Background: Children with celiac disease (CeD) rely on strict dietary gluten elimination to reduce end-organ damage. Adherence to a costly gluten-free diet (GFD) can be challenging for low-income families, leading to a persistently elevated tissue transglutaminase (tTG) IgA. We evaluated how neighborhood deprivation impacts tTG IgA normalization, a key marker of effective gluten elimination.
Methods: We conducted a single-center retrospective cohort study of 207 children ≤18 years old with serology- or biopsy-based diagnosis of CeD identified from electronic health records between 1/1/2013-12/31/2023. The primary exposure was the neighborhood deprivation index, a continuous measure (0-1) derived from the 2018 five-year American Community Survey. We categorized children from lowest to highest deprivation by quartiles (Q): Q1 (<0.15), Q2 (0.15-0.21), Q3 (0.21-0.29), or Q4 (>0.29). The primary outcome was the normalization of tTG IgA over the 60 months after seropositivity. We used Cox regression models to estimate hazard ratios for tTG IgA normalization, adjusting for race, ethnicity, primary-spoken language, and insurance type in multivariate analyses.
Results: Of 207 children, the median deprivation index was 0.22 (IQR: 0.14, 0.29). Higher deprivation was associated with participants identifying as Black or Other race, Hispanic, non-English primary-speaking, and having public insurance.
In univariate analysis, children in the highest quartile of neighborhood deprivation had a 50% lower normalization rate compared to those in the lowest quartile (Q4: HR 0.50; 95%CI 0.27, 0.92; p=0.03). In multivariable analysis, children in the highest quartile of neighborhood deprivation sustained a 67% lower normalization rate after adjusting for race, ethnicity, primary-spoken language, and insurance type (Q4: HR 0.33; 95%CI 0.15, 0.75; p=0.008).
Conclusion: Children living in socioeconomically deprived neighborhoods may have inadequate dietary adherence. Addressing the barriers to gluten elimination in deprived neighborhoods may improve outcomes.