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Celiac Disease in African-Americans


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Celiac disease is generally under diagnosed in the United States and it is unclear whether the disease is encountered in ethnic minorities. Our purpose is to describe a case series of African-American patients with celiac disease. Nine (1.3%) African-American patients with celiac disease were identified from a prospectively generated database of 700 patients with biopsy proven celiac disease and seen between 1981 and 2004. Females predominated, with seven, compared to two males. Diarrhea was the presentation in only two patients, while three presented with iron deficiency anemia. One third had at least one autoimmune disease. Compliance with a gluten-free diet, the only medical therapy of this disease, was poor. Only four patients adhered strictly to the diet. Celiac disease occurs in African-Americans and may well be underdiagnosed. Special attention needs to be given to methods that encourage adherence to the diet in minority groups.
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Dig Dis Sci (2006)
DOI 10.1007/s10620-005-9000-5
Celiac Disease in African-Americans
Pardeep Brar · Ann R. Lee · Suzanne K. Lewis ·
Govind Bhagat · Peter H. R. Green
Received: 11 August 2005 / Accepted: 17 August 2005
Springer Science+Business Media, Inc. 2006
Abstract Celiac disease is generally under diagnosed in
the United States and it is unclear whether the disease is en-
countered in ethnic minorities. Our purpose is to describe a
case series of African-American patients with celiac disease.
Nine (1.3%) African-American patients with celiac disease
were identified from a prospectively generated database of
700 patients with biopsy proven celiac disease and seen be-
tween 1981 and 2004. Females predominated, with seven,
compared to two males. Diarrhea wasthepresentationinonly
two patients, while three presented with iron deficiency ane-
mia. One third had at least one autoimmune disease. Compli-
ance with a gluten-free diet, the only medical therapy of this
disease, was poor. Only four patients adhered strictly to the
diet. Celiac disease occurs in African-Americans and may
well be underdiagnosed. Special attention needs to be given
to methods that encourage adherence to the diet in minority
Keywords: African-American
Celiac disease
Gluten-free diet
HLA DQ typing
Celiac disease is an autoimmune enteropathy that occurs in
genetically predisposed individuals and is precipitated by
the ingestion of gluten containing grains [1]. The disease is
P. Br ar · A. Lee · S. Lewis · G. Bhagat · P. H. R. Green
Department of Medicine, Columbia University
College of Physicians and Surgeons,
New York, New York, USA
P. H. R. Green (
Herbert Irving Pavilion, Room 645, 161 Fort Washington Avenue,
New York, New York 10032
multigenetic, however, there is a requirement that an individ-
ual must possess the HLA alleles that encode for DQ2 and/or
DQ8 [2]. These molecules are involved in the presenta-
tion of pathogenic deamidated gliadins to antigen presenting
cells [3].
Formerly, celiac disease was considered rare in the United
States; however, it is now estimated to occur in about 1% of
the population [4, 5]. The prevalence of this disease in mi-
nority populations within the United States is not known.
It is, however, considered rare in African-Americans, partly
because HLA DQ2 and DQ8 are regarded as primarily Cau-
casian genetic traits. We have, however, detected celiac dis-
ease in African-Americans at our institution and present
these findings in the current report. This is especially impor-
tant because celiac disease, an eminently treatable condition,
is considered to be underrecognized in the United States.
African-American patients who were treated for celiac dis-
ease at the Celiac Disease Center of Columbia University
were identified from an anonymized database of 700 celiac
disease patients (65% females and 35% males). We defined
African-American patients as those Black patients who re-
ported their ethnicity as African-American. Only biopsy-
proven celiac disease patients were included in this study.
Data regarding age, sex, age at diagnosis, mode of presen-
tation, serologic profiles, and response to a gluten-free diet
were prospectively recorded.
Small bowel histology was reviewed for all patients. The
study was approved by our institutional review board. All pa-
tients had intraepithelial lymphocytosis and villous atrophy
corresponding to Marsh stage III [6]. We classified the degree
of villous atrophy as partial villous atrophy (PVA), subtotal
villous atrophy (STVA), or total villous atrophy (TVA).
Dig Dis Sci (2006)
Table 1. Demographics, presentation mode, serology, and histopathology.
