Bones and Coeliac Disease

[kickingfrog]

Bones and Coeliac Disease




*********************
The Institute of Genetics and Molecular Medicine

The University of Edinburgh


Osteoporosis and coeliac disease link
9 October 2009

People with coeliac disease may develop osteoporosis because their immune system attacks their bone tissue, a new study has shown.
It is the first time an autoimmune response - a condition whereby the body can attack itself - has been shown to cause damage to bones directly.

IGMM researchers studied a protein called osteoprotegerin (OPG) in people with coeliac disease - a digestive condition that affects 1 in 100 people.
In healthy people, OPG plays a crucial role in maintaining bone health by controlling the rate at which bone tissue is removed.
The latest research shows that 20 per cent of coeliac patients produce antibodies that attack the OPG protein and stop it working properly. This results in rapid bone destruction and severe osteoporosis.
It was previously thought that osteoporosis - a known complication of coeliac disease - develops in coeliac patients because they cannot properly absorb calcium and vitamin D from their diet. Both nutrients are essential for healthy bone development.
The team found that although this new form of osteoporosis did not respond to calcium and vitamin D supplements, it can be easily treated with drugs that prevent bone loss.
The research is published in the New England Journal of Medicine.
Professor Stuart Ralston, of the Institute of Genetics and Molecular Medicine, who led the team, said: “This is a very exciting step forward. Not only have we discovered a new reason to explain why osteoporosis occurs in coeliac disease, but we have also found that it responds very well to drugs that prevent bone tissue removal.
Testing for these antibodies could make a real and important difference to the lives of people with coeliac disease by alerting us to the risk of osteoporosis and helping us find the correct treatment for them.”




************************************




Osteoporosis and Osteomalacia in Patients with Celiac Disease


Elizabeth Shane, M.D., Endocrinologist

The incidence of osteoporosis in patients with Celiac Disease varies somewhat. The incidence is higher with more severe disease and older age at diagnosis. When children present with Celiac Disease, they usually have evidence of delayed or poor growth, and bone density, if measured, is low.
When a gluten-free diet is maintained, there is usually an increase in bone mass, and the growth rate usually improves.
Some studies suggest that children with Celiac Disease who are diagnosed at a young age and treated effectively will have normal bone mass when they reach adulthood.
Adults who have had lifelong undiagnosed Celiac Disease are more likely to have lower bone density than the average person their age. They are significantly more likely to already have had broken bones than are age and se x matched controls.
Patients with Celiac Disease may also have a different bone disorder called osteomalacia. Osteomalacia differs in several respects from osteoporosis.
In osteomalacia, the amount of bone may be normal, but there is less mineral in the bone. Bone formation is a two-step process. Bone is first made as soft tissue; after the bone has been laid down, calcium and phosphorus are deposited in the tissue, and it hardens.
In osteomalacia, less calcium and phosphorus are deposited into bone. This makes the bone soft and more pliable. In children, the long bones of the legs will bend and bow, which is called rickets.
In contrast to osteoporosis, there are usually symptoms with osteomalacia. The bones may ache and feel sore to the touch. For example, it is common to have hip or heel pain when you stand.
Fractures do occur, but they tend to be a little different from osteoporatic fractures. It is important for the physician and the patient to know whether they’re dealing with osteoporosis or osteomalacia, because they are treated differently, and certain therapies that might make osteoporosis better might make osteomalacia worse.
The definitive diagnosis of osteomalacia is made by bone biopsy, where excess unmineralized bone can be seen, although tests of blood and urine may also be helpful.

www.enabling.org/ia/celiac/osteopo.html#index

******************************************

Bone Mass and Gastrointestinal Disease

CAROL E. SEMRAD
Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
Address for correspondence: Carol E. Semrad, Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York, NY 10032. Voice: 212-305-8156; fax: [phone].
"mailto:[e-mail]"

Several gastrointestinal and liver diseases impair the absorption of calcium, phosphate, and/or vitamin D, and are associated with an increased incidence of bone disease. Changes in bone mineral density (BMD) using dual-energy X-ray absorptiomety (DXA) have been best studied in the malabsorptive disorder, celiac disease. Celiac disease is an inflammatory condition of the small intestine triggered by ingesting gluten present in wheat, rye, or barley. Chronic inflammation leads to intestinal atrophy and nutrient malabsorption.
The disease affects the proximal small bowel; the site where calcium is best absorbed. About 70% of adults with celiac disease have abnormally low BMD values.
Treatment with a gluten-free diet increases BMD, but not to normal values. As celiac disease may not be detected until adult life, the failure to reach normal BMD on a gluten-free diet can be explained, at least in part, by the failure to reach peak bone mass.
All individuals with malabsorptive disorders should be screened for secondary bone disease. The development of easier and less expensive methods to assess BMD will facilitate screening those at risk for bone disease.

Annals of the New York Academy of Sciences 904:564-570 (2000)
© 2000 "/misc/terms.shtml"

*****************************************

Bone and bone health


In adults, poor compliance to their gluten-free diet, and persistent villous atrophy are both associated with low bone mineral density. In a study by Mora et al, lumbar spine and whole body bone mineral density values in children and adolescents, at the diagnosis of coeliac disease, were found to be significantly lower than in control subjects. However, a gluten-free


www.coeliaccentre.org/en/

*****************************************************
Magnesium deficiency: possible role in osteoporosis associated with gluten-sensitive enteropathy.

Rude RK, Olerich M.

…This study demonstrates that GSE patients have reduction in intracellular free Mg2+, despite being clinically asymptomatic on a gluten-free diet. Bone mass also appears to be reduced. Mg therapy resulted in a rise in PTH, suggesting that the intracellular Mg deficit was impairing PTH secretion in these patients. The increase in bone density in response to Mg therapy suggests that Mg depletion may be one factor contributing to osteoporosis in GSE. ….


www.ncbi.nlm.nih.gov/pubmed/9116391

*****************************


Osteoporosis in people with coeliac disease

I have been sent a booklet from National Osteoporosis Society called 'Osteoporosis in people with coeliac disease: recommendations'.
This is very helpful, telling you about osteoporosis & CD, bone & bone health, treatment & prevention of osteoporosis in people with CD.
It points out that research re people with CD on GFD 'with daily calcium intake of 860mg/day were shown to have osteoporosis, whilst those with an intake of 1054mg/day were shown to have normal BMD' (bone mineral density).
You can get the booklet from NOS.

www.nos.org.uk/

**************************************


Silent Coeliac Disease (and increase of bone density on a gluten free diet)

acta.uta.fi/pdf/951-44-5721-8.pdf


*******************************************
International Osteoporosis Foundation

Osteoporosis in the EC

www.iofbonehealth.org/

*****************************************

What is osteoporosis?

C Christodoulou and C Cooper
MRC Environmental Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton

Correspondence to:
Professor C Cooper, MRC Environmental Epidemiology Unit, Southampton General Hospital, Southampton SO16 6YD, UK;
[e-mail]

…Osteoporosis is a very common disorder, which results in an increase in fracture risk. The annual cost attributable to hip, vertebral, and wrist fractures in England and Wales is £1.7 billion.
Significant mortality and morbidity are associated with osteoporotic fractures.
The method that is most widely used for the diagnosis of osteoporosis is dual energy x-ray absorptiometry.
The aim of prevention and treatment of osteoporosis is to prevent the occurrence of future fractures.
Lifestyle changes should be encouraged in high risk patients.
Pharmacological treatments include the bisphosphonates, hormone replacement therapy, selective oestrogen receptor modulators calcitonin, the 1–34 fragment of parathyroid hormone, calcium and vitamin D supplements…


pmj.bmj.com/content/79/929/133.abstract

**********************************

Bone mass and metabolism in patients with celiac disease

BACKGROUND & AIMS: Several aspects of the pathogenesis of osteopenia in celiac disease are still unclear. Therefore, bone mass and metabolism were evaluated in adults with celiac disease in a cross-sectional study.
METHODS: Bone mineral density (BMD), assessed by total body dual- photon absorptiometry, and serum indices of bone metabolism and remodeling were evaluated in 17 patients with untreated celiac disease, 14 with celiac disease on a gluten-free diet, and 24 healthy volunteers.
RESULTS: BMD, expressed as a z score, was significantly lower in patients with untreated celiac disease than in patients with treated celiac disease and volunteers and lower in patients with treated celiac disease than in volunteers. Similar changes were observed in serum calcium level, whereas intact parathyroid hormone level was significantly higher in untreated than in treated patients with celiac disease and volunteers, and no difference was found between the latter two groups. 25-Vitamin D level was significantly lower and 1,25-vitamin D level significantly higher in untreated celiac disease than in treated celiac disease and volunteers. Indices of bone remodeling were significantly higher in untreated than in treated patients and volunteers and significantly and positively correlated with iPTH in untreated patients with celiac disease.

