Where Is Celiac Disease Coming From and Why?

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In 1975, Charlotte Anderson, in her classic textbook on Paediatric Gastroenterology, wrote that “The typical child with celiac disease is usually fair-haired and blue-eyed…” (1). Pioneer epidemiologic studies apparently enforced the concept of the “white face of CD” by reporting the highest world incidence of celiac disease (CD) from Western Ireland, Austria and Sweden (2). Like snow in the sun, these views melted away in the light of the subsequent developments of CD epidemiology.Sensitive serological tools for CD screening (first the antigliadin antibodies, and then the antiendomysial EMA and antitransglutaminase antibodies) became available during the 1980s and 1990s. Disease frequency could then be mapped in terms of prevalence (ratio of affected individuals to overall population) rather than incidence (new diagnoses per unit population per year), as even atypical and silent cases of CD were disclosed by serological screening. Not only was it demonstrated that CD is one of the most common, lifelong disorders affecting around 1% of the general population in Europe (3-4) and other countries of mostly European origin such as the USA (5), Argentina (6), Brazil (7) and Australia (8), but the celiac condition was also unexpectedly found to be frequent in several developing countries populated by non-Caucasian individuals. The Saharawi is a black-eyed, black-haired African population of Arab-Berber origin living in the Western Sahara. They hold the sad Guinness record of the highest CD frequency in the world: 5.6%, which is almost five to ten times the frequency observed in Europe (9). In Saharawi children the predominant clinical picture of CD is typical and the risk of dying from severe diarrhoea and dehydration is considerable, especially during the summer. CD is being more and more frequently recognized in India where presentation in children is usually “hypertypical” with chronic diarrhoea, anaemia and stunting (10).In this issue of the Journal, Imanzadeh, et al. from the Mofid Children's Hospital of Tehran, Iran, report that CD is a common finding among Iranian children admitted to the hospital because of chronic diarrhea (11). This disorder was diagnosed in 6.5% of 825 cases investigated during the years 1997-2003. It is noteworthy that the frequency of CD was also elevated (0.8%) in the control group (825 age- and sex-matched children). The mean age of the study-group was high (8.5 years), suggesting that many of these cases presented with a longstanding history. The clinical picture was characterized by the typical pattern of gastrointestinal symptoms (chronic diarrhoea, weight loss, vomiting, etc), laboratory (iron deficiency, sometimes elevated aminotransferase levels plus EMA positivity), and biopsy findings (severe villous atrophy in most cases or, less frequently, a minimal change enteropathy). Most patients (87%) showed an excellent clinical and laboratory response after only 6 months of treatment with the gluten-free diet (GFD).The interest in CD is currently very high in Iran. Specific sessions were dedicated to this condition at the 2001 and 2003 Meetings of the Iranian Society for Gastroenterology. Other published works have shown that CD is a primary health problem in that country, both in children and in adults. One of the highest world prevalences of CD in blood donors was recently found in 2,000 apparently healthy urban Iranian blood donors (1:166) by Shahbazkhani, et al. (12). The same, very active, “Teheran group” also reported an increased prevalence of CD in 250 patients with type 1 diabetes (2.4%) (13), in adults with irritable bowel syndrome-like symptoms (12%) (14), and again in 100 children with chronic diarrhoea (20%) (15). In a recent review, Rostami et al. underlined that wheat has been a major component of the Iranian diet for many centuries.

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