Celiac Disease is an autoimmune disorder in which the body perceives wheat protein, known as gluten, as well as its equivalent form in certain other grains (most notably rye and barley), as a foreign invader. When a person with Celiac Disease ingests gluten, the absorptive surface of the small intestine becomes inflamed and damaged, leading to nutrient malabsorption and digestive complaints. Untreated, Celiac Disease can lead to various nutrient deficiencies such as anemia, osteoporosis, depression, infertility, and is associated with increased risk of lymphoma and small bowel malignancy. Fortunately, the treatment for Celiac Disease is straightforward and non-invasive: a strict gluten-free diet for life.
It is estimated that one in 133 Canadians currently has Celiac Disease, though many cases are undiagnosed. The symptoms of Celiac disease frequently mirror those of other gastrointestinal conditions, or can vary greatly from the “classic” Celiac presentation. This, combined with a hesitance on the part of many patients to seek medical attention, can make detection and diagnosis challenging.
• Gastrointestinal complaints (chronic diarrhea; abdominal cramping, bloating and pain)
• Weight loss or difficulty gaining weight
• Failure to thrive in children
• Dermatitis herpetiformis (a chronic itchy, bumpy rash)
• Iron or folate deficiency +/- anemia
• Chronic constipation
• Persistent vomiting
If you’re one of the growing number of Canadians prescribed a gluten-free diet to treat Celiac Disease, let’s break down your task into three simple steps: ABC. A: Assess your food choices and abstain from gluten completely; B: Balance your diet; and C: Get Creative.
For a person with Celiac Disease, the gluten-free diet is a lifelong commitment that requires constant attention to every food consumed, and every ingredient in that food. Gluten, unfortunately, is a common additive, filler and binding agent in our food supply. It masquerades under many tricky ingredient names and its presence in any one food product may vary over time without warning.
The first step is familiarizing yourself with the alternate names for wheat, which include spelt, kamut, farro and einkorn. Even trace amounts of these grains must be eliminated from the diet completely, even if they don’t appear to cause symptoms.
Gluten also exists under the following names: couscous, bulgur, malt (including malt extract, malt syrup and malt vinegar), filler, semolina, durum, rye, barley, triticale. Gluten may or may not be present in various food additives such as hydrolyzed vegetable/plant protein and dextrin. When in doubt, call or email the manufacturer to verify.
A few foods that are notorious for containing gluten include beer, bread, pasta, stuffing, breakfast cereals (even rice and corn-based cereals are often flavoured with barley malt), luncheon meats and hot dogs, snack foods, seasonings, broths and soups, Communion wafers, soy sauce, imitation bacon and imitation seafood. Because of the high risk of contamination of oats with wheat and barley residue during harvest and storage, people with Celiac Disease are advised to avoid conventional oat products and limit their consumption to oats declared to be “pure and uncontaminated”, available at specialty food stores and online.
Living with Celiac Disease necessitates becoming a pro at interpreting ingredient lists on food packages. With a bit of coaching and lots of practice, scanning an ingredient list in order to classify ingredients as “safe”, “avoid” and “question” becomes second-nature. Be sure to consult with a registered dietitian (www.dietitians.ca) and visit www.celiacguide.org to get started.
Another important step in complete abstinence from gluten is to avoid its cross-contamination with safe foods. The Canadian Celiac Association advises:
• Doing gluten-free baking prior to baking with wheat to avoid contamination of safe foods with wheat/flour dust
• Using a separate toaster, utensils, cutting boards etc for gluten-free food preparation
• Avoiding shopping in bulk
• Ordering from a menu instead of eating from buffets when possible
• Ask if fried foods have been cooked in oil where battered foods have been fried
After being vigilant to remove and avoid every possible source of gluten, the person with Celiac Disease should review his or her overall diet to ensure that it is balanced and addresses the nutritional challenges specific to Celiac Disease.
• The gluten-free diet is notorious for lacking in fibre because of its limited sources of whole grains. To increase your intake of roughage, reach for allowed grains (try quinoa, millet, flaxseed or brown rice), legumes (chickpeas and beans), and plenty of fruits and vegetables (the ones with edible skins and seeds are highest in fibre).
• Iron deficiency and anemia are common in both men and women with untreated or newly diagnosed Celiac Disease. Ask your doctor or dietitian if you would benefit from an iron supplement. Excellent food sources of iron include meat, poultry and fish, dried fruits, nuts, seeds, eggs, legumes, fortified gluten-free grains (enriched soy and rice flours), and dark green leafy vegetables. Be sure to pair your high-iron foods with a good source of vitamin C for maximal iron absorption – try citrus fruits, strawberries, broccoli, potatoes, melon, papaya and bell peppers.
• People living with Celiac Disease are at higher risk of bone density loss and of developing osteoporosis due to decreased calcium and vitamin D absorption and utilization. Great food sources of calcium include dairy products, fortified fruit juice and soymilk, almonds and dark leafy greens. If you’re not meeting your calcium quota (1000 mg/day for adults under age 50, 1200 mg/day for adults over the age of 50), speak with your doctor or dietitian about choosing a good supplement. Vitamin D supplementation is recommended, whether included in the calcium supplement or as a separate daily tablet or drop. If you suffer from lactose intolerance, which is common in Celiac Disease, speak with a registered dietitian about strategies to ensure that your bone health needs are met.
The common tendency upon diagnosis with Celiac Disease is to focus on what will be permanently missing from the diet. In fact, a period of mourning these loved foods is a very normal reaction to the prospect of a lifelong diet that excludes them. When the fundamentals of the diet have been mastered, I encourage my clients to creatively explore the foods that they can enjoy, rather than staying focused on what’s missing.
Some ideas for creative exploration of the gluten-free diet:
Try a new food you’ve never tasted before. A great place to start is by experimenting with a gluten-free grain. Try millet, quinoa, buckwheat or amaranth. Combine the cooked grain with your favourite legume (chickpeas, lentils, black beans) and chopped veggies. Consider adding cheese or toasted nuts. Toss everything with an easy home-made vinaigrette (olive oil, lemon juice, oregano). An example inspired by Greek salad: quinoa tossed with chickpeas, chopped tomato, cucumber, black olives, feta cheese and lemony vinaigrette. This makes a tasty and highly nutritious packed lunch.
Don’t forget that many of your favourite foods are already gluten-free. Focus your shopping around the perimeter of the grocery store: fruits, veggies, most dairy products, meat, poultry, fish and eggs are naturally gluten-free. When choosing processed or packaged foods, you need not be limited to those specifying that they are “gluten-free”, though this is a great place to start before you become confident at deciphering food labels.
Craving a treat? Packaged mixes for gluten-free cookies, brownies and pancakes are now widely available at grocery, discount and bulk food stores. Add your own custom spin by incorporating dried fruits, nuts or shredded coconut into the batter.
Check out a new bakery or restaurant that specializes in gluten-free delicacies. Members of the local chapters of the Canadian Celiac Association (www.celiac.ca) regularly swap this type of practical information. • Buy a gluten-free cookbook or subscribe to a magazine specializing in easy and delicious gluten-free fare (a popular magazine is “Living Without.”) A new crop of blogs about gluten-free living (check out: http://creativecookinggf.wordpress.com/recipes) are packed with delicious recipes as well as product and restaurant reviews.
Marie Fortin, MEd, RD, a Registered Dietitian, runs Thrive Consulting, a busy nutrition consulting practice in Markham, where she coaches clients of all ages to better health and vitality. Learn more at www.mariefortin.com.