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9/14/2016
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Facts, Tools, & Tips
Deb Zwiefelhofer, RDN, LDNDLTC ‐ September 21, 2016
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Learning ObjectivesAfter completing, the learner will:
Identify the dietary needs between celiac disease, gluten sensitivity and wheat allergy.
Adjust recipes, menus and kitchens workspace to accommodate serving the gluten free diet.
Recognize the variety of resources that support gluten‐free living.
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True or False? 1. About one in every five Americans are allergic to at least one food.
2. Food labels must list all allergenic ingredients.
3. Food intolerances cause less severe reactions than food allergies.
4. Restaurant items identified as gluten free are always “safe”.
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Prevalence Clinically diagnosed Food Allergy
5% of children
4% of adults
Food Intolerance / Sensitivity
Not quantifiable
1:3 people claim issues
Allergy, Intolerance or Sensitivity? Allergy – body’s immune system reacts to a substance that it identifies as harmful
Intolerance – immune system is not directly involved but there are other adverse reactions to normally harmless substances in food
Sensitivity – A non‐allergic, non‐autoimmune reaction
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Definition ‐ Allergy Abnormal response to a ‘normal’ food
Triggered by immune system
Body produces antibody IgE
Reaction may be immediate to hours after exposure
Response ranges from mild to severe
Risk is tied to genetics
Proteins in the offending food have survived usual breakdown from cooking, stomach acids and/or digestive enzymes
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Allergic Response Response & timing unique to individual
Protein fragments are introduced and allergic reactions follow
Itching in mouth as food is eaten
Abdominal discomfort with digestion
Vomiting, diarrhea, GI pain
Allergens in bloodstream
Drop in blood pressure
Upon reaching the skin → hives, eczema
Reaching the lungs → wheezing
Oral Allergy syndrome Allergy to pollen creates an issue with raw fruits/vegetables
Localized to mouth /oral cavity and/or throat
Same item cooked is often tolerated
8 Foods cause 90% of Allergies
Milk
Eggs
Wheat
Soybeans
Peanuts
Tree Nuts
Shellfish
Fish
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BUT…….. Any food can cause an allergic reaction.
Corn, gelatin, grapes, onion, tomato, banana, apple
Stone fruits: plum, peach, nectarine, cherries
Meats: beef, chicken, mutton, pork,
Seeds: sesame, sunflower, poppy
Spices: caraway, coriander, garlic, mustard
Different countries have different “top” allergens
People can have many different types of allergies besides foods. Sometimes leading to cross‐reactions
Separating Wheat from Gluten
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Wheat Allergy Allergy to the whole protein component in wheat.
Evidenced by allergic reaction
Swelling, itching or irritation– especially around mouth
Nasal congestion
Itchy watery eyes
Difficulty breathing
Anaphylactic shock [swelling of throat, rapid heartbeat, dizziness/fainting]
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Wheat Allergy No:
Wheat
Triticale
Generally tolerated grains: Aramanth
Barley
Buckwheat
Corn
Oats
Millet
Rice
Rye
Sorghum
Quinoa
Whereis the Wheat?
