ARS scientists have developed a new process to produce gluten-free bread from corn flour that produces higher quality bread that is closer to the texture of conventional bread like those pictured here. Click the image for more information about it.
A process to produce high-quality, gluten-free bread has been developed by U.S. Department of Agriculture (USDA) scientists in Manhattan, Kan. Millions of Americans affected by celiac disease are unable to digest gluten, a protein in flour from grains such as wheat, barley and rye.
Chemists Scott Bean and Tilman Schober at the Agricultural Research Service (ARS) Grain Quality and Structure Research Unit found that by removing a certain amount of fat from a corn protein called zein, they were able to produce a dough more similar to wheat dough, and free-standing, hearth-type rolls that resemble wheat rolls. ARS is the chief intramural scientific research agency of USDA.
Bean and Schober had some success developing gluten-free pan bread from other grains, but they couldn't make free-standing rolls because the rolls spread out too much. According to Bean, the bread was considered lower in quality than comparable wheat bread. Gluten-free grains include corn, sorghum, and rice.
In previous studies, Bean and Schober found that zein-a readily available byproduct from corn wet milling and fuel-ethanol production-could be used to make dough that was more similar to wheat dough. The dough still didn't meet their standards, though, because it lacked strength, and the rolls produced from it were too flat.
Bean and Schober discovered that removing more of the fat from the zein protein's surface allowed the proteins to stick to each other much like wheat proteins do, giving the zein-based dough the same elastic properties as wheat dough.
According to Bean, while the experiment made more acceptable dough, sorghum may prove to be a better grain to use since it is a gluten-free grain. Bean used corn as an intermediate step toward achieving the ideal in gluten-free breads: a wheat-like dough using non-wheat proteins, resulting in products with a fluffy, light texture.
This research may prove useful for the 2 to 3 million Americans who have celiac disease, a condition in which the human immune system erroneously attacks gluten proteins, causing severe diarrhea and inability to absorb nutrients. Gluten-free palatable rolls from corn, rice and sorghum would be a welcome addition to their diet.
The research results were published in the Journal of Cereal Science and in the November/December 2010 issue of Agricultural Research magazine.
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Very few of the early COVID-19 pandemic-era trends remain. We doubt anyone is still hoarding toilet paper, and there hasn't been much news recently about people still eating horse dewormer as a way to stave off ailments. But one trend that really rose in popularity back in 2020, and has seemingly not ceased, is sourdough baking.
Sourdough refers to baked goods that are made with a sourdough starter . Essentially, it's a culture of wild yeasts and bacteria that ferment and grow on a mixture of flour and water. Caring for a sourdough starter requires daily feeding and removing the sourdough discards . But once you have a steady, well-sustained culture going, you can use it for seemingly everything. Stir it into chewy chocolate chip cookies or stick to classic bread recipes.
The lion's share of sourdough recipes focus on using wheat-based flours, like bread flour, whole wheat, or all-purpose flour. But, believe it or not, it is possible to cultivate a vibrant colony of wild microbiota on a gluten-free flour, too. That way, you can use this recipe for all of your gluten-free favorites, including breads, desserts, and more. We consulted with several baking professionals, including cookbook author Allyson Reedy , co-owner of Bread Bros Amy Jam, and chef Hervé Guillard — the director of education at the Institute of Culinary Education's (ICE) Los Angeles campus — about how to ensure success when making a gluten-free sourdough starter.
The easiest way to whip up a gluten-free sourdough starter is going to be to look for a wheat-analogous product. Some gluten-free flours tend to have more fiber or be a little bit more gritty than white flour, which can alter the texture of your sourdough and the microbes you're trying to attract. Plus, if you consider yourself to be a novice when it comes to gluten-free baking, you may want to use measure-for-measure gluten-free flour to make your sourdough.
Allyson Reedy recommends using a gluten-free flour blend to get your sourdough culture going. "You'll start by mixing a roughly 50/50 blend of the flour and water (use just a smidge more flour than water) in a Mason jar," she explains. "... It can take 10 to 14 days to get a gluten-free starter going, so don't give up! You'll know it's ready when it's doubled in size, has lots of big bubbles, and is nice and fluffy."
One of our favorite measure-for-measure flour blends to work with is from the King Arthur Baking Company. Not only does the brand make a standard gluten-free flour, but it also makes a gluten-free measure-for-measure bread flour . It contains starches and ingredients that will mimic the same elasticity and protein content as traditional wheat flour. "[Flour brands] usually have some basic recipes on their websites as well to get you started. They've done the research so you don't have to," Hervé Guillard explains.
If you're not familiar with gluten-free baking, sorghum might not resonate with you. But folks who frequently whip up gluten-free muffins and treats may have come across it a time or two. It's a flour that's highly desirable for its smooth texture and balanced mouthfeel; you won't notice too much graininess or nutty flavor when you use it in your recipes.
Sorghum flour is one of Jam's favorites for making gluten-free sourdough with. "I swear by sorghum flour when I'm baking gluten-free products because it not only brings nutrition to the table, but it also adds a mild sweetness and makes the bread softer," she explains. Jam also shares that she uses tapioca and potato starch in tandem with the flour to prevent it from getting too dense.
Jam also underscores the importance of hydration when it comes to making a gluten-free sourdough. "When I work with sorghum flour, I make sure the dough is really moist, going for a water content of about 90-100%," she says. "This is important for building the right structure and keeping the bread just perfect." The hydration ratio refers to the amount of water that you should be using for every 100 grams of flour. So, for 100 grams of sorghum flour, you should be using about 90 to 100 grams of water. In comparison, traditional wheat sourdough caps the hydration anywhere between 65% and 90%.
Mastering gluten-free baking often involves getting an entire arsenal of ingredients ready. While making a traditional sourdough really only requires two ingredients, water and wheat flour, your gluten-free sourdough will require you to play around more with starches and ingredients to give your dough its trademark elasticity. One of those, which Jam cooks with frequently, is psyllium husk.
"Psyllium husk powder is another must-have in our kitchen," Jam shares. "It's a fantastic binder for gluten-free baking and, unlike xanthan gum or guar gum, psyllium husk adds a similar elasticity and structure you'd find in gluten-containing doughs." This is because it produces a gelling effect when combined with other ingredients. In short, this property mimics the same strengthening effect as gluten and will ensure your dough gets the proper rise. Jam also shares an important tip with us about working with psyllium husk. "I always hydrate the psyllium husk in water before it goes into the dough," she explains. "This creates a gel that not only improves the dough's texture, but also makes it a lot easier to handle."
The hydration process can take anywhere from 15 minutes to up to 45, so you'll want to be mindful of this when preparing your dough. Or, you can just opt for using a pre-soaked psyllium gel instead and skip the rehydrating step.
Another seed that should be on your gluten-free radar, especially if you're making sourdough bread, is teff. "It adds a unique earthy, nutty flavor that really improves the tanginess of the sourdough," Jam explains. As a general rule of thumb, when substituting white and teff flour , you'll want to stick to a 1-to-1 ratio. The texture of this powder, though, lends itself better to gluten-free batters that don't require the same structure as bread. So, while you can use it as a 1-to-1 replacement for white flour in muffins, you will want to add in some supplementary flours for your bready applications, like buckwheat or a measure-for-measure gluten-free flour.
In terms of sourdough specifically, it's important to note how the teff's texture could alter your finished starter. "Teff can weigh your dough down, so I balance it with lighter flours like white rice flour and allow the dough to ferment a bit longer," Jam explains. "This extra step does wonders for flavor and texture, which makes your gluten-free sourdough come much closer to traditional varieties."
If you don't do a lot of Asian-inspired baking, you may not have ever come across glutinous rice flour. But, if you've ever sampled those delicious frozen ice cream mochi or eaten Thai mango sticky rice , you'll likely know glutinous rice flour better than you'd think. Despite what its name might suggest, glutinous rice flour contains no traces of gluten, which makes it an excellent addition to gluten-free baking.
In particular, Nathan Myhrvold, founder of Modernist Cuisine and the co-author of " Modernist Bread ," adds this rice flour to his sourdough recipe. He told Tasting Table in an interview that he substitutes bread flour in his sourdough with a medley of gluten-free flours, including glutinous rice flour. "Of these ingredients, the glutinous rice flour played a major role in our baking success: When hydrated in doughs and then baked, it retains a particular chewiness reminiscent of gluten," he says.
It's important to note that you can't just load up your sourdough willy-nilly with this flour, as it tends to be quite sweet. Myhrvold adds white and brown rice flour with the glutinous rice flour, along with starches like tapioca and cornstarch. He also swears by some xanthan gum, a common gluten-free baking ingredient. "It absorbs water and makes the mixture more viscous, helping evenly disperse and suspend the starch particles in the crumb and partially substituting for the structure that gluten would normally provide," he explains.
Wait, what is fruit doing in a sourdough recipe? Although it may seem a bit unconventional, you can actually use fruit to kickstart the fermentation in your starter, per Hervé Guillard. He notes that you'll have to dedicate about a week of your time to getting your fruity ferment ready before you can mix it with your gluten-free flour.
Guillard recommends using a ½ pound of organic, skin-on fruit (he prefers dates and fresh peaches) for every 2 cups of filtered water. After the fruit has fermented in the water for a week, he explains how it should be smashed or blended together, then strained to remove the large chunks of fruit. Once you have your fruity ferment, you can mix in your ½ pound of gluten-free flour and get right to work; there's no need to wait the extra time that you would need to wait for a sourdough culture to properly ferment before you bake with it. If you wonder when the right time is to use your ferment, you can always purchase pH test kits. Once it reads a 4, you should be good to go.
There are some fruits that won't work for this technique, including mango, pineapple, kiwi, and papaya. These fruits contain a special enzyme, actinidain, that inhibits protein from correctly developing, which can create issues with the texture and rise of your sourdough.
Buckwheat flour is a commonly used ingredient in the gluten-free kitchen. Whole buckwheat has a profoundly earthy flavor that will really elevate your sourdough in the same way that adding teff to it would. Like teff, buckwheat can be quite heavy, so you'll want to use it in tandem with other lighter gluten-free flours, like brown or white rice flour.
You can make your own starter out of buckwheat flour, but be forewarned: The process takes much more time than other gluten-free flours. You won't notice much activity (in the form of bubbles) for the first 10 to 14 days. You may also notice an outcropping of pink liquid in the top of the starter; this may be because of the anthocyanin compounds in the buckwheat. So, you'll have to have a grasp of what to look for before you just assume your starter has gone bad and needs to be thrown out.
The most important thing to know about adding buckwheat to your sourdough is that the finished bread (or whatever baked good you use it for) will be dark in color, so it can shift the entire balance of your bread to something that's more gray and almost tonal in color. It may not look super appetizing, but the nuttiness of the buckwheat flour will make it taste quite delectable.
One of the most common types of flour used for gluten-free baking is rice flour. There are two predominant types of flour within this category: white and brown. The white flour is more analogous in flavor to plain white wheat flour, while the brown rice tends to have a nuttier and more complex flavor. Regardless of which type you select, it's important to note that the flour tends to be sticky and not behave like wheat-based flour. So, a large portion of the recipes that use rice flour-based starters will also cut in some gluten-free flour blend later on to help make it a bit lighter and ensure that it behaves. When Hervé Guillard makes his brown rice starter, he uses a mixture of rice flour, sweet potato flour, and plantain flour, along with a bit of xanthan gum.
Like a traditional wheat sourdough, you can start the recipe by mixing equal parts brown rice flour and water, then adding a 50/50 ratio of gluten-free flour and rice flour around week three. This medley will give you the body and texture you're looking for, along with a subtle malty flavor.
Millet flour is another gluten-free flour that you should have on your radar, especially if you're craving something nutty and flavorful. You'll need to look for pearl millet in the store — not pearled millet. The latter still contains its hull, and removing it is just one more step in the sourdough process that you'll want to avoid if you can.
As with other types of flour, like buckwheat and teff, you'll want to avoid making a sourdough that's 100% millet. The grain can be sweet and delectable, but it is quite heavy, and needs to be cut with a lighter flour, like brown rice flour, to ensure the proper rise. You'll also want to make sure your millet seeds are finely ground before you mix them into your starter; otherwise, you won't get the proper consistency. The benefit of using millet flour over buckwheat flour is that it tends to have more activity earlier on; you should start noticing activity within about three days rather than having to wait several weeks. Once your sourdough is bubbling and active, it's time to get the rest of your ingredients and get crackin'.
