Practical Quick-Reference Guide to Going Gluten Free
By Dr. Michael Wald - Director of Nutrition at Integrated Medicine of Mount Kisco, P.C.
What Is Gluten?
Gluten is a generic form of protein in grass plants found in the seeds or what is commonly referred to as “grains”. Gluten is found in most grains, including rice and corn but the form of gluten in these foods is 100 % safe for those with Celiac Disease. The specific type of gluten in wheat, barley, rye, possibly oats, and spelt, the most adverse type of gluten proven bad for those with Celiac Disease.
What You Need to Know About The Gluten Proteins
The proteins of barely, rye and wheat consists of two proteins known as gliadin and glutenin. During the baking process these proteins form a stretchy, thick, glue-like substance that provides the appealing texture of elasticity in bread and various baked goods. Gluten allows bread dough to rise by trapping (“gluing”) bubbles that form from the fermentation process of yeast within the dough itself. The rising dough is airy and light. Glutens in other grains do not provide the same bubble trapping effect because of the absence of, or far less, of the gluten proteins. Essentially, the more gluten the more bubble trapping between “sheets” of gluten that form when water is added to the gluten grain during food preparation; the higher the water content the more gluten is formed from the gliadin and glutenin proteins. Gluten-free breads therefore cannot have the same consistency as gluten containing breads.
Modern Day Wheat
Modern wheat has been engineered (bred) to contain much more gluten that the older varieties of wheat such as spelt and Einkorn. This change in wheat in modern day times has unfortunately produced a far more toxic product to those who adversely react to wheat. Gluten in today’s modern society is found in literally thousands of food products. As a result of the demand for foods that contain wheat, wheat is the second most cultivated crop in the U.S behind corn and soybeans exceeding over 47 million acres of production in 2012. Statistics for wheat, barley and rye demonstrate that more farm acres are used for this group of grains than any other crop.
How Much Is Too Much Gluten?
Some studies have shown that 10 mg or less is usually tolerated by most Celiac’s in that this level of dietary intake does not frequently cause histological changes in the small intestine characteristic of Celiac Disease. In the United States, the FDA issued proposed regulations in 2007 limiting the use of "gluten-free" in food products to those with less than 20 parts per million of gluten. The current international Codex Alimentarius standard allows for 20 parts per million of gluten in so-called "gluten-free" foods. Standards for "gluten-free" labeling have been set up by the "Codex Alimentarius"; however, these regulations do not apply to foods that in their “normal or natural form” do not contain gluten. Current research suggests that for persons with celiac disease the maximum safe level of gluten in a finished product is probably less than 0.02% (200 parts per million) and possibly as little as 0.002% (20 parts per million). However, these numbers are essentially meaningless because any amount of gluten whatsoever that is consumed can cause an adverse reaction in an individual.
Why Are We Becoming More & More Gluten Intolerant?
The answer to this question is stranger than fiction. Essentially, human beings have not been around long enough, eating wheat and identical forms of gluten contained in wheat and related products, long enough for our bodies to digest it properly. Think about this…in the 1950ies celiac disease statistics state that the condition was found in 1/8000 people. Today, celiac disease is now found at the much higher prevalence of 1/800 people. Non-celiac disease gluten intolerance, I believe, is far more common than Celiac Disease and almost entirely unrecognized or appreciated by modern day gastroenterologists. Interestingly, the ancient Roman’s harvested grains, but not wheat. Wheat has been a part of our agriculture and diet for only about 10,000 years. Human’s have been evolving on Earth for about 2.5 million years; therefore gluten in the form of wheat has been consumed by humans for only 0.4 % of the time we have been evolving as a species…”just the blink of an evolutionary eye!” Said another way, gluten in wheat is just too new for our bodies to handle it resulting in a backlash from our immune system in the form of Celiac Disease, gluten allergy and gluten intolerance; these last two also known as non-celiac gluten intolerance. Essentially speaking, gluten is a foreign substance to our immune and digestive systems often wreaking havoc for millions of people on the planet.
What Are The Major Gluten Grains ?
