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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Beet + Seed Loaf Cake

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I had an instance last weekend that after some consideration, seemed like a metaphor for life right now. I had been planning a creative cake project for William’s birthday and in retrospect I planned the more creative aspects of it, but not so much the logistics of size and weight, how many layers can actually stack before it’s too much. That sort of thing.

After a few hours of baking, as assembly got underway, the cake began breaking apart before me, each layer collapsing in to the next as their weight was too much. In panic, I *tossed* the whole thing in the freezer, hoping it would chill quickly enough to stop the destruction.

 

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And then like the cake, I completely melted down. William who really didn’t care whether he had cake or not, tried to reassure me, but the damn cake falling apart was in that moment an abject failure on my part after toiling away for hours and planning and looking forward to it for weeks.

So I took a break, made some tea and ate a snack because sometimes a blood sugar boost and tea actually is the best remedy before going on.

A little more resolve in my system, and I found a way to salvage two of the four layers, effectively putting the cake back in adequate proportion territory, and still plenty enough for a birthday.

 

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For the artistic frosting finale, I realized the downsizing really put a hamper on how the color scheme / paint-like effect of the frosting was going to end up and at the end, William laughed at the looks of my finished result, although ‘it doesn’t look bad, really‘ were the words that came from him, and ‘just different than what you were going for.’

 

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Different than what I was going for are probably words that describe most things for me. There’s that river again, which I cannot push. Trust and go with the flow. Again.

And maybe believe in yourself and know that you / I / we can make good come from every challenge.

 

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Back to the birthday cake and it turned out tasting, if not looking, perfect. Almond poppy seed layers from this base recipe, cream cheese frosting, and a few splashes of color from mostly natural food dyes, which was part of the project.

What all that has to do with today’s recipe, I’m not entirely sure. Other than we like poppy seeds in this house. And raisins. And cake, in various forms. Occasionally.

Fittingly though, I first made this beet + seed loaf cake, a major spin-off from Nigel Slater’s popular original, for a Mad Hatter Tea Party at work last spring. The party was for our volunteers and since most of them are retired master gardeners who also love earthy flavors and garden-inspired things, the cake was quickly gobbled up with approval. The tweaks I gave the original involve substantially less sugar and some more wholesome flours and it’s safe to say this is more of a breakfast or snack loaf, rather than a sugar rush in a slice.

 

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Beet + Seed Loaf Cake, makes 1 9×5 or 8×4-inch loaf
The flours can be changed here, depending on what’s on hand. Instead of chickpea, sorghum or millet are great substitutes. I used ground flax seeds here instead of eggs, but an earlier version of this made with 2 eggs instead also resulted well. 

2 Tbs. ground flax seeds
6 Tbs. water

100 grams / 1 cup chickpea flour
70 grams  / a scant 1/2 cup brown rice flour
25 grams / ¼ cup arrowroot flour
½ tsp baking soda

1 tsp. baking powder
½ tsp. salt
½ tsp ground cinnamon
1 tsp. vanilla extract

¼ cup coconut oil
½ cup applesauce
70 grams / 3 Tbs. brown rice syrup
150-170g / 5-6 oz. raw beet, shredded coarsely
juice of half a lemon
½ cup raisins
½ cup mixed seeds (sunflower, pumpkin, etc.)
4 tsp. poppy seeds, divided

  • Preheat the oven to 350F / 180C. Line a loaf pan with baking parchment. A 9×5 will yield a larger, more compact loaf, and a slightly smaller pan will yield slices that are taller.
  • In a small bowl, combine the flax and water and then set aside for a few minutes.
  • Stir together the flour, baking soda, baking powder, salt and cinnamon. In a separate bowl, mix the vanilla, coconut oil, applesauce, and brown rice syrup. Stir in the flax meal.
  • Grate the beetroot coarsely and fold into the mixture, then add the lemon juice, raisins, mixed seeds, and 2 teaspoons of poppy seeds. Then stir in the flour mixture.
  • Pour the mixture into the cake pan, smooth the top, and then sprinkle over the remaining 2 teaspoons of poppy seeds. Bake for 50-55 minutes and test with a toothpick to see if done. The cake should be moist inside but not sticky.
  • Leave the loaf to cool for a good 20 minutes before turning out of its pan on to a  cooling rack.

Mushroom and Black Bean Enchiladas

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Have you ever had days or weeks or seasons where you’re putting a lot of effort in and not seeing much results? And then when you stop trying or put your focus just a little to another direction and stop caring so damn much, the results show up in their own way and on their own timing?

