The Gluten-Free Prescription Diet

               General Basics for the Gluten-Free Diet

           The Prescription Gluten-Free Diet for Celiacs

        The following guide for interpreting the prescription gluten-free diet is based on the grains, chemicals, and natural or artificial ingredients found to be toxic for patients with the conditions of celiac disease and dermatitis herpetiformis.     

             Allowed Flours and Starches:  [for the gluten-free diet]

        Grains:  non-enhanced rice; corn and popcorn; sorghum (milo); flax; wild rice.

         Roots and Tubers:  tapioca; potato; arrowroot; sweet potato.

         Legumes:  bean; fava bean; soybean; garbanzo bean; lentils; peas; peanuts.

         Nuts:  almond; chestnut; acorn; hazelnut; walnuts, Brazil nuts, cashews, water chestnuts.

         Seeds:  sunflower; mustard; sesame; safflower, coconut, poppy, alfalfa, Montina.

             Grains to Avoid:  [for the gluten-free diet]            

wheat     barley     rye     oats

 spelt     semolina      kamut      triticale     quinoa      millet      buckwheat

 amaranth     tef      far      farro      grano     mir      couscous

         Celiacs must read labels carefully when purchasing any packaged or canned products since ingredients may change from one batch to another.  Ingredients marked as additives, cereals, and cereal grains, colorings, emulsifiers, excipients, derivatives of gluten, flavorings or malt, hydrolyzed plant protein (HHP), hydrolyzed vegetable protein (HVP), preservatives, starches, and modified food starches, vegetable gum, and vinegar—may be derivatives of a gluten-containing grain. 

 Abbreviated Food Listing for the Gluten-Free Diet

 

Foods Allowed

Foods to Avoid

 

 

 

 

 

1.  Grains

Non-enhanced rice, corn, and popcorn, sorghum (milo), flax, and wild rice, Montina.

Wheat, barley, rye, oats, and probably millet and buckwheat for most people.

Also:  spelt, semolina, kamut, triticale quinoa, amaranth, tef, far(farro) mir and couscous.  Be careful of breads and rice cakes that often contain both rye and millet.  Avoid wheat starch; the manufacturers say it does contain small amounts of gluten; when questioned, it is represented as 92% to 97% gluten-free.  Most  communion wafers may be made with wheat starch.

 

 

 

 

 

2.  Vegetables

Use fresh, frozen, dried, or canned unless they contain thickening agents.    In canned products, avoid emulsifiers, preservatives, stabilizers, and food starch unless its source is known.

Read INGREDIENT labels.  See glossary of terms and text for ingredients to avoid.

 

 

 

 

 

3.  Fruits

Fruits are simpler.  Use most fresh, frozen, dried, or canned fruits.  Some few contain additives or preservatives.  Read labels.

Avoid thickening agents for some fruits and pie fillings.  If dye sensitive, avoid fruits with “color added.”

 

 

 

 

 

4.   Eggs and Egg

Substitutes

Use eggs, well-cooked.

Avoid all raw and undercooked eggs.  Avoid egg replacers and egg substitutes with additives and any additive of non-allowed  grains or non-allowed preservatives.

 

 

 

 

 

5.  Breads

Use rice flours, white or brown, arrowroot, potato tapioca.  Use soybean (soya) if tolerated; add pea, corn, milo or bean, Montina, and nut flours for variety.

Avoid low-gluten flours and wheat starch.  Avoid flours with wheat, barley, rye, and oats.  Avoid soybean (soya) if sensitive to it.  Avoid millet and buckwheat.

 

 

 

 

 

6.  Cereals

Hot cereals made from corn meal; cream of rice; hominy; rice; cold cereals such as puffed rice, Kellogg’s Sugar Pops, Post’s Fruity and Chocolate Pebbles; Van Brode’s cornflakes and crisp rice; General Mill’s Coca Puffs (unless sensitive to chocolate).

Avoid cereals with wheat, barley, rye, oats, millet, and buckwheat.  Avoid bran, graham, wheat germ, bulgur.  Do not use the several cereals available that contain low amounts of malt unless approved by your physician.

 

 

 

 

 

7.  Cheeses

All aged hard cheeses such as cheddar, Swiss, edam, and parmesan.  Check ingredient list on cottage cheese, cream cheese, and all pasteurized, processed cheese; avoid cheeses with vegetable gum and preservatives.

Avoid all cheese foods, cheese spreads, and nondairy products in the dairy counter such as spreads, and the chip ‘n dip mixes.  Avoid Roquefort cheese, which is based on breadcrumbs, and Ricotta, which uses grain vinegar.

 

 

 

 

 

 

8.  Salad Dressings

Start with the several Kraft dressings that are gluten-free or make your own. Read labels before each purchase.  The ingredients may change with each batch number.  Be aware of the use of grain vinegar.  Choose Hellmann’s regular mayonnaise.

Several commercial salad dressings contain one or more of the offending grains, preservatives, food starch, stabilizers, or dyes.  Avoid the product unless contents are known.  Avoid products with secondary foods added.  Ex: tomato soup in some dressings – usually contains wheat flour.

 

 

 

 

 

9.  Drinks and Juices

Fresh brewed coffee other than a ground coffee with grain added.  Ex: Mellow Roast.  Tea, chocolate made with cocoa, fruit juices, carbonated drinks.  Avoid most of the instant drinks which are processed with or have additives, stabilizers, or emulsifiers added.  Ex: Hawaiian Punch.  Only a few root beers allowed.

Omit all instant coffees, instant tea, instant cocoa mixes, Postum, Ovaltine, Gevalia flavored, malted milk, commercial chocolate milk which may have cereal added, and ground coffees which contain grain and some root beers.  Know the product, read labels, look for excipients (stuffers) and flavoring agents.

 

 

 

 

 

10. Flours

Arrowroot starch, corn flour, cornmeal, corn starch, potato flour, potato starch, rice bran, rice flour, rice polish, soy flour, tapioca flour, tapioca starch milo (sorghum), Montina and nut flours

All flours containing wheat, barley, rye, oats, millet, or buckwheat; also avoid wheat starch, triticale and amaranth.

 

 

 

 

 

11. Soups

Homemade broth and with allowed ingredients.

Most canned soups and soup mixes-- especially bouillon in powder, cubes, or canned form.

 

 

 

 

 

12. Fats and Oils

Most celiacs do best on corn oils; most corn oils, margarines, butter, lard, cream, pure mayonnaise, peanut butters, and most hydrogenated vegetable oils are acceptable.  Some margarines have flour as an additive.  Start with Fleischmann’s Regular.

Check out vegetable oils for additives.  Read labels.  Check out margarines for possible offenders before using. If 60 percent corn oil with remainder not defined—know content before using. Look for salad dressings that contain gluten-free stabilizers and canola.

 

 

 

 

 

13. Vinegars

Use apple cider and wine vinegars.

Avoid distilled white vinegar that uses a grain mash as a starting material.  Check out most flavored vinegars before using. 

 

 

 

 

 

14. Alcoholic Beverages

Wine and brandies without preservatives and added dyes; most celiacs do best on white wines; potato vodka, not grain vodka, most rums and tequila are okay.

Avoid all beers, ales, and anything made from grain alcohol; all whiskey, bourbons, Canadian blends; most liqueurs; corn whiskey also since it uses a grain mash.

 

 

 

 

 

15. Soy Sauce

Use those that do not contain wheat.

Most soy sauces do contain gluten – especially, Kikkoman’s.  Avoid house soy sauces.

 

 

 

 

 

16. Crackers and Snack Foods

Rice wafers; pure cornmeal chips, and tortillas; popcorn; selected Soya crackers.

All others containing the non-allowed grains or coatings of selected soy sauces.  Watch out for “pure corn products” which may be dried on a belt dusted with wheat flour.

 

 

 

 

 

17. Desserts

Custard; junket; homemade puddings from cornstarch, tapioca, and rice; gelatin desserts; selected pudding mixes; ice cream and sherbet if they do not contain wheat flour or gluten stabilizers; products made with allowed flours.

All products prepared with the non-allowed grains; ice cream cones and ice creams which contain gluten stabilizers; most commercially prepared mixes for cakes, cookies, and other desserts.

 

 

 

 

 

18. Sweets

Sugar; honey; non-buttered syrup; molasses; most jellies and jams, plain hard candy; marsh-mallows; gumdrops and homemade or commercial candies made with allowed ingredients.

Check for commercial candies containing the non-allowed grains and gluten stabilizers. 

 

 

 

 

 

19. Meats or Meat Substitutes

All meats, fish, poultry, and eggs prepared without the non-allowed grains; bacteria-ripened cheese and processed cheeses if they do not contain a gluten stabilizer; cottage cheese and cream cheese if the vegetable gum used does not contain a forbidden grain.

Several of the luncheon meats, sausages, and frankfurters may contain a grain as an excipient or as a part of a gluten stabilizer; turkey with HVP injected as a part of basting (avoid self-basting fowl); avoid cheese products containing wheat flour and/or oat gum.  Say “no” to raw eggs and all undercooked meats. 

 

 

 

 

 

20. Potato or Pasta Starches

White and sweet potatoes; yams; hominy; rice and wild rice; gluten-free and corn pastas; look for oriental rice noodles or bean noodles without preservatives and coatings.

Regular noodles, spaghetti, macaroni, and most packaged rice mixes.  See product ingredient listing for clarification.  Watch out for wild rice that has been sprayed with insecticide.

 

 

 

 

 

21. Yogurt

Use yogurts without milk added if lactose intolerant.  Start with plain Dannen or Yoplait.

Several yogurts on the market contain both milk and a thickening agent. Know the product being used.

 

 

 

 

 

22. Miscellaneous

Salt; pepper; herbs; spices;  coconut; chocolate; nuts; pure cocoa; flavorings not made with alcohol – choose imitations; (MSG) monosodium glutamate; yogurt, if made with allowed ingredients; steak sauce, except persons with hypersensitivity.

Some curry powder; most white pepper; some dry seasoning mixes, some gravy mixes and extracts; some meat sauces; some catsup, mustard, and horseradish because of the vinegar; some chewing gum; most dips; flavorings made with alcohol.

 

 

FOR A GLUTEN-FREE DIET, CHECK SOURCE OF THESE INGREDIENTS

        Always check the source of the following nebulous ingredients before eating any product in which they are contained.  Use only those products that specifically state the allowed origin.

 

 

Ingredient (as it may appear on the label)

 

Foods allowed

 

Foods to be Avoided

 

 

 

 

 

HVP – Hydrolyzed Vegetable Protein

TVP – Textured Plant Protein

HPP – Hydrolyzed Plant Protein

corn or soy

mixtures of wheat with corn or soy

 

 

 

 

 

Flour or Cereal Products

rice flour; corn flour; potato flour; soy flour

wheat, barley, rye, oats, millet, buckwheat

 

 

 

 

 

Vegetable Protein

soy; corn

wheat, barley, rye, oats, millet, buckwheat

Malt or Malt Flavoring

those made from corn

those made from barley, barley malt, or barley malt syrup;

Starch

when listed on a U.S. manufacturer’s ingredient list, it can only be cornstarch.

 

Modified Starch or Modified Food Starch

arrowroot; corn; potato; tapioca; maize; waxy maize;

wheat starch; corn starch with wheat starch added;

Vegetable Gum

carob bean; locust bean; cellulose gum; guar gum; gum Arabic; gum acacia; gum tragacanth; xanthan gum;

oat gum.

 Descriptions of Food Categories

[add your own notes as you learn and develop your own listings]

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  Foods  and  Infant  Formulas

         All infant formulas are generally gluten-free. They are sold in ready-to-feed, concentrate or powdered forms.   Note that different manufacturers may not always use the same ingredients for the same product.  Secondly, "tried-and-true" safe products may, without notice, change ingredients from batch to batch. 

         Infants should never be fed raw or undercooked eggs and any kind of undercooked meat.  Most egg substitutes are a caution and may contain a derivative of wheat as a stabilizer or preservative.  Know that all ingredients are non-toxic or avoid altogether.  A high caution for parents of infants through age one and for some up through 18 months is the need to avoid feeding raw carrot and celery and selected raw fruits so as to avoid choking.  Finally, because of the high potential for contamination, no child under age 18 months should be fed honey or any of its derivatives. 

         

Baking Powders

         All commercial baking powders have fillers, which may not be gluten-free.  Common acceptable ingredients include bicarbonate of soda, cream of tartar, tartaric acid, and regular yeast [fresh and dried].

         Since many commercial baking powders are high in sodium and contain aluminum salt compounds, some sensitive celiacs will find it easy to make up a batch of their own baking powder mix and thus avoid the problems with a commercial baking powder product.

Celiac patients should discuss their individual needs for calcium in/with baking powder with their physician and make a decision regarding the planning needed.  The following ingredients, when well-blended make an acceptable baking powder substitute:

                 1/4 cup baking soda (or, potassium bicarbonate)

        1/2 cup of cream of tartar

        1/2 cup arrowroot powder

         Stir with a whisk to mix well; use measurements as suggested for any recipe.  Store in a covered container in a dry place.  Do not store in the freezer or refrigerator.  Shake well before measuring.

 

Gums

         Gums generally allowed in the clinical diet for celiacs include the following items:  carob bean; locust bean; cellulose gum; gum arabic; gum acacia; gum tragacanth; xanthan gum.

         Guar gum, although gluten-free, is often used to facilitate diarrhea or relief from constipation  and hard stools.  Because of  these potential side effects, guar is a caution and is generally not recommended.

        Guar gum is not recommended for use by celiacs except by physician direction.  While guar is an excellent binder and works very will with the gluten-free flours, it also is used medically as an aid to relieve constipation.  It is often suggested for celiacs who have an occasional problem with hard stools.  Guar should not be a choice for patients who have a tendency to have diarrhea or who are just getting started on the prescription diet.

        Several commercial food companies stock a bread which uses guar gum as a binder.  This bread can then be an excellent choice for persons who have been advised by their physicians to use this stimulant.

         Oat gum used in fat-free products and lipsticks; contains gluten and is not allowed.

         Xanthan.  When the microorganism Xanthomonas Campestris is allowed to grow under the right conditions, it builds a protective covering  around itself, a cell coat which possesses very special properties.  If the organism is grown in a laboratory, a chemical process can then remove large amounts of this cell coat, dried, and milled  to form a powder called xanthan gum.

         The cell coat of the organism is somewhat similar to the protective shell surrounding a peanut.  Both are polysacchrides,  which means that they are long chains of simple sugars linked together.   But they are joined by links that the human intestine cannot split apart.  This means that they are not readily absorbed and that very few of the sugar units can be used by our cells for energy.  Thus,  the caloric value of xanthan gum is very low.  It provides only 0.5 kcal per gram, one eighth of the amount provided by sugars that  our bodies can fully utilize.  Each tablespoon contains about eight calories.

         The Use for Xanthan.  The special strength, which makes the cell coat valuable to its tiny inhabitant also, makes it useful in foods.   Xanthan gum is added to salad dressings, gravies and sauces, and even  ice creams to give these foods a smoother texture.  It also has the ability to hold the particles of a food together well which makes it  a good stabilizer.  And, as every celiac cook knows, xanthan has been  shown to be a good substitute for gluten in yeast breads.  Note:  celiacs, especially newly-diagnosed patients, who may be sensitive to molds or have  the condition of trehalose intolerance should avoid the use of xanthan.

         Our experimentation has shown the following proportion of xanthan gum to gluten-free flour to give satisfying results: 

         Product Amount of Xanthan to Use:

                 cakes 1/4 teaspoon per 1 cup of flour mix

                 breads 1 teaspoon per 1 cup of flour mix

                 pizza dough 2 teaspoons per 1 cup of flour mix

         gravies, use only a small pinch with your present flour         and starch mix.

         Natural Gum Systems.  A line of seven ingredient systems based on combinations of natural gums is being marketed under the trade name of Rhodigums.  The blends consist of either guar and xanthan and locust bean gums, or all three gums.  These gums are designed to provide a specific functional performance and optimal texture in many food products, including baked goods, cheese spreads, fruit fillings, puddings, sauces, dressings, and whipped toppings.  In some foods, the gum blends function as cost-effective thickening agents to provide rapid viscosity build-up.  In sauces, dressings, and relishes, they can stabilize emulsions and suspensions, as well as enhance cling and pourability.  Some gums will impart very high viscosity and gel strength even at low concentrations.

