Living a Gluten-free Lifestyle

1. Marisa Bunning, PhD Assistant Professor and Extension Specialist-Food Safety Mary Schroeder MS, RD Extension Research Associate-Food Safety Department of Food Science and Human Nutrition Colorado State University July 9, 2008 Living a Gluten-free Lifestyle In recent years, there has been an increase in the number of people following a gluten-free diet along with an increased need for information related to gluten-free baking and food preparation. In recent years, there has been an increase in the number of people following a gluten-free diet along with an increased need for information related to gluten-free baking and food preparation.

2. Complex Disease Multiple names: Celiac, celiac sprue, non-tropical sprue, gluten intolerance, gluten sensitive enteropathy - but NOT the same as wheat allergy Celiac disease: a complex autoimmune enteropathy caused by a permanent intolerance to gluten in genetically susceptible individuals 1 Exact cause of celiac disease unknown, but is often inherited (5% to 15% chance if in immediate family) Onset can be triggered by trauma (infection, injury, pregnancy, severe stress or surgery) Wheat allergy involves an immune response that is antibody-mediated, thought to be very rare. British Nutrition Foundation The recent article, Advances in Celiac Disease and Gluten-Free Diet by Mary Niewinski from the Journal of the American Dietetic Association provides a good update on the issues of celiac disease.Wheat allergy involves an immune response that is antibody-mediated, thought to be very rare. British Nutrition Foundation The recent article, Advances in Celiac Disease and Gluten-Free Diet by Mary Niewinski from the Journal of the American Dietetic Association provides a good update on the issues of celiac disease.

3. Autoimmune Disease Combination of 3 factors: 1) Genetic predisposition Maternal antibodies produced during pregnancy cross placenta and react with fetal brain tissue Genetic marker (human leukocyte antigen- HLA) has been identified to confirm body’s response to gluten 2) Environmental trigger Gluten in diet 3) Loss of intestinal barrier Gluten triggers an immune response- causing inflammation and damage to lining of the small intestine Detected by transglutaminase (tTG) -standard test for diagnosis Celiac Disease is the only autoimmune disease for which all three factors are known. Autoimmune: the body views proteins from certain grains as harmful resulting in inflammation and damage to the lining of the small intestine.Autoimmune: the body views proteins from certain grains as harmful resulting in inflammation and damage to the lining of the small intestine.

4. Pathogenesis Gluten proteins disrupt the epithelial barrier in the lining of the small intestine. Sets off complex autoimmune (antigen) response, which results in destruction of surface epithelium and flattening of mucosa.1 Develops “leaky gut syndrome” Protein called zonulin “unlocks” intestinal barrier and creates leaky gut, allowing large peptides to cross lining into blood stream2 With celiac disease, the villi may become shortened or blunted, interfering with nutrient absorption. Zonulin: persons with Celiac disease produce higher levels of zonulin. So do people with Type 1 Diabetes, multiple sclerosis and other autoimmune diseases. (per Dr. Fasano, Center for Celiac Research, Univ. of Maryland With celiac disease, the villi may become shortened or blunted, interfering with nutrient absorption. Zonulin: persons with Celiac disease produce higher levels of zonulin. So do people with Type 1 Diabetes, multiple sclerosis and other autoimmune diseases. (per Dr. Fasano, Center for Celiac Research, Univ. of Maryland

5. Prevalence Celiac Disease- often misdiagnosed due to such variety of different symptoms- connection between conditions is not well understood. Estimated 3 million persons in U.S. with Celiac Disease Worldwide prevalence: 1 in 266 General population: U.S. 1 in 133 Females vs. males: 3:1 25% newly diagnosed are over 60 yrs of age African, Hispanic and Asian-Americans 1 in 236 Genetic predisposition First degree relatives: 1 in 22 Second degree relatives: 1 in 39 High association Autoimmune diseases (i.e. Type 1 Diabetes) 1 in 60 Secondary Lactose Intolerance: 30-60% Prior to the Fasano study, Celiac disease was considered to be much more rare in the U.S. Secondary lactose intolerance is common in estimated 30-60% of those diagnosed with CD. Prior to the Fasano study, Celiac disease was considered to be much more rare in the U.S. Secondary lactose intolerance is common in estimated 30-60% of those diagnosed with CD.

