1. What do we mean with Gluten Free diet for life?
When people with coeliac disease eat gluten (a protein found in wheat, rye and barley), their body mounts an immune response that attacks the small intestine. These attacks lead to damage on the villi, small finger like projections that line the small intestine, that promote nutrient absorption. When the villi are damaged, nutrients cannot be absorbed properly into the body. Coeliac disease can lead to serious health problems, if a strict gluten free diet is not followed for life.
Currently, a strict gluten-free diet is the only treatment to the disease. Coeliacs should avoid foods which contain wheat, rye and barley.
Ingesting small amounts of gluten, like crumbs from a cutting board or toaster, can trigger small intestine damage. Coeliacs should not consume any gluten at all times- not even traces of it.
On following a gluten free diet, you can eat many foods including meat, fish, fruit, vegetables, rice and potatoes which are naturally gluten free.
You can also eat gluten free substitute foods and processed foods that don’t contain gluten. Gluten free substitute foods are available, and they include amongst others gluten free bread, flour, pasta, crackers and biscuits. These are available in the free from sections of the supermarket and health food stores.
You can tell whether gluten is in a food by learning about allergen labelling.
It is of course easier to purchase and consume food with the label: ‘Gluten Free’/ ‘Does not contain gluten’. When this is not an option then coeliacs should be able to read the food allergen labelling or get in contact with the manufacturers to ensure if a product contains gluten/ traces of gluten. Some ingredients are confusing as they can be made from wheat, but the final ingredient is gluten free, for example glucose syrup.
It is also very important to understand what cross contact is and to know which questions to ask and what to look out for, when you’re eating out.
The best support comes from people who understand. We can help you make safe food choices. Also, it is good to get in contact with others facing the same condition as you, because we know what it takes to live gluten free every day.
2. What does it mean that a product is free of gluten and what is a cross contact?
Most health authorities define gluten-free products as containing less than 20 parts per million gluten. Therefore, most of the products which are labelled as gluten free have to satisfy this condition.
Before you start cooking at home, or decide to eat out, you’ll need to be aware of all the places where gluten may exist. It doesn’t take very much gluten to make you sick! Even just a crumb of gluten is enough to start the autoimmune response in people with coeliac disease, even if symptoms are not present. Many people find cross-contact to be one of the most difficult parts of the gluten-free diet.
Cross-contact is when gluten-free food is exposed to a gluten-containing ingredient/ food – making it unsafe for people with coeliac disease to eat. There are many obvious and some not-so-obvious sources of cross-contact at home and in restaurants. There is even a risk of cross-contact before ingredients make it to the kitchen, such as during the growing, processing, and manufacturing processes.
From the 13th of December 2014, the European Directive 1169/2011 requires all the processed/ manufactured products to indicate any allergens included on the products. Gluten is included on the list of allergens.
3. Do I have to consume only products which are labelled as Gluten Free?
Of course it is easier to consume products which are labelled as gluten free since by looking at the label you have to search no further, but that cannot always be the case and of course you can consume products which are not labelled as gluten free if you confirm that they do not contain gluten. European coeliac associations are trying to put pressure so that all the manufactured/ processed products are labelled with the ‘may contain’ label as well so that it makes it easier for coeliacs to identify which foods are suitable for them.
It is important to know how your food is made from scratch, in order to avoid possible gluten exposure. Some manufacturers label their products with the may-contain wording which means that even if a product is naturally gluten free it may have been cross contact with gluten during the manufacturing/ packaging process (i.e. used the same equipment for packing as those used for food containing gluten) so they say that it may contain gluten. Not all the manufacturers however use the ‘may contain’ wording which makes it even more difficult for us. In order to be 100% sure that a product does not contain any gluten it is best to call the manufacturer and inquire whether they batch test their product for gluten, if they know how their raw materials were sourced and produced, and what procedures they go through to prevent cross-contact in the factory.
Keep in mind, however, that minimally processed or no processed fresh foods should be the basis of our gluten-free diet (fruits, vegetables, meats, fish).
It is also important to remember that “wheat-free” does not necessarily mean “gluten-free.” Be wary, as many products may appear to be gluten-free but are not.
There are many gluten-free options available that use alternative flours and grains. Often, gluten-free bread can be found in the freezer section. Additionally, there are gluten-free flours and flour blends available in the grocery aisle, allowing you to bake your own bread.
