Gluten-Free Diet Guide

Fact Sheet No. 9.375 Food and Nutrition Series|Health by J. Haas, L. Bellows, and J. Li* What is Gluten? What is Gluten Sensitivity? Quick Facts

Gluten is the general name for one of Non-celiac gluten sensitivity is used • Gluten is a storage protein the proteins found in wheat, barley and to describe people with non-specific found in wheat, barley, rye. Gluten containing foods can be part symptoms such as nausea, abdominal of a healthful, balanced diet; however, cramps, or diarrhea after eating gluten. and rye. some people may suffer from conditions, Gluten sensitivity involves an immune • Celiac disease is a genetic which may require elimination of gluten reaction to gluten. However, unlike celiac disease where gluten in the from the diet. disease, that reaction does not involve the diet causes the immune There are three common medical production of damaging antibodies that system to attack the cells in cause intestinal damage. conditions associated with gluten that your own body. susceptible individuals may encounter— celiac disease, gluten sensitivity, and • The only treatment for celiac gluten intolerance. These conditions What is Gluten Intolerance? disease is a lifelong, gluten- are all commonly used to describe Gluten intolerance is commonly free diet. individuals with adverse physiological used to describe individuals who conditions related to gluten. It is harmful have symptoms after eating gluten, for someone with celiac disease to and who may or may not have celiac eat foods that contain gluten. It is not disease. Similar to gluten sensitivity, recommended, however, that individuals these symptoms may include nausea, who do not suffer from one of these abdominal cramps, or diarrhea. conditions follow a gluten-free diet. Diagnosing Gluten What is Celiac Disease? Intolerance, Gluten In people with a genetic susceptibility, Sensitivity or Celiac Disease celiac disease results from eating gluten, If you experience these symptoms which triggers an immune response to when consuming gluten, you should attack the lining of the small intestine. consult a doctor before eliminating The process may also damage other gluten from your diet. There may be an areas of the body. Damage to the small underlying medical condition, for which intestine interferes with absorption a gluten-free diet is not the treatment. of nutrients and increases the risk for diseases like bone disease, anemia and If you have just been diagnosed with intestinal cancer. Right now, the only celiac disease, gluten sensitivity, or gluten effective treatment for celiac disease is a intolerance, you may be feeling confused, lifelong, gluten-free diet. stressed and concerned about diet changes. This is normal, but this step-by- step guide can help you through the first days of your gluten-free life. The damage caused by celiac disease is reversible, *J. Haas, Colorado State University Extension specialist, and you will often feel better within a © Colorado State University and research associate; L. Bellows, Extension food and few weeks. The day-to-day reality of Extension. 3/09. Revised 3/14. nutrition specialist, and assistant professor; and J. Li, following a gluten-free diet is challenging former graduate student. 3/2014 www.ext.colostate.edu in the beginning, but it can be done of Hidden Gluten is provided for you Step 4. Make a Gluten-Free Shopping and will get easier with practice. Even at the end of this fact sheet (List 2). List if you don’t feel sick after eating gluten- Read the ingredient lists. If you find After you have planned your one containing foods, you can still damage any sources of gluten in the ingredients, week’s menu, make a gluten-free your body. While avoiding gluten- do not eat that food. You can either shopping list for foods you wish to buy. containing foods may seem difficult at get rid of the gluten-containing foods See sample Gluten-Free Shopping List first, it is easy to identify them once you or place them in a separate part of the (List 3) at the end of this fact sheet. are familiar with their names. To get cabinet so others in the household can started, see the list of gluten-containing eat them. Labeling laws now require Step 5. Read Food Labels Every Time foods and ingredients provided at the wheat ingredients to be clearly labeled, You Buy end of this fact sheet (List 1). Take the however this does not necessarily mean list with you when you shop or eat out. the food is gluten-free. A gluten-free Some, but not all products will be label, on the other hand, identifies a labeled as gluten-free. Ingredients may food that