Coeliac disease in the 21st century: paradigm shifts in the modern age

The epidemiology of coeliac disease (CD) is changing. Presentation of CD with malabsorptive symptoms or malnutrition is now the exception rather than the rule and, it now affects those underweight and overweight equally. In concert with these epidemiological shifts, the incidence of CD is increasing. These changing patterns of disease presentation are challenging traditional management paradigms, and clinicians now need to adapt to these changes and respond to the demands of an increasingly well-informed consumer population. This article aims to provide historical context to the epidemiological changes in CD, which provides context to direct future research. Changing definitions and diagnostic paradigms are complicating the management of CD. The gold standard of diagnosis, treatment goals, guidelines for follow-up, and the role of population screening in CD remain controversial and unresolved. Although the patient population is interested in new treatments for CD and alternatives to a gluten-free diet, most therapies are not yet widely available or sufficiently researched, and our understanding of the natural history of CD is limited despite a number of retrospective and population-based studies. The management of asymptomatic CD has only recently been examined despite up to half of patients now presenting with no or minimal symptoms. There is surprisingly little evidence to resolve many of these issues, and only with robust prospective studies will our understanding of the true natural history of coeliac disease be clarified.