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Gatti S, Rubio-Tapia A, Makharia G, Catassi C. Patient and Community Health Global Burden in a World With More Celiac Disease. Gastroenterology 2024; 167:23-33. [PMID: 38309629 DOI: 10.1053/j.gastro.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/21/2024] [Accepted: 01/22/2024] [Indexed: 02/05/2024]
Abstract
Celiac disease is one of the most common life-long disorders worldwide, with a prevalence mostly ranging between 0.7% and 2.9% in the general population and a higher frequency in females and well-defined at-risk groups, such as relatives of affected individuals and patients with autoimmune comorbidities. Increasing clinical detection is facilitated by improving awareness, implementation of a case-finding approach, and serology availability for screening at-risk patients, among other factors. Nevertheless, due to huge clinical variability, many celiac disease cases still escape diagnosis in most countries, unless actively searched by proactive policies. The burden of celiac disease is increasing, as is the need for better longitudinal care. Pediatric screening of the general population could represent the road ahead for an efficient intervention of secondary prevention aimed to reduce the social and health burden of celiac disease. This review analyses the epidemiology of celiac disease continent by continent, discusses current strategies to improve the detection of celiac disease, and highlights challenges related to the burden of celiac disease globally.
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Affiliation(s)
- Simona Gatti
- Department of Pediatrics, Polytechnic University of Marche, Ancona, Italy
| | - Alberto Rubio-Tapia
- Celiac Disease Program, Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Carlo Catassi
- Department of Pediatrics, Polytechnic University of Marche, Ancona, Italy.
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Stahl MG, Pan Z, Germone M, Nagle S, Mehta P, Shull M, Griffith I, Shuler B, Hoffenberg E, Taki I, Geno-Rasmussen C, Rewers MJ, Norris JM, Liu E. One-Year Outcomes Among Children Identified With Celiac Disease Through a Mass Screening Program. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00352-5. [PMID: 38615728 DOI: 10.1016/j.cgh.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/02/2024] [Accepted: 03/11/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND & AIMS Celiac disease (CD) mass screening remains controversial in part because of a paucity of data to support its benefit. The Autoimmunity Screening for Kids study is a mass screening study for pediatric CD and type 1 diabetes in Colorado. METHODS This study prospectively follows up children ages 1 to 17 years who screened positive for tissue transglutaminase IgA autoantibodies in the Autoimmunity Screening for Kids study subsequently referred for diagnostic evaluation. Children diagnosed with CD by biopsy or serologic criteria were included in this study. Evaluation at baseline and 12 month follow-up evaluation included demographics, laboratory studies, symptoms, health-related quality of life, anxiety/depression, and gluten-free diet adherence. Paired Student t test, chi-square, and Wilcoxon sign rank tests compared baseline and follow-up data. For symptom scores, odds of improvement were assessed. RESULTS Of the 52 children with CD enrolled, 42 children completed 12-month follow-up evaluation. On the symptom questionnaire completed at diagnostic evaluation, 38 of 42 children reported 1 or more symptoms. CD mean symptom severity and frequency scores improved from baseline to follow-up evaluation (P < .001). Reported health-related quality of life scores improved among caregivers (P = .002). There was no significant change in reported anxiety or depression. Iron deficiency without anemia was common at baseline (21 of 24 children; 87.5%) and normalized at follow-up evaluation (11 of 21 children; 52.3%). Twenty-six of 28 families reported good or excellent gluten-free diet adherence. CONCLUSIONS This novel study of children with CD identified through a mass screening program demonstrated improvement in symptoms, quality of life, and iron deficiency after 1 year follow-up evaluation. This demonstrates that there may be benefit to CD mass screening.
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Affiliation(s)
- Marisa G Stahl
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Zhaoxing Pan
- Child Health Research Biostatistics Core, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Monique Germone
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sadie Nagle
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Pooja Mehta
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mary Shull
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Isabel Griffith
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brianne Shuler
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Edward Hoffenberg
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Iman Taki
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Cristy Geno-Rasmussen
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Marian J Rewers
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jill M Norris
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Edwin Liu
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Stahl M, Koletzko S, Andrén Aronsson C, Lindfors K, Liu E, Agardh D. Coeliac disease: what can we learn from prospective studies about disease risk? THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:63-74. [PMID: 37972632 PMCID: PMC10965251 DOI: 10.1016/s2352-4642(23)00232-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 11/19/2023]
Abstract
Paediatric prospective studies of coeliac disease with longitudinal collection of biological samples and clinical data offer a unique perspective on disease risk. This Review highlights the information now available from international paediatric prospective studies on genetic and environmental risk factors for coeliac disease. In addition, recent omics studies have made it possible to study complex interactions between genetic and environmental factors and thereby further our insight into the causes of the disease. In the future, paediatric prospective studies will be able to provide more detailed risk prediction models combining genes, the environment, and biological corroboration from multiomics. Such studies could also contribute to biomarker development and an improved understanding of disease pathogenesis.
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Affiliation(s)
- Marisa Stahl
- Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Sibylle Koletzko
- Department of Pediatrics, Dr von Hauner Kinderspital, LMU University Hospital, LMU Munich, Munich, Germany; Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Carin Andrén Aronsson
- Unit of Celiac Disease and Diabetes, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Katri Lindfors
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Edwin Liu
- Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel Agardh
- Unit of Celiac Disease and Diabetes, Department of Clinical Sciences, Lund University, Malmö, Sweden
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Shuler B, Liu E, Stahl MG. Population level screening for celiac disease: is now the time? Curr Opin Gastroenterol 2023; 39:455-462. [PMID: 37678180 DOI: 10.1097/mog.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW As incidence and prevalence of celiac disease is increasing, subclinical and asymptomatic presentations are more commonly identified through celiac disease screening. However, the United States Preventive Services Task Force released a statement in 2017 maintaining that there is insufficient evidence to recommend general population screening for celiac disease for asymptomatic individuals. This review summarizes the current available evidence on celiac disease screening. RECENT FINDINGS Literature demonstrates that by limiting screening to individuals with recognized symptoms, celiac disease diagnosis is frequently delayed or missed entirely. Most individuals with screening-identified celiac disease have previously unrecognized symptoms that improve through treatment with a gluten-free diet. Screening-identified individuals also demonstrate signs of impaired nutrition, growth, bone health, and quality of life which improve with treatment. Overall, celiac disease screening is viewed favorably by those identified through celiac disease screening programs. SUMMARY Individuals with screening-identified celiac disease may still incur complications from untreated disease and receive benefit from treatment with a gluten-free diet. More data is needed to determine the cost effectiveness of different mass screening approaches that incorporate the societal perspective towards screening.