You shouldn't just be mindful of the gluten in the base of your recipe; you'll also have to consider the gluten content of other ingredients you're baking with. For example, some folks will add beer to their sourdough to imbue it with those perfectly malty, toasty notes and also to promote a browner hue. The beer will also accelerate the yeast activity, since it contains digestible sugars, which can decrease your proofing time significantly.
But not all beers are gluten-free. If you can find a gluten-free beer , like one made from certain types of barley, then by all means throw it into your bread recipe. But otherwise, you may be relegated to reading and scrutinizing labels to ensure that your bread is safe for folks who have celiac or who are gluten-intolerant. The same goes for other ingredients that you add to your sourdough — at any point in making it. Depending on who will be eating the bread, you may need to check the labels to ensure that everything is certified gluten-free before you turn on your oven and get baking.
Gluten-free sourdough behaves differently than a wheat-based one and also has differing strength and textural properties — all of which are important to understand before you pull out your ingredients and start cooking. According to Hervé Guillard, "Because gluten-free bread lacks the extensibility of the gluten matrix, it is less forgiving. So, make sure that you feed your starter two days in a row prior to making bread. It should be very bubbly and active to ensure a nice rise." In other words, this is not the time to let your sourdough get super sour in the fridge by not feeding it; you need that activity to get the proper rise. He also shares that because gluten-free bread doesn't have the same structure as wheat, you won't need to knead it as much to shape your loaf.
Guillard also recommends performing an overnight fermentation to max out the flavor in the dough. "Leave the dough covered and undisturbed overnight for a delicious morning bake," he instructs. While this may require that you plan ahead, the flavorful loaf (or sourdough-infused bake) that you get will be well-worth it.
Furthermore, Guillard shares that you should select a baking pan that will help your sourdough rise to its fullest potential. For a classic sandwich bread, he recommends using a tall loaf pan to encourage the bread's rise. Though, for a crusty loaf, he suggests using a Dutch oven, which will trap the steam in and form the perfect crust.
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Compliance and attitudes towards the gluten-free diet in celiac patients in italy: what has changed after a decade.
2. materials and methods, 2.1. questionnaire, 2.2. statistical analysis, 3.1. descriptive analysis of the celiac disease sample of the latest survey, 3.2. comparison between 2022 and 2011, 4. discussion, 5. conclusions, supplementary materials, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.
Click here to enlarge figure
Children and Adolescents | Adults | The Elderly | Total Sample | ||||
---|---|---|---|---|---|---|---|
I (≤10) | II (11–14) | III (15–17) | IV (18–39) | V (40–59) | VI (≥60) | ||
N = 173 | N = 163 | N = 141 | N = 1216 | N = 1451 | N = 380 | N = 3524 | |
N (%) | |||||||
Sex | |||||||
Female | 120 (69) | 103 (63) | 86 (61) | 963 (79) | 1091 (75) | 273 (72) | 2636 (75) |
Male | 52 (30) | 57 (35) | 54 (38) | 243 (20) | 352 (24) | 104 (27) | 862 (24) |
I prefer not to answer | 1 (1) | 3 (2) | 1 (1) | 10 (1) | 8 (1) | 3 (1) | 26 (1) |
Years after diagnosis | |||||||
Less than 3 years | 85 (49) | 43(26) | 29 (21) | 205 (17) | 178 (12) | 32 (8) | 572 (16) |
3–10 years | 85 (49) | 109 (67) | 73 (52) | 405 (33) | 451 (31) | 103 (27) | 1226 (35) |
More than 10 years | 0 (0) | 8 (5) | 38 (27) | 601 (49) | 817 (56) | 245 (64) | 1709 (48) |
ND | 3 (2) | 3 (2) | 1 (1) | 5 (0) | 5 (0) | 0 (0) | 17 (0) |
Are you a member of the Italian Coeliac Association? | |||||||
Yes | 136 (79) | 125 (77) | 106 (75) | 992 (82) | 1243(86) | 347 (91) | 2949 (84) |
A relative of mine is a member | 25 (14) | 23 (14) | 17 (12) | 47 (4) | 33 (2) | 9 (29 | 154 (4) |
No | 12 (7) | 15 (9) | 18 (13) | 177 (15) | 175 (12) | 24 (6) | 421 (12) |
Do you keep yourself informed on celiac disease? | |||||||
Frequently | 104 (60) | 93 (57) | 83 (59) | 539 (44) | 721 (50) | 200 (53) | 1740 (49) |
Occasionally | 56 (32) | 50 (31) | 38 (27) | 490 (40) | 582 (40) | 151 (40) | 1367 (39) |
Rarely | 10 (6) | 14 (9) | 13 (9) | 143 (12) | 127 (9) | 25 (7) | 332 (9) |
Never | 3 (2) | 6 (4) | 7 (5) | 44 (4) | 21 (1) | 4 (1) | 85 (2) |
Do you comply with regular checks? | |||||||
Yes, regularly | 163 (94) | 150 (92) | 128 (91) | 751 (62) | 827 (57) | 215 (57) | 2234 (63) |
Yes, occasionally | 8 (5) | 13 (8) | 8 (6) | 278 (23) | 356 (25) | 96 (25) | 759 (22) |
No | 2 (1) | 0 (0) | 5 (4) | 187 (15) | 268 (18) | 69 (18) | 531 (15) |
Level of education | |||||||
Primary school diploma/none | 173 (100) | 156 (96) | 39 (28) | 2 (0) | 3 (0) | 3 (1) | 376 (11) |
Secondary school diploma | 0 (0) | 7 (4) | 99 (70) | 94 (8) | 93 (6) | 34 (9) | 327 (9) |
High school diploma or equivalent | 0 (0) | 0 (0) | 3 (2) | 481 (40) | 698 (48) | 219 (58) | 1401 (40) |
University degree or higher | 0 (0) | 0 (0) | 0 (0) | 639 (53) | 656 (45) | 124 (33) | 1419 (40) |
ND | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (0) | 0 (0) | 1 (0) |
Main occupation | |||||||
Student/working student | 173 (100) | 163 (100) | 141 (100) | 333 (27) | 5 (0) | 0 (0) | 815 (23) |
Unemployed/searching for first job/occasional job | 0 (0) | 0 (0) | 0 (80) | 100 (8) | 82 (6) | 19 (5) | 201 (6) |
Housewife/househusband | 0 (0) | 0 (0) | 0 (0) | 25 (2) | 100 (7) | 157 (41) | 282 (8) |
Part-time employment | 0 (0) | 0 (0) | 0 (0) | 123 (10) | 234 (16) | 33 (9) | 390 (11) |
Full-time employment | 0 (0) | 0 (0) | 0 (0) | 635 (52) | 1029 (71) | 171 (45) | 1835 (52) |
ND | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (0) | 0 (0) | 1 (0) |
Marital status | |||||||
Single | 173 (100) | 163 (100) | 141 (100) | 775 (64) | 228 (16) | 32 (8) | 1512 (43) |
Life partner | 0 (0) | 0 (0) | 0 (0) | 195 (16) | 150 (10) | 15 (4) | 360 (10) |
Married | 0 (0) | 0 (0) | 0 (0) | 235 (19) | 972 (67) | 285 (75) | 1492 (42) |
Divorced/separated/widowed | 0 (0) | 0 (0) | 0 (0) | 11 (1) | 101 (7) | 48 (13) | 160 (5) |
Do you have any children? | |||||||
Yes | 0 (0) | 0 (0) | 0 (0) | 219 (18) | 997 (69) | 300 (79) | 1516 (43) |
No | 173 (100) | 163 (100) | 141 (100) | 997 (82) | 454 (31) | 80 (21) | 2008 (57) |
Who do you live with? | |||||||
Alone | 0 (0) | 0 (0) | 0 (0) | 100 (8) | 126 (9) | 57 (15) | 283 (8) |
With parents/parents and partner | 169 (98) | 161 (99) | 139 (99) | 568 (47) | 77 (5) | 3 (1) | 1117 (32) |
With partner/spouse only | 0 (0) | 0 (0) | 0 (0) | 261 (21) | 261 (18) | 173 (46) | 695 (20) |
With children/partner and children/partner, children, and children’s family | 0 (0) | 0 (0) | 0 (0) | 220 (18) | 952 (66) | 133 (35) | 1305 (37) |
With other relatives | 4 (2) | 2 (1) | 2 (1) | 18 (1) | 10 (1) | 7 (2) | 43 (1) |
With other cohabitants | 0 (0) | 0 (0) | 0 (0) | 49 (4) | 25 (2) | 7 (2) | 81 (2) |
Net monthly household income * | |||||||
EUR >2000 | 72 (42) | 73 (45) | 69 (49) | 532 (44) | 755 (52) | 202 (53) | 1703 (48) |
EUR 1000–2000 | 41 (24) | 31 (19) | 25 (18) | 479 (39) | 486 (33) | 139 (37) | 1201 (34) |
EUR <1000 | 6 (3) | 6 (4) | 5 (4) | 126 (10) | 140 (10) | 25 (7) | 308 (9) |
None | 54 (31) | 53 (33) | 42 (30) | 79 (6) | 69 (5) | 14 (4) | 311 (9) |
ND | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (0) | 0 (0) | 1 (0) |
Are there other celiac people in your family? | |||||||
Yes | 33 (19) | 38 (23) | 33 (23) | 311 (26) | 494 (34) | 109 (29) | 1018 (29) |
No | 140 (81) | 125 (77) | 108 (77) | 905 (74) | 957 (66) | 271 (71) | 2506 (71) |
A. | Children and Adolescents | Adults | The Elderly | Total Sample | |||
---|---|---|---|---|---|---|---|
I (≤10) | II (11–14) | III (15–17) | IV (18–39) | V (40–59) | VI (≥60) | ||
N = 173 | N = 163 | N = 141 | N = 1216 | N = 1451 | N = 380 | N = 3524 | |
N (%) | |||||||
The gluten-free diet strongly limits my food choices | |||||||
I disagree/quite disagree | 45 (26) | 45 (28) | 32 (23) | 330 (27) | 431 (30) | 117 (31) | 1000 (28) |
Neither agree nor disagree | 47 (27) | 45 (28) | 35 (25) | 352 (29) | 361 (25) | 120 (32) | 960 (27) |
I quite agree/agree | 41 (47) | 73 (45) | 74 (52) | 534 (44) | 659 (45) | 143 (38) | 1564 (44) |
My food choices are driven by worries about my health status | |||||||
Never | 44 (25) | 68 (42) | 47 (33) | 403 (33) | 500 (34) | 137 (36) | 1199 (34) |
Occasionally | 63 (36) | 51 (31) | 44 (31) | 391 (32) | 494 (34) | 132 (35) | 1175 (33) |
Frequently | 41 (24) | 26 816) | 31 (22) | 267 (22) | 267 (18) | 67 (18) | 699 (20) |
Always | 25 (14) | 18 (11) | 19 (14) | 155 (13) | 190 (13) | 44 (11) | 451 (13) |
I think my mood sways my food choices | |||||||
Never | 75 (43) ** | 78 (48) ** | 76 (54) ** | 487 (40) | 577 (40) | 187 (49) | 1480 (42) |
Occasionally | 68 (39) ** | 59 (36) ** | 32 (23) ** | 345 (28) | 444 (31) | 119 (31) | 1067 (30) |
Frequently | 21 (12) ** | 19 (12) ** | 21 (15) ** | 253 (21) | 287 (20) | 52 (14) | 653 (18) |
