Gluten-free diet
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A gluten-free diet (GFD) is a nutritional plan that strictly excludes gluten, which is a mixture of prolamin proteins found in wheat (and all of its species and hybrids, such as spelt, kamut, and triticale), as well as barley, rye, and oats.<ref name=Biesiekierski2017>Template:Cite journalTemplate:Open access</ref> The inclusion of oats in a gluten-free diet remains controversial, and may depend on the oat cultivar and the frequent cross-contamination with other gluten-containing cereals.<ref name=CiacciCiclitira2015>Template:Cite journal</ref><ref name=CominoMoreno2015 /><ref name=PenaginiDilillo /><ref name=DeSouzaDeschenes2016>Template:Cite journal</ref>
Gluten may cause both gastrointestinal and systemic symptoms for those with gluten-related disorders, including coeliac disease (CD), non-coeliac gluten sensitivity (NCGS), and wheat allergy.<ref name=LudvigssonLeffler>Template:Cite journal</ref> In these people, the gluten-free diet is demonstrated as an effective treatment,<ref name=MulderWanrooijQuotation>Template:Cite journal</ref><ref name=HischenhuberCrevelQuotation>Template:Cite journal</ref><ref name=VoltaCaio2015Quotation>Template:Cite journal</ref> but several studies show that about 79% of the people with coeliac disease have an incomplete recovery of the small bowel, despite a strict gluten-free diet.<ref name=SeeKaukinen2015 /> This is mainly caused by inadvertent ingestion of gluten.<ref name=SeeKaukinen2015 /> People with a poor understanding of a gluten-free diet often believe that they are strictly following the diet, but are making regular errors.<ref name="SeeKaukinen2015"/><ref name=MulderWanrooij />
In addition, a gluten-free diet may, in at least some cases, improve gastrointestinal or systemic symptoms in diseases like irritable bowel syndrome, rheumatoid arthritis, or HIV enteropathy, among others.<ref name= ElChammasDanner2011Quotation>Template:Cite journal</ref> There is no good evidence that gluten-free diets are an alternative medical treatment for people with autism.<ref name=MariBausetZazpe2014>Template:Cite journal</ref><ref name=Buie2013>Template:Cite journal</ref><ref name=Millward2008>Template:Cite journal</ref>
The grains that contain gluten are not essential in the human diet.<ref name=LamacchiaCamarca2014>Template:Cite journal</ref> However, an unbalanced selection of food and an incorrect choice of gluten-free replacement products may lead to nutritional deficiencies. Replacing flour from wheat or other gluten-containing cereals with gluten-free flours in commercial products may lead to a lower intake of important nutrients, such as iron and B vitamins. Some gluten-free commercial replacement products are not as enriched or fortified as their gluten-containing counterparts, and often have greater lipid/carbohydrate content. Children especially often over-consume these products, such as snacks and biscuits. Nutritional complications can be prevented by a correct dietary education.<ref name=PenaginiDilillo />
A gluten-free diet may be based on gluten-free foods, such as meat, fish, eggs, milk and dairy products, legumes, nuts, fruits, vegetables, potatoes, rice, and corn.<ref name="Saturni-etal-2010-table2-p21" /> Gluten-free processed foods may be used.<ref name=PenaginiDilillo>Template:Cite journal</ref> Pseudocereals (such as quinoa, amaranth, and buckwheat<ref>Template:Cite journal</ref>) and some minor cereals have been found to be suitable alternative choices that can provide adequate nutrition.<ref>Template:Cite journal</ref>
Rationale behind adoption of the diet
Coeliac disease
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Coeliac disease (American English: celiac) (CD) is a chronic, immune-mediated, and mainly intestinal process, that appears in genetically predisposed people of all ages. It is caused by the ingestion of gluten, which is present in wheat, barley, rye and derivatives. Coeliac disease is not only a gastrointestinal disease, because it may affect several organs and cause an extensive variety of non-gastrointestinal symptoms, and most importantly, it may often be completely asymptomatic. Added difficulties for diagnosis are the fact that serological markers (anti-tissue transglutaminase [TG2]) are not always present,<ref name=NEJM2012>Template:Cite journal</ref> and many people with coeliac may have minor mucosal lesions, without atrophy of the intestinal villi.<ref name=BoldRostami>Template:Cite journal</ref>
