Celiac Disease & Gluten Intolerance Gluten-Free Guidelines

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1 Celiac Disease & Gluten Intolerance Gluten-Free Guidelines What is celiac disease? Celiac disease is damage to the small intestine caused by eating food containing gluten. Gluten is a protein found in wheat, barley and rye. What are the symptoms of celiac disease? Symptoms of celiac disease vary greatly from person to person. However, the disease can also be symptom-free. Common symptoms include: Abdominal distention Abdominal pain Anemia Anorexia (poor appetite) Bloating Bone pain Constipation Cramping Dental hypoplasia (enamel missing on teeth) Dermatitis herpetiformis (rash) Diarrhea Failure to grow (children) Fatigue (tired, no energy) Folate deficiency Foul smelling stools Inability to concentrate Infertility in women Irritability Iron deficiency anemia Muscle cramps Osteopenia and osteoporosis (bone loss) Short stature Sleep disturbance Weakness Weight loss Vomiting How do you know if you have celiac disease? Diagnosis is often difficult because symptoms are frequently minor or unusual, and the disease may even be symptom-free. If your health care provider suspects you have celiac disease, he or she may order blood tests to measure the levels of antibodies to gluten in your blood. If the test comes back positive, you will need a biopsy of your small intestine to confirm the diagnosis. Diagnosis is verified once improvement is seen when all gluten is removed from the diet and symptoms resolve. What is the prevalence of celiac disease? The prevalence of celiac disease in the United States is believed to be approximately one in 100 people, which was published in In the past the prevalence in the United States has been underestimated, due to misdiagnosis and difficulty of diagnosing symptom-free celiac disease. It is estimated that ~97% of the people with celiac disease have not been diagnosed. Approximately 5-16% of people with Type 1 diabetes also have celiac disease as compared to ~1% of the general population. How is celiac disease treated? At this time, the only known treatment is the gluten-free meal plan and this is a lifelong change. Most people with celiac disease who follow a gluten-free meal plan will begin to feel better very quickly. The small intestine will begin to heal and to absorb nutrients within 3-6 days. Copyright 2014 by Joslin Diabetes Center ( All rights reserved. This document may be used for personal, noncommercial use only. For permission for other use call

2 Even though symptoms may disappear quickly, complete recovery may take anywhere from 3 months to 2 years. A gluten-free meal plan has been shown to replenish both body weight and your body s nutrient stores, as well as to decrease the risk of future complications. People with celiac disease who do not follow the gluten-free diet have an increased risk of developing complications, which include many of the symptoms listed and additional autoimmune conditions. Gluten-free guidelines Gluten is a term used to describe certain proteins in wheat, barley and rye. Avoiding all sources of gluten promotes healing of the small intestine, decreases symptoms, and allows normal nutrient absorption. The gluten-free meal plan can be well balanced and include a variety of foods. Breads and cereals can be the most difficult items to find acceptable replacements for. Many of the glutenfree products available are not fortified, so it is important to visit with your dietitian to ensure that your diet is meeting your nutritional needs. In 2006 the US Food Drug and Drug Administration (FDA) passed a law requiring all manufactured foods that contain any of the eight most common food allergens be clearly labeled. These eight foods are wheat, eggs, milk, soy, shellfish, fish, peanuts and tree nuts. If wheat is added to a food the food must be clearly labeled as containing wheat. This law does not cover barley or rye. In 2013 the FDA passed a rule to define gluten-free and it can be labeled gluten free if it meets the following rules: Inherently does not contain gluten (e.g., almonds, bottled water) OR Meets the following criteria o Does not contain wheat, rye, barley or cross-bred hybrids of these grains o May contain an ingredient that is derived from a gluten-containing grain and has been processed to remove the gluten (e.g., wheat starch) as long as the food product contains less than 20 ppm of gluten o Does not contain 20 ppm or more of gluten AND Any unavoidable gluten in the food due to cross-contact or migration of gluten from packaging material is less than 20 ppm gluten. Page 2 of 9

