RevPaulPediatr.2016;34(2):139---140
REVISTA
PAULISTA
DE
PEDIATRIA
www.rpped.com.br
EDITORIAL
In
time:
celiac
disease
---
some
current
aspects
of
epidemiology
and
research
Em
tempo:
doenc
¸a
celíaca
---
alguns
aspectos
atuais
de
epidemiologia
e
investigac
¸ão
Jorge
Amil
Dias
CentroHospitalarSãoJoão,Porto,Portugal
Received27August2015
Sincetheassociationbetweenglutenintakeandceliac dis-ease (CD) was established by Dicke1 during World War II,
ourunderstandingofthepathophysiologyofgluten-sensitive enteropathy has markedly increased, especially with the resources of molecular research. However, although it is clear that gluten intake causes enteropathy and extrain-testinal disease in genetically-susceptible individuals, we still lack information on additional factors to triggering mechanismsanddiseaseprevention.
Inthe60s,therewereahugetendencytointroduce cere-als early in infant feeding toprevent iron deficiency and anemia.Asaconsequence,amarkedincreaseinnewcases ofceliacdiseasewasobservedandthediseaseseemedto alsoberelatedtothetypeoffeeding,whichwouldinfluence theageofonsetofthisdisease.2
Inthe80sand90s,therewasanimportantincreaseinthe incidenceof CD in Sweden,causing the famous ‘‘Swedish epidemicofCeliacDisease’’,whichledtoseveral publica-tionsandanalyses.Themostimmediateexplanationseemed toberelatedtotheageofglutenintroductioninthedietand breastfeedingpattern.Afterimplementationofmeasuresto delaytheintroductionofglutenininfantfeeding,therewas amarkedreductioninthenumberofnewcases.3---5
E-mail:jamildias@zonmail.pt
Theanalysisofthisevolutionsuggestedthatthe introduc-tionofglutenduringbreastfeedingcouldprovideprotection againstthe occurrenceof the disease.An important mul-ticenter study (PreventCD) compared the introduction of gluten or placebo at 4 months of age during breastfeed-ingin agroupof900infants withgeneticriskforCD. The studyoutcomeafterafive-yearfollow-upshowedthatthere was no protective effect of breastfeeding during gluten introduction.6 Another study involving 553 children
eval-uated up to two years of age showed that early or late introduction of gluten did not influence the risk of CD, althoughitinfluencedtheageatitsoccurrence.7A
system-aticreview achievedthesameconclusion,suggestingthat theclassicalrecommendationof delayingtheintroduction ofglutenuntilsixmonthsofagecurrentlylacksascientific basis.8
Onemustconcludethatwestilldonotknowwhatfactors cansafelyreducetheriskofDCingeneticallypredisposed individuals. Other study hypotheses, such as intrauterine exposure,infectionsorotherenvironmentalfactorsneedto beevaluatedinsearchforthecorrectanswer.9
Another very important aspect in the current concept of CD is autoimmunity. It is nowwell recognized that CD is associated with other autoimmune diseases and the prevalenceofCDinpatientswithtype1diabetesmellitus (T1DM)ishigherthaninthegeneralpopulation.Thesearch for serologicalmarkers of CD should becarried outin all
http://dx.doi.org/10.1016/j.rppede.2016.03.012
140 DiasJA
patients with T1DM. The question becomes even more interestingregardingtheanalysisofwhichdiseaseprecedes theotherandthepossibilityofinfluencingtheautoimmune progression.10Aninterestingstudywasreportedin2015by
Korponay-Szabo:agroupof2,690schoolchildrenunderwent screeningforCDin2005.In2014,ascreeningforT1DMinthe same regionwas performed, involving 21,724 children. It wasthenverifiedthatnoneofthe45childrenthathadbeen previously diagnosed with CD and treated had developed T1DM,whiletheprevalencewas0.93/1,000amongchildren whoseparentshaddeclinedtheCDscreeningin2005.This study,which requires confirmation,suggests that onecan modifythedevelopmentofautoimmunitybyscreeningand earlyidentificationofCD.Accordingtotheauthors,theage ofsixyearsseemstobeeffectiveforthisprocess(Abstract PA-0054, available at http://journals.lww.com/jpgn/ Documents/ESPGHAN%202015%20-%20Abstracts%20JPGN% 20FINAL.pdf).
