Living with Celiac Disease A GUIDE TO MANAGING A GLUTEN-FREE DIET Don’t let the gluten-free diet restrict your cooking and baking; use it instead as an opportunity to experiment with new ingredients and flavors. Look for alternative ingredients in your local ShopRite store or use the “Ask the Dietitian” feature at www.shoprite.com to submit a question or favorite recipe. Visit the Live Right with ShopRite section of www.shoprite.com for more information and resources to help you manage a gluten-free lifestyle or call our Customer Care Center: 1-800-ShopRite (1-800-746-7748) PRODUCED IN COOPERATION WITH July 2009 Choices for your Lifestyle What is Celiac Disease? Celiac disease (also referred to as celiac sprue, non-tropical sprue, and gluten-sensitive enteropathy) is a digestive disease that is triggered by consuming a protein called gluten, which is found in wheat, barley and rye. When people with celiac disease eat foods containing gluten, their immune system responds by damaging the fingerlike projections that line the small intestine called “villi.” Damaged villi make it nearly impossible for the body to absorb essential nutrients into the bloodstream, which can lead to malnourishment and a host of other problems including cancer, osteoporosis, infertility, diabetes, and the onset of other autoimmune diseases. WHO GETS CELIAC DISEASE? Managing a gluten-free diet doesn’t have to be a challenge. If you are newly diagnosed, you may feel as though you have to give up all the foods you love! But with a little education and effort, you will learn that there are still many delicious foods you CAN eat. There have been incredible improvements in gluten-free foods and there are new products entering the marketplace everyday. Nearly one out of every 133 Americans has celiac A cross-section of the small intestine disease, equivalent to nearly 1% of the U.S. population. showing the fingerlike villi lining However, 97% of people with celiac disease remain undiagnosed or misdiagnosed. Translated into numbers, this means that up to three million Americans have celiac disease and only about 100,000 know they have the condition. Celiac disease is a genetic disorder, meaning that it passes from parent to child via DNA. In some cases, stressful events like pregnancy, surgery, infection, or severe emotional distress can trigger the onset of the disease. In this guide you’ll find information about celiac disease, symptoms, diagnosis, treatment with a gluten-free diet, safe and unsafe grains, as well as tips and recipes for gluten-free living. Symptoms of Celiac Disease Celiac disease has a wide variety of symptoms that often vary from person to person. Because there are approximately 300 symptoms associated with the disease, doctors often have difficulty diagnosing it and, in some cases, misdiagnose people with other digestive disorders such as irritable bowel syndrome. Be sure to explore our aisles for all of the gluten-free foods available to you at your local ShopRite. We can help make your gluten-free diet easy and delicious. Although the most commonly reported symptoms are gastrointestinal, some people may experience no intestinal issues and some people experience no symptoms at all. THE MOST COMMON GASTROINTESTINAL ISSUES INCLUDE: • Abdominal pain • Bloating • Gas • Constipation • Decreased appetite (may also be increased or unchanged) • Diarrhea • Nausea • Bloody stools — continued Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet 3 COMMON NON-INTESTINAL SYMPTOMS INCLUDE: • Anemia • Fatigue • Attention Deficit Hyperactivity Disorder • Infertility or pregnancy complications • Bone and joint pain • Itchy skin rash (Dermatitis herpetiformis) • Depression • Enamel defects on teeth • Fractures or thin bones • Failure to thrive in childhood (delayed growth) • Migraine headaches • Numbness in legs • Osteoporosis or osteopenia • Pale sore in mouth Anyone who suffers from the above symptoms for several months should speak to their doctor about the possibility of celiac disease being the cause. In all cases of celiac disease, a delayed diagnosis can increase the risk of worsening symptoms, development of new symptoms and other complications. Diagnosis of Celiac Disease To determine if a person has celiac disease, a physician can screen by using an antibody test, genetic test or a small intestine biopsy. Although there are three options, the only definitive test is the small intestine biopsy. Treatment of Celiac Disease: