Gluten-Free Diet

  • Author:
    Betty Kovacs Harbolic, MS, RD

    Betty is a Registered Dietitian who earned her B.S. degree in Food and Nutrition from Marymount College of Fordham University and her M.S. degree in Clinical Nutrition from New York University. She is the Co-Director and Director of nutrition for the New York Obesity Research Center Weight Loss Program.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

What is a gluten-free diet?

Anyone who has had to follow a gluten-free diet has seen a huge change in the availability of these foods. What was once only found in specialty stores and known by very few people has now become a very popular diet trend. Products and restaurants are proudly displaying their gluten-free status. Many now see this as the latest "diet fad." Gluten is the protein found in wheat, rye, barley, and triticale. A gluten-free diet excludes all of these, along with anything that could have come in contact with them. Does everyone need this or only people with specific diseases? This article with provide you with that answer and guide you on how to follow this diet, if in fact, you do need to.

Who needs to follow a gluten-free diet?

People have been following a gluten-free diet for many reasons, but not all are medically necessary. There are some conditions and diseases that do require that you follow a gluten-free diet.

Celiac disease

Probably the most well-known disease that requires a gluten-free diet is celiac disease. Celiac disease is also known as celiac sprue, nontropical sprue, and gluten-sensitive enteropathy. The exact cause of celiac disease is not clear, but it known to have a genetic (inherited) component. Celiac disease affects approximately 1% of the population, but this may increase as there has been a rise in the incidence of celiac disease over the past decade.

Celiac disease is an autoimmune disease, where the immune system starts attacking normal tissue, particularly the inner lining tissue of the small intestine, in response to eating gluten. The specific reaction that leads to inflammation is to proteins called prolamins found in certain grains; gliadin found in wheat, secalin found in rye, horedin found in barley, and for some avenin found in oats. Although only some react to the prolamins in oats, everyone who has celiac and lives in North America is instructed to avoid oats. This is due to the cross contamination caused by the crop being rotated and milled with wheat.

A gluten-free diet is not optional for people with celiac disease. It is considered a necessary medical nutrition therapy. When you have celiac disease your body reacts to gluten as if it were toxic. This reaction occurs in the small intestine and ends up damaging the inner lining of the small intestine (mucosal surface). When the mucosal surface is damaged the small intestine is not able to absorb nutrients properly leaving people at risk for nutritional deficiencies including protein, fat, iron, calcium, and fat soluble vitamins (A, D, E, and K). It can also result in anemia, diarrhea, abdominal cramping, vomiting, failure to thrive, osteoporosis, and delayed growth. When gluten is removed from the diet there are clinical improvements to the small intestines. Getting diagnosed as early as possible and sticking with a gluten-free diet is key to avoid intestinal damage and long-term consequences of lymphoma.

Quick GuideGluten-Free Diet: Popular Gluten-Free Foods in Pictures

Gluten-Free Diet: Popular Gluten-Free Foods in Pictures

Digestion Q&A by Dr. Lee on Gluten Free Diets

Medical Author Dr. Dennis Lee

Viewer Question: Do you know if oat bran contains gluten? And is it OK to eat if I have celiac sprue?

Dietician's Response: A Gluten is the protein fraction of wheat, rye, and barley. Gluten contains several different types of protein, each with a different arrangement of amino acids. (Proteins are chains of amino acids hooked together.) It is believed that several of these proteins are responsible for the inflammation that causes celiac disease (also known as sprue or gluten-sensitive enteropathy).

Dermatitis herpetiformis

Dermatitis herpetiformis, also known as Duhring disease, is an intense burning and extremely itchy rash made up of blisters and bumps. It usually occurs equally on both sides and is found most frequently on the elbows, buttocks, knees, scalp, and back. This is sometimes referred to as "the gluten rash" or the "celiac disease rash" and has been used to diagnose celiac disease for some people. Strict adherence to a gluten-free diet is recommended to prevent flares and complications.

Gluten ataxia

Gluten ataxia is an immune-mediated disease caused by the consumption of gluten in genetically susceptible people. Ataxia is poor coordination and unsteadiness due to the brain's failure to regulate the body's posture, and regulate the strength and direction of limb movements. Antigliadin antibodies (AGA) are produced in response to gliadin, the prolamin found in wheat. Gluten ataxia was first detected in 1998 in people who had ataxia with elevated AGAs. All of these patients in this initial description had gait ataxia, some had limb ataxia, and more than half had peripheral neuropathy. About a third had celiac disease. A gluten-free diet is the treatment for gluten ataxia.

