Gluten Free Diet

Advocate Lutheran General Hospital Food and Nutrition Services (847) 723-7719 Revised January 2012

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The Gluten Free Diet The gluten-free diet is the primary treatment for Celiac disease and Dermatitis Herpetiformis (DH). Celiac disease is a digestive disease that damages the small intestine and interferes with the absorption of nutrients. The gluten-free diet is designed to decrease abdominal distension, diarrhea, steatorrhea and weight loss often associated with ingestion of foods containing gluten, a protein found in wheat, rye, barley, and possibly oats. Also, to interrupt the autoimmune process triggered by gluten. Many people have “silent celiac disease”, with no gastrointestinal symptoms. Down syndrome increases a person’s susceptibility to celiac disease. Celiac disease is more common in people with DS than in the general population and may occur as frequently as 5.5% of people with Down syndrome. Dietary management includes the gluten-free diet along with a gluten-free multivitamin and iron supplement, if needed. Patients should be advised that life-long elimination of gluten-containing products is required, even when symptoms have subsided. For an individual with Down syndrome to successfully follow the gluten-free diet, it can be helpful to use visual supports, since people with DS are often visual learners. Suggestions include: 1. Making a picture guide of acceptable foods 2. Saving food labels from acceptable foods (or making color copies of the labels) and categorizing the foods as snacks and main dishes. Be sure to include pictures of restaurant foods. This is a general list for your information. Always remember to read the full ingredient list when purchasing any product. If in doubt, contact the manufacturer about ingredients used in packaging or processing. This diet is a general diet with the elimination of all goods prepared with wheat, rye, barley, and sometimes oats. Depending on the individual’s food choices, the diet is adequate in all nutrients. Helpful information Medications – Some use gluten as the filler for tablets and capsules. Ask your pharmacist and contact manufacturers. (The website www.glutenfreedrugs.com is a helpful resource) This includes over the counter as well as prescription medicines and vitamins Cross-Contamination – Be careful to always use clean plates and cooking areas. Avoid cross contamination from gluten containing foods. Use a separate toaster, margarine, butter, peanut butter, jelly containers.

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LABEL READING GUIDELINES Food Allergen Labeling and Consumer Protection Act (FAL CPA) became effective on all foods labeled after January 1, 2006. Per this law wheat (not barley or rye) must be labeled in plain terms, such as “contains WHEAT”. Wheat can be listed in ingredient list OR lower on package as “contains wheat” The term “Gluten Free” is not currently regulated, though is generally reliable.

GLUTEN-FREE

FOODS TO QUESTION*

Annatto Dextrin Apple cider vinegar Food starch Ascorbic Acid Modified food starch Calcium carbonate Modified starch Canola Oil Mono and diglycerides Corn starch Dextrose Distilled vinegar Gelatin Glycerides Gram flour (chick peas) Guar gum Hydrolyzed soy protein Lactose Caramel color (for foods made in North America) Monsodium glutamate (made in the USA) Sodium Benzoate Starch (always from corn in the USA for foods only: not Medicines) Stearic acid Vanillin Vinegar (always from apples in U.S.) White vinegar Fructose Aspartame (nutrasweet) Mannitol Maltose Acesulfame-potassium (sweet-one) Maltodextrin Sucralose (splenda) Sorbitol Saccharin (sweet n low)

GLUTEN CONTAINING Barley malt Beer Bran Couscous Durum wheat Germ Graham Malt Malt extract Malt flavoring Malt syrup Malt vinegar Miso Pasta Rice malt Semolina Soy sauce Wheat Rye Bleached Flour Hydrolyzed wheat protein

*May be safe if made from gluten-free source, such as corn

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GRAINS GLUTEN-FREE

FOODS TO QUESTION*

Amaranth Arrowroot Bean Buckwheat (pure) Carob Corn (bran, meal, starch) Chick Pea (garbanzo) Corn tortillas Flax Garfava Hominy Job’s tears Mesquite Millett Montina™(Indian rice grass) Nuts Pea flour Potato and potato starch Quinoa Ragi Rice and rice bran Sago Sorghum (milo) Soy Sweet potato Tapioca (cassava, manioc) Taro Teff Wild rice