   

Yeast

         In the production of baked goods, yeast serves three primary functions:

         Production of Carbon Dioxide CO-2.  CO-2 is generated by the breakdown of fermentable sugars in the dough.  This causes expansion of the dough by entrapment of CO-2 within the protein structure of the dough.

         Maturing the Dough.  This is accomplished by the chemical reaction of yeast produced alcohols and acids on the protein of the flour and by the physical stretching of the protein by CO-2 gas.  This results in the light, airy physical structure associated with yeast-leavened products.

         Flavor Attributes.  Yeast imparts the characteristic flavor of bread and other yeast leavened goods.  During the fermentation, yeast produces many secondary products such as ketones, higher alcohols, organic acids, alde-hydes, esters, etc.  Some of these (alcohols for example) escape during baking.  Others react with each other and with other dough compounds.  These reactions occur mainly in the crust, and the resultant flavor diffuses into the crumb of the baked bread.

        USE ONLY PROTECTED ACTIVE DRY YEAST (PADY).  PADY contains an emulsifier and is produced by a special drying process to a lower moisture content of 5 to 6%.  Both of these factors result in a more stable product.  An antioxidant (0.1% BHA) is also added to protect the yeast from the damaging effect of oxygen in the air.  This reduces the need for protective packaging.  This product is specifically designed for use in prepared complete flour mixes in which the yeast is in contact with other dry ingredients and with air.  In complete mixes, the moisture content of the flour should not exceed 8 to 9%  since the yeast is not stable at higher moisture levels.

          DO NOT USE INSTANT ACTIVE DRY YEAST (IADY).  This is quite a different form of active dry yeast.  It is grown from a more active yeast strain, and its fermentation activity is greater than that of other dry yeasts.  It is also useful in a wider variety of applications. The product does not need separate rehydration and can be mixed directly with all dry dough ingredients in the mixer.  Therefore, it is called IADY.

        For the celiac, there is concern for the actual content and base of the emulsifier and potential dough conditioner in an IADY. Typically, the emulsifier is an oil; the conditioner is often simply an ascorbic acid or a vitamin C product.  There appears to be several varying answers from a series of professionals for their derivation.  There may be a base of beets and molasses used; there is a potential, however slight, for the oil to vary from batch to batch.  For some batches, it appears that oil is not defined further as to derivation. For some batches, the conditioner may be omitted.

        At this time, we continue to search out for some sort of answer for a potential activator or cause for sensitivity or malabsorption for selected celiac and DH patients who use an Instant Active Dry Yeast. Although we have no research evidence, we do have numerous celiac and dermatitis herpetiformis patients who report minor to moderate reactions from home-baked products which have used an IADY as the leavening agent.  These reactions are not present when an Active Dry Yeast (ADY) is used as the leavening agent for a bread.  Until we have more complete case history data and supporting medical recommendations, we believe that all celiacs should use IADYs with question and caution.  Our strong suggestion is to omit products using Instant Active Dry Yeasts (IADYs) from the diet of all celiac patients.

        For the selected few very sensitive celiacs who appear to have sensitivities to all yeast products, we suggest the use of batter breads with the use of soda and/or small amounts of GF baking powders or egg as leaveners.

 

Beverages

          Most soft drinks (except the barley-flavored fruit drinks such as  Hawaiian Punch) are gluten-free.  The dyes in some fruit drinks, however, may  be  toxic to  selected celiacs.  Current technology  has demonstrated that there is a small amount of barley protein in beers and lagers.  Avoid chocolate from vending machines and the small catering packs of tomato juice, which may contain an unsuitable gluten-containing filler.  Review labels of diet soft drinks for the sweetener used and consider if it is based on an offending grain; second, review the base of any preservatives which may be added. 

        Wines and brandies without preservatives (or, with preservatives  that are tolerated, i.e., sulfites) and most added dyes are considered appropriate for the clinical diet.  Celiacs appear to do better on  white wines such as the Chablis and Zinfandels. Try imports from   Germany such as the Rieslings and Mosels (not the French moselles).   In vodkas, choose a potato vodka without grain added, not a grain-based vodka; an example of a potato vodka is Luksusowa, a product of Poland.  Most light  rums and tequilas are permissible.

         Avoid all beers, ales, and anything made from a grain-base or grain  alcohol; avoid all whiskeys, bourbons, Canadian blends, most liqueurs  and corn whiskey since it also uses a grain mash.  There may be trace amounts of distillable nitrogenous compounds such as pyridine, picoline and methyl pyrazine, which are toxic to celiacs.

         Instant cocoa mixes, Postum, Ovaltine, Gevalia flavored coffees, malted  milk, commercial chocolate milk may have cereal grains added or contain toxic chemical residue from processing.  Ground coffees, which contain grain (Mello Roast) and most root beers should be avoided.  Know the product before you use it; read labels, look for excipients and stuffers.

         Individuals with a depressed immune system such as celiacs are  thought to do better on regular green and black teas and fresh perked  coffees.  Our recommendation is to avoid herbal and instant teas.  If the decaffeinating process is water-based for a tea or coffee, it is allowed; if the decaf process is chemically-based or has chemical additives, those products are not recommended for celiac patients. If the decaf process is unknown, stick to regular blends.

 

Candies  and  Gum

          Many commercially-prepared candies may have come into contact with flour during the processing (to aid rolling, molding, or to avoid sticking to conveyor belts) so it is wise to either check them out or avoid until adequate information is in place.  Most solid licorice contains wheat flour.  Use candy and gums from other countries with caution.  Products with artificial sweeteners may cause problems for sensitive celiacs and children.

 

Cereals

          The primary concern for cereal products remains the presence of non-allowed grains. Selected flavoring agents such as malt and grain additives may also make a grain cereal unsuitable for the celiac.

The allowed cereals should be determined with physician direction. The physician will have access to an interpretation of blood tests and the present levels of malabsorption.  Included also will be consideration for the wide variety and severity of symptoms presented.  Within these parameters, some or all of the following cereals may be allowed: rice and precooked rice cereals, Puffed Rice, cornmeal and corn or rice grits, hominy, and Cornflakes.  Note that some rice cereals have milk derivatives added and may be packaged in a container that has been sealed with wheat starch.

            Not allowed are wheat and rye cereals, wheat germ, barley, buckwheat, kasha and farina.  Malt flavorings derived from corn are allowed; malt flavorings derived from oats, barley and cereal sludge are not allowed.  Malt extracts are to be avoided. 

 The standards for enrichment of cereal products are listed in detail in the Federal Register of 20 December 1955 and are repeated in part in most nutrition textbooks.  A minimum and maximum standard is defined for foods labeled "enriched."  A caution needs to be made regarding some rice grain which has been enriched in the hull with barley water  before processing.  Those nutrients include the following items:  thiamin, riboflavin, niacin and iron along with the optionals of calcium and vitamin D.  In the U.S. most white rice is enriched or enhanced.

         Grasses grown for their edible seeds are known as cereal grains.  The seed kernel (cereal kernel) is divided into three distinct portions: the pericarp, or bran layer; the endosperm, or inner portion; and the germ layer, which contains the embryo from which a new grain plant develops.

         The bran layer, which comprises about 14 percent of the cereal kernel, contains mostly cellulose and some protein and minerals.  This layer has three parts:  an outer pericarp or epidermis; an inner pericarp; and, a thin seed coat fused to the pericarp called the endocarp.

The endosperm, which makes up about 83 percent of the cereal kernel, is composed of starch granules embedded in a matrix (framework) of protein.  The milling process separates the endosperm from the bran and germ layers.  This is possible because the endosperm is more easily crushed than the other two layers.  Free bran and germ are removed for other uses, including animal feed.  The aleurone is an outer row of thick-walled cells of the endosperm, which is removed with the bran during the milling process.  This layer does not contain any starch or gluten protein but does have a food reserve of oil and non-gluten protein.

         The germ layer is the richest part of the grain, but it is also the  most  unstable.  Comprising  about  3  percent  of   the cereal kernel, it is high in protein, sugar (mostly sucrose), minerals, and fats.  Because of its high fat content, the germ layer is particularly    susceptible to deterioration during storage.  For this reason, the   germ layer is usually removed during milling and sold separately.    The germ layer is composed of two parts:  the embryonic axis, which   develops into the seedling; and the scutellum, which contains most of  the thiamin of the kernel.

 

Cheeses

         Most natural cheeses (hard cheeses), the ripened cheeses such as Brick, Cheddar, Edam, Gorgonzola, Gouda, Gruyere, Monterey, Muenster and Swiss contain very little, if any, lactose. Check labels of whipped cheeses for additives, flavorings, and colorings not allowed.  Do not use cheese spreads such as Velveeta (most soft cheeses) since they typically contain  flour or a gluten-containing thickening agent.  Avoid all cheese foods, and non-dairy products in the dairy counter such as the chip 'n dip mixes.  Avoid cheese with guar gum added since it is a natural product used to induce diarrhea.  Exception: when used by prescription under physician monitoring for conditions such as constipation and hard stools.  Note the amount of cheese allowed  in your diet because of the potential high salt content of cheese.

         The unripened cheeses such as cottage cheese, cream cheese, Gjetost, Neufchatel and Ricotta, contain lactose.  Ricotta may also contain a grain-based vinegar.  Most Roquefort cheese has the mold introduced into the cheese on bread crumbs.  Unfortunately, it is very difficult to ascertain how much, if any, of the gluten is broken down by the action of the mold during the maturation process.  The best advice is to avoid Roquefort until more complete research information is available.

         Cheese-like Products.  Cheeses made from soy milk or tofu are usually lactose-free, but labels must be checked.  The following are lactose-free products:  Soya Kaas, Cheddar, Mexi-Kaas and Mozzarella-style; Soy-a-Melt (Imitation Cheese), Cheddar and Monterey Jack-style.  

          Cheese as an Additive.  We do not have adequate information on cheese as an additive to products such as cheese snacks and chips, au gratin potatoes, and cheese popcorns.

 

Fats and Oils

           Butter, margarine, lard, cooking oils of all types, reduced and the low-fat spreads are all represented as gluten-free.  Some of the low-fat spreads have non-labeled starches present and should  be avoided until further information becomes available.

         Choose 100% corn oil when possible and not a label of vegetable oil unless it is clearly known what the added oils may be.  Note: when the general category of oils is used it may mean it contains wheat germ oil.  Do not be accepting of oils which have labels with 60% corn oil with the remainder a non-defined vegetable oil.  Many children, older adults, and sensitive celiacs do not do well on Canola Oil.  Until more exact research information is known, we do not recommend the use of Canola or its several by-products by celiac patients.  Most celiacs do well on olive oil, safflower, coconut oil, and oils without a yellow dye added.  Purchase a 100% fat or oil with no enhancers, preservatives, or colorings added.  In general, avoid all cooking spray mixtures in pressurized containers.  Instead, put first pressing olive oil in a spray bottle to make your own quick spray system. Listings from manufacturers may mentions oils that are non-defined (no origin is stated).  Fat and oil substitutes such as Oatrim and Replace are not recommended for use by celiacs.

   

Flours, Starches and Baking Mixes

         Many excellent flours and baking mixes are to be found in the commercial market.  And, every cook has his or her favorite flour mix for use in yeast and batter breads, muffins, pancakes, pizza  dough, etc.  It is typically easier to start with a basic recipe  for a flour mix such as the following, but be sure to do some  experimenting and come up with your own. 

    Flour mix:      1 c cornstarch            1/2 c soy flour

     3 c rice flour 3 c potato starch flour

Use this mix for flours in breads; for muffins, substitute rice polish for the soy flour; for pancakes, omit the soy flour; for pizza, use as is for breads, or add one tablespoon of tapioca flour per cup of the mix used; and for pizza, add two tablespoons of corn flour and then use corn flour to dust the pan.  Add a binder such as xanthan gum at the time of mixing the product for baking. 

  

Grains and Flours Allowed for the Gluten-Free Diet

         The following abbreviated listing of grains and flours is intended for use as a reference for patients who are concerned with problems of malabsorption and sensitivities for the conditions of celiac disease and dermatitis herpetiformis.  It is directed to the malabsorption syndrome associated with gluten-sensitive enteropathy.

         Acorn  -  Quercus prinus, Q. Emoroyi, Q lobata, available through vegetarian sources; does not bind well; is excellent in chocolate and spice products and in pizza dough; for the home gatherer, dry well, shell, finish in a 2-minute 350-degree oven; then run through the food processor or mill on medium coarse.  Store in the freezer to avoid rancidity. 

        Almond  -  Prunus amydgalus, a good choice for celiacs; works well in breads, pastries and cakes; can be used in the form of coarse bits or as a flour; is an excellent addition to white or brown breads; the use of almond in rice bread makes an excellent taste difference.  Can be used as a single flour with binders for an excellent chocolate cake.

        amaranth  -  Amaranthas candatas.  [principal food of the Aztecs].  is often used as an unnamed thickener;  has a slightly gummy texture, like okra. As many as 30 to 40 percent of celiacs in a survey study reported minimal and moderate reactions to amaranth; is typically referred to as pigweed or tumbleweed; refers to any number of related plants, usually with colorful leaves and in some cases, showy, tassel-like flowers; since both CS and DH patients report sensitivities and reactions, it is not recommended.  Note also:  the FDA has placed the dyes obtained from red amaranth on the questionable list for any use by humans.  One researcher has offered that it may in reality be the coloring, which carries over into the seed, which becomes the toxic ingredient for celiacs.  Other observers feel that amaranth is an example of contamination both in growing and in storage.  

         Arrowroot  -  Maranta arundinaces, a tropical American plant with large leaves, white flowers and starch roots; the starch made from the roots is typically used as a thickening agent; it blends well with the common gluten-free flours; arrowroot is not a problem for celiacs.  Referred to in the literature as both a starch and a flour or as arrowroot starch flour.

        Artichoke  -  Articiocco.  The flower head of this thistle like plant may be cooked and eaten as a vegetable.  The dried artichoke may be ground into flour; it is an excellent addition to the rice-potato-tapioca flour combinations for breads and coffeecakes.  Makes up into an excellent flat bread to serve with soups and stews.  Artichoke flour is seen as an appropriate product for use by celiacs.

barley  -  Hordeum vulgare.  Should be avoided in all of its forms; can be a part of many products, but is often used in flavorings, colorings, malt and as a flavor enhancer--especially for cereals; may be used as a part of hydrolyzed plant protein [HPP].  Some food chemists indicate that it may also be a part of hydrolyzed vegetable protein [HVP] as a non-identified extender.  When used as an enhancement or enrichment for products such as rice, it may then cause toxic reactions for the celiac patient.  Protein or barley is known as hordein.

        buckwheat  -  Fagopyrum esculentum.  (see also rye buckwheat, F. tataricum).  Most physicians feel that the information on buckwheat is not yet all in.  Although there is no formal research available, there is action research--patient examples and case histories--of reactions to this grain.  It is recommended that celiac patients avoid all buckwheats grown in the U.S.

         bulgur  -  Sometimes referred to as burghul in foreign literature;  is wheat and should not be used by celiacs.  Often seen as a par-boiled, soaked product which has then been dried; may be seen as wheat nuts; may be touted as gluten-free [or wheat-free] with the reasoning that the gluten has been removed by soaking; this is seen as an unreasonable assumption.  Bulgur and/or wheat in its natural state may be found with [or mixed with] carob and soybeans and then represented as gluten-free flour in health food stores.  These flour mixes are not recommended for use by celiacs.  Beware of the slick, 4-color brochures which tout bulgur as gluten-free, it is still wheat [one of the triticums] and should be avoided.

         Cassava  -  [tapioca].  Manihot esculenta.  Excellent as a thickener for soups, puddings, and gravies; works best when finely ground to a flour consistency; mills well and keeps well in the freezer; celiacs do well on tapioca.  The popular Chebe bread mix shipped into the U.S. from Brazil is based on cassava.  

        Chestnut  -  Castanea.  a smooth-shelled, sweet, edible nut of any genus of the castanea trees;  sometimes referred to as beechnut or horse chestnut;  works well as a flour; does not bind well; is tastier if roasted before grinding as flour; a good choice for celiacs; works well in spice cakes, brown breads, and pancakes.

        Corn  -  Zea mays.  Protein of corn is known as zein.  A smooth flour that can be milled from the entire kernel of corn;  it can be blended with corn meal and small amounts of other flours for making cornbread and cornmeal mush.  Is a good, basic grain product for celiacs.  Exception:  Freeze corn flours to avoid molds and an infestation of bugs.  When molds are a sensitivity as is often the case for newly-diagnosed celiacs, then molded or rancid corn flours can also become a toxic problem for the celiac.  Buy a good product; then store appropriately.

