association

December 15, 2021

Event created by Scott Adams

Event details

From the Experts: Join Our Virtual Monthly Meeting on "Open Mic: Ask the Docs and Dietitian."

Join the National Celiac Association (NCA) and the Harvard Medical School Celiac Research Program for a discussion on Open Mic: Ask the Docs and Dietitian. Fall 2021 series will be held December 15, 2021, at 1pm EST. Speakers will present on selected topics for 60 minutes, followed by 15 minutes for Q&A.

Continuing Education Units (CEUs): 1.25 CEU for Registered Dietitians (pending). CEU certificates will be sent to participants via email after completion of the webinar.

To learn more and register visit: https://nationalceliac.org/from-the-experts-all-things-celiac/

or https://hms.harvard.edu/departments/hms-celiac-research-program/education

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Standardizing Randomized Controlled Trials in Celiac Disease: An International Multidisciplinary Appropriateness Study

Affiliations.

1 Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York. Electronic address: [email protected].
2 Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc, London, Ontario, Canada. Electronic address: [email protected].
3 Department of Pathology and Cell Biology, Columbia University, New York, New York.
4 Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Arizona.
5 Alimentiv Inc, London, Ontario, Canada.
6 Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands.
7 Department of Gastroenterology, University of Paris-Cité, Georges-Pompidou European Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France.
8 Department of Pathology, Boston Children's Hospital, Boston, Massachusetts.
9 Norwegian Coeliac Disease Research Centre, University of Oslo Faculty of Medicine, Oslo, Norway; Department of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo, Norway.
10 Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
11 Department of Pathology, Yale University School of Medicine, New Haven, Connecticut.
12 Celiac Disease Program, Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.
13 Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom.
14 Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada.
15 Department of Gastroenterology, University of Chicago, Chicago, Illinois.
16 Harvard Celiac Research Program, Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Celiac Disease Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
17 Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago, Chicago, Illinois.
18 Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
19 Alimentiv Inc, London, Ontario, Canada; Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.
20 Alimentiv Inc, London, Ontario, Canada; Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital Western Ontario, London Health Sciences Centre, Western University, London, Ontario, Canada.
21 Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
PMID: 37704112
DOI: 10.1053/j.gastro.2023.08.051

Background & aims: There is a need to develop safe and effective pharmacologic options for the treatment of celiac disease (CeD); however, consensus on the appropriate design and configuration of randomized controlled trials (RCTs) in this population is lacking.

Methods: A 2-round modified Research and Development/University of California Los Angeles Appropriateness Method study was conducted. Eighteen gastroenterologists (adult and pediatric) and gastrointestinal pathologists voted on statements pertaining to the configuration of CeD RCTs, inclusion and exclusion criteria, gluten challenge, and trial outcomes. Two RCT designs were considered, representing the following distinct clinical scenarios for which pharmacotherapy may be used: trials incorporating a gluten challenge to simulate exposure; and trials evaluating reversal of histologic changes, despite attempted adherence to a gluten-free diet. Each statement was rated as appropriate, uncertain, or inappropriate, using a 9-point Likert scale.

Results: For trials evaluating prevention of relapse after gluten challenge, participants adherent to a gluten-free diet for 12 months or more with normal or near-normal-sized villi should be enrolled. Gluten challenge should be FODMAPS (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) free, and efficacy evaluated using histology with a secondary patient-reported outcome measure. For trials evaluating reversal of villus atrophy, the panel voted it appropriate to enroll participants with a baseline villus height to crypt depth ratio ≤2 and measure efficacy using a primary histologic end point. Guidance for measuring histologic, endoscopic, and patient-reported outcomes in adult and pediatric patients with CeD are provided, along with recommendations regarding the merits and limitations of different end points.

Conclusions: We developed standardized recommendations for clinical trial design, eligibility criteria, outcome measures, gluten challenge, and disease evaluations for RCTs in patients with CeD.

Keywords: Celiac; Gluten; Histology; Patient-Reported Outcomes.

Celiac Disease* / pathology
Diet, Gluten-Free
Glutens / adverse effects
Neoplasm Recurrence, Local
Randomized Controlled Trials as Topic

Grants and funding

K23 DK119584/DK/NIDDK NIH HHS/United States

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About Adverse Childhood Experiences
Risk and Protective Factors
Program: Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action
Adverse childhood experiences can have long-term impacts on health, opportunity and well-being.
Adverse childhood experiences are common and some groups experience them more than others.

diverse group of children lying on each other in a park

What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

Experiencing violence, abuse, or neglect.
Witnessing violence in the home or community.
Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

