Celiac.com 04/20/2023 - Putting gluten-free policies and processes in writing can help restaurants overcome post-pandemic challenges by saving money, reaching more customers, pleasing more customers, and growing a more thriving business. 

As restaurant business picks back up, establishments face new struggles, like supply chain issues, rising prices, and staffing shortages. These pressures can cause some to pull back, but addressing gluten-free customers can help take the sting out of that reality.

Gluten-free Customers Can be Good for Business

Restaurants that can serve consistent gluten-free dishes can earn a premium on many dishes, along with earning repeat business from happy gluten-free customers and their friends and business associates.

Meanwhile, cutting corners to reduce costs and accommodate staff shortages can negatively affect customers’ health and trust, and potentially damage the restaurant’s reputation. Instead of eliminating gluten-free menu items or cutting corners on food safety, restaurants can maximize resources by putting processes for preparing and serving gluten-free dishes into writing. 

Less Errors, More Money, Happier Customers and Staff

Written policies not only demonstrate compliance with FDA standards, but also create a standard operating process for employees to follow, which can help to prevent errors, save money, and close any gaps in staff knowledge. 

Documenting gluten-free processes can be done cheaply and relatively easily with notebooks, posters, or online postings. 

To do it well though, it is essential to involve appropriate members of staff to weigh in on specific steps, and to conduct ongoing training to accommodate different learning styles among staff members. 

Consider Asking Experts

It's also a good idea to ask people who know a lot about gluten-free food to provide advice on how to prepare and serve it safely. This can be done by inviting support groups or individual customers who eat gluten-free to help you. They can share their needs and concerns, along with what's important to them. 

Another option is to work with an organization like the Gluten-Free Food Service (GFFS) to help you develop rules and training for your staff. This way, you can be sure that you are following the right procedures and keeping your customers safe.

Proper Gluten-Free Procedures Bring Many Benefits

Whatever course you choose, proper implementation of gluten-free food prep and service procedures helps to prevent gluten contamination, and to build trust and loyalty with customers who have dietary restrictions, as well as those who prioritize health and wellness. 

Beyond those benefits, restaurants that demonstrate a commitment to proper handling and preparation of gluten-free dishes, can attract a wider customer base and potentially increase revenue. 

Additionally, implementing written policies and procedures for gluten-free foodservice can position a restaurant as a leader in food safety and compliance with FDA regulations. This can be particularly valuable in today's climate, where consumers are increasingly concerned about health and safety.

Basically, restaurants can gain a great deal by leaning into gluten-free standards and preparation, and using them as a vehicle to improve team cohesion, draw more customers, please more customers, save money, and build a better future for everyone, while increasing the bottom line.

More info is at: fsrmagazine.com
 

Ordering gluten-free food in a restaurant is well covered territory with hundreds, if not thousands of articles on the topic. Most of these articles cover the same territory – research the restaurant beforehand, ask questions to the manager or chef, and tip well. I’m not sure I am going to be able to add anything new, but I’m going to try.

If you don’t want to eat out, or are afraid due to cross-contamination risk, I totally understand because studies have shown that restaurant food is often contaminated. At the same time, I would hate to think that this disease is stopping anyone from living their lives. So, if you are satisfied not eating out, that's great, but I like eating out, so I’ve come up with the following ideas.

Timing is Everything When Ordering Gluten-Free in Restaurants

I recommend that you go to the restaurant during off-hours. In other words, don’t go to the hottest gluten-filled restaurant during the busiest time, which is usually on the weekends. The kitchen is usually slammed then, mistakes can be made, and shortcuts can be taken. Though none of this may be done on purpose, we are still the ones who will pay the price for their mistakes. Try going to dinner at 6 pm on a Thursday night, or even 5 pm or 9 pm on a weekend night. The kitchen will be less busy, and they will be much more likely to take extra time to care for your meal.

Ordering Gluten-Free Smartly

Ordering a burger without a bun and a baked potato is going to be a safer bet than ordering fried chicken when the restaurant doesn’t offer gluten-free fried chicken. That being said my general rule of thumb is to stay away from pasta or pizza places, but if you can cover it in your questions you might be okay, but I stay away from these places almost 100% of the time. I generally try to order something grilled, not marinated and without any sauce unless the sauce is gluten-free, and plain sides. This approach will keep you safer than anything else.

It's important to tell the person who takes your order that your food should be cooked in a separate area on the grill from where bread or gluten items might be made, for example where they heat buns, and to mark your order “gluten-free” and make sure the chef sees this on the ticket.

When talking to the servers, ask specific questions. Don’t ask if the fries are gluten-free, ask if they fry other fried items on the menu in the same fryer as the French fries. Don’t ask if the pizza crust is gluten-free, ask if they cook in in a dedicated area in the oven, or keep the gluten-free toppings in a separate area, or if the same preparation area is shared with both gluten and gluten-free pizzas. Likewise, do they cook their gluten-free pasta in the same water as their wheat pastas? Don’t ask if the butter sauce is gluten-free, ask if they use flour or corn starch to thicken the sauce. For soups marked gluten-free, or ones that can be made so easily – like french onion soup, I ask if they make the stock in house or if they buy it. Purchased, pre-made stock is more likely to contain gluten than a stock that they made in house where the chef knows how it was made. These questions require some knowledge of cooking. It is good knowledge to have even if you never cook, because in situations like this, you can ask smart questions to get the answers needed to keep you safe.

Become a Regular When They Get Your Gluten-Free Order Right

I love a particular local restaurant. After a few times asking for gluten-free items and being safe, the restaurant will get to know you and your needs. Hopefully, they will keep their gluten-free menu items to keep you happy and returning. Make sure to be a good customer and tip well too.

Higher End Restaurants May Do Gluten-Free Better

Go to the highest end restaurant that you can afford. The nicer the restaurant the more likely it is that you will get a truly gluten-free meal.

I was at a restaurant one time that has steak frites–steak and French fries–but it wasn’t marked as gluten-free. They had gluten-free fried items, so I knew they knew what they were doing regarding fried items. I asked why the steak frites was not gluten-free. It turns out that they marinated the steak in a non-gluten-free soy sauce. This is an item that I thought would be safe, but wasn’t, so always, always ask questions.

The bottom line here is that someone should only eat where they feel safe. There are lots of precautions we can all take and we have a 2 out of 3 chance of getting a safe meal. So enjoy eating out if you are willing to take that risk, and if you are, follow some of the steps mentioned here so that you can stay safe whenever dine out!

Celiac.com 04/15/2023 - Celiac disease is a chronic autoimmune disorder that affects the small intestine, triggered by the ingestion of gluten, a protein found in wheat, barley, and rye. One often overlooked consequence of untreated and undiagnosed celiac disease is the potential for nutrient deficiencies. Due to the damage caused to the lining of the small intestine, absorption of various essential nutrients may be impaired, leading to deficiencies that can have wide-ranging health effects. In this article, we will explore the connection between celiac disease and nutrient deficiencies, focusing on several key vitamins, minerals, and other essential nutrients.

The most common nutrient deficiencies associated with celiac disease that may lead to testing for the condition include iron, vitamin D, folate (vitamin B9), vitamin B12, calcium, zinc, and magnesium. Celiac disease can disrupt the absorption of these essential nutrients, potentially leading to anemia, bone health issues, and other health complications. After a celiac disease diagnosis it is important to do follow up testing for these nutrient deficiencies, as well as a follow-up endoscopies/biopsies to make sure that a patient's damaged villi are healing properly. Many of those with celiac disease will need to take vitamin and mineral supplements at the time of their diagnosis, and some will need to continue taking them for life. Note that having nutrient deficiencies alone would not be enough for a definitive diagnosis of celiac disease, and further testing is required to make a formal diagnosis.

Boron

Boron is a trace mineral that plays a role in bone health, brain function, and metabolism of certain nutrients. Deficiency in boron is rare, but it can lead to symptoms such as muscle weakness, joint pain, and impaired cognitive function. Untreated and undiagnosed celiac disease can cause malabsorption of boron due to damage to the small intestine lining, potentially leading to a deficiency. Supplementation of boron may be needed for individuals with celiac disease, especially if they have prolonged untreated celiac disease or other risk factors for deficiency.

Calcium

Calcium is an essential mineral that is crucial for bone health, nerve function, and muscle contraction. Deficiency in calcium can lead to symptoms such as weakened bones, muscle cramps, and numbness and tingling in the extremities. Malabsorption of calcium can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of osteoporosis and other bone-related complications in individuals with celiac disease. Measuring blood levels of calcium alone is not always an accurate indicator of calcium deficiency because the body will leach calcium from the bones to maintain normal blood levels of calcium. Therefore, bone density loss and other secondary indicators are often better diagnostic tools for detecting calcium deficiency. Calcium supplementation, along with a calcium-rich diet, may be necessary for individuals with celiac disease to maintain adequate calcium levels and support bone health.

Chloride

Chloride is an electrolyte that is involved in maintaining proper fluid balance, nerve function, and acid-base balance in the body. Deficiency in chloride is rare, but it can lead to symptoms such as muscle weakness, lethargy, and irregular heartbeat. Malabsorption of chloride can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can disrupt the body's fluid balance and electrolyte levels, further complicating the health of individuals with celiac disease. Proper monitoring of chloride levels and supplementation may be necessary for individuals with celiac disease, especially if they have prolonged untreated celiac disease or other risk factors for deficiency.

Choline

Choline is an essential nutrient that plays a role in brain development, nerve function, and liver health. Deficiency in choline can lead to symptoms such as cognitive decline, liver dysfunction, and muscle damage. In celiac disease, malabsorption of choline can occur due to damage to the small intestine lining, potentially leading to a deficiency. Supplementation of choline may be necessary for individuals with celiac disease, especially if they have prolonged untreated celiac disease or other risk factors for deficiency.

