Handout alert - scroll to the bottom for a free PDF Printable handout

Many moons ago, a patient with a gluten-free diet order was a big deal during my dietetic internship. Back then, the only patients who ordered gluten-free diets had Celiac disease. Celiac patients did not have the luxury of gluten-free bread, noodles, or snacks. Their diets were based on rice, corn, and potatoes. Period.

Today, gluten-free is the norm. Gluten-free products are available in big box stores, specialty markets, and online. As gluten has been blamed for everything from brain fog to bloating, the demand for gluten-free is higher than ever. Do you need to be gluten-free?

Gluten 101

Gluten makes your pizza dough stretchy and bread chewy. It’s a protein found in grains, including barley, rye, and wheat. Most bread, pasta, crackers, cookies, beer, and other wheat-containing foods are off-limits on a gluten-free diet. Gluten may also be hidden in sauces (enchilada, soy sauce, teriyaki, ketchup, some salad dressings), as well as processed meat, canned soup, deli meat, bran cereal, and even communion wafers.

While oatmeal is not a source of gluten, it could be contaminated with gluten if it’s processed in a facility that makes gluten-containing products. According to the FDA, a food must have less than 20 parts per million of gluten to be labeled “gluten-free”. This labeling claim is voluntary. 1

Who Needs Gluten-free?

The only population that absolutely, positively MUST follow a gluten-free diet are individuals with Celiac disease. Celiac disease is an autoimmune disease where a person cannot digest gluten. Exposure to gluten damages the small intestinal lining and can lead to malabsorption, stunted growth, nutrient deficiencies, and certain types of cancer.

According to the CDC, roughly 1 in 141 people (.71%) suffer from Celiac disease in the US, while globally, Celiac disease impacts 1.4% of the population.2 It’s more common in white adults and is not the same as a wheat allergy. Overall, Celiac disease is an uncommon condition.

Who Else May Benefit from Gluten-free?

A gluten-free diet may benefit people with other autoimmune and non-autoimmune diseases. Type 1 diabetes is an autoimmune condition that’s usually seen in children. A recent systematic review estimates that 4 to 5% of people with type 1 diabetes also have Celiac disease.3

The two conditions share a common genetic background. Consuming cow’s milk and gluten under four months of age and having early viral infections have been linked with the development of each disease. 4

Since gluten-free foods tend to be lower in fiber, individuals with type 1 diabetes who suspect they may have Celiac disease should be checked for the condition before removing gluten.

Symptoms of Celiac disease include stunted growth, anemia, bloating and abdominal pain, diarrhea, anxiety, and unintentional weight loss.5

Due to a common genetic background, some research suggests an association between celiac disease and autoimmune thyroid diseases such as Hashimoto’s and Grave’s disease. 6

However, a gluten-free diet is controversial as gluten-free foods may lack important nutrients like selenium and iron, which are important to thyroid function.7

A gluten-free diet may be helpful for those dealing with IBS (Irritable Bowel Syndrome). Some research suggests gluten may trigger IBS, as gut enzymes may not break down gliadin (a protein found in gluten) and could lead to an immune response and inflammation.8

While a gluten-free diet may improve symptoms of IBS, studies suggest that patients find it difficult to adhere to. 9

The Bottom Line on Gluten

The majority of people don’t need to be gluten-free. If you suspect you have Celiac disease, get tested before taking gluten out of your diet. Gluten-free foods are more expensive and tend to be lower in fiber and some micronutrients than traditional grains.

Talk to a dietitian before embarking on an elimination diet. A referral to a gastroenterologist may also be helpful.

If you absolutely need to be gluten-free, below are tips to meet your fiber and other nutrient needs:

• Choose gluten-free rolled oats

• Go for brown rice in place of white rice

• Try soba noodles, which are made of buckwheat. Despite their name, most are gluten-free. Read label to be sure.

• Add beans or lentils to your diet for protein and fiber. Pair them with a food containing vitamin C, such as peppers or tomatoes. This enhances iron absorption.

• Choose quinoa for bowls or unfried corn tortillas for tacos. Both contain dietary fiber.

• Continue to eat fruits, vegetables, nuts, and seeds regularly. These contain fiber, vitamins, minerals, antioxidants, and other plant chemicals to keep you healthy.

Lisa Andrews, MEd, RD, LD

Handout, “Bottom Line on Gluten” - Printable PDF Handout on Gluten

References:

1.   Gluten-Free Labeling of Foods | FDA

2.   Singh P, Arora A, Strand TA, Leffler DA, Catassi C, Green PH, Kelly CP, Ahuja V, Makharia GK. Global Prevalence of Celiac Disease: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol. 2018 Jun;16(6):823-836.e2. doi: 10.1016/j.cgh.2017.06.037. Epub 2018 Mar 16. PMID: 29551598.

3.   Prieto J, Singh KB, Nnadozie MC, Abdal M, Shrestha N, Abe RAM, Masroor A, Khorochkov A, Mohammed L. New Evidence in the Pathogenesis of Celiac Disease and Type 1 Diabetes Mellitus: A Systematic Review. Cureus. 2021 Jul 29;13(7):e16721. doi: 10.7759/cureus.16721. PMID: 34513356; PMCID: PMC8405172.

4.   Goodwin G. Type 1 Diabetes Mellitus and Celiac Disease: Distinct Autoimmune Disorders That Share Common Pathogenic Mechanisms. Horm Res Paediatr. 2019;92(5):285-292. doi: 10.1159/000503142. Epub 2019 Oct 8. PMID: 31593953.

5.   Symptoms of Celiac Disease | Celiac Disease Foundation

6.   Ashok T, Patni N, Fatima M, Lamis A, Siddiqui SW. Celiac Disease and Autoimmune Thyroid Disease: The Two Peas in a Pod. Cureus. 2022 Jun 23;14(6):e26243. doi: 10.7759/cureus.26243. PMID: 35911325; PMCID: PMC9312543.

7.   Ihnatowicz P, Wątor P, Drywień ME. The importance of gluten exclusion in the management of Hashimoto's thyroiditis. Ann Agric Environ Med. 2021 Dec 29;28(4):558-568. doi: 10.26444/aaem/136523. Epub 2021 May 28. PMID: 34969211.

8.   Dionne J, Ford AC, Yuan Y, Chey WD, Lacy BE, Saito YA, Quigley EMM, Moayyedi P. A Systematic Review and Meta-Analysis Evaluating the Efficacy of a Gluten-Free Diet and a Low FODMAPs Diet in Treating Symptoms of Irritable Bowel Syndrome. Am J

9.   Rej A, Sanders DS, Shaw CC, Buckle R, Trott N, Agrawal A, Aziz I. Efficacy and Acceptability of Dietary Therapies in Non-Constipated Irritable Bowel Syndrome: A Randomized Trial of Traditional Dietary Advice, the Low FODMAP Diet, and the Gluten-Free Diet. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2876-2887.e15. doi: 10.1016/j.cgh.2022.02.045. Epub 2022 Feb 28. PMID: 35240330.Gastroenterol. 2018 Sep;113(9):1290-1300. doi: 10.1038/s41395-018-0195-4. Epub 2018 Jul 26. PMID: 30046155.