Protein Labelling Accuracy for UK Patients with PKU Following a Low Protein Diet.

A phenylalanine (protein)-restricted diet is the primary treatment for phenylketonuria (PKU). Patients are dependent on food protein labelling to successfully manage their condition. We evaluated the accuracy of protein labelling on packaged manufactured foods from supermarket websites for foods that may be eaten as part of a phenylalanine-restricted diet. Protein labelling information was evaluated for 462 food items ("free from", n = 159, regular, n = 303), divided into 16 food groups using supermarket website data. Data collection included protein content per portion/100 g when food was "as sold", "cooked" or "prepared"; cooking methods, and preparation instructions. Labelling errors affecting protein content were observed in every food group, with overall protein labelling unclear in 55% (n = 255/462) of foods. There was misleading, omitted, or erroneous (MOE) information in 43% (n = 68/159) of "free from" foods compared with 62% (n = 187/303) of regular foods, with fewer inaccuracies in "free from" food labelling (p = 0.007). Protein analysis was available for uncooked weight only but not cooked weight for 58% (n = 85/146) of foods; 4% (n = 17/462) had misleading protein content. There was a high rate of incomplete, misleading, or inaccurate data affecting the interpretation of the protein content of food items on supermarket websites. This could adversely affect metabolic control of patients with PKU and warrants serious consideration.

New Software for Gluten-Free Diet Evaluation and Nutritional Education.

Following a gluten-free diet (GFD) is the only treatment for celiac disease. This diet must ensure the absence of gluten but also needs to be nutritionally balanced. Dietitians working in this field cannot properly evaluate energy and nutrient intake of celiac people because dietary programs available on the market do not contain the nutritional composition of gluten-free products (GFP). Here we present a new GFD evaluation software that contains more than 700 gluten-free rendered foodstuffs and their macronutrient composition. Apart from diet evaluation and design, the software represents a tool for nutritional education as well, since it shows diet appropriacy and indicates how to promote balanced self-care. Moreover, anthropometric and biochemical data or symptoms presence and diet adherence can be recorded and evaluated. This open free software, can be downloaded in its app format for mobiles and tablets. Software evaluation indicated its correct functionality and the importance of assessing a GFD with GFP instead of with their gluten-containing analogues. Thus, this software represents an essential e-Health tool, not only for proper GFD evaluation, but also for improving life quality of celiac and gluten sensitive people.

[Analysis of the gluten-free menus served in school canteens: are they balanced?] / Análisis de menús sin gluten de comedores escolares en granada capital y área metropolitana: ¿son equilibrados?

INTRODUCTION: Introduction and objectives: the alimentary profile and the nutritional value of the menus adapted for coeliacs in the dining halls of the schools of Granada capital and Metropolitan Area. Material and methods: descriptive study in which we analyzed the menus adapted for children from 41 schools, 5 with their own kitchen and 36 supplied by catering. The information is recognized through the technical sheets of the dishes made with the quantity of each food, in addition to the brands of the gluten-free products. The four-week menus will be analyzed in terms of the distribution of rations, energy, macro and micronutrients for the age group of 10 to 12 years, obtaining average values and standard deviation of 31 parameters. The Odimet program and the CeliacBase database are used. The data will be analyzed using the IBM SPSS 22.0 statistical program. Results: gluten-free pasta was the basis of the first course in 31.7% of the menus analyzed. In the second dish, the meat was the main constituent. In all the menus, at least one daily vegetable ration was offered. 80% of the menus did not reach the recommended energy intake, although the distribution of macronutrients was adequate. The average amount of fiber and total carbohydrates was higher than recommended. The amount of calcium and vitamin has not been recommended. It emphasizes a high consumption of sodium, which doubles the amount recommended for the midday meal. Conclusions: school menus adapted for children conform to the recommendations, although they should be limited to intake.

