Whenever I meet a patient who is new to starting a gluten-free diet, the first food I hear they are eating is rice. Rice cereal for breakfast, rice cakes for lunch, white rice for dinner. It's safe, it's bland, it's the perfect food for going gluten-free.
The problem is, you can get tired of rice pretty quickly.
Besides, regular white rice and white rice products are low in fiber, and if they are replacing foods like whole grain cereal and whole wheat bread, you may be eating a diet much lower in fiber than before you started this gluten-free journey.
What is fiber and why is it important?
Dietary fiber is a substance found in plant products that gives the plant structure. Foods high in fiber, then, have more bulk and structure than foods low in fiber. This is good for the human body because you cannot digest it; instead, your digestive tract sends it on through to the large intestine and out with waste products, or stays and ferments in the large intestine, adding healthy bacteria to your system.
Dietary fiber benefits can be summarized as helping to:
You can find more good information about fiber benefits here from the Mayo Clinic and here from The Nutrition Source at Harvard.
What does this have to do with non-celiac gluten sensitivity? A gluten-free diet can potentially be low in fiber. As mentioned, white rice is a common substitute for wheat in the diet, and is also a common ingredient in gluten-free products such as breads, crackers, cereals, and snack foods. That often leads to a very low fiber intake. Most Americans already eat less than half of the recommended amount of fiber daily, so taking away whole wheat and whole grain products in your diet will only make the problem worse.
Of course, fiber is not found just in whole wheat products, so the solution is easy. Fiber is found in a wide variety of fruits, vegetables, beans, nuts, and seeds. A plant-based diet filled with these food groups can contain the 20-30 grams of fiber you need per day. Try these great high fiber foods!
Sometimes it helps to have a tangible example. Here’s what a day might look like with adequate fiber:
As always, make sure your oats, nuts, and seeds are gluten-free. Then, start to add fiber-rich foods slowly, one serving at a time, until you are eating fiber at every meal. Be sure to increase your water intake as well, drinking about ½ cup with each meal and 8 cups per day.
Gluten-free and high fiber can both be a manageable part of your life!
As you continue to avoid gluten, read labels, and monitor your gluten-related symptoms, eating can get overwhelming. How about taking a break from thinking about food and your illness? Self-care is a somewhat new buzzword for initiating deliberate care of yourself, whether to reduce stress or reduce negative symptoms of fatigue or pain. It is important for both physical and mental health!
These are my favorite areas of self-care.
Physical activity: I have my smart watch set to notify me when it is ten minutes before the hour, every hour. Whatever I am doing, I get up and stretch, walk around the block or the house, go up and down the stairs a few times, and/or do a few calisthenics at my desk. I even have an RBG calendar on my office wall that shows activities I can do if I run out of ideas :)
Exercise: In addition to bits of physical activity throughout the day, I make sure I get at least 30 minutes daily of uninterrupted higher intensity exercise, such as a brisk walk, bike ride, hike, time on an elliptical, etc. This reduces the stress hormone cortisol and helps fight chronic diseases. You do not have to start training for a marathon; just find something you enjoy that raises your heart rate a bit.
Stress management: Physical activity and exercise are major stress busters. Other great habits are meditation (which I am terrible at) and yoga (which I love), as well as journaling, reading, listening to music, and spending time in nature. Surely there is something you can do for 10 minutes a day that is just for you.
Sleep: You’ve heard the advice: get eight hours of sleep every night. While the optimal sleep time varies, I know I feel better with eight hours, and I have to fight the urge to stay up late to enjoy a book or movie or NCIS episode on TV. It’s worth it to set a regular bedtime, make sure it’s dark and cool in your room, and avoid blue lights/screens for the half hour before.
Mindfulness: Mindful eating, especially, is a habit that can leave you feeling more fulfilled and nourished than speed eating while working at your computer or watching TV. Eat meals at the table with a placemat and even a candle.
Social support: A friend, partner, family member, neighbor, or online community can help you feel connected. Reach out to others, and cultivate only the relationships that feel positive.
