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                          CD and Bone Disease
                          -------------------
                          by Dr. Dhanwade Rao
                        summarized by Jim Lyles
 
Dr. Dhanwade Rao, the head of the Department of Bone and Mineral
Metabolism at Henry Ford Hospital, spoke at our April meeting.  What
follows are some highlights of his talk.
 
Most people associate CD more with anemia than bone disease.  This is
because we don't tend to think much about our bones, unless they
break.  We think of bone as a solid structure that will remain forever
to support us until we leave this world.  This is not true.  Bone is
constantly undergoing a renewal process.  Every 15 seconds a piece of
bone is removed and a new piece is formed.  Over the course of the
meeting, about 10% of the bone was renewed.
 
Until about age 25, your bones continually strengthen and acquire more
and more calcium.  At that point you have reached skeletal maturity.
After that, you cannot add any more calcium to them; you can only lose
calcium or try to prevent its loss.  So at age 25 you have built up a
"bank" on which you will draw for the next 50 years (the average life
span).
 
A couple of things happen in a woman's life, and to a lesser extent in
men.  When you reach menopause and lose estrogen, you lose bone
rapidly for about five years, and then a little more slowly after
that.  This leads to osteoporosis, a condition where particles of bone
are removed and never replaced.
 
If you don't take in enough calcium (and Vitamin D to help you absorb
the calcium), you are likely to develop thin bones, a condition which
is known as osteomalacia.  This disease is nothing more than a
counterpart of the bone disease that afflicts children, which is
called rickets.  If a child has a deficiency in Vitamin D, the child
develops rickets.  If an adult has a deficiency in Vitamin D, the
adult does not get rickets; the adult gets osteomalacia, with a
softening of the bones.
 
Frequently patients with osteomalacia will have bone and muscle
weakness.  Sometimes the disease develops slowly over a long period of
time.  You lose bone slowly, without your knowledge, until it breaks
(a hip or vertebrae fracture).
 
The gastrointestinal tract is the route by which nutrients are
absorbed:  calcium, vitamin D, iron, minerals, etc.  You need to have
the intestine in good working order.  The villous atrophy that is
characteristic of untreated CD impairs the absorption of calcium.
 
Most of the celiacs that Dr. Rao sees are people who have severe bone
disease, either because they didn't know, still aren't absorbing,
don't follow the diet, etc.  One of the problems with bone disease is
that, once you've lost bone mass you can never really regain it.  If
you lose 10% and then take corrective behavior, you can maybe get 1%
back.  The other 9% is gone forever.
 
Bone stores approximately 95% of the calcium that is in our bodies.
You lose about 50 milligrams of calcium per day, which is not very
much.  That translates to 18 grams of calcium per year, which is a
sizable amount.
 
There are two types of bone in our bodies:  1) Compact bone, found in
long tubular bones such as those in arms and legs, and 2) spongy bone,
which is mostly present in the vertebrae.  It is the spongy bone that
is generally involved in osteoporosis.  Most of the bone loss in
celiacs occurs in the compact bones, so that a celiac is at risk of
increased hip fractures as opposed to vertebrae fractures.
 
It is important for celiacs to take in enough calcium and vitamin D.
In this part of the world most of the vitamin D comes from diet.
(Your body also produces vitamin D when exposed to sunshine, but
climate and fear of skin cancer limit exposure to sunshine.  However,
an hour of sunshine supplies enough vitamin D for one day.)  In this
country people take supplements to provide extra iron and vitamins,
but fail to take in extra calcium and vitamin D which are even more
important.  If you get tired and anemic, you can go to the doctor,
start taking supplemental iron and vitamins, and return to normal.
But if your bones get thin and break due to insufficient calcium, the
damage is done and it is too late to undo the damage.  Calcium
supplements can help relieve the symptoms of osteomalacia (bone
softening), but will not restore the lost bone mass.  So it is
important to think about vitamin D and calcium just as much as you
think about iron and other vitamin deficiencies.
 
Sometimes we need to do a bone biopsy to diagnose a bone problem,
because often there is confusion as to whether an individual has
osteoporosis or osteomalacia and the treatments are different.
Osteomalacia is almost completely curable, whereas osteoporosis does
not respond as well to treatment.  A bone biopsy can be used to
predict how well the patient will respond to treatment and what the
future prospects are for the patient's skeletal health.
 
Fosamax, a new osteoporosis drug, has been mentioned in _The Sprue-nik
_Press.<1> Dr. Rao does not think it is a good treatment for the
osteoporosis related to CD.  It is good, however, for post-menopausal
osteoporosis and it does appear to be GF.
 
The antibody blood tests have been helpful in finding celiacs among
post-menopausal women with bone problems.  There is some data to
suggest that as many as 20% of patients that present with
post-menopausal osteoporosis seem to have so-called "latent" CD.
Conversely, 20-50% of patients with CD have osteoporosis.  There are
tests now available that can measure bone density and tell you if
you've lost either spongy bone from the vertebrae or compact bone from
the arms and legs.  By doing that particular test we can even begin to
determine whether you have CD-related osteoporosis or the usual
osteoporosis.  It is a simple test using X-rays, it only takes about
15 minutes, and it is not costly.
 
Dr. Rao does not know if store-bought multi-vitamin tablets contain
enough vitamin D, but there is a prescription supplement that you take
once a week and costs about $1 per pill.
 
Dr. Rao answered some questions from the floor:
 
 
Q:  Should all CD patients have a bone density test?  How often?
 
A:  Dr. Rao recommends that all adult celiacs have a bone density
    test once a year.  Also have your vitamin D and calcium levels
    checked regularly.
 
 
Q:  What form of calcium should celiacs take?
 
A:  Calcium carbonate tends to cause constipation, whereas calcium
    citrate is more likely to cause diarrhea.  For most celiacs,
    calcium carbonate would be preferred.
 
 
Q:  How much calcium should you take?
 
A:  500 milligrams, twice a day is recommended; maybe more.
 
 
Q:  If a post-menopausal celiac patient carefully follows the diet,
    and has three or four servings of dairy products a day, is a
    calcium supplement still recommended?
 
A:  In this case the supplement is probably not necessary, but not
    many people actually fit this profile.
 
 
Q:  My wife was fine all her life, then suddenly a year ago she
    started having collapsed vertebrae and a bone density test showed
    only 30%.  Now she's lost five inches in height.  How did bone
    problems occur so quickly?
 
A:  What happens is, you can lose bone gradually over a long period of
    time and not know it, until you reach a critical point where
    you've lost enough bone mass to allow the bone to fracture easily.
    She probably had been losing bone over a 5-10 year period and
    didn't know it.
 
 
Q:  What part does loss of magnesium play in bone disease?
 
A:  It does not seem to have an adverse effect on bone density, though
    it does have other effects such as muscle weakness.