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Affiliation(s)
- Brianne Shuler
- Digestive Health Institute, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Jansson-Knodell CL, Celdir MG, Hujoel IA, Lyu R, Gardinier D, Weekley K, Prokop LJ, Rubio-Tapia A. Relationship between gluten availability and celiac disease prevalence: A geo-epidemiologic systematic review. J Gastroenterol Hepatol 2023; 38:1695-1709. [PMID: 37332011 DOI: 10.1111/jgh.16260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/04/2023] [Accepted: 05/31/2023] [Indexed: 06/20/2023]
Abstract
Celiac disease is a global disease requiring genetic susceptibility and gluten exposure to trigger immune-mediated enteropathy. The effect of the degree of gluten-containing grain availability on celiac disease prevalence is unknown. Our objective was to compare country-based gluten availability to celiac prevalence using a systematic literature review. We searched MEDLINE, Embase, Cochrane, and Scopus until May 2021. We included population-based serum screening with confirmatory testing (second serological study or small intestine biopsy) and excluded specific, high-risk, or referral populations. We determined country-specific gluten availability using the United Nations food balance for wheat, barley, and rye. Human leukocyte antigen (HLA) frequencies were obtained from allelefrequencies.net. The primary outcome was association between gluten-containing grain availability and celiac disease prevalence. Generalized linear mixed models method with Poisson's link was used for analysis. We identified 5641 articles and included 120 studies on 427 146 subjects from 41 countries. Celiac disease prevalence was 0-3.1%, median 0.75% (interquartile range 0.35, 1.22). Median wheat supply was 246 g/capita/day (interquartile range 214.8, 360.7). The risk ratio (RR) for wheat availability on celiac disease was 1.002 (95% confidence interval [CI]: 1.0001, 1.004, P = 0.036). A protective association was seen with barley, RR 0.973 (95% CI: 0.956, 0.99, P = 0.003), and rye, RR 0.989 (95% CI: 0.982, 0.997, P = 0.006). The RR for gross domestic product on celiac disease prevalence was 1.009 (95% CI: 1.005, 1.014, P < 0.001). The RR for HLA-DQ2 was 0.982 (95% CI: 0.979, 0.986, P < 0.001), and that for HLA-DQ8 was 0.957 (95% CI: 0.950, 0.964, P < 0.001). In this geo-epidemiologic study, gluten-containing grain availability showed mixed associations with celiac disease prevalence.
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Affiliation(s)
- Claire L Jansson-Knodell
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melis G Celdir
- Department of Gastroenterology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Isabel A Hujoel
- Department of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Gardinier
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kendra Weekley
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, USA
| | - Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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van der Velde LA, Beth SA, Voortman T, van Zelm MC, Moll HA, Kiefte-de Jong JC. Anti-tissue transglutaminase antibodies (TG2A) positivity and the risk of vitamin D deficiency among children - a cross-sectional study in the generation R cohort. BMC Pediatr 2023; 23:286. [PMID: 37286940 DOI: 10.1186/s12887-023-04041-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 04/27/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Suboptimal vitamin D status is common in people with celiac disease (CeD), a disease that can be characterized by the presence of serum anti-tissue transglutaminase antibodies (TG2A) (i.e., TG2A positivity). To date, it remains unclear whether childhood TG2A positivity is associated with vitamin D status and how this potential association can be explained by other factors than malabsorption only, since vitamin D is mainly derived from exposure to sunlight. The aim of our study was therefore to assess whether childhood TG2A positivity is associated with vitamin D concentrations, and if so, to what extent this association can be explained by sociodemographic and lifestyle factors. METHODS This cross-sectional study was embedded in the Generation R Study, a population-based prospective cohort. We measured serum anti-tissue transglutaminase antibodies (TG2A) concentrations and serum 25-hydroxyvitamin D (25(OH)D) concentrations of 3994 children (median age of 5.9 years). Children with serum TG2A concentrations ≥ 7 U/mL were considered TG2A positive. To examine associations between TG2A positivity and 25(OH)D concentrations, we performed multivariable linear regression, adjusted for sociodemographic and lifestyle factors. RESULTS Vitamin D deficiency (serum 25(OH)D < 50 nmol/L) was found in 17 out of 54 TG2A positive children (31.5%), as compared to 1182 out of 3940 TG2A negative children (30.0%). Furthermore, TG2A positivity was not associated with 25(OH)D concentrations (β -2.20; 95% CI -9.72;5.33 for TG2A positive vs. TG2A negative children), and this did not change after adjustment for confounders (β -1.73, 95% CI -8.31;4.85). CONCLUSIONS Our findings suggest there is no association between TG2A positivity and suboptimal vitamin D status in the general pediatric population. However, the overall prevalence of vitamin D deficiency in both populations was high, suggesting that screening for vitamin D deficiency among children, regardless of TG2A positivity, would be beneficial to ensure early dietary intervention if needed.
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Affiliation(s)
- Laura A van der Velde
- Health Campus The Hague/Department of Public Health and Primary Care, Leiden University Medical Center, The Hague, The Netherlands
| | - Sanne A Beth
- The Generation R Study Group, Erasmus MC, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC, Rotterdam, The Netherlands
| | - Trudy Voortman
- The Generation R Study Group, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Menno C van Zelm
- Department of Immunology and Pathology, Central Clinical School, Monash University and Alfred Health, Melbourne, Australia
| | - Henriette A Moll
- The Generation R Study Group, Erasmus MC, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC, Rotterdam, The Netherlands
| | - Jessica C Kiefte-de Jong
- Health Campus The Hague/Department of Public Health and Primary Care, Leiden University Medical Center, The Hague, The Netherlands.
- Department of Pediatrics, Erasmus MC, Rotterdam, The Netherlands.
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.
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Meijer CR, Auricchio R, Putter H, Castillejo G, Crespo P, Gyimesi J, Hartman C, Kolacek S, Koletzko S, Korponay-Szabo I, Ojinaga EM, Polanco I, Ribes-Koninckx C, Shamir R, Szajewska H, Troncone R, Villanacci V, Werkstetter K, Mearin ML. Prediction Models for Celiac Disease Development in Children From High-Risk Families: Data From the PreventCD Cohort. Gastroenterology 2022; 163:426-436. [PMID: 35487291 DOI: 10.1053/j.gastro.2022.04.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 03/31/2022] [Accepted: 04/15/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Screening for celiac disease (CD) is recommended in children with affected first-degree relatives (FDR). However, the frequency of screening and at what age remain unknown. The aims of this study were to detect variables influencing the risk of CD development and develop and validate clinical prediction models to provide individualized screening advice. METHODS We analyzed prospective data from the 10 years of follow-up of the PreventCD-birth cohort involving 944 genetically predisposed children with CD-FDR. Variables significantly influencing the CD risk were combined to determine a risk score. Landmark analyses were performed at different ages. Prediction models were created using multivariable Cox proportional hazards regression analyses, backward elimination, and Harrell's c-index for discrimination. Validation was done using data from the independent NeoCel cohort. RESULTS In March 2019, the median follow-up was 8.3 years (22 days-12.0 years); 135/944 children developed CD (mean age, 4.3 years [range, 1.1-11.4]). CD developed significantly more often in girls (P = .005) and in Human Leukocyte Antigen (HLA)-DQ2 homozygous individuals (8-year cumulative incidence rate of 35.4% vs maximum of the other HLA-risk groups 18.2% [P < .001]). The effect of homozygosity DR3-DQ2/DR7-DQ2 on CD development was only present in girls (interaction P = .04). The prediction models showed good fit in the validation cohort (Cox regression 0.81 [0.54]). To calculate a personalized risk of CD development and provide screening advice, we designed the Prediction application https://hputter.shinyapps.io/preventcd/. CONCLUSION Children with CD-FDR develop CD early in life, and their risk depends on gender, age and HLA-DQ, which are all factors that are important for sound screening advice. These children should be screened early in life, including HLA-DQ2/8-typing, and if genetically predisposed to CD, they should get further personalized screening advice using our Prediction application. TRIAL REGISTRATION NUMBER ISRCTN74582487 (https://www.isrctn.com/search?q=ISRCTN74582487).
