Background Mass screening for celiac disease (CD) as a public health intervention is controversial. Before implementation, a suitable screening strategy should be outlined, and the acceptability of the screening scrutinized. Also, the benefits of early detection and possible negative consequences should be explored and compared. The overall aim of this thesis was to evaluate different strategies for finding 12-year-olds with undiagnosed CD in the general population, and to explore the experiences of those receiving the diagnosis in a mass screening. Methods A school-based CD screening of 12-year-olds was conducted in five study sites across Sweden. Out of 10041 children who were invited, 7208 had a blood sample analyzed for CD-marker tissue transglutaminase of isotype IgA (tTG-IgA) and 7161 for total serum IgA (s-IgA). If the s-IgA value was low, tTG-IgG was also measured. Additional analysis of endomysial antibodies (EMA) was performed if borderline values of tTG were found. In total, 192 had elevated CD-markers, 184 underwent a small intestinal biopsy and 153 eventually had CD diagnosed. Before receiving knowledge about their CD status, children and their parents filled in questionnaires regarding symptoms and CD-associated conditions. Questionnaires were returned by 7054 children (98%) and 6294 parents (88%). Later, all adolescents who had been diagnosed with CD more than one year ago (n=145), and their parents, were invited to a mixed-method follow-up study in which they shared their experiences in questionnaires, written narratives and focus group discussions. In total, we have information on 117 (81%) of these adolescents, either from the adolescents themselves (n=101) and/or from their parent/s (n=125). Data were analyzed using a combination of descriptive and analytical quantitative and qualitative methodologies. Results We found that information on symptoms and CD-associated conditions were poor predictors for finding undiagnosed CD in the study population. Questionnaire-based case-finding by asking for CD-associated symptoms and conditions would have identified 52 cases (38% of all cases) at a cost of blood-sampling 2282 children (37% of the study population). The tTG-IgA test had an excellent diagnostic accuracy with the area under the receiver operating characteristic curve of 0.988. If using the recommended cut-off for tTG-IgA (>5 U/mL) 151 had fulfilled biopsy criteria and 134 CD cases had been identified. The strategy of lowering the cut-off to tTG-IgA>4 U/mL, and adding the EMA analysis in those with tTG-IgA between 2-4 U/mL, identified another 17 cases (a 12% increase) at the cost of performing 32 additional biopsies. Measuring total s-IgA in 7161 children discovered only two additional cases at the cost of performing 5 additional biopsies. The positive predictive value of our screening strategy was 80%.  Results from the follow-up study of the screening-detected CD cases illustrated that 54% reported health improvement after initiated treatment, but also that these health benefits had to be balanced against social sacrifices. We also found that although the screening-detected diagnosis was met with surprise and anxiety, the adolescents and their parents were grateful for being made aware of the diagnosis. A majority of parents (92%) welcomed a future screening, but both adolescents and parents suggested that it should be conducted earlier in life. Conclusion Obtaining information on symptoms and CD-associated conditions was not a useful step in finding undiagnosed CD cases in a general population. The serological marker tTG-IgA, however, had excellent diagnostic accuracy also when lowering the cut-off. The diagnosis had varying impact on adolescents’ quality of life, and their perceived change in health had to be balanced against the social sacrifices resulting from the diagnosis. Overall, CD mass screening seemed acceptable to most of those who were diagnosed and their parents.

La maladie cœliaque ou sprue cœliaque est une intolérance au gluten. Il s’agit d’une maladie inflammatoire de l’intestin liée à l’ingestion de gluten chez des personnes génétiquement susceptibles. Ce désordre présente une forte prévalence puisqu’il touche 1 % de la population mondiale. En l’état actuel des choses, il n’existe aucun outil pharmacologique pour traiter ou pallier à cette maladie. Cependant, grâce aux avancées dans la compréhension de sa pathogenèse, de nouvelles cibles thérapeutiques ont été identifiées. À l’heure actuelle, le seul traitement efficace consiste à suspendre la consommation de l’agent pathogène, à savoir le gluten. Le gluten est un ensemble de protéines de stockage des céréales contenu dans le blé, l’orge et le seigle. Le gluten du blé se subdivise en gluténines et gliadines. Ce sont ces dernières qui semblent les plus impliquées dans la maladie cœliaque. Les gliadines et ses protéines apparentées (i.e. sécalines et hordéines, respectivement dans le seigle et l’orge) sont riches en prolines et en glutamines, les rendant résistantes à la dégradation par les enzymes digestives et celles de la bordure en brosse. Les peptides résultant de cette digestion incomplète peuvent induire des réponses immunitaires acquises et innées. L’objectif principal de cette thèse était de tester un nouveau traitement d’appoint de la maladie cœliaque utile lors de voyages ou d’évènements ponctuels. Dans les années 80, une observation italienne montra l’inhibition de certains effets induits par des gliadines digérées sur des cultures cellulaires grâce à la co-incubation en présence de mannane: un polyoside naturel composé de mannoses. Malheureusement, ce traitement n’était pas applicable in vivo à cause de la dégradation par les enzymes du tractus gastro-intestinales du