Osteoporosis and
coeliac disease
Alison Andrews
Coeliac disease is a permanent condition in which the surface of the small intestine is damaged by gluten. Ingestion of gluten by a person with the coeliac condition inflames the lining of the small intestine. The small finger-like projections called villi, which line the intestine and increase the surface area for the absorption of food, become flattened and inflame, reducing the ability to absorb nu-trients properly, one of these being calcium.
This reduced ability to absorb calcium leads to a decrease in bone mineral density (BMD) and an increased risk of osteoporosis. The incidence of osteoporosis in coeliac disease may be as high as 50 per cent, with up to 20 per cent of patients having a fivefold increase in their lifetime fracture risk (McFarlaneet al., 1995).
Coeliac disease may present at any age in both sexes, but has a peak incidence between 30 and 45 years of age. More than one family member may be affected, with a 10 per cent chance of the condition occurring in first-degree relatives. The disease may affect at least one in 300 people (Catassiet al., 1994)
and is equal in both sexes. However, the rate of confirmed diagnosis in women is double that of men and is assumed to be because women more frequently present to their GPs.
Symptoms and diagnosis
Coeliac disease is often underdiagnosed or misdiagnosed (Ainet al., 1999) which may be
due to patients presenting with vague symp-toms such as anaemia, fatigue, muscle aches and bone and joint problems. If a GP suspects coeliac disease a blood sample can then be taken to screen for anti-gliadin antibodies (AGA) and/or anti-endomysiam antibodies (AEA). If these circulating antibodies are detected then the patient should be referred to a gastroenterologist for a small intestine biopsy to confirm the diagnosis.
Treatment
The treatment for coeliac disease is life-long adherence to a gluten-free diet. The principles of a gluten-free diet include:
. exclude all sources of gluten which are found in wheat, rye, barley and oats; The author
Alison Andrewsis Senior Dietitian at Nutricia Dietary Care, Trowbridge, Wiltshire, UK.
Keywords
Disease, Health, Diet
Abstract
Describes coeliac disease with its increased risk of osteoporosis for the patient. Often misdiagnosed or not recognised early, coeliac disease leads to further complications, particularly osteoporosis. Provides eating/ nutrition guidelines for coeliac sufferers to avoid osteoporosis in later life.
Electronic access
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Number 6 . November/December 1999 . pp. 285±287
. avoid manufactured products containing gluten ± e.g. meat products which include flour as bulking agent;
. include naturally gluten-free foods such as meat, fish, potatoes, rice, fruit and vegetables;
. a number of commercial gluten-free
foods are available on prescription in-cluding some gluten-free bread which has been enriched with calcium.
Coeliac disease and complications
There are several complications associated with coeliac disease including infertility and malignancy (Holmeset al., 1989) but one of
the main complications of the condition is reduced BMD leading to osteoporosis.
As the diagnosis of coeliac disease is often delayed into adult life (Hinet al., 1999) many
patients will have experienced malabsorption for prolonged periods.
The peak bone mass which is achieved in early adulthood (up to the early 30s) may not be reached and can lead to developing osteoporosis.
Osteoporosis sufferers are ten times more likely to have the coeliac condition than the general population (Lindhet al., 1992). In some cases, hypocalcaemic skeletal disease may be the only presentation of coeliac disease. One study of 15 osteoporotic patients showed that four patients had none of the gastrointestinal symptoms, seven had mild symptoms and four had diarrhoea ± the average age of the group was 62 and all of them were diagnosed with coeliac disease (Shakeret al., 1997).
Prevention of osteoporosis in patients
with coeliac disease
A strategy for the management of osteoporo-sis in coeliac disease has been outlined and recommends that patients with coeliac disease increase their calcium intake to 1,500mg per day (Scott and Scott, 1998). This is more than double the recommendation of the Department of Health's Committee on Medical Aspects of Food Policy (COMA) which recommends that healthy individuals over the age of 19 years have a daily calcium intake of 700mg (Nutrition and Bone Health, date not supplied).
