Foods
for
patients
with
celiac
disease
J.A.
CAMPBELL,*
PH
D
As
a
general
rule
patients
with
celiac
disease
must
avoid
five
cereals
-
wheat,
rye,
triticale,
barley
and
oats.
Very
sensitive
individuals
must
also
avoid
two
products
of
these
cereals
-
malt
and
hydrolyzed
vegetable
protein.
Some
less
sensitive
individuals
may
be
able
to
tolerate
barley
and
oats
in
small
quantities.
All
other
foods
are
acceptable,
including
the
cereals
corn,
rice,
buckwheat,
millet
and
sorghum,
as
well
as
malt-flavoured
breakfast
cereals.
Wine,
spirits,
beer
and
ale
are
also
acceptable
unless
otherwise
contrain-
dicated.
Monosodium
glutamate,
other
food
additives
and
pharmaceutical
preparations
are
also
acceptable.
The
ingredients
of
prepackaged
processed
foods
are
listed
on
the
labels.
Patients
with
celiac
disease
must
examine
labels
to
ensure
that
they
avoid
the
harmful
cereals.
With
appropriate precautions
they
need
not
be
concerned
about
eating
away
from
home.
RAgle
g6n6rale,
les
patients
qui
souffrent
de
maladie
coeliaque
doivent
6viter
cinq
c6r6ales,
soit
le
bl6,
le
seigle,
le
triticale,
l'orge
et
l'avoine.
Les
individus
trAs
sensibles
doivent
aussi
Aviter
deux
d6riv6s
de
ces
c6rAales,
soit
le
malt
et
les
protAines
v6gAtales
hydrolys6es.
Certains
individus
moins
sensibles
peu-
vent
tolArer
l'orge
et
l'avoine
en
petites
quantit6s.
Tous
les
autres
aliments
sont
acceptables,
y
compris
des
cbr6ales
telles
que
le
mais,
le
riz,
le
sarrasin,
le
millet
et
le
sorgho,
ainsi
que
les
c6rbales
A
saveur
de
malt
pour
le
petit
d6jeuner.
Le
vin,
les
alcools,
la
biAre
et
I'ale
sont
aussi
acceptables
A
moins
d'Otre
contre-indiqubs
pour
d'autres
raisons.
Le.
glutamate
monosodique,
d'autres
additifs
alimentaires
et
les
prbparations
pharmaceutiques
sont
Agalement
accep-
tables.
Les
ingr6dients
des
aliments
prbparAs
et
pr6conditionnbs
apparaissent
sur
l'6tiquette.
Le
patient
qui
souffre
de
maladie
coeliaque
doit
lire
attentivement
les
Atiquettes
afin
de
s'assurer
qu'il
ne
consommera
pas
de
cArAles
dommageables.
En
pre-
nant
les
prAcautions
appropri6es,
il
n'a
pas
A
craindre
de
manger
A
1'extArieur.
Although
it
has
been
recognized
for
about
30
years
that
ingestion
of
wheat
is
responsible
for
the
diarrhea,
pale
bulky
stools,
abdominal
cramps,
flatulence
and
failure
to
thrive
of
patients
with
celiac
disease,'
there
is
still
considerable
difference
of
opinion
about
what
foods
such
patients
can
eat.2
For
example,
in
Ontario
patients
are
advised
to
avoid
buckwheat3
but
in
Sweden
they
are
not
(B.
Isaksson,
Sahlgren's
Hospital,
University
of
Goteborg:
personal
communication,
1981),
beer
is
pros-
cribed
in
Ontario3
but
not
in
Scotland,4
and
triticale,
a
*Food
and
nutrition
consultant
This
study
was
undertaken
at
the
request
of
the
Ottawa
chapter
of
the
Canadian
Celiac
Sprue
Association.
Reprint
requests
to:
Dr.
J.A.
Campbell,
1785
Riverside
Dr.,
Ste.
2204,
Ottawa,
Ont.
KIG
3T7
wheat/rye
hybrid
that
obviously
should
not
be
eaten,
is
not
on
any
list
of
prohibited
foods.
