Pancreatitis and Nutritional Deficiencies
Chronic pancreatitis (CP) impacts digestion, making it tough for the body to absorb nutrients from food. This can lead to nutritional deficiencies, meaning the body doesn’t have enough essential nutrients to function properly. Pancreatitis patients need to address these deficiencies early on to prevent additional complications such as fatigue and bone disease.
What are nutritional deficiencies?
Nutritional deficiencies are when the body doesn’t have enough of the essential nutrients it needs to work properly and stay healthy. These nutrients can’t be made in the body or are made in very small amounts, so they need to be included regularly in our diets. Each nutrient serves specific functions, and a deficiency in any of them can lead to health problems.
There are six essential nutrients that the body needs. These include:
- Protein
- Carbohydrates
- Fat
- Vitamins
- Minerals
- Water
Protein, carbs, and fat are macronutrients, while vitamins, minerals, and water are micronutrients. Most people can get enough nutrients by eating a balanced diet, avoiding over-restriction, and eating a good variety of food. However, some may require additional supplements to meet their nutritional needs.
What causes nutritional deficiencies in pancreatitis patients?
Nutritional deficiencies in chronic pancreatitis primarily stem from the pancreas no longer working properly during digestion (exocrine pancreatic insufficiency). This makes it difficult for the body to absorb nutrients from food and drink (malabsorption). However, other factors can make pancreatitis patients more at risk of developing nutritional deficiencies as well.
Other factors that can increase the risk of nutritional deficiencies in CP include:
- Frequent Steatorrhea. Steatorrhea (loose, oily stools) is a common symptom of CP and exocrine pancreatic insufficiency. Steatorrhea indicates that your body isn’t absorbing fat properly, which can lead to nutritional deficiency.
- Poor Diets. CP patients often restrict their diets to alleviate symptoms, like abdominal pain. However, if a diet becomes too limited, patients may not get enough specific nutrients needed to maintain their health.
Patients who have frequent steatorrhea and poor diets should talk to their doctor about starting Pancreatic Enzyme Replacement Therapy (PERT). PERT works by replacing the digestive enzymes your pancreas may not be making enough of. This can make it easier for your body to digest food and reduce digestive symptoms, like steatorrhea. Taking the right amount of PERT can also let you enjoy a wider range of foods, naturally increasing the amount of nutrients in your diet.
Listen to Dr. Sinead Duggan of Trinity College Dublin explain:
- What are vitamins and minerals
- Why are vitamins and minerals important for our health
- Common deficiencies in pancreatitis
- Who’s at risk and why
- Symptoms to look out for
Common Deficiencies & Symptoms
People with chronic pancreatitis face a higher likelihood of developing deficiencies in essential nutrients. When your body doesn’t get enough vitamins and minerals, it can lead to various health issues, such as weakened bones, neurological changes (confusion, difficulty walking, etc.), and noticeable changes in your hair, skin, nails, oral health, and vision. However, symptoms of nutritional deficiency are often subtle and may only include signs like tiredness and fatigue.
Fat-Soluble Vitamins
Because pancreatitis patients often avoid and have trouble digesting dietary fat, they are more at risk of developing fat-soluble vitamin deficiency. Fat-soluble vitamins are absorbed by the body when eaten with some amount of dietary fat and include vitamins A, D, E, and K. These vitamins are stored in body fat and liver tissue, so deficiency can take longer to occur. Because they are stored in the body, people need to be careful not to consume too much of these vitamins. However, fat-soluble vitamin deficiencies may develop sooner if not enough fat is consumed.
Vitamin A
Vitamin A is important for vision, the immune system, reproduction, growth, development, and the proper function of organs.
Symptoms of vitamin A deficiency include:
- Keratitis (inflamed cornea)
- Eye ulceration
- Night blindness (called xerophthalmia)
- Respiratory disease
- Frequent infections
- Anemia
Foods containing vitamin A include:
- Some fish (salmon, herring)
- Green leafy vegetables
- Sweet potatoes
- Carrots
- Broccoli
- Winter Squash
- Some fruits (cantaloupe, mangos, apricots)
- Dairy products
- Eggs
Vitamin D
Vitamin D helps your body absorb calcium, which is important for healthy bones. Without it, pancreatitis patients are at risk of developing bone disease. Vitamin D is also important for muscle movement, nerve function, and the immune system.
