You have celiac disease and, yes, that diagnosis comes with what may seem like an endless list of foods and drinks to avoid so your small intestine can repair and any gastrointestinal and other symptoms will disappear. And, yes, it’s also true that many gluten-free foods are not as nutritious as their enriched gluten-based counterparts. Oh, and let’s not forget that gluten-free foods are often pricier than their gluten-containing equivalents.
But wait, because here’s the good news. When Allergic Living set out in search of powerhouse gluten-free diet options that can and should be eaten for optimum health, the door flew open to a vast and wonderful range of delicious, affordable choices. The experts say that incorporating these foods into a daily diet doesn’t mean endless hours in the kitchen, or forking out huge sums on specialty groceries. All that’s needed is an open mind and some simple strategies.
And here’s another positive. For those with celiac disease, the advice from dietitians is primarily the same message being delivered to the entire population: ditch the carbohydrate-focused diet of empty calorie, pre-packaged, grain-based convenience foods in favor of fresh, whole foods that carry a serious nutritional punch. There are many ways this strategy can be tailored to the gluten-free regime.
“I advise patients to think positively about their approach to the gluten-free diet,” says Rachel Begun, a registered dietitian-nutritionist and expert in gluten-related disorders and food allergies from Boulder, Colorado. “For starters, being diagnosed with celiac disease is a good thing, because being diagnosed and starting a gluten-free diet is the start of their journey back to health.”
What’s Wrong With Gluten-Free Diets?
When someone with celiac disease eats gluten-containing foods, the immune system goes into defensive mode, inflaming the lining of the small intestine. With continued exposure, over time the immune system will damage and flatten the villi, the tiny hair-like projections that are vital to absorbing vitamins, minerals and other nutrients. As the Mayo Clinic notes, this can lead to deficiencies in iron, calcium, folate, zinc, vitamin B12, and vitamins D and K, especially before a celiac diagnosis and the adoption of a strict gluten-free diet.
Replacing those nutrients can be a problem, say dietitians, since many consumers’ gluten-free diets mimic today’s conventional American diet by being too dependent on prepared, carbohydrate-dense foods with an emphasis on breads, cereals, pastas, crackers, muffins, cakes, white rice and other simple grains that do not carry a significant vitamin, mineral or fiber punch.
There is an added negative twist with the gluten-free versions of these foods. In North America, “enriched white flour” must have added iron, folic acid and B vitamins, including riboflavin, niacin and thiamine. Pastas and cereals are also enriched with some nutrients, but gluten-free versions don’t fall under the same legislation. While some manufacturers have started enriching gluten-free packaged foods with vitamins and fiber, these aren’t always easy to find.
Dietitians say no miracle foods resolve celiac symptoms – and no single superfood recipe can guarantee all daily vitamin and mineral needs are met. The key, they say, is to focus on a whole diet of naturally gluten-free foods to heal the gut, which is when nutrition absorption improves and symptoms can begin to clear and health returns. Then the goal needs to be to carry on with that diet for optimal health.
“The irony of it all is that foods we recommend to the general population for a healthy diet are mostly naturally gluten-free fruits, vegetables, plant-based proteins (such as beans, nuts and seeds), lean cuts of meat and poultry, fish, and dairy,” says Begun. The big difference in the recommendations comes in the whole grains category, “and there are just as many gluten-free whole grains as there are gluten-containing ones,” she says.
Nancy Falini, a registered dietitian specializing in gluten-related disorders in West Chester, Pennsylvania, and author of Gluten-free Friends: An Activity Book for Kids, has worked with celiac clients since 1988. They respond best when she gets them focusing on the pages of foods they can eat as opposed to those they can’t have. “Since we are what we eat, and our moods are influenced by what we eat, it’s of the utmost importance that we place more value on the food choices we make,” she says.
Below are some basic rules for a powerhouse gluten-free diet from dietitians. And please take note: a registered dietitian or physician should be consulted to help manage specific needs, including food and cultural preferences, any vitamin or mineral deficiencies, and other food sensitivities or allergies.
Are Supplements Needed?
Deficiencies are quite common with celiac disease, but dietitians differ in approach. Some recommend supplements for almost all clients, while others focus on diet as a primary solution with supplements as a last resort. Iron, vitamin B12, vitamin D, and calcium were the most common deficiencies cited in interviews for this article, with iron being number one.
Shelley Case, a consulting dietitian and international celiac nutrition expert based in Regina, Canada, has advised celiac clients for two decades. The top deficiencies she sees are iron, calcium and vitamin D. Calcium absorption is affected by intestinal inflammation that goes with the disease, and that can cause bone density issues. She focuses on healthy foods whenever possible to manage deficiencies.