Always | 9 (5) ** | 7 (4) ** | 12 (8) ** | 131 (11) | 147 (10) | 22 (6) | 324 (9) |
In the last year, how often did you restrain your food consumption (e.g.,: I do not find/like the gluten-free alternative) | |||||||
Never | 44 (25) | 37 (23) | 40 (28) | 264 (22) * | 322 (22) * | 104 (27) | 811 (23) |
Occasionally | 60 (35) | 81 (50) | 63 (45) | 463 (38) * | 627 (43) * | 161 (42) | 1455 (41) |
Frequently | 53 (31) | 30 (18) | 30 (21) | 406 (33) * | 381 (26) * | 74 (20) | 974 (28) |
Always | 16 (9) | 15 (9) | 8 (6) | 83 (7) * | 121 (8) * | 41 (11) | 284 (8) |
Thinking of food usually worries me | |||||||
Never | 66 (38) | 80 (49) | 58 (41) | 540 (44) * | 789 (54) * | 230 (60) | 1763 (50) |
Occasionally | 74 (43) | 61 (37) | 63 (44) | 449 (37) * | 514 (35) * | 121 (32) | 1282 (36) |
Frequently | 28 (16) | 17 (10) | 13 (9) | 164 (14) * | 109 (8) * | 24 (6) | 355 (10) |
Always | 5 (3) | 5 (3) | 7 (5) | 63 (5) * | 39 (3) * | 5 (1) | 124 (4) |
Having to pay attention to what to eat is a problem that worries me for more than an hour a day | |||||||
Never | 69 (40) | 97 (60) | 82 (58) | 684 (56) * | 902 (62) * | 268 (70) | 2102 (60) |
Occasionally | 76 (44) | 39 (24) | 42 (30) | 327 (27) * | 365 (25) * | 76 (20) | 925 (26) |
Frequently | 23 (13) | 18 (11) | 13 (9) | 134 (11) * | 127 (9) * | 25 (7) | 340 (10) |
Always | 5 (3) | 9 (6) | 4 (3) | 71 (6) * | 57 (4) * | 11 (3) | 157 (4) |
When I go to a grocery shop, I am confused | |||||||
Never | 84 (51) | 106 (65) | 91 (64) | 810 (67) * | 1062 (73) * | 312 (82) | 2470 (70) |
Occasionally | 77 (44) | 45 (28) | 42 (30) | 328 (27) * | 333 (23) * | 60 (16) | 885 (25) |
Frequently | 7 (4) | 7 (4) | 8 (6) | 63 (5) * | 46 (3) * | 7 (2) | 138 (4) |
Always | 0 (0) | 5 (3) | 0 (0) | 15 (1) * | 10 (1) * | 1 (0) | 31 (1) |
I spend a great deal of time thinking about where and what to eat | |||||||
I disagree/quite disagree | 75 (43) | 86 (53) | 82 (58) | 510 (42) * | 852 (59) * | 269 (71) | 1874 (53) |
Neither agree nor disagree | 42 (24) | 36 (21) | 29 (21) | 243 (20) * | 284 (20) * | 46 (12) | 680 (19) |
I quite agree/agree | 56 (32) | 41(25) | 30 (21) | 463 (38) * | 315 (22) * | 65 (17) | 970 (28) |
I eat at home because I feel safer | |||||||
I disagree/quite disagree | 32 (18) | 49 (30) | 48 (34) | 357 (29) | 453 (31) | 128 (34) | 1067 (30) |
Neither agree nor disagree | 39 (22) | 30 (18) | 31 (22) | 371 (22) | 321 (22) | 64 (17) | 756 (21) |
I quite agree/agree | 102 (59) | 84 (51) | 62 (44) | 588 (48) | 677 (47) | 188 (50) | 1701 (48) |
It is difficult to find restaurants that offer gluten-free food | |||||||
I disagree/quite disagree | 37 (21) | 40 (24) | 44 (31) | 390 (32) * | 469 (32) * | 128 (34) | 1108 (31) |
Neither agree nor disagree | 43 (25) | 40 (24) | 40 (28) | 358 (29) * | 449 (31) * | 130 (34) | 1060 (30) |
I quite agree/agree | 93 (54) | 83 (51) | 57 (40) | 468 (38) * | 533 (37) * | 123 (32) | 1356 (38) |
In the last year, how often did you eat in restaurants/pizzerias without asking for information on the served food? | |||||||
Never | 147 (85) | 128 (78) | 117 (83) | 885 (73) * | 1107 (76) * | 324 (85) | 2708 (77) |
Occasionally | 15 (9) | 23 (14) | 17 (12) | 211 (17) * | 246 (17) * | 41 (11) | 553 (16) |
Frequently | 8 (5) | 5 (3) | 7 (5) | 74 (6) * | 62 (4) * | 7 (2) | 163 (5) |
Always | 3 (2) | 7 (4) | 0 (0) | 46 (4) * | 36 (2) * | 8 (2) | 100 (3) |
Did you follow a specific diet other than the gluten-free diet? | |||||||
Yes | 13 (8) | 5 (3) | 11 (8) | 208 (17) | 272 (19) | 88 (23) | 597 (17) |
No | 160 (93) | 158 (97) | 130 (92) | 1008 (83) | 1179 (81) | 292 (77) | 2927 (83) |
If you were not a celiac patient, would you have the same food habits? | |||||||
Yes | 119 (69) | 119 (73) | 103 (73) | 933 (77) | 1098 (76) | 304 (80) | 2676 (76) |
No | 54 (31) | 44 (27) | 38 (27) | 283 (23) | 353 (24) | 76 (20) | 848 (24) |
Celiac disease stops me from following another diet (for example, vegan diet) that I followed in the past/I would have followed otherwise | |||||||
I disagree/quite disagree | 142 (82) | 134 (82) | 118 (84) | 980 (81) * | 1246 (86) * | 315 (83) | 2935 (83) |
Neither agree nor disagree | 22 (13) | 14 (9) | 12 (8) | 101 (8) * | 89 (6) * | 23 (6) | 261 (7) |
I quite agree/agree | 9 (5) | 15 (9) | 11 (8) | 135 (11) * | 116 (8) * | 42 (11) | 328 (9) |
| |||||||
In the last year, how often did you turn down an invitation for fear of eating unsafe food? | |||||||
Never | 39 (23) | 56 (34) | 43 (31) | 358 (29) * | 484 (33) * | 114 (30) | 1094 (31) |
Occasionally | 84 (49) | 58 (36) | 63 (45) | 495 (41) * | 605 (42) * | 153 (40) | 1458 (41) |
Frequently | 44 (25) | 39 (24) | 26 (18) | 304 (25) * | 281 (19) * | 86 (23) | 780 (22) |
Always | 6 (4) | 10 (6) | 9 (6) | 59 (5) * | 81 (6) * | 27 (7) | 192 (5) |
I avoid social situations (parties, happy hours, etc.) where I might not control served food | |||||||
I disagree/quite disagree | 69 (40) | 82 (50) | 63 (45) | 575 (47) | 618 (43) | 123 (32) | 1530 (43) |
Neither agree nor disagree | 50 (29) | 47 (29) | 37 (26) | 262 (22) | 338 (23) | 75 (20) | 809 (23) |
I quite agree/agree | 54 (31) | 34 (21) | 41 (29) | 379 (31) | 495 (34) | 182 (48) | 1185 (34) |
Celiac disease makes my interpersonal relations challenging | |||||||
I disagree/quite disagree | 93 (54) | 88 (54) | 73 (52) | 624 (51) | 810 (56) | 231 (61) | 1919 (54) |
Neither agree nor disagree | 40 (23) | 33 (20) | 33 (23) | 260 (21) | 278 (19) | 61 (16) | 705 (20) |
I quite agree/agree | 40 (23) | 42 (26) | 35 (25) | 332 (27) | 363 (25) | 88 (23) | 900 (26) |
I go out with friends less frequently since I discovered that I have celiac disease | |||||||
I disagree/quite disagree | 78 (45) ** | 83 (51) ** | 88 (62) ** | 732 (60) * | 747 (52) * | 198 (52) | 1926 (55) |
Neither agree nor disagree | 46 (27) ** | 42 (26) ** | 20 (14) ** | 210 (17) * | 248 (17) * | 61 (16) | 627 (18) |
I quite agree/agree | 49 (28) ** | 38 (23) ** | 33 (23) ** | 274 (22) * | 456 (31) * | 121 (32) | 971 (28) |
My diet affects the occupation I have chosen/I want | |||||||
I disagree/quite disagree | 134 (78) | 111 (68) | 98 (70) | 945 (78) * | 1192 (82) * | 309 (81) | 2789 (79) |
Neither agree nor disagree | 26 (15) | 32 (20) | 19 (14) | 126 (10) * | 135 (9) * | 32 (8) | 370 (10) |
I quite agree/agree | 13 (8) | 20 (12) | 24 (17) | 145 (12) * | 124 (8) * | 39 (10) | 365 (10) |
Children and Adolescents | Adults | The Elderly | Total Sample | ||||
---|---|---|---|---|---|---|---|
I (≤10) | II (11–14) | III (15–17) | IV (18–39) | V (40–59) | VI (≥60) | ||
N = 173 | N = 163 | N = 141 | N = 1216 | N = 1451 | N = 380 | N = 3524 | |
N (%) | |||||||
How often are you tempted to transgress the gluten-free diet? | |||||||
I never think about it | 89 (51) | 74 (45) | 66 (47) | 652 (54) * | 897 (62) * | 263 (69) | 2041 (58) |
Occasionally | 74 (43) | 77 (47) | 67 (48) | 489 (40) * | 496 (34) * | 108 (28) | 1311 (37) |
Frequently | 8 (5) | 12 (7) | 8 (6) | 62 (5) * | 47 (3) * | 6 (2) | 143 (4) |
Always | 2 (1) | 0 (0) | 0 (0) | 13 (1) * | 11 (1) * | 3 (1) | 29 (1) |
In the last month, did you transgress the gluten-free diet? | |||||||
Yes | 11 (6) | 14 (9) | 8 (6) | 132 (11) | 136 (9) | 25 (7) | 326 (9) |
No | 162 (94) | 149 (91) | 133 (94) | 1084 (89) | 1315 (91) | 355 (93) | 3198 (91) |
In the last month, how often did you transgress the gluten-free diet? | |||||||
Yes, once | 8 (5) | 9 (6) | 6 (4) | 76 (6) | 85 (6) | 18 (5) | 202 (6) |
Yes, sometimes | 3 (2) | 5 (3) | 2 (1) | 43 (4) | 43 (3) | 7 (2) | 103 (3) |
Yes, many times | 0 (0) | 0 (0) | 0 (0) | 13 (1) | 8 (1) | 0 (0) | 21 (1) |
I did not transgress the gluten-free diet in the last month | 162 (94) | 149 (91) | 133 (94) | 1084 (89) | 1315 (91) | 355 (93) | 3198 (91) |
When you transgressed, how did you feel? | |||||||
I felt bad because I felt guilty | 5 (3) | 5 (3) | 2 (1) | 53 (4) | 52 (4) | 7 (2) | 124 (4) |
It was not a problem | 4 (2) | 7 (4) | 4 (3) | 72 (6) | 69 (5) | 14 (4) | 170 (5) |
I felt good because I was gratified | 2 (1) | 2 (1) | 2 (1) | 7 (1) | 15 (1) | 4 (1) | 32 (1) |
I did not transgress the gluten-free diet in the last month | 162 (94) | 149 (91) | 133 (94) | 1084 (89) | 1315 (91) | 355 (93) | 3198 (91) |
The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
Fiori, F.; Bravo, G.; Neuhold, S.; Bartolone, G.; Pilo, C.; Parpinel, M.; Pellegrini, N. Compliance and Attitudes towards the Gluten-Free Diet in Celiac Patients in Italy: What Has Changed after a Decade? Nutrients 2024 , 16 , 2493. https://doi.org/10.3390/nu16152493
Fiori F, Bravo G, Neuhold S, Bartolone G, Pilo C, Parpinel M, Pellegrini N. Compliance and Attitudes towards the Gluten-Free Diet in Celiac Patients in Italy: What Has Changed after a Decade? Nutrients . 2024; 16(15):2493. https://doi.org/10.3390/nu16152493
Fiori, Federica, Giulia Bravo, Susanna Neuhold, Giovanni Bartolone, Caterina Pilo, Maria Parpinel, and Nicoletta Pellegrini. 2024. "Compliance and Attitudes towards the Gluten-Free Diet in Celiac Patients in Italy: What Has Changed after a Decade?" Nutrients 16, no. 15: 2493. https://doi.org/10.3390/nu16152493
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Dalia el khoury.
1 Department of Family Relations & Applied Nutrition, University of Guelph, 50 Stone Road East, Guelph, ON N1G 2W1, Canada; ac.hpleugou@druoflab
Iris j. joye.