        Cornmeal  -  do not confuse with corn flour or cornstarch; is made in a coarser grade; an excellent cornmeal can be milled at home--use a popcorn or dried sweet corn for a taste change.  Check the ingredient label on commercial cornmeal products for the addition of wheat flour; most commercial products do have wheat added; look for the pure or 100% pure label with no additives for use in the gluten-free diet.  Cornmeal/blue and cornmeal/yellow or white are each gluten-free.  Sweet corn and popcorn are also in the Zea mays botanic group and are excellent choices for celiacs.  Note that maizmeal or maize meal can be corn or wheat.  Review with caution cornmeal and corn flour products not produced within the U.S. for low gluten content or contamination.  Note that several companies are now buying cheaper corn-based products from other countries and then have re-packaged them with gluten-free listings. 

        Cornstarch  -  a carbohydrate polymer derived from corn of various types, composed of 25% amylose and 75% amylopectin.  A white powder which swells in water; is the most widely used starch in the U.S.  Its chief uses are as a source of glucose, in the food industry as a filler in baking powder and a thickening agent in various food products.  Cornstarch is used to make corn sugar and corn syrup.  In the U.S. cornstarch and corn flour are seen as two different products; several foreign sources name cornstarch as corn flour.  All cornstarch flour is used for pretzels;  part cornstarch in a flour mix is often used in making GF doughnuts.

        Cottonseed  -  Gosyplum.  Can be used as flour or as a seed;  may be found seasonally;  more typically pressed and used as an oil for margarine,  cooking oil, and soap.  Appropriate for use by celiacs.

        couscous – a term from the Berbers of Africa;  originally meant to grind and pound;  currently, means a dish made with crushed grain (pounded grain); it usually is steamed and served with lamb or chicken.  Neither the grain nor the mix is seen as gluten-free in the U.S. but it is sold in some commercial outlets as being natural and gluten-free.  Couscous should not be used as a part of the gluten-free diet.

        far  [farro]  -  also called farina and has other spellings; a low-gluten containing grain not recommended for use by celiacs.  Far originally was a buckwheat; present farinas are usually made from wheat.

         Fava Bean -  Faba.  same as broad bean.  leguminose.  One of more than a hundred legumes and beans.  Can be used in many variations by celiacs; is especially useful as a flour.  *Some children and older adults may suffer from fauvism, however; an intense allergy to the beans [not a toxicity] that can cause migraine headaches and related symptoms.  Removed from their pods and steamed, fresh favas taste very sweet and buttery.  Dried fava beans should be soaked and then simmered in water with two tablespoons of oil just like any other bean.  Many recipes exist for the preparation of favas with olive oil, garlic, tomatoes and spinach.  Generally not recommended for use by children nor by older adults and selected celiac patients who are defined as having additional sensitivities. 

         Flax  -  Usitatissiumum linn.  Not seen as a problem grain; typically listed as flax seed or flax seed oil on labels; may be listed as fiber in bulking agents and in high fiber foods.  Note:  additives and colorings, which blend very easily with flax, may then be toxic.  Ex: celiacs report reactions to flax oil capsules which may have a yellow dye or additive.  

         Garbanzo  -  Leguminose.  also known as chickpea; excellent as a flour;  many recipes available in Spanish cookbooks; used in salads and stews; canned products may have inappropriate vinegars or preservatives added; use dry garbanzos without insect repellents added.  Use dry;  may need freezer storage for garbanzos since they pick up moisture and vermin easily in home storage.

Grits  -  a cereal product made by grinding corn to a coarse consistency.  Seen as excellent for the GF diet.  Some commercial products have milk added.  One brand uses a cardboard box container that has been sealed with wheat starch [wheat glue] and could thus become contaminated.  See Southern U.S. cookbooks for recipes.

grano  -  an Italian term for grain; is essentially polished durum wheat, a variety of wheat used to make pasta;  it has a golden hue and has an appealing chewiness when cooked.   The bran of the seed has been removed so the starch is then more accessible.  Grano is used primarily in soups, stews, salads, and in dishes in which you might use a small wheat pasta such as orzo.  As is true of the other durum wheat varieties, grano is not gluten-free.   

groats  -  oat grain with the hull removed. 

Hominy – a type of grits; typically made from white corn; the preservative for hominy may make it not appropriate for the diet of some celiacs.   Review ingredients and use with caution.

         kamut  -  (pasta wheat)  Triticum polinicum.  Nicknamed King Tut's wheat;  is a primitive high-protein variety of wheat and takes its name from the Egyptian word for wheat;  is large kerneled and a heavy producer; not recommended for use by celiac and DH patients.  Do not follow U.S. or foreign brochures that recommend the use of kamut.  Do not use rice breads produced by several commercial companies which use 5, 20, or 50 percent kamut flour--even though they are advertised in 4-color brochures as being "the best selection for the gluten-free diet." 

        kasha  -  see buckwheat and rye buckwheat.

        Maize  -  same information as for corn.  See also the listing for maize under wheat for potential confusion.  Waxy maize is the same as corn.  (some writers may also include milo and sorghum in their definition).  Maizmeal can be wheat or a corn and wheat blend; review ingredient labels.  Maizmeal packaged in most foreign countries may be all wheat or contain a high percentage of wheat and/or kamut.

          Manioc  -  Manihot exculenta, see cassava, tapioca.

Milo  -  see sorghum, L. syricus.  Is an excellent source of GF flour.  Mills easily and is readily available in the commercial market.  Some varieties are more easily digested than others; check with source on the best product for use by celiacs.  

          millet  -  a wide range of reactions to a wide range of varieties;  no botanic name is given since there are dozens of potential listings;  this is another grain for which the information and research is not all in;  our recommendation is to avoid any use of the millet grains.  Common millets available in health food stores include the following:  African millet,  Italian millet, broomcorn millet, pearl millet, spiked millet--plus several German millets and a number of hybrids and crosses such as North Dakota, Canada, etc.  Researchers contacted indicated that while some few of the millet varieties are low gluten content, there is considerable variation between products and within the same product samples.  Second, contamination on farms is thought to be high for the millets.

         mir – formerly, wheat of the peasants;  currently, usually means wheat-containing by most food scientists.  May be used as an extender. 

         Montina - Achnatherum Hymenoides; a perennial bunch grass commonly known as Indian Rice Grass.  available as a gluten-free flour; mixes well with other flours; evaluation shows Montina not to be related to both regular rice and to wild rice of Minnesota.  Central supplier is Amazing Grains of Bozeman, MT.  [also ENER-G Foods of Seattle].

         oats  -  Avena Stativa.  Protein is known as avenin.  Oats in any form or as flour and oat gum in lipsticks and make-up in addition to their several derivatives are suggested as foods to avoid if you are a celiac.  Of special concern are the fat replacers such as Oatrim, Replace, etc., which are currently popular in the market.

        Peas, bean, mung beans, lentils  -  These grain seeds make up as basic protein flours and are commonly available in health food stores.  They can easily be milled at home.  Depending on taste preferences, they are excellent additions for breads and rolls.  They each contribute to hardness in the finished product, however;  egg white and cottage cheese need to be added as softeners in baked goods.   They are each common additions to gravies, meatloaf, soups, and sauces.   Included with this listing of basic protein crop seeds are the following items:  groundnuts (peanuts); pigeon peas; chickpeas; hyacinth beans; cowitch, the Florida velvet bean; tepary bean; lima bean; sieva; scarlet runner bean; ram mungs, kidney beans; horse beans; adzuki beans; asparaus beans; and cowpeas. 

         Peanut  -  Arachis hypogaea.  Of the legume family.  Excellent for use as a flour.  Best if ground after roasting.  Peanut oil and peanut flour are good choices for celiacs.   Caution use for children and for older adults.  

Potato  -  Solanum tuberrosum.  Potatoes, potato starch, (potato starch flour) and potato flour are excellent for CS and DH patients.  Celiacs, who react to sulfites, should avoid instant potato products; tater tots and several of the prepared (manufactured) potato entries (Pringles) which have wheat flour or wheat starch added must also be eliminated from the diet.  Avoid all commercial French fries with coatings that have wheat starch added as one of the ingredients. 

        quinoa  -  (keen-wa), a South American grain product that is common in health food stores;  is listed as a low-gluten grain; food chemists we have contacted list it as suspicious and/or contaminated; we suggest that quinoa in its several forms be avoided.

        Rice  -  Oryza zativa.  Protein of rice is known as oryzenin.  Can be labeled as white rice flour or brown rice flour; it is known for having a bland flavor; it works best when combined with other gluten-free flours--especially potato starch flour.  Celiacs do best on non-enhanced rice products, particularly if the enhancement has been done with barley water.  Also allowed are the outer millings of rice:  rice bran and rice polish.

rye  -  Secale cereale.  A high reactor for CS and DH patients.  It should be avoided.

rye buckwheat  -  agopyrum tataricum, see also buckwheat.  Little or no research is available; most patients report both malabsorption problems similar to wheat and reactions perceived as allergic reactions.  It is recommended that both buckwheat and rye buckwheat and its close “relative,” mir be avoided by celiacs.

Sago  -  Palm metroxylon sagus.  Is slightly gray in color; tastes rather bland, but can be used in baking on its own; good in pastry--especially in pizza dough or in products which have a strong seasoning added or as an accompaniment;  can be used for crumb toppings and in puddings; binds slightly, but is not an easy product with which to work in a dough mixture.

        semolina  -  Wheat.  The larger, hard kernels sifted out in the flour milling process are classified as semolina.  See the definitions on wheat listed under Tritiucum.  Do not be persuaded by 4-color brochures at health food stores.  Should be avoided by celiacs.

         Sesame  -  Whole white, brown or black seeds, coarse ground or as flour are an excellent addition to cookies and breads.  Works well with sandwich pockets made from rice mochi.  No problems are seen for celiacs with sesame seeds, flours, or oils.

        Sorghum  -  Sorgo, soreg, or L. syricus.  Historically referred to as Syrian grass.  Any number of related cereal grasses with sweet juicy stalks grown for grain, stalks and syrups.  Both the sorghum-based syrups and sorghum grains are seen as acceptable for celiacs.  Many sorghum syrups are often heavily sulfated and persons who have reactions or sensitivities to sulfites should then avoid them.

        Soy  -  (soya).  Glycine max.  has strong, distinctive, nut flavor;  has a high protein and fat content; is used best in combination with other flours;  might be better used in double chocolate cakes, and in cinnamon and pumpkin breads in which all or most of the flavor can be hidden.  Do not confuse soy bran with soy flour; soy and soya are the same product.  Soy nuts with unknown oils and additives and honey-roasted soy are typically seen as negative and should not be used by celiacs.  Most recipes are designed to use low-fat soy flours; high-fat soy is a choice for making soy milk, tofu and is used in vegetarian menu selections.

        spelt  -  Triticum spelta.  another primitive form of wheat similar to kamut;  is a low-gluten content wheat.  Common name is dinkle; it is not recommended for use by CS or DH patients.  Botanic name for several varieties is Aegliops speltoides.  Is identified in some sources as "manna." Spelt, like the millets, has evolved into many varieties.  Do not be taken in by 4-color brochures and advertising that represent spelt as a non-wheat or with no harmful gluten.  

Starch  -  a reserve polysaccharide in plants [arrowroot (tapioca, cassava or manioc), corn, potatoes, rice and wheat are commercial sources].  Occurs in two forms:  amylose (long straight-chain glucose units) and amylpectin  (branched arrangement of glucose units).  It is found in grains, roots, vegetables and legumes.  Starches are encased within the plant cells by cellulose walls in the form of granules of varying sizes and shapes that are typical for each starch.  The composition of each starch differs, but all contain both amylose and amylopectin.  Starches are insoluble in cold water and must be cooked.  Cooking causes the granules to swell and the mixture to thicken or gel.  Amylopectin in the starch granules participates in this process.  Cooking softens and ruptures the cell to make starch available for the enzymatic digestive processes in the intestine.  In the U.S., when the term "starch" is used, it must be derived from corn.  That is not true, however, for products brought into the country or when terms or descriptors are used proceeding the word, starch on the ingredient label.  Celiacs should not use starches derived from wheat or any of their derivatives.

        Sunflower  -  The seed may be finely ground and added to flour combinations; result is a dark bread; is an excellent taste difference; may also add a small amount of soy if tolerated.  Sunflower seeds, its flour, and oil are acceptable for celiacs in their pure form.  

        Sweet Potato  -  I pomoea batatas.  A tropical trailing plant of the morning glory family;  has a fleshy, orange or yellow tuber-like root; used as a vegetable or flour;  may be referred to as yam or ocarina;  is well tolerated by celiacs.  More available in the south and southeast part of the U.S., but can be ordered through many commercial sources.

        Sweet Rice Flour  -  contains more starch than the brown and white rice flours; works well as a thickener.  This is a flour that comes from a sticky short grain rice.  It is often referred to as glutinous, but is a safe grain for celiacs.  See oriental cookbooks for recipes.

        Tapioca  -  see cassava and manioc.

        tef  -  tef grass or teff.  Eragrositis tef.  Common in health food stores and promoted as gluten-free.  Rationalized that it is "gluten-free" after cooking or is already gluten-free since it is in the "grass family."  Not suggested for any use by celiacs.

         triticale  -  X triticosecale.  A hybrid grain combination of rye and wheat [a cross]; it is not gluten-free.  Not recommended for use by celiacs.

         wheat  -  [common wheat]  Triticum aestivum.  There are many varieties of wheat, the triticums.  Avoid all wheats and wheat products including wheat starch.  Avoid also T. Durum,  Abyssinian hard wheat and T. monococcum Einkorn wheat which are represented on some labels as non-glutinous, low gluten or are listed as corn or maize product.  Note ingredient labels on products from foreign sources (foreign countries) which may list wheat as maize o as seitan which means the product contains wheat gluten.  See also, kamut and spelt above.

         wheat starch  -  Can be derived from any of the tritiucum wheats.  Found commonly as a binder or used as a freshener or preservative.  Avoid all coatings with wheat starch whether on French fries, or on fruits and vegetables to add shelflife.  See the definition of starch above for the common properties of amylose and amylopectin common to starches.  Avoid all use of wheat starch whether in gluten-restricted or in gluten-free diets.  Note that wheat starch may be included in international products as a minor ingredient [under the 5 % allowed]  without being listed as apart of the contents.  Note also that these products will be listed and advertised as gluten-free when in actuality they are gluten-containing products.

         Wild Rice  -  Oryza fatua and O. spontanea.  A DNA relative of white rice. Wild rice is seen as appropriate for use by celiacs;  know the source of the wild rice used, however. If a preservative or an insecticide has been added, the product is likely to cause reactions.  It is seen as best to avoid the wild rice/white rice mixes and boxed combos (most boxed rice mixes).  Uncle Ben's is an example of a product which typically causes reactions for CS and DH patients. 

 

Starches

          Starches are polysaccharides consisting of repeated  glucose units. With respect to structure, starches will consist of either one or a combination of two different molecules: amylose and amylopectin.  Amylose takes the form of a straight chain with anywhere from 500 to 2,000 glucose units.  On the other hand, amylopectin has a chain length of only 25 to 30 glucose units.  Because amylopectin has a branched structure, however, it actually is a much more massive molecule than amylose, possessing several thousand glucose units.

        The ratio of amylose to amylopectin varies, depending on the source of starch, and is a major contributor to a starch's functional properties.  Corn starch, for example, has around 24% amylose and 76% amylopectin, while potato starch has 20% amylose and 80% amylopectin.  Tapioca only has about 17% amylose and waxy maize or waxy rice have virtually none.

        The most common industrial starch sources include corn, potato, rice, tapioca, arrowroot and wheat.  In the past, the source used varied depending on which part of the world the finished product was to be manufactured.  In other words, food product designers used what was most plentiful--corn starch in the U.S., potato starch in Europe and tapioca in the tropics.  Now, however, products are requiring more specific starch performance, so designers are broadening the sources of the starch used.

         In the U.S., when the label states only the word "starch," then it must be corn starch if it is a food product.  This does not hold true for drugs and pharmaceuticals.  When it is not labeled as starch, then the celiac must either question and learn the content or omit the product.

         Wheat starch and starch gel have a type of gluten associated with them which may cause either an allergic sensitivity or a reported  toxic reaction.  These ingredients are to be avoided by celiacs.