Rice or Potato Mixes Oats (may be safe for some after stabilized on gluten-free diet. Oats must be pure, uncontaminated. Commercial oats contain significant amounts of gluten from crosscontamination. Oats should be labeled gluten free)

GLUTEN CONTAINING Atta Barley Bulgar Cake flour Couscous Einkorn Emmer Farina Farro Graham Kamut Gluten/low gluten flour Matzo/matzah Pumpernickel Rye Semolina Spelt Triticale Wheat Wheat starch, bran and germ Wheat/white flour tortillas

CEREALS GLUTEN-FREE

FOODS TO QUESTION*

Cornmeal Cream of Rice (brown or white) Hominy grits Quinoa flakes Corn flakes – may contain Polenta malt flavoring Puffed Amaranth Puffed corn Rice crispy generic-may contain Puffed rice malt flavoring

GLUTEN CONTAINING All cereals containing wheat, rye, barley or malt

*These foods may contain gluten unless clearly labeled gluten free. The labels on theses foods need to be read carefully and the manufacturer 4

contacted if necessary. Rice flakes Soy Cereal (flakes, grits) General Mills- Chex® Gluten Free (rice, corn, honey nut, chocolate, cinnamon) Cream of Buckwheat Specialty Gluten Free labeled cereals Rice Krispies® labeled Gluten Free

Protein Foods GLUTEN-FREE Beans and legumes Eggs Nuts Peanut Butter Plain tofu Fresh or Frozen meats, fish and poultry

FOODS TO QUESTION* Dried meats Baked beans Canned park & beans Marinated meats Processed/preserved meats such as luncheon meats, ham sausage, pate, wieners Imitation meat or fish Meat loaf Meatballs Basted turkey Tempeh Miso Sushi

GLUTEN CONTAINING Breaded meats Gravy packets Turkey with stuffing Fu Seitan

DAIRY FOODS GLUTEN-FREE

FOODS TO QUESTION*

GLUTEN CONTAINING

Butter Milk: fresh, dry evaporated, condensed Lactaid milk® Cheese Cream cheese Cottage cheese Sour cream Most yogurt Cream Buttermilk Most ice cream

Flavored yogurt Milk drinks Frozen yogurt Cheese sauce Cheese spread

Malted milk Yogurt toppings Ice cream containing cookies or malt

*These foods may contain gluten unless clearly labeled gluten free. The labels on theses foods need to be read carefully and the manufacturer contacted if necessary.

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BEVERAGES GLUTEN-FREE

FOODS TO QUESTION*

Brandy Flavored coffee Champagne Hot chocolate mixes Distilled alcoholic beverages (such as rum, gin, scotch, whiskey, vodka, bourbon) Ouzo Flavored alcoholic beverages Cocoa (such as coolers or cider) Most soft drinks Most root beer Coffee Pure Liqueurs Sake Tea Tequila Wine Specialty gluten-free beers Most non-dairy beverages (such as rice, soy, nut milks)

GLUTEN CONTAINING Beer Lager Ale Malted alcoholic drinks Malted beverages Malted wine coolers Ovaltine® Postum®

SOUPS GLUTEN-FREE

FOODS TO QUESTION*

GLUTEN CONTAINING

Homemade broth or stocks

Bouillon cubes Dried soup mixes Canned soups

Most canned soups Ramen noodle soups Soups made with wheat, rye or barley

Stocks/soups made with gluten-free ingredients Gluten-free bouillon cubes

FRUITS GLUTEN-FREE

FOODS TO QUESTION*

GLUTEN CONTAINING

All fruits, fresh, frozen and canned

Dried fruits Fruit pie fillings

Fruits topped with streusel or granola

*These foods may contain gluten unless clearly labeled gluten free. The labels on theses foods need to be read carefully and the manufacturer contacted if necessary. 6

VEGETABLES GLUTEN-FREE

FOODS TO QUESTION*

GLUTEN CONTAINING

All vegetables, fresh, frozen and canned Dried vegetables

Au gratin/scalloped potatoes

Vegetables, breaded or batter dipped

Creamed vegetables Fried potatoes and French Fries (or other fried vegetables cooked in oil with other gluten containing foods such as chicken nuggets or onion rings)

