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Health Protocols

Celiac Disease and Non-Celiac Gluten Sensitivity

The Gluten-Free Diet: An Overview

The only established treatment for celiac disease is strict, lifelong adherence to a gluten-free diet (Ferri 2015; Kelly 2014; Lidums 2015; Fasano, Catassi 2012). Absolute compliance to the gluten-free diet is vital, as even a tiny amount of gluten can lead to intestinal damage in those with celiac disease. In most cases, with strict adherence, symptoms are halted, existing intestinal damage is healed, and further damage is prevented (UCMC 2013).

The gluten-free diet excludes all foods that contain wheat (including spelt, triticale, and kamut), rye, and barley (Dirks 2004; Bai 2013). This means avoiding these grains, as well as pasta, cereals, and processed foods—unless they are labeled “gluten-free.” The status of oats in the gluten-free diet is less clear; it is thought that most celiac patients can eat modest amounts of pure oats, though some celiac patients do not tolerate oats (Fasano, Catassi 2012; Real 2012). Unless labeled “gluten-free,” oats should be avoided as they can be contaminated with gluten-containing grains (UCMC 2013; Kagnoff 2007).

There are many gluten-free alternatives to wheat: amaranth, buckwheat, corn, millet, rice (all varieties), quinoa, sorghum, teff, yucca, potato, nuts, flax, and all beans and legumes are naturally gluten-free (CDF 2015). There are also alternatives to gluten-containing flour, including potato, rice, soy, tapioca, carob, and bean flour (Zingone 2010; Eberman 2005).

The gluten-free diet is typically considered the primary treatment for non-celiac gluten sensitivity (though some researchers advocate avoidance of FODMAPs as opposed to gluten). While the level of gluten tolerance varies among individuals with non-celiac gluten sensitivity, with rare exceptions, most of these individuals can eat trace amounts of gluten without negative health consequences (Molina-Infante 2014; Sapone 2012; Volta 2013).

Unfortunately, lifelong strict adherence to a gluten-free diet is often difficult. Gluten is common in many types of food, and gluten-free products are often expensive and not widely available. Many people have difficulty maintaining the diet (Vahedi 2003; Abdulkarim 2002).

Gluten-Free Foods: Some Examples

Table 4 contains examples of foods that are allowed and those that are not allowed when eating gluten-free. This is not a complete list, however. It is important to read all ingredient labels carefully to make sure that a food does not contain gluten.

Table 4: Allowed and Disallowed Foods in the Gluten-Free Diet

Allowed Grains and Starches

amaranth
arrowroot
buckwheat
cassava
corn
flax
Job's tears (Coix lacryma-jobi)

legumes/beans
millet
nuts and seeds
potatoes
sweet potatoes/yams
quinoa
rice
sago

sorghum
soy
tapioca
teff
squash
yucca
wild rice

Foods To Avoid

wheat

  • including einkorn, emmer, spelt, kamut
  • wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein

barley
rye
triticale (a cross between wheat and rye)

Other Wheat Products to Avoid

bromated flour
durum flour
enriched flour
farina

graham flour
phosphated flour
plain flour

self-rising flour
semolina
white flour
unbleached flour

Processed Foods that May Contain Wheat, Barley, or Rye*

bouillon cubes
brown rice syrup
candy
chips/potato chips
cold cuts, hot dogs, salami, sausage
communion wafers

French fries
gravy
imitation fish
matzo
rice mixes
sauces

seasoned tortilla chips
self-basting turkey
soup
soy sauce
vegetables in sauce

(NIDDK 2012)
* Most of these foods can be found gluten-free. When in doubt, carefully read food labels and check with the food manufacturer.

Avoiding FODMAPs: Potential Benefits for Those with Non-celiac Gluten Sensitivity?

Although several studies have identified specific reactions to the protein components of wheat and related grains in some people with non-celiac gluten sensitivity, limited evidence suggests that poorly absorbed carbohydrates called fermentable, oligo-, di-, monosaccharides, and polyols (FODMAPs) may drive symptoms in some individuals (Biesiekierski 2013; El-Salhy 2015). 

In one study of people with self-reported non-celiac gluten sensitivity, reducing FODMAP intake significantly reduced gastrointestinal symptoms (Biesiekierski 2013). Thus, avoiding dietary FODMAPs may be beneficial for gluten-sensitive individuals who fail to achieve relief by specifically avoiding gluten. Limiting FODMAP intake has also been shown to improve symptoms among individuals with irritable bowel syndrome (IBS), which has several similarities with non-celiac gluten sensitivity (Lowe 2014; Staudacher 2014).

The low-FODMAP diet emphasizes avoidance of fructose, lactose, fructans, galactans, and polyols. Some examples of foods eliminated in a low-FODMAP diet are wheat, barley, and rye; high-lactose dairy; foods made with high-fructose corn syrup; certain fruits; soy protein; mushrooms; among others (SUMC 2014).

Monash University in Australia has developed a comprehensive low-FODMAP diet program to assist individuals who wish to try this dietary approach. More information is available on Monash University’s website, here: http://www.med.monash.edu/cecs/gastro/fodmap/.