Title: Crohn’s Disease - Avoiding Bone Loss

Key words: Osteoporosis, corticosteroids, calcium deficiency, Vitamin D, calciferol

Date: May 1999

Category: 13. Specific Conditions

Type: Article

Author: Dr van Rhijn

 

Crohn’s Disease

Avoiding Bone Loss

 

 

Introduction

Maintaining remission in Crohn's disease with dietary factors, therefore alleviating the sequelae from nutritional deficiencies, is quite a therapeutic challenge. Osteoporosis is such a condition and this paper will look at preventing further bone loss in these patients.

Symptomatology & Consequences

Crohn’s disease is a chronic intestinal inflammation due to a disordered immune response of unknown aetiology, with a peak occurrence in the 3rd and 4th decade, characterised by remission and relapses. The main symptoms are abdominal pain, diarrhoea (steatorrhoea), weight loss, anorexia, fever, nausea, vomiting, tiredness, intestinal bleeding and fistula. Consequently, significant malnutritional problems arise from anorexia (fear/zinc deficiency), malabsorption (inflammation/resection/fistula/drugs), enteric losses (protein/bleeding) and deficiencies (macro- and micronutrients)1.

Osteoporosis is a condition in which the amount of bone per unit volume (low bone mass) is decreased (porous) due to insufficient calcium, resulting in a predisposition to fractures (vertebral/femoral neck) despite an unchanged composition2. Vit D, magnesium, phosphorus and hormones are also involved.

Therapeutic Avenues

Corticosteroids are still more effective than enteral nutrition3, 4, 5, but with a great risk of calcium deficiency and lower bone density (osteoporosis)6, 7, 8. Dietary manipulation, such as elimination diet9 or a low fat, fibre limited exclusion diet (LOFFLEX)10 is required to control disease activity and maintain remission. Treatment aims11 are to counteract staetorrhoea (low fat, medium-chain triglycerides), weight loss (complete feeds), abdominal distension (avoid milk & non starch poly- & oligosaccharides [leeks/artichokes]/fresh hot rice starch), osteoporosis (Calcium, Vit D12, sunlight, excersise), anaemia and replacement of deficiencies (minerals).

Dietary animal protein or lactose intolerance from milk13 and n-6 PUFA’s14 may contribute to the development of Crohn’s disease, are best avoided. In contrast, n-3 PUFA's supplementation (anti-inflammatory properties), may be beneficial15 although this is still controversial16.

Preventing Further Bone Loss

The importance of calcium17 and vitamin D nutrition18 cannot be minimised in relation to the prevention of osteoporosis. Both nutrients are readily implementable, relatively inexpensive interventions and generally safe. Avoidance of dairy products, a valuable source of calcium, require Calcium supplementation in the form of bio-available Calcium gluconate or carbonate 1200 - 1500 mg/day19 to improve peak bone mass (PBM)20.

Vit D promotes phosphorus and is involved with active calcium absorption, and reduced synthesis of active metabolite 1,25 (OH)2 D3 is associated bone loss21, 22. Vit D may be supplemented by injection (30,000 u), or Calciferol tablets 1mg (40,000 u)/day23.

Other factors, contributing to osteoporosis needs to be addressed such as age, gender24, weight, physical activity (immobility), hormonal status ie, progesterone, oestrogen deficiency25 (menopause, anorexia and long distant runners), caffeine and smoking26 reduce PBM27. Other elements, involved in bone metabolism have to be normalised such as potassium, magnesium and copper.

Conclusion

Achieving remission in Crohn's disease is of primary importance to prevent further nutritional loss and maintaining peak bone mass by treatment has considerable clinical and economical implications. This can be achieved with calcium and vitamin D supplementation, and addressing other promoting factors of bone loss.

 

References
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