Image: CC BY-SA 2.0--User: Pumbaa (original work by commons:User: Greg Robson

Chromium

Chromium is a trace mineral that is important for glucose metabolism and insulin function. Deficiency in chromium can lead to symptoms such as impaired glucose tolerance, increased insulin resistance, and poor blood sugar control. Malabsorption of chromium can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. Supplementation of chromium may be needed for individuals with celiac disease, especially if they have poor blood sugar control or other risk factors for deficiency.

Copper

Copper is an essential trace mineral that plays a role in various processes in the body, including energy production, connective tissue formation, and immune function. Deficiency in copper can cause symptoms such as anemia, bone abnormalities, and impaired immune function. In celiac disease, malabsorption of copper can occur due to damage to the small intestine lining, potentially leading to a deficiency. This can further compromise the overall health of individuals with celiac disease and increase the risk of related complications. Supplementation of copper may be necessary for individuals with celiac disease to maintain adequate copper levels and support overall health.

Iodine

Iodine is a trace mineral that is essential for thyroid function, metabolism, and brain development. Deficiency in iodine can cause symptoms such as goiter, fatigue, weight gain, and impaired cognitive function. Malabsorption of iodine can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further disrupt thyroid function and metabolism, and impair cognitive development in individuals with celiac disease, especially in children. Iodine supplementation, along with a well-balanced diet that includes iodine-rich foods such as seafood and iodized salt, may be necessary for individuals with celiac disease to maintain adequate iodine levels and support overall health.

Iron

Iron is an essential mineral that is required for the production of hemoglobin, the protein in red blood cells that carries oxygen to all parts of the body. Deficiency in iron can cause symptoms such as anemia, fatigue, weakness, and pale skin. Malabsorption of iron can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further exacerbate the risk of anemia and related health issues in individuals with celiac disease. Iron supplementation, along with a well-balanced diet that includes iron-rich foods such as meat, poultry, beans, and fortified cereals, may be necessary for individuals with celiac disease to maintain adequate iron levels and support overall health.

Lutein

Lutein is a carotenoid antioxidant that is important for eye health and vision. Deficiency in lutein can cause symptoms such as blurred vision, macular degeneration, and increased risk of eye-related disorders. Malabsorption of lutein can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of eye-related issues and compromised vision in individuals with celiac disease. Lutein supplementation, along with a diet rich in lutein-containing foods such as leafy green vegetables, egg yolks, and corn, may be necessary for individuals with celiac disease to maintain adequate lutein levels and support overall eye health.

Lycopene

Lycopene is a carotenoid antioxidant that is known for its role in prostate health and reducing the risk of certain cancers. Deficiency in lycopene can cause symptoms such as increased risk of prostate cancer, cardiovascular disease, and oxidative stress. Malabsorption of lycopene can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of prostate cancer, cardiovascular issues, and other health complications in individuals with celiac disease. Lycopene supplementation, along with a diet rich in lycopene-containing foods such as tomatoes, watermelon, and red bell peppers, may be necessary for individuals with celiac disease to maintain adequate lycopene levels and support overall health.

Image: CC BY-SA 2.0--User: Pumbaa (original work by commons: User: Greg Robson)

Magnesium

Magnesium is a vital mineral that plays a critical role in numerous physiological processes, including nerve function, muscle contraction, and bone health. Deficiency in magnesium can cause symptoms such as muscle weakness, tremors, irregular heartbeat, and bone loss. Malabsorption of magnesium can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of muscle weakness, nerve-related issues, and compromised bone health in individuals with celiac disease. Magnesium supplementation, along with a diet rich in magnesium-containing foods such as leafy green vegetables, nuts, seeds, and whole grains, may be necessary for individuals with celiac disease to maintain adequate magnesium levels and support overall health.

Manganese

Manganese is an essential trace mineral that is involved in various metabolic processes, including carbohydrate metabolism and bone formation. Deficiency in manganese can cause symptoms such as impaired glucose tolerance, bone abnormalities, and altered cholesterol levels. Malabsorption of manganese can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of metabolic issues, bone-related complications, and altered cholesterol levels in individuals with celiac disease. Manganese supplementation, along with a diet rich in manganese-containing foods such as whole grains, nuts, seeds, and legumes, may be necessary for individuals with celiac disease to maintain adequate manganese levels and support overall health.

Molybdenum

Molybdenum is a trace mineral that is essential for various enzymatic reactions in the body, including detoxification processes and metabolism of certain nutrients. Deficiency in molybdenum is rare but can cause symptoms such as rapid heartbeat, neurological issues, and growth retardation. Malabsorption of molybdenum can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of cardiovascular issues, neurological complications, and growth retardation in individuals with celiac disease. Molybdenum supplementation, along with a diet rich in molybdenum-containing foods such as legumes, whole grains, and nuts, may be necessary for individuals with celiac disease to maintain adequate molybdenum levels and support overall health.

Nickel

Nickel is a trace mineral that is required in very small amounts for various enzymatic reactions in the body. Deficiency in nickel is rare and typically occurs in individuals with specific health conditions. Malabsorption of nickel can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of compromised enzymatic reactions and related health issues in individuals with celiac disease. Nickel supplementation is not typically necessary, as the body requires only trace amounts of nickel. However, it is important for individuals with celiac disease to maintain a well-balanced diet that includes nickel-containing foods such as nuts, legumes, and whole grains to support overall health.

Phosphorus

Phosphorus is an essential mineral that plays a crucial role in bone formation, energy metabolism, and cellular function. Deficiency in phosphorus is rare and usually occurs in individuals with specific health conditions or imbalanced diets. Malabsorption of phosphorus can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of compromised bone health, energy metabolism, and cellular function in individuals with celiac disease. Phosphorus supplementation is not typically necessary, as phosphorus is abundant in many foods. However, it is important for individuals with celiac disease to maintain a well-balanced diet that includes phosphorus-containing foods such as dairy products, meat, fish, nuts, seeds, and whole grains to support overall health.

Image: CC BY-SA 2.0--User: Pumbaa (original work by commons: User: Greg Robson)

Potassium

Potassium is a crucial mineral that is involved in numerous physiological processes, including nerve function, muscle contraction, and heart health. Deficiency in potassium can cause symptoms such as muscle weakness, fatigue, irregular heartbeat, and increased blood pressure. Malabsorption of potassium can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of nerve-related issues, muscle weakness, and cardiovascular complications in individuals with celiac disease. Potassium supplementation, along with a diet rich in potassium-containing foods such as fruits, vegetables, dairy products, meat, and legumes, may be necessary for individuals with celiac disease to maintain adequate potassium levels and support overall health.

Selenium

Selenium is an essential trace mineral that is involved in various antioxidant and immune functions in the body. Deficiency in selenium can cause symptoms such as compromised immune function, muscle weakness, fatigue, and hair loss. Malabsorption of selenium can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of impaired immune function, muscle weakness, and related health issues in individuals with celiac disease. Selenium supplementation, along with a diet rich in selenium-containing foods such as fish, meat, dairy products, nuts, and seeds, may be necessary for individuals with celiac disease to maintain adequate selenium levels and support overall health.

Silicon

Silicon is a trace mineral that is involved in various processes such as bone formation, connective tissue health, and hair, skin, and nail health. Deficiency in silicon is rare, as it is found in many foods, but it can cause symptoms such as compromised bone health, weak connective tissue, and brittle nails. Malabsorption of silicon can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of compromised bone health, connective tissue issues, and related health concerns in individuals with celiac disease. Silicon supplementation is not typically necessary, as silicon is abundant in many foods. However, it is important for individuals with celiac disease to maintain a well-balanced diet that includes silicon-containing foods such as whole grains, fruits, vegetables, nuts, and seeds to support overall health and prevent deficiency.

Vanadium

Vanadium is a trace mineral that has been suggested to play a role in blood sugar regulation and bone health, although its exact functions are not yet fully understood. Vanadium deficiency is rare, as it is found in small amounts in many foods, and its requirement in the body is low. However, malabsorption of vanadium can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of compromised blood sugar regulation and bone health in individuals with celiac disease. Vanadium supplementation is not typically necessary, as the body's requirement for vanadium is minimal, and excessive intake can be toxic. However, it is important for individuals with celiac disease to maintain a well-balanced diet that includes foods rich in vanadium, such as seafood, mushrooms, whole grains, and vegetable oils, to support overall health.

Vitamin A (Preformed)

Vitamin A is a fat-soluble vitamin that plays a crucial role in vision, immune function, and cellular growth. Deficiency in vitamin A can lead to night blindness, dry skin, and increased susceptibility to infections. Untreated celiac disease can cause malabsorption of vitamin A due to damage to the small intestine lining, leading to a deficiency. It is important for individuals with celiac disease to monitor their vitamin A levels and consider supplementation if necessary.

Vitamin A (Betacarotenes)

Vitamin A in the form of betacarotenes is a precursor that is converted to vitamin A in the body as needed. Betacarotenes are found in colorful fruits and vegetables, and they play a role in maintaining healthy skin, vision, and immune function. Deficiency in betacarotenes can result in similar symptoms as vitamin A deficiency, including impaired vision and weakened immune system. In celiac disease, impaired absorption of betacarotenes can occur due to damage to the small intestine lining, leading to a potential deficiency.

Vitamin B1 (Thiamine)

Vitamin B1, also known as thiamine, is a water-soluble vitamin that is essential for energy metabolism, nerve function, and brain health. Deficiency in thiamine can cause symptoms such as muscle weakness, fatigue, and mental confusion. Severe, prolonged thiamine deficiency can result in beriberi, and symptoms include loss of sensation in extremities, symptoms of heart failure, swelling of the hands and feet, chest pain, feelings of vertigo, double vision, and memory loss. Untreated celiac disease can impair thiamine absorption due to damage to the small intestine lining, potentially leading to a deficiency. It is important for individuals with celiac disease to monitor their thiamine levels and consider supplementation if needed.

