An exponential boom in gluten-based illnesses has generated health crises for individuals and created challenges for camp food service grasping at how to serve these individuals.

Wheat, the most consumed grain in the US diet (along with barley and rye) contains the culprit for this rise: gluten. Wheat allergy, celiac disease (CD), and gluten sensitivity (clinically known as non-celiac gluten sensitivity or NCGS) are commonly known as “gluten-related disorders” (GRDs). However, the National Intitutes of Health (NIH) have now identified these conditions as “major types of diseases” (Asri et al., 2021).

A Mayo Clinic blood test study of transglutaminase antibodies comparing contemporary samples and 50-year-old blood samples showed that the prevalence of CD alone has increased 4.5 fold, or 400 percent within 50 years (Schuppan & Gisbert-Schuppan, 2019). The surge in GRDs has multiple reasons:

• Wheat cultivated in modern times contains a greater concentration of the highly toxic 33-mer gliadin peptide.
• Expanding use of pesticides has caused the growth of toxic gluten peptides.
• Wheat has also been modified to be more drought resistant.
• Digestive enzymes are less capable of digesting gluten proteins than other food proteins.
• Breads and baked products have a higher gluten content than in previous generations (Tovoli et al., 2015).

Gluten Defined

The common link in the three GRDs is gluten, a major protein in wheat containing glutenin and gliadin. In 2012, biochemists at Harvard Medical School in Boston discovered a group of proteins in wheat, barley, and rye called “amylase trypsin inhibitors.” The team, led by Detlef Schuppan of Johannes Gutenberg University Mainz reported that these proteins can provoke immune cells, triggering an immune reaction. The team’s research points to gluten-based carbs as indigestible for some (Servick, 2018).

A Spectrum of Gluten-Related Diseases

Individuals with these three different NIH classified diseases have the same instigator and share similar clinical presentations, which makes their different diagnoses perplexing.

Celiac disease 

CD is a permanent and serious inflammatory bowel disease caused by genetics, environmental factors, and gluten intolerance. It triggers inborn and adaptive self-destructive immune responses. Gliadin, a component of gluten, infiltrates the intestinal lining and causes small intestinal lesions, partial or complete intestinal villi atrophy, and nutrient malabsorption (Taraghikhah et al., 2020). The intestine ultimately loses its ability to retain nutrients, which can result in osteoporosis, chronic anemia, or nervous system damage. As there is currently no cure for CD, a lifelong gluten-free (GF) diet is required to avoid irreversible intestinal damage (Schuppan & Gisbert-Schuppan, 2019).

The University of Chicago Medicine’s Celiac Disease Center (2023) estimates that upwards of three million Americans have celiac disease.

CD is classified as an autoimmune disease (Taraghikhah et al., 2020).

Wheat allergy (WA) 

WA is one of the most common food allergies and a health problem worldwide. It can be caused by Immunoglobulin E (IgE) mediated or non-IgE mediated adverse allergic reactions to proteins contained in wheat. WA mostly occurs in children 3 to 16 years of age, and clinical symptoms differ depending on the route of exposure. In addition to provoking allergic reactions to the proteins that spark celiac disease responses — glutenin and gliadin — wheat allergy IgE antibodies also mediate allergic reactions to the wheat proteins albumin and globulin (Elli et al., 2015)

Wheat allergy symptoms present as: 

• Moderate-to-severe eczema
• Hives
• Angioedema (swelling around eyes, lips, hands, feet, or throat) 
• Bronchial (airway) obstruction
• Asthma
• Nausea
• Abdominal pain
• Anaphylaxis (in severe cases)

WA impacts 1–2 percent of the US population. Primarily affecting children, they typically outgrow it by school age (Patel & Samant, 2022).

Wheat allergy is classified as an allergic and nonautoimmune allergic disease (Taraghikhah et al., 2020).

Non-Celiac Gluten Sensitivity, aka Gluten Sensitivity or Gluten Intolerance

Patients with NCGS report a wide range of intestinal and extraintestinal symptoms arising shortly after the ingestion of foods containing gluten in the absence of celiac disease or wheat allergy. Contrary to CD and WA, NCGS offers no clear serologic or histopathologic criteria for clinicians to confirm the diagnosis, although the presence of antigliadin Immunoglobulin G (IgG) has been reported in up to 50 percent of patients. Further, IgG antigliadin antibodies have been found in up to 56 percent of NCGS cases, compared to 2–8 percent of the general population, proving that NCGS is a veritable illness (Taraghikhah et al., 2020).

A small subset of NCGS patients have shown an increase in the number of lymphocytes infiltrating the epithelium, indicating intestinal damage. Conflicting research points to an immune reaction or indigestible carbs (Servick, 2018).

