Addressing Micronutrient Deficiency in Celiac Disease

Celiac disease is an inflammatory condition of the small intestine that develops in genetically susceptible individuals. The condition is characterized by an initial immune response that is later triggered by gluten ingestion. It occurs in 0.71% of the United States population.[1] Diagnosis of Celiac disease requires the presence of duodenal villous atrophy. Most cases also present with circulating antibodies to tissue transglutaminases. Celiac disease can be asymptomatic, or it can present with symptoms such as gas, bloating, and/or fatigue. Complications can include anemia and osteoporosis. Micronutrient deficiency, which is at the heart of these complications, is a serious concern in Celiac disease.


Current and Emerging Therapies for Celiac Disease

While the only 100% effective treatment for Celiac disease is complete avoidance of gluten, including wheat, rye, and barley, there are several current and emerging therapies for treatment of the condition. This includes the use of prolylendopeptidases for intraluminal digestion of gluten; the use of bacterial-derived peptidase to pre-treat gluten prior to ingestion; the use of zonulin antagonists and other agents to prevent passage of immunogenic peptides through tight junctions; blocking of HLA-DQ2 to prevent binding of immunogenic peptides; the use of gluten-tolerizing vaccines to modulate the immune system, inhibit transglutaminase 2, and induce tolerance to gluten; and the use of gluten-sequestering polymers, anti-inflammatory drugs such as glucocorticoids and budesonides, and anti-cytokines such as anti TNF-α, and anti-interleukin-15.[2]


Micronutrient Deficiency in Celiac Disease

Damage to the small intestine such as is common in Celiac disease can impair absorption of several micronutrients, including iron, folate, calcium, and vitamin D. People diagnosed with this condition can also lose vitamins A, D, E, and K; magnesium; and calcium through their stool.


Micronutrient deficiency is fairly common in Celiac disease, even when strict gluten avoidance is practiced. In fact, research demonstrates micronutrient deficiencies even in Celiac patients who’ve strictly avoided gluten for the preceding two years.[3] In this population, vitamin B12 deficiency was found in up to 30% of adult patients, iron deficiency in up to 40%, folate deficiency in up to 20%, vitamin D deficiency in up to 25%, and zinc deficiency in up to 40%. In children diagnosed with Celiac disease, calcium deficiency was demonstrated in up to 3.6% and magnesium deficiency was demonstrated in up to 20% of children.


For many Celiac disease patients, diet alone is not sufficient to correct these deficiencies. For some of these, oral supplementation also may not yield the desired results. Here’s an example from one of my patients to explain why: This particular patient was referred to me by her primary care physician to address her Celiac-related micronutrient deficiencies. Her PCP had recommended oral supplementation, but when he retested her levels, not much had changed. I took a look at the supplements she was taking and found that many of them were not forms of micronutrients that were easily absorbed. Instead of the low-quality supplements she was taking when she came to me, I recommended higher quality, highly-bioavailable forms of micronutrients for optimal absorption. When she returned to her primary care physician for re-evaluation, he found that her levels had improved and she was feeling much better as well.


Research suggests that evaluating initial blood levels of micronutrients and recommending oral supplementation with appropriate dosages of bioavailable nutrients based on those levels may be a good place to start when it comes to supporting optimal micronutrient status in most Celiac patients who are compliant with gluten avoidance recommendations.[3] In cases where supplementation does not result in improvement of micronutrient status, or in cases where gluten avoidance is not completely adhered to, intravenous nutrient therapy may be necessary in order to improve micronutrient status in Celiac patients.


Because of the limits the body places on the amounts of various nutrients that can be transported and absorbed through the gastrointestinal tract at a time, replenishing optimal micronutrient status through oral supplementation can be a long-term strategy. On the other hand, IV nutrient therapy can be used to bypass the gastrointestinal tract, which is particularly useful in cases where noncompliance to gluten avoidance recommendations has led to moderate to severe intestinal damage, and to deliver larger amounts of micronutrients, which is useful when the goal is to restore micronutrient status more quickly.


Conclusion

In conclusion, there are many current and emerging treatments for Celiac disease, but the only 100% effective treatment is strict gluten avoidance. Micronutrient deficiencies are common in Celiac disease. Oral supplementation may be an effective means of restoring micronutrient status in individuals with Celiac who are strictly avoiding gluten; however, if gluten avoidance is not strictly adhered to or if micronutrient status needs to be replenished quickly, IV nutrient therapy may be a more effective treatment option. To learn more about using IV nutrient therapy in your practice to help your patients with Celiac disease and other conditions, click here.



References

1. Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE. (2012). The prevalence of celiac disease in the United States. Am J Gastroenterol. 107(10):1538-1544. doi: 10.1038/ajg.2012.219.


2. Makharia G. K. (2014). Current and emerging therapy for celiac disease. Frontiers in medicine, 1, 6. doi:10.3389/fmed.2014.00006


3. Rondanelli, M., Faliva, M. A., Gasparri, C., Peroni, G., Naso, M., Picciotto, G., … Perna, S. (2019). Micronutrients Dietary Supplementation Advices for Celiac Patients on Long-Term Gluten-Free Diet with Good Compliance: A Review. Medicina (Kaunas, Lithuania), 55(7), 337. doi:10.3390/medicina55070337

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