The GlutenFree Diet and The Prevention of CrossContamination Medical Program Version

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The Gluten-Free DietandThe Prevention of
Cross-ContaminationMedical Program Version
Celiac Disease
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The Nature of Celiac Disease

• Celiac Disease (CD) is an autoimmune disease.
• It is one of the most common autoimmune diseases.
• The autoimmune response occurs in the gut.
• It is triggered by Gluten, a storage protein in
  wheat, barley and rye.

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The Nature of Celiac Disease

• The onset of CD can occur at any age.
• All people diagnosed with CD will have intestinal
  damage.
• The villi become inflamed, flattened and
  disappear.
• Nutrients, including carbohydrates, proteins,
  fats, vitamins and minerals, can no longer be
  absorbed.
• This leads to malnutrition and other serious
  health problems.

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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 people
  when additional stresses are placed on the body,
  including childbirth, severe infections,
  surgery, food poisoning and emotional stress.

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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 other vitamin deficiencies iron,
  folate, B12, A, D, E, K

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The Nature of Celiac Disease

• It is now recognized as a multi-system disease
  including such additional symptoms as
• Bone and joint pain, including arthritis
• Depression
• Nervous system disorders central and peripheral
• Extreme weakness and fatigue
• Easy bruising of the skin
• Osteoporosis
• Edema of the hands and ankles
• Fertility problems, amenorrhea, impotence
• Mouth ulcers canker sores
• Weight gain
• Constipation
• Lactose intolerance
• Other digestive system symptoms

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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

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The Nature of Celiac Disease

• CD is often associated with some other diseases
  and conditions, including
• Intestinal lymphoma
• Type I diabetes
• Autoimmune thyroid disease
• Liver enzyme elevations
• IgA deficiency
• Autoimmune hepatitis
• Addisons disease
• Epilepsy
• Sarcoidosis
• Sjogrens disease
• Systemic lupus erythematosus
• Turners syndrome, Williams syndrome, Down
  syndrome

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The Nature of Celiac Disease

• When left untreated, CD can result in other
  disorders, including
• Nervous system disorders
• Internal hemorrhaging
• Intestinal lymphoma (non-Hodgkins)
• Anemia
• Osteoporosis
• Vitamin and mineral deficiencies
• Pancreatitis
• Tooth enamel defects

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The Nature of Celiac Disease

• Celiac Disease is often misdiagnosed as other
  common ailments, including
• Allergies
• Anemia
• Crohns disease/colitis
• Diverticulosis/spastic colon
• Gall bladder disease
• Irritable bowel syndrome
• Chronic fatigue syndrome
• Lactose intolerance
• Stress/depression/emotional disturbances
• Viral gastroenteritis

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The Nature of Celiac Disease

• 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.
• It is often treated with dapsone in addition to
  the GF diet.

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Genetic Properties

• Celiac Disease is a true autoimmune disease.
• The genetic predisposition (HLA), the exogenous
  trigger (Gluten) and the autoantigen (tTG) are
  all known.
• CD is currently the only autoimmune disease for
  which all three factors are known.
• Unlike many other autoimmune diseases, the cause
  of the disease has been identified.

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Frequency of Occurrence

• CD occurs in almost 1 of the population.
• CD occurs in 1 in 22 first degree relatives.
  Canadian Research 12-15 per cent
• CD occurs in 1 in 39 second degree relatives.
  Canadian Research 5-12 per cent
• CD occurs in 1 in 56 people with
  gastro-intestinal symptoms.
• CD occurs in 1 in 133 of the not at risk
  population.

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Diagnosing Celiac Disease

• A series of serologic tests can assist in the
  preliminary screening for CD.
• Serum IgA-endomesial antibody testing (IgA-EMA)
  OR
• Serum IgA-tissue transglutaminase testing
  (IgA-tTG) PLUS
• Total serum IgA
• An intestinal biopsy must be performed to confirm
  the diagnosis of CD.

