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Suggest Gluten Free Diet For A Person Suffering From Celiac Disease

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Posted on Mon, 4 Jul 2016
Question: I work at a transitional correctional facility. I am not a Registered Dietitian , however, I am a Certified Dietary Manager. We have 2 client here who requires a gluten free diet due to celiac disease. Is it possible to obtain a gluten free meal plan 0000000?


doctor
Answered by Kathy Shattler (1 hour later)
Brief Answer:
How Sweet of You! (This answer is copy write protected)

Detailed Answer:
Yes, I can get gluten free guidelines to you.

Let me first try to paste them here:

•     You have sensitivity to gluten, which are proteins found in wheat, barley, and rye.
•     Gluten-free nutrition therapy will allow your intestine to heal.
•     It also will help prevent complications like bone disease that can happen if celiac disease goes untreated.
Oats
•     In the past, oats were believed to be harmful to persons with celiac disease.
•     If you would like to eat gluten-free oats, you should discuss their use with your physician and dietitian.
•     Manufacturers of gluten-free oats include Cream Hill Estates, Only Oats, Gluten-Free Oats, Bob’s Red Mill, and Gifts of Nature.
Foods Recommended
The following are examples of the many grains and plant foods that you can safely eat:
•     Amaranth
•     Arrowroot
•     Buckwheat
•     Cassava (manioc)
•     Corn
•     Flax
• XXXXXXX rice grass (Montina)
•     Job’s tears
•     Legumes (dry beans, peas, lentils)
•     Millet
•     Finger millet (Ragi)
•     Nuts
•     Potatoes
•     Quinoa
•     Rice
•     Sago
•     Seeds
•     Sorghum
•     Soy
•     Tapioca
•     Tef (or teff)
•     Wild rice
•     Yucca
You may not be familiar with some of these grains and plant foods. However, they are used in gluten-free foods, and you will often find them in food ingredient lists for gluten-free products.
Foods Not Recommended
Do not eat any foods containing any of the following ingredients:
•     Wheat (all types, including einkorn, emmer, spelt, and kamut)
•     Barley
•     Rye
•     Malt
•     Oats (unless they are gluten-free)
These ingredients are found in many food products, including flours, bread products, pasta, breakfast cereals, cakes, and cookies.
Gluten-Free Sample 1-Day Menu View Nutrient Info
Breakfast     2 cups rice cereal
1/2 cup orange juice
1 cup low-fat milk
Lunch     2 oz taco meat, seasoned with chili powder
2 corn taco shells
1 cup lettuce
1/2 cup diced tomato
2 tablespoons shredded cheese
1 apple
1 cup low-fat milk
Afternoon Snack     1 oz string cheese
3 cups plain microwave popcorn
Evening Meal     2 oz chicken, stir-fried
1 cup vegetables, stir-fried
1 teaspoon oil
1/2 cup plain brown rice
1/2 cup mandarin oranges
1 cup water
Evening Snack     1/2 cup vanilla ice cream
2 tablespoons plain peanuts

Gluten-free: To avoid confusion, it is important to clarify the use of the term"gluten-free" to describe the nutrition prescription of persons with celiac disease. In this context, "gluten-free" is used as a general term to denote a nutrition prescription that does not contain prolamins from wheat, barley, or rye. Technically, however, gluten is found only in wheat and is composed in part of the prolamin gliadin (Kasarda, 1996, Skerritt, 1990).

Damage to the small intestinal mucosa may result in varying degrees of malabsorption. There may be deficiencies of vitamins and minerals, including the following:

Calcium
Vitamin D
Iron
Folate (Farrell, 2002)

Consequently, anemia and bone disease may be presenting features in celiac disease (Murray, 1999). Newly diagnosed patients may be prescribed vitamin and mineral supplements to correct any existing nutrient deficiencies. Because of reduced levels of the enzyme lactase, a (usually) temporary form of lactose intolerance also may affect some persons newly diagnosed with celiac disease (Grefte, 1988). These patients generally are advised to follow a lactose-free or lactose-reduced nutrition prescription while their intestine heals and the lactose intolerance naturally resolves. Vitamin D and calcium intakes should be carefully monitored in these patients.

