Celiac Disease: How to Follow a Gluten-free Diet

In my article on food allergies and intolerances, I discussed the fact that food allergies and sensitivities have become more common in recent years, especially among children. Another common food component people can react to is gluten. Although experts estimate about two million people in the US have celiac disease, many have not been diagnosed. It is thought that about one percent of the world’s population have celiac disease.¹

What is Celiac Disease?

Celiac disease is an autoimmune disorder that causes inflammation and damage to the lining of the intestines when gluten is ingested. The disease has a genetic component and once developed, there is no cure. The only treatment is lifelong avoidance of gluten. Clinical symptoms of celiac disease can range from mild to severe and may include diarrhea, gas, bloating, fatigue, anemia, irritability, and weight loss.

If someone with celiac disease continues to consume gluten, the intestinal damage will result in malabsorption of nutrients which can lead to a deficiency of vitamins and minerals. These deficiencies can result in rickets (in children) or osteomalacia (in adults), and iron or folate deficiency among others. Strict avoidance of gluten is the only way to halt the damage and allow the intestinal lining to heal.

What is Gluten Sensitivity?

 The difference between gluten sensitivity and celiac disease has to do with the autoimmune component. Those with gluten sensitivity can have symptoms when consuming gluten such as diarrhea, gas, bloating, or stomach cramps. But no damage is done to the intestinal lining because there is no immune response triggered. Conversely, those with celiac disease will experience an immune response which damages the lining of the intestinal tract whenever gluten is consumed. The damaged cells of the intestinal wall are no longer able to produce enzymes and absorb nutrients. It may even damage the junctions between cells allowing partially digested food particles to enter the bloodstream from the digestive tract. This is known as intestinal permeability and often referred to as “leaky gut”.

Living Gluten-free

Unfortunately, the only way to avoid the damage gluten causes in celiac disease is to remove all gluten from the diet. For someone who loves their baked goods, bread, and pasta, this can be challenging. The trick is to find alternatives to your favorite gluten-containing foods and incorporate those into your daily meals or snacks. And remember, just because it is gluten-free doesn’t mean it is “healthy”. There are many processed foods on the market that are labeled “gluten-free”, but they are just as unhealthy as their gluten-containing counterparts.

Here are my top strategies for living well on a gluten-free diet.

1. Read your food labels carefully to help you avoid any foods that contain gluten. These include wheat, rye, and barley or anything made from these grains. Some grains, such as oats, do not naturally contain gluten but they may be contaminated with gluten if grown or stored next to wheat, rye, or barley. Most pre-packaged foods must clearly identify if they contain any of the 9 major food allergens (or contain the immune-triggering protein of the major food allergens). Since wheat is one of the top 9 most common food allergens, it will be labeled. However, rye and barley are not required to be labeled under food allergens. Look for the list of ingredients to see if wheat, rye, or barley in any forms is included. Also notice “allergen free” claims, and statements like “may contain” or “produced in a facility that also uses.” If wheat is listed on this list, then the product could potentially be contaminated with trace amounts of gluten.
2. Wash your hands, surfaces, dishes, and utensils well to prevent accidental cross-contamination between gluten-containing and gluten-free foods. This includes cleaning or using a separate toaster or toaster oven for toasting bread.
3. If you’re eating out, confirm whether the meal is gluten free before placing your order. Ask the person taking your order to check with the kitchen if needed to ensure none of the ingredients contain gluten. It’s also important they prevent cross contamination.  
4. Gluten-containing ingredients may also be added to certain medications, oral care products and cosmetics, so check those labels or ask your pharmacist before purchasing.
5. People with celiac’s may also experience lactose intolerance because of the damage gluten does to the intestinal border which affects the production of lactase (the enzyme that helps break down lactose). You may choose to avoid dairy products until your gut heals or you can take the lactase enzyme (available as a dietary supplement) before consuming dairy products. Another option is to use lactose-free milk (which has been pre-treated with the lactase enzyme). This can help you enjoy dairy again.  
6. If you believe that you may have gluten sensitivity or celiac disease, see your healthcare provider about getting tested. A blood test can help determine if you have the markers for celiac disease.

Note: If you do not have Celiac disease or a gluten sensitivity, then it is not necessary to avoid gluten. Only those that react to this protein found in wheat, rye, and barley need to avoid it. Foods containing these grains can be incorporated into an overall healthy diet. Discuss with a dietitian if you have any concerns about consuming gluten or if you aren’t sure you are getting enough nutrients on a gluten-free diet.

References

• 1. Lebwohl B, Sanders DS, Green PHR. Coeliac disease. Lancet. 2018 Jan 6;391(10115):70-81. doi: 10.1016/S0140-6736(17)31796-8. Epub 2017 Jul 28. PMID: 2876044
• 2. What is Celiac Disease? Accessed at https://celiac.org/about-celiac-disease/what-is-celiac-disease/ on September 22, 2023.
• 3. Celiac Disease. Accessed at https://www.mayoclinic.org/diseases-conditions/celiac-disease/symptoms-causes/syc-20352220 on September 22, 2023.

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