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The management of coeliac disease

Michelle Berriedale-Johnson gives a brief introduction

Being diagnosed with coeliac disease, or indeed any food sensitivity, is a scary business. Not only are you faced with what will most likely be a 'life sentence' but, initially at least, everything that you would normally eat has apparently been banned from your daily menu. On the other hand, if you have been feeling as ill as many newly diagnosed coeliacs have been, then almost anything seems worth it if you could just feel a little bit better!

Moreover, there is so now much more awareness of coeliac disease and gluten sensitivity that, not only are you no longer likely to be treated as a weirdo or a pariah, but you will constantly be meeting fellow sufferers, will be able to buy a whole range of foods designed especially for your diet and will often be offered a gluten-free menu even when you go out to eat. Very, very different from the situation twenty or even ten years ago before coeliac disease and gluten-free hit the headlines.

None the less, you do have a good deal of adjustment to do and although looking at the positive before you tackle the negative is normally a good way to go, to get yourself on a good gluten-free path, it is probably better to start with what you can not eat and what you need to get out of your kitchen before starting to explore what you can.

Where you will find gluten

If you use a lot of pre-prepared food then your job will be harder as gluten is much loved by the food industry and finds its way into almost everything. (Gluten is, effectively, a glue and is hugely useful to the food industry, especially the baking industry, as it allows them to create very light baked goods where ingredients are held together by gluten.) So here you go with a list of where you will always find, and where you will probably find, gluten – courtesy of our Allergy Catering Manual:

Gluten is always found in:

Barley
Rye
Wheat

Bran
Bulgar
Cereal binder/filler
Couscous
Flour made from barley, rye or wheat
Malt
Rusk
Semolina
Wheat starch / modified wheat starch

Gluten Is likely to be found in:

Baking powder
Beer
Biscuits (sweet or savoury)
Breakfast cereals/muesli
All breads unless specifically gluten free
All bread, cake or pastry mixes unless specifically gluten free
Breadcrumb coatings
All buns, muffins, scones, cakes and baked goods unless specifically gluten free
Cereal binder/filler
Chapatis, poppadoms, nans
Cheese spread/dips
Confectionery
Fruit drinks
Margarines
Modified starch
Oatcakes*
Pancakes and waffles
All pasta or noodles unless specifically gluten free
Pastry made from wheat, rye or barley
Pitta bread
Pizzas
Ready meals of all kinds
Rusk
Salad dressings
Sauces and gravies
Sausages
Semolina
Samosas
Taramasalata
Tinned meat containing preservatives
Tinned vegetables

* Oats do not contain gliadin, the protein which affects coeliacs, but a 'look-alike' protein called avenin and are now therefore considered to be safe for the vast majority of coeliacs. However, since many oats are milled or processed in, or close to, facilities that also handle wheat, there is a high risk of contamination so only use oats or oatcakes that are guaranteed gluten-free.

Thresholds, contamination and what does 'gluten-free' mean?

If you are a newly diagnosed coeliac or if you have been ill for some time, you may be very sensitive so the tiniest bit of gluten may affect you. And, in this context, tiny really does mean tiny so you do have to be very careful. So, a few 'technical terms'.

A threshold is the amount of gluten (or any other allergen) you need to consume for it to affect you. For some coeliacs this can be the tiniest trace, others may be able to consume low levels of gluten without apparent damage but if you are newly diagnosed it is best to be really strict about this.

Contamination is exactly what it says, accidental contamination of another food with gluten. This can happen very easily if you are not careful. For example, using a toaster for gluten-free bread which has already been used for gluten-filled bread. (Most coeliacs use a separate toaster but you can also get toaster bags into which you can put your slice of gluten-free bread to toast it.) Or using the same bread knife or bread board for gluten-free and gluten-filled bread; or using the same serving spoons for a sauce made with flour and the gluten-free vegetables, or the same frying oil for gluten-free chips and fish in a flour-based batter.