Wheat allergy

The nutrients found in food can prevent disease and sustain life. They can also cause health problems in susceptible people. Food allergies can wreak havoc on a person's health and quality of life. Roughly 5% of individuals in Westernized nations have a true food allergy. A true food allergy is an abnormal response to a food triggered by the body's immune system. Symptoms can range from vomiting, diarrhea, and abdominal cramps to hives or eczema to itching and swelling in the mouth or possibly to a life threatening anaphylactic reaction.

Wheat allergy is defined as an adverse immunologic reaction to wheat proteins that is immunoglobulin E (IgE) mediated. It can present as respiratory symptoms (baker's asthma or rhinitis, more common in adults), food allergy (gastrointestinal symptoms of gas, bloating, diarrhea, and abdominal pain, hives, angioedema, or atopic dermatitis; mainly in children) and contact hives (urticaria).

The top eight food allergens in the United States are peanuts, milk, eggs, fish, crustacean shellfish, soybean, tree nuts, and wheat. Only about 0.1% of all food allergies is a wheat allergy. Wheat allergy symptoms usually occur in the mouth, nose, eyes, and throat (swelling, itching, and irritation); the skin (rash, hives, swelling); respiratory tract (wheezing, difficulty breathing, anaphylaxis); and gastrointestinal tract (cramps, nausea, emesis, gas, bloating, diarrhea, and abdominal pain). The testing options for a wheat allergy include either an IgE serum assay or skin prick test to wheat. Only wheat flour is required to be restricted and there should be no permanent damages caused by it.

Non-celiac gluten sensitivity (NCGS)

Non-celiac gluten sensitivity (NCGS) has also been referred to as gluten sensitivity, gluten hypersensitivity, and non-celiac gluten intolerance. The precise number of people who have this is unknown. The symptoms associated with this are diarrhea, bloating, flatulence (gas), abdominal discomfort or pain, fatigue, lethargy, headaches, "foggy mind," fatigue, depression, and/or skin rash. One study also found that people with this also exhibited glossitis, muscle cramps, leg numbness, bone or joint pain, osteoporosis, and unexplained anemia. There is no specific test to diagnose this which makes it a controversial diagnosis. The diagnosis requires that celiac disease and a wheat allergy are ruled out as possibilities. When the removal of gluten from the diet alleviates the symptoms this is considered the diagnosis.

Irritable bowel syndrome (IBS)

Irritable bowel syndrome (IBS) can be a frustrating and debilitating diagnosis when there is no specific cause or treatment. Recent research has shown improvements in pain, gas, bloating, and diarrhea with or without constipation following a gluten-free diet in some types of IBS. One study showed that 60% of diarrhea predominant IBS patients following a gluten-free diet returned to normal stool frequency and a decrease in gastrointestinal symptoms. The only way to know for sure if you are gluten sensitive with IBS is to follow a gluten-free diet and see if your symptoms dissipate.

Quick GuideGluten-Free Diet: Popular Gluten-Free Foods in Pictures

Gluten-Free Diet: Popular Gluten-Free Foods in Pictures

What are the difficulties with following a gluten-free diet?

Following a gluten-free diet is not as simple as purchasing gluten-free foods. To start with, not every food has a gluten free option and not everyone has access to stores that sell the products that are gluten free. Many of these foods can be costly and that presents another barrier to compliance with this. The labeling laws can also make compliance difficult when they allow incomplete description of food components.

Even with the best intentions you can end up consuming gluten without know it. Gluten can be found in unexpected sources such as in pharmaceuticals (acts as a binder), meat products (acts as extender), or in confectionery, desserts, flavorings and sauces. Cross contamination poses the greatest obstacle when foods are not prepared at home or in a carefully controlled environment. Travelling, eating out, parties, and other social events fall under this category.

Dietary deficiencies are a higher risk for people with celiac disease than for others who follow a gluten-free diet. Anyone who is eliminating food groups should be aware of the nutrients that they may be missing. The deficiencies to be aware of are iron, calcium, vitamin B12, folate, phosphorus, and the fat soluble vitamins A, D, E, and K. Protein-calorie malnutrition is another possible risk that can be avoided with an adequate intake of high protein foods.

What foods do you avoid on a gluten-free diet?

When you begin to make this adjustment to your diet it can feel overwhelming. Start by getting used to the things that you want to avoid. The purpose of eliminating gluten is to improve your health, so remind yourself that you are cutting these out to feel better, not to deprive yourself of anything.

