Amy Keller, MS, RDN, LD - Gluten-Free Living

Gluten-Free Kids: Picky Eaters, Self-Conscious Tweens, Autism and Diet

Amy Keller, MS, RDN, LD, a dietitian and celiac support group leader from Bellefontaine, Ohio, answers your questions on all things gluten in this column from Gluten-Free Living. Amy is the Chief Clinical Dietitian at Mary Rutan Hospital in Ohio. She is also a past chair of the Dietitians in Gluten Intolerance Disorders practice group for the Academy of Nutrition and Dietetics.

My 4-year-old daughter was diagnosed with celiac disease late last year. We’re getting the hang of the gluten-free diet, but she’s becoming increasingly picky about what I serve at dinner. She often refuses to eat what I cook, so I end up making gluten-free mac and cheese or chicken nuggets after dinner so she’ll eat something. It’s made dinnertime stressful. Help!

Most young kids are picky, at least to some extent, about what they eat. It can lead to many of the complaints you are experiencing. It can be even more complicated when your child requires a special diet. One way to approach the issue is to make sure you are doing your job as the parent—providing regular meals and snacks. It is her job to decide whether and how much she will eat. This is called the “division of responsibility” in feeding and was developed by Ellyn Satter, an internationally respected registered dietitian and feeding therapist. We, as parents, often end up trying to do our children’s jobs for them by pressuring or bribing them to eat or short-order cooking favorite foods when they refuse what is served.

Limit eating to mealtime or planned sit-down snacks, with water only between. This allows her to come to the table hungry and ready to eat. If you are serving something she’s never tried before, serve some other familiar foods along with it. Reassure yourself that it can take many attempts for a child to try new food; it’s totally normal. Try to avoid insisting on a “no thank you” bite. It’s a form of pressure that can make children more resistant to trying new foods.

If she doesn’t eat what’s been served, say “you don’t have to eat,” but let her know that you will not be making different food for her after dinner. This can test your mettle as a parent, but it’s worth it. Be prepared as she will test you to see if you’ll give in. Eventually, this will lead to a more relaxed mealtime for everyone and allow her to feel more comfortable around all foods.

For more information about the division of responsibility and feeding, check out Ellyn Satter’s website at ellynsatterinstitute.org.

My 11-year-old daughter has had celiac disease since she was little. Recently, her dad and I have noticed that she is more self-conscious about eating gluten free around her friends. Will she grow out of this? Is there anything we can do to help?

No kid wants to be different, and it can be tough as a parent to watch them feel that way. Just like adults, kids who eat gluten free often feel like they are always in the spotlight at mealtime, which can make them feel very uncomfortable. Try not to let your daughter avoid typical social situations, such as sleepovers or amusement parks. Instead, look for ways to help build her confidence. For these events, talk to the parents who are hosting about what snacks will be served and make a look-alike item that she can enjoy. Help her to recognize that there are lots of naturally gluten-free foods that she can enjoy right along with her friends, such as fruit, veggies, corn tortilla chips and popcorn. You might want to rehearse together what she will say if someone does offer her food that contains gluten. Learning to speak up and say “no thank you” can go a long way. Finally, consider finding a kid-focused celiac support group such as Generation GF (gluten.org/kids).

I’ve heard the gluten-free diet is good for kids on the autism spectrum. Is this true?

There has been much buzz about the gluten-free, casein-free (GFCF) diet as a treatment for autism. Unfortunately, the research on this approach has produced decidedly mixed results. Some children may respond to the GFCF better than others, but if there is no improvement seen in a few weeks, it may not be the right approach. Some children with autism may also have celiac disease, so, as always, test before starting the diet.

Because the GFCF diet is very restrictive, there is a risk of nutritional deficiencies. It’s crucial to find a registered dietitian who is experienced in working with kids on the gluten-free diet to ensure that they receive enough calories and other nutrients needed for proper growth and development.

Back to School Gluten Free

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

My son is a high school freshman and starting his first year of marching band. Band camp is the week before school, and while they used to go away to a local university, this year they will have it at school. While I’m relieved not to have to worry about him being away from home, he will still need to eat meals at the school during camp. I don’t want him to have to pack everything and feel left out. Do you have any suggestions?

Marching band is an excellent experience for kids, so I’m glad he’s involved. I would start by finding out what foods will be served at the camp and who is in charge of purchasing them. If there is a band parent organization that is planning meals for camp, start by contacting those leaders for more information. If you aren’t sure where to start, try contacting the band director to find out who will be taking charge of meals. In future years, maybe you can get involved in some of the meal planning for camp!

While you might need to provide specialty items, such as gluten-free bread, pretzels or cookies, you might be surprised and find out many of the foods served are naturally gluten free. Fresh fruits, veggies, bottled water and tortilla chips are examples of foods that he can safely select without feeling different than his friends. If you send items, remember to keep them cool with enough ice packs or ask if refrigeration is available during the day.

My seven-year-old daughter was diagnosed with celiac last month. Her dad and I are divorced, but both of us have remarried, and we are on good terms. We share custody, and she stays at his house a few times a month. What can I do to help make sure our households are consistent in making sure everything is gluten free?

Because you get along well, this transition will likely be much more manageable. For more contentious divorces, or when one parent doesn’t take the diet seriously, it can be very stressful. In these situations, it may be necessary to sit down with a family counselor or, in extreme conditions, hire a mediator. Still, navigating two households can be complicated for many reasons, especially when there is a special diet involved. It’s vital that everyone is on the same page and that rules are consistent no matter which home she is in. Encourage open communication about what is best for your daughter and talk directly to each other; never send messages regarding food through your daughter.

If you haven’t already seen a registered dietitian, an excellent place to start would be inviting everyone (including step-parents) to that appointment. That way everyone hears the same thing and can ask questions. If that’s not possible, ask for a duplicate copy of the educational materials so each parent has the same information in their home. If there is a local support group, encourage everyone to attend.

If your daughter has a few favorite gluten-free foods, ask her dad to consider purchasing them when she is at his home. Another option would be to pack some food when she stays over. Make sure each home has necessities to prevent cross-contamination, such as a separate toaster and colander. If he does not live locally, sit down together and figure out what restaurants have gluten-free options near his home.

My son is headed to third grade this year, and we are going to let him buy school lunch on some days of the week. The school suggested we have a 504 Plan on file for him, but I’m afraid of him being labeled as “different.” Also, his teacher is very understanding. Is it really necessary?

Having a formal plan in place is good for everyone. Kids have 504 Plans for lots of reasons (not just celiac disease), so there is no cause for him to feel different or singled out. It’s great that his teacher is working well with you, but a 504 Plan provides written documentation and describes the kind of accommodations you would like to have in place. For example, you might request that you be notified if food will be served in the classroom or on field trips, who in the kitchen will be responsible for preparing and handling his lunch, or if macaroni might be used to do a craft project.

How do you get started with a 504 Plan? Contact the school and ask what the procedures are to get one put into place. You will need documentation from your son’s doctor that he has celiac and requires a gluten-free diet. Additional information on 504 Plans for celiac can be found on the Celiac Disease Foundation website at celiac.org.

Weight Gain and Weight Loss on the Gluten-Free Diet

Despite social media and celebrity testimonials, there is no scientific evidence that the gluten-free diet alone leads to weight loss.

According to Lori Welstead, MS, RDN, LD, nutrition advisor at the University of Chicago Celiac Disease Center, weight gain once going gluten-free is extremely common. “At every initial visit with a new patient with celiac disease, I make sure they know that they may gain weight on the gluten-free diet for a variety of reasons,” she said. “Weight gain can occur in patients who have celiac disease because their villi, which is the carpet of hairs lining the intestine that are responsible for absorbing nutrients and enzymes to break down certain foods, that have been blunted, or flattened, are now ‘fluffed back up’ and normally absorbing nutrients.”

This results in unwanted pounds for many of her patients, who previously were able to eat “whatever they wanted” without gaining significant weight, she said.

Welstead said the quality of gluten-free processed foods may play a role, noting, “Gluten means ‘glue’ in Latin; it is the protein portion of wheat, barley and rye, but it also provides the flaky, fluffy, crunchy and crispy textures in foods.” To improve the taste and mouthfeel of gluten-free products, manufacturers often turn to additional fat and sugar as a replacement. “Unfortunately, many gluten-free processed foods, including anything from cookies and crackers to bread, often contain more carbohydrates and fat than gluten-containing foods,” warned Welstead.

Finally, adapting to a strict, lifelong diet can increase emotional eating, said Welstead. “It’s not easy, and many feel overwhelmed, anxious and depressed. This may lead to ‘treating yourself’ more often with high-calorie gluten-free foods.”

Welstead admits that even she wasn’t immune: “Personally, when I was first diagnosed, I was guilty of this. Because I was mourning my favorite gluten-containing foods, I would find myself randomly purchasing cookies, crackers and other items that I wouldn’t have eaten prior to diagnosis.” Welstead discusses potential weight gain with her patients not to discourage them, she said, but to arm them with the knowledge of how to deal with it.

Welsteadr shares these tips for managing weight gain while eating gluten-free.

