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The Gluten-free Diet: Some Examples

In 2006, the American Dietetic Association updated its recommendations for a gluten-free diet. The following chart is based on the 2006 recommendations. This list is not complete, so people with celiac disease should discuss gluten-free food choices with a dietitian or physician who specializes in celiac disease. People with celiac disease should always read food ingredient lists carefully to make sure the food does not contain gluten.

Points to Remember

  • People with celiac disease cannot tolerate gluten, a protein in      wheat, rye, and barley.
  • Untreated celiac disease damages the small intestine and interferes      with nutrient absorption.
  • Without treatment, people with celiac disease can develop      complications such as osteoporosis, anemia, and cancer.
  • A person with celiac disease may or may not have symptoms.
  • Diagnosis involves blood tests and, in most cases, a biopsy of the      small intestine.
  • Since celiac disease is hereditary, family members of a person with      celiac disease may wish to be tested.
  • Celiac disease is treated by eliminating all gluten from the diet.      The gluten-free diet is a lifetime requirement.
  • A dietitian can teach a person with celiac disease about food      selection, label reading, and other strategies to help manage the disease.

Celiac Disease

Celiac disease has been known by many different names in the medical literature over the years, including gluten-sensitive enteropathy and celiac sprue (to differentiate it from tropical sprue). CELIAC DISEASE can be defined as a permanent intolerance to the gliadin fraction of wheat protein and related alcohol-soluble proteins (called prolamines) found in rye and barley. CELIAC DISEASE occurs in genetically susceptible individuals who eat these proteins, leading to an autoimmune disease, where the body’s immune system starts attacking normal tissue. This condition continues as long as these food products are in the diet.

The resulting inflammation and atrophy of the intestinal villi (small, finger-like projections in the small intestine) results in the malabsorption of critical vitamins, minerals, and calories. Signs and symptoms of the disease classically include diarrhea, short stature, iron-deficiency anemia and lactose intolerance. However, many patients will also present with “non-classical” symptoms, such as abdominal pain, “irritable bowel”, and osteoporosis. Patients may also be screened for celiac disease because of the presence of another autoimmune disease, such as type I diabetes or thyroid disease, or a family history of celiac disease, without having any obvious symptoms. Serum antibodies can be utilized to screen for celiac disease. However, the key to confirming the diagnosis remains a small intestinal biopsy, and the patient’s subsequent clinical response to a gluten-free diet. Clinicians in the United States must maintain a high index of suspicion for this disease, as it is significantly under-diagnosed in this country.

What is a wheat allergy?

People can also have other medical problems, besides celiac disease, when they eat wheat and related proteins. Wheat allergy is one of the top 8 food allergies in the United States. Allergic reactions after eating wheat may include reactions in the skin, mouth, lungs, and even the GI tract. Symptoms of wheat allergy can include rash, wheezing, lip swelling, abdominal pain and diarrhea. The branch of the immune system activated in allergic reactions is different from the branch thought to be responsible for the autoimmune reactions of celiac disease.

What is gluten intolerance?

People can also experience ‘intolerance’ to gluten. Food intolerances are not thought to be immune mediated. GI symptoms with wheat or gluten intolerance may include gassiness, abdominal pain, abdominal distension, and diarrhea. These symptoms are usually transient, and are thought NOT cause permanent damage.

Patients with lactose intolerance, where the lactose sugar in diary products is not digested well, may also experience gassiness, abdominal pain, abdominal distension, and diarrhea. Like gluten or wheat intolerance, these symptoms will pass once the lactose is out of the person’s system, and will not cause permanent damage.

Why is it important to know if you have celiac disease, versus wheat allergy or gluten intolerance?

Celiac disease, wheat allergy and gluten-intolerance are treated similarly, in that patients with these conditions must remove wheat from their diet. It is important to note, however, that there is a difference between these three medical problems. Celiac disease is an autoimmune condition, where the body’s immune system starts attacking normal tissue, such as intestinal tissue, in response to eating gluten. Because of this, people with celiac disease are at risk for malabsorption of food in the GI tract, causing nutritional deficiencies. This can lead to conditions such as iron deficiency anemia and osteoporosis. Since a person with wheat allergy or gluten-intolerance usually does not have severe intestinal damage, he or she is not at risk for these nutritional deficiencies. Celiac disease is an autoimmune condition, putting the patient at risk for other autoimmune conditions, such as thyroid disease, type I diabetes, joint diseases and liver diseases. Since wheat allergy and gluten intolerance arenot autoimmune conditions, people who have food allergies and intolerances arenot at increased risk to develop an autoimmune condition over the general population’s risk. And finally, celiac disease involves the activation of a particular type of white blood cell, the T lymphocyte, as well as other parts of the immune system. Because of this, patients with celiac disease are at increased risk to develop GI cancers, in particular lymphomas. Because food allergies and intolerances do not involve this particular immune system pathway, and do not cause severe GI tract damage, these patients are not at increased risk for these cancers.

