Diapositiva 1

1
MEDITERRANEAN NETWORK FOR THE
MANAGEMENT OF GLUTEN INDUCED DISEASES
European Laboratory for Food Induced Diseases
(ELFID) University of Naples Federico II
Prof. Luigi Greco
2
Participants to the MEDICEL network
Abkari Abdelhak, Hopital des Enfant Ibn Rochd de Casablanca, MOROCCO
Abu-Zekry Mona, Childrens Hospital, G.I. Unit, , Cairo University, Cairo, EGYPT
Attard Thomas, Univ of , Med School, Guardamangia, Msida MSD 2080 MALTA
Barada Kassem American University of Beirut Medical Center, Beirut , LEBANON
Bilbao Josè Ramon, Immunogenetics Laboratory, Hospital de Cruces, Bilbao, SPAIN
Boudraa Ghazalia, Clinique Amilcar Cabral, Oran , ALGERIA
Bouguerrà Faouzi, Hopital des Enfants de Tunis, TUNISIA
Cullufi Paskal, Gastrohepatology Hospital Center "Mother Tereza" inTirana, ALBANIA
Dusanka Micetic-Turk. University Medical Centre Paediatric Dpt Ljubljanska, Maribor, SLOVENIA
Hugot Jean Pierre, Hopital Robert Debré, Gastroenterology, Paris, France
Kuloglu Zarife, Dpt of Pediatric Gastroenterology, , Ankara University Ankara, TURKEY
Roma Eleftheria, Aghia Sophia Childrens Hospital, Athens, GREECE
Shamir Raanan, Schneider Children's Medical Center of Israel, Tel Aviv, ISRAEL
Terzic Selma, University Clinical Center Tuzla, University of Tuzla, Sarajevo, BOSNIA
Zrinjka Mišak, for Pediatric Gastroenterology and Nutrition, Children's Hospital , Zagreb, CROATIA
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Mediterranean population
Population Children 0-14 Median age Population growth rate () Children0-14 in 10 years Total population in 10y
ALBANIA 3.639.453 714.250 29,9 0,546 829.795 3.838.167
ALGERIA 34.178.188 8.696.320 26,6 1,196 8.664.171 38.265.899
BOSNIA 3.842.566 668.063 39,8 0,339 510.101 3.972.829
CYPRUS 1.084.748 10.847 35,5 1,69 184.190 1.268.070
CROATIA 4.489.409 698.458 41 -0,052 649.169 4.466.064
EGYPT 78.866.635 26.020.307 24,8 2,033 30.083.678 94.900.222
FRANCE 64.057.792 11.968.654 39,4 0,549 12.078.097 67.574.565
GREECE 10.737.428 1.530.992 41,8 0,127 1.522.030 10.873.793
ISRAEL 7.233.701 2.015.859 29,1 1,671 2.145.154 8.442.452
ITALY 58.126.212 7.870.226 43,3 -0,047 7.132.086 57.853.019
LEBANON 4.017.095 1.034.885 29,3 1,107 1.030.385 4.461.787
LIBYA 6.324.357 63.244 23,9 2,172 2.383.966 7.698.007
MALTA 403.532 65.306 39,5 0,4 62.709 419.673
MOROCCO 31.285.174 8.967.576 25 1,099 9.254.154 34.723.415
SYRIA 21.762.978 217.630 21,7 2,006 8.161.117 26.128.631
SLOVENIA 2.046.976 287.275 41,5 0,007 328.540 2.078.249
SPAIN 40.525.002 5.864.419 41,1 0,072 5.908.545 40.816.782
TUNISIA 10.486.339 2.377.034 29,2 0,98 2.425.490 11.514.000
TURKEY 72.561.312 18.859.334 27,7 1,3 20.353.448 80.252.000
MEDITER 455.668.897 97.930.679 33,2 0,91 104.022.014 499.547.626
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Consumption of wheat per capita (Kcal/Day)
5
Rise in the consumption of wheat flour
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Pasta consumption in the E.U. (1990 - 2008)
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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
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MEDITERRANEAN NETWORK FOR THE MANAGEMENT OF FOOD
INDUCED DISEASES
North France Spain Italy