Vitamin B2 (Riboflavin)

Vitamin B2, also known as riboflavin, is another water-soluble vitamin that plays a key role in energy production, growth, and red blood cell formation. Deficiency in riboflavin can lead to symptoms such as cracked lips, sore throat, and skin rash. Celiac disease can cause impaired absorption of riboflavin due to damage to the small intestine lining, leading to a potential deficiency. Supplementation may be necessary for individuals with celiac disease to maintain adequate riboflavin levels.

Vitamin B3 (Niacin)

Vitamin B3, also known as niacin, is essential for energy metabolism, nervous system function, and DNA repair. Deficiency in niacin can result in a condition known as pellagra, characterized by symptoms such as diarrhea, dermatitis, and mental confusion. Malabsorption of niacin can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. It is important for individuals with celiac disease to monitor their niacin levels and consider supplementation if necessary.

Vitamin B5 (Pantothenic Acid)

Vitamin B5, also known as pantothenic acid, is involved in energy production, hormone synthesis, and nerve function. Deficiency in pantothenic acid can lead to symptoms such as fatigue, numbness and tingling in the hands and feet, and difficulty in coordination. In celiac disease, malabsorption of pantothenic acid can occur due to damage to the small intestine lining, potentially leading to a deficiency. Supplementation may be necessary for individuals with celiac disease to maintain adequate pantothenic acid levels.

Vitamin B6

Vitamin B6, also known as pyridoxine, is a water-soluble vitamin that is important for brain development, immune function, and protein metabolism. Deficiency in vitamin B6 can cause symptoms such as depression, irritability, and weakened immune system. Untreated celiac disease can impair the absorption of vitamin B6 due to damage to the small intestine lining, potentially leading to a deficiency. It is important for individuals with celiac disease to monitor their vitamin B6 levels and consider supplementation if needed.

Vitamin B7 (Biotin)

Vitamin B7, also known as biotin, is essential for healthy skin, hair, and nails, as well as for metabolism of carbohydrates, fats, and proteins. Deficiency in biotin can result in symptoms such as hair loss, brittle nails, and skin rash. Malabsorption of biotin can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. Supplementation may be necessary for individuals with celiac disease to maintain adequate biotin levels.

Vitamin B8 (Inositol)

Vitamin B8, also known as inositol, is involved in cell signaling, nerve function, and brain health. Deficiency in inositol can lead to symptoms such as mood swings, anxiety, and difficulty in concentration. In celiac disease, impaired absorption of inositol can occur due to damage to the small intestine lining, potentially leading to a deficiency. It is important for individuals with celiac disease to monitor their inositol levels and consider supplementation if necessary.

Vitamin B9 (Folate)

Vitamin B9, also known as folate, is important for DNA synthesis, red blood cell formation, and fetal development during pregnancy. Deficiency in folate can result in symptoms such as anemia, fatigue, and neural tube defects in newborns. Malabsorption of folate can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. Supplementation of folate may be necessary for individuals with celiac disease, especially during pregnancy.

Vitamin B9 (Folic Acid)

Folic acid is the synthetic form of folate, often used in dietary supplements and fortified foods. It is converted to folate in the body and plays similar roles in DNA synthesis, red blood cell formation, and fetal development during pregnancy. Deficiency in folic acid can lead to the same symptoms as folate deficiency, including anemia and neural tube defects in newborns. Malabsorption of folic acid can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. It is important for individuals with celiac disease to monitor their folic acid levels and consider supplementation if needed.

Vitamin B12 ( Cobalamin)

Vitamin B12, also known as cobalamin, is essential for nerve function, DNA synthesis, and red blood cell formation. Deficiency in vitamin B12 can cause symptoms such as fatigue, weakness, and numbness and tingling in the hands and feet. In celiac disease, malabsorption of vitamin B12 can occur due to damage to the small intestine lining, potentially leading to a deficiency. This can further exacerbate the symptoms of celiac disease and affect overall health. Supplementation of vitamin B12 may be necessary for individuals with celiac disease to maintain adequate levels and prevent deficiency-related complications.

Vitamin C (Ascorbic Acid)

Vitamin C, also known as ascorbic acid, is a powerful antioxidant that plays a critical role in immune function, collagen synthesis, and wound healing. Deficiency in vitamin C can cause symptoms such as fatigue, weakened immune system, and slow wound healing. A severe vitamin C deficiency can also result in scurvy, and early symptoms of scurvy include weakness, feeling tired and having sore arms and legs. In celiac disease, malabsorption of vitamin C can occur due to damage to the small intestine lining, potentially leading to a deficiency. Supplementation of vitamin C may be necessary for individuals with celiac disease to maintain adequate levels and support immune function.

Vitamin D3

Vitamin D3, also known as the "sunshine vitamin," is crucial for bone health, immune function, and mood regulation. Deficiency in vitamin D3 can cause symptoms such as bone pain, muscle weakness, and increased susceptibility to infections. Malabsorption of vitamin D3 is common in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of osteoporosis, weakened immune system, and mood disorders in individuals with celiac disease. Vitamin D3 supplementation, along with adequate sunlight exposure and a vitamin D-rich diet, may be necessary for individuals with celiac disease to maintain adequate vitamin D levels and support overall health.

Vitamin E (Food Sourced)

Vitamin E is a powerful antioxidant that protects cells from damage, supports immune function, and helps with DNA repair. Deficiency in vitamin E can cause symptoms such as muscle weakness, impaired vision, and increased oxidative stress. Malabsorption of vitamin E can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of oxidative stress and related health issues in individuals with celiac disease. Vitamin E supplementation, along with a vitamin E-rich diet, may be necessary for individuals with celiac disease to maintain adequate vitamin E levels and support overall health.

Vitamin E (Alpha-Tocopherol)

Vitamin E, specifically alpha-tocopherol, is the most active and common form of vitamin E in the body. It plays a crucial role in protecting cells from damage, supporting immune function, and maintaining cardiovascular health. Deficiency in alpha-tocopherol can cause symptoms such as muscle weakness, vision problems, and increased risk of cardiovascular disease. Malabsorption of alpha-tocopherol can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of cardiovascular issues and other health complications in individuals with celiac disease. Supplementation of alpha-tocopherol, along with a vitamin E-rich diet, may be necessary for individuals with celiac disease to maintain adequate alpha-tocopherol levels and support overall health.

Vitamin K

Vitamin K is a fat-soluble vitamin that plays a crucial role in blood clotting and bone metabolism. Deficiency in vitamin K can cause symptoms such as easy bruising, prolonged bleeding, and weakened bones. Malabsorption of vitamin K can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of bleeding disorders and weakened bones in individuals with celiac disease. Vitamin K supplementation, along with a well-balanced diet that includes vitamin K-rich foods such as leafy green vegetables, may be necessary for individuals with celiac disease to maintain adequate vitamin K levels and support overall health.

Zinc

Zinc is an essential mineral that is involved in various enzymatic reactions, immune function, and wound healing. Deficiency in zinc can cause symptoms such as impaired immune function, delayed wound healing, hair loss, and skin issues. Malabsorption of zinc can occur in celiac disease due to damage to the small intestine lining, potentially leading to a deficiency. This can further increase the risk of compromised immune function, delayed wound healing, and related health issues in individuals with celiac disease. Zinc supplementation, along with a diet rich in zinc-containing foods such as meat, fish, dairy products, nuts, and seeds, may be necessary for individuals with celiac disease to maintain adequate zinc levels and support overall health.

Conclusion

In conclusion, untreated and undiagnosed celiac disease can lead to deficiencies in various nutrients due to malabsorption caused by damage to the small intestine lining. These deficiencies can result in a wide range of symptoms and health effects, including compromised bone health, impaired immune function, nerve-related issues, skin, hair, and nail problems, and other related health concerns. Therefore, it is crucial for individuals with celiac disease to be vigilant about their nutrient intake and work with healthcare professionals to ensure proper monitoring and management of their nutrient levels through a well-balanced diet and, if necessary, appropriate supplementation. Proper management of celiac disease, including adherence to a gluten-free diet, regular monitoring of nutrient levels, and appropriate supplementation when needed, can help individuals with celiac disease maintain optimal health and prevent nutrient deficiencies.

Vitamins and Minerals Generally Safe in Excess of Recommended Daily Allowance (RDA):

• Vitamin C (Ascorbic Acid): Excess vitamin C is usually excreted in the urine and is considered safe in higher doses. However, very high doses may cause digestive upset in some individuals.
• Vitamin B1 (Thiamine): Water-soluble, excess thiamine is generally excreted through urine. It is considered safe in higher doses but consult with a healthcare professional.
• Vitamin B2 (Riboflavin): Water-soluble, excess riboflavin is excreted in the urine and is generally safe in higher doses.
• Vitamin B3 (Niacin): Water-soluble, niacin has a well-defined upper limit, but moderate excess is often excreted. Consultation with a healthcare professional is advisable.
• Vitamin B5 (Pantothenic Acid): Water-soluble, excess pantothenic acid is generally excreted through urine and considered safe in higher doses.
• Vitamin B6 (Pyridoxine): While excessive intake from supplements can lead to nerve damage, moderate overages are generally excreted through urine.
• Vitamin B7 (Biotin): Water-soluble, excess biotin is typically excreted and is considered safe in higher doses.
• Vitamin B9 (Folate): Excess folate is usually excreted, but extremely high levels from supplements may have potential risks. It's generally safe when consumed through natural food sources.
• Vitamin B12 (Cobalamin): Water-soluble, excess B12 is typically excreted in the urine and is considered safe in higher doses. Consultation with a healthcare professional is advisable.
• Choline: While not a true vitamin, choline is water-soluble, and excess is usually excreted. It's considered safe in higher doses but consult with a healthcare professional.