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Affiliation(s)
- Caroline R Meijer
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands.
| | - Renata Auricchio
- Translational Medical Sciences and European Laboratory for the Investigation of Food-Induced Disease, University of Naples Federico II, Naples, Italy
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Gemma Castillejo
- Pediatric Gastroenterology Unit, Hospital Universitario Sant Joan de Reus, Reus, Spain
| | - Paula Crespo
- ADViSE, Department of Health Sciences, European University Miguel de Cervantes, Hospital Recoletas Campo Grande, Valladolid, Spain
| | - Judit Gyimesi
- Coeliac Disease Centre, Heim Pál National Paediatric Institute, Budapest, Hungary
| | - Corina Hartman
- Institute for Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Sanja Kolacek
- Referral Center Pediatric Gastroenterology and Nutrition, Zagreb University, Medical School, Zagreb, Croatia
| | - Sibylle Koletzko
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany; Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Ilma Korponay-Szabo
- Coeliac Disease Centre, Heim Pál National Paediatric Institute, Budapest, Hungary
| | - Eva Martinez Ojinaga
- Pediatric Gastroenterology and Nutrition, La Paz University Hospital, Madrid, Spain
| | - Isabel Polanco
- Pediatric Gastroenterology and Nutrition, La Paz University Hospital, Madrid, Spain
| | | | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Hania Szajewska
- Pediatrics, Warsaw, Medical University of Warsaw, Warsaw, Poland
| | - Riccardo Troncone
- Translational Medical Sciences and European Laboratory for the Investigation of Food-Induced Disease, University of Naples Federico II, Naples, Italy
| | | | - Katharina Werkstetter
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany
| | - M Luisa Mearin
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
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Gunnarsdottir S, Albrektsson H, Frydebo J, Miron N, Kindblom JM, Størdal K, Mårild K. Celiac disease screening at a pediatric outpatient clinic: a feasibility study. Scand J Gastroenterol 2022; 57:912-920. [PMID: 35361050 DOI: 10.1080/00365521.2022.2050292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Celiac disease (CD) is a common yet largely underdiagnosed disease. This study aimed to test the feasibility of incorporating a non-targeted CD screening in a pediatric outpatient setting and evaluate its short-term impact on children with serological evidence of disease. METHODS Over five months, 500 children (aged 2-17 years) attending a general pediatric outpatient clinic in Gothenburg, Sweden, were enrolled and surveyed for current symptoms, quality of life, and background characteristics; 481 children were screened for tissue-transglutaminase antibodies (tTGA); repeated tTGA-positivity was defined as CD autoimmunity (CDA). Children with CDA were investigated for CD and for one year monitored for changes in symptoms, and quality of life. RESULTS Eleven of 481 (2.3%) screened children had CDA. Children with CDA were younger (median 3.8 years) than those without CDA (8.8 years). No other major between-group differences were reported in background characteristics, symptoms, or quality of life. The screening was well-accepted by the families/participants. During 1-year follow-up, 8 of 11 children with CDA were diagnosed with CD. Children with screening-detected CD reported no significant changes in symptoms and quality of life and the dietary adherence rate was good. CONCLUSIONS Non-targeted screening for CD was feasible in a general pediatric outpatient setting. While hampered by small sample size, our results are in line with previous screening studies indicating that symptoms do not differentiate CDA from non-CDA children. Also, among an overall minimal-symptomatic group of children, diagnosing CD and installation of treatment did not significantly change their well-being during 1-year follow-up.
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Affiliation(s)
- Sunna Gunnarsdottir
- Department of Pediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | | | - Julia Frydebo
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Nicolae Miron
- Department of Clinical Immunology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jenny M Kindblom
- Department of internal medicine and clinical nutrition, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Pediatric Clinical Research Center, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Ketil Størdal
- Department of Pediatric Research, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Karl Mårild
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Pediatric Gastroenterology, Queen Silvia Children's Hospital, Gothenburg, Sweden
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Légeret C, Furlano R, Stienen Y, Köhler H. Coeliac disease: Evaluation of diagnosis in children and teenagers. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2021; 167:1-5. [PMID: 34815196 DOI: 10.1016/j.zefq.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Coeliac disease is no longer a rare disease, but has a rising prevalence, especially in children, with a shift from malabsorption syndrome to a more subtle presentation. Therefore, European guidelines regarding the diagnosis of coeliac disease were changed in 2012. If laboratory tests are positive, children can now be diagnosed without performing an endoscopy. The aim of this study was to characterize the Swiss patients, who have been diagnosed with coeliac disease. METHODS This is a retrospective study of Swiss paediatric patients who have been diagnosed with coeliac disease according to European guidelines between 01/2011 and 11/2020. The data needed was extracted from medical records. RESULTS A total of 369 children were included in the study. The main complain was abdominal pain (118; 32%), followed by failure to thrive/gain weight (92; 24.9%). 10% (37/367) of all patients had no symptoms at all. In 72.6% (268/369) of all patients, an endoscopy was performed due to lower antibodies. Mean values for ferritin, vitamins D and B12 as well as folic acid were within normal range. CONCLUSION In our cohort of patients, females were clearly more often affected and also showed a small deviation in height and weight. Our finding of 10% of all patients having no symptoms at all is in line with other studies observing a decline in symptoms. A complicating factor for the clinician is the fact that overall no vitamin deficiencies were detected. As the incidence continues to rise but the clinical presentation of coeliac disease is changing from a malabsorption syndrome to a silent disease, further observational studies are needed to monitor this trend.
