Diet for Celiac Disease
by Sue Kira, Naturopath & Clinical Nutritionist
– Celiac Disease and the immune system
– Symptoms of Celiac Disease
– Testing for Celiac Disease
– What is gluten?
– Common foods that contain gluten
– Common foods that may contain hidden gluten
– Ingredients to beware of that may contain gluten
– Other ingredients that may contain gluten within foods
– Gluten in non-food items
– Cross reactive foods
– Overview
Case study: Celiac diagnosis and treatment helps depression
About Celiac Disease
Celiac disease and the immune system
Celiac disease (pronounced ‘seal-ee-ak’) is also spelt Coeliac in some countries. In this article, I refer to it as Celiac disease.
Celiac disease is an autoimmune disease, which is known for its severe reaction against gluten. People with celiac disease have an immune system that reacts to the gluten found in certain grain derived foods which causes damage to their small intestine. So let’s look at what that damage means.
Our small intestine is a tube, about 3.5 x the length of the body, so if you’re 1.6m, it’s about 5.6m long. The main job of the small intestine is digestion and the absorption of nutrients, along with some other functions. Optimal functioning of the small intestine is vital to good health.
Within the inside surfaces of the ‘tube’ are fine hair-like microscopic projections called villi, that are 0.5 to 1.0 mm in height with 10 to 40 per square millimetre packed together – millions and millions of them.
These projections increase the surface area of the small intestine immensely, which means there is much more surface area for nutrients to be absorbed. To give you an idea, if a healthy small intestine was stretched out, because of that extra surface area, it would extend to about the length of a tennis court (kind of like a a flexible laundry hose that can stretch out).
Most of the nutrients you consume via your mouth are absorbed through the wall of the small intestine. But when the small intestine becomes inflamed because of antagonistic food, those villi finger-like projections lining the bowel erode, and villi flattens.
Flattened villi drastically reduces the surface area of the small intestine and thus the absorptive ability of your intestines. This means you won’t get as many nutrients into your cells needed to fuel your body. The vitamin and mineral deficiencies that can arise from this malnutrition can affect many aspects of your health and lead to a variety of gastrointestinal and malabsorptive health problems.
Conditions that have been caused because of celiac disease include mental health issues such as depression, anxiety, mood and behavioural issues, other auto-immune diseases such as Hashimotos thyroiditis, lupus, ulcerative colitis and diabetes. There is also a link to heart disease, which is referred to in the Cardiovascular Support Diet article.
Sensitive to gluten for life
The good news is that villi can grow back provided the conditions are right to make it happen. If so, it can take 3 to 6 months in a young person (say up to 30) and a couple of years for older people .
People with celiac disease remain intolerant to gluten for their life, but a constant gluten free diet allows the condition to be managed effectively.
A gluten free diet removes the cause and triggers of the disease, allowing the small intestine lining to heal, villi to re-grow and symptoms to be resolved.
Genetics and Celiac
Celiac disease affects males and females of all ages. You must be born with a genetic predisposition to develop celiac disease. The most important genes associated with the disease are HLA DQ2 and HLA DQ8. Either one or both of these genes are present in people with celiac disease.
While 30% of the population carry one or both of these genes, approximately 1 in 30 will get celiac disease. But there are many people who can have an allergy or intolerance to gluten even without having celiac disease.
Symptoms of Celiac Disease
- Digestive problems such as gas, bloating, diarrhoea and even constipation. I have often seen clients with constipation from eating gluten.
- Keratosis Pilaris, (also known as ‘chicken skin’ on the back of your arms). These are the little fatty bumps which tend to be a result of a fatty acid deficiency and vitamin A deficiency, because of poor fat digestion, caused by gluten damage to the gut.
- Fatigue, brain fog or feeling tired after eating a meal that contains gluten. If you feel tired after eating other non-gluten foods, there may also be other intolerances or you could be reacting to any of the ‘cross-reactive’ foods (see list below).