6. Relationship with other conditions Dermatitis Herpetiformis (DH) Osteoporosis (bone mineral density test often recommended) Type 1 Diabetes Chronic Fatigue Syndrome Fibromyalgia Irritable Bowel Syndrome Eczema Sjogren’s Syndrome Peripheral Neuropathy Thyroid Disease DH is a chronic, extremely itchy rash - medication can resolve the skin lesions associated with DH but not the intestinal issues: Thompson Sjögren's ("SHOW-grins") syndrome is a chronic disease in which white blood cells attack the moisture-producing glands. The hallmark symptoms are dry eyes and dry mouth, but it is a systemic disease, affecting many organs and may cause fatigue. (http://www.sjogrens.org/) DH is a chronic, extremely itchy rash - medication can resolve the skin lesions associated with DH but not the intestinal issues: Thompson Sjögren's ("SHOW-grins") syndrome is a chronic disease in which white blood cells attack the moisture-producing glands. The hallmark symptoms are dry eyes and dry mouth, but it is a systemic disease, affecting many organs and may cause fatigue. (http://www.sjogrens.org/)

7. Autism and Celiac Disease Autism Spectrum Disorder (ASD) affects 1 in every 150 children in U.S. (up from 1 in 500 in 1995) per Center for Disease Control No evidence that gluten intolerance causes autism; connection is unclear. However… Many autistic individuals respond well to a gluten-free and casein-free diet Leaky gut -opioid peptides (dietary casein and gluten) cross intestinal lining into bloodstream; bind to opiate receptors in brain, resulting in unmanageable behavior and sensory issues

8. Diagnosis Serologic Tests Requires inclusion of gluten in diet before testing Recommended: IgA EMA (immunoglobulin A endomysial antibody immunofluorescence) Intestinal Biopsy Used to confirm but not definitive Food trial Does health improve after 3 weeks of gluten-free diet? Gluten then reintroduced to test The clinical definition requires clinical and/or pathologic improvement following a gluten-free diet.The clinical definition requires clinical and/or pathologic improvement following a gluten-free diet.

9. Symptoms More than 200 signs and symptoms; Many have no symptoms at all Adults- most common symptom is iron deficiency anemia that does not respond to iron therapy Abdominal pain, bloody stools, chest pain, constipation, cough, diarrhea, difficulty swallowing, dizzyness, eye discomfort and redness, foot or ankle pain, foot swelling, headaches, hip pain, knee pain, nasal congestion, nausea and vomiting, neck pain, numbness or tingling in hands, pelvic pain, shortness of breath, shoulder pain, sore throat, urinary problems, vision problems, wheezing

10. Treatment Currently, the only scientifically proven treatment for celiac disease is strict lifelong adherence to a gluten-free diet.1 Elimination of all forms of wheat, rye and barley Even small amounts of gluten can be harmful and can cause continued damage. May need to follow temporary lactose-free diet. Focus on consumption of iron rich foods, calcium, vit.D and enriched gluten-free products (high in protein, vitamins, minerals, dietary fiber)May need to follow temporary lactose-free diet. Focus on consumption of iron rich foods, calcium, vit.D and enriched gluten-free products (high in protein, vitamins, minerals, dietary fiber)

11. Simple treatment not so simple Avoidance requires: Raised awareness Knowledge of ingredients (hidden sources of gluten) Prevention of cross-contamination Vigilance Checking labels regularly, looking for ingredient changes Inquiring about food preparation when eating away from home Takes time and effort to become familiar with GF products and understand the challenges of avoiding gluten.Takes time and effort to become familiar with GF products and understand the challenges of avoiding gluten.

12. Gluten Includes several different grain storage proteins, or prolamins. Wheat: gliadin Rye: secalin Barley: hordein Functions: Provides structure of dough- holding ingredients together, retaining leavening gas as it is formed In contrast…gluten-free flours: Mainly starches and non-sticky proteins Cannot produce same results unless adaptations are made In contrast, most of the gluten-free flours contain mainly starches and non-sticky proteins. Cannot produce same results unless adaptations are made.In contrast, most of the gluten-free flours contain mainly starches and non-sticky proteins. Cannot produce same results unless adaptations are made.

