Gluten Free Works: TREATMENT GUIDE Get well and stay healthy living gluten free
Page Contents
What Is Hypocalcemia?
Hypocalcemia, or low plasma calcium, means the level of calcium in blood is too low to meet metabolic needs of the body for calcium.
Low blood calcium is characterized by bone and tooth demineralization (loss of calcium causing weak teeth and fragile bones), and these impaired functions: nerve conduction, muscle contraction, blood clotting, blood pressure regulation, glycogen to glucose conversion, many hormone actions, many enzyme activities, and acetylcholine production.
Q: Where is calcium found in the body?
A: Calcium is the most abundant mineral in the body, with 99% residing in bones and teeth where it constitutes 40% of skeletal bone weight along with 45% phosphorus. As a component of bone (hard tissue), calcium fulfills a structural role to maintain body size and act as attachments for musculoskeletal tissues. The remaining 1% of calcium is present in blood and soft tissues.
Calcium levels in the blood are maintained within very strict limits by dietary intake, hormonal regulation by the parathyroid gland and a rapidly exchangeable pool in bone tissue.
What Is Hypocalcemia In Celiac Disease and/or Gluten Sensitivity?
- Hypocalcemia is a classic feature of untreated celiac disease.
- Calcium metabolism defects are common in untreated children with celiac disease and they return to normal after gluten-free diet. In study patients after 6 months of a gluten-free diet calcium, 25(OH)vitamin D3 and parathyroid hormone levels normalized, with the improvement of bone mineral density.1
- Significantly lower mean blood calcium levels in children with dental enamel defects were found to have celiac disease (7.9 mg/dL compared to nonceliacs 9.6mg/dl).2
How Prevalent Is Hypocalcemia In Celiac Disease and/or Gluten Sensitivity?
- Hypocalcemia is a significant common serology result in all study patients at diagnosis of celiac disease.3
- Calcium metabolism defects are common in untreated children with celiac disease.4
- Twenty-two percent ( 22%) of patients who were diagnosed with celiac disease at a hospital endocrinology department were shown to have low calcium.5
What Are The Symptoms Of Hypocalcemia?
Hypocalcemia is marked by these symptoms:
- Anxiety.
- Insomnia.
- Muscle spasms/cramps involving the back and legs that may progress to carpal (wrist) or pedal (foot) spasms.
- Numbness/tingling in fingers and toes.
- Low blood pressure.
Chronic hypocalcemia is marked by these symptoms:
- Hypertension.
- Excessive bleeding.
- Depression.
- Mild encephalopathy (forgetfulness, inability to concentrate, poor judgment).
- Bone pain.
- Bone loss disorders (osteoporosis and osteomalacia in adults and rickets in children).
- Easy fractures.
- Tooth decay.
- Periodontal disease.
- Tetany.
- Brittle nails.
- Pre-eclampsia in pregnancy.
- Cataracts (prolonged).
- If low calcium is severe, laryngospasm or generalized seizures may occur.
- May be asymptomatic.
How Does Hypocalcemia Develop In Celiac Disease and/or Gluten Sensitivity?
- Hypocalcemia results from calcium malabsorption in celiac disease, with or without, vitamin D deficiency.
- Magnesium deficiency due to malabsorption is a cause of hypocalcemia.
Does Hypocalcemia Respond To Gluten-Free Diet?
Yes. Celiac disease-related hypocalcemia normalizes on a gluten free diet.3,6
6 Steps To Improve Hypocalcemia In Celiac Disease and/or Gluten Sensitivity:
- 1Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:
- 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.7
- The intestinal lining may take up to a year to heal.
- 2 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).
- Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.8
- 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.8
- 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.8.
- 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.8
- 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.8
- Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.8
- 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 green leafy vegetables such as lettuce and kale, also 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.
- 3 Information Sheet You Can Take to Your Doctor or Other Health Professional:
- 4 Manage Your Medications Safely:
Certain medications deplete calcium which promotes hypocalcemia. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below.
This is not a complete listing.
ANTACIDS / ULCER MEDICATIONS
- Pepcid®, Tagamet®, Zantac® deplete Calcium.
- Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Calcium.
ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.
- Tetracyclines deplete Calcium.
ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.
- Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Calcium.
- Aspirin and Salicylates deplete Calcium.
ANTICONVULSANTS
- Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Calcium.
ANTIVIRAL AGENTS
- Foscanet depletes Calcium.
DIURETICS
- 5Nutritional Supplements To Help Correct Deficiencies:
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. Vitamin D is required to absorb calcium.
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.
- 6Manage Natural Remedies:
- Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
- 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.
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.
Exercise improves circulation and rids the body of toxins.
- Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
- Weight training builds muscle. 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.
What Do Medical Research Studies Tell About Hypocalcemia In Celiac Disease and/or Gluten Sensitivity?
RESEARCH STUDY SUMMARIES
“Screening for celiac disease in children with dental enamel defects.” This prospective study investigating the frequency of celiac disease among 140 children with dental enamel defects (DED) found that celiac disease is more prevalent among children with DED (17.86%) than in the general population (0.97%). Lower serum calcium significantly predicted celiac disease in this cohort. “These DEDs might be the only manifestation of celiac disease; therefore, screening for celiac disease is highly recommended among those patients especially in presence of underweight and hypocalcemia.”
