CELIAC DISEASE

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CELIAC DISEASE

• A PRIMER FOR SCHOOL NUTRITION

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What is Celiac Disease?

• Inherited, Autoimmune Disorder
• Permanent Intolerance to Gluten in WHEAT, RYE AND
  BARLEY
• Also referred to as celiac sprue

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WHAT IS GLUTEN?

• THE PORTION OF THE PROTEIN IN FLOUR THAT FORMS
  THE STRUCTURE OF DOUGH

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SCOPE OF DISEASE

• 2.2 million Americans afflicted-over 10,000
  children diagnosed annually
• Affects 1 in 133 Americans
• 97 go undiagnosed. Celiacs are at greater risk
  of GI cancer and particularly lymphoma
• Dr. Alessio Fasano, University of
  Maryland-Baltimore Center for Celiac Research in
  A Gluten Free Solution, FoodService Director,
  September 15, 2008, p. 50-51.

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DIAGNOSIS

• Initial Blood Tests
• If serology is positive, a biopsy of small
  intestine is the definitive test
• NO CURE person must strictly avoid food
  products, medicines, vitamins and even glue on
  envelopes that may have gluten

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MECHANISM OF ACTION

• Body attacks normal tissue resulting in damage to
  lining of small intestinal villi, the tiny
  hairlike projections that line inside of small
  intestine.
• Villi contain blood vessels which absorb
  nutrients
• Villi increase area for absorption of nutrients
• Digested nutrients are carried away by
  circulating blood
• If villi are damaged, vitamins, minerals,
  calcium, carbohydrates, protein, and fats are not
  absorbed well

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INTESTINAL VILLI
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SYMPTOMS

• Some may be asymptomatic
• Diarrhea
• Short Stature
• Iron Deficiency Anemia
• Lactose Intolerance
• Irritability (common in children)

• Mood Swings (common in children)
• Abdominal Pain
• Irritable Bowel
• Osteoporosis
• Skin rash-very itchy with blisters

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TREATMENT

• GLUTEN FREE DIET
• ELIMINATE ALL WHEAT, RYE, BARLEY AND THEIR
  DERIVATIVES
• MAY TAKE 6-12 MONTHS FOR INTESTINE TO HEAL

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WHAT ABOUT OATS?

• Oats may not be harmful to a celiac patient
  however, oats may be cross-contaminated with
  wheat in the milling process

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FOOD LABELING LAWS

• Under the 2006 Food Allergen Labeling and
  Consumer Act, wheat protein or a derivative must
  be identified, even if used in small amounts
• The law does not address the use of barley, rye
  or oats
• Check with manufacturer if in doubt

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• USDA has given recent clarification on a specific
  case for an individual child
• if the physician, in the documentation for
  special dietary accommodations, identifies celiac
  as a disability, then the school must make the
  accommodations for a disabled student
• Supt. Reg. Memo 8. October 11, 2002

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SCHOOL NUTRITION PROGRAMS SHOULD CONSIDER THE
FOLLOWING PRACTICES

• Determine if the student has an IEP or 504 plan
• Discuss accommodations with the school division
  special education supervisor and/or nurse
  supervisor if necessary
• Consult with a Registered Dietitian if family is
  working with one through their doctor

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Meeting Meal Requirements

• If following a physicians orders, foods do not
  have to meet the same standard as a regular
  component-for example, bread doesnt have to
  weigh 1 oz.

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Rochester MN Public Schools

• GF menu for 5 years-on web site
• Found from surveys with kids/parents that sliced
  bread was least liked item
• Buy locally
• Modifications include chicken nuggets
  (cornflake crumbs, GF chocolate chip cookie
  (school made)

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AVOID CROSS CONTAMINATION-RECOMMENDATIONS

• Separate Fryers or Clean Oil if Breaded Items are
  Fried in Same Vats as Non-Breaded
• Use Separate Jars of Peanut Butter, Jelly,
  Mayonnaise to Avoid Wheat/Bread Crumbs in Jar
• Clean and Sanitize Counters, Cutting Boards,
  Cooking Utensils, Pans after EACH use and BEFORE
  Cooking Gluten Free Products
• Use Separate Colanders for gluten free products

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GLUTEN CONTAINING GRAINS TO AVOID

• Barley
• Barley malt/extract
• Bran
• Bulgur
• Couscous
• Bromated or Durum Flour
• Einkorn
• Emmer
• Enriched or Self Rising Flour
• Farina
• Faro
• Graham Flour
• Kamut

• Matzo Flour/meal
• Orzo
• Panko
• Phosphated Flour
• Rye
• Seltan
• Semolina
• Spelt
• Triticale (cross between wheat/rye)
• Udon
• Wheat
• Wheat Bran
• Wheat germ
• Wheat starch

