Celiac disease limiting fuel for endurance – keto-adaptation would solve that!

Nutritional Ketosis as an Effective Strategy for Fueling Endurance

From New Zealand comes this report of an ultra-endurance athlete who had difficulty meeting fuel needs.
One solution for this would be the strategic use of nutritional ketosis.  To use this strategy, the athlete needs to be metabolically adapted to burning ketones for fuel.  This means being in nutritional ketosis for at least some weeks before the race day. The term that is used is “being in a state of keto-adaptation“. The advantage is that during the endurance exercise, the body can draw on the vast calories stored as fat (even in very slim people), while using less of the glycogen stores.

Case Study: Nutritional Strategies of a Cyclist with Celiac Disease During an Ultra-endurance Cycle Race.

Department of Human Nutrition, University of Otago, Dunedin, New Zealand.


Food intolerance is becoming increasingly prevalent and increasing numbers of athletes participating in sporting events have celiac disease. This poses challenges as dietary recommendations for exercise are largely based on gluten containing carbohydrate-rich foods. The K4 cycle race covers 384 km around the Coromandel Peninsula, New Zealand. Lack of sleep, darkness and temperature variations pose a number of nutritional challenges. Limited food choices present those with celiac disease with even greater challenges. This case study describes the intakes of one such athlete during training and competing in the K4. Nutritional intakes were obtained during training using weighed food records and during the race via dietary recall and the weighing of foods pre- and post- race. As simple substitution of gluten containing foods for gluten-free foods leads to increased energy intake, alternatives need to be considered. During the race, insufficient energy was consumed to meet the nutritional guidelines for endurance performance. This was probably due to the nature of the course, racing conditions, the consistency of gluten-free food, and towards the end of the race, sensory specific satiety.  PMID: 22645170

To go to the font of the scientific knowledge on this, the book to read about the use of nutritional ketosis as a strategy for athletic performance is The Art and Science of Low Carbohydrate Performance by Jeff S. Volek, PhD, RD and Stephen D. Phinney, MD, PhD.  The price is more than reasonable ($8.95 on amazon and no I have absolutely no commercial ties or links).

Gluten awareness even for low-carbers

There has been a fair amount of interest in my article on the need for gluten awareness even in the world of low-carb nutrition or grain-free eating, such as a Paleo lifestyle.

The topic is much larger than can be contained in any one blog post.  I tried to explain my thoughts a bit more in the comments section under the article, including:

With the immune system, the dose causing impact is orders of magnitude less than for the blood-sugar control system.

With the immune-system, the price to pay for small intakes is out of all proportion.

The Canadian Celiac Association is one place to look for info, such as this article on the new food labelling laws coming into effect in Canada in August.

Canada is in a transition period between the old labelling regulations and new regulations that take effect on August 4, 2012. By that date, labels for all food products sold in Canada will have to carry clear identification of the priority allergens, gluten, and added sulphites at a level greater than 10 ppm.

In Canada, gluten means “any gluten protein or modified protein, including any protein fraction derived from the grains of the following cereals: barley, oats, rye, triticale, wheat, kamut or spelt”. The definition also applies to the grains of hybridized strains of the cereals listed above.

And this article on cross-contamination:

People who need to eat gluten free need to check both the ingredients in food and any cross-contamination with gluten-containing ingredients that might happen when the food is manufactured, packaged and prepared for eating.

When you think about avoiding cross-contamination, you need to realize that crumbs matter. Look around your kitchen to see where there are crumbs – on the counter top, in the microwave, on the cutting board or in the corners of your metal baking dishes? Anywhere you see crumbs is a potential place for cross-contamination.

The Celiac Disease Foundation at celiac.org has an article on gluten in medications, along with extensive other info.

Celiac.com offers a mind-boggling list to keep in mind when reading food labels Unsafe Gluten-Free Food List (Unsafe Ingredients), along with extensive other info.

You might enjoy a “Wheat is Murder, Go Paleo” t-shirt from Tom Naughton’s site Fat Head.

I know, I know. Just eat non-processed real foods and you don’t have to worry about labels.  Yeah, that’s what I do.  But life ain’t perfect and neither are people and the penalty for small “sins” should not be so large.

When the 8 percent of us who need to avoid even tiny intakes of gluten (this is a rough estimate, true incidence not known and likely rising) are aware, knowledgable and active, life will get easier as the world adapts to our presence.

