The New Picture of Celiac Disease

Celiac disease was long considered to be a rare condition; characterized by obvious symptoms such as diarrhea, abdominal distention, and failure to thrive; and not common in areas of the Middle East where the domestication and cultivation of wheat began.

Studies in the past several years, including a few new studies, paint a completely different picture.

Research conducted a few years ago found that the majority of adults with newly diagnosed celiac disease do not have the once-considered classic symptoms of diarrhea and malabsorption. A growing percentage have silent or atypical celiac disease, with either no symptoms, or symptoms such as bone disease, anemia, acid-reflux-type conditions, constipation, or neurologic symptoms.

A 2008 study recently found that most children diagnosed with celiac disease don’t have so-called “classic” gastrointestinal symptoms either.

The new study evaluated the presentation of celiac disease in children in a pediatric gastroenterology practice in southeastern Wisconsin during a 17-year period. During that time, 143 patients were diagnosed with celiac disease. Gastrointestinal symptoms predominated in children younger than 3 years, whereas in children older than 3 years, the majority presented with nongastrointestinal conditions associated with a high risk of developing celiac disease, including type 1 diabetes, thyroid disease, Down syndrome, iron-deficiency anemia, short stature, or mood disorders – or they were tested because they were a first-degree relative of a person with celiac disease.

The classic clinical view of pediatric celiac disease, which includes malnutrition, diarrhea, bloating, and abdominal pain, should be replaced with the more typical presentation of an asymptomatic school-aged child who belongs to a high-risk group. The authors of the study recommend screening people, and first-degree family members of people, with Down syndrome, Turner syndrome, type 1 diabetes, thyroiditis, Addison disease, short stature, iron-deficiency anemia, unexplained elevation of aminotransferase levels, and other autoimmune disorders.

In another 2008 study, the prevalence of celiac disease in children was evaluated in Egypt where large amounts of gluten-containing cereals are consumed and where researchers believed that some adaptation to wheat gluten had taken place. However, the study found a prevalence of celiac disease in the general pediatric population in Egypt similar to that in Europe. Many cases were subclinical, showing just a mild degree of growth failure and anemia. Egyptian children with celiac disease often showed only mild to moderate changes in the small intestinal biopsy specimen, leading the researchers to warn that performing blood tests to screen for celiac disease is even more important in these areas.

Egypt, Turkey and Iran are countries in the so-called Fertile Crescent, where the domestication and cultivation of wheat and other grains started approximately 10,000 years ago. It has long been theorized that the high celiac disease frequency in northwestern Europe could be attributed to a lack of exposure to grains until relatively recently and that areas of the Middle East didn’t have similar rates of celiac disease. But these recent studies and studies from Turkey and Iran have found that the prevalence of celiac disease in Fertile Crescent countries are not much different from that in European countries. Current research does not support the theory that celiac disease is less common in areas where wheat was historically eaten first and more prevalent in areas where wheat was introduced more recently.


Abu-Zekry M, Kryszak D, Diab M, et al. Prevalence of celiac disease in Egyptian children disputes East-West agriculture-dependent spread of the disease. Journal of Pediatric Gastroenterology and Nutrition, 2008;47:136-140.

Rampertab SD, Pooran N, Brar P, et al. Trends in the presentation of celiac disease. American Journal of Medicine, 2006;119;355.e9-355.e14.

Rostami K, Malekzadeh R, Shahbazkhani B et al. Coeliac disease in Middle Eastern countries: a challenge for the evolutionary history of this complex disorder? Digestive and Liver Disease, 2004;36;694-697.

Telega GT, Bennet TR, Werlin S. Emerging clinical patterns in the presentation of celiac disease. Archives of Pediatric and Adolescent Medicine, 2008;162:164-168.

Melissa’s Comments:

Virtually everything most doctors learned about celiac disease in medical school is archaic. Many health professionals don’t stay up to date with the latest research. That’s why celiac disease often goes undiagnosed or takes years or decades to be detected.

Many health journalists don’t study the research either. That’s why many stories in the media often perpetuate the idea that people with celiac disease are always underweight and wracked with severe diarrhea and malnutrition.

What’s the new picture of celiac disease? The atypical forms of celiac disease are fast becoming the typical. There are more normal weight or overweight people than underweight people with celiac disease. Celiac disease is common, even in areas of the Middle East where it was thought to uncommon. The condition, however, often goes undiagnosed. The prevalence of celiac disease in many areas of the world still isn’t known, but the highest prevalence known so far is 5.6 percent in the Saharawi, a population of Arab-Berber people living in the western Sahara desert.

Many new discoveries that have changed the picture of celiac disease have surfaced in just the past few years. But that’s just celiac disease. There is an explosion of interest in gluten sensitivity, which affects far more people than celiac disease does, and researchers are now studying that, too. Hopefully, within a decade or so, researchers will understand celiac disease and gluten sensitivity in great detail and information about these conditions (and all the different symptoms that may indicate gluten-related illness) will become common knowledge, dramatically improving public health.

To learn more about celiac disease and gluten sensitivity, be sure to check out my book, Going Against the Grain. The information I wrote about those conditions in my book still holds true today.

© Copyright 2008 Melissa Diane Smith

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