Original ArticlesOsteoporosis in adult patients with celiac disease
Introduction
It has long been recognized that celiac disease may be associated with skeletal disorders. Celiac disease has been found in at least 3% of patients suffering from osteoporosis.17 Using dual-energy X-ray absorptiometry (DXA), McFarlane et al.20, 21 and Butcher et al.3 found reduced bone mineral density (BMD) at both the spine and hip in celiac patients when compared with age- and gender-matched controls. McFarlane et al.21 reported that osteoporosis, defined as BMD ≤2 SD below normal peak bone mass, could be as common as 50% in male and 47% in female celiac patients. According to Walters et al.32 suboptimally treated and newly diagnosed or untreated patients commonly had osteopenia; furthermore, subjects with reduced BMD were more likely to have subtotal or partial villous atrophy.
The pathogenesis of osteoporosis associated with celiac disease is not well understood. It is unclear whether bone loss results from inadequate bone formation or from excessive bone resorption. At diagnosis, the celiac patients frequently have intestinal calcium malabsorption,3, 6, 22 but after 12 months on the gluten-free diet, calcium absorption has been shown to normalize.22 Deficiency of vitamin D and secondary hyperparathyroidism are common in newly diagnosed celiac patients and in those with refractory celiac disease, but are less common in patients who respond to a gluten-free diet.14 There is now substantial evidence that celiac disease is associated with infertility in both men and women. In women, celiac disease can lead to amenorrhea and early menopause,26 which are associated with high risk for osteoporosis.
The absence of any improvement in the BMD of the celiac patients during the first year of a gluten-free diet has also been reported.4 In addition, low BMD in treated celiac patients was noted.2, 11, 19, 21 However, Valdimarsson et al.30, 31 reported that subjects with incomplete dietary treatment had low BMD, whereas a strict gluten-free diet together with recovering villous atrophy resulted in a rapid increase of BMD in patients with minor or no gastrointestinal symptoms. In general, those patients who adhered to the gluten-free diet over a long period showed an improvement in BMD.1, 10, 31 According to Bai et al.,1 remineralization was more pronounced in patients with better compliance to the gluten-free diet in premenopausal women and also in patients with the lowest baseline of BMD. In the present study, we investigated BMD and the prevalence of osteopenia and osteoporosis in adult celiac patients varying in severity of disease state. Furthermore, the factors associated with a low BMD were examined.
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Subjects
The study group consisted of 28 newly diagnosed celiac patients and 49 previously diagnosed celiac patients recruited from the area under the jurisdiction of Kuopio University Hospital, Finland. The celiac patients were recruited for the study between 1990 and 1991; these included newly diagnosed celiac patients from the patients diagnosed in our hospital during this time and previously diagnosed subjects from the patient register of celiac disease. The patient group included 7 women who had
Results
Characteristics of the study subjects are presented in Table 1. There were no significant differences between female celiac patients and female controls in weight or height. Male celiac patients were lighter and shorter than male control subjects. In postmenopausal women with celiac disease mean menopausal age was lower than in controls.
BMD of the lumbar spine (−6%), femoral neck (−5%), and trochanter region (−7%) were significantly lower in the female celiac patients than in controls.
Discussion
The present study suggests that, on average, celiac patients have reduced BMD at the lumbar spine and femoral neck. Furthermore, men with celiac disease were lighter and shorter than controls. Altogether, 26% of celiac patients were defined as having osteoporosis at the lumbar spine, but only 3% at the femoral neck. In particular, women with celiac disease not in remission and men with newly diagnosed disease had osteopenia as well as osteoporosis more often than controls. The exclusion of
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