Children with DED were tested for celiac disease. Gluten-free diet (GFD) was instituted for celiac disease patients. A cohort of 720, age and sex-matched, normal children represented a control group. Both groups were evaluated clinically. Serum calcium, phosphorus, alkaline phosphatase, serum IgA, and tissue transglutaminase (tTG) IgG and IgA types were measured.
Results. Celiac disease was more diagnosed in patients with DEDs (17.86%) compared to controls (0.97%). The majority of non-celiac patients showed grade 1 DED compared to grades 1, 2, and 3 DED in celiac disease. Five children had DED of deciduous teeth and remaining in permanent ones. After 1 year on gluten free diet, DED improved better in celiac disease compared to non-celiac patients. Gastrointestinal symptoms did not vary between celiac and non-celiac DED patients. El-Hodhod MA1, El-Agouza IA, Abdel-Al H, Kabil NS, Bayomi KA. Screening for celiac disease in children with dental enamel defects. ISRN Pediatr. 2012;2012:763783. doi: 10.5402/2012/763783.
“Endocrine manifestations of celiac disease.” This study investigating the prevalence of endocrinopathies in 36 patients who were diagnosed with celiac disease at a hospital endocrinology department found elevated alkaline phospahatase in 67% of patients and hypocalcemia (22%) with X-rays suggestive of osteomalacia or rickets in 8% and carpopedal spasm in 6%. A total of 14% patients had no gastrointestinal symptoms.5
“Bone metabolism in celiac disease.” This study investigating the prevalence of both calcium metabolism alterations and bone defects in 54 untreated children with celiac disease (mean age, 7 years), found that calcium metabolism defects are common in untreated children with celiac disease, and they returned to normal after gluten-free diet. Serum concentration of calcium, magnesium, 25(OH)vitamin D3, alkaline phosphatase, and parathyroid hormone (PTH) of patients with celiac disease was compared with those of 60 healthy children. Children with celiac disease with 2 laboratory alterations further underwent DEXA examination (bone density test), which was evaluated after 6 months of a gluten-free diet.
The calcium and the 25(OH)vitamin D3 levels were lower in children with celiac disease than in control subjects, and the PTH level was higher in children with celiac disease than in control subjects. Hyperparathyroidism was found in 29 children with celiac disease. Twenty patients tested positive for 2 laboratory alterations, and 10 of them were osteopenic. After 6 months of a gluten-free diet calcium, 25(OH)vit.D3 and PTH levels normalized, with the improvement of bone mineral density.4
“Intestinal calcium absorption as shown by stable strontium test in celiac disease before and after gluten-free diet.” This study investigating the effect of gluten free diet on mineral and bone metabolism in celiac disease women on gluten free diet and, using the strontium test to assess intestinal calcium absorption, demonstrated mean strontium absorption was markedly decreased and 61% of celiac disease patients had low values. After gluten free diet, all biochemical variables and strontium absorption normalized whereas BMD (bone mineral density) did not. At diagnosis, the patients frequently had intestinal calcium malabsorption with an early renal compensatory mechanism. After gluten free diet, the normalization of calcium absorption and the decrease of mid-molecule parathyroid hormone suggested a normalization of mineral metabolism.3
CASE REPORT SUMMARIES
“Celiac disease causing symptomatic hypocalcaemia, osteomalacia and coagulopathy.” This case report describes diagnosing celiac disease in a 36-year-old gentleman who presented with 6 months of poor energy, tingling in fingers and weight loss with a change in bowel habit. He appeared cachectic and had clubbing, demineralisation of teeth, pectus carinatus, kyphosis, spinal tenderness, proximal muscle weakness and generalised muscle wasting (atrophy).
Chvostek’s and Trosseau’s signs were positive. His hemoglobin (Hb) was 8.7 g/dl, MCV 64.7 fl with low iron. Calcium corrected was 1.30 nmol/l, parathyroid hormone 440.4 ng/l, vitamin D <12.5 nmol/l; INR was 2.7 with coagulation inhibitor studies negative. Radiographs of spine and pelvis commented on osteopenia with thoracic kyphosis and mild anterior wedging of thoracic vertebrae. Antitissue transglutaminase was 145 U/ml, and antiendomysial antibodies were positive. An esophagogastroduodenoscopy was consistent with celiac disease. A diagnosis of osteomalacia and coagulopathy secondary to celiac disease was made.
