Based on PubMed | Does celiac disease increase the risk of stress fractures during exercise due to reduced bone mineral density?

Yes celiac disease is associated with reduced bone mineral density (BMD), and this appears to raise the overall risk of fractures, which can include stress fractures during exercise. Untreated celiac disease can impair calcium and vitamin D absorption, weaken bones (osteopenia/osteoporosis), and increase fracture risk; a strict gluten‑free diet and bone health measures can improve this risk over time. ^{[1] [2] [3]}

Why celiac disease affects bones

• Malabsorption of key nutrients: Damage to the small intestine can reduce absorption of calcium and vitamin D, which are essential for bone formation and remodeling. ^{[1] [4]}
• Resulting bone loss: This impaired absorption can lead to osteopenia or osteoporosis, conditions where bones are thinner and more fragile. ^{[1] [2]}
• Higher fracture risk: Observational studies and meta‑analyses show that people with clinically diagnosed celiac disease have a modest but real increase in total fractures and hip fractures compared with those without celiac disease. ^{[3] [5]}

What the research shows about fracture risk

• A pooled analysis found about a 30% higher risk of any fracture and a 69% higher risk of hip fracture in adults with celiac disease in prospective studies. This suggests clinically meaningful bone fragility that could include stress fractures under repetitive loading. ^[3]
• Reviews indicate a positive association between celiac disease and fractures overall, supporting the need to assess bone health at or after diagnosis. ^{[6] [7]}

Implications for stress fractures during exercise

Stress fractures occur when repetitive mechanical load exceeds the bone’s ability to repair. If celiac disease has lowered BMD or impaired bone quality, the threshold for stress injury may be lower, especially in high‑impact or endurance activities. ^[3]

• While most studies report overall fracture outcomes rather than specifically stress fractures, the combination of low BMD and high training loads is a recognized pathway to stress injury, making this a plausible and clinically relevant risk in active individuals with celiac disease. ^[3]

How a gluten‑free diet helps

• Primary treatment: A strict, lifelong gluten‑free diet (GFD) is the cornerstone of celiac care and is also the most important step to improve bone health by healing the gut and restoring nutrient absorption. ^[2]
• Bone recovery timeline: Many adults show partial BMD recovery within 1 year of a GFD and more substantial recovery by around 5 years, though not everyone returns fully to normal. Supplementing calcium and vitamin D may be needed, particularly for those who are malnourished at diagnosis. ^{[8] [9]}

Screening and monitoring recommendations

• Initial evaluation: After diagnosis, clinicians often check vitamin levels (including 25‑OH vitamin D), minerals, and consider bone health testing with a bone density scan (DXA), particularly for those at higher risk of osteoporosis. ^[2]
• DXA selection: Position statements suggest checking bone density in adults with classic malabsorption or those otherwise at risk; repeat DXA is typically done 1–2 years after starting a GFD if baseline is abnormal. ^{[10] [11]}
• Ongoing care: Tracking adherence to the GFD, repleting deficiencies, and reassessing bone health help reduce fracture risk over time. ^{[10] [8]}

Practical steps to lower stress‑fracture risk

• Optimize nutrition: Ensure adequate calcium and vitamin D intake and correct deficiencies identified on lab testing. Diet and supplements can be tailored to reach recommended intake targets. ^[2]
• Build bone‑safe training: Gradually increase training loads, include rest days, and avoid sudden spikes in impact volume to give bones time to adapt.
• Strength training: Incorporate resistance and impact‑modulated exercises to stimulate bone, adjusted to current BMD and fitness.
• Risk factor check: Address other contributors (menstrual irregularities, low energy availability, smoking, corticosteroid use), and manage coexisting conditions that affect bone. Comprehensive care can meaningfully lower fracture risk. ^{[12] [13]}
• Medical follow‑up: Work with your clinician for DXA timing, monitoring of vitamin D/calcium status, and considering osteoporosis therapy in those who remain high‑risk (for example, postmenopausal women or older men) even after a GFD. ^{[10] [8]}

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Summary table: Celiac disease and bone/stress fracture risk

Topic	Key point	Why it matters
Malabsorption	Celiac can reduce calcium and vitamin D absorption. [1] [4]	These nutrients are critical for bone strength.
Bone status at diagnosis	Many adults have osteopenia/osteoporosis at diagnosis. [10] [11]	Lower baseline BMD raises fracture risk.
Fracture risk	Increased risk of total and hip fractures vs. controls. [3] [5]	Indicates higher vulnerability, including to stress injuries.
GFD effect	GFD improves BMD; partial gains by 1 year, larger by 5 years. [8] [9]	Healing the gut reduces nutrient loss and strengthens bone.
Screening	Consider DXA at diagnosis for at‑risk adults; repeat in 1–2 years if abnormal. [10] [11]	Guides training, supplementation, and treatment.
Prevention	Adequate vitamin D/calcium, load management, strength work, address other risks. [2] [12]	Lowers likelihood of stress fractures during exercise.

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Bottom line

Celiac disease can lower bone mineral density and is linked to a higher risk of fractures, which can include stress fractures in active people, especially if the disease is untreated or nutrient deficiencies persist. Strict adherence to a gluten‑free diet, correction of vitamin D and calcium deficits, appropriate bone density testing, and smart training strategies together can substantially reduce stress‑fracture risk over time. ^{[2] [3] [8]}