Gluten-free diet

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Further information: The oat controversy and Oat sensitivity

A gluten-free diet is a diet that excludes foods containing gluten. Gluten is a protein complex found in wheat (including kamut and spelt), barley, rye and triticale. A gluten-free diet is the only medically accepted treatment for celiac disease.[1] Being gluten intolerant can often mean a person may also be wheat intolerant as well as suffer from the related inflammatory skin condition dermatitis herpetiformis,[2] There are a smaller minority of people who suffer from wheat intolerance alone and are tolerant to gluten.

Despite unknown benefits for non-celiacs and evidence to suggest adverse affects,[3][4] a significant demand has developed for gluten-free food in the United States.[5]

A gluten-free diet might also exclude oats. Medical practitioners are divided on whether oats are acceptable to celiac disease sufferers[6] or whether they become cross-contaminated in milling facilities by other grains.[7] Oats may also be contaminated when grown in rotation with wheat when wheat seeds from the previous harvest sprout up the next season in the oat field and are harvested along with the oats.

The term gluten-free generally is used to indicate a supposedly harmless level of gluten rather than a complete absence.[8] The exact level at which gluten is harmless for people with celiac disease is uncertain and controversial. A 2008 systematic review tentatively concluded that consumption of less than 10 mg of gluten per day for celiac disease patients is unlikely to cause histological abnormalities, although it noted that few reliable studies had been conducted.[8]

Regulation of the label, gluten-free, varies widely by country. In the United States, the FDA issued proposed regulations in 2007 limiting the use of "gluten-free" in food products to those with less than 20 parts per million of gluten.[9][10] The current international Codex Alimentarius standard allows for 20 parts per million of gluten in so-called "gluten-free" foods.[11] There is at least one website with a table containing information on "gluten-free" food manufacturers and the gluten-parts-per-million levels to which each of those manufacturers tests.[12]

Contents

Gluten-free food [edit]

Gluten-free food is normally seen as a diet for celiac disease, but people with a gluten allergy (an unrelated disease) should also avoid all other grains.

Quinoa is a grain that is gluten-free

Several grains and starch sources are considered acceptable for a gluten-free diet. The most frequently used are corn, potatoes, rice, and tapioca (derived from cassava). Other grains and starch sources generally considered suitable for gluten-free diets include amaranth, arrowroot, millet, montina, lupin, quinoa, sorghum (jowar), taro, teff, chia seed, and yam. Sometimes various types of bean, soybean, and nut flours are used in gluten-free products to add protein and dietary fiber.

Almond flour has a low glycemic index, and is a low-carbohydrate alternative to wheat flour. In spite of its name, buckwheat is not related to wheat. Pure buckwheat is considered acceptable for a gluten-free diet, however, many commercial buckwheat products are mixtures of wheat and buckwheat flours, and thus, not gluten-free. Gram flour, derived from chickpeas, also is gluten-free (this is not the same as Graham flour made from wheat).

Chickpeas

Gluten may be used in foods in some unexpected ways, for example it may be added as a stabilizing agent or thickener in products such as ice-cream and ketchup.[13][14]

People wishing to follow a completely gluten-free diet must take into consideration the ingredients of any over-the-counter or prescription medications and vitamins. Also, cosmetics such as lipstick, lip balms, and lip gloss may contain gluten and need to be investigated before use. Glues used on envelopes may also contain gluten.

Most products manufactured for Passover are gluten-free. Exceptions are foods that list matzah as an ingredient, usually in the form of cake meal.[15]

Cross-contamination issues [edit]

A gluten-free diet allows for fresh fruits, vegetables, meats, and many dairy products. The diet allows rice, corn, soy, potato, tapioca, beans, sorghum, quinoa, millet, pure buckwheat, arrowroot, amaranth, teff, Montina, and nut flours and the diet prohibits the ingestion of wheat, barley, rye, and related components, including triticale, durum, graham, kamut, semolina, spelt, malt, malt flavouring, or malt vinegar.[16]

