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The Gluten-Free Challenge

Given the role processed foods play in the American diet, patients have to exert a significant, daily effort to follow a GF diet.
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When patients are diagnosed with gluten intolerance, shopping in grocery stores and eating in restaurants can be challenging and time-consuming. Although just a few cereal grains--such as wheat, barley, rye and oats--contain gluten, many food products have traces of this protein. Consequently, patients need to be educated about food choices, both what to eat and what to avoid.

Gluten is broken up into two smaller categories of proteins: the prolamine (e.g., gliadin) and the dietary protein (e.g., glutenin). In patients with gluten intolerance, the body reacts negatively to the prolamine. Each grain has a different prolamine: wheat (gliadin), barley (hordein), rye (secalin) and oats (avenin). (A debate continues as to whether the prolamine in oats triggers the allergic reaction in patients with gluten intolerance. Typically, we recommend avoiding oats at the onset of the diet and then discuss a monitored trial with the patient.)

By definition, a true GF diet completely excludes gluten from the diet to eliminate all offending prolamines. The body will then cease to attack itself and can begin the process of healing. A GF diet is mandatory and requires strict compliance for any patient who tests positive for the autoimmune disease, celiac disease.

Additionally, there's interesting discussion about the crossover potential for autoimmune diseases. Therefore, many health care practitioners are experimenting with a GF diet in patients with other autoimmune diseases. In these cases, patients should understand that such a test requires excellent compliance so we can assess the diet's value as a tool in their disease treatment plan. A GF diet may prove effective as part of a treatment plan for autism. Patients with wheat-intolerance or sensitivity who see a reduction in their symptoms by excluding all forms of wheat may try a GF diet to assess whether their symptoms improve.

Foods to Exclude

Implementing a GF diet requires paying significant attention to food choices, as well as nonfood items. When we look at food choices as they're found in nature, the GF diet really only affects choices from the grain group, as well as alcohol.

Thus, the GF diet requires learning about grains and their flours so people learn to avoid all wheat. This includes spelt, kamut, triticale, bulgur/cracked wheat, wheatberries and wheat grass; barley and barley grass; rye; and oats. Acceptable grains and flours include quinoa, millet, rices, amaranth, teff and buckwheat (not related to wheat), as long as they clearly state on their package or Web site that they're not processed in the same location as the unacceptable grains.

When it comes to alcohol, the GF diet excludes beer, malt, grain whiskey and wine coolers, while permitting sake (rice), plum wine, many wines and tequila. In looking at these items, we'd think that a GF diet shouldn't be difficult to follow, right?

Not so. Today's food marketplace presents significant challenges for most GF diet followers. The biggest challenge exists because most Americans rely on "food products." What does this term mean?

"Food products" refer to any item processed, preserved or flavored, essentially having undergone any alteration from the state in which it's found in nature. Thus, food products refer to convenience items, packaged goods and functional foods. During this processing--whether extensive or simple--many natural GF foods become gluten-containing (GC) food products. Thus, food processing generates a world of food products that pose potential risk to those following a GF diet.

Therefore, GF followers must dutifully review all food product labels, call companies when information is unclear and learn to identify alternative options. Following are some examples of food products that require review:

-Thickeners, emulsifiers, stabilizers and flavorings. They're derived from wheat, corn or soy.

-Modified food starch (it must specify "corn"), hydrolyzed vegetable protein, hydrolyzed plant protein, texturized vegetable protein and monosodium glutamate

-Soups, gravies, gelatin, baked beans and pie fillings

-Flavorings, such as vanilla, coffee and caramel coloring

-Salad dressings, spreads, catsup, most ready-made dips and soy sauce

-Processed cheese, as well as other dairy and meats

-Baking powders

-Bin food items, such as nuts, dipped pretzels, candy, etc.

-Functional foods, such as bars, shakes, food enhanced with herbs and vitamins. This includes vitamin waters, rice cakes and with herbs, etc.

Offering Advice to Patients

Given the role processed foods play in the American diet, patients have to exert a significant, daily effort to follow a GF diet. To motivate, improve compliance and minimize patients' effort, we should present two key areas of opportunity.

The second area of opportunity comes in the form of resources available for those following a GF diet. The accompanying table lists Web sites of organizations and food manufacturers offering support for GF diet followers. In many instances, the founders of these organizations and companies follow a GF diet themselves. Thus, they're uniquely capable to provide strategies, products and comforting words to improve compliance among followers of a GF diet.

In many instances, the GF products' nutrient profiles are superior to or on par with their counterparts. But some potential nutrition issues exist with GF food products. These are:

Glycemic control: GF products can have a higher glycemic load than their non-GF counterparts.

Nutrient content: GF products may not be enriched like their non-GF counterparts.

Digestive implications:
GF products can have less fiber than their non-GF counterparts.

Given this, patients need advice on how to balance low glycemic-load carbohydrates, lean proteins, healthy fats and vegetables for an optimal diet.

And finally, in the realm of food choices, offer these dining tips for your patients. First, recommend frequenting establishments that cook food from scratch on the premise as opposed to fast food places that use ready-made items.

Second, stress preparation. Contacting a restaurant ahead of time for a menu and calling with questions helps reduce potential stress at the time of ordering.

Third, teach assertiveness. It's perfectly appropriate for people to order items prepared correctly to ensure GF status. Encourage servers to clarify certain points, such as asking whether the soups are made with flour as a thickener.

Two more areas complete the set of guidelines for a GF diet: nonfood items and nutrient supplementation to support optimal health. A more extensive list of nonfood items presenting potential risk for GF followers can be found on the Web sites listed in the table. A sampling of categories includes soaps/detergents, shampoos, lotions/sunscreens, toothpaste/mouthwash, cosmetics, lickable envelopes and stamps, latex or rubber gloves, art supplies and medications.

Nutrient supplementation acts as a safety net to ensure adequate nutrient levels for the GF diet follower. It also helps optimize digestive function. These include the following:

A multivitamin/multimineral to make up for the lack of nutrient enrichment of certain grain products, as well as those lost in food processing.

A probiotic. Good bacteria may be lost because of increased gut permeability or medications taken before diagnosis.

L-glutamine. This amino acid helps support the mucosal layer of the digestive tract.

Omega-3 fatty acids, such as fish oil, support healthy immune function.

Digestive enzymes, as needed, improve digestion of certain foods.

Fiber. GF choices, such as psyllium, ground flaxseeds and rice bran, help maintain regularity and confer additional health benefits.

When talking with patients about GF diets, remember it's not only the information that will help them achieve optimal compliance, but also the delivery of that information. No one likes being told what they can and cannot eat. So the challenge is to communicate restrictions effectively, but also with an emphasis on what they can eat, the health benefits of such choices and strategies for successful implementation.

This post was adapted from an article that originally appeared in Healthy Aging, published by ADVANCE Newsmagazines.

Ashley Koff, RD, is a registered dietitian in private practice in Santa Monica and Beverly Hills, Calif. She was educated at Duke and New York universities and trained at LA+USC and Columbus Children's hospitals.