Micronutrient Deficiencies Common in Celiac Disease

Celiac disease is an immune reaction to consuming gluten, a protein found in wheat, barley and rye. Eating gluten triggers an immune response in the small intestine that over time damages the intestine's lining and prevents it from absorbing some nutrients, leading to diarrhea, fatigue, anemia, weight loss and other complications.

Recent guidelines on the diagnosis and management of Celiac disease (CD) recommend testing for nutrient deficiencies at the time of new diagnosis, and this assessment should include vitamin D, iron, folic acid, and vitamin B12. Micronutrient deficiencies, including vitamins B12 and D, as well as folate, iron, zinc and copper, are common in adults at the time of diagnosis with celiac disease.

Gastroenterologists at the Mayo Clinic (Rochester, MN, USA) and their colleagues carried out a retrospective analysis of 309 adult patients with a new diagnosis of CD from January 1, 2000, and October 31, 2014. Patients included in this study were diagnosed with CD, with a combination of serological, genetic, and histological parameters yielding a confident diagnosis of CD when patients met one of two clinical scenarios. First, if the patient had positive serology for celiac disease and confirmatory duodenal biopsy, CD was diagnosed. Second, patients without positive serology for celiac disease must have biopsy findings consistent with CD, human leukocyte antigen DQ-2 or DQ-8, and positive response to a gluten-free diet for a diagnosis of CD.

Laboratory parameters were included if they were collected one month before diagnosis to three months after celiac diagnosis. Tissue transglutaminase IgA data were collected to determine whether a positive result was associated with deficiency. Micronutrient data were collected for serum zinc, 25-hydroxy vitamin D, ferritin, albumin, serum copper, serum folate, and vitamin B12. Albumin was assessed, as this can influence serum zinc values and is a predictor of outcome in refractory CD studies.

The investigators found that zinc was deficient in 59.4% (126/212) of patients with CD compared with 33.2% (205/618) of controls. Albumin was low in 19.7% (24/122) compared with 1.1% of controls. Copper was low in 6.4% (13/204) compared with 2.1% (13/618) of controls. Vitamin B12 was low in 5.3% (13/244) compared with 1.8% (11/618) of controls. Folate was low in 3.6% (6/159) compared with 0.3% (2/618) of controls. 25-Hydroxy vitamin D was low in 19.0% (44/213) compared with 18% (111/618) of controls. Ferritin was low in 30.8% (66/214) of patients.

Adam Bledsoe, MD, a gastroenterologist and lead author of the study, said, “Our study suggests that the presentation of celiac disease has changed from the classic weight loss, anemia and diarrhea, with increasing numbers of patients diagnosed with non-classical symptoms. Micronutrient deficiencies remain common in adults, however, and should be assessed.”

The authors concluded that micronutrient deficiencies remain common in adults with recently diagnosed CD despite the low prevalence of weight loss and average overweight BMI. These data, in conjunction with previous descriptions of micronutrient deficiencies, suggest value in continued micronutrient assessment of adults at the time of CD diagnosis. The study was published on June 25, 2019, in the journal Mayo Clinic Proceedings.

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