Bone Fractures 

What Are Bone Fractures?

[dropcap]B[/dropcap]one fractures, or broken bones, are breaks in skeletal bones that occur usually from trauma to the bone itself or by a sudden violent contraction of muscle attached to it.

Q: Are there other causes of bone fractures besides trauma?

A: Fractures may occur spontaneously without trauma in certain pathological disorders such as osteoporosis, osteonecrosis, osteomalacia, osteomyelitis, syphilis, and cancer affecting the bone.

Bone fractures are a major public health problem with treatment costs in the billions of dollars and lead to subsequent disability for many patients.

Hip fractures, for example, may be complicated by infection at the surgical site, pneumonia, decubitus ulcer from lack of movement, and deep vein thrombosis making hip fractures the second leading cause of nursing home admissions in the USA.

Improvement of bone health and reducing risk factors such as smoking, caffeinated drinks (coffee, tea and sodas), and use of alcohol are key to preventing bone fractures.

Bone strength is easily measured by testing bone mineral density (BMD). BMD is evaluated by DEXA scan (dual-energy X-ray absorptiometry).  DEXA at the femoral neck and lumbar spine is considered the gold standard to confirm the diagnosis of osteoporosis.  Results are expressed as T and Z scores. T scores compare the result with a 20 to 40 year old helathy person while  Z scores compare the result with persons in the same age group. Both are measured in standard deviations (SD).

According to WHO criteria (World Health Organization), a T-score of -1 SD or greater denotes normal bone, a T-score between −1 to −2.5 SD denotes osteopenia, and a T-score of −2.5 or more denotes osteoporosis.¹

What Are Bone Fractures In Celiac Disease and/or Gluten Sensitivity?

Bone fractures are a severe complication in celiac disease and can be a presenting feature of celiac disease.

• Relationship between bone fractures and celiac diseaase. In celiac disease, fractures occur more readily when bones are demineralized (thinned) as in osteopenia and the more severe osteoporosis. Demineralized bones are weak because they have been depleted of minerals needed to give them adequate strength to resist easy breakage.
• Relationship between bone fractures and risk in celiac disease. A wide variation in fracture risk, with increasing risk in the peripheral skeleton was found in classically symptomatic patients. Compared with controls, celiac disease patients had significantly more fractures produced by mild trauma.²
• Relationship between bone fractures and diet. Most fractures were found to occur before diagnosis or while patients were noncompliant with gluten free diet. Early diagnosis and treatment were the most relevant measures to protect patients from the risk of fractures.³
• Relationship between bone fractures and complications. Treating bone complications related to celiac disease remains complex.⁴

How Prevalent are Bone Fractures In Celiac Disease and/or Gluten Sensitivity?

• A high prevalence of fractures in the peripheral skeleton was found in patients with celiac disease.  In a case control study of patients with celiac disease, 80% of fractures were detected before the diagnosis of celiac disease or in patients who were noncompliant with the gluten free diet; 7% of fractures occurred after start of gluten free diet.⁵
• Fractures in a study of classically symptomatic celiac disease patients had a 47% occurrence of bone fractures vs. 15% occurrence in controls.⁶

What Are The Symptoms Of Bone Fractures?

Bone fractures are marked by these symptoms:

• Acute pain with tenderness over the break.
• Swelling, bruising  and dysfunction or unnatural mobility of the broken bone.
• Bleeding in open (compound) fractures from the wound.
• Compression fractures of the vertebrae result in loss of height.
• Long term disability may result.

How Do Bone Fractures In Celiac Disease and/or Gluten Sensitivity Develop?

• The etiology, or cause, of pathologic bone alterations in celiac disease is multifactorial; however, two main mechanisms are involved: chronic inflammation and intestinal malabsorption causing deficiency of nutrients that are required for healthy bone.⁷
• Low bone mineral density (BMD), osteopenia, and osteoporosis are frequent complications of celiac disease in which bone is weakened and susceptible to breakage.
• Bone fractures resulting from multiple deficiencies in celiac disease are mainly calcium, vitamin D, and phosphorus. Other deficiencies that contribute to weakening bones include magnesium, copper, and vitamin K.

