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Gluten-Free Diet

Illustration

Gluten is wheat gum, the insoluble component of grains (such as wheat, barley, and rye). It is a mixture of gliadin, glutenin, and other proteins. Gluten causes allergy-like reactions in certain people. While a gluten-free diet is the primary therapeutic treatment for celiac disease, this diet may also help a host of other conditions, including dermatitis herpetiformis, psoriasis, rheumatoid arthritis, HIV enteropathy, and schizophrenia.

Why do people follow this diet?

Celiac disease (also called gluten enteropathy) is a disorder of the small intestine characterized by sensitivity to gluten. In people with celiac disease, eating gluten causes inflammation in and damage to the lining of the small intestine, resulting in diarrhea, malabsorption, fat in the stool, and nutritional and vitamin deficiencies.

A gluten-free diet is the primary treatment for celiac disease. Strict avoidance of wheat, barley, and rye (the three most abundant sources of gluten) usually improves gastrointestinal symptoms within a few weeks, although in some cases improvement may take many months. Some people with celiac disease must remove all gluten-containing foods from their diets in order to relieve symptoms. Following a gluten-free diet has been shown to reduce the incidence of cancer, low bone mineral density, and infertility in persons with celiac disease.

People with dermatitis herpetiformis may benefit from following a gluten-free diet. The cause of dermatitis herpetiformis is mainly an allergic-type reaction. Gluten-sensitivity enteropathy is found in 75 to 90% of people with dermatitis herpetiformis. Unlike celiac disease, however, gastrointestinal symptoms are mild or absent. Strict adherence to a lifelong gluten-free diet can eliminate dermatitis herpetiformis symptoms and intestinal abnormalities, as well as reduce or eliminate the need for medication in most people. However, an average of 8 to 12 months of dietary restriction may be necessary before symptoms resolve. Not all people with dermatitis herpetiformis improve on a gluten-free diet. Preliminary studies indicate sensitivity to other dietary proteins may be involved.

Anecdotal evidence suggests that people with psoriasis may improve on a hypoallergenic diet. Three trials have reported that eliminating gluten (as found in wheat, rye, and barley) improved psoriasis for some people. A doctor can help people with psoriasis determine whether gluten or other foods are contributing to their skin condition.

Preliminary evidence suggests that a gluten-free diet may help improve symptoms of rheumatoid arthritis. In one trial, 14 weeks of a gluten-free (no wheat, rye or barley), pure vegetarian diet, gradually changed to a lactovegetarian diet (permitting dairy), led to significant improvement in rheumatoid arthritis as evidenced by associated symptoms as well as by objective laboratory measures of disease.

HIV enteropathy, a complication of AIDS that is characterized by weight loss and chronic diarrhea, may respond to a gluten-free diet. In a preliminary trial, men with HIV enteropathy experienced a reduction in the number of episodes of diarrhea as well as significant weight gain while following a gluten-free diet.

For many years, researchers have been speculating that certain dietary proteins, including gluten, may contribute to the symptoms of schizophrenia. People with schizophrenia are more likely to have immune-system reactions to gluten than the general population, according to some studies. While clinical research findings have been inconsistent, some, but not all, people with schizophrenia may benefit from a gluten-free (and dairy-free) diet.

What are the symptoms?

Individuals who are sensitive to gluten may have the following symptoms:

  • Abdominal cramping and pain
  • Bloating and flatulence
  • Bone and joint pain
  • Canker sores
  • Chronic diarrhea
  • Delayed growth or short stature
  • Dyspepsia
  • Emotional disturbances, such as anxiety and depression
  • Fatigue
  • Infertility
  • Painful skin rash
  • Weight loss

What do I need to avoid?

To avoid gluten, ask about ingredients at restaurants and others’ homes, and read food labels. Avoid questionable products until the manufacturer guarantees they are gluten-free. Recheck products regularly as ingredients may change.

Beginning in 2006, food labels in the US must accurately declare in a special “allergy statement” if wheat protein, even in small amounts, is present in an ingredient used in that food. However, this regulation does not pertain to other gluten-containing grains, so labels must still be checked carefully for those sources.

At home, care should be taken to keep gluten-containing itemsfoods used by other members of the household from contaminating cooking appliances, food-preparation surfaces, utensils, shared condiment jars, and so forth.

