All types of wheat including spelt, kamut, einkorn, emmer, farro and durum, as well as barley, rye and triticale contain gluten. In addition to baked products, cereals and pastas made from these grains, here are some examples of gluten-containing items that must be avoided.

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Items to Avoid

• Bulgur
• Couscous
• Freekeh
• Wheat Bran
• Wheat Flour
• Wheat Germ
• Wheat Gluten
• Wheat-Based Semolina
• Fu
• Seitan
• Orzo
• Udon
• Barley Malt
• Barley Malt Extract/Barley Malt Syrup
• Barley Malt Flavoring
• Malt Vinegar
• Brewer’s Yeast
• Beer made from barley, wheat or rye

Gluten-containing ingredients often are present in many other foods and beverages such as:

• Broths, Bouillons, Soups
• Sauces
• Soy Sauce
• Marinades
• Salad Dressings
• Gravy
• Prepared Meats (e.g., burgers, hot dogs, sausages)
• Meat Substitutes (e.g., vegetarian burgers, sausages)
• Imitation Crab or Lobster
• Snack Foods
• Candy (e.g., licorice, chocolates, chocolate bars)
• Flavored Coffees and Teas

To learn more about the gluten-free status of foods, beverages and ingredients see Gluten Free: The Definitive Resource Guide by Shelley Case, RD.

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Based on clinical studies over the past 20 years, research has revealed that consumption of pure, uncontaminated oats is safe for the majority of individuals with celiac disease. More information about oats can be found from these sources:

Health Canada: Celiac Disease and Gluten-Free Claims on Uncontaminated Oats

Celiac Canada: Professional Advisory Council Position Statement on Consumption of Oats by Individuals with Celiac Disease

Gluten Free Watchdog: Site hosted by dietitian Tricia Thompson, MS, RD

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In addition, there are many gluten-free flours, cereals and starches that can be substituted for wheat, rye and barley (see below). Distilled alcoholic beverages and wines are also allowed; however, beer derived from barley must be avoided. All vinegars are gluten-free except for malt vinegar (made from barley and is not distilled) and some rice vinegars (if derived from wheat or barley and not distilled).

Gluten-Free Flours, Cereals and Starches

• Amaranth
• Arrowroot
• Buckwheat
• Corn
• Flax
• Pulse flours (bean, lentil, pea)
• Mesquite flour
• Millet
• Nut flours (almond, chestnut, hazelnut, pecan)
• Potato Flour
• Potato Starch
• Quinoa
• Rice (black, brown, glutinous/sweet, purple, red, white, wild)
• Rice Bran
• Rice Polish
• Sago
• Sorghum
• Soy
• Sweet Potato Flour
• Tapioca (cassava/manioc)
• Teff

Gluten-Free Specialty Products

The gluten-free marketplace has expanded rapidly, especially over the past few years. Whereas historically only a handful of small specialty companies made gluten-free products, today many manufacturers of all sizes offer a wide range of options for the gluten-free consumer. Examples of products include ready-to-eat baked items (e.g., breads, buns, bagels, muffins, cakes, cookies, pies, pizza crusts), baking mixes and specialty flours, hot and cold cereals, crackers; snack bars and other snack foods; entrees, pastas, bread crumbs, coating mixes, gravy mixes, soups, sauces, communion wafers, ice cream cones and gluten-free beers.

The post What Can I Eat on a Gluten-Free Diet? appeared first on Shelley Case, RD.

Celiac Organizations

• Celiac Disease Foundation www.celiac.org
• Gluten Intolerance Group (GIG)  www.gluten.org
• National Celiac Association (NCA) www.nationalceliac.org
• Celiac Canada www.celiac.ca
• Coeliaque Québec www.coeliaque.quebec/fr

Other Celiac Organizations:

• Beyond Celiac www.beyondceliac.org
• Society for the Study of Celiac Disease (NASSCD) www.theceliacsociety.org

The post Consultation with a Registered Dietitian appeared first on Shelley Case, RD.

In the quest for determining the gluten-free status of everything you put in your mouth, what’s often overlooked is nutrition. Good nutrition is vital to the wellbeing of all people, but for those with celiac disease following a balanced and healthy gluten-free diet is doubly important for several reasons:

Gut Inflammation

When an individual with celiac disease consumes gluten (proteins found in wheat, rye and barley), an immune reaction is triggered in the small intestine. Tiny finger-like projections or villi in the small intestine become inflamed and eventually damaged from continued exposure to gluten.  This process, called “villous atrophy”, may occur rapidly or gradually over time.  As a result, the body is unable to adequately absorb nutrients, especially iron, calcium and vitamin D.  Also, malabsorption of carbohydrates (e.g., lactose – the carbohydrate in milk), protein and other nutrients may occur.

