Fighting Celiac Disease in Ireland and the United States

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The following includes information on the background and general overview of celiac disease, including individuals diagnosed with gluten sensitivity or gluten intolerance. Furthermore, comparisons between Irish and American epidemiological data, morbidity and mortality, and health systems will explore how celiac disease affects these countries. Finally, education and outreach examples for celiac disease will feature what organizations and physicians are doing to spread awareness.

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Fighting Celiac Disease in Ireland and the United States

  1. 1. Hall-Celiac Disease-Graduate Paper 1Fighting Celiac Disease in Ireland and the United States Kara Leigh Saunders Hall Study Abroad Program: Public Health in Ireland East Carolina University June 16, 2012
  2. 2. Hall-Celiac Disease-Graduate Paper 2 Fighting Celiac Disease in Ireland and the United States Some individuals refer it as “tummy troubles,” or “upset stomach,” while others maycomment on their “sour stomach” or “stomach bug.” Often, individuals may seek advice from aphysician or gastroenterologist and go years with misdiagnosis. The real culprit lurking behindthe shadows of these stomach concerns may be a disease that some physicians are just becomingaware of, known as celiac sprue disease, meaning disease of the small intestine (Celiac SprueAssociation, 2012). Moreover, the disease is also known as coeliac disease in Ireland. Reportsfrom the University of Chicago’s Celiac Disease Center show 97% of Americans with celiacdisease are misdiagnosed a year, and the average individual may go 11 years with the diseaseundiagnosed (Dunbar, 2012). Most commonly diagnosed in Caucasian individuals in the Irishpopulation due to genetic predisposition, the disease is growing more apparent in countries likethe United States (U.S.) too (The New York Times, 2010). The following includes informationon the background and general overview of celiac disease, including individuals diagnosed withgluten sensitivity or gluten intolerance. Furthermore, comparisons between Irish and Americanepidemiological data, morbidity and mortality, and health systems will explore how celiacdisease affects these countries. Finally, education and outreach examples for celiac disease willfeature what organizations and physicians are doing to spread awareness.Background of Celiac Disease The Celiac Sprue Association (2012) verifies first documentation of celiac diseaseoccurred in the second century, and it was not until the 20th century did researchers findcausative factors of celiac disease. The first documentation began around 250 A.D. fromArataeus of Cappadocia detailing individuals with bowel concerns, but the first correlationbetween an individual’s nutritional diet and the treatment of celiac disease came from Dr.Samuel Gee in 1888, as well as the correlation between wheat and celiac disease from Dr.William Karel Dicke in 1952 (Celiac Sprue Association, 2012). These individuals wereinstrumental in discovering the evolution of celiac disease, including its detrimental affects onthose suffering silently from the disease.
  3. 3. Hall-Celiac Disease-Graduate Paper 3 The Coeliac Society of Ireland (2012) define the disease as an autoimmune disease that isnot contagious and affects children and adults when they intake gluten, which is found in wheat,barley, and rye (with some individuals sensitive to oats). Thus, when an individual consumesgluten, their bodies have an allergic reaction. This reaction prevents individuals from absorbingkey nutrients via the villi within their small intestines, because the villi suffered atrophy. Thesymptoms an individual may experience when enduring celiac disease can include a host ofconcerns. For instance, the symptoms may include: “diarrhea, constipation, weight loss, chronictiredness, anemia, failure for a child to thrive, chronic mouth ulcers, stomach pain and bloating,indigestion, bone pain, moodiness or depression, infertility, recurrent miscarriages, flatulence,and nausea” (Coeliac Society of Ireland, 2012).Diagnosis and Treatment The development of celiac disease could result from a combination of factors. Presently,researchers believe these factors include the predisposition genetically to the disease, anautoimmune response to certain antibodies; an environmental, emotional or physical event in anindividual’s life; and a person’s diet (Celiac Sprue Association, 2012). Before testing for celiacdisease, individuals need to continue to consume gluten-containing products for weeks prior totesting. By participating in a gluten-free diet before testing, the results may come backinconclusive. Diagnosis involves different types of tests. Some of the tests involved in celiacdisease diagnosis may consist of blood tests for antibodies, and a tissue biopsy from the wall ofthe intestine to examine if an individual’s villi suffer from atrophy (Coeliac Society of Ireland,2012). This is normally conducted via a physician inserting an endoscope in the individual’smouth, through their esophagus, and then into the stomach. Treatment for celiac disease involves the incorporation of a gluten-free diet into adiagnosed individual’s normal dietary routine. James, Mead, and Smith (2011) suggesttreatment that is “a life-long, gluten free diet” along with annual management by physicians sothat the physicians can help to “increase dietary adherence and monitor for complications ofnutrient deficiency, development of autoimmune disease, and lymphoma” (p. 30). Byincorporating a gluten-free diet into an individual’s life, he or she must eliminate all foods thatcontain gluten in order to achieve healing of the atrophied villi. Therefore, the Mayo Foundation
