Residential/Health Care Facilities Gluten Free Success Celiac Disease prevalence and awareness Menu Design/Food Service Gluten Free Diet management

Residential/Health Care Facilities Residential/Health Care Facilities Gluten Free SuccessGluten Free Success

Celiac Disease prevalence and awareness Celiac Disease prevalence and awareness 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 RD rdronni@optonline.netwww.celinalfoods.comwww.matureceliac.blogspot.com

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

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 USA Arch Int Med 163:286-292, 2003 Fasano et al.

+ Responseto GF diet

Bloodtests

Age >2years

Biopsy

ClinicalPresentation

Definitive Diagnosis

Rule out conditionsthat mimic Celiac Disease

Classic GI Presentation slide 1Classic GI Presentation slide 1HF: 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

Adults are less likely to have digestive symptoms and Adults are less likely to have digestive symptoms and may instead have one or more of the following:may instead have one or more of the following:

unexplained iron-deficiency anemia unexplained iron-deficiency anemia fatigue fatigue bone or joint pain bone or joint pain arthritis arthritis bone loss or osteoporosis bone loss or osteoporosis depression or anxiety depression or anxiety tingling numbness in the hands and feet tingling numbness in the hands and feet seizures seizures missed menstrual periods missed menstrual periods infertility or recurrent miscarriage infertility or recurrent miscarriage canker sores inside the mouth canker sores inside the mouth an itchy skin rash called dermatitis herpetiformisan itchy skin rash called dermatitis herpetiformis

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

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

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

People with celiac disease may have no People with celiac disease may have no symptoms but can still develop symptoms but can still develop complications of the disease over time. complications of the disease over time. Long-term complications include Long-term complications include malnutrition—which can lead to anemia, malnutrition—which can lead to anemia, osteoporosis, and miscarriage, among osteoporosis, and miscarriage, among other problems—liver diseases, and other problems—liver diseases, and cancers of the intestine.cancers of the intestine.

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.

HF: 86 YO WF slide 2Readmit 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.

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 michelle formationFat michelle 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

CONCLUSIONS: Mucosal recovery was absent in a substantial portion of adults with CD after treatment with a GFD.

Am J Gastroenterol advance online publication, 9 February 2010; doi:10.1038/ajg.2010.10

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

Celiac Disease Celiac Disease Diagnosis through blood testsDiagnosis through blood tests

Total IGATotal IGA

tTG-IgA Tissue TransglutaminasetTG-IgA Tissue Transglutaminase

IgA EMA Anti-endomysial Antibodies IgA EMA Anti-endomysial Antibodies (not as Sensitive as tTG)(not as Sensitive as tTG)

Specificity (low false positive)Specificity (low false positive) Sensitivity (low false negative)Sensitivity (low false negative)

IgG AGA Antigliadin Antibodies (high false positive)IgG AGA Antigliadin Antibodies (high false positive) HLA DQ2 and DQ8 98% in celiac but 30% everyoneHLA DQ2 and DQ8 98% in celiac but 30% everyone

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

ASSESSMENTASSESSMENT

Dietary Status: food that provide adequate Dietary Status: food that provide adequate kcal, protein and fiber along with Calcium/Vit kcal, protein and fiber along with Calcium/Vit D, B vitamins, Zinc and PhosphorusD, B vitamins, Zinc and Phosphorus

Nutritional StatusNutritional Status PCM, Bone Density, Vit D status, Iron & B12PCM, Bone Density, Vit D status, Iron & B12 BMI, Dental, Bowel HealthBMI, Dental, Bowel Health

Compliance IssuesCompliance Issues Socio-economic & emotional Socio-economic & emotional

Nutritional Adequacy of Gluten-Free DietNutritional Adequacy of Gluten-Free DietNutritional Nutritional deficiencies of a deficiencies of a Gluten-Free DietGluten-Free Diet

Improvement after Improvement after starting Gluten starting Gluten Free DietFree Diet

Inadequate intake Inadequate intake after starting after starting gluten free dietgluten free diet

Serum HemoglobinSerum Hemoglobin xx

IronIron xx

ZincZinc X*X*

FatFat xx

CarbohydrateCarbohydrate xx

FiberFiber xx

NiacinNiacin xx

B12B12 xx

CalciumCalcium xx

PhosphorusPhosphorus xx

ZincZinc X*X*

American Dietetic Association, Evidence Based Library, American Dietetic Association, Evidence Based Library, http://http://

www.adaevidencelibrary.com/template.cfm?templatewww.adaevidencelibrary.com/template.cfm?template==guide_summary&keyguide_summary&key

=2102=2102, accessed on 3/23/2011, accessed on 3/23/2011

* Zinc levels has been shown to improve after starting a Gluten-Free Diet (GFD) as a result of intestinal healing and improved absorption, but the average daily intake in a GFD is inadequate to meet RDA for zinc.