Individuals with coeliac disease can prevent the risk of developing osteoporosis by adher-ing to the followadher-ing:
. compliance with gluten-free diet;
. calcium enriched foods: for example
gluten-free bread enriched with calcium;
. increase calcium intake to 1,500mg per
day;
. increase weight-bearing exercise;
. avoid smoking;
. avoid excess alcohol.
In addition to this outlined strategy the British Society of Gastroenterology has pro-duced patient guidelines for the follow-up of patients with coeliac disease. This recom-mends that there should be a specialist consultation at six- to 12-month intervals for patients to check dietary compliance and for routine blood tests. This should be for life given the long-term complications such as lymphoma and osteoporosis.
Support services
The Coeliac Society
For patients who require further information, the Coeliac Society offers membership to those who have been medically diagnosed ± current membership stands at 36,423. Each member receives a list of gluten-free manu-factured foods, recipe books and the contact details of local groups. The Coeliac Society, PO Box 220, High Wycombe, Buckingham-shire HP11 2HY. Tel: 01494 437278; Fax: 01494 474349.
The Coeliac Disease Resource Centre The CDRC provides healthcare professionals with a wide variety of resources including clinical updates, abstracts, reviews, literature searches, product information and training services. It can be contacted on 01225 711566 or by writing to: The Coeliac Disease Resource Centre, Newmarket Avenue, White Horse Business Park, Trowbridge, Wiltshire BA14 0XQ. Web site: http//www.glutafin.-co.uk (CDRC page password = CDRC). e-mail: CDRC@nutricia.co.uk
The National Osteoporosis Society (NOS)
For more information on reducing the risks of osteoporosis and an information fact sheet on the coeliac condition and osteoporosis contact The National Osteoporosis Society, PO Box
286
Osteoporosis and coeliac disease Alison Andrews
Nutrition & Food Science
10, Radstock, Bath, Avon BA3 3YB. Tel: 01761 471771 (general enquiries), 01761 4722721.
In summary, osteoporosis is a very common and often unrecognised complication of coe-liac disease. This is compounded by coecoe-liac disease often being underdiagnosed and mis-diagnosed within the primary care setting. Those patients who have been diagnosed with coeliac disease and proven osteoporosis need to comply with a strict life-long calcium-enriched gluten-free diet and receive long-term follow-up.
References
Catassi, C., Ratsch, I-M., Fabiania, E., Rossinin, M., Bordicchia, F. and Candelaet al. (1994), ``Coeliac disease in the year 2000; exploring the iceberg'', The Lancet, Vol. 343, pp. 200-3.
Hin, H., Bird, G., Fisher, P., Mahy, M. and Jewell, D. (1999), ``Coeliac disease in primary care; case finding study'',BMJH, p. 318.
Holmes, G.K.T., Prior, P., Lane, M.R., Pope, D. and Allan, R.N. (198), ``Malignancy in coeliac disease ± effect of a gluten-free diet'',Gut, Vol. 39, pp. 333-83. Lindhet al. (1992), ``Screening for antibodies against
gliadin in patients with osteoporosis'',Journal of Internal Medicine, Vol. 231, pp. 403-6.
McFarlane, X.A., Bhalla, A.K., Reeves, D.E., Morgan, L.M. and Robertson, D.A. (1995), ``Osteoporosis in treated coeliac disease'',Gut, Vol. 36, pp. 710-14. Nutrition and Bone Health (date not supplied), Report of
the Subgroup on Bone Health, Working Group on the Nutritional Status of the Population, Committee on Medical Aspects of Food and Nutrition Policy. Scott, E.M. and Scott, B.B. (1998), ``A strategy for
osteoporosis in gastroenterology'',European Journal of Gastroenterology and Hepatology, Vol. 10 No. 8, pp. 689-98.
Shakeret al. (1997), ``Hypoclacemia in skeletal disease as presenting features of coeliac disease'',Arch. Internal Medicine, Vol. 157, pp. 1013-16.
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