The following list is not complete. Consult with a healthcare professional before making any significant changes to your diet. Grains and grain products to avoid (check ingredients of breads, breading, cereals, coating mixes, crackers, croutons, fried snacks, muffins, pasta, pastries, stuffing, and so on):

  • Barley
  • Bulgar
  • Couscous
  • Dinkle
  • Einkorn
  • Emmer
  • Farina
  • Faro
  • Flour: any made from grains on this list; bread, brown, durum, granary, strong, and whole-meal flour usually indicate flours containing gluten
  • Kamut
  • Malt
  • Matzo
  • Oats and oat bran*
  • Orzo
  • Panko
  • Rye
  • Seitan
  • Semolina
  • Spelt
  • Triticale
  • Udon
  • Wheat
  • Wheat bran
  • Wheat germ

*While oats contain a substance similar to gluten, modern research has found that eating moderate amounts of oats does not appear to cause problems for people with celiac disease or dermatitis herpetiformis. However, oats may be contaminated with gluten from other grains during processing; therefore only useing only oat products tested and guaranteed to be free of gluten is recommended.

Other food products and ingredients that may contain gluten (check labels or manufacturer for ingredients from the list above):

  • Ale, beer, stout, lager
  • Broth
  • Brown rice syrup
  • Candy
  • Cloudy lemonade
  • Curry mixes
  • Dried meals
  • Egg substitutes
  • Flavored instant coffee
  • Ginger beer
  • Grain spirits
  • Gravy cubes and mixes
  • Hot chocolate mixes
  • Hydrolyzed vegetable protein (also called hydrolyzed plant protein or protein hydrolysate) if made from wheat
  • Ice cream
  • Imitation bacon and seafood
  • Licorice
  • Malt vinegar (distilled vinegars are gluten-free)
  • Marinades
  • Mustard powder
  • Nondairy cream substitutes
  • Nuts, dry roasted
  • Prepared meats (bologna, lunch ham, and so on)
  • Rice paper
  • Root beer
  • Roux
  • Sauces and sauce mixes
  • Self-basting poultry
  • Soup and soup mixes
  • Soy sauce and shoyu tamari
  • Starch, when labeled as wheat starch, modified food starch, or vegetable starch
  • Stock cubes
  • Suet in packets
  • Thickeners

Be careful of the following personal and over-the-counter items, which may contain small amounts of gluten:

  • Communion wafers
  • Glue (US-made envelope glue is reportedly gluten-free)
  • Lipstick, gloss, and balms
  • Prescription and over-the-counter medications listing gluten, starch, flour, or dusting powder as excipients
  • Supplements listing gluten, starch, flour, or dusting powder as excipients

Best bets

While wheat is one of the major gluten-containing grains, it is important to remember that “wheat-free” does not mean “gluten-free.” Make sure to carefully read food labels to determine if an item features gluten-containing items.

Prepare a note card with the foods that you need to avoid and bring this with you when food shopping or dining in restaurants. Communicate your special needs to the waiter or manager so that they can guide you to dishes that do not contain gluten.

Gluten allergies can often start in childhood as a result of early feeding of grains; consider breast-feeding your child for the first six months.

Be careful when buying grains from bulk bins. Make sure that the grains are adequately separated from the gluten-containing grains in order to avoid cross-contamination.

Are there any groups or books associated with this diet?

Celiac Sprue Association/USA, Inc.
P.O. Box 31700
Omaha, NE 68131
www.csaceliacs.org

Gluten Intolerance Group of North America
15110 10th Avenue SW, Suite A
Seattle, WA 98166
www.gluten.net

The Gluten-Free Gourmet: Living Well Without Wheat by Bette Hagman, New York: Henry Holt and Co., 2000.

More from the Gluten-Free Gourmet: Delicious Dining Without Wheat by Bette Hagman, New York: Henry Holt and Co., 2000.

Celiac Disease and Gluten-Free Diet Support Page
www.celiac.com

Celiac Disease Foundation
13251 Ventura Boulevard, Suite 1
Studio City, CA 91604-1838 818-990-2354
www.celiac.org

Celiac Disease: A Hidden Epidemic by Peter H. Green and Rory Jones, New York: HarperCollins Publishers, 2006.

Gluten-Free Diet: A Comprehensive Resource Guide by Shelley Case, Regina, Sk CA: Case Nutrition Consulting, 2003. Available from www.glutenfreediet.ca

Gluten-Free 101: Easy, Basic Dishes Without Wheat by Carol Fenster, Centennial, CO: Savory Palate, 2003.

Wheat-Free, Gluten-Free Cookbook series by Connie Sarros. New York: McGraw-Hill, 2003-4.

The Gluten-Free Mall. Gluten-Free Foods for Celiac Disease and Special Diets. www.glutenfreemall.com

Gluten-Free Diet Guide for Families by The Children’s Digestive Health & Nutrition Foundation and The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, 2005. Available at www.naspghan.org/assets/diseaseInfo/pdf/GlutenFreeDietGuide-E.pdf

Gluten in Pharmaceutical Products by Sister Jeanne Patricia Crowe and Nancy Patin Falini. Am J Health-Syst Pharm 2001;58:396-401. Available at www.medscape.com/viewarticle/406948

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