Celiac Disease

WHAT IS CELIAC DISEASE?

It is a condition in which the body’s immune system reacts to gluten. Gluten is a protein found in foods made with: wheat, barley, rye, as well as oats*. Eating foods containing gluten damages the lining of the small intestine and makes it flat which means it becomes harder to absorb nutrients from food.

Celiac disease is not an allergy or intolerance.

*Even though oats are naturally gluten-free they are often processed in the same gluten-containing foods which makes them contaminated and not safe for patients who have celiac disease.

WHAT ARE THE SYMPTOMS OF HAVING CELIAC DISEASE?

If I have celiac disease, I may experience some or all of the following:

• Diarrhea
• Stomach pain
• Fatigue
• Joint pain
• Weight loss
• Itchy skin rash (dermatitis herpetiformis)

Note that not all patients with celiac disease will experience symptoms. Some people with silent celiac disease experience no obvious symptoms.

HOW DO I GET DIAGNOSED?

Normally this is done in two steps:

SCREENING

Several blood tests screen for celiac disease antibodies. tTG-IgA test is one of the most common. To ensure accurate results, gluten should be consumed regularly before the test as avoiding gluten may make the test appear falsely normal.

DIAGNOSIS

If the blood test shows that you likely have celiac disease, the doctor will recommend a biopsy of the small intestine to confirm the disease. This is done with an upper endoscopy. Biopsies are taken from the small intestine and are then studied to see if there is any existing damage in the lining of the small intestine. A biopsy is the only way to confirm the disease 100%.

HOW DO I MANAGE THIS DISEASE?

The only way to treat celiac disease is by following a strict, lifelong gluten-free diet. Following a gluten free diet lifelong allows the bowel lining to heal, resolve nutrient malabsorption, as well as avoid further complications.

GLUTEN-FREE DIET

WHAT IS GLUTEN?

Gluten is a protein found in wheat, rye and barley that causes intestinal damage (often resulting in weight loss and nutrient deficiencies) for individuals with celiac disease. Common symptoms of celiac disease include: diarrhea, abdominal pain, bloating, fatigue, forgetfulness and irritability.

WHAT DO YOU OR YOUR CHILD NEED TO FOLLOW A GLUTEN-FREE DIET?

The gluten free diet is used in the treatment of celiac disease and dermatitis herpetiformis. Although a gluten free diet does not cure celiac disease and dermatitis herpetiformis, following the diet will relieve the symptoms associated with gluten sensitivity and allow the intestinal lining to heal.

HOW DO I KNOW WHAT FOODS CONTAIN GLUTEN?

• To find out what foods contain gluten it is important to read food labels. Products change frequently so check the label carefully before purchasing. Contact the manufacturer if more information on ingredients is needed.
• Oats do not naturally contain gluten, but they are often contaminated with wheat or other grains and may need to be avoided.
• Avoid products with any of the following ingredients on the label:
  • WHEAT: includes items made or processed with flour; various parts of the wheat kernel (including the germ, bran and endosperm [starch]); and grain species derived from prohibited grains (for example: triticale is a hybrid of wheat and rye).
  • BARLEY: includes all parts of the barley grain and items produced from barley (such as malt flavorings, brown rice syrup, brewer’s yeast and beer).
  • RYE: includes all parts of the rye grain, usually found in our food supply as rye flour and rye bread. Unlike wheat and barley, rye is typically not used as a food additive.
  • OATS: includes all products containing oats (including oat flour, oat bran and oat gums). There are sources of uncontaminated oats available; talk with your dietitian or gastroenterologist about how to introduce oats safely.

WHAT ARE THE RISKS IF I DO NOT FOLLOW A GLUTEN-FREE DIET?

1. Damage of the small intestine due to gluten ingestion and malabsorption consequences which include:

• Iron deficiency anemia.
• Osteoporosis.
• Weight loss.
• Other vitamin and mineral deficiencies.

2. Other complications that can be related to untreated celiac disease:

• Infertility.
• Gastrointestinal cancers.
• Altered mental state.
• Reduced bone mineral density.

EATING HEALTHY ON GLUTEN-FREE DIET

I need to have sufficient amounts of B-vitamins (thiamin, riboflavin, niacin, and folate), iron, calcium and fiber in my diet.

• Choose enriched, and whole grain gluten-free products over refined grain gluten-free, for example: choosing whole grain corn or whole grain rice over the others.
• Eat plant foods such as: amaranth, quinoa, and buckwheat since they are good sources of B-vitamins, iron and fiber.
• Eating nongrain sources that are rich in B-vitamins such as: o For thiamine: legumes (dry beans, peas, lentils), nuts, and fish.

• For riboflavin: Dairy products, legumes, nuts, green leafy vegetables, and mushrooms.
• For niacin: Eat poultry, fish, lean cuts of fresh pork, legumes, and seeds. o For folate: Choose legumes, green leafy vegetables, and fruit juices.
• For niacin: Eat poultry, fish, lean cuts of fresh pork, legumes, and seeds.
• For folate: Choose legumes, green leafy vegetables, and fruit juices.

