Celiac Disease - Introduction
Celiac disease, also known as celiac sprue, is an autoimmune disorder in which the body's immune system attacks the intestine upon exposure to the gluten protein. This protein, composed of gliadin and glutenin, is found in certain grains such as wheat, barley, rye, and, to a debated extent, oats. The exact causes of the disease are not fully understood, but it's clear that a combination of environmental and genetic factors plays a significant role. Exposure of individuals with celiac disease to gluten leads to chronic inflammation and damage to the villi (finger-like structures in the small intestine) that absorb nutrients from food. This damage is seen in biopsies as a flattened, villous atrophy without villi and with inflammatory cells within the epithelium. Consequently, this can result in general malnutrition or specific deficiencies, such as iron or protein. Furthermore, chronic inflammation can, over time, increase the risk of malignancies and may lead to reduced bone density and other complications. It's important to note that eliminating gluten from the diet reverses the damage, and the digestive system returns to normal function, including a return to the normal prevalence of celiac disease in the population.
Gluten avoidance is essential for life. However, in the future, treatments might be developed that allow for more lenient dietary options. If gluten consumption is not strictly avoided and symptoms might not be immediately apparent, long-term non-adherence to a gluten-free diet can lead to intestinal damage and various complications.
What Are the Symptoms?
Celiac disease is often referred to as a "disease with a thousand faces," as it presents in many different ways. The disease is characterized by a variety of clinical symptoms, some related to the digestive system, some to other body systems, and some individuals might not experience any symptoms at all. Typical symptoms of celiac disease, most commonly appearing in early childhood, can include abdominal pain, diarrhea or constipation, growth and developmental delays, distended abdomen , lack of appetite, weakness or fatigue, and vomiting. If the inflammation is relatively mild, the symptoms might be less severe or atypical. Less typical symptoms that may appear later in life can include low consciousness, decreased appetite, chronic fatigue, delayed puberty, malabsorption, anemia, hair loss, liver dysfunction, recurring mouth sores, neurological symptoms, skin rash, and decreased bone density. Celiac disease can also manifest as an "asymptomatic disease," meaning without symptoms but with characteristic intestinal damage. Therefore, if celiac disease is diagnosed in a family member, it's recommended to conduct blood tests to screen other first-degree relatives. Routine screening tests are also recommended for populations at risk for celiac disease, such as type 1 diabetes patients, autoimmune disease patients, and those with specific genetic conditions. In high-risk populations, the prevalence of celiac disease can reach up to 10%, compared to only 1% in the general population.
In the past, celiac disease was considered a childhood disease only. Today, with increased awareness of the condition and the availability of accurate blood tests for diagnosis, the number of diagnosed individuals with celiac disease has grown, even in adulthood.
How Is Celiac Disease Diagnosed?
In recent years, there have been significant advancements in diagnostic methods for celiac disease through accurate blood tests. These tests usually include serological tests for specific antibodies in the blood, as well as specialized genetic testing that can be helpful in certain cases. While diagnosis takes into account clinical symptoms and blood test results, the definitive diagnosis is made through a biopsy of the small intestine's lining, obtained during an upper endoscopy procedure by a specialized gastroenterologist. This procedure, which takes only a few minutes, is considered very safe and does not require hospitalization. We typically perform the biopsy under deep sedation to ensure the patient's comfort. In the past, multiple biopsies were required, but with the increased accuracy of serological tests, usually one endoscopy is sufficient.
It's important to know that nutritional therapy begins only after endoscopy and biopsy, as removing gluten from the diet before diagnosis might affect test accuracy.
One Treatment - One Result
The effective and safe treatment for celiac disease is a gluten-free diet (not just low gluten). Strict adherence to a gluten-free diet leads to healing of intestinal damage, digestive system recovery, and proper function restoration. Additionally, a varied and balanced menu that meets the nutritional needs of the patient is important. A well-balanced diet, not just for celiac patients, includes all food groups - carbohydrates, proteins, fats, minerals, and vitamins from nutritious food sources. Changing the diet should only be done under the guidance of a registered dietitian experienced in celiac disease to ensure that the diet remains balanced despite gluten removal.
A gluten-free diet - not the end of the world!
As previously mentioned, it's crucial to avoid consuming foods that contain gluten (i.e., only those labeled as containing less than 20 PPM). Gluten-containing protein is found in certain grains, including wheat, barley, rye, and oats (though the latter remains debated). Other foods are permitted, as long as they're not "contaminated" with gluten. It's important to carefully read the detailed ingredients of processed foods and get specific details from the person who prepared homemade food. In this brochure, we have attempted to provide ways to ease the daily challenges faced by patients by introducing them to gluten-free alternatives and offering practical recommendations based on our years of experience with this disease.
"Seeing the Full Half-Cup"
Despite the strict prohibition on consuming gluten, there are now many foods that are allowed for consumption. It is possible to continue eating healthily and enjoyably. The following table provides a slightly broader overview of the topic.
