Nutrit ion Assessment in CeliacDisease

Suzanne Simpson, RDa,*, Tricia Thompson, RD, MSb

KEYWORDS

� Celiac disease � Gluten-free diet � Nutrition assessment

KEY POINTS

� Nutrition assessment is the first step in the nutrition care process.

� Assessment of typical dietary intake in celiac disease must be thorough.

� The only treatment for celiac disease is a strict, lifelong gluten-free diet.

According to the Academy of Nutrition and Dietetics Evidence Analysis Library,“medical nutrition therapy provided by a registered dietitian is strongly recommendedfor individuals with celiac disease.”1 Therefore, consultation with a dietitian/nutritionistwho has expertise in celiac disease should be mandatory for all patients with celiacdisease at diagnosis aswell as during follow-up (Box 1). The gluten-free diet is currentlythe only treatment for celiac disease; patients with celiac disease must be monitoredclosely by a dietitian to assess the healthfulness of the gluten-free diet as well as todiscuss motivation, quality of life, symptom improvement, and barriers to compliance.Nutrition assessment is the first step in the nutrition care process. During the

assessment pertinent data are gathered and compared with normal values. A nutritiondiagnosis is determined, and a nutrition care plan developed and prescribed. Thenutrition intervention should include goals that are quantifiable, achievable, timedefined, and negotiated with the patient so as to improve dietary intake and reducerisk factors. The assessment continues at each patient visit. A complete nutritionassessment includes a review of dietary intake, anthropometric measures, biochem-ical data, medical tests, and procedures (Box 2). Communication with the referringphysician/gastroenterologist is advisable for optimal patient care. During the assess-ment, the dietitian may determine that a diagnosed patient with gastrointestinal symp-toms, not related to gluten intake, could be related to another food-intolerance ormedical issue that the physician must investigate. Similarly, the dietitian may deter-mine that a micronutrient deficiency or weight loss is not caused by inadequate caloricintake. Dietitians can also recommend that the physician screen for celiac disease in

a Celiac Disease Center at Columbia University, Suite 956, 180 Fort Washington Avenue, NewYork, NY 10032, USA; b Gluten Free Watchdog, LLC, 348 Summer Street, Manchester, MA01944, USA* Corresponding author.E-mail address: Sms2246@columbia.edu

Gastrointest Endoscopy Clin N Am 22 (2012) 797–809http://dx.doi.org/10.1016/j.giec.2012.07.010 giendo.theclinics.com1052-5157/12/$ – see front matter � 2012 Elsevier Inc. All rights reserved.

Box 1

When to refer patients with celiac disease to a dietitian

At diagnosis: initial assessment followed by 2 to 3 more visits within the first year of diagnosisas well as annual visits thereafter (minimally)

Suspicion of gluten ingestion (positive serologies after 1 or more years on a gluten-free diet)

Lactose intolerance

Fructose intolerance

Food allergies

Constipation/diarrhea/gastroesophageal reflux disease

Fluctuations in body mass index: weight gain or loss

Micronutrient deficiencies or toxicities

Gastroparesis

Hypercholesterolemia

Type 1 diabetes

Refractory celiac disease

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patients who do not have a diagnosis but exhibit symptoms, significant medicalhistory or family history, or unexplained nutrient deficiencies.

ASSESSMENT OF DIETARY INTAKE

Assessment of typical dietary intake in celiac disease must be thorough. All food andbeverages consumed on weekdays and weekends should be reviewed, includingname brands of products and frequency of food eaten away from the home (restau-rants, social events, other people’s homes, travel). It is helpful for the patient tocomplete a food diary for the dietitian to review. Dietary restrictions such as food intol-erances, food allergies, religious observances, and self-imposed restrictions areconsidered. Patients should be queried about their compliance to a strict gluten-free diet and the frequency of gluten ingestion (purposely or inadvertently). It is impor-tant to assess patients’ knowledge and understanding of the diet by reviewingtheir label-reading skills, how they order foods in restaurants, and what cross-contamination procedures are used in shared kitchens. Patients may have obtainedinformation about the gluten-free diet elsewhere, and it is important to assess thesource for its accuracy (Internet, other nutritionists, books, peers, magazines). Medi-cations, vitamins, and dietary supplements must be reviewed for their possible glutenstatus, their purpose, and whether they meet or exceed the Dietary Reference Intake.It is important to assess quality of life, social history/social support, sufficiency ofincome, and ability to access gluten-free food. Inquiry should be made as to whoprepares food at home, particularly in a shared kitchen. A review of gastrointestinalsymptoms (such as type, frequency, and volume of bowel movements, abdominalpain, bloating, nausea or vomiting, delayed gastric emptying, reflux, flatulence) isrequired. Compliance with a strict gluten-free diet usually reduces gastrointestinalsymptoms in celiac disease2–13 and should always be encouraged.

