Download The Gluten Free Diet - Calgary Celiac Association

Celiac Disease and Gluten
Sensitivity
The Diseases, the Diet and the
Legislation
Volunteer Training© (Web version)
revised May 2013
Developed and presented by CCA Calgary Chapter
Topics for Today
• The Medical Conditions - Celiac
Disease, including Dermatitis Herpetiformis and Non
Celiac Gluten Sensitivity
• The Gluten-Free Diet and the Cereal
Grains
• Legislative Regulations
• Product Contamination
The Diseases
Celiac Disease including Dermatitis Herpetiformis
and
Non Celiac Gluten Sensitivity
Celiac Disease - Genetic Properties
• Celiac Disease (CD) is a true autoimmune disease.
• The genetic predisposition (HLA), the environmental
trigger (Gluten) and the inflammatory response (tTG)
are all known.
• CD is currently the only autoimmune disease for
which all three factors are known.
• Celiac Disease is the most common autoimmune
disease recognized in the medical community. (~1% of
the population)
The Process of Disease Damage
• Genes determine the risk for developing CD.
(HLA DQ2, HLA DQ8)
• Gluten triggers the abnormal immune response.
• The intestinal villi become damaged.
• Nutrients, including carbohydrates, proteins, fats,
vitamins and minerals, can no longer be absorbed.
• This leads to malnutrition and other serious health
problems.
• Intestinal permeability increases. (Leaky Gut)
• There is a systemic response.
The Nature of Celiac Disease
• CD was formerly thought to be a disease of
childhood.
• It is now recognized as a disease that can occur at
any age.
• CD can be triggered in otherwise healthy, genetically
predisposed people when additional stresses are
placed on the body, including: childbirth, severe
infections, surgery, food poisoning and emotional
stress…
• It can present with a multitude of different symptoms.
The Nature of Celiac Disease
It was once thought that CD had classic
symptoms only, including:
•
•
•
•
•
•
Abdominal cramping and pain
Nausea and/or vomiting
Intestinal gas and bloating
Diarrhea, including steatorrhea
Weight loss
Anemia and vitamin deficiencies – iron, folate,
B12, A, D, E, K
The Nature of Celiac Disease
It is now recognized as a multi-system disease including additional
intestinal symptoms:
• Weight gain
• Constipation
• Lactose intolerance
• Mouth ulcers (canker sores)
And non-intestinal symptoms:
• Easy bruising of the skin
• Edema of the hands and ankles
• Bone and joint pain, including arthritis
• Osteoporosis
• Fertility problems, amenorrhea, impotence
• Depression
• Nervous system disorders – central and peripheral
• Extreme weakness and fatigue
The Nature of Celiac Disease
There are additional symptoms in children, including:
•
•
•
•
•
•
Dental enamel defects
Delayed puberty
Failure to thrive/delayed growth/short stature
Abdominal distension
Learning difficulties
Severe irritability/behavioural changes
The Nature of Celiac Disease
CD is often associated with some other diseases and conditions,
including:
•
•
•
•
•
•
•
•
Type 1 diabetes
Autoimmune thyroid disease
Liver enzymes elevations
Autoimmune hepatitis
Intestinal lymphoma
IgA deficiency
Addison’s disease
Down syndrome, Turner’s syndrome, Williams syndrome
And less commonly:
• Sjogren’s disease
• Systemic lupus erythematosus
• Epilepsy
• Sarcoidosis
Frequency of Occurrence
Celiac Disease occurs in ~1% of the
population.
It occurs more frequently in immediate
family members:
• 8 – 15% of first degree relatives. (Parents,
Children, Siblings)
• 5% of second degree relatives.
(Grandparents, Grandchildren, Aunts, Uncles)
What Happens When We’re
Glutened?
The progression of
damage to the villi
Dermatitis Herpetiformis
• Dermatitis Herpetiformis (DH) is an intensely itchy skin
rash.
• It is a form of celiac disease and is often referred to as
CD of the skin.
• People diagnosed with DH will also have intestinal
damage, with or without symptoms.
• The rash symptoms are often treated with dapsone in
addition to the GF diet.
