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Osteoporosis

Woman with long standing osteoporosis. Courtesy of Wikimedia.
Woman with long standing osteoporosis. Courtesy of Wikimedia.

What Is Osteoporosis?

[dropcap]O[/dropcap]steoporosis is a metabolic bone disorder characterized by diminished bone mass (density) with normal cell appearance but fragile bone strength that prediposes to broken bones, and with high bone turnover.

This condition usually goes undetected until late when loss of height or a bone fracture occurs. In fact, each year  1.5 million fractures mainly of the hip, spine and wrist are attributed to osteoporosis. Compression fractures of vertebrae bones are the most common, accounting for 700,000 cases.

Bone is composed of specialized connective tissue called osseous tissue. Osseous tissue is made up of living bone cells (osteocytes) that are embedded in a hard matrix (framework) of calcified substance.

Bone matrix contains collagen fibers and the minerals calcium phosphate and calcium carbonate, which provide strength to bone. The copper enzyme, lysyl oxidase, is involved in the cross-linking of collagen in forming the framework for depositing calcium and other minerals to build and repair bone.

Q: How do osteocytes function in bone?

A: Osteocytes maintain the health of bone by their metabolic activity in regulating normal bone turnover. Bone turnover is the breaking down and removal of old or damaged bone and rebuilding or remodeling of healthy bone that is ongoing throughout life. The bone formation process takes about 3 months to complete.

Osteoporosis develops from failure of the body to maintain health and to provide bone tissue with adequate nutrition for proper function. Risk factors that can be modified include: low calcium intake, sedentary lifestyle, smoking, drinking alcohol excessively, eating a diet with excessive caffeine, protein, and phosphate, and taking certain medications over a long time such as steroids, thyroid preparations, the anti-convulsive drug phenytoin, aspirin, antacids, anticoagulants, some diuretics, and some chemotherapeutic drugs. See below for a fuller description.

In addition to celiac disease, osteoporosis is associated with advancing age, family history, nulliparity (no pregnancies) and post-menopause in females, certain disorders such as hyperthyroidism, hypogonadism, inflammatory bowel disease like Crohn’s disease, multiple myeloma, anorexia nervosa, and Cushing’s disease.

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

Treatment is aimed to preserve and increase bone density, minimize symptoms for better quality of life and reduce risk of bone fractures.

What Is Osteoporosis In Celiac Disease and/or Gluten Sensitivity?

The cumulative effects of gluten-induced inflammation, treatment delay, and malabsorption result in lower bone density and bone fragility.2

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. Grace-Farfaglia P. Bones of Contention: Bone Mineral Density Recovery in Celiac Disease-A Systematic Review. Nutrients. 2015 May 7;7(5):3347-3369. [↩]

Bone Fractures 

Broken lower leg. Courtesy FreePik.com
Broken lower leg. Courtesy FreePik.com

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?

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. [↩]

Arthritis, Enteropathic

DSCN4748aWhat Is Enteropathic Arthritis?

[dropcap]E[/dropcap]nteropathic arthritis is a form of inflammatory arthritis characterized by peripheral joint disease that also involves the attachments sites for tendons at joints, called entheses, and is characterized by joint stiffness, swelling and loss of motion.

Q: How is enteropathic arthritis classified?

A: Enteropathic arthritis is a form of arthritis classified as one of the group of seronegative spondyloarthropathies, which also includes psoriatic arthritis, reactive arthritis, and idiopathic ankylosing spondylitis.

Enteropathic arthritis is associated with the chronic inflammatory bowel diseases, ulcerative colitis, and Crohn’s disease.  Joint involvement also occurs with other gastrointestinal diseases such as Whipple’s disease, celiac disease, and following intestinal bypass surgery for morbid obesity.1

What Is Enteropathic Arthritis In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Holden W, Orchard T, Wordsworth P. Enteropathic arthritis. Rheumatic Diseases Clinics of North America. Aug 2003;29(3):513-30,viii. [↩]

Selenium Deficiency

selenium gluten free celiac disease symptomWhat Is Selenium?

[dropcap]S[/dropcap]elenium is a mineral that is required by the body  in trace amounts for a healthy immune system, normal thyroid function, and antioxidant protection.