Fruits

         Fruits are simple.  Use most fresh, frozen, dried or canned fruits.  Some canned fruits contain additives or preservatives.  Some fresh fruits may have retained surface pesticide residues.  Note whether a sensitivity exists to the preservatives in selected dried fruits.  Avoid thickening agents for some canned fruits and selected  canned pie fillings.  It is best for celiacs to avoid prepared fruit  preparations from countries such as Italy and Australia until more information is available on contents and the definitions of terms used on labels.

         For those celiacs who are sulfite-sensitive, most dried fruits should be avoided since a sulfite is used as the central preservative.  Children under the age of 7 or 8 should not be fed any variation of dried fruits except through concurrence by parent and physician.  The potential allergic reaction to sulfites can be frightening to both child and parent and can be avoided with omission.

 

Ice Creams and Frozen Desserts

         An abundance of choices is available in ice creams, ice milks, sherbets, and ices.  When fruits and nuts have been added, note whether they have been dusted with flour to add to their combining more evenly within the product.  Regular yogurts are a good choice; frozen yogurts are not acceptable.  The best bets are products with very few  ingredients and in their purest form.  The more complex the ingredient listing,  the greater chance for contamination.  A choice of gums and wheat flour may be used to add body to less expensive frozen desserts and ice milks.

 

Malt,  Malt  Extract,  and  Malt Flavorings

          Malt is typically prepared from sprouted barley and sometimes other cereals or cereal sludge.  It is therefore not allowed in the diet for celiacs.  In the malting process, there is a marked change in the distribution of nitrogenous compounds and it may be noted that the hordein content of malt is about half that of barley.   It is generally agreed that the malt found in malted milk and other foods should also be avoided.

          Malt extract, which is used as a flavoring agent or flavor enhancer in selected rice and corn cereals, is a different product, but may also be toxic in higher amounts for many celiac patients.

          At this time, the unpublished data using fat and dextrose absorption processes is not exact.  In most cases, the total content  is less than .003%.  For the sensitive celiac and for children under  age 8 and for persons over the age of 60, our recommendation is to  avoid malt and malting extracts until further research data is  available as a contraindication.  All celiacs are advised to avoid  products, which contain a very high amount of malt extract such as  malted drinks and pure malt extract.

 

Meats,  Poultry,  and  Seafood

            Use fresh, frozen, and canned meat or pre-packaged meat in its own juices or jelly.  Avoid luncheon meats, prepared sausages, canned meats with preservatives, cereals, flour, food starch, and  grains.  Choose fresh fowl:  turkey, goose, duck, chicken; avoid  injected, stuffed, self-basting, and fat-reduced fowl of any kind.  Avoid low-fat, fat-reduced, and diet hamburger and ground meats since they are likely to have Oatrim, Replace or a grain additive.

          When any meat product is cooked or processed with other ingredients, then we have to be careful as to whether it is still  suitable for inclusion in the diet.  If it is home-made, check the  ingredients; if a manufactured dish, then check the food listing.  Albacore is the highest quality tuna product.

 

Milk,  Milk  Replacements,  and  Yogurt

          All liquid (pasteurized, sterilized, UHT, and homogenized) milks, including the whole (full fat), 2%, semi-skimmed, buttermilks, and the very low fat milks are gluten-free.  Exception: there are some  areas of the country in which low-fat milks have added fiber from  barley or oats.  Read labels on milks that are not whole milk; avoid all milks and milk products with fiber added or that have a reduction agent additive.  For lactose intolerant patients, there are many soy substitute and coconut milk products available in most supermarkets.  The use of Lactaid or similar lactose-reduction products by celiac patients should be done with caution since they are not now known to  reduce the content to the 100% level.  The use of Lactaid is not   recommended for celiacs with severe intolerance.  The present   information on milk whiteners and dairy creamers is inconclusive.   Since many celiacs self-report problems, we suggest non-use until further clinical direction is available to us.

         Coconut Milks.  Some coconut milks may be cow's milk flavored with coconut.

Flavored Milks.  Many flavored milks contain dyes and fat replacers such as Oatrim and Replace.  Best to omit from diet.

        Rice Beverages.  Rice milks are made from rice and contain less  protein and calcium than milk or dairy products.  They are generally  lactose-free, but labels do need to be checked.

        Soy Milks.  Soy milk is made from soybeans and must be fortified with calcium in order to be nutritionally equal to cow's milk.  It can be used in cooking in place of milk.  

        Words on a label that mean a product contains lactose in some form:

                        buttermilk                     milk fat

              cream                           milk solids

              curds                             milk, whole, skim, low-fat

              dry milk solids                nonfat dry milk powder

              ice cream                      whey

              milk by-products

             Words on the label that sound as if they contain lactose, but do not contain lactose:   

                        calcium caseinate            lactic acid

                         calcium lactate                lactoglobulin

                         casein                             sodium caseinate

                         lactalbumin

         "Non-Dairy" does not always mean that the product is lactose free.  It may mean no whole milk, but labels must be checked for lactose or other milk-based ingredients.  Choose powdered coconut milk.

        "Pareve" or "Parve" means having no meat or dairy-based ingredients.  This makes the product permissible for use with both meat and dairy  meals as stated in the Jewish dietary laws.  

Foods that commonly have LACTOSE content

        >Processed breakfast cereals.  Ex:  instant cream of rice.

         >Instant potatoes, instant soups and many breakfast drinks.

         >Margarines and salad dressings.

         >Lunch meats other than kosher.

         >Candies and other sweet snack items.

         >Hot chocolate mixes, instant coffees, and Ovaltine.

         >Omelets, scrambled eggs, and soufflés at restaurants.

         >Gelatins made with carageenan.

         >Cream cheese and peanut butter with fillers of milk solids.

         >Tater curls, corn curls, and French-fries may be processed with both   a milk product and wheat starch.

         >Selected antibiotics, vitamins, and mineral supplements.

         >Artificial sweeteners such as Equal, Sweet n' Low, and Wee Cal.

         >About 20 percent of prescription drugs; 6 percent of over-the-counter drugs including several types of birth control pills. 

       

Nuts  and  Seeds

        Coconuts, peanuts, Brazil nuts, hazelnuts, cashews, walnuts, water chestnuts, and the seeds of sunflower, pumpkin, sesame, poppy, alfalfa, and mustard.  They are usually higher in protein and fat and may be consumed in a variety of forms, e.g., raw, roasted, and as flavorings.

        The celiac needs to be concerned about what ingredients have been added to nuts, e.g., honey-roasted and dry-roasted nuts, which contain wheat, are not allowed in the diet.  A concern for some individuals is the type of oil, which may have been added, or the amount of salt, which is reasonable for the diet.

 

Rice

 Many varieties of rice are available in supermarkets and ethnic grocery stores.  In addition to plain white rice, you are likely to also find wild rice, brown rice, instant rice, and many non-allowed preseasoned mixes.  Some of these products are better than others and the "most expensive ones" generally turn out to be the least healthy.

          A half-cup serving of any kind of plain rice contains about 110 calories, some protein, lots of complex carbohydrates, and very little fat.  Rice has an inedible hull, which is removed when it is harvested.  In making white rice, the layer of bran and germ, which contains most of the vitamins and minerals, also are removed.  Rice processors compensate for some of these nutritional losses by enriching white rice with B vitamins and iron, most of which are lost if the product is rinsed before cooking.  Contrary to myth, brown rice is not significantly more nutritional than white rice.

White Rice (long grain).  The most popular form of rice in the U.S. and Canada, it is usually enriched with niacin, thiamin, and iron.  This enhancement is safe for celiacs; it is when a derivative of barley is used that it becomes unsafe.   Grains of white rice stay separate and fluffy; the grain has a mild flavor.  (medium and short grain, white or brown).  Similar in flavor to white and brown long grain but has a creamy texture and clumps together, but is especially desirable for desserts, molds, and Asian dishes. This rice is a good choice for home milling into flour; it  produces a softer and less grainy texture in the finished product.

        Instant Rice (white or brown).  This expensive, highly processed rice is cooked and dried, then rehydrated when you soak it in boiling water.  Review additives, treatment, enhancement, and processing before deciding on a brand name.  Check out packaging for non-allowed ingredients, which might then cause contamination for the product.

        Brown Rice (long grain).  A favorite in health stores, brown rice retains the grain’s bran but not its hull.  Nutritionally, it contains only slightly more trace minerals and a bit more fat than enriched white varieties.  It also has more fiber.  Has a nutlike flavor; chewy texture and a shorter shelflife than white rice.

        Basmasti Rice  (white or brown).  This aromatic rice, grown in India and Pakistan, has a sweet, nutty flavor and smell.  It is similar nutritionally to other rice and more expensive than plain long grains.  Varieties include texmati, wehnani, and wild pecan.

        Wild Rice.  White rice and wild rice share some of the same DNA; wild rice is grass seed native to North America and grown principally in the wetlands of California and Minnesota.  Nutty and rich, with more protein and fewer calories than plain white rice, plus some B vitamins, it yields double the volume of regular rice when cooked, which partly makes up for its high price.  Look for a non-contaminated product that has not been sprayed with a series of pesticides while in storage.  

        Preseasoned Rice.  Most packaged and pre-seasoned rice mixes are not acceptable for the celiac diet.  These mixes (such as Rice-a-Roni, Uncle Ben’s Country Inn, and Near East Pilaf) are popular and easy to prepare, but they are expensive and very high in sodium.  They also contain partially hydrogenated oils and usually require additional fat in cooking.  Some also contain sugar.  These mixes should be avoided by celiacs.

         Parboiled.  Rice has been steam-pressure treated before milling, forcing all the nutrients from the bran layer into the grain.  The grains remain separate and firm-textured when cooked.

        Rice Blends.  The mixes and blends of every conceivable sort are finding their way into the market.  They’re innovative combinations of brown and dark rices, many of which are grown and packed by Lundberg Family Farms of Richvale, CA.

 

Snacks

        For base ingredients, look for rice, potato, corn, popcorn, soy, sorghum (milo), and beans.  Offending ingredients are non-allowed grains; coatings and flavorings and some hidden glutens may be added in the processing of a product.  Example:  corn taco shells may be totally gluten-free until they go through the drying processor on a belt dusted with wheat flour so they won't stick onto the machine.

 

Soups  and  Broths

          Look for broths with the allowed ingredients. Avoid the unknowns which may have thickeners, emulsifiers, flavor enhancers, and colorings added with non-specific or generic labels.  Unfortunately, most commercially canned soups contain a grain derivative.

 

Home-Done Flavor Enhancers

          Use leftover juices from a roast with aromatic vegetables such as onion, carrots and celery.  Place in the blender with a small section of leftover meat.  Can freeze as cubes or cook to a concentrated form.

 

Bouillon

        Be suspect of all bouillon in powder, cube, or canned form.  The better choice is broth, au juice, and specially prepared stocks that you can make yourself and freeze or can. Some celiacs are sensitive  to MSG which is used in selected bouillons.  Some bouillons from European sources are seen as gluten-free.

 

Spices,  Herbs, and  Seasonings

        Seasonings are often referred to as the "soul of cooking."  The greater the skill in the art of seasoning, the better the cook.   While seasonings do not add food value to the diet, they often make  a dish that has been unacceptable a desirable food.  The main purpose  in seasoning foods is to make the product more palatable.  Celiac cooks are then able to change the bland and mundane into an exciting and gourmet listing.

        In general, celiacs are advised to begin their diets with little or no use of seasonings; [use bland, naked foods to begin the GF diet and then add to it as you learn and have gained experience in self-management]. Patients can then move on into a minimal use of  sugars, salt and pepper, butters and various herbs and spices in  moderation.  The continued caution for most celiacs (although each celiac represents differing needs) is moderation.  Don't overdo with   pre-mixed seasonings such as barbecue sauce, chili pepper, seasoning  salts, and curry.

        Again, the reminder to check for 100% products; red flag such items  as "natural flavorings added," white pepper with wheat flour to increase its pourability, or curry or cinnamon with a lacing of flour  to stretch the content.  If in doubt, buy the whole or fresh product and grind in your own spice mill.  Know the product is pure before use.

        Salt, pepper, herbs, and spices are gluten-free as sold in most grocery stores and supermarkets.  But, we do need to be concerned about the purchase of 100% pure products.  Herb and spice seasonings and some of the mixes do contain flour as a filler so take care when shopping.  Purchase well-known brands such as Schilling and Watkins; be wary of chain brands at reduced prices.   For example, check out cinnamon, white pepper and curry for exact ingredient labels; avoid a product with a label that misleads such as "100% natural   ingredients."  Select a top of the market product, usually the most expensive, for the better selections available in most grocery stores.

 

Flavorings

        Flavorings, artificial flavorings, natural flavorings, assorted  flavorings, natural food sources added—each of these terms is an enigma for the celiac.  Without knowledge of the origin and ingredients of such flavoring agents, the process involved in development, etc—what  otherwise might be a great product must be omitted because of inadequate knowledge. 

            The problem for ingredient selection has become more complex as food developers make purchases of products such as flavorings from secondary sources. Since the manufacturer is not the originator of the product, they may have no  knowledge of the product contents, the process used for  its development, or the content purity status.

            While most flavorings are in the Generally Accepted as Safe (GAS) category, when there are unknowns, the celiac must seek out information to learn the facts for acceptability or reject use of the product if there remains an inadequate knowledge base for product contents.   Liquid flavorings such as vanillas are appropriate when artificial  alcohols are used.  Ener-G Foods and Dietary Specialties are commercial resources for both dry and liquid products.

 

Hydrolized  Plant  Protein  [HPP]

        [HPP] is fine if known to be all vegetable and not to have an offending grain included.  Most manufacturers do not reveal the exact source on the label since it may change or have variations from one batch to another.  Thus, the general label of HPP is thought of as one size which fits all.  The celiac must search out the source of HPP before use of the product—even though seventeen food manufacturers of a sample of twenty indicated HPP would always be made from allowed vegetable sources.

 

Hydrolized  Vegetable  Protein  [HVP]

         [HVP] is a flavor enhancer used in many commercially prepared soups and other prepared foods.  It may be made from soy, wheat, or other cereal proteins.  It has not been required that the exact source be stated on the label of foods.  If HVP is made from soy there is no concern (for most persons unless they are uniquely soy sensitive), but if it is made from wheat gluten it might be at a level to cause toxic reactions.  Most clinicians feel that foods containing HVP should be avoided and eliminated from the diet.

 

Monosodium Glutamate

            MSG as a Flavor Enhancer (sodium salt of glutamic acid).  May be referred to informally as "Chinese powder."  Sources for the production of MSG in the United States usually utilize a source of cane or beets--or, tapioca starch.  Foreign sources of MSG may contain gluten-containing grains and a large majority of U.S. food producers may be importing this product for use as a secondary ingredient.  Some celiacs continue to report having a sensitivity or asthmatic reaction to MSG.

Glutamic acid is found in many popular cheeses, tomatoes, mushrooms, and a number of other foods.  Processed foods contain MSG (the sodium salt of glutamic acid) in the normal range of naturally occurring glutamic acid found in many foods in our food system.

The general conclusion is that glutamic acid (MSG) in commercially processed foods is safe for consumption by celiacs.  This evaluation is not true, however, for its use in restaurant and/or home-prepared foods. 

Chinese Restaurant Syndrome (CRS).  CRS consists of the following symptoms celiacs have reported experiencing after eating in a Chinese restaurant: a burning sensation, pressure and tightness or numbness in the upper chest, arms, neck and face which begin shortly after the start of a meal (in 5 to 35 minutes) and usually lasts less than three hours.  Some persons report itching at all body openings and a burning sensation over the face.  Some report altered breathing along with the itching sensations.  Extreme variations exist in individual response to MSG.  It would appear that CRS symptoms are especially likely to  occur when MSG is eaten without carbohydrates or on an empty stomach.

          Other non-specific symptoms such as chest pain, headache and dizziness are also associated with the syndrome.  The cause of the syndrome is unknown, although many non-medical professionals believe CRS is due to eating MSG as used in selected foods prepared in Chinese restaurants.  At this time, we are recommending that celiac patients avoid all use of MSG (glutamic acid) in home and restaurant prepared foods.

 

Vinegars

         The best vinegar choices for most celiacs are apple cider and wine vinegars and vinegars from corn. 

            Investigate and try out a brand of vinegar that works for you.  Then, realize that vinegars may change from batch to batch and at this time, generally fit into a category of low regulatory control and continuity.  Many vinegars are coming into the market made from corn and can then be represented as gluten-free.  Avoid distilled clear and white vinegars unless you are assured that the product is made from corn and does not use a grain mash (or nondefined grain sludge) as a starting material.  Avoid most of the flavored, fruited, and herbed vinegars; make your own at less than half the cost.  Avoid vinegars which state they are "wine based" or "wine flavored."  Do not fall for advertising, which states that a particular brand name of vinegar is gluten-free, etc., etc.  Check out content, processing, additives, base mash if used, flavoring, and colorings before use as a food product.

