Shanti Patient Related Education And Directions (SPREAD))

If you are a patient with celiac disease what do you need to know about your diet?
Deepa Negi, Ujjal Poddar MD, DNB, DM Department of Pediatric Gastroenterology, SGPGIMS, Lucknow
Gluten is the protein, which is responsible for the disease called celiac disease. This is a food sensitive enteropthy and if we can remove the offending agent (gluten) from the diet, the disease becomes quiescent. Therefore knowledge about gluten free diet is essential for all celiac disease patients. Gluten is the storage protein found in wheat, barley, rye and hybrid of these grains. Diet totally devoid of these gluten containing foods is called gluten free diet.

Difficulties in complete removal of gluten from the diet:

1. Gluten containing grains form the staple food in diet of people of many regions. 2. These grains perform multiple functions due to their cooking properties such as thickening, binding, adding flavors etc. Thus, are used in preparation of many foods in some or the other form at home. That is, hardly we can find a day without eating these. 3. Gluten may be present in various forms (commonly as food additives) in

Gluten free diet is the only accepted treatment for the celiac disease, thus compliance with this diet must be life long. Staying on strict gluten free diet improves the patients condition.

processed foods. Most of the time, you cannot identify them by the ingredients name. 4. There can be contamination of many foods with gluten, while production and processing, though these might not be containing wheat or its products in their ingredients. Thus, one cannot rely on labels also. According to Codex

International, a food product prepared from naturally gluten free ingredient is said to be gluten free if it contains less
Fig: 1. Cereals that should be avoided (marked X) and are safe (marked ).

than 20 ppm gluten, and those prepared from naturally gluten containing food, if

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it contains less than 200 ppm gluten. In Indian market, the processed food products do not contain the mark of gluten free, as it is not mandatory. Moreover, there are so many food processing industries, large and small scale. Though, good brand can be relied, but, most of the time due to wheat grown is ground to wheat flour. Wheat flour is used to prepare chapatti, parathas, and poories etc, which form a part of the main course in the meal, particularly in north Indian diets. Moreover wheat flour, because of its thickening property and round-the-clock availability in Indian

kitchen, is used in most of the recipes e.g.kadi, badi ki sabji. It can be replaced by rice, maize, bajra, jowar and other locally available millets flour or products. Oats (jav), which has been in controversy for inclusion in GFD, has been proven, not containing gluten

inaccessibility and non affordability, people mostly buy the substitute of it, prepared by locally based small scale food processing units. These food most of the time do not follow food standards and insufficient labeling on them can be dangerous. 5. Derivatives from these are used as ingredients in drug, nutritive

themselves. But it is advised to avoid its use in the celiac disease because of its contamination with wheat. Arrowroot flour, dried water chestnut (singara) flour, kootu ka atta, potato flour and starch, tapioca starch, cornstarch can be a good

supplements and any cosmetic products (which can be accidentally being eaten up). People buy them over-the-counter without consulting their doctors. Thus with the above mentioned difficulties, it is essential to educate a patient with celiac disease about list of gluten containing and gluten free foods in his surrounding. If one is holding a good knowledge of gluten free foods, it is not difficult to prepare a gluten free nutritionally adequate diet by proper selection. General guidelines for gluten free diet: In our country, the major portion of the

replacement. Gram flour (besan), soy flour is higher protein gluten free flour. Avoid wheat product like broken wheat (Dalia), semolina (sooji), vermicelli (siwain), noodles (e.g. maggi), pastas, and macaroni. They are used mainly as dessert or in snack items. Eat traditional nutritious snacks and desserts that are also high in protein like rice kheer, moong dal kheer, carrot halva, potato halva, potato wada, pakodas, besan ka chilla, peanut crispies, poha, idli, dosa etc.

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Especially those prepared by halwais; even completely milk based mithai also have maida. Prepare sweets at home which, are purely made of milk or khoa. Make khoa also at home.

Fig: 2 Food items that contains Gluten protein

The bakery products (cake, biscuit, bread, patties) available are made from white flour (maida) as their main ingredient. Moreover, most of the baking powders used contain wheat starch. Replace white flour in baked food with finely ground rice flour combined with other flours or starches. Also use baking powder which have cornstarch in place of wheat starch. Processed sweet food like toffees, chewing gum, and chocolates use wheat starch as additives in the form of thickener, stabilizer, flavors etc. You can eat home prepared sweet dishes not containing gluten. In our country, where almost every month, there is one or the other festival to be celebrated and sweetmeats (mithai), being the one of the main food item, is a problem as most of the sweets contain maida. In cold foods, the popular item like icecream also contains wheat starch as
Fig: 3 Food items which is free from Gluten protein and can be acceptable for patient to eat.

emulsifier. You can eat ice cream prepared at home with milk, sugar and corn flour. Avoid beverages like barley water, soups (thickened by wheat flour or contains bread crumbs), bottled milk shakes.