The nutritional status of people with celiac disease varies considerably between individuals and is influenced by several key factors that can all impact overall nutritional health such as the:

• ­length of time the disease is active prior to diagnosis
• degrees of inflammation, intestinal damage and malabsorption
• nutritional adequacy of the diet before eliminating gluten

By following a strict gluten-free diet the damaged small intestinal villi begin to heal and nutrient absorption from foods will be improved.

Nutritional Quality of Gluten-Free Products

Just because a product is gluten free does not necessarily mean it’s a healthy option. Many gluten-free products are often lower in key nutrients such as fiber, iron and B vitamins than their gluten-containing counterparts. This is common for pasta, cereal, bread and other baked products. Typically, the gluten-free versions of those foods are made with refined flours and starches that often are not enriched or fortified with vitamins/and or minerals. Also, baked products tend to be higher in calories because more sugar and fat are added to improve their flavor, texture and shelf life. So, that is why it is so important to compare the list of ingredients and nutrition facts label of various products in order to choose healthier options.

Healthy Gluten-Free Eating

March is “Nutrition Month” so this is a perfect time to highlight the importance of healthy eating. As a registered dietitian, I want to showcase the power of nutrition to build, restore and sustain healthy lives. My focus on celiac disease means I’m especially pumped during nutrition month.  This month I’m offering a series of posts on key nutritional concerns for those with celiac disease including iron and iron deficiency anemia as well as calcium and vitamin D and their role in bone health.  Whether you are newly diagnosed or a seasoned pro, you’ll be sure to find tips and considerations that will make a difference in your health and your life.

Here’s a brief overview of the most important nutritional considerations for healing and managing celiac disease.

1. First, and most important: Eliminate all sources of gluten from the diet. Learning about foods/ingredients that must be avoided and those that are acceptable is the first step in creating a safe and healthy diet. This is a complex topic which is covered extensively in my book Gluten Free: The Definitive Resource Guide.
2. Eat iron-rich, gluten-free foods.
3. Get adequate amounts of calcium and vitamin D.
4. If you continue to have bloating, gas and diarrhea despite following a strict gluten-free diet you may need to temporarily restrict lactose until the small intestine has had a chance to heal.
5. When looking for gluten-free alternatives choose more nutrient-rich foods. For example, consider serving whole grains such as buckwheat, millet, oats or quinoa instead of white rice. Make sure these are labeled “gluten free”.
6. Choose gluten-free products that are enriched with iron and B vitamins.
7. Make sure to get enough dietary fiber from foods such as fruits, vegetables, nuts, seeds, pulses (dried beans, peas and lentils) and gluten-free whole grains.

My two-page tip sheet Nutrition and the Gluten-Free Diet covers these seven principles in more depth. You can grab a FREE copy here for yourself, family or friends; or for your clients plus get the latest gluten-free information in my newsletter.

*I will never share your email address.

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Since May is Celiac Awareness Month, I’d like to take the time to revisit the basics: What celiac disease is, how it is diagnosed and treated, and where to get more information.

What is Celiac Disease?

Celiac disease is a hereditary autoimmune intestinal disorder that affects both children and adults. It can develop at any age. When an individual with this disorder consumes gluten (proteins found in the grains wheat, barley and rye), an immune reaction is triggered in the small intestine.

Tiny finger-like projections or villi in the small intestine become inflamed and eventually damaged from continued exposure to gluten. This process, called “villous atrophy,” may occur rapidly or gradually over time. As a result, the body is unable to adequately absorb nutrients, especially iron, calcium, vitamin D and folic acid. Also, malabsorption of carbohydrates (e.g., lactose [the carbohydrate in milk]), protein and other nutrients may occur.

Untreated celiac disease can lead to (1) nutrition-related deficiency conditions such as anemia and osteoporosis, (2) neurological complications, (3) infertility in both women and men, (4) an increased risk of miscarriage or of having a low-birth-weight baby, and (5) an increased risk of certain types of cancers.