Age at Mode of
No Sex diagnosis (yr) presentation Associated conditions IgA/G EMA or tTG Villous atrophy HLA DQ2/8
1M64 Anemia ++ Subtotal DQ2
2F37 Edema + NA Subtotal DQ2
3 F 54 Incidental at EGD Rheumatoid arthritis, SLE +− Partial NA
4 F 30 Anemia Myasthenia gravis, DH + NA Partial NA
5 F 59 Anemia IDDM + NA Subtotal NA
6 F 83 Diarrhea MC, osteo-porosis ++ Partial NA
7 F 28 Diarrhea DH + NA Partial DQ2
8 F 15 Abdominal pain −− Partial DQ2/8
9 M 15 Growth failure −+ Partial NA
Note. EGD, esophagogastroduodenoscopy; +, present; , absent; NA, not assessed; EMA, endomysial antibody; tTG, transglutaminase antibody;
M, male;F, female; SLE, systemic lupus erythematosus; DH, dermatitis herpetiformis; IDDM, insulin-dependent diabetes mellitus; MC, microscopic
A total of nine African-American patients, two males and
seven females (Table 1), were identified from the database
of 700 patients, representing 1.3% of all patients. Their mean
age at time of diagnosis was 42 years. Two were children,
aged 15 years.
Only two (22%) patients presented with the classi-
cal presentation of diarrhea. The other seven patients had
“silent” celiac disease, presenting with iron deficiency ane-
mia (n =3), abdominal plain (n =1), growth failure (n =1),
edema because of hypoalbuminemia (n =1), and one as
an incidental finding during endoscopy for gastrointesti-
nal bleeding. Two had already been diagnosed with biopsy-
proven dermatitis herpetiformis, though they had not been
advised about a gluten-free diet. Two had osteoporosis and
three patients had autoimmune diseases, including myasthe-
nia gravis, systemic lupus erythematosus, rheumatoid arthri-
tis, and insulin-dependant diabetes mellitus. One patient had
concomitant microscopic (lymphocytic) colitis.
Serology, HLA, and pathology (Table 1)
All patients had at least one serologic test performed at the
time of diagnosis and all except one had at least one positive
serologic result. Three of five patients had either a posi-
tive endomysial (EMA) or a positive tissue transglutaminase
(tTG) antibody present. Four patients were assessed for the
presence of HLA DQ2 or DQ8 and had positive results.
One patient (No. 8) had a negative serologic profile but was
both DQ2 and DQ8 positive. All patients had villous atrophy
(subtotal n =3, PVA n=6), at presentation.
Follow-up on gluten-free diet (Table 2)
All patients were advised a gluten-free diet. They were seen
by a dietician experienced in the gluten-free diet and were
referred to a celiac support group. The mean duration of
follow-up was 39 months. Four patients adhered to the diet
strictly; two did not attempt the diet, despite counseling from
the physician, the dietician, and a local support group, while
three had poor compliance, admitting to only intermittent ad-
herence to the diet. Despite poor compliance in three patients,
all those on the diet showed an improvement in symptoms.
Antibodies persisted in three of five patients with available
follow-up antibodies, as did villous atrophy, though it was
less marked in three patients.
We identified nine African-American patients with celiac
disease, representing 1.3% of all patients seen at our special-
ist referral center. The demographic profile of the African-
American patients was similar to that of the other patients
seen at our center, in that females predominated, and at least
one associated autoimmune disease was present in a third
of the patients [7]. The majority of the patients presented
with “silent” celiac disease, a trend noted by us and others
[8, 9], and iron deficiency anemia was the most frequent
presentation [10].
Celiac disease is being increasingly diagnosed throughout
the world. While it is recognized throughout Europe and in
countries populated by those of European origin such as
South Africa, Australia, New Zealand, and South America,
it is now being diagnosed in populations where celiac disease
was traditionally not thought to occur. The disease appears
to be common in North Africa [11, 12], as well as in the
Middle East [13, 14] and northern India [15, 16]. Celiac
disease has also been documented in Cuba [17] and in West
Indian children living in England [18].
