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© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Gluten-Free Basics& School Meals
Addressing the Needs of Students with Celiac Disease
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Presenter
Beckee Moreland
Director of GREAT Schools
Beyond Celiac
Ambler, PA
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Learning Objectives
• Identify medical conditions associated with the gluten-free diet
• Recognize common and hidden sources of gluten
• Identify gluten-free substitutions for ingredients
• Describe menu substitutions and provide examples
• Identify potential areas in the cafeteria kitchen for gluten
cross-contact and provide control solutions
• Illustrate product storage and equipment needs for special
diet accommodations
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Definitions
• Food Allergy - A food allergy results when the immune system
mistakenly targets a harmless food protein – an allergen – as a
threat and attacks it. (IgE mediated)
• Food Intolerance – Can cause some of the same symptoms as a
food allergy but not anaphylaxis, no immune reaction, e.g.
lactose intolerance
• Food Sensitivity – Foods that cause reaction/discomfort, e.g.
sulphite sensitivity
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
What is Gluten?
• A protein; a tiny
component of
wheat, rye and
barley.
• It gives baked goods
their structure
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
What is Celiac Disease?
• Bloating, gas, abdominal pain
• Diarrhea or constipation
• Fatigue
• Itchy skin rash (DH)
• Tingling/numbness in hands or
feet
• Discolored teeth or loss of
enamel
• Canker sores
• Joint pain
• Irritability or behavior changes
• Significant unexplained weight
loss
• Poor weight gain
• Delayed growth
• Missed menstrual periods
• Fractures or thin bones
Celiac disease is a genetic autoimmune disorder triggered by the protein gluten.
Symptoms before diagnosis and treatment
Treatment: 100% strict gluten-free diet
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Gluten Damage
• Inflammation and immune
response in the small
intestine that damages the
villi
• Symptoms occur
• Body is unable to absorb
nutrients into bloodstream
• Can lead to malabsorption
• Villi become healthy by
removing gluten from diet
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Non-Celiac Gluten Sensitivity• Also known as gluten sensitivity
• Bodily reaction to gluten that causes
symptoms similar to celiac disease
• Exact cause is unknown
• Blood tests for celiac disease cannot
diagnose NCGS
• Does not involve damage to the small
intestine
• Estimated 6% of the U.S. population or 18
million Americans
Treatment: Gluten-free diet
© 2016 Beyond Celiac www.greatGFKitchens.org
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
“What happens when you get glutened?”
• Vast range of experiences – no two cases alike
• Reaction time – hours to days
• Severity – mild to debilitating
• Multitude of symptoms or none
• Internal damage and autoimmune reaction still
occurs
• Vomiting, stomach cramps, brain fog, mood
swings, rash, bloating, chills, depression,
diarrhea, canker sores, tremors…
© 2016 Beyond Celiac www.greatGFKitchens.org
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Who’s Eating Gluten-Free?
© 2016 Beyond Celiac www.greatGFKitchens.org
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Most Difficult Lifestyle Situations
© 2016 Beyond Celiac www.greatGFKitchens.org
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Impact on Relationships & Daily Life
• “Unwanted Visibility”
• Neglect and/or being “forgotten”
• Risk-taking/not wanting to disclose the gluten-free diet
• Constantly being “on call” and at-risk
• Changes in social life
© 2016 Beyond Celiac www.greatGFKitchens.org
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Needs of the Gluten-Free Student
Food Safety• Safe food is first priority
• Health consequences to
eating gluten
• Debilitating symptoms
challenge students’ ability to
learn and participate in
activities
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Needs of the Gluten-Free Student
Variety• Offering tasty and appealing
menu options
• Mirror traditional menu options
• Substitute nutritious gluten-free
alternatives
• Provide variety of options to
support dietary compliance
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Needs of the Gluten-Free Student
Nutrition
• Nutrition deficiencies are common
with celiac disease diagnosis
• Typical gluten-free diet lacking
nutrients
• Gluten-free foods not required to be
fortified
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Needs of the Gluten-Free Student
Emotional
• Feel welcome and included
• Treated with respect
• Feel comfortable asking food
questions about safety
• Build relationships in order to
develop trust and confidence
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Section 504
Section 504 of the
Rehabilitation Act of 1973
• Requires accommodating students
with special dietary needs,
including the gluten-free diet for
medical reasons
• Dietary modifications documented
within students Individual
Education Plan (IEP)/504 plan
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Process to Identify Students
1. Parents get the necessary paperwork
for school meal modifications
completed by health professional.
