Q: What is gluten?

A: Gluten is a large protein complex that forms when two smaller proteins (called gliadins and glutenins) bind together after being exposed to water. There are about 100 different known forms of gliadins and glutenins found in wheat, rye, barley, and hybrids of these grains (such as triticale—a wheat/rye hybrid). The gluten complex has elastic properties. It can trap gas and expand like a balloon. When carbon dioxide produced by yeast in unbaked dough is trapped in gluten, it causes the dough to rise.

A true gluten-free diet requires the complete exclusion of all whole foods, food products, and even medications containing any gluten proteins. The diet allows naturally gluten-free foods like fruits and vegetables, legumes, nuts, seeds, unprocessed meats, fish, eggs, dairy products, and whole grains that do not have gluten proteins (such as oats, corn, rice, and buckwheat). Products labeled as “gluten-free” (like legume-based pastas and gluten-free baked goods) can also be included.

Q: Who needs to follow a gluten-free diet?

A: For a small segment of the population with certain medical conditions, following a gluten-free diet is essential.

• Celiac disease is a relatively common and underdiagnosed autoimmune condition. “In individuals with celiac disease, gluten ingestion causes an autoimmune reaction that results in damage to the small intestine,” says Nicola McKeown, PhD, a faculty member at the Tufts Friedman School and scientist at the Jean Mayer USDA Human Nutrition Research Center on Aging. Symptoms may include abdominal pain, chronic diarrhea or constipation, vomiting, weight loss, and fatigue, with varying severity. Celiac disease is diagnosed with a blood test that looks for certain antibodies to gluten. If the blood test is positive, an intestinal biopsy may be performed to look for the damage celiac disease causes to the lining of the intestines. Definitive diagnosis is made by instituting a gluten-free diet and seeing if symptoms resolve. If you suspect you may have celiac disease, putting yourself on a gluten-free diet before being tested will make diagnosis difficult, so it is essential to see a doctor before starting any dietary restrictions. Untreated celiac disease has been reported to increase risk for type 1 diabetes, an itchy skin rash called dermatitis herpetiformis, heart disease, intestinal cancers, osteoporosis, infertility, and anemia. Because celiac disease has a strong genetic component, it is recommended that close relatives of people with this condition also be screened. The only treatment currently available for celiac disease is lifelong avoidance of gluten.
• Wheat allergy is another case in which a gluten-free diet may be prescribed (although a wheat allergy may be triggered by either gluten or non-gluten wheat proteins). Wheat is one of the eight most common food allergens. Some, but not all, people with wheat allergy will also react to rye and barley. As with other food allergies, onset of symptoms occurs rapidly after eating wheat and can involve the gastrointestinal tract, skin, and respiratory system. Exercise-induced wheat allergy is a rare condition in which physical exertion and wheat ingestion together can trigger a life-threatening reaction called anaphylaxis. Wheat allergy is diagnosed with blood tests or skin prick tests. Treatment is a wheat-free (and possibly gluten-free) diet, and possibly antihistamines and epinephrine.
• Non-celiac gluten sensitivity (NCGS) is another condition which necessitates gluten-avoidance. People who report an adverse reaction to gluten but for whom wheat allergy and celiac tests are negative are said to have non-celiac gluten sensitivity or gluten intolerance. Symptoms vary and may include stomach pain, diarrhea, fatigue, headache, brain fog, and skin conditions. Little is known about the pathophysiology of this condition and there are no diagnostic tests. Other conditions, such as celiac disease, wheat allergy, inflammatory bowel disease, and irritable bowel syndrome, should be ruled out by testing. Then, if removing or reducing gluten resolves symptoms, and adding it back in causes symptoms to return, the condition is labeled NCGS.
• Mimics of gluten sensitivity could also be responsible for symptoms. In several studies, significant numbers of people who believe they have gluten sensitivity did not develop any more symptoms when unknowingly exposed to gluten than when exposed to a placebo. Researchers suspect that some cases thought to be gluten sensitivity may actually be reactions to other (non-gluten) parts of wheat or other foods. “For people who believe they have a wheat allergy or gluten intolerance but test negative for allergy and celiac disease, it is possible that symptoms are triggered by FODMAPs—short chain carbohydrates that are poorly absorbed and fermentable by gut bacteria,” says McKeown. “These natural sugars and fibers may cause digestive problems similar to that of gluten intolerance.” Because wheat contains FODMAPs called fructans, it is possible that some people who believe they are reacting to gluten are actually reacting to fructans. “A hydrogen breath test may be helpful in identifying fructan intolerance in selected cases,” says John Leung, MD, an allergist, gastroenterologist, and director of the Center for Food Related Diseases at Tufts Medical Center.

