Make no bones about it
Nutritional deficiencies can be a problem for people living with inflammatory bowel disease (IBD), often due to the effects of inflammation on vitamin and mineral absorption and dietary restrictions. This newsletter focuses on calcium and vitamin D deficiencies and their impact on bone health. It also discusses steps you can take to promote strong bones.
Back to top
What is osteoporosis?
Osteoporosis means "porous bones" or a loss of bone tissue resulting in increased risk for fractures. Calcium and vitamin D play key roles in keeping your bones strong and healthy.
Back to top
Why are people with IBD at increased risk of osteoporosis?
An estimated 30% to 60% of people with IBD may have low bone density, putting them at risk for osteoporosis. This may be due to
-
Problems absorbing calcium and vitamin D
Health conditions affecting the gastrointestinal tract can make it difficult to absorb enough nutrients. This is especially true if you have Crohn's disease, which commonly affects the small intestine where calcium and vitamin D are absorbed. If you have inflammation or have had surgery to bypass or remove parts of your small intestine then you may be at increased risk of calcium and vitamin D deficiencies. If you have ulcerative colitis, which primarily occurs in the large intestine, calcium and vitamin D absorption may be less of a problem.
-
Elevated cytokine levels
Again, this is more likely an issue if you have Crohn's disease. Cytokines are proteins that increase inflammation in your body and also appear to slow the rate at which old bone is removed and new bone is formed.
-
Corticosteroid drugs
If you take corticosteroid drugs (like prednisone) to treat IBD, you are at an increased risk of osteoporosis because corticosteroids interfere with calcium absorption. They also cause bone breakdown while preventing new bone from being formed. An estimated 30% to 50% of people who take corticosteroids for an extended period of time develop osteoporosis.
-
Lactose intolerance or sensitivity
Some people with IBD can't tolerate dairy products because of lactose intolerance or sensitivity. This means that they cannot break down lactose, the main carbohydrate in milk. Since milk and other dairy products are good sources of calcium, this can contribute to a deficiency. Note that IBD does not increase your risk for lactose intolerance.
Back to top
Why is calcium important?
Bone may seem lifeless and inert, but it's actually living tissue. Your body is constantly breaking down old bone and creating new bone. Without adequate calcium intake and absorption, your body will take calcium from your bones, decreasing their mass and leading to osteoporosis. Since our bodies don't produce calcium, it's important to get enough from calcium-rich foods and/or supplements. Calcium is also critical for healthy teeth, proper nerve and muscle function, blood clotting, and hormone secretion.
Back to top
What about vitamin D?
It's also important to maintain adequate vitamin D levels. Vitamin D plays a key role in calcium absorption. A study of people with IBD found that those with low bone density also had a significantly higher rate of vitamin D deficiency, and those who increased their vitamin D levels also increased their bone density. Vitamin D may also play a role in regulating and strengthening your immune system and protecting against a number of chronic autoimmune diseases, including IBD.
Back to top
How is osteoporosis diagnosed?
Osteoporosis is typically diagnosed using special x-ray technology called dual energy x-ray absorptiometry (DEXA), a safe and painless test that measures the bone density in your spine, hip, and wrist (the areas most likely to be affected by osteoporosis). The DEXA test can detect osteoporosis before a fracture actually occurs and can predict your chances of having a fracture in the future. If you are being treated for osteoporosis, repeated tests can be used to monitor the effects of your treatment program.
You should be tested for osteoporosis if you are postmenopausal or have missed 3 menstrual periods in a row, are a female over age 50 or a male over age 70, have taken corticosteroids for more than 3 months, have had surgery on your small intestine, or have a history of low-trauma fracture. Once tested, you should repeat the DEXA every 2 years.
Discussing your 25-hydroxy vitamin D level with your physician is another way of monitoring bone health.
Back to top
What can I eat to help prevent and treat osteoporosis?
Research within the past decade has shown that increasing calcium and vitamin D intake can improve bone health in patients with IBD.
-
Calcium
To increase your calcium intake, try low-fat dairy products or calcium-fortified foods and beverages, including soy, almond, and rice milk, as well as calcium-fortified juices and tofu made with calcium sulfate. If you have lactose intolerance, try aged cheeses and yogurt, which are usually well tolerated. Other good sources of calcium are canned sardines and salmon with bones, as well as green, leafy vegetables. Check out the recipes for Banana Oatmeal Parfait and Broccoli, Cannellini Bean, and Cheddar Soup. Both are great ways to boost your calcium.
