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    Diagnosing Celiac Disease in Primary Care Settings


    Jefferson Adams


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    Celiac.com 04/10/2007 - Celiac disease is one of the most common chronic health disorders in western countries. Yet, due largely to poor awareness of celiac disease by primary care physicians, most celiac cases in North America go undiagnosed. A recent study published in the American Journal of Gastroenterology suggests that the North American diagnostic rate for celiac disease can be improved through the use of active case-finding strategies in the primary care setting.

    The study set out to determine the most common celiac symptoms faced by clinicians, and to determine how effective an active case-finding strategy might be in raising the levels of diagnosis. The study drew from a large pool of individuals who attended one of three participating North American clinical practices. 737 women and 239 men with symptoms or conditions known to be associated with celiac disease were tested for immunoglobulin A anti-transglutaminase (tTG) antibodies, and those with elevated anti-tTG were then tested for IgA anti-endomysial antibodies (EMA). Those who tested positive for EMA were encouraged to undergo an intestinal biopsy and HLA typing.

    The median age for those tested was 54.3 years. Of 976 subjects tested, 30 showed a positive anti-tTG test (3.07%, 95% CI 1.98–4.16). 22 patients (18 women, 4 men) were diagnosed with celiac. In these 22 cases, the most frequent reasons for celiac disease screening were bloating (12/22), thyroid disease (11/22), irritable bowel syndrome (7/22), unexplained chronic diarrhea (6/22), chronic fatigue (5/22), and constipation (4/22).

    The prevalence of celiac disease in the serologically screened sample was 2.25% (95% CI 1.32–3.18).

    According to the study, active screening implementation substantially increased diagnostic rates from a baseline low of 0.27 cases per thousand visits (95% CI 0.13–0.41), to a rate of 11.6 per thousand visits (95% CI 6.8–16.4, P < 0.001).

    The study concludes that the implementation of active strategies in primary care settings is likely to improve the diagnostic rate of celiac disease in North America.

    Am J Gastroenterol 2007; 102:1–7

    health writer who lives in San Francisco and is a frequent author of articles for Celiac.com.
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  • About Me

    Jefferson Adams is a freelance writer living in San Francisco. He has covered Health News for Examiner.com, and provided health and medical content for Sharecare.com. His work has appeared in Antioch Review, Blue Mesa Review, CALIBAN, Hayden's Ferry Review, Huffington Post, the Mississippi Review, and Slate, among others.

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  • Related Articles

    Jefferson Adams
    Celiac.com 10/07/2009 - A team of Maltese researchers, led by genetics specialist Christian Scerri, has discovered that a previously unassociated gene contributes to the development of celiac disease. The association of the gene, a variant of a gene called CD59, is the result of three years of research at a University of Malta lab.
    The research team made the discovery after examining the DNA of six people who suffered from gluten intolerance, together with 9 close relatives.
    Armed with about $35,000 in research funds provided by the Malta Council for Science and Technology, the research team set out to examine the DNA of each family member along with their different genes.
    "If you have a grandmother, a mother and a son who all suffer from a particular disease, we will look for the part of DNA that is common in all three," Scerri said.
    Once the researchers isolated the matching parts of the DNA, the researchers begging combing through all the different genes in that section of the DNA.
    Several prior studies have shown that only people with a certain type of the molecule human leukocyte antigen, called HLA-DQ2/DQ8, were pre-disposed to celiac disease. HLA-DQ2/DQ8 is found in about 30 per cent of the worldwide population.
    Although HLA-DQ2/DQ8 does not cause gluten intolerance on its own, it can combine with a number of genes to cause celiac disease. According to Dr. Scerri, the results showed that "all those patients who suffered from celiac disease had both HLA-DQ2/DQ8 and a variant of CD59."
    The study also confirmed that people who had HLA-DQ2/DQ8 or CD59 alone did not suffer from celiac disease, providing strong evidence that the two combine to cause gluten intolerance.
    The gene variant was also rare in Malta and was not found among another 99 families who have members with celiac disease. "This seems to be the only family in Malta which has this gene," Dr Scerri says of the 17-strong family that was tested.
    Though the gene is quite rare, the research is crucial, as it will likely lead to further study to discover how specific genes bring about particular conditions.
    Dr Scerri hopes to have additional staff in place to begin research by the end of next year when a $7 million restructuring of the University's molecular genetics lab would be finalized.
    Source:
    Times of Malta