Q: Is a gluten-free diet healthy for people without these conditions?

A: Gluten-free diets have grown in popularity in recent years. Although less than one percent of people worldwide are known to have celiac disease and only six percent are thought to have non-celiac gluten sensitivity, the most recent available market research suggests nearly one-third of Americans have attempted to eliminate or reduce the amount of gluten they consume. Although a number of mechanisms have been proposed by which gluten may contribute to weight gain, diabetes, and other health problems, human intervention trials to confirm these theoretical connections are lacking. A 2019 review of data from three large American prospective cohort studies found that people who consumed the highest amount of gluten actually had a 13 percent lower risk of type 2 diabetes than those who reported the lowest gluten intake.

“If avoiding gluten leads people to eat less refined starch and sugar, and eat more minimally processed fruits, vegetables, nuts, beans, oats, and buckwheat, this can lead to important health benefits,” says Dariush Mozaffarian, MD, DrPH, dean of the Friedman School and editor-in-chief of Tufts Health & Nutrition Letter. “But, if they simply replace refined wheat products with refined rice and corn products, or with other unhealthy choices like processed meats, there will be little health gain, and possibly harms.”

A 2018 study by Tufts researchers published in the journal Nutrients compared the nutrient composition of gluten-free eating patterns versus gluten-containing diets. The researchers found that, on average, a gluten-free menu was significantly lower in protein, magnesium, potassium, vitamin E, and folate then a similar gluten-containing menu. (On the positive side, the gluten free menu was lower in sodium, although results from other recent studies vary.) The study authors also conducted a meta-analysis of seven studies comparing the nutrient intakes of adults with celiac disease following a gluten-free diet with control subjects eating a standard diet. In this analysis, gluten-free eaters consumed less fiber and folate than the controls. “Gluten-free diets are not weight loss diets or healthier than gluten-containing diets,” says lead author Amy Taetzsch, PhD, RDN, now a clinical assistant professor of nutrition at the University of New Hampshire. “In fact, gluten-free diets may be lower in some important nutrients and higher in calories.”

Whereas refined wheat flour is required by law to be enriched with some of the vitamins and minerals removed in the processing of whole wheat, most gluten-free products are not similarly enriched. “For example, gluten-free cookies, crackers, or snack foods may be made from refined, unfortified rice, tapioca, corn, or potato flours,” says McKeown. “This means that they lack certain nutrients (like iron, folic acid, and other B vitamins) that are required to be added to all refined wheat products. Another major concern is that dietary fiber intake is lower because whole wheat-based foods are a major contributor to dietary fiber intake.” In other studies, people following a gluten-free diet showed significantly increased blood levels of mercury, lead, and cadmium as well as elevated concentrations of total arsenic in urine compared to subjects eating a standard diet, possibly due to the extensive use of rice in gluten-free processed foods.

Q: What does a healthy gluten-free diet look like?

A: For those who must avoid gluten (and those who choose to), a naturally gluten-free diet should be rich in fruits, vegetables, legumes, nuts, seeds, and minimally processed, gluten-free whole grains (like amaranth, buckwheat, millet, oats, quinoa, sorghum, and teff). Relying on commercial, processed/packaged gluten-free foods is not recommended. “Everyone, regardless of whether they have a gluten sensitivity or not, would benefit from increasing fruit and vegetable intake, avoiding highly processed foods, and limiting refined grains,” says McKeown. “Minimally processed, intact whole grains (whether gluten-containing or gluten-free) are rich in micronutrients and fiber and should be consumed regularly.”

