Nutritional status of newly diagnosed celiac disease patients before and after the institution of a celiac disease diet-association with the ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Nutritional status of newly diagnosed celiac disease patients
before and after the institution of a celiac disease diet—
association with the grade of mucosal villous atrophy1–3
Tarja A Kemppainen, Veli-Matti Kosma, Esko K Janatuinen, Risto J Julkunen, Pekka H Pikkarainen, and Matti I Uusitupa
ABSTRACT No systematic studies have been carried out on SUBJECTS AND METHODS
the association of nutritional status with the severity of mucosal
villous atrophy in newly diagnosed celiac disease patients. We Patients
examined the nutritional status of 40 adult patients with newly All newly diagnosed celiac disease patients from Kuopio Uni-
diagnosed celiac disease classified according to the grade of vil- versity Hospital were recruited for an intervention study (6, 12)
lous atrophy: partial, subtotal, and total. Nutritional status was from November 1988 to December 1990. The study population
determined by food records as well as by anthropometric and bio- consisted of 40 newly diagnosed celiac disease patients
chemical measurements. Anthropometric results did not differ (Table 1). They had suffered from abdominal symptoms for
among the three atrophy groups, but serum ferritin and erythrocyte 1–57 y, but the diagnosis of celiac disease was made at the out-
folate were lower in patients with total villous atrophy than in the set of the study. The diagnosis was based on the presence of par-
other groups. Most of the abnormal biochemical values were nor- tial, subtotal, or total villous atrophy of the duodenal mucosa
malized during 1 y of a gluten-free diet; villous atrophy healed before the introduction of a gluten-free diet (13). One newly
concomitantly. To conclude, patients with total mucosal villous diagnosed celiac disease patient was excluded from the analysis
atrophy at diagnosis had low erythrocyte folate and serum ferritin of dietary intakes because of incomplete food records. The
values, but no other major differences were found in nutritional patients were also participants of a randomized trial examining
status among celiac disease patients with different grades of vil- the use of oats as part of a celiac disease diet (12). The study was
lous atrophy. Am J Clin Nutr 1998;67:482–7. conducted according to the guidelines of the Ethics Committee
of Kuopio University Hospital and the University of Kuopio.
KEY WORDS Celiac disease, nutritional status, villous
Methods
atrophy, adults, gluten-free diet, Finland
A screening gastroscopy was performed with an Olympus GIF
Q20 end-viewing gastroscope (Tokyo). Endoscopic biopsy speci-
INTRODUCTION mens were obtained at the duodenal bulb and the duodenal mucosa
Low concentrations of blood hemoglobin and serum albumin, at 5-cm intervals thereafter as far as possible; two specimens at
calcium, potassium, magnesium, and iron are frequently encoun- each level were taken by using jumbo forceps (Olympus FB-13K;
tered in adult celiac disease patients (1). Patients with untreated Tokyo). Specimens were fixed in 10% buffered formalin and
celiac sprue and even those with subclinical disease have been fre- processed by standard methods. The staining method used was van
quently reported to suffer from anemia because of deficiencies of Gieson’s (14). Specimens were oriented with the aid of a dissect-
iron and folate (2–5). Recent studies indicate that 11–38% of ing microscope to get well-oriented villi in the histologic sections.
untreated celiac disease patients have concentrations of hemoglo- The pathologist conducted the histopathologic examinations with-
bin, serum ferritin, iron, vitamin B-12, or erythrocyte folate below out knowledge of the clinical state of the patient. The degree of
reference values (6, 7). At present, celiac disease is commonly crypt hyperplastic villous atrophy was graded as normal (0), par-
diagnosed early enough so that marked abnormalities in labora-
tory values of untreated patients do not occur as frequently as seen 1
From the Departments of Clinical Nutrition and Pathology and Forensic
previously (4, 8, 9). It has also been suggested that there might be Medicine University of Kuopio, Kuopio, Finland; the Departments of Clini-
a new type of disease, clinically silent celiac disease, in which no cal Nutrition and Clinical Pathology and Unit of Gastroenterology, Depart-
marked clinical abnormalities are observed (10, 11). The severity ment of Medicine, Kuopio University Hospital, Kuopio, Finland; and the Unit
of mucosal villous atrophy may in part explain the differences in of Gastroenterology, Department of Medicine, Tampere University Hospital,
Tampere, Finland.
