Obesity in Celiac Disease

Obesity in Celiac Disease.

Widodo Judarwanto. Picky Eaters and Grow Up Clinic, Jakarta Indonesia

Celiac, a genetic autoimmune disease,  has long been associated with a medical picture of patients that look underweight, and malnourished. However, recent studies are finding that obesity and  a high BMI (Body Mass Index) may also be prominent in celiac patients. New studies were conducted  to determine BMI changes after initiation of  a gluten-free diet, and they offer clues to the importance of eating gluten free after being diagnosed with celiac disease.

Obesity in pediatric celiac disease.

Celiac disease (CD) is a T cell-mediated chronic autoimmune enteropathy occurring in genetically susceptible individuals, and manifested by a permanent intolerance to gluten-containing products. CD commonly presents in children as failure to thrive and malabsorption or after screening high-risk groups such as people with diabetes. Almost half of adult patients with CD have a body mass index (BMI) >25 at diagnosis. Classic symptoms like diarrhea are less common in obese patients. Few children have been reported with CD and obesity. Because many children with newly diagnosed CD are identified by screening high-risk groups, obesity is more common than previously suspected. The aim of the study was to estimate the prevalence of obesity at diagnosis in children with CD and to describe the clinical characteristics of this group.

This is a retrospective study of 143 patients with CD diagnosed between 1986 and 2003 at Children’s Hospital of Wisconsin. Data collected included patient’s age, sex, ethnicity, presenting signs and symptoms, BMI, celiac antibody titers, small-intestinal biopsy results, and follow-up weight 1 year after initiating a gluten-free diet (GFD).

Seven of the 143 (5%) patients had BMI >95th percentile. The most common presenting symptoms among obese patients were abdominal pain, diabetes, and diarrhea. Symptoms improved in all of the patients on a GFD. BMI decreased in 4 (50%), increased in 2 (25%), and was not available in 1 patient at 1 year after starting on GFD. Obesity is more common in children with CD than previously recognized. In the appropriate clinical setting, CD must be considered even in obese children.

There are few data on pediatric celiac disease in the United States. The presentation of celiac disease among children with a normal and an elevated body mass index (BMI) for age, and to study their BMI changes following a gluten-free diet (GFD).

One hundred forty-two children (age 13 months-19 years) with biopsy-proven celiac disease, contained in a registry of patients studied at our center from 2000 to 2008, had follow-up growth data available. Patients’ height, weight, and BMI were converted to z scores for age and grouped by BMI as underweight, normal, and overweight. Compliance was confirmed using results of serological assays, and data of noncompliant patients were analyzed separately. Data were analyzed during the observation period and were expressed as change in height, weight, and BMI z score per month of dietary treatment. Nearly 19% of patients had an elevated BMI at diagnosis (12.6% overweight, 6% obese) and 74.5% presented with a normal BMI. The mean duration of follow-up was 35.6 months. Seventy-five percent of patients with an elevated BMI at diagnosis decreased their BMI z scores significantly after adherence to a GFD, normalizing it in 44% of cases. Of patients with a normal BMI at diagnosis, weight z scores increased significantly after treatment, and 13% became overweight. Both normal weight and overweight frequently occur in North American children presenting with celiac disease. A GFD may have a beneficial effect upon the BMI of overweight and obese children with celiac disease.

It is well established that a minority of celiac patients present with “classic” symptoms due to malabsorption. However, few studies have focussed on the distribution of body mass index (BMI) in celiac populations and its relationship to clinical characteristics, or on its response to treatment. Dickey W reported that reviewed BMI measurements and other clinical and pathological characteristics from a database of 371 celiac patients diagnosed over a 10-yr period and seen by a single gastroenterologist. To assess response to gluten exclusion, we compared BMI at diagnosis and after 2 yr treatment in patients with serological support for dietary compliance.

