Forty five women and 10 men with coeliac disease diagnosed in adult life, who were already on a gluten free diet, had serial bone mineral density measurements at the lumbar spine and femoral neck over 12 months. Osteoporosis, defined as a bone mineral density (BMD) ',2 SD below the normal peak bone mass was found in 50° suggest that reduced bone mineral density is common at presentation.9 10 We therefore studied the prevalence of osteoporosis in asymptomatic adults with treated coeliac disease, and utilised serial bone mineral density measurements to detect any change in bone mineral density over 12 months. SubjectsFifty five patients (45 women and 10 men) with coeliac disease diagnosed in adult life (-18 years old at the time of diagnosis) and already established on a gluten free diet were recruited to the study from the gastroenterology outpatients department at the Royal United Hospital, Bath between 24 September 1991 and 21 October 1992. Coeliac disease was defined as small intestinal malabsorption associated with the characteristic small intestinal mucosal lesion together with clinical and histological improvement on a gluten free diet. 1 'The average age of the men was 50.2 years (range 27.0-65.0 years) and that of the women was 51-3 years (range 33.6-69.1 years). With regard to the women, the average age at menarche was 14 years (range 10-20 years; five patients had menarche at age 16 years or older). Five women (no overlap with the delayed menarche group) had a history of an episode of premenopausal amenorrhoea of at least six months. Sixteen women were premenopausal, 11 were perimenopausal, and 18 were postmenopausal (average age at menopause was 46.3 years, range 34 to 57 years, eight patients had had the menopause at age less than 45 years).Seven patients had been previously treated with oral vitamin D preparations, six had been on glucocorticoids in the past, and five of the women were either on, or had previously been on, hormone replacement therapy for more than 12 months. Fourteen patients (two men) had a history of a serious fracture (rib, clavicle, ankle, forearm, sternum, scaphoid).The average weight of the women was 61-7 kg (range 35-92.7 kg) and that of the men was 74.5 kg (range 55-97 kg). The average height of the women was 1.62 m (range 1A40-1.75 m) and that of the men was 1.74 m (range 1-60-1-86 m). The mean times spent on a gluten free diet were 4.25 years (range 0-4-10 years) in men and 9.2 years (range 0.3-40 years) in women. MethodsA dietary assessment was performed, based on a 10 day weighed record'2 of all food consumed, and the dietary intakes of calcium,

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Bone mineral density was measured by dual energy x ray absorptiometry (DEXA) at the lumbar spine and femoral neck in 15 adults who had metabolic bone disease in association with coeliac disease (mean age at diagnosis 53.5 years, range 37 to 66). Results were expressed as a T score (the number of standard deviations by which patient's bone density differed from the sex matched young adult mean). Three patients had no skeletal symptoms and normal routine calcium biochemistry but severely reduced axial bone mineral density on DEXA. Eleven patients had symptomatic skeletal fractures, including fractures of proximal femur (3), vertebrae (4), and radius (6). Three patients had osteomalacia confirmed on bone biopsy, two of whom had characteristic biochemistry. Secondary and tertiary hyperparathyroidism were seen. Seventy five further patients (60 female) with coeliac disease (mean age 52.0 years, median duration of gluten-free diet 3.4 years) and 75 paired healthy age and sex matched controls were questioned on past fracture history. Patients with coeliac disease underwent detailed studies of calcium biochemistry, dietary intake, and bone mineral density. Sixteen had a past history of fractures (chi(2) = 10.7, p = 0.0004, v controls), which were of typical osteoporotic type. Ten patients had fracture before diagnosis of coeliac disease and six after diagnosis. Patients who had a fracture were older (56.3 v 50.3 years, p < 0.02, Wilcoxon rank sum test) than those with no fracture. There was no significant difference in bone mineral density (z score -0.31 v -0. 77), serum calcium (2.30 v 2.26 mmol/l), 25-hydroxyvitamin D (19.7 v 23.7 nmol/l), parathyroid hormone (2.6 v 3.1 pmol/l), or dietary calcium intake (1021.0 v 1033.0 mg/day) in patients with fracture compared with those without fracture. Metabolic bone disease is common in coeliac disease and is associated with premature osteoporotic fractures.

Patients with coeliac disease are started on a gluten free diet at the time of diagnosis, but after a varying period of follow-up are often discharged from outpatient and dietary follow-up. We have studied the nutritional status and dietary intake of 54 patients with treated coeliac disease diagnosed in adult life.Each patient was paired with a healthy age and sex matched control. There was no difference in height in patients compared to controls, but a greater proportion of patients (15%) than controls (4%) had weight below the UK population lower 5th percentile (xz test P< 0.05). Triceps skinfold thickness was 102% of age and sex matched mean reference values, but mid-arm circumference and arm muscle circumference were below reference mean values (93.1% and 91.5% of reference values, respectively). Haemoglobin, mean corpuscular volume, red cell folate and 25 hydroxyvitamin D were all in the normal range.A strict gluten free diet was followed by 78% of patients; 22% had occasional gluten intake. Seventy-four per cent considered that they had reduced their intake of bread since commencing a gluten free diet. In 48% of patients, average daily intake of energy was less than the estimated average requirement, and in more than one-third of patients the intake of iron, copper, magnesium, retinol and folic acid was less than the relevant reference nutrient intake (RNI). In more than 10% of patients, average daily intake of calcium, zinc or vitamin Bs was less than the RNI. Vitamin D intake was lower than the RNI in four of five patients older than 65 years.

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