CONCLUSIONS: BMD is almost invariably low in patients with untreated celiac disease. Results in treated patients suggest that gluten-free diet improves but does not normalize BMD. Untreated celiac disease is characterized by high levels of 1,25-vitamin D and by increased bone turnover, caused by the increase in intact parathyroid hormone level.

(Gastroenterology 1995 Jul;109(1):122-8)

*********************************************

Osteoporosis treatment and prevention


…Preventing osteoporosis by maintaining a health diet rich in calcium and vitamin D and exercising regularly can help many women avoid the serious effects of osteoporosis. Women who have low bone mineral density or osteoporosis may also benefit from taking hormone replacement therapy or other drug therapies…


imaginis.com/osteoporosis/osteo_treatment.asp

****************************************

......How can osteoporosis in men be prevented and treated?


The medical research on osteoporosis in men has been inadequate. However, experts agree that all persons should take the following steps to preserve bone health.
· Recognize and treat any underlying medical conditions that affect bone health. Identify and evaluate the use of medications that are known to cause bone loss.
· Change unhealthy habits, such as smoking, excessive alcohol intake, and inactivity.
· Ensure a daily calcium intake of 1000 mg/day to age 50 and 1200 mg/day over age 51 and over.
· Ensure adequate vitamin D intake. Normally, we make enough vitamin D from exposure to as little as 10 minutes of sunlight a day. If exposure to sunlight is inadequate, then vitamin D intake from supplements should be at least 400 IU but not more than 800 IU/day.
· Engage in a regular regimen of weight-bearing exercises where bone and muscles work against gravity. This includes walking, jogging, racquet sports, stair climbing, and team sports. Also, lifting weights or using resistance machines appears to help preserve bone density. Exercise also improves balance and muscle tone and imparts a sense of well-being. If you have already been diagnosed with osteoporosis, any exercise program should be evaluated for safety by your doctor before you begin. Twisting motions and impact activities may need to be curtailed depending on the severity of your condition.


What medications can slow or stop bone loss in men?
Alendronate (brand name Fosamax®) is approved as a treatment for osteoporosis in men.
Alendronate and risedronate (brand name Actonel®), medications from the class of drugs called bisphosphonates, are approved for use in steroid-induced osteoporosis that occurs in men and women as a result of long term use of steroids such as prednisone or cortisone.
Currently, none of the other osteoporosis medications that have been approved by the Food and Drug Administration (FDA) for postmenopausal women have been approved for men. However, to help men with osteoporosis, physicians may prescribe the following:
· Testosterone replacement therapy may be prescribed for a man with a low testosterone level.
· Calcitonin is a medication that slows or stops bone loss and may relieve the pain of fractures in some patients. Calcitonin is approved by the FDA for the treatment of osteoporosis in postmenopausal women. While its effect in men has not been studied, evidence suggests that it may work the same in men as in women. Calcitonin is available as an injection and as a nasal spray.


www.nof.org/men/index.htm



*****************************************
Bone mass & CD
…Osteoporosis was shown in 47% of patients with treated adult coeliac disease.

www.ncbi.nlm.nih.gov/pubmed/7797121?dopt=Abstract


********************************************************

…Celiac patients had a lower bone mass than controls despite early diagnosis and good compliance with the gluten-free diet. These differences could not be atributed entirely to the lower height of celiac patients. These results suggest that celiac patients constitute a risk group for development of osteoporosis later in life. This fact should be taken into consideration in the treatment of this condition.


www.ncbi.nlm.nih.gov/pubmed/9239290?dopt=Abstract


*******************************************************

…CONCLUSIONS: Treatment of coeliac disease with a gluten free diet is associated with a significant increase in bone mineral density, although patients still had lower bone mineral density than controls.


www.ncbi.nlm.nih.gov/pubmed/8991855?dopt=Abstract


*****************************************************

Associated Medical Conditions in Individuals with Celiac Disease

.... Sixty-two percent of respondents said they had their bone density measured. Twenty-seven percent of respondents had been diagnosed with osteoporosis and 10% with osteopenia. Forty-four percent (n = 116) had a history of a previous fracture and of these individuals, 36% had previously broken their wrist. Five percent were taking calcium and 5% vitamin D after diagnosis of osteoporosis/osteopenia. Thirteen percent were taking an anti-osteoporosis medication such as alendronate, risedronate, HRT or raloxifene.

www.biomedcentral.com/1471-230X/3/8#IDAGEMLP


********************************************

…The most important treatment is the gluten-free diet. The available evidence suggests that if children or adults adhere to a gluten-free diet, bone density will improve, especially during the first year or two of treatment. If you’re an adult at age 30, who has just discovered that you have Celiac Disease and low bone density, your bone density may increase anywhere between 5-10% over the first year or two on a gluten-free diet. There are no good studies looking beyond 1-2 years.
Calcium supplements are important, and may be necessary even in those patients who have a good response to the gluten-free diet. Celiac Disease patients lose more calcium in bowel movements than normal people do, and there is a certain amount of calcium that is lost in the urine whether you have Celiac Disease or not. Calcium is necessary for a myriad of body processes, and if it doesn’t come from the diet or supplements, it is taken from the bones.

Women with Celiac Disease who go through menopause should strongly consider taking estrogen, which will protect them from the additional bone loss that occurs with estrogen deficiency.
There are other newer therapies for osteoporosis. None of them have been evaluated in patients with Celiac Disease. The new Merck drug, Fosamax (Alendronate), is absorbed mainly in the stomach, and should be absorbed in the patient with Celiac Disease. It does not contain gluten, but does contain lactose. The decision to institute Fosamax therapy is a very individual one that should be reached between the Celiac Disease patient and their doctor after a careful evaluation to make sure that there is no evidence of osteomalacia. Fosamax may make osteomalacia worse. Moreover, at this time we don’t really know if Fosamax is effective. The other agent that is approved for osteoporosis is calcitonin, which is available in a nasal spray. Calcitonin probably won’t hurt anybody, but there is no information available about whether it helps. Newer agents that act by different mechanisms to increase bone density are now in clinical trials.

www.enabling.org/ia/celiac/osteopo.html#TREATMENT%20FOR%20CELIAC%20PATIENTS%20WITH%20LOW%20BONE%20DENSITY


**************************************************


Severe osteopenia in symptom-free adults with a childhood diagnosis of coeliac disease.

Cellier C, Flobert C, Cormier C, Roux C, Schmitz J.

Lancet. 2000 Mar 4;355(9206):806.

The frequency of osteopenia in symptom-free adults diagnosed with coeliac disease during childhood and who resumed a normal diet during adolescence is unknown.

Severe osteopenia (a bone mineral density below two standard deviations of the mean) was found in up to a third of symptom-free young adults on a normal diet.

These patients should not be thought to be disease-free but should receive long-term follow-up and most of them should be advised to resume a gluten-free diet.





www.ncbi.nlm.nih.gov/pubmed/10711931?dopt=Abstract

****************************

strategy for osteoporosis in gastroenterology

Reference
EM Scott and BB Scott. Eur Journal of Gastroenterology and Hepatology 1998; 10: 689-698

Osteoporotic fractures are a major public health problem. The estimated total cost of osteoporotic fractures in England and Wales is £742 million per annum. With an increasing elderly population the costs are likely to rise. Osteoporosis can be reliably detected by the measurement of Bone Mineral Density (BMD) using Dual energy X-ray absorptiometry (DEXA). A BMD more than two standard deviations below the mean for a young adult is generally taken as an indication of osteoporosis.

Gastroenterologists have a large proportion of patients who are at increased risk of osteoporosis. One of the main groups is that with coeliac disease (CD). One study showed that 47% of women and 50% of men on a gluten-free diet had osteoporosis. BMD was positively related to calcium intake, body mass index (BMI) and menopausal age. Other studies have shown significant improvement a year after starting a gluten-free diet, normal BMD in patients who had had a gluten-free diet since childhood and improved bone mineralisation on a gluten free diet in childhood and adolescence.

The mechanism of osteoporosis in CD is likely to be related to calcium malabsorption, leading to increased parathormone secretion, which increases bone turnover and cortical bone loss. The following points summarize the strategy for prevention and treatment of osteoporosis in CD as suggested in 1998:

General advice
· Strict gluten-free diet
· 1500mg calcium/day
· Exercise
· No smoking
· No excess alcohol
· Seek and treat Vitamin D deficiency
· Measure BMD at diagnosis – if low reinforce above advice

Post-menopausal women
· Measure BMD at menopause or when first seen
· If osteoporotic offer either HRT, preferably by skin patch, bisphosphonate orally or by calcitonin

Men over 55 years
· Measure BMD
· If osteoporotic offer bisphosphonate or calcitonin

All with fragility fracture
· Measure BMD
· If osteoporotic offer HRT (if post menopausal) bisphosphonate or calcitonin. If already on HRT consider adding bisphosphonate or calcitonin.

