Marisa Bunning, PhD

1
Living a Gluten-free Lifestyle

• Marisa Bunning, PhD
• Assistant Professor and Extension
  Specialist-Food Safety
• Mary Schroeder MS, RD
• Extension Research Associate-Food Safety
• Department of Food Science and Human Nutrition
• Colorado State University
• July 9, 2008

2
Complex Disease

• Multiple names Celiac, celiac sprue,
  non-tropical sprue, gluten intolerance, gluten
  sensitive enteropathy
• - but NOT the same as wheat allergy
• Celiac disease a complex autoimmune enteropathy
  caused by a permanent intolerance to gluten in
  genetically susceptible individuals 1
• Exact cause of celiac disease unknown, but is
  often inherited (5 to 15 chance if in immediate
  family)
• Onset can be triggered by trauma (infection,
  injury, pregnancy, severe stress or surgery)

1Niewinski, 2008
3
Autoimmune Disease

• Combination of 3 factors
• 1) Genetic predisposition
• Maternal antibodies produced during pregnancy
  cross placenta and react with fetal brain tissue
• Genetic marker (human leukocyte antigen- HLA) has
  been identified to confirm bodys response to
  gluten
• 2) Environmental trigger
• Gluten in diet
• 3) Loss of intestinal barrier
• Gluten triggers an immune response- causing
  inflammation and damage to lining of the small
  intestine
• Detected by transglutaminase (tTG) -standard test
  for diagnosis
• Celiac Disease is the only autoimmune disease for
  which all three factors are known.

Living Without Magazine June/July 2008 regarding
research at John Hopkins University School of
Medicine and University of California at Davis
4
Pathogenesis

• Gluten proteins disrupt the epithelial barrier in
  the lining of the small intestine. Sets off
  complex autoimmune (antigen) response, which
  results in destruction of surface epithelium and
  flattening of mucosa.1
• Develops leaky gut syndrome
• Protein called zonulin unlocks intestinal
  barrier and creates leaky gut, allowing large
  peptides to cross lining into blood stream2

Healthy villi lining the intestinal mucosa
1Niewinski, 2008 2Center for Celiac Research
5
Prevalence

• Celiac Disease- often misdiagnosed due to such
  variety of different symptoms- connection
  between conditions is not well understood.
• Estimated 3 million persons in U.S. with Celiac
  Disease
• Worldwide prevalence
  1 in 266
• General population U.S.
  1 in 133
• Females vs. males 31
• 25 newly diagnosed are over 60 yrs of age
• African, Hispanic and Asian-Americans
  1 in 236
• Genetic predisposition
• First degree relatives
  1 in 22
• Second degree relatives
  1 in 39
• High association
• Autoimmune diseases (i.e. Type 1 Diabetes)
  1 in 60
• Secondary Lactose Intolerance 30-60

Fasano, et al., 2003
6
Relationship with other conditions

• Dermatitis Herpetiformis (DH)
• Osteoporosis (bone mineral density test often
  recommended)
• Type 1 Diabetes
• Chronic Fatigue Syndrome
• Fibromyalgia
• Irritable Bowel Syndrome
• Eczema
• Sjogrens Syndrome
• Peripheral Neuropathy
• Thyroid Disease

7
Autism and Celiac Disease

• Autism Spectrum Disorder (ASD) affects 1 in every
  150 children in U.S. (up from 1 in 500 in 1995)
  per Center for Disease Control
• No evidence that gluten intolerance causes
  autism connection is unclear. However
• Many autistic individuals respond well to a
  gluten-free and casein-free diet
• Leaky gut -opioid peptides (dietary casein and
  gluten) cross intestinal lining into bloodstream
  bind to opiate receptors in brain, resulting in
  unmanageable behavior and sensory issues

Special Child, Special Diet, www.livingwithout.co
m
8
Diagnosis

• Serologic Tests
• Requires inclusion of gluten in diet before
  testing
• Recommended IgA EMA (immunoglobulin A endomysial
  antibody immunofluorescence)
• Intestinal Biopsy
• Used to confirm but not definitive
• Food trial
• Does health improve after 3 weeks of gluten-free
  diet?
• Gluten then reintroduced to test

Niewinski, 2008 Thompson, 2008
9
Symptoms

• More than 200 signs and symptoms Many have no
  symptoms at all
• Adults- most common symptom is iron deficiency
  anemia that does not respond to iron therapy
• Abdominal pain, bloody stools, chest pain,
  constipation, cough, diarrhea, difficulty
  swallowing, dizzyness, eye discomfort and
  redness, foot or ankle pain, foot swelling,
  headaches, hip pain, knee pain, nasal congestion,
  nausea and vomiting, neck pain, numbness or
  tingling in hands, pelvic pain, shortness of
  breath, shoulder pain, sore throat, urinary
  problems, vision problems, wheezing

Mayo Clinic, 2008
10
Treatment

• Currently, the only scientifically proven
  treatment for celiac
• disease is
• strict lifelong adherence to a
  gluten-free diet.1
• Elimination of all forms of wheat, rye and barley
• Even small amounts of gluten can be harmful and
  can cause continued damage.

