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Its a piece of cakeHow Certified Dietary Managers can ensure that they are serving gluten free meals Roberta Tripp MS RD LDNRoberta Tripp MS RD LDNClinical Nutrition ManagerClinical Nutrition ManagerSodexo at PinnacleHealthSodexo at PinnacleHealthHarrisburg PAHarrisburg PAIts a piece of cakeHow Certif1 1ObjectivesTo provide more in depth knowledge to CDMs who To provide more in depth knowledge to CDMs who already have a basic knowledge of gluten intolerance already have a basic knowledge of gluten intolerance and celiac disease and celiac disease To discuss which residents may be on a gluten free diet To discuss which residents may be on a gluten free diet in addition to those with diagnosed celiac disease.in addition to those with diagnosed celiac disease.To explain about the special products,cooking and To explain about the special products,cooking and serving procedures involvedserving procedures involvedTo provide a list of resources for use when working with To provide a list of resources for use when working with residents on a gluten free diet.residents on a gluten free diet.To help CDMs do a better job of ensuring no cross To help CDMs do a better job of ensuring no cross contamination occurs in their kitchens when they must contamination occurs in their kitchens when they must ensure a patient receives gluten free foodensure a patient receives gluten free foodObjectives2 2Definition of Celiac DiseaseAn immune-mediated disease triggered by the An immune-mediated disease triggered by the ingestion of gluten-containing grains(wheat,rye,ingestion of gluten-containing grains(wheat,rye,barley)in genetically susceptible individuals.barley)in genetically susceptible individuals.In celiac disease gluten causes damage to the In celiac disease gluten causes damage to the small intestine which affects its ability to absorb small intestine which affects its ability to absorb nutrients.nutrients.Definition of Celiac DiseaseAn3 3GlutenGluten,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.GlutenGluten,a protein found 4 4It Takes A VilliDamagedDamagedHealthyHealthyIt Takes A VilliDamagedHea5 5Can any amount of gluten be harmful?As of October 2009 there is no safe level of As of October 2009 there is no safe level of gluten yet established for people with celiac gluten yet established for people with celiac disease.Sensitivity may vary but as far as food disease.Sensitivity may vary but as far as food preparation and service are concerned,even preparation and service are concerned,even very small amounts of gluten can be harmful.very small amounts of gluten can be harmful.Catassi and colleagues(Am J Clin Nutr 2019;Catassi and colleagues(Am J Clin Nutr 2019;85:160-166)found no significant change in 85:160-166)found no significant change in villous height/crypt depth ratio in participants villous height/crypt depth ratio in participants consuming 10 mg gluten per dayconsuming 10 mg gluten per dayCan any amount of gluten be ha6 6Classic Adult Onset SymptomsDiarrheaConstipationGas and bloatingAbdominal painNausea and vomitingRefluxClassic Adult Onset Symptoms7 7Atypical Adult Onset SymptomsAnemiaBone and joint painOsteoporosis/osteopeniaChronic hepatitisInfertility/recurrent miscarriagesMouth ulcersAtypical Adult Onset Symptoms8 8Symptoms in ChildrenDelayed pubertyDental enamel defectsDiarrhea/constipationDifficulty in learningFailure to thriveShort StatureSymptoms in ChildrenDelayed pu9 9Autoimmune Disorders Associated with Celiac DiseaseAutoimmune hepatitisDowns syndrome,IBD,Crohns DiseaseRheumatoid ArthritisSjogrens SyndromeThyroid DiseaseType I diabetesAutoimmune Disorders Associate1010Intestinal Cancer and Celiac DiseaseA 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.Intestinal Cancer and Celiac D1111“The Hidden Epidemic”The title of Dr.Peter H.Greens 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 dont know they have it.