Do Bone Fractures Respond To Gluten-Free Diet?

Yes. Gluten free diet improves bone density and strength in celiac disease which reduces the risk of bone fractures and promotes healing of the fracture that has occurred. Supplementation with calcium and vitamin D3 is suggested.⁸

Remember, just as adequate calcium (1200 mg to 1500 mg a day) and vitamin D (800 mg a day) are primarily required for bone health, EXCESSIVE fiber, protein, and sodium in the diet harm bone health by decreasing calcium absorption and the body’s ability to use calcium.

6 Steps To Improve Bone Health In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both bone and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁹
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.¹⁰
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.¹⁰
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.¹⁰.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.¹⁰
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.¹⁰
• Alcohol. Disrupts intestinal permeability causing leaky gut¹⁰ and 2 to 3 ounces a day impair calcium absorption which harms bone health and increases the risk of bone fractures through falling.
• Caffeine. Disrupts intestinal permeability causing leaky gut¹⁰ and impairs calcium absorption.[/box ]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

 

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

 

• [dropcap]4[/dropcap] Manage Your Medications Safely:

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Certain prescription drugs can cause deficiencies of these nutrients that cause weak bones that can fracture: calcium, vitamin D, and phosphorus. Other deficiencies that contribute to weakening bones include magnesium, copper, and vitamin K.

Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Calcium, Vitamin D,  Magnesium, Copper.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete  Calcium, Vitamin D,  Magnesium, Copper.
• Alka Seltzer®, Baking Soda deplete Magnesium, Proteins.

ANTIBIOTICS disrupt intestinal permeability.

• Gentomycin, Neomycin, Streptomycin, Cephalosporins, Penicillins deplete Vitamin K.
•  Tetracyclines deplete Calcium, Magnesium.

ANTI-INFLAMMATORIES disrupt intestinal permeability.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Calcium, Vitamin D, Magnesium.
• Aspirin and Salicylates deplete Calcium.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Calcium, Vitamin D, Carnitine, Vitamin K, Copper.

ANTIVIRAL AGENTS

• Zidovudine (Retrovir®, AZT and other related drugs) deplete Carnitine, Copper.
• Foscanet depletes Calcium. 

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Vitamin D, Vitamin K.

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Magnesium.
• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Calcium, Magnesium.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Calcium.

FEMALE HORMONES disrupt intestinal permeability.

• Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Magnesium.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Magnesium.

WEIGHT LOSS DRUGS THAT BIND FAT also interfere with absorption of some nutrients.

• Zenicol (Orlistat®) depletes Vitamin A.

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• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

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The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.
• Vitamin D3 as prescribed following blood test for status.
• Chelated magnesium  as prescribed but do not take at same time as calcium because they compete for absorption.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended for adults per day unless there is a contraindication such as kidney or heart disease.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Weight bearing exercise at least 3 times a week is recommended for strengthening bone. Walking, jogging, dancing, and aerobic exercise recondition the whole body to improve stamina and stimulate the growth of healthy bone.. Read more about Exercise and Fitness.
• Weight training builds muscle and strengthens bone. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Bone Fractures In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Celiac disease and bone fractures: a systematic review and meta-analysis.” This study investigating risk of bone fractures in celiac disease found that clinically diagnosed coeliac disease and bone fractures co-occur and that coeliac disease was associated with an increased risk of hip fractures as well as fractures in general.

