Celiac Disease and Osteoporosis: Do You Have the 9 Increased Risk Factors?

Celiac Disease and Osteoporosis: Do You Have the 9 Increased Risk Factors?

Many studies have demonstrated the connection between celiac disease and osteoporosis. Such persons may present with bone pain, muscle weakness, and even fractures. Bone diseases such as osteopenia and osteoporosis, resulting from celiac disease is due to the inability of the small intestine to absorb calcium, amino acids (the building blocks of protein), and vitamin D. Each of these ingredients is essential for the formation of strong bones, and over time a deficit of these raw materials causes a decrease in bone mass.

The inability of the small intestine to absorb essential nutrients (malabsorption) is due to persistent inflammation of the intestinal epithelial mucosa and atrophy of intestinal villi.

With respect to bone disorders, patients with celiac disease are at a greater risk for:

Osteopenia: a thinning of bone mass that is considered a very serious risk factor for the development of osteoporosis.

Osteoporosis: a loss of bone mass. The diagnostic difference between osteopenia and osteoporosis is the measure of bone mineral density.

Research demonstrates that celiac disease patients have lower bone mineral density at the lumbar spine and top of the femur (femoral neck) than do control subjects. There is an increased prevalence of fracture in celiac disease patients owing to loss of bone mineral density.

Osteopenia in celiac disease is reversible. In one study, after one year on a gluten-free diet the percentage of patients with severe osteopenia in the spine decreased from 9 to 5% and in the femur from 14 to 9%. Normal bone mineral density can be achieved by following a strict gluten-free diet for more than four years.

It has been recognized for several decades that both children and adults with celiac disease and osteoporosis have an increased risk of fractures as compared to the age-matched non-celiac healthy individuals. Based on published data the prevalence of osteoporosis among celiac patients varies from as low as 4% to as high as 70%. The data from our clinic indicate that prevalence of osteoporosis among adults with gluten intolerance and celiac disease is in the vicinity of 30-40%.

Why do people with celiac disease have a greater risk?

There are nine well-characterized risk factors which link celiac disease and osteoporosis.

These include:

1. Malabsorption of vitamin D and secondary hyperparathyroidism
Villous atrophy in celiac patients reduces the active absorption surface and induces steatorrhea (exces fat in feces), which has a chelating effect on calcium and vitamin D, making their absorption difficult. This reduces levels of the vitamin D transporting protein and increases the parathyroid hormone leading to increased bone resorption (bone destruction) causing osteoporosis.

2. Malabsorption of vitamin K
Malabsorption of fat soluble vitamins including vitamin K is a common finding in celiac patients. Three vitamin-K dependent proteins have been isolated in the bone: osteocalcin, matrix Gla protein (MGP), and protein S. Without vitamin K, these proteins are present at low levels and lead to low bone density.

3. Magnesium deficiency
Magnesium deficiency may be an additional risk factor for celiac-associated osteoporosis. This may be due to the fact that magnesium deficiency alters calcium metabolism and the hormones that regulate calcium. Several human studies have suggested that magnesium supplementation may improve bone mineral density. Magnesium deficiency is easily detected with laboratory tests (eg, low serum magnesium, low serum calcium, resistance to vitamin D) or clinical symptoms (eg, muscle twitching, muscle cramps, high blood pressure, irregular heartbeat). Screening for magnesium deficiency should be routinely included in the screening of celiac patients with osteoporosis.

4. Chronic diarrhea and metabolic acidosis
Chronic diarrhea in patients with celiac disease results in significant bicarbonate losses and development of metabolic acidosis. Bone is a major site for the extracellular buffering of the retained acid. Therefore, to maintain a stable bicarbonate level in the face of an uncorrected metabolic acidosis the dissolution of bone buffers occurs and calcium is released from bone. Bicarbonate supplementation in patients with metabolic acidosis decreases the negative effects of acidosis on bone health.