2. Forms to Health Office or School
Office - shared with the kitchen staff.
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Process to Identify Students
3. Collect additional information on child’s
condition, severity of the diet provided
through the nurses/parents.
(Follow up is done for diets that are
unclear or not specific enough.)
4. If possible parents pre-select the foods
from gluten- free menu for students.
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Communication & Team Work
• Meet with parents and all school
personnel assisting with the
student’s food choices (classroom
and lunchroom).
• Parents share the level of dietary
restriction needed for child
– Often times what is on file at school is
more restrictive than what the parents
are allowing at home- a new medical
statement is needed if the diet has
changed.
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Creating Gluten-Free Options
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Challenges to Conquer
• Identify ingredients with allergens and gluten
• Transparent communication with students and
parents
• Education & commitment to training staff
• Eliminate & control allergen/gluten ‘hot spots’
• Create systems to execute controls precisely and
consistently
© 2016 Beyond Celiac www.greatGFKitchens.org
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
What is Gluten?
• Protein found in wheat, barley and
rye and their derivatives:
– Wheat varieties include spelt,
triticale, semolina, durum, farina,
farro… (not a complete list)
– A sticky substance that gives many
foods shape, texture and
consistency
• Most commonly found in flours,
breads, pastas, crackers, cake and
cookies
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Gluten-Free Grains
• Rice (all forms)
• Corn (corn bran, grits,
hominy, hasa marina)
• Potato (starch & flour)
• Soy
• Tapioca
• Bean
• Amaranth
• Quinoa
• Buckwheat
• Millet
• Teff
• Nut Flours
• Sorghum
• Arrowroot
• Wild Rice
• Mesquite
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Overlooked Sources of Gluten
• Soy sauce
• Licorice
• Imitation
seafood
• Communion
wafers
• Play-Doh©
• Gravies and
Sauces
• Broth/Bouillon
• Deli Meats
• Veggie
Burgers
• Refried Beans
• Seasoned Rice
Mixes
• Self-basting
poultry
• Pudding
• Taco
Seasoning
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Food AllergyLabeling Consumer Protection Act-2004
• Top 8 allergens – peanuts, tree nuts, egg, soy, fish, shellfish,
wheat, dairy
• All packaged foods sold in the U.S. - FDA regulated
• Must be clearly labeled in plan English if food contains the
allergen
• Statements like “may contain” “made in facility” etc. not
required & not regulated
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
FDA Gluten-Free Labeling - 2013
• Label “gluten-free”- the product must
contain less than 20 parts per million of
gluten
• Gluten = wheat, rye, barley and cross-
bred hybrids (derivatives)
• Voluntary labeling claim - if labeled
“gluten-free” you must follow the
regulation
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
20 Parts Per Million
• 20 milligrams in one
kilogram
• One wheat seed in
5,000 lentils
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Is It Gluten-Free?
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Research Ingredients
• Undeclared ingredients need to be researched (Colorings,
seasonings and flavorings)
• Many companies will not make promises about their
products
• Commodity foods are difficult to have verification of
ingredient statements prior to the product arriving in your
kitchen
• Create a policy of product usage based on best practices
and FDA guidelines
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Modifying a Standard Menu
• Mirror standard menu if possible.
