IN THIS CHAPTER
Determining whether going gluten-free is right for you
Getting rid of gluten: The basics
Preventing nutritional deficiencies
People with type 1 diabetes have an increased risk of developing celiac disease because both conditions are autoimmune disorders. Celiac disease is a disorder in which eating gluten-containing grains results in damage to the intestine. Having diabetes isn’t a reason for going on a gluten-free diet, so if gluten isn’t a concern for you, feel free to skip this chapter.
Gluten is a protein found in wheat, barley, and rye. A gluten-free diet eliminates those three grains and all ingredients derived from those grains. Going gluten-free is the only treatment for celiac disease. In the case of celiac disease, exposure to even minute amounts of gluten can lead to a long list of serious medical problems and nutrient deficiencies.
Food allergies also impose the need for dietary diligence and avoidance of the offending food. Wheat allergies affect children more so than adults, but anyone with a medically diagnosed wheat allergy should avoid eating gluten. Food intolerances are less medically severe; however, if certain foods produce unpleasant side effects, it pays to steer clear of those foods.
Gluten-free diets have gained popularity in recent years. People go gluten-free for various reasons. In fact, many of the gluten-free foods flying off the supermarket shelves are being consumed by choice, not medical necessity.
Avoiding gluten can be a challenge because wheat is the most predominant grain in the United States. Quitting gluten eliminates many foods, so diets need to be carefully constructed to assure adequate nutrition. Whether going on a gluten-free diet has been medically prescribed for your or is simply your personal preference, this chapter provides information on which foods to choose and which to avoid.
Weighing In on the Gluten-Free Debate: Fad or Fact?
Gluten-free diets have become very trendy in recent years. Increased demand has resulted in an explosion of new gluten-free products. It’s easier than ever to walk into a supermarket and find gluten-free breads, snacks, crackers, pizza crusts, frozen waffles, and even name-brand baking mixes. Stores are stocking a wider array of wholesome grains that are naturally gluten-free. Unfortunately, an abundance of gluten-free snack foods and baked goods are refined, low in nutrients, and high in calories, and they’re no healthier than their gluten-containing junk-food counterparts.
With the right information and a lot of attention, a properly designed gluten-free diet can be healthy, well-balanced, and nutritionally complete, and it can be consistent with diet recommendations for managing diabetes. The following sections take a closer look at the reasons people go gluten-free.
Avoiding gluten fastidiously when you have celiac disease
Celiac disease is a genetic autoimmune disorder affecting 1 out of 100 people. If someone in your immediate family has celiac disease, your risk jumps to 1 in 10. People with one autoimmune disease are more likely to develop other autoimmune diseases. Type 1 diabetes is an autoimmune disorder, and up to 10 percent of those with type 1 diabetes also develop celiac disease. If you have type 1 diabetes, ask your doctor about being screened for celiac disease. Screening involves a blood test that detects antibody markers associated with celiac — specifically, anti-tissue transglutaminase or tTG. A positive tTG lab result is followed by a tissue biopsy for definitive diagnosis.
If you suspect you may have celiac disease, it is critical to be screened before going on a gluten-free diet. Once you’ve been eating gluten-free for a while, the screening tests are less likely to detect the disease.
When people with celiac disease eat gluten, their immune systems produce an antibody. The antibody triggers immune cells within the intestine to release chemicals, which in turn damage and flatten the linings of the intestine. Normally, the small intestine is lined with tiny fingerlike projections called villi. This lining is also called “the brush border” because it resembles a brush. Vitamins, minerals, and nutrients are absorbed into the bloodstream through the tips and sides of the intestinal villi. In people with celiac disease, gluten exposure flattens out the villi, which reduces the ability to absorb key nutrients.
Many of the long-term consequences of undiagnosed or untreated celiac disease are the result of ongoing malnutrition. For example:
· Poor absorption of iron, folate, and B12 leads to anemia.
· Impaired absorption of calcium and vitamin D can cause osteoporosis.
