Gluten Free Webinar Please read below carefully; these are the directions to access the Webinar. This is how you will get information on signing in to the webinar. Yes, it says to register on GoToWebinar - you ARE registered with DHCC and will NOT be charged again at this site. YOU SHOULD DO THIS NOW. PLEASE, contact me directly with any questions. carlsonmom@mchsi.com Marla Carlson DHCC Executive Director

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Residential/Health Care Facilities Gluten Free Success

Celiac Disease prevalence and awareness Menu Design/Food ServiceGluten Free Diet management

RD’s have a leadership role in health management

Ronni Alicea MBA RD rdronni@optonline.netwww.celinalfoods.comwww.matureceliac.blogspot.com

Conclusion: The prevalence of celiac disease was high in elderly people, but the symptoms were subtle….. Increased alertness to the disorder is therefore warranted.

Vilppula A et al. Undetected coeliac disease in the elderly: a biopsy-proven population-based study. Digestive and Liver Diseases 2008;40:809-13

Positive31

Negative4095

Positive81

Negative3155

Positive205

Negative4303

Positive33

Negative1242

Prevalence1:40

Prevalence1:22

Prevalence1:39

Symptomatic subjects3236

1st degree relatives4508

2nd degree relatives1275

Healthy Individuals4126

Risk Groups9019

Population screened13,145

Prevalence1:132

Projected number of celiacs in the U.S.A.: 3 million

Center for Celiac Research Epidemiologic Study in USAArch Int Med 163:286-292, 2003 Fasano et al.

Celiac disease is an immune reaction to proteins found in wheat (Gliadin), rye (secalin) and barley (hordein) collectively known as gluten. Other grains have proteins that food scientists call gluten that are not avoided on physician ordered gluten-free diets, important for pharmacy calls.

Detection of Celiac Disease in Primary Care:A Multicenter Case-Finding Study in North America

Carlo Catassi, M.D., M.P.H.,

CD was diagnosed in 22 out of 976 investigated patientsThe most frequent reasons for CD screeningbloating (12/22) thyroid disease(11/22),

irritable bowel syndrome (IBS) (7/22), unexplained chronic diarrhea (6/22),

chronic fatigue (5/22), and constipation(4/22).

The small bowel biopsy was available in 15 out of 22 GFD was implemented in 17 out of 22 cases.

American Journal of Gastroenterology ISSN 0002-9270 2007 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2007.01173.x

World Gastroenterology Organization Practice Guidelines:

Celiac DiseaseAssociated conditions

Malignant diseaseOsteoporosisAutoimmune disorders

Such disorders include: • Insulin-dependent type 1 diabetes • Thyroid disease • Sjögren’s syndrome • Addison’s disease • Autoimmune liver disease • Cardiomyopathy • Neurological disorders

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Classic GI PresentationHF: 86 YO WF admitted to sub-acute care unit for

DX: Deconditioned post hospitalization for syncope and collapse.

Persistent Diarrhea ċ c-dif negative, anemia of chronic diseaseAdmit wt 112 # family stated UBW 125 5’3 Wt loss ~13# past quarter (90% UBW)Increased confusion, poor po of regular diet and supplements (2Cal product 120 mL QID)Decreased H/H, BUN 32, Cr .5, GFR WNL GI consult ordered, admitted to the hospital

HF: 86 YO WFReadmit new dx: Celiac Disease DO: RegularFacility MD resistant to diet change due to ageFamily meeting: Changed to gluten-free diet orderTherapeutic vitamin (strovite plus), Iron supportNutritional supplements (2-Cal/mL 120 mL QID)Weight gain, increased participation in activities and

Physical therapy and resolved diarrhea Discharged back to the Assisted Living in 15 weeks

at 120 pounds, PO 50-75%, 8 oz 1 cal/mL drinkToday’s dietitian April 2007 vol 9 no 4 Long term care concerns feature for©2007 Becky Dorner & Associates, Inc.