13. Grain Classification Flowering Plants Monocots Dicots Gramineae (Grasses) Polygonaceae Amaranthaceae Wheat, rye, and barley are all members of the Hordeae tribe. Triticale is a cross between wheat and rye. Dicot plants are classified pseudo-cereals, not true grain crops.Wheat, rye, and barley are all members of the Hordeae tribe. Triticale is a cross between wheat and rye. Dicot plants are classified pseudo-cereals, not true grain crops.

14. Gluten Structure & Properties Gluten: 80% protein High molecular weight (glutenin average MW = 3 million) Substantial hydrogen bonding due to amino acid side chains Intertwined network filled with water in inner spaces Chemical structure binds water, helps in holding moisture Gliadin and glutenin absorb about twice their weight in water Also effective in binding lipids 2 main gluten proteins (prolamin + glutelin) Gliadin (prolamin): sticky, extensible, low in elasticity Glutenin (glutelin): rubbery, low extensibility, high in elasticity Gluten controls baking quality of bread wheat flours To follow a gluten-free diet and to understand the challenges of avoiding gluten and finding GF substitutes, it may help to know more about the properties and characteristics of gluten. Two main solubility fractions: Gliadins and Glutenins Prolamins-rich in proline and glutamine undergo incomplete digestion in the small intestine. The interactions of the gluten molecule allow for holding moisture but gluten also has hydrophobic regions that allow binding with lipids. Brown: Glutenin’s elasticity plus gliadin’s stickiness combine to form gluten’s consistency which is ideal for preparing baked products.To follow a gluten-free diet and to understand the challenges of avoiding gluten and finding GF substitutes, it may help to know more about the properties and characteristics of gluten. Two main solubility fractions: Gliadins and Glutenins Prolamins-rich in proline and glutamine undergo incomplete digestion in the small intestine. The interactions of the gluten molecule allow for holding moisture but gluten also has hydrophobic regions that allow binding with lipids. Brown: Glutenin’s elasticity plus gliadin’s stickiness combine to form gluten’s consistency which is ideal for preparing baked products.

15. The ability of a baked product to rise is directly related to its protein content. Because wheat flour has the highest concentration of the proteins that form gluten, it yields baked projects with light, airy textures.The ability of a baked product to rise is directly related to its protein content. Because wheat flour has the highest concentration of the proteins that form gluten, it yields baked projects with light, airy textures.

16. Gluten containing grain products1 Barley Bulgur Cereal Binding Chapatti flour (atta) Couscous Dinkel (Spelt) Durum Einkorn Emmer Farina Farro Fu Gluten, gluten flour Graham flour Kamut Malt (extract, vinegar, syrup) Matzoh meal Oats (commercial*, bran) Orzo Rye Seitan (wheat meat) Semolina Spelt (Dinkel) 2 Triticale Wheat (bran, germ, starch) Spelt/Dinkel are listed both ways. There has been confusion about spelt but it is a subspecies of wheat and contains gliadin so it should not be included in a gluten-free diet. Braithwaite, 2006 Hoseney: Malting is the combination of controlled germination followed by the controlled drying of a seed with the goal of producing high enzyme activity, converts starches into sugars and has characteristic flavor. Barley is the most commonly malted grain. Maltodextrins in the U. S. are usually made from rice, corn or potato – in Europe, often made with wheat.Spelt/Dinkel are listed both ways. There has been confusion about spelt but it is a subspecies of wheat and contains gliadin so it should not be included in a gluten-free diet. Braithwaite, 2006 Hoseney: Malting is the combination of controlled germination followed by the controlled drying of a seed with the goal of producing high enzyme activity, converts starches into sugars and has characteristic flavor. Barley is the most commonly malted grain. Maltodextrins in the U. S. are usually made from rice, corn or potato – in Europe, often made with wheat.

