Coeliac Disease – A Gluten Free Diet

Coeliac Disease – A Gluten Free Diet

What is Coeliac Disease?
Coeliac Disease is an auto-immune condition where the body attacks its own tissues when you eat gluten. It is not an allergy or intolerance. If you have Coeliac Disease, then gluten (a usually harmless protein in food) triggers an immune response by your body which causes damage to your small intestine, and in turn this damages the villi. Villi are finger like projections which increase the surface area of your gut, making it easier for nutrients to be absorbed into your blood stream. When the villi are damaged, this means fewer nutrients can be absorbed, and often leads to nutrient deficiencies. If you follow a strict gluten free diet, then over time your villi can recover.

Picture source: Guts UK (nd) ‘Coeliac Disease’ available from https://gutscharity.org.uk/advice-and-information/conditions/coeliac-disease/ [29/04/2020]

The symptoms of Coeliac Disease are very broad, fluctuate between mild and severe, and vary between
individuals. They may include loose or constipated stools, nutrient deficiencies such as iron-deficiency
anaemia or osteoporosis (weak or brittle bones), stomach pain and bloating, joint pain, mouth ulcers,
repeated miscarriages or a skin rash known as dermatitis herpetiformis. In children, symptoms may also
include faltering growth. Some people with Coeliac Disease have very mild symptoms and may not realise they have Coeliac Disease for a long time.

Regardless of symptoms, the diagnosis of Coeliac Disease is the same; there is no ‘mild’ or ‘severe’ Coeliac Disease, and the treatment is identical – a strict gluten free diet.

What causes Coeliac Disease?
There is no confirmed cause for Coeliac Disease. At present, current research shows those with Coeliac
Disease have genes which predispose them to developing the condition. However, it is not yet known what may trigger, or turn on, these specific genes.

Why do I need to follow a gluten free diet?
By following a gluten free diet, this will reduce the inflammation in your gut, helping the villi to recover. As your gut begins to heal, you will be able to absorb nutrients more effectively and reduce your symptoms. This healing process takes time, so don’t be concerned if you do not see immediate relief from your symptoms.

Furthermore, if a strict gluten free diet is not adhered to this increases the risk of developing problems such as osteoporosis (thinning of the bones), nutrient deficiencies such as anaemia and also increases the risk of certain types of cancer.

If you have Coeliac Disease but stick to a gluten free diet, these risks are significantly reduced, and you can expect to have the same life expectancy as anyone else.

What is gluten?
Gluten is a protein found in wheat, barley and rye grains. A person with Coeliac Disease will have a reaction to gluten, even if the amount is very small (any more than 20 parts per million) in the food item.

Suitable and unsuitable foods in a gluten free diet.
There are a lot of naturally gluten free foods available, and it is important to have a healthy, balanced gluten free diet. ‘Hidden gluten’ is often found in foods where you would least expect it, and so it is important to always check food labels.

The tables below are divided into the main food groups within our diets:

Carbohydrates:
Carbohydrates give you energy, and also contain fibre, iron, calcium and B vitamins. Choosing wholegrain
varieties increases the fibre in your diet, which is important for a healthy gut. Carbohydrates should make up to one third of your diet.

Protein:
Protein is needed for the growth and repair of our body and is important for our muscles. High protein foods include meat and fish, but it is good to include pulses, such as beans, peas and lentils in your diet, as these are lower in fat and higher in fibre and protein too.

Aim for at least 2 portions of fish every week, 1 of which should be oily, such as salmon or mackerel. Choose leaner cuts of meat, limit your intake of red and processed meat where possible.

Dairy:
Dairy products are good sources of protein and calcium, which helps keep our bones strong. Make sure all dairy alternatives such as soya milk are fortified with calcium.

For a healthy diet, try to go for lower fat and lower sugar products where possible, like semi-skimmed or
skimmed milk, reduced-fat cheese or plain low-fat yoghurt.