2 Department of Food Science, University of Guelph, 50 Stone Road East, Guelph, ON N1G 2W1, Canada; ac.hpleugou@eyoji
Consumers, food manufacturers and health professionals are uniquely influenced by the growing popularity of the gluten-free diet. Consumer expectations have urged the food industry to continuously adjust and improve the formulations and processing techniques used in gluten-free product manufacturing. Health experts have been interested in the nutritional adequacy of the diet, as well as its effectiveness in managing gluten-related disorders and other conditions. In this review, we aim to provide a clear picture of the current motivations behind the use of gluten-free diets, as well as the technological and nutritional challenges of the diet as a whole. Alternative starches and flours, hydrocolloids, and fiber sources were found to play a complex role in mimicking the functional and sensory effects of gluten in gluten-free products. However, the quality of gluten-free alternatives is often still inferior to the gluten-containing products. Furthermore, the gluten-free diet has demonstrated benefits in managing some gluten-related disorders, though nutritional imbalances have been reported. As there is limited evidence supporting the use of the gluten-free diet beyond its role in managing gluten-related disorders, consumers are urged to be mindful of the sensorial limitations and nutritional inadequacies of the diet despite ongoing strategies to improve them.
In cereal processing, gluten refers to the combined gliadin (prolamin) and glutenin (glutelin) fraction of wheat [ 1 ]. The gluten protein fraction displays unique structure building properties that are used in food processing. These structure building properties are also reflected in the terminology, as gluten is essentially the Latin translation of “glue” [ 2 ]. Gluten in wheat flour forms a three-dimensional protein network upon proper hydration and mixing. These network-forming properties are utilized in baking applications to create viscoelastic dough matrices. Besides network formation, gluten functionality in food includes water binding and viscosity yielding, which make gluten a widely used food additive [ 3 ].
Gluten is also a nutritional term used to refer to certain cereal prolamins, i.e., the ethanol-soluble proteins of wheat, rye, barley, their cross bred grains, and possibly oats [ 1 , 4 ]. These prolamins are very important in the context of coeliac disease (CD), non-coeliac gluten sensitivity (NCGS), gluten ataxia (GA) and dermatitis herpetiformis (DH). For people suffering from CD, NCGS, GA, and DH, the only effective “treatment” to date consists of eliminating gluten completely and life-long out of their diet. In what follows, general information on gluten-free products and the diet is provided. Challenges when formulating gluten-free products, consumers’ motivations, knowledge and attitudes, as well as the nutritional and therapeutic implications of the gluten-free diet, are also further elaborated on.
Global market data indicate that gluten-free product sales are forecasted to increase by a compound annual growth rate of 10.4% between 2015 to 2020 [ 5 ]. As the clinical application and popularity of the gluten-free diet escalate, consumer demands righteously continue to influence the food market and labelling standards of gluten-free products. In 2013, the European Union Regulation 609/2013 set out rules on compositional and labelling requirements for gluten-free products [ 6 ]. These guidelines ensure that people who are intolerant to gluten are adequately informed of the difference between foods that are naturally free of gluten and foods that are produced, prepared and/or processed in order to reduce their gluten content [ 6 ]. In the same year, the Food and Drug Administration ruled that products labelled “gluten-free” cannot surpass a threshold of 20 parts per million, although the official compliance date was set for 2014 [ 7 ]. This guideline helps gluten-wary customers to navigate the current market and protect themselves from consuming products that may exacerbate their symptoms and/or activate immune-mediated mucosal damage even in the absence of symptoms. The gluten-free diet encompasses food groups that are naturally devoid of gluten, such as fresh fruit, vegetables, seafood, meat, poultry, legumes, nuts, and most dairy products [ 8 ]. However, some of these products may also contain “hidden” gluten. Hence, product labels and ingredient lists need to be carefully reviewed. For the traditional gluten-containing foods, such as bakery products, there is currently a wide variety of gluten-free options available that use gluten-free cereals and pseudocereals, such as rice, corn, quinoa, millet, and amaranth as their base ingredients [ 9 ].
The unique properties of wheat flour can primarily be ascribed to its gluten fraction. Gluten has unequalled network forming properties, which are important for products that are made with hard wheat varieties, and typically involve an intermediate cohesive dough stage during their production process [ 10 ]. Examples of such products are bread, pasta, and pretzels. Gliadin is the 70% ethanol-soluble protein fraction of wheat flour and is essentially present in wheat grain extracts as monomeric proteins [ 1 ]. Glutenin, on the other hand, is the protein fraction that cannot be extracted with water, diluted salt solutions, and 70% ethanol, and is often referred to as the polymeric gluten [ 1 ]. Both gliadin and glutenin are important for network formation and the quality of the final food product. Although the exact structure and interactions of this protein network are still under debate, it is widely accepted that gliadin has a viscosity-increasing effect, whilst the elastic properties of the network and wheat flour dough predominantly stem from the glutenin fraction [ 1 , 10 ]. For soft wheat products such as cakes and cookies, the gluten network-forming properties are not as crucial, but gluten is believed to nevertheless contribute to final product structure and texture [ 11 , 12 ]. In what follows, focus will be laid on gluten-free bread products as bread is an important staple food and its quality heavily relies on gluten properties and functionality. Hence, bread is one of the more challenging food products when making gluten-free alternatives.
Bread baking without gluten essentially removes the most crucial ingredient for product structure and quality. This presents a major challenge to bakers and cereal researchers. In addition, gluten-free products are often consumed by people who have had the opportunity to try and enjoy gluten-containing foods. These consumers, therefore, already have product expectations in terms of texture, structure, flavor and overall quality imprinted. Besides designing gluten-free bread products in such way that they closely mimic the texture of gluten-containing bread products, they also need to have the same sensory profile and shelf life [ 13 ]. One possible strategy that has been identified for matching the volatile flavor of wheat-containing products is combining proline and glucose in the gluten-free product recipe, as these are precursors of the volatile components found in wheat-based bread products [ 14 ]. In what follows, different ingredient and processing strategies will be reviewed, with a focus on texture, structure, and volume of gluten-free bread products. Most of the research done on gluten-free bread formulations focused on the effect of an extra ingredient or a (partial) replacement of one of the base ingredients with a promising other compound. The product against which these new formulations have been tested in terms of quality is almost always the gluten-free product, which does not contain the extra ingredient or the replacement compound. However, as stated above, the real goal of formulating high quality gluten-free products is to achieve the same product characteristics and quality of a regular gluten-containing bread. Therefore, it would be more useful to compare the obtained gluten-free “dough” and bread characteristics with those of an actual similar gluten-containing system.
Imitating the cohesiveness and elasticity of a gluten-containing dough was attempted using a wide range of alternative raw ingredients and/or additives. Gluten-replacing ingredients include starches, gluten-free flours of cereals/pseudocereals, hydrocolloids, and proteins. Minor ingredients that are added to help build and strengthen gluten-free dough and bread structure are enzymes and emulsifiers. Combinations of these are often used to improve the gluten-free product’s rheological characteristics. Some researchers have also invested time and effort in breeding low-gliadin wheat varieties. In general, the recipe alterations for gluten-free bread unfortunately often also lead to an increased product price [ 15 ].
Starch naturally occurs in wheat-based products, as 80% of wheat flour consists of starch. Although starch predominantly acts as a quasi-inert filler material during the initial phases of breadmaking, (part of the) starch gelatinizes upon baking. As a result, starch plays a key role in the structure setting of bread. Hence, the elimination of wheat flour also removes starch from the product recipe. Starches of alternative (gluten-free) sources, such as cassava, tapioca, corn, potato, bean, and rice, have been added to gluten-free recipes [ 16 , 17 , 18 , 19 ]. In recent years, a gluten-free wheat starch was also developed, and has been tested in combination with rice flour and corn starch for the production of gluten-free products [ 20 , 21 ]. In these studies, it was postulated that wheat starch breads were generally better accepted and had an improved loaf volume compared to the corn starch alternative. However, the gluten-freeness of wheat starch preparations is a controversial theme. Starch naturally displays wide variability in terms of morphology, gelatinization behavior, and viscosity yielding. The importance of starch granule morphology was studied using rice starches. In this study, it was found that round starch granules were preferred over polygonal starch structures for product quality [ 22 ]. The underlying reasons for this could, however, expand beyond morphology, and be governed by a rapid gelatinization and good viscosity retention after gelatinization. High viscosity of the batter is essential to build structure in gluten-free food products [ 22 ]. In some cases, the natural variability of starch is not sufficient, and starches are then modified to display a specific characteristic. The use of modified starches has also been investigated in the framework of gluten-free products. Acetylated distarch adipate and hydroxypropyl distarch phosphate were found to increase bread loaf volume, produce a more elastic bread crumb, and result in a slight decrease in hardness and chewiness of the bread crumb [ 23 ].
In addition to starch, gluten-free flours have also been used as base ingredients ( Table 1 ). Examples are flours of pseudocereals, such as amaranth, buckwheat, chia and quinoa, but also cereal flours that do not contain gluten, such as sorghum, rice, corn, teff, and millet. The use of oat flour is controversial, but previous studies have shown that a moderate consumption of oats does not trigger any adverse health effects in most CD patients [ 24 ]. However, the oats that are used need to be certified gluten-free. Oats often become contaminated with gluten-containing cereals during harvest, and the separation of these gluten-containing grains and oats is not that straightforward. Besides cereal and pseudocereal flours, legume (chickpea, pea, carob germ, carob, marama bean, and soy) and chestnut flours have also been successfully used in gluten-free bread applications [ 25 , 26 , 27 , 28 , 29 , 30 ]. The properties of the used gluten-free flours, such as particle size, starch damage, and fiber content, significantly impact the resulting bread characteristics [ 31 ]. This complicates the comparison of the outcomes of different studies on the performance of different ingredients in gluten-free products.
Alternative flours used in gluten-free product formulations with the main quality effects.
Formulation | Main Conclusions | References |
---|---|---|
Base of corn starch with | Replacement of emulsifier and shortening by the chickpea protein and tiger nut lipids: the combination of both maintains baking characteristics of bread loaves with eliminated shortening and emulsifier. | [ ] |
Base of rice flour, potato, tapioca and cassava starch and xanthan gum with | Amaranth and quinoa flour do not affect texture and volume, and final bread loaves are considered ‘moderately acceptable’ in sensory trials. | [ , ] |
Base of rice flour and xanthan gum with | Replacement of potato starch with buckwheat and quinoa flour increases bread volume and softens crumb. Amaranth flour only decreases the crumb firmness. None of the three pseudocereal flours adversely affects the sensory properties. | [ ] |
Base of corn starch with | Acceptable bread loaves are made with regard to volume and crumb structure. | [ ] |
Base of rice flour, maize starch and HPMC with | Bread aroma is enhanced and visual appearance is good. Buckwheat-based sourdough has a bitter taste. | [ ] |
blends | Soy flour alters the textural properties and color of the bread. | [ ] |
Base of rice flour, shortening, gum blend (xanthan, guar and locust bean gum) and DATEM with partial replacement of the rice flour with | Partial replacement of rice flour with chestnut flour results in lower hardness, increased specific volume, and better color and sensory properties. High chestnut flour recipes had low quality. | [ ] |
Base of rice and corn flour, corn starch, HPMC with gradual replacement of rice/corn flour by | Quinoa flour increases loaf volume and yields a more homogeneous crumb structure, whilst not affecting product taste. | [ ] |
Base of | Only oats bread is somewhat comparable to wheat bread. All other loaves are of inferior quality in terms of loaf volume, physical crumb texture, shelf life and aroma profile. | [ ] |
Base of commercial gluten-free mixtures including corn starch, psyllium fiber, guar gum or corn starch, tapioca starch, potato starch and rice flour, HPMC with partial replacement of the flours by | Dehulled buckwheat flour improved the baking performance of commercial mixtures, whilst puffed buckwheat flour had a clear effect on water availability and the interaction between the matrix biopolymers. | [ ] |
Base of corn starch and xanthan gum with | Carob germ flour loaves have the lowest volume, whilst chickpea flour yields the highest volume and the softest crumb. | [ ] |
Base of with cassava starch | Marama bean and cassava starch produce strong dough, similar to wheat flour dough that can hold gas in its structure. | [ ] |
Base of potato starch and rice flour with | Chia flour does not adversely affect loaf volume and crumb firmness. | [ ] |
Base of rice flour, gluten-free wheat starch, albumin, HPMC with | Green plantain flour produces good volume bread loaves, and soft crumb firmness breads having a regular porosity. | [ ] |
Base of rice flour and corn starch with | Sensory and nutritional properties are improved with acorn supplementation, whilst the specific volume is decreased, and the crumb hardness is increased. | [ ] |
Base of corn starch, HPMC with | Carob germ flour is a good alternative to wheat flour to produce viscoelastic dough and high quality gluten-free bread. | [ ] |
DATEM, Diacetyl Tartaric Esters of Monoglycerides; HPMC, hydroxy propyl methyl cellulose.
