Gluten Free Diet,

Because of the broad range of symptoms celiac disease presents, it can be difficult to diagnose. The symptoms can range from "mild weakness, bone pain, and aphthous stomatitis to chronic diarrhea, abdominal bloating, and progressive weight loss." If a person with the disorder continues to eat gluten, studies have shown that he or she will increase their chances of gastrointestinal cancer by a factor of 40 to 100 times that of the normal population. Further, "gastrointestinal carcinoma or lymphoma develops in up to 15 percent of patients with untreated or refractory celiac disease." It is therefore imperative that the disease is quickly and properly diagnosed so it can be treated as soon as possible.

Testing is fairly simple and involves screening the patient's blood for antigliadin (AGA) and endomysium antibodies (EmA), and/or doing a biopsy on the areas of the intestines mentioned above, which is still the standard for a formal diagnosis.

Coeliac disease leads to severe damage of the gut surface, which can be completely reversed by following a gluten-free diet. Shortly after the diagnosis of coeliac disease, you need to be extra careful to ensure you have a nutritionally adequate diet, as you may have been suffering from malabsorption of nutrients.

The only acceptable treatment for celiac disease is strict adherence to a 100% gluten-free diet for life. A gluten-free diet means avoiding all products that contain wheat, rye and barley, or any of their derivatives. This is a difficult task as there are many hidden sources of gluten found in the ingredients of many processed foods.

Traditionally, gluten is defined as a cohesive, elastic protein that is left behind after starch is washed away from a wheat flour dough. Only wheat is considered to have true gluten. Gluten is actually made up of many different proteins.

There are two main groups of proteins in gluten, called the gliadins and the glutenins. Upon digestion, the gluten proteins break down into smaller units, called peptides (also, polypeptides or peptide chains) that are made up of strings of amino acids--almost like beads on a string. The parent proteins have polypeptide chains that include hundreds of amino acids. One particular peptide has been shown to be harmful to celiac patients when instilled directly into the small intestine of several patients. This peptide includes 19 amino acids strung together in a specific sequence. Although the likelihood that this particular peptide is harmful is strong, other peptides may be harmful, as well, including some derived from the glutenin fraction.

It is certain that there are polypeptide chains in rye and barley proteins that are similar to the ones found in wheat. Oat proteins have similar, but slightly different polypeptide chains and may or may not be harmful to celiac patients. There is scientific evidence supporting both possibilities.

When celiac patients talk about "gluten-free" or a "gluten-free diet," they are actually talking about food or a diet free of the harmful peptides from wheat, rye, barley, and (possibly) oats. This means eliminating virtually all foods made from these grains (e. g., food starch when it is prepared from wheat, and malt when it comes from barley) regardless of whether these foods contain gluten in the very strict sense. Thus, "gluten-free" has become shorthand for "foods that don't harm celiacs."

In recent years, especially among non-celiacs, the term gluten has been stretched to include corn proteins (corn gluten) and there is a glutinous rice, although in the latter case, glutinous refers to the stickiness of the rice rather than to its containing gluten. As far as we know, neither corn nor glutinous rice cause any harm to celiacs.

There is no typical celiac. Individuals range from having no symptoms (asymptomatic or "latent" forms of the disease) to extreme cases where patients present to their physicians with gas, bloating, diarrhea, and weight loss due to malabsorption.

In between these two extremes lie a wide variety of symptoms that include:

• Diarrhoea
• Constipation
• Steatorrhea (fatty stools that float rather than sink)
• Abdominal pain
• Excessive gas
• Any problem associated with vitamin deficiencies
• Iron deficiency (anemia)
• Chronic fatigue
• Weakness
• Weight loss
• Bone pain
• Easily fractured bones
• Abnormal or impaired skin sensation (paresthesia), including burning, prickling, itching or tingling
• Edema
• Headaches
• Peripheral Neuropathy* (tingling in fingers and toes)

Individuals have reported such varied symptoms as:

• White flecks on the fingernails
• Fuzzy-mindedness after gluten ingestion
• Burning sensations in the throat

In children, the symptoms may include:

• Failure to thrive
• Paleness
• Querulousness, irritability
• Inability to concentrate
• Wasted buttocks
• Pot belly with or without painful bloating
• Pale, malodorous, bulky stools
• Requent, foamy diarrhoea
• In addition to all of these, dermatitis herpetiformis, a disease in which severe rashes appear (often on the head, elbows, knees and buttocks) is related to celiac disease.

