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Recently, I wrote a brief article for Today Health about how Miley Cyrus took to Twitter to credit a gluten-free diet for her recent weight loss. Because gluten-free diets have become ridiculously popular in recent years, are very challenging to follow, and aren't always warranted, I turned to one of my colleagues, noted gluten expert Shelley Case, B. Sc., RD, author of Gluten Free Diet: A Comprehensive Resource Guide, to share what you need to know about gluten (and celiac disease). Here’s Case’s top 10 list:

1. Celiac disease is serious: Celiac disease is a serious autoimmune disorder that affects 1:100 people yet only about 5-10% with the disease are diagnosed. Symptoms of CD are variable, may occur at any age (including the elderly) and involve not only the gastrointestinal system but many other organ systems. Infants and young children can present with bloating, gas, diarrhea, weight loss, poor growth, irritability, dental enamel defects and/or anemia. In older children and adults, symptoms can be mild to severe. Some may present with only a few symptoms while others can have many different symptoms. These include:

  • Anemia
  • Nausea
  • Reflux
  • Bloating
  • Gas
  • Diarrhea or constipation (or both)
  • Lactose intolerance
  • Weight loss (CD can also occur in obese individuals)
  • Mouth ulcers
  • Extreme fatigue
  • Irritability
  • Bone and joint pain
  • Easy bruising of the skin
  • Menstrual irregularities
  • Miscarriage
  • Infertility (in both women and men)
  • Migraines
  • Depression
  • Ataxia
  • Seizures
  • Neuropathy
  • Elevated liver enzymes

2. Test first, diet later. It is critical you get tested for celiac disease BEFORE going on a gluten-free diet because once on the diet it is difficult to get an accurate diagnosis. The blood and small intestinal biopsy tests requires that you be on a gluten-containing diet for at least 6-8 weeks. In some cases you may need to be on it for months for the tests to be positive.

3. Get screened. If you feel better on a gluten-free diet, it’s possible you may actually have undiagnosed celiac disease. Without a confirmed diagnosis, you may not be motivated to follow the lifelong strict gluten-free diet to prevent complications of celiac disease such as anemia, osteoporosis, development of other autoimmune disease and cancer. Also, celiac disease affects between 5-15 percent of first degree relatives, so it’s important for family members be screened. This may not occur to you if you don’t have an official diagnosis.

4. See if you’re sensitive. If the tests come back negative for celiac disease it is possible you may have non celiac gluten sensitivity (GS). New research from the Center for Celiac Research in Baltimore indicates up to 6 percent of the population may have non celiac gluten sensitivity. Symptoms of GS are often similar to those of celiac disease. Currently, the only way to diagnose GS is to rule out celiac disease. For more information about GS, see:

5. Gluten-free after diagnosis. The only treatment for celiac disease is a strict gluten-free diet for life. It is thought that those with GS also need to follow a gluten-free diet, but it is not known whether the diet needs to be followed as strictly or for life. More research about GS is needed.

6. Eat with caution. A gluten-free diet requires that all forms of wheat, rye and barley, including spelt, kamut, einkorn, emmer, faro, durum, couscous, semolina, bulgur and triticale, as well as barley malt extract/flavoring, malt vinegar and brewer’s yeast must be avoided. The diet is very challenging to follow because gluten is found in such a wide variety of foods such as breads and other baked products, cereals, pastas, soups, sauces such as soy sauce (which is often made from wheat and soy), seasonings, salad dressings, snack foods, prepared meats (e.g., deli meats, hot dogs, hamburger patties, imitation seafood), beer, flavored coffees and teas, some candies (e.g., licorice) and chocolate bars, as well as some nutrition supplements and medications. Because of the complexity of the diet, it is essential you consult with a registered dietitian for a nutritional assessment, education about the diet and to ensure your diet is healthy.

7. Focus on naturally gluten-free foods: A wide variety of foods that are naturally gluten-free include plain meat, poultry, fish, eggs, pulses (legumes), nuts, seeds, milk, yogurt, cheese, fruits, vegetables, as well as many gluten-free flours, cereals and starches* that can be substituted for wheat, rye and barley. Distilled alcoholic beverages and wines are also allowed, however beer derived from barley must be avoided. There are a variety of gluten-free beers made from sorghum, buckwheat, rice and other grains. All vinegars are gluten-free except for malt vinegar (made from barley and is not distilled).

*Gluten-Free Flours, Cereals and Starches

· Amaranth

· Arrowroot

· Buckwheat

· Corn

· Flax

· Pulse flours (bean, chickpea/garbanzo, lentil, pea)

· Mesquite flour

· Millet

· Nut flours (almond, hazelnut, pecan)

· Potato Flour

· Potato Starch

· Quinoa

· Rice Bran

· Rice Polish

· Sago

· Sorghum

· Soy

· Sweet Potato Flour

8. Don’t be fooled. A gluten-free diet is not always synonymous with a nutritious diet. Many gluten-free products are higher in fat, sugar and calories; lower in fiber, iron and B vitamins because they are often made with refined flours and starches (e.g., white rice flour, potato, corn and tapioca starch); and not enriched with vitamins and minerals as their gluten-containing counterparts.