One of the additives often used as a processing aid and/or quality-improving minor ingredient, is dietary fiber ( Table 2 ). The addition of dietary fiber does not only compensate for the nutritional loss of dietary fiber when excluding wheat flour or whole meal from the product recipe, but it also introduces an ingredient with excellent water-binding, viscosity-increasing, and even gel-forming capacities. As a result, product thickening and texturizing characteristics are re-introduced in the gluten-free process. Examples of dietary fiber that were used in gluten-free products are β-glucan, inulin, oligofructose, linseed mucilage, apple pomace, carob fiber, bamboo fiber, polydextrose, and resistant starch [ 32 , 33 , 34 , 35 , 36 , 37 ]. Fiber structure and molecular weight play a crucial role in gluten-free bread quality [ 38 ]. An alternative way of introducing fiber in the (sourdough) bread recipe was explored by Wolter and colleagues [ 39 ]: exopolysaccharide (essentially a dextran) production by bacteria, such as Weissella cibaria , was found to increase dough strength [ 39 ].
Hydrocolloids used in gluten-free product formulations with the main quality effects.
Formulation | Main Conclusions | References |
---|---|---|
Zein-starch base with and high β-glucan oat bran | Hydrocolloid and β-glucan improve bread volume and aid zein to more closely resemble gluten in terms of structural and rheological properties. | [ ] |
Base of soybean flour and corn starch with and emulsifiers | HPMC increases volume and softness more than xanthan gum, but xanthan gum gives a better crumb structure. | [ ] |
Base of teff, buckwheat, corn or rice flour with | Xanthan gum increases the crumb hardness of teff and buckwheat breads, whilst corn breads become softer. HPMC increases loaf volume of teff and corn breads, while xanthan adversely affects the loaf volumes in all different recipes. | [ ] |
Base of rice flour, corn starch and sodium caseinate with and oats β-glucan | Except for xanthan, all gums result in a loaf volume increase. | [ ] |
Base of potato flour with | Gums yield loaves with higher specific volume and reduced hardness. | [ ] |
Base of rice flour, corn starch, soy flour with and transglutaminase | Guar gum increases the specific volume and decreases crumb hardness, while transglutaminase increases crumb hardness but yields a good texture. | [ ] |
Base of chestnut and chia flour with | All hydrocolloids increase “dough” elasticity. | [ ] |
Base of rice flour, corn starch and sodium caseinate with | Carboxymethyl cellulose increases bread volume and sensorial properties. | [ ] |
Base of broken rice berry flour with | Hydrocolloids increase loaf volume, texture, microstructure and sensory properties. | [ ] |
Base of tapioca starch, precooked corn flour with | Guar gum and HPMC reduce dough stickiness and soften the crumb. | [ ] |
Base of rice and corn flour and corn starch with | Both gums improve crumb color and porosity, cress seed gum triggers the formation of more regular and solid pores. | [ ] |
HPMC, hydroxy propyl methyl cellulose.
Hydrocolloids ( Table 3 ) are essentially polymers that display thickening properties through the binding of water. As a result, the viscosity of the gluten-free “dough/batter” is enhanced and gas is better retained in the “dough” matrix, which increases bread loaf volume and improves loaf crumb structure. The most popular hydrocolloids are xanthan gum and hydroxypropyl methyl cellulose (HPMC) [ 40 , 41 , 42 , 43 , 44 ]. Other gums that have been studied are pectin, guar gum, locust bean gum, agarose, tragacanth gum, cress seed gum, and carboxymethyl cellulose [ 26 , 40 , 45 , 46 , 47 , 48 , 49 ].
Fiber (sources) used in gluten-free product formulations with the main quality effects.
Formulation | Main Conclusions | References |
---|---|---|
Base of corn flour, corn starch, dried eggs and carrageenan with and glucose oxidase | Addition of dietary fiber alters dough cohesion and starch pasting properties. (Glucose oxidase increased the specific loaf volume). | [ ] |
Base of corn starch, rice flour, starch and protein, HPMC, locust bean gum, guar gum and alfa-amylase with | Both psyllium and sugar beet fiber improve dough workability. Psyllium fiber is superior in its film forming ability and has an antistaling effect due to higher water binding capacity. | [ ] |
Base of rice and corn flour, corn starch, HPMC with | Quinoa bran increases carbon dioxide production, while the gas retention is reduced. Bread volume can be increased without adversely affecting the taste. | [ ] |
Base of corn and potato starch, pectin, guar gum with replacement of pectin and guar gum with | Replacement of pectin or guar gum with linseed mucilage improves the sensory acceptance and does not affect texture and bread staling. | [ ] |
Base of rice flour, corn starch and HPMC with | Soluble fiber decreases dough consistency, increases bread volume and decreases crumb hardness. The fine insoluble fibers also increase bread volume and decrease the crumb hardness, the coarse insoluble fibers decrease bread volume and increase hardness. In general, soluble fiber increases the structural stability, while insoluble fiber disrupts the structure. | [ ] |
Base of rice flour, HPMC with | Low molecular weight β-glucan develops a gel network structure, whilst high molecular weight β-glucan predominantly increases viscosity. | [ ] |
Base of white rice, corn and buckwheat flour with | Carob fiber improves volume, color and crumb texture whilst increasing the antioxidant activity of the breads. | [ ] |
Base of rice flour, cassava starch, full-fat active soy flour with | Insoluble fiber increases dough firmness and decreases loaf volume, whilst soluble fiber decreases dough firmness. | [ ] |
Base of corn and potato starch, guar gum and pectin with | Inulin addition leads to an increased loaf volume and reduces crumb hardness, whilst the internal structure is more polydisperse. | [ ] |
Gluten is essentially a protein, and it is logical to explore alternative proteins to make up for the loss of gluten functionality in gluten-free products. In the absence of other structure-forming molecules (such as gums), the structure-forming capacity of proteins was explored. Non-gluten proteins have largely varying effects on dough rheology, as well as final bread characteristics and appearance. In the study by Ziobro and colleagues [ 50 ], the most promising protein in terms of volume increase was albumin, whilst pea and lupine proteins were preferred over soy protein, sensory-wise. Examples of proteins used are legume, egg, dairy, and non-gluten cereal proteins [ 13 , 43 , 51 , 52 , 53 , 54 ]. These alternative proteins/protein sources often also display a better amino acid profile than gluten, which is deficient in essential amino acids such as lysine, and hence, cannot be considered as a “balanced” protein. As a result, these alternative proteins are preferred over gluten, from a nutritional perspective. These proteins also lead to a well-appreciated sensory pallet, as they are involved in Maillard browning reactions, which do not only improve product color but also flavor (compared to, e.g., hydrocolloid-based gluten-free products). However, the increased darkness of the bread may not always be perceived as exceptionally desirable.
Enzymes, as processing aids, are often chosen based on their potential to induce the formation of crosslinks in between the polymers present in the product recipe, thus triggering the formation of a network, similar to what would be the case if gluten was present in the recipe. Examples of studied enzymes are transglutaminase, glucose oxidase, tyrosinase, and laccase [ 55 , 56 , 57 ]. In addition, proteolysis, through the addition of peptidases, has also been explored. These enzymes, similar to what glutathione addition would trigger in bread recipes, lead to depolymerization [ 58 ]. In rice flour, for example, it has been shown that the degradation of the high molecular weight protein fraction of rice is needed to allow small protein aggregates to crosslink through disulfide bonds. This process helps to ensure better rheological properties, improved gas retention during baking, and increased overall product quality [ 59 , 60 ]. Starch hydrolyzing enzymes such as alfa-amylase and amyloglycosidase, were added in some product recipes as well [ 45 ]. One of the reasons for alfa-amylase addition is the in situ production of sugars to sustain yeast activity [ 61 ].
In gluten-free bread products, emulsifiers such as diacetyl tartaric esters of monoglycerides [ 40 ], mono- and diacylglycerol [ 41 ], lecithin [ 62 ] and sodium stearoyl-2-lactylate [ 63 ] are used to establish better interactions between the different ingredients. Emulsifiers may also play a role in stabilization of interfaces such as water/air or water/lipid interfaces. The former interfaces are especially important to the fine crumb structure of gluten-free bread loaves. Some proteins are known to display good interface stabilizing properties as well.
In addition to rational ingredient and/or additive choice, different processing paths have also been explored to alter the gluten content of gluten-containing flours and improve rheological properties of gluten-free products, particularly gluten-free dough.
Gluten-containing flours have been used in combination with protein hydrolysis strategies or sourdough fermentation to produce gluten-free or so-called ‘gluten-reduced’ bread products. Both the aforementioned technologies are believed to eliminate, or at least significantly reduce, gluten levels in dough. Detoxification of gluten through proteolysis targeting proline and glutamine peptide bonds has been explored recently [ 81 ]. These proteolytic enzymes essentially cleave those peptide bonds that human peptidases cannot affect. The hydrolysis products should be broken down to less than nine amino acids in order not to trigger any reaction in the gastrointestinal tract of people suffering from CD. Similarly, using sprouted grain to formulate products safe for coeliac patients is based on extensive protein hydrolysis, reducing the immune response to the hydrolyzed gluten in the product. However, in the latter case, sprouting conditions need to be tightly controlled and monitored, not only to ensure proper gluten hydrolysis, but also to retain some wheat flour functionality for baking applications. Sourdough fermentation is another strategy which is believed to reduce the level of immunoresponse-triggering gluten. In this framework, the right selection of lactic acid bacteria that display peptidase activity hydrolyzing the appropriate peptide bonds is crucial [ 82 ].
In addition to modifying wheat flour, the gluten-free flours can also be processed in a particular way to change their rheological behavior in dough-like systems. A myriad of different strategies has been explored:
The origin of the gluten-free diet dates back to 1941, when it made its debut in a report on the dietary treatment of CD by paediatrician and scientist Willem Karl Dicke [ 90 ]. Today, the diet continues to be applied and investigated for a variety of additional health purposes, including the management of NCGS, irritable bowel syndrome (IBS), diabetes, DH, inflammation and obesity.
Research interest in the gluten-free movement, in addition to the clinical and practical uses of the diet, has been growing for many years. In what follows, the current trends, attitudes, and knowledge surrounding the gluten-free diet, as well as its nutritional adequacy, will be covered. Furthermore, the implications of the gluten-free diet on gluten-related conditions, diabetes and other autoimmune diseases, as well as weight management, will be explored.
3.1.1. consumers’ motivations.
Over the past decade, surveys have been conducted to better understand the underlying reasons behind rising trends in gluten-free living [ 91 , 92 , 93 , 94 ]. While the clinical diagnosis of CD influences adherence to the gluten-free diet, data indicate that this disease affects less than 1% of the general population [ 95 ]. Studies show that adverse symptoms, as well as individual efforts to manage them without a clinical diagnosis, impact gluten-avoidance behavior [ 92 , 93 ]. Symptomatic self-management strategies involving a gluten-free diet have been supported by ethnographic research findings as well [ 96 ]. In their field-based study, Copelton and Valle [ 96 ] learned that a self-imposed gluten-free diet was common among individuals presenting with unexplained symptoms for extended periods of time. The anticipated length of time, invasiveness, and frustrations associated with diagnostic tests persuade many of these people to eliminate gluten from their diet on their own [ 96 ].
Expected health benefits of the gluten-free diet also influence dietary decisions. Although beneficial effects of the diet have yet to be demonstrated in healthy individuals [ 97 , 98 ], consumer market survey data demonstrate that 33% and 26% of Canadians and Americans, respectively, believe gluten-free products are healthier [ 99 , 100 ]. These trends are consistent with the findings of another study investigating health beliefs surrounding the gluten-free diet [ 101 ]. In Dunn et al.’s [ 101 ] study, 31% of participants believed that gluten avoidance would promote general health, whilst 37% felt that gluten-free products were healthier than their conventional equivalents. Weight loss was reported as another common motivator for adopting the gluten-free diet, especially among younger adult populations [ 94 ]. However, evidence supporting the effectiveness of a gluten-free diet in weight management is limited, as discussed later.
