title: Dianna Agron

text: While Agron is known for keeping her romances private, she has been in several high-profile relationships. In July 2010, she began dating British actor Alex Pettyfer, her "I Am Number Four" co-star. Pettyfer was reportedly controlling and paranoid throughout their relationship, though they began cohabiting in 2010. The couple had a messy break-up in February 2011, the day after the film was released, with reports that he threatened her over the phone and had a "heated confrontation" with actor Sebastian Stan, someone with whom Agron was close in early 2011. She temporarily moved to a hotel under a false name so that Pettyfer would not be able to find her, and Pettyfer was instructed not to attend an event at which she would be present. In early 2011, Agron met actor Chris Evans at an Oscars party and the two were linked in April that year; reportedly, Evans' brother Scott was a fan of Agron from "Glee" and supported the idea of the couple. Agron began dating Stan in June 2011; they split in December, due to Agron being unable to spend time with him while having to work on "Glee", but began dating again in February 2012 and were still together later that year.


title: Dianna Agron

text: It was first reported that Agron was dating Mumford & Sons guitarist Winston Marshall in July 2015, and the couple became engaged in winter 2015/16. They were married on October 15, 2016, in Morocco, with Agron wearing a Valentino Fall 2016 off-the-runway dress noted as one of the most expensive celebrity wedding dresses ever. Agron and Marshall kept their relationship private, including not posting about each other on social media. After splitting, they separated in 2019 and divorced in 2020. In 2022, Marshall said that splitting up, which they did around the same time he got sober, was painful.


title: Dianna Agron

text: Agron was linked to Belgian painter Harold Ancart in 2021 and reportedly dated actor Bradley Cooper in 2022. She was again with Ancart in 2022, when it was reported that an incident involving her and publisher Lucas Zwirner caused Ancart to suddenly cut ties with art dealer and gallery owner (and Lucas' father) David Zwirner.


title: Dianna Agron

text: Agron's sexuality has been subject to much public speculation; lesbian culture website "Autostraddle" reflected that Agron wearing a T-shirt reading "Likes Girls" in 2011 "was the moment that started the whole [internet] gay discourse", and a 2016 episode of IFC's "Boxed In" satirized Agron making ambiguous statements on the subject, something common in Celesbian culture. Her close friendship with Taylor Swift led to some fans developing a long-standing theory that Swift is "secretly gay"; speculation of a relationship between the pair was common in Hollywood in 2012 and Agron was asked about its veracity as a guest on "Jimmy Kimmel Live!". She was described as a "queer personality" in the 2022 Pride Month edition of "BELLA" magazine.


title: Dianna Agron

text: "The Guardian" noted in 2015 that Agron is "also known for her activism, supporting charities and advocacy groups when not acting." She is an activist for LGBT+ rights and human rights, and has said that being able to engage with large-scale charity work is one of the positives of her job. She has also given her time to charitable endeavors supporting children, including organizations like Camp Wonder and UNICEF, and has hosted and participated in various fundraisers for literacy non-profit 826LA, including emceeing the 2010 concert "Chickens in Love". Since 2012, Agron has been a GLAAD Spirit Day ambassador, and since 2014 she has been a Global Citizen Ambassador, regularly participating in the Global Citizen Festival. In politics, Agron endorsed Barack Obama's 2012 presidential campaign, Hillary Clinton's 2016 presidential campaign, and Joe Biden's 2020 presidential campaign.


title: Dianna Agron

text: In 2011 she attended the Trevor Project's Trevor Live! with "Glee" co-stars Kevin McHale and Darren Criss, and on June 2, 2012, she hosted the GLAAD Media Awards in San Francisco. Naya Rivera and Cory Monteith had hosted a parallel event on March 24, 2012, in New York City, auctioning off kisses to the audience; Agron did the same, raising $5,500 for the campaign. In women's rights, Agron spoke at the 18th San Francisco Power of Choice Luncheon to celebrate the 40th anniversary of "Roe v. Wade" in 2013, and criticized the Supreme Court of the United States when it repealed this in June 2022. In the arts, Agron works with Platform Presents, a British organization founded by Gala Gordon to provide a platform to new talent, and is an advocate for female filmmakers: she was a jurist for the Nora Ephron Prize at the 2017 Tribeca Film Festival, and for the Through Her Lens grant at Tribeca in 2017 and 2018. Supporting youth causes, in 2014, Agron took part in a charity weekend as part of the Big Slick Foundation, an organization of Kansas City-related celebrities, to help raise funds for Children's Mercy Hospital, and she and other "Glee" stars participated in the Young Storytellers Foundation "Glee Big Show", which featured live performances of five scripts written by fifth grade students to support arts programs in public schools. In August 2014 she wrote an article for NBC News to promote United Nations (UN) International Youth Day.


title: Dianna Agron

text: Agron has prominently been a supporter of charities for refugees, particularly children, affected by war. In 2012, Agron visited the Somaly Mam Foundation's Kampong Cham center, where she met child and teenage residents, and in 2013 she promoted a campaign fundraiser benefiting the foundation. In November 2014, Agron, among many other international artists, was featured on the United Nations Children's Fund charity single "Imagine". She has raised money and advocated for War Child since 2014, particularly for Syrian refugees, and in 2016, she traveled with the UN to visit resettled Syrian refugees in Austria and Jordan. She has also supported military personnel, providing services and live entertainment to United States troops and their families as part of the December 2014 United Service Organizations tour at Bagram air field, Afghanistan, and locations in Spain, Italy, Turkey, and the UK.


title: Dianna Agron

text: You, Me & Charlie (YM&C) was a curation platform launched by Agron on December 12, 2011. Along with help from several other contributors, she wrote and collected posts on subjects including music, art, fashion, and daily inspiration. The name of the website refers to Charlie, one of Agron's childhood nicknames, "her male alter ego[,] and the star of the short stories she'd write in high school". Several short films and videos created by Lexy Hulme, a dancer and friend of Agron, were also shared on the website, which accepted submissions for inspiration posts through a related Tumblr blog. The site served as inspiration for young artists, and "Vanity Fair" championed it as a stress reliever, saying that the site is "full of sunshine, optimism, and pretty people"; "InStyle" promoted how the platform spread activism, saying that "these days it seems every celebrity has an online presence [but] Agron uses social media in a truly inspired way." The idea for YM&C came from how "people really responded so well to [Agron's personal blog], so [she] just wanted to open it up and have it be more of a community". In February 2013, Agron hosted a concert for the curation blog in Los Angeles, where she performed Fleetwood Mac's "Dreams" and Tina Turner's "What's Love Got to Do with It" with the band A House For Lions.


title: Church of England

text: The Church of England (C of E) is the established Christian church in England and the mother church of the international Anglican Communion. It traces its history to the Christian church recorded as existing in the Roman province of Britain by the 3rd century and to the 6th-century Gregorian mission to Kent led by Augustine of Canterbury.


title: Church of England

text: The English church renounced papal authority in 1534 when Henry VIII failed to secure a papal annulment of his marriage to Catherine of Aragon. The English Reformation accelerated under Edward VI's regents, before a brief restoration of papal authority under Queen Mary I and King Philip. The Act of Supremacy 1558 renewed the breach, and the Elizabethan Settlement charted a course enabling the English church to describe itself as both Reformed and Catholic. In the earlier phase of the English Reformation there were both Roman Catholic martyrs and radical Protestant martyrs. The later phases saw the Penal Laws punish Roman Catholics and nonconforming Protestants. In the 17th century, the Puritan and Presbyterian factions continued to challenge the leadership of the church, which under the Stuarts veered towards a more Catholic interpretation of the Elizabethan Settlement, especially under Archbishop Laud and the rise of the concept of Anglicanism as a "via media" between Roman Catholicism and radical Protestantism. After the victory of the Parliamentarians, the Prayer Book was abolished and the Presbyterian and Independent factions dominated. The episcopacy was abolished in 1646 but the Restoration restored the Church of England, episcopacy and the Prayer Book. Papal recognition of George III in 1766 led to greater religious tolerance.


title: Church of England

text: Since the English Reformation, the Church of England has used the English language in the liturgy. The church contains several doctrinal strands, the main three being known as Anglo-Catholic, evangelical and liberal. Tensions between theological conservatives and progressives find expression in debates over the ordination of women and homosexuality.


title: Church of England

text: The British monarch (currently Charles III) is the supreme governor and the archbishop of Canterbury (currently Justin Welby) is the most senior cleric. The governing structure of the church is based on dioceses, each presided over by a bishop. Within each diocese are local parishes. The General Synod of the Church of England is the legislative body for the church and comprises bishops, other clergy and laity. Its measures must be approved by the Parliament of the United Kingdom.


title: Church of England

text: There is evidence for Christianity in Roman Britain as early as the 3rd century. After the fall of the Roman Empire, England was conquered by the Anglo-Saxons, who were pagans, and the Celtic Church was confined to Cornwall and Wales. In 597, Pope Gregory I sent missionaries to England to Christianize the Anglo-Saxons. This mission was led by Augustine, who became the first Archbishop of Canterbury. The Church of England considers 597 the start of its formal history.


title: Church of England

text: In Northumbria, Celtic missionaries competed with their Roman counterparts. The Celtic and Roman churches disagreed over the date of Easter, baptismal customs, and the style of tonsure worn by monks. King Oswiu of Northumbria summoned the Synod of Whitby in 664. The king decided Northumbria would follow the Roman tradition because Saint Peter and his successors, the bishops of Rome, hold the keys of the kingdom of heaven.


title: Church of England

text: By the late Middle Ages, Catholicism was an essential part of English life and culture. The 9,000 parishes covering all of England were overseen by a hierarchy of deaneries, archdeaconries, dioceses led by bishops, and ultimately the pope who presided over the Catholic Church from Rome. Catholicism taught that the contrite person could cooperate with God towards their salvation by performing good works (see synergism). God's grace was given through the seven sacraments. In the Mass, a priest consecrated bread and wine to become the body and blood of Christ through transubstantiation. The Church taught that, in the name of the congregation, the priest offered to God the same sacrifice of Christ on the cross that provided atonement for the sins of humanity. The Mass was also an offering of prayer by which the living could help souls in purgatory. While penance removed the guilt attached to sin, Catholicism taught that a penalty still remained. It was believed that most people would end their lives with these penalties unsatisfied and would have to spend time in purgatory. Time in purgatory could be lessened through indulgences and prayers for the dead, which were made possible by the communion of saints.