            Common categories of vinegars include the following gluten-free items:  apple cider vinegar, balsamic vinegar, and wine vinegars.  Pure apple cider vinegars without added colorings are appropriate choices for celiacs.  Apple added or apple cider added to vinegar usually make this choice inappropriate.  Balsamic vinegars are blends of wine and unfermented grape juice.  Domestic brands of wine vinegars are generally gluten-free.  Re-processed, stabilized, and recycled vinegars may be a combination of several batches of vinegar that have been returned following the “age date” for use.  In general, these recycled products should not be chosen for use by celiacs.

 

Holy Communion Wafers

            Communion wafers made from wheat flour and/or wheat starch may provoke symptoms in patients with celiac disease.  However, many agents of the church believe the gliadin content is insufficient to damage intestinal mucosa.  Gliadin was extracted from gluten by ethanol precipitation in 14 different wafers made for Roman Catholic and Anglican use, of which 4 were defined as “gluten-free.”  Regular wafers were found to contain 2.2 to 4.9 mg of gliadin; gluten-free wafers, 0.28 to 0.66 mg; and the large altar breads used by priests, 11.9 to 12.7 mg; starch gel urea electrophoresis revealed a, B, y, and w gliadin.  On a weekly basis, a daily communicant might consume 35 mg of gliadin, and a priest up to 150 mg, including 40 mg on Sundays.  Such cumulative amounts are likely to maintain the mucosa in a “primed” condition, leading to abnormal jejunal morphology or clinical symptoms.

          A further concern is that continued ingestion of gluten may predispose patients with celiac disease to neoplasia, including small-intestinal lymphoma and carcinoma of the oropharynx and esophagus.  A recent long-term follow-up study has shown a markedly reduced prevalence of such complications when a gluten-free diet is vigorously maintained, providing strong support for the practice of advising all patients with celiac disease to adhere to a strict gluten-free diet for life.

            Therefore, there remains considerable concern about the continued ingestion of gliadin-containing communion wafers by patients with celiac disease, especially priests, daily communicants, older adults, and children.  Although it would seem desirable for them to receive “gluten-free” wafers, there is a dilemma for Roman Catholics in that Codex Juris Canonici, the code of canon law, states, “The bread must be wheaten only, and recently made, so there is no danger of corruption.”  The Roman Catholic Bishops’ Conferences of England and Wales and of Ireland have appealed to the Vatican to recognize the legality of gluten-free wafers.  The contrary ruling by the Sacred Congregation for the Doctrine of the Faith in Rome has distressed many patients with celiac disease whose main concern is to follow a gluten-free diet.  Moreover, the current compromise of taking only a fragment of wafer, or wine alone, involves a psychologically unacceptable stigma for many patients with celiac disease.  Indeed, a report from Chile has shown that children with this disease who were aware that communion wafers contain gluten received holy communion less frequently than did those who were unaware;  some stopped receiving the Eucharist—a situation unacceptable both to practicing Catholics and to the Vatican.   Source:  The New England Journal of Medicine, 3 August 1989, p 332.

            Communion wafers advertised as gluten-free from sources in England and several foreign countries, in actuality do contain wheat starch.  The content may be described as gluten-free since it meets the specifications of being at or below the 5 percent level of gross weight of the product as is recommended by the International Codex Alimentarius headquartered in Rome, Italy.

            Celiacs should discuss their own particular situation with their local pastor or priest and learn the guidelines and/or dictates of their particular denomination, bishop or diocese. 

            Recipe for Communion Bread.  4 cups of a flour mix (1 ½ cups of the white cake mix from Dietary Specialties and 1 ½ cups of a white flour mix for bread, 1 cup of potato starch and 2 tablespoons of cornstarch for the base flour.

            Then add:  2 t of a gluten-free baking powder such as Clabber Girl; ½ to ¾  teaspoon of xanthan gum (or substitute 2 well-beaten egg whites) and 2 scant teaspoons of salt (can be omitted). 

            Sift flours with the baking powder, xanthan gum, and salt three or four times, then beat and mix with a wire whisk.  Withhold one half to three quarters of a cup of the finished mix for flouring the dough and the pastry board. 

            Then add:  2 tablespoons of olive or corn oil.  1 ¾  cup water (cut down if you are adding honey)  2 to 3 tablespoons of honey (optional, improves consistency).

            The dough will be sticky.  Divide into 4 parts (easier to work with smaller portions) and then pat a few drops of oil on each section and sprinkle lightly with some of the flour mix.  Roll out to desired thickness; (thin, maybe 1/8-inch).  This amount makes four 8- to 10-inch rounds of dough.  Cut out wafers; use either a small-sized juice can or the hole-section of a doughnut cutter. 

            Lightly grease a cookie sheet with a solid gluten-free vegetable shortening such as Crisco.  Place wafers on prepared pan and then with the blunt end of a knife, mark each bread with a cross in the middle.

            Bake in a preheated 350-degree oven for 12 to 15 minutes; remove from oven and paint the surface of each wafer (bread) very lightly with corn or olive oil and return to the oven for 6 to 10 minutes to finish baking.  Watch baking carefully so as not to over bake or brown.  Note the flour combinations you are using and adjust the baking time to fit.  [It is best to do a trial of 2 or 3 wafers to check out a preferred baking time for your mix].  

            When baked and cooled, these wafers can be stored individually in plastic sandwich bags and placed in the freezer.  They are best stored individually wrapped and then placed in metal cookie tins with tight-fitting lids.  Place this container in a larger plastic container which also seals.  With this pattern of triple sealing, this recipe stores well in the freezer for up to 6 months.

            While some denominations can allow the use of a non-wheat (or non-wheat starch) containing wafer for use as communion bread, several disciplines cannot because of the definition for the content of the host.  Many celiacs are in disciplines that allow them to take only the wine at communion; they thus can omit the problem relating to their need for a gluten-free bread.

Always Question [or avoid] these Items for 

Your Shopping Cart:

             If you don’t know that ALL ingredients in the following items are gluten-free, they then should be avoided and omitted from the diet:

                       ice cream cheese spreads
                       non-dairy creamer chip and dip mixes
                       yogurts with fruits meat sauces
                       luncheon meats wieners and sausage products
                       instant coffees flavored coffees
                       instant teas herbal and flavored teas
                       canned soups bouillon cubes
                       soup mixes dry cereals
                       salad dressings mustards
                       catsups                       peanut butter
                       tomato sauce tomato paste
                       sour cream brown sugar
                       marshmallows margarines
                       French fries enriched products
                       self-basting turkeys soy sauces
                       rice mixes soft drinks w/caramel coloring
                       honey-baked hams Worcestershire sauce
                       corn tortillas distilled white vinegar
                       brown rice syrup Hawaiian punch
                       brown sugar vanilla with grain alcohol
                       dry roasted nuts Uncle Ben's rice mix
                       self-basting fowl enriched products
                       cinnamon dry mustard powder

 Personal and over-the-counter items that

commonly have GLUTEN content

                      communion wafers lipsticks
                      face powder hand lotions
                      body powder toothpaste
                      Tylenol chap stick
                      Rolaids envelope glue and stamp glue
                      aspirin sizing in new garments

 

   ADDITIVES THAT ARE THOUGHT TO BE GLUTEN-FREE

BHA

BHT

Beta Carotene

Biotin

 

Calcium Phosphate

Calcium Chloride

Calcium Pantothenate

Carboxymethylcellulose

Carrageenan

Citric Acid

Corn Sweetener

Corn Syrup Solids

 

Demineralized Whey

Dextrose – Dextrins

Dioctyl Sodium  

     Sulfosuccinae

 

Extracts

 

Folic Acid – Folacin

Fructose

Fumaric Acid

Gums:  Acacia, Arabic, Carob, Bean, Cellulose, Guar, Locust Bean, Tragacanth, Xanthan

 

Invert Sugar w/o additives

 

Lactose

Lecithin

 

Magnesium Hydroxide

Malic Acid

Mictrocrystallin Cellulose

Mono- & Di-glycerides

MSG – Monsodium

     Glutamate

 

Niacin

 

Polyglycerol

Polysorbate 60 and 80

Potassium Citrate

Propylene Glysol

      Monosterate

Propygallate

Pryidoxine Hydrochloride

Riboflavin

 

Sodium Acid Pyrophosphate

Sodium Ascorbate

     Ascorbic Acid

Sodium Benzoate

Sodium Caseinate

Sodium Citrate

Sodium

     Hexametraphosphate

Sodium Nitrate

Sodium Silaco Aluminate

Sorbitol – Mannitol

Sulfosuccinate

 

Tartaric Acid

Thiamine Hydrochloride

Tri-Calcium Phosphate

 

Vanillan

Vitamins & Minerals

Vitamin A - Palmitate

            

            Other Intolerances and Sensitivities:

          Beyond the Gluten-Free Diet

             Lactose Intolerance.  Persons with lactose intolerance lack sufficient amounts of the enzyme lactase that breaks down lactose or milk sugar.  When milk products are consumed by the lactose intolerant patient, the lactose remains undigested in the intestine; in some people it then causes gastrointestinal pain, bloating, cramps, flatulence, and diarrhea.  Lactose becomes a problem for some celiacs not only from milk and selected soft cheeses, but is commonly used inert excipients in the formulation of tablets, capsules, and suspensions, which then cannot be tolerated.  Notable examples are selected brands of calcium tablets, which may be made of an excess of 90 percent powdered milk and thus not be acceptable for use by the lactose intolerant individual.

             In the celiac patient, lactase deficiency is suspected to occur as a genetically inherited trait, but it may also be acquired as an adult through environmental factors.  Studies reviewed confirmed that 70 to 75 percent of American Blacks; 75 percent of American Indians; and, 90 percent of Orientals manifest some degree of lactase deficiency.  This contrasts with a 5 to 10 percent deficiency rate in Caucasians.  We may then generalize that it is a fairly common problem, particularly in non-Caucasians.  Based on the data from these studies, it is estimated that 3 in 10 non-Caucasians have the problem and about 1 in 10 Caucasians have the problem.  For non-celiacs, the problem is typically recognized between the ages of 10 and 20.  For most celiacs, the problem is often concurrent with the onset of celiac disease (and/or dermatitis herpetiformis).  For the lactose intolerant celiac, foods containing either lactose or gluten will then need to be on the non-allowed listing for the prescription diet. 

             Lactase deficiency is referred to in professional journals as the most common disaccharidase deficiency.  Disaccharides are normally split into monosaccharides by specific enzymes such as lactase, maltase, iso-maltase or sucrase—all are located in the brush border of the intestinal mucosal cells.  When lactose or galactose is ingested in a lactase-deficient individual, a high percentage of these disacharides remain in the lumen and osmotically retain fluid; then bacterial fermentation leads to gaseous acidic stools.  The abdominal pain, nausea, and cramps generally will occur within 30 minutes of ingestion—usually followed within two hours of ingestion by bloating, flatulence, and explosive, odoriferous, watery stools.  (medically, the condition is often referred to as gangliosidosis).   The same condition may occur in both children and adults. 

             With lastase deficiency, there is damage to the brush border membrane of the intestine.  Thus, it is a complicating factor for celiac disease.  The condition of lactase deficiency may accompany gastroenteritis, the condition of alcoholism where/if malnutrition is involved, Crohn’s disease, radiation enteritis, and AIDS enteropathy.  With each condition there is damage to the gut.  With each condition, there is then need for diet modification. 

              Lactose Tolerance Test. Lactose deficiency is diagnosed from a history of gastrointestinal symptoms that occur after milk ingestion.  That may typically include a breath or hydrogen test, a lactose intolerance test, or a biopsy of the intestinal mucosa.  Most commonly, the method of establishing that milk intolerance is due to lactase deficiency is the lactose intolerance test.  In this test, a child is given a dose of lactose based on his or her body weight;  an adult is given 50 or more grams of lactose, the equivalent of a quart of milk.  Blood samples are taken after various periods of time have passed.  When digestion of lactose is normal, two things will happen:  a) the lactose is broken down into galactose and glucose; and, b)  the blood glucose levels increase appreciably within 30 to 60 minutes.  In lactase-deficient individuals, the lactose is not digested and glucose is not released for absorption.  Hence, the blood glucose level does not increase. 

             Although some patients will appear abnormal when tested, they will have had no history of intolerance to milk.  This raises the question of whether the blood glucose level is truly an indicator of lactose intolerance.  Such patients appear able to tolerate small amounts of milk in their diets, but cannot accommodate the large test load of 50 gm when it is given undiluted and on an empty stomach.  Other diagnostic tests are stool examination for reducing sugars, a low stool pH, increased stool lactic acid level, and the blue chip standard: a mucosal enzyme assay of biopsy material which has remained the most definitive and accurate.  For a more extensive review of lactose intolerance, the reader is referred to:  Paige DM and Bayless TM, editors:  Lactose Digestion: Clinical Nutritional Implications, Johns Hopkins University Press, 1981. 

              Nutritional Care for Lactose Intolerance.  There is good news for persons who have the condition of milk intolerance because they are deficient in lactase.  Yogurt, a product made almost entirely from milk, (if in a pure form without additives, preservatives, and colorings) is well tolerated by most people with this problem and can be eaten by most celiacs.  They can then reap the nutritional benefits of milk—the protein, calcium, and riboflavin—without side effects. 

             Dietitians have been recommending yogurt to lactase-deficient patients for years, but they did so under the mistaken assumption that the lactose had been “predigested” by the bacteria in yogurt.  Now, research has provided a more complete explanation.  The bacteria used to make yogurt produce the enzyme lactase breaks down about 25 percent of the lactose.  By the time the yogurt gets to the grocery shelf, it has become quite acid and is chilled; the result is that the bacteria stop working on the lactose.  When, however, the yogurt is eaten, the same bacteria react to the warmth of the body and the low acid conditions of the small intestine and produce lactase again.  The remaining lactose in the yogurt can then be “digested” by the bacteria.  However, it is now felt that the process happens in the intestine and not in the yogurt on the grocery shelf.  And, the process occurs without untoward effects such as bloating and gas for the patient. 

             Most children and a number of adults will find that the condition of lactose intolerance diminishes after 4 to 6 months and they then are able to ingest small amounts of hard cheese and small amounts of whole milk along with yogurt.  For those individuals who remain lactose intolerant, selected hard cheeses and yogurt may be their best choices for a life-long “milk diet.”

             It is important for persons with a low tolerance for lactose to know about the many foods that may contain lactose even in small amounts.  Items, which may have lactose content, include the following food items:

               ·        Processed breakfast cereals (Ex: instant cream of rice)

               ·        Instant potatoes, instant soups, and many breakfast drinks

               ·        Margarines and salad dressings

               ·        Lunch meats other than kosher

               ·        Candies and other snacks

               ·        Hot chocolate mixes, instant coffees and Ovaltine

               ·        Omelets, scrambled eggs, and souffles at restaurants

               ·        Gelatins made with carageenan

               ·        Cream cheese and peanut butter with milk solids as fillers

               ·        Tater curls, corn curls, and French fries may be processed       with both a milk product and include wheat starch

               ·        Selected antibiotics, vitamins, and mineral supplements

               ·        Artificial sweeteners such as Equal, Sweet n’ Low, and Wee Cal

            ·   Some so-called nondairy products such as powdered coffee

 creamers, whipped toppings, and artificial sour cream also may include

 ingredients that are derived from milk and therefore will contain lactose.

             Most celiacs will NOT do well on lactose reducing items such as Lactaid, Pregetimil, and Lidalac.  First most of these products are tested on non-celiac population groups [normals without autoimmune deficiencies]; second, most products do not remove or “predigest” all of the lactose that may cause either overt or non-recognized covert problems. Both celiac and dermatitis herpetiformis patients will do best on non-milk (non-dairy) containing products.  Most celiacs with lactose intolerance will need total removal of milk from their diet—not just the base residuals that occur with an additive for lactose reduction. 

             The celiac shopper will learn to read food labels with care, looking not only for milk and lactose among the contents, but also for such terms as whey, curds, caseinate, lactoglobulin and other milk by-products.  If any of these names are listed on the label, the possibility then remains that this product contains lactose.  

