Living with
Coeliac
Disease
Dietitian Jeni Pearce
explains a condition that’s
becoming more common;
how to know if you have
it, how to live with it and
where to get help.
40
www.healthyfood.co.nz
Jeni Pearce is a leading health and sports
dietitian and nutritionist. She is Chairperson
for the New Zealand Nutrition Foundation
and a senior lecturer in Nutrition at Auckland
University of Technology.
Many of my patients know
that my dad has Coeliac disease
and has learned to work with this
condition for many years. The
diagnosis was a surprise at first,
but it did help explain some of
the problems he had had with his
health (including problems with
his iron levels, issues with vitamin
B12, distension and fatigue).
Today, he feels much better but
still needs to be careful when
eating out. He travels, with my
mother, frequently around NZ
in their campervan. They find
cooking their own meals less
stressful and safer, as eating foods
containing gluten can result in
severe pain and discomfort for
several days.
Managing a gluten free diet is
important, as there is an increased
risk for coeliacs of developing
small intestine cancers (called
enteropathy lymphomas). Coeliac
disease may present as a skin
disorder called dermatitis herpetiformis in some people.
What is Coeliac
disease?
What it is not is a diet that just
excludes wheat or bread. Coeliac
is from a Greek word meaning
‘suffering in the bowels’ and was
first described almost 2000 years
ago. It is an adverse reaction in
the body’s digestive system to
gliadin, which is a part of the plant
protein called gluten, naturally
found in many grains. Gluten is
found in a range of wheat and
grasses (including rye, barley,
and oats). In people with Coeliac
disease, eating these grains
results in the damage of the villi
(finger-like projections important
in the small intestine for digesting
and absorbing nutrients) and
inflammation of the tissues. The
effects of this damage occur a few
hours (not minutes) after intake of
the offending food.
due to the poor absorption of
the inadequately digested food.
Although some of the symptoms
of malabsorption include changes
in bowel motions (pale bulky
stools), growth failure (especially in children) and abdominal
discomfort, this is rarely seen and
less specific symptoms are more
usual. This makes an accurate
diagnosis more difficult and more
time consuming.
Coeliac is from a Greek word meaning ‘suffering
in the bowels’ and was first described almost
2000 years ago. It is an adverse reaction in the
body’s digestive system to gliadin, which is a part
of the plant protein called gluten, naturally found
in many grains.
As a result of this damage the
absorption of almost all nutrients
appears to be affected in some
way. How this happens is still
unknown but genetics play a
key part along with the immune
system. The first and mid portions
of the small intestines are usually
affected, although the end or
whole of the small intestine can
be involved. The villi cells contain
many important enzymes needed
for the digestion of carbohydrates
and proteins as well as nutrient
transporters (a bit like being
beamed aboard star trek) that
helps move the nutrients from
the digested food into the blood
stream. This means that overall
a lower nutrient uptake occurs
In infants and children the
symptoms are more easily identified, as after eating gluten they
become tired and lethargic, with
changes in bowel motions that
often have a very strong smell.
Older children do not grow as
predicted and can have various
mineral deficiencies (low iron is
common), abdominal pain or
discomfort and more frequent,
softer bowel motions. For adults
the picture is more clouded as
diarrhoea, unexplained weight
loss, bone pain, bone fracture,
mild gastric upsets, abdominal
distension, tiredness, irritability and other symptoms that
could easily be put down to the
stresses and strains of modern
www.healthyfood.co.nz
41
Allergic
to Food?
living with
dietary restrictions?
'ntolerance specialises in
providing food that is
gluten free, wheat free,
dairy free, nut free,
egg free, soy free,
sugar free…
shop online at:
www.ntolerance.co.nz
life make the identification of
Coeliac disease more difficult.
In my Dad’s case it took a
while as fatigue, low iron and
abdominal distension were the
symptoms. Many patients actually
have normal body weights.
Researchers have suggested
that anaemia may be one of the
important things to look for in
adults, especially in those people
with a family history of Coeliac
disease.
By far the greatest concern for Coeliacs as they
age is bone health. Osteomalacia (weakening
and softening of bone) results from the impaired
absorption of vitamin D and osteoporosis can
occur due to impaired calcium absorption and
transport to the bone.