title: Church of England

text: In 1527, Henry VIII was desperate for a male heir and asked Pope Clement VII to annul his marriage to Catharine of Aragon. When the pope refused, Henry used Parliament to assert royal authority over the English church. In 1533, Parliament passed the Act in Restraint of Appeals, barring legal cases from being appealed outside England. This allowed the Archbishop of Canterbury to annul the marriage without reference to Rome. In November 1534, the Act of Supremacy formally abolished papal authority and declared Henry Supreme Head of the Church of England.


title: Church of England

text: Henry's religious beliefs remained aligned to traditional Catholicism throughout his reign. In order to secure royal supremacy over the Church, however, Henry allied himself with Protestants, who until that time had been treated as heretics. The main doctrine of the Protestant Reformation was justification by faith alone rather than by good works. The logical outcome of this belief is that the Mass, sacraments, charitable acts, prayers to saints, prayers for the dead, pilgrimage, and the veneration of relics do not mediate divine favor. To believe they can would be superstition at best and idolatry at worst.


title: Church of England

text: Between 1536 and 1540, Henry engaged in the dissolution of the monasteries, which controlled much of the richest land. He disbanded religious houses, appropriated their income, disposed of their assets, and provided pensions for the former residents. The properties were sold to pay for the wars. Historian George W. Bernard argues:


title: Church of England

text: In the reign of Edward VI (1547–1553), the Church of England underwent an extensive theological reformation. Justification by faith was made a central teaching. Government sanctioned iconoclasm led to the destruction of images and relics. Stained glass, shrines, statues, and roods were defaced or destroyed. Church walls were whitewashed and covered with biblical texts condemning idolatry. The most significant reform in Edward's reign was the adoption of an English liturgy to replace the old Latin rites. Written by Archbishop Thomas Cranmer, the 1549 "Book of Common Prayer" implicitly taught justification by faith, and rejected the Catholic doctrines of transubstantiation and the sacrifice of the Mass. This was followed by a greatly revised 1552 "Book of Common Prayer" that was even more Protestant in tone, going so far as to deny the real presence of Christ in the Eucharist.


title: Church of England

text: During the reign of Mary I (1553–1558), England was briefly reunited with the Catholic Church. Mary died childless, so it was left to the new regime of her half-sister Queen Elizabeth I to resolve the direction of the Church. The Elizabethan Religious Settlement returned the Church to where it stood in 1553 before Edward's death. The Act of Supremacy made the monarch the Church's supreme governor. The Act of Uniformity restored a slightly altered 1552 "Book of Common Prayer". In 1571, the Thirty-nine Articles received parliamentary approval as a doctrinal statement for the Church. The settlement ensured the Church of England was Protestant, but it was unclear what kind of Protestantism was being adopted. The prayer book's eucharistic theology was vague. The words of administration neither affirmed nor denied the real presence. Perhaps, a spiritual presence was implied, since Article 28 of the Thirty-nine Articles taught that the body of Christ was eaten "only after an heavenly and spiritual manner". Nevertheless, there was enough ambiguity to allow later theologians to articulate various versions of Anglican eucharistic theology.


title: Church of England

text: The Church of England was the established church (constitutionally established by the state with the head of state as its supreme governor). The exact nature of the relationship between church and state would be a source of continued friction into the next century.


title: Church of England

text: Struggle for control of the church persisted throughout the reigns of James I and his son Charles I, culminating in the outbreak of the First English Civil War in 1642. The two opposing factions consisted of Puritans, who sought to "purify" the church and enact more far-reaching Protestant reforms, and those who wanted to retain traditional beliefs and practices. In a period when many believed "true religion" and "good government" were the same thing, religious disputes often included a political element, one example being the struggle over bishops. In addition to their religious function, bishops acted as state censors, able to ban sermons and writings considered objectionable, while lay people could be tried by church courts for crimes including blasphemy, heresy, fornication and other 'sins of the flesh', as well as matrimonial or inheritance disputes. They also sat in the House of Lords and often blocked legislation opposed by the Crown; their ousting from Parliament by the 1640 Clergy Act was a major step on the road to war.


title: Church of England

text: Following Royalist defeat in 1646, the Episcopacy was formally abolished. In 1649, the Commonwealth of England outlawed a number of former practices and Presbyterian structures replaced the episcopate. The 39 Articles were replaced by the Westminster Confession, the Book of Common Prayer by the Directory of Public Worship. Despite this, about one quarter of English clergy refused to conform to this form of state presbyterianism. It was also opposed by religious Independents who rejected the very idea of state-mandated religion, and included Congregationalists like Oliver Cromwell, as well as Baptists, who were especially well represented in the New Model Army.


title: Church of England

text: After the Stuart Restoration in 1660, Parliament restored the Church of England to a form not far removed from the Elizabethan version. Until James II of England was ousted by the Glorious Revolution in November 1688, many Nonconformists still sought to negotiate terms that would allow them to re-enter the Church. In order to secure his political position, William III of England ended these discussions and the Tudor ideal of encompassing all the people of England in one religious organisation was abandoned. The religious landscape of England assumed its present form, with the Anglican established church occupying the middle ground and Nonconformists continuing their existence outside. One result of the Restoration was the ousting of 2,000 parish ministers who had not been ordained by bishops in the apostolic succession or who had been ordained by ministers in presbyter's orders. Official suspicion and legal restrictions continued well into the 19th century. Roman Catholics, perhaps 5% of the English population (down from 20% in 1600) were grudgingly tolerated, having had little or no official representation after the Pope's excommunication of Queen Elizabeth in 1570, though the Stuarts were sympathetic to them. By the end of 18th century they had dwindled to 1% of the population, mostly amongst upper middle-class gentry, their tenants and extended families.


title: Church of England

text: By the Fifth Article of the Union with Ireland 1800, the Church of England and Church of Ireland were united into "one Protestant Episcopal church, to be called, the United Church of England and Ireland". Although "the continuance and preservation of the said united church ... [was] deemed and taken to be an essential and fundamental part of the union", the Irish Church Act 1869 separated the Irish part of the church again and disestablished it, the Act coming into effect on 1 January 1871.


title: Church of England

text: As the British Empire expanded, British colonists and colonial administrators took the established church doctrines and practices together with ordained ministry and formed overseas branches of the Church of England. As they developed or, beginning with the United States of America, became sovereign or independent states, many of their churches became separate organisationally but remained linked to the Church of England through the Anglican Communion. In the provinces that made up Canada, the church operated as the "Church of England in Canada" until 1955 when it became the Anglican Church of Canada.


title: Church of England

text: In Bermuda, the oldest remaining English colony (now designated a British Overseas Territory), the first Church of England services were performed by the Reverend Richard Buck, one of the survivors of the 1609 wreck of the "Sea Venture" which initiated Bermuda's permanent settlement. The nine parishes of the Church of England in Bermuda, each with its own church and glebe land, rarely had more than a pair of ordained ministers to share between them until the 19th century. From 1825 to 1839, Bermuda's parishes were attached to the See of Nova Scotia. Bermuda was then grouped into the new Diocese of Newfoundland and Bermuda from 1839. In 1879, the Synod of the Church of England in Bermuda was formed. At the same time, a Diocese of Bermuda became separate from the Diocese of Newfoundland, but both continued to be grouped under the "Bishop of Newfoundland and Bermuda" until 1919, when Newfoundland and Bermuda each received its own bishop.


title: Church of England

text: The Church of England in Bermuda was renamed in 1978 as the Anglican Church of Bermuda, which is an extra-provincial diocese, with both metropolitan and primatial authority coming directly from the Archbishop of Canterbury. Among its parish churches is St Peter's Church in the UNESCO World Heritage Site of St George's Town, which is the oldest Anglican church outside of the British Isles, and the oldest Protestant church in the New World.


title: Church of England

text: The first Anglican missionaries arrived in Nigeria in 1842 and the first Anglican Nigerian was consecrated a bishop in 1864. However, the arrival of a rival group of Anglican missionaries in 1887 led to infighting that slowed the Church's growth. In this large African colony, by 1900 there were only 35,000 Anglicans, about 0.2% of the population. However, by the late 20th century the Church of Nigeria was the fastest growing of all Anglican churches, reaching about 18 percent of the local population by 2000.


title: Church of England

text: The Church established its presence in Hong Kong and Macau in 1843. In 1951, the Diocese of Hong Kong and Macao became an extra-provincial diocese, and in 1998 it became a province of the Anglican Communion, under the name Hong Kong Sheng Kung Hui.


title: Church of England

text: From 1796 to 1818 the Church began operating in Sri Lanka (formerly Ceylon), following the 1796 start of British colonisation, when the first services were held for the British civil and military personnel. In 1799, the first Colonial Chaplain was appointed, following which CMS and SPG missionaries began their work, in 1818 and 1844 respectively. Subsequently the Church of Ceylon was established: in 1845 the diocese of Colombo was inaugurated, with the appointment of James Chapman as Bishop of Colombo. It served as an extra-provincial jurisdiction of the Archbishop of Canterbury, who served as its Metropolitan.


title: Church of England

text: Under the guidance of Rowan Williams and with significant pressure from clergy union representatives, the ecclesiastical penalty for convicted felons to be defrocked was set aside from the Clergy Discipline Measure 2003. The clergy union argued that the penalty was unfair to victims of hypothetical miscarriages of criminal justice, because the ecclesiastical penalty is considered irreversible. Although clerics can still be banned for life from ministry, they remain ordained as priests.