polymère, de par sa nature osidique. Les polymères de synthèse, grâce à la diversité et au contrôle de leurs propriétés physico-chimiques, se révèlent être une alternative attrayante à ce polymère naturel. L’objectif de cette recherche était d’obtenir un polymère liant la gliadine, capable d’interférer dans la genèse de la maladie au niveau du tube digestif, afin d’abolir les effets délétères induits par la protéine. Tout d’abord, des copolymères de type poly (hydroxyéthylméthacrylate)-co-(styrène sulfonate) (P(HEMA-co-SS)) ont été synthétisés par polymérisation radicalaire contrôlée par transfert d’atome (ATRP). Une petite bibliothèque de polymères a été préparée en faisant varier la masse molaire, ainsi que les proportions de chacun des monomères. Ces polymères ont ensuite été testés quant à leur capacité de complexer la gliadine aux pH stomacal et intestinal et les meilleurs candidats ont été retenus pour des essais cellulaires. Les travaux ont permis de montrer que le copolymère P(HEMA-co-SS) (45:55 mol%, 40 kDa) permettait une séquestration sélective de la gliadine et qu’il abolissait les effets induits par la gliadine sur différents types cellulaires. De plus, ce composé interférait avec la digestion de la gliadine, suggérant une diminution de peptides immunogènes impliqués dans la maladie. Ce candidat a été testé in vivo, sur un modèle murin sensible au gluten, quant à son efficacité vis-à-vis de la gliadine pure et d’un mélange contenant du gluten avec d’autres composants alimentaires. Le P(HEMA-co-SS) a permis de diminuer les effets sur les paramètres de perméabilité et d’inflammation, ainsi que de moduler la réponse immunitaire engendrée par l’administration de gliadine et celle du gluten. Des études de toxicité et de biodistribution en administration aigüe et chronique ont été réalisées afin de démontrer que ce dernier était bien toléré et peu absorbé suite à son administration par la voie orale. Enfin des études sur des échantillons de tissus de patients souffrants de maladie cœliaque ont montré un bénéfice therapeutique du polymère. L’ensemble des travaux présentés dans cette thèse a permis de mettre en évidence le potentiel thérapeutique du P(HEMA-co-SS) pour prévenir les désordres reliés à l’ingestion de gluten, indiquant que ce type de polymère pourrait être exploité dans un avenir proche. / Celiac Disease or celiac sprue is identified as a gluten intolerance. It is an inflammatory disorder of the intestine triggered by the ingestion of gluten in genetically susceptible individuals. This condition is highly prevalent because it affects up to 1% of the worldwide population. Nowadays, there is no pharmacological treatment available to treat or off set to the disease. Due to the huge progress in the understanding of the pathogenesis, new therapeutic targets have been discovered. At the present time, the only effective treatment remains the strict lifelong abandonment of the pathogen agent, gluten. Gluten encompasses the storage proteins in wheat, rye and barley. The wheat gluten is divided into glutenins and gliadins. The latter seem to be the most important trigger in the celiac disease. Gliadins and the related proteins (i.e. secalins and hordeins, respectively in rye and barley) are rich in prolin and glutamin residues, conferring them to be resistant by enzymatic digestion. The resulting peptides of the incomplete process may set off the inflammatory reaction. The main objective of this thesis was to test a new supportive therapy in treating celiac disease, useful in punctual occasion (i.e. during travel or social event when the gluten-free property cannot be ascertained). In the 1980’s, inhibition of some gliadin-induced effects on cell cultures were observed owing to mannan co-incubation. However, this compound, due to his osidic nature, may be cleaved by digestive enzymes in vivo. Synthetic polymers prove to be an attracting alternative owing to the tunability of their physical and chemical properties. The goal of this study was to obtain a polymeric gliadin-binder, interferring with the pathogenesis of the celiac disease in the gastro-intestinal tract, to abrogate the gliadin induced effects. Atom transfer radical polymerization was used to synthesize copolymers of the type poly (hydroxyethylméthacrylate)-co-(styren sulfonate) (P(HEMA-co-SS)). A small library of polymers varying in their molecular weight and in their constituting monomers ratio was prepared. The ability of these polymers to sequester gliadin was assessed at stomacal and intestinal pH. The best candidates were further evaluated in cell cultures. Our results revealed that a selective binding was obtained with the P(HEMA-co-SS) (45:55 mol%, 40 kDa). This compound abolished gliadin-induced effects on various cell lines. In addition, gliadin digestion was hindered, suggesting a decrease in the formation of immunogenic peptides known to trigger the diseases. In vivo experiments were additionally carried out on a murine model of gluten-sensitivity with this polymeric candidate. Its efficacy towards pure gliadin and gluten containing food was tested. P(HEMA-co-SS decreased gliadin–induced effect on permeability and inflammatory parameters and modulated the immune response due to gliadin/gluten gavage. Toxicity and biodistribution studies following acute and chronic administration were performed on murine to demonstrate that the polymer was well tolerated and not absorbed after oral administration. Finally, biopsies of patients suffering from CD disease exhibited therapeutic benefit of the polymer. Altogether, the results presented in this thesis evidenced the potential of P(HEMA-co-SS) to prevent the gluten-induced disorder, indicating that this type of polymer may be useful in a near future.