· Vitamin and mineral deficiencies contribute to nerve problems, improper blood clotting, bone and joint pain, dental issues, headaches, depression, impaired concentration, dementia, fatigue, infertility, and an increased risk of intestinal cancer.
Symptoms of malabsorption may include gas, bloating, diarrhea or constipation, oily stools, nausea, and vomiting. Some people with celiac develop an itchy skin rash. Celiac disease can cause poor growth and delayed puberty in children. It may lead to weight loss in adults; however, many people with celiac disease are at normal weights or may be overweight. Gastrointestinal symptoms drive some individuals to seek medical attention, which leads to the diagnosis of celiac disease. Celiac disease may go undiagnosed for many years because some people have no obvious symptoms until they are in the middle of a health crisis. Lack of symptoms does not mean lack of damage to the intestine, however, which is why screening is important for anyone with type 1 diabetes or a family history of celiac disease.
If you’ve been diagnosed with celiac disease, it’s imperative to follow a strict gluten-free diet lifelong even if eating gluten doesn’t produce any obvious discomfort. Small exposures to gluten can lead to damaged intestinal villi and malabsorption of nutrients, which increases your risk of developing serious medical conditions. Strict avoidance of gluten allows the intestine to heal; villi eventually regenerate, but it takes time. Even an occasional dietary slip-up or that “once-in-a-while” intake of a gluten-containing food could result in ongoing atrophied, poorly functioning villi.
Forgoing gluten if you are allergic or have an intolerance
It’s estimated that up to 15 million Americans have food allergies, with an uptick in new cases in the past two decades. Roughly 1 in 13 children have a food allergy. Some, but not all, outgrow their allergy by adulthood. Eight foods account for over 90 percent of all food allergies: peanuts, tree nuts, milk, fish, shellfish, eggs, soy, and wheat.
Having diabetes doesn’t increase your risk of having food allergies or food intolerances. The following sections cover both allergies and intolerances.
Proper diagnosis by a qualified medical professional is important. Self-diagnosis isn’t reliable and may lead to improper treatments and unnecessary food restrictions. A registered dietitian can provide in-depth education and additional resources if you need to avoid gluten or wheat for medical reasons such as celiac disease, food allergies, or food intolerances. This chapter covers just the basics.
Food allergies
The immune system is supposed to protect us from viral and bacterial invaders. Fighter cells travel through the bloodstream, patrolling the body in search of germs. A food allergy occurs when the immune cells react to a food rather than a germ. This case of mistaken identity results in a battle that should have never taken place.
The immune system mounts its attack by making an antibody called IgE, short for immunoglobin E. The IgE antibody binds to the surface of immune cells called mast cells and basophils. IgE is like a detective that has been trained to recognize the food allergen. Exposure to the food causes the immune cells to release histamines and other chemicals that are responsible for the allergy symptoms. Symptoms usually occur within 30 minutes to a few hours after exposure to the food. Symptoms can be mild to severe and include swelling, itching, hives, watery eyes, cramps, nausea, diarrhea, congestion, shortness of breath, dizziness, loss of consciousness, or, in the rarest but most severe reaction, anaphylaxis, which is life threatening.
The treatment for the food allergy is complete avoidance of the problem food. Mild symptoms may be treated with the appropriate antihistamines, oral steroids, or steroid creams. Severe reactions are treated with injected epinephrine; people at risk carry an epi pen.
Food intolerances
The main difference between food allergies and food intolerances (also called food sensitivities) is that food intolerances don’t involve the immune system. Food intolerances may elicit some of the same milder symptoms associated with a food allergy, such as gastrointestinal upset, but an intolerance doesn’t lead to severe reactions such as anaphylaxis.
Lactose intolerance is an example of food intolerance. Lactose, the natural sugar in milk, is made from two sugar molecules bonded together — specifically, glucose and galactose. Digestion of lactose requires an enzyme in the intestine called lactase. Lactase enzyme cleaves the double sugar into its two individual sugar molecule components. People who lack sufficient amounts of lactase enzyme are unable to digest lactose. Symptoms of lactose intolerance are cramping, bloating, gas, and diarrhea. Lactose-free milk has been treated with the enzyme lactase so the double sugar molecule has already been split into the two individual sugars before you drink it. Lactase enzyme is also available in liquid drops or tablets to minimize symptoms when lactose-containing foods are consumed.
