Aim: Children with celiac disease (CeD) are at increased risk for low bone mineral density (BMD). We evaluated associations between BMD and anthropometric, body composition, laboratory, and gluten-free diet adherence in pediatric CeD.
Methods: We conducted a retrospective cohort study of pediatric participants with CeD who underwent dual x-ray absorptiometry (DXA) scans greater than 1 year after diagnosis at UCSF Benioff Children’s Hospital Oakland from 2014–2026. BMD Z-scores were categorized as low (≤−2), at-risk (>−2 to <−1), or normal (≥−1). Associations between BMD category and body mass index (BMI), lean body mass (LBM), fat mass, vitamin D levels, tissue transglutaminase (TTG) IgA, and clinical variables were assessed. Gluten-free diet adherence was measured using the Celiac Disease Adherence Test (CDAT).
Results: Among 99 participants with available BMD measurements, median age was 16 years old (IQR 12, 18), 71.2% were female, and 17.2% had low BMD. BMI differed significantly across BMD categories (Kruskal–Wallis, H=18.17, P<0.001). BMI increased from median 16.68 kg/m² (IQR 15.13, 18.34) in participants with BMD Z-score <−2 to 21.00 kg/m² (IQR 18.13, 23.90) among those with BMD Z-score ≥−1. LBM differed significantly across BMD categories (H=10.43, p=0.0054), whereas fat mass (P=0.522) and vitamin D (P=0.855) did not. BMI remained independently associated with BMD after adjustment for age and TTG-IgA (β=0.084, P=0.002). Among 19 participants with paired CDAT and BMD measurements, CDAT scores did not differ across BMD categories (H=1.17, P=0.558).
Discussion: This study found that low BMD among children with CeD had decreased LBM and BMI percentiles. These results reinforce body composition as a key marker of skeletal health in pediatric CeD. Our work supports anthropometrics and body composition assessments in the routine care of children with CeD, enabling targeted nutritional interventions for individuals at most risk for low bone mass, fractures, and osteoporosis later in life.