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            Oh, Canada: Highlights from the CCA Conference
            ----------------------------------------------
      summarized by Janet Armil, Chris Brecka, and Beth Coderre

In May we attended the Canadian Celiac Association (CCA) national
conference in Hamilton, Ontario.  We found the conference edifying and
worth the trip.  We also came home with a trunk full of food purchased
from GF food vendors.  Next year's CCA conference will be held in
Winnipeg, Manitoba from May 25-27, 2001.  For more information,
contact the CCA at 800-363-7296, or by e-mail at <[log in to unmask]>.
The CCA website is at <http://www.celiac.ca>.

As an aside, we learned that there is a restaurant outside of Toronto
(Oakville, Ontario) called "Il Fornello" that has a menu page
exclusive to special dietary needs and a staff that is specially
trained and has good knowledge of food preparation for celiacs.  A
half-dozen entrees can be prepared gluten-free (GF), including
bruschetta, pizza, and pasta.  We didn't get to try it, but if you do,
let us know what you think.  Toto, we're not in Kansas anymore!

Here are highlights from the conference presentations:


Prevalence of Celiac Disease
----------------------------
Dr. Markku Maki, Professor, Institute of Medical Technology,
University of Tampere, Finland

Dr. Maki considers the total number of diagnosed celiacs the "tip of
the iceberg", those with the clinical disease.  The larger, submerged
portion of the "iceberg" represents those with clinically silent
celiac disease (CD), and those with disorders resulting from
undiagnosed and untreated CD, like osteoporosis.  Looking back on
forty years of variable CD prevalence figures from Finland, Dr. Maki
discovered that prevalence figures varied over the years depending on
whether physicians at that time were looking for CD in patients with
atypical presentations (thus discovering/diagnosing more CD), or just
in patients with the typical classic textbook presentation (thus
diagnosing fewer cases of CD).  These Finnish prevalence figures
reflect changes in diagnostic practices more than changes in the true
prevalence of CD.

Dr. Maki, an advocate for the early detection of CD, recommends
liberal use of serological screening (blood testing for CD-specific
antibodies) with patients presenting with minor GI symptoms, delayed
puberty, or dental enamel defects.  A biopsy remains the gold standard
of diagnosis when there is strong clinical suspicion of CD (e.g., when
a patient presents with symptoms and has a family member who is a
diagnosed celiac, or when serological antibody testing is positive),
or when an endoscopy is already being performed for something else.
("While you're down there, you might as well take a biopsy to rule out
CD").


Getting Physicians to Change
----------------------------
Dr. Robert Issenman, Professor of Pediatrics at McMaster University
and Chief of Pediatric Gastroenterology of the Children's Hospital of
the Hamilton Health Science Corporation

Dr. Issenman, recognizing that CCA has a long history of education
and advocacy about CD, addressed the factors effecting the continuing
education of physicians, and why it sometimes seems hard to get
physicians to change.

It's hard to get physicians' attention because demand for change comes
from so many:  government agencies, insurance companies, politicians,
newspapers, and patients (so many disease associations...).  Part of
the resistance to change comes from the education process; after long
schooling and apprenticeship, once out in practice, they're reluctant
to change just because of something they've read in a medical journal.
Typically, physicians gain new information from medical journals,
rounds/lectures, courses, the internet, drug salespeople, and
colleagues.  This type of learning changes knowledge, but doesn't
change behavior.  In order to change behavior, physicians, like the
rest of us, need several things:  to see a reason to change, to be
able to "risk" change, to be shown how to change, to be able to
practice change, and to be reinforced for changing.  Additionally,
physicians, like the rest of us, learn according to "change theory";
the spread of ideas follows certain laws of nature.  New ideas are
adopted first by "visionaries" (about 2% of a group), then "early
adopters" (about 13%), then the "early majority" (about 34%), then the
"late majority" (about 34%).  "Laggards" (those who won't change no
matter what) take great pride in not changing.  CCA would best aim
change efforts toward early adopters, since visionaries are less
socially connected, and the early majority likes to wait-and-see.

A new idea begins to take hold when 10 to 20% of the target group
embrace it and begin to function as the "heart of diffusion", or
spreaders of the word.  Since physicians are a part of the general
public too, one of the ways to get physicians to change is to make CD
better known and understood to the national media.  Other methods
include books (with meetings to promote) about CD by physicians,
medical journals, news media (both lay and medical journalists), small
group practice-based learning, education of opinion leaders, and
opportunities for practice.


Osteoporosis: New Research in Bone Loss
---------------------------------------
Dr. Jonathan D.  Adachi, FRCP(C), Professor, Department of Medicine,
St. Joseph's Hospital, McMaster University, Hamilton, Ontario

Osteoporosis is a systemic skeletal disorder characterized by a
decrease in bone mass and microarchitectural deterioration of bone
tissue, with a resultant increase in bone fragility and susceptibility
to fracture.  Bone is comprised of metabolically active cells
(osteoclasts for bone resorption and osteoblasts for bone formation).
Under normal circumstances, there is equilibrium between bone
formation and resorption, and bone mass is maintained.  When
resorption exceeds formation, mass is lost.  Bone mass increases
during childhood and adolescence, peaks in the twenties and thirties,
and declines thereafter at a rate of 1% per year.  Menopause
accelerates rates of bone loss to an average of 3-5% per year.
Malabsorption of calcium, as may occur in CD, is one of the risk
factors for osteoporosis.

Prevention includes adequate dietary calcium intake, or calcium
supplementation, and vitamin D.  Treatment includes adequate calcium
(over 50 years old-1500 mg/day in combination of diet and supplements
taken with food) and vitamin D intake (over 50 years old-700-800
IU/day), weight bearing exercises (not to increase bone mass, but to
increase overall conditioning and balance; only in those who have been
very sedentary does the introduction of exercise increase bone mass),
minimizing risk factors (fall-proofing a home environment), and
education about posture and prevention of falls at home.  Treatment
may also include hormone replacement therapy (i.e., postmenopausal
estrogen therapy), raloxifene (a selective estrogen receptor
modulator, e.g.  Evista), disphosonates like alendronate (Fosamax), or
calcitonin (in nasal spray form).  The good news:  research shows that
small increases in bone density result in large declines in fracture
rates, so a small increase in bone mass brings far more protection
from fracture.