- Neurological symptoms such as dizziness or feeling unbalanced.
- Migraine headaches and toxic feeling headaches across the forehead.
- Inflammation, swelling or pain in your joints such as fingers, knees or hips.
- Psychological issues such as anxiety, depression, mood swings and ADD.
Testing for celiac disease
Doctors will typically do the gliadin or anti-transglutaminase antibody tests. The problem with these tests, when run alone, is that they are often an incomplete view. This can be confusing, because you never really know if you have a sensitivity unless you happen to show positive to at least one of these tests.
Here is a list of tests that can be performed….
Gliadin test
The protein component of gluten has four different sub classifications:
- Alpha gliadin
- Beta gliadin
- Gamma gliadin
- Omega gliadin
Most labs that test gliadin antibody only test for alpha gliadin. You may have a negative alpha gliadin antibody test – but if you were tested for another form of gliadin, you could have a positive response. This can give many people the impression that gluten isn’t a problem for them, and they continue to eat gluten foods, slowly poisoning their body.
Anti-transglutaminase antibody test
This test is used to rule out celiac, the autoimmune disease which is known for its severe reaction against gluten. It will show up in 98% of celiac cases but that means that there is still a 2% chance of being misdiagnosed. For these people a biopsy of the small intestine is the only way to diagnose celiac disease.
Deamidated Gliadin test
In many processed foods, wheat is put through a process called deamidation which makes it mix better with other ingredients. Your body may tolerate every other form of gluten except deamidated gliadins.
Glutenin test
Within gluten is another compound called glutenin which was once thought not to cause an inflammatory response in the body, but recent research has shown this not to be the case.
Gluteomorphins test
Many people feel worse when they first come off of gluten because they are withdrawing (detoxing) off of gluteomorphins or gliadorphin. Gluteomorphins are opiate-like compounds that can make gluten rather like an addictive drug. Coming off gluten can correlate with several days or weeks of irritability, brain fog, headaches and lethargy for some people.
Wheat Germ Agglutinin test
Wheat germ agglutinin is the lectin component of wheat which binds to nutrients to make them unavailable for your body. They lectins can trigger an immune response in your body that leads to chronic systemic inflammation.
Gluten Cross-Reactivity test
Gluten cross reactivity can be the missing link for many people who are eating ‘gluten free’ but still feel the symptoms. When the body makes antibodies against gluten, those antibodies can also recognize similar proteins in other foods and your body reacts as though they contain gluten. You can test these foods with an IgG antibody test to see if you have cross-reactivity or do an Elimination Diet.
About Gluten
What is gluten?
The name gluten is derived from a Latin term, meaning ‘glue’ (which is quite appropriate). Gluten is a mixture of proteins called Prolamins. Prolamins are joined to starch molecules found in wheat and related grains, including barley, oats and all their species and hybrids such as spelt, kamut and triticale.
Within the grains, the combination of gluten and the starch molecules results in a sticky substance that is poorly digested. Gluten is favoured by bakers for its elastic properties, helping dough to rise and keep its shape and often gives the final product a chewy texture.
Gluten proteins have low biological and nutritional value. It’s interesting to note that the amount of gluten in grains is now 80% higher than the original wheat and similar grains of yesteryear. Could this hybridisation be a reason why gluten is now not tolerated by many?
For those with Celiac Disease, complete avoidance of gluten is important. Some non-celiac patients may also be very sensitive, so that even tiny exposures are problematic.
At a seminar held by Metagenics/Health World, research was presented showing that everybody has some degree of gluten sensitivity
There is variability – some have minimal sensitivity to gluten while others have major reactions, particularly those with Celiac Disease.
In my case, I don’t have celiac disease but my sensitivity to gluten is so strong that if I accidentally have some (usually due to chefs not realising what ingredients do contain gluten, such as soy sauce) then I spend the next 6-8hrs in abdominal agony.