Duration of drug treatment
· For bisphosphonate and calcitonin measure BMD yearly
· If BMD falls below 4% per year in 2 successive years change to another drug
· If no fall continue drug for at least 3 years, possibly long term.
· Restart drug if, on stopping, yearly BMD falls below 4%
· For HRT check BMD after 10 years and continue HRT if osteoporosis persists

www.cdrc.org.uk/en/article.asp?chco_id=427


********************
Bone mineral density and importance of a gluten-free diet in patients with celiac disease in childhood

Posted by Charlotte, Oxford on 10/2/2005

GF board


Came across this very interesting study from Turkey ........

Abstract:

www.ncbi.nlm.nih.gov/pubmed/11694673?dopt=Abstract


Bone mineral density and importance of a gluten-free diet in patients with celiac disease in childhood.
Kalayci AG, Kansu A, Girgin N, Kucuk O, Aras G.
Department of Pediatric Gastroenterology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey. [e-mail]

"OBJECTIVES: Celiac disease (CD), a common cause of malabsorption, is known to be associated with disorders of the skeleton, but there are conflicting data about the effect of diet on bone metabolism. The aims of this study were to investigate the prevalence of osteopenia; to identify the relationship between bone mineral density (BMD), serum calcium, and parathyroid hormone levels; and to determine the effect of gluten-free diet on BMD in children with celiac disease.....

CONCLUSIONS: BMD is almost invariably low in newly diagnosed celiac patients in childhood. We therefore recommend that BMD should be evaluated in patients with CD. Strict gluten avoidance promoted a significant increase in BMD. However, values still remained markedly low after 1 year of follow-up in some patients. These patients should be followed for longer periods of time with yearly BMD evaluation, as 1 year of diet therapy was found to be insufficient for osteopenia to be resolved."


pediatrics.aappublications.org/cgi/content/full/108/5/e89

**************************

Increased prevalence of CD among patients with osteoporosis


Stenson WF, Newberry R, Lorenz R, Baldus C, Civitelli R.

Increased prevalence of celiac disease and need for routine screening among patients with osteoporosis. Archives of Internal Medicine; vol. 165, pp. 393-399, Feb. 28, 2005.

"Our results suggest that as many as three to four percent of patients who have osteoporosis have the bone disease as a consequence of having celiac disease, which makes them unable to absorb normal amounts of calcium and vitamin D," says principal investigator William F. Stenson, M.D., a Washington University physician at Barnes-Jewish Hospital. The study is reported in the Feb. 28 issue of the Archives of Internal Medicine’’


www.medicalnewstoday.com/articles/20501.php

*******************************

Recommendations for the treatment of osteoporosis in CD


Recommendations for the treatment of osteoporosis in coeliac disease and prevention of osteoporosis in people with coeliac disease have been produced in conjunction with a diverse panel of healthcare specialists.


www.cdrc.org.uk/en/article.asp?chco_id=466

******************************************
Bisphosphonates.

Drug for Bone Disease Linked to 'Jaw Death'

Researchers Report Cases of Osteonecrosis of Jaw in Patients Who Had Teeth Pulled

WebMD Medical News

Oct. 3, 2005 -- Millions of people treated for bone diseases such as osteoporosis may be at risk for developing a potentially serious jawbone condition that seems to be triggered by having teeth pulled.
More than a thousand cases of osteonecrosis of the jaw, or jaw death, have been reported in patients taking a class of drugs known as bisphosphonates. Osteonecrosis indicates that part of the bone is no longer alive; unlike normal bone it cannot regenerate itself because of a lack of blood supply.
Most cases occurred in cancer patients taking the intravenous bisphosphonates Aredia and Zometa to prevent cancer-related bone loss. But osteonecrosis of the jaw has also been reported in women who had teeth pulled while taking the widely prescribed osteoporosis pill Fosamax, dentistry professor Ken Hargreaves, DDS, PhD, tells WebMD.
"Even if this is a rare condition, so many women now take bisphosphonates to prevent bone loss that the numbers could grow," he says. "We just became aware of this a few years ago, and it has been called a growing epidemic."
The study appeared in the October issue of the Journal of Endodontics.

Saving Teeth Lowers Risk
A newly published report edited by Hargreaves outlines two cases of osteonecrosis of the jaw in cancer patients on monthly doses of intravenous bisphosphonates.
He says it is clear from these and other published cases that patients taking bisphosphonates should be warned that they may be at risk if they have teeth pulled. Osteonecrosis of the jaw is very painful and can lead to serious complications, including ulcerations within the lining of the mouth, infection, and breakdown of the jawbone with disfigurement.
"People taking these drugs need to see their dentist regularly, and they need to recognize the importance of preventive dental care," he says. "And when there is a problem, we need to do everything we can to save teeth."
That means performing root canals on patients taking these drugs rather than tooth extractions, he says.

my.webmd.com/content/article/113/110591.htm

******************************

PREVENTION AND MANAGEMENT OF OSTEOPOROSIS

Report of a WHO Scientific Group World Health Organization Geneva ...

whqlibdoc.who.int/trs/WHO_TRS_921.pdf

**********************************

Re: Bone Scan/Dexa scan

Posted by Eileen on 16/11/2005

GF board

I arranged it through my Gp using the Fast Track system (NHS), and the cost was £62. I waited 2 weeks for the appointment. If you don't have time to visit the Gp, perhaps you could drop him a line instead requesting one.


*******************

Osteoporosis guide


A guide to osteoporosis for all ages

actnowosteoporosis.co.uk/index.html

*******************************

osteoporosis and coeliac disease


Question: I read your answer to a question on osteoporosis and coeliac disease in Oct 2002. Is there any evidence to suggest that adults with coeliac disease need dexa scanning? What is the start age and how frequently should they be investigated?

Answer:
ATTRACT found a few documents discussing this issue which differ slightly in their recommendations.

A position statement from the American Gastroenterological Association (2003)(1) states:
“DXA scans are likely unnecessary in patients with newly diagnosed uncomplicated pediatric celiac disease, but should be considered for adults with newly diagnosed celiac disease 1 year after initiation of a gluten-free diet, to allow for stabilization of bone density (level D evidence).”

The British Society of Gastroenterology produced interim guidelines on the management of patients with coeliac disease in April 2002 (2). This guideline states:
“It is usual practice to consider bone densitometry scanning on presentation which may be repeated after one to two years of dietary therapy if the initial value is low.”

The Primary Care Society for Gastroenterology published a document entitled Follow-up care of adult coeliac disease in August 2001 (3). This states:
“Osteoporosis risk assessment and management
DEXA at menopause for women, at 55 years for men, at any age following fragility fracture.”

The British Society of Gastroenterology guidelines for osteoporosis in coeliac disease and inflammatory bowel disease published in 2000 state:

“The timing of densitometry presents a problem. In women, postmenopausal densitometry will be more sensitive at detecting osteoporosis but the delay will give less scope for achieving a higher bone density with treatment, despite evidence that bisphosphonates may produce some reversal of osteoporosis.
Conversely, screening at presentation may reveal osteoporosis at a young age when intervention would theoretically have greater potential …
On balance, one could recommend that all patients have densitometry at diagnosis. This would allow reinforcement of general advice if BMD is low.
However, we can appreciate that the burden on both the clinician and the densitometry service might be counter-productive and deter any screening.
A simpler strategy, omitting BMD at presentation in younger patients and restricting BMD measurement to the older patients who are more likely to benefit, could therefore be more effective in IBD.
In any case, patients with IBD at presentation are unlikely to have osteoporosis as a result of their disease. There is more reason for measuring BMD at diagnosis in patients with coeliac disease because they will already have suffered malabsorption for many years.
In women, if the diagnosis is made earlier the BMD should be measured at the menopause.
It is debateable whether a single measurement at the menopause is adequate because there is considerable variation in the rate and duration of rapid perimenopausal bone loss. For this reason it would be sensible to repeat the BMD after perhaps two years in those whose BMD does not suggest osteoporosis.
Similarly, in men the BMD should be measured at about 55 years of age if they presented at an earlier age. BMD should be done at any age if there has been a fragility fracture, namely one which is atraumatic or follows a simple fall.”

American Gastroenterological Association. American Gastroenterological Association medical position statement: guidelines on osteoporosis in gastrointestinal diseases. Gastroenterology 2003 Mar;124(3):791-4.

www.bsg.org.uk/pdf_word_docs/coeliac.doc

www.bsg.org.uk/pdf_word_docs/osteo.pdf

Date Posted : 22/08/2005
Evidence:
Evidence 1:- 0
Evidence 2:- 0
Evidence 3:- 0
Evidence 4:- 2
Evidence G:- 2


***********************************************
Osteomalacia causes bone pain

Posted by Charlotte, Oxford on 6/3/2007
GF board

Bone pain is caused by osteomalacia which is common in (mainly younger) coeliacs. It's known as rickets in children. You should not continue in pain. Your doctors should be treating you for this - you may need quite aggresive treatment with Vitamin D and calcium:

www.nhsdirect.nhs.uk/en


In the majority of cases, treatment will cure osteomalacia, although it may be several months before you have any relief from bone pain and muscle weakness. The increased vitamin D must be taken regularly otherwise the condition will come back.

www.netdoctor.co.uk/diseases/fac ... ickets.htm

What treatment is available?

