Pam Cureton

Healthy Holiday Eating

Q: When I go for a holiday cocktail hour, I usually find few, if any, gluten-free appetizers. As a result I end up drinking more cocktails and eating very little. How do I keep from getting tipsy under these circumstances?

A: The “holiday cheer” can present a problem on empty stomach. For parties on your calendar, plan ahead how to handle holiday eating. If held at an unfamiliar place, don’t arrive hungry. Plan on a light meal before leaving the house and, if appropriate, take along a gluten-free appetizer to share so you have at least one safe item to eat. If you are going straight from the office, that morning pack a gluten-free energy bar (LÄRABAR), a piece of fruit, peanut butter on gluten-free whole grain crackers (Crunchmaster) or a Greek yogurt and carrot sticks, and take a minute to enjoy this snack before the party. Limit alcoholic drinks by first drinking a large glass of water (with a twist of lemon or lime), then alternate a cocktail with a nonalcoholic beverage. As always, remember to drink responsibly and have a designated driver.

Q: How do I avoid getting lots of fat in my otherwise healthy gluten-free diet during this time of year when all the gluten-free goodies, cookies, for example, are so high in fat?

A: An increase in the amount of fat and calories in food is a problem in both gluten-free and gluten-containing holiday foods and treats. If you are the one doing the baking or cooking, experiment with alternative ingredients to butter and oil such as applesauce or prune puree. Replace cream or whole milk in recipes with evaporated skim milk, and try yogurt to replace sour cream in dips. If someone else has prepared the gooey goody or rich dish, portion size is the key. Pick just one of the special holiday treats and then enjoy it guilt free.

Q: I am gluten free and want to host a holiday party. Is okay to go all gluten free so I do not have to worry at my own party?

A: Every year I host the neighborhood cookie exchange and my friend Anne, who has celiac disease, never misses it. The first year, I served gluten-free crackers along with separate dips to avoid cross contamination. I overheard one of my guests raving about the delicious crackers. The next year, I replaced all the wheat crackers with a selection of gluten-free crackers and corn chips to go with my cheese and gluten-free dips. No one missed the old crackers. By the way, the favorite Christmas cookie that year was Anne’s Russian Tea cookie made with gluten-free Bisquick. (You can find the recipe at bettycrocker.com.) There’s no reason to think gluten-free food is not good enough to be enjoyed by everyone. So plan that gluten-free menu, relax and have a good time. Your guests surely will.

Q: I am self-conscious about letting holiday hosts know I am gluten free, especially with all the backlash about whiny guests wanting special dietary treatment. What do you think?

A: As a holiday host, I want to know if my guests need special dietary accommodations such as vegetarian, lactose free or gluten free. Once I was just about to serve a wonderful dinner for my son’s friends when I found out one is a vegetarian. Several dishes could have been easily adapted (no added bacon on top, a vegetable broth instead of chicken broth) and no one would have been left out. When you respond to an invitation, let the hostess know you are on a gluten-free diet and offer to bring a dish to share. Your hostess then can decide to alter recipes or purchase special gluten-free products for you or, at least, inform you of ingredients in recipes so you’ll know what’s safe to eat.

Q: The holidays are so busy and stressful and I find it hard to fit in my regular exercise routine. Any suggestions on exercise to avoid extra holiday pounds?

A: This is another problem not unique to the gluten free. Americans gain an average of one pound from Thanksgiving to New Year’s, one study shows. The Academy of Nutrition and Dietetics recommends waiting to start a weight loss diet until after the holidays so you are more likely to succeed. However, cutting back on fats, limiting portions of holiday treats and exercising will help maintain your weight.

Try these fun activities to burn holiday calories and reduce stress:

Power-walk around the mall (but leave the charge card at home) and enjoy the decorations and holiday music.
Go sledding, ice skating or play touch football.
Sign up the entire family for annual “Turkey Trots” or other holiday walk/runs.
Take a brisk walk around the neighborhood looking at holiday lights.

Q: A food safety commission in Europe is allowing chocolate to be considered a health food because it is beneficial for blood circulation. Does this mean I can indulge in chocolate guilt-free this holiday season?

A: Don’t we wish! Chocolate (especially dark chocolate) does have many good things to offer, including flavonoids and antioxidants. It also comes wrapped in fat and calories. One bar of dark chocolate has around 400 calories, so, just like all the other holiday goodies, enjoy in moderation. Most of the studies done used no more than about 3.5 ounces of dark chocolate a day to get the benefits.

Pam Cureton is a clinical and research dietitian specializing in the treatment of celiac disease at the Center for Celiac Research at the University of Maryland, School of Medicine.

When, Why and How to Consult a Dietitian

Q: When I was first diagnosed with celiac disease, I asked my doctor if I should see a dietitian. He did not see the need and said I could find information on the Internet. My 6-month follow-up lab work shows that my antibody levels are down but not back to normal, and I still have symptoms. Would it help to see a dietitian now?

