SUPPLEMENTS AND THE GLUTEN-FREE DIET
Before reading this level, try this quiz.
MVM = multivitamin/mineral supplement (in this document)
After a diagnosis of celiac disease, it is important to pay attention to your vitamin and mineral levels, because it can be difficult to restore vitamin, mineral and essential fatty acid levels with the gluten-free diet alone. In addition, vitamin deficiencies may occur even if you have been carefully following the gluten-free diet for several years. 1 Click here to view the most important blood tests if you have celiac disease.
A gluten-free multivitamin/mineral supplement (MVM) that is chosen based on your gender, age, diet history, and blood tests is a standard recommendation for those with celiac disease.2
Read Level 3 to read about the fat-soluble vitamins A, E and K which are more commonly seen in people with more severe malabsorption. Vitamin D, which was covered in the first section, is also a fat-soluble vitamin and is commonly low in people with celiac disease.
TIPS FOR CHOOSING SUPPLEMENTS:
Most MVMs are best absorbed and tolerated when taken with meals.
Fiber, coffee, and tea lower absorption of some vitamins and minerals. Fiber binds with minerals and can excrete them from the body before you can absorb them. The Tannin in coffee and tea can block absorption of minerals.
Chewable vitamins should be checked carefully to make sure they contain 100% Daily Value of B vitamins as well as fat soluble vitamins A, D, E and K. Chewable vitamins may not contain iron because iron can affect taste. Chewables may have added sugar. Liquid vitamins are available and may contain less sugar and may be better absorbed.
Remember, cheaper is rarely better! You often get what you pay for, and cheap forms of vitamins and minerals are often less absorbable and cause more symptoms than the higher quality versions that can cost more.
It is best to choose labeled gluten-free supplements that have been tested for gluten contamination. This may not always be possible. 3
Some supplements are labeled “gluten-free.” Others have “no gluten” printed on the label. “All non-prescription multivitamin and mineral supplements taken by mouth are covered under the Food and Drug Administration’s Food Allergen Labeling and Consumer Protection Act (FALCPA). If an ingredient in a supplement contains protein from wheat, the word “wheat” will be included on the label. It will be listed in the ingredients list or “Contains” statement. Barley and rye are not covered under FALCPA. Protein from rye will not be included in a supplement. Protein from barley (e.g. malt) might be included. “ 3
IMPORTANT THINGS TO KNOW ABOUT VITAMINS & MINERALS:
How much calcium do I need each day?
IMPORTANT POINT: Calcium recommendations include DIET AND SUPPLEMENTS COMBINED. It is important to factor in the calcium you are getting on average each day and then take the appropriate amount of calcium supplement, if needed, to make up the difference. Avoid taking excess calcium.
My age is...
||SO, I NEED (MG) CALCIUM…
||IF PREGNANT OR LACTATING
- With celiac disease, you may need more. Ask your doctor.
Reference: Recommended Dietary Allowances for Calcium. Office of Dietary Supplements. National Institute of Health. http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional. Accessed April 16, 2013.
- The body can only absorb 500-600 mg of calcium at a time, so split your doses.
- Calcium can have a natural sedative effect on the body so you may benefit from taking your calcium supplements later in the day and in the evening. If you suffer from mild anxiety, taking it during the day can have a calming effect.
- Calcium decreases the absorption of iron and zinc, as well as thyroid medication and some antibiotics. Take them at least 2 hours apart. See Level 3 for more details.
- Try to choose a calcium that contains magnesium for absorption; this may help prevent constipation, as well. If you have significant issues with loose stool, however, you may want to choose a calcium supplement that does not contain magnesium since magnesium is a natural laxative.
- There are several calcium formulas on the market.
||Take with meals. If you have gas or constipation, increase fluids and activity or switch formulas. In many formulas.
||Well absorbed. Typically, no gas or constipation. Difficult to find.
||Most easily absorbed. No gas or constipation. Safest for individuals prone to kidney stones. Easy to find.
- People who take calcium supplements commonly experience constipation or dark stools. If you experience these or any other side effects, talk to your doctor.
- Before starting a calcium supplement, talk to you doctor if you take prescription medication or take antacids containing aluminum.
- If after taking calcium, you experience kidney disease, constipation, colitis, diarrhea, nausea, vomiting, stomach or intestinal bleeding, slow or irregular heartbeat, heart problems, poor digestion, headaches or confusion, talk to your doctor.
- Do not take > 2500 mg/ day of calcium from diet and/or supplements combined unless supervised by your doctor.
- Do not take calcium supplements that contain bone meal, dolomite, or oyster shell. These may contain toxic substances.
- Do not take calcium if you have a high blood calcium level, or sarcoidosis.
- Read the chart on Level 3 to see when to take a calcium supplement in relation to other supplements and some other medications.
- Getting enough vitamin D has many health benefits. Vitamin D helps the body absorb calcium, influences many hormones, may help prevent infection, and helps reduces inflammation. New research shows that it also may provide protection from high blood pressure and cancer.
- Foods that contain vitamin D are limited. You can get vitamin D from sun exposure, but not in the winter months (Oct-April) if you live in colder climates. Suntan lotion blocks out the rays required to get Vitamin D from the sun. Supplementation is the best way to ensure you get enough vitamin D.