Vitamins and Minerals with Potential for Toxicity in Excess of Recommended Daily Allowance (RDA):

• Vitamin A (Retinol): Excessive vitamin A intake, especially from supplements, can lead to toxicity, causing symptoms like nausea, dizziness, and, in severe cases, organ damage.
• Vitamin D -  While moderate excess may be excreted, prolonged high doses can lead to vitamin D toxicity, resulting in hypercalcemia, kidney damage, and other complications.
• Vitamin E (Tocopherols): Excess vitamin E is usually excreted, but high doses from supplements may have adverse effects. Obtaining it through a balanced diet is preferable.
• Vitamin K: Excess vitamin K from supplements can interfere with blood thinning medications and cause issues in some individuals.
• Iron: Excessive iron intake, especially from supplements, can lead to iron toxicity, causing symptoms like nausea, abdominal pain, and, in severe cases, organ failure.
• Zinc: While zinc is essential, excessive intake can lead to zinc toxicity, affecting the immune system and causing digestive issues.
• Copper: High copper levels, often from supplements, can lead to toxicity, causing symptoms such as nausea, vomiting, and liver damage.
• Selenium: Excessive selenium intake, especially from supplements, can lead to selenosis, causing symptoms like hair loss, gastrointestinal issues, and neurological problems.

It's crucial to note that individual tolerances can vary, and supplementation should be done under the guidance of a healthcare professional.

Sources:

• National Institute of Diabetes and Digestive and Kidney Diseases. (2021). Celiac Disease. Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease 
• Rubio-Tapia, A., Hill, I. D., Kelly, C. P., Calderwood, A. H., & Murray, J. A. (2013). ACG clinical guidelines: Diagnosis and management of celiac disease. The American Journal of Gastroenterology, 108(5), 656-676. doi:10.1038/ajg.2013.79
• Complementary Medicine, Penn State Hershey. (n.d.). B vitamins. Retrieved from https://pennstatehershey.adam.com/content.aspx?productId=107&pid=33&gid=000336 
• National Institutes of Health, Office of Dietary Supplements. (2021). Vitamin B5 (Pantothenic Acid) - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/ 
• National Institutes of Health, Office of Dietary Supplements. (2021). Vitamin B12 - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/ 
• National Institutes of Health, Office of Dietary Supplements. (2021). Chloride - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/ 
• National Institutes of Health, Office of Dietary Supplements. (2021). Iodine - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Magnesium - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/ 
• National Institutes of Health, Office of Dietary Supplements. (2021). Phosphorus - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Silicon - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Vanadium - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Manganese - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Lycopene - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Lutein and Zeaxanthin - Fact Sheet for Health Professionals. https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Nickel - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Selenium - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Iron - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Calcium - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Zinc - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/
• National Institutes of Health, Office of Dietary Supplements. (2021). Chromium - Fact Sheet for Health Professionals. Retrieved from https://ods.od.nih.gov/factsheets/list-all/

Celiac.com 04/04/2023 - Throughout this book (published one chapter per quarter on Celiac.com), we’ve discovered gluten centric practices in various vexing venues that constrain the lives of those dealing with gluten sensitivity. (For your convenience, here are links to previous chapters 1, 2, 3, 4, 5, 6, 7, 8.) In this chapter, we’ll discuss tactics gleaned from those interviewed, as well as an extensive restaurant primer featuring Chef Daniel Carpenter. As we’ve seen in so many illustrations in the book, having a strategy, language, and even a catch phrase (#glutencentric) empowers us to gracefully negotiate our gluten-free lives.

Best Places to Travel

When talking to my respondents, I asked them to tell me about their gluten free lifestyle when traveling. Stella (#21), for example, reports that her experience on Royal Caribbean cruise was successful; that the chefs are trained by the Culinary Institute of America, and know about cross-contamination. She felt safe eating the food they prepared. Lilly (#59) said the people at Disney were very accommodating. Vivian (#51) filled her suitcase before packing off to Ireland – just in case. While there, she discovered that Ireland is heaven for those with celiac disease. She noted, “The Catholic Church in Ireland has a separate line for the gluten free host!” Piper (#43) says, “In Italy, everybody knows what celiac disease is. Everyone is tested in elementary school.” It is reassuring to learn there are entire countries where we are safe to eat with celiac disease.

On the other hand, Asian countries aren’t as safe. Lillian (#58) traveled to Thailand, Cambodia, and Burma on a guided tour. She handed the tour guide a card she brought with her explaining her food allergies. Unfortunately, he had “no clue about food allergies, didn’t know how to read the card, or what the ingredients were.” She notes further, “In Thailand, [wheat containing] soy sauce is in everything.” When attempting to go on a guided all-inclusive trip to Japan, Liza (#68) reports the tour company told her she could not go because it was impossible to ensure the foods would be gluten free. When traveling anywhere, some participants report they freeze food to take on the airplane and then put it in the hotel refrigerator upon arrival. Others use Teflon bags to heat food in toaster ovens. However, when traveling to Asia, meats and many other foods are prohibited upon entry and all food must be declared at customs. Many I interviewed said they simply quit traveling because it was just too risky to rely on other people to prepare every meal.

It’s Better Than Staying Home

This excerpt from Gluten Centric Culture first appeared in the Journal of Gluten Sensitivity Autumn, 2019

Before I was diagnosed, my husband and I traveled quite a bit. After being diagnosed and becoming more sensitive to gluten over time, I traveled less and less, and only to places I knew. But that changed when my husband gave me an “adventure-island hopping tour” to Greece for a graduation present that included two dedicated guides, all meals, and multiple adventures a day with a group of thirteen others. To prepare, we increased our workouts and added regular six-mile walks. We were excited to see Greece in this way! The tour company sent me a form, asking me to disclose food allergies. I investigated common Greek foods to see what they ate and how foods were prepared to get an idea of what might be safe for me to consume. I also watched videos on how foods are prepared and saw that a frequent practice is to grill meats and bread on the same grill. That was worrisome. Rather than bogging them with a list of what I cannot eat, I said that I was allergic to dairy and gluten and the best foods for me to eat were steamed poultry or fish, steamed vegetables, and fruit such as oranges or bananas. Steaming seemed to be the safest suggested cooking method. In interviews for my study, I had learned that Greece was on the top of the list of countries that people reported was the most challenging, so I was a little concerned about going. But I resolved that I wouldn’t let celiac disease force me to stay at home.

I want to experience life! So, whenever I travel, I always carry a 3 oz. pouch of tuna, a Lara bar, and a sealed package of walnuts. (Note: these foods get through TSA in my carry-on every time!) It is amazing how many times that little meal has saved the day. I feel confident knowing I always have food with me. So even though I anticipated finding safe foods in Greece, I packed energy bars, pre-packaged walnuts and almonds, pouches of tuna, dehydrated vegetables, and jerky (easy to reconstitute into soup), just in case. I even brought my favorite chocolate.

The welcome meal was abundant with lovely Greek foods served family style and I realized that nothing on the table was safe for me. Nearly every dish contained gluten, and I feared the salads were prepared on surfaces also used to slice bread. Foods that didn’t contain gluten, contained dairy. Feta cheese, Parmesan, and yogurt were abundant at every meal. A plate of chicken was presented near my plate, apparently for me, but it had cheese on it. I passed it down to the others at the table. Even though I filled out that travel form disclosing my allergies, there was nothing for me to eat at that meal.

I have a great appreciation for the “art” of cooking, for flavor-pairing, for attaining the right mouth feel, and balance of flavors. The Greeks do too. In fact, the word epicurean (pleasure of food and drink) originated in Greece in the 15th century. In Greece, typical evening meals start at 9:00 PM and end around 2:00 AM, served with weak wine so people can eat, drink, and chat throughout the evening. Meals are a social event enjoyed regularly by immediate and extended family and friends. At our meals, every dish was paired with lovely sauces or accompaniments to enhance the flavors and texture. Our guide carefully explained how to eat each dish, whether to stir in the cheese or sauce, or to eat it on the side, what to dip where, and what to pair with what. Wines were selected based on the entrée. The culinary skills demonstrated in the dishes were superior. Food in Greece is revered and celebrated. While my companions were exuberantly eating, I sat hungry, remembering a time before diagnosis when I went through a “Greek Food” phase. I reminisced on the lovely taste combinations of Greek foods. As a guest in their country, the last thing I wanted to do was to suggest alterations in the way they prepared these beautifully balanced meals to accommodate my strict dietary requirements. I didn’t want to insult their “art.” I also didn’t want to come off as a demanding person requiring them to change century-old practices for my needs. Finally, I didn’t want to make a spectacle of myself in the group I’d be spending the next ten days with. I didn’t want to be that needy person. I sat hungry, while my fellow travelers raved about the flavors. I wanted to sneak-eat the pre-packaged walnuts from my purse, but I couldn’t discretely get the darn bag to open.

Lunch the next day featured a similar array. This time, I pre-opened my walnuts and brought a banana. Tour participants noticed and passed various dishes to me. I told them I have food allergies and wanted to stay “safe.” The tour guides also noticed and asked me what I could eat, saying they would order anything I wanted. I said I was fine, that I wasn’t feeling that great and that the banana and walnuts were adequate. I really didn’t feel like exerting my needs and risking insulting anyone. After lunch, the two guides met with me privately and said, “You paid for food on this trip and we want to accommodate your needs. Please tell us how to do that.” I told them I’d think about it and get back to them. I felt overwhelmed with desperation and a little depressed. I was catching a cold from a direct-hit sneeze at the Parthenon, had a low-grade fever, and felt pretty bummed that I may be eating the foods I packed three times a day. The food in my backpack was intended for emergencies, not for every meal. My resolution to lead a normal life was evaporating, too. I was beginning to wonder if going on this trip was a big mistake, and thinking maybe it would be better if I had stayed home. Feelings of “food insecurity” set in, despite my suitcase of food. It was definitely the low-point of the trip, likely magnified by the fever.

