Coeliac disease and the importance of calcium

By Sandy Soni

Dr Megan Rossi in a lab looking through a microscope

Coeliac Disease (CD) is an auto-immune condition which currently affects 1% of the population and the only treatment is a strict lifelong gluten free diet.

CD can be challenging to live with since everything that is eaten or drunk has to be safe, checked and monitored. Organising meals or planning to eat outside of home can be time consuming, frustrating and hard to navigate. It may even take the small bowel anything from 2-5 years to fully recover depending on the amount of initial damage done. 

A key consideration for those diagnosed with CD is the importance of ensuring adequate nutrient intake. Any person diagnosed with CD should not only be aiming to adhere to a strict gluten free diet, to prevent damage, but also be able to and be aiming to eat a diverse and varied diet to try and optimise gut health and the absorption of vitamins and minerals – this includes calcium, a key nutrient for overall health, wellbeing and longevity.

How does Coeliac Disease impact our calcium needs?

The general population requires 700 milligrams (mg) of calcium a day but the recommendation for those adults with coeliac disease is to consume at least 1,000 mg of calcium each day.

Calcium is important for the body as it is needed to help build and maintain strong bones and teeth – a lack of calcium can subsequently result in osteoporosis. Osteoporosis is a condition where bones become weak, fragile and more prone to fractures or breakages. Osteoporosis is commonly associated with coeliac disease due to the damage in the lining of the gut leading to to a reduction in the absorption of calcium from food consumed. The result – people living with coeliac disease need to have a diet rich in calcium.

What is the role of Vitamin D?

In order to absorb calcium your body needs sufficient vitamin D.

So how do we get vitamin D?

Vitamin D is made by the skin from spending time in the sun. In the UK, people will get more vitamin D from sunlight between March and September but are generally unable to get enough sunlight, and therefore create sufficient vitamin D, during the winter months. 

There are unfortunately only a few foods which are good sources of vitamin D, these include oily fish (salmon, mackerel, kippers), eggs, margarine and fortified breakfast cereals. It is unlikely that most people will be able to meet their vitamin D requirements through diet alone which is likely to result in those living in the UK having insufficient levels of vitamin D throughout the winter months (October – March).

As a result, the Scientific Advisory Committee on Nutrition (SACN) recommends everyone in the UK aged 4 years and older (including pregnant and breastfeeding women) should have a 10 microgram supplement of vitamin D per day between September and March to support their overall health.

For some people the risk of vitamin D deficiency is higher and these people should consider taking a daily supplement containing 10 micrograms of vitamin D all year round, rather than just throughout winter. Some people who may wish to consider this includes:

  • People who spend very little or no time outside.
  • People who always cover their skin when outside.
  • Ethnic minority populations with darker skin.

You can find out more about the importance of vitamin D here.

What is a DEXA scan and do I need it if I have Coeliac Disease?

A DEXA scan stands for ‘dual-energy X-ray absorptiometry, quite a complicated way of saying a scan that measures the density of your bones. As mentioned above, due to the damaged gut lining, those with CD may not absorb all nutrients consumed in their diet including calcium and vitamin D which are both vital for bone growth and maintenance. Some studies report evidence of reduced bone mineral density, in up to 75% of patients at diagnosis of CD. As a result, adhering to a gluten free diet is important to promote not only healing of the gut lining but to optimise absorption of calcium from the diet and optimise bone mineral density.

The need for a DEXA scan and calcium supplementation, in addition to dietary calcium consumption, should be assessed on an individual basis as part of the annual review conducted by a dietitian or a doctor. DEXA scans are generally advised for women >65 years or in people < 65 years if they have had previous bone fractures, low BMI or they have a history of falls. 

Calcium

Knowing whether you are getting enough dietary calcium can be difficult so we have summarised some good sources of calcium in both dairy and non-dairy forms in the table below. Low fat dairy products contain just as much calcium as full fat versions so if you are choosing semi skimmed or skimmed milk and low-fat yoghurt and cheese, then you don’t have to worry about losing any nutrients.

Table 1: Calcium content of a range of foods

 

Food per serving Amount (milligrams (mg)
Skimmed milk, 200ml 248mg
Semi-skimmed milk, 200ml 244mg
Calcium enriched milk alternative (soya/almond, 200ml) 240mg
1./2 can tinned sardines with bones (42g) 230mg
Cheddar cheese, 30g 220mg
½ can rice pudding (200g) 176mg
Sesame seeds, 2 teaspoons 170mg
Pot of yoghurt, 125g 170mg
Kale, 3 teaspoons 120mg
½ tin baked beans, 120g 105mg
Kidney beans 85mg
Dried figs,30g 75mg
1 orange 70mg
Almonds, 30g 70mg
Gluten free bread, 2 slices 70mg
Broccoli, 3 tablespoons (80mg) 32mg
Dried apricots, 30g 30mg

Calcium on a vegan diet

Those opting for a vegan diet or those with a lactose intolerance may need to consider alternative sources of calcium or calcium fortified products to meet their requirements. Foods such as dried fruit, nuts, seeds, beans and green vegetables are all rich in calcium and fit well into a diverse, plant-based diet.

So, do I need a calcium supplement?

If you can’t get all the calcium you need from your diet and your calcium levels are low, you may need to take a calcium supplement. Some are combined with vitamin D.

The need for supplements will vary person to person but if you feel you may need these, speak to your doctor or dietitian who will provide further advice and prescribe them if necessary.

Takeaway

There are three considerations for those people with Coeliac Disease to help minimise risk of osteoporosis and optimise long term bone health.

  1. A strict gluten free diet.
  2. Aiming for 1000mg of calcium per day.
  3. Taking a vitamin D supplement of 10 micrograms per day, combined with calcium if you are unable to get enough from your diet.

You can seek further advice from a healthcare professional or support networks like Coeliac UK.

This article was authored by our coeliac & oncology specialist dietitian, Sandy Soni. If you need 1:1 advice for managing CD or minimising the risks associated with a restrictive diet, you can find out more information about booking in with Sandy or any member of our specialist team here.

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