asta, bread, cereal and cake are all delicious foods that appear regularly in our diets to provide energy, fiber, whole grains and serve as the occasional treat, but for some genetically susceptible individuals a single bite of these foods can cause abdominal pain and intestinal damage.

Many people have never heard of the chronic autoimmune intestinal disorder called celiac disease. People with celiac disease cannot tolerate any amount of gluten, the protein that is found in wheat, rye, barley and some oats. For these sensitive individuals, eating gluten damages the small intestine so that, over time, nutrients such as protein, fat, carbohydrates, vitamins and minerals are not able to be absorbed, leading to nutritional deficiencies and malnutrition. Approximately 1% of Americans have celiac disease, but only a small fraction of that population has actually been diagnosed with the disease.

The disease is genetic and often runs in families. Unfortunately, most people who have celiac disease don’t know it and it takes an average of ten years before most people are properly diagnosed with it, often because many of the symptoms of the disease are similar to those of other intestinal disorders and the symptoms can be extremely varied from person to person. Some people may have just one symptom, such as iron deficiency anemia, or even have no symptoms at all. However, the most common symptoms of celiac disease include:

Abdominal cramping, bloating, pain and gas
Chronic diarrhea, constipation or both
Nausea and vomiting
Lactose intolerance
Acid reflux (heartburn)
Unexplained anemia (iron, folate or vitamin B12)
Vitamin or mineral deficiencies
Easy bruising
Fatigue
Weight loss or weight gain
Canker sores
Bone or joint pain
Infertility
Depression
Migraines

In children and infants, other symptoms include lack of adequate growth, failure to thrive, vomiting, dental enamel abnormalities, irritability and behavioral changes. To further complicate diagnoses, the disease can appear at any stage of a person’s life, not just in infancy. It is often initially triggered by a major stressor, such as a viral or gastrointestinal infection, surgery, pregnancy, childbirth or severe emotional stress.

Once it is triggered, the body’s immune system will recognize gluten as a menace and respond to it by damaging the small intestine. Specifically, the villi, which are small, finger-like projections that line the walls of the intestine, will be flattened. The villi function to increase the absorptive surface area so that the maximum amount of nutrients can be absorbed from food. When villi are flattened, they cannot absorb nutrients --such as iron, calcium and folic acid in the first part of the gastrointestinal (GI) tract and protein, fat, certain vitamins and carbohydrates further down the GI tract – to their full potential, which can lead to nutrient deficiencies and malnutrition.

The long-term consequences of untreated celiac disease are osteoporosis, osteopenia, certain cancers of the digestive system, central nervous system disorders, peripheral nerve damage, pancreatic insufficiency and permanent damage to the small intestine. That is why it is crucial to have a proper diagnosis from a gastroenterologist so that if the illness is celiac disease, proper treatment can commence right away. There is evidence that a portion of the autistic population also has celiac disease, and those with other autoimmune disorders such as lupus, thyroid disease, dermatitis herpetiformis, type 1 diabetes and liver diseases may also have gluten intolerance, so the treatment for celiac disease may also be of benefit to people with these associated conditions.

Unfortunately, there is only one treatment for celiac disease: a gluten-free diet. Anyone with gluten intolerance must avoid the gluten found in wheat, rye and barley for the rest of their lives. These grains are commonly found in bread, crackers, pasta, cookies, snack foods and beer. They are also usually hidden in deli meats, soy sauce, soups, and even candies. Following a gluten-free diet gets easier every year as more and more food manufacturers create gluten-free products and new labeling laws require that potential allergens such as wheat (but not rye or barley) appear in bold on the ingredient lists of packaged foods. However, a trip to the market can still be a scavenger hunt and eating in restaurants can always be risky, since even a trace amount of gluten left on a spoon can contaminate a whole meal. For all of these reasons, someone who is newly diagnosed with the disease should work with a registered dietitian to help them learn how to identify both offending foods and safe foods both when shopping at the market and when eating in restaurants.

