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    New Communion Wafer a Blessing for Catholics with Gluten-sensitivity


    Jefferson Adams
    Image Caption: A gluten-free communion wafer

    Celiac.com 10/13/2010 - Until now Catholics with gluten-sensitivity have found it difficult to participate fully in Mass by consuming the communion wafers, which traditionally contain gluten.


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    To address that situation, the Benedictine Sisters of Perpetual Adoration in Clyde, Mo., have developed a Communion host that is extremely low in gluten – allowing Catholics with gluten sensitivity an alternative to taking only the cup during communion.

    Low-gluten communion wafers mean that more Catholics with gluten-sensitivity will be able to consume both the body and the blood of the host, both the communion wafer and the wine, in their celebration of Mass.

    Canon law and tradition require that communion wafers contain a percentage of wheat for a valid celebration of Eucharist, said Timothy Johnston, Director of Liturgy of the Catholic Diocese of Salt Lake City.

    However, the host made by the Benedictine Sisters of Perpetual Adoration contains gelatinized wheat starch. The sisters report the hosts test to a level of 0.01 percent gluten. The Secretariat for the Liturgy of the United States Conference of Catholic Bishops has stated that these hosts meet the requirements of the Code of Canon Law (924 §2) and may be used at the celebration of the Eucharist with permission of the person’s pastor.

    “They are the only group of sisters (or Catholic group at that) that make valid low-gluten hosts. Any other company or group is not approved for use during the liturgy,” Johnston said.

    He encourages Catholics with gluten-sensitivity who wish to learn more to begin a discussion with their pastor so that each may understand the church doctrine and teaching regarding low-gluten hosts, as well as the practical steps necessary for Holy Communion.

    Johnston also advises Catholics who wish to receive the low-gluten wafer to discuss the matter in advance with the celebrant and Extraordinary Ministers of Holy Communion so that everyone is comfortable with the procedure.

    “There are several parishes that use low-gluten hosts,” Johnston said, including St. Andrew, the Cathedral of the Madeleine and Saint Thomas More.

    Responding in a letter to expressions of gratitude from many Catholics with gluten-sensitivity, the Sisters of Perpetual Adoration write that they are “inspired by the deep desire of those suffering from gluten intolerance to receive Holy Communion…[and] humbled by the many letters, emails, and phone calls we have received thanking us for our efforts to produce low gluten altar bread.”

    The letter adds that the Sisters “blessed to have the opportunity to allow God to work through our hands…[and] honored and privileged to provide for you and your parish the bread that becomes the Body of Christ.”

    Obviously, since the new wafers are not completely gluten-free,  questions of individual sensitivity will need to be addressed. However, this is a huge step toward allowing people with gluten sensitivity to take both the body and the blood when taking communion.

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    Unfortunately, these still contain gluten. And unfortunately, this still isn't safe for celiacs. I think the Catholic Church needs to be very, very clear that this is a Roman Catholic policy / tradition that does not apply to other denominations. Other denominations do not require that a specific grain be used in the communion wafers!

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    My 13 year old son receives these each Sunday. His GI approved them, providing he doesn't have any reaction to them, which he doesn't. We're both very thankful that the sisters make them and that our Church offers them.

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    My children and I have been receiving these low-gluten hosts for a year and have figured out that these are now causing the same reaction as a gluten accident. At first, I thought they were mainly rice flour with a smidgen of wheat. I would not buy anything off of the shelf containing wheat starch so why will I subject my family to these hosts. We are strong in our faith. We will abstain from the Holy Eucharist and partake of the Precious Blood if available. God understands.

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    My mom & I have be using these hosts since 2004 and have had no ill effects. Like the article says, they are VERY LOW gluten, meeting the proposed acceptable level. The Catholic Church never claimed that this policy applies to other denominations. I think it is great that these hosts are available to gluten free Catholics desiring to receive the BODY of CHRIST.

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    I cannot believe that a celiac journal would print this - the only treatment for celiac disease is a totally gluten free diet.

     

    It's a bit of catch 22 for Roman Catholics - Your not permitted to knowingly do something which is bad for you (ie. have wheat products) but if you don't have communion you can't get to heaven.

     

    PS. Roman Catholics can still have wine.

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    Guest Jennifer

    Posted

    I live near the Benedictine Sisters and my parish has been using their low-gluten wafers for a few years now. The ability to participate in Communion is a wonderful blessing for a Gluten Intolerant newly converted Catholic. The Catholic Church made it very clear the reason behind the "policy/tradition" when I converted this past year with no apprehension. Our parish has set the standard for our diocese on how to safely provide this alternative for gluten intolerant Catholics thanks to the Benedictine Sisters.