Coeliac disease affects approximately 1–2% of the general population all over the world<ref name=LundinWijmenga2015>Template:Cite journal</ref> and is on the increase,<ref name=LionettiGatti2015>Template:Cite journal</ref> but most cases remain unrecognized, undiagnosed and untreated, exposing patients to the risk of long-term complications.<ref name=Fasano2005Pediatric>Template:Cite journal</ref><ref name=ElliBranchi>Template:Cite journal</ref> People may develop severe disease symptoms and be subjected to extensive investigations for many years before a proper diagnosis is achieved.<ref name="LudvigssonCard">Template:Cite journal</ref> Untreated coeliac disease may cause malabsorption, reduced quality of life, iron deficiency, osteoporosis, obstetric complications (stillbirth, intrauterine growth restriction, preterm birth, low birthweight, and small for gestational age),<ref name=SacconeBerghella2015>Template:Cite journal</ref> an increased risk of intestinal lymphomas and greater mortality.<ref name="LebwoholLudvigsson-quotation"/> Coeliac disease is associated with some autoimmune diseases, such as diabetes mellitus type 1, thyroiditis,<ref name="LundinWijmenga2015"/> gluten ataxia, psoriasis, vitiligo, autoimmune hepatitis, dermatitis herpetiformis, primary sclerosing cholangitis, and more.<ref name="LundinWijmenga2015"/>
Coeliac disease with "classic symptoms", which include gastrointestinal manifestations such as chronic diarrhea and abdominal distention, malabsorption, loss of appetite, and impaired growth, is currently the least common presentation of the disease and affects predominantly small children generally younger than two years of age.<ref name=Fasano2005Pediatric /><ref name=LudvigssonCard />
Coeliac disease with "non-classic symptoms" is the most common clinical type and occurs in older children (over two years old), adolescents and adults.<ref name=LudvigssonCard /> It is characterized by milder or even absent gastrointestinal symptoms and a wide spectrum of non-intestinal manifestations that can involve any organ of the body, and very frequently may be completely asymptomatic<ref name=Fasano2005Pediatric /> both in children (at least in 43% of the cases<ref name="VriezingaSchweizer2015">Template:Cite journal</ref>) and adults.<ref name=Fasano2005Pediatric />
Following a lifelong gluten-free diet is the only medically accepted treatment for people with coeliac disease.<ref name=LamacchiaCamarca2014 /><ref name="De Palma">Template:Cite journal</ref>
Non-coeliac gluten sensitivity
{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}} Non-coeliac gluten sensitivity (NCGS) is described as a condition of multiple symptoms that improves when switching to a gluten-free diet, after coeliac disease and wheat allergy are excluded.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> People with NCGS may develop gastrointestinal symptoms, which resemble those of irritable bowel syndrome (IBS)<ref name=ElliRoncorni>Template:Cite journal</ref><ref name=CatassiBai>Template:Cite journal</ref> or a variety of nongastrointestinal symptoms.<ref name=VoltaCaio2015>Template:Cite journal</ref><ref name=FasanoSapone2015 /><ref name="CatassiBai2013">Template:Cite journal</ref>
Gastrointestinal symptoms may include any of the following: abdominal pain, bloating, bowel habit abnormalities (either diarrhea or constipation),<ref name=VoltaCaio2015 /><ref name="CatassiBai2013" /> nausea, aerophagia, gastroesophageal reflux disease, and aphthous stomatitis.<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /> A range of extra-intestinal symptoms, said to be the only manifestation of NCGS in the absence of gastrointestinal symptoms,<ref name=VoltaCaio2015 /><ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /> have been suggested, but remain controversial.<ref name="LebwoholLudvigsson-quotation"/><ref name=AzizHadjivassiliou2015>Template:Cite journal</ref> These include: headache, migraine, "brain fog", fatigue, fibromyalgia,<ref name=AzizHadjivassiliou2015 /><ref name=RossiDiLollo>Template:Cite journal</ref> joint and muscle pain, leg or arm numbness, tingling of the extremities, dermatitis (eczema or skin rash), atopic disorders such as asthma, rhinitis, other allergies, depression, anxiety, iron-deficiency anemia, folate deficiency or autoimmune diseases.<ref name=VoltaCaio2015 /><ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=AzizHadjivassiliou2015 /> NCGS has also been controversially implicated in some neuropsychiatric disorders, including schizophrenia, eating disorders, autism, peripheral neuropathy, ataxia and attention deficit hyperactivity disorder (ADHD).<ref name=VoltaCaio2015 /><ref name="LebwoholLudvigsson-quotation"/><ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=AzizHadjivassiliou2015 /> Above 20% of people with NCGS have IgE-mediated allergy to one or more inhalants, foods or metals, among which most common are mites, graminaceae, parietaria, cat or dog hair, shellfish and nickel.<ref name=VoltaCaio2015 /> Approximately, 35% of people with NCGS have other food intolerances, mainly lactose intolerance.<ref name=AzizHadjivassiliou2015 />
