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Obesity in Coeliac Disease
Introduction
Coeliac disease is an autoimmune disease believed to affect 1% of the population (Bingley et al
2004; BSG 2010). As a result of the ingestion of Gluten (found in Wheat, Rye and Barley) the villi
in the small bowel becomes atrophied and this is diagnosed by biopsy at endoscopy (BSG 2010).
Diagnosis rates are considerably lower than this with only 10-15% of patients actually diagnosed
with the disease (NICE 2009), possibly due to the insidious nature of the wide variety of
symptoms which a person can experience with the disease. Some patients experience no
symptoms and others have some or all of those listed in table 1.







diarrhoea, excessive wind, and/or
constipation
persistent or unexplained
gastrointestinal symptoms, such as
nausea and vomiting
recurrent stomach pain, cramping
or bloating
any combination of iron, vitamin
B12 or folic acid deficiency
tiredness and/or headaches
weight loss (but not in all cases)
mouth ulcers









hair loss (alopecia)
skin rash (dermatitis herpetiformis
(DH))
tooth enamel problems
osteoporosis
depression
infertility
repeated miscarriages
joint and/or bone pain
neurological (nerve) problems such
as ataxia (poor muscle coordination) and neuropathy
(numbness and tingling in the
hands and feet). (Coeliac UK
2009a)
Table 1: Symptoms of Coeliac disease
Obesity is acknowledged as an increasing health problem for the population as a whole (DoH
2012). In 2010 62.8% of the adult population had a Body Mass Index (BMI) of between 25 and
29. 0, in addition 26.1% had a BMI of greater than 30 (DoH 2012). There is little official data
about obesity in celiac disease, though some recent studies are beginning to emerge, such as
Tucker et al (2012) who identifies that more patients are being diagnosed who are actually
obese, Cheng et al (2009) who identifies that the traditionally accepted presentation of
malnutrition and weight loss are rarely seen now, and Ukkola et al (2012) as well as identifying
that most patients are overweight at diagnosis raised the concern that there is potential for
weight gain on a gluten free diet.
Coeliac disease and dietary restrictions
In Coeliac disease the damage to the villi is usually rectified when the disease is appropriately
treated and treatment is the life long abstinence of gluten from the diet (BSG 2010 ). Should the
patient be exposed to gluten, even only a little, the damage to the villi in the small bowel recurs
(Prasenjit Das et al 2012) and mal-absorption results to a greater or lesser degree. It can take
about 6 months for the villi to recover (Cummins et al 2001), but some patients have persistant
villi damage despite strict adherence to their gluten free diet (Tuire et al 2012) and in this time not
only is the patient not absorbing their nutriments properly, but they have the potential for poor
absorption of calcium and Iron Deficiency Anaemia (IDA). Gluten occurs in Wheat, Rye and
Barley and some patients react to a similar, but different enzyme found in oats called avenin
(Coeliac UK 2009b). The issue of Oats exclusion from a gluten free diet is controversial (Tuire et
al 2012) and if the patient does want to eat oats, then a trial of Gluten free oats is usually
undertaken to ensure that they are not also reacting to the avenin (Coeliac UK 2009b). For the
patient a Gluten free diet means that they must eat specially modified foods which many find
unattractive, unappealing and different in taste and texture. However despite their dislike of the
alternative foods available, evidence suggests that concordance to the diet is better when these
alternative products are prescribed (BSG 2010) and there is much debate about the affordability
for the NHS to provide such foods in the current financial constraints (BBC 2012). The BSG
(2010) do recommend gluten free food is prescribed and in their latest guidelines allow for each
service user to have between 12 and 18 units of food each month on prescription (MIMS 2011),
see table 2.
Age group
Recommended number of units
1 - 3 years
10
4 - 6 years
11
7 - 10 years
13
11 - 14 years
15
15 - 18 years
18
Male 19 - 59 years
18
Male 60 - 74 years
16
Male 75 + years
14
Female 19 - 74 years
14
Female 75 + years
12
Breast feeding
Add 4 units
3rd trimester pregnancy
Add 1 unit
Table 2: Prescribing guide for gluten free foods (Coeliac UK 2011)
It should be noted that this is not a generous allowance. Each unit is one loaf of bread packet of
pasta or pack of flour and these are considerable smaller than the equivalent available in the
supermarket (Singh & Wheelan 2011). Whilst gluten free foods are available in many
supermarkets, and the choice is ever increasing, these are at least 4 times the cost of the gluten
containing foods and this makes them unaffordable for many people with coeliac disease. As the
pressure is placed on General Practitioners (GP’s) to reduce their spending local patients have
reported that the types of foods they are permitted by GP’s on prescription is being restricted
(BBC 2012) and in some case the amount also reduced from that recommended. However many
of the foods available on prescription are not available in supermarkets and the costs of foods
available in supermarkets is reported as being at least twice the cost than for non gluten free
alternatives (Coeliac UK 2012). However by medicalising the diet there is a risk that patients are
unable to choose the foods that they eat and thus are denied the opportunity for a full variation in
their food intake.
