Residential/Health Care Facilities Residential/Health Care Facilities Food Avoidance/Gluten Free Food Avoidance/Gluten Free

SuccessSuccess

Celiac Disease prevalence and awareness Celiac Disease prevalence and awareness Food avoidance- Food allergyFood avoidance- Food allergy Menu Design/Food ServiceMenu Design/Food Service Gluten Free Diet management Gluten Free Diet management

RD’s have a leadership role in health management

Ronni Alicea MBA RDN CSG rdronni@optonline.net

22

1 out of 3 people say they modify 1 out of 3 people say they modify their diets because they, or a their diets because they, or a loved one, have a food loved one, have a food intoleranceintolerance/allergy/allergy

www.Niaid.nih.govwww.Niaid.nih.gov

~110,000,000 people~110,000,000 people,,70% of people over 65 can expect to 70% of people over 65 can expect to

use residential care use residential care longtermcare.gov longtermcare.gov

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

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

F325 F325 §483.25(i)(2) Receives a therapeutic diet §483.25(i)(2) Receives a therapeutic diet

when there is a nutritional problem.when there is a nutritional problem.

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

FNC Food Allergy and FNC Food Allergy and IntoleranceIntolerance 66

483.35 Dietary Services483.35 Dietary Services(d) Food(d) Food

F365 Food prepared in a form designed to F365 Food prepared in a form designed to meet individual needmeet individual need

F366 Substitutes offered of similar nutritive F366 Substitutes offered of similar nutritive value to residents who refuse food servedvalue to residents who refuse food served A food Substitute should be consistent with A food Substitute should be consistent with

the usual and ordinary food items providedthe usual and ordinary food items provided

FNC Food Allergy and FNC Food Allergy and IntoleranceIntolerance 88

Resident ChoiceResident Choice

See Residents Rights at 42 CFR 483.10 See Residents Rights at 42 CFR 483.10 (b)(3) and (4) and F 154 and F155(b)(3) and (4) and F 154 and F155

‘‘In order for a resident to exercise his/her In order for a resident to exercise his/her right appropriately to make informed right appropriately to make informed choices … consequences of refusing choices … consequences of refusing treatment….. When allergies are in the treatment….. When allergies are in the medical record, a medical note is needed medical record, a medical note is needed if ‘allergy to food’ is to be served. if ‘allergy to food’ is to be served.

Admin support

FacilityTraining

Standardize diet ordersAssess

food delivery systems

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Cross contamination Kitchen training

Tray Accuracy

Check your Policy: Therapeutic DietsCheck your Policy: Therapeutic Diets

Therapeutic diets are prepared and served Therapeutic diets are prepared and served as prescribed by the attending physician. as prescribed by the attending physician.

Therapeutic diets are planned and are on Therapeutic diets are planned and are on menu extensions.menu extensions.

Check there is a solid policy for like Check there is a solid policy for like substitutions. Many with gluten/dairy substitutions. Many with gluten/dairy restrictions will want their favorite brand!restrictions will want their favorite brand!

1010

1111

Admin support

Facility Mission

StatementLiability

Satisfaction Survey’s

3 Million Celiac12 Million Food Allergy

F- tag Potential

Food, personal products and

crafts may cause reactionsInterdepartme

ntal

1212

Food Intolerances

Non-immunologic Allergy

Metabolic Disorders

False food AllergIdiosyncratic

IgE Mediated T-cell Mediated

Lactose Intolerance

Inborn Errors

Sulfites

Food colors

Celiac Disease

Cow’s Milk / soyaAllergy

Sensitivity/Intolerances

Gluten Intolerance

Pharmacologic

CaffeineAlcohol

MSG

Gluten IIntolerance

Big 8 Allergens

160 foods

Latex

Food Intolerances

Non-immunologic Allergy

Metabolic Disorders

False food AllergIdiosyncratic

IgE Mediated T-cell Mediated

Lactose Intolerance

Inborn Errors

Sulfites

Food colors

Celiac Disease

Cow’s Milk / soyaAllergy

Sensitivity/Intolerances

Gluten Intolerance

Pharmacologic

CaffeineAlcohol

MSG

Gluten IIntolerance

Big 8 Allergens

160 foods

Latex

1313

Food Avoidance

Food Aversion Intolerance Allergy

(Immune)

