Celiac Disease and its Consequences on Bone Mineral Density and Osteoporosis


by: Rachel Olivier, MS, ND, PhD


have the diagnosis of CD. In CD the intestinal tract, particularly the small intestines, is by and large the site of infection and/or inammation.


In CD, the immune system responds to continued gluten consumption, creating inammation, which in turn re- sults in damage to the villi of the small intestines (the small intestinal lining), consequently leading to medical complications. This sensitivity and resulting inammation hinders the absorption of some nutrients resulting in malabsorption. Coinciding with celiac disease and its associated malabsorption syndrome, is an estimated 40% increased risk of bone fracture.2


recognized as one of the most effective management tools for celiac disease, and is associated with a positive effect on bone mineral density.3,4,5,6


of malabsorption, leading to greater bone loss in these patients. Subclinical or silent cases have also demonstrated to have lower bone mineral density (BMD) as compared to healthy controls.10,11


disease there is a “distinct antibody responses to gluten and the autoantigen transglutaminase 2.”12


against gluten peptides” as well as “autoantibodies against transglutaminase are produced by B-cells.”13


for the elastic texture of dough. Gluten is also a food additive, and is present in many unsuspected foods, such as canned spaghetti/marinara sauce, processed meats,


THE ORIGINAL INTERNIST MARCH 2017


 Gluten is a general name for the proteins found in wheat (wheatberries or wheat kernel, durum, emmer, semolina, spelt, farina, farro, graham, KAMUT khorasan wheat and einkorn), rye, barley and triticale  a wheat/rye cross.14


It is a substance that is responsible


small intestine is responsible for absorbing nutrients from food into the bloodstream for use by the body, damage to the intestinal lining results in inability to properly absorb these nutrients. The classical characterization is “small intestinal villous atrophy, crypt hyperplasia, and increased lymphocyte inltration.”13


Other damaging “antibodies


In those with Celiac Because the


For more than 70 years, metabolic bone disease in CD patients has been reported,7,8,9


with a greater degree A gluten free diet is


 Celiac disease (CD), also referred to as sprue or celiac sprue, is characterized as an inherited intestinal immune disorder in which the body has an intolerance to gluten. It is classically dened as “a multifactorial and a multisystem disorder involving a genetic predisposition, environmental exposure of the small bowel mucosa to gluten, and an immunologic response to gluten.1


An estimated 1.8 million Americans


tortillas, emulsiers, herbal teas made with malted barley, soy sauce, etc.15


It has been estimated that for those who consume gluten on a daily basis, the consumption rate is approximately 10- 40 grams of gluten per day.16


According to Catassi, et al., in celiac patient’s gastrointestinal damage has been observed by biopsy in those consuming a daily amount of as little as 0.1 gram of gluten. The classication “gluten-free” on a food label is dened by a gluten limit set by the FDA of less than 20 ppm (parts per million).18


wheat bread contains about “4.8 grams of gluten (10% gluten by weight), while the amount of gluten in a serving of pasta is roughly 6.4 grams of gluten (11% gluten by weight).”17


The average slice of whole


Symptoms: Symptoms of celiac disease can vary from mild to severe, and in some, there are no symptoms at all. However, even without symptoms, gastrointestinal damage may be occurring. Often CD is diagnosed as other types of gastrointestinal diseases, including irritable bowel syndrome, Crohn’s Disease, or gastric ulcers. The classic symptom of celiac disease is diarrhea. Other symptoms include abdominal bloating, gas, fatigue, low blood count (anemia), and osteoporosis. They may also include abdominal pain, diarrhea, vomiting, constipation, and pale, foul-smelling stools.19


may not be restricted to the gastrointestinal tract. Other commonly associated manifestations include failure to grow (delayed puberty and short stature), iron deciency, recurrent miscarriages, osteoporosis, chronic fatigue, canker sores, dental enamel hypoplasia, and dermatitis herpetiformis. These patients may also present with neuropsychiatric manifestations including ataxia and peripheral neuropathy, and are at increased risk for de- velopment cancers, including non-Hodgkin lymphoma, enteropathy-associated T-cell lymphoma (EATL) and adenocarcinoma of the small intestine.20


also be associated with other clinical disorders including thyroiditis, type I diabetes mellitus, Down syndrome, and IgA deciency.21


number of other mechanisms have been proposed. These include: “increase in parathyroid hormone (PTH) levels; increase in inammatory and immunological markers including interleukin (IL)-1, IL-6 and tumor necrosis factor (TNF)-alpha; increase in the receptor activator of nuclear factor kappa (RANK)-B ligand (RANKL)/osteoprotegrin (OPG) ratio, which, particularly in women, causes in- creased activation and differentiation of osteoclasts; and hypogonadism, with decreases in the levels of circulating estrogen, which also contributes to bone loss.”22


According to Webmd, “children with Celiac may have teeth that are pitted, grooved, discolored, or poorly formed.” Damage to the small intestine due to Celiac disease, results in poor nutrient absorption, which in turn can result in signicant tooth deciencies in children. Additionally, those with celiac disease are at an increased risk for osteoporosis, and may need “aggressive treatment” to address low bone density.24


Bone loss is also prevalent, which is attributed to “in- creased bone resorption without sufcient corresponding bone formation and mineralization.”22


Additionally a The disease may Symptoms, however,


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