Are you suffering from digestive health symptoms such as bloating, constipation, gas, low energy, or diarrhea? With the popularity of the gluten free diet, you may think you have a gluten sensitivity. It’s not always this straightforward!
With the gluten free diet running rampant as a food trend for the last few years, it’s about time we cleared the air and got down to the bottom line on all things related to celiac disease, non-celiac gluten sensitivity and going gluten free.
The truth is, many unpleasant symptoms of digestive distress are common between different conditions, and symptoms of celiac disease and IBS may overlap! If you have IBS and are familiar with the Low FODMAP diet, you’ll know that gluten-containing foods are commonly avoided on this diet as well. But it’s not the gluten – the protein in wheat, rye and barley – that causes symptoms for those with IBS, it’s actually the sugars in gluten containing grains that makes them troublesome.
Today’s guest post comes to us from Registered Dietitian Selena Devries who is an expert on celiac disease (after all, she has it herself!) and going gluten free. She was kind enough to share her expertise on these topics, and why you should check in with a doctor or dietitian before you decide to remove gluten from your diet.
Celiac disease is an autoimmune disease that is triggered by the ingestion of gluten. Gluten is a mixture of two proteins called glutenin and gliadin, which are found in wheat, rye, and barley and many other products made from these grains.
Celiac disease is very much related to genetics. About 30 to 40 percent of North Americans have the genes that make them susceptible to developing celiac disease, but this does not mean all of these people will eventually get celiac disease! You see, our genetics have a very interesting relationship with our environment. This genetic component of celiac disease also means that family members have a 5-10 percent higher risk of developing the condition at any point in life.
A common metaphor used to describe this complex relationship is that our genes are like the gun, and our environment the trigger. This means that it is our environment (ie. diet and lifestyle) that causes certain genes to be expressed (ie. cause disease). Just because you have the gene, doesn’t mean it will necessarily ever be expressed. When it comes to celiac disease, only about 3 percent of the people who have the celiac disease genes are actually diagnosed with celiac disease. In addition, it is estimated that about 6 percent of the population may suffer from non-celiac gluten sensitivity.
Testing for Celiac Disease
In order to correctly test an individual or celiac disease, gluten must still be consumed in the diet! Current testing for celiac disease involves two parts:
- Celiac blood screen
- Biopsy of the small intestine
Celiac Blood Screen
The most important thing to consider is that in order for the blood screen to be accurate, gluten needs to be present in the diet prior to and at the time of the test. The reason for this is that the blood test is looking for certain components in the blood that are only produced when an individual consumes adequate amounts of gluten. These components are antibodies against the enzyme tissue transglutaminase (Anti-tTG).
Total serum IgA should also be tested to ensure that the individual is able to produce Anti-tTG antibodies in sufficient amounts. If an individual doesn’t produce enough IgA, then this can result in a false negative Anti-tTG number.
Biopsy of the Small Intestine
If the blood screen comes back positive, the next step would be a procedure called an endoscopy. This procedure uses a flexible tube that has a light and a camera attached to it so your doctor can look at your digestive system, particularly your small intestine. In addition, your doctor will take small samples, called biopsies, from the tissue of your small intestine so the villi (tiny finger-like structures that line the inner walls of the intestine to increase surface area for nutrient absorption) can be assessed for damage, an indicator of celiac disease.
Celiac disease can be patchy in appearance in the small intestine. This means that part of your small intestine may appear healthy while other parts may be damaged. This i why it is very important that multiple biopsies are taken so celiac disease is appropriately ruled out. At least 4-8 biopsies should be taken from the duodenum – the first part of the small intestine connected to the stomach.
Top Three Reasons to Test for Celiac Disease
It may be tempting to just remove gluten from your diet to see if you feel better without having to go through all of the testing. But, there are many reasons why this is not a smart idea. Here are the top three:
1. Celiac disease doesn’t just affect the individual, it can affect the whole family.
Celiac disease has a genetic component and family members are at a 5-10 percent increased risk of developing it as compared to the general population. By accurately testing for celiac disease, you could potentially help your family members get diagnosed early and save them the trouble of years of experiencing ‘mystery’ symptoms.
2. Celiac disease results in nutritional deficiencies.
Celiac disease results in malabsorption and can cause a multitude of nutritional deficiencies. Common nutrient deficiencies include iron, folate, B12, B6, magnesium, zinc, copper, calcium and Vitamin D. If an individual truly has celiac disease and transitions to a gluten free diet without first testing for celiac disease, these deficiencies may go unnoticed and untreated.
In addition, a gluten free diet tends to be lower in fibre and higher in sugar as many individuals gravitate towards gluten free processed foods when transitioning to a gluten free diet. This can increase digestive symptoms such as bloating, gas, and constipation – the exact symptoms you are trying to avoid!
3. Celiac disease requires strict adherence to avoiding cross contamination.
Imagine a grain of rice, split into 3 pieces. It is just one of those pieces that can cause the autoimmune response of celiac disease and result in damage to the small intestine.
It is not enough to order gluten free in a restaurant without asking certain questions about the preparation methods. Most often, you cannot order gluten free baked goods along with your latte in a regular coffee shop. If a family member cooks for you, butter (a seemingly innocent ingredient) may in fact be contaminated with gluten.
If you think you have celiac disease, but went on a gluten free diet before being tested for it, a typical gluten free diet will not be enough to heal the digestive system.