“Supplements provide a single nutrient, but not in the same balance as foods do,” says Case, who has celiac disease and is the author of the bestselling Gluten-Free: The Definitive Resource Guide.
Clients are often unaware of the complexity of vitamins and minerals. Take calcium for instance. There are two kinds — carbonate and calcium citrate — with citrate being the more easily absorbed. Carbonate needs to be taken with meals for maximum uptake and regardless of which form is being taken, the body can only absorb about 500 mg at a time. So that means if 1,000 mg is needed daily, it needs to be divided between two mealtimes, Case says.
Iron is equally complex. It’s important to be aware that the more easily absorbed heme iron is found in meats, fish and poultry. Non-heme iron, which is not absorbed as efficiently, is found in fruits and vegetables, including raisins, apricots, cooked spinach, brussels sprouts, blackstrap molasses, nuts, seeds, lentils and beans. Plus, non-heme iron foods should be consumed alongside vitamin C-rich foods to help improve absorption.
All the dietitians advise bumping up the vitamin and mineral content of every meal with fresh fruits and vegetables. To keep you satiated, they recommend that meals and snacks include some form of protein. Naturally gluten-free proteins include lean meats, poultry, fish, low-fat milk and yogurt, nuts, seeds and legumes (dried beans, peas, lentils). Swap out wheat with one of the many gluten-free grains available, such as amaranth, buckwheat (unrelated to wheat), millet, quinoa, sorghum, and teff (an Ethiopian grain), as well as flours made from grains, nuts and legumes.
Gluten-free grains are the seeds of plants and include corn, millet, uncontaminated oats, sorghum, teff, and rice (black, brown, red, and wild) – as well as the pseudo-grains of amaranth, buckwheat and quinoa. Whole grains have developed a stellar reputation because of the nutrients that remain in the grains since the bran and germ are not removed through a milling process. These complex whole grains are a great source of fiber and other important nutrients, including selenium, potassium and magnesium.
The overall message from dietitians is that gluten-free simple carbohydrates, like rice crackers, should be limited to special occasions, and that eve the whole grain versions should be given a power-boost with protein-rich nut butters or cheese spreads. And always look for the words iron and folic acid on the package’s nutrient list. Case also recommends buying brands that are enriched with thiamin, riboflavin and niacin, which will be shown in the ingredient list.
It’s a common misconception that all individuals with newly diagnosed celiac disease have diarrhea, when there is wide variation of symptoms. “About a third of the people with the disease may have constipation,” says Case. She warns that eliminating fiber-rich, gluten-containing foods can worsen constipation for those who have it, and cause those with diarrhea to become constipated. So it’s important to eat gluten-free items that are fiber-rich.
“Some people become constipated if they rely heavily on packaged gluten-free foods as they tend to be low in fiber,” says Suzanne Simpson, a registered dietitian with the Celiac Disease Center at Columbia University in New York. “Fruits, vegetables and gluten-free whole grains must be consumed daily in appropriate amounts.”
Falini recommends grain products with three or more grams of fiber per serving. Her strategies for increasing fiber include: tossing chickpeas on a salad or black beans into a rice or soup recipe, red beans into a tomato sauce, or white beans into casseroles, and replacing some of the chicken or beef in meatballs with pureed beans. Or add fruits, vegetables and gluten-free whole grains to meals and snacks, and ground flax, chia or hemp seed to cereals, baked foods and smoothies.
Finding A Winning Diet
A powerhouse gluten-free diet won’t require becoming an award-winning chef. The goal is basic cooking skills focused on unprocessed foods to ensure that every meal and all snacks provide a range of nutrients and help avoid processed food additives that may contain gluten.
It all starts with a shopping cart filled with fresh fruit and vegetables, non-processed lean meats, poultry and fish, plant-based proteins of beans, nuts, seeds, and dairy products, including protein and vitamin rich yogurts and kefir (their probiotic qualities may help improve digestive health), cheeses, and a reasonable portion of complex gluten-free whole grains.
When you add in any baked or prepared foods, read the labels carefully, says Simpson. “All grains, cereals and flour-based foods must be labeled gluten-free,” she says, and processed meats should also carry the label. She advises avoiding foods not labeled gluten-free if they are made in the same facility as gluten-based foods. And whenever possible, the experts say to choose nutrient-dense baked goods made with enriched gluten-free flours, including potato, corn, rice, and the more protein-dense soy, bean, and almond.
Look for more nutritious gluten-free pastas such as quinoa and brown rice instead of the common go-to solution: white-rice pasta. And, whenever possible, look for options enriched with iron and B vitamins. Addicted to your rice maker? Simply switch that plain white rice with brown or wild rice or quinoa (a tasty seed). Case recommends mixing the old with the new 50/50 to help with the transition.
