Level 3

KEY POINTS:

MVM = multivitamin/mineral supplement (in this document)

• Fat-soluble Vitamins: A, E, D and K are commonly deficient in people with the more severe malabsorption sometimes seen in celiac disease. ^1,2

VITAMIN A ³

Symptoms of deficiency: poor night vision, frequent infections, small bumps on the skin (usually back of the arm)

Most multivitamin/mineral supplements (MVMs) contain vitamin A.

• There are two forms of Vitamin A:
  Beta-carotene (water soluble) and Retinoids (fat soluble; examples retinol, retinal, retinoic acid)

Supplements often contain a mixture of both forms. Beta carotene must be converted in the liver into the fat soluble form of vitamin A, a process which can happen inefficiently. Therefore, if you are diagnosed with vitamin A deficiency, choose a supplement with the active, retinoid form of vitamin A to restore levels and improve symptoms. If you do NOT have vitamin A deficiency or for general health purposes, use the beta carotene form or a mixed formula in a MVM (recommended amount 3,000-5,000IU/day). If you have any of the symptoms listed above, talk to your doctor about taking the active form of vitamin A. ³

Vitamin A can be toxic to your liver and cause birth defects so don’t take more than 5,000IU daily without discussing it with your doctor. Vitamin A is commonly found in skin care products and can cause toxicity through skin application. Check your skincare products to see if they contain vitamin A. It can cause an elevation in liver enzyme blood tests if you are getting too much.

VITAMIN E

Symptoms of deficiency: restless leg syndrome, neuropathy , infertility

Vitamin E is an antioxidant that protects cells and is occasionally low in people with severe malabsorption. Most MVMs contain vitamin E. Look for the natural form (D-alpha tocopherol) or mixed tocopherols. Avoid supplements with DL-alpha tocopherol which is synthetic and not well used by the body. Most supplements of vitamin E are derived from soy but some whole food vitamins use wheat germ oil which might be unsuitable for those with celiac disease because some of the toxic gliadin protein may be left in the oil. ³

VITAMIN K

Symptoms of deficiency: easy bruising, heavy menstrual periods, bleeding gums, osteoporosis

Vitamin K deficiency is very rare because beneficial bacteria in the gut is responsible for making vitamin K. Vitamin K improves bone health and reduces fractures. Therefore, vitamin K deficiency may be related to the low bone mineral density common in celiac disease. ⁴

Vitamin K helps blood clot. People who take Coumadin must maintain a consistent dietary and supplemental intake of vitamin K to get the most from this medicine. Sudden increases in vitamin K may decrease the effectiveness of Coumadin while a sudden lowering in daily vitamin K intake may actually increase the effect of Coumadin. Therefore, it is important to keep vitamin K intake as consistent as possible on a day-to-day basis to prevent these potential changes. Most healthy bone supplements contain about 150mg of vitamin K but many MVMs do not contain vitamin K. Food sources high in vitamin K include dark leafy greens, such as kale, spinach and turnip greens. ³

• Each vitamin and mineral has unique functions in the body and can have distinct signs and symptoms of deficiency. Learn more about important vitamins and minerals.
• View a list of the vitamins and minerals that can be toxic if taken in high doses.

ESSENTIAL FATTY ACIDS

Omega-3 fatty acids can help to reduce inflammation found in celiac disease and other chronic health conditions. Review Level 2 for tips on how to read a fish oil supplement label and contraindications which are important to understand.