utrition counseling should enable patients with celiac disease to do the following:

Define the gluten-free nutrition prescription and list the grains that must be avoided (eg, wheat, barley, rye, triticale)

List common foods that contain wheat, barley, and rye (eg, bread and bread products, pasta, breakfast cereals)

List grains that are allowed in a gluten-free nutrition prescription (eg, rice, corn, amaranth, buckwheat, quinoa, millet, sorghum)

Read a food label and know how to identify sources of gluten (eg, malt)

Identify places where specially formulated, gluten-free products can be purchased (eg, mail-order companies, health food stores, some supermarkets)
Plan healthful, gluten-free meals at home

Identify the nutritional risks of the gluten-free nutrition prescription and steps that can be taken to ensure a healthful meal plan

Explain cross-contamination and steps to take at home to avoid contaminating gluten-free foods with wheat, barley, or rye

Identfy nonfood items that may be sources of gluten, such as supplements and medications
Know where to look for additional reputable information on celiac disease (eg, support

Persons with celiac disease may suffer from gastrointestinal symptoms for many years before being diagnosed with celiac disease. As a result, some individuals may experience an aversion to food in general or to specific foods they associate with symptoms. They may need support as they relearn to eat a varied meal plan. Individuals may avoid the following:

Milk products
Fiber-rich foods
Gluten-free grains

The gluten-free nutrition prescription can be nutritionally adequate. However, registered dietitians should carefully monitor patient intake of the following nutrients:

B-vitamins
Iron
Fiber
Calcium

The following are grains to avoid in a gluten-free nutrition prescription:

Wheat
All varieties, including einkorn, emmer, spelt, and kamut
All forms, including wheat starch, wheat XXXXXXX wheat germ, cracked wheat, and hydrolyzed wheat protein
Barley
Rye
Cross-bred varieties, such as triticale (a cross between wheat and rye)
1The FDA is proposing that a food containing wheat starch may be labeled gluten-free if the final food product contains less than 20 ppm gluten.

To read the entire FDA proposed rule on gluten-free food labeling, click here.

Grains to Include
Following are grains and plant foods to include in a gluten-free nutrition prescription:

Rice
Corn
Amaranth
Quinoa
Teff (or Tef)
Millet
Finger Millet (Ragi)
Sorghum XXXXXXX Rice Grass (Montina)
Arrowroot
Buckwheat
Flax
Job’s Tears
Sago
Potato
Soy
Legumes XXXXXXX
Tapioca
Wild rice
Cassava (Manioc)
Yucca
Nuts
Seeds
Oats

Findings from in vivo research on the safety of oats suggest that most persons with celiac disease and dermatitis herpetiformis can safely consume moderate amounts of uncontaminated oats without adversely affecting the intestinal mucosa (Janatuinen, 1995, XXXXXXX 1996, Hardman, 1997, Reunala, 2000, Janatuinen, 2000, Hoffenberg, 2000, Janatuinen, 2002, Storsrud, 2003, Hogberg, 2004, Holm, 2006). However, limited evidence suggests that in some persons with celiac disease, the consumption of uncontaminated oats may result in mucosal inflammation (Lundin, 2003, Peraaho, 2004, Arentz-Hansen, 2004).

Concerns also remain that even if the oat prolamin avenin is not harmful, oats nonetheless may be contaminated with wheat or barley. Because oats are frequently grown in rotation with wheat and other grains, they may be contaminated with foreign grain when they arrive at the mill (McCann's Irish Oatmeal, La Crosse Milling Company). In an assessment of gluten contamination of commercial oat products available in the United States, oats were found to contain from less than 3 ppm gluten to 1,807 ppm gluten (Thompson, 2004). To put this amount in context, the Codex Draft Revised Standard for Foods for Special Dietary Use for Persons Intolerant to Gluten states that foods labeled as gluten-free may contain no more than 20 ppm gluten (Codex, 2007). For more information on Codex guidelines, see the wheat starch section.

