>- English reference of Celiac Disease for students

Biopsy of small bowel showing coeliac disease ...
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Celiac Disease

A. Introduction

Celiac disease (also known as celiac sprue and gluten senstive enteropathy) is a chronic inflammatory disorder characterized by mucosal damage to the small intestine leading to gastrointestinal illness, nutrient malabsorption, and a wide range of clinical manifestations (NIH, 2004; han, et al. 2002). There is a consensus opinion that celiac disease is caused by an aberrant (T lymphocyte) immune response to dietary glutens predominantly found in wheat, barley, and rye (NIH, 2004). However, there is evidence that at least some persons who have celiac disease may not tolerate oats (Lundin et al., 2003; Arentz-Hansen et al., 2004). Those individuals who have a genetic predisposition to celiac disease react to peptides within the proline- and glutamine-rich protein fractions of the grains (Dewar et al., 2004). For affected individuals, celiac disease is a lifelong condition and, if not treated, is associated with significant morbidity and increased mortality (Fasano, 2003; Corrao et al., 2001; Dewar et al., 2004). There is no cure for celiac disease (NIH, 2004). Strict avoidance of potentially harmful concentrations of glutens in the diet is the only known means of completely preventing the clinical and pathological complications of celiac disease (NIH, 2004; Fasano and Catassi, 2001).

B. Mechanism of Pathogenesis

Celiac disease is characterized by injury to the mucosa of the small intestine and specifically targets the fingerlike projections, called villi, where absorption of key nutrients takes place (Figure III-1). This injury is believed to be due to an autoimmune disorder involving modification of the antigenic presentation of gluten in the intestinal tract of genetically predisposed individuals expressing the major histocompatibility haplotypes HLA-DQ2 or HLA-DQ8 (Farrell and Kelly, 2002; Fasano, 2003). In these individuals, binding of the enzyme tissue transglutaminase (tTG) to wheat gluten (a glutamine rich protein) potentiates uptake and presentation by antigen-presenting cells in the lamina propria, triggering a vigorous T-cell response (Schuppan and Hahn, 2002), leading to production of IgG and IgA antibodies directed to wheat gluten peptides (i.e., gliadins and glutenins) and to tissue transglutaminase (tTG). The activated T-cells are responsible for the mucosal damage seen in celiac disease (Fasano and Catrassi, 2001). This immune-mediated damage occurs in two compartments, the epithelium and the lamina propria (Green and Jabri, 2003). Early intestinal disease is characterized by an increased number of intestinal intraepithelial lymphocytes (IELs). As the disease progresses, increasing numbers of lymphocytes and plasma cells infiltrate the lamina propria. This increase in the numbers of cells leads to elongation of intestinal crypts and shortening of villi, which eventually results in partial or total villous atrophy (James, 2005). Elimination of intestinal gluten results in modification of T lymphocyte and antibody responses and, in most cases, full mucosal recovery (Kaukinen et al., 1999; Fasano and Catassi, 2001).