A Gluten-Free Diet To date, there are no medications or surgeries that can cure celiac disease. The only treatment is a gluten-free diet. People with celiac disease must avoid all foods that contain wheat, rye and barley. The gluten-free diet is a lifelong commitment for people with celiac disease. Eating any amount of gluten, no matter how tiny it is, can cause damage to the villi of the small intestines and prevent the absorption of essential nutrients. A physician will typically recommend that a newly diagnosed celiac disease patient consult with a registered dietitian. These professionals can help someone with celiac learn how to plan a healthy and wellbalanced gluten-free diet. They can also help people network with local celiac support groups. Most people who strictly follow a gluten-free diet will experience relief of symptoms within a few days, although it will take up to six months for the small intestine to heal in children and up to two years to heal in adults. A small number of people will continue to experience symptoms even when following a glutenfree diet. This is called unresponsive celiac disease and generally occurs when the small intestine has been severely damaged by celiac disease. According to the National Institutes of Health, researchers are currently working to develop a drug therapy to treat people with unresponsive celiac disease. How to Live with Celiac Disease Eliminating all foods made with wheat, rye and barley from the diet can seem overwhelming when a person is first diagnosed, but with a little extra effort in the kitchen, people with celiac disease can eat delicious food that tastes just as good as their glutinous counterparts. STEPS TO LIVING WITH CELIAC DISEASE: 1. Accept that you have celiac disease. The first step towards managing a successful gluten-free diet is accepting the fact that your health depends on it. Keep in mind that you are finally on the road to becoming healthy. Having a positive attitude will make managing the diet a much easier task. 2. Schedule an appointment with a registered dietitian. As soon as you receive a celiac disease diagnosis, you should ask your doctor for a referral to see a registered dietitian. Studies show that repeated visits with a dietitian, who is experienced with a gluten-free diet helps with diet compliance and positive outcomes. 3. Learn which foods contain gluten. Gluten is a protein found in all forms of wheat, rye, and barley. You will also need to familiarize yourself with hidden sources of gluten. 4. Learn how to read food labels. It is important to always read the labels of prepared, canned, and packaged foods to be sure they are gluten-free. Plain meat, poultry, fish, fruits and vegetables are all naturally gluten-free, as are rice, potatoes, corn, quinoa, sorghum, millet, and teff. 5. Research gluten-free manufacturers. As more people are diagnosed with celiac disease, the gluten-free marketplace will continue to expand with better tasting products on our shelves. 6. Prevent cross-contamination at home. Learning to prevent cross-contamination is key to maintaining a gluten-free diet. This means separating gluten-free products from other items in your pantry and washing all cooking surfaces and equipment before preparing gluten-free foods. 7. Educate your family. You must educate your family about the gluten-free diet and — continued 4 Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet 5 how to prevent cross-contamination. Remind your family not to share utensils, pots and pans, toasters and other cooking items without thoroughly washing them. For example, teach your family not to dip a knife in peanut butter that has already touched a piece of bread. 8. Attend local celiac support group meetings. These meetings can help you to learn more, plus they are a great opportunity for sharing cooking tips as well as your favorite gluten-free recipes. 