1414

No MilkDairy Allergy

Milk freeLactose Free

Food Aversion

I do not like milkI am Vegan

IntoleranceMay not drink milk but

uses Lactose Free milk eats yogurt and cheese

Allergy

No Casein, WheyOr Lactose

An in-depth food preference interview is needed to help your kitchen be successful Follow the most strict diet order until individualized!

XXXXXXXXX

xxxxxxxxxxxxxxxx

People and Professionals may use different words to describe food avoidance

FNC Food Allergy and FNC Food Allergy and IntoleranceIntolerance 1616

Food AversionFood Aversion

Phobia’sPhobia’s Food Preferences Food Preferences Vegan, Kosher, HalalVegan, Kosher, Halal Food Fad’sFood Fad’s Clockwork orange conditioningClockwork orange conditioning Disordered eatingDisordered eating

What’s your most unusual one?What’s your most unusual one?

Allergies are to proteins Allergies are to proteins

Gal d 6 is the second allergen characterized from egg yolk.

Only one allergen from the egg yolk, alpha-livetin (Gal d 5) has been described thus far. A new egg yolk allergen was detected studying 27 egg allergic patients. 5 of the 27 patients (18%) detected a yolk allergen of an apparent molecular weight of 35 kDa. Heating and reduction treatments did not affect its allergenicity, although digestion with simulated gastric fluid diminished the IgE-binding capacity of the allergen. The N-terminal amino acid sequence corresponded with the YGP42 protein, a fragment of the vitellogenin-1 precursor. The allergen was designated Gal d 6.

Amo A, Rodríguez-Pérez R, Blanco J, Villota J, Juste S, Moneo I, Caballero ML.Gal d 6 is the second allergen characterized from egg yolk.J Agric Food Chem 2010 Jun 23;58(12):7453-7.

1717

FNC Food Allergy and FNC Food Allergy and IntoleranceIntolerance 1818

FNC Food Allergy and FNC Food Allergy and IntoleranceIntolerance 1919

Metabolic intolerance Metabolic intolerance FavismFavism Trehalose insufficiency Trehalose insufficiency Pancreatic dysfunction Pancreatic dysfunction Inborn Errors of MetabolismInborn Errors of Metabolism Damage to enzyme producing cells can Damage to enzyme producing cells can

cause secondary Intolerancescause secondary Intolerances Histamine intolerance: reduced activity of Histamine intolerance: reduced activity of

diamine oxidase (DAO). diamine oxidase (DAO).

FNC Food Allergy and FNC Food Allergy and IntoleranceIntolerance 2020

Digestive Enzymes and sourceDigestive Enzymes and source Mouth: ∂ amylaseMouth: ∂ amylase Stomach: pepsinsStomach: pepsins Pancreas: amylase, Pancreas: amylase,

lipase and Proteaseslipase and Proteases Gall Bladder: BileGall Bladder: Bile Brush BorderBrush Border

LactaseLactase ∂ ∂ glucosidaseglucosidase ββ galactosidase galactosidase Sucrase-IsomaltaseSucrase-Isomaltase Amino-ogliopeptidaseAmino-ogliopeptidase

Starch ∂ 1 →4 bondsStarch ∂ 1 →4 bonds ProteinProtein dextrin, triglyceridesdextrin, triglycerides

PeptidesPeptides Fat micelle formationFat micelle formation

Lactose→glu + galLactose→glu + gal ∂ ∂ 1 →4 bonds ∂ 1→6 bonds1 →4 bonds ∂ 1→6 bonds Sucrose → glu & fruSucrose → glu & fru maltose → glu & glumaltose → glu & glu Removal of N terminal aa’sRemoval of N terminal aa’s

Why is GF so popular?Why is GF so popular?

