Transcript Celiac Disease Primer for Schools

CELIAC DISEASE
A PRIMER FOR SCHOOL
NUTRITION
What is Celiac Disease?
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Inherited, Autoimmune Disorder
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Permanent Intolerance to Gluten in
WHEAT, RYE AND BARLEY
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Also referred to as celiac sprue
WHAT IS GLUTEN?
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THE PORTION OF THE PROTEIN IN
FLOUR THAT FORMS THE STRUCTURE OF
DOUGH
SCOPE OF DISEASE
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2.2 million Americans afflicted-over 10,000
children diagnosed annually *
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Affects 1 in 133 Americans
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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
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Initial Blood Tests
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If serology is positive, a biopsy of small
intestine is the definitive test
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NO CURE: person must strictly avoid food
products, medicines, vitamins and even
glue on envelopes that may have gluten
MECHANISM OF ACTION
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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
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If villi are damaged, vitamins, minerals, calcium,
carbohydrates, protein, and fats are not
absorbed well
INTESTINAL VILLI
SYMPTOMS
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Some may be
asymptomatic
Diarrhea
Short Stature
Iron Deficiency
Anemia
Lactose Intolerance
Irritability (common in
children)
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Mood Swings
(common in children)
Abdominal Pain
Irritable Bowel
Osteoporosis
Skin rash-very itchy
with blisters
TREATMENT
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GLUTEN FREE DIET
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ELIMINATE ALL WHEAT, RYE, BARLEY
AND THEIR DERIVATIVES
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MAY TAKE 6-12 MONTHS FOR INTESTINE
TO HEAL
WHAT ABOUT OATS?
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Oats may not be harmful to a celiac
patient; however, oats may be crosscontaminated with wheat in the milling
process
FOOD LABELING LAWS
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Under the 2006 Food Allergen Labeling
and Consumer Act, wheat protein or a
derivative must be identified, even if used
in small amounts
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The law does not address the use of
barley, rye or oats
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Check with manufacturer if in doubt
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
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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
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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
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)
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AVOID CROSS CONTAMINATIONRECOMMENDATIONS
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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
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Barley
Barley malt/extract
Bran
Bulgur
Couscous
Bromated or Durum Flour
Einkorn
Emmer
Enriched or Self Rising Flour
Farina
Faro
Graham Flour
Kamut
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Matzo Flour/meal
Orzo
Panko
Phosphated Flour
Rye
Seltan
Semolina
Spelt
Triticale (cross between
wheat/rye)
Udon
Wheat
Wheat Bran
Wheat germ
Wheat starch
OVERLOOKED GLUTEN SOURCES
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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
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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)
GLUTEN FREE GRAINS AND STARCHES
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Amaranth
Arrowroot
Buckwheat
Corn
Flax
Flours made from nuts, beans and
seeds
Millet
Montina
Potato Starch
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Potato Flour
Quinoa
Rice
Rice Bran
Sago
Sorghum
Soy (soya)
Tapioca
Teff
GLUTEN FREE SHOPPING LIST
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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
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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, CONTINUED
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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
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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
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?
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Culinary Standards Seasoned Pork,
Cuban Brand 98465
Ingredients:
 Boneless pork legg-outside roast (fresh HamPFOF), 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
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**According to manufacturer, the starch is CORN (8/4/2008 per Jose Quinones)
OK? What about modified food
starch?
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Modified food starch has been treated
physically or chemically to modify its
properties. The “starch” can be from
corn, WHEAT, potato, rice or tapiocadepends on the manufacturer.
National Starch and Chemical; www.foodstarch.com
Food Allergy Network; http:www.foodallergy.org/index.html
Landis Cooked Beef Meatball 36612
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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
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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?
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
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compound with water which results in decomposition of a
compound (salt in water e.g.)
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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
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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
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)
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*dried
UTZ Salt ‘n Vinegar Artificially
Flavored Potato Chips
(sold ala carte only)
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Ingredients: Cottonseed Oil, Salt,
Lactose, Malic Acid, Sodium Acetate,
Fumaric Acid, Soybean Oil
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Allergy Information: Contains Milk. This
is a gluten free food.
Baked Lays Potato Crisps
(sold ala carte only)
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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.
TIME TO PRACTICE
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
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
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
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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
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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
Developed by:
Dr. Becky Domokos-Bays, RD SNS
Director, Food and Nutrition Services
Alexandria City Public Schools
[email protected]
Fall 2008 (for SNA-VA)