nutritional status found earlier. However, to our knowledge the 2
Supported by grants from the Olvi Foundation, the Finnish Association
association between biochemical measurements and the grade of of Academic Agronomist and Finnish Cultural Foundation.
villous atrophy in newly diagnosed celiac disease patients has not 3
Address reprint requests to TA Kemppainen, Department of Clinical
been reported before. Therefore, we set up a study to examine the Nutrition, PO Box 1627, 70211 Kuopio, Finland.
association of the grade of villous atrophy with the nutritional sta- Received May 14, 1997.
tus in newly diagnosed celiac disease patients. Accepted for publication October 13, 1997.
482 Am J Clin Nutr 1998;67:482–7. Printed in USA. © 1998 American Society for Clinical NutritionKEMPPAINEN ET AL 483
TABLE 1 millimeter at four sites (biceps, triceps, subscapular, and suprail-
Age, anthropometric characteristics, and duration of symptoms related to iac) and the mean of six measurements at each site was calcu-
celiac disease in newly diagnosed celiac disease patients1 lated. Body density and fat-free mass (FFM) were calculated
Men Women according to the method of Durnin and Womersley (18) and the
Variables (n = 12) (n = 28) body fat content from the body density by using Siri’s 1956
Age (y) 47 ± 12 (24–65) 44 ± 13 (18–62)
equation as described by Durnin and Womersley (18).
BMI (kg/m2) 25 ± 12 (20–32) 24 ± 5 (17–46) Blood samples were taken from the subjects after they had
Fat-free mass (kg) 57 ± 8 (47–70) 43 ± 4 (35–49) fasted overnight. The following analyses were made by using
Fat mass (%) 22 ± 7 (8–34) 32 ± 4 (23–40) routine clinical laboratory methods: blood hemoglobin, serum
Weight loss (kg) 1.2 ± 2.2 (0–6.0) 2.1 ± 3.7 (0–13.0) total protein, serum albumin, iron, ferritin (immunoluminometric
Duration of celiac disease– 5.0 ± 2.6 (2.0–7.0) 14.1 ± 11.0 (6.0–36.0) assay), transferrin, vitamin B-12 (radioisotope dilution assay),
related weight loss (mo) calcium, magnesium, alkaline phosphatase, and folic acid in ery-
Duration of celiac disease– 15.8 ± 19.2 (0–51) 13.1 ± 18.4 (0–57) throcytes (saturation analysis). Serum zinc was determined by
related symptoms (y) using atomic-absorption spectrophotometry. All specimens were
1 –
x ± SD; range in parentheses. analyzed in a single run and the within-run CV was 3.6%. Serum
vitamin D metabolite (calcidiol) was assayed as described by
Parviainen et al (19). Vitamins A and E were determined by
using HPLC with ultraviolet detection by the method of De
tial (I), subtotal (II), and total (III) (12, 13). In partial atrophy, villi Leenheer (1979) as modified by Parviainen and Koskinen (20).
were broadened and shortened. In subtotal atrophy, villi were Antigliadin antibodies (AGAs) of immunoglobulin class A (IgA)
more damaged and almost completely absent. No villous projec- were measured by an enzyme immunoassay as described by
tions from the surface were seen in total atrophy. Ascher et al (21). Antireticulin antibodies (ARAs) of IgA was
One investigator also measured histomorphometrically the determined by indirect immunofluorescence (22).
ratio of the perimeter area to lamina propria area of the same
Statistics
biopsy specimens without knowledge of the patient’s clinical
state, according to the procedure of Corazza et al (15). In brief, Statistical analyses were performed by using the SPSS statis-
the Quantimet 570 image analyzer (Leica, Cambridge, United tical program (23). The results for continuous variables are given
Kingdom), operated in an interactive mode with a cursor used to as the arithmetic mean ± SD and the range. The results for non-
draw on a digitizing table at an objective magnification of 325 continuous variables are given as the frequency and the percent-
(Olympus Vanox T light microscope; Tokyo), was used for these age. Parametric tests were used when applicable, otherwise non-
measurements. Length of perimeter is given by tracing along sur- parametric tests were used. The association between the
face epithelium, sides of the field, and the superficial aspect of nutritional status of the newly diagnosed celiac disease patients
muscularis mucosae. Area of lamina propria was measured by and their grade of villous atrophy was tested by using analysis of
tracing around the basement membrane of the epithelium, cut variance or the Kruskall-Wallis test between the three groups.
