Understanding Persistent Anemia in Celiac Disease Despite a Gluten-Free Diet

Celiac.com 04/14/2025 - Celiac disease is an autoimmune disorder triggered by gluten, a protein found in wheat, barley, and rye. The primary treatment for celiac disease is a strict gluten-free diet, which helps heal the damaged small intestine and alleviates symptoms. However, some patients continue to experience health issues, such as anemia, even after adopting a gluten-free diet. This study explores why anemia persists in some individuals with celiac disease and how the timing of diagnosis and dietary adherence play a role.

The Link Between Celiac Disease and Anemia

Anemia, particularly iron deficiency anemia, is a common symptom of celiac disease. This occurs because the damaged small intestine cannot properly absorb nutrients, including iron, folate, and vitamin B12, which are essential for producing healthy red blood cells. While a gluten-free diet often resolves these issues, some patients continue to struggle with anemia despite following the diet for years.

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This study aimed to:

1. Determine the prevalence of anemia in patients with celiac disease at the time of diagnosis.
2. Evaluate whether anemia improves after starting a gluten-free diet.
3. Identify factors that contribute to persistent anemia in these patients.

How the Study Was Conducted

Researchers analyzed medical records of 311 patients with celiac disease, including 184 adults and 127 children, from the University Hospital of L’Aquila in Italy. Data were collected at three time points:

• At diagnosis (T0).
• After 3 to 5 years on a gluten-free diet (T1).
• After 8 to 10 years on a gluten-free diet (T2).

The study focused on hemoglobin levels, iron, folate, and vitamin B12 levels, as well as other factors like age, gender, and the severity of intestinal damage at diagnosis. Patients with conditions that could independently cause anemia, such as chronic kidney disease or inflammatory bowel disease, were excluded from the study.

Key Findings

1. Anemia at Diagnosis

At the time of diagnosis, 24% of adults and 5.6% of children with celiac disease had anemia. Adult women were more likely to be anemic, likely due to factors like menstruation. In children, anemia was more common in younger patients, possibly because they had more severe intestinal damage at diagnosis, leading to greater nutrient malabsorption.

2. Anemia After Starting a Gluten-Free Diet

After 3 to 5 years on a gluten-free diet, there was no significant improvement in anemia rates for either adults or children. However, after 8 to 10 years, a notable reduction in anemia was observed in adults, with the prevalence dropping from 24% to 17.8%. In children, the prevalence of anemia remained low at 4.4%.

3. Factors Contributing to Persistent Anemia

The study identified several factors that may explain why some patients continue to experience anemia despite following a gluten-free diet:

• Delayed Diagnosis: Adults often experience a longer delay in receiving a celiac disease diagnosis compared to children. This prolonged exposure to gluten can cause more severe intestinal damage, making it harder to fully recover.
• Ultrastructural Damage: Even after the visible healing of the intestinal lining, microscopic damage to the cells responsible for nutrient absorption may persist. This could impair the body’s ability to absorb iron and other nutrients effectively.
• Dietary Adherence: While all patients in the study were advised to follow a gluten-free diet, the researchers did not have detailed data on how strictly each patient adhered to the diet.

Why These Findings Matter for People with Celiac Disease

This study highlights the importance of early diagnosis and strict adherence to a gluten-free diet for individuals with celiac disease. The longer the delay in diagnosis, the greater the risk of persistent health issues like anemia. For adults, who often face longer diagnostic delays, this can mean a slower recovery and a higher likelihood of ongoing symptoms.

The findings also underscore the need for ongoing monitoring and support for patients with celiac disease. Even after starting a gluten-free diet, some individuals may require additional interventions, such as iron supplements or further medical evaluation, to address persistent anemia.

Limitations of the Study

While the study provides valuable insights, it has some limitations:

• The retrospective design means that some data, such as dietary adherence and additional health conditions, were not consistently available.
• The study population was limited to patients from a single hospital in Italy, so the results may not apply to all populations.
• The researchers did not have detailed information on the types of iron supplements or other treatments patients may have used.

Conclusion

This study reveals that anemia is a persistent issue for some individuals with celiac disease, even after years on a gluten-free diet. Early diagnosis and strict dietary adherence are crucial for improving outcomes, but additional factors, such as microscopic intestinal damage, may also play a role.

For those living with celiac disease, these findings emphasize the importance of regular follow-up care and open communication with healthcare providers. By addressing persistent anemia and other ongoing symptoms, patients can work toward better long-term health and quality of life.

Read more at: bmcgastroenterol.biomedcentral.com