             In addition to foods, lactose is often used as the base for more than 20 percent of prescription drugs and about 6 percent of over-the-counter medicines.  Many types of birth control pills, for example, contain lactose, as do some tablets for stomach acid and gas.  The pharmacist can answer questions about lactose content in various medicines; or, the consumer can call one of the pharmacist hot lines [or 800 numbers listed in drug information brochurees] for product information.

             Trehalose Intolerance.  For some few celiac patients, it is theorized that when symptoms develop after the ingestion of mushrooms, that there is then a possibility of trehalase deficiency.  For selected patients, this may extend to molds from other food sources; it may also then be seen as a brush border deficiency-related problem.  Medically, the mold problem is referred to as a carbohydrase deficiency and/or as trehalose intolerance.   For the celiac, in addition to mushrooms, xanthan used in selected gluten-free breads, most regular yeasts, a series of medications, and dried fruits may then become non-allowed foods for the diet.

            Sucrose Intolerance.  For a minority of celiacs, sucrose intolerance exists when there is a deficiency of the enzyme sucrase.  The symptoms are the same as those of lactose intolerance and result from bacterial fermentation of the undigested sugar.  Much less common than lactose intolerance, sucrose intolerance is thought to develop temporarily as a result of the condition of severe gastroenteritis.  For most patients, the substitution of an artificial sugar substitute, which has not been based on a grain in its development, can be used as a substitute.  The patient with sucrose intolerance will need to work with a monitoring physician and dietitian team for both food selections and a series of commonly used toilet articles such as toothpaste.  Not just any of the sugar substitutes will be an acceptable choice since many are based on derivatives of gluten-containing ingredients from wheat or other cereal grains. 

      Food Sensitivities.  A selected few hypersensitive celiac patients may also need to omit food choices such as seafood, undercooked chicken, undercooked eggs, and dyes made from lakes.  The one red maraschino cherry on the ice cream sundae may cause problems similar to having eaten a slice of wheat bread.  The patient with secondary food problems in addition to those foods not allowed in the gluten-free diet may do best in working with a dietitian in a series of food elimination studies to learn the foods that can be included in their version of an acceptable prescription diet.  It is not a good philosophy that such a little bit won’t hurt.   

 

                Restaurants, Hospitals, and Airlines

            In Restaurants.  The newly-diagnosed celiac and especially children and teens can be easily introduced to “eating out” at the same time they are developing skills for “eating at home.”  Most cooks and chefs and their unit managers are very willing to assist with making selective and appropriate gluten-free food and menu choices at their place of business.  “I will need your help in choosing foods from your menu” appears to open the doors to both their kitchen and their friendly cooperation. 

             In some instances, a telephone call or a visit a few days prior to the restaurant meal can be helpful.  Call or visit at a time when the chef or cook is not occupied with heavy meal traffic and ask if he or she can help you, a special needs customer, to become a better patron of their restaurant.  A call ahead, a mailing of a copy of your gluten-free diet, a sharing of literature on the celiac condition can be helpful and will be graciously accepted and appreciated.  Lead into making things simple.  Do not expect every item of a particular menu to be adapted to gluten-free.  Do not get off into a litany of all of the food items you can and cannot have.  For a dinner, suggest selecting a meat entry, a vegetable, perhaps a salad with an acceptable dressing or ask if you might bring your own dressing.  Choose an appropriate drink—perhaps water.  If a dessert is suggested, ask what items are available.  Choose wisely—perhaps a scoop of ice cream if tolerated or some fresh or canned fruit.  Ask how you can best order from the wait staff at the time of your dinner.  Ask if a record of your choices can be made.   Some restaurant personnel will ask to keep the card in their file and invite you to order these selections whenever you come in to be served.   Some managers will suggest that you keep your menu card and their business card in your billfold and present your order with these identifications any time you come to dine. 

             With many restaurants that you may visit over a period of several months, you are likely to be pleasantly surprised with the interest of their staff in you and the needs represented in your specific version of the gluten-free diet.  The waiter will memorize your food selections and share immediately that he already has your order—unless there are changes.  From time-to-time, you can expect some new food selections to be added.  You can expect that the cook will prepare some new recipes—just for you!  And you can expect a telephone call with the message that “there’s this new family in today with a father that is celiac just like you, can you come over and meet him?”  You will win new friends, a support group, and also develop a promotion unit for celiac disease and its associated diet. 

             Fast food chain restaurants can be more of a challenge, but with the interest and support of the manager on duty, food selections that are safe for the celiac can typically be made.  They want to help and they are happy to do so—if the customer can communicate what is needed.  They may not know about the wheat starch coatings on French Fries and they may not know about the addition of oat products to low-fat content hamburger.  But they can ask questions and check out the labels.  They can also call their region offices and headquarter training centers.  They are typically most cooperative and want to serve the customer in the best way possible.

            For trips across the country, it is often best to call ahead to hotels and restaurants, to Disneyland, to resorts, to the destination for the next night—to learn if a specific location can accommodate the needs of the gluten-free diet.  What is presently available and what could be made available.  It is typical that chefs contacted several days ahead of time will be happy to make up special gluten-free entries for a visit to their restaurant and be able to assist with contacts for the next day as well.  With a few added snack items and a few gluten-free purchases from grocery stores along the way, the family trip can be a success for everyone and especially for the diet of the celiacs involved. 

             For your home base, your immediate living area—develop relationships, a set of information resources, and simple food lists with a core group of restaurants who can then in turn support your dietary needs with appropriate food selections.  Your connections with a hotel or two and with several restaurants can then become your system, your support groups for eating out.  With a bit of planning, communication of the dictates of the gluten-free diet, your group of restaurants can be as good as eating at home.  

             In Hospitals.  With the variety and varying services of hospitals and the differing levels of knowledge of the gluten-free diet, entrance to a hospital without previous communication and planning can be [and will likely be] a problem for the celiac.  Most celiacs are admitted to a hospital with the primary diagnosis of celiac disease and an accompanying definition of needs no matter what the procedure or medical problem that has prompted admission. 

             Some celiac patients have distorted or confused the issue through the use of a physician who has never been apprised of their celiac condition and thus find that symptoms of celiac sprue have returned and new difficulties are added to current problems while an inpatient at a hospital.  With only a little communication and pre-planning, however, a hospital stay for most patients can be managed very well in terms of both the handling of the disease and the clinical needs of the diet and for medications. 

             Education of hospital personnel about celiac disease is necessary and important, but is not likely to be achieved or maintained with less than 1 per 25,000 admissions relating to this particular condition—celiac disease.  Thus, it becomes a responsibility that celiacs be prepared for several aspects of self-care and make advance preparations through their admitting physician for any special needs related to the illness and for their particular need for the gluten-free diet as it relates to both foods and medications.   Or, it may become necessary for a family member or friend of the celiac to be available to provide the information needed to represent the diet for the celiac patient.  Preplanning, communication, and monitoring are critical needs if the expected result is to be a strict gluten-free diet. 

             The two cardinals rules for admission to the hospital are as follows:

    a)  ask to be admitted as a patient whose primary illness is celiac disease.

             b)  ask to be admitted as a patient with needs for a strict gluten-free diet.

             It will be helpful to take a diet listing which includes an introduction to the gluten-free diet to the hospital.  Or, ideal if a pre-conference can be arranged with the dietitician who will be supervising menu choices and meal preparation and with the pharmacist who will be issuing medications.  Be proactive and be prepared to explain to hospital staff members, including physicians, nurses, pharmacists, and dietitians—about your celiac condition and its dietary needs, as you understand them at this stage of the illness.  Expect that most specialists and consulting physicians other than gastroenterologists and your primary care physician may have no reason to know what foods or medications are permissible on the gluten-free diet.   Do not expect the dietitian or pharmacist to have first-hand knowledge of the gluten-free diet.  You could be the first celiac patient they have met in their practice. 

             In terms of the diet, explain simply and in explicit terms what you can have and omit the listing of what is not acceptable for your dietary intake.  Concentrate on a few foods that will work and leave out all of the many items that will cause problems.  Keep it simple. With many hospitals working within a system and with outside contractors for food services, expect that some very well-meaning staff member along the way will make the observation that your food tray has been overlooked for the chocolate cake dessert or for the extra toast or the honey-roasted peanuts for snacks today.  And, they may also have been thoughtful enough to add wheat flour-thickened gravy to your blank mashed potatoes.  So, what may have started out in the kitchen as a perfect gluten-free meal, now is contaminated—at least, for you and your diet needs.  So, you may always need to do a quick check of foods served.  Just as in your own home, you need to be in charge of what makes up your intake of food and you need to choose it wisely.  

             And, if it doesn’t upset you to get a bit overly organized, try this plan:  pack a toilet kit with any personal items needed such as appropriate soaps, toothpaste, lotions, etc.  But, along with these items, also include a listing of your needs for the gluten-free diet and a copy of all of the medications you are taking by prescription.  You can use this kit for trips; overnight visits to family and friends, and for a possible hospital or care center stay in your future. 

             In addition to the dietitian and the dietary department, make certain also that head nurse for your floor and the nursing department along with the pharmacist and the pharmacy department within the hospital have adequate information on your needs that all items taken by mouth can be gluten-free.  Selected staff members may not be aware of the differences between such items as gluten-free Tylenol and regular Tylenol, the potential of wheat starch coatings on pills, etc.  Critical for the celiac patient is to have access to gluten-free medications as well as gluten-free foods.  For some select few celiacs, there may be additional needs related to gluten-free items for use on the skin.  Thus, both put-ins as well as put-ons will need to be gluten-free.

             For the celiac patient who may be moving on from the hospital to a care center or rehabilitation facility, be sure to have your admitting physician include in the orders for admission the need for the gluten-free diet.  Once again, communication and pre-planning will be helpful in preparing nursing staff, the dietitian and the dietary department, and for the definition of both over-the-counter and prescription medications.  The care center or nursing home can do a good job when adequate information has been provided.  Without good information, additional problems and concerns may be added unnecessarily and without reason.

            On Airlines.  If you fail to plan you plan to fail.  It may not always be quite that severe, but without planning at the time of ticket purchase, it may not be easy to convert from a “regular” meal order to “gluten-free” or an alternate choice which would be appropriate for the clinical dietary needs for the celiac.  Of the airlines surveyed, it was found that virtually all offer lacto-ovo, vegetarian, strict vegetarian, fruit platter, seafood, low-fat, low cholesterol, low- or no-salt, and kosher meals.  A number of the larger airlines also serve Hindu, Muslim, Oriental, bland, and low-fiber meals.  Several airlines responded that they often can accommodate passengers with a 24-hour or even shorter notice; but they do best when special diets are ordered at the time a ticket is confirmed.  Four airline representatives shared that the expectancy at the present time is to offer fewer specialty meal choices and both reduced servings and fewer snack item choices until the economy has turned for the airline industry. 

             Most overseas flights can handle both gluten-free meals and gluten-free snacks.  Five airline service personnel responded, however, that they really can only promise to do gluten-free meals and not snacks since snack foods are typically large contract items without a great deal of variance and choice allowed from the providers.  Thus, the celiac passenger should expect that snack items on most flights would likely be the general offerings scheduled for a particular flight and would not include gluten-free choices.  With a bit of planning, however, snack items might be saved from a previous meal or more realistically brought on board as a planned food item for the trip [if allowed by the airline and/or governing regulations].   

             Short flights within the U.S. usually can offer menu items with limited or no choices;  coast-to-coast flights usually offer a selection of red meats, chicken or fish.  Some airlines are able to offer a gluten-free diet, but can do best with their strictly vegetarian or fruit plate offerings which will easily fit into several aspects of the clinical diet for celiac patients.  Special diets cost no more at this time; just remember to ask if a special meal choice can be made available when you make your reservation and then double-check when you hand over your money.

             Vegetarian offerings are typically well done, nicely served, and often include a rice dish.  However, the celiac passenger will need to make the choice not to include the wheat crackers or breads that come with the vegetarian selection.  For the next flight, learn what the food choices will be available at the same time you plan your routing; then, choose wisely for your own individual needs so that you can be pleased with the results.   With most of the economy ticket purchases, the so-called “hot rates,” there is often no potential for a meal choice.  The special airfare reservations come with a reduced rate and with “regular meals only” so the passenger will have no menu choices available.  In such cases, it is well to plan ahead with both snack and sandwich items—if these items can be allowed on board. 

             For those airlines that include a gluten-free diet through their catering services, the choices are exact and well done.   There can be and there almost always is a hitch with international flights whose food preparation base is located in another country outside the USA.  This problem occurs since those companies are likely to be using the definition of the 5 percent level of tolerance [5% of total weight for gluten allowed] approved by the International Codex Alimentarius that is seated in Rome, Italy.  All breads, cakes, pastries, and commercial food items may have been prepared to fit under or into that particular formula.  Thus, these offerings that will be defined as gluten-free and wheat-free are in actuality only gluten-restricted.  The celiac, whose dietary needs must fit under zero tolerance or a totally gluten-free diet, should not be accepting of these meals and diet offerings.  Again, it is likely best to choose a vegetarian meal and then just omit the accompanying gluten-containing items.  Secondly, the celiacs that are also lactose intolerant will likely always do better with the vegetarian offerings even though gluten-free offerings [with 5 percent by weight gluten allowed] are available as menu items. 

             Most snack offerings on U.S. flights will fit the standard rotation schedule for that particular airline.  The celiac needs to be selective of snacks and drinks prepared from instant mixes as well as the coatings on nuts, candies, and gum that are typically served on flights.  Choices to avoid will likely include such items as honey-roast peanuts, instant coffees,  instant teas, pretzels, fig Newtons with wheat crusts, dried fruits with yeast, and non-ingredient defined chocolates from both the U.S. and foreign countries. 

             After using a special diet from an airline service, remember to send a thoughtful note to the airline to share what worked for you and what went well.  Remember, too, that “a little bit of honey is much better than a few drops of vinegar.”  Share your thanks and appreciation for extra efforts for you and for all celiacs and their need for the gluten-free diet. The changes and improvements in diet formulations by airlines are vastly improved.  Let’s let them know how much we appreciate their extra services for persons with special needs diets—and especially for the needs of celiacs. 

  

            Pharmaceuticals and Nutritional Products

                The Need for Gluten-Free Medications.  The gluten-free diet must be extended to include all pharmaceutical and nutritional products to be used by the celiac or dermatitis herpetiformis patient.  Because of the adverse effects of gluten in the diet of patients with celiac disease, strict adherence to a gluten-free diet in the selection of all medications is essential.  Celiac sprue patients should first consult with their physicians and pharmacists regarding current and long-term needs regarding their needs concerning all “put-ins” and “put-ons.”  Additional information resources include the following agencies: the medical center at the state university; regional drug information centers; hotlines and/or manufacturers or providers of medications for the source of current information on gluten-free pharmaceutical products.

           Overall, when one looks at the thousands of medications available, the problem for a potential of gluten in a drug preparation is very small.  However, the celiac needs to be concerned about those very few prescription and over-the-counter products that do contain one or more of the offending grains and thus gluten.  For both the celiac and the dermatitis herpetiformis patient, it is prudent to have medical direction for all medications—both prescriptions and over-the-counter non-prescription choices.  And, secondarily for all “put-ons,” items which will touch the skin.  This kind of planning and monitoring allows the physician to prescribe gluten-free, preservative-free, and red and yellow dye-free medications—if any of these contents should be a problem for the patient.  If the celiac patient is to be self-directed and self-managed in the handling of the medication regimen, it is critical to have good information and to know which aspects to search out and which sensitivities and malabsorption problems are considerations as  toxic reactions.

             Because of the propensity for confusion and error with drug names for the consumer, it may be best for the celiac patient to always present questions regarding pharmaceutical and nutritional products to a physician or pharmacist.  With the several references and services available to health professionals and the in-print product information found in the Physicians’ Desk Reference (PDR) on medications and the 800-number information service to drug companies, the pharmacy can then have access to current information about drugs being considered for prescription or non-prescription over-the-counter use.

             The use of pharmaceuticals and nutritional products represents an area of responsibility that needs to be moved to self-care for the celiac and DH patient.  While the percentage of pharmaceutical products containing gluten is small, gluten is used as an “inert” excipient in tablets, capsules and suspensions for both oral and rectal products.  The central message is this:  Both over-the-counter and prescription medications may be toxic to patients with the conditions of celiac disease and dermatitis herpetiformis. 

