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I often see people ask if they can drink alcohol on a gluten free diet. Since I do not drink alcohol myself, I usually keep scrolling whenever I see this question asked on coeliac support groups. However, there are a few myths going around on the topic so I thought I would just clear the issue for anybody who is interested.
First of all, you can drink alcohol if you are on a gluten free diet. But not all alcohol is gluten free.
- According to Coeliac Australia (2), all alcohol is gluten free with the exception of beer. On their website they state that this means anything from bourbon to tequila, sparkling wines, spirits, port, sherry and even cider, in moderation, is safe as part of a gluten free diet.
- Coeliac UK state that people with coeliac disease should avoid barley squashes, beer, lager, stout and ales unless they are specially made gluten-free beers and lagers. Cider, wine, sherry, spirits (whiskey, vodka, rum, gin, tequila), port and liquors are safe for people with coeliac disease (3).
As a rule of thumb alcohol that is made through a brewing process is not gluten free. It is important to only drink beers that are labelled ‘gluten free’- these are the only beers that should be considered to be gluten free despite claims by various people that other beers could be gluten free.
Some people think that if a hard alcohol is made from wheat, barley or rye they are prohibited. The truth is that if the distillation process is done correctly. it actually removes all of the gluten. However, according to Anderson (2014) (1) not all makers of alcoholic beverages distil enough times to purify their beverages completely. In addition, some add in a little of the grain “mash” (which does contain gluten) following distillation to improve colour and flavour, and there’s always the possibility of cross contamination from gluten grains in the manufacturing facility following distillation.
So what should we do?
If you are newly diagnosed, you might want to take small amounts of gluten free alcoholic beverages that are derived from gluten and assess your reaction. If anybody is still worried about drinking alcohol that has been made from gluten containing grains, there is potato based vodka, rum and tequila. And there is always wine, and gluten free beer.
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So here we go again.
It’s funny how I tend to forget what the pain of accidentally ingesting gluten is like every time. For me, symptoms are very specific and only occur with gluten exposure. So I am lucky enough to know that the cause is gluten beyond doubt.
As I was lying on my bed this afternoon, trying not to focus on the pain I got thinking. It is not all bad.
In most auto-immune conditions, the trigger is unknown, but thanks to the work of doctors and scientists in the last century, the trigger of coeliac disease has been identified as gluten. In my article titled A little history about coeliac disease, I explained that before the introduction of the famous banana diet by Sidney Haas in 1924, the only treatment was introducing food in stages to the coeliac patient over a period of months to years. Just think of the pain the patients with coeliac disease had to endure on a daily basis at the time. Not to mention the complications they suffered as a result of untreated coeliac disease. It wasn’t until the second world war that Dutch pediatrician Willem Karel Dicke, MD noted that his paediatric patients improved when wheat was excluded from the diet and replaced with rice and maize flours. The discovery was due to the shortage of wheat grain during the war years in Holland. These children deteriorated again when wheat was re-introduced post war.
We are lucky that we know that we should avoid gluten. Even an episode of accidental gluten exposure only causes temporary discomfort for people who have been diagnosed with coeliac disease. By knowing our trigger to ill health, we have a chance to prevent complications and to improve our life expectancy to the same as the general population. We also have the chance to reverse some of the damage that occurred from years of gluten exposure. I say some, because although the intestine will eventually heal, the systemic effects of years of malabsorbtion might not all be fully reversible depending on the age of diagnosis.
Even people with silent coeliac disease are now being diagnosed, something that was impossible in the past due to lack of awareness that coeliac disease can manifest with atypical or no symptoms, and due to the fact that it was still unknown that certain groups of people are at a higher risk of developing the condition. Thanks to screening programmes whereby people with a family history of coeliac disease, other autoimmune conditions, type 1 diabetes, IBS, anaemia of unknown cause and symptoms of coeliac disease amongst others are tested, more cases are being diagnosed. There still remains a high percentage of undiagnosed people who suffer from coeliac disease, but this is improving with greater awareness and diagnostic criteria.
With regards to diagnosis, antibody blood tests have become more specific and sensitive. An endoscopy is a much milder and easier way of viewing one’s insides and taking a biopsy than previous methods that caused much more discomfort and were not as accurate. We also now know the genes that are associated with coeliac disease. Genetic tests are available, and are useful to rule out coeliac disease or to know if one has the gene/s that give them the potential to develop coeliac disease.
As I am typing this out I am already feeling a little better about myself. At least I know that I will feel better soon because I know what it is that makes me ill. And although complex, expensive and at many times inconvenient, a gluten free diet is just that. A diet. Not too bad as a treatment for a serious auto-immune condition.