Mixed rationales for following the gluten-free diet may be reflective of society’s limited understanding of gluten and gluten-free food formulation. In the United States, survey findings from 1012 respondents suggested that, although gluten-awareness is high, a substantial proportion of citizens can neither describe what it is, nor determine product sources of it [ 94 ]. These conclusions have been consistent among smaller studies indicating confusion around gluten-free terms [ 102 ], and issues identifying the gluten content of foods [ 103 ]. Dietitians also express concern for clients with CD who struggle to identify safe options due to their limited knowledge about gluten-free foods [ 104 ].
According to Halmos et al.’s [ 105 ] findings, the greatest challenge may lie in identifying gluten-free ingredients rather than gluten-containing ones. This supports the results of an earlier study by Zarkadas et al. [ 106 ], in which 85% of respondents with CD struggled to determine whether or not certain foods were gluten-free ( n = 2681). Lack of knowledge surrounding the diet has implications for both CD patients and the general public. Leffler et al. [ 107 ] reported that individuals commonly overestimate their adherence to the diet. Recent literature points to the fact that an inadequate understanding of the diet may not only lead to an unintentional ingestion of gluten, but also to an over-restriction of certain foods and poor adherence to the diet overall [ 103 , 105 , 108 ].
Research has also explored the most common sources of information on gluten and gluten-free diets. Questionnaire-derived data indicate that popular sources of gluten-free information include the internet, print media sources, cookbooks, coeliac support groups, and other coeliac patients or individuals on the diet [ 92 , 103 , 109 , 110 ]. Compared to dietitians, family physicians were found to be less likely referred to for gluten-free information [ 103 ], and were rated low or lowest with respect to usefulness [ 109 , 110 ].
Individuals follow the gluten-free diet to varying degrees [ 101 , 103 ]. This may be influenced by the attitudes that people share toward the diet. For example, purchasing gluten-free products may have some negative economic consequences, especially for low-income families [ 104 , 109 , 111 ]. In contrast to their gluten-containing counterparts, gluten-free products are considerably more expensive. In fact, gluten-free items were reported to be approximately 200–500% more expensive than the equivalent standard products, depending on the product and shopping location [ 112 , 113 , 114 , 115 ]. Thus, the affordability and long-term sustainability of the diet continues to spark evaluation.
The inadequate availability of high quality gluten-free items is another burden. Many people report challenges locating such products in local grocery stores [ 106 , 111 ], where their availability varies across shopping venues [ 113 , 115 ]. Individuals with lower socioeconomic status, with limited resources available, or those living in remote cities are certainly at a disadvantage.
Other opinions about the diet focus on the sensory aspects of gluten-free products, as well as the impact it has on many personal and social domains. While consumers may be relatively satisfied with the taste and texture of gluten-free products, continued efforts to improve the palatability of these items are still being urged [ 111 ]. Furthermore, individuals avoiding gluten express a lack of confidence when eating outside of the home [ 106 , 116 ], while many find the length of time involved in the at-home preparation of gluten-free options a nuisance [ 110 ].
The nutritional adequacy of the gluten-free diet and associated products has always been a concern for consumers, health care professionals, and the industry. While the gluten-free diet is known to alleviate symptoms and promote gastrointestinal healing in patients with gluten-related disorders, long-term adherence to the diet may have concurrent nutritional limitations.
The nutritional profiles of gluten-free products, as well as the dietary intake patterns of individuals on the diet, were assessed in several studies. According to Do Nascimento et al. [ 117 ], gluten-free products share a common composition of raw ingredients, including corn, rice, soy, cassava, and potato. These ingredients replace gluten-containing grains like wheat, rye, and barley in regular products. Overall, gluten-free items are higher in fat, sugar, and sodium compared to regular products, though compositional trends may vary by product type [ 118 ]. Studies have shown that the total fat content of gluten-free breads is at least twice the amount found in their gluten-containing counterparts, contributing to the improved mouthfeel of these products [ 119 , 120 ]. Conversely, many gluten-free pasta products appear to have significantly higher carbohydrate [ 120 ] and sodium contents [ 121 ]. Gluten-free products are generally inferior sources of protein and dietary fiber as well [ 118 , 119 ]. The glycemic index (GI) of gluten-free products varies based on the type and quality of ingredients used, as well as the food-processing procedures performed to manufacture them [ 121 ]. Since gluten-free items are not typically fortified or enriched in the way that many regular products are, they are also generally lower in folate, iron, niacin, thiamin and riboflavin [ 122 , 123 ]. Efforts have been made to improve the formulation of these products without compromising their sensory appeal [ 64 ].
Studies evaluating the dietary intakes of CD patients on a gluten-free diet have reached similar conclusions. According to Barone et al. [ 124 ], CD patients, compared to healthy adults, consume significantly higher quantities of fat and sugar, and lower amounts of fiber on the gluten-free diet. Similar findings were reported by other researchers reporting food-record and questionnaire-based data from adults and children [ 125 , 126 , 127 , 128 ]. However, it is being questioned whether this trend is reflective of overall dietary habits rather than the gluten-free diet alone [ 125 , 129 ]. For example, while CD patients have been shown to share similar intake patterns of cereal-based products in general with the total population, biscuits and crackers are consumed more frequently among individuals with CD [ 129 ]. According to Valitutti et al. [ 129 ], the popularity of these high GI products may also reflect consumer dissatisfaction with the palatability and availability of other gluten-free carbohydrate options, such as bread. Finally, inadequate intakes of iron, folate, calcium, selenium, magnesium, zinc, niacin, thiamine and riboflavin, as well as vitamins A and D were reported in CD patients following a gluten-free diet [ 125 , 126 , 127 , 130 , 131 , 132 ]. While it could be argued that nutrient deficiencies in CD patients can be largely explained by impaired nutrient absorption resulting from CD-associated intestinal damage, Hallert et al. [ 131 ] argue that this may not entirely be the case. Despite 10 years on the diet and evidence of mucosal recovery, the total plasma homocysteine levels of CD patients were still higher than average, reflecting ongoing deficiencies in folate, vitamin B6, and vitamin B12 [ 131 ].
Dietary evaluations performed on CD patients following a gluten-free diet have largely been based on self or proxy-reported data. As always, it is important to acknowledge the potential for participant bias in these types of studies. Nutritional inadequacies associated with gluten-free diets have been shown to vary by gender and dietary experience [ 132 ]. It is therefore, reasonable to assume that gluten-free diet education, health awareness, and other lifestyle factors may influence food choices, and consequently impact study results. Researchers agree that proper follow-up, dietitian collaboration, and nutrition education are important to ensure that those following the diet are not at any additional health risks [ 120 , 130 , 131 ]. Furthermore, a closer look into fortifying or improving the quality of ingredients in gluten-free products continues to be recommended [ 121 , 130 ].
Media and celebrity endorsements of the gluten-free diet for weight loss have stimulated public interest and driven gluten-free market sales [ 133 ]. Empirical evidence confirming the diet’s effects on weight, however, is still unclear. Not only is there limited literature available on the weight-related implications of the diet for the general public, but inconsistent study findings involving CD patient requires further research in this area. To date, the influence of the gluten-free diet on body mass index (BMI), waist circumference, and lipid profiles has been investigated.
It is possible that gluten avoidance might support weight management in healthy individuals, although the evidence is minimal and largely derived from self-reported data [ 134 ]. It has been speculated that losses in weight associated with the gluten-free diet may, instead, be a reflection of health-conscious behaviors [ 134 ], exaggerated reductions in carbohydrates, and low availability of gluten-free food products [ 133 ]. Therefore, contrary to popular belief, there are currently insufficient grounds to verify that gluten elimination results in weight loss for the general public.
Conversely, studies indicate that strong adherence to the gluten-free diet may actually result in weight gain in many CD patients [ 124 , 135 , 136 , 137 , 138 , 139 ]. For those who are underweight at diagnosis, weight gain on the diet is generally more pronounced and favorable [ 136 , 137 , 138 , 139 ]. That said, some evidence suggests that, without adequate dietary counselling, initially overweight and obese CD patients may be at increased long-term health risks on the gluten-free diet [ 135 , 136 , 140 ]. CD patients may also be more susceptible to developing metabolic syndrome in as early as 1 year on the diet [ 140 ]. Nutritional imbalances and shortcomings of gluten-free products, as described in an earlier section, may contribute to some of these changes. On the other hand, a few studies have revealed that a gluten-free diet may help some overweight and obese CD patients lose weight [ 137 , 138 , 139 ]. Earlier diagnosis, perceived mastery of the diet [ 139 ] and counselling by a dietitian [ 138 ] were shown to influence positive weight outcomes on the diet.
Variations between studies may reflect regional or cultural differences in the type and quality of foods consumed on the gluten-free diet, as well as individual exercise practices [ 136 , 138 ]. To gain a better understanding of the actual effects of gluten-free diet on weight and weight management, consistent efforts should be made across studies to monitor the dietary and physical activity habits of participants, as well as their compliance to the gluten-free diet. Additional research is recommended to ensure that healthy and CD individuals are appropriately informed and advised.
As previously stated, the gluten-free diet is to date, the only effective treatment to a number of gluten-related disorders, including CD, NCGS, GA, and DH. The role of this diet in alleviating the symptoms of these disorders, in part through the modulation of gut microflora, is discussed in the following sections and summarized in Figure 1 .
Summary of the effects of the gluten-free diet on the outcomes of gluten-related disorders.
The introduction of wheat to the human diet prompted a myriad of health conditions derived from the body’s immune response to gluten [ 141 ]. While there is an overlap in their symptomatic presentation, experts have agreed on several distinctions between these gluten-related disorders [ 141 , 142 ]. Wheat can trigger immunologic reactions depending on its route of exposure, by ingestion, inhalation, or skin contact [ 141 ]. When consumed, wheat can act as a food allergen, initiating immunoglobulin E (IgE) or non-IgE mediated reactions [ 143 , 144 ].
CD, DH, and GA are gluten-related autoimmune conditions [ 141 ]. CD is a chronic enteropathy involving a gliadin-specific T-cell response, causing inflammation, villous atrophy, and malabsorption in the small bowel of genetically vulnerable individuals [ 141 , 145 ]. In fact, an association between CD and other gastrointestinal and extraintestinal disorders was reported. DH is a common comorbidity of CD and is often called “coeliac disease of the skin” [ 141 , 145 , 146 ]. It presents as an itchy, blistering rash and is detected by the existence of IgA epidermal transglutaminase antibody complexes in the papillary dermis [ 147 ]. Finally, GA is a condition in which cerebellar damage results from the production of antibodies, following gluten ingestion by susceptible patients [ 141 ]. NCGS, on the other hand, is diagnosed by exclusion criteria; when a reaction to gluten is evident after both a wheat allergy and CD have been ruled out [ 142 , 143 ]. A significant proportion of patients with IBS have a sensitivity to gluten [ 148 ]. Literature indicates that similarities in the clinical presentation of NCGS and IBS generate confusion when evaluating the causes and management options for the manifested symptoms [ 142 , 149 , 150 ].
One way the gluten-free diet can be beneficial to gluten-related disorders is through the management of related symptoms. Researchers agree that strict adherence to the gluten-free diet offers the greatest relief of symptoms for most patients with CD [ 151 , 152 , 153 , 154 , 155 ]. However, symptom recovery rates differ across age and gender [ 151 , 152 , 153 , 154 ]. It is also worth noting that diagnostic delays over 5 years may worsen recovery rates on a gluten-free diet [ 151 ].
Changes in CD-related serum antibody concentrations and mucosal recovery rates, following the gluten-free diet, have also been investigated. Studies provide clear evidence of a decline in tissue-transglutaminase antibodies in CD patients on the diet [ 154 , 156 ], even as early as 3 months following a diagnosis [ 157 ]. Rates of histological normalization on the gluten-free diet are less consistent across studies [ 158 , 159 , 160 , 161 , 162 ]. Longer duration on the diet, however, appears to improve villous recovery [ 160 ]. Adherence to the gluten-free diet, education level, and gluten-free knowledge, as well as age at CD diagnosis, were all shown to influence mucosal recovery [ 158 , 160 , 161 , 163 ].
