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Sirs,

We welcome the paper by De Marchi et al.[1] describing a possible increased risk of atherosclerosis in young adults with coeliac disease. The authors aimed to evaluate features of early atherosclerosis in 20 adults with coeliac disease (CD) at the time of diagnosis, and after 6–8 months of a gluten-free diet.

All patients were studied for total cholesterol, high-density lipoprotein and low-density lipoprotein cholesterol, triglycerides, C-reactive protein, plasma concentration of folic acid, vitamin B12 and homocysteine; moreover, study participants underwent colour doppler ultrasound measurement of carotid intima-media thickness (IMT) and endothelium-dependent dilatation (EDD) evaluation of the humeral artery.

According to their results, coeliac patients at diagnosis showed an increased IMT and a decreased EDD, suggesting early vascular dysfunction; surprisingly, both these parameters returned within the normal ranges after only 6–8 months on a gluten-free diet.

However, some limitations of the study should be taken into account. First, the authors clearly stated that the study had a small size and lacked a power calculation, both features requiring a high degree of caution when interpreting clinical data. Moreover, some doubts arise with regard to the control group: the choice of health providers as controls does not seem appropriate, as it has been demonstrated that this group might be scarcely representative of the overall population and introduces a selection bias in observational studies.[2]

Secondly, the excellent rate of mucosal healing after only 6–8 months of strict gluten avoidance in the coeliac group has not been so commonly reported, especially among adults.[3] It could be speculated that these patients perhaps had a relatively recent onset of disease, thus questioning whether the study findings are generalisable for the whole Italian coeliac population prior to diagnosis, who may theoretically have a better lipid profile – regardless of the inflammation markers – and both normal IMT and EDD.

In conclusion, the possibility of an increased risk of early atherosclerosis in young adults with coeliac disease underscores once more the ‘changing paradigm’ of coeliac disease, previously labelled as a mere enteropathy with malabsorption and nowadays fully considered as a systemic immune disorder.[4] However, these findings need to be confirmed in larger and unbiased studies.

Acknowledgement

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Declaration of personal and funding interests: None.

References

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  3. References