It’s a piece of cake

1. It’s a piece of cake How Certified Dietary Managers can ensure that they are serving gluten free meals Roberta Tripp MS RD LDN Clinical Nutrition Manager Sodexo at PinnacleHealth Harrisburg PA

2. Objectives • To provide more in depth knowledge to CDMs who already have a basic knowledge of gluten intolerance and celiac disease • To discuss which residents may be on a gluten free diet in addition to those with diagnosed celiac disease. • To explain about the special products, cooking and serving procedures involved • To provide a list of resources for use when working with residents on a gluten free diet. • To help CDMs do a better job of ensuring no cross contamination occurs in their kitchens when they must ensure a patient receives gluten free food

3. Definition of Celiac Disease • An immune-mediated disease triggered by the ingestion of gluten-containing grains (wheat, rye, barley) in genetically susceptible individuals. • In celiac disease gluten causes damage to the small intestine which affects its ability to absorb nutrients.

4. Gluten • Gluten, a protein found in wheat, barley, and rye, forms when water is added and the protein molecules glutanin and gliadin combine. • Gluten gives dough its sticky and pliable consistency.

5. Damaged Healthy It Takes A Villi

6. Can any amount of gluten be harmful? • As of October 2009 there is no safe level of gluten yet established for people with celiac disease. Sensitivity may vary but as far as food preparation and service are concerned, even very small amounts of gluten can be harmful. • Catassi and colleagues (Am J Clin Nutr 2007; 85:160-166) found no significant change in villous height/crypt depth ratio in participants consuming 10 mg gluten per day

7. Classic Adult Onset Symptoms • Diarrhea • Constipation • Gas and bloating • Abdominal pain • Nausea and vomiting • Reflux

8. Atypical Adult Onset Symptoms • Anemia • Bone and joint pain • Osteoporosis/osteopenia • Chronic hepatitis • Infertility/recurrent miscarriages • Mouth ulcers

9. Symptoms in Children • Delayed puberty • Dental enamel defects • Diarrhea/constipation • Difficulty in learning • Failure to thrive • Short Stature

10. Autoimmune Disorders Associated with Celiac Disease • Autoimmune hepatitis • Down’s syndrome, IBD, Crohns Disease • Rheumatoid Arthritis • Sjogren’s Syndrome • Thyroid Disease • Type I diabetes

11. Intestinal Cancer and Celiac Disease A type of non Hodgkins lymphoma that develops in the small bowel is one of the most common causes of death in people with celiac disease.

12. “The Hidden Epidemic” • The title of Dr. Peter H. Green’s book “Celiac Disease: The Hidden Epidemic” serves as an unfortunate answer to the question “If there are so many people with gluten intolerance and celiac disease, where are they?” It has been estimated that 97% of people with celiac disease don’t know they have it.

13. The average celiac goes eleven years prior to being diagnosed • Symptoms such as diarrhea, gas, bloating, and abdominal pain are often wrongly diagnosed as irritable bowel syndrome (and ironically, patients are told to “eat more fiber”, which usually translates to whole wheat and bran!)

14. Not everyone who avoids gluten has celiac disease • At least 1 out of every 133 people have celiac disease in the US (3 million people) • As many as 13 million people have other forms of gluten sensitivity • Approximately 6 million people claim to have a wheat allergy in this country • Therefore the total number of people who need to follow a GF diet could be as high as 22 million in the United States (about 1 out of every 13 people). • Parents of children with Autism Spectrum Disorder may want the child on a gluten free (and casein free) diet even though this approach to treating ASD is unproven.

15. Amaranth Arrowroot Buckwheat Corn Flax Millet Montina Potato Quinoa Rice Sorghum Tapioca Teff Flours made from nuts, seeds, and beans (garfava, soy flour) What Grains are Gluten Free?

