Download Clearing Up the Clutter in a Gluten-Filled World

Celiac Disease and GlutenRelated Disorders:
Clearing Up the Clutter in a
Gluten-Filled World
© 2013 Celiac Sprue Association
1
National numbers adding up……..
3,128,450
18,772,705
1% CD
6% NCGS
__________________________________________
.
21,901,000
7% Total CS and NCGS
US Census Bureau as of 8/22/11: 312,045,081
© 2013 Celiac Sprue Association
2
Nebraska numbers
adding up……..
18,555
1%
CD
111,331 6% NCGS
______________________________________
129,886
7%
Total Estimate CD & NCGS
.
Census Data 2012 Estimate for Nebraska and Grand Island 1,855,525 and 49,989 respectively
© 2013 Celiac Sprue Association
3
Most Common Nutrient Deficiencies
Iron
B-12
Folic Acid
Calcium
Vitamin D
Fiber
© 2013 Celiac Sprue Association
4
Sources of Heme-Iron
Iron (mg)
Food
%DV
Beef, chuck, lean only, braised, 3 oz
3.2
20
Turkey, light meat, roasted, 3½ oz
1.6
8
Chicken, breast, roasted, 3 oz
1.1
6
Pork, loin, broiled, 3 oz
0.8
4
Tuna, white, canned in water, 3 oz
0.8
4
U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard R
eference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp
© 2013 Celiac Sprue Association
5
Sources of Non-heme Iron
Food
Chex Cereal, ¾ c
Iron(mg)
%DV
9
50.00%
Soybeans, mature, boiled, 1 c
8.8
50.00%
Beans, kidney, mature,
boiled, 1 c
5.2
25.00%
Molasses, blackstrap, 1 T
3.5
20.00%
Spinach, boiled, drained, ½ c
1.9
10.00%
U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory
6
Home Page, http://www.nal.usda.gov/fnic/foodcomp © 2013 Celiac Sprue Association
Sources of B-12
Food
B-12 (mcg)
%DV
Trout, rainbow, farmed, cooked, 3 oz
5.4
90.00%
Salmon, sockeye, cooked, 3 oz
4.9
80.00%
Beef, top sirloin, broiled, 3 oz
Breakfast Cereals, fortified with 25% B12
(Chex Cereal, 3/4c)
Yogurt, plain, 1 cup
Milk, 1 cup
Egg, large, 1 whole
2.4
1.5
40.00%
25.00%
1.4
0.9
0.6
25.00%
15.00%
10.00%
U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient D
ata Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp
© 2013 Celiac Sprue Association
7
Food Sources of Calcium
Food
Calcium(mg)
%DV
Yogurt, plain, low fat, 8 oz
415
42.00%
Sardines, canned in oil, with bones, 3 oz
324
32.00%
Cheddar cheese, 1.5 oz
306
31.00%
Milk, nonfat, 8 oz
302
30.00%
Mozzarella, part skim, 1.5 oz
275
28.00%
200-260
20-26%
Orange juice, calcium-fortified, 6 oz
© 2013 Celiac Sprue Association
U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16.
Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp
8
Sources of Folate/Folic Acid
Food
Micrograms(μg)
Chex Cereal, fortified with 50% of DV,
Spinach, frozen, cooked, boiled, ½ c
Great Northern beans, boiled, ½ c
Asparagus, boiled, 4 spears
Rice, white, long-grain, parboiled, enriched,
cooked, ½ c
200
100
90
85
65
%DV
50.00%
25.00%
25.00%
20.00%
15.00%
U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. N
utrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp
© 2013 Celiac Sprue Association
9
Food Sources of Vitamin D
Food
Cod liver oil, 1 T
Salmon, sockeye, cooked, 3 oz
Tuna fish, canned in water, drained, 3 oz
Milk, nonfat, reduced fat, and whole,
vitamin D-fortified, 1c
Orange juice fortified with vitamin D, 1c
Vitamin D
(IU’s)
%DV
1360
340.00%
794
199.00%
154
39.00%
115-124 29-31.00%
100
25.00%
80
20.00%
(check product labels, as amount of added vitamin D varies)
Yogurt, fortified with vitamin D, 6 oz
(more heavily fortified yogurts provide more of the DV)
U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. N
utrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp
10
© 2013 Celiac Sprue Association
Non-Food Sources of Vitamin D
Be sensible!! Don't burn!