Prevalence of Celiac Disease

Originally thought to be a rare disorder, celiac disease is now recognized as one of the most common inherited diseases. Serological (blood) screening tests have revealed that the global prevalence is approximately 1% of the population, although in some countries (e.g., Finland and Sweden) the rate is as high as 2%–3%. Celiac disease is common in people of North American and European ancestry, as well as in the populations of South America, North Africa, India, Pakistan and the Middle East.

Symptoms and Presentations of Celiac Disease

Celiac disease affects not only the gastrointestinal tract but also many other organ systems in the body. Below are some of the many symptoms that can vary in severity from one person to another. Onset of symptoms may appear suddenly or gradually, and may progress slowly or rapidly. Some individuals have “silent celiac disease”, displaying no or very subtle symptoms in spite of the presence of villous atrophy. For many adults, one of the most common presentation is iron-deficiency anemia.

• Abdominal pain, bloating and gas
• Indigestion/reflux (“heartburn”)
• Nausea and vomiting
• Ongoing or intermittent diarrhea and/or constipation
• Lactose intolerance
• Chronic fatigue and weakness
• Iron, folic acid and/or vitamin B12 deficiencies
• Other vitamin and mineral deficiencies (e.g., A, D, E, K, calcium, zinc)
• Weight loss (note that CD also can occur in overweight or obese individuals)
• Bone/joint pain
• Bone disease (osteomalacia, osteopenia, osteoporosis)
• Muscle cramps
• Easy bruising of the skin
• Itchy, blistering rash (dermatitis herpetiformis)
• Tingling or numbness in hands and feet (peripheral neuropathy)
• Swelling (edema) of hands and feet
• Migraine headaches
• Seizures
• Mood swings
• Depression
• Elevated liver enzymes
• Mouth ulcers (canker sores)
• Menstrual irregularities
• Infertility (in women and men)
• Recurrent miscarriages

Additional symptoms of celiac disease in children

• Failure to thrive (delayed growth and short stature)
• Irritability and behavioral changes
• Concentration and learning difficulties
• Delayed puberty
• Dental enamel abnormalities (discoloration, loss of tooth enamel)

Diagnosis of celiac disease

Diagnosis of celiac disease often is very difficult because of its diverse range of symptoms, some of which overlap with other conditions. Many individuals with celiac disease are misdiagnosed as having other disorders such as irritable bowel syndrome (IBS), lactose intolerance, ulcers and/or chronic fatigue syndrome. It has been shown that individuals with celiac disease see multiple physicians over an average of 11 years before receiving a definitive diagnosis, as shown in research studies conducted at Columbia University in New York and by the Canadian Celiac Association. Other countries have reported similar delayed diagnosis rates. It is estimated that 60-70% of individuals with celiac disease still remain undiagnosed.

Because it is a genetic condition, all first-degree relatives (parents, siblings, children) of celiac individuals should be screened for the disease. First-degree relatives have a 5-15% risk of developing celiac disease at any age. However, a negative screening test result does not rule out the possibility that a family member could develop the disease in the future. Therefore, if a family member subsequently experiences celiac-related symptoms in spite of previous negative celiac serology results, repeat testing is recommended.

Various blood tests are used to screen for celiac disease including:

• IgA and IgG tissue transglutaminase (tTG)
• IgA endomysial (EMA)
• IgA and IgG deamidated gliadin peptide (DGP) antibody tests

Small intestinal biopsy in celiac diagnosis

The definitive test for diagnosing celiac disease is a small intestinal biopsy, done in a hospital or clinic endoscopy unit.

A gluten-free diet should never be started before the celiac blood and small intestinal biopsy tests are completed, as this can interfere with making an accurate diagnosis.

Treatment of celiac disease

Currently, the only treatment for celiac disease is a strict gluten–free diet for life. Following the diet will result in improved health and well-being, as well as greatly reduce the risk of celiac-related complications. The time needed for resolution of symptoms and the healing process varies considerably, with children tending to heal more quickly and completely than adults. Individuals with long-standing untreated celiac disease may require several years on the diet before the small intestinal damage is repaired. In some cases complete healing may not occur, especially if the villous atrophy is severe and/or in older adults with long-standing symptoms prior to diagnosis.

Due to the complexities of the gluten-free diet, consultation with an expert registered dietitian (RD) is highly recommended. After completing a thorough nutritional assessment, s/he will address any nutritional concerns and will work with the individual to learn how to successfully adapt to the gluten-free lifestyle. Practical information about label reading, meal planning, shopping, budgeting, food preparation, cross-contamination and eating away from home will be provided, as well as suggestions on how to effectively cope with the social and emotional aspects of following the diet. Joining a celiac group for further information and ongoing support also is beneficial (see below).