Have fresh juice, milk, home prepared clear soup or soup prepared with corn starch. An increasing trend of using nutritional supplements has been observed. Most of the nutritional supplements available over the

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counter contain maltodextrin, which is derived from wheat starch. The most popular brands available in India are bournvita, complain, horlicks etc. Eat healthy nutritious diet; you will not need nutritional supplements. Still, if you are not clear, consult your doctor for the gluten free foods. Good dietary habits will reduce the risk for further complication. Points to remember 1. Dal, vegetables, fruits, milk, nonvegetarian food, sugar, and oil can be taken. 2. Avoid recipes in which wheat or barley is added in any from. 3. Avoid contamination of food from wheat during preparation and processing time e.g. from utensils. Gluten free flour (corn flour and others) should be grinded at home or grinder used for spices. 4. Preferentially eat home prepared foods. To help the patient, family should eat mostly gluten free recipes, whenever eating together. If possible at lest the lunch on Sundays. 5. Avoid doubtful foods containing wheat/ barley.

supplement. Those who eat frequently out of the home should be careful about taking thickened recipes, coated food, and stuffed food. With these foods, the accompaniment like

vinegar, sauce, cheese, mayonnaise, pickles also contain derivatives from wheat starch. You should also be careful about

contamination while preparation. Avoid eating out. Eat home prepared food

preferentially. At home, be careful about contamination while preparation e.g. from utensils, cooking surfaces. Those whose diet consists mainly of processed, canned or packaged food should be careful of the ingredients. Avoid them if possible or read the label for ingredients carefully. Avoid food, whose ingredients list contains words like flour, starch, malt. It is best to avoid these as you can not be sure about contamination at any step of the production, processing, packaging etc. Thus, it is advisable to base your meal on naturally

Guidelines for the gluten free diet chart is given in the Table below.

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r Not to be given
Wheat & Barley Cereals Wheat flour (Atta), Barley (Jaun) flour (Roti, Paratha, Poori, Nan) Wheat flour (Maida) Broken wheat (Dalia) Semolina (Sooji) Vermicelli (Siwain) Noodles Pasta (Spaghetti, macaroni) Bakery Foods Bread Burger, Hot dog Biscuits, Cookies, Nan khatai Patties, Pizza Cake, Pastry, Pie Sweets & Confectionery Chocolates Toffees (Milk & chocolate), Chewing gum Most Sweetmeats (mithai) Ice-cream & ice-cream mixes, custard

aTo be given

Rice/ Pulav/ Biryani Maize Bajra Roti Jowar Roti Arrowroot flour Gram flour Water chestnut flour (Singhara ka atta) Kuttu ka atta

Home- prepared biscuits or cake replacing white flour with rice flour or arrowroot flour, corn flour

Sugar candy (poppins, chlormint, mango bite) Home prepared sweets Ice-cream candy or home prepared ice cream, Jam

Beverages Nutritional drinks e.g. Bournvita, Complan, Boost, Horlicks etc. Chocolate drinks, Barley water Flavored milk, Flavored Coffee Canned soup & soup mixes Thick soup (Broth thickened by barley or macaroni) Most stew (thickened by refined flour) Milk and buttermilk Coffee, tea Squashes, fruit juices Home prepared clear soups (Only stock, no refined flour)

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rNot to be given
Other Processed Food Cheese (mozzarella) Corn flakes Sauces, puree Instant curry mixes White vinegar Mayonnaise Commercial salad dressing Pickles (in white vinegar) Food additives Most baking powder, Ajinomoto Food Preparation

aTo be given
Cottage cheese (Preferred home prepared) Home prepared sauces e.g. tomato sauce Rice or cider vinegar

Home prepared pickles in oil only

Recipes thickened by wheat flour

Recipes

thickened

by

corn

starch,

arrowroot flour, rice flour, potato starch Recipes with stuffing of bread crumb. tapioca starch, water chestnut (Singhara), starch, ground onion, coconut & poppy Food coated by wheat flour batter or bread crumbs seeds. Food coated by gram flour batter.

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