Substance use problems.
Mental health problems.
Instability due to parental separation.
Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:999-1005. DOI: http://dx.doi.org/10.15585/mmwr.mm6844e1 .
Cain KS, Meyer SC, Cummer E, Patel KK, Casacchia NJ, Montez K, Palakshappa D, Brown CL. Association of Food Insecurity with Mental Health Outcomes in Parents and Children. Science Direct. 2022; 22:7; 1105-1114. DOI: https://doi.org/10.1016/j.acap.2022.04.010 .
Smith-Grant J, Kilmer G, Brener N, Robin L, Underwood M. Risk Behaviors and Experiences Among Youth Experiencing Homelessness—Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts. Journal of Community Health. 2022; 47: 324-333.
Experiencing discrimination: Early Childhood Adversity, Toxic Stress, and the Impacts of Racism on the Foundations of Health | Annual Review of Public Health https://doi.org/10.1146/annurev-publhealth-090419-101940 .
Sedlak A, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4): Report to Congress. Executive Summary. Washington, DC: U.S. Department of Health an Human Services, Administration for Children and Families.; 2010.
Font S, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions. Child Abuse Negl. 2016;51:390-399.
Swedo EA, Aslam MV, Dahlberg LL, et al. Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020. MMWR Morb Mortal Wkly Rep 2023;72:707–715. DOI: http://dx.doi.org/10.15585/mmwr.mm7226a2 .
Bellis, MA, et al. Life Course Health Consequences and Associated Annual Costs of Adverse Childhood Experiences Across Europe and North America: A Systematic Review and Meta-Analysis. Lancet Public Health 2019.
Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students — Adolescent Behaviors and Experiences Survey, United States, January–June 2021 | MMWR
Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics. 2004 Feb;113(2):320-7.
Miller ES, Fleming O, Ekpe EE, Grobman WA, Heard-Garris N. Association Between Adverse Childhood Experiences and Adverse Pregnancy Outcomes. Obstetrics & Gynecology . 2021;138(5):770-776. https://doi.org/10.1097/AOG.0000000000004570 .
Sulaiman S, Premji SS, Tavangar F, et al. Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review. Matern Child Health J . 2021;25(10):1581-1594. https://doi.org/10.1007/s10995-021-03176-6 .
Ciciolla L, Shreffler KM, Tiemeyer S. Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization. Journal of Pediatric Psychology . 2021;46(7):801-813. https://doi.org/10.1093/jpepsy/jsab027 .
Mersky JP, Lee CP. Adverse childhood experiences and poor birth outcomes in a diverse, low-income sample. BMC pregnancy and childbirth. 2019;19(1). https://doi.org/10.1186/s12884-019-2560-8 .
Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. No youth left behind to human trafficking: Exploring profiles of risk. American journal of orthopsychiatry. 2019;89(6):704.
Diamond-Welch B, Kosloski AE. Adverse childhood experiences and propensity to participate in the commercialized sex market. Child Abuse & Neglect. 2020 Jun 1;104:104468.
Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663
Narayan AJ, Kalstabakken AW, Labella MH, Nerenberg LS, Monn AR, Masten AS. Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction. Am J Orthopsych. 2017;87(1):3. https://doi.org/10.1037/ort0000133 .
Schofield TJ, Donnellan MB, Merrick MT, Ports KA, Klevens J, Leeb R. Intergenerational continuity in adverse childhood experiences and rural community environments. Am J Public Health. 2018;108(9):1148-1152. https://doi.org/10.2105/AJPH.2018.304598 .
Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):S32-38. https://doi.org/10.1016/j.jadohealth.2013.05.004 .

Adverse Childhood Experiences (ACEs)

ACEs can have a tremendous impact on lifelong health and opportunity. CDC works to understand ACEs and prevent them.

