Celiac Disease and B12
You’re at increased risk with celiac disease for B12 deficiency. Celiac disease causes gluten to be a danger to many aspects of an individual’s health. The small intestine can be heavily damaged by gluten with celiac. This leads to nutrient concerns due to malabsorption.
Vitamin B12 is one of the nutrients of major concern. It’s an even greater concern if someone is following a vegan diet with celiac. This is why it is important to ensure someone with celiac disease is not deficient in this nutrient.
Drafted by Dietetic Intern, Jan Wasmuth, revised by Registered Dietitian, Tayler Silfverduk
Table of Contents
What is Celiac Disease?
When talking about celiac disease and vitamin B12, we need to know what Celiac is. To keep it brief, celiac disease is an autoimmune disease where the body reacts to gluten.
Gluten is a protein found in wheat, barley, and rye. For those with celiac disease, exposure to gluten causes inflammation and damage to the small intestine. The inflammation and damaged small intestines can cause nutrients to not be absorbed properly.
Additionally, the autoimmune reaction to gluten with celiac disease can cause over 300 different symptoms in the body. From things GI distress like bloating and constipation to things like headaches and anxiety.
The only way to manage celiac and all of these symptoms is to eat gluten-free.
What is Vitamin B12
Continuing the conversation on the relationship between celiac disease and B12, we also need to know what B12 is. Vitamin B12 (also referred to as cobalamin) is an essential B vitamin. It’s typically found in animal foods but can be fortified in plant-based food.
It’s important for the formation and health of cells, including those of the brain and nerves. It is a key player in the development of DNA and red blood cells.
Why is Vitamin B12 Important with Celiac Disease
Now that we know what celiac disease and vitamin B12 are, we can talk about how they are related. More importantly, we can talk about why it’s essential to pay attention to B12 with celiac disease.
Due to the small intestinal damage that occurs when a celiac eats gluten, vitamin B12 deficiency can be common. Although vitamin B12 deficiency can negatively impact anyone, it is especially concerning for those with celiac disease.
This is because damage to the small intestine from eating gluten with celiac disease can impair absorption of vitamin B12 causing low-levels in people with celiac. This can be come even more concerning if the person is vegan and already consuming less B12.
What’s more concerning is that these low levels of vitamin B12 can develop into a nutritional anemia. Which is where the body is lacking in a specific nutrient that impacts the health of the red blood cells in your body.
Symptoms of B12 Deficiency with Celiac Disease
Vitamin B12 deficiency with celiac disease can look like a lot of things. However, it is most tricky because symptoms of low B12 can be similar to symptoms already experienced as a result of celiac disease.
These symptoms include nausea, decreased appetite, weight loss, low energy and tiredness, and diarrhea. Other symptoms can include tingling or numbness in extremities, muscle weakness, difficulty walking, feeling irritable, tenderness of the tongue, and a fast heart rate.
Generally, seeking a nutrient panel that assesses for the nutrients of concern with celiac disease can help you determine if vitamin deficiencies related to celiac are causing or worsening symptoms.
Testing for B12 Deficiency in Celiac
Speaking of nutrient panels, testing B12 levels with celiac disease can be done with a simple blood test.
The blood test does not require fasting and the results will be analyzed to determine if there is a vitamin B12 deficiency.
The blood test may also be ordered to check for folate deficiency because symptoms of the deficiencies of both nutrients are extremely similar.
Of course lab ranges and units of measure vary by lab and healthcare system. As always interpretation of your lab results should always be discussed with your doctor. This post is for educational purposes only.
Can Celiac Disease Cause High B12?
So celiac disease and B12 are related in that celiac can cause low-levels of B12 in celiac patients. But can celiac disease also cause high levels of B12?
There is limited clinical data on high B12 with celiac disease, however I am often asked about if there is a relationship. While I most often see low B12 with celiac disease, I’ve heard people complain of high B12 on social media
It’s important to note that high B12 levels can indicate serious problems like liver disease. This also could be used to speculate why some people with celiac can have high B12 levels.