Most people’s symptoms will improve within days of starting a gluten-free diet and the damaged villi in the small intestines will usually be repaired within three to 24 months. Because healing occurs so rapidly, is important that a gluten-free diet is not started before a firm diagnosis has been made, since the diet can interfere with an accurate diagnosis. Furthermore, the diet is difficult to follow, so nobody who doesn’t absolutely need to be on it will want to go to the trouble of adhering to it strictly and those who are undiagnosed may not be as motivated to stay on a strict gluten-free diet if the need for it has never been confirmed.

A gluten–free diet requires an enormous lifestyle change. A person with gluten intolerance must become a food detective, examining food ingredient lists, interrogating those who prepare their food in restaurants and at people’s homes and making sure that no cross-contamination occurs in their own kitchen if other family members eat foods that contain gluten. At times, it may feel like there is nothing that is safe to eat. The good news is that a gluten-free diet can still be a healthy, well-balanced diet. Fruit, vegetables, fish, beans, legumes, nuts, poultry, meat, eggs, milk and certain grains are all naturally free of gluten. Potatoes, corn, peas, winter squash and sweet potatoes are starchy vegetables that can stand in for other starches in the diet, and grains such as rice, wild rice, quinoa, cornmeal (polenta), amaranth, buckwheat and uncontaminated oats can replace the forbidden grains. Although up to 50 grams a day of oats are acceptable on a gluten-free diet, they often become cross-contaminated with wheat, barley or rye during harvesting or processing. Some companies, such as The Silver Palate, McCann’s and Bob’s Red Mill, take extra measures to avoid contaminating their oats. Processed foods are the most difficult to deal with, since gluten can sneak into them in some unexpected ingredients, such as brown rice syrup, and trace amounts of gluten can be picked up in the manufacturing process if the factory also processes foods that contain wheat, rye or barley.

The following is a listing of grains and starches that are allowed on a gluten-free diet. These basic foods can be made into flours, cereals, pastas, chips, bread, baked goods, thickeners, binders and fillers.

Foods Allowed: Amaranth Arrowroot Beans (including soy) Buckwheat Cassava Corn Job’s Tears Legumes Millet Montina (Indian rice grass) Nuts Oats* Potato Quinoa Rice Seeds Sorghum Sweet Potato Tapioca Taro Teff Wild Rice Yucca *only uncontaminated oats from certain manufacturers

The following is a listing of grains and starches that are not allowed on a gluten-free diet. These foods can be hidden in processed foods as flour, binders, fillers, starch, stabilizers, thickeners, preservatives and texture enhancers.

Foods Not Allowed: Barley Barley Flour Barley Malt Beer Ale Lager Rye Triticale Wheat Atta Bulgur Durum Graham Einkorn Emmer Farina Faro Kamut Seitan Semolina Spelt Triticale Wheat bran Wheat Starch Wheat Germ Wheat Four Hydrolyzed Wheat Protein Enriched flour Other Commercial oats and oat products Unidentified flour Unidentified starch Textured Vegetable Protein Brewer’s Yeast Malt Certain pharmaceutical products

A gluten-free diet requires that all processed foods become suspect; even if you have bought them before. Manufacturers sometimes change ingredients, so a food that was gluten-free this week might not be so next week. All food labels must be scrutinized. As with any healthy diet, though, minimally processed, whole foods should make up the majority of what is eaten. Processed foods should only be a small part of an overall diet. I understand that they are not unavoidable, though, so I have compiled a Gluten-Free Shopping List that is available to our customers who need to follow a gluten-free diet. The list makes no guarantees that a product will be gluten free, but it is a great starting point for those who need guidance in choosing gluten-free foods. If you would like more information about gluten-free diets, contact the Celiac Disease Foundation (www.celiac.org) or use the book Gluten-Free Diet by Shelley Case. Of course, you can always contact me, as well, at 1-800-GELSONS.