1Niewinski 2008
11
Simple treatment not so simple

• Avoidance requires
• Raised awareness
• Knowledge of ingredients (hidden sources of
  gluten)
• Prevention of cross-contamination
• Vigilance
• Checking labels regularly, looking for ingredient
  changes
• Inquiring about food preparation when eating away
  from home

12
Gluten

• Includes several different grain storage
  proteins, or prolamins.
• Wheat gliadin
• Rye secalin
• Barley hordein
• Functions
• Provides structure of dough- holding ingredients
  together, retaining leavening gas as it is formed
• In contrastgluten-free flours
• Mainly starches and non-sticky proteins
• Cannot produce same results unless adaptations
  are made

13
Grain Classification

• Flowering Plants
• Monocots
  Dicots
• Gramineae (Grasses)
  Polygonaceae Amaranthaceae

Chenopodiaceae
Rice Corn Millet Sorghum Jobs Tears Ragi Teff Wil
d Rice Oats
Wheat Rye Barley Triticale
Buckwheat Rhubarb
Amaranth
Quinoa Spinach
Kasarda, 2003
14
Gluten Structure Properties

• Gluten 80 protein
• High molecular weight (glutenin average MW 3
  million)
• Substantial hydrogen bonding due to amino acid
  side chains
• Intertwined network filled with water in inner
  spaces
• Chemical structure binds water, helps in holding
  moisture
• Gliadin and glutenin absorb about twice their
  weight in water
• Also effective in binding lipids
• 2 main gluten proteins (prolamin glutelin)
• Gliadin (prolamin) sticky, extensible, low in
  elasticity
• Glutenin (glutelin) rubbery, low extensibility,
  high in elasticity
• Gluten controls baking quality of bread wheat
  flours

Brown, 2008 Hoseney, 1998
15
Wheat Flour Proteins
15
Dough forming
Non-dough forming
85
Gliadin
Glutenin
Non-gluten
Prolamin
Glutelin
Gluten
When wheat flour is mixed with water, a cohesive,
viscoelastic dough is formed.
Brown, 2008 Hoseney, 1998
16
Gluten containing grain products1

• Barley
• Bulgur
• Cereal Binding
• Chapatti flour (atta)
• Couscous
• Dinkel (Spelt)
• Durum
• Einkorn
• Emmer
• Farina
• Farro
• Fu
• Gluten, gluten flour

• Graham flour
• Kamut
• Malt (extract, vinegar, syrup)
• Matzoh meal
• Oats (commercial, bran)
• Orzo
• Rye
• Seitan (wheat meat)
• Semolina
• Spelt (Dinkel) 2
• Triticale
• Wheat (bran, germ, starch)

• See next slide
• 1Niewinski, 2008
• 2 Braithwaite, D. 2006

17
Oats

• Oats are often avoided-although storage protein
  in oats called avenin does not illicit same
  response as gluten
• Commercial oats have risk of cross-contamination
  from harvesting or processing
• Pure oats in moderation not a problem for most
• ½ cup dry rolled oats or ¼ c dry steel-cut oats
  per day1
• Expensive
• Proposed FDA rule Oats can be labeled GF if lt 20
  ppm gluten
• Availability
• Specialty markets or order online

1 Thompson, 2008
18
Gluten in food products

• Gluten often added at bakery to strengthen dough
• Often 20 of flour weight1
• Hamburger and hot dog buns
• Produces a strong hinge
• Stonger to withstand use of heavy condiments and
  sauces
• Used to increase protein content (breakfast
  cereals)
• Vital Gluten used as meat analog (vegetarian
  products, pet foods)
• Binder in sausage products
• 2005 Per Capita consumption of wheat products
  324.6 lbs2
• White bread reported to have 124,000 ppm gluten3

1Hoseney, 1998 2USDA, ARS, 2008 3Thompson, 2008
19
Questionable products

• Blue cheese (crumbles)
• Beer (GF-Greenes, Redbridge)
• Broth or bouillon
• Candy
• Caramel color/flavor
• Chocolates
• Communion wafers
• French fries
• Glucose syrup
• Herbal teas
• Ice cream

