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:
There are also other varieties of wheat to know and avoid:
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:
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:
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…
*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: Expanding your gluten free diet!
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.
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!
When I talk to clients about gluten-related disorders (GRDs), they usually want to dive right into a gluten-free diet. I will help you start doing that in the next blog, but we should first discuss the different kinds of GRDs and their identification, because it is important to NOT be avoiding gluten in order to make the diagnosis.
I know, I am suggesting eating gluten right now when you are pretty sure gluten is causing you all kinds of negative symptoms. Bear with me…
A GRD is a condition in which the body reacts to gluten in the diet. In other word, consuming (eating, drinking, absorbing) gluten causes problems; it may trigger a wide spectrum of symptoms or it may be present without symptoms. It may affect the digestive system, or it may be completely unrelated to the gut. It is estimated that at least 5% of the population has some type of gluten-related disorder. I personally believe the impact is much higher, as many people have not been properly diagnosed.
GRDs include Celiac Disease, Gluten Ataxia, Non-Celiac Gluten Sensitivity and Wheat Allergy. This blog will just focus on Celiac Disease and Non-Celiac Gluten Sensitivity.
Celiac Disease may first develop in children or adults. It is an autoimmune disorder in which gluten damages the lining of the small intestine. With an autoimmune disorder, the immune system (which is usually a great defense against infection and disease) malfunctions, and it attacks healthy parts of the body. Type 1 diabetes and lupus are other examples. In Celiac Disease, gluten triggers the immune system activity of the digestive tract, which can cause poor absorption of nutrients and a variety of symptoms. There are more than 200 symptoms (but remember, many people do not have any!).
Non-Celiac Gluten Sensitivity is a condition in which the body reacts to and rejects gluten without the presence of Celiac Disease. Studies show that the immune system plays a role, but the process isn't well understood. It may first develop in children or adults, and has also been called Gluten Intolerance. Although Non-Celiac Gluten Sensitivity (NCGS) is more common than many people realize, it often goes undetected because the gluten-free weight loss and clean-eating crazes have diminished its credibility. It is more difficult to diagnose than celiac disease because blood tests and physical exams often seem normal. Well, “normal” is up for debate. I have had many professional conversations with medical doctors, including gastroenterologists, who say they are always surprised by what patients think is “normal” - the symptoms they ignore for months or years. It may be very beneficial to start keeping a symptom journal, which I will discuss in the next blog.
What to do: Start a journal or diary where you write down everything you eat and drink, as well as any symptoms you have throughout the day. You can do this throughout the day, in the evening before bed, or first thing in the morning while you enjoy your first cup of coffee. Details on keeping this journal – next blog.
Next up: Keeping a symptom journal.
Resources: Further description is really beyond the capacity of this blog (unless you want to be reading for hours, which defies the purpose of a blog) but as promised, I will also provide you with recommendations and resource for further reading! If you want in-depth information on the science of gluten-related disorders, I recommend these two publications:
Clinical and Diagnostic Aspects of Gluten Related Disorders
Gluten and Associated Medical Problems
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,
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.