3 Reading food labels carefully and becoming familiar with gluten-containing ingredients is important to ensure a gluten-free diet. Some food ingredients can contain gluten and their source should always be checked. They are listed below. Malt or malt flavoring are made from barley Flavorings if wheat is used it will be on the label, if barley is used it is listed as malt flavoring in the ingredient list. Seasonings are often mixtures of several herbs and spices. Check the label for wheat, barley and rye; they are rarely added but could be. Starch in medicines, vitamins, dietary supplements In the United States approximately 20,000 new food products are introduced to the grocery store on a yearly basis. In addition, products are constantly being improved and changed. Always check the labels to make sure that the products that you are consuming continue to be glutenfree. Gluten-free foods can be found in many grocery store chains, Asian markets and specialty health food stores. There are also many food mail-order companies that specialize in gluten free foods. Tax deduction for gluten-free foods If you or your child has celiac disease and you itemize your deductions, the additional cost for the GF foods can be counted as a medical expense. The difference in the cost of gluten-free food and a similar food item is tax deductible. For example if a gluten-free loaf of bread cost $7 and wheat bread cost $4, the difference of $3 can be counted as a medical expense. You can also declare the mileage when traveling to and from health food stores, and the shipping cost of the special food items. You may deduct 23 cents per mile (2012) and tolls and parking expenses. The total cost of necessary GF items that are not commonly used in other cooking is also deductible. For example the cost of xanthan gum can be declared since it is very different from any other item you might use in baking. The total amount of your deductions should be added to your other medical expenses and are reported on Schedule A of form Save all your cash receipts and cancelled checks to be able to document the claim. If audited you will need a letter from your provider stating that you or your child have celiac disease and must follow a gluten-free diet. For more information refer to IRS ruling and IRS Publication 502. Page 3 of 9

4 Grains and Flours Amaranth, arrowroot, artichoke, bean flours (beans, lentils, kidney beans, peas, fava, romano), buckwheat, corn (cornstarch, cornmeal, maize and waxy maize, hominy), flax seeds, garbanzo bean (chickpea, besan, gram, or channa), Garfava flour (garbanzo + fava bean flours), Indian grass (also known as wild rice), Mesquite flour, millet, Montina, nut flours and nut meals, pea flour, potato starch, potato flour, quinoa (keen-wa), African Millet (ragi), rice, all forms (brown, white, sweet, sticky, wild, jasmine, basmati, glutinous rice, rice polish, rice bran), sago, sesame, sorghum, soy flour, Imported Gluten-free Foods, containing wheat starch are not considered gluten free Buckwheat flour (make sure it is not a blend) Prepackaged rice mixes Rice pilaf may contain vermicelli a wheat pasta and other gluten containing ingredients Oats (certified GF only) most are contaminated with wheat All flours containing wheat, barley, rye and non GF certified oats. Common Wheat Names: chapatti flour (atta), bulgur, couscous, dinkel, durum, einkorn, emmer, farina, farro (or faro),, freekeh, fu, gluten, gluten flour, graham flour, kamut, malt (from barley), matzoh meal, modified wheat starch, orzo, seitan, semolina, spelt, triticale, and all forms of wheat (wheat bran, wheat starch, and wheat germ) Common Barley Names: ale, barley flakes, barley four, beer, brewers yeast, brown rice syrup, lager, and malt (extract, flavoring, vinegar, and milk) sunflower, tapioca (cassava, manioc, yucca) and teff flour Breads Those made especially with the above ingredients and Gluten-free breads made in a non gluten-free All bread products made with wheat, oats, barley, and rye baked in a gluten-free environment environment Cereals Hot or cold cereal made from 100% recommended flours: buckwheat, corn, cornmeal, quinoa, millet, grits and rice Rice and soy pablum (can contain wheat or barley) Cereals made from wheat, oat, barley, and rye. All cereals made with malt (a flavoring derived from barley) (brown or white) Bold indicates whole grains Page 4 of 9