The pathogenesis of NCGS is not yet well understood. For this reason, it is a controversial syndrome<ref name=VriezingaSchweizer2015/> and some authors still question it.<ref name=FasanoSapone2015Quotation2>Template:Cite journal</ref> There is evidence that not only gliadin (the main cytotoxic antigen of gluten), but also other proteins named ATIs which are present in gluten-containing cereals (wheat, rye, barley, and their derivatives) may have a role in the development of symptoms. ATIs are potent activators of the innate immune system.<ref name="FasanoSapone2015">Template:Cite journal</ref><ref name=Verbeke2018 /> FODMAPs, especially fructans, are present in small amounts in gluten-containing grains and have been identified as a possible cause of some gastrointestinal symptoms in persons with NCGS.<ref name=FasanoSapone2015 /><ref name="VoltaCaioQuestions" /><ref name=Verbeke2018 /><ref name=OntiverosHardy>Template:Cite journal</ref> As of 2019, reviews have concluded that although FODMAPs may play a role in NCGS, they only explain certain gastrointestinal symptoms, such as bloating, but not the extra-digestive symptoms that people with NCGS may develop, such as neurological disorders, fibromyalgia, psychological disturbances, and dermatitis.<ref name=Verbeke2018 /><ref name=VoltaDeGiorgio2019 /><ref name="FasanoSapone2015" />
After exclusion of coeliac disease and wheat allergy,<ref name="mansueto-etal-2014">Template:Cite journal</ref> the subsequent step for diagnosis and treatment of NCGS is to start a strict gluten-free diet to assess if symptoms improve or resolve completely. This may occur within days to weeks of starting a GFD, but improvement may also be due to a non-specific, placebo response.<ref name="GenuisLobo2014">Template:Cite journal</ref> Recommendations may resemble those for coeliac disease, for the diet to be strict and maintained, with no transgression.<ref name=VoltaCaio2015 /> The degree of gluten cross contamination tolerated by people with NCGS is not clear but there is some evidence that they can present with symptoms even after consumption of small amounts.<ref name=VoltaCaio2015 /> It is not yet known whether NCGS is a permanent or a transient condition.<ref name=VoltaCaio2015 /><ref name=VriezingaSchweizer2015 /> A trial of gluten reintroduction to observe any reaction after one–two years of strict gluten-free diet might be performed.<ref name=VoltaCaio2015 />
A subgroup of people with NCGS may not improve by eating commercially available gluten-free products, which are usually rich of preservatives and additives, because chemical additives (such as sulphites, glutamates, nitrates and benzoates) might have a role in evoking functional gastrointestinal symptoms of NCGS. These people may benefit from a diet with a low content of preservatives and additives.<ref name="VoltaCaioQuestions">Template:Cite journal</ref>
NCGS, which is possibly immune-mediated, now appears to be more common than coeliac disease,<ref name="Hogg-Collars-2014">Template:Cite journal</ref> with prevalence rates between 0.5 and 13% in the general population.<ref name=MolinaInfanteSantolaria2015SystematicReview>Template:Cite journal</ref>
Wheat allergy
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People can also experience adverse effects of wheat as result of a wheat allergy.<ref>Template:Cite journal</ref> Gastrointestinal symptoms of wheat allergy are similar to those of coeliac disease and non-coeliac gluten sensitivity, but there is a different interval between exposure to wheat and onset of symptoms. Other symptoms such as dermal reactions like as rashes or hyperpigmentation may also occur in some people. Wheat allergy has a fast onset (from minutes to hours) after the consumption of food containing wheat and could be anaphylaxis.<ref name=NEJM2012 /><ref name=ScherfBrockowQuotation>Template:Cite journal</ref>
The management of wheat allergy consists of complete withdrawal of any food containing wheat and other gluten-containing cereals.<ref name=HischenhuberCrevelQuotation /><ref name=ScherfBrockowQuotation /> Nevertheless, some people with wheat allergy can tolerate barley, rye or oats.<ref name="Pietzak2012">Template:Cite journal</ref>
Gluten ataxia
Gluten ataxia is an autoimmune disease triggered by the ingestion of gluten.<ref name="sapone-etal-2010-b">Template:Cite journal</ref> With gluten ataxia, damage takes place in the cerebellum, the balance center of the brain that controls coordination and complex movements like walking, speaking and swallowing, with loss of Purkinje cells. People with gluten ataxia usually present gait abnormality or incoordination and tremor of the upper limbs. Gaze-evoked nystagmus and other ocular signs of cerebellar dysfunction are common. Myoclonus, palatal tremor, and opsoclonus-myoclonus may also appear.<ref name="HadjivassiliouSanders2015" />