Regular daily supplements of vitamin D and calcium, eg Calcichew D3 or Adcal D3, are usually used for people with simple vitamin D deficiency, but some people have a single injection vitamin D, in the form of calciferol (vitamin D2). This is stored in the body and can last up to a year before another injection may be needed.
People with vitamin D deficiency due to intestinal problems are best treated with calciferol. Most people with osteomalacia find their pain is reduced about two weeks after the injection. Extra calcium may also be needed while bone is healing.

bone-muscle.health-cares.net/ost ... atment.php

What's the treatment for osteomalacia?

Oral supplements of vitamin D, calcium and phosphorus may be given depending on the underlying cause of the disorder.
Larger doses of vitamin D and calcium may be needed for people with intestinal malabsorption. Monitoring of blood levels of phosphorus and calcium may be indicated for people with certain underlying conditions. Regular daily supplements of vitamin D and calcium are usually used for people with simple vitamin D deficiency, but some people have a single injection vitamin D, in the form of calciferol (vitamin D2). This is stored in the body and can last up to a year before another injection may be needed. People with vitamin D deficiency due to intestinal problems are best treated with calciferol. Most people with osteomalacia find their pain is reduced about two weeks after the injection. Extra calcium may also be needed while bone is healing. Direct exposure of the skin (i.e., hands, face, arms, etc.) to sunlight stimulates the body to manufacture vitamin D. However, both clothing and use of a sunscreen prevent the ultraviolet light that triggers the formation of vitamin D from reaching the skin. Depending on latitude, sunlight during the winter may not provide enough ultraviolet light to promote adequate vitamin D production. At other times during the year, even 30 minutes of exposure per day will usually lead to large increases in the amount of vitamin D made. If it is difficult to get sunlight exposure, full-spectrum lighting can be used to stimulate vitamin D production.

**************
….differences between osteomalacia (soft bones) and osteoporosis (bone loss).
Both are common in coeliacs: the former tends to affect young coeliacs and the latter older ones:

…..

In children, this is also known as rickets; in grown-ups, it is sometimes known as 'adult rickets'. This condition is caused by a deficiency in Vitamin D. Osteomalacia is more common than most physicians realize and should always be considered in patients with unexplained pain -especially the kind you describe.

The pain of osteomalacia is typically difficult to localize. All the bones are tender - especially the long ones in the legs and arms- because of inflammation of the nerve fibers imbedded in the lining of the bone (called the periosteum). When Vitamin D is deficient, the lining of the bone becomes activated, causing more bone to be absorbed and replaced at an accelerated rate. This is similar to the 'growing pains' experienced by adolescents who are going through the growth spurt.

In diagnosed cases of osteomalacia, 94% of patients complain of pain; 94% complain of muscle weakness; 88% complain of bone tenderness with pressure on touch; 24% complain of a waddling gait and muscle cramps; and, there is a higher incidence of fracture than expected for age- even in bones that test 'normal'on the DEXA bone density test.

It is very difficult these days to become deficient in Vitamin D because it is frequently supplemented in foods. Most vitamin preparations also contain Vitamin D. The most common cause of osteomalacia with apparently normal nutrition is bowel disorders, as in your case. Your bowel was bypassed, which can cause malabsorption of nutrients, including vitamins. The most common bowel disorder is celiac sprue, also known as gluten sensitivity. Gluten is present in wheat. Celiac disease may be present in as much as 5% of the population and is often confused with irritable bowel syndrome.

Researchers at the Henry Ford Health System reporting in The American Journal of Medicine, Vol. 108, 296 -300, looked at the causes of osteomalacia in patients they have seen with stomach surgery (for ulcers), gastric stapling, intestinal bypass, intestinal removal, removal of the pancreas and pancreatitis, and celiac disease. Most of these patients had their symptoms for more than two years. The average time for symptoms to develop from diagnosing the intestinal problem was 14 years! It is easy to see how physicians could overlook this condition, as these changes develop slowly over time. Additionally, these patients get passed on from physician to physician and often get labeled as chronic complainers or malingerers. The 'label' itself, like fibromyalgia, can mislead subsequent physicians.

Simple blood tests should help the doctor make the diagnosis. The bone density test you've had reveals bone loss, but that deficiency is not due to osteoporosis. Unfortunately, though, doctors often mistakenly treat patients for osteoporosis based on test results such as yours. Indeed, people who take this test may have osteomalacia and osteoporosis. However, the osteomalacia 'accidentally' gets better when Vitamin D and calcium are prescribed for the osteoporosis. Osteoporosis does not usually cause generalized bone pain or tenderness.

Doctors in the 'good ole days' would probably have made the diagnosis of osteomalacia very quickly. Rickets was common prior to 1940, as were nutritional diseases. Today, osteomalacia and rickets are relatively rare, so some of us doctors who are 'youngsters' (age 40 or so) may not have seen many cases.
If you have unexplained bone pain, ask your doctor to check for osteomalacia or adult rickets.
...
************************************

Coeliac Disease and the Risk of Fractures - A General Population-based Cohort Study

Posted by Charlotte, Oxford on 16/3/2007
GF board

This new study (full text available in link) confirms earlier findings by Joe West but also suggests that the risk remains even after years on the diet and that coeliac children are at particular risk. It suggests (to me) that all coeliacs need to be particularly careful to maximise their bone health with calcium, vitamin D, sunlight, weight-bearing exercise etc.
From the Discussion:
"We found a statistically significantly positive association of CD with hip fracture or any fracture, irrespective of whether the fracture occurred prior to or after the diagnosis of CD. The overall risk estimates for subsequent hip fracture and any fracture were almost identical to those of West et al.[14] Individuals with CD diagnosed in childhood were at increased risk of subsequent hip fracture and may also be at increased risk of fracture of any type. The duration to and after diagnosis of CD did not notably influence the risk of hip fracture. Hence, this study found no evidence that a gluten-free diet lowers the risk of hip fracture. Even 20 years after diagnosis of CD were individuals with CD at increased risk of hip fracture."


Coeliac Disease and the Risk of Fractures - A General Population-based Cohort Study

J. F. Ludvigsson; K. Michaelsson; A. Ekbom; S. M. Montgomery

Aliment Pharmacol Ther. 2007;25(3):273-285. �2007 Blackwell Publishing
Posted 03/08/2007

Summary and Introduction
Summary
Background: Earlier studies have suggested that untreated coeliac disease may be associated with osteoporosis, but results are contradictory for the risk of long-term fractures.
Aim: To study the association between coeliac disease and fractures.
Methods: We used Cox regresson to examine the future risk of hip fracture and fracture of any type in more than 13 000 individuals with coeliac disease and 65 000 age- and sex-matched reference individuals in a general population-based cohort.
Results: During follow-up, 1365 first hip fractures and 4847 fractures of any type occurred. Coeliac disease was positively associated with subsequent hip fracture (hazard ratio = 2.1; 95% CI = 1.8-2.4) (in children: hazard ratio = 2.6; 95% CI = 1.1-6.2) and fractures of any type (hazard ratio = 1.4; 95% CI = 1.3-1.5) (in children: hazard ratio = 1.1; 95% CI = 1.0-1.2). The absolute excess risk of hip fractures in children with coeliac disease was 4/100 000 person-years. Incidence ratios for hip fracture in individuals with CD were around two both prior to diagnosis of coeliac disease and afterwards; this risk increase remained 20 years after diagnosis of coeliac disease.
Conclusions: Individuals with coeliac disease, including children with coeliac disease, may be at increased risk of hip fracture and fracture of any type. Coeliac disease may be positively associated with long-term hip fracture risk.

Link: www.medscape.com:80/viewarticle/552626_print

*****************************

CD and bones


From Pubmed:

Endocr Pract. 2004 May-Jun;10(3):203-7.

Celiac disease manifesting as isolated hypocalcemia.

Rickels MR, Mandel SJ.

Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.

OBJECTIVE: To describe a patient who presented with hypocalcemia and hypocalciuria as the initial manifestations of celiac disease, despite a normal vitamin D status.
METHODS: We review the diagnostic evaluation, treatment, and biochemical and bone mineral density responses of a patient with asymptomatic celiac disease, which was initially suggested because of a low serum calcium level that became attributable to isolated malabsorption of calcium.
RESULTS: A 36-year-old woman presented with hypocalcemia in the presence of normal serum 25-hydroxyvitamin D and high serum 1,25-dihydroxyvitamin D levels. She had hypocalciuria and secondary hyperparathyroidism that were refractory to pharmacologic calcium and cholecalciferol supplementation. Fecal calcium excretion indicated malabsorption of calcium, and biopsy of the small intestine demonstrated pathologic changes characteristic of celiac disease. Bone mineral density, determined by dual-energy x-ray absorptiometry, was in the osteopenic range at the femoral neck. The initiation of a gluten-free diet resulted in correction of all biochemical abnormalities and a substantial increase in bone mineral density.
CONCLUSION: Primary intestinal malabsorption of calcium without concomitant vitamin D deficiency is possible in celiac disease because of the preferential involvement of the proximal small intestine early in the disease process. Our patient had hypocalcemia caused by celiac disease and values for serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D that were normal and elevated, respectively. Correction was demonstrated after dietary gluten withdrawal.

