Classically, CD presents with gastrointestinal symptoms like diarrhea, abdominal pain, cramping or bloating, failure to thrive, weight loss, irritability, and weakness; an increasing number of children exhibit delayed onset or atypical manifestations. These can include minimal intestinal complaints like nausea, vomiting, or even constipation, along with extra-intestinal manifestations such as short stature, delayed puberty, iron deficiency anemia, and other nutritional deficiencies (7).
In recent decades, celiac disease prevalence has risen in children, with an increasing proportion of overweight and obese patients at diagnosis, contrasting with the traditional view of the disease causing malabsorption and growth failure (8)(9)(10). This shift may be attributable to an improved understanding of disease genetics and immune features, enhanced recognition of atypical presentations, expanded serological testing and screening of at-risk asymptomatic groups, and a potential actual rise in prevalence (9)(11).
Several theories may explain the increasing prevalence of overweight/obesity in pediatric celiac disease patients. The "compensation theory" suggests that unabsorbed nutrients from proximal intestinal villous atrophy get compensatory absorbed distally, preventing weight loss, and patients may also become overweight/obese, like anybody else (4)(12)(13). Another theory is the emerging evidence of the roles of epigenetics, gut microbiota, and specific disease pathways contributing to this phenomenon. Additionally, the rising overweight and obesity trends in the general pediatric population and early diagnosis before malnutrition occurs may also be reflected in celiac patients (10)(14).
While obesity is a known presentation in adults with CD, affecting 0.45% to 39% at diagnosis (4) (12), it is a very rare and atypical presentation in children (15). In pediatric CD patients, the prevalence of obesity has ranged from 5% to 21%, with recent reports suggesting over 50% of newly diagnosed cases have a normal BMI (2)(4)(16). A study on 143 American children aged 13 months to 19 years revealed that 74.5% had a normal BMI, similar to findings in Sweden, where 72.8% of children with CD had a normal weight (2). An Iranian study found that 3.4% were overweight/obese at diagnosis (4), while another reported 5% obese pediatric CD patients at a tertiary center over 17 years (16). Therefore, normal body weight in children with CD is a common finding, and BMI is not a reliable indicator for predicting CD in children (4)(17).
Notably, Nenna et al. reported a 4% prevalence of CD among overweight/obese Italian children and adolescents referred to an auxological clinic (3)(10). In an English study, 6% of the children with CD were underweight, 66% normal weight, 28% overweight, and 5% obese according to WHO criteria (6). These findings and other studies suggest that normal body weight is common in pediatric CD cases, and BMI is not a reliable indicator for predicting CD in children (2).
Our study aligns with previous findings, revealing that 73% of pediatric CD patients had a normal BMI, 13.1% were underweight, 9.1% were overweight, and 4.8% were obese at diagnosis. These results further reinforce the notion that CD occurs across different weight categories, including overweight and obesity, in the pediatric population.
Furthermore, our study revealed that obese and underweight CD patients were generally older at diagnosis (mean age 9 years) compared to overweight (mean age 8 years) and normal BMI patients (mean age 7.6 years). This contrasts with another study suggesting overweight/obese children were slightly younger at diagnosis, though the difference was insignificant (4). Our findings may indicate a potential diagnostic delay for obese CD patients, as excess weight gain and obesity are unexpected and atypical presentations associated with the intestinal mucosal damage caused by CD.
Additionally, most CD patients were females (57.5%), consistently across all BMI categories. However, males had a higher risk of being underweight or obese at CD diagnosis compared to females, while other studies reported conflicting evidence (4)(18).
Regarding SES, most patients had lower SES, and those with lower SES had the lowest BMI. This finding suggests that having a lower SES increases the prevalence of being an underweight CD patient at diagnosis.
Additionally, the proportion of Jews and Arabs diagnosed with CD was in accordance with the general population distribution in Israel. The higher underweight prevalence among Arab CD patients might indicate delayed diagnosis until severe manifestations like significant weight loss become apparent. In contrast, the higher overweight/obesity among Jewish patients could stem from socioeconomic factors and diagnostic bias, wherein clinicians may overlook CD in overweight or obese individuals. These findings warrant further research to explore the underlying factors contributing to ethnic differences in disease presentation, diagnosis, and referral patterns, such as healthcare access barriers or cultural influences impacting timely referrals for Arab patients. Addressing these potential disparities is crucial for improving early CD identification and management across diverse populations.
In summary, the year of celiac disease diagnosis did not show a statistically significant association with being overweight or obese, while there is a significant relationship with decreasing the chances of being an underweight CD patient at diagnosis. However, other demographic factors such as age, gender, ethnicity, and SES were considered, and their associations with overweight were evaluated. Arabs and female gender had significantly lower odds of being obese compared to Jews.
Further in-depth research is needed to explore potential contributing factors influencing the association between ethnicity and overweight/obesity status in CD patients. Understanding sociocultural, economic, and healthcare access influences is crucial to
address these disparities and improve diagnostic practices and management strategies across different populations, ultimately leading to better outcomes for all CD patients.