INTRODUÇÃO: O diabetes mellitus tipo 1 (DM1) e a doença celíaca (DC) são doenças de origem autoimune, com padrão genético similar e terapias embasadas em alterações dietéticas distintas; ou seja, monitorização da ingestão de carboidratos nas refeições no DM1 e dieta livre de glúten na DC.OBJETIVO: O objetivo deste estudo foi comparar o estado nutricional, o consumo alimentar, a saúde óssea e a qualidade de vida em indivíduos com associação com duas doenças crônicas. PACIENTES E MÉTODOS: Os voluntários portadores de DM1, DC e indivíduos hígidos foram recrutados no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e divididos conforme os grupos: DMDC (portadores de DM1 e DC), DM (portadores de DM1), DC (portadores de DC) e GC (indivíduos hígidos). Utilizamos a bioimpedância octopolar para aferir a área de gordura visceral e a densitometria de corpo inteiro para estimar o total de gordura corporal e a densidade mineral óssea; o índice de massa corporal (IMC) e a circunferência da cintura também foram empregados para avaliação nutricional, além de exames laboratoriais. Verificou-se o consumo alimentar pelo registro alimentar de três dias e a qualidade de vida pelo questionário SF-36. RESULTADOS: Foram incluídos no estudo sessenta indivíduos controlados segundo sexo, idade, índice de massa corporal (IMC) distribuídos em quatro grupos conforme diagnóstico prévio. Houve predomínio do sexo feminino (80%) e o tempo de diagnóstico de DM foi semelhante entre os grupos DMDC e DM; no entanto, a duração da DC foi significativamente maior no grupo DC comparado ao DMDC (p = 0,0015). Em relação ao IMC, os participantes foram classificados como dentro da normalidade ou pré-obesidade e em 53,3% deles observamos aumento da circunferência da cintura. A porcentagem média de massa gorda e a área de gordura corporal foi semelhante entre os grupos e não representou aumento de risco de doenças associadas à obesidade. O consumo diário de macronutrientes foi semelhante ao padrão de referência para a população adulta; mas a ingestão de fibras, cálcio e vitamina D foi menor que a recomendada. Os parâmetros descritos para saúde óssea e as medidas laboratoriais de vitaminas e minerais foram homogêneas entre os grupos, com exceção da concentração sérica de ácido fólico e de magnésio naqueles com DC e DM1, respectivamente. A análise do SF-36 evidenciou diferença significativa entre os grupos DM e GC no domínio estado geral de saúde e vitalidade. A presença de complicações relacionadas ao diabetes foi associada a menor escore no domínio limitação emocional. CONCLUSÃO: A ingestão dietética habitual de macronutrientes e micronutrientes dos portadores de diabetes mellitus tipo 1 e doença celíaca foi semelhante aos demais grupos e não houve associação com indicadores laboratoriais de deficiências nutricionais. Além disso, a presença das duas doenças não acarretou prejuízo adicional ao metabolismo ósseo e não impactou na qualidade de vida / BACKGROUND: Type 1 diabetes mellitus (T1DM) and celiac disease (CD) are autoimmune diseases, they have similar genetic patterns and their therapies are based upon different dietary changes. Monitoring of carbohydrate intake per meal is recommended to patients with DM1, whereas a gluten-free diet, for those with CD.OBJECTIVE: The aim of the study was to compare the nutritional status, food intake, bone health and quality of life of individuals with the association of the two chronic diseases. PATIENTS AND METHODS: Volunteers with T1DM, CD and healthy subjects were recruited at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo divided into four different groups: patients with type 1 diabetes and celiac disease (DMDC group), only T1DM (DM group), only CD (DC group) and healthy controls (GC group). We used the octopolar bioimpedance to measure the area of visceral fat and whole-body densitometry to assess total body fat and bone mineral density; while nutritional status was determined by body mass index (BMI), waist circumference and general laboratory tests. We assessed food intake by a three-day food record and quality of life using the SF-36 questionnaire. RESULTS: The study included sixty individuals controlled by sex, age, BMI and distributed in four groups according to previous diagnosis and there were sex female predominance (80%). The time of diagnosis of T1DM was similar between DMDC and DM groups; however the duration of CD was significantly higher in DC group compared to DMDC (p = 0.0015). The participants were classified as normal or overweight through BMI and 53.3% of them had increased waist circumference. The average percentage of fat mass and body fat area was similar in both groups and did not represent an increased risk of diseases associated with obesity. The macronutrients consumed were usually distributed according to the reference standard for the adult population; while fiber, calcium and vitamin D intake did not reach the daily recommendations. The parameters described for bone health and laboratory measures of vitamins and minerals were similar in all groups, except for serum concentration of folic acid that was lower in individuals with CD and magnesium in those with diabetes. The SF-36 analysis revealed significant differences between the DM and the control groups regarding general health and vitality. The presence of diabetes-related complications was associated with lower scores on the emotional limitation domain among patients with T1DM. CONCLUSION: The nutritional status, food intake, bone health and quality of life of individuals of DMDC group were similar to the others groups. This allowed us to conclude that the combination of the two chronic diseases with therapies based upon different dietary changes did not deteriorate the general state of health