C. Range of Adverse Effects

The clinical manifestations of celiac disease are highly variable in character and severity. The reasons for this diversity are unknown but may depend on the age and immunological status of the individual, the amount, duration, or timing of exposure to gluten, and the specific area and extent of the gastrointestinal tract involved by disease (Dewar et al., 2004). These clinical manifestations can be divided into gastrointestinal, or “classic,” and non-gastrointestinal manifestations. Gastrointestinal manifestations usually present in children 4 to 24 months old and include abdominal pain and cramping, bloating, recurrent or chronic diarrhea in association with weight loss, poor growth, nutrient deficiency, and (in rare cases) a life-threatening metabolic emergency termed celiac crisis, characterized by hypokalemia and acidosis secondary to profuse diarrhea (Farrell and Kelly, 2002; Baranwal et al., 2003). Non-gastrointestinal manifestations are more insidious and highly variable and are the common presenting signs in older children and adults. These manifestations are frequently the result of long-term nutrient malabsorption, including iron deficiency anemia, short stature, delayed puberty, infertility, and osteoporosis or osteopenia (Fasano, 2003). In children, progressive malabsorption of nutrients may lead to growth, developmental, or neurological delays (Catassi and Fasano, 2004). Extra-intestinal manifestations such as dermatitis herpetiformis, hepatitis, peripheral neuropathy, ataxia, and epilepsy have also been associated with celiac disease (Fasano and Catassi, 2001). Individuals with untreated celiac disease are also at increased risk for potentially serious medical conditions, such as other autoimmune diseases (e.g., Type I diabetes mellitus) and intestinal cancers associated with high mortality (Farrell and Kelly, 2002; Peters et al., 2003; Catassi et al., 2002). For example, individuals with celiac disease have an 80-fold greater risk of developing adenocarcinoma of the small intestine, a greater than two-fold increased risk for intestinal or extraintestinal lymphomas (Green and Jabri, 2003) and a 20-fold greater risk of developing enteropathy-associated T cell lymphoma (EATL) (Catassi et al., Dietary Gluten Tissue Tranglutaminase (tTGA)Antigen Presenting Cells Deaminated Gluten/tTGA Activated T-Cells Symptoms Anti-Gluten and Anti-tTGA IgG and IgA Mucosal Damage

2005a). These are rare intestinal malignancies with a high mortality rate. In addition, the relative risk for developing non-Hodgkin’s lymphomas, intestinal or extraintestinal, is three fold greater than in the general population (Catassi et al., 2002). These cancers contribute to nearly two thirds of deaths due to celiac disease and are a major reason for the nearly two-fold increase in overall mortality of adult patients with celiac disease compared to the general population (Corrao et al., 2001).

Currently, individuals with clinical manifestations, or “symptomatic” celiac disease, are believed to represent a small portion of the total affected population (Mäki and Collin, 1997). A larger number of individuals are believed to have “silent” celiac disease, characterized by positive serology and intestinal mucosal abnormalities in the absence of symptoms or nutritional deficiencies. Mäki and Collin (1997) also suggested that there is an even larger population with “latent” celiac disease, individuals who are positive for serological markers or genetic susceptibility to disease and are entirely asymptomatic. It is generally accepted that individuals with silent or latent disease, although asymptomatic, have the capability to manifest aberrant immune responses following exposure to dietary glutens and are, therefore, at increased risk for both acute and long-term complications of celiac disease (Fasano, 2003; Schuppan, 2000). However, the long-term benefit of strict gluten avoidance for these individuals is unproven (Green and Jabri, 2003).

D. Prevalence

Until recently, celiac disease was considered to be a rare disorder in the U.S., with an estimated prevalence rate of 1:5,000 (Talley, 1994). However, a large epidemiological study screened more than 13,000 people in 23 states and estimated a prevalence rate of 1:133 within the general U.S. population (Fasano et al., 2003). The National Institutes of Health Consensus Development Conference Statement on Celiac Disease currently estimates that 3 million Americans, a little less than 1 percent of the population, may have celiac disease (NIH, 2004). Celiac disease occurs widely among North American and European populations, where wheat is a staple food, but is infrequent among native descendents of China and Japan and those with an African-Caribbean background, where wheat is not as widely consumed (Farrell and Kelly, 2002).

Precise prevalence data for celiac disease are not available. This disease is often misdiagnosed as another gastrointestinal malabsorptive disorder (e.g., irritable bowel syndrome) due to similarities in their symptoms (Sanders et al., 2001). Due to the existence of silent or latent cases, it is assumed that the incidence of celiac disease is underreported (Mäki and Collin, 1997). These forms of celiac disease may go undetected in individuals for years before they develop symptoms causing them to seek medical attention (Green and Jabri, 2003). Mäki and Collin (1997) postulated that there are many more currently healthy individuals who are genetically predisposed to developing celiac disease in future years than there are individuals who are now affected by celiac disease. Only recently has the medical community become more aware of the need to screen for celiac disease when patients experience health problems that may be associated with the disease or when patients have family members, especially first- and second-degree relatives, who have celiac disease (NIH, 2004).

