Stephanie Fairweather, dietetic intern at Lenoir-Rhyne University contributed this post.
What kind of grocery shopping and eating changes would a person recently diagnosed with Celiac disease need to make in life? May is Celiac Awareness Month, and Ingles Markets Dietitian Leah McGrath posed this question, challenging me to observe and experience how food buying and dining habits would be affected with this condition.
Many people associate Celiac disease with consuming the grain protein formed by processing wheat – gluten (It’s also found in barley and rye grains). In fact, Celiac disease is an autoimmune response. Exposure to gluten causes a reaction that damages the intestinal lining, making it difficult to absorb nutrients in the GI tract. The condition can also cause pain, bloating, diarrhea, anemia, depression, and can contribute to long-term chronic disease. Celiac disease affects just under 1% of the U.S. population, approximately 3 million Americans (1).
Even a tiny amount of gluten consumed can cause the GI antibody reaction; the FDA requires that any food product with a “gluten free” label to contain no more than 20 parts per million of gluten. That translates into roughly 20 milligrams of gluten in two pounds of grain-based food that’s considered gluten free (2). In real terms, adult nutrition requirements for most people range from 6 to 10 ounces of grains per day, so gluten thresholds in gluten-free grain servings would be between 3.42 and 5.7 milligrams (3). This means a few crumbs of gluten-containing bread can spark a debilitating response.
To delve into the question of changes with Celiac, I put together two days of meals and a shopping list for a family of four. When I started going through the grocery aisles, two things became apparent: 1) It takes a lot more time in the store and costs more money to go gluten free, and 2) Grocery employees are well-versed in the gluten-free products their stores carry, and are helpful in directing customers to them. I found that Ingles also makes locating gluten free foods very easy for consumers, placing “gluten free” tags below items, which are located among similar items such as baked goods and pastas.
The two day meal menu reflected what we might eat on a typical weekday and a special birthday weekend day:
Day 1
Breakfast: Raisin bran, lowfat milk, orange slices
Lunch: Turkey sandwiches with lettuce, grapes
Dinner: Spaghetti and meatballs with tomato sauce, green beans, brownie
Day 2
Breakfast: Scrambled eggs, waffles with syrup and sliced bananas, yogurt
Lunch: Birthday burger BBQ, oven fries, ketchup and a homemade yellow birthday cake
Dinner: Asian chicken stir fry with veggies and rice
I estimated that the grocery store visit took an extra 17 minutes to read the nutrition labels on all of the foods. Over a year of shopping, the need to scrutinize labels could easily add an extra 50 hours to the task. I could see how this would create brand loyalty and a repertoire of go-to foods for busy households. I also appreciate that adventurous cooks need to make a major time commitment to find Celiac-safe foods.
One big surprise was that wheat was an ingredient in foods that I would never associate with gluten. In frozen French fries, wheat was added as a coating to keep them from sticking together. Almost all brands of soy sauce on the shelves also contained wheat (a gluten-free option that is available is tamari sauce). Glancing at other common condiments, I noticed that most gravy mixes had wheat in them, and a pale ale mustard that would need to be avoided (beer is brewed with barley and is off the list as an alcohol option for those with Celiac).
I decided that for our family scenario, I would trade out gluten-free ingredients for those containing wheat, to find the cost difference. The two day grocery bill was $23.67 more expensive for non-gluten foods! Some items, including freezer waffles and cereal, were fairly closely priced. Here’s a glance at similar breakfast cereal types:
| Product | Amount | Cost |
| Post Bran Flakes | 16 oz | 3.88 |
| Special K Gluten Free Multigrain Rice + Cornflakes | 11 oz | 4.31 |
| Special K Honey Granola | 11.3 oz | 3.78 |
| Kind Gluten Free Oat + Honey Cluster Granola | 11 oz | 4.68 |
| Lara Lynn Golden Crunches | 12 oz | 2.58 |
| General Mills Gluten Free Honeynut Chex | 12.5 oz | 3.38 |
Specialty pastas are a burgeoning industry. The least expensive gluten free pasta option still cost $2.10 more per pound than wheat pasta. I had to laugh at some of the packaging, which read, “Good Consistent Texture, Not Mushy” (!) Clearly, a good toothy gluten free pasta is difficult to formulate, and manufacturers are aware of consumer response to early versions. Good tasting alternatives are now springing up including pastas made from rice, corn, quinoa and even soybeans and black beans (that’s some high fiber pasta!). I boiled up a new bean pasta and found it kept its angel-hair shape and bite quite nicely. Sauteed with a few shrimp, asparagus and crushed red pepper flakes, it tasted very much like lightly salted thin spaghetti. These new pastas are also uniformly $2 to $4 more per pound to buy.
