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