Dietary Recommendations for
Celiac Disease and Non-Celiac Gluten Sensitivity (NCGS)
Lisa Helffrich Hudson, RDN
Celiac Disease and Non-Celiac Gluten Sensitivity (NCGS) are similar conditions in that they both have food, and specifically gluten, as the common factor that elicits a significant immune response. Celiac disease is an autoimmune disorder that affects genetically susceptible individuals when they ingest gluten, a protein found in many foods in our diet. The gluten protein is detected by the immune system as “foreign” and triggers an autoimmune response. The result is inflammation and damage of the small intestines ultimately leading to severe nutritional deficiencies and chronic health challenges. NCGS is also an autoimmune disorder triggered by gluten ingestion but these individuals do not have the genetic predisposition. The inflammation may occur in the small intestines, but not always, and is systemic so symptoms can be diverse and difficult to track. Both conditions are often undiagnosed leading to mal-absorption, nutritional deficiencies and chronic inflammation. The good news is once gluten is identified as the problem these individuals can make the necessary dietary changes to promote healing and restore their health. The purpose of this article is to provide an overview of the dietary recommendations for celiac and NCGS patients and also supply a list of resources for further learning.
Regardless of the health condition your patient presents with, the food they consume, their nutrition, is the foundation of their recovery. Persons with celiac and NCGS are certainly not exempt. In fact, nutritional deficiencies are two fold in this patient population. Before these individuals realize gluten is the trigger of the inflammation, the damage to the small intestines has already occurred leading to mal-absorption of key vitamins and minerals such as iron, calcium, B12, folate, magnesium, phosphorus, zinc and vitamin D. Secondarily, once they are aware of their inability to tolerate gluten, the avoidance of grains and fortified foods may lead to further deficiencies and impaired healing. Luckily with the help of a Registered Dietitian or nutrition professional, it is very easy to learn how to eat a nutrient dense, whole foods diet that is gluten free and contains all the vitamins and minerals necessary to restore the integrity of the gut and overall health.
First let’s identify where gluten is found in the diet? Gluten is a protein found in wheat, barley and rye. It sounds simple enough to remove these three grains from our diet. However, the challenge is gluten is not only found in the obvious foods where flour is the key ingredient such as breads, cereals, pasta and baked goods. It is also used as a filler, a binder and a processing aide in many other processed foods like condiments, soups, gravies, luncheon meats and so many other foods. And it is not just food we have to be concerned about. Supplements, prescription medications and even skin care products often contain gluten. Furthermore, while wheat, barley and rye are three grains known to contain gluten, many gluten-free advocates include oats in this list as well. Oats, while technically gluten free, may be contaminated during manufacturing so it is important to look for oat products specifically labeled gluten free.
Receiving a diagnosis of celiac disease or learning that you are NCGS can be very overwhelming and is only amplified by all the information available for eating gluten free. As a dietitian one of my biggest challenges is telling my clients what they cannot eat. So, I prefer to focus on what they can eat. Persons with celiac disease and NCGS can eat all fresh fruits and vegetables, all of them! They are loaded with vitamins, minerals, antioxidants, phyto-nutrients, fiber and naturally occurring anti-inflammatory compounds. The more color the better. My preference is organic when possible, or purchase from a local farmer who uses sustainable agriculture practices with no harmful herbicides or pesticides.
The gluten free diet allows for all fresh or frozen (not processed) animal proteinssuch as beef, poultry, pork and seafood. Proteins supply vital amino acids necessary for growth and repair of damaged tissue. Again organic when possible or ask for grass fed, free range, wild caught animals with no growth hormones or antibiotics. Eggs, plain unflavored milk and yogurt, andaged hard cheeses such as cheddar, Swiss, Edam, and Parmesan are naturally gluten free as well. Check the ingredient list on cottage cheese, cream cheese, and all pasteurized, processed cheese. Note, eggs and dairy are common allergy foods so you will want to confirm there are no sensitivities to these foods.
Healthy fats will supply the necessary fat soluble vitamins and essential fatty acids that are also anti-inflammatory. These include olive oil, coconut oil, avocado, nuts, seeds and butter from grass fed cows.
