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RISK OF AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER-LIKE PHENOTYPE IN CHILDREN WITH CELIAC DISEASE: A NATIONWIDE POPULATION-BASED COHORT STUDY

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RISK OF AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER-LIKE PHENOTYPE IN CHILDREN WITH CELIAC DISEASE: A NATIONWIDE POPULATION-BASED COHORT STUDY

Jialu Yao 1, Lisa Dinkler 1, Jiangwei Sun 2,1, David Bergman 1, Peter HR Green 3, Elisabet Wentz 4,5, Mariel Arvizu 6, Benjamin Lebwohl 3,7, Jonas F Ludvigsson 1,3,8

Affiliations

1 Karolinska Institutet, Solna, Sweden

2 Sun Yat-sen University, Shenzhen, China

3 Columbia University College of Physicians and Surgeons, New York, United States

4 University of Gothenburg, Gothenburg, Sweden

5 Sahlgrenska University Hospital, Gothenburg, Sweden

6 Takeda, Cambridge, United States

7 Columbia University, New York, United States

8 Örebro University Hospital, Örebro, Sweden

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Abstract

Introduction

Children with celiac disease (CeD) may face an increased risk for avoidant/restrictive food intake disorder (ARFID, first defined in the Diagnostic and Statistical Manual of Mental Disorders [DSM]-5 in 2013) due to generalized fear of adverse consequences associated with gluten exposure. However, population-based evidence linking CeD to the development of ARFID is lacking.

Aims & Methods

To investigate the risk of incident ARFID-like phenotype before adulthood in children with CeD. Children (≤16 years) with biopsy-confirmed CeD from 2001 through 2022 were identified from a Swedish nationwide histopathology cohort "ESPRESSO" (n=13,576) and matched with ≤5 reference individuals from the general population (n=66,068) by sex, birth year, calendar year of diagnosis, and county of residence. ARFID-like phenotype was identified in the Swedish National Patient Register via the tenth revision of the International Classification of Diseases (ICD)-10 codes F98.2 and R63.3 (as an extension of infant or early childhood feeding disorders according to DSM-5, the specific code for ARFID has only been introduced in ICD-11). To mitigate potential detection bias, follow-up started one year after CeD diagnosis or matching until incident eating disorders, or the earliest occurrence of 18th birthday, death, emigration, or 31 December 2023. The adjusted hazard ratio (aHR) was estimated using Cox regression. In sensitivity analyses, we excluded conditions that may cause secondary eating disturbances to increase the specificity for ARFID, and addressed intra-familial factors via comparison with CeD-free full siblings.

Results

Over a median follow-up of 12.6 years, 89 children with CeD had an ARFID-like diagnosis before adulthood, compared to 160 reference individuals (incidence rate: 57 vs. 21 per 100,000 person-years). After adjusting for matching variables, country of birth, parental educational level, and specialist visit frequency, the aHR for ARFID-like phenotype in CeD was 1.70 (95% confidence interval:1.19 to 2.44). In subgroup analyses, the positive association was significant among boys and among those 6-11 years (Table 1). The association between CeD and childhood ARFID-like phenotype became non-significant when excluding conditions potentially causing secondary eating disturbances (aHR=1.36 [0.83 to 2.22]), while was similar when compard to CeD-free siblings (aHR=1.78 [0.96 to 3.31]).

