To offer you the best service possible, Dr. Schär Institute uses cookies. By using our services, you agree to the use of cookies. I agree

Professional resource for gluten free nutrition.

Dr. Schär Institute
Menu

Reduced bone mineral density in children with screening-detected coeliac disease.

Bjork S, Brundin C, Karlsson M et al. Journal of Paediatric Gastroenterology & Nutrition. Epub ahead of print.
DOI: 10.1097/MPG.0000000000001568

It is known that low BMD is found in children with clinically-detected coeliac disease at diagnosis and that this is reversed once on a gluten-free diet (GFD). However, the question remains as to whether children identified through screening, often with asymptomatic or subclinical disease, also have low BMD. It is also not known if a GFD influences the development of BMD in this group.
A prospective population-based cohort study (Coeliac Disease Prediction in Skane- CiPiS) was used to recruit the study population and controls. The aim of the cohort study was to identify coeliac disease by repeated screening in HLA genotyped children. 13,860 three-year old children included in the Diabetes Prediction in Skane (DiPiS) study were invited to participate in the CiPiS study of which 25% (n=3435) agreed to participate and 1.6% (n=56) were diagnosed with coeliac disease. Over 13,000 children from the same birth cohort were re-invited to a repeated coeliac screen at 9 years of age of which 31% (n=4077) agreed to participate and 1.8% (n=72) were diagnosed with coeliac disease. Those already diagnosed with coeliac disease at three years of age or those cases identified clinically were excluded.

In this case-control study, the researchers looked to evaluate if BMD is affected in children with screening-detected coeliac disease with and without a GFD. It was hypothesised that those children with screening-detected disease would have lower BMD and that those children diagnosed at an earlier age, already following a GFD, would not present with bone deterioration. Children with tTGA detected at the follow-up screening at 9 years of age were invited to have their BMD assessed and anthropometrics measured at time of biopsy. A questionnaire looking at lifestyle factors known to potentially affect bone mineral metabolism was completed by their caregiver and a blood sample was collected from the child to measure levels of 25 (OH) vitamin D3, parathyroid hormone (PTH) and for a number of cytokines (IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-15, IFNγ and TNFα). Children already diagnosed with coeliac disease at three years of age and on a GFD were invited for equivalent measurements, including tTGA. Two controls (matched for gender, HLA-DQ and birth year) were selected per every child with coeliac disease from the tTGA negative group. The same measurements were also taken for controls. In this study, coeliac disease diagnosis was based on persistently positive tTGA in combination with a Marsh I score or higher. 

In all, 71 children with coeliac disease and 142 matched controls were included in the final analysis. An additional 56 children, already diagnosed at the initial screening at 3 years of age and on a GFD were invited to participate, of which 39 (70%) agreed. Nine of this group reported regular intake of gluten-containing foods and/or had tTGA values above the cut-off for a positive result and were therefore excluded. 30 children on a GFD and 60 matched controls were included.

No differences in lifestyle factors were observed between children with screening-detected coeliac disease compared with matched controls. The same was true of the children on a GFD when compared with their matched controls, apart from a GFD. It was found that at diagnosis children with screening-detected coeliac disease had lower BMD in total body and spine measurements. No correlation was observed between BMD and levels of IgA-tTGA and Marsh score. The BMD measurements of children with coeliac disease and on a GFD did not differ when compared to controls. Lower levels of 25 (OH) vitamin D3 and higher PTH levels were found in untreated children when compared with controls. In children with screening-detected coeliac disease a weak correlation between total body BMD and levels of vitamin D was observed, however no correlation was seen between the BMD measurements and PTH levels. The low levels of vitamin D observed in this study are in contrast to other recent studies indicating levels of vitamin D in children with coeliac disease that are comparable to the normal population. No obvious reasons for the lower levels, such as inadequate intake of vitamin D or other forms of malnutrition, could be found. Children with coeliac disease on a GFD did not differ from controls in levels of vitamin D3 and PTH. It is important to note that vitamin D3 levels and BMD were not measured before a GFD was commenced in children already on a GFD and therefore it was not possible to assess the effect of a GFD between 3-10 years of age. Despite this the consistency in findings between control children and those screening-detected children with coeliac disease already on a GFD could indicate a benefit from the treatment. 

Systemic levels of most of the cytokines examined were also found to be increased in children with screening-detected coeliac disease compared to matched controls, with the exception of IL-15 levels which were decreased in screening-detected children and correlated positively to BMD. In this study IL-10 and IL-13 were inversely correlated to BMD indicating that these cytokines may have a possible role in bone metabolism in coeliac disease but further investigation is required. IL-1β, IL-6 and TNFα, well-recognised as having a role in the inflammation interaction in bone resorption in inflammatory bowel disease (IBD) were also increased at diagnosis of screening-detected coeliac disease at 10 years of age. This has also been observed in adults with asymptomatic coeliac disease. The levels of cytokines in children on a GFD did not differ from controls.

This study demonstrated that children with screening-detected coeliac disease had lower total body and spine BMD measurements as well as lower levels of 25 (OH) vitamin D3 compared to control children. This group could therefore be at risk of lower peak bone mass and future fractures in later life. It also showed that children with screening-detected disease diagnosed at an earlier age and following a GFD have comparable BMD and vitamin D3 levels to controls. Whilst the long-term clinical consequences of these findings were not examined in this study, the findings suggest there is a benefit to early identification and treatment of the condition. Further research is needed to determine the rate and quality of bone health recovery in adolescents with coeliac disease. 
www.drschaer-institute.com