  4. 4. Hall-Celiac Disease-Graduate Paper 4for Medical Education and Research (2012) suggests the elimination of foods containing thefollowing: barley, bulgar, durum, farina, graham flour, rye, semolina, spelt, triticale, and wheat.In order to accomplish a gluten-free diet, it may be beneficial for the diagnosed individual tocollaborate with a nutritionist or dietician so he or she has an outline of foods to eat each week.Moreover, the Mayo Foundation for Medical Education and Research (2012) also recommendsan individual diagnosed with celiac disease to take vitamin supplements like calcium, folate,iron, vitamin B-12, vitamin D, and vitamin K as to reduce the possibility of malnutrition. Insome severe instances, a diagnosed individual may need medication to help control thesymptoms of celiac disease. A physician may prescribe steroids for a certain period of time sothat an individual may have relief until the positive effects of a diet without gluten begin takingplace (Mayo Foundation for Medical Education and Research, 2012).Health Complications Symptoms of celiac disease may trigger other health complications, such as osteoporosisdue to the inability to absorb enough calcium, and cancer that could result from an increased riskof lymphoma in the small intestine (Coeliac Society of Ireland, 2012). Other complicationsassociated with celiac disease include diabetes, lactose intolerance, and thyroid disease (CoeliacSociety of Ireland, 2012). Therefore, it is essential for individuals diagnosed with celiac diseaseto talk to their physicians not only about symptoms from their disease, but also complicationsthat may result or have already occurred due to the disease. While each individual diagnosed with celiac disease responds differently to gluten intheir diet, it is important to note that regardless of differing experiences, the symptoms are veryreal to the individual. Mentally and emotionally, the disease may cause individuals a range offeelings. Some of these feelings may include depression, anxiety, and irritability. The CoeliacSociety of Ireland (2012) indicates that these feelings are the product of repressed emotions fromdiagnosis as well as denial of diagnosis, difficulty in accepting physical side effects, feelingburdensome on others, and having to worry if others will remember dietary needs in socialsituations. By continued education and awareness, planning and preparation, as well as buildinga strong support system of family members, friends, and health care professionals, many
  5. 5. Hall-Celiac Disease-Graduate Paper 5individuals diagnosed with celiac disease are able to manage their symptoms, maintain overallwell-being and good quality of life.Gluten Sensitivity and Gluten Intolerance While some individuals may experience some of the exact same symptoms of celiacdisease, these same individuals may receive testing from their physician that indicates they donot have celiac disease. Even though sometimes the testing may reveal a negative for celiacdisease, it may not truly indicate whether the individual has celiac disease. This becomes thecase when an individual consumes part, if not all of a gluten-free diet before testing. Therefore,it is of extreme importance that, before testing, an individual continues to eat and drink allproducts that contain gluten. In the event however, that physicians rule out celiac disease, thismay still mean that the individual has gluten sensitivity or gluten intolerance. The Wall StreetJournal (2011) confirms that not only is gluten sensitivity different from celiac disease, but itmay affect as many as 1 in 20 Americans, or around 6% of Americans. Triggers of glutensensitivity involve drinks and food that contain gluten, although small amounts in moderation aretolerable for some people. Some symptoms that a person with gluten sensitivity may experienceinclude stomach concerns, headaches, balance problems, and other issues (The Wall StreetJournal, 2011). Recommendations for people the gluten sensitivity still advises that theindividual—at the advice and disease management of a physician—begin and remain on agluten-free dietEpidemiological Data Comparisons Statistics in the past may have not accurately illustrated the ratio of Americans and Irishindividuals that have celiac disease. The reasoning behind this could consist of a number ofcomponents. First, some individuals are not comfortable talking with others (family members,friends, physicians, etc.) about stomach-related issues. In addition, some physicians have notparticipated in adequate training on identifying and diagnosing celiac disease, which leads tosome patients not receiving a definite diagnosis for ten years or more. In the U.S., around 97%of individuals with celiac disease have not received an accurate diagnosis—or a diagnosis at all(The University of Chicago Celiac Disease Center, 2012). Interestingly, in the U.S, celiac disease