Early diagnosis and treatment with a gluten-free diet can improve ataxia and prevent its progression. The effectiveness of the treatment depends on the elapsed time from the onset of the ataxia until diagnosis, because the death of neurons in the cerebellum as a result of gluten exposure is irreversible.<ref name="HadjivassiliouSanders2015" /><ref name="MitomaAdhikari2016">Template:Cite journal</ref>
Gluten ataxia accounts for 40% of ataxias of unknown origin and 15% of all ataxias.<ref name="HadjivassiliouSanders2015">Template:Cite journal</ref><ref name="pmid12566288">Template:Cite journal</ref> Less than 10% of people with gluten ataxia present any gastrointestinal symptom, yet about 40% have intestinal damage.<ref name="HadjivassiliouSanders2015" />
As a popular diet
Since the beginning of the 21st century, the gluten-free diet has become the most popular fad diet in the United States and other countries.<ref name="FasanoSapone2015" /> Clinicians worldwide have been challenged by an increasing number of people who do not have coeliac disease nor wheat allergy, with digestive or extra-digestive symptoms which improved removing wheat/gluten from the diet. Many of these persons began a gluten-free diet on their own, without having been previously evaluated.<ref name=VoltaCaio2017>Template:Cite journal</ref><ref name="LebwoholLudvigsson-quotation"/> Another reason that contributed to this trend was the publication of several books that demonize gluten and point to it as a cause of type 2 diabetes, weight gain and obesity, and a broad list of diseases ranging from depression and anxiety to arthritis and autism.<ref name="NashSlutzky2014" /><ref name="ShewryHey2016">Template:Cite journal</ref> The book that has had the most impact is Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar—Your Brain's Silent Killers, by the American neurologist David Perlmutter, published in September 2013.<ref name="NashSlutzky2014" /> Another book that has had great impact is Wheat Belly: Lose the Wheat, Lose the Weight, and Find Your Path Back to Health, by the cardiologist William Davis, which refers to wheat as a "chronic poison" and became a New York Times bestseller within a month of publication in 2011.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The gluten-free diet has been advocated and followed by many celebrities to lose weight, such as Miley Cyrus, Gwyneth Paltrow, and Kourtney Kardashian, and are used by some professional athletes, who believe the diet can improve energy and health.<ref name="LebwoholLudvigsson-quotation">Template:Cite journal</ref><ref name="Jones2017">Template:Cite journal</ref><ref name="USAToday2013">Template:Cite news</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> It became popular in the US, as the popularity of low-carbohydrate diets faded.<ref name=":0">Template:Cite news</ref>
Estimates suggest that in 2014, 30% of people in the US and Australia were consuming gluten-free foods, with a growing number, calculated from surveys that by 2016 approximately 100 million Americans would consume gluten-free products.<ref name=FasanoSapone2015 /><ref name="NashSlutzky2014">Template:Cite journal</ref><ref name="HeraldSun2014">Template:Cite news</ref> Data from a 2015 Nielsen survey of 30,000 adults in 60 countries around the world conclude that 21% of people prefer to buy gluten-free foods, being the highest interest among the younger generations.<ref name="Reilly2016">Template:Cite journal</ref> In the US, it was estimated that more than half of people who buy foods labeled gluten-free do not have a clear reaction to gluten, and they do so "because they think it will help them lose weight, because they seem to feel better or because they mistakenly believe they are sensitive to gluten."<ref name=CBS>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Although gluten is highly immunologically reactive and humans appear not to have evolved to digest it well, a gluten-free diet is not a healthier option for the general population, other than people with gluten-related disorders or other associated conditions which improve with a gluten-free diet in some cases, such as irritable bowel syndrome and certain autoimmune and neurological disorders.<ref name="ElChammasDanner2011Quotation" /><ref name="Pietzak2012"/><ref name="GaesserAngadi2012">Template:Cite journal</ref> There is no published experimental evidence to support that the gluten-free diet contributes to weight loss.<ref name="GaesserAngadi2012" />