5 Pastas Pasta made from corn, (legumes), potato, peas, or other allowed flours rice, quinoa, soy, beans Always check-label may have added wheat Pasta made from the not recommended flours, udon noodles, buckwheat noodles (soba) usually contains wheat Crackers and Snack Foods 100% cornmeal tortillas; rice wafers or crackers, plain mochi, plain popcorn, 100% corn and potato chips, nuts (almonds, chestnuts, acorns, hazelnuts, walnuts, Brazil nuts, cashews, etc) and seeds (sunflower, pumpkin, etc) Rice cakes, microwave popcorn, flavored potato and corn chips Flavored mochi Rice crackers check for soy sauce Crackers and snack foods made with not recommended flours Nuts and seeds with wheat starch coating Buckwheat pasta (soba) might contain wheat Meat and Meat Alternatives Beef, Fish and Poultry Fresh, frozen, canned, salted, and smoked Eggs Fresh Eggs Most liquid egg products Prepared or preserved meats such as luncheon meat, ham, bacon, sandwich spreads, meatloaf, frozen meat patties, sausages, pate, frankfurters, imitation meats or fish products, meat extenders Egg substitutes, dried eggs, and egg whites Canned fish or meat in vegetable broths containing hydrolyzed vegetable protein (HVP) or hydrolyzed plant protein (HPP) made from ingredients not allowed. Self-basting or injected with broth (may have wheat protein) turkeys Surimi imitation crab and seafood contains wheat Meat and Meat Alternatives: Continued Meat Analogs - Lentils, chickpeas, peas, beans (red, black, kidney, etc.), plain nuts, peanuts, seeds, soybeans, tofu, Most nut butters (peanut, soy, cashew) Baked beans, dry roasted nuts and peanuts, peanut butter, reduced fat nut putters, flavored tofu, some vegetarian burgers Barley miso Page 5 of 9

6 Milk Products Milk (fresh, dry, evaporated, or condense), potato milk, cream, buttermilk, plain yogurt, aged cheese, cream cheese, processed cheese Milk drinks, flavored yogurts, frozen yogurts, non dairy creamer, sour cream, and ice cream Malted milk, commercially prepared milkshakes Cheese products containing oat gum Soy, hemp, coconut, and rice milks may contain barley flavoring and/or enzymes Processed or shredded cheese Fruits and Fruit Juices Fresh, frozen, and canned fruits Dried fruits (raisins, dates, Bulk bin dried fruits due to and fruit juices prunes, apricots, etc), cross contamination thickened or prepared fruits for pie fillings Vegetables Fresh, frozen, and canned French fries seasoned or Vegetables in sauces (thickened vegetables fries with other foods with flour), battered or breaded Vegetable juices fried vegetables Fats Butter, lard, vegetables oils (canola, olive, corn), cream, salad dressing made with the allowed ingredients Salad dressings, mayonnaise, margarine, and bacon grease Packaged suet, wheat germ baking shortening, nonstick spray containing flour, oatbased fat substitutes (Oatrim, Z trim ) Desserts Commercially prepared glutenfree cakes, cookies, and baking mixes, homemade puddings with cornstarch, gelatin desserts, frozen fruit pops Sherbets and ice creams (made in a batch type manner), pudding cups, candy Most commercially prepared pies, cakes, cookies, etc., ice cream made with ingredients not allowed, ice cream cones Flourless cakes may be baked in flour dusted pans Page 6 of 9

7 Soups Homemade broth and soups made with allowed ingredients, gluten-free bouillon cubes or broth Canned soups, dried soup mixes, soup bases, and bouillon cubes and prepared broths Soups made with glutencontaining ingredients, if containing HVP, HPP, (need to know source), noodles, barley or roux (i.e., gumbo and chowder) Beverages Tea, coffee (regular or decaffeinated), carbonated beverages, apple cider, distilled alcohol beverages such as rum, gin, whiskey, and vodka, wines Instant tea and coffee, flavored coffee drinks, fruit-flavored drinks, chocolate drinks, flavored and herbal teas (can contain Beer, ale, and lager; cereal and malted beverages Postum or other grain-based coffee substitutes and brandy made without glutencontaining additives barley or barley malt), root beer Sweets Honey, molasses, 100% fruit jams, marmalades, corn syrup, 100% maple syrup, sugar Licorice, candies with glutencontaining ingredients Icing and powdered sugar, fruit spreads, candy, chocolate bars and chips, chewing gum, marshmallows, lemon curd Condiments Pickles, relish, olives, ketchup, most prepared mustards, most mayonnaises, tomato paste, all pure herbs and spices, black pepper, most vinegars, wheat - free soy sauce, tahini Worcestershire sauce, salad dressings, prepared mustards, spice and herb mixes, and seasonings (chili powder, curry powder, etc.) Soy sauce, teriyaki, tamari or shoyu sauce made from wheat, imitation pepper (may contain wheat), and malt vinegars Wheat-free soy sauce Some prepared mustards have wheat Imitation pepper used in small individual packages Page 7 of 9

