The Nutritional Supplement

Nutrient deficiencies are a common complication of celiac disease; this is a direct result of malabsorption due to enterocyte destruction. Awareness of nutrient deficiencies in celiac disease is pertinent for both diagnosis and management. In some cases, for example, the only presenting symptom of celiac disease is microcytic or macrocytic anaemia. A study of 80 patients newly-diagnosed with celiac disease in the Netherlands showed zinc deficiency in more than 66% and ferritin deficiency in more than 46% of cases.[1] Some of the most common nutrient deficiencies associated with celiac disease include iron, calcium, magnesium, zinc, vitamin D3, vitamin B12, folic acid, and other B vitamins. The following case study demonstrates the importance of evaluating all patients with celiac disease for nutrient deficiencies.

A 24-year-old female patient presented with digestive problems, fatigue, and a diagnosis of celiac disease. At the age of 22, after 11 months of apthous ulcers in the mouth, constipation, dermatitis herpetiformis, weight loss, anaemia, and eventual explosive diarrhoea, the patient had finally been referred for duodenal biopsy and diagnosed with celiac disease. The anaemia resolved within 6 months of following a gluten-free diet. The fatigue continued, however, and occupational exposure to gluten made it worse (she worked with special needs children and occasionally had topical exposure from crumbs at snack time). With a recent stress of moving and beginning a new job, she had developed diarrhoea once again. Lab results showed low ferritin at 5 ng/mL (reference range, 15-25 ng/mL) and low total iron at 20 μg/dL (reference range, 60-160 μg/dL); serum B12 and thyroid panel were within normal limits; she reacted to 35 out of 115 foods tested on an IgG food allergy panel; and salivary cortisol was low throughout the day.

This case demonstrates the complexity of patients with celiac disease; the patient had an exacerbation of symptoms that appeared to result from stress; but on evaluation, lab results revealed iron deficiency, adrenal fatigue, and multiple food sensitivities. Her presenting symptom of fatigue was likely a direct result of iron deficient anaemia, but it may not have resolved by taking iron alone. Multiple food sensitivities suggest that the integrity of the lining of the gut is compromised, contributing to malabsorption and resultant nutrient deficiencies. In this case, it was likely that deficiencies of nutrients other than iron (eg, B vitamins) were contributing to the observed low cortisol levels. The most effective plan, therefore, would address the integrity of the intestinal lining as well as the replenishment of depleted nutrients.

The patient was advised to avoid the 35 food irritants for 90 days and was prescribed digestive enzymes, probiotics as combination Lactobacillus and Bifidus with 5 billion cfu/gm, and a smoothie containing slippery elm (2500mg) and l-glutamine (3,000mg – 5,000mg). Iron bis-glycinate (28 mg per day) was prescribed to correct iron deficiency. Vitamin B complex (50 mg with breakfast) and a tincture of Glycyrrhiza glabra (1 tsp with breakfast) were prescribed to support adrenal function. Within 6 months, the patient’s diarrhoea resolved and fatigue improved dramatically.

[1] Wierdsma NJ, van Bokhorst-de van der Schueren MA, Berkenpas M, Mulder CJ, van Bodegraven AA. Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients. Nutrients. 2013;5(10):3975-3992.