A Guide to Eating Gluten-Free

For people with celiac disease and non-celiac gluten sensitivity, gluten — a protein found in wheat, barley, and rye that also provides structure and elasticity to food— can cause a host of disruptive symptoms.

Celiac disease is a condition in which gluten triggers the immune system and affects about 2 million Americans, according to the National Institutes of Health. “There isn’t a cure for celiac disease; the only form of treatment is to follow a permanent gluten-free diet, which will help manage symptoms,” says Jessica Lebovits, RD, CDN, a clinical dietitian at NewYork-Presbyterian/Columbia University Irving Medical Center.

The prospect of giving up gluten and having to constantly monitor what is and isn’t safe to eat can be intimidating, but there are ways to make it more manageable and enjoyable. “Thanks to more readily available gluten-free alternatives, better product labeling, and increased awareness, it’s easier than ever before,” says Jessica.

Health Matters spoke to Jessica to better understand the condition and how to adopt a gluten-free diet that is flavorful, rich in nutrients, and celiac-safe.

How is celiac disease diagnosed and what are the most common symptoms?
Jessica: Gastroenterologists conduct celiac antibody testing and sometimes genetic testing in order to detect celiac disease. They usually also administer an endoscopic biopsy to see if there’s damage in the small intestine caused by celiac disease.

Celiac disease can present differently from person to person. Gastrointestinal symptoms can include abdominal pain, bloating, nausea, vomiting, diarrhea, and constipation. Other symptoms may include anemia, osteoporosis, arthritis, canker sores, dental enamel defects, infertility, and neurological symptoms.

It’s important to note, however, that even if someone with celiac disease does not exhibit any of these symptoms, they still need to follow a gluten-free diet. Gluten consumption can still cause damage to their intestines, which can lead to more serious health risks.

Should people who are not officially diagnosed with celiac disease follow a gluten-free diet?
Even if you suspect you might have celiac disease, you should wait until you are evaluated by a gastroenterologist before starting a gluten-free diet; otherwise, it may affect the accuracy of testing. Since the doctor is assessing your body’s response to gluten through antibodies and intestinal damage, these markers might not show up if you’re already avoiding gluten.

Before committing to a lifelong gluten-free diet, it’s important to really understand why gluten may be a problem for you. If celiac disease is ruled out, gluten may be triggering symptoms due to non-celiac gluten sensitivity (NCGS). However, although many people attribute their symptoms to gluten, they may actually have an alternate condition that needs to be addressed — such as irritable bowel syndrome (IBS), small intestinal bacterial overgrowth (SIBO), or inflammatory bowel disease (IBD). Similarly, there are other triggers within gluten-containing foods that might provoke symptoms, such as dietary fructans (certain carbohydrates that may contribute to IBS symptoms when eaten). This is why it is so important to work with a gastroenterologist and dietitian to ensure a proper diagnosis is made and the appropriate therapeutic diet is recommended.

We don’t recommend gluten-free diets unless they are medically indicated. A gluten-free diet is not healthy by default and can cause certain nutrient deficiencies.

Gluten-free products tend to have lower iron, B vitamins, calcium, zinc, and magnesium. While the FDA enriches wheat products back to the natural nutrient value of the wheat grain, gluten-free products (breads, pastas, cereals) are not required to be enriched by the FDA. Additionally, these products often have higher sugar, fat, and calories to compensate for the lack of gluten. Therefore, meeting with a dietitian is strongly recommended to ensure that if you are following a gluten-free diet you will still meet your fiber and nutrient needs as well as optimize your overall health.

What are some of the challenges of following a gluten-free diet?
Receiving a celiac disease diagnosis can feel scary, especially when you’re so used to having certain foods in your diet, whether the context is cultural, religious, or even just emotional.

Adopting a gluten-free diet may also pose financial challenges. People with celiac disease often have to pay premiums for gluten-free products, whether they’re at the grocery store or a restaurant. That said, sticking with naturally gluten-free foods is a healthier and more affordable option.

While it might be difficult at first to navigate eating at restaurants and social gatherings, on vacation, and in school and work environments, having celiac disease does not mean that your social life has to suffer. It can be helpful to see a dietitian, who can help you create a plan around your specific nutritional needs and lifestyle.

How can you tell if a food or product is gluten-free?
Always check the ingredient list on a product label. If a product contains wheat, barley, rye, malt, or brewer’s yeast, that means it contains gluten.

If a product is branded with a “gluten-free” label, it means that the product not only doesn’t contain gluten, but also that the manufacturer tested the food to confirm that it contains less than 20 parts per million of gluten – this is a concentration of gluten that is deemed acceptable for somebody with celiac disease.

If a product has a “certified gluten free” label, it means that the manufacturer paid an outside certification agency to come in and check the testing to make sure the gluten levels are safe.

People with celiac disease don’t necessarily need to eat strictly certified gluten-free foods. Seeing a gluten-free label can provide some reassurance that the product is safe, but I always tell patients to read the ingredient list to look out for any potential mistakes. And there are also plenty of foods, like fruits and vegetables, that are completely safe and naturally gluten-free without any labels.

What are some tips for identifying and avoiding “hidden gluten”?
Gluten isn’t as hard to spot as people might think. For the most part, a product label will always say if an item contains any gluten ingredients.  Since allergen labels are mandatory in the U.S and wheat is a major allergen, wheat will always be highlighted when present.

That said, there are some unexpected sources of gluten to look out for: for example, soy sauce, imitation crab, communion wafers, malt vinegar, licorice, beer, couscous, and certain dressings, marinades, and gravies.

Medications rarely contain gluten, but I do tell patients to always double check the ingredients. It’s better to be safe than sorry.