Gluten-related disorders (GRDs) refer to a group of conditions that are caused by the ingestion of the gluten proteins present in wheat, barley, and rye. The global prevalence of GRDs is estimated to range from 0.6% to 10.6% of the general population, making it a significant global health issue. Treatment of GRDs requires dietary gluten avoidance. In China, there is believed to be a growing number of people with GRDs associated with changing eating patterns, increasing awareness, and better detection methods of these conditions in China. However, there is a lack of research about how to help this population maintain a restrictive diet and navigate food and social environment. The main purpose of this study was to explore the feasibility and acceptability of a culturally adapted low-gluten diet intervention among young adults in southeastern China. This study was a pre-post study design to investigate whether the intervention is effective in helping participants maintain a low-gluten diet for eight weeks. Participants were 62 young adults living on campus in southeastern China. Image-based food records and questionnaires were used to assess their dietary adherence, dietary quality, satisfaction, knowledge, self-efficacy, and other related determinants of following a low-gluten diet. Results suggested good feasibility of this dietary intervention. Only 1.9% of the total items consumed during the intervention was high-gluten or likely-high-gluten items, such as processed meat, mixed dishes, and fried food, and traditional noodles, suggesting an overall good compliance to the low-gluten diet. Specifically, over 95% of participants were found to be compliant with the diet based on all adherence measures. Females had better compliance than males (p=0.005 based on frequency, p=0.039 based on grams of gluten intake). Results also suggested good acceptability of this dietary intervention. All participants found the dietary intervention to be satisfactory with group communication and reminders rated to be the most helpful components. The perceived difficulty level of maintaining the low-gluten diet was 6.34 out of 10 (10 being the most difficult). The most rated barriers were fewer food choices and change of eating habits. Participants reported having more perceived barriers at the end of study compared to the beginning of the study, mean (SD) 17.19 (5.82) vs. 16.13 (4.19) out of 32, p = 0.285. Motivation scores were significantly lower at the end of study compared to the beginning of the study, mean (SD) 11.66 (2.21) vs. 13.40 (2.37) out of 16, p < 0.001. Increased perceived barriers and decreased motivation may suggest that they experienced more challenges in maintaining the low-gluten diet at the end of this two-month intervention. During the intervention, participants had significantly lower calories, carbohydrates, and vitamin B1 (thiamin) intake compared to baseline (p <0.05). Participants’ average dietary diversity score had no significant difference compared to baseline, 7.68 (1.10) vs. 7.69 (1.35), p=0.96. Participants had increased objective knowledge (p<0.0001), subjective knowledge (p< 0.0001), and behavioral capability (p<0.0001) compared to baseline. However, univariate and multivariate regression analyses did not find significant predicting effects of any determinants on dietary adherence. Our dietary assessment method, the image-based food records, was shown to be a reasonably valid and reliable tool to estimate the dietary intake among Chinese young adults based on comparison to weighted food records with the Bland–Altman plot and inter-rater reliability test (Cohen’s kappa=0.875). These findings suggested that a culturally adapted low-gluten dietary intervention was feasible and acceptable among Chinese young adults. Improvement on long-term dietary adherence and more research on determinants is needed. This study may inform health practitioners and policy makers to provide better culturally tailored support to patients who need to follow a low-gluten diet in China.

Celiac disease (CD) is a highly prevalent autoimmune disease in which intestinal inflammation is induced by dietary gluten. The means through which gluten-specific CD4+ T cell activation culminates in intraepithelial T cell (T-IEL) mediated intestinal damage remain unclear. Here, we performed multiplexed-single cell analysis of intestinal and gluten-induced peripheral blood T cells from patients with different celiac disease states and controls. Untreated, active CD (ACD) and potential CD (PCD) were associated with an enrichment of activated intestinal T cell populations including CD4+ follicular T-helper (TFH) cells, regulatory T cells (Tregs), and Natural CD8+ αβ and γδ T-IELs. Natural CD8+ αβ and γδ T-IELs expressing activating Natural Killer Cell Receptors (NKRs) exhibited a distinct TCR repertoire in CD and persisted in patients on a gluten-free diet (GFD) without intestinal inflammation. Our data further show that NKR-expressing cytotoxic cells, which appear to mediate intestinal damage in CD, arise from a distinct NKR-expressing memory population of T-IELs. Following gluten ingestion, both αβ and γδ T cell clones from this memory population of T-IELs circulated systemically with gluten-specific CD4+ T cells and assumed a cytotoxic and activating NKR-expressing phenotype. In patient-derived organoid (PDO) model of CD, gluten exposure induced the presence of this cytotoxic, NKR-expressing population exclusively in PDOs generated from CD patients. The increased abundance of cytotoxic, NKR-expressing T-IELs following gluten exposure corresponded to histologic observations of altered organoid morphology including degenerated organoid structures and the presence of infiltrating immune cells co-localized with apoptotic epithelial cells. Collectively, these findings suggest that these cytotoxic, NKR-expressing T cells in CD are rapidly mobilized in parallel with gluten-specific CD4+ T cells following gluten ingestion to mediate the destruction of intestinal epithelial cells in CD.