One of the reasons, local patients say, they experience restrictions in the prescription foods
available is the issue of obesity, and as a consequence some surgery’s have initiated bans on the
prescription of biscuits and cakes and even pastry flour and pizza bases. Whilst for most of the
population food choices are not restricted by medical staff there is much concern reported by for
example, Coeliac UK in their patient forums that some people with celiac disease feel aggrieved
that the same element of choice is not afforded to them
Coeliac disease and obesity
An audit was undertaken in a local NHS Trust in 2012 by the Coeliac support team looking at the
incidence of obesity in patients with celiac disease. They investigated 20% of the clinic (65
patients). Each patient was active in the clinic, had been diagnosed for more than 12 months and
was shown in the clinic documentation to be adhering to a Gluten free diet. This was to ensure
that the effects of malnutrition associated with the disease were most likely to be overcome. Their
weight and BMI at diagnosis was identified and compared with the last weight and BMI recorded
in the clinic notes which was at least one year after diagnosis. The results showed a lower,
though not significantly lower, rate of obesity that the general population as cited by the DoH
(2012), (see table 1). Some patient’s weight had increased and there seemed to be a trend for
those who had a normal or higher than normal BMI at diagnosis to increase slightly making some
obese in the BMI scale, that said the distribution was still do not deviate from the statistics cited
by the DoH for the general population.
This suggests that whilst some patients do gain weight on their diet, there is no evidence of
greater rates of obesity in this patient group than the rest of the population. Clearly this is a small
local study and so the findings need to be considered with caution. There is an opportunity for a
more detailed study using patients from multiple centres, and if this evidence is consistent across
this patient group then any policy to limit prescription availability on the basis of obesity needs to
be carefully and individually applied.
Weight at diagnosis
Increased weight
after diagnosis
Decreased weight
after diagnosis
Weight remained
stable after
diagnosis
Table 3: Audit results
BMI below
18.5
4
3
BMI 18.525
35
19
BMI 2530
21
8
BMI greater
than 30
5
3
Total
0
6
0
1
7
1
7
16
1
25
65
33
So why does the patients weight increase when on a gluten free diet? Firstly once stable on the
diet patients are better absorbing their food nutrients. This will inevitably lead to weight gain if the
amount of food eaten is not reduced as well. Many patients complain of this weight gain in their
annual review and some people with celiac disease have re-introduced gluten into their diet as a
way to manage their weight. This is not ever to be advised as discussed earlier. In the local clinic
most people with celiac disease manage this initial weight gain by portion control, and if followed
sensibly using the eat well plate (Food standards Agency 2011) they find that this is a healthy diet
and it is possible to control the weight.
A second reason for the weight gain, though unproven may well relate to how food is prepared.
Since meat and vegetables are naturally gluten free, people who are able to cook can eat very
healthily. However there is evidence to suggest that cooking is a skill which is not prevalent in
society (Daily Mail On-Line 2010) hence a perceived need for cooking lessons on the core skills
taught in primary schools (House of Commons Children, Schools and Families Committee 2009).
For clients who cannot or do not cook, there is a need to buy in ready meals or eat out. If they did
not have the need for a gluten free diet, snacks such as a sandwich could be eaten, but for those
with celiac disease, whilst a gluten free sandwich is possible, for many the taste in not acceptable
so choices are limited unless they can afford to eat out. There are ready meals available that are
gluten free, but like many of the convenience foods these also contain more fats and sugars. It is
not possible to tell if patients with celiac disease who are unable to cook would also increase in
weight if they did not have celiac disease, but It is likely that they would since there has been
considerable concerns about the links between fast foods and ready meals in relation to obesity
(Howard et al 2012).
The third reason for weight gain is because people with celiac disease also risk poor calcium
absorption (Larussa et al 2012), they are advised to eat a daily recommended intake of Calcuim
of 1500mgs (BSG 2010) in their diets. This can be achieved in many ways including eating baked
beans, fortified cereals, Dried apricots, sesame seeds and tins of fish with bones such at
sardines, tinned salmon and pilchards. Many patients prefer to increase their cheese, milk, yogurt
intake. Whilst there are low fat options for each of these foods, patients report these as not
tasting as nice and many prefer to eat the full fat options, despite there being more calcium in the
low fat alternatives.
