It’s Halloween! Costumes, Trick or Treat, and parties. As with most holidays there are natural anxieties that surround eating felt by anybody who deals with celiac disease, gluten intolerance, or food allergies. Wanting to participate in the festivities without worry is a very understandable feeling that most of my patients struggle with.
As a gastroenterologist it is very hard for me to endorse the excessive consumption of candy. (Yes, stealing my kids’ dark chocolate even gives me reflux). However during celabratory times of the year being able to enjoy some candy in moderation is not the worst health habit. My father is a dentist. Growing up on Halloween, if we gave out candy people would accuse him of “drumming up business”. Dad therefore would typically handout chips or pencils. He always made note that as long as you did not chew on Jolly ranchers and brush your teeth, your dental health would be okay on Halloween.
I wonder if I should be handing out Metamucil instead of candy for trick or treat. Maybe not the best call as this may be an invitation for Halloween “tricks” on the house. We will stick to candy.
Fortunately, the Celiac Disease Foundation has a guide on gluten free candy options. A few take home points after my review:
– They make note of the importance of reading food labels. Fortunately most major manufactures are following food label guidelines.
-During busy times of the year such as Halloween, Christmas, and Easter, candy manufactures often need to increase their production. Due to this, they may use additional factories. Some of these factories result in some candies that typically are being gluten free not being gluten-free due to cross-contamination on the assembly line. For example, regular York Peppermint Patties and Reese’s Peanut Butter cups are gluten free; however the “shapes” and “minis” made around Halloween are not. This is outlined on the labels. Thus illustrating the importance of the food labeling.
Hope you all enjoy the festivities and Trick or Treat.
Currently the only known treatment for celiac disease is a gluten free diet. While the diet is highly effective, many patients with celiac disease will still experience symptoms while following a gluten free diet. Some of these issues may relate to cross contamination events; some may relate to incomplete healing of the intestine causing irritable bowel like symptoms.
Larazotide is a medication currently being researched for the treatment of persistent symptoms in the setting of celiac disease in patients following a gluten free diet. It is felt to limit the inflammation from gluten exposure by tightening the junctions between the cells that line the small intestines.
I am excited about the promise of a new therapy for celiac disease and the potential to offer options other than a gluten free diet. I am also excited that Allegiance Research Specialists has partnered with us at GI Associates to be a study site for the medication.
As anyone diagnosed with celiac disease knows well, a gluten-free diet can present a challenges when having to avoid food with wheat, barley, and rye. Many other people without celiac may also choose to a eat gluten free diet for a variety of other health concerns. Whatever the reasons for adopting a gluten-free diet, the diet itself can present some nutritional challenges such as getting adequate dietary fiber. Because many gluten free breads and baked goods use substitute flours that have a higher than usual starch content and less dietary fiber than traditional multigrain breads or pastas, this can create issues with constipation.
Diet therapy is a very important element of managing all types of digestive diseases. Patients often ask me for dietary management options for issues such as constipation as an alternative to using medications. What I often counsel patients is to focus on choosing foods that are already naturally gluten free such as fruits and vegetables, which also happen to provide additional dietary fiber. In fact, I counsel all my patients – even those not on a gluten free diet – to eat a diet filled with fruits and vegetables. An easy way to remember is to “eat from the perimeter of the grocery store” as a general rule of thumb.
But what fruits and vegetables are the best to get additional fiber in your diet? While the usual suspects of broccoli, lentils, beets and apples are all great options, more exotic fruits can actually provide just as much fiber and digestive benefits when added into daily diet. In fact, some recent studies on constipation and irritable bowel syndrome have shown that Kiwifruit may be a natural remedy.
In 2 studies presented at the 2018 Digestive Disease Week, researchers in Italy and New Zealand, which perhaps non-coincidentally are the top two exporting countries of kiwi in the world) found that incorporation of kiwifruit into the diet could replace the use of daily medication for the management of digestive distress. In the studies, patients with irritable bowel syndrome, constipation, and healthy volunteers were given either 2 kiwi per day, or psyllium (fiber supplement) for 4 weeks. The results showed that the group ate kiwi had better results, with the researchers proposing that kiwis are comparable if not more effective than psyllium fiber supplements for constipation and irritable bowel syndrome.
