Going Gluten Free: Separating Fact From Fad. By Arianne Corbett, MS, RD.

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1 Going Gluten Free: Separating Fact From Fad By Arianne Corbett, MS, RD

2 Going Gluten-Free: Separating Fact from Fad By Arianne Corbett, MS, RD Learning Objectives: At the conclusion of this article, readers will be able to: 1. define gluten and where it is found 2. define celiac disease, and how it differs from non-celiac gluten sensitivity 3. list two triggers for celiac 4. list two ways the RDN can be helpful in guiding a client to a healthy gluten-free lifestyle 5. identify specific attributes of the gluten-free diet When dietitian, Shelley Case began her career, she had little experience with gluten-free diets. She encountered no cases of celiac disease in her internship and her training left her ill equipped to support her clients. She recalls, As a new graduate dietitian in 1981, while preparing to counsel my first client with celiac disease, I remember scrambling to find any useful information about the disease itself, but especially regarding the gluten-free diet. She began searching for answers. When I counseled clients with celiac disease, every one of them was seeking very specific and practical information on food labeling and ingredients; names of gluten-free companies and products and where and how to access them, recipes, meal-planning suggestions, tips for eating out, how to prevent cross-contamination and how to locate other gluten-free diet resources, she says. Unfortunately, at that time this information usually was available only from assorted different pamphlets, books, manuals and other sources, which meant that after a counseling session the client went home carrying a loose pile of many papers! When dietitians across North America began reaching out to Case for the same information, she knew she needed to develop a comprehensive resource for health professionals and clients. Her first book, Gluten-Free Diet: A Comprehensive Resource Guide was self-published in Since then, four other editions have been published, with the newest, Gluten Free: The Definitive Resource Guide, released in the fall of 2016.

3 Times have changes in the 35 years since Shelley Case s first celiac client. Today, it s difficult to find another nutrition topic more widely discussed from clinics to cocktail parties than gluten. Open the New York Times, Wall Street Journal, Facebook or Twitter and you will find a headline about going gluten-free. Celiac diagnosis is on the rise, researchers are learning more about non-celiac gluten sensitivity, and an estimated 3.1 million people without celiac disease are now avoiding gluten (Choung, et al, 2017). Market research shows that 20% of Americans are seeking out gluten-free products (The Hartman Group, 2015; Rifkin, 2015). Gluten-free diets are fad no longer, they are here to stay and the public needs education to help them navigate fact from fiction. Celiac Disease and Non-Celiac Gluten Sensitivity Gluten is the general name for the proteins found in wheat, rye, and barley. Gluten provides stability to allow foods to maintain their shape. In baking, gluten gives dough its elasticity. While most tolerate these proteins well, some experience a range of gastrointestinal and other symptoms in response to consumption of the prolamin and glutelin proteins found in gluten. The major conditions associated with ingestion of gluten are celiac disease and non-celiac gluten sensitivity. Celiac disease is a hereditary, autoimmune intestinal disorder that affects both children and adults. The disease impacts about one percent of the global population. The development of celiac disease involves a combination of genetic, environmental and immunological factors. For some people it may be triggered by a gastrointestinal or viral infection, pregnancy or surgery, Case explains. Scientists also are investigating other factors that may play a role in the development of celiac disease, such as the method of birth, breastfeeding, age of gluten introduction and quantity of gluten consumed, as well as changes in the bacterial composition of the gut. When an individual with celiac disease consumes gluten, the prolamin and glutelin proteins trigger an autoimmune response that inflames and damages the villi in the small intestine. The continued damage is called villous atrophy and renders the body unable to properly absorb carbohydrates, proteins, and nutrients including iron, calcium, Vitamin D, and folic acid. Individuals with untreated celiac disease face a range of complications including nutrient deficiencies like osteoporosis and anemia, neurologi