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BREAKFAST
ORANGE JUICECEREAL OF CHOICEBAKED EGG OMELET
TOASTMARGARINE
JELLYCOFFEE/SUGAR/CREAMER /MILK
LUNCHITALIAN CRUSTED FISH
SOUR CREAM MASHED POTATOESSEASONED PEAS
BREAD / MARGARINERASPBERRY PARFAIT SQUARE
COFFEE/SUGAR/CREAMER/MILKGARNISH LEMON WEDGE
SLICED TURKEYKEY LARGO VEGETABLES
Definition ‐ Intolerance Intolerance / Hypersensitivity ‐ not a true allergy
Non‐IgE mediated
Not linked to genetics
Abnormal physiological response to food or food compound
Varied mechanisms of action:
Metabolic: absence of chemicals/enzymes to digest a food Lactose, fructose intolerance
GI: Inability to absorb nutrients Fructose malabsorption
Pharmacologic: natural/artificial food chemical sensitivity Salicylate, sulphites, nitrate
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Intolerance/Sensitivity Response Chronic vs. acute, less obvious
Dose / exposure dependent
Symptoms vary greatly
Skin: rash, hives, dermatitis, eczema
Respiratory: nasal congestion, sinusitis, throat irritation, asthma, cough
GI: mouth ulcers, cramping, nausea, gas, diarrhea, IBS
Anaphylaxis
What is Celiac Disease? An intolerance
Triggered by gluten in wheat (gluten), rye (hordein), and barley (secalin) in the diet
Inflammation of the small intestine mucosa
Causes malabsorption of nutrients
Sets off intestinal symptoms &/or extra‐intestinal symptoms
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Effect on Mucosal Villi
Healthy Mucosal Villi
Compromised Villi
Death of Villi
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Clinical PresentationYounger Age Onset Adult Onset
Abdominal pain, gas &
distention
Chronic diarrhea
Vomiting
Constipation
Pale, foul‐smelling or fatty stool
Weight loss
Failure to thrive/short stature
Unexplained iron ‐deficiency anemia
Bone / joint pain
Arthritis
Bone loss or osteoporosis
Depression or anxiety
Tingling numbness
Infertility and recurrent miscarriages
Dermatitis Herpetiformis
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Complications Short or long term reactions affect many body systems
Malabsorption
“Starvation”
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Gluten Generic term for the proteins found in grains and grasses
Corn and rice gluten are NOT implicated with Celiac disease
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Wheat, rye and barley and all forms of these grains or hybrids of these grains are implicated in Celiac disease
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Common Sources of Gluten
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BulgurCouscousDurum EinkornEmmerFarinaTriticaleKamut
Graham flourMatzo flour & mealSpelt/speltaWheat germWheat starchBarley malt & extractSemolinaHydrolyzed Vegetable Protein (HVP)
BranOrzoPankoSeitanUdonFaro
Common Sources of Gluten Breads and bread products
Cakes, cookies, pies
Pasta and noodles
Rice mixes
Cereal
Pancakes, waffles, sweet rolls
Tea
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Hidden Sources of Gluten Processed dairy products
Processed fruits and vegetables
Processed meats, fish, poultry
Soups and bouillon
Matzo and communion wafers
Lipstick, toothpaste, chewing gum, mints
Licorice and some candies
Breading, coating mixes, croutons, stuffing/dressing mixes
Roux, thickeners
Soy sauce, marinades
Modified food starch, malt and malt flavoring
Supplements
Medications
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Naturally Gluten‐Free Foods Plain fruits and vegetables
Plain dairy products, milk, cheeses
Fresh meat, poultry, fish, eggs, legumes, plain nuts and seeds
Rice, corn, potatoes, buckwheat, sorghum
Margarine, butter, oils, nuts, other fats
Spices (Spice blends – Read label)
Water, most coffees, some teas, juices, most sodas, wines
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Treatment Strict, life long compliance with a gluten‐free diet
Daily multivitamin with minerals
Diet education with knowledgeable RD
Label reading and product manuals
Access to gluten‐free products
Gluten free cookbooks
Support from family and advocacy groups
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Fix the Recipe Chicken Noodle SoupIngredients
1 tablespoon butter
1/2 cup chopped onion
1/2 cup chopped celery
4 (14.5 ounce) cans chicken broth
1 (14.5 ounce) can vegetable broth
1/2 pound chopped cooked chicken breast
1 1/2 cups egg noodles
1 cup sliced carrots
1/2 teaspoon dried basil
1/2 teaspoon dried oregano
salt and pepper to taste
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Gluten Sensitivity Non‐celiac gluten sensitivity
Difference clinically
Similar complaints / symptoms to celiac disease
Most often GI related
No intestinal inflammation
Does not cause long‐term damage to intestinal villi
Affects ~18 million people in US
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Celiac Disease (CD)
Gluten Sensitivity (GS)
Wheat Allergy(WA)
Time between gluten exposure & symptoms
Weeks – Years Hours – Days Minutes ‐ Hours
Pathogenesis Autoimmunity Immunity? (Innate) Allergic ImmuneResponse
HLA HLA DQ2/8 restricted(~97% positive)
Not HLA DQ2/8 restricted(50% positive)
Not HLA DQ2/8 restricted35‐40% positive)
Autoantibodies Almost always present
Always absent Always absent
Enteropathy Almost always present
Always absent Always absent
Symptoms Both intestinal and extra intestinal(indistinguishable form GS & WA with GI symptoms)
Both intestinal and extra intestinal(indistinguishableFrom CD & WA with GI symptoms)
Both intestinal and extra intestinal(indistinguishablefrom CD & GS when presenting with GI symptoms
Adapted from the book Gluten Freedom by Alessio Fasano, MD
Menu Activity
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Setting up the Gluten‐Free Kitchen Store gluten‐free products and prep equipment separate from gluten containing products / prep items.