In the United States, the FDA considers foods containing less than or equal to 20 ppm to be gluten-free,[17] but there is no regulation or law in the U.S. for labeling foods as 'gluten-free'. The finding of a current study indicates that some inherently gluten-free grains, seed, and flours not labeled gluten-free are contaminated with gluten. The consumption of these products can lead to inadvertent gluten intake.[18] The use of highly sensitive assays is mandatory to certify gluten-free food products. The European Union, World Health Organization, and Codex Alimentarius require reliable measurement of the wheat prolamins, gliadins rather than all-wheat proteins.[19]

There still is no general agreement on the analytical method used to measure gluten in ingredients and food products.[20] The official limits described in the Codex Draft are 20 ppm for foodstuffs that are considered naturally gluten-free and 200 ppm for foodstuffs rendered gluten-free.[21] The ELISA method was designed to detect w-gliadins, but it suffered from the setback that it lacked sensitivity for barley prolamins.[22]

Restaurants with gluten-free menus obviously recognize the importance of providing such a service, but those who are gluten-sensitive always must aware that the variety of procedures used in kitchens and grills may allow cross contamination to occur. This especially is the case in buffets where utensils typically are used in different food bowls by customers.

Cross-contamination problems [edit]

A growing body of evidence suggests that a majority of people with celiac disease and following a gluten-free diet can safely consume pure oats in moderate amounts. Studies have indicated, however, that the commercial oat supply in Canada and other countries is contaminated with other grains.[23]

Special care is necessary when checking product ingredient lists since gluten comes in many forms: vegetable proteins and starch, modified food starch (when derived from wheat instead of maize), malt flavoring, including maltodextrine, dextrine, unless specifically labeled as corn malt. Many ingredients contain wheat or barley derivatives. Dextrose is considered gluten-free, however, since it is highly modified, no matter what the source.[24]

Controversy over oats [edit]

Further information: The oat controversy and Oat sensitivity
Oat grains in their husks

The suitability of oats in the gluten-free diet is still somewhat controversial. Some research suggests that oats in themselves are gluten-free, but that they are virtually always contaminated by other grains during distribution or processing. Recent research,[25] however, indicated that a protein naturally found in oats (avenin) possessed peptide sequences closely resembling wheat gluten and caused mucosal inflammation in significant numbers of celiac disease sufferers. Some examination results show that even oats that are not contaminated with wheat particles are nonetheless dangerous, while not very harmful to the majority. Such oats are generally considered risky for children with celiac disease to eat, but two studies show that they are completely safe for adults with celiac disease to eat.

People who merely are "gluten-sensitive" may be able to eat oats without adverse effect,[26] even over a period of five years.[27] Given this conflicting information, excluding oats appears to be the only risk-free practice for celiac disease sufferers of all ages,[28] however, medically approved guidelines exist for those with celiac disease who do wish to introduce oats into their diet.[29]

Unless manufactured in a dedicated facility and under gluten-free practices, all cereal grains, including oats, may be cross-contaminated with gluten. Grains become contaminated with gluten by sharing the same farm, truck, mill, or bagging facility as wheat and other gluten-containing grains.

Accuracy of "gluten-free" labels [edit]

Sausages may contain gluten via fillers or binders such as Butcher's Rusk

Standards for "gluten-free" labelling have been set up by the "Codex Alimentarius"; however, these regulations do not apply to "foods which in their normal form do not contain gluten".[30]

The legal definition of the phrase "gluten-free" varies from country to country. Current research suggests that for persons with celiac disease the maximum safe level of gluten in a finished product is probably less than 0.02% (200 parts per million) and possibly as little as 0.002% (20 parts per million).[citation needed]

Australian standards reserve the "gluten-free" label for foods with less than 5 parts per million of gluten, as this is the smallest amount currently detectable. In the processing of gluten-containing grains, gluten is removed (shown in the processing flow below)

Wheat Flour (80,000ppm) > Wheat Starch (200ppm) > Dextrin > Maltodextrin > Glucose Syrup (<5ppm) > Dextrose > Caramel Color

Since ordinary wheat flour contains approximately 12% gluten,[31] even a tiny amount of wheat flour can cross-contaminate a gluten-free product, therefore, considerable care must be taken to prevent cross-contamination in both commercial and home food preparation.

