**Preeti Rajpoot and Govind K. Makharia \***

Departments of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; E-Mail: prajpoot15@gmail.com

**\*** Author to whom correspondence should be addressed; E-Mail: govindmakharia@gmail.com or govindmakharia@aiims.ac.in; Tel.: +91-11-2658-8091 or +91-11-2659-6546; Fax: +91-11-2658-8641 or +91-11-2658-8663.

*Received: 11 October 2013; in revised form: 5 November 2013 / Accepted: 20 November 2013 / Published: 27 November 2013* 

**Abstract:** Celiac disease is emerging in India and has become a public health problem. Almost 6–8 million Indians are estimated to have celiac disease. While there is a large pool of patients with celiac disease in India, until now, only a fraction of them have been diagnosed. With increasing awareness about celiac disease amongst health care providers and the general population, a massive increase in the number of patients with celiac disease is expected now and in the subsequent decade in India. While the number of patients with celiac disease is increasing, the country's preparedness towards the emerging epidemic of this disease is minimal. There are a number of issues, which requires urgent attention. Some of the key issues include increased awareness amongst health care professionals and the general public about the disease and its management, team-based management of patients with celiac disease, proper counseling and supervision of patients, training of dietitians in the management of patients with celiac disease, industrial production of reliable and affordable gluten-free food, and food labeling for gluten contents.

**Keywords:** nutrition; India; wheat; barriers; compliance, counseling

#### **1. Introduction**

Celiac disease (CeD) is an immune-mediated enteropathy caused by exposure to gluten in genetically susceptible individuals [1,2]. Once thought to be a rare disease and believed to occur only in Western Europe, CeD is now a global disease and affects almost 0.6%–1% of the world's population [3,4]. After Europe, America (both North and South), and the Middle East, it is now emerging in the East, including many Asian countries [5–13]. Also, once thought to be a disease of children and therefore to be managed mainly by pediatricians; CeD is now known to affect all the age groups including the elderly [14]. While CeD is emerging, the level of the awareness it too low amongst health care professionals, even amongst those most closely involved such as general physicians, family physicians, internists, gastroenterologist and pathologists [7,9].

#### **2. Emergence of CeD in India**

An increase in number of patients with CeD has been observed from many centers in India including ours [15,16]. Furthermore, two community based prevalence studies have been reported, both from the Northern part of India. In the first report from Ludhiana (Punjab), a questionnaire based survey of 4347 school children (3–17 years), Sood *et al.* [17] reported prevalence of CeD to be 1 in 310. In another community-based study including 10,488 subjects, both children and adults, we reported the prevalence of CeD in the Northern part of India to be 1.04% (1 in 96) and the prevalence of seropositivity (anti-tTG ab) to be 1.44% (1 in 69) [18]. Based on these two general population based studies, 5–8 millions of Indians are expected to have CeD. Of such a large pool of patients, only a fraction has been diagnosed to have CeD. The results of these studies suggest that CeD is a much greater problem in India than has been previously thought [18].

At present, only those with the most typical manifestations of CeD come to clinical attention and are ultimately diagnosed to have CeD. Now screening programs within populations indicate that celiac disease is under-diagnosed and what we detect clinically represents only the tip of the iceberg. With an appreciation of the existence of an iceberg of CeD in any society, and with increased awareness of CeD, patients with even milder symptoms are likely to be diagnosed in the coming years [19,20]. Currently, most celiac specific serology ELISA kits in India are imported from Europe. Their diagnostic cut-off values of antibody concentrations are based on Caucasian population data. With the difference and diversity in gluten ingestion, the cut-off values for a positive test in India may not be similar to those reported in the Caucasians.

#### **3. Evolution of Dietary Management of CeD**

Dietary management was a mainstay of treatment of CeD even in the early part of the 20th century [21]. During 1930s, clinical improvement was observed with several differing diets including an oyster diet suggested by Gee and the banana diet popularized by Haas [22]. Stools of such patients were quite greasy and worsening of their diarrhea after a carbohydrate diet led to another dietary approaches such as reduction or almost complete elimination of dietary fat or carbohydrates. A remarkable observation by a Dutch pediatrician, Willem Dicke [23], gave the birth to an idea from listening to one of his child patients' mothers. The mother of the patient told Willem

Dicke that her child used to become better if he did not eat porridge. From a clinical observation of one child and through years of clinical questioning and dietary therapy, he concluded that wheat was the toxic agent leading to CeD [23,24]. Toward the end of World War II, the so-called "winter of starvation" when even bread was not available in Holland; children with CeD paradoxically improved even though they were consuming a starvation diet (almost devoid of wheat products). When bread was airdropped in Holland, deterioration was noticed in these children [23]. Such an observation further strengthened the idea that some of the ingredients of wheat were the toxic agents for CeD.

#### **4. What Is Gluten?**

The protein content of wheat varies between 8% and 17%, depending on the genetic make-up and external factors associated with the crop. When wheat flour is washed with water, the insoluble protein fraction forms a viscoelastic protein mass, called gluten. Gluten, which comprises roughly 78% to 85% of the total wheat protein, is a very large complex mainly composed of polymeric (multiple polypeptide chains linked by disulphide bonds and monomeric (single-chain polypeptides) proteins. Gluten plays a key role in determining the unique-baking quality of wheat by conferring water absorption capacity, cohesively, viscosity and elasticity on dough [25–27].

Gluten is classified into two main fractions according to their solubility in aqueous alcohols: the fraction which is soluble in aqueous alcohol is gliadin and those insoluble are called glutenins. Both the fractions consist of numerous, closely related polypeptides that are rich in glutamine and proline amino acids. Gliadins are mainly monomeric proteins with molecular weights around 28,000–55,000 #