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    Guest G Harrison

    Posted

    The headline is misleading. The wafers still contain gluten and unless you experience one of those catholic miracles, you will be exposed to gluten.

     

    The only answer is for the Catholic church to recognize that until there is a cure, gluten is poison for those afflicted.

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    I cannot believe that a celiac journal would print this - the only treatment for celiac disease is a totally gluten free diet.

     

    It's a bit of catch 22 for Roman Catholics - Your not permitted to knowingly do something which is bad for you (ie. have wheat products) but if you don't have communion you can't get to heaven.

     

    PS. Roman Catholics can still have wine.

    In response to GTT517: No, you can still get into heaven even if you can't take communion. My father was too ill to take solid foods and there are many people who can't take communion because of the wheat, but we don't believe you will be condemned to the netherworld if you can't take communion.

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    I cannot believe that a celiac journal would print this - the only treatment for celiac disease is a totally gluten free diet.

     

    It's a bit of catch 22 for Roman Catholics - Your not permitted to knowingly do something which is bad for you (ie. have wheat products) but if you don't have communion you can't get to heaven.

     

    PS. Roman Catholics can still have wine.

    Actually, if you are unable to take communion because of an illness, you are not excluded from going to heaven.

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    Guest Jefferson

    Posted

    The headline is misleading. The wafers still contain gluten and unless you experience one of those catholic miracles, you will be exposed to gluten.

     

    The only answer is for the Catholic church to recognize that until there is a cure, gluten is poison for those afflicted.

    As seen from numerous comments, many people with gluten-intolerance will be able to consume these communion wafers with no issue. Others will not. People with celiac disease likely cannot tolerate these. However, I feel that the development of the wafers helps to raise celiac/gluten awareness in general, and that is not a bad thing. Nor is having an alternative for some people.

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    Guest Ferd Burfle

    Posted

    I cannot believe that a celiac journal would print this - the only treatment for celiac disease is a totally gluten free diet.

     

    It's a bit of catch 22 for Roman Catholics - Your not permitted to knowingly do something which is bad for you (ie. have wheat products) but if you don't have communion you can't get to heaven.

     

    PS. Roman Catholics can still have wine.

    "PS. Roman Catholics can still have wine."

     

    ...unless they are alcoholics with celiac disease. THEN the church suggests you become a Jew.

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    Guest Robyn

    Posted

    As a Catholic I would like to clear up a few misconceptions in the comments section here.

     

    I think the most important thing to know is that one does NOT have to receive communion to go to heaven! I think the best way to explain the idea that you "must" receive communion (which is based on John 6) is that the Eucharist helps *draw us* toward heaven—but it is no absolute requirement. God is merciful.

     

    Catholics believe that in the Eucharist, we receive the complete and undivided Body, Blood, Soul, and Divinity of Jesus Christ, in a real and literal way. A worshiper who receives EITHER the host OR the chalice, receives that complete Body, Blood, Soul, and Divinity. (And, technically, after consecration, it shouldn't be called "bread" or "wine" anymore.)

     

    The extremely low-gluten hosts are probably the best that can possibly done for people with gluten sensitivity. Of course, if a low-gluten host is unacceptable, a celiac sufferer can still receive communion from the chalice. One can even arrange to have a separate chalice of wine consecrated just for celiac worshipers, to prevent any gluten cross contamination.

     

    If a person can't tolerate ordinary wine either, it can be arranged that a very low-alcohol, only slightly fermented wine called mustum can be used. If even that can't be tolerated, then the worshiper will have to go without the sacrament, knowing that he or she can still make a spiritual communion. God is merciful.

     

    The incredible teaching of the Real Presence shows why the Church considers it gravely important to "get it right." Wheat for the host and fermented grape wine for the chalice are essential. For this reason Catholic requirements are more strict than those of most Protestant denominations.

     

    Nobody knows what celiac disease means for you better than God. He knows what He is doing by making this cross a part of your journey here on earth. He understands even if nobody in your parish seems to "get it." It can even be just between you and Him. Imagine Him looking right at you, shrugging, and saying "I know, they're clueless. Tell me about it."

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    Guest Caroline

    Posted

    Thank you, Robyn! God Bless you! As a fellow Catholic and a celiac sufferer, I find the Church's stance on "no gluten free communion" to be difficult, especially with cross-contamination issues regarding the wine BUT your comments certainly put me at ease.