To trust people you do not know, whose language you do not speak, who have never heard of celiac disease (and once they have, think it is shocking that anyone can be that sensitive) daunted me. And because we’d be travelling to different places every day, I’d have to trust different cooks to judge my needs as credible. The thought of this, especially when witnessing how much gluten was present in every dish, caused me to have a great deal of anxiety about becoming cross-contaminated, no matter what I ordered. I’ve worked in big kitchens with multiple cooks, and know that getting meals on the table requires “rote cooking” skills, often in a frenzy during peak times. Disrupting that assembly-line rhythm when trying to serve a lot of people causes problems. Old habits kick in, and cooks forget about the special requirements in their haste. Food is “glutened” without a thought because that is the way it is always prepared. It is not necessarily a reflection on the cook—they are simply doing what they do to get hot, tasty food on the table. Knowing this, I’d rather go hungry. Cross-contamination in one meal by just a speck of gluten could ruin my trip and make me miserable for weeks. It was a real dilemma.

For years after being diagnosed, my husband and I didn’t attempt group-trips that required others to prepare my meals. Rather, we’d stick to American cities and finally branched out to Europe once or twice, finding grocery stores to purchase suitable foods. We had lovely picnics in scenic places. Occasionally in restaurants, I would present my “dietary restrictions card” in the language of the country, and to my relief, usually received safe meals. But something about Greece was different. In most countries in Europe, gluten intolerance is well known. Here, it seemed obscure. In fact, I learned that the Celiac Society (a celiac disease awareness and advocacy group) only had a presence in Greece for one year. As a result, celiac disease is virtually “unknown” in Greece.

I thought about the “raw ingredients” contained in the two meals we’d had so far, and determined that zucchini, green beans, potatoes, carrots, chicken, or fish were regular fare. Thinking most restaurants would have those foods I met with the two guides and gave them the card I brought with me explaining my dietary issues and what an ideal meal would be. Though their English was exceptional, I gave them the card in both English and Greek. They asked me what I would ideally like, and I said, “Let’s keep it simple. I’m happy to eat the same foods for lunch and dinner … so a steamed piece of fish or chicken with some zucchini, potato, and a carrot would be fine.” They said, “None of the restaurants have steamers. How about if we ask them to use a clean pan that has been washed free of grains to boil your meals?” I said, “That is a great idea! I would feel comfortable with that.” Over the course of the week, they called each restaurant in advance of our arrival, and I was presented with lovely plates of these foods.

The guides had to explain these “safe practices” to each of the restaurants—a new concept for most of them (though one cook had a sister with celiac disease and understood completely). Many of the cooks wanted to add things to make it taste better, and the guide explained, “No, this is all she can have.” Sometimes, the restaurants didn’t have the foods I requested and the guide went to a grocery store and brought it to the chef. He was very discrete about this and no one on our tour knew he did it. I was deeply touched by his kindness. One time, the guide actually cooked my meal for me! Several of the chefs objected to boiling fish, while others, since they were given a few days notice, sourced a type that could be boiled. I would have suggested grilling it on a “clean” grill using olive oil, but in the interest of keeping it as simple as possible, I stuck with “boiled.” Simplicity seemed the best tactic. And since it was so different from how the chefs typically cooked, I felt safe that old habits wouldn’t kick in to cross-contaminate the foods.

Others on the trip were very cooperative, no longer strangers, but fun travel companions who kept bread crumbs from flying on my plate when we were eating a picnic on a windy day, and who were careful to keep the bread basket away from my plate while sitting at the table. I sat on the end of the table to dodge crumbs, and to have access to the waiter if I needed to – though I didn’t – the guides did all of the interfacing for me. When everyone else stopped for a gelato, the guide handed me a banana or an orange. My gratitude for the meals they prepared for me influenced the way the others viewed my meals – with appreciation that the guides and restaurants were so accommodating and cooperative. The experience forced me to come to terms with my insecurities about speaking up, my food anxiety, and the reality of my limited diet.

I learned a few lessons too. For someone as outspoken about celiac disease, sometimes my own timidity surprises me. I realized that I had allowed myself to fall into the absence of agency ideology by being shy about asserting my needs. As a foreign traveler, I didn’t want to be a bother or make the entire trip focused on my food requirements. An extensive study conducted on adults with celiac disease (Peniamina, Bremmer, Conner, & Mirosa, 2014) found “the main qualities seen as important for coping with allergen-free eating were assertiveness and organizational skills” (p. 943). Assertiveness, they found, is paramount to ensure the person with allergies conveys his or her needs to avoid risk-taking behaviors. I admit that I did not initially assert myself, and it was only because of the guide’s insistence that I was given suitable meals. However, eating is a fact of life, and it comes up at least three times a day, so it has to be dealt with. Assertiveness means being confident enough with yourself to ask for your special needs to be met, or to bring foods for yourself and eat them openly. It doesn’t mean being demanding or rude. It means simply stating the facts and asking for cooperation. Assertiveness would have meant that I initiated that private conversation with the guides, rather than the other way around. Both guides said I was too polite, and that they wanted to help me. They said if I had been demanding, they still would have helped me, but reluctantly. I really didn’t want to be a problem, but in the end, I did have to eat. It feels like walking a tightrope to find that happy medium to be assertive, firm, friendly and respectful, all at the same time. It is a social skill worth practicing.

Even though they accommodated my needs, the meals required supplementation. I was glad I had high-fat bars and nuts with me. Several things contributed to my successful trip. I came home un-contaminated, and didn’t lose much weight! (By contrast, my fellow travelers complained about gaining weight because the food was so fantastic, and isn’t that a sign of a great trip!) I ate my bars and nuts for breakfast. I wouldn’t have come up with the idea of a “boiled meal” on my own, but I worked with the others to find a solution. The guides, who had never heard of celiac disease before, did some research between day one and our meeting. They learned from reading the Internet about safe practices. I am grateful they proposed the “boiled meal” idea. The guides’ cooperation was key to a successful, pleasant trip. The guides also coached me on what would have been a better way to write my card. Based on their suggestions, here is what it now says:

I have celiac disease and am allergic to gluten (wheat, barley, rye, spelt, oats); dairy (cheese, milk, butter, yogurt); coconut, palm, and pine. Would it be possible for me to please have fish or chicken boiled or steamed with vegetables (with no added sauces or condiments) served with potato, beet, turnip, or rice? It is essential that foods prepared for me have not come into contact with gluten-containing grains or dairy. Please boil, pan fry (with olive oil), or steam my food in a pan that has been thoroughly cleaned from any residual grain. Thank you.

Was it better than staying home? YES! I was really proud of myself for having the courage to travel again. My planning coupled with the compassion of the guides provided me with the trip of a lifetime.

The Letter

In addition to a card to hand a food server, it is a great idea to get a letter from your doctor on official letterhead that says you have celiac disease or gluten intolerance, and that you must follow a strict gluten free diet. You never know where you might end up while travelling. For example, if you were checked into a hospital, the medical letter would instruct the staff what to feed you. It is important to ask your doctor to write what you can eat, rather than listing all the foods you cannot eat. For example, you might ask the doctor to write that you should stick to a diet comprised of lean meats, steamed or lightly stir-fried vegetables, fruits, nuts, etc. This way, when taking it to a kitchen, the staff knows what to make for you. I keep a digitized copy of my letter in my purse on a USB drive, and have a printed copy with me whenever I travel. It has also helped me keep food that would have otherwise been tossed as I go through security in airports.

RESTAURANT PRIMER

After explaining her gluten free needs, Ruth (#69) describes how her companion mocked her in front of the server and said, “Give me all of her gluten! Make mine ‘normal’” he said, thereby undermining Ruth’s needs and making her order seem “abnormal.” Should Ruth point this out to her friend? If it is a close friend (or spouse), it might make sense to discuss how his comment undermines the severity of her needs. He may not realize that his joke is having a negative effect. In fact, these scenarios happen frequently when we go out to eat which is what prompted this Restaurant Primer gleaned from the wealth of information shared by study participants. In order to understand the restaurant’s perspective, this section includes insight from a prominent Chef, Daniel Carpenter.

We discussed day-to-day restaurant experiences of interviewees at length in Chapter 5. This section takes us from the “front of the house” where we sit and eat, to the “back of the house” where food is prepared. Every step of the way is fraught with the possibility of errors being made. The following will attempt to provide some guidelines so we feel like we can go out to eat. Nearly everyone I interviewed said that eating in restaurants was their number one issue. Many simply do not feel safe because of worries about food being cross-contaminated in the kitchen. We also dread having a confused or dis-compassionate server. We have every reason to be concerned. A recent study shows that one-third of foods labeled gluten free in restaurants actually contain gluten (Lerner, et al., 2018). This eighteen-month study asked 804 people to carry a portable Nima gluten detection device in various restaurants across the U.S. Five thousand six hundred twenty-four items were tested and 32% of the foods that were labeled gluten free, contained gluten (Lerner et al., 2018). This is likely because of cross-contaminating practices and because so many foods contain hidden gluten with confusing names. It takes a certain amount of expertise to read labels accurately, and unfortunately many restaurant workers lack this skill.

Ordering Strategies

Not quite as bad as Ruth described above, but never the less, a challenge—here’s a scenario that happens when I dine out with a friend. If I order the salad with no dressing, no cheese, no tortilla strips, and a piece of dry-grilled fish on the top. Inevitably, my companion orders that same salad, but makes different changes to the order. That shows comradery – eating the same foods is a subtle gesture of “togetherness.” But it usually results that I get some unusual combination of the two orders, with toppings I am allergic to. This has happened enough times that I have specific restaurant strategies.

First of all, I try to order last. If the server starts with me, I now say, “Oh, I need another minute…” That way, the server takes everybody else’s orders first. Second, I arrange it so I am sitting on the end seat at the booth, or if at a table, I ask the wait staff person to come over to where I am so I’m not announcing my dietary requirements across the table. Third, I order discretely, so nobody gets the idea to change their order to what I am ordering, thereby causing the same confusion as mentioned above. Using this new strategy, more often, I get a meal I can eat. Let’s hear now from Chef Daniel Carpenter on “front and back of the house strategies.”

