Is it necessary to screen for celiac disease in adult idiopathic osteoporosis? A response longer than intended.

Low bone mineral density, reduced bone mass, increased fractures and osteoporosis are well-known, common symptoms of celiac disease, affecting up to 70% of celiac patients.[1] [2] [3] [4] In fact, a Brazilian study was just published in September that found a whopping 69% of patients with celiac disease (N=101) have low bone mineral density.[5] Malabsorption resulting in nutritional deficiencies that compromise bone mineral density are especially common during the initial year of treatment for celiac disease. [6]

If so many of us with celiac disease also have low bone mineral density, is the reverse true and do a large percentage of those diagnosed with osteoporosis have celiac disease and therefore is testing of ALL osteoporotic patients for celiac disease warranted? A Tehran University of Medical Sciences study, also recently published in 2015, sought to answer this question and concluded that “the prevalence of celiac disease in osteoporotic patients is not high enough to justify recommendation for serologic screening of celiac disease in all patients with idiopathic osteoporosis”.[7] In their study of 460 osteoporosis patients, only 5 were found to also have celiac disease.

Unfortunately, this recent study has been used to justify not testing for celiac disease when osteoporosis is present. There are several problems with this justification. First, the biggest problem with this study is that it excludes osteoporosis patients that already had a diagnosis of celiac disease at the time of the study! The study fails to report how many were excluded for this reason. That means this study is really only showing the prevalence of UNDIAGNOSED celiac disease among idiopathic osteoporosis patients.

Second, the study excluded all osteoporosis patients that also had a diagnosis of thyroid disease and again did not report how many were excluded for this reason and the study did not test those with thyroid disease for celiac disease. Alessio Fasano, in fact, reported back in 2003 in a large study (N=13,145) that about one-half of newly diagnosed celiac disease patients have thyroid disease.[8] Even the more conservative, long-term longitudinal Swedish study in 2008  (N=14,021) found that adults with celiac disease are 4.4 times more likely to have hypothyroidism and 2.9 times more likely to have hyperthyroidism compared to the general public.[9] The same study found that in children with celiac, those rates are even higher at 6 times the likelihood of developing hypothyroidism and 4.8 times the risk of developing hyperthyroidism. In bone, calcium is regulated by the parathyroid hormone and hyperparathyroidism is common in untreated celiac disease and is actually characterized by high bone turnover and cortical bone loss.[10] [11]

Third, even the authors’ final conclusion was that testing for celiac disease is warranted, “when in addition to osteoporosis, any other symptoms of celiac disease are also present.” The authors went on to list only intestinal celiac symptoms. As we know, based on the work of Fasano and others there are over 200 different symptoms of gluten sensitivity and most patients are actually asymptomatic. In fact, bone mineral density may be even lower in clinically silent CD patients than in symptomatic celiac patients![12] [13] [14]

Fourth, the results of other studies contradict the results of the Iranian study, likely because patients with celiac disease and/or thyroid disease were rightfully not excluded from the other studies. For example, a small 2007 Slovakian study of 52 women diagnosed with idiopathic osteoporosis found over 40% to also have celiac disease![15]

What does this mean for us?

Unfortunately, in the US at this time, patients diagnosed with low bone mineral density are not automatically screened for celiac disease, but based on this research, they should be! This makes it our responsibility to spread awareness and education as to possible symptoms of celiac disease and to make sure that when friends and family are diagnosed with osteoporosis, pre-osteoporosis or any form of low bone mineral density that we share with them the research about celiac disease, strongly recommend that they get tested for celiac disease and support them with how to be successfully and healthily gluten-free if they do receive a diagnosis of celiac disease. We are all in this together! It is our responsibility to support our community to support ourselves.

Second, have you been tested for osteoporosis? Unfortunately, early signs of pre-osteoporosis are not often easy to discover. The Mayo Clinic lists the symptoms of osteoporosis as back pain, loss of height, a stooped posture and bone fractures that occur easier than expected.[16] I would also add that bone fractures that resist healing is another symptom. Due to the common co-occurrence of celiac disease and osteoporosis, if you have any question regarding your bone density status or mineral levels, why not get your bone mineral density tested the next time you are scheduled for a check-up so that you have a baseline level to work from?