4 cal issues, infertility, and increased risk of gastrointestinal cancers. Five to ten percent of those with celiac disease also develop dermatitis herpetiformis, characterized by an intense, itchy and blistering rash. Individuals with non-celiac gluten sensitivity experience many of the same symptoms as celiac disease; however without the intestinal damage that is the hallmark of celiac. Non-celiac gluten sensitivity is characterized by a wide variety of symptoms including abdominal pain, bloating, gas, diarrhea, headaches, and chronic fatigue, as well as evidence of intestinal cell damage and immune activation (Uhde, et al, 2016). While this sensitivity has been known for a number of years, much is still not understood about the disease. Case expands, The phenomenon of gluten sensitivity in the absence of celiac disease was first described in the medical literature in the late 1970 s. Since then, clinicians have continued to encounter clients who report adverse reactions to gluten. In spite of a growing number of publications on the subject, non-celiac gluten sensitivity continues to be widely debated. Still unclear is whether individuals are reacting to gluten or some other component in foods, such as FODMAP carbohydrates. FODMAP are fermentable, poorly digested, short-chain carbohydrates that can cause bloating, gas, and other digestive symptoms. Barley, rye, and wheat are included in this group, as are foods like beans, onions, and milk and milk products. She adds, On the other hand, individuals with [what s diagnosed as] non celiac gluten sensitivity may actually have undiagnosed celiac disease. Clearly, a lot more research is necessary in this field. Case discusses the gluten-free phenomenon, The gluten-free world has continued to expand. More individuals are being diagnosed with celiac disease and the number and type of gluten-free products available in the marketplace has increased dramatically, especially in the last 4-5 years. However, she cautions the public against jumping on the gluten-free band wagon too quickly, Going gluten free is not a magic bullet for optimum health, weight loss, increased energy or many of the other claims made about the diet. She argues that while some may lose weight or feel better on a gluten-free diet, this could occur due to a number of factors from eating more fruits and vegetables to eating less processed prepackaged foods.

5 In the last few decades, doctors and researchers have learned much more about celiac disease. High-risk screening has improved, diagnosis is on the rise, and we have a much better understanding of the disease process and treatment. Awareness of the signs and symptoms has increased and the outcry for more gluten-free options has triggered a major response from the food industry. Case explains that increased access to products without gluten and naturally gluten-free grains has helped bring the gluten-free diet into the mainstream. In my first book, there were 1600 products and this new edition has over 3700 items. Also, gluten-free products are more readily available not only in health food stores but grocery and other retail outlets as well as online. The Role of the Registered Dietitian Nutritionist Registered Dietitian Nutritionists (RDN) are the go-to resource for management of gluten-related disorders. Case describes the challenges of the diet, For those who are newly diagnosed with celiac disease or non-celiac gluten sensitivity, adapting to the gluten-free lifestyle can be overwhelming at first. Adding, Learning to read labels and knowing which ingredients, foods, and beverages are safe; preventing cross-contamination; and gluten-free meal planning, cooking and baking are just some of the many challenges they face. Many must also learn, for the first time, how to maintain a balanced, healthy diet. Case encourages dietitians to get involved in the education and care needed to counsel patients on gluten-free diets. Because of the complexities of the diet and knowing how to eat safely in all types of scenarios is why it is essential for clients to consult with a registered dietitian with expertise in gluten-related disorders. The dietitian can provide evidence-based and practical information along with emotional support so that individuals can successfully manage their condition. RDNs also must be the first line of defense in helping clients decipher the medical nutrition therapy from the fad. Many clients come looking for information on gluten-free diets because they believe eliminating gluten will resolve all their problems. However, before counseling a client on a gluten-free diet, a thorough assessment that includes symptoms and family history must be completed. Case recommends this checklist for celiac disease symptoms: Dieti