Now that I am much more aware, I ask the waiter to check with chef and I’ll double check on gluten in foods if I am suspicious. It’s just too painful to take any risks.
To support healing for all health conditions, it makes good sense for recipes to be gluten free as a basic foundation.
Common foods that contain gluten:
- Barley
- Bulgur
- Couscous
- Kamut
- Oats
- Rye
- Semolina
- Spelt
- Triticale
- Wheat
- Wheat germ
Common foods that may contain hidden gluten:
- Artificial coffee creamer
- Beer
- Bouillon cubes
- Broth/stocks
- Candy
- Certain ground spices
- Certain veined cheeses
- Chewing gum
- Chips
- Cold cuts
- Flavoured teas
- Flavoured rice
- Fish sticks
- Flavoured crackers
- French fries
- Gravies
- Hot dogs
- Imitation seafood
- Instant coffee and other instant hot drinks
- Ketchup
- Matzo flavour
- Mustard
- Mayonnaise
- Pasta side dishes
- Rice mixes
- Roasted nuts
- Soy sauce
- Salad dressing
- Seitan (wheat gluten, used in meat substitutes)
- Self-basting turkey
- Soy and teriyaki sauces
- Tinned baked beans
- Tomato sauces
- Vegetable cooking spray
- Veggie burgers
- Vodka
- Wine coolers
Ingredients to beware of that may contain gluten:
- Artificial colour
- Baking powder
- Barley extract or lipids
- Brown rice syrup
- Caramel colour/flavouring (frequently made from barley)
- Citric acid (can be fermented from wheat, corn, molasses or beets)
- Colouring
- Dextrose (primarily corn and potato, but can come from wheat, rice, tapioca)
- Diglycerides
- Emulsifiers
- Enzymes
- Fermented grain extract
- Fat replacers
- Flavourings
- Food starch
- Gelatinized starch
- Glucose syrup
- Glycerides
- Hydrolysate
- Hydrolyzed malt extract
- Hydrolyzed oat flour or protein
- Hydrolyzed plant protein (HPP)
- Hydrolyzed soy protein
- Hydrolyzed vegetable protein (HVP)
- Malt extract
- Maltodextrin (corn, wheat, potato, rice)
- Mustard powder (some contain gluten)
- Monosodium Glutamate (MSG)
- Modified food starch (source is either corn or wheat)
- Natural juices
- Natural flavouring, fillers
- Peptide bonded glutamine (hydrolyzed wheat gluten)
- Rice malt (contains barley or Koji)
- Rice syrup (contains barley enzymes)
- Sulfonate
- Stabilizers
- Starch
- Triticum aestivum (common or bread wheat)
- Wheat starch
- Whey protein concentrate
- Whey sodium caseinate
- White vinegar or white grain vinegar
- Yeast extract
Other ingredients that may contain gluten within foods:
- Amino peptide complex (from barley)
- Avena sativa (oat starch, extract, flour or oil)
- Barley (extracts, lipids)
- Beta glucan (from oats)
- Cocodimonium hydroxypropyl hydrolyzed
- Dextrin
- Fermented grain extract
- Hordeum distichon (barley extract)
- Hordeum vulgare (barley extract)
- Hydrolyzed wheat protein (HWP) also seen as wheat hydrolysate, enzyme-modified gluten or wheat peptides
- Phytosphingosine extract (fermented yeast)
- Pregelatinized starch (corn, wheat, potato, tapioca)
- Secale cereale (Rye)
- Sodium lauroyl oat amino acid
- Sodium starch glycolate (commonly found in processed potatoes like chips, hash browns and potato powders)
- Stearidimoium (hydrolyzed wheat protein)
- Triticum vulgare (wheat germ oil)
- Tocopherol/vitamin E
- Wheat germ (extracts, glycerides, oil, protein)
- Xantham gum (may be derived from wheat)
Gluten in non-food items
Did you know that there is gluten found in many other items that are not foods, such as shampoos, conditioners, creams and other personal care items and even dental products?