margins, and muscular mucosae and editing out any cross-sec- Also, the analysis of variance standardized for sex was used to
tioned crypts. These measurements were done on three random test the association between nutritional status and the grade of
fields from each biopsy specimen. As a sensitive indicator for the villous atrophy. Multiple comparison tests (multiple classifica-
changes in villous architecture, the ratio of perimeter to lamina tion analysis) and distribution-free multiple comparisons based
propria area was calculated for each specimen: the final index at on previous rank sums test were used after analysis of variance
each level was the mean of all three measurements, and the mean and Kruskall-Wallis tests, respectively, as secondary analyses.
histomorphometric index was the mean of all level indexes. The differences in the frequency or proportion of the categorized
A structured questionnaire was used to collect data on symp- variables were analyzed by chi-square test, and the distribution
toms and signs possibly related to celiac disease and their dura- of abnormal laboratory values by the grade of villous atrophy
tion. Nutritional status was determined on the basis of food was checked by the nonparametric chi-square test. The associa-
records and anthropometric and biochemical measurements. Four- tions between the variables of interest were assessed by non-
day food records were kept by all subjects with amounts deter- parametric (Spearman) correlations. The Wilcoxon test was used
mined by using household measures. Nutrient intake was calcu- in comparisons of continuous variables between the time points
lated by using the NUTRICA computer program (Social Insurance (before and after the celiac disease diet).
Institution, Helsinki), which uses the Food and Nutrient Data Base
of the Social Insurance Institution (16). The nutrient content data
on the gluten-free products used were collected from the manu- RESULTS
facturers and added into the database before calculations. At the time of diagnosis the mean histomorphometric index of
Body weight was determined with the subject standing bare- the patients was 0.018 ± 0.003 in patients with partial villous atro-
foot on a digital scale (Seca 770; Dayton, Hamburg, Germany) phy, 0.015 ± 0.002 in patients with subtotal villous atrophy, and
and wearing light clothing. Height of subjects without shoes was 0.013 ± 0.002 in patients with total villous atrophy (P = 0.004 for
measured with a wall-mounted stadiometer. Body mass index trend). IgA ARA values were abnormal in five of eight patients
(BMI) was calculated as body weight (kg)/height 2 (m). Skinfold with partial villous atrophy, 12 of 17 patients with subtotal villous
thicknesses were measured on the nondominant side of the body atrophy, and 13 of 15 patients with total villous atrophy (P = 0.53).
as described by Weiner and Lourie (17) by using Harpenden IgA AGA values were abnormal in five of eight patients with par-
skinfold calipers (John Bull, British Indicators, St Albans, tial villous atrophy, 13 of 17 patients with subtotal villous atrophy,
United Kingdom). The measurements were taken to the nearest and 12 of 15 patients with total villous atrophy (P = 0.27).484 NUTRITIONAL STATUS IN UNTREATED CELIAC DISEASE
TABLE 2
Age, duration of celiac disease–related symptoms, and weight loss in newly diagnosed celiac disease patients according to grade of villous atrophy
Grade of villous atrophy
Partial Subtotal Total
Variables (n = 8) (n = 17) (n = 15)
Sex
Men 1 9 2
Women 7 8 13
Age
Men (y) 60 46 ± 14 (24–65)1 46 ± 2 (44–47)
Women (y) 40 ± 17 (18–61) 49 ± 10 (33–62) 42 ± 13 (19–58)
All (y) 42 ± 18 (18–61) 47 ± 12 (24–65) 43 ± 12 (19–58)
Duration of celiac disease–related symptoms
Men (y) 0 19 ± 21 (1–51) 12 ± 16 (1–24)
Women (y) 14 ± 22 (0–54) 26 ± 24 (0–57) 5 ± 4 (1–13)2
All (y) 12 ± 20 (0–54) 22 ± 22 (0–57) 6 ± 7 (1–24)
Weight loss (kg) 2.6 ± 5.0 (0–13.0) 1.4 ± 2.8 (0–8.0) 1.7 ± 2.5 (0–6.5)
Duration of celiac disease–related weight loss 24 ± 17 (12–36) 5 ± 3 (2–7) 9 ± 3 (6–12)
(mo)
1 –
x ± SD; range in parentheses.
