Celiac disease is a frequent problem affecting approximately 1% of the general population.1 The prevalence of diagnosed disease is much lower and it has been estimated that for every diagnosed case there are at least 5-10 undiagnosed ones. This epidemiologic behavior is summarized with the celiac iceberg concept (or the visible part of the disease) and the majority of the undiagnosed cases make up the submerged part of the celiac iceberg (or the hidden part of the disease).2

There are different strategies for detecting celiac disease.3 The traditional passive identification of cases with the classic symptoms of the disease is insufficient for detecting the majority of persons with celiac disease. The active search for cases among high-risk populations is a strategy that has been shown to be useful in facilitating the clinical diagnosis of celiac disease.4 Currently, the active search for cases using serology as an initial screening method followed by confirmation through biopsy of the intestine is the strategy of choice for detecting cases of celiac disease. Active search has been recommended in high-risk populations such as first degree relatives, individuals with Down syndrome, unexplained iron deficiency anemia, infertility, liver function alterations, and others.5 This strategy is effective but clearly insufficient. A third controversial strategy is population screening for celiac disease.

The study by Sotelo-Cruz et al. describes the clinical presentation patterns of celiac disease in a population of Northwestern Mexico. They confirm the fact that the classic form of the disease is the predominant form of clinical presentation, suggesting that the passive search for cases with classic symptoms is the predominant strategy. In other words, this important study presents the tip of the celiac iceberg in the Mexican Northwest. The submerged part of the iceberg in Mexico has recently been described and suggests a disease prevalence of 0.59% among blood donors. This implies that there is a considerable number of hidden cases waiting to be diagnosed.6

In their study, Sotelo Cruz et al.7 also detail the characteristics of other disorders related to gluten as defined in the Oslo Consensus.8

Determining the prevalence of celiac disease in high-risk populations in Mexico will be a pending challenge for researchers. In the meantime, the water level remains very high and the visible portion of the iceberg, very small.