A. The only treatment for celiac disease is a strict, lifelong gluten-free diet. The Internet can be a wonderful help but can also be a source of confusion and misinformation. The National Institutes of Health consensus statement on the management of celiac disease advises consulting with a skilled dietitian. The Academy of Nutrition and Dietetics Evidence Based Nutrition Practice Guideline for celiac disease says medical nutrition therapy provided by a registered dietitian is strongly recommended for individuals with celiac disease.

A consultation would include:

An assessment to determine a nutritional plan. This includes the review of nutritional anemias, vitamin deficiencies, and other factors affecting quality of life. It would also include an assessment of gastrointestinal symptoms as well as others related to celiac disease and the conditions it sometimes causes.
Nutritional advice and education on how to follow a gluten-free diet. A registered dietitian would advise you on gluten-free meal plans, the consumption of whole and enriched gluten-free grains, the addition of multivitamins and mineral supplements (calcium, Vitamin D, iron) and how to read labels to determine if a food is gluten free. In addition, he or she would provide you with reliable sources of further information.
Monitoring and evaluation of follow-up lab work and a dietary questionnaire to determine if you are complying with a gluten-free diet.

You should consult with a dietitian to look for any sources of gluten inadvertently getting into your diet. A dietitian will also be able to help determine if your current symptoms are related to other dietary intolerances such as lactose or fructose. In addition, a review of your diet will indicate if you are receiving important nutrients and essential vitamin/minerals.

Q: I did seek the help of a dietitian when I was diagnosed, but she did not seem familiar with celiac disease or the gluten-free diet. How do I find a dietitian who can help me?

A. Within the medical profession, many health care providers have chosen to specialize in a concentrated area of practice. Just as your primary care physician relies on specialists for further evaluation and treatment of specific diseases, the same holds true for dietitians. We all have an excellent background in nutrition assessment and treatment; some diseases need more in-depth skill. I specialize in celiac disease and other gluten-related disorders and would be helpful in managing those patients. However, I would not be the one to treat and manage renal transplant patients. I would refer a patient to my colleagues who specialize in those areas.

There are a number of resources to help find a dietitian knowledgeable about celiac disease. The Dietitians in Gluten Intolerance Disorders have a resource list of celiac centers and dietitians who specialize in gluten-related disorders that is available at mnpgdpg.org (click on DIGID Resources). Tricia Thompson’s website, glutenfreedietitian.com, provides a list of dietitians who specialize in gluten-related illness, listed by state, under “Resources.” The Academy of Nutrition and Dietetics (eatright.org) will also help you find a dietitian by specialty and zip code.

Q. I have been following a gluten-free diet for two years and my symptoms have improved, but I worry that I am not getting a balanced diet. I recently read an article that vitamin/mineral supplements are not helpful and can even be harmful. Should I be taking a supplement?

A. This is an example of why is it so important to work with your dietitian to evaluate your diet and assess whether you may need a supplement and what kind.

First and foremost, essential nutrients should come from the foods we eat by including a wide variety of foods from each of the basic food groups (dairy, lean protein, fruits and vegetables, whole grains and healthy fats/oils). That said, few of us eat a perfectly balanced diet every day, and on occasion our daily vitamin consumption is less than stellar. As a result it can be a good idea to take a daily vitamin and/or other needed supplement.

The gluten-free diet can be low in iron, calcium, magnesium, vitamin D, zinc, folate and other B vitamins. A general gluten-free multivitamin/mineral supplement that supplies no more than the recommended daily allowance (RDA) or daily value (DV) of the B vitamins plus minerals (no mega or high-potency brands) will fill in the gaps. Overdoing certain vitamins can lead to toxic levels causing harm. If you are already eating the recommended amount of a nutrient, you may not get any further health benefit from taking a supplement. In some cases, supplements and fortified foods may actually cause you to exceed safe levels of nutrients.

For more detailed information about supplements, see GF Vitamin Guide: Food is the Best Source but Supplements May be Needed.
The NIH Office of Dietary Supplements has a series of vitamin and mineral fact sheets that provide scientifically based overviews of a number of vitamins and minerals.
Webmd.com also provides sound information.

Q. Does insurance usually cover a consultation with a dietitian?

A. Insurance coverage will vary greatly depending on the insurance company and the specific plan. It is best to check with your insurance provider for the coverage details and to see if you have to select a dietitian from a pre-approved list. If coverage is denied, you can ask for a letter of necessity from your physician and dietitian to appeal the decision to deny coverage. Also, it may be covered under your pre-tax health care spending account.

Q. If not, how much would it cost me to see a dietitian?

A. This is also variable. Some dietitians’ services are included in the physician’s bill and are not charged separately. Others charge by the session or time increments if seen without a physician’s visit. Exact fees and billing procedures need to be discussed at the time the appointment is made. Most hospital-based outpatient services, including medical nutrition therapy, can be prorated if payment is an issue.

Q. How does a dietitian treat gluten sensitivity?

A. Non-celiac gluten sensitivity also requires a strict gluten-free diet, and a knowledgeable dietitian would provide treatment to be sure the diet is nutritionally sound and effective.

Pam Cureton is a clinical and research dietitian specializing in the treatment of celiac disease. She currently works with Alessio Fasano, M.D., at the Center for Celiac Research & Treatment at Massachusetts General Hospital and the University of Maryland celiac disease clinic. Cureton’s recurring column answers readers’ questions about managing the gluten-free diet. Send yours to [email protected].