Latin terms for gluten that you should be familiar with include:
- Triticum vulgaris (wheat)
- Triticale (cross between wheat types)
- Hordeum vulgare (barley)
- Secale cereale (rye)
- Tricum spelta (spelt wheat)
- Oats: Because of cross-contamination oats can cause gluten-reactions for those with either Celiac Disease and/or non-celiac gluten intolerance. Therefore in packaged foods, oats should be considered gluten free only when the packaging states, Gluten-Free. Oats do have contain a different, non-reactive, form of gluten that is perfectly safe for those with gluten intolerance of any kind.
Wheat derivatives include:
- Bulgar: cereal food make from the groats (hulled grains outer shell (i.e., oats, wheat, barley, rye, etc.)
- Durum: “hard” in Latin, high protein, lowest of the gluten grains in gluten
- Farro (best to soak overnight): composed of certain wheat species (i.e., emmer. Barley is sometimes called Farro (due to similarities of the grains)
- Kamut (Khorasan wheat)
- Semolina: Is the coarse, packed, wheat “middlings (by-products of wheat milling industry)” of durum wheat commonly used for cereals, puddings, pasta and couscous.
- Spelt wheat
Other Foods That may Include Gluten
- Flavored foods
- Canned baked beans (which may contain a thickener)
- Canned soups
- Cheese spreads
- Creamed foods
- Egg mixes
- Fillers or extenders
- Flavorings and icing/frosting
- Malt (which can be found in beverages and cereals)
- Malt vinegar (barley)
- Matzo balls (unless they are made with potato flour)
- Rye, oats
- Salad dressings
- Seeds/snack mixes
Prepackaged foods that may contain gluten
chips, hot dogs
instant tea or coffee
Fried foods, beer
Dextrin is usually made from corn, but is sometimes made from wheat sources.
HPP equals hydrolyzed plant starch.
HVP equals hydrolyzed vegetable protein.
TVP equals texturized vegetable protein.
Incipience: Incipients are filler ingredients that may be added to the active medication or drug, including colorings, dextrates, malt and starches. The purpose of the incipience is to provide bulk to the medication, to act as a lubricant for the powdered form of the medication and/or to absorb water. The composition and source of the specific incipience must be identified on a medication label.
Inactive ingredients: Inactive ingredients are defined as any component other than the active ingredient in the medication. The inactive ingredient involves the entire manufacturing process, including packaging, processing and holding of a medication.
Active ingredients: Active ingredients are defined as any ingredient that the drug manufacturers use for the intention of producing the drug product.
Note: The composition and source of each of the incipience must be identified to assure that the drug is GF medication product.
Additional Potential Gluten Sources: Makeup, Play dough, stamps, pet food, lipstick, paints, envelopes, baby powder, lip balm, toothpaste, suntan lotion and bath salts.
Unspecified starches: Sodium starch glycolate
List Of Health Problems That May Be Caused By Gluten
- Abdominal pain
- aphthous ulcers
- autoimmune hepatitis
- canker sores
- colon cancer
- elevated liver enzymes
- elevated transaminases
- enamel defects in teeth
- eosinophilic esophagitis
- eosinophilic gastroenteritis
- fructose intolerance
- hepatic steatosis
- hepatic T-cell lymphoma
- intestinal bleeding
- lactose intolerance
- liver disease
- occult blood in stool
- impaired pancreatic exocrine function
- primary biliary cirrhosis
- pprimary sclerosing cholangitis
- sore throat, chronic
- steatorrhea – fatty stools
- villous atrophy
- dermatitis herpetiformis
- dry skin
- follicular keratosis
- psoriasis welts
- dark circles under eyes
- linear IgA bullous dermatosis
- hereditary angioneurotic edema
- cutaneous vasculitis
- erythema nodosum
- erythema elevatum diutinum
- necrolytic migratory erythema
- vitiligo disease
- behcet’s disease
- oral lichen planus
- alopecia areata – hair loss
- acquired hypertrichosis lanuginosa
- pyoderma gangrenosum
- ichthyosiform dermatoses
- generalized acquired cutis laxa
- atypical mole syndrome and congenital giant nevus
- ups & downs
- weight loss
- weight gain
- poor endurance