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Affiliation(s)
- Corinne Légeret
- University Children's Hospital Basel, Paediatric Gastroenterology & Nutrition, Basel, Switzerland.
| | - Raoul Furlano
- University Children's Hospital Basel, Paediatric Gastroenterology & Nutrition, Basel, Switzerland
| | - Yvonne Stienen
- University Children's Hospital Basel, Paediatric Gastroenterology & Nutrition, Basel, Switzerland; Children's Hospital of Aarau, Tellstrasse 9, 5001, Aarau, Switzerland
| | - Henrik Köhler
- Children's Hospital of Aarau, Tellstrasse 9, 5001, Aarau, Switzerland
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Diagnosing Coeliac Disease During Mass-Screening of General Paediatric Population: Is Biopsy Avoidable? J Pediatr Gastroenterol Nutr 2021; 73:e63-e67. [PMID: 33938527 DOI: 10.1097/mpg.0000000000003164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Studies evaluating the correlation between tissue transglutaminase immunoglobulin antibody (TGA-IgA) levels and the degree of enteropathy in screening-detected coeliac disease (CD) patients from the general childhood population are scarce. The objectives of our study were to evaluate the correlation between the TGA-IgA titre and the degree of enteropathy and to evaluate whether the no-biopsy approach to diagnose CD in symptomatic patients proposed by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition could be extended to asymptomatic CD patients diagnosed during mass screening studies. METHODS The present study is a sub-study of a cross-sectional mass screening study, "Exploring the Iceberg of Coeliacs in Saudi Arabia", conducted among school-aged children (6-15 years) in 2014-2015. The 93 biopsy-confirmed CD patients constituted the study cohort of the present study (mean age 11.4 ± 2.6 years; 24 males). TGA-IgA titres and endomysial antibodies (EMA) at the time of biopsy and grade of enteropathy were assessed, and human leukocyte antigen DQ 2.2/2.5/8 genotyping was performed. RESULTS Thirty-four patients had TGA-IgA titres >10× upper limit of normal (ULN; 36%); all had villous atrophy with positive EMA and DQ 2.2/2.5/8. The sensitivity and specificity of a TGA-IgA titre >10× ULN in correctly diagnosing CD was 100%. There was a significant positive correlation between the anti-TGA-IgA titre and the severity of enteropathy (P < 0.001). There was no significant difference in the TGA-IgA titre between the asymptomatic and symptomatic CD patients. CONCLUSIONS Our results provide evidence that a TGA-IgA titre >10× ULN correlates with villous atrophy in CD patients detected by mass screening.
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Meijer-Boekel C, van den Akker M, van Bodegom L, Escher J, van Geloven N, van Overveld F, Rings EHH, Smit L, de Vries MC, Mearin ML. Early diagnosis of coeliac disease in the Preventive Youth Health Care Centres in the Netherlands: study protocol of a case finding study (GLUTENSCREEN). BMJ Paediatr Open 2021; 5:e001152. [PMID: 34466665 PMCID: PMC8359518 DOI: 10.1136/bmjpo-2021-001152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/02/2021] [Indexed: 01/02/2023] Open
Abstract
Introduction Coeliac disease (CD) occurs in 1% of the population, develops early in life and is severely underdiagnosed. Undiagnosed and untreated disease is associated with short-term and long-term complications. The current healthcare approach is unable to solve the underdiagnosis of CD and timely diagnosis and treatment is only achieved by active case finding. Aim: to perform a case finding project to detect CD children who visit the Youth Health Care Centres (YHCCs) in a well-described region in the Netherlands to evaluate whether it is feasible, cost-effective and well accepted by the population. Methods/analysis Prospective intervention cohort study. Parents of all children aged 12 months and 4 years attending the YHCCs for a regular visit are asked whether their child has one or more CD-related symptoms from a standardised list. If so, they will be invited to participate in the case finding study. After informed consent, a point of care test (POCT) to assess CD-specific antibodies against tissue transglutaminase (TG2A) is performed onsite the YHCCs. If the POCT is positive, CD is highly suspected and the child will be referred to hospital for definitive diagnosis according to the Guideline Coeliac Disease of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition guideline. Main outcomes Incidence rate of new CD diagnoses in the study region in comparison to the one in the same age diagnosed by standard of care in the rest of the Netherlands.Feasibility and cost-effectiveness of active CD case finding at the YHCCs. All costs of active case finding, diagnostics and treatment of CD and the potential short-term and long-term consequences of the disease will be calculated for the setting with and without case finding.Ethical acceptability: by questionnaires on parental and healthcare professionals' satisfaction.A statistical analysis plan was prepared and is published on the GLUTENSCREEN website (Statistical-Analysis-Plan-11-5-2021_def.pdf (glutenscreen.nl) and added as annex 1). Ethics and dissemination The Medical Ethics Committee Leiden approved this study. If we prove that case finding at the YHCC is feasible, cost-effective and well accepted by the population, implementation is recommended. Trial registration number NL63291.058.17.
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Affiliation(s)
- Caroline Meijer-Boekel
- Paediatric Gastroenterology, Leiden University Medical Center, Leiden, Zuid Holland, The Netherlands
| | - M.Elske van den Akker
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Leti van Bodegom
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Johanna Escher
- Paediatric Gastroenterology, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Nan van Geloven
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | | | - Edmond H H.M Rings
- Paediatric Gastroenterology, Leiden University Medical Center, Leiden, Zuid Holland, The Netherlands
| | - Lucy Smit
- Youth Health Care Centre, Kennemerland, The Netherlands
| | - Martine Charlotte de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - M. Luisa Mearin
- Paediatric Gastroenterology, Leiden University Medical Center, Leiden, Zuid Holland, The Netherlands
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Payne K, Ramharack L, Bierly P, Feigenbaum K, Steinhoff J, Hlywiak K, Farrara A, Verma R, Singh A, Fahey LM. Repeat Biopsy to Assess Duodenal Healing in Children With Celiac Disease and Eosinophilic Gastrointestinal Disorders. JPGN REPORTS 2021; 2:e097. [PMID: 37205963 PMCID: PMC10191486 DOI: 10.1097/pg9.0000000000000097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/21/2021] [Indexed: 05/21/2023]
Abstract
The aim of the study was to determine the correlation between duodenal mucosal biopsies and tissue transglutaminase immunoglobulin A (tTG-IgA) levels in pediatric patients with biopsy-confirmed celiac disease (CD) and eosinophilic gastrointestinal disorders (EGID) who have had repeat duodenal biopsies after initiating a gluten-free diet. Methods A retrospective chart review was performed of children with CD and EGID seen at the Children's Hospital of Philadelphia between 2003 and 2018. Data collected included duodenal biopsy pathology, celiac serology including tTG-IgA, and symptom reports. Duodenal healing was defined as normal villous architecture and no intraepithelial lymphocytes. These data were compared with tTG-IgA level. Data were analyzed with Fisher exact test and t test methods. Results Thirty-nine patients had normal IgA and diagnoses of both CD and EGID. At second biopsy, 44% (17/39) of patients showed no histologic evidence of active CD and 36% (14/39) of patients had negative tTG-IgA values. Sixty percent (9/15) of patients with no evidence of CD on biopsy had abnormal tTG-IgA levels, and 57% (8/14) of patients with normal tTG-IgA levels had evidence of active disease on biopsy. Conclusions The data show that an abnormal tTG-IgA drawn after initiation of a gluten-free diet is not correlated with duodenal mucosal injury in pediatric patients with CD and EGID. This suggests that serologic surveillance with tTG-IgA is not sufficient to monitor CD intestinal healing in this patient cohort. Persistent elevations of tTG-IgA in CD patients with normal duodenal biopsies should prompt investigation into other potential causes.