Celiac disease is considered rare in individuals of central
African descent [19], however, the blood donor screening
study by Not et al., in Baltimore, Maryland, in the United
Dig Dis Sci (2006)
States, revealed that 1 of 250 African-Americans had pos-
itive endomysial antibodies, a frequency similar to that of
entire group [20]. There have been no systematic screen-
ing studies of celiac disease among African-Americans, so
we are not aware of just how common this disease may
be. African-Americans make up 12% of the U.S. popula-
tion, yet only 1% of the patients with celiac disease that
we have seen were African-Americans. The low prevalence
of disease may be due to a lower frequency of the DQ2 or
DQ8 alleles in the African-American population or it may
be the consequence of other factors such as referral bias or
socioeconomic factors affecting access to health care. We
are not aware of studies of the frequency of DQ2 or DQ8
among African-Americans. Future research should include
studies of HLA DQ2/8 frequency among African-American
patients from different geographic locations in the United
One striking feature observed in our series of patients is
the poor dietary compliance among five patients, with two
not attempting the diet at all. Compliance with a gluten-free
diet is often a problem. In France and Belgium, less than half
of all adult patients studied adhered strictly to the diet for
more than 1 year postdiagnosis [21]. In the United Kingdom
a low compliance has been reported for both teenagers and
adults [22]. Reasons for poor dietary compliance include
expense, availability, and palatability of gluten-free food.
Other factors associated with poor compliance with the diet
include lack of symptoms at diagnosis [23], inadequate initial
dietary counseling [24], inadequate medical or nutritional
follow-up [25], and inaccurate dietary information provided
by resources such as the Internet [26]. Minority populations
have been noted to have compliance difficulties. One study
from the United Kingdom, comparing dietary compliance
between members of a minority population (South Asians)
and Caucasians, all with celiac disease, reported a higher
compliance rate among the Caucasians [27]. South Asians
were less likely to attend dietetic clinics, join a support group,
and be satisfied with information provided by doctors and
dieticians. Compliance with diet in those with celiac disease
should be encouraged because it is associated with a good
quality of life [28].
In conclusion, we have identified celiac disease in only
nine African-Americans. The true prevalence of celiac dis-
ease among this population in the United States needs to
be determined. In addition, when celiac disease is identified
in minority groups, special attention needs to be placed on
factors that increase dietary compliance.
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... The rates of CD diagnoses have been found to be higher among non-Hispanic whites than non-Hispanic blacks; 17,18 however these rate differences may be due to referral bias or healthcare access disparities. 17 Most patients with CD had positive tTG IgA and/or EMA serological levels at diagnosis. Based upon results from other studies, both tTG IgA and EMA have high sensitivity (90-100% vs, 93-100% respectively) and high specificity (95-100 vs, 98-100% respectively) for CD.7 DGP IgG has a lower sensitivity (between 88-95%) and therefore not used as a screening test.7,19 ...
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Purpose Celiac disease (CD) is a disorder in which gluten ingestion triggers an autoimmune response causing inflammation and damage to the small intestine. With improved awareness and screening availability, prevalence and variation in clinical presentation have subsequently increased. Thus, our study identified the disease characteristics and presentation patterns of pediatric CD in southern West Virginia. Methods We retrospectively reviewed charts for pediatric patients (age <18 years) diagnosed with CD during a 10-year period at a tertiary care hospital. Results A total of 59 patients met inclusion criteria. The mean age of diagnosis was 10.0+4.6 years, with 61% of patients being female. One-third of cases were asymptomatic and diagnosed from screenings of patients with hypothyroidism or type 1 diabetes mellitus. In symptomatic patients (n=40), abdominal pain was the most common presenting symptoms (78%), followed by constipation (30%). Classical symptoms of diarrhea and failure to thrive/unexplained weight loss were less common (n=9). At diagnosis, anti-tissue transglutaminase (tTG) IgA antibodies and deamidated gliadin peptide IgG antibodies were both positive in 88% of cases, and endomysial antibodies were positive in 70% cases. One-year post-diagnosis clinic follow-up rate was 63%. A gluten-free diet improved symptoms and tTG IgA serology levels in all patients with follow-up. Conclusion Our data fills in the gap of the paucity of information available about CD in children from Appalachia. A high index of suspicion is required to screen and diagnose CD as many patients are either asymptomatic or lack classical findings. A gluten-free diet is a highly effective treatment, although follow-up after initial diagnosis remains a challenge.