- inability to gain weight
- chronic fatigue
- failure to thrive
- short stature
- difficulty concentrating
- cerebellar atrophy
- mental fog
- brain white-matter lesions
- insomnia/difficulty sleeping
- ataxia/difficulty with balance
- multifocal axonal polyneuropathy
- peripheral neuropathy (numbness/tingling of hands or feet)
- Rett Syndrome
- rheumatoid arthritis
- muscle aches
- joint pain
- loss os strength
- short stature
- multiple sclerosis
- myasthenia gravis
- chronic sinusitis
- shortness of breath
- irrgeular cycle
- infertility – also male infertility
- delayed start of menstruation
- premature menopause
- alopecia areata (hair loss)
- Addison’s disease
- autoimmune chronic hepatitis
- Type 1 diabetes
- Graves’ disease
- secondary hyperparathyroidism
- hypothyroidism, autoimmune
- idiopathic autoimmune hypoparathyroidism
- idiopathic thrombocytopenic purpura (ITP)
- Lupus (SLE)
- myasthenia gravis
- Sjogrens syndrome
- villous atrophy
- iron deficiency
- vitamin B12 deficiency
- vitamin K deficiency
- folate deficiency
- Raynaud’s syndrome
- elevated eosinophils
- cystic fibrosis
- pulmonary hemosiderosis
- colon cancer
- esophageal and oro-pharyngeal carcinoma
- Non-Hodgkin’s lymphoma
- small bowel adenocarcinoma
It is an interesting bit of trivia to know that freshly milled wheat flour has no gluten in it. Wheat flour does contain the two proteins gliadin and glutenin that turns into gluten when mixed with water. Elastic bonding occurs between gliadin and glutenin when combined with water creating the doughy and stretchy quality so desirable for bread baking. Pizza dough is a common example of a form of bread that contains a lot of gluten (the stretchier, generally speaking, the greater the gluten content. Thus, more water, used during baking, the more stretchy, the more chewy and the higher the gluten content. Also, kneading the dough for longer periods of time allows more gluten to form in the food product.
What are the Gluten-Free Grains?
- Buckwheat (i.e., used as Kasha)
- Gram Flour, derived from chickpeas, also is gluten-free (this is not the same as Graham flour made from wheat).
- Montina (Indian Rice Grass)
- Oats: a protein naturally found in oats (avenin) possessed peptide sequences closely resembling wheat gluten and caused mucosal inflammation in significant numbers of celiac disease sufferers. Some examination results show that even oats that are not contaminated with wheat particles are nonetheless dangerous, while not very harmful to the majority.
- Rice: sushi rice usually contains vinegar that is derived from gluten grains; flavored rice may also contain gluten). Ask for plain rice instead, brown rice, polished or white rice, basmati and exotic black rice.
- Hidden Sources of Gluten: Candy, sauces, malt flavoring, processed foods.
Root Vegetables and other gluten substitutes for cooking and for creating gluten-free flour mix include:
- Arrowroot *
- Potato starch*
- Potato flour*
- Tapioca (starch extracted from the cassava root plant)*
- Rice flour
- Using these gluten free foods with food like: beans, chestnuts, mesquite, potato, soy, tapioca makes for improved taste for cooking efforts.
- All fruits, vegetables, meats, beans, nuts and seeds are gluten free in their unprocessed forms.
Gluten Gluten Substitutes
1 cup of wheat, spelt, kamut and rye 1 cup gluten flours equivalent to 7/8th cup gluten-free flour + 2 tablespoons tapioca flour + 1/4th teaspoon xanthan gum
Flour as a thickener You can use equal amount arrowroot powder
Oats Certified gluten-free oats. However, highly sensitive individuals may react even to this product due to its avenin protein component (similar structure to gluten)
Tortillas Corn or brown rice tortillas
Soy Sauce Use wheat-free tamari sauce
Gluten Free Cooking Tips
- If you need to coat a food then it is easy to use just a single gluten free grain or flour.
- For baking, you will get a far better result when combining a few different gluten-free flours. Corn or potato starch is great for creating sauces and gravies.
- Start with a gluten-free flour mix that your recipe allows a one-for-one for wheat flour. Gluten-free mixes are available in stores or on-line or you can make one yourself.