Figure 9.1 [Licensed with permission from Cartoon Collections.]

Front of the House – To Restaurant Patrons

For this section, I interviewed Chef Daniel Carpenter from Crooked Tree Culinary who develops restaurant best practices for “back of house” (the kitchen). Insight to how restaurant workers fulfill the needs of the food sensitive helps us to communicate better to each other. Harmonious interaction with front of house workers (the serving staff) often determines success with the back of house fulfillment.

Carpenter says, “I’ve been thinking more about the question of how diners can best present their needs at the point of ordering and it feels as though your message might center both on vocabulary and on self-advocacy. If a diner is fortunate enough to be speaking to a manager (or a seasoned server), the need for self-advocacy should be lower, because they will be interacting with a professional who understands how high the stakes are.” How do we ensure we have self-advocacy? Several suggestions come directly from participants in the study. For example, Hazel (#22) recommends using an app to find “safe” restaurants. She reads the comments of others before deciding which restaurant to choose. After a meal, she also provides feedback for others on the app. Just search for “GF apps.” Also, the Gluten Intolerance Group of North America has certified some restaurants, and a list of those establishments can be found at (gfco.org). Other participants suggest calling the restaurant in advance and speaking directly to the chef to work out the best thing to order. Many said they deliberately go to the restaurant during off-hours so their needs can be tended to with un-hurried staff.

When eating outside of our home, we are empowering many who do not understand the severity of our disease to cook for us. Consider how much time and effort it has taken for us to fully understand the nuances of the disease and the foods that trigger reactions. For many, the list of foods we avoid expands the older we get and longer we live with celiac disease. We can’t reasonably expect a cook in a kitchen who is focusing on getting hot plates of different foods served to worry about the extensive list of foods we cannot eat. They would have to understand all of our allergies, read every label of everything they use, and know what the obscure words mean. Most people simply can’t do that. And consider the foods mentioned in Chapter 8 describing the able-body bias that have hidden gluten such as grocery store rotisserie chickens – it’s complicated! The best advice when ordering is to stick to naturally gluten-free foods like salad, vegetables, fruit, and unprocessed meat. Participants also said they always brought their own tamari or gluten free soy sauce so they knew they had a condiment they liked if ordering steamed rice and vegetables.

When ordering, speak “restaurant talk.” Order something grilled “dry” if you do not want oil. If ordering from a menu, tell the server what you do not want. For example, if the salad’s description says it comes with shredded cheese and croutons, say you do not want the cheese and croutons. In fine restaurants, take a look at the menu to see what meats/proteins and what vegetables are offered. Then close the menu and after explaining what allergies you have, order the meat “dry” and the vegetable “steamed.” Carpenter suggests, “I would recommend including (in a firm but non-confrontational way) how the possible outcome of a failure could look.” You might say, “I have Celiac disease and if I consume gluten, I will become very ill.” Further he recommends not using the term “sensitivity” but rather say “allergy” or even “extreme food allergy.” “Leaving any gray area is a recipe for heartache.” Be very specific and practice what you’ll say beforehand. You might decide to say, “I have an allergy to gluten, (a protein found in barley, rye, oats, wheat, and spelt) and I need to be assured that my food doesn’t contain it.” I don’t advocate leaving the table and seeking out the server for a tête-a-tête because that might disrupt the flow of how the server takes orders.

Carpenter says, “The case where problems might arise is where [restaurant] guests are dealing with a junior server or one who does not, or does not care to, understand the importance of respecting the guests' needs.” It’s a good idea to “test” servers before ordering a meal, just to see if they are listening. For example, order club soda with lemon before ordering food. If the server has listened and brings lemon (rather than the usual lime garnish with club soda), you feel more confident that they might get your dinner order right. If they don’t bring it with lemon, you know this server is not concerned about special requests. In this case, it makes sense to ask to speak directly with the chef or to the manager when ordering your meal. This is a delicate issue because you rely on the server to bring something safe for you to eat, and the last thing you want to do is to make them angry. Carpenter says, “Unfortunately, many servers do not have a solid relationship with the kitchen or simply are afraid to place modifiers on tickets because cooks often respond with hostility to any changes, especially during busy times. Here is where the self-advocacy comes in; guests (even though it might feel ungraceful) need to escalate to a manager any time there’s even the hint that they are not being heard.” Knowing this, you might say, “My needs are complicated. I’m really sorry, but I wonder if it might make sense for me to speak directly with the chef?” Even if you don’t end up talking with the chef, you’ve still made your point.

When servers and staff try to accommodate your needs, thank them for taking care of you and speak to the manager to thank them for working with people with special needs. It is important to positively reinforce everyone involved.

Back of House – To Restauranteers

Carpenter has worked with many restaurants to ensure special orders are fulfilled properly. He says:

The model I recommend creates a separate pathway in the point-of-sale ordering system whereby tickets that address specific dietary needs are printed on their own color or type of paper [and potentially sent to printers on portions of the line where specific food types are (or are not) prepared]. Of course, none of this means anything unless the server and manager are proactive in receiving and confirming with the guest exactly what needs must be met. That language will vary depending on the type and style of restaurant concept: a fast casual outlet that serves no shellfish will approach the scripting of that conversation differently from how a full-service fine dining restaurant will.

Once the order has been taken and verified with the guest - ideally by the front-of-house manager-on-duty - and the ticket has been sent to the kitchen, I recommend mandating direct verbal confirmation between the front-of-house / manager-on-duty and the back-of-house manager on duty/chef. In my experience, most breakdowns occur when both the dining room and kitchen are very busy. The team is skimming the surface of orders/tickets [not reading them closely]. [Busy] times during most shifts [are] when the team switches into auto-pilot and sometimes makes both major and minor mistakes. Escalating every order containing special dietary needs to the shift leads, in their respective sectors of the operation, provides an invaluable double-safe. The final step is for the front-of-house / manager-on-duty to run the plate personally and to repeat the special need that has been met in the preparation of the dish.

Many operators will resist the notion that the operation needs to come to a screeching halt and that a conversation between front-of-house and back-of-house has to happen, but the stakes here are so high that I insist on that exact sequence of events, even if it’s multiple times/evening and during rush periods. Operators who have experienced the pain of an order slipping through the cracks know just how much effort prevention is worth; those who have yet to experience that unfortunate event often fail to understand that it’s not a matter of if but one of when it will happen to them if they do not take proper measures.

As we know, training and consistency are keys in every aspect of foodservice. Repetition in pre-shift meetings/ongoing training and in new hire seminars is critical to success, especially when it comes to the health and welfare of guests who have dietary needs to be met.

Perhaps this information will help restaurants to develop best practices in their kitchens.

What diet is right for us?

What should we even ask for when ordering in a restaurant, to ensure our safety? Some said they chose to follow diets that completely eliminate bread such as the Paleo diet where one eats meats, above ground vegetables, nuts, and fruit. Many participants told me they were initially diagnosed with irritable bowel syndrome (IBS) and followed the Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (FODMAP) diet plan, which are names for certain types of carbohydrates that ferment in the body and cause digestive disorders (Nanayakkara, et al., 2016). Avoiding foods with this type of carbohydrate eases these troubles. Lists vary, but according to Nanayakkara, fruits such as bananas, and blueberries are low while apples, pears, and cherries are high. Vegetables such as zucchini, carrots, and green beans are low, while snap peas, mushrooms, and asparagus are high. Grains such as brown rice and gluten free grains are low, while gluten-containing grains are high. Nuts are preferable to beans and alternatives are suggested for dairy. If you are still plagued with gas, constipation, bloating, vomiting, or diarrhea and you are following a gluten free diet, ask your doctor if you should consider the FODMAPs plan. Like everything, it takes trial and diligence to understand what works for you.

Fixed Menu Formal Dinners

If forced into a situation where there is no other alternative other than to sit with a plate of food in front of you that you cannot eat, such as at a banquet or a wedding where no provisions were made for your special needs, an alternative is to “fake eat.” I hate to admit this, and I think wasting food is terrible, but some social norms make it necessary to “pretend eat.” The “look like you are eating” tactic is well-known to anorexics – where you cut up food and hold it on the fork while talking, put it back and pick up another morsel and cut it up into little bits, and make a small pile. I learned about this technique in an Abnormal Psychology book in the discussion on anorexics and thought, this would be useful for those occasions that I cannot control. The food never enters my mouth. I’d rather go hungry than to take a chance on eating foods with ingredients I don’t know, and getting a reaction, and I also don’t want to offend anybody by rejecting the offered food. I use this technique sparingly, and less since I’ve become empowered after my Big Shift, but it is in my arsenal if I’m in a public “vexing venue” because it affords me agency to protect myself in an otherwise dangerous situation.

My husband has my back at organized meals where provisions for my needs are not met. We have a system we call “plate and switch.” If I am with my husband at a business meal, I can usually do the plate and switch maneuver sometime during the meal. Here’s how it works: I sit next to my husband and start off with the “look like you’re eating” tactic. When my co-conspirator has eaten most of his meal, we switch plates. You’d be surprised at how easily this can be done and go unnoticed. Then, I can put my silverware on the plate in the “I am finished” position (and hope that the waiter has read the same etiquette book as I have) and my husband can finish eating my meal. He loves it – he gets two meals, and I love it because it looks like I’ve eaten like everybody else.

Gluten Detection Kits

There are several gluten-detection kits on the market designed to test foods on-the-spot. These can really ease the worry and some of the participants advised using them before consuming restaurant foods. These tests might be acceptable when dining with family and close friends, but it could also become a conversation diverter as dining companions inquire about it. Results occur after approximately three to ten minutes (depending on the test) and food can become cold during the testing process. Even though the dinner table isn’t the ideal testing location, these tests are invaluable to isolate hidden gluten in foods, pharmaceuticals, or cosmetics you use at home.

