Celiac Disease, Gluten Sensitivity and Wheat Allergy: what’s the difference and what are the concerns?

I remember the beginning nearly exactly. Lower GI pain that began in the afternoon, dull enough at first I tried to ignore it, and would only go away after eating dinner, coming back at nearly the same time the next day without any apparent linkage to what I had eaten. I was in the first month of my one-year graduate program for teaching at the time, age 22. I was otherwise healthy and relatively stress-free. Over the next two and a half years, without doing anything about it, the pain intensified and some days was nearly constant.

And I developed more symptoms, many of them far beyond my GI system.

After the first couple hour-long meeting with my doctor, a naturopath, she told me she highly suspected what was going on, but we’d confirm with further testing. It was nearly Thanksgiving then and some of my symptoms were overwhelming anxiety, daily headaches, acne that was far worse than I ever had as a teen, and a nearly complete inability to concentrate. Having formerly struggled with an eating disorder, I was weary of having restrictions in what I ate. Plus, I was making incredibly delicious homemade bread and pastries regularly and I didn’t enjoy the idea of changing that. So I pushed the testing off, dug in my heels, and waited to confirm or change anything until after the holidays. What we confirmed was that I was significantly depleted in nutrients despite eating normally, and highly reacting to gluten. In addition to those other symptoms above, test results also showed a bunch of the wrong type of bacteria hanging out in my system, further contributing to my complete sense of not-at-all-wellbeing. At the time I had many other life events happening with tight finances, job/career uncertainty, and an upcoming wedding halfway planned–so I didn’t push for further testing or a celiac disease biopsy like I should have. Instead, I grudgingly and not altogether stringently, took out gluten from my diet with the knowledge I had.

I felt better very very slowly, but after six months, I was only better enough to know I was still reacting to more than gluten. So we tested again and found more problem foods.

Celiac Disease

Celiac Disease is an autoimmune condition characterized by damage or destruction of the villi in the small intestine resulting in malabsorption of nutrients and widespread pathophysiological symptoms throughout the digestive tract and often in other areas of the body (1, 2)

The only current long-term treatment to successfully stop the autoimmune response that occurs in celiac disease is to strictly adhere to a life-long gluten free diet. This includes avoiding wheat and its relatives (spelt, kamut, emmer, einkorn, triticale, etc.), barley, rye, and in some individuals, oats (3). In celiac disease, the inflammatory response invoked by the gluten proteins leads to destruction of enterocytes, the cells in the small intestine, then atrophy of the intestinal villi, the tiny, fingerlike projections along the small intestine lining that enable nutrient absorption to occur.

The lining of the small intestine is one cell thick, and these cells are semi-permeable, which allows for tiny molecules of nutrients to pass through into the bloodstream. The cells of the gut lining are also joined together by what are known as tight junctions, which are supposed to be tight, but damage can cause larger particles to slip through. When the body negatively reacts to gluten proteins, chemicals that are released in their presence causes the lining of the small intestine to become much more permeable, and substances that normally would not be allowed to pass through now can, causing even more inflammation.

When the area of the body that is responsible for nutrient absorption is so critically damaged, decreased nutrient absorption quickly follows. Likewise, the immune complexes attacking the small intestine don’t just stay there. They travel throughout the body and can damage other organ systems, which is why it is common to see symptoms that are far beyond the gut in those negatively responding to gluten, such as depression or anxiety, headaches or migraines, joint and muscle pain or weakness, skin conditions, fatigue, infertility or repeat miscarriages, frequent bruising, brain fog or difficulty concentrating, osteoporosis, tooth enamel damage, canker sores, and many more associated with lack of adequate nutrients. Lastly, if not diagnosed, or one does not adhere to a strict gluten-free diet, those with celiac disease are at much more risk for developing secondary autoimmune and other diseases, such as cancer.  

When gluten is no longer triggering the immune system, the enterocytes and then villi can begin to heal (3). The goal in implementing a strict gluten free diet is to heal the gut lining so nutrient depletion and widespread symptoms stop occurring. After just one meal containing gluten, symptoms can appear for up to six months in those with celiac disease, which makes paying close attention to cross contamination, and educating friends and family who prepare meals a primary concern. So too is being particularly careful about eating out at restaurants that pay strict attention to cross contamination, or that don’t prepare any food with gluten, which is rare but a real haven for those that need to avoid it.

