Go Gluten Free Nutritiously

Suzanne Bowland was tired of feeling not quite right. So she started an elimination diet, thinking that perhaps losing a few pounds might help. “After two or three weeks, I felt incredible. The bloat and gas were gone and so was the brain fog and negative outlook on life,” Bowland says. “I felt so good that I decided to revisit my old ways and eat a bowl of cereal. Bam! That’s when I crashed. The stomach cramps, the gastrointestinal distress hit me like a ton of bricks.”

That was seven years ago. Today, Bowland, author of The Living Gluten-Free Answer Book: Practical Answers to 275 of Your Most Pressing Questions, can tell you that it was gluten—a protein found in wheat, rye, and barley—that was the culprit.

Celiac disease, or gluten-sensitive enteropathy, is an inherited autoimmune disorder that affects roughly 3 million Americans, or one in every 133 people in the United States. The crux of the problem is that the gluten found in wheat, rye, and barley damages the villi of the small intestine. Villi are the tiny, fingerlike projections that protrude from the intestinal wall and increase the absorptive area of the intestine.

Eliminating gluten is the mainstay of treatment. That means no wheat-based breads, pastas, most breakfast cereals, and less obvious foods such as certain seasonings, sauces, soy sauce, marinades, salad dressings, soups, prepared meats, candy, and even flavored coffees and teas. Removing so many everyday foods from the diet after a diagnosis raises the risk of nutrient deficiencies.

A delayed diagnosis can also result in nutrient deficiencies, not from food elimination but from malabsorption. “For many with a delayed diagnosis, which is the majority, there is a significant risk for a variety of vitamin and mineral deficiencies,” says Shelley Case, BSc, RD, a consultant dietitian specializing in celiac disease and the author of Gluten-Free Diet: A Comprehensive Resource Guide. “In severe cases, malabsorption of fat; fat-soluble vitamins A, D, E, and K; iron; folic acid; B12; calcium; and magnesium can occur. In order for the intestinal villi to regenerate and reverse the nutritional deficiencies, it’s important to focus on a few key dietary guidelines.”

Fill Up on Fiber
Diarrhea is one of the classic symptoms of celiac disease. However, says Case, “Once a gluten-free diet is introduced and the gut heals, diarrhea subsides and constipation often occurs due to the absence of high-fiber, gluten-containing foods such as wheat bran and whole wheat breads and cereals.”

Eating enough fiber does much more than keep constipation at bay. Whole grains, a potent source of dietary fiber, are linked to a lower likelihood of obesity, decreased cholesterol levels, and a reduced risk of heart disease, stroke, type 2 diabetes, and cancer. The USDA and the Whole Grains Council recommend three to five servings of whole grains per day. Look for the council’s yellow stamp to find whole grain products at the supermarket. Then make sure to only pick up whole grains that are gluten free. These include brown rice, corn, flax, millet, sorghum, teff, and wild rice, as well as the pseudograins amaranth, buckwheat, and quinoa.

Oats, once forbidden on a gluten-free diet, now have a green light—if they are in a pure uncontaminated form. Case explains, “Avenin, a protein in oats, was originally thought to trigger the same toxic reaction as wheat and other gluten-containing grains. Studies in Europe and the United States during the past 12 years have shown that consuming moderate amounts of oats is safe for the majority of people with celiac disease.” The problem with most commercial oats is cross-contamination with wheat, barley, or rye during the harvesting, milling, and packaging processes, so consumers must be careful.

“Whole grains add a chewy texture, intriguing flavor, visual appeal, and greater variety to gluten-free meals,” Case says. “Use them as an extra ingredient or replacement for [wheat] or to stand alone. For example, sprinkle cooked whole grains over mixed green salads. Extend hamburger patties or meatloaf with gluten-free rolled oats or cooked brown rice, quinoa, amaranth, or teff. Spoon ground flax or flax meal on yogurt or hot cereal. Replace one quarter of the cornmeal with teff grains for a cornmeal-teff polenta. And finally, try adding cooked buckwheat, oat groats, steel-cut oats, quinoa, sorghum, or wild rice to rice pilaf.”

Don’t go overboard when it comes to adding high-fiber whole grains and other high-fiber foods such as fruits, vegetables, nuts, seeds, and dried peas and beans to the diet, Case cautions. “Add fiber slowly because too much fiber from too many sources at once can cause celiaclike symptoms such as bloating and gas. To promote regular bowel function, it’s also important to drink plenty of water and exercise regularly,” she says.