Anthropometric Assessment

Assess age, height, weight, body mass index, growth parameters in children, weighthistory, physical activity, and disordered eating and/or diets (currently or in the past).

Box 2

Nutrition assessment checklist

Dietary history: foods and beverages consumed at all meals and snacks, including name brands

Adequate calories, protein, micronutrient intake (the typical gluten-free diet can increase therisk of calcium, iron, fiber, vitamin D, folate, niacin, zinc, and vitamin B12 deficiencies becauseof lack of fortification of gluten-free packaged foods including breads and pastas)

Foods away from the home: restaurant frequency, fast food, take out, order in, cafeteria, otherpeople’s homes, social and work events

Travel: foods consumed, frequency of travel

Supplements: herbal remedies, over-the-counter diet aids

Vitamins and minerals: check if gluten-free and check amounts of micronutrients comparedwith recommended intake

Prescription medications: must be gluten-free

Cross-contamination prevention measures

Medical history, family history, symptoms, laboratory measures, review of all tests andprocedures

Anthropometrics: height, weight, body mass index

Social support: family, work, peers

Quality of life: work, family, exercise, risk of depression

Physical activity level

Assess knowledge of gluten-free diet food labels: knowing how to identify gluten in aningredient list; understanding the meaning of nutrition food claims such as no gluten, gluten-free, wheat-free, made in the same factory that processes wheat, low gluten

Readiness for change: assess the patient’s willingness to change diet and the patient’s goals forlearning and meeting with the dietitian

Family history: other family members with celiac disease; family members tested for celiacdisease

Potential nutrition diagnoses: follows a strict gluten-free diet, ingesting gluten inadvertentlyin restaurants, ingesting gluten on purpose monthly, inadequate calcium/vitamin D intake,inadequate fiber intake, risk of iron deficiency, constipation due to inadequate fiber intake,excessive caloric intake resulting in weight gain, at risk of overweight

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Medical Procedures

Review all medical procedures including: endoscopy report (classification of Marshscore, number and location of segments biopsied); bone mineral density; breath tests(bacterial overgrowth, fructose intolerance, lactose intolerance); gastric emptyingstudy; colonoscopy; and surgery. Reviewmedical history (eg, gastrointestinal, immune,neurologic, and psychological); other health conditions; autoimmune diseases; familyhistory of celiac disease; allergies;muscle stores; and fat stores. Inquire about appetite,current gastrointestinal symptoms, and symptoms prior to the diagnosis of celiacdisease.

Physical

Assess appearance of hair, skin, nails, and body shape.

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NUTRITION INTERVENTION AND EDUCATION

The gluten-free diet is the medical and nutritional treatment for celiac disease. Agluten-free diet is discussed in later sections of this article. Gluten must be removedfrom the diet completely and permanently. Box 3 includes a list of items that must beincluded in the nutrition education for patients with celiac disease. It is important toanswer questions the patient may have, establish trust, and set goals with the patientthat can be addressed during follow-up.

FOLLOW-UP

Celiac disease is a lifelong systemic disease with a burdensome treatment thatrequires regular follow-up visits with the expert dietitian and gastroenterologist; pa-tients must be monitored for compliance, symptoms, well-being, and medical issues.Box 4 lists items that need to be monitored during follow-up visits.If a patient with celiac disease is not treated with the gluten-free diet, there can be

serious consequences. The intake of gluten may result in gastrointestinal symptoms,malabsorption and micronutrient deficiencies, villous atrophy and the developmentof neurologic complications, fertility problems, reduced quality of life, intestinallymphoma, and reduced bone mineral density. The dietitian must assess complianceduring follow-up, particularly in patients with symptoms. If gluten exposure is deter-mined not to be the cause of symptoms, other potential causes could be lactose, fruc-tose, and carbohydrate intolerances, bacterial overgrowth, refractory celiac disease,related cancers, and other gastrointestinal diseases and conditions. These conditionswould require investigation by a gastroenterologist.