Food Avoidance

Gluten/Wheat

Food Aversion

High Protein DietFad Diet

IntoleranceMay limit pasta and

bread due to digestive discomfort

Allergy/Celiac

Wheat Free isNot Gluten Free

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.:3.3 million

Center for Celiac Research Epidemiologic Study in USA Arch 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.

FNC Food Allergy and FNC Food Allergy and IntoleranceIntolerance 2525

A. Fasano and T. Shea Donohue, Nature Clin Pract Gastroenterol Hepatol 2005 (in press)

World Gastroenterology Organization Practice Guidelines:

Celiac Disease Associated conditions

Malignant disease Osteoporosis Autoimmune disorders

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

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

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

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

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

Classic GI PresentationClassic 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 disease

Admit 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 drink

Today’s dietitian April 2007 vol 9 no 4 Long term care concerns feature for©2007 Becky Dorner & Associates, Inc.

LN admitted sub acute 02/2008LN admitted sub acute 02/2008 DiagnosisDiagnosis

MSMS Multiple stage III & IVMultiple stage III & IV AnemiaAnemia constipationconstipation

Weight Loss 30# in 3 years Weight Loss 30# in 3 years 5’3 admitted 97# UBW 1105’3 admitted 97# UBW 110

Diet History : Diet History : 2000 cal daily (45cal/kg)2000 cal daily (45cal/kg)

Labs: Hydration normalLabs: Hydration normal Alb 2.7 Ca++ 8.3Alb 2.7 Ca++ 8.3 H/H 8.3/2.7H/H 8.3/2.7

Requested ‘Celiac Requested ‘Celiac panel’, total IGA and panel’, total IGA and Vit DVit D

Lab results: Lab results:

Reticulin IgA WNLReticulin IgA WNL

EMA WNL, EMA WNL,

Gliadin IgA WNLGliadin IgA WNL

Gliadin IgG WNLGliadin IgG WNL

LN: Cal count resultsLN: Cal count results45kcal /kg 1.8 g protein/kg45kcal /kg 1.8 g protein/kg

WT: 98#WT: 98#

MD concluded negative for celiac

www.celiac.nih.gov

LN continuedLN continued

Went home and was readmitted to Went home and was readmitted to the hospital with respiratory distress.the hospital with respiratory distress.

Was to return to the sub-acuteWas to return to the sub-acute

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

Celiac panel inconclusive: no total IgACeliac panel inconclusive: no total IgA

Recommendations for practiceRecommendations for practice Call lab and ask for lab numbers for Total Call lab and ask for lab numbers for Total

IgA and tTG instead of the ‘celiac panel’IgA and tTG instead of the ‘celiac panel’ Acculab in NJ total IgA # 1029Acculab in NJ total IgA # 1029 Acculab in NJ tTG # 1506Acculab in NJ tTG # 1506

Less expensive test ideal for screeningLess expensive test ideal for screening With results seek GI referral. Will justify With results seek GI referral. Will justify

EGD when presented with extraintestional EGD when presented with extraintestional symptomssymptoms

LL admitted 01/2008LL admitted 01/2008

DiagnosisDiagnosis Syncope and CollapseSyncope and Collapse Pneumonia Pneumonia AnemiaAnemia Celiac DiseaseCeliac Disease

Diet History : Diet History : Gluten Free Diet 20 Gluten Free Diet 20

yearsyears Lived with niece due Lived with niece due

to mental deficit to mental deficit Rice Krispee’s AMRice Krispee’s AM Communion (regular)Communion (regular)

Labs: As expectedLabs: As expected

Nutrition Plan of Care:Nutrition Plan of Care:

1- Review GF diet with 1- Review GF diet with KitchenKitchen

2- Review facility GF 2- Review facility GF diet with resident diet with resident and and FamilyFamily

3- Give Activities GF 3- Give Activities GF hosts for Pastor to hosts for Pastor to blessbless