Table 1. Incident ARFID-like phenotype in patients with CeD and their matched reference individuals, stratified by sex, age, and calendar period
ARFID: avoidant/restrictive food intake disorder; CeD: celiac disease; CI: confidence interval; HR: hazard ratio; IR: incidence rate ^aIndex date: one year after CeD diagnosis/matching ^bConditioned on the matching variables (birth year, sex, county of residence, and calendar year of index date) and further adjusted for country of birth, parental educational attainment, number of healthcare visits between two years and six months before the index date
		Patients No. of events (IR, per 100,000 person-years)	Matched reference individuals No. of events (IR, per 100,000 person-years)	IR difference (95%CI), per 100,000 person-years	HR (95%CI) ^b
Age at index date, years ^a	1-5	42 (80)	80 (32)	49 (24 to 74)	1.31 (0.80 to 2.15)
	6-11	37 (67)	58 (22)	45 (23 to 68)	2.32 (1.27 to 4.25)
	12-17	10 (21)	22 (10)	11 (-2 to 25)	1.93 (0.53 to 7.04)
Sex	Female	55 (57)	114 (24)	32 (17 to 48)	1.36 (0.88 to 2.11)
Sex	Male	34 (58)	46 (16)	42 (22 to 62)	2.86 (1.47 to 5.58)
Calendar period at index date^a	2002-2012	53 (43)	109 (18)	24 (12 to 36)	1.59 (1.03 to 2.46)
Calendar period at index date^a	2013-2023	36 (115)	51 (34)	81 (43 to 120)	2.11 (1.03 to 4.32)

Conclusion

Children with CeD, specifically boys and those diagnosed during primary school years, were at an increased risk of developing an ARFID-like phenotype. Clinicians should actively discuss with patients and their families about the mental distress when maintaining a gluten-free diet, and be cautious to avoid hypervigilance when guiding disease management.

Disclosure

MA is an employee of Takeda Pharmaceuticals and owns stock in this company.
JFL has coordinated a study on behalf of the Swedish IBD quality register (SWIBREG). That study received funding from Janssen Corporation. JFL has also received financial support from MSD developing a paper reviewing national healthcare registers and for research on IBD. JFL also has a research collaboration on celiac disease with Takeda.
The other authors report no disclosures relevant to the manuscript.

Event

UEG Week Barcelona 2026

Topics

Endoscopy Small Intestine & Nutrition Immunology

Submission format

Abstract

Session

From modern diagnostics to treatments in coeliac disease

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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David Surendran Sanders

RISK OF AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER-LIKE PHENOTYPE IN CHILDREN WITH CELIAC DISEASE: A NATIONWIDE POPULATION-BASED COHORT STUDY

Jonas F Ludvigsson

Behavioural assessment and treatment in disordered eating

Ines Trindade

FIRST-LINE EMPIRICAL ERADICATION THERAPY FOR HELICOBACTER PYLORI INFECTION: EXPERIENCE FROM 1,500 CASES OF THE BRAZILIAN REGISTRY ON H. PYLORI MANAGEMENT (HP-BRAREG/WORKDHPREG)

Luiz Coelho

GASTROINTESTINAL INFECTIOUS PATHOGENS IN GEORGIA (SOUTH CAUCASUS): A MULTI-PATHOGEN SURVEILLANCE SYNTHESIS REVEALING CRITICAL EPIDEMIOLOGICAL GAPS AND ALARMING ANTIMICROBIAL RESISTANCE PATTERNS

George Mgeladze

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FIRST-LINE EMPIRICAL ERADICATION THERAPY FOR HELICOBACTER PYLORI INFECTION: EXPERIENCE FROM 1,500 CASES OF THE BRAZILIAN REGISTRY ON H. PYLORI MANAGEMENT (HP-BRAREG/WORKDHPREG)

Sandro Rodrigues Chaves 1, Olga P. Nyssen 2, Júlio César Soares Veloso 3, Leonardo Soares da Silva drleonardoss 4, James Marinho 5, Hoiti Okamoto 6, Gustavo Coutinho Couto 7, Helenice Breyer 8, CHRISTIANE ALENCAR 9, ERNESTO COMELLI 10, Luis Alberto Sousa 11, Mariana Horn 12, Maria José Gilberto Massote 13, Marcela Loures 14, MARIA DE FÁTIMA PIETROLUONGO VIDAL 15, Rosival Vicente De Paula 16, Laércio Tenório Ribeiro 17, Bruno Squárcio Sanches 18, Humberto Galizzi 19, Daniel Antônio de Albuquerque Terra 18, Guilherme Grossi Lopes Cançado 20, Bibiana Possobon Burmann 21, Jardel Caetano 22, Luiz Fernando Pena 23, Mario Augusto Moreira Decanio 24, Heitor Siffert Pereira de Souza 25, Aline Kuniyoshi 26, Ludmila Resende Guedes 27, Maria do Carmo Friche Passos 28, Frederico Passos Marinho 18, Isadora Bombassaro 29, Aline Domingues 30, Jaques Garcia 31, Islaine Martins Nogueira 32, Ana Flavia Passos Ramos 33, DANIELLA KORMAN 34, Teógenes Barbosa Souza 35, Moni Chiara Barbosa 36, Decio Chinzon 37, Leandro Lima da Silva 38, Augusto Mantovani 39, Alzimara Hemerly de Almeida Freitas 40, Christiane Poncinelli 41, Marcelo Alexandre Francato 42, Jussiane Nader Gonçalves 18, Leticia Moreira Ruiz 43, Pablo Parra 2, Alba Singla 44, Javier P. Gisbert 2, Luiz Coelho 18

