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Celiac.com 10/12/2023 - Celiac disease is a chronic, inflammatory disease triggered by the consumption of gluten-containing foods. Early diagnosis and proper management with a gluten-free diet can reduce its impact on patients' quality of life. People with a family history of celiac disease are at a higher risk, making it crucial to actively identify cases within this group. A new study conducted by a team of researchers in Australia offers new insight into rates of celiac disease, particularly among first-degree relatives of individuals with the condition. The research team included Richard Muir, Anuj Sehgal, Jason A Tye‐Din and A James M Daveson. They are variously affiliated with The Wesley Hospital, Brisbane, QLD; St Andrew's War Memorial Hospital, Brisbane, QLD; the Wesley Research Institute, Brisbane, QLD; The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC; The Royal Melbourne Hospital, Melbourne, VIC; and The University of Queensland, Brisbane, QLD. Celiac Disease Affects Approximately 1.4% of People Globally Their research found that celiac disease affects approximately 1.4% of both the global and Australian populations. The study, conducted at the Wesley Research Institute in Brisbane, targeted first-degree relatives of individuals already diagnosed with celiac disease. These relatives were invited to participate in the research, and the study involved genetic testing for celiac disease risk alleles (HLA‐DQ2/8/7 polymerase chain reaction genotyping) and serological tests to detect specific antibodies related to celiac disease. Key findings from the study include: High Celiac Disease Susceptibility Among the participants, 86% had celiac disease susceptibility haplotypes, with 50% of children and 53% of adults carrying high-risk celiac-associated genotypes. Serology Results Sixteen individuals with susceptibility haplotypes tested positive for serological markers associated with celiac disease. Biopsy Confirmation Small bowel biopsies were performed on individuals with positive serological results, confirming celiac disease in seven children and two adults who had high-risk alleles. Celiac Disease Prevalence Among Child First-Degree Relatives Between 11% and 14% Among child first-degree relatives, the estimated rates of celiac disease was 11%, rising to 14% among those with celiac disease susceptibility haplotypes. In contrast, only 1.4% of adult first-degree relatives were confirmed to have celiac disease. These findings highlight the importance of active case finding, especially among first-degree relatives of individuals diagnosed with celiac disease. Such screening can lead to early diagnosis and timely intervention, improving the quality of life and health for celiacs. However, the study also acknowledges limitations, including the fact that not all individuals with positive serological results underwent small bowel biopsies. Additionally, the research was conducted at a single center, and a non-first-degree relatives group was not included for comparison. Overall, the study's results support international guidelines recommending active case finding among first-degree relatives of individuals with celiac disease. Read more in The Medical Journal Of Australia

Celiac.com 06/27/2023 - Some individuals with celiac disease experience liver complications such as elevated liver enzymes, liver cirrhosis, and autoimmune hepatitis. A group of researchers conducted a systematic review with meta-analyses to determine the combined prevalence of celiac disease in patients with different liver conditions. Here's what they found. The research team included Yoosuf, Shakira MD; Singh, Prashant MD; Khaitan, Ashank MBBS; Strand, Tor A. MD; Ahuja, Vineet MD, DM; and Makharia, Govind K. MD, DM, DNB. They are variously affiliated with the Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, Delhi, India; the Chettinad Hospital and Research Institute, Chennai, Tamilnadu, India; the Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA; the Department of Global Public Health, Innlandet Hospital Trust, Lillehammer, Norway. Medical Databases Searched for Relevant Liver and Celiac Diesase Studies They searched medical databases for relevant studies up to January 2022. Studies that performed serological tests and/or intestinal biopsy for celiac disease on patients with cryptogenic cirrhosis, all-cause cirrhosis, cryptogenic hypertransaminasemia (elevated liver enzymes), and all-cause hypertransaminasemia were included. The researchers calculated the pooled estimates of seroprevalence (presence of celiac antibodies in the blood) and the rates of biopsy-confirmed celiac disease in these four groups. Out of the many articles screened, 20 articles were included in the final analysis for cryptogenic cirrhosis, all-cause cirrhosis, and cryptogenic hypertransaminasemia. However, for all-cause hypertransaminasemia, a qualitative review of four studies was conducted due to significant differences in the studies. Patients with Cryptogenic Cirrhosis ~5% and Cryptogenic Hypertransaminasemia 6% The results showed that the pooled prevalence of biopsy-confirmed celiac disease in patients with cryptogenic cirrhosis was approximately 5%. For all-cause cirrhosis, the prevalence was less than 1%. In the case of cryptogenic hypertransaminasemia, the pooled prevalence of biopsy-confirmed celiac disease was nearly 6%. These findings suggest that approximately 1 in 20 patients with cryptogenic cirrhosis or cryptogenic hypertransaminasemia have celiac disease. Therefore, individuals with these liver conditions should be considered high-risk groups for celiac disease and may benefit from screening. Although the prevalence of celiac disease in individuals with all-cause cirrhosis is similar to the general population, it may still be worth conducting celiac screening the, because the liver damage in these cases has the potential for reversal. Read more in The American Journal of Gastroenterology 118(5):p 820-832, May 2023.

Celiac.com 09/02/2019 - A team of researchers recently set out to investigate rates of first-degree relatives (FDRs) with celiac disease detected at screening, and the diagnostic significance of anti-tissue transglutaminase (anti-TTG). The research team included Shilpa S. Nellikkal, MBBS, Yamen Hafed, MD, Joseph J. Larson, BS, Joseph A. Murray, MD, and Imad Absah, MD. They are variously affiliated with the the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; the Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; and the Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota. Using data from the Mayo Clinic going back to 1983, the team conducted a retrospective study on a group of 104 patients diagnosed with celiac disease and their first-degree relatives. The data included demographics, original symptoms, reasons for testing, family history, number of other family members screened, biopsy reports, and results of serologic tests. The team screened 360 out of a total of 477 first-degree relatives, finding a total of 160 first-degree relatives who were diagnosed with celiac disease, 62% of whom were female. All diagnosed first-degree relatives had positive anti-TTG titers. They found clinical features in 148 diagnosed first-degree relatives. Just nine of those diagnosed first-degree relatives had classic symptoms, 97 showed non-classic symptoms, and 42 showed no symptoms. Histology reports from 155 first-degree relatives showed 12 with Marsh 1, 77 with Marsh 3a, and 66 with Marsh 3b. The team used levels of anti-TTG greater than or equal to 2.75 of the upper limit of normal to spot first-degree relatives with villous atrophy with 87% sensitivity, 82% specificity, and a positive predictive value of 95%. This study of diagnosed celiac patients showed high rates of celiac disease among screened first-degree relatives. Small bowel biopsies revealed that high anti-TTG titers were associated with villous atrophy, irrespective of symptoms. Read more at Mayoclinicproceedings.org.