North-East Slovenia Bosnia Croatia Albania
Middle East Greece Malta Turkey Cyprus
South Morocco Algeria Egypt Libia Tunisia
East Lebanon Israel Syria
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Mediterannean population
Regions Population Children 0-14 Median age Population growth rate () Children0-14 in 10 years Total population in 10y
North 162.709.006 25.703.299 41,3 0,2 25.118.728 166.244.366
N.East 14.018.404 2.368.046 38,1 0,2 2.317.604 14.355.309
M.East 84.787.020 20.466.479 36,1 0,9 22.122.378 92.813.537
East 33.013.774 3.268.374 26,7 1,6 11.336.656 39.032.871
South 161.140.693 46.124.481 25,9 1,5 52.811.460 187.101.543
MED tot 455.668.897 97.930.679 33,2 0,9 104.022.014 499.547.626
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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 36.395 7.143 38.382 8.298
ALGERIA 341.782 86.963 382.659 86.642
BOSNIA 38.426 6.681 39.728 5.101
CYPRUS 10.847 1.840 12.681 1.842
CROATIA 44.894 6.985 44.661 6.492
EGYPT 788.666 260.203 949.002 300.837
FRANCE 640.578 119.687 675.746 120.781
GREECE 107.374 15.310 108.738 15.220
ISRAEL 72.337 20.159 84.425 21.452
ITALY 581.262 78.702 578.530 71.321
LEBANON 40.171 10.349 44.618 10.304
LIBYA 63.244 632 76.980 23.840
MALTA 4.035 653 4.197 627
MAROCCO 312.852 89.676 347.234 92.542
SYRIA 217.630 79.275 261.286 81.611
SLOVENIA 20.470 2.873 20.782 3.285
SPAIN 405.250 58.644 408.168 59.085
TUNISIA 104.863 23.770 115.140 24.255
TURKEY 725.613 188.593 802.520 203.534
Med Tot 4.264.968 976.389 4.644.529 1.040.220
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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 1.627.090 257.033 251.187 1.662.444
N.East 140.184 23.680 23.176 143.553
M.East 847.870 204.665 221.224 928.135
East 330.138 32.684 113.367 390.329
South 1.611.407 461.245 528.115 1.871.015
MED tot 4.556.689 979.307 1.040.220 4.995.476
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Clinical Symptoms in CD Cases
Population Projected prevalence of CD in next 10 yrs Projected celiac children in 10 years Symptomatic adults 17 next 10y Sympomatic children 15 next 10y
ALBANIA 3639453 38.382 8.298 4.298 1.660
ALGERIA 34.178.188 382.659 86.642 42.288 17.328
BOSNIA 3.842.566 39.728 5.101 4.947 1.020
CYPRUS 1.084.748 12.681 1.842 1.548 368
CROATIA 4.489.409 44.661 6.492 5.453 1.298
EGYPT 78.866.635 949.002 300.837 92.595 60.167
FRANCE 64.057.792 675.746 120.781 79.281 24.156
GREECE 10.737.428 108.738 15.220 13.360 3.044
ISRAEL 7.233.701 84.425 21.452 8.996 4.290
ITALY 58.126.212 578.530 71.321 72.458 14.264
LEBANON 4.017.095 44.618 10.304 4.902 2.061
LIBYA 6.324.357 76.980 23.840 7.591 4.768
MALTA 403.532 4.197 627 510 125
MAROCCO 31.285.174 347.234 92.542 36.385 18.508
SYRIA 21.762.978 261.286 81.611 25.668 16.322
SLOVENIA 2.046.976 20.782 3.285 2.500 657
SPAIN 40.525.002 408.168 59.085 49.869 11.817
TUNISIA 10.486.339 115.140 24.255 12.984 4.851
TURKEY 72.561.312 802.520 203.534 85.569 40.707
TOTAL 455.668.897 4.644.529 1.040.220 514.901 208.044
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Prevalence of symptoms in Celiac population
Population GI Symptoms Anaemia Osteopenia Abnormal Liver Short Stature Children
ALBANIA 3639453 5064 2383 1787 596 332
