American Journal of Gastroenterology ISSN 0002-9270


C 2006 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2006.00750.x
Published by Blackwell Publishing

Overweight in Celiac Disease: Prevalence, Clinical

Characteristics, and Effect of a Gluten-Free Diet
William Dickey, M.D., Ph.D., F.A.C.G., and Natalie Kearney, B.Sc.
Departments of Gastroenterology and Dietetics, Altnagelvin Hospital, Londonderry, Northern Ireland, United
Kingdom

BACKGROUND: 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.
METHODS: We 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.
RESULTS: Mean BMI was 24.6 kg/m2 (range 16.3–43.5). Seventeen patients (5%) were underweight (BMI
<18.5), 211 (57%) were normal, and 143 (39%) were overweight (BMI ≥25), including 48 (13% of
all patients) in the obese range (BMI ≥30.0). 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.
CONCLUSIONS: 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.
(Am J Gastroenterol 2006;101:2356–2359)

INTRODUCTION in the west of Northern Ireland. Celiac disease is diagnosed

Celiac disease is a genetically mediated autoimmune prox-
imal enteropathy triggered by the ingestion of gluten, with
a prevalence of 0.5–1% in European and American popu-
lations (1). Its clinical manifestations are extremely diverse
and the “classic” celiac presentation, due to malabsorption, of
weight loss and diarrhea is increasingly the exception rather
than the rule (2). In a 1998 paper (3), we reported that only a
minority of newly diagnosed celiacs fitted the stereotype of
underweight, with a high proportion having a body mass in-
dex (BMI) of 25 or over. In this study, we have reviewed BMI
in celiac patients diagnosed over a 10-yr period in order to
obtain an updated prevalence of overweight in celiac disease,
to assess associated clinical characteristics, and to determine
the impact of gluten exclusion on BMI.
SUBJECTS AND METHODS
Our department provides gastroenterology services for a
mixed urban and rural population of approximately 270,000
by duodenal biopsy after initial investigation at our clinics or
referral from family practitioners or other hospital clinicians.
We reviewed a database of all patients newly diagnosed
as celiac over the 10-yr period November 1995 through
October 2005. BMI, defined as body weight (kg)/height (m2 ),
was recorded before gluten exclusion was prescribed under
the supervision of hospital and community dietitians. The
World Health Organisation (WHO) defines BMI <18.5 as
underweight, 18.5–24.9 as normal, and 25 or over as over-
weight (and 30 or over as obese) (4). As these criteria are
only applicable above the age of 20, younger patients were
excluded. Also, for this study, only patients with a Marsh
III lesion (5) (villous atrophy with intraepithelial lympho-
cytosis) were included. Additional data recorded for each
patient and used in analyses included age, gender, clini-
cal presentation, hemoglobin concentration, corrected (ion-
ized) serum calcium levels, celiac serological testing (IgA
endomysial antibody was measured using the same indi-
rect immunofluorescence technique throughout the study pe-
riod), and grade of villous atrophy (partial, subtotal, or total).

2356
 Overweight in Celiac Disease 2357

Table 1. Clinical Characteristics of All 371 Celiac Patients

BMI (kg/m2 ) <20 20–24.9 ≥25 p
Total number of patients (% of total) 43 (12) 185 (50) 143 (39)
Demographics
Female patients (%) 34 (79) 137 (74) 86 (60) 0.0030
Mean age, yr (range) 51 (21–90) 48 (20–85) 46 (20–80) 0.2279
Presentation
Patients reporting diarrhea (%) 20 (47) 61 (33) 39 (27) 0.0237
Mean hemoglobin concentration, g/dL (range) 11.8 (5.6–15.7) 12.2 (6.0–16.7) 12.6 (6.4–17.4) 0.0270
Mean serum ionized calcium, mmol/L (range) 2.27 (1.62–2.50) 2.30 (2.03–2.61) 2.31 (1.91–2.60) 0.2925
Serology, histology
EmA +ve patients (%) 35 (81) 158 (85) 114 (80) 0.6192
Patients with subtotal/total villous atrophy (%) 40 (93) 134 (72) 96 (67) 0.0028