• The mechanism for developing DH is through the
ingestion of gluten.
What Happens When We’re
Glutened?
DH on the elbow
DH on the knee
Diagnosing Celiac Disease
• A series of serologic (blood) tests can assist in
the preliminary screening for CD.
• Serum IgA-tissue transglutaminase testing (IgA-tTG)
OR/AND
• Serum IgA-endomesial antibody testing (IgA-EMA)
PLUS
• Total serum IgA
In Calgary, the standard lab requisition has a Celiac Screen request for these
specific tests.
• An intestinal biopsy must be performed to
confirm the diagnosis of CD.
Treatment of CD
The only treatment for Celiac Disease is a
STRICT GLUTEN-FREE DIET
FOR LIFE.
The GF Diet should not be started without
an accurate biopsy diagnosis of Celiac
Disease.
What Happens When We’re
Glutened?
• Even small amounts of gluten can be harmful to
people with celiac disease and can cause
continued small bowel damage.
(With or without apparent symptoms)
*******
• The accidental ingestion of gluten does not
cause the profound anaphylactic response that
is common with peanuts and other allergens.
What Happens When We’re
Glutened?
• Many people with CD will have immediate intestinal
symptoms.
• Many will have delayed intestinal symptoms.
• Many will have non-intestinal symptoms. Immediate or
delayed
• Many will have no symptoms but will still have
intestinal damage which can lead to other illnesses.
• The amount of gluten that causes symptoms varies
greatly amidst individuals, with some being extremely
sensitive.
Gluten Sensitivity
• Scientific research now supports the existence of this
distinct condition and that many people can be gluten
sensitive without having biopsy proven celiac disease.
• This research also indicates that Gluten Sensitivity
affects ~10% of the general population. Fasano 6%, Ford 30%
• The symptoms of Gluten Sensitivity are similar to CD
symptoms.
• There are currently no reliable tests to diagnose Gluten
Sensitivity.
• This condition is referred to as Non-Celiac Gluten
Sensitivity (NCGS).
The Gluten-Free Diet
and
The Cereal Grains
The Cereal Grains
Gluten Containing Grains
& Grain Products
Grasses, Grains, Cereals
Wheat including
Bulgur
Emmer
Spelt(Dinkel)
Barley
Oats*
Durum
Farro
Einkorn
Kamut
Rye
Triticale
_____________________________________________________________________________
Cereal Binding
Graham flour**
Semolina
Couscous
Malt
* Included in the Canadian Gluten-Free Regulation
** Not to be confused with Gram flour
Filler
Roux
Gluten-Free Grains &
Grain Substitutes
Corn (Maize)
Rice
Sorghum
_____________________________________________________________________________
Amaranth
Cassava
Flax
Nuts
Potatoes
Soy
Wild Rice
Arrowroot*
Coconut
Legumes
Poi
Quinoa
Tapioca
Buckwheat
Dahl (Gram)**
Millet
Polenta
Sago
Teff
_____________________________________________________________________________
Montina® (Indian Rice Grass)
* A GF Flour not to be confused with ‘Arrowroot Cookies’
** Not to be confused with Graham flour
Timtana® (Timothy)
Other Gluten-free Foods
• Fresh meat, poultry, fish and seafood (unseasoned)
• Fresh vegetables and fruits (including fresh frozen)
• Eggs
• Nuts and seeds
• Legumes
• Cheese and other dairy – lactose intolerance vs milk protein allergy
(Lactose intolerance is often associated with Celiac Disease)
• All products made with gluten-free ingredients
Questionable Products
Baking powder
Bouillon cubes
Condiments
Dry roasted nuts
Herbal teas
Ice cream and yogurt
Imitation seafood
Marinades and sauces
Pilaf mixes
Puddings
Salad dressing
Seasoned fries
Smarties**
Soy sauce
Beverage mixes
Cheese spreads
Dried fruit
*Flavourings
HPP/HVP
Icing sugar products
Licorice and candies
Modified food starch
Processed meats
Rice and soy beverages
*Seasonings
Self basting poultry
Soups and broths
Worcestershire sauce
* The new allergy labelling will clearly include all gluten sources. Remember to review all product
labels. Seasonings and flavourings are often overlooked.