Gluten Intolerance

Beyond celiac disease, there is the slightly more common gluten sensitivity (also called gluten intolerance), which often displays the same or similar symptoms as celiac disease, but does not cause intestinal damage, often will not take as long for healing and symptom remission to occur, and is not always lifelong. Gluten sensitivity also is not autoimmune, and does not appear to have a genetic linkage. When enough healing has occurred in one that is gluten sensitive but does not have celiac, the individual can often reintroduce gluten in small amounts and/or return to eating it normally.

The one caveat in determining between lifelong strict avoidance of gluten for those with celiac disease, and perhaps less stringency with those with gluten sensitivity, is that the only way to definitely diagnose those with celiac disease is with an intestinal biopsy, and damage will only be ‘complete’ enough to diagnose with daily consumption of gluten for at least six months. I had an unfortunate episode a couple years after I removed gluten in which I unknowingly was eating contaminated oatmeal every day for a month. After realizing and removing it, it still took me over six months to be symptom-free, and that very small amount of gluten daily for about 30 days was nowhere near enough gluten to be able to diagnose. So if one suspects gluten is a problem, I always recommend ruling out celiac disease before completely removing gluten from the diet.

Wheat Allergy

Now, for a slightly different but similar condition—wheat allergy.
Those with wheat allergy have developed an antibody to a particular structure in wheat. Similar to a peanut allergy, symptoms can occur immediately after eating, up to within two hours later, and include swelling, itching or irritation of the mouth or throat, itching, hives, or skin rash, itchy watery eyes, GI concerns such as diarrhea, cramps, nausea, vomiting, difficulty breathing, chronic hay fever, heart palpitations, etc. Like other food allergies that cause similar reactions, even a trace of the food allergen can trigger a severe reaction, and the way your body reacts to a food allergen one time does not predict how it will react the next time. So a mild response in the past does not mean the response will always be mild, and vice versa for severe reactions.

Gluten-Free Diet for other Autoimmune Conditions

A question and/or concern that comes up routinely in those that have been diagnosed with other autoimmune conditions is why is a gluten-free diet commonly suggested if one has something like Hashimotos thyroiditis, Lupus, or others?
The answer here is slightly complicated—but the simplest way to describe it is that it is commonly believed that the gluten proteins are highly complex and difficult molecules to break down, and they are mildly inflammatory in most individuals, but highly inflammatory in others. For those individuals that already have an autoimmune response occurring in the body, an immune system that is “on alert” does not need more inflammatory molecules entering the system. That is why many feel better when removing gluten and other inflammatory foods, such as refined sugar, dairy, processed meat, etc., and load up on anti-inflammatory foods to help heal the whole system.

Sourcing Gluten-Free Products

If one does need to avoid gluten and/or wheat, pay particular attention to sourcing, packaging, and labeling of all foods, and in particular grains that might be processed in the same facilities as wheat and other gluten-containing grains. Flours that are certified gluten-free, or that at least say on the label they are not processed on a line that also processes gluten-containing grains is essential –that’s how I got into trouble with the oats! This means purchasing flours and grains from bulk bins needs to be done with care, as well as knowing the source and details of the processors so as to avoid cross-contamination. Edison Grainery (my favorite source currently), Arrowhead Mills, Bob’s Red Mill (which has two lines so pay attention to whether food is from the gluten-free line!), and One Degree Organics are great companies, but there are many more to be found as long as you read the ingredient list, look for a gluten-free certification, and read the small print about allergen cross-contamination.

I hope this informational article clarifies some of the myths and misconceptions about these challenging dietary conditions. Feel free to comment below or contact me with your further questions or for more information on working with me if you or a loved one are concerned about gluten and/or wheat. In addition to my own experience mentioned above, I studied gluten-associated pathophysiologies extensively while in graduate school for clinical nutrition.