None of this discussion however considers the psychological effects on patients of having their
weight constantly checked and their diet regulated by health care professionals, however
necessary that may be. Patients often struggle to find suitable alternatives to gluten particularly if
they do not cook and need to eat out. Work canteens reportedly rarely offer a gluten free
alternative and why would they given the few numbers of people who might purchase such items,
and where there is a gluten free alternative, such as in some well known coffee shops,
practicalities are that this is often a single choice. Eating out is another issue for these patients.
Many plan a meal out well in advance selecting restaurants where they can be assured of a
suitable menu choice by previous visits, or recommendation (Coeliac UK 2009c). There is always
the fear of some contamination in the kitchen, for example from chips cooked with the battered
fish. Whilst such contamination may only involve a small intake of gluten and this is an
autoimmune disease rather than an allergy with associated anaphylactic reactions, some patients
will experience very unpleasant symptoms such as diarrhoea bloating and painful flatus and
others will experience no symptoms but none the less the villi will be damaged.
Patients who suffer from Coeliac Disease, regardless of their BMI, need to be fully assessed by a
qualified dietitian (BSG 2010). This not only allows for advice to be given in relation to accidental
exposure of gluten, and where it is identified non-compliance of a gluten free diet, but also
ensures that patients are given quality advice about nutritional intake tailored to the individual.
Regular reviews allow for ongoing weight management issues to be identified and advice and
support given as needed.
Conclusion
In conclusion there is considerable concern about obesity across all groups in British society, and
patients with celiac disease share these concerns both as individuals and as the health care
professionals involved in their care. Whilst there is no evidence that this group of patients has any
higher rate of obesity than any other patient group, and the local study suggests that there is no
increased rate in the local population, it is clear that there is the potential for weight gain following
diagnosis and health care professionals need to be advising patients how to manage this
potential risk as part of their ongoing care and support.
References
BBC (2012) NHS 'paid £17 for gluten-free pizza base' 24th May 2012 Newsnight by
By Liz MacKean . [online] available: http://www.bbc.co.uk/news/health-17755552 accessed
10/8/12.
BBC (2012) Oxfordshire coeliacs could lose NHS food prescriptions. Oxford News. [online]
available http://www.bbc.co.uk/news/uk-england-oxfordshire-17309712 accessed 10/8/12.
BSG (2010) BSG guidance on Coeliac Disease. [online] available
http://www.bsg.org.uk/sections/small-bowel-nutrition-articles/bsg-guidance-on-coeliac-disease2010.html accessed 10/08/12
Bingley P. J, Williams A. J. K, Norcross A, Unsworth J, Lock R. J, Ness A. R, Jones R. W. (2004).
Avon Longitudinal Study of Parents and Children Study Team. BMJ. 328: 322-3.
Cheng J, Brar P S, Lee A R & Green P H R. (2009) Body Mass Index in Celiac Disease Benificial
Effect of a Gluten Free Diet. J Gastrointestin Liver Dis. (March 2012 Vol. 21 No 1, 11-15) [online]
available
http://scholar.google.co.uk/scholar?q=coeliac+disease+presentation+mal+nutrition+and+underwe
ight&hl=en&as_sdt=0%2C5. accessed 28/01/2013
Ciclitira P. J, Dewar D. H, McLaughlin S. D, Sanders D. S. (2010) The Management of Adults
with Coeliac Disease. British Society of Gastroenterology [online] available:
http://www.bsg.org.uk/sections/small-bowel-nutrition-articles/bsg-guidance-on-coeliac-disease2010.html
Accessed 3/8/12
Coeliac UK (2009a) Symptoms of celiac disease. [online] available:
http://www.coeliac.org.uk/healthcare-professionals/diagnosis-of-coeliac-disease/symptoms-ofcoeliac-disease accessed 3/8/12
Coeliac UK (2009b) Oats in the Gluten free diet. [online] available:
http://www.coeliac.org.uk/healthcare-professionals/diet-information/oats-in-the-gluten-free-diet
Accessed 10/8/12
Coeliac UK (2009c) Eating out and Travel [online] available http://www.coeliac.org.uk/gluten-freediet-lifestyle/eating-out-and-travel accessed 28/03/2013.
Coeliac UK (2010) Cost project update. Coeliac UK December 2010 [online] available
http://www.coeliac.org.uk/node/167597. accessed 28/03/2013.