Box 3

Nutrition education for the gluten-free diet

Label reading: list of ingredients that must be avoided, review of labeling laws, surprisingsources of gluten, cross-contamination procedures, nutrition claims (eg, gluten-free, wheat-free, low gluten, made in the same facility as wheat), sources of important nutrients such ascalcium, vitamin D, iron, fiber

Recommendations for portions and variety of foods from all food groups

Heart-healthy recommendations to prevent high cholesterol

High fiber, as tolerated, to prevent weight gain and constipation

Review of gluten-free grains: 50% of grains consumed should be whole grains

Discuss risk of vitamin deficiencies

Encourage healthful gluten-free food choices

Discuss risks associated with ingesting gluten

Discuss vitamin supplementation as needed

Discuss use of supplements such as probiotics, over-the-counter remedies

Discuss family testing

Discuss restaurant eating, social situations, menu planning, recipes, grocery shopping

Coordinate care with other providers as needed

Discuss other dietary restrictions within the confines of the gluten-free diet: lactose-free diet,low-fructose diet, diabetes meal plan/carbohydrate counting

Implement weight-centered guidelines as needed: weight control or high calorie

Box 4

Nutrition items to monitor at follow-up visits

Implementation of nutrition goals

Factors affecting the quality of life

Medical status (eg, gastrointestinal, immune, neurologic, psychological)

Social supports

Body mass index

Compliance with the gluten-free diet

Label reading

Restaurant habits

Diet history and gluten-free dietary pattern with specific focus on intake of nutrients at risk ofdeficiency (iron, calcium, vitamin D, B vitamins, fiber, folate, niacin, zinc), intake comparedwith recommendations, excessive sugar and fat from prepared gluten-free foods, caloric intake

Vitamin intake

Medications and supplements

Antibody levels, potential exposure to cross-contamination, hidden sources of gluten in foods

Answer patient’s questions

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Individuals with celiac disease have been found to show improved quality of life aftercompliance with a gluten-free diet for at least 1 year.12,13 However, they may not attainthe same level of quality of life as the general population; this has been reported morefrequently by women thanmen, and particularly by those who continue to have gastro-intestinal symptoms despite adherence to a gluten-free diet.14,15

For most patients with celiac disease, compliance with a gluten-free dietary patternresults in significant improvements in hematological parameters including anemia andiron deficiency.15–19 Iron supplementation in a gluten-free multivitamin with iron oradditional therapeutic doses of iron may be required.

THE GLUTEN-FREE DIET

The only treatment for celiac disease is a strict, lifelong gluten-free diet. The gluten-free diet is free of all but very small amounts of gluten, defined in celiac disease asspecific sequences of amino acids found in wheat, barley, and rye. All foods contain-ing these grains as ingredients or through contamination must be removed from thediet. The gluten-free diet should be based on gluten-free whole grains (eg, wholecorn, brown rice, millet, sorghum, wild rice, teff, buckwheat, amaranth, and quinoa),plain low-fat milk and milk products (or milk alternatives such as soy milk), unpro-cessed lean protein (meat, poultry, fish, legumes), fruits, and vegetables.

Labeled Gluten-Free Foods

There is an abundance of food products labeled gluten-free, including breads, pastas,breakfast cereals, and baking mixes. Under the US Food and Drug Administration(FDA) proposed rule for labeling of food as gluten-free, food labeled gluten-freemust meet all of the following criteria20:

� It cannot include an ingredient that is a prohibited grain. Prohibited grains includewheat, barley, rye, and triticale (a cross between wheat and rye).

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� It cannot include an ingredient derived from a prohibited grain that has not beenprocessed to remove gluten. Examples of these types of ingredients includewheat flour, hydrolyzed wheat protein, wheat germ, malt, and barley maltflavoring.

� It can include an ingredient derived from a prohibited grain that has been pro-cessed to remove gluten as long as use of the ingredient does not result in thefinal food product containing 20 parts per million (ppm) or more gluten. Examplesof these types of ingredients are wheat starch and modified food starch madefrom wheat.

� It must contain less than 20 ppm gluten.

The definition of gluten-free differs slightly from the Codex Standard for Foods forSpecial Dietary Use for Persons Intolerant to Gluten.21 Under this standard, gluten-free foods are dietary foods that fit one of the following two definitions:

� Foods that are made only from ingredients that do not contain wheat, barley, rye,oats (under Codex, the use of oats uncontaminated with wheat, barley, and ryemay be determined at a national level), or their cross-bred varieties, and witha gluten content not greater than 20 ppm.

