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CELIAC DISEASE. A PRIMER FOR SCHOOL NUTRITION. What is Celiac Disease?. Inherited, Autoimmune Disorder Permanent Intolerance to Gluten in WHEAT, RYE AND BARLEY Also referred to as celiac sprue. WHAT IS GLUTEN?. THE PORTION OF THE PROTEIN IN FLOUR THAT FORMS THE STRUCTURE OF DOUGH.

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celiac disease

CELIAC DISEASE

A PRIMER FOR SCHOOL NUTRITION

what is celiac disease
What is Celiac Disease?
  • Inherited, Autoimmune Disorder
  • Permanent Intolerance to Gluten in WHEAT, RYE AND BARLEY
  • Also referred to as celiac sprue
what is gluten
WHAT IS GLUTEN?
  • THE PORTION OF THE PROTEIN IN FLOUR THAT FORMS THE STRUCTURE OF DOUGH
scope of disease
SCOPE OF DISEASE
  • 2.2 million Americans afflicted-over 10,000 children diagnosed annually *
  • Affects 1 in 133 Americans
  • 97% go undiagnosed. Celiacs are at greater risk of GI cancer and particularly lymphoma

*Dr. Alessio Fasano, University of Maryland-Baltimore Center for Celiac Research in A Gluten Free Solution, FoodService Director, September 15, 2008, p. 50-51.

diagnosis
DIAGNOSIS
  • Initial Blood Tests
  • If serology is positive, a biopsy of small intestine is the definitive test
  • NO CURE: person must strictly avoid food products, medicines, vitamins and even glue on envelopes that may have gluten
mechanism of action
MECHANISM OF ACTION
  • Body attacks normal tissue resulting in damage to lining of small intestinal villi, the tiny hairlike projections that line inside of small intestine.
    • Villi contain blood vessels which absorb nutrients
    • Villi increase area for absorption of nutrients
    • Digested nutrients are carried away by circulating blood
  • If villi are damaged, vitamins, minerals, calcium, carbohydrates, protein, and fats are not absorbed well
symptoms
Some may be asymptomatic

Diarrhea

Short Stature

Iron Deficiency Anemia

Lactose Intolerance

Irritability (common in children)

Mood Swings (common in children)

Abdominal Pain

Irritable Bowel

Osteoporosis

Skin rash-very itchy with blisters

SYMPTOMS
treatment
TREATMENT
  • GLUTEN FREE DIET
  • ELIMINATE ALL WHEAT, RYE, BARLEY AND THEIR DERIVATIVES
  • MAY TAKE 6-12 MONTHS FOR INTESTINE TO HEAL
what about oats
WHAT ABOUT OATS?
  • Oats may not be harmful to a celiac patient; however, oats may be cross-contaminated with wheat in the milling process
food labeling laws
FOOD LABELING LAWS
  • Under the 2006 Food Allergen Labeling and Consumer Act, wheat protein or a derivative must be identified, even if used in small amounts
  • The law does not address the use of barley, rye or oats
  • Check with manufacturer if in doubt
slide12
USDA has given recent clarification on a specific case for an individual child:

…if the physician, in the documentation for special dietary accommodations, identifies celiac as a disability, then the school must make the accommodations for a disabled student

Supt. Reg. Memo #8. October 11, 2002

school nutrition programs should consider the following practices
SCHOOL NUTRITION PROGRAMS SHOULD CONSIDER THE FOLLOWING PRACTICES
  • Determine if the student has an IEP or 504 plan
  • Discuss accommodations with the school division special education supervisor and/or nurse supervisor if necessary
  • Consult with a Registered Dietitian if family is working with one through their doctor
meeting meal requirements
Meeting Meal Requirements
  • If following a physician’s orders, foods do not have to meet the same standard as a regular component-for example, bread doesn’t have to weigh 1 oz.
rochester mn public schools
Rochester MN Public Schools
  • GF menu for 5 years-on web site
  • Found from surveys with kids/parents that sliced bread was least liked item
  • Buy locally
  • Modifications include: chicken nuggets (cornflake crumbs, GF chocolate chip cookie (school made)
avoid cross contamination recommendations
AVOID CROSS CONTAMINATION-RECOMMENDATIONS
  • Separate Fryers or Clean Oil if Breaded Items are Fried in Same Vats as Non-Breaded
  • Use Separate Jars of Peanut Butter, Jelly, Mayonnaise to Avoid Wheat/Bread Crumbs in Jar
  • Clean and Sanitize Counters, Cutting Boards, Cooking Utensils, Pans after EACH use and BEFORE Cooking Gluten Free Products
  • Use Separate Colanders for gluten free products
gluten containing grains to avoid
Barley

Barley malt/extract

Bran

Bulgur

Couscous

Bromated or Durum Flour

Einkorn

Emmer

Enriched or Self Rising Flour

Farina

Faro

Graham Flour

Kamut

Matzo Flour/meal

Orzo

Panko

Phosphated Flour

Rye

Seltan

Semolina

Spelt

Triticale (cross between wheat/rye)