“The Hidden Epidemic”The title1212The average celiac goes eleven years prior to being diagnosedSymptoms such as diarrhea,gas,bloating,and Symptoms such as diarrhea,gas,bloating,and abdominal pain are often wrongly diagnosed as abdominal pain are often wrongly diagnosed as irritable bowel syndrome(and ironically,patients irritable bowel syndrome(and ironically,patients are told to“eat more fiber”,which usually are told to“eat more fiber”,which usually translates to whole wheat and bran!)translates to whole wheat and bran!)The average celiac goes eleven1313Not everyone who avoids gluten has celiac diseaseAt least 1 out of every 133 people have celiac disease in At least 1 out of every 133 people have celiac disease in the US(3 million people)the US(3 million people)As many as 13 million people have other forms of gluten As many as 13 million people have other forms of gluten sensitivitysensitivityApproximately 6 million people claim to have a wheat Approximately 6 million people claim to have a wheat allergy in this countryallergy in this countryTherefore the total number of people who need to follow Therefore the total number of people who need to follow a GF diet could be as high as 22 million in the United a GF diet could be as high as 22 million in the United States(about 1 out of every 13 people).States(about 1 out of every 13 people).Parents of children with Autism Spectrum Disorder may Parents of children with Autism Spectrum Disorder may want the child on a gluten free(and casein free)diet want the child on a gluten free(and casein free)diet even though this approach to treating ASD is unproven.even though this approach to treating ASD is unproven.Not everyone who avoids gluten1414What Grains are Gluten Free?AmaranthAmaranthArrowrootArrowrootBuckwheatBuckwheatCornCornFlaxFlaxMilletMilletMontinaMontinaPotatoPotatoQuinoaQuinoaRiceRiceSorghumSorghumTapiocaTapiocaTeffTeffFlours made from Flours made from nuts,seeds,and nuts,seeds,and beans(garfava,soy beans(garfava,soy flour)flour)What Grains are Gluten Free?Am1515What 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(bobsredmill,glutenfreeoats,onlyoats and creamhillestates)What About Oats?Oats that are 1616Surprisingly gluten freeMSGCorn glutenVegetable brothGlutinous riceSurprisingly gluten free1717Food labels:youre confusing me with the factsIn 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.Food labels:youre confusing1818FDAs Food Allergens Labeling and Consumer Protection Act(FALCPA)In 2019,the Food and Drug Administration,In 2019,the Food and Drug Administration,which regulates most of the food supply,which regulates most of the food supply,enacted a new a regulation known as enacted a new a regulation known as FALCPA that requires that 8 known allergens,FALCPA that requires that 8 known allergens,including wheat,be declared in plain English including wheat,be declared in plain English terms on the label of all packaged goods they terms on the label of all packaged goods they regulate.regulate.FDAs Food Allergens Labeli1919Because of FALCPA,in FDA regulated foods,you dont have to worry aboutBecause of FALCPA,in FDA regu2020Modified food starchIn 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 starchModified food starch2121Maltodextrin,dextrin,or hydrolyzed vegetable proteinIf any of these are made from wheat the ingredient list would have to state this fact(in the US and Canada).Maltodextrin,dextrin,or hyd2222Vinegar 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)Vinegar or AlcoholDist2323USDA RegulationFoods 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.USDA RegulationFoods regulate2424USDA RuleTo be consistent with FALCPA,the USDAs Food Safety and Inspection Service is undertaking rulemaking to adopt the FALCPA requirements for the products it regulates.Currently FSIS permits voluntary allergens labeling.USDA RuleTo be consistent with2525Labeling requirements for allergens to extend to meat,poultry,and egg products When the USDA regulation is enacted,labels on When the USDA regulation is enacted,labels on meat,poultry,and egg products regulated by meat,poultry,and egg products regulated by FSIS will be FSIS will be requiredrequired to state if wheat is an to state if wheat is an ingredient.ingredient.Presently it is recommended that the Presently it is recommended that the manufacturer be contacted if there are any manufacturer be contacted if there are any ingredients listed on meat,poultry,or egg ingredients listed on meat,poultry,or egg products that are questionable to make sure products that are questionable to make sure they come from a gluten free source.they come from a gluten free source.Labeling requirements for all2626Its wheat free,but is it gluten free?At this time there is no universally At this time there is no universally agreed upon definition of the term agreed upon definition of the term“gluten free”.