The gluten-free diet: everything you need to know

With a specialism in food allergies and intolerances, Charlotte Foster looks at the reasons why someone might need to adopt a gluten-free diet and how it can help. She also shares tips on eating, cooking and dining out on a gluten-free diet.

What is gluten?

 Gluten refers to the storage proteins (prolamines) found in wheat (gliadin), barley (hordein) and rye (secalin).

The gluten-free diet first emerged in the 1940s during post-war Europe where diets were limited and food was scarce. Doctors noted that children with coeliac disease had an improvement of their symptoms. They realised that this was down to the scarcity of wheat in the population’s diet.

The reasons why people choose to follow a gluten-free diet are varied. For some, it is a personal preference or the belief that gluten is bad for our health. For others, it is due to experiencing unwanted symptoms associated with eating gluten-containing foods.

A number of conditions have been identified which may require the exclusion of gluten- and wheat-containing foods. These include:

• coeliac disease
• non-coeliac gluten sensitivity (NCGS)
• wheat intolerance
• wheat allergy
• irritable bowel syndrome

While these all share similar symptoms, they have very different effects on the people who have them, and they are managed very differently too. But, since there is a growing trend in people choosing to avoid or limit gluten for non-medical reasons, the gluten-free diet is sometimes considered a fad diet.

But for the 1 in 100 people in the UK who have coeliac disease, following a strict gluten-free diet is a medical necessity.

How does a gluten-free diet help those with coeliac disease?

Coeliac disease is a condition caused by the body’s immune system reacting to the gluten found in wheat, barley and rye. For some people, eating oats can also cause problems as oats contain a similar protein to gluten called avenin.

Eating gluten damages the lining of the small intestine, affecting how it absorbs nutrients from food. This can sometimes cause further problems such as diarrhoea, bloating or vomiting, and even long-term issues such as osteoporosis.

There is no cure for coeliac disease, but it can be managed by sticking to a gluten-free diet.

Avoiding gluten can also help a skin condition called dermatitis herpetiformis, which is also caused by the immune system attacking the body, similar to coeliac disease. Dermatitis herpetiformis causes skin rashes anywhere on the body, but on the buttocks, knees and elbows in particular.

Which foods contain gluten?

As gluten is the storage protein in wheat, rye and barley, it will be found in any foods made with these ingredients. Such foods often include:

• bread
• pasta
• breakfast cereals
• cakes
• biscuits
• pies
• pastries
• flour
• pizza bases
• crackers

However, gluten can also be found in soups, pasta sauces and table condiments such as ketchup, malt vinegar and some soy sauces. Many beers also contain gluten as they’re made from barley and wheat. Gluten is in seitan too – a vegan substitute for meat made entirely from wheat gluten.

You can even find gluten in lipsticks, glosses and balms and postage stamps, all of which can cause a reaction in someone with a gluten intolerance.

Which foods are gluten-free?

A food can only be labelled gluten-free if it contains less than 20 parts per million of gluten.

Foods that are naturally gluten-free include:

• fruits and vegetables
• unprocessed meats, poultry and fish
• certain grains e.g. rice, quinoa, buckwheat, teff, amaranth and sorghum
• beans, lentils and pulses.

There are also many gluten-free alternatives to foods that usually contain gluten, such as flour, bread, pasta, and pizza bases. Back in the 1990s and 2000s, these alternatives were limited, not easily accessible and not particularly appetising.

Thankfully, supermarkets are now filling their shelves with a bigger range of products that are either labelled as naturally gluten-free or have been produced to be “free from” gluten. And, thanks to advances in recipe and product development, “free from” products are much more palatable.

Why are gluten-free diets more expensive?

One problem with following a gluten-free diet is cost. At present, most gluten-free products tend to be more expensive than gluten-containing equivalents.

There are several reasons why gluten-free foods tend to be more expensive including:

• relatively low consumer demand – the demand for an extensive product range has only developed in recent years
• complex processing steps involved to create a satisfactory gluten-free equivalent food
• additional safety and quality checks to ensure that foods are meeting the standards for those with coeliac disease
• increased cost of ingredients and equipment to ensure no cross-contamination.

Those who have been formally diagnosed with coeliac disease may be eligible to receive certain gluten-free products on prescription. However certain areas may be exempt due to budget cuts in the NHS – speak to a GP or dietitian for further information.

My top tips for following a gluten-free diet while trying to save money include:

• keep gluten-free breads in the freezer and take slices out to use as needed
• base dishes around naturally gluten-free foods rather than processed gluten-free alternatives
• batch cook to take advantage of bulk savings
• use beans, pulses, fruits and vegetables to make dishes nutritious and delicious, and bulk them out so they last longer
• take advantage of offers and supermarket deals.

