A recent prospective study (E Liu et al. Gastroenterol 2017; 152: 1329-36) reports a very high rate of celiac disease in Denver.
The authors collected data on HAL-DR, DQ genotypes in 31,766 infants. Among the various genotypes, a total of 1339 were followed .for 20 years (starting in 1993). The key outcomes were development of celiac disease autoimmunity (CDA) indicated by persistence of anti-TTG IgA antibody for at least 3 months or development of celiac disease (CD) with biopsies showing at least Marsh 2 histologic lesions. The authors weighted the genotypes based on their frequency in the population to develop estimates for the entire Denver population.
- 66 (of 1339) developed both CD and CDA. Another 46 developed only CDA. In this group of 46, seropositivity reverted to normal in 21 (46%).
- Cumulative incidence for CDA at 5, 10 and 15 yrs of age: 2.4%, 4.3%, and 5.1% respectively
- Cumulative incidence for CD at 5, 10 and 15 yrs of age: 1.6%, 2.8%, and 3.1% respectively
In their discussion, the authors note that “the 3.1% cumulative incidence of CD in Denver by age 15 is the highest to date in North America and is consistent with the 3% prevalence reported in Sweden for 12 year olds born during an ‘epidemic’ thought to be the result of early introduction…of gluten.” This theory about the epidemic is has been discounted: “timing of gluten introduction is not likely a factor” though the quantity could be a factor.
My take: These rates of CD and CDA are very high; ongoing data to determine the frequency in other parts of the country are needed. This high rate of CD is clearly bad news for a lot of people, excepting those with commercial interests in gluten free products.
For 1-3 year old, AAP recommendation for maximum of 4 oz./day of 100% juice, and for 4-6 year olds a maximum of 6 oz/day. For 7 years and older, AAP recommends a maximum of 8 oz/day
A recent study (KM Kemppainen et al. Clin Gastroenterol Hepatol 2017; 15: 694-702, editorial 703-5) showed that gastrointestinal infections can trigger celiac disease (CD) and that immunization with the rotavirus vaccine was protective against developing CD.
This study is part of the TEDDY study: The Environmental Determinants of Diabetes in the Young. The TEDDY cohort involves more than 8000 children who are part of an international prospective cohort who carry genes (HLA-DR-DQ genotypes) with increased risk for diabetes and CD. In this particular group, the authors identified 6327 children who were 4 yrs old by March 2015.
Key Definition: CD autoimmunity (CDA) -children who tested positive for tTG IgA at their annual visit and remained persistently positive 3 months later
- Gastointestinal infections (n=13,881) but not respiratory infections (n=79,816) were associated with an increased risk of CDA. CDA risk was increased within the 3 months of the GI infection.
- 732 of 6327 (11.6%) developed CDA. In this cohort, 318 underwent duodenal biopsy and 283 (90%) had biopsy indicative of CD (Marsh score >1). Thus, in their cohort, there is variability in the onset of CD from the onset of CDA.
- Risk of CDA was reduced in children vaccinated against rotavirus and introduced to gluten before age 6 months (HR =0.57).
- The exact risk depending on interaction with multiple factors including breastfeeding, HLA genotype, seasonality of birth, and timing of gluten introduction. Timing of infection plays a role as well, as earlier exposure to GI infections earlier in life was associated with a decreased risk of celiac disease.
This reference should be kept handy for vaccine advocates. Not only can vaccines prevent infections, but they have now been shown to prevent an autoimmune disease (CD). In addition, previous studies have shown that vaccines can prevent cancers, including hepatocellular carcinoma and cervical cancer.
My take (modified from editorial): This study “demonstrates the power of rigorously conducted prospective studies to reveal complex interactions among genetic and environmental factors.” In addition, this study shows that preventing rotavirus infection with vaccination lowers the risk of celiac disease.
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SuperPoopers CCFA Team 2017