Reactions to ingestion of gluten can be immediate, or delayed for weeks or even months.

The amazing thing about celiac disease is that no two individuals who have it seem to have the same set of symptoms or reactions. A person might have several of the symptoms listed above, a few of them, one, or none. There are even cases in which obesity turned out to be a symptom of celiac disease.

A gluten-free diet is essential for people who have coeliac disease or dermatitis herpetiformis (a gluten induced skin sensitivity).

Some people may choose to follow a gluten-free diet for other reasons, although these two diseases are the only ones where a gluten-free diet is considered medically imperative.

Gluten is a mixture of proteins found in some cereals, particularly wheat. It is the gliadin component of gluten which is responsible for coeliac disease. A gluten-free diet is not the same as a wheat-free diet, and some gluten-free foods are not wheat free. Despite a good deal of research, it is unknown how or exactly why gluten harms the gut. It is now considered likely that coeliac disease involves an abnormal immunologic response, rather than an enzyme deficiency as was suggested in the past.

It is possible to follow a gluten-free vegan diet, although you must be extra careful to ensure that your diet is nutritionally adequate. It is essential that you seek the advice of a sympathetic dietician if you want to follow a vegan gluten-free diet.

Vegetarians may initially find it difficult to establish what foods they can and cannot have.

A gluten-free diet involves the complete avoidance of all foods made from or containing wheat, rye, barley and usually, oats. Some doctors say oats may be permitted, although The Coeliac Society advise against the inclusion of oats in a gluten-free diet.

The Coeliac Society publishes a list of gluten-free manufactured products in a booklet which is updated every year. You can check with The Vegetarian Society if you are unsure whether any particular foods on this list are suitable for vegetarians or vegans. Some manufacturers use the gluten-free symbol on their label.

A wide range of specially manufactured gluten-free foods such as, bread, bread mix, pasta, biscuits, cakes, crispbread and flour are prescribable under the NHS.

Some gluten-free flours are low in protein, because they have had the gluten removed, which is itself a protein. Specially manufactured, prescribed gluten-free flours usually have milk protein added. Vegetarians can get protein from nuts & seeds, pulses, the non-gluten containing cereals, soya products, milk, cheese and free range eggs. Make sure some protein is included in each meal, and practice protein complementation with the vegetable proteins, for example, combine a nut or pulse dish with a suitable cereal.

Gluten is a protein found in wheat, rye, barley, triticale and oats. The component of gluten that causes problems for people with coeliac disease is the prolamine fraction. The prolamine fraction in wheat is called gliadin; in rye, it is called secalin; in barley, it is hordein; and in oats, it is avenin.

A person with coeliac disease should avoid any foods that contain gluten. It is important to read the labels of all packaged or prepared foods. Some foods that may contain gluten include:

• Meat products - any products prepared with breadcrumbs or batter, most sausages and other processed meats (including smallgoods), thickened soups, meat pies and frozen meals.
• Dairy products - malted milk, some flavoured milks, cheese spreads, icecream in a cone, many custards and many soymilks.
• Fruits and vegetables - canned and sauced vegetables, textured vegetable protein (found in some vegetarian products) and fruit-pie filling.
• Cereal and baking products - wheat, wheaten or unspecified corn flour, semolina, couscous, wheat bran, barley, oats, porridge, breakfast cereals containing wheat, rye, oats or barley, corn or rice cereals containing malt extract, icing sugar mixtures and baking powder.
• Pasta and noodles - spaghetti, pasta, lasagne, gnocchi, hokkein noodles, soba noodles and two-minute noodles.
• Bread, cakes and biscuits - all bread, cakes and biscuits prepared with flours that contain gluten. This also includes communion hosts.
• Condiments - malt vinegar, many mustards, relishes, pickles, salad dressings, sauces, gravy and yeast extracts.
• Snacks - liquorice, some lollies and chocolates, packet savoury snacks, and some flavoured potato and corn chips.
• Drinks - cereal coffee substitutes, milk drink powders, beer, stout, ale, guinness and lager.

