# Calcium carbonate from the Winter 2000 issue of IFFGD's Participate Newsletter



## Jeffrey Roberts (Apr 15, 1987)

I would like to thank the International Foundation for Functional Gastrointestinal Disorders (IFFGD) for the permission to post this article.For further information please refer to IFFGD's IBS site: http://www.aboutibs.org.


> quote:From the Winter 2000 issue of ParticipateReaders' ExchangeWe have received a number of inquiries from readers asking us about the use of calcium carbonate for diarrhea. Does it cause constipation? Can it be used for the treatment of diarrhea or even for IBS? We thank W. Grant Thompson, M.D., a frequent contributor to Participate, for helping us find the following answers.Calcium carbonate is better known as chalk. It has been used for generations as an antacid for "stomach upsets" that we would now call heartburn, or dyspepsia due to peptic ulcers. It was effective because of its acid neutralizing properties. More recently, the powerful acid inhibiting drugs such as the H2 antagonists and the proton pump inhibitors have made antacids less necessary. Nowadays calcium carbonate is also used as a calcium supplement. Calcium is an important constituent of bones, and may be prescribed to older people orally, sometimes with other agents to treat or prevent bone disease such as osteoporosis. Healthy young people usually get enough calcium in their diet, especially if they drink milk. Surprisingly in light of the common belief that calcium carbonate may have constipation as a side effect, the belief is not substantiated by scientific evidence. Various reports on this question are contradictory. Calcium is not usually promoted as an antidiarrheal agent. It is not recognized as a treatment for IBS.Questions from some inquiring readers arise from information found on the Internet. When considering the usefulness of such information, some guidelines are in order. For example, is the information grounded in some scientific credibility, is the information applicable to your diagnosis and to your unique health circumstances. Consider the normal presentation, or life-cycle, of your disorder. For example, with irritable bowel syndrome (IBS) symptoms tend to wax and wane. For most sufferers, symptoms alternate between constipation and diarrhea. Furthermore each year, in about 10% of those with IBS, symptoms resolve completely on their own. Credible studies are controlled and designed to take multiple factors into account in an attempt to avoid misleading conclusions. For anyone who might consider using calcium as a treatment for diarrhea, especially in the form of calcium carbonate, there are issues that need to be clarified before calcium is tried on a long-term basis. First, be certain there is no correctable cause of the diarrhea; an accurate diagnosis is therefore important. Second, it is worthwhile to consider the usefulness of calcium as an aid to health. Finally, like most things in life, be aware of any downsides, and use it carefully.Diagnosis -- Diarrhea has a great many causes. Acute diarrhea is most often infectious, and passes with time or treatment. Diarrhea can also occur chronically. There are few infectious causes of chronic diarrhea in otherwise healthy people, but in some areas of North America such as the Rocky Mountains, the Appalachians, or Northern Ontario giarrdia (a parasite) are common. Diarrhea caused by a parasite would not likely respond well to calcium. Diarrhea associated with inflammatory bowel disease (Crohn's disease or ulcerative colitis) would present other manifestations and likely be recognized. Many people unwittingly take things in their diet that may cause diarrhea. One of the most common is caffeine, which is not only present in coffee, but also in tea and cola drinks. Excessive alcohol also can cause diarrhea. Some sugars used as sweeteners are not absorbed in the small intestine and act as osmotic laxatives. These include sorbitol, mannitol, and fructose, which are used to sweeten gums, candies, soft drinks, and many other "sugar-free," or low-calorie items. Avoiding these for a week or so should help one decide if they are causing diarrhea. Laxatives are frequently present in herbal remedies (e.g., senna tea). Herbs with a laxative effect like senna, cascara, or aloe vera can be found in many popular remedies. It is not uncommon to have no idea of what an herbal package includes. Only by stopping the herbal remedy for a trial period can one be confident that it is not the cause of the chronic diarrhea.The list of medications that cause diarrhea is extensive and includes certain antibiotics, magnesium containing antacids, blood pressure lowering agents, and drugs to control irregular heart beat. All medications, whether prescription or "over the counter," should be brought to the attention of your