References:
1: Lipski, L. (2012). Digestive Wellness (4th ed.). New York, NY: McGraw Hill.
2: Hardy, M.Y. and Tye-Din, J.A. (2016). Coeliac disease: a unique model for investigating broken tolerance in autoimmunity. Clinical and Translational Immunology, 5(11): e112. doi: 10.1038/ct.2016.58.  
3: Barker, J. M., & Liu, E. (2008). Celiac Disease: Pathophysiology, Clinical Manifestations and Associated Autoimmune Conditions. Advances in Pediatrics55, 349–365. http://doi.org/10.1016/j.yapd.2008.07.001.

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Meeting Your Protein Needs as a Vegan Athlete – and a quick socca recipe

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Over the years as I increased my athletic activity load and gradually began eating in a way that was more vegetable and plant heavy and included even less animal protein than before, I was curiously never asked the question that so often comes up when one stops eating meat. No one ever asked me Where do you get your protein?, the stereotypical question that so often comes up about plant-based diets. Knowing the basics of nutrition, and always adding a small protein source to my meals, I wasn’t at all worried about not getting enough. And interestingly, amongst many of the athletic women in my community who choose predominately vegan meals, it’s common that no one else is worried about protein either, with many active individuals like myself commonly eating plenty of whole grains and plant-heavy dishes that seem incredibly nutrient dense–yet they’re still left wondering over time why their health is in decline. I know I’ve for sure been in this scenario.

It wasn’t until I saw a nutritionist near the beginning of graduate school that I began to realize I too fell into dietary imbalance. My nutritionist mentor pointed out, You’re REALLY active. And for your activity level and because you tend to avoid meat, you need A LOT more protein. For quite a few months before I learned the particulars of what protein’s amino acids are doing in the body, and the higher needs of plant-based athletes, I really struggled with her suggestions to increase my intake.

Now before we get into the particulars, I’ll add a caveat that I do tend to eat some animal protein, usually in the form of monthly-ish wild-caught fish, a handful of eggs per month, and every once in a while, a bit of other meat. This blog post is not about the why’s of how I eat, or to encourage or discourage anyone from adopting a plant-based or vegan diet, it’s simply to support what the nutritional science currently knows about protein and our needs based on activity level and dietary choices.

 

As we all learned in grade school science, protein is made up of amino acids. Certain amino acids are essential to eat because the body, though incredibly wise, cannot make them out of other amino acids, as it otherwise can do.

Protein at its most basic understanding, builds muscle. We all learned that in elementary school and the idea is popularized in the cross-fit / weightlifting community. Beyond that role, amino acids from protein are used for bone health, enzyme formation to catalyze and carry out essential metabolic reactions, energy creation, to bind together skin and tendons, blood vessels, in the digestive system, and more. Nearly every one of the body’s 100 trillion or so cells is composed of various proteins, so our bodies require amino acids to function optimally. We don’t necessarily need “a lot” of protein in the diet, but we do need enough to meet our individual body’s needs.

 

Where vegetarian and vegans differ from meat-eating individuals is that they actually require a bit more protein as a percentage of body weight. Athletes of all types who train more than about 30 minutes 3x / week require more too than the non-athletic community. And vegetarian and vegan athletes require just a bit more. So compared to their meat-eating counterparts, a vegan marathon or ultrarunner for example, needs quite a bit more protein than an individual who fuels with meat, and that protein can be more difficult to come by—especially when or if further dietary limitations come into play, such as when soy, legume, or nut allergies also limit food choices.

 

When I work with individuals, I don’t tend to give amounts or percentages of protein because we all eat food and food contains many different macro and micronutrients. In fact, even a plate of plain vegetables can offer a little boost of protein. I also never encourage anyone to get caught up in tracking meals rigidly to reach a certain number of either calories or nutrient values. That practice breeds its own problems.

But for the sake of being more precise, our current research suggests that vegan athletes need from 1.3-2.0 grams of protein per kilogram of body weight in the diet per day (1, 2, 3), with that intake being closer to the high end when there is a lot of high intensity or big-mileage pursuits in the regular training plan. For a 130-ish pound female athlete, that’s roughly 120 grams of protein per day, which is more easily achieved with two servings of fish or meat in the meal plan for a day, but maybe not so much with beans, quinoa, and lots of fresh vegetables. In other words, active vegan athletes training for challenging events are going to have to work to get the necessary protein in to meet the body’s needs and repair itself adequately. That’s where and why a good-quality protein powder might come in handy, as well as adding in little extras throughout the day and diet to help.

