Benefits of a Gluten-free Diet for Asymptomatic Patients With Serologic Markers of Celiac Disease

Kalle Kurppa; Aku Paavola; Pekka Collin; Harri Sievänen; Kaija Laurila; Heini Huhtala; Päivi Saavalainen; Markku Mäki; Katri Kaukinen

Disclosures

Gastroenterology. 2014;147(3):610-617. 

In This Article

Abstract and Introduction

Abstract

Background & Aims We investigated whether screen-detected and apparently asymptomatic adults with endomysial antibodies (EmA) benefit from a gluten-free diet (GFD).

Methods We performed a prospective trial of 3031 individuals at risk for celiac disease based on screens for EmA. Of 148 seropositive individuals, 40 fulfilled inclusion criteria and were assigned randomly to groups placed on a GFD or gluten-containing diets. We evaluated ratios of small-bowel mucosal villous height:crypt depth, serology and laboratory test results, gastrointestinal symptom scores, physiologic well-being, perception of health by a visual analog scale, bone mineral density, and body composition at baseline and after 1 year. Thereafter, the group on the gluten-containing diet started a GFD and was evaluated a third time; subjects in the GFD group remained on this diet.

Results After 1 year on the GFD, the mean mucosal villous height:crypt depth values increased (P < .001), levels of celiac-associated antibodies decreased (P < .003), and gastrointestinal symptoms improved to a greater extent than in patients on gluten-containing diets (P = .003). The GFD group also had reduced indigestion (P = .006), reflux (P = .05), and anxiety (P = .025), and better health, based on the visual analog scale (P = .017), than the gluten-containing diet group. Only social function scores improved more in the gluten-containing diet group than in the GFD group (P = .031). There were no differences between groups in laboratory test results, bone mineral density, or body composition. Most measured parameters improved when patients in the gluten-containing diet group were placed on GFDs. No subjects considered their experience to be negative and most expected to remain on GFDs.

Conclusions GFDs benefit asymptomatic EmA-positive patients. The results support active screening of patients at risk for celiac disease. Clinicaltrials.gov no: NCT01116505.

Introduction

Celiac disease is a lifelong disorder caused by ingested cereal-derived gluten in predisposed individuals.[1] Screening studies have shown the prevalence in the European and North American population to be 1%–2%, and to be increasing over time.[2–5] Serum transglutaminase 2 (TG2ab) and endomysial antibodies (EmA) are used widely in first-line case-finding for further endoscopic studies, but demonstration of small-bowel mucosal damage still is required for the diagnosis in adults.[1,6] Since celiac disease is common but difficult to detect because of the heterogeneous clinical picture, a wide-scale screening of the whole population with noninvasive serologic tests frequently has been suggested.[7,8] However, the only current treatment of the condition, a lifelong strict gluten-free diet (GFD), is restrictive and difficult to maintain and thus the positive effects of the screening are not straightforward.[9] There have been some previous studies exploring the benefits of a GFD in screening-detected celiac disease patients, but the results have been somewhat inconsistent, in particular with asymptomatic subjects;[10–14] hitherto randomized studies have been lacking. A further problem is that wide-scale screening frequently detects seropositive subjects who are apparently asymptomatic and evince only mild enteropathy or even normal small-bowel mucosa; it has been unclear whether all such individuals in fact suffer from a true gluten-induced clinical disease.[15]

The aim of this randomized trial was to establish whether asymptomatic adults with positive EmA benefit from a serologic screening and subsequent GFD. Because celiac disease is known to run in families, recruitment was executed by screening at-risk relatives of celiac patients. By reason of its high specificity, EmA was selected as the inclusion criterion.[1]

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