TIPS FOR CHOOSING A GOOD FISH OIL SUPPLEMENT ³

• Choose one that contains a small amount of vitamin E to help prevent rancidity of the fish oil in the capsule.
• Choose one labeled "molecularly distilled" which means the heavy metals, such as mercury found in deep water fish, have been removed.
• If you are concerned about burping, take your fish oil at night. Good quality fish oil should not cause burping or have a strong fish smell. Some come with a citrus or flavored essence. Refrigerate the bottle to help reduce any odor and to help those who have difficulty swallowing them.
• Fish oil supplements also come in liquid, gel caps, chewable and paste forms that can be mixed with applesauce or yogurt to disguise the taste.
  • Vegetarians can choose flax seed oil or capsules as their omega-3 form. Flax seed oil contains a certain omega-3 fatty acid called alpha linolenic acid, ALA). ALA converts slowly to EPA and DHA, the more potent forms, and can be inhibited by various conditions.
  • About 15% of ALA converts to EPA. It is unclear whether it converts to DHA (the form which is particularly important to brain and neurological health). Some forms of algae contain DHA and are available as vegan DHA supplements. Because the rest of the flax seed is so nutrient dense and high in fiber, it is healthier to choose whole, ground flax seed than flax seed oil. Always drink water when eating ground flax seed, because of the high fiber content.³ Store ground flax seed in a tightly sealed package where it is not exposed to sunlight.

WHEN TO TAKE YOUR SUPPLEMENTS*

If you're on:

*Check with your doctor or pharmacist for interactions between supplements and medications not listed. This list is not comprehensive.

WHAT ELSE IS IN YOUR SUPPLEMENTS?

Here are some additives that may cause gastrointestinal or allergic reactions in sensitive people.

• Avoid supplements that contain inorganic materials such as chloride, hydroxide, oxides, phosphates, and/or sulfates, when possible. They are inexpensive but more difficult for the body to absorb and may cause digestive problems.
• Some supplements use chelated minerals which are more readily absorbed because the mineral is bonded to an amino acid. Amino acids are easily absorbed by the body. Minerals in higher quality supplements will most likely be in a chelated form. Examples are calcium citrate and magnesium glycinate.
• Watch out for "polyethylene glycol" on the ingredient list. This is the drug Miralax, a laxative. It can cause increased loose stools in those who are prone to diarrhea. If you experience loose stools, be mindful of how much combined polyethylene glycol is in all your supplements.
• If you have food intolerances read labels carefully for problem ingredients such as sugars (dextrose, glucose, fructose, etc) fillers, artificial colors, lactose and soy, fish, corn, etc. And, of course, avoid supplements that contain gluten.
• If you are taking multiple supplements, add up the total amount of each vitamin, mineral, herbal or other supplement to avoid taking any one in excess.
• Avoid overloading on the following, as they can be toxic at high doses and can be found in several different kinds of commonly used formulas, beyond a MVM:
  • Zinc is in eye health formulas and many immune formulas.
  • Iron may be in energy formulas.
  • Vitamin A may be found in immune formulas and skin supplements.
  • Vitamin D can be in bone formulas, immune formulas and mood formulas.
  • Niacin (B3) can be found in cholesterol lowering formulas, joint pain formulas and mood formulas.
  • Pyridoxine (B6) is found often in mood, pain and energy formulas and can be high in energy drinks.
  • Taking too much calcium, magnesium and vitamin C can cause digestive symptoms like gas, bloating, diarrhea or constipation. They, too, can be found in several kinds of supplements beyond a MVM.
  • Fish oil supplements may contain varying amounts of vitamin D and Vitamin A. If so, factor them into your other supplements containing those vitamins.
• Almost any vitamin or mineral can be toxic at high dose, especially if those doses are sustained over time. The exceptions are B12, folic acid, riboflavin (B2), thiamin (B1), biotin and pantothenic acid (B5) which have very low potential for toxicity, even at high doses.

GLUTEN-FREE SUPPLEMENTS

• It is best to choose labeled gluten-free supplements that have been either certified gluten-free or tested for gluten contamination. See Level 2 for more details.
• Some companies are certifying their products.
  • Look for the certification logos on the products.
  • More and more companies are investing in the certification programs to distinguish themselves in the gluten-free market.
• Independent testing for gluten contamination
  • A company may decide not to certify but instead to do independent testing. If so, they will indicate this on the label. Products can be tested to below 5 parts per million (ppm) gluten.
• ALWAYS read the label carefully.
  • Labels can change at any time without notice.
  • Avoid wheat grass and barley grass unless the label specifically indicates that it has certification from one of the North American certification programs. Wheat grass and barley grass are likely to be contaminated with gluten.