Diagnosis
or visit our store at:
5c Glasgow Road •Pukekohe
Mon-Fri 10am-4.30pm
Sat 10am-2pm
‘ntolerance Ltd
5C Glasgow Road
PO Box 532
Pukekohe
Phone: 09 238 2323
Fax: 09 238 2322
Email: [email protected]
www.ntolerance.co.nz
42
www.healthyfood.co.nz
reported in some research). It’s
also more common in people in
or from Europe, and among those
with a family history. The disease
is rare among Asian and African
people.
Coeliac disease can be tricky
to diagnose, as it is usually not
tested until several other possibilities have been eliminated.
A biopsy (small pieces of tissue
taken from the first part of the
small intestine) is usually required
There is a general belief among
experts that Coeliac disease may
be under diagnosed. Although
my Dad was diagnosed later in
life, Coeliac disease can
develop at any age. I
have several patients
who are young children
and teenagers and
lead very busy, active,
sporty lives.
Diagnosis now
appears to be more
common, but not
limited to, people
around 40-50
years of age, and
appears more
commonly in
women than men
(a ratio of 3:1 has been
to completely confirm the
damage to the lining of the small
intestine due to the disease. A
second biopsy is often taken after
several months on a gluten free
diet to examine the repair
process and improvement in
the structure of the lining.
Biopsies are peformed
by a gut specialist, called
a gastroenterologist, on
referral from a GP. More
recently blood tests
to measure antibodies have been
developed and are
used. However these
may be less reliable,
and can sometimes
give misleading
results. Talking
this over with
Achieve
Some confusion over oats:
Oats were once excluded from a gluten free diet. More recent studies
have shown that including some oats in the diet does not appear
to have any effect. It appears that the compounds in oats are less
harmful than those in wheat and rye and moderate amounts (4060g per day) are not harmful to most Coeliacs. Foods identified as
‘low gluten’ are generally accepted as being safe and appropriate
for those with Coeliac disease (less than 20mg of gluten per
100gm of food will not damage the small intestine
nor produce any symptoms). However, for highly
reactive individuals oats are best avoided and
exposure to a large amount over time may possibly
trigger a reaction.
What are the health
problems associated
with coeliac disease?
The most frequent health problem
experienced by people who
suffer from Coeliac disease is
anaemia due to poor absorption. There are various types of
anaemia due to a deficiency of
iron, vitamin B12, folate or vitamin
B6 and there may be only minor
symptoms in adults. A wellcontrolled gluten free diet, the
use of supplements (see below)
and improved dietary intake
providing plenty of these nutrients
is recommended, with blood tests
to monitor progress. In some
cases haemorrhage and further
blood loss may be a concern due
to the possible impaired absorption of vitamin K (this has an
essential role in clotting blood).
But by far the greatest concern
peace.
for Coeliacs as they age is bone
health. Osteomalacia (weakening
and softening of bone) results
from the impaired absorption of
vitamin D and osteoporosis can
occur due to impaired calcium
absorption and transport to the
bone. People with osteoporosis
appear to be 10 times more likely
to have Coeliac disease.
Muscle cramps, due to poor
absorption of calcium and
magnesium, are also possible.
How to eat if
you are Coeliac
The most important thing
for Coeliacs is to remove all
gliadin/gluten from the diet.
This involves the removal of all
sources of wheat, rye, barley and
often oats (including tabbouleh,
couscous and semolina). This is
a major undertaking, so if you’re
newly diagnosed a visit to a
dietitian is a really good idea to
get guidance since many regular
food items and processed foods
All-natural Vitasoy ricemilk is gluten
and lactose free and has no added
sugar, so coeliacs can enjoy it without
any internal anarchy.
VIT3833
your doctor can help to you to
determine the most appropriate
action.
inner
www.healthyfood.co.nz
43
feature
are no longer allowed. Without
guidance it could be difficult to
get all the nutrients you need
while still having an interesting
diet.
People with Coeliac disease
soon learn the food and ingredients which naturally contain
gluten (wheat, rye, barley) and
those free of gluten (which
includes all fresh fruit and vegetables, eggs, fish, chicken, nuts,
legumes, milk and unprocessed
meat ). Learning to substitute
with alternatives is often a huge
learning curve. Bread is the one
food my Dad misses the most
despite the range of gluten free
breads available (check with local
bakeries).
