Obesity in an 18-Year-Old Boy With Untreated Celiac Disease

To the Editor: We read with great interest the article by Hoppi and Kaplan entitled “The Leptin Era: New Insight Into the Mechanisms of Body Weight Homeostasis” (J Pediatr Gastroenterol Nutr 1999;3:250–64). An 18-year-old boy with celiac disease, in whom disturbances in body weight homeostasis changed completely the primary pattern of the disease, has been seen by us all his life. During the newborn period, the introduction of gluten to his diet resulted in chronic diarrhea and a body weight deficit (third percentile), which resolved after elimination of gluten. Since he was 3 years old, his growth status has remained in the 25th percentile. His body weight increased systematically, exceeding the 97th percentile when he was 5 years old. A gluten provocation test was performed when the boy was 8 years old. Although the test was asymptomatic, the duodenal mucosa was completely atrophic, and antigliadin and antiendomysial immunoglobulin A antibodies were present in the blood. Despite the presence of malabsorption syndrome, the boy has remained obese since he was 8 years old (body mass index > 4 standard deviations since his 15th year). His leptin concentration is high (48.8 ng/mL). Clinical signs suggestive of endocrine and genetic syndromes presenting as obesity are absent. At the age 16 years, our patient followed a gluten-free diet for 6 months, which caused a rapid increase in body weight (by 9.5 kg), and was the reason why gluten was reintroduce into the diet. Bone mineral density and iron concentration in blood were always normal, which indicates that adaptive jejunal mechanisms for depressive duodenal absorption are developed. In the literature there are reports that diagnose celiac disease in obese children and adults, and obesity in adults on gluten-rich and gluten-free diets have been reported (1–3) Our patient demonstrates the occurrence of malnutrition during the newborn period and obesity in later childhood in a child with completely atrophic duodenal villi.