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Gluten-free diet

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A gluten-free diet is a diet completely free of ingredients derived from gluten-containing cereals: wheat (including kamut and spelt), barley, rye, and triticale, as well as the use of gluten as a food additive in the form of a flavoring, stabilizing or thickening agent. It is recommended amongst other things in the treatment of coeliac disease, non-coeliac gluten intolerance[citation needed], dermatitis herpetiformis[citation needed], migraines[citation needed], Lyme disease[citation needed] and wheat allergy[citation needed]. Additionally, the diet may exclude oats. Some people for whom the diet is recommended can tolerate oat products and some medical practitioners say they may be permitted,[1] but there is some controversy about including them in a gluten-free diet because studies on the subject are incomplete.[2] Even if oats are included, it is important to source these from a facility that is gluten free, as most oats are contaminated during processing.

Gluten-free food

Quinoa
Chickpeas

Several grains and starch sources are considered acceptable for a gluten-free diet. The most frequently used are corn, potatoes, rice, and tapioca (derived from cassava). Other grains and starch sources generally considered suitable for gluten-free diets include amaranth, arrowroot, millet, montina, lupin, quinoa, sorghum (jowar), sweet potato, taro, teff, chia seed, and yam. Various types of bean, soybean, and nut flours are sometimes used in gluten-free products to add protein and dietary fiber. In spite of its name, buckwheat is not related to wheat; pure buckwheat is considered acceptable for a gluten-free diet, although many commercial buckwheat products are actually mixtures of wheat and buckwheat flours, and thus not acceptable. Gram flour, derived from chickpeas, is also gluten-free (this is not the same as Graham flour made from wheat).

Gluten is also used in foods in some unexpected ways, for example as a stabilizing agent or thickener in products like ice-cream and ketchup.[3][4]

People wishing to follow a completely gluten free diet must also take into consideration the ingredients of any over-the-counter or prescription medications and vitamins. Also, cosmetics such as lipstick, lip balms, and lip gloss may contain gluten and need to be investigated before use.

Cross-contamination issues

Special care is necessary when checking product ingredient lists since gluten comes in many forms: vegetable proteins and starch, modified food starch (when derived from wheat instead of maize), malt flavoring, and glucose syrup. Many ingredients contain wheat or barley derivatives. Maltodextrin, formerly thought to contain gluten, is now generally considered gluten free.[5]

Although many foods contain gluten, it is not always included in ingredients lists. This lack of inclusion is because gluten is not used in the formulation of the product, but in the preparation (or manufacturing) of listed ingredients. One example is the dusting of the conveyor belts in the production facilities with gluten products to prevent the foods from sticking during processing.

Controversy over oats

Oat grains in their husks

The suitability of oats in the gluten-free diet is still somewhat controversial. Some research suggests that oats in themselves are gluten free, but that they are virtually always contaminated by other grains during distribution or processing. However, recent research[6] indicated that a protein naturally found in oats (avenin) possessed peptide sequences closely resembling wheat gluten and caused mucosal inflammation in significant numbers of celiac disease sufferers. Some examination results show that even oats which are not contaminated with wheat particles are nonetheless dangerous to about 10 percent of coeliacs, while not very harmful to the majority. Such oats are generally considered risky for coeliac children to eat, but two studies show that they are completely safe for coeliac adults to eat, [7] even over a period of five years.[8] Given this conflicting information, excluding oats appears to be the only risk-free practice for celiac disease sufferers of all ages.[9] However, medically approved guidelines exist for those coeliacs who do wish to introduce oats into their diet.[10]

Further information: [[:The oat controversy and Oat sensitivity]]

Unless manufactured in a dedicated facility and under gluten-free practices, all cereal grains, including oats, can be cross-contaminated with gluten. Grains become contaminated with gluten by sharing the same farm, truck, mill, or bagging facility as wheat and other gluten-containing grains. Therefore, removing all flours and grains from the diet may be the only way to guarantee a complete absence of gluten in the diet.

