By Amy Ratner, Medical and Science News Analyst
Marisa Gallant Stahl, M.D. was recently selected as the recipient of the Society for the Study of Celiac Disease/Beyond Celiac Early Career Investigator grant. She was chosen from a competitive field of candidates who are focusing their research on celiac disease.
Stahl, who is currently a fellow at Children’s Hospital Colorado, will receive nearly $75,000 for each of two years for a study to evaluate the impact of celiac disease on the health and quality of life of children who are identified through a mass screening program. Since these children have no obvious symptoms of celiac disease, they would be unlikely to be diagnosed otherwise.
The study will address the dilemma of weighing the potential health problems related to undiagnosed celiac disease in asymptomatic children with the potential burden of the gluten-free diet, which can be socially limiting and lead to problems with anxiety, depression and a general reduction in quality of life, plus some nutritional concerns.
Stahl’s study is a follow up to the Autoimmunity Screening for Kids (ASK) research that is being done by the Barbara Davis Center for Diabetes at the School of Medicine at the University of Colorado. ASK is designed to find early signs of diabetes or celiac disease in children. About 50,000 children between the ages of 1 and 17 are expected to be screened over three years. About 900 children with celiac disease are expected to be identified through ASK screening and 50 with biopsy-proven celiac disease will be enrolled in Stahl’s study.
The study has two aims. One is to determine whether children found through screening will see improvement in height, weight, nutritional measures and symptoms that might not have been associated with celiac disease prior to screening.
The second is to determine whether their health-related quality of life is affected. The study will test the hypothesis that improvement will occur in both areas and that screening for and treating of celiac disease in the general pediatric population can reduce morbidity. The U.S. Preventive Services Task Force in 2017 concluded it did not have enough evidence to make a recommendation on general population screening for celiac disease and this study can help provide some of that evidence, according to Stahl.
She will begin working as a junior faculty member at the University of Colorado this summer. She began her fellowship in pediatric gastroenterology there after a pediatric residency at the North Carolina Children’s Hospital. Stahl grew up in New Jersey and received her undergraduate degree in biology from the University of Virginia and her medical degree from Northwestern University.
Following announcement of her selection to receive the SSCD/Beyond Celiac grant, she and I talked about her background, her career and her research. Here is some of what she had to say.*
Tell us a little about your career.
In terms of my research career there's definitely been a progression. In undergrad, I did basic science research looking at cancer in mouse models. That was a nice introduction to the basic mechanisms of the diseases that we see. In medical school I initially actually thought I wanted to do pediatric oncology, and so I did basic science research in Burkitt's lymphoma.
I always enjoyed my interactions with patients. I like the idea of research and being able to give back to patients and to help progress medicine in that sense, but for me being in the basic lab was not as much my cup of tea.
In medical school I did an elective in pediatric gastroenterology, and I just loved the idea of being able to follow patients with chronic diseases, to be able to develop relationships with the families and help them through the diagnosis process and then the treatment process and having that longitudinal relationship.
Going into residency in North Carolina, I also was lucky to have really great gastrointestinal mentors and their specialty was in irritable bowel disease. In residency I was able to pursue more translational and clinical research. You could have that interaction with patients but then give back on a bigger level by being able to do research and find ways to improve the treatments that we have.
When I started my fellowship in Colorado, I did not have a lot of experience with celiac disease or celiac disease research. I met Ed Liu, M.D., director of the Colorado Center for Celiac Disease, and heard more about the Diabetes Autoimmunity Study in the Young (DAISY) and the Environmental Determinants of Diabetes in the Young (TEDDY), which were right in line with the type of research I thought I wanted to do.
I was also able to work with Ed more and got to see patients in celiac clinic and decided that was what I wanted to pursue for research in my fellowship. I was also working with our celiac team to plan things like education day and going to Round Up River, which is our camp for children with all gastrointestinal diagnoses.
I've found something that I'm really passionate about, which is exciting.
Growing up, did you always want to be a doctor?
The very first time that I really thought about being a doctor was when my grandfather was sick with colon cancer, and he was in hospice care. Interacting with his doctors, they were just so wonderful, and they helped so much with his pain and what he was going through. I was in 5th grade, and that was the first time I thought about it.
In undergrad, I worked at a camp for kids with special medical needs, and once again was able to see how much of a difference you could make for kids with congenital heart disease and cerebral palsy and other conditions. With the right treatments and the new things that research made available they were able to have a relatively normal camp experience. After that summer experience I really knew medicine was the right choice for me, and specifically pediatrics.
What has been your most exciting moment in medicine so far?
Getting this early career research grant has been one of my most exciting moments. It’s been a culmination of what I've been working on with Ed in fellowship, first with TEDDY and looking at the incidence of celiac disease and celiac disease autoimmunity. Then we did a growth study, but most importantly the autoimmunity screening study and being able to present at Digestive Disease Week and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
In research, it’s not always one big moment but a progression of moments. A lot has changed with our study design for this follow-up work because of the “Aha!” moments that we've had over the course of the two years that I've been working with ASK.
