By Leesha Lentz
Patients with celiac disease often ask dietitians about gluten-free meal planning and preparation and strategies for dining out. But what many clients may not realize is that gluten can hide in nonfood products they may use every day, and also must avoid.
There are recommendations for following a gluten-free diet and rules food manufacturers must adhere to when promoting products as gluten-free, but there are no clear, easy-to-follow rules for nonfood items, says Marlisa Brown, MS, RD, CDE, CDN, author of Gluten-Free, Hassle-Free and president of Total Wellness. And yet many ingestible nonfood products, such as supplements, drugs, lipstick, and toothpaste, may contain gluten and cause problems for those with celiac disease.
As a result, it’s important for RDs to understand how to counsel clients and patients on what to look for when purchasing nonfood items, and offer gluten-free alternatives. The following strategies will help dietitians do just that.
Recommendations
• Supplements and vitamins: “I tell clients to look for supplements that have gluten-free mentioned on the label,” Brown says. “And if it doesn’t have that, I suggest they contact the manufacturer, because ingredients change. If the manufacturer doesn’t have a clear answer, then the product may not be safe. Usually the companies that have checked the supplement are pretty definitive in their answers.”
Alice Bast, CEO and president of the National Foundation for Celiac Awareness (NFCA), says that the NFCA doesn’t recommend specific brands of vitamins or supplements because formulations change, but she agrees that clients and patients should contact the manufacturer to verify whether they’re safe for use, and look for certain excipients used as binders (ie, inactive ingredients) on the labels, such as modified starch, pregelatinized starch, dextrates, dextrimaltose, dextrin, and caramel coloring, which may contain gluten. “Some of the supplements and vitamins are starting to get their products gluten-free certified, but if they’re reading the ingredients, gluten can be sneaky,” she explains.
• Lipstick: Brown says that if the client doesn’t reapply lipstick much during the day, it’s unlikely that the product would be harmful, even if it contained more than 20 parts per million of gluten. But if clients or patients are uncertain or if the label doesn’t specify whether or not the lipstick contains gluten, they should contact the manufacturer.
• Dental products: “We tell people to look for the toothpaste that’s as pure as possible. It’s important for them to make sure that their toothpaste is gluten-free, because it’s something that’s going in their mouths,” Bast says.
“I called several toothpaste manufacturers, and I haven’t had any company tell me that their product had gluten in it, which is a good sign,” Brown says. “But I’ve had difficulty with some of the mouth rinses, and the companies weren’t able to answer me. It could have been just the person who was talking to me, but how is the consumer supposed to know?”
Bast refers to an “Answers from a Dietitian” blog post on the NFCA website, in which Rachel Begun, MS, RD, an NFCA medical/scientific advisory council member, lists several gluten-containing ingredients that may be hidden in dental and cosmetic products, such as wheat germ oil and barley extract. For the full list, clients and patients can access the webpage at www.celiaccentral.org/ask-the-dietitian/hidden-gluten-in-dental-and-cosmetic-products.
Brown also warns clients and patients not to rely on information found in blog reviews alone, especially from questionable websites, as they can be misleading since some may be accurate and others may not.
In the NFCA blog post, Begun also suggests that clients and patients call their dentist’s office ahead of an appointment to let the staff know they cannot use any gluten-containing products. For example, a young boy with celiac disease became sick after receiving braces, because the rubber bands on the braces were coated in a gluten-containing anticaking agent, Brown says.
• Drugs: The NFCA surveyed 5,623 of its website users and others in the celiac disease community and found that about 25% said they believed they had a reaction to some medication, Bast says. As of August 2014, the FDA issued gluten-free labeling standards for foods, but this regulation doesn’t extend to prescription or over-the counter drugs, which also can use gluten-containing starches as inactive ingredients.
“Medications don’t fall under the same guidelines as foods do, because they aren’t being regulated,” Brown says. She recommends patients with celiac disease check with a pharmacist before taking any medication. Brown also suggests patients visit the website glutenfreedrugs.com for a list of gluten-free medications and an explanation of fillers and other ingredients they may contain.
Support From RDs
Because of the lack of information on some labels and the changing nature of formulations of nonfood items, it’s imperative for patients with celiac disease to garner support. The NFCA has received a grant from the FDA to study which medications contain gluten, and hosted a research summit last month to bring researchers and patients together to discuss the issues surrounding gluten-containing products and how to reduce the day-to-day challenges of living with celiac disease.
In a study published in the September 2014 issue of the American Journal of Gastroenterology, Shah and colleagues noted that patients with celiac disease have a high treatment burden because of their necessary lifelong adherence to a gluten-free diet. Patients with celiac disease were perceived to have the most difficulty managing their illness compared with other chronic medical conditions. Therefore, Bast says it’s important for patients to talk to their physicians and dietitians to discuss their specific needs and gain their support.
When patients must be cognizant of everything they put into their mouths from the moment they wake up until the time they go to bed, they can feel overwhelmed, Bast says. RDs can help reduce the stress by working with patients and providing them with important information regarding the foods and nonfood products they can eat and use each day.
— Leesha Lentz is a freelance writer based in Pottstown, Pennsylvania.