title: Church of England

text: Bishop Sarah Mullally has insisted that declining numbers at services should not necessarily be a cause of despair for churches, because people may still encounter God without attending a service in a church; for example hearing the Christian message through social media sites or in a café run as a community project. Additionally, 9.7 million people visit at least one of its churches every year and 1 million students are educated at Church of England schools (which number 4,700). In 2019, an estimated 10 million people visited a cathedral and an additional "1.3 million people visited Westminster Abbey, where 99% of visitors paid / donated for entry". Nevertheless, the archbishops of Canterbury and York warned in January 2015 that the Church of England would no longer be able to carry on in its current form unless the downward spiral in membership were somehow to be reversed, as typical Sunday attendance had halved to 800,000 in the previous 40 years:


title: Church of England

text: Between 1969 and 2010, almost 1,800 church buildings, roughly 11% of the stock, were closed (so-called "redundant churches"); the majority (70%) in the first half of the period; only 514 being closed between 1990 and 2010. Some active use was being made of about half of the closed churches. By 2019 the rate of closure had steadied at around 20 to 25 per year (0.2%); some being replaced by new places of worship. Additionally, in 2018 the church announced a £27 million growth programme to create 100 new churches.


title: Church of England

text: In 2015 the Church of England admitted that it was embarrassed to be paying staff under the living wage. The Church of England had previously campaigned for all employers to pay this minimum amount. The archbishop of Canterbury acknowledged it was not the only area where the church "fell short of its standards".


title: Church of England

text: The canon law of the Church of England identifies the Christian scriptures as the source of its doctrine. In addition, doctrine is also derived from the teachings of the Church Fathers and ecumenical councils (as well as the ecumenical creeds) in so far as these agree with scripture. This doctrine is expressed in the Thirty-Nine Articles of Religion, the Book of Common Prayer, and the Ordinal containing the rites for the ordination of deacons, priests, and the consecration of bishops. Unlike other traditions, the Church of England has no single theologian that it can look to as a founder. However, Richard Hooker's appeal to scripture, church tradition, and reason as sources of authority, as well as the work of Thomas Cranmer, which inspired the doctrinal status of the church, continue to inform Anglican identity.


title: Church of England

text: The Church of England's doctrinal character today is largely the result of the Elizabethan Settlement, which sought to establish a comprehensive middle way between Roman Catholicism and Protestantism. The Church of England affirms the protestant reformation principle that scripture contains all things necessary to salvation and is the final arbiter in doctrinal matters. The Thirty-nine Articles are the church's only official confessional statement. Though not a complete system of doctrine, the articles highlight areas of agreement with Lutheran and Reformed positions, while differentiating Anglicanism from Roman Catholicism and Anabaptism.


title: Church of England

text: While embracing some themes of the Protestant Reformation, the Church of England also maintains Catholic traditions of the ancient church and teachings of the Church Fathers, unless these are considered contrary to scripture. It accepts the decisions of the first four ecumenical councils concerning the Trinity and the Incarnation. The Church of England also preserves catholic order by adhering to episcopal polity, with ordained orders of bishops, priests and deacons. There are differences of opinion within the Church of England over the necessity of episcopacy. Some consider it essential, while others feel it is needed for the proper ordering of the church. In sum these express the 'Via Media' viewpoint that the first five centuries of doctrinal development and church order as approved are acceptable as a yardstick by which to gauge authentic catholicity, as minimum and sufficient; Anglicanism did not emerge as the result of charismatic leaders with particular doctrines. It is light on details compared to Roman Catholic, Reformed and Lutheran teachings. The Bible, the Creeds, Apostolic Order, and the administration of the Sacraments are sufficient to establish catholicity. The Reformation in England was initially much concerned about doctrine but the Elizabethan Settlement tried to put a stop to doctrinal contentions. The proponents of further changes, nonetheless, tried to get their way by making changes in Church Order (abolition of bishops), governance (Canon Law) and liturgy ('too Catholic'). They did not succeed because the monarchy and the Church resisted and the majority of the population were indifferent. Moreover, "despite all the assumptions of the Reformation founders of that Church, it had retained a catholic character." The Elizabethan Settlement had created a cuckoo in a nest..." a Protestant theology and program within a largely pre-Reformation Catholic structure whose continuing life would arouse a theological interest in the Catholicism that had created it; and would result in the rejection of predestinarian theology in favor of sacraments, especially the eucharist, ceremonial, and anti-Calvinist doctrine". The existence of cathedrals "without substantial alteration" and "where the "old devotional world cast its longest shadow for the future of the ethos that would become Anglicanism," This is "One of the great mysteries of the English Reformation," that there was no complete break with the past but a muddle that was per force turned into a virtue. The story of the English Reformation is the tale of retreat from the Protestant advance of 1550 which could not proceed further in the face of the opposition of the institution which was rooted in the medieval past, and the adamant opposition of Queen Elizabeth I.


title: Church of England

text: The Church of England has, as one of its distinguishing marks, a breadth of opinion from liberal to conservative clergy and members. This tolerance has allowed Anglicans who emphasise the catholic tradition and others who emphasise the reformed tradition to coexist. The three schools of thought (or parties) in the Church of England are sometimes called high church (or Anglo-Catholic), low church (or evangelical Anglican) and broad church (or liberal). The high church party places importance on the Church of England's continuity with the pre-Reformation Catholic Church, adherence to ancient liturgical usages and the sacerdotal nature of the priesthood. As their name suggests, Anglo-Catholics maintain many traditional catholic practices and liturgical forms. The Catholic tradition, strengthened and reshaped from the 1830s by the Oxford movement, has stressed the importance of the visible Church and its sacraments and the belief that the ministry of bishops, priests and deacons is a sign and instrument of the Church of England's Catholic and apostolic identity. The low church party is more Protestant in both ceremony and theology. It has emphasized the significance of the Protestant aspects of the Church of England's identity, stressing the importance of the authority of Scripture, preaching, justification by faith and personal conversion. Historically, the term 'broad church' has been used to describe those of middle-of-the-road ceremonial preferences who lean theologically towards liberal protestantism. The liberal broad church tradition has emphasized the importance of the use of reason in theological exploration. It has stressed the need to develop Christian belief and practice in order to respond creatively to wider advances in human knowledge and understanding and the importance of social and political action in forwarding God's kingdom. The balance between these strands of churchmanship is not static: in 2013, 40% of Church of England worshippers attended evangelical churches (compared with 26% in 1989), and 83% of very large congregations were evangelical. Such churches were also reported to attract higher numbers of men and young adults than others.


title: Church of England

text: In 1604, James I ordered an English language translation of the Bible known as the King James Version, which was published in 1611 and authorised for use in parishes, although it was not an "official" version per se. The Church of England's official book of liturgy as established in English Law is the 1662 version of the Book of Common Prayer (BCP). In the year 2000, the General Synod approved a modern liturgical book, "Common Worship", which can be used as an alternative to the BCP. Like its predecessor, the 1980 "Alternative Service Book", it differs from the "Book of Common Prayer" in providing a range of alternative services, mostly in modern language, although it does include some BCP-based forms as well, for example Order Two for Holy Communion. (This is a revision of the BCP service, altering some words and allowing the insertion of some other liturgical texts such as the "Agnus Dei" before communion.) The Order One rite follows the pattern of more modern liturgical scholarship.


title: Church of England

text: The liturgies are organised according to the traditional liturgical year and the calendar of saints. The sacraments of baptism and the eucharist are generally thought necessary to salvation. Infant baptism is practised. At a later age, individuals baptised as infants receive confirmation by a bishop, at which time they reaffirm the baptismal promises made by their parents or sponsors. The eucharist, consecrated by a thanksgiving prayer including Christ's Words of Institution, is believed to be "a memorial of Christ's once-for-all redemptive acts in which Christ is objectively present and effectually received in faith".


title: Church of England

text: The use of hymns and music in the Church of England has changed dramatically over the centuries. Traditional Choral evensong is a staple of most cathedrals. The style of psalm chanting harks back to the Church of England's pre-reformation roots. During the 18th century, clergy such as Charles Wesley introduced their own styles of worship with poetic hymns.


title: Church of England

text: In the latter half of the 20th century, the influence of the Charismatic Movement significantly altered the worship traditions of numerous Church of England parishes, primarily affecting those of evangelical persuasion. These churches now adopt a contemporary worship form of service, with minimal liturgical or ritual elements, and incorporating contemporary worship music.


title: Church of England

text: Just as the Church of England has a large conservative or "traditionalist" wing, it also has many liberal members and clergy. Approximately one third of clergy "doubt or disbelieve in the physical resurrection". Others, such as Giles Fraser, a contributor to "The Guardian", have argued for an allegorical interpretation of the virgin birth of Jesus. "The Independent" reported in 2014 that, according to a YouGov survey of Church of England clergy, "as many as 16 per cent are unclear about God and two per cent think it is no more than a human construct." Moreover, many congregations are seeker-friendly environments. For example, one report from the Church Mission Society suggested that the church open up "a pagan church where Christianity [is] very much in the centre" to reach out to spiritual people.


title: Church of England

text: Women were appointed as deaconesses from 1861, but they could not function fully as deacons and were not considered ordained clergy. Women have historically been able to serve as lay readers. During the First World War, some women were appointed as lay readers, known as "bishop's messengers", who also led missions and ran churches in the absence of men. After the war, no women were appointed as lay readers until 1969.


title: Church of England

text: Legislation authorising the ordination of women as deacons was passed in 1986 and they were first ordained in 1987. The ordination of women as priests was approved by the General Synod in 1992 and began in 1994. In 2010, for the first time in the history of the Church of England, more women than men were ordained as priests (290 women and 273 men), but in the next two years, ordinations of men again exceeded those of women.


title: Church of England

text: In July 2005, the synod voted to "set in train" the process of allowing the consecration of women as bishops. In February 2006, the synod voted overwhelmingly for the "further exploration" of possible arrangements for parishes that did not want to be directly under the authority of a bishop who is a woman. On 7 July 2008, the synod voted to approve the ordination of women as bishops and rejected moves for alternative episcopal oversight for those who do not accept the ministry of bishops who are women. Actual ordinations of women to the episcopate required further legislation, which was narrowly rejected in a General Synod vote in November 2012. On 20 November 2013, the General Synod voted overwhelmingly in support of a plan to allow the ordination of women as bishops, with 378 in favour, 8 against and 25 abstentions.