Spiritual self-care: Remember your spiritual side, which needs nurturing along with your body and brain. Spiritual values may include religion, the environment, social justice and peace, or believing in anything else that is greater than yourself.
I often combine these habits, such as walking my dog (exercise) through the woods (stress management) while reflecting (spiritual) or inviting my partner along (social). Do I always follow my own recommendations? Maybe not, but it’s an ongoing effort!
Today, give yourself the care and compassion you give others; you deserve it.
Have you heard of “cross-contamination”? It is a term often used to refer to gluten-free food coming into contact with gluten. For example, oats are naturally gluten-free but may contain gluten if they have been cross-contaminated, or touched by, gluten, either in processing or packaging. Experts recommend we now use the term “cross-contact” instead, because cross-contamination is also used in the world of food safety and food service; it refers to food being exposed to bacteria or other microorganisms that could result in illness when eaten. If we use that definition, it makes it sound like we can cook / kill the contaminant, right? So let’s not confuse things. We cannot get rid of gluten with cooking, so I will try to only use the term “cross-contact”.
If you have celiac disease, any exposure to gluten can make you sick, causing an autoimmune response even if you do not feel it. It is critical that you avoid all gluten, all the time. Beyond Celiac has designed an infographic to help you think about potential gluten sources not just in food but in toys, lotions, and kitchen equipment: Hot Spots
If you have a gluten-related disorder, such as non-celiac gluten sensitivity, you may experience the same symptoms as someone with celiac or you may have fewer or more symptoms of varying degrees of severity. It is very individual. That said, the jury is still out about the degree of cross-contact to cause you concern. For many of us who do not have celiac disease, we are able to tolerate small amounts of cross-contact without harm. The rest of this blog is for gluten-related disorders, not celiac disease.
When you are first diagnosed, it is important to follow an elimination diet and reintroduction of foods to determine your sensitivities, as you know from reading my previous blogs. In this blog, we will consider cross-contact in food processing and packaging, stores and markets, restaurants, and at home.
FOOD PROCESSING AND PACKAGING
Continue to read ingredient lists on food packages and continue to avoid wheat, barley, rye and anything derived from them! Remember, too, that refining and processing equipment may be shared with wheat and other gluten-containing foods. The FDA gluten-free labeling rule is voluntary so it is our responsibility to read ingredients and call the manufacturer if we are not sure.
GROCERY STORES AND MARKETS
As discussed in previous articles, bulk bins and deli items are potential sources of cross-contact and you should proceed with caution. You could do your research and ask a lot of questions, but I just avoid both for now.
When eating out, I check the restaurant’s website to view the menu ahead of time. If it isn’t available, or you forget, take your time in reviewing your choices and ask the server to check with the chef if you want to make sure gluten-free items are kept separate from gluten-containing items. I avoid buffets, as utensils, fingers or other food may accidentally come in contact with foods that are naturally gluten-free. Be careful with fried foods, too; many restaurants (including fast food) use the same fryers to cook French fries and breaded chicken, so you would likely get gluten with your potatoes. This reference may help you decide what to choose at fast food establishments: GF Fast Food.
Unless you keep a completely gluten-free household, you may come into contact with gluten in your home. Common causes of concern include the toaster, toaster oven, convection oven, utensils, pots and pans, griddle, cutting board, and even dishcloths and sponges.
In your toaster and toaster oven where food comes in direct contact with cooking surfaces, and in convection ovens, where a fan blows food particles including gluten that may have been in the oven previously, your gluten-free foods may receive gluten transfer. Traditional advice recommends sharing toaster ovens and convection ovens only if your food is covered; I do not worry about this will discuss further in a minute.
Significant gluten transfer can also occur with utensils, dishes and cookware. Do not use the same knife, for example, to cut or butter GF and wheat bread, and do not use the same serving spoon to scoop up GF foods and those with gluten. Do not share a knife between condiments, either; peanut butter, mayonnaise and other spreads need their own utensils - and double dipping needs to be avoided. Same with sharing dishes and cutting boards - don't. As for cookware, foods cooked in a fryer that also cooks gluten-containing foods can cause enough gluten transfer to be a problem, as can griddles that cook pancakes and waffles. Be sure to wash all dishware and cookware between uses.
