It’s a piece of It’s a piece of cakecake

How Certified Dietary Managers can How Certified Dietary Managers can ensure that they are serving gluten ensure that they are serving gluten

free meals free meals

Roberta Tripp MS RD LDNRoberta Tripp MS RD LDN

Clinical Nutrition ManagerClinical Nutrition Manager

Sodexo at PinnacleHealthSodexo at PinnacleHealth

Harrisburg PAHarrisburg PA

ObjectivesObjectives

To provide more in depth knowledge to CDMs who To provide more in depth knowledge to CDMs who already have a basic knowledge of gluten intolerance already have a basic knowledge of gluten intolerance and celiac disease and celiac disease

To discuss which residents may be on a gluten free diet To discuss which residents may be on a gluten free diet in addition to those with diagnosed celiac disease.in addition to those with diagnosed celiac disease.

To explain about the special products, cooking and To explain about the special products, cooking and serving procedures involvedserving procedures involved

To provide a list of resources for use when working with To provide a list of resources for use when working with residents on a gluten free diet.residents on a gluten free diet.

To help CDMs do a better job of ensuring no cross To help CDMs do a better job of ensuring no cross contamination occurs in their kitchens when they must contamination occurs in their kitchens when they must ensure a patient receives gluten free foodensure a patient receives gluten free food

Definition of Celiac DiseaseDefinition of Celiac Disease

An immune-mediated disease triggered by the An immune-mediated disease triggered by the ingestion of gluten-containing grains (wheat, rye, ingestion of gluten-containing grains (wheat, rye, barley) in genetically susceptible individuals.barley) in genetically susceptible individuals.

In celiac disease gluten causes damage to the In celiac disease gluten causes damage to the small intestine which affects its ability to absorb small intestine which affects its ability to absorb nutrients.nutrients.

GlutenGluten

Gluten, a protein found in wheat, barley, Gluten, a protein found in wheat, barley, and rye, forms when water is added and and rye, forms when water is added and the protein molecules glutanin and gliadin the protein molecules glutanin and gliadin combine.combine.

Gluten gives dough its sticky and pliable Gluten gives dough its sticky and pliable consistency.consistency.

It Takes A VilliIt Takes A Villi

DamagedDamaged HealthyHealthy

Can Can anyany amount of gluten be amount of gluten be harmful?harmful?

As of October 2009 there is no safe level of As of October 2009 there is no safe level of gluten yet established for people with celiac gluten yet established for people with celiac disease. Sensitivity may vary but as far as food disease. Sensitivity may vary but as far as food preparation and service are concerned, even preparation and service are concerned, even very small amounts of gluten can be harmful. very small amounts of gluten can be harmful.

Catassi and colleagues (Am J Clin Nutr 2007; Catassi and colleagues (Am J Clin Nutr 2007; 85:160-166) found no significant change in 85:160-166) found no significant change in villous height/crypt depth ratio in participants villous height/crypt depth ratio in participants consuming 10 mg gluten per dayconsuming 10 mg gluten per day

Classic Adult Onset SymptomsClassic Adult Onset Symptoms

DiarrheaDiarrhea ConstipationConstipation Gas and bloatingGas and bloating Abdominal painAbdominal pain Nausea and vomitingNausea and vomiting RefluxReflux

Atypical Adult Onset SymptomsAtypical Adult Onset Symptoms

AnemiaAnemia Bone and joint painBone and joint pain Osteoporosis/osteopeniaOsteoporosis/osteopenia Chronic hepatitisChronic hepatitis Infertility/recurrent miscarriagesInfertility/recurrent miscarriages Mouth ulcersMouth ulcers

Symptoms in ChildrenSymptoms in Children

Delayed pubertyDelayed puberty Dental enamel defectsDental enamel defects Diarrhea/constipationDiarrhea/constipation Difficulty in learningDifficulty in learning Failure to thriveFailure to thrive Short StatureShort Stature