Sometimes the word gluten is not written on a label, but the following wording is written instead. If any of the following is used, then there is a high possibility of the food containing gluten this be extra careful:
- Wheat protein
- Hydrolysed wheat protein
- Wheat starch / hydrolysed wheat starch
- Wheat flour
- Malt (from barley)
- Wheat extract
- Triticum vulgare (wheat)
- Hordeum vulgare (barley),
- Secale cereal (rye),
- Triticum spelt
You should read the ingredients of a product always since the manufacturer may change the ingredients of a product without warning.
4. What is starch and what is modified starch?
Starch is one of the polysaccharides (tens of thousands of glucose molecules). Foods that contain starch are foods of plant origin that do not contain high levels of water such as potatoes, corn, rice, cereals etc. and therefore bread, flour, pasta etc.
Food starch can also be found as a “modified starch”. The “modified starch” is obtained after processing the original starch with enzymes or inorganic compounds, in order to make it easier for the food industry to use.
Therefore, when the ingredients of a product contain starch or modified starch or vegetable starch without defining where the starch is derived from then it is not permitted to be consumed by people suffering from coeliac disease unless the product is labelled without gluten. However, if a product contains starch or modified starch from corn or other sources not containing gluten and which has been confirmed that it was not cross contact with gluten then this product can be consumed by coeliacs.
5. After following a gluten free diet for a long time my antibodies on IgA- tTG tests are still positive. Why is that? Am I doing something wrong?
Laboratory tests should be done within three to six months following a diagnosis and annually thereafter for the rest of your life. However it is best to obtain your doctor’s advice as personal circumstances differ. While blood tests are extremely helpful, visiting a registered dietitian knowledgeable of coeliac disease and following a gluten-free diet is considered the “gold standard” for understanding how to know if you are accidentally being exposed to gluten (even if symptoms are not present).
Studies have shown that it can take between 15-20 months for adults of strict gluten-free diet before complete internal healing can take place. It is critical to be monitored during this phase to ensure your diet and lifestyle are providing you the needed benefits.
Having said the above, if results are positive and high in the next months after following a strict gluten free diet then you should reconsider and check the food that you consume thoroughly. Maybe you are consuming gluten which is hidden in one of the foods you consume or in the process you follow to prepare/ store your food.
If you are diagnosed with coeliac disease and your antibodies are still positive, then discuss it with your doctor.
6. Can I visit a restaurant and order food without containing gluten?
Being a celiac does not mean that you should be isolated and give up dining out or with your friends or family. You just need to be more organised, proactive and explain well what everyone should look out to cater for your needs. Of course, there are always risks when someone else is preparing your food, but these risks could be minimised with a good understanding of ingredients/ labelling and cross contact processes to be avoided.
In Cyprus there are currently several establishments which have been certified by the Cyprus Celiac Association for offering gluten free food under the umbrella of the Eating Out Project which is run by the association. Establishments which hold this certification have gone through a training in what to watch out in preparing gluten free food (i.e. using the right gluten free ingredients and following a process which ensures no cross contact) and have succeeded in a related audit performed by industry professionals who have been selected by the association in order to perform these audits.
Similar establishments exist around the world and are certified by the local celiac associations.
Pls. click on this link for all the establishments which are now certified under the ‘Eating Out’ Project in Cyprus:…… (“can we add eating out banner here?”)
You can still eat out at restaurants even if they are not certified under the Eating Out project but you need to prepare yourself better prior and while you are there.
When eating out consider asking the following questions even when visiting certified establishments:
- It is better to call the restaurant and talk to the chef/ server prior to you going there in order to ensure that they can cater for your needs.
- It is better not to book on rush hours so that you give time to people working in the kitchen to take care of you properly and ensure no cross contact.
- Explain in detail what you request and enquire both about the ingredients as well as the process of preparing the food so that cross contact is avoided.
- Do not rely only in what the catalogues states as Gluten Free.
- Food which has been prepared using stock cubes (meat/ chicken/ vegetable) most probably contain gluten, unless the cubes were prepared at the restaurant in which case you need to ask what they have used. You need to ask what brand of cubes was used. There are some cubes that are gluten free but the vast majority contain gluten.
7. Where can I find gluten free products?
8. Is meat and fish gluten free? Is there anything to pay attention to when buying meat fish or cold cuts?
Meat, poultry and fish are naturally gluten free thus can be consumed by celiacs. However please be extra careful if you are using marinated meat/ fish/ poultry or in ready- made sauces or ready from frozen. Ready -made sauces could contain gluten, making them not suitable for celiacs. In some cases, flour or bread-crumps are used to prepare them making them not suitable. When you purchase meat, poultry and fish please rinse them well with water to ensure that even if they have been cross contact, any traces of gluten have gone away.
