Celiac Disease: Epidemiology and Management

Background: Celiac disease (CeD) has evolved from a perceived Western rarity to a recognised global health issue, with a significant and rising prevalence in the Indian subcontinent. Despite this, it remains underdiagnosed in India, often masked by non-specific paediatric presentations such as refractory iron-deficiency anaemia and short stature—a phenomenon known as the ‘celiac iceberg’. Methods: This review synthesises current data on the epidemiology, pathophysiology, and clinical spectrum of CeD, with a specific focus on the unique diagnostic and management challenges within the Indian paediatric context. Results: In India, CeD prevalence follows a geographic gradient correlating with wheat consumption, reaching nearly 1% in Northern Indian states. The pathophysiology is driven by the HLA-DQ2/DQ8 haplotype, with DQ2 being predominant in Indian patients. While international guidelines increasingly recognise a ‘no-biopsy’ pathway for specific cases, histological confirmation via duodenal biopsy remains the diagnostic gold standard in the Indian context to ensure accuracy, given the variability in serological testing. However, management in India faces unique hurdles, including frequent cross-contamination in shared household flour mills (chakkis), inconsistent food labelling, and the hidden gluten content in common spices like compounded asafoetida (hing). Conclusion: Addressing the ‘celiac iceberg’ in India requires clinicians to maintain a high index of suspicion for non-classical symptoms. Transitioning from wheat-based diets to naturally gluten-free indigenous grains like millets (bajra, jowar, ragi) offers a nutritionally sound and culturally viable management strategy. Early intervention is critical to prevent long-term complications such as permanent growth failure and reduced bone mineral density.