February 20, 2013
I get quite a few questions from readers who want to know how a gluten free diet will affect them nutritionally. Since that’s not my area of expertise, I went to my friend Tovah to get an answer for a mom who recently wrote it, concerned about how to give her autistic child a well-balance diet on a gluten free, casein free diet. Tovah Gidseg is a nutrition educator, freelance food/health writer and recipe developer specializing in gluten-free and kosher diets. One of her great joys is creating delicious recipes for people with multiple dietary restrictions. She lives with her family in New Jersey and blogs her recipe at Gluten-Free Bay.
There are many reasons why one might choose, or be prescribed, a gluten-free and casein-free diet for themselves or their children. Because GFCF eating requires the removal of two significant groups of foods from one’s diet, it is understandable that people often have big worries about how to get their nutritional needs met within the dietary restrictions they must follow. That level of worry only increases for parents of small children who want to make sure their little ones are getting all the necessary building blocks for healthy growth. While there are important nutrients that most people rely on gluten and dairy for, the good news is that there are plenty of non-dairy, non-gluten sources of those nutrients. Armed with some nutritional knowledge and an openness to trying new foods and recipes, most adults and children can get their nutritional needs met on a GFCF diet.
First, let’s take a look at which nutrients are commonly found in foods that contain gluten. We will define gluten-containing foods here as foods made with wheat, barley, rye and oats. While certified gluten-free oats are increasingly available, most commercially available oats are cross-contaminated with wheat or barley, and some people with celiac disease and gluten intolerance cannot digest even gluten-free oats. We will define casein-free as dairy-free, because there are few commonly available dairy products that are casein-free. Keep in mind, however, that properly prepared clarified butter (ghee) and pure whey protein do not contain casein.
Fiber: Dietary fiber is a carbohydrate that mostly passes through our digestive system intact. It helps maintain intestinal health, keeps us from becoming constipated, slows down sugar absorption in our bodies after eating, and helps maintain a healthy cholesterol level. It also tells our bodies that we are full and helps with our feeling of satiety. We need two kinds of fiber in our diets, soluble and insoluble. Although many gluten-free foods are high fiber, whole wheat and barley and oat products are common sources of fiber in conventional diets. These days there are fiber-fortified foods ranging from pastas to snack bars. When we remove gluten from the standard American diet, we have to be sure to consume plenty of fiber-rich gluten-free foods to ensure that there’s not a drop in our fiber intake. Gluten-free processed foods tend to be very low fiber since they’re made mostly with low-fiber starches like potato and tapioca starch, and flour from white rice.
Lack of dietary fiber intake can result in dry, hard bowel movements, constipation, bowel straining, hemorrhoids and diverticulosis. It can also lead to unstable blood glucose, especially in diabetics, and in higher cholesterol. Adequate fiber intake can help alleviate irritable bowel syndrome and can also contribute to the prevention of colon cancer.
B-vitamins: B vitamins are a group of water-soluble vitamins sometimes called the “B complex”. People commonly associate them with energy production, though they also serve other purposes. In the wheat flour manufacturing process and the production of processed gluten-containing foods like bread, pasta, cereal and more, B-vitamins are often added. This is called fortification. Gluten-free foods are almost never fortified. Between lingering malabsorption issues from celiac disease and the lack of fortification, some people who are gluten-free will develop deficiencies in B vitamins.
B vitamin deficiency symptoms vary depending on which B vitamin you are deficient in, but they tend to primarily include neurological symptoms (numbness, tingling, nerve pain, gait problems), skin problems (including dry, itchy or cracking skin), fatigue and loss of energy, cognitive problems (such as confusion), mood issues, and issues with the tongue and lips. The mucous membranes are negatively affected by some deficiencies. When pregnant women are deficienc in the B vitamin folate, this can cause severe birth defects such as spina bifida. This is why folic acid supplements are critical before and during pregnancy. Vitamin B12 deficiency (called “pernicious anemia”) is not uncommon in people with gastrointestinal and autoimmune diseases such as celiac disease and in people on vegan diets.
Iron: Iron is an important mineral that helps form the structure of proteins, plays a critical role in the function immune system and the production of energy, and plays a role in the growth and differentiation of cells. Iron deficiency anemia occurs in all populations, but it’s more common in people who have celiac disease because the celiac gut may continue to have problems absorbing iron even well after someone starts to follow a gluten-free diet.