Symptoms of vitamin D deficiency include:
- Bone loss (osteoporosis, osteopenia)
- Fractures (broken bones)
- Soft bones (osteomalacia)
- Severe muscle weakness (myopathy)
Most foods do not contain vitamin D unless artificially added (fortified foods). Foods that may contain vitamin D include:
- Fortified milk (in the U.S.)
- Fortified breakfast cereals
- Fortified orange juice
- Fortified yogurt
- Fatty fish (trout, salmon, tuna)
- Egg yolks
- Cheese
- Mushrooms
Vitamin E
Vitamin E acts as an antioxidant, protecting cells from damage. It also helps the immune system, blood circulation, and cell function.
Symptoms of vitamin E deficiency include:
- Neurological changes
- Brown Bowel Syndrome (BBS)
- Nerve damage
- Muscle damage
- Loss of body movement control
- Muscle weakness
- Vision problems
Foods containing vitamin E include:
- Vegetable oil (wheat germ, sunflower, safflower oil)
- Nuts (peanuts, hazelnuts, almonds)
- Seeds (sunflower seeds)
- Green vegetables (spinach, broccoli)
- Fortified breakfast cereals
- Fortified fruit juice
- Fortified margarine and spreads
Vitamin K
Vitamin K plays an important role in blood clotting, wound healing, and maintaining bone health.
Symptoms of vitamin K deficiency include:
- Coagulation (abnormal blood clotting)
- Bleeding disorders
- Bruising easily
- Reduced bone strength
- Bone loss (osteoporosis, osteopenia)
Foods containing vitamin K include:
- Green leafy vegetables (spinach, kale, lettuce)
- Vegetable oils
- Some fruits (blueberries, figs)
- Meat
- Cheese
- Eggs
- Soybeans
Water-Soluble Vitamins
Water-soluble vitamins include the B vitamins and vitamin C. These vitamins are not stored in the body and must be included regularly in our diet. For pancreatitis patients, restricted diets and malabsorption increase the risk of water-soluble vitamin deficiency.
Vitamin B1 (Thiamin)
Vitamin B1 (Thiamin) helps turn food into energy in the body. It also supports the growth, development, and function of cells.
Symptoms of vitamin B1 deficiency include:
- Weight loss
- Reduced appetite
- Confusion
- Memory loss
- Muscle weakness
- Heart problems
Foods containing vitamin B1 include:
- Whole grains
- Fortified grains (bread, cereal, pasta, rice)
- Meat
- Fish
- Legumes
- Seeds
- Nuts
Vitamin B12
Vitamin B12 keeps your body’s blood and nerve cells healthy and plays an important role in making DNA (the genetic material of cells). Vitamin B12 is found naturally in animal products and added to some fortified foods.
Symptoms of vitamin B12 deficiency include:
- Megaloblastic anemia
- Apathy
- Irritability
- Memory loss
- Dementia
- Psychosis
Foods containing vitamin B12 include:
- Fish
- Meat
- Poultry
- Eggs
- Milk
- Dairy products
- Fortified breakfast cereals
- Fortified nutritional yeast
Vitamin B2 (Riboflavin)
Vitamin B2 (Riboflavin) helps turn food into energy in the body. It also supports the growth, development, and function of cells.
Symptoms of vitamin B2 deficiency include:
- Changes in skin
- Mouth sores
- Swollen, cracked lips
- Hair loss
- Sore throat
- Liver disorders
- Reproductive problems
- Nervous system problems
- Anemia
- Cataracts (cloudy eyes)
Foods containing vitamin B2 include:
- Eggs
- Lean meats
- Low-fat milk
- Some vegetables (mushrooms, spinach)
- Fortified grains (cereal, bread)
Vitamin B3 (Niacin)
Vitamin B3 (Niacin) helps turn food into energy in the body. It also supports the development and function of cells.
Symptoms of vitamin B3 deficiency include:
- Pellagra
- Rough skin that turns red or brown in sunlight
- Bright, red tongue
- Vomiting, constipation, diarrhea
- Depression
- Headaches
- Fatigue
- Behavioral changes (aggression, paranoia, apathy)
- Hallucinations
- Memory loss
- Loss of appetite
Foods containing vitamin B3 include:
- Meat
- Some nuts, legumes, and grains
- Fortified foods (breads, cereals)
Vitamin B5 (Pantothenic acid)
Vitamin B5 (Pantothenic acid) helps turn food into energy in the body. It also supports many other bodily functions, like making and breaking down fats.