Commencing in 2000, every newly diagnosed patient had a
dual-energy x-ray absorptiometry (DEXA) scan performed
within 4 wk of diagnosis. Bone mineral density (BMD) val-
ues were recorded for the lumbar spine (L2–4) and neck of
left femur, and expressed in absolute figures (g/cm2 ) and as
the number of standard deviations above or below the mean
BMD of young adults of the same sex. The WHO defines
osteoporosis as a T score < –2.5 (6).
To assess the effect of gluten exclusion on BMI, we se-
lected those patients, initially EmA seropositive, who had
disappearance of serum EmA within 12 months and who
maintained their seronegative status as an objective indicator
of dietary compliance (7). BMI after 2 yr gluten exclusion
was compared with that recorded at diagnosis.
Statistical analysis was performed using a statistical soft-
ware package (InStat, GraphPad Software, San Diego, CA).
Discrete variables were analyzed using the χ 2 test for trend
and continuous variables by the Mann-Whitney U test for
two categories, Kruskal-Wallis one-way analysis for three,
and the Wilcoxon signed-ranks test for paired variables. In
all cases p < 0.05 was taken as significant.
RESULTS
Over the study period, 371 patients were diagnosed as celiac
on the basis of duodenal villous atrophy, of which 257 (69%)
were female. Apart from five completely asymptomatic in-
dividuals identified by voluntary family screening, all had
one or more symptoms leading to the diagnosis. Diarrhea
was reported as a symptom by 120 (32%). The mean BMI
was 24.6 (95% confidence interval 24.1–25.1); median 23.7,
range 16.3–43.5. Seventeen patients (5%) were underweight,
211 (57%) were normal, and 143 (39%) were overweight ac-
cording to WHO criteria; in this last category, 48 (13% of
the total population studied) were obese with BMI ≥ 30.0.
By gender, 57 (50%) of 114 men and 86 (33%) women were
overweight, and 17 (15%) men and 31 (12%) women were
obese.
There was a trend towards higher BMI in later years that
did not reach statistical significance: mean BMI of patients
diagnosed from 1995 through 2000 was 24.0 (range 17.0–
40.9), compared with 24.9 (16.3–43.5) from 2001 through
2005 (p = 0.076).
As patients meeting the WHO criterion for underweight
numbered only 17, we used a modified categorization for
analysis of clinical characteristics: BMI <20, 20–24.9, and
25 or over.
There was a significant association between low BMI and
female gender, diarrhea, reduced hemoglobin concentration,
and higher grades (subtotal/total) of villous atrophy (Table 1).
The DEXA scan data of 265 patients who underwent scan-
ning at diagnosis are shown in Table 2. There was a significant
upward trend in BMD of both lumbar spine and neck of fe-
mur with increasing BMI. Osteoporosis was present in only
6% of overweight patients in spine and/or femur, compared
with 48% in patients with BMI <20.
A total of 188 patients meeting the stated criteria for com-
pliance had BMI data recorded after 2-yr gluten exclusion.
Mean BMI rose from 24.4 to 25.9. On gluten exclusion,
weight gain was recorded in 152 (81%), no change in 8 (4%),
and loss in 28 (15%). Table 3 shows the pattern of weight
change for each category. After treatment, 82% of initially
overweight patients had gained further weight and the pro-
portion of patients in the overweight category increased from