2
Significantly different from other grades of villous atrophy, P < 0.05 (Kruskall-Wallis test).
Age, duration of symptoms, weight loss, and the period of ferrin (P < 0.05). Because the number of men and women was
time of weight loss of the newly diagnosed celiac disease different in the different villous atrophy groups (P < 0.05), the
patients according to the grade of villous atrophy before the effect of sex was standardized in analysis of variance; after this,
institution of a celiac disease diet are presented in Table 2. Mean serum ferritin (P < 0.05) and erythrocyte folate concentrations
duration of symptoms in subjects with subtotal villous atrophy (P < 0.05) were still lower in the patients with total villous atro-
tended to be longer than that in the other groups, but this differ- phy than in the other groups (Table 5). The severity of villous
ence was not significant. atrophy correlated weakly (from –0.25 to –0.43, P < 0.05) with
Energy intake was higher in patients with subtotal villous serum ferritin, erythrocyte folate, and serum vitamin B-12 con-
atrophy than in others, probably because most of them (9 of 17) centrations.
were men. However, no significant differences were found in the The frequency of abnormally low erythrocyte folate concen-
intakes of carbohydrate, protein, and fat among the groups with trations tended to be higher in the patients with total villous atro-
different grades of villous atrophy (Table 3). Patients with par- phy (9 of 15) than in those with subtotal villous atrophy (4 of 17)
tial villous atrophy consumed 160 ± 60 g cereals, those with or partial villous atrophy (1 of 5), but the difference was not sig-
subtotal villous atrophy consumed 263 ± 86 g, and those with nificant (P = 0.07). Generally, prevalences of abnormal values of
total villous atrophy consumed 213 ± 97 g (P = 0.013, compari- serum protein, vitamin A, and vitamin B-12 in the groups with
son among the three groups). Patients with subtotal villous atro- different grades of villous atrophy were low (Table 6). None had
phy had the highest use of cereals (P = 0.05). Severity of villous abnormal vitamin E values.
atrophy had no effect on the results of anthropometric measure- In women, height (r = –0.43, P < 0.05) and serum transferrin
ments in men or women (Table 4). concentration (r = –0.49, P < 0.05) had an inverse association
When biochemical measurements were examined according with the duration of symptoms. In men, the duration of symptoms
to the grade of villous atrophy, significant differences were had an inverse correlation with serum vitamin B-12 concentration
found among the groups for serum ferritin (P < 0.01) and trans- (r = –0.84, P < 0.05). The duration of symptoms was not associ-
TABLE 3
Associations between energy intake and the percentage of energy from different nutrients and grade of villous atrophy in newly diagnosed celiac disease
patients1
Grade of villous atrophy
Partial Subtotal Total
Variables (n = 7) (n = 17) (n = 15)
Energy (MJ) 7.6 ± 1.6 (4.8–9.8) 9.5 ± 2.3 (4.6–13.1)2,3 7.9 ± 1.1 (5.8–9.3)
Carbohydrate (% of energy) 46 ± 7 (36–53) 48 ± 5 (41–57) 50 ± 6 (39–59)
Protein (% of energy) 15 ± 2 (13–18) 17 ± 3 (9–22) 16 ± 3 (13–21)
Fat (% of energy) 37 ± 5 (30–43) 35 ± 5 (23–42) 33 ± 5 (25–43)
Alcohol (% of energy) 2 ± 3 (0–8) 1 ± 3 (0–10) 1 ± 1 (0–4)
1 –
x ± SD; range in parentheses.
2
Significantly different from other grades of villous atrophy, P < 0.05 (Kruskall-Wallis test).