Packaged foods have ingredient labels stamped on the box, package or bottle, but products are not always labelled if they are 'gluten free'. Also, the ingredient label may not list 'gluten' as a component, but it can be present within other ingredients such as thickeners, which could be wheat based. Effective from December 2002, new Australian food labelling laws will ensure that any ingredient (for example starches, thickeners, maltodextrin etc) derived from gluten-containing grains will need to have the source indicated. Also, processing aids derived from gluten-containing grains used to assist in the manufacture of foods will have to be declared.

There is an Australian Food Standard for processed foods labelled 'gluten free'. When foods are tested using the prescribed test, there must be 'no detectable gluten'. Currently (June 2001) this test is sensitive to 0.003% (3 parts per million).

Despite the restrictions, a person with coeliac disease can still enjoy a wide and varied diet if they take an open-minded approach.

Corn (maize), rice, soy, potato, buckwheat, millet, quinoa, lentils and amaranth are all gluten free. It is important to read the labels of all packaged or prepared foods. Some gluten free foods that people with coeliac disease can enjoy include:

• Meat products - plain meat, fish, chicken, bacon, ham off the bone and meats that are frozen or canned but with no sauce.
• Dairy products - eggs, full cream milk, low fat milk, evaporated milk, condensed milk, fresh cream, processed or block cheese and some soymilks.
• Fruits and vegetables - fresh, canned or frozen but not sauced; fruit juices, nuts and peanut butter.
• Cereal and baking products - corn (maize) flour, soya flour, lentil flour, rice (all types), rice flour, rice bran, potato flour, buckwheat, millet, amaranth, breakfast cereals made from corn and rice without malt extract, polenta and psyllium.
• Bread, cakes and biscuits - most rice crackers, corn cakes, rice crispbreads, corn tortillas and corn taco shells.
• Pasta and noodles - gluten free pasta, rice noodles, bean vermicelli and 100% buckwheat noodles.
• Condiments - tomato paste, tahini, jam, honey, maple syrup, cocoa, all kinds of vinegars (except malt), some sauces and some salad dressings.
• Snacks - plain chips and corn chips, popcorn and plain chocolate.
• Drinks - tea, coffee, mineral water, wine, sports drinks, spirits and liqueurs (check these for gluten-containing ingredients first).

Naturally gluten free cereal products that can be enjoyed include:

• Amaranth
• Arrowroot
• Buckwheat
• Cornflour
• Cornmeal
• Corn tortillas
• Lentil flour
• Malt-free rice and corn breakfast cereals
• Millet meal
• Most pappadums
• Polenta
• Potato flour
• Psyllium
• Quinoa
• Rice (any kind)
• Rice bran
• Most rice crackers
• Rice flour
• Rice vermicelli
• Sago
• Soya flour
• Soy-based lecithin
• Taco shells
• Tapioca

In some cases, you can modify existing recipes for cakes and biscuits to make them gluten free. Gluten is the ingredient in wheat that helps the cooked produce to hold together, so you will need to use some other types of 'binding' agents.

Suggestions include:

• Be prepared to experiment, and accept that a few of your first attempts may be unsuccessful.
• Replace the role of gluten with xanthan gum or guar gum powders. These products are available from some coeliac societies and some supermarkets
• Try adding more baking powder to cakes
• Add an additional egg to pancake batters.
• Make your own flours.

The following mixtures may be used to make adequate flour substitutes:

• Self-raising flour - two tablespoons potato flour, sufficient white rice flour to make it up to one cup, half a teaspoon of bicarbonate soda, half a teaspoon of cream of tartar, one teaspoon of xanthan gum (or guar gum).
• Plain flour - combinations include: two cups rice flour, two thirds cup potato flour and one third cup tapioca flour; equal portions of soya flour and cornstarch; equal portions of soya flour and potato flour; equal portions of soya flour and rice flour.
• Sweet pastry - 60g cornstarch, three quarters cup milk powder, one and a half cups coconut, 120g melted butter.
• Baking powder - one quarter cup bicarbonate soda and half cup cream of tartar.

If you have any doubts about the self-healing power of your body, consult your naturopath or health practitioner for advice!