NCGS patients are prescribed a “diet of exclusion,” which is made after other wheat-related and nonwheat-related disorders have been ruled out. NCGS is often described as an irritable bowel syndrome (IBS)-like entity based on symptoms, particularly IBS with diarrhea, and is more common in adult females by six to one. Its prevalence is an estimated 6 percent of the general population (Igbinedion et al., 2017).

NCGS is classified as an allergic and nonautoimmune allergic disease (Taraghikhah et al., 2020).

Conversely, some clinicians say that NCGS refers to a reaction to gluten leading to intestinal and extraintestinal manifestations that are not mediated by an allergic or immunologic response (Taraghikhah et al., 2020).

Accommodate Your Non-Gluten Guests

Camp administrators and food service professionals sometimes view accommodating gluten-free diets as a hardship or inconvenience because of food or staffing cost. Others see it as an unnecessary extra step because of the mistaken belief that it is only a fad or a lifestyle change rather than a proper dietary treatment. However, gluten-related disorders are real allergies and illnesses, and we must endeavor to accommodate gluten-free diets on the following grounds:

• Health and wellness: Just as we would accommodate a child who needs a wheelchair in order to be mobile, we should accommodate a child who needs special foods in order to stay well. Ensure your campers and staff experience wellness. When our gluten-free guests find little or no edible menu options, they face lack of nutrition, hunger, fatigue, or headaches, which affects their overall camp experience. CD can provoke serious illness, and children with WA are more susceptible to experience ER visits from symptoms.
• Inclusion: We should desire our guests and staff to feel included. When all other guests enjoy pasta with marinara, a salad, and garlic knots, and our gluten-free diners are left to eat just a salad, inclusion is not a priority.
• Hospitality: We are in the hospitality industry with an element of customer service. Are we engaged in customer service and expressing customer service when we ask our guests to bring and prepare their own food in a microwave, while our staff serve other campers a full, hot menu?

Consider these cost-reduction possibilities. Allocate a percentage of your food service budget for gluten-free items, perhaps a minimum of 5 percent. Seek donors for gluten-free foods, or contact gluten-free manufacturers to see if they’d be willing to donate a case if you buy a case. Assess a gluten-free upcharge as national restaurants do. Build an internship position solely for GF/allergy food prep or a combination of camp duties. Interns could be university nutrition or culinary majors, registered dietician candidates needing an internship, or a local individual already familiar with gluten-free cooking.

Have a Gluten-Free Game Plan

Consider one or a combination of the following game plans:

1. Prepare and plate gluten-free meals separately. Use specifically trained cooking staff in a specifically gluten-free area of your kitchen, with cookware, utensils, and dinnerware designated for gluten-free diners to avoid cross contamination. Covered gluten-free plates should be held in separate warm-hold and cold-hold units. (Remember, this will likely only be an estimated 1 in every 13 campers. This is possible at many camps, with a little foresight, creativity, and a modestly allocated budget.)
2. Make meals gluten free by supplementing. Provide gluten-free pasta, breads, pancakes, and desserts for GF diners if those items are on your regular menu. Remember, there are excellent-quality gluten-free breads that you can freeze until needed, as well as pancake and cake mixes and pastas. Keep these items separated in bins with lids, and prepare in a gluten-free kitchen area to prevent cross contamination.
3. Prepare mostly gluten-free meals. Use mostly naturally gluten-free foods, minimizing the need to supplement meals with non-gluten items. Find ways to de-gluten your recipes, such as using gluten-free cream of chicken/mushroom soup. The chef in you may even enjoy baking a delicious gluten-free sourdough bread with a one-to-one replacement flour such as Bob’s Red Mill, flourless gluten-free brownies, or simply provide low-cost, gluten-free graham crackers to roast s’mores.

Always read ingredient labels. Use the following gluten avoidance lists as references:

Wheat Allergy Avoidance List

• Bran
• Bread crumbs
• Bulgur
• Cereal extract
• Couscous
• Cracker meal
• Durum/Durum flour
• Einkorn
• Emmer (aka farro)
• Enriched flour
• Farina
• Flour (Atta, club, common, kamut, maida, semolina, spelt, triticale, triticum)
• Flour (All purpose, bread, bromeated, cake, enriched, high gluten, high protein, instant pastry, phosphates, plain, soft wheat, steel ground, stone ground, self-rising, unbleached, white, whole wheat)
• Fu (processed, solidified wheat gluten powder or blocks used in Japanese cooking)
• Graham flour
• High gluten flour
• High protein flour
• Kamut — Khorasan wheat
• Malt, malt extract
• Matzo, matzo meal, matzoh, matza
• Noodles
• Seitan
• Semolina
• Soft wheat flour
• Spelt
• Tabbouleh
• Vital gluten
• Wheat (bran, gluten, germ, malt, starch, whole wheat berries, whole wheat flour, whole wheat bread, wheat germ oil, wheat protein isolate, wheat sprouts, sprouted wheat, wheat grass)