A gluten-free diet rules out all ordinary breads, pastas, and many convenience foods; it also excludes gravies, custards, soups, and sauces thickened with wheat, rye, barley, or other gluten-containing flour. Many countries do not require labeling of gluten containing products, but in several countries (especially Australia and the European Union) new product labeling standards are enforcing the labeling of gluten-containing ingredients. Various gluten-free bakery and pasta products are available from specialty retailers.

In the United States, gluten may not be listed on the labels of certain foods because the U.S. Food and Drug Administration has classified gluten as GRAS (Generally Recognized As Safe).[32] Requirements for proper labeling are being formulated by the USDA. It is currently up to the manufacturers of "gluten-free" food items to guarantee such a claim. "A final rule that defines the term gluten-free and identifies the criteria that would enable the food industry to use that term" was scheduled to be released by the FDA on August 2, 2008.[33] This final rule has not yet come to fruition. For now, many individuals who must eat gluten-free diets use sources online to search the gluten-free content of products.

Many so-called gluten-free products, such as chicken bouillon, corn cereal, and caramel ice cream topping, have been found to have been contaminated with gluten.[34] For example, in an investigation reported by the Chicago Tribune on November 21, 2008, Wellshire Farms chicken nuggets labeled "gluten-free" were purchased from a Whole Foods Market and samples were sent to a food allergy laboratory at the University of Nebraska.[35] Results of the testing indicated gluten was present in levels exceeding 2,000 ppm. After the article was published, the products continued to be sold. After receiving customer inquiries, however, more than a month later, the Whole Foods Market removed the product from their shelves. Wellshire Farms has since replaced the batter used in their chicken nuggets.[36]

In the United Kingdom, only cereals currently need to be labeled regarding gluten, while other products are voluntary.[37] For example, most British sausages contain Butcher's Rusk, a grain-derived food additive.[38] Furthermore, while UK companies selling food prepared on their own premises are given guidance by the Food Standards Agency, they are not required to meet any labeling requirements.[39]

Lastly, some non-foodstuffs such as medications and vitamin supplements, especially those in tablet form, may contain gluten as an excipient or binding agent.[40][41] People with gluten intolerances may therefore require specialist compounding of their medication.[31]

Alcoholic beverages [edit]

Gluten-free beer

Several celiac disease groups report that according to the American Dietetic Association's "Manual of Clinical Dietetics",[42][43] many types of alcoholic beverages are considered gluten-free, provided no colourings or other additives have been added as these ingredients may contain gluten. Although most forms of whiskey are distilled from a mash that includes grains that contain gluten, distillation removes any proteins present in the mash, including gluten. Although up to 49% of the mash for Bourbon and up to 20% of the mash for corn whiskey may be made up of wheat, or rye, all-corn Bourbons and corn whiskeys do exist, and are generally labeled as such. Spirits made without any grain such as brandy, wine, mead, cider, sherry, port, rum, tequila, and vermouth generally do not contain gluten, although some vineyards use a flour paste to caulk the oak barrels in which wine is aged,[44] and other vineyards use gluten as a clarifying agent (though it is unclear whether gluten remains at the end of the clarification process).[45][46] Therefore, some celiac disease patients may wish to exercise caution. Liqueurs and pre-mixed drinks should be examined carefully for gluten-derived ingredients.