Find the balance. Instead of trying to find replacements for all your favorite gluten-containing foods, Welstead recommends a more moderate approach. “Although I still enjoy trying all the new gluten-free foods out there and treating myself, I don’t at every meal and snack.”
Think naturally gluten free whenever possible. “Aim for a less-processed gluten-free diet; load up on naturally gluten-free foods, such as fish, lean meat, poultry, fruits, vegetables, beans, nuts, seeds and dairy (if tolerated).”
Get moving! Aim for about 30 minutes a day, five days a week of moderate-intensity exercise, such as brisk walking.
Think benefits beyond the scale. Improved fitness and healthier eating can improve your quality of life long-term, even without losing weight.

Gluten-Free Myths That Still Persist

If you’ve been eating gluten-free for many years, you may feel very confident in your ability to avoid foods that make you sick. Still, you may hear an occasional piece of information that makes you question what you know. It might be from a well-meaning friend or family member, or something you see on social media. If you dig further, you might get more confused as you sift through blog comments and online forums. Despite all the research around the gluten-free diet over the last few years, significant misinformation remains. Let’s set the record straight on some of the most popular myths that persist.

Manufacturers “hide” gluten under natural flavorings or ingredients such as caramel coloring.

“Consumers should not worry about the ingredient ‘natural flavoring’ in a labeled gluten-free food,” said Tricia Thompson, MS, RD, founder of the independent testing organization Gluten Free Watchdog, LLC. Thompson said that natural flavoring can be derived from wheat, but in FDA-regulated foods, this wheat would have to be declared in the ingredients list or “Contains” statement. “If natural flavoring contains barley protein or rye, these might not be declared in the ingredients list,” she said. “That said, flavoring containing barley protein will most likely be declared in the ingredients list as malt flavoring and malt extract.”

While USDA-regulated foods do not fall under the labeling jurisdiction of the FDA’s gluten-free labeling rule, the USDA does say ingredients containing protein, such as gluten, can’t be included under the name “flavoring,” noted Thompson. “They must be declared in the ingredients list by their common or usual name, such as malt.”

The fear of hidden gluten in caramel coloring also persists, but it shouldn’t, said Thompson. Caramel coloring is the world’s most widely used food colorant, and the myth that it contains gluten likely stems from the fact that it can be made from wheat, but this is rare. Just like natural flavorings, however, if caramel coloring was derived from wheat, it would be noted in the ingredients list or “Contains” statement. In the U.S., however, most caramel coloring is derived from corn. According to the website for Sethness Caramel Color, a worldwide caramel coloring manufacturer, its coloring is made from corn syrup or sugar and is gluten free.

Even if the starting material was wheat, experts agree that the final product would be unlikely to contain gluten because it is so highly processed. This led the European Union to permanently exclude caramel coloring, as well as maltodextrin and wheat-based glucose syrup, from allergen labeling.

Sourdough bread is safe for people with celiac disease.

“The belief that sourdough wheat breads that undergo long fermentations are safe for people with celiac disease and other gluten-related disorders stems in part from a misread of studies on wheat flour hydrolyzed under laboratory conditions,” said Thompson. “One such study found that wheat flour fermented with sourdough lactobacilli reduced the intact gluten content of wheat flour to under 2,500 parts per million.”

This is compared to wheat flour that comes in at approximately 100,000 parts per million of gluten. “In that same study, wheat flour fermented with sourdough lactobacilli and fungal proteases decreased the intact gluten content to under 10 parts per million.”

Unfortunately, Thompson said, this has led some artisanal bakers to claim and advertise that their sourdough bread is safe for consumption by people with celiac disease and other gluten-related disorders. “Sourdough wheat bread made in an artisanal bakery is not using hydrolyzed wheat flour to make their bread,” she said. “Commercially available products that were not produced in a lab are testing upwards of 100,000 parts per million gluten.”

It is necessary to look for a gluten-free label on ALL foods that you eat.

While the FDA’s gluten-free labeling rule states that manufacturers may choose to use a gluten-free label on foods or beverages such as grapefruit or bottled water, it does not mean you need to limit yourself to only foods labeled gluten free. Other examples of naturally gluten-free foods that do not need a gluten-free label include fresh fruits and vegetables; canned or frozen fruits and vegetables without sauces; plain meats, pork, fish or poultry (without broth); plain dairy products; and beverages such as water, soda or fruit juice.

The only exception to the naturally gluten-free status are grains and lentils, said Thompson. “Naturally gluten-free grains and products made from them should be labeled gluten free,” she said. “There is simply too great a chance for cross-contact with wheat or barley to take the chance on grains or flours not labeled gluten-free.” Thompson also advises that whenever possible, lentils should be labeled gluten-free. This, too, is because of cross-contact concerns.

Busted: Other myths that just won’t go away

Strawberries might contain gluten if they are exposed to straw in the fields.

“I have been in the strawberry industry for more than 25 years and never heard this myth,” said Kevin Schooley, executive director of the North American Strawberry Growers Association. “Straw does not store gluten, and any dust that might be on straw from harvesting the grain would be washed away by rain or other precipitation. Most straw is used to protect berries over winter, so there would be lots of opportunities for any possible minute quantity to be washed off. The majority of strawberries likely never even come in contact with the straw.”

Envelope glue contains wheat/gluten.

According to the Envelope Manufacturers Association’s website, “remoistenable adhesives are derived from cornstarch and do not contain wheat or rye gluten.” The U.S. Postal Service sells only adhesive postage now, so you don’t even have to lick the stamp.

Foods labeled gluten free still contain significant amounts of gluten.

The FDA’s gluten-free labeling rule allowing < 20 ppm gluten in foods labeled gluten-free does not mean that the vast majority of foods contain anywhere close to that amount. “Ninety-six percent of foods tested through Gluten Free Watchdog test below 20 parts per million of gluten,” said Thompson, “while 87 percent of those tested below 5 ppm.”

Monosodium glutamate (MSG) contains gluten.

Some people complain of physical symptoms such as nausea or headaches, after eating foods that contain MSG; however, this is not a reaction to gluten. Interestingly, MSG used to be derived from wheat gluten, but this has not been the case since the 1960s. Now, it’s made from the fermentation of certain sugars and starches, such as beet sugar, sugar cane, tapioca starch and cornstarch. Rest assured that on the off chance it was made from wheat, it would be required to be on the food label of an FDA-regulated product, either in the ingredients list or “Contains” statement.

How Worried You Should be About Allergen Advisory Statements

When you see the label “gluten free” on food, how does it make you feel? Confident? Secure? Or do you still have questions about whether the food is genuinely gluten free? What about statements like “made in a shared facility with wheat” or “may contain wheat” on foods labeled gluten free? Do those phrases cause you to think twice?

The gluten-free labeling rule, which went into effect in 2014, was intended to help gluten-free consumers easily identify foods that are safe to eat. It also provided specific guidance to manufacturers on what is, and what is not, allowed in gluten-free food. Before the gluten-free labeling rule, there were no set standards for the labeling of gluten-free foods, so it was a significant step forward for the gluten-free community.

Recently, however, consumers have begun discovering that there are foods labeled gluten-free on store shelves that contain ingredients that don’t meet the requirements of the rule. Also, allergen advisory statements indicating a labeled gluten-free food was manufactured on shared equipment or in a facility with wheat cause concern among gluten-free consumers. Is the Food and Drug Administration (FDA) doing enough to protect the gluten-free consumer?

Allergen advisory statements

Perhaps no other phrase on a food package is more unsettling to a gluten-free consumer than an allergen advisory statement. Statements warning of shared equipment, shared facility or the even more ominous “may contain wheat” may make consumers feel like manufacturers are trying to hide something.

“Many find it nonsensical to see both a gluten-free claim and a ‘may contain wheat’ statement on a product label, and who can fault them?” notes Tricia Thompson, MS, RD, founder of the independent gluten testing organization Gluten Free Watchdog, LLC. Unlike mandatory food allergy labeling for wheat, allergen advisory statements are voluntary and not covered by any federal regulation. “Some manufacturers use them, and others do not,” notes Thompson.

Even more confusing, the gluten-free labeling rule allows these precautionary statements to be included on foods labeled gluten free, provided the final product meets the required standard.

In 2016 and 2018, Thompson and her team of researchers reviewed products with and without gluten-free labels to determine if an allergen advisory statement was helpful in predicting gluten contamination. What they found surprised many in the gluten-free community. “Based on our database reviews, four out of 45 (9 percent) products that did include an allergen advisory statement for wheat or gluten on product packaging contained quantifiable gluten,” says Thompson. “But 52 out of 384 (14 percent) of products that did not list an allergen advisory statement for wheat or gluten on product packaging contained quantifiable gluten.” In short, an allergen advisory statement was not a good predictor of gluten contamination.

The type of allergen advisory statement (shared facility/equipment or may contain) was also not useful in determining risk. “In our latest research, 31 products contained an allergen advisory statement, but only three contained quantifiable gluten,” says Thompson. “The three foods that contained quantifiable gluten carried an advisory statement for a shared facility, not shared equipment or ‘may contain wheat.’”

Despite studies like this, allergen advisory statements still tend to cause a lot of worry and confusion, notes Thompson. As part of her 2018 study, she conducted an informal poll on Twitter asking how gluten-free consumers felt when they saw an allergen advisory statement on a gluten-free product. The poll indicated that consumers viewed allergen advisory statements in a generally negative light. In particular, shared equipment and “may contain wheat” caused the most concern.

Thompson hopes that the FDA will take action to help make these statements more useful to the consumer. “The FDA should strongly consider regulating allergen advisory statements, especially in light of the recent Food Safety and Modernization Act,” she says. “They should be standardized and related to consumer risk. Allergen advisory statements should be helpful to consumers. Currently, due to lack of regulation, they result in a lot of confusion.”

