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How Vitamin Deficiencies Are Making Your Crohns Worse

Vitamins are important for optimal health but they are especially important in Crohn’s disease because the damage to the gastrointestinal tract affects their absorption. Therefore, vitamin deficiencies are quite common among patients with Crohn’s disease. Vitamin deficiencies not only keep Crohn’s disease active, they may cause severe complications in other organs in the body. This article discusses the most important vitamin deficiencies to patients with Crohn’s disease and how to reverse them.
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Nutritional deficiencies are quite common among people living with Crohn’s disease.

Although mineral and vitamin deficiencies mostly affect those with active Crohn’s disease, it can also affect Crohn’s disease patients in remission.

Causes of Vitamin Deficiencies in Crohn’s Disease
  • Diet – Consuming foods low in certain vitamins can cause nutritional deficiencies. Often, people with Crohn’s disease are placed on special diets such as low fiber, non-fortified cereals that are lacking essential nutrients
  • Malabsorption – Vitamins are absorbed in the intestines. Therefore, inflammation and damage to the sites of absorption can significantly reduce the rate and extent of absorption of vitamins
  • Presentations of the Disease – Diarrhea, one of the most common symptoms of Crohn’s disease, can speed up the emptying of the gut and, therefore, reduce absorption of nutrients. In addition, Crohn’s disease patients may have difficulty swallowing and lose their appetite; both of these presentations can lower dietary sources of essential vitamins
  • Treatment – Both the surgical removal of parts of the small intestine and some drugs used in the management of Crohn’s disease can block the absorption and uptake of vitamins

Discussed below are the most common vitamin deficiencies affecting Crohn’s disease patients.

Vitamin A Deficiency

Studies show that the serum concentrations of vitamin A and plant-derived pro-vitamin A compounds such as lutein, zeaxanthin as well as alpha and beta carotene are significantly lower in patients with Crohn’s disease than in healthy subjects.

A 1998 study published in the Journal of Pediatric Gastroenterology and Nutrition also confirmed that vitamin A deficiency was more common among children and young adults with Crohn’s disease than healthy controls.

In addition, the study also found that

  • Low vitamin A levels were more common than low vitamin E levels in Crohn’s disease
  • Vitamin A deficiency was more common in patients with active disease than those in remission
  • The severity of Crohn’s disease is a better way of predicting vitamin A deficiency in these patients than measuring serum retinol (active form of vitamin A) levels

In fact, some researchers have reported that serum retinol levels can be normal in patients with Crohn’s disease even when they show clear signs of vitamin A deficiency.

Although serum retinol levels are not a good predictor of vitamin A deficiency, studies show that low levels of serum retinol-binding protein is a good indicator of low vitamin A levels.

One identified cause of vitamin A deficiency in Crohn’s disease is malabsorption of fats.

Because vitamin A is a fat-soluble vitamin, it needs fats to be absorbed in the gastrointestinal tract. Support for this conclusion comes from the low serum carotene levels in patients with Crohn’s disease who are also experiencing steatorrhea (increased fecal excretion of dietary fat).

Vitamin A Supplementation

Supplements are commonly recommended to correct vitamin A deficiency in Crohn’s disease. However, vitamin A supplements can be toxic in high doses.

Therefore, you should consult your physician before starting vitamin A supplementation.

Besides simply correcting vitamin A deficiency, there are indications that vitamin A may help in the other ways in the management of Crohn’s disease.

A 2009 study published in the journal, Gastroenterology, showed that retinoic acid (another form of vitamin A) can induce a sub-family of T cells known to suppress intestinal inflammation. Although vitamin A supplements are not used as anti-inflammatory agents in the treatment of Crohn’s disease, this study suggests the possibility of such therapy.

Vitamin B9 Deficiency

Vitamin B9 is a water-soluble B vitamin also known as folic acid. Although deficiencies of water-soluble vitamins are not common in Crohn’s disease, folate deficiency (and vitamin B12) is quite common.

Studies show that folate deficiency affects about 30% of patients with Crohn’s disease.

Signs of folate deficiency include weight loss, loss of appetite, depression, lethargy, irregular heartbeat and anemia.

Causes of Vitamin B9 Deficiency

The 4 known causes of folate deficiency in Crohn’s disease are malnutrition, malabsorption, increased utilization of folic acid and drugs used in the treatment of Crohn’s disease.

While folate deficiency due to malnutrition can easily be corrected with foods rich in folic acid and folate supplements, correcting malabsorption of the vitamin may require administering the vitamin by alternative delivery routes that bypass the gastrointestinal tract.

In addition, the inflammatory component of Crohn’s disease increases the utilization of folate in the body. This means that folate deficiency may result even when its absorption is unaffected.

The cells of the immune system are believed to use up more folate as they mount an inflammatory response to widespread bacterial attack in the gastrointestinal tract.

Lastly, the treatment options for Crohn’s disease can also lower folate levels in the body.

For example, the surgical removal of parts of the intestine may impair the absorption of folic acid. Besides surgery, some drugs commonly used in the management of Crohn’s disease can also cause folate deficiency.

Methotrexate and sulfasalazine are 2 such drugs proven to lower folate levels in Crohn’s disease.

Folic Acid, Vitamin B12 and Homocysteine

Homocysteine is a toxic intermediate product of amino acid synthesis. It is quickly converted to non-toxic compounds in the body.

