Measuring the Risk of Gluten Exposure: Development of the Gluten Exposure Risk Assessment (GERA) in Pediatric Patients

Introduction: Treatment of Celiac Disease (CeD) requires a strict gluten-free diet (GFD). Adherence is difficult to assess and influenced by many factors. Identification of potential gluten exposures is essential, but no validated screening measures exist in pediatrics. The aim of this study was to develop and validate a measure screening for gluten exposure risk in pediatric patients with CeD. Methods: The Gluten Exposure Risk Assessment (GERA) was developed in three phases. First, items were generated and refined via a modified Delphi process. Next, psychometrics, factor structure, and validity was examined in a sample of caregivers of pediatric patients <18 years old with CeD at 12 pediatric celiac centers. Lastly, the final measure was tested on an independent sample population using confirmatory factor analysis (CFA) and test-retest data. Results: A total of 134 items were generated representing up to 6 domains, with 36 items selected for initial testing. Based on psychometrics and CFA data from 484 caregivers, the final measure included a total of a single screening question and 9 validated items representing two domains (Home, Outside). Repeat testing on a separate sample (N=369) confirmed factor structure and validity of the final measure (CFI = 0.96, TLI = 0.95, RMSEA = 0.06). Discussion: The Gluten Exposure Risk Assessment is a valid screening measure, completed by caregivers, for assessment of gluten exposure in children and adolescents with CeD following a gluten-free diet. GERA is a useful tool for evaluating the potential of risk for gluten exposure and potential need for intervention.