The major cost differences in gluten free foods I found are in baked goods, notably breads and desserts. This is one area where food marketers are seeing almost unbounded business growth: Euromonitor estimated the U.S. gluten-free market was $486 million in 2013 – just for products that were specifically formulated to replace wheat flour. Think bread, cookies, pasta and ready-prepared meals. Their sales projections are for gluten-free market growth by 38% between now and 2018 (4). The sandwich bread loaves I compared were $2.50 more expensive for a gluten-free loaf than for a wheat loaf. That adds up quickly for a household staple!
For a home baking fan, finding gluten-free recipes and mixes is doubly challenging: it’s expensive, and texture results can be disappointing. That’s because it’s the gluten protein that makes doughs stretchy and traps gases in the dough in a nice hot oven, providing lightness and structure to baked goods (5). The yellow cake mix for my two day grocery scenario cost $2.40 more for the non-gluten version. Fresh brownies had a cost difference of $3.69 each gluten-free vs. $1.24 each wheat flour-containing for a 3 inch brownie from the grocery store bakery. Here’s a comparison of more bakery items:
| Product | Amount | Cost |
| Pepperidge Farm 15 Grain Sandwich Bread | 24 oz | 2.98 |
| Udi’s Gluten Free Multigrain Sandwich Bread | 18 oz | 5.48 |
| Ingles Honey Wheat Table Loaves | 13 oz | 2.18 |
| Promise Gluten Free Seeded Table Loaves | 6.34 oz | 3.58 |
| Nature’s Own Whole Wheat Hamburger Buns | 15 oz | 2.97 |
| Udi’s Gluten free Classic Hamburger Buns | 10.4 oz | 4.58 |
| Betty Crocker Yellow Cake Mix | 15.25 oz | 1.98 |
| Glutino Gluten Free Yellow Cake Mix | 15 oz | 4.38 |
| Lara Lynn Chocolate Chip Cookie Mix | 17.5 oz | 1.98 |
| Immaculate Gluten Free Chocolate Chip Cookie Mix | 19 oz | 4.98 |
Suddenly, fruits, frozen yogurt and ice cream started sounding like great dessert options for a family of four.
Dining out with Celiac presents another challenge, and it’s one that many Americans must navigate carefully. On an evening visit to a small cafe, I found 19 entree selections. Paring out the wheat-containing choices, that left five dinner options. I asked the cook how she handled menu requests from customers with Celiac. She was forthright in mentioning that the baking/prep area of the kitchen was too small to avoid cross-contamination of baked goods, so she accommodates customers with soups and salad offerings, and the cafe has a work-around in burgers served on lettuce “buns” instead of bread. Those with Celiac routinely must ask about kitchen prep areas and the establishment’s gluten-food policy; it’s also common to avoid ordering entrees with sauces or gravies and deep fried foods.
A bright spot in being a gluten-free consumer these days is that Celiac awareness is much broader now than in the past few years. Grocery chains train staff and restaurants train servers to be knowledgeable about the products and menu items offered. Great information and support can also be found online. Here are a few resources:
Gluten Intolerance Group – www.gluten.org provides info on symptoms of Celiac, proper testing, potential nutrient deficiencies associated with the condition, food choice alternatives and cooking characteristics of non-gluten foods such as flours, thickeners and starches.
Ingles Markets – www.ingles-markets.com/inside/gluten-free carries a list of foods on their website which are listed “gluten free” by their manufacturers, and they also list stores in the Ingles chain which have gluten free sections.
Gluten Free in NC – www.glutenfreeinnc.com shares information about restaurants and bakeries that cater to gluten-free customers throughout the state of North Carolina.
Gluten Free Girl and the Chef – www.glutenfreegirl.com is an enticing website for seasonal, sweet and savory baked goods recipes, and offers a simple guide to gluten-free baking.
As professional dietitians (and dietitians-to-be), it’s key to remember that we need to do more than simply educate our clients on healthy food choices. We also need to understand individual challenges to making changes, and be able to collaborate, find solutions and share resources with those we serve. It was thought-provoking to step into the shoes of a person with Celiac, and also heartening to know that there are delicious and accessible workarounds, both at the grocery store and in restaurants, for those who suffer the disease.
References
- Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE. The prevalence of celiac disease in the United States. American Journal of Gastroenterology. 2012 Oct;107(10):1538–44
- U.S. National Library of Medicine Celiac disease. Retrieved from http://ghr.nlm.nih.gov/condition/celiac-disease. Accessed May 11, 2015.
- Thompson T. How much gluten is 20 parts per million (2008). Retrieved from http://www.glutenfreedietitian.com/how-much-gluten-is-20-parts-per-million/. Accessed May 11, 2005.