There is a lot of fuss about gluten these days – gluten is good for you, bad for you, the gluten-free craze is just a “fad”, gluten sensitivity is not a real condition, and so on.

It’s hard to keep it all straight. Well, it turns out, there is a lot of validity to the fuss surrounding gluten for patients who have a condition called celiac disease. Celiac disease is a genetic, autoimmune condition characterized by inflammation of the small intestines.

The genetic part means that this condition is passed down in families due to the fact that individuals with celiac disease have inherited genes that predispose them to this condition. The genes can be “activated” at any time or not at all due to certain environmental factors.

Celiac disease is an autoimmune condition since the immune system in patients with this condition attack a healthy part of the body by mistake.

Celiac disease affects at least 1% of the U.S. population, possibly higher in other parts of the world. This condition affects all races and ethnic groups and can occur at any age.

In celiac disease, exposure to dietary gluten (a protein found in wheat, rye and barley) leads to inflammation of the small intestine, as well as other parts of the body. Because the small intestine plays a key role in absorbing vitamins and minerals, inflammation can lead to poor absorption of these things, and can cause significant nutritional deficiencies. Patients with celiac disease often have unexplained weight loss and diarrhea. Other common symptoms include abdominal pain, gas, bloating, low energy/fatigue and unexplained anemia or low iron levels.

These are considered to be “classic” symptoms. There are also many “non-classic” symptoms that actually account for the majority of symptoms in patients with celiac disease. These include unexplained constipation, dental problems, weak bones (osteoporosis), heartburn, nausea/vomiting, skin rash, joint and muscle aches and pains, migraine headaches, fertility problems…just to name a few. It is important to emphasize that many patient with celiac disease have NO SYMPTOMS. These patients usually come to medical attention when a family member is diagnosed with celiac disease and, consequently, they are screened for this condition with blood testing.

The treatment of celiac disease is complete, 100% avoidance of gluten for life.

The symptoms discussed above are not unique to celiac disease and can occur with other conditions. However, if you think you might have celiac disease, recognize any of the symptoms described above or have any symptoms that concern you, please speak with your doctor and consider getting tested.

Testing is simple and involves a blood test to start. If you think you might have celiac disease, do not start a gluten free diet until you have consulted with your doctor. Going gluten free before testing usually makes it difficult to interpret the test results. Early diagnosis of this condition and effective treatment can get you back on the right track towards health and improved quality of life.

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Food For Thought: Gluten Sensitivity

“Food For Thought” is a recurring column on bellyblog.ca, where we will share a well-curated collection of high quality, thought-provoking pieces, usually about food, diet, nutrition, and the gut.

2 thought-provoking pieces on gluten sensitivity. The second is authored by our resident celiac disease expert, Dr. Rupa Mukherjee

Against The Grain – Should You Go Gluten Free?

Non-Celiac Gluten Sensitivity Where are We Now in 2015?

Diagnostic Algorithm to Differentiate Non-Celiac Gluten Sensitivity (NCGS) from Celiac Disease and
Wheat Allergy (WA)

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Elimination Diets – Everything You Need to Know

If you’ve been diagnosed with IBS, your doctor may have recommended an elimination diet. You may have been advised to eliminate dairy, gluten, fructose, FODMAPs, or other food categories.

Typically, the rational behind this is it to identify which foods trigger your symptoms. For example, you may notice that you get bloated every time you go to your favourite restaurant and order the pasta. So you may have assumed it was the cheese. But when you have cheese at home and you feel fine.

There are few important things to remember about elimination diets to make them a whole lot less frustrating.

Here are my top 5:

1. It’s a trial, not a life sentence. Your heart might sink at the very prospect of a day without a latte. Just remember – when your doctor suggests an elimination diet, the idea is to eliminate the food 100%, but just for a      week or two to see if your symptoms are better or not without it. So it’s not a lifetime commitment to a dairy-free or gluten-free or whatever-free diet – it’s just a short trial to see how you do. Let’s say you feel exactly the same? Well then clearly that food isn’t causing your symptoms, so go back to eating it! Now lets say you feel a lot better. Here’s where things can get tricky – see #3.
2. Neither your gut nor your cheeseburger read the textbook on IBS. So this can be frustrating. But food intolerance isn’t black and white. So what causes bad symptoms on one day may not cause bad symptoms the next day. The idea is to identify foods that tend to cause your symptoms, most of the time.
3. The treatment shouldn’t be worse than the symptoms. Once you’ve identified which foods trigger your symptoms, the next step is decided whether or not you want to avoid them. Remember – unless you’ve been diagnosed with an actual food allergy, or you have celiac disease, what we are talking about are food intolerances. This means that when you eat your trigger food, you may get your symptoms, whatever those are (bloating, diarrhea, indigestion, etc). Unlike, say, an anaphylactic allergy to peanuts, food intolerances are not life-threatening and won’t have any impact on your overall long-term health. The purpose of identifying your triggers isn’t to sentence you to life without them, but rather to give you some control over your symptoms. One the one hand, your symptoms may be so bad that you welcome a life without, say, dairy, because the trade off in terms of how much better you feel is worth it. On the other hand, if your symptoms aren’t severe, you may chose to consume your trigger foods every now and then, but at least you can know what to expect after. So you may not have ice cream on your wedding day, or bread on a long flight overseas…
4. Buy a knockoff! I don’t mean a Chanel bag. That’s illegal. I mean a gluten-free cookie, or dairy free ice-cream. When I was nursing my son Max, I was advised to eliminate soy and dairy because of severe eczema (this is controversial, but that’s another story. I found a local cupcake shop that made soy and dairy free cupcakes, and guess what – I liked them better than the real thing. Go figure.
5. Ok, I don’t have a 5th thing. But a top 4 list seemed silly.

