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
If you’ve been a registered dietitian for more than 10 years and haven’t had any continuing education recently in celiac disease or gluten free diets, don’t be surprised if one of your clients or patients knows more than you do about the GF diet!! In 2004 a landmark study by Alessio Fasano, MD at the Center for Celiac Research in Maryland, showed that approximately 1 in 133 individuals in this country have celiac disease, and 97% of them are undiagnosed. Prior to the results of this study being publicized, the general consensus was that celiac disease was rare in the US and was primarily a childhood disease. More and more physicians have had celiac in their radar screens since the results of this study were released and you may have noticed an increase in the number of gluten free diet orders at your facility in the past few years. Even if a patient doesn’t have biopsy proven celiac disease, more and more individuals with gluten intolerance, autism spectrum disorder, or other motivating factors are currently attempting to avoid gluten in their food and want to feel confident if they are hospitalized that the food they will be served will be gluten free. What about YOUR confidence level? Are YOU confident that when a doctor writes a diet order for “gluten free” in the medical record that the patient will only receive meals devoid of gluten? We as dietitians working in healthcare settings need to be the interpreters of the “gluten free language” to the diet office and kitchen staffs at our hospitals and long term care facilities.

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.
Celiac disease is the one inherited autoimmune disorder with a known trigger (gluten) and a known treatment (a gluten free diet for life). There are several genes that have been identified as necessary if celiac disease is going to develop over a person’s lifetime, but it is possible to go through life with one of these genes and not develop the disease. Researchers suspect that factors such as puberty, pregnancy, surgery, illness, or other stressful occurrences may trigger the onset of the disease in some of the individuals with the HLA DQ2 and DQ8 genes. It has even been suggested by some research that early introduction of gluten into a baby’s diet may be a trigger, but this has not yet been proven.
The damage to the small intestine actually is damage to the villi, the fingerlike projections inside the small intestine that absorb nutrients (fat, carbohydrate, protein vitamins and minerals).

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.
You may remember from your college food science courses that gluten is formed when water is combined with glutanin and gliadin, two proteins that are present in wheat, barley, and rye. Gluten is not present in oats unless they have been contaminated (more about that later in this presentation).

5. It Takes A Villi Damaged Healthy
The “gold standard” used to diagnose celiac disease is an endoscopy that includes a biopsy of the small intestine. Usually gastroenterologists will only perform an endoscopy with a biopsy of the small bowel after a patient has had several blood tests (usually called a “celiac panel”) that show an increase in one or more antibodies that indicate probable celiac disease. Patients are told to NOT restrict gluten before they are tested because the results of the tests will be skewed. The tests are very sensitive and specific, but can still show a false positive, so that is why it is recommended to wait until a positive biopsy is confirmed before someone is told to follow a gluten free diet for life. The photo on the left shows a blunted villi which has little to no absorptive surfaces as compared to the normal healthy one on the right. Nutrients are absorbed through the villi and with less surface area available for this absorption, fewer nutrients are usually absorbed in the individual with celiac disease.

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: ) found no significant change in villous height/crypt depth ratio in participants consuming 10 mg gluten per day
The idea of completely eliminating gluten from the diet for life usually prompts people to ask if it’s ok to have “a little bit” occasionally. Unfortunately, the answer to that question is no. Even a small amount of gluten (exact amount is still unknown) can cause damage to the villi that can be undetected by the person with celiac disease but observable during a biopsy of the small intestine.
Clinical trials are currently being conducted on a medication that when ingested would break down gluten before it could reach the villi and cause damage. This would not be a “cure” for CD by any means, and wouldn’t even promise to block 100% of the gluten ingested, but would give celiacs an extra edge when eating in questionable circumstances outside the home.

7. Classic Adult Onset Symptoms
Diarrhea
Constipation
Gas and bloating
Abdominal pain
Nausea and vomiting
Reflux
Symptoms of celiac disease may include the classic intestinal ones listed on this slide, but some patients have no intestinal symptoms.

8. Atypical Adult Onset Symptoms
Anemia
Bone and joint pain
Osteoporosis/osteopenia
Chronic hepatitis
Infertility/recurrent miscarriages
Mouth ulcers
Other symptoms may include discolored teeth or dental enamel defects, skin rash (may be dermatitis herpetiformis, the skin version of celiac disease), fatigue, irregular menstrual periods, weight loss or gain, depression and irritability, intestinal lymphoma, or Vitamin K deficiency. Vitamins and minerals are absorbed through the intestinal villi, so it is easy to understand how these symptoms, which are results of malabsorption, can happen in untreated celiac disease.