Concerns arise with certain foods like buckwheat, millet, quinoa, teff, amaranth, sorghum, fava beans, chickpeas, lentils, and beans. There is a risk of cross-contamination with gluten-containing grains during harvesting or processing. Therefore, it's important to buy packages with clear labels indicating gluten-free status.
Today, it is much easier to live with celiac disease than in the past. Many food companies produce specialized gluten-free products such as flour, bread, cereals, cookies, and snacks. Grocery stores offer a wide range of gluten-free products, allowing you to create a balanced and tasty menu. Food companies explicitly label whether their products contain gluten or not.
Principles of Reading Labels and Purchasing Products
In the food industry, wheat flour or wheat starch is used for various purposes such as food stabilization or thickening. Sometimes, even if the food itself doesn't contain gluten, it might be produced on machines that previously processed gluten-containing products. Therefore, it's wise to avoid consuming such foods.
To detect hidden gluten in food products, it's important to carefully read the nutritional information on the packaging. The law requires labeling of gluten-containing products, but it's not always done clearly. Sometimes, food labels are not detailed enough. For instance, when "stabilizing agents" are listed without specifying their origin, it might indicate the presence of gluten. In such cases, it's advisable to contact the company representatives for clarification.
Keywords that sometimes indicate gluten presence include quaker, semolina, modified starch, processed starch, plant-based protein, wheat protein, hydrolyzed plant protein, stabilizers, emulsifiers, grain extracts, and caramel.
It's recommended to also check the allergen ingredient box on food packaging.
In 2011, a law was enacted that requires products containing less than 20 ppm of gluten to be labeled as "containing up to 20 ppm of gluten." Such products can be consumed without worry.
It's advised to avoid purchasing foods without clear gluten status. If there is any doubt about the gluten content of a product, it's best to avoid consuming it until verified.
Gluten can be found in medications and dietary supplements, including vitamins. It's recommended to avoid these products unless there is clear information indicating they are gluten-free.
When buying meat from a butcher, it's recommended to purchase fresh ground meat or grind it at home, as most store-bought ground meat contains plant-based protein that might contain gluten. If buying ground meat from the butcher, ensure that their grinder is not used for bread, bread crumbs, or gluten-containing spices.
When purchasing food from Delis, such as sausages, cheeses, fish, and salads, make sure they are gluten-free and that the area is clean of gluten (e.g., no sandwiches are prepared on the same cutting board).
It's advisable not to buy foods with crumbs (croutons, dried fruits, and spices).
Before purchasing any medication or dietary supplement, like vitamins, make sure they are gluten-free.
When eating at restaurants, it's recommended to avoid foods with sauces and soups, as they might contain gluten.
Permissible Foods
Products containing less than 20 ppm of gluten: potato, sweet potato, rice, corn, quinoa, millet, buckwheat, soy flour, cornflour, rice flour, cornflakes, rice cakes, gluten-free crackers, pasta, clean oatmeal, lentils, chickpeas, fava beans, soybeans.
- Meat: beef, turkey, chicken, fish - all types - fresh or frozen.
- Eggs
- Fruits - all types: fresh, dried, and preserved.
- Vegetables
- All types of foods
- Kitchen Recommendations
When preparing food, it's advisable to separate gluten-containing and gluten-free items.
However, the same tools can be used if they are washed and cleaned thoroughly between uses. Avoid using wooden utensils (cutting board, wooden spoon, spatula) that are used for both gluten-containing foods (e.g., pasta) and gluten-free foods, as it's difficult to clean them entirely, and even a small amount of residue could be harmful.
It's wise to follow the correct sequence in the kitchen - prepare gluten-free food first, then gluten-containing food, to prevent cross-contamination.
As an alternative to bread crumbs (e.g., in breading schnitzels), you can use gluten-free breadcrumbs or flour, ground rice, potato flour, or cornflour.
Ensure that the utensils and surfaces used are clean and free from crumbs, including marble and cutting boards.
It's recommended to store gluten-free baked goods and dry foods (e.g., gluten-free pasta) in a separate area in the cupboard, fridge, or freezer, using separate containers to differentiate them from gluten-containing foods.
Many Passover-certified products are also gluten-free. However, make sure they don't contain matzo flour.
Stay updated with comprehensive information from the Celiac Association of Israel at https://www.celiac.org.il, which works to support individuals with celiac disease. The association provides an annual detailed food guide that clarifies which medications and dietary supplements contain gluten and which do not. You can use their online guide or mobile application.
Additional Resources:
1. Celiac Association of Israel: www.celiac.org.il
Helpline: 03-6781481
2. Gluten-Free Products Shop: www.glutenfree.co.il
Phone order: 03-9191025; Fax order: 03-9191026
Moreover, gluten-free products can be found in the grocery store chains Shufersal Deal, Mega, Rami Levy, Super Green (in Beit Shemesh and Jerusalem), Tav, Tav Market, and the Kibbutz Gan Shmuel store.