Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Awareness of Celiac Disease among the General Public in Saudi Arabia

Maha H. Alhussain

Department of Food Sciences and Nutrition, College of Food and Agriculture, King Saud University, Riyadh 11451, Saudi Arabia

Abstract: Background: Celiac disease (CD) is an immune-mediated systemic disorder triggered by dietary gluten and is considered one of the most common lifelong food-related disorders worldwide. The knowledge of CD among the general public in Saudi Arabia remains limited. Therefore, we aimed to assess the awareness and knowledge of CD among the general public in Saudi Arabia. Methods: A cross-sectional online survey including members of the general public was conducted in Saudi Arabia. The survey included questions assessing the public’s awareness about CD, gluten sensitivity, and peanut allergy, as well as celiac disease-related knowledge. Results: From a total of 1230 responses received, 76.7% (95% confidence interval [CI], 74.0%–79.4%) were females, 42.0% (95% CI, 37.7–46.3) were aged between 31–45 years, and 64.3% (95% CI, 61.0%–67.6%) had Bachelor’s degree. Less than half of the participants had heard of CD (48.4%; 95% CI, 44.4%–52.4%), but the majority had heard of peanut allergy (80.1%; 95% CI, 77.6%–82.6%) and gluten sensitivity (72.4%; 95% CI, 69.5%–75.3%). The prevalence of CD was estimated incorrectly by more than 80% of participants. Other questions on participants’ knowledge associated with CD were answered “Do not know” by the majority. Females demonstrated a greater awareness of CD, peanut allergy, and gluten sensitivity, and had a higher percentage of correct responses to questions related to CD than males. Conclusion: This study highlights the need to increase the awareness and knowledge of CD, especially in the recognition of its symptoms. Educational efforts toward increasing the awareness of the general public about CD could help optimize its diagnosis and management.

Keywords: Celiac Disease, Gluten-Free Diet, Gluten Sensitivity, Saudi Arabia, questionnaire

Received April 03, 2021; Revised May 09, 2021; Accepted May 18, 2021

Citation: Maha H. Alhussain, Awareness of Celiac Disease among the General Public in Saudi Arabia. International Journal of Celiac Disease, 9 (2). 71-76. January 2021. doi:10.12691/ijcd-9-2-4

1. Introduction

Celiac disease (CD) is an immune-mediated systemic disorder characterized by mucosal damage of the small intestine. This disease is capable of impeding the absorption of nutrients [1]. Celiac disease develops in genetically susceptible individuals exposed to gliadin proteins and related prolamines (defined as gluten, which is present in grains, including wheat, rye, and barley) [2]. A lifelong strict adherence to a gluten-free diet (GFD) is the only currently available treatment for CD, allowing the restoration of the structure and function of the small intestinal mucosa [3,4,5].

A wide range of clinical symptoms, including gastrointestinal issues (e.g., chronic constipation, diarrhea, vomiting, and abdominal pain and distention), malabsorption, delayed puberty, amenorrhea, chronic iron-deficiency anemia, and osteoporosis may be associated with CD [1,6]. CD could be hard to recognize, owing to variations in the presentation and intensity of its symptoms. It can also be asymptomatic at presentation [4]. Historically, CD was thought to primarily affect children; however, it is now recognized that the initial symptoms of this disease may present at any age from childhood to late in adult life [7]. Further, it is now considered to be one of the most common lifelong food-related disorders worldwide.

The estimated prevalence of CD is approximately 1% in the US and Europe [8]. Studies from South-East Asia and the Middle East show a similar prevalence [9,10]. Comparable epidemiological studies conducted among the Saudi population are limited, wherein CD is broadly perceived as being uncommon. Some descriptive small studies were conducted to determine the prevalence of CD in some regions of Saudi Arabia. In a study carried out by Aljebreen et al. [11], healthy adolescent students selected from three regions of Saudi Arabia were included, and the prevalence of CD by region was as follows: Madinah, 1.8%; Aseer, 2.1%; and Al-Qaseem, 3.2%. A more recent study reported a high prevalence of CD in Saudi school-aged children in Riyadh (1.5%) [12]. It has been proposed that there is an amplified possibility of CD epidemics, particularly in countries with gluten-rich dietary patterns, including Saudi Arabia [13].

