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

2. Participants to the MEDICEL network

3. PopulationChildren 0-14 Median age Population growth rate (%) Children0-14 in 10 years Total population in 10y ALBANIA3.639.453714.25029,90,546829.7953.838.167 ALGERIA34.178.1888.696.32026,61,1968.664.17138.265.899 BOSNIA3.842.566668.06339,80,339510.1013.972.829 CYPRUS1.084.74810.84735,51,69184.1901.268.070 CROATIA4.489.409698.45841-0,052649.1694.466.064 EGYPT78.866.63526.020.30724,82,03330.083.67894.900.222 FRANCE64.057.79211.968.65439,40,54912.078.09767.574.565 GREECE10.737.4281.530.99241,80,1271.522.03010.873.793 ISRAEL7.233.7012.015.85929,11,6712.145.1548.442.452 ITALY58.126.2127.870.22643,3-0,0477.132.08657.853.019 LEBANON4.017.0951.034.88529,31,1071.030.3854.461.787 LIBYA6.324.35763.24423,92,1722.383.9667.698.007 MALTA403.53265.30639,50,462.709419.673 MOROCCO31.285.1748.967.576251,0999.254.15434.723.415 SYRIA21.762.978217.63021,72,0068.161.11726.128.631 SLOVENIA2.046.976287.27541,50,007328.5402.078.249 SPAIN40.525.0025.864.41941,10,0725.908.54540.816.782 TUNISIA10.486.3392.377.03429,20,982.425.49011.514.000 TURKEY72.561.31218.859.33427,71,320.353.44880.252.000 MEDITE R 455.668.8 9797.930.67933,20,91 104.022.01 4499.547.626 Mediterranean population

4. Consumption of wheat per capita (Kcal/Day)

5. Rise in the consumption of wheat flour

6. Pasta consumption in the E.U. (1990 - 2008)

7. 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 3.191.505 t Turkey 566.303 t Egypt 400.000 t France 241.121 t Spain 224.000 t Greece 151.000 t Tunisia 110.000 t Syria 9.005 t

8. 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

9. Mediterannean population RegionsPopulationChildren 0-14Median age Population growth rate (%) Children0-14 in 10 years Total population in 10y North162.709.00625.703.29941,30,225.118.728166.244.366 N.East14.018.4042.368.04638,10,22.317.60414.355.309 M.East84.787.02020.466.47936,10,922.122.37892.813.537 East33.013.7743.268.37426,71,611.336.65639.032.871 South161.140.69346.124.48125,91,552.811.460187.101.543 MED tot455.668.89797.930.67933,20,9104.022.014499.547.626

10. 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 36.3957.14338.3828.298 ALGERIA 341.78286.963382.65986.642 BOSNIA 38.4266.68139.7285.101 CYPRUS 10.8471.84012.6811.842 CROATIA 44.8946.98544.6616.492 EGYPT 788.666260.203949.002300.837 FRANCE 640.578119.687675.746120.781 GREECE 107.37415.310108.73815.220 ISRAEL 72.33720.15984.42521.452 ITALY 581.26278.702578.53071.321 LEBANON 40.17110.34944.61810.304 LIBYA 63.24463276.98023.840 MALTA 4.0356534.197627 MAROCCO 312.85289.676347.23492.542 SYRIA 217.63079.275261.28681.611 SLOVENIA 20.4702.87320.7823.285 SPAIN 405.25058.644408.16859.085 TUNISIA 104.86323.770115.14024.255 TURKEY 725.613188.593802.520203.534 Med Tot4.264.968976.3894.644.5291.040.220

11. 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 North1.627.090257.033251.1871.662.444 N.East140.18423.68023.176143.553 M.East847.870204.665221.224928.135 East330.13832.684113.367390.329 South1.611.407461.245528.1151.871.015 MED tot4.556.689979.3071.040.2204.995.476

12. 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 363945338.3828.2984.2981.660 ALGERIA 34.178.188382.65986.64242.28817.328 BOSNIA 3.842.56639.7285.1014.9471.020 CYPRUS 1.084.74812.6811.8421.548368 CROATIA 4.489.40944.6616.4925.4531.298 EGYPT 78.866.635949.002300.83792.59560.167 FRANCE 64.057.792675.746120.78179.28124.156 GREECE 10.737.428108.73815.22013.3603.044 ISRAEL 7.233.70184.42521.4528.9964.290 ITALY 58.126.212578.53071.32172.45814.264 LEBANON 4.017.09544.61810.3044.9022.061 LIBYA 6.324.35776.98023.8407.5914.768 MALTA 403.5324.197627510125 MAROCCO 31.285.174347.23492.54236.38518.508 SYRIA 21.762.978261.28681.61125.66816.322 SLOVENIA 2.046.97620.7823.2852.500657 SPAIN 40.525.002408.16859.08549.86911.817 TUNISIA 10.486.339115.14024.25512.9844.851 TURKEY 72.561.312802.520203.53485.56940.707 TOTAL455.668.8974.644.5291.040.220514.901208.044 Clinical Symptoms in CD Cases