************
Osteoporos Int. 1996;6(6):453-61.
Magnesium deficiency: possible role in osteoporosis associated with gluten-sensitive enteropathy.
Rude RK, Olerich M.
Department of Medicine, University of Southern California School of Medicine, Los Angeles, USA.
Osteoporosis and magnesium (Mg) deficiency often occur in malabsorption syndromes such as gluten-sensitive enteropathy (GSE). Mg deficiency is known to impair parathyroid hormone (PTH) secretion and action in humans and will result in osteopenia and increased skeletal fragility in animal models. We hypothesize that Mg depletion may contribute to the osteoporosis associated with malabsorption. It was our objective to determine Mg status and bone mass in GSE patients who were clinically asymptomatic and on a stable gluten-free diet, as well as their response to Mg therapy. Twenty-three patients with biopsy-proven GSE on a gluten-free diet were assessed for Mg deficiency by determination of the serum Mg, red blood cell (RBC) and lymphocyte free Mg2+, and total lymphocyte Mg. Fourteen subjects completed a 3-month treatment period in which they were given 504-576 mg MgCl2 or Mg lactate daily. Serum PTH, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D and osteocalcin were measured at baseline and monthly thereafter. Eight patients who had documented Mg depletion (RBC Mg2+ < 150 microM) underwent bone density measurements of the lumbar spine and proximal femur, and 5 of these patients were followed for 2 years on Mg therapy. The mean serum Mg, calcium, phosphorus and alkaline phosphatase concentrations were in the normal range. Most serum calcium values fell below mean normal and the baseline serum PTH was high normal or slightly elevated in 7 of the 14 subjects who completed the 3-month treatment period. No correlation with the serum calcium was noted, however. Mean serum 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D and osteocalcin concentrations were also normal. Despite only 1 patient having hypomagnesemia, the RBC Mg2+ (153 +/- 6.2 microM; mean +/- SEM) and lymphocyte Mg2+ (182 +/- 5.5 microM) were significantly lower than normal (202 +/- 6.0 microM, p < 0.001, and 198 +/- 6.8 microM, p < 0.05, respectively). Bone densitometry revealed that 4 of 8 patients had osteoporosis of the lumbar spine and 5 of 8 had osteoporosis of the proximal femur (T-scores < or = -2.5). Mg therapy resulted in a significant rise in the mean serum PTH concentration from 44.6 +/- 3.6 pg/ml to 55.9 +/- 5.6 pg/ml (p < 0.05). In the 5 patients given Mg supplements for 2 years, a significant increased in bone mineral density was observed in the femoral neck and total proximal femur. This increase in bone mineral density correlated positively with a rise in RBC Mg2+. This study demonstrates that GSE patients have reduction in intracellular free Mg2+, despite being clinically asymptomatic on a gluten-free diet. Bone mass also appears to be reduced. Mg therapy resulted in a rise in PTH, suggesting that the intracellular Mg deficit was impairing PTH secretion in these patients. The increase in bone density in response to Mg therapy suggests that Mg depletion may be one factor contributing to osteoporosis in GSE.
***************
J Pediatr Gastroenterol Nutr. 2003 Oct;37(4):434-6.

Bone mineral density in children with untreated and treated celiac disease.
Kavak US, Yüce A, Koçak N, Demir H, Saltik IN, Gürakan F, Ozen H.
Hacettepe University, Department of Pediatrics, Ankara, Turkey.

OBJECTIVES: Osteopenia is a common complication in adults with celiac disease. The effect of a gluten-free diet on bone mineral density is a matter of controversy. The aim of this study was to investigate bone mineral density in children with celiac disease at diagnosis and in patients treated for 1 year.
METHODS: Bone mineral density and bone mineral content were measured in 34 children with untreated celiac disease at diagnosis and in 28 patients on a gluten-free diet for 1 year. The results were compared with those of 64 gender- and age-matched healthy control subjects. Serum calcium, phosphate, alkaline phosphatase, 25 -hydroxy vitamin D, and intact parathormone levels were determined in treated and untreated patients.
RESULTS: The mean values of bone mineral density and bone mineral content of untreated patients with celiac were significantly lower than the control group (P = 0.006 and P = 0.005, respectively) and treated patients (P = 0.015 and P = 0.011 respectively). Treated patients had mean bone mineral density and bone mineral content values not significantly different from those of healthy control subjects. Minor hypocalcemia was detected in 17.6% of the patients with new diagnoses and 3.6% of the treated patients. Of the untreated patients, 29.4% had high intact parathormone concentrations; in untreated patients, the total was 14.3%. Untreated patients had significantly lower serum calcium and significantly higher intact parathormone levels than did treated patients. The other bone metabolism parameters were similar in the two celiac groups.
CONCLUSION: Children with celiac disease are at risk for reduced bone mineral density. A strict gluten-free diet improves bone mineralization, even in 1 year. Early diagnosis and treatment of celiac disease during childhood will protect the patient from osteoporosis

********************************



Nobody looks for osteoporosis in males

From:
Men's Osteoporosis Support Group


…"I have never had any symptoms of sprue and never suspected it until my daughter's gastroenterologist suggested that my wife and I have blood tests. My wife's were negative, while both of mine (I think they tested for two antibodies) were positive for sprue. I then went in for a gastroscopy, which was also positive. I spoke with my gastroenterologist earlier this week and he told me that based on the severe nature of my osteoporosis I've probably had celiac sprue for a long time. Unfortunately, the long-term osteoporosis also went undiagnosed until I had a bone
density test after breaking my arm and then my leg within the span of a month a couple of years ago. My primary care physician did some research and found that osteoporosis is a common result of untreated celiac disease. Of course, now that we know about celiac disease and osteoporosis, I've been reading all kinds of information about it on the Web.

Unfortunately, nobody looks for osteoporosis in a fairly young male--or any male--for that matter. (My Fosamax packages still say the drug is for post-menopausal women!) It was apparently so uncommon in my immediate area that the only place with a bone density machine was a local women's health center….


maleosteoporosis.citywebshop.com ... celiac.htm

**************

Adrian S on 2/4/2010
GF board

…

Any decent GP should know the facts before refusing a DEXA. CD is associated with low bone density regardless of age and sex. Many of us here are do not meet the normal criteria for a DEXA but have to take supplements or meds to treat low bone density. I am male and was diagnosed with osteopenia at 39, I asked for a scan.

…
This should be the most useful reference.

"Dual energy x-ray absorptiometry (DXA) is the most widely used test to assess bone mineral density. Bone densitometry should be checked at diagnosis with a DXA scan." - British society of Gastroenterology - The Management of Adults with Coeliac Disease.

www.bsg.org.uk/images/stories/cl ... iac_10.pdf



www.bsg.org.uk/clinical-guidelin ... sease.html




***************
Osteoporosis Associated with Neutralizing Autoantibodies against Osteoprotegerin

N Engl J Med. 2009 Oct 8;361(15):1459-65.

Osteoporosis associated with neutralizing autoantibodies against osteoprotegerin.

Riches PL, McRorie E, Fraser WD, Determann C, van't Hof R, Ralston SH.

Rheumatic Diseases Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom.
Abstract

Autoantibodies against osteoprotegerin, which block the inhibitory effect of osteoprotegerin on signaling by the receptor activator of nuclear factor (NF)-kappaB (RANK), were identified in a man with celiac disease who presented with severe osteoporosis and high bone turnover.
The osteoporosis did not respond to the treatment of his celiac disease but was completely reversed by bisphosphonate therapy.
Autoantibodies against osteoprotegerin were detected in three additional patients with celiac disease.
Such autoantibodies may be associated with the development of high-turnover osteoporosis, but whether autoantibodies against osteoprotegerin commonly contribute to the pathogenesis of osteoporosis in patients with celiac disease remains to be determined.
2009 Massachusetts Medical Society

PMID: 19812402 [PubMed - indexed for MEDLINE]

maleosteoporosis.citywebshop.com/maleosteo/celiac.htm

*********************

Proximal myopathy and bone
pain as the presenting features
of coeliac disease


It is rare for coeliac disease to present only
with symptoms of osteomalacia, without the
classic symptoms of diarrhoea, steatorrhoea,
and abdominal discomfort....

