April, 2007

Putting the Healthy into Gluten-Free
Today’s Dietitian
By Sharon Palmer, RD
Vol. 9 No. 4 P. 40

Nutrition educators instructing patients on the gluten-free diet tend to place an emphasis on a “don’t list,” often leaving out the important message of eating a nutritionally adequate and healthy diet.

It has probably caught your attention that the gluten-free (GF) diet is basking in the public glow. You’ve likely noticed a widening GF specialty section in supermarkets, a surge in products bearing GF labeling, and more restaurants displaying GF items on their menus and Web sites. And it’s hard to miss Internet information on the GF diet and products. A recent Google search for the phrase gluten-free diet yielded 1.1 million results. In fact, GF is so hot that some food manufacturers are betting it will replace the recently vacated low-carb niche, and high-profile companies such as Walt Disney World Resorts are hiring chefs to integrate GF food into their operations.

What’s behind the love fest for all that is GF? One factor is the discovery that nearly one of every 133 Americans (a statistic 10 times higher than previously thought) has celiac disease (CD), a genetically determined, immune-mediated disorder in which gluten damages the lining of the small intestine.1 The treatment for CD is a lifelong diet void of gluten. In addition, those with gluten intolerance are among the growing number of GF followers.

The GF diet has also gained fame for nontraditional treatments, whether or not scientific evidence backs their efficacy. A grassroots movement is picking up among parents of autistic children who have turned to the GF diet as an alternative method of treating the condition. GF food manufacturers report that their customers are also purchasing GF products because they believe the GF diet will help them treat behavior conditions, strengthen the immune system, feel better, or lose weight. Some speculate that the GF diet may become the next “it” diet, replacing the low-carb diet.

“I am seeing people who don’t need to be on a gluten-free diet choosing gluten-free products because they think [they’re] healthier. It’s kind of comical, as it is healthier to eat conventional 100% whole grain products rather than [ones that are] processed,” says Earline Griffith, MA, RD, corporate dietitian at Raley’s, a supermarket chain in northern California and Nevada.

The Task of Teaching GF
When dietitians find themselves face-to-face with patients new to the GF lifestyle—one of the most radical dietary changes they will ever make—it’s no wonder RDs typically reveal a “no-no” list. The overriding objective is to ensure patients understand how to avoid gluten, so ubiquitous and cleverly hidden in the U.S. food supply. But far too often, nutrition education stops there.

“We’re so focused on the safety of a gluten-free diet that we have lost sight of a healthy lifestyle,” says Carol Fenster, PhD, president and founder of Savory Palate, Inc., author of several GF cookbooks, and a culinary consultant. Fenster has personal experience with the GF diet—she herself is gluten-intolerant.

“I think for the longest time with the gluten-free diet, dietitians have been so focused on what people cannot eat. We have a history of handing out a list of ‘nos’ for diets,” says Tricia Thompson, MS, RD, an independent nutritional consultant specializing in CD and author of the American Dietetic Association (ADA) patient education booklet Celiac Disease Nutrition Guide. It’s hard enough for dietitians to keep up with the latest in the GF diet, a dynamic landscape of shifting food labeling laws, manufacturers’ practices, and food additives. Thus, dietitians may not stop to consider how healthy this newfound lifestyle they are advocating will be. Will the diet provide an adequate source of vitamins, minerals, and fiber? Will it overload patients with refined carbs and fat? Will they be at risk for obesity, diabetes, or heart disease?

The Nutritional Backdrop
Dietitians dedicating their careers to the GF world are growing concerned over the nutritional health of patients on the GF diet. The nutritional status for patients newly diagnosed with CD can be compromised from the start due to malabsorption. There is a significant risk for various vitamin and mineral deficiencies, as well as secondary lactose intolerance, which can interfere with calcium and vitamin D intake.

The GF diet in itself can pose further challenges for nutritional adequacy. People on a GF diet often consume less-than-recommended amounts of folate, B vitamins, iron, calcium, fiber, and grain servings. “There is some propensity for nutrients to be missed in the gluten-free diet,” says Thompson, who notes that there are few studies on the nutritional adequacy of the GF diet. When you consider that this diet is a lifelong approach, possibly starting in childhood during the growth and development years, the worries over nutritional adequacy multiply.

In a 1998 study published in the Journal of Pediatric Gastroenterology and Nutrition, researchers examined the habits of and diet composition in 47 adolescents with CD and 47 healthy aged-matched control subjects. The results of the analysis indicated that in people with CD, adherence to a strict GF diet worsens the already nutritionally unbalanced diet of adolescents and increases elevated protein and lipid consumption.2

In a study published in 2002, 30 adults with CD in biopsy-proven remission following eight to 12 years of dietary treatment were studied. The patients showed higher total plasma homocysteine levels than the general population, indicating poor vitamin status. The levels of folate and pyridoxal 5-phosphate (vitamin B6) were lower in 37% and 20% in patients with CD, respectively, and the mean daily intakes of folate and vitamin B12 were significantly lower in patients with CD than in controls. The researchers concluded that one half of the adult patients with CD treated with a GF diet for several years displayed signs of poor vitamin status.3

Fattening Up
Contrary to popular assumption, obesity happens in CD. Patients who have been experiencing malabsorption and then get healthy through a GF regimen often start to pack on the pounds once they start eating again. Some even come to the GF table for the first time as obese.

