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Its a piece of cake How Certified Dietary Managers can ensure that they are serving gluten free meals Roberta Tripp MS RD LDN Clinical Nutrition Manager.

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Presentation on theme: "Its a piece of cake How Certified Dietary Managers can ensure that they are serving gluten free meals Roberta Tripp MS RD LDN Clinical Nutrition Manager."— Presentation transcript:

1 Its a piece of cake How Certified Dietary Managers can ensure that they are serving gluten free meals Roberta Tripp MS RD LDN Clinical Nutrition Manager Sodexo at PinnacleHealth Harrisburg PA

2 Objectives To provide more in depth knowledge to CDMs who already have a basic knowledge of gluten intolerance and celiac disease To provide more in depth knowledge to CDMs who already have a basic knowledge of gluten intolerance and celiac disease To discuss which residents may be on a gluten free diet in addition to those with diagnosed celiac disease. To discuss which residents may be on a gluten free diet in addition to those with diagnosed celiac disease. To explain about the special products, cooking and serving procedures involved To explain about the special products, cooking and serving procedures involved To provide a list of resources for use when working with residents on a gluten free diet. To provide a list of resources for use when working with residents on a gluten free diet. To help CDMs do a better job of ensuring no cross contamination occurs in their kitchens when they must ensure a patient receives gluten free food To help CDMs do a better job of ensuring no cross contamination occurs in their kitchens when they must ensure a patient receives gluten free food

3 Definition of Celiac Disease An immune-mediated disease triggered by the ingestion of gluten-containing grains (wheat, rye, barley) in genetically susceptible individuals. An immune-mediated disease triggered by the ingestion of gluten-containing grains (wheat, rye, barley) in genetically susceptible individuals. In celiac disease gluten causes damage to the small intestine which affects its ability to absorb nutrients. In celiac disease gluten causes damage to the small intestine which affects its ability to absorb nutrients.

4 Gluten Gluten, a protein found in wheat, barley, and rye, forms when water is added and the protein molecules glutanin and gliadin combine. Gluten, a protein found in wheat, barley, and rye, forms when water is added and the protein molecules glutanin and gliadin combine. Gluten gives dough its sticky and pliable consistency. Gluten gives dough its sticky and pliable consistency.

5 It Takes A Villi Damaged Damaged Healthy Healthy

6 Can any amount of gluten be harmful? As of October 2009 there is no safe level of gluten yet established for people with celiac disease. Sensitivity may vary but as far as food preparation and service are concerned, even very small amounts of gluten can be harmful. As of October 2009 there is no safe level of gluten yet established for people with celiac disease. Sensitivity may vary but as far as food preparation and service are concerned, even very small amounts of gluten can be harmful. Catassi and colleagues (Am J Clin Nutr 2007; 85: ) found no significant change in villous height/crypt depth ratio in participants consuming 10 mg gluten per day Catassi and colleagues (Am J Clin Nutr 2007; 85: ) found no significant change in villous height/crypt depth ratio in participants consuming 10 mg gluten per day

7 Classic Adult Onset Symptoms Diarrhea Diarrhea Constipation Constipation Gas and bloating Gas and bloating Abdominal pain Abdominal pain Nausea and vomiting Nausea and vomiting Reflux Reflux

8 Atypical Adult Onset Symptoms Anemia Anemia Bone and joint pain Bone and joint pain Osteoporosis/osteopenia Osteoporosis/osteopenia Chronic hepatitis Chronic hepatitis Infertility/recurrent miscarriages Infertility/recurrent miscarriages Mouth ulcers Mouth ulcers

9 Symptoms in Children Delayed puberty Delayed puberty Dental enamel defects Dental enamel defects Diarrhea/constipation Diarrhea/constipation Difficulty in learning Difficulty in learning Failure to thrive Failure to thrive Short Stature Short Stature

10 Autoimmune Disorders Associated with Celiac Disease Autoimmune hepatitis Autoimmune hepatitis Downs syndrome, IBD, Crohns Disease Downs syndrome, IBD, Crohns Disease Rheumatoid Arthritis Rheumatoid Arthritis Sjogrens Syndrome Sjogrens Syndrome Thyroid Disease Thyroid Disease Type I diabetes Type I diabetes

11 Intestinal Cancer and Celiac Disease A type of non Hodgkins lymphoma that develops in the small bowel is one of the most common causes of death in people with celiac disease.