In the domestic kitchen it is usually easier for the coeliac just to have their own area and a few basic utensils of their own – but you then do have to be sure that everyone else in the family is aware of the risk of contamination and does not use any of your 'dedicated coeliac' equipment.

If you see 'gluten-free' on a food you are thinking of buying that does now mean that that food is guaranteed to have less that 20 parts per million of gluten. (For more details on exactly what this means see the Food Standards Agency article here.) In fact, most manufactured foods which claim to be gluten free will have less than 20 parts per million, but you know this will be the maximum and this is deemed to be little enough not to cause a problem for coeliacs. A food that is labelled 'low gluten' will have less than 100 parts per million of gluten.

Not just food...

However, you cannot restrict your gluten wariness just to food. You also need to be careful of drinks, drugs – and nutritional supplements.

Beer and whisky

The main 'no-no' in terms of drinks for coeliacs is beer which is normally brewed from barley. However, there are now a number of very good gluten-free beers on the market (see here for the winners of the g-f beer category in the 2012 FreeFrom Food Awards) and the levels of gluten in beer is a complex question – see Sue Cane's 2011 article here for much more detail on this.

In theory whisky which is fermented from barley or rye should not cause a problem for coeliacs as the spirit is distilled so there should be no protein left in the resulting alcohol. However, there are reports on some of the coeliac forums which suggest that this is not the case so those who are super sensitive would probably do well to avoid it.

In theory again, coeliacs should be perfectly safe drinking wines, brandy, or any other non-grain distilled spirits. However.... once again, if you are super sensitive, you may react if the wines or spirits have been aged or stored in barrels which have previously held grain-based spirits or which have been caulked or sealed with grains. See this post on the Truly Gluten Free site.

Drugs

If you use prescription drugs, unless you have read the accompanying leaflets in great detail, you may not realise that the active part of the drug (which is usually tiny, too small to be practically stored in a pill or a capsule) is bulked out with various other substances, known as excipients, and that these often include starches. See this lengthy article on the FoodsMatter site about how to get prescription drugs which do not contain allergens.

Nutritional supplements

Unfortunately for those who are trying to build up their nutritional status while remaining gluten free, nutritional supplements are also regularly bulked out with lactose, starches and other ingredients which you may be trying to avoid. Read Micki Rose's article Grain and Corn Free Supplements for more on this.

Eating out

Eating out with any kind of a food sensitivity, be it coeliac disease or a food allergy, remains a challenge, although very much easier than it used to be. Although many establishments of all kinds do now offer gluten-free dishes, you do, especially if you are either newly diagnosed or particularly sensitive, need to remain wary as, although often well intentioned, restaurants, pubs, cafés and canteens often do not really understand issues such as contamination or realise that many ingredients which on the surface appear to be gluten free, in fact are not.

Planning ahead and calling ahead to discuss your needs with the restaurant remain good policies or, if you are at all nervous, sticking to dishes which are unlikely to contain gluten or at least avoiding the suspect elements – such as the gravy on the roast which will almost inevitably have been thickened with flour. There are several helpful articles on eating out with an allergy on our FreeFrom Foods Matter site here – in particular one by blogger Pig in the Kitchen here, and another by Eve Menezes Cunningham here.

So, for the good news....

There are a wealth of foods that are naturally gluten free, an increasing number of very good ready-made gluten-free foods that you can buy and positively thousands of gluten-free recipes scattered across the web and in cookbook shops if you are up for cooking at home. Working backwards:

Recipes

There are well over 500 recipes on our FreeFrom Recipes Matter site all of which are gluten free – and many do which are also dairy free, egg free, soya, free and nut free. The vast majority of these are 'naturally' gluten free – eg they use ingredients that never have contained gluten – but they cover every kind of dish that you might want to cook.

There is also a page of links to recipe blogspots and other recipes sites and to gluten-free/allergy cookery courses.