Efforts are being made by some companies in North XXXXXXX (Gluten Free Oats, Cream Hill Estates, Only Oats, Gifts of Nature, Bob's Red Mill) to produce oats free of substantial gluten contamination through carefully monitored growing, harvesting, and processing procedures. The FDA is proposing to allow oat products to qualify for a gluten-free label as long as the final food product contains less than 20 ppm gluten (FDA, 2007).

Patients consuming oats should be advised to limit consumption to amounts found safe in several studies (ie, approximately 50 g dry oats) (Thompson, 2003) and only consume those oats that have been tested and found to be gluten free. In addition, it may be prudent for patients to add oats to their diet after they are stabilized on a gluten-free diet. It also is important to closely monitor all patients who choose to consume oats, keeping in mind that gastrointestinal symptoms experienced while consuming oats may be due to fiber content.

For more information on oats, see the Celiac Disease/Gluten Intolerance topic at ADA's Evidence Analysis Library (www.adaevidencelibrary.com)

Wheat Starch
Historically, in the United States, a nutrition prescription that is naturally gluten free (ie, based on grains such as rice and corn) has been prescribed for persons with celiac disease. This nutrition prescription differs slightly from what is prescribed in other parts of the world, including Scandinavia and the United Kingdom. In these countries, foods containing wheat, barley, or rye that have been rendered gluten free may be included in a gluten-free nutrition prescription even though they may contain small amounts of gliadin and other harmful prolamins. These foods, such as wheat starch, have been specially formulated to comply with Codex standards for gluten-free foods (Codex, 2006).

The discrepancy in the use of foods rendered gluten free exists in part because it is unknown what daily amount of gliadin and other harmful prolamins may be consumed by persons with celiac disease without damaging the mucosa of the small intestine. Whereas some experts on celiac disease believe that only naturally gluten-free foods should be consumed, others believe that the small amount of gliadin present in foods rendered gluten free is safe (Thompson, 2001b). In the United States, manufacturers of gluten-free foods currently do not use wheat starch in their products.

However, the use of wheat starch in gluten-free diets in the United States may be changing. The US Food and Drug Administration is proposing that foods containing wheat starch may qualify for gluten-free labeling as long as the final food product contains less than 20 ppm gluten (FDA, 2007).

Clarification of terms:

Naturally gluten free: Foods composed of ingredients that do not naturally contain prolamins from wheat, barley, rye, oats, or their derivatives. Examples include corn, rice, amaranth, and quinoa.
Rendered gluten free: Foods composed of ingredients that contain prolamins from wheat, barley, rye, oats, or their derivatives, but comply with Codex standards for gluten-free foods. Codex wheat starch is an example of such a food.
Codex standards for gluten-free foods: Codex standards are developed by the Codex Alimentarius Commission, a program jointly run by the World Health Organization (WHO) and the Food and Agricultural Organization (FAO) of the United Nations. The purpose of the commission is to develop universal food laws and internationally agreed upon standards to protect the health of consumers (FAO/WHO Food Standards Codex Alimentarius).
Based on the Codex Draft Revised Standard for Foods for Special Dietary Use for Persons Intolerant to Gluten, foods labeled "gluten free" may not contain more than 20 ppm gluten (Codex, 2007).

Foods and Ingredients Derived from Barley
According to the U.S. Food and Drug Administration's Code of Federal Regulations and Compliance Policy Guide, the following foods and ingredients generally are derived from barley:

Beer, ale, XXXXXXX stout, and other such fermented beverages (27CFR25.11). Note: Pure distilled alcoholic beverages (eg, gin, vodka) may be included in a gluten-free nutrition prescription. Although these beverages may be derived from a gluten-containing grain, the process of distillation should prevent any protein from remaining in the final distillate.
Malt (21CFR184.1443a).
Malt syrup/malt extract (CPG 7105.02). Note: If a malted grain other than barley is used to make malt syrup or extract, it should be declared on the label (eg, extract of malted corn).
Malt beverages (41CFR101-48.001-6).
Malted milk (CPG 7106.01).
Malt vinegar (CPG 7109.22). Note: Non-malt vinegar, including cider vinegar, wine vinegar, and distilled vinegar, are gluten free.
1Gluten-free beers are available.