LN admitted sub acute 02/2008Diagnosis

MSMultiple stage III & IVAnemiaconstipation

Weight Loss 30# in 3 years 5’3 admitted 97# UBW 110Diet History :

2000 cal daily (45cal/kg)Labs: Hydration normal

Alb 2.7 Ca++ 8.3H/H 8.3/2.7

Requested ‘Celiac panel’, total IGA and Vit D

Lab results: Reticulin IgA WNLEMA WNL, Gliadin IgA WNLGliadin IgG WNL

LN: Cal count results45kcal /kg 1.8 g protein/kg

WT: 98#

MD concluded negative for celiac

ww.celiac.nih.gov

LN continuedWent home and was readmitted to the hospital with respiratory distress.Was to return to the sub-acute

53 YO with weight loss despite a hearty appetite died of respiratory failure

Celiac panel inconclusive: no total IgA

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Recommendations for practiceCall lab and ask for lab numbers for Total IgA and tTG instead of the ‘celiac panel’

Acculab in NJ total IgA # 1029Acculab in NJ tTG # 1506

Less expensive test ideal for screeningWith results seek GI referral. Will justify EGD when presented with extraintestional symptoms

LL admitted 01/2008

DiagnosisSyncope and CollapsePneumonia AnemiaCeliac Disease

Diet History : Gluten Free Diet 20 yearsLived with niece due to mental deficit Rice Krispee’s AMCommunion (regular)

Labs: As expected

Nutrition Plan of Care:

1- Review GF diet with Kitchen

2- Review facility GF diet with resident and Family

3- Give Activities GF hosts for Pastor to bless

4- Meet Nutrition needsas assessed

Admin support

FacilityTraining

Standardizediet ordersAssess

food delivery systems

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Cross contamination Kitchen training

Tray Accuracy

Communication channels:Dietary: Clinical and Food Service Nursing Functions: med pass/ HS snacksActivities: Rehab Therapies Other: Chaplin; Pharmacy; IT department

Administration support needed for Interdepartmental communication to be successful

CMS INTENT: §483.25(i) 325 Nutritional Status uses Celiac

Disease example:

A resident with known celiac disease (damage to the small intestine related to gluten allergy) develops persistent gastrointestinal symptoms including weight loss, chronic diarrhea, and vomiting, due to the facility's failure to provide a gluten-free diet (i.e., one free of wheat, barley, and rye products) as prescribed by the physician.

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Admin support

Standardizediet orders

Facility Knowledge:

FSD first GF resident was from the UK. They requested Rice Krispees… on the UK list of ‘allowed’ prior to 2008.

Food Avoidance

Gluten/Wheat

Food AversionHigh Protein Diet

Fad Diet

IntoleranceMay limit pasta and

bread due to digestive discomfort

Allergy/Celiac

Wheat Free isNot Gluten Free

Standard All DO’s Policy until individualized

Gluten Free Celiac, wheat allergy, wheat free, no bread

No Wheat, rye, barley aka malt, spelt or oats

Dairy Free No Milk, Milk or diary allergy, Casein Free

No animal milk: Lactose, Casein, whey ingredients

Lactose Free Lactose Intolerance, lactose free, low Lactose

Food preferences may have milk protein (casein & whey) e.g. coffee creamers

Egg Free Egg allergy, no Eggs No egg ingredientsNo egg substitutes

Peanut/tree nut free Peanut allergy, nut allergy, no seeds or nuts

No nuts/peanuts including their oils

Soy-Free Soy allergy, no soy No soy ingredients. Soy oil and lecithin allowed unless specified

Additive-Free Feingold diet, sulfite, MAO MSG, asthma diet

No additives: low sulfite, Salicylates, tyramine

Latex Free Any diet with latex allergy Identified in chart

No latex gloves around food or tray, no banana, kiwi, avocado, chestnuts

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Check the Diet Manual!!!!! Popular state 2008 edition has misinformation‘ Read all labels carefully. Many ingredients contain gluten

but may not list it as such. Avoid: commercial products or mixes containing malt or malt flavorings, textured vegetable protein, hydrolyzed vegetable protein, cereal products, flour, starch, wheat, rye, barley, oat, farina, semolina, durum, triticale, gums, emulsifier ….

MENU PLANNING GUIDELINES:stabilizers, vinegar, artificial colors or flavors, some

monosodium glutamate, vanilla.

What’s up with this statement in the manual guidelines? Use of soy products should be individually evaluated. Millet and

buckwheat may not be tolerated by some.XXXXXXXXX

xxxxxxxxxxxxxxxx

People and Professionals may use different words to describe food avoidance

Admin support

Standardizediet ordersMeal Service

system

Review your system and risks Tray Line PlateBuffet Style Room Service cook to order

Snack carts, Floor Stock and Activities

Assess Food Service Systems

Admin support

Standardizediet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

Frequently a gluten-free diet is one of exclusion.

