Gluten free diet primer: What, How, Why & Caveats

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Note: The article is taken in part from National Institute of Diabetes and Digestive and Kidney diseases and Food and Drug Administration.

A fact to ponder: Packaged Facts research estimated the sales of gluten free products to be $4.2 billion in 2012 rising to as high as $6.6 billion by 2017.

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While most people with celiac disease improve upon gluten-free diet, there is increasing focus on use of gluten free diet in non-celiac gluten sensitivity and even studies suggesting beneficial effect in non-gastrointestinal disorders like autism.

Need for standardized definition of gluten-free

Consistently following a gluten free diet is a daunting undertaking. A standard definition of ``gluten-free'' and uniform conditions for use in food/product labels would help subjects disease get uniform and correct information.

What is gluten free

Food and Drug Administration proposed a definition of gluten-free in 2007 based on provisions of the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA).

In an announcement in August 2013, the FDA announced that a gluten-free product hey will have to contain less than 20 parts per million of gluten. This amount is believed to be less than what would cause a problem in disorders like celiac disease.

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Based on FDA, Gluten free food/product does not contain any of the following:

An ingredient that is any species of the grains wheat, rye, barley, or a crossbred hybrid of these grains (all noted grains are collectively referred to as ``prohibited grains'')
An ingredient that is derived from a prohibited grain and that has not been processed to remove gluten (e.g., wheat flour)
Products of prohibited grain that have been processed to remove gluten (e.g., wheat starch) with any products containing over 20 parts per million (ppm) of gluten

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FDA proposed Label of Misbranding Gluten-free

Food labelled as ``gluten-free'' or making similar claim but does not meet the criteria for ``gluten-free'' would be considered mis-branded.
Food label claiming to be gluten-free if the claim does not refer to all foods of that same type (e.g., ``milk, a gluten-free food'' or ``all milk is gluten-free'').
Food made from oats and claiming to be gluten-free if the claim suggests that all such foods are gluten-free or if 20 ppm or more gluten is present in the food.

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Why some patients may not respond to gluten free diet

Patients may be consuming small amounts of gluten by ingesting gluten from hidden sources like additives such as modified food starch, preservatives, and stabilizers made with wheat. And because many corn and rice products are produced in factories that also manufacture wheat products, they can be contaminated with wheat gluten.

Cross-contamination of gluten into inherently gluten-free foods

While oats contamination is the most talked about, cross-contamination with other grains, seeds and flour also occur.
Thompson and colleagues examined 22 gluten free grains, seeds and flours were examined for gluten.
Gluten was detected in 41% of the products varying from 8.5 ppm to 2950 ppm with the limit of detection being 5 ppm. In fact, 32% of these products contained greater than allowed 20 ppm to be classified as gluten-free.

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The Gluten-free Diet

A gluten-free diet means not eating foods that contain wheat, rye, and barley. The foods and products made from these grains should also be avoided.

Major implication of gluten free diet

Patients should avoid most grain, pasta, cereal, and many processed foods.
Patients can get complete nutrition by eating a well-balanced diet with a variety of foods; however, a dietary consultation to accomplish this goal may be important..

Nutrition implications of gluten free diet

Unless properly undertaken, the gluten free diet tends to be:

High fat
Low carbohydrate
Low fiber
Low elements/minerals (iron, zinc, calcium,phosphorus)
Low vitamins (Niacin, folic acid, vitamin B12)

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Overcoming nutritional implications of gluten-free diet

Consume whole grain like brown rice, wild rice, whole corn, sorghum, teff, amaranth and buckwheat (see Table below)
Include quinoa in diet. Quinoa is one complate vegetarian food.
or enriched/supplemented gluten free products.
Take vitamin-mineral supplements.
Consume healthy amounts of vegetables, fruit
Eat legumes, seeds and nuts as allowed. Many nuts contain allergans and may need to be avoided as appropriate
Consume fish and lean meats/poultry. Beware: All fish are not equally healthy
Take milk (if allowed) or milk substitutes like gluten-free soy milk
Consume calcium rich foods or calcium enriched gluten free products
Choose products with lower fat content. Make Trans Fat a big No No!
Best of all, seek dietician help.