** Some alternate M&M products do not contain gluten.
Quick and Easy References
Using Safe Alternatives
• Many common food products have safe
alternatives: Eg. Soy sauce.
• Safe thickening agents can be used in place of
flour: Eg. Potato starch, tapioca starch
• Many food items have gluten-free alternatives:
Eg: Pizza shells, pasta
Domestic vs. Commercial Products
Many products marketed in regular grocery stores contain
different ingredients than their commercial counterparts
marketed to restaurants and other high volume
commercial facilities.
Examples include: Worcestershire sauces, salad dressings,
marinades, bouillon bases, pilaf seasonings,
flavourings…
Check with restaurant staff (and staff of other facilities) and
review labels carefully to assure safety of ingredients.
Thoughts to Consider
Thoughts to keep in mind about gluten free choices:
• Manufacturers do not commonly fortify milled GF grains with
essential nutrients including vitamins and minerals. (This appears to
be changing)
• Many gluten free grains and grain substitutes are more calorie
dense than gluten containing flours.
• Many gluten free baked goods use more fats, oils, sugar and
eggs to prevent crumbling of the products.
Consult a Registered Dietitian to determine optimal
nutritional intake on the Gluten Free Diet.
(Include current lab results to review any nutrient deficiencies.)
Legislation and Labelling
Major Concerns
• Product Labelling
•
•
•
•
Safe and Unsafe Ingredients
Hidden Sources of Gluten*
Ambiguous Ingredients*
Ambiguous Labeling*
• *With the newly revised allergy legislation, these
concerns have been resolved. (with a few exceptions).
• Contamination and Cross-Contamination
• These continue to be of concern
What is Gluten ?
• Gluten refers to several different cereal
grain storage proteins, or prolamins.
• Gliadin in wheat
• Secalin in rye
• Hordein in barley
There is ongoing confusion over references to glutinous
rice and corn gluten
(Avena is the protein found in Oats)
The New Allergy Regulation
The new Allergy Regulation came into effect 4 Aug 2012…
In addition to the declaration of the top allergens,
…The gluten source must be declared when a food
contains gluten protein or modified gluten protein
from barley, oats, rye, triticale or wheat, including
kamut or spelt… and must be written in plain language.
•
Information about gluten content can be found in:
• The INGREDIENT list
• The WARNINGS section – CONTAINS, MAY CONTAIN. (The ‘may
contain’ statement is a voluntary statement.)
The Allergy Regulation pertains to food ingredients
The New Gluten-Free Regulation
Revisions to the Gluten-Free Regulation also came into effect on 4 Aug 2012…
•
It is prohibited to label, package, sell or advertise a food in a manner likely to create an impression
that it is a gluten-free food if the food contains any gluten protein or modified gluten protein,
including any gluten protein fraction, referred to in the definition "gluten" in subsection
B.01.010.1(1).
•
Subsection B.01.010.1(1) reads:
"gluten“
(a) any gluten protein from the grain of any of the following cereals or the grain of a hybridized
strain created from at least one of the following cereals:
(i) barley,
(ii) oats,
(iii) rye,
(iv) triticale, or
(v) wheat, kamut or spelt; or
(b) any modified gluten protein, including any gluten protein fraction, that is derived from the grain
of any of the cereals referred to in subparagraphs (a)(i) to (v) or the grain of a hybridized strain
referred to in paragraph (a). (gluten)
The New Gluten-Free Regulation
Also included in the gluten free regulation…
Based on available scientific evidence, Health Canada
considers that gluten-free foods prepared under good
manufacturing practices, which contain levels of gluten
not exceeding 20 ppm as a result of crosscontamination, meet the health and safety intent of the
gluten-free regulation (B.24.018) when a gluten-free claim is
made…
The Gluten-Free Regulation pertains to cross-contamination of gluten-free
ingredients.
20 parts per million
½ tsp.
