1. Your name and job title Coeliac Disease and A Gluten Free Diet

2. What will be covered? What is Coeliac Disease? What are the symptoms? What causes Coeliac Disease? The gluten free diet Help with reading food labels Important nutrients Top tips – cross-contamination and eating away from home Take home messages Coeliac Disease and a Gluten Free Diet

3. What is Coeliac Disease? An ‘auto-immune’ disease A life-long intolerance to gluten – a protein found in wheat, rye and barley When gluten is eaten an immune response is triggered, resulting in damage to the delicate lining of small intestine – the ‘villi’ Coeliac Disease and a Gluten Free Diet

4. What is Coeliac Disease? Coeliac Disease and a Gluten Free Diet

5. What are the symptoms? Coeliac Disease and a Gluten Free Diet Symptoms include: Diarrhoea, nausea & vomiting, bloating, constipation, pain and wind… Damage to the gut reduces your absorption of important nutrients and may result in anaemia This immune response may also trigger symptoms outside of the gut: – Tiredness, headache/ migraine, joint/ muscle pain

6. Dermatitis Herpetiformis Coeliac Disease and a Gluten Free Diet The skin manifestation of Coeliac Disease Much rarer than CD, affecting less than 1 in 3000 people

7. What causes Coeliac Disease? Coeliac Disease and a Gluten Free Diet Occurs in people with the right genetic profile for the disease Affects 1 in 100 people Your risk increases to 1 in 10 if you have a close relative with the condition Affects more women than men Can occur at any stage of life, most commonly diagnosed > 40 years Many people with the condition are still not diagnosed Closely linked with other autoimmune conditions – e.g Type 1 diabetes, thyroid disease

8. How is it diagnosed? Blood test – Measures levels of coeliac-specific antibodies – tTG (tTGA) and EMA Endoscopy and biopsy (camera investigation) Gluten-containing diet is essential before and during these tests Coeliac Disease and a Gluten Free Diet

9. Why do I need a gluten free diet? To allow your gut to heal To manage symptoms To increase your general feeling of well-being To encourage normal growth & development (children) To reduce the risk of complications, – including anaemia, osteoporosis (thinning of the bones) & small bowel cancer Coeliac Disease and a Gluten Free Diet

10. Where is gluten found? Wheat, rye, barley & contaminated oats and products that contain these, including: Wheat/ rye flours Breads, pasta & breakfast cereals Cakes & pastries Biscuits & crackers Batters & thickened sauces Beers/lagers and barley water Coeliac Disease and a Gluten Free Diet

11. … so what can I eat? Many foods are naturally gluten free Rice & potatoes Fruit & vegetables Other cereal grains including corn (maize), millet and polenta Dairy foods & eggs Meat, fish and poultry where gluten has not be added during processing Coeliac Disease and a Gluten Free Diet

12. Foods to check Coeliac Disease and a Gluten Free Diet Processed/ ready made foods and dishes may contain unexpected gluten added as a stabiliser or binder – always check the label Coeliac UK Food and Drink Directory lists over 10,000 gluten free products sold in the UK

13. Specialist gluten free foods A range of specialist gluten free foods are available in supermarkets, health food shops, online and on prescription. Try a variety of brands to see which one you prefer! Coeliac Disease and a Gluten Free Diet

14. Gluten free on prescription Coeliac Disease and a Gluten Free Diet AgeNumber of Units 1-310 4-611 7-1013 11-1415 15-1818 19-59 (Male)18 60-74 (Male)16 75+ (Male)14 19-74 (Female)14 75+ (Female)12 Breastfeeding+4 Pregnancy (3 rd Trimester)+1

15. What is a unit? Food DescriptionNo. Units Bread Loaf (400g)1 Rolls/ Baguettes (100-250g)½ Rolls/ Baguettes (251-400g)1 Flour/ Bread mix (500g)2 Savoury biscuits/ crackers (100g)1 Savoury biscuits/ crackers (200g)2 Pasta (250g)1 Pasta (500g)2 Pizza bases (2 x 110-180g)1 Breakfast cereal (300g)1 ½ Xanthan gum (100-170g)1 Coeliac Disease and a Gluten Free Diet

16. Help with reading food labels ‘Gluten Free’: foods that contain less than 20 ppm gluten – enforced by law & safe to eat – Naturally gluten free foods – Specialist gluten free foods & prescription products – Uncontaminated oats ‘No Gluten Containing Ingredients’: – Used when a manufacturer is confident the product does not contain gluten from raw ingredients or via production processes Coeliac Disease and a Gluten Free Diet

