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HIBD Horizon

Part 3 · Living well with IBD · 12/22

Fatigue is not inevitable

With IBD, you are often short of vitamins and minerals. The good news: they can be measured, and corrected.

Have you been told “it's normal to be tired with IBD”?Not necessarily. Part of the fatigue comes from deficiencies that can be corrected. And “within the normal range” does not mean “at its best”: a result at the bottom of the range can be enough to wear you out. Ask for the blood test, and aim high.

Ferritin

units: µg/L (= ng/mL)

Your iron stores. Too low: fatigue, breathlessness, hair loss.

deficient< 30 µg/L
low30 to 70 µg/L
target70 to 150 µg/L

At risk : Bleeding, flares, heavy periods.

Supplement tipIron bisglycinate + vitamin C, every other day, away from tea, coffee and dairy (black stools: that's normal). Recheck at 3 months. During a flare, with marked anaemia or if you tolerate it badly: iron by infusion is often better.

During a flare, inflammation pushes ferritin up: it can look fine even though you are short of iron. During a flare, a ferritin below 100 µg/L can already hide a deficiency: transferrin saturation is checked too (above 20%).

Vitamin D

units: ng/mL or nmol/L

Bones, muscles, immune defences. Very often low with IBD.

deficient< 20 ng/mL< 50 nmol/L
low20 to 50 ng/mL50 to 125 nmol/L
target50 to 80 ng/mL125 to 200 nmol/L
too high> 100 ng/mL> 250 nmol/L

At risk : Everyone in winter, steroids, Crohn's of the ileum.

Supplement tipD3 + K2 (MK-7) drops: 2,000 IU a day (or 50,000 IU a month), with a meal containing some fat. A higher dose only on medical advice, with a follow-up blood test.

A high target suited to autoimmune diseases, with a blood test every 3 to 6 months. Kidney stones: also have your urine calcium measured. 1 ng/mL = 2.5 nmol/L.

Vitamin B12

units: pg/mL or pmol/L

Energy, nerves, memory, mood.

deficient< 200 pg/mL< 150 pmol/L
low200 to 450 pg/mL150 to 330 pmol/L
target> 450 pg/mL> 330 pmol/L

At risk : Crohn's of the ileum, ileum operated on.

Supplement tipMethylcobalamin (under the tongue or swallowed): 1,000 µg a day is often absorbed even with a diseased ileum. After major surgery on the ileum or if you have pins and needles: injections, with your doctor.

Many practitioners aim for 600 to 1,000 pg/mL. A deficiency is not trivial: anaemia, pins and needles, memory problems, and nerve damage that can become permanent. Tired with an “acceptable” B12? Ask for homocysteine and MMA.

Vitamin B9

units: ng/mL or nmol/L

Folates: they make red blood cells and help the gut lining repair itself.

deficient< 4 ng/mL< 9 nmol/L
low4 to 8 ng/mL9 to 18 nmol/L
target> 8 ng/mL> 18 nmol/L

At risk : Methotrexate, Salazopyrin, few green vegetables.

Supplement tipActive folates (5-MTHF, such as Quatrefolic) rather than folic acid, always together with B12.

On methotrexate, folic acid is prescribed at a set dose on a set day: do not replace it without medical advice. For a pregnancy, follow your folic acid prescription.

Zinc

units: µg/dL or µmol/L

Healing, taste, skin, immune defences.

deficient< 70 µg/dL< 10.7 µmol/L
low70 to 90 µg/dL10.7 to 13.8 µmol/L
target90 to 120 µg/dL13.8 to 18.4 µmol/L
too hightoo many supplements

At risk : Long-lasting diarrhoea, fistulas, Crohn's of the small intestine.

Supplement tipZinc bisglycinate or picolinate, 15 to 25 mg a day with a meal, for 2 to 3 months, then a recheck. On the days without iron: they get in each other's way.

Blood test in the morning on an empty stomach (during a flare, zinc drops without a true deficiency). Long term, no more than 25 mg a day in total (European limit): too much zinc makes copper drop.

On your plate: the most nutritious foods

Liver and offalB12, B9, iron, zinc
Oysters, musselszinc, B12, iron
Red meatwell-absorbed iron, zinc, B12
Sardines, mackerel, salmonvitamin D, omega-3
EggsB12, vitamin D
Cooked green vegetablesB9
Puréed lentils, chickpeasB9, iron, zinc
Yoghurt, cheesecalcium, B12

Iron from plants is absorbed better with vitamin C (kiwi, citrus fruit). If you have a stricture: vegetables well cooked or blended, without skins or seeds.

!
Supplements don't replace your plate

They correct a shortfall, but nothing beats a rich and varied diet. The trap is “empty” foods: lots of calories, almost no vitamins or minerals.

Fizzy drinks and shop-bought juicesShop-bought biscuits and cakesCrisps and party snacksSugary breakfast cerealsWhite bread and pastriesUltra-processed ready mealsSweets and chocolate barsAlcohol

+Going further and optimising

Mg
Magnesium

Often low with IBD (diarrhoea, small intestine affected or operated on). It affects energy, muscles, sleep and stress.

How : once a day, as bisglycinate or glycerophosphate (better tolerated). Avoid oxide and citrate if you have diarrhoea: they can make it worse.

Coenzyme Q10

The cells' “fuel”. With IBD, the gut's antioxidant defences are often lowered. The UC trial that reported an effect (200 mg a day for 8 weeks) was retracted by the journal in 2022: there is no reliable evidence to date.

How : No dose to recommend: no reliable evidence in IBD.

How often
Once a yearat the very least, a full set of blood tests.
3 monthsafter starting any supplement, a recheck.
All year roundvitamin D: in France, from late October to March, the skin makes almost none. Without a supplement, your level is bound to fall. Take it continuously, adjusting according to your blood tests.
CautionThese targets come from functional medicine (practitioners' benchmarks), not from official reference ranges. Talk to your doctor or pharmacist before taking any supplement. No vitamin K2 or coenzyme Q10 if you are on a vitamin K antagonist anticoagulant (Previscan, Coumadine). Magnesium: be careful if you have kidney failure. On methotrexate, do not change the folic acid you have been prescribed. Too much vitamin D or zinc is dangerous.