Symptoms of vitamin B5 deficiency include:
- Numbness and burning of hands and feet
- Headache
- Fatigue
- Irritability
- Restlessness
- Sleeping problems
- Stomach pain
- Heartburn
- Diarrhea, nausea, and vomiting
- Loss of appetite
Foods containing vitamin B5 include:
- Meat
- Eggs
- Milk
- Some vegetables (mushrooms, potatoes, broccoli)
- Whole grains
- Peanuts, sunflower seeds, and chickpeas
Vitamin B6
Vitamin B6 supports enzyme reactions in metabolism. It also plays a role in the immune system and brain development during pregnancy and infancy.
Symptoms of vitamin B6 deficiency include:
- Anemia
- Itchy rashes
- Chapped, cracked lips
- Swollen tongue
- Depression
- Confusion
- Weak immune system
Food containing vitamin B6 include:
- Meat
- Starchy vegetables (potatoes)
- Non-citrus fruits
Vitamin B7 (Biotin)
Vitamin B7 (Biotin) helps turn food into energy in the body.
Symptoms of vitamin B7 deficiency include:
- Thinning hair
- Loss of body hair
- Face and anal rash
- Pinkeye
- High levels of acid in blood and urine
- Seizures
- Skin infection
- Brittle nails
- Nervous system disorders
Foods containing vitamin B7 include:
- Meat
- Nuts and seeds
- Some vegetables (sweet potatoes, spinach, broccoli)
Vitamin B9 (Folate)
Vitamin B9 (Folate) helps the body make DNA and other genetic material and supports cell division.
Symptoms of vitamin B9 deficiency include:
- Megaloblastic anemia
- Weakness
- Fatigue
- Trouble concentrating
- Irritability
- Headache
- Heart palpitations
- Shortness of breath
- Tongue and mouth sores
- Hair, skin, and nail changes
Foods containing vitamin B9 include:
- Beef liver
- Vegetables (asparagus, brussels sprouts, spinach)
- Fruits and fruit juices
- Nuts, beans, and peas
Vitamin C
Vitamin C acts as an antioxidant, protecting cells from damage. Vitamin C also supports the production of collagen, the absorption of iron, and the immune system.
Vitamin C deficiency can cause scurvy, which symptoms include:
- Fatigue
- Inflamed, bleeding gums
- Small red or purple skin spotting
- Joint pain
- Poor wound healing
- Corkscrew hairs
- Loose teeth
- Depression
- Anemia
Foods containing vitamin C include:
- Citrus fruits (oranges, grapefruit)
- Some other fruits (strawberries, cantaloupe, tomato)
- Red and green pepper
- Vegetables (broccoli, baked potatoes)
- Fortified foods and drinks
Minerals
Minerals are elements or compounds that support a healthy body. Minerals are split into two categories: major minerals and trace minerals. Major minerals are needed in large amounts and are stored in the body. Trace minerals are needed in smaller amounts, but are just as important. Pancreatitis patients who have poor diets and frequent steatorrhea are at risk of developing deficiencies in certain minerals.
Magnesium
Magnesium is a major mineral that serves many functions in the body. This includes regulating muscle and nerve function, blood sugar levels, and blood pressure. It also plays a role in making protein, bone, and DNA.
Symptoms of magnesium deficiency include:
- Loss of appetite
- Vomiting, nausea
- Confusion
- Weakness
- Tremor
- Numb, tingling hands
- Leg cramps (especially at night)
- Muscle twitching
Foods containing magnesium include:
- Legumes
- Nuts and seeds
- Whole grains (brown rice, oats)
- Green leafy vegetables (spinach)
- Fortified foods
- Some dairy products (milk, yogurt)
Copper
Copper is a trace mineral that helps make energy, connective tissue, and blood vessels. Copper also is needed for brain development and to support the nervous system, immune system, and the activation of genes.
Symptoms of copper deficiency include:
- Fatigue
- Lightened patches of skin
- High cholesterol
- Connective tissue disorders
- Weak and brittle bones
- Loss of balance and coordination
- Increased risk of infections
Foods containing copper include:
- Beef liver
- Shellfish
- Nuts
- Seeds
- Chocolate
- Whole grains
- Wheat-bran cereals
- Potatoes
- Mushrooms
- Avocado
- Chickpeas
- Tofu
Selenium
Selenium is a trace mineral that plays a role in reproduction, thyroid gland function, and DNA production. It also acts as an antioxidant and protects the body from infections.
