Original contribution
Osteoporosis in a North American adult population with celiac disease1

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Abstract

OBJECTIVE:

Osteoporosis, common in European and South American adults with celiac disease, has not been reported in those patients with celiac disease residing in North America. We therefore evaluated bone density in a group of patients from the United States.

METHODS:

Patients (105 women and 23 men) with celiac disease, who had completed a questionnaire and had bone mineral density (BMD) measured by dual energy x-ray absorptiometry, were evaluated. The patients were an average age of 56 yr old (range 21–83 yr) and had been on a gluten-free diet from 0 months to 46 yr (mean 7.5 yr).

RESULTS:

Osteoporosis (T score <−2.5) was present in 34% of the patients at the lumbar spine, 27% at the femoral neck, and 36% at the radius. Low bone mass (T score between −1.0 and −2.5) was present in 38% at the lumbar spine, 44% at the femoral neck, and 32% at the radius. When compared to age-matched controls, men were more severely affected than women. BMD did not differ between those on a gluten-free diet and those who had not begun therapy. BMD was remeasured 16 ± 2 months after beginning a gluten-free diet in 5 patients; it increased by 7.5% at the femoral neck (p < 0.02). In 16 patients who had followed a gluten-free diet for an average of 12 yr, BMD remained stable over an additional 2 yr of observation.

CONCLUSIONS:

Osteoporosis and low bone mass often affect North American adults with celiac disease, whether or not they are on dietary therapy. Routine screening for osteoporosis is indicated in patients with celiac disease.

Introduction

Celiac disease, or gluten-sensitive enteropathy, is caused by intolerance to gluten, occurring in genetically predisposed individuals (1). While celiac disease is common in Europe 2, 3, it is considered to be a rare disease in the United States (4). The reasons for this discrepancy are unclear, particularly since a recent study of healthy blood donors in Baltimore, MD found the prevalence of endomysial antibodies to be similar to that observed in Europe (5). This suggests that celiac disease may be underdiagnosed in the United States, either because of a low index of suspicion in American physicians 6, 7, 8 or because of a shift to a more silent form of the disease in which gastrointestinal symptoms are not prominent (9).

Within the past 10 yr, dual energy x-ray absorptiometry (DXA), a relatively inexpensive, accurate, and reproducible technique, has become available to physicians for measuring bone mineral density (BMD) (10). Several European and South American studies have now reported that bone mass is reduced in both treated and untreated adults and children with celiac disease 11, 12, 14, 15, 16, 17, 18, 19, 20. There are no published data on bone density in patients with celiac disease who reside in the United States. In an effort to determine the extent of skeletal demineralization associated with celiac disease in this country and whether they resembled celiac patients in other countries, we surveyed a group of adults with celiac disease.

Section snippets

Study design

We mailed a survey to 300 adults who had biopsy-proven celiac disease as identified from a databank at Columbia-Presbyterian Medical Center (21). In responding to a previous questionaire, these individuals had indicated that they had at least one BMD determination. Survey questions included: age, gender (and menopausal status), race, height, and weight; information on celiac disease, including age at diagnosis, symptoms at presentation (specifically, diarrhea), duration of gluten-free diet,

Study population

The study group Table 1, Table 2included 23 men, 26 premenopausal women, and 79 postmenopausal women, predominantly (n = 128) Caucasian. The average age was 56 yr (range, 21–83 yr). All claimed to adhere to a gluten-free diet (mean duration 9 ± 10 yr). The premenopausal women were approximately 2 decades younger than the men and postmenopausal women. Average age at diagnosis was 48 yr (range 6 months–83 yr), although the premenopausal women were diagnosed at a significantly younger age. Only 2

Discussion

In this study, BMD, measured predominantly in community-based settings, was evaluated in individuals with celiac disease residing in the United States. We noted, osteoporosis, as defined by the WHO, was common, as was low bone mass or osteopenia. In fact, only 28% of the participants in our study had normal BMD by these criteria. In 75% BMD was below average for their age, and in 46% it was more than one standard deviation below age-matched norms. Because the relative risk of fracture increases

References (44)

  • A Fasano

    Where have all the American celiacs gone?

    Acta Pediatr

    (1996)
  • P.H.R Green et al.

    The diagnosis of celiac disease

    Clin Persp Gastroenterol

    (1998)
  • C.C Johnston et al.

    Clinical use of bone densitometry

    New Engl J Med

    (1991)
  • A.P Keaveny et al.

    Bone remodeling indices and secondary hyperparathyroidism in celiac disease

    Am J Gastroenterol

    (1996)
  • J.L Shaker et al.

    Hypocalcemia and skeletal disease as presenting features of celiac disease

    Arch Int Med

    (1997)
  • N Molteni et al.

    Bone mineral density in adult celiac patients and the effect of gluten-free diet from childhood

    Am J Gastroenterol

    (1990)
  • R Mazure et al.

    Bone mineral affection in asymptomatic adult patients with celiac disease

    Am J Gastroenterol

    (1994)
  • X.A McFarlane et al.

    Osteoporosis in treated adult coeliac disease

    Gut

    (1995)
  • T Valdimarsson et al.

    Bone mineral density in coeliac disease

    J Gastroenterol

    (1994)
  • S Bode et al.

    Body composition and calcium metabolism in adult treated coeliac disease

    Gut

    (1991)
  • G.R Corazzo et al.

    Bone mass and metabolism in patients with celiac disease

    Gastroenterol

    (1995)
  • M Bayer et al.

    Spinal bone mineral density in children with celiac disease

    J Clin Densitometry

    (1998)
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    This study was approved by the Institutional Review Board of Columbia-Presbyterian Medical Center.

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