Celiac.com 01/03/2019 - Celiac disease is common in Saudi Arabia, affecting about 1.5% of the country's total population, according to a recent mass screening study. A team of researchers recently set out to determine the frequency of celiac disease-predisposing human leukocyte antigen (HLA)-DQ genotypes in the Saudi population. The research team included A Al-Hussaini, H Alharthi, A Osman, N Eltayeb-Elsheikh, and A Chentoufi. They are variously affiliated with the Division of Pediatric Gastroenterology, Children's Specialized Hospital, King Fahad Medical City; College of Medicine, Alfaisal University; Prince Abdullah bin Khalid Celiac Disease Research Chair, Department of Pediatrics, Faculty of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia; the Department of Pathology and Laboratory Medicine, Division of Immunology, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia; the Department of Immunology, University of Mohammed VI for health sciences, Casablanca, Morocco. For their cross-sectional population-based study, the team enrolled 192 randomly selected healthy school children, who all tested negative for tissue transglutaminase-IgA. The team then used polymerase chain reaction sequence-specific oligonucleotide probes to type the children for D QA1 and D QB1 genes. More than half of the children carried the high-risk celiac disease-associated HLA-DQ molecules at the following rates: homozygous DQ2.5 ( 2.6%), DQ2.5/DQ2.2 ( 4.7%), heterozygous DQ2.5 ( 28.15%), homozygous DQ8 ( 4.2%), DQ8/DQ2.2 ( 3.6%), and double dose DQ2.2 ( 9.4%). Another 13% had low-risk celiac disease-associated HLA-DQ molecules, single dose DQ2.2 and heterozygous DQ8. In the ultra low-risk groups, subjects without alleles that promote DQ2/DQ8 variants (33.5%), 13.5% carried only one of the alleles of the high-risk HLA-DQ2.5 heterodimer called "half-heterodimer" (HLA-DQA1*05 in 12% and HLA-DQB1* 02 in 1.5%), and 20.8% lacked all the susceptible alleles (DQX.x). The celiac disease-risk groups showed no important differences in gender distribution. More than half the healthy general Saudi population carries celiac disease-predisposing HLA-DQ genotypes, one of the highest general rates in the world; a fact that may help to explain the high rates of celiac disease in the Saudi population. Source: Saudi J Gastroenterol. 2018 Sep-Oct;24(5):268-273. doi: 10.4103/sjg.SJG_551_17

Celiac.com 09/09/2013 - Many people with celiac disease show slightly elevated liver enzymes, though these enzyme levels usually return to normal after gluten-free diet. A team of researchers recently set out to investigate the cause and prevalence of altered liver function tests in celiac patients, basally and after 1 year of gluten-free diet. The research team included Giovanni Casella, Elisabetta Antonelli, Camillo Di Bella, Vincenzo Villanacci, Lucia Fanini, Vittorio Baldini, and Gabrio Bassotti. They are affiliated with the Medical Department, and the Clinical Pathology Department of Desio Hospital in Monza and Brianza, Italy, the Department of Clinical and Experimental Medicine, Gastroenterology and Hepatology Section at the University of Perugia in Perugia, Italy, and with the Department of Laboratory Diagnostics, Pathology Section, Brescia, Italy. The team gathered data from 245 untreated celiac disease patients, 196 women and 49 men, ranging in age from 15 to 80 years. They then analyzed the data, and assessed the results of liver function tests performed before and after diet, as well as associated liver pathologies. They found that 43 (17.5%) of the 245 patients, showed elevated levels of one or both aminotransferases; In 41 patients (95%) the elevation was mild, meaning that it was less than five times the upper reference limit. The remaining two patients (5%) showed marked elevation, meaning levels more than ten times the upper reference limit. After patients eliminated gluten for one year, aminotransferase levels normalized in all but four patients, who had HCV infection or primary biliary cirrhosis. Celiac patients who show hypertransaminaseaemia at diagnosis, and who do not show normalization of liver enzymes after 12 months of gluten-free diet, likely suffer from coexisting liver disease. In such cases, the research team recommends further assessment to assess the possible coexisting liver disease. Spotting and treating coexisting liver disease in celiac patients is important for improving liver function and preventing possible complications. Source: Liver International. 2013;33(7):1128-1131.

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.

