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. 2017 Mar 25;9(3):3883–3895. doi: 10.19082/3883

Celiac disease in Iran: a systematic review and meta-analysis

Roghayeh Mohammadibakhsh 1, Rahim Sohrabi 2, Morteza Salemi 3, Masood Taheri Mirghaed 4, Masoud Behzadifar 5,✉
PMCID: PMC5407219  PMID: 28461861

Abstract

Introduction

Celiac disease (CD) is a chronic autoimmune-mediated disorder with both intestinal and systemic manifestations. The aim of this study was to determine the prevalence of celiac disease in Iran.

Methods

We conducted a systematic search on Embase, Pub Med, Web of Science, Google Scholar, MagIran, Scientific Information database (SID) and Iranmedex from 2003 through to November 2015. The Der-Simonian/Laird’s (DL), with a 95% confidence interval employed to estimate the overall pooled prevalence. Heterogeneity was investigated by using subgroup analysis based on sample size and time of study.

Results

Sixty-three studies with 36,833 participants met inclusion criteria for analysis. The overall prevalence of celiac disease in 63 studies that had used serological tests for the diagnosis was observed as 3% (95% CI: 0.03–0.03) and the overall prevalence of celiac disease in studies that had used biopsy method for diagnosis was observed as 2% (95% CI: 0.01–0.02).

Conclusion

The prevalence of celiac disease in Iran was similar or even higher than world-wide reported.

Keywords: Prevalence, Meta-analysis, Celiac disease, Iran, Systematic review

1. Introduction

Celiac disease (CD) is one of the most important malabsorption diseases caused by sensitivity to gluten grains in the small intestine. This disease causes inflammation in the small intestine and it can impede the absorption of nutrients (1). Gluten can be found in cereals such as wheat and barley (2). This disease can occur at any age (1). Celiac disease can cause symptoms such as weight loss, growth retardation, osteoporosis, anemia, classic symptoms of malabsorption, chronic constipation, abdominal pain and metabolic bone diseases in patients (3). Signs of mental illness such as depression and cognitive impairment are variable in this disease (4). There are several ways to diagnose celiac disease and using Anti-Tissue Transglutaminase and duodenal biopsy (1). Various studies around the world have investigated the prevalence of celiac disease. IgA-class tissue transglutaminase antibody test has been used in most of these studies. Prevalence of celiac disease in populations of America and Europe has been reported nearly 1% (5–9). In studies carried out in Finland, Sweden and Mexico based on serology and duodenal biopsy in the general population, the prevalence of celiac disease has been reported about 1% (10–12). Also in studies conducted on different individuals based on serology, prevalence rate has been reported as 0.7% in Italy, and 0.3% in Germany (13). Celiac disease in countries of Eastern Mediterranean Region Organization (EMRO) including North Africa and the Middle East are increasingly on the rise (6, 14–17). Accordingly, it has imposed a lot of economic costs on the respective countries (18). In some studies, this disease has been diagnosed two to three times more in women than in men (19). However, in studies carried out in the general population, a significant difference was not observed between the prevalence of the disease in both sexes (7, 9). Increased prevalence of celiac can be due to the high sensitivity of serological tests and more attention to this disease. If just a clinical method is used to diagnose this disease, a large proportion of people may not be diagnosed with the disease (20). Thus, this systematic review and meta-analysis study was conducted to assess the prevalence of celiac disease in Iran. The results may also be helpful in enlightening researchers and policy makers for adopting effective policies and programs to reduce the prevention and prevalence of celiac disease.

2. Material and Methods

2.1. Search methods

To perform this study and find the related studies, Embase, Pub Med, Web of Science, Google Scholar, MagIran, Scientific Information Database (SID) and Iranmedex databases were searched to December 2015. Searching for studies was carried out in two languages of English and Persian. Moreover, conferences related to celiac disease, and the reference lists of studies were also assessed. For finding the related studies, the keywords based on Medical Subject Headings (MeSH) were used and the search strategy in databases was applied according to title and abstract as “Prevalence” OR “Frequency” AND “Celiac Disease” OR “coeliac disease” AND” Iran “.