Recommended dietary allowances (RDAs) tell you how much calcium you need each day, as shown in Table 1.
Table 1. Recommended Dietary Allowances (RDAs) for Calcium
Table 1. Recommended Dietary Allowances (RDAs) for Calcium
-
Vitamin D
Our bodies make vitamin D when our skin is directly exposed to the sun, and most people get at least some of the vitamin D they need this way. However, it may be difficult to get enough sun exposure if you have dark-colored skin, always wear sunscreen, are age 70 or older, or live in the northern part of the United States where the sun is not strong enough during the winter months. If that is the case, you can increase your intake by eating foods that contain significant amounts of vitamin D, such as fortified dairy products and orange juice; fatty fish like herring, mackerel, salmon, sardines, and tuna; and shitake mushrooms.
The amount of vitamin D you need each day to promote optimal bone health depends on your age, as shown in Table 2. Recommended intakes are based on the assumption that you are getting little sun exposure.
Table 2. Recommended Dietary Allowances (RDAs) for Vitamin D
Table 2. Recommended Dietary Allowances (RDAs) for Vitamin D
Back to top
Boost your calcium with these recipes
Back to top
What else can I do to decrease my osteoporosis risk?
There are a number of other risk factors for developing osteoporosis, some of which you can't control (frame size, family history, being postmenopausal, and age) and some of which you can.
-
If you smoke, quit. Tobacco use contributes to weak bones and an increased risk of fractures by decreasing the amount of calcium your body absorbs. Additionally, women who smoke tend to go through earlier menopause, which decreases estrogen, a bone-preserving hormone
-
If you drink alcohol, do so in moderation. Regularly consuming more than 2 alcoholic drinks per day can interfere with your body's ability to absorb calcium. Heavy alcohol consumption is also usually accompanied by poor nutrition and an increased risk of falling and bone fracture
-
If you are sedentary, increase your physical activity. People with a sedentary lifestyle are more likely to develop osteoporosis. Physical activity, especially if it's weight bearing, helps strengthen your bones. Strengthening your muscles, improving your balance and flexibility, and preserving your joint mobility will also reduce your risk of falls
-
If you take medication that is associated with bone loss, talk to your doctor about other options. In addition to corticosteroids, medications like aromatase inhibitors, methotrexate, selective serotonin reuptake inhibitors, proton pump inhibitors, aluminum-containing antacids, and some antiseizure medications are all associated with increased osteoporosis risk
Back to top
What about calcium and vitamin D supplements?
Calcium supplements, like calcium carbonate or calcium citrate, can be a way to make sure you are getting enough calcium in your diet. Calcium carbonate is less expensive and best absorbed when taken with food. Calcium citrate can be taken either with food or on an empty stomach and is more easily absorbed in people with lower levels of stomach acid, such as older adults and people on proton pump inhibitors.
Regardless of the type of calcium supplement you take, absorption is best when you take no more than 500 mg at once. So if you need to take 1000 mg per day, try splitting the dose. If you find that your calcium supplement causes gas, bloating, and/or constipation, try taking it in a liquid or chewable form, spread throughout the day, and/or with food.
Vitamin D supplements come in 2 different forms that appear to be equivalent: D2 (ergocalciferol) and D3 (cholecalciferol). Both increase the amount of vitamin D in the blood.
Back to top
The bottom line
When you have IBD, it's important to be an active participant in maintaining your bone health. Be sure to discuss any concerns with your physician or nutritionist, and remember that early intervention can help you reverse bone loss before osteoporosis becomes a problem.
Back to top
If you found this article interesting, you may also be interested in our previous Your Digestive Health newsletters:
Have a great new year and look forward to more Your Digestive Health newsletters in 2012!
