OATS AND THE GLUTEN - FREE DIET

When i was training in pediatric gastroenterology and nutrition, we used to tell parents that the 4 main sources of gluten were: oats, whheat, rye, and barley. But as you've learned from our other blogposts and particularly the one on Good Grains for the Gluten-free Diet, there are other sources as well--and oats themselves contain gluten.

That's right. Oats are gluten free-unless they become contaminated during the milling, baking or processing. That's because most bakeries and food companies will either combine the two or use the same equipment to make their oat products (or they aren't focused on selling to the gluten-free families). Or they are small-scale bakeries with limited means to separate their oat and gluten-free grains from those that contain gluten.

So our resident dietitian has prepared a list of sources for you: (please feel free to comment if you have others to add). 

o Commercial oats (i.e. Quaker, Country Choice, McCann’s) are NOT gluten free.

o Canadian oats are NOT always gluten free.

o Gluten free oats are available.

§ Cream Hill Estates- www.creamhillestates.com

§ FarmPure foods- www.onlyoats.com

§ Gluten-Free Oats- www.glutenfreeoats.com

§ Gifts of Nature- www.giftsofnature.com

HIDDEN GLUTEN AND CONTROVERSIAL FOODS

Thanks to the allergy labeling laws, all major food allergens must be identified in plain language on the nutrition label.  Most of the “hidden and controversial foods” are no longer a question since wheat is the only gluten containing grain utilized to make most of these items. Here's the list prepared by Bailey Koch, RD, one of our advisory board members:

• Alcohol and vinegar
  • If distilled properly, they should not contain gluten.  Be careful of any additives.  Malt vinegar is not distilled so it is not gluten free.  
• Annatto
  • Gluten free 
• Baking Soda
  • If made in North America, it is made from allowed sources. 
• Candy
  • Always read the label.  It is always a good idea to call the company and ask how the candy is made and packaged. 
• Caramel color
  • If made in the US or Canada, it is made from allowed sources.  If imported, the caramel color could come from malt syrup or starch hydrolysates that can contain wheat. 
• Citric, lactic and malic acids
  • Gluten free 
• Coffee
  • Okay if plain and manufactured in the US or Canada.  Flavored coffees and coffee substitutes may contain gluten. 
• Dextrin
  • If product is made in the US or Canada, dextrin usually comes from corn or tapioca.  If wheat is the source, the company must disclose this on the label.  Imported dextrin may come from wheat. 
• Flavorings
  •  
• Glucose syrup
  • Gluten free. This is a highly processed ingredient that is usually made from corn in the US, but even when made from wheat is gluten free.  
• Hydrolyzed Vegetable Protein (HVP) and Hydrolyzed Plant Protein (HPP)- 
  • They are added to many foods (soups, sauces, spice mixtures and gravies) and may come from wheat.  If made from wheat, the label will say so.  Other sources include soy, corn, rice, peanuts, and casein.
• Isomalt
  •  Gluten free 
• Lecithin
  • Gluten free 
• Maltodextrin
  • In the US, this ingredient is made from corn, potato or rice but NOT wheat. 
• Modified Food Starch
  • Sources include corn, tapioca, potato, wheat, and other starches.  In the US, if the label says “starch” then it is cornstarch. 
• Mono and Diglycerides
  • Are fats and therefore gluten free. 
• Monosodium Glutamate (MSG), Calcium Caseinate, Sodium Caseinate 
  • If product is made in the US, a gluten containing grain is not utilized. 

·         Oat Gum

                 o   Gluten free

 ·         Oats

                  o   Are gluten free.  Concern is the contamination of oats

• Seasoning/spices
  • Pure spices and herbs do not contain gluten.  Seasoning mixes may contain gluten.

·         Silicon Dioxide

                      Gluten free

      Always read food labels. 

o   Recipes do change and therefore labels must be read every time you buy a product! 

o   Wheat is a major food allergen.  By law, all major food allergens must be identified in plain language on the nutrition label.  Remember that wheat free does not mean gluten free!  Wheat free products may still contain barley or rye.

·        Call the company for any product you are unsure of.

GLUTEN CROSS CONTAMINATION

Cross contamination occurs when a food that is gluten-free comes into contact or is cooked with foods that contain gluten. Obviously this can trigger symptoms in sensitive individuals.

