Symptoms: Weight loss, poor sleep, diarrhea, tremors, nervous feeling, heart palpitations, hair loss, and muscle weakness

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Level 3 Weight Loss after Starting a Gluten-Free Diet KEY POINTS: What are the medical conditions that contribute to continued weight loss or difficulty gaining weight after the diagnosis of celiac disease
Level 3 Weight Loss after Starting a Gluten-Free Diet KEY POINTS: What are the medical conditions that contribute to continued weight loss or difficulty gaining weight after the diagnosis of celiac disease and initiation of the gluten-free diet? Hyperthyroidism: Thyroid disorders are commonly associated with celiac disease. 1 Low or Hypothyroid disease is more commonly seen and may result in weight gain, but an overactive thyroid (Hyperthyroid) can also occur, and may cause weight loss. Definition: Hyperthyroid disorders occur when the thyroid gland produces too much thyroid hormone. Thyroid hormones are responsible for regulating metabolism. Symptoms: Weight loss, poor sleep, diarrhea, tremors, nervous feeling, heart palpitations, hair loss, and muscle weakness Diagnosis: Hyperthyroid disorders are diagnosed through a series of blood tests that must be ordered by your physician. Treatment: Medications, surgery or radiation. The treatment varies based on your individual situation. Microscopic Colitis: This inflammatory disorder of the large intestine occurs more frequently in patients with celiac disease. 2 It can be related to taking certain medications so please always inform your doctor of all medications and supplements you are taking. Definition: An inflammatory process that occurs in the large intestine. It is divided into two types, collagenous or lymphocytic. It may be caused by medication but often times the cause is not known. Symptoms: Chronic, watery diarrhea, not bloody. This may be accompanied by stomach pain and/or cramping. Weight loss is common. Diagnosis: Requires a colonoscopy with a biopsy (a small piece of tissue is taken.) The tissue is examined under a microscope. Evaluation typically also involves blood and stool tests as well as an upper endoscopy to rule out other conditions such as celiac disease. Treatment: If caused by a medication, your doctor will change the causative medication. Some dietary changes have shown to be helpful such as decreasing caffeine, fat, and alcohol intake. Medications may be required to control symptoms. Small Intestinal Bacterial Overgrowth (SIBO): The incidence of SIBO in celiac disease is high, especially if patients are experiencing ongoing symptoms after starting a gluten-free diet. 3,4 SIBO is associated with many other conditions in addition to celiac disease. See the section on SIBO on this website for more detailed information. Definition: SIBO occurs when there is an increase in the number of abnormal types of bacteria in the small intestine. Symptoms: Gas, bloating, abdominal pain, diarrhea, malabsorption, maldigestion, weight loss, fatigue, etc. Diagnosis: The gold standard is taking an aspirate (take a sample of fluid) from the small intestine but most doctors will use a hydrogen and methane breath test for diagnosis. It is less invasive. Treatment: The underlying cause of SIBO must be treated first or SIBO may recur. If you have celiac disease this means following a lifelong gluten-free diet. Most physicians will start treatment with antibiotics and dietary changes such as eliminating lactose and reducing simple sugars. During treatment, supplemental nutrition may be needed with elemental formulas or fats if malabsorption and weight loss are severe. Treatment may have to be repeated if symptoms recur. 5 In mild cases, some practitioners may start with dietary changes and probiotics followed by antibiotics, if needed. Other Gastrointestinal Disorders: This list may include Ulcerative Colitis, Crohn s disease, Irritable Bowel Syndrome, and many others. 6 Other gastrointestinal disorders may occur with celiac disease and result in weight loss. Complete evaluation of this possibility should be addressed by your gastroenterologist. Lactose Intolerance: Lactose is the natural sugar found in milk. The inability to digest lactose properly results in gas/bloating, cramping, and often diarrhea. Lactose intolerance occurs commonly in patients with celiac disease and the persistent loose stool or diarrhea may result in weight loss. Please refer to the Lactose Intolerance section on for a detailed description of symptoms and treatment of this disorder. Fructose Malabsorption: Fructose and other closely related sugars known as FODMAPS are notoriously hard to digest even in a person with a healthy gastrointestinal tract. When digestion is impaired, such as in celiac disease, these sugars can create gastrointestinal symptoms and ongoing weight loss. A section on fructose malabsorption will be coming to in early 2014 or sooner. Pancreatic Insufficiency: The pancreas is an organ that sits behind the stomach and is responsible for producing enzymes that aid in the digestion of your food. Definition: Pancreatic insufficiency (PI) occurs when the pancreas no longer produces enough enzymes to properly digest food. This results in malabsorption. PI happens for many reasons but should be thought of in anyone with celiac disease who has ongoing symptoms after starting a gluten-free diet. Symptoms: Diarrhea, fatigue, weight loss, fat in the stools Diagnosis: An evaluation for all causes of malabsorption will be done and used in conjunction with the clinical presentation to determine the cause of malabsorption. Most practitioners do not test pancreatic enzyme levels due to the laborious nature of the test and the low risk associated with a trial of pancreatic