Wheat flour (whether white or whole wheat) and products made from it are often iron fortified. Gluten-containing breakfast cereals, for instance, are almost always iron fortified. A significant amount of dietary iron in a typical diet is from wheat-based products. Iron can be found in wheat-based pastas, breads and more. If you transition to eating gluten-free, your iron intake is likely to go down unless you intentionally consume more iron-rich gluten-free foods. Few gluten-free processed foods are fortified with iron. This is a particular concern for infants, toddlers and young children.
Signs of iron deficiency anemia include skin paleness, weakness, mouth soreness, cracks around the lips and sleeping disorders such as insomnia.
Calcium: This mineral is best known as a major building block of strong bones, but it plays other roles as well. Calcium helps the body’s muscles move and helps nerves conduct messages from the brain to other areas of the body. It is necessary for the health of the cardiac muscle and the movement of blood throughout the blood vessels, as well. Calcium is required by the endocrine system. It plays a role in releasing neurotransmitters and regulating hormones. Typical Western diets get most of their calcium from dairy products such as milk, cheese, and yogurt.
A lack of calcium in the diet can lead to osteoporosis, a condition where the structure of the bone deteriorates and becomes prone to fractures. Certain types of fractures can potentially be fatal, especially in older adults. It can also lead to rickets, which causes soft, weak bones. Problems with blood clotting can occur, and tooth strength may be compromised.
Protein: Proteins are made up of chains of amino acids, and various proteins are required in order to repair and maintain the body. Dietary protein is required by our bodies for the replication of DNA, stimuli response, and the transport of molecules from one location to another. Protein is required by many life processes. Some organisms can create all of the proteins they need for survival, whereas human beings’ bodies produce some but others are required to be obtained from food sources (called “essential amino acids”). Cheese and yogurt, as well as milk, are significant sources of protein in many diets. This is especially true for young children who may not be able to chew meat yet, and for vegetarians.
Most people in the Western world consume enough protein, but some signs you’re not getting enough include overeating due to lack of satiation after meals, decreased energy, decreased immunity and loss of muscle mass or lessened ability to build muscle, slowed recovery from injuries. Extreme protein deficiency (rare in the developed world) can result in weakened heart, growth failure, changes in skin pigment, diarrhea, fatigue, hair changes, infections, protruding belly, swelling and more.
Fortunately, there are plenty of ways to get your nutritional needs met without dairy and gluten if you pay plenty of attention to eating a varied diet and learning which foods will meet your body’s needs. Here are some gluten-free, casein-free (GFCF) sources of the nutritional components we mentioned earlier:
Fiber: Although many processed gluten-free foods are low-fiber, a few gluten-free brands have recently started to fortify their breads and other products with high-fiber grains and seeds. Of course, the best source of fiber for someone who’s gluten-free is naturally high-fiber fruits, vegetables, legumes, nuts, seeds and grains! High-fiber GFCF foods include quinoa, split peas, lentils, beans, raspberries, artichokes, green peas, broccoli, pears (with skin), kale, millet, ground flax seeds, sweet potatoes with skin attached, chia seeds, walnuts, almonds and dried plums (prunes). If despite consuming many good sources of high-fiber whole foods you have irregularity in your bowel movements, or if you have a gastrointestinal issue that makes your gut easily irritated by the insoluble fiber found in many whole foods, you may want to consider adding a gluten-free soluble fiber powder made of inulin to your diet.
B-Vitamins: Different B vitamins have different dietary sources, although foods such as leafy greens, tuna, and legumes are robust GFCF sources of multiple B vitamins. Here are more GFCF sources of specific B vitamins:
Folate: Leafy greens, beef liver, lentils and beans, citrus fruit, asparagus and avocado.
Thiamin: Tuna, sunflower seeds, navy beans, black beans and dried peas.
Niacin: Chicken, legumes, nuts, tuna, beef, turkey, halibut and venison.
Riboflavin: Venison, mushrooms, spinach and soybeans.
If you or your child are vegan, nutritional yeast and B12-fortified gluten-free soy milk are two possible sources of vitamin B12 (which is otherwise found mostly in animal products) but a vitamin B12 supplement may still be necessary.
