With almost every news story about the gluten-free diet, we hear dire warnings about the risks of nutritional deficiencies. While there are certainly valid reasons for this, the good news is that it’s absolutely possible to eat a healthy, balanced gluten-free diet and fill in any nutrient gaps with a little planning.
A range of vitamin and mineral deficiencies are common right after diagnosis with celiac disease. Most nutrients are absorbed in the small intestine, and since celiac disease causes damage to the small intestine, it can’t do its job properly. The extent of the deficiencies depends on the length of time someone has had untreated celiac disease and the location of the damage within the intestine.
An Italian study published in 2010 in the journal #Nutrients# showed iron, calcium, magnesium, Vitamin D, zinc, folate, niacin, B12 and riboflavin deficiencies in newly diagnosed celiac patients. Less often, people are low in vitamins A, E and K and copper as well.
According to Melinda Dennis, R.D., nutrition coordinator of the Celiac Center at Beth Israel Deaconess Medical Center, new clients should always have tests run to determine nutrient levels. “We look at iron levels, B vitamins like folate and B12, Vitamin D and zinc. If clients have fat malabsorption, we look at vitamins A, E and K, too.”
But vitamin and mineral deficiencies aren’t only concerns for people just starting out. Several studies have shown that people on a long-term gluten-free diet may not eat enough iron, calcium or B vitamins. “It’s important to keep monitoring iron levels over time, and we look at B12 and folate levels very two years,” Dennis says.
Experts estimate that more than half of those newly diagnosed with celiac disease have iron deficiency anemia. Iron is essential because it binds oxygen and transports it through the body. With low iron levels, people may experience fatigue, weakness, irritability, headaches or difficulty concentrating.
Thanks to the cartoon character Popeye, many of us think of spinach as a good source of iron. Actually, our bodies use iron most efficiently from “heme,” or animal-based sources, like liver, red meat, poultry, fish, etc. Non-heme, or plant-based, sources of iron include nuts, seeds, beans, quinoa and teff.
Iron deficiency is common during periods of rapid growth, so toddlers, teens and pregnant women are often affected. One 2005 study in the Journal of Human Nutrition and Dietetics found that only 44 percent of women were eating enough iron. Vegetarians are also at a higher risk for iron deficiency, since vegetarian iron sources are less absorbable. On the flip side, post-menopausal women and men generally do not need supplemental iron unless their blood levels show a deficiency.
Here are some quick ways to increase the amount of iron in your diet:
- Pair foods with iron with foods high in Vitamin C, like peppers, citrus, berries and other fruits or vegetables to increase absorption.
- Substitute the chips and crackers with nuts and seeds for snacks.
- Upgrade the carbs. Trade rice pasta for beans, quinoa or teff.
Calcium is best known for promoting bone health, but it also plays a role in blood clotting, muscle contractions and nerve function, too.
Getting adequate calcium can be tricky. The damage due to celiac disease affects calcium absorption, so many have been absorbing it poorly for years before diagnosis. To add to the difficulty, many people with recently diagnosed celiac disease are at least temporarily lactose intolerant.
Lactose is the sugar found in milk products, and the enzyme that digests it is frequently missing until the small intestine starts healing. With lactose intolerance, regular milk, ice cream and other dairy can cause gas, diarrhea and bloating, while hard cheeses, lactose-free milk and some yogurts are typically well digested. After 6 months to a year, some people are able to digest lactose again.
Fortunately, a range of other foods contain calcium, such as sardines, firm tofu, teff, black-eyed peas and some greens, like collards, turnip greens or kale. A wide variety of “milks” are calcium fortified, such as almond, rice, soy and hemp, and there are many fortified fruit or vegetable juice blends, too. Not all milk substitutes and juices have added calcium, so check labels carefully.
Calcium intake tends to be low across the board. In a 2005 study in the Journal of Nutrition and Dietetics, men reported consuming only 66 percent of their recommended daily calcium needs, while women only ate 31 percent. This is especially troubling because the rates of osteopenia and osteoporosis, or low bone density, are high in people with celiac disease.
Here are some quick ways to get calcium in your diet:
- For people who are lactose intolerant, use supplemental lactase enzymes or look for low-lactose options, like lactose-free milk, hard cheese or yogurt.
- Choose dairy products or calcium-fortified “milks” a few times a day
- Add in green leafy veggies daily.
Not only does Vitamin D play a key role in building strong bones, but it is also important for immune function, blood pressure, and even cancer prevention. Evidence on the link between Vitamin D status and prevention of further autoimmune diseases is still mixed, although the most recent study from Columbia University showed no effect.
Vitamin D is known as the sunshine vitamin because our bodies can produce it from the sun’s rays, but regretfully, most of us don’t live on a tropical island. People at northern latitudes often can’t get enough Vitamin D, especially during winter months. Sunblock, UV protection and even pollution limit Vitamin D production in the skin. There is some Vitamin D in food, such as fortified dairy and fatty fish, but for many people, supplements are necessary to reach to an adequate level.
Here are some quick ways to get Vitamin D in your diet:
- Get 10 to 20 minutes of sunshine daily.
- Look into supplements if necessary.
The eight B vitamins are essential for the production of red blood cells, heart and nerve function, and for a healthy pregnancy. Like the other nutrients, B vitamins may be poorly absorbed with celiac disease. The bigger problem is the nutrient gap between gluten-free and regular products. In response to widespread nutritional deficiencies, Congress passed a law in the 1940s requiring that refined flour products like white flour, breads, cereals and pastas have added B vitamins and iron. Gluten-free flours, breads, pastas, etc., are considered specialty foods and do not have to follow enrichment rules. They are often made with ingredients with very little nutritional value, like potato starch, cornstarch, tapioca starch and white rice flour. The good news is that more gluten-free companies are beginning to voluntarily enrich products and are using more healthy gluten-free whole grains.
B vitamins are found in a range of foods, including gluten-free whole grains, meats, leafy green vegetables, nuts, seeds, beans and fruit. Vegans tend to be particularly low in B12, which is mainly found in animal products. B12 absorption decreases with age and medications that suppress acid production.
Here are some quick ways to get B vitamins in your diet:
- Choose gluten-free whole grains, like brown rice, wild rice, gluten-free oatmeal, quinoa, buckwheat, etc.
- Look for enriched gluten-free products when possible. Mainstream products that happen to be gluten-free, like Rice Chex, are enriched.
Nutrient gaps for the gluten-intolerant
People who are gluten-intolerant are likely to be eating the typical gluten-free foods, but they don’t have the same issues with years of malabsorption. Since studies looking at diet records from people with celiac disease show a low intake of calcium and B vitamins and inadequate iron for women, it’s likely that this is also true for anyone who is gluten-free, regardless of the reason for following the diet.
But before going out and gulping down the biggest bottle of vitamins on the shelf, it’s important to remember that everyone has different needs. While too little Vitamin D is harmful, too much can be dangerous. Taking a gluten-free multivitamin and a calcium supplement with Vitamin D is wise for almost all anyone with celiac disease. It’s also essential to get tested for nutrition deficiencies by a physician. If there is a real deficiency, higher doses of supplements and ongoing monitoring is necessary.
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