  6. 6. Hall-Celiac Disease-Graduate Paper 6was not as well-known around ten years ago, and ratios were far greater (for example, 1 in1,000). Currently, ratios by the University of Chicago Celiac Disease Center (2012) verify that 1in 133 Americans have celiac disease. This portrays a disease ratio that is far more common thanpreviously believed. Even more alarming, The Wall Street Journal (2011) shows that the rate ofceliac disease in the last 50 years within the U.S. has increased almost four-fold, and somephysicians believe that individuals are not born with the disease, but instead, they believe theenvironment plays a crucial role in the development of celiac disease. Thus begs the question,“what in the environment could trigger this development?” Research indicates that withagricultural changes to wheat, the protein content of some food ingredients has increased, whichcould lead to an increase of gluten in an individual’s diet (The Wall Street Journal, 2011).Overall, the U.S. has just really begun to increase awareness surrounding celiac disease. Thereason behind the increase in awareness may come from the dramatic increases in celiac diseaserates over the past few years. Some theorize the reasoning behind the U.S. have a late start toceliac disease awareness could involve the U.S. government’s resistance to providing researchgrants to this autoimmune disease, as most autoimmune diseases receive grants(GlutenFreeHelp.info, 2012). However, within the U.S., some visible changes have already takenplace at some common restaurants offering gluten-free menus. For example, on the east coast, inNorth Carolina, restaurants like Bonefish Grill, Buffalo Wild Wings, Lone Star Steakhouse,Maggiano’s Little Italy, Mama Fu’s Asian House, Mellow Mushroom, Moe’s Southwest Grill,Olive Garden, Outback, and T.G.I Friday’s (and many more) offer gluten-free options. On thewest coast, in California, restaurants like Asgew Grill, Claim Jumper, Dawgs!, Easy Creole, LeSt. Tropez, LIBA Falafel Truck, Melting Pot, P.F. Chang’s China Bistro, Pei Wei Asian Diner,and Romano’s Macaroni Grill. Within Ireland, statistics show 1 in 100 people may have celiac disease (Coeliac Societyof Ireland, 2012). This ratio (more than likely) still does not represent the total population ofIrish individuals that are undiagnosed. Even worse, there remains the possibility of under-diagnosis, as some people will not receive the medical attention needed for the disease, leadingto the naming of, “the silent disease.” The Coeliac Society of Ireland (2012) verifies that forevery one person diagnosed in Ireland with celiac disease, there remains 5-10 undiagnosed.Many individuals do not receive a diagnosis of celiac disease until after the age of 40 in Ireland,
  7. 7. Hall-Celiac Disease-Graduate Paper 7much like within the United States, but an individual can now obtain a celiac disease diagnosis atany age. This illustrates the need for communities to begin offering alternative options that arereadily accessible and contain only gluten-free products that have not endured cross-contamination with other products containing gluten. Within Ireland, the awareness of thecondition throughout the community, including funding has made it a disease recognized as areal concern. The food industry, including restaurants within Ireland have madeaccommodations for several years for people diagnosed with celiac disease, gluten sensitivityand gluten intolerance (Coeliac Society of Ireland, 2012). This awareness and ability to adapt toIrish individual’s dietary concerns provides a great model for other countries (like the U.S.) thatare just beginning to make needed changes.Morbidity and Mortality Comparisons The quality of life of a person diagnosed with celiac disease is a very significant topic,along with the threat of death due to health complications associated with the disease. In regardsto morbidity, health complications such as osteoporosis and cancer could arise due to celiacdisease (as mentioned before). Studies show increased rates of hypothyroidism, and reducedbody mass index, cholesterol, and ferritin (Godfrey et al., 2010). With the aforementionedsymptoms of celiac disease, people diagnosed are also more at risk for short stature, lymphomas,adenocarcinoma, miscarriages, along with bearing infants that have congenital malformations,(Coeliac Society of Ireland, 2012). In addition, in both the U.S. and Ireland, celiac disease israrely lethal, but health complications from the disease could result in mortality. Some researchshows that regardless of the country an individual lives in, he or she may have a two-foldincrease in overall mortality, and the rate of mortality increases if an individual has just receiveda diagnosis of celiac disease (Corrao et al., 2001). Other research depicts conflicting data, as 21papers within 25 years show either a 0.52% decrease in mortality rates among individualsdiagnosed with celiac disease, or a 3.9% increase, as compared to the general population(Celiac.com, 2012). However, if an individual receives a diagnosis of celiac disease, and issymptomatic, he or she is more likely to have an increased mortality rate (Celiac.com, 2012).Overall, the consensus (regardless which country) remains—if an individual is diagnosed with
