This book is dedicated to my testers throughout the years who worked quietly and without acclaim to improve food for fellow celiacs, and especially to Virginia and Genevieve.
C eliac disease, or gluten-sensitive enteropathy, is a lifelong intolerance to gluten occurring in genetically predisposed individuals who mount an immunological response to an environmental factor. Dermatitis herpetiformis can be regarded as celiac disease of the skin. The offending agents are the gliadin fractions of the gluten molecule, which are found in wheat. Similar proteins, prolamines, are found in barley and rye. Oats, formerly considered toxic, were recently shown to be tolerated by some patients with celiac disease and dermatitis herpetiformis. However, oats should be avoided because there are small amounts of prolamines in oats and there is the possibility of contamination with other grains during production and processing. Children with celiac disease, on a gluten-free diet, have normal longevity and health. Undiagnosed adults have an increased mortality compared to the general population, mainly due to an increase in the incidence of malignant disease. The increased mortality returns to normal after a period of about five years on the gluten-free diet. Adherence to the diet has also been demonstrated to reduce the increased rate of malignancy.
The gluten-free diet is therefore necessary for life. This diet is also the only therapy currently available for uncomplicated celiac disease. Compliance is difficult in this day and age partially because of inadequate food labeling, a preeminence of fast foods, and a lack of awareness about the disease among food preparers. In addition, when the diagnosis is established in one family member, other first-degree relatives (parents, siblings, and children) should have serological blood tests for celiac disease. This is because at least 10 percent of these family members will have the disease, although at this stage they might be asymptomatic. In view of this, the diagnosis must be well established. The gold standard of diagnosis is a duodenal biopsy. The biopsy also provides a baseline; further biopsies may be necessary to document adequate response to the diet because symptoms rapidly improve on a gluten-free diet, and recurrent or persistent symptoms may need to be explained.
The recommendation by physicians, nutritionists, naturopaths, and osteopaths to try a gluten-free diet as a trial of therapy for a set of symptoms, without biopsy confirmation of the diagnosis, should be discouraged.
The majority of patients diagnosed with celiac disease in the United States present with diarrhea, and have positive antibodies to gliadin in their serum and totally flat biopsies. They often have had many years of symptoms, have seen many physicians, and have had a diagnosis of irritable bowel disease along the way. This is, however, the tip of the iceberg. The great majority of celiacs are probably not as yet diagnosed. They are the untested relatives of celiac patients, the patient receiving therapy for osteoporosis, the anemic patient who responds only partially to iron pills, the depressed hypothyroid patient, or even the young patient with a malignancy. Rather than total villous atrophy (destruction of the villi), they may have only partial villous atrophy on the intestinal biopsy.
Celiac disease is not often considered as a diagnosis by the medical community because it is considered a rare disease in the United States. A recent study from Baltimore in which asymptomatic blood donors had their blood screened with antibody tests, which are highly sensitive and specific for celiac disease, revealed 1 in 250 to be positive. This is identical to the figures from Europe, indicating the disease is not rare but in fact is one of the most common genetically determined diseases.
More research needs to be done to establish the true prevalence of the disease in the United States and its many modes of presentation. The result of this research will need to be published in reputable medical journals facilitating the education of physicians. Only research and publication will result in government regulatory bodies listening to the patient population and changing the current status with respect to standardization of blood tests and such important issues as food labeling.
When finally established, physicians regard making a diagnosis of celiac disease as a rewarding process for patients who merely have to change their diet. Avoid wheat, barley, rye, and oats are the usual instructions. This is followed by Here is the phone number of a dietitian. Physicians are wrong in this respect. Patients need to be monitored, vitamin and mineral levels need to be measured, and bone density needs to be quantified because osteopenia and osteoporosis are common, and if present, parameters of calcium absorption need to be assessed.
For the patient the often long and arduous journey to health continues after the diagnosis is finally attained, but with a new twist. Many questions arise: What is gluten? Where is it found? Is any gluten allowed? What if I ingest some gluten? Is it okay if I ingest some gluten and do not experience any symptoms? Do I really need to check with the manufacturers of all my medications for gluten content? What are food starches? What grains can I tolerate? Where do I get all this information?
Most celiacs must become educated consumers. Their education about how to live with celiac disease comes mainly from other patients who have gone through the ordeal of the odyssey of diagnosis, the dismay of the change in lifestyle, and finally the prospects of good health. Bette Hagmans books are an example of how one person can provide an extraordinary educational service to fellow celiacs. Bettes experience and talents have gone a long way to demonstrate how, with imagination, knowledge, and some ability, a restrictive diet can be transformed into a culinary delight.
Peter H. R. Green, M.D., F.R.A.C.P.
Clinical Professor of Medicine
College of Physicians and Surgeons,
Columbia University, New York
T his is not the book I started out to write three years ago. Oh, it was going to be on breads, all right, but I thought the work was all done; I would simply put together a collection of bread recipes from my first three books.
I had been satisfied with those recipes because they were still better than those so-called breads of twenty-five years ago when I was first diagnosed as a celiac and wrapped my sandwich filling in cold rice pancakes and pretended I ate like everyone else. When fellow teachers in the staff room laughed at my lunch, I resolved that something had to be done to make celiac food more appetizing. I never dreamed that Id be one of the ones to help do so. I thought I was born to write; I certainly was not a born cook. Believe me, I have learned the hard way.
I had never baked yeast bread in my life, and my first attempt could have been used as a doorstop. There were no recipes using rice flour at that time, so when the University of Washingtons home economics department came out with a recipe using xanthan gum to give spring to the loaf, the results seemed like a miracle. Finally, celiacs had real yeast-tasting bread that we could actually cut and eat. It was heavy, bland flavored, gritty tasting, and dried out quicklybut it was still bread. Later, I experimented and added tapioca, potato starch, and/or cornstarch to the rice flour to lighten the bread in both texture and taste.
In my third book, The Gluten-free Gourmet Cooks Fast and Healthy, I introduced bean flour in baking breads, a great improvement in flavor, texture, and nutrition over the rice breads. I could have lived happily ever after with these breads until a lucky coincidence opened up a whole new world of baking. When a box containing twenty-five pounds of Jowar sorghum flour was delivered to me unexpectedly, I hadnt the faintest notion how I was going to use up this new product. Id tasted a few cakes and cookies made from it but felt that, like rice, it was a flour that needed to be combined with others to produce the best baked products. I tried pairing it with rice flour but wasnt really satisfied with the results. Then, while making a bean dish and pouring in molasses, I remembered my mother calling it sorghum. A thought occurred to me: Would this sorghum flour be compatible with bean flour?