Coeliac disease in developing countries: Middle East, India and North Africa

Following the application of simple serological tests for the diagnosis of coeliac disease (CD) in the 1980s, it gradually became clear that the prevalence of CD in different countries in the Middle East, North Africa and India is almost the same as that in Western countries. The prevalence of CD in at-risk populations in these regions is reported to range between 3 and 20% and the prevalence in people with type 1 diabetes is approximately 3-5%. Clinical manifestations of CD vary markedly with age, the duration and the extent of disease. Clinical studies showed that presentation with non-specific symptoms or no symptoms is as common in the Middle East as it is in Europe. Wheat has been the major staple food in these regions for many centuries and it is possible that the continuous and high level of exposure to wheat proteins has induced some degree of immune tolerance, leading to milder symptoms, which are misdiagnosed as irritable bowel syndrome or unexplained gastrointestinal disorders. A high index of suspicion for CD should be maintained in all developing countries for patients who present with chronic diarrhoea or iron deficiency anaemia.The best method for diagnosing CD in patients with diarrhoea is the panel of coeliac serological tests followed by small-bowel biopsy. In the absence of supplies for a gluten-free diet in Middle Eastern countries, maintaining this diet represents a real challenge to both patients and clinicians.