Table 2. Bone Density Data of 265 Patients Who Had DEXA Scanning at Diagnosis
BMI <20 20–24.9 ≥25 p
Total number of patients (% of total) 25 (9) 133 (50) 107 (40)
Mean BMD lumbar spine- g/cm2 (range) 0.926 (0.548–1.293) 1.075 (0.500–1.553) 1.169 (0.681–1.613) <0.0001
Mean BMD femoral neck- g/cm2 (range) 0.768(0.465–1.017) 0.907 (0.467–1.234) 0.966 (0.622–1.465) <0.0001
Patients with osteoporosis lumbar spine (%) 11 (44) 29 (22) 3 (3) <0.0001
Patients with osteoporosis neck femur (%) 9 (36) 17 (13) 3 (3) <0.0001
Patients with osteoporosis at either site (%) 12 (48) 33 (25) 6 (6) <0.0001
2358 Dickey and Kearney
Table 3. Effect of 2-yr Gluten Exclusion on BMI Category in 188 Patients
Initial BMI Category No. of Patients Patients Increasing Weight (%)
<20 27
20–24.9 94
≥25 67
26% (67 patients) to 51% (95). Eleven patients in the over-
weight and two in the normal BMI categories had BMIs in
the obese category after 2 yr, while only two patients left the
obese group.
Records did not allow retrospective analysis of dietary ad-
vice given regarding calorie restriction or of caloric intake of
patients before and after gluten exclusion.
DISCUSSION
This study included a large number of patients recruited from
a defined catchment area over a 10-yr period who underwent a
standard protocol of initial investigation and follow-up under
the supervision of a single gastroenterologist. As a result,
we believe that the data included for analysis are valid and
reliable. To our knowledge, no similar study of BMI and
related clinical characteristics has been published to date.
In a small survey of 50 newly diagnosed patients that we
published in 1996 (3), 22% had BMI <20, 44% in the range
20–24.9, and 34% ≥25. The current, larger study of patients
diagnosed over a decade confirms that a minority (only 5%)
of celiacs meet the WHO criteria for underweight at diagno-
sis and that many (39%: 33% of women, 50% of men) are
overweight, with 13% (12% of women, 15% of men) in the
obese category. These figures are similar to those of the gen-
eral population of Northern Ireland: public health surveys of
adults indicate that 27–58% of women and 47–58% of men
are overweight and that 11–21% of women and 13–16% of
men are obese (8). There has been little focused interest in
BMI in celiac disease, though various studies that included
BMI values as part of their patient demographics indicate
that celiac patients overweight at diagnosis are commonly
observed. In a study comparing Finnish celiacs detected by
screening with those identified through symptoms (9), mean
BMIs were 26.6 and 24.6, respectively, with 19% and 14%
obese. West et al. (10) reported that of 2,649 English celiacs
with recorded BMI, 6% were underweight, 66% were normal,
and 28% were overweight (including 5% obese) by WHO cri-
teria. A recent North American study (11) found that 28% of
male celiacs (33% of females) had BMI less than 20, 41%
(32%) 20–24.9, and 31% (26%) ≥25.0 (with 15% of men and
12% of women in the obese category).
Our celiac patients with BMI <20 had significantly lower
hemoglobin concentrations and were more likely to report
diarrhea as a symptom, in keeping with a malabsorption pre-
sentation less evident in their overweight counterparts. This
correlated with a higher prevalence of severe villous atrophy
BMI Category After 2 yr
<20 20–24.9 ≥25
25 (93) 7 (26%) 18 (67%) 2 (7%)
72 (77) 1 (1%) 64 (68%) 29 (31%)
55 (82) 3 (4%) 64 (96%)
(subtotal or total) in the low BMI group. There was no as-
sociation between EmA positivity and BMI, in keeping with
observation by us and others (12, 13) that the clinical char-
acteristics of EmA negative patients do not differ from those
who are EmA positive. The variation in BMI may reflect
variations in the percentage of small bowel involved by the
enteropathy. It is also possible that some untreated celiacs
modify their diets through trial and error to avoid symptoms
associated with the ingestion of gluten: this could also ex-
plain the reduced prevalence of diarrhea among overweight
patients. While weight gain in underweight patients is ex-
pected and desired following dietary gluten exclusion, this
was also observed in patients with normal BMI, of whom
almost a third had entered the overweight category after 2
yr, and in overweight patients. Studies of response to diet
suggest that gluten exclusion is associated with a significant
increase in body fat stores, though these have been conducted
on patients with BMI significantly lower than healthy controls
(14, 15).
There was a striking relationship between BMI and bone
density measurements. Only 6% of overweight patients had
osteoporosis in either lumbar spine or neck of femur, com-
pared with 48% of patients with BMI <20. Previous studies
have reported a high prevalence of osteoporosis among celiac
patients (16, 17) prompting a call for routine DEXA scanning
in all at diagnosis (18) and this has been our practice since
2000. However, reduced BMD does not appear to translate
into a large increase in fracture risk (19). Furthermore, a re-
cent English study of 43 patients found osteoporosis of the
hip and spine in only 7% and 14%, respectively, and ques-
tioned whether DEXA scanning is needed for all patients
(20). Their small study found a significant correlation be-
tween BMI and BMD at the hip, but not at the spine. Though
analysis of other factors predictive of osteoporosis was be-
yond the remit of this study, BMI should be considered as
one important consideration in selecting celiac patients for
DEXA scanning.
In conclusion, few celiac patients meet the underweight
stereotype and almost half are overweight. Failure to recog-
nize this undoubtedly contributes to failed and delayed diag-
nosis (21, 22), particularly as other “classic” symptoms like
diarrhea are less common in heavier patients. A high pro-
portion of overweight patients will gain further weight with
gluten exclusion. This represents a potential cause of morbid-
ity that may counteract any benefits of diagnosis, particularly
in patients identified by screening (1). Dietetic advisors need
to recognize this and modify advice depending on BMI at
diagnosis.