GF Grains – High in Fiber & NutrientsGF Grains – High in Fiber & Nutrients Tef: calcium, magnesium, iron, zinc, and B vitaminsTef: calcium, magnesium, iron, zinc, and B vitamins

Quinoa: potassium, zinc, phosphorous, iron, B-vits, magnesium, Quinoa: potassium, zinc, phosphorous, iron, B-vits, magnesium, and calcium and calcium

Amaranth: calcium and ironAmaranth: calcium and iron

Buckwheat: magnesium, phosphorous, potassium, B6 vits, iron, Buckwheat: magnesium, phosphorous, potassium, B6 vits, iron, niacin, thiamin and zincniacin, thiamin and zinc

Indian rice grass (Montina): phosphorous, iron, and B-vitamins Indian rice grass (Montina): phosphorous, iron, and B-vitamins

Chia, flax: omega 3 fatty acidsChia, flax: omega 3 fatty acids

Sorghum (milo): phosphorous, potassium, B vitamins, ironSorghum (milo): phosphorous, potassium, B vitamins, iron

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

When a personwas diagnosedwill reflect theirknowledge

< 1960 known as‘Banana Babies’Most were taken off the GF diet ~14 yo

1960-2005Over restrictiveRecommendations

2005 to presentInternet ‘knowledge’

Possible Causes of GI Symptoms on a Gluten-Free Diet

•Acidic foods •Sorbitol •Olestra •Guar gums •Antibiotics •Lactose •Alternate flours made from

beans or nuts

GI BugGI Bug C-DiffC-Diff Food borne illnessFood borne illness Medication rx- not glutenMedication rx- not gluten Medication rx- gluten Medication rx- gluten

containingcontaining Co-Morbid IBS/Crohn’sCo-Morbid IBS/Crohn’s Co-Morbid additional food Co-Morbid additional food

sensitivities/allergiessensitivities/allergies

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

DO: Gluten-Free POS: allergy: DO: Gluten-Free POS: allergy: wheatwheat

4/2009 WT 122 BMI 19.54/2009 WT 122 BMI 19.5 2-cal product 2-cal product strovite plus vitaminsstrovite plus vitamins 8/2010 WT 136. RD/RN charting 8/2010 WT 136. RD/RN charting

on overt intake of gluten on overt intake of gluten containing food between meals. containing food between meals. (husbands PB&J HS snack). PO (husbands PB&J HS snack). PO improving, improving,

9/2010 1349/2010 134 10/2010 13510/2010 135 11/2010 supplement d/c'd11/2010 supplement d/c'd DO continued Gluten-FreeDO continued Gluten-Free 3/2011 RD asst.: seeking gluten 3/2011 RD asst.: seeking gluten

containing food items. No GI containing food items. No GI distress H/H decliningdistress H/H declining

Family meeting: DO regular with Family meeting: DO regular with monitor H/H. Plan for transfusions monitor H/H. Plan for transfusions as needed to maintain H/H WNL. as needed to maintain H/H WNL.

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

Food Intolerance

Non-immunologic Allergy

Metabolic Disorders

Idiosyncratic IgE Mediated T-cell Mediated

Lactose Intolerance

Gluten Intolerance

Sulfites

Food colors

Celiac Disease

Cow’s Milk Allergy

Top 8 Allergens

170 foods

Soya

Sensitivity/Intolerances

Gluten Intolerance

Pharmacologic

CaffeineAlcohol

MSG

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

www.dmaonline.org

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

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

XXXXXXXXX

xxxxxxxxxxxxxxxx

People and Professionals may use different words to describe food avoidance

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

Facility Knowledge:

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

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

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 Snacks

MENU PLANNING GUIDELINES:• Read all labels carefully. Many ingredients contain gluten but may notlist it as such. Avoid: commercial products or mixes containingmalt or malt flavorings, textured vegetable protein, hydrolyzedvegetable protein, cereal products, flour, starch, wheat, rye,barley, oat, farina, semolina, durum, triticale, gums, emulsifiers,stabilizers, vinegar, artificial colors or flavors, some monosodiumglutamate, vanilla.