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OVERLOOKED GLUTEN SOURCES

• Ales
• Beer and Lagers
• Bouillon Cubes
• Breading
• Brown Rice Syrup
• Coating Mix
• Communion Wafers
• Croutons
• Candy
• Some Chips/Potato chips
• Luncheon Meats, hot dogs, salami, sausage
• French Fries
• Gravy
• Pasta
• Rice Mixes
• Seasoned Tortilla Chips
• Sauces

• Soup Base
• Stuffing
• Self-basting Poultry
• Imitation Bacon/Seafood
• Soy Sauce
• Marinades Thickeners Herbal
• Supplements, Prescription Meds
• Over the Counter Meds
• Vitamin and Mineral Supplements
• Lipstick
• Lip Gloss and Balms
• Play Dough (hands must be properly washed after
  playing with)

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GLUTEN FREE GRAINS AND STARCHES

• Amaranth
• Arrowroot
• Buckwheat
• Corn
• Flax
• Flours made from nuts, beans and seeds
• Millet
• Montina
• Potato Starch

• Potato Flour
• Quinoa
• Rice
• Rice Bran
• Sago
• Sorghum
• Soy (soya)
• Tapioca
• Teff

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GLUTEN FREE SHOPPING LIST

• Fresh Fruits
• Fresh Vegetables
• Tofu
• Fresh Beef
• Fresh Pork
• Fresh Poultry (self-basting)
• Fresh Fish or Seafood
• Eggs
• Unflavored Milk
• Most Yogurts
• Butter, Margarine
• Cream Cheese
• Cottage Cheese

• Sour Cream
• Plain Frozen Fruits/Veggies
• Most Ice Cream/Sherbet
• Potato Chips (beware flavored ones)
• Corn Chips
• Popcorn
• Rice Crackers, Rice Cakes
• Jello
• Pudding
• Plain Canned Fruits/Veggies
• Canned Tuna or Chicken
• Dried Beans, Lentils, Peas
• Most Baked Beans

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GLUTEN FREE SHOPPING LIST, CONTINUED

• Cream of Rice
• Grits
• Puffed Rice
• Plain Brown or White Rice
• CORN Tacos/Tortillas
• Ketchup
• Mustard
• Distilled Vinegars
• Most Salad Dressings
• Vegetable, Canola and Olive Oil

• Jams/Jellies, Marmalade
• Honey
• Peanut Butter
• Corn or Potato Starch
• Corn and Maple Syrup
• Brown, White and Confectioners Sugar
• Spices and Herbs
• Salt, Pepper
• Relish, Pickles, Olives

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ACTIVE LEARNING

• Pull several ingredient statements from labels
  and see if any of the prohibited items are listed
• Look at your current menu and develop 3 gluten
  free menus-what ingredients can you substitute?

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Culinary Standards Seasoned Pork, Cuban Brand
98465

• Ingredients
• Boneless pork legg-outside roast (fresh
  Ham-PFOF), salt, olive oil, garlic, onion,
  spices, sugar, dehydrated yogurt (nonfat milk
  solids, lactic acid, cultures, and natural and
  artificial flavor), orange flavor (natural
  flavors, maltodextrin, modified food starch,
  silicon dioxide), lemon flavor (gum arabic,
  natural flavors (including citrus oils) and mixed
  tocopherols
• According to manufacturer, the starch is CORN
  (8/4/2008 per Jose Quinones)

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OK? What about modified food starch?

• Modified food starch has been treated physically
  or chemically to modify its properties. The
  starch can be from corn, WHEAT, potato, rice or
  tapioca-depends on the manufacturer.
• National Starch and Chemical www.foodstarch.com
• Food Allergy Network httpwww.foodallergy.org/in
  dex.html

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Landis Cooked Beef Meatball 36612

• Ingredients ground beef (not more than 20
  fat), water, bread crumbs (bleached wheat flour,
  sugar, salt, yeast), vegetable protein product
  (soy protein concentrate, zinc oxide,
  niacinamide, ferrous sulfate, copper gluconate,
  vitamin A palminate, calcium pantothenate,
  thiamine mononitrate (B1), pridoxine (sic)
  hydrochloride (B6), ribo-flavin (B2), and
  cyanocobalamin (B12), salt, dextrose, onions,
  romano cheese (cows milk, cheese culture, salt
  enzymes), onion powder, garlic powder, spices,
  monosodium glutamate, parsley flakes, natural
  flavorings

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USDA Beef Taco Filling

• Ingredients Ground Beef (no more than 16 fat),
  water, flavor, isolated oat product, salt,
  seasoning (textured soy protein soy flour,
  caramel color, zinc oxide, ferrous sulfate
  niacinamide, calcium pantothenate, pyridoxine
  hydrochloride(B6), riboflavin (B2), thiamine
  mononitrate (B1), vitamin A palmitate,
  cyanocobalamin (B12), onion spices including
  paprika, salt, beef fat, tomato powder,
  hydrogenated cottonseed oil, garlic, wheat flour
  (enriched with niacin, reduced iron, thiamine
  mononitrate, riboflavin, folic acid), cocoa,
  citric acid, autolyzed yeast extract and natural
  flavor), paprika, yellow corn flour, lecithin,
  sugar, autolyzed yeast extract, beef fat, malic
  acid

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What about caramel color?