Accuracy of "gluten-free" labels

Sausages may contain gluten via fillers or binders such as Butcher's Rusk

Standards for "gluten-free" labelling have been set up by the "Codex Alimentarius"; however, these regulations do not apply to "foods which in their normal form do not contain gluten".[11]

The legal definition of the phrase "gluten-free" varies from country to country. Current research suggests that for persons with celiac disease the maximum safe level of gluten in a finished product is probably less than 0.02% (200 parts per million) and possibly as little as 0.002% (20 parts per million).

Australian standards reserve the "gluten free" label for foods with less than 5 parts per million of gluten, as this is the smallest amount currently detectable. In the processing of gluten-containing grains, gluten is removed (shown in the processing flow below)

Wheat Flour (80,000ppm) > Wheat Starch (200ppm) > Dextrin > Maltodextrin > Glucose Syrup (<5ppm) > Dextrose > Caramel Color

Since ordinary wheat flour contains approximately 12% gluten,[12] even a tiny amount of wheat flour can cross-contaminate a gluten-free product. Therefore, considerable care must be taken to prevent cross-contamination in both commercial and home food preparation.

This diet rules out all ordinary breads, pastas, and many convenience foods; it also excludes gravies, custards, soups and sauces thickened with wheat, rye, barley or other gluten-containing flour. Many countries do not require labeling of gluten containing products, but in several countries (especially Australia and the European Union) new product labeling standards are enforcing the labeling of gluten-containing ingredients. Various gluten-free bakery and pasta products are available from specialty retailers.

In the United States, gluten may not be listed on the labels of certain foods because the U.S. Food and Drug Administration has classified gluten as GRAS (Generally Recognized As Safe).[13] Requirements for proper labeling are being formulated by the USDA. It is currently up to the manufacturers of "gluten free" food items to guarantee such a claim. "A final rule that defines the term gluten-free and identifies the criteria that would enable the food industry to use that term" was scheduled to be released by the FDA on August 2, 2008 [14]. This final rule has not yet come to fruition. For now, many individuals who must eat gluten free use sources online to search the gluten free content of products. One common gluten free product search site is Celiaccess.com [2]

Many so-called gluten free products have been found to have been contaminated with gluten such as chicken bouillon, corn cereal, and caramel ice cream topping. [15]. For example, in a investigation reported by the Chicago Tribune on November 21, 2008, Wellshire Farms chicken nuggets labeled "gluten-free" were purchased and samples were sent to a food allergy lab at the University of Nebraska.[16] Results of the testing indicated gluten was present in levels exceeding 2,000 ppm. After the article was published, the products were continued to be sold. However, after receiving customer inquiries, Whole Foods Market removed the product from their shelves over a month later. Wellshire Farms has since replaced the batter used in their chicken nuggets.[17]

In the United Kingdom, only cereals currently need to be labeled, while other products are voluntary.[18] For example, most British sausages contain Butcher's Rusk, a grain-derived food additive.[19] Furthermore, while UK companies selling food prepared on their own premises are given guidance by the Food Standards Agency, they are not required to meet any labeling requirements.[20]

Lastly, some non-foodstuffs such as medications and vitamin supplements, especially those in tablet form, may contain gluten as an excipient or binding agent.[21][22] People with gluten intolerances may therefore require specialist compounding of their medication.[12]

Alcoholic beverages

Several celiac groups report that according to the American Dietetic Association's "Manual of Clinical Dietetics" [23] [24] many types of alcoholic beverages are considered gluten free, provided no colourings or other additives have been added as these ingredients may contain gluten. Although most forms of whiskey are distilled from a mash that includes grains that contain gluten, distillation removes any proteins present in the mash, including gluten. Although up to 49% of the mash for Bourbon and up to 20% of the mash for corn whiskey may be made up of wheat, or rye, all-corn Bourbons and corn whiskeys do exist, and are generally labeled as such. Spirits made without any grain such as brandy, wine, mead, cider, sherry, port, rum, tequila and vermouth do not contain gluten, although some vineyards use a flour paste to caulk the oak barrels in which wine is aged[25], so some celiacs may wish to exercise caution. Liqueurs and pre-mixed drinks should be examined carefully for gluten-derived ingredients.