INTRODUCCIÓN: Introducción y objetivos: analizar el perfil alimentario y el valor nutricional de los menús adaptados para celiacos ofertados en los comedores de los centros escolares de Granada capital y área metropolitana. Material y métodos: estudio descriptivo en el que se han analizado los menús adaptados para niños celiacos de 41 centros escolares, cinco con cocina propia y 36 abastecidos por catering. La participación de los centros fue voluntaria, una vez fueron informados de las características y objetivos del estudio. Se recogió información a través de las fichas técnicas de los platos elaborados con la cantidad de cada alimento, además de las marcas de los productos sin gluten utilizados. Se analizaron menús de cuatro semanas en cuanto a distribución de raciones, energía, macro y micronutrientes para el grupo de 10 a 12 años, obteniendo valores medios y desviación estándar de 31 parámetros. Se utilizaron el programa Odimet y la base de datos CeliacBase. Se usó el programa estadístico IBM SPSS 22.0. Resultados: la pasta sin gluten fue la base del primer plato en el 31,7% de los menús analizados. En el segundo plato, la carne fue el constituyente principal. En todos los menús se ofertaba, al menos, una ración diaria de verdura. El 80% de los menús no alcanzaron la ingesta energética recomendada, aunque la distribución de macronutrientes fue adecuada. La cantidad media de fibra y de hidratos de carbono totales fue superior a lo recomendado. La cantidad de calcio y vitamina D no alcanzó la ingesta recomendada. Destaca un elevado consumo de sodio, que duplica la cantidad recomendada para la comida del mediodía. Conclusiones: los menús escolares adaptados para niños celiacos se ajustan a las recomendaciones, aunque deberían limitar la ingesta semanal de carne y presentan exceso de azúcares totales y sal.

Detection of Gluten in Gluten-Free Labeled Restaurant Food: Analysis of Crowd-Sourced Data.

INTRODUCTION: Adherence to a gluten-free (GF) diet is the mainstay of therapy for celiac disease. Until now, those wishing to avoid gluten in restaurants had to rely on menu labels, word of mouth, intuition, and restaurant workers' advice, with a relative dearth of supporting data. We used crowd-sourced data from users of a portable gluten detection device to estimate rates of, and identify risk factors for, gluten contamination of supposed GF restaurant foods. METHODS: We analyzed data from a portable gluten detection device (Nima), collected across the United States during an 18-month period by users who opted to share the results of their point-of-care tests. Data were sorted by region, time of day, median household income in the restaurant's vicinity, restaurant genre, and food items. We used the χ test for bivariate analysis and multiple logistic regression for multivariate analysis to identify predictors of gluten detection in restaurant food. RESULTS: There were 5,624 tests, performed by 804 users, in the examined period. Gluten was detected in 32% of GF labeled foods. Rates of gluten detection differed by meal, with 27.2% at breakfast and 34.0% at dinner (P = 0.0008). GF labeled pizza and pasta were most likely to test positive for gluten, with gluten detected in 53.2% of pizza and 50.8% of pasta samples. On multivariate analysis, GF labeled food was less likely to test positive for gluten in the West than in the Northeast United States (odds ratio 0.80; 95% confidence interval 0.67-0.95). CONCLUSIONS: This study of crowd-sourced data suggests that a substantial fraction of GF labeled restaurant foods contain detectable gluten. Although the highly sensitive Nima device may detect gluten at levels <20 parts per million (ppm), leading to gluten exposure of unknown clinical significance, our findings raise a potential concern. In addition, our findings of higher rates of gluten detection in pizza and pasta provide practical data when providing dining strategies for patients with celiac disease.

The Availability and Nutritional Adequacy of Gluten-Free Bread and Pasta.

