The only treatment for celiac disease is a gluten-free diet for life.  It has been shown that as little as 1/8th teaspoon of flour will cause changes in the intestinal mucosa (Semrad 2004).   Maintaining a gluten-free diet means constant vigilance.

Follow the golden rule: When in doubt, leave it out!

Safe Starches:
• Corn,
• Rice,
• Potato and tubers,
• Buckwheat,
• Amaranth,
• Quinoa,
• Tapioca,
• Teff,
• Oats*, Oats are considered safe but they are often time processed in a facility where there is the possibility of cross contamination.
• Arrowroot,
• Sourghum,
• Montina,
• Millet

In addition to the standard grains, bean flours offer gluten-free and nutritious alternatives to wheat flour.
• Chickpea
• Lentil
• Soy

Un-Safe Starches:
• Wheat: including Kamut, spelt, semolina, triticale,
• Rye
• Barley (including malt)

Beyond the foods that we eat, we need to be aware that gluten is contained in many other products.  Wheat is commonly used as a thickener, a stabilizer and a texture enhancer, It is also added to many non-food products.  Products may contain gluten as a filler, binder or texture enhancer and therefore they need to be eliminated from your gluten-free lifestyle.

Gluten Sources That You Might Not Think ABout:
• Chapstick, Lipstick
• Dairy Substitutes
• Licorice
• Malt or malt flavoring
• Modified food starch
• Playdough
• Brewers Yeast
• Prepared cake frosting
• Soy Sauce
• Medications (esp. in tablet form: Over the counter, prescription, and herbal supplements)
• Toothpaste
• Salad Dressing, Soups, Gravy (Malt Vinegar /wheat)
• Seasonings
• Malted Beverages
• Communion Wafers
• Vitamins

If the ingredient list does not contain gluten, it does not mean the product is gluten-free.  Cross-contamination may occur in the processing of food, for example, dusting a conveyor belt with flour.  Ask the manufacturer about the product’s process and contamination possibilities.  Many boxes are labeled with information about the production process, for example, that the factory also mills wheat products. You will need to make a decision about whether to risk eating the product.

Safe Additives and Ingredients:
• Artificial color and flavor
• Baking powder
• Baking Soda
• Carmel color
• Citric Acid
• Maltodextrin
• Mono and diglycerides
• Monosodium glutamate
• Natural color and flavor (Most are fine)
• Soy
• Vanilla
• Vinegar (except malt)

What to look for on labels:
• Always read ingredient labels
• For example, a number of Tea’s may contain barley
• If the food contains any of the ingredients on the hidden sources list,  then you need to contact the manufacturer and ask them if the product is 100% gluten free:
o Modified Food Starch (In North America, most are GF)
o Natural Flavors (Most are Gluten Free)
o Hydrolyzed Vegetable Protein (HPV)
o Hydrolyzed Plant Protein (HPP)
o Dextrin
o Seasonings

Is “wheat-free” also gluten-free?
No, as other grains or derivatives may be present.  You must continue to read labels for other gluten-containing ingredients such as barley or spelt.

Is any amount of gluten safe to eat?
Studies underway are looking at parts per million, indicating that even trace amounts can be harmful to the small intestine.  Remember, the small intestine sees itself as the “enemy” when gluten enters and an immuno-response is triggered as a result. 

What to watch out for
A gluten free diet can be healthy and tasty but constant diligence is necessary.

How do I prevent cross contamination?

• Tips At home: 
o Use a separate toaster– do not share common items.  
o Wash utensils, pots, pans and dishes thoroughly between uses.  
o Perhaps use a specific color bowl for gluten-free items on the table.
o Keep your gluten-free items labeled and store in a gluten-free location 
o Buy and use squeeze bottles when possible
o Purchase duplicate containers of peanut butter and spreads

• When out at a restaurant:
o Explain that you have a food intolerance and that will get very sick if the food is not prepared properly.
o Order plain meats and veggies.  Bring your own gluten-free soy sauce and dressings.
o Roasted and grilled foods are generally safe.
o If contamination is suspected, do not eat the food.  Send it back to the kitchen if eating out or eat only those foods that did not have contact with gluten.

Basics to living gluten free
Gluten-free living can be an adventure. Explore new foods and concentrate on what you can eat rather than feeling deprived of the foods that you can’t eat.

Celiac Disease increases subsequent risk of anemia, osteoporosis and diabetes.  Therefore a well-balanced diet, high in nutrients and low in fat and calories is the key to good health.  Fruits and veggies are an easy gluten-free option. Fish provides essential fatty acids that should be present in any healthy diet.  You will find that there are gluten-free foods that don’t require special thought or extra preparation time. 

Many foods are naturally gluten free:
• Meats
• Fish
• Poultry
• Vegetables
• Fruits
• Legumes
• Dairy Products

It’s not hard to cook gluten- free. Here are some tips to make your kitchen gluten-free-friendly.
• Basics:
        o Baking powder
        o Baking soda
        o Oils
        o Spices
        o Sugar
        o Vinegar

• Foods to stock: 
        o Gluten-free baked items in the freezer
        o Gluten-free Pastas
        o Spices
        o Gluten-free Flours

• Invest in some gluten-free cookbooks for great new ideas!

• Buy a Breadmaker
Purchasing your own will provide convenience between shipments of bread. Also, you now have the ability to mix herbs and other fun ingredients into dough for a bit of a kick!

• Buy a separate freezer

Good for storing baked products when buying in bulk – reduces shipping costs, great for convenience.
Loaves of bread or cakes – separate by slices and pull out individual servings when needed.

