According to StatPearls, almost 65 percent of people with chronic pancreatitis — the main cause of EPI in adults, according to Cleveland Clinic — have either osteoporosis or osteopenia (bone thinning). “It’s quite well-established that patients with chronic pancreatitis have low bone mass,” says Awais Ahmed, MD, a pancreatologist (a specialist in pancreatic disorders) at Beth Israel Deaconess Medical Center in Boston. Having EPI puts you at a greater risk for low bone mass and the conditions that result from it, like osteopenia and osteoporosis, mainly because of the absorption issues caused by EPI. The condition arises when you lack enough quality digestive enzymes, which makes it difficult to digest fat, protein, and carbohydrates. This then affects your absorption of fat-soluble vitamins A, E, D, and K and other nutrients. Vitamin D, especially, is important for bone health because it helps your body absorb calcium. “If your vitamin D is low, your body can’t extract adequate amounts of calcium from the food that you’re eating,” explains Dr. Ahmed. As a result, if you don’t get enough calcium, your body will leach it from your bones, according to the Harvard T.H. Chan School of Public Health. This process can lead to osteopenia and osteoporosis. Ultimately, this leaching of calcium creates an “imbalance between the body’s ability to create and absorb bone, which causes bone thinning,” says Ahmed. The good news is that once you know you have EPI, you can be empowered to take care of your bone health, says Ahmed. Here are six things you can do.
1. Ask about necessary testing.
Once you know you have EPI, your doctor should test your vitamin D and calcium levels and check for osteopenia and osteoporosis. People who have EPI may need bone testing sooner than guidelines may recommend. “In our pancreas center, we send an alert to a patient’s primary care physician or endocrinologist that they need to set up regular DXA scans,” says Ahmed. DXA (also called DEXA) is an imaging test that measures a person’s bone density (i.e., bone strength), according to Cleveland Clinic.
2. Use PERT as directed.
If you have EPI, you’ll need to take an oral medication called pancreatic enzyme replacement therapy (PERT). Available via a prescription, PERT are replacement digestive enzymes that are taken orally with meals and snacks to help you digest the protein, fat, and carbohydrates from your food. Once you can digest fat, you’ll be better able to absorb the vitamins that protect your bones.
3. Don’t avoid fat.
Because people with EPI have trouble digesting fat, they often tend to avoid it in food, says Ahmed. But because fat is so important for brain and bone health, doctors recommend eating normal amounts of healthy fats, he says. Consuming frequent and smaller meals may help with comfort and absorption of nutrients, but what’s really key is seeing a nutritionist who is knowledgeable in EPI to help you develop a diet plan that maximizes your nutritional needs. Ask your doctor for a referral.
4. Supplement with vitamin D and calcium.
Ask your doctor about taking vitamin D and calcium supplements, and get advice about the dosage they recommend for you. Ahmed advises taking this supplement either with food or at night. Since vitamin D is a fat-soluble vitamin, your body needs fat to absorb it; alternatively, you can also take vitamin D at night when food is moving through your gut slower than other times during the day, which will provide the fat you need for absorption, he explains.
5. Avoid smoking and alcohol use.
Cigarette smoking is a well-known risk factor for developing fractures and osteoporosis, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). In addition, consuming just one to two drinks per day has been shown to increase the risk of osteoporosis by 34 percent, as it may interfere with calcium in the body and impact hormones, according to a systematic review and meta-analysis in Drug and Alcohol Dependence in April 2019. Both smoking and alcohol use are problematic for anyone, but they can be particularly problematic for people with EPI, says Ahmed. Chronic alcohol use causes 40 to 70 percent of chronic pancreatitis diagnoses, notes StatPearls. In addition, tobacco exposure has been found to be associated with a four times greater risk of EPI compared with controls, according to research, as smoking has toxic effects on the pancreas. Talk to your doctor about resources to help you stop smoking and drinking alcohol.
6. Move more.
Whether or not you have EPI, exercise is important for building bone mass. Weight-bearing exercise (such as walking, hiking, running, and dancing) as well as resistance exercise can help prevent bone loss, according to NIAMS. In addition, for those who have existing osteopenia or osteoporosis, exercise has been shown to improve bone density of a few areas of the body (including the lumbar spine) compared to remaining sedentary, concluded a November 2021 review and meta-analysis in the Journal of Clinical Nursing. Now’s a great time for a walk!
