Obesity is a significant health problem in the United States and many other parts of the world. It is estimated that just under 36% of Americans are overweight, and 3% to 7% are what is known as morbidly obese. Celiac disease is also common, affecting 1% of the population. It would seem unlikely that people with celiac disease would be obese, but researchers are discovering that the two problems can exist together, and it is very important for doctors and affected individuals to recognize this fact.
Overweight and obesity are actually defined by a person’s BMI, or Body Mass Index. It is calculated by multiplying a person’s weight in pounds by 703, and dividing that by the person’s height in inches, squared. This automatically converts pounds to kilograms and inches to meters. The formula looks like this:
Weight in pounds x 703 / (Height in inches)2
A BMI of 40 (kg/m2) or more, or a BMI equal to or greater than 35 along with another related condition is considered morbid obesity. Morbid obesity contributes to a variety of health problems, from heart disease and diabetes to osteoarthritis. For this reason, surgery to help these patients lose weight, called bariatric surgery, has become more commonplace. It is frequently covered by insurance.
Some surgeries simply involve making the available space for food in the stomach smaller. Stomach banding is the most common procedure. There are also procedures in which part of the intestine is actually bypassed, the most common called a Roux-en-Y. Because food doesn’t get to the area where it can be absorbed, this surgery causes a loss of nutrients. The procedure can lead to even greater weight loss along with a host of problems related to the lack of absorbed key minerals and vitamins.
Children and adults with classical celiac disease have malabsorption already. But people with “silent” CD may not have obvious evidence of malabsorption, even though their intestines are damaged. They can suffer from complications such as anemia or osteoporosis.
The assumption that morbidly obese people could not have celiac disease was shown to be untrue in a recent study. During the pre-operative evaluation of approximately 400 morbidly obese adults, 5 were discovered to have what appeared to be celiac disease on endoscopy. This was later confirmed by biopsy results and blood tests. Four of the 5 had no symptoms of CD.
Because of the possibility of malabsorption already occurring in these patients, they were only offered procedures to make the area of the stomach smaller (restrictive surgery). Three of them had surgery and did well afterwards, losing weight on a gluten-free diet. Two are still being evaluated.
A rare case report from the 1980’s involved a patient with undiagnosed celiac disease who had an intestinal bypass procedure and subsequently died. While this is unlikely to happen now, it underscores the importance of screening for CD before weight loss surgery. After surgery, patients with celiac disease still need to be on a gluten-free diet to prevent complications of CD.
The authors of this study strongly suggest evaluating all morbidly obese patients for CD with endoscopy, biopsy and blood tests before a surgical procedure is chosen.
The most important thing to learn from this is that a person who is overweight or obese can still have celiac disease.