6 tians also must work closely with the client and their physician to ensure the right tests are ordered and conducted if a gluten-related disorder is suspected. They must also urge patients not to start a gluten-free diet before celiac blood and biopsy tests are completed, because the diet can interfere with accurate diagnosis. Separating Fact from Fiction Case s Gluten Free: The Definitive Resource Guide offers a wealth of knowledge on every aspect of gluten-free diets. Below are a few highlights to help give clients the facts they need to be successful. FACT: Individuals with gluten-related disorders must follow a strict gluten-free diet for life. Lifetime avoidance of gluten is necessary to prevent the symptoms and damage resulting from the body s autoimmune response. Patients may struggle with this life-sentence wondering if they will ever enjoy eating again. RDNs must educate and counsel with compassion to guide their clients to a healthy gluten-free lifestyle. Start by focusing on foods that are naturally gluten-free fruits, vegetables, milk and most dairy products, corn, beans, un-breaded meats, eggs, nuts and more. Offer a few naturally gluten-free recipes for family favorites, like tacos made with corn taco shells and gluten-free taco seasoning, to help ease clients into the first few weeks. FACT: Not all gluten-free diets are healthy. Teaching patients and clients how to build a nutritious gluten-free diet is just as important as educating on the foods that are free of gluten. There is a common misconception that gluten-free products are health foods. In many cases, the opposite is true, as numerous gluten free products are made with refined grains that are often not enriched or fortified. Instruct clients to build diets with gluten-free whole grains, like brown rice, quinoa, buckwheat, and gluten-free oats, alongside plenty of fruits and vegetables, low-fat dairy and lean meats. FACT: Wheat-free does not mean gluten-free. Product labels provide important information to help consumers choose safe, gluten-free options, but they are also confusing. Clients need help identifying the ingredient list, understanding gluten-free claims, symbols and certifications, and the manufacturer s contact information. Be sure they can also spot keywords including wheat, rye, barley, oats, malt and/or brewer s yeast and understand precautionary advisory statements.

7 FACT: Any contact between gluten-free foods and foods containing gluten is cross-contamination. This means, salads that come in contact with croutons or burgers that have been touched by buns are no longer safe to consume. Cross-contamination can occur anywhere along the food supply chain in manufacturing and production, in distribution, at the store, at home, or in the restaurant. Even small amounts of gluten can be harmful if consumed by an individual with celiac disease. RDNs can help patients understand how to protect themselves at home by keeping gluten-free foods labeled and separate in the pantry and refrigerator and using clean and separate preparation equipment. Even using a dedicated toaster for bread and colander for pasta can reduce the chance of cross-contamination. FACT: Oats labeled gluten-free are safe for most patients. While oats were originally thought to be harmful for those with celiac disease, research has debunked this myth and identified the root cause of reaction to oats as cross-contamination in production. Oats are often cross-contaminated due to their close proximity to gluten containing crops. Equipment used to plant, harvest, store, transport and process oats is also frequently used in production of gluten-containing grains like wheat, rye and barley. Individuals following a gluten-free diet must purchase oats labeled gluten-free to be sure the manufacturer follows a purity protocol. FACT: Eating away from home presents unique challenges, but can be done safely. Case describes, Regardless of whether someone has just begun the gluten-free diet or been following it for awhile, they always have to be on guard to prevent from getting sick. This is especially difficult when eating away from home in restaurants, at work or school, or at social gatherings with family, friends or colleagues. Ensuring the ingredients are gluten-free and items are prepared safely to prevent cross-contact with gluten-containing foods is a huge concern and is often easier said than done. Encourage clients to call ahead to get a feel for the restaurant s knowledge and comfort level with gluten-free diets. Use restaurant websites to identify gluten-free options before stepping into the establishment. For social gatherings, contact the host and offer to bring a few gluten-free dishes. Above all, help clients feel comfortable advocating for themselves in a respectful way.

