European Laboratory for Food Induced Diseases (ELFID) University of Naples Federico II University of Naples Federico II Prof. Luigi Greco

Participants to the MEDICEL network

PopulationChildren 0-14 Median age Population growth rate (%) Children0-14 in 10 years Total population in 10y ALBANIA ,90, ALGERIA ,61, BOSNIA ,80, CYPRUS ,51, CROATIA , EGYPT ,82, FRANCE ,40, GREECE ,80, ISRAEL ,11, ITALY ,3-0, LEBANON ,31, LIBYA ,92, MALTA ,50, MOROCCO , SYRIA ,72, SLOVENIA ,50, SPAIN ,10, TUNISIA ,20, TURKEY ,71, MEDITE R ,20, Mediterranean population

Consumption of wheat per capita (Kcal/Day)

Rise in the consumption of wheat flour

Pasta consumption in the E.U. ( )

CONSUMPTION OF PASTA PER CAPITA Italy 28.0 kg Tunisia 11.7 kg Greece 9.6 kg France 7.3 kg Turkey 5.6 kg Spain 4.7 kg Israel 4.0 kg Libya 2.0 kg Egypt 1.2 kg Production of pasta in the world Italy t Turkey t Egypt t France t Spain t Greece t Tunisia t Syria t

North France Spain Italy North-East Slovenia Bosnia Croatia Albania East Lebanon Israel Syria Middle East Greece Malta Turkey Cyprus South Morocco Algeria Egypt Libia Tunisia MEDITERRANEAN NETWORK FOR THE MANAGEMENT OF FOOD INDUCED DISEASES

Mediterannean population RegionsPopulationChildren 0-14Median age Population growth rate (%) Children0-14 in 10 years Total population in 10y North ,30, N.East ,10, M.East ,10, East ,71, South ,91, MED tot ,20,

Prevalence of Celiacs Estimated Celiacs today at 1% Estimated celiac children today at 1% Projected prevalence of CD in next 10 yrs Projected celiac children in 10 years ALBANIA ALGERIA BOSNIA CYPRUS CROATIA EGYPT FRANCE GREECE ISRAEL ITALY LEBANON LIBYA MALTA MAROCCO SYRIA SLOVENIA SPAIN TUNISIA TURKEY Med Tot

Prevalence of Celiacs Regions Estimated Celiacs today at 1% Estimated celiac children today at 1% Projected celiac children in 10 years Projected prevalence of CD in next 10 yrs North N.East M.East East South MED tot

Population Projected prevalence of CD in next 10 yrs Projected celiac children in 10 years Symptomatic adults 1:7 next 10y Sympomatic children 1:5 next 10y ALBANIA ALGERIA BOSNIA CYPRUS CROATIA EGYPT FRANCE GREECE ISRAEL ITALY LEBANON LIBYA MALTA MAROCCO SYRIA SLOVENIA SPAIN TUNISIA TURKEY TOTAL Clinical Symptoms in CD Cases

Prevalence of symptoms in Celiac population PopulationGI SymptomsAnaemiaOsteopenia Abnormal Liver Short Stature Children ALBANIA ALGERIA BOSNIA CYPRUS CROATIA EGYPT FRANCE GREECE ISRAEL ITALY LEBANON LIBYA MALTA MAROCCO SYRIA SLOVENIA SPAIN TUNISIA TURKEY TOT MED

Diseases in symptomatic cases RegionsGI SymptomsAnaemiaOsteopeniaAbnormal Liver Short Stature Children North N.East M.East East South MED tot

Excess mortality of undiagnosed celiacs Population Projected prevalence of CD in next 10 yrs Death rate deaths/ 1,000 population Population Expected Deaths next 10 y Celiacs Deaths Next 10 y Excess Death in Celiacs next 10 yr ALBANIA , ALGERIA , BOSNIA , CYPRUS , CROATIA , EGYPT , FRANCE , GREECE , ISRAEL , ITALY , LEBANON , LIBYA , MALTA , MAROCCO , SYRIA , SLOVENIA , SPAIN , TUNISIA , TURKEY , Tot ,

Excess mortality of undiagnosed celiacs Regions Death rate deaths/ 1,000 population Population Expected Deaths next 10 y Celiacs Deaths Next 10 y Excess Death in Celiacs next 10 yr North9, N.East8, M.East7, East5, South4, MED tot7,