Is a gluten-free diet healthier?

Anyone with a condition like coeliac disease needs to avoid eating gluten. If they don’t, the immune system will attack the lining of the small intestine and eventually cause so much damage that it becomes difficult to absorb vital nutrients.

But if you are following the diet for non-medical reasons and don’t experience issues/symptoms after eating gluten-containing foods, then there is no benefit in excluding gluten from your diet. According to the research published, there is no evidence to suggest that following a gluten-free diet leads to a better quality of your overall diet.

In fact, most of these “free from” gluten-free substitutes are even higher in fat, sugar and calories (to help compensate for the loss of taste and texture) than non-gluten containing equivalents.

And eliminating gluten-containing foods altogether can mean that the diet lacks carbohydrate, which along with energy provides other nutrients including the B vitamins and fibre. We need B vitamins for releasing the energy from our food and fibre for a healthy gut.

So it’s important to make sure you still eat a balanced diet. Brown rice, gluten-free grains and potatoes with their skins on should make up around a third of your meals each day.

Your GP or gastroenterologist may refer you to a dietitian to help you ensure you are able to follow a healthy and balanced diet.

What about cross-contamination?

Avoiding gluten isn’t just about avoiding foods that contain gluten: avoiding cross-contamination is equally important. Even tiny amounts of gluten can pose a risk to those with coeliac disease. Therefore, it is really important to consider how food is prepared and cooking equipment is used.

Here are some tips to help avoid cross-contamination:

• wash up all kitchen utensils thoroughly in hot soapy water – you don’t need to buy new separate cooking utensils to cook a safe gluten-free meal
• clean all kitchen work surfaces and ensure that the cooking/ food preparation area is uncontaminated from gluten
• be careful to make sure that the gluten-free meal is prepared safely – avoid using toasters/ appliances that are at high risk of gluten exposure
• use foil and thoroughly cleaned tupperware to store gluten-free foods and ingredients and keep these away from any gluten-containing foods that could lead to cross-contamination.

Remember to watch out for:

1. Condiments: knives or utensils that have been used near gluten-containing foods or dipped into condiments pose a risk of gluten-contamination. Make sure you label condiments that are gluten-free and keep these stored separately.
2. Toasters:these can pose a serious gluten cross-contamination hazard to coeliac disease sufferers. Coeliac disease patients are advised to have their own toasters and to keep gluten-containing foods away from them.
3. Chopping boards and utensils:cooking equipment made from porous substances like wood (e.g. wooden spoons) can hold onto particles of gluten. To be on the safe side, use plastic or metal alternatives.

How can I get help with reading food labels?

During a recent focus group held here at the King Edward VII’s Hospital, many coeliac sufferers said that they felt confused about what they could and couldn’t eat.

They also said that they struggled with inconsistent product labelling and having to learn about the concept of hidden gluten in foods and cross-contamination.

So if you’re struggling, you’re not alone. Coeliac UK has a helpful page on reading food labels and which foods are safe and which ones aren’t.

What about eating out?

There’s no reason why you can’t enjoy eating out, but it will pose extra challenges.

By law, all eateries must provide a list of any foods that contain allergens such as nuts and shellfish, as well as gluten. Many restaurants now highlight foods that are gluten-free.

This makes eating out much easier than it used to be with coeliac disease. Phoning ahead and talking to your waiting staff will also help to ensure you don’t accidentally eat something containing gluten. If you’re worried, try to stick to restaurants that you know have strict kitchen policies.

There are also a growing number of places to eat that make sure their entire menus are gluten-free. Many vegan cafes and restaurants are also completely gluten-free.

Where is a good place to look for gluten-free recipes and blogs?

There are hundreds of gluten-free recipe books available on the market as well as lots of great online blogs and sites. Instagram and Pinterest are overflowing with gluten-free recipes and advice too.

Popular websites with recipes and blogs about the gluten-free diet include:

• BBC Good Food
• The Gluten-free Blogger
• My Gluten-free Guide
• Deliciously Ella has a website and a range of cookbooks containing recipes that are all gluten-free.
• Officially Gluten-free
• Gluten-free Cuppa Tea
• Life After Wheat
• Ambitious Kitchen (not all recipes are gluten-free)
• Downshiftology (not all recipes are gluten-free)

More information

• If you have the symptoms of coeliac disease or you think you might have the condition, speak to your GP as the first line of investigation. They may refer you to a specialist doctor called a gastroenterologist for more tests.
• If you don’t currently have a GP, you can make an appointment with one of our same day private GPs.
• At King Edward VII’s Hospital, we also have specialist departments that can help with diagnosing and treating the symptoms of coeliac disease, including our dedicated Gastroenterology, Endoscopy and Dermatology