Abstract and Introduction
Abstract
OBJECTIVES: Celiac disease (CD) is an increasingly common disease that may affect as many as 1% of the North American population. Recent population-based data suggest a substantial increase in the prevalence of CD over the last several decades. Several factors are hypothesized as possible disease triggers including intercurrent illnesses, such as gastroenteritis, surgeries, and trauma. We used the active duty US military, a unique healthy worker population with essentially complete medical diagnostic coding, as an opportunity to describe trends in CD and deployment-related risk factors.
METHODS: Using electronic medical encounter data (1999–2008) on active duty US military (over 13.7 million person-years), a matched, nested case–control study describing the epidemiology and risk determinants of CD (based on ≥2 ICD-9 medical encounters) was conducted. Incidence and duration of CD-related medical care were estimated, and conditional logistic regression was utilized to evaluate CD risk following infectious gastroenteritis (IGE) occurring within 3 years before CD diagnosis while controlling for other risk factors.
RESULTS: A total of 455 incident cases of CD were identified and age, gender, and time matched to 1,820 controls. The incidence of CD increased five-fold from 1.3 per 100,000 in 1999 to 6.5 per 100,000 in 2008, with the highest rates of increase among those over 34 years of age (average annual increase of 0.8 cases per 100,000). A total of 172 IGE episodes, predominately of "viral etiology" (60.5%), were documented. In multivariate models, a significant association between IGE and CD was found (Odds ratio (OR): 2.06, 95% confidence interval (CI) 1.43, 2.97). Risk generally increased with temporal proximity to, and non-viral etiology of, exposure. Other notable risk factors for CD in multivariate models were Caucasian race (OR: 3.1, P<0.001), non-Army service (OR: 1.5, P=0.001), and greater than a high-school education (OR: 1.3, P=0.05).
CONCLUSIONS: Incidence of CD diagnosis in the US military is increasing, particularly among those in the fourth and fifth decades of life and appears higher than other population-based estimates. An association between antecedent IGE and risk of CD was noted, but the potential for exposure misclassification cannot be ruled out and further study is needed to link pathogen-specific exposure to incident CD anti-gluten antibody development or symptom onset.
Introduction
Celiac disease (CD) is an increasingly common disorder that may affect as much as 1% of the North American population. It is known to affect all ages, including young adults, and may be more prevalent in Caucasians.[1] The rate of diagnosis in other racial groups is largely unknown. However, due to the broad spectrum of clinical presentation, and, until recently, the unavailability of sensitive and specific diagnostics, most affected individuals are never diagnosed.[2] The consequence of the disease may be diverse in terms of issues such as bone fragility, depressed resistance to bacterial and fungal infections, reduced ability to respond to vaccinations, and a variety of other nutritional, immunological, and inflammatory comorbidities. The majority of CD patients have 1 of 2 HLAs encoded by genes that are also found in approximately one-third of the North American population. Considering that virtually the entire population consumes food containing significant amounts of the primary exogenous trigger (i.e., gluten), yet only 1% of the population may get the disease, research has been conducted to identify other factors triggering disease onset, or associated with increased CD risk among genetically susceptible individuals. Several factors have been suggested including early introduction or large consumption of gluten early in life after weaning and childhood,[3] and infant infections.[4] Other triggers include the seasonality of birth and risk of disease.[5] In addition, intercurrent illnesses, such as surgeries, and trauma, are potential triggers. The role of infection early in life, especially in those that overlap with the introduction of high-dose gluten follow-on formulas that are often used after weaning, may be particularly likely to increase the rate of disease.
Recent population-based data suggest a substantial increase in the prevalence of CD over the last several decades.[6–9] This increase is unlikely to be due to a change in human genetics or population changes in wheat consumption, but may reflect a change in other environmental factors. It has also recurred in adults, a phenomenon that may be more marked in North America than in Europe. In this study, we aim to explore the recent incidence and risk factors of CD in one of the largest and best documented adult populations in North America of active service personnel. This population includes substantial diversity of race and ethnicity and education level.
Am J Gastroenterol. 2012;107(8):1248-1255. © 2012 Nature Publishing Group