“gluten free”.The FDA is working on defining this The FDA is working on defining this term.term.The proposed FDA rule says that The proposed FDA rule says that gluten free foods must contain less gluten free foods must contain less than 20 parts per million gluten.than 20 parts per million gluten.10 ounces of grain foods containing 10 ounces of grain foods containing 20 ppm gluten would contain 5.70 20 ppm gluten would contain 5.70 mg gluten.mg gluten.Its wheat free,but is it glu2727Foods from EuropeCodex,the organization responsible for Codex,the organization responsible for regulations regarding food labeled regulations regarding food labeled“gluten-free”in many European countries,“gluten-free”in many European countries,has finalized a rule that these foods,has finalized a rule that these foods,including those made from wheat starch,including those made from wheat starch,will contain no more than 20 parts per will contain no more than 20 parts per million gluten.million gluten.For gluten-free foods containing wheat For gluten-free foods containing wheat starch this is a much lower amount than starch this is a much lower amount than the previously allowed amount of 200 and the previously allowed amount of 200 and 100 parts per million gluten.100 parts per million gluten.Foods from EuropeCodex,the or2828Ingredients Worth QuestioningIngredients Worth Questioning2929Soup,bouillon,broth,and soup basel lSoup and stocks(including au jus,broth,and Soup and stocks(including au jus,broth,and bouillon)may contain gluten so ingredients bouillon)may contain gluten so ingredients should always be checked.should always be checked.l lSome soups are USDA regulated so wheat Some soups are USDA regulated so wheat might not be disclosed on the labelcheck might not be disclosed on the labelcheck with the company.with the company.Soup,bouillon,broth,and so3030Soy Saucel lSoy sauce usually contains wheat in addition Soy sauce usually contains wheat in addition to soy,and therefore may contain gluten.to soy,and therefore may contain gluten.Check the label.Check the label.l lIf a non-FDA regulated product contains soy If a non-FDA regulated product contains soy sauce(Chinese take out food,for example)it sauce(Chinese take out food,for example)it would would not not have to state it contains wheat if it have to state it contains wheat if it did.did.Soy SauceSoy sauce usually con3131Spices and Seasoningsl lPure spices and herbs are gluten freePure spices and herbs are gluten freel lSeasoning blends may contain gluten from Seasoning blends may contain gluten from anti-caking or flow agents.If these additives anti-caking or flow agents.If these additives are present it will be clearly labeled on the are present it will be clearly labeled on the package if they are derived from wheat and package if they are derived from wheat and should therefore be avoided.should therefore be avoided.Spices and SeasoningsPure spi3232Talking TurkeyBecause fresh and frozen turkeys are under jurisdiction of the USDA,any injected basting solution containing gluten would not have to be disclosed on the labelIt is recommended to contact the company to verify the turkeys gluten free status.Talking TurkeyBecause fresh an3333Dont be so crabbyImitation seafood(surimi or“Sea Legs”)contains wheat but since it is a USDA regulated food does not need to state so on the label.Dont be so crabbyImitation se3434Theres gluten in that?All Kelloggs 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 labelSeasoned French fries or batter dipped fries;Rice-a-RoniTheres gluten in that?3535More possible hidden glutenSome egg substitutes Some egg substitutes Flourless chocolate cake(may be made in a Flourless chocolate cake(may be made in a floured pan)floured pan)Some shredded cheese(may be dusted with Some shredded cheese(may be dusted with flour)flour)Some dried fruitSome dried fruitSome canned beansSome canned beansMore possible hidden gluten3636More ingredients to look for and avoid Natural flavorings(rarely from wheat)Natural flavorings(rarely from wheat)Malt/Malt Extract,“barley malt”,or“barley malt Malt/Malt Extract,“barley malt”,or“barley malt extract”extract”Brown Rice Syrup(may be made with barley)Brown Rice Syrup(may be made with barley)Modified hop extractModified hop extractMore ingredients to look for a3737MarinadesMany marinades contain soy sauce or other gluten containing Many marinades contain soy sauce or other gluten containing ingredientsingredientsMost beer is made with barley malt so any marinade Most beer is made with barley malt so any marinade containing beer probably contains glutencontaining beer probably contains glutenPatients who have been on a gluten free diet may be skeptical Patients