Despite being less likely to be overweight, have high blood pressure or cholesterol, a higher risk persists
By Amy Ratner, director of scientific affairs
Despite being less likely to be overweight, have high blood pressure or high cholesterol and other known risk factors, people who have celiac disease may be more likely to develop heart disease than people who don’t, according to a new UK study.
The equivalent of an annual rate of 9 in every 1,000 people with celiac disease developed cardiovascular disease compared to an annual rate of 7.4 in 1,000 people who did not have celiac disease, researchers from the University of Oxford found.
The study was based on data from the UK Biobank, which tracks health information including hospital records for nearly half a million people from England, Scotland and Wales. Over the 12 years of the study, about 41,000 people developed heart disease, including coronary heat disease, heart attack and stroke. Of these, 218 of about 2,000 people with celiac disease had cardiovascular events.
The reason for the increased risk isn’t known, but study authors hypothesize that the systemic inflammation found in celiac disease, as well as other autoimmune conditions, might be to blame. Another possibility is that a gluten-free diet could contribute because processed gluten-free foods can be higher in saturated fats, sugar and salt and lower in whole grains, which are heart healthy.
“Celiac disease was associated with a 27 percent increased risk of cardiovascular disease compared to participants who did not have celiac disease,” the study, published in the journal BMJ Medicine, says.
The risk of cardiovascular disease overall is high, with about 50 percent of people developing some form in their lifetime, so the fact that the study found it is 0.27-fold higher in those with celiac disease, is “somewhat important,” said Dan Leffler, MD, a gastroenterologist at Beth Israel Deaconess Medical Center and medical director of clinical science at Takeda Pharmaceutical Company, who was not involved in the study. For comparison, intestinal cancer in those with celiac disease is 10-fold higher than the general population, but intestinal cancer overall is rare, he said.
“To put the .27-fold increase in perspective, the risk of cardiovascular disease from smoking ranges from 2-fold to 8-fold,” Leffler noted. “So anywhere from 10 to 40 times higher risk than from having celiac disease.”
The increased risk persisted despite the fact that study participants with celiac disease were more likely to have lower body mass index and systolic blood pressure and less likely to smoke, all of which are traditional risk factors for heart disease.
Still, for those with celiac disease, the “modestly increased” risk of cardiovascular disease makes it even more important to avoid smoking and to exercise, maintain a healthy diet and keep an eye on cholesterol and blood pressure,” Leffler said.
When researchers broke the data down by time since diagnosis, they found that the risk of cardiovascular disease increased the longer someone had been diagnosed. Those who had celiac disease for less than 10 years had a 30 percent increased risk compared to those who don’t have celiac disease and those diagnosed for more than 10 years a 34 percent greater risk.
The study is likely the largest, longitudinal investigation of the association between celiac disease and cardiovascular disease that adjusted for lifestyle, medical and cardiovascular risk factors, the authors wrote. Those factors included smoking, family history of heart disease, blood pressure and cholesterol medication use and physical activity, as reported by study participants. All participants also gave consent for researchers to access electronic health records to allow for collection of information over time.
Those with celiac disease were also more likely to have an ideal cardiovascular risk score, according to the study. Consequently, risk scores used by physicians might not adequately capture the excess risk of heart disease in people with celiac disease, the study says.
Researchers looked at cardiovascular risk factors only once, when participants joined the study, so they don’t know if risk changed over time, something identified as a limitation.
Although one possible explanation for the added risk is related to the gluten-free diet, the study did not take the diet into account because the questionnaire filled out by biobank participants only asked if a wheat-free diet was being followed. “The impact of the gluten-free diet could not be assessed,” the study says.
Researchers noted that more investigation is needed to determine if risk is reduced by the gluten-free diet in people who have celiac disease or whether the diet contributes to increased risk.
Previous research into celiac disease and cardiovascular risk has had conflicting results, the new study notes. Some show an increased risk, while others show no association. But most studies did not adjust for lifestyle and other health related factors. Based on the conflicting evidence, cardiovascular disease is not considered a complication of celiac disease by the National Institute for Health and Care Excellence, the body that sets guidelines for care in the UK. Likewise, cardiovascular disease is not recognized as a complication in the United States.
Leffler said the new study is good, though not dramatically different from earlier investigations based on Swedish data. It’s not clear the study found a degree of risk that on a population level warrants inclusion of cardiovascular disease as complication of celiac disease, he noted. “But this is definitely a discussion that should happen and awareness of the potential complications of celiac disease needs to improve,” he said, adding that the study demonstrates the value of the UK Biobank and other large research initiatives.
“While I wouldn’t want anyone to lose sleep over this, it reinforces that celiac disease is a serious lifelong condition and deserves to be taken seriously by clinicians,” Leffler said. “It also reinforces how much we still have to learn about celiac disease, and I hope encourages people to be involved in research.”
You can read more about the study here.
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