People have different levels where gluten will upset their systems. Some are more sensitive than others. Understand that even gluten-free products can have tiny, tiny amounts of gluten (up to about 10 mg per pound of bread, for example). Since researchers estimate that it takes about 10 mg to do any intestinal damage, your child would have to eat an entire pound of that gluten-free bread to notice any symptoms.  On the other hand, regular bread contains much larger amounts and a single slice might cause symptoms that last for several days.

So if a gluten-free bread is used to make french toast, for example, on a griddle where regular bread was cooked first, the gluten free bread could possibly become tainted by crumbs from the gluten in the regular bread.

 Some ways to avoid cross contamination at home:

• Ensure that fried foods are fried in dedicated fryers.
• Buy squeeze bottles of condiments or buy separate containers for other family members.
• Use a dedicated toaster, or purchase Toast-It Bags (ie. at Amazon.com), which protect GF foods from cross-contamination in the family’s regular toaster or toaster oven.
• Use a separate butter dish and cutting board.
• Use ceramic, glass or stone rolling pins vs wood rolling pins.
• Ensure that counter space, utensils and cookware are clean. 
• Do not use sponges.
• Avoid buying or storing in bulk bins.

And see our post about eating in restaurants or at school.

GOOD GRAINS FOR GLUTEN-FREE DIETS

The North American diet is so focused on wheat products, we often forget that there are actually numerous other grains that can be used to make breads and pastries. So here's a comprehensive list provided by Bailey Koch, RD, whois on our advisory board.

Allowed grains and flours:

Rice                 Beans                          Buckwheat                              Vegetable gums

Corn                Garfava                       Arrowroot (i.e. guar gum)       Soy

Sorghum         Amaranth                    Flax                                         Potato

Quinoa             Teff                             Mesquite                                 Tapioca                      

Millet                Cassava                      Sago                                        Nuts and Seeds

Indian rice grass

Oats present a special case because they are often milled with wheat

o   Are gluten free.  Concern is the contamination of oats.

o   Commercial oats (i.e. Quaker, Country Choice, McCann’s) are NOT gluten free. 

o   Canadian oats are NOT always gluten free.

o   Gluten free oats are available. 

§  Cream Hill Estates- www.creamhillestates.com

§  FarmPure foods- www.onlyoats.com

§  Gluten-Free Oats- www.glutenfreeoats.com

§  Gifts of Nature- www.giftsofnature.com

o   Avoid until gluten free diet is mastered and there are no gastrointestinal symptoms.

o   Then one should limit the amount of pure, uncontaminated oats to:

§  ¼ cup per day in children

§  ½- ¾ cup per day in adults

§  The reason behind limiting pure, uncontaminated oats is the fact that there are case reports of patients with celiac disease relapsing from the consumption of pure, uncontaminated oats.  If this happens to you, discontinue the oats and contact your physician.

A gluten-free diet can provide all of the nutrition an individual needs.  Fruits, vegetables, corn, potatoes, rice, beans, most dairy products, nuts, seeds, eggs, and plain meats can be eaten on a gluten-free diet.

GLUTEN-FREE NO-NOs

A gluten-free diet is intended to be that: entirely gluten-free. To help you along, Bailey Koch, RD, one of our advisory board members has compiled several lists and suggestions to help you. Please also see her Good Grains Blogpost on our site as well:

Grains and flours that are not allowed:

Barley             Einkorn            Gluten             Orzo               Spelt                Bulgur

Emmer            Graham           Panko              Triticale          couscous        Farina 

Kamut             Rye                 Udon               Dinkel              Farro               Malt *

Seitan             Matzoh**         Wheat ***        Durum             Fu                    Semolina                             

*Includes extract, flavoring, syrup and vinegar

**Includes meal, farfel and flour

***Includes bran, flour, germ, gluten and starch

Foods/ingredients that may or may not contain gluten:

Breading, coating mixes                     Imitation bacon                                   Soup base

Broth                                                   Imitation seafood                                Stuffing/dressing        

Brown rice syrup                                 Luncheon meats                                 Soups

Candy                                                 Marinades/sauces/gravies                  Seasonings

Croutons                                             Pasta                                                   Salad dressing

Cereal products                                  Roux                                                   Communion wafers   

Soy sauce                                           Cracker meal                                      Self-basting poultry

Other potential gluten sources:

Medications                             Vitamin and mineral supplements

Play dough                              Toothpaste

*Gluten does not pass through the skin.  One should ensure proper hand washing to ensure gluten on the skin is not ingested when fingers are put in the mouth or food is eaten with unclean hands.