17. Oats Oats are often avoided-although storage protein in oats called avenin does not illicit same response as gluten Commercial oats have risk of cross-contamination from harvesting or processing Pure oats in moderation: not a problem for most ½ cup dry rolled oats or ¼ c dry steel-cut oats per day1 Expensive Proposed FDA rule: Oats can be labeled GF if < 20 ppm gluten Availability: Specialty markets or order online Thompson: For most, uncontaminated oats appear safe to consume in moderation (1/2 cup dry rolled oats or ¼ c dry steel-cut oats per day).Thompson: For most, uncontaminated oats appear safe to consume in moderation (1/2 cup dry rolled oats or ¼ c dry steel-cut oats per day).

18. Gluten in food products Gluten often added at bakery to strengthen dough Often 20% of flour weight1 Hamburger and hot dog buns Produces a strong hinge Stonger to withstand use of heavy condiments and sauces Used to increase protein content (breakfast cereals) Vital Gluten used as meat analog (vegetarian products, pet foods) Binder in sausage products 2005 Per Capita consumption of wheat products: 324.6 lbs2 White bread reported to have 124,000 ppm gluten3 Avoiding gluten can be a challenge. Brown: Dried gluten, sold as vital wheat gluten, is often used to increase the protein content of flours, cereals, meat analogs, pasta, and used to manufacture simulated meat products for vegetarians. Avoiding gluten can be a challenge. Brown: Dried gluten, sold as vital wheat gluten, is often used to increase the protein content of flours, cereals, meat analogs, pasta, and used to manufacture simulated meat products for vegetarians.

19. Questionable products Blue cheese (crumbles) Beer (GF-Greenes, Redbridge) Broth or bouillon Candy Caramel color/flavor Chocolates Communion wafers French fries Glucose syrup Herbal teas Ice cream Licorice Malt vinegar Maltodextrin (from wheat starch) Medications Nuts Puddings Salad dressings Rice mixes Sauces Seasonings Soy sauce Vegetarian “burgers” This is not a complete list but will give you an idea that gluten can be found in a wide variety of food products. Low-gluten (wheat-starch based) Communion wafers have been developed – very small amount of gluten per wafer. Wine and pure distilled spirits are gluten free but fermented alcoholic beverages (beer) are normally made from wheat, barley or rye; however, GF beers are available. Blue cheese: http://www.organicvalley.coop/products/gluten-free-products/?gclid=CK-egtj_sJQCFR8SQQodjwiztw This is not a complete list but will give you an idea that gluten can be found in a wide variety of food products. Low-gluten (wheat-starch based) Communion wafers have been developed – very small amount of gluten per wafer. Wine and pure distilled spirits are gluten free but fermented alcoholic beverages (beer) are normally made from wheat, barley or rye; however, GF beers are available. Blue cheese: http://www.organicvalley.coop/products/gluten-free-products/?gclid=CK-egtj_sJQCFR8SQQodjwiztw

20. Nutritional considerations Due to decreased absorption of nutrients (damage to intestinal lining), and Lack of nutrient-fortified gluten-free products Fiber Look for “whole grain” versions that contain the bran layer (i.e. Rice bran, “whole grain” brown rice pasta, sprouted grains) Add ground flax seed to recipes Nutrient density Choose more nutritious ingredients such as amaranth, brown rice flour, buckwheat, flax, Montina™, nut flours, quinoa, teff and legume flours (e.g. garbanzo/chick pea, Garfava ™ and soy) Variety is key-to maximize protein, fiber and nutrients Nutrients of concern (focus on foods high in the following): Calcium: May need lactase enzyme temporarily with dairy Iron: Heme iron sources-red meats, chicken and fish, blackstrap molasses Folate and Vitamin B-12: Look for enriched products Many foods are naturally gluten-free: fresh fruits and vegetables, eggs, beef, pork, poultry, dairy, corn, rice…..pure chocolateMany foods are naturally gluten-free: fresh fruits and vegetables, eggs, beef, pork, poultry, dairy, corn, rice…..pure chocolate

21. Eight Most Common Food Allergens Peanut Tree nuts Fish Crustaceans Milk Egg Wheat Soy The labeling of wheat containing ingredients will be a big help to anyone that can’t eat gluten, however wheat-free does not mean gluten-free: ingredients in a wheat-free product could still include barley or rye.The labeling of wheat containing ingredients will be a big help to anyone that can’t eat gluten, however wheat-free does not mean gluten-free: ingredients in a wheat-free product could still include barley or rye.