12 The Hidden Epidemic The title of Dr. Peter H. Greens book Celiac Disease: The Hidden Epidemic serves as an unfortunate answer to the question If there are so many people with gluten intolerance and celiac disease, where are they? It has been estimated that 97% of people with celiac disease dont know they have it. The title of Dr. Peter H. Greens book Celiac Disease: The Hidden Epidemic serves as an unfortunate answer to the question If there are so many people with gluten intolerance and celiac disease, where are they? It has been estimated that 97% of people with celiac disease dont know they have it.

13 The average celiac goes eleven years prior to being diagnosed Symptoms such as diarrhea, gas, bloating, and abdominal pain are often wrongly diagnosed as irritable bowel syndrome (and ironically, patients are told to eat more fiber, which usually translates to whole wheat and bran!) Symptoms such as diarrhea, gas, bloating, and abdominal pain are often wrongly diagnosed as irritable bowel syndrome (and ironically, patients are told to eat more fiber, which usually translates to whole wheat and bran!)

14 Not everyone who avoids gluten has celiac disease At least 1 out of every 133 people have celiac disease in the US (3 million people) At least 1 out of every 133 people have celiac disease in the US (3 million people) As many as 13 million people have other forms of gluten sensitivity As many as 13 million people have other forms of gluten sensitivity Approximately 6 million people claim to have a wheat allergy in this country Approximately 6 million people claim to have a wheat allergy in this country Therefore the total number of people who need to follow a GF diet could be as high as 22 million in the United States (about 1 out of every 13 people). Therefore the total number of people who need to follow a GF diet could be as high as 22 million in the United States (about 1 out of every 13 people). Parents of children with Autism Spectrum Disorder may want the child on a gluten free (and casein free) diet even though this approach to treating ASD is unproven. Parents of children with Autism Spectrum Disorder may want the child on a gluten free (and casein free) diet even though this approach to treating ASD is unproven.

15 What Grains are Gluten Free? Amaranth Amaranth Arrowroot Arrowroot Buckwheat Buckwheat Corn Corn Flax Flax Millet Millet Montina Montina Potato Potato Quinoa Quinoa Rice Rice Sorghum Sorghum Tapioca Tapioca Teff Teff Flours made from nuts, seeds, and beans (garfava, soy flour) Flours made from nuts, seeds, and beans (garfava, soy flour)

16 What About Oats? Oats that are uncontaminated by gluten containing grains are usually tolerated by individuals with celiac disease or gluten intolerance. Oats that are uncontaminated by gluten containing grains are usually tolerated by individuals with celiac disease or gluten intolerance. The recommendation is to introduce oats gradually and slowly into the gluten free diet after consulting your physician. The recommendation is to introduce oats gradually and slowly into the gluten free diet after consulting your physician. These certified gluten free oats are available from 4 suppliers in North America (www.bobsredmill.com, These certified gluten free oats are available from 4 suppliers in North America (www.bobsredmill.com, and ) and )

17 Surprisingly gluten free MSG MSG Corn gluten Corn gluten Vegetable broth Vegetable broth Glutinous rice Glutinous rice

18 Food labels: youre confusing me with the facts In the US, foods are either under the jurisdiction of the Food and Drug Administration (FDA) or the USDA FSIS (United States Department of Agriculture Food Safety and Inspection Service). In the US, foods are either under the jurisdiction of the Food and Drug Administration (FDA) or the USDA FSIS (United States Department of Agriculture Food Safety and Inspection Service). The FDA regulates all foods except meat, poultry, and egg products, which are under FSIS jurisdiction. The FDA regulates all foods except meat, poultry, and egg products, which are under FSIS jurisdiction. Each of these agencies has different policies regarding food labeling. Each of these agencies has different policies regarding food labeling.

19 FDAs Food Allergens Labeling and Consumer Protection Act (FALCPA) In 2004, the Food and Drug Administration, which regulates most of the food supply, enacted a new a regulation known as FALCPA that requires that 8 known allergens, including wheat, be declared in plain English terms on the label of all packaged goods they regulate.

20 Because of FALCPA, in FDA regulated foods, you dont have to worry about…

21 Modified food starch In the US and Canada if a food starch in an FDA regulated food is made from wheat the label would have to say so In the US and Canada if a food starch in an FDA regulated food is made from wheat the label would have to say so Rye and barley are not used to make food starch Rye and barley are not used to make food starch

22 Maltodextrin, dextrin, or hydrolyzed vegetable protein If any of these are made from wheat the ingredient list would have to state this fact (in the US and Canada). If any of these are made from wheat the ingredient list would have to state this fact (in the US and Canada).

