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Healthy bones are big news these days. That's because osteoporosis, a disease in which fragile bones break easily, is an important American health concern. Osteoporosis can be prevented or at least alleviated. Diagnosing and treating gluten sensitivity is one way to lessen the significant impact of osteoporosis on lifestyles, health-care costs and longevity.
People who are gluten sensitive are at higher risk for osteoporosis. The longer the sensitivity is undetected or untreated, the higher the risk and the greater the damage. The sooner gluten sensitivity is diagnosed and treated with the gluten-free diet and other bone-preserving measures, the greater the opportunity to lessen the debilitating impact of osteoporosis.
The popular media regularly dispenses information about the critical role adequate calcium intake plays in maintaining bone health. We need adequate calcium to maintain strong bones that sustain us throughout our lives. When we do not absorb enough calcium from food to fuel bone and other body processes, our body steals what it needs from our bones, sapping their strength.
In general, Americans do not ingest enough calcium-containing foods. In particular, gluten-sensitive individuals, not only may not get enough calcium, but the calcium they do ingest may not be absorbed by their body -- especially if they are unaware of the problem gluten can cause and continue to ingest it.
You'll find the top ten tips to help celiacs maintain healthy bones on page x. What follows is celiac-specific information about calcium, bone health and osteoporosis.
Celiac Bones Need Special Attention
Celiac Disease impairs the ability of our small intestine to absorb nutrients from food by harming the surfaces where absorption occurs. The harm usually occurs at the beginning of the small intestine, which happens to be the same area where calcium is absorbed. Some celiacs also malabsorb vitamin D, a fat-soluble vitamin that plays a critical role in proper calcium metabolism.
Intestinal damage was probably going on for some time before it produced your unique celiac-symptom profile, which was eventually diagnosed as being caused by gluten sensitivity. Sometimes, but not always, an individual's profile includes hairline fractures caused by fragile bones, in turn caused by years of unknowingly malabsorbing calcium.
Undiagnosed Celiac Disease also usually destroys the lactase-producing enzymes found at the tips of the villi, the hair-like structures that bring about nutrient absorption in the small intestine. These enzymes help digest the lactose in dairy products, which are the best human dietary source of calcium.
Without these enzymes, the individual develops lactose intolerance, a condition that causes gas, bloating, cramping, diarrhea or general discomfort after ingesting lactose-containing foods. It can be so unpleasant that those who believe they are lactose intolerant, whether self- or physician-diagnosed, might tend to avoid dairy products, thus worsening the problem of calcium depletion.
Then there is the thyroid connection. People with Celiac Disease are more likely to have thyroid problems that require use of a thyroid hormone. Excess amounts of thyroid medication (and some other medications) can lead to calcium loss in the bone, so these medications must be carefully monitored by your physician.
Finally, people with Celiac Disease can be a tired bunch of individuals. The period that precedes diagnosis, whatever its length, is often especially debilitating and thoughts of exercise may never be acted on due to lack of energy. Weight-bearing exercise is believed to be beneficial for bone health.
And those individuals dragging themselves through life due to undetected gluten sensitivity may simply figure they're not the exercising type. Lack of exercise, for whatever reason, can impact bones and many other aspects of healthy living.
Women at Risk; Men not Immune
Celiac women should be as concerned about their calcium intake and bone density scores (a measure of bone stores taken via densitometry, a noninvasive, painless testing method) as they are about getting regular mammograms. Women are more at risk for osteoporosis because they tend to have a smaller "store" of bones from which to lose than men.
Women also begin depleting their store sooner, around menopause which can occur as early as about age 45. Men usually build up greater bone stores and don't begin losing bone until about age 65. So all women need to be concerned about calcium throughout their lives.
But men are not immune to osteoporosis, particularly celiac men. Even though men are hormonally protected from serious calcium loss until a later age, undetected gluten sensitivity could compromise their body's ability to absorb this vital mineral, leaving them with diminished stores from which to lose.
In addition, calcium depletion, bone problems and osteoporosis are almost universally seen as female problems, so calcium-compromised male celiacs are in danger of falling through the medical cracks of inattention. The New York Times recently reported that 1.5 million American men have osteoporosis and 3.5 million more are at high risk.