� Foods made using one or more ingredients from wheat, barley, rye, oats, or theircross-bred varieties, which have been specially processed to remove gluten andwith a gluten content not greater than 20 ppm.

Reading Labels of Foods Not Labeled Gluten-Free

If a food product sold in the United States is not labeled gluten-free, consumers mustbe educated as to how to read labels carefully and look for sources of wheat, barley,and rye. The ingredients list (and in the case of wheat, the “Contains” statement)should be read for the words and ingredients that follow. If any of these words or ingre-dients are included on the label of a food not labeled gluten-free, the product shouldbe avoided by individuals with celiac disease.

� “Wheat.” Under the FDA Food Allergen Labeling and Consumer Protection Act(FALCPA), if an ingredient in a packaged food product regulated by the FDAincludes protein from wheat, the word wheat must be included on the food labeleither in the ingredients list or “Contains” statement.22 As a result, consumers donot need to be concerned about ingredients such as modified food starch anddextrin if wheat is not named on the food label.

� “Barley”� “Rye”� “Oats.” Only oats and products containing oats labeled gluten-free should beeaten by individuals with celiac disease.23 Although oats are considered inher-ently gluten-free, they also are highly likely to be contaminated with wheat,barley, or rye.24,25

� “Malt.” The single wordmalt in an ingredients list refers to barley malt.26 If anothersource of malt is used, such as corn, the ingredients list will read “corn malt.”

� “Brewer’s yeast.” This type of yeast may be a product of the beer-brewingprocess (ie, spent brewer’s yeast).27 As a result it may be contaminated withmalt and grain.

Foods regulated by the United States Department of AgricultureAlthough the labeling of most food in the United States is under the jurisdiction of theFDA, some foods are regulated by the United States Department of Agriculture

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(USDA). These foods are meat products, poultry products, egg products (defined asliquid, dried, and frozen, whole eggs, egg yolks, and egg whites with or without addedingredients), and mixed food products containing in general more than 3% raw meator 2% or more cooked meat or poultry meat.28–30 Whereas the FDA has mandatoryallergen labeling under FALCPA, the USDA does not. Manufacturers are encouragedto voluntarily follow FALCPA-like allergen labeling, and the USDA believes 80% to90% of product labels are in voluntary compliance.28 There are a few additional ingre-dients consumers must look for in the ingredients lists of foods regulated by the USDAif the manufacturer is not voluntarily complying with FALCPA. If any of the ingredientsthat follow (this is in addition to the ingredients already listed) are included on the labelof a USDA-regulated food not in voluntarily compliance with FALCPA-like allergenlabeling, the food should be avoided until the manufacturer is contacted and it isconfirmed that the source of the ingredient is not wheat.

� “Modified food starch.” Modified food starch in a food regulated by the USDAmay be derived from wheat, and “wheat” may not be included on the food labelif the manufacturer is not voluntarily complying with FALCPA-like allergenlabeling.31 Although wheat can be the source of modified food starch, the sourceis most likely corn if the ingredient is manufactured in the United States.

� “Dextrin.” Dextrin in a food regulated by the USDA may be derived from wheat,and “wheat” may not be included on the food label if the manufacturer is notvoluntarily complying with FALCPA-like allergen labeling.31 Although wheat canbe the source of dextrin, the source is most likely corn if the ingredient is manu-factured in the United States.

� “Starch.” The single word starch in the ingredients list of a food product regulatedby the USDA may refer to either corn starch or wheat starch.32 If the starch isderived from wheat, the word “wheat” may not be included on the food label ifthe manufacturer is not voluntarily complying with FALCPA-like allergenlabeling.31 Although the starch may be wheat, it is most likely corn if the ingre-dient is manufactured in the United States.

It is important to emphasize that the vast majority of manufacturers of USDA-regulated foods are in voluntary compliance with FALCPA-like allergen labeling, andin most cases modified food starch, dextrin, and starch are derived from corn, notwheat.