             Before using a hand lotion (with a grain derivative), a face powder (with wheat starch extender), a lipstick (with oat gum), a shampoo (with wheat germ oil), a mouthwash (with a grain derivative), a toothpaste (with one of several glutens); or, an array of tablets and pills with colorings based on grains, dyes based on lakes and/or other glutens such as wheat germ oil, wheat flour or barley water, the patient must know their needs related to avoidance of gluten-containing products and then check with their pharmacist or physician for information and direction. Celiacs will need to read labels for all over-the-counter and toilet items to be assured they are appropriate choices.  Some celiacs may wish to make use of selected non-allergenic items [which are available in the non-allergenic sections at most pharmacies] such as hand soaps for the shower, detergents for the laundry, and lipsticks without grain stabilizers.    

             Celiac patients with lactose intolerance will need to review with pharmacists the use of powdered milk as an excipient in a variety of medications and supplements.  A  common example is selected brands of calcium which may contain 90 percent+ powdered milk as an intended “inert” ingredient.  Since individual needs are unique among celiac patients, those products that represent sensitivities and allergic reactions should be kept on a file record with pharmacies and clinics that might be used on a continuing basis by the celiac patient.

             The celiac should work out with their physician the personal medical information records that should be kept relative to medications, particularly for an item such as an antibiotic that is appropriate for infections, etc.  The celiac should know the name and dosage and the basic directions that his/her primary physician recommends.  Thus, for an out-of-town emergency or when traveling, this reference is at hand and available in a written form. 

             An important learning for all celiacs is represented in the continued upgrade and change in formulation for medications.  This appears to be as true for over-the-counter medications as it is for prescriptions.  Thus, a double-check is always prudent and in order for refills on prescriptions and the continued purchase of the same shampoo—since some of the basic items may have changed since your previous use and purchase.  New formulations of a tablet may look the same, but in actuality now use wheat starch as the sealer. 

             “If you stick your head in the sand, nobody is going to notice.”  But in this situation, we need to add to this concept—but you!  And, that little bit that you put into your mouth or smear onto your body or into your hair—will gladly do it for you.

           The Caution for Nutritionals.  The manufacturers and the many and varied businesses that sell vitamins, minerals, and food supplements have a vested interest in trying to persuade more and more people to swallow more and more vitamin pills and the vast array of “health foods” and food supplements now available.  But, are they really necessary?  The answer in almost all cases is an unequivocal, No!  The simple sentence that can sum it all up for this section would read as follows:  “Don’t take either a vitamin or food supplement unless you do it with a prescription following a medical evaluation which has determined the need.”

             The professional who is in the best position to suggest that a celiac may need supplements vitamins, over and above those provided in the regular diet, is the monitoring physician. It is in and with the physical examination that determinations can be made if added nutritionals and supplementation are needed.   If extra vitamins beyond the diet are indicated, then a prescription for the appropriate gluten-free product should then be developed and processed.

             Celiacs who take vitamins, minerals, and food supplements without an evaluation of need along with the appropriate blood tests to learn which nutrients are being absorbed at proper levels and without a prescription based on these evaluations are likely doing one of two things: a) throwing money away for unnecessary and non-used nutrients which then pass on to the stool;   b) and/or  they are doing a disservice to their own body which already has a lower-functioning immune system. 

             The vitamin story is a simple one.  Vitamins are essential nutrients that are required by the body in very minute amounts.  These minute amounts can be provided by a sensible, balanced gluten-free diet selected from a variety of foods.  It is NOT the case that if a little bit is good that a whole lot more will be that much better. 

             The facts indicate that excessive amounts of the fat-soluble vitamins, for example vitamins A and D can be extremely harmful.  The water-soluble vitamins in the B group and vitamin C cannot be stored in the body, so any excessive amounts are excreted in urine.

             The Need for Supplementation.  Of course, there is an important place for vitamin supplements for selected celiac patients; these extra food sources are particularly helpful in building up patients after an initial diagnosis when the need is warranted.  For children, vitamins may be helpful at times when extra nutrients are required to cope with growth phases.  They may be prescribed for celiac women who have incurred a pregnancy or for persons at any age after an illness or infection, an accident or a surgical procedure.  However, for the typical healthy celiac, extra vitamins beyond diet are most often superfluous.

             Malabsorption is the Problem.  Celiac disease is primarily a malabsorption syndrome.  It is a malabsorption problem for the body.  The important concern with this syndrome must be whether or not the intestine is able to absorb vitamins, minerals, and the major and minor nutrients in any format and at what level.  Is the “sieve” working and able to absorb and thus benefit the body from nutrients present in any form in the diet.  The critical underlying issue for the celiac patient is to pay attention to the diet that is required in order to improve absorption; there is not a need to overdose nor to be take the current fad vitamin and food supplements advertised and available.  A major relationship to absorption is dependent on the strict adherence to the gluten-free diet, and not on the supplementary vitamins that may be taken.

             What are Health Foods?  Sometimes advertisers claim that certain foods can prevent or cure a disease, maintain youthful vigor, improve the immune system, get rid of that “tired out feeling,” or lead to superior health.  In reality, all foods are health foods with each one supplying a variety of nutrients needed by humans.  Health foods offer the same nutritive qualities expected in any wholesome food product.  It is the unproven health claims made for these foods that are questionable, not the foods themselves.  It is interesting to note that the health claims are found in magazines and pamphlets or given verbally.  Rarely are they found on the labels of the product, thus avoiding prosecution from the Food and Drug Administration. 

            Most foods contribute in a number of ways to our nutritional health.  Some are regarded as good sources of vitamins, some are good sources of minerals, and others contribute protein, carbohydrate or some of the minor nutrients.  If the celiac is able to select a variety of foods in the proper amounts, a balance of vitamins, minerals and protein will be typically readily supplied for nutritional health.

             Clerks in health food stores are frequently asked to be the first line advisors to celiac customers.  In some cases, celiac customers ask clerks for advice on health matters.  Keep in mind that these clerks may not have degrees or training in nutritional science or medicine.  They are sales persons whose job is to sell their products.  Clerks often must tell customers what they want to hear although it may not meet the real needs of individuals with the celiac condition.

             Case in point: Celiac has read about the body’s need for zinc in a magazine article.  Celiac is certain from this information that zinc is a present need for her diet.  Celiac goes to store, asks about zinc, relates needs described in article, reads promo material and immediately knows she has found a match.  Celiac takes zinc for 30 days and returns for a new supply.  Talks again to clerk.  Reads promo material at store one more time.  Decides that the trial must have worked pretty well, so she will double the intake and buys a 250-tablet size since it will be cheaper in the long run.  But some gaps in information were inadvertently missed. Nobody told her that zinc gluconate is tolerated well and does not cause the gastric distress caused by zinc sulfate.  Celiac was taking zinc sulfate.   Nobody told her that zinc should not be taken with meals, because absorption is reduced by food.  Nobody told her that zinc ingestion reduces copper absorption and can cause clinically significant copper and iron deficiency.  Nobody told her that taking 2 gm or more of zinc per day can cause gastrointestinal irritation and vomiting. [and now the villain enters].  Celiac becomes ill.  Thinks all of her old symptoms have returned.  Regular gastroenterologist is out of town, so she sees a “new and better doctor” in a neighboring state.  Comes home with a possible diagnosis of irritable bowel syndrome.  Gets sicker.  Can no longer work full days at her job.  Diarrhea is up to 12 times a day.  Sees regular doctor but does not share that she’s taking zinc plus a sack full of other things she’s learned from celiacs are good and have helped them immeasurably.  Continues with illness and after it becomes chronic, is hospitalized.  Blood work-up begins to get at the details of the problem.  She does then share details on her total intake of supplements and her need for zinc, which she doesn’t plan to give up.  However, with a bit more information, she’s willing to go off zinc—just to see, and to show the doctors what’s really needed.  

 There’s more to the story, but after a clinical work-up, some good follow-through, some more re-education, and 15 months of time, she’s off zinc.  And, best of all, she’s back just to being a regular old ordinary celiac on the gluten-free diet.  But things are much simpler now; it’s all a great deal cheaper and she’s back at work full-time.  And as she shared, “I know now that I’m not going to die and I won’t be fooling around on my own again—ever.”   Sadly, there are always replays and new versions of this story—but with a different celiac character on stage.  And, with a differing set of needs and  problems.  But again and again, the same villain is there.  Hopefully you will choose not to “act in this play.”  Of course getting onto the diet and maintaining the diet and an adequate lifestyle is a puzzle, but try putting the pieces together—just one at a time.  And without this kind of fanfare!

Vitamin Supplements.  At the time of an annual physical or check-up; or, in checking in for monitoring of celiac disease with your physician—also ask to review your potential need for any specialized vitamin formula, or for an over-the-counter selection which will match your particular deficiency, should one even exist.  It is generally best not to go off on your own for a nutrient selection such as vitamins.  Check out nutrient needs which are not being met for your body and then match those needs with an appropriate vitamin or supplement choice.  Use physician and pharmacist recommendations.  Follow prescribed needs and direction for your body and for the dictates of the clinical gluten-free diet.  Include beyond gluten-free, toxicants, sensitivities, and allergies for you. 

             Common risks associated with nutrient supplements include the following:  (Note:  this is only a basic listing; there are many additional concerns that can be shared by your physician).  

Nutrient Toxic Dose Signs of Toxicity
Vitamin A 12,000 RE  [adult]

7500 Re  [child]

headache, nausea, vomiting, double-vision, muscle pain, birth defects;-
Vitamin D >25 mcg  [1,000 IU] calcification of soft tissues, loss of appetite, diarrhea, vomiting, mental confusion;
Vitamin C 2 - 10 mg destruction of vitamin B-12, diarrhea, intestinal cramps, skin rash, nausea, vomiting, scurvy, kidney stones;
Folate >400 mcg vitamin B-12 deficiency, masked symptoms;
Niacin >100 mcg blood vessel dilation, headache, itching;
Pyridoxine Vitamin B-6 >100 mcg irreversible nerve damage;
Calcium >2500 mg risk of kidney stones;
Copper 10 - 15 mg vomiting, nervous system disorders;
Selenium 2 - 3 mg hair loss, nausea, vomiting;
Zinc >2 mg reduction in HDL cholesterol, diarrhea, cramps, nausea;

Source:  Wardlaw, GF, Insel PM, Perspectives in Nutrition, 2nd Ed, St. Louis:

Mosby-yearbook, Inc.   1993.

              The Definition and Function of Vitamins.  A vitamin is an organic, noncalorigenic food substance that is required in small amounts for certain metabolic functions and cannot be manufactured in the body.  Vitamins may be fat- or water- soluble, and their solubility affects their absorption and mode of transport through the body to target tissues.

             Use of Folic Acid.   Folic acid may be effective in the treatment of megaloblastic anemias due to a deficiency of folic acid.  (this often happens with the condition of non-tropical sprue, celiac disease).  But, it also may happen for many other reasons.  Examples:  anemias of nutritional origin; during or following a pregnancy; in infancy or in childhood.  Celiacs who use folic acid are strongly advised to do so only under the monitoring and prescription of a physician because of the marked side effects, which may be present.

             Use of Potassium.  Potassium is a common mineral, which is extremely difficult to prescribe.  The problem relates to having too little or having too much; both situations can cause untoward side effects for the patient.  Any use of potassium needs to be monitored by the physician after a clinical workup that indicates a need for additional potassium.  Common food sources of potassium include fruits, milk, red meats, most cereals, vegetables, and legumes.  A deficiency of potassium is highly unlikely for most celiac patients, but a conditional or short-term deficiency may be found in kidney disease, diabetic acidosis, and in diseases, which have excessive vomiting or diarrhea over an extended period of time.  Potassium excess, however, can cause a long range of problems including renal failure.  And, for celiacs, it is important to know that potassium relates to soft tissue as calcium relates to hard tissue.

             Use of Calcium.    The body needs calcium throughout life, but especially during periods of growth, pregnancy, and lactation.  In the bones, calcium occurs in the form of salts.  Hydroxyapatite, composed of calcium phosphate and calcium carbonate arranged around a structure of softer protein material.  Many other ions are also present in this crystal complex, including fluoride, magnesium, zinc and sodium.  In the skeleton, calcium exists in two chemically and physically distinct forms:  a relatively non-exchangeable calcium component not available for short-term regulation of calcium homeostasis, and a rapidly exchangeable component used for metabolic activities. 

             The rapidly exchangeable component of the bone may be considered a reserve that may be built up when the diet provides an adequate intake of calcium.  This reserve is stored, especially in the trabeculae, the ends of the long bones.  This is the calcium that may be mobilized to meet the body’s increased need if calcium is not supplied in adequate amounts by the food intake.  If there is no reserve, the calcium must be drawn from the more stable bone substance itself, which must be broken down before calcium is liberated.  This results in a deficiency in the bone structure following prolonged inadequate intake, which may result  during the active phase of a malabsorption syndrome such as celiac disease.  As it is with most components in the body, bone is constantly being synthesized and reabsorbed.  If there should be a significant increase in serum calcium, a resulting side effect can cause cardiac or respiratory failure and a decrease almost always causes tetany.  The same type of crystals is present in the enamel and dentin of teeth; however, these crystals are larger.  There is little turnover of calcium in teeth, i.e., the calcium or phosphate is not readily available during periods of deprivation.

             Factors that may decrease calcium absorption.  Critical is the lack of or insufficient amount of vitamin D.  Diets high in fat may affect calcium absorption.  The amount and availability of oxalic acid from fruits and vegetables; in the digestive tract oxalic acid combines with calcium oxalate, so that the calcium is not absorbed.  Rhubarb, chard, spinach, and beet greens contain appreciable amounts of oxalic acid, as does the green-colored section on some irrigated potatoes.  Phytic acid from the outer husks of some cereal grains combines with calcium to form calcium phytate, which is insoluble and is not absorbed from the intestine.  And, there is some evidence that fiber, not just the phytate associated with it, may decrease calcium absorption.  In an alkaline medium, calcium and phosphorus will form an insoluble and non-absorbable calcium phosphate.  When food passes through the gut too rapidly, calcium absorption is decreased.  Lack of exercise and a lack of weight bearing on the legs cause a decrease in the ability of the intestine to absorb calcium.  Stress, emotional instability, and perception of stressful situations may influence the efficiency of calcium absorption.  And, finally, there are a series of drugs that affect calcium absorption such as thiazide diuretics and aluminum-containing preparations. 

             Dietary food sources for calcium include milk and milk products, (yogurts and hard cheeses) dark leafy vegetables such as kale, turnip greens, mustard greens, broccoli, sardines, clams, and oysters.  Some of the more common minor sources include fish such as halibut, peanuts, and eggs and selected fortified choices of the enriched gluten-free breads. 

             Two principal concerns for the celiac are the potential clinical problems of osteomalacia and osteoporosis, that are characterized by abnormalities of calcium in structural bone.  Two other clinical problems, tetany and hypertension, may be related to abnormalities of ionized calcium. 

             Osteomalacia.  (sometimes referred to as adult rickets), is a failure to mineralize the bone matrix, resulting in a reduction in the mineral content of the bone.  Usually, rickets and osteomalacia are associated with a concurrent lack of vitamin D and imbalance in the calcium-phosphorus intake.  [rickets is more commonly seen in children; osteomalacia is more commonly seen in adults]. 

             Osteoporosis.  This is a metabolic disorder that may be defined as a reduction in the amount of bone without any changes in the chemical composition.  With bone loss, skeletal strength cannot be maintained and fractures occur with minimal stress.  Osteoporosis (de-ossification) is frequently confused with osteomalacia (demineralization).   Whether deficient calcium intake is a factor in the etiology of osteoporosis is not clear.  A person with osteoporosis is in negative calcium balance and may have a daily calcium loss as high as 90 mg/day.  Over a lifetime this can result in a significant loss of skeleton.  Other factors, such as decreased calcium absorption, level of protein intake, dietary calcium/phosphorus ratio, impaired renal function, lack of weight-bearing exercise, and estrogen level are important in the development of osteoporosis.

             Tetany.  Low levels of calcium in the blood may increase the irritability of nerve fibers and nerve centers and result in muscle spasms such as leg cramps, known as tetany.  The symptom of tetany is more common previous to diagnosis and up until the body has begun to absorb more closely to the normal needs for the body. 

             Hypertension.  Recently, the literature has described abnormalities of extracellular and intracellular calcium metabolism as being identified with hypertension.  There appears to be an inverse correlation between the total calcium intake and mean arterial pressure.  There is also indication that a high sodium intake is associated with calciuresis.  Much more information is needed; there are also many hazards in linking a single nutrient with a complex problem.