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Treatment of CD

• The only treatment for Celiac Disease is a
• STRICT GLUTEN-FREE DIET FOR LIFE
• The GF Diet should never be started without an
  accurate diagnosis of Celiac Disease.

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What Happens When Were Glutened?

• Even small amounts of gluten can be harmful to
  people with celiac disease and can cause
  continued small bowel damage.
• The accidental ingestion of gluten does not cause
  the profound anaphylactic response that is common
  with peanuts and other allergens.

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What Happens When Were Glutened?

• Many people with CD will have immediate
  intestinal symptoms.
• Many will have headaches or other non- intestinal
  symptoms.
• Many will have delayed symptoms.
• Many will have no symptoms but will still have
  intestinal damage which can lead to other
  illnesses.

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What Happens When Were Glutened?

• The progression of damage to the villi

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What Happens When Were Glutened?
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What Happens When Were Glutened?

• DH on the abdomen

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What Happens When Were Glutened?

• DH on the elbow DH on the knee

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Major Concerns

• Increase Awareness
• Safe Ingredients
• Hidden Sources of Gluten
• CROSS CONTAMINATION

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What is Gluten ?

• Gluten refers to several different cereal grain
  storage proteins, or prolamins.
• Gliadin in wheat
• Secalin in rye
• Hordein in barley

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Gluten Containing Grains Grain Products

• Barley Bulgar Cereal Binding
• Couscous Durum Einkorn
• Emmer Filler Farro
• Graham flour Kamut Malt
• Oats Roux Rye
• Semolina Spelt (Dinkel) Triticale
• Wheat
• Oats are currently excluded from the gluten-free
  diet because of the high risk of contamination
  from gluten containing grains

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Gluten-Free Grains Grain Substitutes

• Amaranth Arrowroot Buckwheat
• Cassava Corn (Maize) Dahl
• Flax Legumes Millet
• Nuts Poi Polenta
• Potatoes Quinoa Rice
• Sago Sorghum Soy
• Tapioca Teff Wild Rice

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Other Gluten-free Foods

• Fresh meat, poultry, fish and seafood
• Fresh vegetables and fruits
• Eggs
• Cheese and other dairy
• All products made with gluten-free ingredients

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The Questionable Products

• Baking powder Beverage mixes
• Bouillon cubes Cheese spreads
• Condiments Dried fruit
• Dry roasted nuts Flavourings
• Herbal teas HPP/HVP
• Ice cream and yogurt Icing sugar products
• Imitation seafood Licorice and candies
• Marinades and sauces Modified food starch
• Pilaf mixes Processed meats
• Puddings Rice and soy beverages
• Salad dressing Seasonings
• Seasoned fries Self basting poultry
• Smarties Soups and broths
• Soy sauce Worcestershire sauce

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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 gluten-free
  foods remain gluten-free.

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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.

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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.

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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.

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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

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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
  gluten-containing foods is unsafe for gluten-free
  cooking.
• Fresh water must always be used for boiling,
  poaching or steaming.

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Preventing Contamination Cross-contamination

• Use the top oven racks.
• Use caution with convection ovens.
• Use toaster bags to prevent contamination of GF
  bread products.
• Arrange buffet tables with gluten-free selections
  first and separated from the gluten-containing
  selections. Label them.
• Bulk bins can be a source for cross-contamination.

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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.
• Select pure spice blends rather than seasoning
  blends that may contain gluten-containing
  fillers.

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Using Safe Alternatives

• Many foods start out gluten-free and are glutened
  in menu preparation Eg. Salads
• Many food items have gluten-free alternatives
  Eg. Pizza shells, pasta
• Develop clearly identified gluten-free
  alternatives as part of a standard menu.

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For More Information

• Our website www.calgaryceliac.com
• National website www.celiac.ca
• Links to other chapter and resource websites
• Email Jo Anne Murray murray2_at_telusplanet.net