When buying minced meat please ask your butcher whether the mince mincer is clean and has not been cross contact with gluten (i.e. no meat containing breadcrumbs/ flour etc. was minced in their before/ or it has been properly cleansed).
Be extra careful with products such as burgers, sausages, nuggets, meatballs/ keftedes, shieftalies, as they may contain ingredients with gluten.
Cold cuts are generally not safe unless they are made of pure meat thus you should always read the ingredients very carefully. There is a huge range of labelled gluten free cold cuts nowadays in Cyprus.
It is always better to prepare food at home at a gluten free environment. Oat can be used as a breadcrumbs substitute, the same as shredded potato or breadcrumbs from gluten free bread. Some brands also offer gluten free breadcrumbs for sale.
9. Is cheese gluten free?
10. How can I ensure that I am properly following a strict gluten free diet?
Laboratory tests (EMA, AGA, IgA, Ttg) should be done within three to six months following a diagnosis and annually for the rest of your life. While blood tests are extremely helpful, visiting a registered dietitian knowledgeable of celiac disease and the gluten-free diet is considered the “gold standard” for understanding how to know if you are accidentally being exposed to gluten (even if symptoms are not present).
Many people with celiac disease do not have any symptoms at all. However, people with celiac disease that don’t experience symptoms will still have intestinal damage if they ingest gluten, even if they do not feel sick. Some others are able to tell instantly if they have been exposed to gluten as they have severe symptoms.
11. What do I have to pay attention to when I leave in a house where others consume gluten?
If you leave in a house with others consuming gluten, then your chances of being ‘glutened’ are higher so you must be extra careful. Be aware of the following:
- You cannot use the same toaster for both gluten-free and gluten-containing items.
We strongly recommend that you buy a separate toaster for gluten-free items to avoid cross-contact with gluten-containing foods. On the market there are reusable “toaster bags” which can be used to avoid cross contact and are particularly useful when visiting friends/ travelling etc. Toaster bags are not fool-proof, and you must use them with caution. It is important to remember to never place the bag itself on gluten-free plates of food, as the outside of the bags will expose the other foods to any gluten from the toaster. Similar caution should be used when preparing gluten-free foods on grills or convection ovens.
- Be very careful when using convection ovens used to make gluten-containing food. There is a high risk for cross-contact. Convection ovens use a fan to circulate air around food. This process can cause cross-contact because gluten particles can be blown by the fan. You can use such ovens but please ensure that you cover your feed tightly so that it is not ‘glutened’. Once used to cook food with gluten it is also advisable to clean the ovens very careful prior to using to cook any gluten free food even in the cases where no traces of gluten are visible.
- Do not use the same sponges and dish rags to clean tableware/ cutlery to be used by a celiac when these have been used to clean tableware/ cutlery which may have contained gluten. You should have separate sponges and dishrags to clean gluten-free cookware.
- Wash your hands when serving a celiac or if you are a celiac when you touch something which may contain gluten. If you do not keep plates/ cutlery separately to be used by a celiac in the house, it is always a good idea to clean (even the clean dishes and cutlery) with a separate sponge before using them.
- Do not use condiments from the same containers that have been used to prepare gluten-containing foods. Utensils that are used to spread butter, mayonnaise, cream cheese and other condiments will expose the product to gluten which can then be spread onto your gluten-free breads, bagels, etc. It is always better to have separate condiments, and to clearly label the condiments that are dedicated gluten-free.
- When preparing food containing gluten and food without gluten then it is better to prepare the gluten free food first.
- Do not use the same water for boiling gluten- free pasta, vegetables, and preparing gluten-free sauces that was used to boil gluten-containing pasta. Also do not drain gluten free pasta in the same colander and drain gluten containing pasta.
- Do not fry gluten free food in the same fryer/ oil where gluten containing food was fried. High heat does not ‘kill’ gluten.
- Do not use the same towel to dry utensils or other items or your hands after touching gluten. Have separate towels to use for preparing gluten free foods or dry your hands.
- Do not use the same cutting board for cutting gluten free food with the one used to cut gluten containing food. Plastic/ Ceramic boards could be used for cutting gluten free food if they have been thoroughly cleansed with water and soap. However wooden boards cannot be cleansed from gluten since wood absorbs any traces of gluten. Therefore, do not use any wooden boards you used prior to be diagnosed for cutting bread with gluten, post your diagnosis. If living with others, then may be is best to have your own cutting board.