Symptoms of selenium deficiency include:
- Keshan disease (a type of heart disease)
- Male infertility
- Kashin-Beck disease (a type of arthritis)
Foods containing selenium include:
- Meat
- Seafood
- Eggs
- Dairy products
- Grains (breads, cereals)
Calcium
Calcium is a major mineral that is important for building and maintaining healthy bones. It also helps muscle movement, nerve function, blood circulation, and the release of hormones. Vitamin D (a fat-soluble vitamin) helps the body absorb calcium.
Symptoms of calcium deficiency include:
- Bone loss (osteoporosis, osteopenia)
- Soft bones (rickets, osteomalacia)
Foods containing calcium include:
- Dairy products
- Some fish (canned sardines, salmon with bones)
- Some vegetables (kale, broccoli, bok choi)
- Fortified drinks
- Grains (small amounts)
Iron
Iron is a trace mineral that helps the body make hemoglobin, which carries oxygen from the lungs throughout the body, and myoglobin, which provides oxygen to the muscles. Iron also helps the body make some hormones.
Symptoms of iron deficiency include:
- Anemia
- Fatigue
- Pallor (pale skin)
- Breathlessness
- Frequent infections
Foods containing iron include:
- Lean meat, seafood, and poultry
- Fortified grains (cereals, breads)
- White beans
- Lentils
- Leafy greens (spinach)
- Kidney beans
- Peas
- Nuts
- Some dried fruits (raisins)
Zinc
Zinc is a trace mineral that helps your body fight off infections, make DNA, and make protein. It also supports growth, development, and wound healing.
Symptoms of zinc deficiency include:
- Poor wound healing
- Pink eye
- Dermatitis (swollen, irritated skin)
- Alopecia (bald spots)
- Frequent infections
Foods containing zinc include:
- Seafood, oysters
- Meat, fish, poultry
- Fortified grains (cereals)
- Beans
- Nuts
- Whole grains (brown rice, oats)
- Eggs
- Dairy products
Diagnosis
Diagnosing nutritional deficiencies in pancreatitis patients typically involves a combination of medical history assessment, physical examination, and laboratory tests. Tests are specific to the patient, the patient’s condition, and symptom presentation. Common tests used to diagnose nutritional deficiencies include:
- Blood Tests
- Urinalysis
- Bone Density Testing
- Fecal Fat Test
- Specialized Tests (determined by doctor)
Unfortunately, no one test will screen for all micronutrients (vitamins and minerals). As a result, your doctor will start by looking at specific micronutrient deficiencies based on your symptoms and medical history. For pancreatitis patients, this often begins with screening for fat-soluble vitamin deficiencies and specific minerals. If a test confirms you are deficient in one of these, then your doctor may consider ordering more tests.
Listen to Dr. Kristen Roberts from The Ohio State University explain:
- Diagnosing vitamin deficiencies in pancreatitis
- Treating vitamin deficiencies in pancreatitis
Diagnostic Challenges
Chronic inflammation in pancreatitis can make it difficult to accurately diagnose nutritional deficiencies. Unfortunately, when inflammation is present in the body during a test, it can result in inaccurate results. This can make it challenging for you and your doctor to understand your micronutrient levels.
Given these complexities, healthcare professionals need to consider the clinical context, including the presence of inflammation, when interpreting laboratory results. In some cases, additional tests or clinical assessments may be needed to get a more accurate picture of a person’s nutritional status.
Consult with your healthcare provider to discuss the appropriateness of undergoing testing and to determine which specific tests align with your individual health needs.
How often should I be tested?
If you’ve been diagnosed with chronic pancreatitis, your doctor should conduct annual screenings for fat-soluble vitamins, vitamin B12, zinc, and iron (with a marker of inflammation). If any of the tests come back not normal, your doctor may recommend additional testing.
If you are not being screened for these vitamin and mineral deficiencies every year, ask your doctor to order these tests.
If you have a deficiency, your doctor should check your vitamin and mineral levels every three months until they are back to normal. If any of the tests show sudden changes to your vitamin and mineral levels, your doctor may check your levels more often.