If you didn’t know, celiac can have liver presentations. Most commonly, can cause liver inflammation, also known as hepatitis. This could be a reason for high B12 levels in the blood as sometimes an inflamed liver has trouble properly storing b12.
I share this speculation with a big warning: do not try to self-diagnose this. Be sure you are working closely with your healthcare team to determine the cause.
Celiac Disease and B12 Deficiency Anemia
Low and high B12 with celiac aside, what about anemia? Since B12 is necessary for red blood cell development and health, a deficency in B12 can lead to B12 deficiency anemia.
Red blood cells help carry oxygen throughout the body. Anemia is a condition where there is not an adequate number of healthy red blood cells. Since celiac disease can impact B12 status and can lead to deficiency, this form of nutritional anemia can occur. However both low B12 status and the nutritional anemia can be addressed by intaking enough B12.
It’s also important to know that B12 deficiency anemia is not the only form of anemia someone with celiac can struggle with. Other dietary forms like folate and iron-based anemia are common to. Learn more about anemia and celiac disease here.
This is also important to know because vitamin B12 deficiencies can make it look like someone is deficient in folate, another nutrient of concern with celiac, when they aren’t.
What to do About Low B12 With Celiac Disease
Now that we know about the risks of low B12 with Celiac Disease, it’s important to know how to manage these risks should you find you have low b12.
Although supplementation may be necessary, there are many other ways to help achieve normal vitamin B12 levels for those deficient due to celiac disease.
First, make sure to avoid all gluten. Staying gluten-free ensures that you will not cause further damage to your small intestines and will give your gut a chance to heal. A damaged gut can cause you not to properly absorb nutrients such as vitamin B12. A healed gut allows you to absorb these vitamins.
Also, avoid cross-contact between gluten and gluten-free foods during preparation and serving because even a little gluten can further exacerbate damage and inflammation.
If you need help with learning how to avoid gluten and cross-contact, check out my Celiac Crash Course which covers ALL of the basics so that you’re staying as safe as possible.
Additionally, be mindful of where you B12 is coming from in your food. B12 is naturally found in animal-based products like dairy and meat. That said, you can also find it in nutritional yeast and in fortified foods like plant-based milks. We’ll talk more about food sources later.
Lastly, be sure to discuss with your healthcare team if a supplement would be a good fit. There’s no shame in taking supplements if you need them. Sometimes the nutrients we get from our diet are not enough.
Gluten-Free Food Sources of B12
So boosting b12 intake can help with low b12 with celiac disease. But what foods can you eat to make sure you’re getting enough of this essential nutrients?
There are many foods that are naturally gluten-free and contain vitamin B12. Adults should generally consume the RDA (recommended daily allowance) of 2.4 mcg (micrograms) of vitamin B12 daily (however, these needs could be higher if malabsorption is happening).
You can meet the recommended amount of this nutrient through certain foods. Great foods to meet or exceed the daily recommended intake include:
- 3.5 oz beef/lamb/veal liver or kidneys
- 3.5 oz clams, 1 cup sardines
- 3.5 oz cuts of beef (such as steak)
- 3.5 oz trout or cooked tuna, half a fillet (about 6 oz) salmon
- slightly over 2 cups whole milk
- a little less than 3 slices of Swiss cheese
- or 4 eggs
Obviously, you don’t need to eat these exact portions to meet your needs. Mixing and matching different portions should suffice. And clearly, you don’t have to eat any abnormal amount of food to meet these needs.
The biggest concern is if you are vegan, these animal sources of B12 are no longer available and you need to rely on supplements or fortified foods.
Gluten-Free Foods Fortified with B12
Speaking of gluten-free fortified foods to eat to boost B12 with celiac disease, let’s talk about your options! Some gluten-free foods that naturally are not rich in vitamin B12 can be great sources of the nutrient due to fortification.