22. Food Allergen Labeling and Consumer Protection Act (FALCPA) Labeling requirement effective: 1/01/2006 Amends the Federal Food, Drug, and Cosmetic Act Requires label to disclose certain allergenic ingredients Eight major food allergens A food ingredient that contains protein derived from a major food allergen Includes incidental additives, flavors, and colors that contain allergenic protein In response to the public health implications of individuals with food allergies, Congress enacted the Food Allergen Labeling and Consumer Protection Act (FALCPA) into law in August, 2004. FALCPA requires labels of food products to declare certain allergenic ingredients. This labeling requirement applies to foods that are labeled on or after January 1, 2006. Thompson: You have to be more vigilant when considering USDA-regulated foods, such as meat or poultry products, these products need only list the common or usual names of ingredients containing wheat – FSIS is in the process of developing regulation for labeling of allergens in meat and egg products.In response to the public health implications of individuals with food allergies, Congress enacted the Food Allergen Labeling and Consumer Protection Act (FALCPA) into law in August, 2004. FALCPA requires labels of food products to declare certain allergenic ingredients. This labeling requirement applies to foods that are labeled on or after January 1, 2006. Thompson: You have to be more vigilant when considering USDA-regulated foods, such as meat or poultry products, these products need only list the common or usual names of ingredients containing wheat – FSIS is in the process of developing regulation for labeling of allergens in meat and egg products.

23. FDA Voluntary Gluten Labeling Final rule on “gluten free” labeling by August 2008 Gluten: the proteins that naturally occur in a prohibited grain and that may cause adverse health effects in persons with celiac disease Prohibited grain: Wheat (Triticum), rye (Secale), barley (Hordeum), crossbred hybrids (e.g. triticale) Ruling: Spelt is not GF Threshold: less than 20 ppm Proposal on display @ Office of the Federal Register: 72 FR 2795 GF labeling is voluntary. According to an article in the American Journal of Clinical Nutrition (AJCN Jan’07), Safe Gluten Threshold for Patients with Celiac Disease, ingestion of gluten should be less than 50 mg/day. (reported in ADA Times-March/April 2007)GF labeling is voluntary. According to an article in the American Journal of Clinical Nutrition (AJCN Jan’07), Safe Gluten Threshold for Patients with Celiac Disease, ingestion of gluten should be less than 50 mg/day. (reported in ADA Times-March/April 2007)

24. Preventing cross-contamination Cross-contamination can introduce gluten into gluten-free foods Even tiny amounts can cause damage Contaminates can be air-borne or on surface Shopping: Avoid purchasing staples from bulk bins At Home: Keep food preparation areas separate Prepare GF foods before non-GF foods Clean grills, cutting boards, knives, utensils, thermometers, cloths and sponges Color-coding can help Separate toaster, butter dish, condiments (use squeeze bottles) Toaster bags: reusable, transparent bags for use in toasters, countertop grills, toaster ovens Containers should be well marked and sealed Use pure spices rather than blends

25. Gluten Free Grains, Flours, and Starches1 Amaranth Arrowroot Bean Flours (garbanzo, fava) Buckwheat Corn Fava Flax seed Garbanzo beans Garfava flour (garbanzo + fava) Hominy Mesquite flour Millet Montina Nut flour and meats Oats* (uncontaminated) Peas flour Potato flour Potato starch Quinoa Rice, all forms even glutinous Sago Sorghum flour Soy flour Tapioca (manioc, cassava, yucca) Teff (or tef) flour Alternative grains add flavor and nutritional attributes to GF products. One ounce of teff (28 grams) provides 9% Daily Value dietary fiber and 12% iron. Quinoa is an ancient grain, grows well in higher altitudes, including Colorado – 1 cup = 21% dietary fiber, 15% iron, 8 grams protein.Alternative grains add flavor and nutritional attributes to GF products. One ounce of teff (28 grams) provides 9% Daily Value dietary fiber and 12% iron. Quinoa is an ancient grain, grows well in higher altitudes, including Colorado – 1 cup = 21% dietary fiber, 15% iron, 8 grams protein.

