Residential/Health Care Facilities Food Avoidance/Gluten Free Success

RD’s have a leadership role in health management  Celiac Disease prevalence and awareness  Food avoidance- Food allergy  Menu Design/Food Service  Gluten Free Diet management [email protected]

1 out of 3 people say they modify their diets because they, or a loved one, have a food intolerance /allergy

www.Niaid.nih.gov

~110,000,000 people

, 70% of people over 65 can expect to use residential care

longtermcare.gov 2

Conclusion:

The prevalence of celiac disease was high in elderly people, but the symptoms were subtle….. Increased alertness to the disorder is therefore warranted.

Vilppula A et al. Undetected coeliac disease in the elderly: a biopsy-proven population-based study. Digestive and Liver Diseases 2008;40:809-13

§483.35 /Dietary Services (e) Therapeutic Diet (LTC)



F325 §483.25(i)(2) Receives a therapeutic diet when there is a nutritional problem.

Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible

483.35 Dietary Services (d) Food

 F365 Food prepared in a form designed to meet individual need  F366 Substitutes offered of similar nutritive value to residents who refuse food served  A food Substitute should be consistent with the usual and ordinary food items provided FNC Food Allergy and Intolerance

6

Resident Choice

 See Residents Rights at 42 CFR 483.10 (b)(3) and (4) and F 154 and F155 ‘In order for a resident to exercise his/her right appropriately to make informed choices … consequences of refusing treatment….. When allergies are in the medical record, a medical note is needed if ‘allergy to food’ is to be served. FNC Food Allergy and Intolerance

8

Assess food delivery systems Standardize diet orders Facility Training Plan Menu Plan Nourishments Plan Snacks

Admin support

Tray Accuracy Buy and store food Cross contamination Kitchen training

Check your Policy: Therapeutic Diets Therapeutic diets are prepared and served as prescribed by the attending physician. Therapeutic diets are planned and are on menu extensions.

Check there is a solid policy for like substitutions. Many with gluten/dairy restrictions will want their favorite brand!

10

Food, personal products and crafts may cause reactions Interdepartmental Facility Mission Statement F- tag Potential Admin support Liability Satisfaction Survey’s 3 Million Celiac

11

Metabolic Disorders False food Allerg Idiosyncratic Caffeine Alcohol MSG Food Intolerances Cow ’ s Milk / soya Allergy

12

Food Avoidance

Food Aversion Intolerance Allergy (Immune)

13

No Milk Dairy Allergy Milk free Lactose Free

Food Aversion

I do not like milk I am Vegan

Intolerance

May not drink milk but uses Lactose Free milk eats yogurt and cheese

Allergy

No Casein, Whey Or Lactose An in-depth food preference interview is needed to help your kitchen be successful Follow the most strict diet order until individualized!

14

xxxxxxxxxxxxxxxx XXXXXXXXX People and Professionals may use different words to describe food avoidance

Food Aversion

 Phobia’s  Food Preferences   Vegan, Kosher, Halal Food Fad’s  Clockwork orange conditioning  Disordered eating  What’s your most unusual one?

FNC Food Allergy and Intolerance

16

Allergies are to proteins



Gal d 6 is the second allergen characterized from egg yolk.

Only one allergen from the egg yolk, alpha-livetin (Gal d 5) has been described thus far. A new egg yolk allergen was detected studying 27 egg allergic patients. 5 of the 27 patients (18%) detected a yolk allergen of an apparent molecular weight of 35 kDa. Heating and reduction treatments did not affect its allergenicity, although digestion with simulated gastric fluid diminished the IgE-binding capacity of the allergen. The N-terminal amino acid sequence corresponded with the YGP42 protein, a fragment of the vitellogenin-1 precursor. The allergen was designated Gal d 6.  Amo A, Rodríguez-Pérez R, Blanco J, Villota J, Juste S, Moneo I, Caballero ML.

Gal d 6 is the second allergen characterized from egg yolk.

J Agric Food Chem 2010 Jun 23;58(12):7453-7.

17

FNC Food Allergy and Intolerance

18

Metabolic intolerance

 Favism  Trehalose insufficiency  Pancreatic dysfunction  Inborn Errors of Metabolism  Damage to enzyme producing cells can cause secondary Intolerances  Histamine intolerance: reduced activity of diamine oxidase (DAO). FNC Food Allergy and Intolerance 19

Digestive Enzymes and source

     Mouth: ∂ amylase Stomach: pepsins Pancreas: amylase, lipase and Proteases Gall Bladder: Bile Brush Border      Lactase ∂ glucosidase β galactosidase Sucrase-Isomaltase Amino-ogliopeptidase     Starch ∂ 1 →4 bonds Protein dextrin, triglycerides Peptides Fat micelle formation      Lactose→glu + gal ∂ 1 →4 bonds ∂ 1→6 bonds Sucrose → glu & fru maltose → glu & glu Removal of N terminal aa’s FNC Food Allergy and Intolerance

20

Why is GF so popular?