Dermatitis Herpetiformis

Dermatitis herpetiformis (DH) is another presentation of celiac disease. This chronic skin condition is characterized by an intense itchy and blistering rash. The rash is symmetrically distributed on both sides of the body. Commonly found on the elbows, knees and buttocks, it also can occur on the back of the neck, upper back, scalp and hairline. Initially, groups of small blisters (looking similar to those of chicken pox or herpes) are formed on the skin, and these soon erupt into small erosions. Most people with DH have varying degrees of small intestinal villous atrophy, although some have no gastrointestinal complaints.

Diagnosis of dermatitis herpetiformis

Individuals with DH frequently are misdiagnosed as having other skin conditions such as eczema, contact dermatitis, allergies, hives, herpes or psoriasis. The only way to correctly diagnose DH is with a skin biopsy from unaffected skin adjacent to blisters or erosions. A small intestinal biopsy is not required if the skin biopsy is positive for DH.

Treatment of dermatitis herpetiformis

The treatment for DH is a strict gluten–free diet for life. Following the diet allows the gastrointestinal damage to resolve within several months and over time results in an improvement in the skin lesions. Depending on the severity of the rash, between six months to two years on the diet may be necessary in order for the skin to heal completely.

Celiac Disease Resources

Check out the following resources for more information about celiac disease and the gluten-free diet:

American Celiac Organizations

• Celiac Disease Foundation
• Gluten Intolerance Group
• Beyond Celiac
• National Celiac Association (NCA)

Canadian Celiac Organizations

• Celiac Canada 
• Coeliaque Québec

Ready to learn more? Check out my latest edition of Gluten-Free: The Definitive Resource Guide – Revised Edition. It covers all aspects of nutrition and the gluten-free diet, while offering healthy eating guidelines, meal plans, recipes, detailed information about safe foods/ingredients and labeling, helpful resources and more. Get it here!

The post Celiac Disease 101 — Get the Facts! appeared first on Shelley Case, RD.

If you read last week’s post on calcium, bone health & the gluten-free diet, you’ll recall that people with celiac disease need to take special care to monitor their intake of bone-enhancing nutrients. You’ll also likely remember that nutritional deficiencies leading to bone weakness or bone loss are often the hallmark of undiagnosed celiac disease owing to inflammation and impaired intestinal absorption. We also discussed calcium as the lynchpin nutrient you need to consider, both in terms of intake and absorption, if you want to build and maintain strong bones for a lifetime.

But there’s more to the story… Turn the page and you’ll see that calcium doesn’t work alone. It has a partner – vitamin D, which assists in the absorption of calcium.

Importance of vitamin D

While vitamin D plays a starring role in your body’s calcium balance and bone health, it is also crucial to the functioning of your immune system, heart, muscles, lungs and brain. Medical experts have been investigating the relationship between vitamin D and a wide range of diseases, such as autoimmune disorders, diabetes, heart disease, stroke, cancer and neurocognitive disorders. Although researchers have found vitamin D plays a role in these conditions, the verdict is still out on whether vitamin D can reduce their risk of occurring.

However, what is clear is that, for people with celiac disease wishing to ensure bone health, as well as the health of their immune, muscular, cardiovascular systems and more, it is vital to get enough vitamin D. Adequate vitamin D levels can help prevent or treat osteopenia and osteoporosis, as well as osteomalacia.

Osteomalacia is a condition where calcium in not deposited into newly formed bones, causing them to become soft, flexible and weak. Symptoms in adults include bone pain, muscle weakness and fractures.  In children, this bone condition is called rickets. Symptoms can include bone pain, skeletal deformities (e.g., bow legs, curved spine), dental deformities (delayed formation of teeth, holes in the enamel, cavities), bone fractures and short stature.

Vitamin D and sunlight

Now, here is some good news: Our skin can generate vitamin D from sunlight. But here is some bad news: Obtaining adequate vitamin D from sunlight isn’t always possible, meaning all people, and especially those with celiac disease, still need to pay attention to dietary vitamin D intake.