Ready made food and ingredients

Our FreeFrom FoodsMatter site includes a huge directory of hundreds of 'freefrom' foods, 90% of which are gluten free. It also includes the judges' comments on winners of recent FreeFrom Food Awards to give you some idea of what they taste like.

Alternative foods

Below are, courtesy again of our Allergy Catering Manual, a number of suggestions for alternatives to gluten and wheat that you might wish to consider. Although the book was published some years ago, the basic advice remains the same.

Gluten, in the guise of wheat and wheat flours, starches and thickeners, is very widely used within the food industry both as an ingredient and in the manufacture of ingredients. This means that great care must be taken, when using anything which is not a primary ingredient, to check the ingredients lists on the packaging.

Breads and Breakfast Goods
Gluten free bread flours include combinations of buckwheat, gram (chickpea), corn/maize, millet, potato, rice and tapioca flour.

These are not easy to use as they lack the elasticity and 'setting' quality of gluten. As a result breads may rise (thanks to yeast or raising agents) but promptly fall again to produce brick like loaves.

It is now possible to buy xanthan gum which, if added in moderation, makes a reasonable substitute for gluten. Even so, it remains difficult to produce reasonable bread with these flours.

However, over the last few years a number of companies have produced very acceptable part baked, frozen or long life breads, rolls, baguettes and croissants. These taste reasonable (if not always brilliant) and look like the original. See here for breads on the market in the UK.

Corn Bread
The only exception to this rule is corn bread which is delicious and extensively eaten in the US and North America. This is made from ground corn or maize meal, not what the UK knows as 'cornflour' which is the purified starch from corn/maize meal. Most US recipe books will have a number of recipes for corn bread.

Biscuits & Crackers
Pure oat oatcakes or rye crackers may be fine for anyone with a wheat allergy; there are also a number of proprietary gluten free crackers on the market. See here for crackers on the market in the UK.

Biscuits, Cakes & other Baked Goods
Making good gluten free cakes and biscuits is far easier than making bread, especially if you are using eggs.

There are now several proprietary gluten free flours on the market which work quite well, especially if you add a little xanthan gum. (Doves Farm is the best known and most of the Doves Farm mixes already include a little xanthan gum.) Alternatively combinations of the stronger flours (gram or maize) with the finer, lighter flours (white rice, potato, cornflour/starch or tapioca), in approximately equal quantities, gives a reasonable balance which holds together well without being too strongly flavoured. They are very successful in cakes although biscuits can be rather crumbly.

See here for cakes on the market in the UK, and here for sweet biscuits and cookies.

You can also use ground oats (rolled oats whizzed for some minutes in a food processor) in combination with some of the finer flours. The oats give quite a coarse, slightly crumbly texture but lots of flavour - excellent for hearty cakes such as gingerbreads.

There are some excellent Italian and American recipes for cakes made purely with ground corn/maize meal (polenta).

Oats
Under current medical thinking oats (provided they have not been contaminated by being processed with wheat products) are safe for all but the most sensitive coeliacs.

Breadcrumbs
You can crumb gluten/wheat-free bread. Alternatively use proprietary gluten free breadcrumbs. See here for store cupboard products available in the UK.

Pasta
There are a number of excellent dried gluten free varieties on the market.
See here for store cupboard products available in the UK.

Pastry
Combination flours, as for cakes and biscuits, work best. 60% gram to 40% rice, made in the normal way, gives a well textured, quite crisp and flavoursome pastry although it is very crumbly. Adding a small amount of xanthan gum helps hold it together. See here for store cupboard products available in the UK.

Pizza & Pizza Bases
Making edible gluten free pizza bases is difficult although there are a couple of quite good mixes. Alternatively there are a number of proprietary frozen or long life pizza bases which are not wonderful but adequate if covered with good toppings.
You can also buy frozen ready made pizzas which would be good for emergencies. See here for store cupboard product available in the UK and here for ready made pizza and pasta meals.

