• Centers and Departments
• Back to Digestive Disease Center
• Celiac Center
• CeliacNow
• Research at the Celiac Center
• Resources
• FAQ
  • Associated Conditions
  • Diagnosis and Testing of Celiac Disease
  • General FAQ
  • Gluten and the Gluten Free Diet
  • Probiotics Reference Guide
• Our Celiac Center Team
• View Our Glossary

Gluten and the Gluten Free Diet

What is gluten/gluten-free?
What is the difference between gluten and gliadin?
Can I cheat on my gluten-free diet?
What are the consequences of not following a strict gluten-free diet?
I suspect I have celiac disease. Should I start on a gluten-free diet?
I've been on a gluten-free diet for a while and I don't feel better. Why?
What are the nutritional consequences of celiac disease?
Besides avoiding gluten, are there other changes I should make in my diet?
Which grains are safe for me to eat? Which are not?
Can I eat oats?
Which alcoholic beverages are safe for me to drink?
Can I take communion at church?
What are the basics of gluten-free grocery shopping?
How should I choose a gluten-free supplement?
What is the best way to take a multivitamin or a multivitamin with iron?
Should I take a separate iron supplement?
Should I take a calcium and vitamin D supplement?
Which companies make gluten-free supplements?
Are my medications gluten-free?
What are my options if my medicine contains gluten?

What is gluten/gluten-free?

Gluten is a protein found in wheat, barley, rye, spelt, and triticale. While oats themselves do not contain gluten, they are often processed in the same place as wheat and become contaminated. The term "gluten-free" does not have a strict definition in the United States. In parts of Europe, it means that there is less than 200 parts per million of gluten in a food product. In the US, there may also be some contamination of gluten in foods that are labeled "gluten-free". As of October 2009, the proposed but not approved definition of "gluten free" is <20ppm.

What is the difference between gluten and gliadin?

Gluten is the generic term for the storage protein found in grains. Gluten is what gives dough its elasticity, and allows bread to be leavened. Gliadin is the specific name of the protein found in wheat, and is a type of gluten. Different grains have different names for their specific glutens, but the general term gluten is most commonly used.

Can I cheat on my gluten-free diet?

Unfortunately, the answer to this question is no. Even when you are sticking to a gluten-free diet, it is impossible to eat gluten-free 100% of the time. This is because there is always some level of contamination of foods, whether it is when the food is processed, when dining out, or in your own kitchen at home. Intentional or unintentional ingestion of gluten will prevent your villi from healing well. Therefore, it is very important to follow the gluten-free diet as carefully as you can to benefit from it.

What are the consequences of not following a strict gluten-free diet?

There are serious consequences of not following a gluten-free diet when advised to do so by your physician. There will be continued changes in the lining of your intestines. These changes will lead to decreased absorption of nutrients, possibly leading to other conditions such as osteoporosis and anemia. You will also be at increased risk for gastrointestinal cancers, as well as non-Hodgkin's lymphoma.

I suspect I have celiac disease. Should I start on a gluten-free diet?

No, not immediately. If you are extremely ill and your primary care physician agrees that your symptoms may be due to celiac disease, it is reasonable to begin a gluten-free diet immediately, while waiting for the appropriate blood tests to return. Otherwise starting a gluten-free diet without first confirming the diagnosis of celiac disease using blood tests and endoscopy with biopsy of the small intestine is not recommended. The reason is that celiac disease is a lifelong illness, not only necessitating keeping a gluten-free diet indefinitely, but also involving multiple parts of the body. A number of other tests including nutritional status and bone density scan (DEXA) may need to be performed. If testing is done after a gluten-free diet is initiated, blood tests and biopsies may appear normal, and your doctor will be unable to accurately diagnose celiac disease.

I've been on a gluten-free diet for a while and I don't feel better. Why?

Most commonly, the reason why you don't feel better is because you have not completely eradicated gluten from your diet. Once a hidden source of gluten is removed from the diet, patients often start to feel better. Other reasons for experiencing symptoms while on a gluten-free diet may because you have another condition, such as irritable bowel syndrome (IBS), refractory celiac disease, lactose intolerance, small intestine bacterial overgrowth, or microscopic colitis.1 You should consult with your gastroenterologist if you are continuing to experience symptoms while on the gluten-free diet.

If you began to feel well on the gluten-free diet, and then your symptoms returned, it is important that you contact your gastroenterologist, as this may be a sign of a more serious medical condition.

What are the nutritional consequences of celiac disease?

There can be a number of vitamin and mineral deficiencies associated with celiac disease such as:

You should check with your doctor or dietitian about which vitamins and minerals to supplement. Some vitamin supplements are made with gluten-containing ingredients such as wheat starch, so it is important that you purchase a vitamin supplement that is gluten-free. The vitamins and minerals themselves do not inherently contain gluten, but gluten is sometimes used as a filler or coating in the supplement.