When
the
proteins
of
cereals
are
fractionated
the
toxic
factor
is
extracted
into
the
alcohol-soluble
prola-
mine
fraction,
called
gliadin
in
the
case
of
wheat.
Prolamines
are
complex
mixtures
of
proteins
that
are
insoluble
in
water
but
soluble
in
dilute
alcohol.
They
make
up
a
large
and
variable
part'
of
the
protein
of
cereals,
both
those
that
cause
celiac
disease
and
those
that
do
not.
The
gliadin
of
wheat
has
been
fractionated
still
further,
so
that
we
now
know
that
the
toxicity
lies
largely,6
but
not
entirely,7
in
the
a-gliadin
fraction.
The
grain's
toxicity
does
not
appear
to
be
related
to
the
amount
of
prolamine,
as
suggested
by
Bell
and
associ-
ates,8
because
rye,
which
is
toxic,
has
about
the
same
prolamine
content
as
corn,
which
is
not
toxic.
Gliadin's
toxicity
may
be
due
to
unique
combinations
of
amino
acids
in
the
polypeptide
chain.9
The
exact
nature
of
these
complexes
is
unknown,
but
when
the
toxic
proteins
are
hydrolyzed
to
their
constituent
amino
acids
they
lose
their
toxicity.
It
has
been
suggested
that patients
with
celiac
disease
lack
an
intestinal
peptidase
essential
for
the
ultimate
detoxification
of
gliadin.9"0
It
has
also
been
suggested
that
they
are
prone
to
the
development
of
localized
immune
reactions
when
exposed
to
dietary
gluten.
There
is
some
evidence
that
the
latter
theory
may
be
the
sounder
one,
but
the
exact
mechanism
is
not
known.
Diagnosis
Patients
with
celiac
disease
usually
present
with
a
variety
of
intestinal
complaints,
including
diarrhea,
flatulence
and
bulky
stools,
or
with
breathlessness
and
fatigue.
Children
have
a
lack
of
appetite
and
retarded
growth.
Steatorrhea
has
generally
been
accepted
as
the
most
constant
finding,"
but
decreased
fat
absorption
and
reduced
d-xylose
excretion
have
been
considered
diagnostic.
The
final
diagnosis'2
is
now
made
by
histolo-
gic
and
enzymatic
study
of
a
jejunal
biopsy
specimen,
which
includes
subjective
assessment,
determination
of
the
activity
of
disaccharidase
and
other
enzymes,
and
measurement
of
surface-to-volume
ratios.
Removing
wheat
from
the
patient's
diet
usually
reduces
the
symptoms
and
signs,
sometimes
in
days,
and
the
intesti-
nal
villi
usually
return
to
normal
within
a
few
months.
Testing
offoods
Techniques
to
test
the
acceptability
of
foods
are
also
based
on
studies
of
fat
absorption,
d-xylose
excretion
and
jejunal
biopsy
specimens
in
treated
patienis
with
celiac
disease
who
have
been
given
challenge
doses
of
the
food.
Jejunal
biopsy
is
now
considered
the
rnost
reliable
method
of
diagnosing
the
disease
and
testing
foods;
symptoms
alone
are
a
poor
guide
to
the
damaging
effects
of
cereals
in
these
patients.'2
CMA
JOURNAL/NOVEMBER
15,
1982/VOL.
127
963
Guidelines
Foods
to
be
avoided
Wheat:
The
toxic
properties
of
wheat
appear
to
reside
largely
in
the
gliadin
fraction
of
the
protein.'3'4
Thus,
all
wheat
products
must
be
avoided
except
wheat
starch
flour,8
which
lacks
the
protein
of
the
wheat
endosperm.
Rye:
A
few
years
after
the
discovery
of
wheat
intolerance
in
celiac
disease
rye
was
also
found
to
be
harmful'4
and
is
now
generally
considered
toxic.8
'2
Triticale:
Triticale
is
a
genetic
hybrid
of
wheat
(triticum)
and
rye
(secale).'3
Its
amino
acid
content
is
similar
to
that
of
these
grains.