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Gluten Free Whole Grains and Your Diet

Grains are an essential part of a healthy and nutritious diet since they are low in fat and high in vitamins and minerals.

In a previous blog post, I provided a list of grains that are gluten-free and safe for patients with celiac disease. The problem is that when grains are processed or refined, they are often stripped of fiber and essential nutrients.

During processing, the outer and inner layers of the grain, which contain most of the fiber, protein, vitamins, and minerals, are removed. What is left behind is the starchy middle layer, which doesn’t contain much of anything.

Many gluten-free foods are made with refined flour and/or starches that are low in fiber, vitamins and minerals. A classic exampled of a gluten-free refined grain is white rice.

The most beneficial grains are the so-called whole grains. These grains are unrefined which means that they contain all three layers of the grain. As a result, they are higher in fiber than processed grains, and they contain protein, are low in fat, and rich in vitamins and minerals, particularly the B vitamins.

Here is a quick look at some gluten-free whole grains:

• Brown rice, brown rice flour
• Wild rice
• Amaranth – a seed grain comparable to rice or maize that was a staple food of the Aztecs
• Buckwheat – despite its unfortunate name for celiacs, buckwheat is NOT a wheat but rather it is a fruit seed that is related to rhubarb and sorrel
• Chia – considered by some to be a “superfood”, this seed was an important food source for the Aztecs and Mayans
• Whole corn, popcorn, kernels, cornmeal
• Flax seed
• Millet – the name given to a collection of small-seeded grains
• Gluten-free oats, oatflour
• Quinoa – a grain crop grown for its edible seeds consumed widely by the
• Incan empire, believed to be sacred and the “mother of all grains”
• Sorghum – a cereal grain often produced as a syrup called “sweet sorghum”
• Teff – an Ethiopian seed grass commonly used in the preparation of injera – a sourdough flatbread with a spongy texture and Tella, a traditional Ethiopian gluten free beer

You can vastly improve the nutritional content of your meals by substituting the more common gluten free grains and starches such as white rice or potato with gluten free whole grains.

You should try it…you just might like it!

Some people have intolerances or allergies to certain grains, as well as medical conditions for which they cannot tolerate moderate or high levels of fiber, so please speak with your doctor about how best to balance your diet with the benefits of a gluten free diet.

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So, to make a diagnosis of celiac disease, you need to have positive blood test results and positive small intestinal biopsies ON a gluten-containing diet.

The blood tests can be complicated, so I’ll try to make it simple.

As with a lot of things in medicine, the celiac blood tests have their own language. Your doctor may refer to the celiac blood tests as “serology”. Serology is another term for antibody, or immunoglobulin (Ig). The reason for this is because the celiac blood tests are, in fact, a measurement of specific antibodies or immunoglobulins produced in your blood stream upon exposure to gluten.

Are you still with me?

There are various classes of antibodies – the A class, M class, G class etc,. The celiac specific antibody is usually based on the ‘A’ class.

The most frequently tested celiac antibody is the immunoglobulin A-based tissue transglutaminase (commonly known as “tTG”). I know, it’s a mouth-full.
This antibody has been determined to be the single best test to help detect celiac disease. In addition to the tTG, another commonly tested antibody is the IgA/IgG-based deamidated gliadin peptide (commonly known as “DGP”). Since both antibody tests are based on the antibody A level, it is important that your doctor check your IgA level to make sure that is normal at baseline.

To summarize, if your doctor suspects celiac disease, they should check:

• IgA level in your blood
• tTG-IgA
• IgA/IgG-DGP

You may have heard of the IgA-based endomysial antibody (EMA). This is an older blood test that is sometimes used to confirm the results of the tTG. The anti-gliadin antibodies (commonly called AGA) are older, less accurate blood tests that are rarely used in common practice. The AGA blood test has been replaced by the DGP test.

There is no easy way to detect celiac disease in someone already on a gluten free diet.

For that reason, it is very important to consult with your doctor first before going gluten free.

The tTG and DGP antibody tests are useful tests to monitor if someone with celiac disease is following a gluten free diet. A drop in these antibodies every 3 months or so is a good indication that a patient is following and responding to a gluten free diet. Usually, this goes along with an improvement in symptoms, but not always. In those cases, other co-existent conditions need to be investigated.

Despite the accuracy of the blood tests, still, the best way to see how you are doing on a gluten free diet is evaluation by an experienced nutritionist. There really is no substitute for a heart-to-heart with your nutritionist. Feel free to express your concerns and fears, your frustrations and questions, and let your healthcare team do the best they can to help you stay healthy.

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There’s a lot of confusion out there about what grains are considered to be gluten-free. A question that I commonly get from my patients with celiac disease is, “Can I eat rice?”

I want to clear up this confusion by providing you with a list of safe gluten-free grains.

Whole grain brown rice (preferable to white rice due to higher fiber content, vitamins and minerals)
Wild rice
Quinoa
Buckwheat
Amaranth – this used to be a staple food of the Aztecs!
Millet
Sorghum
Teff
Whole corn
Potato
Tapioca
Arrowroot
Flax
Flours made from nuts, beans and seeds

 
So yes, feel free to eat rice as part of your gluten-free diet.

Try not to stick with a single grain source as your new wheat substitute. Instead, rotate these new grains into your diet for yummy meals full of nutritional benefit.

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