2.2. Study selection

All Iranian population-based studies in which the prevalence of celiac disease has been reported, the studies in which the diagnostic methods including serological tests and a biopsy of the duodenum have been used according to the Marsh classification (21) and those that their results clearly suggest the prevalence of celiac, were selected as inclusion criteria. Moreover, some researches with the following characteristics were excluded from the study:

  1. Case Report, Case Series and Quasi-Experimental studies.

  2. Those which lacked appropriate data for estimating prevalence.

  3. The studies not conducted based on population.

  4. Case Report, Case-Series, Quasi-Experimental and Letter of Editor studies.

  5. The studies not applied standard diagnostic method and those with unclear results.

  6. Those conducted on non-Iranian population.

2.3. Data collection

Two authors independently evaluated title and abstract of studies based on inclusion and exclusion criteria. To increase the quality of the studies, blinding method was used and the authors’ names and the journal characteristics were hidden. If there is disagreement between the authors about studies, a third person was asked to act as a judge and resolve disagreements with discussion. The agreement between the two authors to extract information was 95.2% and the agreement was 81.5% based on Kappa reliability statistics. After reviewing the studies and finding original studies to analyze, the information contained the name of the first author, year of publication, place of study, the average age in years, the number of positive people by serological test, the number of positive people were extracted by serological test and the number of positive people by duodenal biopsy according to Mesh classification and the type of studies were extracted. All reviews and analyses on literature were conducted based on the PRISMA guidelines.

2.4. Quality assessment of studies

After finding studies, the STROBE check list (22) was used to assess their quality. According to items of this checklist, the studies that had all the desired items were classified with high quality, those which lacked two of the items with medium quality and those which lacked more than two items were classified as low quality studies. No study with low quality was excluded. The mean score of all studies was 15.75.

2.5. Statistical analysis

In this meta-analysis, the prevalence was calculated based on Der-Simonian/Laird’s (DL) test, using random effects model (23). The findings were presented in Forest Plot graph. All data were reported with 95% confidence intervals based on random model. To assess heterogeneity between studies, statistical tests I2 and Q-test (24) were used. P-value of less than 0.05 was considered as statistically significant amount. To explore sources of heterogeneities, variables such as publishing year of studies, geographic area of study, sample size, quality of studies and individuals’ age were subject to sub-group analysis. Also, to explore more sources of heterogeneity, some effective factors such as publishing year and participants’ age were meta-regressed according to prior defined variables. To assess publication bias, Egger and Begg tests (25, 26) were used. Studies data were given to the Stata 12.0 software (StataCorp LP, College Station, TX) and analyzed.

3. Results

In the initial search on databases and reference lists search, 520 studies were eligible, of which, 269 studies were duplicate items. According to the survey conducted on the remaining studies, 93 studies were excluded because of lack of relevance on the subject. The full texts of the 158 studies were investigated. Finally, 63 studies were entered to meta-analysis phase (27–89). Figure (1) shows PRISMA flowchart of selecting the studies.

Figure 1.

Figure 1

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PRISMA flowchart of selecting the studies

3.1. Characteristics of the included studies

The number of participants in these studies was 36,833. Mirzaagha’s study of 2,999 participants in Golestan province was the largest, and Najafi’s study with 64 participants in Tehran province, was the smallest study. Studies were conducted between years 2003 and 2015. The participants’ age in these studies varied between 5–57 years. Table (1) shows the characteristics of the included studies.

Table 1.