             Calcium Intake.  For the celiac, a calcium source may need to be what is available that meets the needs of the individual.  This may mean no milk products as an excipient or major ingredient; there is likely to need to be a check on the binder, emulsifier, coloring agent, and any additives as well as gluten-containing ingredients.  For most celiacs, the over-the-counter Tums product should not be a choice.  Because malabsorption is the primary problem or gatekeeper for the celiac, the physician may recommend that two different preparations be taken:  perhaps one in the morning with food; and, a second in the afternoon, about 2 hours before any food intake.  In addition, the celiac should choose three to five servings of the calcium-containing foods per week in their dietary regimen.

               The Fat-Soluble Vitamins:  A,  D,  E,  and  K.  Vitamin A, as a part of the visual pigment rhodopsin is essential for vision, especially in dim light.  Vitamin A is involved in maintaining the integrity of the mucous membranes throughout the internal linings of the body, and thus in promoting resistance to infection.  It helps to maintain the health of the skin and is essential for the remodeling of bones during their grown or mending; it also plays a part in cell membrane functions, in hormone synthesis, in reproduction and other functions.

             Deficiency of vitamin A causes night blindness due to the failure to regenerate rhodopsin; a failure of mucous secretion, which can lead by way of keratinization of the cornea to blindness; disorder of the respiratory, urogenital, reproductive and nervous systems; and abnormalities of bones and teeth.  Toxicity symptoms are caused by excesses (10 times the recommended intake or more) taken over a prolonged period and result only from the preformed vitamin (from supplements or animal products such as liver)—not from the precursor carotene and its relatives, the yellow pigments found in plants.

             The recommended intake for vitamin A (800 RE for women, 1,000 RE for men) is easily met by periodically consuming the vitamin’s richest food sources:  liver or dark leafy vegetables or by consuming other more concentrated sources daily, such as carrots, cantaloupe, yellow squash or broccoli.  All food sources of vitamin A or the carotenoids have some color.

             Vitamin D promotes intestinal absorption of calcium, mobilization of calcium from bone stores, and retention by the kidneys and is therefore essential for the calcification of bones and teeth.  Given reasonable exposure to sun, humans can synthesize this vitamin in the skin from a precursor manufactured by the liver.  Deficiency of vitamin D causes the calcium deficiency disease (rickets in children and adult rickets or osteomalacia in adults); excesses cause abnormally high blood calcium levels, due to excessive GI absorption and withdrawal from bone, and results in deposition of calcium crystals in soft tissues, such as the kidneys and major blood vessels.  The recommended intake to 400 IU per day is best met by drinking fortified milk; food sources of vitamin D are seen as unreliable.  However, exposure to sunlight probably ensures vitamin D adequacy for the average adult.

             The best-substantiated role of vitamin E in humans is as an antioxidant that protects vitamin A and the polyunsaturated fatty acids (PUFAs) from destruction by oxygen.  Although many vitamin E-deficiency symptoms have been observed in animals, only one has been confirmed in humans; hemolysis of red blood cells due to oxidative destruction of the PUFAs in their membranes.  The recommended intake of about 6 to 10 mg/day for an adult is more than adequate to prevent this condition.  The human requirements for vitamin E are known to vary with PUFA intake, since the vitamin occurs with PUFAs in foods.  It is normally supplied in the needed amounts.  Deficiencies are seldom observed but there is some concern that the overuse of processed foods may make deficiencies.  Toxicity symptoms are rare to non-existent.

             Vitamin K, the coagulation vitamin, promotes normal blood clotting; deficiency causes hemorrhagic disease.  The vitamin synthesized by intestinal bacteria and is available from foods such as green vegetables and milk.  Deficiency is normally seen only in newborns whose intestinal flora have not become established, in people taking one of the sulfa drugs, or in people whose fat absorption is impaired. 

             For most celiacs, adequate intake of all nutrients is ensured by selecting a variety of foods allowed within the definition of the gluten-free diet. 

               More on Safe Amounts of Vitamins.  Most celiacs don’t truly appreciate the “vitamin use rug” until its pulled out from under them.  The question is whether that has to happen before any one of us can reach the teachable moment.

             It’s likely well-established that most celiacs don’t need to worry about getting enough nutrients once they are stabilized and on an appropriate clinical diet adjusted to their condition and appropriate for them at their particular age and state in life.  But should we be concerned about getting too much?

             Reports in two national journals related to both women and men who had lost bone mineral density from taking too much vitamin D.  All patients were taking some combination of dietary supplements, some of which contained 3600 to 5000 (IU) international units of vitamin D.  The recommended dosage and generally accepted ranges are between 200 to 800 IU.  And those levels include intake from both food and supplements.

             Adequate levels of vitamin D and calcium are important for preventing osteoporosis, but too much [as well as too little], disrupts normal calcium metabolism which then often results in a loss of calcium from bones.  Once the patients stop taking excess vitamin D, their bone density typically returns back to normal over a 2- to 3-year period.

             Adverse reactions to vitamin and mineral supplements are seen as rare and most people are likely using them safely.  But, now that both the literature and case histories are indicating that more people are taking supplements above the (RDA) recommended daily allowance, perhaps it is time once again for each celiac to review some common sense caution.  Perhaps it is only to deal with out temptation to think that if a little is good, more must be better.

             Fortunately, for all of us, the release of (DRI) Dietary Reference Intakes as they are called, include at least three reference values for each nutrient or food component:  the estimated average requirement, the traditional RDA and a tolerable upper limit.  It is expected that these values will be provided by age and sex groupings.

             But again one of the critical points for celiacs is that only healthy adults should take nutrient supplements without a physician’s monitoring.  That recommendation comes to us since guidelines are based on studies of healthy people; thus, anyone with a disease or chronic medical condition should take supplements only under medical supervision.  Without heeding that caution, there goes that rug. 

 

    Food Labeling Laws

            Foundation Principles.  The United Stated Department of Agriculture (USDA) enforces Federal laws governing the labeling of food for meat and poultry and by the Food and Drug Administration (FDA) for all other foods.  Most of federal laws in place regarding foods were originally passed in 1906, and although some revisions have been made since then, the basic concepts with respect to food labeling have remained unchanged for almost 100 years.  Significant advances in food technology during this time, coupled with increasing demand for extensive and sophisticated information about food products and increasingly antiquated statutes, have led to a complex set of food labeling regulations.  The details of many of those changes have only recently been put into practice, and more will follow.

             The current goal of the Food and Drug Administration (FDA) and the United States Department of Agriculture (USDA) is the continued development of the overall labeling strategy that will provide consumers with information they want and need.  In order to achieve this goal, a number of programs are underway including an audit of existing regulations to determine whether labeling regulations are adequate and to identify candidates for simplification, improved internal consistency, and/or elimination.  The Federal Trade Commission (FTC) is also interested in food labeling because of its responsibility for regulating food advertising. 

             Listing of Ingredients in Order of Predominance.  Government regulations called Standards of Identity define the composition of many foods, state which optional ingredients may be used, and specify those ingredients which must be declared on the label.  Examples of standardized foods are most canned fruits and vegetables, milk, cheeses, ice cream, breads, margarine, selected seafood, sweeteners, and food dressings.  Required or mandatory ingredients used in such standardized foods are exempt by law from label declaration.  The FDA has sought the legal authority to require the declaration of mandatory ingredients for a number of years. Proposed laws would allow regulations which require the listing of ingredients in all foods, whether standardized or not.

             Earlier standards require declaration of only a limited number of optional ingredients since the specific ingredients that could be used were named in the standard.  Most standards have been or are being revised to permit greater flexibility in the use of ingredients and, at the same time, to require the declaration of all optional ingredients.  The law requires, with few exceptions (e.g., spices flavors, colors) a specific listing of ingredients.  The label declaration of all ingredients in foods whether standardized or not, must list ingredients.  Government regulations require that whenever ingredients must be declared on the label, the ingredients must be listed in descending order of predominance by weight.

             Naming of Ingredients.  Most ingredients must be listed on the label by the specific name of the ingredient.  However, there are some exceptions to this rule.  For example, under the law, spices, flavorings, and colors may be declared in the ingredient statement without naming the specific ingredient used.  Furthermore, any of a series of generic or collective names can be used instead of the specific name and/or common reference for an ingredient of product.  Example: “whey” can be declared when it is reconstituted whey.  Some consumers are confused by chemical names, while others want some specific information about specific ingredients and specific food items because they may be sensitive or have an intolerance [a toxicity] to specific ingredients.  Example:  persons with celiac disease who have a malabsorption problem for gliadin in wheat, barley, rye, oats, millet, buckwheat, triticale, etc.  In addition, they have a need to have knowledge of additives, preservatives, emulsifies, thickeners, and excipients and any minute amount of a protein from a grain.  Without definitive ingredient labeling information to identify protein sources that are toxic, the celiac must then avoid these products and make other selections.  

             Changes in Ingredients.  Some consumers want to require that food labels be flagged in some way when a change is made in the ingredients used.  This is because once a product has been used for some time, the consumer might not realize that an ingredient change was made or that changes may be made with each batch number.  Example:  a salad dressing which uses tomato soup as a base may use wheat flour or wheat starch as a thickener for one batch and cornstarch for the next without label notation and/or ingredient identification. 

             Total Food Label.  Labels have a limited amount of space on which there is a large quantity of information.  Some information is required by law:  common or usual name of food; name and address of packager; manufacturer or distributor; listing or ingredients for most foods; presence of artificial flavorings, coloring or preservatives; and, the amount of food contained in the package.

             Nutrition labeling is required by regulation if vitamins, minerals or protein are added to the food or if nutrition claims are made.  The nutrition label may contain up to 28 items of information, such as the amount of vitamins, minerals, calories, protein, carbohydrate, and fat present. 

             In addition, the label may contain other information that the manufacturer wants represented such as brand name, price, vignettes or product photographs, serving directions, a code number related to the date of manufacture, recipe suggestions, offer to send information, premium offers, product guarantee, product coupons, advertising/benefit claims, ethnic symbols, universal product code, patent numbers, storage directions and name and address of the container manufacturer.

             Container, Production, and Storage Problems.  A totally gluten-free product may become contaminated because the box in which the product is sold is put together with a wheat-containing glue or the surface has been treated [sealed for freshness] with a grain product that may turn out to also be wheat.   In the production process, a machine belt may have been dusted with wheat flour so that drying shells will peel off the belt without tearing.  Such processes can contaminate a totally gluten-free product such as a corn taco shell and make it unfit for use by the celiac.  Similarly, a bakery that produces excellent gluten-free bread and pastry products may not clean machines or have a clean air facility which has been cleaned of wheat flour dust; thus, all or most of their products become contaminated.  Grains in storage and grains being shipped often of necessity must be sprayed with a pesticide to help to prevent vermin.  But, a product such as wild rice that is an excellent gluten-free grain for celiacs becomes toxic with the additions of pesticides which may not be a problem for the individual with a total functioning immune system.   But for the celiac with a compromised and lower-functioning immune system, a toxicity and illness will follow ingestion of this pesticide-contaminated grain.

             Are Prescription Medical Foods an Answer?  Some government agency staff members along with physicians and celiacs have proposed for review, the idea of providing 20 to 30 prescription medical foods that would be available for purchase at specified grocery outlets.  These foods would have strict standards for production, storage, and manufacturing.  They would be reviewed for compliance with the current medical recommendations and practice for the clinical gluten-free diet.  They would be available for purchase by any consumer, but would be made available especially for celiacs in care centers, hospitals, and jails.  These foods would be available to senior centers and for programs such as meals-on-wheels.  They would be available to newly diagnosed celiacs of any age, but especially to parents of newly diagnosed children and to government and community social service agencies.  Such a government reviewed program of medical foods would not be intended to interfere with the celiac’s own self-management, but would be available for those who choose this option and for those with special needs. 

             The Current Law.  Actions  possible under current laws include changes calling for more complete optional ingredient labeling of all foods subject to FDA’s standards of identity; expanded use of quantitative amounts on the ingredient labeling; and, additional nutrition labeling information of the amount of sugars, sodium (salt), cholesterol and fatty acids present in a given food.  Without a fulfillment of this regulation, there will continue to be products that are labeled with one detail, but may actually mean another.  Example:  2% Milk is not it reality lowfat, but has a content to 60 percent.

             Questions and Answers.  The celiac consumer needs to be aware that the process of government grinds slow; but it does move ahead.  However, the informed consumer can help this process by sharing.  What needs are represented by your version of the celiac condition that come under the umbrella of Food Labeling Laws?  How can you best represent those concerns in a positive and constructive manner? 

             There are many questions that need to be answered before a comprehensive food policy plan can be developed.  It is important that the need of everyone along the way who is in contact with the food chain is involved.  That’s an element of the democratic process.  But, you can help.  You, as a celiac, must share your specific needs and indicate what your feel should be included in a Federal Food Labeling Policy.

             Your are invited to send your written comments on labeling issues to the following address:

Hearing Clerk, HFC - 18
Food and Drug Administration # 4-62
5600 Fishers Lane
Rockville, MD  20857

              The Consumer Protection Role of FDA.  First and foremost, FDA is a regulatory agency, charged with enforcing the Federal Food, Drug, and Cosmetic Act and several related public health laws.  To carry out this mandate of consumer protection, FDA has some 1,100 investigators and inspectors who cover the country’s more than 90,000 FDA-regulated businesses.  These employees are located in district and local offices in 157 cities across the country, from Puerto Rico to Alaska and from Maine to Hawaii.

             These investigators and inspectors visit more than 20,000 facilities a year, seeing that products are made right and labeled truthfully.  Their responsibilities also include checking wharfs for imports of foods, drugs, cosmetics, medical devices and radiation-emitting products.  As part of the inspections, they collect more than 70,000 domestic and imported samples for examination by FDA scientists or for label checks.

             An inspection may involve a sprawling, high technology drug plant that takes several weeks to scrutinize or a small food warehouse in which the main object may be to ensure that foods are stored away from harmful contaminants or possible vermin infestation.

             If a company is found violating any of the laws that FDA enforces, it is usually given a chance to correct the problem voluntarily before FDA pursues legal action.  Less severe problems can sometimes be remedied by reconditioning the product—for example, replacing labeling on food or drug containers.

             FDA also can encourage a company to correct an improper manufacturing process or voluntarily recall a faulty product from the market.  A recall is generally the fastest and most effective way to protect the public from an unsafe product.  If the product poses an imminent danger to the consumer, the agency will closely monitor the recall and, with the help of the media, alert the public to the problem, advising consumers what to do.

             When a company can’t or won’t correct a public health problem with one of its products voluntarily, FDA has legal sanctions that the agency can bring to bear.  The agency can go to court to force a company to stop selling a product and to have items already produced seized and destroyed.  When warranted, criminal penalties—including prison sentences—are sought against manufacturers and distributors.

             Almost 3,000 products a year have been found to be unfit for consumers and are withdrawn from the marketplace, either by voluntary recall or by court-ordered seizure.  In addition, more than 20,000 import shipments a year are detained at the port of entry because the goods appear to be unacceptable. 

             FDA Offices in Your State.  The FDA has an excellent set of literature, which you can access, either in your own state or through a district office for your state.  Make yourself acquainted with both its location and telephone number.  Review the titles and reference materials available which relate to your interests and your particular food needs.  Check out with your local library to learn which FDA brochures and materials they might maintain as shelf files. 

       FDA Hotline for Consumer Information: 

       1/800/332-4010  Open M-F 12 noon to 4:00 p.m. EST

        Internet address:            http://www.fda.gov

        Mailing Address:   Food and Drug Administration
200 C Street, SW  {HFS-55]
Washington, DC  20234

             The FDA distributes millions of publications a year, most of them reprints from their magazine, FDA Consumer.  Through these articles, FDA has spread the word on vitally important issues such as steroid abuse, food poisoning, and medical quacks and practices.  The agency sends its FDA Drug Bulletin to more than a million doctors and health professionals to keep them abreast of news about drugs, biologics and radiological and medical devices. 

             Safe and wholesome foods, safe and effective drugs and medical devices, safe cosmetics and radiation-emitting products—these are the responsibility of FDA.  Plant and warehouse inspections, laboratory analyses, review of product test data, consumer education—these are some of the faces of FDA—faces that celiac consumers often encounter but seldom see.  Each celiac can choose to become proactive with the excellent resources available through FDA:  1] avail yourself of the excellent publication and public information available;  2]  help the FDA to become better informed of the labeling information that could be helpful for the celiac population. 

 

 

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Updated on 02.08.02      webmaster@e-celiacs.org