9. Schedule annual follow-up appointments with your doctor. To make sure you are adhering to the gluten-free diet, schedule annual exams to receive the celiac antibody test. If your blood test comes back normal, it will confirm that you are maintaining a completely gluten-free diet! Build the base of your diet around healthy and naturally gluten-free foods such as plain meat, fish, poultry, fruits and vegetables, as well as rice, potatoes, corn and quinoa. START SIMPLY A first and simple step is to look for dishes that need very little customization, perhaps just the substitution of one gluten-free ingredient for one that is not gluten-free. For example, make macaroni and cheese Quinoa (pronounced “keen-wha”) is a delicious and or baked ziti with rice, corn, or lentil pasta, nutritious whole grain! or prepare enchiladas with corn tortillas instead of the wheat flour variety. UNSAFE GRAINS/INGREDIENTS The following grains and ingredients should not be consumed as they are derived from wheat, barley or rye: Durum Eikorn Emmer Farina Faro Graham Kamut Matzo meal Malt flavor Orzo Panko/Bread Crumbs Gluten is often found in places you would never suspect. Below is a list of common items that can contain gluten: Vitamins Toothpaste Lipgloss Lip balm Lipstick Dairy substitutes Dextrin Hydrolyzed protein Imitation seafood Licorice Lunch meats Modified food starch Play dough Seasonings Soy sauce Bouillon cubes Brown rice syrup Candy Rice mixes Sauces Self-basting turkey Vegetables in sauce French Fries Gravies Seasoned tortilla chips/potato chips Chicken, beef, vegetable Broths Over-the-counter and prescription medications OATS — A SPECIAL CAUTION Keeping a Gluten-free Kitchen Wheat Rye Barley Bran Bulgur Couscous HIDDEN SOURCES OF GLUTEN Malt vinegar Seitan Semolina Spelt Tritacale Udon Oats in their natural form do not contain the gluten protein. However, most mills that produce and store oats also manufacture wheat, making the chances of cross contamination inevitable. In addition, current research shows that approximately 1%–5% of celiac sufferers react to oats in their pure form. Although the cause for this reaction is unknown, some literature suggests that a protein in oats can trigger a similar response to gluten. There is no way to determine if you will react, so the best advice is to proceed with caution and consult with your doctor or a registered dietitian. Oats in their natural, pure form that are produced in a gluten-free facility can be enjoyed by most people with celiac disease. Gluten-Free Safe Substitutes If you don’t use the correct substitutes when replacing wheat flour in gluten-free recipes, your cookies may come out of the oven flat and tasting like rubber. Below is a list of the most useful gluten-free flours that can be substituted in recipes that call for wheat flour. For best results, use these flours in combination with other gluten-free flours — they are not intended to be used individually as a one-to-one substitute for wheat flour. If you can’t find an item in your local ShopRite, stop by the customer service desk or give us a call at 1-800-ShopRite (1-800-746-7748) and we’ll do our best to help you locate it. Almond Meal Flour is made from whole almonds that have been finely ground into a powder. It is used in cookies, cakes and other desserts. Be sure to store almond meal flour in the freezer. Amaranth has a very high protein and fiber content and adds a nutty flavor to glutenfree baked goods. It is most commonly used in combination with other flours to make breads, pasta, pancakes and other recipes. — continued 6 Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet 7 Buckwheat is a grain-like ingredient but it has no relation to wheat and is therefore gluten-free. Buckwheat is used throughout Europe to make pancakes and serves as a fantastic alternative for gluten-free cooking, especially when used to make breakfast cereal and lower calorie gluten-free breads. When being used as a replacement for wheat, buckwheat is best used in combination with other glutenfree substitutes. It is only recommended for replacing up to half of the wheat flour content in any recipe. Coconut Flour is a delicious and healthy alternative flour that has a high fiber content. It provides a natural sweetness and added moisture to baked goods. When being used as a replacement for wheat, coconut flour is best used in A delicious stack of buckwheat combination with other gluten-free substitutes. It is only pancakes with fresh fruit recommended for replacing up to one-quarter of the wheat topping flour content in recipes. Cornstarch is made by grinding up the starchy portion of a corn grain and turning it into a very fine powder. Cornstarch is typically used as a thickening agent, such as for soups, sauces and stews. It is also used in pre-made gluten-free flour blends because it creates a smoother texture. When using cornstarch in place of wheat flour, use one-and-onehalf teaspoons cornstarch for every tablespoon of flour. Garbanzo Bean (chickpea) Flour — All bean flours, are