Meal can be dry and is missing at least 240 calories

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§483.35 Dietary Services(c) Standard Menus/Adequacy

F 363 Probe (c) (1)

If a food group is missing from the resident’s daily diet, does the facility have an alternative means of satisfying the resident’s nutrient needs.

F 363 Probe (c) (3)Is food served as planned?

Oven Fried chicken Baked Chicken Breast- GF gravy

Rice Pilaf White Rice- GF Soy Sauce

Buttered Beets Buttered Beets

Dinner Roll GF Microwave Cornbread

Margarine Margarine

Lemon Meringue Pie Lemon Pudding onGF Microwave BiscuitWhipped Cream

Specifics help the production staff

All Wheat Flour is Enriched Thiamin

Riboflavin

Niacin

Iron

Folate

GF products usually are not fortified

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§483.35 /Dietary Services(e) Therapeutic Diet (LTC)

F325 §483.25(i)(2) Receives a therapeutic diet when there is a nutritional problem.

Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible

Admin support

Standardizediet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Watch Gravy and bacon bits Gluten Free Stock Certified:

Celinal FoodsCuisine Santé (HACO)RC Fine Foods

Read all labels for ingredients: recipes can change on non-certified food.Limit Cross Contamination!

Make GF gravyportion, label and freeze

Ingredients: Enriched flour (wheat flour, malted barley, niacin, reduced iron, thiamin mononitrate, riboflavin, folic acid), sugar, partially hydrogenated soybean oil, and/or cottonseed oil, high fructose corn syrup, whey (milk), eggs, vanilla, natural and artificial flavoring) salt, leavening (sodium acid pyrophosphate, monocalcium phosphate), lecithin (soy), mono-and diglycerides (emulsifier)

ORContains wheat, milk, egg and soy ingredients

FALCPA

WHEAT FREE IS NOT GLUTEN FREE!

Made in plant with Wheat- GMP

Shared Equipment : GMP more difficult

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FDA advised that advisory labeling such as "may contain [allergen]" should not be used as a substitute for adherence to current Good Manufacturing Practices (cGMPs). In addition, any advisory statement such as "may contain [allergen]" must be truthful and not misleading.

Fines attached for non-compliance

CONTAINS BARLEY

Rice Chex are Gluten Free The barley has been replaced with Molasses!

www.tastelikerealfood.comNET WT 14.7 oz. (417g) Makes 1 loaf. Mix contains less than 20 ppm total gluten content, which is considered gluten-free according to the Codex Alimentarius, the European food safety standard. Ingredients SPECIALLY FORMULATED WHEAT STARCH*, BUCKWHEAT (WHOLE GRAIN AND FLOUR), PRECOOKED RICE FLOUR, GLUCOSE, BEET FIBER, POTATO FIBER, SESAME SEEDS, POTATO STARCH, STABILIZER (E464), SALT, RICE STARCH, VEGETABLE FAT (PALM OIL), RAISING AGENT (CALCIUM PHOSPHATE, SODIUM HYDROGEN CARBONATE), THICKENING AGENT (XANTHAN GUM).

Certification/ Dedicated Plants

Recognized by

Ingredients on lists to QuestionModified Food Starch*Citric Acid*

need to ask if using imported

Caramel Coloring*Flavoring*Dextrin*

Soy Sauceoften contains wheat

Mono and Diglyceridesmay have a wheat carrier when used in dry ingredients but it should be declared

Brown Rice Syrupmay be made from barley

* By definition may contain wheat but US manufactures say they are not using gluten containing grains

Field to Plate: 0ats

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Other ConcernsWhere to purchase?

Distributor: May stock or Special OrderLocal Grocery: Keep Receipts!Mail Order: Celinal Foods, Glutenfree.com

Check Labels Each Time!