In the meantime, consumers can ask questions when they see an allergen advisory statement. Calling the manufacturer may be helpful; it’s important to speak to someone who is familiar with how the facility controls for allergens. Ask about specific procedures regarding how equipment is cleaned, whether gluten-free products are made on separate days (or at least before gluten-containing foods), and whether there are particular areas or employees who are dedicated to the production of gluten-free foods.

Facial misbranding

“At Gluten Free Watchdog, we use the term ‘facial misbranding’ to describe a product label displaying a ‘gluten-free’ claim but the ingredients list includes an ingredient that is prohibited under FDA rules from being contained in any product labeled ‘gluten-free,’” says Thompson. “It tends to involve the same ingredients, which include barley malt, barley malt extract/barley malt syrup, barley malt vinegar and wheat-based soy sauce.” Consumers notify Thompson about products that contain prohibited ingredients frequently, in everything from malt vinegar potato chips to ice cream containing dry malt extract.

When she receives these reports from consumers, she investigates, and then she brings it to the manufacturer’s attention. The reactions she receives from the manufacturers run the gamut, she says. “Some are incredibly appreciative and take immediate corrective actions. Others refuse to make any changes to their product labeling.” Thompson believes that some manufacturers don’t fully understand the rules. “They believe that the only criterion for making a gluten-free claim is that the product contains a level of gluten below 20 parts per million (ppm),” she says. “This is not true. Certain ingredients are not allowed in foods labeled gluten free in the U.S.”

In August of 2017, Thompson filed a citizen petition to the FDA listing numerous food products on store shelves that met the definition of facial misbranding. The petition requested that the FDA establish protocols for better surveillance, investigation and, most importantly, enforcement of products that are potentially misbranded. Additional lists of misbranded products were sent to the FDA in 2018. Despite the FDA stating that enforcement of the gluten-free labeling rule includes food label reviews, Thompson says she did not see action to remove these products from stores shelves. Since the beginning of 2016, the FDA has issued only two recalls of food products that were misbranded.

Thompson took to social media to encourage gluten-free consumers to tweet the FDA with the hashtag #EnforceGFRule, andcontinued to encourage and educate consumers about how to properly report misbranded product. In late 2018, the FDA took action. “We had a positive meeting with several folks from the FDA on gluten-free labeling issues. The nation’s most prominent gluten-free and celiac groups participated in the meeting, including representatives from the National Celiac Association, Beyond Celiac, Gluten Intolerance Group and the Celiac Disease Foundation, she reports. “We discussed consumer reporting issues, enforcement issues, and education and awareness. This is the first of hopefully many more interactions with the FDA to help solve the various issues we’ve identified related to facial misbranding and consumer trust in the gluten-free claim.”

Thompson does caution that there are some situations where food may appear to be misbranded when it is not. The most common one that she sees is the presence of an allergen advisory statement on a food with a gluten-free label. “Consumers should not report perceived facial misbranding due to the presence of an allergen advisory statement on a labeled gluten-free food,” she says. “These statements are allowed on foods labeled gluten-free in the U.S.”

Thompson encourages gluten-free consumers to be patient, however. “Change does not happen fast. We are grateful for all movement in a positive direction and for FDA’s willingness to engage and meet with us,” she says. “While we wait for change to take place, it is really important for consumers to continue reporting facial misbranding to the FDA and USDA [United States Department of Agriculture] and to Gluten Free Watchdog.”

Mandatory Food Allergy Labeling vs. Allergen Advisory Statements

	Mandatory Food Allergy Labeling	Allergen Advisory Statements
What is it?	The Food Allergen Labeling and Consumer Protection Act (FALCPA) specifies that any of the eight major food allergens (wheat, egg, dairy, soy, tree nuts, peanuts, fish and shellfish) on FDA-regulated products must be clearly listed under their “common and usual name” in either the ingredients list or in a Contains statement. Usually, it’s in both places.	Allergen advisory statements such as “may contain,” “made on shared equipment” and “made in a shared facility” refer to manufacturing practices. They may be present on foods labeled gluten-free as long as the final product meets the standard set by the gluten-free labeling rule (< 20 ppm). The use of an allergen advisory statement is voluntary on the part of the manufacturer.
Are they regulated?	Yes. FALCPA is mandatory. It is important to note that FALCPA refers to ingredients only, not to manufacturing practices such as shared facility or shared equipment.	No. Allergen advisory statements are not regulated by any agency. However, the FDA does state that they should be “truthful and not misleading” and should not be “used as a substitute for adherence to Good Manufacturing Practices.”

What should you do if you spot a misbranded food?

FDA-Regulated Foods (most packaged foods, shelled eggs, dietary supplements)

Take photos that capture the entire label. It is critical to photograph the UPC code (12-digit numeric code).
Contact an FDA consumer complaint coordinator. A state-by-state listing or regional listing is available at https://www.fda.gov/ReportaProblem/ConsumerComplaintCoordinators.

USDA-Regulated Foods (meat products, poultry products, mixed products that contain more than 3 percent raw meat or 2 percent cooked meat or poultry, egg products including dried, frozen or liquid eggs.)

Take photos that capture the entire label. For USDA-regulated foods it is critical to photograph the establishment number/EST number).
Contact the USDA at 1-888-674-6854.

If you have any questions or are unsure about whether a product is misbranded, you can contact Gluten Free Watchdog at [email protected]

Test your knowledge

True or False: Choosing a product without an allergen advisory statement for wheat guarantees it was made in a dedicated gluten-free facility.

False: Allergen advisory statements are voluntary. Choosing a product without one does not guarantee a gluten-free facility. The product could have been made on shared equipment or in a shared facility, but the manufacturer chose not to use an allergen advisory statement.

True or False: A product listed as “made in a shared facility” is a safer choice than “made on shared equipment” or “may contain wheat.”

False: Recent research has shown that the type of allergen advisory statement listed is not a useful predictor of the risk of gluten contamination.

True or False: A gluten-free product with a “may contain wheat” statement is not considered misbranded.

True: “May contain wheat” and other allergen advisory statements are permitted on gluten-free products, provided the final product meets the standard of the gluten-free rule.

Whole Grains Continue to be Trendy and Tasty

Sorghum, sprouting and sustainability—these were just a few of the topics presented at the recent Oldways Whole Grains Council Conference in Seattle. This biannual event brings together chefs, manufacturers, distributors and registered dietitians and provides the latest information on consumer attitudes about whole grains. The consensus among all presenters was that whole grains aren’t going anywhere, which is good news for those on a gluten-free diet.

Not just healthy

In her welcoming remarks, Sara Baer-Sinnott, president of Oldways, noted that whole grains, no longer considered just a tasteless health food, have a wide range of uses in cooking and creating a low environmental footprint. Despite trends toward low-carb diets, people are consuming more whole grains than ever before. The council shared data from its 2018 Consumer Insights Survey, which found that two out of three people make at least half their grains whole, which is in line with the 2015 U.S. Dietary Guidelines. More impressively, four out of five people who “nearly always” choose whole grain foods are eating more of them than they did five years ago.

But why are whole grains so popular? Caroline Sluyter, director of the Oldways Whole Grains Council, thinks it’s a combination of health and taste. “Eating healthy foods is becoming trendier, and that includes whole grains,” Sluyter said at the conference. “Our palates are adjusting, too, and we’re coming to appreciate the fuller, richer flavor of whole grains.”

Going gluten free doesn’t mean that whole grains are off the table. Sluyter reported that 2018 survey data indicates more people are familiar with ancient grains, which include many gluten-free choices. The number of people who had heard of quinoa increased from 55 percent in 2015 to 68 percent in 2018, millet rose from 38 percent to 41 percent, and sorghum from 29 percent to 31 percent. The move toward ancient grains has extended to manufacturers and food service as well. The National Restaurant Association recently put ancient grains on its list of the Top 20 Food Trends for 2018.

Boil, drain and done!

“Using whole grains and whole-grain flour is a really good way to make a recipe more achievable and approachable, and just plain easier,” noted Andrea Geary, senior editor of Cook’s Illustrated magazine and America’s Test Kitchen, at the conference. Geary also acknowledged that can be a tough sell. She shared a recent question to the magazine’s Facebook page: “Do you cook and bake with whole grains? If not, why not?” The responses she received were eye-opening. “People were worried that whole grains might taste bad, that they aren’t compatible with the foods they know and love, that they take forever to cook and are easy to mess up, and would make baked goods heavy, dense and tough,” Geary said.

Geary said a fan-favorite recipe, fried rice, was the first time the magazine explored the benefits of cooking with whole grains. “Brown rice has some distinct advantages in this type of recipe,” noted Geary, “and it has nothing to do with nutrition and everything to do with the bran.” Bran, the outer layer of a grain, protects the food supply located in the endosperm. While refined grains strip the bran away, whole grains leave it intact, increasing nutritional content and durability of the grain during cooking. Geary pointed out that brown rice also speeds up preparation because it can be cooked utilizing the pasta method. “Many whole grains are easy to cook as pasta. Boil, drain and done!”

Brown rice also eliminates the need to chill the grain before adding it to the pan, which saves significant time. “You can take that grain, still warm from the colander, and throw it right in the wok,” advised Geary. “Unlike white rice that needs to be chilled down, the bran protects it, so it’s not going to clump together…It’s really sturdy.”