4- Meet Nutrition needs4- Meet Nutrition needs

as assessedas assessed

Admin support

FacilityTraining

Standardize diet ordersAssess

food delivery systems

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Cross contamination Kitchen training

Tray Accuracy

Communication channelsCommunication channels::

Dietary: Clinical and Food Service Dietary: Clinical and Food Service

Nursing Functions: med pass/ HS snacksNursing Functions: med pass/ HS snacks

Activities: Rehab Therapies Activities: Rehab Therapies

Other: Chaplin; Pharmacy; IT departmentOther: Chaplin; Pharmacy; IT department

Administration support needed for Interdepartmental communication to be successful

Religious NeedsReligious Needs

Low-Gluten HostsLow-Gluten Hosts 1-800-223-2772 1-800-223-2772

www.benedictinesisters.orgwww.benedictinesisters.org

MatzoMatzo www.glutenfreematzo.comwww.glutenfreematzo.com Made from GF OatsMade from GF Oats

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

Disease example:Disease example:

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

Admin support

Standardize diet orders

Check the Diet ManualCheck the Diet Manual!!!!!!!!!! misinformationmisinformation

‘ 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.

StandardStandard All DO’sAll DO’s Policy until individualizedPolicy until individualized

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

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

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

No animal milk: Lactose, No animal milk: Lactose, Casein, whey ingredientsCasein, whey ingredients

Lactose FreeLactose Free Lactose Intolerance, lactose Lactose Intolerance, lactose free, low Lactosefree, low Lactose

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

Egg FreeEgg Free Egg allergy, no EggsEgg allergy, no Eggs No egg ingredientsNo egg ingredients

No egg substitutesNo egg substitutes

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

No nuts/peanuts including No nuts/peanuts including their oilstheir oils

Soy-FreeSoy-Free Soy allergy, no soySoy allergy, no soy No soy ingredients. Soy oil No soy ingredients. Soy oil and lecithin allowed unless and lecithin allowed unless specifiedspecified

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

No additives: low sulfite, No additives: low sulfite, Salicylates, tyramine Salicylates, tyramine

Latex FreeLatex Free Any diet with latex allergy Any diet with latex allergy Identified in chartIdentified in chart

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

Worcestershire SauceWorcestershire Sauce

Ingredients: distilled white Ingredients: distilled white vinegar, molasses, water, sugar, vinegar, molasses, water, sugar, onions, anchovies, salt, garlic, onions, anchovies, salt, garlic, cloves, tamarind extract, natural cloves, tamarind extract, natural flavorings, chili pepper extract. flavorings, chili pepper extract.

Contains anchoviesContains anchovies..

4545

4646

Dairy allergy Diets EliminateDairy allergy Diets Eliminate Fluid MilkFluid Milk Ingredient MilkIngredient Milk CreamCream ButterButter Check All processed foodsCheck All processed foods Cream SoupCream Soup CheeseCheese YogurtYogurt Check non-dairy creamer Check non-dairy creamer

(sodium caseinates) (sodium caseinates)

CaseinWheylactose

FDA definition gluten freeFDA definition gluten free

< less then 20 PPM in finished goods < less then 20 PPM in finished goods

One slice of regular bread has 124,000 PPMOne slice of regular bread has 124,000 PPM

One slice of gluten free bread usually < 5 PPMOne slice of gluten free bread usually < 5 PPM

Claims for food service are encouraged to follow Claims for food service are encouraged to follow FDA regulation for manufacturersFDA regulation for manufacturers

TIP: Use ‘ Gluten-restricted’ as term TIP: Use ‘ Gluten-restricted’ as term

Use gluten-free ingredients or TEST.Use gluten-free ingredients or TEST.