Management of coeliac disease (CD) requires the removal of gluten from the diet. Evidence of the availability, cost, and nutritional adequacy of gluten-free (GF) bread and pasta products is limited. GF flours are exempt from UK legislation that requires micronutrient fortification of white wheat flour. This study surveyed the number and cost of bread and pasta products available and evaluated the back-of-pack nutritional information, the ingredient content, and the presence of fortification nutrients of GF bread and pasta, compared to standard gluten-containing equivalent products. Product information was collected from four supermarket websites. Standard products were significantly cheaper, with more products available than GF (p < 0.05). GF bread products were significantly higher in fat and fiber (p < 0.05). All GF products were lower in protein than standard products (p < 0.01). Only 5% of GF breads were fortified with all four mandatory fortification nutrients (calcium, iron, niacin, and thiamin), 28% of GF breads were fortified with calcium and iron only. This lack of fortification may increase the risk of micronutrient deficiency in coeliac sufferers. It is recommended that fortification legislation is extended to include all GF products, in addition to increased regulation of the nutritional content of GF foods.

The Nutritional Quality of Gluten-Free Products for Children.

OBJECTIVES: To examine the nutritional quality of gluten-free (GF) products specifically marketed for children. METHODS: All child-targeted food products were purchased from 2 major supermarket chains in Calgary, Alberta, Canada. Using the Pan American Health Organization Nutrient Profile Model, the nutritional quality of products with a GF claim was compared with those without such a claim. A secondary analysis further compared the nutrient profile of child-targeted GF products to their product "equivalents." RESULTS: Overall, child-targeted GF products had lower levels of sodium, total fat, and saturated fat but also had less protein and a similar percentage of calories from sugar compared with child-targeted products without a GF claim. According to the Pan American Health Organization criteria, both GF products and "regular" products designed for children can be classified as having poor nutritional quality (88% vs 97%; P < .001). When analyzed in light of their product equivalents without a GF claim, both had similarly high levels of sugar (79% vs 81%; P < .001). CONCLUSIONS: GF supermarket foods that are targeted at children are not nutritionally superior to regular child-targeted foods and may be of greater potential concern because of their sugar content. The health halo often attributed to the GF label is not warranted, and parents who substitute GF products for their product equivalents (assuming GF products to be healthier) are mistaken. Parents of children with gluten intolerance and/or sensitivity, along with parents who purchase GF products for other health reasons, need to carefully assess product labels when making purchases.

Dietary Patterns After the Weaning and Lactation Period Are Associated With Celiac Disease Autoimmunity in Children.

BACKGROUND & AIMS: There have been many studies of associations between infant feeding practices and development of celiac disease during childhood, but few studies have focused on overall diets of young children after the weaning period. We aimed to examine the association between common dietary patterns in infants and the occurrence of celiac disease autoimmunity during childhood. METHODS: We performed a prospective analysis of data from the Generation R Study that comprised 1997 children born from April 2002 through January 2006 in Rotterdam, the Netherlands. Food consumption around 1 year of age was assessed with a validated food-frequency questionnaire. Dietary data were examined using a priori (based on existing guidelines) and a posteriori (principal component analysis and reduced rank regression) dietary pattern analyses. Five dietary patterns were compared. Celiac disease autoimmunity, determined on the basis of serum concentration of transglutaminase-2 autoantibody (ie, TG2A) below or above 7 U/mL, was evaluated at 6 years. Associations between dietary pattern adherence scores and celiac disease autoimmunity were examined using multivariable logistic regression models. RESULTS: Higher adherence to the a posteriori-derived prudent dietary pattern (high intake of vegetables, vegetable oils, pasta, and grains and low consumption of refined cereals and sweet beverages) at 1 year was significantly associated with lower odds of celiac disease autoimmunity at 6 years (odds ratio, 0.67; 95% confidence interval, 0.53-0.84). No significant associations were found for the 4 remaining dietary patterns. CONCLUSIONS: In a prospective study of dietary patterns of young children in the Netherlands, we associated a dietary pattern characterized by high consumption of vegetables and grains and low consumption of refined cereals and sweet beverages, with lower odds of celiac disease autoimmunity. Early-life dietary patterns might therefore be involved in the development of celiac disease during childhood.