EXCESS CONSUMPTION OF MEDICAL RESOURCES BY UNDIAGNOSED SYMPTOMATIC CELIACS ADULTS in 6 years CHILDREN in 2 years In-patient admission21 Out-patient admission11 Medical consultations : primary care 2/year 124 Specialized Consultations :21 Lab Test42 Minimal Estimate of excess request for medical services compared to age and sex matched controls

Purchasing power parity The concept is founded on the law of one price;law of one price in absence of transaction costs, identical goods will have the same price in different markets. the purchasing power of different currencies is equalized for a given basket of goods.currencies basket of goods

Costs of celiac disease Purchasi ng Power Parity Sympto matic adults 1:7 next 10y Symptom atic children 1:5 next 10 y Standir dized Cost for adult € Standar dized Cost for children € Tot Cost Adult next 10 y € Tot Cost Children next 10 yr € TOT Cost Symptomatic next 10 yr € ALBANIA7, ALGERIA6, BOSNIA7, CYPRUS17, CROATIA28, EGYPT6, FRANCE33, GREECE29, ISRAEL28, ITALY29, LEBANON14, LIBYA14, MALTA23, MAROCCO4, SYRIA4, SLOVENIA29, SPAIN33, TUNISIA8, TURKEY12, MED17,

Costs of undiagnosed celiac disease Regions Purchasing Power Parity Standardized Cost for adult € Standardized Cost for children € Total Cost Adult next 10 y € Total Cost Children next 10 yr € TOTAL Cost Symptomatic next 10 yr € North N.East M.East East South8, MED

The epidemic of coeliac disease years Celiacs/1000

WE HAVE TO FACE A SUBSTANTIAL TASK : HOW ?

HOW MANY CENTRES DIAGNOSE COELIAC DISEASE IN EACH MEDITERRANEAN COUNTRY? COUNTRYN° CENTRES ALBANIA2 ALGERIA>10 BOSNIA<5 CROATIA~10 EGYPT5 GREECE12 ISRAEL~10 MALTA5 MAROCCO4 SLOVENIA7 TUNISIA7 TURKEY30 N° CASES ˜ 12/year (Tirana) 100 new/year (Oran) 35 (Tuzla) >200 (Zagreb) 1,2% 326 (Athens) NA 680 NA ˜ 12 new/year(Maribor) 10 new/year 150 (Ankara)

COUNTRY ALBANIA ALGERIA BOSNIA CROATIA EGYPT GREECE ISRAEL MALTA MAROCCO SLOVENIA TUNISIA TURKEY WHERE BIOPSY Hospital+private NA 3 centres 7 centres Hospital+private 10 centres 3 centres 4 hospital+private 2 centres 7 centres 30 centres WHERE TGASI Hospital+private NA 6 centres 7 labs Hospital+private Very diffuse Hospital+private Private Hospital+private 7 centres Many centres WHERE ARE AVAILABLE DIAGNOSTIC RESOURCES ?

COUNTRY ALBANIA ALGERIA BOSNIA CROATIA EGYPT GREECE ISRAEL MALTA MAROCCO SLOVENIA TUNISIA TURKEY SUPPORT TO DIET 60 € monthly None G.F. flour 10 kg G.F. flour monthly None G.F. products by NHS None Financial support None yes KIND OF DIET Naturally G.F. foods Case by case Naturally+manufactured Naturally Naturally+manufactured Case by case Naturally Naturally+manufactured Naturally+casebycase Naturally+manufactured HOW IT IS MANAGED THE GLUTEN-FREE DIET ?

COUNTRY ALBANIA ALGERIA BOSNIA CROATIA EGYPT GREECE ISRAEL MALTA MAROCCO SLOVENIA TUNISIA TURKEY Biopsy 80 € € 25 € NA 70 € € 200 € € 60 € NA 18€ (bio+path) 36,70 € TGasi 35 € 60 € 112 € NA 50 € € 20 € € 40 € NA 30 € 7,20 € … A ROUGH ESTIMATION OF COST Kg of G.F. Food 5€5€ 3 € 5,50 € 5 € NA 9-14 € NA 5-6 € 10 € P athology 50 € 15 € 30 € NA 30 € € 50 € 200 € 30 € NA 18€(bio+path) 16,30 €

We see a ‘mosaic’ type picture : not enough for the epidemic !

We need actions !  Set up a National Task Force of stakeholders  Agree on a common strategy  DISSEMINATION and in-Field Training  Reinforce Diagnostic Resources  National sustainable Gluten-Free

Let us start : it is up to you !