Calcium absorption is particularly important in children, who need to build up maximum bone stores during the growth years when these stores are laid down. Gluten sensitivity, particularly undetected gluten sensitivity, not only interferes with achieving maximum bone stores, but it also can seriously affect a child's growth during critical growth periods.
No matter how you look at it, what you usually get coming in to Celiac Disease is a calcium-starved individual whose calcium malabsorption may well have occurred during the early glory years of bone-store accumulation. Plus, depending on age at diagnosis and rate of healing, calcium absorption may or may not reach "normal" after being on the gluten-free diet.
The Good News
A diagnosis of Celiac Disease can spell relief for bones at risk. Celiacs who follow the strict gluten-free diet that helps repair the absorptive surfaces of the small intestine can return to absorbing calcium at a much better rate and may even increase their bone stores.
A study presented at the recent international celiac conference in Finland (see enclosed "GFL Special Report") described patients who started a gluten-free diet and then showed marked improvement in their bone density, although it did not return to normal. The improvement was better in the spine than in the hip and better in the hip than elsewhere. Premenopausal women did better than postmenopausal women.
In an Argentinean study described in the July/August issue of Gluten Free Living (page 6), the researchers said, "Strict gluten restriction from the diet for one year produces significant bone remineralization (building up) in adults with Celiac Disease." In this study, remineralization was more pronounced in patients who followed strict gluten restriction compared to those with partial compliance.
The GF diet may be rigorous, especially at first, but the rewards are great. And the more time one spends learning all the subtleties of gluten-free eating, the easier it becomes to vary the diet and include calcium-rich foods, a plus for every body, celiac or not.
Eventually, too, lactose intolerance may resolve, and dairy foods can be eaten without fear of distressing consequences. Plus, the gluten-free diet brings back energy and strength, making exercise a viable option.
The availability of a relatively new drug, Fosamax, which helps restore lost bone, is not yet great news for celiacs. Fosamax is said to be gluten free, and Merck and CO, the manufacturers, claim the medication rebuilds bone, inhibits bone breakdown and decreases the amount of bone lost.
But Fosamax is not yet recommended for those with esophageal problems and, according to Merck, "should be used with caution if you have certain stomach or digestive problems." Reported side effects include stomach and muscle/bone pain, weighty considerations for gluten-sensitive individuals.
So celiacs need to consult their physicians about the advisability of taking Fosamax. A physician might decide it is appropriate in some cases, but the drug is so new, there is not yet any data on its use in Celiac Disease.
Toward the Future
The earlier gluten sensitivity is diagnosed, the better. Period. In fact, osteoporosis is one of the best (if not the best) reasons we have for agitating to make Celiac Disease better known and for screening those at risk for the problem, especially females. According to the National Osteoporosis Foundation, 25 million Americans have osteoporosis. The disease leads to 1.5 million fractures, usually of the hip, spine and wrist, and costs $10 billion annually.
Those figures should make everyone sit up and take notice. But they are still cold numbers that do a poor job of describing the devastating effect fragile bones can have on daily living. According to the National Osteoporosis Foundation, 50 percent of individuals with hip fractures will need some help with daily living activities and 15 to 25 percent will need care in a long-term care institution. More ominously, some 12 to 20 percent of hip-fracture victims die shortly after a fracture, usually from complications related to either the fracture or surgery.
And much of this can be prevented. Americans need to:
And we lucky diagnosed gluten-sensitive individuals need to put Celiac Disease on the tips of the tongues of all preventive-health-conscious physicians in this country -- which should be all physicians. Help give unsuspecting gluten-sensitive individuals the diagnosis they need to begin eating the diet that will make them healthier than they ever imagined they could be in all ways, not just in their bones.
Finding more of the celiacs among us will help put a dent in the huge numbers noted above. More importantly, it will mean a happier, healthier life for those whose later years are in danger of being compromised by the serious drawbacks of a fragile skeleton.
Ann Whelan is editor/publisher of Gluten-Free Living.
TOP TEN TIPS TO HELP CELIACS MAINTAIN STURDY BONES
1. Every patient diagnosed with Celiac Disease, male and female alike, should have a bone densitometry test at the time of diagnosis. If the test shows evidence of bone disease, be sure to follow your doctor's advice and have repeat testing to show improvement.