17. Allergen labelling law Gluten containing cereals (however small the amount) must be emphasised in bold, italics, or highlighted text within the ingredients list Look for: Wheat, Rye, Barley, Oats Allergy Warning boxes are voluntary and will be phased out with the new law ….. But you might see allergy advice that directs you to the ingredients list for more information, e.g: Coeliac Disease and a Gluten Free Diet

18. Confusing ingredients Codex Wheat Starch (gluten free wheat starch) – safe to consume Barley Malt Extract/Flavouring – some products using small amounts of this ingredient may be safe to consume Malt vinegar – safe to consume Oats…. Tesco own label Cornflakes Kellogg’s Cornflakes Coeliac Disease and a Gluten Free Diet

19. Oats Oats offer many nutritional and health benefits Oats contain a protein called Avenin (similar to Gluten) Oats & oat products are often contaminated with gluten Uncontaminated oats are tolerated by the majority of people with coeliac disease Only consume oats that are labelled as ‘gluten free’ Coeliac Disease and a Gluten Free Diet

20. Label Reading Activity

21. Important nutrients: Calcium Coeliac Disease and a Gluten Free Diet People with coeliac disease may need more calcium. Adults should aim to eat 1000-15000mg/day; 300-800mg more than people without coeliac disease! Vitamin D is important for calcium absorption: – Sunshine – Oily fish, eggs and fortified margarine/ dairy products Supplements can be prescribed for people with a poor calcium intake/ poor bone health

22. Good sources of calcium FoodApprox Calcium level 1/3 pint of milk (200ml)240mg 1/3 pint Calcium-enriched soya/ rice milk (200ml)240mg Matchbox-sized piece of hard cheese (30g)220mg ½ tin of sardines with bones (60g)220mg Pot of fruit/ plain yogurt (150g)210mg ½ tin Rice pudding/ custard (200g)180mg 4 Dried figs180mg Tofu (60g)180mg 2 slices of calcium-fortified gluten free bread85mg Handful of almonds (30g)70mg 1 serving of spring greens (75g)55mg 8 dried apricots50mg Coeliac Disease and a Gluten Free Diet

23. Important nutrients: Fibre Fibre intakes in the UK are less than recommended levels People on a gluten free diet may consume even less fibre Fibre helps to maintain a healthy gut, cholesterol and blood sugar levels Good, gluten free sources of fibre include: – Fresh fruit and vegetables – Dried fruit – High fibre gluten free breads, crackers and pasta – Brown rice – Nuts – Beans and pulses Coeliac Disease and a Gluten Free Diet

24. Important nutrients: Iron Approx 25% of newly diagnosed coeliacs have iron deficiency anaemia at diagnosis Iron is essential to form healthy red blood cells – carrying oxygen around the body Haem iron (more readily absorbed) – red meat Non-haem iron (less well absorbed) – green leafy veg, beans, pulses, dried fruit Coeliac Disease and a Gluten Free Diet

25. Top tips: Cross-contamination Invest in extra equipment – use a separate chopping board and toaster (or toaster bags) for gluten free food Clean-up well – wipe surfaces, wash hands and utensils thoroughly before handling gluten free food Keep gluten free food separate – store gluten free food at the top of the fridge to prevent contamination, store unpacked/ open gluten free food in sealed bags/ Tupperware Use different butter/ margarine & preserves – butter knives can easily transfer crumbs, use coloured stickers to highlight what is to be kept gluten free Don’t re-use/ share cooking oil with those who are not gluten free Coeliac Disease and a Gluten Free Diet

26. Top tips: Eating away from home Be prepared – keep a selection of gluten free snacks to hand; in the car, at work, in handbag/ rucksack Make extra – cook additional portions of your evening meal to take to work/ eat the following day, e.g gluten free pasta/ cooked meat for jacket potatoes or salads Do your homework- take time to check restaurant websites for their gluten free offerings, ring ahead to check what might be suitable… caterers must be able to provide this information by law! Don’t be afraid to ask – if you’re not confident that your meal or where it was prepared is gluten free, ask for more information Coeliac Disease and a Gluten Free Diet

27. Take home messages The only treatment for coeliac disease is a life-long gluten free diet Naturally gluten free foods include: fresh meat, poultry, fish, eggs, dairy foods, fruit, veg, nuts, rice and potatoes Contact gluten free food manufacturers to obtain samples of prescription foods – use prescription staples to supplement naturally gluten free foods in your diet Join Coeliac UK for additional information and support & to obtain a Food and Drink Directory Check food labels for gluten containing ingredients – Wheat, Rye, Barley & Oats Be careful about cross contamination and ensure that gluten free food is prepared in a gluten free environment Coeliac Disease and a Gluten Free Diet

28. Questions Coeliac Disease and a Gluten Free Diet