... However, the term African-American is a relatively recent social construct that encompasses people with significant differences in their genomes and who hail from an enormous part of the world. We do not know the incidence of CD in North America amongst African-Americans but is believed to be quite low [5]. However, in some populations of Africa, like those with Sub-Saharan origins may have an extraordinarily high prevalence of CD [6]. ...
... Rafael Parra-Medina Alejandra Claudia Cherñavsky 33 Amerindian or African American origins (4,5). CD affects 0.6 to 1.0% of the population worldwide, the female-to-male ratio is 2.8:1 and the age distribution of onset shows a first peak between nine months and two years and a second peak during the fourth decade (6). ...
... However, it is best for those most adapted to it, which does not seem to include Forest West Africans. Forest West Africans are adapted to yams, fruits, and leafy green vegetables and are, therefore, more susceptible to gut diseases and metabolic syndromes, including obesity, diabetes and hypertension, associated with the Wheat-Milk diet of modernity [41,42,43]. ...
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This review paper notes that the nutritional essence of an indigenous people’s diet can, broadly, be outlined in terms of their food-inherent bioactive chemical functions. Two food crops; Yam (Dioscorea spp.) and the Oil-palm (Elaeis guineensis), define Forest West Africa, agriculturally, as Yam or Palm belt. They can also be said to, broadly, define the diet of the region, which staple base they constitute, as the Yampalm Diet type. Some unique, bioactive, chemical functions of yam identified include; dioscorin, lipoic acid, potassium, biotin and, thiocyanate, while those of oil-palm include; tocotrienols, carotenoids, retinoids and lauric acid. These alkalizing food functions are, in theory, complementary to the acidic tropical physiology of Forest West Africans. Fed on other than the Yampalm diet, Forest West Africans have been demonstrated to be highly susceptible to metabolic syndrome, and some other diseases, due to adopted alien diets. Examples are lactose intolerance from milk and inflammation reaction to wheat gluten. Some food functions of Yampalm diet; dioscorin in yam and tocotrienol from oil-palm, as examples, are efficacious in metabolic syndrome management. They are potential ‘Gene-adapted food-function supplements’ for emigrants from this area who adopt alien diets. Experiments have shown that restoration of the Forest West African diet ameliorates metabolic syndrome among the people, including their Diaspora in America. Restoration of, genetically or epigenetically, adapted indigenous diet among peoples recommends itself as part of management strategy for modernization diseases. Key terms: Yampalm diet, food function, dioscorin, tocotrienol, alien diet, lactose intolerance, metabolic syndrome, epigenetic adaptation.
... 145 African Americans CD and CD serology is much less common among African Americans than among non-Hispanic White Americans despite some genetic risk. 4,146,147 Vitamin supplementation in general is less common in the African American community than among non-Hispanic White Americans. 148 Smoking ...
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The prevalence of celiac disease (CD) has increased significantly in some developed countries in recent decades. Potential risk factors that have been considered in the literature do not appear to provide a convincing explanation for this increase. This has led some researchers to hypothesize that there is a "missing environmental factor" that increases the risk of CD. Based on evidence from the literature, the author proposes that elevation in plasma levels of 1,25-dihydroxyvitamin D [1,25(OH)2D] is a missing risk factor for CD, and relatedly that significant oral vitamin D exposure is a "missing environmental factor" for CD. First, elevated plasma levels of 1,25(OH)2D are common in CD, especially in the newly diagnosed. Second, nine distinct conditions that increase plasma levels of 1,25(OH)2D are either associated with CD or have indications of such an association in the literature. Third, a retrospective study shows that sustained oral vitamin D supplementation in infancy is associated with increased CD risk, and other studies on comorbid conditions support this association. Fourth, large doses of oral vitamin D upregulate many of the same cytokines, chemokines, and toll-like receptors that are upregulated in CD. Fifth, epidemiological evidence, such as the timing of the inception of a CD "epidemic" in Sweden, the increased prevalence of CD in Finland and the United States in recent decades, the unusually low prevalence of CD in Germany, and the differential in prevalence between Finnish Karelians and Russian Karelians, may all be explained by oral vitamin D exposure increasing CD risk. The same is true of some seemingly contradictory results in the literature on the effects of breastfeeding on CD risk. If future research validates this hypothesis, adjustments to oral vitamin D consumption among those who have genetic susceptibility may decrease the risk of CD in these individuals.