Store High if possible away from Air-borne

Label book for reference

Assess production ability: make or buy

Assess product availability: Distributor

Nutritionally Adequate

Assess Other Departments Food Needs

Include all Therapeutic and Consistency

Don’t forget the disaster menu

Plan meals and snacks

Admin support

Standardizediet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Cross contamination Kitchen training

F 371

Store, prepare distribute and serve food under sanitary conditions;

Reduce the practices which result in food contaminationStore GF foods higher then flour bins and away from mixes

- Wrap, date and Identify clearly

LL admitted 01/2008 2 weeks later

DiagnosisAdd persistent diarrheaBenign pancreatic mass

Diet Facility Gluten Free DietNo Outside snacks Communion (low-gluten)

Plan of Care:

1- Review GF diet with Kitchen

2- MD to evaluate Pancreatic Mass for change

3- R/O C- Diff4- Nurses to check

medications with pharmacy

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Crumbs Count Double Dipping

Trouble hot spots

Flour and rice scoop stored together

No Ingredient statement

The KitchenThere are no scientific studies to evaluate cleaning

practices or methods

Food Allergy News suggestions 1- Warm soapy water 2- Fresh cloth or paper towel to wipe3- Prep the special diet foods first4- Wrap and Identify clearly

Ongoing InserviceEducation

Admin support

Standardizediet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Cross contamination Kitchen training

Tray Accuracy

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Right Tray, Right Person

Visual cues Tray colornapkin colorIcon

Tray ticket color

Privacy rights

What if Everything was perfect: except the roll?

Prepare for Kitchen Training

Rewrite inservices to include an allergy component for continued reinforcement

Topics to update:

Sanitation, Inventory storage, Food preparationTray line Services, Therapeutic Diets, Food Safety

Mechanically Altered, Residents Rights

Food Allergy Kitchen ProtocolFollow Recipes

Allergen trays prepared first

Equipment and work surfaces will be cleaned before use with a fresh cloth or paper towel.

Clean and Sanitized utensils to be used in food production and portioning.

Label read every time unless specific claim made on the label

Food can not be fixed…. start over

Admin support

Tray delivery feeding asstsTherapists

Standardizediet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Cross contamination Kitchen training

Tray Accuracy

October 31, 2008

By DAVID GIALANELLA Staff Writer

Prosecutors said Thursday they are reviewing the case of an Elgin Mental

Health Center patient who died months ago after two facility employees allegedly gave him

a meal containing fish despite a severe fish allergy.

Morris Howard, 58, formerly of Chicago, died on June 20 after the employees gave him the meal, which

investigators said sent him into anaphylactic shock. A coroner's jury on Wednesday ruled the death a reckless homicide.

Illinois State Police investigators earlier this week handed the case off to the Kane County State's Attorney's Office, and

criminal charges against the employees could be announced in the coming days, according to State's Attorney John Barsanti.

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Nutrition Diagnosis

Altered GI function as evidenced by:weight loss with excessive caloric intakeNutrient Deficiency with adequate dietary intakePersistent Diarrhea

Food related knowledge deficit AEB by:Persistent elevated tTG of unknown origin

Limited Adherence to nutrition related recommendations

Diet history reveals overt gluten intake

§483.35 Dietary Services(e) Therapeutic Diet (LTC)

F 367 (see also 483.25 (i)Therapeutic Diets must be ordered by the

attending physician

Interpretive guideline: part of treatment for a disease or clinical condition or to eliminate or decrease specific nutrients in the diet, or to provide food the resident is able to eat: mechanically altered.

325 Nutritional Status but….

42 CFR 483.10, Tag F150, Resident Rights to Determine if the resident’s preferences related to nutrition and food intake were considered.

42 CFR 483.40(a)(1)(2), Tag F385, Physician Services – Physician Supervision And many more:

Religious Needs

Low-Gluten Hosts1-800-223-2772 www.benedictinesisters.org

Matzowww.glutenfreematzo.comMade from GF Oats

LB CCRC DNR DNH resident in Skilled NursingDiagnosis

Alzheimer’s DiseaseOsteoporosisDepressionHypercholestermia

4/2009 WT 122 BMI 19.5DO: Gluten-Free POS: allergy: wheat5/2009 WT 120 RD selected menu for resident for GF status6/2009 WT 115 (new MDS significant change) Supplement 2cal/mL and magic cupsVitamin not ordered after call to pharmacy no GF guarantee.

7/2009 WT 1138/2009 WT 114 (husband admitted to share room) 9/2009 WT 115-11810/2009 WT 12011/2009 WT 118-12012/2009 weight gain started 124

7/2010 Wt 133- nurses are concerned due to acute decrease in PO. No GI distress reported.

Resident states: ‘I eat gluten-free foods: no bread or pasta’Strovite Plus Vitamin ordered

Celiac panel ordered

LB CCRC DNR DNH resident in Skilled Nursing

Reticulin IgA WNLEndomysial IgA WNL

Gliadin IgG 15.8 HGliadin IgA 13.2 H

Labs inconclusive would need an EGD to confirm celiac disease at this time.