Two investigators independently and systematically reviewed and pooled the evidence for the relationship of celiac disease with prevalence and incidence of bone fractures from eligible studies. Data sources: Pubmed, Scopus, Web of Science and Cochrane Library in January 2014 for studies of celiac disease and bone fractures. Study selection: Observational studies of any design, in which bone fracture outcomes were compared in individuals with and without coeliac disease were included. In the meta-analyses of case-control and cross-sectional studies, bone fractures were almost twice as common in individuals with a clinically diagnosed celiac disease as in those without the disease. In the meta-analyses of prospective studies, celiac disease at baseline was associated with a 30% increase (95% CI: 1.14, 1.50) in the risk of any fracture and a 69% increase in the risk of hip fracture (95% CI: 1.10, 2.59). Heikkilä K, Pearce J, Mäki M, Kaukinen K. Celiac disease and bone fractures: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2014 Oct 3:jc20141858. [Epub ahead of print]

“Prevalence and predictors of abnormal bone mineral metabolism in recently diagnosed adult celiac patients.” This study investigating the prevalence of low bone mineral density (BMD) in recently diagnosed adult celiac patients and aiming to identify the factors associated with this found that low BMD is common in newly diagnosed adult celiac patients with approximately one fifth of them having osteoporosis and low vitamin D level.

BMD was measured in 54 newly diagnosed adult celiac patients between February 2008 and April 2009 and its correlation with clinical and biochemical parameters was analyzed. Fifty-four (24 male) newly diagnosed celiac patients ages 18-50 were included. Thirty-nine (72.2 %) presented with intestinal symptoms and the rest with extraintestinal symptoms. Low vitamin D levels were seen in 11 (20.3 %) patients and elevated iPTH (secondary hyperparathyroidism) in 12 (22.2 %) patients. Twenty-one (39 %) patients had normal BMD, 23 (43 %) had osteopenia (T-score -1 to -2.5), and 10 (18 %) patients had osteoporosis (T-score <-2.5). A statistically significant association was seen between BMD and age of onset, duration of illness, serum tTGA levels, serum vitamin D levels, and cellular changes seen on biopsy. BMD should be measured in all newly diagnosed celiac patients and calcium and vitamin D supplementation included in the treatment regimen.¹¹

“Stratification of bone fracture risk in patients with celiac disease.” This study investigating celiac osteopathy revealed a wide variation in fracture risk, with increasing risk in the peripheral skeleton in classically symptomatic patients. Fractures in subclinical/silent celiac disease patients were no different than controls. Compared with controls, celiac disease patients had significantly more fractures produced by mild trauma. Diagnostic and therapeutic strategies to prevent bone loss and fracture should be preferentially used in the subgroup of patients with classic clinical disease.⁶

“Risk of fractures in celiac disease patients: a cross-sectional, case control study.” This study investigating the prevalence of bone fractures and vertebral deformities in celiacs revealed that patients with celiac disease had a high prevalence of fractures in the peripheral skeleton. Most of these events occurred before diagnosis or while patients were noncompliant with gluten free diet. Early diagnosis and treatment were the most relevant measures to protect patients from the risk of fractures.⁵

“Osteomalacia due to vitamin D depletion: a neglected consequence of intestinal malabsorption.” This study investigating the belief that vitamin D depletion is rare in the United States because of the routine fortification of milk and other dairy products with vitamin D shows that osteomalacia due to vitamin D depletion appears not to be suspected or diagnosed promptly in susceptible patients. Researchers present a series of patients with histologically verified osteomalacia due to vitamin D depletion to emphasize the need for more careful and systematic surveillance of patients at risk of this metabolic bone disease.

Between 1989 and 1994, 17 patients with osteomalacia due to vitamin D depletion were seen in the Bone and Mineral Division of Henry Ford Health System, Detroit. All patients had a transiliac bone biopsy. Biochemical indexes of vitamin D nutritional status, parathyroid function, markers of bone turnover, and bone mineral density were assessed at the time of bone biopsy. The duration of symptoms, the lag between the cause of vitamin D depletion and the development of symptoms, and the x-ray findings were recorded. Osteomalacia was suspected by the referring physician in only 4 of the 17 patients, although a gastrointestinal disorder that can lead to vitamin D depletion was present in every patient. Thirteen of the patients had sustained at least one osteoporotic fracture (wrist, spine, or hip), and most had low appendicular and axial bone mineral density. All patients had one or more biochemical abnormalities consistent with vitamin D depletion. In 4 patients, a progressive rise in the serum alkaline phosphatase level was recorded but was not investigated until the patient presented with bone pain, muscle weakness, or fracture.¹²

