Download Gluten Free Diets

Residential/Health Care Facilities
Gluten Free Success
RD’s have a leadership role in health management

Celiac Disease prevalence and awareness
 Menu Design/Food Service
 Gluten Free Diet management
Ronni Alicea MBA RD
[email protected]
www.celinalfoods.com
www.matureceliac.blogspot.com
Why is GF so popular?
Population screened
13,145
Healthy Individuals
4126
Risk Groups
9019
Symptomatic subjects
3236
Positive
31
Negative
4095
Prevalence
1:132
Positive
81
Negative
3155
Prevalence
1:40
1st degree relatives
4508
Positive
205
Negative
4303
Prevalence
1:22
2nd degree relatives
1275
Positive
33
Prevalence
1:39
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.
Negative
1242
Biopsy
Blood
tests
Clinical
Presentation
Definitive
Diagnosis
+ Response
to GF diet
Age >2
years
Rule out conditions
that mimic Celiac Disease
Classic GI Presentation slide 1
HF: 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
may instead have one or more of the following:
 unexplained iron-deficiency anemia
 fatigue
 bone or joint pain
 arthritis
 bone loss or osteoporosis
 depression or anxiety
 tingling numbness in the hands and feet
 seizures
 missed menstrual periods
 infertility or recurrent miscarriage
 canker sores inside the mouth
 an 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 patients
The most frequent reasons for CD screening
bloating (12/22)
thyroid disease(11/22),
irritable bowel syndrome (IBS) (7/22),
unexplained chronic diarrhea (6/22),
chronic fatigue (5/22),
and constipation(4/22).
The small bowel biopsy was available in 15 out of 22
GFD was implemented in 17 out of 22 cases.
American Journal of Gastroenterology ISSN 0002-9270
2007 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2007.01173.x
World Gastroenterology
Organization Practice Guidelines:
Celiac 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
symptoms but can still develop
complications of the disease over time.
Long-term complications include
malnutrition—which can lead to anemia,
osteoporosis, and miscarriage, among
other problems—liver diseases, and
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 2
Readmit new dx: Celiac Disease
DO: Regular
Facility MD resistant to diet change due to age
Family meeting: Changed to gluten-free diet order
Therapeutic vitamin (strovite plus), Iron support
Nutritional 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 source





Mouth: ∂ amylase
Stomach: pepsins
Pancreas: amylase,
lipase and Proteases
Gall Bladder: Bile
Brush Border





Lactase
∂ glucosidase
β galactosidase
Sucrase-Isomaltase
Amino-ogliopeptidase









Starch ∂ 1 →4 bonds
Protein
dextrin, triglycerides
Peptides
Fat michelle formation
Lactose→glu + gal
∂ 1 →4 bonds ∂ 1→6 bonds
Sucrose → glu & fru
maltose → glu & glu
Removal of N terminal aa’s
Am J Gastroenterol advance
online publication, 9 February
2010; doi:10.1038/ajg.2010.10
 CONCLUSIONS:
Mucosal recovery was
absent in a substantial portion of adults
with CD after treatment with a GFD.

LN admitted sub acute 02/2008

Diagnosis




MS
Multiple stage III & IV
Anemia
constipation

Weight Loss 30# in 3 years
5’3 admitted 97# UBW 110
 Diet History :


2000 cal daily (45cal/kg)
Labs: Hydration normal


Alb 2.7 Ca++ 8.3
H/H 8.3/2.7
LN: Cal count results
45kcal /kg 1.8 g protein/kg
WT: 98#
Requested ‘Celiac panel’,
total IGA and Vit D
Lab results:
Reticulin IgA WNL
EMA WNL,
Gliadin IgA WNL
Gliadin IgG WNL
MD concluded negative for celiac
ww.celiac.nih.gov
LN continued



Went home and was readmitted to the
hospital with respiratory distress.
Was to return to the sub-acute
53 YO with weight loss despite a hearty
appetite died of respiratory failure
Celiac panel inconclusive: no total IgA
Celiac Disease
Diagnosis through blood tests