title: Church of England

text: On 14 July 2014, the General Synod approved the ordination of women as bishops. The House of Bishops recorded 37 votes in favour, two against with one abstention. The House of Clergy had 162 in favour, 25 against and four abstentions. The House of Laity voted 152 for, 45 against with five abstentions. This legislation had to be approved by the Ecclesiastical Committee of the Parliament before it could be finally implemented at the November 2014 synod. In December 2014, Libby Lane was announced as the first woman to become a bishop in the Church of England. She was consecrated as a bishop in January 2015. In July 2015, Rachel Treweek was the first woman to become a diocesan bishop in the Church of England when she became the Bishop of Gloucester. She and Sarah Mullally, Bishop of Crediton, were the first women to be ordained as bishops at Canterbury Cathedral. Treweek later made headlines by calling for gender-inclusive language, saying that "God is not to be seen as male. God is God."


title: Church of England

text: In May 2018, the Diocese of London consecrated Dame Sarah Mullally as the first woman to serve as the Bishop of London. Bishop Sarah Mullally occupies the third most senior position in the Church of England. Mullally has described herself as a feminist and will ordain both men and women to the priesthood. She is also considered by some to be a theological liberal. On women's reproductive rights, Mullally describes herself as pro-choice while also being personally pro-life. On marriage, she supports the current stance of the Church of England that marriage is between a man and a woman, but also said that: "It is a time for us to reflect on our tradition and scripture, and together say how we can offer a response that is about it being inclusive love."


title: Church of England

text: The Church of England has been discussing same-sex marriages and LGBT clergy. The church plans to continue discussing human sexuality and whether or not to bless or perform same-sex marriages at General Synod. The church holds that marriage is a union of one man with one woman. However, the church teaches "Same-sex relationships often embody genuine mutuality and fidelity." The church also officially supports celibate civil partnerships; "We believe that Civil Partnerships still have a place, including for some Christian LGBTI couples who see them as a way of gaining legal recognition of their relationship." The "Church of England does not conduct Civil Partnership Ceremonies or Same Sex Marriages but individual churches can conduct a service of thanksgiving after a ceremony." The church says "clergy in the Church of England are permitted to offer prayers of support on a pastoral basis for people in same-sex relationships;" Therefore, many Anglican churches, with clergy open to it, "already bless same-sex couples on an unofficial basis."


title: Church of England

text: Civil partnerships for clergy have been allowed since 2005, so long as they remain sexually abstinent, and the church extends pensions to clergy in same-sex civil partnerships. In a missive to clergy, the church communicated that "there was a need for committed same-sex couples to be given recognition and 'compassionate attention' from the Church, including special prayers." "There is no prohibition on prayers being said in church or there being a 'service'" after a civil union. After same-sex marriage was legalised, the church sought continued availability of civil unions, saying "The Church of England recognises that same-sex relationships often embody fidelity and mutuality. Civil partnerships enable these Christian virtues to be recognised socially and legally in a proper framework."


title: Church of England

text: In 2014, the bishops released guidelines that permit "more informal kind of prayer" for couples. In the guidelines, "gay couples who get married will be able to ask for special prayers in the Church of England after their wedding, the bishops have agreed." In 2016, the bishop of Grantham, Nicholas Chamberlain, announced that he is gay, in a same-sex relationship and celibate, becoming the first bishop to do so in the church. The church had decided in 2013 that gay clergy in civil partnerships so long as they remain sexually abstinent could become bishops. "The House [of Bishops] has confirmed that clergy in civil partnerships, and living in accordance with the teaching of the church on human sexuality, can be considered as candidates for the episcopate."


title: Church of England

text: In 2017, the House of Clergy voted against the motion to "take note" of the bishops' report defining marriage as between a man and a woman. Due to passage in all three houses being required, the motion was rejected. After General Synod rejected the motion, the archbishops of Canterbury and York called for "radical new Christian inclusion" that is "based on good, healthy, flourishing relationships, and in a proper 21st century understanding of being human and of being sexual." The church officially opposes "conversion therapy", a practice which attempts to change a gay or lesbian person's sexual orientation, calling it unethical and supports the banning of "conversion therapy" in the UK. The Diocese of Hereford approved a motion calling for the church "to create a set of formal services and prayers to bless those who have had a same-sex marriage or civil partnership." In 2022, "The House [of Bishops] also agreed to the formation of a Pastoral Consultative Group to support and advise dioceses on pastoral responses to circumstances that arise concerning LGBTI+ clergy, ordinands, lay leaders and the lay people in their care."


title: Church of England

text: Regarding transgender issues, the 2017 General Synod voted in favour of a motion saying that transgender people should be "welcomed and affirmed in their parish church". The motion also asked the bishops "to look into special services for transgender people." The bishops initially said "the House notes that the Affirmation of Baptismal Faith, found in "Common Worship", is an ideal liturgical rite which trans people can use to mark this moment of personal renewal." The Bishops also authorised services of celebration to mark a gender transition that will be included in formal liturgy. Transgender people may marry in the Church of England after legally making a transition. "Since the Gender Recognition Act 2004, trans people legally confirmed in their gender identity under its provisions are able to marry someone of the opposite sex in their parish church." The church further decided that same-gender couples may remain married when one spouse experiences gender transition provided that the spouses identified as opposite genders at the time of the marriage. Since 2000, the church has allowed priests to undergo gender transition and remain in office. The church has ordained openly transgender clergy since 2005.


title: Church of England

text: The Church of England is generally opposed to abortion but believes "there can be strictly limited conditions under which abortion may be morally preferable to any available alternative". The church also opposes euthanasia. Its official stance is that "While acknowledging the complexity of the issues involved in assisted dying/suicide and voluntary euthanasia, the Church of England is opposed to any change in the law or in medical practice that would make assisted dying/suicide or voluntary euthanasia permissible in law or acceptable in practice." It also states that "Equally, the Church shares the desire to alleviate physical and psychological suffering, but believes that assisted dying/suicide and voluntary euthanasia are not acceptable means of achieving these laudable goals." In 2014, George Carey, a former archbishop of Canterbury, announced that he had changed his stance on euthanasia and now advocated legalising "assisted dying". On embryonic stem-cell research, the church has announced "cautious acceptance to the proposal to produce cytoplasmic hybrid embryos for research".


title: Church of England

text: In the 19th century, English law required the burial of people who had died by suicide to occur only between the hours of 9 p.m. and midnight and without religious rites. The Church of England permitted the use of alternative burial services for people who had died by suicide. In 2017, the Church of England changed its rules to permit the full, standard Christian burial service regardless of whether a person had died by suicide.


title: Church of England

text: The Church of England set up the Church Urban Fund in the 1980s to tackle poverty and deprivation. It sees poverty as trapping individuals and communities with some people in urgent need, leading to dependency, homelessness, hunger, isolation, low income, mental health problems, social exclusion and violence. They feel that poverty reduces confidence and life expectancy and that people born in poor conditions have difficulty escaping their disadvantaged circumstances.


title: Church of England

text: In parts of Liverpool, Manchester and Newcastle two-thirds of babies are born to poverty and have poorer life chances, also a life expectancy 15 years lower than babies born in the best-off fortunate communities.


title: Church of England

text: Many prominent people in the Church of England have spoken out against poverty and welfare cuts in the United Kingdom. Twenty-seven bishops are among 43 Christian leaders who signed a letter which urged David Cameron to make sure people have enough to eat.


title: Church of England

text: Thousands of UK citizens use food banks. The church's campaign to end hunger considers this "truly shocking" and called for a national day of fasting on 4 April 2014.


title: Church of England

text: , the Church of England estimated that it had approximately 26 million baptised members – about 47% of the English population. This number has remained consistent since 2001 and was cited again in 2013. According to a study published by the "Journal of Anglican Studies", distributed by the "Cambridge University Press", the Church of England continues to claim 26 million baptised members, while it also has approximately 1.7 million active baptised members. Due to its status as the established church, in general, anyone may be married, have their children baptised or their funeral in their local parish church, regardless of whether they are baptised or regular churchgoers.


title: Church of England

text: Between 1890 and 2001, churchgoing in the United Kingdom declined steadily. In the years 1968 to 1999, Anglican Sunday church attendances almost halved, from 3.5 percent of the population to 1.9 per cent. By 2014, Sunday church attendances had declined further to 1.4 per cent of the population. One study published in 2008 suggested that if current trends continued, Sunday attendances could fall to 350,000 in 2030 and 87,800 in 2050.


title: Church of England

text: In 2011, the Church of England published statistics showing 1.7 million people attended at least one of its services each month, a level maintained since the turn of the millennium; approximately one million participated each Sunday and three million took part in a Church of England service on Christmas Day or Christmas Eve. The church also claimed that 30% attended Sunday worship at least once a year; more than 40% attend a wedding in their local church and still more attend a funeral there. Nationally, in 2011 the Church of England baptised one child in ten. In 2015, the church's statistics showed that 2.6 million people attended a special Advent service, 2.4 million attended a Christmas service, 1.3 million attended an Easter service, and 980,000 attended service during an average week. In 2016, 2.6 million people attended a Christmas service, 1.2 million attended an Easter service, 1.1 million people attended a service in the Church of England each month, an average of 930,000 people attended a weekly service, an additional 180,000 attended a service for school each week, and an average of 740,000 people attended Sunday service. In 2017 Cathedral statistics showed that a total of 135,000 attended a Christmas service, an increase of 13% and overall Sunday attendance has risen from 7000 in 2000 to 18,000 in 2017 which had increased over the past 10 years. Also in 2017, approximately 1.14 million people were a part of the regular worshipping community, meaning those attending church once a month or more, 6.8 million were reached in the Advent campaign, and 2.68 million people attended a Christmas service, representing a slight increase.