However, this conversion requires folic acid and vitamin B12. Therefore, folate and vitamin B12 deficiencies can lead to the accumulation of homocysteine. Because these two deficiencies are common in Crohn’s disease, high blood levels of homocysteine is also a common feature of Crohn’s disease.

In one study, half of the Crohn’s disease patients pooled had very high levels of this toxic compound.

Homocysteine is especially harmful to the nervous and cardiovascular systems. It is known to cause nerve damage as well as increase the risk of heart disease.

However, new evidence shows that the negative effects of homocysteine extend beyond these two organ-systems. In fact, homocysteine can directly worsen the symptoms of Crohn’s disease. One study found that homocysteine can also accumulate in the mucosal surfaces of the gastrointestinal tract.

The presence of homocysteine in the mucosal lining of the gut can only promote inflammation as the compound releases harmful free radicals to further attack the exposed mucosal layer of the gut.

Vitamin B12 Deficiency

Vitamin B12 deficiency is even more common than folate deficiency among patients with Crohn’s disease.

The site of vitamin B12 absorption in the gastrointestinal tract is the terminal ileum (end of the small intestine). Unfortunately, this is one of the two sites most affected by Crohn’s disease (the other site is the colon).

Therefore, vitamin B12 supplementation is especially important in the management of Crohn’s disease and patients are advised to regularly check their vitamin B12 status.

Like folate deficiency, vitamin B12 can cause weakness, depression, anemia and also raise the concentration of homocysteine in the blood.

Because of the damage to the ileum, most patients with Crohn’s disease cannot simply raise their vitamin B12 levels with foods rich in the vitamin or oral supplements. This is because vitamin B12 obtained from these sources still need to be absorbed in the ileum before it becomes available.

In place of oral supplementation, vitamin B12 is delivered by other routes in the management of Crohn’s disease.

The most common method of raising patients’ vitamin B12 levels is with vitamin B12 injections.

Vitamin B12 injection is given as a monthly shot. Other routes of administering vitamin B12 for patients with extensive damage to the ileum include by nasal spray and transdermal patches.

The vitamin B12 released from these dosage forms is readily available because it does not pass through the gastrointestinal tract.

Vitamin D Deficiency

Vitamin D status is relevant to Crohn’s disease because the vitamin plays important roles in inflammation and the immune system. In addition, vitamin D has been shown to have antibacterial properties and it is also needed for the regulation of certain minerals such as calcium.

In fact, vitamin D is related to multiple risk factors for Crohn’s disease and researchers are not sure whether vitamin D deficiency increases the risk of Crohn’s disease or the disease causes the deficiency.

Some expert believe that the high incidence of vitamin D deficiency among Westerners especially African-Americans is responsible for the high incidence of Crohn’s disease in Europe and America.

Already, scientists have identified a few genetic links between vitamin D and the immune deficiency that leads to Crohn’s disease.

Besides African-Americans, studies show that vitamin D deficiency is most likely to affect patients with Crohn’s disease restricted to the upper gastrointestinal tract as well as patients who are placed on long-term glucocorticoid therapy.

Can vitamin D supplementation correct vitamin D deficiency in Crohn’s disease? Yes.

Vitamin D supplementation has been proven to relieve the symptoms of Crohn’s disease. Regular supplementation is also recommended even for patients in remission.

Besides dietary sources of vitamin D and vitamin D supplements, patients can also raise their vitamin D levels by increased sun exposure. Where this is not possible, studies have shown that exposure to ultraviolet (UVB) rays on a tanning bed is equally effective.

In fact, UVB tanning has been shown to effectively raise vitamin D levels when oral vitamin D supplements failed.

Vitamin E Deficiency

Vitamin E is another fat-soluble vitamin. Therefore, its deficiency can easily result from impaired fat absorption commonly experienced in Crohn’s disease.

Signs of vitamin E deficiency include muscle weakness, impaired muscle coordination, impaired immune function and progressive loss of vision.

Because it is an antioxidant vitamin, low levels of vitamin E can result in increased oxidative stress. This can worsen inflammation in Crohn’s disease. Therefore, vitamin E supplementation can significantly reduce oxidative stress and inflammation as well as relieve symptoms in patients with Crohn’s disease.

Vitamin K Deficiency

Vitamin K is another fat-soluble vitamin. Its deficiency is quite common among patients who have lived longest with Crohn’s disease.

In addition, studies show that vitamin K deficiency mostly occurs in patients with damaged ileum. Long-term antibiotics and sulfasalazine use can also lower vitamin K levels.

Another cause of vitamin D deficiency in Crohn’s disease is the restricted diet commonly recommended for patients with inflammatory bowel disease. High-fiber vegetables and fortified cereals rich in vitamin K are commonly excluded from the diets designed to relieve the symptoms of Crohn’s disease.

The most important danger of vitamin K deficiency in Crohn’s disease is the increased risks of osteoporosis and osteopenia.

Studies show that 12% of patients with Crohn’s disease also suffer from osteoporosis and 30% of them already have osteopenia.

Vitamin K is required as a cofactor for the production of osteocalcin, the protein needed to bind calcium to bones. Therefore, vitamin K deficiency can reduce bone mineral density and increase the risk of bone diseases.

The combination of vitamin K deficiency and vitamin D deficiency can significantly accelerate bone loss in patients with long-standing Crohn’s disease.

To increase vitamin K levels in Crohn’s disease, studies show that green, leafy vegetables rich in vitamin K1 and vitamin K2 supplements are equally effective. These sources of vitamin K can also reduce the risk of bone fracture.





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