Celiac DiseaseAN EPIDEMIOLOGICAL REVIEW

Stephanie Thompson, RN BSN

QUANTITATIVE EPIDEMIOLOGY I Pao-Feng Tsai, PhD, RN

What is Celiac Disease?

The History of Celiac DiseaseCeliac disease (CD) was first described in the second century by a Greek physician Aretaeus of Cappodocia. 18 centuries later, primary factors for CD were finally identified.

(Freeman, 2015)

• Life-long gluten-sensitive immune-mediated disorder caused from ingesting gluten (a protein found in wheat, rye and barley)

• Hereditary

• Affects the small intestinal mucosa leading to damage on the villi causing nutrients to by be properly absorbed

(Lionetti & Catassi, 2011)

Risk Factors of Celiac Disease• Affects both men and women

(National Foundation for Celiac Disease Awareness NFCA, 2014)

• 1st or 2nd degree relative with celiac disease (NFCA, 2014)

• HLA-DQ2 and DQ8 genes (Freeman, 2015)

• Some autoimmune diseases (Type 1 DM, primary biliary cirrhosis, autoimmune thyroid disease) and Down syndrome, Sjogren’s syndrome and immunoglobulin A [IgA] deficiency make developing CD more likely (Freeman, 2015)

• Potential risk factors for CD include perinatal events and infant feeding practice. (Ludvigsson & Fasano, 2011)

Distribution of Celiac Disease Populations at Risk

• Early reported CD risk was restricted to Europe and other developed countries, such as the USA, Canada, and Australia

• Northern India

• In China and other Asian countries, the epidemiology of celiac disease is currently unknown, but ongoing studies are showing early evidence that CD may become more prevalent due to the rising consumption of wheat-based products

(Catassi, Gatti, & Fasano, 2014)

Morbidity & Mortality of Celiac Disease

• Conflicting information was found on Morbidity and Mortality of CD: The 1st paper to describe mortality in CD patients was written only 25 years ago. The mortality rates from this paper and the 21 subsequent papers have varied from 0.52 to 3.9.

• The causes of mortality vary from GI malignancies (non-Hodgkin lymphoma and small bowel cancer) to autoimmune complications (RA, diffuse disorders of connective tissue) and ischemic heart disease

• Mortality rate is associated with the extent of the lesions and the amount of gluten consumed (before and after diagnosis)

• Morbidity is related to the clinical presentation of CD and CD is on the rise

• An estimated 1 in 133 Americans, or about 1% of the population, has CD.

Biagi, F., & Corazza, G. R. (2010)

Introduction of Gluten, HLA Status, and the Risk of Celiac Disease in Children Purpose: To clarify the relationship between the age at which gluten is introduced to a child’s diet and the risk of celiac disease.

Method: Randomly assigned newborns who had a first-degree relative with celiac disease to the introduction of dietary gluten at 6 months (group A) or 12 months (group B).

Findings & Implications: Significantly higher proportions of children in group A than in group B had celiac disease autoimmunity and overt celiac disease at age 2 By age 5, the differences were no longer significant for autoimmunity or disease. Neither the delayed introduction of gluten nor breast-feeding modified the risk of celiac disease among at-risk infants, although the later introduction of gluten was associated with a delayed onset of disease. A high-risk HLA genotype was an important predictor of disease.

Lionetti, Castellaneta, Francavilla, Pulvirenti, Tonutti, Amarri, ... & Catassi, C. (2014)

Prevalence of Childhood Celiac Disease and Changes in Infant FeedingPurpose: Sweden experienced an increase clinical celiac disease in children partly to changes in infant feeding. The study was to to determine whether infant feeding affects celiac disease.

Method: A 2-phase cross-sectional screening study. 13,279 children from 2 birth cohorts participated: children born during the epidemic (1993) and children born after the epidemic (1997). Blood samples, serological markers and small intestinal biopsies were completed. Infant feeding practices in the cohorts were ascertained via questionnaires.

Findings & Implications: Children born in 1997 had a significantly lower risk of having celiac disease compared with those born in 1993. The cohorts differed in infant feeding (the proportion of infants introduced to dietary gluten. Gradually introduce gluten-containing foods from 4 months of age, preferably during ongoing breastfeeding, is favorable.

(Ivarsson, Myléus, Norström, Van der Pals, Rosén, Högberg, ... & Carlsson, 2013)

Randomized Feeding Intervention in Infants at High Risk for Celiac Disease

Purpose: To determine if there is an opportunity to reduce the risk of celiac disease by introducing gluten to infants at 4 to 6 months of age.

Method: Multicenter, randomized, double-blind, placebo-controlled dietary intervention study

Findings & Implications: The introduction of small quantities of gluten at 16 to 24 weeks of age did not reduce the risk of celiac disease by 3 years of age in this group of high-risk children compared with placebo.

