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Reply to A Hörnell

Mayo Clinic
200 First Street, SW
Room 301, Guggenheim Bldg
Rochester, MN 55905
E-mail: murray.joseph{at}mayo.edu

Dear Sir:

We are glad to have the opportunity to respond to the letter of Dr Hörnell and to the concerns she raised about our recent article (1).

First, the questionnaire was administered after 6 mo of a gluten-free diet, and the results reflect the patients' perceptions and reports of the effects of that diet on their gastrointestinal symptoms at a point 6 mo after beginning the diet.

Second, the correspondent is surprised at the wide range of variation in weight change reported by subjects in the period after the start of a gluten-free diet. In most but not all cases, it was possible to verify the patient-reported weight during his or her clinic visit. Whereas most patients had weight changes that were well within a range that could result from changes in absorption or modification of food intake, wide ranges of weight change were reported. The extremes of the ranges of change were quite dramatic. A small but significant proportion of these patients were morbidly obese at the time of diagnosis of celiac disease, and large changes in weight are certainly possible in this cohort, a finding that has been reported anecdotally and recently in another cohort (2).

We agree that it would be naive to believe that these morbidly obese patients who lost so much weight did so only because of treatment of celiac disease. Patients of this size would certainly have been advised to lose weight. We did not control for confounding events such as intervening bariatric surgery, which is quite common in the Midwest United States. It is certainly possible that patients with morbid obesity may have received substantial additional therapy to address their morbid obesity, although this was not provided or advised by the physicians treating the celiac disease (3). Such dramatic weight loss could be explained if patients, for example, underwent a bariatric procedure (4).

With regard to weight gain, whereas this degree of weight gain is unusual, several patients were extremely malnourished at the time of their diagnosis and often were substantially dehydrated. The patient who had the largest weight regain had reported losing 40 kg over a 9-mo period with frank steatorrhea before treatment. His baseline weight before weight loss was 115 kg.

However, these are the extremes of the range, and most patients' weight gain or weight loss was well within what would normally be expected in response either to substantial dietary intervention or fairly rapid correction of malabsorption (or both). These extreme cases were adults at the time of diagnosis of celiac disease, as were the vast majority of our patients, and that reflects the usual circumstance in the United States (2).

Clinicians must be prepared to deal with nutrition-related issues in addition to the institution of a gluten-free diet, because most patients currently being diagnosed with celiac disease do not present with severe malabsorption.

Third, Hörnell quite correctly points out our incorrect use of the SEM with the median, as written in the Results. The SD is provided in the table. Nonetheless, the data are correct as published.

Fourth, with regard to the time period of the study, the abstract is correct. We included only patients who were evaluated during the period of 1990 through 1997, when the primary author was engaged in seeing these patients. Patients who were seen before 1990 were no longer available for follow-up and were not included, and patients seen for the first time after 1997 were not included. The correct period for initial diagnosis was 1984–1997. The follow-up period for some of the patients diagnosed toward the end of 1997 stretched into 1998, and that is the source of our error.

We thank Dr Hörnell for her interest in our publication and for the opportunity to correct these errors and provide clarification.

ACKNOWLEDGMENTS

Neither of the authors had any personal or financial conflicts of interest with respect to the subject under discussion or to the author of the letter, Dr Hörnell.

REFERENCES

1. Murray JA, Watson T, Clearman B, Mitros FA. Effect of a gluten- free diet on gastrointestinal symptoms in celiac disease. Am J Clin Nutr 2004;79:669–73.
2. Murray JA, Van Dyke C, Plevak MF, Dierkhising RA, Zinsmeister AR, Melton LJ. Trends in the identification and clinical features of celiac disease in a North American community. Clin Gastroenterol Hepatol 2003;1:19–27.
3. Owen DA, Thorlakson TK, Walli JE. Celiac disease in a patient with morbid obesity. Arch Intern Med 1980;140:1380–1.
4. Logan RF, Ferguson A. Jejunal villous atrophy with morbid obesity: death after jejunoileal bypass. Gut 1982;23:999–1004.

This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Murray, J. A Articles by Clearman, B. Search for Related Content PubMed Articles by Murray, J. A Articles by Clearman, B. Agricola Articles by Murray, J. A Articles by Clearman, B.