Autoimmune Disorders Associated Autoimmune Disorders Associated with Celiac Diseasewith Celiac Disease

Autoimmune hepatitisAutoimmune hepatitis Down’s syndrome, IBD, Crohns DiseaseDown’s syndrome, IBD, Crohns Disease Rheumatoid ArthritisRheumatoid Arthritis Sjogren’s SyndromeSjogren’s Syndrome Thyroid DiseaseThyroid Disease Type I diabetesType I diabetes

Intestinal Cancer and Celiac Intestinal Cancer and Celiac DiseaseDisease

A type of non Hodgkins A type of non Hodgkins lymphoma that develops in the lymphoma that develops in the small bowel is one of the most small bowel is one of the most

common causes of death in common causes of death in people with celiac disease.people with celiac disease.

““The Hidden Epidemic”The Hidden Epidemic”

The title of Dr. Peter H. Green’s book The title of Dr. Peter H. Green’s book “Celiac Disease: The Hidden Epidemic” “Celiac Disease: The Hidden Epidemic” serves as an unfortunate answer to the serves as an unfortunate answer to the question “If there are so many people with question “If there are so many people with gluten intolerance and celiac disease, gluten intolerance and celiac disease, where are they?” It has been estimated where are they?” It has been estimated that 97% of people with celiac disease that 97% of people with celiac disease don’t know they have it.don’t know they have it.

The average celiac goes eleven The average celiac goes eleven years prior to being diagnosedyears prior to being diagnosed

Symptoms such as diarrhea, gas, bloating, and Symptoms such as diarrhea, gas, bloating, and abdominal pain are often wrongly diagnosed as abdominal pain are often wrongly diagnosed as irritable bowel syndrome (and ironically, patients irritable bowel syndrome (and ironically, patients are told to “eat more fiber”, which usually are told to “eat more fiber”, which usually translates to whole wheat and bran!)translates to whole wheat and bran!)

Not everyone who avoids gluten Not everyone who avoids gluten has celiac diseasehas celiac disease

At least 1 out of every 133 people have celiac disease in At least 1 out of every 133 people have celiac disease in the US (3 million people)the US (3 million people)

As many as 13 million people have other forms of gluten As many as 13 million people have other forms of gluten sensitivitysensitivity

Approximately 6 million people claim to have a wheat Approximately 6 million people claim to have a wheat allergy in this countryallergy in this country

Therefore the total number of people who need to follow a Therefore the total number of people who need to follow a GF diet could be as high as 22 million in the United States GF diet could be as high as 22 million in the United States (about 1 out of every 13 people).(about 1 out of every 13 people).

Parents of children with Autism Spectrum Disorder may Parents of children with Autism Spectrum Disorder may want the child on a gluten free (and casein free) diet even want the child on a gluten free (and casein free) diet even though this approach to treating ASD is unproven. though this approach to treating ASD is unproven.

What Grains are Gluten Free?What Grains are Gluten Free?

AmaranthAmaranth ArrowrootArrowroot BuckwheatBuckwheat CornCorn FlaxFlax MilletMillet MontinaMontina PotatoPotato

QuinoaQuinoa RiceRice SorghumSorghum TapiocaTapioca TeffTeff Flours made from Flours made from

nuts, seeds, and nuts, seeds, and beans (garfava, soy beans (garfava, soy flour)flour)

What About Oats?What About Oats? Oats that are uncontaminated by gluten Oats that are uncontaminated by gluten

containing grains are usually tolerated by containing grains are usually tolerated by individuals with celiac disease or gluten individuals with celiac disease or gluten intolerance.intolerance.

The recommendation is to introduce oats The recommendation is to introduce oats gradually and slowly into the gluten free diet gradually and slowly into the gluten free diet after consulting your physician.after consulting your physician.