Although
triticale&has
not
been
tested
clinically
one
might
expect
it
to
cause
a
similar
toxic
reaction.8
Barley:
A
study
of
14
centres
in
Great
Britain
found
that
7
allowed
barley
but
advised
its
exclusion
if
the
response
to
wheat
and
rye
was
poor.'6
More
recently
it
was
concluded
from
histologic
and
enzymatic
study
of
biopsy
specimens
that
barley
is
harmful
even
if
it
does
not
produce
symptoms.'2
Certain
groups
in
Great
Brit-
ain
recommend
avoidance
of
barley
(C.C.
Booth
and
P.J.
Bereton,
Clinical
Research
Centre,
Northwick
Park
Hospital,
Harrow,
England
and
M.R.
Ward,
The
Coe-
liac
Society
of
the
United
Kingdom,
London:
personal
communications,
1981).
It
would
seem
wise,
as
Bell
and
associates8
recommended,
to
consider
barley
unaccepta-
ble,
except
possibly
for
patients
who
are
less
sensitive
to
wheat.
Oats:
A
group
of
investigators
working
in
the
Nether-
lands
in
the
1950s
found
that
oats
produce
symptoms
similar
to
those
caused
by
wheat
and
rye
in
patients
with
celiac
disease.'3"4
Studies
done
more
recently
have
concurred
with
these
findings
(C.C.
Booth,
P.J.
Bereton
and
M.R.
Ward:
personal
communications,
1981).
Baker
and
Read,'6
using
the
d-xylose
test,
concluded
that
both
oats
and
barley
are
harmful.
On
the
other
hand,
Watson'7
stated
that
in
his
experience
large
doses
of
oats
do
not
seem
to
be
harmful.
Dissanayake
and
colleagues'8
concluded
from
mucosal
examination
that
oats
are
acceptable
although
others
have
questioned
this
conclusion.'1920
Bell
and
associates8
recommended
that
once
the
full
health
of
a
patient
with
celiac
disease
is
restored
(in
3
to
6
months)
oats
may
be
allowed
in
small
amounts,
although
the
authors
were
mindful
of
the
possible
subclinical
assault
resulting
from
the
continued
ingestion
of
small
amounts
of
toxic
prolamine
(gluten).
Foods
and
food
products
that
are
acceptable
Corn:
Although
the
prolamine
content
of
corn
is
almost
as
high
as
that
of
wheat
it
is
generally
agreed
that
corn
causes
no
toxic
effects.
Studies
have
shown
that
it
does
not
affect
fat
absorption'4
or
alter
the
jejunal
lining.'2
Rice:
Early
work
also
showed
that
rice
did
not
affect
fat
absorption
in
patients
with
celiac
disease.'4
Since
then
it
has
been
generally
accepted
that
rice
is
not
toxic.
More
recent
work
has
confirmed
this
view
using
the
jejunal
biopsy
technique.'2
Buckwheat:
Buckwheat
is
a
member
of
the
family
Polygonaceae,
which
is
quite
distinct
from
the
grass
family
Gramineae,
in
wbich
wheat,
rye,
triticale,
barley
and
oats
belong.
For
this
reason
we
have
no
reason
to
964
CMA
JOURNAL/NOVEMBER
15,
1982/VOL.
127
suspect
that
buckwheat
is
toxic.
In
an
unpublished
paper
cited
by
Bell
and
associates8
buckwheat
was
reported
to
be
nontoxic
in
two
patients.
It
has
been
stated
without
supporting
data
that
buckwheat
can
be
used
for
gluten-free
diets,2'
and
this
grain
is
recommend-
ed
without
question
by
several
groups
in
Great
Britain.
It
is
fairly
widely
used
in
Sweden
(B.
Isaksson:
personal
communication,
1981)
and
in
other
parts
of
Europe.
Millet
and
sorghum:
In
cereal
grain
evolution
these
grains
are
more
closely
related
to
corn
and
rice
than
to
wheat,
rye,
barley
and
oats.8
It
has
been
suggested,
therefore,
that
the
prolamines
of
millet
and
sorghum
may
not
be
toxic.
