Celiac disease could be the cause of osteoporosis
What is celiac disease?
Dr. Stenson: Celiac disease is an abnormal immune response to a protein that is found in wheat, rye and barley. In this abnormal immune response, the immune cells in the intestine are activated. Their activation injures the cells in the intestine that are responsible for absorbing nutrients from the bile. So, the disease itself is a manifestation of the injury to these cells that absorb nutrients from the diet, and the consequence is that you have difficulty absorbing nutrients from the diet. For some people, that’s all nutrients, fats, and proteins; and for some people it’s very specific nutrients, like calcium or vitamin D — which causes osteoporosis — or iron, which causes iron deficiency
What are the symptoms of celiac disease?
Dr. Stenson: The classic symptoms are weight loss and diarrhea, and one of the difficulties with celiac disease is that a lot more people have it than we appreciate. It’s also clear a lot of people don’t have the classic symptoms of weight loss and diarrhea, and some people have fairly subtle problems caused by celiac disease, which could be abdominal discomfort, and manifestations of the inability to absorb certain nutrients, like iron deficiency or osteoporosis.
I’ve read there’s not really a good answer as to how many people have it?
Dr. Stenson: There are all kinds of different estimates from 1 person in 100 to 1 person in 1,000. I think most people would agree it’s between 1 person in 250 and 1 person in 500. So it’s not common, but it’s not rare either.
What kind of doctor would be good to go to for this?
Dr. Stenson: Well, the initial doctor you went to would depend on what sort of symptoms you were having. So a lot of people would go to their general practitioner or general internist. The people who tend to diagnose the disease are gastroenterologists, because it’s a GI disease and part of the diagnostic process is having a biopsy of the small intestine
What does your study of celiac disease entail?
Dr. Stenson: One of the big things with celiac disease is that we know it’s more common than we appreciate. We know there are a lot of people out there who have the disease and don’t know it. We also know there’re a lot of people who have fairly subtle symptoms. Over the last few years, some blood tests have become available that are very sensitive and very accurate in picking up celiac disease, so the question came who should be screened. The disease is not common enough that you want to screen the whole population, and there was an interest in identifying groups of people who would be more suitable for screening. We knew celiac disease was associated with osteoporosis in the sense that people who have celiac disease frequently have osteoporosis as a consequence. What wasn’t known was if you take everyone who has osteoporosis, how many of them have osteoporosis as a consequence of celiac disease. So that’s what our study looked at.
How many people did your study include?
Dr. Stenson: We studied about 850 people, two-thirds of who had normal bone density, and a third of who had osteoporosis. Among the 500 or so people with normal bone density that we studied, only one had celiac disease, but among the 280 or so who had osteoporosis, nine had celiac disease. So, the incidence of celiac disease in patients with osteoporosis was high enough, we think, to justify screening patients with osteoporosis for celiac disease.
When some people see those numbers, they may think the study included a small amount of people. Can you explain the significance of this finding?
Dr. Stenson: Yes. Well, it was between 3 percent and 4 percent of people who had celiac who also had osteoporosis. There’re 10 million people in the United States who have osteoporosis, so 3 percent of 10 million is 300,000 people. So if what we found can be expanded to the general population, which we can’t say for sure, there are 300,000 people out there who have osteoporosis as a consequence of celiac disease. This group would benefit from having the diagnosis made because if their celiac disease is treated, their osteoporosis will improve dramatically.
How did you treat the nine people in the study who had celiac disease and osteoporosis?
Dr. Stenson: The nine people we identified who had celiac disease and osteoporosis had all been on standard therapy for osteoporosis, which would be calcium, Fosamax (alendronate), and some of them were on hormone replacement therapy. When they went on their gluten-free diets, which is the treatment for celiac disease, their bone densities improved dramatically.
Did they get off the drugs once starting the gluten-free diet?
Dr. Stenson: No. They stayed on the drugs. That’s a study that hasn’t been done — to see if you could get off the drugs by just going on the diet. But what was remarkable was how much improvement they had in their osteoporosis, considering that they had already been on the standard drug therapy for a while.
How did you measure their improvement?
Dr. Stenson: These patients had what we call a bone density study. That’s how osteoporosis is diagnosed. You get a score on your bone density study called a T-score, and the patients who entered the study all had abnormal T-scores, even though they were on therapy for osteoporosis already. Their T-scores improved dramatically when they went on the gluten-free diet.
What is a gluten-free diet?
Dr. Stenson: A gluten-free diet is a diet in which you don’t consume wheat or wheat products, rye, or barley, and this is a fairly difficult diet because these products are in more things than you might imagine. So it’s not just avoiding bread and pasta, it’s avoiding a lot of processed foods that contain wheat. One of the important issues with this diet is because the damage is driven by an immune response to the gluten, it doesn’t take very much gluten to trigger the immune response, and therefore the people who take these diets have to stick with them in a very rigid way. It’s like you have to reduce your gluten intake by 100 percent.
It seems like diet as a treatment could be more beneficial since it is natural, right?
Dr. Stenson: Right. The upsides of it are that it’s not expensive, and there’s no bad consequence of being on a gluten-free diet. The bad part is that it demands a fairly extensive change in most people’s dietary intake. My experience is that most people, once they get on the diet, don’t have so much difficulty staying on it. The hard part is getting on the diet in the first place and altering their habits.
What kind of impact does this diet change have for people with osteoporosis?
Dr. Stenson: The number one thing we saw was their bone density improved dramatically, which should reduce their risk of fractures. Second, many of these people had other complaints that were probably due to their celiac disease. Some of them had diarrhea, some of them lost weight, some of them had abdominal discomfort, and all of those things improved on the gluten-free diet
After this study, what’s your recommendation?
Dr. Stenson: Well, based on this study, we would recommend that people who have osteoporosis have a blood test for celiac disease. There’re two blood tests that are available. One is called a tissue transglutaminase (TTG) antibody, and the other is called an antiendomysial antibody (EMA). The TTG is about $45, so it’s not an extraordinarily expensive study. People who turn up with a positive study of antibodies almost all have celiac disease, but the usual recommendation is that they have an embryoscopy, a biopsy of their small intestine to confirm the diagnosis.
Does celiac disease run in families?
Dr. Stenson: Yes. There is a genetic component to this, and if you have a parent or sibling who has celiac disease, your risk of having celiac disease is considerably higher than the general population.
So if your parent or sibling has celiac disease, would it be worthwhile to get checked now to hopefully prevent osteoporosis?
Dr. Stenson: Yes. One of the groups in which there have been recommendations that they be tested for celiac disease are people who have parents or siblings who have celiac disease.
What is the message you want to get out there about celiac disease and osteoporosis?
Dr. Stenson: That there is a small but real portion of people who have osteoporosis who have it as a consequence of celiac disease. The numbers are high enough to justify screening everybody with osteoporosis for celiac disease and those patients who have osteoporosis as a result of celiac disease will improve have their symptoms improves when they go on a gluten-free diet.
You found that that even works better than drug programs?
Dr. Stenson: Right. So these were people whose osteoporosis improved dramatically, even above what they’d done previously on the standard drug therapy.
Does celiac disease result in any other conditions?
Dr. Stenson: There is an increased incidence of malignancy in people who have celiac disease. It’s a fairly small increase, but it appears to be associated with a kind of lymphoma. There’s some suggestion that treatment of the celiac disease will reduce the likelihood of the development of lymphoma down the line, but that affects a relatively small portion of people who have celiac disease.
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