ALGERIA 34.178.188 50674 23847 17885 5962 3466
BOSNIA 3.842.566 5072 2387 1790 597 204
CYPRUS 1.084.748 1629 767 575 192 74
CROATIA 4.489.409 5738 2700 2025 675 260
EGYPT 78.866.635 129848 61105 45829 15276 12033
FRANCE 64.057.792 87921 41375 31031 10344 4831
GREECE 10.737.428 13943 6561 4921 1640 609
ISRAEL 7.233.701 11293 5315 3986 1329 858
ITALY 58.126.212 73714 34689 26017 8672 2853
LEBANON 4.017.095 5918 2785 2089 696 412
LIBYA 6.324.357 10506 4944 3708 1236 954
MALTA 403.532 540 254 191 64 25
MAROCCO 31.285.174 46659 21957 16468 5489 3702
SYRIA 21.762.978 35692 16796 12597 4199 3264
SLOVENIA 2.046.976 2683 1263 947 316 131
SPAIN 40.525.002 52433 24674 18506 6169 2363
TUNISIA 10.486.339 15159 7134 5350 1783 970
TURKEY 72.561.312 107335 50511 37883 12628 8141
TOT MED 455.668.897 661.823 311.446 233.584 77.861 45.483
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Diseases in symptomatic cases
Regions GI Symptoms Anaemia Osteopenia Abnormal Liver Short Stature Children
North 214.069 100.738 75.554 25.185 10.047
N.East 18.557 8.733 6.550 2.183 927
M.East 123.447 58.093 43.570 14.523 8.849
East 52.903 24.896 18.672 6.224 4.535
South 252.846 118.986 89.240 29.747 21.125
MED tot 657.119 309.232 231.924 77.308 41.609
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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 3639453 38.382 5,1 184.520 3.503 1.557
ALGERIA 34.178.188 382.659 4,6 1.585.868 31.960 14.204
BOSNIA 3.842.566 39.728 8,6 331.613 6.171 2.743
CYPRUS 1.084.748 12.681 6,4 69.424 1.461 649
CROATIA 4.489.409 44.661 11,8 527.506 9.446 4.198
EGYPT 78.866.635 949.002 4,9 3.848.692 83.360 37.049
FRANCE 64.057.792 675.746 8,6 5.483.347 104.119 46.275
GREECE 10.737.428 108.738 10,5 1.128.504 20.571 9.143
ISRAEL 7.233.701 84.425 5,4 392.790 8.252 3.667
ITALY 58.126.212 578.530 10,7 6.231.130 111.633 49.615
LEBANON 4.017.095 44.618 6,0 242.231 4.843 2.152
LIBYA 6.324.357 76.980 3,4 215.661 4.725 2.100
MALTA 403.532 4.197 8,4 33.816 633 281
MAROCCO 31.285.174 347.234 4,7 1.482.917 29.626 13.167
SYRIA 21.762.978 261.286 3,7 809.583 17.496 7.776
SLOVENIA 2.046.976 20.782 9,2 188.322 3.441 1.530
SPAIN 40.525.002 408.168 10,0 4.048.448 73.397 32.621
TUNISIA 10.486.339 115.140 5,2 545.290 10.777 4.790
TURKEY 72.561.312 802.520 6,0 4.353.679 86.672 38.521
Tot 455.668.897 4.995.476 7,0 31.703.339 612.086 272.038
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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
North 9,8 15.762.925 289.149 128.511
N.East 8,7 1.231.961 22.561 10.027
M.East 7,8 5.585.422 109.337 48.594
East 5,1 1.444.604 30.590 13.596
South 4,6 7.678.427 160.448 71.310
MED tot 7,2 31.703.339 612.086 272.038
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EXCESS CONSUMPTION OF MEDICAL RESOURCES BY UNDIAGNOSED SYMPTOMATIC CELIACS ADULTS in 6 years CHILDREN in 2 years
In-patient admission 2 1
Out-patient admission 1 1
Medical consultations primary care 2/year 12 4
Specialized Consultations 2 1
Lab Test 4 2
Minimal Estimate of excess request for medical
services compared to age and sex matched controls
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Purchasing power parity
The concept is founded on the 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.