In a review of May 2015 published in Gastroenterology, Fasano et al. conclude that, although there is an evident "fad component" to the recent rise in popularity of the gluten-free diet, there is also growing and unquestionable evidence of the existence of non-coeliac gluten sensitivity.<ref name="FasanoSapone2015-quotation">Template:Cite journal</ref>
In some cases, the popularity of the gluten-free diet may harm people who must eliminate gluten for medical reasons. For example, servers in restaurants may not take dietary requirements seriously, believing them to be merely a preference. This could prevent appropriate precautions in food handling to prevent gluten cross-contamination.<ref name="NWF">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Medical professionals may also confuse medical explanations for gluten intolerance with patient preference.<ref name="Pietzak2012" /> On the other hand, the popularity of the gluten-free diet has increased the availability of commercial gluten-free replacement products and gluten-free grains.<ref name="GaesserAngadi2012" />
Gluten-free commercial replacement products, such as gluten-free cakes, are more expensive than their gluten-containing counterparts, so their purchase adds a financial burden.<ref name="LudvigssonCard" /> They are also typically higher in calories, fat, and sugar, and lower in dietary fibre.<ref name=":0" /> In less developed countries, wheat can represent an important source of protein, since it is a substantial part of the diet in the form of bread, noodles, bulgur, couscous, and other products.<ref name=LamacchiaCamarca2014 /><ref>Template:Cite book</ref>
In the British National Health Service, gluten-free foods have been supplied on prescription. For many patients, this meant at no cost. When it was proposed to alter this in 2018, the Department of Health and Social Care made an assessment of the costs and benefits. The potential annual financial saving to the service was estimated at £5.3 million, taking into account the reduction in cost spending and the loss of income from prescription charges. The proposed scenario was actually that patients could still be prescribed gluten-free breads and mixes but would have to buy any other gluten-free products themselves. The savings would only amount to £700,000 a year. Local initiatives by clinical commissioning groups had already reduced the cost of gluten-free foods to the NHS by 39% between 2015 and 2017.<ref>Template:Cite journal</ref>
Healthcare professionals recommend against undertaking a gluten-free diet as a form of self-diagnosis,<ref name="slewis">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> because tests for coeliac disease are reliable only if the person has been consuming gluten recently. There is a consensus in the medical community that people should consult a physician before going on a gluten-free diet, so that a medical professional can accurately test for coeliac disease or any other gluten-induced health issues.<ref name="ElliBranchi2015">Template:Cite journal</ref>
Although popularly used as an alternative treatment for people with autism, there is no good evidence that a gluten-free diet is of benefit in reducing the symptoms of autism.<ref name=MariBausetZazpe2014 /><ref name=Buie2013 /><ref name=Millward2008 />
Research
In a 2013 double-blind, placebo-controlled challenge (DBPC) by Biesiekierski et al. in a few people with irritable bowel syndrome, the authors found no difference between gluten or placebo groups and the concept of non-celiac gluten sensitivity as a syndrome was questioned. Nevertheless, this study had design errors and an incorrect selection of participants, and probably the reintroduction of both gluten and whey protein had a nocebo effect similar in all people, and this could have masked the true effect of gluten/wheat reintroduction.<ref name=ElliBranchi /><ref name="AzizHadjivassiliou2015" />
In a 2015 double-blind placebo cross-over trial, small amounts of purified wheat gluten triggered gastrointestinal symptoms (such as abdominal bloating and pain) and extra-intestinal manifestations (such as foggy mind, depression and aphthous stomatitis) in self-reported non-celiac gluten sensitivity. Nevertheless, it remains elusive whether these findings specifically implicate gluten or other proteins present in gluten-containing cereals.<ref name="AzizHadjivassiliou2015" />