The power of positivity….
How do you feel about this?
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Have you noticed how many restaurants are offering gluten free pizza on their menu? And have you noticed that many of these restaurants are not dedicated to preparing gluten free pizzas only?
This can be very risky for a person with coeliac disease or other gluten related disorders due to the high risk of cross contamination.
Although a pizza cannot be guaranteed to be gluten free unless only gluten free foods are prepared in the kitchen, there are steps that can be taken to minimise the risk, even in restaurants that offer both gluten containing and gluten free pizzas on their menu. Some establishments in several countries are already taking measures to ensure the safety of their customers by implementing extraordinary measures to avoid cross contamination.
Here are 10 tips for the preparation of gluten free pizza.
- CHEF CLOTHING The person who will prepare the gluten free pizza must be wearing clothes that are not contaminated with gluten containing flour, or a disposable apron/overall must be worn over the clothes.
- CLEAN HANDS The persons who will be handling the food must wash their hands thoroughly before handling gluten free food items, and must wash them every time gluten free food is handled.
- USE A SEPARATE AND UNCONTAMINATED WORK AREA FOR GLUTEN FREE FOOD PREPARATION. If this is not possible, the work surface must be thoroughly cleaned before gluten free food is prepared.
- EQUIPMENT: the machinery, equipment, accessories and ingredients necessary for the production of gluten-free pizza must be absolutely distinct and separate. Food items must be covered with plastic wrap or closed in a container and utensils must be kept in a separate cupboard to guarantee that they will not be contaminated.
- ONLY USE GLUTEN FREE FLOUR TO ROLL OUT PIZZA DOUGHS Although this can be costly due to the price of gluten free flours, it can greatly decrease the cross contamination risk by keeping the kitchen free from wheat flour.
- A SEPARATE OVEN IS PREFERABLE: pizzas containing gluten should not be cooked in the oven at the same time as gluten free pizzas. Either make sure that the gluten free pizza is placed in the oven separately, or have a dedicated oven for gluten free pizza. This solution means that it is not necessary to interrupt the production of pizzas containing gluten in order to cook the gluten-free one(s), thus also avoiding lengthy waiting times, besides guaranteeing that no contamination takes place during cooking.
- USE BAKING PANS WITH HIGH SIDES: if there is only one oven available, it is necessary to stop cooking pizzas with gluten and the gluten-free pizza must not be placed directly on the base of the oven. The gluten-free pizza must be isolated from flour by cooking it in a baking pan with high sides.
- PREVENT ALL TYPES OF CONTAMINATION: even passing utensils containing flour over gluten free pizzas increases the risk of cross contamination.
- INGREDIENTS FOR PIZZA TOPPING: all ingredients for topping pizzas must be gluten free and must be kept in separate containers. Hands must be washed thoroughly before touching pizza toppings and clean utensils must be used to prevent contamination of the ingredients with floury hands or utensils.
- SERVING THE PIZZA Serve the pizza without slicing it to prevent the risk of using contaminated utensils. Each pizza can be served with a clean cutter for the client to use themselves. Use an identifying marker to show that the pizza is gluten free like a different coloured plate or a flag/sticker to avoid mix ups when the pizza is served.
Finally, it is important to be honest. If any of the above criteria cannot be met, explain to the customer so that he/she can make an informed decision about whether they feel it is safe for them to dine at your establishment or not.
Special thanks goes to S. Bugeja of Alfresco restaurant, B’Bugia, Malta for his feedback regarding gluten free pizza preparation.
This article that I wrote was published on The Sunday Times, on the 18th of May, 2014 for coeliac awareness week.
Published on this blog with permission from The Sunday Times.
Gluten-free – the latest cliché in the world of trendy diets. The current popularity of this diet can be largely attributed to bestsellers like ‘’Wheat Belly’’ by Dr. William Davis, and ‘’Grain Brain’’ by Dr. David Perlmutter. Unfortunately these books and much of the anti-gluten propaganda is based on little or no scientific literature. It is a combination of celebrity doctors, popular bloggers and clever marketing strategies that are fuelling the anti gluten sentiments in the general population.
Usually, the first thought that pops into somebody’s head when the word gluten is uttered, is ‘’bread and pasta’’. Gluten is found in wheat, barley, rye and their derivatives. Although gluten is found in yummy breads and cakes, it is also hidden in many unlikely foods like imitation meats, stock cubes, deli meats, sauces, chocolate, ice cream and in so many other processed foods. A gluten free diet is not as simple as eating a burger without a bun. A person who requires a gluten free diet, will become an excellent gluten detective, scrutinizing every label and questioning every person who prepares their meals. Even a trace of gluten can make people with true gluten related medical condition ill.
