Sunday, January 19, 2014

Multivitamins and IBD

Vitamin and Mineral Deficiencies with Crohn's Disease and Ulcerative Colitis

A recent study on multivitamins confirmed what previous studies have increasingly found – for healthy individuals there is no reason whatsoever to take a multivitamin.  In fact, taking too many vitamins can lead to toxic levels – more isn’t better when it comes to the trace vitamins and minerals our body needs.  Additionally, there is the cost factor – spending money on multivitamins that have no benefit and a possible downside doesn’t make sense.  The study above looked at healthy individuals, though.(1)  What about those with IBD, where malabsorption is one of the common issues?

A previous blog post (http://evidencebasedibd.blogspot.com/2013/05/malabsorption-and-ibd.html) covered the areas of the small and large intestine that cause malabsorption when active disease is present.  What specific vitamin deficiencies are most common in the IBD population? 

A preliminary study found that general deficiencies existed in:

·         Biotin
·         Folate
·         Beta-carotene
·         Vitamin A
·         Vitamin C
·         Vitamin B1
·         Vitamin B6

Additionally, individuals with small bowel specific Crohn’s had lower Vitamin B12 levels compared to a control group.(2)  A second study largely confirmed the results above, and found that those with Ulcerative Colitis had additional serum deficiencies in the minerals magnesium, selenium and zinc.(3)  Crohn’s serum levels of copper, niacin, and zinc were found to be low in a separate study.(4)

Another vitamin that gets a lot of attention and has marked deficiencies in long term Crohn’s patients is Vitamin D.  While only a fraction of patients will be Vitamin D deficient (between 10 and 25%), the long term impact on osteoporosis can be high.(5,6)

Perhaps the most frequent deficiency is related to the most common complication with IBD - anemia. Anemia is generally directly associated with disease activity – increased intestinal bleeding being the primary cause.  Anywhere from 25% to 43% of patients with IBD will have an iron deficiency present.(7,8)  Unlike other deficiencies, there is some evidence that taking oral iron may increase disease activity through the Fenton reaction, and intravenous iron supplementation is the preferred option in many cases.(9)

Why individuals with IBD are vitamin deficient can have a range of causes:

·         Malabsorption due to inflammation in the intestinal areas responsible for uptake
·         Loss of vitamins and minerals through gastrointestinal bleeding
·         Poor nutrition through unnecessary food avoidance (eating a limited diet out of fear)
·         Poor nutrition through necessary food avoidance
·         Generally increased intestinal transit time
·         Side effects of medication

Whatever the reason for the deficiency, the general treatment will be with vitamin supplementation – either through a multivitamin or even better through targeted vitamin enhancement.

 IBD is one of the exceptions to the rule about not taking multivitamins, but doing so should only occur after a complete blood workup by your physician.  This should happen at your annual checkup, and more frequently if recurring deficiencies are identified.  Additionally, patients may want to consider seeing a Registered Dietician (RD) to better round out their diet to address deficiencies in lieu of the multivitamin approach (except where the deficiency is severe).  IBD patients are not immune from taking too much in the way of vitamins – mega-dose vitamins should be avoided unless specifically prescribed by your doctor for short term use.

Bottom Line


·         Individuals with both Crohn’s and Ulcerative Colitis frequently have vitamin and mineral deficiencies not present in the normal population.
·         Having at least an annual screening for deficiencies should be part of all treatment regimes.
·         Taking multivitamins to address deficiencies may be warranted, but dietary changes are also a possibility in most cases.

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1.       Guallar E, et al. Enough is enough: stop wasting money on vitamin and mineral supplements. Ann Intern Med 2013;159:850-851.
2.       Fernandez-Banares, F., A. Abad-Lacruz, X. Xiol, J. J. Gine, C. Dolz, E. Cabre, M. Esteve, F. Gonzalez-Huix, and M. A. Gassull. "Vitamin status in patients with inflammatory bowel disease." The American journal of gastroenterology 84, no. 7 (1989): 744.
3.       Geerling, B. J., A. Badart-Smook, R. W. Stockbrügger, and R. J. Brummer. "Comprehensive nutritional status in recently diagnosed patients with inflammatory bowel disease compared with population controls." European journal of clinical nutrition 54, no. 6 (2000): 514-521.
4.       Filippi, Jérôme, Rima AlJaouni, JeanBaptiste Wiroth, Xavier Hébuterne, and Stéphane M. Schneider. "Nutritional deficiencies in patients with Crohn's disease in remission." Inflammatory bowel diseases 12, no. 3 (2006): 185-191.
5.       Tajika, Masahiro, Akira Matsuura, Tsuneya Nakamura, Takashi Suzuki, Akira Sawaki, Tetsuya Kato, Kazuo Hara et al. "Risk factors for vitamin D deficiency in patients with Crohn’s disease." Journal of gastroenterology 39, no. 6 (2004): 527-533.
6.       Siffledeen, Jesse S., Kerry Siminoski, Hillary Steinhart, Gordon Greenberg, and Richard N. Fedorak. "The frequency of vitamin D deficiency in adults with Crohn's disease." Canadian journal of gastroenterology= Journal canadien de gastroenterologie 17, no. 8 (2003): 473.
7.       Thomson, A. B. R., R. Brust, M. A. M. Ali, M. J. Mant, and L. S. Valberg. "Iron deficiency in inflammatory bowel disease." The American journal of digestive diseases 23, no. 8 (1978): 705-709.
8.       Brozović, B., N. H. Dyer, D. L. Mollin, and A. M. Dawson. "The diagnosis of iron deficiency in patients with Crohn's disease." Gut 14, no. 8 (1973): 642-648.
9.       Gasche, Christoph, Arnold Berstad, Ragnar Befrits, Christoph Beglinger, Axel Dignass, Kari Erichsen, Fernando Gomollon et al. "Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases." Inflammatory bowel diseases 13, no. 12 (2007): 1545-1553.

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