Abstract Bullous pemphigoid (BP) is the most common autoimmune blistering disease. It mostly affects elderly patients and is characterized by intense pruritus and blistering or bullae. Treatment options include topical and systemic corticosteroids, other immunosuppressive drugs and doxycycline. Disease course may be chronic and relapses are common. The incidence of BP has been reported to have increased in the last few decades, but the reason for this trend is not known. The aim of this thesis was to study the risk factors of BP. Firstly, the influence of the use of dipeptidyl peptidase (DPP-4) inhibitors was analyzed as a risk factor, and then those of other oral diabetes medications. This study also aimed to determine whether drugs used for psychiatric and neurologic conditions are risk factors for BP. Finally, previously diagnosed dermatitis herpetiformis (DH) and celiac disease (CD) were examined as potential risk factors for subsequent BP. For this retrospective, matched case-control study, patient data were obtained from the Finnish Care Register for Health Care database, and data on reimbursed drugs from the Social Insurance Institution of Finland. In the present study, prior use of DPP-4 inhibitors was found to increase the risk of BP twofold and in particular, vildagliptin increased the risk tenfold. The mean time between the initiation of vildagliptin and diagnosis of BP was 449 days. Metformin and other conventional diabetes drugs were not risk factors for BP. Several drugs used for neurological and psychiatric diseases were associated with an elevated risk for BP, but no pharmacological or chemical properties of these drugs emerged as candidates to explain the increased risk. A prior diagnosis of DH increased the risk of BP 22-fold and a diagnosis of CD doubled it. Dapsone had been used in the two years before BP diagnosis by 44% of patients whose BP was preceded by DH. The mean time between the diagnoses of DH and BP was 3.3 years. This study confirms the view that DPP-4 inhibitors increase the risk for BP. No such association was found with other classes of diabetes drugs and therefore their use can be continued following a diagnosis of BP. Doctors treating patients with DH should be aware of the association between DH and BP, and be particularly vigilant if a DH patient’s skin symptoms change or become unresponsive to a gluten-free diet and/or dapsone. / Tiivistelmä Rakkulainen pemfigoidi (pemfigoidi) on yleisin ihon autoimmuunirakkulatauti. Pemfigoidi on pääasiassa ikääntyneiden sairaus, ja sen tyypillisiä oireita ovat kova kutina ja rakkulat iholla. Pemfigoidin hoitoon käytetään paikallisia ja systeemisiä kortikosteroideja, muita immunosuppressiivisia lääkkeitä sekä doksisykliiniä. Taudinkulku on usein krooninen ja uusiutumiset ovat yleisiä. Rakkulaisen pemfigoidin ilmaantuvuuden on raportoitu lisääntyneen, mutta syitä tähän muutokseen ei täysin ymmärretä. Tämän tutkimuksen tavoite oli tutkia pemfigoidin riskitekijöitä Suomessa. Retrospektiivisessä tapaus-verrokkitutkimuksessa käytettiin aineistona Terveyden ja hyvinvoinnin laitoksen hoitoilmoitusrekisteristä poimittuja pemfigoidipotilaita (N=3397) ja verrokkeina ihon tyvisolusyöpäpotilaita (N=12941). Tiedot korvatuista lääkeostoista saatiin Kelan lääkekorvausrekisteristä. Tutkimuksessa todettiin DPP-4:n salpaajien kaksinkertaistavan pemfigoidin riskin ja DPP-4:n salpaaja vildagliptiini lisäsi riskiä jopa kymmenkertaiseksi. Vildagliptiinin aloituksen ja pemfigoidin toteamisen välillä kului keskimäärin 449 vuorokautta. Metformiini ja muut tutkitut suun kautta otettavat diabeteslääkkeet eivät lisänneet pemfigoidin riskiä. Useiden psykiatrisiin ja neurologisiin sairauksiin käytettävien lääkkeiden todettiin lisäävän pemfigoidin riskiä. Pemfigoidin on kuvattu voivan puhjeta ihokeliakian jälkeen, mutta laajempia tutkimuksia näiden sairauksien yhteydestä ei oltu aiemmin tehty. Tämän vuoksi samassa potilasaineistossa tutkittiin ihokeliakiaa ja keliakiaa pemfigoidin riskitekijöinä. Edeltävä ihokeliakia lisäsi pemfigoidin toteamisen riskiä selvästi, jopa 22-kertaiseksi ja keliakia kaksikertaiseksi. Huomattava osa potilaista oli ostanut ihokeliakian hoitoon käytettävää dapsonia edeltävän 2 vuoden aikana ennen pemfigoidin toteamista, mikä voi kertoa ihokeliakian oireiden aktiivisuudesta. Tämä tutkimus vahvistaa näkemystä siitä, että DPP-4:n salpaajat ovat pemfigoidin riskitekijä. Muut tutkitut diabeteslääkkeet eivät lisänneet riskiä ja voidaan ajatella, että ne eivät edelleen hankaloita aiemmin todetun pemfigoidin oireita. Koska ihokeliakian todettiin olevan pemfigoidin riskitekijä, tulee näitä potilaita hoitavan lääkärin muistaa pemfigoidin mahdollisuus, jos ihokeliakian oireet muuttuvat tai hoitovaste menetetään.