SWEETS AND DESSERTS GLUTEN-FREE

FOODS TO QUESTION*

GLUTEN CONTAINING

Fruit ice Gelatin Specialty gluten-free desserts Gummy candy Honey Jam/jelly/marmalade Corn syrup Maple syrup Molasses Sugar (brown and white) Pure chocolate Sherbet Whipped topping Marshmallows

Candy Chocolate bars Caramel

Candy with malt or crispy rice Ice cream cones

Nougat candy Chewing gum Icing/frosting Lemon curd

Licorice Regular cookies, pies and cakes

SNACK FOODS GLUTEN-FREE

FOODS TO QUESTION*

Most rice or popcorn cakes Flavored/smoked chips, popcorn, Nuts nuts, rice or popcorn cakes Popcorn Soy nuts Most potato chips Seeds Specialty Gluten-free crackers Tortilla/corn chips

GLUTEN CONTAINING Chex® mix Regular pretzels Pringles® Regular crackers

*These foods may contain gluten unless clearly labeled gluten free. 7

The labels on theses foods need to be read carefully and the manufacturer contacted if necessary.

FATS GLUTEN-FREE

FOODS TO QUESTION*

GLUTEN CONTAINING

Butter Lard Margarine Vegetable Oil Shortening

Mayonnaise Salad dressing

Salad dressing made with wheat, rye or barley

CONDIMENTS GLUTEN-FREE

FOODS TO QUESTION*

Distilled vinegar Marinades Specialty gluten-free soy Worcestershire sauce or teriyaki sauce Mustard pickles Ketchup Steak sauce MSG (monosodium glutamate made in USA) Teriyaki sauce Most spices Spice mixes Mustard Curry paste Olives Plain pickles Pure herbs and spices Red wine/cider vinegar Relish Salt

GLUTEN CONTAINING Malt vinegar Regular soy sauce Yeast malt

MISCELLANEOUS FOODS GLUTEN-FREE

FOODS TO QUESTION*

GLUTEN CONTAINING

Aspartame Baking soda Carob chips and powder Chocolate chips Coconut Cream of tartar

Baking powder Regular communion wafers Low gluten communion wafers Sauces/gravies made from to order: wheat, rye or barley Benedictine Sister Altar Brewer’s yeast Bread Department 31970 State Hwy P Cyde, MO 64432 [email protected]

Sauces and gravies made with gluten-free ingredients Most yeast Gluten-free communion wafers Vanilla extract

*These foods may contain gluten unless clearly labeled gluten free. 8

The labels on theses foods need to be read carefully and the manufacturer contacted if necessary.

SAMPLE MENU FOR GLUTEN-FREE DIET Breakfast Orange juice Poached egg Hash brown potatoes Soft margarine or butter Jelly Coffee Half and Half Sugar

Lunch Gluten-free deli meat Gluten-free bread Sliced tomato & lettuce Corn chips Salad Peach halves Mild or soda

Dinner Juice or milk Broiled beef or chicken or fish Rice or potato or quinoa Spinach Butter or margarine or sour cream Gluten free ice cream or sherbets

Snack Nuts Yogurt Fruit

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When You Want to Do Your Own Baking Flours for Gluten-Free Baking Rice Rice flour is frequently used in gluten-free baking. Since it has a slightly gritty texture, it is best combined with smooth flours or starches. Brown rice flour is ground from the whole unpolished grain and retains most of the vitamins and minerals of the bran and polish. Nutritionally, it is preferred to white rice flour. White rice flour is derived from white milled rice. Use only enriched white rice flour. Sweet rice flour is ground from short rice and is more gelatinous in nature. It is useful in thickening liquids to be frozen or refrigerated, as it prevents separation, or in small amounts in baking, as it improves binding and structure. Rice bran is the fluffy layers of bran removed from brown rice in milling into white rice, and is rich in iron, calcium, phosphorus, potassium, vitamins B and E, and protein. It should only be used in small amounts, as it adds fiber to the diet and tends to make baked goods more crumbly. Rice polish is the inner layers of bran derived from the milling process and is high in vitamins, minerals, and protein. Use in small amounts, as it does have a distinct texture and flavor.