More Changeover Tips
For those accustomed to convenience foods, cooking time can be a stumbling block. But a healthy, balanced diet doesn’t mean cooking from scratch every day.
Incorporating a few new basic cooking skills can result in quick, tasty and nutritious meals, says Falini. One of her suggestions is to explore squeeze tubes of herbs and spices. “They are a wonderful convenience that can be used on even simple foods to bring them to life with flavor,” she says, as well as offering health benefits linked to herbs and spices.
Case has an inventive cooking strategy: “planned overs”. When she cooks, she doubles or triples the recipes, and divides the extras between the fridge and the freezer for future no-fuss meals.
Boost That Breakfast
For those in the habit of morning carb-rich cereals, toast, pancakes, waffles, and muffins, a gluten-free breakfast can be a challenge. Eggs and egg whites are a protein-rich way to start a day, as are low-fat cheeses. For a quick, energy-boosting hit, Simpson suggests a quick, cooking-free breakfast of Greek yogurt, cottage cheese and fruit.
If craving bread, seek out gluten-free versions enriched with iron, B vitamins and fiber, and up the protein with nut or sesame seed butters or cheeses.
For hot cereal, turn to gluten-free, nutrient-rich ancient grains: amaranth, quinoa, and teff. Amaranth is high in protein and fiber. Quinoa is a complete protein containing all nine essential amino acids. Or try cream of brown rice, or cream of buckwheat. Falini suggests bumping the nutritional value of all cereal based meals by adding quinoa or buckwheat flakes and using milk or a substitute, like coconut or almond milk, as a base instead of water.
Cereals can also be given a nutrition boost by tossing in nuts such as almonds, which add a calcium and iron hit, dried fruits and ground flax seed, and serving with plain vitamin D fortified milk or yogurt. Or choose enriched soy, almond, and rice beverage options. On the side, have a calcium- and vitamin D fortified orange juice. Just be sure to shake it well, says Case, as the calcium and vitamin D often sinks to the bottom.
For a non-traditional breakfast, Falini recommends combining proteins and complex carbohydrates, like cheese sticks with whole grain, gluten-free crackers, half an avocado and a cup of vegetable juice.
Or for another quick powerhouse breakfast, throw together a smoothie with the healthy foods now stocked in your refrigerator. Gluten-free recipes are available everywhere and cover the full range of whole food ingredients, from the more traditional fruit, milk, yogurt, a dash of vanilla and sugar, and some flax seed, to vegetable-based versions that combine everything from kale, cucumbers, carrots, avocados, and more.
Oats can be another quick and healthy breakfast option, but cross-contamination with wheat is not uncommon, and a few celiac patients will even react to pure, uncontaminated oats.
Caution on Oats
While a moderate amount of oats is usually safe, dietitians recommend being on a gluten-free diet for several months before introducing gluten-free oats under the supervision of a physician or dietitian. “I recommend that clients hold off on certified gluten-free oats until they have been following the gluten free diet for at least six months, and there is indication they are responding well to the gluten-free diet,” says Begun.
Elevating Lunch and Dinner
One of Simpson’s favorites is a nutrient-packed lunch of kale salad, with brussels sprouts, broccoli, green cabbage, chicory, dried mulberries and pumpkin seeds, coupled with fruit, a half cup of cooked quinoa, and three ounces of protein from cheese, meat, eggs, legumes or edamame beans.
Basic chili is one of Case’s go-to gluten-free meals. It’s loaded with iron, fiber and protein, and rich in vitamins. Use a small amount of beef and red kidney beans. Chili’s tomato-based sauce adds the vitamin C, while taking advantage of the bean iron source.
Carry small bags of almonds, cashews, sesame seeds, dried cranberries, dates, and raisins for that afternoon coffee break to get your protein, calcium, fiber and a burst of energy Or munch on dried tomatoes, fresh grape or cherry tomatoes, and baby carrots with hummus or salsa for a fiber-rich snack.
At home, try nut butters with bananas on gluten-free crackers or gluten-free whole grain enriched bread, and throw apple slices on top. Or use cheese in place of nut butters and bake muffins using nut based, protein-rich flour or other gluten-free grains.
When choosing gluten-free snack bars, look for fiber-rich ones made from dried fruits, nuts, and seeds without added sugar.
So, there you have it, proof that a gluten-free diet need not be a life of culinary deprivation. In fact, starting a gluten-free diet provides a unique opportunity to explore new foods and expand your dietary repertoire – from all the gluten-free healthy fresh whole foods available to the growing list of gluten-free ready-to-eat options.
“I set the tone for my patients to think positively about their approach to the gluten-free diet,” says Begun, who was diagnosed with celiac disease six years ago. “While there’s a learning curve to mastering the gluten-free diet that can be challenging, with time and practice it will become second nature.”