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Affiliation(s)
- Kaitlin Payne
- From the Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lydia Ramharack
- From the Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Patricia Bierly
- From the Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kara Feigenbaum
- From the Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Janel Steinhoff
- From the Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karen Hlywiak
- From the Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ann Farrara
- From the Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ritu Verma
- University of Chicago, Pediatric Gastroenterology, Hepatology, and Nutrition, Chicago, Illinois
| | - Arunjot Singh
- From the Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lisa M. Fahey
- From the Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Roberts SE, Morrison-Rees S, Thapar N, Benninga MA, Borrelli O, Broekaert I, Dolinsek J, Martin-de-Carpi J, Mas E, Miele E, Pienar C, Ribes-Koninckx C, Thomassen RA, Thomson M, Tzivinikos C, Thorne K, John A, Williams JG. Systematic review and meta-analysis: the incidence and prevalence of paediatric coeliac disease across Europe. Aliment Pharmacol Ther 2021; 54:109-128. [PMID: 34115894 DOI: 10.1111/apt.16337] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 09/30/2020] [Accepted: 03/04/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coeliac disease is one of the most prevalent immune-mediated gastrointestinal disorders in children. AIM To review the incidence and prevalence of paediatric coeliac disease, and their trends, regionally across Europe, overall and according to age at diagnosis. METHODS Systematic review and meta-analysis from January 1, 1950 to December 31, 2019, based on PubMed, CINAHL and the Cochrane Library, searches of grey literature and websites and hand searching of reference lists. A total of 127 eligible studies were included. RESULTS The prevalence of previously undiagnosed coeliac disease from screening surveys (histology based) ranged from 0.10% to 3.03% (median = 0.70%), with a significantly increasing annual trend (P = 0.029). Prevalence since 2000 was significantly higher in northern Europe (1.60%) than in eastern (0.98%), southern (0.69%) and western (0.60%) Europe. Large increases in the incidence of diagnosed coeliac disease across Europe have reached 50 per 100 000 person-years in Scandinavia, Finland and Spain. The median age at diagnosis increased from 1.9 years before 1990 to 7.6 since 2000. Larger increases in incidence were found in older age groups than in infants and ages <5 years. CONCLUSIONS Paediatric coeliac disease incidence and prevalence have risen across Europe and appear highest in Scandinavia, Finland and Spain. The most recent evidence shows large increases in incidence in most regions, but stabilisation in some (notably Sweden and Finland). Sharp increases in the age at diagnosis may reflect increases in milder and asymptomatic cases diagnosed since reliable serology testing became widely used, through endomysial antibodies after 1990 and tissue transglutaminase antibodies around 2000.
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Miró M, Alonso-Garrido M, Lozano M, Peiró J, Manyes L. Adherence to dietary treatment and clinical factors associated with anti-transglutaminase antibodies in celiac disease during the follow-up. Heliyon 2021; 7:e06642. [PMID: 33889773 PMCID: PMC8047491 DOI: 10.1016/j.heliyon.2021.e06642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/30/2021] [Accepted: 03/26/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION In clinical practice, celiac disease (CD) is monitored through anti-transglutaminase (TGA-IgA) antibody levels. The normalization of serum levels in successive periodic measurements indicates good response and adherence to dietary treatment. OBJECTIVES To evaluate the factors associated with the evolution of TGA-IgA antibodies and their association with dietary non-compliance and diseases related to CD. METHODS This prospective observational study was carried out in 254 participants, who were recruited from patients from a hospital in southern Spain. Information about sex, age, serological test results, HLA DQ2/DQ8 haplotypes, mucosal atrophy, gastrointestinal and extra-intestinal symptoms, as well as diagnosis of diseases related to CD, was collected. RESULTS Clinical manifestations, such as diarrhoea, abdominal pain and weight loss, showed differences according to sex and age. Children under 18 years of age presented a degree of total or severe atrophy of the intestinal villi. TGA-IgA antibodies concentrations were directly associated with the number of digestive disorders manifested by the patient and the record of dietary non-compliance and inversely related to the number of extra-digestive disorders. CONCLUSIONS Adolescents between 12 and 18 years old were the least monitored as well as the group with more extra-intestinal symptoms reported. Therefore, it is necessary to develop strategies in clinical practice aimed at this population group and continuous monitoring should be implemented to improve life quality and reduce complications that may arise in the long term.
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Affiliation(s)
- Marta Miró
- Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine Department, Universitat de València, Valencia, Spain
| | - Manuel Alonso-Garrido
- Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine Department, Universitat de València, Valencia, Spain
| | - Manuel Lozano
- Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine Department, Universitat de València, Valencia, Spain
- Epidemiology and Environmental Health Joint Research Unit, FISABIO−Universitat Jaume I−Universitat de València, Valencia, Spain
| | - Juanjo Peiró
- Department of Statistics and Operations Research, University of Valencia, Valencia, Spain
| | - Lara Manyes
- Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine Department, Universitat de València, Valencia, Spain
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Abstract
OBJECTIVES During the past decades, there has been a shift in the clinical presentation of coeliac disease (CD) to nonclassical, oligosymptomatic, and asymptomatic forms. We assessed clinical presentation of CD in children and adolescents in Central Europe. METHODS Paediatric gastroenterologists in 5 countries retrospectively reported data of their patients diagnosed with CD. Clinical presentation was analyzed and the differences among very young (<3 years) and older children and adolescents were studied. RESULTS Data from 653 children and adolescents (median age 7 years 2 months; 63.9% girls) from Croatia, Germany, Hungary, Italy, and Slovenia were available for the analysis. One fifth (N = 134) of all children were asymptomatic. In symptomatic children, the most common leading symptom was abdominal pain (33.3%), followed by growth retardation (13.7%) and diarrhoea (13.3%). The majority of symptomatic children (47.6%; N = 247) were polysymptomatic. Abdominal pain was the most common symptom in polysymptomatic (66.4%) as well as in monosymptomatic children (29.7%). Comparing clinical presentation of CD in very young children (younger than 3 years) with older children (3 years or older), we found that symptoms and signs of malabsorption were significantly more common in younger (P < 0.001), whereas abdominal pain and asymptomatic presentation were more common in older children and adolescents (both P < 0.001). CONCLUSION In children with CD, abdominal pain has become the most common symptom. However, in younger children, symptoms of malabsorption are still seen frequently. This raises a question about the underlying mechanism of observed change in clinical presentation in favour of nonclassical presentation and asymptomatic disease at certain age.
