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The Link Between Celiac Disease and Osteoporosis

By Kaley Todd, MS, RDN

Patients with celiac disease not only have gastrointestinal and possibly mental health issues to contend with; they also have to be concerned about their bone health, as the disease is associated with osteoporosis.

Osteoporosis is a known complication of celiac disease; it usually occurs due to malabsorption of calcium and vitamin D. Malabsorption occurs because gluten aids in the destruction of the villi lining the small intestine, a circumstance that results in less available surface area to absorb calcium and vitamin D, key nutrients for bone health. Other possible causes include secondary hyperparathyroidism or autoimmune factors, which may impact bone remodeling, as well as inflammation that can alter bone formation.

Osteoporosis is a disease in which bones are less dense than normal, making them more fragile and more likely to break. In a related condition, called osteopenia, bone density is lower than normal but isn’t low enough to qualify as osteoporosis.

Osteoporosis affects men and women of all races; however, postmenopausal white and Asian women are at highest risk due to differences in bone mass and density compared with other ethnic groups. Bones also tend to thin with age, and there’s a direct relationship between the lack of estrogen postmenopause and osteoporosis development.

When an individual with celiac disease consumes gluten, an immune response in the small intestine occurs; over time, it damages the villi of the small intestine. These fingerlike projections that line the small intestine are responsible for key nutrient absorption; thus, as a result, nutrient malabsorption occurs. It’s a common disorder estimated to affect approximately 1 in 100 individuals. However, according to the Celiac Disease Foundation, 83% of people with celiac disease don’t know they have it, a circumstance that paves the way for osteoporosis development.

The prevalence of osteoporosis and osteopenia in patients newly diagnosed with celiac disease may be as high as 75%, while only 35% of diagnosed celiac disease patients have established osteoporosis. Low bone density is common in children and adults with celiac disease; however, the risk of osteoporosis is especially high in celiac patients who weren’t diagnosed until adulthood because, as a result of consuming gluten for so long, their small intestines haven’t absorbed enough calcium and vitamin D for an extensive amount of time.

Protecting the bones should take precedence in MNT for patients with celiac disease. Clinical trials and cross-sectional studies have reported reduced bone mineral content and bone mineral density in untreated children, adolescents, and adults with celiac disease. They have shown significant improvement when complying with a gluten-free dietary pattern for at least one year. Early compliance with dietary treatment during childhood or adolescence enables patients to achieve normal bone mineralization. However, studies in untreated adults have shown that a gluten-free dietary pattern improves but may not normalize bone mineral density. Patients who don’t receive treatment in childhood and adolescence may never reach peak bone mass; thus, successful treatment depends on the age at diagnosis.

Continually monitoring bone status is critical in caring for celiac patients. “Evaluating bone health in pediatric and adult patients with celiac disease is important, including checking blood calcium and vitamin D levels,” says Shelley Case, RD, author of Gluten Free: The Definitive Resource Guide. “Bone mineral density [BMD] testing is recommended for newly diagnosed adults with classic malabsorption symptoms and/or clinical manifestations suggestive of bone disease. Asymptomatic adults with risk factors for low BMD or high celiac serology markers also may undergo BMD testing.” Case recommends individuals with celiac disease consume age-appropriate amounts of calcium and vitamin D through dietary sources and/or supplementation if necessary.

In addition to a gluten-free diet, a well-balanced diet rich in calcium and vitamin D is important for healthy bones. The Institute of Medicine recommends a daily calcium intake of 1,000 mg for men and women up to age 50. Women over age 50 and men over age 70 should increase their intake to 1,200 mg daily. The recommended intake for vitamin D is 600 to 800 IU per day. Older individuals often are deficient in this vitamin and may need vitamin D supplements to achieve the required intake.

Dietitians are instrumental in helping patients manage celiac and prevent any bone issues. Amy Jones, MS, RD, LD, chief clinical dietitian at Mary Rutan Hospital in Bellefontaine, Ohio, and outgoing chair of the Dietitians in Gluten Intolerance Diseases practice group of the Academy of Nutrition and Dietetics, believes “Food is the number one best defense to help manage celiac disease and prevent osteoporosis in celiac patients.” She recommends dairy consumption to help boost calcium and vitamin D levels; however, she also suggests other sources including almonds, calcium-enriched tofu, fortified juices, and nut milks.

According to Jones, newly diagnosed celiac patients initially can exhibit secondary lactose intolerance. “In such patients, I recommend yogurt, cheeses, and alternative calcium-fortified foods,” Jones says. Lactose intolerance issues typically will clear up once such individuals begin to follow a gluten-free diet. Additional dairy foods can be added slowly as tolerated, she says. Using lactase enzyme supplementation, while consuming dairy, is something she suggests to consider in certain individuals. To promote vitamin D intake, spending time in the sun and including good vitamin D food sources such as sardines, saltwater fish, egg yolks, and liver are recommended. Calcium and vitamin D supplements also can help if patients aren’t consuming sufficient amounts of these nutrients each day through food.

Exercise also should be encouraged since, like muscle, bone is living tissue that grows stronger with physical activity. The best kind of activity for bones is weight-bearing exercises. Avoiding smoking and keeping alcohol consumption to a minimum also are lifestyle factors that can help protect bones.

Patient awareness of hidden gluten sources also is critical in managing celiac disease and preventing associated complications. A session presented at the annual Food & Nutrition Conference & Expo™ of the Academy of Nutrition and Dietetics in October 2016 identified beer with the gluten removed and other fermented foods as possible trace sources of gluten that may cause problems in celiac disease patients. According to Jones, the session’s moderator, soy sauce, marinades, condiments, and certain medications also are potential sources that may contain gluten and be problematic. Dietitians should work closely with their patients to help them identify foods they can consume safely, as well as potential sources that could be harmful.

— Kaley Todd, MS, RDN, is the dietitian for Sun Basket, a healthy meal kit delivery service. In addition, she’s a freelance writer, clinician, and culinary and communications specialist. She’s also the founder of Kaley Todd Nutrition at kaleytoddnutrition.com.