Total IGA

tTG-IgA Tissue Transglutaminase

IgA EMA Anti-endomysial Antibodies





(not as Sensitive as tTG)
Specificity (low false positive)
Sensitivity (low false negative)
IgG AGA Antigliadin Antibodies (high false positive)
HLA DQ2 and DQ8 98% in celiac but 30% everyone
Recommendations for practice

Call lab and ask for lab numbers for Total IgA
and tTG instead of the ‘celiac panel’


Acculab in NJ total IgA # 1029
Acculab in NJ tTG # 1506

Less expensive test ideal for screening

With results seek GI referral. Will justify
EGD when presented with extraintestional
symptoms
ASSESSMENT
 Dietary
Status: food that provide adequate
kcal, protein and fiber along with Calcium/Vit
D, B vitamins, Zinc and Phosphorus
 Nutritional


Status
PCM, Bone Density, Vit D status, Iron & B12
BMI, Dental, Bowel Health
 Compliance

Issues
Socio-economic & emotional
Nutritional Adequacy of Gluten-Free Diet
Nutritional
deficiencies of a
Gluten-Free Diet
Improvement after
starting Gluten
Free Diet
Serum Hemoglobin
x
Iron
x
Zinc
X*
Inadequate intake
after starting
gluten free diet
Fat
x
Carbohydrate
x
Fiber
x
Niacin
x
B12
x
Calcium
x
Phosphorus
x
Zinc
X*
American Dietetic Association, Evidence Based Library,
http://www.adaevidencelibrary.com/template.cfm?template=guide_summary&key
=2102, 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 & Nutrients


Tef: calcium, magnesium, iron, zinc, and B vitamins
Quinoa: potassium, zinc, phosphorous, iron, B-vits, magnesium,
and calcium

Amaranth: calcium and iron

Buckwheat: magnesium, phosphorous, potassium, B6 vits, iron,
niacin, thiamin and zinc

Indian rice grass (Montina): phosphorous, iron, and B-vitamins

Chia, flax: omega 3 fatty acids

Sorghum (milo): phosphorous, potassium, B vitamins, iron
Barriers to Compliance
 Daily
Lifestyle Challenges
 Quality of Life Issues
 Limited Cooking availability and/or skill
 Not Convenient
 Costly
 Misinformation
 Psych-Social Challenges
 Knowledge Deficit of suitable substitutions
When a person
was diagnosed
will reflect their
knowledge
< 1960 known as
‘Banana Babies’
Most were taken off
the GF diet ~14 yo
1960-2005
Over restrictive
Recommendations
2005 to present
Internet ‘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 Bug
C-Diff
Food borne illness
Medication rx- not gluten
Medication rx- gluten
containing
Co-Morbid IBS/Crohn’s
Co-Morbid additional food
sensitivities/allergies
LB CCRC DNR DNH resident in Skilled Nursing

Reticulin IgA WNL
 Endomysial IgA WNL

Gliadin IgG 15.8 H
 Gliadin IgA 13.2 H

Labs inconclusive
would need an EGD
to confirm celiac
disease at this time.
LB CCRC DNR DNH resident in Skilled Nursing

Diagnosis




Alzheimer’s Disease
Osteoporosis
Depression
Hypercholestermia

DO: Gluten-Free POS: allergy:
wheat
4/2009 WT 122 BMI 19.5
2-cal product

strovite plus vitamins

8/2010 WT 136. RD/RN charting
on overt intake of gluten
containing food between meals.
(husbands PB&J HS snack). PO
improving,







9/2010 134
10/2010 135
11/2010 supplement d/c'd
DO continued Gluten-Free
3/2011 RD asst.: seeking gluten
containing food items. No GI
distress H/H declining

Family meeting: DO regular with
monitor H/H. Plan for transfusions
as needed to maintain H/H WNL.

www.glutenfreedrugs.com to
review medications as needed.
Food
Intolerance
Allergy
Non-immunologic
Sensitivity/Intolerances
Metabolic
Disorders
Idiosyncratic
Lactose Intolerance
Sulfites
Gluten Intolerance
Food colors
Gluten Intolerance
Pharmacologic
Caffeine
Alcohol
MSG
IgE Mediated
T-cell Mediated
Top 8 Allergens
Celiac Disease
170 foods
Cow’s Milk Allergy
Soya
LL admitted 01/2008
Nutrition Plan of Care:

Diagnosis





Diet History :





Syncope and Collapse
Pneumonia
Anemia
Celiac Disease
Gluten Free Diet 20
years
Lived with niece due
to mental deficit
Rice Krispee’s AM
Communion (regular)
Labs: As expected
1- Review GF diet with
Kitchen
2- Review facility GF
diet with resident
and Family
3- Give Activities GF
hosts for Pastor to
bless
4- Meet Nutrition needs
as assessed
www.dmaonline.org
Assess
food delivery
systems
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Facility
Training
Admin support
Tray Accuracy
Cross contamination
Kitchen training
Communication channels:
Dietary: Clinical and Food Service
Nursing Functions: med pass/ HS snacks
Activities: Rehab Therapies
Other: Chaplin; Pharmacy; IT department
Administration support
needed for
Interdepartmental
communication to be
successful
CMS INTENT: §483.25(i) 325
Nutritional Status uses Celiac
Disease example:
A
resident with known celiac disease
(damage to the small intestine related to
gluten allergy) develops persistent
gastrointestinal symptoms including weight
loss, chronic diarrhea, and vomiting, due
to the facility's failure to provide a glutenfree diet (i.e., one free of wheat, barley,
and rye products) as prescribed by the
physician.
Standardize
diet orders
Admin support
xxxxxxxxxxxxxxxx
XXXXXXXXX
People and Professionals may use different words to describe food avoidance
Food
Avoidance
Gluten/Wheat
Food Aversion
High Protein Diet
Fad Diet
Intolerance
May limit pasta and
bread due to
digestive discomfort
Allergy/Celiac
Wheat Free is
Not 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.
Standard
All DO’s
Gluten Free
Celiac, wheat allergy, wheat No Wheat, rye, barley aka
free, no bread
malt, spelt or oats
Dairy Free
No Milk, Milk or diary
allergy, Casein Free
Lactose Free
Lactose Intolerance, lactose Food preferences may have
free, low Lactose
milk protein (casein & whey)
e.g. coffee creamers
Egg Free
Egg allergy, no Eggs
No egg ingredients
No egg substitutes
Peanut/tree nut free
Peanut allergy, nut allergy,
no seeds or nuts
No nuts/peanuts including
their oils
Soy-Free
Soy allergy, no soy
No soy ingredients. Soy oil
and lecithin allowed unless
specified
Additive-Free
Feingold diet, sulfite, MAO
MSG, asthma diet
No additives: low sulfite,
Salicylates, tyramine
Latex Free
Any diet with latex allergy
Identified in chart
No latex gloves around food
or tray, no banana, kiwi,
avocado, chestnuts
Policy until individualized
No animal milk: Lactose,
Casein, whey ingredients
Meal Service
system
Standardize
diet orders
Admin support
Assess Food Service Systems
 Review



your system and risks
Tray Line Plate
Buffet Style
Room Service cook to order
 Snack
carts, Floor Stock and Activities
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Standardize
diet orders
Admin support
MENU PLANNING GUIDELINES:
• 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, emulsifiers,
stabilizers, vinegar, artificial colors or flavors,
some monosodium
glutamate, vanilla.
text: Outdated info with the 2004 label laws
Ingredients to Avoid












Wheat
Rye
Oats
Barley
Semolina
Durham
Einkorn
Triticale
Spelt
Kamut
Farina
Flour












Breading
Cereal
Malt/Malt Flavoring/Malt Syrup
Malt Vinegar
Cracked wheat
Graham
Wheat germ
Wheat Starch
Bulgur
Wheat gluten
Matzo/Matzo Meal
Couscous
Field to Plate: OATS
Frequently overlooked foods
that often contain gluten





Broth/ soup bases
Quick Fried meats
Communion Wafers
Miso
Imitation foods


Surimi
Bacon bits
Marinades
 Processed Meats







Roux
Sauces
Seasoning
Self-basting
poultry
Thickeners
Vegetarian Meat
Substitutes
Gluten-Free Grains & Starches