Although results may take months to years, patients with DH have shown significant improvements and better long-term management of symptoms on a strict gluten-free diet. The diet may also provide a protective effect against the development of lymphoma, which is a potential risk for patients with DH and CD [ 164 ]. According to the literature, the diet can not only help clear skin lesions, but may also heal the small bowel mucosa, decrease IgA and epidermal transglutaminase deposits in the skin, and reduce the need for oral medications in these patients [ 165 , 166 , 167 , 168 ].
Case reports [ 169 , 170 ] and other studies [ 171 , 172 ] indicate that patients with GA may show clinical improvements on a gluten-free diet as well. Neurological benefits, including improved cerebellar function and stabilization of the condition, are influenced by patient adherence to the gluten-free diet [ 172 ]. At least one year on the diet may be required for clear signs of improvement to be detected in GA patients [ 173 ].
The gluten-free diet’s effectiveness in managing NCGS and IBS symptoms is a popular area of debate. For individuals with NCGS, whose symptoms are provoked by gluten, the gluten-free diet is shown to keep the number and severity of their symptoms at bay [ 148 , 173 , 174 , 175 ]. However, randomized, double-blind placebo-controlled challenge studies revealed that the true proportion of gluten-sensitive individuals may be overestimated [ 174 , 176 , 177 ]. Furthermore, although the gluten-free diet was found to provide some relief for patients with diarrhea-dominant IBS [ 178 , 179 ], the roles of α-amylase/trypsin inhibitors and fermented oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) in triggering IBS-type symptoms cannot be ignored [ 180 , 181 , 182 ].
Another way the gluten-free diet may benefit some gluten-related disorders is through modulation of gut microflora. The gluten-free diet has been shown to beneficially alter the gut bacterial composition and function in individuals with CD [ 183 , 184 ]. The low polysaccharide content of the gluten-free diet could help explain some of the changes observed in the microbiota [ 185 ]. Intestinal healing on the diet may also help support the growth of different bacterial species [ 183 ]. However, findings are still inconsistent. In adults with CD, Nistal et al. [ 183 ] found that adult patients on the diet began to show some changes similar to the microbial community patterns of healthy adults, but that differences in the richness and presence of unknown bacterial communities still existed. In child CD patients, more than 1 year on the diet seems to be needed to restore normal functions of the gut microflora [ 184 ]. Differences in the reported benefits also exist between the gut microbial composition of symptomatic and asymptomatic CD patients on a gluten-free diet [ 186 ].
Additional studies are still needed for a consensus to be reached. Research of this kind is limited and mostly restricted to small sample sizes. There is also inconsistency in the target age groups across studies, as well as the duration and adequacy of gluten-free dietary adherence. The effects of confounding genetic and other environmental factors on the gut microbiome must also be considered.
An association was described between type 1 diabetes (T1D) and CD, with a 1–16% prevalence of CD found in T1D cases [ 187 ]. In addition to T1D, patients with CD are more susceptible to developing autoimmune diseases including autoimmune thyroiditis, psoriasis, rheumatoid arthritis, Sjögren’s syndrome, DH, and Addison’s disease [ 188 , 189 ].
Both genetic and environmental elements are known to influence the development of T1D, and researchers suspect that dietary gluten may be one contributing factor [ 190 ]. Human studies have produced less conclusive results than pre-clinical studies and additional research is still needed. Variations in the clinical backgrounds, age groups, and dietary compliance of subjects, as well as the lack of controls and small sample sizes across studies might explain the inconsistencies. Owing to the association between T1D and CD, researchers have also investigated the gluten-free diet’s impact on glycemic control in patients with both autoimmune diseases. The gluten-free diet reduced severe hypoglycemia in children with T1D and CD, over the short term [ 191 ]. Although the level of clinical significance varies between studies, HbA1c levels were also found to improve in children with T1D and CD following a gluten-free diet intervention [ 192 , 193 ]. However, other studies found no significant improvement in metabolic control in T1D patients with CD following a gluten-free diet [ 194 , 195 , 196 ]. Furthermore, the high GI of many gluten-free products could put ill-informed T1D patients at risk of a loss of glycemic control [ 197 ].
The role of the gluten-free diet in reducing the risk of comorbidities of autoimmune diseases in CD patients remains unclear. In 1999, Ventura et al. proposed that the incidence of other autoimmune diseases in patients with CD may be linked to prolonged exposure to gluten. Since then, other studies have been conducted to further explore the association between gluten exposure in CD patients and the development of these disorders [ 188 , 198 , 199 , 200 ]. Three of the studies revealed that the risk for developing other autoimmune diseases does not appear to be significantly impacted by the duration of gluten exposure in CD patients [ 188 , 198 , 199 ]. Cosnes et al. [ 200 ], on the other hand, reported a possible protective effect of the gluten-free diet. As many of these studies are based on retrospective data [ 198 , 199 , 200 ], prospective research in this area is advised.
The replacement of gluten as a vital ingredient in numerous food products is not straightforward. Different ingredients and processing techniques have been investigated to date. However, the quality of gluten-free products is often not comparable to gluten-containing products. More effort should be devoted to a more rational approach which uses the gluten-containing product as the golden standard.
The motivation to adopt a gluten-free lifestyle goes beyond its original application for CD management. Perceived health benefits and relief of adverse symptoms on the diet influence individual decisions to abstain from gluten. Even so, confusion surrounding gluten and gluten-free options, as well as the high cost and low availability of gluten-free products, can be burdensome for many people. For others, drawbacks of the gluten-free diet may be small in comparison to the clinical improvements made on the diet. Despite media claims, there is also limited evidence confirming the diet’s effectiveness in weight loss for the general public. Furthermore, the reported weight gain in CD patients on the diet may not always be favorable, particularly among previously overweight and obese individuals. However, to date, no beneficial effects from a gluten-free diet have been shown in healthy individuals. Most importantly, individuals choosing to follow a gluten-free diet should take caution of the macronutrient and micronutrient inadequacies of the diet. Overall, it is generally recommended that dietary education and counselling be offered to support gluten-free dieters.
Writing-Original Draft Preparation, D.E.K., S.B., I.J.J.; Writing-Review & Editing, D.E.K., S.B., I.J.J.; and Supervision, D.E.K., I.J.J.
This research received no external funding.
The authors declare no conflict of interest.
Personalization.
One of the most common sources of carbohydrates in the average person’s diet is bread. Pre-sliced, whole grain, tortillas, naan, pita bread, bagels… there are literally hundreds of types of bread to choose from. But what do you do when you’re living a low-carb lifestyle? What bread is good for people with diabetes? What is a good substitute bread for people with diabetes if you’re cutting bread out completely? What bread is lowest in sugar? Let’s take a look at some of the good substitute bread options available on store shelves, and a few tasty options you can cook up in your own kitchen.
At Virta , our stance is to generally avoid traditional bread and grain-based products that are high in carbs. These foods trigger an insulin response from your body and make blood sugar levels more difficult to control, especially for people with diabetes. There are a number of good bread substitutes that can satisfy your craving without spiking your blood sugar.
So, what is a good substitute for bread with diabetes? For starters, this skillet bread with cheese is a good substitute bread option. Packed with cheddar cheese, and using substitutes of almond flour and flaxseed meal in place of traditional flour gives this cheesy bread all the chew and flavor of traditional bread without the bump in blood sugar.
You also might wonder, is sourdough a good bread for people with diabetes? Sadly, no, but if you’re craving dinner rolls, these easy-to-prepare low-carb dinner rolls with garlic and parmesan can scratch your bread itch. Spread the butter on and enjoy the garlic-y goodness, because coconut flour and psyllium powder again take the place of traditional flour to make this a good bread substitute for people with diabetes
Need something to take the place of waffles or pancakes for your weekend breakfast or brunch? Chaffles . Cheese waffles. Sounds like a match made in heaven, right? Only three ingredients, and almond flour takes the place of traditional flour to give you a low-carb breakfast go-to. Top with full-fat yogurt and berries, butter, or sugar-free whipped cream.
While some solid low-carb and bread substitutes are available at the grocery store, it’s important to remember that not every low-carb product is right for every person. For example, low net carbs doesn’t always mean low total carbs , and if you have high blood sugar those options may not be a great choice.
That said, low-carb tortillas, keto bread, and almond, coconut, flaxseed or chia seed breads can be good substitute breads for people with diabetes. Some of the best store bought bread substitutes for people with diabetes can actually be found in the produce and dairy aisles.
Ultimately, there is no silver bullet when it comes to what bread is good for people with diabetes. But through a combination of homemade, store bought, and produce or dairy based bread substitutes, you can find something to scratch your bread itch without sacrificing stable and lower blood glucose levels.
If you want to live a low carb lifestyle and reclaim your metabolic health, Virta Health may be able to help. By making healthy lifestyle changes in a medical setting with supportive resources like 1:1 virtual coaching, you can regain control of your health and feel like yourself again. See if you’re eligible for Virta Health here.
This blog is intended for informational purposes only and is not meant to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or any advice relating to your health. View full disclaimer
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Frequently asked questions.
This gluten free stuffed flatbread is filled with a delicious mix of swiss chard, parsley and cheese – but the filling recipe is incredibly flexible and you can tweak it to use whatever ingredients you have on hand. the gluten free dough handles beautifully: you can easily roll it out until it’s very thin and assemble the flatbread without any issues or tearing. it’s then pan-fried until golden and crispy and simply irresistible..
I’ve made this flatbread at least four or five times just in the last week, and I still can’t get enough of it. While it may look simple on the surface – it’s just a very basic dough, rolled out until it’s super thin and then stuffed with a mix of chard, parsley and cheese – something truly magical happens when you combine these elements together and pan-fry the flatbread to golden, crispy perfection.
The recipe uses a yeast-free variation of my gluten free pita bread dough , which works perfectly: you can easily roll it out until it’s very thin and then assemble the stuffed flatbreads without any issues or tearing.
For the best possible texture and taste, these flatbreads are pan-fried in a bit of olive oil . This makes them wonderfully rich and it gives them a delicious crispness (though note that they’ll lose most of their crispy texture as they cool). And you can easily store them until the next day and then reheat them on the stovetop – this actually makes them *extra* crispy!
Before we get to the bits and bobs of making this amazing stuffed flatbread – if you like what you’re seeing, subscribe to my newsletter to keep up to date on the latest recipes and tips!
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Note: the whole recipe, including the ingredient quantities, can be found at the bottom of this page – just scroll down to the bottom, or click the ‘Jump to Recipe’ button at the top of this post.
When developing this recipe, I was inspired by the Turkish savoury stuffed flatbread called ‘gozleme’ – but this is by no means a traditional interpretation of that recipe, it’s just loosely based on it. Gozleme can be prepared with either a leavened or unleavened dough, typically made from wheat flour, water, salt and sometimes yeast. Some variations also include yoghurt in the dough.
It can be stuffed with a variety of fillings, the most commonly encountered ones being minced lamb with an abundance of spices and a spinach and feta version – but there are many other variations out there as well. It’s cooked on the stovetop with a bit of olive oil, which makes it deliciously crispy, and it’s then cut into smaller, easy-to-grab portions before serving.
For this gluten free recipe, I used an unleavened dough that’s based on my gluten free pita bread recipe – it’s essentially that same dough minus the yeast. And it works PERFECTLY for this stuffed flatbread.
The dough comes together quickly and easily either by hand or with a stand mixer, and it handles beautifully thanks to the addition of psyllium husk (in the form of a psyllium gel). You can knead it, shape it and roll it out without any problems whatsoever.
This recipe makes four large-ish flatbreads, so you’ll need to divide the dough into four equal portions and shape each portion into a ball. (As you’re working on one flatbread, keep the other dough balls covered with a clean tea towel to prevent them from drying out.)
When it comes to the filling, the recipe is super flexible. For this version, I used Swiss chard, plenty of parsley and caramelised shallots (because that’s what’s thriving in our garden at the moment), as well as some cream cheese (for just the right amount of creaminess) and coarsely grated cheddar.
But you can easily use spinach instead of the chard, and swap crumbled feta for the cheddar. You could also add some red pepper flakes, and chopped-up sun-dried tomatoes would be amazing in there as well! So, treat the filling recipe below more as a rough guideline or a gentle suggestion rather than something you have to follow to a T.
To shape the stuffed flatbreads:.