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Nonbiopsy Approach for Celiac Disease Is Accurate When Using Exact Duodenal Histomorphometry: Prospective Study in 2 Countries. J Clin Gastroenterol 2021; 55:227-232. [PMID: 32301831 DOI: 10.1097/mcg.0000000000001349] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 03/01/2020] [Indexed: 01/13/2023]
Abstract
GOALS To test the accuracy of serology-based criteria for diagnosing celiac disease utilizing quantitative histomorphometry. BACKGROUND The revised European pediatric guidelines allow noninvasive celiac disease diagnosis for a subgroup of children. However, in some of the studies on this issue, the positive predictive value (PPV) of serology has remained suboptimal, possibly because of challenges of histopathology as the reference standard. STUDY Prospectively enrolled children with transglutaminase 2 antibodies (TGA) above the upper limit of normal (ULN) underwent blood sampling and duodenal biopsy in Finland and Romania. Those with TGA ≥10× ULN, positive endomysium antibodies (EmA), and disease-associated genetics were considered to fulfill triple criteria for celiac disease. Initial histopathologic analysis was conducted using grouped classification, whereupon centralized morphometry was performed. RESULTS Altogether 88 (54%) children were triple positive. In local evaluation, 99% of triple-positive children and 73% of children with TGA <10× ULN had celiac disease. These figures increased to 100% and 85% after more precise morphometric analysis. Triple-positive children had more anemia and higher median EmA and liver enzyme values than those with TGA<10× ULN; the groups were comparable in other clinical features and laboratory parameters. CONCLUSIONS When applied as recommended, the nonbiopsy strategy had already yielded excellent PPV regardless of the site of diagnosis or clinical presentation in the local analysis. PPV further increased to 100% with standardized duodenal morphometry.
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Meijer CR, Schweizer JJ, Peeters A, Putter H, Mearin ML. Efficient implementation of the 'non-biopsy approach' for the diagnosis of childhood celiac disease in the Netherlands: a national prospective evaluation 2010-2013. Eur J Pediatr 2021; 180:2485-2492. [PMID: 33856540 PMCID: PMC8285331 DOI: 10.1007/s00431-021-04068-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/11/2021] [Accepted: 04/04/2021] [Indexed: 01/11/2023]
Abstract
The aim of this study was (1) to prospectively evaluate the nationwide implementation of the ESPGHAN-guidelines for the diagnosis of celiac disease (CD), (2) to investigate the incidence and clinical presentation of diagnosed childhood CD (0-14 years) in the Netherlands, and (3) to compare the findings with national survey data from 1975 to 1990 and 1993 to 2000 using the same approach. From 2010 to 2013, all practicing paediatricians were invited to report new celiac diagnoses to the Dutch Pediatric Surveillance Unit. Data were collected via questionnaires. A total of 1107 children with newly diagnosed CD were reported (mean age, 5.8 years; range, 10 months-14.9 years; 60.5% female). After the introduction of the non-biopsy approach in 2012, 75% of the diagnoses were made according to the guideline with a significant decrease of 46.3% in biopsies. The use of EMA and HLA-typing significantly increased with 25.8% and 62.1%, respectively. The overall incidence rate of childhood CD was 8.8-fold higher than in 1975-1990 and 2.0-fold higher than in 1993-2000. During the study period, the prevalence of diagnosed CD was 0.14%, far below 0.7% of CD identified via screening in the general Dutch paediatric population. Clinical presentation has shifted towards less severe and extra-intestinal symptoms.Conclusion: ESPGHAN guidelines for CD diagnosis in children were effectively and rapidly implemented in the Netherlands. Incidence of diagnosed CD among children is still significantly rising with a continuous changing clinical presentation. Despite the increasing incidence of diagnoses, significant underdiagnosis still remains. What is Known: • Since 2000 the incidence of diagnosed childhood CD in the Netherlands has shown a steady rise. • The rise in incidence has been accompanied by a changing clinical presentation at diagnosis. What is New: • The ESPGHAN guidelines 2012 for CD diagnosis were effectively and rapidly implemented in the Netherlands. • The incidence of diagnosed childhood CD in the Netherlands has continued to rise significantly during the reported period.
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Affiliation(s)
- Caroline R. Meijer
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Joachim J. Schweizer
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anne Peeters
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - M. Luisa Mearin
- Department of Paediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Sharma N, Bhatia S, Chunduri V, Kaur S, Sharma S, Kapoor P, Kumari A, Garg M. Pathogenesis of Celiac Disease and Other Gluten Related Disorders in Wheat and Strategies for Mitigating Them. Front Nutr 2020; 7:6. [PMID: 32118025 PMCID: PMC7020197 DOI: 10.3389/fnut.2020.00006] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/20/2020] [Indexed: 12/12/2022] Open
Abstract
Wheat is a major cereal crop providing energy and nutrients to the billions of people around the world. Gluten is a structural protein in wheat, that is necessary for its dough making properties, but it is responsible for imparting certain intolerances among some individuals, which are part of this review. Most important among these intolerances is celiac disease, that is gluten triggered T-cell mediated autoimmune enteropathy and results in villous atrophy, inflammation and damage to intestinal lining in genetically liable individuals containing human leukocyte antigen DQ2/DQ8 molecules on antigen presenting cells. Celiac disease occurs due to presence of celiac disease eliciting epitopes in gluten, particularly highly immunogenic alpha-gliadins. Another gluten related disorder is non-celiac gluten-sensitivity in which innate immune-response occurs in patients along with gastrointestinal and non-gastrointestinal symptoms, that disappear upon removal of gluten from the diet. In wheat allergy, either IgE or non-IgE mediated immune response occurs in individuals after inhalation or ingestion of wheat. Following a life-long gluten-free diet by celiac disease and non-celiac gluten-sensitivity patients is very challenging as none of wheat cultivar or related species stands safe for consumption. Hence, different molecular biology, genetic engineering, breeding, microbial, enzymatic, and chemical strategies have been worked upon to reduce the celiac disease epitopes and the gluten content in wheat. Currently, only 8.4% of total population is affected by wheat-related issues, while rest of population remains safe and should not remove wheat from the diet, based on false media coverage.