WHERE CAN I FIND GLUTEN-FREE SUPPLEMENTS?

Below is a partial list of supplements FREE of ingredients containing gluten. ⁵

Be sure to ask for gluten-free supplements when you call as some of these companies also make products that contain gluten. If you are already taking a supplement, read the label to check for ingredients that may contain gluten, or be contaminated with gluten, such as wheat grass or barley grass. Call the product research department to assure that your supplement is gluten-free, if needed. Caution: Some vitamin and mineral supplements contain lactose and soy.

Carlson Labs: 800-323-4141
www.carlsonlabs.com
All Carlson products are gluten-free and contain no wheat, casein, milk, rye, oats, MSG, preservatives, artificial colors or sweeteners, peanuts, eggs, or corn.

Country Life: 800-645-5768
www.countrylifevitamins.com/
Product line is certified gluten-free by the Gluten-Free Certification Organization.

Freeda Vitamins: 800-777-3737
www.freedavitamins.com
Product line does not include ingredients containing gluten.

Hero Nutritionals: 800-500-4376
www.heronutritionals.com
Product line is free of ingredients containing gluten. Products are manufactured in a facility free of many allergens.

Kirkman Labs: 800-245-8282
Kirkman’s product line is gluten-free and tested for gluten.

Integrative Therapeutics: 800-931-1709
www.integrativeinc.com
Sells to medical professionals
Gluten-free products will be labeled as “Contains no gluten.” Some products are tested for gluten contamination.

Metagenics: 800-638-2848
www.metagenics.com
Sells to medical professionals
All Metagenic’s products are gluten-free unless otherwise stated on the label. Metagenics clearly states if there are any allergens or if the product has been processed in a plant with gluten.

Nature Made: 800-276-2878
www.naturemade.com
Most products are free of ingredients containing gluten.

Pioneer Nutritionals: 800-458-8483
www.pioneernutritional.com
Product line is gluten-free and tested for gluten.

Pure Encapsulations: 800-753-2277
www.pureencapsulations.com
Available through health professionals
Pure Encapsulations products do not contain wheat, gluten, nuts, egg, or hydrogenated oils.

Solgar: 877-SOLGAR-4
www.solgar.com
Contact the manufacturer directly regarding the gluten-free status of any Solgar product.

TAKE HOME MESSAGES:

• Low vitamin D levels are commonly seen in people with newly diagnosed celiac disease. Low levels of the other fat-soluble vitamins (vitamin A, E and K) can be seen in people with severe malabsorption and chronic diarrhea. If you are struggling with these issues, ask your doctor to test your vitamin A, E, and K levels, as well.
• To avoid overdosing on any particular nutrient, add up the total amount of each vitamin, mineral, herbal or other supplement you may be taking and talk to your doctor or dietitian. Keep a list of your supplements (and medications), including the brands and the doses in your purse or wallet.
• If you are not getting enough omega-3 fatty acids from your food, consider a fish oil supplement. Refrigeration, taking them at night, and choosing a formula that works best for you (liquid, paste, gel capsule) can minimize any side effects of taking them. Plant-based omega-3 supplements are also available. Always speak to your doctor before starting an omega-3 supplement.

References:

1. 1. Barton SH, et al. Nutritional Deficiencies in Celiac Disease. Gastroenterol Clin N Am, 2007(36):93-108.
2. See J, Murray JA. Gluten-free diet; the medical and nutritional management of celiac disease. Nutrition in Clinical Practice, 2006;21:1-15).
3. 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.
4. Weber P. Vitamin K and bone health. Nutrition 2001;17(10):880-87.
5. Dennis M, Kupper C, Lee AR, Sharrett MK, Thompson T. Celiac Disease Toolkit. American Dietetic Association, 2011.

Revision Date: 5-8-13
Authors: Melinda Dennis, MS, RD, LDN, Lindsey O’Regan, Lauren Alder Dear
Editors: Christine Doherty ND, Suzanne Simpson RD, Rupa Mukherjee MD

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