Gluten is the protein found in the grains wheat, rye, barley, and triticale (a hybrid of wheat and rye). Read the labels on foods, health and beauty aids, and medications carefully and don't assume that the ingredients stay the same. Something that did not contain gluten could contain it the next time you purchase it. Keep this list with you:

Foods that are unsafe to eat

  • Barley
  • Bleached flour
  • Bran Brewer's yeast
  • Bromated flour
  • Bulgur
  • Couscous
  • Durum flour
  • Enriched flour
  • FarinaFarro
  • Germ
  • Graham
  • Flour
  • Hydrolyzed protein
  • Malt or malt flavoring (can be made from barley)
  • Malt vinegar (made from barley)
  • Matzo meal/flour
  • OrzoPanko
  • Phosphated flour
  • Plain flour
  • RyeSeitan
  • Self-rising flour
  • Semolina
  • Tabouli
  • Teriyaki sauce
  • Triticale (a cross between wheat and rye)
  • Udon
  • Wheat
    • Einkorn
    • Emmer
    • SpeltKamut
    • Wheat starch
    • Wheat bran
    • Wheat germ
    • Cracked wheat
    • Hydrolyzed wheat protein
  • White flour

There are many other products that contain gluten that you will also need to avoid unless they are clearly labeled as gluten-free. Read the labels on each of these:

  • Beer and other grain-based alcohol
  • Breading
  • Brown rice syrup
  • Candies
  • Cakes/pies
  • Caramel color
  • Cereals
  • Communion wafers
  • Couscous
  • Croutons
  • Dairy substitutes
  • Dextrin
  • Dry roasted nuts
  • French fries
  • Gravy
  • Herbs
  • Hydrolyzed vegetable protein
  • Imitation seafood or meat
  • Lipstick, lip gloss, chapstick
  • Luncheon meats
  • Malt flavoring
  • Matzo
  • Modified food starch
  • Pasta
  • Play clay
  • Postage stamp
  • Poultry, self-basting
  • Rice with seasoning
  • Salad dressings
  • Sauces
  • Seasonings
  • Snack foods with seasonings (chips)
  • Soups, bouillon, broths
  • Soy sauce
  • Supplements
  • Toothpaste
  • Vegetables in sauce
  • Vitamins
  • Wheat-free products - this does not mean gluten-free so you still need to read the list of ingredients
  • Medications - gluten containing fillers can be found in some prescription and over-the-counter medications. You can check the list of ingredients, ask the pharmacist or your doctor, and/or use the resource at the end for more information. You can even contact the manufacturer of the medication to ask.

Cross-contamination is a potential problem that needs to be monitored. Whenever products containing gluten touch a bowl, utensil, or cutting board there is a risk of it getting into the gluten-free food. Other possibilities for cross-contamination are:

  • Toaster/toaster oven - use a separate toaster
  • Crumbs being left in jams, butter, condiments - use squeeze containers
  • Storage - make a separate space in cabinets and refrigerator
  • Double dipping - make sure that no one sticks utensils or food in gluten-free foods, such as butter or hummus.

Quick GuideGluten-Free Diet: Popular Gluten-Free Foods in Pictures

Gluten-Free Diet: Popular Gluten-Free Foods in Pictures

What foods can you consume on a gluten-free diet?

The greatest difficulty with following a gluten-free diet used to be the limited availability of foods that do not contain gluten. This is no longer the case. There are many more options than ever and it appears that this will continue to grow as more people are finding relief from health issues with following a gluten-free diet.

Foods that are safe to eat

  • Amaranth
  • Arrowroot
  • Bread made from rice flour or potato flour
  • Buckwheat
  • Chestnuts
  • Corn
  • Distilled vinegars
  • Flax
  • Garbanzo beans (chickpeas)
  • Grits (corn or soy)
  • Herbs
  • Hominy
  • Job's tears
  • Lentils
  • Millet
  • Nut flours
  • Potatoes
  • Pumpkin
  • Quinoa
  • Rapeseed oil
  • Rice
  • Sago
  • Seeds
  • Soy
  • Sorghum
  • Tapioca
  • Teff

The other foods that you are able to eat with a gluten-free diet are:

  • Meats (these are your high protein options)
  • Plan meat, poultry, fish, shellfish, and eggs
  • Dry peas and beans, nuts, peanut butter, and soybeans
  • Tofu

Fruit

  • Fruit
  • Fruit juice

Vegetables

  • Fresh, frozen, and canned vegetables

Dairy

  • Milk Plain yogurt
  • Cottage cheese
  • Cheese

Beverages

  • Pure instant or ground coffee
  • Tea
  • Carbonated beverages
  • Beer made with buckwheat, sorghum, rice, or corn
  • Alcohol – brandy, champagne, gin, run, tequila, vodka, wine