Choosing to go gluten-free for personal reasons
Gluten-free diets have increased in popularity in the past decade or so. The diet is portrayed as being healthier and solving a rash of maladies, which isn’t necessarily true. Some people with digestive issues, fatigue, or other physical complaints try gluten-free diets to see whether they’ll feel better or have more energy. Others go gluten-free in hopes of losing weight. Weight loss isn’t guaranteed but can occur due to the number of foods on the “do-not-eat list.” When you eliminate a whole category of foods, it follows that you may lose weight. You may also lose the vitamins, minerals, and fiber typically obtained from the foods you are avoiding.
If you’re thinking of going gluten-free due to physical symptoms, you should first speak to a medical specialist for evaluation and proper diagnosis. If you go gluten-free for nonmedical reasons, be mindful to eat a balanced diet, as I explain later in this chapter. Going gluten-free eliminates many foods, some of which are quite wholesome while others do fall into the junk-food category. A gluten-free diet is healthy only if efforts are made to assure a balanced intake of vitamins, minerals, and other nutrients.
Against the Grain: Beginning a Gluten-Free Diet
If you have diabetes and celiac disease, you need to manage both conditions. A gluten-free diet is the only treatment for celiac disease. Many gluten-free grains can be safely included; just remember the importance of carb counting and the other diabetes management principles in this book.
A person with celiac disease requires a more restrictive diet than a person with an allergy or food intolerance to wheat. A gluten-free diet not only eliminates wheat, barley, and rye, but it also banishes a long list of products derived from those grains. People with celiac disease must avoid even traces of gluten or they may suffer medical consequences. Someone allergic or intolerant to wheat, on the other hand, may still be able to eat other gluten-containing grains and byproducts. If you follow a gluten-free diet for personal choice rather than medical necessity, there are no medical consequences to adding gluten-containing foods into your diet as desired. The following sections focus on how to start a gluten-free diet.
Avoiding grains that contain gluten
The Food Allergen Labeling and Consumer Protection Act requires common food allergens to be clearly identified on food labels. Allergens must be noted within the ingredient list or in a callout below the ingredient list. Wheat falls into the group of the eight most common food allergens, so if a product contains wheat, it must be clearly identified. Barley and rye don’t fall into the list of risky food allergens and therefore don’t require an allergen warning. See Chapter 7 for more details on food labeling and how to assess the presence of food allergens.
Labels are allowed, but not required, to identify gluten-free products. The FDA states that a food can be advertised as gluten-free provided that food has less than 20 parts per million (ppm) of gluten. Restaurants that use the term “gluten-free” are expected to comply with the federal definition.
A gluten-free diet eliminates wheat, barley, and rye. If only it were that simple. Many terms indicate wheat without actually saying wheat. Durum, for example, means wheat. Triticale is a hybrid of wheat and rye. For starters, giving up gluten requires learning a few new vocabulary words. Here are the names of gluten-containing grains and some of their aliases:
· Barley
· Bran
· Bulgur
· Couscous
· Cracked wheat
· Dinkel
· Durum
· Einkorn
· Emmer
· Farina
· Farro
· Flour
· Germ
· Gliadin
· Gluten
· Graham
· Groats
· Kamut
· Malt
· Pearl barley
· Rye
· Semolina
· Spelt
· Sprouted wheat
· Tabbouleh
· Triticale
· Wheat
WHAT ABOUT OATS?
While oats themselves do not contain gluten, they may become contaminated by coming in contact with gluten. When farms grow, harvest, and store gluten-containing grains, the contamination of gluten-free grains, such as oats, is nearly inevitable. Harvesting machines and grain silos used for processing and storing wheat, rye, or barley end up harboring residual amounts of gluten. When oats come into contact with that gluten during harvesting, production, or storage, they are cross-contaminated.