23 Vinegar or Alcohol Distillation proteins are too large to pass through the distillation process (this includes gluten). All vinegars are distilled and are therefore gluten free except Malt Vinegar (has added malt from barley)

24 USDA Regulation Foods regulated by the USDA FSIS (meat, poultry, and processed egg products) are not covered by this regulation and therefore could contain hidden gluten from wheat. Neither agency has to disclose barley, oats, or rye on an ingredient label.

25 USDA Rule To be consistent with FALCPA, the USDAs Food Safety and Inspection Service is undertaking rulemaking to adopt the FALCPA requirements for the products it regulates. Currently FSIS permits voluntary allergens labeling. To be consistent with FALCPA, the USDAs Food Safety and Inspection Service is undertaking rulemaking to adopt the FALCPA requirements for the products it regulates. Currently FSIS permits voluntary allergens labeling.

26 Labeling requirements for allergens to extend to meat, poultry, and egg products When the USDA regulation is enacted, labels on meat, poultry, and egg products regulated by FSIS will be required to state if wheat is an ingredient. When the USDA regulation is enacted, labels on meat, poultry, and egg products regulated by FSIS will be required to state if wheat is an ingredient. Presently it is recommended that the manufacturer be contacted if there are any ingredients listed on meat, poultry, or egg products that are questionable to make sure they come from a gluten free source. Presently it is recommended that the manufacturer be contacted if there are any ingredients listed on meat, poultry, or egg products that are questionable to make sure they come from a gluten free source.

27 Its wheat free, but is it gluten free? At this time there is no universally agreed upon definition of the term gluten free. At this time there is no universally agreed upon definition of the term gluten free. The FDA is working on defining this term. The FDA is working on defining this term. The proposed FDA rule says that gluten free foods must contain less than 20 parts per million gluten. The proposed FDA rule says that gluten free foods must contain less than 20 parts per million gluten. 10 ounces of grain foods containing 20 ppm gluten would contain 5.70 mg gluten. 10 ounces of grain foods containing 20 ppm gluten would contain 5.70 mg gluten.

28 Foods from Europe Codex, the organization responsible for regulations regarding food labeled gluten-free in many European countries, has finalized a rule that these foods, including those made from wheat starch, will contain no more than 20 parts per million gluten. Codex, the organization responsible for regulations regarding food labeled gluten-free in many European countries, has finalized a rule that these foods, including those made from wheat starch, will contain no more than 20 parts per million gluten. For gluten-free foods containing wheat starch this is a much lower amount than the previously allowed amount of 200 and 100 parts per million gluten. For gluten-free foods containing wheat starch this is a much lower amount than the previously allowed amount of 200 and 100 parts per million gluten.

29 Ingredients Worth Questioning

30 Soup, bouillon, broth, and soup base Soup and stocks (including au jus, broth, and bouillon) may contain gluten so ingredients should always be checked. Soup and stocks (including au jus, broth, and bouillon) may contain gluten so ingredients should always be checked. Some soups are USDA regulated so wheat might not be disclosed on the labelcheck with the company. Some soups are USDA regulated so wheat might not be disclosed on the labelcheck with the company.

31 Soy Sauce Soy sauce usually contains wheat in addition to soy, and therefore may contain gluten. Check the label. Soy sauce usually contains wheat in addition to soy, and therefore may contain gluten. Check the label. If a non-FDA regulated product contains soy sauce (Chinese take out food, for example) it would not have to state it contains wheat if it did. If a non-FDA regulated product contains soy sauce (Chinese take out food, for example) it would not have to state it contains wheat if it did.

32 Spices and Seasonings Pure spices and herbs are gluten free Pure spices and herbs are gluten free Seasoning blends may contain gluten from anti-caking or flow agents. If these additives are present it will be clearly labeled on the package if they are derived from wheat and should therefore be avoided. Seasoning blends may contain gluten from anti-caking or flow agents. If these additives are present it will be clearly labeled on the package if they are derived from wheat and should therefore be avoided.