Made available in DSpace on 2017-07-21T18:53:02Z (GMT). No. of bitstreams: 1 Christiane Schamne.pdf: 2521926 bytes, checksum: b4f1eed111a019961433a0be8ece30f3 (MD5) Previous issue date: 2007-09-25 / Fundação Araucária de Apoio ao Desenvolvimento Científico e Tecnológico do Paraná / The celiac disease is associated to food ingestion containing gluten, a protein that is found in some vegetable raw materials, as wheat, rye, barley and oats, damaging the surface of the intestine mucosa, making difficult nutrients absorption by the organism. The celiac disease has been object of frequent technological and clinical research on food alternatives to persons having the disease. The objective of this study was to develop the gluten free baked products, having a good sensorial acceptance, using cassava starch with the addition of soybeans derived products . From the rice cream, the cassava starch and the maize starch used in the formulation, the experimental design for Simplex-Centróide mixtures was carried through, and after that the software called Statistica 7.0 was used, inserting the maximum limit restriction of 50% of cassava starch, resulting in the experimental design for mixtures, giving then seven samples. Using these seven samples, sensorial and instrumental analysis composed of specific volume, elasticity and firmness analysis was carried through. For the sensorial analysis, the optimized formulation of mixture was 50% of rice cream and 50% of cassava starch, and for the instrumental analysis, the optimal simultaneous point for the three conducted analyses was 20% of rice cream, 50% of maize starch and 30% of cassava starch. From these two optimal points, a second sensorial analysis was realized, and the optimal formulation obtained from instrumental analyses was significantly preferred (hedonic scale average=6,96±1,71, using scale of 1 to 9) comparing to the first sensorial analysis (hedonic scale average=5,77±1,83, using scale of 1 to 9). From these samples, it was realized the comparative analysis of specific volume, elasticity, firmness and triangular test between baked bread and pre-baked and freeze bread. The baked sample and the pre-baked and freeze sample showed differences only in product elasticity, having not showed sensorial difference between the samples analyzed. For the muffin, a sensorial analysis was conducted, that resulted on hedonic scale average 7,76±1,07, using scale of 1 to 9. It was realized instrumental analysis of specific volume, elasticity and firmness, and comparative analysis between baked muffin and pre-baked and freeze muffin, adopting the same procedure used for bread analysis. The baked muffin and pre-baked and freeze muffin differed on specific volume and elasticity, however they didn´t have any sensorial difference when the triangular test was applied. For both, the bread and muffin, it was realized the physic-chemistry, nutritional and microbiological analysis, and both were according to the current law. It was realized cost analyses of the developed products, and the conclusion was that they are economically according with similar products. / A doença celíaca está relacionada à ingestão de alimentos que contêm glúten, proteína presente em algumas matérias-primas vegetais, como trigo, centeio, cevada e aveia, danificando a superfície da mucosa do intestino, dificultando a absorção de nutrientes pelo organismo. A doença celíaca tem sido objeto freqüente de estudos clínicos e tecnológicos em busca de alternativas alimentares para indivíduos que sofrem da enfermidade. O objetivo desse trabalho foi desenvolver produtos panificados isentos de glúten, de boa aceitação sensorial, utilizando amido de mandioca e adicionados de derivados de soja. A partir do amido de mandioca, creme de arroz e amido de milho utilizados na formulação, foi realizado o delineamento experimental para misturas Simplex-Centróide, e posteriormente os dados foram lançados no software Statistica 7.0, inserindo-se a restrição do limite máximo de 50 % de amido de mandioca, que resultou no delineamento para misturas originando sete amostras. A partir dessas sete amostras, foram realizadas análises sensorial e instrumentais de volume específico, elasticidade e firmeza. Para a análise sensorial, a formulação ótima de mistura encontrada foi 50% de creme de arroz e 50% de amido de mandioca, e para a análise instrumental, o ponto ótimo simultâneo das três análises realizadas foi 20% de creme de arroz, 30% de amido de mandioca e 50% de amido de milho. A partir dos dois pontos ótimos obtidos, foi realizada uma segunda análise sensorial, na qual a formulação ótima obtida a partir das análises instrumentais realizadas foi significativamente preferida (média escala hedônica=6,96±1,71, numa escala de 1 a 9) em relação à formulação ótima obtida na primeira análise sensorial (média escala hedônica 5,77±1,83, numa escala de 1 a 9). A partir dessa amostra, foram realizadas análises comparativas de volume específico, elasticidade e firmeza, e teste triangular entre o pão assado e o pão pré-assado e congelado. A amostra assada e a amostra pré-assada e congelada do pão diferiram apenas com relação à elasticidade do produto, não sendo percebida nenhuma diferença sensorial entre as amostras analisadas.Para o muffin foi realizada análise sensorial, a qual apresentou média de escala hedônica de 7,76±1,07, numa escala de 1 a 9. Foram realizadas análises sensorial e instrumentais de volume específico, elasticidade e firmeza comparativas entre a amostra assada e a amostra pré-assada e congelada, adotando o mesmo procedimento aplicado ao pão. O muffin assado e o muffin pré-assado e congelado diferiram com relação ao volume específico e elasticidade, porém não apresentaram diferença sensorial significativa aplicando-se o teste triangular. Para ambos os produtos foram realizadas análises físico-químicas, nutricionais e microbiológicas, as quais mostram estar de acordo com a legislação vigente. Foram realizadas levantamento de custo dos produtos desenvolvidos, os quais mostram estar economicamente de acordo com produtos similares encontrados no mercado.