Farms that are dedicated solely to growing oats produce uncontaminated oats, which are usually well-tolerated by individuals with celiac disease. Oats labeled gluten-free are available in some stores and can be purchased online. Several brands advertise gluten-free, uncontaminated oats.
Eliminating gluten-containing foods
Many foods are made from gluten-containing grains. Wheat shows up more often than rye or barley. Most people on a gluten-free diet easily identify that bread products and foods made from wheat flour, such as baked goods, need to be avoided. However, some gluten-containing items are not so obvious. For example:
· Beers and ales are made with barley, hops, and malt. Some beers are made with wheat.
· Many processed foods have starch and fillers that may be wheat-based.
· Standard soy sauce is made from fermented soy and wheat. That means many soy-based sauces, including teriyaki sauce, must be avoided.
The following list identifies some obvious and not-so-obvious sources of gluten, but note that it’s not an all-inclusive list. (The next section goes a layer deeper and looks at where else gluten may be lurking.)
· Ale
· Bagels
· Baked goods
· Beer
· Biscuits
· Bread
· Brewer’s yeast
· Cake
· Cereals
· Cookies
· Crackers
· Crepes
· Croissants
· Croutons
· Crust
· Filo dough
· Food coloring
· Gnocchi
· Graham crackers
· Granola
· Licorice
· Macaroni
· Malt
· Matzo
· Muesli
· Muffins
· Noodles
· Orzo
· Pancakes
· Pasta
· Pastries
· Pita bread
· Pizza crust
· Pretzels
· Ramen
· Roux
· Sauces
· Scones
· Seitan
· Soups
· Spaghetti
· Stuffing
· Tempura
· Tortillas (flour)
· Waffles
Finding hidden gluten
Processed foods often contain fillers, food coloring, and flavor enhancers that may contain gluten. If something has modified starch, thickeners or stabilizers, texturized vegetable protein (TVP), hydrolyzed plant proteins, or any other ingredient you are unsure of, contact the manufacturer for clarification and to make sure it’s gluten-free.
Some stores have done the research for you. Several supermarket chains have compiled lists of the gluten-free products that they carry. Inquire at your local stores or look on their websites.
Here’s just a sample of some unusual items that may have gluten:
· Fillers added to processed meats and deli meats may contain gluten. Beware of hot dogs, sausages, bologna, and salami. Self-basting turkeys and plumped hams are injected with broth solutions that may contain gluten. Meatballs and meatloaf often incorporate breadcrumbs.
· Malt vinegar and any condiment made with malt vinegar should be avoided.
· Be especially careful with sauces, marinades, and products that contain soy sauce. Typical soy sauce contains wheat, but wheat-free versions are available. Miso may contain barley. Flour is often used to thicken gravies, soups, and sauces. Roux is flour-based and used in the preparation of sauces and many Cajun dishes.
· Communion wafers may contain gluten.
· Candies, bouillon, and imitation crab are surprise sources of hidden gluten.
· Many vitamins, over-the-counter medications, and prescription drugs contain gluten. Your pharmacist should be able to identify which ones. People with celiac disease are encouraged to take gluten-free multivitamins.
· Lipstick and lip balms, play dough, stamps, and gummed envelopes are nonfood items that may have gluten.
If in doubt, check it out by contacting the company.
Avoiding cross-contamination
Individuals with celiac disease need to avoid exposure to gluten, which is hard to do unless the whole household goes gluten-free. Wheat flour used in baking may result in airborne particles of gluten, which contaminate kitchen surfaces. If a household doesn’t go entirely gluten-free, a separate cupboard and counter should be reserved for gluten-free products only.
Extra precautions need to be in place to prevent accidental exposure. Here are some additional tips to reduce cross-contamination:
· Invest in a new toaster and reserve it for gluten-free products. Using the same toaster for wheat-containing bread is not acceptable.
· Buy condiments in squirt bottles. Double-dipping a knife into a jar of peanut butter, jelly, ketchup, or mayonnaise contaminates the remaining product once the knife has touched wheat bread.