Coeliac UK (2011) Gluten Free Foods a Revised Prescribing Guide 2011 [online] available
http://www.coeliac.org.uk/revisedprescribingguideline2011 accessed 28/03/2103
Cummins A., Thompson F. M, Butler R. N, Cassidy J. C, Gillis D, Lorenzetti M, Southcott E. K
and Wilson P. C (2001)
Improvement in intestinal permeability precedes morphometric recovery of the small intestine in
coeliac disease. Clinical Science 100, (379-386), [online] available:
http://www.clinsci.org/cs/100/0379/cs1000379.htm accessed 3/8/12
Daily Mail On-Line (2010) Traditional cooking skills are dying out, with modern mothers unable to
make gravy, custard or shortcrust pastry. Daily Mail On-Line 22nd February 2010. [online]
available: http://www.dailymail.co.uk/femail/food/article-1252216/Traditional-cookingskills-dying-modern-mothers-unable-make-gravy-custard-shortcrust-pastry.html
Accessed 10/8/12.
DoH (2012) Facts and figures on obesity. London: DoH [online] available:
http://www.dh.gov.uk/health/2012/04/obesityfacts/
Accessed 3/8/12.
Food Standards Agency (2011) Eat well plate London: DoH [online] available
www.food.gov.uk/multimedia/pdfs/publication/eatwellplate0210.pdf. accessed 10/08/2012
House of Commons Children, Schools and Families Committee (2009) National Curriculum
Fourth Report of Session 2008–09 Volume I HC 344-I Incorporating HC 651-i to -viii, Session
2007–08 Published on 2 April 2009 by authority of the House of Commons London: The
Stationery Office Limited [online] available: www.parliament.the-stationeryoffice.co.uk/pa/cm200809/cmselect/... Accessed 10/8/12.
Howard s, Adams J & White M (2012) Nutritional content of supermarket ready meals and recipes
by television chefs in the United Kingdom: cross sectional study. BMJ. 2012; 345: e7607.
Published online 2012 December 17. doi: 10.1136/bmj.e7607 Accessed 28/03/2013.
Larussa T, Suraci E, Nazionale I, Abenavoli L, Imeneo M, and Luzza F (2012) Bone
Mineralization in Celiac Disease Gastroenterology Research and Practice
Volume 2012 (2012), Article ID 198025 [online] available doi:10.1155/2012/198025
Accessed 10/8/12
MIMS (2012) Gluten-free Foods: A prescribing guide [online] available:
http://www.mims.co.uk/news/882161/Gluten-Free-Foods-Prescribing-Guide/
Accessed 10/8/12
NICE (2009) Coeliac disease
Recognition and assessment of coeliac disease
NICE clinical guideline 86
Developed by the Centre for Clinical Practice at NICE. [online] available: www.nice.org.uk/CG86
Accessed 3/8/12
Prasenjit Das. S, Sreenivas, V, Siddhartha, Gupta D, Panda, S. K and Makharia. G. K (2012)
Effect of Addition of Short Course of Prednisolone to Gluten-Free Diet on Mucosal Epithelial Cell
Regeneration and Apoptosis in Celiac Disease: A Pilot Randomized Control Trial [online]
available http://www.springerlink.com/content/e1v4578482670136/ Accessed 3/8/12
Singh, J. and Whelan, K. (2011), Limited availability and higher cost of gluten-free foods. Journal
of Human Nutrition and Dietetics, 24: 479–486. [online] available: doi:10.1111/j.1365277X.2011.01160.x accessed 3/8/12
Tuire I, Lähdeaho M-L, Salmi T, Haimila K, Partanen J, Saavalainen P, Huhtala H, Mäki M, Pekka
C and Kaukinen K. (2012) Persistent Duodenal Intraepithelial Lymphocytosis Despite a LongTerm Strict Gluten-Free Diet in Celiac Disease. The American Journal of Gastroenterology ,
(24 July 2012) [online] available:| doi:10.1038/ajg.2012.220 accessed 10/8/12
Tucker E, Rostami K, Prabhakaran S & Dulaimi D A. (2012) Patients with Coeliac Disease Are
Increasingly Overweight or Obese on Presentation. J Gastrointestin Liver Dis. (March 2012 Vol.
21 No 1, 11-15) [online] available
http://scholar.google.co.uk/scholar?hl=en&q=patients+with+coeliac+disease+are+increasingly+ov
erweight+or+obese+on+presentation&as_sdt=1%2C5&as_sdtp=. Accessed 28/03/13
Ukkola A, Maki M, Kurppa K, Collin P, Huhtala H, Kekkonen L & Kaukinen K. (2012) Changes in
Body mass index on a Gliten free diet in Coeliac Disease: A nationwide study. Eur J Intern Med
(2012) [online] availsable doi:10.1016/j.ejim.2011.12.012. Accessed 28/03/2013