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Some recent medical news on Celiac:

July 30, 2010 — Studies from the United States, Europe, and elsewhere 
indicate that the prevalence of celiac disease (CD) has increased 
significantly in the last 3 decades — possibly by as much as a factor of 4.

"More and more studies indicate a prevalence of CD of more than 1% in 
both adults and children. This should be compared with lower prevalence 
figures [from] 20 to 30 years ago," Jonas Ludvigsson, MD, from the 
Department of Medicine, Epidemiology Unit, at the Karolinska Institute 
and Orebro University Hospital, Sweden, and an expert in CD, noted in an 
email to Medscape Medical News.

"The reason for this increase is mutlifactorial, but there is probably a 
true underlying increase. This has been shown when old sera have been 
analyzed with modern techniques, (eg, in Finland)," Dr. Ludvigsson 
pointed out.

Mayo Clinic Research Confirms Rise in CD

Researchers at the Mayo Clinic also report an increase in CD, according 
to an article in the summer issue of the Mayo Clinic's research magazine 
Discovery's Edge. Joseph Murray, MD, and colleagues analyzed stored 
blood samples, taken from Air Force recruits in the early 1950s, for 
gluten antibodies. They assumed that 1% would be positive, mirroring 
today's rate. That assumption was wrong — the number of positive results 
was far smaller, indicating that CD was "rare," Dr. Murray noted in the 
article.

This led him and his colleagues to compare those results with 2 more 
recently collected sets from Olmsted County, Minnesota. Their findings 
suggest that CD is roughly 4 times more common now than in the 1950s.

"This tells us that whatever has happened with CD has happened since 
1950," Dr. Murray said. "This increase has affected young and old 
people. It suggests something has happened in a pervasive fashion from 
the environmental perspective," he added.

Excess Mortality Seen With CD and Latent CD

Recent research by Dr. Ludvigsson's team (JAMA. 2009;302:1171-1178) and 
others supports the concept of "latent CD" or "gluten sensitivity." 
Latent CD, defined in the Journal of the American Medical Association 
study by Dr. Ludvigsson's team as having normal small intestinal mucosa 
but positive CD serology, is something that is estimated to occur in at 
least 1 in 1000 individuals.

Dr. Ludvigsson's team has also reported evidence that in 1 year, 10 of 
1000 individuals with CD will die compared with an expected 7 in 1000 
without the disease.

"Not only is the mortality raised in patients with [CD] but also in 
those individuals with latent [CD]," Dr. Ludvigsson noted in a statement 
from the United European Gastroenterology Federation.

However, in comments to Medscape Medical News, he emphasized that 
"although patients with CD are at increased risk of a number of 
disorders, and at increased risk of death, the absolute risk increase is 
very small."

A Tricky Disease

CD remains a "tricky disease," Dr. Ludvigsson said. "It can be 
asymptomatic; have so-called traditional symptoms such as diarrhea, 
weight loss, failure to grow (in children), fatigue, and malnutrition; 
and have nontraditional symptoms such as osteoporosis, depression, 
adverse pregnancy outcome; and increased risks of both malignancy and 
death."

The onset of certain autoimmune disorders including autoimmune liver 
disease, thyroid disease, type 1 diabetes, and Addison's disease can 
actually signal CD, he noted. "This means that clinicians should 
consider CD in a number of symptoms and disorders."

CD Often Undetected; Cause Unknown

CD often goes undetected, although the percentage of undetected cases 
varies between countries, Dr. Ludvigsson noted. "In most countries, at 
least two thirds of individuals with CD have not received a diagnosis by 
a doctor." The reason for the high percentage of undetected disease is 
that the disease can be difficult to diagnose, and "it is sometimes 
almost asymptomatic," he added.

Detection Methods Are Improving

Over the years, Dr. Ludvigsson told Medscape Medical News, "we have 
improved existing means to diagnose CD. Antibody tests are becoming 
better and better, although a positive antibody test should be confirmed 
with a small intestinal biopsy before the diagnosis is certain. 
Transient increases in CD antibody levels occur. In the future, I expect 
microscopy in the very small intestine to become a tool for diagnosis."

Alternatives to the Gluten-Free Diet?

At this time, Dr. Ludvigsson said, the gluten-free diet remains the 
cornerstone of treatment for CD. However, "in the future, alternative 
treatment strategies may be available. The recent discovery of the 
structure of transglutaminase 2 may help in designing inhibitors of 
transglutaminase 2 to treat CD," he said. "Another potential treatment 
strategy is to ingest enzymes that digest gluten, thereby increasing the 
safe threshold for gluten intake.

"There is also ongoing research on the topic of decreasing the bowel's 
permeability to gluten, Dr. Ludvigsson told Medscape Medical News. He 
added, however, that the safety of this approach is unclear, as "a 
decreased permeability here might mean that the body cannot absorb other 
needed substances.

"Finally, agricultural research may mean that we can modify the gluten 
structure in wheat produce a kind of wheat that will not illicit an 
immune response in patients with CD," the researcher noted.

Counseling CD Patients Is Important

Although evidence is scarce, said Dr. Ludvigsson, "most researchers 
believe that a gluten-free diet will reduce the risk of 
complications/comorbidity in CD, and it is important for the doctor to 
underline this for the patients. In patients with CD who do not become 
better on a gluten-free diet, the most common reason is probably that 
the patients do not eat a strictly gluten-free diet," he said.

Dr. Murray advocates greater vigilance in CD patients. "It's not enough 
to say, 'You've got CD, be gluten-free, goodbye,' " he said. "CD 
requires medical follow-up."

This October, at the United European Gastroenterology Week in Barcelona, 
Spain, Dr. Ludvigsson will be 1 of 8 researchers to receive the 
Association of National European and Mediterranean Societies of 
Gastroenterology and United European Gastroenterology Federation Rising 
Stars award.

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