It’s best to cook the stuffed flatbread in a large cast iron skillet or frying pan – make sure that it’s at least 11 inches (28cm) in diameter, otherwise your flatbread won’t fit comfortably.
For maximum crispness, eat the flatbread straight away while it’s still hot. I like to slice them into easy-to-grab wedges, and serve them with some yoghurt for dipping.
However, these are also absolutely incredible lukewarm or cooled completely to room temperature – they just won’t be as crisp. In fact, the flavour of the filling is actually more intense if you serve the flatbread at room temperature.
This gluten free stuffed flatbread is definitely at its best fresh, on the day of preparation, but it also keeps really well until the next day in a closed container in the fridge.
The next day, you can reheat it in a hot pan: just cook it over medium to medium-high heat for 4-5 minutes, flipping it occasionally. That will actually make it even crisper than it was on day one!
You can also prep the stuffed flatbread in advance!
For this, you need to fully assemble the flatbreads, place them on a baking sheet, cover it tightly with plastic wrap/cling film and then store it in the fridge overnight. You can then cook and serve the flatbreads the next day.
Although all the ingredients in the recipe should be easily accessible either in your local grocery store or online, I still wanted to include a list of substitutions you can make. (NOTE: all substitutions should be made by weight and not by volume.)
And, as I’ve mentioned above, you can also play around with the filling ingredients depending on what you have on hand and what you fancy eating.
While I’ve included the volume measurements (cups and spoons) in the recipe card below, if at all possible (and I really cannot overemphasise this): USE METRIC GRAM MEASUREMENTS IF YOU CAN.
They’re much more precise and produce more reliably delicious results. This is true for pretty much all of baking – a kitchen scale will invariably give better results than cups and tablespoons.
I really hope you’ll love it as much as I do.
If you’re looking for more amazing gluten free bread recipes (that are nearly indistinguishable from their “regular” equivalents made from wheat flour), you’re definitely in the right place!
Quick & easy gluten free naan (no yeast).
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Making the filling:.
Easy gluten free flour tortillas (only 5 ingredients).
and I’m so excited to welcome you to The Loopy Whisk, where we’re all about feel good recipes that make living with food allergies and dietary requirements easy as cake! (And there’s a lot of cake round these parts.)
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and I’m so glad to welcome you to The Loopy Whisk, where we’re all about feel good recipes that make living with food allergies and dietary requirements easy as cake! (And there’s a lot of cake round these parts.) I’m happiest in the kitchen and behind the camera, bringing my allergy friendly dreams to life, and sharing them with you.
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Gluten free, cheesecakes.
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All of the flavor, none of the gluten.
Whether you have a gluten intolerance or simply want to broaden your baking skills to be inclusive for all your friends, family, and guests, this collection of delicious gluten-free cookie recipes truly has something for everyone. From the best gluten-free chocolate chip cookie recipe to classic sugar cookies , keep scrolling to find your find your next go-to gluten-free recipe.
"Delicious and gluten-free!" — Sophia Terrazas-Chadwick
"Excellent cookie... They don't break apart nor do they bend once cooled so they were ideal for decorating. I left them covered with cheesecloth on the counter overnight and decorated the next day and packaged once the icing dried. They make great gift cookies. Thank you for sharing this recipe." — Buckwheat Queen
"These cookies are delicious and I can't really tell that they are gluten-free. Baked beautifully! I also used some butterscotch chips. Thanks!" — Zosgood
"These are the best gluten-free cookies I have ever made. The only changes I made were I used 1 c. of Bob's Red Mill Gluten Free 1-to-1 flour instead of the four different flours in the recipe (omit the xanthan gum since Bob's already has it) and used dark chocolate chips. The flavor is incredible and the texture is spot on! Highly recommend!" — KW
"I just love them. Being Argentinian and living in another country, by following this recipe I always feel at home." — Anitasuperpoderosa_89
"Divine! These are the best peanut butter cookies! My mom can't get enough of these either. One thing I would make note of is that this recipe doesn't make very much. I highly recommend doubling the amounts." — Java_Girl
"Easily best cookies I’ve ever had. My 10 year old cousins came up from Florida to Baltimore last month. We hadn’t seen them in 3 years, as they live so far away. They made me signs about the cookies I made from when they were 7 years old. I had to make them, and my cousins were so happy. 100 percent recommend." — Goldenfood
"This recipe turned out really well! A very light soft cookie with a bit of toasty on the outside! It's my first time making Snickerdoodle cookies and heard to call of cream of tartar not being present, did my research and added 1/4 tsp. Not sure if it made a difference but my cookies are checking the traditional box, light and delicious!" — Angela Sackett Superhotmama
"These were a bit heavier than a traditional chocolate chip cookie, almost cake-like. They remained puffy instead of spreading out flat. Thank you for the recipe." — Buckwheat Queen
"Delicious! My family (with 4 kids) always eats all of them within an hour or two! We hardly ever cook gluten-free, but I had almond flour so I decided to try it. My husband told me to buy more almond flour, because these are so delicious. I used regular sugar and followed the recipe exactly." — LivinginJapan
"These were delicious! They turned out great and I'll be making these again." — Kate
"These have become my go-to for gluten-free cookies. My sister has celiac and I LOVE peanut butter, so this is perfect because I think the absence of flour (even GF flour) makes the peanut butter stand out more. I really like it with the modification of 1/2 white 1/2 brown sugar and adding a pinch of baking powder." — 88keys4god
"Wow! Amazing! Dessert can be delicious without the gluten! Because several others had mentioned it was sticky, I spread butter in the bottom of my stoneware jelly pan and no problems. This was my first try at gluten free and it was a success! I made these for a friend who is gluten free, but my son ended up eating half of them! Thank you, Jewel! I will make these again!" — Momof3
"Loved these. Made them for a tailgate and they were a big hit with the college crowd. They held together well. Crispy on the outside and chewy chocolate on the inside. I cheated and used egg whites from a carton, no problem. I thought they tasted better on the day after I made them." — Sue
"I have just been diagnosed myself gluten-free lifestyle, so needless to say..I am experimenting. I was so amazed at how these tasted. This was a pleasure to bake and eat. I did substitute butter instead of margarine and used 1/2 the corn flour mixture and substituted it w/ rice flour instead for the remaining half. Excellent, thanks!" — Rev. Michaela
"This cookie was very easy to make. It was a must-have with the family and I will keep this recipe." — Allrecipes Member
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COMMENTS
A unique property of wheat gluten realizes bread with high quality. However, some genetically predisposed people cannot eat wheat bread, because gluten causes harmful reactions to them. In this short review, we will summarize the gluten-dependent swelling mechanism of wheat bread and the recent scientific effort to make bread without gluten. Go to:
This study aimed to perform a systematic review on gluten-free bread formulations using specific volumes as a quality indicator. In this systematic review, we identified 259 studies that met inclusion criteria. From these studies, 43 met the requirements ...
The increasing demand for gluten-free products, primarily GF bread with a good nutritional profile and sensory quality, justify the importance and the need to evaluate the glycemic index of gluten-free bread and the main ingredients used in their formulations.
Gluten-free bread is usually characterised by an overall poorer quality compared to wheat bread. On average, it has a lower nutritional value as it is mostly based on starch and refined flours [1, 2].
Although the production of GF bread still remains a technological challenge, research continues to find innovative approaches to improve the quality of GF bread. Literature shows that an important aim is to imitate the gluten-network by combining several ingredients, from which hydrocolloids play a crucial role.
The need for better quality gluten-free (GF) bread is constantly growing. This can be ascribed to the rising incidence of celiac disease or other gluten-associated allergies and the widespread incorrect public belief, that GF diet is healthier. Although there is a remarkable scientific interest shown to this topic, among the numerous studies only a few deals with commercially available ...
Despite the commercial availability of gluten-free (GF) products, numerous nutritional, sensory, and textural limitations have been brought to the att…
PDF | High-quality, gluten-free doughs and bakery products are clearly more difficult to produce than wheat flour-based products. The poor quality of... | Find, read and cite all the research you ...
Abstract Gluten-free foods have attracted increased attention in the food industry due to health issues (i.e., celiac disease and other gluten-related disorders) associated with gluten and the changes in eating habits, such as following gluten-free diet (GFD). Among this food segment, gluten-free (GF) bread plays a crucial role because of the stable consumption of bread in many parts of the ...
High-quality, gluten-free doughs and bakery products are clearly more difficult to produce than wheat flour-based products. The poor quality of the breads that are currently available demonstrates that manufacturing remains a significant technological problem. This is mainly due to the absence of gluten, which has a huge negative impact on dough rheology and bread characteristics. Gluten ...
The techniques used in gluten-free bread making research vary widely. This review focuses on the methodological aspects of gluten-free bread making research and extracts relevant data from all Web of Science peer reviewed research articles on gluten-free bread published from 2010 to date.
This research aims to enhance the nutritional value of gluten-free bread by incorporating a diverse range of components, including additives with beneficial effects on human health, e.g., dietary fibers. The research was focused on improving the texture, taste, and nutritional content of gluten-free products by creating new recipes and including novel biological additives. The goal was to ...
Request PDF | Gluten-Free Breadmaking: Facts, Issues, and Future | Gluten-free foods have attracted increased attention in the food industry due to health issues (i.e., celiac disease and other ...
The market for gluten-free products is steadily growing and gluten-free bread (GFB) keeps on being one of the most challenging products to develop. Although numerous research studies have worked on improving the manufacture of GFBs, some have adopted approaches far from commercial reality. This review analyzes the ingredient list and nutrition ...
The unattractive appearance of gluten-free bread still remains a challenge in gluten-free breadmaking. In response to this, additives such as dairy products, soya and eggs have been used to improve the quality of gluten-free bread, but with limited success. In recent years, enzymes (transglutaminase …
In this short review, we introduce the ongoing advancements in the development of gluten-free bread, by our laboratory as well as others, focusing mainly on rice-based breads.
Due to the absence of gluten, several challenges arise during gluten-free (GF) bread baking, affecting the mid-and-end-product quality. The main approach to overcome this issue is to combine certain functional ingredients and additives, to partially simulate wheat bread properties. In addition, the optimization of the baking process may contribute to improved product quality. A recent and very ...
The market for gluten-free products is steadily growing and gluten-free bread (GFB) keeps on being one of the most challenging products to develop. Although numerous research studies have worked on improving the manufacture of GFBs, some have adopted approaches far from commercial reality.
Bread and bakery products are an essential part of the daily diet. Therefore, new naturally gluten-free baking ingredients and new methods of processing traditional ingredients are sought.
ARS scientists have developed a new process to produce gluten-free bread from corn flour that produces higher quality bread that is closer to the texture of conventional bread like those pictured here. Click the image for more information about it.
At that time, where I lived in Alabama anyway, there were no gluten-free breads in the freezer case at my local grocery store, like there are now and there were no gluten-free baked goods to be ...
Ensure success when making a gluten-free sourdough starter with these expert-approved tips. You'll be baking gluten-free breads, desserts, and more in no time.
If you have celiac disease, sourdough bread is off the table, but if you typically avoid bread as part of a gluten-free diet, sourdough can still be an option.
A gorgeous loaf of gluten-free sourdough bread is possible — and simple — thanks to our Gluten-Free Bread Flour and gluten-free sourdough starter. Bake it today!
In conclusion, it is important to periodically monitor celiac patients' compliance and attitudes towards the gluten-free diet. As also highlighted in international guidelines, a reorganization of the diagnosis/follow-up visits, including an expert dietary consultation, is needed.
The nutritional profiles of gluten-free products, as well as the dietary intake patterns of individuals on the diet, were assessed in several studies. According to Do Nascimento et al. [ 117 ], gluten-free products share a common composition of raw ingredients, including corn, rice, soy, cassava, and potato.
If you're baking gluten-free, you know that some unexpected ingredients may contain gluten. One common question we get: Is yeast gluten-free? Yes, the kind of yeast that's used for baking bread is gluten-free. Baker's yeast is a single-cell organism that consumes sugar and starch and produces carbon dioxide and alcohol through fermentation.
Is there a good bread substitute for people with diabetes? Take a look at some of the smartest bread substitutes for type 2 diabetes.
This gluten free stuffed flatbread is filled with a delicious mix of Swiss chard, parsley and cheese, and it's super easy to make!
From the best gluten-free chocolate chip cookies and classic gluten-free sugar cookies to meringue, these are our 16 best gluten-free cookie recipes.