Anemia in coeliac disease

Anemia is the result of a decrease in the size or number of red blood cells, or a reduction of haemoglobin, which is the red pigment in red blood cells. Red blood cells carry oxygen from the lungs to the rest of the body. In one popular metaphor, the red blood cells are ships that transport oxygen, and haemoglobin is what the crates that hold the oxygen are made of.  

If there is a shortage of red blood cells or haemoglobin, oxygen cannot be properly delivered to all of the body’s cells. Oxygen is essential to convert food into energy, required to make all the body’s processes function. Symptoms of anemia include easy fatigue and loss of energy, unusually fast heartbeat, shortness of breath and headaches during exercise, difficulty concentrating, dizziness and pale skin.  

Coeliac disease is an autoimmune disorder related to gluten, a protein found in the cereals wheat, barley and rye. When a person has coeliac disease, the immune system mistakenly identifies substances found inside gluten as a threat to the body and attacks them. This damages the lining of the small intestine, and disrupts the body’s capacity to absorb nutrients from food.   

Iron, folate and vitamin B12 are among the nutrients a person with coeliac disease may stop absorbing properly. A shortage of any of these nutrients can lead to anemia. Iron is an essential component of haemoglobin, while folate and vitamin B12 are essential for the formation and growth of red blood cells.  

Iron and folate deficiencies are the most common causes of anemia among coeliac patients because both of these nutrients are absorbed in the upper two parts of the intestine, where damage can occur in earlier stages of coeliac disease. If coeliac disease is not diagnosed or treated for a long time, the lower part of the small intestine can also suffer damage, potentially leading to vitamin B12 deficiency.  

A separate autoimmune condition that also leads to vitamin B12 deficiency is called pernicious anemia. In these cases, the body’s immune system attacks cells in the stomach that produce a substance which allows for the absorption of vitamin B12. Eventually, these cells stop producing the substance and vitamin B12 cannot be absorbed, leading to anemia. 

The most commonly noticed sign of coeliac disease in adults is iron-deficiency anemia. Typically, an adult will be diagnosed with an iron deficiency and not respond to treatment with supplementary iron. If you are having difficulty dealing with iron-deficiency anemia, it is possible that you have coeliac disease, something you should discuss with your doctor. Although coeliac disease can cause symptoms such as abdominal cramping and bloating, and diarrhoea or constipation, some people do not experience these kinds of symptoms but the damage to the small intestine occurs nonetheless. 

Women who have not reached the menopause require more iron than men due to menstrual loss. Up to the age of 50, women are recommended a daily iron intake of 14.8 mg, compared to 8.7 mg for men and older women.  

Research has shown that coeliac disease is a major cause of iron-deficiency anemia in children.  Medical profession recommend that screening for coeliac disease should be carried out routinely on any child who has iron-deficiency anemia. Coeliac disease in children can also lead to reduced growth and delayed puberty owing to the intestine’s reduced capacity to absorb nutrients.  

The good news is that, once diagnosed and treated with a gluten free diet, coeliac patients are usually able to leave malabsorption-related health problems such as anemia behind. The small intestine begins to heal as soon as the autoimmune reaction stops occurring. It can take as little as a few weeks or up to 18 months for nutritional deficiencies to be corrected

For everyone, and especially people with coeliac disease, it is important to ensure you are getting enough iron in your diet. There are two types of iron in food: haem iron from animal sources, and non-haem iron from plant sources. Both are valid sources of the nutrient, but haem iron is absorbed more easily. Foods rich in haem iron include red meat, liver and egg yolk. Good sources of non-haem iron suitable for a gluten free diet include green leafy vegetables, pulses, dried fruits, and nuts and seeds. 

Absorption of iron is enhanced by also eating vitamin C, so combining a source of iron with citrus fruits, peppers, tomatoes or other fruit and vegetables high in vitamin C will help.  

Iron supplements are a way of boosting intake, but some people find them hard on the stomach. Taking them with meals can help to ease the discomfort, although bear in mind this may mean you absorb less of the iron. 

Folic acid (folate) and vitamin B12 can also be taken as supplements. Consult with your doctor to ensure your diet is getting all the nutrients you need.