- Since gluten-free flours made into breads and rolls do not hold their shapes well, use loaf and Bundt pans and muffin tins for rolls.
- To thicken or create a more sticky effect when using non-gluten flours you could add guar gum or xantham gum; not much of these products are needed perhaps 1/8th or 1/4th teaspoon per cup of non-gluten flour used. Some commercially available gluten-free mixes already have these thickeners added.
- Gluten is very high in protein so it might be best when using non-gluten flours to substitute with a protein such as egg whites into baking recipes.
Gluten Free Shopping Tips
Labeling laws do not require the manufacturer of a product to list all gluten containing ingredients except wheat. Gluten grain derivatives of wheat are not required to be listed. The use of gluten-free on the label is the most reliable indication that the product has no gluten added. The US Food Allergen Labeling and Consumer Protection Act mandates that foods manufactured after January 2006 list the word “wheat” to indicate its presence, but makes no mention of other grains that contain wheat. Safe foods are: all fruits, vegetables, nuts, fish, poultry – in their unprocessed form. Processing might involve using flowers are thickeners, batters and fillers. Gluten flours to avoid that contain gluten:
- All-purpose flour
- Bulgar flour
- Bread flour
- Cake flour
- Durham flour
- Granary flour
- Graham flour
- Kamut flour
- Plain flour
- Sauce flour
- Self-rising flour
- Semolina flour
- Spelt flour
- Tricale flour
- Wheaten corn flour
- Wholemeal flour
Avoiding Cross-Contamination Of Gluten And Non-Gluten Foods
- Consider separate utensils and baking sifters
- Separate cooking supplies including pans, etc.
- Do not cook gluten products prior to cooking non-cooking products
- Wash kitchen surfaces thoroughly
- Do not use the same toaster oven for gluten and gluten-free cooking
- Do not deep-fry gluten and non-gluten foods in the same oils. This is a big issue in restaurants.
- Sharing gluten and non-gluten foods in the same household can be troublesome lending to cross-contamination
- Using gluten free flours in the same kitchen as non-gluten items can be an issue. Gluten powder released into the air can remain airborne for hours finding its way onto non-gluten foods.
- Commercial oats are considered cross-contaminated with gluten because they are either harvested next to wheat and/or they are processed using the same equipment, transport containers, grain elevators and even are milled with, gluten products. Thankfully, Oat free gluten is available.
Gluten and Laboratory Testing
Unfortunately, lab testing for gluten sensitivity is far from perfect. For my patients I take a simple approach: if you feel better when you remove gluten from your diet, and worse when it is added back in, you should avoid gluten. Depending upon the individual, some amount of gluten may not cause problems, but this is something that each person must determine for themselves. I suggest the use of a food and symptom log to keep tract of potential responses from gluten and a log helps to figure out if gluten is the real cause and not something else in the diet or environment.
Having said this about testing inaccuracies and maintaining a gluten/food log, testing may be useful for some people particularly if they have Celiac Disease (testing is far more accurate than non-gluten celiac intolerance or gluten allergy or intolerance. Testing may be very useful, in the context with my detailed metabolic symptom-body system questionnaires, for determining how various body systems are being affected by gluten. Tests for absorption, nutritional balance, immunity and body composition, just to name a few, can be invaluable when used in context for designing a health and recovery program from years of nutritional and immune problems stemming from gluten exposure. Merely focusing on the “leaky gut” is a mistake! Each person with a gluten issue has entirely varied nutritional needs and healing approaches. As far as testing is concerned, below I have outlined just some of the essential testing considerations for those who have Celiac Disease and those with some form of gluten sensitivity;
Blood Detective Fundamental Lab Considerations
- HLA-DQ2 and HLA DQ-8 – genetic tests for Celiac Disease and many other health conditions that share the same genes
- A procedure where the gastroenterologist uses a long tube with a camera at the end and the ability to take biopsy samples. This is considered the “gold standard
Celiac Blood Panel:
- AGA (antigliadin antibodies)-IgA
- tTG (anti-tissue transglutaminase)-IgA
- EMA (anti-endomysial antibodies)-IgA
- Total serum IgA
Gluten Sensitivity & Allergy Testing
- Gliadin IgG
- Gliadin IgA
- Gliadin IgE
Gluten Malabsorption Nutritional Tests
Vitamins B1, B2, B3, B6, B12, folic acid, vitamin C, Vitamin D3, absorption/malabsorption tests, etc.