Daily intake of Carbs and ppm of Daily intake of Carbs and ppm of gluten in food for celiacsgluten in food for celiacs

50 g50 g 100 g100 g 200 g200 g 300 g300 g

200 ppm200 ppm 10 mg10 mg 20 mg20 mg 40 mg40 mg 60 mg60 mg

100 ppm100 ppm 5 mg5 mg 10 mg10 mg 20 mg20 mg 30 mg30 mg

50 ppm50 ppm 2.5 mg2.5 mg 5 mg5 mg 10 mg10 mg 15 mg15 mg

20 ppm20 ppm 1 mg1 mg 2 mg2 mg 4 mg4 mg 6 mg6 mg

www.tastelikerealfood.com www.tastelikerealfood.com NET WT 14.7 oz. (417g) Makes 1 loaf. NET WT 14.7 oz. (417g) Makes 1 loaf.

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

Admin support

Standardize diet ordersMeal Service

system

Review your system and risks Review your system and risks Tray Line PlateTray Line Plate Buffet Style Buffet Style Room Service cook to orderRoom Service cook to order

Snack carts, Floor Stock and ActivitiesSnack carts, Floor Stock and Activities

Assess Food Service Systems

Admin support

Standardize diet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

§483.35 Dietary Services§483.35 Dietary Services(c) Standard Menus/Adequacy(c) Standard Menus/Adequacy

F 363 Probe (c) (1)F 363 Probe (c) (1)

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

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

Specifics help the production staff

Facility Knowledge:

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

5656

Menu Analysis: Food Allergy extension

Do Not Serve Do not serve Do not serve Do not serve Do not serve Do no serve Do not serve Do not serve

Recipe #Menu item name

Dairy allergy Egg Allergy Fin Fish allergy gluten reduced Lactose reduced peanut/nut free Seafood Free Shellfish allergy

1Juice of Choice

2Cold Cereal (Chex Cereal only)

3Oatmeal ? Made with milk? (Cream rice only) ? Made with milk?

4Farina ? Made with milk? (Cream rice only) ? Made with milk?

5Cream of Rice ? Made with milk? ? Made with milk?

6Scrambled Egg

? Made with milk? ( Greek yogurt or

other 7 gram protein

7Bacon

8Toast? Made with milk? Made with egg? (Gluten Free bread)

9Milk Soy, almond milk lactose reduced

10Tuna Salad Sandwich

? Milk in dressing ? Mayo Ham salad (gluten free bread ham salad

11 beef Pot Pie Worchester sauce?

Serve Beef stew if flour not used or beef stir fry on rice

5757

5858

Foods that contain: _____Gluten/wheat__________________

Recipe # Sub with:

1.__white/rye/toast/rolls__________ Sub_ gluten-free bread or fruit cup_

2.__Muffins/croissants____________ Sub__gluten-free muffin or fruit cup

3. _pancake/waffle _______________ Sub __gluten-free pancake

4.__blintz__________________ _ Sub ___omelet_______

5._______________________ Sub ____________________

6.______________________ Sub____________________

7.______________________ Sub____________________

8. ______________________ Sub ____________________

9.______________________ Sub ____________________

Cheat sheets can assist departments

Oven Fried chickenOven Fried chicken Baked Chicken BreastBaked Chicken Breast

- - GF gravyGF gravy

Rice PilafRice Pilaf White RiceWhite Rice

- - GF Soy SauceGF Soy Sauce

Buttered BeetsButtered Beets Buttered BeetsButtered Beets

Dinner RollDinner Roll GF Microwave CornbreadGF Microwave Cornbread

MargarineMargarine MargarineMargarine

Lemon Meringue PieLemon Meringue Pie Lemon Pudding onLemon Pudding on

GF Microwave BiscuitGF Microwave Biscuit

Whipped CreamWhipped Cream

6060

CONTAINS BARLEY

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

Watch Gravy and bacon bits Watch Gravy and bacon bits Gluten Free Stock Gluten Free Stock

Certified:Certified: Celinal FoodsCelinal Foods Cuisine Santé (HACO)Cuisine Santé (HACO) RC Fine FoodsRC Fine Foods