Other Terms for Wheat
According to the U.S. Food and Drug Administration's (FDA) Code of Federal Regulations (21CFR137), the following terms, when used on a food label or ingredient list, indicate the presence of wheat:

Flour
White flour
Plain flour
Bromated flour
Enriched flour
Phosphated flour
Self-rising flour
Durum flour
Farina
Semolina XXXXXXX flour
Under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), if a food or an ingredient contains wheat or protein derived from wheat, the word "wheat" must be clearly stated on the food label. This means that if the common or usual name of an ingredient that is or contains wheat does not include the word "wheat" in its name (eg, semolina) and wheat is not included elsewhere in the ingredient list, then the word "wheat" must be included on the food label either parenthetically immediately after the ingredient's name (eg, semolina [wheat]) or in a separate "Contains" statement. All packaged food products regulated by the FDA that are labeled on or after January 1, 2006, must be in compliance with FALCPA allergen labeling requirements.

Ingredients Derived from Wheat
According to the U.S. Food and Drug Administration's (FDA) Code of Federal Regulations and Compliance Policy Guide, dextrin (21CFR184.1277) and caramel color (21CRF73.85), as well as modified food starch and maltodextrin, may be derived from wheat. However, under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), if a food or an ingredient contains protein derived from wheat, the word "wheat" must be clearly stated on the food label. This means that if an ingredient such as dextrin, caramel color, maltodextrin, or modified food starch found in a food product contains protein derived from wheat, the word "wheat" must be included on the food label either in the ingredient list or in a separate "Contains" statement. This applies to flavorings, colorings, and incidental additives as well. In addition, if a spice blend or seasoning mix contains wheat, it must be declared on the food label. All packaged food products regulated by the FDA that are labeled on or after January 1, 2006, must be in compliance with FALCPA allergen labeling requirements.

At the present time, food products regulated by the US Department of Agriculture (USDA) (meat products, poultry products, and egg products) are only required to list ingredients by their common or usual name. Therefore, in a USDA-regulated food product, ingredients such as modified food starch, dextrin, maltodextrin, and caramel color may be derived from wheat and not be stated on the food label. If these ingredients are made in the United States, they are most likely derived from corn

Processed Foods That May Contain Wheat, Barley, or Rye
Examples of processed foods that may contain wheat, barley, or rye include the following:

Bouillon cubes
Brown rice syrup
Candy
Cold cuts, hot dogs, salami, sausage
Communion wafers1
French fries
Gravy
Imitation fish
Licorice
Matzo2
Rice mixes
Sauces
Seasoned snack foods (eg, tortilla chips, potato chips)
Seitan
Self-basting turkey
Soups
Soy sauce
Vegetables in sauce

1. Communion wafers are generally made from wheat, although some manufacturers of gluten-free foods (eg, Ener-G Foods, http://www.ener-g.com/) make gluten-free wafers for use by persons with celiac disease. However, the official position of the Catholic Church is that gluten-free hosts may not be used to celebrate the Eucharist. Catholics with celiac disease have been encouraged to take Communion in the form of wine only. The Congregation of Benedictine Sisters of Perpetual Adoration has developed a low-gluten Communion wafer that conforms to Canon law. For ordering information, contact the Benedictine Sisters at 800/223-2772 or go to the Web site at http://www.benedictinesisters.org/.

2. Matzo and matzo meal are made from wheat, although Shemura oat matzos are produced in England by Rabbi E. Kestenbaum for use by persons with celiac disease. For more information, contact Rabbi Kestenbaum at +44-208-455-9476 or go to the Web site at http://www.glutenfreeoatmatzos.com.

Supplements and Pharmaceuticals
Supplements and pharmaceuticals may contain fillers made from wheat or barley (Crowe, 2001). As a result, it is important to clarify the gluten-free status of all supplements and medications a patient is taking. An excellent article on pharmaceuticals and gluten by pharmacist XXXXXXX Plogsted—Medications and Celiac Disease--Tips from a Pharmacist.

In addition to conventional food, the Food Allergen Labeling and Consumer Protection Act of 2004 also applies to dietary supplements, infant formulas, and medical foods. This means that if one of these products contains wheat or protein derived from wheat, the word "wheat" must be clearly stated on the label. This applies to flavoring and coloring ingredients, as well as incidental ingredients.

