Post on 30-Mar-2015
Coeliac Disease in the Maltese Islands
Thomas M Attard MD FAAP FACG
Consultant Paediatrician and gastroenterologist
Mater Dei Hospital, B’Kara, Malta
The Maltese Islands - statistics
• Surface area 316 km2• Population 413,609• Population density 1,309†
• Live births 4,126 : • Crude birth rate 10.0• GDP € 5,758.8 million
• Registered medical practitioners 1,374
†(persons per sq. km.)
The ‘Maltese’ Diet• wheat products (bread and pasta), and rice are the major
source of energy in the Maltese diet contributing a third to the total energy
• The staple cereal in Malta is wheat, mainly as bread (78%) and then, mainly as local white bread (99%).
• Pasta contributes 11% to the total purchase of cereal products .
• Multigrain and brown bread appear to be becoming more popular. • Bellizzi, M. (1992).The Maltese Food Revolution :
An analysis of the eating habits in Malta. Technical Report of the Malta Case Study for the International Conference on Nutrition, Department of Health, Valletta.
• Dietary trends are geared toward 'healthy' eating: low fat, low clarorie diet with more fish and less beef-pork
• Socioeconomic pressures still promote bread and pastry based foods as cheap, convenient and easily accessible.
The ‘Maltese’ Diet
Regional distribution of Coeliac Disease in the Maltese Islands*
17
17
18
5
10
44
5
5
31
32
9
5
8
9
9
30
9
75
10
1
4
14
9
20
5
7
4
17
6 35
8
17
3
3
20
23
4
72
25
25
8
21
2
29
24
3
15
3
5
15
15
40
18
7
12
85
7
26
16
30
20
* Crude prevalence individuals receiving benefits for GFD
Clinical Case recognition in the Maltese Islands
• Prevalence of CD based on clinical diagnosis & GFD: 1.9 / 1,000 (1 in 526 gen. Popn)
Older age at diagnosis of paediatric cases C. Vella, V Grech Ind. J Peds 2004
• cf Analogous population based study (clincal presentation / GFD) from Sicily - prevalence 1.65/1,000; adjusted actual standardized rate 3 /1,000 .
• cf worldwide average 1:3345, on clinical, 1:266 on screening data † † Fasano & Catassi, Gastroenterology 2001;
120:636‑651.
Magazzú G, et al. Acta Paediatr. 1994;83(10):1065-9.
Age at diagnosis distribution, Coeliac patients in the Maltese Islands
0
20
40
60
80
100
120
140
160
180
< 5
06
-Oc
t
No
v-1
5
16
- 20
21
- 30
31
- 40
41
- 50
51
- 60
61
- 70
> 7
0
Age at diagnosis distribution by gender of Coeliacs in the Maltese Islands
0
20
40
60
80
100
120
140
< 5
6 - 1
0
11
- 15
16
- 20
21
- 30
31
- 40
41
- 50
51
- 60
61
- 70
> 7
0
FEMALE
MALE
The Maltese Islands – Tourists with Coeliac Disease
• Tourist arrivals 1.3 million
• Average tourist length of stay 8.5 nights
• A minority of restaurants, most 5-star establishments offer gluten-free meals
• Gluten free menus not yet established
Coeliac Association Malta• Founded 1989
• Currently has 307 active members and 288 ex-members (defaulted / otherwise)
• Frequency of CD membership 1:1,347 cf Europe 1:2,377†
• Supports members wrt issues pertaining to the day to day management of coeliac disease facilitates government-provided assistance and monitors restaurant and food-outlet coeliac-friendliness
†A. Catassi, A. Fasano . Curr Gastroenterol Rep 2002;4:238‑243.
CD in Malta – diagnosisSerology: tTG IgA, tTG IgG
– Limited accessibility of Total serum IgA
Screening at risk populations – recognized (but no standardized approach)
• Asymptomatic relatives • Downs (8%), Turner & Williams syndrome
Schiberras C. et al. Ann. Trop. Peds, 2004
• Type 1 diabetes • Autoimmune Thyroiditis
Biopsy: endoscopy / Cosby Capsule • Inconclusive findings can be further studied through
capsule endoscopy
CD in Malta – opportunities in Education and Case Recognition
• Patient education: seminars / association website / leaflets
• Public education efforts
• Caregiver education: medical / nursing school, postgraduate education; background, curriculum
CD in Malta; management - limitations
• Nutrition support services in the community / through MDH
• Time to new appointment, waiting list for follow up appointments at MDH – nutritionist services highly variable
• Limited resources in numbers of government-employed nutritionists – no dedicated child / coeliac specialization
• Legislation - enforcement regarding the correct labeling of food
CD in Malta; future needs and opportunities
• Easier access to specialist care and nutritionist consultation
• Merging legislation, EU mandated standards and
monitoring – enforcement
• Standardized protocol for screening at risk populations and streamlined referral
Education and Academics
National awareness programs
Public oriented
Provider oriented Genetic testing & research initiatives
novel gene mechanisms in Maltese CD families (non-HLA, CD 59, CD 44 coinheritance)
Vidal C. et al. Tiss. Antigens 2009
Support for pertinent patient support resources