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Allowed Gluten free alternatives

Potato, rice, soy, amaranth, quinoa, buckwheat, or bean flour instead of wheat flour. Remember bean or pea flour is superior to rice flour in its nutritional profile and helps narrow the gaps in gluten-free diet.
Gluten-free bread, pasta
Gluten-free products are available fat many mainstream stores.

Common foods devoid of gluten

“Plain” meat, fish, rice, fruits, and vegetables do not contain gluten and as such people with celiac disease can eat these foods ad libitum.

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Gluten and oats controversy/confusion

Most people can safely eat small amounts of oats (up to 50g dry oats per day), as long as the oats are not contaminated with gluten during mill processing.
Oats or oats products are deemd to contain gluten unless labelled gluten free
Oats may be labelled gluten free as long as the gluten content of the product is less than 20 ppm.
According to Dr. Thompson and published in New England Journal of Medicine, gluten content of commercial oats products not labelled as gluten free varies widely not just among products also by the lot. Mean gluten content of 4 lots of Quaker Old fashioned Oats was found to vary from 338 ppm to 1807 ppm. Another brand McCann's Street Cut Irish Oats contained less than 3 ppm to 725 ppm of gluten depending upon the lot.

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A word about oat avenin

A few patients with celiac disease have avenin sensitivity . Oat avenin contain glutinous proteins analogous to wheat gliadin. As such some celiac disease patients may have an adverse immune reaction to oat avenin.

Look out for following on product not labelled gluten free

Wheat
Rye
Malt
Barley
Malt
Oats (do not consume if not labelled gluten free)
Brewer's yeast

Be extra-careful eating/purchasing out of home

Lunch at school or work
Grocery store
Restaurants
Parties
Snack vending machines

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Gluten in unexpected places

Medications
Additive in products like lipstick and play dough
Meat, poultry and egg products may contain wheat protein

Sources of wheat protein

Modified food starch may actually be modified wheat starch
Dextrin may wheat based
Starch may be wheat or corn based. FDA regulated foods only contain corn based starch

A word on wheat starch

According to the Academy of Nutrition and Dietetics, "Studies have shown that both natural and wheat starch based GF diets produce similar histological and clinical recovery in people with CD." While wheat starch may be included in gluten-free foods if it has been processed for gluten content of less than 20 ppm. However, most gluten-free products avoid that as do many patients consuming gluten-free diet.

New Food Labeling

The Food Allergen Labeling and Consumer Protection Act (FALCPA) of 2006 required food labels to clearly identify wheat and other common food allergens in the list of ingredients. FALCPA also required the U.S. Food and Drug Administration to develop and finalize rules for the use of the term “gluten free” on product labels.

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The Gluten-free Diet: Some Examples

Chart below is a select description of foods and based on 2006 American Dietetic Association recommendations for a gluten-free diet as described in the NIDDK website.

Allowed Foods
amaranth arrowroot buckwheat cassava corn flax Indian rice grass Job's tears	legumes millet nuts potatoes quinoa rice sago	seeds sorghum soy tapioca teff wild rice yucca
Foods To Avoid
wheat including einkorn, emmer, spelt, kamut wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein		barley rye triticale (a cross between wheat and rye)
Other Wheat Products
bromated flour durum flour enriched flour farina	graham flour phosphated flour plain flour	self-rising flour semolina white flour
Processed Foods that May Contain Wheat, Barley, or Rye^*
bouillon cubes brown rice syrup candy chips/potato chips cold cuts, hot dogs, salami, sausage communion wafers	French fries gravy imitation fish matzo rice mixes sauces	seasoned tortilla chips self-basting turkey soups soy sauce vegetables in sauce

^* Most of these foods can be found gluten-free. When in doubt, check with the food manufacturer.

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