33 Talking Turkey Because fresh and frozen turkeys are under jurisdiction of the USDA, any injected basting solution containing gluten would not have to be disclosed on the label Because fresh and frozen turkeys are under jurisdiction of the USDA, any injected basting solution containing gluten would not have to be disclosed on the label It is recommended to contact the company to verify the turkeys gluten free status. It is recommended to contact the company to verify the turkeys gluten free status.

34 Dont be so crabby Imitation seafood (surimi or Sea Legs) contains wheat but since it is a USDA regulated food does not need to state so on the label. Imitation seafood (surimi or Sea Legs) contains wheat but since it is a USDA regulated food does not need to state so on the label.

35 Theres gluten in that?? All Kelloggs dry ready-to-eat cereals contain gluten in some form (either barley malt, wheat, oats that have not been certified gluten free, or wheat starch). All Kelloggs dry ready-to-eat cereals contain gluten in some form (either barley malt, wheat, oats that have not been certified gluten free, or wheat starch). Some premade hamburger or turkey burger patties contain wheat but may not state it on the label Some premade hamburger or turkey burger patties contain wheat but may not state it on the label Seasoned French fries or batter dipped fries; Rice-a-Roni Seasoned French fries or batter dipped fries; Rice-a-Roni

36 More possible hidden gluten Some egg substitutes Some egg substitutes Flourless chocolate cake (may be made in a floured pan) Flourless chocolate cake (may be made in a floured pan) Some shredded cheese (may be dusted with flour) Some shredded cheese (may be dusted with flour) Some dried fruit Some dried fruit Some canned beans Some canned beans

37 More ingredients to look for and avoid Natural flavorings (rarely from wheat) Natural flavorings (rarely from wheat) Malt/Malt Extract, barley malt, or barley malt extract Malt/Malt Extract, barley malt, or barley malt extract Brown Rice Syrup (may be made with barley) Brown Rice Syrup (may be made with barley) Modified hop extract Modified hop extract

38 Marinades Many marinades contain soy sauce or other gluten containing ingredients Many marinades contain soy sauce or other gluten containing ingredients Most beer is made with barley malt so any marinade containing beer probably contains gluten Most beer is made with barley malt so any marinade containing beer probably contains gluten Patients who have been on a gluten free diet may be skeptical that they are being served food that is indeed gluten free. They will appreciate it if after you have checked and verified the marinade is gluten free, you reassure them that you have done so. Patients who have been on a gluten free diet may be skeptical that they are being served food that is indeed gluten free. They will appreciate it if after you have checked and verified the marinade is gluten free, you reassure them that you have done so.

39 Understanding the gluten free diet is everything: the role of the CDM Because there is no medication that will cure someone with celiac disease or gluten intolerance, the CDM, acting as a liaison between the food preparation area and the patient, has a tremendous opportunity to positively impact the meal service experience for the patient or resident on a gluten free diet. Because there is no medication that will cure someone with celiac disease or gluten intolerance, the CDM, acting as a liaison between the food preparation area and the patient, has a tremendous opportunity to positively impact the meal service experience for the patient or resident on a gluten free diet.

40 Do You Really Have a Gluten Free Diet? If your diet manual allows Rice Krispies or Kelloggs Corn Flakes on your gluten free diet, its time to revise it. If your diet manual allows Rice Krispies or Kelloggs Corn Flakes on your gluten free diet, its time to revise it. Every department in your organization needs to understand what gluten free means Every department in your organization needs to understand what gluten free means Activities Departmentcookies, etc Activities Departmentcookies, etc Nursing– snacks from a pantry and med pass Nursing– snacks from a pantry and med pass Pharmacy – are the drugs and vitamins GF? Pharmacy – are the drugs and vitamins GF? Chaplain – communion wafers Chaplain – communion wafers

41 What if the resident demands something with gluten? If it is documented that they are on a GF diet, you should not send any food containing gluten without documentation by Nursing of the choice to be noncompliant If it is documented that they are on a GF diet, you should not send any food containing gluten without documentation by Nursing of the choice to be noncompliant

42 Is Your GF Diet Nutritionally Adequate? Does it provide enough calories? If you dont appropriately substitute when you take a gluten containing food off the menu, you could be deficient. Does it provide enough calories? If you dont appropriately substitute when you take a gluten containing food off the menu, you could be deficient.