Affiliations

1 Mater Dei Rede de Saúde, Belo Horizonte, Brazil

2 Department of Gastroenterology, Madrid, Spain

3 Hospital Santa Helena, Brasilia, Brazil

4 Hospital Adventista de Manaus, Manaus, Brazil

5 UNIVERSIDADE ESTADUAL DE CIÊNCIAS DA SAÚDE DE ALAGOAS - UNCISAL, Maceió, Brazil

6 Centro Médico Oxford, São Bento do Sul, Brazil

7 Centro de Atenção Especializada -Prefeitura Municipal de Contagem, Contagem, Brazil

8 Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

9 Katz Endoimagem, Rio De Janeiro, Brazil

10 Castromed, Castro, Brazil

11 Coopclin, Recife, Brazil

12 Clinica Endocentro, Florianopolis, Brazil

13 Unidade de Saúde de Santos, Santos, Brazil

14 Hospita Nossa Senhora Das Graças, Curitiba, Brazil

15 Hospital Ana Costa, Santos, Brazil

16 Hapclinica Hermes Fontes, Aracaju, Brazil

17 Hospital Universitário Prof. Alberto Antunes, Maceió, Brazil

18 Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil

19 Hepscan, Belo Horizonte, Brazil

20 Hospital Militar de Minas Gerais, Belo Horizonte, Brazil

21 MedPlus, Porto Alegre, Brazil

22 Hospital Cardiopulmonar, Salvador, Brazil

23 Hospital Socor, Belo Horizonte, Brazil

24 Hospital Português da Bahia, Salvador, Brazil

25 Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil

26 Universidade Estadual de Maringá, Maringá, Brazil

27 Rede Mater Dei de Saúde, Belo Horizonte, Brazil

28 Hospital das Clinicas, UFMG, Belo Horizonte, Brazil

29 Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil

30 GRD Gastro Resolução em Diagnóstico, Rio de Janeiro, Brazil

31 Santa Casa de Barretos, Barretos, Brazil

32 Ame Maria Zelia, São Paulo, Brazil

33 Santa Casa de Belo Horizonte, Belo Horizonte, Brazil

34 Endoscopia Clínica e Cirúrgica, Belo Horizonte, Brazil

35 Faculdades Integradas de Patos, Patos, Brazil

36 Private practice, Arapiraca, Brazil

37 University of Sao Paulo Dept. of Gastroenterology, Sao Paulo, Brazil

38 Monte Sinai Hospital e Maternidade, Juiz de Fora, Brazil

39 Associacao Hospital Moinhos de Vento, Porto Alegre, Brazil

40 Unimed Sul Capixaba, Cachoeiro do Itapemirim, Brazil

41 Biogastro, Belo Horizonte, Brazil

42 Hospital Municipal Antonio Giglio, Osasco, Brazil

43 Department of Gastroenterology, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelon

44 Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain

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Abstract

Introduction

Standard triple therapy has been the first-line empirical eradication treatment for Helicobacter pylori (H. pylori) in Brazil. Bismuth salts, only available as compounded drugs, remain scarcely used in first-line therapy.