Foods which contain no gluten
include corn, potato, rice, soy,
tapioca and arrowroot. Many
Coeliacs become excellent label
readers and will phone manufacturers to ask about product
ingredients or processing. One
Coeliac disease vs.
Gluten SENSITIVITY
– is there a
difference?
Lyn Gillanders, Manager
of the Manufactured Food
Database(MFD)and Senior
Clinical Dietitian at Auckland
Hospital, explains:
“Coeliac disease is certainly
being diagnosed a lot more
frequently these days, but the
diagnosis as far as we know is
still just Coeliac disease, which
must be diagnosed by a small
bowel biopsy. Gluten sensitivity
as distinct from Coeliac disease
is not a medically recognized
condition. It is a construct of the
alternative health industry, and it
is possible some people are on
gluten free diets unnecessarily
because of this. It is important
to note that symptoms from
exposure to gluten are delayed,
If you’re newly diagnosed a visit to a dietitian is
a really good idea to get guidance since many
regular food items and processed foods are no
longer allowed. Without guidance it could be
difficult to get all the nutrients you need while
still having an interesting diet.
of the most reliable sources of
information is the Manufacturers’
Food Database (see website list
page 47), which is free, updated
regularly and managed by skilled
and specialised dietitians. It
contains lists of the gluten free
foods available in the local super-
44
www.healthyfood.co.nz
market. If in doubt, don’t eat it.
Remember “wheat free” may not
be gluten free, so check labels
very carefully.
Where does gluten
hide?
The exclusion of wheat, rye and
often for several hours, so
people who say they have
an immediate response are
probably experiencing some
other allergic response.”
A wheat allergy, on the other
hand, is a different distinct
condition, being an immune
system response to wheat
specifically. People with this
allergy only need to avoid
wheat, and most children
with wheat allergies will
outgrow them.
barley as an ingredient or food is
relatively easy, but gluten is also
hidden in many foods. Gluten can
be eaten by mistake: eating out
at friends’ houses, in restaurants,
cooking food in a pan previously
used to cook bread crumbed or
flour-coated food items. Home
brewed beers (hops are from
the wheat family) contain gluten,
while commercial beers that are
clear are filtered and contain no
detectible gluten. Gluten can be
added as an ingredient to assist
processing as a filler, a binding
agent or added to make
Everything
Some foods
that are
gluten free:
Meat/PROTEIN:
Fresh meat, fish, chicken, pork,
eggs, milk, cheese
Produce:
Fresh, canned and frozen fruit
and vegetables (check labels on
canned)
Carbohydrates:
Potato, rice, corn, buckwheat,
soy, polenta, millet, sorghum,
maize cornflour, rice cakes,
rice crackers, corn thins, rice
noodles, rice pasta, corn pasta
Some common
foods containing
gluten:
Meat/PROTEIN:
Sausages, rissoles, fish cakes
Gluten Free/
Wheat Free
Trust Orgran
Over 60 Gluten Free Products!
Totally Dedicated Gluten Free
Manufacturer!
Exported to over 45 countries!
Carbohydrates:
Breadcrumbs, pasta and wheatbased noodles, pizza base, pastry,
croutons, pancakes, bread and
baked products, stuffing, trifle,
sponge
Cereals/grains:
Wheat, rye, barley, oats, spelt,
wheatgerm, bran, semolina,
couscous, malt, malted barley,
durum wheat, breakfast cereal
Cereals:
GF muesli and cereals
Condiments:
Butter, margarine, oils, salt,
peppers, herbs, spices, garlic,
nuts, seeds
Sweeteners:
Jam, honey, nut butters,
glucose, golden syrup
Beverages:
Tea, coffee, fruit juice,
vegetable juice
Snacks:
Plain popcorn, plain salted
potato chips, jelly, meringue,
lollies and chocolate made with
GF ingredients, ice cream made
with GF ingredients.
Condiments:
Cheese spread, soy sauce, packet
sauces, packet gravy
Beverages:
Barley waters, homemade beer,
milk shakes, flavoured milk
Snacks:
Most lollies and sweets, takeaway
French fries (contamination from
other battered food), pretzels,
crackers, instant meals
Always check the
ingredient label!