title: Church of England

text: The Church of England has 18,000 active ordained clergy and 10,000 licensed lay ministers. In 2009, 491 people were recommended for ordination training, maintaining the level at the turn of the millennium, and 564 new clergy (266 women and 298 men) were ordained. More than half of those ordained (193 men and 116 women) were appointed to full-time paid ministry. In 2011, 504 new clergy were ordained, including 264 to paid ministry, and 349 lay readers were admitted to ministry; and the mode age-range of those recommended for ordination training had remained 40–49 since 1999.


title: Church of England

text: The British monarch has the constitutional title of Supreme Governor of the Church of England. The canon law of the Church of England states, "We acknowledge that the King's most excellent Majesty, acting according to the laws of the realm, is the highest power under God in this kingdom, and has supreme authority over all persons in all causes, as well ecclesiastical as civil." In practice this power is often exercised through Parliament and on the advice of the Prime Minister.


title: Church of England

text: The Church of Ireland and the Church in Wales separated from the Church of England in 1869 and 1920 respectively and are autonomous churches in the Anglican Communion; Scotland's national church, the Church of Scotland, is Presbyterian, but the Scottish Episcopal Church is part of the Anglican Communion.


title: Church of England

text: In addition to England, the jurisdiction of the Church of England extends to the Isle of Man, the Channel Islands and a few parishes in Flintshire, Monmouthshire and Powys in Wales which voted to remain with the Church of England rather than joining the Church in Wales. Expatriate congregations on the continent of Europe have become the Diocese of Gibraltar in Europe.


title: Church of England

text: All rectors and vicars are appointed by patrons, who may be private individuals, corporate bodies such as cathedrals, colleges or trusts, or by the bishop or directly by the Crown. No clergy can be instituted and inducted into a parish without swearing the Oath of Allegiance to His Majesty, and taking the Oath of Canonical Obedience "in all things lawful and honest" to the bishop. Usually they are instituted to the benefice by the bishop and then inducted by the archdeacon into the possession of the benefice property—church and parsonage. Curates (assistant clergy) are appointed by rectors and vicars, or if priests-in-charge by the bishop after consultation with the patron. Cathedral clergy (normally a dean and a varying number of residentiary canons who constitute the cathedral chapter) are appointed either by the Crown, the bishop, or by the dean and chapter themselves. Clergy officiate in a diocese either because they hold office as beneficed clergy or are licensed by the bishop when appointed, or simply with permission.


title: Church of England

text: The most senior bishop of the Church of England is the Archbishop of Canterbury, who is the metropolitan of the southern province of England, the Province of Canterbury. He has the status of Primate of All England. He is the focus of unity for the worldwide Anglican Communion of independent national or regional churches. Justin Welby has been Archbishop of Canterbury since the confirmation of his election on 4 February 2013.


title: Church of England

text: The second most senior bishop is the Archbishop of York, who is the metropolitan of the northern province of England, the Province of York. For historical reasons (relating to the time of York's control by the Danes) he is referred to as the Primate of England. Stephen Cottrell became Archbishop of York in 2020. The Bishop of London, the Bishop of Durham and the Bishop of Winchester are ranked in the next three positions, insofar as the holders of those sees automatically become members of the House of Lords.


title: Church of England

text: The process of appointing diocesan bishops is complex, due to historical reasons balancing hierarchy against democracy, and is handled by the Crown Nominations Committee which submits names to the Prime Minister (acting on behalf of the Crown) for consideration.


title: Church of England

text: The Church of England has a legislative body, General Synod. This can create two types of legislation, measures and canons. Measures have to be approved but cannot be amended by the British Parliament before receiving the Royal Assent and becoming part of the law of England. Although it is the established church in England only, its measures must be approved by both Houses of Parliament including the non-English members. Canons require Royal Licence and Royal Assent, but form the law of the church, rather than the law of the land.


title: Church of England

text: Another assembly is the Convocation of the English Clergy, which is older than the General Synod and its predecessor the Church Assembly. By the 1969 Synodical Government Measure almost all of the Convocations' functions were transferred to the General Synod. Additionally, there are Diocesan Synods and deanery synods, which are the governing bodies of the divisions of the Church.


title: Church of England

text: Of the 42 diocesan archbishops and bishops in the Church of England, 26 are permitted to sit in the House of Lords. The Archbishops of Canterbury and York automatically have seats, as do the bishops of London, Durham and Winchester. The remaining 21 seats are filled in order of seniority by date of consecration. It may take a diocesan bishop a number of years to reach the House of Lords, at which point he or she becomes a Lord Spiritual. The Bishop of Sodor and Man and the Bishop of Gibraltar in Europe are not eligible to sit in the House of Lords as their dioceses lie outside the United Kingdom.


title: Church of England

text: Although they are not part of England or the United Kingdom, the Church of England is also the established church in the Crown Dependencies of the Isle of Man, the Bailiwick of Jersey and the Bailiwick of Guernsey. The Isle of Man has its own diocese of Sodor and Man, and the Bishop of Sodor and Man is an ex officio member of the legislative council of the Tynwald on the island. Historically the Channel Islands have been under the authority of the Bishop of Winchester, but this authority has temporarily been delegated to the Bishop of Dover since 2015. In Jersey the Dean of Jersey is a non-voting member of the States of Jersey. In Guernsey the Church of England is the established church, although the Dean of Guernsey is not a member of the States of Guernsey.


title: Church of England

text: The 2020 report from the Independent Inquiry into Child Sexual Abuse concluded that the Church of England did not protect children from sexual abuse, and allowed abusers to hide. The Church spent more effort defending alleged abusers rather than supporting victims or protecting children and young people. Allegations were not taken seriously, and in some cases clergymen were ordained even with a history of child sex abuse. Bishop Peter Ball was convicted in October 2015 on several charges of indecent assault against young adult men.


title: Church of England

text: Although an established church, the Church of England does not receive any direct government support, except some funding for building work. Donations comprise its largest source of income, and it also relies heavily on the income from its various historic endowments. In 2005, the Church of England had estimated total outgoings of around £900 million.


title: Church of England

text: The Church of England runs "A Church Near You", an online directory of churches. A user-edited resource, it currently lists more than 16,000 churches and has 20,000 editors in 42 dioceses. The directory enables parishes to maintain accurate location, contact and event information, which is shared with other websites and mobile apps. The site allows the public to find their local worshipping community, and offers churches free resources, such as hymns, videos and social media graphics.


title: Church of England

text: The "Church Heritage Record" includes information on over 16,000 church buildings, including architectural history, archaeology, art history, and the surrounding natural environment. It can be searched by elements including church name, diocese, date of construction, footprint size, listing grade, and church type. The types of church identified include:


title: Neilia Hunter Biden

text: Neilia Hunter Biden (July 28, 1942 – December 18, 1972) was an American teacher and the first wife of Joe Biden, the 46th and current president of the United States. She died in a car crash in 1972 with her one-year-old daughter, Naomi. Her two sons, Beau and Hunter, were both critically injured, but survived the wreck.


title: Neilia Hunter Biden

text: Neilia Hunter was born on July 28, 1942, in Skaneateles, New York, to Louise (née Basel; 1915–1993) and Robert Hunter (1914–1991) who were Presbyterians. She attended Penn Hall, a secondary boarding school in Pennsylvania. She was active in the school's French club, hockey, swimming and student council. After secondary school, she attended Syracuse University and was a school teacher in the Syracuse City School District. She was an English teacher at the Bellevue Academy in Syracuse, New York. She was related to former Auburn city councilman Robert Hunter.


title: Neilia Hunter Biden

text: Neilia Hunter met Joe Biden in Nassau, Bahamas, while they were both on spring break. Shortly after, Biden moved to Syracuse and attended law school. The couple married on August 27, 1966. After Biden graduated from law school, the Bidens moved to Wilmington, Delaware, where Biden was on the New Castle County Council. The couple had three children: Joseph Robinette "Beau", Robert Hunter and Naomi Christina "Amy". While Biden campaigned to unseat U.S. Senator from Delaware J. Caleb Boggs, Neilia was described by "The News Journal" as the "brains" of his campaign.


title: Neilia Hunter Biden

text: On December 18, 1972, shortly after Joe became U.S. senator-elect, Neilia was driving with her three children west along rural Valley Road in Hockessin, Delaware. At the intersection with Delaware Route 7 (Limestone Road), she pulled out in front of a tractor-trailer truck traveling north along Route 7. Police determined that Neilia drove into the path of the tractor-trailer, possibly due to visibility issues. The truck driver, identified as Curtis C. Dunn, 33, of Avondale, Pa., escaped without any major injury. All four occupants were taken to Wilmington General Hospital, where Neilia and Naomi were pronounced dead on arrival, but Beau and Hunter both survived with multiple serious injuries. Two weeks after the crash, Joe was sworn into the Senate at the hospital, where Beau and Hunter were being treated. Neilia and Naomi were buried in St. Joseph on the Brandywine Cemetery in Greenville, Delaware.


title: Neilia Hunter Biden

text: In a commencement speech at Yale University in 2015, Joe Biden, then serving as Vice President of the United States in the administration led by Barack Obama, spoke of his wife, saying, "The incredible bond I have with my children is the gift I'm not sure I would have had, had I not been through what I went through [after the fatal crash]. But by focusing on my sons, I found my redemption."


title: Neilia Hunter Biden

text: A park in a suburban area of unincorporated New Castle County, Delaware, outside the city of Wilmington, Neilia Hunter Biden Park, is dedicated in her memory. Cayuga Community College in Auburn, New York, where Neilia's father ran the food service operation for many years, annually confers the Neilia Hunter Biden Award on two graduates, one for journalism and one for English literature. Among the early winners was William "Bill" Fulton, who later served as mayor of Ventura, California.