- A standard vitamin D supplement recommendations is 800-1000 IU/day. However, everyone is different. Ask your doctor to check your blood levels (25 OHD) of vitamin D and to tell you how much vitamin D to take. You are aiming for blood levels of >35ng/mL.
- Choose vitamin D3 instead of vitamin D2 when you are purchasing over-the-counter vitamin D. Vitamin D is measured in international units (IU).
- If your serum vitamin D level (25 OHD) is too low, your doctor may give you therapeutic dosing (50,000 IU/ week for 6-8 weeks or longer) of vitamin D. After finishing your therapeutic dose, your doctor will recheck your vitamin D level. You will need to take a lower maintenance dose to stay in the healthy range. If you stop taking vitamin D after the doctor prescribed dose, your blood level may drop too low again putting your bones at risk. Ask your doctor or dietitian to tell you how much vitamin D to take going forward.
Pantothenic acid (B5)
Pyridoxine hydrochloride (B6)
- Research indicates that people with celiac disease need higher amounts of folate and vitamin B12. 4,5,6,7 They are important for energy, mood, mental clarity, and preventing anemia. Ask your doctor or dietitian to check your vitamin B blood levels. If you have deficiencies, they may recommend an appropriate B complex. Most MVM contain sufficient B vitamins.
- Folate is found in whole grains and dark leafy greens. Folic acid is the name for folate in supplement form.
- Vitamin B12 is found mainly in animal products (such as meat, fish, poultry, eggs, and dairy products), so vegetarians and vegans are at risk for deficiency. Other sources include fortified gluten-free cereals.
- Choose vitamins that offer at least 100% of the daily value (DV) of each B vitamin, unless directed otherwise. Most supplements come in the form of a mixture of B vitamins.
- Supplementation of B vitamins may cause nausea on an empty stomach, so take them with food.
- Since a vitamin B complex can improve your mood and energy, it’s best to take this supplement in the morning to benefit from its effects all day long. Do not take a B complex before making sure you need one.
- Magnesium is needed for over 300 enzymatic reactions in the body including muscle relaxation, protein and fat synthesis, energy production, building healthy bone and calcium absorption.
- Magnesium intake is low in the diets of most Americans and MVMs usually contain less than the recommended daily value (450 mg). Foods high in magnesium include whole grains, nuts, legumes, seafood, and leafy green vegetables. When choosing a supplement with magnesium, choose magnesium citrate or glycinate over magnesium oxide, when possible. See Level 3 for more details on formulations.
- Magnesium has a laxative effect, which can be helpful for constipation. Magnesium can also help with the constipating effects of taking a calcium supplement, so choose one that also contains magnesium.
- Magnesium helps the body to absorb calcium. It is best to take calcium and magnesium in a ratio of 2:1 (Example: 500 mg calcium:250 mg magnesium).
- Take magnesium with food to prevent loose stools.
- Check with your doctor before taking magnesium if you have a history of heart or kidney problems.
- Iron is responsible for the production of red blood cells and for carrying oxygen to the cells.
- What’s the difference between men’s and women’s multivitamins? A big difference is iron! View the chart.
HOW MUCH IRON DO YOU USUALLY SEE IN A MULTIVITAMIN/MINERAL SUPPLEMENT?
|Males over 18 years
|Females 19-50 years
- Animal protein, such as red meat and dark poultry, contain heme iron which is easily absorbed. Most supplements and plant-based sources contain non-heme iron, which is not as well absorbed. There are some heme based supplements.
- Iron in food is best absorbed with a vitamin C source such as citrus, peppers, and strawberries. Iron supplements are often taken with vitamin C.
- Most iron supplements are in the form of ferrous sulfate.
- For best results, wait 4 hours between taking iron and drinking coffee or tea.
- To avoid upset stomach, take an iron supplement with food.
- Separate iron and thyroid medication by 4 hours. Separate iron and calcium by 4 hours. Calcium can decrease iron absorption.
- People who take iron supplements commonly experience constipation or dark stools. If you experience these or any other side effects, talk to your doctor.
- Iron supplementation for those with celiac disease is recommended based on age, gender, diet, and blood tests. Talk to your doctor about supplementation. Your doctor should monitor your iron levels. Research shows that iron deficiency anemia will resolve in 95% of people with celiac disease after 1 year on a gluten free diet. Therapeutic supplementation (higher doses) can be discontinued after iron levels are restored. Menstruating women and vegetarians are at the highest risk of on-going iron deficiency.
- Talk to your doctor before taking iron supplements if you have or develop peptic ulcer disease, enteritis, colitis, pancreatitis, hepatitis, kidney disease, intestinal disease, alcoholism, hemochromatosis, beta thalassemia, excessive vitamin C, or if you plan to become pregnant or are breastfeeding, or if you are over 55 years old and have a family history of heart disease.
- Store your iron supplements safely, as they are a leading cause of fatal poisoning in children. This is why iron supplements come with a safety cap.