A 22 year old woman presented with 18
months of a waddling gait disturbance. Hip
and back x rays were normal. She experienced
bone pain when being hugged, when laughing,
or coughing, and had difficulty standing
up from a low chair and holding her arms up
to blow-dry her hair.

She had extreme
tiredness and thought she might have lost
some weight, but there were no gastrointestinal
symptoms.

On examination, she was pale and had difficulty
squatting and holding her arms above
her head.


www.ncbi.nlm.nih.gov/pmc/articles/PMC1753868/pdf/v061p00087.pdf

*************************************
Prevention of conditions associated with coeliac disease

Osteoporosis
If you are diagnosed with coeliac disease you should also have a DEXA scan. This is to check the density of your bones. You should also have this scan again when you reach the menopause if you are a woman, or at 55 if you are a man. If you have a fragility fracture, which is linked to osteoporosis, at any point during your life you should have a DEXA scan.
..…

www.bupa.co.uk/individuals/health-information/directory/c/coeliac-disease

********************

[kickingfrog]

Bone mineral density and importance of strict gluten-free diet in children and adolescents with celiac disease.


BONE 2010 Jun 19. [Epub ahead of print]

Blazina S, Brataniè N, Campa AS, Blagus R, Orel R.

University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, Ljubljana, Slovenia.

Abstract
OBJECTIVES: Low bone mineral density (BMD) is common in children and adolescents with celiac disease. Strict gluten-free diet (GFD) improves bone mineralization, even in 1year. The effect of occasional gluten intake is not known. The aims of this study were to compare BMD and prevalence of low BMD in children and adolescents on strict and not strict GFD.
METHODS: We measured BMD in 55 children and adolescents (strict GFD) with negative endomysium antibodies (EMA) in the last 2years and in 19 (not strict GFD) with positive EMA at the time of the study. Lumbar, left hip and total body BMD were measured by dual-energy X-ray absorptiometry. Four-day weighted dietary protocols were obtained by means of a self-completed questionnaire of total food and beverage intake. Energy and calcium intake were calculated using nutrition data software. EMA, tissue transglutaminase antibodies, serum calcium, phosphate, 25-hydroxy vitamin D, intact parathormone, albumin, urea and creatinine levels were determined in all patients.
RESULTS: BMD in patients on strict GFD was significantly higher than in patients on not strict GFD (lumbar p=0.01; total body p=0.005). There were significantly more patients with total body BMD below -1.0 in not strictly compliant group (71% compared to 38%; p=0.03). Calcium intake and vitamin D levels were below recommendations in both groups.

CONCLUSION: Children and adolescents on not strict GFD are at increased risk for low BMD. We therefore recommend that BMD should be evaluated in patients with positive EMA. In addition, patients on strict GFD are at risk for low BMD because of low calcium intake or vitamin D deficiency.
Therefore, strict GFD with recommended calcium intake and vitamin D supplementation during winter and spring should be encouraged in all children and adolescents with celiac disease.

Copyright © 2010 Elsevier Inc. All rights reserved.
*******************************************

.
Risk of osteoporosis in endocrine disorders
and celiac disease


Ann Ist Super Sanità 2007 | Vol. 43, No. 4: 430-433


Anna Velia Stazi(a) and Biagino Trinti(b)

(a)Dipartimento Ambiente e Connessa Prevenzione Primaria, Istituto Superiore di Sanità, Rome, Italy
(b)Istituto di Ingegneria Biomedica, Consiglio Nazionale delle Ricerche, Rome, Italy


…older men with late-onset CD, for whom damage to
bones is more serious and the risk fracture greater,
for whom vitamin D and calcium supplements are
highly recommended.

The use of pharmacological therapy (for example
bisphosphonates) for the prevention and treatment
of osteoporosis in postmenopausal women
has long been recognized. The use of these agents
has been traditionally based on date obtained predominantly
from postmenopausal women and cases
glucocorticoid-induced osteoporosis, but data are
becoming increasingly available to justify their use
in osteoporotic men. Moreover, there are evidence
that treatment with risedronate increases BMD and
reduces hip fractures in elderly men …

In conclusion, increased risk of osteoporosis should
not be considered as an isolated factor, but as part
of a more generalized endocrine-environmental imbalance
with possible serious effects on health on
account of its influence on a fairly broad range of
tissues and functions of which metabolism and bone
structure are a major target. ….


www.iss.it/binary/publ/cont/430%20-%20ANN_07_61_Stazi.1201595028.pdf





**********************

[kickingfrog]

Bisphosphonates, raloxifene and teriparatide.

NICE has made the following recommendations about the use of bisphosphonates, raloxifene and teriparatide.

The recommendations concern the use of these medicines to reduce the risk of further osteoporosis-related fractures (broken bones) in women who have gone through the menopause and who have already had an osteoporosis-related fracture. They do not cover the treatment of women who have osteoporosis as a result of taking medicines called corticosteroids.

Bisphosphonates
Bisphosphonates (alendronate, etidronate and risedronate) are recommended by NICE to be used in postmenopausal women
……….(if)…
· they have a medical condition that increases the risk of osteoporosis – for example, rheumatoid arthritis, chronic inflammatory bowel disease, hyperthyroidism or coeliac disease


www.nice.org.uk/page.aspx?o=241341

[kickingfrog]

Increased prevalence of CD among patients with osteoporosis

Stenson WF, Newberry R, Lorenz R, Baldus C, Civitelli R.

Increased prevalence of celiac disease and need for routine screening among patients with osteoporosis. Archives of Internal Medicine; vol. 165, pp. 393-399, Feb. 28, 2005.

"Our results suggest that as many as three to four percent of patients who have osteoporosis have the bone disease as a consequence of having celiac disease, which makes them unable to absorb normal amounts of calcium and vitamin D," says principal investigator William F. Stenson, M.D., a Washington University physician at Barnes-Jewish Hospital. The study is reported in the Feb. 28 issue of the Archives of Internal Medicine’’


www.medicalnewstoday.com/articles/20501.php

*********

[kickingfrog]

Calcium & coeliacs question and Vit D

Posted by Charlotte, Oxford on 7/1/2011
GF board


Actually 1200-1500mg pd is the recommendation for older coeliacs and a DEXA scan is still by far the best way to establish bone health at dx or at menopause, and after treatment.

In general bone loss and the risk of osteoporosis is very common throughout the UK in the elderly (50% over age 75) and getting worse as we're all living longer. Bone loss is worse:
- in women (childbirth, hormones, menopause)
- if underweight especially as a child
- with malabsorption disorders esp over long period (eg adult diagnosed CD)
- diets in low in calcium (ie gluten-free diet; dairy avoidance)
- lack of weight bearing exercise (eg caused by tiredness or illness)
- lack of sunlight (Vitamin D) eg in northern climes or from sun avoidance/ skin protection

www.nos.org.uk/netcommunity/page.aspx?pid=263&srcid=234

Who is at risk of osteoporosis and broken bones?

www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/celiac.asp

What People With Celiac Disease Need to Know About Osteoporosis
All this makes it clear why coeliacs are at particular risk. Recent studies now show that, although malabsorption improves with mucosal recovery, even treated coeliacs do not get adequate calcium.

CALCIUM INTAKE OF PATIENTS WITH COELIAC DISEASE
10th International Symposium on Coeliac Disease Pathogenesis and Outcomes POSTERS ABSTRACTS - 75 - F Moor, GKT Holmes Derbyshire Royal Infirmary, Derby, UK
"Introduction. Calcium intake in coeliac disease (CD) is important for it is related to osteoporosis and fracture risk. We found earlier, that calcium intakes of coeliac patients on strict gluten free diet (GFD) were less than 1054 mg/day in 70% and less than 860 mg/day in 45%. The present study assessed calcium intakes of newly diagnosed coeliac patients and after 6 weeks on GFD.
Methods. Calcium ingestion was assessed using a ready reckoner method for 92 newly diagnosed coeliac patients and after 6 weeks on GFD.
Results. At diagnosis of CD, calcium intakes varied between 350-2000 mg/day, with 23% ingesting below the reference nutrient intake of 700 mg/day. After 6 weeks on GFD this fell to 15%. The British Society of Gastroenterology recommends an intake of 1500 mg/day for coeliac patients. Based on this, 76% of coeliac patients on GFD for 6 weeks still had intakes below this amount, 37% of whom, despite consuming calcium enriched foods or supplements were unable to achieve the recommended level.
Conclusions. Achieving recommended intakes for calcium is difficult for coeliac patients which exposes them to the risk of osteoporosis and fractures."

OSTEOPOROSIS AND COELIAC DISEASE: IS THE 1500 MG/DAY GUIDELINE FOR CALCIUM ACHIEVABLE BY DIET? A. Holdoway1, W.E. Fickling1, A.K. Bhalla2, D.A.F. Robertson1.1Royal United Hospital; 2Royal National Hospital for Rheumatic Diseases, Bath, UK
"Conclusions: Whilst it is possible to achieve a calcium intake of 1500 mg/day on a strict GF diet, careful dietetic assessment is required in the majority of patients to identify those with sub-optimal intakes (up to 2/3 of patients) and improve calcium intake through diet and/or supplements. The new generation* calcium-enriched GF breads may help achieve dietary intakes of 1500 mg of calcium/day."

