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CELIAC DISEASE

CELIAC DISEASE A PRIMER FOR SCHOOL NUTRITION What is Celiac Disease? Inherited, Autoimmune Disorder Permanent Intolerance to Gluten in WHEAT, RYE AND BARLEY Also referred to as celiac sprue WHAT IS GLUTEN? THE PORTION OF THE PROTEIN IN FLOUR THAT FORMS THE STRUCTURE OF DOUGH

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CELIAC DISEASE

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  1. CELIAC DISEASE A PRIMER FOR SCHOOL NUTRITION

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

  3. WHAT IS GLUTEN? • 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 * • Affects 1 in 133 Americans • 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.

  5. DIAGNOSIS • Initial Blood Tests • 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

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

  7. INTESTINAL VILLI

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

  9. TREATMENT • GLUTEN FREE DIET • ELIMINATE ALL WHEAT, RYE, BARLEY AND THEIR DERIVATIVES • 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

  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 • The law does not address the use of barley, rye or oats • 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 • 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

  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.

  15. 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)

  16. AVOID CROSS CONTAMINATION-RECOMMENDATIONS • 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

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

  18. 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 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) OVERLOOKED GLUTEN SOURCES

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

  20. 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 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

  21. 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 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 GLUTEN FREE SHOPPING LIST, CONTINUED

  22. 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?

  23. Culinary Standards Seasoned Pork, Cuban Brand 98465 • 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 **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. • National Starch and Chemical; www.foodstarch.com • Food Allergy Network; http:www.foodallergy.org/index.html

  25. Landis Cooked Beef Meatball 36612 • 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

  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. • 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.

  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

  29. 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) • *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 • 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 • 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 • 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.

  37. REFERENCES, CONTINUED • 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

  38. Developed by: Dr. Becky Domokos-Bays, RD SNS Director, Food and Nutrition Services Alexandria City Public Schools becky.domokos-bays@acps.k12.va.us Fall 2008 (for SNA-VA)

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