“If you suspect a food intolerance, consult a doctor,” says Leung. “Unnecessary food avoidance can be harmful because of risk of malnutrition.”

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In a nutshell, gluten is a protein that causes some people to feel bloated, cramps, and fatigue. Their gluten sensitivity may lead to a diagnosis of celiac disease (more on that in a minute).

What Is Gluten? And Where is It?

Gluten is commonly found in wheat, barley, or rye—common ingredients in popular foods. You’ll find wheat in breads, other baked goods, soups, pasta, cereals, sauces, salad dressings, or roux. You’ll find barley in malt, food coloring, soups, malt vinegar, even beer. Rye is found in rye bread such as pumpernickel, rye beer and many kinds of cereals.

If you and your doctor suspect you have a gluten sensitivity, it’s easy to figure out what to avoid. But in the food world, what is gluten-free? Fortunately for people who have gluten intolerance, there are a variety of items you likely already enjoy that are naturally gluten-free. They include fruits, vegetables, meat and poultry, fish and seafood, and dairy, plus beans, legumes, and nuts.

Finding Your Diet Groove

There are lots of tasty, creative ways to enjoy a gluten-free diet—and no shortage of gluten-free recipes for all tastes and all meals. The Celiac Disease Foundation recommends things like oat bran muffins, lox and cream cheese on a gluten-free bagel, a breakfast burrito with eggs, bell peppers, avocado and olive oil. If you’re hosting a party, you can ensure your guests’ gluten intolerance symptoms are properly respected with snack items like strawberries and gluten-free goat cheese crackers, or tomato-garlic focaccia, which relies on sorghum and chopped herbs.

Bottom line: If you’re gluten-sensitive, don’t worry about finding foods you enjoy. There are lots of choice gluten-free recipes to choose from.

If you think your condition might be more serious, your doctor may suspect you’re suffering from celiac symptoms.

The first step in diagnosing celiac disease is usually a blood test to measure levels of certain auto-antibodies produced by the immune system in response to ingested gluten. As a result, it’s important to be eating a regular, gluten-containing diet when being tested for celiac disease; if you’ve been on a gluten-free diet longer than a couple of months, results may be negative—even if celiac disease is present. After that, your doctor might recommend an elimination diet to get at the root of your difficulties.

For further reading: See “Quick-Start Guide to Celiac Disease and Gluten Sensitivity.”

Originally published 2016, this post is regularly updated.

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On the other hand, the gluten-free diet requires a completely new approach to eating. People on a celiac disease diet have to be extremely careful about what they buy for lunch at school or work and what they eat at cocktail parties or order from restaurants.

Cheating (eating food containing gluten) or cross-contamination (even as small as one-eighth of a teaspoon) can cause intestinal damage. A dietitian who specializes in celiac disease can help patients learn about their new diet.

Gluten-Free Basics

A strict gluten-free diet—one free of all forms of wheat, barley, and rye—is necessary to help prevent both short-term and long-term consequences of celiac disease. Miniscule amounts of gluten—a crumb on a shared stick of butter—can be enough to cause problems for those with celiac disease.

Don’t eat a food if you are unable to verify the ingredients or if the ingredient list is unavailable. Regardless of the amount eaten, if you have celiac disease, damage to the small intestine occurs every time gluten is consumed, whether symptoms are present or not.

Understanding these dietary requirements will enable the newly diagnosed to read labels of food products and determine whether a product is gluten-free—critical knowledge for anyone on a celiac disease diet.

Grains Allowed

Sticking to a celiac disease diet starts with watching for gluten content in the food you buy. Understand which foods are absent of gluten and keep them around.