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

Make GF gravyportion, label and freeze

All Wheat Flour is Enriched All Wheat Flour is Enriched ThiaminThiamin

RiboflavinRiboflavin

NiacinNiacin

IronIron

FolateFolate

GF products usually are GF products usually are not fortifiednot fortified

Field to Plate: 0atsField to Plate: 0ats

6464

Admin support

Standardize diet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

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

OROR

Contains wheat, milk, egg and soy ingredientsContains wheat, milk, egg and soy ingredientsFALCPA

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

Fines attached for non-complianceFines attached for non-compliance

WHEAT FREE WHEAT FREE IS NOT GLUTEN FREE!IS NOT GLUTEN FREE!

Made in plant with Wheat- GMPMade in plant with Wheat- GMP

Shared Equipment : GMP more difficultShared Equipment : GMP more difficult

CONTAINS BARLEY

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

Certification/ Dedicated Certification/ Dedicated PlantsPlants

Recognized by

Ingredients on lists to Ingredients on lists to QuestionQuestion

Modified Food Modified Food Starch*Starch*

Citric Acid*Citric Acid* need to ask if using need to ask if using

imported imported Caramel Coloring*Caramel Coloring* Flavoring*Flavoring* Dextrin*Dextrin*

Soy SauceSoy Sauce often contains wheatoften contains wheat

Mono and Mono and DiglyceridesDiglycerides may have a wheat may have a wheat

carrier when used in carrier when used in dry ingredients but it dry ingredients but it should be declaredshould be declared

Brown Rice SyrupBrown Rice Syrup may be made from may be made from

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

Other ConcernsOther Concerns

Where to purchase?Where to purchase? Distributor: May stock or Special OrderDistributor: May stock or Special Order Local Grocery: Keep Receipts!Local Grocery: Keep Receipts!

Check Labels Each Time!Check Labels Each Time!

Store High if possible Store High if possible

Label book for referenceLabel book for reference

Assess production ability: make or buyAssess production ability: make or buy

Assess product availability: Distributor Assess product availability: Distributor

Nutritionally AdequateNutritionally Adequate

Assess Other Departments Food NeedsAssess Other Departments Food Needs

Include all Therapeutic and ConsistencyInclude all Therapeutic and Consistency

Don’t forget the disaster menuDon’t forget the disaster menu

Plan meals and snacks

F 371F 371

Store, prepare distribute and serve food Store, prepare distribute and serve food under sanitary conditions;under sanitary conditions;

Reduce the practices which result in food Reduce the practices which result in food contaminationcontamination

Store GF foods higher then flour bins and Store GF foods higher then flour bins and away from mixesaway from mixes

- Wrap, date and Identify clearly- Wrap, date and Identify clearly

Admin support

Standardize diet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Cross contamination Kitchen training

LL admitted 01/2008 2 weeks laterLL admitted 01/2008 2 weeks later

DiagnosisDiagnosis Add persistent diarrheaAdd persistent diarrhea Benign pancreatic massBenign pancreatic mass

Diet Diet Facility Gluten Free DietFacility Gluten Free Diet No Outside snacks No Outside snacks Communion (low-gluten)Communion (low-gluten)

Labs: IV for Labs: IV for dehydrationdehydration

Plan of Care:Plan of Care:

1- Review GF diet with 1- Review GF diet with KitchenKitchen

2- MD to evaluate 2- MD to evaluate Pancreatic Mass Pancreatic Mass for for changechange

3- R/O C- Diff3- R/O C- Diff

4- Nurses to check 4- Nurses to check medications with medications with pharmacypharmacy

Crumbs CountCrumbs Count

Double DippingDouble Dipping

Trouble hot spotsTrouble hot spots

Flour and rice scoop stored together

No Ingredient statement

The KitchenThe Kitchen

There are no scientific studies to evaluate cleaning There are no scientific studies to evaluate cleaning practices or methodspractices or methods