COMMENTS

HMS Celiac Research Program
Founded in 2013, the Harvard Medical School (HMS) Celiac Research Program is a collaborative effort of Harvard-affiliated hospitals including the Celiac Center at Beth Israel Deaconess Medical Center (BIDMC), the Center for Celiac Research and Treatment at MassGeneral Hospital for Children (MGHfC) and the Boston Children's Hospital Celiac Disease Program (BCH).
Harvard Medical School Celiac Program
Speakers included the founders of the HMS Celiac Research Program: Alessio Fasano, MD, of MGfC; Ciarán Kelly, MD, of BIDMC; and Alan Leichtner, MD, of BCH. Visit the Harvard Medical School Celiac Research Program. Improving the quality of life for people with celiac disease and other gluten-related disorders is the goal of the Harvard Medical ...
Division of Nutrition at Harvard Medical School
Maureen Leonard, MD, MMSc, is the Clinical Director of the Center For Celiac Research And Treatment at MassGeneral Hospital for Children (MGHfC) and an Assistant Professor of Pediatrics at Harvard Medical School (HMS). She sees adult and pediatric patients with celiac disease, non-celiac gluten sensitivity, and other gluten-related disorders.
Celiac Webinar: Harvard Medical School Celiac Research Program and the
Join the National Celiac Association (NCA) and the Harvard Medical School Celiac Research Program for a discussion on celiac disease and neurology. The first webinar in our "Ask the Experts: All Things Celiac" Fall 2021 series will be held Thursday, September 30, 2021, at 1pm EST.
Celiac Program at Harvard Medical School April 11 Symposium "Gluten
The "Celiac Program at Harvard Medical School (HMS)" was born. On April 11, experts from the three programs will be joined by regional and national leaders in the field for the inaugural symposium of the Celiac Program at HMS, supported by the New England Celiac Organization (NECO).
Harvard Medical School Celiac Research Program and National Celiac
From the Experts: Join Our Virtual Monthly Meeting on "All Things Celiac" Aging Well with Celiac Disease Join the National Celiac Association (NCA) and the Harvard Medical School Celiac Research Program for the third webinar in our Spring 2022 "All Things Celiac" series. Speakers will present on ...
Celiac Disease Microbiome and Metabolomic Study
A versatile team of doctors and scientists at the Center for Celiac Research and Treatment at Massachusetts General Hospital, Mass General for Children, and the Celiac Research Program at Harvard Medical School created the CDGEMM study to learn more about each of the many factors that contribute to the development of celiac disease. This long-term, multi-center study will follow infants from ...
Alessio Fasano, M.D.
Research lab website Publications Clinical Profile. [email protected]. 6177244604. Mucosal Immunology and Biology Research Center CNY-Building #114 114 16th Street 574 Charlestown, MA 02129-2000. Edit your page. Dr. Fasano is director of the Mucosal Immunology and Biology Research Center at MassGeneral Hospital for Children. Dr.
Maureen Leonard, M.D., MMSc
Dr. Leonard currently holds funding from the NIH (K23DK122127) and was previously funded by the Thrasher Research Fund, the Nutrition Obesity Research Center at Harvard, and the NIH (FDK109620A). Dr. Leonard's research is focused on predicting and preventing celiac disease through precision medicine. Precision medicine is an emerging appro...
Society for the Study of Celiac Disease position statement on ...
In March 2020, the Celiac Disease Foundation and the Society for the Study of Celiac Disease convened a consensus workshop to identify high-yield areas of research that should be prioritized. Workshop participants included leading experts in clinical practice, academia, government and pharmaceutical development, as well as representatives from ...
An updated overview on celiac disease: from immuno ...
2 Mucosal Immunology and Biology Research Center, Mass General Hospital for Children, Harvard Medical School, Boston, MA, USA. 3 Celiac Research Program, Harvard Medical School, Boston, MA, USA. 4 Vita-Salute San Raffaele University, Milan, Italy. 5 Harvard Medical School, Boston, MA, USA. 6 European Biomedical Research Institute of Salerno ...
Understanding celiac disease monitoring patterns and outcomes after
Ciaran P Kelly, Celiac Center Beth Israel Deaconess Medical Center, Celiac Research Program Harvard Medical School, Boston, MA 02115, United States. David S Sanders, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2TN, United Kingdom. Kristina Chen, Takeda Pharmaceuticals International Co., Cambridge, MA 02139, United States.
From the Experts: All Things Celiac
The National Celiac Association and the Harvard Medical School Celiac Education & Research Program are co-hosting a series of 75-minute virtual meetings. Speakers present on selected topics for 60 minutes, followed by a 15-minute question-and-answer period. For live technical support during the webinars, please call 857-282-6470 or email ...
An updated overview on celiac disease: from immuno-pathogenesis and
Paolo D'Avino a Division of Pediatric Gastroenterology and Nutrition, Mass General Hospital for Children, Harvard Medical School, Boston, MA, USA;b Mucosal Immunology and Biology Research Center, Mass General Hospital for Children, Harvard Medical School, Boston, MA, USA;c Celiac Research Program, Harvard Medical School, Boston, MA, USA;d Vita-Salute San Raffaele University, Milan, ItalyView ...
Most Patients With Celiac Disease on Gluten-Free Diets Consume ...
1 Harvard Medical School Celiac Research Program, Boston, Massachusetts; Boston Children's Hospital, Boston, Massachusetts; Beth Israel Deaconess Medical Center, Boston, Massachusetts; Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada. Electronic address: [email protected] ...
Celiac Webinar: Harvard Medical School Celiac Research Program and the
From the Experts: Join Our Virtual Monthly Meeting on "Open Mic: Ask the Docs and Dietitian." Join the National Celiac Association (NCA) and the Harvard Medical School Celiac Research Program for a discussion on Open Mic: Ask the Docs and Dietitian. Fall 2021 series will be held December 15, 2021...
Standardizing Randomized Controlled Trials in Celiac Disease ...
Standardizing Randomized Controlled Trials in Celiac Disease: An International Multidisciplinary Appropriateness Study Gastroenterology. 2023 Sep 11 ;S0016-5085 ... 16 Harvard Celiac Research Program, Harvard Medical School, Boston, Massachusetts, USA; Division of Gastroenterology, Department of Pediatrics, Boston Children's Hospital, Boston ...
Weight-Loss Drugs Like Wegovy Protect Heart Health
Wegovy Should Be Treating More Than Obesity. Research is accumulating showing that GLP-1s can protect against cardiovascular problems — even when weight-loss is minimal. May 17, 2024 at 3:00 AM ...
About Adverse Childhood Experiences
Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children's brain development, immune systems, and stress-response systems. These changes can affect children's attention, decision-making, and learning. 18. Children growing up with toxic stress may have difficulty forming healthy and stable relationships.