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CELIAC DISEASE A PRIMER FOR SCHOOL NUTRITION. What is Celiac Disease? Inherited, Autoimmune Disorder Inherited, Autoimmune Disorder Permanent Intolerance.

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Presentation on theme: "CELIAC DISEASE A PRIMER FOR SCHOOL NUTRITION. What is Celiac Disease? Inherited, Autoimmune Disorder Inherited, Autoimmune Disorder Permanent Intolerance."— Presentation transcript:

1 CELIAC DISEASE A PRIMER FOR SCHOOL NUTRITION

2 What is Celiac Disease? Inherited, Autoimmune Disorder Inherited, Autoimmune Disorder Permanent Intolerance to Gluten in WHEAT, RYE AND BARLEY Permanent Intolerance to Gluten in WHEAT, RYE AND BARLEY Also referred to as celiac sprue Also referred to as celiac sprue

3 WHAT IS GLUTEN? THE PORTION OF THE PROTEIN IN FLOUR THAT FORMS THE STRUCTURE OF DOUGH THE PORTION OF THE PROTEIN IN FLOUR THAT FORMS THE STRUCTURE OF DOUGH

4 SCOPE OF DISEASE 2.2 million Americans afflicted-over 10,000 children diagnosed annually * 2.2 million Americans afflicted-over 10,000 children diagnosed annually * Affects 1 in 133 Americans Affects 1 in 133 Americans 97% go undiagnosed. Celiacs are at greater risk of GI cancer and particularly lymphoma 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 * Dr. Alessio Fasano, University of Maryland-Baltimore Center for Celiac Research in A Gluten Free Solution, FoodService Director, September 15, 2008, p

5 DIAGNOSIS Initial Blood Tests Initial Blood Tests If serology is positive, a biopsy of small intestine is the definitive test 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 NO CURE: person must strictly avoid food products, medicines, vitamins and even glue on envelopes that may have gluten

6 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. 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 contain blood vessels which absorb nutrients Villi increase area for absorption of nutrients Villi increase area for absorption of nutrients Digested nutrients are carried away by circulating blood Digested nutrients are carried away by circulating blood If villi are damaged, vitamins, minerals, calcium, carbohydrates, protein, and fats are not absorbed well If villi are damaged, vitamins, minerals, calcium, carbohydrates, protein, and fats are not absorbed well

7 INTESTINAL VILLI

8 SYMPTOMS Some may be asymptomatic Some may be asymptomatic Diarrhea Diarrhea Short Stature Short Stature Iron Deficiency Anemia Iron Deficiency Anemia Lactose Intolerance Lactose Intolerance Irritability (common in children) Irritability (common in children) Mood Swings (common in children) Mood Swings (common in children) Abdominal Pain Abdominal Pain Irritable Bowel Irritable Bowel Osteoporosis Osteoporosis Skin rash-very itchy with blisters Skin rash-very itchy with blisters

9 TREATMENT GLUTEN FREE DIET GLUTEN FREE DIET ELIMINATE ALL WHEAT, RYE, BARLEY AND THEIR DERIVATIVES ELIMINATE ALL WHEAT, RYE, BARLEY AND THEIR DERIVATIVES MAY TAKE 6-12 MONTHS FOR INTESTINE TO HEAL MAY TAKE 6-12 MONTHS FOR INTESTINE TO HEAL

10 WHAT ABOUT OATS? Oats may not be harmful to a celiac patient; however, oats may be cross- contaminated with wheat in the milling process Oats may not be harmful to a celiac patient; however, oats may be cross- contaminated with wheat in the milling process

11 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 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 The law does not address the use of barley, rye or oats Check with manufacturer if in doubt Check with manufacturer if in doubt

12 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

13 SCHOOL NUTRITION PROGRAMS SHOULD CONSIDER THE FOLLOWING PRACTICES Determine if the student has an IEP or 504 plan 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 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 Consult with a Registered Dietitian if family is working with one through their doctor

14 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. 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.

15 Rochester MN Public Schools GF menu for 5 years-on web site GF menu for 5 years-on web site Found from surveys with kids/parents that sliced bread was least liked item Found from surveys with kids/parents that sliced bread was least liked item Buy locally Buy locally Modifications include: chicken nuggets (cornflake crumbs, GF chocolate chip cookie (school made) Modifications include: chicken nuggets (cornflake crumbs, GF chocolate chip cookie (school made)

16 AVOID CROSS CONTAMINATION- RECOMMENDATIONS Separate Fryers or Clean Oil if Breaded Items are Fried in Same Vats as Non-Breaded 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 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 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 Use Separate Colanders for gluten free products

17 GLUTEN CONTAINING GRAINS TO AVOID Barley Barley Barley malt/extract Barley malt/extract Bran Bran Bulgur Bulgur Couscous Couscous Bromated or Durum Flour Bromated or Durum Flour Einkorn Einkorn Emmer Emmer Enriched or Self Rising Flour Enriched or Self Rising Flour Farina Farina Faro Faro Graham Flour Graham Flour Kamut Kamut Matzo Flour/meal Matzo Flour/meal Orzo Orzo Panko Panko Phosphated Flour Phosphated Flour Rye Rye Seltan Seltan Semolina Semolina Spelt Spelt Triticale (cross between wheat/rye) Triticale (cross between wheat/rye) Udon Udon Wheat Wheat Wheat Bran Wheat Bran Wheat germ Wheat germ Wheat starch Wheat starch