Food Allergy News suggestions Food Allergy News suggestions 1- Warm soapy water 1- Warm soapy water 2- Fresh cloth or paper towel to wipe2- Fresh cloth or paper towel to wipe3- Prep the special diet foods first3- Prep the special diet foods first4- Wrap and Identify clearly4- Wrap and Identify clearly

Ongoing Inservice Education

Admin support

Standardize diet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Cross contamination Kitchen training

Tray Accuracy

Right Tray, Right PersonRight Tray, Right Person

Visual cues Visual cues Tray colorTray color napkin colornapkin color IconIcon

Tray ticket colorTray ticket color

Privacy rightsPrivacy rights

XXXXX

What if Everything was perfect: What if Everything was perfect: except the roll?except the roll?

Prepare for Kitchen TrainingPrepare for Kitchen Training

Rewrite inservices to include an allergy Rewrite inservices to include an allergy component for continued reinforcementcomponent for continued reinforcement

Topics to update: Topics to update:

Sanitation, Inventory storage, Food preparationSanitation, Inventory storage, Food preparation

Tray line Services, Therapeutic Diets, Food Safety Tray line Services, Therapeutic Diets, Food Safety Mechanically Altered, Residents RightsMechanically Altered, Residents Rights

Food Allergy Kitchen ProtocolFood Allergy Kitchen ProtocolFollow RecipesFollow Recipes

Allergen trays prepared first Allergen trays prepared first

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

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

Label read every time unless specific claim made on the Label read every time unless specific claim made on the labellabel

Food can not be fixed…. start overFood can not be fixed…. start over

Admin support

Tray delivery feeding asstsTherapists

Standardize diet ordersMeal delivery

system

Plan MenuPlan Nourishments

Plan Snacks

Buy and store food

Cross contamination Kitchen training

Tray Accuracy

October 31, 2008 October 31, 2008

By By DAVID GIALANELLADAVID GIALANELLA Staff Writer Staff Writer

Prosecutors said Thursday they are reviewing the case of an Elgin MentalProsecutors said Thursday they are reviewing the case of an Elgin Mental Health Center patient who died months ago Health Center patient who died months ago

after two facility employees allegedly gave him after two facility employees allegedly gave him a meal containing fish despite a severe fish a meal containing fish despite a severe fish

allergyallergy. . Morris Howard, 58, formerly of Chicago, died on June 20 after the employees gave him the meal, which 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.investigators said sent him into anaphylactic shock. A coroner's jury on A coroner's jury on Wednesday ruled the death a reckless homicide. 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 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 Barsanticriminal charges against the employees could be announced in the coming days, according to State's Attorney John Barsanti ..

Barriers to ComplianceBarriers to Compliance

Daily Lifestyle ChallengesDaily Lifestyle Challenges

Quality of Life Issues Quality of Life Issues Limited Cooking availability and/or skillLimited Cooking availability and/or skill

Not ConvenientNot Convenient Costly Costly

MisinformationMisinformation Psych-Social ChallengesPsych-Social Challenges

Knowledge Deficit of suitable substitutionsKnowledge Deficit of suitable substitutions

LB CCRC DNR DNH resident in Skilled NursingLB CCRC DNR DNH resident in Skilled Nursing DiagnosisDiagnosis

Alzheimer’s DiseaseAlzheimer’s Disease OsteoporosisOsteoporosis DepressionDepression HypercholestermiaHypercholestermia

4/2009 WT 122 BMI 19.54/2009 WT 122 BMI 19.5 DO: Gluten-Free POS: allergy: DO: Gluten-Free POS: allergy:

wheatwheat 5/2009 WT 120 RD selected 5/2009 WT 120 RD selected

menu for resident for GF statusmenu for resident for GF status 6/2009 WT 115 (new MDS 6/2009 WT 115 (new MDS

significant change) Supplement significant change) Supplement 2cal/mL and magic cups2cal/mL and magic cupsVitamin not ordered after call to Vitamin not ordered after call to pharmacy no GF guarantee. pharmacy no GF guarantee.

