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Celiac Sprue Disease

Gluten Free Diet

           

This diet is used to treat persons with celiac sprue and dermatitis herpetiformis.  Wheat, rye, oats, barley, and derivatives of these grains are omitted from the gluten restricted, gliadin-free diet.  Quinoa, spelt, teff, buckwheat, millet, and amaranth are also omitted due to incomplete information about their gluten content.  It is specifically the gliadin fraction of the gluten proteins that causes the response in susceptible persons.  Products that may be used are corn, potato, rice, tapioca, arrowroot, and soy; however, 20% of celiac patients report intolerances to soy.

           

Celiac sprue is an immune disorder of the small intestine, whereas dermatitis herpetiformis manifests itself on the skin.  The disease may appear at any age and is not outgrown.  Children 6 months to 3 years of age usually have diarrhea, projectile vomiting, a bloated abdomen, and growth failure.  Adults display various symptoms.  Diarrhea may or may not be present.  Appetite is often increased due to the inability to absorb nutrients.  Atrophy and flattening of the intestinal wall limit the absorptive surface for nutrients.  Weight loss, weakness, fatigue, flatulence, constipation, and abdominal pain and distention are common complaints.

           

Persons with newly diagnosed celiac sprue may have difficulty digesting lactose.  This lactose intolerance is usually temporary.  As the intestine heals, milk and milk products may be reintroduced in the diet. 

 

Celiac disease and dermatitis herpetiformis are permanent conditions.  It is not advisable to lapse from the diet even if it does not produce symptoms as gluten can still cause significant damage.  Noncompliance to the diet results in malabsorption of fat, fat-soluble vitamins, folate, vitamin B12, and the minerals calcium, magnesium, and iron.  A balanced diet can be achieved by choosing a variety of foods that are gluten-free.  A vitamin-mineral supplement and extra protein may be warranted initially. 

 

Reading Labels

 

Food labels must be read thoroughly to avoid wheat, rye, oats, barley, and their derivatives.  Essentially everything that is consumed by mouth or is used on the lips is suspect.  This includes medications, over-the-counter drugs, glue on envelopes and stamps, lip balms, and communion bread/wafers.  The following are ingredients that are often grain derived: hydrolyzed vegetable protein, flour or cereal products, texturized vegetable protein, malt and malt flavoring, modified starch or modified food starch, vegetable gum, soy sauce or soy sauce solids, mono- and diglycerides, vinegar, brown rice syrup, caramel coloring, natural flavorings, autolyzed yeast, and vanilla and other extracts. 

 

General Guidelines

  • Choose unprocessed meat, fish, poultry, fruits, vegetables, and dairy products.

  • When eating in restaurants, avoid sauces, soups, and gravies.  Avoid deep fat fried foods and bring your own salad dressings or use fresh lemon.

  • The alternative flours have individual characteristics and are often best used in combinations.  Alternative flours obtained from flour bins in co-ops may contain gluten due to cross-contamination with gluten-containing flours.

Foods Allowed and Foods to Avoid

 

Food Group

Foods Allowed

Foods to Avoid

Beverages

Instant and ground coffee (100% pure), instant tea (100% pure), tea, carbonated beverages, pure cocoa powder, wines made in the US, rums, some root beers, vodka distilled from grapes or potatoes, brandy, sake.

Ovaltine, malted milk, ale, beer, gin, whiskeys, vodka distilled from grains, flavored coffees, some herbal teas with malted barley, dark rum and brandies containing malt flavoring, Postum

Breads

Specially prepared breads using only allowed flours.  Examples of commercially availably breads: Ener-G Foods Brown Rice Bread®, White Rice Bread®, and Xanthan Gum Bread®.

All others containing wheat, rye, oat, barley flours; buckwheat, millet, spelt, amaranth, teff, and quinoa; breads made with carob soy flour from Sterling Food Company, Seattle (contains 80% wheat flour).

Cereals

Hot cereals made from cornmeal, Cream of Rice®, hominy, rice; Puffed Rice®, Kellogg’s Corn Pops®, Kellogg’s Kenmei Rice®, Post’s Fruity and Chocolate Pebbles®; special cereals made without malt (Van Brode®, Feather-weight brands), Ralston’s Sun Flakes®--corn and rice flakes only.

All other containing wheat, rye, oats, barley, bran, graham, wheat germ, malt, kaska, bulgur, buckwheat, millet, triticale, amaranth, spelt, teff, quinoa, kamut.

Cheeses

All aged cheeses such as cheddar, Swiss, edam, parmesan; cottage cheese, cream cheese, pasteurized processed cheese; cheese spreads

Any cheese product containing oat gum as an ingredient, some veined cheeses (blue, stilton, Roquefort, gorgonzola)

Crackers, snack foods

Rice crackers, specialty crackers using only allowed flours, rice cakes, pure cornmeal tortillas, popcorn, plain corn and potato chips.

All other containing wheat, rye, oats, or barley.  Those containing brown rice syrup.

