There is a connection between bone fractures, bone loss and Celiac disease. There is a connection between gastrointestinal disease and bone fractures. As we will see in the research, identifying Celiac disease and gastrointestinal disease and adjusting for diet can help significantly reduce the risk of fracture. First we will discuss issues surrounding Celiac disease and then discuss how all gastrointestinal disease can put you at risk for bone loss and fractures.

According to the Celiac Disease Foundation, Celiac disease is a serious genetic autoimmune disorder where the ingestion of gluten leads to damage in the small intestine. It is estimated to affect 1 in 100 people worldwide. Two and one-half million Americans are undiagnosed and are at risk for long-term health complications. Studies have shown and confirmed that Celiac disease is over four times more common today than it was 50 years ago and this is leading to a vast array of health complications including what three studies say: A greater risk in breaking a bone.

Despite these numbers and more people at risk, researchers still struggle to understand the best ways to help patients.

Malabsorption of calcium and vitamin D is a focus

In June 2018, researchers from the Professional Advisory Council for the Canadian Celiac Association published findings in the journal Canadian family physician (1)  that suggested certain guidance recommendations on monitoring bone health in Celiac disease patients. What they were looking for was treatments that may help. Addressing malabsorption of calcium and vitamin D was the focus.

  • “Bone health can be negatively affected in both adults and children with Celiac disease owing to the inflammatory process and malabsorption of calcium and vitamin D. Most adults with symptomatic Celiac disease at diagnosis have low bone mass. Bone mineral density should be tested at diagnosis and at follow-up, especially in adult patients.
  • Vitamin D levels should be measured at diagnosis and annually until they are normal. In addition to a strict gluten-free diet, supplementation with calcium and vitamin D should be provided and weight-bearing exercises encouraged.”

A December 2018 study published in the Scandinavian journal of gastroenterology (2) focused on younger patients with celiac disease and the concerns of adequate calcium and vitamin D supplementation. Here doctors in the United Kingdom questioned guidelines that do not support routine investigation of bone loss in younger patients when clearly the problem of bone loss will manifest itself in their later life. They argued: “Early identification may improve motivation to comply with gluten-free diet and allow adequate calcium and vitamin D supplementation to reduce risk of fracture later in life.

Untreated Celiac disease and substantial risk of osteoarthritis and osteoporosis

Researchers in Italy published their findings in the October 2018 issue of the United European gastroenterology journal (3) suggesting up to 75% of patients with untreated Celiac disease show up at doctor’s offices with osteopenia or osteoporosis. The aim of  their study was to evaluate the prevalence of bone mineral density alterations at diagnosis and risk factors associated with osteoporosis in these Celiac disease patients.

What is important here is the patients who were being studied. 

  • A total of 214 adult patients (average age 38 years old; 7 out of 10 were female)
  • These patients had newly diagnosed with Celiac disease and underwent a DEXA bone scan.
    • 39.7% had normal Bone Mineral Density
    • 42.5%  had osteopenia
    • 17.8% had osteoarthritis

Sixty percent of the patients in this study, average age 38 years old, newly diagnosed with Celiac disease had bone deformity and bone loss.

A recent study published in The Journal of clinical endocrinology and metabolism (4) led by a research team from Massachusetts General Hospital found that bone fractures were almost twice as common in individuals with a clinically diagnosed Celiac disease as in those without the disease. Especially hip fractures, where the research team reported a 69% increase in the risk of hip fracture.

When you have Celiac disease and gastrointestinal disease

According to the Celiac Disease Foundation, “At least 20% of individuals with Celiac disease continue to have symptoms on a gluten-free diet. Other estimates show that more than one third of celiac disease patients have altered gut motility or “IBS-like” symptoms. Likewise, about 25% of those with non-celiac gluten sensitivity also continue to have symptoms on a gluten-free diet. While continued gluten ingestion is the most common cause of persistent symptoms in both populations, a dual diagnosis of irritable bowel syndrome (IBS) is also common.”

This is the danger of relying on the “magic bullet theory,” of treating anything. Patients with Celiac disease will follow a strict gluten-free diet yet continue to suffer from symptoms. The symptoms are caused by other gastrointestinal disease. As the focus of this article i on bone loss and fracture risk, let’s support this idea that you need to treat the entire gastrointestinal when you treat symptoms of Celiac disease

In November 2018, researchers wrote in the Journal of Bone Metabolism: (5)

  • Patients with gastrointestinal disease are at risk for osteopenia or osteoporosis, which can lead to fractures. Although these patients may be at risk from a young age, gastroenterologists often overlook this fact in practice.
  • There are well-known GI diseases associated with osteopenia and osteoporosis, such as the post-gastrectomy state, inflammatory bowel disease (IBD), and celiac disease. As there is an increase in the prevalence of IBD patients, newly diagnosed celiac disease in adulthood, and gastric cancer survivors following gastrectomy, bone disease in these patients becomes an important issue.
  • We have confirmed that the prevalence of osteoporosis and fractures in each of these diseases is high.
  • Intensive surveillance and management are needed to ensure that these patients attain peak bone mass for age and sex to prevent fractures.

“Intensive surveillance and management are needed to ensure that these patients attain peak bone mass for age and sex to prevent fractures”

1 Duerksen D, Pinto-Sanchez MI, Anca A, et al. Management of bone health in patients with celiac disease: Practical guide for clinicians. Can Fam Physician. 2018;64(6):433-438.
2 Pritchard L, Wilson S, Griffin J, Pearce G, Murray IA, Lewis S. Prevalence of reduced bone mineral density in adults with coeliac disease–are we missing opportunities for detection in patients below 50 years of age?. Scandinavian journal of gastroenterology. 2018 Nov 26:1-4.
3 Galli G, Lahner E, Conti L, Esposito G, Sacchi MC, Annibale B. Risk factors associated with osteoporosis in a cohort of prospectively diagnosed adult coeliac patients. United European Gastroenterol J. 2018;6(8):1161-1168.
4 Heikkila K, Pearce J, Maki M, Kaukinen K. Celiac disease and bone fractures: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015 Jan;100(1):25-34. doi: 10.1210/jc.2014-1858.
5 Oh HJ, Ryu KH, Park BJ, Yoon BH. Osteoporosis and Osteoporotic Fractures in Gastrointestinal Disease. Journal of bone metabolism. 2018 Nov 1;25(4):213-7.

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