5 - 10 minutes per day
30 minutes = 20,000 IU's
VitaminDHealth.org
© 2013 Celiac Sprue Association
11
Gluten-Free Sources of Fiber
Food
Fiber (g)
Wild Rice, ½ c
4.5
Flax Seed, 2 T
6
Raspberries, ½ c
4
Baked Beans, canned, plain, ½ c
5.2
Sweet potato, cooked, no skin, 1 medium
3.9
Almonds, 1 oz
3.3
Jean E. Guest, PhD, RD, LMNT. Fiber! Fiber! Fiber! CSA Lifeline Volume XXVII, 2007.
Tricia Thompson, MS, RD and Suzanne Simpson, RD. Counting Gluten-Free Carbohydrates 2010. Located at http://csaceliacs.org/.
© 2013 Celiac Sprue Association
12
Gluten-Free Sources of Fiber
•
•
•
•
•
•
Almond
Amaranth
Buckwheat
Cornmeal, corn bran
Flax seed and meals, Chia seed
Bean (garbonzo, garfava, black, white, pinto,
navy, soy, kidney)
© 2013 Celiac Sprue Association
13
Gluten-Free Sources of Fiber
•
•
•
•
•
•
•
•
Indian wheat grass (Montina)
Millet
Rice bran
Brown rice flour
Soy flour
Teff
Quinoa
Pea Hull Fiber
© 2013 Celiac Sprue Association
14
Supplement Savvy
GF Multivitamin
GF Vitamin D
GF Calcium
© 2013 Celiac Sprue Association
15
The Diet is the Prescription!
Medical Nutrition Therapy
Dietitians are
the
Nutrition Experts
© 2013 Celiac Sprue Association
16
Three Step Approach
A Self-Management Guide to the GF Diet
Step 1 – Foundation
Basic self-management
Begin healing
Make risk-free choices
Choose naturally gluten-free foods
Eliminate wheat, barley, rye, common oats, crosses
and derivatives
Become knowledgeable Prepared by Jean Guest, PhD, RD, LMNT
© 2013 Celiac Sprue Association
17
Three Step Approach
A Self-Management Guide to the GF Diet
Step 2 – Expansion
Intermediate self-management
Symptoms resolving
Evaluate choices
Address intolerances and allergies
Continue knowledge process
© 2013 Celiac Sprue Association
18
Three Step Approach
A Self-Management Guide to the GF Diet
Step 3 – Maintenance
Advanced self-management
Habits for optimal health
Evaluate and update plan
Living a full life
© 2013 Celiac Sprue Association
19
Preparing for the grocery store
© 2013 Celiac Sprue Association
20
U.S. retail sales of gluten-free
products forecast for 2017
16.4%--- 20.2% nat
ural food stores 20
08
$200 million $680.3 million $4.2 billion
$6.2 billion
PF projects that U.S. sales of gf foods and beverages
will exceed $6.6 billion by 2017.
© 2013 Celiac Sprue Association
Source: Packaged Facts 2006 -2012
21
Navigating the grocery store
• Specialty areas may be located within
the store with gluten-free items
• Select package items rather than bulk
bins
• Select products with gluten-free seals
whenever possible (especially grains,
seeds, and flours*)
*Thompson T, Lee AR, Grace T. Gluten contamination of grains, seeds, and flours in the United States: a pilot
study. Am Diet Assoc 2010 Jun;110(6):937-40.
© 2013 Celiac Sprue Association
22
Where is gluten found?...
•
•
•
•
•
wheat
barley
rye
oats (unless gf)
(WBRO)
© 2013 Celiac Sprue Association
23
Additional sources of gluten….
A gluten-free diet means no:
• Wheat
– wheat flour, AP flour, wheat bran, wheat
starch, wheat germ and other forms of
wheat:
-Durum -Emmer -Semolina -Kamut
-Triticale -Spelt -Einkorn
-Graham
-Seitan - Bulgur - Couscous - Faro
© 2013 Celiac Sprue Association
24
Gluten-free basic choices
• Gluten-free foods include:
– Fresh salad (no croutons)
– Fruits and vegetables
– Milk
– Meats, fish or poultry
• (no breading, no marinade)
– Pure spices and herbs
• (watch out for seasonings)
– Pasta and breads labeled gluten-free
© 2013 Celiac Sprue Association
25
Grains - Make at least half your grains
whole grains!
© 2013 Celiac Sprue Association
26
How many grains are recommended
per day?
© 2013 Celiac Sprue Association
27
What counts as 1 ounce?
© 2013 Celiac Sprue Association
28
What are healthy and tasty glutenfree grains?