Rice


Corn


all forms
corn bran, corn
grits, hominy,
Potato





potato starch &
potato flour

Legumes
 Tapioca aka yuca or
Manioc and Cassava






Amaranth
Quinoa
Buckwheat
Millet
Tef
Nut flours
Montina
Sorghum
Arrowroot
Wild Rice
Gluten Free Ingredients That
Are Frequently Questioned






Buckwheat/Kasha
Millet
Monosodium
Glutamate MSG
Maltodextrin *
Corn Gluten
Glutinous Rice
*not true for medications





Starch*
Vinegar
Vegetable Broth
Canola oil
Vinegar
Review these Ingredients
Modified Food
Starch*
 Citric Acid*


Soy Sauce

often contains wheat

Mono and Diglycerides

wheat carrier will be
declared
Brown Rice Syrup
 may be made from
barley
need to ask if using
imported
Caramel Coloring*
 Flavoring*
 Dextrin*



* By definition may contain wheat but US manufactures
say they are not using gluten containing grains
Daily intake of Carbs and ppm of
gluten in food for celiacs
50 g
100 g
200 g
300 g
200 ppm
10 mg
20 mg
40 mg
60 mg
100 ppm
5 mg
10 mg
20 mg
30 mg
50 ppm
2.5 mg
5 mg
10 mg
15 mg
20 ppm
1 mg
2 mg
4 mg
6 mg
Oven Fried chicken
Baked Chicken Breast
- GF gravy
Rice Pilaf
Buttered Beets
White Rice
- GF Soy Sauce
Buttered Beets
Dinner Roll
GF Microwave Cornbread
Margarine
Margarine
Lemon Meringue Pie
Lemon Pudding on
GF Microwave Biscuit
Whipped Cream
§483.35 Dietary Services
(c) Standard Menus/Adequacy

F 363 Probe (c) (1)
If a food group is missing from the resident’s daily diet, does
the facility have an alternative means of satisfying the
resident’s nutrient needs.

F 363 Probe (c) (3)
Is food served as planned?
Frequently a gluten-free diet is one of exclusion.
Meal can be dry and is missing at least 240 calories
Input as Allery
Diet extension planned
Specifics help the
production staff
All Wheat Flour is Enriched

Thiamin

Riboflavin

Niacin

Iron

Folate

GF products usually are
not fortified
Atrophic Glossitis Leading to the Diagnosis of
Celiac Disease
N Engl J Med 2007; 356:2547June 14, 2007
CONTAINS BARLEY
Rice Chex are Gluten Free
The barley has been replaced
with Molasses!
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Admin support
Watch Gravy and bacon bits

Gluten Free Stock
Certified:




Limit Cross Contamination!
Make GF gravy
portion, label and freeze
Celinal Foods
Cuisine Santé (HACO)
RC Fine Foods
Read all labels for
ingredients: recipes
can change on noncertified food.

Ingredients: Enriched flour (wheat flour,
malted barley, niacin, reduced iron, thiamin
mononitrate, riboflavin, folic acid), sugar,
partially hydrogenated soybean oil, and/or
cottonseed oil, high fructose corn syrup, whey
(milk), eggs, vanilla, natural and artificial
flavoring) salt, leavening (sodium acid
pyrophosphate, monocalcium phosphate),
lecithin (soy), mono-and diglycerides
(emulsifier)
 OR
Contains wheat, milk, egg and soy ingredients
FALCPA
 FDA advised
that advisory labeling such
as "may contain [allergen]" should not be
used as a substitute for adherence to
current Good Manufacturing Practices
(cGMPs). In addition, any advisory
statement such as "may contain [allergen]"
must be truthful and not misleading.
 Fines
attached for non-compliance
Certification/ Dedicated
Plants
Recognized by
Other Concerns
 Where



to purchase?
Distributor: May stock or Special Order
Local Grocery: Keep Receipts!
Mail Order: Celinal Foods, Glutenfree.com
 Check
Labels Each Time!
 Store
High if possible away from Air-borne
 Label
book for reference
Plan meals and snacks
Assess production ability: make or buy
Assess product availability: Distributor
Nutritionally Adequate
Assess Other Departments Food Needs
Include all Therapeutic and Consistency
Don’t forget the disaster menu
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Admin support
Cross contamination
Kitchen training
LL admitted 01/2008 2 weeks later