3
P = 0.05 for the distribution-free comparison based on the previous rank-sums test.KEMPPAINEN ET AL 485
TABLE 4
Associations between anthropometric measurements and the grade of villous atrophy in newly diagnosed celiac disease patients1
Grade of villous atrophy
Partial Subtotal Total
Variables (n = 1M, 7W) (n = 9M, 8W) (n = 2M, 13W)
Men
Weight (kg) 64 76 ± 14 (58–95)2 66 ± 5 (62–69)
Height (cm) 170 173 ± 5 (167–184) 166 ± 3 (164–169)
BMI (kg/m2) 22 25 ± 4 (20–32) 24 ± 3 (22–26)
Fat-free mass (kg) 47 59 ± 8 (47–70) 49 ± 1 (49–50)
Fat mass (%) 27 21 ± 8 (9–34) 25 ± 4 (22–28)
Women
Weight (kg) 66 ± 5 (67–72) 68 ± 24 (46–119) 62 ± 8 (47–79)
Height (cm) 164 ± 9 (155–178) 163 ± 5 (156–171) 164 ± 4 (155–169)
BMI (kg/m2) 24 ± 3 (20–27) 26 ± 9 (17–46) 23 ± 3 (18–28)
Fat-free mass (kg) 45 ± 4 (40–49) 42 ± 3 (39–46) 42 ± 4 (35–48)
Fat mass (%) 32 ± 5 (23–40) 32 ± 3 (29–36) 32 ± 4 (25–39)
1
There were no significant differences among grades of villous atrophy (Kruskall-Wallis test).
2 –x ± SD; range in parentheses.
ated with the severity of villous atrophy. Weight loss before diag- ments, and biochemical measurements did not differ between the
nosis had an inverse correlation with serum total protein (r = groups with and without oats (12).
–0.44, P < 0.05) and calcium (r = –0.38, P < 0.05) concentrations Most of the initially abnormal biochemical values improved
in the subjects who reported weight loss. In men only, weight loss during the 1 y of follow-up concurrently with the improvement
had an inverse correlation with serum protein (r = –0.64, P < of villous atrophy (Figure 1). However, one of the two patients
0.05) and serum ferritin (r = –0.75, P < 0.05) concentrations. with subtotal villous atrophy still had a low hemoglobin value. In
Villous atrophy improved in all patients within 12 mo of fol- 29 patients with partial villous atrophy, low values were regis-
low-up: only 2 patients had subtotal villous atrophy (mean histo- tered for erythrocyte folate (3 patients), hemoglobin
morphometric index of 0.016 ± 0.003), 29 patients had partial (7 patients), serum vitamin B-12 (1 patient), serum protein
villous atrophy (0.019 ± 0.002), and 3 patients had normal vil- (1 patient), serum vitamin A (5 patients), serum ferritin (5
lous architecture (0.022 ± 0.002). Six patients withdrew from the patients), serum iron (15 patients), and serum zinc (10 patients).
follow-up. As reported earlier, the severity of villous atrophy did One of three patients with normal villous architecture had a low
not differ between the oat and control groups (12). hemoglobin value at this stage of the follow-up.
During the 1 y of gluten-free diet with or without oats, BMI
increased but no changes in intakes of energy, carbohydrate, pro-
tein, or fat were found in the whole group. On the other hand, DISCUSSION
intakes of fiber and thiamine decreased with the gluten-free diet. The aim of the current study was to examine an association
Nutrient intakes, except for thiamine, anthropometric measure- between biochemical measurements and the grade of villous
TABLE 5
Associations between biochemical measurements and grades of villous atrophy in newly diagnosed celiac disease patients1
Grade of villous atrophy
Partial Subtotal Total