•
•
•
•
•
•
•
•
•
•
© 2013 Celiac Sprue Association
Brown rice
Whole Corn
Millet
Teff
Sorghum
Wild Rice
Buckwheat
Amaranth
Quinoa
Gluten-Free Oats? Not
recommended until 1 year on gluten-free diet ;
then self-assessment and antibody testing
29
recommended
Ways to increase whole grains?
•
•
•
•
•
Add to soups, stews& casseroles
Make cold salads
Serve as a substitute for rice
Use whole grain flours in baking
Enjoy hot cereal
© 2013 Celiac Sprue Association
30
Discover New Foods –
Sorghum Tabbouli Salad
Sorghu
© 2013 Celiac Sprue Association
31
Discover New Foods
Quinoa Mint Salad
© 2013 Celiac Sprue Association
32
Discover New Foods – Teff Pudding
© 2013 Celiac Sprue Association
33
The Scoop on Oats
• Oats appear to be suitable for most people with gluten-related
disorders, but not all
• Medical experts advise waiting until symptoms have resolved
before introducing pure, uncontaminated oats (labeled glutenfree
• Current recommendations for those with gluten-related
disorders is to limit consumption of dry oats to no more than:
• 50 grams per day (50/g day is equivalent to about 1/2c dry oats) for
adults
• 25 grams per day (25g/day is equivalent to about 1/4 cup dry oats) for
children
© 2013 Celiac Sprue Association
34
Are Inherently GF Grains
Gluten-Free?
•
•
•
•
Small 2010 Study
22 samples tested
None of the products were labeled gluten-free
32% had levels > 20 ppm
• Choose grains, seeds, and flours labeled glutenfree
.
Thompson T, Lee AR, Grace T. J Am Diet Assoc. 2010 Jun;110(6):937-40
© 2013 Celiac Sprue Association
35
Hidden Sources of Gluten
The Three C’s – Content, Contact, Contamination
•
•
•
•
•
•
•
•
Alcohol
Breading
Brewer’s Yeast
Broth
Brown rice syrup
Casseroles
Candy
Croutons
• Gravies
•
•
•
•
•
•
•
Foods injected with broth
Modified food starch
Sauces
Soy sauce
Seasonings
Processed foods
Cold cuts, deli foods, precooked foods, frozen foods
© 2013 Celiac Sprue Association
36
Hidden Sources of Gluten
The Three C’s – Content, Contact, Contamination
• Manufacturing
• Flour dust in air
• Flour on conveyor
belts
• School
• Play dough
• Paints
• Crayons
• Personal Care Items
• Medications
© 2013 Celiac Sprue Association
37
FDA’s Voluntary
Gluten-Free Final Rule
• Applies to labeling of packaged foods (including dietary
supplements)
• The rule does not apply to: pet foods, cosmetics, prescription,
non-prescription, USDA regulated foods, beverages regulated by
the Alcohol Tobacco Tax and Trade Bureau
• Manufacturers have to comply by August 5, 2014
• https://www.federalregister.gov/articles/2013/08/05/201318813/food-labeling-gluten-free-labeling-of-foods
© 2013 Celiac Sprue Association
38
FDA’s Voluntary
Gluten-Free Final Rule
• Cannot contain wheat, barley, rye (W, B, R)or a crossbred hybrid
of these grains
• Cannot contain ingredient derived from W, B, R that has not
been processed to remove gluten
• Can contain an ingredient derived from W, B, R that has been
processed to remove gluten but with final product containing
< 20 ppm gluten
• Must contain <20 ppm or less gluten, whether gluten comes
from an ingredient or is in the food unintentionally due to cross
contact
© 2013 Celiac Sprue Association
39
How to know if
something is gluten-free?
CSA
Recognition Seal
< 5 ppm
GIG
Certification
< 10 ppm
NFCA
Certification
<10 ppm
Health Canada dictates - 20 ppm is guide
© 2013 Celiac Sprue Association
40
Regulatory Agencies
• FDA
– Regulates all foods except meat, poultry &
egg products
– FALCPA covers all packaged foods in the US
except those covered by the USDA
© 2013 Celiac Sprue Association
41
Label reading know how….
8 Allergens
Eggs
Fish
Milk
Peanuts
Shellfish
Soybeans
Tree nuts
Wheat
Food Allergy Labeling and Consumer Protection Act (FALCPA)
requires only top 8 allergens to be identified. Barley, rye, oats and
their derivatives are not required to be listed.
© 2013 Celiac Sprue Association
42
42
Label reading know how….