Fortify With Iron and B Vitamins
Iron and the B vitamins thiamin, riboflavin, and niacin have been added to bread and cereal products for more than 50 years and the B vitamin folate for the past decade. However, says Case, “Most gluten-free products are not enriched or are made from refined flours and starches that are low in vitamins, minerals, and dietary fiber. Now, though, several companies are enriching their gluten-free products with iron and B vitamins at the same levels as gluten-containing breads, cereals, pastas, and flours. This is good news and a good way for those with celiac disease to ensure they’re taking in an adequate amount of these nutrients.”

Iron is an especially important nutrient. “Iron-deficiency anemia is often a presenting symptom of celiac disease,” says Case. “Therefore, someone might be behind the eight ball as far as this mineral is concerned right from the start after diagnosis.”

There are two forms of dietary iron, heme and nonheme. Meat, fish, and poultry contain heme iron. Nonheme iron—found mainly in fruits, vegetables, grains, and eggs—isn’t absorbed as well as heme iron. Vitamin C increases nonheme iron absorption, so it’s beneficial to consume foods containing both at once. Good sources of vitamin C are citrus fruits and juices, kiwis, strawberries, cantaloupe, broccoli, tomatoes, peppers, chiles, potatoes, and cabbage. Preparing foods in cast iron cookware adds iron to food—for example, scrambling eggs in an iron skillet or simmering spaghetti sauce in an iron pot can double or triple the iron content the meals.

As far as the B vitamins missing when foods aren’t fortified, thiamin is found in dried beans and lentils, nuts, and lean pork; riboflavin in nonfat milk, cheddar cheese, eggs, almonds, salmon, chicken, beef, and broccoli; and good sources of niacin include meat, poultry, fish such as tuna and salmon, dried beans and peas, and seeds. Folate or folic acid is found in orange juice, spinach, asparagus, lentils, garbanzo beans, and lima beans.

Soak Up a Little Calcium and Vitamin D
Like anemia, says Case, “Early bone disease, including osteopenia and osteoporosis, is another common presenting symptom in people with celiac disease. Some people may not be able to meet the recommended daily intake for calcium through diet alone and may need a supplement. Vitamin D intake is also frequently low, and patients may have low serum levels due to malabsorption. In these cases, it’s best to look for gluten-free supplements with both calcium and vitamin D.

Dairy products are the richest and most absorbable sources of calcium. Calcium-rich plants in the kale family, such as broccoli, bok choy, cabbage, mustard, and turnip greens, contain calcium that is as bioavailable as that in milk. However, the oxalate in spinach and rhubarb, and to a lesser extent in sweet potatoes and dried beans, prevents the calcium in these foods from being absorbed.

Vitamin D is a tough nutrient to find. It occurs naturally in very few foods, such as fatty fish (mackerel, salmon, and sardines) and eggs from hens fed vitamin D. Milk produced in the United States is fortified with vitamin D at the level of 400 IU (10 micrograms) per quart. Some brands of orange juice now are also now fortified with both calcium and vitamin D.

Beyond diet, sunlight can provide most people with their entire vitamin D requirement, as UVB radiation stimulates production of this vitamin in the skin. Optimally, this translates to five to 10 minutes of direct sunlight between the hours of 11 am and 2 pm two to three days a week. There are a couple of caveats. Sunscreen with a sun protection factor of 8 and higher can block production of vitamin D by up to 95%. People with dark-colored skin make markedly less vitamin D when exposed to sunlight than those with light-colored skin. And, in latitudes around 40 degrees north (New York City) and above, there is insufficient UVB radiation available for vitamin D synthesis from November to early March.

People with newly diagnosed celiac disease may also experience lactose intolerance. Lactose is the predominant sugar in milk. Says Case, “Those with mild to moderate lactose intolerance may not have any difficulty tolerating some of the lower lactose, calcium-rich dairy foods such as hard cheeses, yogurt with live cultures, and lactose-reduced milk. If these are a problem and severe malabsorption continues to be a problem, I have three recommendations. First, use lactase enzyme drops or tablets when consuming dairy products. Second, choose lactose-reduced milk products such as milk, yogurt, and ice cream. Third, opt for soy, rice, nut, and potato beverages as these are lactose free.”

The best way to ensure a nutritionally adequate diet is to eat a variety of foods. This isn’t easy or necessarily possible on a gluten-free diet. But the day may soon come when people with celiac disease can safely include a wider selection of foods—including those that contain gluten—in their diets.

— Carol M. Bareuther, RD