These certified gluten free oats are available These certified gluten free oats are available from 4 suppliers in North America (from 4 suppliers in North America (www.bobsredmill.comwww.bobsredmill.com, , www.glutenfreeoats.comwww.glutenfreeoats.com,,

www.onlyoats.comwww.onlyoats.com and and www.creamhillestates.comwww.creamhillestates.com))

Surprisingly gluten freeSurprisingly gluten free

MSGMSG Corn glutenCorn gluten Vegetable brothVegetable broth Glutinous riceGlutinous rice

Food labels: you’re confusing Food labels: you’re confusing me with the factsme with the facts

In the US, foods are either under the In the US, foods are either under the jurisdiction of the Food and Drug Administration jurisdiction of the Food and Drug Administration (FDA) or the USDA FSIS (United States (FDA) or the USDA FSIS (United States Department of Agriculture Food Safety and Department of Agriculture Food Safety and Inspection Service).Inspection Service).

The FDA regulates all foods except meat, The FDA regulates all foods except meat, poultry, and egg products, which are under poultry, and egg products, which are under FSIS jurisdiction.FSIS jurisdiction.

Each of these agencies has different policies Each of these agencies has different policies regarding food labeling. regarding food labeling.

FDA’s Food Allergens FDA’s Food Allergens Labeling and Labeling and

Consumer Protection Act Consumer Protection Act (FALCPA)(FALCPA)

••In 2004, the Food and Drug Administration, In 2004, the Food and Drug Administration, which regulates most of the food supply, which regulates most of the food supply, enacted a new a regulation known as FALCPA enacted a new a regulation known as FALCPA that requires that 8 known allergens, including that requires that 8 known allergens, including wheat, be declared in plain English terms on wheat, be declared in plain English terms on the label of all packaged goods they regulate.the label of all packaged goods they regulate.

Because of FALCPA, in FDA Because of FALCPA, in FDA regulated foods, you don’t have regulated foods, you don’t have

to worry about…to worry about…

Modified food starchModified food starch

In the US and Canada if a food starch in In the US and Canada if a food starch in an FDA regulated food is made from an FDA regulated food is made from wheat the label would have to say so wheat the label would have to say so

Rye and barley are not used to make food Rye and barley are not used to make food starchstarch

Maltodextrin, dextrin, or hydrolyzed Maltodextrin, dextrin, or hydrolyzed vegetable proteinvegetable protein

If any of these are made from wheat If any of these are made from wheat the ingredient list would have to state the ingredient list would have to state this fact (in the US and Canada).this fact (in the US and Canada).

Vinegar or AlcoholVinegar or Alcohol

Distillation proteins are too large to Distillation proteins are too large to pass through the distillation process pass through the distillation process

(this includes gluten).(this includes gluten).

All vinegars are distilled and are All vinegars are distilled and are therefore gluten free except Malt therefore gluten free except Malt

Vinegar (has added malt from barley)Vinegar (has added malt from barley)

USDA RegulationUSDA Regulation

••Foods regulated by the USDA FSIS (meat, Foods regulated by the USDA FSIS (meat, poultry, and processed egg products) are poultry, and processed egg products) are not not covered by this regulation and therefore covered by this regulation and therefore could contain hidden gluten from wheat.could contain hidden gluten from wheat.

••Neither agency has to disclose barley, oats, Neither agency has to disclose barley, oats, or rye on an ingredient label.or rye on an ingredient label.

USDA RuleUSDA Rule

To be consistent with FALCPA, the USDA’s To be consistent with FALCPA, the USDA’s Food Safety and Inspection Service is Food Safety and Inspection Service is undertaking rulemaking to adopt the undertaking rulemaking to adopt the FALCPA requirements for the products it FALCPA requirements for the products it regulates. Currently FSIS permits regulates. Currently FSIS permits voluntary allergens labeling.voluntary allergens labeling.

