Disclaimer: This information is based on my own research into this particular aspect of IBD as well as some personal experience and should not be used as medical advice or a diagnostic tool. The suggestions given within are taken from sources laid out in the references header. If you seek advice regarding the things you experience within your own disease, please contact your IBD team for medical advice.
If you are looking for the entire ‘What and Why’ series, you can find them all here.
What is Calcium?
Calcium is vital mineral, it is important for the health of your teeth and bones. 99% of the calcium in your body is stored there; but calcium also helps the heart, brain, nerves, and muscles, and helps blood clot among other things.
Most people are not aware of how they feel when they don’t have enough calcium. Calcium is so important for keeping your heart beating and your brain going that when we don’t have enough in our diets, the body takes it from our bones. You may not realise your deficient until it’s reached a dangerous level – such as a fracture of a bone.
Why is it important?
When you don’t get enough calcium, you increase your risk of developing disorders like:
- Osteopenia – means you have lower bone density than normal. Bone mineral density (BMD) is the measurement of how much bone mineral is in your bones. People who have osteopenia have a lower BMD than normal, but it’s not a disease. However, having osteopenia does iincrease your chances of developing osteoporosis.
- Osteoporosis – increases the size of these spaces, causing your bones to lose strength and density. In addition, the outside of the bone grows weaker and thinner.
- Hypocalcemia – calcium deficiency disease
The loss of calcium from bone is called Osteopenia when it is mild and Osteoporosis when it is severe. If calcium deficiency continues over a long time you can have permanent loss of bone that can result in fragility, broken bones, loss of mobility and more.
It is important to maintain the recommended daily allowances (RDA) for calcium to avoid and prevent possibly calcium deficiency in the future. However, there is increased chance of Hypocalcemia if you have an issue with malnutrition – when you do not get enough nutrients – or malabsorption – when your body can not absorb the vitamins and minerals you need from the food you eat.
Additional causes can be:
- low levels of vitamin D, which makes it harder to absorb calcium
- medications, such phenytoin, phenobarbital, rifampin, corticosteroids, and drugs used to treat elevated calcium levels
- septic shock
- massive blood transfusions
- certain chemotherapy drugs
If you miss your daily dose of calcium, you won’t become calcium deficient overnight. But it’s still important to make an effort to get enough calcium every day, since the body uses it quickly. Early stage calcium deficiency may not cause any symptoms. However, symptoms will develop as the condition progresses.
The severe symptoms of Hypocalcemia include:
- confusion or memory loss
- muscle spasms
- numbness and tingling in the hands, feet, and face
- muscle cramps
- weak and brittle nails
- easy fracturing of the bones
Calcium deficiencies can affect all parts of the body, resulting in weak nails, slower hair growth, and fragile, thin skin. Calcium plays an important role in both neurotransmitter release and muscle contractions. So, if you start experiencing neurological symptoms like memory loss, numbness and tingling, hallucinations, or seizures, make an appointment to see your doctor as soon as possible.
What is the relevance to IBD?
The use of corticosteroids – as a powerful anti-inflammatory medication, corticosteroids such as prednisone can produce serious side effects, and bone loss is one of them. Between 30 – 50% of people who take corticosteroids on a long-term basis develop osteoporosis, and the effects are cumulative—with the impact on bone health depending largely on the dose and length of time that a person is on these medications. Corticosteroids impair the formation of new bone by:
- Decreasing the amount of calcium (an essential bone-building mineral) absorbed by the intestines from food
- Increasing the excretion of calcium in the urine
- Stimulating the production of cells that break down bone
- Decreasing the number of bone-forming cells
- Reducing the production of the hormone estrogen, which contributes to strong bones
Inflammation in active disease – People with IBD have elevated concentrations of specialized proteins, called cytokines, which increase the body’s inflammatory response. These chemicals can disrupt normal bone metabolism—the pace at which old bone is removed and new bone is formed. It also appears that individuals with more active forms of Crohn’s may be at increased risk of developing osteoporosis because their cytokine activity is greater. The cytokine connection also might explain why people with Ulcerative Colitis suffer less bone loss than those with Crohn’s disease. Although the two diseases have many similarities, they differ when it comes to cytokine balance. This is when there becomes more evidence to show bone loss in those individuals who have used corticosteroids for some time.
Poor absorption – The nutrients important to bone formation, especially calcium and vitamin D, are absorbed in the small intestine. So if you have extensive Crohn’s Disease affecting your small bowel, or have had parts of your small intestine removed, you may be at additional risk of developing a calcium deficiency.
Avoidance of dairy foods – If there is an avoidance to dairy products, perhaps because of lactose intolerance or abdominal pain, there is more likely chance of having a shortage of calcium in your diet, unless you are taking a regular supplement. This shortage can slow down bone formation.
Vitamin D Deficiency – Vitamin D is necessary for the absorption of calcium. Together, these two are critical for building healthy bone. Because this vitamin is absorbed in the small intestine, people with Crohn’s disease— particularly those who have undergone small bowel resection or who have extensive small bowel involvement—are at increased risk for vitamin D deficiency. This, in turn, may result in bone loss due both to reduced calcium absorption and to poor bone mineralisation. That is why people who have undergone surgery to remove much of their small bowel are at increased risk of developing osteoporosis. The remaining intestine may not be adequate to absorb necessary quantities of calcium and vitamin D.
