Abstracts & Literature Review 1
Bone Mineral Density at Diagnosis of Celiac Disease
and after 1 Year of Gluten-Free Diet
JACO Editorial Reviewer: Thomas Mack DC, FACO
Journal of the Academy of Chiropractic Orthopedists
June 2015, Volume 12, Issue 2
The original article copyright belongs to the original publisher. This review is available from: http://www.dcorthoacademy.com © 2015 (Mack) and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Atypical or silent celiac disease may go undiagnosed for many years and can frequently lead to loss of bone mineral density, with evolution to osteopenia or osteoporosis. The prevalence of the latter conditions, in case of new diagnosis of celiac disease, has been evaluated in many studies but, due to the variability of epidemiologic data and patient features, the results are contradictory. The aim of this study was to evaluate bone mineral density by dual-energy X-ray absorptiometry (DXA) in 175 consecutive celiac patients at time of diagnosis (169 per-protocol, 23 males, 146 females; average age 38.9 years). Dualenergy X-ray absorptiometry was repeated after 1 year of gluten-free diet in those with T-score value <–1 at diagnosis. Stratification of patients according to sex and age showed a higher prevalence of low bone mineral density in men older than 30 years and in women of all ages. A 1-year gluten-free diet led to a significant improvement in lumbar spine and femoral neck mean T-score value. We propose that dual-energy X-ray absorptiometry should be performed at diagnosis of celiac disease in all women and in male aged >30 years, taking into account each risk factor in single patients.
A prospective study was conducted consisting of evaluation of BMD using DXA on 175 consecutive outpatients with new diagnosis of CD and after one year of GFD. Renal function was normal and none of these patients were on treatment with calcium or vitamin D.
The authors propose to perform DXA at diagnosis of CD in all women and men older than 30 years, considering each patient, all the potential risk factors (age, prior osteoporosis fracture, family history of hip fracture, low body mass index, use of drugs like corticosteroids, smoking and alcohol excess. Long term studies are however needed to evaluate the contribution of these factors to risk of fractures in CD patients.
DXA (dual energy X-ray absorptiometry), CD (celiac disease), GFD (gluten free diet), BMD (bone mineral density)
JACO Editorial Summary:
- This article was written by authors from the Department of Gastroenterology, Molinette Hospital, University of Turin, Italy, Clinic of Gastroenterology and Hapatology, Via Cavour 31, Turin, Italy and Gerontology and Bone Metabolic Disease Section, Molinette Hospital, University of Turin, Turin, Italy.
- The purpose of this study was to evaluate the prevalence of abnormalities of DXA (osteopenia/osteoporosis) in patients with new diagnosis of CD and to assess the impact of a gluten free diet on BMD 1 year after the diagnosis. References for this body of work range from 1994 to 2013.
- The authors investigate the relationship of celiac disease (a chronic immune mediated disorder) with bone density of the lumbar spine and femoral neck. The authors suggest initial studies should be considered on newly diagnosed CD patients and follow up studies one year post gluten free diet. During the year of GFD, neither calcium nor Vitamin D were provided to patients.
- The study evaluated BMD using DXA on 175 patients with newly diagnosed CD and after 1 year of GFD. CD diagnosis in this study used the Marsh- Oberhuber classification using only patients who had classical duodenal mucosal villus atrophy and crypt hyperplasia (Marsh Grade III). WHO criteria of osteoporosis was used as the bone density benchmark.
- Lower bone density in CD patients (newly diagnosed) showed a higher prevalence in men older than 30 years and women of all ages. Significant improvement in T-score values were noted after one year in the lumbar spine and femoral neck in this study group leading the authors to recommend DXA be performed on all women and men > 30 years.
- The authors have also identified an increased risk of fractures as a consequence of osteoporosis due to CD. Malabsorption and inflammation are hallmarks of CD leading to lower serum levels of calcium as well as hypovitaminosis of vitamin D.
- Thorough history and identification of CD, malabsorptive and maldigestive diseases, have become increasingly paramount in the treatment and prevention of osteoporosis.
Comorbid factors should be considered such as corticosteroid use, smoking, and alcohol abuse in determining DXA screening.
- The significance of this study reveals the relationship of gastrointestinal issues with bone density. Practitioners of manual/musculoskeletal medicine should identify such issues in the patient’s history and also consider conservative management protocols. This study merits further investigation.
- This paper is well written, interesting, and appropriate in length.