Variables (n = 5) (n = 17) (n = 15)
Serum protein (g/L) 79 ± 6 (72–86) 75 ± 7 (54–84) 76 ± 5 (65–82)
Serum albumin (g/L) 46 ± 6 (38–53) 46 ± 6 (37–58) 47 ± 4 (42–55)
Blood hemoglobin (g/L) 134 ± 12 (128–156) 138 ± 16 (114–168) 129 ± 14 (98–154)
Serum iron (mmol/L) 17 ± 9 (11–33) 15 ± 6 (7–24) 16 ± 8 (4–36)
Serum ferritin (mg/L) 187 ± 361 (9–831) 49 ± 42 (7–143) 18 ± 18 (8–79)2
Serum transferrin (g/L) 3.2 ± 0.9 (2.4–4.8) 2.8 ± 0.1 (2.2–3.4) 3.3 ± 0.5 (2.5–4.4)
Erythrocyte folate (nmol/L) 570 ± 357 (211–1159) 407 ± 156 (157–769) 309 ± 167 (0–582)2
Serum vitamin B-12 (pmol/L) 366 ± 134 (209–525) 332 ± 149 (95–564) 277 ± 152 (122–661)
Serum calcium (mmol/L) 2.3 ± 0.2 (2.1–2.6) 2.2 ± 0.1 (1.9–2.4) 2.3 ± 0.01 (2.1–2.4)
Serum magnesium (mmol/L) 0.8 ± 0.03 (0.78–0.85) 0.8 ± 0.07 (0.73–0.91) 0.8 ± 0.06 (0.70–0.95)
Serum zinc (mmol/L) 11 ± 0 13 ± 2 (8–17) 12 ± 2 (10–14)
Serum vitamin A (mmol/l) 1.3 ± 0.4 (0.9–1.7) 1.5 ± 0.5 (1.0–2.5) 1.4 ± 0.4 (0.8–2.2)
Serum vitamin E (mmol/L) 26 ± 12 (14–41) 23 ± 5 (14–36) 24 ± 12 (12–46)
Serum calcidiol (nmol/L) 51 ± 18 (27–70) 44 ± 17 (25–77) 45 ± 17 (29–97)
1 –
x ± SD; range in parentheses.
2
Significantly different from other grades of villous atrophy, P < 0.05 (ANOVA standardized for sex and multiple classification analysis).486 NUTRITIONAL STATUS IN UNTREATED CELIAC DISEASE
TABLE 6
The frequency of newly diagnosed celiac disease patients with abnormal biochemical values by grade of villous atrophy1
Grade of villous atrophy
Partial Subtotal Total
Biochemical variable Limit of abnormal value (n = 5) (n = 17) (n = 15)
Hemoglobin
Men < 135 g/L 0 3 0
Women < 125 g/L 0 (0) 4 (41) 5 (33)
Serum vitamin B-12 < 150 pmol/L 0 4 (24) 2 (13)
Erythrocyte folate < 300 nmol/L 1 (20) 4 (24) 9 (60)
Serum ferritin
Men < 25 mg/L 0 2 2
Women < 12 mg/L 2 (40) 1 (18) 6 (53)
Serum iron
Men < 14 mmol/L 0 2 1
Women < 13 mmol/L 2 (40) 6 (47) 4 (33)
Serum protein < 64 g/L 0 1 (6) 0
Serum zinc < 13 mmol/L 1 (20) 9 (53) 9 (60)
Serum vitamin A < 1 mmol/L 1 (20) 1 (6) 3 (20)
Serum ferritin and erythrocyte folate 0 1 (6) 7 (47)
1
n; percentage in parentheses. There were no significant differences among grades of villous atrophy (chi-square test and nonparametric chi-square test).
atrophy in newly diagnosed celiac disease patients. The grade of could explain part of the abnormal biochemical values after 1 y
villous atrophy was examined with two different methods that of gluten-free diet in our study.
gave consistent results regarding the severity of villous damage. Similarly to previous studies (33, 34), this study showed no
Furthermore, only 75% of patients showed abnormal ARA or correlation between the duration of symptoms related to celiac
AGA concentrations at the time of diagnosis. None of the disease and the grade of villous atrophy. The duration of symp-
patients had IgA deficiency. toms did not correlate with the occurrence of abnormal labora-
Serum ferritin and erythrocyte folate concentrations were tory values either. The reason for this may be that symptoms of
lower in patients with total villous atrophy than in those with celiac disease have not been typical and there is variability in
subtotal or partial atrophy, but anthropometric measurements and gluten sensitivity from patient to patient.