- Do not grill on the same grill/ griddle used to prepare gluten containing foods. Traces of gluten from toasting a pitta bread on the grill for example may be left on the grate of the grill, and it is difficult to properly clean after it has charred on. When eating out please ask questions and ask what they grill on the griddle. If the answer is unclear, then maybe you need to opt for another type of food which can be prepared separately on a clean pan for example.
- All handles in the kitchen (including the refrigerator’s handle) can expose you to gluten thus you always need to clean your hands and clean the kitchen’s surfaces well with soap regularly.
- It is better to keep your gluten free food at the top shelf of the fridge once others use the fridge for food containing gluten.
- Do not use the same spoon/ utensils to stir any gluten free food with the ones to stir gluten containing food.
12. Shall I worry about the airborne flour?
13. Can I eat at a buffet that has both gluten-free and gluten containing foods?
14. What do I do if I accidentally consume gluten?
15. Am I going to be able to go on vacations again away from home?
Of course, you will! Celiac disease should not affect any other area of your life and you should continue to live like before but without the bad symptoms accompanied by celiac disease!! In other words, you should enjoy life! In order to do so you will need to learn to be more organized when planning your holidays and you should do a lot of research prior and while you are at your destination. Do contact us at the Cyprus Celiac Association and we can offer you advice on holidaying in Cyprus and abroad and share our experiences with you.
- There are many different sites on the web offering advice for celiacs, spend time to read them and get ready.
- Check out which hotels offer gluten free dining. Call them before you make your booking to ensure they understand your request for gluten free food and the risks of cross contamination. It is better to speak to the head chef prior to your arrival or the F&B manager. If you are booking with a tourist operator, ask to obtain such a confirmation in writing.
- It is always best to take with you your gluten free snacks/ crisps/ cake cereal in case of emergency.
- Some airlines offer gluten free meals but do check before booking and prepare a snack/ fruit before you leave hotel or the hotel.
- Airports are usually not very glute free friendly, even though some have a good variety of options. Check before you go there and be ready in case no gluten free food is available.
- Check if there are any restaurants offering gluten free food at your destination or what the local supermarkets sell in gluten free.
- Some people find it easier to rent apartments and prepare their own food rather than staying at hotels. This depends of where you are heading to and what type of person you are.
- It is always good to have with you a card explaining what you suffer from and what food you can consume in the local language of the place you are visiting. Please find below a card which can be used in many languages/ countries: https://www.celiactravel.com/cards/
16. What do I need to do when my celiac kid goes to school?
The golden rule here is to start training your kid as early as possible and try to make him/ her responsible for himself/ herself. He/ she should be able to explain what he/ she is suffering from and why he/ she cannot eat gluten. It is very important to make your child comfortable with what he is suffering from and not embarrass about it. He/ she should embrace the new reality and stand out with confidence to explain the situation.
Of course, when the children are young you always must contact their teachers/ school administration and explain the condition of the child and that he/ she avoid gluten. It always helps if the teacher explains in the class what celiac disease is and why the child cannot consume any gluten. Attention should be taken when of how this is communicated to the kids so that it makes the child feel at ease. Some parents find that treating other kids in the class with gluten free sweets/ chocolates etc. is a good introduction as the other kids get to understand that gluten free food is also tasty but just different.
It is also a good excuse to get more involved with the school and the activities and even with the parents’ association! With this you are close to all the happenings and be able to meet other parents explain what the disease is all about so that others understand as well.
The teacher and the child should ensure that they never share food with other kids and they never touch in other kids’ plates nor do the other kids touch their food. They should clean their hands regularly.
Some parents also find it helpful to provide the teacher with gluten free snacks/ sweets which the teacher keeps and provides to the child in case of emergency or when any of the other kids are treating the rest so that he/she does not feel left out.
If there is a refectory at the school where the kids buy snacks/ sweets etc. talk to your kid and explain what she/ he can purchase from the refectory. Visit the refectory together with your kid and see what is on sale so that you show to your kid what he can buy. If nothing is on sale then request from the person in charge to bring some gluten free snacks so that your kid can purchase. Talk to the school administration office or the parents’ association if needed.
17. Are oats gluten free?
Oats are naturally gluten free. The biggest problem with oats is that they are very often cross contact with gluten because oats are normally packaged in places with other gluten containing cereals such as wheat or even grown is places around wheat and barley. For this reason, you should only consume oats if it is clearly labelled that they are gluten free.