title: Coeliac disease

text: Coeliac disease (British English) or celiac disease (American English) is a long-term autoimmune disorder, primarily affecting the small intestine, where individuals develop intolerance to gluten, present in foods such as wheat, rye and barley. Classic symptoms include gastrointestinal problems such as chronic diarrhoea, abdominal distention, malabsorption, loss of appetite, and among children failure to grow normally. This often begins between six months and two years of age. Non-classic symptoms are more common, especially in people older than two years. There may be mild or absent gastrointestinal symptoms, a wide number of symptoms involving any part of the body, or no obvious symptoms. Coeliac disease was first described in childhood; however, it may develop at any age. It is associated with other autoimmune diseases, such as Type 1 diabetes mellitus and Hashimoto's thyroiditis, among others.


title: Coeliac disease

text: Coeliac disease is caused by a reaction to gluten, a group of various proteins found in wheat and in other grains such as barley and rye. Moderate quantities of oats, free of contamination with other gluten-containing grains, are usually tolerated. The occurrence of problems may depend on the variety of oat. It occurs more often in people who are genetically predisposed. Upon exposure to gluten, an abnormal immune response may lead to the production of several different autoantibodies that can affect a number of different organs. In the small bowel, this causes an inflammatory reaction and may produce shortening of the villi lining the small intestine (villous atrophy). This affects the absorption of nutrients, frequently leading to anaemia.


title: Coeliac disease

text: Diagnosis is typically made by a combination of blood antibody tests and intestinal biopsies, helped by specific genetic testing. Making the diagnosis is not always straightforward. About 10% of the time, the autoantibodies in the blood are negative, and many people have only minor intestinal changes with normal villi. People may have severe symptoms and they may be investigated for years before a diagnosis is achieved. Increasingly, the diagnosis is being made in people without symptoms, as a result of screening. Evidence regarding the effects of screening, however, is not sufficient to determine its usefulness. While the disease is caused by a permanent intolerance to gluten proteins, it is distinct from wheat allergy, which is much more rare.


title: Coeliac disease

text: The only known effective treatment is a strict lifelong gluten-free diet, which leads to recovery of the intestinal lining (mucous membrane), improves symptoms, and reduces the risk of developing complications in most people. If untreated, it may result in cancers such as intestinal lymphoma, and a slightly increased risk of early death. Rates vary between different regions of the world, from as few as 1 in 300 to as many as 1 in 40, with an average of between 1 in 100 and 1 in 170 people. It is estimated that 80% of cases remain undiagnosed, usually because of minimal or absent gastrointestinal complaints and lack of knowledge of symptoms and diagnostic criteria. Coeliac disease is slightly more common in women than in men.


title: Coeliac disease

text: The classic symptoms of untreated coeliac disease include pale, loose, or greasy stools (steatorrhoea), and weight loss or failure to gain weight. Other common symptoms may be subtle or primarily occur in organs other than the bowel itself. It is also possible to have coeliac disease without any of the classic symptoms at all. This has been shown to comprise at least 43% of presentations in children. Further, many adults with subtle disease may only present with fatigue, anaemia or low bone mass. Many undiagnosed individuals who consider themselves asymptomatic are in fact not, but rather have become accustomed to living in a state of chronically compromised health. Indeed, after starting a gluten-free diet and subsequent improvement becomes evident, such individuals are often able to retrospectively recall and recognise prior symptoms of their untreated disease that they had mistakenly ignored.


title: Coeliac disease

text: Diarrhoea that is characteristic of coeliac disease is chronic, sometimes pale, of large volume, and abnormally foul in odor. Abdominal pain, cramping, bloating with abdominal distension (thought to be the result of fermentative production of bowel gas), and mouth ulcers may be present. As the bowel becomes more damaged, a degree of lactose intolerance may develop. Frequently, the symptoms are ascribed to irritable bowel syndrome (IBS), only later to be recognised as coeliac disease. In populations of people with symptoms of IBS, a diagnosis of coeliac disease can be made in about 3.3% of cases, or four times more likely than in general. Screening them for coeliac disease is recommended by the National Institute for Health and Clinical Excellence (NICE), the British Society of Gastroenterology and the American College of Gastroenterology, but is of unclear benefit in North America.


title: Coeliac disease

text: Coeliac disease leads to an increased risk of both adenocarcinoma and lymphoma of the small bowel (enteropathy-associated T-cell lymphoma (EATL) or other non-Hodgkin lymphomas). This risk is also higher in first-degree relatives such as siblings, parents and children. Whether a gluten-free diet brings this risk back to baseline is not clear. Long-standing and untreated disease may lead to other complications, such as ulcerative jejunitis (ulcer formation of the small bowel) and stricturing (narrowing as a result of scarring with obstruction of the bowel).


title: Coeliac disease

text: The changes in the bowel reduce its ability to absorb nutrients, minerals, and the fat-soluble vitamins A, D, E, and K.


title: Coeliac disease

text: Coeliac disease has been linked with many conditions. In many cases, it is unclear whether the gluten-induced bowel disease is a causative factor or whether these conditions share a common predisposition.


title: Coeliac disease

text: Coeliac disease is associated with several other medical conditions, many of which are autoimmune disorders: diabetes mellitus type 1, hypothyroidism, primary biliary cholangitis, microscopic colitis, gluten ataxia, psoriasis, vitiligo, autoimmune hepatitis, primary sclerosing cholangitis, and more.


title: Coeliac disease

text: Coeliac disease is caused by an inflammatory reaction to gliadins and glutenins (gluten proteins) found in wheat and to similar proteins found in the crops of the tribe Triticeae (which includes other common grains such as barley and rye) and to the tribe Aveneae (oats). Wheat subspecies (such as spelt, durum, and Kamut) and wheat hybrids (such as triticale) also cause symptoms of coeliac disease.


title: Coeliac disease

text: A small number of people with coeliac disease react to oats. Oat toxicity in coeliac people depends on the oat cultivar consumed because the prolamin genes, protein amino acid sequences, and the immunoreactivities of toxic prolamins are different in different oat varieties. Also, oats are frequently cross-contaminated with other grains containing gluten. The term "pure oats" refers to oats uncontaminated with other gluten-containing cereals. The long-term effects of pure oat consumption are still unclear, and further studies identifying the cultivars used are needed before making final recommendations on their inclusion in a gluten-free diet. Coeliac people who choose to consume oats need a more rigorous lifelong follow-up, possibly including periodic intestinal biopsies.


title: Coeliac disease

text: Other cereals such as corn, millet, sorghum, teff, rice, and wild rice are safe for people with coeliac disease to consume, as well as noncereals such as amaranth, quinoa, and buckwheat. Noncereal carbohydrate-rich foods such as potatoes and bananas do not contain gluten and do not trigger symptoms.


title: Coeliac disease

text: There are various theories as to what determines whether a genetically susceptible individual will go on to develop coeliac disease. Major theories include surgery, pregnancy, infection and emotional stress.


title: Coeliac disease

text: The eating of gluten early in a baby's life does not appear to increase the risk of coeliac disease but later introduction after 6 months may increase it. There is uncertainty whether being breastfed reduces risk. Prolonging breastfeeding until the introduction of gluten-containing grains into the diet appears to be associated with a 50% reduced risk of developing coeliac disease in infancy; whether this persists into adulthood is not clear. These factors may just influence the timing of onset.


title: Coeliac disease

text: Almost all people (95%) with coeliac disease have either the variant HLA-DQ2 allele or (less commonly) the HLA-DQ8 allele. However, about 20–30% of people without coeliac disease have also inherited either of these alleles. This suggests that additional factors are needed for coeliac disease to develop; that is, the predisposing HLA risk allele is necessary but not sufficient to develop coeliac disease. Furthermore, around 5% of those people who do develop coeliac disease do not have typical HLA-DQ2 or HLA-DQ8 alleles (see below).


title: Coeliac disease

text: There are seven HLA-DQ variants (DQ2 and DQ4–DQ9). Over 95% of people with coeliac have the isoform of DQ2 or DQ8, which is inherited in families. The reason these genes produce an increase in the risk of coeliac disease is that the receptors formed by these genes bind to gliadin peptides more tightly than other forms of the antigen-presenting receptor. Therefore, these forms of the receptor are more likely to activate T lymphocytes and initiate the autoimmune process.


title: Coeliac disease

text: Most people with coeliac bear a two-gene HLA-DQ2 haplotype referred to as DQ2.5 haplotype. This haplotype is composed of two adjacent gene alleles, DQA1*0501 and DQB1*0201, which encode the two subunits, DQ α and DQ β. In most individuals, this DQ2.5 isoform is encoded by one of two chromosomes 6 inherited from parents (DQ2.5cis). Most coeliacs inherit only one copy of this DQ2.5 haplotype, while some inherit it from "both" parents; the latter are especially at risk for coeliac disease as well as being more susceptible to severe complications.


title: Coeliac disease

text: Some individuals inherit DQ2.5 from one parent and an additional portion of the haplotype (either DQB1*02 or DQA1*05) from the other parent, increasing risk. Less commonly, some individuals inherit the DQA1*05 allele from one parent and the DQB1*02 from the other parent (DQ2.5trans) (called a trans-haplotype association), and these individuals are at similar risk for coeliac disease as those with a single DQ2.5-bearing chromosome 6, but in this instance, the disease tends not to be familial. Among the 6% of European coeliacs that do not have DQ2.5 (cis or trans) or DQ8 (encoded by the haplotype DQA1*03:DQB1*0302), 4% have the DQ2.2 isoform, and the remaining 2% lack DQ2 or DQ8.


title: Coeliac disease

text: The frequency of these genes varies geographically. DQ2.5 has high frequency in peoples of North and Western Europe (Basque Country and Ireland with highest frequencies) and portions of Africa and is associated with disease in India, but it is not found along portions of the West Pacific rim. DQ8 has a wider global distribution than DQ2.5 and is particularly common in South and Central America; up to 90% of individuals in certain Amerindian populations carry DQ8 and thus may display the coeliac phenotype.


title: Coeliac disease

text: Other genetic factors have been repeatedly reported in coeliac disease; however, involvement in disease has variable geographic recognition. Only the HLA-DQ loci show a consistent involvement over the global population. Many of the loci detected have been found in association with other autoimmune diseases. One locus, the LPP or lipoma-preferred partner gene, is involved in the adhesion of extracellular matrix to the cell surface, and a minor variant (SNP=rs1464510) increases the risk of disease by approximately 30%. This gene strongly associates with coeliac disease (p < 10) in samples taken from a broad area of Europe and the US.