*The problem here of course is that today most GF breads, including supermarket breads (Genius, M&S, Tesco etc) and many prescription breads & flours (Livwell, Lifestyle, Proceli, Schar, Wellfoods), are NOT enriched with calcium:. All Juvela's are fortified but others need to be checked: some Glutafin products but not all; most DS loaves are fortified but not the rolls. The lack of calcium is partly a result of the retailers' desire to combine the wheat free and dairy free markets. Adding additional calcium costs and affects bread quality. They only do it if they have to. This seems pretty scandalous given that all normal gluten bread is required by law to contain a certain amount of calcium iron (& protein): www.graininformationservice.co.uk/content/1/58/vitamins-and-minerals.html
“The fortification of flour contributes to 14% of the total calcium intake and in the absence of this fortification it would be assumed that these intakes would fall below the recommended nutrient intake (RNI). The current RNI for calcium is 600mg a day for children and 1000mg a day for an adult.”

Personally I’m not sure why the NHS should be prescribing ‘sub nutrient quality’ breads and flours to coeliacs, whose bones are particularly at risk. I can only assume that, as with all CD prescriptions, the main purpose is to improve (the more important) diet compliancy: if a coeliac is more likely to stick to the diet eating subsidised carbohydrates, and more likely to eat pappy bread than biscuits, crisps and chocolate, then it’s justified. I would have concerns if I avoided dairy or if it were my child, especially a girl, eating these products all the time without professional dietary input and, almost certainly, supplements.

Now that more coeliacs are clearly eating more of these non-fortified staples it’s even more reason to be aware of the deficit. Calcium supplements and vitamin D may necessary for the bone health of most coeliacs (many will also need iron). Some, like myself, may also find the current clinical evidence on the benefits of high dose Vitamin D (for, amongst other things autoimmune disorders and bone health) very compelling. Doses of 25ug (1000iu) are considered safe but, as with all supplements, should be cleared by your GP.

BTW the BMJ study on calcium, while it grabbed headlines, had many flaws (not least that ‘adverse events’ were self reported) and did not present any real new data. These concerns can be seen in the Response to Letters to BMJ re Bolland et al: www.bmj.com/content/336/7638/262.full/reply#bmj_el_194771
There is useful comment and advice from Osteoporosis Society:
www.osteoporosis.org.au/files/research/Safety%20of%20calcium.pdf
They also have a good file on osteoporosis and CD:
www.nos.org.uk/NetCommunity/Document.doc?id=391
"One of the commonest problems is osteoporosis, leading to an increased risk of broken bones. One study showed half of those with the coeliac disease had low bone density (bone density is the quantity of bone that, when measured, helps to indicate bone strength) even if they were on a gluten-free diet. This was especially so for those who were diagnosed later in life, were underweight or were post-menopausal women. One osteoporosis clinic found that six per cent of men with osteoporosis had an undiagnosed coeliac disease."

Vit D deficiency has been much more in the news with reports of rickets returning etc

www.bmj.com/content/340/bmj.b5664.extract

Recent reports identify Vitamin D as preventing heart disease:

news.bbc.co.uk/1/hi/health/1945496.stm

www.bmj.com/external-ref?access_num=17720017&link_type=MED

Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Tang et al, Lancet. Aug 2007

******************

[kickingfrog]

Bones of Coeliac Children

From CUK:
…
What about children’s bone health?
As long as a child with coeliac disease follows a well-balanced gluten-free diet, their future bone health is very good. Absorption of calcium and other bone-forming nutrients will improve as their gut heals, allowing them to develop normally. Children and young adults who follow the gluten-free diet should be able to reach their ideal level of bone strength, minimising the risk of developing osteoporosis in future life.
As with adults, it is also important that children eat a healthy, balanced diet. Children’s nutritional requirements vary according to their age, so for specific advice about your child, talk to their dietitian. There are no increased calcium requirements for children with coeliac disease compared to other children.
…



*******************************

Orv Hetil. 1997 Dec 21;138(51):3233-8.

Mineral content in bones of children with symptomless celiac disease and gluten-free diet


[Article in Hungarian]
Szathmári M, Tulassay T, Arató A, Bodánszky H, Szabó A, Tulassay Z.
Semmelweis Orvostudományi Egyetem, Budapest, I. Belgyógyászati Klinika.

Abstract
Osteoporosis is a complication of adult celiac disease. The gluten-free diet improves but does not normalize bone mineral density.

Only few and conflicting data are known about the influence of the disease and diet on bone mineralization in children.
The aim of this study was to evaluate the radial bone mineral content (BMC) and density (BMD) in children and adolescents who are asymptomatic on gluten-free diet.

The BMD and BMC values of non-dominant radius midshaft in ninety-one children (53 girls and 38 boys, mean age: 11.7 years, mean duration of disease: 8.7 years) were determined by single photon absorptiometry.
At the diagnosis and at least three years after gluten-free diet, serum calcium, phosphorous and albumin concentrations and alkaline phosphatase activities were determined in all, and additionally intact parathormone concentrations in 16 patients.

The mean BMC Z-score value in the entire study population did not differ from the value of normal age-matched population (mean Z-score: -0.27), but in female adolescent group was significantly lower than the normal value (mean Z-score: -1.04, p < 0.01).
In contrast, the mean BMC Z-score value was significantly higher than in normal value in girls (mean Z-score: +1.36, p < 0.001), in boys (mean Z-score: +0.53, p < 0.02) as well as in the total patients group (mean Z-score: +1.01, p < 0.001).
The diameter of radius midshaft was significantly smaller in all age group than the normal mean value. Serum laboratory parameters of asymptomatic patients were in the normal range. The serum parathormone value in treated patients was significantly lower than in untreated celiac children (mean +/- SD: 3.77 +/- 1.07 versus 7.89 +/- 2.54, p < 0.01), but significantly higher compared to controls (2.89 +/- 0.9, p < 0.05).

The data indicate that the gluten-free diet alone is not able to normalize bone mineralization in children.
The significant increase of serum parathormone level in treated asymptomatic patients may be explained by the lower calcium content of gluten-free diet.

The authors suppose that low calcium supply in children similarly to adult patients can lead to increased parathormone secretion, which can cause the retardation of bone growth even in treated patients with celiac disease.

PMID: 9454102 [PubMed - indexed for MEDLINE]

www.ncbi.nlm.nih.gov/pubmed/9454102


***********


Reversal of low bone density with a gluten-free diet in children and
adolescents with celiac disease

1,2

Stefano Mora, Graziano Barera, Alberto Ricotti, Giovanna Weber, Cesare Bianchi, and Giuseppe Chiumello


ABSTRACT Osteoporosis is a common finding in adult celiac
disease patients; however, there are still few data regarding children
and adolescents.

In the present study we measured the bone mineral
density (BMD) in children and adolescents at diagnosis of celiac disease
and after <1 y of a gluten-free diet. BMD was measured at the
lumbar spine and in the whole skeleton by dual-energy X-ray absorptiometry
in 44 celiac disease patients aged 2.58–20.42 y at diagnosis.
BMD was also measured in a subset of 25 patients after 1.4 ± 0.04 y
of a gluten-free diet. BMD was compared with that of 177 healthy
control subjects aged 1.52–20.99 y. Lumbar spine and whole-body
BMD values at diagnosis of celiac disease were significantly lower
than in control subjects (P = 0.015 and P = 0.0001, respectively)
after differences in age and anthropomorphic variables were controlled
for.

The subjects studied after the gluten-free diet had BMD
values not significantly different from those of control subjects.

In conclusion, children and adolescents with celiac disease have
remarkably reduced lumbar spine and whole-body bone density.

A gluten-free diet promotes a rapid increase of BMD that leads to a
complete recovery of bone mineralization.

These results emphasize
the need for an early diagnosis and treatment in patients with celiac
disease to obtain an adequate peak bone mass at the end of puberty.

Am J Clin Nutr 1998;67:477–81.