There was a significant association between low BMI and female gender, history of diarrhea, reduced hemoglobin concentration, reduced bone mineral density (BMD), osteoporosis, and higher grades (subtotal/total) of villous atrophy. Of patients compliant with a gluten-free diet, 81% had gained weight after 2 yr, including 82% of initially overweight patients. Few celiac patients are underweight at diagnosis and a large minority is overweight; these are less likely to present with classical features of diarrhea and reduced hemoglobin. Failed or delayed diagnosis of celiac disease may reflect lack of awareness of this large subgroup. The increase in weight of already overweight patients after dietary gluten exclusion is a potential cause of morbidity, and the gluten-free diet as conventionally prescribed needs to be modified accordingly.

Other studied the BMI of 369 patients proven through biopsy to have celiac disease, spanning from 1981 to 2007. Men and women were evaluated separately for the sake of this study and the test patients were classified as “classical” meaning diarrhea prominent, or “atypical” meaning they had no diarrhea at the time of celiac diagnosis. Atypical patients were further divided into groups of  ‘Anemia present’ and ‘no anemia present’ at time of diagnosis. Body Mass Index was then categorized into four groups based on the criteria of the World Health Organization.

The BMI of all test celiac patients were compared to the general United States population. Using the regression model, the study found that there are obvious predictors for low BMI; patients classified as   “classical”  celiac, female, and with severe villous atrophy,  were all revealed as predictors for low BMI. These findings further exemplify that the most dramatic changes in BMI rates were in underweight females with celiac disease.  Celiac females had a considerably lower mean BMI than the general population, thereby indicating an important association between females with celiac disease and low BMI. In fact, celiac females that tested with a normal or low BMI were also found to have  higher rates of critical villous atrophy than those with a higher BMI. However,  more males with celiac were found to be overweight compared to the general population.

After initiating  a gluten free diet, most BMI changes were shown to be directly associated with an initial baseline appearance of  “classical” symptoms. While on a gluten free diet, over 50% of the overweight and obese  patients lost weight, and of the group who  initially had a low BMI, 42.4% attained a normal weight. Thereby concluding that treatment of a gluten free diet after celiac diagnosis provides advantageouschanges in BMI results. Further evidence of the importance in early diagnosis and prompt treatment of celiac disease.

Of course it is critical to note that, all the patients utilized for this study were monitored closely by a  care center dedicated to celiac disease, and continually followed by an experienced dietician with expert knowledge of celiac disease.  And, while you may not be able to afford the kind of dietician these patients  were provided with, it is always very important to be under the care of a doctor or clinic dedicated to treating celiac disease, as well as to be receiving  experienced dietary counseling when transitioning to a gluten free diet.

More than 20 years of serological approach to diagnosis of celiac disease (CD) has deeply changed the classical clinical presentation of the disease, and some reports indicate that CD and obesity can coexist in both childhood and adolescence. Valletta E et al reported that reviewed clinical records of 149 children with CD followed in our institution between 1991 and 2007, considering weight, height and body mass index (BMI), both at diagnosis and after at least 12 months of gluten-free diet (GFD). In all, 11% of patients had BMI z-score >+1 and 3% were obese at presentation. In our population, there was a significant  increase in BMI z-score after GFD and the percentage of overweight subjects almost doubled. These study suggest the need for a careful follow-up of nutritional status after diagnosis of CD, especially addressing those who are already overweight at presentation.

References:

  • J Pediatr Gastroenterol Nutr. 2010 Sep;51(3):295-7. Obesity in pediatric celiac disease. Venkatasubramani N, Telega G, Werlin SL.
  • Reilly NR, Aguilar K, Hassid BG, Cheng J, Defelice AR, Kazlow P, Bhagat G, Green PH.  Celiac disease in normal-weight and overweight children: clinical features and growth outcomes following a gluten-free diet. J Pediatr Gastroenterol Nutr. 2011 Nov;53(5):528-31.
  • Dickey W, Kearney N. Overweight in celiac disease: prevalence, clinical characteristics, and effect of a gluten-free diet.  Am J Gastroenterol. 2006 Oct;101(10):2356-9.
  • Valletta E, Fornaro M, Cipolli M, Conte S, Bissolo F, Danchielli C. Celiac disease and obesity: need for nutritional follow-up after diagnosis. Eur J Clin Nutr. 2010 Nov;64(11):1371-2.

Pediatric Articles Dr Widodo Judarwanto (pediatrician)

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