Additional Testing Considerations
Other blood tests and non-blood evaluations, such as a body composition test, are always necessary to measure, and manage, a healthy body percentage of muscle, water and fat and metabolic rate. It is important to realize that that the gluten tests described herein are basic only and comprehensive evaluations should be based upon many other considerations when dealing with individuals. All other evaluations, and the overall approach to recovery from a gluten problem, must be based upon other health issues, health goals and other considerations. In my experience, the elimination of gluten almost never entirely manages the quality of life issues of my patients. Diligent investigations can lead the way for recovery and the potential for living an energetic, happy, gluten-free life!
THIS IS ADDITIONAL MATERIAL THAT YOU MIGHT WANT TO CONSIDER (BELOW)
More Questions Answered by
Dr. Michael Wald, The Blood Detective, about Gluten
Q: You are called "The Blood Detective" why is that?
“People call me the blood detective. It all started when a grateful patient said to me, “Dr. Wald, you’re like a real life blood detective” (after Dr. Wald diagnosed her illness after years of suffering), and the name stuck. Sadly, each day in my practice I uncover health issues missed by many different types of doctors. I attribute this to not enough time paid during consultation with the patient and limited laboratory tests (often limited by medical specialty). I perform testing often, on a single patient, that may span more than 6 medical specialties; this allows me to build a “metabolic map” of my patients and appreciate health issues that are simple missed when doctors “divide up” organ systems by medical specialty. Q: Celiac disease has seemed to be on the rise in the U.S. Can you briefly explain what gluten is and why we have seen a rise in gluten intolerances?
Radio Show Interview with Dr. Michael Wald about gluten: “People call me the blood detective. It all started when a grateful patient said to me, “Dr. Wald, you’re like a real life blood detective” (after Dr. Wald diagnosed her illness after years of suffering), and the name stuck.
Gluten is an insoluble protein found in grains such as barley, rye, oats, triticale and wheat. Rice and corn have a different kind of gluten and only need to be avoided if a person is found to be specifically allergic to them (see allergy testing below). In wheat flower, gluten acts to bind the mixture together when added to water. Gluten traps air bubbles created by a leavening agent allowing the bread to rise. Gluten-free flowers or flowers with little gluten do not trap bubbles and will either not rise or rise well – they are generally heavy, soggy and flat.
Why should you care about gluten?
It has been determined that gluten can cause a wide-variety of symptoms and diseases. Many of these symptoms and disease states go unidentified by most medical specialists. The health care providers of Integrated Medicine & Nutrition, P.C. believe that gluten intolerance is often missed as it can appear as vague symptoms and specific disease states. Extensive testing has been performed on hundreds of patients that have demonstrated that the prevalence of gluten intolerance is far greater than previously suspected. In fact, our clinical suspicions have been studied and confirmed by other researchers and scientists. This paper includes many references to the scientific literature supporting our major assertion; namely, that the protein gluten can trigger the immune system to initiate an inflammatory-autoimmune (self-directed) reaction that can cause cellular and tissue destruction of virtually any tissue of the body. Most importantly, the autoimmune destruction can go unrecognized as caused by gluten intolerance by most medical professionals. The main reason for the lack of recognition of gluten as the cause of destructive immune reactions against one’s tissues is because the symptoms produced look like the characteristic disease that has been diagnosed. For example, a sub-type of multiple sclerosis, some seizures and even cerebella ataxia can all be caused initially by an adverse autoimmune reaction provoked by gluten. The immune system, in its attempt to deal with the undesirable protein (namely gluten) inadvertently causes destruction of tissues; in the three examples given above the tissues include the white matter of the central nervous system (multiple sclerosis), neurologic and neurotransmitters of the brain (seizures) and the cerebellum (hindbrain). Allopathic physicians are divided among various medical specialties, some of which are outlined below. The medical profession has traditionally chosen to compartmentalize (separate) the enormous amount of educational materials that is available regarding health and disease into the various branches of medicine. There is little doubt that expert knowledge in a particular area of medical study is necessary on many occasions. This approach also has inherent limitations often preventing a given medical specialist from appreciating the large number of disease states and symptoms that can be caused by a single trigger (i.e. gluten).