Fruit and Vegetables:
Fruit and vegetables are a good source of vitamins, minerals and fibre, and should make up a 3rd of the diet (aim to eat at least 5 portions a day). This includes fresh, frozen, tinned, dried or juiced, but limit your juice to just a small glass (150ml) per day due to its high sugar content.

Foods High in Fat and Sugar:
These foods include chocolate, cakes, biscuits, sugary soft drinks, butter, ghee and ice cream. These not
needed in our diet, so should be eaten less often and in smaller amounts.

Fats and oils are essential in our diet but only in a small amount. Choosing unsaturated varieties such as
vegetable, rapeseed, olive and sunflower oils and spreads are healthier, and better for your heart health
compared to saturated varieties such as butter or lard. However, remember all types of fat are high in energy and should be eaten sparingly.

Miscellaneous

Drinks

Meal Ideas
The following are examples of meal options and may be useful if you are struggling with meal ideas. It is
important to consider the balance of your diet as a whole.

Breakfast:

• Gluten free cereal with milk.
• Gluten free bread toasted with butter, jam or nut butter.
• Scrambled / poached / boiled / grilled eggs with gluten free bread toasted.
• Cooked breakfast – grilled bacon, GF sausages, GF baked beans, GF hash browns, grilled tomatoes, mushrooms, GF toast.
  Having a piece of fruit or small glass of fruit juice with breakfast can help to achieve your 5-a-day.

Light Meals:

• Soup with GF bread roll.
• Jacket potato with GF baked beans / cheese / tuna mayo / coleslaw and salad.
• Grilled chicken/ ham/ GF fishcake with salad.
• Sandwich made with GF bread.
• Omelette with variety of fillings – ham, peppers, mushroom, cheese etc.

Main Meals:

• Roast chicken, roast / boiled / mashed potatoes, steamed vegetables and GF gravy.
• Grilled chicken /salmon, rice and vegetables.
• Meat or vegetable curry or chilli with rice.
• Spaghetti bolognaise with GF pasta.
• Lentil and chickpea dahl with poppadum
• Cottage pies with mincemeat or Quorn mince.

Snacks:

• Fresh / dried fruit or vegetable sticks.
• Yogurts.
• GF biscuit or fruit / breakfast bar.
• GF crackers with cheese.
• Nuts, boiled egg or olives.
• GF crisps with salsa.

Food Labelling
The term ‘gluten free’ is covered by law and can only be used on foods which contain 20 parts per million
(ppm) or less of gluten. Therefore, anything labelled as ‘Gluten Free’ is safe to consume if you have Coeliac Disease.

UK and EU labelling laws state the allergen information of a product must be provided on the label. Gluten containing ingredients are one of the 14 listed allergens that must be emphasised in the ingredients list. Therefore, if something containing gluten is used as an ingredient, it must be listed and clearly emphasised such as in bold or italics.

Look out for this crossed grain symbol on packing, as it guarantees it is gluten free.

As well as checking the ingredients list, it is also important to check the whole packaging for ‘allergy advice’. This may include statements such as:

• May contain traces of gluten.
• Made on a line handling wheat.
• Made in a factory also handling wheat.

Food products with these warnings should not be consumed by someone with Coeliac Disease.

Ingredients list:
Below is a table of suitable and unsuitable ingredients to look for on food packaging:

Where can you buy gluten free foods?
Specially formulated gluten free foods such as bread, pasta and biscuits are available in most large UK
supermarkets in the ‘free-from’ sections. Naturally gluten free foods such as fresh meat, fruit, vegetables and rice are readily available.