Udon

Wheat

Wheat Bran

Wheat germ

Wheat starch

GLUTEN CONTAINING GRAINS TO AVOID
overlooked gluten sources
Ales

Beer and Lagers

Bouillon Cubes

Breading

Brown Rice Syrup

Coating Mix

Communion Wafers

Croutons

Candy

Some Chips/Potato chips

Luncheon Meats, hot dogs, salami, sausage

French Fries

Gravy

Pasta

Rice Mixes

Seasoned Tortilla Chips

Sauces

Soup Base

Stuffing

Self-basting Poultry

Imitation Bacon/Seafood

Soy Sauce

Marinades Thickeners Herbal

Supplements, Prescription Meds

Over the Counter Meds

Vitamin and Mineral Supplements

Lipstick

Lip Gloss and Balms

Play Dough* (hands must be properly washed after playing with)

OVERLOOKED GLUTEN SOURCES
gluten free grains and starches
Amaranth

Arrowroot

Buckwheat

Corn

Flax

Flours made from nuts, beans and seeds

Millet

Montina

Potato Starch

Potato Flour

Quinoa

Rice

Rice Bran

Sago

Sorghum

Soy (soya)

Tapioca

Teff

GLUTEN FREE GRAINS AND STARCHES
gluten free shopping list
Fresh Fruits

Fresh Vegetables

Tofu

Fresh Beef

Fresh Pork

Fresh Poultry (self-basting)

Fresh Fish or Seafood

Eggs

Unflavored Milk

Most Yogurts

Butter, Margarine

Cream Cheese

Cottage Cheese

Sour Cream

Plain Frozen Fruits/Veggies

Most Ice Cream/Sherbet

Potato Chips (beware flavored ones)

Corn Chips

Popcorn

Rice Crackers, Rice Cakes

Jello

Pudding

Plain Canned Fruits/Veggies

Canned Tuna or Chicken

Dried Beans, Lentils, Peas

Most Baked Beans

GLUTEN FREE SHOPPING LIST
gluten free shopping list continued
Cream of Rice

Grits

Puffed Rice

Plain Brown or White Rice

CORN Tacos/Tortillas

Ketchup

Mustard

Distilled Vinegars

Most Salad Dressings

Vegetable, Canola and Olive Oil

Jams/Jellies, Marmalade

Honey

Peanut Butter

Corn or Potato Starch

Corn and Maple Syrup

Brown, White and Confectioner’s Sugar

Spices and Herbs

Salt, Pepper

Relish, Pickles, Olives

GLUTEN FREE SHOPPING LIST, CONTINUED
active learning
ACTIVE LEARNING
  • Pull several ingredient statements from labels and see if any of the prohibited items are listed
  • Look at your current menu and develop 3 gluten free menus-what ingredients can you substitute?
culinary standards seasoned pork cuban brand 98465
Culinary Standards Seasoned Pork, Cuban Brand 98465
  • Ingredients:
  • Boneless pork legg-outside roast (fresh Ham-PFOF), salt, olive oil, garlic, onion, spices, sugar, dehydrated yogurt (nonfat milk solids, lactic acid, cultures, and natural and artificial flavor), orange flavor (natural flavors, maltodextrin, modified food starch, silicon dioxide), lemon flavor (gum arabic, natural flavors (including citrus oils) and mixed tocopherols

