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Osteoporosis and Coeliac Disease Osteoporosis is a common problem in our society and Osteoporosis may will affect 2 in every 3 women who reach 60 and 1 in every 3 men. The risk is even higher as a consequence in those with coeliac disease. *Associate Professor Nick Pocock and Kate Noakes coeliac disease.
;LEXMWSWXISTSVSWMW#Osteoporosis is most easily thought of as a thinning of bones. Our bones are dynamic organs and are constantly being ‘remodelled' to cope with changing stresses imposed by our lifestyle and to repair microscopic damage to the bones which happens as a normal part of living. The remodelling of bones involves an initial ‘resorption' phase where the old bone is removed, followed by a ‘formation' phase where new bone is formed. Osteoporosis occurs when the Bone Density Scanner resorption phase is not matched by the formation phase resulting in a net loss of bone from our skeleton. fractures involve the vertebrae and they lose calcium and the protein Our bones, which contain a large typically result in the spinal bones, framework. After the menopause amount of calcium bound to a the vertebrae, being crushed by the the bone density in women, and protein framework, subsequently weight of the body. These spinal consequently bone strength, become more porous and fragile fractures however often go unnoticed decreases more rapidly due to the which causes them to break more and may cause no symptoms even loss of their sex hormone oestrogen. easily. This is often referred to by though a vertebra has been crushed. Men also progressively lose bone health professionals as a fracture, Eventually the loss of height due density and strength after about 30 which simply means a broken bone. to these spine fractures and the but on average start declining from An osteoporotic fracture is a broken resulting stooped spine cause the a higher peak bone density and bone which has occurred after classic ‘Dowager's Hump' seen in don't suffer as sudden a reduction in relatively little force; often as mild many elderly women, which can be sex hormones as occurs in women as coughing, sneezing or lifting. an uncomfortable and debilitating (sex hormones in general have a Osteoporosis usually does not cause protective effect on the bones). any signs or symptoms, or result Once a person has a history of When the bone density goes below a in any medical problems, until a any osteoporotic fracture, they are certain value (T = -2.5), osteoporosis fracture occurs. Consequently, far more likely to suffer another, can be diagnosed even if a fracture individuals with osteoporosis will perhaps more serious, osteoporotic has not occurred.
commonly not be aware of the fracture. Osteoporosis can however The risk of osteoporosis as we age is problem until they break a bone.
be diagnosed before a fracture has increased by many factors, such as Common sites of osteoporotic occurred by measuring the bone certain medications, smoking, heavy fractures are the ribs, wrists, spine density. Bone density, which is a alcohol consumption, poor diet, a and hips. Most non spine fractures measure of bone strength, increases family history of osteoporosis, lack cause significant pain, deformity through our childhood, teenage and of exercise, malabsorption, small and loss of lifestyle. Hip fractures young adult years, until we reach our stature and some diseases. Coeliac in particular are a major health peak bone density; the maximum disease, by affecting the small problem, leading to hospitalisation strength our bones will obtain. intestine, causes malabsorption and may cause complications From the age of about 30, our bones of food including calcium. Calcium sometimes resulting in death. Spinal start to deteriorate in strength as is used by the body to maintain proper function of the major organs entitled to a Medicare rebate for a and it is essential that normal blood bone density measurement under levels be maintained. Consequently item number 12315, having ‘a proven if not enough calcium is obtained malabsorptive disorder'. Repeat bone Individuals medically by absorption from the diet, it may density scans are also covered by diagnosed with coeliac be ‘leached' from the bones by Medicare, up to one scan every two disease are entitled increasing the resorption phase of years. Despite this, many of those to a Medicare rebate the bone remodelling. This reduces diagnosed with coeliac disease are the amount of bone, causing them either unaware of the importance for a bone density to become ‘thinner' and weaker and of having a bone density test, or are measurement under may eventually lead to osteoporosis. unable to receive a referral for one to item number 12315, Children who develop coeliac disease be performed.
are affected slightly differently and having ‘a proven the reduced absorption of calcium malabsorptive disorder' may impair the skeleton's ability to A bone density test is performed grow and develop normally. This may using a bone densitometer. This is result in reduced bone growth or sometimes referred to as DXA (Dual strength during the growing years.