Labeling requirements for Labeling requirements for allergens to extend to meat, allergens to extend to meat, poultry, and egg products poultry, and egg products

When the USDA regulation is enacted, labels on When the USDA regulation is enacted, labels on meat, poultry, and egg products regulated by meat, poultry, and egg products regulated by FSIS will be FSIS will be requiredrequired to state if wheat is an to state if wheat is an ingredient. ingredient.

Presently it is recommended that the Presently it is recommended that the manufacturer be contacted if there are any manufacturer be contacted if there are any ingredients listed on meat, poultry, or egg ingredients listed on meat, poultry, or egg products that are questionable to make sure products that are questionable to make sure they come from a gluten free source. they come from a gluten free source.

It’s wheat free, but is it gluten It’s wheat free, but is it gluten free?free?

At this time there is no universally At this time there is no universally agreed upon definition of the term agreed upon definition of the term “gluten free”.“gluten free”.

The FDA is working on defining this The FDA is working on defining this term.term.

The proposed FDA rule says that The proposed FDA rule says that gluten free foods must contain less gluten free foods must contain less than 20 parts per million gluten.than 20 parts per million gluten.

10 ounces of grain foods containing 10 ounces of grain foods containing 20 ppm gluten would contain 5.70 20 ppm gluten would contain 5.70 mg gluten.mg gluten.

Foods from EuropeFoods from Europe

Codex, the organization responsible for Codex, the organization responsible for regulations regarding food labeled “gluten-regulations regarding food labeled “gluten-free” in many European countries, has free” in many European countries, has finalized a rule that these foods, including finalized a rule that these foods, including those made from wheat starch, will those made from wheat starch, will contain no more than 20 parts per million contain no more than 20 parts per million gluten. gluten.

For gluten-free foods containing wheat For gluten-free foods containing wheat starch this is a much lower amount than starch this is a much lower amount than the previously allowed amount of 200 and the previously allowed amount of 200 and 100 parts per million gluten.100 parts per million gluten.

Ingredients Worth Ingredients Worth QuestioningQuestioning

Soup, bouillon, broth, and Soup, bouillon, broth, and soup basesoup base

Soup and stocks (including au jus, broth, and Soup and stocks (including au jus, broth, and bouillon) may contain gluten so ingredients bouillon) may contain gluten so ingredients should always be checked. should always be checked.

Some soups are USDA regulated so wheat Some soups are USDA regulated so wheat might not be disclosed on the label—check might not be disclosed on the label—check with the company.with the company.

Soy SauceSoy Sauce Soy sauce usually contains wheat in addition Soy sauce usually contains wheat in addition

to soy, and therefore may contain gluten. to soy, and therefore may contain gluten. Check the label.Check the label.

If a non-FDA regulated product contains soy If a non-FDA regulated product contains soy sauce (Chinese take out food, for example) it sauce (Chinese take out food, for example) it would would not not have to state it contains wheat if it have to state it contains wheat if it did.did.

Spices and SeasoningsSpices and Seasonings

Pure spices and herbs are gluten freePure spices and herbs are gluten free Seasoning blends may contain gluten from Seasoning blends may contain gluten from

anti-caking or flow agents. If these additives anti-caking or flow agents. If these additives are present it will be clearly labeled on the are present it will be clearly labeled on the package if they are derived from wheat and package if they are derived from wheat and should therefore be avoided. should therefore be avoided.

Talking TurkeyTalking Turkey

Because fresh and frozen turkeys are Because fresh and frozen turkeys are under jurisdiction of the USDA, any under jurisdiction of the USDA, any injected basting solution containing gluten injected basting solution containing gluten would not have to be disclosed on the would not have to be disclosed on the labellabel

It is recommended to contact the company It is recommended to contact the company to verify the turkey’s gluten free status.to verify the turkey’s gluten free status.

Don’t be so crabbyDon’t be so crabby

Imitation seafood (surimi or “Sea Legs”) Imitation seafood (surimi or “Sea Legs”) contains wheat but since it is a USDA contains wheat but since it is a USDA regulated food does not need to state so regulated food does not need to state so on the label.on the label.