Celiac.com 08/15/2017 - Some evidence indicates that rates of celiac disease in the general population are increasing over time. Prior to the discovery of gluten's role in celiac disease, the prognosis for celiac sufferers was bleak. Did higher betas of death keep celiac disease rates correspondingly lower? To provide an answer, a team of researchers set out to examine a possible relationship between mortality rates for children under five, and prevalence rates of celiac disease. The research team included Federico Biagi; Alberto Raiteri; Annalisa Schiepatti; Catherine Klersy; and Gino R. Corazza. Their team conducted a review of literature, and found 27 studies done in 17 different countries between 1995 and 2011 describing rates of celiac disease in schoolchildren. Four of the studies were conducted in Italy. Their meta-analysis compared prevalence rates between specific-country under-five mortality groups, publication year and age. In recent decades, mortality rates for under-five year olds have been decreasing all over the world. This reduction is paralleled by rising rates of celiac disease. The Spearman correlation coefficient for these terms was -63%, 95%CI -82% to -33% (p < 0.001). So, the higher the mortality rate, the lower the prevalence of celiac disease. This finding is confirmed by the meta-analysis of the 4 studies conducted in Italy over time. The mortality rate for under five-year-olds seems to influence the rate of celiac disease in the general population. They predict a rise, in the near future, of the number of celiac disease patients, due to better survival rates of celiac children. Source: Journal of Pediatric Gastroenterology & Nutrition: Post Acceptance: July 27, 2017. doi: 10.1097/MPG.0000000000001696

Celiac.com 01/04/2017 - A team of researchers recently set out to investigate the impact of celiac disease diagnosis on anthropometric measures at late adolescence, and to assess trends in the prevalence of diagnosed celiac disease over time. The research team included Amit Assa, Yael Frenkel-Nir, Ya'ara Leibovici-Weissman, Dorit Tzur, Arnon Afek, Lior H Katz, Zohar Levi, and Raanan Shamir. They are variously affiliated with the Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petach Tikva, Israel, the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, the Medical Corps of the Israel Defense Forces, Ramat-Gan, Israel, the Institute of Gastroenterology, Rabin Medical Center-Beilinson Campus, Petach Tikva, Israel, and with the Ministry of Health in Jerusalem, Israel. Around 17 years of age, most of the Israeli Jewish population undergoes a general health examination, before enlistment in the Defense Forces. Individual medical information, diagnoses, etc., are entered into a structured database. For their population based study, the research team reviewed the enlistment data base for celiac disease cases between the years 1988 and 2015. In all, the team reviewed the medical records of 2,001,353 individuals, focusing on body measurements and physical health at the age of 17 years. Overall, they found and assessed 10,566 cases of celiac disease (0.53%). Multivariable analysis showed that adolescent boys with celiac disease were leaner (Body Mass Index 21.2±3.7 vs 21.7±3.8, p=0.02), while girls with celiac disease were shorter (161.5±6 cm vs 162.1±6 cm, p=0.017) than the general population. The prevalence of diagnosed celiac disease increased from 0.5% to 1.1% in the last 20 years, mainly among females, who saw a rise of 0.64% vs 0.46% for males. Celiac disease rates were far lower in people of lower socioeconomic status, and those of African, Asian and former Soviet Union origin. However, the clinical relevance of the small differences suggests that when celiac disease is diagnosed during childhood, final weight and height are not severely impaired. The team's cohort supports an observed rise in celiac disease diagnoses in the last couple of decades. Source: Arch Dis Child doi:10.1136/archdischild-2016-311376

Celiac.com 12/20/2011 - There has been some controversy surrounding the idea that there is a higher prevalence of undiagnosed celiac disease in people with infertility, with some studies finding it but others not. Most of these studies have been performed in Europe; only two to date have taken place in the United States. Peter Green’s group at Columbia recently tried to establish the actual prevalence of undiagnosed celiac disease in the infertile population in the United States, to determine if it would make sense to routinely screen a subgroup of infertile patients for celiac disease. Their results are published in The Journal of Reproductive Medicine. Study participants were recruited from the population who came to Columbia’s Center for Women’s Reproductive Care to deal with their infertility issues, which they had been coping with for at least a year. One hundred eight-eight women, ages 25-39, volunteered to participate in the study. They underwent serological screening for tissue transglutaminase (tTG IgA) and endomysial antibodies (EMA IgA), and measurement of total IgA and both IgA and IgG antigliadin antibodies was done to control for the potential IgA deficiency in some individuals. Four of the 188 patients enrolled in the study were diagnosed with celiac disease, making the prevalence of celiac disease in this population 2.1%. Yet a subgroup analysis of the prevalence of celiac disease in women with unexplained fertility revealed a prevalence of 5.9%, which achieves statistical significance. All four women reported suffering from gastrointestinal symptoms before their diagnosis, and they had a significantly increased prevalence of Irritable Bowel Syndrome as well. The authors admit that this is quite a small sample, and because screening was voluntary, it is also a selected population. But even so, they suggest that physicians should inquire about GI symptoms when patients present with infertility, and that screening for celiac is appropriate in those with unexplained infertility who complain of gastrointestinal distress. They even go so far as to posit that all women with unexplained infertility be screened for celiac, even if they don’t have gastrointestinal trouble. All four women conceived within ten months after starting on a gluten free diet, two naturally and two with help. And all of them went on to deliver healthy babies. Source: Choi JM, Lebwohl B, Wang J, Lee SK, Murray JA, Sauer MV, Green PH. Increased prevalence of celiac disease in patients with unexplained infertility in the United States. J Reprod Med. 2011 May-Jun; 56(5-6):199-203.

Celiac.com 10/12/2011 - According to recent estimates, three million Americans suffer from celiac disease—approximately 1% of the population, and only three percent of them have to this writing been correctly diagnosed. As startling as that sounds to us all, according to a news article on Medscape Today, the incidence of celiac disease has increased markedly over the last three decades, perhaps even as fourfold, and studies are suggesting the incidence may actually be higher than 1% of the population. What is the reason for this? According to Dr. Jonas Ludvigsson, MD, from the Department of Medicine, Epidemiology Unit at the Karolinska Institute and Orebro University Hospital in Sweden, and a renowned celiac expert, there may be many factors explaining this, but there probably is an actual increase underlying these. The Medscape article went on to report that the Mayo Clinic has confirmed increase in celiac disease incidence, reported in Discovery's Edge, the Mayo Clinic's research magazine. Dr. Joseph Murray, MD, and colleagues analyzed stored blood samples from Air Force recruits in the early 1950s for gluten antibodies. It was assumed that 1% would be positive, given today's estimates, but the number of positive results was far smaller. Dr. Murray and his colleagues compared their results with two more recently collected sets with the conclusion that celiac disease is about four times more common today than it was in the 1950s. Additionally, Dr. Ludviggon's research team in Sweden has found that those living with celiac disease and latent celiac disease have higher mortality than those who don't have these conditions. Latent celiac disease is also known as "gluten sensitivity," a term to describe those who have "normal small intestinal mucosa but positive celiac disease serology," estimated to affect 1 in 1000 people. According to Dr. Ludvigsson's research team, in 1 year, 10 of 1000 individuals with celiac disease will die, as compared with 7 in 1000 individuals without the disease. The mortality rate is increased among those who also have latent celiac disease as well. The increased risk, however, is quite small. As alarming as the statistics are regarding the increasing rate of celiac disease, Dr. Ludvigsson shares some good news with Medscape—the methods of diagnosing celiac disease are actually improving. According to some other estimates, the rate of celiac diagnosis rate is increasing. For those who are testing positive for the celiac disease, the only method of treatment currently available is eliminating gluten from the diet. Yes, this is a simple treatment, although it can require some challenging lifestyle adjustments for the gluten-free community, something which I address in my work as an author, researcher, and gluten-free advocate. In the future, we may see other treatments such as gluten-digesting enzymes (which are on the rise) or even the genetic modification of the structure of gluten in wheat so that it will not cause an autoimmune reaction in celiac patients. Even with celiac diagnosis incidence on the rise, with raised awareness and effective diagnosis, we can help change the lives of millions of celiac Americans for the better. This is an important endeavor.