Sustainability is key

Climate change and a dramatic increase in the world’s population will soon necessitate a different approach to agriculture, noted Sharon Palmer, award-winning registered dietitian and author. “We’re all concerned because we are living on an increasingly hot and crowded planet. By 2050, it has been reported that we’re going to have 9.7 billion people.”

Increasing available land for agriculture to feed people means a negative impact on climate, greenhouse gas emissions and water usage. “We are using 70 percent of our fresh water supplies for agriculture,” warned Palmer. “And if we continue to eat a high animal-protein, Western-style diet, we could increase greenhouse gas emissions by 80 percent by 2050.” Greenhouse gas emissions come in the form of methane from livestock, nitrous oxide from fertilizer use and carbon dioxide from fossil fuels required to run tractors and other equipment.

Palmer suggested that plant-based diets could be part of the solution. “Dramatically reducing animal foods and increasing plant foods could be the most powerful thing we could do in our individual lifetimes to reduce our carbon footprint; this is even more impactful than the cars we drive,” she said. It is not necessary to be a full-time vegetarian to make a difference. A “flexitarian” approach (eating meat only occasionally) could cut greenhouse gas emissions by half and save enough water to take care of 1.8 billion additional people on the planet.

Whole grains in particular have the lowest carbon footprint among nearly 500 foods, Palmer said. “Grains grow in all sorts of climates, with less water and with soils that may not be as fertile. For example, sorghum has become particularly adapted to arid conditions and teff can thrive in drought and waterlogged soil.” These are also crops that have stood the test of time. Quinoa was domesticated in the Andes 4,000 years ago, amaranth is traced back to the Aztecs in Mexico, and teff is a regular staple in Ethiopia.

Gluten-free whole grains should be a significant part of a healthy, plant-based diet. Palmer suggested incorporating them into the popular food trend of bowls. “Bowls are not going away. Use a whole-grain base such as sorghum, add a flavorful vegetable, a healthy protein, and some sort of sauce.”

The benefits of sprouted grains

While they sound like something found only in a health food store a few years ago, sprouted grains are becoming mainstream. They are even making their way to the gluten-free market. Sprouted gluten-free grains can be found in everything from crackers to pancake mixes. Some are sold as ready-to-eat toppings for salads or yogurt.

“A sprouted grain is a germinated seed,” said Carlee Kelly, MSN, co-founder of Lettuce Eat. “It’s a seed that’s awakened from its dormant state.” This germination occurs when the right combination of temperature, moisture and light come together, which activate enzymes that initiate a cascade of chemical reactions within the seed.

“Sprouting is a positive form of processing,” noted Kelly. “So often, processing methods are stripping the nutritional content from our foods. Sprouting is a form of natural processing of grains that can enhance their nutritional attributes.” Potential nutritional benefits of consuming sprouted grains include better bioavailability of iron, zinc, calcium, omega-3 fatty acids, phosphorous, potassium and folic acid. Also, there are increased levels of protein, fiber and antioxidants in these grains.

Looking to the future

The Whole Grain Stamp program also continues to see growth, with the stamp currently appearing on more than 12,000 products. The amounts of whole grains in products are also steadily increasing. “In 2008, the average product had 19 grams of whole grain; today it’s 25 grams,” said Sluyter. “I think that’s very exciting. It’s driven a lot by consumer demand and product innovation by manufacturers who are making whole grains more delicious.”

While quinoa is still a favorite, Sluyter said she is frequently asked what grains she sees as up-and-comers. “We don’t like to play favorites here at the Whole Grains Council, but it was very interesting to take a look at the prevalence of various ancient grain ingredients that are being registered and see that both sorghum and teff had really consistent growth over the last several years. That’s where I’m putting my money.”

10 Sweet Ways to Reduce Added Sugar in Your Diet

Added sugars are added to products during processing, and it seems they are just about everywhere. They can lead to weight gain and raise blood triglyceride levels, which contribute to heart disease. Institute these healthy habits to reduce the amount of added sugar in your diet.

1. If you drink sugar-sweetened beverages frequently, try to cut down or quit them entirely. Examples include soda, lemonade, fruit punch, sweet tea, sweetened coffee and sports drinks.

2. If you add sugar or sugar-sweetened creamer to coffee or tea, try to gradually reduce the amount that you use.

3. Sweeten gluten-free pancakes and waffles with fresh fruit.

4. Replace the brown sugar in your gluten-free oatmeal with unsweetened dried fruit or fresh fruit.

5. If you use milk alternatives, such as soy milk or almond milk, choose unsweetened varieties.

6. Buy canned fruits in their own juice or in water.

7. Check the labels of frozen fruits. They are great for making smoothies, but some have added sugar.

8. When baking with sugar, you can reduce the amount in the recipe by a third or a half without noticing a difference in taste. You can also substitute unsweetened applesauce. Use more spices, such as cinnamon, cardamom or nutmeg. Vanilla extract and almond extract also add a lot of flavor without sugar.

9. Beware of sugar in foods that don’t need it, such as ketchup, barbecue sauce, pasta sauce, yogurt and gluten-free cereal.

10. Some gluten-free granola or nut/fruit bars contain added sugars. Look for varieties with the lowest amounts.

Do Fruits and Veggies Need a Gluten-Free Label to be Safe?

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

I noticed the other day that the canned green beans I bought are labeled gluten free. I thought all green beans were gluten free. Do I need to be looking for a gluten-free label on fruits and vegetables, too?

It is not necessary to look for a gluten-free label on most naturally gluten-free foods, including fruits and vegetables. The U.S Food and Drug Administration’s gluten-free labeling rule notes that naturally gluten-free foods, like the green beans you mentioned, may have a gluten-free label but it’s not necessary. Do be cautious, however, with vegetables that contain sauces or marinades—check the label or ingredients list to ensure those are gluten free.

The exception to this is naturally gluten-free grains, such as quinoa or millet. These can be at risk for cross-contamination with gluten, so look for a gluten-free label on all your grain products. Always look for a gluten-free label on products made with oats, too.

Make a Fresh Start for a Healthy Heart

Heart disease is the No. 1 killer of both men and women in the U.S., responsible for one in every four deaths. In addition, about 735,000 people will suffer a heart attack every year, and nearly 800,000 people will have a stroke. Contributing factors to heart disease and stroke include high blood pressure and diabetes, which occur in one in three and one in 10 adults, respectively. What can you do to reduce your risk?

Gluten free is key

A 2014 study from the American College of Cardiology of nearly 24,000 people with celiac found a roughly twofold increase in heart disease compared to those without celiac. Researchers noted that systemic inflammation related to untreated celiac was the most likely culprit. Another 2017 review of studies found that those with celiac who were not on the gluten-free diet had increased risks of heart disease, stroke and death from a heart attack.

“Several studies have indicated that people with celiac disease have a higher risk for coronary artery disease and stroke when compared with the general population,” notes Trisha Lyons, RDN, LD, a dietitian who specializes in celiac treatment at the MetroHealth Medical Center in Cleveland, Ohio. “The vast majority of people with active celiac disease in the U.S. are believed to be underdiagnosed or misdiagnosed. These people may be experiencing a myriad of signs and symptoms, and are at risk for heart disease. Receiving a proper diagnosis is the first step in reducing that risk.”

However, research also notes that the gluten-free diet goes a long way in helping to reduce the chance of developing one of these conditions. “It is critically important for those people with celiac disease to follow the gluten-free diet carefully to maintain the gut integrity and prevent chronic inflammation,” says Lyons. “This gives them the best chance.”

Steps to a healthier heart

Even just a few years ago, dietary fat was public enemy No. 1 when it came to heart disease. Now we know that many nutritional factors likely play a role in developing the disease, including sugar, salt, fiber and type of fat. “While cholesterol-lowering medications might be necessary for some people, taking heart-healthy measures can assist in lowering blood lipid levels and may even result in lower doses of medication,” says Lyons. “Consume a heart-healthy diet the majority of the time, get regular exercise, consume alcohol in moderation and lose weight if you need to. Keep in mind that even small or modest weight loss can make a difference.” (See chart below for the heart health benefits derived from 5 to 10 percent weight loss.)

Lyons finds that many of her patients struggle to eat enough whole grains, which are likely protective against heart disease. A 2018 study found that men who ate whole grains had decreased levels of stiffness in the aorta, the main artery in the body. High levels of aortic stiffness are often predictive of heart disease and stroke. Other studies have linked whole grains to less inflammation in the body, weight loss, a reduction in diabetes and cancer, and increased longevity.

Perhaps the most significant benefit of whole grains is dietary fiber, which is often lacking in the gluten-free diet. “Fiber is beneficial to the body in many ways, including heart health, weight control, blood sugar control and reducing cholesterol levels,” notes Lyons. “But fiber is low in most processed gluten-free foods.” Lyons encourages her patients to seek out whole grain choices such as quinoa, certified gluten-free oats and brown rice. As always, any gluten-free grain that you purchase should be labeled gluten free.

Despite grains’ health benefits, some with celiac still shy away from them. Fortunately, fiber is found in other healthy foods, says Lyons. “Besides gluten-free whole grains, fiber can be found in nuts, seeds, flaxmeal, beans, peas, fruits, vegetables and foods made from them, such as hummus, lentil soup and trail mix. Also, I might suggest a multivitamin with minerals to make up for the nutrition not being acquired from grains.”