Treatment
The first step for treating a nutritional deficiency is correcting what caused it. However, treatment for nutritional deficiencies is different from person to person and depends on the deficiency’s severity, cause, and the risk of it coming back. Your doctor may recommend either dietary changes, micronutrient supplements, or both.
Dietary Changes
Your provider may first recommend dietary changes (interventions) to treat nutritional deficiencies. This is because food provides many nutrients that artificial supplements cannot completely replace. In general, it is recommended for those with chronic pancreatitis to eat a low-fat, high-protein diet with plenty of fruits and vegetables.
Often, chronic pancreatitis patients limit how much fat they include in their diet to avoid digestive symptoms. However, this may negatively affect your body’s ability to absorb fat-soluble vitamins. As a result, your doctor may recommend adjusting the types of fats and foods you eat or prescribing pancreatic enzyme replacement therapy (PERT). PERT can help your body better absorb nutrients from the foods you eat.
It’s important to work with your healthcare team to come up with a diet plan that gives you the nutrients you need.
Learn more about nutrition for pancreatitis.
Dietary Supplements
If you have nutritional deficiencies and weight loss, your doctor may recommend supplements. There are many different types of supplements, depending on your nutritional needs. Your doctor or registered dietitian will help you choose which supplements are right for you.
Types of Supplements
Many different kinds of supplements can help manage deficiencies; however, some work better than others.
Types of supplements include:
- Tablets, capsules, pills. Tablets, capsules, and pills are common dietary supplements that should be taken with water. These are designed to contain the maximum amount of micronutrients, making sure that the most amount of nutrients is absorbed by your body.
- Gummies. Multivitamin gummies are very popular due to their fun flavors and convenience. However, gummies may not be the best supplement choice, because the micronutrient content can vary in gummy form.
- Liquids. Taking supplements in liquid form can sometimes be very helpful for those with EPI. However, liquid supplements may cause loose stools or diarrhea in some people. Talk to your doctor about any symptoms you may have.
- Water-miscible form. Your doctor may recommend a water-miscible (mixed with water/liquid) form of supplement if you are having severe diarrhea. Water-miscible supplements can be easily absorbed by the body, which may help prevent digestive symptoms. However, this form of supplement is quickly removed from the body by your kidneys and needs to be taken regularly.
Non-Prescription Supplements
If you’re considering an over-the-counter supplement, it’s recommended to talk to your doctor and choose supplements that have been tested by a third party. Look for certifications from groups like the United States Pharmacopeia (USP), ConsumerLab.com, and the National Sanitation Foundation (NSF) on the label. These organizations make sure the nutrition label is correct and that the supplement can be properly absorbed by your body. Carefully read the label to make sure you’re taking the right amount (dose).
How to Take Supplements
Always talk to your doctor before taking any supplements. Supplements can be harmful to your body if you don’t need them or are taking more than you need.
Your body can’t absorb certain micronutrients when they are taken together. Your dietician or pharmacist can set up a schedule for when to take each supplement. Your doctor will monitor your progression to maintain stable levels.
The following are general guidelines for taking specific micronutrients:
- Fat-Soluble Vitamins. Take Vitamins A, E, D, and K with foods containing some amount of fat.
- Folic acid. It’s better to take folic acid (Vitamin B9) on an empty stomach, without food.
- Zinc. Take zinc on an empty stomach; one hour before or two hours after eating.
- Iron. Take iron on an empty stomach; one hour before or two hours after eating.
- Copper. Take on an empty stomach; one hour before or two hours after eating.
- Calcium. Take calcium right after eating.
Frequently Asked Questions
Listen to Dr. Kristen Roberts from The Ohio State University answer your frequently asked questions about vitamin deficiencies and pancreatitis.
Key Takeaways
- Chronic pancreatitis increases the risk of nutritional deficiencies often due to the pancreas no longer working properly during digestion. Patients with EPI are especially at risk.
- Common deficiencies in pancreatitis patients include fat-soluble vitamins (A, D, E, K), water-soluble vitamins (B vitamins, vitamin C), and minerals. Deficiencies in these can lead to serious health problems, such as bone disease or anemia.
- Symptoms of nutritional deficiency are often vague, like tiredness or fatigue, or can be more noticeable, like the inability to see well at night (night blindness).
- Diagnosis typically involves a combination of medical history assessment, physical examination, and laboratory tests.
- The first step in treating nutritional deficiencies is to identify and correct the cause of the deficiency. This may involve dietary intervention and/or micronutrient supplements.