Background Sweden has experienced a unique epidemic of celiac disease (CD) in children younger than 2 years of age. The epidemic was partly explained by changes over time in infant feeding and indicated a multifactorial aetiology. In CD, a strict lifelong gluten-free diet (GFD) is crucial for health but noncompliance is often reported among adolescents. Knowledge is limited regarding their own perspectives and experiences of managing the disease and adhering to GFD. Objectives To analyse the incidence of CD in epidemic and post epidemic birth cohorts, and explore and understand how adolescents with CD perceive and manage their everyday lives in relation to the GFD. Methods A population-based incidence register of CD in children covering the entire nation from 1998 to 2003, and part of the country back to 1973. ESPGHAN diagnostic criteria for CD and NUTS classification of regions were used. Incidence rates for each year of diagnosis, age group, gender and region, and cumulative incidence by age for each birth cohort were calculated. Ten focus groups were conducted with 47 CD adolescents aged 15-18 years. Transcribed interviews were analysed to illustrate and explain adolescents’ own perspectives concerning life with a GFD, and to search for recurrent stigma-related themes across the groups. Results A considerable gap in the cumulative incidence of CD at comparable ages was demonstrated between birth cohorts of the epidemic and post-epidemic periods. The gap persisted during pre-school years, although it decreased somewhat with age. During the final years of follow-up there was again a gradual increase in incidence rate among children younger than 2 years of age. The childhood populations in ‘West Sweden’ and ‘Småland and the islands’ had a significantly higher incidence rate compared to ‘North Middle Sweden’ and ‘Stockholm’. CD adolescents described an awareness of being different from others produced by meal appearance and the poor availability of gluten-free (GF) food. Eating in public had the effect of making an invisible condition visible and thereby creating a context for felt or enacted stigma. Maintaining invisibility avoided the negative consequences of stigma. The probability of compliance with the GFD was compromised by insufficient knowledge of significant others, problems with the availability and sensory acceptance of GF food, insufficient social support and their perceived dietary deviance. Three different approaches to the GFD emerged: compliers, occasional non-compliers, and non-compliers. Conclusions The difference in CD risk between birth cohorts at comparable ages may suggest an opportunity for primary prevention. Based on post-epidemic incidence trends, the Swedish epidemic might not have been as unique as previously thought, even though its magnitude was striking. The regional variation in CD risk supports multifactorial aetiology. Continued efforts are warranted to define factors besides gluten exposure that modulate CD risk. CD adolescents experience various dilemmas related to the GFD. It can produce stigma experiences in adolescence, and dietary compliance (or lack of) can be understood in terms of dealing with GFD concealment and disclosure. The increase in CD prevalence over time and unmet needs in young celiacs require resources to attain adequate levels of dietetic provision, regulated subsidies for covering additional costs for GF food, evidence-based practice, and increased general CD awareness for optimum clinical outcomes.

La maladie cœliaque ou sprue cœliaque est une intolérance au gluten. Il s’agit d’une maladie inflammatoire de l’intestin liée à l’ingestion de gluten chez des personnes génétiquement susceptibles. Ce désordre présente une forte prévalence puisqu’il touche 1 % de la population mondiale. En l’état actuel des choses, il n’existe aucun outil pharmacologique pour traiter ou pallier à cette maladie. Cependant, grâce aux avancées dans la compréhension de sa pathogenèse, de nouvelles cibles thérapeutiques ont été identifiées. À l’heure actuelle, le seul traitement efficace consiste à suspendre la consommation de l’agent pathogène, à savoir le gluten. Le gluten est un ensemble de protéines de stockage des céréales contenu dans le blé, l’orge et le seigle. Le gluten du blé se subdivise en gluténines et gliadines. Ce sont ces dernières qui semblent les plus impliquées dans la maladie cœliaque. Les gliadines et ses protéines apparentées (i.e. sécalines et hordéines, respectivement dans le seigle et l’orge) sont riches en prolines et en glutamines, les rendant résistantes à la dégradation par les enzymes digestives et celles de la bordure en brosse. Les peptides résultant de cette digestion incomplète peuvent induire des réponses immunitaires acquises et innées. L’objectif principal de cette thèse était de tester un nouveau traitement d’appoint de la maladie cœliaque utile lors de voyages ou d’évènements ponctuels. Dans les années 80, une observation italienne montra l’inhibition de certains effets induits par des gliadines digérées sur des cultures cellulaires grâce à la co-incubation en présence de mannane: un polyoside naturel composé de mannoses. Malheureusement, ce traitement n’était pas applicable in vivo à cause de la dégradation par les enzymes du tractus gastro-intestinales du polymère, de par sa nature osidique. Les polymères de synthèse, grâce à la diversité et au contrôle de leurs propriétés physico-chimiques, se révèlent être une alternative attrayante à ce polymère naturel. L’objectif de cette