 

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I think this is simply God or the universe’s way of telling us to trust and go with the flow a bit more. There’s a Chinese proverb that states, “Don’t push the river, it flows by itself.”  I love this one. It generally seems to apply, always.

 

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This is all to say, I had a very different blog post and recipe planned for this week but after many drafts and recipe variations, I’ve accepted it simply wasn’t ready to come out. On the other hand, I wrote down mushroom and black bean enchiladas in my blog ideas journal recently and with putting hardly any effort in at all, this recipe worked itself out in my head and then in the kitchen, and it came out so completely to perfection in one easy go that it became clear this is the recipe and message to be shared this week instead.

 

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So if enchiladas with mushrooms and black beans, zucchini and a coconut, cilantro and lime drizzle sound delicious, go make them. They’re tasty. And if not, go ahead and think about applying that proverb to whatever you need to. Or join me and do both.

 

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Mushroom and Black Bean Enchiladas, serves 3-5
This is a recipe that comes together with a little prep ahead. Most of the seasoning comes from the Spicy Tomato Sauce and the Creamy Black Beans. You can of course skip these and opt for ready-made enchilada sauce and canned black beans, but just understand the flavorings will be a little flat in comparison. After 10 years of blogging in this space, my Creamy Black Beans are the one recipe that I make from the blog most often and they have ruined our household of all other black beans, so if you have some time to prep and let them simmer ahead, they’re worth it. Otherwise, I used light coconut milk in the coconut lime sauce but a full-fat version would be a tasty and decadent alternative to top these enchiladas with. Enjoy!

coconut oil
1 medium onion, diced
1 medium sweet pepper, diced
1 jalapeño pepper, finely diced and seeded
1 medium zucchini, diced
1 large handful of shiitake mushrooms, sliced (about 1 1/3 cups or 100 grams)
2 cloves garlic
1/2 tsp. smoked paprika
1/2 tsp. ground cumin
2 cups Creamy Black Beans
salt to taste
2 cups Spicy Tomato Sauce, see below
10 6-inch corn tortillas
Coconut lime sauce, see below

  • Preheat the oven to 400°F.
  • Make the enchilada filling: In a large skillet, heat a little oil over medium heat. Add the onion and cook until it’s soft, about 5 minutes. Add the peppers, zucchini, and mushrooms and cook until they begin to soften, about 5 minutes or a little more.
  • Stir in the garlic, cooked black beans, spices, and salt. Remove from the heat.
  • Brush a 9 × 13-inch baking dish with a little oil, then spread a heaping 1⁄2 cup of the tomato sauce on the bottom of the dish. Fill each tortilla with about 1⁄2 cup of the enchilada filling. Roll the tortillas and place them seam-side down in the baking dish. Pour the remaining 1-1/2 cup sauce over the enchiladas, down the middle, leaving a bit of the edges dry. Bake, covered, for 25 minutes. Uncover and bake for 10 minutes more.
  • While the enchiladas are baking, make the cilantro lime sauce, below.
  • Let the enchiladas cool slightly, then drizzle with half of the coconut lime sauce. Top Serve with the remaining cashew cream on the side, as desired.


Spicy Tomato Sauce
1 28-oz. can diced tomatoes
2 tsp. olive oil
3 cloves garlic, minced
1 Tbs. chili powder
1 tsp. garlic salt
1/4 tsp. onion powder
1/4 tsp. red pepper flakes
1/4 tsp. dried oregano
1/4 tsp. dried coriander
1/2 tsp. paprika
1 1/2 tsp. ground cumin
1 tsp. black pepper

  • In a medium saucepan, heat olive oil and garlic over medium-high heat. Saute garlic until just beginning to brown, about 30 seconds.
  • Stir in the tomatoes and spices.
  • Bring to a boil and then turn down to medium-low. Simmer for about 45 minutes to thicken a bit and have flavors develop. Remove from heat and allow to cool slightly. At this point, the sauce can be pureed if you’d like a smooth sauce, but I opted to leave it slightly chunky.


Coconut Lime Sauce

1 cup coconut milk
1/4 cup cilantro, minced
1 garlic clove
2 Tbs. fresh lime juice
1/4 tsp. sea salt

  • In a high-speed blender, place the coconut milk, cilantro, garlic, lime juice, and salt and blend until smooth. Chill until ready to use.