Last on the list are whole naturally gluten free grains such as brown or wild rice, quinoa, amaranth, millet and teft. These grains are a good source of B vitamins, minerals and fiber essential for the restoration of gut health. Because they are naturally gluten free these grains are not always labeled as such. If the grains are no longer whole and have been processed into flour or meal, be sure they are specified gluten free. Again, unless the oat product is specifically labeled gluten free there is the possibility of cross contamination.
With this extensive list of foods to choose from what are some of the challenges I see and how can they be addressed?
- How can we help our patients learn how to read labels and identify the hidden gluten. This can be a daunting task as most often it does not simply say “gluten”. The following is a modified list of the names for how gluten may appear in the “other ingredients” section of a label. These ingredients should be avoided as they contain the gluten protein: any form of wheat, barley or rye, Brewer's yeast, bulgur, durum, dinkel, farro/faro, graham flour, hydrolyzed wheat protein, kamut, malt extract, syrup or flavoring, malt vinegar, malted milk, matzo, modified wheat starch, seitan, semolina and triticale. As mentioned earlier, whole oats, oatmeal, oat bran or oat flour should not be eaten unless they are from pure, uncontaminated oats.
So, while I am a label scrutinizer, I find the easiest way to avoid hidden gluten when first learning is to choose from the list of naturally gluten free foods provided above. I encourage my clients to choose fresh, whole foods as they most likely have no other ingredients so they do not have to worry about hidden gluten and “other ingredients”. It is the processed, pre-packaged foods that they have to be more cautious with. When purchasing processed or packaged foods you will want to look for gluten free on the label.
- How can I eat out and still remain gluten free? This can be difficult and for the newly diagnosed it might be best to avoid eating out until you have your diet under control and your gut is on the mend. Fortunately, the awareness of gluten free is growing and there are more restaurants providing gluten free options on their menu. The concern is cross contamination. This means a naturally gluten free food is prepared in a kitchen where breads, pasta and other gluten products are prepared and gluten can easily contaminate the gluten free food. Some restaurants will dedicate an area gluten free to avoid cross contamination so I suggest making a phone call ahead of time to find out. Other situations may arise, such as a sleep over or friend’s dinner party, where I encourage my clients to prepare their own food and take it with them or eat ahead of time. Being prepared is always best.
- How do I get my child to adhere to a gluten free diet? This is a real challenge mainly because kids do not want to be “different” and they want to fit in. They are also at a time where they are exerting their independence. The key is educating the child on the benefits of gluten free for their health and the consequences of not following the diet. I have seen the best success when the whole family goes gluten free so while at home there is no perceived difference. For lunch at school or sleep overs with friends, the food needs to be prepared at home. Again, the prevalence awareness of gluten free is on the rise so more and more schools and families are familiar with the importance of eating gluten free.
As with anything new there is a learning curve and a period of changing old habits and learning new ones. The first step with celiac and NCGS is being properly diagnosed. Once gluten is identified, the dietary modifications and adherence to a gluten free lifestyle is the number one priority to reverse the damage and restore health. There are other treatments (acupuncture, chiropractic, digestive enzymes and probiotic supplements) that I also recommend, but nothing works optimally until the gluten is removed. The gluten free diet is paramount to recovery.
The information provided in this article is an introductionto the importance of diet and nutrition for celiac and NCGS patients.For more comprehensive information I recommend the following list of resources.( is at the top of the list because it is a very extensive educational website).
Registered Dietitians:
Melinda Dennis, MS, RD, LDN,
Tricia Thompson, MS, RD,
Shelley Case, RD,
Marlisa Brown, MS, RD, CDE, CDN,
American Dietetic Association's Client Education Booklet: Celiac Disease Nutrition Guide,
American Dietetic Association's Easy Gluten-Free: Expert Nutrition Advice with More than 100 Recipes,
National Organizations and Support Groups:
American Celiac Disease Alliance
Canadian Celiac Association
Celiac Disease Center at Columbia University
Celiac Disease Foundation
Gluten Intolerance Group of North America
National Foundation for Celiac Awareness
North American Society for the Study of Celiac Disease
Raising Our Celiac Kids (ROCK)