• Main entrées and side dishes may be easier to adapt
• Save extra portions of foods to use for gluten-free options
(rice or ground beef)
• Similar meals for special diets students creates inclusion,
confidence, pleasant experience
• Wheat/gluten substitutions: gluten-free bread, pasta, waffles,
buns, rolls
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Creating SubstitutionsStandard Menu Option
• Soft shell beef taco on flour
tortilla
• Hot Dog on Bun
• Cheesy Taco
• Chef salad with roll
Gluten-Free Option
• GF Taco – no taco
seasoning, plain ground
beef or diced chicken on
hard corn taco shell
• Hot Dog on gluten-free
bun
• Cheesy Taco – NO
OPTION
• Chef Salad with gluten-
free muffin
Standard &
Gluten-Free
Refried Beans
Shredded Lettuce
Tomato
Plum & Grapes
Peaches
Low Fat Milk
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Gluten-Free Breakfast Menu
Monday Tuesday Wednesday Thursday Friday
Cereal:
• Cinnamon
Rice Chex
• Cheerios (GF)
With Gluten free
toast (bread)-
302792 & jelly
Gluten Free
waffles- 302798
Syrup is gluten
free
Yogurt with
Gluten free muffins
(order from your
central)
Gluten free English
Muffin-(302779 with
jelly, order from
your central kitchen
Cereal:
• Cinnamon
Rice Chex
• Cheerios (GF)
With Gluten free
toast (bread)-
302792 & jelly
Lincoln Public Schools, Lincoln, NE
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Controlling Gluten Hot Spots
Courtesy of www.easyeats.com
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Gluten or allergen-containing food
transfers to gluten or allergen-free
food - PROTEIN TRANSFER
✓Production
✓Transportation
✓Storage
✓Preparation
Unsafe for those with gluten-related
disorders or food allergies
Cooking at high temperatures does
not kill gluten/allergen
Cross-Contact
© 2016 Beyond Celiac www.greatGFKitchens.org
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Bacteria and some virus transfer to food- can lead to food-borne illnesses
✓Production✓Transportation✓Storage✓Preparation
Unsafe for EVERYONE
Proper cooking can kill bacteria – some virus – limits food-borne illnesses
Cross-Contamination
© 2016 Beyond Celiac www.greatGFKitchens.org
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Cross-Contact ExamplesDirect - Indirect
• Bread knife cutting a baked potato
• Salad dressing on a salad bar
• Peanut or sun butter sandwiches – gluten cross contact (multiple
allergens)
• Tongs used for hot dogs on bun
• Gloved hands – Salad, roll – not changing gloves
• (picture or samples of purple gloves – kids see the gloves they
know you have their backs)
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Communication is Key
• Educate staff, train, again
– Focus on seriousness of conditions –
medical necessity
– Cross-contact
– Make mistake; start over
• Assign staff to special diet duty
• Build relationship with student
• Identify student with correct meal -
label
• Talk with student about what THEY like
• Attend 504 planning meeting
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Keep it Simple and Separate
• Be aware of the crumb factor; airborne
flour
• Wash hands; change gloves often
• Separate gluten & gluten-free foods, i.e.
cold & dry storage, warmers, serving
racks
• Identify best prep area for gluten-free
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
© 2016 Beyond Celiacwww.greatGFKitchens.org
Keep it Simple and Separate
• Clean & sanitize surfaces before use
• Label – menus, products, menu items, meals
• Color-code – products, meals, equipment
• Use barriers in production and for meals
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Ordering Channels for Special Diets
• Use foodservice website for purchasing and sourcing products
• Add slide of Rice Krispies
• Foodservice distributors can assist in sourcing and providing
smaller orders
• Caution using commodities (averaging used on labels, natural
foods okay)
• Parents offering to provide certain products – Check with the
Health Dept.
• Work with local grocery stores – RD’s, Big Box online ordering
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Resources
Beyond Celiac:
• Quick & Easy to Fix, Nutritious Gluten-Free Snacks
• Gluten-Free Menu Planning: Budget-Friendly Tips
• The Gluten-Free Diet
• Back-to-School Toolkit
• GREAT Schools, Colleges, & Camps program
© COPYRIGHT 2017 SCHOOL NUTRITION ASSOCIATION | #ANC17 | ATLANTA, GA
Questions?
Beckee Moreland
Director of GREAT Schools, Colleges, and Camps
Beyond Celiac
Ambler, PA
www.greatgfkitchens.org
www.beyondceliac.org