Many celiac disease experts say that the lack of early career researchers studying celiac disease has hurt progress. What are your thoughts?
One of the reasons that it's so great that SSCD and Beyond Celiac are offering this award is that it is a lot harder as a celiac researcher to get funding. Other diseases that we treat in gastroenterology, like inflammatory bowel disease or liver disease, the researchers get a lot more funding early in their careers.
As an early career researcher getting exposure to celiac research and being able to participate in projects that helped fuel a research career, I was incredibly lucky to be able to work with Ed and work on TEDDY and ASK. From an early career research standpoint, it's two things -- it's the funding and the exposure.
Describe the research you will do with the SSCD/Beyond Celiac grant.
The goal of the research that we are conducting is to evaluate screening-identified celiac disease. Are there complications associated with screening-identified celiac disease, is question one. We will be looking at both biological and psychosocial complications. Biological means any symptoms and results of lab tests while psychosocial includes quality of life, depression and anxiety.
We will be looking at screening-identified patients and comparing how they are after being treated with the gluten-free diet for a year.
A lot of screening-identified individuals wouldn't have been diagnosed otherwise. So, a potential benefit of mass screening is that we're able to identify these individuals, and then the question that follows that is do they have complications from their celiac disease and do those complications get better with treatment? On the flip side, after being treated with the gluten-free diet do things like psychosocial measures get worse? Do they have worse quality of life, worse anxiety?
Why is this study meaningful to celiac disease patients overall?
It's meaningful to be able to see if diagnosing earlier improves outcomes. When we do mass screening are we able to identify individuals sooner and are we able to help prevent complications or to treat complications associated with celiac disease? While it may not be pertinent to all patients right now, when they think back to their diagnosis, it might have been helpful to have been diagnosed earlier.
We usually assume that diagnosing celiac disease patients even when they are not having symptoms is a good thing. How does your research relate to that assumption?
I think it helps support that assumption. Most likely what we will find is that it is helpful to be diagnosed early even if you don’t have obvious symptoms. We are also thinking about the psychosocial aspects, and the effect that a gluten-free diet may have on things like quality of life or anxiety. Weighing that treatment effect with the potential benefits we see are really important when as we are thinking on a global policy level of whether mass screening for celiac disease should be recommended.
How do researchers and ultimately patients balance the positive effect on blood test and biopsy results and feeling better on the gluten-free diet with a negative effect on things like anxiety, depression and reduced quality of life?
We're trying to better study the balance of those two things. If we're seeing conflict between the two and the biological effects of screening-identified celiac disease is improved by treatment with a gluten- free diet but quality of life, anxiety, or depression are worse, that would argue for better psychosocial support in our clinics to help our patients. If we're really seeing biologic benefit, then that's an argument for treatment. But we really need to be able to support our patients if treating them is making things worse from a psychosocial standpoint.
Do you have a sense of what the best outcome of the research would be?
I think all possible outcomes from this research will be important because we're looking at the associated morbidity, which includes both biological and psychosocial effects. It's important to know if there is associated morbidity or not. I think we will see improvement treating this group of patients with the gluten-free diet, but if there is a negative result when we are screening for celiac disease on a more universal scale, it’s important to know that.
Do you hope to be able to provide evidence to the U.S. Preventive Services Task Force regarding general population screening for celiac disease?
My hope is that we will see improvement [in screening-identified children on a gluten-free diet], but if we don't then I think that that also helps provide evidence as well.
In the long run of your career what would you like to accomplish in celiac disease research?
How do we help with prevention? How do we help in the longer term? Potentially, can we find options for patients other than the gluten-free diet, particularly those who are identified by screening and maybe didn't even realize that they had symptoms to begin with?
We have talked a lot about your work, but can you tell me a little bit about yourself outside of your work?
I met my husband during fellowship, and so I just got married in September in Colorado, which was a lot of fun for my family and friends who are mostly on the East Coast. And I have two dogs that I'm absolutely obsessed with, Wrigley and Brand.
I love running. I did the Chicago Marathon in my fourth year of medical school. I've now done three marathons and many more half-marathons. It's a fun way to stay healthy and a really great way to help relieve stress as well. I really enjoy cooking. I also find that to be a great stress reliever.
Have you ever tried gluten-free cooking?
I do not have celiac disease, but I do think it's important to try to understand what the patients you see in clinic are going through. So, I did go gluten-free just for a month to get a better idea of the barriers that patients run into at home and when they're eating out. During that time period I really did stick to a strict gluten-free diet. I would call restaurants ahead of time. I wanted to get the full idea of what it was truly like to live on a gluten-free diet.
With that said, at the end of a month I was able to go off the diet, so I understand that it's not the same thing. But at least it gave me some idea of the things people struggle with. And I got to try different gluten-free foods. At Round Up River camp they make a pumpkin cookie that is gluten-free and tastes like a muffin top because it’s very soft. It’s still one of my favorite things to make.
*Edited for length and clarity