43 Give Your Cooks Guidance Dont just use your regular menu and expect them to adjust each selection to GF. What happens if there is 1 cookie on the menu and you dont have GF cookies? Dont just use your regular menu and expect them to adjust each selection to GF. What happens if there is 1 cookie on the menu and you dont have GF cookies? Review products like your soup basedoes it contain gluten? Review products like your soup basedoes it contain gluten? How often do items like meatloaf, Sloppy Joes, or meat balls come up and do you have a substitute available? How often do items like meatloaf, Sloppy Joes, or meat balls come up and do you have a substitute available?

44 Gravy and bacon bits Make sure your cooks know how to make a gluten free gravy. They can use cornstarch and gluten free soup base. Make sure your cooks know how to make a gluten free gravy. They can use cornstarch and gluten free soup base. Some bacon bits are not actually bacon and may contain wheat Some bacon bits are not actually bacon and may contain wheat

45 GF products are generally not enriched… All wheat flour in this country is enriched with B vitamins, folate and iron All wheat flour in this country is enriched with B vitamins, folate and iron Most GF foods are low in fiber unless they are made with garbanzo bean flour or flax Most GF foods are low in fiber unless they are made with garbanzo bean flour or flax The GF resident is at risk of deficiencies unless you give like substitutions with these nutrients The GF resident is at risk of deficiencies unless you give like substitutions with these nutrients

46 What should the Activity Director know Rice Krispies Treats are NOT gluten free Rice Krispies Treats are NOT gluten free Neither is Play Doh or paper mache Neither is Play Doh or paper mache These items should be substituted with similar nutrition These items should be substituted with similar nutrition

47 To oats or not to oats? (with apologies to Shakespeare) Until the dietitian or RN puts it in writing, the following should not be served oats, even if they are certified gluten free – just in case the pt actually has celiac disease Until the dietitian or RN puts it in writing, the following should not be served oats, even if they are certified gluten free – just in case the pt actually has celiac disease Wheat allergy Wheat allergy Gluten free Gluten free no bread no bread wheat free wheat free

48 If the resident can have oats, what kind should I give them?

49 Rice cakes AGAIN??!! What residents on a gluten free diet want Meals that are gluten free by substitution, not by elimination Meals that are gluten free by substitution, not by elimination Food that is good tasting, not just gluten free Food that is good tasting, not just gluten free As much variety as possible As much variety as possible Most importantly: residents want to trust that the food is gluten free when you say it is Most importantly: residents want to trust that the food is gluten free when you say it is

50 Your Kitchen Staff Needs to Know Patients arent being high maintenance or picky when they are checking to make sure their meals are gluten free. They are trying not to get sick. Patients arent being high maintenance or picky when they are checking to make sure their meals are gluten free. They are trying not to get sick. Something may seem obvious to you (someone who needs to avoid wheat cant eat white bread as well as wheat bread) that isnt obvious to a kitchen employee Something may seem obvious to you (someone who needs to avoid wheat cant eat white bread as well as wheat bread) that isnt obvious to a kitchen employee Have a dual person check for safest tray accuracy Have a dual person check for safest tray accuracy

51 Handling gluten free ingredients in a non gluten free kitchen Food and beverage consumption should not be allowed where the food is produced Food and beverage consumption should not be allowed where the food is produced Clean lab coats, aprons, and gloves are important Clean lab coats, aprons, and gloves are important Equipment should be clearly marked and separate Equipment should be clearly marked and separate Storage, preparation, and serving areas should be separatebest practice would be controlled air flow between the two production areas Storage, preparation, and serving areas should be separatebest practice would be controlled air flow between the two production areas Gluten containing foods should be stored below gluten free foods to decrease the possibility of contamination Gluten containing foods should be stored below gluten free foods to decrease the possibility of contamination Your staff should always be mindful of preventing cross contamination. Your staff should always be mindful of preventing cross contamination.

52 Cross Contamination: What You Cant See CAN Hurt You Because even a miniscule amount of gluten containing ingredients can damage the small intestine of a person with celiac disease, health care food service departments have to be especially diligent in not cross contaminating gluten free meals. Because even a miniscule amount of gluten containing ingredients can damage the small intestine of a person with celiac disease, health care food service departments have to be especially diligent in not cross contaminating gluten free meals.

53 Its as easy as sliced br…uh… If it doesnt make sense to have a separate toaster for gluten free bread, use foil and toast it in the oven. If it doesnt make sense to have a separate toaster for gluten free bread, use foil and toast it in the oven. Do you use a bucket with cleaner and a cloth to wipe tables? Do you clean a table and then dip the rag back in the bucket after it has cleaned up a table with wheat crumbs on it? You have just contaminated the surface with gluten. Do you use a bucket with cleaner and a cloth to wipe tables? Do you clean a table and then dip the rag back in the bucket after it has cleaned up a table with wheat crumbs on it? You have just contaminated the surface with gluten.