energy X-ray) bone density which bone strength has decreased from involves a special very low dose their peak bone density (the T score) Osteoporosis may sometimes be a X-ray technique. The bone density and therefore how likely they are to symptom as well as a consequence scans provide a measurement of suffer a fracture. As bone density of undiagnosed coeliac disease. how dense, or strong, the bones measurement decreases, the risk This occurs in patients who present are and allow a comparison with of fracturing a bone progressively to their doctors with fractures, or ‘normal' values for the same age. increases. Osteopenia is a term low calcium levels, and subsequent Bone densitometers are located which is used to mean a low bone investigations diagnose coeliac at hospitals, usually in either the density measurement which however disease, despite there being no nuclear medicine or radiology is not yet in the osteoporotic range. prior gastrointestinal symptoms. departments, in private clinics, or in The diagnosis of osteoporosis occurs Many other patients, who do have specialists' rooms. The test requires when the patient's bone density gastrointestinal symptoms and who no preparation, is non-invasive and measurement falls below a certain end up with a diagnosis of coeliac takes approximately 10-20 minutes to level compared to young people (less disease, often have unsuspected than T = -2.5). Treatment however osteopenia, which is a low bone Usually the spine and hip bone may sometimes be recommended density, or even osteoporosis, when a density are measured as these are before this level is reached.
bone density test is performed. Some have already developed osteoporotic the two sites which are of most If possible, it is important to have fractures, even at a young age. concern for osteoporotic fractures. your bone density test repeated on Although there is often a significant If either of these sites are unable the same bone densitometer where increase in bone density and strength to be measured, for example due to you attended for your initial visit, in individuals with coeliac disease the patient having artificial hips, or as there may be slight differences after the commencement of a having severe osteoarthritis in the in the results obtained on different gluten free diet, the improvement spine, another site can be measured, machines. The doctor will usually may not be sufficient to prevent such as the wrist, where osteoporotic decide when the next measurement problems occurring later in life fractures also commonly occur.
is necessary, typically no sooner and in some patients there may During a bone density scan the than every two years, unless there be no improvement at all. Even patient lays on a scanning table has been a change in the patient's young adults with coeliac disease and the technologist positions the condition or treatment.
who present with osteopenia or machine's scanning arm above the Heel ultrasound is another useful osteoporosis may sometimes show part of the skeleton to be measured. tool for measuring fracture risk, and little or no improvement in bone If the spine is being measured, the involves placing the patient's heel in mineral density despite normalisation technician will position the patient's a small machine which uses sound of absorption of calcium following a legs on a block-shaped cushion. This waves to measure the amount of gluten free diet. Women who have causes the spine to straighten giving bone contained in the heel bone. gone through menopause with a clear picture of each vertebra. Although this type of measurement coeliac disease are particularly at When the hip is measured, the leg will give some indication of fracture risk and may similarly show lack will be moved at an angle away from risk, it should not be used to guide of improvement in bone mineral the body and slightly rotated.
treatment and therefore does density even after a gluten free diet The densitometer uses low dose not replace a bone density test. is followed strictly for a prolonged X-rays to measure bone density At present heel ultrasound is not and the results are plotted on a covered by Medicare.
Due to the risk of osteoporosis it graph comparing the patient's bone is recommended that all adults density measurement to the normal The main goal in treating diagnosed with coeliac disease range for their age, sex and weight. osteoporosis is to maintain or have a bone density test performed The patient's bone density is also improve bone strength and prevent regardless of age, sex or menopausal compared to the normal range of fractures from occurring. It is status. Individuals medically healthy young people, which provides never too late to treat osteoporosis diagnosed with coeliac disease are an indication as to how much their
however also available from dietary sources, including meat, milk and eggs but most people get only small It is never too late to amounts of Vitamin D from their treat osteoporosis as diets. Supplements of Vitamin D sor Nick P are however readily available and even a small increase are relatively inexpensive. In many in bone strength can individuals these offer the easiest decrease significantly and most reliable means of ensuring adequate Vitamin D levels. For the likelihood of sociate PrAs people who do not get adequate sun fracturing a bone light exposure a supplement of at least 800IU (20 micrograms) per day include a group of drugs called º is recommended.