In included the patient education sheet in the first part of the paste, and important issues for the RD educational piece in the lower half.

I do hope this is enough to give you a quick course in gluten free diets.

Healthy Regards, XXXXXXX

Oh, and if you need clarification, write back. Otherwise if this is all you need, please close and rate the question. Thanks!

Above answer was peer-reviewed by : Dr. Arnab Banerjee
doctor
Answered by
Kathy
Kathy Shattler

Dietitian & Nutritionist

Practicing since :1985

Answered : 901 Questions

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Suggest Gluten Free Diet For A Person Suffering From Celiac Disease

Brief Answer: How Sweet of You! (This answer is copy write protected) Detailed Answer: Yes, I can get gluten free guidelines to you. Let me first try to paste them here: • You have sensitivity to gluten, which are proteins found in wheat, barley, and rye. • Gluten-free nutrition therapy will allow your intestine to heal. • It also will help prevent complications like bone disease that can happen if celiac disease goes untreated. Oats • In the past, oats were believed to be harmful to persons with celiac disease. • If you would like to eat gluten-free oats, you should discuss their use with your physician and dietitian. • Manufacturers of gluten-free oats include Cream Hill Estates, Only Oats, Gluten-Free Oats, Bob’s Red Mill, and Gifts of Nature. Foods Recommended The following are examples of the many grains and plant foods that you can safely eat: • Amaranth • Arrowroot • Buckwheat • Cassava (manioc) • Corn • Flax • XXXXXXX rice grass (Montina) • Job’s tears • Legumes (dry beans, peas, lentils) • Millet • Finger millet (Ragi) • Nuts • Potatoes • Quinoa • Rice • Sago • Seeds • Sorghum • Soy • Tapioca • Tef (or teff) • Wild rice • Yucca You may not be familiar with some of these grains and plant foods. However, they are used in gluten-free foods, and you will often find them in food ingredient lists for gluten-free products. Foods Not Recommended Do not eat any foods containing any of the following ingredients: • Wheat (all types, including einkorn, emmer, spelt, and kamut) • Barley • Rye • Malt • Oats (unless they are gluten-free) These ingredients are found in many food products, including flours, bread products, pasta, breakfast cereals, cakes, and cookies. Gluten-Free Sample 1-Day Menu View Nutrient Info Breakfast 2 cups rice cereal 1/2 cup orange juice 1 cup low-fat milk Lunch 2 oz taco meat, seasoned with chili powder 2 corn taco shells 1 cup lettuce 1/2 cup diced tomato 2 tablespoons shredded cheese 1 apple 1 cup low-fat milk Afternoon Snack 1 oz string cheese 3 cups plain microwave popcorn Evening Meal 2 oz chicken, stir-fried 1 cup vegetables, stir-fried 1 teaspoon oil 1/2 cup plain brown rice 1/2 cup mandarin oranges 1 cup water Evening Snack 1/2 cup vanilla ice cream 2 tablespoons plain peanuts Gluten-free: To avoid confusion, it is important to clarify the use of the term"gluten-free" to describe the nutrition prescription of persons with celiac disease. In this context, "gluten-free" is used as a general term to denote a nutrition prescription that does not contain prolamins from wheat, barley, or rye. Technically, however, gluten is found only in wheat and is composed in part of the prolamin gliadin (Kasarda, 1996, Skerritt, 1990). Damage to the small intestinal mucosa may result in varying degrees of malabsorption. There may be deficiencies of vitamins and minerals, including the following: Calcium Vitamin D Iron Folate (Farrell, 2002) Consequently, anemia and bone disease may be presenting features in celiac disease (Murray, 1999). Newly diagnosed patients may be prescribed vitamin and mineral supplements to correct any existing nutrient deficiencies. Because of reduced levels of the enzyme lactase, a (usually) temporary form of lactose intolerance also may affect some persons newly diagnosed with celiac disease (Grefte, 1988). These patients generally are advised to follow a lactose-free or lactose-reduced nutrition prescription while their intestine heals and the lactose intolerance naturally resolves. Vitamin D and calcium intakes should be carefully monitored in these patients. utrition counseling should enable patients with celiac disease to do the following: Define the gluten-free nutrition prescription and list the grains that must be avoided (eg, wheat, barley, rye, triticale) List common foods that contain wheat, barley, and rye (eg, bread and bread products, pasta, breakfast cereals) List grains that are allowed in a