Other factors to consider with the LOW FODMAP Diet
Celiac disease is an autoimmune disease in which the immune system’s response to gluten severely injures the body.
Gluten is the main protein component of wheat, rye, and barley (and some people with celiac disease also react to avenin, a protein in oats). In people with celiac disease, the immune response to gluten causes damage to the lining of the small intestine, particularly the villi, fingerlike structures that help absorb nutrients. As a result of dramatically decreased nutrient absorption and ongoing inflammation, people with celiac disease may become very ill.
Typical symptoms can include:
- iron deficiency
People with untreated celiac disease are also at greater risk for certain cancers and other maladies.
Celiac disease is diagnosed by antibody blood tests and a confirming endoscopic biopsy of the small intestine if the tests are positive. People being tested for celiac disease need to be eating gluten for the tests to be useful; otherwise, false negatives are common.
Celiac disease is a lifelong condition treated by a diet free from all gluten. This prevents further damage to the villi and allows them to return to normal so that nutrients can be properly absorbed.
The gluten-free diet permits fruits, vegetables, meat, fish, chicken, legumes (including lentils), most dairy foods, oils and margarines, and many grains. Breads, pasta, and cereals can be made from alternative sources, including corn, rice, soy, buckwheat, sorghum, nuts, and legumes, to name a few. These days, there are many specialty gluten-free products available, and many of those are also low-FODMAP. Look for them in the health food section of supermarkets and in health food stores.
For people prescribed a gluten-free diet, the change in lifestyle is often overwhelming. Learning which foods are suitable and which foods are no longer permitted in the diet is time-consuming at first, and the diet can seem very restrictive. I hope that this book will help you enjoy the great tastes of a gluten-free and low-FODMAP diet with confidence.
While every effort has been made to indicate and ensure gluten-free and low-FODMAP ingredients, it is essential to read the ingredients list of all food products to determine whether they are suitable for inclusion in your diet. The recipes in this book comply with the FDA’s gluten-free labeling standards at the time of printing and exclude foods known at the time of printing to be high in FODMAPs. However, the gluten-free status of individual brands may change, the process of testing foods for their FODMAP content is ongoing, and the finished recipes have not been laboratory tested for FODMAP levels. Gluten-free labeling standards in other countries may also be different from the FDA’s, so I stress again the importance of reading all food labels. Always assess your own level of tolerance when it comes to specific FODMAPs and recommended serving sizes.
Celiac disease is estimated to affect about 1 percent of Americans. It is a medical condition of intolerance to dietary gluten. Gluten is the protein component of wheat, rye and barley (and, in some countries, is considered to be present in oats), and is found in derivatives of these, including triticale and malt. (Note that because gluten is a protein, it is not a FODMAP, all of which are carbohydrates.) In people with celiac disease, gluten causes an immune reaction that damages the small protrusions on the lining of the small intestine (the villi), flattening them and dramatically decreasing the ability of the intestine to absorb nutrients from food. Celiac disease is not a food allergy.
There’s currently no cure for celiac disease. The only treatment is a strict lifelong gluten-free diet (even if symptoms are mild or there are no symptoms at all). It’s not a trendy “fad” diet, but rather a real medical therapy for a real medical condition. A gluten-free diet is more restrictive and excludes more foods than a wheat-free diet. Regular bread, pasta, cereals, cakes, cookies, pizza, pastries and so on are all obvious gluten sources, but it can also be hidden in many foods, including commercially prepared condiments and sauces, gravies, candy, charcuterie and even beer!
Symptoms of celiac disease range from none at all to the following, with varying severity:
- diarrhea and/or constipation
- fatigue, weakness and lethargy
- weight loss and, in children, failure to grow
- abdominal distension and bloating
- nausea and vomiting
- reflux (heartburn)
- nutritional deficiencies (in iron, folate, vitamin B12, zinc and vitamin D).
Because these symptoms are quite similar to those of IBS, it’s extremely important that anyone who has them be investigated for celiac disease before removing gluten from their diet. Even if you have been told you have, say, fructose malabsorption, that doesn’t mean you can’t also have celiac disease. Celiac disease should be investigated in all people with these symptoms.
The tests for celiac disease include blood test screening, but the gold standard remains a small intestine biopsy. A gene test (performed as a blood test) can be helpful to exclude celiac disease, since only people with the genes HLA DQ-2 or HLA DQ-8 can develop the disease. If you do have either of these genes, this doesn’t guarantee that you’ll get celiac disease – one third of the population carries one or both of these genes, but only about 1 to 2 percent of the population actually develops celiac disease.
The reason you should never trial a strict gluten-free diet is that if you actually have celiac disease, a proper diagnosis won’t be possible, as your small bowel may already have begun to repair itself as a result of the gluten-free diet. People being investigated for celiac disease still need to be consuming gluten in their diet.
It is also worthwhile noting that just like asthma and diabetes are two different conditions that can occur in the same person, celiac disease and IBS can occur in the same person, too. If you have been diagnosed with celiac disease and are strictly compliant with your gluten-free diet but still experience symptoms, you may have IBS. Consult a dietitian with experience in celiac disease, who will first check your diet for any accidental gluten intake and, if necessary, will teach you how to combine a gluten-free and low-FODMAP diet to manage your celiac disease and possible IBS.
