Amy Burkhart, MD, RD, is a board-certified emergency medicine physician and registered dietitian. She also trained in integrative medicine with Dr. Andrew Weil at the University of Arizona Center for Integrative Medicine. Her practice is located in Napa, CA.
1100 Lincoln Ave. Suite 200
Napa, CA 94558
(707) 927-5622 Office
This month I address a topic that is rarely covered in the media swirl surrounding the gluten-free diet, yet is vitally important. When symptoms are persistent while on a gluten-free diet, common culprits such as other food sensitivities or exposure to gluten are evaluated, as I addressed in a previous column onongoing symptoms. While these factors are often the cause and are important to consider, they aren’t the only reasons for symptoms to persist. At times, ongoing symptoms are a result of the treatment itself.
Patients are becoming more aware that they are at risk for vitamin and nutrient deficiencies on a gluten-free diet. Common deficiencies include vitamin D, iron, B vitamins, calcium, zinc, copper, and vitamins A, E and K. As supplements are easily available over the counter, patients on a gluten-free diet are taking them to prevent deficiencies or address persistent symptoms. Supplements can be beneficial, but they need to be used with caution.
A patient recently came to my office for chronic digestive symptoms. She was on a gluten-free diet for non-celiac gluten sensitivity. During her initial visit, she mentioned painful burning and numbness she had been experiencing in her feet for about a year. As many people do, she had started herself on nutritional supplements to ensure she was getting adequate vitamins and minerals. She knew the gluten-free diet could be deficient in many nutrients so she wanted to safeguard against any potential problems. What she didn’t realize, however, was that supplements can be toxic, even to those at risk of deficiency.
When her vitamin B6 level came back “too high to count,” we addressed the safe use of vitamins and supplements, an important topic for anyone taking nutritional supplements.
Since her recent visit, I have seen many other patients with vitamin toxicities due to supplements they were taking before our initial visit, suggesting this issue may be more common than is realized. It is difficult to say how common it is as there is little to no medical data on vitamin toxicity while on a gluten-free diet. The cases I have seen all occurred in people taking supplements. Below are four examples of vitamin toxicities I have seen the most in my practice, although the potential for toxicity exists with other vitamins taken in supplementation.
1. Vitamin B6
Taking high doses of vitamin B6 for prolonged periods can lead to permanent nerve damage.
Vitamin B6 serves as a co-factor (helper) for many metabolic functions in the body. It is vital in maintaining health, but when taken at high doses for prolonged periods of time, it can cause nerve destruction. If high blood levels are not addressed, the damage can be irreversible. Common symptoms of vitamin B6 toxicity include painful numbness and tingling of the hands and feet, ataxia (loss of coordination in body movement), painful skin lesions, nausea, heartburn and photosensitivity.
Recommended doses vary, but suggested doses for adults range from 1-2mg per day. Many supplements contain much higher quantities. Recommended amounts for a safe upper limit of normal range from 50mg-100 mg per day. If blood levels are found to be high, all supplements containing vitamin B6 should be discontinued until levels return to normal. Good food sources of vitamin B6 are whole grains, chickpeas, starchy vegetables such as potatoes and organ meats. There are no reported cases of B6 toxicity from food sources.
Iron deficiency is common whether or not a person is on a gluten-free diet, but taking iron without appropriate monitoring can be dangerous.
Iron is essential for carrying oxygen in the blood. It is also needed for many enzymes and proteins to function. Although it is an essential nutrient, the potential for iron toxicity is high because very little of it is excreted from the body. Symptoms of iron overload include joint pain, fatigue, weight loss, nausea and stomach pain.
A very common genetic condition called hemochromatosis occurs in 1% of the population. Most people with this condition do not know they have it. People with hemochromatosis are very efficient at absorbing iron. When iron accumulates in the body, it deposits in body tissues and in organs like the liver. I have seen several cases of hemochromatosis in the past few months, as it is not rare. If someone with this very common condition takes iron supplements, they can become iron toxic rather quickly.
If iron levels are elevated, typically stopping all iron is all that is needed. If the person has hemochromatosis, frequent blood draws ( a process known as therapeutic phlebotomy) may be needed to get iron levels back to the normal range.
The recommended daily intake for adults is based on age and ranges from 8-18mg per day. Tolerated upper limits are 45mg per day. Supplementation beyond the daily recommended amount should be under medical supervision and should not be undertaken without first evaluating baseline level. Food sources of iron include liver, beef, chicken, fortified cereals, beans, lentils, spinach and molasses.
3. Vitamin A
Vitamin A is necessary for normal vision, organ and immune function as well as reproduction, but toxicity can cause serious symptoms.
There are two forms of vitamin A:
– Preformed (animal sources and many supplements) In supplements the preformed vitamin A is typically called retinyl acetate and retinyl palmitate.
– Provitamins (plant sources and some supplements) In supplements this form of vitamin A is called beta carotene. Provitamins do not appear to be toxic, but can turn the skin orange if ingested in very high amounts.
High intake of the preformed types of Vitamin A are associated with toxicity, and can cause nausea, dizziness, elevated intracranial pressure (pressure around the brain), headaches, coma and death. High vitamin A levels during pregnancy are associated with birth defects. The recommended daily intake of vitamin A is 2300 IU for women and 3000 IU for men. The recommended daily allowances differ during pregnancy and for children based on age. The daily upper safe limits for Vitamin A are 2000 IU for infants, 3000-5000 IU for children (depending on age) and 10,000 IU per day for adults.
If levels are elevated, treatment typically consists of stopping all supplements. If someone has neurologic symptoms, additional treatments or medications may be required. Food sources of preformed vitamin A are liver and fish oil, milk, and eggs. Good plant sources of vitamin A are sweet potato, spinach, carrots and pumpkin.
4. Vitamin D
Vitamin D has become a panacea, but high doses can work to our detriment.
Vitamin D is important for numerous functions in our body including healthy bone formation, calcium regulation, neuromuscular and immune function. It is also important in minimizing inflammation. It is present in very few foods unless they are fortified, but is produced by our bodies when we are exposed to sunlight. Due to lack of dietary sources and minimal exposure to sunlight for many people, toxicity is rare unless supplementation is taken.
Symptoms of toxicity are vague and include poor appetite, weight loss, irregular heart rhythms and increased urination. Recommended daily intake ranges from 400-600 IU per day, depending on age, but there has been a movement to shift that recommendation closer to 1000-2000 IU per day based on more recent findings. Daily upper tolerable limits range from 1000 IU – 4000 IU per day depending on age. Clinically, many patients require higher doses to maintain adequate serum levels so monitoring is necessary.
If levels are unsafely elevated, stopping supplementation is all that is required. Food sources of vitamin D include fortified products such as milk, cereals and orange juice. Small amounts of vitamin D are found in beef liver and egg yolks.
Back to my patient We stopped all her vitamins that contained B6 and her levels came down. Her numbness and tingling are resolving, and with time have a good chance of disappearing completely. I hope her story and this information makes you more aware of the caution to be taken with supplements. They can be very helpful in improving health, but please use them with care and under the supervision of a health care practitioner.