The hypocalcaemia was treated with calcium gluconate infusions with symptomatic relief. Coagulopathy was treated with vitamin K intravenously with normalization of INR (international normalised ratio), a lab measurement to determine coagulation.9
“Irreversible end-stage heart failure in a young patient due to severe chronic hypocalcemia associated with primary hypoparathyroidism and celiac disease.” This case report describes diagnosis of celiac disease upon finding hypocalcemia and primary hypoparathyroidism in a 39-year-old male who was admitted to the emergency room with acute retrosternal pain and dyspnea (shortness of breath). He exhibited severe hypocalcemia and acute renal failure. High creatine kinase (CK) levels did not correlate with biomarkers of myocardial necrosis (negative troponin test, heart type creatine kinase isoenzyme (CK-MB) < 1% of CK value). The ECG showed an extremely long QT interval (0.6 sec) and T-wave inversions on V(4) through V(6). The left ventricular ejection fraction (LVEF) was as low as 25%, while coronary angiography was normal.
Investigation of the hypocalcemia revealed primary hypoparathyroidism (Parathyroid hormone (PTH) < 3 pg/ml) and concomitant celiac disease with positive antigliadin and endomysial antibodies. The cardiovascular episodes and the dilated heart failure were attributed to the chronic hypocalcemia since no other cause was found. The correction of hypocalcemia has not been sufficient to reverse the end-stage heart failure after more than 6 months of treatment, even though ECG abnormalities have receded, implying permanent cardiac impairment.10
“Convulsive disorder in celiac disease.” This case report of a 40 year old woman with hypopcalcemia and generalized tonic-clonic seizures describes subsequent diagnosis of celiac disease. Hypocalcemia was corrected and convulsions disappeared, but the EEG showed persistent occipital epileptiform activity. Patients with celiac disease and low calcium are particularly at risk for convulsions, therefore even a mild degree of hypocalcemia in these patients should be corrected as soon as possible.11
“Laryngospasm: unusual manifestation of celiac disease.” This case report of an elderly woman describes investigation of presenting laryngospasm secondary to severe hypocalcemia and hypomagnesemia in celiac disease. The malabsorption syndrome was responsible for low levels of vitamin D causing the electrolyte imbalance.12
- Zanchi C, Di Leo G, Ronfani L, Martelossi S, Not T, Ventura A. Bone metabolism in celiac disease. J Pediatr. 2008 Aug;153(2):262-5. doi: 10.1016/j.jpeds.2008.03.003. [↩]
- El-Hodhod MA, El-Agouza IA, Abdel-Al H, Kabil NS, Bayomi KA. Screening for celiac disease in children with dental enamel defects. ISRN Pediatr. 2012;2012:763783. [↩]
- Molteni N, Bardella MT, Vezzoli G, Pozzoli E, Bianchi P. Intestinal calcium absorption as shown by stable strontium test in celiac disease before and after gluten-free diet. American Journal of Gastroenterology. Nov 1995;90(11):2025-8. [↩] [↩] [↩]
- Zanchi C, Di Leo G, Ronfani L, Martelossi S, Not T, Ventura A. Bone metabolism in celiac disease. J Pediatr. 2008 Aug;153(2):262-5. doi: 10.1016/j.jpeds.2008.03.003. [↩] [↩]
- Philip R, Patidar P, Saran S, Agarwal P, Gupta K. Endocrine manifestations of celiac disease. Indian J Endocrinol Metab. 2012 December; 16(Suppl 2): S506–S508. [↩] [↩]
- Rickels MR, Mandel SJ. Celiac disease manifesting as isolated hypocalcemia. Endocrine Practice: Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. May-Jun 2004;10(3):203-7. [↩]
- 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. [↩]
- 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. [↩] [↩] [↩] [↩] [↩] [↩]
- McNicholas BA, Bell M. Coeliac disease causing symptomatic hypocalcaemia, osteomalacia and coagulapathy. BMJ Case Rep. 2010 Dec 1;2010. pii: bcr0920092262. doi: 10.1136/bcr.09.2009.2262. [↩]
- Mavroudis K, Aloumanis K, Stamatis P, Antonakoudis G, Kifnidis K, Antonakoudis C. Irreversible end-stage heart failure in a young patient due to severe chronic hypocalcemia associated with primary hypoparathyroidism and celiac disease. Clin Cardiol. 2010 Feb;33(2):E72-5. doi: 10.1002/clc.20512.
“Celiac disease manifesting as isolated hypocalcemia.” This case report of a 36 year old woman with hypocalcemia describes subsequent diagnosis of celiac disease. Patient had hypocalciuria and secondary hyperparathyroidism that were refractory to pharmacologic calcium and cholecalciferol supplementation. The gluten free diet resulted in correction of all biochemical abnormalities and a substantial increase in BMD. Primary intestinal malabsorption of calcium without concomitant vitamin D deficiency is possible in celiac disease because of the preferential involvement of the proximal small intestine early in the disease process. ((Rickels MR, Mandel SJ. Celiac disease manifesting as isolated hypocalcemia. Endocrine Practice: Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. May-Jun 2004;10(3):203-7. [↩]
- Cohen O, River Y, Zelinger I. Convulsive disorder in celiac disease. Harefuah. Jun 15, 1994;126(12):707-10,763. [↩]
- Waeber G, Pralong G, Breitenstein E, Nicod P. Laryngospasm: unusual manifestation of celiac disease. Schweizerische Medizinische Wochenschrift. Mar 13, 1993;123(10):432-4. [↩]