There’s gluten in that??There’s gluten in that??

All Kellogg’s dry ready-to-eat cereals All Kellogg’s dry ready-to-eat cereals contain gluten in some form (either barley contain gluten in some form (either barley malt, wheat, oats that have not been malt, wheat, oats that have not been certified gluten free, or wheat starch).certified gluten free, or wheat starch).

Some premade hamburger or turkey Some premade hamburger or turkey burger patties contain wheat but may not burger patties contain wheat but may not state it on the labelstate it on the label

Seasoned French fries or batter dipped Seasoned French fries or batter dipped fries; Rice-a-Ronifries; Rice-a-Roni

More possible hidden glutenMore possible hidden gluten Some egg substitutes Some egg substitutes

Flourless chocolate cake (may be made in a floured Flourless chocolate cake (may be made in a floured pan)pan)

Some shredded cheese (may be dusted with flour)Some shredded cheese (may be dusted with flour)

Some dried fruitSome dried fruit

Some canned beansSome canned beans

More ingredients to look for and More ingredients to look for and avoid avoid

Natural flavorings (rarely from wheat)Natural flavorings (rarely from wheat) Malt/Malt Extract, “barley malt”, or “barley malt Malt/Malt Extract, “barley malt”, or “barley malt

extract” extract” Brown Rice Syrup (may be made with barley)Brown Rice Syrup (may be made with barley) Modified hop extractModified hop extract

MarinadesMarinades

Many marinades contain soy sauce or other gluten containing Many marinades contain soy sauce or other gluten containing ingredientsingredients

Most beer is made with barley malt so any marinade Most beer is made with barley malt so any marinade containing beer probably contains glutencontaining beer probably contains gluten

Patients who have been on a gluten free diet may be skeptical Patients who have been on a gluten free diet may be skeptical that they are being served food that is indeed gluten free. that they are being served food that is indeed gluten free. They will appreciate it if after you have checked and verified They will appreciate it if after you have checked and verified the marinade is gluten free, you reassure them that you have the marinade is gluten free, you reassure them that you have done so.done so.

Understanding the gluten free diet is Understanding the gluten free diet is everything: the role of the CDMeverything: the role of the CDM

Because there is no medication Because there is no medication that will cure someone with that will cure someone with celiac disease or gluten celiac disease or gluten intolerance, the CDM, acting as intolerance, the CDM, acting as a liaison between the food a liaison between the food preparation area and the preparation area and the patient, has a tremendous patient, has a tremendous opportunity to positively impact opportunity to positively impact the meal service experience for the meal service experience for the patient or resident on a the patient or resident on a gluten free diet. gluten free diet.

Do You Really Have a “Gluten Free Do You Really Have a “Gluten Free Diet”?Diet”?

If your diet manual allows Rice Krispies or If your diet manual allows Rice Krispies or Kellogg’s Corn Flakes on your gluten free Kellogg’s Corn Flakes on your gluten free diet, it’s time to revise it.diet, it’s time to revise it.

Every department in your organization Every department in your organization needs to understand what “gluten free” needs to understand what “gluten free” meansmeans Activities Department—cookies, etcActivities Department—cookies, etc Nursing– snacks from a pantry and med passNursing– snacks from a pantry and med pass Pharmacy – are the drugs and vitamins GF?Pharmacy – are the drugs and vitamins GF? Chaplain – communion wafersChaplain – communion wafers

What if the resident demands What if the resident demands something with gluten?something with gluten?

If it is documented that they are on a GF If it is documented that they are on a GF diet, you should not send any food diet, you should not send any food containing gluten without documentation containing gluten without documentation by Nursing of the choice to be by Nursing of the choice to be noncompliantnoncompliant

Is Your GF Diet Nutritionally Is Your GF Diet Nutritionally Adequate?Adequate?