1 From the Laboratory of Pediatric Endocrinology and the Department of
Pediatrics, Scientific Institute H San Raffaele, University of Milan, Italy.
2 Address reprint requests to S Mora, Department of Pediatrics, H San
Raffaele, via Olgettina 60, 20132 Milano MI, Italy. E-mail: s.mora@.hsr.it.
Received April 25, 1997.
Accepted for publication November 3, 1997.

www.ajcn.org/cgi/reprint/67/3/477.pdf

******************************************

American Journal of Clinical Nutrition, Vol. 76, No. 3, 675-680, September 2002
© 2002 American Society for Clinical Nutrition


Original Research Communication


Children who avoid drinking cow milk have low dietary calcium intakes and poor bone health

1,2,3
Ruth E Black, Sheila M Williams, Ianthe E Jones and Ailsa Goulding
1 From the Departments of Human Nutrition (REB), Preventive and Social Medicine (SMW), and Medical and Surgical Sciences (IEJ and AG), University of Otago Medical School, Dunedin, New Zealand.
Background: Information concerning the adequacy of bone mineralization in children who customarily avoid drinking cow milk is sparse.
Objective: The objective was to evaluate dietary calcium intakes, anthropometric measures, and bone health in prepubertal children with a history of long-term milk avoidance.
Design: We recruited 50 milk avoiders (30 girls, 20 boys) aged 3–10 y by advertisement. We measured current dietary calcium intakes with a food-frequency questionnaire and body composition and bone mineral density with dual-energy X-ray absorptiometry and compared the results with those of 200 milk-drinking control children.
Results: The reasons for milk avoidance were intolerance (40%), bad taste (42%), and lifestyle choice (18%). Dietary calcium intakes were low (443 ± 230 mg Ca/d), and few children consumed substitute calcium-rich drinks or mineral supplements. Although 9 children (18%) were obese, the milk avoiders were shorter (P < 0.01), had smaller skeletons (P < 0.01), had a lower total-body bone mineral content (P < 0.01), and had lower z scores (P < 0.05) for areal bone mineral density at the femoral neck, hip trochanter, lumbar spine, ultradistal radius, and 33% radius than did control children of the same age and sex from the same community. The z scores for volumetric (size-adjusted) bone mineral density (g/cm3) were -0.72 ± 1.17 for the lumbar spine and -0.72 ± 1.35 for the 33% radius (P < 0.00l). Twelve children (24%) had previously broken bones.

Conclusions: In growing children, long-term avoidance of cow milk is associated with small stature and poor bone health.
This is a major concern that warrants further study.


www.ajcn.org/cgi/content/abstract/76/3/675

**************************



Journal of the American College of Nutrition, Vol. 20, No. 2, 168S-185S (2001)
Published by the American College of Nutrition

Review

The Importance of Meeting Calcium Needs with Foods

Gregory D. Miller, PhD, FACN, Judith K. Jarvis, MS, RD, LD and Lois D. McBean, MS, RD

National Dairy Council, Rosemont, Illinois (G.D.M., J.K.J.)
Nutrition Consultant, Ann Arbor, Michigan (L.D.M.)
Address reprint requests to: Gregory D. Miller, PhD, FACN, Vice President, Nutrition Research and Technology Transfer, National Dairy Council, 10255 West Higgins, Suite 900, Rosemont, IL 60018-5616. E-mail: gregorymrosedmi.com.


Calcium can be obtained from foods naturally rich in calcium such as dairy foods, from calcium-fortified foods and beverages, from supplements or from a combination of these. Recognition of calcium’s many health benefits, along with Americans’ low calcium intake, has led to interest in how best to meet calcium needs. Foods are the preferred source of calcium.

Milk and other dairy foods are the major source of calcium in the U.S. In addition, these foods provide substantial amounts of other essential nutrients. Consequently, intake of dairy foods improves the overall nutritional quality of the diet.

Other foods such as some green leafy vegetables, legumes and cereals provide calcium, but generally in lower amounts per serving than do dairy foods. Also, some components such as phytates in cereals and oxalates in spinach reduce the bioavailability of calcium.

Calcium-fortified foods and calcium supplements are an option for individuals who cannot meet their calcium needs from foods naturally containing this mineral. However, their intake cannot correct poor dietary patterns of food selection which underlie Americans’ low calcium intake. Considering the adverse health and economic effects of low calcium intakes, strategies are needed to optimize calcium intake.

A first step is to recognize factors influencing dietary calcium consumption.

Substituting soft drinks for milk and eating away from home are among the barriers to adequate calcium intake.
The American public needs to understand why consuming foods containing calcium is the best way to meet calcium needs and learn how to accomplish this objective.

www.jacn.org/cgi/content/abstract/20/2/168S

***************************

From Food Standards Agency:

….
Calcium in the diet

You shouldn’t give 1% fat or skimmed milk as a main drink to children under 5 years old because they don’t have enough vitamin A and skimmed milk doesn't contain enough calories for growing children. Reduced-fat milks contain less vitamin A and research has shown that around half of pre-school age children don’t get enough vitamin A from their diet.

Children under 2 years should drink full-fat milk because it contains more calories to help them grow. Children between 2 and 5 years can have semi-skimmed milk, as long as they’re eating a balanced and varied diet and are growing well…..

…Calcium is especially important for growing children and young people, to help build healthy bones and teeth. Two glasses (300ml) of milk will provide enough calcium for children aged one to three.

Remember children need full-fat milk until they're at least two. After this age, you can gradually start giving them semi-skimmed milk, as long as they're eating a varied and balanced diet and growing well. But fully skimmed milk and 1% fat milk aren't suitable for children under five.

…..

Canned sardines, and other fish where we eat the bones, are good sources of calcium. If you eat canned sardines in tomato sauce, two slices of toast, an orange and a small pot of fruit fromage frais, that would also give an adult enough calcium for the day.

Other sources of calcium include fortified breakfast cereal, soya beans, tofu, soya drinks with added calcium, dried figs, okra, curly kale, rice pudding and baked beans.

…There are a number of foods you can eat, apart from milk and dairy products, to help you get enough calcium. Canned sardines, and other fish where we eat the bones, are good sources of calcium.

Other foods that contain calcium include:

soya beans and tofu
bread
pulses such as chickpeas
green vegetables, especially watercress and okra (but not spinach)
other vegetables, such as cabbage and onions
dried fruit, especially dried figs
nuts, such as almonds, and seeds, such as sesame seeds

To help our bodies absorb the calcium from the foods we eat, it's important to get enough vitamin D. We get vitamin D from sunlight on our skin and from foods such as margarines and spreads, breakfast cereals and oily fish.

If you use soya, rice or oat drinks as a substitute for milk, try to choose those with added calcium.

People with lactose intolerance often find that they can eat cheese and yoghurt without any problems. Cheese contains much less lactose than milk. Yoghurt contains a similar amount of lactose to milk, but it still seems to be easier to digest for people with lactose intolerance. This might be something to do with the bacteria used to make it. Yoghurt and cheese are both excellent sources of calcium. Try to choose lower-fat types, or eat just a small amount of the high-fat options.

However, if you have a milk allergy, rather than lactose intolerance, you should avoid all milk products, including those made with milk from sheep and goats….

www.eatwell.gov.uk/asksam/healthydiet/milkanddairyq/

*****************************
National Osteoporosis Society

Your children & bone health

www.nos.org.uk/NetCommunity/Document.Doc?id=500

*****************************

[kickingfrog]

FSA advice on Vit A and osteoporosis

Posted by Charlotte, Oxford on 8/9/2005,

Gf board

There is advice from the FSA today about the link between too much Vit A and osteoporosis especially in older women Vit A (retinol) may inhibit the uptake of Vit D.

In the full report (based on many studies) the evidence is far from conclusive but it is something that some older coeliacs (perhaps with anaemia and bone loss) may want to be aware of if they regularly eat liver or take fish liver oil supplements.
FSA advice:
www.food.gov.uk/news/newsarchive/2005/sep/newadvicevita

There’s also full pdf SACN report available which is long but quite interesting and very thorough on the (mixed) medical evidence. Its conclusions:

18. The evidence for an association between high intakes of retinol and poor
bone health is inconsistent. There are some epidemiological data to suggest
that retinol intakes of 1500 µg/day and above are associated with an
increased risk of bone fracture. Data published since the EVM report do
not strengthen the evidence for an association between retinol intake and
bone health.
19. In the UK, liver is the major source of retinol for those with retinol intakes
exceeding 1500 µg/day. Supplements also make an important contribution
to retinol intakes of those consuming more than 1500 µg/day of retinol.
Overall, retinol intakes in the UK were less in 2000/1 than in 1986/7.
Recommendations
20. There is currently insufficient evidence on the association between bone
health and retinol intakes above 1500 µg/day to justify a change in dietary
advice to all consumers regarding consumption of foods or supplements
containing retinol.
21. As a precaution, however, it may be advisable for regular consumers of
liver (once/week or more) not to increase liver intakes or take supplements
containing retinol (including those containing fish liver oil).
22. It may also be advisable for population subgroups at increased risk of
osteoporosis, such as postmenopausal women and older people, not to
consume more than 1500 µg/day of retinol. This could be achieved by
limiting intakes of liver and limiting intakes of supplements containing
retinol (including those containing fish liver oil).


************

[kickingfrog]

Also please see:

coeliac.proboards.com/index.cgi?action=display&board=othercon&thread=309&page=1

[kickingfrog]

Also please see:

coeliac.proboards.com/index.cgi?board=othercon&action=display&thread=3522