high in protein and fiber content. As opposed to rice, tapioca, and potato flours, bean flours more closely mimic the texture of white flour when used in baked products. Guar Gum is made from guar beans and has eight times the thickening ability of corn starch. It works well for thickening sauces and is often used to make gluten-free breads. Guar gum is to be used as a binding agent only in combination with gluten-free flour substitutes. Use one teaspoon of guar gum for each cup of flour called for in the recipe. be refrigerated. As with white rice flour, it is best to combine brown rice flour with several other flours to avoid the grainy texture. Ener-G Foods and Bob’s Red Mill produce a finer, lighter brown rice flour that works well with dense cakes such as pound cake. Xanthan Gum is used to add volume or fluffiness to gluten-free bread and other baked goods. It is made from Xanthomonas and is a natural carbohydrate. Like Guar gum, Xanthan gum is to be used as a binding agent only in combination with gluten-free flour substitutes. Use one teaspoon of xanthan gum for each cup of flour called for in the recipe. KITCHEN TIPS FOR GLUTEN-FREE COOKING: • For gravy: Use arrowroot starch or cornstarch as a thickener. • For stuffing: Make your favorite recipe with gluten-free cornbread or gluten-free white bread (homemade or store-bought) or experiment with rice stuffing. • For flouring or breading meat and fish: Try cornmeal, potato flakes or mixtures of gluten-free flours, seasoned to taste. To create a gluten-free coating, whirl some dry, gluten-free bread or corn tortilla chips in a food processor until fine. Or, some people enjoy crumbled gluten-free waffles or crisped rice — these are not usually sweetened and, when seasoned, create a tasty, crunchy coating. • For pudding and pie filling: Try gluten-free starches such as cornstarch, potato starch, tapioca or arrowroot. Cornmeal is great for breading meat or fish! • Find a prepared gluten-free baking mix to keep handy in your refrigerator. These tried and true mixtures of gluten-free flours, starches, and leavening agents can usually be substituted with wheat flour on a one-for-one basis. • Use rice flour for a roux or white sauce — you will find that bean and soy flours have too strong a taste. CAROL FENSTER’S GLUTEN-FREE FLOUR BLENDS Potato Flour is made by grinding potato roots and subsequently removing the fibrous material. Potato flour is most commonly used to thicken sauces and is generally included in gluten-free flour blends because it adds moisture to baked goods. Sorghum Flour is a millet-like grain and adds a strong flavor to gluten-free baked goods. Add in about one-eighth cup to enhance the flavors of breads, cookies and cakes. Tapioca Flour can add chewiness to baked goods, and is wonderful thickening agent. Tapioca flour is known for being one of the more flavorless gluten-free flours, so it won’t affect the taste of your dish. Brown Rice Flour is milled from unpolished brown rice and has a higher nutrient value than white rice flour. Since this flour contains bran it has a shorter shelf life and should 8 Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet Reprinted with permission from Carol Fenster, author of 1,000 Gluten-Free Recipes (Wiley, 2008) and Gluten-Free Quick & Easy (Avery, 2007). Rice Flour Blend (#1) 3 cups brown rice flour 1-1/4 cups potato starch or cornstarch 3/4 cup tapioca flour Brown rice flour blends should be refrigerated. Bean Flour Blend (#2) 2 cups potato starch or cornstarch 1-2/3 cups garbanzo/fava flour 2/3 cup tapioca flour 2/3 cup sorghum flour Store your blend in an airtight container in a dark, dry place. These flour blends may be used cup for cup as a substitute for all-purpose wheat flour in your favorite recipes. Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet 9 TIPS FOR EATING AWAY FROM HOME • When traveling, pack staple, nonperishable, gluten-free grain foods, such as cereal, bread, rice cakes, and crackers. low fat dairy fruits & vegetables • When eating at other people’s homes, offer to bring a gluten-free dish everyone can enjoy. • The safest choices will be foods without sauce, breading, marinades, or gravies. • Before going to a restaurant, call ahead to speak with the manager. Explain your dietary restrictions and discuss the restaurant’s menu options. • Since cross-contamination is a concern ask how food is prepared and if it is prepared with the same oil or on a the same surface