Some argue this is not relevant unless it goes into our digestive systems or into an open wound, but in fact, many people do have a reaction to products that contain gluten. Even though I don’t have celiac disease, I get an itchy scalp if a hairdresser uses a shampoo or hair care product with gluten in it and I know many of my clients are the same. It would be a shame to go to all the trouble with food ingredients avoidance, only to have irritations from personal care and other items.
Following are some common items that may contain gluten. If in doubt check the label, however some companies don’t list everything on the packet but may have details on their website or on the folded paper inside the original packaging.
Non-food items that may contain gluten:
- Dental sealants
- Dental plastics (some)
- Glue on stamps and envelope seals
- Hairspray
- Laundry detergent
- Lip balms
- Lotions
- Low quality vitamins and supplements
- Makeup
- Medications
- Mouthwash
- Playdough
- Shampoo & conditioners
- Soap
- Sunscreens
- Toothpaste
Cross reactive foods
If you have Celiac Disease then your body may also react to various other non-gluten foods such as cheese, chocolate and coffee. The reason is that these contain proteins that are very similar to gluten and your body confuses them with gluten. When you eat these foods, your body and immune system react as if you just ate a bowl of wheat pasta.
It is estimated that at least 50% of people with gluten sensitivity or Celiac disease are also sensitive to dairy products such as cheese, yogurt, milk and butter due to their cross-reactivity with gluten.
Below is a list of common foods that cross-react with gluten:
- Amaranth
- Barley
- Buckwheat
- Chocolate
- Coffee (instant, latte, espresso etc)
- Corn
- Dairy i.e. milk and cheese (alpha-casein, beta-casein, casomorphin, butyrophilin, whey protein and whole milk)
- Egg
- Hemp
- Millet
- Oats
- Polished wheat (often thought to be gluten free due to processing)
- Potato
- Rye
- Rice
- Sesame
- Spelt (has a small amount of gluten)
- Sorghum
- Soy
- Tapioca (cassava, yucca)
- Teff
- Yeast
If you continue to have health issues after removing gluten from your diet, try eliminating the above foods for at least two months and see if your symptoms improve. Also, ensure you have healed your gut with the help of a natural health practitioner.
After two months, you may wish to reintroduce the above foods, one at a time, to determine which are causing cross-reactions. You may find that after doing a gut healing protocol (with help from your practitioner) that you then don’t react to these other foods.
Overview
The consumption of gluten is a major health issue for those with celiac disease. While a diet for celiac is not considered a cure, by including foods that support your body and eliminating foods considered detrimental, you will help your body to do its natural job of healing.
Naturally a diet for celiac disease is gluten free, but because there is often a degree of gut lining damage and inflammation in the digestive systems of those with celiac disease, foods should be anti-inflammatory and supportive of gut healing, thus gluten-free, dairy-free and additives free.
Cross-reactive foods such as dairy products, yeast, soy products, potatoes, all grains, sesame seeds, chocolate, corn, coffee and eggs should be eliminated from your diet to give your digestive system the best chance of healing.
Important: Before you change your diet, see your medical or health care professional for qualified guidance and do not stop any medications or supplements previously prescribed unless advised otherwise by your health care professional, who may even prescribe extra supplementation to assist with gut healing.
Note: During the early stages of your new diet, you may experience symptoms such as fatigue, headaches or body aches, which may occur because your body is detoxifying. However, if you are unsure about a symptom at any time, check immediately with your medical or health care professional.
Case study: Celiac diagnosis and treatment helps depression
Client names and identifying information changed
Caleb was so sick that he couldn’t make it to the clinic for his first consultation, so I first saw him via skype. He had gut pains, body aches, diarrhoea, foggy head and depression. The depression bothered him the most as he was unable to work and could barely function.