Selenium is absolutely required in the production of at least 30 selenoproteins in the body. First, selenium is joined to the amino acids cysteine as selenocysteine and to methionine as selenomethionine before being used as components for selenoproteins. Many selenoproteins are important antioxidant enzymes such as glutathione peroxidase.

Q: How does glutathione peroxidase work?

A: Glutathione peroxidase activity helps the recycling of vitamins C and E in optimizing the performance of the antioxidant system. The antioxidant properties of selenoproteins help prevent cellular damage from free radicals. Free radicals are natural by-products of oxygen metabolism that may contribute to the development of chronic diseases such as cancer and heart disease.

In the immune system, selenium stimulates immune properties of lymphocytes (white blood cells) by contributing to higher natural killer lymphocyte activity. Natural killer lymphocytes have the ability to destroy cancer cells and bacterial and viral agents.

Other selenoproteins help protect the thyroid gland from anti-oxidants and regulate thyroid function. Specifically, selenium plays an integral role in thyroid gland metabolism.1 Functions are more fully described below.

According to the Food and Agriculture Organization, United Nations, approximately 30 percent of tissue selenium is contained in the liver, 15 percent in kidney, 30 percent in muscle, and 10 percent in blood plasma.

What Is Selenium Deficiency In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Stazi AV, Trinti B. Selenium status and over-expression of interleukin-15 in celiac disease and autoimmune thyroid diseases. Ann Ist Super Sanita. 2010;46(4):389-99.DOI: 10.4415/ANN_10_04_06. [↩]

Dysgeusia (Impaired Taste)

Loss of TasteWhat Is Dysgeusia?

[dropcap]D[/dropcap]ysgeusia is impaired or altered sense of taste characterized by the inability to distinguish the flavor of a substance.

Q: What causes loss of the ability to taste?

A: Some causes of impaired taste include these health conditions: malnutrition, hypothyroidism, diabetes mellitus,  hypertension, adrenal cortical insufficiency, liver disease, and Sjogren’s syndrome.

What Is Dysgeusia In Celiac Disease and/or Gluten Sensitivity?

Bone Pain

Chiropracter Adjusting Spine for Back Pain.
Chiropractor Adjusting Spine for Back Pain.

What Is Bone Pain?

[dropcap]B[/dropcap]one pain is pain or tenderness in bone tissue. Bone pain intensity and location depend on the causative disorder.

Q: What are causative disorders of bone pain?

A: Bone pain is a feature of various disorders that include malnutrition, bone disease such as osteoarthritis, infection, inflammation, hyperparathyroidism, immune mechanisms, fractures, adverse effects or toxic effects of certain medications, and cancer such as sarcoma, leukemia, multiple myeloma, and metastatic lesions from a primary tumor elsewhere.

What Is Bone Pain In Celiac Disease and/or Gluten Sensitivity?

Osteitis Fibrosa Cystica 

X-ray showing osteitis fibrosa cystica in long bones. Courtesy Wikimedia.
X-ray showing osteitis fibrosa cystica in long bones. Courtesy Wikimedia.

What Is Osteitis Fibrosa Cystica?

[dropcap]O[/dropcap]steitis fibrosa cystica is a metabolic bone disease characterized by decalcification and softening of bones with bone cyst formation and bone tumors developing from effects of chronic vitamin D deficiency causing hyperparathyroidism and parathyroid adenoma (tumor).

Hyperparathyroidism is a sustained elevated parathyroid hormone level in the blood which draws calcium from bone tissue.

Q: How does vitamin D deficiency cause hyperparathyroidism?

A: Vitamin D is required to absorb calcium from the food we eat. Deficiency of vitamin D  in turn causes deficiency of calcium to develop. Without adequate calcium for essential body functions, the pituitary gland stimulates the parathyroid glands to produce parathyroid hormone for the purpose of getting calcium from bone tissue which is less essential to life.

Unfortunately, the bones become depleted of calcium and become soft and disfigured.

What Is Osteitis Fibrosa Cystica In Celiac Disease and/or Gluten Sensitivity?