Although the prevalence of CD is increasing worldwide [14,15,16], the rate of diagnosis increases more slowly [17]. A large number of patients with CD remain undiagnosed and more likely to develop complications of the latent disease, including severe health complications, morbidity, and mortality [18,19,20]. Increasing the awareness of CD and its varied gastrointestinal and extra-intestinal manifestations is crucial in minimizing the undiagnosed burden of CD. A similar condition to CD is peanut allergy. Peanut allergy is reported by nearly 1% of the US population, and appears to be increasing in children over the past decade [21].

In Saudi Arabia, there is no information on the knowledge of gluten-related health issues and CD among the general public. Therefore, the objectives of this study were to assess the level of awareness and knowledge with regard to CD among the general public in Saudi Arabia. The awareness of gluten sensitivity and peanut allergy conditions was also assessed.

2. Methods

2.1. Study Population

The sample of this study comprised 1230 members (23.3% males and 76.7% females) of the general Saudi population. We included Saudi adults aged 18 years and above who responded to the announcement and had the ability to comprehend relevant information properly. Eligibility was confirmed by answers to explicit selection questions in the survey. Non-Saudi persons and those aged under 18 years were excluded from the analysis.

2.2. Ethical Consideration

Informed consent was obtained electronically from all participants included in the study. The informed consent page displayed two options: “Yes” and “No.” Only participants who chose “Yes” were taken to the questionnaire page, and they could quit the process at any time. The study was conducted according to the principles outlined in the Declaration of Helsinki. All procedures performed in this study were reviewed and approved by the institutional Research Ethics Committee (King Saud University, reference no. KSU-HE-19-90).

2.3. Data Collection

In this cross-sectional study, data were collected over a period of 4 months, October 2019 to January 2020, using a self-administered survey questionnaire. After being pre-tested for clarity and efficiency, the final version was converted to an online format using an internet survey tool (Google forms). The survey was delivered in Arabic and took approximately 10 min to complete. To maintain confidentiality and privacy, the responses were anonymous, and no identifiable information was collected from the respondents.

An invitation containing a link to the electronic survey was posted on a social media platform. The invitation was re-posted every other day to increase the response rate and make it visible to a larger number of individuals.

The survey comprised two parts: (1) demographic characteristics: age, gender, city of residence, education level, and family monthly income; and (2) awareness of CD, gluten sensitivity, and peanut allergy, and knowledge related to CD. The survey included the following questions: How many people do you think are affected by CD? Do you think that CD affects children only? Can CD occur without symptoms? Does CD, if not treated, lead to other diseases? Can patients with CD eat foods containing gluten if they do not show any symptoms?

2.4. Statistical Analyses

Data management and statistical analyses were conducted by using IBM SPSS Statistics (Version 23.0) for Windows. Data were cleaned for missing and invalid responses. Frequencies and percentages with 95% confidence intervals (CIs) were calculated for categorical data. Participants’ awareness and knowledge of CD were compared by gender with chi-square analysis with a two-tailed p-value. Values of p < 0.05 were considered statistically significant.

