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Recommendations Summary

CD: Supplements (2021)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CD: Addition of Vitamin and Mineral Supplements

    For all individuals with celiac disease, it is reasonable for the registered dietitian nutritionist or international equivalent to advise daily consumption of gluten-free age-and sex-appropriate vitamin and mineral supplements if dietary intake and/or laboratory tests indicate nutritional inadequacies.

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      • Supplementation must be considered on an individual basis. Individuals supplemented with micronutrients should be monitored regularly to determine the continuing need  for supplementation and to avoid toxicity. 
      • Based on the included studies, there is no clear evidence of direct benefit from vitamin/mineral supplements. However, no undesirable/negative effects were reported with supplement use in these studies. However, consumption of nutrients should not exceed the upper limit of the Dietary Reference Intakes (DRIs).

    • Conditions of Application

      This recommendation applies to individuals when usual food intake shows nutritional inadequacies that cannot be alleviated through improved eating habits. Certain populations might be at higher risk of micronutrient deficiencies, and this must be taken into consideration. Those that are pregnant, vegan, vegetarian or have various diagnoses such as malabsorption, anorexia, status post gastric bypass surgery or are taking certain medications with drug-nutrient interaction, may have different micronutrient needs requiring supplementation of specific nutrients.  

      Refer to Refer to the Nutrition Care Manual for Client Education documents for Education on Gluten-Free Nutrition Therapy, Label reading tips, and healthy eating tips. https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=163

      Implementation Considerations

      • Obtain information from individuals regarding the type and amounts of any current micronutrient and/or multivitamin/mineral supplements.
      • Assess an individual’s dietary intake, including consideration of fortified foods.
      • Recommendations for vitamin/mineral supplementation dosage should be individualized based on each patient’s nutritional assessment, including their age-appropriate micronutrient needs and risk profile.
      • Generally, an individual’s vitamin/mineral intake should be based on the recommendations for the general population (ex: Dietary Reference Intake or Recommended Dietary Allowance) unless there are specific considerations requiring modification.

    • Potential Costs Associated with Application

      The cost of nutrition supplements should be considered before recommending these to a patient.

    • Recommendation Narrative

      A total of five studies (all rated neutral-quality) examined the effects of supplements, compared to a control, on nutrition-related outcomes in patients with celiac disease. Of the included studies, three studies were conducted in Europe (Italy, Sweden and the Netherlands) and two in India. Three studies included adults with celiac disease and two studies included children with celiac disease as their target population. Time since diagnosis varied across studies, with participants ranging from newly diagnosed (Ciacci et al, 2007; Negi et al, 2018; Rawal et al, 2010) to over 8 years since diagnosis (Hallert et al, 2009). Sample sizes of participants analyzed ranged from 22-48 per group (some studies included additional participant groups not considered for this review). The type of supplements utilized in the intervention group varied across the studies, and included L-carnitine (Ciacci et al, 2007), vitamin B6, folate and vitamin B12 (Hadithi et al, 2009; Hallert et al, 2009) and zinc (Negi et al, 2018; Rawal et al, 2010). Only two studies (Negi et al, 2018; Rawal et al, 2010) reported on baseline nutrient status. Both focused on nutrient-deficient populations.

      Of the studies that examined the effects of supplements, compared to a control group, on nutrition related outcomes in patients with celiac disease, two reported on indicators of quality of life, including fatigue, general health perception and psychological well-being (Ciacci et al, 2017; Hallert et al, 2009). All studies (Ciacci et al, 2007; Hadithi et al, 2009; Hallert et al, 2009; Negi et al, 2018; Rawal et al, 2010) reported on nutrition-related laboratory measures, including serum levels of L-carnitine (Ciacci et al, 2007), vitamin B6 (Hadithi et al, 2009;), folate (Hadithi et al, 2009; Hallert et al, 2009), vitamin B12 (Hadithi et al, 2009; Hallert et al, 2009), hemoglobin (Hallert et al, 2009; Negi et al, 2018), ferritin (Negi et al, 2018), zinc deficiency (Negi et al, 2018), copper (Negi et al, 2018), homocysteine (Hadithi et al, 2009; Hallert et al, 2009), creatinine (Hallert et al, 2009) and plasma zinc (Rawal et al, 2010). Negi et al, 2018 also reported on weight gain among the intervention and control groups. 

      Results Overview
      The effects of supplements, compared to a control group, on nutrition-related outcomes in patients with celiac disease is unclear. While Ciacci et al, 2017 noted a significant improvement in self-reported fatigue after the study period among the intervention group in comparison to the control group (p=0.021), there were no significant differences observed in other scales, including the EuroQoL and the Short Form-36 General Health Perception Scale in the same study. Hallert et al, 2009 also noted no significant difference between the intervention and control group on self-reported psychological well-being.

      All studies (Ciacci et al, 2007; Hadithi et al, 2009; Hallert et al, 2009; Negi et al, 2018; Rawal et al, 2010) assessed the effect of supplements on nutrition-related laboratory measures. While Ciacci et al, 2007 and Rawal et al, 2010 found no significant differences in laboratory measures between the intervention and control groups (serum L-carnitine and plasma zinc, respectively), Hadithi et al, 2009; Hallert et al, 2009; and Negi et al, 2018 noted significant differences between the groups taking supplements when compared to the control groups in levels of homocysteine, hemoglobin, folate, vitamin B6 and B12, ferritin and occurrence of zinc deficiency. Negi et al, 2018 assessed differences in anthropometrics (weight gain) between the group who received supplementation (zinc) and those who did not and found no difference.

    • Recommendation Strength Rationale

      The recommendations regarding general guidance for micronutrient supplementation are based on Consensus/Expert Opinion. 

    • Minority Opinions

      Consensus reached.