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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.