It should be noted that, while many spirits were traditionally made without grain, such as tequila, rum and vodka, today they are more commonly made with barley, wheat or rye (instead of agave, sugar or potatoes, etcetera). Often, only high-end specialty alcoholic brands are made with what are considered the traditional ingredients. In addition, many people diagnosed with celiac disease still experience symptoms when drinking distilled alcoholic beverages. Therefore, it is advised that a person with celiac disease check with a manufacturer about the ingredients that have been used in a hard liquor, and to proceed with caution if choosing to drink a liquor that is made with wheat, barley, oats or rye.

Almost all beers are brewed with malted barley or wheat and will contain gluten. Sorghum and buckwheat-based gluten-free beers are available, but remain very much a specialty product. Some low-gluten beers are also available, however there is disagreement over the use of gluten products in brewed beverages: Some brewers argue that the proteins from such grains as barley or wheat are converted into amino acids during the brewing process and are therefore gluten-free,[26] however there is evidence that this claim is false.[27]

Medical benefits

The scientific literature on the link between gluten and autism is mixed and there is no substantial research on in utero causality. There have been too few adequately designed, large-scale controlled studies and clinical trials to state whether the diet is effective.[28] A small, single-blind study has documented fewer autistic behaviors in children fed a gluten-free, casein-free diet, but noted no change in cognitive skills, linguistic ability, or motor ability.[29] This study has been criticized for its small sample size, singleblind design which may have skewed results on the basis of a "parent placebo effect".[30] A 2006 double-blind short-term study found no significant differences in behavior between children on a gluten-free, casein-free diet and those on regular diets.[31] A long term double-blind clinical trial sponsored by the National Institute of Mental Health ran from 2004 until November 2008; as of July 2009, results are not yet available[32].


Gluten sensitivity is also seen as a genetically inheritable problem. Though limited studies have been conducted some people [who?] have seen the gluten free diet improve their life while handling problems such as: Parkinson’s disease, Multiple sclerosis, Seizures, Cognitive problems, Type 2 and Type 1 diabetes, Down syndrome, Rheumatoid arthritis, and other medical conditions. [33][volume & issue needed] While treating other conditions people need to be aware that some medications contain gluten. With gluten being an ingredient in medication it is highly advised that a person on the gluten free diet consult a doctor and check the labels of medications before beginning a medication. [34]

Deficiencies linked to maintaining a gluten-free diet

After the implementation of a gluten-free diet there can be many persisting deficiencies, which can be “due to slow or incomplete healing of the small intestine, failure to eat foods rich in needed nutrients, eating too much fiber with meals, thus binding nutrients, H. pylori infection, small bowel bacterial overgrowth, giardia, or other infections and parasites”[35]. Many gluten-free made products are not fortified, enriched, or have all the nutrients that the natural sources contain, thus these products are especially low in folate, iron, and fiber. Also, due to the fact that gluten-free products are not always available, many Gluten-Sensitive Enteropathy (GSE) patients do not consume the recommended amount of grain servings per day. The standard gluten-free diet does not meet the recommended intake for fiber, thiamine, riboflavin, niacin, folate, iron, or calcium. People that change their standard gluten-free diet to implement gluten-free oats at breakfast, high fiber brown rice bread at lunch, and quinoa as a side at dinner have been found to have significant increases in protein (20.6g versus 11g), iron (18.4mg versus 1.4mg), calcium (182mg verses 0mg), and fiber (12.7g verses 5g). The B vitamin group did not have significant increases, but were still found to have improved values of thiamine, riboflavin, niacin, and folate [36]. These dietary changes can greatly reduce a GSE patient’s risk for anemia (especially Iron Deficiency Anemia) and low blood calcium levels or poor bone health. Not only is it important to avoid gluten, but also finding more nutrient-dense, gluten-free food sources to prevent patients from other diseases due to deficiencies.