  8. 8. Hall-Celiac Disease-Graduate Paper 8celiac disease, it is imperative that he or she partner with their physician so that he or she cansuccessfully manage symptoms.U.S. and Irish Health Systems Comparisons The health systems of the U.S. and the Republic of Ireland provide very differentlandscapes of health care to its citizens. However, they are quite alike in that both countries areundergoing reforms to their health systems. Beginning with Ireland, the government exercisesrights over the health system, via the Department of Health and Children, with guidance by theMinister of Health and Children (McDaid, Wiley, Maresso, & Mossialos, 2009). With thesweeping health reforms in Ireland, changes occurred to create a new health structure. Thisincludes the Health Service Executive (HSE). The HSE is the largest employer in Ireland, andtakes responsibility for the provision of health care and personal social services (McDaid et al.,2009). Other organizations within the HSE include the Irish Cancer Screening Board, the IrishBlood Transfusion Service, the Department of Social and Family Affairs, and the Department ofJustice, Equality, and Law Reform. Furthermore, the Health Information and Quality Authority(established in 2007 due to reforms) is “responsible for developing health information, settingand monitoring standards, promoting and implementing quality assurance programs nationally,and overseeing health technology assessments” (McDaid et al., 2009, p. xx). The types of insurance citizens have in Ireland can range from public to private healthinsurance. Around half of the population in Ireland have voluntary private health insurancethrough the Voluntary Health Insurance Board, a non-profit with board members elected by theMinister of Health and Children (McDaid et al., 2009). Ireland also has a system of insuranceregulation. To regulate private insurance, the Health Insurance Authority ensures thatcompetition exists through community rating, open enrollment and lifetime coverage (McDaid etal., 2009). In addition, the health care system has a unique financing structure that does notinvolve social security contributions. The system is mostly funded through taxes, with theremaining amount funded through “private sources, in particular out-of pocket-householdexpenditures on general practitioner visits, pharmaceuticals and public/private hospital stays, aswell as payments to voluntary health insurance providers” (McDaid et al., 2009, xxi). Forindividuals with additional needs (such as those living in poverty), they are entitled to most
  9. 9. Hall-Celiac Disease-Graduate Paper 9services free of charge. These individuals make up around 30% of the population (McDaid etal., 2009, xxi). Within the U.S., Medicare is available to those with disabilities, along withindividuals 65 years and older, as well as Medicaid, which is available to individuals withfinancial need. Ireland also focuses on the importance of primary care to prevent disease andillness rather than the reactive focus of the U.S. As for improvements and ongoing tasks, Ireland has made a consistent effort and placedemphasis on increasing inpatient beds, along with improvements in overall medical practice,increasing staff members, and increasing the skill set of these members via a multidisciplinaryapproach. Since Ireland ranks the lowest out of all Organization for Economic Co-operation andDevelopment countries (OECD) with the number of general practitioners per 1000 population,an enhanced prominence envelops this essential matter (McDaid et al., 2009). Moreover, Irelandtackles mental health practices throughout the country. The country hopes to strengthen theirmultidisciplinary teams to improve the state of mental health care delivery. Reforms alsoinclude medical training and education, which began in 2006, highlighting the need formodernization. In addition, Ireland has plans to extend their information and communicationtechnologies and create an electronic health record system (McDaid et al., 2009). Lastly,Ireland’s health care system is focusing on primary care strategies that center on 400-600multidisciplinary teams (McDaid et al., 2009). Another provision of service targets access toprimary and secondary care in Ireland. Some individuals who do not have a medical card, norprivate health insurance “reduce inappropriately their use of primary health care services toavoid high out-of-pocket payments” (McDaid et al., 2009, p. xxiii). To address these concernsover access to care, Ireland introduced several new reforms. The general practitioner visit cardprovides coverage to 230,000 more individuals, along with implementation of “out of hours”general practitioner cooperatives, increased number of acute beds, reduced waiting times, andincreased public sector-only contracts (McDaid et al., 2009). The final improvement to helpcombat inequities involves the National Treatment Purchase Fund. This fund allows individualswaiting for three months or more to receive treatment in either Ireland or the United Kingdomvia the private sector (McDaid et al., 2009).
