Gluten-free diet

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Meat
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Further information: The oat controversy and Oat sensitivity

A gluten-free diet (GF diet) is a diet that excludes foods containing gluten. Gluten is a protein composite 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] Celiac disease is an autoimmune disease attacking the small intestine due to the presence of gluten.[2][3] Dermatitis herpetiformis (DH) is a form of celiac disease in which gluten causes the immune system to attack the skin; therefore a gluten-free diet is essential. People with these diseases are considered gluten intolerant.[2] There is a minority of people who suffer from wheat intolerance alone and are tolerant to gluten. Gluten sensitivity is another reason people will choose to go gluten-free.[2]

Some people believe that there are health benefits to gluten-free eating for the general population, but there is no published experimental evidence to support such claims.[4][5] A significant demand has developed for gluten-free food in the United States whether it is needed or not.[6] Peter H.R. Green, MD, director of the Celiac Disease Center at Columbia University stated that the gluten-free market is expanding greatly. This expansion is extremely valuable for those with celiac disease or other medical reasons, such as gluten intolerance or sensitivity. However, a gluten-free diet does not hold the same benefits for the general public.

A gluten-free diet might also exclude oats. Medical practitioners are divided on whether oats are acceptable to celiac disease sufferers[7] or whether they become cross-contaminated in milling facilities by other grains.[8] Oats may 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 with the oats.

The exact level at which gluten is harmless for people with celiac disease is uncertain. 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.[9]

Gluten-free food[edit]

Quinoa is a pseudocereal that is gluten-free.

Gluten-free food is normally seen as a diet for celiac disease, but people with a gluten allergy (an unrelated disease) should avoid wheat and related grains. Meat, fish, poultry, fruit, vegetables, potato, and rice are gluten-free foods.

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, almond meal flour, coconut flour, pea flour, cornstarch 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. Despite 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[citation needed] of wheat and buckwheat flours, and thus, not gluten-free. Gram flour, derived from chickpeas, is gluten-free (this is not the same as Graham flour made from wheat).

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.[10][11]

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. Gluten-free bakery and pasta products are available from specialty retailers.

Cross-contamination issues[edit]

A gluten-free diet allows for fruit, vegetables, meat, 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.[12]

The finding of a 2010 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.[13] 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.[14]

There is no general agreement on the analytical method used to measure gluten in ingredients and food products.[15] The ELISA method was designed to detect w-gliadins, but it suffered from the setback that it lacked sensitivity for barley prolamins.[16]

In the processing of gluten-containing grains, gluten is removed as 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,[17] 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 commercial and home food preparation.

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.[18] 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.[19] 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.[20]

Pure chocolate is gluten free but additives with gluten or contamination from the use of machines which previously processed gluten containing food is possible. Several vendors produce chocolate labeled "gluten free".[21]

Some non-foodstuffs such as medications and vitamin supplements, especially those in tablet form, may contain gluten as an excipient or binding agent.[22][23] People with gluten intolerances may therefore require specialist compounding of their medication.[17]

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.

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, unless specifically labeled as corn malt. Many ingredients contain wheat or barley derivatives. Maltodextrin is gluten-free since it is highly modified, no matter what the source.[24]

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 somewhat controversial. Some research suggests that oats in themselves are gluten-free, but 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.

Alcoholic beverages[edit]

Several celiac disease groups report that according to the American Dietetic Association's Manual of Clinical Dietetics,[30][31] 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. While some vineyards use a flour paste to caulk the oak barrels in which wine is aged,[32] tests have shown that no detectable amounts of gluten are present in the wine from those barrels.[33] A small number of vineyards have also used gluten as a clarifying agent, though it is not the standard process; some studies have shown small amounts of gluten to remain in the wine after clarification.[34] Therefore, some people with celiac or strong gluten sensitivity may wish to exercise caution. Liqueurs and pre-mixed drinks should be examined carefully for gluten-derived ingredients.

Almost all beers are brewed with malted barley or wheat will contain gluten. Sorghum and buckwheat-based gluten-free beers are available, but remain a niche market. Some low-gluten beers are available, however, there is disagreement over the use of gluten products in brewed beverages: Some brewers argue that in certain beers the proteins from such grains as barley or wheat are converted into amino acids during the clarification step of the brewing process and are therefore gluten-free,[35] although there is evidence that this protein degradation is only partial.[36] The Swedish government agency Livsmedelsverket carried out a study of the gluten content in a wide range of beers in 2005 and found that the majority of the beers tested contained less than 200 ppm gluten, with several brands containing less than 20 ppm.[37] However, they also found that many beers have extremely high levels of gluten so. If unsure, coeliacs are advised to avoid beer.

