PrecautionsIn addition to gluten-containing grains, gluten
can be found in a large variety of foods including
soups, salad dressings, processed foods, candy, imi-
tation bacon and seafood, marinades, processed lun-
cheon meats, sauces and gravies, self-basting poultry,
soy sauce or soy sauce solids, thickeners, communion
wafers, and natural flavorings. Unidentified starch,
binders and fillers in medications. supplements, or
vitaminsand adhesives in stamps and stickers can
also be unsuspected sources of gluten. Playdough,
which contains wheat, can be harmful if hands are
put on or in the mouth after contact or hands are not
washed after play.
An individual following a gluten-free diet must
read labels every time a food item purchased or con-
sumed. Ingredients that may contain hidden sources of
gluten include unidentified starch, modified food
starch, hydrolyzed vegetable or plantprotein(HVP
or HPP), texturized vegetable protein (TVP), and
binders, fillers, and extenders. In addition, manufac-
turers can change ingredients at any time, and a prod-
uct may no longer be gluten-free. Ingredients may be
verified by contacting a manufacturer and specifying
the ingredient and lot number of a food item. If a
person cannot verify ingredients in a food product or
if the ingredient list is unavailable, the food should not
be eaten, to avoid damage to the small intestine that
occurs every time gluten is consumed.
Gluten-free recommendations can be difficult to
follow. It is recommended that an affected person
keeps the diet simple at the beginning by eating fresh
fruits and vegetables, milk, unprocessed protein foods
such as fresh beef, pork, poultry, fish, and eggs, natu-
ral nuts, seeds, and vegetable oils without additives.
Pure, uncontaminated oats eaten in moderation
(one cup cooked daily) may be safe for persons with
celiac disease. However, in many cases oats can
become cross-contaminated with grains containing
gluten during growth, harvest, transport, storage, or
processing. Some persons with celiac disease who
introduce oats to their diet may experience abdominal
discomfort, gas, and stool changes until they become
accustomed to the increasedfiberlevels from the oats.
Others with celiac disease may exhibit a hypersensitiv-
ity to oats and should avoid their consumption.
Recent research published in the last few years (2000
to 2004) has indicated that oats may contain a protein
similar to gluten that has caused intestinal inflamma-
tion in many persons with celiac disease. At this time,
because of conflicting information on the effects of
oats on persons with celiac disease, excluding oats
from the diet may be the best and most risk-free
choice. In all cases, persons with celiac disease should
consult their health care provider or dietitian before
including oats in their diet and should have their anti-
body levels monitored regularly.
Almost all beers are brewed with barley (some are
brewed with wheat) and should not be consumed by a
person following a gluten-free diet. Sorghum and buck-
wheat beers are available but are a specialty product.
Most distilled forms of alcohol are gluten-free, unless
additives and colorings have been added, which may
contain glutens. Wines are also usually gluten-free.
Since celiac disease is an inherited autoimmune
disease, screening of family members is recommended.
The chances of developing gluten-sensitive enterop-
athy increases to 10 to 20% in persons who have a
first-degree relative with celiac disease. Celiac disease
is also associated with other autoimmune syndromes
such as Type 1 diabetes.RisksA gluten-free diet is difficult to follow, and con-
tinued health problems are usually associated with
problems with adhering to the gluten-free diet. A per-
son can exhibit celiac-related symptoms for months
after a single gluten intake. Persons with gluten-sensi-
tivity who do not treat their disease are at a higher risk
for enteropathy-associated T-cell lymphoma and
other gastrointestinal cancers. However, the mainte-
nance of a long-term gluten-free state reduces the risk
of lymphoma to the level seen in the general popula-
tion. Other complications of gluten-sensitivity include
decreased mineral bone density and iron-deficiency.
Persons with celiac disease and dermatitis herpetifor-
mis must maintain a gluten-free diet for the rest of
their lives, for these diseases cannot be cured.
Persons are more likely to adhere to the diet if a
dietitian and support group are involved. If a person is
not responding well to a gluten-free diet, the doctor
should:
Investigate whether the initial diagnosis of celiac dis-
ease was correct
Check for other conditions that can be causing symp-
toms, such as pancreatic insufficiency, irritable bowel
syndrome, bacterial overgrowth, lymphocytic colitis, T-
cell lymphoma, fructose intolerance, or tropical sprue
Refer the person to a dietician to check for errors in
the diet or for compliance with the dietGluten-free diet