16. What About Oats? • Oats that are uncontaminated by gluten containing grains are usually tolerated by individuals with celiac disease or gluten intolerance. • The recommendation is to introduce oats gradually and slowly into the gluten free diet after consulting your physician. • These certified gluten free oats are available from 4 suppliers in North America (www.bobsredmill.com, www.glutenfreeoats.com, • www.onlyoats.com and www.creamhillestates.com)

17. Surprisingly gluten free • MSG • Corn gluten • Vegetable broth • Glutinous rice

18. Food labels: you’re confusing me with the facts • In the US, foods are either under the jurisdiction of the Food and Drug Administration (FDA) or the USDA FSIS (United States Department of Agriculture Food Safety and Inspection Service). • The FDA regulates all foods except meat, poultry, and egg products, which are under FSIS jurisdiction. • Each of these agencies has different policies regarding food labeling.

19. FDA’s Food Allergens Labeling and Consumer Protection Act (FALCPA) •In 2004, the Food and Drug Administration, which regulates most of the food supply, enacted a new a regulation known as FALCPA that requires that 8 known allergens, including wheat, be declared in plain English terms on the label of all packaged goods they regulate.

20. Because of FALCPA, in FDA regulated foods, you don’t have to worry about…

21. Modified food starch • In the US and Canada if a food starch in an FDA regulated food is made from wheat the label would have to say so • Rye and barley are not used to make food starch

22. Maltodextrin, dextrin, or hydrolyzed vegetable protein • If any of these are made from wheat the ingredient list would have to state this fact (in the US and Canada).

23. Vinegar or AlcoholDistillation proteins are too large to pass through the distillation process (this includes gluten).All vinegars are distilled and are therefore gluten free except Malt Vinegar (has added malt from barley)

24. USDA Regulation •Foods regulated by the USDA FSIS (meat, poultry, and processed egg products) are not covered by this regulation and therefore could contain hidden gluten from wheat. •Neither agency has to disclose barley, oats, or rye on an ingredient label.

25. USDA Rule • To be consistent with FALCPA, the USDA’s Food Safety and Inspection Service is undertaking rulemaking to adopt the FALCPA requirements for the products it regulates. Currently FSIS permits voluntary allergens labeling.

26. Labeling requirements for allergens to extend to meat, poultry, and egg products • When the USDA regulation is enacted, labels on meat, poultry, and egg products regulated by FSIS will be required to state if wheat is an ingredient. • Presently it is recommended that the manufacturer be contacted if there are any ingredients listed on meat, poultry, or egg products that are questionable to make sure they come from a gluten free source.

27. It’s wheat free, but is it gluten free? • At this time there is no universally agreed upon definition of the term “gluten free”. • The FDA is working on defining this term. • The proposed FDA rule says that gluten free foods must contain less than 20 parts per million gluten. • 10 ounces of grain foods containing 20 ppm gluten would contain 5.70 mg gluten.

28. Foods from Europe • Codex, the organization responsible for regulations regarding food labeled “gluten-free” in many European countries, has finalized a rule that these foods, including those made from wheat starch, will contain no more than 20 parts per million gluten. • For gluten-free foods containing wheat starch this is a much lower amount than the previously allowed amount of 200 and 100 parts per million gluten.

29. Ingredients Worth Questioning

30. Soup, bouillon, broth, and soup base • Soup and stocks (including au jus, broth, and bouillon) may contain gluten so ingredients should always be checked. • Some soups are USDA regulated so wheat might not be disclosed on the label—check with the company.

31. Soy Sauce • Soy sauce usually contains wheat in addition to soy, and therefore may contain gluten. Check the label. • If a non-FDA regulated product contains soy sauce (Chinese take out food, for example) it would not have to state it contains wheat if it did.

32. Spices and Seasonings • Pure spices and herbs are gluten free • Seasoning blends may contain gluten from anti-caking or flow agents. If these additives are present it will be clearly labeled on the package if they are derived from wheat and should therefore be avoided.

33. Talking Turkey • Because fresh and frozen turkeys are under jurisdiction of the USDA, any injected basting solution containing gluten would not have to be disclosed on the label • It is recommended to contact the company to verify the turkey’s gluten free status.