Aims & Methods

Aim: To evaluate the effectiveness of first-line empirical H. pylori eradication therapy in real clinical practice in Brazil.
Methods: Data were collected at AEG-REDCap from March 2022-October 2024 as part of the multicentre, prospective Brazilian Registry on H. pylori management (Hp-BrazilReg; WorldHpReg partner) evaluating the decisions and outcomes by gastroenterologists. Effectiveness was assessed by modified intention-to-treat (mITT) analysis.

Results

Overall, 1,577 Brazilian H. pylori-infected adult patients (mean age 52 years, 60% women) were included. The main indications for treatment were dyspepsia (66%) and gastroduodenal ulcers (11%). Allergy to the antibiotics usually prescribed in eradication regimens ocurred in 2.6%. Statin use was reported in 17%, and probiotics were used in 14%. Diagnosis was mostly performed through endoscopy (96%) using histology (93%) and/or rapid urease test (RUT, 15%). Pre-treatment bacterial resistance testing was not performed. Eradication was mostly confirmed by endoscopy (88%) using histology (87%) and/or RUT (14%), or by 14C-urea breath test (8%). Triple, dual and quadruple regimens were used in 95%, 4% and 1%, respectively, with 14-day regimens prescribed in 93% of cases. Low-, standard-, and high-dose proton pump inhibitors (PPIs), as well as vonoprazan (VPZ), were used in 31%, 40%, 18%, and 11% of cases, respectively. Compliance (≥ 90% drug intake) was 99%. Table 1 shows the main regimens and their eradication rates (ERs): PPI-clarithromycin(C)-amoxicillin(A) (85% of cases; ER 78%; reference category for comparison), VPZ-C-A (6%; ER 86%; OR 1.70; 95% CI 0.95-3.04) and VPZ-A (4%, ER 97%; OR 17.80; 95% CI 2.46-129). Independent predictors of higher effectiveness included 14-day prescriptions, using a dual regimen instead of a triple therapy, being adherent to treatment and prescribing VPZ instead of PPIs. The multivariate analysis confirmed that dual therapy was significantly associated with higher mITT, compared to other treatment combinations; that longer treatment durations were significantly associated with an effectiveness
increase; and that VPZ-based regimens were superior to PPI-based, especially when standard-dose (OR 0.49; 95% CI 0.26-0.88) or low-dose (OR 0.52; 95% CI 0.26-0.97) were used. At least one adverse event was reported in 25% of patients, mainly nausea (12%) and diarrhea (8%), typically mild (63%) and during less than 7 days (52%).

Table 1. Effectiveness results of first line treatments - Brazilian Registry on H. pylori management
Source: Hp-BrazilReg, data from march, 2022 to november, 2024. Abbreviations: mITT-modified intention to treat analysis; C-clarithromicin; A-amoxicillin; PPI-proton pump inhibitor; VPZ-vonoprazan; L-levofloxacin; Bi-bismuth salts; M-metronidazole; T-tetracycline; N/A-non-applicable. Univariate analysis of eradication (C+A+PPI as comparison category): () C+A+VPZ (OR 1.70; 95% CI 0.95-3.04); () A+VPZ (OR 17.80; 95% CI 2.46-129); (**) (C + L + PPI) or (Bi + M + T + PPI/VPZ) vs C+A+PPI: p > 0.05
Therapeutic schemes	N (%)	Effectiveness, mITT % (95% CI)
C + A + PPI	1,328 (85.3%)	77.9 (75.6-80.1)
C + A + VPZ	98 (6.3%)	85.7 (77.2-92.0) (*)
A + VPZ	64 (4.1%)	96.9 (89.3-99.6) (**)
C + L + PPI	27 (1.7%)	85.2 (66.3-95.8) (***)
Bi + M + T + PPI/VPZ	7 (0.4%)	85.7 (42.0-99.6) (***)
Other (15 different schemes)	33 (2.1%)	72.9 (N/A)
Total	1,557 (100%)	79,3 (77.1-81.2)

Conclusion

The effectiveness of PPI-C-A for H. pylori eradication in Brazil was suboptimal (78%); VPZ-C-A might represent an alternative, with cure rates ≈90%. However, VPZ-A was the only regimen achieving >90% effectiveness.