9. Go for gluten-free grains. Incorporate more gluten-free whole grains in your diet. For tips and recipes see

10. Stay in the know. For more information about celiac disease, gluten sensitivity, and the gluten-free diet see

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Going gluten-free--avoiding foods that contain this certain type of protein--has become a popular trend over the last few years. While many who cut gluten out of their diets do so because of sensitivities or because they've been diagnosed with Celiac Disease, others have begun to do so because they think it'll help them cut calories and lose weight, or even get healthier.

The popularity of The G-Free Diet by The View co-anchor and GMA contributor Elizabeth Hasselback*, and the estimated $2.6 billion in sales of 'G-Free' foods in the U.S. in 2010 (not to mention 30 percent growth between 2006 and 2010) show us that gluten-free foods may become, in many ways, more of a rule than an exception for many.

Because May is National Celiac Awareness Month, and because many ask me about the gluten-free trend, I asked my colleague and friend Rachel Begun, a registered dietitian, to share some information about Celiac Disease as well as her personal experiences as someone with the condition.

EZ: What exactly is Celiac Disease (CD) and how common is it?

RB: According to the Celiac Disease Foundation, Celiac Disease (CD) is a lifelong inherited autoimmune condition that affects both children and adults. When people with CD consume foods that contain gluten, it creates an immune-mediated toxic reaction that damages the small intestine and doesn't allow food to be properly absorbed. Even small amounts of gluten in foods can affect those with CD and cause health problems. Damage can occur to the small bowel even when there are no symptoms present.

About 1 in 133 Americans have CD, but of those, only an estimated 3 percent are diagnosed; that means about 97 percent of people with the condition walk around undiagnosed, not knowing they have the condition and not getting the proper dietary and lifestyle treatment they need to manage the condition. Symptoms of CD vary among individuals, but if left untreated it can lead to:

o   Nutrition deficiencies and their associated conditions, including anemia and osteoporosis

o   Neurological disorders

o   Liver and thyroid conditions

o   Infertility (men and women)

o   Depression

o   Intestinal lymphomas and other GI cancers

o   Other autoimmune diseases, including lupus and rheumatoid arthritis

A strict gluten-free diet is the only treatment for CD--easier said than done since gluten is omnipresent in our food supply, cross contamination in restaurants is highly prevalent, and standardized gluten free labeling on food packaging has not yet been approved by the Food and Drug Administration (FDA.)

EZ: What exactly is gluten, and what foods contain it?

RB: Gluten is the common name for the proteins found in specific grains that are harmful to people with CD. Gluten is found in all forms of wheat (including durum, semolina, spelt, kamut, einkorn and faro) and in rye, barley and triticale. All of these must be eliminated in the diet of someone with CD. And although oats do not specifically contain gluten, they can become contaminated in the manufacturing process; I encourage people with CD to consume only certified gluten free oats.

Question (EZ): When were you diagnosed with CD?

Answer (RB): I was diagnosed in 2009.  I am a classic example of a person with CD who was misdiagnosed for many years. Like so many others, I was told I had Irritable Bowel Syndrome (IBS).

Question (EZ): What were your symptoms?

Answer (RB): My whole life I’ve had a “bad stomach” and suffered repeatedly with symptoms such as diarrhea, gas, cramping and bloating.  Then my symptoms started getting much worse.  I was extremely lethargic all the time, sleeping too much and experiencing what I now know to be “brain fog.”  When I had three stomach virus-like episodes within a month, I knew there was something else going on. I wasn’t eating dairy, so I knew it wasn’t lactose.  I began an elimination diet and, when I put gluten back in my diet, I noticed the more severe symptoms returned.  That’s when I went to a GI specialist.  Initial blood tests showed I was deficient in iron, B12 and carnitine.  My doctor then tested me specifically for CD and that's when I found out I had the condition.

Question (EZ): I understand that eating out can be a real challenge for those who have to eliminate certain foods--and such pervasive ones like that including bread and pasta. Having eaten with you, I know that having a conversation with the waiter or the chef at a restaurant, is often needed (and not so bad--especially if they're cute!) What do you and recommend others with CD do when they eat out?

Answer (RB): Whenever possible, I call the restaurant ahead of time to let them know that I have CD and that I have to completely avoid coming into contact with wheat, rye, barley and oats.  Prior to going to the restaurant, I review the menu so I can get an idea of the items I would like to have and which are generally less likely to have gluten or be contaminated so that I can focus my questions on these items. At the restaurant, I clearly communicate to the waiter that I have to avoid gluten and when ordering I ask very precise questions to know all of the ingredients in the dishes I am interested in, as well as exactly how they are prepared and whether they can be made with sterilized cookware, utensils and surfaces.  For example, eggs and omelets are generally gluten free, but not if they are made on the same grill on which pancakes are made, which is common in diners. In such a situation, I would ask that they be prepared in a pan that has been cleaned. If the waiter or chef cannot confirm what ingredients are in a dish or how it is prepared, I err on the side of caution and don’t order it.  There have been times when I’ve (politely) walked out of a restaurant due to not feeling comfortable about eating safely.