When ultraviolet rays found in sunshine hit your bare skin, you generate large amounts of vitamin D. Humans are uniquely designed to do this, and sunlight is the major source of vitamin D for most people. Nevertheless, several factors can impair or limit the body’s ability to synthesize vitamin D from sunlight:

• In the sunlight of northern latitudes during the winter months, the necessary UV wavelengths are blocked by the atmosphere due to the angle of the sun.
• Sunscreen with a sun protection factor (SPF) of 8 or greater can interfere with vitamin D synthesis. While regular use of sunscreen is essential for prevention of skin cancer, sun exposure of the hands, arms and legs without sunscreen for only 10–15 minutes at least two to three times per week can help meet vitamin D requirements. After 10–15 minutes of such exposure, slather it on.
• Heavy cloud cover or significant smog also can block the necessary rays.
• Sunlight through a window cannot stimulate the skin synthesis of vitamin D.
• Dark-skinned individuals with greater amounts of the pigment melanin require longer sun exposure time to produce vitamin D.
• Housebound individuals or those who wear full body coverings are less likely to get an adequate amount of vitamin D from sunlight.
• Vitamin D synthesis declines with age.

What about dietary sources of vitamin D for those who can’t obtain enough from sun exposure?

Remember I said to fortify yourself? I meant it quite literally. There are just a small number of foods that feature this sunshine vitamin. These include fatty fish like mackerel, salmon, tuna and sardines; fish liver oils; beef liver; and egg yolks. Some types of mushrooms (grown under special ultraviolet lights) are the only common natural plant-based source of vitamin D.

If you experience any of the above challenges in obtaining adequate vitamin D from sunlight and, especially, if you have impaired absorption from celiac disease, or have other dietary limitations, then you may wish to turn to foods fortified with vitamin D.

In North America, fortified foods are the major dietary sources of vitamin D. The fortification regulations in the US and Canada differ. In the U.S, although a range of foods are permitted to be fortified with vitamin D on a voluntary basis (e.g., milk, yogurt, cheese, margarine, cereals, rice, cornmeal, pasta, plant-based beverages, fruit drinks and juices), fluid milk and ready-to-eat cereals are the most common fortified sources. In Canada, fortification of milk and margarine is mandatory, and these two foodstuffs are the most commonly fortified products. However, plant-based beverages, orange juice, yogurt, yogurt-based beverages and cheese are permitted to be fortified with vitamin D.

Daily requirements for vitamin D 

How much dietary vitamin D should you get? Check the table below for your daily requirement. Vitamin D levels are expressed as micrograms (mcg) or International Units (IU) with 1 mcg of vitamin D equivalent to 40 IU.

Dietary Reference Intake (DRI) for Vitamin D

*Expressed as cholecalciferol. 1 microgram (mcg) of cholecalciferol = 40 IU vitamin D.
Recommended amounts in the absence of adequate exposure to sunlight.

Vitamin D content of foods

You can meet your daily requirements of vitamin D with a mix of naturally vitamin-D-rich and fortified foods. Check the chart to assess how you’re doing.

Vitamin D content of various foods (shown greatest to least)

Vitamin D supplements

 If you’re not sure you can obtain enough vitamin D from diet and sunlight alone (and frolicking all winter in Florida, Hawaii or the Caribbean is not in the cards) you might consider supplements.

Most multivitamin and mineral supplements contain at least 10 mcg (400 IU) and some calcium supplements have added vitamin D. You can also find vitamin D in single-dose supplements ranging from 5-25 mcg (200-1000 IU).  Braver souls often try cod liver oil, which is naturally rich in vitamin D, but please note that plain fish oil or omega-3 supplements will not have vitamin D unless the manufacturer has added it.

Although it is possible to get too much vitamin D, it is unlikely to happen from supplements taken as directed.

Putting it all together

Now that you’ve boned up on the sunshine vitamin, you should be well on your way toward building and maintaining a healthy skeleton. So, remember…

• Get enough calcium.
• Eat your eggs, fatty fish and fortified milks or plant-based milks.
• Add a supplement if needed.
• If you have celiac disease, follow your gluten-free diet with care so that your gut is healed and absorbing nutrients well.
• And, with spring on the way, pop out and enjoy the sun at last! Just remember to don your hat and sunscreen after the first 10-15 minutes.

Ready to learn more? Ready to learn more? Check out my latest edition of Gluten-Free: The Definitive Resource Guide – Revised Edition. It covers all aspects of nutrition and the gluten-free diet, while offering healthy eating guidelines, meal plans, recipes, detailed information about safe foods/ingredients and labeling, helpful resources and more. Get it here!

The post Shining Light on Vitamin D, Celiac Disease and Bone Health appeared first on Shelley Case, RD.