Food Avoidance Gluten/Wheat

Food Aversion

High Protein Diet Fad Diet

Intolerance

May limit pasta and bread due to digestive discomfort

Allergy/Celiac Wheat Free is Not Gluten Free

Population screened 13,145 Healthy Individuals 4126 Risk Groups 9019 Positive 31 Negative 4095 Symptomatic subjects 3236 1st degree relatives 4508 2nd degree relatives 1275 Positive 81 Negative 3155 Positive 205 Negative 4303 Positive 33 Negative 1242 Prevalence 1:132 Prevalence 1:40 Prevalence 1:22 Prevalence 1:39 Projected number of celiacs in the U.S.A.: 3.3 million Center for Celiac Research Epidemiologic Study in USA Arch Int Med 163:286-292, 2003 Fasano et al.

Celiac disease is an immune reaction to proteins found in wheat (Gliadin), rye (secalin) and barley (hordein) collectively known as gluten. Other grains have proteins that food scientists call gluten that are not avoided on physician ordered gluten-free diets, important for pharmacy calls.

FNC Food Allergy and Intolerance

A. Fasano and T. Shea Donohue, Nature Clin Pract Gastroenterol Hepatol 2005 (in press) 25

World Gastroenterology Organization Practice Guidelines:

 

Celiac Disease

Associated conditions

  

Malignant disease Osteoporosis Autoimmune disorders

Such disorders include:  • Insulin-dependent type 1 diabetes       • Thyroid disease • Sjögren’s syndrome • Addison’s disease • Autoimmune liver disease • Cardiomyopathy • Neurological disorders

Detection of Celiac Disease in Primary Care: A Multicenter Case-Finding Study in North America Carlo Catassi, M.D., M.P.H., CD was diagnosed in 22 out of 976 investigated patients The most frequent reasons for CD screening bloating (12/22) thyroid disease(11/22), irritable bowel syndrome (IBS) (7/22), unexplained chronic diarrhea (6/22), chronic fatigue (5/22), and constipation(4/22). The small bowel biopsy was available in 15 out of 22 GFD was implemented in 17 out of 22 cases. American Journal of Gastroenterology ISSN 0002-9270 2007 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2007.01173.x

Classic GI Presentation

  HF: 86 YO WF admitted to sub-acute care unit for DX: Deconditioned post hospitalization for syncope and collapse. Persistent Diarrhea ċ c-dif negative, anemia of chronic disease Admit wt 112 # family stated UBW 125 5’3 Wt loss ~13# past quarter (90% UBW)  Increased confusion, poor po of regular diet and supplements (2Cal product 120 mL QID)  Decreased H/H, BUN 32, Cr .5, GFR WNL  GI consult ordered, admitted to the hospital

HF: 86 YO WF

Readmit new dx: Celiac Disease DO: Regular Facility MD resistant to diet change due to age Family meeting: Changed to gluten-free diet order Therapeutic vitamin (strovite plus), Iron support Nutritional supplements (2-Cal/mL 120 mL QID) Weight gain, increased participation in activities and Physical therapy and resolved diarrhea Discharged back to the Assisted Living in 15 weeks at 120 pounds, PO 50-75%, 8 oz 1 cal/mL drink Today’s dietitian April 2007 vol 9 no 4 Long term care concerns feature for ©

2007 Becky Dorner & Associates, Inc.

LN admitted sub acute 02/2008

 Diagnosis  MS    Multiple stage III & IV Anemia constipation  Weight Loss 30# in 3 years 5’3 admitted 97# UBW 110  Diet History :  2000 cal daily (45cal/kg)  Labs: Hydration normal   Alb 2.7 Ca++ 8.3

H/H 8.3/2.7

LN: Cal count results 45kcal /kg 1.8 g protein/kg WT: 98# Requested ‘Celiac panel’, total IGA and Vit D Lab results: Reticulin IgA WNL EMA WNL, Gliadin IgA WNL Gliadin IgG WNL MD concluded negative for celiac

www.celiac.nih.gov

LN continued

  Went home and was readmitted to the hospital with respiratory distress.

