Due to long-term steroid use and inflammation, half of all patients with IBD will show a significant reduction of their bone mass during the course of their disease. In this blog, we explain why that is and what you can do to monitor and improve your bone health.

If IBD is a gut issue, why talk about bone health?

People with IBD are particularly susceptible to bone-related comorbidities including reduction in bone density (osteopenia), porous bones (osteoporosis), and softening of the bones (osteomalacia), but these slow-developing conditions of the bone often go undetected until something major like a fracture occurs. In our focus on inflammation and acute symptoms of GI distress, bones are definitely not the first thing on our mind, and so monitoring efforts like dual energy x-ray absorptiometry (DEXA) scans fall by the wayside. With bone density loss affecting half of all IBDers over the course of their disease, vigilance about bone health is indeed an unfortunate necessity.

Understanding the connection between bone density and IBD

Because the gut is the main avenue for the body to receive nutrients, any disruption to the gut’s functionality can have detrimental effects on nutrient absorption. Calcium and vitamin D, both necessary for proper bone mineralization and skeletal health, are absorbed in the small intestine, so severe inflammation or surgical removal of this area may mean the body simply doesn’t have the material it needs to build healthy bones (1). Indeed, bone density loss is more common in people with Crohn’s disease than people with ulcerative colitis which may be attributed to the location of inflammation associated with each (the small intestine and colon, respectively). Not only is the IBDer’s body at a disadvantage of nutrient absorption when it comes to bone loss, but the very medications prescribed for treating IBD also disrupt the development and maintenance of healthy bones. Glucocorticosteroids (i.e prednisone) can prevent the IBDer’s body from integrating what calcium it does manage to absorb–we observe a direct correlation between the length of steroid usage and dosage and the severity of bone loss. This is not to detract from steroids’ use and efficacy at controlling inflammation, but rather to highlight that regular bone density check ups can be an important part of steroid treatment. Lastly, recent research investigating the relationship between the gut microbiota and bone-related metabolism suggests our gut microbiota can influence immune mechanisms, hormone secretion, and general metabolism which in turn can affect bone metabolism (2). It is also now clear that a metabolite produced by our intestinal bacteria, hydrogen sulfide, is implicated in bone formation (3). In understanding the importance of the gut microbiota in other aspects of IBD, we eventually hope to better understand how the microbes in our gut communicate with our bones in order to more specifically address the bone density concerns in IBD.

What can we do?

First and foremost, measuring your bone mineral density by a dual energy x-ray absorptiometry (DEXA) scan is crucial to monitor skeletal health. Be sure to speak with your doctor about routine check-ups on your bones, especially when in an active flare. This can be particularly relevant for children with IBD while their bones are still developing.  Secondly, a diet rich in calcium and vitamin D will give the body the building blocks it needs for strong bones. For adults, the daily recommendation of calcium is 1,000 mg and can be obtained through foods such as dairy, green leafy vegetables, and fish with bones (like sardines). The daily recommendation of  15 μg of vitamin D can be achieved through adequate sun exposure and fatty fish (e.g. salmon), red meat, liver, and egg yolks. These nutrients could also be incorporated in part through supplements or even vitamin injections.  Other lifestyle factors like exercise and limiting alcohol can also promote healthy bones.  Similar to muscle, bone becomes stronger when worked through weight-bearing and strength-training exercises such as walking, hiking, team sports, jump rope, and resistance training with weights or bands. One randomized, controlled study on Crohn’s disease found significantly increased bone mineral density in participants trained on low-impact exercise compared to controls, highlighting the benefits exercise can confer (4).  Additionally, both smoking and alcohol use have been shown to increase bone loss, so limiting their consumption can also contribute to skeletal health (5). With all the attention given to the gut and medications when it comes to IBD, it is all too common for regular DEXA scans to slip through the cracks and for bone density loss to occur silently in the background. The best thing the IBDer can do is continue to educate and advocate for themselves to address the whole-body condition that is IBD.

References 

1. Khazai, N., Judd, S. E. & Tangpricha, V. Calcium and Vitamin D: Skeletal and Extraskeletal Health. Curr. Rheumatol. Rep. 10, 110–117 (2008).
  1. Li, L. et al. Microbial osteoporosis: The interplay between the gut microbiota and bones via host metabolism and immunity. MicrobiologyOpen 8, (2019).
  2. Zaiss, M. M., Jones, R. M., Schett, G. & Pacifici, R. The gut-bone axis: how bacterial metabolites bridge the distance. J. Clin. Invest. 129, 3018–3028.
  3. Robinson, R. J. et al. Effect of a low-impact exercise program on bone mineral density in Crohn’s disease: a randomized controlled trial. Gastroenterology 115, 36–41 (1998).
  4. Smoking and Bone Health | NIH Osteoporosis and Related Bone Diseases National Resource Center. https://www.bones.nih.gov/health-info/bone/osteoporosis/conditions-behaviors/bone-smoking.

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