Characteristics of studies included

Athur Year City Age Sample size Type of study Quality of study
Shahbazkhania 2003 Tehran 35.5 2000 Cross-sectional Intermediate
Shahbazkhani 2004 Tehran 18.7 250 Cross-sectional Low
Shahbazkhania 2004 Tehran 31 100 Cross-sectional High
Ale Yasin 2004 Tehran 29.55 250 Case-control Intermediate
Tirgar-Fakheri 2004 Sari 35.5 1438 Cross-sectional Intermediate
Farahmand 2004 Tehran 13.9 35 Cross-sectional Intermediate
Nikpour 2005 Tehran 39 400 Cross-sectional Intermediate
Khoshnia 2005 Gonbad-Kavoos 50 1209 Cross-sectional Intermediate
Sheikholeslami 2005 Ghazvin 31.87 120 Case-control Intermediate
Akbari 2006 Kerman-Sari 33.7 2799 Cross-sectional Intermediate
Joshaghani 2006 Golestan 30 2547 Cross-sectional Intermediate
Masoodi 2007 Bandar Abbas 36.7 150 Cross-sectional High
Nikpour 2007 Tehran 40.3 126 Prospective Low
Sharifi 2008 Tabriz 25.35 250 Case-control Intermediate
Saberi-Firouzi 2008 Shiraz 45.3 1440 Cross-sectional Intermediate
Hashemi 2008 Ahwaz 16.8 104 Cross-sectional High
Dehghani 2008 Shiraz 9.8 72 Cross-sectional High
Emami 2008 Tehran 35.3 270 Cross-sectional Low
khoshbaten 2008 Tabriz 25.35 250 Case-control Intermediate
Zamani 2009 Tehran 36.7 288 Cross-sectional High
Rostami-Nejad 2009 Tehran 36 411 Cross-sectional High
Ghahramani 2009 Arak 40 810 Case-control Low
khoshbaten 2009 Tabriz 37 300 Cross-sectional Low
Bahari 2010 Zahedan 33.2 1600 Cross-sectional High
Keshavarz 2010 Kermanshah 31 170 Cross-sectional Intermediate
Ghergherehchi 2010 Tabriz 9.05 135 Cross-sectional Low
Mirzaagha 2010 Tehran 36.5 2999 Cross-sectional High
Sima 2010 Tehran 33.7 112 Cross-sectional Low
Shahbazkhani 2010 Tehran 39.79 100 Cross-sectional Low
Farahmand 2011 Tehran 7.18 301 Cross-sectional High
Rahimi 2011 Tehran 40.56 316 Cross-sectional High
Norouzinia 2011 Tehran 26 796 Cross-sectional Intermediate
Rostami-Nejad 2011 Tehran 36.1 407 Cross-sectional Low
Bashiri 2011 Kermanshah 18 241 Cross-sectional High
Inaloo 2011 Shiraz 10.6 1600 Case-control Intermediate
Akhondi-Meybodi 2011 Yazd 29.85 125 Cross-sectional Low
Farahmand 2012 Tehran 12.8 634 Cross-sectional High
Bakhshipour 2012 Zahedan 37.4 364 Cross-sectional High
Emami 2012 Isfahan 34.3 324 Case-control Intermediate
Mehrdad 2012 Rasht 39.46 454 Cross-sectional Low
Khoshbaten 2012 Tabriz 37 200 Cross-sectional High
VosoghiniaH 2012 Mashhad 19.78 87 Cross-sectional Intermediate
Bakhshipour 2013 Zahedan 37.4 403 Cross-sectional High
Amini-Ranjbar 2013 Kerman 6 144 Cross-sectional High
Dehghani 2013 Shiraz 9.5 1500 Cross-sectional High
Houshiyar 2013 Ardabil 31.4 105 Cross-sectional Low
Jafarihaydarlo 2013 Ilam 29.02 1000 Cross-sectional Low
Hayatbakhsh 2013 kerman 43 2259 Cross-sectional Intermediate
Shaykhesmaili 2013 Sanandaj 35.45 180 Case-control Low
Ghergherehchi1 2013 Tabriz 12 200 Cross-sectional Intermediate
Mahmoodi 2014 Ilam 29.02 1000 Cross-sectional High
Shayesteh 2014 Ahvaz 31.8 465 Cross-sectional High
Najafi 2014 Tehran 8.39 64 Cross-sectional High
Zahmatkeshan 2014 Shiraz 5.73 82 Case-control Intermediate
Honar 2014 Shiraz 12.7 215 Case-control Low
Yazdanbod 2014 Ardabil 28.45 181 Cross-sectional Intermediate
Honar 2015 Shiraz 10.38 83 Prospective High
Fallahi 2015 Tehran 12 96 Cross-sectional Low
Ahmadi 2015 kerman 34.57 143 Cross-sectional High
Dehghani 2015 Shiraz 57.68 101 Cross-sectional Intermediate
Shahramian 2015 Zahedan 43.09 1002 Case-control High
Jandaghi 2015 Tehran 35.03 406 Case-control High
Shahramian 2015 Zabol-Zahedan 28.81 620 Case-control High
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3.2. Quality of studies

After checking quality of included studies based on the STROBE checklist, 25 of them (39.6%) were of high-quality, 22 papers (34.9%) were of average quality and 16 papers (25.5%) were of low quality.

3.3. Prevalence of celiac disease

The overall prevalence of celiac disease in 63 studies that had used serological tests for the diagnosis, was observed as 3% (95% CI: 0.03–0.03, I2: 90.9%) (Figure 2). The number of participants in this study was 36,833. Besides, the overall prevalence of celiac disease in 41 studies that had used biopsy method for diagnosis, was observed as 2% (95% CI: 0.01–0.02, I2: 87.7%) (Figure 3). The number of participants in this study was 24,538.