Some people find that vitamin and mineral supplements cause abdominal discomfort. If this is the case, be sure to take your supplement with a meal, as this helps prevent discomfort. Supplements are also available in liquid, powder, or chewable form for those who cannot tolerate the capsule or pill form.

Besides avoiding gluten, are there other changes I should make in my diet?

Yes. Many patients may need to initially avoid lactose-containing foods, such as milk, cheese, and other dairy products if they are having gastrointestinal symptoms such as diarrhea, bloating, cramping or gas. This is because lactase, the enzyme that digests the lactose sugar found in dairy products, is made on the tips of the villi in the intestine. Celiac disease destroys these villi, also destroying the lactase enzyme. As the villi heal, lactose tolerance usually returns. Once a patient follows the gluten-free diet for a few months, s/he may try reintroducing dairy products back into the diet, as long as they are tolerated.

Gluten-free soy, rice, and nut milks, yogurts, and cheeses are good substitutions if lactose must be avoided.

You should also avoid any other foods to which you are allergic or sensitive.

It is also important that your gluten-free diet is heart healthy. Your diet should be low in fat and sodium, high in fruits and vegetables, and include lean proteins, such as chicken, fish, a limited amount of lean meat, beans and legumes. Additionally, you should be sure to incorporate gluten-free whole grains into your diet, such as amaranth, millet, and quinoa. Most importantly, you should consult with a dietitian in order to be sure that your new diet contains appropriate amounts of vitamins and nutrients, specifically iron, calcium, vitamin D, and B vitamins.

Which grains are safe for me to eat? Which are not?

Wheat, barley, rye, triticale, kamut, and spelt all contain gluten, and should be avoided. Rice, corn, millet, amaranth, quinoa, sorghum, potato, buckwheat, and teff are all safe choices. Oats are a specific issue discussed separately.

Can I eat oats?

Based on numerous studies conducted with adults and children in Europe and the United States, it appears that the majority of individuals with CD can tolerate oats. Oats, however, are often grown or processed with other cereals leading to cross-contamination with wheat, barley or rye.

Currently, there are a growing number of producers of pure gluten-free oats in North America. The Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommends that interested individuals discuss the gradual introduction of specially produced labeled gluten-free oats into their diet with their dietitian or doctor before starting. Adequate water, when adding oats, is recommended, as is contacting the doctor or dietitian if any gastrointestinal symptoms occur.

Although oats appear to be safe in the vast majority of individuals with celiac disease, there is evidence that, in some individuals, the protein in oats (avenin) can trigger an immune response similar to gluten. In addition, some people may need to avoid oats due to sensitivities or allergies, similar to other foods, such as nuts or shellfish. For these reasons, close monitoring by a healthcare professional experienced in celiac disease is recommended during introduction of oats into a gluten-free diet.

Currently, avoiding consumption of oats is recommended by the clinicians of the Celiac Center at BIDMC for newly diagnosed patients until it can be clearly demonstrated that celiac disease is well-controlled. Good control is demonstrated by the complete resolution of symptoms (diarrhea, other symptoms of malabsorption or DH skin rash) and a normal or nearly normal tissue transglutaminase level (IgA tTG). At that point, under physician guidance, the gradual addition of pure oats up to 50 grams/day (a little more than 1/2 cup rolled oats or ¼ cup steel oats) from a dedicated gluten-free facility may be attempted. Follow-up with the patient's gastroenterologist should occur three to six months after the addition of oats into the gluten-free diet.

Gluten-free oats are a tasty and excellent source of dietary fiber. We remain optimistic that uncontaminated sources of oats will continue to be available and affordable in this country and can be a safe and useful addition to the gluten-free diet.

Which alcoholic beverages are safe for me to drink?

Most distilled alcoholic beverages are safe for patients with celiac disease to drink. Wine and distilled liquors to which no additional flavoring has been added are safe. Beer, ale, lager, and other malt beverages are not safe, and should be avoided, since they are made from wheat or barley and contain gluten. If you have a question about a specific beverage, consult with your dietician or call the manufacturer.

Can I take communion at church?