Because it’s so vital to life, your calcium level is always tightly regulated. If you don’t eat or absorb enough from your diet, your body will first try to slow the amount of calcium excreted through the urine and, failing that, it will literally pull needed calcium from its main storehouse — your bones. Since bones are built during childhood and adolescence, with 90% of bone mass acquired by age 18-20, your job in adulthood is to maintain the bone mass you have.  If you’re steadily losing bone calcium due to poor nutrition or digestion, your skeleton will weaken, with potentially serious consequences, ranging from osteopenia (a thinning of the bones) to osteoporosis (a thinning serious enough that bones become porous, weak and easily broken). In growing children and adolescents, too little calcium can mean that they don’t lay down adequate bone mass in the first place, increasing their risk of fracture and osteoporosis later in life.

Getting adequate calcium is a serious nutritional consideration for everyone. Studies in the US and Canada have found that many people are not meeting recommended calcium intakes.

For those with celiac disease, the challenge can be even greater. For one thing, it common for individuals with celiac disease to remain undiagnosed and thus untreated for many years. American and Canadian researchers have found the average delay in diagnosis was 10-12 years! Because of the intestinal atrophy and impaired nutrient absorption (see my post The Gluten-Free Diet: Don’t Forget About NUTRITION! for an explanation), people with celiac disease may not have built sufficient bone mass during childhood, or they may have steadily been losing bone mass for a period of years, or both.

Making matters even trickier, some individuals with celiac disease develop a secondary lactose intolerance. This usually is a temporary condition in which the level of lactase is decreased as a result of injury to the small intestinal villi. Once on a gluten-free diet, the villi begin to heal and over time the lactase levels usually return to normal. Until then, the individual may need to follow a lactose restricted diet. Lactose is a naturally occurring sugar found in milk and milk products. Eliminating or restricting dairy products is a challenge as they are one of the best and most common sources of dietary calcium. However, there are lactose reduced or lactose-free dairy products on the market. Another option is to use lactase enzyme preparations while consuming milk, yogurt and other dairy products.

Continuing our discussion of nutrition and the gluten-free diet for Nutrition Month, here are my answers to questions I frequently address about getting enough calcium.

How much calcium do I need?

Adequate intake levels depend on your age and gender, ranging from 200mg/day for infants to 1300/day for adolescent women. You can find your own recommended intake on this chart.

Dietary Reference Intake (DRI) for Calcium

* Adequate Intake (AI)

What are the best food sources of calcium on a gluten-free diet?

Milk and milk products are major sources of calcium and many other nutrients, providing over 75% of the total calcium in the North American diet. A cup of reduced-fat milk provides 350 mg of highly absorbable calcium. Two ounces of cheese will yield as much as 498 mg for harder cheeses like Swiss. A mere 6 oz. of low-fat yogurt will give you 311 mg of calcium. Ice cream, while delicious, only offers 84 mg per half cup, about the same as a half cup of baked beans.

If you don’t particularly like drinking milk, you can still use it in cream soups, sauces, tea, coffee, smoothies, or tuck it in baked products. Or sweeten the pot and try chocolate milk!

What if I am also dairy free?

Non-dairy foods, such as broccoli, spinach, almonds and dried beans, offer calcium, but generally in smaller amounts or in a form that the body absorbs less efficiently. Nevertheless, don’t overlook them, as intake throughout the day will add up. Furthermore, a diverse diet of fruits, vegetables, grains, seeds and nuts will not only provide calcium, but a wide range of other nutrients vital to your health.

One of your best sources will be fortified non-dairy beverages (made from soy, nuts, seeds, rice or gluten-free oats), fortified orange juice, and cereals with added calcium.

Here is a list of the calcium content of various non-dairy foods to get you started (shown highest to lowest).

* 
The calcium content for tofu is an approximation based on products available on the market. Calcium content varies greatly from one brand to the other and can be quite low. Tofu processed with magnesium chloride contains less calcium.

What about calcium supplements?