Corn Cornmeal is a course flour ground from white or yellow corn. Yellow corn meal is available in the regular texture, and also in a fine milled texture. Unbolted (stone ground) cornmeal retains the nutritious outer layers of the corn grain, whereas refined cornmeal has undergone further processing and requires enrichment. Cornmeal, particularly yellow cornmeal, contains Vitamin A, and is used as predominant flour in gluten-free baking. Since it is not as nutritious as rice or soy flour, its use in the daily diet should be balanced with other flours. Corn grits are coarsely broken, dried grains of corn. Hominy grits are degerminated corn grits. Grits can be cooked as a cereal or served as a side dish. Cornstarch is a smooth white starch for thickening sauces and puddings.

Soybean Soy flour is a smooth, yellow flour milled from soybeans. Soya flour (soy flour which has been lightly toasted) or soya milk powder, when available, is preferred in baking to soy flour for a lighter product. Defatted soy flour has had the natural oil of the soybean removed. Since it is a rich, heavy flour and imparts a nut-like flavor, it is generally used in small amounts with rice flour or potato starch, and in products containing chocolate, coconut, nuts, applesauce and spices. As it is high in protein, it should not be overlooked. Soy grits are similar to meal flour in texture, and can be added to casseroles and hot corn meal in small amount to increase protein content.

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Potato starch is a fine white starch used in thickening and excellent in baking if sifted several times. Potato flour is coarser than potato starch, similar to granular instant potatoes. One or two teaspoons in a recipe will make a product smoother, moister and less crumble.

Tapioca Tapioca is a derivative of the Brazilian cassava root. Pearly tapioca must be soaked for an hour before using to soften. Minute or granular tapioca is smaller in size and can be used as a thickener. Mix tapioca in all the liquid, then boil. Either tapioca can be used in puddings and fruit pies. Sprinkle tapioca evenly over the top of fruit in a pie shell then bake. Tapioca starch is a very smooth white starch, excellent for thickening liquid to be frozen and for glazes.

Arrowroot Arrowroot is a derivative of a tropical American plant. Arrowroot starch is excellent for creams and glazes and can also be used in cookies.

Lentil, Lima Bean and Green Pea Lentil flour, lima bean flour and green pea flour are made from legumes.

Buckwheat Buckwheat is a plant, not a member of the wheat family. Pure buckwheat is gluten-free.

Carob Carob is a chocolate-flavored flour or powder ground from the pods of the St. John’s bread tree. There are many more gluten free grains not described here to try. Most are listed in the grains food section. Gluten free baking mixes are a good option also.

Baking Hints 1.

Gluten-free flours can produce delicious baked goods, although they will not taste exactly like wheat products.

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Since gluten is the element in wheat, rye, oats and barley that gives structure and binding properties to baked goods, baking with gluten-free flours presents a challenge to make a comparable light, smooth-textured product with little crumbling. You might have some disappointments at first, as it takes a little practice working with the various flours – measuring, sifting and beating – to achieve uniform results. Brands of flours vary in texture. You’ll be more satisfied with your first attempts if you stick with one cookbook and use the brands of flours recommended. Do not substitute ingredients. If you are not satisfied with one batch of bread or muffins, recycle it by crumbling and adding it to meat loaf or salmon loaf; or run it through the blender for breading on fried chicken or crumb topping on casseroles.

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Stir flour lightly before measuring and spoon into cup. Mix dry ingredients while sifting to blend the different textures of the flours evenly in the batter. Try a sieve and spoon rather than a conventional sifter, particularly for rice polish. Sifting flours three times improves texture. 11

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Follow recipes carefully, using exact measurements. Blend dry and moist ingredients well. Gluten-free batters may appear thicker than a comparable wheat recipe.

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Each gluten-free flour or starch has its own unique characteristics – rice flour and cornmeal tend to be grainy; soy flour imparts an oily texture and nut-like flavor, potato and corn starches thicken and toughen upon heating. Therefore, a combination of flours with rice flour or cornmeal predominating and soy flour or other starches in small amount produces a lighter product with better texture.