Through the beliefs of the Roman Catholic Church, the communion host must be made from wheat flour. This tradition stems from the story in the Catholic Bible of the Last Supper that Jesus used wheat bread and commanded to his followers, "Do this in memory of me." The Roman Catholic Church believes that by allowing the consecration of only a communion host made of wheat, that they are able to continue their tradition of faith as commanded by Jesus in the Bible.8

Recently, the Congregation of Benedictine Sisters of Perpetual Adoration in Missouri developed a low-gluten host that may be suitable for patients with celiac disease. This host is made from wheat-starch, which has had almost all of the gluten removed from it. The end product has 0.01% gluten, which may be safe for celiac patients.9

The following is a highlight of the procedures set forth by the Roman Catholic Church that one must follow in order to be eligible to receive the low-gluten host:

1. Parishioner requests pastor to seek permission to use low-gluten hosts.
2. Pastor seeks permission from Archdiocese for use of low-gluten hosts. The pastor will fill out the permission form and send it to the Archdiocese with the name and address of the parishioner requesting permission.
3. When permission is granted, the parishioner and pastor will receive :
   1. A letter of permission
   2. Guidelines concerning liturgical issues
4. What to do when going to mass at a parish other than your home parish.
5. A certificate will be given to the parishioner that they may take to other parishes.
6. As soon as permission is received, the parishioner is free to use the low-gluten host.
7. If you have questions, you may contact the Office for Worship of the Archdiocese of Boston at (617) 746-5880.10

If you would like to order low-gluten communion wafers, you can contact the Benedictine Sisters by phone at (800) 223-2772 or by email at altarbreads@benedictinesisters.org. You can also visit their website at undefined http://www.benedictinesisters.org/english/site.php?use=low_gluten.

Gluten-free communion wafers are available through Ener-G Foods, Inc. These wafers do not contain wheat starch, and are therefore appropriate for those with celiac disease. You may contact them at 1-800-331-5222.

Individuals who receive communion in a church other than a Roman Catholic Church should contact their parish directly regarding this matter. You should assume that there is gluten in the host unless told otherwise by your pastor or parish.

What are the basics of gluten-free grocery shopping?

Gluten-free shopping doesn't have to be difficult. By following some basic steps, you will become more familiar with products that are gluten-free.

• Look for fresh or frozen produce. Fruits and vegetables (without additives) are naturally gluten-free, and you can eat as many of these as you'd like.
• Plain meat, poultry, and fish are also gluten-free. To keep with a healthy diet, try to consume lean proteins, and limit red meat consumption.
• Legumes, such as chickpeas, lentils, and kidney beans, are excellent sources of protein and fiber. Many people find that they do not include enough fiber in their gluten-free diet, and legumes are an excellent way to add more fiber.
• Low-fat dairy products, if well tolerated, are an excellent source of calcium and vitamin D in the diet. If you cannot tolerate dairy products, substitute gluten-free soy, rice, or nut milk that is fortified with calcium and vitamin D.
• Gluten-free whole grains are an excellent way to add fiber and other vitamins and nutrients into your diet. Try to eat grains like amaranth, millet, and quinoa, which are high in complex carbohydrates, iron, calcium, B vitamins, and minerals. You may also eat starches such as corn, potato, and white rice, but they are high in refined carbohydrates, and should be used minimally.
• Look for products that are labeled "fortified". These products have more vitamins and minerals, and are an important part of the gluten-free diet.
• Look for products labeled "gluten-free". You may find these more easily at natural and organic markets, where they often have gluten-free foods displayed prominently.
• Learn to read the ingredients on all processed foods very carefully, avoiding products with wheat, barley, rye, triticale, spelt, and oats.
• Avoid foods that use wheat, barley, rye, or other gluten-containing grains in their processing.
• Most importantly, consult with a dietician who specializes in celiac disease. A skilled dietician will not only monitor your diet, but will also help you to identify hidden sources of gluten, and give you new ideas and recipes.

How should I choose a gluten-free supplement?

Choose a GLUTEN-FREE multivitamin with minerals, such as magnesium and zinc, which provides no more than 100% of the recommended daily allowance for each nutrient. The percentages of each nutrient are listed on the label. Check the label for "gluten free" or call the manufacturer to determine the status of each supplement you would like to take.

What is the best way to take a multivitamin or a multivitamin with iron?

Read the label for instructions on when to take your multivitamin. Most multivitamins are best absorbed when taken with meals. Do not take your multivitamin with iron at the same time as you take your calcium supplement, since the two minerals compete for absorption.

Should I take a separate iron supplement?

Only take iron supplements as prescribed by your doctor and have your iron levels monitored. If you are recommended to take an iron supplement by your doctor or dietician, please keep the following in mind:

• Do not take your iron supplement at the same time as your calcium, your multivitamin, or other medications.
• Distribute the dose over 2-3 doses throughout the day to enhance your absorption.
• Take your iron supplement with food to avoid stomach upset.
• Caution: DO NOT take an iron supplement if you have or develop acute hepatitis, a condition involving excess iron in the body, hemolytic anemia, or if you've had repeated blood transfusions. See your doctor before taking iron if you've had or develop peptic ulcer disease, enteritis, colitis, pancreatitis, hepatitis, kidney disease, intestinal disease, alcoholism, excess vitamin C, or if you plan to become pregnant or are breastfeeding, or if you are over 55 years old and have a family history of heart disease.
• Most common side effects: people who take iron supplements may experience constipation or dark stools. Talk to your doctor if you experience any other side effects

Should I take a calcium and vitamin D supplement?