Supplements

It is also important for GSE patients to consume a variety of fruits and vegetables (all which are gluten-free) to ensure consumption of recommended dietary intake of all nutrients. While avoiding gluten and eating enriched gluten-free sources can be stressful and overwhelming, supplements can be a good choice to include in order to avoid common deficiencies and help with intestinal restoration. Dr. Lieberman [37] suggests using a wide-range of multivitamin/mineral supplementation, which can be found in multi-nutrient formation in a daily dose of 4 to 6 capsules. The optimal amounts of nutrients that can be taken as a preventative measure for different types of anemia and to avoid bone loss are found in the following table:

Nutrient Quantity
Vitamin D 400 IU (if low take 2,000–4,000 IU to increase bone health)
B-complex (thiamin, riboflavin, niacin, pyridoxine, pantothenic acid, para-aminobenzoic acid, choline, and inositol) 25 mg of each 25 mg of each
Folic acid 400 mcg
Calcium 500 mg (aim for 500–1,000 mg extra in diet)
Iron Only take in case of iron deficiency or anemia
Magnesium 15 mg (aim for 500–750 mg total)
Phosphorus and potassium Found in most foods

Along with these nutrients, there are other nutrients used to heal the digestive tract and prevent malabsorption. Fish oil (omega-3 and omega-6 fatty acids) can help to heal the inflammation of the digestive tract because chronic inflammation in the small intestine can cause tissue damage and stress on GSE patient’s organs stressing the immune system. Dr. Lieberman recommends taking 1500–4000 mg (4–6 capsules) a day of fish oil. Acidophilius and other beneficial microorganisms are important to help break down food and even protect the gastrointestinal tract from bacteria and viral infections. Lactobacillus casei GG is recommended for patients with gluten intolerance. Glutamine, an important amino acid in the GI tract, helps to heal inflammation and repair damaged tissues. This is made in our body, but supplementing 500 to 3,000 mg of L-glutamine may be taken under professional advice to nourish and restore the intestinal villi. Phosphatidylcholine can be supplemented to help heal the intestinal mucosa at a dose of 100 to 300 mg. Lastly, fiber supplementation is healthy in those patients experiencing constipation and should not be taken unless needed, due to a major side effect of excessive gas if the digestive tract is inflamed (highly likely in GSE patients).

