Anemia and Celiac Disease: A Complete Guide

Anemia is common in celiac disease. This is because there are quite a few nutrient deficiencies that occur with celiac disease that can lead to dietary anemias.

In this post, we will discuss celiac disease and anemia, signs of anemia with celiac, tools to treat anemia in celiac disease, and how to monitor for anemia in celiac patients.

Table of Contents

Anemia and Celiac Disease: A Complete Guide​​ - Tayler Silfverduk, celiac dietitian

What is Celiac Disease

Celiac disease is an autoimmune disease in which an autoimmune reaction is triggered in response to gluten. The autoimmune response that’s triggered by gluten can cause a cascade of inflammation and symptoms throughout the entire body.

Most importantly, this autoimmune reaction causes damage in the duodenum section of the small intestine. The duodenum of the small intestine is the main site of iron and folate absorption. This is important because damage to this portion of the small intestine can impair the uptake of folate and iron into the body.

This impaired uptake of folate and iron into the body can cause celiac to lead to anemia.

What is Anemia

The Mayo Clinic defines anemia as a condition where you don’t have enough healthy red blood cells to carry oxygen throughout your body. There are different types of anemia but the most commonly known is dietary anemia caused by a lack of iron.

The Different Types of Dietary of Anemia

There are many types of anemia but when it comes to celiac, dietary anemias are the main concern. Dietary anemias are forms of anemia that are caused by nutrient deficiencies. While there are quite a few nutrients that can cause dietary anemia, we will be focusing on the main ones which are: iron, folate, and vitamin B12.

  • Iron Deficiency Anemia is an anemia caused by a deficiency in iron. It’s what’s known as microcytic anemia, or anemia characterized by small red blood cells that can’t appropriately transport oxygen. With celiac disease, the main site of absorption of iron is damaged and thus, iron deficiency anemia is common in celiacs.
  • Folate Deficiency Anemia is an anemia caused by folate deficiency. It’s characterized by overly large red blood cells that don’t function properly (macrocytic anemia). It’s a risk in celiac because the main site of folate absorption, the duodenum, is damaged.
  • B12 Deficiency Anemia is an anemia caused by a deficiency in vitamin B12. This is another macrocytic anemia. This is a risk in celiac disease because vitamin B12 deficiency remains common. In fact, in a small study done in 2001, 41% of celiac participants were vitamin B12 deficient.

It’s important to note that diagnosing these deficiencies and anemias can be tricky.  In some cases, vitamin B12 deficiency can mask iron deficiencies. In other cases, folate deficiencies can mask B12 deficiencies. Making sure you’re working closely with a doctor to monitor your nutrition and anemia status is essential to making sure you’re targeting the right condition.

General Symptoms of Anemia with Celiac Disease - Anemia and Celiac Disease A Complete Guide​​ - Tayler Silfverduk, celiac dietitian

General Symptoms of Anemia with Celiac

General symptoms of anemia include:

  • Fatigue and weakness – this happens because your body’s red blood cells aren’t transporting oxygen appropriately and thus less oxygen reaches your tissues and muscles. As a result, your body is deprived of much-needed oxygen to operate so you may feel tired and weak. This can be confused with gluten causing chronic fatigue in celiac disease.
  • Pale skin – those with anemia may have pale skin because there is a lack of hemoglobin in their red blood cells plus they may not be enough red blood cells circulating so the skin begins to lose color.
  • Dizziness, lightheadedness or headaches – may occur because not enough oxygen is circulating to your brain due to lack of or impaired red blood cells.
  • Cold hands and feet – may occur because again, an impaired ability of your red blood cells to deliver oxygen throughout your body.

Some of these symptoms may overlap with celiac disease, which is why it’s essential to do proper follow-up testing for both nutrient deficiency and celiac disease.

Can Celiac Disease Cause Anemia?

Celiac disease can lead to dietary anemias.  With iron, vitamin B12 and folate deficiencies being common in celiac patients, these deficiency-based anemias can develop.

These dietary anemias can be caused by celiac disease because of intestinal damage. Remember, with celiac the duodenum of the small intestine is damaged and this is the main site for iron and folate absorption. Thus, iron deficiency and folate deficiency anemia can occur as a result of celiac.

Additionally, vitamin B12 deficiency is common in celiac disease too. As a result, vitamin B12 deficiency anemia can co-occur with celiac.