People diagnosed with celiac disease may experience symptoms when drinking distilled alcoholic beverages. Therefore, it is advised that a person with celiac disease check with a manufacturer about the ingredients that have been used in a hard liquor, and to proceed with caution if choosing to drink a liquor that is made with wheat, barley, oats, or rye.[citation needed]

Almost all beers are brewed with malted barley or wheat and will contain gluten. Sorghum and buckwheat-based gluten-free beers are available, but remain a niche market. Some low-gluten beers are also available, however, there is disagreement over the use of gluten products in brewed beverages: Some brewers argue that the proteins from such grains as barley or wheat are converted into amino acids during the brewing process and are therefore gluten-free;[47] however, there is evidence that this claim is false.[48]

Gluten-free bread [edit]

rice bread

Bread, which is a staple in most diets, typically is made from grains such as wheat, that contain gluten. Wheat gluten contributes to the elasticity of dough and is thus an important component of bread. Gluten-free bread is made with ground flours from a variety of materials such as almonds, rice (rice bread), sorghum (sorghum bread), corn (cornbread), or legumes such as beans (bean bread), but since these flours lack gluten it can be difficult for them to retain their shape as they rise and they may be less "fluffy". Additives such as xanthum gum, hydroxypropyl methylcellulose (HPMC), corn starch, or eggs are used to compensate for the lack of gluten.[49]

Popularity and nonceliac health effects [edit]

Gluten-free fad diets have become popular. This may be because celiac disease was underdiagnosed and also that people are "unnecessarily turning to the diets as a food fad". There also appears to be an increased incidence of celiac disease, with one study which looked for antibodies from 1950s American blood samples finding that celiac disease is about four times as common as it was.[50] Many are adopting gluten-free diets to treat celiac disease-like symptoms in the absence of a positive test for celiac disease.

A 2011 panel of celiac experts concluded that there is a condition related to gluten other than celiac disease and named it "non-celiac gluten sensitivity".[51] however, for those without celiac disease or gluten sensitivity, the diet is unnecessary.[52][53] There are a wide variety of names which have been used in medical literature for gluten-related disorders which are different from celiac disease. Some of them are confusing and ambiguous. "Non-celiac gluten sensitivity" or "non-coeliac gluten sensitivity" is the recommended umbrella term for conditions where symptoms different from celiac disease result from ingestion of gluten.[54]

Despite some advocacy, evidence of the diet's efficacy as an autism treatment is poor.[55] Despite vigorous marketing, a variety of studies, including a study by the University of Rochester, found that the popular autism diet does not demonstrate behavioral improvement and fails to show any genuine benefit to children diagnosed with autism who do not also have a known digestive condition which benefits from a gluten-free diet.[56]

Deficiencies linked to maintaining a gluten-free diet [edit]

Many gluten-free products are not fortified or enriched by such nutrients as folate, iron, and fiber as traditional breads and cereals have been during the last century.[57] Additionally, because gluten-free products are not always available, many Gluten-Sensitive Enteropathy (GSE) patients do not consume the recommended number of grain servings per day. People who change their standard gluten-free diet to implement gluten-free oats at breakfast, high fiber brown rice bread at lunch, and quinoa as a side at dinner have been found to have significant increases in protein (20.6 g versus 11 g), iron (18.4 mg versus 1.4 mg), calcium (182 mg versus 0 mg), and fiber (12.7 g versus 5 g). The B vitamin group did not have significant increases, but were still found to have improved values of thiamine, riboflavin, niacin, and folate.[58] These dietary changes can greatly reduce a GSE patient's risk for anemia (especially Iron Deficiency Anemia) and low blood calcium levels or poor bone health.

Oats can increase intakes of vitamin B1, magnesium, and zinc in celiac disease patients in remission.[59]

See also [edit]

General:

References [edit]