One other thing to note is that our currently data suggest that a good amount of protein per meal is from 20 to 30 grams, and this is enough to help the body begin to recover post-exercise and throughout the day. More than 30 grams in a single meal is not necessarily beneficial, i.e. the body metabolizes protein best when it’s eaten throughout the day in meals that contain that 20-30 gram amount. Weightlifters slamming 50+ grams post-workout aren’t necessarily doing their body any favors. And neither is the person that eats one large meal that contains a burger and bacon, or a surf and turf steak and seafood meal, or a meat-lovers pizza.

 

Beyond just needing more protein if you’re a vegan athlete, those with active inflammation, such as when healing from an injury, getting over a long illness, or dealing with an autoimmune disorder likely need more protein as well, since more (of all nutrients) are going to be used in the body’s process to repair itself.

 

For a lot of individuals who know or suspect their protein intake is low for their needs, I generally suggest making small changes that start to add up. Adding more nuts and seeds of all types to morning porridge, swapping the amounts of beans and rice for dinner (more beans / less rice), rotating in tofu and tempeh more often, and adding in chickpea or other bean flours where previously grain-based flour was used are examples I often employ in my own meal patterns.

When choosing to eat whole grains, there are also certain choices that are higher in protein than others, such as wild rice (6.6g / cup), spelt berries (6.6g / cup), quinoa (6.4g / cup), amaranth (6.4g / cup), buckwheat (6g / cup), oats (5.9g / cup), and barley (5.6g / cup) (4).

Another idea is to start being more creative with beans such as using a chickpea flour to make delicious socca, a French pancake or crepe-like flatbread that’s simple, quick, and tasty. Socca is one of my favorite ways to add a little extra protein boost in a meal when I’d otherwise reach for a more-carbohydrate-rich food, like bread, flatbread, or a cooked grain.

 

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If this topic interests you, below are a couple follow-up articles that give more meal ideas and delve deeper into one of the amino acids that frequently falls short in a vegan diet (leucine). They are all great short reads.
Thinking about becoming a vegan athlete? (with information about meeting leucine requirements)
No Meat Athlete Protein Bowl with 30 grams protein
The Full Helping’s protein meals combinations (not specific to athletes / contains some lower protein examples)

 

 

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Socca, makes 2
1 cup chickpea flour
1/2 tsp. baking powder
pinch of salt and dash or two of black pepper
1 tsp. turmeric
1 cup water
oil, just enough to coat the pan

  • In a medium bowl, combine the flour, baking powder, salt and pepper, turmeric, and then water. Whisk until you have a smooth batter. Set aside while you heat a large skillet over medium heat.
  • When the pan is hot, lightly brush the bottom with oil. Pour in half the socca batter (about 3/4 cup) and tilt the pan to distribute it evenly. Cook for about four minutes, until the bottom is browned and comes away easily from the pan, and then flip to do the same on the other side. Repeat with the remaining socca batter.
  • Remove the socca to a plate, and serve alongside or as a base for whatever other ingredients you prefer.

References:

  1. Kerksick, C.M. and Kulovitz, M. (2013). Requirements of Energy, Carbohydrates, Proteins, and Fat for Athletes. Nutrition and Enhanced Sports Performance. Doi: http://dx.doi.org/10.1016/B978-0-12-396454-0.00036-9.
  2. Zhou, J., Li, J., and Campbell, W.W. (2013). Vegetarian Athletes. Nutrition and Enhanced Sports Performance. Doi: http://dx.doi.org/10.1016/B978-0-12-396454-0.00036-9.
  3. Witard, O.C., Garthe, I., and Phillips, S.M. (2019). Dietary Protein for Training Adaptation and Body Composition Manipulation in Track and Field Athletes. International Journal of Sports Nutrition and Exercise Metabolism, 29(2), 165-174. Doi: https://doi.org/10.1123/ijsnem.2018-0267.
  4. Whole Grains Council. (2014). Whole Grain Protein Power! Retrieved from: https://wholegrainscouncil.org/blog/2014/02/whole-grain-protein-power.