Figure 2.

Figure 2

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Forest plot of prevalence of celiac disease used serological tests

Figure 3.

Figure 3

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Forest plot of prevalence of celiac disease used biopsy method

3.4. Results of subgroup analysis

The pooled prevalence was stratified according to age, sample size, the quality of studies, year of publication, and geographic area of studies in Table (2).

Table 2.

Results of subgroup analysis

Variables Serological tests Marsh
Prevalence 95% CI p-value I2 (%) Prevalence 95% CI p-value I2 (%)
Age (year) <10 3% 1%–4% 0.000 60.5 2% 0%–4% 0.012 74.4
10–20 5% 3%–6% 0.000 86.4 3% 1%–4% 0.000 87.2
20–30 3% 2%–4% 0.000 93.0 1% 1%–2% 0.000 0.0
30–40 3% 3%4% 0.000 91.7 2% 2%–3% 0.000 90.3
40–50 2% 1%–4% 0.003 95.8 0% 0%–1% 0.003 0.0
50–60 4% 0%–4% 0.041 - 1% −1%–3% 0.315 -
Sample size <800 4% 3%–5% 0.000 85.7 3% 3%–4% 0.000 82.0
800–1600 3% 2%–4% 0.000 96.0 0% 0%–1% 0.002 73.3
1600–2400 2% −1%–6% 0.191 98.5 1% 0%–1% 0.001 -
>2400 1% 0%–2% 0.008 93.0 1% 1%–2% 0.000 71.0
Quality of the studies High 3% 2%–4% 0.000 91.3 3% 2%–3% 0.000 90.0
intermediate 5% 4%–7% 0.000 88.1 1% 1%–1% 0.000 85.8
Low 2% 1%–2% 0.000 88.1 4% 2%–6% 0.000 83.5
Year of publication 2003–2007 1% 1%–2% 0.000 81.8 1% 1%–1% 0.000 73.9
2007–2011 3% 2%–4% 0.000 90.0 2% 1%–2% 0.000 91.5
2011–2015 4% 3%–5% 0.000 81.8 3% 2%–4% 0.000 73.9
Regional background Central 3% 2%–4% 0.000 88.3 2% 2%–3% 0.000 81.8
North 1% 0%–1% 0.001 76.1 1% 0%–1% 0.004 46.0
South 2% 1%–3% 0.000 84.3 1% 0%–1% 0.003 83.8
West 5% 4%–7% 0.000 89.9 5% 3%–8% 0.000 85.0
East 4% 2%–5% 0.000 94.9 2% 1%–3% 0.000 91.0
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3.5. Ages categories and prevalence of celiac disease

The prevalence of celiac disease in studies that had used serological tests for the diagnosis was observed as 3% (95% CI: 0.03–0.06) for the age group of less than ten years, 5% (95% CI: 0.03–0.06) for the age group 10 to 20 years, 3% (95% CI: 0.02–0.04) for the age group of 20–30 years, 3% (95% CI: 0.02–0.04) for the age group 30–40 years, 2% (95% CI: 0.03–0.04) for the age group 40–50 years and 4% (95% CI: 0.00–0.04) for the age group 50 to 60 years. The prevalence of celiac disease in studies that had used duodenal biopsy for diagnosis was 2% (95% CI: 0.00–0.04) for the age group less than 10 years, 3% (95% CI: 0.01–0.04) for the age group 10–20 years, 1% (95% CI: 0.01–0.02) for the age group 20–30 years, 2% (95% CI: 0.02–0.03) for the age group 30–40 years, 0% ( 95% CI: −0.01–0.03) for the age group 40–50 years, and 1% ( 95% CI: −0.01–0.03) for the age group 50–60 years.

3.6. Sample size and prevalence of celiac disease

The prevalence of celiac disease in studies that had used serological tests for the diagnosis was 4% (95% CI: 0.03–0.05) for studies with the sample size less than 800 participants, 3% (95% CI: 0.02–0.04) for studies with 800 to 1,600 participants, 2% (95% CI: −0.01–0.06) for studies with 1,600 and 2,400 participants, and 1% (95% CI: 0.00–0.02) for studies with more than 2,400 participants. Prevalence of celiac disease in studies that had used the duodenal biopsy for diagnosis was 3% (95% CI: 0.03–0.04) in sample sizes less than 800 participants, 0% (95% CI: 0.00–0.01) for studies with 800–1,600 participants, 1% (95% CI: −0.00–0.01) for studies with 1,600–2,400 participants and 1 % (95% CI: 0.01–0.02) for studies with more than 2,400 participants.