Does it provide enough calories? If you Does it provide enough calories? If you don’t appropriately substitute when you don’t appropriately substitute when you take a gluten containing food off the menu, take a gluten containing food off the menu, you could be deficient.you could be deficient.

Give Your Cooks GuidanceGive Your Cooks Guidance

Don’t just use your regular menu and expect Don’t just use your regular menu and expect them to adjust each selection to GF. What them to adjust each selection to GF. What happens if there is “1 cookie” on the menu and happens if there is “1 cookie” on the menu and you don’t have GF cookies?you don’t have GF cookies?

Review products like your soup base—does it Review products like your soup base—does it contain gluten?contain gluten?

How often do items like meatloaf, Sloppy Joes, How often do items like meatloaf, Sloppy Joes, or meat balls come up and do you have a or meat balls come up and do you have a substitute available? substitute available?

Gravy and bacon bitsGravy and bacon bits

Make sure your cooks know how to make Make sure your cooks know how to make a gluten free gravy. They can use a gluten free gravy. They can use cornstarch and gluten free soup base.cornstarch and gluten free soup base.

Some “bacon bits” are not actually bacon Some “bacon bits” are not actually bacon and may contain wheatand may contain wheat

GF products are generally not GF products are generally not enriched…enriched…

All wheat flour in this country is enriched All wheat flour in this country is enriched with B vitamins, folate and ironwith B vitamins, folate and iron

Most GF foods are low in fiber unless they Most GF foods are low in fiber unless they are made with garbanzo bean flour or flaxare made with garbanzo bean flour or flax

The GF resident is at risk of deficiencies The GF resident is at risk of deficiencies unless you give like substitutions with unless you give like substitutions with these nutrientsthese nutrients

What should the Activity Director What should the Activity Director knowknow

Rice Krispies Treats are NOT gluten freeRice Krispies Treats are NOT gluten free Neither is Play Doh or paper macheNeither is Play Doh or paper mache These items should be substituted with These items should be substituted with

similar nutritionsimilar nutrition

To oats or not to oats?To oats or not to oats?(with apologies to Shakespeare)(with apologies to Shakespeare)

Until the dietitian or RN puts it in writing, Until the dietitian or RN puts it in writing, the following should the following should not not be served oats, be served oats, even if they are certified gluten free – just even if they are certified gluten free – just in case the pt actually has celiac diseasein case the pt actually has celiac disease Wheat allergyWheat allergy Gluten freeGluten free ““no bread”no bread” ““wheat free”wheat free”

If the resident can have oats, what If the resident can have oats, what kind should I give them?kind should I give them?

Rice cakes AGAIN??!! What residents Rice cakes AGAIN??!! What residents on a gluten free diet wanton a gluten free diet want

Meals that are gluten free by substitution, not Meals that are gluten free by substitution, not by eliminationby elimination

Food that is good tasting, not just gluten freeFood that is good tasting, not just gluten free As much variety as possibleAs much variety as possible Most importantly: residents want to trust that Most importantly: residents want to trust that

the food is gluten free when you say it isthe food is gluten free when you say it is

Your Kitchen Staff Needs to Your Kitchen Staff Needs to KnowKnow

Patients aren’t being high maintenance or picky Patients aren’t being high maintenance or picky when they are checking to make sure their meals when they are checking to make sure their meals are gluten free. They are trying not to get sick.are gluten free. They are trying not to get sick.