• I can get iron from: lean meat, poultry, seafood, legumes, dried fruits, green leafy vegetables, nuts, and seeds.
• I can get fiber from: all plants foods; fruits, vegetables, legumes, seeds, gluten-free whole grains, and nuts.
• I can get calcium from dark green leafy vegetables and plain dairy (plain milk, natural yoghurts and unprocessed cheese).
• I might have to consider taking a gluten-free (calcium, folate, iron, B-12, Vit.D, Vit.K, and zinc) supplement if needed.

THE IMPORTANCE OF CALCIUM WHEN HAVING CELIAC DISEASE:

As calcium is important for bone health, it is important to make sure that I am getting sufficient amounts of calcium if I have celiac disease. Osteoporosis is linked with celiac disease because of the fact that this disease damages the lining of the small intestine which makes it hard to absorb nutrients including calcium.

WHAT SHOULD I DO?

Patients with celiac disease should have at least 1,000 milligrams (mg) of calcium each day. Which can be reached easily by having:

• Dairy sources: milk, yoghurt and cheese.
• Non-dairy sources: dried fruit, nuts, beans and green vegetables. Note: don’t forget to check that the sources of calcium are also gluten-free.

COMMON PROCESSED FOODS CONTAINING WHEAT, BARELY OR RYE
Stock Cubes e.g. Maggi	Matzo
Sweeteners	Seasoned rice mixes
Candy	Soy sauce and marinades
Cold cuts, hot dogs, sausages, salami	Seasoned tortilla/potato chips
French fries	Self-basting turkey
Gravies and sauces	Soups and soup bases
Imitation fish and imitation bacon	Trail mixes
Malted Products	Panko (Japanese bread crumbs)
Cereals (including rice and soy varieties)	Energy bars and supplements
Meat and dairy substitutes	Flavored beverages

MISCELLANEOUS INGREDIENTS ON FOOD LABELS
Wheat starch	Natural and artificial flavorings
Seasonings	Hydrolyzed vegetable protein (HVP)
Emulsifiers	Textured vegetable proteins (TVP)
Stabilizers	Hydrolyzed plant protein (HPP)
Starch	Cereal Extracts
Caramel Coloring	Dextrins

Example(s) of the wheat allergy statement:

1. INGREDIENTS: Water, skim milk, hydrolyzed vegetable protein, salt, potassium sorbate (preservative). Contains wheat, milk, soy.
2. INGREDIENTS: Semolina (wheat), egg whites, ground flaxseed, durum flour (wheat), niacin, thiamine.

A FEW THINGS TO CONSIDER WHEN SHOPPING FOR A GLUTEN-FREE DIET

• There is no reliable food labelling in the UAE, so please check product labels very carefully.
• There isn’t always a separated Gluten-free section, so products will be mixed in with general items.
• Any flavorings, no matter how small, are subject to the wheat disclaimer.
• Though unlikely, flavorings may be made with malt flavoring (which is not covered by the wheat disclaimer because it is made from barley).
• Caramel coloring and dextrins are not typically made from wheat, but should now contain a wheat disclaimer if they are made using the grain.
• Many products containing starches (if made in North America) are likely made from corn. Modified food starch, though unlikely, could be made from barley (which is not covered by the labeling law).
• When in doubt contact the product’s manufacturer. There have been cases in which companies have not yet changed food labels.

Some imported products will easily be identified as gluten-free by having a logo that looks like the following:

CROSS-CONTAMINATION

• Cross contamination can occur in the factory, restaurants or even at home if gluten-free foods came in contact with gluten.
• To avoid cross contamination, I should be aware of crumbs of gluten-containing foods and make sure they don’t touch my gluten-free food.
• I should make sure I have my own seasoning containers such as: jam, peanut butter, spread cheese, or any seasoning that may come in contact with bread.
• I have to make sure during food preparation that all gluten-free food should be touched only by clean utensils that have not touched gluten before.
• Labelling utensils or colour coding them at home would be helpful to separate gluten and gluten-free equipment from each other.
• I have to clean gluten and gluten-free utensils separately if I use a dishwasher.

EATING OUT

• I should inform the waiter/host that I can’t eat anything that contains gluten.
• If I am eating at a restaurant, I should ask the waiter which items from the menu are gluten-free.
• Even if the food appears gluten free I should double check with the waiter that the food was prepared and cooked separately from gluten-containing foods.

TRAVELLING

• It is important to pack gluten-free snacks for emergency.
• While booking a ticket at any airlines, I should inform them that I need a gluten-free diet.
• Most four and five star hotels are aware of celiac disease and the gluten free diet and should be able to provide the needed diet as long as they are informed.
• It is a good idea to check if the hotel can provide gluten-free food before booking.
• Checking the approved labelling of the glute-free products in the country I am traveling to is very important.
• Making sure that I know how to say/write (Gluten-free diet) using the language of the country that I will travel to will make things easier when I travel.