Is Vitamin B Deficiency A Risk In A Gluten Free Diet?

Awareness of the impact on Celiac disease and gluten intolerance has grown in recent years.  In these patients, ingestion of gluten (a protein prevelant in wheat products, but in other grains as well) causes damage to the lining of the intestine as the body treats it like any other allergen.  For those of you who suffer from season allergies, imagine if your nasal and eye reaction to pollen was taking place in your gut.  The red, itchy reaction in your eyes is comparable to the inflamation that takes place in your intestines in someone who cannot tolerate gluten.   This has systemic ramifications as well because of the heightened total-body immune reaction that takes place.

Depression and anxiety has been associated with Celiac Disease for some time.  Questions about gut health have become more standard in the evaluation of my patients.  If a patient has a history of irritable bowel issues, periodic food intolerance, diarrhea, or ‘stomach pain’, I will include screening for Celiac in my work up. I will discuss with them a trial off gluten as well.  While this is much easier than it was in years past . . . the proliferation of gluten-free products has made gluten-free living much less constricting . . . it is still a hard sell to patients who LOVE their bread products (and who doesn’t).  Sometimes, however, a strict gluten-free diet can make a big difference in how a patient feels physically and how they feel emotionally.  When this happens, it makes avoidance of wheat products worth it.

Patients who have Celiac or a gluten intolerance can be depressed and anxious even with strict adherence to a gluten-free diet.  In those cases, use of antidepressants is certainly indicated.  I made an interesting observation recently, however, when one of my patients who follows a strict gluten-free diet came back deficient in folic acid.  Folic acid is key to neurotransmitter production.  Without adequate amounts of folic acid, the response rate to antidepressants falls to near zero.  This patient clearly needed to begin a program of vitamin supplementation.

The etiology of the folic acid deficiency in this patient is likely due to the strict gluten-free diet that the patient was following.  Patients who follow a strict gluten-free diet do not get the B-vitamins that are present in enriched wheat products.  It was first observed in the 1920s that the process of refining white flour resulted in the stripping off of many of the vitamins present in unrefined wheat.  Some of these vitamins are key to good health. The addition of vitamins and some minerals to wheat products began in the 1940s as an effort to support the health of the population that was suffering from food rationing that was part of the war effort.  Folic acid deficiency is exceedingly rare in this country because of prevalence of enriched wheat products in our diets.  It is so rare, that I generally do not measure it when I add a vitamin panel to my patient’s bloodwork. But, in this case, the results were highly significant.

Going forward, I plan on including vitamin B supplementation as part of my recommendations for patients on a gluten-free diet.  While you can get folic acid from green leafy vegetables, it is the rare patient who consumes enough of these on a regular basis.  Especially in pediatric patients where the advice to skip the bread and eat more spinich is typically not well received.  Folic acid is also present in citrus fruit and beans, but cross contamination with gluten is a risk for processed products (for example, orange juice and canned beans).  Even supplementation with OTC multi-B vitamins must be done with caution because of the potential for gluten to be present in vitamins.  Look for products that are certified as  “gluten-free”.  This refers to the concentration of gluten found in the product.  Currently, this means that there are less than 20 parts per million (ppm) of gluten found in that product.  This level of gluten is acceptable for patients with a gluten intolerance.  For some patients with true Celiac Disease, even that level of gluten can cause symptoms of being “glutenized”.  For them, they need “gluten-free” to mean gluten-free.  You can check with the manufacturer of the products or look on one of the many websites set up to screen products.  You can find additional information at, and through the Celiac Disease Foundation at

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