Osteomalacia

The woman's legs second from the right show bowing in osteomalacia.
The legs second from the right show bowing in osteomalacia in contrast to the others.

What Is Osteomalacia?

[dropcap]O[/dropcap]steomalacia is a metabolic bone disorder that causes abnormal skeletal changes characterized by generalized reduction in bone density (bone softening) in adults and pseudofractures (apparant on x-ray) with muscular weakness and bone tenderness.

Bones have the normal amount of living collagen tissue that make up their structure but lack adequate calcium and phosphorus minerals that are required for strength.

Blood studies show the level of parathyroid hormone (PTH), which maintains calcium and phosphorus balance in the body, and the enzyme bone alkaline phosphatase (BALP), which breaks down bone, are elevated while calcium and phosphorus are decreased. Bone biopsy gives the definitive diagnosis.

Q: How do bones get soft?

A: Bones get soft because the normal process of depositing minerals in bone tissue is defective. Bone is continually being remodelled. This is the normal process of breaking down small areas of weak or fractured bone and replacing with healthy bone. The unique cells that break down or dissolve damaged bone are called osteoclasts and cells that build new bone in its place are osteoblasts.

In the condition of osteomalacia, there is not adequate calcium and phosphorus to strengthen new bone made by the osteoblasts and this is the result of inadequate vitamin D. The result is soft bones and weak muscles that worsen as the condition progresses.

The main causes of vitamin D deficiency include malabsorption, poor diet, lack of sunshine, and disorders of vitamin D metabolism. Osteomalacia can also be a feature of systemic disorders such as hyperparathyroidism, partial gastrectomy, pancreatic disease, kidney disease, biliary disease and inflammatory bowel disease. Osteomalacia may be induced by tumors and drugs such as bisphosphonates and certain anti-seizure medications.

What Is Osteomalacia In Celiac Disease and/or Gluten Sensitivity?

Osteonecrosis

X-ray showing osteonecrosis of the femur. Courtesy Wikimedia.
X-ray showing osteonecrosis of the femur (right side). Courtesy Wikimedia.

What Is Osteonecrosis?

[dropcap]O[/dropcap]steonecrosis is a bone disorder resulting from insufficient blood flow to a part of the skeleton and is characterized by resulting death of bone cells (necrosis).

After a while the bone can collapse. If this condition is not treated, the joint will deteriorate and this will become severe arthritis.

It is most common in the hip and shoulder, but can affect other large joints such as knee, elbow, wrist and ankle.1

What Is Osteonecrosis In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004519/ [↩]

Psoriatic Arthritis

Bone scintigraphy showing left elbow affected by psoriatic arthritis. Photo by P Kitsoulis et. al. Courtesy BioMed Central.
Bone scintigraphy rear view showing left elbow with psoriatic arthritis. Photo P. Kitsoulis et. al. Courtesy BioMed Central.

What Is Psoriatic Arthritis?

[dropcap]P[/dropcap]soriatic arthritis is a joint manifestation of psoriasis, a systemic autoimmune disease, characterized by asymmetric involvement in one or more joints, especially affecting the distal phalangeal joints of fingers and toes (joints nearest nails).

In some patients, psoriatic arthritis can occur only with peripheral enthesitis which is inflammation where tendons insert into bone, particularly Achilles tendinitis and plantar fascitis, and/or dactylitis. Dactylitis is inflammation of the entire toe, also called “sausage toe.”1

Early treatment is crucial to symptom control. Even a 6-month delay from symptom onset to the first visit with a rheumatologist contributes to the development of peripheral joint erosions and worse long-term physical function.2

Q: Does psoriatic arthritis get worse when skin symptoms get worse?

A: Joint symptoms may coincide with exacerbations and remissions of skin symptoms.

What Is Psoriatic Arthritis In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Salvarani C, Cantini F, Olivieri I, Macchioni P, Niccoli L, Padula A, Ferri S, Portioli I. Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis. J Rheumatol. 1997 Jun;24(6):1106-10. [↩]
  2. Haroon M, Gallagher P, Fitzgerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2014 Feb 13. doi: 10.1136/annrheumdis-2013-204858. [↩]