13. Prevalence of symptoms in Celiac population PopulationGI SymptomsAnaemiaOsteopenia Abnormal Liver Short Stature Children ALBANIA3639453506423831787596332 ALGERIA34.178.18850674238471788559623466 BOSNIA3.842.566507223871790597204 CYPRUS1.084.748162976757519274 CROATIA4.489.409573827002025675260 EGYPT78.866.63512984861105458291527612033 FRANCE64.057.792879214137531031103444831 GREECE10.737.42813943656149211640609 ISRAEL7.233.70111293531539861329858 ITALY58.126.21273714346892601786722853 LEBANON4.017.095591827852089696412 LIBYA6.324.35710506494437081236954 MALTA403.5325402541916425 MAROCCO31.285.17446659219571646854893702 SYRIA21.762.97835692167961259741993264 SLOVENIA2.046.97626831263947316131 SPAIN40.525.00252433246741850661692363 TUNISIA10.486.33915159713453501783970 TURKEY72.561.3121073355051137883126288141 TOT MED455.668.897661.823311.446233.58477.86145.483

14. Diseases in symptomatic cases RegionsGI SymptomsAnaemiaOsteopeniaAbnormal Liver Short Stature Children North214.069100.73875.55425.18510.047 N.East18.5578.7336.5502.183927 M.East123.44758.09343.57014.5238.849 East52.90324.89618.6726.2244.535 South252.846118.98689.24029.74721.125 MED tot657.119309.232231.92477.30841.609

15. 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 363945338.3825,1184.5203.5031.557 ALGERIA 34.178.188382.6594,61.585.86831.96014.204 BOSNIA 3.842.56639.7288,6331.6136.1712.743 CYPRUS 1.084.74812.6816,469.4241.461649 CROATIA 4.489.40944.66111,8527.5069.4464.198 EGYPT 78.866.635949.0024,93.848.69283.36037.049 FRANCE 64.057.792675.7468,65.483.347104.11946.275 GREECE 10.737.428108.73810,51.128.50420.5719.143 ISRAEL 7.233.70184.4255,4392.7908.2523.667 ITALY 58.126.212578.53010,76.231.130111.63349.615 LEBANON 4.017.09544.6186,0242.2314.8432.152 LIBYA 6.324.35776.9803,4215.6614.7252.100 MALTA 403.5324.1978,433.816633281 MAROCCO 31.285.174347.2344,71.482.91729.62613.167 SYRIA 21.762.978261.2863,7809.58317.4967.776 SLOVENIA 2.046.97620.7829,2188.3223.4411.530 SPAIN 40.525.002408.16810,04.048.44873.39732.621 TUNISIA 10.486.339115.1405,2545.29010.7774.790 TURKEY 72.561.312802.5206,04.353.67986.67238.521 Tot 455.668.8974.995.4767,031.703.339 612.086272.038

16. 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 North9,815.762.925289.149128.511 N.East8,71.231.96122.56110.027 M.East7,85.585.422109.33748.594 East5,11.444.60430.59013.596 South4,67.678.427160.44871.310 MED tot7,231.703.339612.086272.038

17. 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

18. 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

19. 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 € ALBANIA7,164.2981.6602.80482112.049.8271.362.96713.412.794 ALGERIA6,8742.28817.3282.688787113.685.29713.645.185127.330.482 BOSNIA7,364.9471.0202.88184414.251.119860.89815.112.016 CYPRUS17,701.5483686.9282.02910.728.077747.60511.475.682 CROATIA28,545.4531.29811.1713.27260.914.2384.248.45765.162.695 EGYPT6,1292.59560.1672.396702221.893.12242.233.211264.126.334 FRANCE33,6879.28124.15613.1813.8611.045.004.70093.264.5511.138.269.251 GREECE29,8813.3603.04411.6953.426156.241.66610.427.781166.669.447 ISRAEL28,398.9964.29011.1123.25599.967.60013.964.606113.932.206 ITALY29,1172.45814.26411.3933.337825.483.17847.599.543873.082.721 LEBANON14,234.9022.0615.5681.63127.292.8063.360.78930.653.594 LIBYA14,337.5914.7685.6081.64342.570.0527.831.49450.401.546 MALTA23,585101259.2302.7044.706.912339.0835.045.995 MAROCCO4,6036.38518.5081.80252865.560.9689.768.57075.329.537 SYRIA4,7025.66816.3221.83953947.214.9558.794.40356.009.358 SLOVENIA29,692.50065711.6193.40329.043.1042.236.36331.279.467 SPAIN33,7049.86911.81713.1893.863657.735.86645.653.007703.388.873 TUNISIA8,2512.9844.8513.23094641.942.1674.590.10846.532.275 TURKEY12,4885.56940.7074.8831.430417.816.32158.220.010476.036.331 MED17,92514.901208.0447.0122.0543.894.101.974369.148.6314.263.250.605

20. 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 € North3212.5883.6872.528.223.744 186.517.1022.714.740.846 N.East187.1192.085116.258.288 8.708.685124.966.973 M.East218.1842397589.492.976 69.734.479659.227.455 East166.1731.808174.475.361 26.119.797200.595.158 South8,03.145921 485.651.60678.068.568563.720.174 MED1937.20910.8993.894.101.974 369.148.6314.263.250.605

21. The epidemic of coeliac disease years Celiacs/1000

22. WE HAVE TO FACE A SUBSTANTIAL TASK : HOW ?

23. 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)

24. 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 ?

25. 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 ?

26. COUNTRY ALBANIA ALGERIA BOSNIA CROATIA EGYPT GREECE ISRAEL MALTA MAROCCO SLOVENIA TUNISIA TURKEY Biopsy 80 € 25-30 € 25 € NA 70 € 88-800 € 200 € 600-1000 € 60 € NA 18€ (bio+path) 36,70 € TGasi 35 € 60 € 112 € NA 50 € 18-36 € 20 € 60-80 € 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 € 30-400 € 50 € 200 € 30 € NA 18€(bio+path) 16,30 €

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

28. 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

29. Let us start : it is up to you !