3.7. Quality of the studies included and prevalence of celiac disease

The prevalence of celiac disease was observed for high-quality studies that had used serological tests for diagnosis as 3% (95% CI: 0.02–0.04), for studies of medium quality, 5% (95% CI: 0.04–0.07) and for low quality studies, 2% (95% CI: 0.01–0.02). Prevalence of celiac disease in high-quality studies that had used the duodenal biopsy for diagnosis was 3% (95% CI: 0.02–0.03), for studies of medium quality, 1% (95% CI: 0.01–0.01) and for poor quality studies, 4% (95% CI: 0.02–0.06).

3.8. Publication of year studies included and prevalence of celiac disease

The prevalence of celiac disease in studies that had used serological tests for diagnosis and published in the years 2003–2007 was observed as 1% (95% CI: 0.01–0.02) in the years 2007–2011, 3% (95% CI: 0.02–0.04) for the years 2011–2015 and 4% (95% CI: 0.03–0.05) in the years 2011–2015. The prevalence of celiac disease in studies that had used the duodenal biopsy for diagnosis and published was 1% (95% CI: 0.01–0.01) in 2003–2007, 2% (95% CI: 0.01–0.02) for the years 2007 to 2011, and 3% (95% CI: 0.02–0.04) for the years 2011–2015.

3.9. Geographical background and prevalence of celiac disease

The prevalence of celiac disease was 3% (95% CI: 0.02–0.04) in studies that had used serological tests for the diagnosis and were carried out in central Iran, 1% (95% CI: 0.00–0.01) for studies conducted in northern Iran, 2% (95% CI: 0.01–0.03) for studies conducted in the south. 5% (95% CI: 0.0–0.07) for studies conducted in West region of Iran and 4% (95% CI: 0.02–0.05) for studies conducted in eastern regions. The prevalence of celiac disease was 2% (95% CI: 0.02–0.03) in studies that had used the duodenal biopsy for diagnosis, 1% (95% CI: 0.00–0.01) for studies conducted in central Iran, 1% (95% CI: 0.00–0.01) for studies carried out in northern Iran, 1% (95% CI:0.00–0.01) for studies conducted in the south, 5% (95% CI: 0.03–0.08) for studies conducted in West region and 2% (95% CI: 0.01–0.03) for studies performed in the eastern regions.

3.10. Publication bias

The results of the assessment of publication bias were observed in the studies that had used serological tests for the diagnosis, and were observed for the tests Begg = 0.000, Egger = 0.000, and for studies that had used duodenal biopsy for the diagnosis, Begg = 0.001, Egger = 0.000. The results suggest that publication bias has occurred.

3.11. Sensitivity analysis

To ensure strong results, we excluded Mirzaagha’s study and conducted sensitivity analysis. For studies that had used serological tests, the prevalence remained unchanged and only CI 95%, 3% (95% CI: 0.03–0.04) changed. For studies that had used the duodenal biopsy, no change was created in prevalence. Hence exclusion of this study did not have much effect on the results.

3.12. Results of meta-regression

Meta-regression results are shown in Table (3). Meta-regression for studies that had used serological tests showed that the prevalence of celiac disease increases based on the publishing year of studies, decreases based on participants’ age, and increases based on a sample size of studies. But none are statistically significant. Meta-regression for studies that had used the duodenal biopsy, reduced based on the participants, age, and none were significant, but significantly increased based on sample size.

Table 3.

Results meta-regression analysis

Items Serological tests Marsh
Coefficient SE T p 95% CI Coefficient SE T p 95% CI
Lower Upper Lower Upper
Year −0.00 −0.11 0.34 0.95 0.00 0.00 0.00 0.00 0.60 0.55 −0.00 0.00
Age −0.00 −0.00 0.86 0.17 0.00 0.00 −0.00 0.00 −0.20 0.83 −.000 0.00
Sample size −2.28 −.000 0.02 −2.36 −6.41 0.00 −0.00 5.04 −2.90 0.00 −.000 −4.38
Cons 3.01 −8.25 0.35 −0.93 2.81 −2.62 −1.35 2.32 −0.58 −0.56 −6.05 3.35
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3.13. Results of cumulative meta-analysis

For cumulative meta-analysis, studies and samples were ranked according to year of publication. Prevalence was declining for studies that used serological tests, when they were ranked according to year of publication and sample size. For studies that used duodenal biopsy, a decreasing prevalence was observed when studies were ranked according to year of publication and sample size.

