12 steps toward gluten freedom

Going against the grain, part 2

By Shannon Lewis, M.D., gastroenterologist, The Oregon Clinic, and Niki Strealy, RD, LD, outpatient dietitian, Providence Nutrition Services

In part 1 of Going against the grain, we explained three reasons to go gluten free, and three reasons not to. If you are considering going gluten free because you think it’s a good way to lose weight, to eat healthier or to diagnose your own symptoms, read part 1 to learn why this might not be such a good idea.

However, if your doctor has diagnosed you with celiac disease, dermatitis herpetiformis (DH) or gluten sensitivity, giving up gluten should make a huge difference in your health.

Gluten – a protein found in several types of grains – assaults people with these conditions in different ways.

In people with celiac disease, it triggers the immune system to attack the small intestine. Even the tiniest bit of gluten – a few crumbs transferred from a knife to a mayonnaise jar, for example – can cause serious damage, preventing the small intestine from absorbing nutrients from food. As a result, many people with this autoimmune disease suffer from severe malnutrition, which can cause them to feel extremely fatigued. Some have digestive symptoms, but many have no outward symptoms at all. Most of the damage occurs inside, increasing the risk of serious vitamin deficiencies, osteoporosis, infertility, neurologic disturbances and certain autoimmune diseases and cancers.

In people with DH, gluten does its damage on the outside, causing the immune system to attack the skin. People with this disease develop very painful, red bumpy rashes after eating gluten. With repeated exposure to gluten, they also may have a higher risk of intestinal damage.

People with gluten sensitivity simply can’t tolerate gluten. Eating gluten doesn’t raise any long-term risks, but its short-term consequences are often immediate and severe: instant stomach pain, diarrhea, gas, bloating or constipation.

Giving up gluten alleviates these problems. For the person with celiac disease, it allows the small intestine to heal and to be able to absorb nutrients again. Energy returns; gut symptoms, if there were any, go away; and the long-term risks of autoimmune diseases, cancers and other associated health problems drop to about the same level as in the general population. For people with DH, giving up gluten gets rid of the painful red rashes, and keeps them away. For those with gluten sensitivity, it prevents a lot of unpleasant digestive episodes.

Motivation, if you have any of these conditions, probably isn’t an issue. The benefits of giving up gluten are all too clear. It’s compliance that’s tricky. Eliminating every possible source of gluten is much more challenging and complex than most people realize. But many people have done it, and you can, too. Here are 12 steps that will help you succeed.

1. Assemble a team.
Because it’s so challenging, don’t attempt to go gluten free on your own. Enlist a dietitian to partner with your primary care provider in putting together the best plan for your diet and health. A dietitian can give you detailed information about what is safe to eat and what isn’t, and can help answer all the questions that are bound to come up as you make the switch to a gluten-free life. If you have celiac disease, it’s also important to include a gastroenterologist on your team for long-term monitoring of your intestinal health.

2. Get to know your grains.
Going gluten free does not mean giving up all grains. Whole grains are an important source of fiber and other nutrients. Once you cross the toxic grains of your list – wheat, rye, barley, spelt, kamut, triticale and malt – make an extra effort to include safe grains in your diet. These include rice, corn, amaranth, quinoa, buckwheat, millet and certified gluten-free oats. A very small percentage of people with celiac disease do react to oats, but this is usually because of cross contamination. The “certified gluten free” seal means that a product has been grown, stored and processed without coming into contact with soil, equipment or facilities that may have been used to grow or process wheat.

3. Read every label.
Be vigilant about checking every ingredient in packaged and prepared foods for hidden gluten. If the label says that the product was “processed in a facility that also processes wheat,” don’t eat it.

4. Know where gluten hides.
Gluten hides in some unexpected places, including soy sauce, malted vinegar, most beers, many processed foods, French fries that have been fried in the same oil as breaded foods – even some medications and supplements contain gluten. Enlist your dietitian’s help in identifying other places where gluten hides.

5. In restaurants – don’t let your guard down.
Portland is a great place to live if you have gluten issues. The city has a growing selection of gluten-free restaurant and bakery choices – but not every restaurant has caught on. Be very clear about your needs when dining out. Call ahead to ask about gluten-free options. Arrive early to allow time to talk to the server. Ask the server to tell the chef that your food must be strictly gluten free. Consider printing up cards to give out, listing all the foods and ingredients that you can’t have. Triumph Dining Cards offers pre-printed cards in multiple languages tailored to specific cuisines.

6. At parties – BYOB.
There’s no need to ditch every dinner party just because you can’t have everything they’re having. Bring your own gluten-free beer, or bread, or even your own ready-to-eat main course, to make sure there is at least one thing that you can eat and drink. Some well-meaning hosts may offer to prepare a gluten-free dish for you, but don’t be too quick to accept until you are absolutely sure that they understand all of the risks of hidden ingredients and cross contamination; the safest route is to bring something you’ve cooked yourself, at your home.

7. In the grocery store – get to know the gluten-free aisle.
Most stores in the Portland area carry gluten-free items, and some group them together so you can find them easily. New Seasons Markets give tours to familiarize shoppers with its gluten-free selections. Trader Joes and Whole Foods also stock many gluten-free options. Lingonberries Market in Vancouver is entirely gluten free.

8. In the kitchen – avoid contamination.
If you are the only gluten-free person in a house full of gluten gluttons, set up a corner of the kitchen that is just for you, and make sure everyone knows the rules for avoiding contamination. Your cutting board is just for you. You’ll need your own toaster, too – even a few crumbs from their bread could damage your intestine. Use separate pots for boiling regular and gluten-free pasta, or, if using the same water, cook the gluten-free pasta first. Wooden spoons are risky and shouldn’t be used. Don’t share the same bowl of dip with gluten-eaters, and be sure to enforce the no-double-dipping rule when sharing condiments.

9. Find replacement versions of your favorite foods.
It’s easier to stick with a gluten-free diet if you don’t have to radically alter your normal eating pattern. Most people tend to rely on the same 50 or so foods for most of their meals. Go through your “staples” and find replacements for those that contain gluten. By replacing flour tortillas with gluten-free corn tortillas (some do contain wheat flour, so be sure to check), for example, you can still eat your favorite tacos. Gluten-free pastas and breads allow you to keep spaghetti, burgers and sandwiches on the menu, if those are your regular choices.

10. Take your vitamins.
On a gluten-free diet, you’ll be skipping many of the grains and fortified products that are key sources of fiber, B vitamins, folate, iron, calcium and vitamin D. To prevent nutrient deficiencies in these areas, take a daily multivitamin – preferably in chewable or liquid form, which is the easiest for your body to absorb. A probiotic supplement is a good idea, too. Celiac disease may be associated with low levels of the good gut bacteria that are needed for healthy digestion. Probiotics help replace these helpful bacteria.

11. If in doubt, leave it out.
This is the simplest rule of them all: If you have any doubts about whether or not a food contains gluten, don’t eat it. It’s just not worth the risk.

12. Seek support.
Build a network of support, starting with your inner circle. Educate your family and friends about what it takes to keep you safe, and ask for their support. Expand your network by finding your local chapter of the national Gluten Intolerance Group. You’ll gain access to gluten-free recipes, restaurant recommendations, monthly support meetings, conferences, food fairs and, most importantly, other people who are going through the same things as you.

Having so many dietary issues can seem frustrating and isolating at first, but with time, practice and support, it gets better – and so does your health.