Oats have a protein called avenin, which, along with fiber, is why oats are a healthy food. For many people who eat a gluten-free diet, oats are a good way to get nutrients often lacking in the gluten-free diet.
Oats contain avenin, which is a protein similar to gluten. Research has shown that most people with coeliac disease can tolerate gluten free oats with no problems, however some people are sensitive to avenin and avoid it.
18. Is soya sauce gluten free?
19. Which soft drinks/ beverage/ alcohol are gluten free?
- Gluten may be hidden in all kinds of beverages, including coffee, tea, soda, and energy and sports drinks. You should be careful when consuming processed drinks.
- 100% natural juices are gluten-free. However not natural juices may include gluten. One way to check is by looking at the ingredients list on the bottles and cans.
- Most of the sodas are gluten free.
- Coffee without any flavours is normally gluten free, same as cocoa. Always read the labels to ensure that it does not contain gluten and it was not processed/ packed at a place where gluten is present. Be careful with flavour drinks such as chocolate drinks, some brands do contain gluten. Read the labels carefully.
- Gluten free beer is relatively new but there are several gluten free beers on the market (including Cyprus)! So cheers!
- All wine is gluten free unless it is infused in which case you must read the label and confirm it is ok. Wheat paste may be used to seal the heads of oak barrels, but even if they do, it doesn’t touch the wine, and even if it did, any transfer of gluten to the wine would be far less than the minimum. Gluten is also not commonly used in fining or clarifying wine. Even if a winemaker uses gluten to fine their wine, it is skimmed off with the particles that cling to it and make wine cloudy. Even if there was some gluten left after that process (again, highly unlikely), it would be so small as to be negligible in your glass or bottle of wine. So generally, one could say that wine is gluten free!
- “Rice wine” or sake — is also gluten free.
- Distilled Alcohol Is Gluten Free. Distilled grain alcohols including vodka, bourbon, whiskey, scotch, brandy, and gin ARE gluten free even though they are made with gluten containing grains. The distillation process removes the gluten from the end product, so unless the manufacturer adds gluten as a flavoring AFTER distillation, those liquors are indeed gluten free.
- Liquors like rum (made from sugar cane), tequila (made from the agave plant) and brandy (distilled wine) are not made with gluten, so they are safe for celiacs and others with gluten sensitivity.
- Hard ciders are almost always gluten free, unless the manufacturer has added malt (made from barley).
- Malted beverages ARE NOT gluten free. Malt is derived from barley which contains gluten, and these drinks are not distilled, so the gluten remains in the bottle.
- Home made lemonade is normally gluten free but please ask how the manufactured one or squash is made from because it may contain gluten so you have to read the ingredients.
20. Do medicines/ vitamins/ supplements contain gluten?
This is a topic which is not straight forward. Most medicines do not contain labels of gluten free thus patients need to watch out, read the labels, search on the internet, ask their doctor/ pharmacist or contact the manufacturer.
Manufacturers use excipients, which bind pills together and help deliver the medication to the patient. There are several types of excipients, and some of them may contain gluten.
Few medications contain gluten, but it is important that the ingredients of each medication are explored to find the source of excipients – and to verify the particular drug is gluten-free.
The generic form of a medication may use different excipients than the brand name drug. Even if the brand name is determined to be gluten-free, the gluten-free status of each generic must be verified.
There are currently no requirements for labeling gluten or common allergens found in drug ingredients. There are no specific precautions for individuals with celiac disease in labelling, thus all celiacs should be extra careful.
21. When cooking gluten free can I follow any recipe used and replace the ingredients with gluten free ones?
Gluten free products such as gluten free flours are very different to wheat flour and thus replacing them and following the recipe does not always work. In general, though, sweets/ cakes and desserts can be made just by following the recipe using gluten containing flour or other ingredients.
When it comes to preparing bread/ pittas/ savouries such as bourekkia etc. In this case you need to experiment. Gluten free flour is not as a elastic as gluten containing bread. Also, gluten is not there to ‘glue’ all the ingredients together and thus other substitutes are required. Here are some tips:
- Each gluten free flour is different to the rest and therefore you should experiment ith using different amounts of liquids, use different kinds of flour together. Usually when baking a gluten free bread, the use of one type of flour does not do the job.
- Place a metal bowl with water at the bottom of the oven when baking gluten free b read.
- Use xantham gum/ guar gum or eggs to make your dough more elastic and bring the ingredients together.
There are many gluten free recipes on the net. There are several on our website which have been used and we like them! Please share with us your experiments!