Treatment with a gluten-free diet for a year resulted in improved BMD in individuals with celiac disease and osteoporosis.

Patients with celiac disease have an inappropriate immune response to gluten, a component of wheat proteins, which makes it difficult to properly digest many foods, according to background information in the article.

Gluten-Free Diet Improves BMD

Although adults diagnosed with celiac disease commonly have a low bone mineral density (BMD), and treatment with a gluten-free diet increases their BMD, there has not been clear evidence of the benefit of screening everyone with osteoporosis for celiac disease.

William F. Stenson, M.D., of Washington University School of Medicine, St. Louis, and colleagues evaluated 840 individuals from the Washington University Bone Clinic -- 266 with and 574 without osteoporosis -- by serologic screening for celiac disease (blood test for antibodies associated with celiac disease).

The diagnosis of celiac disease then was confirmed with an intestinal biopsy, and individuals with a confirmed diagnosis were treated with a gluten-free diet and followed up for improvement in BMD.

Twelve of the 266 patients with osteoporosis and six of those without osteoporosis tested positive by serological screening for celiac disease, the researchers found. Nine patients with osteoporosis (3.4 percent) and one of those without osteoporosis (0.2 percent) had biopsy-proven celiac disease. Further, “... the more severe the celiac disease, the more severe the resulting osteoporosis,” the authors write.

Evidence Justifies Screening Recommendation

“Treatment with a gluten-free diet for a year resulted in improved BMD in individuals with celiac disease and osteoporosis,” say the authors. “The improvement in BMD for celiac disease patients on the gluten-free diet was greater than that expected for osteoporotic patients receiving standard therapy,” the article notes.

“In conclusion, we found that the prevalence of celiac disease among osteoporotic patients was much higher than among the nonosteoporotic population and high enough to justify a recommendation that all individuals with osteoporosis undergo serologic screening for celiac disease,” the researchers state. “[I]ndividuals with positive serological screening should be evaluated with endoscopy and small-intestine mucosal biopsy to establish the diagnosis of celiac disease. Treatment of these individuals with a gluten-free diet will improve their BMD.”

Reducing Fractures Primary Goal

The primary reason to diagnose and treat osteoporosis is to prevent bone fractures. “Low bone mineral density (BMD) is associated with increased fracture risk, and increased BMD during therapy is associated with a corresponding decrease in fracture risk. However, BMD is only one factor that contributes to bone strength and fracture risk in spine and hip,” says Alan L. Buchman, M.D., M.P.H., of the Feinberg School of Medicine at Northwestern University, Chicago, in an editorial accompanying this study.

“Given that most bone mass is achieved by age 18 years, and setting aside cost for the moment, it may be prudent to screen the entire population of high-risk individuals (white girls) during childhood or adolescence, prior to development of osteoporosis or osteopenia,” Dr. Buchman writes.

“Even patients diagnosed as having celiac disease before menopause have more significant improvements in BMD that those diagnosed after menopause. However, one must evaluate the cost not just to identify an asymptomatic individual with celiac disease, but also to prevent a fracture,” he notes.

Evaluating Benefits, Costs

“The cost to prevent a single fracture in a patient with celiac disease and osteoporosis would be $43,000 (similar to the cost of screening mammography to detect a breast cancer). This cost would be far greater for a patient with osteopenia, to say nothing of a population screen,” Dr. Buchman states.

“Not all investigations have reported an increased prevalence of celiac disease in individuals with osteoporosis or an increased fracture risk in patients with celiac disease,” Dr. Buchman also points out.

“However, the questions remain: Who should be screened for celiac disease? And at what cost? The data from Stenson, et al, raise an important issue, but given the variations in study findings and cost estimates, it is impossible to make a clear recommendation for celiac disease screening in a population even as defined as those with osteoporosis,” Dr. Buchman concludes. “As is often the case, further study is indicated.”