An investigation into the nutritional composition and cost of gluten-free versus regular food products in the UK.

BACKGROUND: The gluten-free (GF) food market has expanded considerably, although there is limited comparative evidence for the nutritional quality and cost of GF food products. The present study aims to compare the nutrient composition and cost of GF and gluten-containing (regular) foods across 10 food categories in the UK. METHODS: Nutritional information and the cost of GF foods available in the UK (n = 679) and comparable regular foods (n = 1045) were systematically collected from manufacturer and supermarket websites. Foods were classified using UK front-of-pack labelling for content of fat, saturated fat, sugar and salt and nutrient content, and cost per 100 g were identified and compared between GF and regular foods. RESULTS: Overall, more GF foods were classified as containing high and medium fat, saturated fat, sugar and salt than regular foods, although this was not universally consistent. More GF bread and flour products contained high fat and sugar, whereas fewer GF crackers contained high fat and sugar compared to regular foods. High salt content was found more frequently in GF than regular products. On average, GF products were 159% more expensive than regular (£0.44/100 g versus £1.14/100 g). GF items were also more likely to be lower in fibre and protein content than regular foods. CONCLUSIONS: Differences exist in the nutritional composition of GF and regular food. GF food is unlikely to offer healthier alternatives to regular foods, except for those who require a GF diet for medically diagnosed conditions, and it is associated with higher costs.

Chemometric analysis of minerals in gluten-free products.

BACKGROUND: Numerous studies indicate mineral deficiencies in people on a gluten-free (GF) diet. These deficiencies may indicate that GF products are a less valuable source of minerals than gluten-containing products. In the study, the nutritional quality of 50 GF products is discussed taking into account the nutritional requirements for minerals expressed as percentage of recommended daily allowance (%RDA) or percentage of adequate intake (%AI) for a model celiac patient. Elements analyzed were calcium, potassium, magnesium, sodium, copper, iron, manganese, and zinc. Analysis of %RDA or %AI was performed using principal component analysis (PCA) and hierarchical cluster analysis (HCA). RESULTS: Using PCA, the differentiation between products based on rice, corn, potato, GF wheat starch and based on buckwheat, chickpea, millet, oats, amaranth, teff, quinoa, chestnut, and acorn was possible. In the HCA, four clusters were created. The main criterion determining the adherence of the sample to the cluster was the content of all minerals included to HCA (K, Mg, Cu, Fe, Mn); however, only the Mn content differentiated four formed groups. CONCLUSION: GF products made of buckwheat, chickpea, millet, oats, amaranth, teff, quinoa, chestnut, and acorn are better source of minerals than based on other GF raw materials, what was confirmed by PCA and HCA. © 2017 Society of Chemical Industry.

Gluten-Free Diet Indications, Safety, Quality, Labels, and Challenges.

A gluten-free diet (GFD) is the safest treatment modality in patient with coeliac disease (CD) and other gluten-related disorders. Contamination and diet compliance are important factors behind persistent symptoms in patients with gluten related-disorders, in particular CD. How much gluten can be tolerated, how safe are the current gluten-free (GF) products, what are the benefits and side effects of GFD? Recent studies published in Nutrients on gluten-free products' quality, availability, safety, as well as challenges related to a GFD are discussed.

A Research Communication Brief: Gluten Analysis in Beef Samples Collected Using a Rigorous, Nationally Representative Sampling Protocol Confirms That Grain-Finished Beef Is Naturally Gluten-Free.

Knowing whether or not a food contains gluten is vital for the growing number of individuals with celiac disease and non-celiac gluten sensitivity. Questions have recently been raised about whether beef from conventionally-raised, grain-finished cattle may contain gluten. To date, basic principles of ruminant digestion have been cited in support of the prevailing expert opinion that beef is inherently gluten-free. For this study, gluten analysis was conducted in beef samples collected using a rigorous nationally representative sampling protocol to determine whether gluten was present. The findings of our research uphold the understanding of the principles of gluten digestion in beef cattle and corroborate recommendations that recognize beef as a naturally gluten-free food.