Was to return to the sub-acute  53 YO with weight loss despite a hearty appetite died of respiratory failure Celiac panel inconclusive: no total IgA

Recommendations for practice

 Call lab and ask for lab numbers for Total IgA and tTG instead of the ‘celiac panel’  Acculab in NJ total IgA # 1029  Acculab in NJ tTG # 1506   Less expensive test ideal for screening With results seek GI referral. Will justify EGD when presented with extraintestional symptoms

LL admitted 01/2008

Nutrition Plan of Care:  Diagnosis  Syncope and Collapse    Pneumonia Anemia Celiac Disease  Diet History :     Gluten Free Diet 20 years Lived with niece due to mental deficit Rice Krispee’s AM Communion (regular)  Labs: As expected 1- Review GF diet with Kitchen 2- Review facility GF diet with resident and Family 3- Give Activities GF hosts for Pastor to bless 4- Meet Nutrition needs as assessed

Assess food delivery systems Standardize diet orders Facility Training Plan Menu Plan Nourishments Plan Snacks

Admin support

Tray Accuracy Buy and store food Cross contamination Kitchen training

Communication channels:

Dietary: Clinical and Food Service Nursing Functions: med pass/ HS snacks Activities: Rehab Therapies Other: Chaplin; Pharmacy; IT department Administration support needed for Interdepartmental communication to be successful

Religious Needs

 Low-Gluten Hosts  1-800-223-2772 www.benedictinesisters.org

 Matzo  www.glutenfreematzo.com

 Made from GF Oats

CMS

INTENT: §483.25(i) 325 Nutritional Status uses Celiac Disease example:



A resident with known celiac disease (damage to the small intestine related to gluten allergy) develops persistent gastrointestinal symptoms including weight loss, chronic diarrhea, and vomiting, due to the facility's failure to provide a gluten free diet (i.e., one free of wheat, barley, and rye products) as prescribed by the physician.

Standardize diet orders

Admin support

Check the Diet Manual !!!!!

misinformation

‘ Read all labels carefully. Many ingredients contain gluten but may not list it as such.

Avoid: commercial products or mixes containing malt or malt flavorings, textured vegetable protein , hydrolyzed vegetable protein, cereal products, flour, starch , wheat, rye, barley, oat, farina, semolina, durum, triticale, gums, emulsifier …. MENU PLANNING GUIDELINES: stabilizers, vinegar, artificial colors or flavors, some monosodium glutamate, vanilla.

What’s up with this statement in the manual guidelines? Use of soy products should be individually evaluated. Millet and buckwheat may not be tolerated by some .

Standard

Gluten Free Dairy Free Lactose Free Egg Free Peanut/tree nut free Soy-Free Additive-Free Latex Free

All DO’s Policy until individualized

Celiac, wheat allergy, wheat free, no bread No Wheat, rye, barley aka malt, spelt or oats No Milk, Milk or diary allergy, Casein Free No animal milk: Lactose, Casein, whey ingredients Lactose Intolerance, lactose free, low Lactose Food preferences may have milk protein (casein & whey) e.g. coffee creamers Egg allergy, no Eggs Peanut allergy, nut allergy, no seeds or nuts No egg ingredients No egg substitutes No nuts/peanuts including their oils Soy allergy, no soy No soy ingredients. Soy oil and lecithin allowed unless specified Feingold diet, sulfite, MAO MSG, asthma diet Any diet with latex allergy Identified in chart No additives: low sulfite, Salicylates, tyramine No latex gloves around food or tray, no banana, kiwi, avocado, chestnuts

Worcestershire Sauce



Ingredients: distilled white vinegar, molasses, water, sugar, onions, anchovies, salt, garlic, cloves, tamarind extract, natural flavorings, chili pepper extract. Contains anchovies

.

45

Dairy allergy Diets Eliminate

Casein Whey lactose  Fluid Milk  Ingredient Milk  Cream  Butter  Check All processed foods  Cream Soup  Cheese  Yogurt  Check non-dairy creamer (sodium caseinates) 46

FDA definition gluten free

< less then 20 PPM in finished goods One slice of regular bread has 124,000 PPM One slice of gluten free bread usually < 5 PPM Claims for food service are encouraged to follow FDA regulation for manufacturers TIP: Use ‘ Gluten-restricted’ as term Use gluten-free ingredients or TEST.