“I have found that when they go to gluten-free convenience products or bake, their weight creeps up. They have the same weight challenges as people who do not have CD after their body is healed,” says Dee Sandquist, MS, RD, CD, director of nutrition, diabetes, weight management, and wound healing at Center Southwest Washington Medical Center, who reports that she finds only approximately 30% of her patients with CD with diarrhea and weight loss. The rest tend to have a problem with being overweight or having abdominal pain or constipation.

“High-sugar, high-starch foods are not satisfying, so there’s a tendency to gain weight. They can go from one extreme to another—undernutrition to overweight,” says Shelley Case, RD, author of Gluten-Free Diet: A Comprehensive Resource Guide.

Mixing It up With Other Diseases
The bet noir for GF nutrition educators is the intersection of CD with diseases such as diabetes, heart disease, and renal disease, as this is unchartered territory. “There [are] no research and guidelines written to handle patients with diabetes and celiac disease,” says Cynthia Kupper, RD, CD, executive director of the Gluten Intolerance Group of North America. Kupper has been living a GF life due to a diagnosis of CD and reports that she recently worked with a dietitian who was at a loss for what to do with a patient with diabetes, renal disease, and CD.

According to a 2006 article in the Revue Médicale de Liège, CD is more prevalent in patients with type 1 diabetes than the general population, possibly due to a common genetic background or an immune response triggered by CD.4

Case reports, “The data suggest that 5% to 10% of type 1 diabetes patients have celiac disease, and patients are actively screened. Diabetic celiacs need to be aware of the carbohydrate load of gluten-free foods.” Type 2 diabetes can also crop up as an extension of a diet high in refined carbohydrates, obesity, and an aging population.

Sandquist points out that it’s important to consider that other health issues can emerge in CD, just within the general population. “Just because they have celiac disease doesn’t mean that they cannot get heart disease,” adds Thompson, noting that sometimes those on a gluten-free diet can have high cholesterol levels and may benefit from a heart-healthy program.

GF Food Bonanza
Food manufacturers are quick to respond to today’s increased interest in GF living by flooding the market with a growing array of special products. “The gluten-free industry is growing by leaps and bounds. It is expected to grow by 25% per year over the next few years,” says Kupper.

Unfortunately, GF food manufacturers are often more concerned about banning gluten from their ingredient list than creating healthful food products. “I don’t think healthiness is well-addressed in the gluten-free industry. When I look at gluten-free products, I see a string of ingredients like sugar, refined white rice, and fiber additives with diminished holistic benefits of whole foods,” says Matthew Cox, marketing manager of Bob’s Red Mill Natural Foods, Inc., a food manufacturer that produces a number of whole foods, including GF products. “It is contrary to the needs of CD; with a compromised immune system, it certainly doesn’t help strengthen it.”

Kupper says she recently conducted a survey of people on a GF diet and found they were not selecting food based on nutrition; instead, they cared more about taste and cost. When people are confronted with losing some of their favorite foods, such as breads, baked goods, and pasta, their preeminent concern seems to be finding something that tastes as close to the real thing as possible.

“There’s a lot of work that needs to be done with gluten-free foods. They can be so high in carbohydrates. A gluten-free hot dog bun can be twice as high in carbohydrates as a regular bun,” notes Kupper.

To Enrich or Not to Enrich
An issue rising to the forefront focuses on the fortification of refined GF products. “In the U.S., our wheat-based foods that are refined are enriched. Gluten-free refined foods, for the most part, are not enriched,” says Thompson. Nutrition educators may not be aware that most foods in the processed GF food stream are refined but not enriched. When dietitians instruct patients to replace wheat-based bread—likely a staple in their diet—with GF bread, it is probable that patients will regularly depend on a bread made of a refined rice flour-starch combination that is unenriched and extremely low in nutrient value. Since most GF cereals, pastas, and breads are not enriched, they are low in thiamin, riboflavin, niacin, iron, and folate.

While some argue that enrichment of processed GF products supports the practice of stripping grains of their full nutrient potential, then adding some vitamins and minerals back in, many experts believe enrichment can offer a safeguard for a vulnerable population. “It needs to happen. I believe the gluten-free version of wheat-based products needs to be fortified,” says Kupper.

Dietitians can help steer patients to search for enriched products, as some companies are now enriching their GF products with iron and B vitamins at the same levels as gluten-containing breads, cereals, pastas, and flours.

Pushing Whole Foods
Often, when patients first embrace the GF diet, they go on a GF shopping binge for processed foods and grow dependent on them. “Instead of processed gluten-free foods, people could be eating whole fruits, whole grains, peanut butter, eggs, salads, and soups,” says Fenster.