is safe to eat. change over time for the same brand 10 Steps to the Gluten- product. For foods that are not labeled Free Diet Step 3. Plan One Week's Menu as gluten-free, be sure to check the around Naturally Gluten-Free Foods ingredients for hidden gluten every Switching to a gluten-free diet time you buy a packaged product. Take can be difficult in the beginning. Looking for a place to start? Try the Shopping Guide: Sources of Gluten Following these 10 steps can make the these suggestions: (List 4) provided at the end of this changes easier. Breakfasts fact sheet with you when you go food shopping. However, when purchasing • Cream of rice cereal with fresh Step 1. Identify Naturally Gluten-Free items with a gluten-free label, you fruit or nuts Foods at Home can be sure that it is gluten-free. In Many foods are naturally gluten- • Cottage cheese or yogurt with August 2013, the U.S. Food and Drug fresh fruit free. Before you buy expensive store- Administration (FDA) published a new regulation defining the term "gluten- bought gluten-free breads and cereals, • Scrambled eggs, bacon and fresh fruit free" for food labeling. The regulation look in your kitchen cupboards and provides a uniform standard definition. refrigerator for the following items. • Egg, cheese, and vegetable omelet So, if a manufacturer labels a product Note that ‘Plain’ refers to no additives. with potatoes and fresh fruit "gluten-free," the food must meet all • Fresh fruits Lunches and Dinners of the requirements of the definition, including that the food must contain • Fresh beef, pork, chicken, turkey, • Baked potato with cheese less than 20 parts per million of gluten. fish, and seafood and vegetables The rule also requires foods with the • Fresh eggs • Corn tortillas with stir-fried meat claims “no gluten,” “free of gluten,” and • Fresh, plain milk, butter, and vegetables “without gluten” to meet the definition margarine, cream • Stir-fried meat and vegetables for “gluten-free.” • Plain beans with rice and wheat-free tamari Step 6. Avoid Cross-Contact • Plain corn • Bean-and-cheese burritos made with corn tortillas If you also shop and prepare • Plain white rice, brown rice, food for people who do eat gluten- wild rice • Grilled meat or fish, baked potato and vegetables containing foods, it is important to • Plain nuts and seeds protect your gluten-free foods from Snacks contact with gluten. • Oils • Plain rice cakes with cheese or • Buy two jars of jam, mayonnaise, • Sugar, honey, molasses peanut butter and peanut butter. One is for you, • Spices and herbs • Nachos made with plain corn and the other is for everyone else. A chips, cheese and salsa knife with bread crumbs will leave Step 2. Identify Gluten-Free Packaged • Celery sticks with cream cheese gluten behind in a shared jar. Be Foods at Home or peanut butter sure to label which jar is gluten-free. You can also buy squeeze bottles so Next, take out all of the packaged • String cheese nobody needs to use a knife. foods with food labels and put them on your kitchen table. Some packaged • Plain popcorn with oil and salt • Buy a separate toaster for gluten- foods have gluten hidden in the • Fresh or canned fruit with yogurt free breads, or put clean aluminum ingredients. A list of Common Sources or ice cream foil on the rack of your toaster oven when you use it for gluten-free • Make your first visit to a restaurant enough nutrients from your diet? If products. Buy a separate colander/ before or after peak dining hours so not, be sure to include some nutrient strainer for gluten-free pasta. the staff has enough time to answer dense gluten-free foods listed below Colanders are too hard to clean to your questions. and/or take a multivitamin and mineral completely remove gluten. Color • Always identify yourself as someone supplement. Additionally, look for coding with a permanent marker who is allergic to wheat, rye and “whole grain” versions that contain the can help keep all kitchen utensils barley. Though many people may bran layer (rice bran, brown rice, brown separate. be familiar with the term “gluten- rice flour). Variety is key to maximize • Clean counter tops and cutting free,” they may not know what foods protein, fiber, and nutrients. boards often to remove gluten contain gluten. Bring your own containing crumbs. gluten-free food when traveling. Step 9. Identify Any Additional Food Intolerances • Clean cooking utensils, knives, pans, This way, you will always have grills, thermometers, cloths, and something you can eat. Apples, If you are not feeling better on a sponges carefully after each use and raisins, fruit