This article originally appeared in the Spring 2011 edition of Celiac.com's Journal of Gluten-Sensitivity. Celiac.com 09/07/2011 - Through the hard work and concerted efforts of many support groups and individuals throughout the US, along with the generosity of Instituto Di Ricerca in Italy, research funding was accumulated. Early in the Twenty-First Century, under the auspices of the Center for Celiac Disease Research, a new epoch in celiac disease awareness was born. Spearheaded by Dr. Alessio Fasano and several other prominent gastroenterologists, a large multi-center study was undertaken and the rate of celiac disease in the general U.S. population was determined to be at least 1 in 133 (1). This pains-taking, thorough, time-consuming and expensive research started a landslide of opinions that shifted the medical paradigm on the prevalence of celiac disease in the US, and caused ripples in medical thinking throughout the world. Celiac disease quickly became known as a very common ailment that is partly driven by a genetic predisposition, and is now thought to afflict about one percent of Americans. This increase in recognized prevalence is largely the result of studies that are conducted by testing blood from healthy blood donors to determine these numbers (more on this shortly). Yet a recent article from the medical literature asserts that current reports of the prevalence of celiac disease are over-estimating the actual portion of the population that is afflicted by this ailment. This article, published in the Annals of Medicine and Expert Opinion in December of 2010, offers its own estimate the prevalence of celiac disease at about 1 in 160 (2). What are we to believe? Is the rate of celiac disease really overestimated by many of the experts conducting research in this area? Or is there some other explanation? There are actually several reasons that Biagi and colleagues have arrived at their reduced estimate of prevalence, and there is good cause to reject their claim in favor of the data indicating a prevalence of celiac disease that is close to 1% of American and other populations where gluten grains form a major part of the diet. The biases expressed by Biagi et al combine in this report to form what is probably the most glaring cause of their aberrant finding. These biases show up, both in their computations and in several emotion laden statements that appear in their report. There are also some indications to suggest that the statistical methods they employed are not appropriate for the data presented, especially when publishing an account that relies so heavily on statistical tools. For instance, they have failed to include some of the published data that fit within their inclusion criteria and would have significantly altered their results. There are also several confounding variables that were either overlooked or that warranted more attention than they were given by Biagi et al. Finally, despite their acknowledgement of some of the weaknesses in the process by which they arrived at their estimate, they have chosen to impugn the work of other researchers who have reported a higher frequency of celiac disease rather than entertain the possibility that it is their own analyses and paradigm that are problematic. Even their choice of research method, the systematic review, is suspect, as it offers more opportunities for inclusion of the very errors they have made. Systematic reviews provide estimates based on averages of published research findings drawn from groups of studies of similar structure and design. The intent of this approach is to dampen the effects of extreme results, providing a more widely applicable and a more generally accurate perspective, eliminating variations driven by geographic location, accessibility of health care, research biases, etc. This is a useful tool that can be very helpful to busy clinicians by providing summaries that explain and clarify variations in findings as well as identifying mitigating factors in extreme findings. When done properly, these reviews reduce bias and other confounding factors, ultimately enhancing evidence-based optimal health care (3). However, Biagi and colleagues have fallen short of these ideals (2). They twice refer to their feelings in this report. Such expressions of the authors’ personal feelings reflect biases and preconceived notions that should not form any part of a scientific report. Yet they repeatedly do so. They go on to offer a rather snide parenthetic comment suggesting abuses of tissue transglutaminase testing. Such remarks demonstrate strong personal biases that interfere with the provision of objective information. Since bias reduction is an important, stated objective of the systematic review, this report by Biagi and colleagues should have been rejected by those who reviewed it. Biagi and colleagues do acknowledge that published research results vary so widely that they can not use the superior statistical method called a meta-analysis. (This is a method that can be especially useful with respect to celiac disease because when groups of research subjects are small, meta-analyses can be used to combine the findings from many small groups and provide more meaningful information.) The authors of the paper in question explain their choice of systematic review, yet this approach requires an exhaustive exploration of the relevant literature (3) which should have reached further than the small set of search terms they used. In the interests of accuracy, it is important to find most or all of the relevant literature. Their limited search methods may explain why they missed several important studies, including the investigation of 989 Saharawi children by Catassi et al (4). Such studies would have altered their findings substantially which they side-step in a letter defending their original paper, published in the subsequent issue of the same journal (5). For instance, Catassi et al found a 5.6% prevalence of celiac disease among the sub-Saharan African children investigated (4). That is five and one half times as frequent as the prevalence figure that they have impugned. Surely they needed to at least acknowledge the existence of this report. They neither included it nor acknowledged it. In their letter of defence they assert that diagnoses were made on the basis of blood tests, not intestinal biopsies. However, many of the studies they did include in their data also offered diagnoses on the basis of blood tests in the absence of intestinal biopsies (5). Biagi et al also assert over-estimation due to inclusion of “patients already known to be affected by celiac disease” (celiac disease). But how could their approach lead to an accurate tally of the percentage of all persons in a given population who have celiac disease? There appears to be some confusion about the meaning of the term “prevalence”. For instance, if a test group of 10,000 is identified and all participants are tested for celiac disease, yet several of them were previously diagnosed with celiac disease, Biagi and colleagues expect these previously diagnosed celiac patients to be excluded. Most of those who were previously diagnosed would test negative because they are now eating a gluten free diet. According to the Biagi paper, we should either exclude these people from our test group, or identify them as not having celiac disease. Either alternative