54 Possible sources of cross contamination Cutting boards; knives, spoons or ladles; butter, peanut butter, or mayonnaise knives Cutting boards; knives, spoons or ladles; butter, peanut butter, or mayonnaise knives Grills, toasters, or toaster ovens used for both gluten free and non gluten free food should be thoroughly cleaned so no traces of gluten remain Grills, toasters, or toaster ovens used for both gluten free and non gluten free food should be thoroughly cleaned so no traces of gluten remain Deep fryer used to cook breaded or battered food as well as French fries Deep fryer used to cook breaded or battered food as well as French fries Gloved hand that has touched gluten containing food and then touches gluten free food Gloved hand that has touched gluten containing food and then touches gluten free food

55 More ways to avoid cross contamination Work surfaces and microwaves should be clean. Work surfaces and microwaves should be clean. Use designated cutting boards, knives, and toasters Use designated cutting boards, knives, and toasters Fresh, clean water for boiling, steaming, and poaching (pasta) Fresh, clean water for boiling, steaming, and poaching (pasta) If there is not a dedicated fryer for gluten free foods, fry them in a skillet If there is not a dedicated fryer for gluten free foods, fry them in a skillet No common prep equipment or surfaces without appropriate dishwashing and cleaning No common prep equipment or surfaces without appropriate dishwashing and cleaning

56 You dont bring me flours anymore Even the most well intentioned cooks can inadvertently turn a gluten free food into a gluten containing food simply by not paying attention to some simple practices in the kitchen. Even the most well intentioned cooks can inadvertently turn a gluten free food into a gluten containing food simply by not paying attention to some simple practices in the kitchen. This is particularly an issue where baking is done from scratch (flour in the air). This is particularly an issue where baking is done from scratch (flour in the air).

57 An easy way to explain this to kitchen staff is to compare gluten to raw chicken. Just as its common knowledge that raw chicken is dangerous and should never come in contact with food, utensils, or plates that are ready to be served, it should be made absolutely clear that gluten containing food needs to be kept away from gluten free food at all stages of preparation and service.

58 Oopshe said no croutons In the event an accident happens the entire plate of food needs to be replaced In the event an accident happens the entire plate of food needs to be replaced Removing the bread, wrap, breading, croutons, etc is not acceptable once contamination has occurred. Even a bread stick on a plate that isnt touching the food can leave some gluten behind. Removing the bread, wrap, breading, croutons, etc is not acceptable once contamination has occurred. Even a bread stick on a plate that isnt touching the food can leave some gluten behind. Garnishes that start out gluten free may become contaminated, so any gluten containing garnishes should be stored below gluten free items. Garnishes that start out gluten free may become contaminated, so any gluten containing garnishes should be stored below gluten free items.

59 Major food companies are finally marketing to the gluten free consumer

60 Gluten Free Becomes Mainstream Most Chex cereals are now gluten free (with the exception of Wheat Chex and Bran Chex). Most Chex cereals are now gluten free (with the exception of Wheat Chex and Bran Chex). Betty Crocker has recently come out with gluten free mixes for chocolate chip cookies, brownies, chocolate cake and yellow cake. Betty Crocker has recently come out with gluten free mixes for chocolate chip cookies, brownies, chocolate cake and yellow cake.

61 Some Excellent Resources The New Ultimate Guide to Gluten-Free Living The New Ultimate Guide to Gluten-Free Living Celiac Disease Center at Columbia University Celiac Disease Center at Columbia University org org Gluten-Free Diet: A Comprehensive Resource Guide, Expanded Edition. Shelley Case, BSc, RD Gluten-Free Diet: A Comprehensive Resource Guide, Expanded Edition. Shelley Case, BSc, RD Gluten Intolerance Group. Gluten Intolerance Group. Gluten-Free Living magazine Gluten-Free Living magazine Celiac Sprue Association Celiac Sprue Association National Foundation for Celiac Awareness National Foundation for Celiac Awareness

62 More Resources Evidence based guidelines for celiac disease

63 Ronni Alicea, RD, MBA Celinal Foods Ronnis article on the DMA website:

64 Ask Roberta

65 Questions?


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