    Scott Adams
    I wrote this response below to address a recent New York Times article: Confirming a Diagnosis of Celiac Disease.
    Celiac.com 01/13/2010 - The problem with current diagnosis criteria for celiac disease is that it takes a certain degree of damage to intestinal villi in order to get a formal diagnosis. Since celiac disease with villi damage are just one manifestation of a much broader and more widespread problem--gluten sensitivity--many people who could still develop serious health problems if they continue to eat gluten, will go undiagnosed under the current definition of celiac disease.
    The reality of gluten sensitivity is that around 7 to 12% of the US population test positive for antibodies which are an indicator that their immune system is mounting a response to gliadin, the part of gluten that causes the reaction in those who are sensitive. Many of these people may never get flattened villi, however, many may end up with other conditions that are triggered by gluten exposure in sensitive individuals, for example nerve damage (ataxia), liver problems, diabetes, thyroid issues, etc..
    In the past 10 years the diagnostic criteria for celiac disease have been changed significantly to include various degrees of villi damage (Marsh Criteria), and as a result, more people are now being properly diagnosed. In the next 10 years I predict that blood tests alone will replace the use of all biopsy results to diagnose celiac disease, as they are a far more sensitive indicator of gluten sensitivity. Once this happens we will finally reach a point where those affected can be properly treated and avoid the risk of the many disorders that have been associated with sensitive individuals who eat gluten, some of which are described here.


    Dr. Tom O'Bryan
    Question:  Do I have to re-introduce gluten in order to have an accurate gluten sensitivity test done?
     Answer: Yes and No
     If a person knows they are sensitive to gluten and have gone on a gluten-free diet, and want to know if they can have gluten again, then a  challenge is in order (reintroduce gluten). THIS IS STRONGLY NOT RECOMMENDED. The gluten challenge has many cases of people who were damaged (some permanently) from the reaction to reintroducing gluten Even Small Amounts of Gluten Cause Relapse in Children With Celiac Disease, Journal of Pediatric Gastroenterology and Nutrition 34:26­30,   and it is no longer a requirement for diagnosing celiac disease Am J Clin Nut 1999;69:354-65.
     Among 374 children in whom celiac disease was diagnosed before the age of 2, 5% developed an auto-immune disorder while on a gluten-free diet. Of those who went gluten-free, had years of no symptoms, then went back on a gluten-containing diet, 3.65% prevalence of systemic auto-immune disease with less than 12 months of eating gluten 9.1  % prevalence for 13-36 months of eating gluten again 26.3% prevalence for > 36 months of eating gluten again This means 1 out of 4 people who were sensitive to gluten, went gluten-free and eliminated all of their symptoms developed auto-immune diseases within 3 years of eating gluten again. Gastroenterology 1999;117:297-303.
     If you know you are Gluten Sensitive, and you've gone on a gluten-free diet, and you want to know "am I better", then testing will confirm you are being successful in 'quieting down' the inflammatory cascade that occurs with gluten sensitivity and which sets one up for the development of autoimmune disease.
     And if you want to 'throw the dice', if you want to gamble that you won't be the '1 out of 4' who develops an autoimmune disorder, then you would want to first check and make sure your tests are negative while being on a gluten-free diet, then do your gluten challenge and test again 1-2 months later. Once again, not recommended to do this.
     Many people do not develop celiac disease until later in life. So even if one tests negative now, if they're genetically vulnerable, celiac disease can develop at any time as a result of the body no longer able to handle the stress of life. Something will be the 'straw that broke the camels back' and a person who has had negative tests in the past will begin producing the antibodies and begin the tissue destruction that will eventually manifest as Gluten Sensitivity and/or celiac disease. So in this scenario, these people want to know if they're genetically vulnerable.
     The question is, am I sensitive to wheat?  When a test looking at Gluten Sensitivity comes back positive, it tells us the immune system is reacting to an exposure to gluten. And if you are not eating gluten, it's one of a few things:

     A hidden exposure to gluten  A cross-reactive food  A cross-reactive virus or bacteria  A poorly functioning GI Tract (consider Array #2-Intestinal Antigenic Permeability Screen) An unknown cause (potentially Refractory Sprue).