26. Alternative Grains Beyond breads: salads and main dishes Don’t have same framework as gluten Elasticity Extensibility Storage: shelf-life is often shorter than flour Tip: Cook extra grains; freeze in small batches to thaw and use in recipes as needed In 2007, 636 GF food products on the market

27. Gums & other binders Xanthan gum: is a polysaccharide produced by a process involving fermentation of glucose or sucrose by the bacterium Xanthomonas campestris. Used as a stabilizer, binder- prevents crumbling Yeast breads: 1 tsp. per cup of non-GF flour Quick breads: ½ tsp. per cup of non-GF flour Guar Gum: Isolated from guar beans Best in baking that does not require yeast Tapioca: plant starch derived from cassava (manioc) root Thickener and binder

28. Baking - flour options Low-Gluten Flour: combination used is key! Keep various mixtures on hand-refrigerate in covered containers until used. All purpose flour blend* (general baking) High fiber blend (breads, pancakes, snack bars, cookies) High-protein blend (baked goods requiring elasticity (pie crust)) Self-rising blend: (muffins, scones, cakes, cupcakes) *All Purpose Mixtures (to replace wheat flour): 1) ½ cup sorghum flour; ½ cup bean flour; 2 T. tapioca starch 2 ) ½ c. rice flour, ¼ c. tapioca starch, ¼ c. cornstarch or potato starch 3) 1 c. brown rice flour, 1 c. white rice or teff flour, 2/3 c. potato starch, 1/3 c. tapioca starch

29. Baking tips: Better results with combination of alternative flours Use gelatin, extra egg or oil to increase moisture Enhance flavor: add chocolate chips, nuts, dried fruits, extra spices Milk products can enhance structure (cottage cheese, dry milk solids, extra eggs, evaporated milk) Reduce grainy texture: mix rice flour or corn meal with liquid called for; bring to boil and cool before adding to recipe. Honey or rice malt syrup can help retain moisture Dough enhancers improve tenderness & staling resistance Brown sugar often works better than white Be creative! (i.e. Casserole topper: use crushed rice cakes for bread crumbs) Dough enhancers contain lecithin from soy or eggs, ascorbic acid - Dough enhancers contain lecithin from soy or eggs, ascorbic acid -

30. Baking tips Leavening Starch flours need more leavening than wheat flours ROT: use 2 tsp. baking powder per each cup of low gluten flour If baking soda and buttermilk are used for leavening, add 1 & 1/8 tsp. cream of tartar for each ½ tsp. baking soda used (to sufficiently neutralize the acid) For better rise, dissolve leavening in liquid before adding to other ingredients. Pre-baking Refrigerate low gluten products before baking –to improve texture. Let non-yeast doughs rest for 30 minutes before baking (kneading time is shorter-no “elastic” feel) Grease pans well (non-stick spray) Use dull or dark pans for better browning Time and Temperature Bake in smaller than usual portions at lower temperature for a longer time English muffin tins good size for bread recipes ROT = rule of thumbROT = rule of thumb

31. High Altitude Adjustments Cannot assume that “usual” high altitude adjustments will work with gluten-free recipes Additional adjustments may or may not be necessary Standard recipes: adjust for gluten-free first, then experiment with altitude adjustments Tested gluten-free recipes: try basic altitude guidelines (extra moisture, slightly less leavening, shorter rise time, etc.) More research needed in this area (large variety of gluten-free ingredients available now)

32. Bread making and storage Add 1 to 2 T. more flour Decrease sugar by 1 to 2 tsp. Shorten rising time by ~10 min. Gluten-free breads will lose moisture quickly! To retain moisture: Wrap product well in airtight packaging i.e. Use wax paper in between layers Wrap individually Store in refrigerator Freeze product if won’t be consumed within 3 days Brown sugarBrown sugar

33. Retail Products GF is mainstream GF food industry: > 25% growth annually; $700 million(2006) Expected to top $1 billion by 2010 Ask/look for lists of gluten-free products available Read food labels Many cereals and grain products are labeled Rice Chex: first mainstream GF cereal Check out local resources Natural food markets: some have list of all GF products Specialty bakeries Restaurants: many offer GF entries Local products: Fiona’s Gluten-Free Quinoa Crunch