gluten-free nutrition prescription (eg, rice, corn, amaranth, buckwheat, quinoa, millet, sorghum) Read a food label and know how to identify sources of gluten (eg, malt) Identify places where specially formulated, gluten-free products can be purchased (eg, mail-order companies, health food stores, some supermarkets) Plan healthful, gluten-free meals at home Identify the nutritional risks of the gluten-free nutrition prescription and steps that can be taken to ensure a healthful meal plan Explain cross-contamination and steps to take at home to avoid contaminating gluten-free foods with wheat, barley, or rye Identfy nonfood items that may be sources of gluten, such as supplements and medications Know where to look for additional reputable information on celiac disease (eg, support Persons with celiac disease may suffer from gastrointestinal symptoms for many years before being diagnosed with celiac disease. As a result, some individuals may experience an aversion to food in general or to specific foods they associate with symptoms. They may need support as they relearn to eat a varied meal plan. Individuals may avoid the following: Milk products Fiber-rich foods Gluten-free grains The gluten-free nutrition prescription can be nutritionally adequate. However, registered dietitians should carefully monitor patient intake of the following nutrients: B-vitamins Iron Fiber Calcium The following are grains to avoid in a gluten-free nutrition prescription: Wheat All varieties, including einkorn, emmer, spelt, and kamut All forms, including wheat starch, wheat XXXXXXX wheat germ, cracked wheat, and hydrolyzed wheat protein Barley Rye Cross-bred varieties, such as triticale (a cross between wheat and rye) 1The FDA is proposing that a food containing wheat starch may be labeled gluten-free if the final food product contains less than 20 ppm gluten. To read the entire FDA proposed rule on gluten-free food labeling, click here. Grains to Include Following are grains and plant foods to include in a gluten-free nutrition prescription: Rice Corn Amaranth Quinoa Teff (or Tef) Millet Finger Millet (Ragi) Sorghum XXXXXXX Rice Grass (Montina) Arrowroot Buckwheat Flax Job’s Tears Sago Potato Soy Legumes XXXXXXX Tapioca Wild rice Cassava (Manioc) Yucca Nuts Seeds Oats Findings from in vivo research on the safety of oats suggest that most persons with celiac disease and dermatitis herpetiformis can safely consume moderate amounts of uncontaminated oats without adversely affecting the intestinal mucosa (Janatuinen, 1995, XXXXXXX 1996, Hardman, 1997, Reunala, 2000, Janatuinen, 2000, Hoffenberg, 2000, Janatuinen, 2002, Storsrud, 2003, Hogberg, 2004, Holm, 2006). However, limited evidence suggests that in some persons with celiac disease, the consumption of uncontaminated oats may result in mucosal inflammation (Lundin, 2003, Peraaho, 2004, Arentz-Hansen, 2004). Concerns also remain that even if the oat prolamin avenin is not harmful, oats nonetheless may be contaminated with wheat or barley. Because oats are frequently grown in rotation with wheat and other grains, they may be contaminated with foreign grain when they arrive at the mill (McCann's Irish Oatmeal, La Crosse Milling Company). In an assessment of gluten contamination of commercial oat products available in the United States, oats were found to contain from less than 3 ppm gluten to 1,807 ppm gluten (Thompson, 2004). To put this amount in context, the Codex Draft Revised Standard for Foods for Special Dietary Use for Persons Intolerant to Gluten states that foods labeled as gluten-free may contain no more than 20 ppm gluten (Codex, 2007). For more information on Codex guidelines, see the wheat starch section. Efforts are being made by some companies in North XXXXXXX (Gluten Free Oats, Cream Hill Estates, Only Oats, Gifts of Nature, Bob's Red Mill) to produce oats free of substantial gluten contamination through carefully monitored growing, harvesting, and processing procedures. The FDA is proposing to allow oat products to qualify for a gluten-free label as long as the final food product contains less than 20 ppm gluten (FDA, 2007). Patients consuming oats should be advised to limit consumption to amounts found safe in several studies (ie, approximately 50 g dry oats) (Thompson, 2003) and only consume those oats that have been tested and found to be gluten free. In addition, it may be prudent for patients to add oats to their diet after they are stabilized on a gluten-free diet. It also is important to closely monitor all patients who choose to consume