· Get rid of wooden cutting boards and wooden spoons. When used to prepare gluten-containing foods, traces of gluten can seep into the grain of the wood and then leach back out later when preparing a gluten-free item. Sanitize plastic spoons and cutting boards in the dishwasher or with hot soapy water after exposure to gluten.
· Use separate sponges for cleaning up surfaces that have come into contact with gluten. Sponges not only harbor bacteria but are also a source of gluten cross-contamination.
· Grill or deep-fry gluten-free foods first. Once oil has been used to fry breaded items, such as nuggets or onion rings, it will contaminate subsequent foods. Fryers and grills are key sources of gluten contamination in many restaurants. Although potatoes are naturally gluten-free, making French fries in the same oil that was used for breaded items ends up contaminating the potatoes.
· Consider the cross-contamination that can happen during food manufacturing. Corn tortillas are gluten-free, but if a conveyer belt runs flour tortillas prior to corn tortillas, the corn tortillas may become contaminated.
· Bulk bin scoops may be contaminated with gluten if customers switch scoops or use the same scoop for various bins.
· The meat slicer used in a deli may harbor hidden gluten.
Restaurant dining can be tricky. If you order your salad without croutons, for example, the server may not think twice about picking off the croutons before serving you a pre-made salad. The fact that croutons touched the salad could cause a reaction for a person with celiac disease. Consider also that some restaurant kitchens reuse woks and skillets over and over again. Scraping out the wok doesn’t remove the soy sauce used in preparation of the previous dish.
It’s best to plan in advance and find out whether the restaurant can accommodate your dietary needs. Call or stop by during nonpeak hours to meet with the chef to discuss the diligence needed in preparing foods that are truly gluten-free and free from cross-contamination. Many restaurants are trying to meet the needs of their gluten-free customers. Some mark the menus to identify gluten-free dishes, while others have a separate gluten-free menu. It doesn’t hurt to ask.
Staying Gluten-Free Without Nutrient Deficiencies
Maintaining a gluten-free diet requires diligent avoidance of many foods. It’s important to choose a variety of gluten-free whole grains along with foods that are naturally gluten-free. While planning a nutritionally complete, gluten-free diet is entirely possible, some people tend to do what’s easy and eat the same limited selections over and over. Lack of variety can lead to nutrient deficiencies. Eating a wide variety of foods from all food groups helps assure adequate intakes of all key vitamins and minerals.
Slipping up and ingesting gluten damages the capacity of the intestine to digest and absorb nutrients. It can take quite a while for the gut to heal. Impaired absorption of vitamins and minerals can lead to nutritional deficiencies.
After hearing all about what you can’t eat on a gluten-free diet earlier in this chapter, you may be wondering whether there is anything left that you can eat! This section identifies foods that are naturally gluten-free, introduces the numerous gluten-free grains that you can enjoy, and discusses nutrients at risk if you stick with a gluten-free diet.
Embracing foods naturally free of gluten
Any food that has been packaged and processed could potentially have additives that contain gluten. For example, corn is gluten-free, but canned creamed corn may have flour added. Read all packaged food labels carefully. Keep in mind that many wholesome, natural foods are completely free of gluten. In their natural, unprocessed state, the following foods are gluten-free:
· Fresh fruits and vegetables
· Legumes, dried beans, split peas, lentils, soybeans, and tofu
· Nuts (unseasoned) and nut butters
· Fish and seafood (with the exception of surimi and imitation crab)
· Unprocessed meats and poultry
· Eggs
· Vegetable oils and butter
· Milk and plain yogurt (check labels on flavored yogurt)
· Cheese (not necessarily processed cheese spreads)
· Cottage cheese, buttermilk, cream, cream cheese, and sour cream
The list of gluten-free products is continuously growing. Check your local supermarkets for gluten-free flours, baking mixes, pastas, crackers, breads, cereals, waffles, baked goods, pizza crusts, bagels, frozen entrées, canned foods, snack foods, and more. If you aren’t satisfied with their offerings, check online for products you can order. Gluten Free Mall has a wide selection of gluten free products. See www.glutenfreemall.com/catalog/ .