Other heart-healthy choices

Choosing healthy sources of fat is also essential to heart health. Thankfully, harmful trans fats were banned in the U.S. in 2018, so partially hydrogenated oils that raise “bad” cholesterol (LDL) and lower “good” cholesterol (HDL) are no longer available. Choose healthy oils when cooking or baking, such as olive or canola oil. Limit butter and other animal-based saturated fats. Lyons also encourages her patients to look for foods rich in omega-3 fatty acids, such as walnuts, flaxmeal and salmon.

Reducing the amount of added sugar in the diet is also crucial to both cardiovascular health and weight control. Lyons notes that the significant increase in the variety of gluten-free products has not necessarily helped the heart health of her patients with celiac. “Gluten-free specialty goods frequently contain more fat and sugar than their wheat-based counterparts and should be consumed in moderation,” she advises. “Contrary to popular belief, gluten free does not always indicate the healthiest choice.” Keep added sugars, such as the ones found in gluten-free cakes, cookies and sugar-sweetened beverages, to a minimum.

Too much sodium in the diet can contribute to high blood pressure, which can put extra strain on the heart’s arteries. Start by reducing the amount of salt you add to foods, both when cooking and at the table. Consider removing the salt shaker from the table so you aren’t tempted to use it. However, added salt isn’t the end of the story—about 80 percent of the sodium in our diets comes from processed foods. Microwavable meals, canned soups, lunch meat, cheese, bacon, sausage, chips and other snack foods are all examples of foods that may be high in sodium. Try to keep your sodium intake to about 2,000 to 3,000 milligrams (mg) per day.

Roadblocks

The gluten-free diet can often feel overwhelming, and choices may already feel limited. Lyons notes that availability of heart-healthy gluten-free foods can be an issue. “High-fiber, whole-grain, gluten-free specialty foods are not as readily available as highly processed, fiber-poor specialty foods,” she says. “And while gluten-free food options have increased exponentially during the last two decades, some stores still have a limited selection.” If you live in an area where grocery stores offer few choices, it may be a good idea to find whole-grain products online. Lyons also notes that higher prices for gluten-free foods can create a barrier. Consider shopping in bulk for whole grains (but do not buy from bulk bins because of cross-contamination concerns).

Healthy gluten-free foods may not be as convenient to prepare as some of their gluten-containing equivalents. “It is occasionally necessary to prepare gluten-free foods from scratch, where you might not have needed to do that before,” says Lyons. “People with limited cooking skills, time or access to a kitchen have additional challenges.” There are now commercially frozen gluten-free grains such as brown rice and quinoa that only require a microwave for preparation. Choose whole-grain, gluten-free crackers or popcorn for an easy snack and whole-grain bread and tortillas for sandwiches. These need no or minimal preparation.

Lyons also realizes that motivation can be an issue, especially when the diet already feels limited. “Some patients note that they feel significant loss when foods they’ve consumed their entire lives are suddenly off limits,” she says. “Some have little interest in nutrition, so figuring out what foods are safe and heart healthy can be a challenge, especially when eating outside of the home or traveling.”

Lyons provides additional words of encouragement when patients have other conditions that require a restricted diet, such as diabetes. “Having one major dietary restriction can be challenging at times,” she says, “but having to factor in additional restrictions can feel downright overwhelming, especially in the beginning.” She encourages her patients to take it one step at a time. “Numerous gluten-free foods and ingredients are suitable for most diets, including lean meats and fish, dairy, eggs, beans, nuts, gluten-free whole grains, fruits and vegetables,” she notes. “Get a good start by learning about each diet, be willing to plan meals, shop and spend some time in the kitchen.” Taking these suggestions to heart can set you up for a healthy 2019 and beyond!

A little bit can make a big difference

While getting down to your ideal body weight might seem like the ultimate accomplishment, as far as your health is concerned, losing even just 5 to 10 percent of your weight can lead to big gains in your health.

Other benefits of 5 to 10 percent weight loss

A reduction in insulin resistance, which leads to increased abdominal fat and high cholesterol. Insulin resistance can also cause changes in hormone levels that may lead to infertility in women.
An improvement in obstructive sleep apnea (OSA). OSA is commonly diagnosed in those who are overweight, and it can lead to symptoms like loud snoring and gasping for air during sleep. This can lead to daytime sleepiness, increased hunger, weight gain and diabetes. It can also make high blood pressure more difficult to treat. OSA is treated with a continuous positive airway pressure (CPAP) machine, a specific type of breathing machine that is worn at night. By losing just 5 to 10 percent of body weight, OSA may be improved, and some patients may no longer have to wear the CPAP.
Reduce chronic inflammation in the body, which improves vascular health. Along with a 100 percent gluten-free diet, losing a little bit of weight can lead to less inflammation in the body. Weight loss of 10 percent reduces the levels of inflammatory substances in the blood in a significant way.

Dealing With Celiac and Iron Deficiency

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

My daughter, who is in college, was diagnosed with celiac over the summer. Her doctor told us that she also has iron-deficiency anemia, which she said could be caused by the damage done by the celiac. She’s so tired—is there anything she can eat to improve her energy levels? She tried iron supplements, but they upset her stomach.

Your daughter’s doctor is correct that celiac can cause iron-deficiency anemia. This is due to the malabsorption of iron in the intestine. In addition to the fatigue your daughter has experienced, other symptoms of anemia include pale skin, weakness, dizziness, headache and glossitis (an inflamed tongue). Iron supplements are best absorbed when the stomach is empty, but this can make side effects such as nausea worse.

Heme iron, which is found in animal foods such as beef, liver, chicken and turkey, is readily absorbed by the body. Non-heme iron from plant foods such as beans, tofu, dark leafy greens and cashews is not as well absorbed, but these are still good choices. Look for gluten-free bread and cereal products that are fortified with iron. To get the most iron out of food, eat it with foods that are high in vitamin C—for example, pair a baked tomato half with beef pot roast or mandarin orange slices on top of spinach salad.

Do I Have a Gluten and Lactose Intolerance?

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

I was recently diagnosed with celiac. I am doing pretty well eating gluten free, but it also appears I’m now lactose intolerant. I miss ice cream! Is this a forever thing, or do you think it will get better?

The good news is that it will (most likely) get better, and you’ll be able to enjoy ice cream again. A new celiac diagnosis indicates that there is damage to your small intestinal villi. These villi have many functions related to the absorption of nutrients, and they also house our lactase enzyme. Lactase enzyme is necessary to break down lactose found in foods such as ice cream and milk. Continuing on your gluten-free diet will help heal these villi, and the lactase enzyme should become more readily available over time.

What can you do until then? Keep in mind that there can be varying degrees of lactose intolerance. Some people with lactose intolerance can enjoy small amounts of dairy products without issues while others are more sensitive. Let your symptoms guide your choices. If tolerated, lower-lactose dairy products, such as aged cheeses (cheddar, Swiss, Parmesan), cream cheese, half-and-half and sour cream, can be enjoyed. Dairy products with added lactase enzyme are also good choices, including milk, cottage cheese, yogurt and, yes, even ice cream! Some fermented forms of dairy may also be tolerated, such as kefir or yogurt.

You might also consider taking an over-the-counter lactase enzyme when you plan to eat dairy products, which may help reduce symptoms. Furthermore, plant-based milk such as almond or soy milk can be a good alternative. Of course, check the label of all products to make sure they don’t also contain gluten.

Dairy is also a great source of calcium, which prevents loss of bone mineral density. People with celiac are at risk for osteopenia (reduced bone mass), which can lead to the more severe condition osteoporosis. Osteoporosis can result in fractures, which can significantly affect your quality of life. If you continue to struggle with dairy products long term, consider non-dairy sources of calcium, including leafy green vegetables such as kale, collard greens and bok choy, calcium-fortified orange juice or plant-based milk, almonds, white beans, teff flour and almond flour. You might also discuss with your physician whether a calcium supplement might be appropriate.

What Is Your Number Two Trying To Tell You?

“Everyone poops” as the famous children’s book says, but sometimes going can be a less than pleasant and even worrisome experience. You might even find yourself asking “Dr. Google” about what’s normal and what’s not. Let’s take a look at what your number two might be trying to tell you.

Your stool is hard, and you go infrequently.

Recent research shows that about 50% of those diagnosed with celiac disease experience diarrhea. Constipation, however, is also common in those with celiac disease, either before diagnosis or when eating gluten-free. Occasional constipation is normal, but when stools become infrequent or hard to pass for several weeks, it’s time to take action.

If you’re feeling a little backed up, drinking more fluid and eating more dietary fiber can help. You’ll find fiber in fruits, vegetables, beans and gluten-free whole grains. Increase your fiber intake slowly; eating “too much too soon” can increase gas and bloat. Adequate fluid intake is important too, so drink plenty of water or other beverages to help stools pass more easily.

You’re eating gluten free but still having diarrhea.

Continuing to have diarrhea on the gluten-free diet can be a frustrating experience. Most often, unresolved symptoms are due to unintentional ingestion of gluten. Take a careful look at your diet to make sure that gluten isn’t sneaking in where you might not expect it. Consider a visit to a registered dietitian nutritionist (RDN) experienced in counseling patients with celiac disease, who may be able to help you figure out the mystery.