enzymes. A trial of pancreatic enzymes may be tried and the clinical response to supplementation with enzymes is then assessed. Treatment: Pancreatic enzyme supplementation, dietary modifications, lowering fat intake, limiting alcohol and caffeine, and correction of any resulting nutritional deficiencies. Refractory Celiac Disease: This is a rare cause of ongoing weight loss in patients with celiac disease. Definition: Refractory celiac disease occurs when there are persistent symptoms including flattening of the villi in patients who have been on a gluten-free diet for more than 6 months. All other possible causes of ongoing symptoms must be eliminated before this diagnosis is made. Symptoms: Some patients improve on a gluten-free diet and then symptoms relapse; others never improve on a gluten-free diet and their symptoms persist. Typical symptoms are diarrhea, weight loss, and other symptoms of malabsorption, including nutritional deficiencies. Diagnosis: You must consider: Is the diagnosis of celiac disease correct? Have all other possible causes of ongoing symptoms been evaluated? If the answer is yes to these questions a repeat biopsy of the small intestine, colonoscopy, and often additional studies, such as capsule endoscopy, may be performed. Treatment: Hospitalization may be required. Several therapies may be used including immunosuppressive treatments, and IV nutrition. Vitamin Deficiencies: Vitamin deficiencies are common in celiac disease. Certain deficiencies such as zinc and iron may decrease a person s appetite and contribute to weight loss. Other deficiencies, such as vitamin E, may result in nausea and a decreased desire to eat. Please consult Common Nutritional Deficiencies of People with Celiac Disease on for potential deficiencies that may be contributing to weight loss. Cancer: Certain types of cancer have been shown to occur more frequently in people with celiac disease. The good news is their occurrence is rare. Early diagnosis and following a strict gluten-free diet brings your risk back to that of the non-celiac population in about 5 years. Definition: Certain lymphomas and cancers of the small intestine and esophagus are more common in undiagnosed celiac disease. The risk of these cancers is greatest in the first two years after diagnosis. Symptoms: Depend on the location/type of cancer but can include ongoing weight loss or difficulty gaining weight Diagnosis: If this is a concern, please consult your physician but know that this is a rare cause of ongoing weight loss in celiac disease. Treatment: Will depend on many factors Anxiety: Anxiety occurs more commonly in people with celiac disease when compared to the general population. 7 Definition: A persistent worry or concern beyond what is expected for a situation. It may cause interference with daily activities such as work, life, sleep, or diet. Symptoms: Feeling apprehensive, powerless, trembling, disrupted sleep, sweating, poor appetite Diagnosis: Medical causes must be evaluated first as possible causes of the anxiety. Treatment: Treat the underlying cause, if one is found. Counseling and medications may be needed. Depression: Depression is common in celiac disease and can result in a very poor appetite, insufficient caloric intake, and persistent weight loss. Definition: Persistent feeling of sadness or worthlessness that results in emotional and physical symptoms Symptoms: Loss of interest in activities, feeling of hopelessness, weight loss or gain, low energy, feelings of worthlessness, difficulty concentrating, poor/disrupted sleep Diagnosis: Medical causes of depression such as thyroid disorder, sleep disruption, and nutrient deficiencies should be considered and evaluated by your physician before starting any medications. Treatment: Eliminating gluten often improves depressive symptoms in celiac disease but may not fully eliminate them. Treatment will depend on the cause of the depression and may include such therapies as vitamins, exercise, addressing sleep disorders, or thyroid medications. If a medical cause is not found, counseling and anti-depressants may be used. TAKE HOME MESSAGES 1. Work with your physician and/or dietitian to determine the cause of your weight loss and initiate the proper therapy. 2. Using the proper medical or dietary treatment will have you on the road to a healthy weight and wellness in no time. References: 1. Counsell CE, Taha A, Ruddell WS. Coeliac disease and autoimmune thyroid disease. Gut Jun;35(6): Stewart M, Andrews CN, Urbanski S, Beck PL, Storr M. The association of coeliac disese and microscopic colitis: a large population based study. Aliment Pharmacol Ther Jun;33(12): Bures J, Cyrany J, Kohoutova D, Förstl M, Rejchrt S, Kvetina J, Vorisek V, Kopacova M. Small intestinal bacterial overgrowth syndrome. World J Gastroenterol Jun 28;16(24): Leffler D. Small Intestinal Bacterial Overgrowth. In Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free. Dennis, M., Leffler D, eds. AGA Press. Bethesda, MD, Rosania R, Giorgio F, Principi M, Amoruso A, Monno R, Di Leo A, Ierardi E. Effect of probiotic or prebiotic supplementation on antibiotic therapy in the small intestinal bacterial overgrowth: a comparative evaluation. Curr Clin Pharmacol May;8(2): Cottone M, Marrone C, Casà A, Oliva L, Orlando A, Calabrese E, Martorana G, Pagliaro L. Familial occurrence of inflammatory bowel disease in celiac disease. Inflamm Bowel Dis Sep;9(5): Hauser W, Janke K,Klump B, Gregor M, Hinz A. Anxiety and depression in adult patients with celiac disease on a gluten free diet. World J Gastroenterol June 14; 16(22): Revision Date: Author: Amy Burkhart MD, RD Editors: Melinda Dennis, MS, RD, LDN and Rupa Mukherjee MD
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