• Amaranth
• Arrowroot
• Beans
• Buckwheat
• Corn (maize)
• Flax
• Garfava
• Millet
• Montina
• Nut flours
• Potato
• Quinoa
• Rice
• Sorghum
• Soy
• Tapioca
• Teff

Grains Not Allowed in Any Form

• Wheat (einkorn, durum, faro, graham, kamut, semolina, spelt)
• Rye
• Barley
• Triticale

Foods/Products That May Contain Gluten

• Beers, ales, lager
• Breading and coating mixes
• Brown rice syrup
• Communion wafers
• Croutons
• Dressings
• Drugs and over-the-counter medications
• Energy bars
• Flour and cereal products
• Herbal supplements
• Imitation bacon
• Imitation seafood
• Marinades
• Nutritional supplements
• Oats
• Pastas
• Processed luncheon meats
• Sauces, gravies
• Self-basting poultry
• Soup bases
• Soy sauce or soy sauce solids
• Stuffings, dressings
• Supplements
• Thickeners (roux)
• Vitamins & minerals

Pantry Preparation

Those who eat a celiac disease diet know it’s essential to prevent gluten cross-contamination. Clean or replace the items in your kitchen where gluten contamination can occur: scratched pans, the toaster, colanders, cutting boards, your food mill. Do the homework to truly understand cross-contamination, gluten-containing ingredients, and food labeling so that your kitchen becomes a safe haven.

If your kitchen is not fully gluten-free, take steps to make sure there is no cross contact with gluten before baking. Scrub your counters and put utensils, pans, bowls, cutting boards and sponges in the dishwasher before baking gluten-free. Be aware that particles of wheat flour can linger in the air for 24 to 36 hours.

If someone in your household plans to continue to eat gluten, organize your pantry and cabinets so that no gluten-containing foods, pots, or pans are mistakenly used. Use clear plastic bins in your pantry to segregate items so there are no mix-ups when unpacking the groceries or when reaching for cereals or snacks. Color-code pots, pans, utensils, and the like with fun-colored duct tape so that it’s easy to tell which are dedicated for gluten-free use.

Take out everything in the pantry, refrigerator, and freezer and check labels. Keep a permanent marker in the kitchen and write “GF” (gluten-free) on all safe foods and condiments. Use separate jars of mustard, peanut butter, and jelly and separate sticks of butter to avoid cross-contamination from wheat crumbs. Or buy squeeze bottles for condiments, which reduces the chance of cross-contamination. Don’t buy foods from bulk bins that are prone to contamination from other grains.

Buy some prepared gluten-free foods, like frozen pizza, pasta, soup, pretzels, and other favorite snacks—whatever you enjoyed eating before going gluten-free. Having these on hand will keep you from feeling deprived and help you avoid the temptation to eat gluten. Try a few different brands to figure out which you like best. The best ways to find tasty alternatives are to get connected with others by joining a support group and to attend gluten-free fairs and expos, where you can sample different items before buying.

You’ll also want to stock some gluten-free baking mixes and a reliable all-purpose gluten-free flour blend. Find an all-purpose flour blend that can be used for almost everything, from fish sticks and tempura to birthday cake and sandwich bread. Once you’ve gained confidence, you can experiment with the growing variety of alternative gluten-free flours made from whole grains and seeds. The best ones offer rich flavor, nutrients, and fiber that will enhance your culinary repertoire.

Even if you’ve never baked from scratch, consider doing it now. Despite all the new gluten-free products available, many just don’t taste like the foods you remember. That’s where you and your oven come in. Any item you enjoyed prior to your diagnosis, you’ll be able to enjoy once again, gluten-free. Bread, cookies, cake, muffins, pizza—you’re limited only by your imagination.

Labeling Lingo

The sweeping legislation known as FALCPA, the Food Allergen Labeling and Consumer Protection Act of 2004, requires clear labeling of the top eight allergens (milk, eggs, tree nuts, peanuts, fish, shellfish, soy, and wheat, frequently referred to as “the great eight”). Thus, all food containing wheat must declare it on the label.