7/2009 WT 1137/2009 WT 113 8/2009 WT 114 (husband 8/2009 WT 114 (husband

admitted to share room) admitted to share room) 9/2009 WT 115-1189/2009 WT 115-118 10/2009 WT 12010/2009 WT 120 11/2009 WT 118-12011/2009 WT 118-120 12/2009 weight gain started 12412/2009 weight gain started 124

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

Resident states: ‘I eat gluten-free Resident states: ‘I eat gluten-free foods: no bread or pasta’foods: no bread or pasta’

Strovite Plus Vitamin orderedStrovite Plus Vitamin ordered

Celiac panel orderedCeliac panel ordered

LB CCRC DNR DNH resident in Skilled NursingLB CCRC DNR DNH resident in Skilled Nursing

Reticulin IgA WNLReticulin IgA WNL Endomysial IgA WNLEndomysial IgA WNL

Gliadin IgG 15.8 HGliadin IgG 15.8 H Gliadin IgA 13.2 HGliadin IgA 13.2 H

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

LB CCRC DNR DNH resident in Skilled NursingLB CCRC DNR DNH resident in Skilled Nursing DiagnosisDiagnosis

Alzheimer’s DiseaseAlzheimer’s Disease OsteoporosisOsteoporosis DepressionDepression HypercholestermiaHypercholestermia

4/2009 WT 122 BMI 19.54/2009 WT 122 BMI 19.5 DO: Gluten-Free POS: DO: Gluten-Free POS:

allergy: wheatallergy: wheat 8/2010 WT 136. RD/RN 8/2010 WT 136. RD/RN

charting on overt intake of charting on overt intake of gluten containing food gluten containing food between meals. (husbands between meals. (husbands PB&J HS snack). PO PB&J HS snack). PO improving, seeking food improving, seeking food items. No GI distressitems. No GI distress

9/2010 1349/2010 134 10/2010 13510/2010 135 11/2010 supplement d/c'd11/2010 supplement d/c'd

DO continued Gluten-Free. DO continued Gluten-Free.

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

www.glutenfreedrugs.com to www.glutenfreedrugs.com to review medications as review medications as needed. needed.

GF resident admittedGF resident admitted

Review diet management with kitchenReview diet management with kitchen

Review diet order rational with nursing/caregiversReview diet order rational with nursing/caregivers

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

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

Management MustsManagement Musts

All therapeutic diets should be in the diet All therapeutic diets should be in the diet manuals. Road map for staff success. manuals. Road map for staff success.

Policy for purchasing foods for ‘free-of’ diet Policy for purchasing foods for ‘free-of’ diet requests. (Therapeutic diet vs preferences)requests. (Therapeutic diet vs preferences)

If allergen food requested (Resident Rights) If allergen food requested (Resident Rights) written medical approval is required.written medical approval is required.

9898

Resources & Web SitesResources & Web Sites Gluten-Free Diet: A Comprehensive Resource GuideGluten-Free Diet: A Comprehensive Resource Guide - Shelley Case www.glutenfreediet.ca - Shelley Case www.glutenfreediet.ca

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

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

Gastroenterology 2006;131:1977-1980Gastroenterology 2006;131:1977-1980

Center for Celiac ResearchCenter for Celiac Research www.celiaccenter.orgwww.celiaccenter.org

Steve Plogsted’s medication listSteve Plogsted’s medication list www.glutenfreedrugs.comwww.glutenfreedrugs.com

Local Support Groups: CSA, GIG,CDF, IndependentsLocal Support Groups: CSA, GIG,CDF, Independents rdronni@optonline.netrdronni@optonline.net

Religious resourceReligious resource altarbreads@benedictinesisters.orgaltarbreads@benedictinesisters.org, , http://glutenfreematzo.comhttp://glutenfreematzo.com

Allergen Food for Institutions mailorderAllergen Food for Institutions mailorder www.celinalfoods.com (also available thru Gordon Food Service) www.med-diet.com www.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):763-9

Collin 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;42:59-61

Hu 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