So how can you incorporate more (or any) kiwi into your diet? While some people like to eat kiwis with the skin on (myself included) and it does add some additional fiber the fuzzy skin can be peeled and still have the same effect according to Prof. Giovanni Barbara, M.D., the author of one of the studies. In addition to finding them in the produce section of your favorite grocery store, many warehouse clubs such as Costco or Sam’s Club sell kiwi in bulk. Kiwis are a great addition to any fruit salad, are delicious when incorporated in a morning smoothie (try this kid-friendly kiwi, banana, avocado and spinach green smoothie), and are even great in baked goods (try this kiwi tart, but substitute the flour in the pastry recipe for your favorite gluten-free mix such as Cup for Cup or Bob’s Red Mill). And while I doubt that there would be any dietary fiber benefits of this white kiwi sangria recipe, it looks like it would be a fun addition to any party (make kid-friendly by swapping orange juice for the orange liquor and sparkling white grape juice for the wine)!
Cesare Cremon, Juliet Ansell, Isabella Pagano, Barbara Kuhn-Sherlock, Lynley Drummond, M. Raffaella Barbaro, Eleonora Capelli, Lara Bellacosa, and others. A Randomized, Controlled, Single-Blind, Cross-Over Study Assessing the Effect of Green Kiwifruit on Digestive Functions and Microbiota in Constipated Patients. Gastroenterology, Vol. 154, Issue 6, S-565–S-566 https://www.gastrojournal.org/article/S0016-5085(18)32081-X/fulltext
Giovanni Barbara, Shin Fukudo, Lynley Drummond, Barbara Kuhn-Sherlock, Juliet Ansell, Richard Gearry. Green Kiwifruit Compared to Psyllium for the Relief of Constipation and Improving Digestive Comfort in Patients with Functional Constipation and Constipation Predominant Irritable Bowel Syndrome — Analysis of Three International Trial Centres. Gastroenterology, Vol. 154, Issue 6, S-979–S-980 https://www.gastrojournal.org/article/S0016-5085(18)33288-8/fulltext
Whether you’re avoiding gluten because of celiac disease or for other reasons, here are a few tried and true tips or easy swaps to making your holiday celebrations easier and allow you to enjoy the day with family and friends
Food is an integral part of American culture and a major way how we socialize with friends and loved ones; so having a dietary restriction can add an extra layer of stress to social gatherings. Now that the holiday season is in full swing with parties and gatherings seemingly every night through the New Year, maintaining a gluten-free diet can become especially challenging. Holiday potlucks with family or at the office can especially become a minefield when you have less control of the menu or don’t know what is being served.
Whether you’re avoiding gluten because of celiac disease or for other reasons, here are a few tried and true tips or easy swaps to making your holiday celebrations easier and allow you to enjoy the day with family and friends:
Offering to bring a few appetizers to a party can be a way to always make sure you have something to fill up on even if the main course isn’t gluten-free. Check out the recipe below for bacon-wrapped, blue-cheese stuffed grapes and an easy option for a festive baked brie topped with pecans. My sister makes the bacon appetizer which is always a hit.
Bring tortilla chips or gluten-free crackers to eat with dips or cheese that other people bring to share. See our recipe below for a 7-layer Mexican Dip that is great with tortilla chips and a family friend’s recipe for delicious homemade GF crackers.
Make a hearty side dish to bring to dinner parties in case the main course isn’t celiac-friendly, but make enough for everyone to share. The loaded-cauliflower bake linked below was a huge hit at a friend’s holiday party I attended and will easily replace anyone’s favorite mac n cheese recipe.
If a friend or family member asks you “What can I make?” it is helpful to have a few easy suggestions or guidelines. Offer recipes for your favorite gluten-free spice rubs or marinades, suggest grilling meat main dishes, or ask that turkeys be made with the stuffing on the side to prevent cross-contamination. Penzey’s spice mixes are frequently gluten-free.
Just because you’re following a gluten-free diet, doesn’t mean you can’t enjoy some holiday sweets and traditions. Many easily found store-brand hot cocoa mixes are gluten-free; Hershey’s Cocoa in the Cocoa, Special Dutch flavors are all gluten free, as are all Swiss Miss varieties. Make a mug of cocoa extra festive with a topping of whipped cream or gluten-free marshmallows (Kraft Jet-Puffed marshmallows are GF!).
And with three young kids, baking Christmas cookies are always a favorite in our house during the holiday season. My wife Katie has always been an awesome baker, and has used her skills to be an awesome gluten free baker. While Gluten free baking can be a bit challenging to adapt for family recipes, all-purpose alternative flour blends do not always translate well into those that were made for wheat based flours. In our house we enjoy the Land o Lake flour blend (see below) which we make ourselves to make Christmas cookies and treats every year; our family loves to make snickerdoodles and vanilla pound cake.