So, should perfectly healthy individuals follow a gluten free diet for improved well-being or other reasons? That is a personal decision, but I urge you to continue reading before you embark on this lifestyle change.
If anybody eats healthy and unprocessed foods, increases their intake of foods rich in nutrients and fibre, and couples this with regular exercise, they will definitely help to prevent a myriad of health problems. But a gluten free diet that includes highly processed substitute foods is definitely not the way to go. Although gluten itself does nothing for the body, it is found in grains that are high in fibre like wheat. The gluten free diet tends to be lacking in fibre, iron, calcium, thiamine, riboflavin, niacin, and folate if one is not careful. Gluten free products are also packed with sugars and preservatives and are often higher in calories. So substituting gluten containing products with their gluten free counterparts will definitely not improve health or help a person to lose weight
I have seen so many claims about the negative effects of gluten in perfectly healthy people that it is difficult to list them all. Some examples are that gluten causes auto-immune diseases, brain dysfunction, neurological disorders, and even cancer. It is claimed that gluten is inflammatory and that it wreaks havoc in your system in every way imaginable.
The truth is that gluten has been proven to have many negative effects, but only in a small percentage of the population who suffer from certain gluten related medical conditions.
Gluten cannot be tolerated by 1% of the population who suffer from coeliac disease, people with a coeliac related skin condition called dermatitis herpetiformis, and others who have been diagnosed with non-coeliac gluten sensitivity, previously known as gluten intolerance.
Coeliac disease is not an allergy or food intolerance. It is actually an auto-immune, multi- system condition that is triggered off when even a tiny amount of gluten is ingested. Surprisingly, adults with coeliac disease rarely present with classical manifestations such as diarrhoea, weight loss and abdominal pain or bloating. Most present with atypical symptoms, most commonly anaemia. Other symptoms can include constipation, mouth ulcers, recurrent fractures, bone and joint pain, infertility, neurological problems and many others. Repeated ingestion of gluten or a late diagnosis can lead to serious side effects and health problems.
Gluten sensitivity is a recently accepted medical condition in which sufferers test negative for coeliac disease or wheat allergy but have improved symptoms with the removal of gluten from their diets. Although symptoms are similar to those of coeliac disease, no long term damage appears to occur if gluten is ingested.
So what should be done if you suspect your symptoms are related to gluten consumption?
It is important to continue eating gluten until you visit a doctor and get tested for coeliac disease and wheat allergy for accurate results. The gold standard for coeliac disease diagnosis is a simple blood test, followed by an endoscopy if the blood test is positive. If you have stopped eating gluten but wish to be tested for coeliac disease, speak to your doctor.
Some might argue that if a person feels better on a gluten free diet, they should just go ahead and start a gluten free diet. However, it is important to get tested to eliminate the possibility of other health problems, and to distinguish between coeliac disease and non-coeliac gluten sensitivity. People with coeliac disease have an increased risk of other auto-immune conditions and long term complications if a strict gluten free diet is not followed for life. It is also genetic, so family members would need to get tested. Regular follow up, and care of complications would be needed.
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Last Friday, the 16th of May was International coeliac awareness day. For this occasion I was interviewed by a local newspaper and was asked about my experience with coeliac disease and about other related issues.
This is a link to an online version of the article:
‘When a pizza could make you sick, The Malta Independent, 17th of May, 2014.
I also wrote an article for the The Sunday Times of Malta that was published yesterday. I cannot share the link as it still has not been posted online. It was about the fact that gluten is harmful for a small percentage of the population who suffer from gluten related disorders and spoke about getting tested for coeliac disease and wheat allergy before eliminating gluten from one’s diet. It also discussed the fact that gluten free products can be unhealthy, and that we should include plenty of vegetables, fruit and other natural gluten free products in our diets.
Over 99% of people affected by coeliac disease have the HLA DQ2, HLA DQ8, or parts of these genes. Interestingly, 20-30% of the population carry one or both of these genes. However, only 3% of the people who carry one or both genes will actually develop coeliac disease.
Genetic testing, also known as DNA testing, can be done to find out if a person is a carrier of these genes. It is performed by a blood test or buccal (inside cheek) scraping and the sample is sent to a lab to be analysed. Since not everybody who possesses the coeliac gene/s will go on to develop the condition, a genetic test is useful to rule out, and not confirm coeliac disease. In other words, if a person does not have either of these 2 genes, there is virtually no chance of ever developing coeliac disease in their lifetime.