Lastly, you may need separate dishcloths and sponges to clean gluten-free dishes and cookware, and always use fresh water to rinse. This category of cleaning items is eliminated if you use the dishwasher, and actually not a problem for most people with gluten-disorders who do not have celiac. While I am careful not to share utensils and cutting boards with gluten and GF foods, I have never had an issue with dishcloths or sponges.
For more information, enjoy this guide to reducing cross-contact here.
So, does all cross-contact matter? For me personally, and for many of my friends and clients, the small amount of gluten in a toaster or convection oven does not cause us any discomfort. Nuts processed in a facility that processed wheat, however, caused problems. With a careful food diary, we were able to track symptoms to their sources. (Remember, if you have celiac, you must follow the strictest guidelines). New research published in the journal Gastroenterology in January 2020 supports this; it showed that gluten exposure in the kitchen varies. For example, they found gluten transfer in toasters to be low and that typical dishwashing removes gluten so that separate pots are not needed. You can read more here and here.
While you learn more about cross-contact and get in tune with your body, stay well, my friends, and remember to eat mindfully and joyfully.
Have you ever realized how many foods have gluten? For such a little protein, it seems to show up in a wide variety of places. My last blog highlighted oats, spices, nuts, seeds, alcohol, and coffee - - be sure to view that if you haven’t already.
There are many other hidden sources of gluten, and some of them may surprise you! Let’s walk through increasing your chances of avoiding them.
First, be sure to recognize all the grains and pastas that are actually WHEAT, including bulgur, semolina, durum, spelt, kamut, graham, einkorn, farina, couscous, orzo, seitan, matzah (or matzoh or matzo) and cake flour to name a few. I had a client tell me she eats spelt because she read somewhere that it isn’t really wheat. It is!
Second, my ongoing recommendation is to read all INGREDIENTS on food labels. Some food packages make it easy for us by stating “gluten-free”; this is a voluntary claim that can be used by food manufacturers on food labels if they meet all the requirements of the regulations. A symbol is not required. If the food package does not say “gluten-free”, then we need to look at the list of Ingredients. Food manufacturers are required to list all ingredients in order from highest to lowest amount. Here are a few ingredients to avoid:
Unfortunately some ingredients can be listed as “flavors” or “spices” without naming each one, making your symptoms journal all the more important. For example, I had a client who was symptom-free and doing well, so he purchased a new type of rice, a flavored mix to add variety to his diet. It turned out to cause him quite a bit of bloating and pain, and he realized the source of the problem was the spice mix it contained.
Food labels do have to list wheat, thanks to the federal Food Allergen Labeling and Consumer Protection Act (FALCPA). Any packaged food regulated by the FDA must state that it contains wheat; furthermore, it may also have the statements “may contain wheat” or “made in a facility with wheat”, which are voluntary statements. These come in very handy for me when I am choosing nuts.
My third suggestion is to take a second look at the MEAT, FISH and POULTRY you are eating, as processed versions may contain gluten. Starting with meat and poultry, it is good to know that plain beef, chicken, turkey and pork do not naturally contain gluten. But when they are packaged or processed in any way, they may contain additional ingredients, or if they are sliced in the deli they may come into contact with gluten from other foods. The more the meat or poultry strays from its origin, say into the form of bologna or salami, the more likely it is to have outside ingredients. Your safest approach is to look for those clearly labeled “gluten-free”. These are helpful lists of brands of gluten-free deli meat and gluten-free sausages.
In addition to deli meat, beware of hot dogs, self-basting turkey or seasoned chicken breast. Even rotisserie chicken may have gluten; when roasted in the store, flour is often added to the skin to make it crisper, and there are also many spices and sauces that are used that may contain gluten. Also, as if that isn’t all worrisome enough, the rotisserie chicken may be exposed to gluten when it is packaged, since fired chicken is usually prepared right next to it. Look for “gluten-free” rotisserie chicken.