is likely to produce much less accurate results than including them in the group that has celiac disease. (This approach alone would produce the faulty results they report in any population where there is reasonable access to modern health care.) Prevalence, after all, is a statement of the number of cases of a particular disease in a particular population. Excluding cases that were previously identified just doesn’t make any sense. Further, since IgA deficiency forms almost 2% of some populations (6) and the prevalence of celiac disease in IgA deficiency, in the same population is reported at 14% (4), such a significant confounding variable warrants attention. Yet Biagi et al do not even mention it. Let me explain. If total IgA was not measured in some, most, or all of the studies reviewed by Biagi et al, then IgA deficiency should reduce the reported prevalence by about 14%. That difference alone would bridge most of the gap between the 1:133 and 1:160 prevalence findings. But serology (blood testing) misses more than just IgA deficiency (7). This significant portion of the reports reviewed should therefore be expected to significantly under-estimate the prevalence of celiac disease. This is because, in these studies, case finding is often done with serological testing. Thus, these researchers will often fail to detect, and they will therefore have failed to biopsy, significant numbers of cases of seronegative celiac disease, both because of those excluded as blood donors due to their anaemia and/or malnourished condition and because of those who are seronegative, whether due to IgA deficiency or other reasons. If any of the studies Biagi and colleagues reviewed used symptoms and signs for case finding, this is yet another source of underestimation, one that is probably the cause of current under-diagnosis of celiac disease that is estimated at above 95%. These authors point out that “anaemia or insufficient body weight are universally recognized as criteria that preclude enrolment as blood donors.” Since more than one quarter (13/41) of the studies they reviewed report rates based on case finding through the screening of healthy blood donors, the results of these studies must underestimate prevalence regardless of the authors’ feelings on the topic. Yet it is their feelings they harken to on this issue: “We feel that we did not find this difference because of the wide heterogeneity of the published papers which hampered a specific analysis focusing on this point.” I don’t much care what they feel. I want to know what evidence they can report. If they are interested in communicating about their feelings, there are many appropriate venues for such exchanges, but the medical research literature seems, at best, a very questionable choice. Much of the evidence they offered in support of their assertions that researchers are over-estimating celiac disease could more accurately be seen as inducing under-estimations of this common ailment. Finally, are the researchers who authored 41 separate reports failing so miserably at the diagnostic process that they miss the mark on a majority of marginal cases of celiac disease? This is the thrust of the Biagi et al statement: “Again, patients with minimal intestinal lesions and/or negative coeliac antibodies were always considered to be affected by celiac disease. Although these patients certainly exist, in our clinical experience they are very rare and most of the time they are not affected by celiac disease but are the result of diagnostic mistakes.“(2) In short, Biagi and colleagues claim to be so superior to the world leaders in celiac research that Biagi et al’s clinical experience is somehow more valid and accurate than the peer-reviewed, reported findings of most others working in this field (5). The proposition that the majority of celiac researchers are over-estimating the prevalence of celiac disease ignores variations due to IgA deficiency, seronegativity (negative blood tests), and ignores the variability of intestinal damage as shown by the Marsh system and other approaches for evaluating intestinal histology and/or diagnosing celiac disease without intestinal biopsies (8, 9, 10, 11, 12). Further, while many investigators have reported that potential or latent celiac disease often shows a similar constellation of signs and symptoms to those seen in celiac disease, Bertini et al have recently demonstrated that many cases of potential celiac disease show the same signatures of metabolic disturbances, both in the bloodstream and in urinary excretions, as those found in celiac disease (12). Such disturbances, whether in the context of celiac disease or potential celiac disease, normalize on a gluten free diet (13). In all, the Biagi et al article reflects the authors’ biases, serious limitations in the authors’ applications of the relevant statistical tools, and calls into question the quality of the process in this instance. Sources: Fasano A, Berti I, Gerarduzzi T, Not T, Colletti RB, Drago S, Elitsur Y, Green PH, Guandalini S, Hill ID, Pietzak M, Ventura A, Thorpe M, Kryszak D, Fornaroli F, Wasserman SS, Murray JA, Horvath K. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003 Feb 10;163(3):286-92 Biagi F, Klersy C, Balduzzi D, Corazza GR. Are we not over-estimating the prevalence of coeliac disease in the general population? Ann Med. 2010 Dec;42(8):557-61. Epub 2010 Oct 1. Cook DJ, Mulrow celiac disease, Haynes RB.Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med. 1997 Mar 1;126(5):376-80. Catassi C, Rätsch IM, Gandolfi L, Pratesi R, Fabiani E, El Asmar R, Frijia M, Bearzi I, Vizzoni L. Why is coeliac disease endemic in the people of the Sahara? Lancet. 1999 Aug 21;354(9179):647-8. Hoggan, R. Comment on: Are we not over-estimating the prevalence of celiac disease in the general population? Annals of Medicine and Expert Opinion, 2011, 43: 164-65 Bahari A, Karimi M, Sanei-Moghaddam I, Firouzi F, Hashemi M. Prevalence of celiac disease among blood donors in Sistan and Balouchestan Province, Southeastern Iran. Arch Iran Med. 2010 Jul;13(4):301-5. Sugai E, Hwang HJ, Vázquez H, Smecuol E, Niveloni S, Mazure R, Mauriño E, Aeschlimann P, Binder W, Aeschlimann D, Bai JC. New serology assays can detect gluten sensitivity among enteropathy patients seronegative for anti-tissue transglutaminase. Clin Chem. 2010 Apr;56(4):661-5. Epub 2009 Dec 18. Kurppa K, Ashorn M, Iltanen S, Koskinen LL, Saavalainen P, Koskinen O, Mäki M, Kaukinen K. Celiac disease without villous atrophy in children: a prospective study. J Pediatr. 2010 Sep;157(3):373-80, 380 Salmi TT, Collin P, Reunala T, Mäki M, Kaukinen K. Diagnostic methods beyond conventional histology in coeliac disease diagnosis. Dig Liver Dis. 2010 Jan;42(1):28-32. Kaukinen K, Collin P, Mäki M.Latent coeliac disease or coeliac disease beyond villous atrophy? Gut. 2007 Oct;56(10):1339-40. Troncone R, Auricchio R, Granata V. Issues related to gluten-free diet in coeliac disease. Curr Opin Clin Nutr Metab Care. 2008 May;11(3):329-33. Bertini I, Calabrò A, De Carli V, Luchinat C, Nepi S, Porfirio B, Renzi D, Saccenti E, Tenori L. The metabonomic signature of celiac disease. J Proteome Res. 2009 Jan;8(1):170-7. Bernini P, Bertini I, Calabro A, la Marca G, Lami G, Luchinat C, Renzi D, Tenori L. Are Patients with Potential Celiac Disease Really Potential? The Answer of Metabonomics. J Proteome Res. 2010 Dec.