In a 2018 double-blind, crossover research study on 59 persons on a gluten-free diet with challenges of gluten, fructans or placebo, intestinal symptoms (specifically bloating) were borderline significantly higher after challenge with fructans, in comparison with gluten proteins (P=0.049).<ref name=Verbeke2018>Template:Cite journal</ref><ref name=VoltaDeGiorgio2019>Template:Cite journal</ref> Although the differences between the three interventions was very small, the authors concluded that fructans (the specific type of FODMAP found in wheat) are more likely to be the cause of gastrointestinal symptoms of non-celiac gluten sensitivity, rather than gluten.<ref name=Verbeke2018 /> For this previous study, experts recommend a low FODMAP diet instead of a gluten free diet for those patients suffering from functional gastrointestinal disorders as bloating.<ref>Template:Cite journal</ref> In addition, fructans used in the study were extracted from chicory root, so it remains to be seen whether the wheat fructans produce the same effect.<ref name=VoltaDeGiorgio2019 />
Eating gluten-free
A gluten-free diet is a diet that strictly excludes gluten, proteins present in wheat (and all wheat varieties such as spelt and kamut), barley, rye, oat, and derivatives of these grains such as malt and triticale, and foods that may include them, or shared transportation or processing facilities with them.<ref name=Biesiekierski2017 /><ref name="Saturni-etal-2010-table2-p21"/> The inclusion of oats in a gluten-free diet remains controversial.<ref name=Biesiekierski2017 /> Oat toxicity in people with gluten-related disorders depends on the oat cultivar consumed because the immunoreactivities of toxic prolamins are different among oat varieties.<ref name=PenaginiDilillo /><ref name=CominoMoreno2015 /> Furthermore, oats are frequently cross-contaminated with the other gluten-containing cereals.<ref name=PenaginiDilillo /> Pure oat (labelled as "pure oat" or "gluten-free oat"<ref name=CiacciCiclitira2015 />) refers to oats uncontaminated with any of the other gluten-containing cereals.<ref name=CominoMoreno2015>Template:Cite journal</ref> Some cultivars of pure oat could be a safe part of a gluten-free diet, requiring knowledge of the oat variety used in food products for a gluten-free diet.<ref name=CominoMoreno2015 /> Nevertheless, the long-term effects of pure oats consumption are still unclear<ref name=HaboubiTaylor2006>Template:Cite journal</ref> and further studies identifying the cultivars used are needed before making final recommendations on their inclusion in the gluten-free diet.<ref name=DeSouzaDeschenes2016 />
Other grains, although gluten-free in themselves, may contain gluten by cross-contamination with gluten-containing cereals during grain harvesting, transporting, milling, storing, processing, handling or cooking.<ref name=FSAI>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=CominoMoreno2013>Template:Cite journal</ref>
Processed foods commonly contain gluten as an additive (as emulsifiers, thickeners, gelling agents, fillers, and coatings), so they would need specific labeling. Unexpected sources of gluten are, among others, processed meat, vegetarian meat substitutes, reconstituted seafood, stuffings, butter, seasonings, marinades, dressings, confectionary, candies, and ice cream.<ref name=Biesiekierski2017 />
Cross-contamination in the home is also a consideration for those who have gluten-related disorders.<ref name=FrancavillaCristofori2014 /><ref name=SeeKaukinen2015>Template:Cite journal</ref> There can be many sources of cross-contamination, as for example when family members prepare gluten-free and gluten-containing foods on the same surfaces (countertops, tables, etc.) or share utensils that have not been cleaned after being used to prepare gluten-containing foods (cutting boards, colanders, cutlery, etc.), kitchen equipment (toaster, cupboards, etc.) or certain packaged foods (butter, peanut butter, etc.).<ref name=SeeKaukinen2015 />
Restaurants prove to be another source of cross-contamination for those following a strict gluten-free diet. A study conducted by Columbia University Medical Center found that 32% of foods labeled gluten-free at restaurants contain above 20 parts per million of gluten, meaning that it contains enough gluten that it is no longer considered gluten-free by the Codex Alimentarius.<ref>Template:Cite news</ref> Cross-contamination occurs in these areas frequently because of a general lack of knowledge about the needed level of caution and the prevalence of gluten in restaurant kitchens.<ref>Template:Cite journal</ref> If cooks are unaware of the severity of their guest's diet restrictions or of the important practices needed to limit cross-contamination, they can unknowingly deliver contaminated food. However, some restaurants utilize a training program for their employees to educate them about the gluten-free diet.<ref>Template:Cite journal</ref> The accuracy of the training varies. One resource to find these safer restaurants is an app and website called "Find Me Gluten Free" that allows people following a gluten-free diet to rate the safety of different restaurants from their point of view and describe their experience to help future customers.
