Healthy bone is constantly being recycled. In a process called bone remodeling, old bone is broken down and new bone created. But for this to work well you need the right nutrients. A steady supply of protein, vitamins, minerals and healthy fats are required for our biochemistry to work, and for us to have healthy, strong bones. There are two ways in which your bones might be starving for the right nutrition. You simply may not be eating well. Most Americans follow the Standard American Diet (SAD), which is nutritionally quite poor.

But even if you’re eating the most pristine diet in the world, full of whole foods and ample amounts of protein and healthy fats, if you aren’t absorbing those nutrients, you might as well not have eaten them in the first place. Malabsorption is the inability to effectively absorb nutrients. It can cause osteoporosis, nutritional deficiencies and is a risk factor for many other diseases. Crohn’s disease, ulcerative colitis, Celiac disease and chronic pancreatic insufficiency all create malabsorption. Radiation treatment for cancer, diabetes and cirrhosis of the liver can all also lead to malabsorption. People who have had gastric bypass surgery, or a lap band procedure to treat obesity, can also experience malabsorption and nutritional deficiencies. Gut bacteria help us digest and absorb our food, and abnormal gut bacteria, called intestinal dysbiosis, is also associated with osteoporosis.

Symptoms include abdominal discomfort, such as gas, bloating, cramping or pain; diarrhea; fatigue; seeing undigested food in your stool or stools that float or may leave a greasy sheen in the water. People can also experience headaches and fatigue. Malabsorption lead to deficiencies in iron, B vitamins, vitamin D, vitamin K, vitamin C, protein, folic acid and more.

While the inability to absorb nutrients can be a direct cause of osteoporosis, medications used to treat some of the diseases causing malabsorption can also cause osteoporosis. The best example of this is prednisone (corticosteroids). Prednisone is frequently prescribed to treat gastrointestinal disorders that cause malabsorption, such as Crohn’s disease and ulcerative colitis. Prednisone weakens bones and increase fracture risk, independent of the disease itself.

Celiac disease, caused by an immune reaction to gluten that damages the intestinal lining, causes malabsorption and bone loss. Gluten is a protein found in many foods, including wheat, rye, barley, bulgur, couscous, farina, kamut, semolina and triticale. Many food products are hidden sources of gluten. It’s found in malt, soups, commercial bullion and broths, cold cuts, French fries (often coated with flour), processed cheese, soy sauce, salad dressings, gravy, hot dogs, and many more products.

People with Celiac Disease must strictly avoid all gluten, even trace amounts. However, avoiding gluten doesn’t’ appear to be enough to protect the bones in people with Celiac Disease. Seventy-four percent of patients with celiac disease who strictly avoid gluten still have low bone density. And bone fractures were almost two times as common in patients with celiac disease than in those without.

Healthy digestion is crucial for bone health. Diseases and medications can cause bone loss, osteoporosis and fractures. Poor nutrition and the inability to absorb and utilize nutrients are risk factors that you might may be able to improve. If you think you might have malabsorption, speak with your healthcare provider about getting a proper evaluation. And if you have conditions—or are taking medications—that cause osteoporosis, take steps to reduce your risk.

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