    Jefferson Adams
    Celiac.com 06/27/2013 - Patients with villous atrophy and negative celiac disease serologies pose a diagnostic and therapeutic dilemma.
    When doctors are unable to determine what is causing villous atrophy in a patient without celiac disease, they usually classify it as a case of "unclassified sprue." However, doctors currently know very little about the best way to treat and manage cases of unclassified sprue.
    To get a better picture of this dilemma, a team of researchers recently examined the connections between villous atrophy and negative celiac serology.
    The research team included M. Degaetani, C.A. Tennyson, B. Lebwohl, S.K. Lewis, H. Abu Daya, C. Arguelles-Grande, G. Bhagat G, and P.H. Green. They are variously affiliated with the Celiac Disease Center, and the Department of Medicine at Columbia University College of Physicians and Surgeons at Columbia University Medical Center in New York, USA.
    For their study, the team looked at adult patients with biopsy-proven villous atrophy and negative celiac serology, evaluated at our tertiary referral center over a 10-year period.
    They noted test results for HLA DQ2/8 alleles, antienterocyte antibodies, giardia stool antigen, bacterial overgrowth, total serum immunoglobulins, and HIV. They also recorded treatment, response, and repeat-biopsy findings for each patient.
    They found that most of the 72 cases were classified as seronegative celiac disease, medication-related villous atrophy, and unclassified sprue.
    The majority of patients diagnosed with unclassified sprue reported symptomatic improvement with immunosuppressive therapy.
    Some patients diagnosed with unclassified sprue were found to have villous atrophy associated with the use of olmesartan.
    The team encourages further examination of the role of medications in the development of villous atrophy, along with the optimal dose and length of immunosuppression for patients with unclassified sprue.

    Source:
    Am J Gastroenterol. 2013 May;108(5):647-53. doi: 10.1038/ajg.2013.45.

  • Recent Articles

    Jefferson Adams
    Celiac.com 06/23/2018 - If you’re looking for a great gluten-free Mexican-style favorite that is sure to be a big hit at dinner or at your next potluck, try these green chili enchiladas with roasted cauliflower. The recipe calls for chicken, but they are just as delicious when made vegetarian using just the roasted cauliflower. Either way, these enchiladas will disappear fast. Roasted cauliflower gives these green chili chicken enchiladas a deep, smokey flavor that diners are sure to love.
    Ingredients:
    2 cans gluten-free green chili enchilada sauce (I use Hatch brand) 1 small head cauliflower, roasted and chopped 6 ounces chicken meat, browned ½ cup cotija cheese, crumbled ½ cup queso fresco, diced 1 medium onion, diced ⅓ cup green onions, minced ¼ cup radishes, sliced 1 tablespoon cooking oil 1 cup chopped cabbage, for serving ½ cup sliced cherry or grape tomatoes, for serving ¼ cup cilantro, chopped 1 dozen fresh corn tortillas  ⅔ cup oil, for softening tortillas 1 large avocado, cut into small chunks Note: For a tasty vegetarian version, just omit the chicken, double the roasted cauliflower, and prepare according to directions.
    Directions:
    Heat 1 tablespoon oil in a cast iron or ovenproof pan until hot.
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    Cut cauliflower into small pieces and place in the oiled pan.
    Roast in oven at 350F until browned on both sides.
    Remove from the oven when tender. 
    Allow roasted cauliflower to cool.
    Chop cauliflower, or break into small pieces and set aside.
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    Heat 1 inch of cooking oil in a small frying pan.
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    Remove soft tortilla to a paper towel and repeat with remaining tortillas.
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    Dunk a tortilla into the sauce and cover both sides. Add more sauce as needed.
    Fill each tortilla with bits of chicken, cauliflower, onion, and queso fresco, and roll into shape.
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    Roxanne Bracknell
    Celiac.com 06/22/2018 - The rise of food allergies means that many people are avoiding gluten in recent times. In fact, the number of Americans who have stopped eating gluten has tripled in eight years between 2009 and 2017.
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    Perhaps unsurprisingly, the U.S is a hotbed of gluten-free options, with four cities making the top 10, as well as the Hawaiian island of Maui. Chicago, in particular, is a real haven of gluten-free fare, with 240 coeliac-safe eateries throughout this huge city. The super hip city of Portland also ranks highly on this list, with the capital of counterculture rich in gluten-free cuisine, with San Francisco and Denver also included. Outside of the states, several prominent European capitals also rank very highly on the list, including Prague, the picturesque and historic capital of the Czech Republic, which boasts the best-reviewed restaurants on this list.
    The Irish capital of Dublin, meanwhile, has the most gluten-free establishments, with a huge 330 to choose from, while Amsterdam and Barcelona also feature prominently thanks to their variety of top-notch gluten-free fodder.
    Finally, a special mention must go to Auckland, the sole representative of Australasia in this list, with the largest city in New Zealand rounding out the top 10 thanks to its 180 coeliacsafe eateries.
    The full top ten gluten-free cities are shown in the graphic below:
     

