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KEY POINTS:

  • Malabsorption of many nutrients, including iron 1, vitamin D and zinc, is common in a person with newly diagnosed or untreated celiac disease.
  • Even though celiac disease typically damages the upper part of the small intestine, the entire small bowel can be affected 2 by celiac disease. Vitamin B12, absorbed in the lower part of the small intestine, is also a common deficiency seen in celiac disease. 3
VITAMIN AND MINERAL DEFICIENCIES IN CELIAC DISEASE:

The chart below will help you discover each vitamin and mineral's role in the body and common signs of deficiency.4-11 This list is not comprehensive.

For a list of where to find these vitamins and minerals in food sources, stay tuned for the Common Nutrient Deficiencies of the Gluten-Free Diet.

NUTRIENT NAME USE BY THE BODY COMMON SYMPTOMS OF DEFICIENCY
CALCIUM Builds and maintains bones and teeth; Aids in blood clotting, nerve function, and muscle contraction; Maintains normal levels of blood pressure and stomach acid; required for several enzymatic reactions in the body; influences neurotransmitters4and protein hormones Brittle and porous bones (osteoporosis), frequent bone fractures, softening of the bones in children leading to deformities, short stature, tooth decay, brittle and misshapen nails, joint swelling and pain, heart palpitations, abnormal heart rate and rhythm 5
FOLATE Works with Vitamin B12 to make red and white blood cells; critical during pregnancy and infancy when new cells are being formed; needed for metabolism of protein and building blocks of DNA 4 Anemia; causing fatigue, difficulty breathing, heart palpitations, forgetfulness, sensitivity to cold, nausea, fatigue, weakness, confusion, depression, swollen red tongue 5
IRON Needed to produce hemoglobin; protects against damage to cell membranes; produces many important neurotransmitters; involved in cellular respiration, immune function, cognitive performance and many other functions 4. Iron deficiency anemia; causing headache, dizziness, irritability, pale skin, cold hands and feet, fatigue, rapid heartbeat, brittle nails, shortness of breath5.
MAGNESIUM Needed for normal muscle (relaxer) and nerve function, to keep heart rhythm steady, to support the immune system; involved in bone health and the functioning of over 300 enzymes in the body, including metabolism4 Tremors, irritability of nerves and muscles causing twitching, tingling, spasm and cramps, fatigue, confusion, irritability, increased blood pressure, softening and weakening of bones, insulin resistance,5constipation,6irregular heartbeat7
VITAMIN A Needed for night vision, growth of skin, bones, and male and female reproductive organs and for maintaining tissue growth, immune function; needed for growth of a healthy fetus in pregnant women4 Poor tooth development, slow bone growth, night blindness, rough dry scaly skin, sinusitis, frequent infections of bladder or urinary tract infections,5dry eyes, eye infections8
VITAMIN B6 Needed to build brain neurotransmitters and for myelin formation, as well as for energy production and digestion Eczema or dermatitis, cracks or sores on lips and mouth, inflammation of mucus membranes and tongue, irritability depression, nerve involvement, numbness of hands and feet, tingling and cramping of legs and hands, migraines, fatigue, and muscle weakness5
VITAMIN B12 Used to produce red blood cells, DNA (the building block of cells), and myelin formation, as well as for energy production and digestion; Pernicious anemia leading to fatigue, weakness, weight loss, pale skin, sore and red tongue and mouth, low blood pressure, loss of appetite, heart palpitations, irritability, depression5
VITAMIN D Helps maintain normal blood levels of calcium and phosphorus; helps with the absorption of calcium to form and maintain strong bones; increases bone mineral density and decreases fractures; helps maintain cell membranes and several organs (skin, muscles, pancreas, nerves, parathyroid gland and immune system4 Rickets: soft bones causing bowing of legs and skeletal deformities, muscle weakness, muscle and bone pain, possible link to decreased insulin production and type 2 diabetes,5dental deformities, reduced bone mineral density9
VITAMIN E An antioxidant; needed to protect cells by scavenging and neutralizing free radicals from the body which may help protect against aging, infection and disease4 Loss of appetite, nausea, anemia, decreased immunity, degeneration of retina, muscle cramping and pain, restless leg, numbness, tingling, and burning sensation in limbs5
VITAMIN K Necessary for normal blood clotting. Some studies suggest that it helps promote strong bones. Easy bruising, delayed clotting, easy bone fracture, low bone mineral density5
ZINC Needed for more than 200 enzymatic reactions in the body including our immune system, sense of taste and smell, brain function (including memory), the synthesis of insulin, growth and development, health of skin, hair and nails, and wound healing Impaired sense of smell and taste, decreased immune function, skin ulcers, slow wound healing, low glucose tolerance, weight loss, hair loss5, poor health of skin (including gums), hair and nails10
COPPER Needed for the normal functioning of enzymes responsible for normal growth and health, bone growth, iron transportation, building neurotransmitters, helping your body use sugar effectively11and scavenging and neutralizing free radicals Anemia, neutropenia, skeletal abnormalities, hair and skin depigmentation (loss of color), defective elastin formation4, neurological abnormalities (such as unsteady gait)

Recommended Daily Allowance (RDA) of Vitamins and Minerals:

  • An RDA is the average daily dietary intake level of a vitamin or mineral which is sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals in a group. 