text: Outdated info with the 2004 label laws

Ingredients to AvoidIngredients to Avoid WheatWheat Rye Rye OatsOats BarleyBarley SemolinaSemolina DurhamDurham EinkornEinkorn TriticaleTriticale SpeltSpelt KamutKamut FarinaFarina FlourFlour

BreadingBreading CerealCereal Malt/Malt Flavoring/Malt SyrupMalt/Malt Flavoring/Malt Syrup Malt VinegarMalt Vinegar Cracked wheatCracked wheat GrahamGraham Wheat germWheat germ Wheat StarchWheat Starch BulgurBulgur Wheat glutenWheat gluten Matzo/Matzo MealMatzo/Matzo Meal CouscousCouscous

Field to Plate: OATSField to Plate: OATS

Frequently overlooked Frequently overlooked foods that often contain foods that often contain

glutengluten Broth/ soup basesBroth/ soup bases Quick Fried meatsQuick Fried meats Communion WafersCommunion Wafers Miso Miso Imitation foodsImitation foods

SurimiSurimi Bacon bitsBacon bits

MarinadesMarinades Processed MeatsProcessed Meats

RouxRoux SaucesSauces SeasoningSeasoning Self-basting Self-basting

poultrypoultry ThickenersThickeners Vegetarian Meat Vegetarian Meat

SubstitutesSubstitutes

Gluten-Free Grains & Gluten-Free Grains & StarchesStarches RiceRice

all formsall forms CornCorn

corn bran, corn corn bran, corn grits, hominy, grits, hominy,

PotatoPotato potato starch & potato starch &

potato flourpotato flour LegumesLegumes Tapioca aka yuca Tapioca aka yuca

or Manioc and or Manioc and CassavaCassava

AmaranthAmaranth QuinoaQuinoa BuckwheatBuckwheat MilletMillet TefTef Nut floursNut flours MontinaMontina SorghumSorghum ArrowrootArrowroot Wild RiceWild Rice

Gluten FreeGluten Free Ingredients Ingredients That Are Frequently That Are Frequently

QuestionedQuestioned Buckwheat/Buckwheat/

KashaKasha MilletMillet Monosodium Monosodium

Glutamate MSGGlutamate MSG Maltodextrin * Maltodextrin * Corn GlutenCorn Gluten Glutinous RiceGlutinous Rice

Starch*Starch* VinegarVinegar Vegetable BrothVegetable Broth Canola oilCanola oil VinegarVinegar

*not true for medications

Review these Review these IngredientsIngredients

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 wheat carrier will be wheat carrier will be

declareddeclared Brown Rice SyrupBrown Rice Syrup

may be made from may be made from barley barley

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

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


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


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

§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?

Frequently a gluten-free diet is one of exclusion.

Meal can be dry and is missing at least 240 calories

Specifics help the production staff

Input as Allery Diet extension planned

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

Atrophic Glossitis Leading to the Diagnosis of Celiac DiseaseN Engl J Med 2007; 356:2547June 14, 2007

CONTAINS BARLEY

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

Admin support


system


Plan Snacks

Buy and store food

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

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

Certification/ Dedicated Certification/ Dedicated PlantsPlants

Recognized by

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! Mail Order: Celinal Foods, Glutenfree.com Mail Order: Celinal Foods, Glutenfree.com

Check Labels Each Time!Check Labels Each Time!

Store High if possible away from Air-borne Store High if possible away from Air-borne

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

Admin support


system


Plan Snacks

Buy and store food


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


system


Plan Snacks

Buy and store food


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

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


system


Plan Snacks

Buy and store food


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 ..

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

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

attending physicianattending physician

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

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

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.

Resources & Web SitesResources & Web Sites 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 General guidelines: General guidelines: http://www.digestive.niddk.govhttp://www.digestive.niddk.gov search celiac search celiac

Evidence Based Standards of PracticeEvidence Based Standards of Practicehttp://celiac.nih.govhttp://celiac.nih.govwww.eatright.orgwww.eatright.org manual of clinical dietetics 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 [email protected]@optonline.net

Religious resourceReligious resource [email protected]@benedictinesisters.org, , http://http://glutenfreematzo.comglutenfreematzo.com

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

Documents

Residential/Health Care Facilities Gluten Free Success Celiac Disease prevalence and awareness Menu Design/Food Service Gluten Free Diet management