Overview

Celiac disease, an autoimmune condition induced by gluten intake, may result in osteoporosis, which is characterised by fragile bones. Individuals with osteoporosis have a significantly higher prevalence of celiac disease compared to those without it, to the point where all patients with osteoporosis are recommended to be screened for celiac disease. Individuals who suffer from either condition should prioritise holistic health treatment since they have similar risk factors, such as nutritional deficiencies.¹ Understanding the complex links between the two diseases might enable the development of more effective treatments.

What is celiac disease?

Celiac disease, an immune-mediated condition, is characterised by intolerance and an adverse reaction to gliadin. Gliadin is a gluten-derived protein present in wheat, barley, and rye. When an individual has celiac disease, their immune system mistakenly targets the sensitive small intestine's lining, inducing a localised inflammatory response and impairment, which prevents the intestines from efficiently absorbing nutrients.² Celiac disease may lead to multiple challenges if left untreated, which can disrupt not just the digestive system but also other bodily functions.

Causes and risks

The exact cause of celiac disease is not known, but it is believed to result from a combination of environmental, genetic, and immunological factors. Individuals with specific genetic markers, specifically the HLA-DQ2 and HLA-DQ8 genes, are at a higher risk of developing celiac disease.² However, not everyone with these genetic markers will acquire the condition, suggesting that external factors, such as infections and dietary choices, may also play a role.

Diagnosis and symptoms

Celiac disease is diagnosed in two steps: examination of intestinal tissue samples and blood testing. During the biopsy, changes in the intestinal lining are observed, including the presence of specific antibodies in the blood. High antibody levels and symptoms in children may exclude the necessity for a biopsy, based on the "four out of five rule," which takes into account symptoms, antibodies, genes, intestinal damage, and diet response. Additionally, anaemia and nutritional deficiencies may be detected by blood testing; some tests, such as those for EmA and anti-tTG antibodies, are especially useful for detecting celiac disease.^2,3 Regardless of modern blood testing, confirmation generally involves examining intestinal tissue under a microscope. Ongoing research intends to simplify this procedure by investigating techniques such as swallowable cameras for intestine exploration in cases where a biopsy is not possible.²

The following are some primary symptoms:^2,3

• Bones: osteopenia or osteoporosis
• Digestive problems: diarrhoea, constipation, bloating
• Growth: weight loss, growth difficulties
• Neurological: headache, tingling sensations
• Reproductive: frequent miscarriages, changes in sperm quality
• Others: iron deficiency, dental enamel abnormalities

What is osteoporosis?

Osteoporosis is a prevalent medical condition that affects the entire body, marked by a significant decrease in bone mass and the deterioration of its structure, leading to fragile and weak bones that are highly susceptible to fractures.⁴ This condition arises when the body fails to maintain a balance between the formation of new bone and the removal of old bone, causing a gradual reduction in bone density and the gradual breakdown of bone structure.

Causes and risks

When bone loss exceeds bone growth, the result is osteoporosis, making bones prone to fractures. There are many contributing factors:⁴

1. Genetics: family history may increase the risk
2. Hormonal imbalance: low oestrogen and other hormones accelerate bone loss (such as menopause in women and low testosterone levels in men)
3. Nutrition: deficiencies in essential nutrients like calcium and vitamin D are detrimental to bone health
4. Micro-damages: minor bone injuries trigger excessive bone breakdown
5. Immune system: mechanisms such as RANK/RANKL/OPG disrupts bone cell activity
6. Wnt and BMP pathways: these control bone formation; disruption can lead to weaker bones
7. Ageing: as we age, bone growth slows down
8. Fat and bone cells: changes in fat-bone balance affect bone health
9. Epigenetics: environmental factors can change the expression of bone-related genes
10. Intestinal bacteria: this affects nutrient absorption and bone strength

Diagnosis and symptoms

The diagnosis of osteoporosis includes asking about previous fractures, health conditions, medications, and lifestyle, while also examining height, spine, and muscle function. Lab tests involve checking the blood for calcium, vitamin D, and hormones in order to identify the causes of bone loss. A bone density test (DXA) measures bone strength at specific locations and compares it to standard values (T-scores for young adults and Z-scores for peers), diagnosing fractures based on low trauma, even in the absence of low bone density. Using advanced scans to examine bone structure in greater detail, particularly in more compact regions.⁵ Testing is recommended for certain age and risk groups, such as older women and men who have specific risks.