• Licorice
• Malt vinegar
• Maltodextrin (from wheat starch)
• Medications
• Nuts
• Puddings
• Salad dressings
• Rice mixes
• Sauces
• Seasonings
• Soy sauce
• Vegetarian burgers

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Nutritional considerations

• Due to decreased absorption of nutrients (damage
  to intestinal lining), and
• Lack of nutrient-fortified gluten-free products
• Fiber
• Look for whole grain versions that contain the
  bran layer
• (i.e. Rice bran, whole grain brown rice pasta,
  sprouted grains)
• Add ground flax seed to recipes
• Nutrient density
• Choose more nutritious ingredients such as
  amaranth, brown rice flour, buckwheat, flax,
  Montina, nut flours, quinoa, teff and legume
  flours (e.g. garbanzo/chick pea, Garfava and
  soy)
• Variety is key-to maximize protein, fiber and
  nutrients
• Nutrients of concern (focus on foods high in the
  following)
• Calcium May need lactase enzyme temporarily
  with dairy
• Iron Heme iron sources-red meats, chicken and
  fish, blackstrap molasses
• Folate and Vitamin B-12 Look for enriched
  products

21
Eight Most Common Food Allergens

• Peanut
• Tree nuts
• Fish
• Crustaceans

• Milk
• Egg
• Wheat
• Soy

90 of allergies to food
22
Food Allergen Labeling and Consumer Protection
Act (FALCPA)

• Labeling requirement effective 1/01/2006
• Amends the Federal Food, Drug, and Cosmetic Act
• Requires label to disclose certain allergenic
  ingredients
• Eight major food allergens
• A food ingredient that contains protein derived
  from a major food allergen
• Includes incidental additives, flavors, and
  colors that contain allergenic protein

23
FDA Voluntary Gluten Labeling

• Final rule on gluten free labeling by August
  2008
• Gluten the proteins that naturally occur in a
  prohibited grain and that may cause adverse
  health effects in persons with celiac disease
• Prohibited grain Wheat (Triticum), rye
  (Secale), barley (Hordeum), crossbred hybrids
  (e.g. triticale)
• Ruling Spelt is not GF
• Threshold less than 20 ppm
• Proposal on display _at_ Office of the Federal
  Register 72 FR 2795

http//www.cfsan.fda.gov/dms/glutqa.htmlq8
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Preventing cross-contamination

• Cross-contamination can introduce gluten into
  gluten-free foods
• Even tiny amounts can cause damage
• Contaminates can be air-borne or on surface
• Shopping
• Avoid purchasing staples from bulk bins
• At Home
• Keep food preparation areas separate
• Prepare GF foods before non-GF foods
• Clean grills, cutting boards, knives, utensils,
  thermometers, cloths and sponges
• Color-coding can help
• Separate toaster, butter dish, condiments (use
  squeeze bottles)
• Toaster bags reusable, transparent bags for use
  in toasters, countertop grills, toaster ovens
• Containers should be well marked and sealed
• Use pure spices rather than blends

25
Gluten Free Grains, Flours, and Starches1

• Amaranth
• Arrowroot
• Bean Flours (garbanzo, fava)
• Buckwheat
• Corn
• Fava
• Flax seed
• Garbanzo beans
• Garfava flour (garbanzo fava)
• Hominy
• Mesquite flour
• Millet

• Montina
• Nut flour and meats
• Oats (uncontaminated)
• Peas flour
• Potato flour
• Potato starch
• Quinoa
• Rice, all forms even glutinous
• Sago
• Sorghum flour
• Soy flour
• Tapioca (manioc, cassava, yucca)
• Teff (or tef) flour

• See Oats slide
• 1Niewinski 2008

26
Alternative Grains

• Beyond breads salads and main dishes
• Dont have same framework as gluten
• Elasticity
• Extensibility
• Storage shelf-life is often shorter than flour
• Tip Cook extra grains freeze in small batches
  to thaw and use in recipes as needed
• In 2007, 636 GF food products on the market