title: Coeliac disease

text: The prevalence of coeliac disease genotypes in the modern population is not completely understood. Given the characteristics of the disease and its apparent strong heritability, it would normally be expected that the genotypes would undergo negative selection and to be absent in societies where agriculture has been practised the longest (compare with a similar condition, lactose intolerance, which has been negatively selected so strongly that its prevalence went from ~100% in ancestral populations to less than 5% in some European countries). This expectation was first proposed by Simoons (1981). By now, however, it is apparent that this is not the case; on the contrary, there is evidence of "positive" selection in coeliac disease genotypes. It is suspected that some of them may have been beneficial by providing protection against bacterial infections.


title: Coeliac disease

text: The majority of the proteins in food responsible for the immune reaction in coeliac disease are the prolamins. These are storage proteins rich in proline ("prol-") and glutamine ("-amin") that dissolve in alcohols and are resistant to proteases and peptidases of the gut. Prolamins are found in cereal grains with different grains having different but related prolamins: wheat (gliadin), barley (hordein), rye (secalin) and oats (avenin). One region of α-gliadin stimulates membrane cells, enterocytes, of the intestine to allow larger molecules around the sealant between cells. Disruption of tight junctions allow peptides larger than three amino acids to enter the intestinal lining.


title: Coeliac disease

text: Membrane leaking permits peptides of gliadin that stimulate two levels of the immune response: the innate response, and the adaptive (T-helper cell-mediated) response. One protease-resistant peptide from α-gliadin contains a region that stimulates lymphocytes and results in the release of interleukin-15. This innate response to gliadin results in immune-system signalling that attracts inflammatory cells and increases the release of inflammatory chemicals. The strongest and most common adaptive response to gliadin is directed toward an α2-gliadin fragment of 33 amino acids in length.


title: Coeliac disease

text: The response to the 33mer occurs in most coeliacs who have a DQ2 isoform. This peptide, when altered by intestinal transglutaminase, has a high density of overlapping T-cell epitopes. This increases the likelihood that the DQ2 isoform will bind, and stay bound to, peptide when recognised by T-cells. Gliadin in wheat is the best-understood member of this family, but other prolamins exist, and hordein (from barley), secalin (from rye), and avenin (from oats) may contribute to coeliac disease. Avenin's toxicity in people with coeliac disease depends on the oat cultivar consumed, as prolamin genes, protein amino acid sequences, and the immunoreactivities of toxic prolamins vary among oat varieties.


title: Coeliac disease

text: Anti-transglutaminase antibodies to the enzyme tissue transglutaminase (tTG) are found in the blood of the majority of people with classic symptoms and complete villous atrophy, but only in 70% of the cases with partial villous atrophy and 30% of the cases with minor mucosal lesions. Tissue transglutaminase modifies gluten peptides into a form that may stimulate the immune system more effectively. These peptides are modified by tTG in two ways, deamidation or transamidation.


title: Coeliac disease

text: Deamidation is the reaction by which a glutamate residue is formed by cleavage of the epsilon-amino group of a glutamine side chain. Transamidation, which occurs three times more often than deamidation, is the cross-linking of a glutamine residue from the gliadin peptide to a lysine residue of tTg in a reaction that is catalysed by the transglutaminase. Crosslinking may occur either within or outside the active site of the enzyme. The latter case yields a permanently covalently linked complex between the gliadin and the tTg. This results in the formation of new epitopes believed to trigger the primary immune response by which the autoantibodies against tTg develop.


title: Coeliac disease

text: Stored biopsies from people with suspected coeliac disease have revealed that autoantibody deposits in the subclinical coeliacs are detected prior to clinical disease. These deposits are also found in people who present with other autoimmune diseases, anaemia, or malabsorption phenomena at a much increased rate over the normal population. Endomysial components of antibodies (EMA) to tTG are believed to be directed toward cell-surface transglutaminase, and these antibodies are still used in confirming a coeliac disease diagnosis. However, a 2006 study showed that EMA-negative people with coeliac tend to be older males with more severe abdominal symptoms and a lower frequency of "atypical" symptoms, including autoimmune disease. In this study, the anti-tTG antibody deposits did not correlate with the severity of villous destruction. These findings, coupled with recent work showing that gliadin has an innate response component, suggest that gliadin may be more responsible for the primary manifestations of coeliac disease, whereas tTG is a bigger factor in secondary effects such as allergic responses and secondary autoimmune diseases. In a large percentage of people with coeliac, the anti-tTG antibodies also recognise a rotavirus protein called VP7. These antibodies stimulate monocyte proliferation, and rotavirus infection might explain some early steps in the cascade of immune cell proliferation.


title: Coeliac disease

text: Other intestinal disorders may have biopsy that look like coeliac disease including lesions caused by Candida.


title: Coeliac disease

text: Alternative causes of this tissue damage have been proposed and involve the release of interleukin 15 and activation of the innate immune system by a shorter gluten peptide (p31–43/49). This would trigger killing of enterocytes by lymphocytes in the epithelium. The villous atrophy seen on biopsy may also be due to unrelated causes, such as tropical sprue, giardiasis and radiation enteritis. While positive serology and typical biopsy are highly suggestive of coeliac disease, lack of response to the diet may require these alternative diagnoses to be considered.


title: Coeliac disease

text: Diagnosis is often difficult and as of 2019, there continues to be a lack of awareness among physicians about the variability of presentations of coeliac disease and the diagnostic criteria, such that most cases are diagnosed with great delay. It can take up to 12 years to receive a diagnosis from the onset of symptoms and the majority of those affected in most countries never receive it.


title: Coeliac disease

text: Several tests can be used. The level of symptoms may determine the order of the tests, but "all" tests lose their usefulness if the person is already eating a gluten-free diet. Intestinal damage begins to heal within weeks of gluten being removed from the diet, and antibody levels decline over months. For those who have already started on a gluten-free diet, it may be necessary to perform a rechallenge with some gluten-containing food in one meal a day over 6 weeks before repeating the investigations.


title: Coeliac disease

text: Serological blood tests are the first-line investigation required to make a diagnosis of coeliac disease. Its sensitivity correlates with the degree of histological lesions. People who present with minor damage to the small intestine may have seronegative findings so many patients with coeliac disease often are missed. In patients with villous atrophy, anti-endomysial (EMA) antibodies of the immunoglobulin A (IgA) type can detect coeliac disease with a sensitivity and specificity of 90% and 99%, respectively. Serology for anti-transglutaminase antibodies (anti-tTG) was initially reported to have a higher sensitivity (99%) and specificity (>90%). However, it is now thought to have similar characteristics to anti-endomysial antibodies. Both anti-transglutaminase and anti-endomysial antibodies have high sensitivity to diagnose people with classic symptoms and complete villous atrophy, but they are only found in 30–89% of the cases with partial villous atrophy and in less than 50% of the people who have minor mucosal lesions (duodenal lymphocytosis) with normal villi.


title: Coeliac disease

text: Tissue transglutaminase modifies gluten peptides into a form that may stimulate the immune system more effectively. These peptides are modified by tTG in two ways, deamidation or transamidation. Modern anti-tTG assays rely on a human recombinant protein as an antigen. tTG testing should be done first as it is an easier test to perform. An equivocal result on tTG testing should be followed by anti-endomysial antibodies.


title: Coeliac disease

text: Guidelines recommend that a total serum IgA level is checked in parallel, as people with coeliac with IgA deficiency may be unable to produce the antibodies on which these tests depend ("false negative"). In those people, IgG antibodies against transglutaminase (IgG-tTG) may be diagnostic.


title: Coeliac disease

text: If all these antibodies are negative, then anti-DGP antibodies (antibodies against deamidated gliadin peptides) should be determined. IgG class anti-DGP antibodies may be useful in people with IgA deficiency. In children younger than two years, anti-DGP antibodies perform better than anti-endomysial and anti-transglutaminase antibodies tests.


title: Coeliac disease

text: Because of the major implications of a diagnosis of coeliac disease, professional guidelines recommend that a positive blood test is still followed by an endoscopy/gastroscopy and biopsy. A negative serology test may still be followed by a recommendation for endoscopy and duodenal biopsy if clinical suspicion remains high.


title: Coeliac disease

text: Historically three other antibodies were measured: anti-reticulin (ARA), anti-gliadin (AGA) and anti-endomysial (EMA) antibodies. ARA testing, however, is not accurate enough for routine diagnostic use. Serology may be unreliable in young children, with anti-gliadin performing somewhat better than other tests in children under five. Serology tests are based on indirect immunofluorescence (reticulin, gliadin and endomysium) or ELISA (gliadin or tissue transglutaminase, tTG).


title: Coeliac disease

text: Other antibodies such as anti–Saccharomyces cerevisiae antibodies occur in some people with coeliac disease but also occur in other autoimmune disorders and about 5% of those who donate blood.


title: Coeliac disease

text: Antibody testing may be combined with HLA testing if the diagnosis is unclear. TGA and EMA testing are the most sensitive serum antibody tests, but as a negative HLA-DQ type excludes the diagnosis of coeliac disease, testing also for HLA-DQ2 or DQ8 maximises sensitivity and negative predictive values. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) does not (as of 2015) recommend the use of HLA typing to rule out coeliac disease outside of a specialist setting, for example, in children who are not having a biopsy, or in patients who already have limited gluten ingestion and opt not to have a gluten challenge.


title: Coeliac disease

text: An upper endoscopy with biopsy of the duodenum (beyond the duodenal bulb) or jejunum is performed to obtain multiple samples (four to eight) from the duodenum. Not all areas may be equally affected; if biopsies are taken from healthy bowel tissue, the result would be a false negative. Even in the same bioptic fragment, different degrees of


title: Coeliac disease

text: Most people with coeliac disease have a small intestine that appears to be normal on endoscopy before the biopsies are examined. However, five findings have been associated with high specificity for coeliac disease: scalloping of the small bowel folds ("pictured"), paucity in the folds, a mosaic pattern to the mucosa (described as a "cracked-mud" appearance), prominence of the submucosa blood vessels, and a nodular pattern to the mucosa.