How to Manage Celiac Disease
Celiac disease is a very complex condition that requires a team of experts that can get you back on track and feeling good. The first step in getting better is seeking out a team of professionals that specialize in celiac disease and chronic disease management. Hopefully, the doctor who diagnosed you will be your first team member and advocate on your behalf.
The gluten free diet can be very tricky to follow. From gluten hiding out in seemingly innocent foods to cross contamination issues, even the most educated can inadvertently make errors.
Gluten free education from an expert is essential. Be sure to seek out a Registered Dietitian specializing in the management of celiac disease.
Removing gluten from the diet can lead to many emotional feelings and problems. In fact, numerous studies have found that celiac disease patients report a reduced quality of life. Along with your dietitian and medical doctor, connecting with a celiac disease support group or a mental health professional can prove extremely beneficial.
Gluten Containing Foods
Gluten is found in a wide array of foods made from wheat, rye and barley. Thanks to Health Canada, gluten is part of the enhanced labeling of allergens, making it easy to spot in a product if you remember these five words:
- Oats (except for pure, gluten free oats, or uncontaminated oats)
If those five words appear in ingredient list or in the ‘contains’ statement below the ingredient list, then the product contains gluten and it is not safe to consume.
Are Oats Gluten Free?
Oats are naturally gluten free. However, regular oats are typically grown in fields near wheat, processed on the same belts in manufacturing facilities, and/or transported in the same trucks to the grocery store resulting in cross contamination. However, there are now oats that are grown following strict protocols that deem the oats ‘pure’ meaning they have not been contaminated with wheat and are safe with people with celiac disease.
Cross Contamination and the Gluten Free Diet
There are many ways that your food may be contaminated with gluten! The first step to reducing cross contamination is to set up a gluten free safe zone in your home kitchen. Ideally, have a separate cupboard(s) and counter space that is designated gluten free, or have the whole kitchen gluten free.
Make sure your gluten free space is thoroughly washed down with soap and water. Wooden equipment is not recommended, as it is porous and gluten can seep into it. Equipment that has scratches or equipment that is difficult to clean can also harbor gluten.
Equipment that should be replaced includes:
- Wooden equipment such as cutting board, wooden spoons, rolling pin
- All types of cutting boards
- Non-stick pans that contain scratches
- Pasta strainer
- Muffin pans, loaf pans, baking/roasting pans
Some kitchen tools you may be able to modify include muffin tins (use liners), baking sheets (line with parchment or foil), and your grill or BBQ (again, just use foil).
In addition, condiments and foods that are frequently ‘double dipped’ can result in inadvertent cross contamination. So, an individual with celiac disease should have their own butter, nut butter, and jam jars. To reduce cross contamination with condiments, squeeze top mayo, mustard, and ketchup should be used.
How to Eat Well with Celiac Disease
Learning to eat a nutritious diet is very important for those living with celiac disease, as nutrient deficiencies are quite common. See the notes below for suggestions that are also Low FODMAP!
Aim to fill your plate with the following:
25% of your plate should come from protein sources
Foods especially beneficial for celiac disease include:
- Plant based proteins such as beans and legumes (1), tofu (2), and nuts and seeds (3)
- Fatty fish such as salmon, mackerel, and snapper
- Plain yogurt (4) and kefir
- Moderate amounts of quality sources of beef, eggs, and chicken
25% of your plate should be filled with high fibre carbohydrates
Foods especially beneficial for celiac disease include:
- Yams, sweet potatoes, and regular potatoes* all with the skin on
- Winter squash such as butternut, acorn, pumpkin or spaghetti*
- Moderate amounts of gluten free whole grains including wild rice, sorghum*, gluten free oats*, millet*, teff*, amaranth, and buckwheat*
- Fruits including banana*, apple, berries (5), pears, orange*, papaya*, apricots, and figs.
50% of your plate should be filled with colourful carbohydrates
Foods especially beneficial for celiac disease include:
- Artichoke and sunchoke
- Onions, leeks, garlic
- Cruciferous vegetables including cabbage (6), broccoli*, cauliflower, watercress, bok choy*, Brussels sprouts*
- Lacto-fermented vegetables such as fermented salsa and pickles
- Sea vegetables*
- Leafy greens such as kale*, beet greens, dandelion greens, and mustard greens
Depending on digestive symptoms, your registered dietitian may modify the portions of these foods, eliminate certain foods and/or adjust the cooking techniques.
* Low FODMAP
- Canned lentils and sprouted mung beans
- Firm tofu
- Chestnuts, macadamia nuts, brazil nuts, peanuts, pecans, pine nuts, chia seeds, pumpkin seeds, sesame seeds, sunflower seeds, and walnuts
- Lactose-free cow’s milk yogurt, goat milk yogurt, and coconut yogurt
- Raspberries, strawberries and blueberries
- Red and common cabbage
Please note that this list is not exhaustive. Refer to the Monash Low FODMAP app for applicable Low FODMAP serving sizes.
Canadian Food Inspection Agency. http://www.inspection.gc.ca/food/labelling/food-labelling-for-industry/list-of-ingredients-and-allergens/eng/1383612857522/1383612932341?chap=7#s16c7
Case S. Gluten Free. The Definitive Resource Guide.
Dennis M, Leffler D. Real Life With Celiac Disease
Thalheimer J. Gluten-Free Living and Emotional Health: What Every Dietitian Must Know. Today’s Dietitian. http://www.todaysdietitian.com/newarchives/1215p36.shtml