  1. ^ Hischenhuber, C.; Crevel, R.; Jarry, B.; Maki, M.; Moneret-Vautrin, D. A.; Romano, A.; Troncone, R.; Ward, R. (2006). "Review article: safe amounts of gluten for patients with wheat allergy or coeliac disease". Alimentary Pharmacology and Therapeutics 23 (5): 559–575. doi:10.1111/j.1365-2036.2006.02768.x. PMID 16480395.  edit
  2. ^ "Coeliac Disease". National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. 2008. 
  3. ^ Gaesser, G. A.; Angadi, S. S. (2012). "Gluten-Free Diet: Imprudent Dietary Advice for the General Population?". Journal of the Academy of Nutrition and Dietetics 112 (9): 1330–1333. doi:10.1016/j.jand.2012.06.009. PMID 22939437.  edit
  4. ^ Auffret S. (October 18, 2012). "Gluten-free fad not backed by science". Western Farm Press. 
  5. ^ Kenneth Chang (February 4, 2013). "Gluten-Free, Whether You Need It or Not" ("Well" blog by expert journalist). The New York Times. Retrieved February 5, 2013. "The definition is less a diagnosis than a description — someone who does not have celiac, but whose health improves on a gluten-free diet and worsens again if gluten is eaten. It could even be more than one illness." 
  6. ^ N Y Haboubi, S Taylor, S Jones (2006). "Celiac disease and oats: a systematic review". The Fellowship of Postgraduate Medicine. 
  7. ^ "The Gluten-Free Diet" – CeliacSociety.com
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  9. ^ Section 206 of the Food Allergen Labeling and Consumer Protection Act of 2004, Title II of Pub.L. 108–282, 118 Stat. 891, enacted August 2, 2004
  10. ^ 72 F.R. 2795-2817
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  43. ^ "Which alcoholic beverages are safe?" Celiac.com
  44. ^ StaVin Barrel Inserts Inc. [1] Retrieved on 05/18/2009
  45. ^ WSU Extension Manual "A Guide to the Fining of Wine" [2] Retrieved on 3/18/10
  46. ^ Evaluation of residual immunoreactivity in red and white wines clarified with gluten or gluten derivatives [3] Retrieved on 3/18/10
  47. ^ "Is Beer Gluten-Free and Safe for People with Coeliac Disease?". Celiac.com. 2006. 
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  50. ^ http://www.cbsnews.com/8301-504763_162-57483789-10391704/gluten-free-diet-fad-are-celiac-disease-rates-actually-rising/
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  52. ^ http://www.andjrnl.org/article/S2212-2672(12)00743-5/fulltext
  53. ^ http://westernfarmpress.com/management/gluten-free-fad-not-backed-science
  54. ^ Jonas F Ludvigsson; Daniel A Leffler, Julio C Bai, Federico Biagi, Alessio Fasano, Peter H R Green, Marios Hadjivassiliou, Katri Kaukinen, Ciaran P Kelly, Jonathan N Leonard, Knut Erik Aslaksen Lundin, Joseph A Murray, David S Sanders, Marjorie M Walker, Fabiana Zingone, Carolina Ciacci (February 16, 2012). "The Oslo definitions for coeliac disease and related terms". Gut (BMJ and British Society of Gastroenterology) 62 (1): 43–52. doi:10.1136/gutjnl-2011-301346. Retrieved February 5, 2013. "CD was defined as ‘a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals’. Classical CD was defined as ‘CD presenting with signs and symptoms of malabsorption. Diarrhoea, steatorrhoea, weight loss or growth failure is required.’ ‘Gluten-related disorders’ is the suggested umbrella term for all diseases triggered by gluten and the term gluten intolerance should not to be used. Other definitions are presented in the paper." 
  55. ^ Millward C, Ferriter M, Calver S, Connell-Jones G (2008). "Gluten- and casein-free diets for autistic spectrum disorder.". In Ferriter, Michael. Cochrane Database Syst Rev (2): CD003498. doi:10.1002/14651858.CD003498.pub3. PMID 18425890. 
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  58. ^ Lee AR, Ng DL, Dave E, Ciaccio J, Green PHR (2009). "The effect of substituting alternative grains in the diet on the nutritional profile of the gluten-free diet". Journal of Human Nutrition and Dietetics 22 (4): 359–363. doi:10.1111/j.1365-277X.2009.00970.x. PMID 19519750. 
  59. ^ Kemppainen, T. A.; Heikkinen, M. T.; Ristikankare, M. K.; Kosma, V. -M.; Julkunen, R. J. (2009). "Nutrient intakes during diets including unkilned and large amounts of oats in celiac disease". European Journal of Clinical Nutrition 64 (1): 62–67. doi:10.1038/ejcn.2009.113. PMID 19756027.  edit

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