Note: these lists are not
complete and are provided
as a guideline only.
ORGRAN NATURAL FOODS
Division of Roma Food Products
For Orgran stockists, please contact
Crombie & Price
Tel:
(03) 434 8311
Fax:
(03) 434 9688
Email: [email protected]
www.healthyfood.co.nz 45
feature
flavourings adhere to products (flavoured snacks).
Gluten-containing starches are used in spices,
seasonings, sauces, dressings and as thickeners
(starch, wheat corn flour).
Cooking processes are also important as breadcrumbs are often forgotten as a gluten-containing
ingredient. Even though only small amounts may be
used, it can be enough to set off an attack.
For children it can be particularly difficult dealing
with Coeliac disease. While fruits, vegetables, rice
and potato become great staples, many common
“treats” are off limits. Although popcorn and plain
potato chips are a great standby, home baking
using gluten free baking mixes or specialised gluten
free foods (biscuits, cakes) are important to provide
variety and additional energy. Eating away from
home is perhaps the greatest challenge and being
prepared by having food in the car, at school, or at
sports events is the safest way to prevent an attack.
A shared lunch is not an option.
Free of Gluten, Full of Taste
For recipes or further information on our
entire Gluten Free range contact us on
0800 BAKELS
www.nzbakels.co.nz.
www.nzbakels.co.nz
46
0800 BAKELS
www.healthyfood.co.nz
[email protected]
Supplements Coeliacs may need
Because of the damage to the small intestine and
the reduction in nutrient absorption that occurs in
Coeliacs, some vitamin and mineral supplementation may be necessary to correct a deficiency or to
improve intake. The most likely nutrients include
iron, vitamin D, calcium and vitamin B12. The need
for these should be confirmed with a blood test
or bone scans. If gluten is introduced to the diet
accidentally and the gut lining is damaged, this may
also be a time when additional nutrient support may
be necessary. Check that any supplements are also
gluten free.
Lactose intolerance
Lactose is the carbohydrate found in milk. An
intolerance can sometimes occur due to Coeliac
disease, particularly where there is damage to
the intestinal lining of the digestive system. A
lactose free diet is used in conjunction with
the gluten free diet, and once healing of the
lining has occurred (due to removing gluten)
the lactose intolerance disappears. This is
because the enzymes needed to digest the
milk sugar are found in the lining of the small
intestine, which the gluten has damaged.
Symptoms of abdominal distension, gas production and changes in bowel functions are further
aggravated by the undigested lactose. Foods
containing lactose include all milk products,
including ice cream,yoghurt and foods where
milk or milk solids are added as an ingredient.
Hard cheeses (cheddar) do not contain lactose.
Replace the milk in beverages, on breakfast
cereal and in cooking with soy milk, rice milk and
almond milk.
i
For people diagnosed with Coeliac
disease, the Coeliac Society of NZ is a
useful source of information. They publish
a regular magazine ‘Coeliac Link’, which
contains articles, recipes and information
for Coeliacs. Email [email protected] for
information.
Where to get help
If you feel you may have Coeliac disease, you should contact your local
doctor and if necessary a referral to a specialist will be arranged. Proper
diagnosis is very important.
Once diagnosed, a visit to a dietitian is often recommended. There are
a number of manufacturers who supply gluten free foods and these are
listed below.