Easily locating gluten-free items is one of the main difficulties in following a gluten-free diet. To assist in this process, many restaurants and grocery stores choose to label food items. Restaurants often add a gluten-free section to their menu, or specifically mark gluten-free items with a symbol of some kind. Grocery stores often have a gluten-free aisle, or they will attach labels on the shelf underneath gluten-free items. Though the food is labeled gluten-free in this way, it does not necessarily mean that the food is safe for those with gluten-related disorders, as a compilation of studies suggest.<ref name=":02">Template:Cite journal</ref>
Medications and dietary supplements are made using excipients that may contain gluten.<ref>Template:Cite journal</ref>
Gluten-free food
The gluten-free diet includes naturally gluten-free food, such as meat, fish, seafood, eggs, milk and dairy products, nuts, legumes, fruit, vegetables, potatoes, pseudocereals (in particular amaranth, buckwheat, chia seed, quinoa), only certain cereal grains (corn, rice, sorghum), minor cereals (including fonio, Job's tears, millet, teff, called "minor" cereals as they are "less common and are only grown in a few small regions of the world"),<ref name="Saturni-etal-2010-table2-p21">Template:Cite journal. See Table 2 and page 21.</ref> some other plant products (arrowroot, mesquite flour,<ref name="Kohlstadt2012-p318">O'Brian T, Ford R, Kupper C, Celiac Disease and Non-Celiac Gluten Sensitivity: The evolving spectrum, pp. 305–330. In: Template:Cite book</ref> sago,<ref name="pmid13560852">Template:Cite journal</ref> tapioca<ref name="pmid13560852"/>) and products made from these gluten-free foods. Many Indian cuisine options, particularly South Indian cuisine, are gluten-free.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
Risks
An unbalanced selection of food and an incorrect choice of gluten-free replacement products may lead to nutritional deficiencies. Replacing flour from wheat or other gluten-containing cereals with gluten-free flours in commercial products may lead to a lower intake of important nutrients, such as iron and B vitamins and a higher intake of sugars and saturated fats. Some gluten-free commercial replacement products are not enriched or fortified as their gluten-containing counterparts, and often have greater lipid / carbohydrate content. Children especially often over-consume these products, such as snacks and biscuits. These nutritional complications can be prevented by a correct dietary education.<ref name=PenaginiDilillo /> Pseudocereals (quinoa, amaranth, and buckwheat) and some minor cereals are healthy alternatives to these prepared products and have higher biological and nutritional value.<ref name=PenaginiDilillo /><ref name=LamacchiaCamarca2014 /> Advances towards higher nutrition-content gluten-free bakery products, improved for example in terms of fiber content and glycemic index, have been made by using not exclusively corn starch or other starches to substitute for flour. In this aim, for example the dietary fibre inulin (which acts as a prebiotic<ref>Template:Cite journal</ref>) or quinoa or amaranth wholemeal have been as substitute for part of the flour. Similarly, xanthan gum can be used in up to gram quantities per serving in some gluten-free baked goods and can be fermented by specific microbiomes in the gastrointestinal tract.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>Template:Cite journal</ref> Such substitution has been found to also yield improved crust and texture of bread.<ref name="GallagherGormley2004">Template:Cite journal</ref> It is recommended that anyone embarking on a gluten-free diet check with a registered dietitian to make sure they are getting the required amount of key nutrients like iron, calcium, fiber, thiamin, riboflavin, niacin and folate. Vitamins often contain gluten as a binding agent. Experts have advised that it is important to always read the content label of any product that is intended to be swallowed.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
Up to 30% of people with known coeliac disease often continue having or redeveloping symptoms.<ref name=SeeKaukinen2015 /><ref name=AGA2006>Template:Cite journal</ref> Also, a lack of symptoms or negative blood antibodies levels are not reliable indicators of intestinal recuperation. Several studies show an incomplete recovery of small bowel despite a strict gluten-free diet, and about 79% of such people have persistent villous atrophy.<ref name=SeeKaukinen2015 /> This lack of recovery is mainly caused by inadvertent exposure to gluten.<ref name=SeeKaukinen2015 /><ref name=AGA2006 /> People with poor basic education and understanding of the gluten-free diet often believe that they are strictly following the diet, but are making regular errors.<ref name=MulderWanrooij /><ref name="SeeKaukinen2015"/> In addition, some people often deliberately continue eating gluten because of limited availability, inferior taste, higher price, and inadequate labelling of gluten-free products. Poor compliance with the regimen is also influenced by age at diagnosis (adolescents), ignorance of the consequences of the lack of a strict treatment and certain psychological factors.<ref name=SeeKaukinen2015 /> Ongoing gluten intake can cause severe disease complications, such as various types of cancers (both intestinal and extra-intestinal) and osteoporosis.<ref name=SeeKaukinen2015 /><ref name=AGA2006 />
Regulation and labels
The term gluten-free is generally used to indicate a supposed harmless level of gluten rather than a complete absence.<ref name=Akobeng2008>Template:Cite journal</ref> The exact level at which gluten is harmless is uncertain and controversial. A 2008 systematic review tentatively concluded that consumption of less than 10 mg of gluten per day is unlikely to cause histological abnormalities, although it noted that few reliable studies had been done.<ref name=Akobeng2008/>
Regulation of the label gluten-free varies by country. Most countries derive key provisions of their gluten-free labelling regulations from the Codex Alimentarius international standards for food labelling as a standard relating to the labelling of products as gluten-free. It only applies to foods that would normally contain gluten.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Gluten-free is defined as 20 ppm (= 20 mg/kg) or less. It categorizes gluten-free food as:
- Food that is gluten-free by composition
- Food that has become gluten-free through special processing.
- Reduced gluten content, food which includes food products with between 20 and 100 ppm of gluten Reduced gluten content is left up to individual nations to more specifically define.