recherche était d’obtenir un polymère liant la gliadine, capable d’interférer dans la genèse de la maladie au niveau du tube digestif, afin d’abolir les effets délétères induits par la protéine. Tout d’abord, des copolymères de type poly (hydroxyéthylméthacrylate)-co-(styrène sulfonate) (P(HEMA-co-SS)) ont été synthétisés par polymérisation radicalaire contrôlée par transfert d’atome (ATRP). Une petite bibliothèque de polymères a été préparée en faisant varier la masse molaire, ainsi que les proportions de chacun des monomères. Ces polymères ont ensuite été testés quant à leur capacité de complexer la gliadine aux pH stomacal et intestinal et les meilleurs candidats ont été retenus pour des essais cellulaires. Les travaux ont permis de montrer que le copolymère P(HEMA-co-SS) (45:55 mol%, 40 kDa) permettait une séquestration sélective de la gliadine et qu’il abolissait les effets induits par la gliadine sur différents types cellulaires. De plus, ce composé interférait avec la digestion de la gliadine, suggérant une diminution de peptides immunogènes impliqués dans la maladie. Ce candidat a été testé in vivo, sur un modèle murin sensible au gluten, quant à son efficacité vis-à-vis de la gliadine pure et d’un mélange contenant du gluten avec d’autres composants alimentaires. Le P(HEMA-co-SS) a permis de diminuer les effets sur les paramètres de perméabilité et d’inflammation, ainsi que de moduler la réponse immunitaire engendrée par l’administration de gliadine et celle du gluten. Des études de toxicité et de biodistribution en administration aigüe et chronique ont été réalisées afin de démontrer que ce dernier était bien toléré et peu absorbé suite à son administration par la voie orale. Enfin des études sur des échantillons de tissus de patients souffrants de maladie cœliaque ont montré un bénéfice therapeutique du polymère. L’ensemble des travaux présentés dans cette thèse a permis de mettre en évidence le potentiel thérapeutique du P(HEMA-co-SS) pour prévenir les désordres reliés à l’ingestion de gluten, indiquant que ce type de polymère pourrait être exploité dans un avenir proche. / Celiac Disease or celiac sprue is identified as a gluten intolerance. It is an inflammatory disorder of the intestine triggered by the ingestion of gluten in genetically susceptible individuals. This condition is highly prevalent because it affects up to 1% of the worldwide population. Nowadays, there is no pharmacological treatment available to treat or off set to the disease. Due to the huge progress in the understanding of the pathogenesis, new therapeutic targets have been discovered. At the present time, the only effective treatment remains the strict lifelong abandonment of the pathogen agent, gluten. Gluten encompasses the storage proteins in wheat, rye and barley. The wheat gluten is divided into glutenins and gliadins. The latter seem to be the most important trigger in the celiac disease. Gliadins and the related proteins (i.e. secalins and hordeins, respectively in rye and barley) are rich in prolin and glutamin residues, conferring them to be resistant by enzymatic digestion. The resulting peptides of the incomplete process may set off the inflammatory reaction. The main objective of this thesis was to test a new supportive therapy in treating celiac disease, useful in punctual occasion (i.e. during travel or social event when the gluten-free property cannot be ascertained). In the 1980’s, inhibition of some gliadin-induced effects on cell cultures were observed owing to mannan co-incubation. However, this compound, due to his osidic nature, may be cleaved by digestive enzymes in vivo. Synthetic polymers prove to be an attracting alternative owing to the tunability of their physical and chemical properties. The goal of this study was to obtain a polymeric gliadin-binder, interferring with the pathogenesis of the celiac disease in the gastro-intestinal tract, to abrogate the gliadin induced effects. Atom transfer radical polymerization was used to synthesize copolymers of the type poly (hydroxyethylméthacrylate)-co-(styren sulfonate) (P(HEMA-co-SS)). A small library of polymers varying in their molecular weight and in their constituting monomers ratio was prepared. The ability of these polymers to sequester gliadin was assessed at stomacal and intestinal pH. The best candidates were further evaluated in cell cultures. Our results revealed that a selective binding was obtained with the P(HEMA-co-SS) (45:55 mol%, 40 kDa). This compound abolished gliadin-induced effects on various cell lines. In addition, gliadin digestion was hindered, suggesting a decrease in the formation of immunogenic peptides known to trigger the diseases. In vivo experiments were additionally carried out on a murine model of gluten-sensitivity with this polymeric candidate. Its efficacy towards pure gliadin and gluten containing food was tested. P(HEMA-co-SS decreased gliadin–induced effect on permeability and inflammatory parameters and modulated the immune response due to gliadin/gluten gavage. Toxicity and biodistribution studies following acute and chronic administration were performed on murine to demonstrate that the polymer was well tolerated and not absorbed after oral administration. Finally, biopsies of patients suffering from CD disease exhibited therapeutic benefit of the polymer. Altogether, the results presented in this thesis evidenced the potential of P(HEMA-co-SS) to prevent the gluten-induced disorder, indicating that this type of polymer may be useful in a near future.