Half a teaspoon
In a bathtub filled with water
(125 litre bathtub)
20 parts per million
Less than a drop
In 2 litres of ice cream
(1 drop in 2.5 litres)
20 ppm in Daily Living
Based on the gluten-free regulation (<20 ppm), scientific
evidence and the usual eating practices of people on a
gluten free diet consuming 250 – 400 grams of GF foods
daily, the average person with Celiac Disease could
safely consume up to 10 mg of gluten daily without
adverse effects.
Based on this evidence, less than a teaspoon of
pure gluten, (equivalent to 3500 mg), would be the
maximum tolerable amount for an entire year.
10 milligrams daily
•Less than one
teaspoon of gluten
•Equivalent to one sugar sweetener for
your coffee (3.5 gr)
•Is the maximum amount considered
safe in a year
Preventing Contamination and CrossContamination
In food service industries and facilities.
•
•
•
•
•
Restaurants and banquet halls
Seniors’ facilities
Day care centres
School classrooms, lunchrooms and cafeterias…
Other locations
Preventing Contamination &
Cross-contamination
• When preparing a gluten-free meal, it is
important to prevent contamination of the
gluten-free foods with gluten-containing food
particles and residues.
• Even small amounts of gluten can result in
continued intestinal damage for people with CD
and DH
• Care must be taken to ensure that glutenfree foods remain gluten-free.
Preventing Contamination &
Cross-contamination
• Select a preparation area that is separate from
other food preparation areas.
• Air-borne flour and other gluten-containing
particles can contaminate gluten-free foods.
• Ensure all preparation surfaces, cooking
surfaces and cooking utensils have been
thoroughly cleaned, including counter top,
meat slicer, grill surface, cutting boards, bowls,
knives, utensils, thermometers, cleaning
cloths, aprons.
Preventing Contamination &
Cross-contamination
• Use dedicated pots, pans, utensils and cutting
boards whenever possible.
• Rolled edge pans are easier to clean.
Scrub with soap and water to ensure removal of gluten-containing particle. Disinfect according
to current standards of practice.
Preventing Contamination &
Cross-contamination
• Follow impeccable hand washing practices.
• Use sanitary gloves for food preparation and
change them before handling GF foods.
• Ensure the powder used is gluten-free. Even
powder-free gloves can have trace amounts of
powder.
• Become knowledgeable about special needs
diets and menu selections.
Educational programs are offered through many of the local chapters of the Canadian Celiac Association.
Preventing Contamination &
Cross-contamination
• Ensure all ingredients are gluten-free.
• Check product ingredients regularly.
Manufacturers and suppliers can change ingredients
without notice.
• Ensure that anti-caking and flow agents are GF.
These agents may not be identified in the ingredient
lists.*
• Use boldly labeled, air tight containers for all products
designated as GF.
• Prepare GF meals before other menu selections
* the new allergy labeling requires these agents to be declared.
Preventing Contamination &
Cross-contamination
• Clean utensils must be used for each
condiment, butter, sauce and all other items.
• Use individual portions and/or squeeze bottles.
• Deep fryer oil previously used for glutencontaining foods is unsafe for gluten-free
cooking. (Particles and residues)
• Fresh water must always be used for boiling,
poaching or steaming.
Preventing Contamination &
Cross-contamination
• Use the top oven racks and refrigerator shelves.
• Use caution with convection ovens.
• Use toaster bags to prevent contamination of GF
bread products. (Check with the Calgary office for availability.)
• Bulk bins can be a source for crosscontamination.
Using Safe Alternatives
• Many foods start out gluten-free and are
glutened in menu preparation: Eg. Salad croutons
• Develop clearly identified gluten-free
alternatives as part of a standard menu.
• Arrange buffet tables with gluten-free selections
first and separated from gluten-containing
selections. Label them.
Reliable Websites
Canadian Celiac Association
http://www.celiac.ca
Calgary Chapter (Dr. Decker Butzner, Dr. Paul Beck)
http://www.calgaryceliac.ca
University of Maryland (Dr. Alessio Fasano)
http://www.celiaccenter.org
Mayo Clinic (Dr. Joe Murray)
http://www.mayoclinic.com/health/celiac-disease/
Columbia University (Dr. Peter Green)
http://www.celiacdiseasecenter.columbia.edu
The Gluten Free Diet – Shelley Case, RD
www.glutenfreediet.ca