References

1. Coelho LGV, Marinho JR, Genta R, et al. IVth Brazilian Consensus Conference on Helicobacter Pylori Infection. Arq Gastroenterol. 2018;55(2):97-121.
2. Nyssen OP, Bordin D, Tepes B, et al. European Registry on Helicobacter pylori management (Hp-EuReg): patterns and trends in first-line empirical eradication prescription and outcomes of 5 years and 21 533 patients. Gut. 2021; 70(1):40–54
3. Pabón-Carrasco M, Keco-Huerga A, Castro-Fernández M, et al. Role of proton pump inhibitors dosage and duration in Helicobacter pylori eradication treatment: Results from the European Registry on H. pylori management. United European Gastroenterol J. 2024;12(1):122-138
4. Malfertheiner P, Megraud F, Rokkas T, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022;9(71):1724–1762.

Conference

UEG Week Barcelona 2026

Topics

Oesophagus

Submission format

Abstract

Session

Helicobacter pylori: Global insights (Posters)

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

More Like This:

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COELIAC DISEASE OUTCOMES OF BUDESONIDE RESPONSE IN ADULTS: COBRA STUDY FROM THE EUROPEAN SOCIETY FOR THE STUDY OF COELIAC DISEASE (ESSCD)

David Surendran Sanders

RISK OF AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER-LIKE PHENOTYPE IN CHILDREN WITH CELIAC DISEASE: A NATIONWIDE POPULATION-BASED COHORT STUDY

Jonas F Ludvigsson

Behavioural assessment and treatment in disordered eating

Ines Trindade

FIRST-LINE EMPIRICAL ERADICATION THERAPY FOR HELICOBACTER PYLORI INFECTION: EXPERIENCE FROM 1,500 CASES OF THE BRAZILIAN REGISTRY ON H. PYLORI MANAGEMENT (HP-BRAREG/WORKDHPREG)

Luiz Coelho

GASTROINTESTINAL INFECTIOUS PATHOGENS IN GEORGIA (SOUTH CAUCASUS): A MULTI-PATHOGEN SURVEILLANCE SYNTHESIS REVEALING CRITICAL EPIDEMIOLOGICAL GAPS AND ALARMING ANTIMICROBIAL RESISTANCE PATTERNS

George Mgeladze

	NO CANCER - CMDS ≤13 (n=77)	CANCER - CMDS ≤13 (n=19)	p-value
	mean±SEM	mean±SEM
Waist Circumference (cm)	101.7±1.9	108.3±2.9	0.0016**
HDL Cholesterol (mg/dl)	53.4±3.8	38.7±3.9	0.0031**
Triglycerides (mg/dl)	107.3±4.1	148.1±11.3	0.0322*
Fasting Glucose (mg/dl)	100.7±4.4	118.1±4.1	0.0177*
Fatty Liver Index	38.2±6.1	69.4±5.7	0.0021**

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Non-immune-mediated enteropathies

COELIAC DISEASE OUTCOMES OF BUDESONIDE RESPONSE IN ADULTS: COBRA STUDY FROM THE EUROPEAN SOCIETY FOR THE STUDY OF COELIAC DISEASE (ESSCD)

RISK OF AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER-LIKE PHENOTYPE IN CHILDREN WITH CELIAC DISEASE: A NATIONWIDE POPULATION-BASED COHORT STUDY

Behavioural assessment and treatment in disordered eating

FIRST-LINE EMPIRICAL ERADICATION THERAPY FOR <EM>HELICOBACTER PYLORI</EM> INFECTION: EXPERIENCE FROM 1,500 CASES OF THE BRAZILIAN REGISTRY ON <EM>H. PYLORI</EM> MANAGEMENT (HP-BRAREG/WORKDHPREG)

GASTROINTESTINAL INFECTIOUS PATHOGENS IN GEORGIA (SOUTH CAUCASUS): A MULTI-PATHOGEN SURVEILLANCE SYNTHESIS REVEALING CRITICAL EPIDEMIOLOGICAL GAPS AND ALARMING ANTIMICROBIAL RESISTANCE PATTERNS