Contamination

Inherently gluten-free grains and flours may become contaminated with wheat, barley,or rye any time they are grown, harvested, transported, or processed in the same area.A study by Thompson and colleagues33 found that of 22 samples of naturally gluten-free grains and flours sold in the United States, 9 contained mean levels of glutenranging from 8.5 to 2925.0 ppm of gluten. Seven of these samples contained meanlevels of gluten at or above 20 ppm gluten and would not be considered gluten-freeunder the FDA’s proposed gluten-free labeling rule. Because of the possible risk ofcross-contamination, the Academy of Nutrition and Dietetics Celiac Disease Toolkitrecommends that individuals with celiac disease buy naturally gluten-free grainsand flours that are labeled gluten-free.34 It is also recommended that products thatare predominantly grain-based be labeled gluten-free.34 A comparison of the glutencontent of labeled versus nonlabeled gluten-free millet, rice, soy, and sorghum floursis provided in Table 1. On testing, labeled gluten-free brands contained loweramounts of gluten than the brands not labeled gluten-free.33,35

Table 1Content of labeled versus nonlabeled gluten-free flours

Flour Labeled Gluten-Free? Mean Gluten Content (ppm)a

Millet No 305.0

Millet No 327.0

Millet Yes 15.5

Rice No 8.5

Rice Yes <5

Sorghum No 234.0

Sorghum Yes <5b

Soy No 2925.0

Soy No 92.0

Soy Yes <5c

Abbreviation: ppm, parts per million.a Flours not labeled gluten-free: 1 sample tested in duplicate (mean of 2 extractions); flours

labeled gluten-free: 3 samples of same brand tested in duplicate (6 extractions).b Five extractions tested at less than 5 ppm gluten; 1 extraction tested at 7 ppm gluten.c Five extractions tested at less than 5 ppm gluten; 1 extraction tested at 6 ppm gluten.Data from Thompson T, Lee AR, Grace T. Gluten contamination of grains, seeds, and flours in the

United States: a pilot study. J Am Diet Assoc 2010;110:937–40; and Gluten-free watchdog, LLC.Available at: http://www.glutenfreewatchdog.org/. Accessed August 14, 2012.

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Nutritional Quality of the Gluten-Free Diet

As with any eating plan, a gluten-free diet may be healthy or unhealthy, depending inlarge part on food choice. According to the Academy of Nutrition and DieteticsEvidence Analysis Library, “adherence to the gluten-free dietary pattern may resultin a diet that is high in fat and low in carbohydrates and fiber, as well as low in iron,folate, niacin, vitamin B12, calcium, phosphorus and zinc.”36 As a result, the Aca-demy’s Evidence-Based Nutrition Practice Guideline for Celiac Disease recommendsthe consumption of whole and enriched gluten-free grains and products.23 The addi-tion of a gluten-free age-specific and gender-specific multivitamin andmineral supple-ment is advised if “usual food intake shows nutritional inadequacies that cannot bealleviated through improved eating habits.”23

There are several possible reasons for this macronutrient and micronutrient profileof the gluten-free diet. Individuals with celiac disease may not consume the recom-mended number of servings of grain foods. A study conducted by Thompson andcolleagues37 found that only 21% of adult female participants in the United Statesconsumed the minimum recommended number of grain food servings. A retrospectivereview of diet histories of patients with celiac disease at a United States celiac diseasecenter found that 38% of meals and snacks eaten by study participants did notcontain a grain or starch component.38 Low overall grain consumption can result indiets that are low in carbohydrates and fiber and proportionally higher in fat.39 Italso can result in diets that are low in iron, folate, niacin, and zinc.39

Individuals with celiac diseasemay consumegrain foodsmade primarily from refinedgluten-free grains and starch. One study found that of 268 gluten-free breads, pastas,and breakfast cereals for sale in the United States and reviewed for ingredients, 73%listed a refined grain or starch as the first ingredient.40 Of these refined grain foods,only 16% were enriched or fortified with B vitamins and iron. These data are in stark

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contrast to thoseof refinedwheat-basedbreads, pastas, andbreakfast cereals,most ofwhich are enriched or fortified. Since the time this study was conducted there appearsto have been an increase in products incorporating gluten-free whole grains, such asamaranth, buckwheat, sorghum, quinoa, millet, teff, wild rice, brown rice, whole corn,and gluten-free oats. However, the number of manufacturers of refined grain foodsenriching or fortifying their products has remained roughly the same. An overrelianceon refined grain-based foods (vs whole grains) that are not enriched or fortified canresult in diets that are low in fiber, iron, folate, niacin, vitamin B12, and zinc.39