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Affiliation(s)
- Natasha Sharma
- Agri-Food Biotechnology Laboratory, National Agri-Food Biotechnology Institute, Mohali, India
| | - Simran Bhatia
- Agri-Food Biotechnology Laboratory, National Agri-Food Biotechnology Institute, Mohali, India
| | - Venkatesh Chunduri
- Agri-Food Biotechnology Laboratory, National Agri-Food Biotechnology Institute, Mohali, India
| | - Satveer Kaur
- Agri-Food Biotechnology Laboratory, National Agri-Food Biotechnology Institute, Mohali, India
| | - Saloni Sharma
- Agri-Food Biotechnology Laboratory, National Agri-Food Biotechnology Institute, Mohali, India
| | - Payal Kapoor
- Agri-Food Biotechnology Laboratory, National Agri-Food Biotechnology Institute, Mohali, India
| | - Anita Kumari
- Agri-Food Biotechnology Laboratory, National Agri-Food Biotechnology Institute, Mohali, India
| | - Monika Garg
- Agri-Food Biotechnology Laboratory, National Agri-Food Biotechnology Institute, Mohali, India
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European Society Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for Diagnosing Coeliac Disease 2020. J Pediatr Gastroenterol Nutr 2020; 70:141-156. [PMID: 31568151 DOI: 10.1097/mpg.0000000000002497] [Citation(s) in RCA: 505] [Impact Index Per Article: 126.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The ESPGHAN 2012 coeliac disease (CD) diagnostic guidelines aimed to guide physicians in accurately diagnosing CD and permit omission of duodenal biopsies in selected cases. Here, an updated and expanded evidence-based guideline is presented. METHODS Literature databases and other sources of information were searched for studies that could inform on 10 formulated questions on symptoms, serology, HLA genetics, and histopathology. Eligible articles were assessed using QUADAS2. GRADE provided a basis for statements and recommendations. RESULTS Various symptoms are suggested for case finding, with limited contribution to diagnostic accuracy. If CD is suspected, measurement of total serum IgA and IgA-antibodies against transglutaminase 2 (TGA-IgA) is superior to other combinations. We recommend against deamidated gliadin peptide antibodies (DGP-IgG/IgA) for initial testing. Only if total IgA is low/undetectable, an IgG-based test is indicated. Patients with positive results should be referred to a paediatric gastroenterologist/specialist. If TGA-IgA is ≥10 times the upper limit of normal (10× ULN) and the family agrees, the no-biopsy diagnosis may be applied, provided endomysial antibodies (EMA-IgA) will test positive in a second blood sample. HLA DQ2-/DQ8 determination and symptoms are not obligatory criteria. In children with positive TGA-IgA <10× ULN at least 4 biopsies from the distal duodenum and at least 1 from the bulb should be taken. Discordant results between TGA-IgA and histopathology may require re-evaluation of biopsies. Patients with no/mild histological changes (Marsh 0/I) but confirmed autoimmunity (TGA-IgA/EMA-IgA+) should be followed closely. CONCLUSIONS CD diagnosis can be accurately established with or without duodenal biopsies if given recommendations are followed.
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Wahab RJ, Beth SA, Derks IPM, Jansen PW, Moll HA, Kiefte-de Jong JC. Celiac Disease Autoimmunity and Emotional and Behavioral Problems in Childhood. Pediatrics 2019; 144:peds.2018-3933. [PMID: 31492765 DOI: 10.1542/peds.2018-3933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Celiac disease (CeD) is associated with psychopathology in children. It is unknown whether this association is present in children with celiac disease autoimmunity (CDA) identified by screening. We examined the associations between subclinical CDA and emotional and behavioral problems in children without previous CeD diagnosis. METHODS In a population-based cohort study of 3715 children (median age: 6 years), blood titers of tissue transglutaminase autoantibodies were analyzed. CDA was defined as a measurement of tissue transglutaminase autoantibodies ≥7 U/mL (n = 51). Children with previous CeD diagnosis or children on a gluten-free diet, were excluded. The Child Behavior Checklist (CBCL) was filled in by parents and was used to assess behavioral and emotional problems of children at a median age of 5.9 years. Multiple linear regression models were applied to evaluate the cross-sectional associations between CDA and CBCL scores. Sensitivity analyses were done in a subgroup of children who were seropositive carrying the HLA antigen risk alleles for CeD. RESULTS In basic models, CDA was not associated with emotional and behavioral problems on the CBCL scales. After adjustment for confounders, CDA was significantly associated with anxiety problems (β = .29; 95% confidence interval 0.02 to 0.55; P = .02). After exclusion of children who did not carry the HLA-DQ2 and/or HLA-DQ8 risk alleles (n = 4), CDA was additionally associated with oppositional defiant problems (β = .35; 95% confidence interval 0.02 to 0.69). Associations were not explained by gastrointestinal complaints. CONCLUSIONS Our results reveal that CDA, especially combined with the HLA-DQ2 and HLA-DQ8 risk alleles, is associated with anxiety problems and oppositional defiant problems. Further research should be used to establish whether behavioral problems are a reflection of subclinical CeD.
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Affiliation(s)
- Rama J Wahab
- Generation R Study Group and.,Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Sytske A Beth
- Generation R Study Group and.,Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ivonne P M Derks
- Generation R Study Group and.,Departments of Child and Adolescent Psychiatry and Psychology and
| | - Pauline W Jansen
- Departments of Child and Adolescent Psychiatry and Psychology and.,Psychology, Education, and Child Studies, Erasmus University Rotterdam, Rotterdam, Netherlands; and
| | - Henriëtte A Moll
- Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jessica C Kiefte-de Jong
- Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands; .,Department of Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, The Hague, Netherlands
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Diagnosing Celiac Disease: Towards Wide-Scale Screening and Serology-Based Criteria? Gastroenterol Res Pract 2019; 2019:2916024. [PMID: 31467522 PMCID: PMC6701393 DOI: 10.1155/2019/2916024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 07/16/2019] [Indexed: 12/12/2022] Open
Abstract
Celiac disease is one of the most common food-related chronic disorders in children. Unfortunately, this multifaceted disease is challenging to recognize and remains markedly underdiagnosed. Screening of either known at-risk groups or even the whole population could increase the suboptimal diagnostic yield substantially. Many recent guidelines recommend screening of at least selected risk groups, but more wide-scale screening remains controversial. The increasing prevalence of celiac disease and the development of autoantibody assays have also led to a gradual shift in the diagnostics towards less invasive serology-based criteria in a subgroup of symptomatic children. The main open questions concern whether these criteria are applicable to all countries and clinical settings, as well as to adult patients. On the other hand, widening screening and the mistaken practice of initiating a gluten-free diet before the appropriate exclusion of celiac disease increase the number of borderline seropositive cases, which may also challenge the classical histopathological diagnostics. Sophisticated diagnostic methods and a deeper understanding of the natural history of early developing celiac disease may prove useful in these circumstances.
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Prevalence and Clinical Features of Celiac Disease in Healthy School-Aged Children. Dig Dis Sci 2019; 64:173-181. [PMID: 30311156 DOI: 10.1007/s10620-018-5320-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/03/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND/AIMS The aim of this study was to determine the prevalence of celiac disease (CD) in healthy school-aged children in the northern region of Cyprus and to investigate the existence of potential markers that may accompany CD. This is the first study to measure the prevalence of CD in the northern region of Cyprus. METHODS This study included 3792 school-aged children who were between the ages of 6 and 10 years between January 2015 and October 2016. CD was screened using total serum IgA, IgA anti-tissue transglutaminase (tTG), and IgA antiendomysial (EMA) antibodies. Subjects with selective IgA deficiency were further tested for IgG-tTG. Small intestinal biopsies were performed on all subjects with tTG antibody positivity. Risk factors and symptoms related to CD were evaluated using questionnaires in both the CD and control groups. RESULTS Of the 3792 subjects, 39 were antibody positive (IgA-tTG was positive only in 14 subjects, IgA-tTG plus IgA-EMA in 21 subjects, and IgG-tTG in 4 subjects). IgA deficiency was detected in 11 subjects (0.29%). IgG-tTG was positive in 4 subjects with IgA deficiency (36.3%). Intestinal biopsies were performed on 28 of the 39 seropositive subjects. The biopsy findings of 15 children were consistent with CD (IgA-tTG positive in 3, IgA-tTG and IgA-EMA positive in 10, and IgG-tTG positive in 2). Thus, biopsies confirmed CD in 1:256 children (0.39%). CONCLUSIONS Our study, which is the first study of school-aged children from the northern region of Cyprus, revealed that CD is a prevalent disease in this region.