nutrient intake did not differ among the patients with different In women, duration of symptoms related to celiac disease had
grades of villous atrophy in this study. In a recent study, Bode and an inverse correlation with height. Although adult celiac disease
Gudmand-Hoyer (7) reported that the percentage of patients patients are claimed to be shorter than average, the height of
showing signs of malabsorption in laboratory measurements is patients with celiac disease diagnosed after reaching adulthood
lower than that reported previously. Their findings agree with the does not differ significantly from that of the general population
results of our study (6). Previously, weight loss has been the most (30). The fact that weight loss before diagnosis had an inverse
common presenting feature in adult celiac disease patients correlation with serum protein and calcium concentrations and
(24–26). Nowadays, celiac disease seems to be diagnosed suffi- that the duration of symptoms related to celiac disease had an
ciently early so that marked abnormalities in laboratory and inverse correlation with serum vitamin B-12 concentrations in
anthropometric measurements of untreated celiac disease are not men may reflect the possible existence of abnormal absorption
expected. In contrast with many earlier studies (6, 11, 27–30), due to a delayed diagnosis of celiac disease.
none of the patients in our study were clearly malnourished.
Corazza et al (31) reported that patients with subclinical pre-
sentation had better nutritional status than those with symptoms
of malabsorption. None of the patients with subclinical presenta-
tion had evidence of severe malnutrition. However, Crofton et al
(32) showed that increased loss of endogenous zinc occurs even
in mild untreated celiac disease. This finding suggests a possibil-
ity of finding abnormal serum zinc values as well as some other
abnormal biochemical measurements in celiac disease patients
irrespective of the severity of the disease. In our study, serum zinc
concentration was low in 18 of 37 patients at diagnosis.
Celiac disease patients with classical presentation may require
a longer period of gluten-free diet to achieve a significant
improvement of their nutritional status than those with subclini-
cal presentation, probably because of greater intestinal damage FIGURE 1. Number of celiac disease patients with values of ery-
(11). In the present study, the type of presentation of celiac dis- throcyte folate, serum vitamin B-12, serum vitamin A, hemoglobin,
ease was not examined, but according to the study of Corazza et serum ferritin, serum iron, and serum zinc below the reference values
al (11), the variability of presentation and severity of disease before (h) and after (j) 1 y of a celiac disease diet. n = 40.KEMPPAINEN ET AL 487
In conclusion, newly diagnosed celiac disease patients with 16. Rastas M, Seppänen R, Knuts L-R, Karvetti R-L, eds. Nutrient com-
different grades of villous atrophy did not differ from each other position of foods. 3rd ed. Helsinki: the Social Insurance Institution,
with respect to height, weight, BMI, fat mass, or most of the lab- 1990.
oratory values reflecting nutritional status. The only exceptions 17. Weiner JS, Lourie JA, eds. Human biology: a guide to field meth-
ods. IBP handbook no. 9. Oxford, United Kingdom: Blackwell,
were serum ferritin and erythrocyte folate concentrations, which
1969.
were lower in patients with total villous atrophy than in those 18. Durnin J, Womersley J. Body fat assessed from total body density
with partial or subtotal atrophy. and its estimation from skinfold thickness: measurements on 481
men and women aged from 16 to 72 years. Br J Nutr 1974;
32:77–97.
REFERENCES 19. Parviainen M, Savolainen K, Korhonen P, Alhava E, Visakorpi J. An
improved method for routine determination of vitamin D and its
1. Corazza GR, Gasbarrini G. Coeliac disease in adults. Baillieres Clin hydroxylated metabolities in serum from children and adults. Clin
Gastroenterol 1995;9:329–50. Chim Acta 1981;114:233–46.
2. Hoffbrand AV. Anaemia in adult coeliac disease. Clin Gastroenterol 20. Parviainen M, Koskinen T. Vitamin A, D and E status in Finnish
1974;3:71–89. population—a multivitamin study. Hum Nutr Clin Nutr
3. Cooke WT, Holmes GKT. Coeliac disease. New York: Churchill 1983;37C:397–403.
Livingstone, 1984. 21. Ascher H, Lanner Å, Kristansson B. A new laboratory kit for
4. Pare P, Douville P, Caron D, Lagace R. Adult celiac sprue: changes antigliadin IgA at diagnosis and follow-up of childhood coeliac dis-
in the pattern of clinical recognition. J Clin Gastroenterol ease. J Pediatr Gastroenterol Nutr 1990;10:443–50.