STUDY HIGHLIGHTS
What Is Current Knowledge
r A minority of celiac patients present with classic symp-
toms due to malabsorption.
r Newly diagnosed celiac disease patients with body
mass index (BMI) in the overweight range have been
described, but there have been no recent studies of the
prevalence of this problem.
What Is New Here
r Of 371 celiac patients, only 4% were underweight while
39% were overweight.
r Overweight patients are less likely to be female, report
diarrhea, or have high grade villous atrophy, and have
higher hemoglobin concentrations and bone mineral
densities.
r A majority of overweight patients gain further weight
with gluten exclusion.
r To avoid delay or failure of diagnosis, physicians need
to be aware that celiac patients often have high BMI,
with milder clinical presentations.
r Dietary advice needs tailoring to facilitate weight loss
and prevent further gain in overweight patients.
Reprint requests and correspondence: Dr. W. Dickey, Altnagelvin
Hospital, Londonderry BT47 6SB, Northern Ireland, UK.
Received January 12, 2006; accepted April 27, 2006.
REFERENCES
1. Mearin ML, Ivarsson A, Dickey W. Coeliac disease: Is it
time for mass screening? Best Pract Res Clin Gastroenterol
2005;19:441–52.
2. Green PH. The many faces of celiac disease: Clinical pre-
sentation of celiac disease in the adult population. Gastroen-
terology 2005;128(suppl 1):S74–8.
3. Dickey W, Bodkin S. Prospective study of body mass index
in coeliac disease. BMJ 1998:317;1290.
4. World Health Organization. Report of a WHO consul-
tation on obesity. Obesity: Preventing and managing the
global epidemic. Geneva: World Health Organization,
1998.
5. UEGW 2001 Working group on coeliac disease. When
is a coeliac a coeliac? Eur J Gastroenterol Hepatol
2001;13:1123–8.
6. World Health Organization. Assessment of fracture risk and
its application to screening for postmenopausal osteoporo-
sis. Geneva: World Health Organization, 1994.
Overweight in Celiac Disease 2359
7. Bürgin-Wolff A, Dahlbom I, Hadziselimovic F, et al. Anti-
bodies against human tissue transglutaminase and endomy-
sium in diagnosing and monitoring coeliac disease. Scand J
Gastroenterol 2002;37:685–91.
8. Clinical Resource Efficiency Support Team. Guidelines for
the management of obesity in secondary care. Available at
www.crestni.org.uk/publications/obesity management html.
9. Viljamaa M, Collin P, Huhtala H, et al. Is coeliac disease
screening in risk groups justified? A fourteen-year follow-
up with special focus on compliance and quality of life.
Aliment Pharmacol Ther 2005;22:317–24.
10. West J, Logan RFA, Card TR, et al. Risk of vascular disease
in adults with diagnosed coeliac disease: A population-based
study. Aliment Pharmacol Ther 2004;20:73–9.
11. Murray JA, Watson T, Clearman B, et al. Effect of a gluten-
free diet on gastrointestinal symptoms in celiac disease. Am
J Clin Nutr 2004;79:669–73.
12. Abrams JA, Diamond B, Rotterdam H, et al. Seronegative
celiac disease: Increased prevalence with lesser degrees of
villous atrophy. Dig Dis Sci 2004;49:546–50.
13. Dickey W, Hughes DF, McMillan SA. Reliance on serum
endomysial antibody testing underestimates the true preva-
lence of coeliac disease by one fifth. Scand J Gastroenterol
2000;35:181–3.
14. Capristo E, Addolorato G, Mingrone G, et al. Changes
in body composition, substrate oxidation, and resting
metabolic rate in adult celiac disease patients after a 1-y
gluten-free diet treatment. Am J Clin Nutr 2000;72:76–81.
15. Smecuol E, Gonzalez D, Mautalen C, et al. Longitudinal
study on the effect of treatment on body composition and
anthropometry of celiac disease patients. Am J Gastrenterol
1997;92:639–43.
16. Mazure R, Vasquez H, Gonzalez D, et al. Bone mineral
affection in asymptomatic adult patients with celiac disease.
Am J Gastroenterol 1994;89:2130–4.
17. Valdimarsson T, Toss G, Ross I, et al. Bone mineral density
in coeliac disease. Scand J Gastroenterol 1994;29:457–61.
18. Scott EM, Gaywood I, Scott BB. Guidelines for osteoporo-
sis in coeliac disease and inflammatory bowel disease. Gut
2000;46(suppl 1):1–8.
19. West J, Logan RFA, Card TR, et al. Fracture risk in peo-
ple with celiac disease: A population-based cohort study.
Gastroenterology 2003;125:429–36.
20. Lewis NR, Scott BB. Should patients with coeliac disease
have their bone mineral density measured? Eur J Gastroen-
terol Hepatol 2005;17:1065–70.
21. Dickey W, McConnell JB. How many hospital visits does it
take before celiac sprue is diagnosed? J Clin Gastroenterol
1996;23:21–3.
22. Furse RM, Mee AS. Atypical presentation of coeliac disease.
BMJ 2005;330:773–4.
CONFLICT OF INTEREST
Guarantor of the article: William Dickey
Financial support:. None
Potential competing interests: William Dickey is an unpaid
medical advisor to Coeliac UK.