Daily intake of Carbs and ppm of gluten in food for celiacs

50 g 100 g 200 g 300 g 200 ppm

10 mg

100 ppm

5 mg

50 ppm

2.5 mg

20 ppm

1 mg 20 mg 10 mg 5 mg 2 mg 40 mg 20 mg 10 mg 4 mg 60 mg 30 mg 15 mg 6 mg

www.tastelikerealfood.com

 NET WT 14.7 oz. (417g) Makes 1 loaf. Mix contains less than 20 ppm total gluten content, which is considered gluten-free according to the Codex Alimentarius, the European food safety standard. Ingredients SPECIALLY FORMULATED WHEAT STARCH*, BUCKWHEAT (WHOLE GRAIN AND FLOUR), PRECOOKED RICE FLOUR, GLUCOSE, BEET FIBER, POTATO FIBER, SESAME SEEDS, POTATO STARCH, STABILIZER (E464), SALT, RICE STARCH, VEGETABLE FAT (PALM OIL), RAISING AGENT (CALCIUM PHOSPHATE, SODIUM HYDROGEN CARBONATE), THICKENING AGENT (XANTHAN GUM).

Meal Service system Standardize diet orders

Admin support

Assess Food Service Systems

 Review your system and risks  Tray Line Plate  Buffet Style  Room Service cook to order  Snack carts, Floor Stock and Activities

Meal delivery system Standardize diet orders Plan Menu Plan Nourishments Plan Snacks

Admin support

§483.35 Dietary Services (c) Standard Menus/Adequacy

 F 363 Probe (c) (1) If a food group is missing from the resident’s daily diet, does the facility have an alternative means of satisfying the resident’s nutrient needs.

 F 363 Probe (c) (3) Is food served as planned?

Specifics help the production staff

Facility Knowledge: FSD first GF resident was from the UK. They requested Rice Krispees… on the UK list of ‘allowed’ prior to 2008.

56

Menu Analysis: Food Allergy extension Do Not Serve Recipe # Menu item name Dairy allergy Do not serve Egg Allergy Do not serve Do not serve Fin Fish allergy gluten reduced Do not serve Do no serve Do not serve Do not serve Lactose reduced peanut/nut free Seafood Free Shellfish allergy Juice of 1 Choice 2 Cold Cereal 3 Oatmeal ? Made with milk?

4 Farina ? Made with milk?

5 Cream of Rice ? Made with milk?

Scrambled 6 Egg ? Made with milk? ( Greek yogurt or other 7 gram protein 7 Bacon 8 Toast 9 Milk ? Made with milk? Made with egg?

Soy, almond milk Tuna Salad 10 Sandwich ? Milk in dressing ? Mayo 11 beef Pot Pie (Chex Cereal only) (Cream rice only) (Cream rice only) (Gluten Free bread) Ham salad (gluten free bread Worchester sauce?

Serve Beef stew if flour not used or beef stir fry on rice ? Made with milk?

? Made with milk?

? Made with milk?

lactose reduced ham salad 57

Foods that contain: _____Gluten/wheat__________________ Recipe # Sub with: 1.__white/rye/toast/rolls__________ Sub_ gluten-free bread or fruit cup_ 2.__Muffins/croissants____________ Sub__gluten-free muffin or fruit cup 3. _pancake/waffle _______________ Sub __gluten-free pancake 4.__blintz__________________ _ Sub ___omelet_______ 5._______________________ Sub ____________________ 6.______________________ Sub____________________ 7.______________________ Sub____________________ 8. ______________________ Sub ____________________ 9.______________________ Sub ____________________ Cheat sheets can assist departments 58

Oven Fried chicken Rice Pilaf Buttered Beets Dinner Roll Margarine Lemon Meringue Pie Baked Chicken Breast -

GF gravy

White Rice -

GF Soy Sauce

Buttered Beets

GF Microwave Cornbread

Margarine Lemon Pudding on GF Microwave Biscuit Whipped Cream

CONTAINS BARLEY Rice Chex are Gluten Free The barley has been replaced with Molasses! 60

Watch Gravy and bacon bits

 Gluten Free Stock Certified:   Celinal Foods Cuisine Santé (HACO)  RC Fine Foods Limit Cross Contamination! Make GF gravy portion, label and freeze  Read all labels for ingredients: recipes can change on non certified food.