- Zinc is a trace mineral. Trace minerals are required for normal body functions, but in smaller amounts than essential minerals. Like any mineral, the amount needed varies based on age and gender, ranging from 3-13 mg/ day.
- Zinc plays a role in numerous cell functions including protein synthesis, growth and development, immune function, and wound healing.
- Zinc is found in meats, dairy products, cooked dried beans, lentils, soy products, nuts and seeds.
- Malabsorption and chronic diarrhea can cause low zinc and may require supplementation. 9 If you are having these problems or problems with your hair, appetite, skin, and/or nails, ask your doctor to check your zinc level.
- To increase absorption, take supplement 1 or 2 hours after meals. If you experience gastrointestinal discomfort, take with low fiber foods. High dose zinc supplements can cause nausea and constipation.
- Click here to read more about these nutrients.
ESSENTIAL FATTY ACIDS 8
- Celiac disease, like many chronic health conditions, has a strong inflammatory component. It is important to focus on nutrients that decrease inflammation and protect tissues. There is no data from properly controlled studies specific to omega-3 fatty acids and celiac disease. However, studies on other diseases, such as heart disease, show that these fatty acids help control inflammation.
- Eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA) are the names of the beneficial omega-3 essential fatty acids.
- Would you like to get your omega-3 fatty acids from food? Click here to see charts on types of fish and plant foods that are high in them. If you do not regularly eat fish or other foods high in essential fatty acids, consider taking a fish oil or other omega-3 supplement.
HOW TO READ A FISH OIL SUPPLEMENT LABEL
- Look for the words “fish oil concentrate” and then a number in milligrams (for example: 1000mg)
- Underneath it you will see the amounts of EPA and DHA in milligrams (for example: EPA 300mg; DHA 250mg).
- Add up the EPA and DHA amounts.
- The difference between the total amount of fish oil concentrate (1000mg) and the combined amount of EPA and DHA (550mg) is the fish oil that contains no EPA or DHA.
- Choose a supplement that has the highest amount of EPA and DHA so that you get as much omega-3 rich fatty acids as possible.
- Ask your doctor the appropriate amount for your health.
- Always speak to your doctor or dietitian before starting a fish oil supplement as there are several contraindications:
- Fish oil supplements have blood thinning properties; they are generally discontinued before surgery.
- If you are on blood thinners like Coumadin or Warfarin, make sure to monitor your INR closely as you may have to adjust the dose of the medications as you slowly increase the dose of the fish oil. Make sure your doctors know you are starting fish oil supplements. Fish oil supplements do not contain vitamin K.
- If you have ongoing diarrhea, these concentrated fats may cause gas and bloating and worsen diarrhea.
- If you have an allergy to fish, you can try plant-based fatty acids.
- Visit Level 3 for more tips on choosing a high quality fish oil supplement and recommendations for vegetarians.
www.glutenfreedrugs.com (listing of supplements and medications maintained by Pharmacist Steve Plogsted PharmD, BCNSP)
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
Plogsted S, Edmonds J. Gluten in Medications and Supplements. In Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free . Eds. Dennis M, Leffler D. AGA Press. Bethesda, MD.2010.
Centers for Disease Control and Prevention. Nutrition for Everyone: Vitamins and Minerals. Accessed April 16, 2013.
TAKE HOME MESSAGES:
- When choosing a supplement make sure it contains all of the vitamins and minerals in the appropriate amounts that you have been advised to take. 3
- It is best to choose labeled gluten-free supplements that have been tested for gluten contamination. Contact the manufacturer if you have any questions about the gluten-free status of a supplement. Ask if there is any barley protein in the supplement. Remember: wheat will be included on the label. 3
- Read all about your supplements before taking them. You can often easily reduce or eliminate common side effects by paying attention to what you are taking, how much, with what and when.
- Hallert C, Grant C, Grehn S, et al. Evidence of poor vitamin status in celiac patients on a gluten-free diet for 10 years. Aliment Pharmacol Ther 2002;16:1333-39.
- ADA Evidence Analysis Library. Executive Summary of Recommendations.http://www.adaevidencelibrary.com/topic.cfm?cat=3726
- Dennis M, Kupper C, Lee AR, Sharrett MK, Thompson T. Celiac Disease Toolkit. American Dietetic Association, 2011.
- Thompson T, Dennis M, Higgins LA, Lee AR, Sharrett MK, Gluten-free diet survey: are Americans with coeliac disease consuming recommended amounts of fibre, iron, calcium and grain foods? J Hum Nutr Dietet 2005;18:163-69.
- Lee A. Celiac disease: detection and treatment. Top Clin Nutr 2005;20(2):139-45.
- Thompson T. Thiamin, riboflavin, and niacin content of the gluten-free diet: is there cause for concern? J Am Diet Assoc 1999;99:858-62.
- Thompson T. Folate, iron and dietary fiber contents of the gluten-free diet. J Am Diet Assoc 2000;100:1389-96.
- 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.
- 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.
Revision Date: 5-8-13
Authors: Melinda Dennis, MS, RD, LDN, Lindsey O’Regan and Lauren Alder Dear
Editors: Christine Doherty ND, Suzanne Simpson RD, Rupa Mukherjee, MD