If you have any concerns about your dietary calcium intake, consult with a registered dietitian who can evaluate your diet and options for supplementation. Here are some key points to keep in mind when selecting a supplement:

• Calcium is available in different forms such as calcium carbonate, calcium citrate, calcium lactate, calcium gluconate, calcium phosphate and calcium citrate. The most commonly available forms of calcium in supplements are carbonate or citrate.
• Check the label to determine the amount of total “elemental” calcium in the supplement. This is the amount of calcium that can be absorbed by the body. On average, calcium supplements contain 300–600 mg of elemental calcium, whereas most multivitamin/mineral supplements contain lower amounts (e.g., 100–200 mg).
• Calcium is absorbed more effectively when taken in divided doses throughout the day, e.g., a maximum of 500 mg at one time twice daily, rather than 1000 mg in a single daily dose.
• For maximum absorption, calcium carbonate should be consumed with food or immediately after eating. Conversely, calcium citrate can be taken at any time as it does not depend on stomach acid for its absorption.
• Some individuals may experience gas and/or constipation when taking calcium supplements. Strategies to alleviate the gastrointestinal symptoms include (1) starting with a smaller dose (e.g., 200–300 mg elemental calcium) for 1–2 weeks, then gradually increasing the amount, (2) spreading the dose throughout the day, (3) increasing fluid intake and/or (4) trying a different brand or form of calcium (calcium carbonate tends to cause more side effects than does calcium citrate).

What if I’ve been untreated for a long time and have evidence of bone loss? Are bone loss and/or osteoporosis reversible?

When celiac disease develops in childhood or adolescence, bone mass can be restored to normal levels following treatment, provided the gluten-free diet contains adequate nutrients for bone health. For adults whose celiac disease has contributed to osteopenia or osteoporosis, correcting the bone abnormalities may be more difficult. Nevertheless, the condition can be managed by diet and nutrient supplementation, and, if necessary, using bone-enhancing medications. Discuss this with your physician.

Do you have any other bone-heath tips?

Stay tuned for the next post in our series on Vitamin D and its bone building powers. And here are a few more of my favorites:

• Eat a wide variety of foods to ensure adequate nutrients to build and maintain bone density.
• Limit your intake of alcohol and caffeine and, especially, do not smoke. All three are risk factors for osteoporosis.
• Stay active! Regular weight-bearing exercise such as brisk walking, hiking, stair climbing, dancing, and weight training can help maintain bone mass. Always consult your physician before beginning a new fitness program, especially if you have osteopenia, osteoporosis or a history of fractures.

Want to know more? My book Gluten-Free: The Definitive Resource Guide – Revised Edition dives deep into the unique nutritional needs of individuals with celiac disease and the gluten-sensitive, while offering easy-to-follow guidelines, meal plans, recipes and more. Get it here!

The post Make No Bones Without It — Calcium is Critical on a Gluten-Free Diet appeared first on Shelley Case, RD.

Segmented into three regions (duodenum, jejunum and ileum), your small intestine is the largest site of nutrient absorption in your body and its health is key to your health. Lined with velvety fingers of cells, called villi, the small intestine presents over 250 square meters (2700 square feet) of absorptive surface. This large surface area allows for the uptake of proteins, fats, carbohydrates, vitamins and minerals from your daily meals.

Healthy villi maximize their surface area, standing up like microscopic fingers bordered by cell-producing valleys called crypts. But if you have undiagnosed celiac disease (an autoimmune intestinal disorder), the surface of the small intestine changes – flattening and losing the depth of these hills and valleys. What once looked like a vibrant neighborhood now looks more like a Caribbean island after a hurricane has blown through.

Healthy villi (left) and damaged villi (right).
Images courtesy of Dr. Mohsin Rashid.

In this new landscape, cell damage and reduced surface area mean the small intestine has trouble doing its job. One consequence is the failure to absorb adequate amounts of many nutrients such as calcium, vitamin D, folate, and especially IRON. In this post, I’d like to focus on iron deficiency in celiac disease. In future blog posts, we’ll look at other nutrients including calcium, vitamin D and fiber.

Role of iron

This mineral is needed to produce hemoglobin and myoglobin. Hemoglobin is the component of red blood cells that carries oxygen throughout the body.  Myoglobin protein stores oxygen in the muscle cells. Iron is also needed for the formation of certain enzymes and is involved in many other metabolic functions. Most of the iron is found in hemoglobin, myoglobin and enzymes, while the remaining stored in the liver, bone marrow and spleen.

Iron Deficiency and Iron-Deficiency Anemia

Iron deficiency occurs when the normal stores of iron decline gradually over time. The main reasons for iron deficiency are: 1) an inadequate dietary iron intake, 2) impaired iron absorption and 3) blood loss.  If the amount of iron becomes severely depleted, the production of hemoglobin is impaired. Thus, the red blood cells deliver less oxygen throughout the entire body. This state is referred to as iron-deficiency anemia (microcytic hypochromic anemia).