Diagnosis



Add persistent
diarrhea
Benign pancreatic
mass
Diet



Facility Gluten Free
Diet
No Outside snacks
Communion (lowgluten)
Plan of Care:
1- Review GF diet with
Kitchen
2- MD to evaluate
Pancreatic Mass
for change
3- R/O C- Diff
4- Nurses to check
medications with
pharmacy
Crumbs Count
Double Dipping
Trouble hot spots
Flour and rice scoop stored
together
No Ingredient
statement
The Kitchen
There are no scientific studies to evaluate cleaning
practices or methods
Food Allergy News suggestions
1- Warm soapy water
2- Fresh cloth or paper towel to wipe
3- Prep the special diet foods first
4- Wrap and Identify clearly
Ongoing Inservice
Education
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Admin support
Tray Accuracy
Cross contamination
Kitchen training
Right Tray, Right Person

Visual cues



Tray color
napkin color
Icon

Tray ticket color

Privacy rights
What if Everything was perfect:
except the roll?
Prepare for Kitchen Training
Rewrite inservices to include an allergy
component for continued reinforcement
Topics to update:
Sanitation, Inventory storage, Food preparation
Tray line Services, Therapeutic Diets, Food Safety
Mechanically Altered, Residents Rights
Food Allergy Kitchen Protocol
Follow Recipes
Allergen trays prepared first
Equipment and work surfaces will be cleaned before use
with a fresh cloth or paper towel.
Clean and Sanitized utensils to be used in food
production and portioning.
Label read every time unless specific claim made on the
label
Food can not be fixed…. start over
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Admin support
Tray delivery
feeding assts
Therapists
Tray Accuracy
Cross contamination
Kitchen training
October 31, 2008
By DAVID GIALANELLA Staff Writer
Prosecutors said Thursday they are reviewing the case of an Elgin Mental
Health Center patient who died months ago
after two facility employees allegedly gave him
a meal containing fish despite a severe fish
allergy.
Morris Howard, 58, formerly of Chicago, died on June 20 after the employees gave him the meal, which
A coroner's jury on
Wednesday ruled the death a reckless homicide.
investigators said sent him into anaphylactic shock.
Illinois State Police investigators earlier this week handed the case off to the Kane County State's Attorney's Office, and
criminal charges against the employees could be announced in the coming days, according to State's Attorney John Barsanti
.
§483.35 Dietary Services
(e) Therapeutic Diet (LTC)
F
367 (see also 483.25 (i)
Therapeutic Diets must be ordered by the
attending physician
Interpretive guideline: part of treatment for a
disease or clinical condition or to eliminate
or decrease specific nutrients in the diet,
or to provide food the resident is able to
eat: mechanically altered.
Religious Needs

Low-Gluten Hosts


1-800-223-2772
www.benedictinesisters.org
Matzo


www.glutenfreematzo.com
Made from GF Oats
GF resident admitted

Review diet management with kitchen

Review diet order rational with nursing/caregivers

Review religious needs with activities. Review
with other departments as needed: speech
therapy screens no crackers.

Request baseline tTG for monitoring on
admission with known celiac residents.
Resources & Web Sites


The Celiac Diet, Series 1-7 Carol Rees Parshi MS RD

http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/resources.cfm
General guidelines: http://www.digestive.niddk.gov search celiac

Evidence Based Standards of Practice
http://celiac.nih.gov
www.eatright.org manual of clinical dietetics
AGA Institute Medical Position Statement on the DX and Mngt of Celiac Disease:
Gastroenterology 2006;131:1977-1980

Center for Celiac Research

www.celiaccenter.org

Steve Plogsted’s medication list

www.glutenfreedrugs.com

Local Support Groups: CSA, GIG,CDF, Independents

[email protected]

Religious resource

[email protected], http://glutenfreematzo.com
 Allergen Food for Institutions mailorder

www.celinalfoods.com (also available thru Gordon Food Service)
www.med-diet.com
Celiac Disease and the aged: limited clinical studies






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 biopsyproven 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.