9. Symptoms in Children Delayed puberty Dental enamel defects
Diarrhea/constipation
Difficulty in learning
Failure to thrive
Short Stature
Children should not be tested for antibodies to gluten until they have been started on a gluten containing diet. Many doctors will tell parents with celiac disease themselves to have their children tested for celiac disease and if the result is negative, have them tested every 3-5 years unless they develop overt symptoms, in which case they should be tested immediately. There is no evidence that breastfeeding prevents celiac disease development. More research is needed before the optimal time to introduce gluten into a child’s diet is identified.

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
It has been estimated that up to 8% of patients with Type I Diabetes have celiac disease. Microscopic colitis, which can be treated with medication, is also associated with the diagnosis of celiac disease.

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.
Other symptoms may include discolored teeth or dental enamel defects, skin rash (may be dermatitis herpetiformis, the skin version of celiac disease), fatigue, irregular menstrual periods, weight loss or gain, depression and irritability, intestinal lymphoma, or Vitamin K deficiency. Vitamins and minerals are absorbed through the intestinal villi, so it is easy to understand how these symptoms, which are results of malabsorption, can happen in untreated 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.
Peter H. Green, MD, is the Director of The Celiac Disease Center at Columbia University, and a Professor of
Clinical Medicine at the College of Physicians and Surgeons, Columbia University and Attending Physician at the New York-Presbyterian Hospital.

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!)
An excellent resource for increasing fiber in a gluten free diet may be found at:

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.
Whereas celiac disease is an autoimmune disorder, gluten intolerance is not immune mediated. Symptoms of gluten intolerance may include gassiness, abdominal pain, abdominal bloating or distention, and diarrhea. Usually these symptoms are transient and are not thought to cause permanent damage.
Wheat allergy is one of the top 8 food allergies in the United States and symptoms can include wheezing, swelling of the lips, rash, diarrhea, and abdominal pain. The branch of the immune system thought to be responsible for the autoimmune reactions of celiac disease is not the same as the branch activated in allergic reactions to wheat and other proteins.
It is estimated that 97% of the people in the US with celiac disease are undiagnosed, which might explain why the typical hospital food service is not seeing 1 diet order out of 133 be for a gluten free diet. However, as the public becomes more aware of celiac disease and gluten intolerance it is inevitable that the demand for gluten free diets in health care will increase.

15. What Grains are Gluten Free?
Amaranth
Arrowroot
Buckwheat
Corn
Flax
Millet
Montina
Potato
Quinoa
Rice
Sorghum
Tapioca
Teff
Flours made from nuts, seeds, and beans (garfava, soy flour)
Because many grains that are naturally gluten free are refined prior to their use in baked goods, it can be a challenge for someone avoiding gluten to get enough fiber in their diet. Incorporating gluten free whole grains is encouraged rather than substituting refined flours such as tapioca, potato, and rice to ensure adequate fiber, vitamin and mineral intake as well as reducing cost. Some individuals gain weight after a diagnosis of CD because they start eating gluten free cookies, cakes, and other desserts not realizing many of these products are often higher in calories and fat than their non-gluten free counterparts.

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 (
and
Most dietitians recommend no more than ¾ cup oats per day if acceptable with the patient’s physician. Quaker products are not certified gluten free as they are not made with certified gluten free oats.
Gluten free granola and granola bars:

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 Alcohol Distillation 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.
Rice Chex is now available in single serving bowl packs.

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.
The Codex rule is just a benchmark—it will not be enfoced by the World Health Organization.

29. Ingredients Worth Questioning
A tasty gluten free soy sauce is San-J Wheat Free Tamari.

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
Usually gluten free: corn tortillas or plain corn chips, plain potato chips, plain roasted meats with no gravy or “seasoning”
Some rice pilaf contains wheat in addition to rice.

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
Brown rice syrup can be an ingredient in processed foods. If it is listed as an ingredient in a food that is labeled as gluten free it can be assumed it is gluten free. Malt usually comes from barley, and is an ingredient in many ready to eat cereals that otherwise might seem gluten free (Rice Krispies for example).

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?
Certified gluten free oats are certified to not be contaminated with wheat.

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
If you have a patient on a gluten free diet who refuses to eat because they are afraid they will “be glutened”, see if they will at least take a can of Ensure until you can get the situation straightened out (Ensure is gluten free).