E. Celiac Foods of Concern

Celiac disease is caused by an immune response in genetically predisposed individuals to specific storage proteins, commonly referred to as “glutens,” that occur naturally in cereal grains (Shan et al., 2002). Technically, “gluten” is a term applied specifically to the combination of the prolamin proteins called “gliadins” and the glutelin proteins called “glutenins” found in wheat (Brown, 2004). However, the term “gluten” has been used generically to refer to prolamin and glutelin protein mixtures found in other cereal grains (Kasarda, 2005, personal communication). Although all cereal grains contain prolamin and glutelin proteins, these proteins are not identical in different grains. These proteins differ in their amino acid sequences in different grains, and not all have been shown to evoke an abnormal immune response that affects the intestinal lining of persons genetically susceptible to celiac disease (Kasarda, 2003). The term “gluten” will be used in this report in the more general sense of the combination of both prolamin and glutelin proteins found in cereal grains.

The grains considered to be capable of producing adverse effects in individuals with celiac disease include the different species of wheat (e.g., durum, spelt, kamut), barley, rye, and their cross-bred hybrids (e.g., triticale, which is a genetic cross between wheat and rye) (Kasarda, 1994; Kasarda, 2004). There is also evidence that some individuals with celiac disease may react adversely to oats (Lundin et al., 2003; Arentz-Hansen, 2004). These grains are all members of the grass family (Gramineae, also known as Poaceae) and are closely related taxonomically. The cereal grains assumed to be safe for persons with celiac disease include amaranth, buckwheat, corn, Indian ricegrass, Job’s tears, millet, quinoa, ragi, rice, sorghum, teff (or tef), and wild rice (Kasarda, 2001; Johnson et al., 2002; Kasarda, 2004b; Kupper, 2004).

The grain prolamins of concern include gliadin in wheat, secalin in rye, hordein in barley (Thompson, 2001; Green and Jabri, 2003; Kagnoff, 2005) and possibly avenin in oats (Arentz-Hansen, et al. 2004; Lundin, et al., 2003). There is substantial evidence that both prolamin proteins (i.e., gliadins) and glutelin proteins (i.e., glutenins) in wheat affect individuals with celiac disease (Shan et al., 2002; Hausch et al., 2002; Vader et al., 2002; van de Wal et al., 1999; Molberg et al., 2003).

Wheat gliadin subtypes alpha, beta, gamma, and omega, have been shown to affect individuals with celiac disease (Ciclitira et al., 1984; EFSA, 2004). Rye, barley and triticale are taxonomically related to wheat, express peptides structurally similar to those found in wheat, and have been reported to affect individuals with celiac disease (Vader et al., 2002; Kasarda, 2001; Kasarda, 2004b). In contrast, the prolamins in other cereal grains (e.g., zein in corn and orzenin in rice) have been shown not to affect individuals with celiac disease (EFSA, 2004; Kasarda, 2004b). However, much is still unknown about which proteins in the different grains can affect individuals with celiac disease (Kasarda, 2001).

Analytical information is not available on the actual amount of gluten proteins in different grain-derived food ingredients or finished foods. For single ingredient foods made from wheat, rye, barley, triticale, and oats, the simple presence of “protein” in that

food may be used as an indicator that gluten proteins are present. The USDA National Nutrient Database for Standard Reference, Release 17 (USDA, 2004), the major source of composition data for foods in the U.S., includes hundreds of food items that contain wheat, rye, barley, triticale or oats as an ingredient. Wheat, in particular, is used to manufacture a wide range of food ingredients and finished foods. Rye, barley, triticale, and oats are used to make substantially fewer food products.

Koehler and FDA (2005) estimated the average amount of total grain and individual types of grain available for consumption per person in the U.S., and the total exposure to gluten-forming proteins that would result from this grain consumption. The estimated mean daily consumption rate was approximately 250 grams of grain per capita. Wheat provided 180 of the 187 grams per person per day of grains that are of concern for individuals with celiac disease.