Riscos de contaminação por glúten em um restaurante universitário com preparações para indivíduos celíacos: um estudo de caso / Contamination risk for gluten in a restaurant university with preparations for individuals celiacs: a case study

Objetivo: Este estudo teve como objetivo avaliar os riscos de contaminação por glúten em um restaurante universitário com preparações para indivíduos celíacos. Métodos: Trata-se de um estudo observacional descritivo desenvolvido entre os meses de setembro e novembro de 2014 em um restaurante universitário do município de Belo Horizonte-MG, Brasil. Foi elaborado um check list baseado na literatura referente à doença celíaca e na Resolução n.º 275, de 21 de outubro de 2002, para identificar os riscos de contaminação cruzada por glúten de acordo com o fluxo de produção adotado pelo restaurante. A análise dos resultados foi realizada de forma qualitativa. Resultados e Discussão: Foram identificados oito principais pontos críticos que abrangem desde a recepção da matéria-prima à distribuição das refeições. Os dois pontos críticos identificados no check list como susceptíveis à altera- ção encontravam-se no almoxarifado. Os demais itens não apresentam possibilidade de alterações em curto prazo. Conclusões: Apesar dos manipuladores de alimentos do restaurante serem capacitados previamente para realizar preparações isentas de glúten, os riscos de contaminação por esta proteína são grandes. Nesse cenário faz-se necessá- rio um controle rigoroso em relação à linha de produção em um restaurante que distingue preparações com e sem glúten ou optar em realizar as preparações em outro espaço físico para garantir a inocuidade do alimento (AU)

Objective: This study aimed to evaluate the risks of cross-contamination of gluten in a university restaurant with preparations for celiac individuals. Methods: This is an observational descriptive study carried out between the months of September and November 2014 in a university restaurant in the city of Belo HorizonteMG, Brazil. A checklist was elaborated, based on literature related to celiac disease and on Resolution 275, issued on October 2002, to identify the risks of cross contamination by gluten according to the production flow adopted at the restaurant. The analysis was performed in a qualitative manner. Results and Discussion: Eight critical points were identified, ranging from the reception of raw material to the meal distribution at the restaurant’s dining hall. The two critical points identified in the checklist as susceptible to change were in the warehouse. The remaining items have no possibility of changes in the short term. Conclusions: Despite the restaurant food handlers have been trained previously to make preparations gluten-free, the risk of contamination by this protein are great. In this scenario it is necessary strict control over the production line in a restaurant that distinguishes preparations with and without gluten or choose to make preparations in another physical space to ensure the safety of food (AU)

Celiac disease and school food service in Piedmont Region: Evaluation of gluten-free meal.

