Population screening suggests that coeliac disease is much commoner than previously supposed. The prevalence of biopsy proved classic coeliac disease, with subtotal or total villous atrophy of the small bowel, ranges from 1:150 to 1:300 in adults in western Europe1,2 and many patients have mild symptoms. We noticed that few of our new patients with coeliac disease were obviously malnourished and conducted a prospective study of body mass index to investigate further.
Patients, methods, and results
Over a period of 26 months 50 adult patients (age 16-64 years) were diagnosed as having uncomplicated coeliac disease by WD in this district general hospital (catchment population around 160 000). Seven patients aged ⩾65 years who received a diagnosis during this period were excluded from the study. Patients had subtotal or total villous atrophy with lymphocytic infiltrate on duodenal biopsy. Biopsy had been prompted by one or more of strong clinical suspicion, serum IgA endomysial antibody (present in 48 patients), or visible endoscopic duodenal abnormalities during routine upper gastrointestinal endoscopy. Thirty five patients were women. Eighteen patients presented with diarrhoea; the primary indications for investigation in the others were anaemia without gastrointestinal symptoms (7 patients), nausea or reflux with characteristic changes seen in the duodenum during upper gastrointestinal endoscopy (7), dermatitis herpetiformis (5), abdominal pain (5), arthralgia (4), fatigue without anaemia (3), and osteomalacia (1). Weight (kg) and height (m) were measured during first attendance at the dietetic department for calculation of body mass index (weight(kg)/(height(m)2)). Patients were classified as underweight, normal, and overweight according to ranges defined by Garrow.3
Eleven patients were underweight (body mass index <20), 22 were within the normal range (20-24.9), and 17 were overweight (⩾25). Only one of the 15 men (7%) was underweight compared with 10 of the 35 women (29%); 10 men (67%) and 7 women (20%) were overweight. Three of the 17 overweight patients (two women, one man) had a body mass index of ⩾30. Clinical characteristics did not differ significantly between men and women, but men had a significantly higher body mass index (table). In all 50 patients a history of diarrhoea or anaemia was not associated with a body mass index <20.
Comment
Although age and sex specific reference ranges for body mass index are available, we applied the ranges given to patients aged from late teens to early 60s by Garrow3; these ranges form the basis of acceptable values in widespread use. By these criteria, men had a significantly higher mean body mass index than women, although the two sexes had no obvious clinical differences. Less than a third of women with untreated coeliac disease was underweight and a fifth was overweight, while two thirds of men were overweight. In contrast, Ciacci et al found that, although coeliac symptoms were more severe and of earlier onset in women, body mass index was not significantly different in men and women.4 A milder manifestation of the disease, irrespective of whether this is expressed as symptoms or as higher body mass index, would explain the low proportion of men in most clinical series.
Our study suggests that a minority of patients with villous atrophy fit the obviously malnourished stereotype and that the possibility of coeliac disease should not be discounted in overweight patients. Many patients with gluten sensitivity have less severe small bowel damage5 and may be even less likely to be underweight.
Table.
Body mass index and characteristics of men and women studied
| Women (n=35) | Men (n=15) | P value | |
|---|---|---|---|
| Mean age (95% CI) | 44 (16 to 64) | 42 (14 to 57) | 0.69* |
| Body mass index (95% CI) | 23.2 (21.7 to 24.6) | 26.0 (24.1 to 28.0) | 0.02* |
| No (%) of patients with anaemia | 8 (23) | 4 (27) | 1.00† |
| No (%) of patients with diarrhoea | 12 (34) | 6 (40) | 0.75† |
Mann-Whitney U test.
Fisher’s exact test.
Footnotes
Funding: None.
Conflict of interest: None.
References
- 1.Johnston SD, Watson RGP, McMillan SA, McMaster D, Evans A. Preliminary results from follow-up of a large-scale population survey of antibodies to gliadin, reticulin and endomysium. Acta Paediatr Suppl. 1996;412:61–41. doi: 10.1111/j.1651-2227.1996.tb14255.x. [DOI] [PubMed] [Google Scholar]
- 2.Grodzinsky E, Franzen L, Hed J, Strom M. High prevalence of celiac disease in healthy adults revealed by antigliadin antibodies. Ann Allergy. 1992;69:66–70. [PubMed] [Google Scholar]
- 3.Garrow JS. Treatment of obesity. Lancet. 1992;340:409–413. doi: 10.1016/0140-6736(92)91481-m. [DOI] [PubMed] [Google Scholar]
- 4.Ciacci C, Cirillo M, Sollazzo R, Savino G, Sabbatini F, Mazzacca G. Gender and clinical presentation in adult coeliac disease. Scand J Gastroenterol. 1995;30:1077–1081. doi: 10.3109/00365529509101610. [DOI] [PubMed] [Google Scholar]
- 5.Marsh MN. Gluten, major histocompatibility complex, and the small intestine. A molecular and immunobiologic approach to the spectrum of gluten sensitivity (“celiac sprue”) Gastroenterology. 1992;102:330–354. [PubMed] [Google Scholar]