There is no consensus as to whether oats present a hazard for all individuals with celiac disease. Several studies, including one that lasted 5 years, have reported that most celiac study participants tolerated moderate amounts (e.g., 50-70 grams daily) of oats (Janatuinen et al., 1995; Janatuinen et al., 2000; Janatuinen et al., 2002; Lundin et al., 2003; Arentz-Hansen et al., 2004). The oats used by Lundin et al. (2003) and Arentz-Hansen et al. (2004) were tested to ensure that they did not contain any gluten proteins from wheat, rye, or barley.

F. Gluten Contamination of Grains

In the U.S., most commercially available oat products are believed to contain some gluten proteins from wheat, rye, or barley due to cross-contact with these grains during growth, harvest, transport, storage, or processing (Kasarda, 1999; Kasarda, 2001; AGA, 2001; Thompson, 2003). In a recent study, Thompson (2004) analyzed four lots of three brands of rolled or steel-cut oats commercially available in the U.S. for prolamins from wheat, barley, or rye. For one brand, all samples contained 338 to 1807 ppm gluten (expressed as the mean of duplicate determinations). For each of the other two brands, the level of gluten detected in all but one lot ranged from 12-725 ppm in one brand and 120-131 ppm in the other brand (expressed as the mean of duplicate determinations). Thus, only one lot of these two brands was negative for gluten. Thompson (2004) concluded that none of these three brands could be considered a reliable source of oats free of potentially harmful gluten proteins.

Grains that do not contain gluten can become contaminated with grains that contain gluten at any step in the farm-to-table continuum, particularly if shared equipment is not thoroughly cleaned between uses. It is difficult, if not impossible, to prevent all cross-contact situations, considering the tons of grain handled by farm equipment, bulk storage, and transport containers on a daily basis. In fact, the Official United States Standards for Grains (USDA, 1999) assume that most grains that have an established U.S. standard will contain a small percentage of other grains.

G. Gluten Challenge Studies

There is little information in the literature on minimal disease-eliciting doses of gluten for sensitive individuals. Gluten challenges have generally been performed in individuals where diagnosis is uncertain (e.g., infants, Laurin et al., 2002) or in individuals with unclear intestinal pathology results (Wahab et al., 2001). Challenges have also been performed to determine the time of disease relapse after a prolonged period of gluten avoidance (Mayer et al., 1989). In most cases, gluten challenges have been performed to elicit or confirm disease rather than to measure the level of sensitivity (Farrell and Kelly, 2002).

There is no standard protocol for gluten challenges, and challenge studies have varied greatly in amount and duration of gluten exposure. Although some studies have been designed to determine the acute effects (i.e., after 4 hours) of exposure to gluten (Sturgess et al., 1994; Ciclitira et al., 1984), most challenges consist of an open challenge to a fixed or incremental dose of daily gluten over a minimum period of 4 weeks. Many challenge studies use a high exposure (> 10 g/day) to gluten, because this is believed to shorten time to disease confirmation or relapse and, therefore, to minimize discomfort to subjects (Rolles and McNeish, 1976). However, some studies have shown that low daily exposures to gluten also can elicit a disease response (Catassi et al., 1993; Laurin et al., 2002; Hamilton and McNeill, 1972).

Catassi et al. (1993) reported that children, whose celiac disease had previously been controlled on gluten-free diet, had evidence of intestinal mucosal or immunological changes (changes in intraepithelial lymphocyte counts and the villous height to crypt depth ratio) following 100 mg or 500 mg of daily gliadin over 4 weeks; this corresponds to 200 mg and 1000 mg of daily gluten respectively (Collin et al., 2004). The degree of inflammation was dose dependent. However, this study had several important limitations, which include the short-term follow up (4 weeks), testing in young children, the small number of subjects (n=20), and the lack of control groups. In addition, although gliadin is believed to be the major immunogenic portion of gluten, T cells from the small intestine of celicac disease patients have been shown to be responsive to peptides from the glutenin portion as well (Van de Wal et al., 1999). Thus, the Castissi et al. (1993) study was also limited by the use of gliadin rather than gluten. Estimating potential harm by extrapolating from gliadin levels may not be representative of the harm from total gluten exposure.