• Caramel coloring is one of the most widely used
  colorants in food. GENERALLY, it comes from a
  high dextrose containing starch hydrolysate or
  corn syrup.
• Hydrolyis chemical reaction where there is an
  interaction of a compound with water which
  results in decomposition of a compound (salt in
  water e.g.)
• Caramel coloring can be made from corn, invert
  sugar, lactose, molasses, or beet or cane sugar.
  These are gluten free. Malt syrup or starch
  hydrolysate may be WHEAT.

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Uncle Bens Southwestern Pinto Beans and Rice

• Ingredients Parboiled long grain rice enriched
  with ferric orthophosphate (iron), thiamine
  mononitrate (thiamine) and folic acid precooked
  pinto beans dried vegetables (tomato, corn,
  onion, garlic, cilantro) sugar salt hydrolyzed
  corn gluten soy protein and wheat gluten corn
  syrup solids corn starch autolyzed yeast
  extract paprika partially hydrogenated
  vegetable oil (soybean and/or cottonseed) spice
  xanthan gum calcium chloride maltodextrin
  dried soy sauce (wheat, soybeans, salt) natural
  flavor, torula yeast, caramel color

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Uncle Bens Long Grain Wild Rice Original Recipe

• Ingredients long grain parboiled rice enriched
  with iron (ferric orthophosphate), thiamin
• (thiamine mononitrate) and folate (folic acid)
  wild rice vegetables(onion, parsley, spinach,
  garlic, celery, tomato, carrot) hydrolyzed
  corn/soy/wheat protein sugar, autolyzed yeast
  extract salt spices smoked yeast sunflower
  oil natural flavors turmeric (color) paprika
  (color)
• dried

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UTZ Salt n Vinegar Artificially Flavored Potato
Chips(sold ala carte only)

• Ingredients Cottonseed Oil, Salt, Lactose,
  Malic Acid, Sodium Acetate, Fumaric Acid, Soybean
  Oil
• Allergy Information Contains Milk. This is a
  gluten free food.

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Baked Lays Potato Crisps (sold ala carte only)

• Ingredients Dehydrated Potatoes, Modified Food
  Starch, Sugar, Corn Oil, Salt, Soy Lecithin,
  Leavening (Monocalcium Phosphate and Sodium
  Bicarbonate), and Dextrose
• Per Frito Lay, the modified starch is corn.
  Written confirmation July 2008.

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TIME TO PRACTICE
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MENU I

• Choose One
• Whole Grain Chicken Corn Dog Bites
• Hamburger/Cheeseburger on Whole Wheat Bun
• PBJ Sandwich w/ String Cheese
• Yogurt w/ Graham Crackers
• Chef Salad/Tuna Salad (contains saltine crackers)
• Choose Two
• Steamed Whole Kernel Corn
• Fresh Orange Wedges
• Fresh Red Grapes
• Chilled Diced Pears
• Assorted Milk

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MENU II

• Choose One
• Chicken Drummie w/ Biscuit
• Grilled Cheese Sandwich on Whole Wheat Bread
• PBJ Sandwich w/ String Cheese
• Yogurt/Graham Crackers
• Spinach Chef (diced egg, mushrooms, onions,
  tomatoes)
• Choose Two
• Glazed Sweet Potatoes
• Chilled Applesauce
• Fresh Pear
• Dried Cranberries
• Assorted Milk

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MENU III

• Pancakes w/Syrup
• OR
• Fat Free Yogurt
• OR
• Cereal w/ Graham Cracker
• OR
• Turkey Sausage w/ Biscuit
• OR
• PBJ Sandwich
• Fresh Orange Wedges or Orange Juice
• Assorted Milk

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REFERENCES

• www.CeliacHealth.org
• www.Celiac.org
• www.glutenfree.com
• www.celiac.com
• www.CDHNF.org (Childrens Digestive Health and
  Nutrition Foundation)
• www.NASPGHAN.org (North American Society for
  Pediatric Gastroenterology, Hepatology and
  Nutrition)
• USDA. Accommodating Children with Special
  Dietary Needs in the School Nutrition Programs
  Guidance for School Food Service Staff 2001.

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REFERENCES, CONTINUED

• http//digestive.niddk.nih.gov/ddiseases/pubs/celi
  ac_ez/ (National Digestive Diseases Information
  Clearinghouse)
• http//familydoctor.org
• http//resources.schoolscience.com.uk/ABPI/digesti
  on/digest6.html
• Food allergy intolerance survival guide.
  Enjoy Life Foods.
• http//www.enjoylifefoods.com
• www.rochester.k12.mn.us. Rochester, Minnesota
  Public Schools
• http//www.schoolnutrition.org. School Nutrition
  Association

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