Common symptoms of iron-deficiency anemia can include fatigue, weakness, shortness of breath, pale skin, headache and dizziness. In addition, individuals can present with irritability, brittle nails, sore tongue, decreased appetite plus they have an increased susceptibility to infections. In children, reduced iron levels can even contribute to problems with attention and behavior. 

Iron-Deficiency Anemia in Celiac Disease

Studies in adults and children reveal that undiagnosed/untreated celiac disease often leads to iron-deficiency anemia. For many adults, this form of anemia is one of the tell-tale symptoms of celiac disease. The main cause of this iron deficiency anemia is impaired iron absorption. Consumption of gluten (found in the grains wheat, rye and barley) triggers an immune reaction that damages the intestinal villi. As a result, individuals are unable to adequately absorb enough iron from their diet and/or supplements.

Surprisingly, not all adults and children are under-weight at diagnosis, as you might suppose. The reason is that intestinal damage can be patchy — spotty enough to cause stores of critical nutrients to be used faster than they’re replaced, but intact enough to ensure that calories are still obtained from proteins, fats and carbohydrates.  

Treatment of Iron-Deficiency Anemia in Celiac Disease

Treatment for celiac disease is a strict gluten-free diet for life.  With time and careful adherence to the diet, the small intestine begins to heal and regain its ability to absorb iron and other nutrients.

Following a strict gluten-free diet is essential! However, it’s equally important to pay attention to the quality of gluten-free food choices. Studies show that gluten-free diets are often unbalanced. For example, they are frequently low in key nutrients (e.g., iron, B vitamins and fiber). Also, GF diets tend to be high in calories, fat, sugar and refined flours/starches. Because of the challenges of impaired absorption and following a GF diet that supplies adequate nutrients, I always recommend individuals consult with a registered dietitian with expertise in celiac disease. The dietitian can help design and assess the success of a customized gluten-free diet as well as suggest and monitor appropriate supplementation when needed. 

Iron Requirements

*Adequate Intake (AI)

Good Sources of Iron

Absorption of iron from dietary sources will vary depending on several factors. These include: 1) the body’s total iron stores (when iron levels are low, absorption increases), 2) the type of iron in the food and 3) other dietary factors. The two types of iron in foods are heme and non-heme:

Heme Iron

• Is more readily absorbed by the body than is non-heme iron
• Absorption is not changed by other foods in the diet
• Is found only in meat, poultry, fish and shellfish

Non-Heme Iron

• Is not absorbed as well as is heme iron
• Absorption can be increased or decreased by other foods in the diet
• Is found in fruits, vegetables, pulses (dried beans, peas, lentils), grains, nuts, seeds, eggs and blackstrap molasses
• Is also found in meat, poultry, fish and shellfish

Tips for Maximizing Iron Absorption

1. Choose foods high in iron
2. Eat a source of heme iron with non-heme iron at the same meal, for example:
   • Stir-fried beef, chicken, pork, fish or seafood with vegetables (e.g., broccoli, mushrooms, snow peas) and rice and toasted almonds or sesame seeds
   • Chili made with meat and beans
     
3. Vitamin C increases absorption of non-heme iron; therefore, combine a vitamin C-rich food (e.g., citrus fruits and juices, kiwi fruit, strawberries, cantaloupe, broccoli, peppers [green, orange, red and yellow], tomatoes, potatoes, cabbage) with non-heme iron foods at the same meal, for example:
   • Poached egg and glass of orange juice
   • Casserole containing rice, beans and canned tomatoes or tomato sauce
   • Spinach salad with strawberries or orange segments
   • Hummus with broccoli and sliced raw peppers
4. Avoid drinking coffee or tea with meals as these beverages contain tannins that interfere with iron absorption.

If you’re one of the many people with celiac disease struggling with iron-deficiency anemia – take heart. Time to heal along with a strict gluten-free diet will begin to revitalize your small intestine. Combine that with a healthy diet that maximizes iron intake and iron absorption and you’ll soon be taking the stairs two at a time!

For more information about iron deficiency and detailed lists of the iron content of gluten-free foods; celiac disease and the gluten-free diet including healthy eating strategies, recipes, meal plans, labeling, safe foods/ingredients, helpful resources and more… get a copy of Shelley’s best-selling book Gluten Free: The Definitive Resource Guide- Revised Edition!

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