Tuesday, March 13, 2018

Celiac Disease and Osteoporosis

The Pearl

If you are diagnosed with Celiac Disease and osteoporosis, the Celiac Disease should be treated first, 
through a strict gluten restricted diet for at least 3 months. Your physician should be sure that you have a 
restored normal level of vitamin D (which can be measured by a vitamin D 25-OH blood test) before 
considering starting treatment of your osteoporosis.  
Why? Because the medications we use to treat osteoporosis; Forteo, a bisphosphonate like Boniva, 
Fosamax, and Reclast,  or a Rank Ligand monoclonal antibody like Prolia, can lead to severe even life 
threatening low levels of circulating blood calcium (hypocalcemia). This can cause seizures, 
muscle spasms, and cardiac arrhythmias that are potentially fatal.

More Explanation

Celiac Disease is a condition that is associated with an immune overstimulation process that starts in the 
small intestine lining in response to a specific type of gluten. Gluten is a common plant protein storage 
molecule, but the particular gluten molecule produced by Wheat, Barley, and Rye are problematic for a 
small subset of genetically predisposed persons. 
How common is this? Forty percent of the population carries one or both susceptibility genes, yet less that one in a hundred persons develop Celiac Disease. In this subset, grain glutens result in inflammation throughout the body, but especially inside the lining of the small intestine. This “enteropathy” and inflammation can lead to many other problems throughout all the bodies systems.
Why is celiac disease related to osteoporosis? Inflammation excess itself can lead to damage to the 
skeletal bones through remodeling imbalances, where not enough new bone is laid down and too much 
existing bone is resorbed back into the blood stream from existing bone. Add to this the malabsorption of 
nutrients vitamins and minerals, and you have a perfect storm of risk for those who are suffering from 
Celiac Disease in developing osteoporosis.
Calcium absorption is reduced, and an acquired lactose intolerance from Celiac Disease leads to a lower 
threshold of a person to tolerate dairy products. Vitamin D is poorly absorbed from the diet through the 
inflamed intestine, and, if a person with Celiac Disease feels unwell, they are less likely to exercise or spend time outdoors in natural sunlight to make vitamin D in their skin.

What else should I know? Dental maturation and enamel, our tooth protective coatings, are reduced 
and often secondary teeth are slow or late to develop.
Over years and decades, even in those without obvious intestinal symptoms of Celiac Disease that might 
otherwise lead to a timely diagnosis, bone does not fully calcify and mature, and the bones natural 
remodeling process is in constant imbalance. Cancellous spongy bone which provides the interior bone 
scaffolding to provide bone strength and resiliency to the outer cortical bone becomes more fragile and 
brittle and less supportive. Premature or severe osteoporosis and or fracture may be the first sign that you may have Celiac Disease.
In the setting of active intestinal inflammation, dietary calcium is poorly absorbed. The body requires a 
very specific and narrow range of calcium to constantly circulate to support cells throughout the body in 
particular nerve, muscle and cardiac/heart cells. Most treatments for osteoporosis stop the body from 
recruiting the bone cells, the osteoclasts, from breaking down existing bone and releasing calcium back 
into the circulation.  In common osteoporosis, this leads to beneficial balance of bone remodeling, where 
osteoblasts create new bone and calcium deposits, while inhibiting the activity of the osteoclasts that will 
now greatly reduce their break down the bone and release of calcium stored there. If, however, your 
calcium levels drop, the body automatically absorbs more calcium from the intestines and increases the 
osteoclast activity to breakdown and release stored calcium form the bones into the blood stream. If the 
intestinal inflammation limits intestinal calcium absorption in Celiac Disease, and the osteoporosis 
medications prevent the bone from releasing calcium back into the bloodstream by their very mechanism,
it could spell a recipe for disaster.