All Wheat Flour is Enriched

 Thiamin  Riboflavin  Niacin  Iron  Folate  GF products usually are not fortified

Field to Plate: 0ats

64

Meal delivery system Standardize diet orders Plan Menu Plan Nourishments Plan Snacks

Admin support

Buy and store food



Ingredients: Enriched flour (wheat flour, malted barley, niacin, reduced iron, thiamin mononitrate, riboflavin, folic acid), sugar, partially hydrogenated soybean oil, and/or cottonseed oil, high fructose corn syrup, whey (milk), eggs, vanilla, natural and artificial flavoring) salt, leavening (sodium acid pyrophosphate, monocalcium phosphate), lecithin (soy), mono-and diglycerides (emulsifier)



OR

Contains wheat, milk, egg and soy ingredients

FALCPA

 FDA advised that advisory labeling such as "may contain [allergen]" should not be used as a substitute for adherence to current Good Manufacturing Practices (cGMPs). In addition, any advisory statement such as "may contain [allergen]" must be truthful and not misleading.  Fines attached for non-compliance

WHEAT FREE IS NOT GLUTEN FREE!

 Made in plant with Wheat- GMP  Shared Equipment : GMP more difficult

Rice Chex are Gluten Free The barley has been replaced with Molasses! CONTAINS BARLEY

Certification/ Dedicated Plants

Recognized by

Ingredients on lists to Question

     Modified Food Starch* Citric Acid*  need to ask if using imported Caramel Coloring* Flavoring* Dextrin*    Soy Sauce  often contains wheat Mono and Diglycerides  may have a wheat carrier when used in dry ingredients but it should be declared Brown Rice Syrup  may be made from barley * By definition may contain wheat but US manufactures say they are not using gluten containing grains

Other Concerns

 Where to purchase?

 Distributor: May stock or Special Order  Local Grocery: Keep Receipts!

 Check Labels Each Time!

 Store High if possible  Label book for reference

Plan meals and snacks Assess production ability: make or buy Assess product availability: Distributor Nutritionally Adequate Assess Other Departments Food Needs Include all Therapeutic and Consistency Don’t forget the disaster menu

F 371

 Store, prepare distribute and serve food under sanitary conditions;   Reduce the practices which result in food contamination Store GF foods higher then flour bins and away from mixes - Wrap, date and Identify clearly

Meal delivery system Standardize diet orders Plan Menu Plan Nourishments Plan Snacks

Admin support

Buy and store food

Cross contamination Kitchen training

LL admitted 01/2008 2 weeks later

Plan of Care:  Diagnosis   Add persistent diarrhea Benign pancreatic mass  Diet  Facility Gluten Free Diet   No Outside snacks Communion (low gluten) 1- Review GF diet with Kitchen 2- MD to evaluate Pancreatic Mass for change 3- R/O C- Diff 4- Nurses to check medications with pharmacy

Crumbs Count

Double Dipping

Trouble hot spots

Flour and rice scoop stored together No Ingredient statement

The Kitchen

There are no scientific studies to evaluate cleaning practices or methods

Food Allergy News suggestions

1- Warm soapy water 2- Fresh cloth or paper towel to wipe 3- Prep the special diet foods first 4- Wrap and Identify clearly

Ongoing Inservice Education

Meal delivery system Standardize diet orders Plan Menu Plan Nourishments Plan Snacks

Admin support

Tray Accuracy Buy and store food

Cross contamination Kitchen training

Right Tray, Right Person

 Visual cues    Tray color napkin color Icon  Tray ticket color  Privacy rights

XXXXX

What if Everything was perfect: except the roll?

Prepare for Kitchen Training

Rewrite inservices to include an allergy component for continued reinforcement Topics to update: Sanitation, Inventory storage, Food preparation Tray line Services, Therapeutic Diets, Food Safety Mechanically Altered, Residents Rights

Food Allergy Kitchen Protocol

Follow Recipes Allergen trays prepared first Equipment and work surfaces will be cleaned before use with a fresh cloth or paper towel. Clean and Sanitized utensils to be used in food production and portioning. Label read every time unless specific claim made on the label Food can not be fixed…. start over

Meal delivery system Standardize diet orders Tray delivery feeding assts Therapists Plan Menu Plan Nourishments Plan Snacks

Admin support

Tray Accuracy Buy and store food

Cross contamination Kitchen training

October 31, 2008 By

DAVID GIALANELLA

Staff Writer

Prosecutors said Thursday they are reviewing the case of an Elgin Mental Health Center patient who died months ago after two facility employees allegedly gave him a meal containing fish despite a severe fish allergy . Morris Howard, 58, formerly of Chicago, died on June 20 after the employees gave him the meal, which investigators said sent him into anaphylactic shock.