as foods containing gluten. If so, ask that a portion of the surface or grill be cleaned prior to your meal preparation. HOW TO GET THE NUTRIENTS YOU NEED The growing number of gluten-free products available in stores provide great alternatives to their gluten containing counterparts. However, some gluten-free products may be more processed and lack much needed nutrients like fiber, calcium, and iron. These gluten-free foods should be seen as “once-in-a-while” foods leaving room for the bulk of your diet to come from naturally gluten-free foods. A healthy gluten-free diet should focus on all food groups; including low fat dairy, fruits and vegetables, lean protein, and of course gluten-free whole grains. Gluten in Medications Although people with celiac disease are generally focused on the food they eat, it is important to remember that it is possible to be exposed to gluten when taking medication. Gluten is used in many medications as a binder to hold the pills together. There are currently NO requirements for labeling gluten or common allergens that may be found in drug ingredients, so it is important to always check with the manufacturer to make sure that the particular medication you are taking is indeed gluten-free. To learn more about the inactive ingredients in medications, you can download a short flyer from the NFCA website (www.CeliacCentral.org). 10 • Choose pre-packaged deli meats and cheeses to avoid cross-contamination that may occur from deli slicers. gluten-free whole grains Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet Gluten-free Recipe lean protein WILD RICE STUFFED CHICKEN BREASTS Prep time: 15 minutes Cook time: 20 minutes 4 boneless, skinless chicken breast halves 3 tbsp. chopped onion or shallot 2 tbsp. chopped celery 1 cup cooked wild or brown rice 1/4 cup chopped dried apricots 3 tbsp. chopped pecans 1/2 tsp. dried thyme leaves 1 tbsp. finely chopped pecans 1. Preheat oven to 375°F. Place chicken on clean work surface. Cut pocket in side of thick portion of meat, not cutting all the way through. 2. Spray small nonstick skillet with nonstick cooking spray and place over medium-high heat. Add onion and celery. Cook and stir until onion is tender. Stir in wild rice, dried apricots, pecans, thyme and pepper to taste. Cook and stir until hot. Stuff each chicken breast with filling; fold chicken to enclose filling. Place chicken breasts in shallow baking pan. 3. Sprinkle evenly with finely chopped pecans to coat. Bake 15 to 18 minutes or until thermometer in stuffing registers at least 165°F. Serves 4 NUTRITIONAL INFORMATION Per serving: 247 calories, 17g carbohydrate, 30g protein, 2g fiber, 7g fat, 1g saturated fat, 68mg cholesterol, 81mg sodium Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet 11 Gluten-free Meal Ideas Here are a few ideas for preparing healthy, gluten-free meals: • Grilled London Broil with baked potato and steamed green beans BREAKFAST • Grilled Portabella mushrooms, drizzled with olive oil and balsamic vinegar, served with a mixed green salad Gluten-free Recipe • Omelet prepared with chopped veggies, gluten-free toast and fresh sliced fruit such as melon • Asian-style Chicken and Broccoli over brown rice (check marinades to ensure they are gluten-free) • Plain yogurt with fresh berries and ground flax seeds • Oatmeal (gluten-free) or another gluten-free, whole grain cereal with fresh sliced apples, cinnamon and a touch of brown sugar BANANA BREAD/MUFFINS 3 bananas 1 egg 1/2 cup of brown sugar 1/4 cup of white sugar 1/4 cup of oil 1/2 cup of skim milk 1/2 teaspoon of vanilla 1/2 cup of potato starch 1/2 cup of cornstarch 4 teaspoons of baking powder 1 teaspoon of guar gum 1/4 teaspoon of baking soda 1/4 teaspoon of salt 1/2 cup of dried flake coconut (either sweetened or unsweetened) Preheat oven to 350°F. In a large mixing bowl mash bananas. Add egg, brown sugar, oil, milk/yogurt, and vanilla. Beat until no lumps appear. Add potato starch, cornstarch, baking powder, guar gum, baking soda and salt. Beat until no lumps appear. By hand stir in coconut. Pour into • Gluten-free toast topped with peanut butter and banana LUNCH loaf pan or line muffin tins. Bake bread for about 40 minutes and muffins for 30 minutes, until a toothpick inserted in the middle tests clean. Allow to cool briefly before removing from the pan. Serves 12 NUTRITIONAL INFORMATION Per Serving: 180 calories, 6g fat, 1.5g saturated fat, 0g trans fat, 15mg cholesterol, 230mg sodium, 33g