Rocky Mountain Food Safety Conference, 2008
27
Gums other binders

• Xanthan gum is a polysaccharide produced by a
  process involving fermentation of glucose or
  sucrose by the bacterium Xanthomonas campestris.
• Used as a stabilizer, binder- prevents crumbling
• Yeast breads 1 tsp. per cup of non-GF flour
• Quick breads ½ tsp. per cup of non-GF flour
• Guar Gum Isolated from guar beans
• Best in baking that does not require yeast
• Tapioca plant starch derived from cassava
  (manioc) root
• Thickener and binder

http//en.wikipedia.org/wiki/Xanthan_gum
28
Baking - flour options

• Low-Gluten Flour combination used is key!
• Keep various mixtures on hand-refrigerate in
  covered containers until used.
• All purpose flour blend (general baking)
• High fiber blend (breads, pancakes, snack bars,
  cookies)
• High-protein blend (baked goods requiring
  elasticity (pie crust))
• Self-rising blend (muffins, scones, cakes,
  cupcakes)
• All Purpose Mixtures (to replace wheat flour)
• 1) ½ cup sorghum flour ½ cup bean flour 2 T.
  tapioca starch
• 2 ) ½ c. rice flour, ¼ c. tapioca starch, ¼ c.
  cornstarch or potato starch
• 3) 1 c. brown rice flour, 1 c. white rice or
  teff flour, 2/3 c. potato starch, 1/3 c. tapioca
  starch

1) Dietitians of Canada 2) Substitution
Solutions www.livingwithout.com June/July
2008 3) Bette Hagman, 1999
29
Baking tips

• Better results with combination of alternative
  flours
• Use gelatin, extra egg or oil to increase
  moisture
• Enhance flavor add chocolate chips, nuts, dried
  fruits, extra spices
• Milk products can enhance structure (cottage
  cheese, dry milk solids, extra eggs, evaporated
  milk)
• Reduce grainy texture mix rice flour or corn
  meal with liquid called for bring to boil and
  cool before adding to recipe.
• Honey or rice malt syrup can help retain moisture
• Dough enhancers improve tenderness staling
  resistance
• Brown sugar often works better than white
• Be creative! (i.e. Casserole topper use crushed
  rice cakes for bread crumbs)

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Baking tips

• Leavening
• Starch flours need more leavening than wheat
  flours
• ROT use 2 tsp. baking powder per each cup of low
  gluten flour
• If baking soda and buttermilk are used for
  leavening, add 1 1/8 tsp. cream of tartar for
  each ½ tsp. baking soda used (to sufficiently
  neutralize the acid)
• For better rise, dissolve leavening in liquid
  before adding to other ingredients.
• Pre-baking
• Refrigerate low gluten products before baking to
  improve texture.
• Let non-yeast doughs rest for 30 minutes before
  baking (kneading time is shorter-no elastic
  feel)
• Grease pans well (non-stick spray)
• Use dull or dark pans for better browning
• Time and Temperature
• Bake in smaller than usual portions at lower
  temperature for a longer time
• English muffin tins good size for bread recipes

Wheat, Gluten, Egg and Milk Free Recipes for Use
at High Altitudes and at Sea Level. CSU
Extension Bulletin 530A
31
High Altitude Adjustments

• Cannot assume that usual high altitude
  adjustments will work with gluten-free recipes
• Additional adjustments may or may not be
  necessary
• Standard recipes adjust for gluten-free first,
  then experiment with altitude adjustments
• Tested gluten-free recipes try basic altitude
  guidelines (extra moisture, slightly less
  leavening, shorter rise time, etc.)
• More research needed in this area (large variety
  of gluten-free ingredients available now)

Wheat, Gluten, Egg and Milk Free Recipes for Use
at High Altitudes and at Sea Level. CSU
Extension Bulletin 530A
32
Bread making and storage

• Add 1 to 2 T. more flour
• Decrease sugar by 1 to 2 tsp.
• Shorten rising time by 10 min.
• Gluten-free breads will lose moisture quickly!
• To retain moisture
• Wrap product well in airtight packaging
• i.e. Use wax paper in between layers
• Wrap individually
• Store in refrigerator
• Freeze product if wont be consumed within 3 days

Hagman,1999
33
Retail Products

• GF is mainstream
• GF food industry gt 25 growth annually 700
  million(2006)
• Expected to top 1 billion by 2010
• Ask/look for lists of gluten-free products
  available
• Read food labels
• Many cereals and grain products are labeled
• Rice Chex first mainstream GF cereal
• Check out local resources
• Natural food markets some have list of all GF
  products
• Specialty bakeries
• Restaurants many offer GF entries
• Local products Fionas Gluten-Free Quinoa Crunch

Denver Metro Chapter-Celiac Sprue Association
34
Eating away from home

• Some restaurants have special menus, have to
  request
• Some available online
• Call ahead and speak with manager or chef to
  determine what food items are GF.
• Beware- oil in deep fat fryers often contaminated
• Make server aware (no croutons on salad, etc.)
• Ask him/her to check with cook/chef or read
  ingredient label if in doubt