3. Results

3.1. Descriptive Characteristics

By the end of the data collection (4 months), 1230 adults in the general public completed the survey. The descriptive demographic characteristics of the participants are shown in Table 1. The majority of the participants were females (n = 944 [76.7%; 95% CI, 74.0%–79.4%]), with males making up the minority (n = 268 [23.3%; 95% CI, 18.4%–28.2%]). The age range of approximately half of the participants was 31–45 years. The majority of the study participants indicated that their permanent residence was the capital city of Saudi Arabia, Riyadh (n = 874 [71.1%; 95% CI, 68.1%–74.1%]). More than half of the participants (n = 791 [64.3%; 95% CI, 61.0%–67.6%]) had at least a bachelor’s degree. With respect to the average family monthly income, the least represented category came from the “less than SAR 5000” category, whereas the highest and second highest categories came close, at 523 (42.5%; 95% CI, 38.3%–46.7%) and 501 (40.7%; 95% CI, 36.4–45.0%), respectively, for the SAR 5000–15,000 category and the more than SAR 15,000 category.

Table 1. Demographic characteristics of the study participants

3.2. Awareness of Peanut Allergy, Gluten Sensitivity, and Celiac Disease

The awareness of peanut allergy, gluten sensitivity, and CD is shown in Figure 1. The majority of the participants had heard of peanut allergy (n = 985 [80.1%; 95% CI, 77.6%–82.6%]) and gluten sensitivity (n = 890 [72.4%; 95% CI, 69.5%–75.3%]). In contrast, less than half of the participants had heard of CD (n = 595 [48.4%; 95% CI, 44.4%–52.4%]). The numbers of participants who had not heard of peanut allergy, gluten sensitivity, and CD were 245 (19.9%; 95% CI, 14.9%–24.9%), 340 (27.6%; 95% CI, 22.8%–32.4%), and 635 (51.6%; 95% CI, 47.7%–55.5%), respectively.

3.3. Knowledge of Celiac Disease

Table 2 displays responses to questions on the participants’ knowledge of CD. When we asked participants to estimate the prevalence of CD, more than 80% of them estimated it incorrectly. CD was underestimated by 33.4% of participants, but it was overestimated by approximately half of the participants (49.8%). Other questions on the participants’ knowledge of CD, including “Do you think that CD affects children only? Does CD have symptoms? Does CD, if not treated, lead to other diseases? Can patients with CD eat foods containing gluten if they do not show any symptoms?” were answered with a response of “Do not know” by the majority.

Figure 1. Awareness of peanut allergy, gluten sensitivity, and celiac disease among the study participants

Table 2. Participants’ knowledge of celiac disease

Table 3. Participants’ knowledge of celiac disease according to gender

The knowledge of CD among participants according to gender is shown in Table 3. Gender was associated significantly with all questions on CD perception, except for the question, “How many people do you think are affected by CD?” The percentages of females who had heard about peanut allergy, gluten sensitivity, and CD were greater than those of males. “Do not know” was the predominant male response to the questions, “Do you think that CD affects children only? Does CD have symptoms? “Does CD, if not treated, lead to other diseases?” and “Can patients with CD eat foods containing gluten if they do not show any symptoms?”

4. Discussion

The present study aimed to evaluate the level of awareness of CD among the general public in Saudi Arabia. Among those surveyed, we found that less than half (48.4%) had heard of CD. Our findings are consistent with those of a previous study conducted in the US, which reported that among 861 adults of the general public, 47% had heard of CD [22]. However, the awareness of the general public of CD in this study was greater than that reported in a study conducted in the UK among 513 adults from the general public, wherein 44.2% had heard of CD [23].

In the current study, participants were more likely to have heard of peanut allergy and gluten sensitivity than CD. This finding is in agreement with the two previous studies conducted in the US and the UK, which reported a greater awareness of peanut allergy and gluten sensitivity than of CD [22,23].

Approximately 1% of the population is reportedly affected by CD [19,24]. In this study, only a small percentage (16.9%) of the participants estimated the prevalence of CD correctly. Similarly, CD was estimated incorrectly by the majority of people who participated in the US study [22]. Other questions on the knowledge associated with CD were answered with a response of “Do not know” by the majority. We found that males are less aware of peanut allergy, gluten sensitivity, and CD than females. Furthermore, females had a higher percentage of correct responses to questions related to CD than males.

