Does Gluten Cause Fat Malabsorption?

Mainstream nutritionists have touted the evils of fat for years. This misinformation campaign has led to the demonization of fat and the popularization of low fat processed foods and low fat diets.  

Because of this fat phobia, the problem of fat malabsorption has been largely ignored.  Fat is one of the three major macronutrients that provide a source of energy to the body.  Fat is an essential nutrient that your body cannot function without, and it plays a role in hormone production, inflammation control, brain health, immune function, skin health, and energy production.

This article will discuss what fat malabsorption is, its symptoms and causes, and how to improve fat absorption.  It will also discuss the relationship between gluten sensitivity, celiac disease, and fat malabsorption.

What Is Fat Malabsorption?

Malabsorption is defined as the inadequate assimilation of dietary nutrients due to defects in digestion, absorption, or transport. Malabsorption can affect macronutrients (the proteins, carbohydrates, and fats that make up the food you eat), micronutrients (the vitamins and minerals that your food contains), or both.

Fat malabsorption refers specifically to the inadequate breakdown and uptake of fat into the body. Gluten induced liver and intestinal damage can contribute to fat malabsorption. Specific causes are discussed in more depth below.

What Are The Symptoms?

Symptoms of fat malabsorption include light-colored stools, foul-smelling stools, or soft stools that may either float or may stick to the sides of the toilet bowl.

There are a number of health problems linked to malabsorption, ranging from mild (if the malabsorption is a newer concern) to severe (when a malabsorption has existed over a longer period of time):

• Weight loss due to malnutrition
• Malnutrition complications: increased susceptibility to infections, increased morbidity and mortality from various disease states, growth failure and poor neurological development (in children)
• Deficiencies of fat-soluble vitamins A, D, E, and K
• Poor bone health and related disease (osteopenia, osteoporosis, and bone fractures)
• Iron deficiency anemia and megaloblastic anemia (due to B12 deficiency)
• Zinc deficiency
• Dermatitis herpetiformis, non-Hodgkin lymphoma, adenocarcinoma of the upper gastrointestinal tract
• Pancreatic pseudocyst, ascites, splenic vein thrombosis, diabetes, pancreatic cancer
• Seizure, osteopenia, ataxia, early bruising, headache, hyposplenism, and tetany
• Cirrhosis, end-stage liver disease

What causes fat malabsorption?

There are a number of causes of fat malabsorption. The following are common contributors to this condition:

• Decreased duodenal pH: an optimal pH of the upper part of the small intestine (duodenum) is 6.5. When the pH is lower, fat is less able to be broken down and absorbed.
• Decreased absorptive intestinal surface area: when part of the small intestine mucosa is lost, the digestive system experiences a decreased transit time for food to pass through  and a reduced exposure to digestive enzymatic activity. A decreased surface area may result from mucosal injury or enterocyte disease like Crohn’s disease, ulcerative colitis, or celiac disease. It may also result from a surgical resection, like that involved with elective bariatric surgery.
• Impaired fat processing by bile acids: Bile acids facilitate digestion and absorption of fats in the small intestine. Sometimes, bile acid synthesis does not reach levels needed for adequate fat absorption. It can also happen when bile acid secretion is impaired, or bile acids remain in the intestinal lumen instead of being absorbed. This may result from liver disease or cholestasis.
• Small intestinal bacterial overgrowth (SIBO): This results from the disruption of the normal, established ecology of the small bowel. Overgrowth of certain bacteria disrupt bile acids which makes the bile acids ineffective for fat absorption.
• Pancreatic exocrine insufficiency: this involves defective production of pancreatic lipase, colipase, and bicarbonate, all needed to break down fats. It may result from a number of conditions like chronic pancreatitis, pancreatic resection, cystic fibrosis, pancreatic cancer, Schwachman syndrome, Zollinger-Ellison syndrome, celiac disease, and gastric surgery.
• Lymphatic system disorders: these include intestinal lymphangiectasia (impaired lymphatic flow that affects fat processing) and Whipple disease (a rare bacterial disease).

How does gluten play a part?

So what is the connection between gluten and fat malabsorption? Well, as we know, celiac disease is a chronic autoimmune disorder of the small intestine. It is characterized by progressive atrophy or degeneration of the small intestinal villi after the consumption of gluten. Since the small intestinal villi are responsible for nutrient absorption, their destruction means that nutrients can no longer be effectively absorbed. Therefore, gluten consumption in a celiac disease patient contributes to fat malabsorption, and following a gluten-free diet is the only effective treatment for repairing the small intestinal villi and improving fat absorption. Numerous studies have explored this connection.

Furthermore, celiac disease is also associated with liver disease and gallbladder damage. Both conditions can be driven by celiac disease and gluten consumption can lead to insufficiency of the bile that aids in the absorption of fat, which then results in fat malabsorption.

In addition, celiac disease is associated with exocrine pancreatic insufficiency. This condition involves a deficiency of the exocrine pancreatic enzymes, amylase, lipase, and protease. Under normal conditions, these enzymes break undigested fats into fatty acids and monoglycerides, which are then solubilized by bile salts. An insufficiency in the amount of enzymes present, as is often the case in those with celiac disease, results in the inability to digest food properly. While enzyme supplementation is often needed to help support the breakdown of fats in those with celiac disease, research suggests that supplementation may not need to occur indefinitely.

Deficiencies resulting from fat malabsorption

Fat malabsorption from celiac disease can also cause deficiencies in fat soluble vitamins and essential fatty acids. Fat is needed to help absorb vitamins A, D, E, and K, and the malabsorption of fat includes the malabsorption of fatty acids like omega-3, omega-6, and omega-9 fatty acids in addition to other dietary fats found in food.

Another study found that deficiencies of fat-soluble vitamins and a decreased bone mineral density is frequently present in patients with chronic pancreatitis and fat malabsorption issues.

These deficiencies have also been observed in children. One study found that a significant lowness was established in vitamin D and A levels in newly diagnosed children with celiac disease. This can have a significant

Diagnosing Fat Malabsorption

How do you know whether fat malabsorption is a problem?  Because fat malabsorption has multiple causes, accurate diagnosis should always be done by your doctor through proper exam, history taking, and testing.  If you are experiencing chronic diarrhea, weight loss, tan or clay colored stools, foul smelling gas, jaundice (yellow discoloration of skin), you should talk with your doctor to further investigate.

The following tests can be helpful to help with the diagnosis:

• Pancreatic enzyme testing to include lipase
• Fat soluble vitamin deficiency testing
• Endoscopy can help rule out celiac disease as a cause
• Fecal Fat Testing
• Imaging of the GI tract and abdomen to help rule out intestinal,  liver, and gallbladder dysfunction

How to improve fat absorption

Improvement of fat malabsorption is specifically dependent upon knowing what is causing it.  In those with gluten sensitivity and celiac disease, a gluten free diet is essential to healing the small intestinal mucosal lining, pancreas, and liver in order to enable effective fat absorption. In addition, certain supplements like digestive enzymes and ox bile can be helpful in supporting the digestion of fat. If you suspect you may be experiencing difficulty digesting fats, ensure you are adhering to a strict gluten free diet and talk with your practitioner about including supplements like Lipogest (contains ox bile) and Ultra Digest(contains fat digesting enzymes) into your daily routine.

You might also consider supplementing with the following fat soluble nutrients:

• Vitamin E
• Vitamin A
• Vitamin D
• Vitamin K
• Omega Fats