THE GLUTEN-FREE DIET:
Management Strategies &
Should We All be Gluten-Free?
Janelle Smith, MS, RD
Celiac Disease Foundation
Registered Dietitian
Nutritionist
June 11, 2017
Today’s Presentation
• The gluten-free diet
• Cross-contact with gluten
• Continuing symptoms
• Who should eat gluten-free
What is gluten?
Proteins in:
• Wheat
• Barley (malt, malt extract, malt syrup, malt flavor,
brewer’s yeast)
• Rye
• (Triticale)
Step 1: Look for “Gluten-Free” Label
Which do you look for?
Gluten Free
Naturally
gluten-free
Step 1: Look for “Gluten-Free” Label
• Survey in 2015 found 98.9% products labeled GF were
compliant with FDA definition on random testing
(Sharma, Pereira & Williams, 2015)
• Foods do not need to be “certified” or have a
specific symbol. No significant difference found in
Thompson & Simpson, 2014 (95% met <20ppm, 85-87%
<5ppm)
• Still advisable to read ingredients label
Sharma G.M., Pereira M., Williams K.M., (2015). Gluten detection in foods availabe in
the United States - a market survey. Food Chemistry 169 (2015) 120-126.
Thomspon T., Simpon S. (2014). A comparison of gluten levels in labeled gluten-free and
certified gluten-free foods sold in the United States. European Journal of Clinical
Nutrition (2014), 1-4.
Step 2: Read Ingredients
Look for these most common ingredients - especially in products
NOT labeled GF:
o Wheat (must be declared in allergen label)
o Barley: Malt, malt extract, malt syrup, malt flavor
o Rye
o Brewer’s yeast
o Oats - if product is NOT labeled GF
What if these ingredients are in a product that IS labeled GF?
• If labeled GF it must still meet the <20 ppm gluten definition
made by the FDA, or it is mislabeled!
Commonly questioned ingredients
Maltodextrin - always GF. So highly refined that even if made from
wheat/barley (which it usually isn’t) the end product is GF
Yeast extract - typically gluten-free. SMALL chance that it comes from
brewer’s yeast. If worried, choose only in products labeled GF
Caramel color - always GF. Even if made from wheat, highly processed.
Natural flavoring - typically GF. SMALL chance it could contain malt
Modified food starch – typically GF unless product states “contains wheat”.
SMALL chance of wheat in USDA products or medications
Wheat starch modified to remove gluten - GF. Safely used in Europe in past
decade!
Distilled vinegar and alcohol - always GF. Distillation process removes all
proteins
Dextrin – usually GF. SMALL chance it could contain wheat in USDA
products or medications
Case, S. (2010). Gluten Free Diet: A Comprehensive Resource Guide. Case Nutrition
Consulting, Inc.
How much is too much?
⅛ teaspoon wheat flour contains enough
gluten to damage villi of most people with
celiac disease
Cross-Contact at Home
Separate these things at home:
• Toasters and toaster ovens
• Sifters, colanders
• Baking supplies with nooks and crannies
• Condiment jars
Okay to share other items that are washed thoroughly!
Cross-Contact when Dining Out
Request these things when dining out:
• Separate fryers, pasta water, woks, toasters,
steamers
• Clean or dedicated pots, pans, utensils
• Avoid areas of loose, airborne flour
Ask questions:
• Do you know what gluten is?
• How do you prevent cross-contact with gluten in your
kitchen?
Should we all go gluten-free?
Risks of gluten-free diet in people undiagnosed with
celiac disease:
• difficult to get accurate diagnosis without gluten in diet
• lower intake of certain nutrients: iron, folate, B12, zinc
• lower fiber intake and higher fat, sugar, refined
starches… may be associated with weight gain and/or
higher risk of type 2 diabetes
GLUTEN FREE ≠ HEALTHY
Should we all go gluten-free?
Possible benefits of gluten-free diet in people who do
not have celiac disease
• reducing FODMAPs - including wheat, barley, and rye - often
helpful in many conditions
o
o
o
o
irritable bowel syndrome
inflammatory bowel disease
endometriosis
functional bloating, diarrhea, constipation
• wheat-allergic people have more options
• non-celiac wheat or gluten sensitivity - resolve almost all the
same symptoms of celiac disease
What if I still don’t feel well?
Common causes of continued symptoms on GFD:
1. continued gluten intake
2. lactose and fructose intolerance
3. small intestinal bacterial overgrowth
4. pancreatic insufficiency
5. irritable bowel syndrome
6. inflammatory bowel diseases: Crohn’s, colitis
A very small fraction of the celiac population may need a “gluten
contamination elimination diet” to put celiac in remission (i.e.
those with non-responsive celiac disease)
Hollon J.R., Cureton P.A., Martin M.L., Leonard Puppa E.L., Fasano A. (2013). Trace gluten contamination may
play a role in mucosal and clinical recovery in a subgroup of diet-adherent non-responsive celiac disease
patients. BMC Gastroenterology 13:40 (e-pub).
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