    It is calculated from an Estimated Average Requirement (EAR). If sufficient scientific evidence is not available to establish an EAR, and thus calculate an RDA, an Adequate Intake (AI) is usually developed. 12

To view the Recommended Daily Allowances (RDA) and Adequate Intakes (AI) for each vitamin and mineral, click on the link below.

Dietary Reference Intakes: RDA and AI for Vitamins and Elements. National Academy of Sciences. Institute of Medicine, Food and Nutrition Board.)

  • Please note that individuals with celiac disease may need more than the RDA or AI for specific nutrients.
  • To learn more about these particular nutrients, please visit Healthy Eating.
HOW CELIAC DISEASE AFFECTS ABSORPTION OF VITAMINS AND MINERALS IN YOUR BODY:

Iron 
Iron deficiency anemia is a very common symptom of celiac disease. People complain of fatigue when they have low iron stores. Women who are menstruating (and lose iron through bleeding) or pregnant women and growing children are the most prone to iron deficiency. 13 The gluten-free diet can restore dietary iron absorption and resolve anemia. 14

Folate 
In the past, folic acid deficiency (folate, otherwise known as B9), was the second most common cause of anemia in celiac disease. Fortunately, more gluten-free foods are now fortified with folate, making deficiency far less common.13 An inadequate folate level is a risk factor for breast, prostate and colon cancer, depression, and spinal cord defects. For this reason, pregnant women or women who wish to become pregnant need a prenatal supplement containing 800mcg/day of folic acid in addition to adequate folate in the diet. 10

Vitamin B12 
Vitamin B12 deficiency is a third and important cause of anemia in untreated celiac disease. Fatigue is a common symptom. Vitamin B12 deficiency can also lead to disorders of the brain, spinal cord, and nerves in the arms and legs. This nerve injury may not reverse completely with vitamin B12 therapy, so early recognition and prevention are especially important. 13 B12 deficiency can resolve on a gluten-free diet alone; however, specific B12 supplementation may be needed for some individuals. 3

Calcium 
Calcium is absorbed in the duodenum and damage to this absorption site is the cause of calcium deficiency in newly diagnosed or untreated celiac disease. Enzymes that digest lactose are also damaged, and this can lead to a condition called secondary lactose intolerance . Secondary lactose intolerance causes gas, bloating, and loose stools whenever dairy products (such as cow's milk, yogurt and cheese) are eaten. 13 Visit the section on Lactose Intolerance to learn more. Because most people's bodies can pull calcium out of their bones if needed, only very ill people with severe damage to their small intestine will have low calcium blood levels.

Vitamin D 
Vitamin D is a fat-soluble vitamin; its absorption from the gut depends on fat absorption. Fat malabsorption in untreated celiac disease can lead to vitamin D deficiency. Vitamin D is important in helping calcium get absorbed from the gut . Vitamin D also regulates the "deposits and withdrawals" of calcium from the calcium bank in the bones. 13

Vitamin D levels in the blood are commonly low in the U.S. population, especially in those living in northern climates where sun exposure is limited thus leading to less vitamin D production by the skin. As a result, thinning of the bones, called osteopenia when it is mild and osteoporosis when it is more severe, is common in newly diagnosed celiac disease. In severe cases, calcium concentrations in the blood may fall, leading to muscle spasms, known as tetany. Over the long term, the body's practice of taking calcium from the bones to support blood calcium concentrations can lead to fractures in the spine and long bones that occur spontaneously or with minimal trauma. 13

Vitamin A, Vitamin E and Vitamin K: 
Like vitamin D, vitamin A, vitamin E and vitamin K are fat-soluble vitamins. How well they are absorbed depends on how well the body absorbs fat in general. These three vitamins are not as poorly absorbed as often as vitamin D is in celiac disease.

Zinc: 
Zinc, a micronutrient , is absorbed in the jejunum and there can be significant deficiencies in patients with active celiac disease. Diminished taste and smell of foods, a metallic taste in the mouth, and slow wound healing are some signs of zinc deficiency. In particular, this can affect patients with severe diarrhea, as zinc is lost in the diarrheal fluid. Studies suggest that zinc levels can rise to normal on a gluten-free diet, without requiring additional zinc supplementation, although in some cases additional supplementation may be important. 15

Magnesium: 
The body needs magnesium for hundreds of enzymatic reactions. Along with vitamin D, it helps the body absorb calcium. Most Americans' diets are deficient in magnesium and a standard multivitamin/mineral supplement only contains a small percentage of the recommended Daily Value (DV) of magnesium (450mg).