18 OVERLOOKED GLUTEN SOURCES Ales Ales Beer and Lagers Beer and Lagers Bouillon Cubes Bouillon Cubes Breading Breading Brown Rice Syrup Brown Rice Syrup Coating Mix Coating Mix Communion Wafers Communion Wafers Croutons Croutons Candy Candy Some Chips/Potato chips Some Chips/Potato chips Luncheon Meats, hot dogs, salami, sausage Luncheon Meats, hot dogs, salami, sausage French Fries French Fries Gravy Gravy Pasta Pasta Rice Mixes Rice Mixes Seasoned Tortilla Chips Seasoned Tortilla Chips Sauces Sauces Soup Base Soup Base Stuffing Stuffing Self-basting Poultry Self-basting Poultry Imitation Bacon/Seafood Imitation Bacon/Seafood Soy Sauce Soy Sauce Marinades Thickeners Herbal Marinades Thickeners Herbal Supplements, Prescription Meds Supplements, Prescription Meds Over the Counter Meds Over the Counter Meds Vitamin and Mineral Supplements Vitamin and Mineral Supplements Lipstick Lipstick Lip Gloss and Balms Lip Gloss and Balms Play Dough* (hands must be properly washed after playing with) Play Dough* (hands must be properly washed after playing with)

19 GLUTEN FREE GRAINS AND STARCHES Amaranth Amaranth Arrowroot Arrowroot Buckwheat Buckwheat Corn Corn Flax Flax Flours made from nuts, beans and seeds Flours made from nuts, beans and seeds Millet Millet Montina Montina Potato Starch Potato Starch Potato Flour Potato Flour Quinoa Quinoa Rice Rice Rice Bran Rice Bran Sago Sago Sorghum Sorghum Soy (soya) Soy (soya) Tapioca Tapioca Teff Teff

20 GLUTEN FREE SHOPPING LIST Fresh Fruits Fresh Fruits Fresh Vegetables Fresh Vegetables Tofu Tofu Fresh Beef Fresh Beef Fresh Pork Fresh Pork Fresh Poultry (self-basting) Fresh Poultry (self-basting) Fresh Fish or Seafood Fresh Fish or Seafood Eggs Eggs Unflavored Milk Unflavored Milk Most Yogurts Most Yogurts Butter, Margarine Butter, Margarine Cream Cheese Cream Cheese Cottage Cheese Cottage Cheese Sour Cream Sour Cream Plain Frozen Fruits/Veggies Plain Frozen Fruits/Veggies Most Ice Cream/Sherbet Most Ice Cream/Sherbet Potato Chips (beware flavored ones) Potato Chips (beware flavored ones) Corn Chips Corn Chips Popcorn Popcorn Rice Crackers, Rice Cakes Rice Crackers, Rice Cakes Jello Jello Pudding Pudding Plain Canned Fruits/Veggies Plain Canned Fruits/Veggies Canned Tuna or Chicken Canned Tuna or Chicken Dried Beans, Lentils, Peas Dried Beans, Lentils, Peas Most Baked Beans Most Baked Beans

21 GLUTEN FREE SHOPPING LIST, CONTINUED Cream of Rice Cream of Rice Grits Grits Puffed Rice Puffed Rice Plain Brown or White Rice Plain Brown or White Rice CORN Tacos/Tortillas CORN Tacos/Tortillas Ketchup Ketchup Mustard Mustard Distilled Vinegars Distilled Vinegars Most Salad Dressings Most Salad Dressings Vegetable, Canola and Olive Oil Vegetable, Canola and Olive Oil Jams/Jellies, Marmalade Jams/Jellies, Marmalade Honey Honey Peanut Butter Peanut Butter Corn or Potato Starch Corn or Potato Starch Corn and Maple Syrup Corn and Maple Syrup Brown, White and Confectioner’s Sugar Brown, White and Confectioner’s Sugar Spices and Herbs Spices and Herbs Salt, Pepper Salt, Pepper Relish, Pickles, Olives Relish, Pickles, Olives

22 ACTIVE LEARNING Pull several ingredient statements from labels and see if any of the prohibited items are listed 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? Look at your current menu and develop 3 gluten free menus-what ingredients can you substitute?

23 Culinary Standards Seasoned Pork, Cuban Brand Ingredients: 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 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)

24 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. 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; National Starch and Chemical; Food Allergy Network; Food Allergy Network;

25 Landis Cooked Beef Meatball 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 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

26 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 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

27 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. 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.) 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. 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.

28 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 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

29 Uncle Ben’s Long Grain & Wild Rice Original Recipe Ingredients: long grain parboiled rice enriched with iron (ferric orthophosphate), thiamin 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) (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 *dried

30 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 Ingredients: Cottonseed Oil, Salt, Lactose, Malic Acid, Sodium Acetate, Fumaric Acid, Soybean Oil Allergy Information: Contains Milk. This is a gluten free food. Allergy Information: Contains Milk. This is a gluten free food.

31 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 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 Per Frito Lay, the modified starch is corn. Written confirmation July 2008.

32 TIME TO PRACTICE

33 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

34 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

35 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

36 REFERENCES (Children’s Digestive Health and Nutrition Foundation) (Children’s Digestive Health and Nutrition Foundation) (North American Society for Pediatric Gastroenterology, Hepatology and Nutrition) (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; USDA. Accommodating Children with Special Dietary Needs in the School Nutrition Programs Guidance for School Food Service Staff; 2001.

37 REFERENCES, CONTINUED (National Digestive Diseases Information Clearinghouse) (National Digestive Diseases Information Clearinghouse) Food allergy & intolerance survival guide. Enjoy Life Foods. Food allergy & intolerance survival guide. Enjoy Life Foods. Rochester, Minnesota Public Schools Rochester, Minnesota Public Schools School Nutrition Association School Nutrition Association

38 Developed by: Dr. Becky Domokos-Bays, RD SNS Director, Food and Nutrition Services Alexandria City Public Schools Fall 2008 (for SNA-VA)


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