May Contain Wheat Protein

• Artificial flavoring
• Caramel color
• Dextrin
• Food starch, gelatinized starch, modified starch, modified food starch, vegetable starch
• Glucose syrup
• Hydrolyzed vegetable protein (HVP)
• Maltodextrin
• Matzoh
• Modified food starch
• Monosodium glutamate (MSG)
• Natural flavoring
• Oats
• Soy sauce, shoyu, tamari, teriyaki sauce
• Starch
• Surimi
• Textured vegetable protein
• Vegetable gum
• Vegetable starch

Frequently Found in These Packaged Foods

• Beers, ales, and malt beverages and vinegars
• Baked goods and mixes
• Breads — croissants, pita, naan, bagels, flatbreads, cornbread, potato bread
• Breakfast foods — pancake and waffle mixes, French toast, crepes, biscuits
• Cake, pie, cookies, crackers, muffins, donuts
• Candy
• Cereal/granola, energy bars — corn flakes and rice cereals sometimes contain malt extract/flavoring. Granola is often made with regular oats instead of gluten-free oats
• Crackers — graham crackers, cheese crackers
• Flour tortillas
• French fries — some are covered with batter. Many are cross contaminated from frying in the same fryer as nongluten-free foods
• Multigrain or “artisan” tortilla chips or tortillas
• Noodles — ramen, udon, soba, chow mein, egg noodles
• Pretzels
• Salad dressings/marinades — can contain malt vinegar, soy, soy sauce, or flour
• Sauces and gravies — wheat flour is usually the base ingredient
• Self-basting poultry
• Soups — most cream-based soups contain flour as a thickener, and some contain barley
• Soy sauce
• Starch or dextrin found on a meat or poultry product
• Pastas including gnocchi
• Potato chips — may contain malt vinegar or wheat starch
• Pre-seasoned meats, processed lunch meats, breaded meats, meat casseroles
• Vegetarian meat substitutes — some are made with seitan (wheat gluten)

Non-Wheat Gluten Sources

• Barley
• Brewer’s yeast
• Malt in various forms: malted barley flour, malted milk or Milkshakes, malt extract, malt syrup, malt flavoring, malt vinegar
• Rye
   

References

• Asri, N., Rostami-Nejad, M., Anderson, R. P., & Rostami, K. (2021). The Gluten Gene: Unlocking the Understanding of Gluten Sensitivity and Intolerance. The application of clinical genetics, 14, 37–50. doi.org/10.2147/TACG.S276596
• Elli, L., Branchi, F., Tomba, C., Villalta, D., Norsa, L., Ferretti, F., Roncoroni, L., & Bardella, M. T. (2015). Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity. World Journal of Gastroenterology, 21(23), 7110–7119. doi.org/10.3748/wjg.v21.i23.7110
• Igbinedion, S. O., Ansari, J., Vasikaran, A., Gavins, F. N., Jordan, P., Boktor, M., & Alexander, J. S. (2017, October 28). Non-celiac gluten sensitivity: All wheat attack in not celiac. World Journal of Gastroenterology. ncbi.nlm.nih.gov/pmc/articles/PMC5677194/#__ffn_sectitle
• Patel, N. & Samant, H. (2022, May 30). Wheat allergy. StatPearls Publishing ncbi.nlm.nih.gov/books/NBK536992/
• Schuppan, D. & Gisbert-Schuppan, K. (2019). Wheat syndromes: How wheat, gluten and ATI cause inflammation, IBS, and autoimmune diseases. Springer Nature Switzerland AG, Switzerland.
• Servick, K. (2018, May 23). What’s really behind gluten sensitivity? Conflicting research points to an immune reaction or indigestible carb. Science. science.org/content/article/what-s-really-behind-gluten-sensitivity
• Taraghikhah, N., Ashtari, S., Asri, N., Shahbazkhani, B., Al-Dulaimi, D., Rostami-Nejad, M., Rezaei-Tavirani, M., Razzaghi, M. R., & Zali, M. R. (2020). An updated overview of spectrum of gluten-related disorders: Clinical and diagnostic aspects. BMC Gastroenterology. bmcgastroenterol.biomedcentral.com/articles/10.1186/s12876-020-01390-0
• Tovoli, F., Masi, C., Guidetti, E., Negrini, G., Paterini, P., & Bolondi, L. (2015). Clinical and diagnostic aspects of gluten related disorders. World Journal of clinical cases, 3(3), 275–284. https://doi.org/10.12998/wjcc.v3.i3.275
• University of Chicago Medicine Celiac Disease Center. (2023). Celiac disease facts and figures. cureceliacdisease.org/wp-content/uploads/341_CDCFactSheets8_FactsFigures.pdf

Kimberly Whiteside Truitt is former food service manager at Camp Gilmont and Camp Zephyr and has served on Camping Magazine’s Editorial Advisory Committee. Kimberly was a presenter at the 2018, 2020, and 2023 North American Food Service and Maintenance Conferences.