The Codex Standard suggests the enzyme-linked Immunoassay (ELISA) R5 Mendez method for indicating the presence of gluten, but allows for other relevant methods, such as DNA. The Codex Standard specifies that the gluten-free claim must appear in the immediate proximity of the name of the product, to ensure visibility.
There is no general agreement on the analytical method used to measure gluten in ingredients and food products.<ref>Template:Cite journal</ref> The ELISA method was designed to detect w-gliadins, but it suffered from the setback that it lacked sensitivity for barley prolamins.<ref>Template:Cite journal</ref> The use of highly sensitive assays is mandatory to certify gluten-free food products. The European Union, World Health Organization, and Codex Alimentarius require reliable measurement of the wheat prolamins, gliadins rather than all-wheat proteins.<ref>Codex Alimentarius (2003) Draft revised standards for gluten-free foods, report of the 25th session of the Codex Committee on Nutrition and Foods for Special Dietary Uses, November 2003</ref>
Australia
The Australian government recommends<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> that:
- food labelled gluten-free include no detectable gluten (<3ppm <ref>{{#invoke:citation/CS1|citation
|CitationClass=web }}</ref>) oats or their products, cereals containing gluten that have been malted or their products
- food labelled low gluten claims such that the level of 20 mg gluten per 100 g of the food
Brazil
All food products must be clearly labelled whether they contain gluten or they are gluten-free.<ref name='"ANVISA2017"'>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Since April 2016, the declaration of the possibility of cross-contamination is mandatory when the product does not intentionally add any allergenic food or its derivatives, but the Good Manufacturing Practices and allergen control measures adopted are not sufficient to prevent the presence of accidental trace amounts.<ref name="ANVISA2016">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> When a product contains the warning of cross-contamination with wheat, rye, barley, oats and their hybridized strains, the warning "contains gluten" is mandatory. The law does not establish a gluten threshold for the declaration of its absence.<ref name='"ANVISA2017"' />
Canada
Health Canada considers that foods containing levels of gluten not exceeding 20 ppm as a result of contamination, meet the health and safety intent of section B.24.018 of the Food and Drug Regulations when a gluten-free claim is made.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Any intentionally added gluten, even at low levels must be declared on the packaging and a gluten-free claim would be considered false and misleading. Labels for all food products sold in Canada must clearly identify the presence of gluten if it is present at a level greater than 10 ppm.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
European Union
The EU European Commission delineates<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> the categories as:
- gluten-free: 20 ppm or less of gluten
- very low gluten foodstuffs: 20-100ppm gluten.
All foods containing gluten as an ingredient must be labelled accordingly as gluten is defined as one of the 14 recognized EU allergens.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
United States
Until 2012 anyone could use the gluten-free claim with no repercussion.<ref>Template:Cite news</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> In 2008, Wellshire Farms chicken nuggets labelled gluten-free were purchased and samples were sent to a food allergy laboratory<ref>Template:Cite news</ref> where they were found to contain gluten. After this was reported in the Chicago Tribune, the products continued to be sold. The manufacturer has since replaced the batter used in its chicken nuggets.<ref>Template:Cite news</ref> The U.S. first addressed gluten-free labelling in the 2004 Food Allergen Labeling and Consumer Protection Act (FALCPA). The Alcohol and Tobacco Tax and Trade Bureau published interim rules and proposed mandatory labelling for alcoholic products in 2006.<ref>Template:USFR (26 July 2006), Template:USFR (26 July 2006)</ref> The FDA issued their Final Rule on August 5, 2013.<ref>Template:USFR (5 August 2013). Codified at Template:USCFR.</ref> When a food producer voluntarily chooses to use a gluten-free claim for a product, the food bearing the claim in its labelling may not contain:
- an ingredient that is a gluten-containing grain
- an ingredient that is derived from a gluten-containing grain that has not been processed to remove gluten
- an ingredient that is derived from a gluten-containing grain, that has been processed to remove gluten but results in the presence of 20 ppm or more gluten in the food. Any food product claiming to be gluten-free and also bearing the term "wheat" in its ingredient list or in a separate "Contains wheat" statement, must also include the language "*the wheat has been processed to allow this food to meet the FDA requirements for gluten-free foods," in close proximity to the ingredient statement.
Any food product that inherently does not contain gluten may use a gluten-free label where any unavoidable presence of gluten in the food bearing the claim in its labelling is below 20 ppm gluten.
See also
- 2010s in food
- Gluten-free, casein-free diet
- List of diets
- Paleolithic diet
- Specific carbohydrate diet
References
External links
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