European Laboratory for Food Induced Diseases (ELFID)European Laboratory for Food Induced Diseases (ELFID) University of Naples Federico IIUniversity of Naples Federico II

Prof. Luigi GrecoProf. Luigi Greco

Participants to the MEDICEL network

PopulationChildren 0-

14Median

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 10.873.793ISRAEL 7.233.701 2.015.859 29,1 1,671 2.145.154 8.442.452ITALY 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 4.461.787LIBYA 6.324.357 63.244 23,9 2,172 2.383.966 7.698.007MALTA 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 34.723.415SYRIA 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

Mediterranean populationMediterranean population

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

Rise in the consumption of wheat flourRise in the consumption of wheat flour

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

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

NorthFranceSpainItaly

North-EastSloveniaBosniaCroatiaAlbania

EastLebanon

IsraelSyria

Middle EastGreeceMalta

TurkeyCyprus

SouthMoroccoAlgeriaEgyptLibia

Tunisia

MEDITERRANEAN NETWORK FOR THE MANAGEMENT

OF FOOD INDUCED DISEASES

Mediterannean populationMediterannean population

Regions PopulationChildren 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

Prevalence of CeliacsPrevalence of CeliacsEstimated 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

Prevalence of CeliacsPrevalence 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

PopulationProjected 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 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

TOTAL455.668.89

7 4.644.529 1.040.220 514.901 208.044

Clinical Symptoms in CD Cases

Prevalence of symptoms in Celiac Prevalence of symptoms in Celiac populationpopulation

Population GI Symptoms Anaemia OsteopeniaAbnormal

LiverShort 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

Diseases in symptomatic cases

Regions

GI Symptoms

Anaemia

Osteopenia

Abnormal Liver

Short Stature Children

North 214.069100.73

8 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 252.846118.98

6 89.240 29.747 21.125

MED tot 657.119

309.232 231.924 77.308 41.609

Excess mortality of undiagnosed celiacsExcess mortality of undiagnosed celiacs

PopulationProjected 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

Excess mortality of undiagnosed Excess mortality of undiagnosed celiacsceliacs

Regions

Death rate deaths/ 1,000

population

Population Expected Deaths

next 10 yCeliacs 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 71.310MED tot 7,2 31.703.339 612.086 272.038

EXCESS CONSUMPTION OF MEDICAL RESOURCES BY UNDIAGNOSED

SYMPTOMATIC CELIACS

ADULTS in 6

years

CHILDRENin 2 years

In-patient admission 2 1

Out-patient admission 1 1

Medical consultations : primary care 2/year12 4

Specialized Consultations : 2 1

Lab Test 4 2

Minimal Estimate of excess request for medical services compared to age and sex matched controls

Purchasing power parityPurchasing 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.

Costs of celiac diseaseCosts of celiac diseasePurchasing Power Parity

Symptomatic adults

1:7 next 10y

Symptomatic

children 1:5

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 17,92514.90

1208.04

4 7.012 2.0543.894.101.97

4369.148.63

14.263.250.60

5

Costs of undiagnosed celiac Costs of undiagnosed celiac diseasedisease

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

The epidemic of coeliac diseaseThe epidemic of coeliac disease

years

Celiacs/1000

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

HOW MANY CENTRES DIAGNOSE COELIAC DISEASE IN EACH MEDITERRANEAN COUNTRY?

COUNTRY N° CENTRES

ALBANIA 2

ALGERIA >10

BOSNIA <5

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)

>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

7 centres

Hospital+private

10 centres

3 centres

4 hospital+private

2 centres

7 centres

30 centres

WHERE TGASI

Hospital+private

NA

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

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

Naturally+manufactured

Naturally+manufactured

Naturally

Naturally+manufactured

Case by case

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 €

25-30 €

25 €

NA

70 €

88-800 €

200 €

600-1000 €

60 €

NA18€

(bio+path)

36,70 €

TGasi

35 €

60 €

112 €

NA

50 €

18-36 €

20 €

60-80 €

40 €

NA

30 €

7,20 €

… … A ROUGH ESTIMATION OF COSTA ROUGH ESTIMATION OF COST

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 €

NA18€(bio+path)

16,30 €

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

We need actions !We need actions !

Set up a National Task Force of stakeholdersSet up a National Task Force of stakeholders Agree on a common strategy Agree on a common strategy DISSEMINATION and in-Field TrainingDISSEMINATION and in-Field Training Reinforce Diagnostic ResourcesReinforce Diagnostic Resources National sustainable Gluten-FreeNational sustainable Gluten-Free

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