<<Disclaimer: Verify this information before applying it to your situation.>> CD and Bone Disease ------------------- by Dr. Dhanwade Rao summarized by Carolyn Sullivan Dr. Dhanwade Rao, the head of the Dept. of Bone and Mineral Metabolism at Henry Ford Hospital, spoke at our October meeting. What follows are some highlights of his talk: The bone density test is based on a comparison to a 25 year old "normal" person. [Author's note: The T Score is the number of standard deviations (SD) an individual is above or below the Young reference value (expected bone mass at age 20-25.) The Z score is the number of standard deviations that an individual is above or below the Age-Matched reference value. So the Z score compares your results with the norm for someone your age. If the T-Score is below the mean by: Then you have: ------------------------------------ -------------- 1 SD Normal bone density 1-2.5 SD Osteopenia more than 2.5 SD Osteoporosis Reference: Grosse Pointe Physicians X-Ray Center, P.C.] Celiac disease (CD) is not readily recognized. Undiagnosed celiacs lose bone mass without knowing it. It is a peculiarity of bone that you can never put bone back but can only prevent further bone loss, once you reach a certain age. A second aspect of bone disease is vitamin D deficiency. We make vitamin D when our skin is exposed to sunlight. It turns out that lighter skin makes more vitamin D than darker skin. Plus in this country, most of the milk is vitamin D enriched. In contrast, India has a population with darker skin that does not make as much vitamin D, and vitamin D is not added to food products like it is here. Therefore vitamin D deficiency has been more common in India. However, in the last five years, studies say 20-50 % of northern Michigan people have vitamin D deficiency, in spite of fortified milk. This is a double whammy because it lowers absorption of calcium and causes parathyroid excess which leaches calcium from bones. About 20% of those who present with bone disease, when tested, are also found to have CD. Osteomalacia, softening of the bones, is associated with vitamin D deficiency. Unlike osteoporosis, it is generally reversible. There are two good sources of calcium in supplements in the USA: calcium carbonate and calcium citrate. Other sources such as calcium phosphate are not recommended, because the body doesn't absorb them well. The recommended daily intake [for post-menopausal women]of elemental calcium is 1500-2000 mg per day, taken in two or three doses. Note that a cup of milk has 280-300 mg of calcium. Extra vitamin D is needed if your calcium intake is low, so that you better absorb the calcium you take in. 800 units of vitamin D per day are recommended [for post-menopausal women]. The types of bone density tests are: 1. Ultrasound of the heel and 2. Dual Energy Absorption. It is reasonable for all celiacs to consider having one done. [author's note: This includes both men and women.] Bone density tests for women should be done after age 50 but Dr. Rao doesn't know when for celiacs and/or children. [Dr. Alexander said that children who grow like weeds on a GF diet are probably OK but every new adult celiac should get one and consider repeating it every 3 to 5 years.] Both Dr. Rao and Dr. Alexander believe that every celiac should have a bone density test. Bone density tests are now paid for by Medicare according to the Bone Density Act of 1998. Once diagnosed, what drugs can or cannot be taken? There are: Calcitonin (a nasal spray), Evista (like Estrogen) and Fosamax (Alendronate, which has very poor absorption, goes only to bone, and has no toxicity.) It is unclear whether they work in CD because, when drugs are tested, 1000 mg. calcium and vitamin D are also given. His suspicion is that it doesn't. Fosamax's main side effect is heartburn. Evista is a new type of estrogen replacement. The downside is that it may result in hot flashes and there is some concern about blood clots in the legs. Compared to hormone replacement therapy (HRT) there is no significant difference [regarding prevention of osteoporosis]. HRT, calcium, and Fosamax used together can have a scientific benefit because each works differently. Hormone Replacement Therapy (HRT) can be started up to age 75 when the risk over benefit dividing line is reached. At age 50, the risk of breast cancer for those on Estrogen is 1 in 6; those not, 1 in 8. Lifetime risk without HRT is 1 in 10. One can take it forever but it needs 7 years for full efficacy. There will be breast tenderness if you've been off of estrogen for 10 years before starting HRT, but it gets better with time. Start with a lower dose and build up. Dr. Rao recommends checking Vitamin D and calcium levels to find out if anything is needed for the individual. New studies only have a few people in them. [Dr. Alexander said that some studies have shown 30-40% of Celiacs have osteoporosis or osteopenia.] Dr. Alexander stated that he rarely sees B12, folic acid or other vitamin deficiencies and is amazed at the accommodation that the gut makes. Dr. Rao thinks the concern about aluminum in Tums is way overblown and that carbonated beverages may increase absorption of calcium. Caffeine and alcohol decrease bone density. Regarding the relationship of arthritis to CD, there is an "old saw" that people with osteoarthritis do not get osteoporosis and vice versa but it is not always so.