A study currently in progress [The Italian Microchallenge Study] has extended the scope of these earlier findings by evaluating the effects of exposure to either 10 or 50 mg of purified gluten per day for 3 months with a population of 36 celiac disease individuals in a double-blind, placebo-controlled study (Catassi et al., 2005b). Preliminary unpublished results suggest that minimal mucosal abnormalities occur with a strict gluten-free diet, that both 10 mg and 50 mg daily gluten are well-tolerated, but that there is a trend for mucosal changes to occur at the 50 mg dose. These results can be compared to estimated gluten exposures from gluten-free diets containing various levels of gluten contamination (Table III-1, from Collin et al., 2004, reproduced below). Fasano (2005 personal communication) used these values to suggest that a

conservative threshold for gluten exposure for sensitive individuals would lie between 20 and 100 ppm.

Table III-1. Estimated Daily Gluten Consumption from Combinations of Different Amounts of Food Containing Different Levels of Gluten

Gluten Content in Food (ppma)

Daily Amount of Gluten-Free Food Consumed (g)





—————-Daily Amount of Gluten Consumed (mg)—————–





















The Gluten-free Diet: Some Examples

In 2006, the American Dietetic Association updated its recommendations for a gluten-free diet. The following chart is based on the 2006 recommendations. This list is not complete, so people with celiac disease should discuss gluten-free food choices with a dietitian or physician who specializes in celiac disease. People with celiac disease should always read food ingredient lists carefully to make sure the food does not contain gluten.

Allowed Foods
Indian rice grass
Job’s tears
wild rice
Foods To Avoid
  • including einkorn, emmer, spelt, kamut
  • wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein
  • barley
  • rye
  • triticale (a cross between wheat and rye)Other Wheat Productsbromated flour
  • durum flour
  • enriched flour
  • farinagraham flour

phosphated flour
plain flourself-rising flour
white flourProcessed Foods that May Contain Wheat, Barley, or Rye*bouillon cubes
brown rice syrup
chips/potato chips
cold cuts, hot dogs, salami, sausage
communion wafersFrench fries
imitation fish
rice mixes
saucesseasoned tortilla chips
self-basting turkey
soy sauce
vegetables in sauce

* Most of these foods can be found gluten-free. When in doubt, check with the food manufacturer.

Source: Thompson T. Celiac Disease Nutrition Guide, 2nd ed. Chicago: American Dietetic Association; 2006. © American Dietetic Association. Adapted with permission. For a complete copy of the Celiac Disease Nutrition Guide, please visit www.eatright.org.



                was presented by dr. Amekhezeem and prepared by consultant suad al-feraih

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What is Celiac Disease?

Celiac Disease is an autoimmune disorder that damages or destroys the lining of the intestines

in reaction to gluten, which is the protein found in wheat, barley, rye, and sometimes oats.

What are the Effects?

When a person with Celiac Disease digests food containing wheat, barley, rye and sometimes

oats, the gluten shortens and eventually flattens the villi, which are small finger-like projections

that line the small intestine. The villi produce enzymes and allow nutrients from digested food

to pass into the body. If the villi are flat, the body will not be able to absorb vital nutrients such

as vitamins, minerals, proteins, fats and carbohydrates.

Common Symptoms of Celiac Disease

Although there is no one set of symptoms for Celiac Disease, the following conditions may be


• Slower or poor growth • Diarrhea

• Irritability • Anemia

• Weight loss or slow weight gain • Tiredness or fatigue

• Bloating and cramps • No real interest whether things happen

or not; minor depression

What happens if a Celiac digests gluten – what is the reaction like?