bisphosphonates. Most of these medications work by slowing the as even a small increase in bone rate at which bone is resorbed. The strength can decrease significantly bisphosphonates include ‘Fosamax', the likelihood of fracturing a bone. Weight bearing exercise helps ‘Actonel' and ‘Aclasta' and have Treatment includes a combination of: stimulate the bone cells to build been shown to decrease the risk bone. It also increases strength of fractures by approximately 50%. • calcium rich diet and improves coordination, which Some of the bisphosphonates may • adequate Vitamin D helps to prevent falls. A good form of be given at intervals of weekly or • weight bearing exercise, and weight bearing exercise is walking. monthly and one is available as a lifestyle changes to avoid heavy Before commencing any exercise once a year injection.
lifting and falls program, talk to your doctor.
There are a number of newer • Specific medications to improve It is also very important to medications which are also effective prevent falls from occurring. in the treatment of osteoporosis. Some medications which cause These include strontium ranelate drowsiness, poor balance, poor (Protos) and a group of medications A diet high in calcium is important eyesight, ill fitting footwear, loose related to oestrogens which includes for the body to maintain normal carpets and lack of care taken drugs such as raloxifene (Evista).
function of the major organs and when walking can all lead to falls. A to continue the rebuilding of bone person whose bone density is only which continues throughout life. slightly low but who falls frequently Osteoporosis is a common problem Dairy products are a good source of may be more likely to break a bone in our society and will affect 2 in calcium but other foods also contain than a person with osteoporosis who every 3 women who reach 60 and varying amounts. For those who are never falls. Balance and coordination one in every three men. The risk is unable to obtain sufficient calcium can be improved through exercise, even higher in those with coeliac from their diet, calcium tablets and studies have shown that Tai Chi disease who are also at risk of are available. Different amounts also helps significantly. Sensible developing osteoporotic fractures at of calcium are needed throughout shoes, improved vision with the an earlier age than in the general a person's life, depending on their correct glasses and the removal population. Early diagnosis by the sex, menopausal status, age, and in of any items from the home which use of bone density has proven to be women, whether they are pregnant can cause tripping will also help to an important intervention and can or breastfeeding. Your doctor will prevent falls.
significantly reduce the incidence of be able to tell you how much you osteoporosis and reduce the number require and whether calcium tablets of osteoporotic fractures in the are needed. Most adults require Specific medications are now approximately 1000mg calcium per available which have been shown to *Nick Pocock is Associate Professor in Nuclear be very effective for the treatment Medicine and Bone Densitometry at of osteoporosis and there are St. Vincent's Hospital, Sydney NSW. Kate many that are gluten free and Noakes is an RN and has been medically Vitamin D is essential for the normal diagnosed with coeliac disease.
therefore suitable to be taken by formation of bone and deficiency those with coeliac disease. These will result in increased bone resorption and osteoporosis. In any individual with malabsorption it is very important to ensure that the blood Vitamin D level is adequate. Gluten free hits prime time TV > > > A Vitamin D level below 50 nmol/L increases the risk of osteoporosis. Recently on a high profile quiz program there was a question Vitamin D is normally made by the every coeliac could answer – action of sunlight on skin. As we Which of the following grains is naturally gluten free: age however our skins become Wheat, Barley, Rye or Rice? less efficient at making Vitamin D Who wants to be a millionaire?? and many individuals do not obtain enough sun exposure. Vitamin D is
El ejército que ¿Qué queda de las Fuerzas Armadas que rompieron la democracia en Chilehace 30 años? Seguramente, más la forma que el fondo. Por primera vez, la Escue-la Militar, el gran centro de formación de oficiales, ha abierto sus puertas. Asíson los nietos uniformados del ex dictador. Por Francesc Relea. Fotografía de Luis Poirot.
BDA evidence summary Periodontal debridement in medically compromised patients receiving bisphosphonate treatment Periodontal debridement in medically compromised patients receiving bisphosphonate treatment This evidence summary aims to locate and summarise evidence on periodontal debridement in medically compromised patients taking