34. Eating away from home Some restaurants have special menus, have to request Some available online Call ahead and speak with manager or chef to determine what food items are GF. Beware- oil in deep fat fryers often contaminated Make server aware (no croutons on salad, etc.) Ask him/her to check with cook/chef or read ingredient label if in doubt

35. Eating away from home Traveling: restaurant cards are available in 42 languages http://www.celiactravel.com/restaurant-cards.html Hospital: ask to speak with dietician School: talk with teacher, cafeteria director or food service manager Potlucks: take something filling, GF selections may be limited

36. Living a Gluten-free Lifestyle View as an opportunity to follow a healthy diet Experiment with recipes Focus on the wide array of GF foods Try out new GF foods carefully Take advantage of growing number of resources, cook books & support groups Attitude is important “Quite frankly, there has never been a better time to be diagnosed with celiac disease.” Tricia Thompson, M.S., R.D.

37. Resources-Handouts Living Without® Pantry: Substitution Solutions www.livingwithout.com Go Gluten Free! Tips for Getting More Nutrition Into the Gluten-Free Diet By Shelley Case, RD; www.livingwithout.com New Horizons for Whole Grains and the Gluten-Free Diet; By Carol Fenster, PhD; wwwglutenfreequickandeasy.com and Shelley Case, RD, author of The Gluten-Free Diet: A Comprehensive Resource Guide at wwwglutenfreediet.ca Wheat, Gluten, Egg and Milk Free Recipes: for use at high altitudes and at sea level; CSU Extension Bulletin 530A http://www.cerc.colostate.edu/titles/530A.html

38. Resources & References Alessio Fasano, M.D., director; Univ. of Maryland School of Medicine’s Center for Celiac Research; www.celiaccenter.org Celiac disease, MayoClinic.com, accessed July, 2008: http://www.mayoclinic.com/health/celiac-disease/DS00319 Celiac Sprue Association-Denver Metro Chapter: http://www.geocities.com/csadenver17 Gluten-Free Diet Guide for Families Children’s Digestive health and Nutrition Foundation (CDHNF); University of Maryland Center for Celiac Research. www.celiachealth.org Health Canada (Oat Safety Technical Review) www.hc-sc.gc.ca/fn-an/securit/allerg/cel-coe/oats_cd-avoine_e.html High Altitude Food Preparation http://www.cerc.colostate.edu/titles/P41.html and http://www.cerc.colostate.edu/titles/530A.html Questions and Answers on the Gluten-Free Labeling Proposed Rule; U.S. Food and Drug Administration ,Center for Food Safety and Applied Nutrition (FDA-CFSAN) at http://www.cfsan.fda.gov/~dms/glutqa.html#q8. The Faces of Celiac Disease trifold; Celiac Disease Foundation. www.celiac.org

39. References Braithwaite, D. (2006) Do Oats or Spelt Belong in a Gluten-free Diet?, MS Thesis, Colorado State University, Fort Collins, Colorado Brown, A. Understanding Food. Thomson/Wadsworth, Belmont, CA Fasano, A., I. Berti, T. Geraduzzi, T. Not, R. Colletti, S. Drago, Y. Elitsur, P. Green, S. Guandalini, I. Hill, M. Pietzak, A. Ventura, M. Thorpe, D. Kryskak, R. Fornroli, S. Wasserman, J. Murray, K. Horvath (2003) Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: A large multicenter study. Archives of Internal Medicine 163: 286-92. Hagman, B. (1999) The Gluten-Free Gourmet Bakes Bread. Owl Books, New York. Hoseney, C. (1998) Principles of Cereal Science and Technology, AACC, St. Paul, MN Kasarda, D. (2003) Celiac Disease and Safe Grains. USDA. wheat.pw.usda.gov Niewinski, M. (2008) Advances in Celiac Disease and Gluten-Free Diet. Journal of the American Dietetic Association, 2008:108:661-672 Thompson, T. (2008) The Gluten-Free Nutrition Guide, McGraw Hill, New York USDA, United States Department of Agriculture, Economic Research Service. www.usda.gov

40. Acknowledgements-CSU Extension Laura Bauer, Master’s student-FSHN Linda Quaratino, Administrative Assistant Pat Kendall, PhD, RD, Professor and Extension Specialist Mary Harris, PhD, RD, Professor Martha Stone, PhD, Professor