Celiac.com 08/19/2011 - According to recent estimates, 3 million Americans suffer from celiac disease - approximately 1% of the population, and only three percent of them have to this writing been correctly diagnosed. As startling as that sounds to us all, according to a news article on Medscape Today, the incidence of celiac disease has increased markedly over the last three decades, perhaps even as fourfold, and studies are suggesting the incidence may actually be higher than 1% of the population. What is the reason for this? According to Dr. Jonas Ludvigsson, MD, from the Department of Medicine, Epidemiology Unit at the Karolinska Institute and Orebro University Hospital in Sweden, and a renowned celiac expert, there may be many factors explaining this, but there probably is an actual increase underlying these. The Medscape article went on to report that the Mayo Clinic has confirmed increase in celiac disease incidence, reported in Discovery's Edge, the Mayo Clinic's research magazine. Dr. Joseph Murray, MD, and colleagues analyzed stored blood samples from Air Force recruits in the early 1950s for gluten antibodies. It was assumed that 1% would be positive, given today's estimates, but the number of positive results was far smaller. Dr. Murray and his colleagues compared their results with two more recently collected sets with the conclusion that celiac disease is about four times more common today than it was in the 1950's. Additionally, Dr. Ludviggon's research team in Sweden has found that those living with celiac disease and latent celiac disease have higher mortality than those who don't have these conditions. Latent celiac disease is also known as "gluten sensitivity," a term to describe those who have "normal small intestinal mucosa but positive celiac disease serology," estimated to affect 1 in 1000 people. According to Dr. Ludvigsson's research team, in 1 year, 10 of 1000 individuals with celiac disease will die, as compared with 7 in 1000 individuals without the disease. The mortality rate is increased among those who also have latent celiac disease as well. The increased risk, however, is quite small. As alarming as the statistics are regarding the increasing rate of celiac disease, Dr. Ludvigsson shares some good news with Medscape—the methods of diagnosing celiac disease are actually improving. According to some other estimates, the rate of celiac diagnosis rate is increasing. For those who are testing positive for the celiac disease, the only method of treatment currently available is eliminating gluten from the diet. Yes, this is a simple treatment, although it can require some challenging lifestyle adjustments for the gluten-free community, something which I address in my work as an author, researcher, and gluten-free advocate. In the future, we may see other treatments such as gluten-digesting enzymes (which are on the rise) or even the genetic modification of the structure of gluten in wheat so that it will not cause an autoimmune reaction in celiac patients. Even with celiac diagnosis incidence on the rise, with raised awareness and effective diagnosis, we can help change the lives of millions of celiac Americans for the better. This is an important endeavor.

This article originally appeared in the Spring 2011 edition of Celiac.com's Journal of Gluten-Sensitivity. Celiac.com 09/07/2011 - Through the hard work and concerted efforts of many support groups and individuals throughout the US, along with the generosity of Instituto Di Ricerca in Italy, research funding was accumulated. Early in the Twenty-First Century, under the auspices of the Center for Celiac Disease Research, a new epoch in celiac disease awareness was born. Spearheaded by Dr. Alessio Fasano and several other prominent gastroenterologists, a large multi-center study was undertaken and the rate of celiac disease in the general U.S. population was determined to be at least 1 in 133 (1). This pains-taking, thorough, time-consuming and expensive research started a landslide of opinions that shifted the medical paradigm on the prevalence of celiac disease in the US, and caused ripples in medical thinking throughout the world. Celiac disease quickly became known as a very common ailment that is partly driven by a genetic predisposition, and is now thought to afflict about one percent of Americans. This increase in recognized prevalence is largely the result of studies that are conducted by testing blood from healthy blood donors to determine these numbers (more on this shortly). Yet a recent article from the medical literature asserts that current reports of the prevalence of celiac disease are over-estimating the actual portion of the population that is afflicted by this ailment. This article, published in the Annals of Medicine and Expert Opinion in December of 2010, offers its own estimate the prevalence of celiac disease at about 1 in 160 (2). What are we to believe? Is the rate of celiac disease really overestimated by many of the experts conducting research in this area? Or is there some other explanation? There are actually several reasons that Biagi and colleagues have arrived at their reduced estimate of prevalence, and there is good cause to reject their claim in favor of the data indicating a prevalence of celiac disease that is close to 1% of American and other populations where gluten grains form a major part of the diet. The biases expressed by Biagi et al combine in this report to form what is probably the most glaring cause of their aberrant finding. These biases show up, both in their computations and in several emotion laden statements that appear in their report. There are also some indications to suggest that the statistical methods they employed are not appropriate for the data presented, especially when publishing an account that relies so heavily on statistical tools. For instance, they have failed to include some of the published data that fit within their inclusion criteria and would have significantly altered their results. There are also several confounding variables that were either overlooked or that warranted more attention than they were given by Biagi et al. Finally, despite their acknowledgement of some of the weaknesses in the process by which they arrived at their estimate, they have chosen to impugn the work of other researchers who have reported a higher frequency of celiac disease rather than entertain the possibility that it is their own analyses and paradigm that are problematic. Even their choice of research method, the systematic review, is suspect, as it offers more opportunities for inclusion of the very errors they have made. Systematic reviews provide estimates based on averages of published research findings drawn from groups of studies of