34. Don’t be so crabby • Imitation seafood (surimi or “Sea Legs”) contains wheat but since it is a USDA regulated food does not need to state so on the label.

35. There’s gluten in that?? • All Kellogg’s dry ready-to-eat cereals contain gluten in some form (either barley malt, wheat, oats that have not been certified gluten free, or wheat starch). • Some premade hamburger or turkey burger patties contain wheat but may not state it on the label • Seasoned French fries or batter dipped fries; Rice-a-Roni

36. More possible hidden gluten • Some egg substitutes • Flourless chocolate cake (may be made in a floured pan) • Some shredded cheese (may be dusted with flour) • Some dried fruit • Some canned beans

37. More ingredients to look for and avoid • Natural flavorings (rarely from wheat) • Malt/Malt Extract, “barley malt”, or “barley malt extract” • Brown Rice Syrup (may be made with barley) • Modified hop extract

38. Marinades • Many marinades contain soy sauce or other gluten containing ingredients • Most beer is made with barley malt so any marinade containing beer probably contains gluten • Patients who have been on a gluten free diet may be skeptical that they are being served food that is indeed gluten free. They will appreciate it if after you have checked and verified the marinade is gluten free, you reassure them that you have done so.

39. Understanding the gluten free diet is everything: the role of the CDM • Because there is no medication that will cure someone with celiac disease or gluten intolerance, the CDM, acting as a liaison between the food preparation area and the patient, has a tremendous opportunity to positively impact the meal service experience for the patient or resident on a gluten free diet.

40. Do You Really Have a “Gluten Free Diet”? • If your diet manual allows Rice Krispies or Kellogg’s Corn Flakes on your gluten free diet, it’s time to revise it. • Every department in your organization needs to understand what “gluten free” means • Activities Department—cookies, etc • Nursing– snacks from a pantry and med pass • Pharmacy – are the drugs and vitamins GF? • Chaplain – communion wafers

41. What if the resident demands something with gluten? • If it is documented that they are on a GF diet, you should not send any food containing gluten without documentation by Nursing of the choice to be noncompliant

42. Is Your GF Diet Nutritionally Adequate? • Does it provide enough calories? If you don’t appropriately substitute when you take a gluten containing food off the menu, you could be deficient.

43. Give Your Cooks Guidance • Don’t just use your regular menu and expect them to adjust each selection to GF. What happens if there is “1 cookie” on the menu and you don’t have GF cookies? • Review products like your soup base—does it contain gluten? • How often do items like meatloaf, Sloppy Joes, or meat balls come up and do you have a substitute available?

44. Gravy and bacon bits • Make sure your cooks know how to make a gluten free gravy. They can use cornstarch and gluten free soup base. • Some “bacon bits” are not actually bacon and may contain wheat

45. GF products are generally not enriched… • All wheat flour in this country is enriched with B vitamins, folate and iron • Most GF foods are low in fiber unless they are made with garbanzo bean flour or flax • The GF resident is at risk of deficiencies unless you give like substitutions with these nutrients

46. What should the Activity Director know • Rice Krispies Treats are NOT gluten free • Neither is Play Doh or paper mache • These items should be substituted with similar nutrition

47. To oats or not to oats?(with apologies to Shakespeare) • Until the dietitian or RN puts it in writing, the following should not be served oats, even if they are certified gluten free – just in case the pt actually has celiac disease • Wheat allergy • Gluten free • “no bread” • “wheat free”

48. If the resident can have oats, what kind should I give them?

49. Rice cakes AGAIN??!! What residents on a gluten free diet want • Meals that are gluten free by substitution, not by elimination • Food that is good tasting, not just gluten free • As much variety as possible • Most importantly: residents want to trust that the food is gluten free when you say it is

50. Your Kitchen Staff Needs to Know • Patients aren’t being high maintenance or picky when they are checking to make sure their meals are gluten free. They are trying not to get sick. • Something may seem obvious to you (someone who needs to avoid wheat can’t eat white bread as well as wheat bread) that isn’t obvious to a kitchen employee • Have a dual person check for safest tray accuracy