INTRODUCTION: The Law 123/2005 recognizes celiac disease as a social disease and so Ministry of Public Health annually allocates specific resources to Regions for managing gluten-free meals in school canteens. Therefore in 2009 Piedmont Region approved a specific project, in collaboration with Food Hygiene and Nutrition Department (SIAN) of several ASL (Local Health Authority), including ASL TO3 as regional leader, and the "Italian Celiac Association - Piedmont and Valle d'Aosta". This project was intended to facilitate the natural integration of celiac people in social life. A retrospective analysis of data has been carried out to assess the management of gluten- free meal of school food services in Piedmont Region in 2010. Furthermore the intervention efficacy has been evaluated comparing the critical points observed in 2010 and 2012. METHODS: The object of the study includes primary and secondary schools that have provided gluten-free food service in Piedmont Region. These school were examined by SIAN staff. (the examination included the check of hygienic aspects and qualitative assessment of the meal). The data were collected using the same checklist throughout the region. All data were included in the unified regional system ("Reteunitaria"). RESULTS: The results show that 29% of the sampled schools (277) are acceptable in all eight sections (supply, storage, process analysis, equipment check, packaging and transport, distribution of meals, self-control plan and qualitative assessment), whereas 71% are inadequate for at least one of the profiles (60% does not perform the qualitative valuation of service) and in 18% of schools three to seven insufficiencies are observed. Correlations between the number of total insufficiencies and the most critical sections of the check list were performed (with lower scores in "good") such as process analysis, distribution of meals, self-control plan and qualitative assessment. The analysis process has achieved a high score in the field of deficiency for at least 3 parameters. Schools with a good self-control plan have a significant correlation with schools suitable for the analysis process, instead schools appeared insufficient in the process analysis have an increased chance of being insufficient also in the distribution of meals. The schools that provide a transported meal (municipalities highly populated, generally) have many differences in distribution of meals respect schools that prepare food in the school kitchen. In fact, 88% of school that provide a transported meal achieved an appropriate score in distribution of meals section and collected fewer failures in overall assessment than the others. 120 structures are included in the indirect comparison between the checklist's sections with criticisms, during years 2010 and 2012: in 2010 32% of schools were recorded acceptable in all of the eight sections of the checklist and in 2012 this percentage rose to 54%. An improvement can be observed in all areas, but a statistical significant result do not turn out. DISCUSSION AND CONCLUSIONS: Data show that carry on the control activities of production of gluten free meal in school canteens would be appropriate. Actions focused on improving the methods of preparing meal without gluten were recommended, especially in under populated municipalities with school kitchen on site. The constant presence of ASL staff in school has promoted important changes: cultural change and about the management of allergy and food intolerance. An improvement can be observed: a transition from a suspicion about "special diet" management to an appropriate and responsible management of meals for children and young people suffering from this specific condition.

Un título que llama a error: ¿cuál es la edad adecuada para la introducción del gluten en la dieta de los lactantes? / No disponible

No disponible

Approaches to reduce the glycemic response of gluten-free products: in vivo and in vitro studies.

This article aims to discuss the current approaches used to reduce the postprandial glycemic response (GR) of starchy gluten-free products (GFP) and to provide some further prospects. The GR is evaluated through in vivo trials to determine the glycemic index (GI) and the glycemic load (GL) of foods or using the in vitro starch digestibility method to predict the GI. The reviewed studies demonstrated that a reduction in the GR of GFP can be achieved by replacing traditionally used refined flours and starches with nutrient-dense alternative raw materials due to an increase in dietary fiber, resistant starch and protein contents, which can alter the rate of starch digestion, reduce the GI and dilute the amount of available carbohydrate; both the factors contribute to reduce the GL. The addition of viscous dietary fibers could also be a successful way to reduce the GR of GFP. Some studies have demonstrated the potential of germination of GF grains and sourdough fermentation in decreasing the GR of GF bread. Further studies could evaluate alternative GF flours, soluble fibers, resistant starch, and other formulation factors that may affect the GR of different types of GFP. New studies should be performed to test and optimize processing methods by considering the reduction of GR of GFP. Another key aspect for further investigation is the confirmation of the promising results obtained through in vitro assays by in vivo GI evaluation.

La introducción del gluten en la dieta del lactante. Recomendaciones de un grupo de expertos / The introduction of gluten into the infant diet. Expert group recommendations