Likewise, have you retested for mineral levels post-diagnosis or were you tested for mineral levels and anemia originally? If your mineral levels were low at diagnosis of celiac disease, have levels come back up? The nutrients that tend to be most impacted by celiac disease that also most influence bone mineral density are zinc, iron, magnesium, vitamin D, calcium, folate and vitamin B12.[17] [18]

As you already know, as a result of celiac or non-celiac gluten sensitivity diagnosis, the more information we can access about our bodies the more equipped we are to create more health in our lives. Having celiac disease with low bone mineral density or nutrient deficiencies is simply another reason to adhere to a strictly gluten-free diet and avoid any risks of gluten cross-contamination, even if we have no noticeable external symptoms. Improvements in bone mineral density after beginning a gluten-free diet can take as long as two to five years after mucosal recovery and mucosal recovery is dependent on strict adherence to the gluten-free diet and avoiding any gluten cross-contamination.[19] [20] [21] [22]

In addition to being strictly gluten-free, if you have low bone mineral density, low mineral levels or anemia, it may be necessary for you to supplement with nutrients and consume a more nutrient dense gluten-free diet. Even when supplementing with Vitamin D and calcium, a 2010 study published in Gastroenterology found that nutritionally compromised celiac patients with malabsorption associated malnutrition did not improve within a year although those supplementing that were less nutritionally compromised had improved bone mineral density, progressing from osteoporosis to an osteopenia (decreased bone density no longer characterized as osteoporosis) within the year.[23]

Supplementation with Vitamin D, combined with Vitamin K has been shown to increase bone mineral density in osteoporosis and reduce fracture rates by supporting calcium balance.[24] Additionally, depending on malabsorption and nutrient deficiency levels, celiac disease patients may benefit from supplementing with iron, folate, B12, vitamin D, vitamin K, calcium, magnesium and docosahexaenoic acid (DHA).[25] [26] The typical, highly processed, high glycemic gluten-free diet has extreme nutrient density shortcomings and can worsen nutrient deficiencies if not improved upon.[27] If your bone mineral density and nutrient deficiencies do not improve within a year, it is recommended that you contact a nutritionist with celiac disease expertise that can support you to improve both your dietary and supplementation choices.

Sources Referenced

[1] Vazquez H, Mazure R, Gonzales D, Flores D, Pedreira S, Niveloni S, et al. Risk of fractures in celiac disease patients: a cross-sectional, case-control study. Am J Gastroenterol. 2000;95:183–89. http://www.ncbi.nlm.nih.gov/pubmed/10638580

[2] Albulova, E.A.; Drozdov, V.N.; Parfenov, A.I.; Viazhevich Iu, V.; Petrakov, A.V.; Varvanina, G.G. Bone mineral density in patients with gluten-sensitivity celiac disease. Ter. Arkh. 2010, 82, 43–48. http://europepmc.org/abstract/med/20387675

[3] Bianchi, M.L., Bardella, M.T. Bone in celiac disease. Osteoporos Int. 2008;19:1705–1716. http://www.ncbi.nlm.nih.gov/pubmed/18418638?dopt=Abstract

[4] Meyer, D., Stavropolous, S., Diamond, B. et al, Osteoporosis in a North American adult population with celiac disease. Am J Gastroenterol. 2001;96:112–119. http://www.ncbi.nlm.nih.gov/pubmed/11197239?dopt=Abstract

[5] Silva J.T.P, Nisihara R.M, Kotze L.R., Olandoski M., Kotze L.M.S. Low bone mineral desnity in Brazilian Patients at Diagnosis of Celiac Disease. Arquivos de Gastroenterologia. 2015; 52:3, 176-179. https://dx.doi.org/10.1590/S0004-28032015000300004

[6] Caraceni, M.P.; Molteni, N.; Bardella, M.T.; Ortolani, S.; Nogara, A.; Bianchi, P.A. Bone and mineral metabolism in adult celiac disease. Am. J. Gastroenterol. 1988, 83, 274–277. http://www.ncbi.nlm.nih.gov/pubmed/3257843

[7] Shahbazkhani, B., Aletaha, N., khonche, A., Farahvash, B., & Malekzadeh, R. (2015). Is it necessary to screen for celiac disease in adult idiopathic osteoporosis? Gastroenterology and Hepatology From Bed to Bench, 8(2), 140–145. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4403026/

[8] Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States. Arch Intern Med. 2003;163(3):286-292. http://www.ncbi.nlm.nih.gov/pubmed/12578508

[9] Elfström P, Montgomery SM, Kämpe O, Ekbom A, Ludvigsson JF. Risk of thyroid disease in individuals with celiac disease. J Clin Endocrinol Metab. 2008;93(10):3915-3921. http://www.ncbi.nlm.nih.gov/pubmed/18611971

[10] Krupa-Kozak, U. Pathologic bone alterations in celiac disease: Etiology, epidemiology, and treatment. Nutrition 2014, 30, 16–24. http://www.ncbi.nlm.nih.gov/pubmed/24290593

[11] Zanchi, C.; Di Leo, G.; Ronfani, L.; Martelossi, S.; Not, T.; Ventura, A. Bone metabolism in celiac disease. J. Pediatr. 2008, 153, 262–265. http://www.ncbi.nlm.nih.gov/pubmed/18534236