Identify and organize an area for GF food preparation.
Designate certain appliances for use only with gluten‐free products.
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Equipment To prevent cross contamination, purchase new items and store separately.
Any rubber, plastic/acrylic or wooden utensils need a dedicated gluten‐free duplicate.
Think about:
Colanders Cutting boards
Baking pans Rubber spatula
Pastry brushes Grater or shredder
Flour sifter Rolling pin
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Equipment Review menu cycle and consider needs:
Toaster
Countertop fryer
Waffle maker
Microwave
Blender
What else?
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…more kitchen thoughts Metal small wares and china must be properly washed and sanitized
Best practices with food handling, equipment and serving.
Use wet cleaning systems
Cross contamination prevention
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Don’t Forget to Train all Staff
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ChecklistProcedure for handling food allergiesHow is person identified?
How is [all] staff informed?
Who / how are concerns addressed?
Who answers the individuals food questions?
Who [regularly] checks recipes / ingredients?
Who is trained?
What are they trained on?
Procedure for a reaction situationPost‐review of the situation to improve procedures
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Menu Activity
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Food Allergen Labeling
Consumer Protection Act
(FALCPA) of 2004
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Thou Shalt Not Hide the top 8http://www.fda.gov/Food/LabelingNutrition/FoodAllergensLabeling/GuidanceComplianceRegulatoryInformation/ucm106187.htm
Labels must list ingredients using common names Sodium caseinate (milk)
Every ingredient source from the top 8 allergens must be disclosed
Species must be declared for nuts, fish & shellfish Gluten Free rule – just came into law in 2013 NOT covered under this law
Meat, poultry & eggs fall under USDA Alcohol falls under ATTB Drugs (Rx & OTC), Cosmetics, Health & Beauty items Kosher Labeling Restaurant foods
Gluten‐Free Labeling Published Sept. 2013 Enforced August 5th 2014
“Gluten‐free”; “No Gluten”; “Free of Gluten”; Without Gluten
Means the food does NOT contain:
An ingredient that is a gluten‐containing grain
An ingredient derived from a gluten‐containing grain
Unless it has bee processed to remove the gluten
<20 ppm of gluten is threshold
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Foods Not Subject to FALCPA Raw foods
Whole fruits, vegetables
Foods approved as exempt
Molluscan shellfish
Oysters, clams, mussels, scallops
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Caveats… Any law is only as good as the ability to enforce it.
Label omission vs. commission
Imported goods – should follow rules of destination country
Label Sleuthing Know the source
USA major manufacturer
Imported vs. US based
If in doubt…
Call the manufacturer and ask
Don’t serve the item
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Voluntary Labeling How many ways can we say “maybe”?
May Contain: Peanuts
Produced on equipment that also makes product containing peanuts.
Processed in a manufacturing plant that also processes peanuts.
Produced in a facility that also handles peanuts.
This product is manufactured on equipment that also processes peanut containing products.
FOOD SHOW
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Resources Celiac Disease Foundation
www.celiac.org
Celiac Sprue Association www.csaceliac.org
Food Allergy Research & Education www.foodallergy.org
Gluten Intolerance Group www.gluten.org
National Foundation for Celiac Awarenesswww.beyondceliac.org
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References Catassi, C et al. A prospective, double‐blind, placebo‐controlled trial to
establish a safe gluten threshold for patients with celiac disease. Am J Clin Nutr. 2007; 85:160‐166.
Celiac Disease. National Digestive Disease Information Clearinghouse. US Dept of Health and Human Services. NIH Publ. No. 08‐4269 Sept. 2008
NIH Consensus Statement on Celiac Disease. NIH Consens State Sci Statements. 2004 Jun28‐30; 21(1) 1‐22.
Celiac Disease Facts and Figures. University of Chicago Celiac Disease Center. Accessed on‐line at www.CeliacDisease.net 2010.
Gluten Freedom. Alessio Fasano, MD. 2014 Wiley New York, New York.
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