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Will the Real Coeliac Disease Please Stand Up? Coeliac Disease Prevalence in the German LIFE Child Study. J Pediatr Gastroenterol Nutr 2018; 67:494-500. [PMID: 29901554 DOI: 10.1097/mpg.0000000000002052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Assessing the seroprevalence and the prevalence of definite coeliac disease (CD) in the German LIFE Child Health study cohort including immunoglobulin A (IgA) antibodies against tissue transglutaminase (IgA-TTG) in addition to IgG antibodies against deamidated gliadin peptides (IgG-DGP) and human leukocyte antigen (HLA)-DQ2/8 genotyping. METHODS Samples from children and adolescents were first screened for IgA-TTG and IgG-DGP. If IgA-TTG was above 0.5 times the upper limit of normal and/or IgG-DGP was positive, IgA antibodies against endomysium (IgA-EmA) were measured, and HLA was genotyped. In patients with only IgG-DGP positivity, total IgA was assayed. Subjects with suspicious results were followed up serologically and, in case of repeatedly positive antibody results, invited for a personal interview. Further diagnostic data were obtained independent from our study. RESULTS We screened 2363 children's blood samples collected from 2011 to 2015. The seroprevalence, that is, IgA-TTG and/or IgA-EmA positivity or IgG-DGP positivity with IgA <0.05 g/L, was 1.57% (95% confidence interval [CI95%] 1.14-2.15). The prevalence of suspected CD, that is, seroprevalence and compatible HLA genotype with hitherto unknown mucosal damage, was 1.35% (CI95% 0.96-1.91). Definite CD, that is, seropositivity accompanied by positive intestinal biopsy or IgA-TTG ≥ 10 × upper limit of normal, was found in 0.42% (CI95% 0.22-0.80). Seven children claimed to have CD. The HLA haplotype, however, matched in only 4 of them resulting in an overall CD prevalence of at least 0.59% (CI95% 0.34-1.02). Thirteen unclear cases remained; therefore, the prevalence may even be higher. CONCLUSIONS The prevalence of definite CD in a population-representative German cohort is higher than previously described. HLA-DQ typing is helpful to identify false-positive IgA-TTG patients negative for IgA-EmA and/or IgG-DGP under screening conditions and unmasks possible misdiagnoses of CD.
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Barroso M, Beth SA, Voortman T, Jaddoe VWV, van Zelm MC, Moll HA, Kiefte-de Jong JC. Dietary Patterns After the Weaning and Lactation Period Are Associated With Celiac Disease Autoimmunity in Children. Gastroenterology 2018; 154:2087-2096.e7. [PMID: 29481779 DOI: 10.1053/j.gastro.2018.02.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/03/2018] [Accepted: 02/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS There have been many studies of associations between infant feeding practices and development of celiac disease during childhood, but few studies have focused on overall diets of young children after the weaning period. We aimed to examine the association between common dietary patterns in infants and the occurrence of celiac disease autoimmunity during childhood. METHODS We performed a prospective analysis of data from the Generation R Study that comprised 1997 children born from April 2002 through January 2006 in Rotterdam, the Netherlands. Food consumption around 1 year of age was assessed with a validated food-frequency questionnaire. Dietary data were examined using a priori (based on existing guidelines) and a posteriori (principal component analysis and reduced rank regression) dietary pattern analyses. Five dietary patterns were compared. Celiac disease autoimmunity, determined on the basis of serum concentration of transglutaminase-2 autoantibody (ie, TG2A) below or above 7 U/mL, was evaluated at 6 years. Associations between dietary pattern adherence scores and celiac disease autoimmunity were examined using multivariable logistic regression models. RESULTS Higher adherence to the a posteriori-derived prudent dietary pattern (high intake of vegetables, vegetable oils, pasta, and grains and low consumption of refined cereals and sweet beverages) at 1 year was significantly associated with lower odds of celiac disease autoimmunity at 6 years (odds ratio, 0.67; 95% confidence interval, 0.53-0.84). No significant associations were found for the 4 remaining dietary patterns. CONCLUSIONS In a prospective study of dietary patterns of young children in the Netherlands, we associated a dietary pattern characterized by high consumption of vegetables and grains and low consumption of refined cereals and sweet beverages, with lower odds of celiac disease autoimmunity. Early-life dietary patterns might therefore be involved in the development of celiac disease during childhood.
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Affiliation(s)
- Monica Barroso
- Generation R Study Group, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sytske A Beth
- Generation R Study Group, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Trudy Voortman
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Vincent W V Jaddoe
- Generation R Study Group, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Menno C van Zelm
- Department of Immunology and Pathology, Central Clinical School, Monash University and Alfred Hospital, Melbourne, Victoria, Australia
| | - Henriette A Moll
- Department of Pediatrics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jessica C Kiefte-de Jong
- Department of Pediatrics, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Leiden University College, the Hague, the Netherlands.
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Abstract
Celiac disease (CD) is a common autoimmune disorder induced by ingestion of gluten in genetically susceptible individuals. Despite the prerequisite for a genetic predisposition, only a minority of the 40% of the Caucasian population that has this genetic predisposition develops the disease. Thus, environmental and/or lifestyle factors play a causal role in the development of CD. The incidence of CD has increased over the last half-century, resulting in rising interest in identifying risk factors for CD to enable primary prevention. Early infant feeding practices have been suggested as one of the factors influencing the risk of CD in genetically susceptible individuals. However, recent large prospective studies have shown that neither the timing of gluten introduction nor the duration or maintenance of breastfeeding influence the risk of CD. Also, other environmental influences have been investigated as potential risk factors, but have not led to primary prevention strategies. Secondary prevention is possible through early diagnosis and treatment. Since CD is significantly underdiagnosed and a large proportion of CD patients are asymptomatic at the time of diagnosis, secondary prevention will not identify all CD patients, as long as mass screening has not been introduced. As following a gluten-free diet is a major challenge, tertiary prevention strategies are discussed as well.
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Affiliation(s)
- Caroline Meijer
- Deptartment of Pediatrics, Leiden University Medical Center, Willem Alexander Children's Hospital, Leiden, Netherlands
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hania Szajewska
- Department of Pediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Luisa Mearin
- Deptartment of Pediatrics, Leiden University Medical Center, Willem Alexander Children's Hospital, Leiden, Netherlands
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