| | About the authors |
 | Colleen D Webb, MS, RD, CDN Colleen Webb is the Clinical Nutritionist at the Jill Roberts Center for Inflammatory Bowel Disease at Weill Cornell Medical College in New York City. She is a member of the Medical Advisory Committee of the Crohn's and Colitis Foundation of America (New York chapter) as well as an active member of the American Dietetic Association and the Greater New York Dietetic Association. She presents frequently on nutrition and IBD at IBD support groups throughout New York City. Ms Webb holds a Master of Science degree in Clinical Nutrition and Dietetics from New York University and a Bachelor of Arts degree from the University of Florida. Before joining the Jill Roberts Center for Inflammatory Bowel Disease, she provided medical nutrition therapy to veterans at the James J Peters VA Medical Center in the Bronx. |
 | Ellen J Scherl, MD, AGAF, FACG, FACP, FASGE Dr Scherl is Director of Research at the Jill Roberts Center for Inflammatory Bowel Disease, the Jill Roberts Associate Professor of Medicine at Weill Medical College of Cornell University/New York-Presbyterian Hospital in New York, and Adjunct Associate Professor of Medicine at Columbia University College of Physicians and Surgeons. Her current interests encompass investigational therapies for ulcerative colitis and Crohn's disease. Dr Scherl is an editorial reviewer for Inflammatory Bowel Diseases, Journal of Clinical Gastroenterology, Gastrointestinal Endoscopy, and Gastroenterology and Hepatology. She has extensive experience in many clinical trials and has coauthored or coedited a number of publications. She also lectures frequently on IBD at local, regional, and national meetings. |
| | About the authors |
| Colleen D Webb, MS, RD, CDN Dr Webb is the Clinical Nutritionist at the Jill Roberts Center for Inflammatory Bowel Disease at Weill Cornell Medical College in New York City. She is a member of the Medical Advisory Committee of the Crohn's and Colitis Foundation of America (New York chapter) as well as an active member of the American Dietetic Association and the Greater New York Dietetic Association. She presents frequently on nutrition and IBD at IBD support groups throughout New York City. Dr Webb holds a Master of Science degree in Clinical Nutrition and Dietetics from New York University and a Bachelor of Arts degree from the University of Florida. Before joining the Jill Roberts Center for Inflammatory Bowel Disease, she provided medical nutrition therapy to veterans at the James J Peters VA Medical Center in the Bronx. |
| Ellen J Scherl, MD, AGAF, FACG, FACP, FASGE Dr Scherl is Director of Research at the Jill Roberts Center for Inflammatory Bowel Disease, the Jill Roberts Associate Professor of Medicine at Weill Medical College of Cornell University/New York-Presbyterian Hospital in New York, and Adjunct Associate Professor of Medicine at Columbia University College of Physicians and Surgeons. Her current interests encompass investigational therapies for ulcerative colitis and Crohn's disease. Dr Scherl is an editorial reviewer for Inflammatory Bowel Diseases, Journal of Clinical Gastroenterology, Gastrointestinal Endoscopy, and Gastroenterology and Hepatology. She has extensive experience in many clinical trials and has coauthored or coedited a number of publications. She also lectures frequently on IBD at local, regional, and national meetings. |
| About the authors |
|
Colleen D Webb, MS, RD, CDN Dr Webb is the Clinical Nutritionist at the Jill Roberts Center for Inflammatory Bowel Disease at Weill Cornell Medical College in New York City. She is a member of the Medical Advisory Committee of the Crohn's and Colitis Foundation of America (New York chapter) as well as an active member of the American Dietetic Association and the Greater New York Dietetic Association. She presents frequently on nutrition and IBD at IBD support groups throughout New York City. Dr Webb holds a Master of Science degree in Clinical Nutrition and Dietetics from New York University and a Bachelor of Arts degree from the University of Florida. Before joining the Jill Roberts Center for Inflammatory Bowel Disease, she provided medical nutrition therapy to veterans at the James J Peters VA Medical Center in the Bronx. |
|
Ellen J Scherl, MD, AGAF, FACG, FACP, FASGE Dr Scherl is Director of Research at the Jill Roberts Center for Inflammatory Bowel Disease, the Jill Roberts Associate Professor of Medicine at Weill Medical College of Cornell University/New York-Presbyterian Hospital in New York, and Adjunct Associate Professor of Medicine at Columbia University College of Physicians and Surgeons. Her current interests encompass investigational therapies for ulcerative colitis and Crohn's disease. Dr Scherl is an editorial reviewer for Inflammatory Bowel Diseases, Journal of Clinical Gastroenterology, Gastrointestinal Endoscopy, and Gastroenterology and Hepatology. She has extensive experience in many clinical trials and has coauthored or coedited a number of publications. She also lectures frequently on IBD at local, regional, and national meetings. |
Back to top