Alternative whole grains offer an easy fix for helping to repair a broken-down GF diet. “People need to be introduced to different grains such as amaranth, quinoa, and buckwheat—these are so incredibly healthy,” says Fenster, who is currently taping a PBS show that will focus on using whole grain quinoa. In addition, GF dieters can benefit from choosing nutritious grain flours such as amaranth, brown rice flour, buckwheat, flax, Montina, nut flours, quinoa, teff, and legume flours as a source in GF foods. “It’s easy to use healthy whole grains, but people are reticent to use them,” adds Thompson, who has observed in patient food records that people with CD are not typically consuming alternative grains.

Case says, “There are a lot of naturally gluten-free foods you can stress. Instead of thinking that they can’t have bread or pasta, focus on all the things they can have.” Recognizing vulnerability in the current nutrition education model for the GF diet, the third edition of Case’s book includes twice the number of recipes, practical information about tips to increase B vitamins and calcium, nutritional analysis of recipes, and an updated food guide that helps readers understand alternative grains.

Get Cooking GF
One secret to discovering a healthy GF diet is to pull out the oven mitts and wooden spoons. Many GF cookbooks offer quick, healthy recipes. It’s difficult to eat optimally if one relies on mostly GF convenience products. “We need to have more cooking and less reliance on processed foods,” suggests Thompson. Sandquist stresses that you should start nutrition education by asking patients about their cooking skills.

Tips for better GF cooking include the use of more nutritious flours such as brown rice, sorghum, or buckwheat flour for baking. The nutritional quality of dishes can be further improved by stirring in flax meal, almond meal, or Montina into recipes such as pancakes, hot cereal, smoothies, and casseroles. By rediscovering the slow cooker and rice cooker, people can enjoy quick meals featuring healthy whole grains and legumes as a breakfast, side dish, soup, or one-dish meal. In addition, patients can stir more beans into their cooking pots and mixing bowls, both in their whole state or as flour. “People dismiss beans, but they are chock-full of vitamins, protein, and fiber,” says Fenster.

Dietitians on the Path to Better GF Understanding
“The challenge for RDs is to keep up-to-date. We need to keep a step ahead. I am hearing from patients that they are seeing registered dietitians who are not familiar with the gluten-free diet,” says Sandquist. It’s important to remember that most patients have already been surfing the Internet before they come in to see a dietitian; thus, they may have great expectations from their session. Says Kupper, who will be presenting at a GF workshop at the ADA Food & Nutrition Conference & Expo this fall, “When I talk to dietitians, they are desperate for information on the gluten-free diet. They are frantic because they don’t know enough.”

“Dietitians need to let their patients know that there are healthier options. Look at the foods that people can eat,” says Sandquist. “We need a balanced feeding approach that emphasizes fiber, beans, with lots of vegetables and fruits.”

The bottom line: It’s no longer enough to hand out a “don’t” list for the GF diet.

— Sharon Palmer, RD, is a contributing editor at Today’s Dietitian and a freelance food and nutrition writer in southern California.

1. Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: A large multicenter study. Arch Intern Med. 2003;163(3):286-292.

2. Mariani P, Viti MG, Montuori M, et al. The gluten-free diet: A nutritional risk factor for adolescents with celiac disease. J Pediatr Gastroenterol Nutr. 1998;27(5):519-523.

3. Hallert C, Grant C, Grehn S, et al. Evidence of poor vitamin status in celiac patients on a gluten free diet for 10 years. Aliment Pharmacol Ther. 2002;16(7):1333-1339.

4. Mathieu S, Stassen A, Paquot N, et al. Type 1 diabetes and celiac disease. Rev Med Liege. 2006;61(9):637-642.

A Gluten-Free Information Resource Guide
Celiac.com, www.celiac.com

Celiac Disease Center at Columbia University, www.cdcc.hs.columbia.edu

Celiac Disease Foundation, www.celiac.org

Celiac Sprue Association of the United States of America, www.csaceliacs.org

Children’s Digestive Health and Nutrition Foundation, www.celiachealth.org

Cooking Gluten-Free! www.cookingglutenfree.com/index.htm

Gluten Intolerance Group, www.gluten.net

Gluten-Free Cooking Club and School, www.glutenfreecookingclub.com

Gluten-Free Diet: A Comprehensive Resource Guide by Shelley Case, RD (Case Nutrition Consulting, 2006), www.glutenfreediet.ca

Glutenfreeda.com, www.glutenfreeda.com

Living Without magazine, www.livingwithout.com

Medical Nutrition Practice Group DPG/Dietitians in Gluten Intolerance Diseases sub-unit, www.eatright.org

Savory Palate, Inc., Cookbook Series by Carol Fenster, PhD, www.savorypalate.com

University of Chicago Celiac Disease Program, www.uchospitals.edu/specialties/celiac

University of Maryland School of Medicine Center for Celiac Research, www.celiaccenter.org

What? No Wheat? by LynnRae Ries, www.whatnowheat.com