Desserts

Cakes, quick breads, pastries, and puddings prepared with allowed ingredients; cornstarch, tapioca, and rice puddings; some pudding mixes, custard; ice cream with few, simple ingredients, sorbet, Junket®; meringues; mousse; sherbets; frozen yogurt

Commercial cakes, cookies, pies made with wheat, rye, oats, barley, millet, amaranth, buckwheat, spelt, teff, quinoa, kamut; prepared mixes; puddings; ice cream cones;

Jell-O instant pudding; cream fillings; products made with brown rice syrup.

Eggs

Plain or in cooking

Eggs in sauce made with gliadin-containing ingredients such as a wheat-based white sauce

Fats

Butter, margarine, vegetable oil, nuts, peanut butter, hydrogenated vegetable oils, some salad dressings, mayonnaise, nonstick cooking sprays

Some commercial salad dressings, wheat germ oil, nondairy cream substitutes, most commercial gravies and sauces.

Flours and thickening agents

Arrowroot starch; corn bran, corn flour, corn germ, cornmeal, cornstarch; potato flour, potato starch flour; rice bran; rice polish; rice starch; rice flours: plain, brown, sweet; soy flour; tapioca starch; garbanzo bean and lentil flours; nut flours

Amaranth, wheat germ, bran, wheat starch; all flours containing wheat, rye, oats, or barley; carob soy flour made by Sterling Foods Company, Seattle (contain 80% wheat flour), buckwheat, spelt, quinoa, teff, kamut, millet

Fruits, fruit juices

All fresh, frozen, canned, or dried fruits; all fruit juices; some canned pie fillings

Thickened or prepared fruits; some pie fillings; raisins and dried dates that have been dusted with flour

Meat, substitutes

All kinds of fresh meats, fish, other seafood, poultry; fish canned in oil, brine or water; some prepared meat products such as hot dogs and luncheon meats; tofu

Prepared meats containing wheat, rye, oats, or barley, such as some sausages, hot dogs, bologna, luncheon meats, chili con carne, sandwich spreads; bread-containing products such as Swiss steak, croquettes, meatloaf; tuna canned in vegetable broth; turkey with hydrolyzed vegetable protein injected as part of the basting solution; ground beef or pork with oat bran added in the form of “Oattrim®” or “Lean Maker®”; “imitation crab” containing wheat starch or other unacceptable filler


 

Milk

Fresh, dry, evaporated, or condensed milk; cream; sour cream; whipping cream; yogurt

Malted milk, some commercial chocolate drinks, some nondairy creamers

Potatoes, substitutes

White and sweet potatoes, yams, hominy, rice, wild rice, special gliadin-free noodles (APROTEIN® and other brands), some oriental rice and bean thread noodles

Regular noodles, spaghetti, macaroni, most packaged rice mixes, semolina, spinach noodles, frozen potato products with wheat flour added

Soups

Homemade broth and soups made with allowed ingredients, some commercially canned soups, specialty dry soup mixes

Most canned soups and soup mixes, bouillon and bouillon cubes with hydrolyzed vegetable protein (HVP- may appear as “natural flavorings” on the label)

Sugars, sweets

Jelly, jam, honey, brown and white sugar, molasses, most syrups, some candy, chocolate, pure cocoa, coconut, marshmallows (may be floured)

Some commercial candies (i.e., Almond Roca is dusted with wheat flour, chocolate-coated nuts are often rolled in flour); butterscotch chips; whipped toppings; chewing gum; flavored syrups, sweets containing malt/malt flavorings, natural flavorings, or brown rice syrup.

Vegetables, juices

All plain, fresh, frozen, or canned vegetables; dried peas and beans; lentils; some commercially prepared vegetables

Creamed vegetables, vegetables canned in sauce, some canned baked beans, commercially prepared vegetables and salads

Miscellaneous

Salt, pepper, cloves, allspice, ginger, nutmeg, cinnamon, chili powder; herbs; extracts: herb, alcohol-free flavoring; tomato puree and paste; olive; pickles; vinegar: cider, rice and whine; active dry yeast; bicarbonate of soda; baking powder; cream of tartar; dry mustard; some condiments; Tamari Soy Sauce-Wheat Free®; monosodium glutamate on US labels

Curry powder, dry seasoning mixes, gravy extracts, meat sauces, catsup, mustard, horseradish, chip dips, most soy sauce, distilled white vinegar, instant dry baking yeast, yeast extracts, cinnamon (may contain wheat flour, condiments made with wheat derived distilled white vinegar, alcohol based flavoring extracts, communion wafers/bread

Sample Menu

Breakfast

½ c orange juice

½ c Cream of Rice® cereal

1 egg, soft-cooked

1 slice rice bread, toasted

1 tsp butter

1 tbsp jelly

1 c 2% milk

2 tsp sugar

Coffee or tea

Lunch

2 oz slice chicken

1 c cooked rice

½ c green beans

1 slice tomato/lettuce

1 Gluten-free rice muffin

2 tsp butter

½ c canned peaches

1 Gluten-free cookie

1 c 2% milk

Coffee or tea

Dinner

3 oz roast beef

1 large baked potato

½ c cooked carrots

1 c tossed salad

1 tbsp Gluten-free dressing

1 Gluten-free cornmeal muffin

2 tsp butter

½ c Gluten-free ice cream

1 c 2% milk

Coffee or tea

Snack

1 banana

Snack

1 oz potato chips

Snack

1 apple

 

Reference:

 

Recent Advances in Therapeutic Diets, Fifth Edition.  Dietary Department, The University of Iowa Hospitals and Clinics, 1996; p134-139.

