Benefit of Gluten-free Diet in Older Celiac Disease Patients
Benefit of Gluten-free Diet in Older Celiac Disease Patients
An increasing number of patients with celiac disease will be diagnosed among the older people. The correct diagnosis may have been missed even when the patients had contacted their physicians for many years due to unexplained symptoms or abnormalities in blood tests. Altogether, older patients may have more symptoms than younger ones, and may have an increased risk of malabsorption or enteropathy-associated T-cell lymphoma. Anemia, iron, vitamin B12, folic acid, and calcium deficiency have been the major malnutrition findings in older celiac disease patients. It would thus, appear desirable to detect the disease as early as possible.
On the other hand, it is of crucial importance to know what the overall implications of the diagnosis are in older people. Mortality has not increased among older undiagnosed celiac disease patients and the effect of the diagnosis on well-being has not been investigated. In this prospective follow-up study we evaluated the consequences of dietary treatment in a definite celiac disease patient series obtained by population-based mass screening in the older. Since neither celiac disease nor any abdominal disease was the target of the original GOAL project, there was no selection bias towards individuals suffering from gastrointestinal symptoms. Of note, the rate of detection of celiac disease in Finland is relatively high, and in the present series, 0.9% of individuals already had the diagnosis of celiac disease established before the screening program. This notwithstanding, even here the majority of older celiac disease patients would have remained undiagnosed without active screening or case finding.
In these screen-detected patients an improvement in GSRS was evident under dietary treatment, both in total score and in virtually in all subscores, displaying an alleviation in gastrointestinal symptoms. The effect of the treatment on quality of life (PGWB) was not so evident, but it is of note that the diet did not worsen it. A comparable finding was obtained in our recent study where celiac patients detected by screening at risk groups were investigated. An improvement in laboratory values was seen almost invariably. This was most evident in serum mean ferritin indicating the presence of subclinical iron deficiency, as the serum iron levels remained within normal range. A low ferritin level was similarly observed in a series from Godfrey and colleagues. Apart from gluten-free diet, iron or vitamin supplementation was given to some of our patients, but the beneficial effect was evident also in those subjects, who did not receive any substitution. There was a slight but statistically significant decrease in blood hemoglobin levels in females (Table 3), but none of the patients suffered from severe anemia. A regular follow-up of hemoglobin values is in any case indicated in celiac patients.
A risk of low bone mineral density is possible in screen-detected apparently asymptomatic celiac disease patients. In the present study, Z-scores, reflecting the values in the age- and sex-matched population, were within reference levels at baseline, but a significant improvement was observed on a gluten-free diet. As Z-score reference values usually decrease with age, we concluded that this process was slowed down by dietary treatment. Though no improvement was observed in T-scores in the total series, such an effect was seen in subjects with osteoporosis or osteopenia, even when subjects treated with bisphosphonates were excluded. The analysis would have been impossible if also subjects receiving vitamin D or calcium substitution were excluded. On the other hand, in the randomized study carried out by Mautalen et al., strict gluten-free diet promoted a significant increase in bone mineral density, but calcium and vitamin D supplementation did not provide additional benefit. We will further point out, that the medical management for bone disease of malabsorption would not have been possible without our active screening. There was a small but significant decrease in serum calcium levels. This may be due to ongoing bone restoration, which implies that calcium substitution is indicated after the commencement of a gluten-free diet. Our results further suggest that low-energy fractures may be a risk in untreated celiac disease. Larger prospective studies are however needed to confirm this finding.
Compliance with a gluten-free diet does not seem to be a problem in older patients with celiac disease, as compliance rates have been more than 90%. Accordingly, the histological or serological recovery in the 32 patients adhering to a gluten-free was virtually complete. However, our results cannot directly be applied in every country, as the availability of gluten-fee diet may not be as good as in Finland. Another limitation of the study was that we did not have laboratory or bone mineral density values for the control group. Nevertheless, we emphasize that a favorable outcome can be achieved by screening older population for celiac disease.
None of our celiac disease patients suffered from severe malabsorption syndrome, and they did not have refractory sprue or any other severe complications. Ten (29%) of these 35 screen-detected celiac patients had had relatives with celiac disease and 10 autoimmune diseases, which should both alert to celiac disease. Katz and associates concluded that symptoms do not predict who will have celiac disease, making case-finding ineffective, and they therefore suggested that general population screening may be needed to find the disorder. To the contrary, we believe that in this older population case finding will be effective as long as symptoms and risk-groups are taken into account. Altogether, 29 out of 35 of our celiac patients would have been detected without serologic mass-screening if family history, bone fractures or concomitant diseases (Table 1) had alerted the physicians (in patient 35 routine duodenal biopsy would have detected celiac disease). We therefore recommend screening in groups, where the costs are lower than in mass-screening, and as shown here, the patients benefit from dietary treatment.