Individuals with celiac disease also may consume grain-based foods that are high infat. Gluten-free versions of foods that are typically thought of as low-fat or fat-free,such as pretzels, may contain large amounts of fat, because manufacturers ofgluten-free foods may add extra fat to their products to improve the taste and texture.In addition, many individuals with celiac disease are lactose intolerant when they are

newly diagnosed. As a result, they may limit their intake of milk-based products, whichmay result in decreased intakes of calcium, vitamin B12, and phosphorus.39

To help ensure a healthy gluten-free diet, individuals should be:

� Referred to a dietitian well-versed in celiac disease as soon as possible afterdiagnosis

� Encouraged to consume foods made from gluten-free whole grains (eg, quinoa,gluten-free oats, teff) and to choose these products over refined gluten-freegrains (eg, white rice, milled corn)

� Counseled to choose enriched or fortified refined grain foods over refined grainfoods that are not enriched

� Advised to use the Nutrition Facts panel to compare the fat and fiber content ofgluten-free grain foods and to choose products with more fiber and less fatwhenever possible

� Eat or drink calcium rich foods such as calcium-fortified soy milk, calcium forti-fied orange juice, and calcium-processed plain tofu

Weight Gain and the Gluten-Free Diet

According to the Academy of Nutrition and Dietetics Evidence Analysis Library, “asmall number of studies in adults show a trend toward weight gain after diagnosis;further research is needed in this area.”36 There are reasons why individuals withceliac disease might gain weight after diagnosis. Before diagnosis, increased amountsof calories may have been necessary to prevent or slow weight loss caused by malab-sorption. Once a diagnosis is made, a gluten-free diet is started, and the intestineheals, fewer calories may be needed. Individuals may have to adjust their caloricintake and relearn appropriate portion control to prevent unwanted weight gain.

Unintentional Gluten Ingestion

If gluten ingestion is suspected but the patient appears to be following a strict gluten-free diet, gluten contamination should be considered. To help ferret out possible sour-ces of contamination, the following areas should be investigated.

Contaminated food at point of purchase� What types of grains (eg, rice, buckwheat, quinoa) are eaten? What specificbrands are purchased? Are they labeled gluten-free?

� What types of foods not labeled gluten-free are purchased? Are any of thesepredominantly grain-based (eg, breakfast cereals, rice pastas, buckwheatnoodles, taco shells, rice crackers, and so forth)?

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� What types of labeled gluten-free foods are eaten? Do any brands have a historyof contamination?

� Are any grains or flours purchased from bulk bins? Gluten-free grains and floursfrom bulk bins may be contaminated with wheat, barley, or rye, owing to the useof shared scoops.

� Areanygrainsor flourspurchased fromco-operatives thatbuyproducts inbulkandrepackage in smaller containers? If so, they may be contaminated with gluten-containing grains if wheat, barley, and/or rye are repackaged in the same area.

� Are any grains or flours purchased from ethnic food stores? These grains andflours may not be labeled gluten-free.

Contaminated food at home� Is the home completely gluten-free?� If not, are gluten-free foods stored separately or on a higher shelf from gluten-containing foods? Doing so will prevent gluten-containing crumbs from rainingdown on the gluten-free food.

� Are products such as peanut butter, jelly, and mayonnaise used on both gluten-free and gluten-containing bread? If so, these products may be contaminatedwith gluten-containing crumbs due to “double-dipping.”

� Are separate cooking and serving utensils used to prepare both gluten-free andgluten-containing meals?

� Are shared plates, pots, and so forth well cleaned after use with gluten-containing food?

� Are microwaves, toaster ovens, counter tops, silverware drawers, and so forthkept clean and free of wheat-containing crumbs?

� Is there shared use of a traditional pop-up toaster? This type of toaster is veryhard to clean. If it has to be shared, the use of toaster bags is recommended.

Contaminated food at a restaurant� How often are meals eaten away from home?� Is wait staff queried about gluten-free options?� Is wait staff informed about the need for the meal to be gluten-free and free ofcross-contamination (eg, cleaned section of grill, separate pans, preparationtools) to the extent possible?

� Are French fries and/or tortilla chips frequent choices? These foods may becooked in oil previously used to prepare breaded foods, such as onion rings.

� Is soup a frequent choice? Soup may be thickened with wheat flour or containa wheat-based commercial broth/bouillon.