Despite the increasing prevalence of CD worldwide, the disease still remains heavily underdiagnosed. The diagnosis of CD is a challenge, as this disease has a multifaceted clinical presentation [25]. Moreover, the diagnostic rate relies mainly on the level of awareness of the disease. The variations in the presentation of CD and the limited awareness of this condition could result in diagnostic delays exceeding 10 years [26,27]. Hence, the increased awareness and knowledge of CD and its broad spectrum of symptoms among the general public are warranted. Improved awareness of CD among healthcare professionals is also recommended. A previous study [28] conducted in Saudi Arabia assessed the knowledge of CD and reported poor knowledge among a significant proportion of healthcare professionals, including consultants.

Delays in the diagnosis of CD could negatively affect patients’ health and cause. The untreated condition can lead to numerous complications, such as nutritional deficiencies (e.g., anemia and osteoporosis), an increased risk of developing other autoimmune disorders, and small intestinal lymphoma [3].

Gluten is the main environmental risk factor for the development of CD [20]. At present, the only proven treatment for CD is a lifelong strict GFD, which shows overall excellent results. Early adherence to a GFD has been demonstrated to eliminate symptoms and to halt the progression of several complications of CD. A GFD seems to remain a crucial aspect of disease management in the future, as no medications have been approved for the disease so far [20,25]. Good adherence to a GFD is associated with the level of knowledge and motivation of patients [25]. It should be mentioned that knowledge about a GFD is essential, not only of the hidden sources of gluten but also of healthy gluten-free substitute grains that supply sufficient amount of nutrients and fiber.

Some limitations of our study should be considered: a self-administered electronic questionnaire was used, which increases the likelihood of recall bias. The study might evaluate the level of awareness and knowledge less accurately, as it was delivered online, meaning that only people who have access to social media networks have been included in the study. One of the major strengths of the current study is that this is the first study to assess the awareness of CD among the general public in Saudi Arabia.

5. Conclusion

The present study demonstrated gaps in knowledge with regard to CD among the general public. These findings support a need to increase the awareness and knowledge of CD, especially in the recognition of its symptoms. Educational efforts are needed to increase the awareness of the general public about CD, which could help optimize its diagnosis and care.

Ethics Approval and Consent to Participate

The study was conducted according to the principles outlined in the Declaration of Helsinki. All procedures performed in this study were reviewed and approved by the institutional Research Ethics Committee (King Saud University, reference no. KSU-HE-19-90). Informed consent was obtained electronically from all participants included in the study.

Funding

Not applicable.

Conflict of Interest

Authors declare no conflict of interest.

Acknowledgments

The author is thankful to all participants who contributed to this research. I also thank the Research Support and Services Unit of the Deanship of Scientific Research at King Saud University for their technical support.

