But if you’ve been treating your condition with medications called glucocorticoids, such as prednisone or cortisone, you may be at risk for a common UC-related health complication: bone density loss. And as your bones become less dense, you may develop osteopenia, weakening of the bones, or osteoporosis, a serious condition that makes your weakened bones more likely to fracture.  “There are several reasons that people with inflammatory bowel disease [IBD], both ulcerative colitis and Crohn’s disease, are at an increased risk for bone loss or low bone density,” says Jami Kinnucan, MD, an IBD specialist and assistant professor of internal medicine at Michigan Medicine at the University of Michigan in Ann Arbor. “The reasons for this increased risk include the presence of active inflammation, need for steroid therapy, and vitamin D deficiency.” Indeed, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD), more than 53 million Americans have either already been diagnosed with osteoporosis or have low bone mass. In general, postmenopausal women are at highest risk for the condition, but people with UC also need to be mindful, because while glucocorticoid therapy reduces the inflammation associated with IBD, it can also weaken bones. In addition, those who have undergone small bowel surgery — more common in people with Crohn’s than those with UC — may have difficulty absorbing calcium and vitamin D, two essential nutrients for bone health. “Low physical activity also plays a role,” says Madalina Butnariu, MD, an assistant professor in the division of gastroenterology, hepatology, and nutrition at The Ohio State University Wexner Medical Center in Columbus. If you have UC, here’s what you need to know about osteoporosis and what you can do to prevent it.

What Is Osteoporosis?

Known as a “silent” condition, because it often goes undetected for many years, osteoporosis causes bones to become less dense and more likely to fracture. Bone fractures resulting from osteoporosis can be extremely painful and cause disability.  Unfortunately, many people with osteoporosis aren’t diagnosed until after they’ve suffered one of these debilitating fractures, according to the NIAMSD. Part of the reason is that those with the condition may not experience any symptoms, other than some back pain or a change in posture, which they may associate with advancing age. Most osteoporosis-related fractures occur in the spine and hips, which makes it difficult to walk and move around, so getting screened for bone loss (bone density testing) and taking preventive measures to halt it are extremely important.

Preventing Osteoporosis in UC

If you know you’re at risk for bone loss because of your UC treatment, here are steps you can take to prevent it. 

  1. Undergo routine bone density testing. If you have UC and take a glucocorticoid, it’s important to have your bone density checked regularly, says Dr. Butnariu. If you’re not currently getting routine tests, talk to your doctor. “We perform what’s called a DEXA scan to assess bone density in people at risk of bone loss, especially those with a history of long-term steroid use,” says Butnariu. “If the DEXA scan is consistent with osteoporosis, we refer them to an appropriate specialist for treatment.” 
  2. Treat your osteoporosis if you already have it. Knowing you have osteoporosis and getting appropriate therapy can reduce your risk for painful fractures, says Butnariu. Part of that therapy may include medications designed to enhance bone health, such as once-a-week bisphosphonate drugs approved for steroid-induced osteoporosis, according to the Crohn’s and Colitis Foundation. Bisphosphonates are most often prescribed to people who are just starting out on glucocorticoid treatment and have other risk factors for osteoporosis — like a family history of the condition — or low bone density.
  3. Take calcium. The Crohn’s and Colitis Foundation recommends eating a diet rich in calcium and/or supplementing your calcium intake with 1,500 milligrams of the mineral daily. Calcium is “an essential bone-building mineral … absorbed by the intestines from food,” the Crohn’s and Colitis Foundation says. According to the Cleveland Clinic, the best sources of calcium are dairy products, such as milk, yogurt, and cheese. It can also be found in almond or soy milk, dark green leafy vegetables, dried peas and beans, fish with bones, and calcium-fortified juices and cereals. Extra calcium may be particularly helpful during a UC flare, when absorption of the mineral often declines.
  4. Take vitamin D. Vitamin D is essential for your body to absorb calcium, the Crohn’s and Colitis Foundation notes. Because D is absorbed in the small intestine, people with UC — particularly those who have had surgery to remove part of their small bowel — may have difficulty maintaining healthy vitamin D levels, which may in turn cause calcium deficiency and poor bone health. Sunlight works to synthesize vitamin D in your skin, so if you don’t get adequate natural sunlight, the Crohn’s and Colitis Foundation recommends supplementing with foods, such as fortified milk, fish oil, or liver, or taking 400 IU of supplemental vitamin D daily, which can be found in most over-the-counter multivitamins. “I typically recommend all my patients with UC take a multivitamin, and in those patients with low vitamin D levels, we supplement to achieve a goal of vitamin D levels in blood above 30 nanograms per milliliter (ng/mL),” says Dr. Kinnucan. “We check this through regular blood tests. Typically you can take supplements of calcium with vitamin D in addition to vitamin D alone.”
  5. Change your medication therapy. According to the Crohn’s and Colitis Foundation, steroid use is a risk factor for osteoporosis, so it is ideal to consider steroid-sparing treatments for UC. Joseph Feuerstein, MD, associate clinical chief at the Center for Inflammatory Bowel Disease at Beth Israel Deaconess Medical Center, in Boston, says he recommends steroid-sparing drugs like immunomodulators or biologics. “Corticosteroids have long been associated with bone loss that can be persistent and long-standing,” he explains. “Typically, once someone is on a high dose of corticosteroid for more than 4 to 6 weeks, there is a risk of bone loss. Steroids should be used sparingly to treat UC and avoided unless absolutely necessary.”  But if you’ve been taking a glucocorticoid and it’s working to control your UC symptoms, a change may not be worth the risk. “The most important step in decreasing the risk of bone loss is achieving UC remission,” says Butnariu.
  6. Limit alcohol consumption. Drinking excessive amounts of alcohol is a risk factor for osteoporosis. It also isn’t ideal for managing your UC. Although there are no hard-and-fast rules for “healthy” alcohol consumption, the Mayo Clinic defines moderate alcohol use for healthy adults as up to one drink a day for women of all ages and men older than 65, and up to two drinks a day for men 65 and younger.
  7. Quit smoking. Like excessive alcohol consumption, smoking is a risk factor for osteoporosis and bad for your overall health. If you quit smoking, you can reduce your risk for bone density loss and other health complications.
  8. Exercise regularly. According to Dr. Feuerstein, weight-bearing exercises help build bones and maintain their strength. If you have broken a bone due to osteoporosis or are at risk of breaking a bone, you may need to avoid high-impact exercises. If you’re well enough to exercise, the National Osteoporosis Foundation (NOF) recommends bone-building exercises, such as dancing, aerobics, hiking, jogging, running, or tennis. Low-impact exercises such as using an elliptical machine or walking fast on a treadmill can also help keep bones strong and are a safe alternative if you can’t do high-impact exercises, the NOF adds.