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.
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
Quick GuideGluten-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
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 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.
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
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
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,
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,
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.
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
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
- Bleached flour
- Bran Brewer's yeast
- Bromated flour
- Durum flour
- Enriched flour
- Hydrolyzed protein
- Malt or malt flavoring (can be made from barley)
- Malt vinegar (made from barley)
- Matzo meal/flour
- Phosphated flour
- Plain flour
- Teriyaki sauce
- Triticale (a cross between wheat and rye)
- 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
- Beer and other grain-based alcohol
- Brown rice syrup
- Caramel color
- Communion wafers
- Dry roasted nuts
- French fries
- Imitation seafood or meat
- Lipstick, lip gloss, chapstick
- Luncheon meats
- Malt flavoring
- Modified food starch
- Play clay
- Poultry, self-basting
- Rice with seasoning
- Salad dressings
- Snack foods with seasonings (chips)
- Soups, bouillon, broths
- Soy sauce
- Vegetables in sauce
- 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
- 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
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
- Bread made from rice flour or potato flour
- Distilled vinegars
- Garbanzo beans (chickpeas)
- Grits (corn or
- Job's tears
- Nut flours
- Rapeseed oil
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
- Fresh, frozen, and canned vegetables
- Milk Plain yogurt
- Cottage cheese
- Pure instant or ground coffee
- Carbonated beverages
- Beer made with
buckwheat, sorghum, rice, or corn
- Alcohol – brandy, champagne, gin, run,
tequila, vodka, wine
- Vegetable oils
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
- 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
- 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
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.