A reaction will vary depending on how sensitive the individual person is and according to how

much gluten was ingested. A visible reaction will usually occur within four hours of ingesting

the gluten and can include:

• stomach cramping

• “fuzzy” or unclear feeling; difficult concentrating

• irritability

• diarrhea

How do you know if food contains gluten?

Most ingredients are obvious. For example, enriched flour. Flour is generally made from

wheat. However, most times it can be very difficult to tell. Even when reading the ingredients

on a label, gluten can be hidden in many forms. Also, FDA labeling requirements do not

require manufacturers to define things like “artificial and natural ingredients” or any ingredient

that comprises less than 2% of the product. These items often contain gluten. See attached


What do you do if gluten is digested by mistake?

Please notify parent(s) as soon as possible. Also, the student may need to suddenly run to

the bathroom.

What is the treatment for Celiac Disease?

The treatment for Celiac Disease is quite simple – a diet that excludes gluten. A gluten-free

diet means completely omitting wheat, rye, barley and sometimes oats in any form from the

diet. Although the treatment is simple, it is not always easy. If you have have any questions,

please ask. The following website provides a list of products that are gluten free::


Other Websites if interested in more information:



Gluten-Free Ingredients

Acacia Gum Distilled Vinegar Rice

Acorn Quercus Eggs Rice Flour

Alcohol (Spirits-Specific Types) Fish (fresh) Rice Vinegar

Alfalfa Flaked Rice Romano Bean (chickpea)

Amaranth Flax Sago Palm

Adzuki Bean Fruit (including dried) Sago Flour

Agar Gelatin Saifun (bean threads)

Algae Gram Flour (chick peas) Scotch Whisky

Almond Nut Grits, Corn Seaweed

Annatto Guar Gum Seed – Sesame

Apple Cider Vinegar Herbs Seed – Sunflower

Arabic Gum Honey Soba (be sure it’s 100%

Arrowroot Hyacinth Bean Buckwheat)

Artichokes Job’s Tears Sorghum

Astragalus Gummifer Kasha (roasted buckwheat) Sorghum Flour

Baking Soda Kudzu Root Starch Soy

Balsamic Vinegar Lentil Soybean

Beans Locust Bean Gum Spices (pure)

Bean, Adzuki Maize Spirits (Specific Types)

Bean, Hyacinth Maize Waxy Starch (made in USA)

Bean, Lentil Maltodextrin(ˇ) Succotash (corn & beans)

Bean, Mung Manioc Subflower Seed

Bean Romano (Chickpea) Masa Flour Sweet Chestnut Flour

Bean Tepary Masa Harina Tapioca

Besan Meat (fresh) Tapioca Flour

Bicarbonate of Soda Methyl Cellulose (ˇ) Tea

(some contain gluten) Milk Tea-Tree Oil

Buckwheat Millet Teff

Butter (beware of additives) Milo Teff Flour

Canola Oil Mung Bean Tepary Bean

Carageenan Chondrus Crispus Nut, Acorn Tofu-Soya Curd

Carob Bean Nut, Almond Tragacanth

Carob Bean Gum Oats (ˇ) Tragacanth Gum

Carob Flour Oils & Fats Turmeric (Kurkuma)

Cassava Manihot Esculenta Peas Urad Beans

Cellulose(ˇ) Pea – Chick Urad Dal (peas) Vegetables

Cellulose Gum Pea – Cow Urid Flour

Cheeses (except blue & chilton) Pea Flour Vinegars (Specific Types)

Chickpea Pigeon Peas Waxy Maize

Corn Polenta Whey

Cornmeal Potatoes White Vinegar

Corn Flour Potato Flour Wines

Cornstarch Prinus Wine Vinegars (& Balsamic)

