After reading my previous blog, you hopefully started your Gluten-free Elimination Diet. Some experts recommend you follow an elimination diet for three to four weeks; I did it for eight weeks because I had little setbacks along the way, and many of my clients have as well, so here is some advice for navigating this phase!
 
ELIMINATION
First, you eliminate all obvious sources of gluten. To review, obvious sources of gluten include:

• Wheat and all its forms, such as whole grain, multigrain, enriched, graham, semolina, and self-rising flour. These are found in bread, pasta, bagels, frozen waffles, flour tortillas, cookies, crackers, pretzels, pizza dough, and many breakfast cereals.
• Rye
• Barley
• Oats (more below)

 
At this point in your journey, I recommend you keep your meal plan / dietary intake as simple as possible with mostly whole foods - foods that you recognize in their original form, not processed, such as fruits, vegetables, beans (dried or canned such as black, pinto, kidney, and navy beans), meat, fish, eggs, milk, and yogurt. See my meal plan here.
 
If you are craving carbohydrate foods like pasta, turn to potatoes, rice and quinoa instead. You should also stick to salt and pepper for seasonings unless the label clearly says gluten-free (more on that in a minute). You will be reintroducing all your favorite flavors soon. By keeping your intake simple for now, you are most likely to avoid all gluten and start to feel better.
 
That said, it is easy to encounter gluten in hidden places!  After my previous blog, you are paying attention to processed foods that may contain gluten, such as beer, malt, modified food starch, soups, seasoned snack food, some cereals, soy sauce, spices, and seasoning mixes. It sounds straightforward until you are actually trying it. I started to expand my diet after about four weeks because I wanted more variety, and I realized how it important it was to continue keeping a Symptom Journal! Let’s look at a few of the hidden gluten sources I encountered.  
 
HIDDEN SOURCES OF GLUTEN
 
Oats

• Oats are a wonderfully delicious and nutritious whole grain that can be made into oatmeal, baked into granola, and used in a variety of recipes. They are naturally gluten-free, but unfortunately are often contaminated with wheat and other gluten-containing products. How? They are often grown next to wheat in the fields or exposed to gluten in the facilities where they are packaged. So, you need to buy and eat only oats that are labeled “gluten free”. Popular brands include Bob’s Red Mill, Arrowhead Mills, Nuts.com, and Thrive Market; even Quaker has a select gluten-free variety  now. Read the label and make sure it says certified gluten-free, gluten-free, or pure/uncontaminated.

• Do not buy oats from a bin - you know, those bulk bins in grocery stores where you scoop your own. The container or scoop may have been contaminated by gluten and there is no way to know.
• Do not eat oatmeal flavored with molasses or brown sugar flavorings, which may have caramel coloring that contains wheat.

 
Spices

• Ground spices are sometimes contaminated with gluten in a facility that processes other foods, or they are sometimes intentionally processed with wheat to keep them from clumping. I discovered that my favorite ground cinnamon contained gluten. I was four weeks into my elimination diet and felt great, then added cinnamon to my safe foods. I felt those old familiar symptoms the next day - fogginess, headache, blurred vision, and fatigue. I quickly wrote out a symptom journal since I had stopped keeping one, and the only food item that was new was the cinnamon. I tried it again with the same results. After another week of my original elimination diet and back to feeling great, I tried a different brand of cinnamon with the same results. I finally found a brand that was gluten-free and have been successfully enjoying cinnamon with no problems.
• Other possible contaminated spices are ground paprika, turmeric, curry powder and spice mixes. Read labels and experiment carefully.
• One website that lists a variety of gluten-free spices and seasonings is www.verywellfit.com. I would add Savory Spice to the list.

 
Nuts and Seeds

• Like spices, nuts and seeds are sometimes processed or contaminated with gluten. Who would have thought? Fortunately, these are a little easier to catch because their food labels have to say if they were processed in a facility that also processes wheat. I discovered store brands of peanuts and walnuts from two of my favorite stores were contaminated with flour, so I had to search for others.
• Read labels and avoid nuts or seeds processed in a facility that processes wheat.
• Do not buy nuts and seeds from bulk bins.

 
Beverages

• Beer is often a source of gluten because it is usually made from malted barley and hops, and sometimes wheat. During the first few weeks of your elimination diet, I recommend you steer clear of all beer. Once you are feeling well, it is safe to try gluten-free beer. Do not drink “gluten-removed beer” if you have celiac, as it is not necessarily safe. Good gluten-free beer options are now fairly widely available, with some good options identified in this Gluten-Free Beer Roundup.  