    Jefferson Adams
    Celiac.com 06/21/2018 - Would you buy a house advertised as ‘gluten-free’? Yes, there really is such a house for sale. 
    It seems a Phoenix realtor Mike D’Elena is hoping that his trendy claim will catch the eye of a buyer hungry to avoid gluten, or, at least one with a sense of humor. D’Elena said he crafted the ads as a way to “be funny and to draw attention.” The idea, D’Elena said, is to “make it memorable.” 
    Though D’Elena’s marketing seeks to capitalizes on the gluten-free trend, he knows Celiac disease is a serious health issue for some people. “[W]e’re not here to offend anybody….this is just something we're just trying to do to draw attention and do what's best for our clients," he said. 
    Still, the signs seem to be working. D'elena had fielded six offers within a few days of listing the west Phoenix home.
    "Buying can sometimes be the most stressful thing you do in your entire life so why not have some fun with it," he said. 
    What do you think? Clever? Funny?
    Read more at Arizonafamily.com.

    Advertising Banner-Ads
    Bakery On Main started in the small bakery of a natural foods market on Main Street in Glastonbury, Connecticut. Founder Michael Smulders listened when his customers with Celiac Disease would mention the lack of good tasting, gluten-free options available to them. Upon learning this, he believed that nobody should have to suffer due to any kind of food allergy or dietary need. From then on, his mission became creating delicious and fearlessly unique gluten-free products that were clean and great tasting, while still being safe for his Celiac customers!
    Premium ingredients, bakeshop delicious recipes, and happy customers were our inspiration from the beginning— and are still the cornerstones of Bakery On Main today. We are a fiercely ethical company that believes in integrity and feels that happiness and wholesome, great tasting food should be harmonious. We strive for that in everything we bake in our dedicated gluten-free facility that is GFCO Certified and SQF Level 3 Certified. We use only natural, NON-GMO Project Verified ingredients and all of our products are certified Kosher Parve, dairy and casein free, and we have recently introduced certified Organic items as well! 
    Our passion is to bake the very best products while bringing happiness to our customers, each other, and all those we meet!
    We are available during normal business hours at: 1-888-533-8118 EST.
    To learn more about us at: visit our site.

    Jefferson Adams
    Celiac.com 06/20/2018 - Currently, the only way to manage celiac disease is to eliminate gluten from the diet. That could be set to change as clinical trials begin in Australia for a new vaccine that aims to switch off the immune response to gluten. 
    The trials are set to begin at Australia’s University of the Sunshine Coast Clinical Trials Centre. The vaccine is designed to allow people with celiac disease to consume gluten with no adverse effects. A successful vaccine could be the beginning of the end for the gluten-free diet as the only currently viable treatment for celiac disease. That could be a massive breakthrough for people with celiac disease.
    USC’s Clinical Trials Centre Director Lucas Litewka said trial participants would receive an injection of the vaccine twice a week for seven weeks. The trials will be conducted alongside gastroenterologist Dr. James Daveson, who called the vaccine “a very exciting potential new therapy that has been undergoing clinical trials for several years now.”
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    Read more at the website for Australia’s University of the Sunshine Coast Clinical Trials Centre.

    Source:
    FoodProcessing.com.au