2. Make sure your daily diet includes foods that are naturally high in calcium. This is particularly important when you are newly diagnosed and making the transition to a gluten-free diet. The rigors of learning the diet might make you forget your urgent need for calcium. Dairy products are the best dietary source of calcium but many, if not most, newly diagnosed celiacs are also lactose intolerant (see next tip). The following foods are among the best non-dairy sources of calcium and they are all naturally gluten free (but check out the items that come in cans): canned sardines and canned salmon with bones, canned shrimp, bok choy, collards, turnip greens, broccoli.
3. Make sure your daily diet includes plenty of dairy products. If you are lactose intolerant, use one of the products currently available that helps people digest lactose, but remember to check out the gluten status. The Calcium Information Center suggests that lactose-intolerant individuals consume food at the same time as lactose-containing beverages to help delay gastric emptying and decrease symptoms. Lactose intolerance often improves after you have followed the gluten-free diet for some time. It's not a bad idea to check out your lactose status from time to time to see if it's less troublesome, or even resolved. Drink some milk and await developments. If you are "cured" of lactose intolerance, you'll find ingesting dairy foods pleasanter and less anxiety provoking, and you will probably become more likely to make sure you include adequate dairy products in your daily diet.
4. Take calcium supplements every day. Calcium carbonate is usually recommended as the best, most bioavailable (meaning it dissolves so the body can absorb it*) form to take. The suggested general dose is 1,000 mg a day. Postmenopausal females need 1,500 mg and pregnant and lactating women should take 1,200 mg. Health care professionals recommend not taking your recommended dose all at once but spreading it out over 2-3 doses throughout the day, with each partial dose taken at or near mealtimes because the hydrochloric acid excreted in response to eating enhances absorption. If you are also using iron supplements, don't take them with your calcium, since iron interferes with calcium absorption.
5. Vitamin D is particularly important in regulating the body's absorption of calcium, and it is also one of the vitamins some celiacs malabsorb before they are diagnosed. Make sure your levels of Vitamin D are checked when you are diagnosed and follow your doctor's recommendation if you are found to be deficient. Vitamin D malabsorption needs careful follow-up.
6. Look into existing products that include added calcium. Currently calcium is added to some supermarket breads and cereals, which obviously won't help gluten-sensitive individuals. But calcium-fortified orange juice is said to be gluten-free and it also gives a nice Vitamin C boost. Vitamin C, by the way, helps in calcium absorption.
7. Postmenopausal women should check with their doctors about the advisability of taking estrogen supplements and decide whether or not to take them. Estrogen helps prevent bone loss. At press time, both Premarin and Provera were deemed gluten-free.
8. Do weight-bearing exercises (walking, hiking, stair climbing, jogging, dancing, skiing, etc.) that place positive stress on the leg, hip and back bones for at least 1/2 hour three to four times a week. More is better. Add weights to exercise your arms and strengthen armbones. According to the National Osteoporosis Foundation, "regular exercise may increase peak bone mass in younger people and decrease bone loss or even increase bone mass in older women and men." It also has the serendipitous effect of increasing a person's muscle strength and balance, perhaps helping make falls less likely.
9. Restrict your intake of coffee, alcohol and salt, all of which deplete the body of calcium.
10. Don't smoke. It is believed that smoking accelerates bone loss.
* To check the bioavailability of your calcium (and other) supplements: Place the tablet in a container with six ounces of room-temperature distilled white vinegar and wait 30 minutes, stirring occasionally to mimic the action of the stomach. According to the National Osteoporosis Foundation, tablets that do not dissolve in 30 minutes probably won't dissolve in your stomach, either.
This fact sheet has been designed to be a general information resource. However, it is not intended for use in diagnosis, treatment, or any other medical application. Questions should be directed to your personal physician. This information is not warranted and no liability is assumed by the author or any group for the recommendations, information, dietary suggestions, menus, and recipes promulgated. Based upon accepted practices in supplying the source documents, this fact sheet is accurate and complete. Products mentioned or omitted do not constitute endorsement.