Millet
is
used
in
some
gluten-free
recipes,
and
experience
in
Great
Britain
indicates
that
it
is
acceptable.
It
is
also
claimed
that
sorghum
has
no
gluten.8
Nevertheless,
Bell
and
associates8
recommended
that
millet
and
sorghum
be
avoided
until
more
informa-
tion
is
available.
Gluten-free
foods:
Foods
that
contain
gluten
(or
gluten-like
substances)
in
their
natural
form
but
have
had
the
gluten
removed
may
be
labelled
"gluten-free".22
In
such
products
the
nitrogen
content
must
not
exceed
0.05
g/100
g
of
grain,
the
equivalent
of
0.3%
protein.
Alcoholic
beverages:
Since
gluten
(a
protein)
cannot
pass
through
an
alcohol
still,
distilled
alcoholic
bever-
ages
are
gluten-free.
Rye
whisky,
scotch
whisky
and
other
spirits
made
from
gluten-containing
cereals
need
not
be
excluded.
Most
authorities
(C.C.
Booth,
P.J.
Bereton
and
M.R.
Ward:
personal
communications,
1981)
agree
with
this
position,
although
some
concern
has
been
expressed
recently.8
There
is
even
less
reason
for
excluding
brandy
and
wine
made
from
grapes,
which
contain
no
gluten.4
Because
beer
and
ale
are
produced
from
barley
there
is
concern
that
they
may
be
toxic.
Some
workers
recommend
that
beer
and
ale
be
avoided
even
in
the
absence
of
clinical
data
to
justify
that
position.38'2
On
the
other
hand,
the
enzymatic
breakdown
products
of
barley
have
not
been
shown
to
be
harmful
to
patients
with
celiac
disease
(M.R.
Ward:
personal
communica-
tion,
1981).
Gluten-containing
material
is
insoluble
in
water
and
is
largely
if
not
entirely
removed
in
clarifica-
tion
and
filtration.
Beer
and
ale
are
permitted
by
most
authorities,4
including
groups
in
Great
Britain
(C.C.
Booth,
P.J.
Bereton:
personal
communication,
1981).
Flavourings
and
additives:
Malt
is
prepared
from
sprouted
barley
and
is
therefore
suspected
of
being
toxic
even
though
barley
does
not
seem
to
be
as
toxic
as
wheat
and
rye.8
The
levels
of
barley
in
malted
foods
are
probably
low
enough
that
only
very
sensitive
individuals
need
avoid
such
food.
Malt
extract
and
malt
flavour-
ings,
used
in
some
breakfast
cereals,
are
safe
for
patients
with
celiac
disease
since
the
toxic
proteins
are
removed
in
processing
(A.B.
French,
University
of
Michigan
Medical
School,
Ann
Arbor:
personal
com-
munication,
1981).
Monosodium
glutamate
(MSG),
an
amino
acid
wide-
ly
present
in
foods,
has
been
used
without
ill
effects
(A.B.
French:
personal
communication,
1981).
It
is
acceptable
for
patients
with
celiac
disease.8
Hydrolyzed
vegetable
protein
(HVP),
a
flavour
en-
hancer
in
many
commercially
prepared
soups
and
foods,
may
be
made
from
soy,
wheat
or
other
cereal
proteins.
It
is
not
required
that
the
source
of
HVP
be
given
on
food
labels.
Some
authorities
recommend
that
foods
containing
HVP
be
avoided;8
others
allow
them
(C.C.
Booth
and
P.J.
Bereton:
personal
communication,
1981).
The
amount
of
HVP
used
in
soups
and
other
foods
is
small,
and
even
if
the
HVP
is
made
from
wheat
it
probably
need
be
avoided
only
by
very
sensitive
individuals.
All
other
foods:
Since
toxic
prolamines
apparently
occur
naturally
only
in
wheat,
rye,
triticale,
barley
and
oats,
all
other
foods
are
safe
for
patients
with
celiac
disease.
