Gluten-Free Living: Helping People to Eat Safely, Healthfully and Happily Rachel Begun, MS, RDN www.rachelbegun.com @RachelBegunRD
What is Gluten?
What is Gluten? Gluten is the collective term for a group of proteins found in the grains wheat, rye and barley and their various forms (i.e., spelt, einkorn, triticale)! It is best known for giving baked goods their doughy, elastic structure, however many foods contain gluten for other purposes, including as a thickening agent or flavor enhancer! For people with celiac disease (CD), every time gluten is consumed the immune system triggers an attack on the intestines. When the villi of the intestines become damaged, the body is unable to absorb nutrients into the bloodstream, which can lead to malnourishment and other serious chronic conditions! People with non-celiac gluten sensitivity (NCGS) may experience similar symptoms as those with CD, however, antibodies to gluten are not produced nor is there intestinal damage (two hallmarks of CD). We do not yet know if eating small amounts of gluten causes damage.
Why Go Gluten-Free? Comparing and Classifying Gluten-Related Disorders
Nomenclature and classification of gluten-related disorders Source: Fasano A, et al. Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Medicine. 2012; 10:13.
Comparison of Gluten-Related Disorders Celiac Disease Wheat Allergy Non-Celiac Gluten Sensitivity Autoimmune disorder Immune system triggers attack on intestines when gluten is eaten Blood tests reveal autoantibodies to gluten; biopsy reveals intestinal damage Affects 1% of population 3 million Americans Allergic (IgE-mediated) immune response Affects 0.1% of population 300,000 Americans Not autoimmune disorder No auto-antibodies to gluten; no intestinal damage Not allergic disorder No disease definition yet Diagnosis of exclusion 6% of population? No biomarker yet 300+ symptoms have been reported: - Intestinal - Extra-intestinal - No symptoms Swelling/itching; hives/rash; itchy watery eyes; difficulty breathing; anaphylaxis Symptoms mirror CD Extra-intestinal symptoms more likely
Diagnostic Testing
Testing for CD: The 5 Pillars of Diagnosis 1. Signs or symptoms compatible with CD 2. Positive serological screening tests (need to be eating gluten for accurate results) 3. Presence of genetic markers: HLA-DQ2 or HLA-DQ8 4. Intestinal damage typical of CD detected by endoscopy/biopsy (need to be eating gluten) 5. Symptom resolution following implementation of gluten-free diet Dr. Alessio Fasano says in his book, Gluten Freedom: The majority of people with CD will meet all five criteria, but there are exceptions to each of these pillars. As a result, meeting four of the five criteria should be sufficient to cover most people with CD and may prevent the need for using one of the criteria (i.e., invasive endoscopy/biopsy in children
Genetic Testing for Celiac Disease 30-40% of population has one or both genes; however, only 1-3% develops CD Having one or both genes only shows you may develop CD; it is not a confirmed diagnosis for CD Physicians primarily use genetic testing to rule out CD Other reasons for recommending genetic testing: in young children who have family history; if negative, no need for invasive procedures or lifelong monitoring for those who may have other conditions with similar changes/damage to intestines for those who have self-diagnosed as being gluten sensitive, have been gluten-free for several months, and do not want to undergo a gluten challenge for formal testing
Testing for Non-Celiac Gluten Sensitivity (NCGS)? Currently, there is no accepted diagnostic test for NCGS NCGS is a diagnosis of exclusion first rule out celiac disease and wheat allergy through proper testing then conduct elimination diet to determine if gluten is really the trigger other components of wheat may be the cause of symptoms Elimination diet should be done under supervision of healthcare team with gluten-related disorders expertise
The Gluten-Free Trend: Where We ve Been
Gluten-Free 2012 - $4.5 billion in GF retail sales* Annual growth rate of 28-30% each year from 2008-2012* In 2012, National Restaurant Association named GF a top three lasting trend in the industry GF menu claims grew 280% from 2008-2011 - Mintel Menu Insights *Source: 2013 Gluten-Free/Diabetes Friendly Handbook, a Supplement to Grocery Headquarters Magazine
GF Trend Drivers Started with celiac community Continued growth with increased awareness and rising prevalence of celiac disease and other gluten-related disorders Dramatic growth due to health halo effect and weight loss myths Contribution of other diet trends: low-carb, paleo, raw, anti-wheat Lack of gluten-free labeling standard allowed all to enter marketplace Source: Hartbeat, The Newsletter of the Hartman Group: Consumer Trend in Self-Diagnosis: The Gluten-Free Conundrum
The Gluten-Free Trend: Where Are We Headed?
Has the GF trend peaked? GF retail sales projected to reach $6.2 billion by 2018* Annual growth rate of 28-30% from 2008-2012; expected to drop to 10% 2012-15 and 7% in 2016-17** 52% of chain restaurants plan to add GF options in 2014*** Trend may peak, but people requiring medically-necessary GF diet continues to grow ~80% still undiagnosed GF health/weight loss myths being corrected * Source: MarketsandMarkets Report: Gluten-Free Products Market by Type, Sales Channel & Geography - Global Trends & Forecasts to 2018) ** Source: Packaged Facts Report: Gluten-free Foods and Beverages in the U.S., 4th Edition *** Source: SpenDifference national menu price survey
Gluten-Free Food Choices Focus majority of diet on whole, nutrient-dense, naturally gluten-free foods: fruits and veggies plant-based proteins: beans, nuts, seeds lean meats, poultry and fish dairy, when tolerated gluten-free whole grains
Gluten-Free Whole Grains and Flours are Abundant Certified, gluten-free oats Sorghum Brown and wild rices Quinoa Millet Nut flours (i.e. almond), bean flours (i.e., chickpea), starches (i.e., potato, tapioca) Recommend certified gluten-free for items at high risk for cross contact Amaranth Buckwheat Corn Teff
Living Gluten-Free Healthfully and Happily
Preventing Cross Contact: When Eating Out When possible, choose restaurants recommended by the GF community or that have gone through training/certification Call ahead to let restaurant know your GF needs in advance Review menu online prior to arriving at restaurant; narrow to a few selections Communicate to wait staff clearly, assertively and graciously File complaint report for bad service/mistakes If good service, tip well and spread the word!
Preventing Cross Contact: When Traveling Research GF friendly hotels/resorts - kitchenette Contact hotel chef Make restaurant reservations in advance Reserve room with mini-fridge or kitchenette Ship GF non-perishables in advance Carry abundance of GF options Invest in a portable personal cooler
Preventing Cross Contact: When Shopping ALWAYS read labels: FDA gluten-free labeling rule is voluntary and doesn t apply to all foods in the supermarket; ingredients can change without warning Seek services of supermarket dietitian nutritionist Obtain gluten-free product list; submit GF requests to manager Search for gluten-free recipes; attend culinary demos Use caution with deli items, prepared foods, bulk foods, and other high risk items
Gluten-Free Resources Apps for gluten-free shopping and eating out not foolproof; must still read labels and be diligent about asking questions Restaurant and Grocery Guides Gluten-Free Restaurant Cards Gluten-Free Travel Site, www.glutenfreetravelsite.com Ask local support group or listserve members
To Eat Safely, Healthfully and Happily Choose mostly whole, nutrient-dense, naturally gluten-free foods; save highly processed foods for special occasions and convenience purposes Learn basic cooking skills Invest in a few good gluten-free cookbooks to get you started Always carry healthy, gluten-free snacks with you Join a celiac disease/gluten-free support group
Think positively! Living gluten-free is not a culinary death sentence. It may even expand your culinary horizons!