En el momento actual existe una situación de indefinición con respecto a cuándo, cómo y de qué forma debe introducirse el gluten en la dieta del lactante. Durante años ha prevalecido la recomendación del Comité de Nutrición de la ESPGHAN de evitar tanto la introducción precoz, antes de los 4 meses, como la tardía, después de los 7 meses, y de introducir el gluten gradualmente mientras el lactante recibe leche materna; se pretendía con ello reducir el riesgo de enfermedad celiaca, diabetes y alergia al gluten. Sin embargo, 2 estudios independientes publicados en octubre de 2014 en The New England Journal of Medicine llegan a la conclusión de que la edad de introducción del gluten no modifica el riesgo de desarrollar la enfermedad celiaca y que la lactancia materna a cualquier edad tampoco confiere protección. Por otra parte, según la evidencia científica disponible, en general, se recomienda la introducción de otros alimentos en la dieta distintos de la leche materna o de fórmula alrededor de los 6 meses de edad, ya que la introducción antes de los 4 meses se asociaría a un riesgo aumentado de enfermedades autoinmunes y alergia alimentaria, y retrasarla más allá de los 7 meses no tendría efecto protector. En este contexto, un grupo de expertos ha considerado pertinente elaborar un documento de consenso basado en las evidencias científicas actuales y establecer unas recomendaciones generales para la introducción del gluten en la práctica clínica diaria (AU)

At present there is a degree of uncertainty regarding when, how and in what form gluten should be introduced into the infant diet. For years the recommendations of the ESPGHAN Committee on Nutrition have prevailed, which include avoiding early introduction, before 4 months, and late, after 7 months, and gradually introducing gluten into the diet while the infant is being breastfed, with the aim of reducing the risk of celiac disease, diabetes and gluten allergy. However, 2 independent studies published in The New England Journal of Medicine in October 2014 reached the conclusion that the age of introduction of gluten does not modify the risk of developing celiac disease, and that breastfeeding at any age does not confer protection against celiac disease development. On the other hand, according to available scientific evidence, the introduction of foods other than breast milk or formula into the infants diet is generally recommended around 6 months of age, since the introduction before 4 months could be associated with an increased risk of food allergy and autoimmune diseases, and delaying it beyond 7 months would not have a protective effect. In this context, a group of experts has considered it appropriate to produce a consensus document based on the current scientific evidence and present general recommendations for daily clinical practice on the introduction of gluten into the diet (AU)

Treatment of celiac disease: from gluten-free diet to novel therapies.

Gluten-free diet (GFD) is the cornerstone treatment for celiac disease (CD). This diet excludes the protein gluten a protein forum in in grains such as wheat, barley, rye and triticale. Gluten causes small intestines inflammation in patients with CD and eating a GFD helps these patients in controlling signs and symptoms and prevent complications. Following a GFD may be frustrating, however, it is important to know that plenty of foods are naturally gluten-free and nowadays is relatively easy to find substitutes for gluten-containing foods. Certain grains, such as oats, are generally safe but can be contaminated with wheat during growing and processing stages of production. For this reason, it is generally recommended avoiding oats unless they are specifically labelled gluten-free. Other products that may contain gluten include food additives, such as malt flavouring, modified food starch and some supplement and/or vitamins that use gluten as a binding agent. Cross-contamination occurs when gluten-free foods come into contact with foods that contain gluten. It can happen during the manufacturing process or if the same equipment is used to make a variety of products. Cross-contamination can also occur at home if foods are prepared on common surfaces or with utensils that have not been cleaned after being used to prepare gluten-containing foods (using a toaster for gluten-free and regular bread). Although safe and effective, the GFD is not ideal: it is expensive, of limited nutritional value, and not readily available in many countries. Consequently, a need exists for novel, non-dietary therapies for celiac disease. Advances in understanding the immunopathogenesis of CD have suggested several types of therapeutic strategies alternative to the GFD. Some of these strategies attempt to decrease the immunogenicity of gluten-containing grains by manipulating the grain itself or by using oral enzymes to break down immunogenic peptides that normally remain intact during digestion. Other strategies focus on preventing the absorption of these peptides, preventing tissue transglutaminase from rendering gluten peptides more immunogenic, or inhibiting their binding to CD-specific antigen-presenting molecules. Strategies that limit T cell migration to the small intestine or that re-establish mucosal homeostasis and tolerance to gluten antigens are also being explored.