title: Coeliac disease

text: European guidelines suggest that in children and adolescents with symptoms compatible with coeliac disease, the diagnosis can be made without the need for intestinal biopsy if anti-tTG antibodies titres are very high (10 times the upper limit of normal).


title: Coeliac disease

text: Until the 1970s, biopsies were obtained using metal capsules attached to a suction device. The capsule was swallowed and allowed to pass into the small intestine. After x-ray verification of its position, suction was applied to collect part of the intestinal wall inside the capsule. Often-utilised capsule systems were the Watson capsule and the Crosby–Kugler capsule. This method has now been largely replaced by fibre-optic endoscopy, which carries a higher sensitivity and a lower frequency of errors.


title: Coeliac disease

text: Capsule endoscopy (CE) allows identification of typical mucosal changes observed in coeliac disease but has a lower sensitivity compared to regular endoscopy and histology. CE is therefore not the primary diagnostic tool for coeliac disease. However, CE can be used for diagnosing T-cell lymphoma, ulcerative jejunoileitis, and adenocarcinoma in refractory or complicated coeliac disease.


title: Coeliac disease

text: The classic pathology changes of coeliac disease in the small bowel are categorised by the "Marsh classification":


title: Coeliac disease

text: Marsh's classification, introduced in 1992, was subsequently modified in 1999 to six stages, where the previous stage 3 was split in three substages. Further studies demonstrated that this system was not always reliable and that the changes observed in coeliac disease could be described in one of three stages:


title: Coeliac disease

text: The changes classically improve or reverse after gluten is removed from the diet. However, most guidelines do not recommend a repeat biopsy unless there is no improvement in the symptoms on diet. In some cases, a deliberate gluten challenge, followed by a biopsy, may be conducted to confirm or refute the diagnosis. A normal biopsy and normal serology after challenge indicates the diagnosis may have been incorrect.


title: Coeliac disease

text: In untreated coeliac disease, villous atrophy is more common in children younger than three years, but in older children and adults, it is common to find minor intestinal lesions (duodenal lymphocytosis) with normal intestinal villi.


title: Coeliac disease

text: At the time of diagnosis, further investigations may be performed to identify complications, such as iron deficiency (by full blood count and iron studies), folic acid and vitamin B deficiency and hypocalcaemia (low calcium levels, often due to decreased vitamin D levels). Thyroid function tests may be requested during blood tests to identify hypothyroidism, which is more common in people with coeliac disease.


title: Coeliac disease

text: Osteopenia and osteoporosis, mildly and severely reduced bone mineral density, are often present in people with coeliac disease, and investigations to measure bone density may be performed at diagnosis, such as dual-energy X-ray absorptiometry (DXA) scanning, to identify the risk of fracture and need for bone protection medication.


title: Coeliac disease

text: Although blood antibody tests, biopsies, and genetic tests usually provide a clear diagnosis, occasionally the response to gluten withdrawal on a gluten-free diet is needed to support the diagnosis. Currently, gluten challenge is no longer required to confirm the diagnosis in patients with intestinal lesions compatible with coeliac disease and a positive response to a gluten-free diet. Nevertheless, in some cases, a gluten challenge with a subsequent biopsy may be useful to support the diagnosis, for example in people with a high suspicion for coeliac disease, without a biopsy confirmation, who have negative blood antibodies and are already on a gluten-free diet. Gluten challenge is discouraged before the age of 5 years and during pubertal growth. The alternative diagnosis of non-coeliac gluten sensitivity may be made where there is only symptomatic evidence of gluten sensitivity. Gastrointestinal and extraintestinal symptoms of people with non-coeliac gluten sensitivity can be similar to those of coeliac disease, and improve when gluten is removed from the diet, after coeliac disease and wheat allergy are reasonably excluded.


title: Coeliac disease

text: Up to 30% of people often continue having or redeveloping symptoms after starting a gluten-free diet. A careful interpretation of the symptomatic response is needed, as a lack of response in a person with coeliac disease may be due to continued ingestion of small amounts of gluten, either voluntary or inadvertent, or be due to other commonly associated conditions such as small intestinal bacterial overgrowth (SIBO), lactose intolerance, fructose, sucrose, and sorbitol malabsorption, exocrine pancreatic insufficiency, and microscopic colitis, among others. In untreated coeliac disease, these are often transient conditions derived from the intestinal damage. They normally revert or improve several months after starting a gluten-free diet, but may need temporary interventions such as supplementation with pancreatic enzymes, dietary restrictions of lactose, fructose, sucrose or sorbitol containing foods, or treatment with oral antibiotics in the case of associated bacterial overgrowth. In addition to gluten withdrawal, some people need to follow a low-FODMAPs diet or avoid consumption of commercial gluten-free products, which are usually rich in preservatives and additives (such as sulfites, glutamates, nitrates and benzoates) and might have a role in triggering functional gastrointestinal symptoms.


title: Coeliac disease

text: There is debate as to the benefits of screening. As of 2017, the United States Preventive Services Task Force found insufficient evidence to make a recommendation among those without symptoms. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) recommend testing for coeliac disease in first-degree relatives of those with the disease already confirmed, in people with persistent fatigue, abdominal or gastrointestinal symptoms, faltering growth, unexplained weight loss or iron, vitamin B12 or folate deficiency, severe mouth ulcers, and with diagnoses of type 1 diabetes, autoimmune thyroid disease, and with newly diagnosed chronic fatigue syndrome and irritable bowel syndrome. Dermatitis herpetiformis is included in other recommendations. The NICE also recommend offering serological testing for coeliac disease in people with metabolic bone disease (reduced bone mineral density or osteomalacia), unexplained neurological disorders (such as peripheral neuropathy and ataxia), fertility problems or recurrent miscarriage, persistently raised liver enzymes with unknown cause, dental enamel defects and with diagnose of Down syndrome or Turner syndrome.


title: Coeliac disease

text: Some evidence has found that early detection may decrease the risk of developing health complications, such as osteoporosis, anaemia, and certain types of cancer, neurological disorders, cardiovascular diseases, and reproductive problems. They thus recommend screening in people with certain health problems.


title: Coeliac disease

text: Serology has been proposed as a screening measure, because the presence of antibodies would detect some previously undiagnosed cases of coeliac disease and prevent its complications in those people. However, serologic tests have high sensitivity only in people with total villous atrophy and have a very low ability to detect cases with partial villous atrophy or minor intestinal lesions. Testing for coeliac disease may be offered to those with commonly associated conditions.


title: Coeliac disease

text: At present, the only effective treatment is a lifelong gluten-free diet. No medication exists that prevents damage or prevents the body from attacking the gut when gluten is present. Strict adherence to the diet helps the intestines heal, leading to resolution of all symptoms in most cases and, depending on how soon the diet is begun, can also eliminate the heightened risk of osteoporosis and intestinal cancer and in some cases sterility.


title: Coeliac disease

text: Dietitian input is generally requested to ensure the person is aware which foods contain gluten, which foods are safe, and how to have a balanced diet despite the limitations. In many countries, gluten-free products are available on prescription and may be reimbursed by health insurance plans. Gluten-free products are usually more expensive and harder to find than common gluten-containing foods. Since ready-made products often contain traces of gluten, some coeliacs may find it necessary to cook from scratch.


title: Coeliac disease

text: The term "gluten-free" is generally used to indicate a supposed harmless level of gluten rather than a complete absence. The exact level at which gluten is harmless is uncertain and controversial. A recent systematic review tentatively concluded that consumption of less than 10 mg of gluten per day is unlikely to cause histological abnormalities, although it noted that few reliable studies had been done. Regulation of the label "gluten-free" varies. In the European Union, the European Commission issued regulations in 2009 limiting the use of "gluten-free" labels for food products to those with less than 20 mg/kg of gluten, and "very low gluten" labels for those with less than 100 mg/kg. In the United States, the FDA issued regulations in 2013 limiting the use of "gluten-free" labels for food products to those with less than 20 ppm of gluten. The current international Codex Alimentarius standard allows for 20 ppm of gluten in so-called "gluten-free" foods.


title: Coeliac disease

text: Gluten-free diet improves healthcare-related quality of life, and strict adherence to the diet gives more benefit than incomplete adherence. Nevertheless, gluten-free diet doesn't completely normalise the quality of life.


title: Coeliac disease

text: Even though it is unclear if coeliac patients have a generally increased risk of infectious diseases, they should generally be encouraged to receive all common vaccines against vaccine preventable diseases (VPDs) as the general population. Moreover, some pathogens could be harmful to coeliac patients. According to the European Society for the Study of Celiac Disease (ESsCD), coeliac disease can be associated with hyposplenism or functional asplenia, which could result in impaired immunity to encapsulated bacteria, with an increased risk of such infections. For this reason, patients who are known to be hyposplenic should be administered at least the pneumococcal vaccine. However, the ESsCD states that it is not clear whether vaccination with the conjugated vaccine is preferable in this setting and whether additional vaccination against Haemophilus, meningococcus, and influenza should be considered if not previously given. However, Mårild et al. suggested considering additional vaccination against influenza because of an observed increased risk of hospital admission for this infection in celiac patients.


title: Coeliac disease

text: Between 0.3% and 10% of affected people have refractory disease, which means that they have persistent villous atrophy on a gluten-free diet despite the lack of gluten exposure for more than 12 months. Nevertheless, inadvertent exposure to gluten is the main cause of persistent villous atrophy, and must be ruled out before a diagnosis of refractory disease is made. People with poor basic education and understanding of gluten-free diet often believe that they are strictly following the diet, but are making regular errors. Also, a lack of symptoms is not a reliable indicator of intestinal recuperation.


title: Coeliac disease

text: If alternative causes of villous atrophy have been eliminated, steroids or immunosuppressants (such as azathioprine) may be considered in this scenario.