Meat substitutes are not necessarily a safe replacement, as there may be gluten in veggie burgers and other meat alternatives products (veggie bacon, sausage, burritos, etc.). Seitan is a common meat substitute, but is almost completely wheat gluten. Soy and bean products may have gluten-containing ingredients added. As always, read labels or call the manufacturer if you are not sure.
As for fish, seafood itself is naturally gluten-free and a wonderful source of nutrients, but processed fish such as imitation crabmeat usually contains wheat. Also, seafood that has been pre-seasoned, breaded, or packaged with a sauce are risky. I recommend you stick to plain fish that you can season and prepare yourself. This is a good overview of choosing safe seafood.
Another popular food is PIZZA. I know it seems obvious that pizza with a wheat crust has gluten and should be avoided. But also be careful with other pizzas, as sometimes they have a gluten-free crust but contain gluten in the cheese (shredded cheese may be mixed with a gluten-containing starch to prevent sticking and clumping) or the toppings (such as pepperoni). Read, call, ask, become informed. Whether you are buying a pizza from a grocery store or ordering pizza from a restaurant, use the same rules.
SAUCES, GRAVIES AND SPICE mixes may contain gluten from wheat or other culprits because they provide thickening (think roast beef gravy made from a roux) or stability (e.g. a package of fajita seasoning may have wheat added to prevent caking). Or they may be made of wheat; for example, soy sauce is a mixture of soy and wheat fermented together.
SOUPS from a manufacturer (premade) often contain pasta, barley, or spices that potentially contain gluten. Some brands are great about using the “gluten-free” designation on the label, but others just provide the list of ingredients, so you have to read carefully. If in doubt, don’t buy it; if you already bought it, call the manufacturer to check.
SALADS can be a nutrition dream of a variety of colorful greens and other fresh vegetables like tomatoes, cucumbers, peppers, carrots and mushrooms. As is, these are all naturally gluten-free ingredients. Make your own dressing or simply toss with vinegar, oil, salt and pepper for one of my favorite lunches and side dishes. Be careful, though, with store bought and restaurant salad dressing as well as croutons and other toppings that may have gluten containing elements.
Between meals, SNACK BARS can give you a boost but could also make you sick, so be sure to know what you are getting. With over 100 different brands and even more flavors, they also come with a variety of names: protein bars, energy bars, granola bars, health bars, and cereal bars. Start by eliminating those with wheat, rye and barley, then study the ingredient list. Avoid any that say “may contain” or “processed in a facility with” wheat. Bars often contain oats that are not gluten-free, wheat starch, rice syrup, yeast extract, and natural flavors. Some also contain dextrin and maltodextrin, which may or may not be made from wheat. If the bar is labeled “gluten-free”, of course, you do not need to worry, but if it is not, you should probably avoid or call the manufacturer to check.
SWEETS such as cookies and cake are probably obvious to you has potential sources of gluten. But what about ice cream, candy, candy bars and even cheesecake filling? All potential sources of gluten due to wheat and other gluten containing ingredients that are added. For example, vanilla ice cream is gluten-free while cookies and cream flavor is not; plain M&M’s are gluten-free but pretzel and crispy M&M’s are not; cheesecake is sometimes thickened with wheat. Other times, the product comes into contact aith gluten during processing. If you have celiac disease, you must carefully avoid all of these. If you have non-celiac gluten sensitivity, you may tolerate a product that has only slight exposure to gluten. Your symptom journal will help you. And fortunately for us, the most trusted celiac and nonceliac gluten sensitivity expert sites list gluten-free candy sources every Halloween and Easter; start with this one: Gluten and Candy.
That is a lot of information and there is so much more out there! I don’t attempt to list all the brand names of what does and does not contain gluten because there are other sites that serve that purpose. My favorites are www.celiac.org and www.beyondceliac.org.
If you are doing your elimination diet, you can start to add them back foods in just a few weeks to identify which are bothersome to you. Until then, continue to keep a symptoms journal, read food labels and watch for those gluten sources.
What does a dietitian, nutritionist, and health professional do when she discovers she has to avoid gluten? I mean, avoid it to prevent painful symptoms, not to follow a trend. Find out here and get insider tips on diagnosis, management, and navigating a life-long journey.