leather, rice cakes, and gluten-free diet, you may have other before cooking gluten-free foods. nuts are good travel snacks. food intolerances such as lactose (milk sugar), cow’s milk, soy, corn, eggs, • Store gluten-free foods above • Always ask how the food is nuts, yeast, and acidic foods. Talk to gluten-containing foods in your prepared. Talk to the manager your doctor and registered dietitian if refrigerator and cupboards. By or chef if your server doesn’t you are not feeling better on a gluten- doing this you prevent the risk of know. Some specific questions to free diet. gluten-containing food particles ask include: falling below onto gluten-free foods, • Is the meat marinated in causing contamination. soy sauce, teriyaki sauce, or Step 10. Get Support • Use pure spices rather than blends. Worcestershire sauce? For a successful transition to the gluten-free lifestyle, you need support • If you bake with gluten-containing • Is the chicken dusted with flour before pan-frying? from your doctor, dietitian, family, flours, put away or cover your friends, and others. gluten-free foods when you bake. • Is the oil used for French fries also Flour dust can float in the air for used for frying onion rings (or If you have celiac disease, joining a several hours and contaminate your other breaded foods)? local support group can be very helpful. gluten-free products. Individuals in this group understand • Are there croutons or bacon bits what you are going through better than • Avoid purchasing staples on the salad? anyone else. They will be able to offer from bulk bins to minimize • Do you use wheat flour to make you emotional support and answer cross contamination. the gravy (or thicken the soup)? all many of the questions you have. • If your meals will be prepared For a list of support groups, see the Step 7. Eat Out and Travel Gluten- for you (hospital, college dining Resources section. Free with Ease hall), ask to speak with the You can eat out at restaurants. dietary manager. Although there is concern for cross- Resources Major National Celiac Support Groups contact when you eat out, you can Step 8. Eat a Balanced Diet reduce the risk by planning ahead. (they will give you information on People on a gluten-free diet may local groups) • Before you leave home, do a little not get enough calcium, vitamin D, homework. Many restaurants have iron, B vitamins, or fiber. For example, Gluten Intolerance Group a website where they post their many gluten-free breads, cereals, and www.gluten.net menus. Write down all the choices pasta are not fortified with vitamins Celiac Disease Foundation that are gluten-free. Often a menu and may be low in fiber. Are you getting www.celiac.org with gluten-free options is available on request. • Avoid bakery-type restaurants Table 1. Nutrient Dense, Gluten-Free Foods or pizza places where the gluten- containing flour can stay in the Calcium Milk, yogurt, cheese, sardines and salmon with bone, broccoli, collard greens, almonds, calcium-fortified juice, amaranth, teff, quinoa air and come in contact with other foods. Iron Meat, fish, chicken, beans, nuts, seeds, eggs, amaranth, quinoa, teff B vitamins Eggs, milk, meat, fish, orange juice, beans, nuts, seeds, gluten-free whole grains • Call ahead and talk to the manager or chef about items that are prepared Vitamin D Vitamin D-fortified milk and yogurt, egg yolks, salmon, sardines, tuna gluten-free. Fiber Vegetables, fruits, beans, amaranth, quinoa, millet, buckwheat, sorghum, teff, flax List 1. Gluten-Containing Foods and Ingredients (This is not a complete list.) Celiac Sprue Association-USA Ale Durum Lager Seitan www.csaceliacs.info Atta Einkorn Malt Semolina Canadian Celiac Association Autolyzed yeast Emmer Malt extract, malt Soy sauce www.celiac.ca syrup, malt flavoring, malt vinegar Professional and Barley (pearl, flakes, Farina Malted milk Spelt Government Websites flour) Beer (gluten-free beer Faro/Farro Matzoh Triticale American Dietetic Association is available) www.eatright.org Brewer’s yeast Fu Modified food starch Wheat Celiac Disease Center at Bulgur Gluten, gluten flour Oats* Wheat bran Columbia University Chapatti Graham flour Orzo Wheat flour www.celiacdiseasecenter.columbia.edu Couscous Hydrolyzed vegetable/ Rye Wheat germ Celiac Disease and Gluten-free plant protein Resource Dinkel Kamut Seasoning Wheat starch www.celiac.com *Those labeled gluten-free are fine. Oats do not contain gluten, but have the risk of cross-contact Center for Celiac Research & during harvesting or processing. Treatment at MassGeneral Hospital for Children ww.celiaccenter.org