Thus, while celiac disease, wheat allergy, and gluten-intolerance may be treated with similar diets, they are not the same conditions. It is very important for a person to know which condition they have, as the person with celiac disease needs to monitor himself or herself for nutritional deficiencies, other autoimmune diseases, and GI cancers. In general, the symptoms from food allergies and intolerances resolve when the offending foods are removed from the diet and do not cause permanent organ damage

The Gluten-free Diet

A gluten-free diet means not eating foods that contain wheat, rye, and barley. The foods and products made from these grains should also be avoided. In other words, a person with celiac disease should not eat most grain, pasta, cereal, and many processed foods.

Despite these restrictions, people with celiac disease can eat a well-balanced diet with a variety of foods. They can use potato, rice, soy, amaranth, quinoa, buckwheat, or bean flour instead of wheat flour. They can buy gluten-free bread, pasta, and other products from stores that carry organic foods, or order products from special food companies. Gluten-free products are increasingly available from mainstream stores.

“Plain” meat, fish, rice, fruits, and vegetables do not contain gluten, so people with celiac disease can freely eat these foods. In the past, people with celiac disease were advised not to eat oats. New evidence suggests that most people can safely eat small amounts of oats, as long as the oats are not contaminated with wheat gluten during processing. People with celiac disease should work closely with their health care team when deciding whether to include oats in their diet. Examples of other foods that are safe to eat and those that are not are provided in the table.

The gluten-free diet requires a completely new approach to eating. Newly diagnosed people and their families may find support groups helpful as they learn to adjust to a new way of life. People with celiac disease must be cautious about what they buy for lunch at school or work, what they purchase at the grocery store, what they eat at restaurants or parties, and what they grab for a snack. Eating out can be a challenge. When in doubt about a menu item, a person with celiac disease should ask the waiter or chef about ingredients and preparation or if a gluten-free menu is available.

Gluten is also used in some medications. People with celiac disease should ask a pharmacist if prescribed medications contain wheat. Because gluten is sometimes used as an additive in unexpected products—such as lipstick and play dough—reading product labels is important. If the ingredients are not listed on the label, the manufacturer should provide a list upon request. With practice, screening for gluten becomes second nature.

What is Gluten?

Gluten is a protein found in grains including wheat, rye, oats and barley. Patients with Coeliac disease are sensitive to gluten which damages the lining of the small bowel. This damage affects the absorption of food and can lead to symptoms including weight loss, diarrhoea, iron and folic acid deficiency. A gluten free diet is the only long term treatment for Coeliac disease. Complete removal of gluten from the diet allows the gut to recover to normal over a period of time. Even small amounts of gluten are enough to prevent recovery or cause further damage. Obvious symptoms or damage may not occur at the time of consumption.

It is important to include a wide variety of gluten free cereal products in a Gluten Free diet. This can be as simple as adding small amounts of soy, potato flour or rice bran to a dish. These are important sources of fibre, B group vitamins, zinc and increase the variety of the diet.

Food Labelling and Gluten

The Australian Standard of Gluten Free foods1 now requires that foods labelled as “Gluten Free” contain no detectable gluten using a sensitive assay. There is no evidence that inclusion of extracted ingredients causes mucosal damage2 although some patients with Coeliac disease may prefer not to eat products which contain these extracted ingredients. The Coeliac Society of Australia has changed the category of these products in their ingredient list including glucose syrup, dextrose and caramel colouring. Under the new standard, it will require careful reading of ingredients on products labelled as “gluten free”if Coeliacs choose to avoid these foods.

Foods may also contain less obvious sources of gluten as there is no requirement for manufacturers to specify the composition of ingredients that contribute less than 10% of a food. For example, it may be difficult to determine the origin of a soy sauce included as an ingredient in a commercial marinade. This means that gluten may be “carried over” into the marinade via the soy sauce. It is best to contact the manufacturer directly to determine the source of these ingredients.

It is essential that all food labels be rechecked regularly since the composition may change. Avoid any food that is doubtful.

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