oats, keeping in mind that gastrointestinal symptoms experienced while consuming oats may be due to fiber content. For more information on oats, see the Celiac Disease/Gluten Intolerance topic at ADA's Evidence Analysis Library (www.adaevidencelibrary.com) Wheat Starch Historically, in the United States, a nutrition prescription that is naturally gluten free (ie, based on grains such as rice and corn) has been prescribed for persons with celiac disease. This nutrition prescription differs slightly from what is prescribed in other parts of the world, including Scandinavia and the United Kingdom. In these countries, foods containing wheat, barley, or rye that have been rendered gluten free may be included in a gluten-free nutrition prescription even though they may contain small amounts of gliadin and other harmful prolamins. These foods, such as wheat starch, have been specially formulated to comply with Codex standards for gluten-free foods (Codex, 2006). The discrepancy in the use of foods rendered gluten free exists in part because it is unknown what daily amount of gliadin and other harmful prolamins may be consumed by persons with celiac disease without damaging the mucosa of the small intestine. Whereas some experts on celiac disease believe that only naturally gluten-free foods should be consumed, others believe that the small amount of gliadin present in foods rendered gluten free is safe (Thompson, 2001b). In the United States, manufacturers of gluten-free foods currently do not use wheat starch in their products. However, the use of wheat starch in gluten-free diets in the United States may be changing. The US Food and Drug Administration is proposing that foods containing wheat starch may qualify for gluten-free labeling as long as the final food product contains less than 20 ppm gluten (FDA, 2007). Clarification of terms: Naturally gluten free: Foods composed of ingredients that do not naturally contain prolamins from wheat, barley, rye, oats, or their derivatives. Examples include corn, rice, amaranth, and quinoa. Rendered gluten free: Foods composed of ingredients that contain prolamins from wheat, barley, rye, oats, or their derivatives, but comply with Codex standards for gluten-free foods. Codex wheat starch is an example of such a food. Codex standards for gluten-free foods: Codex standards are developed by the Codex Alimentarius Commission, a program jointly run by the World Health Organization (WHO) and the Food and Agricultural Organization (FAO) of the United Nations. The purpose of the commission is to develop universal food laws and internationally agreed upon standards to protect the health of consumers (FAO/WHO Food Standards Codex Alimentarius). Based on the Codex Draft Revised Standard for Foods for Special Dietary Use for Persons Intolerant to Gluten, foods labeled "gluten free" may not contain more than 20 ppm gluten (Codex, 2007). Foods and Ingredients Derived from Barley According to the U.S. Food and Drug Administration's Code of Federal Regulations and Compliance Policy Guide, the following foods and ingredients generally are derived from barley: Beer, ale, XXXXXXX stout, and other such fermented beverages (27CFR25.11). Note: Pure distilled alcoholic beverages (eg, gin, vodka) may be included in a gluten-free nutrition prescription. Although these beverages may be derived from a gluten-containing grain, the process of distillation should prevent any protein from remaining in the final distillate. Malt (21CFR184.1443a). Malt syrup/malt extract (CPG 7105.02). Note: If a malted grain other than barley is used to make malt syrup or extract, it should be declared on the label (eg, extract of malted corn). Malt beverages (41CFR101-48.001-6). Malted milk (CPG 7106.01). Malt vinegar (CPG 7109.22). Note: Non-malt vinegar, including cider vinegar, wine vinegar, and distilled vinegar, are gluten free. 1Gluten-free beers are available. Other Terms for Wheat According to the U.S. Food and Drug Administration's (FDA) Code of Federal Regulations (21CFR137), the following terms, when used on a food label or ingredient list, indicate the presence of wheat: Flour White flour Plain flour Bromated flour Enriched flour Phosphated flour Self-rising flour Durum flour Farina Semolina XXXXXXX flour Under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), if a food or an ingredient contains wheat or protein derived from wheat, the word "wheat" must be clearly stated on the food label. This means that if the common or usual name of an ingredient that is or contains wheat does not include the