Gluten-free and low FODMAP?
The ‘Low FODMAP’ diet reduces certain groups of sugars which trigger IBS symptoms. One group of FODMAPs are fructans.
Fructans are found in rye, wheat and barley. Gluten (a protein) is also found in rye, wheat and barley.
The low FODMAP diet happens to be low in gluten because it is low in fructans, but it is not ‘gluten-free’. This means you can still have small amounts of gluten containing products e.g. soy sauce which contains trace amounts of wheat.
‘Gluten-free’ means a diet completely free of any foods that contain gluten. The only medical reason to follow a gluten free diet is if you have coeliac disease. If you have coeliac disease you need to avoid even the trace amounts of gluten e.g soy sauce or foods that have been processed near gluten.
This is not necessary if you are following the low FODMAP diet as you are not avoiding gluten (the protein) but fructans (the sugars).
Remember that gluten free is not necessarily FODMAP free. Many ‘gluten-free’ products contain high FODMAP ingredients such as apple juice, onion powder, and inulin which are sometimes used to sweeten, enhance taste, or thicken products.
Inflammatory bowel disease (IBD)
IBD includes Crohn’s disease and ulcerative colitis, illnesses in which the bowel becomes chronically inflamed. Symptoms include diarrhea (sometimes bloody), abdominal pain, bloating, gas, and fatigue. As for celiac disease, the “gold standard” for diagnosing IBD is an intestinal endoscopy with biopsies, though blood tests, stool samples, colonoscopies, and other medical procedures may also be considered.
The causes of IBD are not known, and treatment is directed toward controlling the inflammation and preventing it from returning. Those whose bowel inflammation is well controlled but whose gastrointestinal symptoms continue may find the low-FODMAP diet a useful tool.
Other factors to consider with the LOW FODMAP Diet
- Lactose intolerance
Lactose as a naturally occurring sugar that is found in cow’s, goat’s, and sheep’s milk. Typically in people with lactose intolerance, the body stops making enough lactase, the enzyme that breaks down the sugar lactose. However, people can differ in the severity of their intolerance. Most people are able to tolerate small amounts of lactose (up to 4 grams) in their diet.
Lactose intolerance can cause symptoms of IBS. Additionally, many people with celiac disease have a secondary lactose intolerance, meaning an intolerance caused by the damage to their small intestine. Secondary lactose intolerance is generally but not always temporary.
Lactose is present in large amounts in milk, ice cream, and pudding. It is present in small to moderate amounts in products such as yogurt, cream, crème fraîche, and soft or unripened cheeses (e.g., cottage, ricotta, and cream cheese). Hard and ripened cheeses (cheddar, Parmesan, Camembert, Edam, Gouda, blue, mozzarella, etc.) and butter are virtually free of lactose.
- Fructose malabsorption
Fructose malabsorption is a condition in which the small intestine is impaired in its ability to absorb fructose (a naturally occurring sugar). Fructose malabsorption is different from hereditary fructose intolerance (HFI), a condition usually diagnosed in children in which the complete inability to digest fructose may result in symptoms such as vomiting, low blood sugar, and jaundice, and can lead to death.
Fortunately, in people who have fructose malabsorption, there still exists a pathway through which fructose can be absorbed in the small intestine. If glucose is present at the same time, the glucose “piggybacks” the fructose across the intestine into the bloodstream.
This is good news for fructose malabsorbers. It means that fructose and foods that contain it do not need to be avoided altogether (as is the case with HFI).
As mentioned previously, only foods that contain more fructose than glucose (excess fructose foods) need to be avoided on the low-FODMAP diet.
If a food contains more glucose than fructose, or if glucose and fructose are present in equal amounts, then it is suitable on the low-FODMAP diet. However, fructose malabsorbers do need to be aware of serving sizes. Only consume one serving of suitable food (such as fruit) at a time. Spread them out through the day so you only have one per meal or sitting.
Although all the recipes have been formulated with ingredients that are suitable for fructose malabsorption, ensure that you limit the serving size of any fruit-based dish to the quantity indicated in the recipe. Consuming large quantities of even “safe” fruits can cause symptoms.
- Wheat as an ingredient
Both a gluten-free diet and a low-FODMAP diet restrict wheat. On a low-FODMAP diet, this is due to wheat’s fructan content rather than its gluten content. The good news is that although wheat is a source of both fructans and gluten, not every wheat ingredient contains both (see the table on the opposite page).
You will notice that some ingredients in the recipes are specified as “gluten-free.” Gluten must be avoided by those with celiac disease, and is present in wheat, rye, and barley. Some people on a gluten-free diet also react to oats. Every recipe in this book is gluten-free, which also ties that fructans from wheat, rye, and barley are restricted.
If you do not need to follow a gluten-free diet, you need not seek out gluten-free-labeled versions of some ingredients, such as sauces, which are unlikely to contain enough fructans to trigger a reaction.