The Gluten-Free Diet and The Prevention of Cross-Contamination Medical Program Version

1. Celiac Disease The Gluten-Free DietandThe Prevention of Cross-ContaminationMedical Program Version www.calgaryceliac.com

2. 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. www.calgaryceliac.com

3. 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. www.calgaryceliac.com

4. 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. www.calgaryceliac.com

5. 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 www.calgaryceliac.com

6. 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 www.calgaryceliac.com

7. 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 www.calgaryceliac.com

8. 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 • Addison’s disease • Epilepsy • Sarcoidosis • Sjogren’s disease • Systemic lupus erythematosus • Turner’s syndrome, Williams syndrome, Down syndrome www.calgaryceliac.com

9. The Nature of Celiac Disease • When left untreated, CD can result in other disorders, including: • Nervous system disorders • Internal hemorrhaging • Intestinal lymphoma (non-Hodgkin’s) • Anemia • Osteoporosis • Vitamin and mineral deficiencies • Pancreatitis • Tooth enamel defects www.calgaryceliac.com

10. The Nature of Celiac Disease • Celiac Disease is often misdiagnosed as other common ailments, including: • Allergies • Anemia • Crohn’s disease/colitis • Diverticulosis/spastic colon • Gall bladder disease • Irritable bowel syndrome • Chronic fatigue syndrome • Lactose intolerance • Stress/depression/emotional disturbances • Viral gastroenteritis www.calgaryceliac.com

11. 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. www.calgaryceliac.com

12. GeneticProperties • 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. www.calgaryceliac.com

13. 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. www.calgaryceliac.com

14. 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. www.calgaryceliac.com

15. 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. www.calgaryceliac.com

16. What Happens When We’reGlutened? • 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. www.calgaryceliac.com

17. What Happens When We’re 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. www.calgaryceliac.com

18. What Happens When We’re Glutened? The progression of damage to the villi www.calgaryceliac.com

19. What Happens When We’re Glutened? www.calgaryceliac.com

20. What Happens When We’re Glutened? DH on the abdomen www.calgaryceliac.com

21. What Happens When We’re Glutened? DH on the elbow DH on the knee www.calgaryceliac.com

22. Major Concerns • Increase Awareness • Safe Ingredients • Hidden Sources of Gluten • CROSS CONTAMINATION www.calgaryceliac.com

23. What is Gluten ? • Gluten refers to several different cereal grain storage proteins, or prolamins. • Gliadin in wheat • Secalin in rye • Hordein in barley www.calgaryceliac.com

24. 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 www.calgaryceliac.com

25. 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 www.calgaryceliac.com

26. 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 www.calgaryceliac.com

27. 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 www.calgaryceliac.com

28. 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. www.calgaryceliac.com

29. 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. www.calgaryceliac.com

30. 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. www.calgaryceliac.com

31. 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. www.calgaryceliac.com

32. 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 www.calgaryceliac.com

33. 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. www.calgaryceliac.com

34. 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. www.calgaryceliac.com

35. 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. www.calgaryceliac.com

36. 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. www.calgaryceliac.com

37. 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@telusplanet.net www.calgaryceliac.com