Good Carbs vs. Bad Carbs: Your Questions Answered

Pam Cureton is a clinical and research dietitian specializing in the treatment of celiac disease. She currently works with Alessio Fasano, M.D., at the Center for Celiac Research at Massachusetts General Hospital and for the University of Maryland celiac clinic. Cureton’s recurring column answers readers’ questions about nutrition and the gluten-free diet. In this article, she answers your questions on carbs, whole grains, weight gain and the most nutritious gluten-free flour.

Q: I am trying to eat healthier while following my gluten-free diet. Should I be avoiding all carbs? Are there good carbs and bad carbs?

“Carbs,” or carbohydrates, are your body’s primary energy source, and they’re a crucial part of any healthy diet plan, gluten free, of course. Carbs should never be avoided, but it is important to understand that not all carbs are created equal.

Carbs can be classified as either simple or complex. Simple carbohydrates considered “bad” are composed of easy-to-digest, basic sugars with little nutritional value for your body. These carbs break down quickly and enter the blood stream, causing a rapid rise in blood sugar, and can lead to a quick crash as the blood sugar level quickly falls. Examples of simple carbs would include cake, cookies, candy, sodas, and other refined and processed sugars.

Complex carbohydrates are considered “good” because they take more time to break down and contain important nutrients such as vitamins and fiber. Complex carbs help keep blood sugars on an even keel, without big spikes and dips. These include foods such as vegetables, beans and lentils, whole-grain flours and cereals, high-fiber breads and pastas.

It is not necessary to avoid “bad” carbs completely. Moderation is the key to following a healthy diet. There are so many great-tasting gluten-free bakery products on the market today, it is difficult to avoid indulging once in a while. Follow the 90/10 rule: eat healthy nutritious foods 90 percent of the time and enjoy the fun stuff 10 percent of the time!

Q: I am reading a lot lately about the importance of whole grains. I worry that I am not getting enough whole grain following a strict gluten-free diet. How do I know if I am getting enough?

It is true that studies have indicated people following a gluten-free diet can be low in whole grains. However, you are not alone as 40 percent of people on gluten-containing diets are also missing the 2010 Dietary Guidelines for Americans. The guidelines recommend three to five servings of whole grains be included daily (or at least 48 grams).

Whole grains provide an excellent source of Vitamin E, B vitamins, fiber and minerals such as zinc, iron and magnesium. Wheat is not the only grain that provides such nutrients as the gluten-free alternative grains can be powerhouses for nutrient rich products. Look for the yellow Whole Grain Stamp on the label to identify if a product is, indeed, a whole grain.

For more detailed information and recipes for incorporating whole grains in the gluten-free diet, visit glutenfreediet.ca.

Q: I was diagnosed with celiac disease and have been following a gluten-free diet for the past year. Contrary to the popular belief that gluten free helps with weight loss, I have gained more than 10 unwanted pounds. Please help!

This is a good news-bad news situation. The good news is that your weight gain is a sign of healing in the intestines and your villi are repairing and doing their job of absorbing nutrients again. Before your diagnosis, the damage to the gut may have prevented the absorption of these important nutrients/calories and therefore you did not gain weight. Now that you have followed the diet, healing has occurred and you have regained your ability to absorb again.

Now that you have adjusted to the gluten-free diet, it is time to take a closer look at what types and amounts of gluten-free foods you are including. It is also time to not only look at the ingredient list for sources of gluten but look at the nutritional label for key nutritional facts.

Start with portion size. Not all packages are a single serving, and their idea of a serving may not be the same as yours. Next, look at calories and fat per serving to see if the gluten-free product is equal to your former wheat product. Recently, many gluten-free products have improved on their calorie and fat content and are closer to the wheat counterpart. But many remaining products still contain more of both.

Also look at the nutritional panel for the amount of fiber in the product as fiber will help to fill you up and stay satisfied longer. Here again, the gluten-free market has made many improvements, so look for breads, crackers and pasta that provide at least 2 grams per serving.

For more information on what to include for a balanced diet, check out choosemyplate.gov to find out how many calories per day you should aim for and what foods you should use to fill up your plate .

Q: Is there one ideal gluten-free flour that I should be including in my diet, the one that has the best nutritional profile?

With the great selection of ancient grains and gluten-free alternative flours, it would be difficult to choose just one. Each grain/flour has distinctive properties it brings to the end product—different taste, texture and nutrients. But you should try new gluten-free alternatives if you are currently using only refined rice flour and starches.

Coconut flour is an interesting one to experiment with. It’s rich in protein, fiber and fat, which makes it filling. Coconut flour is also an exceptionally good source of manganese, which helps you to better utilize many nutrients, including choline and biotin (found in eggs), Vitamin C and thiamin.

Coconut flour needs special consideration when used in recipes as it is extraordinarily absorbent, and very little coconut flour is needed to successfully produce a recipe. Because of this characteristic, it is best to start with established recipes. For more information about baking with coconut flour and recipes, visit bobsredmill.com or nourishedkitchen.com/baking-with-coconut-flour.