This chapter has provided a smattering of survival strategies for travelling and eating in restaurants gleaned from the many interviews, and my nearly twenty years of living this lifestyle. The next chapter takes a look at the legal protections offered by the American Disabilities Act, and how changes in it could positively affect the lives of those with celiac disease.

Jean’s Story – May I Have a Fruit Plate, please?

My worst nightmare is going to a banquet where the food is pre-determined – known as a Fixed Menu. You never know what will be on that plate! Usually it is rubbery chicken in some kind of sauce with limp vegetables and dessert with whipped cream that won’t lose its shape in 10 years. Knowing that most of the time, there are pre-made fruit plates in the back for people on special diets, I usually flag down the server for my table and ask if one is available.

Sometimes this backfires, when the food is served and the server bellows “WHO WANTED THE FRUIT PLATE?” Or, when everybody else is served and the fruit plate hasn’t found its way to the table and everyone is waiting on you to be served before eating. Very embarrassing. This always prompts the question “Are you on a special diet?” I say yes, and look down, hoping it won’t go further.

But there’s always one who probes, and when you finally tell them, they inevitably say, “Oh my Aunt Sally is on a gluten-free diet. She bloats up like a dead fish when she eats gluten, what happens to you?” How do you politely divert the conversation? I have a number of conversation starters (How about those [fill in the favorite football team]? Did you see [fill in favorite streaming series] last night? What was the last book you read? Can you believe the weather we’re having?)

One evening, I was at a dinner meeting in banquet room in a nice downtown hotel to discuss funding for a start-up. I quietly summoned the server and asked if they had a fruit plate, without dairy (since they often come with cottage cheese or yogurt). He said they had a few back there, and he would get one for me. I thanked him, and rejoined the conversation at the table. Servers arrived with huge trays with plates covered with metal lids. They were presented to each of the people around the table and the lids were removed with a flare. The waiter forgot about my request and huffed off with the plate he had just served when I reminded him of the fruit plate.

Underneath the metal lids, guests found rubbery stuffed chicken, with a mysterious white sauce, limp broccoli, and parsley as a garnish. After a while, my fruit plate finally arrived. I was hungry. It was beautiful and had slices of cantaloupe, honeydew, strawberries, blueberries, a bunch of red grapes and wedges of orange. The others at my table eyed my colorful fruit plate enviously. I ate the cantaloupe and honeydew. I looked at the grapes – how does one eat grapes still on the stem at a dinner? I decided since they were still on the stem, to pick it up and pluck them off with my fingers. The grapes felt grainy to my fingertips. I looked more closely at them, and noticed dirt on them. They were not washed! I wondered if I could discretely wash them in my water glass… and decided there was no way to do that without looking really weird, and calling attention to myself. I put them back on my plate.

I continued participating in the conversation around the table about fund raising for entrepreneurial ventures and cut into a very large red strawberry. Out popped a surprised, live green worm! He was about an inch and a half long and a little chubby. He had little green antennas and beady black eyes. He looked around – wondering what happened to his home! I obviously couldn’t eat the strawberry – and really didn’t want anyone at the table to notice the worm. I had lost my appetite anyway, and started feeling sorry about ruining the worm’s home and blowing his cover.

I pretended to eat the rest of the meal, and gave the plate back to the waiter as soon as he came around. The next month, when I attended the same dinner for the same group, and ordered the same fruit plate, the strawberries were sliced. Sometimes, even with all of our conversations, precautions, and strategies, things just don’t work out. It’s part of living with food sensitivities.

Discussion Questions:

1. What are your most successful travel strategies?
2. What restaurant strategies do you deploy in order to avoid consuming gluten?

References in Chapter 9

Carpenter, Chef Daniel. Crooked Tree Culinary. https://www.linkedin.com/in/danielkcarpenter 
Lerner, B., Vo., L., Yates, S., Rundle, A., Green, P., Lebwoh, B. (2018). Gluten Contamination of Restaurant food: Analysis of Crowd-Sourced Data. The American Journal of Gastroenterology, 113, S658-S658. doi: no doi.

Continue to: Gluten-Centric Culture: Chapter 10 - Taking Action–It's the Law!

Back to: Gluten-Centric Culture: Chapter 8 - Empowering Language

Celiac.com 03/27/2023 - Celiac disease, a chronic inflammatory disorder of the intestines, affects about 1% of the world's population. Celiac disease causes diarrhea, abdominal discomfort, bloating, flatulence, and, in rare cases, constipation in the digestive tract. Since the identification of gluten as the disease-causing antigen, celiac patients have been treated with a gluten-free diet, which usually eliminates symptoms and restores gut health, but which also has limitations for some patients. Celiac disease is also associated with numerous neurological and psychological manifestations. A recent article details findings from the most recent study, but here we try to provide more comprehensive information.

Neurological Manifestations of Celiac Disease

The neurological manifestations of celiac disease are varied and can include psychiatric and neurological symptoms such as ataxia, peripheral neuropathy, seizures, headaches, cognitive impairment, and myoclonus. The specific mechanisms of celiac disease's neurological effects are still being researched, but they may involve gluten-mediated pathogenesis that can lead to antibody cross-reactions, immune-complex deposition, direct neurotoxicity, or extreme vitamin or food deficiencies. A gluten-free diet can alleviate most celiac disease symptoms, except for cortical myoclonus and dementia, which may require immunosuppressive therapy. However, there is currently no consensus on whether serological or neurophysiological data can accurately predict or monitor celiac disease-related neurological involvement.

Treatment for gluten-related neurological symptoms typically involves embarking on a strict gluten-free diet as soon as possible, which can have a positive therapeutic effect for most cases. Symptomatic management may also be required. Immunosuppression is only used in cases where a gluten-free diet alone has not been beneficial or for patients with refractory celiac disease.

Peripheral Neuropathy and Gluten Ataxia

Peripheral neuropathy and gluten ataxia are common in celiac patients, with up to 39% of patients experiencing gluten neuropathy. Gluten-free diets have been shown to improve neuropathy and ataxia.

Gluten ataxia is an uncommon immune-mediated neurological disease that can be difficult to identify. The early signs of ataxia may be subtle, but worsen if left untreated. Patients with gluten ataxia may experience structural alterations in different parts of the brain, including the cerebellum and thalamus, and have larger lateral ventricles.

Higher Epilepsy Risk

Celiac disease increases the risk of epilepsy, especially in children and adolescents. The presence of villus atrophy on follow-up biopsies may reduce the risk of epilepsy but does not affect hospitalizations for epilepsy emergencies. Unexplained epilepsy should prompt celiac disease screening since early identification and therapy may increase the effectiveness of anti-epileptic drugs.

Celiac patients also have a higher prevalence of migraines and tension headaches. The underlying relationship between celiac disease and headache involvement is still unknown, but adherence to a gluten-free diet can alleviate neurological symptoms.

Celiac disease can also cause cognitive impairment, including memory loss, clouded thinking, personality shifts, and an inability to calculate. Nutrient deficiencies, systemic inflammation, and low brain serotonin levels have been suggested as possible reasons for this. Celiac disease has also been associated with Alzheimer's and vascular and fronto-temporal dementias. Neuropsychological assessments should be conducted in celiac disease patients to assess cognitive function.

Psychiatric Manifestations of Celiac Disease

Celiac disease is associated with depression, anxiety, eating disorders, autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), bipolar disorder, schizophrenia, and mood disorders. The relationship between celiac disease and these psychiatric disorders is not well-known or established. Particular biological aspects as well as the effect of a gluten-free diet require additional research.

Depression and Anxiety

Celiac disease has been associated with various psychiatric disorders such as depression, anxiety, eating disorders, autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), bipolar disorder, schizophrenia, and mood disorders. However, the relationship between these disorders and celiac disease remains unclear and requires further research.

Research suggests that gastrointestinal disorders have a link with depression and anxiety due to prolonged pain and inflammation, affecting specific brain targets like the anterior cingulate cortex. Gastrointestinal disorder patients have reduced cognitive and mood status, leading to anxio-depressive phenotypes, even in the absence of clear evidence of threats.

Children with celiac disease may experience anxiety and depressive symptoms, and pediatric patients with celiac disease should be frequently assessed for mental health issues, especially anxiety and sadness. Adults with celiac disease have reported experiencing anxiety and depression as well, particularly due to clinical illnesses and symptoms.

Following a gluten-free diet may worsen symptoms like anxiety and fatigue, leading to a diminished quality of life. Therefore, clinicians must recognize the importance of promoting both dietary adherence and social and emotional well-being in celiac disease patients.

Studies have shown that individuals with celiac disease experience low quality of life, anxiety, and depressive symptoms, and nutrition plays a crucial role in reducing these effects. However, the role of motivation in the quality of life and adherence remains unclear and requires further research.

Eating Disorders

Eating disorders may be a comorbidity with celiac disease (celiac disease) and the need for further investigation. celiac disease patients may experience disordered eating due to the disease itself or other factors such as food neophobia. It is crucial for gastroenterology clinicians to be aware of potential risks for eating disorders in celiac disease patients.

The article notes that while numerous examples of eating disorders have been described in celiac disease patients, few epidemiological studies have investigated this potential link. One study found that patients with celiac disease had higher Eating Attitude Test scores than controls when testing individuals aged 13 and up, but no clear differences were seen between patients with celiac disease and controls when using other screening measures for ED. The article suggests that further investigations with larger samples and prospective designs are needed to corroborate these results.

The article also discusses how celiac disease may cause food neophobia, which is linked to sensory aversions or fears of the negative effects of eating particular foods. This fear may be more severe in celiac disease patients than in non-celiac disease patients who choose to follow a gluten-free diet and can be linked to the possibility of having an unfavorable reaction to gluten-contaminated food products.

The article emphasizes the importance of gastroenterology clinicians being aware of potential risks for eating disorders in celiac disease patients. It notes that eating disorders are defined by thoughts and actions linked to physical and/or psychological problems and that it is crucial to identify past, current, and potential risks for eating disorders in celiac disease patients.