Gluten-free bread[edit]

Bread, which is a staple in many 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). 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, guar gum, hydroxypropyl methylcellulose (HPMC), corn starch, or eggs are used to compensate for the lack of gluten.[38]

Regulation[edit]

Regulation of the label gluten-free varies internationally, however the use of gluten free claims is voluntary in most countries.[39]

Most countries derive key provisions of their gluten free labeling regulations from the Codex Alimentarius Standard (“Codex Standard”). Codex Alimentarius began their work on gluten intolerance in 1979, with updates in 1983 and 2008.[40] The Codex Standard reflects thirty years of differences of opinion that exist between countries on the treatment of gluten free labeling.[41] The Codex Standard divides gluten free food into two categories: (1) food that is gluten free by composition and (2) food that has become gluten free through special processing.[42] Both categories of gluten free food must contain 20 ppm or less of gluten.[43] The Codex Standard also recognizes a third category of food, “reduced gluten content,” which includes food products with between 20 ppm and 100 ppm of gluten.[44] Reduced gluten content is left up to individual nations to more specifically define. The Codex Standard suggests the Enzyme-linked Immunoassay (“ELISA”) R5 Mendez Method for indicating the presence of gluten, but allows for other “relevant” methods, such as DNA.[45] The Codex Standard has four additional guidelines to outline the procedures that are acceptable for applying any method.[46] Finally, the Codex Standard specifies that the gluten free claim must appear in the immediate proximity of the name of the product, to ensure visibility.[47]

European Union: Following the 2008 update of the Codex Standard, the European Union (“EU”) adopted its own regulations, substantially based on the Codex Standard.[48] The EU’s Commission Regulation No 41/2009 (“EU Standard”) delineates the categories differently: “gluten free foodstuffs” contain 20 ppm or less of gluten, and “very low gluten foodstuffs” containing 20-100ppm gluten.[49] The EU Standard also provides for special treatment of oats. Acknowledging the high potential of oats to become cross-contaminated, the EU Standard specifies that gluten free oat claims must have been specially produced, prepared and/or processed in a way to avoid cross-contamination.[50]

Canada: Health Canada’s §B.24.018 of the Food and Drug Regulation (“Canadian Standard”) neglects to identify a process for determining the presence of gluten or an acceptable threshold amount, however, they cite to the Codex Standard for further inquiries. One provision of the Canadian Standard that is noteworthy is that they require manufacturers to list a source of gluten.[51]

Australia/New Zealand: Gluten claims are currently regulated in clause 16, Standard 1.2.8 – Nutrition Information Requirements in the Australia New Zealand Food Standards Code (“Australian Standard”).[52] In addition, clause 4, Standard 1.2.3 – Mandatory Warning and Advisory Statements and Declarations requires that cereals containing gluten and their products, namely wheat, rye, barley, oats and spelt and their hybridized strains must be declared on the label if present in a food.[53] Food Standards Australia New Zealand (“FSANZ”) is currently reconsidering their threshold of “no detectable gluten” (5 ppm) citing a lack of manufacturers being willing to meet that standard.

United States: Manufacturers in the United States have been able to use the gluten free claim since 1993, as long as it was not “false or misleading.” Because there was no federal definition until 2013, nothing was false or misleading, which meant anyone could use the gluten free claim with no repercussion. The U.S. first addressed gluten free labeling in the Food Allergen Labeling and Consumer Protection Act of 2004 (“FALCPA”) which provided a mandate to the FDA to define “gluten free” for the voluntary use on labels. Some ten years later, the FDA issued their Final Rule on August 5, 2013.[54] Where a food voluntarily chooses to use a gluten free claim, the food bearing the claim in its labeling may not contain: (1) an ingredient that is a gluten-containing grain; (2) an ingredient that is derived from a gluten-containing grain that has not been processed to remove gluten; or (2) an ingredient that is derived from a gluten-containing grain, that has been processed to remove gluten but results in the presence of 20 ppm or more gluten in the food.[55] Any food product that inherently does not contain gluten may use a gluten free label where any unavoidable presence of gluten in the food bearing the claim in its labeling is below 20 ppm gluten.[56] A food that chooses to bear a gluten free claim and fails to meet the requirements of §§101.91(a)(3) will be deemed misbranded.[57] Similarly, the use of the claims “no gluten,” “free of gluten” or “without gluten” will also be deemed misbranded where they do not meet the requirements of §§(a)(3).[58] Finally, any food product claiming to be gluten free and also bearing the term “wheat” in its ingredient list or in a separate “Contains wheat” statement, must also include the language “*the wheat has been processed to allow this food to meet the FDA requirements for gluten free foods,” in close proximity to the ingredient statement.[59]