The term “gluten-free” took shape in the United States in 2013. Updating an earlier proposal, the Food & Drug Administration issued a rule on Aug. 5, 2013 defining the term “gluten-free” for voluntary use in the labeling of foods. The compliance date for manufacturers was Aug. 5, 2014. Food products bearing a “gluten-free” label on or after that date are to meet the rule’s requirements: gluten content has to be less than 20 ppm (parts per million).

“In general,” the FDA ruling stated, “foods may be labeled ‘gluten-free’ if they meet the definition and otherwise comply with the final rule’s requirements. More specifically, the final rule defines ‘gluten-free’ as meaning that the food either is inherently gluten free; or does not contain an ingredient that is: 1) a gluten-containing grain (e.g., spelt wheat); 2) derived from a gluten-containing grain that has not been processed to remove gluten (e.g., wheat flour); or 3) derived from a gluten-containing grain that has been processed to remove gluten (e.g., wheat starch), if the use of that ingredient results in the presence of 20 parts per million (ppm) or more gluten in the food. Also, any unavoidable presence of gluten in the food must be less than 20 ppm.”

Permissible synonyms for “gluten free” include “free of gluten,” “without gluten” and “no gluten.”

For further reading, see these University Health News posts:

• “What Is Gluten?“
• “Celiac Disease Symptoms: Get Ready For Related Conditions“
• “Celiac Disease Diagnosis? 10 Steps You Can Take Right Now“

This article was riginally published in 2016 and is regularly updated.

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What is gluten?

Gluten is the generic name for a number of different proteins contained in the common cereal grains wheat, barley, rye and their common derivatives (see full list below). Sources of gluten include bread, noodles, pasta, pastries, baked goods, and cereals, even those labeled “whole-grain” and “wheat-free.” (Be aware that “wheat-free” does NOT guarantee gluten-free). 

Identifying gluten-containing foods is not always black and white

At first glance, you might think it would be easy to learn which foods have gluten and which don’t. But the truth is that gluten is often hidden. Many processed food contain gluten. It can difficult to tell if gluten is present, even in foods that have all the ingredients listed on the label.

Anyone newly diagnosed with celiac or gluten sensitivity must carefully read all labels and be willing to ask questions and investigate to determine if a food is appropriate. This is true even if it is a food you have eaten before because ingredients can change without warning. If you are ever in doubt, call the company to confirm ingredients. If you are unsure, it is better to not eat the food than risk exposure to gluten.

The U.S. FDA defines “gluten-free” foods as food that is either inherently gluten-free (such as rice), or a food that does not contain a gluten-containing grain (such as wheat, barley, or rye); and states that “any unavoidable presence of gluten” — such as foods made in a shared facility — must be less than 20 parts per million (ppm) of gluten. The World Health Organization and the United Nations also use the 20 ppm standard for gluten-free label claims. There are a variety of gluten-free symbols used to designate whether or not a product is truly “gluten-free”. Most of these symbols look similar to this:

Foods that are inherently gluten-free include: rice (rice bran, rice flour (brown, white, or sweet), rice polish, rice starch flour), corn (corn starch, corn bran, corn flour, corn germ, corn meal), soy flour, potato flour, tapioca starch, bean (garbanzo and broad beans/garfava), sorghum, quinoa, millet, buckwheat (kasha), arrowroot, amaranth, teff, Montina (Indian rice grass), chia, flax, and nut flours. Specially prepared gluten-free breads, baked goods, and other foods should use these gluten-free grains and ingredients.

The following grains, starches, and baking ingredients contain gluten:

• Barley
• Bulgur
• Einkorn
• Emmer
• Faro
• Malt (malt extract, malt flavoring, malt syrup, malt vinegar)
• Oats (assume contaminated unless specifically labeled gluten-free)
• Rye
• Triticale (a combination of wheat and rye)
• Wheat (wheat germ, durum, graham, kamut, farina, semolina, spelt, matzo, couscous, all-purpose flour, cake flour, pastry flour, self-rising flour, bread flour, whole wheat flour, stone ground flour, wheat starch, modified wheat starch, hydrolyzed wheat protein)

All breads, cereals, baked goods, and other foods containing these gluten-containing grains, flours, thickening agents, and baking products should be avoided.