Even though he was 48 at the time, Caleb had to move in with his mother so she could cook for him. Mum Janet was very stressed and worried about her son and was committed to doing what was needed to get him better as soon as possible.
We ran some tests and he had ‘leaky gut’ which was quite bad, multiple vitamin B6, B12, Iron and vitamin D mineral deficiencies, and he tested positive for celiac disease. He already had a strong feeling that he had an issue with gluten foods, but because he was so exhausted, he often ate two minute noodles until he moved back to his mother’s house.
He also drank copious amounts of chocolate milk when he didn’t have much energy, as it was easy and filling, but the milk also tested reactive, along with most of the gluten cross-reactive foods and a few others. His system was so sensitive that every time he tried to take any vitamins he would feel too sick, so we just needed to work with food to get Caleb feeling better.
Once we knew what we were working with, Caleb and Janet were instructed to go 100% gluten free and also be totally free of all the cross reactive and other reactive foods. We couldn’t risk any gluten or reactive foods in the entire house in case of any cross contamination, even down to checking all personal care items for gluten.
That might seem strange, but did you know that wheat protein is used as a thickener in many products like shampoo and creams? They all had to be checked and removed from the house.
I put Caleb onto a diet that was not only reactive food free, but also included foods that would help to heal his leaky gut and damaged microvilli, as well as being rich in nutrients to re-build his deficiencies. Initially we started with some basic broths to help settle the inflammation in his gut. The broths felt very calming for Caleb’s digestive and nervous systems.
Although he didn’t have much energy from the broths alone, he was happy to sleep a lot while his body healed. It took about a month to settle his system from the inflammation. Then we added some good fats such as avocado to build up his calories and give the body more healing nutrients to help him to feel better mentally and emotionally.
We also gradually added slow cooked meats to the broth and some low fibre vegetables. Note: high fibrous vegetables can further inflame an already inflamed, irritated, damaged gut lining.
As Caleb’s energy and appetite gradually increased, he added more meats and a broader range of vegetables (leaving the fat on his meat cuts). He ate low inflammation foods and stayed off foods he was reactive to, as well as foods from the nightshade and brassica families and all legumes, to keep it simple for his digestive system.
Then after a month, with Caleb’s recovery going well, we introduced some small quantities of coconut milk/cream/yoghurt and oil (all unsweetened and plain at this stage) plus sweet potato which he craved. Caleb was gradually getting better every week and by about four months he was eating a full range of foods except for the known reactive foods.
We left these out for 12 months and then tested him to see what was reactive. At that point only quinoa and rice showed reactive, along with gluten and dairy which will probably never be appropriate for him again.
Caleb left all reactive foods out of his diet for about 14 months as this felt right for him. He then re-introduced one at a time, feeling his body for reactions and energy drops, and he found he was fine. He did sneak in some dairy one day and felt so bad energy wise that he didn’t have it again.
It can take two to three years for a gut to heal from celiac disease, and Caleb was no exception. He had a stool check and a colonoscopy with biopsy after two years and he was nearly completely healed with back to normal microvilli. Inflammation markers in the gut were all good and his bacteria levels were reasonable.
It took a lot of work for Caleb to get back to where he felt ‘normal’ again, but well worth it.
After the initial 12 months of just working with the diet, his sensitivities were not so bad, so we introduced some probiotic bacteria to increase his levels of good bacteria (the ‘good guys’) along with some zinc and vitamin D supplements because he wasn’t getting much sun and his zinc levels weren’t increasing enough with the diet to help to fully heal his gut. It was great that he could tolerate the supplements.
He didn’t like to eat fish so we also used some omega fats to support his mental health. The combination of the above in the right sequence, worked to get Caleb feeling better physically, mentally and emotionally and he was back at work after 12 month’s recovery.
Many of my clients have recovered faster, but Caleb was in a bad way and probably had celiac disease for some time, but ignored the symptoms until his body couldn’t take any more.