Incorporating gluten-free grains
If you’re going to be gluten-free, it’s time to branch out and try some new grains. The following list identifies gluten-free grains as well as other starches that can be used when planning meals. Choose “whole” grains when possible. You don’t have to have celiac disease to enjoy these foods:
· Amaranth
· Arrowroot
· Buckwheat
· Cassava
· Corn
· Corn taco shells
· Corn tortillas
· Cream of rice cereal
· Grits
· Hominy
· Kasha
· Legumes
· Maize
· Millet
· Polenta
· Potatoes
· Quinoa
· Rice (all types)
· Rice cakes
· Sorghum
· Sweet potatoes
· Tapioca
· Teff
· Wild rice
· Yams
· Yucca
See Appendix A to locate the gluten-free grains and starches in the starch list. Serving sizes on the list provide approximately 15 grams of carbohydrate.
Watching out for nutrient deficiencies
Eliminating foods and food groups potentially limits the nutrients provided by those particular foods. Restricting gluten is not a treatment for diabetes, so I don’t recommend eliminating gluten unless you have a medical reason for doing so. It takes careful planning to find those nutrients elsewhere. Whether diet restrictions are medically necessary or self-directed, it is important to eat a variety of foods that provide a wide spectrum of vitamins, minerals, and fiber.
Celiac disease requires lifelong avoidance of gluten. Exposure to gluten leads to intestinal damage, which results in impaired absorption of numerous vitamins and minerals. Ongoing nutrient deficiencies may lead to malnutrition with serious medical consequences. The best prevention is persistent dietary diligence. Blood tests can determine whether you are currently low in any particular vitamins or minerals. Bone density scans are used to assess bone health. Restrictive diets may necessitate vitamin and mineral supplementation. Discuss your situation with your healthcare provider. A registered dietitian is the medical professional best suited to assess your dietary intake and provide nutritional guidance.
For healthy blood cells and to reduce the risk of anemia, focus on eating foods rich in these three critical nutrients, all of which are vital to blood-cell formation:
· Vitamin B12: Food sources rich in this vitamin include meat, poultry, seafood, eggs, milk, and yogurt.
· Folate (folic acid): Choose leafy green vegetables, legumes (dried bean family), and gluten-free grains and cereals that have been fortified with this nutrient.
· Iron: Meat, poultry, fish, and seafood are rich in iron. Other sources include eggs, nuts, leafy green vegetables, and gluten-free grains and cereals that have been enriched with iron.
Bone health relies on adequate intakes of these two key nutrients:
· Calcium: Calcium is needed for healthy bones and teeth. Focus on getting at least three servings per day from milk, yogurt, cheese, or calcium-enriched nondairy milk substitutes such as enriched soy, rice, or almond milk. Dark green vegetables, legumes, almonds, and sesame tahini also offer calcium, as do fish canned with bones such as sardines and salmon.
· Vitamin D: Vitamin D is needed for the absorption of calcium. Adequate intakes of both calcium and vitamin D help reduce the risk of osteoporosis and fractures. Food sources of this fat-soluble vitamin include fatty fish, egg yolk, fortified milk and yogurt, and gluten-free grains and cereals that have been enriched with this nutrient.
The following vitamins and minerals are also important for the critical roles they play in staying healthy:
· Vitamin A: Required for cell growth, healthy skin, vision, and fighting infections. Food sources include cod liver oil, leafy green vegetables, dark yellow-orange vegetables, egg yolks, and vitamin-fortified milk.
· Vitamin E: Necessary for nerve health and tissue repair. Foods that contain this vitamin include avocados, nuts, vegetable oils, margarine, and leafy green vegetables. Vitamin E is also found in gluten-free “whole” grains.
· Vitamin K: Critical for normal blood clotting. Sources include leafy green vegetables, broccoli, asparagus, Brussels sprouts, and spinach.
· Magnesium: Plays a role in muscle, heart, and nerve function. To increase your intake of this mineral, choose nuts, gluten-free “whole” grains, meats, dairy products, and leafy green vegetables.