Calcium is required for the proper functioning of a number of systems throughout the body. Calcium is normally absorbed from foods through the small intestine. When individuals are diagnosed with celiac disease, this portion of the small intestine has been damaged and cannot adequately absorb calcium and many other vitamins and minerals. In order to keep the body functioning normally, calcium is released from bone into the blood stream, and is delivered to other parts of the body that need it. This process, in turn, can lead to osteopenia or osteoporosis: porous, fragile bones that are prone to breaking.

The problem of calcium malabsorption is also related to malabsorption of vitamin D and magnesium. Both of these are needed to absorb calcium from food. If vitamin D and magnesium are also not being absorbed from the intestine because of intestinal damage, calcium will not be absorbed either.

If you have celiac disease and osteoporosis or osteopenia, it is not only necessary that you eat a diet rich in calcium, but that you also take calcium and vitamin D supplements. Men and women require different amounts of these supplements, so it is important that you speak with your doctor or dietician to find the correct dosage. Do not take calcium and iron together as they compete for absorption.

Which companies make gluten-free supplements?

Contact one of the companies listed below for gluten-free supplements. Be sure to ask for gluten-free supplements when you call, as some of these companies make gluten-containing products as well. If you are already taking a supplement, read the label carefully. Some of the most common gluten-containing ingredients in a supplement are unidentified starches. Always call the product research department to assure that your supplement is gluten-free.

Freeda's Vitamins: 800-777-3737
Great Earth: 800-284-8243
Nature's Bounty: 800-433-2990
Solgar: 877-SOLGAR-4
Wyeth (makers of Centrum): 877-CENTRUM
Kirkman Labs: 800-245-8282
Pioneer Vitamins: 800-458-8483

Are my medications gluten-free?

Some medications have gluten-containing fillers or coatings. To find out if your medications contain gluten, visit www.glutenfreedrugs.com. This website gives helpful information regarding how to identify gluten in your medications, as well as a list of gluten-free drugs. If you are still concerned, call your medication's manufacturer and ask if your medication is gluten-free. It is best to check directly with the manufacturer and website listings may not reflect the most current status of a drug

What are my options if my medicine contains gluten?

You can ask your doctor if there is a reasonable substitute for your medication that does not contain gluten. You can also order your medication or supplement from a compounding pharmacy.

References

1. Leffler DA, Dennis M, Hyett B, Kelly E, Schuppan D, Kelly CP. Etiologies and predictors of diagnosis in nonresponsive celiac disease. Clin Gastroenterology Hepatology. 2007;5:445-450.
2. Storsrud S, Olsson M, Arvidsson Lenner R, Nilsson LA, Nilsson O, Kilander A. Adult coeliac patients do tolerate large amounts of oats. Eur J Clin Nutr. 2003 Jan;57(1):163-9.
3. Janatuinen EK, Pikkarainen PH, Kemppainen TA, et al. A comparison of diets with and without oats in adults with celiac disease. N Engl J Med.1995;333:1033-1037.
4. Hogberg L, Laurin P, Flath-Magnusson K, et al. Oats to children with newly diagnosed coeliac disease: a randomized double blind study. Gut 2004; 53:649-654
5. Janatuinen EK, Pikkarainen PH, Kemppainen TA, et al. Lack of cellular and humoral immunological responses to oats in adults with coeliac disease. Gut 2000;46:327-331
6. Peraaho M, Kaukinen K, Mustalahti K, Vuolteenaho N, Maki M, Laippala P, et al. Effect of an oats-containing gluten free diet on symptoms and quality of life in coeliac disease. A randomized study. Scand J Gastroenterol. 2004, Jan;39(1):27-31.
7. Arentz-Hansen H, Fleckenstein B, Molberg O, Scott H, Koning F, Jung G, Roepstorff P, Lundin KE, Sollid LM. The molecular basis for oat intolerance in patients with celiac disease. PLos Med. 2004 Oct;1(1):el. Epub 2004. Oct 19.
8. Archdiocese of Boston. Office for Worship and Spiritual Life. undefined http://www.rcab.org/OfficeForWorship/PastoralNotes/CeliacWorship.html. Accessed 19 June 2007.
9. Benedictine Sisters of Perpetual Adoration. undefined http://benedictinesisters.org/english/site.php?use=lowgluten. Accessed 19 June 2007.
10. 1Archdiocese of Boston. Office for Worship and Spiritual Life. undefined http://www.rcab.org/OfficeforWorship/Pastoral/Notes/Celiacworship/html. Accessed June 19, 2007.