References

[1]   | Glissen Brown, J.R. and P. Singh, Coeliac disease. Paediatrics And International Child Health, 2019. 39(1): p. 23-31.
[2]   | Green, P.H. and C. Cellier, Celiac disease. New England Journal of Medicine, 2007. 357(17): p. 1731-1743.
[3]   | Hill, I.D., et al., Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Journal of pediatric gastroenterology and nutrition, 2005. 40(1): p. 1-19.
[4]   | Husby, S., et al., European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease. Journal of Pediatric Gastroenterology and Nutrition, 2012. 54(1): p. 136-160.
[5]   | Murch, S., et al., Joint BSPGHAN and Coeliac UK guidelines for the diagnosis and management of coeliac disease in children. Archives of Disease in Childhood, 2013. 98(10): p. 806-811.
[6]   | Green, P.H. and B. Jabri, Coeliac disease. The Lancet, 2003. 362(9381): p. 383-391.
[7]   | Ediger, T.R. and I.D. Hill, Celiac disease. Pediatrics in Review, 2014. 35(10): p. 409-15; quiz 416.
[8]   | Dubé, C., et al., The prevalence of celiac disease in average-risk and at-risk Western European populations: a systematic review. Gastroenterology, 2005. 128(4): p. S57-S67.
[9]   | Rostami, K., et al., Coeliac disease in Middle Eastern countries: a challenge for the evolutionary history of this complex disorder? Digestive and Liver Disease, 2004. 36(10): p. 694-697.
[10]   | Singh, P., et al., Prevalence of celiac disease in Asia: A systematic review and meta‐analysis. Journal of Gastroenterology and Hepatology, 2016. 31(6): p. 1095-1101.
[11]   | Aljebreen, A.M., et al., Seroprevalence of celiac disease among healthy adolescents in Saudi Arabia. World Journal of Gastroenterology: WJG, 2013. 19(15): p. 2374.
[12]   | Al-Hussaini, A., et al., Mass screening for celiac disease among school-aged children: Toward exploring celiac iceberg in Saudi Arabia. Journal of Pediatric Gastroenterology and Nutrition, 2017. 65(6): p. 646-651.
[13]   | El-Metwally, A., et al., The Epidemiology of Celiac Disease in the General Population and High-Risk Groups in Arab Countries: A Systematic Review. BioMed Research International, 2020. 2020: p. 6865917.
[14]   | Lohi, S., et al., Increasing prevalence of coeliac disease over time. Alimentary Pharmacology & Therapeutics, 2007. 26(9): p. 1217-1225.
[15]   | Rubio–Tapia, A., et al., Increased prevalence and mortality in undiagnosed celiac disease. Gastroenterology, 2009. 137(1): p. 88-93.
[16]   | Catassi, C., et al., Natural history of celiac disease autoimmunity in a USA cohort followed since 1974. Annals of Medicine, 2010. 42(7): p. 530-538.
[17]   | Gasbarrini, G., et al., Celiac disease in the 21st century: issues of under-and over-diagnosis. 2009, SAGE Publications Sage UK: London, England.
[18]   | Fasano, A., et al., Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Archives of Internal Medicine, 2003. 163(3): p. 286-292.
[19]   | Rubio-Tapia, A., et al., The prevalence of celiac disease in the United States. American Journal of Gastroenterology, 2012. 107(10): p. 1538-1544.
[20]   | Lebwohl, B., D.S. Sanders, and P.H. Green, Coeliac disease. The Lancet, 2018. 391(10115): p. 70-81.
[21]   | Sicherer, S.H., et al., US prevalence of self-reported peanut, tree nut, and sesame allergy: 11-year follow-up. Journal of Allergy and Clinical Immunology, 2010. 125(6): p. 1322-1326.
[22]   | Simpson, S., et al., Awareness of gluten-related disorders: A survey of the general public, chefs and patients. e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism, 2011. 6(5): p. e227-e231.
[23]   | Karajeh, M.A., et al., Chefs’ knowledge of coeliac disease (compared to the public): a questionnaire survey from the United Kingdom. Clinical Nutrition, 2005. 24(2): p. 206-210.
[24]   | Larson, S.A., et al., Prevalence and morbidity of undiagnosed celiac disease from a community-based study. Gastroenterology, 2017. 152(4): p. 830-839. e5.
[25]   | Lindfors, K., et al., Coeliac disease. Nature Reviews Disease Primers, 2019. 5(1): p. 1-18.
[26]   | Fuchs, V., et al., Delayed celiac disease diagnosis predisposes to reduced quality of life and incremental use of health care services and medicines: A prospective nationwide study. United European Gastroenterology Journal, 2018. 6(4): p. 567-575.
[27]   | Rampertab, S.D., et al., Trends in the presentation of celiac disease. The American Journal of Medicine, 2006. 119(4): p. 355. e9-355. e14.
[28]   | Assiri, A.M., et al., Assessment of knowledge of celiac disease among health care professionals. Saudi Medical Journal, 2015. 36(6): p. 751.