See also

Wikibooks Cookbook has a recipe/module on

Notes

  1. ^ N Y Haboubi, S Taylor, S Jones (2006). "Coeliac disease and oats: a systematic review". The Fellowship of Postgraduate Medicine.{{cite web}}: CS1 maint: multiple names: authors list (link)
  2. ^ "The Gluten-Free Diet" – CeliacSociety.com
  3. ^ Pat Kendall, Ph.D., R.D. (March 31, 2003). "Gluten sensitivity more widespread than previously thought". Colorado State University Extension.{{cite web}}: CS1 maint: multiple names: authors list (link)
  4. ^ "Following a Gluten-free Diet". Beth Israel Deaconess Medical Center. A Harvard teaching hospital. {{cite web}}: Check date values in: |date= (help)
  5. ^ Gluten Free Living: Ingredients. Accessed 2009-08-31.
  6. ^ Arentz-Hansen, Helene (2004-10-19). "The Molecular Basis for Oat Intolerance in Patients with Celiac Disease". PLoS Medicine. Retrieved 2006-07-22. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  7. ^ Størsrud, S (2002-05-07). "Adult coeliac patients do tolerate large amounts of oats". European Journal of Clinical Nutrition. Retrieved 2008-08-14. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  8. ^ Janatuinen, E K (2002-05-01). "No harm from five year ingestion of oats in coeliac disease". GUT Journal Online. Retrieved 2008-08-14. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  9. ^ "The Scoop on Oats". Celiac Sprue Association (CSA). February 20, 2008.
  10. ^ Mohsid, Rashid (2007-06-08). "Guidelines for Consumption of Pure and Uncontaminated Oats by Individuals with Coeliac Disease". Professional Advisory Board of Canadian Coeliac Association. Retrieved 2008-08-14.
  11. ^ "Codex Standard For "Gluten-Free Foods" CODEX STAN 118-1981" (PDF). Codex Alimentarius. February 22, 2006.
  12. ^ a b Spersud, Erik and Jennifer (January 3, 2008). Everything You Want To Know About Recipes And Restaurants And Much More. USA: Authorhouse. p. 172. doi:10.1007/b62130. ISBN 9781434360342.
  13. ^ "Sec. 184.1322 Wheat gluten". Code of Federal Regulations Center. April 1, 2007.
  14. ^ Kane, Rhonda (August 19, 2005). "Public Meeting On: Gluten-Free Food Labeling". U.S. FDA. Retrieved 2007-03-27.
  15. ^ Schorr, Melissa (March 22, 2004). "Study: Wheat-Free Foods May Contain Wheat". WebMD.com. Retrieved 2008-08-14.
  16. ^ "Children at risk in food roulette". Chicagotribune.com. Retrieved 2009-09-20.
  17. ^ "Whole Foods pulls 'gluten-free' products from shelves after Tribune story". Chicagotribune.com. Retrieved 2009-09-20.
  18. ^ "Guidance Notes on the Food Labeling (Amendment)(No. 2) Regulations 2004" (PDF). Food Standards Agency. 2005. {{cite web}}: Unknown parameter |month= ignored (help)
  19. ^ "Labelling and Composition of Meat Products" (PDF). Food Standards Agency. April 22, 2004. Retrieved 2008-02-23.
  20. ^ "Food allergy guidance published". BBC News. January 16, 2008. Retrieved 2008-02-24.
  21. ^ "Frequently Asked Questions". IPC Americas Inc. 2008-02-27. Retrieved 2008-04-15. {{cite web}}: External link in |publisher= (help)
  22. ^ "Excipient Ingredients in Medications". Gluten Free Drugs. November 3, 2007. Retrieved 2008-04-15. {{cite web}}: External link in |publisher= (help)
  23. ^ "ADA Publishes Revised GF Diet Guidelines"
  24. ^ "Which alcoholic beverages are safe?" Celiac.com
  25. ^ StaVin Barrel Inserts Inc. [1] Retrieved on 05/18/2009
  26. ^ "Is Beer Gluten-Free and Safe for People with Celiac Disease?". Celiac.com. 2006.
  27. ^ "Improved Methods for Determination of Beer Haze Protein Derived from Malt". Marian Sheehan A, Evan Evans B, and John Skerritt. 2001. {{cite web}}: Text "Australian barley technical Symposium" ignored (help)
  28. ^ Millward C, Ferriter M, Calver S, Connell-Jones G (2008). "Gluten- and casein-free diets for autistic spectrum disorder". Cochrane Database Syst Rev (2): CD003498. doi:10.1002/14651858.CD003498.pub3. PMID 18425890.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  29. ^ Knivsberg AM, Reichelt KL, Høien T, Nødland M (2002). "A randomised, controlled study of dietary intervention in autistic syndromes". Nutr Neurosci. 5 (4): 251–61. doi:10.1080/10284150290028945. PMID 12168688.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  30. ^ Christison GW, Ivany K (2006). "Elimination diets in autism spectrum disorders: any wheat amidst the chaff?". J Dev Behav Pediatr. 27 (2 Suppl 2): S162–71. doi:10.1097/00004703-200604002-00015. PMID 16685183.
  31. ^ Elder JH, Shankar M, Shuster J, Theriaque D, Burns S, Sherrill L (2006). "The gluten-free, casein-free diet in autism: results of a preliminary double blind clinical trial". J Autism Dev Disord. 36 (3): 413–20. doi:10.1007/s10803-006-0079-0. PMID 16555138.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  32. ^ "Diet and Behavior in Young Children With Autism".
  33. ^ Kimberly Burnham, "Benefits of a Gluten-Free;Gluten Sensitivity and Celiac Disease – Not Just a Digestive Problem" Feb. 20 2007
  34. ^ Betty Kovacs, MS, RD, "Celiac Disease: Gluten-Free Diet". Foods Containing Gluten. http://www.medicinenet.com/celiac_disease_gluten_free_diet/page5.htm
  35. ^ Libonati J, Libonati C (2009). "Understanding celiac disease". Today's Dietician. 11 (6): 50. {{cite journal}}: |access-date= requires |url= (help)
  36. ^ Lee AR, Ng DL, Dave E, Ciaccio J, Green PHR (2009). "The effect of substituting alternative grains in the diet on the nutritional profile of the gluten-free diet". Journal of Human Nutrition and Dietetics. 22: 359–363. {{cite journal}}: Text "accessdate 2009-11-02" ignored (help)CS1 maint: multiple names: authors list (link)
  37. ^ Lieberman S (2007). The gluten connection. pp. 124–136. {{cite book}}: Unknown parameter |subtitle= ignored (help)
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