4. Discussion

This study is the first systematic review and meta-analysis of celiac disease in Iran. The prevalence of celiac disease in different parts of Iran was studied. The results showed that the prevalence was 3% (95% CI: 0.03–0.03) for studies which used serological methods for diagnosis and 2% (95% CI: 0.01 – 0.02), for those used biopsy method for diagnosis. The prevalence of celiac disease was 0.71% in a study carried out in America (90) based on serological tests and 1.5% in Finland on the basis of conducted serological tests (91). In another study in Saudi Arabia (92), the prevalence rate was 3% and 1% respectively on the basis of serological tests and biopsy method. The results show that the prevalence of celiac disease in Iran is more than in developed countries and is almost identical to the developing countries. Differences in the prevalence difference, between developed and developing countries, may be due to ideal health status, better servicing, and more advanced medical equipment in developed countries. The difference observed between the prevalence of serological tests and a biopsy method in the present study, is often due to lack of proper and accurate use of biopsy for the diagnosis of celiac disease in the developing countries (93). Unfortunately, in many cases, the diagnosis of celiac disease is solely based on serological tests. Factors such as intestinal parasitic and bacterial infections and malnutrition can cause changes in intestinal tissue similar to celiac disease characteristics. This could be the reason for the high prevalence of celiac disease in studies that have used serological tests. Our results showed that the lack of cohesion in the diagnostic criteria for celiac disease could be one reason for heterogeneity among studies based on p-value of Chi-square Test and I2. Additionally, high heterogeneity observed in this study may be due to the high number of studies and their sample size. Dietary habits can play an important role in the increased prevalence of celiac disease in respective countries. In the Iranian people’s diet, grain and especially “Wheat”, is widely consumed and this is an important factor for the increase in celiac disease. Celiac disease is rising not only in developed countries but in developing regions such as the Middle East, South Asia, North East, West Africa, and South America where taking a diet of grains, especially wheat, is common (94). Serologic tests are required in Iran for screening groups at risk to identify the disease. The prevalence of celiac disease is in all age groups up to 20 years. Given that traditional methods for breastfeeding and prolonged feeding with this practice and not cutting it at the right time is responsible for mild symptoms in these patients, these eating habits create a protecting effect for gluten intolerance in these individuals and a factor for more difficult reorganization of celiac disease (95). According to the study results, the prevalence of celiac disease is more common in the central and western regions of Iran. The high prevalence of celiac disease in these areas is because of the great city of Tehran. High population density, wrong eating habits, different ethnicities, population access to diagnostic centers of this disease can cause high prevalence in central Iran. Moreover, the prevalence of celiac disease is very high in Western Iran. Wheat consumption in these areas is very high. In the present study, some limitations were observed which can be referred as follows: 1) High heterogeneity was observed due to variety of diagnostic methods of patients in studies, this factor can influence the results, 2) The studies data were not possible for investigating the prevalence of celiac disease in terms of gender, 3) Only 36.9% of studies were of high-quality, which can be a cause for bias, 4) In some studies, only a diagnostic method had been used, 5) Carrying a large number of studies in Tehran also could be a factor affecting the bias, 6) The various diseases in people in some studies could also be another factor to influence the results. In conclusion, data from our meta-analysis confirmed higher serological tests for the diagnosis compared to biopsy method for diagnosis celiac disease. Further studies regarding the entire Iranian population and compared serological tests and biopsy method are needed to validate diagnosis celiac disease.

5. Conclusions

In conclusion, celiac disease in Iran has an estimated prevalence that was 3% (95% CI: 0.03–0.03) for studies which used serological methods for diagnosis and 2% (95% CI: 0.01 – 0.02) for those which used biopsy method for diagnosis. The prevalence of celiac disease in Iran was similar or even higher than that reported world-wide.

Acknowledgments

The authors are grateful to the reviewers for their constructive comments, which improved the manuscript.

Footnotes

iThenticate screening: November 18, 2016, English editing: February 10, 2017, Quality control: March 02, 2017

Conflict of Interest:

There is no conflict of interest to be declared.

Authors’ contributions:

All authors contributed to this project and article equally. All authors read and approved the final manuscript.

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