You can also experience celiac disease and lactose intolerance at the same time. Many with newly diagnosed celiac disease are temporarily lactose intolerant, but this usually resolves as the intestine heals. Lactose intolerance is also prevalent worldwide, affecting 60-70% of people. Without adequate lactase enzyme to break down lactose (the natural sugar found in milk), symptoms such as bloating, gas, and diarrhea can occur. If you suspect lactose is an issue for you, consider using lactose-free dairy products or dairy alternatives. Also, some dairy foods are naturally low in lactose, such as aged cheese.

Irritable Bowel Syndrome (IBS) can make going to the bathroom an unpleasant, and often urgent, experience. IBS can occur alongside celiac disease and is more common in those with celiac disease than in the general population. There are three types of IBS: IBS-D or diarrhea predominant, IBS-C or constipation predominant, or IBS-M which alternates between diarrhea and constipation. IBS can range from being quite mild to severe enough that it affects work and family life. While the causes of IBS are not entirely understood, genetics, psychosocial factors, diet, gut function and infectious/inflammatory processes all likely play a role. There are various dietary and medical therapies available to help treat IBS, including the low FODMAP diet. Discuss what options might be best for you with your medical provider or your RDN.

Small Intestinal Bacterial Overgrowth, also known as SIBO, is when excessive amounts of gut bacteria end up in the small intestine. Once thought to be rare, new research indicates SIBO has been underdiagnosed and attributed to other conditions, such as IBS. It is more common in people with celiac disease and can cause continued bathroom issues such as gas, bloating, diarrhea and constipation. SIBO is typically diagnosed via breath test and is treated with antibiotics.

Your stool smells particularly bad or is difficult to flush.

Occasional steatorrhea, or too much fat in the stool, is normal. It can be the result of a high-fat meal, eating too many nuts or drinking too much alcohol. It can also be a symptom of celiac disease. Symptoms of steatorrhea can include stools that have an oily or greasy look to them, stool that is bulky or difficult to flush or stools that have an extremely foul smell. While short-term steatorrhea isn’t usually a sign of anything serious, more chronic steatorrhea should be brought to the attention of your medical provider. Exocrine Pancreatic Insufficiency (EPI) can occur along with celiac disease and can cause steatorrhea.

Don’t ignore more severe issues.

While everyone’s bathroom experience is different, there are a few “red flag” symptoms that are never normal that you should bring to the attention of your physician. These include unintentional weight loss, new-onset symptoms after the age of 50, rectal bleeding, nighttime diarrhea and abdominal or rectal masses. You should never ignore these signs and symptoms, and you should not attempt to treat them on your own.

Eating Vegan On the Gluten-Free Diet

Use this practical advice and information to healthfully eat vegetarian or vegan on the gluten-free diet

Everywhere you look, it seems meat is back. The average American will eat more than 222 pounds of red meat and poultry in 2018, according to the U.S. Department of Agriculture (USDA), which also expects sales of eggs, cheese and butter to hit all-time highs. Popular diets, including Paleo and keto, lead some to think that a diet based on high consumption of meat could afford even more health benefits.

For others, however, the decision to leave meat and other animal products behind is a personal one and may be rooted in concerns for the welfare and treatment of animals, worries about food safety or religious beliefs. Others believe that a meat-heavy lifestyle isn’t good for long-term health and that a plant-based diet can help prevent chronic disease and improve longevity.

For those who combine a vegetarian or vegan lifestyle with the gluten-free diet, food choices require careful planning to avoid nutritional deficiencies. Also, many processed vegetarian products, such as veggie burgers, often contain gluten, so label reading is critical. In this edition of Not Just Gluten Free, we’ll discuss the potential health benefits of vegetarianism, how to combine the vegetarian diet and gluten-free diet, address nutritional concerns, and navigate challenges in living both gluten free and vegetarian or vegan.

Making the choice

For Renee Euler, MS, RD, LD, who is in private practice in Albuquerque, New Mexico, the decision to eat a primarily vegetarian diet came when she met her husband. “When I met my future husband, he had been a lacto-ovo vegetarian [a vegetarian who consumes dairy and eats eggs] for almost five years,” she explains. “I had been following a gluten-free diet for celiac disease for about three years. Dating is difficult when following a special dietary therapy, but it worked out well for our relationship. It made us much more sensitive to the needs of others who follow a special diet.”

It wasn’t easy getting started, notes Euler. “At first, we were what I called ‘bad’ vegetarians, mostly relying on highly processed meat substitutes and other products,” she says. “We realized early on, before I became a dietitian, that we needed to improve our vegetarian diet.” Euler and her husband found the solution in the kitchen, preparing one new vegetarian recipe per week utilizing whole food ingredients and exploring other world cuisines. “While we are not vegan, I do appreciate the need or desire to follow a vegan, gluten-free diet, whether for ethical or personal reasons or additional intolerances to dairy or eggs.”

Euler sees many health benefits to cutting out meat for those who are already gluten free. “There is evidence that a well-planned vegetarian or vegan diet pattern can reduce the risk of cardiovascular disease, cancer, type 2 diabetes and other chronic conditions,” she notes. “Vegetarians tend to consume more fiber, potassium, vitamins C and E, and phytochemicals from their increased intake of fruits and vegetables, which are all thought to be protective against chronic disease.” What’s not in the diet is also notable, says Euler, as vegetarians typically consume less saturated fat and fewer added sugars and processed foods than those who eat meat.

Good nutrition is key

When most people think meat, they think protein. However, with a little planning, vegetarians and vegans can get plenty of protein, too. “Most Americans consume more than enough protein, and we need less than most people think,” says Euler. “The key to getting enough protein is to make sure you include a serving with every meal and snack.” Euler encourages her clients to think of simple ways to include protein, such as stirring almond or peanut butter into gluten-free oatmeal in the morning or having a couple tablespoons of hummus with vegetables for a snack (for more gluten-free and vegetarian/vegan sources of protein, and to learn how to calculate how much protein you need each day, see below).

Click “next” to learn about specific nutrient needs, including vitamin B12, calcium and iron

Savor the Flavor of the Mediterranean Diet

For those eating gluten free, the Mediterranean diet provides variety and great-tasting foods

The Mediterranean diet is considered perhaps the healthiest way to eat in the whole world. Inspired by research on the dietary patterns of those who lived in Greece and the southern part of Italy in the 1940s and 1950s, the Mediterranean diet is based on fruits, vegetables, whole grains, fish, beans and even small servings of red wine. This style of eating offers health benefits for almost every part of the body, including the heart and brain.

In this edition of Not Just Gluten Free, let’s take a culinary trip to learn about the nutritional benefits and flavors of these often naturally gluten-free foods, as well as practical suggestions for making your diet just a little more Mediterranean.

The path to the Pyramid

While the Mediterranean style of eating extends back much longer, the Mediterranean Pyramid (see below) is celebrating a milestone in 2018. Introduced in 1993 by Oldways, a nonprofit organization dedicated to promoting the Mediterranean diet as well as other traditional diets, the Pyramid was a result of a 1993 International Conference on the Diets of the Mediterranean. “Oldways brought together world-class nutrition scientists, public policy experts, food writers and chefs to counter the ‘fat phobia’ and provide an alternative to the USDA’s Food Guide Pyramid, first introduced in 1992,” notes Kelly Toups, registered dietitian and nutrition director at Oldways. “In the years since, the Pyramid has been updated to include new illustrations and reflect the wealth of nutrition science that supports it.”

Oldways developed the Pyramid to help consumers understand the total diet at a glance, notes Toups. “The Mediterranean Diet Pyramid shows examples of what to eat over time, not just at one meal, and the relative proportion of each food group.” Toups stresses that the Mediterranean diet is about lifestyle change, not a short-term fix. “People can get a sense of the combination of all our meals over days or weeks, demonstrating a clear, long-term path to better health.”

The Pyramid design allows for easy interpretation of the diet’s structure. “When deciding what to eat, consumers should make sure that foods at the base of the Pyramid, such as vegetables, fruits, beans and whole grains, are featured in every meal,” advises Toups. “Foods further up the pyramid, including traditional cheeses, seafood and poultry, are used in smaller portions. Foods at the very top of the Pyramid, such as red meat and sweets, are occasional foods and should not be part of the regular weekly diet.”

Click below to learn about the numerous health benefits of the Mediterranean diet.

5 Conditions Linked to Celiac

Research has uncovered several seemingly unrelated conditions linked to celiac. Just a few years ago, doctors may have only looked for gastrointestinal symptoms to indicate potential celiac, but it’s now widely accepted that many other health conditions are related. Some are well known, such as osteoporosis and anemia. Others, such as liver disease and oral inflammation, are less likely to be connected to celiac. This review will describe some less-frequently recognized conditions, highlight recent research and discuss benefits of the gluten-free diet.

1. Nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is a common form of liver disease. It is most frequently found in people who are overweight or obese and those with diabetes or high cholesterol. The liver performs many vital functions in the body, including detoxification and energy storage. It also stores fat, which, in the right amounts, isn’t a problem. When patients have too much accumulation of fat in the liver, however, NAFLD can develop. In most people, NAFLD does not present with any symptoms. But in some it can progress to more severe conditions, including fibrosis and cirrhosis.

NAFLD is also seen more frequently in patients with celiac, according to a study published in 2015. Researchers from the U.S. and Sweden found that of 26,816 celiac patients, 53 were eventually also diagnosed with NAFLD. This risk was highest in the first year after diagnosis. According to lead researcher Dr. Norelle Reilly, assistant professor of pediatrics and director of pediatric celiac disease at Columbia University Medical Center, “The rationale for exploring the risks of NAFLD in individuals with celiac disease may demonstrate unexpected or undesirable weight gain following the initiation of the gluten-free diet.” This weight gain, cautions Reilly, may increase the risk of developing NAFLD for patients with newly diagnosed celiac. Also, Reilly states that processed gluten-free food, which is often higher in fat and calories, may play a role.