physician.One reader using calcium assumed their diarrhea was associated with irritable bowel syndrome (IBS). IBS typically swings from constipation to diarrhea, and back again at irregular intervals. The reader mentioned that if they take too much calcium, they become constipated, and then reduce the dose. The individual did not mention constipation without the calcium, and apparently does not have pain, so IBS seems unlikely. Nevertheless, calcium would seem unsuitable for most people with IBS because constipation is often part of the disorder. Irritable bowel syndrome is currently understood as a dysregulation of brain-gut function that alters normal intestinal transit. This in turn can lead to pain and multiple other symptoms that include constipation and/or diarrhea. There are no studies of the use of calcium for diarrhea associated with IBS. The drug loperamide (Imodium) has been shown to improve diarrhea in some people with IBS whose primary symptom is diarrhea. Another reader dates their diarrhea to removal of their gall bladder. In this case, because there is now no gall bladder to store the bile for the next meal, the bile trickles into the intestine throughout the day. This is thought to cause diarrhea in some people who have their gall bladders removed. In addition, removal of the lower small intestine may cause diarrhea. Usually in such cases, the diarrhea improves if the person takes small doses of a bile salt binding drug such as cholestyramine (Questran) or colestipol (Colestid). For the treatment of idiopathic, or functional diarrhea drugs such as loperamide (Imodium) or diphenoxylate (Lomotil) have been used. Occasionally a bulking agent such as bran or psyllium helps patients. However, if a reader feels that calcium carbonate works best for them and decides to continue to use it, then it is important to keep in mind that there may be limitations, risks, and even adverse effects as described below.Downsides -- Adverse effects from calcium are generally minimal if used infrequently in low doses. However, there are risks associated with higher dosages and prolonged use. As is true in so many cases, we can sometimes get too much of a good thing. Prolonged ingestion of calcium carbonate along with milk and vitamin D can lead to milk-alkali syndrome, a very serious disorder. There are illnesses where the concentration of calcium in the blood or urine is too high. The former is called hypercalcemia and can be life threatening. Several uncommon diseases cause this condition, and calcium carbonate would make matters worse. Also the body's ability to get rid of excess calcium is impaired in severe kidney disease, and in some cases too much calcium in the urine may cause kidney stones. Calcium should not be used in excessive doses, especially with vitamin D. There may be a risk if calcium is taken with the heart drug digitalis, or if using thiazide diuretics. Calcium may interfere with the absorption of certain medications such as the antibiotic, tetracycline. It interacts with minerals such as iron, zinc, magnesium, and phosphorus and creates a potential for risk of mineral depletion in vulnerable people. Because of these considerations, if you plan to use calcium for diarrhea, it is wise to discuss it with your doctor.Final note -- It is a good idea to think of any substance you take for a therapeutic affect as a medication. Tell your doctor about it. This applies whether taking a prescription or over the counter drug, herb, or supplement. Remember, even "natural" supplements and herbs can interact with other substances, or have unexpected and undesirable side effects. We recommend consultation with a qualified health care professional familiar with your particular circumstances for any treatment of a chronic condition. How much calcium?Risks from taking calcium supplements, or antacids, may be minimized if used periodically in small amounts. However, because of the potential for adverse effects or drug interactions, it is advisable to limit intake of calcium carbonate supplements to about 1,200 mg/day. (Maton and Burton, 1999)A 1994 NIH consensus conference on Optimal Calcium Intake concluded, "Practices that might encourage total calcium intake to approach or exceed 2,000 mg/day seem more likely to produce adverse affects and should be monitored closely."A 1998 report from the National Academy of Sciences on Establishing Upper Intake Levels for Nutrients stated, "Like all chemical agents, nutrients (e.g., calcium) can produce adverse health effects if intakes from any combination of food, water, nutrient supplements, and pharmacologic agents is excessive. It is not possible to identify a single "risk-free" intake level for a nutrient that can be applied with certainty to all members of a population."


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