Recognising the many faces of coeliac disease

Amanda Lyons

15/03/2018 11:20:39 AM

Gastroenterologist Dr Jason Tye-Din wants to help increase awareness about the diversity of coeliac disease presentation.

Recent research has shown evidence of the significant diversity of people who can be affected by coeliac disease. (Images: Coeliac Australia)
Recent research has shown evidence of the significant diversity of people who can be affected by coeliac disease. (Images: Coeliac Australia)

Coeliac disease affects one in 70 Australians. It can manifest in symptoms ranging from bloating and abdominal pain through to anaemia and even some forms of cancer. And yet, despite the condition’s seriousness, only 20% of affected Australians have a medical diagnosis.
According to Dr Jason Tye-Din, who is also Chair of the Medical Advisory Committee of Coeliac Australia, the broad range of coeliac symptoms can make it relatively difficult to identify in general practice. But another reason it may often elude diagnosis can be found in entrenched beliefs about who is affected by the disease.
‘Traditionally, the face of coeliac disease has been the white, Anglo-Saxon person with abdominal symptoms,’ Dr Tye-Din said, speaking in a video to mark the 2018 Coeliac Awareness Week.
Such assumptions can result in its presentation in other populations being missed when, in fact, recent evidence shows that coeliac disease is a global illness.
‘The disease is out there, it’s just a matter of looking for it,’ Dr Tye-Din told newsGP. ‘To some extent, we are not picking up on it because we’re simply not looking for it.’
According to Dr Tye-Din, coeliac’s characterisation as a disease more likely to affect Caucasian people can be traced back to its research history.
‘Most of the research comes from European studies. The person who, in the 1950s, discovered gluten is the driver and cause of coeliac disease was a Dutch paediatrician,’ Dr Tye-Din explained. ‘That set the scene for the perception that coeliac was a white person’s disease that you didn’t really see in places like Africa.’
However, recent research has shown that coeliac disease results from the collision of two factors – genetics and environment. People from any type of population can carry the genetic predisposition for coeliac disease, but it must be triggered by gluten to manifest. If a person comes from a culture that consumes a low-wheat diet, they are far less likely to come into contact with that trigger, leading to a perception that such people do not have the genetic predisposition for coeliac disease.
‘A good example is in northern India, the Punjab region, which has a high wheat intake and slightly high genetic predisposition to coeliac disease, so they have a high rate of the disease,’ Dr Tye-Din said. ‘But in southern India, they have a rice-based diet and much lower rates of coeliac disease. They have slightly lower rates of the genetic marker.
‘So it’s really an environmental factor driving that difference between the north and south of India.’
The fact that coeliac presentations rise in the event such populations begin to adopt a more westernised diet further supports this observation.
‘When I speak to my Somalian patients, a lot of them say, “I didn’t have any symptoms until I started adopting more of a local diet because we couldn’t get access to stuff like teff,” which is a gluten-free grain common in Africa,’ Dr Tye-Din said.
‘So these patients have got the genetic predisposition, but the genes on their own aren’t particularly harmful.’
Improvements in testing technology for coeliac disease over the last several decades have resulted in more research and screening throughout the world, revealing that coeliac disease is more wide-spread than previously thought.
‘Lo and behold, there does appear to be a lot of the disease in areas where it had not previously been considered common,’ Dr Tye-Din said. ‘In fact, the highest prevalence of coeliac disease anywhere in the world is in northern Africa.’
Because targeted testing by GPs is the best way to detect cases of coeliac disease, Dr Tye-Din believes it is important those in general practice are aware that coeliac presentations can be far more diverse than might have previously be assumed.
‘In my practice, for instance, I have seen an increase in Somalian patients with coeliac disease in the last few years,’ Dr Tye-Din said. ‘I have quite a large number of patients from Somalia, the Middle East, Mediterranean regions, and I’m starting to see a lot more people from Asia.
‘The idea is to be mindful of the condition in those people and to test for it.’
Visit the Coeliac Australia website to access resources to help diagnose and manage coeliac disease in general practice.

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