� Is rice pilaf a frequent choice? This rice dish typically contains wheat noodles andcould contain a wheat-based broth/bouillon.

� What sauces or dressings are eaten? These products may contain wheat orbarley ingredients.

Learning all of this dietary information may be overwhelming to patients, especiallyat first. Referral to a dietitian well versed in celiac disease and the gluten-free diet isessential.

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22. US Food and Drug Administration. Center for Food Safety and Applied Nutrition.Food Allergen Labeling and Consumer Protection Act of 2004 (Title II of PublicLaw 108-282). 2004. Available at: http://www.fda.gov/food/labelingnutrition/FoodAllergensLabeling/GuidanceComplianceRegulatoryInformation/ucm106187.htm.Accessed August 14, 2012.

23. Academy of Nutrition and Dietetics Evidence Analysis Library. Celiac diseaseevidence-based nutrition practice guideline. Available at: http://www.adaevidencelibrary.com/. Accessed August 14, 2012.

24. Thompson T. Gluten contamination of commercial oat products in the UnitedStates. N Engl J Med 2004;351:2021–2.

25. Koerner TB, Cleroux C, Poirier C, et al. Gluten contamination in the Canadiancommercial oat supply. Food Addit Contam Part A Chem Anal Control ExpoRisk Assess 2011;28:705–10.

26. US Food and Drug Administration. Code of Federal Regulations. Malt.21CFR184.1443a. Revised April 2009. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr5184.1443a&SearchTerm5malt. Accessed August 14, 2012.

27. Thompson T. Is marmite gluten-free? 2010. Available at: glutenfreedietitian.com;http://www.glutenfreedietitian.com/newsletter/is-marmite-gluten-free/. AccessedAugust 14, 2012.

28. Thompson T. Labeling of USDA-regulated foods. 2009. Available at:glutenfreedietitian.com; http://www.glutenfreedietitian.com/newsletter/?s=labeling1of1USDA1regulated1foods. Accessed August 14, 2012.

29. US Department of Agriculture. A guide to federal food labeling requirements formeat and poultry products. 2007. Available at: http://www.fsis.usda.gov/pdf/labeling_requirements_guide.pdf. Accessed August 14, 2012.

30. US Department of Agriculture. Food Safety and Inspection Service. Definition eggproduct. 9 CFR 590.5. Available at: http://edocket.access.gpo.gov/cfr_2008/janqtr/pdf/9cfr590.5.pdf. Accessed August 14, 2012.

31. US Department of Agriculture. Food Safety and Inspection Service. Questionsand answers related to ingredients of public health Concern. Available at:http://www.fsis.usda.gov/regulations/FAQs_for_Notice_45-05/index.asp. Access-ed August 14, 2012.

32. USDepartment of Agriculture. FoodSafety and Inspection Service. Food safety. Foodstandards and labeling policy book. 2005. Available at: http://www.fsis.usda.gov/OPPDE/larc/Policies/Labeling_Policy_Book_082005.pdf.AccessedAugust14,2012.

33. Thompson T, Lee AR, Grace T. Gluten contamination of grains, seeds, and floursin the United States: a pilot study. J Am Diet Assoc 2010;110:937–40.

34. Academy of nutrition and dietetics celiac disease toolkit. Chicago: American Die-tetic Association; 2011.

35. Gluten-free watchdog, LLC. Available at: www.glutenfreewatchdog.org. Ac-cessed August 14, 2012.

36. Academy of Nutrition and Dietetics Evidence Analysis Library. Celiac DiseaseEvidence Analysis Library Project. Available at: http://www.adaevidencelibrary.com/. Accessed August 14, 2012.

37. Thompson T, Dennis M, Higgins LA, et al. Gluten-free diet survey: are Americanswith coeliac disease consuming recommended amounts of fibre, iron, calciumand grain foods? J Hum Nutr Diet 2005;18:163–9.

38. Lee AR, Ng DL, Dave E, et al. The effect of substituting alternative grains in thediet on the nutritional profile of the gluten-free diet. J Hum Nutr Diet 2009;22:359–63.

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39. Thompson T. ADA pocket guide to gluten-free strategies for clients with multipledietary restrictions. Chicago (Illinois): American Dietetic Association; 2011.

40. Thompson T. Thiamin, riboflavin, and niacin contents of the gluten-free diet: isthere cause for concern? J Am Diet Assoc 1999;99:858–62.