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    I cannot believe that a celiac journal would print this - the only treatment for celiac disease is a totally gluten free diet.

     

    It's a bit of catch 22 for Roman Catholics - Your not permitted to knowingly do something which is bad for you (ie. have wheat products) but if you don't have communion you can't get to heaven.

     

    PS. Roman Catholics can still have wine.

    Your ignorance is stunning. Please don't comment on things you have no knowledge about.

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    Guest Dorothy Ayer

    Posted

    Unfortunately, these still contain gluten. And unfortunately, this still isn't safe for celiacs. I think the Catholic Church needs to be very, very clear that this is a Roman Catholic policy / tradition that does not apply to other denominations. Other denominations do not require that a specific grain be used in the communion wafers!

    You are correct.

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    Guest pubis

    Posted

    What a joke. If the church cared about its members, they wouldn't subject them to something that will cause them illness. Of course, they wouldn't expose children to known predators either.

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    Guest Marilyn

    Posted

    I cannot believe that a celiac journal would print this - the only treatment for celiac disease is a totally gluten free diet.

     

    It's a bit of catch 22 for Roman Catholics - Your not permitted to knowingly do something which is bad for you (ie. have wheat products) but if you don't have communion you can't get to heaven.

     

    PS. Roman Catholics can still have wine.

    They always brush the crumbs of wheat from their hands into the wine..

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    Guest Michelle

    Posted

    As a Catholic I would like to clear up a few misconceptions in the comments section here.

     

    I think the most important thing to know is that one does NOT have to receive communion to go to heaven! I think the best way to explain the idea that you "must" receive communion (which is based on John 6) is that the Eucharist helps *draw us* toward heaven—but it is no absolute requirement. God is merciful.

     

    Catholics believe that in the Eucharist, we receive the complete and undivided Body, Blood, Soul, and Divinity of Jesus Christ, in a real and literal way. A worshiper who receives EITHER the host OR the chalice, receives that complete Body, Blood, Soul, and Divinity. (And, technically, after consecration, it shouldn't be called "bread" or "wine" anymore.)

     

    The extremely low-gluten hosts are probably the best that can possibly done for people with gluten sensitivity. Of course, if a low-gluten host is unacceptable, a celiac sufferer can still receive communion from the chalice. One can even arrange to have a separate chalice of wine consecrated just for celiac worshipers, to prevent any gluten cross contamination.

     

    If a person can't tolerate ordinary wine either, it can be arranged that a very low-alcohol, only slightly fermented wine called mustum can be used. If even that can't be tolerated, then the worshiper will have to go without the sacrament, knowing that he or she can still make a spiritual communion. God is merciful.

     

    The incredible teaching of the Real Presence shows why the Church considers it gravely important to "get it right." Wheat for the host and fermented grape wine for the chalice are essential. For this reason Catholic requirements are more strict than those of most Protestant denominations.

     

    Nobody knows what celiac disease means for you better than God. He knows what He is doing by making this cross a part of your journey here on earth. He understands even if nobody in your parish seems to "get it." It can even be just between you and Him. Imagine Him looking right at you, shrugging, and saying "I know, they're clueless. Tell me about it."

    Thank you Robyn for your comment. I have been very saddened in my heart when I found out there was wheat in the Eucharist . Your comments confirmed what some of my sisters in Christ have shared with me seeing as I also have epilepsy and cannot take the wine regularly because of my medicine. I just need to pray.

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    I cannot believe that a celiac journal would print this - the only treatment for celiac disease is a totally gluten free diet.

     

    It's a bit of catch 22 for Roman Catholics - Your not permitted to knowingly do something which is bad for you (ie. have wheat products) but if you don't have communion you can't get to heaven.

     

    PS. Roman Catholics can still have wine.

    The Church teaches that the FULL manifestation is in BOTH the Host and in the wine. So, you can get the full mass from just the wine.

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    Guest uxordepp

    Posted

    As a Catholic I would like to clear up a few misconceptions in the comments section here.

     

    I think the most important thing to know is that one does NOT have to receive communion to go to heaven! I think the best way to explain the idea that you "must" receive communion (which is based on John 6) is that the Eucharist helps *draw us* toward heaven—but it is no absolute requirement. God is merciful.

     

    Catholics believe that in the Eucharist, we receive the complete and undivided Body, Blood, Soul, and Divinity of Jesus Christ, in a real and literal way. A worshiper who receives EITHER the host OR the chalice, receives that complete Body, Blood, Soul, and Divinity. (And, technically, after consecration, it shouldn't be called "bread" or "wine" anymore.)