• Food Allergy Labeling and Consumer
Protection Act (FALCPA) requires the 8
top allergens to be identified.
• Barley, rye, oats and their derivatives are not
included…keep an eye out for malt and
brewers yeast too.
© 2013 Celiac Sprue Association
43
Regulatory Agencies
• USDA
– Regulates meat, poultry and eggs
– No allergen labeling requirements at this
time
– If there is a “Contains” statement the
manufacturer is voluntarily complying with
FALCPA
© 2013 Celiac Sprue Association
44
Label Reading Savvy Ex 1
Is this nutrition bar gluten-free?
• Ingredients: Whole Grain Oats, Maltose Corn Syrup,
Sugar, Rice Flour, Almonds, Honey, Dried cranberries,
Fructose, Canola Oil, Maltodextrin, Dried
Pomegranate Arils, Soy Lecithin, Salt, Malt Extract,
Baking Soda, Natural Flavor.
CONTAINS ALMOND, SOY; MAY CONTAIN PEANUT AND
SUNFLOWER INGREDIENTS
© 2013 Celiac Sprue Association
45
Label Reading Savvy Ex 2
Frozen Turkey
Ingredients: Turkey, Water,
Salt, Modified Food Starch,
Sodium Phosphates, Natural
Flavorings
Modified Food Starch:
USDA product may include
modified food starch and “wheat”
might not be stated on the label
Natural Flavorings: USDA
product containing protein from W,
B, R, the flavoring ingredient must
be listed in the ingredients list by
its common or usual name
Bottom line – call on ? products
© 2013 Celiac Sprue Association
46
Tips to avoiding cross-contact
Separate area and items needed to avoid crosscontact:
• Strainers
• Utensils, Parchment Paper
• Toaster Oven
• Designated Prep Area or Station
© 2013 Celiac Sprue Association
47
Kitchen Pantry Smarts!
Keep gf items in separate container
Keep gf items above other items
© 2013 Celiac Sprue Association
48
Resources –Support Groups
• Celiac Sprue Association www.csaceliacs.org
© 2013 Celiac Sprue Association
49
What does a support group provide?
• Resources for daily living that are based on
science and research
• Life long friendships to journey the path of
living gluten-free
• National support from
headquarters
• An RD, to help groups “filter” information
© 2013 Celiac Sprue Association
50
What does CSA membership and
headquarters provide?
• Quarterly newsletter and
email updates with the
latest information and
research.
• CSA Annual Conference
with world renown celiac
experts.
• Phone and email support
for questions.
© 2013 Celiac Sprue Association
51
AND Resources
 Evidence Analysis Library (EAL) 2009
– Evidence-based Nutrition
Practice Guidelines for Celiac Disease
– www.adaevidencelibrary.com
© 2013 Celiac Sprue Association
52
AND Resources
• Celiac Disease Toolkit based on the EAL
data,visit www.eatright.org for more
information
• DIGID-Dietitians in Gluten Intolerance
Diseases (a sub- unit of the Medical Nutrition
Practice Group) www.mnpg.org
© 2013 Celiac Sprue Association
53
CSA Resources
• CSA Web-site: www.csaceliacs.org
– Toll Free: 877-272-4272
– Local Support Group Information
– Three Step Diet Approach (Self-Mngt Approach)
– Counting Gluten-Free Carbohydrate Guide!!!
»Just download, its free!
– Fact Sheets on Common Nutrient Deficiencies
© 2013 Celiac Sprue Association
54
CSA Tools
CSA Gluten-Free Product Listing
Available:
- CD
- Spiral Bound Book
- iPad or iPhone App “GlutenFreeMe”
http://itunes.apple.com/us/app/glutenfreeme
© 2013 Celiac Sprue Association
55
Other resources
• Grocery Store Gluten-Free Listings
– Hy-Vee Example: http://www.hy-vee.com/mealsolutions/special-diets/default.aspx
• NIH – Teaching Materials
– http://www.celiac.nih.gov/Materials.aspx
• Gluten Free Drugs:
– www.glutenfreedrugs.com
© 2013 Celiac Sprue Association
56
Gluten-free living!
© 2013 Celiac Sprue Association
57
Create a Question!
Create a question about today’s
presentation that anyone present
would be able to answer.
Share with the group!
© 2013 Celiac Sprue Association
58
Shelly Asplin, MA, RD, LMNT
Celiac Sprue Association
[email protected]
www.csaceliacs.org
www.facebook.com/csaceliacs
www.twitter.com/csaceliacs
© 2013 Celiac Sprue Association
59