8 FACT: Traveling requires preparation. Traveling also is another challenge, says Case. It is critical to do a lot of planning in advance so that options are available while en route and at the destination. It is not uncommon for people to cram food in their travel bags so they have something safe to eat no matter what situation they encounter. Case recommends packing gluten-free snacks like snack bars, granola, oatmeal, nuts and fruits to ensure there are always safe options on the go. A Final Thought Diagnosis of celiac disease and gluten sensitivity are on the rise and awareness of these conditions has never been greater. Gluten-free options are increasing, but so is misinformation. As nutrition professionals, we must arm ourselves with evidence-based knowledge and practical tools to guide clients to a healthy, and balanced gluten-free lifestyle. References and For Your Continued Learning Case, Shelley. Personal Interview. Conducted 1/5/17. Case, Shelley. (2016). Gluten Free: The Definitive Resource Guide. Case Nutrition Consulting, LLC. Seskatchewan: Canada. Choung et al. Less Hidden Celiac Disease But Increased Gluten Avoidance Without a Diagnosis in the United States: Findings From the National Health and Nutrition Examination Surveys From 2009 to Mayo Clinic Pro, January 2017; 92(1): Riffkin R. One in five Americans include gluten-free foods in diet. Gallup website. Published July 21, The Hartman Group, Inc. The Hartman Group s Health & Wellness 2015 and Organic & Natural 2014 reports. 03pdf. Uhde M, Ajamian M, Caio G, et al Intestinal cell damage and systemic immune activation in individuals reporting sensitivity to wheat in the absence of coeliac disease Gut 2016;65: CE Quiz: 1. Which of the following is true about gluten? (Select all that apply.) A. It is a general name for the proteins found in wheat, rye, barley, kamut and spelt B. The proteins found in gluten are prolamin and glutelin

9 C. FODMAPs are a component of gluten D. Gluten is found in edamame 2. Which of the following is true about celiac disease? A. It is less prevalent now than it was 30 years ago B. The development of celiac disease involves a combination of genetic, environmental and immunological factors C. When gluten is consumed, the proteins trigger an autoimmune response that inflames and damages the villi in the large intestine D. Small amounts of gluten can be safely consumed by one with celiac disease 3. How is celiac disease different from non-celiac gluten sensitivity? A. Non-celiac gluten sensitivity is a more serious form of gluten intolerance than celiac disease B. There has been general consensus in the medical community since the 1970 s about the causes of non-celiac gluten sensitivity C. Individuals with non-celiac gluten sensitivity experience many of the same symptoms as celiac disease D. Rye is an acceptable grain for those with non-celiac gluten sensitivity 4. Which of the following can be a trigger for celiac? (Select all that apply.) A. breastfeeding B. infection C. pregnancy D. surgery 5. List two ways the RDN can be helpful in counseling those who need to follow a gluten-free diet. 6. True or false? Going gluten-free means the diet will become more well-balanced. 7. Which of the following is true regarding the gluten-free diet? A. Standard commercial oats are safe for those on a gluten-free diet B. It s not possible to safely eat away from home for those with celiac disease

10 C. Clients should look for the label wheat-free or gluten-free to be sure the food does not contain gluten D. A key pitfall for those on a gluten-free diet is the issue of cross-contamination Please see below to learn how to obtain your 1 CPEU credit. Need More CPEUs? Learn more and earn 15 CPEUs with our new self-study course: Gluten Free: The Definitive Resource Guide (15 CPEUs). Available at: Getting your 1 CPEU: Once you re ready, go to this link: The CE quiz questions listed above will display. Answer them and then use the answer key provided to score yourself. Once you ve reviewed your progress and corrected any wrong answers, complete the feedback survey and reporting form. Once you submit that, you ll be provided with your 1 CPEU CE Certificate of Completion. Questions? Contact us at info@skellyskills.com! (Please note: the above URL is an https: NOT http. If your organization s network blocks https: extensions, you ll need to use another device!) Learn more about all our CE courses for RD/RDNs, CDEs and DTRs at! Skelly Skills is an accredited CPE Provider for RD/RDNs and DTRs by the Commission on Dietetic Registration (CDR), and an approved CE provider for CDEs by the National Certification Board for Diabetes Educators (NCBDE). (c) 2017 Skelly Skills. All Rights Reserved.

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