No Contradiction: Overweight With Celiac

Marcia Frellick

November 01, 2019

SAN ANTONIO — One of the misconceptions Ciarán Kelly, MD, hears most is that people who are overweight can't have celiac disease.

They certainly can, and a substantial proportion do, said Kelly, professor of medicine and cofounder of the Celiac Research Program at Harvard Medical School, and director of gastroenterology training at Beth Israel Deaconess Medical Center in Boston.

In a longitudinal study he and his team conducted, 33% of 679 the participants had a high body mass index (BMI) at diagnosis (21% were overweight and 12% were obese). And of those with a normal or high BMI at diagnosis, 22% gained more than 2 BMI points over an average follow-up of 39.5 months.

Weight-maintenance counseling should be part of the physician's guidance for a patient on a gluten-free diet, he emphasized.

He debunked some prominent myths about celiac disease as he delivered the American Journal of Gastroenterology lecture here at the American College of Gastroenterology 2019 Annual Scientific Meeting.

Another misunderstanding is that celiac is concentrated in Europe or in those of European descent. But research has shown that its prevalence is fairly similar on all continents, aside from Antarctica, Kelly said.

Table. Global Prevalence of Celiac Disease
Continent Seroprevalence, %
Africa 1.1
Asia 1.8
Australia 1.4
Europe 1.3
North America 1.4
South America 1.3
Source: Clin Gastroenterol Hepatol. 2018;16:823-836.e2.

Gluten-Free for No Good Reason

Kelly also busted the myth that most people on a gluten-free diet are following this regimen because they have celiac disease.

"That's actually not the case," he said, citing a survey of people in the United States. "The prevalence of celiac is about 0.7% — perhaps a little higher — and there are about 2 million people on the gluten-free diet in the United States. But if you look at the overlap, it's small. There are only 300,000 people who have celiac and are on the gluten-free-diet. Most people on the gluten-free diet do not have celiac, and most people with celiac disease are not on the gluten-free diet."

Kelly said the disconnect seems to be mainly from people who do not have celiac but who are under the misconception that the diet will help them lose weight or who have a vague notion that gluten is bad and they should generally avoid it.

"I think there's a little bit of work to be done there," he said, pointing to a study that describes the patient burden surrounding the only current treatment for celiac — the gluten-free diet.

He said he was surprised to learn that celiac was perceived to have a greater burden than hypertension, gastroesophageal reflux disease, insulin-dependent diabetes, congestive heart failure, and inflammatory bowel disease.

The only condition in the study that had a higher burden was end-stage renal failure requiring hemodialysis. When you think about it, that makes sense, said Kelly.

"Patients must treat their disease themselves — at every meal, every snack, every day, in every location, no matter where they are — and they don't get to take a break," he said.

Hope for a Cure

Kelly explained there has been a surge in clinical and preclinical programs targeting celiac disease.

He said the treatments that most interest him are those intended to restore or induce tolerance to gluten, which he calls the "Holy Grail" of celiac disease.

One drug to watch, he said, is CNP-101/TAK 101 (Takeda and Cour Pharmaceuticals), which just yielded phase 2a data in October. The proof-of-concept study of the potential first-in-class investigational drug met its primary end point in findings announced at the United European Gastroenterology Week in Barcelona, Spain.

Drugs in development to induce tolerance to gluten are encouraging, said James Morris, MD, a gastroenterologist and associate professor of medicine at Louisiana State University in Shreveport.

It's important to counsel patients on how restrictive a gluten-free diet must be, he told Medscape Medical News.

"Emphasizing the need to completely avoid gluten should be a primary goal," he said, adding that help from a dietitian is essential, particularly for patients with type 1 diabetes.

Morris said he was struck by findings of exposure to gluten in Kelly's presentation. A 2013 study showed that 70% of 269 people on the gluten-free diet reported intentional or inadvertent gluten consumption.

"With 70% of patients with celiac disease reporting gluten exposure, these patients are at risk for small bowel injury and symptoms and increasing the risk for small bowel lymphoma," he said.

American College of Gastroenterology (ACG) 2019 Annual Scientific Meeting. Presented October 29, 2019.

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