TESTING FOR CELIAC DISEASE AND WHEAT/GLUTEN DISORDERS

So you or your doctor (or your neighbor's second cousin) thinks you might have a problem with wheat or gluten. How can you tell?

Wheat Allergy

You may be familiar with tests for wheat allergy. Blood tests for allergies all show the amount of IgE antibody that is circulating in the blood stream. That's IgE antibody, because those are the factors that seem to be what reacts in an allergic event, where you have a actual reaction to eating wheat. There's also blood tests for IgG reactions to foods, but most allergists feel these are not worthwhile and show only that you've recently had that food rather than any reaction to it. Other practitioners may agree that it's not a true allergy but that the test may suggest you are more likely to have a sensitivity to that food.

Skin prick tests usually pick up similar IgE allergies, as long as the patient is not on an antihistamine or similar medicine at the time. Occasionally, allergists who deal with a lot of food reactions will also do patch testing where they will put a small amount of the fresh food on the back to test if the person will have a reaction that can go along with a condition known as eosinophilic esophagitis (covered in a separate post).

And sometimes, allergists will try a food challenge in their office or another safe place, where they will give you the food in increasing (but small quantities) to see if they can provoke some of the symptoms you describe with that food.

Celiac Disease

The blood tests for celiac disease have gotten progressively more accurate. We have been able to hone in on fewer tests and get better results.

Tissue Transglutaminase (tTG), which is the enzyme that acts on gluten, forms an antibody that is 97% accurate in suggesting which individuals might have celiac disease. Two forms exist, the IgA and IgG, and if either is significantly elevated, one should be suspicious that the person has celiac disease, with an intestinal biopsy performed to confirm the diagnosis in most instances. Since this is in part a genetic condition, some doctors will make the diagnosis on a family member without a biopsy, if they have an elevated tTG level and someone else in the family already has had a biopsy.

Two notes of caution

•  This test is not very helpful for the initial diagnosis in someone who has already restricted gluten from their diet.
• The IgA fraction will be low in someone who has an immune defect involving their IgA (and they will be 10 times more likely to have celiac disease.

The Endomysial Antibody, which is antibody to gastrointestinal tissue, may be positive in someone who is already on a gluten-free diet. Thus, it is helpful if it is positive, but is meaningless if it is negative .

The antigladin antibody level is an interesting test since it reflects a reaction to the fraction of wheat gluten that actually causes the intestinal damage. In young children, we will occasionally find an elevated IgA antibody to gliadin before the tTG shows up. The problem is that often we are confronted with increased IgG antibodies to gliadin. When they are strikingly elevated, that can be indicator of celiac or non-celiac sensitivity, but at lower levels they can be normal or can show that some other allergy or problem is causing a reaction in the small intestine.

Non-celiac gluten sensitivity requires a strict elimination diet for 3-4 weeks after excluding these other conditions (as discussed in another blog post).

Stool tests for gluten are not routinely accepted as evidence of celiac disease because they have not been proven to be sensitive or specific enough. In the same way that the IgG test for antigliadin antibody can be positive in normal people, and lead them to think they have celiac disease, the stool tests can potentially do the same--and they might miss those who actually have gluten sensitivity.  

Genetic Testing

Genetic testing for celiac disease is available, but the problem is that 1/3 of everyone has the gene that allows them to develop celiac disease. So the test should not be routinely performed--but it is useful in 2 settings. Someone in the family has been diagnosed and the doctor is trying to find who else in the family might have it. This is particularly important if a child is diagnosed, since one of the parents by definition, should have the gene. Second, a negative test strongly suggests that the person is in the other 2/3 who will never get celiac disease, and that is useful to know in someone who might have bad intestinal problems and negative tests for celiac disease, so that the doctor knows that the tests for celiac disease don't have to be repeated in the future.

Other tests

Your doctor may also want to run other tests if you have celiac disease or if he/she is concerned you might. He might test your iron levels because iron is absorbed in the intestinal area where celiac disease does the most damage. Other nutrients (vitamin D, B12, Folate, Zinc) may be tested to assure you are absorbing them. Similarly, your stool may be tested to make sure you are not having a problem absorbing fat (that provides evidence that you are at risk for multiple nutrient losses). Since uncontrolled or unrecognized celiac disease can affect how your liver functions and because autoimmune liver disease can occur with celiac disease, your doctor may want to check your liver with blood tests as well.

Bottom line: Reliable tests for celiac disease and its consequences are available. At the same time, some commercial tests are marketed, but they are not sensitive or specific enough.