[12]  Mazure R, Vazquez H, Gonzalez D, Mautalen C, Pedreira S, Boerr L, et al. Bone mineral affectation in asymptomatic adult patients with coeliac disease. Am J Gastroenterol. 1994;89:2130–34. http://www.ncbi.nlm.nih.gov/pubmed/7977227

[13] Cellier C, Flobert C, Cormier C, Roux C, Schmitz J. Severe osteopenia in symptom-free adults with a childhood diagnosis of coeliac disease. Lancet. 2000;355. http://www.ncbi.nlm.nih.gov/pubmed/10711931

[14] Mustalahti K, Collin P, Sievanen H, Salmi J, Mäki M. Osteopenia in patients with clinically silent celiac disease warrant screening. Lancet. 1999;28:744–45. http://www.ncbi.nlm.nih.gov/pubmed/10475193

[15] Kubincová L, Payer J, Killinger Z, Macugová I, Beráková K. Celiac disease–a frequent cause of “idiopathic osteoporosis” in premenopausal and early postmenopausal women. Vnitr L. 2007 Dec;53(12):1296-302. http://www.ncbi.nlm.nih.gov/pubmed/18357865

[16] Mayo Clinic Staff (2014). Osteoporosis Symptoms. Mayo Clinic, Dec 13. http://www.mayoclinic.org/diseases-conditions/osteoporosis/basics/symptoms/con-20019924

[17] Caruso, R.; Pallone, F.; Stasi, E.; Romeo, S.; Monteleone, G. Appropriate nutrient supplementation in celiac disease. Ann. Med. 2013, 45, 522–531. http://www.ncbi.nlm.nih.gov/pubmed/24195595

[18] Garcia-Manzanares, A.; Tenias, J.M.; Lucendo, A.J. Bone mineral density directly correlates with duodenal marsh stage in newly diagnosed adult celiac patients. Scand. J. Gastroenterol. 2012, 47, 927–936. http://www.ncbi.nlm.nih.gov/pubmed/22587226

[19] Hjelle, A.M.; Apalset, E.; Mielnik, P.; Bollerslev, J.; Lundin, K.E.; Tell, G.S. Celiac disease and risk of fracture in adults—A review. Osteoporos. Int. 2014, 25, 1667–1676. http://www.ncbi.nlm.nih.gov/pubmed/24691647

[20] Ludvigsson, J.F.; Michaelsson, K.; Ekbom, A.; Montgomery, S.M. Coeliac disease and the risk of fractures–A general population-based cohort study. Aliment. Pharm. Ther. 2007, 25, 273–285. http://dx.doi.org/10.1111/j.1365-2036.2006.03203.x

[21] Capriles, V.D.; Martini, L.A.; Areas, J.A. Metabolic osteopathy in celiac disease: Importance of a gluten-free diet. Nutr. Rev. 2009, 67, 599–606. http://www.ncbi.nlm.nih.gov/pubmed/19785691

[22] Larussa, T.; Suraci, E.; Nazionale, I.; Abenavoli, L.; Imeneo, M.; Luzza, F. Bone mineralization in celiac disease. Gastroenterol. Res. Pract. 2012, 2012, 198025. http://www.ncbi.nlm.nih.gov/pubmed/22737164

[23] Papamichael, K.; Kokkinakis, E.; Archavlis, E.J.; Theodoropoulos, I.; Tzivras, D.; Karakoidas, C.; Papaioannou, F.; Tsironikos, D.; Karga, H.; Mantzaris, G.J. S2044 effect of a gluten-free diet on bone mineral density in patients with celiac disease. Gastroenterology 2010, 138, S308. http://dx.doi.org/10.1016/S0016-5085(10)61416-3

[24] Weber, P. Vitamin K and bone health. Nutrition 2001, 17, 880–887. http://www.ncbi.nlm.nih.gov/pubmed/11684396

[25] Hadithi, M.; Mulder, C.J.; Stam, F.; Azizi, J.; Crusius, J.B.; Pena, A.S.; Stehouwer, C.D.; Smulders, Y.M. Effect of B vitamin supplementation on plasma homocysteine levels in celiac disease. World J. Gastroenterol. 2009, 15, 955–960. http://www.ncbi.nlm.nih.gov/pubmed/19248194

[26] Genuis, S.J.; Bouchard, T.P. Combination of micronutrients for bone (comb) study: Bone density after micronutrient intervention. J. Environ. Public Health 2012, 2012, 354151. http://www.ncbi.nlm.nih.gov/pubmed/22291722

[27] Hallert, C.; Grant, C.; Grehn, S.; Granno, C.; Hulten, S.; Midhagen, G.; Strom, M.; Svensson, H.; Valdimarsson, T. Evidence of poor vitamin status in coeliac patients on a gluten-free diet for 10 years. Aliment. Pharmacolo. Ther. 2002, 16, 1333–1339. http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2036.2002.01283.x/abstract