  10. 10. Hall-Celiac Disease-Graduate Paper 10 To highlight the U.S. health care system, it is crucial to point out the differences inoverall strategy. Whereas in Ireland, the spotlight is on primary care-driven initiatives, the U.S.revolves around a primarily chronic disease and reactive initiative. About 80% of health costsspent target 20% of the population, which significantly intertwine with the aging population andchronic diseases (Kovner & Knickman, 2011). Much like in Ireland, cardiovascular diseasetakes the precedent as the leading cause of death. Defining features within the U.S. healthsystem involves how institutions deliver care, the role of health professionals, medicaltechnology, electronic communication, emergence of new drugs, tensions between the freemarket and governmental control, and the dysfunctional financing and payment system (Kovner& Knickman, 2011). Unfortunately, the health status in America really comes down to whetheror not an individual or a family receives a definition by poverty standards as poor. Issues within the U.S. ( in some ways) mirror Ireland. While Ireland has its own reformsin place, a significant reform within the U.S. involves the Patient Protection and Affordable CareAct of 2010, with various rules enacted that occur in a gradual state. This act aims to improveaccess and coverage to the 50.7 million Americans lacking health insurance as of 2009 (Kovner& Knickman, 2011). In general, the U.S. health care system differs from many OECD countriesin regards to the health care system. This is due to the prominence that the U.S. gives to theprivate health insurance organizations like Aetna, United Health, Cigna, Blue Cross/Blue Shield,etc. Government regulation of these private health insurance companies in the U.S. remains at aminimum, unlike in Ireland and most other OECD countries. As Kovner and Knickman (2011)state, “in economic terms, the U.S. system is much less progressive because low incomeindividuals pay a higher percentage of their income for health care than do the wealthy” (p. 73).Thus, in the U.S. an ongoing topic revolves around health disparities, and then need the addressthis growing issue. Likewise, within the U.S., rural areas have health professional shortages, or somephysicians will refuse to treat patients who have Medicare or Medicaid. Other areas ofimportance for the U.S. health care system include slowing growth of health care costs, andencouraging healthy behaviors. Kovner and Knickman (2011) state, “healthy behavior can helppeople disease and injury or prevent disease or disability from worsening” (p. 6). In addition, the
  11. 11. Hall-Celiac Disease-Graduate Paper 11variability of the public health system is another area of improvement, as well as thecoordination, transparency, and accountability of local systems of care. This need for localsystems of care arises from “a lack of integrated and electronic record systems, but by culturaltraditions of independence” (Kovner & Knickman, 2011, p. 6). The U.S. found that their besthealth results generated from accountable and large health care systems throughout the country.This included systems like Kaiser Permanente, Mayo Clinic, Cleveland Clinic, Geisinger HealthSystem, and the Veterans Health Administration (Kovner & Knickman, 2011). As a final note on the U.S. health care system, it is vital to discuss the thoughts of thepublic in regards to government involvement in health care. Whether it is due to lack ofawareness, many Americans do not understand the overall amount of involvement the U.S.government really has in health care. The tagline, “get government out of my healthcare”remains the perception of many Americans. However, many within the U.S. do not know thatsince the late 1700’s, the government has had an essential role in health care (Kovner &Knickman, 2011). The responsibility for health care within the U.S. is actually shared myvarious U.S. governmental departments. To name a few, the governmental departments consistof: the Social Security Administration, the Department of Labor., the Department of HomelandSecurity, the Department of Defense, the Department of Veterans Affairs, the Department ofTransportation, the Department of Education, etc. (Kovner & Knickman, 2011).Education and Outreach for Celiac Disease It is vital to any public health concern to create programs of education and outreach thathelp people to not only become more aware of the public health concern, but also havemanageable avenues to take to help prevent or treat the public health concern in their own lives.For example, in the U.S., the National Foundation for Celiac Awareness (NFCA) providestraining and education for health care professionals, food industry professionals, and patients andprofessionals. For health care professionals, the foundation offers two continuing educationclasses to dieticians, as well as health care programs targeting celiac disease for varioushealthcare disciplines, and a medical education module for primary physicians and nursesaccredited by the Accreditation Council for Continuing Medical Education (NFCA, 2011). Theorganization also provides gluten-free foodservice training for the food industry. Courses that