similar structure and design. The intent of this approach is to dampen the effects of extreme results, providing a more widely applicable and a more generally accurate perspective, eliminating variations driven by geographic location, accessibility of health care, research biases, etc. This is a useful tool that can be very helpful to busy clinicians by providing summaries that explain and clarify variations in findings as well as identifying mitigating factors in extreme findings. When done properly, these reviews reduce bias and other confounding factors, ultimately enhancing evidence-based optimal health care (3). However, Biagi and colleagues have fallen short of these ideals (2). They twice refer to their feelings in this report. Such expressions of the authors’ personal feelings reflect biases and preconceived notions that should not form any part of a scientific report. Yet they repeatedly do so. They go on to offer a rather snide parenthetic comment suggesting abuses of tissue transglutaminase testing. Such remarks demonstrate strong personal biases that interfere with the provision of objective information. Since bias reduction is an important, stated objective of the systematic review, this report by Biagi and colleagues should have been rejected by those who reviewed it. Biagi and colleagues do acknowledge that published research results vary so widely that they can not use the superior statistical method called a meta-analysis. (This is a method that can be especially useful with respect to celiac disease because when groups of research subjects are small, meta-analyses can be used to combine the findings from many small groups and provide more meaningful information.) The authors of the paper in question explain their choice of systematic review, yet this approach requires an exhaustive exploration of the relevant literature (3) which should have reached further than the small set of search terms they used. In the interests of accuracy, it is important to find most or all of the relevant literature. Their limited search methods may explain why they missed several important studies, including the investigation of 989 Saharawi children by Catassi et al (4). Such studies would have altered their findings substantially which they side-step in a letter defending their original paper, published in the subsequent issue of the same journal (5). For instance, Catassi et al found a 5.6% prevalence of celiac disease among the sub-Saharan African children investigated (4). That is five and one half times as frequent as the prevalence figure that they have impugned. Surely they needed to at least acknowledge the existence of this report. They neither included it nor acknowledged it. In their letter of defence they assert that diagnoses were made on the basis of blood tests, not intestinal biopsies. However, many of the studies they did include in their data also offered diagnoses on the basis of blood tests in the absence of intestinal biopsies (5). Biagi et al also assert over-estimation due to inclusion of “patients already known to be affected by celiac disease” (celiac disease). But how could their approach lead to an accurate tally of the percentage of all persons in a given population who have celiac disease? There appears to be some confusion about the meaning of the term “prevalence”. For instance, if a test group of 10,000 is identified and all participants are tested for celiac disease, yet several of them were previously diagnosed with celiac disease, Biagi and colleagues expect these previously diagnosed celiac patients to be excluded. Most of those who were previously diagnosed would test negative because they are now eating a gluten free diet. According to the Biagi paper, we should either exclude these people from our test group, or identify them as not having celiac disease. Either alternative is likely to produce much less accurate results than including them in the group that has celiac disease. (This approach alone would produce the faulty results they report in any population where there is reasonable access to modern health care.) Prevalence, after all, is a statement of the number of cases of a particular disease in a particular population. Excluding cases that were previously identified just doesn’t make any sense. Further, since IgA deficiency forms almost 2% of some populations (6) and the prevalence of celiac disease in IgA deficiency, in the same population is reported at 14% (4), such a significant confounding variable warrants attention. Yet Biagi et al do not even mention it. Let me explain. If total IgA was not measured in some, most, or all of the studies reviewed by Biagi et al, then IgA deficiency should reduce the reported prevalence by about 14%. That difference alone would bridge most of the gap between the 1:133 and 1:160 prevalence findings. But serology (blood testing) misses more than just IgA deficiency (7). This significant portion of the reports reviewed should therefore be expected to significantly under-estimate the prevalence of celiac disease. This is because, in these studies, case finding is often done with serological testing. Thus, these researchers will often fail to detect, and they will therefore have failed to biopsy, significant numbers of cases of seronegative celiac disease, both because of those excluded as blood donors due to their anaemia and/or malnourished condition and because of those who are seronegative, whether due to IgA deficiency or other reasons. If any of the studies Biagi and colleagues reviewed used symptoms and signs for case finding, this is yet another source of underestimation, one that is probably the cause of current under-diagnosis of celiac disease that is estimated at above 95%. These authors point out that “anaemia or insufficient body weight are universally recognized as criteria that preclude enrolment as blood donors.” Since more than one quarter (13/41) of the studies they reviewed report rates based on case finding through the screening of healthy blood donors, the results of these studies must underestimate prevalence regardless of the authors’ feelings on the topic. Yet it is their feelings they harken to on this issue: “We feel that we did not find this difference because of the wide heterogeneity of the published papers which hampered a specific analysis focusing on this point.” I don’t much care what they feel. I want to know what evidence they can report. If they are interested in communicating about their feelings, there are many appropriate venues for such exchanges, but the medical research literature seems, at best, a very questionable choice. Much of the evidence they offered in support of their assertions that researchers are over-estimating celiac disease could more accurately be seen as inducing under-estimations of this common ailment. Finally, are the researchers who authored 41 separate reports failing so miserably at the diagnostic process that they miss the mark on a majority of marginal cases of celiac disease? This is the thrust of the Biagi et al statement: “Again, patients with minimal intestinal lesions and/or negative coeliac antibodies were always considered to be affected by celiac disease. Although these patients certainly exist, in our clinical experience they are very rare and most of the time they are not affected by celiac disease but are the result of diagnostic mistakes.