**According to manufacturer, the starch is CORN (8/4/2008 per Jose Quinones)

ok what about modified food starch
OK? What about modified food starch?
  • Modified food starch has been treated physically or chemically to modify its properties. The “starch” can be from corn, WHEAT, potato, rice or tapioca-depends on the manufacturer.
  • National Starch and Chemical; www.foodstarch.com
  • Food Allergy Network; http:www.foodallergy.org/index.html
landis cooked beef meatball 36612
Landis Cooked Beef Meatball 36612
  • Ingredients: ground beef (not more than 20% fat), water, bread crumbs (bleached wheat flour, sugar, salt, yeast), vegetable protein product (soy protein concentrate, zinc oxide, niacinamide, ferrous sulfate, copper gluconate, vitamin A palminate, calcium pantothenate, thiamine mononitrate (B1), pridoxine (sic) hydrochloride (B6), ribo-flavin (B2), and cyanocobalamin (B12), salt, dextrose, onions, romano cheese (cow’s milk, cheese culture, salt enzymes), onion powder, garlic powder, spices, monosodium glutamate, parsley flakes, natural flavorings
usda beef taco filling
USDA Beef Taco Filling
  • Ingredients: Ground Beef (no more than 16% fat), water, flavor, isolated oat product, salt, seasoning (textured soy protein: soy flour, caramel color, zinc oxide, ferrous sulfate niacinamide, calcium pantothenate, pyridoxine hydrochloride(B6), riboflavin (B2), thiamine mononitrate (B1), vitamin A palmitate, cyanocobalamin (B12), onion spices including paprika, salt, beef fat, tomato powder, hydrogenated cottonseed oil, garlic, wheat flour (enriched with: niacin, reduced iron, thiamine mononitrate, riboflavin, folic acid), cocoa, citric acid, autolyzed yeast extract and natural flavor), paprika, yellow corn flour, lecithin, sugar, autolyzed yeast extract, beef fat, malic acid
what about caramel color
What about caramel color?
  • Caramel coloring is one of the most widely used colorants in food. GENERALLY, it comes from a high dextrose containing starch hydrolysate or corn syrup.
  • Hydrolyis: chemical reaction where there is an interaction of a compound with water which results in decomposition of a compound (salt in water e.g.)
  • Caramel coloring can be made from corn, invert sugar, lactose, molasses, or beet or cane sugar. These are gluten free. Malt syrup or starch hydrolysate may be WHEAT.
uncle ben s southwestern pinto beans and rice
Uncle Ben’s Southwestern Pinto Beans and Rice
  • Ingredients: Parboiled long grain rice enriched with ferric orthophosphate (iron), thiamine mononitrate (thiamine) and folic acid; precooked pinto beans; dried vegetables (tomato, corn, onion, garlic, cilantro): sugar; salt; hydrolyzed corn gluten; soy protein and wheat gluten; corn syrup solids; corn starch; autolyzed yeast extract; paprika; partially hydrogenated vegetable oil (soybean and/or cottonseed); spice; xanthan gum; calcium chloride; maltodextrin; dried soy sauce (wheat, soybeans, salt); natural flavor, torula yeast, caramel color
uncle ben s long grain wild rice original recipe
Uncle Ben’s Long Grain & Wild Rice Original Recipe
  • Ingredients: long grain parboiled rice enriched with iron (ferric orthophosphate), thiamin
  • (thiamine mononitrate) and folate (folic acid); wild rice; vegetables*(onion, parsley, spinach, garlic, celery, tomato, carrot); hydrolyzed corn/soy/wheat protein; sugar, autolyzed yeast extract; salt; spices; smoked yeast; sunflower oil; natural flavors; turmeric (color); paprika (color)
  • *dried
utz salt n vinegar artificially flavored potato chips sold ala carte only
UTZ Salt ‘n Vinegar Artificially Flavored Potato Chips(sold ala carte only)
  • Ingredients: Cottonseed Oil, Salt, Lactose, Malic Acid, Sodium Acetate, Fumaric Acid, Soybean Oil
  • Allergy Information: Contains Milk. This is a gluten free food.
baked lays potato crisps sold ala carte only
Baked Lays Potato Crisps (sold ala carte only)
  • Ingredients: Dehydrated Potatoes, Modified Food Starch, Sugar, Corn Oil, Salt, Soy Lecithin, Leavening (Monocalcium Phosphate and Sodium Bicarbonate), and Dextrose
  • Per Frito Lay, the modified starch is corn. Written confirmation July 2008.
menu i
MENU I

Choose One:

Whole Grain Chicken Corn Dog Bites

Hamburger/Cheeseburger on Whole Wheat Bun

PB&J Sandwich w/ String Cheese

Yogurt w/ Graham Crackers

Chef Salad/Tuna Salad (contains saltine crackers)

Choose Two

Steamed Whole Kernel Corn

Fresh Orange Wedges

Fresh Red Grapes

Chilled Diced Pears

Assorted Milk

menu ii
MENU II

Choose One:

Chicken Drummie w/ Biscuit

Grilled Cheese Sandwich on Whole Wheat Bread

PB&J Sandwich w/ String Cheese

Yogurt/Graham Crackers

Spinach Chef (diced egg, mushrooms, onions, tomatoes)

Choose Two

Glazed Sweet Potatoes

Chilled Applesauce

Fresh Pear

Dried Cranberries

Assorted Milk

menu iii
MENU III

Pancakes w/Syrup

OR

Fat Free Yogurt

OR

Cereal w/ Graham Cracker

OR

Turkey Sausage w/ Biscuit

OR

PB&J Sandwich

Fresh Orange Wedges or Orange Juice

Assorted Milk

references
REFERENCES
  • www.CeliacHealth.org
  • www.Celiac.org
  • www.glutenfree.com
  • www.celiac.com
  • www.CDHNF.org (Children’s Digestive Health and Nutrition Foundation)
  • www.NASPGHAN.org (North American Society for Pediatric Gastroenterology, Hepatology and Nutrition)
  • USDA. Accommodating Children with Special Dietary Needs in the School Nutrition Programs Guidance for School Food Service Staff; 2001.
references continued
REFERENCES, CONTINUED
  • http://digestive.niddk.nih.gov/ddiseases/pubs/celiac_ez/ (National Digestive Diseases Information Clearinghouse)
  • http://familydoctor.org
  • http://resources.schoolscience.com.uk/ABPI/digestion/digest6.html
  • Food allergy & intolerance survival guide. Enjoy Life Foods.

http://www.enjoylifefoods.com

  • www.rochester.k12.mn.us. Rochester, Minnesota Public Schools
  • http://www.schoolnutrition.org. School Nutrition Association
slide38
Developed by:

Dr. Becky Domokos-Bays, RD SNS

Director, Food and Nutrition Services

Alexandria City Public Schools

[email protected]

Fall 2008 (for SNA-VA)

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