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Grease pans well and flour with the predominant flour in the recipe.

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In substituting gluten-free flours in your favorite wheat flour recipes, you will have better results if:

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a. The original calls for 2 cups or less of wheat flour which require substitution. b. Leavening is increased slightly, generally 2 ½ teaspoons baking powder to 1 cup coarse flour, like cornmeal or rice flour. Baking soda and an acid can also be used, generally ½ tsp soda, 1 1/8 tsp cream of tartar to 1 cup buttermilk. If buttermilk is allowed on the diet, you will find recipes utilizing buttermilk produce light, fine-textured pancakes and breads. An extra egg in place of the liquid, 1 tbsp gelatin dissolved in the liquid of the recipe, or beating yolks and whites separately will aid leavening. c. A teaspoon of potato flour for each cup of flour is added for binding. d. White rice flour is used when lightness and smooth texture are necessary; however, brown rice flour is more nutritious and preferred as the usual choice. e. Evaporated milk is substituted for whole mild or cottage cheese, dry milk powder or extra eggs are added, to compensate for the lower protein content of gluten-free flours. f. Recipes include applesauce, mashed pumpkin or mashed banana to smooth the gritty nature of rice flour; or raisins, chopped nuts, chocolate chips, coconut or grated carrots to cover the grainy texture of rice flour and cornmeal or the distance flavor of soy flour. g. Product is baked in small servings – small cookies, cupcakes or muffins, 8” loaves or 8” square pans. h. Dough without baking powder is refrigerated ½ hour before baking i. Cakes and cookies are frosted to prevent drying. j. Paper muffin liners are used. k. Baked good is loosened from sides of pan immediately after removing from the oven. Leave baked goods in pan, resting for 5 minutes before removing to cooling racks. This helps minimize crumbling. After cooling, wrap baked goods tightly and refrigerate for a maximum of 4 days, as product will begin to dry out. For longer periods of time, store in an airtight bag in freezer. If the texture of cornmeal or brown rice flour products is too course, or is difficult to digest, try: a. Heating the liquid in the recipe to boiling and pouring over the flour before combining all the ingredients. Let cool about 10 minutes and proceed with the recipe. b. Heating the liquid in the recipe to boiling in the top of the double boiler. Add flour and cook, stirring frequently, for 10 minutes. Remove the mixture from the heat, let cool 10 minutes and proceed with the recipe. 12

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Gluten-free flours and baked products do not contain preservatives and are perishable. It is recommended that flours be tightly packaged and placed in the freezer when purchased. A three or four week supply may be kept in the refrigerator for ready access.

Gluten-Free Flour Substitutes Substitutions for 1 Tablespoon Wheat Flour ½ tbsp Cornstarch ½ tbsp Potato starch or flour ½ tbsp White rice flour ½ tbsp Arrowroot starch 2 tsp Quick-cooking tapioca 2 tsp Tapioca starch 2 tbsp Uncooked rice

7 ml 7 ml 7 ml 7 ml 10 ml 10 ml 30 ml

Substitutions for 1 Cup (240 ml) Wheat Flour Mix: 2 cups Brown rice flour 500 ml 2 cups Sweet rice flour 500 ml 2 cups Rice polish 500 ml Store in an airtight container and use 7/8 cup (215 ml) of the mixture in place of 1 cup (240 ml) wheat flour. Other Substitutions for 1 Cup (240 ml) Wheat Flour 5/8 cup Potato starch 150 ml 7/8 cup White or brown rice flour 215 ml 1 cup Corn flour 240 ml 1 cup Fine cornmeal 240 ml ¾ cup Coarse cornmeal 175 ml 5/8 cup White or brown rice flour 150 ml 1/3 cup Plus Potato starch flour 75 ml 1 cup Soy flour 240 ml ¼ cup plus Potato starch flour 50 ml ¾ cup Rice flour 175 ml ¼ cup plus Cornstarch 50 ml 7/8 cup Whole bean flour 215 ml

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