Iron: Iron-rich foods that are GFCF include chicken and beef liver, oysters, beef, poultry, tuna, soybeans, lentils and other beans, spinach and some dried fruits. Iron supplementation can be useful for some children and adults who have anemia or cannot get their iron needs met through food alone, although it’s important to do so with the consultation of a doctor to avoid taking too much, as consuming too much iron can be toxic. Iron supplements are best taken at the same time that a Vitamin C-rich food is consumed, and should not be taken with a meal that’s high in calcium, in order to optimize absorption. Similarly, you will absorb more iron from iron-rich foods if you include foods high in Vitamin C in your meal (such as sauteeing red bell peppers with spinach or having orange juice with hamburgers).
Calcium: Good GFCF foods that are calcium-rich include kale, broccoli, Swiss chard, spinach, collard greens, mustard greens, fortified non-dairy milk substitutes (soy milk, rice milk, almond milk, and other non-dairy milks that are fortified with calcium), sesame seeds, sardines, canned salmon with the bones in, flax seeds, brazil nuts, almonds, soy beans, tofu, tempeh, calcium-fortified orange juice, blackstrap molasses and navy beans. Many leafy greens and legumes contain oxalates, compounds that compromise calcium absorption, so you should not rely only on these foods to meet your calcium needs. In addition to needing calcium for strong bones, Vitamin D and magnesium are critical components to bone health. People who are at risk of osteoporosis (such as individuals with celiac disease, even after they begin a gluten-free diet, anyone with osteopenia, post-menopausal women, and others) may be encouraged by their doctor or nutritionist to take a calcium supplement. Some doctors recommend these supplements for all adult women regardless of whether they have additional osteoporosis risk, or for all adults who don’t consume dairy. GFCF calcium supplements are available. Look for a supplement with calcium, magnesium, and Vitamin D.
Protein: GFCF sources of protein are plentiful. Consider chicken, beef, pork, lamb, fish and shellfish, eggs, nuts, tofu, beans and lentils. Meat substitutes generally contain gluten, but some products can be found that are based on soy protein instead. Dairy substitutes vary in their protein levels, but use caution as casein can be found in some non-dairy cheese substitutes. Very few children or adults need any kind of protein supplementation, protein bars, or protein powders. If you are concerned that you or your child are not consuming enough protein, consult a dietitian before supplementing as excess protein can be unsafe and may lead to dehydration, loss of calcium from your body, and kidney stress.
Coming up with meal and snack ideas for your GFCF child can be a challenge to people who are new to this diet. There are lots of great GFCF blogs that are full of ideas (LINKS?), and cookbooks are available that may also help. But to get you started, here are a handful of meal and snack ideas that can get you off to a healthy start:
-Baked potatoes with homemade dairy-free cashew “sour cream”, roast chicken, sauteed broccoli with red peppers
-Kale and white bean soup with gluten-free bread
-Hamburgers with or without gluten-free buns, with oven-baked sweet potato “fries” (keep the skin on for extra fiber!) and edamame with peanut-soy dipping sauce
-Chicken-noodle soup made with quinoa noodles, with a plate of crudites and hummus as an appetizer
-Pumpkin pancakes made with fortified almond milk and ground flax seeds, served with spinach scrambled eggs or tofu.
-Salmon salad made from bone-in canned salmon and chopped apple, served on multigrain gluten-free bread with steamed green beans and orange slices on the side.
-Salmon or chicken fajitas with corn tortillas, refried beans, salsa, avocado. Serve with a cabbage salad with cashews and a honey-lime dressing.
-Grilled skewers of tofu, cherry tomatoes and zucchini, served with millet pilaf (steamed millet with sliced almonds and raisins).
-Mushroom-kale frittata with turkey bacon and fruit salad.
-Banana-walnut muffins with chia or flax seeds added
-Celery with peanut butter and raisins
-”Cheesy” vegan kale chips
-Crackers with hummus or cashew butter
-Steamed green beans with dipping sauce (such as dairy-free ranch dressing)
-Trail mix made from dried fruit, nuts, seeds and coconut (add dairy-free chocolate pieces for a treat!)
-Black bean brownies
Do you have more questions about a gluten free, casein free diet? Please leave them in the comments!