... In addition, according to Rubio-Tapia et al., CD prevalence varies with race/ethnicity, with non-Hispanic whites showing a marked predominance [46], a finding in agreement with the high prevalence of the HLA-DQ2 heterodimer reported among this population [47]. On the other hand, African Americans appear to account for 1.3 % of patients with CD as was previously reported [48]. The CD rate in North American healthy people was reported to be 1 in 133, whereas it is higher in individuals with related symptoms (1 in 56) and significantly higher in individuals with first-degree relatives affected by CD [21]. ...
Celiac Disease (CD) is a complex immunogenic disease mainly triggered by gluten intake in genetically susceptible individuals with a prevalence of 1 in 100-300. CD results from the interplay between genetic and environmental factors. Genetic susceptibility is believed to play a prominent role in the pathogenicity of CD, mainly due to human leukocyte antigen (HLA)-related class II genes. Although CD is well-recognized among Arab populations, there are few studies on the genetic epidemiology and prevalence of CD in the Arab countries. Therefore, in this review, we aim to highlight the importance of studying this disease in the Arab world in the context of a global perspective. Within the few studies published so far, we found that Arab populations have a distinctive susceptibility genetic profile from other ethnic groups with the DQ2.5 and DQ8 genotypes that are considered the major genotypes that confer susceptibility among Arab patients with CD. Our findings will pave the way to perform further epidemiological studies that will help identify potential therapeutic targets against CD among Arab patients that are diagnosed with CD.
Gluten-related disorders (GRDs) are the common diseases of the gastrointestinal tract, with a global prevalence between 1% and 1.4%. Its dominated disease is celiac disease (CD), which its incidence is increasing in recent years. CD is associated with autoimmune diseases, including type 1 diabetes, thyroiditis, inflammatory bowel diseases, and autoimmune liver disease. In addition, CD may increase the chance of some malignancies and is considered to be associated with the risk of coronary heart disease and cardiovascular disease. Besides, women with unexplained infertility or recurrent miscarriage are significantly at the higher risk of CD. There is no evidence to recommend about the gluten introduction or optimal breastfeeding time and duration in order to prevent CD in children. CD patients face substantial expense and economic burden not only for buying gluten-free products but also for direct and indirect medical costs. Although screening for CD with serological tests is not recommended for the general population, it should be considered in high-risk groups. Nonceliac gluten sensitivity, wheat allergy, dermatitis herpetiformis, and gluten ataxia are other GRDs with similar symptoms that may be confused with CD and their prevalence reports are heterogeneous.
While in the past, celiac disease (CD) was considered the only clinical entity caused by the ingestion of gluten-containing grains, now there is evidence that a spectrum of gluten-related disorders, including also wheat allergy and non-celiac gluten (wheat) sensitivity (NCGS/NCWS), exists. The prevalence of gluten-related disorders is rising, and increasing numbers of individuals are empirically trying a gluten-free diet for a variety of signs and symptoms. CD is a gluten-induced immune-mediated enteropathy characterized by a specific genetic genotype [human leukocyte antigen (HLA)-DQ2 and HLA-DQ8 genes] and autoantibodies (antitissue transglutaminase and antiendomysial). NCGS/NCWS is diagnosed in individuals who do not have CD or wheat allergy but who, like CD patients, may experience intestinal symptoms, extraintestinal symptoms, or both, related to ingestion of gluten-containing grains, with symptomatic improvement on their withdrawal. The clinical variability and the lack of validated biomarkers for NCGS/NCWS have as consequences unclear prevalence, difficult diagnosis and still fuzzy. Conversely, CD pathogenesis has been the object of intense studies thanks to its unique features, including genetic and environmental factors.
