Autoimmune conditions v lifestyle diseasesBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2363 (Published 26 March 2014) Cite this as: BMJ 2014;348:g2363
The management of autoimmune diseases takes on a different dimension when compared with diseases attributed to factors in an individual’s lifestyle. Not just the medical community but also public health policy planners, individuals, and their families tend to view these conditions differently, which translates into a different approach towards the disease. This is exemplified through the conditions of coeliac disease and obesity that we cover on bmj.com this month.
In a personal view (doi:10.1136/bmj.g2046), Pankaj Vohra, a paediatric gastroenterologist, shares his insights into managing coeliac disease in India, and laments the problems of underdiagnosis and overdiagnosis. A lack of awareness of coeliac disease in the general public, and of its varied manifestations among doctors often results in a missed diagnosis and inappropriate treatment. On the other hand, he says, doctors practising in the northern and predominantly wheat-eating belt of India, might label patients as having coeliac disease on the basis of a mere serology report showing borderline results, and prescribe a “gluten-free diet for life.” This is made more grievous given the dearth of resources available to support such a diet. There are not enough trained nutritionists in the country, he says, to support the individual in planning and maintaining such a diet, and a lack of certified and affordable gluten-free foods in the market.
Indeed, in a linked clinical review (doi:10.1136/bmj.g1561), Peter Mooney and colleagues highlight that patients diagnosed with coeliac disease on a gluten-free diet have been shown to have a lower quality of life when compared with the general population. Hence, “appropriate investigation and management of symptoms as well as support with a gluten-free diet” form key elements of their care. They discuss the evidence on various serological tests available for screening at risk populations, and strongly recommend that a positive serology test is followed by a duodenal biopsy to confirm the diagnosis, without which a patient may not be started on a gluten-free diet.
Sticking to the role of diet in diseases, obesity has long been attributed to factors in the environment and lifestyle of an individual that lead to greater consumption of fatty foods. Reiterating this, a study conducted in the UK by Thomas Burgoine and colleagues (doi:10.1136/bmj.g1464), finds greater exposure to fast food outlets in home, work, and commuting environments of people to be associated with a greater body mass index, and greater odds of obesity.
Presenting a slightly divergent angle, Qi and colleagues examined the interplay of genetic risk factors and consumption of fried foods in relation to obesity in three US cohort studies. And their research published in the BMJ (doi:10.1136/bmj.g1610) provides formal proof that fried food consumption could interact with genetic predisposition to place an individual at a higher risk of obesity.
In a linked editorial (doi:10.1136/bmj.g1900), Alexandra Blakemore and Jessica Buxton suggest that, “these results are unlikely to have a direct impact on personal healthcare because, though such genetic risk scores are statistically robust at the population level, they have poor predictive power for any given individual.” Yet genetics clearly can no longer be ignored in the management of obesity. They present an interesting dynamic whereby an attitude of blame and “personal responsibility” among clinicians and the society, at large, towards patients with morbid obesity might deprive them of appropriate treatment and support. This is quite contrary to diseases such as diabetes, hypertension, or indeed, autoimmune conditions wherein the need for drugs and a lifelong care plan is recognised and accepted.
Just as Vohra argues that health policy planners, doctors, patients and their families, the food and hospitality industries, and drug manufacturers need to come together to systematically improve the management of patients with coeliac disease in our communities; so it needs to be for obesity too.
Cite this as: BMJ 2014;348:g2363