<<Disclaimer: Verify this information before applying it to your situation.>>

A few posts have been on the list recently regarding the gluten free  
status of multivitamins and mineral supplements.  This is a  
legitimate issue and a significant concern to celiacs.  The list has  
contained recommendations on products, and as we know, the products  
need to be monitored for changes in formulation.  In addition, a list  
of gluten free vitamins is available at my website,  
www.napervillegi.com under the celiac link.  (The list is maintained  
by folks at the Wheaton Celiac Support group, which I started a few  
years ago.)

Celiacs have a significantly increased chance of having an abnormal  
bone density test.  There is substantial controversy in the medical  
literature on whether there is an increased risk of bone fracture in  
Celiacs.  It was a surprise that the abnormal bone density did not  
predict fracture risk as it did in the elderly population.  When a  
study does show an increased risk of hip fracture the absolute risk  
is low.  That is, risk of fracture may increase 1.5 to 2 fold, but  
that brings the risk from something like 1 in 1000 to 1 in 500.   
Additionally, we actually don't have studies that show treatments in  
Celiac patients decrease the risk.  Also, there is data that once a  
celiac begins a gluten free diet their bone mass improves just from  
the diet treatment.  The present state of knowledge leads to  
divergent recommendations on treatment of patients with low density  
bone scans.

A practical issue is that a person just diagnosed with celiac should  
not start taking a biphosphonate class of drug (like Fosamax or  
Actonel) in the first several months after initial diagnosis of  
celiac disease, since the poor intestinal absorption of calcium  
coupled with the effects of the drug can cause the blood calcium  
level to drop precipitously to dangerous levels, so low that seizures  
or severe muscle spasms develop.

Mineral supplements are safe to take.  It is best to take them with  
food for several reasons.  Calcium binds to oxalic acid, an organic  
acid found in foods.  Binding oxalic acid in the gut prevents kidney  
stones.  If you take other medicines, calcium can bind to some  
drugs.  Taking calcium with meals simplifies your dosing regimen.   
Minerals are also better tolerated on a full stomach.

While calcium seems to get the most press for osteoporosis, magnesium  
is important in bone formation.  It is the second most important  
mineral in bone.  Also, osteoporosis will not respond to treatment if  
magnesium is inadequate.  Magnesium also helps with the constipation  
often seen with calcium supplements.

The daily dose of Calcium is typically 1000 to 1500 mg of Calcium  
Carbonate, and should be taken with meals.  Magnesium dosing is 250  
to 500 mg of Magnesium Oxide, also with meals.  It is fine to take  
the amount just once a day or divided among meals.

The bigger question is should you take the supplements.  I generally  
advise my patients to take supplements if they have an abnormal bone  
density.  I generally don't get a bone density up front at  
diagnosis.  I also get my patients to a dietician to monitor adequacy  
of diet at 6 months out.  I think a bone density after 1 year on a  
gluten free diet is reasonable.  I also think that any other advice  
is reasonable since there is such variation in study results.  I can  
make very compelling arguments for all sorts of regimens.  Again,  
this variety in advice is due to the lack of a good study that looks  
at long term results of any regimen!

As to whether get a natural vitamin or a chemically manufactured one,  
for most vitamins there is no difference between them.  Vitamin E is  
one where the chirality of the molecule is specific in the body,  
while Vitamin E made in a non-enzymatic fashion may not be chirally  
pure.  (Chirality is the expression of the fact that while the left  
and right hand are identical they do differ in a mirror image way.   
Some molecules are like that.)  Thus, most of the vitamins that are  
chemically manufactured are natural in all respects.

Stephen Holland, M.D.

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