Guest Post: Dr. Jonas Ludvigsson Summarizes the UEGW Celiac Disease Interest Group Meeting
A few weeks ago, Kristin (NFCA’s Healthcare Relations Manager) received an email about the United European Gastroenterology Week (UEGW) Interest Group Meeting on Celiac Disease, held in Stockholm, Sweden on Oct. 23, 2011. While Kristin wasn’t able to hop a flight to attend, she asked celiac expert Jonas F. Ludvigsson, MD, PhD, of the Department of Pediatrics, Örebro University Hospital, Örebro, Sweden, to share his thoughts from the meeting. Here’s what Dr. Ludvigsson had to say:
This year’s celiac disease group meeting had the title “Quantifying the frequency and consequences of coeliac disease: perspectives from coeliac disease and related areas.” The meeting was chaired by Chris Mulder and Jonas F. Ludvigsson.
Tim Card, Nottingham, was the first speaker and had been given the task to review the prevalences of GI diseases in Europe. He did, however, start out with a slide showing Robin Hood! Tim Card noted that the celiac disease prevalence is difficult to estimate since it is dependent on the definition of celiac disease. The celiac disease definition has changed over time, and in general the prevalence is highest in studies where only antibody positivity is required for diagnosis, while histology gives you intermediate prevalences; and clinically diagnosed celiac disease gives you the lowest prevalence.(1)
Card commented on the Mustahlati study(2) and during the celiac disease interest group meeting there was some discussion regarding geographical differences in celiac disease. Mulder pointed out that many cases of tropical sprue in India are actually celiac disease.
In contrast to celiac disease, the definition of inflammatory bowel disease (IBD) has been fairly constant over time, which makes the prevalence much easier to follow over time. Of note, Tim Card showed that data on prevalence and incidence could be used to calculate the duration of IBD in a patient (patients may die). He also estimated that about 1/3 of all ulcerative colitis patients are unknown to British health care.
I talked about shared risk factors in celiac disease with regards to selected complications, but I let myself stray into related areas as well, and talked about mechanisms behind complications in celiac disease. Most emphasis was placed on malabsorption of nutrients (vitamin D deficiency may explain the increased risk of asthma(3) and tuberculosis(4) in celiac disease; folic acid deficiency the increased risk of unipolar depression(5); while sometimes celiac disease complications per se lead to malabsorption (e.g. pancreatic insufficiency in celiac disease (6; 7))).
We also discussed the role of inflammation in celiac disease (8;9) and how this might influence the risk of complications(10-12). Finally, I mentioned shared genetic risk factors(13;14), which may explain the 2-3-fold increased risk of future type 1 diabetes seen in celiac disease.
After this talk, we discussed breastfeeding in celiac disease and that recent data have been contradicting regarding the role of breastfeeding. For instance, the German group Decker et al found an increased risk of future celiac disease in
children with long breastfeeding duration(15); while Welander et al found no association between breastfeeding and future celiac disease (16).
Steffen Husby talked about the link between celiac disease and type 1 diabetes (T1D). He mentioned the underlying shared genetics (DQ2/DQ8) and pointed out that there have been several publications suggesting that certain mutations (SNPs) are shared in T1DM and celiac disease (17).
In a Danish study from 2006, Hansen et al found an overall prevalence of T1D of 12.3% (18). Also Hungarian researchers have found very high prevalences of celiac in T1D patients (8.3%) (19). Patients with T1D and celiac disease have lower weight and height than non-celiac T1D patients. They more often suffered from arthralgia, loose stools, iron deficiency anaemia and abdominal pain. Untreated celiac disease resulted in lower BMI, but also lower HbA1C(!). Treatment with a gluten-free diet then led to a recovery of BMI, but also increased insulin requirements (20).
The recent paper by the Sheffield group (21), showed higher rates of advanced retinopathy 58% vs. 25%, and nephropathy 42% vs. 4% in patients with T1D and celiac disease vs. those who only had T1D. Patients with both diseases also had lower cholesterol. It seems that patients with both diseases have an increased intimal media thickness with implications for atherosclerosis (22). Husby also reviewed the evidence of other autoimmune diseases in patients with celiac disease and a gluten-free diet (23).
Cosnes et al have found that patients with a gluten-free diet were at a lower risk of other autoimmune diseases than those on a gluten-containing diet; and the potential role of gluten-free diet in T1D (24).
Joe West, Nottingham, had been asked to talk about cardiovascular disease in celiac disease. He began his lecture by listing modifiable risk factors for cardiovascular disease (smoking, cholesterol, diabetes, high blood pressure, BMI, homocysteine, etc). He then underlined that the risk of cardiovascular disease does not seem to be increased in undiagnosed celiac disease (25), but rather decreased (26).
During the meeting, we had a discussion about the slight discrepancy in cardiovascular results in Swedish data (small increased risk (11)) and British data (potentially a small decrease (27)). As Joe West pointed out, the results are not really contradicting since confidence intervals overlap. Among reasons for a potential discrepancy are 1) different socioeconomic characteristics of celiac disease patients in Sweden and Britain, 2) different smoking patterns; and perhaps 3) different BMI/risk of underweight in celiac disease patients.
Dr Fabiana Zingone, Naples, reviewed the literature around infectious diseases in celiac disease. Swedish cause-of-death data have shown an increased risk of dying from infections (28). The increased risk of infection has since been confirmed for tuberculosis (4; 29; 30), pneumococcal infections (31; 32), and influenza (33).
The increased risk of pneumococcal infections may be due to hyposplenism (34; 35). Hyposplenism is associated with fewer IgM memory B-cells that are important in the defence against encapsulated bacteria. Zingone also commented on pneumococcal vaccination in celiac disease. A British study recently suggested that the frequency of deaths from pneumonia in celiac disease is an argument to vaccinate against pneumococci (36).
Celiac disease patients may also be at increased risk of Helicobacter pylori infections (37). Park et al, as well as Zingone herself, have shown that celiac patients have a defective response to the Hepatitis vaccine (38; 39).
Finally, Luisa Mearin, the Netherlands, talked about quality of life (QoL) in celiac disease. Unfortunately, I had some problems with my computer during this last lecture, so I took fewer notes. Mearin stated that parents usually think that the quality of life is lower in their celiac children than the children themselves think! It seems that the QoL is not influenced by compliance, but by the perceived degree of difficulty.
We also discussed if/how the celiac disease diagnosis in someone with few symptoms can have a negative effect on quality of life. At the same time, a study by van Koppen et al found a good quality of life in children whose celiac disease was detected through mass screening (40).
– Jonas F. Ludvigsson, MD, PhD