Gluten Free Diet on a Budget
Specially formulated gluten free foods found in the ‘free-from’ aisles of supermarkets are often more
expensive than the gluten containing varieties. However, it is still possible to maintain a gluten free diet on a budget, with these handy tips:

• Choose naturally gluten free foods such as meat, fish, rice, potatoes, vegetables and fruit where
  possible.
• Look out for ‘accidentally gluten free’ foods in the regular aisles of supermarkets, which may not state ‘gluten-free’ on the packaging, but have no gluten containing ingredients or contamination warnings. Your Coeliac UK Food directory and gf food checker app will help you to identify if a food is safe to eat or not.
• Look out for offers or promotions and stock up if possible.
• Plan ahead with a weekly meal plan to ensure you are only buying the items you need.
• Where possible, cook and bake your own gluten free products such as biscuits at home, as this will be a lot cheaper then pre-made varieties. Batch cooking meals is a great way to reduce the overall cost of your food shopping.
• Preparing your own packed lunch, for example, is a much cheaper alternative then purchasing lunch
  each day.
• Frozen, tinned and dried foods such as fruit and vegetables are often cheaper but are still as nutritious.
• Using supermarket own rather than branded products.

Calcium and Vitamin D
If you have Coeliac Disease, you need slightly more calcium due to your increased risk of osteoporosis.
Osteoporosis is associated with Coeliac Disease because the lining of the gut is damaged and this reduces the absorption of vitamins and minerals from food, including calcium. Your dietitian will discuss your specific calcium requirements with you.

Foods high in calcium include dairy products such as milk, cheese and yogurts, baked beans, kale, fish with bones (i.e. tinned sardines) and calcium fortified products like soya or almond milks.

To absorb calcium, it is also important to have enough vitamin D. Vitamin D is made by the skin when in the sun; however, during the winter months it is difficult to meet your vitamin D requirements from sunshine alone. It is recommended everyone should consider taking a 10-microgram vitamin D supplement during autumn and winter. There are only a few foods which are good sources of vitamin D including oily fish, eggs, margarine and fortified breakfast cereals, and so you may wish to consider taking a daily supplement.

Iron Requirements
Iron deficiency is common in people with undiagnosed Coeliac Disease due to poor nutrient absorption when the lining of the gut is damaged. As the gut heals on a gluten free diet, nutrient deficiencies are often reduced. Iron deficiency is diagnosed by blood test, and common symptoms include fatigue, pale skin, headaches and shortness of breath.

Having Coeliac Disease does not increase your iron requirements, but it is important to be aware of the iron content in your diet. Good sources of iron include red meat, liver, egg yolks, leafy green vegetables, pulses, dried fruit and nuts and seeds.

Vitamin C can help the absorption of iron, so having fruit juice (limit to 150ml a day), fruit (especially citrus) or vegetables with your meals can be beneficial.

Lactose Intolerance
Lactose intolerance is associated with undiagnosed Coeliac Disease as the enzyme lactase which breaks
down lactose is found in the lining of the gut, which is often damaged. Fortunately, this is usually temporary, and as the gut heals with a gluten free diet, most people find they can then tolerate lactose again.

If you experience temporary lactose intolerance, reduce the amount of lactose in your diet and your symptoms should improve within a few days. You can then gradually increase the amount you eat until your symptoms appear, then stick to having just below this amount in your diet. Continuing to have a tolerable amount of lactose in your diet is important to continue the stimulation of lactase.

It is important you still have enough calcium and nutrients in your diet when limiting lactose, so choosing fortified alternatives such as soya, gluten free oat or rice (if >5yrs old) milks is important. Cow’s milk with reduced lactose is also available from supermarkets. Although made from milk; yogurts and cheeses are very low in lactose and so can usually be well tolerated.

Fibre
Fibre is an important part of a healthy diet and is found in wholegrain cereals, fruit, vegetables and pulses (peas, beans and lentils).

Handy hints to improve your fibre intake:

• Aim for at least five portions of fruit and vegetables each day (especially those with skins, pips and seeds). Add fruits, nuts or seeds to your breakfast or pulses and extra vegetables to soups, stews and sauces.
• Opt for brown, multigrain or fibre versions of gluten free breads, rolls, flour, pasta and rice.
• Opt for wholegrain/high fibre snacks throughout the day such as a handful of apricots or figs, seed mixes or cereal or fruit bars.