Useful websites:
www.mdf.co.nz
manufactured food database
www.dietitians.org.nz
NZ Dietetic Association
www.coeliac.co.nz
Coeliac Society of NZ
www.coeliac.org.au
Coeliac Society of Australia
www.allergy.org.nz
Allergy NZ
www.4everfree.co.nz gluten free cakes
www.annies.co.nz gluten free fruit and vege bars
www.benlea.co.nz
frozen gluten free bread dough
www.ceres.co.nz
has a range of gluten free products
www.chantal.co.nz
manufacturer of gluten free pasta and cereal
www.crombie-price.co.nz
manufacturer of gluten free products
www.dovedalebread.co.nz
gluten free bread
www.greenmonkey.co.nz
gluten free baby food
www.healtheries.co.nz range of gluten free products
www.huckleberryfarms.co.nz retail stores in Auckland and Christchurch
www.ieproduce.com
gluten free products for nationwide delivery
www.naturallyorganic.co.nz
gluten free products for nationwide delivery
www.ntolerance.co.nz
online shop & store in Papakura, Auckland
www.nzbakels.co.nz
manufacturer of gluten free baking mixes
www.organicbakeworks.co.nz gluten free bread and other products
www.realfoods.co.nz
gluten free and lactose free products
www.venerdi.co.nz
gluten free and low gluten bread
“New Zealand’s largest range of Gluten-Free foods”
– NZ Coeliac Society
Deliveries in New Zealand and worldwide
1 Barry’s Point Rd, Takapuna, Auckland
Ph: 09 488 0211 www.ieproduce.com
feature
Recipes
Stuffed Peppers
GF LF
garlic 2 cloves, finely chopped
onions 2 medium, chopped
olive oil 1 tablespoon
lamb or beef 340g, cooked and
cut into small pieces
currants 2 tablespoons
salt and freshly ground pepper
ground cinnamon ½ teaspoon
marjoram ½ teaspoon
tinned tomatoes 400g
peppers 4, red or green
brown rice 400g, cooked
gluten free tomato puree
4 teaspoons
Pre-heat the oven to 190ºC.
In a frying pan, fry the garlic
and onions in the olive oil for a
few minutes, then add the meat
and currants. Season, add the
cinnamon, marjoram and two of
the tomatoes and 1 tablespoonful
of their juice. Leave uncovered to
simmer very gently.
Meanwhile, cut off the stalk
ends of the peppers and pull
out the core and seeds. Rinse
under cold water to remove all
the seeds. Stand upright in a
small casserole. Add the cooked
rice to the meat mixture and mix
thoroughly. Check seasoning. Fill
the peppers with as much of the
mixture as you can and put any
remaining around the bases of the
peppers.
Top each with 1 teaspoon of
tomato puree and pour the rest
of the tinned tomatoes around
the peppers. Cover and casserole
48
www.healthyfood.co.nz
and bake for 45-50 minutes or
until the peppers are tender.
SERVES 4
DATE AND NUT SQUARE
per serve
Energy 595kJ
Protein
1.6g
Fat 6.3g
- saturated 1.9g
Carbohydrates 19.9g
- sugars 15.9g
Fibre 0.9g
Sodium 80mg
Calcium 19mg
Iron 1.0mg
STUFFED PEPPERS
per serve
Energy 1650kJ
Protein 32.7g
Fat 14.4g
- saturated 4.7g
Carbohydrates 33.9g
- sugars 16.5g
Fibre 4.7g
Sodium 305mg
Calcium 70mg
Iron 3.9mg
% Day*
18
40
18
16
11
20
16
13
7
24
7
2
8
7
7
20
3
3
2
6
*see page 50 for details
*see page 50 for details
Date and Nut Square
% Day*
GF
margarine 85g
stoned dates 115g, chopped
soft brown sugar 60g
walnuts 30g, chopped
glace cherries 30g, chopped
Rice Bubbles 60g
gluten-free muesli 30g
gluten-free plain chocolate 115g
Grease an 18cm square cake tin
and line the bottom with greased
greaseproof paper.
Place the margarine and the
dates in a pan and heat slowly.
Stir in the sugar and cook for a
few minutes. Mix in the walnuts,
cherries, Rice Bubbles and muesli.
Press the mixture firmly into the
prepared tin. Melt the chocolate
in a basin over hot water, allow to
cool slightly and spread over the
biscuit mixture. Chill in the refrigerator until set. Cut into fingers.
MAKES 15
* These recipes are
from The Ultimate
Gluten-free Diet, by
Dr Peter Rawcliffe
and Ruth James.
(Random House,
$29.95).
This is a no-nonsense guide for
people with Coeliac disease.
The authors, who both have
a wealth of experience in
treating Coeliacs, offer reassuring and practical advice
on causes, symptoms and
diagnosis. They also outline a
practical and simple gluten-free
diet complete with nutritional
guidance and tips, a good
range of recipes and lots of
useful information. The recipes
are tasty enough that you could
feed them to everyone in the
family, and no-one would suffer.
(This is a UK book and so the
occasional ingredient may not
be available here.)
HFG
For sources of information for
this article see page 80 or
www.healthyfood.co.nz