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
This also pertains to fried food that is fried in the same oil as battered food (it may not be obvious to your kitchen staff).

51. Handling gluten free ingredients in a non gluten free kitchen
Food and beverage consumption should not be allowed where the food is produced
Clean lab coats, aprons, and gloves are important
Equipment should be clearly marked and separate
Storage, preparation, and serving areas should be separate—best practice would be controlled air flow between the two production areas
Gluten containing foods should be stored below gluten free foods to decrease the possibility of contamination
Your staff should always be mindful of preventing cross contamination.

52. Cross Contamination: What You Can’t See CAN Hurt You
Because even a miniscule amount of gluten containing ingredients can damage the small intestine of a person with celiac disease, health care food service departments have to be especially diligent in not cross contaminating gluten free meals.

53. It’s as easy as sliced br…uh…
If it doesn’t make sense to have a separate toaster for gluten free bread, use foil and toast it in the oven.
Do you use a bucket with cleaner and a cloth to wipe tables? Do you clean a table and then dip the rag back in the bucket after it has cleaned up a table with wheat crumbs on it? You have just contaminated the surface with gluten.

54. Possible sources of cross contamination
Cutting boards; knives, spoons or ladles; butter, peanut butter, or mayonnaise knives
Grills, toasters, or toaster ovens used for both gluten free and non gluten free food should be thoroughly cleaned so no traces of gluten remain
Deep fryer used to cook breaded or battered food as well as French fries
Gloved hand that has touched gluten containing food and then touches gluten free food

55. More ways to avoid cross contamination
Work surfaces and microwaves should be clean.
Use designated cutting boards, knives, and toasters
Fresh, clean water for boiling, steaming, and poaching (pasta)
If there is not a dedicated fryer for gluten free foods, fry them in a skillet
No common prep equipment or surfaces without appropriate dishwashing and cleaning
Wet cleaning rather than dry is recommended as the best way to remove gluten from utensils and equipment that is used to produce both gluten free and gluten containing foods. Without wet washing, there is a greater chance of cross contamination.

56. You don’t bring me flours anymore
Even the most well intentioned cooks can inadvertently turn a gluten free food into a gluten containing food simply by not paying attention to some simple practices in the kitchen.
This is particularly an issue where baking is done from scratch (flour in the air).
Flour dust can stay in the air for 24 hours, so production of gluten free food should be done after no baking or other production using regular flour has occurred for 24 hours or more.

57. An easy way to explain this to kitchen staff is to compare gluten to raw chicken.
Just as it’s common knowledge that raw chicken is dangerous and should never come in contact with food, utensils, or plates that are ready to be served, it should be made absolutely clear that gluten containing food needs to be kept away from gluten free food at all stages of preparation and service.

58. Oops—he said no croutons
In the event an accident happens the entire plate of food needs to be replaced
Removing the bread, wrap, breading, croutons, etc is not acceptable once contamination has occurred. Even a bread stick on a plate that isn’t touching the food can leave some gluten behind.
Garnishes that start out gluten free may become contaminated, so any gluten containing garnishes should be stored below gluten free items.
Did the employee with the gloved hand that grabbed a dinner roll change his glove before grabbing the plate for the gluten free meal? If not it may be contaminated.

59. Major food companies are finally marketing to the gluten free consumer

60. Gluten Free Becomes Mainstream
Most Chex cereals are now gluten free (with the exception of Wheat Chex and Bran Chex).
Betty Crocker has recently come out with gluten free mixes for chocolate chip cookies, brownies, chocolate cake and yellow cake.
Did the employee with the gloved hand that grabbed a dinner roll change his glove before grabbing the plate for the gluten free meal? If not it may be contaminated.

61. Some Excellent Resources
The New Ultimate Guide to Gluten-Free Living
Celiac Disease Center at Columbia University
Gluten-Free Diet: A Comprehensive Resource Guide, Expanded Edition. Shelley Case, BSc, RD
Gluten Intolerance Group.
Gluten-Free Living magazine
Celiac Sprue Association
National Foundation for Celiac Awareness
You are welcome to contact me with any questions at or

62. More Resources www.eatright.org
Evidence based guidelines for celiac disease

63. Ronni Alicea, RD, MBA Celinal Foods
Ronni’s article on the DMA website:

64. www.glutenreview.com “Ask Roberta”
You are welcome to contact me with any questions at or

65. Questions?
You are welcome to contact me with any questions at or