Management of under nutrition
Coeliac disease can result in severe symptoms of malabsorption such as steatorrhoea, abdominal discomfort and weight loss. Most people with coeliac disease gain weight as absorption increases following diagnosis and treatment with a gluten free diet. Others may find it hard to regain any weight lost prior to diagnosis.
The first step is to consider if nutrient requirements can be met via ordinary foods and drinks. It is only when this option does not satisfy requirements that other measures need to be considered.
In practice, nutritional support can be regarded as a graded process of increasing levels of intervention:
- improving energy and nutrient intake from ordinary foods
- fortifying the energy and nutrient intake from ordinary foods
- sip feed and other forms of supplementation
- enteral nutrition
- parenteral nutrition.
The type and level of nutritional support must be determined on an individual basis.
In the elderly, micronutrient deficiency is not uncommon and should be addressed. Adequate amounts of zinc are required to stimulate appetite.
Nutritional deficiencies and supplements
There is no evidence to suggest that nutritional deficiencies are a significant problem in individuals diagnosed with coeliac disease who are established on a gluten free diet.
However, the malabsorption that occurs in undiagnosed and untreated coeliac disease can lead to multiple nutritional deficiencies. The most common nutritional problems include deficiencies of essential fatty acids, iron, vitamin D, vitamin K, calcium, magnesium, folic acid and zinc.
Once treatment with a gluten free diet is established and there is healing of the lining of the gut, absorption of nutrients from food generally normalises and nutritional status improves.
- People with coeliac disease seek advice from a member of their healthcare team if they are thinking about taking over the counter vitamin or mineral supplements
- To explain to people with coeliac disease that they may need to take specific supplements such as calcium or vitamin D if their dietary intake is insufficient.
Unexplained iron deficiency anaemia is a common symptom of undiagnosed coeliac disease and should be investigated.
The British Society of Gastroenterology (BSG) provides guidance on the treatment of iron deficiency anaemia. All people with low iron levels should have iron supplementation both to correct anaemia and replenish blood stores.
Goddard F, James MW, McIntyreAS et al (2005) Guidelines for the management of iron deficiency anaemia.
It is important that people with coeliac disease meet their dietary calcium requirements to reduce their risk of osteoporosis. The calcium requirements for adults with coeliac disease are greater than the general population. Those who cannot meet their needs from diet alone may require additional supplements. We have information and practical dietary advice to help patients meet their calcium requirements on our main site.
Vitamin D deficiency
Meeting vitamin D requirements is important to reduce the risk of rickets in children and osteomalacia in adults.
Public Health England and the Scottish Government provide advice on vitamin D intakes, based on recommendations from the Scientific Advisory Committee on Nutrition, saying:
- Everyone in the general population aged 4 years and older, is recommended to have an intake of 10 micrograms of vitamin D per day. In the winter months they may struggle to get enough vitamin D and should consider taking a daily supplement containing 10 micrograms of vitamin D from October to February.
- All infants from birth to one year of age should have an intake of between 8.5 to 10 micrograms per day. This should be as a daily supplement, unless the infant is having more than 500ml of infant formula a day, as formula milk is already fortified with vitamin D.
- Children aged one to four years should have a supplement of 10 micrograms per day, all year round.
- Pregnant and breastfeeding women should consider taking a daily supplement of 10 micrograms vitamin D daily.
- Those in groups at risk of vitamin D deficiency, such as those who are housebound, older people, those with darker skin tones and those who cover their skin completely when outside, should consider taking a supplement of 10 micrograms of vitamin D each day, all year round.
Ensuring nutritional needs are met
Wheat used as a basis for making the staple gluten-containing bread is a good source of minerals such as zinc, magnesium, manganese, copper and selenium compared to the gluten free cereals rice and maize, used in the production of gluten free bread. Wheat is also a richer source of fibre. It is therefore important to provide advice to individual patients on achieving a nutrient rich diet without wheat based on individual assessment and dietary intake.
Specialist gluten free substitute foods, can be an important source of energy, carbohydrate and fibre, and some products may also be fortified with calcium and iron.
Assessing people with coeliac disease for nutritional deficiencies
Poor compliance to the gluten free diet after diagnosis of coeliac disease can result in ongoing nutritional deficiencies. If the gluten free diet is not followed there is a higher chance of low nutrient levels not being corrected.
Assessment of nutritional status can be difficult to ascertain. Monitoring BMI, body weight, haemoglobin and IgA tTG or EMA antibody levels can help to assess compliance and response to the gluten free diet.
If people with coeliac disease are deficient in any vitamins or minerals they may need to be corrected by dietary supplements, prescribed by their healthcare team.