Celiac disease and other medical reason[edit]

Celiac disease is the primary reason that one would switch to a gluten-free diet. Celiac disease is an autoimmune disease, affecting between about 0.06 to 1% of all Americans. In patients with celiac disease, gluten causes the immune system to attack the intestinal lining of the small intestine. Over time this then triggers the small intestine to lose the ability to absorb nutrients into the body, such as fiber and vitamins. If gone untreated the lack of nutrients can initiate other health problems that include osteoporosis, iron-deficiency anemia, other autoimmune disorders, extreme fatigue, infertility, neurological problems and, in rare cases, lymphoma of the small intestine. Symptoms rarely occur, but if they do, they include diarrhea, anemia, bone pain, and a severe skin rash called dermatitis herpetiformis. Because of the lack of symptoms, it is believed only five to ten percent of people with celiac disease are diagnosed.[2][3]

Dermatitis herpetiformis (DH) is a type of celiac disease that causes the immune system to attack the skin rather than the small intestine. When it attacks the skin it produces inflammation, irritation, redness. This creates a chronic itchy and bumpy rash to appear. Typically, this appears after the intake of gluten. People with DH are advised to adhere to a gluten-free diet.[2]

Gluten sensitivity is the inability and trouble for a person to metabolize gluten. This results in digestive distress, which can cause symptoms such as diarrhea, gas, bloating, constipation, and bowel discomfort. These digestive symptoms occur after the intake of gluten. Gluten sensitivity is far less severe and does not appear to have any long term effects. A reduced-gluten or gluten-free diet is suggested to prevent the discomfort.[2][3]

Popularity and nonceliac health effects[edit]

Gluten-free fad diets have become popular. This may be because celiac disease was under diagnosed or because people are unnecessarily turning to the diet as a food fad. There 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 more common now as it was then.[60] Many are adopting gluten-free diets to treat celiac disease-like symptoms in the absence of a positive test for celiac disease.

The existence of gluten sensitivity in non-celiac individuals remains contentious. A double-blind experiment conducted in 2013 concluded that non-celiac gluten sensitivity does not exist, and that the symptoms are caused by the nocebo effect.[61] However, a prior, less rigorous, study in 2011 by the same authors concluded that there is a condition related to gluten other than celiac disease that was named "non-celiac gluten sensitivity".[62] In either case, for those without celiac disease or gluten sensitivity, the diet may be unnecessary.[63][64] 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" is the recommended umbrella term for conditions where symptoms different from celiac disease result from ingestion of gluten.[65]

Despite some advocacy, evidence of the diet's efficacy as an autism treatment is poor.[66] 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.[67]

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.[68] 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.[69] 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.[70]

Selenium deficiency in gluten-free diet, combined with malabsorption of selenium in patients with uncontrolled celiac disease is considered a direct factor in the development of comorbid autoimmune thyroid diseases for celiac patients.[71][72]

See also[edit]

References[edit]

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  32. ^ StaVin Barrel Inserts Inc. [1] Retrieved May 18, 2009
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  39. ^ In the United Kingdom, only cereals currently need to be labeled regarding gluten, while other products are voluntary.
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  41. ^ Id.
  42. ^ Codex Standard 118-1979
  43. ^ Id.
  44. ^ Id.
  45. ^ Id.
  46. ^ Id.
  47. ^ Id.
  48. ^ McCabe, supra note 40, at 375.
  49. ^ Id.
  50. ^ Id.
  51. ^ §B.24.018 of the Food and Drug Regulation
  52. ^ Australia New Zealand Food Standard Code, 1.2.8 (2003).
  53. ^ Id. at 1.2.3.
  54. ^ 21 C.F.R. §101.
  55. ^ Id. at §101(a)(3)(A).
  56. ^ Id. at §101(a)(3)(B).
  57. ^ Id. at §101(b)(1).
  58. ^ Id. at §101(b)(2).
  59. ^ Id. at §101(b)(3).
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  61. ^ http://www.gastrojournal.org/article/S0016-5085(13)00702-6/abstract
  62. ^ Gluten-Free, Whether You Need It or Not. New York Times.
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  65. ^ 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." 
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External links[edit]