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CD and Bone Disease
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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.
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