Statistics from Altmetric.com
Low carbohydrate diets are currently being promoted as an effective treatment for weight reduction.1 The most popular, the Atkins’ diet, is a worldwide bestseller with over 10 million book copies sold (the earliest being Dr Atkins’ New Diet Revolution2). Two randomised clinical trials in obese patients have shown effective weight loss at six months on the Atkins’ diet compared with a low fat calorie reduced diet although the difference was not significant or sustained at 12 months.3,4 The Atkins’ diet recommends unlimited protein and fat intake, with carbohydrate intake initially restricted to 20 g/day (5–10% of daily calorie intake), mainly as salad greens and other non-starchy vegetables. In the longer term maintenance phase, the diet remains low in cereal grains (wheat, rye, and barley), which are toxic in coeliac disease.
We report three patients seen in the last year who sought medical advice because of symptoms noticed after stopping the Atkins’ diet, which subsequently proved to be due to coeliac disease.
Case No 1
A 46 year old woman, with coexisting treated primary hypoadrenalism and autoimmune hypothyroidism, followed the Atkins’ dietary regimen strictly as published. She described “feeling amazing” and “wide awake” on the regimen. After six months she lost 12 kg and decided to reintroduce bread. She soon noticed bloating, tiredness, and upper abdominal pain. Her physician suspected coeliac disease and initiated testing for antiendomysial antibody (positive), with subsequent diagnostic duodenal biopsy (crypt hyperplastic partial villous atrophy). All symptoms resolved on a gluten free diet.
Case No 2
A 45 year old woman, with coexisting treated autoimmune hypothyroidism, followed the Atkins’ diet strictly as published for three months, losing 7 kg. On this regimen she described feeling “really well” and “fantastic”. On reintroducing bread she noticed symptoms of tiredness, abdominal gurgling noises, and pain, and increased flatulence. Her father was diagnosed with coeliac disease around this time. These symptoms led her to suspect coeliac disease. Subsequent tests showed positive antiendomysial antibody and small intestinal crypt hyperplastic partial villous atrophy. Her symptoms resolved on a gluten free diet.
Case No 3
A 43 year old woman who commenced a low carbohydrate diet (cutting out bread, pasta, potatoes, and rice but including fruit and vegetables) noticed increased wellbeing on this regimen. She reintroduced some bread at one month and noticed abdominal bloating and pain, with increased tiredness. These symptoms led her to suspect coeliac disease. Her physician found iron deficiency anaemia and subsequent tests showed positive antiendomysial antibody and small intestinal crypt hyperplastic partial villous atrophy. Her symptoms resolved on a gluten free diet except for occasional abdominal bloating.
Recent large studies (using highly sensitive and specific serological screening tests) have suggested coeliac disease is much more prevalent (∼1%) in the UK population than previously recognised.5,6 In addition to those symptoms presenting clinically, untreated coeliac disease has silent features, including anaemia, osteoporosis, and modest increases in overall risks of malignancy and mortality.7 In a recent prospective study of seven year old children, those with positive coeliac serology were significantly shorter and lighter.5 Awareness of coeliac disease has recently been increasing, and all major UK supermarket chains now stock a varied range of gluten free products.
Symptoms induced by wheat ingestion in coeliacs are often more marked after a period following a gluten free diet than occur prior to diagnosis and treatment. Consistent with this observation, interferon γ peripheral blood T cell responses to the immunodominant A-gliadin epitope (QLQPFPQPELPYPQPQS) after short term oral gluten challenge are not observed in untreated coeliac cases but are detectable in significant numbers after two weeks of a gluten free diet.8,9 The immunological basis of the heightened sensitivity after gluten withdrawal is unknown but intestinal immune responses to antigen are likely to be downregulated in conditions of ongoing chronic inflammation compared with those occurring in normal (treated) mucosa.
Although some individuals will have simple wheat intolerance, we conclude that the occurrence of gastrointestinal symptoms after a period following an Atkins-type low carbohydrate diet should prompt investigation for coeliac disease.
Conflict of interest: None declared.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.