Celiac News

Celiac Disease and Osteoporosis

Professional Advisory Board of the Canadian Celiac Association

Celiac disease is now widely recognized as a common cause of osteoporosis. A large portion of celiac patients who are not on a gluten-free diet have a reduced bone mass. In a recent Canadian celiac health survey, 27% of the respondents had been diagnosed with osteoporosis (25% or more bone loss), and another 10% with osteopenia (10-25% bone loss). Similar results have been reported in the USA and Finland.

Osteoporosis

In osteoporosis bone loss may result in spontaneous bone breakage or fractures from very little trauma (e.g., a simple fall from a standing height). Most commonly affected are the bones of the spine, ribs, hips and wrists.

Osteoporosis is more common in women than in men, partly because their total bone mass is less, and their rate of bone loss is generally greater.  After menopause there can be a rapid drop in bone mass related to a decline in female hormone levels.

The Celiac Connection

Celiac disease is an inherited medical condition, in which the absorptive surface of the small intestine is damaged by certain proteins of wheat, barley and rye, that are collectively called “gluten”. As the disease progresses, the body's ability to absorb protein, fat, carbohydrates, vitamins and minerals, especially calcium and vitamin D, is greatly reduced. Both calcium and vitamin D are essential in bone growth and repair, which partly explains why osteoporosis is so common in celiac disease. Another important factor in osteoporosis are cytokines, substances released into the bloodstream from the inflamed intestine, which increase bone loss. Recent studies also indicate that the autoimmune processes that damage the intestine in celiac disease also attack the bones. Osteoporosis can affect both male and female celiac patients at any age, if they are not on a strict gluten-free diet. If celiac disease is not recognized during childhood, affected individuals may not gain the optimum amount of bone during the period of adolescent bone growth to meet their skeletal needs in later life.

The symptoms of celiac disease vary greatly in number and severity from one person to another. This makes diagnosis difficult, and misdiagnosis is common. Symptoms of celiac disease include bloating, nausea and diarrhea. Other common symptoms, which are often not recognized as being related to intestinal damage include anemia, extreme tiredness, mouth ulcers, easy bruising, depression and others. One common symptom of celiac disease is bone and joint pain, which is thought to be related to bone depletion and vitamin D deficiency.

Celiac disease seriously affects bone growth in children, and many pediatricians now routinely screen for celiac disease in children who are short for their age, even if none of the typical gastrointestinal problems of celiac disease are present. It is also recommended that adults with osteoporosis, who have unexplained digestive difficulties, be screened for celiac disease. If celiac disease is suspected after blood screening (using a tissue transglutaminase [tTG], or an IgA endomysial antibody test), an intestinal biopsy must be done to provide a definitive diagnosis.

The only treatment for celiac disease is a strict gluten-free diet for life. It is essential that if a person suspects they have celiac disease, they should never go on a gluten-free diet before an intestinal biopsy is done, since it can seriously affect making an accurate diagnosis.

Celiac disease has recently been found to affect 1 in 133 in the United States. It is estimated that there could be as many as 250,000 Canadians with celiac disease, most of them yet undiagnosed.

The Good News

Research indicates that if celiac patients are diagnosed early and follow a strict and nutritious gluten-free diet for life they can prevent unnecessary further bone loss and fractures. In other words, their risk of osteoporosis can be reduced if celiac disease is diagnosed early and treated effectively! When children have been diagnosed with celiac disease, instituting a gluten-free diet usually will normalize bone mass within one or two years.

Once the bone loss has occurred in adults, the research is less clear whether full bone recovery is possible. However, most recent studies report that major improvements in bone mass are possible, if a strict gluten-free diet is followed. In some cases drug therapy may also be required to treat osteoporosis.

Guidelines for Healthy Bones

The following guidelines for good bone health should become part of everyone's lifestyle (not just those with celiac disease).

• Consume adequate amounts of calcium at all ages, preferably from milk and milk products. Calcium supplements may be used as an alternative. If lactose intolerance is a problem, use lactase enzyme or lactose reduced milk, or see your doctor or dietitian for the best calcium source for you. Bones continue to increase in density, in both males and females, until approximately 35 years of age, so adequate calcium throughout these years is essential to ensure maximum bone mass. During pregnancy and lactation, women’s needs for calcium are even higher.  Adequate calcium at this time can reduce the risk of osteoporosis in later years.
  
  
• Ensure adequate Vitamin D. See your doctor or dietitian for amounts and sources.
  
  
• Keep active with weight bearing exercises e.g., walking, low impact aerobics, dancing, hiking, stair climbing, resistance training and using weights.  Remember that pulling against gravity helps maintain bone mass.
  
  
• Moderate your intake of alcohol, coffee and salt since all of these, in excess, can be harmful to bone health. Limit alcohol to two drinks per day, and coffee to two or three cups.
  
  
• Don’t smoke, since smoking is another risk factor for osteoporosis.
  
  
• If you have been diagnosed with celiac disease, follow a gluten-free diet, and ask your doctor about having a bone density evaluation.

For More Information

• On celiac disease: The Canadian Celiac Association at 1-800-363-7296, or info@celiac.ca
• On required calcium levels: The Osteoporosis Society of Canada at www.osteoporosis.ca

Bibliography

• Brown JP, Josse RG. 2002 Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 2002;167 (10 suppl) S1-S34.

• Cranney A, Zarkadas M, Graham ID, Switzer C. The Canadian celiac health survey – the Ottawa chapter pilot. BMC Gastroenterol 2003;3:8.

• Kemppainen T, Kröger H, Janatuinen E, Arnala I, Kosma V-M, Pikkarainen P, Julkunen R, Jurvelin J, Alhava E, Uusitupa M.  Osteoporosis in adult patients with celiac disease.  Bone 1999;24:249-255.

• Meyer D, Stavropoulos S, Diamond B, Shane E, Green PHR. Osteoporosis in a North American adult population with celiac disease. Am J Gastroenterol 2001;96:112-119.

• Mora S, Weber G, Barera G, Bellini A, Pasolini D, Prinster C, Bianchi C, Chiumello G.  Effect of gluten-free diet on bone mineral content in growing patients with celiac disease. Am J Clin Nutr 1993;57:224-228.

• Valdimarsson T, Toss G, Löfman O, Ström M.  Three years follow-up of bone density in adult coeliac disease: significance of secondary hyperparathyroidism. Scand J Gastroenterol 2000;35:273-280.

• Vazquez H, Mazure R, Gonzalez D, Flores D, Pedreira S, Niveloni S, Smecuol E, Mauriño E, Bai JC.  Risk of fractures in celiac disease patients: a cross-sectional, case-control study. Am J Gastroenterol 2000;95:183-189.