Fats

  • Butter
  • Margarine
  • Vegetable oils
  • Lard
  • Shortening

There is a way to convert recipes that contain gluten into gluten-free recipes. You will need to experiment with the ingredient substitution, length of time, and temperature used for baking. Here are some substitutions that you can make in your recipes:

For 1 tablespoon of wheat flour, substitute one of these:

  • 1 1/2 teaspoons cornstarch
  • 1 1/2 teaspoons potato starch
  • 1 1/2 teaspoons arrowroot starch
  • 1 1/2 teaspoons rice flour
  • 2 teaspoons quick-cooking tapioca

For 1 cup of wheat flour, substitute one of these:

  • 3/4 cup plain cornmeal, coarse
  • 1 cup plain cornmeal, fine
  • 5/8 cup potato flour
  • 3/4 cup rice flour

You are going to need time, patience, persistence, and support with making these changes. These changes can affect you and everyone in your life, but it will get easier as you all get used to it. You are not alone in this so reach out to those who know what you are going through. The important thing to remember is that your body needs this diet to function correctly and for you to feel well and live symptom free.

Medically reviewed by Joseph Palermo, DO, American Osteopathic Board Certified Internal Medicine

REFERENCES:

Aziz I. Does gluten sensitivity in the absence of coeliac disease exist? BMJ. Nov 2012;vol 30;pp 1-4.

Biesiekierski JR. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroentero, 2011; vol 106: pp 508-514.

Di Sabatino A. Nonceliac gluten sensitivity: sense or sensibility? Ann Intern Med, Feb 2012;vol 156(4):pp 309-11.

Hadjivassiliou M. Gluten ataxia. Cerebellum, 2008;vol 7(3):pp 494-8.

Harper JW. Anemia in celiac disease is multifactorial in etiology. Am J Hematol, Nov 2007;vol 82(11):pp 996-1000.

Kupper C. Dietary guidelines and implementation for celiac disease. Gastroenterology, Apr 2005;vol 128(4 Suppl 1):pp 121-127.

Mulder CJ. Gluten-free diet in gluten-related disorders. Digestive Diseases. 2013;vol 31(1):pp 57-62.

Nakajima K. Recent advances in dermatitis herpetiformis. Clin Dev Immunol. Jul 2012; pp 1-5.

Pietzak M. Celiac disease, wheat allergy, and gluten sensitivity: when gluten free is not a fad. J Parenter Enteral Nutr. Jan 2012;vol 36(1 Suppl):pp 68S-75S.

Sapone A. Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Med, Feb 2012;vol 10:13;pp 1-12.

Thomson T. Oats and the gluten-free diet. J Am Diet Assoc, Mar 2003;vol 103(3):pp 376-379.

MedlinePlus. Food Allergy.

Last Editorial Review: 4/8/2015

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Reviewed on 4/8/2015
References
Medically reviewed by Joseph Palermo, DO, American Osteopathic Board Certified Internal Medicine

REFERENCES:

Aziz I. Does gluten sensitivity in the absence of coeliac disease exist? BMJ. Nov 2012;vol 30;pp 1-4.

Biesiekierski JR. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroentero, 2011; vol 106: pp 508-514.

Di Sabatino A. Nonceliac gluten sensitivity: sense or sensibility? Ann Intern Med, Feb 2012;vol 156(4):pp 309-11.

Hadjivassiliou M. Gluten ataxia. Cerebellum, 2008;vol 7(3):pp 494-8.

Harper JW. Anemia in celiac disease is multifactorial in etiology. Am J Hematol, Nov 2007;vol 82(11):pp 996-1000.

Kupper C. Dietary guidelines and implementation for celiac disease. Gastroenterology, Apr 2005;vol 128(4 Suppl 1):pp 121-127.

Mulder CJ. Gluten-free diet in gluten-related disorders. Digestive Diseases. 2013;vol 31(1):pp 57-62.

Nakajima K. Recent advances in dermatitis herpetiformis. Clin Dev Immunol. Jul 2012; pp 1-5.

Pietzak M. Celiac disease, wheat allergy, and gluten sensitivity: when gluten free is not a fad. J Parenter Enteral Nutr. Jan 2012;vol 36(1 Suppl):pp 68S-75S.

Sapone A. Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Med, Feb 2012;vol 10:13;pp 1-12.

Thomson T. Oats and the gluten-free diet. J Am Diet Assoc, Mar 2003;vol 103(3):pp 376-379.

MedlinePlus. Food Allergy.

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