8 Miscellaneous Pure cocoa powder, cream of tartar, baking soda, brewer s yeast, aspartame, Splenda, sucralose, stevia-based sweeteners, monk fruit extract, coconut, monosodium glutamate (MSG) if made in the USA, imitation flavorings, water chestnuts, vanilla extract, vanilla flavor, vanillan, vegetable gums (xanthan, guar, carageenan, acacia, carob bean, cellulose, arabic, locust bean, tragacanth). Sauces and gravies, baking powder Oat gum, communion wafers, barley miso. OTHER THINGS to CONSIDER Toothpaste and mouthwash Stamps, envelopes, stickers Play-Doh, glue, crayons, other art supplies Pet food can contain wheat Cosmetics, lotions, soaps, shampoos and hair styling products, especially lipsticks/glosses Vitamins, herbal supplements, and medications, for info on over the counter medication Cross contamination cutting boards, colanders, toasters, condiment jars, sponges, and counter top. Maltodextrin is gluten-free. If wheat is used, however, the ingredient must be declared as wheat maltodextrin and should be avoided. Caramel color can be made from sweeteners such as fructose, glucose, sucrose, and/or starch hydrolysates and fractions thereof. Although gluten-containing ingredients {malt syrup (barley) and starch hydrolysates} can be used in the production of caramel color, they are not used according to food processors in North America. Corn is used most often, as it produces a longer shelf life and is a much better product. 1 Modified food starch is derived from corn and potatoes. In the United States the single word starch is made from corn. Starches derived from other grains must be identified on the label. Smoke flavoring is made by burning certain woods and may use malted barley flour as a carrier for the smoke. Barley might not be listed in the ingredients, suggest check with manufacturer to see if barley was used. Roquefort and blue cheese made with mold can be derived from wheat bread and could contain very small amounts of gluten, but unlikely to be over the 20ppm. It is safe unless it lists gluten-containing ingredients. Page 8 of 9

9 Carbohydrate (Carb) Content of Gluten-Free Flours Flours and Grains Amount Carb grams Protein grams Fat grams Amaranth flour 1 cup Arrowroot flour 1 cup <1 4.3 Buckwheat flour 1 cup Buckwheat groats, roasted, cooked ¾ cup <1 1 Corn starch 1cup 116 <1 0 1 Garfava flour 1 cup Grits, instant 1 packet <1 1.2 Ground flax seed 2 Tbsp Millet, flour 1 cup Montina Pure Baking Supplement 2/3 cup Potato flour 1 cup <1 9.4 Potato starch 1 cup Quinoa flour 1 cup Quinoa, cooked 1 cup Rice, brown cooked 1 cup Rice flour, white 1 cup Rice flour, brown 1 cup Rice, long grain & wild, cooked 1 cup <1 3.0 Rice, white, cooked 1 cup <1 <1 Soy flour 1 cup Fiber grams References 1. Case, S. Gluten-Free Diet: Comprehensive Resources Guide. Saskatchewan, Canada: Case Nutrition Consulting; 2001, Fasano A, Berti I, Gerarduzzi T, Not T, Colletti RB, et al. Prevalence of celiac disease in at-risk and not at-risk groups in the United States: a large multicenter study, Arch Intern Med, 2003;163: Dennis M, Leffler DA. Real Life with Celiac Disease: Troubleshooting and thriving gluten free. AGA Press, Page 9 of 9