So as you see, gluten-free holiday parties can be just as merry and festive as any other! Enjoy your time with your family, and check out our favorite recipes below to help ease your way through the holiday season and into the New Year!
Preheat your over to 375 degrees. In a bowl, combine the almond flour and flax meal, salt and pepper and your chosen herbs (Italian seasoning, dill, garlic, ground black truffles all work well depending on what you want to pair the crackers with) mix well and add the water. Let this mixture sit until all of the water is absorbed. When all of the water has been absorbed, roll out little balls approximately the size of a large marble. Place these on a greased cookie sheet and cover with a piece of saran wrap. Using the bottom of a glass, press the balls down into a flat circular shape. Bake at 375 for 15 minutes or until slightly golden. Allow to cool on the sheet and place in an airtight container will keep for up to two weeks.
Eating out with any sort of dietary restriction can be tough. We eat out for the experience of eating different foods and for the camaraderie of being with others. Not being able to relax when out in a social setting and needing to worry about diet restrictions is stressful and can be upsetting.
Many restaurants now have gluten free menus. As gluten free diets have become trendy as people use them for weight loss and some other health conditions, there is a demand for more gluten free dining options. Things like gluten free bread and gluten free pasta are becoming more common. Many restaurants offer items that are already naturally gluten free like meat, potatoes, and rice.
There can be some pitfalls to these menus; while the items on the menus often are gluten free ,a common concern is cross contamination. Many of my patients have this correct concern when eating out. Cross contamination is when food containing gluten gets mixed into the gluten free food. Cross contamination often occurs when eating out when bread products are placed on the grill in the kitchen, when fryers are used for products that contain breading, or when wheat flour is used to thicken sauces. For example, french fries fried in oil are gluten free, until the breaded chicken strips are fried in the same fryer. In order to avoid cross contamination, it is important to be able to ask a few questions when ordering food:
Is anything breaded put in the fryer?
Is any flour added to this soup or sauce?
Can this meat/fish be prepared in a separate pan if bread products are placed on the grill?
I often get asked about cross contamination. “How much gluten is safe?” This is a great question. We typically advise celiac patients to be 100% gluten free, as cheating on the diet has been associated with health and nutrition problems. Small medical research studies have suggested that less than 50 mg of gluten per day does not causes changes in the small intestine on biopsies. The FDA regulation of 20 parts per million (PPM) for a food to be considered gluten free means 20 mg of gluten per 1000 mg of the food. This suggests that very small accidental exposures may be tolerated by the intestine, but intentional exposure should still be avoided. This is an evolving question for medical research to answer.
Prior to going out, review the restaurant’s menu online. Try to identify 2-3 options that may work for you on the menu.
Consider calling ahead to make sure the establishment can accommodate people with dietary restrictions
When ordering, tell the waiter you have Celiac disease. You need a gluten free meal and say “Allergy, not preference”. Yes, celiac is an autoimmune condition and not technically a food allergy like a peanut allergy, but using the term “allergy” can help to alert the kitchen that you are not going gluten free because it is trendy.
Keep things simple when ordering and asking questions. Polite, but not pushy goes a long way.
If ordering anything fried that is gluten free, be careful and ask if it is a dedicated fryer (it usually is not).
There are a variety of tests available for celiac disease. Confirming a diagnosis of celiac disease is important, as there can be some implications of a confirmed diagnosis of celiac disease versus “gluten intolerance”. Patients with celiac disease are at risk for certain types of cancers, nutritional problems, and diminished bone density. Knowing for sure is very important as patients with a confirmed diagnosis of celiac disease require monitoring by a physician. Patients with celiac disease also need to be 100% gluten-free in regards to diet.
“Gluten intolerance”, also known as “non celiac wheat sensitivity”, causes people health issues or digestive distress when they are exposed to gluten. People with gluten intolerance do not have a confirmed diagnosis of celiac disease. Patients with gluten intolerance do not always need to be 100% gluten-free. Patients with gluten intolerance do not require the same level of monitoring that a patient with celiac disease would require. Both conditions can make people feel rather sick. The symptoms of gluten intolerance can mimic other serious health issues, hence it is important to seek a formal opinion from a doctor.
Simply feeling better on a gluten-free diet does not constitute a diagnosis of celiac disease.
Given these factors, formal testing is important. There are 2 types of tests for celiac disease. It is important to know that both are measuring the body’s response to gluten. In order for proper testing and confirmation of a diagnosis of celiac disease, the patient must be exposed to gluten.
