Staying gluten-free in the season of gluttony

Anyone who is suffering from celiac disease or has a gluten sensitivity knows what a minefield the winter holidays can be.

Thanksgiving stuffing. Christmas cookies. Hanukkah noodle kugel. All contain grains rich in gluten, the proteins that serve as a kind of glue to hold food together — and wreak havoc on the insides of the gluten-sensitive.

Well-meaning hosts or office mates can cook up tasty family favorites that might be loaded with gluten or may just have that one stealth ingredient that is sure to leave the gluten-averse in pain.

"Holidays are hard," said Stephanie M. Moleski, a gastroenterologist at Thomas Jefferson University Hospitals. Even a serving spoon from another dish can accidentally contaminate the gluten-free offerings at the holiday tables or buffets, with enough of the offending ingredient to trigger painful symptoms in those who are highly sensitive.

As for dining out, cross contamination also can inadvertently occur in a commercial kitchen.

About three million Americans — or 1 percent of the population — suffer from celiac disease, an autoimmune disorder in which eating gluten leads to damage in the small intestine, according to the Centers for Disease Control and Prevention. The numbers seem to be increasing, for reasons that aren't clear, Moleski said. As many as 6 percent of Americans may have non-celiac gluten sensitivity, according to Healthline.

Moleski and her colleagues at Thomas Jefferson University Hospitals are currently recruiting for a clinical trial involving people with non-celiac gluten sensitivity who have gastrointestinal symptoms after eating gluten, she said.

Gluten is the protein that is in wheat, barley, and rye. It is found in breads, pastas, baked goods — and less obvious products including soy sauces, fillers in medications, tooth pastes, and even lip gloss, she said.

"It is what gives bread that nice chewy texture," said Moleski.

It's also what gives some people gastrointestinal grief.

But, how do you know that bloating, abdominal pain and fatigue are from a sensitivity to gluten, overindulgence, or something else entirely?

There are three main issues in people who are avoiding gluten, Moleski said.

There is the wheat allergy — a true food allergy. It can result in hives, vomiting and the most severe reaction of anaphylaxis, she added.

The second type is celiac disease, an autoimmune condition thought to start when a particular gene is triggered by something like a virus, said Moleski.

"You can have that gene and be fine," she said, explaining that many people have the gene, but few have celiac disease. Type 1 diabetes is another autoimmune condition related on a genetic level to celiac. About 6 percent of people with Type 1 diabetes also have celiac, compared with 1 percent of the general population. There is no known connection between the much more common Type 2 diabetes — which is not an autoimmune condition — and celiac.

The third condition has come to be known as non-celiac gluten sensitivity, which is a non-allergic, non-autoimmune condition, Moleski said.

These are the people who may not have actual medical confirmation of a gluten problem, but indeed have problems digesting the protein. Added to that misery is the fact that they may be wrongly dismissed as "celiac wanna-be's" with imaginary symptoms, she said.

"It is a legit condition that causes symptoms in people," she said. Some might even have the gene associated with celiac, but not the markers of active inflammation, such as small-bowel damage that would be discovered during an endoscopy.

A visit to the doctor and a blood test to check for the condition is needed for a proper diagnosis. The most common test is the tissue transglutaminase antibodies (tTG-IgA) test. If lab results suggest a problem, the next step would be an upper endoscopy to check for small-bowel damage, she said.

The holidays might also be a good time to ask relatives about their history. "We do recommend getting tested if you have a first-degree relative with celiac disease," Moleski said.

It's not surprising in an era when food marketers are pushing "gluten-free" products that sometimes patients tell her they have determined the cause of their gastrointestinal problems and have adopted a gluten-free diet. But it can lead to major problems.

"That is the one that tortures me," said Moleski.

Here's why: While the do-it-yourself diagnosis and diet change may make patients feel better in the short run as their intestines heal, going without medical attention is a bad idea. Once you have one autoimmune disease, you're more likely to develop others, and a physician is much likelier to figure that out before it becomes a bigger problem.

To get an accurate diagnosis,  patients must be eating gluten when testing is done — defeating the whole effort to get off gluten before seeing the doctor.

For holiday parties, Moleski suggests eating "real foods" and avoiding anything processed or that includes a lot of ingredients, making it harder to detect one with gluten. Consider the classic green bean casserole. The original recipe calls for soy sauce (which has gluten) and canned french-fried onions (ditto).

Baked, steamed, sautéed or roasted veggies and potatoes are fine, as are mashed potatoes with milk and butter. Proteins such as turkey are great — without traditional stuffing, of course. Beware of foods that are fried after being coated with batter, which generally contain wheat flour.

Moleski's suggestions for a gluten-free holiday: 

The Celiac Disease Foundation offers up a number of holiday recipes that include everything from soup to nuts.

There is one bit of good news for those with celiac disease or gluten sensitivities who want to imbibe during the holiday celebrations.

"Wine is safe," Moleski said.