By Melinda Dennis, MS, RD, LDN
Overview of the Gluten-Free Diet
Following a strict gluten-free diet is the most important key to optimizing health with celiac disease. This diet avoids foods made from the gluten-containing grains wheat, rye, barley, and oats (unless dedicated gluten-free oats), as well as cross contamination from these grains.
Since the gluten-free diet is often found to be low in calcium, iron, fiber, zinc, B vitamins, vitamin D, and magnesium 1,2,3,4 it is very important to replace these nutrients through a healthy, balanced diet and appropriate gluten-free multivitamin/mineral supplementation.
Most people cannot meet their nutritional needs through diet alone and consider taking a standard gluten-free multivitamin/mineral supplement. Since lactose intolerance is common in the celiac population, it is often difficult to reach the recommended goal of calcium and vitamin D, and a calcium supplement with vitamin D is often recommended. Other vitamins or minerals may also be recommended such as in the case of iron or B vitamin deficiencies. Whole gluten-free grains, such as brown rice, quinoa, millet and amaranth, are excellent sources of fiber, vitamins and minerals, and are a key component to a healthy gluten-free diet.
Good nutritional status and celiac disease remission should be reached before a woman becomes pregnant to maximize the health of both mother and child.5 Since nutritional deficiencies can impact reproductive function, (specifically zinc, selenium, iron and folate),6 all labs should be normal or considered close enough to goal by the physician (see Testing below). A woman should begin her gluten- free prenatal vitamin/mineral supplement as soon as she begins to consider pregnancy.
Key Components for a Healthy Pregnancy Include:
Appropriate weight gain – estimated calorie needs during pregnancy vary by individual based on age, trimester of pregnancy, number of fetuses, weight gain, etc.
Appropriate physical activity
Consumption of a variety of foods in accordance with the Dietary Guidelines for Americans 2010
Appropriate and timely vitamin and mineral supplementation
Avoidance of alcohol, tobacco and other harmful substances
Safe food handling5
Nutrition for Prenatal and Pregnant Women: The Basics
Assuming a good health status and strong adherence to the gluten-free diet, here are some specific nutrient guidelines to keep in mind before and while pregnant.
Iron: Intake of iron-rich foods or iron-fortified foods, along with vitamin C rich foods to increase absorption, is recommended. A standard gluten-free prenatal vitamin/mineral supplement contains 27mg of iron.
Folic acid: Daily intake of 600mcg of synthetic folic acid (from fortified foods or supplements) as well as folate from food forms,5 such as dark, leafy greens, dried beans, and whole gluten-free grains, is recommended. Unlike commercial gluten-containing products, many gluten-free commercial products such as cereals, breads and pasta are not fortified or enriched with folic acid or iron.3,7
Calcium and vitamin D: Although the National Osteoporosis Foundation recommends 1000mg of calcium and 400-800IU (international units) of vitamin D per day for adults under 50 years of age,8 individual needs vary, particularly in celiac disease. Many health care providers recommend 1200mg of calcium and 1,000IU of vitamin D per day for adults with celiac disease.9
Omega-3 (n3) Fatty Acids: "Ensuring maternal dietary intake of long chain n-3 fatty acids, in particular DHA, during pregnancy and lactation through two or more servings of seafood per week also has benefits for the infant, especially when women emphasize types of seafood high in n-3 fatty acids and with low methyl mercury content.10” Salmon, tuna, lake trout, herring and sardines are some examples of fish containing good levels of omega-3 fatty acids.
By following the recommendations below, women who may become pregnant, pregnant women, nursing mothers, and young children can benefit from the protein, essential nutrients, omega-3 fatty acids and low fat content of fish and shellfish while reducing their exposure to the harmful effects of mercury:
"1. Do not eat shark, swordfish, king mackerel or tilefish because they contain high levels of
2. Eat up to 12 ounces (two average meals) a week of a variety of fish and shellfish that are lower in mercury.
Five of the most commonly eaten fish that are low in mercury are shrimp, canned light tuna, salmon, pollock and catfish.
Another commonly eaten fish, albacore ("white") tuna has more mercury than canned light tuna. So, when choosing your two meals of fish and shellfish, you may eat up to 6 ounces (one average meal) of albacore tuna per week.
3. Check local advisories about the safety of fish caught by family and friends in your local lakes, rivers, and coastal areas. If no advice is available, eat up to 6 ounces (one average meal) per week of fish you catch from local waters, but don't consume any other fish during that week.”
Your health care provider will also discuss adequate calories, protein, omega-3 fatty acids and other healthy fats, fiber, fluid, vitamin, mineral, and other supplement needs based on your labs, diet and past medical history. For optimal and individualized care, women should seek prenatal and pregnancy counseling from physicians and registered dietitians specializing in celiac disease.
Recommended Lab Testing for Newly Diagnosed Celiac Disease
CBC (complete blood count)
Iron studies (ferritin preferred)
25 OHD (vitamin D)
IgA-tTG (celiac antibody)
Bone mineral density test (BMD)-usually done 12 months after starting the gluten-free diet; talk to your doctor about the timing for BMD test and pregnancy.
Other labs (based on need): Fat soluble vitamins (A, E and K), zinc, selenium, magnesium, etc.
Melinda Dennis, MS, RD, LDN, is nutrition coordinator for the Celiac Center at Beth Israel Deaconess Medical Center in Boston and owner/founder of Delete the Wheat Nutritional Counseling. Melinda is also coauthor of the book Real Life with Celiac Disease, AGA Press, Bethesda, MD, 2010.
1. Hallert C, et al. Clinical trial: B vitamins improve health in coeliac patients living on a gluten-free diet. Aliment Pharmacol Ther 2009;29(8):811-16.
2. Kupper C. Dietary guidelines and implementation for celiac disease. Gastroenterol 2005;128:S121-127.
3. Thompson T, et al. Gluten-free diet survey: are Americans with coeliac disease consuming recommended amounts of fibre, iron, calcium and grain foods? J Hum Nutr Dietet 2005;18:163-169.
4. What is the evidence to support the nutritional adequacy of a gluten-free dietary pattern? American Dietetic Association Evidence Analysis Library. http://www.adaevidencelibrary.com/topic.cfm?cat=3169. Accessed October 13, 2010.
5. Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome. J Am Diet Assoc. 2008;108:553-561.
6. Shah S, et al. Celiac disease: an underappreciated issue in women’s health. Journal of Women’s Health 2010;6(5):1-14.
7. Thompson T. Thiamine, riboflavin, and niacin contents of the gluten-free diet: is there cause for concern? J Am Diet Assoc 1999;99:858-62.
8. National Osteoporosis Foundation. Prevention. http://nof.org/aboutosteoporosis/prevention.
Accessed October 11, 2010.
9. Bone Disease. In Real Life with Celiac Disease. Dennis M, Leffler D. AGA Press, Bethesda, MD, 2010.
10. United States Department of Agriculture, Center for Nutrition Policy and Promotion. Dietary Guidelines for Americans, 2010. Executive Summary. http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/DGAC/Report/A-ExecSummary.pdf . Accessed October 29, 2010.
11. U.S. Department of Health and Human Services. U.S. Food and Drug Administration. What You Need to Know about Mercury in Fish and Shellfish, March 2004. http://www.fda.gov/food/foodsafety/product-specificinformation/seafood/foodbornepathogenscontaminants/methylmercury/ucm115662.htm. Accessed October 29, 2010.