If you are increasing your fibre, it is better to do this gradually over time with the addition of plenty of fluids.

Cross contamination
People with Coeliac Disease are very sensitive to gluten, and only a small amount will cause damage to the lining of the gut and unfavourable symptoms. It is therefore important to take sensible steps to avoid cross contamination:

• There is no need to go out and buy separate utensils or appliances such as toasters. However, all utensils should be washed well between foods and, toaster bags or clean foil under a grill should be used when toasting gluten free bread.
• Wash your hands and clean down all surfaces when preparing food.
• Use a separate tub of butter/margarine, and other spreads such as jam, to avoid crumbs from gluten containing items contaminating gluten free food.
• Wrap up gluten free foods well and if possible, store away from gluten-containing foods (especially in floury environments).
• Make sure to cook gluten free foods in separate dishes/on different baking trays, and place gluten
  free foods at the top of the oven, with gluten containing foods below to avoid any contamination from falling crumbs, etc. If you are unsure whether a food has become contaminated, it is best to avoid it.

What should I do if I accidentally eat gluten?
Mistakes happen, and following a gluten free diet is a learning process. Therefore, there may be an occasion where you accidentally eat gluten. If you make the occasional mistake and eat gluten by accident, it’s unlikely to cause lasting gut damage. Try not to worry and use it as a positive learning experience to know for next time.

You may have a return of your symptoms after eating gluten and these can last from a few hours to several days. The effects vary from person to person and depend on how much gluten you’ve eaten; how sensitive you are and how long you have been on a gluten free diet.

If you have diarrhoea or you are vomiting, it’s important to keep yourself well hydrated by drinking lots of water. Some people find that taking medication to treat constipation, diarrhoea or headaches can ease symptoms but check with your pharmacist or GP. If your symptoms are severe and persist, speak to your GP.

The most important thing is to get back onto your gluten free diet to try to prevent further symptoms.

Coeliac UK
Coeliac UK is an independent charity that has supported people with Coeliac Disease for over 50 years. You can become a member of Coeliac UK online or via a paper application form provided by your dietitian. When registered, you will receive a food and drink guide which contains a list of all the available gluten free products in most supermarkets. You will also receive a quarterly ‘Live Well Gluten Free’ magazine, regular email updates and access to all the Coeliac UK resources (such as translation cards). They also offer a telephone helpline service.

As a member, you will also be able to access two apps produced by Coeliac UK:

• GF Food Checker – With this app you can scan the barcode of food items, or search for foods and it will highlight if it is suitable for you or other members of your family.
• Gluten Free On The Move – With this app you can search for gluten free eateries in a particular area and specialise your search for different cuisines.

The cost of membership is reduced if you are a student, unemployed or on a low income. This can be paid upfront or by a monthly direct debit.

Eating out
Eating out with friends and family is still very much possible when you have Coeliac Disease. Lots of restaurants and establishments are now producing gluten free options on their menu, but it is important to ensure they are minimising the risk of cross contamination and preparing them safely.

Coeliac UK have accredited many restaurants through additional training and are a great place to start when dining out. A list is freely available on their website. Local groups are also a great way to find other gluten free eateries – check out your local Coeliac UK group or search online.

Ideally, it is best to ring in advance to check a restaurant can cater for you. When arriving, it is important to communicate your gluten free needs to waiting staff, so that you can work out which meals are suitable. Be careful to check soups, dishes with sauces or gravies, stock cubes, and foods like sausages and chips. Some may have a coating that contains gluten, or they may be fried in the same oil as products that contain gluten, like onion rings.

Restaurants must have an allergy list (including gluten containing grains) for their meals by law.