List 2. Common Sources of Hidden Gluten (This is not a complete list.) National Institutes of Health Baked beans Flavoring Marinades Seasonings http://digestive.niddk.nih.gov/ Blue cheese crumbles French fries Meat loaf Self-basting poultry ddiseases/pubs/celiac/ Breading Gravy Nuts Soups, soup bases University of Chicago Celiac Broth, bouillon Herbal Teas Processed meat Soy sauce Disease Program Candy Ice cream Puddings Stuffing www.uchospitals.edu/specialties/ celiac/index.php Cereal binding Icing/frosting Rice mixes Thickeners Chocolates Imitation seafood Roux Vegetarian “burgers” Guides for Gluten-Free Color (artificial, Imitation bacon Salad dressings caramel) Dining Out and Travel Communion wafers Licorice Sauces Bob and Ruth’s Gluten-Free Dining &

Dry roasted nuts Maltodextrin Sausage Travel Club www.bobandruths.com

Gluten Free on the Go www.gluten-free-onthego.com List 3. Sample Gluten-Free Shopping List Gluten-free Restaurant Vegetables Awareness Program Lettuce Tomatoes Cabbage Carrots www.glutenfreerestaurants.org Broccoli Potatoes Celery Fruits The Essential Gluten-Free Apples Oranges Bananas Grapes Restaurant Guide Meat, Proteins Triumph Dining Cards Beef Chicken Fish Eggs www.triumphdining.com Pork Turkey Shrimp Celiac Chicks Dairy www.celiacchicks.com/CF-HOME. Milk* Cheddar cheese Cream cheese* Butter htm Yogurt* Cottage cheese* Sour cream Waiter, is There Wheat in my Soup? Binders (for baking) The Offiicial Guide to Dining Out, Xanthan gum Guar gum Tapioca Shopping, and Traveling Gluten-Free and Allergen-Free Frozen Foods by LynnRae Ries Berries Corn Sorbet Gluten-free waffles www.whatnowheat.com Mangoes Peas List 3. Sample Gluten-Free Shopping List (continued) Books Canned and Packaged Foods 100 Best Gluten-Free Recipes Peaches Pears Green beans Dried beans by Carol Fenster Gluten-free Grains http://savorypalate.com/index. Rice* (all forms, even Amaranth Buckwheat Soy php/100-best-gluten-free-recipes/ glutinous) Easy Everyday Gluten-Free Cooking Quinoa Arrowroot Potato flour, starch Teff by Donna Washburn and Heather Butt Millet Bean flours (garbanzo, Sorghum Tapioca (manioc, www.csaceliacs.info/shop.jsp fava) cassava) Corn Magazines Snacks Gluten-Free Living Popcorn* Corn chips* Nuts and seeds* Jello www.glutenfreeliving.com Rice cakes, rice Potato chips* crackers* Sully’s Living Without Magazine www.livingwithout.com Condiments Honey Jams, jellies, Herbs Pickles marmalade References Ketchup Corn and maple syrup Salt Vinegars Case, S., Heap, J., Raymond, N. (2006). Mustard Sugar Pepper Regular mayonnaise and salad dressings* The Gluten-Free Diet: An Update Peanut butter Spices Olives Vegetable oils for Health Professionals. Practical Gastroenterology. 67-92. Drinks Children’s Digestive Health and Nutrition Fruit juice Coffee Tea Foundation. (2005). Gluten-Free Diet *With no gluten-containing additives. Guide for Families. Retrieved from: http://www.naspghan.org/user- assets/documents/pdf/diseaseinfo/

List 4. Shopping Guide: Sources of Gluten (This is not a complete list. If in doubt, choose another glutenfreedietguide-e.pdf brand.) Read labels every time you buy! Ingredients can change at any time. Cranney, A. et al. (2007) The Canadian Celiac Health Survey. Dig Dis Sci. 52(4) Foods to Avoid 1087-95. Ale Dinkel Lager Seasonings Cureton, P. (2006) Gluten-Free Dining Out: Atta Dry roasted nuts Licorice Seitan Is It Safe? Practical Gastroenterology. Autolyzed yeast Durum Malt Self-basting poultry 61-68. Baked beans Einkorn Malt extract, malt Semolina Mahan, L., Escott-Stump, S., and Raymond, syrup, malt flavoring J. (2012). Food and the Nutrition Care Barley (pearl, flakes, Emmer Malted milk Soups, soup bases Process. St. Louise, Missouri: Elsevier flour) Saunders. Beer (gluten-free beer Farina Marinades Soy sauce Niewinski, M. (2008). Advances in Celiac is available) Disease and Gluten-Free Diet. Journal of Breading Faro Matzoh Spelt the American Dietetic Association. 108 Brewer’s yeast Flavoring Meat loaf Stuffing (4), 661–672. Pagano, A. E. (2006). Whole Grains Broth, bouillon Fu Modified food starch Textured vegetable protein (TVP) and the Gluten-Free Diet. Practical Brown rice syrup Gelatinized starch Mono- and Thickeners Gastroenterology. 66-78. di-glycerides Thompson, T. et al. (2005).Gluten-free Bulgur Graham flour Oats (not labeled Triticale Diet Survey: Are Americans with Celiac gluten-free) Disease Consuming Recommended Cereal binding Gravy Processed meat Wheat Amounts of Fiber, Iron, Calcium and Grain Foods? J Hum Nutr Diet. 18(3), Chocolate bars Hydrolyzed vegetable/ Roux Wheat bran plant protein 163-9. Color (artificial, Icing/frosting Rye Wheat flour U.S. Food and Drug Administration. caramel) (2013). FDA defines “gluten-free” for Communion wafers Imitation seafood Salad dressings Wheat germ food labeling. Retrieved from: http:// www.fda.gov/NewsEvents/Newsroom/ Couscous Imitation bacon Sauces Wheat starch PressAnnouncements/ucm363474.html Dextrin Kamut Sausage

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