1. Labs. A tissue transglutaminase antibody is most sensitive lab test for celiac disease. There are older antibody tests that are still available. We typically only use these older antibodies in certain clinical situations.
2.Biopsies of the small intestine. A biopsy of the small intestine enables the doctor to see how the small intestine is reacting to gluten. Biopsies of the small intestine are the most accurate test. The endoscopy will show breakdown of the intestine lining and the biopsy will show inflammation as well as breakdown of the intestine cells. An adequate number of biopsies is required to make a proper diagnosis. Typically this is 6 specimens. Biopsies are taken during an upper endoscopy procedure.
Endoscopic pictures and biopsy example of celiac disease.
I typically advise patients not to start a gluten-free diet until they have at least considered laboratory testing for celiac disease. If somebody is already on a gluten-free diet the standard labs and biopsies are rendered inaccurate. There is a genetic test we can do for celiac disease but this only rules out celiac disease it does not rule it in. Establishing a diagnosis of celiac in a patient already on a gluten-free diet requires the patient to ingest at least one serving of gluten per day for at least 4 weeks in order to measure the body’s response to gluten.
The bottom line is to consult with a physician on testing for celiac prior to starting a gluten free diet.
Video of me discussing these tests can be found here.
“I can’t eat bread?!?” This is the most common thing I hear when I break the bad news to a patient who has celiac disease. We most often associate celiac disease and gluten with not being able to eat bread, even though wheat and gluten is found in many other food products.
Gluten free bread is tricky. There are some decent pre-made breads that can be found in most grocery stores, but the good ones can be hard to find. Many need to be kept frozen, some expire quickly, and some frankly just are not that good.
Why is gluten free bread so crumbly? Ask anyone with celiac and they can tell you stories of crumbly bread that disintegrates when you pick it up. Gluten protein gives wheat containing breads the sticky, doughy properties that we most associate with bread’s texture. Gluten free flours and starches can be used to make baked goods, but they usually rely on using multiple combinations of substitute flours and xantham gum to obtain that stickiness. Some gluten free breads are heavy in starch and low in dietary fiber.
There are some amazing gluten free bread recipes on several blogs and in several cookbooks. Due to the number of ingredients and time involved, they are not always realistic solutions for a mid week sandwich fix in our house. Using a bread maker and a bread mix seems to hit the sweet spot for our family and gluten free bread. Store bought is pricey, high maintenance, and sometimes not that good. Scratch bread takes too long and has too many ingredients. A gluten free bread mix and a bread machine hits the sweet spot of ease to make and freshness. It is also not that crumbly and has as much fiber as normal wheat bread. My youngest kid who does not have celiac requests this bread over wheat bread.
To make gluten free bread all you need is:
Pamela’s Gluten Free Bread Mix
2 eggs
1/3 cup of oil
Warm water
Bread machine (does not need a gluten free setting). Nothing fancy; models less than $70 will do. A good gift for somebody who is gluten free in your life.
2 cup measuring cup.
The instructions on the package are easy to follow. I also have a video to walk you through it if you would like to try.
I am a board certified gastroenterologist working in Southeastern Wisconsin with GI Associates. I have a special interest in celiac disease and gluten related issues.
After being in GI practice for several years my wife began having digestive issues. Evaluation eventually led to a diagnosis of celiac disease ( TTG over 100 and severe villous atrophy on biopsy). We were shocked. As a Gastroenterologist I was knowledgeable about the diagnosis of celiac and I knew that a strict gluten fee diet was needed. I had no idea what it was like for a patient and a young family to navigate the diet and lifestyle. The experience of being on the “other side of a diagnosis” was difficult. On our journey, my wife taught me so much about handling a difficult diagnosis with grace. We have used what we have learned to share with my patients more practical approaches to handling celiac disease and gluten free diets. The learning curve can be steep but, we hope that we can ease some of the initial shock and help you to feel empowered to put you on the path to good digestive health.
Overall, this experience has given me a unique perspective. As a GI specialist, this drives my desire to focus on the latest science and research surrounding celiac disease. As a supportive family member, it has helped me learn the day to day struggles of living with a chronic GI illness that must be managed with a strict diet. I hope to share in my experience as both a physician and as a family member. This blog will focus both on science as well as day to day life with celiac disease and other digestive health problems.
Starting out on gluten free diet is a challenge. Any major lifestyle change can be a process and takes time. Education can be an empowering tool for anyone needing to change their diet. This is my 10 step process to starting a gluten free diet.