5. Hypogonadism
Decline of estrogen production and activity is one of the main events in the development of age-related osteoporosis. It is well known that estrogen deficiency is important in the pathogenesis of osteoporosis not only in women but also in men. Increase in bone mineral density in young men and declines in older men are related to circulating free estrogen, not testosterone. In general, patients with celiac disease are characterized by low levels of circulating estrogens which contributes to the development of premature osteoporosis.

6. Chronic use of Proton Pump Inhibitors
Proton pump inhibitors (PPIs) are one of the most widely used classes of drugs. The commonly used PPIs include such drugs as Omeprazole (brand name: Prilosec), Lansoprazole (brand name: Prevacid), Dexlansoprazole (brand names: Kapidex, Dexilant), Esomeprazole (brand name: Nexium), Pantoprazole (brand name: Protonix) and Rabeprazole (brand name: AcipHex). Chronic use of PPIs for gastroesophageal reflux disease and other related conditions has been associated with impaired calcium and magnesium absorption and increased risk of vertebral and nonvertebral fractures.

7. Chronic use of Selective Serotonin Reuptake Inhibitors
Selective Serotonin Reuptake Inhibitors (SSRIs) are frequently used in celiac patients for treatment of depressive disorders. The commonly used SSRIs include such drugs as Citalopram (brand name: Celexa), Escitalopram (brand name: Lexapro), fluoxetine (brand name: Prozac), fluvoxamine (brand name: Luvox), Paroxetine (brand name: Paxil) and Sertraline (brand name: Zoloft). It has been demonstrated that SSRIs increase extracellular 5-HT (5-Hydroxytryptophan) levels that have deleterious skeletal effects.

8. Autoimmune mechanisms
Autoimmune mechanisms have been long suspected as risk factors contributing to development of osteoporosis in celiac patients. Near a decade ago, it was demonstrated that sera from celiac patients with osteoporosis contains significantly high titers of antibodies against bones as compared to non-celiac osteoporotic patients.

9. Chronic inflammation
Chronic inflammatory diseases, including celiac disease, are associated with overproduction of proinflammatory cytokines such as TNF-α, interleukin(IL)-1, IL-6, IL-11, IL-15 and IL-17 among others which activate osteoclasts and accelerate bone resorption leading to osteoporosis.

Cytokines are cell signaling molecules that regulate a person’s a response to infection, immune responses, inflammation, and trauma. They communicate by stimulating the movement of cells toward the harmed site. Some cytokines act to make disease worse (proinflammatory), whereas others serve to reduce inflammation and promote healing (anti-inflammatory).

Osetoporosis in Children

Osteoporosis may even occur in children who have gluten intolerance and celiac disease. Importantly, with a gluten-free diet, osteoporosis in children usually resolves completely. Eliminating all sources of gluten reduces chronic inflammation in the small intestine, and nutrients begin to be absorbed normally, normal bone mass begins to be restored, and risk of fracture is reduced. In children, normalization of bone mineral density levels may be reached in as early as two years following the initiation of a strict gluten-free diet.

In one study, patients with celiac disease were followed for up to five years while on a gluten-free diet. Bone mineral density increased or remained stable in 52% of patients at the lumbar spine and in 68% at the femoral neck. These findings show that bone disorders in patients with celiac disease may recover during long-term adherence to a gluten-free diet. Following a strict gluten-free diet for one year results in significant improvement (5–8%) in bone mineral density. Following such a diet for two years improved bone mass and improved levels of serum markers of bone and mineral metabolism. Persistent bone loss (compared to the normal population) in celiac disease patients maintaining a gluten-free diet may be related to chronic inflammation. Thus, early detection of celiac disease leads to improved outcomes.

Dietary supplements and a gluten free diet can help slow the progression of osteoporosis

Treating osteoporosis naturally includes the following dietary supplements:

BoneDense: the active ingredient, Drynaria, has been shown to improve the strength of fragile bones.
Calcium Lactate: a highly absorbable source of calcium; maintains strength of bones.
Magnesium Malate: maintenance of bone health.
Vitamin D3: vitamin D deficiency can lead to osteopenia/osteoporosis.
Strontium Citrate: stimulates new bone formation and delays bone resorption.

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