B6: 
B6 (pyridoxine hydrochloride), like the other B vitamins, is needed for hundreds of critical biochemical processes in the body, such as energy production, digestion, red blood cell production, and brain function, among others. Common symptoms of deficiencies of B vitamins in general are fatigue, depression, headache, and poor memory.

Copper: 
Copper is a micronutrient which is primarily absorbed in the small intestine. The extent to which copper deficiency appears in the celiac population is unclear. A few studies indicate that there is some association between low copper levels and unexplained anemia, microcytic anemia , normocytic anemia , and neutropenia 13

  • Other vitamin and mineral deficiencies in untreated celiac disease are less common and usually only seen in people with longstanding and untreated celiac disease, severe diarrhea, significant weight loss, and malnutrition. 13
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TAKING TOO MUCH?

  • It is also possible to take too much of a particular vitamin or mineral which can lead to toxic overdose in the body. The most common vitamins and minerals which can be dangerous in high doses include:
    • Iron
    • Fat-soluble vitamins: vitamin A, vitamin E, vitamin K and vitamin D*
    • Calcium
    • B3 (niacin) can be toxic to the liver in high doses.
    • B6 (pyridoxine hydrochloride) elevated levels in the blood can cause or worsen neuropathy (numbness and tingling in the extremities). 10
  • Speak with your doctor or dietitian before starting any supplements to ensure that you are taking the correct amount and for an appropriate length of time.
  • To learn more about vitamins and minerals, stay tuned for the Supplements section.

     

    *Please note that Vitamin D deficiency is very common in celiac disease. High, therapeutic doses are often given to people to restore their vitamin D levels to normal. Do not worry about overdosing on vitamin D if you have been prescribed high doses of vitamin D and are being monitored by your doctor.

TAKE HOME MESSAGES:

  • Celiac disease can affect the absorption of vitamins and minerals along the entire small intestine.
  • Talk to your doctor if you have any of the symptoms above or you are concerned that you have nutritional deficiencies. Testing is simple. Be sure to follow up with your doctor to review lab results.
  • Individuals with celiac disease may need more than the Recommended Daily Allowance or Adequate Intake for specific nutrients.
  • It is very common for doctors to treat certain nutritional deficiencies with high doses of vitamins and minerals. When this is done, labs are monitored carefully to prevent toxic overload.

References:

  1. Saturni L. The gluten-free diet: safety and nutritional quality. Nutrients, 2010;2:16-34.
  2. Singh H, Case S, Duerksen DR. An update on celiac disease and the gluten-free diet. Clinical Nutrition Rounds. Canadian Society for Clinical Nutrition. October 2003;3(8).
  3. Dahele A, et al. Vitamin B12 deficiency in untreated celiac disease. American Journal of Gastroenterology, 2001,96(3):745-750.
  4. Mahan LK, Escott-Stump S. (2000). Krause's Food, Nutrition and Diet Therapy. WB Saunders Company, Philadelphia, PA.
  5. Edlestein, E. Sharlin, J. (2009).Life Cycle Nutrition; an evidence based approach. Jones & Barlett, Sudbury, MA
  6. Lipski E. Digestive Wellness, Updated Second Edition. Keats Publishing. Los Angeles, 2000.
  7. Magnesium Supplement. Mayo Clinic. https://www.mayoclinic.org/drugs-supplements/magnesium-supplement-oral-route-parenteral-route/description/drg-20070730. Accessed September 6, 2011.
  8. Vitamin A. Mayo Clinic. http://www.mayoclinic.com/health/drug- information/DR601623. Accessed September 6, 2011.
  9. Vitamin D. Mayo Clinic. http://www.mayoclinic.com/health/vitamin-d/NS_patient-vitamind. Accessed September 7, 2011.
  10. Dennis M, Doherty C. Supplements 101. In Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free . Eds. Dennis M, Leffler D. AGA Press. Bethesda, MD, 2010.
  11. Copper. Mayo Clinic. http://www.mayoclinic.com/health/drug-information/DR602273 . Accessed January 26, 2012.
  12. Dietary Reference Intakes: RDA and AI for Vitamins and Elements. National Academy of Sciences. Institute of Medicine, Food and Nutrition Board.) http://iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity Files/Nutrition/DRIs/RDA and AIs_Vitamin and Elements.pdf. Accessed January 19, 2012.
  13. Kelly, C. Common and Uncommon Presentations of Celiac Disease. In Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free . Eds. Dennis M, Leffler D. AGA Press. Bethesda, MD, 2010.
  14. Annibale B, et al. Efficacy of gluten-free diet alone on recovery from iron deficiency anemia in adult celiac patients. Am J of Gastro, 2001, vol 96, no 1:132-137.
  15. Rawal P, Thapa BR, Prasad R et al. Zinc supplementation to patients with celiac disease - is it required? J Trop Pediatr. 2010;56(6):391-7.

Revision Date: 8-21-12 
Author: Melinda Dennis, MS, RD, LDN 
Editors: Anne Lee, MSEd, RD, LD and Rupa Mukherjee, MD

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