• Other alcoholic beverages such as wine, hard cider, and distilled alcohol are usually safe. Wine is made from fruit, so no worries there. Hard cider is also made from fruit, but sometimes barley is added so ask or read the label. Most spirits, hard alcohol, or distilled alcohol are made with a process that removes any potential gluten proteins; this means vodka, tequila, whiskey, rum and gin are okay for you, but do read this informative article to tease out the details before taking a sip: Gluten-Free Alcoholic Beverages.
• Flavored coffees and teas, as well as specialty drinks that contain added flavors (such as a vanilla latte) may contain gluten. Explore websites or call the manufacturer if you aren’t sure.

 
 
That’s a lot of information for one read! To recap, if you have symptoms despite carefully choosing gluten-free foods, consider the hidden sources discussed here. And keep going with your Symptom Journal so you can go back and identify the culprits.
 
Be kind to yourself as you continue this journey. Get some fresh air every day and treat yourself to regular physical activity, like walking around the block or stretching every hour.
 
Best of health!
 
Resources in today’s blog include

• https://health.clevelandclinic.org/spot-secret-sources-gluten-infographic/
• https://www.verywellfit.com/gluten-free-spices-562362
• https://www.uchicagomedicine.org/-/media/pdfs/adult-pdfs/conditions-and-services/gastrointestinal-disease/celiac-impact-beer.pdf
• https://www.glutenfreeliving.com/gluten-free-foods/diet/gluten-free-beer-roundup/
• https://www.celiac.com/articles.html/gluten-free-alcoholic-beverages-r218/

 
UP NEXT… More hidden sources of gluten: I will look at protein foods, pizza, and a variety of
​S foods: sauces, sweets, snacks, soups, and salads.
 
 
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​Now that you have used your Symptom Journal to identify potential triggers, you should avoid those foods or drinks, then eventually reintroduce them, with an Elimination Diet. As the name implies, this is a meal plan that eliminates or removes certain foods and drinks. The idea is to remove your symptoms, too! That said, it is important to follow an Elimination Diet for 3 to 4 weeks, or until you have do not feel symptoms anymore and you feel good. (I like to say “health” is not just the absence of illness, but a feeling of physical and emotional wellbeing).   Then you will gradually reintroduce one at a time to see if it creates symptoms again.
 
Before I go on, please know that you should do this with the help of a dietitian or specialist in integrative medicine for several reasons:

1. Guidance in creating a meal plan that give you a variety of nutrients. If you simply cut out everything gluten and just eat gluten-free crackers for a month, you will likely develop other problems such as constipation and fatigue due to lack of fiber and vitamins.

2. Moral support. An experienced health expert knows this can be a frustrating period of time, and she/he can help you know what to expect.

3. Adding foods back to your intake should be slow and systematic. It is important to introduce one gluten-containing food at a time, in a small amount. If that does not cause problems, you can increase it to what you consider a normal serving size the next day. Some practitioners say to add something new every two days, but I recommend (and used myself) a more cautious and informative approach: add back one gluten-containing food (let’s say one piece of wheat bread) and otherwise follow your elimination diet. If you feel old symptoms returning (I felt bloated and brain fog in just a few hours), spend the next day on your full elimination diet again then add the bread again on the third day. This helps make sure you are not having a placebo effect or imagining the symptoms. It can be tricky and it really does help to work with someone.
 
The key to this phase of your health journey is patience.
 
And of course knowledge. How do you know what to eliminate? Let’s start here…
 
What and Where is Gluten?
Gluten is a protein found in many grains, including wheat, barley, rye and triticale (a cross between wheat and rye). Gluten is also often found in oats. While oats are naturally gluten-free, they may be contaminated during production with wheat, barley or rye. Oats and oat products labeled gluten-free have not been cross-contaminated. Some people with gluten sensitivity or celiac disease, however, cannot tolerate the gluten-free-labeled oats, so avoid them for now.
There are different names for wheat flour depending on how it is processed, so look for and avoid these:

• enriched flour with added vitamins and minerals
• farina, milled wheat usually used in hot cereals
• graham flour, a course whole-wheat flour
• self-rising flour, also called phosphate flour
• semolina, the part of milled wheat used in pasta and couscous

 
There are also other varieties of wheat to know and avoid:

• durum
• einkorn
• emmer
• kamut
• spelt

 
Lastly, many processed foods and drinks contain gluten (even foods you don’t really think of as processed). some to watch for and carefully read labels on:

• beer, malt, modified food starch, soups, seasoned snack food, some cereals, soy sauce, spices, seasoning mixes.