So can celiac disease cause anemia? Yes. Celiac disease can cause anemia. In fact, it’s one of the common women’s health symptoms of celiac disease.

Why do Celiacs Have Low Iron?

Celiacs can have low iron for a variety of reasons.

First, low iron in celiac disease can be a result of intestinal damage. As discussed previously, the small intestinal damage that occurs when a celiac eats gluten can impair iron absorption and storage in enterocytes. Thus, leading to low iron status in celiac patients. 

Second, a gluten-free diet often involves removing a lot of commonly iron-fortified foods. This includes many breakfast cereals. Because people with celiac are likely to eat less iron-fortified foods, they are at higher risk for low iron status. 

Lastly, you may be at even high risk for iron deficiency with celiac if you are also vegan. This is because now, not only are you removing fortified foods from your diet but you’re also eliminating meats that have the most bioavailable form of iron in them.

Unexplained Anemia is a Sign of Celiac

Because people with celiac disease are at such a high risk for dietary anemias, unexplained anemia and iron deficiency is often a warning sign of celiac disease. Be mindful of this as you talk with family. And, if you have unexplained anemia and were diagnosed with celiac, I hope this offers validation for your experience.

Treating Celiac Disease and Anemia

Treating anemia from celiac disease involves healing the small intestine, healing your relationship with food, and addressing associated nutrient intake.

First, if you don’t heal the small intestines from celiac, then it doesn’t matter how much iron, folate, or B12 you eat, you’ll still struggle with absorption. Thus, you’ll continue to struggle with low levels of them. So priority is eating gluten-free to prevent damage and give you body a chance to heal.

Second, if you don’t heal your relationship with food, then it will be hard to eat and trust the foods that will renourish your body. This is a step in the celiac healing journey that is so often forgotten but so essential.

Third, to address the deficiencies you need to give your body the nutrients. This can be from nutrient-specific dense foods or through supplementation. If you are unsure which is the right choice for you, discuss your options with your health care team.

That said, below are some gluten-free foods high in the 3 common dietary deficiency anemias seen in celiac disease.

Gluten-free Foods High in Iron

Iron is essential to celiac fertility, blood circulation and oxygenation, women’s health, and so much more. If you’re looking to increase your iron-intake consider adding the following gluten-free iron-rich foods to your diet:

  • Eggs
  • Beef
  • Chicken
  • Turkey
  • Lamb
  • Pork
  • Bacon
  • Liver
  • Oily fish and shellfish
  • Wholegrains like amaranth, brown rice, buckwheat, millet, oats, and quinoa
  • Beans
  • Nuts and seeds

If you’re looking to really increase your iron intake, consider cooking with a dedicated gluten-free cast iron skillet or a lucky iron fish.

Gluten-free Foods High in Folate

Folate based anemia can occur with celiac. Additionally, eating gluten free can eliminate a lot of folate-fortified grains. Thus, it is important to pay attention to the gluten free grain products that you buy to see if folate/folic acid is added into them or if you will need to get them in your diet elsewhere from other food sources or supplementation.

You can get folate from gluten-free foods like beans, dark leafy greens, broccoli, brussels sprouts, liver, and gluten-free fortified grain products.

Gluten-free Foods High in B12

Foods high in B12 primarily include animal-based products. This means meats and dairy products have high amounts of B12. Thus, if you’re gluten-free and not vegan, including animal products in your diet can help with B12 deficiency.

However, if you are vegan or plant-based, it may be harder to get B12. Soy milk and almond milk tend to be fortified with vitamin B12. Nutritional yeast is also a good source.

Just be sure when you’re sourcing nutritional yeast, it’s not coming from bulk bins. Bulk bins can be a big source of cross-contact with celiac.

Monitoring Anemia in Celiac Disease

Monitoring anemia in celiac disease typically involves blood tests. Most commonly anemia is screened for using a Complete Blood Count. They may also test your iron, folate, and b12 levels to assess for the type of dietary anemia.

What to do if you Have Celiac and are Anemic

If you have celiac disease and are anemia, don’t panic. As discussed, anemia is a common symptom of celiac disease due to intestinal damage.

The best thing to do if you have anemia with celiac disease is to focus on healing your small intestine, your relationship with food, eating a balanced gluten-free diet, and taking supplements as needed.

Rest assured, as you heal, your anemia should go away too (unless it’s caused by another underlying condition).

Worried about your nutrition status? Work with a Celiac Dietitian to make sure you’re nourishing yourself properly with celiac.