GENERAL RISK FACTORS – According to experts; increasing age, female gender, and low body mass index (BMI) put people with IBD at greater risk for bone loss than any of the other causes described above. That means that older, female Crohn’s patients who are of slight build are at greater risk for bone-thinning conditions than younger and heavier patients. Smoking and alcohol consumption also contribute to increases in that risk.
How can it be resolved?
Osteoporosis often can be prevented. It is known as a silent disease because if undetected, bone loss can progress for many years without symptoms until a fracture occurs. Osteoporosis has been called a childhood disease with old age consequences because building healthy bones in youth helps prevent osteoporosis and fractures later in life. However, it is never too late to adopt new habits for healthy bones.
Preventive measures include reducing the controllable risk factors that contribute to bone loss:
- Reduce steroid use (under your doctor’s supervision)
- Use steroid-sparing drugs such as azathioprine, 6-MP, methotrexate, infliximab, or budesonide—a systemic corticosteroid with fewer side effects than traditional steroids.
- Take medications to enhance bone health.
People with IBD also can take the following self-care steps to help prevent bone loss:
- Restrict alcohol consumption.
- Stop smoking.
- Engage in regular physical activity.
- Eat a diet rich in calcium or take 1,500 mg of calcium daily. If you don’t get enough natural exposure to sunlight, then dietary sources of vitamin D are essential or taking 400 units daily of supplemental vitamin D (contained in many multivitamins).
The very best sources of calcium in food are dairy products such as milk, yogurt and cheese. There is also calcium in fortified soy and rice drinks, fortified juice. But calcium can also be found in dietary supplements as liquids, powders, tablets, capsules, and soft chews.
Recommended Gender and age specific RDA:
- 9-18 yrs: 1300 mg
- 19-50 yrs: 1000 mg
51-70 yrs:1000 mg (male) and 1200 mg (female)
- 71+ years: 1200 mg3
- Because you can’t usually feel calcium deficiency, many people do not know when they are not getting enough. Your doctor may ask you to have a bone density test to look at how much calcium you have in bone, or ask specific questions about your diet to learn how much calcium you typically eat.
- If you have low calcium or loss of bone, it is important that you follow-up with your doctor for lab tests and other recommended care.
- Bone Density Test – A bone mineral density (BMD) test measures bone density in various parts of the body. This safe and painless test can detect Osteoporosis before a fracture occurs and can predict one’s chances of fracturing in the future. Adults with IBD should talk to their doctors about whether they might be candidates for a BMD test. This test can help determine whether medication should be considered and can be used to monitor the effects of an osteoporosis treatment program.
- Exercise: Like muscle, bone is living tissue that responds to exercise by becoming stronger. The best activity for your bones is weight-bearing exercise that forces one to work against gravity. These and other types of exercise also strengthen muscles that support bone, enhance balance and flexibility, and preserve joint mobility, all of which help reduce the likelihood of falling and breaking a bone.
I remember when I went for my first body density scan – it was a couple of weeks after starting Humira back in late 2011 – and I constantly thought ‘I hope this one does hurt like the rest have‘ and truth be told, it never did.
My first scan revealed that the calcium I had taken along side my steroids on all my previous four admissions had done some good; there was nothing to indicate any issues with my bones or my ability to absorb calcium. This felt like relief and it was the first of a few good things to happen from there onwards.
As I got more experience with my IBD, I learnt more about the body, about the disease and about complications or additional manifestation of my bad gut. For me, calcium was not a problem – I didn’t have an issue with lactose so could enjoy dairy and dairy products. I hadn’t had any surgery to remove small bowel at that point; absorption through lack of intestine wasn’t an issue. I was compliant when I had to take my steroids, as I knew that prevention was better than cure for a calcium deficiency.
However, when I needed to have surgery to resect my bowel by remove my ileum – the cause of the IBD flare ups I had continued to have under biological treatment – I knew that I was letting myself in for potential deficiencies. And after the ostomy was created, this was increased again. I now have a vitamin D deficiency, which means taking regular medication to supplement that but also my calcium.
I have to admit, my adherence to supplements is strong but it was probably late in the making. However, I am keeping track of them, I’ve seen improvement with my Vitamin D levels with my B12 injections and my tablets, so hopefully my calcium is up there. Whether I am to receive another BD scan yet, is to be determined.
Are you calcium deficient? How did you find out about this? Are you currently on medication or recently finished?
Do you have any questions or queries? Or just want to share your own experiences? You can leave me a reply here or leave comments via my social media accounts – on Twitter, find my blog page on Facebook and over on Instagram
Healthline – Hypocalcemia: Calcium Deficiency Disease
The Whittington Hospital NHS Trust – Calcium & Calcium Deficiency
IBD Relief – Calcium deficiency and IBD
VeryWell – Calcium Deficiency in People with IBD
IBD Clinic – IBD and Bones
GI Society – IBD and Osteoporosis