who have been on a gluten free diet may be skeptical that they are being served food that is indeed gluten free.that they are being served food that is indeed gluten free.They will appreciate it if after you have checked and verified They will appreciate it if after you have checked and verified the marinade is gluten free,you reassure them that you have the marinade is gluten free,you reassure them that you have done so.done so.MarinadesMany marinades contai3838Understanding the gluten free diet is everything:the role of the CDMBecause there is no medication Because there is no medication that will cure someone with that will cure someone with celiac disease or gluten celiac disease or gluten intolerance,the CDM,acting as intolerance,the CDM,acting as a liaison between the food a liaison between the food preparation area and the preparation area and the patient,has a tremendous patient,has a tremendous opportunity to positively impact opportunity to positively impact the meal service experience for the meal service experience for the patient or resident on a the patient or resident on a gluten free diet.gluten free diet.Understanding the gluten free 3939Do You Really Have a“Gluten Free Diet”?If your diet manual allows Rice Krispies or Kelloggs Corn Flakes on your gluten free diet,its time to revise it.Every department in your organization needs to understand what“gluten free”meansl lActivities Departmentcookies,etcActivities Departmentcookies,etcl lNursing snacks from a pantry and med passNursing snacks from a pantry and med passl lPharmacy are the drugs and vitamins GF?Pharmacy are the drugs and vitamins GF?l lChaplain communion wafersChaplain communion wafersDo You Really Have a“Gluten F4040What 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 noncompliantWhat if the resident demands s4141Is Your GF Diet Nutritionally Adequate?Does it provide enough calories?If you dont appropriately substitute when you take a gluten containing food off the menu,you could be deficient.Is Your GF Diet Nutritionally 4242Give Your Cooks GuidanceDont just use your regular menu and expect Dont just use your regular menu and expect them to adjust each selection to GF.What them to adjust each selection to GF.What happens if there is“1 cookie”on the menu and happens if there is“1 cookie”on the menu and you dont have GF cookies?you dont have GF cookies?Review products like your soup basedoes it Review products like your soup basedoes it contain gluten?contain gluten?How often do items like meatloaf,Sloppy Joes,How often do items like meatloaf,Sloppy Joes,or meat balls come up and do you have a or meat balls come up and do you have a substitute available?substitute available?Give Your Cooks GuidanceDont 4343Gravy and bacon bitsMake 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 wheatGravy and bacon bitsMake sure 4444GF products are generally not enrichedAll wheat flour in this country is enriched with B vitamins,folate and ironMost GF foods are low in fiber unless they are made with garbanzo bean flour or flaxThe GF resident is at risk of deficiencies unless you give like substitutions with these nutrientsGF products are generally not 4545What should the Activity Director knowRice Krispies Treats are NOT gluten freeNeither is Play Doh or paper macheThese items should be substituted with similar nutritionWhat should the Activity Direc4646To 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 diseasel lWheat allergyWheat allergyl lGluten freeGluten freel l“no bread”“no bread”l l“wheat free”“wheat free”To oats or not to oats?(with 4747If the resident can have oats,what kind should I give them?If the resident can have oats,4848Rice cakes AGAIN?!What residents on a gluten free diet wantMeals that are gluten free by substitution,not Meals that are gluten free by substitution,not by eliminationby eliminationFood that is good tasting,not just gluten freeFood that is good tasting,not just gluten freeAs much variety as possibleAs much variety as possibleMost importantly:residents want to trust that Most importantly:residents want to trust that the food is gluten free when you say it isthe food is gluten free when you say it is Rice cakes AGAIN?!What res4949Your Kitchen Staff Needs to KnowPatients arent being high maintenance or picky Patients arent being high maintenance or picky when they are checking to make sure their when they are checking to make sure their meals are gluten free.They are trying not to get
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