1. Coeliac Disease in the Maltese Islands Thomas M Attard MD FAAP FACG Consultant Paediatrician and gastroenterologist Mater Dei Hospital, BKara, Malta

2. The Maltese Islands - statistics Surface area316 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.)

3. 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.

4. 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

5. Regional distribution of Coeliac Disease in the Maltese Islands* 17 18 5 10 44 5 5 31 3 2 9 5 8 9 9 30 9 7 5 10 1 4 14 9 20 5 7 4 17 6 35 8 17 3 3 20 23 4 7 2 25 8 21 2 29 24 3 15 3 5 40 18 7 12 8 5 7 26 16 30 20 * Crude prevalence individuals receiving benefits for GFD

6. Clinical Case recognition in the Maltese Islands Prevalence of CD based on clinical diagnosis & GFD: 1.9 / 1,000 (1 in 526 gen. Pop n ) 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.

7. Age at diagnosis distribution, Coeliac patients in the Maltese Islands

8. Age at diagnosis distribution by gender of Coeliacs in the Maltese Islands

9. 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

10. 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.

11. CD in Malta – diagnosis Serology: 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 T ype 1 diabetes Autoimmune Thyroiditis Biopsy: endoscopy / Cosby Capsule Inconclusive findings can be further studied through capsule endoscopy

12. 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

13. 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

14. 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

15. 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