 

Hidden Sources of Wheat Gluten 

 

Wheat flour is present in many products, but it isn’t always listed as such.  Avoid products containing ingredients such as all-purpose flour, unbleached flour, bread flour, cake flour, whole-wheat flour, semolina, or durum because these are alternate terms for wheat flour and will contain gluten. And yes—white bread contains wheat (and, therefore, gluten).  Also, you must check to see whether your food is prepared in the same receptacle or manufacturing line as wheat-containing foods or somehow contaminated with wheat flour—even though it’s not listed as an ingredient.  Finally, this list may change over time so you must continually be careful and read labels.

 

Beverages: Avoid beer and ale, gin, whisky (bourbon, scotch and rye), vodka (if it’s grain-based; potato and grape-based vodka are wheat-free), Postum, and Ovaltine.

 

Breads: Unless the label says “wheat-free”, avoid any biscuits, breads, crackers, croutons, crumbs, doughnuts, tortillas, or wafers.  (You should also avoid breads made of oats, spelt, kamut, barley, and rye because they are similar to wheat and contain gluten.

 

Candy: Wheat may be an ingredient (for example, licorice contains wheat flour) or used in the shaping or handling of the candy.

 

Caramel Color or Flavoring: This may contain malt syrup or wheat starch.  Caramel flavoring is usually from corn.  To be safe, ask the manufacturer about the source.

 

Cereal: Avoid those made from wheat, rye, oats, barley, spelt, and kamut or if they contain malt flavoring or malt syrup.  Some associations also advise Celiac Sprue patients to avoid quinoa and amaranth.

 

Coffee: Some decaffeinated, flavored, and instant coffees may cause distress for persons who avoid wheat and gluten.

 

Condiments and Baking Ingredients: Check labels, especially on mixed spices, ketchup, some dried or prepared mustards, mayonnaise, salad dressings, and most soy sauces.  Look for wheat-free or gluten-free versions of these ingredients.

 

Dairy Products: Some flavored yogurts contain modified food starch (which could be wheat, but is most likely corn if made in the U.S.).  Malted milk, processed cheese spreads, and chocolate milk may contain wheat.  Low-fat sour cream may contain wheat.

 

Desserts and Other Sweets: You’ll bake your own pies, cakes and cookies—but also avoid commercial pudding mixes, marshmallow crème, cake decorations, and marzipan because they may contain wheat flour as a thickener or binder.

 

Distilled Vinegar: Vinegar made from wine, rice, or cider is usually safe for wheat-sensitive persons.  Revised standards now say distilled vinegar is safe for celiacs.

 

Hydrolyzed Plant Protein (HPP): Can be made from wheat starch.

 

Hydrolyzed Vegetable Protein (HVP): Labels should list source of protein.

 

Flavorings and Extracts: Revised standards now permit flavorings and extract on gluten-free diets.

 

Meat and Eggs: Avoid any meat that’s been breaded or in which fillers might be used such as sausage, luncheon meats, or hot dogs.  Avoid self-basting turkeys.  Buy tuna in spring water rather than oil.  Egg-substitutes are not pure eggs but often contain many other additional ingredients—possibly wheat flour.

 

Modified Food Starch: This could be corn or wheat or some other unidentified food starch.  Unless the label specifically states the source, it’s best to avoid altogether.  Generally speaking, modified food starch is corn if made in the U.S.

 

Pastas: You can eat some Oriental rice noodles, bean threads, and commercial pasta made from rice, corn, tapioca, or potato starch flour.  Be sure to read labels since some pasta is made from a mixture of flours, which may also include wheat, or a member of the wheat family.

 

Soups and Chowders: Most canned soups, soup mixes, and bouillon cubes or granules contain hydrolyzed vegetable protein (HVP), which may contain wheat.

 

Texturized Vegetable Protein (TVP): Avoid vegetables that are breaded, creamed, or scalloped because this usually involves wheat flour or bread crumbs made from wheat flour.  When you see “vegetable starch” or “vegetable protein” on a label, this could mean protein from corn, peanuts, rice, soy—or wheat.


 

For more information about Celiac Disease, contact the following organizations:

 

The Celiac Disease Foundation, www.celiac.org

The National Institute of Diabetes and Digestive and Kidney Diseases, NIH, http://digestive.niddk.nih.gov/index.htm