Healthy dietary changes would be beneficial for society, as the economic burden of diet-related diseases is massive, and for the individual, who would reduce their risk of ill health. However, it is not easy to change dietary habits. Therefore, the aim of this thesis was to better understand dietary change, focusing on the barriers to and facilitators of healthy dietary change by i) examining changes in food choices when dietary change is imposed by a medical diagnosis, ii) examining experiences related to dietary change and its sustainability after participation in a study where healthy dietary changes were required, and iii) examining diet cost in relation to healthiness of the diet. Methods Eighty children aged 13 who were diagnosed with celiac disease (CD) by a screening study reported their food intake in a food frequency questionnaire before and 1,5 years after commencing a gluten-free diet. Changes in food intake and the healthiness of the diet were examined, controlling for societal changes through the use of an age- and sex-matched control group. Diet healthiness was assessed using the National Food Administration’s (NFA) food index and the Diet Quality Index-Swedish Nutritional Recommendations. Qualitative interviews were conducted with 14 individuals who participated in an intervention study five years earlier where they had been randomly selected to adhere to a Mediterranean-like diet for three months. Analyses of the transcribed interviews focused on their experiences of barriers to and facilitators of dietary change and its sustainability. The costs related to healthy diets were examined by comparing consumer food prices with dietary intake data collected in two separate studies. The first study collected dietary intake data through a diet history interview with participants who had been randomized to either a Mediterranean-like diet or to continue their normal diet. The second study collected dietary intake data from 4-, 8-, and 11-year-old children by means of food diaries and was conducted by the NFA. Diet healthiness was assessed using the Healthy Eating Index 2005. Results The screened CD group made relatively few changes to their diets. They decreased their intake of certain gluten-containing products, including pizza, chicken nuggets, fish sticks, and pastries. There were no changes in the healthiness of their diet. The narratives of the individuals changing their diets showed that social relationships were the main barrier to sustainability. Social relationships within the household were especially troublesome, and various coping strategies were required on an everyday basis. Dietary change also increased the burden of food work (e.g., planning, shopping, cooking), which was another major barrier to dietary change. Comparisons between consumer costs of healthy and less healthy diets showed that those consuming the healthier diets also had consumed more expensive diets. Conclusion More barriers to healthy dietary changes were found than facilitators of these transitions. For instance, the impact of social relationships on sustainability of dietary change was found to be high, indicating the importance of participation of other household members when dietary changes are implemented. The higher cost of the healthier diets may be another barrier for healthy dietary changes, especially for those with limited resources. Even though it is possible to eat healthily at a lower cost, such a diet would likely require both cooking skills and time, thus making the task more difficult. However, the finding that children diagnosed with CD only made minor changes in their consumption of, for instance, bread and pasta, indicates that one way of increasing the healthiness of a diet is to substitute healthier alternatives within the same food group for less healthy food items.

CNPQ; Fundação Araucária / O grão de chia (Salvia hispânica L.) vem despertando um grande interesse das indústrias alimentícias por suas características nutricionais. Assim, o presente estudo teve como objetivo elaborar pães isentos de glúten, avaliando a influência da adição de farinha de Chia parcialmente desengordurada (FCPD), e das goma xantana e hidroxipropilmetilcelulose (HPMC), nas características reológicas, físico-químicas e sensoriais dos pães. Para tanto, foi utilizado um delineamento composto central rotacional (DCCR), do tipo 23 para investigar a influência do teor de ômega-3, lipídios totais, proteína bruta e carboidratos totais. Dentro das faixas estudadas para as três variáveis, foi possível verificar que a adição da FCPD promoveu maior contribuição nos modelos matemáticos, cujo R2 calculado possibilitou explicar até 94 % dos fenômenos ocorridos na faixa investigada. Através da análise de desejabilidade identificouse que a formulação do ponto central convergiu na otimização para as três variáveis estudadas. No teste de aceitação para a amostra contendo 20 % de FCPD, o atributo textura foi melhor avaliado, os atributos aroma, sabor e aspecto global não evidenciaram uma maior ou menor aceitação. Para a FCPD, foram encontrados teores elevados de proteínas (30,15 %), carboidratos (41,60 %), e capacidade de absorção de água de 10,53 g g-1 de amostra, sendo este valor metade daquele encontrado para a farinha de chia integral (20 g g-1 de amostra). A FCPD apresentou valores elevados de ômega-3 (60 %) e ômega-6 (24 %). O Uso da FCPD e das gomas foi promissor no desenvolvimento de pão isento de glúten com boas características sensoriais e nutricionais. / The chia seed (Salvia hispanica L.) has attracted a great interest of the food industry for its nutritional characteristics. Thus, this study aimed to prepare bread gluten-free, assessing the influence of the addition of partially defatted chia flour (PDCF), and xanthan gum and hydroxypropyl methylcellulose gum (HPMC), in the rheological characteristics, physico-chemical and sensory characteristics of bread. Thus, a central composite rotational design was used (CCRD), type 23 to investigate the influence of omega-3 content, total fat, crude protein and total carbohydrates. Within the ranges studied for the three variables, it was possible verify that the addition of PDCF promoted greater contribution to mathematical models, which calculated R2 allowed to explain 94 % of the phenomena occurring in the investigated range. Through the desirability analysis it was found that the formulation of the central point converged on optimizing for the three variables. At the acceptance test for the sample containing 20 % PDCF, texture attribute was better evaluated; the attributes aroma, flavor and overall appearance did not show a larger or smaller acceptance. For PDCF, elevated protein (30.15 %) and carbohydrates (41.60%) levels were found, and water absorption capacity of 10.53 g g-1 of sample, this value being half of that found for the chia integral flour (20 g g-1 of sample). PDCF showed high levels of omega-3 (60 %) and omega-6 (24 %). The use of PDCF and gums was promising in the development of gluten-free bread with good sensory and nutritional characteristics.

The Dissertation deals with educational materials for patients with celiac disease. It describes general requirements for teaching materials and the didactical principles suitable for educational materials for patients with celiac disease. It presents a draft criteria for assessment of web sites intended for people suffering of celiac disease. Five Czech, as well as foreign Internet-based resources, have been selected and assessed for compliance with the criteria given by technical properties, contents, page structures, criteria evaluating credibility of the sites and educational criteria. All the sites assessed can be used for education of patients with celiac disease, but they are rather information sites with a low content of educational characteristics.