Why talk gluten when low-carb or grain-free?

Even with low-carb or grain-free eating, avoiding gluten still takes knowledge, awareness and vigilance.  The problem is common and the down-side is serious.


  • because 1% plus 7% of the population equals a whole lot of people (8 of 100 people).
  • because gluten hides unsuspected in low-carb foods (e.g. most sausages).
  • because when eating out, travelling or eating at friend’s homes, people may make-do by removing croutons, removing the bun, removing the breaded coating, etc.
  • because people may sometimes make the choice to, say, have a tiny pinch of their daughter’s wedding cake or other special meaningful food.
  • because even these small exposures could cause strong symptoms. On top of that, this can be very confusing. Confusion and doubt can bring their own harm if they discourage someone from maintaining the low-carb lifestyle that was benefiting them.
  • because the consequences can be more than “just” the unpleasant hours or days of the obvious symptoms.  Unlike with other food reactions, these responses to gluten are not an allergy.  Gluten sensitivity is an autoimmune disease and celiac disease is just one version of this.  It is never good to poke-at or prod an auto-immune response, which is the body attacking itself.  There can be more health consequences on the line than you think.

When people first switch to a low-carb diet, if they are following the advice of the most knowledgable and experienced clinicians*, they will be having no grains.  Having no grains means they will not be having any gluten.  For some people, part of the improvements in health that they achieve will be due to removal of gluten from the diet.  However, for the reasons above, they may be intermittently exposed without realizing just what is happening to them.  As their health improves, they may come to a point where they are slowly intentionally expanding their diet choices to include small servings of gluten grains – for example, using a rye cracker to build a sandwich on.       (* for example Dr. Atkins, Jackie Eberstein, Dr. Eric Westman)

Because gluten sensitivity is an autoimmune disease, the true cost of even small exposures can be hidden and unrecognized.  Because the opportunity for un-intended intake of gluten is ubiquitous in our society, exposures that keep the immune system provoked are very likely unless the person has been diagnosed and is aware of what they need to be on the look-out for.

Rev Neurol. 2011 Sep 1;53(5):287-300.

[Neurological disorders associated with gluten sensitivity].

[Article in Spanish]
Hernandez-Lahoz C, Mauri-Capdevila G, Vega-Villar J, Rodrigo L.

Source: Hospital Universitario Central de Asturias, 33006 Oviedo, Espana. carloshlahoz@gmail.com


Gluten sensitivity is a systemic autoimmune disease that occurs in genetically susceptible individuals on ingesting gluten. It can appear at any age, then becoming a permanent condition. It is more frequent in women, as happens with other autoimmune diseases. Celiac disease is the intestinal form and the most important manifestation among a set of gluten-induced autoimmune pathologies that affect different systems. Neurological manifestations of gluten sensitivity, with or without enteropathy, are also frequent, their pathogenesis including an immunological attack on the central and peripheral nervous tissue accompanied by neurodegenerative changes. The clinical manifestations are varied, but the most common syndromes are cerebellar ataxia and peripheral neuropathy. Finally, gluten sensitivity is associated to a varying degree, with other complex diseases and could influence their evolution. The early detection of cases of gluten sensitivity with neurological manifestations and subsequent treatment with the gluten-free diet could provide remarkable benefits to the patients.

PMID: 21796607

Consider visiting the website of one of the most experienced clinicians, Dr. Rodney Ford (aka Dr. Gluten). His recently updated book Gluten Brain (http://t.co/yTonFF5t)  offers the provocative hypothesis that the principal damage involved in the gluten syndrome is to the brain and nerves.  (Note: at only $9.99 for the ebook the price is right, but myself I was not able to make the Kindle version I downloaded open in my Kindle app, so I settled for the PDF download (all versions are included in the one price) — the read was worth the inconvenience).

Consider visiting The University of Maryland Center for Celiac Research, where Dr. Fasano is one of the world’s top experts.

Addendum: Thank-you for all the interest in this article.  The subject is much too much to properly address in just a blog post.  If you are interested in more, please see my comment below and click on the Topic “Gluten and Wheat” in the side bar for my other posts, including two new ones today, May 26th.  There are foodie blogs that offer gluten-free low-carb recipes and suggestions.
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