Genetic testing can also be useful when a person has started a gluten free diet before getting tested for coeliac disease. To diagnose coeliac disease, gluten must be eaten for 6-8 weeks before testing. This is known as taking a gluten challenge. If this gluten challenge is not possible for various reasons, a genetic test can be done to rule out coeliac disease (or to know if there is a possibility of having coeliac disease). Gluten does not have to be eaten for a genetic test to be done. Another good use for genetic testing is when an endoscopy is difficult. Similarly, in this case, a negative genetic test will rule out coeliac disease.
The gold standard for diagnosing coeliac disease in adults is an antibody blood test followed by confirmation by endoscopy and biopsy. A positive genetic test alone does not confirm coeliac disease. However, in children, genetic testing may be useful in diagnosing coeliac disease. New guidelines in the UK, published by the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) and Coeliac UK in February 2013 state that a biopsy may not be necessary in every case. These new guidelines state that children with symptoms of coeliac disease, who have a high level of antibodies by blood test, and have the gene/s for coeliac disease do not need confirmation by biopsy.
Personally, as a mother, I feel that genetic testing is useful for children of parents with coeliac disease. It is always a relief to know if your child does not carry the genetic makeup that makes them vulnerable to this condition. On the other hand, it is useful to know if your child does possess HLA DQ2/8, so that regular monitoring for symptoms and testing can be done.
What do you think about this?
“Diagnosis Guidelines.” Coeliac UK. N.p., n.d. Web. 07 May 2014. <https://www.coeliac.org.uk/healthcare-professionals/diagnosis/diagnosis-guidelines/>.
Jenkins R (2010) Gene tests for coeliac disease used inappropriately: experts. Australian doctor.
Welcome to May, the month dedicated to Coeliac Disease Awareness!
International Coeliac Awareness Day is on the 16th of May, 2014.
One of the greatest difficulties I find with having coeliac disease is dining out safely. The only times I have been in contact with gluten have been when dining out. So many restaurants and outlets claim to serve gluten free food, but how many really know about avoiding cross contamination and about different ingredients that contain hidden gluten?
I prepared a small fact sheet for you all to download and print out. This can be handed to restaurant staff to keep in their kitchen as a brief explanation of what a gluten free diet entails. This might give them an incentive to research more about what is allowed and not allowed in our diet.
Click here to download: catering for a person with coeliac disease
Have you ever seen a product labelled as gluten free but when searching through the list of ingredients you are dismayed to see items like wheat, barley or rye listed? Do you worry when a gluten free item contains glucose syrups or maltodextrin made from wheat?
These products are safe for people with coeliac disease and gluten sensitivity and I will explain why in this post.
If a product is labelled as gluten free it must contain less than a cut-off level of gluten that has been deemed safe for coeliacs. In Europe, the UK, USA and Canada this level is less than 20ppm of gluten. In Australia and New Zealand gluten free means no detectable gluten- this level is becoming lower as modern technology improves the sensitivity of testing.
However, a gluten free product can contain wheat , barley, rye, oats or any of their derivatives in the list of ingredients. In the UK and Europe these gluten containing ingredients must be labelled, no matter how little is used and that is why they are sometimes found in the ingredients list.
On the other hand, items like glucose syrup, wheat based maltodextrin and alcoholic spirits made from cereals that contain gluten can also be labelled as gluten free because the grain highly processed and the gluten is removed. Although some manufacturers do list gluten containing grains like wheat in these products, they are not required to do this by law in the UK and Europe when gluten has been removed by processing .
In the US, although the law requires wheat to be listed on food labels, manufacturers are not required to list gluten, so determining if any product contains gluten is more difficult considering the names gluten can be hiding behind. If a product is specifically labelled as gluten-free, it saves alot of detective work.
Note that although 20ppm has been ruled as safe for coeliacs, I know that some still complain of reacting to this small amount of gluten in products. In my opinion, every individual should consume these products or not based on their own personal experience.
Wheat free/Gluten free
It is important to note that wheat free is not necessarily gluten free. Although wheat does contain gluten, gluten can also be found in barley, rye and their derivatives, as well as in contaminated oats. Alternatively, gluten free is not surely wheat free as the product may contain wheat starch or products derived from wheat but that meet the criteria for gluten free labelling. Although these products are safe for most people with coeliac disease, wheat allergy sufferes should avoid consuming these items.
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