Celiac Disease The Gluten-Free Diet and The Prevention of Cross-Contamination Medical Program Version Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

It was once thought that CD had classic symptoms only, including: 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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

There are additional symptoms in children, including: 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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

Celiac Disease is a true autoimmune disease. 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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

STRICT GLUTEN-FREE DIET FOR LIFE 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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

What Happens When We’re 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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

What Happens When We’re Glutened? The progression of damage to the villi Avoiding Gluten and Cross Contamination www.calgaryceliac.com

What Happens When We’re Glutened? Avoiding Gluten and Cross Contamination www.calgaryceliac.com

What Happens When We’re Glutened? DH on the abdomen Avoiding Gluten and Cross Contamination www.calgaryceliac.com

What Happens When We’re Glutened? DH on the elbow DH on the knee Avoiding Gluten and Cross Contamination www.calgaryceliac.com

Hidden Sources of Gluten CROSS CONTAMINATION Major Concerns Increase Awareness Safe Ingredients Hidden Sources of Gluten CROSS CONTAMINATION Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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

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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

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. Avoiding Gluten and Cross Contamination www.calgaryceliac.com

Our website: www.calgaryceliac.com National website: www.celiac.ca 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 Avoiding Gluten and Cross Contamination www.calgaryceliac.com