 
I know it is a long list. The easiest way to start an elimination diet is to stick to naturally
gluten-free foods! This list is pretty great – lots of variety, color, and nutrients. I found it satisfying and sufficient for my four week trial:

• fruits and vegetables
• unflavored dairy products (milk, plain yogurt)
• beans and legumes
• eggs
• unprocessed meats, fish and poultry

 
My first week, I admit to looking for gluten-free breakfast cereals, snack foods, and baked goods; just knowing I couldn’t have gluten made me crave carbs. But I soon found I didn’t feel great because they ended up giving me more sugar and less fiber than I was used to. So here is what I ate…

• Breakfast: plain Greek yogurt + berries or a banana + flax seed*
• Lunch: large tossed salad of dark greens, carrots, cucumbers, tomatoes, peppers and a protein (canned drained tuna, leftover chicken breast, and garbanzo beans were my favorite)
• Dinner: steamed/grilled/roasted vegetables like green beans, Brussel spouts or broccoli + a protein (fish, turkey breast, chicken and black beans were my favorite)
• Snacks: apple slices with peanut butter; nectarine with almonds*; melon with cottage cheese**; popcorn; smoothie of fruit + Greek yogurt + almond butter

 
*some nuts and seeds are processed with flour so check the label to make sure it says gluten free. Imagine my surprise when I felt great until I ate a handful of store brand peanuts; not good!
**most cottage cheese if safe but some are processed with modified food starch.
 
Do you love cheese and want more information? I love this website: Beyond Celiac.
  
Up next... Hidden Sources Of Gluten: Improving Your Elimination Diet
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You’ve realized that your stomach aches, pains and processes are not “normal”. What next? It’s time to keep track of your symptoms in an organized manner over a specific period of time – using something we call a Symptom Journal, Patient Log, or Medical Diary. For consistency, I’m going to call it a symptom journal in this blog.
 
A symptom journal is all about identifying the what, when, why, and how of your gastrointestinal (GI) issues.

• What: What exactly are you experiencing? Bloating? Pain? Gas? Cramps? Nausea? These obviously are your symptoms.
• When: Are you having symptoms when you first wake up, during a meal, immediately following a meal, an hour after eating or drinking? These can be identified as timing and duration of symptoms.
• Why: Do you tend to have symptoms with certain foods, such as bread? Certain spices, such as cinnamon? Certain beverages, such as soda? These can be identified as triggers.
• How: How are symptoms improved? Do they go away if you don’t eat or drink for two hours? Do they go away with rest, with exercise, with a gas-relieving medication like Gas-X? These are your alleviating factors.
• What else: I think it is also important to record lifestyle considerations. Are you feeling stressed, sleeping poorly, or dehydrated? And maybe you want to record positives, like when you get fresh air, stretch, listen to good music, or have a good video chat. 

 
Keeping this journal for at least a week will give you a clearer picture of what is going on with your body. You know your body better than anyone, and this allows you to know it even better. You will be more mindful and knowledgeable instead of just guessing or assuming.
 
This symptom journal can also provide information for your physician or dietitian, as it takes much less time for your healthcare provider to review your diary than to gather a verbal report.
 
There are several ways to start this journal. Some of my clients use a composition notebook, a legal pad, or printed form where they can fill in the blanks. Others like a document, template, or spreadsheet they can keep open on their laptop or phone. Do what is most likely to work for you. Here are just a couple of examples (I do not get any kickbacks by recommending these; please find ones that you like.)
1. Digital Tracker
2. iPhone App
3. Example (if you use this example, be sure to customize to include how long symptoms last as well as alleviating factors and any other details that might help):

Up next: The Elimination Diet!

Happy New Year to followers, friends and colleagues!

Like you, I had a very unusual 2020. My travel plans were all cancelled, work shifted to remote only, and health was of utmost importance. I was fortunate to continue to teach online courses as well as counsel clients via video chat. At the same time, though, I struggled to feel well, brushing it off for months as the fatigue of all things pandemic-related. But medical visits and paying closer attention to my body helped me determine that I could not tolerate gluten.

Having to follow a gluten-free diet was never something I aspired to. Raised on spaghetti and bread, I love carbs more than anyone I know. And as a dietitian, I have warily watched the trend of going gluten-free for all the wrong reasons (weight loss, improved athletic performance, cleaner eating – none of which are scientifically supported) but have also worked with many clients suffering from gluten-related disorders, namely Celiac Disease and Non-Celiac Gluten Sensitivity.

My mission for 2021 is to focus on this topic while sharing my journey with you. Together we will explore the latest research, examine different gluten-related disorders, figure out steps for diagnosis, look at how to improve quality of life, and of course, manage a gluten-free diet. I cannot wait to continue this conversation with you and connect you with all kinds of other resources. Until then, get plenty of fresh air, sleep well, be mindful, maintain your physical activity, and eat lots of fruits and vegetables.

​Best in health,
Melissa

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