Something may seem obvious to you (someone Something may seem obvious to you (someone who needs to avoid wheat can’t eat white bread who needs to avoid wheat can’t eat white bread as well as wheat bread) that isn’t obvious to a as well as wheat bread) that isn’t obvious to a kitchen employeekitchen employee

Have a dual person check for safest tray Have a dual person check for safest tray accuracyaccuracy

Handling gluten free ingredients Handling gluten free ingredients in a non gluten free kitchenin a non gluten free kitchen

Food and beverage consumption should not be allowed Food and beverage consumption should not be allowed where the food is producedwhere the food is produced

Clean lab coats, aprons, and gloves are importantClean lab coats, aprons, and gloves are important

Equipment should be clearly marked and separateEquipment should be clearly marked and separate

Storage, preparation, and serving areas should be Storage, preparation, and serving areas should be separate—best practice would be controlled air flow separate—best practice would be controlled air flow between the two production areasbetween the two production areas

Gluten containing foods should be stored below gluten Gluten containing foods should be stored below gluten free foods to decrease the possibility of contaminationfree foods to decrease the possibility of contamination

Your staff should always be mindful of preventing cross Your staff should always be mindful of preventing cross contamination. contamination.

Cross Contamination: What You Cross Contamination: What You Can’t See CAN Hurt YouCan’t See CAN Hurt You

Because even a miniscule Because even a miniscule amount of gluten containing amount of gluten containing ingredients can damage the ingredients can damage the small intestine of a person small intestine of a person with celiac disease, health with celiac disease, health care food service care food service departments have to be departments have to be especially diligent in not especially diligent in not cross contaminating gluten cross contaminating gluten free meals.free meals.

It’s as easy as sliced br…uh…It’s as easy as sliced br…uh…

If it doesn’t make sense to have a If it doesn’t make sense to have a separate toaster for gluten free bread, use separate toaster for gluten free bread, use foil and toast it in the oven.foil and toast it in the oven.

Do you use a bucket with cleaner and a Do you use a bucket with cleaner and a cloth to wipe tables? Do you clean a table cloth to wipe tables? Do you clean a table and then dip the rag back in the bucket and then dip the rag back in the bucket after it has cleaned up a table with wheat after it has cleaned up a table with wheat crumbs on it? You have just contaminated crumbs on it? You have just contaminated the surface with gluten.the surface with gluten.

Possible sources of cross Possible sources of cross contaminationcontamination

Cutting boards; knives, spoons or ladles; butter, Cutting boards; knives, spoons or ladles; butter, peanut butter, or mayonnaise knivespeanut butter, or mayonnaise knives

Grills, toasters, or toaster ovens used for both Grills, toasters, or toaster ovens used for both gluten free and non gluten free food should be gluten free and non gluten free food should be thoroughly cleaned so no traces of gluten remainthoroughly cleaned so no traces of gluten remain

Deep fryer used to cook breaded or battered food Deep fryer used to cook breaded or battered food as well as French friesas well as French fries

Gloved hand that has touched gluten containing Gloved hand that has touched gluten containing food and then touches gluten free foodfood and then touches gluten free food

More ways to avoid cross More ways to avoid cross contaminationcontamination

Work surfaces and microwaves Work surfaces and microwaves should be clean.should be clean.

Use designated cutting boards, Use designated cutting boards, knives, and toastersknives, and toasters

Fresh, clean water for boiling, Fresh, clean water for boiling, steaming, and poaching (pasta)steaming, and poaching (pasta)

If there is not a dedicated fryer for If there is not a dedicated fryer for gluten free foods, fry them in a skilletgluten free foods, fry them in a skillet

No common prep equipment or No common prep equipment or

surfaces without appropriatesurfaces without appropriate dishwashing and cleaningdishwashing and cleaning

You don’t bring me flours You don’t bring me flours anymoreanymore

Even the most well intentioned cooks can Even the most well intentioned cooks can inadvertently turn a gluten free food into a inadvertently turn a gluten free food into a gluten containing food simply by not gluten containing food simply by not paying attention to some simple practices paying attention to some simple practices in the kitchen. in the kitchen.

This is particularly an issue where baking This is particularly an issue where baking is done from scratch (flour in the air).is done from scratch (flour in the air).

An easy way to explain this to An easy way to explain this to kitchen staff is to compare gluten to kitchen staff is to compare gluten to

raw chicken. raw chicken.

