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.
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!
First, you eliminate all obvious sources of gluten. To review, obvious sources of gluten include:
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
Nuts and Seeds
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
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.
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... Hidden Sources Of Gluten: Improving Your Elimination 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.