Autism Disorder

Autism spectrum disorder is caused by a complex interplay of genetic and environmental factors, affecting individuals in diverse ways. Recent studies suggest that immune system dysfunction could contribute to the development of autism spectrum disorder in some people [55]. While some research suggests a connection between celiac disease, an autoimmune disorder triggered by gluten consumption that mainly affects the small intestine, and autism spectrum disorder, other studies have not found a significant association between the two conditions.

Attention Deficit Hyperactivity Disorder (ADHD)

Research has suggested a potential link between celiac disease and ADHD, with studies showing that celiac disease is overrepresented in ADHD patients, and a gluten-free diet improved ADHD symptoms in celiac disease patients. However, routine screening for ADHD in people with celiac disease or vice versa is not recommended. Cognitive problems similar to those seen in children with ADHD, such as a lack of focus or trouble paying attention, were linked to gluten-free diet noncompliance in childhood celiac disease, as were psychosomatic symptoms and antisocial behavior. Individuals with untreated celiac disease may be at risk for engaging in ADHD-like behavior, specifically inattention. Out of 23 studies, 13 found a favorable correlation between ADHD and celiac disease.

Bipolar Disorder

Bipolar Disorders refer to a group of serious and long-term mental health conditions that are characterized by manic and depressive episodes. Research has shown that people with bipolar disorder have higher levels of immunoglobulin G (IgG) antibodies against gliadin than those without a history of psychiatric illness. However, there is still a need for further investigation into the specific antibody response to gluten antigens in bipolar disorder. Close associations have also been observed between celiac disease and major depressive disorder, panic disorder, and bipolar disorder, leading to reduced quality of life. Therefore, early reporting of symptoms and screening for celiac disease is recommended, especially for those with a family history of the disease or essential symptoms.

Schizophrenia

Schizophrenia is a severe mental illness that increases the risk of premature death 2-4 times compared to the general population. Genetic and environmental factors, including drug abuse, especially involving cannabis, are associated with an increased risk of developing schizophrenia. Research suggests an association between schizophrenia and celiac disease, although a causal link has yet to be established. 

Although having elevated antibodies against gliadin is a common immunological abnormality between schizophrenia and celiac disease, most patients with schizophrenia who had elevated anti-gliadin antibodies (AGA) did not have celiac disease. However, there is evidence that a gluten-restricted diet may benefit schizophrenia patients with immunological gluten sensitivity. One treatment-resistant schizophrenia patient with immunological gluten sensitivity benefited from a gluten-restricted diet improvement in both mental and physical symptoms, as well as a reduction in the plasma quantitative level of AGA-IgG. Chronic inflammation, which is thought to increase due to gluten intolerance, may worsen the symptoms of schizophrenia and make it harder for patients to respond to treatment and absorb medications.

Schizophrenia patients also have a higher rate of digestive and liver problems. While removing gluten from the diet may alleviate some symptoms, it is not recommended for all patients. Gluten intolerance is believed to increase chronic inflammation, exacerbating symptoms and reducing medication absorption. However, the available data on the link between celiac disease, gluten allergies, and schizophrenia are inconsistent, and a gluten-free diet is not recommended for people with psychosis and mood disorders without further research.

Other Psychiatric Disorders

Previous research has shown that people with celiac disease are more likely to suffer from neuropsychiatric disorders than the general population. So far, more than 60 non-human leukocyte antigen (HLA) genes have been linked to celiac disease by genome-wide association studies; of these, it is believed that 15% have a role in neurological health.

Many common neuropsychiatric disorders include celiac disease as a primary predisposing factor. It's possible that the co-occurrence of diseases is in large part due to shared molecular networks and biological processes. To determine what causes these disorders, we need to look at the underlying molecular mechanisms. Celiac disease was associated with an increased risk of psychiatric problems in children, raising their lifetime risk by 1.4 times that of the general population. Celiac disease in children has been linked to an increased likelihood of developing psychosocial difficulties later in life, including depression, anxiety, eating disorders, antisocial behavior, attention deficit hyperactivity disorder, autism spectrum disorder, and intellectual disability. It was also more common to have been diagnosed with a mood, eating, or behavioral condition prior to the celiac disease diagnosis. In contrast, no elevated risk was found for any of the psychological diseases studied in the siblings of people with celiac disease.

A cohort study included nearly 20,000 children with biopsy-verified celiac disease, pairing each patient with 5 reference child controls. Approximately 16.5% of celiac children were diagnosed with a psychological condition during a median follow-up of 12.3 years, compared to 14.1% of controls.

Celiac disease in childhood increased the risk of psychiatric illness by 19% and this risk increases during maturity, in particular, mood, anxiety, eating, ADHD, and autism spectrum problems. There was no statistically significant increase in psychotic disorders, psychoactive substance use, behavioral disorders, personality disorders, suicide attempts, or suicides. Celiac disease increases the use of psychiatric medication. Psychological issues associated with celiac disease were also more prevalent.

As a result, the attending physician should conduct routine surveillance of potential psychiatric symptoms in patients of all ages who have gluten-related diseases, including both children and adults.

Conclusions

In conclusion, celiac disease has been linked to numerous neurological and psychiatric conditions, including depression, anxiety, eating disorders, autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), bipolar disorder, schizophrenia, and mood disorders. Clinicians should assess mental health factors when making a celiac disease diagnosis. 

Overall, the relationship between celiac disease and these neurological and psychiatric disorders is not well-known or established. More research is needed to understand the pathophysiology of celiac disease's neurological and psychiatric manifestations. Particular biological aspects as well as the effect of a gluten-free diet require additional research.

Read more at Cureus.com

Celiac.com 03/06/2023 - We get a lot of questions about celiac disease and gluten-free-related issues. One question we've seen lately is: Is there a connection between the human gut microbiome and celiac disease? The short answer is yes. The longer answer is that research has show a number of connections between the two conditions, but we still have far more questions than answers. Here's a rundown of what we do know.

Celiac disease is an autoimmune disorder that affects the small intestine. When individuals with celiac disease consume gluten, a protein found in wheat, barley, and rye, it triggers an immune response that damages the lining of the small intestine and interferes with the absorption of nutrients.

One of the key components of the gut environment is the microbiome, a complex community of microorganisms that live in the gut. Recent research has shown that the gut microbiome plays a crucial role in the development and progression of celiac disease.

Studies have shown that celiac disease is associated with changes in the composition and diversity of the gut microbiome. In individuals with celiac disease, there is a decrease in beneficial bacteria, such as Lactobacillus and Bifidobacterium, and an increase in pathogenic bacteria, such as Clostridium. This disruption of the gut microbiome, also known as dysbiosis, can lead to an imbalance in the gut environment, which can trigger an immune response and further damage to the small intestine.

Celiac Disease Disrupts the Gut Microbiome

Recent studies have shown that celiac disease not only affects the gut lining but also disrupts the balance of the gut microbiome. The gut microbiome is made up of trillions of microorganisms that reside in the gut and play a crucial role in maintaining overall health. In healthy individuals, the gut microbiome is diverse and balanced, but in celiac patients, the gut microbiome is often imbalanced, known as dysbiosis.

Gluten-Free Diet Affects Gut Microbiome

Dysbiosis in celiac patients can lead to a reduction in beneficial bacteria and an increase in harmful bacteria. This can cause a number of issues such as inflammation, changes in gut motility and nutrient malabsorption. Additionally, research has shown that the gut microbiome in celiac patients also changes after starting a gluten-free diet. For instance, the levels of certain beneficial bacteria such as Lactobacillus and Bifidobacterium increase, which can help to restore balance in the gut microbiome.

Gut-Brain Axis

It is not entirely clear yet how the gut microbiome is affected in celiac disease, but researchers believe that the gut-brain axis, which connects the gut and the brain, plays a key role. Studies have shown that the gut microbiome can influence the brain-gut axis and may impact nociceptive behavior and brain function.

There's also a connection between gut-brain axis and migraines in people with celiac disease.

Connections Between Microbiome and Celiac Research

We also know that Genetic Risk for Autoimmune Disease Tied to Gut Microbiome

We know that Celiac Disease Onset Changes Gut Microbiota in Children

Recent research shows that Gluten Does Not Change Gut Microbiome in Patients with Celiac Disease and Non-Celiac Gluten Sensitivity

We just recently learned that Altered Gut Bacteria Linked With Long COVID-19 Symptoms

We also know that, in some cases, Fecal Microbiota Transplant Restores Gut Microbiome

New research tells us that interaction between the gut microbiome and micronutrients are a key to the availability of minerals and vitamins.

Gut Microbiome Affects Bioavailability of Micronutrients

The gut microbiome can variously influence the bioavailability of micronutrients, as well as be influenced by micronutrient supplementation, with potential implications for health, even in the long term. 

Although several mechanisms have been advanced, a thorough characterization of the microbiome–micronutrient bidirectional axis is of utmost importance, as it can guide the design of microbiome‐based precision intervention strategies, aimed at improving micronutrient status and overall health.

Studies have shown that celiac disease is associated with changes in the composition and diversity of the gut microbiome, which can lead to an imbalance in the gut environment, known as dysbiosis. Gut microbiome imbalance can lead to a number of issues such as inflammation, changes in gut motility and nutrient malabsorption. 

Research has shown that the gut microbiome in celiac patients also changes in some worrisome ways after starting a gluten-free diet.

Much Unknown About "Healthy" Gut Microbiome

Additionally, we need a clear understanding of what constitutes a "healthy" gut microbiome in people with or without celiac disease to fully understand the implications of gut health on celiac disease.

When it comes to the connection between the human gut microbiome and celiac disease, we're learning that the two conditions are connected. Some evidence suggests that the health of the gut microbiome can influence certain symptoms of celiac disease, especially headaches.

However, much more research is needed before we can make any hard conclusions about the exact nature of the connections, and the implications for people with celiac disease and other auto-immune conditions.