These
include
legumes
(e.g.,
peas,
beans,
soy-
beans
and
chickpeas),
starchy
roots
(e.g.,
potatoes,
sweet
potatoes,
arrowroot,
sago
and
tapioca),
all
nuts
and
seeds,
and
all
fruits,
vegetables,
meats,
poultry,
fish,
eggs,
milk,
cheese
and
related
products,
provided
that
toxic
cereals
have
not
been
added
in
their
processing
or
preparation.
Product
labels
Probably
the
most
difficult
decision
faced
by
patients
with
celiac
disease
is
whether
to
eat
certain
prepackaged
processed
foods.
However,
all
prepackaged
foods
now
carry
a
list
of
ingredients
on
the
label,23
and
the
consumer
must
check
for
the
five
harmful
cereals
and
possibly
malt
and
HVP.
If
there
is
doubt
abQut
a
label
or
a
particular
product,
information
must
be
obtained
from
the
vendor
or
manufacturer,
who
is
usually
aware
of
the
problem
and
very
willing
to
assist.
Some
recommendations
in
Great
Britain
for
gluten-
free
foods
contain
warnings
about
certain
drugs
(C.C.
Booth
and
P.J.
Bereton:
personal
communication,
1981).
Advice
from
the
health
protection
branch
of
the
Depart-
ment
of
National
Health
and
Welfare
in
Canada
indicates
that
flour
and
gluten
.re
almost
never
used
in
pharmaceutical
preparations
in
this
country.
Individual
concerns
Authorities
in
the
field
of
celiac
disease
differ
in
their
opinions
about
the
acceptibility
of
several
foods.
The
recommendations
I
have
listed
are
general
ones
applica-
ble
to
most
patients
with
celiac
disease.
A
few
patients,
however,
may
find
it
necessary
to
modify
the
recom-
mendations
to
meet
their
individual
needs
or
problems.
Individuals
differ
in
their
response
to
doses
of
foods
such
as
barley
and
oats,'2"6
probably
because
of
differing
sensitivity
to
various
types
and
amounts
of
prolamines
(gluten).
The
effect-s
of
deviating
from
a
strict
diet
are
not
known.24
Patients
with
celiac
disease
have
a
slightly
increased
risk
of
certain
types
of
malignant
disease25
and
intestinal
ulcers?6
There
are
no
data,
however,
to
indicate
that
this
risk
is
lowered
by
complete
avoidance
of
gluten.
A
patient
with
celiac
disease
therefore
has
the
choice
of
following
a
strict
diet
with
its
disadvantages
or
of
consuming
an
occasional
serving
of
a
food
that
does
not
cause
serious
symptoms
but
may
increase
the
risk
of
cancer.
Long-term
dietary
therapy
is
generally
recommended
for
children,2728
although
Bell
and
associates8
have
suggested
that
once
full
health
is
restored
the
patient
can
consume
oats
in
reasonable
amounts.
The
patient's
attitude
The
well-being
of
a
patient
with
celiac
disease
depends
not
only
on
the
effectiveness
of
dietary
modifi-
cation
but
also
on
the
patient's
physiologic
and
mental
reactions
to
these
modifications.
Patients
have
the
most
difficulty
in
adhering
to
the
diet
when
away
from
home,29
but
some
helpful
suggestions
in
this
area
have
been
given
by
the
Coeliac
Society.30
Wheat
flour,
as
either
flour
or
bread,
must
be
avoided
when
eating
out.
Other
toxic
cereals
may
be
largely
disregarded,
for
they
are
seldom
encountered.
Soups,
gravies
and
sauces
should
be
avoided
unless
they
are
known
to
contain
no
flour.30
Certainly
the
best attitude
for
a
patient
with
celiac
disease
is
a
positive
one.
An
interest
in
new
and
different
foods
will
also
help.
I
thank
Dr.
W.
Strober,
National
Cancer
Institute,
Bethesda,
Maryland,
and
Dr.
D.D.
Kasarda,
Western
Regional
Research
Center,
Berkeley,
California
for
reviewing
the
manuscript
and
providing
many
helpful
suggestions.
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JOURNAL/NOVEMBER
15,
1982/VOL.
127
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