“(2) In short, Biagi and colleagues claim to be so superior to the world leaders in celiac research that Biagi et al’s clinical experience is somehow more valid and accurate than the peer-reviewed, reported findings of most others working in this field (5). The proposition that the majority of celiac researchers are over-estimating the prevalence of celiac disease ignores variations due to IgA deficiency, seronegativity (negative blood tests), and ignores the variability of intestinal damage as shown by the Marsh system and other approaches for evaluating intestinal histology and/or diagnosing celiac disease without intestinal biopsies (8, 9, 10, 11, 12). Further, while many investigators have reported that potential or latent celiac disease often shows a similar constellation of signs and symptoms to those seen in celiac disease, Bertini et al have recently demonstrated that many cases of potential celiac disease show the same signatures of metabolic disturbances, both in the bloodstream and in urinary excretions, as those found in celiac disease (12). Such disturbances, whether in the context of celiac disease or potential celiac disease, normalize on a gluten free diet (13). In all, the Biagi et al article reflects the authors’ biases, serious limitations in the authors’ applications of the relevant statistical tools, and calls into question the quality of the process in this instance. Sources: Fasano A, Berti I, Gerarduzzi T, Not T, Colletti RB, Drago S, Elitsur Y, Green PH, Guandalini S, Hill ID, Pietzak M, Ventura A, Thorpe M, Kryszak D, Fornaroli F, Wasserman SS, Murray JA, Horvath K. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003 Feb 10;163(3):286-92 Biagi F, Klersy C, Balduzzi D, Corazza GR. Are we not over-estimating the prevalence of coeliac disease in the general population? Ann Med. 2010 Dec;42(8):557-61. Epub 2010 Oct 1. Cook DJ, Mulrow celiac disease, Haynes RB.Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med. 1997 Mar 1;126(5):376-80. Catassi C, Rätsch IM, Gandolfi L, Pratesi R, Fabiani E, El Asmar R, Frijia M, Bearzi I, Vizzoni L. Why is coeliac disease endemic in the people of the Sahara? Lancet. 1999 Aug 21;354(9179):647-8. Hoggan, R. Comment on: Are we not over-estimating the prevalence of celiac disease in the general population? Annals of Medicine and Expert Opinion, 2011, 43: 164-65 Bahari A, Karimi M, Sanei-Moghaddam I, Firouzi F, Hashemi M. Prevalence of celiac disease among blood donors in Sistan and Balouchestan Province, Southeastern Iran. Arch Iran Med. 2010 Jul;13(4):301-5. Sugai E, Hwang HJ, Vázquez H, Smecuol E, Niveloni S, Mazure R, Mauriño E, Aeschlimann P, Binder W, Aeschlimann D, Bai JC. New serology assays can detect gluten sensitivity among enteropathy patients seronegative for anti-tissue transglutaminase. Clin Chem. 2010 Apr;56(4):661-5. Epub 2009 Dec 18. Kurppa K, Ashorn M, Iltanen S, Koskinen LL, Saavalainen P, Koskinen O, Mäki M, Kaukinen K. Celiac disease without villous atrophy in children: a prospective study. J Pediatr. 2010 Sep;157(3):373-80, 380 Salmi TT, Collin P, Reunala T, Mäki M, Kaukinen K. Diagnostic methods beyond conventional histology in coeliac disease diagnosis. Dig Liver Dis. 2010 Jan;42(1):28-32. Kaukinen K, Collin P, Mäki M.Latent coeliac disease or coeliac disease beyond villous atrophy? Gut. 2007 Oct;56(10):1339-40. Troncone R, Auricchio R, Granata V. Issues related to gluten-free diet in coeliac disease. Curr Opin Clin Nutr Metab Care. 2008 May;11(3):329-33. Bertini I, Calabrò A, De Carli V, Luchinat C, Nepi S, Porfirio B, Renzi D, Saccenti E, Tenori L. The metabonomic signature of celiac disease. J Proteome Res. 2009 Jan;8(1):170-7. Bernini P, Bertini I, Calabro A, la Marca G, Lami G, Luchinat C, Renzi D, Tenori L. Are Patients with Potential Celiac Disease Really Potential? The Answer of Metabonomics. J Proteome Res. 2010 Dec.

Celiac.com 03/28/2011 - While rates of diagnosed celiac disease are less than 1 in 2,000 in the United States, screening studies in European and other populations have shown a much higher prevalence. A team of researchers recently set out to assess rates of celiac disease and the benefits of screening in the general adult population in certain geographically isolated areas. The research team included Kent D. Katz MD, Shahrooz Rashtak MD, Brian D. Lahr BS, MS, L. Joseph Melton III MD, Patricia K. Krause BS, MBA, Kristine Maggi PA-C, Nicholas J. Talley MD, PhD, and Joseph A. Murray MD. They are affiliated variously with the Wyoming Medical Center in Casper, Wyoming, the Department of Dermatology, the Division of Gastroenterology and Hepatology of the Department of Internal Medicine, the Division of Biostatistics, and the Division of Epidemiology in the Department of Health Sciences Research at the Mayo Clinic in Rochester, Minnesota. The team measured serum tissue transglutaminase antibodies (tTG-IgA) in adult volunteers at the annual Casper, Wyoming, Blue Envelope Health Fair blood draw. The team then checked endomysial IgA antibodies in those with positive tTG-IgA results. For those who tested positive for both screens, the team offered endoscopy with small bowel biopsy. All participants completed a short gastrointestinal (GI) symptom questionnaire. The team did blood tests on a total of 3,850 subjects, 34 of whom tested positive for both tTG and endomysial antibody (EMA) IgA. The team excluded three individuals who had been previously diagnosed with celiac disease, leaving 31 subjects, and making the total positive celiac serology in this community sample 0.8%. The team offered small bowel biopsy to those 31 subjects. They performed a total of 18 biopsies, with 17 patients (94%) showing at least partial villous atrophy. Symptoms reported by test subjects did not predict positive diagnosis. In fact, most subjects showed no symptoms, or else showed atypical symptoms. Serologic testing readily detects celiac disease in a general population. Screening results showed that undiagnosed celiac disease affects 1 in 126 individuals in this Wyoming community. Source: Am J Gastroenterol advance online publication 1 March 2011. doi: 10.1038/ajg.2011.21