word "wheat" in its name (eg, semolina) and wheat is not included elsewhere in the ingredient list, then the word "wheat" must be included on the food label either parenthetically immediately after the ingredient's name (eg, semolina [wheat]) or in a separate "Contains" statement. All packaged food products regulated by the FDA that are labeled on or after January 1, 2006, must be in compliance with FALCPA allergen labeling requirements. Ingredients Derived from Wheat According to the U.S. Food and Drug Administration's (FDA) Code of Federal Regulations and Compliance Policy Guide, dextrin (21CFR184.1277) and caramel color (21CRF73.85), as well as modified food starch and maltodextrin, may be derived from wheat. However, under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), if a food or an ingredient contains protein derived from wheat, the word "wheat" must be clearly stated on the food label. This means that if an ingredient such as dextrin, caramel color, maltodextrin, or modified food starch found in a food product contains protein derived from wheat, the word "wheat" must be included on the food label either in the ingredient list or in a separate "Contains" statement. This applies to flavorings, colorings, and incidental additives as well. In addition, if a spice blend or seasoning mix contains wheat, it must be declared on the food label. All packaged food products regulated by the FDA that are labeled on or after January 1, 2006, must be in compliance with FALCPA allergen labeling requirements. At the present time, food products regulated by the US Department of Agriculture (USDA) (meat products, poultry products, and egg products) are only required to list ingredients by their common or usual name. Therefore, in a USDA-regulated food product, ingredients such as modified food starch, dextrin, maltodextrin, and caramel color may be derived from wheat and not be stated on the food label. If these ingredients are made in the United States, they are most likely derived from corn Processed Foods That May Contain Wheat, Barley, or Rye Examples of processed foods that may contain wheat, barley, or rye include the following: Bouillon cubes Brown rice syrup Candy Cold cuts, hot dogs, salami, sausage Communion wafers1 French fries Gravy Imitation fish Licorice Matzo2 Rice mixes Sauces Seasoned snack foods (eg, tortilla chips, potato chips) Seitan Self-basting turkey Soups Soy sauce Vegetables in sauce 1. Communion wafers are generally made from wheat, although some manufacturers of gluten-free foods (eg, Ener-G Foods, http://www.ener-g.com/) make gluten-free wafers for use by persons with celiac disease. However, the official position of the Catholic Church is that gluten-free hosts may not be used to celebrate the Eucharist. Catholics with celiac disease have been encouraged to take Communion in the form of wine only. The Congregation of Benedictine Sisters of Perpetual Adoration has developed a low-gluten Communion wafer that conforms to Canon law. For ordering information, contact the Benedictine Sisters at 800/223-2772 or go to the Web site at http://www.benedictinesisters.org/. 2. Matzo and matzo meal are made from wheat, although Shemura oat matzos are produced in England by Rabbi E. Kestenbaum for use by persons with celiac disease. For more information, contact Rabbi Kestenbaum at +44-208-455-9476 or go to the Web site at http://www.glutenfreeoatmatzos.com. Supplements and Pharmaceuticals Supplements and pharmaceuticals may contain fillers made from wheat or barley (Crowe, 2001). As a result, it is important to clarify the gluten-free status of all supplements and medications a patient is taking. An excellent article on pharmaceuticals and gluten by pharmacist XXXXXXX Plogsted—Medications and Celiac Disease--Tips from a Pharmacist. In addition to conventional food, the Food Allergen Labeling and Consumer Protection Act of 2004 also applies to dietary supplements, infant formulas, and medical foods. This means that if one of these products contains wheat or protein derived from wheat, the word "wheat" must be clearly stated on the label. This applies to flavoring and coloring ingredients, as well as incidental ingredients. In included the patient education sheet in the first part of the paste, and important issues for the RD educational piece in the lower half. I do hope this is enough to give you a quick course in gluten free diets. Healthy Regards, XXXXXXX Oh, and if you need clarification, write back. Otherwise if this is all you need, please close and rate the question. Thanks!