Question (EZ): How do you eat at home?

Answer (RB): Eating at home is much easier, as I know exactly what goes into my food.  While I’ve always enjoyed cooking, I do so much more now than before being diagnosed.  My husband is really supportive and has offered to be completely gluten free in the house, but I don’t want him to have to miss out and encourage him to keep some of his favorite gluten-containing items on hand. To make sure I am safe:

  • the counters are always wiped down after a gluten-containing item is prepared
  • we have two toasters and two sets of pots and pans, one for gluten free foods and one for gluten-containing foods
  • we do not share jarred and spreadable items, like butter, jams, nut butters and hummus; instead, we purchase two jars of the same product and print out a gluten free label to put on one
  • gluten-containing items are placed on the bottom shelf of the pantry so that they don’t contaminate gluten-free items

This sounds very restrictive, but it’s really not.  It’s more about getting into a routine and sticking to it. In fact, we have been able to explore cooking with so many new foods and probably eat a wider variety now than before I was diagnosed.

Question (EZ): Do you think people who don't have CD or certain sensitivities should go gluten-free? What are the perks/perils of doing so?

Answer (RB): There are some people without CD or non-Celiac gluten sensitivity that swear they feel better without gluten in their diet.  If that's the case, then good for them and they should avoid gluten.  I say that with a big caveat, however.  I think taking gluten out of the diet is often confused for taking highly processed gluten-containing foods out of the diet and, yes, anyone taking processed foods out of the diet and replacing them with wholesome, natural foods is going to feel better.  That isn’t an effect of removing gluten from the diet, it is the result of removing low nutrient foods from the diet!  For those taking gluten out of the diet (both processed and natural foods) because they think it is a magic bullet for losing weight or being healthier, that just isn’t so.  Unlike their gluten-containing counterparts, many gluten free products on the market aren't enriched with iron and B-vitamins, are made with starch fillers devoid of fiber and trace minerals, and contain more fat, sugar and calories.  The perks come when people begin adding more naturally gluten-free foods like fruits and vegetables, low-fat dairy, lean cuts of meat and poultry, fish, beans, nuts and seeds into their diets. The perils come when the diet is heavy in highly processed gluten-free foods.

Question (EZ): What are your favorite resources for those with CD to help them better understand and get a better handle on the condition in the real world?

Answer (RB): There are so many great gluten free resources, but the ones I use on a regular basis include:


The Ultimate Guide to Gluten-Free Living – Celiac Disease Center at Columbia University

Gluten-Free Diet: A Comprehensive Resource Guide – by registered dietitian Shelley Case

The Essential Gluten-Free Restaurant Guide – Triumph Dining


Gluten Free Living

Living Without

Informational/Advocacy Websites

National Foundation for Celiac Awareness (disclosure: I am an Ask the Dietitian expert and consulting dietitian for NFCA)

Celiac Disease Foundation

Gluten Free Recipe Websites

Silvana’s Kitchen

Elana’s Pantry

Gluten Free Girl and the Chef

EZ: Can you share a favorite recipe?

RB: Here's a delicious one (if I say do say so myself) for ChocoCocoNut Cookies. It shows you that you can be gluten-free and still eat deliciously and healthfully.

ChocoCocoNut Cookies

These cookies are gloriously rich and satisfying without containing any refined grains, gluten, dairy or refined sugar. A great way to indulge while feeling good about what you put into your body.
These cookies are gluten free and dairy free.


2 cups walnut pieces

1⁄2 tablespoon ground cinnamon

2 egg whites, whisked until frothy

1/8 cup plus 3 tablespoons honey

1 teaspoon vanilla extract

1⁄4 cup coconut flakes

1⁄2 cup large semi-sweet chocolate chips (optional)

Preheat the oven to 350°F. Grease a cookie sheet. Grind the walnut pieces and cinnamon in a small food processor to a flour-like consistency. Mix the walnut cinnamon mixture with the eggs, honey and vanilla extract to make a batter. Mix in the coconut flakes. Batter should thicken. If desired, toss in chocolate chips. Drop equal-sized portions of batter onto cookie sheet. Bake for 12 - 15 minutes, or until edges start to brown.

Makes 12 cookies.

About Rachel Begun, MS, RD, CDN:

Rachel Begun, MS, RD, CDN is a registered dietitian and accomplished food and nutrition communications professional.  She provides food and nutrition marketing, communications, education and spokesperson expertise to food companies, retailers and foodservice/hospitality providers, as well as to schools, camps and health organizations. Rachel also provides gluten-free/allergy-friendly counsel to private clients and educates the public via speaking opportunities and writing, including her own blog, The Gluten Free RD.

*I have not read the book The G-Free Diet, and my mention of it here is not meant to be an implied endorsement.

If you have celiac disease, please share your tips for eating and living in the real world.

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