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Costs of celiac disease
Purchasing Power Parity Symptomatic adults 17 next 10y Symptomatic children 15 next 10 y Standirdized Cost for adult Standardized Cost for children Tot Cost Adult next 10 y Tot Cost Children next 10 yr TOT Cost Symptomatic next 10 yr
ALBANIA 7,16 4.298 1.660 2.804 821 12.049.827 1.362.967 13.412.794
ALGERIA 6,87 42.288 17.328 2.688 787 113.685.297 13.645.185 127.330.482
BOSNIA 7,36 4.947 1.020 2.881 844 14.251.119 860.898 15.112.016
CYPRUS 17,70 1.548 368 6.928 2.029 10.728.077 747.605 11.475.682
CROATIA 28,54 5.453 1.298 11.171 3.272 60.914.238 4.248.457 65.162.695
EGYPT 6,12 92.595 60.167 2.396 702 221.893.122 42.233.211 264.126.334
FRANCE 33,68 79.281 24.156 13.181 3.861 1.045.004.700 93.264.551 1.138.269.251
GREECE 29,88 13.360 3.044 11.695 3.426 156.241.666 10.427.781 166.669.447
ISRAEL 28,39 8.996 4.290 11.112 3.255 99.967.600 13.964.606 113.932.206
ITALY 29,11 72.458 14.264 11.393 3.337 825.483.178 47.599.543 873.082.721
LEBANON 14,23 4.902 2.061 5.568 1.631 27.292.806 3.360.789 30.653.594
LIBYA 14,33 7.591 4.768 5.608 1.643 42.570.052 7.831.494 50.401.546
MALTA 23,58 510 125 9.230 2.704 4.706.912 339.083 5.045.995
MAROCCO 4,60 36.385 18.508 1.802 528 65.560.968 9.768.570 75.329.537
SYRIA 4,70 25.668 16.322 1.839 539 47.214.955 8.794.403 56.009.358
SLOVENIA 29,69 2.500 657 11.619 3.403 29.043.104 2.236.363 31.279.467
SPAIN 33,70 49.869 11.817 13.189 3.863 657.735.866 45.653.007 703.388.873
TUNISIA 8,25 12.984 4.851 3.230 946 41.942.167 4.590.108 46.532.275
TURKEY 12,48 85.569 40.707 4.883 1.430 417.816.321 58.220.010 476.036.331
MED 17,92 514.901 208.044 7.012 2.054 3.894.101.974 369.148.631 4.263.250.605
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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 32 12.588 3.687 2.528.223.744 186.517.102 2.714.740.846
N.East 18 7.119 2.085 116.258.288 8.708.685 124.966.973
M.East 21 8.184 2397 589.492.976 69.734.479 659.227.455
East 16 6.173 1.808 174.475.361 26.119.797 200.595.158
South 8,0 3.145 921 485.651.606 78.068.568 563.720.174
MED 19 37.209 10.899 3.894.101.974 369.148.631 4.263.250.605
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The epidemic of coeliac disease
Celiacs/1000
years
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WE HAVE TO FACE A SUBSTANTIAL TASK HOW ?
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HOW MANY CENTRES DIAGNOSE COELIAC DISEASE IN EACH
MEDITERRANEAN COUNTRY?
COUNTRY N CENTRES
ALBANIA 2
ALGERIA gt10
BOSNIA lt5
CROATIA 10
EGYPT 5
GREECE 12
ISRAEL 10
MALTA 5
MAROCCO 4
SLOVENIA 7
TUNISIA 7
TURKEY 30
N CASES
12/year (Tirana)
100 new/year (Oran)
35 (Tuzla)
gt200 (Zagreb)
1,2
326 (Athens)
NA
680
NA
12 new/year(Maribor)
10 new/year
150 (Ankara)
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WHERE ARE AVAILABLE DIAGNOSTIC RESOURCES ?
COUNTRY
ALBANIA
ALGERIA
BOSNIA
CROATIA
EGYPT
GREECE
ISRAEL
MALTA
MAROCCO
SLOVENIA
TUNISIA
TURKEY
WHERE BIOPSY
Hospitalprivate
NA
3 centres
7 centres
7 centres
Hospitalprivate
10 centres
3 centres
4 hospitalprivate
2 centres
7 centres
30 centres
WHERE TGASI
Hospitalprivate
NA
NA
6 centres
7 labs
Hospitalprivate
Very diffuse
Hospitalprivate
Private
Hospitalprivate
7 centres
Many centres
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HOW IT IS MANAGED THE GLUTEN-FREE DIET ?
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
G.F. products by NHS
G.F. products by NHS
None
Financial support
None
yes
KIND OF DIET
Naturally G.F. foods
Case by case
Naturallymanufactured
Naturallymanufactured
Naturally
Naturallymanufactured
Case by case
Case by case
Naturally
Naturallymanufactured
Naturallycasebycase
Naturallymanufactured
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A ROUGH ESTIMATION OF COST
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 (biopath)
36,70
TGasi
35
60
112
NA
50
18-36
20
60-80
40
NA
30
7,20
Kg of G.F. Food
5
3
5,50
5
NA
9-14
NA
NA
NA
NA
5-6
10
Pathology
50
15
30
NA
30
30-400
50
200
30
NA
18(biopath)
16,30
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We see a mosaic type picture not enough for
the epidemic !
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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

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Let us start it is up to you !