35
Eating away from home

• Traveling restaurant cards are available in 42
  languages
• http//www.celiactravel.com/restaurant-cards.html
• Hospital ask to speak with dietician
• School talk with teacher, cafeteria director or
  food service manager
• Potlucks take something filling, GF selections
  may be limited

36
Living a Gluten-free Lifestyle

• View as an opportunity to follow a healthy diet
• Experiment with recipes
• Focus on the wide array of GF foods
• Try out new GF foods carefully
• Take advantage of growing number of resources,
  cook books support groups
• Attitude is important
• Quite frankly, there has never been a better
  time to be diagnosed with celiac disease.
  Tricia Thompson,
  M.S., R.D.

Thompson, 2008
37
Resources-Handouts

• Living Without Pantry Substitution Solutions
  www.livingwithout.com
• Go Gluten Free! Tips for Getting More Nutrition
  Into the Gluten-Free Diet
• By Shelley Case, RD www.livingwithout.com
• New Horizons for Whole Grains and the Gluten-Free
  Diet
• By Carol Fenster, PhD wwwglutenfreequickandeasy.
  com and
• Shelley Case, RD, author of The Gluten-Free
  Diet A Comprehensive Resource Guide
• at wwwglutenfreediet.ca
• Wheat, Gluten, Egg and Milk Free Recipes for use
  at high altitudes
• and at sea level CSU Extension Bulletin
  530A http//www.cerc.colostate.edu/titles/530A.h
  tml

38
Resources References

• Alessio Fasano, M.D., director Univ. of Maryland
  School of Medicines Center for Celiac Research
  www.celiaccenter.org
• Celiac disease, MayoClinic.com, accessed July,
  2008 http//www.mayoclinic.com/health/celiac-dise
  ase/DS00319
• Celiac Sprue Association-Denver Metro Chapter
  http//www.geocities.com/csadenver17
• Gluten-Free Diet Guide for Families Childrens
  Digestive health and Nutrition Foundation
  (CDHNF) University of Maryland Center for Celiac
  Research. www.celiachealth.org
• Health Canada (Oat Safety Technical Review)
  www.hc-sc.gc.ca/fn-an/securit/allerg/cel-coe/oats_
  cd-avoine_e.html
• High Altitude Food Preparation http//www.cerc.col
  ostate.edu/titles/P41.html and
  http//www.cerc.colostate.edu/titles/530A.html
• Questions and Answers on the Gluten-Free Labeling
  Proposed Rule U.S. Food and Drug Administration
  ,Center for Food Safety and Applied Nutrition
  (FDA-CFSAN) at http//www.cfsan.fda.gov/dms/glutq
  a.htmlq8.
• The Faces of Celiac Disease trifold Celiac
  Disease Foundation. www.celiac.org

39
References

• Braithwaite, D. (2006) Do Oats or Spelt Belong
  in a Gluten-free Diet?, MS Thesis, Colorado State
  University, Fort Collins, Colorado
• Brown, A. Understanding Food. Thomson/Wadsworth,
  Belmont, CA
• Fasano, A., I. Berti, T. Geraduzzi, T. Not, R.
  Colletti, S. Drago, Y. Elitsur, P. Green, S.
  Guandalini, I. Hill, M. Pietzak, A. Ventura, M.
  Thorpe, D. Kryskak, R. Fornroli, S. Wasserman, J.
  Murray, K. Horvath (2003) Prevalence of celiac
  disease in at-risk and not-at-risk groups in the
  United States A large multicenter study.
  Archives of Internal Medicine 163 286-92.
• Hagman, B. (1999) The Gluten-Free Gourmet Bakes
  Bread. Owl Books, New York.
• Hoseney, C. (1998) Principles of Cereal Science
  and Technology, AACC, St. Paul, MN
• Kasarda, D. (2003) Celiac Disease and Safe
  Grains. USDA. wheat.pw.usda.gov
• Niewinski, M. (2008) Advances in Celiac Disease
  and Gluten-Free Diet. Journal of the American
  Dietetic Association, 2008108661-672
• Thompson, T. (2008) The Gluten-Free Nutrition
  Guide, McGraw Hill, New York
• USDA, United States Department of Agriculture,
  Economic Research Service. www.usda.gov

40
Acknowledgements-CSU Extension

• Laura Bauer, Masters student-FSHN
• Linda Quaratino, Administrative Assistant
• Pat Kendall, PhD, RD, Professor and Extension
  Specialist
• Mary Harris, PhD, RD, Professor
• Martha Stone, PhD, Professor