Just as it’s common knowledge Just as it’s common knowledge that raw chicken is dangerous and that raw chicken is dangerous and should never come in contact with should never come in contact with food, utensils, or plates that are food, utensils, or plates that are ready to be served, it should be ready to be served, it should be made absolutely clear that gluten made absolutely clear that gluten containing food needs to be kept containing food needs to be kept away from gluten free food at all away from gluten free food at all stages of preparation and service.stages of preparation and service.

Oops—he said no croutonsOops—he said no croutons

In the event an accident happens the entire In the event an accident happens the entire plate of food needs to be replacedplate of food needs to be replaced

Removing the bread, wrap, breading, Removing the bread, wrap, breading, croutons, etc is not acceptable once croutons, etc is not acceptable once contamination has occurred. Even a bread contamination has occurred. Even a bread stick on a plate that isn’t touching the food stick on a plate that isn’t touching the food can leave some gluten behind.can leave some gluten behind.

Garnishes that start out gluten free may Garnishes that start out gluten free may become contaminated, so any gluten become contaminated, so any gluten containing garnishes should be stored below containing garnishes should be stored below gluten free items.gluten free items.

Major food companies are finally Major food companies are finally marketing to the gluten free marketing to the gluten free

consumerconsumer

Gluten Free Becomes Gluten Free Becomes MainstreamMainstream

Most Chex cereals are now gluten free (with Most Chex cereals are now gluten free (with the exception of Wheat Chex and Bran the exception of Wheat Chex and Bran Chex).Chex).

Betty Crocker has recently come out with Betty Crocker has recently come out with gluten free mixes for chocolate chip cookies, gluten free mixes for chocolate chip cookies, brownies, chocolate cake and yellow cake.brownies, chocolate cake and yellow cake.

Some Excellent ResourcesSome Excellent Resources

The New Ultimate Guide The New Ultimate Guide to Gluten-Free Living to Gluten-Free Living

Celiac Disease Center Celiac Disease Center at Columbia Universityat Columbia University

www.celiacdiseasecenter.www.celiacdiseasecenter.orgorg

Gluten-Free Diet: A Gluten-Free Diet: A Comprehensive Resource Comprehensive Resource Guide, Expanded Edition. Guide, Expanded Edition. Shelley Case, BSc, RDShelley Case, BSc, RDwww.glutenfreediet.cawww.glutenfreediet.ca

Gluten Intolerance Group. Gluten Intolerance Group. www.gluten.netwww.gluten.net

Gluten-Free Living magazineGluten-Free Living magazine

www.glutenfreeliving.comwww.glutenfreeliving.com Celiac Sprue Association Celiac Sprue Association

www.csaceliacs.orgwww.csaceliacs.org National Foundation for National Foundation for

Celiac Awareness Celiac Awareness

www.celiaccentral.orgwww.celiaccentral.org www.foodallergy.comwww.foodallergy.com www.cfsan.fds.govwww.cfsan.fds.gov

More ResourcesMore Resources

www.eatright.orgwww.eatright.org

Evidence based guidelines for celiac Evidence based guidelines for celiac diseasedisease

altarbreads@benedictinesisters.orgaltarbreads@benedictinesisters.org

http://glutenfreeoatmatzos.comhttp://glutenfreeoatmatzos.com

www.glutenfreedrugs.comwww.glutenfreedrugs.com

Ronni Alicea, RD, MBARonni Alicea, RD, MBACelinal FoodsCelinal Foods

http://www.celinalfoods.com/pdfs/select_menu.pdfhttp://www.celinalfoods.com/pdfs/select_menu.pdf

Ronni’s article on the DMA website:

http://www.dmaonline.org/CE/nutrition_connection/2008_spring.shtml

““Ask Roberta”Ask Roberta”

www.glutenreview.comwww.glutenreview.com

Questions?Questions?