     

    The extremely low-gluten hosts are probably the best that can possibly done for people with gluten sensitivity. Of course, if a low-gluten host is unacceptable, a celiac sufferer can still receive communion from the chalice. One can even arrange to have a separate chalice of wine consecrated just for celiac worshipers, to prevent any gluten cross contamination.

     

    If a person can't tolerate ordinary wine either, it can be arranged that a very low-alcohol, only slightly fermented wine called mustum can be used. If even that can't be tolerated, then the worshiper will have to go without the sacrament, knowing that he or she can still make a spiritual communion. God is merciful.

     

    The incredible teaching of the Real Presence shows why the Church considers it gravely important to "get it right." Wheat for the host and fermented grape wine for the chalice are essential. For this reason Catholic requirements are more strict than those of most Protestant denominations.

     

    Nobody knows what celiac disease means for you better than God. He knows what He is doing by making this cross a part of your journey here on earth. He understands even if nobody in your parish seems to "get it." It can even be just between you and Him. Imagine Him looking right at you, shrugging, and saying "I know, they're clueless. Tell me about it."

    Robyn, this is well-put, but I would like to emphasize that one receives Jesus, Body and Blood in even a tiny amount of the "host" or the "wine". This means that for someone very sensitive (and I realize this may not include those with celiac disease) to gluten or alcohol, can receive just a tiny piece of a "host", or a drop of "wine".

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    Guest Daniel

    Posted

    Unfortunately, these still contain gluten. And unfortunately, this still isn't safe for celiacs. I think the Catholic Church needs to be very, very clear that this is a Roman Catholic policy / tradition that does not apply to other denominations. Other denominations do not require that a specific grain be used in the communion wafers!

    Why should the Catholic church have to make something clear to other denominations?

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    Guest Gloria

    Posted

    Unfortunately, these still contain gluten. And unfortunately, this still isn't safe for celiacs. I think the Catholic Church needs to be very, very clear that this is a Roman Catholic policy / tradition that does not apply to other denominations. Other denominations do not require that a specific grain be used in the communion wafers!

    -Worshipers with gluten-free/coeliac condition

     

    Gluten-free wafer is given to communicants in my Church.

    I worship in Anglican Church in Essex.

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    Jefferson Adams
    Celiac.com 02/12/2015 - Gwyneth Paltrow is making gluten-free celebrity news again for helping her longtime stylist go gluten-free and drop some major weight.
    David Babaii is one of Hollywood's top hair stylists. In addition to Paltrow, his celebrity roster includes Kate Hudson, Scarlett Johansson, Christina Aguilera and Uma Thurman, among others.
    After working with Paltrow for about 10 years, the man Vogue-crowned the "king of curls" had ballooned to 285 pounds with a 44-inch waist. At just five feet five inches tall, he became compelled to lose weight.
    In a recent exclusive with Marc Malkin in eonline, Babaii opens up about how Paltrow and Equinox trainer Will Castillo helped him lose 135 pounds in just four months.
    Babaii says that Paltrow was very supportive, non-judgmental, and encouraging of his efforts. When Babaii asked Paltrow about gluten, he says she advised him not to do anything drastic, and to take it slowly.
    And, armed with determination and with Paltrow's support and encouragement, Babaii began his transformation in earnest.
    Of course, being a personal of Gwyneth Paltrow has its perks. In Babaii's case, whenever he was hungry or in need of support, he could "email her any time of the day and if she wasn't sleeping, she'd reply right away," he told Malkin. "She would say, 'Try this. I think you'll like it. It's not boring.'"

  • Recent Articles

    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.

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    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.”
    Dr. Daveson said the investigational vaccine might potentially restore gluten tolerance to people with celiac disease.The trial is open to adults between the ages of 18 and 70 who have clinically diagnosed celiac disease, and have followed a strict gluten-free diet for at least 12 months. Anyone interested in participating can go to www.joinourtrials.com.
    Read more at the website for Australia’s University of the Sunshine Coast Clinical Trials Centre.