Corn Syrup Psyllium Wild Rice

Cowitch Quinoa Xanthan Gum

Cowpea Ragi Yam Flour

Cream of Tartar Rape Yogurt

Gluten-Free Food Additives

Adipic Acid Dioctyl Sodium Polysorbate 60; 80

Acacia Gum Elastin Potassium Citrate

Agar Ester Gum Potassium Iodide

Algin Folic Acid-Folacin Pristane

Alginate Formaldehyde Propolis

Allicin Fructose Propylene Gycol

Aluminium Fumaric Acid Monostearete

Annatto Color Gelatine Propylgallate

Arabic Gum Glutamine (amino acid) Pyridoxine Hydrochloride

Aspartame (can cause IBS Glutamic Acid Rennet

Symptoms) Glycerides Reticulin

Aspic Glyceryl Nono-Oleate Rosin

Ascorbic Acid Glycerol Mono-Oleate Royal Jelly

Benzoic Acid Glycol Sphingolipids

Bentaine Glycolic Acid Sodium Acid Pyraphosphate

BHA Guar Gum Sodium Ascorbate

BHT Hemp Sodium Benzoate

Beta Carotene Hydrogen Peroxide Sodium Citrate

Biotin Iodine Sodium Erythrobate

Butylated Hydroxyanisole Invert Sugar Sodium Hexametaphosphate

Butyl Compounds Keratin Sodium Lauryl Sulfate

Calcium Carbonate Lactic Acid Sodium Nitrate

Calcium Chloride Lactose Sodium Silaco Aluminate

Calcium Phosphate Lanolin Sodium Stannate

Calcium Silicate Lecithin Sorbic Acid

Calcium Stearate Lipase Sorbitol-Mannitol (can cause

Camphor Locust Bean Gum IBS symptoms)

Caprylic Acid Magnesium Carbonate Soy Lecithin

Carboxymethylcellulose Magnesium Hydroxide Stearates

Carnuaba Wax Malic Acid Stearamide

Carob Bean Gum Maltitol Stearamine

Carrageenan Microcrystallin Cellulose Stearic Acid

Casein Mineral Oil Sucrose

Castor Oil Mineral Salts Sulfosuccinate

Cellulose Gum Monosodium Glutamate Sulphites

Cetyl Alcohol MSG (Made in USA) Sulpur Dioxide

Chlorella Monopotassium Phosphate Tallow

Chymosin Musk Tartaric Acid

Citric Acid (Made in USA)ˇ M Vitamins & Minerals TBHQ is Tetra or

Collagen Niacin-Niacinamide Tributylhydroquinone

Corn Sweetener Oleyl Alcohol/Oil Thiamine Hydrochloride

Corn Syrup Solids Parrafin Tolu Balsam

Cortisone Pepsin Tragacanth Gum

Cotton Seed Oil Peru Balsam Tri-Calcium Phosphate

Cysteine, L Petrolatum Tyrosine

Demineralized Whey Phenylalanine Vanillan

Desamidocollagen Polyethylene Glycol Vitamin A (palmitate)

Dextrimaltose Polyglycerol Whey

Dextrose Polysorbates Xanthan Gum

Gluten-Containing Food Ingredients**

Abyssinian Hard (Wheat Germ

Triticum Duran) Glutamate (free) Small Spelt

Alcohol (Spirits-Specific Graham Flour Soba Noodlesˇ

Types) Granary Flour Sodium Caseinate

Artificial Flavoringˇ Gravy Cubesˇ (Contains MSG)

Baking Powderˇ Groats (barley, buckwheat Soy Sauce

Barley Grass (can contain Or oats) Spirits (Specific Types)

Seeds) Ground Spicesˇ Spelt Triticum Spelta

Barley Hordeum Vulgare Gum Base Sprouted Wheat Barley

Barley Malt Hard Wheat Starch (Outside USA)

Beer Hydrolyzed Plant Protein Stock Cubesˇ

Bleached Flour (HPP) Strong Flour

Blue Cheese (made from Hydrolyzed Vegetable Suet in Packets

Bread) Protein (HVP) Tabbouleh

Bran Kamut (Pasta Wheat) Teriyaki Sauce

Bread Flour Malt Textured Vegetable Protein

Brewer’s Yeast Malt Extract (TVP)

