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Coeliac Disease in the Maltese Islands

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 :

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Coeliac Disease in the Maltese Islands

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  1. Coeliac Disease in the Maltese Islands Thomas M Attard MD FAAP FACG Consultant Paediatrician and gastroenterologist Mater Dei Hospital, B’Kara, Malta

  2. 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.)

  3. 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 Studyfor the International Conference on Nutrition, Department of Health, Valletta.

  4. The ‘Maltese’ Diet • 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.  

  5. Regional distribution of Coeliac Disease in the Maltese Islands* 9 29 40 9 20 24 9 5 14 7 3 1 3 18 8 44 2 17 2 7 17 3 5 10 3 15 7 30 5 5 25 26 5 31 23 9 12 17 4 15 5 18 35 6 3 17 4 21 7 16 25 * Crude prevalence individuals receiving benefits for GFD 5 20 5 15 30 8 4 9 2 7 8 8 20 10

  6. 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 † Magazzú G, et al.Acta Paediatr. 1994;83(10):1065-9. † Fasano & Catassi, Gastroenterology 2001; 120:636‑651.

  7. Age at diagnosis distribution, Coeliac patients in the Maltese Islands

  8. Age at diagnosis distribution by gender of Coeliacs in the Maltese Islands

  9. 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

  10. 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.

  11. CD in Malta – diagnosis • Serology: 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

  12. 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

  13. 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 

  14. 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

  15. 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 Education and Academics

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