Aims: To assess the prevalence and characteristics of CD in all patients with Type 1 diabetes mellitus (T1DM) attending a tertiary adult diabetes clinic in Durban, South Africa. Methods: This was a cross‐sectional observational study which screened 202 patients; of these 56.4% were African (black), 31.7% Asian Indian, 4.5% White and 7.4% mixed race. Demographic data, symptoms and anthropometry were documented. Blood tests included anti‐tissue transglutaminase antibody (tTG), anti‐endomysial antibody (EMA), anti‐gliadin antibody (AGA). Endoscopy and duodenal biopsy was performed in patients with celiac antibodies. Diagnosis of CD was based on the modified Marsh classification. Results: Mean age and mean duration of diabetes was 26.4±11.4 and 10.7±9.1 years respectively. Celiac antibodies were found in 65 (32.2%) patients: EMA 7.4%, tTG IgA 8.4%, tTG IgG 1.9%, AGA IgA 18.3% and AGA IgG 21.8%. Histologic evidence of CD was found in 5.9% (n:12/202): 2.5% were classed as definite CD (Marsh 3) and 3.4% as potential CD (Marsh 1). None of the patients with CD were symptomatic. The sensitivity of AGA IgA, EMA and tTG IgA antibodies for detecting histologically proven CD was 66.7%, 50.0%, and 41.7%, respectively. Conclusion: The prevalence of CD was similar to reports from western countries. No ethnic specific differences were noted. CD was silent in all patients in this study. The sensitivity of EMA and tTG antibody was poor and merit further evaluation as screening tools for CD in South African patients with T1DM.
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Over a 10 year period a total of 102 teenage patients with coeliac disease were assessed on transfer from paediatric hospitals to an adult clinic. Fifty seven patients said they were on a strict gluten free diet; 36 were semistrict, and nine admitted to eating a normal diet. Jejunal mucosal abnormalities, however, suggested that many patients on the 'strict' diet were actually consuming gluten. All patients were well with biochemical parameters within the normal range. Height percentiles were not significantly different from the normal population but patients, as a group, were significantly lighter.
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Coeliac disease is uncommon in populations of non-European origin. Two English born West Indian children with coeliac disease are presented. The diagnosis should be considered in children of West Indian origin with chronic diarrhoea.
Background: Serum antibodies to tissue transglutaminase (tTGA) are reported to have high sensitivity and specificity for coeliac disease and to correlate closely with endomysial antibodies (EmA). We assessed their performance in a coeliac population with a high proportion of EmA-negative patients, who have been under-represented in previous studies. Methods: We used a commercial ELISA kit to test for IgA class tTGA in sera from a population of 73 untreated coeliac patients with normal serum IgA and a high percentage (19%) EmA-negative, taking 58 patients with normal duodenal biopsies as controls. EmA was measured using indirect immunofluorescence. Results: Forty-six (63%) patients with villous atrophy (VA) had both tTGA and EmA. However, when considered separately, sensitivities of tTGA and EmA for VA were similar (75% versus 81%) and both had high specificity (98% versus 97%). As 9 patients were tTGA-positive only and 13 had EmA only, selection of patients for biopsy on the presence of either antibody wo...
We studied 243 children aged between 6 months and 18 years presenting with features suggestive of coeliac disease to Al-Fateh Children's Hospital, Benghazi, Libya from 1976 to 1993. The diagnosis of coeliac disease was made using the revised diagnostic criteria of the European Society of Paediatric Gastroenterology and Nutrition. Seventy-seven of the children conformed to these criteria. The demographic and clinical features of the disease were studied and compared with other studies in Arab countries and elsewhere. The male:female ratio was 1:1.3. Weight loss, anaemia, anorexia, diarrhoea and abdominal distention, in descending order of frequency, were the most frequently occurring clinical features. Jejunal biopsy is mandatory for the diagnosis of coeliac disease.
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The literature review and the recommendations therein were prepared for the American Gastroenterological Association (AGA) Clinical Practice and Practice Economics Committee. The paper was approved by the Committee on September 23, 2000, and by the AGA governing board on November 12, 2000.
Ten cases of coeliac disease in Iraqi children were found in a three year period. This condition has not been described in Iraq before but it is probably more frequent than has been recognised in the past.
Peroral jejunal biopsies were performed on 69 of 85 1st-degree relatives of 20 index coeliac patients in 20 families. Three had mucosal changes typical of coeliac disease, giving an incidence of 4.3%. This figure is similar to that for family studies in England, and it confirms the familial nature of coeliac disease in a population with different racial characteristics from countries where coeliac disease is common.