Why a rise in gluten intolerance?
It is my belief that the exponential rise in gluten intolerance is a matter of evolution. Human beings evolved on earth for approximately 250 million years. Agricultural process of wheat has only existed for approximately 10.000 years. Humans adapt to their environment if given enough times. Those humans that could not during the course of our evolutionary development died off. Ultimately, our genetic prowess today is the end product of millions of years of adaptation to our environment. Wheat, and the gluten that it exposes us to, has simply not been in the human diet long enough for our natural development to adapt to it. The result of wheat’s (gluten) recent introduction into the human diet, many people (maybe most) will suffer severe and or subtle and often hidden health problems as a result of gluten consumption. In short, human beings have been consuming wheat (gluten) for the “blink of an evolutional eye” in the context of our human development. The holistic perspective to true health care (as opposed to disease care), has uncovered many more people who have previously remained undiagnosed for years who were in fact suffering from outright Celiac Disease or the more common – non-celiac gluten intolerance. Lastly, gluten is like becoming a bigger problem over time because, as allergists are aware of, gluten in its many forms in specific food products, insights immune reactivity, illness and disease because it is ubiquitious in our food chain. Said another way, wheat (gluten) is in the majority of our foods and it’s constant consumption, and early (too early in terms of age and evolution) introduction into our diets causes greater and greater intolerance with their corresponding health consequences. Q: Many celebrities have come out with books, shops and such trying to spread the word on this disease. Is it becoming a serious issue or is it more of a health trend — with people jumping on board to seem like they are eating healthy?
People might be “jumping on board” but for good reason…whether they realize it or not. The gluten problem is nothing new at all. The holistic segment of health care providers have been at the forefront of diagnosing and spreading awareness of gluten intolerance in the face of the failure of gastroenterologists to recognized gluten intolerance when digestive symptoms (i.e., diarrhea) is not present. Many dozens of health issues and diseases are known to be aggravated or caused by gluten consumption. Q: Should people without intolerance eati gluten-free foods? Does it matter? There is:
- gluten intolerance – a person may have no symptoms in their intestinal tracts but suffer from other symptoms of intolerance that disappear when they stop eating gluten products. This is curable
- gluten allergy: this involves the specific stimulation of what is known as type I hypersensitiy (allergy) reactions called IgE. Symptoms are produced immediately or within 3 days of gluten consumption and can involve any system of the body whatsoever. This is curable
- Celiac Disease – This is an incurable form of gluten intolerance that can only be resolved with complete, or nearly complete, gluten elimination from the diet including, but not limited to, barley, rye, oats, wheat and spelt. Fifty percent of the time the only symptom is diarrhea, but 50% of the time symptoms can be anything and are extra-intestinal (i.e, headaches, skin condition called dermatitis herpetiformis, autoimmune disease, osteoporosis, infertility, migraines and many more). Q: How do you know if you really have an actual intolerance or just a certain food doesn't settle well? If you remove gluten and you feel better, or your health problems resolve, then you have an intolerance. The diagnosis of Celiac Disease is accepted only when small intestinal biopsy demonstrates a loss of intestinal absorption cells known as villi. Lab tests include: transglutaminase, reticulin and gliadin antibodies.
Q: When should you see a doctor or just avoid gluten products on your own?
Most internists, family practitioners and gastroenterologists are ill-equipped to both recognize or advise long-term health building strategies except in the case of obvious celiac disease. Celiac disease diagnosis however is commonly delayed, due to lack of clinical suspicion on the part of the doctor, who does not connect the diet with diarrhea or diet with other extra-intestinal symptoms. GI doctors will often make the diagnosis of Celiac Disease with diarrhea, but without this symptom, my 23 years of clinical experience shows a failure to diagnose celiac disease. The other forms of gluten intolerance and allergy are almost never considered, or taken seriously, by mainstream GI docs, family practitioners and internists.