Sausages
Most UK sausages use a substantial amount of wheat based rusk. Sausages using gluten free rusk and fillers are available. Alternatively use (or make) pure meat sausages which use no fillers at all. Frankfurters, chorizo and other continental sausages may be free of gluten but check ingredients carefully, especially for dairy products. See here for freefrom sausages, burgers etc

Sauces & Thickeners
Cornflour/starch, potato flour and arrowroot all work well as thickeners for sauces, both savoury and sweet. Use as flour but be aware that you will need approximately 30% less by weight of these starches to thicken the same volume of liquid. See here for store cupboard products available in the UK.

Beer
You can now get gluten free beer, lager and stout. Alternatively, go for wine!
See here for gluten-free beers available in the UK.

Non-wheat Flours

If you do wish to experiment with alternative flours here are a few notes on their properties for which we are grateful to Andrew Whitley of www.breadmatters.com.
Andrew (founder of The Village Bakery) runs wonderful courses on craft and gluten free baking.

Buckwheat flour: Very little binding power and a strong flavour which some people love. Widely used in Russia to make porridge and pancakes (blini). Use in combination with other flours.

Chestnut flour: Good binding properties and very distinctive, sweet flavour which may be overpowering. Good in combination with other flours. Expensive.

Cornflour/starch and Corn/maize meal: Cornflour is the purified starch of the maize meal. A good thickener with good binding properties and useful in combination with other flours in baking - too fine and tasteless on its own.
Corn/maize meal is the whole maize seed ground into flour. Quite coarse and because it oxidises quickly, often leaves a bitter taste. Maize flour is the very finely ground maize meal from which all bran and germ have been removed so it does not oxidise.

Gram/chickpea flour: High in protein, so good for binding. It is widely used for making flat breads in India. However, used on its own gram flour can taste very 'beany' and have a rather claggy, 'beany' mouthfeel. Use in combination with other finer flours such as rice, potato or tapioca.

Lupin flour: Made from the seeds of the sweet lupin which has been bred to remove the bitter alkaloids. Very nutritious and with good binding qualities but strong flavoured. More importantly, 70% of peanut allergics are also allergic to lupin so it is a dangerous flour to use when cooking for food allergics/intolerants.

Millet flour: A fine, bland flour. It goes rancid very quickly making everything taste bitter so needs to be bought from a source with a quick turnover and kept in the freezer. Works best in combination with a strong flour like gram flour.

Potato flour/starch: The flour is the dried and ground potato tubor; the starch is a refined derivative of potatoes. In moderation (not more than 20%) both flour and starch can give some binding and lightness but more than 20% will become gummy and heavy. Very little flavour but good as a thickener.

Quinoa flour: Light, creamy flour from the seeds of the quinoa plant from South America. Not much binding power as a flour and a distinctive, slightly bitter taste - but very nutritious. If you cook the grains like rice until they have absorbed as much water as they can then beat them to a sticky mush they will aid binding and moisture retention, but do not use more than 10% of the mush in the dough. Not widely available so expensive.

Rice flour - brown & white: Neither white nor brown rice flour have much binding power but are useful in combination with other stronger flours like gram or maize. Even when finely ground, rice flour can have a gritty texture when baked, and leave a slightly bitter taste. Ground rice (much coarser) can also be used for cakes in much the same way as polenta.

Soya flour: Although excellent nutritionally soya flour, if used at more than 5% of the total weight, gives a very heavy texture and an unpleasant taste to the product. Because of its high protein levels it can have an 'egg substitute' effect in cakes and biscuits (most 'egg replacers' are based on soya) but this does not outweigh its disadvantages.

Tapioca flour: Ground from cassava roots.Very light and bland but a reasonable binding quality. In moderate amounts gives a pleasant chewy texture to breads. If it forms more than 50% of the flour in breads or pastry the texture can become dusty and strange background flavours emerge. Use at 5-10% in breads and up to 40% in pastry or biscuits.

 

First published August 2012

More articles on the management of coeliac disease

 

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