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LB CCRC DNR DNH resident in Skilled NursingDiagnosis

Alzheimer’s DiseaseOsteoporosisDepressionHypercholestermia

4/2009 WT 122 BMI 19.5DO: Gluten-Free POS: allergy: wheat8/2010 WT 136. RD/RN charting on overt intake of gluten containing food between meals. (husbands PB&J HS snack). PO improving, seeking food items. No GI distress

9/2010 13410/2010 13511/2010 supplement d/c'd

DO continued Gluten-Free.

Recommend to change to regular diet with RD selecting gluten-free meals as preference 2° to behavior and clinical presentation.

www.glutenfreedrugs.com to review medications as needed.

Barriers to Compliance

Daily Lifestyle ChallengesQuality of Life Issues

Limited Cooking availability and/or skillNot Convenient

Costly Misinformation

Psych-Social ChallengesKnowledge Deficit of suitable substitutions

GF resident admittedReview diet management with kitchen

Review diet order rational with nursing/caregivers

Review religious needs with activities. Review with other departments as needed: speech therapy screens no crackers.

Request baseline tTG for monitoring on admission with known celiac residents.

Next Case Studies:Renal Diabetic on Gluten-Free Diet in AL

86 YO WF, BMI 18.5, 96% UBW with Labs WNL except elevated Alkaline Phosphatase

CCRC Four Independent Mature WF with one meal daily and no gluten-free menu.

Follow: www.matureceliac.blogspot.com

Resources & Web SitesGluten-Free Diet: A Comprehensive Resource Guide - Shelley Case www.glutenfreediet.ca

The Celiac Diet, Series 1-7 Carol Rees Parshi MS RDhttp://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/resources.cfm

Evidence Based Standards of Practicehttp://celiac.nih.govwww.eatright.org manual of clinical dieteticsAGA Institute Medical Position Statement on the DX and Mngt of Celiac Disease:

Gastroenterology 2006;131:1977-1980

Center for Celiac Researchwww.celiaccenter.org

Steve Plogsted’s medication listwww.glutenfreedrugs.com

Local Support Groups: CSA, GIG,CDF, Independentsrdronni@optonline.net

Religious resourcealtarbreads@benedictinesisters.org, http://glutenfreematzo.com

Allergen Food for Institutions mailorderwww.celinalfoods.com (also available thru Gordon Food Service) www.med-diet.com

Murray JA. Et al. Morbidity and mortality among older individuals with undiagnosed celiac disease. Gastroenterology. 2010 Sep;139(3):763-9Collin P et al. Increasing Prevalence and high incidence of celiac disease in elderly people: A population-based study. BMC Gastroenterology 2009; 9:49 Vilppula A et al. Undetected coeliac disease in the elderly: a biopsy-proven population-based study. Digestive and Liver Diseases 2008;40:809-13.Lurie Y et al. Celiac disease diagnosed in the elderly. Journal of Clinical Gastroenterology 2008;42:59-61Hu WT et al. Cognitive impairment and celiac disease. Archives of Neurology 2006;63:1440-46.Hankey GL, Holmes GK. Coeliac disease in the elderly. Gut 1994;35:65-67.

Celiac Disease and the aged: limited clinical studies

CERTIFICATE OF COMPLETION - CDR

Gluten Free  30 November 2010 Date of Completion

Dietetics in Health Care Communities - DHCC Commission on Dietetic Registration CPE Accredited Provider

AM003________________________________ CPE Provider Accreditation Number

CPE Accredited Provider

Participant’s Name Has successfully completed 1.5 CPEUs (Level II)

DHCC – DPG #31, Brenda Richardson, MA, RD, LD, CD Chair Signature of CDR CPE Accredited Provider, Date 30 November 2010

CERTIFICATE OF COMPLETION - State

Gluten Free 30 November 2010 Date of Completion

Dietetics in Health Care Communities - DHCC Commission on Dietetic Registration CPE Accredited Provider

AM003________________________________ CPE Provider Accreditation Number

CPE Accredited Provider

Participant’s Name Has successfully completed 1.5 CPEUs (Level II)

DHCC – DPG #31, Brenda Richardson, MA, RD, LD, CD Chair Signature of CDR CPE Accredited Provider, Date 30 November 2010