A coroner's jury on Wednesday ruled the death a reckless homicide. Illinois State Police investigators earlier this week handed the case off to the Kane County State's Attorney's Office, and criminal charges against the employees could be announced in the coming days, according to State's Attorney John Barsanti .

Barriers to Compliance

 Daily Lifestyle Challenges  Quality of Life Issues  Limited Cooking availability and/or skill  Not Convenient  Costly  Misinformation  Psych-Social Challenges  Knowledge Deficit of suitable substitutions

LB CCRC DNR DNH resident in Skilled Nursing  Diagnosis  Alzheimer’s Disease    Osteoporosis Depression Hypercholestermia       7/2009 WT 113 8/2009 WT 114 (husband admitted to share room) 9/2009 WT 115-118 10/2009 WT 120 11/2009 WT 118-120 12/2009 weight gain started 124     4/2009 WT 122 BMI 19.5

DO: Gluten-Free POS: allergy: wheat 5/2009 WT 120 RD selected menu for resident for GF status 6/2009 WT 115 (new MDS significant change) Supplement 2cal/mL and magic cups Vitamin not ordered after call to pharmacy no GF guarantee.  7/2010 Wt 133- nurses are concerned due to acute decrease in PO. No GI distress reported. Resident states: ‘I eat gluten-free foods: no bread or pasta’ Strovite Plus Vitamin ordered  Celiac panel ordered

LB CCRC DNR DNH resident in Skilled Nursing  Reticulin IgA WNL  Endomysial IgA WNL  Gliadin IgG 15.8 H  Gliadin IgA 13.2 H  Labs inconclusive would need an EGD to confirm celiac disease at this time.

LB CCRC DNR DNH resident in Skilled Nursing  Diagnosis  Alzheimer’s Disease    Osteoporosis Depression Hypercholestermia    9/2010 134 10/2010 135 11/2010 supplement d/c'd  DO continued Gluten-Free.    4/2009 WT 122 BMI 19.5

DO: Gluten-Free POS: allergy: wheat 8/2010 WT 136. RD/RN charting on overt intake of gluten containing food between meals. (husbands PB&J HS snack). PO improving, seeking food items. No GI distress  Recommend to change to regular diet with RD selecting gluten-free meals as preference 2 ° to behavior and clinical presentation.

 www.glutenfreedrugs.com

review medications as needed. to

GF resident admitted

 Review diet management with kitchen  Review diet order rational with nursing/caregivers  Review religious needs with activities. Review with other departments as needed: speech therapy screens no crackers.  Request baseline tTG for monitoring on admission with known celiac residents.

Management Musts All therapeutic diets should be in the diet manuals. Road map for staff success. Policy for purchasing foods for ‘free-of’ diet requests. (Therapeutic diet vs preferences) If allergen food requested (Resident Rights) written medical approval is required.

98

Resources & Web Sites



Gluten-Free Diet: A Comprehensive Resource Guide

- Shelley Case www.glutenfreediet.ca

 The Celiac Diet, Series 1-7 Carol Rees Parshi MS RD  http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/resources.cfm

  Evidence Based Standards of Practice http://celiac.nih.gov

www.eatright.org

manual of clinical dietetics AGA Institute Medical Position Statement on the DX and Mngt of Celiac Disease: Gastroenterology 2006;131:1977-1980 Center for Celiac Research  www.celiaccenter.org

 Steve Plogsted’s medication list  www.glutenfreedrugs.com

 Local Support Groups: CSA, GIG,CDF, Independents  [email protected]

  Religious resource  [email protected]

, http://glutenfreematzo.com

Allergen Food for Institutions mailorder  www.celinalfoods.com

(also available thru Gordon Food Service) www.med-diet.com

Celiac Disease and the aged: limited clinical studies       Murray JA .

Et al. Morbidity and mortality among older individuals with undiagnosed celiac disease.

Gastroenterology. 2010 Sep;139(3):763-9 Collin P et al. Increasing Prevalence and high incidence of celiac disease in elderly people: A population-based study.

BMC Gastroenterology

2009;

9

:49 Vilppula A et al. Undetected coeliac disease in the elderly: a biopsy proven population-based study. Digestive and Liver Diseases 2008;40:809-13.

Lurie Y et al. Celiac disease diagnosed in the elderly. Journal of Clinical Gastroenterology 2008;42:59-61 Hu WT et al. Cognitive impairment and celiac disease. Archives of Neurology 2006;63:1440-46.

Hankey GL, Holmes GK. Coeliac disease in the elderly. Gut 1994;35:65-67.