CASE REPORT SUMMARIES

“Severe osteomalacia in endemic sprue. An important differential diagnosis in osteoporosis.” This case report describes a 67 year old woman with a 20 year history of recurrent abdominal pain, diarrhea and diffuse bone pain. Diagnoses of iron deficiency disorder, iron absorption disorder, osteoporosis and hyperthyroidism had been made. Despite treatment with vitamin D3, calcium, fluorides and iron, patient’s condition deteriorated to the point where she needed constant care. Celiac disease with secondary intestinal osteopathy was identified. High-dose parenteral treatment with vitamin D3, oral calcium supplementation and a gluten free diet resulted in improvement within 3 months, and the patient can largely look after herself again.¹³

Sources:

1. Pantaleoni S, Luchino M, Adriani A, Pellicano R, Stradella D, Ribaldone DG, Sapone N, Isaia GC, Di Stefano M, Astegiano M. Bone mineral density at diagnosis of celiac disease and after 1 year of gluten-free diet. ScientificWorldJournal. 2014;2014:173082. doi: 10.1155/2014/173082. [↩]
2. Vasquez H, Mazure R, Gonzalez D, et al. Risk of fractures in celiac disease patients: a cross-sectional, case control study. The American Journal of Gastroenterology. Jan 2000;95(1):183-9. [↩]
3. Vasquez H, Mazure R, Gonzalez D, et al. Risk of fractures in celiac disease patients: a cross-sectional, case control study. The American Journal of Gastroenterology. Jan 2000;95(1):183-9. [↩]
4. Krupa-Kozak U. Pathologic bone alterations in celiac disease: Etiology, epidemiology, and treatment. Nutrition. 2014 Jan;30(1):16-24. doi: 10.1016/j.nut.2013.05.027. [↩]
5. Vasquez H, Mazure R, Gonzalez D, et al. Risk of fractures in celiac disease patients: a cross-sectional, case control study. The American Journal of Gastroenterology. Jan 2000;95(1):183-9. [↩] [↩]
6. Moreno ML, Vazquez H, Mazure R, et al. Stratification of bone fracture risk in patients with celiac disease. Clinical Gastroenterology and Hepatology. Feb 2004;2(2):127-34. [↩] [↩]
7. Krupa-Kozak U. Pathologic bone alterations in celiac disease: Etiology, epidemiology, and treatment. Nutrition. 2014 Jan;30(1):16-24. doi: 10.1016/j.nut.2013.05.027. [↩]
8. Dorst AJ, Ringe JD. Severe osteomalacia in endemic sprue. An important differential diagnosis in osteoporosis. Fortschritte der Medizin. Mar 20, 1998;116(8):42-5. [↩]
9. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
10. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩] [↩]
11. Chakravarthi SD, Jain K, Kochhar R, Bhadada SK, Khandelwal N, Bhansali A, Dutta U, Nain CK, Singh K. Prevalence and predictors of abnormal bone mineral metabolism in recently diagnosed adult celiac patients. Indian J Gastroenterol. 2012 Jul;31(4):165-70. Epub 2012 Aug 11. [↩]
12. Basha B, Rao DS, Han ZH, Parfitt AM. Osteomalacia due to vitamin D depletion: a neglected consequence of intestinal malabsorption. Am J Med. 2000 Mar;108(4):296-300. [↩]
13. Dorst AJ, Ringe JD. Severe osteomalacia in endemic sprue. An important differential diagnosis in osteoporosis. Fortschritte der Medizin. Mar 20, 1998;116(8):42-5. [↩]