Celiac link theory

Why some with celiac disease go onto develop NAFLD remains a bit of a mystery. But there is one theory, Reilly explains. “One possible route, proposed by Ludovico Abenavoli and colleagues, is that increased gut permeability, sometimes referred to as ‘leakiness,’ may be triggered by conditions associated with celiac disease, such as small intestinal bacterial overgrowth (SIBO). This can lead to exposing the liver to bacterial toxins, which can lead to injury and stress that can trigger the development of the condition.”

Most people with NAFLD are unaware they have the condition, and this is no different for those who have celiac. “NAFLD may have no symptoms, but at this point, screening is not recommended for average adults, with or without celiac disease,” says Reilly. “However, in any patient with elevated liver transaminases, NAFLD should certainly be considered among many disorders, and an appropriate evaluation is then warranted.”

Can NAFLD be prevented or treated? Because the condition is very much related to lifestyle choices, healthy eating can go a long way. “Maintaining a healthy diet and body weight with plenty of (gluten-free) whole grains, fruits and vegetables is associated with many health benefits, not just related to NAFLD,” advises Reilly. “Following regularly with a registered dietitian is recommended for all with celiac disease to help in maintaining this balance. Even among those who have already developed NAFLD, the mainstay of treatment involves lifestyle modifications and weight loss in those patients who are overweight.”

Why would gluten-free candy upset my stomach?

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

Q: I have diabetes and celiac. I bought a bag of sugar-free candy that was labeled gluten free, but my stomach got very upset after I ate several pieces. Do you think the label is wrong?

A: I think the more likely culprit is the sweeteners that are often found in sugar-free candy, gum, mints and even some medications. In candy, sugar alcohols such as xylitol and mannitol are used to sweeten with fewer calories and carbohydrates. They are derived from many sources, including some fruits, vegetables and wheat, but the final product is so refined that there is no gluten protein left. However, they can cause significant gastrointestinal upset, such as diarrhea, bloating and gas, especially when too many are consumed at one time. Be assured, however, that they don’t contain gluten.

Q: My brother works at an Italian restaurant. He told me that the same pot of boiling water is used to cook pasta all evening long and that sometimes they cook vegetables in it too. Is that true?

A: Yes, restaurants may use one pot of water for pasta throughout a mealtime. If you plan to order gluten-free pasta or vegetables, ask the restaurant to prepare yours in a separate pot of water that hasn’t been used to cook other food and to drain it separately. If the dish calls for sauce, ask for fresh sauce and a separate ladle that has not come into contact with gluten-containing pasta.

For more of Amy Keller’s advice on following and thriving on the gluten-free diet, check out these Q&As:

To read resident pharmacy expert Steve Plogsted’s advice and information on gluten-free medications, check out these Q&As:

Eating gluten free in the hospital

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

Q: I have been eating gluten free for the past three years. I’m going to have my right knee replaced and will be in the hospital for three days. What do I need to do to make sure I get safe meals?

A: A hospital stay is stressful on many levels, but it can be even more worrisome when eating gluten free. The good news is that most hospitals have had patients who eat gluten free before. However, it’s still a good idea to plan so you’ll have less to worry about when you get there. Ask your doctor to include a gluten-free diet in your post-surgery orders. I recommend that my patients ask to have gluten, wheat, rye, barley and oats entered into the allergy section of the chart. Allergy information is shared with the pharmacy, nurses, physicians and the nutrition department. If the hospital uses allergy wristbands, ask to have these specifications included on yours.

Consider informing the hospital’s registered dietitian about your planned procedure and the dates you will be there. Ask questions about what gluten-free foods might be available and how you can request them. Is there a gluten-free menu that you should ask for? Do they have room service-style meals, or will you be marking your choices on a paper menu? What procedures are in place in the kitchen to keep your foods separate from others? Ask if the hospital allows food brought in from home; a box of your favorite cereal, crackers or cookies is easy to keep in your room.

Of course, some hospital admissions are emergencies and unplanned. Make sure that family members or close friends are aware that you need a gluten-free diet in the hospital in case you are unable to speak for yourself. Keep a current list of medications readily available. If your admission is unplanned, ask to talk to the registered dietitian or foodservice director as soon as possible (it may be the next day if you are admitted late in the evening or in the middle of the night).

For more of Amy Keller’s advice on following and thriving on the gluten-free diet, check out these Q&As:

To read resident pharmacy expert Steve Plogsted’s advice and information on gluten-free medications, check out these Q&As:

Setting up a safe gluten-free kitchen

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

Q: I was diagnosed with celiac a few months ago, and while I’m pretty good at avoiding gluten at the grocery store, I still am worried about my kitchen at home. My sister read that I need a new toaster, all new pots and pans, and that even my paper plates aren’t safe. Is this true?

A: Setting up a safe kitchen can feel overwhelming, but the good news is that it’s not necessary to throw everything away. Yes, you’ll want to buy a new toaster because the crumbs seem to linger no matter how much you clean it. If you live in a house with other people who may toast regular bread, keep your safe toaster separate. I recommend keeping it covered or put away, so no one else is tempted to use it. You don’t need to purchase new pots and pans; washing them is adequate. However, if you have deep scratches in coated pans or those that you don’t wash in between uses (such as cast iron), you may want to invest in something new. Other examples of things you’ll want to keep separate in the kitchen include a bread machine, can opener, condiments such as butter or jelly, cutting boards, flour sifter, colander, mixer and dish towels. There are no gluten concerns with items like paper plates, paper towels or plastic utensils.

For more of Amy Keller’s advice on following and thriving on the gluten-free diet, check out these Q&As:

To read resident pharmacy expert Steve Plogsted’s advice and information on gluten-free medications, check out these Q&As:

Can Dairy Free Do Your Body Good?

You might remember that catchy slogan from the 1980s, “Milk, it does a body good.” Dairy products are nutritional powerhouses, full of bone-building calcium, vitamin D, magnesium and protein. While the average American drinks less milk than in the 1970s, we eat more cheese and yogurt than ever before. But what happens when dairy doesn’t agree with your body?

For many with celiac and other gluten-related disorders, dairy can be a source of discomfort. Lactose is the natural form of sugar found in dairy products. Many newly diagnosed celiac patients experience secondary lactose intolerance, a result of damaged intestinal villi. This can cause continued gastrointestinal complaints such as bloating, pain, nausea and diarrhea, even when eating gluten free. Lactose intolerance is prevalent in the general population as well; the National Institutes of Health estimates that 30 to 50 million people suffer from the condition. Those who suffer from lactose intolerance may be able to tolerate small amounts of lactose in the forms of cheese and butter or fermented foods such as yogurt and kefir. Consider taking lactase enzyme tablets or using lactose-free versions of milk and ice cream.

Allergic reactions to the protein in milk are most common in children. In fact, the incidence of milk allergies comes in second only to peanuts. Fortunately, most (but not all) will outgrow an allergy to milk. On the other hand, some adults may develop allergic reactions to dairy, including skin rash, eczema, wheezing and congestion. It can also cause life-threatening anaphylaxis. For those with milk allergies, it is necessary to avoid all forms of milk and dairy, even lactose-free items.

Unexplained symptoms

For Gina Passantino, a food allergy blogger, it’s been an almost lifelong struggle. “I’ve apparently had an allergy to dairy my whole life but didn’t know about it until I was an adult,” she explains. “I was very thin growing up, and I was prescribed a high-calorie, dairy-based milkshake to help me gain weight. But instead of gaining weight, I just felt worse.” Her symptoms didn’t go away with time. “As an adult, I knew I needed to get calcium, but eating dairy just made me sicker and sicker.”

Initially diagnosed with lactose intolerance, she wasn’t able to start on the right path until a visit to the ophthalmologist, after she started experiencing unexplained facial and eye swelling. “He said, ‘You have a food allergy.’ I got tested, and milk was a huge indicator,” she recalls. “It finally made sense that this is what I’d been dealing with my whole life.” Giving up dairy caused almost immediate improvements in her health that have lasted. “I don’t have a lot of the symptoms that I had as a kid. My abdominal and skin issues went away.”

Pittsburgh-based registered dietitian Jody Garlick found both professional and personal benefits after omitting dairy. “Most of my patients who have dairy issues suffer from digestive, skin and respiratory problems,” she notes. “Giving up dairy provides incredible relief from all of that. Also, I have a milk allergy and have been living dairy free for years. It sure makes it easier to guide others on this type of diet.”

Strong bones without dairy

Those with celiac are at risk for decreased bone density, so it’s vital to consume plentiful dietary calcium, vitamin D and magnesium, with or without dairy products. Garlick suggests a variety of non-dairy foods that are high in calcium. “I recommend green vegetables such as broccoli, bok choy and kale,” she advises. “While spinach and collard greens are high in calcium, the high oxalate content keeps our bodies from absorbing the calcium as well as it could.” Garlick recommends fortified and enriched products as well. “Try fortified orange juice, cereals or fortified milk such as almond, soy or rice milk. I might also encourage almond butter, sesame tahini, tofu and blackstrap molasses.”