carbohydrates, 19g sugar, 1g fiber, 1g protein. • Green leafy salad topped with fresh veggies, canned tuna fish, sliced hardboiled egg and low-fat dressing • Quinoa salad, Mexican style, prepared with frozen corn and black beans. Top with grilled chicken strips • Turkey or Roast Beef Sandwich — prepare with gluten-free, whole grain bread and pre-packaged Black Bear gluten-free deli meats • Gluten-free frozen meals • Chili with whole grain, gluten-free corn chips • Hearty minestrone soup with chickpeas or gluten-free pasta (be sure the broth is gluten-free) • Gluten-free tacos or wraps filled with any of these: fish, beans, ground turkey breast, low fat sour cream, salsa, avocado, or lowfat cheese • Lasagna or ziti using gluten-free pasta and low fat cheeses • Risotto: primavera or seafood (make sure canned broth is gluten-free) SNACKS • Yogurt parfait — use plain yogurt and mix with fresh fruit and gluten-free, whole grain cereal • Celery topped with peanut butter, then sprinkle with raisins. • Air-popped Popcorn • Fresh vegetables such as carrots, celery and broccoli with hummus or gluten-free dip • Low-fat chocolate milk • Fresh or dried fruit • Edamame DINNER • Gluten-free trail mix • Broiled salmon (or fish of choice) over brown or wild rice with fresh or frozen vegetables • Rice cake with melted lowfat cheese and tomato • Lowfat corn chips and salsa 12 Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet 13 Gluten-free Products at ShopRite Listed below are a few of the gluten-free brands and product lines available at ShopRite. For a complete listing, visit the Live Right with ShopRite section of www.shoprite.com. If you can’t find an item in your local ShopRite, give us a call at 1-800-ShopRite and we’ll do our best to help you locate it. Amy’s frozen entrees Al Fresco sausages Annie’s Naturals dressings Applegate Farms deli meats and cheeses Arrowhead Mills baking mixes and cereals Nature’s Path cereals and snack bars Gefen cookies Newman’s Own snacks Genisoy snacks Notta Pasta Gillian’s Food cooking and baking mixes Nu World Foods Glenny’s snacks Bakery on Main granola and snack bars Glutano breads, cookies, pasta, and sweets Bionaturae pastas Gluten-free Pantry baking mixes Bob’s Red Mill baking mixes and cereals Chebe baking mixes Glutino pasta, entrees, snack bars, and sweets Ore-Ida Golden Crinkle fries Pacific Natural Foods beverages, soups Pamela’s Products cookies and baking mixes Panderos Delights cookies Perky’s cereal Golden Valley beef jerky Rice Dream beverages Hodgson Mills baking mixes Roland crackers Dr. Praeger’s frozen entrees Hol-Grain crackers, bread crumbs Southern Homestyle cooking mixes Eat Smart Chips Honest Kids beverages Soy Joy snack bars Eden canned beans Ian’s frozen entrees Ener-G cooking/baking mixes and snacks Kinnikinnick Foods breads, cookies, baking mixes, and sweets Spectrum Naturals condiments Chex rice cereal Conte’s frozen pasta DeBoles pasta Enjoy Life granola, cookies, and snacks Envirokidz cereals, snack bars Erewhon cereal Fantastic Foods soup, rice, and dip mix Fearn Baking Mix 14 Foods Should Taste Good chips Kozy Shack puddings and desserts Seeds of Change dressing Tinkyada pasta Lifestream waffles Tribe of Two Sheiks hummus Flavorganics extracts Food For Life breads Mi-Del cookies Foods by George pizza, breads, muffins, and brownie Mrs. Leeper’s pasta Nasoya tofu Nature’s Highlights pizza crust The NFCA website offers free, comprehensive information and support materials for celiac patients, their families and health care professionals. Tabatchnick soups Tribe hummus Mary’s Gone Crackers snacks The National Foundation for Celiac Awareness is a non-profit organization made up of medical specialists, professionals, and industry leaders — all dedicated to working with leading researchers to better understand celiac and to find a cure. NFCA is a leading resource for celiac information and the only organization with a nationally focused celiac awareness campaign. Success rice Larabar snack bars Lundberg Family Farms entrees, baking mixes, snacks About NFCA Van’s waffles Wholesoy & Co yogurt Wholly Guacamole Wolfgang Puck broth Yoplait yogurts Zensoy beverages Zhena’s Gypsy Tea assorted teas Living with Celiac Disease — A Guide to Managing a Gluten-Free Diet Contact Information Main: 215-325-1306 Media/Press: 215-325-1306 x.103 Philadelphia Office: P.O. Box 544, Ambler, PA 19002 www.CeliacCentral.org
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