  12. 12. Hall-Celiac Disease-Graduate Paper 12the NFCA (2011) conducts include the “Great Business Association” for individuals andbusinesses, “Great Kitchens” for chefs and food service managers, and “Great Schools, Colleges,and Camps” for dining hall directors, managers, and staff. Finally, the NFCA provides archivesof gluten-free webinars to patients, professionals, and anyone interested in the content. Many ofthe webinars not only discuss celiac disease, but also other concerns such as links to ADHD,autism, non-celiac gluten sensitivity, and heart health. Another great example of education and outreach for celiac disease centers on long-termcare management. Since the course or duration of celiac disease is different for each individual,the long-term care management component enables the physician to specifically tailor the dietaryneeds of the patient. Regular physician follow-ups may improve dietary adherence, and the waythat a physician interacts with the patient is crucial to adherence as well. James, Mead, andSmith (2011) suggest that physicians style their patient appointments to meet the needs andwants of the patient. For example, instead of the traditional model of face-to-face consultation,physicians may utilize more modern, or creative, strategies. This could include online healthinterventions, webcams, telemedicine, and telephone reviews. James, Mead, and Smith (2011)advise that the long-term management approach ultimately needs to “be cost-effective, minimizeunnecessary hospital visits, encourage self-efficacy, meet patient’s individual needs, and involvethe multi-disciplinary team” (p. 33). Furthermore, a tactic for outreach and education for thosediagnosed with celiac disease could include the virtual clinic system. The advent of the virtualclinic system began in 2006, with adult patients diagnosed with celiac disease. They providingfeedback that they had to pay excessive hospital parking charges, and were unpaid from missingtime from their jobs, just to visit their doctor and receive their blood results (James, Mead, &Smith, 2011). This feedback, along with the need to reduce the number of follow-up hospitalvisits provided the inception of the virtual clinic system. The virtual clinic system focuses onpatient empowerment and self-efficacy, but also the clinical expertise of the physician (James,Mead, & Smith, 2011). This intertwines not only the patient’s own knowledge and managementof his or her disease, but also the physician’s own understanding of the disease process andclinical management. The virtual clinic system utilizes a database to send out virtual clinic packsannually to individuals diagnosed with celiac disease. The pack includes “how the processworks, contact details (including local and national celiac support mechanisms), a symptom
  13. 13. Hall-Celiac Disease-Graduate Paper 13questionnaire, and blood test request forms” (James, Mead, & Smith, 2011, p. 34). In the event apatient responds “yes” to any of the questions on the symptom questionnaire, he or she canphone the physician as to receive the care needed. After an examination of the blood results, thedatabase receives an update with the patient’s blood results, and the patient and his or her generalpractitioner will obtain a letter with data from the blood results. If the blood results areabnormal, a gastrointestinal nurse specialist contacts the patient, and the patient will receivedisease management by his or her physician. For patient education and outreach, James, Mead,and Smith (2011) verify that the virtual clinic system, in tandem with the long-term celiacdisease management approach has already showed success, and its model could be appliedthroughout the world, with an emphasis on implementation for patients at the earliest stagepossible. A final example of education and outreach for celiac disease involves the month of Maydesignated in the U.S. as Celiac Awareness Month. The Celiac Disease Foundation (2012)provides information on patient support groups, along with information to medical andhealthcare professionals. In addition, this organization collaborates with “Team Gluten-Free,” afundraising organization. This organization participates in walk/run races throughout the U.S.,with proceeds going toward summer camp scholarships for children on a gluten-free diet, as wellas research, and support and awareness programs (Team Gluten-Free, 2009). Moreover, theCeliac Disease Foundation raises awareness about ways to promote education and outreach. Forexample, they encourage individuals to not only to write a member in their congress aboutdesignating May as Celiac Awareness Month, but also placing brochures about Celiac Disease indoctor and dentist offices. The organization even suggests having a gluten-free dinner party forthose diagnosed and not diagnosed with celiac disease to show that gluten-free food can still befantastic! As a current awareness model, the Celiac Disease Foundation even presentsinformation on Domino’s recent promotion of “Gluten-Free Pizza.” Therefore, the CeliacDisease Foundation (2012) was able to identify that while the pizza is touted as “gluten-free,”people with celiac disease should still not eat this pizza as all Domino’s locations do not have theoperational space to ensure that gluten from their normal processing of dough is notcontaminated with the gluten-free pizza dough and ingredients.