 

 

 

summer peach oatmeal

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At times over the years, I’ve considered making this a blog of oatmeal recipes. It’s pretty much my favorite food, I’ll eat it just about any time of day and it’s been my breakfast of choice for the strong majority of my life.

What I’ve added to the oats has definitely changed over the years however. From the brown sugar, milk, and stink bugs (aka raisins) of my youth, to the 10 carefully counted blueberries and half a banana of the days when I ate religiously too rigid during my eating disorder, to now when the toppings are varied and more numerous, oatmeal has been my tried and true.

 

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For many years the one ‘error’ I made in my morning bowl was that I was afraid of adding any healthy fats to it. I notice this with others too. Either seasonal fruits or berries or dried fruit are a popular topping but the thing about eating nutrient rich foods like fresh berries or anti-oxidant filled fruits (and vegetables), is that without a carrier fat in the meal they’re eaten with, those fat-soluble vitamins A, D, E, and K can’t actually be absorbed. We need healthy fats to make them effective. After years of being afraid of fat, I’m now a big fan of eating it in moderate amounts since fats are important for both cellular and hormonal health. Fats surround all cells and organelles in what is called the phospholipid bilayer and they are essential for proper cellular development, as well as carrying messages throughout the body in the hormones.

It’s important for us to eat a variety of fat types from foods rich in saturated fat to the unsaturated mono and polyunsaturated omega 6 and 3 fatty acids. Our modern diets tend to be less diverse and mainly have an abundance of saturated and omega-6 polyunsaturated fats. The omega 6 fats are found in soy, corn, safflower, sunflower and peanut oils, as well as sesame, sunflower, and pumpkin seeds, and most nuts. In whole food form, they are incredibly healthy and essential, but need to be balanced with omega-3 fats such as freshly ground flax, chia, walnuts and wild caught cold-water fish such as salmon, halibut, anchovies, cod, and sardines. The ratio of omega 6 to omega 3’s should be under 5:1 to be considered anti-inflammatory and for most individuals, this ratio is at least 20:1 or more.  For anyone with health concerns that are inflammation-related such as any of the common ‘lifestyle diseases’ like diabetes, high cholesterol or blood pressure, autoimmune conditions, arthritis of any type, and/or you are an otherwise healthy athlete looking to improve recovery between workouts, consuming those delicious nutrient-filled fruits and vegetables along with a healthy fat source and eating an optimal balance of omega 3s and 6s can be incredibly helpful. (My personal example is as an athlete trying to improve recovery and with an underlying chronic autoimmune/arthritic-like condition.)

One other thing to note is that all fat digestion first takes place in the mouth from chewing and saliva beginning to break down food–so chewing is important–and intestinal digestion requires bile salts and pancreatic lipase, an enzyme that specifically helps to break down and absorb fat molecules. If you find you don’t digest fats well, consider sending me a note. There are lots of natural ways to assist the digestive process!

 

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Now for my favorite oatmeal bowl lately. It’s got a super-seasonal local peach chopped and added in the last few minutes to old-fashioned oats, a pinch of salt, a teaspoon or so of tahini, and a good tablespoon of ground flax seed. In the summer, I tend to always add a sprinkle of fennel seeds, which also support digestion, and then top it all off with a bit of cinnamon.

 

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Creamy Summer Peach Oatmeal, makes 1 large or 2 small bowls

1 1/2 cups water
1/2-3/4 cups old-fashioned oats, gf certified as necessary
1/8 tsp. salt
1 tsp. fennel seeds
1 large peach, chopped
1 tsp. tahini
1 Tbs. ground flax
cinnamon, to sprinkle

  • Bring the water to a boil, add the oats, and turn down to medium-low. Cook until nearly all the water is absorbed and then stir in the remaining ingredients except the cinnamon. Cook until it is creamy and all the water is absorbed.
  • Turn out into a bowl and then top with cinnamon.