Those avoiding gluten must be extra cautious about the following foods:

• Gravy, sauces, soups are often thickened with gluten-based ingredients. Soy sauce contains wheat and therefore gluten unless specifically labeled gluten-free. Many dressings and marinades contain soy sauce or other gluten ingredients. Teriyaki sauces almost always contain gluten. Worcestershire sauce may or may not contain gluten.
• Dairy. While most dairy products, including milk, cream, and yogurt are gluten-free, watch out for sour cream, commercial chocolate drinks, and non-dairy creamers, which may contain gluten. Avoid malted milk. Processed cheeses (spray cheese) may contain gluten.
• Meats and eggs. While all fresh meats, seafood, and poultry are gluten-free, be cautious about any processed meats (some hot dogs, sausages, lunch meats, cured meats), canned meat and fish, imitation crab, imitation bacon, and imitation seafood. Canned chili with meat may contain gluten. Meat dishes such as Swiss steak, meat loaf, meatballs, and croquettes usually contain gluten. Tuna canned with hydrolyzed wheat protein and turkey injected with hydrolyzed wheat protein as part of the basting solution contain gluten. “Imitation crab” or other meat analogs often contain wheat starch or other gluten ingredients. Quick individually frozen seafood may also be coated in gluten-containing flours. While eggs are certainly gluten-free, some restaurants may add a wheat-based filler to scrambled eggs and omelets.
• Vegetables and fruits. Some canned, frozen, or commercially-prepared vegetables, salads, and bean dishes, such as creamed vegetables and some baked beans and chili, and some commercially-prepared vegetables and salads (deli salads) may contain gluten. All batter dipped vegetables must be avoided, as should French fries made in a fryer shared with breaded products. Some dried, thickened or prepared fruits and pie fillings have gluten.
• Alcoholic beverages. Beer, ale and lager all contain gluten and must be avoided unless specifically labeled gluten-free. Distilled alcoholic beverages are gluten free because distillation effectively removes gluten from wheat.

Other controversial ingredients that may contain gluten:

• Modified food starch. This ingredient may be made from a variety of starches (generally corn or tapioca). Under today’s labeling laws, modified food starch is gluten free unless it is made from wheat, in which case “wheat” will appear on the label. If you don’t see the word wheat on the label, the modified food starch is not wheat derived.
• Hydrolyzed vegetable protein. Hydrolyzed vegetable protein is a phrase that under current federal regulation should not be used on food labels; the “vegetable” must be identified, so “hydrolyzed wheat protein,” is not gluten-free but “hydrolyzed soy protein” is gluten-free.
• Seasonings, seasoning mixes, flavorings, dextrin, and caramel color could contain gluten from wheat or barley. If made from wheat, wheat will be noted on the label as required by law. If made from barley, malt or barley will almost always be listed. Caramel color is almost always made from corn, but it can be made from malt syrup. Most experts now say you can consider caramel color to be gluten free.
• Oats. Most oats are highly contaminated with gluten, but several companies produce pure, gluten-free oats that are labeled gluten free.
• Soy Sauce is usually fermented from wheat. However, some brands don’t include wheat and are gluten free. Read the label to be sure. Tamari is like soy sauce but almost always gluten-free.
• Certain candies like licorice contain gluten.
• Some medications, dietary supplements and herbal products may contain gluten ingredients. Some hair care products, makeup, lotions also contain gluten.

Knowing what foods have gluten is just the tip of the iceberg when it comes to understanding why gluten can negatively affect health and knowing how to live a gluten-free lifestyle. For more gluten-related information, see the following articles:

• Grain Brain – Dr. Perlmutter’s Controversial Book on Dietary Grain Perils
• Depression Symptoms Linked to Gluten Sensitivity
• Gluten Allergy Symptoms Are Commonly Mistaken for Irritable Bowel Syndrome

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