Performing a DEXA scan at the time of celiac disease (CeD) diagnosis is the optimal approach for detecting early bone mineral density (BMD) loss, a new study of more than 600 patients suggested.

The study, published in the American Journal of Gastroenterology, reported low BMD in more than 17% and more than 13% in young adults aged 25-34 years.

While low BMD is common even in younger patients, a high risk for fracture is less so, reported researchers led by Francesco Tovoli, MD, of the Department of Medical and Surgical Sciences at the University of Bologna in Bologna, Italy. “Still, meta-analyses show that people with CeD have around a 30% higher risk of any fracture compared with the general population, and some studies report an even higher risk for major osteoporotic fractures,” Tovoli told Medscape Medical News.

The risk is greatest in patients with signs of malabsorption, poor adherence to a gluten-free diet (GFD), or those diagnosed later in life. “While younger adults have lower absolute fracture rates, early bone loss can increase future fracture risk if not addressed,” Tovoli said. In the setting of limited healthcare resources, he added,10-year fracture risk can be reduced by using the United Kingdom’s National Osteoporosis Guideline Group (NOGG) algorithm. That strategy can avoid unnecessary DEXAs in approximately 67% of patients while the risk of missing clinically significant cases will be minimal at just 0.5%.

International guidelines differ on when to assess bone BMD, Tovoli said. The American College of Gastroenterology recommends DEXA at CeD diagnosis, whereas other countries favor more selective, risk-based approaches, leading to variability in clinical practice and uncertainty about optimal DEXA use. “Our study aimed to compare universal vs targeted screening strategies to better understand the trade-offs between early detection, healthcare resource use, and expected clinical benefit,” he said.

While DEXA is relatively inexpensive and involves minimal radiation, overuse can create workflow burden, increase patient anxiety, and contribute to overdiagnosis, particularly in low-risk individuals in whom findings may not change clinical management. “Therefore, judicious use of DXA [DEXA] based on clinical risk may help optimize resources and avoid unnecessary testing,” Tovoli said.

He stressed that bone loss occurs even in young adults with CeD, especially those showing signs of malabsorption such as low BMI, weight loss, or iron deficiency and this low BMD is multifactorial. “Calcium and vitamin D malabsorption play a central role, but systemic inflammation, hormonal changes, and broader nutritional deficiencies contribute as well — even in patients with few or no gastrointestinal symptoms,” he said.

Tovoli hastened to add that a well-balanced GFD is not associated with bone loss, provided it ensures adequate caloric intake and nutrient composition. “In fact, adherence to a GFD helps restore BMD by improving nutrient absorption. However, calcium intake may be suboptimal if the diet is overly restrictive or lacks proper counseling.”

Study Details

The observational study, which is part of the larger Celiac Disease Manifestations and Complications study, prospectively enrolled 627 newly diagnosed patients with CeD, age > 25 years (mean age, 42 years; 78% women), who had DEXA scans of the lumbar spine and hip as part of standard care. Data on clinical presentation, serology, histology, and fracture risk were analyzed. Logistic regression identified risk factors for low BMD and osteoporosis. The reliability of NOGG recommendations for avoiding unnecessary DEXAs was assessed.

Analysis was done by the following age groups: 25-34, 35-44, 45-54, 55-64 years, and older than 65 years. Low BMD for age was present in 17.2% of patients, with a significant prevalence of 13.4% in the 25-34 years age group, which further increased in the 45-54 years age group. Osteoporosis was detected in 17.9% of patients, with prevalence increasing significantly in patients older than 45 years: 47.1% for 55-64 years; 53.7% for those older than 65 years.

“Though significant, the risk of BMD is not as high in CeD patients as in older adults, especially postmenopausal women, owing to the combined effect of age-related bone loss and a likely longer duration of untreated malabsorption,” Tovoli said.

Risk factors in the cohort included weight loss, underweight, and iron-deficiency anemia. Using the NOGG criteria, 67% of patients could have avoided DEXA, and there would have been only a 0.5% risk of missing clinically significant findings that required treatment but also losing 15.7% of patients with low-for-age BMD.

The two approaches highlight a tradeoff between a proactive standardized management strategy aimed at early detection and a cost-effective, targeted approach that reduces patient burden but may delay diagnoses in some cases, Tovoli and associates wrote. “The choice between the different strategies depends on geographical and healthcare factors. DEXA may be more suitable in regions with a high prevalence of low BMD and abundant healthcare resources, while the second strategy might be better in settings with a low pretest probability of low BMD and/or limited resources.” 

Commenting on the study for Medscape Medical News but not involved in it, Benjamin Lebwohl, MD, MS, a professor of medicine and epidemiology and director of clinical research at the Celiac Disease Center at Columbia University Medical Center in New York City, said, “Identification of low bone density and osteoporosis, even among young adults who are at low risk for fracture, may allow for monitoring proactively, and might prevent consequences in the long-term.” He agreed with the study’s finding that low bone density and osteoporosis are common in patients with CeD: “If bone density is not measured, clinical prediction tools would potentially miss individuals with these conditions.”

While there is no broad consensus on whether to screen for low BMD in CeD, Lebwohl added that the 2023 US guidelines “allude to doing a DXA but it is not explicitly recommended.” The European guidelines note that DEXA and bone metabolism markers could be useful to assess baseline bone health at diagnosis, “however, experts have not reached consensus on the best time to indicate this test.”

He added that “often insurance companies will cover these scans for people with celiac disease, but not always, so access may be an issue.”

Tovoli stressed that if the goal is early detection of bone loss, DEXA at the time of CeD diagnosis is the most effective strategy, even in young adults, but in resource-limited settings, risk-based tools such as the NOGG algorithm can prioritize patients most likely to benefit. “One size doesn’t fit all. DEXA timing should match healthcare system resources and clinical priorities.”

A portion of DEXA expenses could be offset by a more relaxed DEXA follow-up protocol for patients without significant BMD alterations. “This approach is supported by evidence showing that DEXA parameters improve after initiating a gluten-free diet and remain largely stable 7-10 years following CeD diagnosis,” he and his associates wrote.

Diagnosis is only the starting point, and long-term follow-up is just as important, Tovoli cautioned. “Bone health is just one example of the long-term consequences that require ongoing attention. A proactive approach, including nutritional counseling and support for dietary adherence, helps prevent complications and improves long-term outcomes.”

The authors hope the findings will inform future guidelines and contextualize the results within specific healthcare settings.

This study had no specific funding. The authors had no competing interests to disclose. Lebwohl had no relevant conflicts of interest but reported being co-principal investigator on the GLUTECH trialexamining the role of gluten-detection technology in improving CeD care.