Managing Vitamin Deficiencies in Celiac Disease With Tailored Nutrition

While a gluten-free diet remains the primary treatment for celiac disease, careful nutritional management is essential to address both disease-related and diet-induced vitamin deficiencies, according to a review.¹

The results highlight the risk of both disease-related and diet-induced vitamin deficiencies in celiac disease, emphasizing the need for tailored gluten-free diets to ensure adequate nutrient intake and improve patient outcomes. | Image credit: Best - stock.adobe.com

The review, published in Metabolites, was conducted to highlight the risk of both disease-related and diet-induced vitamin deficiencies in celiac disease, emphasizing the need for tailored gluten-free diets to ensure adequate nutrient intake and improve patient outcomes.

Biopsy-confirmed celiac disease is estimated to affect 0.7% of the population, while serology-based diagnoses suggest a prevalence of 1.4%.² The incidence of celiac disease varies by region and has been rising in several parts of the world.^3,4 Screening studies indicate that the condition is often underdiagnosed, likely because many individuals exhibit nonclassical or asymptomatic forms of the disease.⁵

The incidence of celiac disease is higher in women, with 17.4 cases per 100,000 person-years, compared with 7.8 cases per 100,000 person-years in men, according to a meta-analysis.⁶ Among children, the incidence is 21.3 per 100,000 person-years, whereas in adults, it is 12.9 per 100,000 person-years. Over time, these rates have been rising, with an average annual increase of 7.5% in recent decades.

Researchers conducted a PubMed literature search on vitamin deficiencies in untreated celiac disease and the effects of a gluten-free diet, focusing on vitamins A, E, B9 (folate), B12, and K.¹ They also consulted medical textbooks and authoritative sources. Studies were included if they explored the link between celiac disease and vitamin deficiencies, were in English, and focused on humans. Data was gathered through manual reference review and synthesized qualitatively, highlighting the prevalence and causes of vitamin deficiencies in relation to the disease and diet changes.

Vitamin A

Vitamin A deficiency emerged as a potential concern in untreated celiac disease due to malabsorption. Early studies demonstrated low vitamin A levels in symptomatic celiac disease patients, with improvements seen after adopting a gluten-free diet. However, even patients on a long-term gluten-free diet may still experience vitamin A deficiency, primarily due to inadequate dietary intake rather than malabsorption.

Studies have shown that many patients with celiac disease fail to meet daily vitamin A requirements, highlighting the need for ongoing nutritional education and structured follow-up to ensure a balanced diet. Regular dietary assessments were recommended to mitigate the risk of deficiency in celiac disease management.

Vitamin E

Deficiency of vitamin E has been linked to neurological disorders, including cerebellar ataxia, myelopathy, and neuropathy, particularly in celiac disease patients due to impaired intestinal absorption. Clinical cases suggest a potential association between vitamin E deficiency and neurological symptoms in celiac disease, with some improvement seen after vitamin E supplementation and adherence to a gluten-free diet.

However, the link remains uncertain, as neurological issues appear primarily in adults, and vitamin E levels often normalize with a strict gluten-free diet alone. Studies indicate that many untreated patients with celiac disease have low vitamin E levels, but those adhering to a balanced gluten-free diet generally maintain adequate levels. Research on the nutritional adequacy of a gluten-free diet varies, with some studies showing deficiencies in meeting daily dietary recommendations.

Vitamin K

Nutrient malabsorption, common in celiac disease, can lead to vitamin K deficiency, resulting in coagulation imbalances. However, acute bleeding is rare, despite prolonged prothrombin time, in 18.5% to 25.0% of untreated patients with celiac disease. Symptoms can range from mild bruising to severe coagulopathy and hemorrhagic manifestations.

A gluten-free diet typically reverses vitamin K deficiency without the need for supplementation. Interestingly, celiac disease is also associated with a hypercoagulable state, predisposing patients to conditions such as stroke, deep vein thrombosis, and pulmonary embolism. Hyperhomocysteinemia, vitamin deficiencies, and genetic factors further contribute to increased thrombotic risk. In some cases, thrombotic events may be the first indication of undiagnosed celiac disease.

Vitamin B12

In celiac disease, vitamin B12 deficiency is not as common as vitamin B9 deficiency. Studies report insufficient vitamin B12 levels in up to 41% of patients with celiac disease at diagnosis, but the actual prevalence of deficiency is lower, ranging from 5% to 12% in most studies. Deficiency is more common in severe celiac disease cases, though symptoms like weight loss and stool changes are not reliable predictors.

Long-term adherence to a gluten-free diet generally prevents persistent vitamin B12 deficiency. Several studies found adequate vitamin B12 intake and normal serum levels in patients with celiac disease following a strict gluten-free diet for extended periods (8-12 years). This may be due to the higher vitamin B12 content in gluten-free products and passive absorption in the small intestine.

However, in cases of persistent vitamin B12 deficiency despite strict adherence to a gluten-free diet, further investigations are needed to rule out accidental gluten exposure or conditions like autoimmune atrophic gastritis that impair absorption. Hyperhomocysteinemia, associated with both vitamin B12 and B9 deficiencies, improves after initiating a gluten-free diet, highlighting the importance of these nutrients in vascular health.

Other Vitamin Deficiencies

Folate is a water-soluble B vitamin essential for DNA and RNA synthesis, amino acid metabolism, and red blood cell production. Deficiency, especially in conditions like celiac disease, can lead to megaloblastic anemia and elevated homocysteine levels, increasing cardiovascular risks. While a gluten-free diet improves folate levels in patients with celiac disease, it may not fully resolve deficiencies, and folate supplementation may be necessary for optimal health.

References

1. Scarampi M, Mengoli C, Miceli E, Di Stefano M. Vitamins and celiac disease: beyond vitamin D. Metabolites. 2025;15(2):78. doi:10.3390/metabo15020078

2. Singh P, Arora A, Strand TA, et al. Global prevalence of celiac disease: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2018;16(6):823-836.

3. Kang JY, Kang AH, Green A, et al. Systematic review: Worldwide variation in the frequency of coeliac disease and changes over time. Aliment Pharmacol Ther. 2013;38(3):226-245.

4. Altobelli E, Paduano R, Petrocelli R, et al. Burden of celiac disease in Europe: A review of its childhood and adulthood prevalence and incidence as of September 2014. Ann Ig. 2014;26(6):485-498.

4. Choung RS, Larson SA, Khaleghi S, et al. Prevalence and morbidity of undiagnosed celiac disease from a community-based study. Gastroenterology. 2017;152(4):830-839.

5. Choung RS, Unalp-Arida A, Ruhl CE, et al. Less hidden celiac disease but increased gluten avoidance without a diagnosis in the United States: Findings from the National Health and Nutrition Examination Surveys from 2009 to 2014. Mayo Clin Proc. 2017;92(1):30-38.

6. King JA, Jeong J, Underwood FE, et al. Incidence of celiac disease is increasing over time: a systematic review and meta-analysis. Am J Gastroenterol. 2020;00:1-19. doi:10.14309/ajg.0000000000000523