Brown Flour Malt Syrup Triticale X Triticosecale

Bulgar (Bulgar Wheat/Nuts) Malt Flavoring Udon (Wheat Noodles)

Bulgar Wheat Malt Vinegar Vegetable Starch

Calcium Caseinate Misoˇ Vinegars (Specific Types)

(contains MSG) Matzo Semolina Vitaminsˇ

Caramel Colorˇ Modified Food Starchˇ Wheat Triticum Aestivum

Cereal Binding Mono and Diglyceridesˇ Wheat Nuts

Chilton MSG (Made outside USA)ˇ Wheat, Abyssinian Hard

Citric Acid (made outside Mustard Powderˇ Triticum Durum

USA) Natural Flavoringˇ Wheat, Bulgar

Couscous Pasta Wheat, Durum Triticum

Dextrinsˇ Pearl Barley Wheat Triticum Mononoccum

Durum Wheat Triticum Rice Malt (contains barley Wheat Starchˇ

Edible Starch Or Koji) Wheat Germ

Einkorn Wheat Rye Wheat Grass (can contain

Farina Graham Semolina Triticum seeds)

Filler Semolina Whole-Meal Flour

Fu (dried wheat gluten) Shoyu (Soy Sauce)ˇ

**Some foods containing one of these ingredients may be gluten-free. However, you should

always check with the manufacturer on the gluten status of a food item if you see one of the

above ingredients listed.

Gluten-Free Snack Ideas

Gluten-Free Snack Ideas

Celery/Carrots Planters Dry Roasted Peanuts

Fritoes Cheetos

Ruffles Potato Chips Fruit roll-ups

Fruit chews/gushers Orville Reddenbacher Popcorn

Blue Diamond Crackers (Pecan) Mott’s Applesauce

Apples w/Skippy’s or Jiff Peanut



Hunts chocolate & vanilla pudding

Gluten-Free Birthday Treat Ideas

3 Muskateer Bars M&M’s (all flavors EXCEPT rice krispy)

Almond Joy O’Henry candy bars

Baby Ruth Popsicles & Freezes

Bit-O-Honey Raisinets

Butterfinger & Butterfinger BB’s Reese’s Peanut Butter Cups

Caramel Nips – Pearson Candy,

Hersheys caramels also ok

Reese’s pieces

Charm’s Blow Pops Smarties

Dum Dum Lollipops Starbursts

Gum – Bubble Yum Bubble Gum, Big


Skittles – all flavors

Goobers Spree

Hershey’s chocolate bars Sweetarts

Hershey Kisses Snicker Candy & Ice Cream Bars

Ice Cream – Kemps vanilla &

chocolate. Snickers ice cream bars.

Dairy Queen Starkiss. Snickers Ice

Cream Bars.

Tootsie Rolls + Tootsie Roll pops

Jelly belly jelly beans York Peppermint Patties

Jolly Ranchers & Jolly Rancher



-Necco Valentine Hearts

-Hershey Caramel Eggs

-Hershey Easter Eggs

-Candy Canes

-Jelly Belly Jelly Beans

-Peeps marshmallow animals

Junior Mints

Life Savers – all flavors + lollipops


Kool-Aid Play-Doh

This is not food!

1-1/2 cups GF flour

¼ cup salt

1-1/2 tsp. oil

1 pkg. Unsweetened Kool-Aid

1 cup boiling water

Mix and have fun! Will keep for weeks in covered container. Not necessary to

refrigerate. Can be stored in small freezer bags.

NOTE: If there are other medical conditions that you would like school staff to

be aware of, you may complete the following format and include in your

handbook. Otherwise, you may delete this page.

What is  _________________________?

What are the effects_____________?

Common Symptoms of _________?

What is the treatment___________?

____________________?Is there a cure

احصل على كود الصفحات المحجوبة

أو أحد الكتب الآن pls Note: "السعر مختلف لكل كتاب"




  1. Reply

    How can I tell if my children will be allergic to a dog’s hair. We want to get a puppy for them but just want to make sure we don’t give’em allergies.

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