  14. 14. Hall-Celiac Disease-Graduate Paper 14 ReferencesCeliac disease. (2012). Celiac Disease Foundation. Retrieved June 12, 2012, from http://www.celiac.org/index.php?option=com_content&view=article&id=3&Itemid=9.Celiac disease. (2012). Celiac Sprue Association. Retrieved June 13, 2012, from http://www.csaceliacs.info/.Celiac disease. (2012). Mayo Foundation for Medical Education and Research. Retrieved June 13, 2012, from http://www.mayoclinic.com/health/celiac-disease/DS00319.Celiac disease foundation team gluten-free. (2009). Team Gluten-Free. Retrieved June 13, 2012, from http://www.celiac.org/tgf/.Coeliac disease. (2012). Coeliac Society of Ireland. Retrieved June 12, 2012, from http://www.coeliac.ie/.Clues to gluten sensitivity. (2011). The Wall Street Journal. Retrieved June 13, 2012, from http://online.wsj.com/article/SB10001424052748704893604576200393522456636.html.Corrao, G., Corazza, G.R., Bagnardi, V., Brusco, G., Ciacci, C., Cottone, M., Guidetti, C. S., Usai, P., Cesari, P., Pelli, M.A., Loperfido, S., Volta, U., Calabro, A., & Certo, M. (2001). Mortality in patients with coeliac disease and their relatives: A cohort study. The Lancet, 358, p. 356-361.Dunbar, A. (2012, February 9). Celiac disease is misdiagnosed in 97% of all cases despite growing awareness. Retrieved June 12, 2012, from http://www.cnycentral.com/news/story.aspx?id=717796.Genetic testing for celiac disease. (2010). The New York Times. Retrieved June 12, 2012, from http://consults.blogs.nytimes.com/2010/01/13/genetic-testing-for-celiac-disease/.Godfrey, J.D., Brantner, T.L., Brinjikji, W., Christensen, K.N., Brogan, D.L., Van Dyke, C.T., Lahr, B.D., Larson, J.J., Rubio-Tapia, A., Melton, L.J., Zinsmeister, A.R., Kyle, R.A., & Murray, J.A. (2010). Morbidity and mortality among older individuals with undiagnosed celiac disease. Gastroenterology, 139(3), p. 763-769.
  15. 15. Hall-Celiac Disease-Graduate Paper 15Increased mortality rates for celiac. (2012). Celiac.com. Retrieved January 14, 2012, from http://www.celiac.com/articles/22028/1/Increased-Mortality-Rates-for- Celiacs/Page1.html.James, S.A., Mead, R.J., & Smith, T. (2011). Coeliac disease: The virtual clinic approach. Gastrointestinal Nursing, 9(8), p. 30-36.Kovner, A.R., & Knickman, J.R. (2011). Jonas & kovner’s health care delivery in the united states. (10th ed.) New York: Springer Publishing Company, LLC.McDaid, D., Wiley, M., Maresso, A., & Mossialos, E. (2009). Ireland: Health system review. Health Systems in Transition, 11(4), p. 1-268.Understand the challenges of celiac disease diagnosis. (2012). The University of Chicago Celiac Disease Center. Retrieved June 12, 2012, from http://www.cureceliacdisease.org/medical-professionals/guide/diagnosis.Welcome to celiac central. (2012). National Foundation for Celiac Awareness. Retrieved June 13, 2012, from http://www.celiaccentral.org/About-NFCA/19/.

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