1988;10:395–400. 22. Mäki M, Hällström O, Vesikari T, Visakorpi J. Evaluation of serum
5. Corazza GR, Valentini RA, Andreani ML, et al. Subclinical coeliac IgA-class reticulin antibody test for the detection of childhood
disease is a frequent cause of iron-deficiency anaemia. Scand J Gas- coeliac disease. J Pediatr 1984;105:901–5.
troenterol 1995;30:153–6. 23. SPSS Inc. SPSS reference guide. Chicago: SPSS Inc, 1990.
6. Kemppainen T, Uusitupa M, Janatuinen E, et al. Intakes of nutrients 24. Evans W, Wollaeger E. Incidence and severity of nutritional defi-
and nutritional status in coeliac patients. Scand J Gastroenterol ciency in chronic exocrine pancreatic insufficiency: comparison
1995;30:575–9. with nontropical sprue. Am J Dig Dis 1966;11:594–606.
7. Bode S, Gudmand-Hoyer E. Symptoms and haematologic features 25. Green P, Wollaeger E. The clinical behaviour of sprue in the United
in consecutive adult coeliac patients. Scand J Gastroenterol States. Gastroenterology 1969;38:399–418.
1996;31:54–60. 26. Bossak E, Wang C, Adlesberg D. Clinical aspects of the malabsorp-
8. Paerregaard A, Vilien M, Krasilnikoff PA, Gudmand-Hoyer E. Sup- tion syndrome (idiopathic sprue). J Mt Sinai Hosp N Y 1957;6:
posed coeliac disease during childhood and its presentation 14–38 286–303.
years later. Scand J Gastroenterol 1988;23:65–70. 27. Collins B, Bell P, Thomson J, et al. Dietary history and nutritional
9. Midhagen G, Järnerot G, Kraaz W. Adult coeliac disease within a state in treated coeliac patients. J R Soc Med 1986;79:206–9.
defined geographic area in Sweden. Scand J Gastroenterol 28. Bode SH, Bachmann EH, Gudmand-Hoyer E, Jensen GB. Stature of
1988;23:1000–4. adult coeliac patients: no evidence for decreased attained height.
10. Collin P, Hällström O, Mäki M, Viander M, Keyriläinen O. Atypical Eur J Clin Nutr 1991;45:145–9.
coeliac disease found with serologic screening. Scand J Gastroen- 29. Mayer M, Grege L, Troncone R, Auricchio S, Marsh M. Compliance
terol 1990;25:245–50. of adolescents with coeliac disease with a gluten-free diet. Gut
11. Corazza GR, Di Sario A, Sacco G, et al. Subclinical coeliac disease: 1991;32:881–5.
an anthropometric assessment. J Intern Med 1994;236:183–7. 30. Cacciari E, Corazza G, Salardi S, et al. What will be the adult height
12. Janatuinen EK, Pikkarainen PH, Kemppainen TA, et al. A compari- of coeliac patients? Eur J Pediatr 1991;150:407–9.
son of diets with and without oats in adults with celiac disease. N 31. Corazza G, Frisoni M, Treggiari E, et al. Subclinical celiac sprue.
Engl J Med 1995;333:1033–7. Increasing occurrence and clues to its diagnosis. J Clin Gastroen-
13. Roy-Choudhury D, Cooke WT, Banwell JG, Smits BJ. Jejunal terol 1993;16:16–21.
biopsy: criteria and significance. Scand J Gastroenterol 32. Crofton RW, Aggett PJ, Gvozdanovic S, Gvozdanovic D, Mowat
1966;1:57–74. NA, Brunt PN. Zinc metabolism in celiac disease. Am J Clin Nutr
14. Bancroft J, Stevens A, eds. Theory and practice of histological tech- 1990;52:379–82.
niques. 2nd ed. Edinburgh, Scotland: Churchill Livingstone, 1982. 33. Thornquist H, Jacobsen GS, Marhauug G. Coeliac disease and
15. Corazza G, Frazzoni M, Dixon M, Casbarrini G. Quantitative gluten-free diet: a following-up study of fifteen young adults. Ann
assessment of the mucosal architecture of jejunal biopsy specimens: Nutr Metab 1993;37:295–301.
a comparison between linear measurement, stereology, and com- 34. Bardella MT, Molteni N, Prampolini L, et al. Need for follow up in
puter aided microscopy. J Clin Pathol 1985;38:765–70. coeliac disease. Arch Dis Child 1994;70:211–3.You can also read