Discussion
An increasing number of patients with celiac disease will be diagnosed among the older people. The correct diagnosis may have been missed even when the patients had contacted their physicians for many years due to unexplained symptoms or abnormalities in blood tests. Altogether, older patients may have more symptoms than younger ones, and may have an increased risk of malabsorption or enteropathy-associated T-cell lymphoma. Anemia, iron, vitamin B12, folic acid, and calcium deficiency have been the major malnutrition findings in older celiac disease patients. It would thus, appear desirable to detect the disease as early as possible.
On the other hand, it is of crucial importance to know what the overall implications of the diagnosis are in older people. Mortality has not increased among older undiagnosed celiac disease patients and the effect of the diagnosis on well-being has not been investigated. In this prospective follow-up study we evaluated the consequences of dietary treatment in a definite celiac disease patient series obtained by population-based mass screening in the older. Since neither celiac disease nor any abdominal disease was the target of the original GOAL project, there was no selection bias towards individuals suffering from gastrointestinal symptoms. Of note, the rate of detection of celiac disease in Finland is relatively high, and in the present series, 0.9% of individuals already had the diagnosis of celiac disease established before the screening program. This notwithstanding, even here the majority of older celiac disease patients would have remained undiagnosed without active screening or case finding.
In these screen-detected patients an improvement in GSRS was evident under dietary treatment, both in total score and in virtually in all subscores, displaying an alleviation in gastrointestinal symptoms. The effect of the treatment on quality of life (PGWB) was not so evident, but it is of note that the diet did not worsen it. A comparable finding was obtained in our recent study where celiac patients detected by screening at risk groups were investigated. An improvement in laboratory values was seen almost invariably. This was most evident in serum mean ferritin indicating the presence of subclinical iron deficiency, as the serum iron levels remained within normal range. A low ferritin level was similarly observed in a series from Godfrey and colleagues. Apart from gluten-free diet, iron or vitamin supplementation was given to some of our patients, but the beneficial effect was evident also in those subjects, who did not receive any substitution. There was a slight but statistically significant decrease in blood hemoglobin levels in females (Table 3), but none of the patients suffered from severe anemia. A regular follow-up of hemoglobin values is in any case indicated in celiac patients.
A risk of low bone mineral density is possible in screen-detected apparently asymptomatic celiac disease patients. In the present study, Z-scores, reflecting the values in the age- and sex-matched population, were within reference levels at baseline, but a significant improvement was observed on a gluten-free diet. As Z-score reference values usually decrease with age, we concluded that this process was slowed down by dietary treatment. Though no improvement was observed in T-scores in the total series, such an effect was seen in subjects with osteoporosis or osteopenia, even when subjects treated with bisphosphonates were excluded. The analysis would have been impossible if also subjects receiving vitamin D or calcium substitution were excluded. On the other hand, in the randomized study carried out by Mautalen et al., strict gluten-free diet promoted a significant increase in bone mineral density, but calcium and vitamin D supplementation did not provide additional benefit. We will further point out, that the medical management for bone disease of malabsorption would not have been possible without our active screening. There was a small but significant decrease in serum calcium levels. This may be due to ongoing bone restoration, which implies that calcium substitution is indicated after the commencement of a gluten-free diet. Our results further suggest that low-energy fractures may be a risk in untreated celiac disease. Larger prospective studies are however needed to confirm this finding.
Compliance with a gluten-free diet does not seem to be a problem in older patients with celiac disease, as compliance rates have been more than 90%. Accordingly, the histological or serological recovery in the 32 patients adhering to a gluten-free was virtually complete. However, our results cannot directly be applied in every country, as the availability of gluten-fee diet may not be as good as in Finland. Another limitation of the study was that we did not have laboratory or bone mineral density values for the control group. Nevertheless, we emphasize that a favorable outcome can be achieved by screening older population for celiac disease.
None of our celiac disease patients suffered from severe malabsorption syndrome, and they did not have refractory sprue or any other severe complications. Ten (29%) of these 35 screen-detected celiac patients had had relatives with celiac disease and 10 autoimmune diseases, which should both alert to celiac disease. Katz and associates concluded that symptoms do not predict who will have celiac disease, making case-finding ineffective, and they therefore suggested that general population screening may be needed to find the disorder. To the contrary, we believe that in this older population case finding will be effective as long as symptoms and risk-groups are taken into account. Altogether, 29 out of 35 of our celiac patients would have been detected without serologic mass-screening if family history, bone fractures or concomitant diseases (Table 1) had alerted the physicians (in patient 35 routine duodenal biopsy would have detected celiac disease). We therefore recommend screening in groups, where the costs are lower than in mass-screening, and as shown here, the patients benefit from dietary treatment.