Many traditional pastas, breads, and cereals that contain gluten are fortified with B vitamins, but most gluten-free grain-based products are not.
Therefore, it is important to be mindful of labels and find gluten-free products (grain-based and otherwise) that are fortified with vitamin B12 (in addition to gluten-free foods naturally high in vitamin B12) in order to ensure you meet your needs.
A couple foods commonly fortified with vitamin B12 include nutritional yeast and nondairy milks (soy, almond, rice). Additionally, soy-based products are often fortified with vitamin B12, but make sure you choose gluten-free soy products.
However, it’s important to note that not every single one of these plant-based alternatives will be fortified. You will need to check. When checking to see if a food is fortified with B12 you may see it on the nutrition panel or listed in the ingredients as Vitamin B12 or Cyanocobalamine. Two milks that are fortified with B12 include many Dream Blends Milk (like Coconut or Rice Dream Milk) and many Silk products.
Gluten-Free B12 Supplements
Food sources of b12 our of the way, sometimes people with celiac may need B12 supplements. Although sticking to a gluten-free diet will help heal the gut and lower inflammation (which helps improve nutrient absorption), supplements may be needed during the time while the gut is not fully healed.
Furthermore, deficiencies can continue due to the gluten-free diet often being lower in B12 fortified foods than traditional gluten-containing diets, especially if you are following both a vegan and gluten-free diet.
Therefore, vitamin B12 supplementation can be advised in some cases. There are many options for supplementing B12. Forms that require a prescription and are sometimes used to treat severe deficiencies include B12, cyanocobalamin or hydroxocobalamin. These forms of B12 are given parenterally as injections.
You can also get over-the-counter B12 supplements. The typical form of B12 in supplements is cobalamin. These type of supplement options are multivitamins that include B12 (usually B12 doses of 5-25 mcg), supplements that are B-complex formulas (usually doses of 50-500 mcg), supplements that solely contain B12 (usually doses of 500-1000 mcg), and B12 lozenges or tablets.
The absorption rate of B12 supplements is believed to be similar for all forms. However, the absorption rate is only 50% for small doses (1-2 mcg) and even less for larger doses (for example, the absorption rate for a dose of 500 mcg is only 2%).
There is no upper limit for B12 because it is a water soluble vitamin, so excess is excreted instead of being stored in the body. Therefore, there are no known risks of taking B12 oral supplements for most people (unborn babies and individuals with diabetic nephropathy could experience negative consequences with overdose of B12).
However, B12 injections can cause symptoms of dizziness, headaches, nausea, diarrhea, tiredness, irritated skin, and tingling in the extremities. A general recommendation for those with gastrointestinal issues is 1mg daily.
Your healthcare providers can help you determine if you need to supplement B12 and if so, what size dose you need. Always consult your doctor before starting any new supplement.
Summary
B12 and celiac disease are related in that celiac can cause low B12. This is because celiac disease leads to damage and inflammation in the small intestine. This causes malabsorption of nutrients, including B12.
Those with celiac disease may be deficient in B12 due to gluten exposure that occurred prior to a recent diagnosis, due to cross-contact while following a gluten-free diet, or due to a lack of adequate B12 intake while following a gluten-free diet.
B12 is necessary for cell and DNA formation, along with metabolism of carbs to energy. Symptoms include many of those experienced with celiac disease, such as gastrointestinal and stomach issues, fatigue, etc
Blood tests are used to determine deficiency. There are many animal-based foods that are naturally gluten-free and contain notable amounts of B12. There are also gluten-free foods that are fortified with B12. Even vegans have options for gluten-free foods that are fortified with B12.
Supplementation may be necessary in some cases. There are many options, including over-the-counter forms of B12 (multivitamins, lozenges, etc.) and prescriptions, including injections.
It’s possible to stay celiac-safe, enjoy a gluten-fee diet, and keep your B12 levels adequate.