The disclosure of the potential association between glutenintakeand diseaseshas been broadlydisseminated in the media. In addition to the ‘‘non-celiac sensitivity to gluten’’, a good number of famous personalities have announced their decision to adopt a gluten-free diet to loseweightortofeelgood.Socialnetworksquickly ampli-fied this trend as a way to be fashionable or healthy (http://glutenull.com/gluten-free-celebrities/).Giventhis importantinfluenceofopinions,manypeoplehavecurrently decided to start a gluten-free diet, even in the absence ofadefiniteCDdiagnosis.Thereisnothingtobedisputed regardingtheadoptionofagluten-freedietbecauseitis‘‘in fashion’’,butthereisa realrisk intreating CDonly tem-porarily(untilitisoutoffashion),ifthediseaseispresent, andreturntotheincreasedriskofcomplicationswhenadiet withoutrestrictionsisresumed.Forthisreasonandbecause oftheinherentrisk,itisstronglyrecommendedthathealth professionalsadvisetheirpatientstostartagluten-freediet onlyafter being tested withreasonable safety (using,for instance,anti-transglutaminaseoranti-endomysial antibod-ies)andthediagnosisisruledoutorconfirmed.
In spite of the great progress in research and knowl-edge,CDremainsafascinatingdisease,withanundeniable genetic component, but also environmental factors that arenotcompletelyknown.Inthenearfuture, new devel-opments are expected in the diagnosis and treatment of
the disease, which will teach us how to better help our patients.
Funding
Thisstudydidnotreceivefunding.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.DickeWK.Coeliacdisease.Investigationoftheharmfuleffects
ofcertaintypesofcerealonpatientswithcoeliacdisease.
The-sis,Utrecht1950.
2.Kelly DA, Phillips AD, Elliott EJ, Dias JA, Walker-Smith JA. Rise and fall of coeliac disease 1960---85. Arch Dis Child. 1989;64:1157---60.
3.IvarssonA,PerssonLA,NyströmL,AscherH,CavellB,Danielsson L,etal.EpidemicofcoeliacdiseaseinSwedishchildren.Acta Paediatr.2000;89:165---71.
4.IvarssonA,PerssonLA,StenhammarL,HernellO.Isprevention ofcoeliacdiseasepossible?ActaPaediatr.2000;89:749---50.
5.MyléusA.TowardsexplainingtheSwedishepidemicofceliac disease---anepidemiologicalapproach,inDepartmentofPublic HealthandClinicalMedicine,EpidemiologyandGlobalHealth. Umea◦,Sweden:Print&Media,Umea◦University;2012.
6.VriezingaSL,AuricchioR,BraviE,CastillejoG,Chmielewska A, Crespo Escobar P, et al. Randomized feeding interven-tionin infantsathigh riskfor celiacdisease. NEngl JMed. 2014;371:1304---15.
7.LionettiE,CastellanetaS,FrancavillaR,PulvirentiA,TonuttiE, AmarriS,etal.Introductionofgluten,HLAstatus,andtherisk ofceliacdiseaseinchildren.NEnglJMed.2014;371:1295---303.
8.SzajewskaH, ShamirR,ChmielwskaA, Piescil-LechM, Auric-chioR,IvarsonA,etal.Systematicreviewwithmeta-analysis: earlyinfantfeedingandcoeliacdisease---update2015.Aliment PharmacolTher.2015;41:1038---54.
9.LebwohlB,MurrayJA,VerduEF,CroweSE,DennisM,Fasano A, et al. Gluten introduction, breastfeeding, and celiac disease: back to the drawing board. Am J Gastroenterol. 2016;111:12---4.