There are fewer dietary sources of vitamin D, although it is found in fish such as salmon, sardines and cod. Our skin helps make vitamin D when exposed to sunshine, but it can be difficult for people who live in northern climates to reliably get enough sun exposure to produce adequate amounts.

Passantino has already seen consequences to her bone health because of her dairy allergy. “I do have osteopenia, and I’m still young, so I know I need to pay attention to it. I try to add non-dairy sources of calcium, like kale and broccoli, whenever I can.” In addition to diet, other ways to keep bones healthy include regular weight-bearing exercise like walking, running, weightlifting and avoiding smoking. For those with deficiencies, short- or long-term supplementation with calcium or vitamin D may be necessary.

Label lingo

Just like the gluten-free diet, reading food labels for dairy free takes practice. “One of the biggest challenges I’ve had is getting to know the other names for milk on food labels,” Passantino says. “I also never thought there could be milk in certain foods, like mustard. It can be in so many foods that you would never think of.” Learn other names for milk found on food labels in the sidebar below.

Fortunately, there are a multitude of dairy-free options now available, even for traditionally milk-based foods like cheese and ice cream. “When I’m baking, I typically like to use coconut or olive oil to replace butter,” notes Garlick. “Sometimes I will use a combination of pureed fruit or applesauce along with oil as a butter replacement. I also like dairy-free margarine.” Both Passantino and Garlick recommend milk alternatives. “I love nut-based milk,” says Passantino. “I can bake with both coconut and almond milk, and even hemp and flaxseed milk are great alternatives.” Garlick agrees, “Milk is by far the easiest to replace. My favorites are unsweetened coconut or almond milk.”

Not all dairy substitutions are easy, though, as Garlick notes. “Cheese is the most difficult to replace. My usual go-to for this is nutritional yeast, but I only use it when a recipe calls for a small amount of cheese.” Passantino recommends some of the alternative cheese products now commonly available. “There are so many great products around now that weren’t before.”

Dining out without dairy

Eating away from home presents significant challenges for those on the gluten-free diet, and eliminating dairy can further complicate things. Garlick advises that particular styles of restaurants may be more able to accommodate. “Chinese, Thai and Japanese restaurants use virtually no dairy in most dishes,” she notes. “For more traditional places, it’s best to stay away from cream-based sauces, soups and salad dressings. Try to stick to the basics, such as ordering foods that are baked, grilled or broiled with oil rather than butter.” Garlick also recommends caution when ordering breakfast foods and desserts because they are often made with dairy ingredients. “Just like you have to with gluten free, when in doubt, always ask.”

Passantino finds that preparation helps in many restaurant situations. “I recently also became a vegan, so I often carry my own food to make sure I have something safe to eat. One thing I’ve learned, though, is to bring a separate serving spoon.” She also recommends planning ahead. “I do a lot of research to see who can accommodate my meals before I go. I’m a big fan of Disney for this reason, because I know I can get safe food.”

Tips for getting started

If you’re thinking of giving up dairy, it may be best to start slow. “I encourage my patients to look at the main sources of dairy to get a sense of what needs to be replaced,” advises Garlick. “I suggest baby steps to replace one item at a time with something they really enjoy. There are so many great products available now, so I encourage them to try lots of different options before deciding what they like best.”

Even so, she admits it’s not easy. “The biggest challenge for many people is living without cheese. It’s such a big part of the Western diet and is used so often to add flavor,” she says. “It’s much more challenging to replace cheese than it is milk, butter or even yogurt.” Passantino also advises a gradual transition, if possible. “Pick two nights out of the week to make those your dairy-free nights,” she recommends. “Start slow.”

Coping with even more restriction

Eating gluten and dairy free can feel overwhelming, but Passantino offers words of encouragement. “Try not to think of it as a burden, like, ‘I’ll never have pizza or ice cream again.’ Don’t be afraid to try new products, and try to keep an open mind,” she says. “My husband grew up in a milk- and cheese-eating family, and he now finds that vegan cheeses are good.”

Passantino notes she has found eating dairy free rewarding in many ways. “I think I am healthier now and am more aware of what’s in food. On top of that, I’ve developed great relationships with the food allergy community,” she says. “I started the blog with the thought that I had a story to share. I also wanted to reach out to other adults to let them know that your life isn’t over when you’re diagnosed with a food allergy.”

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

Next time the munchies strike, try whipping up some or all of these crave-worthy Gluten-Free, Dairy-Free Snack Recipes and wash them down with Our Picks for Dairy-Free Milks!

Want more information on adhering to other dietary restrictions in addition to gluten free? Check out our Not Just Gluten Free section!

Lowering Cholesterol On the Gluten-Free Diet

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

Q: I was diagnosed with celiac three years ago and have done well with the gluten-free diet, but at my recent physical, I found out I have high cholesterol. I’m not overweight, so I was surprised. I don’t want to start taking cholesterol medication if I can avoid it. Are there some things I can try with my diet first?

A: Making changes to your diet is certainly a good start in regard to controlling your cholesterol. A heart-healthy gluten-free diet includes fruits, vegetables, whole grains, dairy, lean protein and healthy fat. Try to fill half your plate with fruits and vegetables—fresh, frozen and even canned are all good choices. If you choose frozen or canned fruits and vegetables, avoid sauces or syrups because they add sugar, fat and calories. Choose gluten-free whole grains whenever possible. For example, swap out brown rice for white rice and quinoa-based pasta for rice-based pasta. Fruits, vegetables and whole grains contain dietary fiber, which is beneficial for those with high cholesterol levels.

Choose lean proteins at each meal, such as salmon and chicken. You might even consider going “meatless” a few meals a week, utilizing proteins such as beans or nuts. Olive oil is a great choice for added fat. You can even use it in baking. Choose extra virgin olive oil for the lightest flavor. Drizzle it on vegetables and meats for added flavor and to boost your heart health.

Added sugars and trans fats are both detrimental to your heart. Limit your consumption of regular soda and other sweetened beverages, as well as gluten-free goodies like cakes and brownies. Remember that just because it’s gluten free doesn’t necessarily make it a healthy choice. Avoid foods that contain unhealthy trans fats—the words “partially hydrogenated” in the ingredients list indicate the presence of these fats that raise “bad” (LDL) cholesterol levels and lower “good” (HDL) cholesterol levels. Finally, get moving. Exercise is great for raising good cholesterol levels. Walking briskly for 30 minutes a day on most days of the week is a helpful, realistic goal.

Long-Distance Running and the Gluten-Free Diet

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

Q: I have set a goal to run my first half-marathon. I’ve been eating gluten free for about a year, and I’ve been a runner for about three years. Is there anything special I need to do with my diet to start working toward my race?

A: Congratulations on setting such a healthy resolution. Gluten-free runners have the same requirements for good nutrition as those who eat gluten, although it can take extra planning. While you’re training, make sure you eat a balanced diet, with plenty of carbohydrates, protein and healthy fats. Many runners find that they gain weight when training for longer races, so be mindful of calories, even if you feel like you’re exercising a lot. During training, experiment with how you plan to fuel during the race. Runners often rely on carb gels or chews for energy—many are gluten free, but still check the label to be sure. Carb gels can also be upsetting to a sensitive stomach, so try out all fuels during training. Never wait until race day to try a new gel or chew.

On the days leading up to your race, take in extra carbohydrates to store in your muscles. You’ll sometime hear this called “carb loading.” While most runners do this with pasta, runners who are gluten free can accomplish it with other carbs, including rice and potatoes. Don’t forget to hydrate before and during the race, and just like with fuel, practice this during training. Getting dehydrated can increase your risk of an upset stomach or cramps.

For more advice from our experts, check out these Q&As:

Making the Gluten-Free Diet Work for You

Packing a Gluten-Free Emergency Kit

Preventing Gluten Cross-Contamination in Medications

Packing a Gluten-Free Emergency Kit

Amy Keller, MS, RDN, LD, is a dietitian and celiac support group leader from Bellefontaine, Ohio.

Q: With hurricane season here, I keep meaning to put together an emergency kit for our family in case we lose power or need to leave our house. We have two family members who eat gluten free. What should I include in the kit for them?

A: No one likes to think about an emergency situation in which you could be forced out of your home for days or weeks. But these things do happen, and getting prepared now is smart. Emergency shelters will not likely stock gluten-free foods. The Federal Emergency Management Association (FEMA) recommends that you have a three-day supply of nonperishable food and at least 1 gallon of water per person per day (more if you live in a hot climate).

When preparing your emergency kit, make sure it’s large enough to hold what you need, but not so big and heavy that you can’t carry it. Store it on a high shelf in case of flooding, ideally near the door where you most often exit your home. Stock items that don’t need added water, cooking or refrigeration, such as ready-to-eat canned meats, fruits and vegetables. Keep in mind that canned goods can become heavy if you have too many. Peanut butter, cereal, granola, energy bars and crackers are easier to tote around. If you have a favorite “comfort” food that isn’t perishable, include that as well.

Don’t forget plastic utensils, a knife, can opener, hand sanitizer and disinfectant wipes. You might also consider a small bag of first aid supplies, and FEMA recommends at least a seven-day supply of medications. Find additional information on preparing an emergency kit at www.ready.gov.

For more advice from our experts, check out these Q&As:

Making the Gluten-Free Diet Work for You

Eating Gluten Free in the Hospital

Preventing Gluten Cross-Contamination in Medications

FDA Issues Guidance On Labeling Gluten-Free Medications