Takeaway Tips
Indian:

• Avoid breads such as naan bread and choose a gluten free side such as rice.
• Poppadoms are usually made with rice and lentil flour and so are gluten free. Make sure these are cooked in oil that has not been used to cook gluten containing foods to avoid any contamination.
• Indian sauces are usually thickened with chickpea flour or yoghurt rather than a wheat-based starch, so are safe for people with Coeliac Disease, but do check.

Chinese:

• A Chinese takeaway is one of the hardest to ensure as gluten free due to the contamination risk of cooking methods using Soy Sauce (which contains gluten).
• Avoid wheat noodles – rice and rice noodles are a great alternative.
• Remember that meat, fish and vegetables are naturally gluten free but check that they are not cooked in soy sauce or oil that has been used to fry gluten containing foods such as spring rolls.

Fish and Chips:

• Avoid chips if they are cooked in the same oil as battered fish as the oil has been contaminated. Even if the chips appear to be cooked separately, be aware that the oil is often rotated so the chip oil may have previously been used to cook battered fish.
• Removing batter from fish does not make it safe to eat as it will already have been contaminated with gluten.
• Some shops have designated gluten free nights (usually after the oil is changed!) or have a dedicated gluten free fryer so it is worth asking your local.

Pizza:

• Conventional pizzas made with a wheat-based dough are unsuitable if you have Coeliac Disease.
• Lots of pizzerias are now offering a gluten free base, but make sure it is prepared and cooked separately from gluten containing pizzas.

Travelling Abroad
Coeliac UK have produced a variety of translation cards and guides which you can take with you, explaining Coeliac Disease and a gluten free diet in various languages. The guide and translation documents require you to be a member of Coeliac UK.

Researching gluten free eateries online is a good start before you head away. If you are staying in an ‘all inclusive’ resort, phone in advance or speak to the catering team on the first day to ensure you can be catered for during your stay. Some hotels have an excellent provision for catering for gluten free customers, so it is worth looking for reviews and recommendations.

If you wish to take gluten free foods with you, some airlines will allow you extra luggage space if you contact them in advance.

Prescriptions
Gluten free food on prescription is unavailable in Worcestershire. Prescriptions are available in other areas of the UK, but it is down to funding from CCGs (Clinical Commissioning Group). Coeliac UK is currently campaigning for all areas to prescribe gluten free products, so this may change in the future.

Medical Follow Up
It is important to have regular follow ups with your gastroenterologist and GP now that you are diagnosed. You are also entitled a DEXA scan to measure your bone density (in relation to your osteoporosis risk) which you can arrange with your GP. If you have any concerns about your gluten free diet in the future, your GP can refer you to see a dietitian.

Vaccinations
The spleen is an important part of the immune system, so if it doesn’t work properly it can lead to an increased risk of infection. Some people with coeliac disease have reduced spleen function; therefore, certain vaccinations are recommended:

• Vaccination against pneumococcal infection and a booster every five years
• Annual flu vaccination
• Meningococcal A, C, W, Y should be given to anyone born between 1995 and 2014

For more information visit coeliac.org.uk/vaccinations and discuss with your GP.

Getting Support
Being newly diagnosed with Coeliac Disease can be overwhelming, but there is lots of support available.

• Coeliac UK have a large online community, but also a phone helpline service where you can chat to specialist dietitians if you have any concerns or questions.
• Coeliac UK also run local groups, hosted by others with Coeliac Disease. These groups often host meals out or family picnics where you can get support, and be supported, by others in the same situation.
• There are numerous blogs online with hints and tips with regards to baking and cooking, or gluten free supermarket finds. Social media groups can also be useful, but these sites are not run or regulated by health care professionals, so please do not take medical advice without consulting your doctor or dietitian.
• Supportive friends and family are vital to help you with your gluten free journey. It is important that they fully understand your diagnosis, and so you are welcome to bring them to your clinical appointments or direct them to the resources provided by Coeliac UK.

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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