Attitude is everything
It’s natural to ask yourself “Why Me?” and yes, it’s easy to be depressed about all the foods you will have to sacrifice.  You may feel “different” when with others who can eat without thought or hesitation.  BUT, your attitude is what will make this situation one that is back in your control.  After some time, you will develop a routine, you will meet others diagnosed and you may even develop a sense of humor about it all.

 Ethnic food alternatives
Rice- and corn-based foods, like Asian and Mexican dishes, provide ways of eating out or “spicing” up what could seem like a fairly bland diet.  Locate the Indian or Mexican stores in your area or buy specific cookbooks that use spices to make an “ok” dish into a “wow” dish when your taste buds have fallen asleep!

Gluten free in the real world
Navigating the grocery store and going to restaurants may seem overwhelming but it will all soon become second nature.

Where do I buy food?
• Local health food stores
• Co-op stores, natural/organic food stores, ethnic stores
• Internet
• The list of gluten-free product websites grows daily!!
• National Chains such as Whole Foods, Wegmans, and Trader Joe’s, etc.  These stores keep a list of the gluten-free items they carry and some even have gluten-free aisles.  Often they hire dieticians to research new products and some even carry freshly baked items.   http://wholefoodsmarket.com/healthinfo/list_gf.html

Talk to the store’s manager about your special needs.

Provide them with a description of Celiac Disease and prepare a list of items that you would like to see the store carry.  Let them know that you will tell those in your support group about the store’s willingness to help. 

Before buying items that you are unsure of call the manufacturers, inquire about gluten status and then return to buy items when cleared as gluten-free. Keep a notebook for future reference.

Tips on eating out:
• Gluten Intolerance Card  

• Call ahead to the restaurant. Go or call on off-peak time and speak to the manager or chef.

• Asian & Mexican restaurants: Most ethnic restaurants use rice or corn-based food items

• National Chains such as Outback, PF Chang’s, Tony Romano’s carry gluten-free items on their menus. Checkout their websites!

• Surf the internet for menus on restaurant websites.  Use the “contact us” feature when menus aren’t available or call the company’s hotline.

• http://www.glutenfreerestaurants.org/  This lists gluten-free restaurants by state.  List is updated regularly.

• Order “Safe” items 
        o A salad without croutons 
        o Plain piece of meat/fish without fries, marinades or seasonings 
        o Rice

• Bring your own dressing & sauces
        Carry travel-sized bottles of gluten-free condiments

How do I travel?
• Plan ahead!  Call the hotel, motel, inn, or ship where you will be staying and explain your dietary requirements.  Give them time to prepare for your arrival.

• Always carry an “emergency stash” of gluten-free food.
        o Trail mix
        o crackers
        o nuts
        o Fruit
        o Energy bar

•  Search the web for local support groups that may have a list of restaurants or food stores that accommodate gluten free patrons.

• If possible, choose suites with amenities such as a refrigerator, microwave and a toaster oven

• European Travel – gluten-free is common

• Pack some gluten-free snacks/breads in your carry-on luggage if permitted

• Bring restaurant cards in foreign language for wait staff

• Have Fun!

Tips for going to parties:
• If you know the host/hostess…call ahead and ask what they are serving.  Advise them that have special dietary needs. Avoid getting into too much detail.

• Offer to bring a gluten-free dish/meal.  Your friends may end up trying the gluten-free dish and preferring it over gluten-containing alternatives! 

• Enjoy yourself!

• Eat a meal or snack before going. Pick & choose lighter fare while socializing such as fresh veggies.

How do I eat on the go?
Keep energy bars, trail mix, nuts, and/or gluten free crackers in your car, gym bag, desk, briefcase, pocketbook…just in case….

How will my social life be affected?
• Dating?  Don’t need to say anything on the first date.

• But, tell family & friends.  By advising them of your new situation, you can feel more comfortable when in a social setting.  And possibly, it may spur them to get tested as well.

• Plan on eating before going out.  You’ll be less likely to feel depressed about what you can’t have if your stomach is already full.  And you’ll be prepared if you are stuck in a place with only gluten-containing food.

Are family members at risk?
Yes, CD is one of the leading genetic disorders in the country.
• University of Maryland Study shows 1:10 risk of immediate family member
   having Celica Disease
• 1:22 risk of first degree relative having Celiac Disease
• Family members may have Celiac Disease without experiencing symptoms and should be tested every year or so.

What if I cheat?
Know that your small intestine has a memory.  What you were feeling while eating gluten-containing foods, you will most likely experience again.  Your villi may flatten and it may take days to recover from the insult.

How do I cover increased costs for food?
• Gluten-free food & shipping is a tax-deductible medical expense

• Buy in bulk & store. This saves on traveling expense, and sometimes shipping expense if flat fee charged.

• A support group may purchase a case of food and divide the contents between its members.  This gives those with celiac a chance to experiment with new foods without bearing the full cost of shipping or purchasing a large quantity of items that may not like.

What medicines are ok?
• Celiac.com – list of GF medications

• Talk to/educate your pharmacist of your limitations.  Should they be unfamiliar with Celiac Disease, give them material to read.  By advising them of your situation before emergencies arise, a pharmacist can be aware of Gluten-free alternatives such as Antibiotics and know where to turn when you need it most.

• Special pharmacies can compound most medications to be gluten-free
        Stokes Pharmacy (800)754-5222

Six keys to managing a gluten-free lifestyle:
1) Consultation with a skilled dietician
2) Education about the disease
3) Lifelong adherence to a gluten-free diet
4) Identification and treatment of nutritional deficiencies
5) Access to a support group
6) Continuous long-term follow-up by a multidisciplinary team