Can Celiac Disease Cause Folate Deficiency?
Yes, celiac disease commonly causes folate deficiency due to malabsorption in the proximal small intestine where folate is primarily absorbed, and this deficiency often persists even in patients following a gluten-free diet.
Mechanism and Prevalence
Folate deficiency in celiac disease occurs through multiple pathways 1:
- Proximal small bowel involvement directly impairs absorption of this water-soluble vitamin, as the duodenum and proximal jejunum—the primary sites of folate absorption—are most severely affected in untreated celiac disease 1
- Low serum folate levels were documented in half of adult celiac patients on a gluten-free diet for several years in one cohort study 2
- The deficiency is common at diagnosis and represents one of the most frequent nutritional complications alongside iron deficiency 1
The Gluten-Free Diet Paradox
A critical pitfall often overlooked: the gluten-free diet itself perpetuates folate deficiency because gluten-free products in the United States are rarely enriched with folate compared to wheat-containing products 1. This creates a secondary nutritional challenge beyond the initial malabsorption problem.
Research confirms this concern:
- All celiac patients in one cross-sectional study had folate intake below the Estimated Average Requirement (130.8 ± 53.6 μg/day) despite following a strict gluten-free diet 3
- Low serum folate concentrations (7.7 ± 3.5 ng/mL) were significantly lower in celiac patients compared to healthy controls 3
- Even patients adherent to a gluten-free diet for years showed persistent low folate levels 2
Clinical Monitoring Strategy
The British Society of Gastroenterology recommends checking serum folate at diagnosis and during annual follow-up to assess intact small intestinal absorption 2. The American Gastroenterological Association similarly advises measuring folate at diagnosis and during follow-up visits 1.
Special Populations at Risk
Pregnant women with celiac disease face compounded risk, as both pregnancy and celiac disease independently increase folate requirements 4. Folate deficiency in this population is linked to neural tube defects, spontaneous abortion, preterm birth, and intrauterine growth restriction 4.
Treatment Approach
When folate deficiency is identified:
- Oral folate supplementation effectively restores body stores in celiac patients 5
- A case report documented successful reversal of folate insufficiency with supplementation combined with a gluten-free diet 5
- The gluten-free diet alone may normalize levels in some patients, but many require ongoing supplementation due to the poor nutrient density of gluten-free products 1, 3
Key Clinical Pitfall
Do not assume that mucosal healing on a gluten-free diet will automatically correct folate deficiency. The nutritional inadequacy of commercially available gluten-free products means that dietary counseling must emphasize folate-rich foods and consider prophylactic supplementation, particularly in women of childbearing age 1, 3.