Osteoporosis symptoms often present as:⁴

• Fractures: these are especially prevalent in the hips and spine because of weaker bones
• Bone loss: reduced bone density, resulting in brittle bones
• Height loss: a noticeable reduction in height due to spine curvature
• Muscle weakness: linked to diminished bone strength and mobility

Connection between celiac disease and osteoporosis

The ingestion of gluten has a significant effect on bone health. Gluten consumption in celiac disease patients triggers an immune reaction that destroys the small intestinal lining, decreasing nutritional absorption, including critical minerals like calcium and vitamin D, which are required for bone health. Osteoporosis develops because of the malabsorption of essential nutrients, which reduces bone mineralisation and density.⁴

The development of osteoporosis in individuals with celiac disease is complex and involves various factors. The autoimmune reaction in the intestine leads to ongoing inflammation, which triggers the release of inflammatory molecules like interleukin-6 and tumour necrosis factor-alpha. These molecules disrupt the normal process of bone remodelling by increasing the activity of osteoclasts (cells that break down bone) and suppressing the function of osteoblasts (cells that build bone).⁶ Additionally, the poor absorption of important nutrients like calcium and vitamin D due to intestinal damage further hinders bone formation and mineralisation, ultimately contributing to bone loss and a higher risk of fractures in celiac patients.

Studies after studies have repeatedly shown that individuals with celiac disease have greater rates of osteoporosis and osteopenia, which is a condition that may develop into osteoporosis, than the general population. Moreover, research highlights a strong correlation between celiac disease and weaker bones, where up to 75% of newly diagnosed cases have reduced bone mineral density. Furthermore, osteoporosis in celiac disease sometimes remains undetected until it reaches a severe level, highlighting the need for routine bone health tests for those who have this condition.⁷

Management and prevention of osteoporosis in celiac disease patients

Celiac disease patients with osteoporosis are treated with a comprehensive approach that involves dietary modifications, lifestyle changes, supplements, and medication if necessary. These individualised strategies are regularly assessed for effectiveness.⁸

Non-pharmacological approach

• Lifestyle: focus on maintaining healthy habits like exercise, quitting smoking, and moderate alcohol intake
• Diet: to promote healing and bone health, adhere strictly to a gluten-free diet
• Supplements: take vitamin D and calcium supplements as required

Medication considerations

• Indications: drugs used to treat osteoporosis if the risk of osteoporosis is high or associated with fractures. For drug suggestions contact your doctor
• Monitoring: regularly checking bone health and adjusting dosages as needed

Special considerations

• Premenopausal women: discuss treatment options while considering pregnancy plans
• Men: ensure prompt diagnosis and treatment to prevent potential complications
• Follow-up: monitor regularly and seek advice from specialists when necessary

Summary

Gluten consumption causes minor intestinal damage that impairs the absorption of nutrients, especially vital minerals like calcium and vitamin D that are necessary for healthy bones. This condition, known as celiac disease, can give rise to osteoporosis, a disorder characterised by fragile bones that make patients prone to fractures. Research indicates a robust correlation between osteoporosis and celiac disease, with newly diagnosed incidents of the condition exhibiting decreased bone mineral density.

Gluten ingestion triggers an immunological reaction that damages the intestines and causes inflammation, which interferes with proper bone remodelling. This process releases inflammatory chemicals that worsen bone loss and inhibit bone-forming cells, further impairing the health of bones. Osteoporosis in celiac disease patients may be difficult to detect and often goes unnoticed until it is well advanced. Therefore, regular checks of bone health are essential for those with celiac disease. Patients with celiac disease need a multimodal strategy to treat their osteoporosis. It is advised to modify one's lifestyle and to stop smoking, consume alcohol in moderation, and exercise often. Strict adherence to a gluten-free diet supports bone strength and intestinal repair.

To address nutritional deficiencies, supplements like calcium and vitamin D are often recommended. Medication such as bisphosphonate or denosumab may be required for those who are more susceptible to fractures or who already have fractures, but its usage has to be closely managed by a doctor. Men and women who are not yet menopausal need special attention and customised treatment regimens to reduce subsequent problems. Ensuring continuous management and making necessary modifications to treatment regimens requires regular follow-ups with healthcare specialists. A multifaceted approach to treating both osteoporosis and celiac disease may help patients improve their overall well-being.