(Vriezinga, Auricchio, Bravi, Castillejo, Chmielewska, Crespo Escobar, ... & Mearin 2014)

Synthesis of the Findings:In reviewing these studies it is evident that :

• postponing the introduction of gluten until 12 months of age had no effect on the risk of the development of celiac disease in the long term, therefore delaying the development of celiac disease and reducing the prevalence of CD among children with high-risk HLA genotype

• the present infant feeding recommendation to gradually introduce gluten-containing foods from 4 months of age, preferably during ongoing breastfeeding, is favorable in reducing the prevalence of CD

• it is found that breast-feeding, whether exclusive or not, did not have a significant effect on the frequency of celiac disease

Strengths & Weakness of the Studies Introduction of Gluten, HLA Status, and the Risk of Celiac Disease in Children

• Strength: adequate sample size, standards for labs samples with the same lab company for all specimens, very good documentation regarding villous height to crypt depth

• Weakness: underestimated the number of children in whom CD developed, incomplete follow-ups, varying gluten free diets,

Prevalence of Childhood Celiac Disease and Changes in Infant Feeding • Strength: 2 cohorts of 12-year-olds with differences in infant feeding, with findings

that suggest gradual introduction of gluten in small amounts during ongoing breastfeeding is favorable but not significant; adequate sample size

• Weakness: beginning of study showed conflicting information, different labs used for diagnostics, varying strictness of gluten free diets.

Randomized Feeding Intervention in Infants at High Risk for Celiac Disease • Strength: double blind study that is randomized and placebo controlled, excellent

follow ups• Weakness: gluten introduced artificially due to the small percent amts, older

comparisons data (mid 1980’s), only clinically dx CD patients for study.

Application of the Body of Knowledge to Practice • Application of the knowledge I’ve gained while doing this course project will be

very beneficial as I further my education and begin my clinical practice.

• The increase in knowledge and awareness of celiac disease in order to improve the health care delivery and quality of life for people with these conditions is the best application to practice.

• Since CD is reversible, early diagnosis is important in the management of the disease, by knowing this, I can recommend a strict gluten-free diet.

• The most important application of knowledge I learned is that ongoing education and support are vital to helping the patient (and family) comply with the dietary changes and management of CD.

Meeting Course Objectives• Compare and contrast the strengths and weaknesses of the major study designs used in

epidemiology: cross-sectional, case-control, cohort, and clinical trials.This objective was met with this project by doing extensive research analysis while locating studies to use for the epidemiology of celiac disease. Each study was read and strengths and weaknesses located throughout the study as listed on the slide titled Strengths & Weakness of the Studies.

• Define and contrast incidence, prevalence, rate, ratio, risk, exposure, and susceptibility in order to identify health risks in individuals, families, and groups.

This objective was met by reading and studying material related to celiac disease. Each of the above topics was located throughout research studies and articles. This is where I learned more about celiac disease and how I can use the information in my clinical practice.

• Evaluate and synthesize the scientific literature on an epidemiological problem with consideration of ethical, legal, cultural, and environmental influences.

This objective was met while researching material to use for this project. The scientific literature is overwhelmingly full of epidemiological information that can be used when considering the above influences. The most prominent one that I found was cultural and environmental influences. Depending on the country where I child is raised has an influence on whether or not they are at risk for developing celiac disease.

Learning experiences to nursing practice, education or research.

Learning experiences I have gained while working on this epidemiological project are substantial. Not only have I learned the basics about the disease process of celiac disease, but I’ve learned how to effectively assess, diagnosis and manage the disease. This knowledge alone will benefit my future patients greatly. Application of the knowledge gained through the coursework as listed on the slides titled Application of the Body of Knowledge to Practice and Meeting Course Objectives outlines the information I have gleaned through the course. I am looking forward to learning more and being able to participate in evidence based practice regarding celiac disease.

REFERENCESBiagi, F., & Corazza, G. R. (2010). Mortality in celiac disease. Nature Reviews Gastroenterology and Hepatology, 7(3),

158-162.

Catassi, C., Gatti, S., & Fasano, A. (2014). The new epidemiology of celiac disease. Journal of pediatric gastroenterology and nutrition, 59, S7-S9.

Freeman, H. J. (2015). Celiac Disease: A Disorder Emerging from Antiquity, Its Evolving Classification and Risk, and Potential New Treatment Paradigms. Gut and liver, 9(1), 28.

Ivarsson, A., Myléus, A., Norström, F., van der Pals, M., Rosén, A., Högberg, L., ... & Carlsson, A. (2013). Prevalence of childhood celiac disease and changes in infant feeding. Pediatrics, 131(3), e687-e694.

Lionetti, E., & Catassi, C. (2011). New clues in celiac disease epidemiology, pathogenesis, clinical manifestations, and treatment. International reviews of immunology, 30(4), 219-231.

Ludvigsson, J. F., & Fasano, A. (2011). Timing of introduction of gluten and celiac disease risk. Annals of nutrition & metabolism, 60, 22-29.

National Foundation for Celiac Disease Awareness. (n.d.). Retrieved January 21, 2015.

Vriezinga, S. L., Auricchio, R., Bravi, E., Castillejo, G., Chmielewska, A., Crespo Escobar, P., ... & Mearin, M. L. (2014). Randomized feeding intervention in infants at high risk for celiac disease. New England Journal of Medicine, 371(14), 1304-1315.