    Source:
    FoodProcessing.com.au

    Jefferson Adams
    Celiac.com 06/19/2018 - Could baking soda help reduce the inflammation and damage caused by autoimmune diseases like rheumatoid arthritis, and celiac disease? Scientists at the Medical College of Georgia at Augusta University say that a daily dose of baking soda may in fact help reduce inflammation and damage caused by autoimmune diseases like rheumatoid arthritis, and celiac disease.
    Those scientists recently gathered some of the first evidence to show that cheap, over-the-counter antacids can prompt the spleen to promote an anti-inflammatory environment that could be helpful in combating inflammatory disease.
    A type of cell called mesothelial cells line our body cavities, like the digestive tract. They have little fingers, called microvilli, that sense the environment, and warn the organs they cover that there is an invader and an immune response is needed.
    The team’s data shows that when rats or healthy people drink a solution of baking soda, the stomach makes more acid, which causes mesothelial cells on the outside of the spleen to tell the spleen to go easy on the immune response.  "It's most likely a hamburger not a bacterial infection," is basically the message, says Dr. Paul O'Connor, renal physiologist in the MCG Department of Physiology at Augusta University and the study's corresponding author.
    That message, which is transmitted with help from a chemical messenger called acetylcholine, seems to encourage the gut to shift against inflammation, say the scientists.
    In patients who drank water with baking soda for two weeks, immune cells called macrophages, shifted from primarily those that promote inflammation, called M1, to those that reduce it, called M2. "The shift from inflammatory to an anti-inflammatory profile is happening everywhere," O'Connor says. "We saw it in the kidneys, we saw it in the spleen, now we see it in the peripheral blood."
    O'Connor hopes drinking baking soda can one day produce similar results for people with autoimmune disease. "You are not really turning anything off or on, you are just pushing it toward one side by giving an anti-inflammatory stimulus," he says, in this case, away from harmful inflammation. "It's potentially a really safe way to treat inflammatory disease."
    The research was funded by the National Institutes of Health.
    Read more at: Sciencedaily.com

    Jefferson Adams
    Celiac.com 06/18/2018 - Celiac disease has been mainly associated with Caucasian populations in Northern Europe, and their descendants in other countries, but new scientific evidence is beginning to challenge that view. Still, the exact global prevalence of celiac disease remains unknown.  To get better data on that issue, a team of researchers recently conducted a comprehensive review and meta-analysis to get a reasonably accurate estimate the global prevalence of celiac disease. 
    The research team included P Singh, A Arora, TA Strand, DA Leffler, C Catassi, PH Green, CP Kelly, V Ahuja, and GK Makharia. They are variously affiliated with the Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Lady Hardinge Medical College, New Delhi, India; Innlandet Hospital Trust, Lillehammer, Norway; Centre for International Health, University of Bergen, Bergen, Norway; Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Gastroenterology Research and Development, Takeda Pharmaceuticals Inc, Cambridge, MA; Department of Pediatrics, Università Politecnica delle Marche, Ancona, Italy; Department of Medicine, Columbia University Medical Center, New York, New York; USA Celiac Disease Center, Columbia University Medical Center, New York, New York; and the Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.
    For their review, the team searched Medline, PubMed, and EMBASE for the keywords ‘celiac disease,’ ‘celiac,’ ‘tissue transglutaminase antibody,’ ‘anti-endomysium antibody,’ ‘endomysial antibody,’ and ‘prevalence’ for studies published from January 1991 through March 2016. 
    The team cross-referenced each article with the words ‘Asia,’ ‘Europe,’ ‘Africa,’ ‘South America,’ ‘North America,’ and ‘Australia.’ They defined celiac diagnosis based on European Society of Pediatric Gastroenterology, Hepatology, and Nutrition guidelines. The team used 96 articles of 3,843 articles in their final analysis.
    Overall global prevalence of celiac disease was 1.4% in 275,818 individuals, based on positive blood tests for anti-tissue transglutaminase and/or anti-endomysial antibodies. The pooled global prevalence of biopsy-confirmed celiac disease was 0.7% in 138,792 individuals. That means that numerous people with celiac disease potentially remain undiagnosed.
    Rates of celiac disease were 0.4% in South America, 0.5% in Africa and North America, 0.6% in Asia, and 0.8% in Europe and Oceania; the prevalence was 0.6% in female vs 0.4% males. Celiac disease was significantly more common in children than adults.
    This systematic review and meta-analysis showed celiac disease to be reported worldwide. Blood test data shows celiac disease rate of 1.4%, while biopsy data shows 0.7%. The prevalence of celiac disease varies with sex, age, and location. 
    This review demonstrates a need for more comprehensive population-based studies of celiac disease in numerous countries.  The 1.4% rate indicates that there are 91.2 million people worldwide with celiac disease, and 3.9 million are in the U.S.A.
    Source:
    Clin Gastroenterol Hepatol. 2018 Jun;16(6):823-836.e2. doi: 10.1016/j.cgh.2017.06.037.