Gluten-Free Food Handling: What’s Your Plan? Key Area 1 - Nutrition

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

Beckee Moreland Director of GREAT Schools Beyond Celiac Ambler, PA

Jessie Coffey, RDN, LMNT Nutrition Specialist Lincoln Public Schools Lincoln, NE

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

What is Gluten? • A protein; a tiny component of wheat, rye and barley. • It gives baked goods their structure

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

© 2016 Beyond Celiac www.greatGFKitchens.org

What is Celiac Disease? Celiac disease is a genetic autoimmune disorder triggered by the protein gluten. Symptoms before diagnosis and treatment • • • • • • • • • •

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

Treatment: 100% strict gluten-free diet © COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

© 2016 Beyond Celiac www.greatGFKitchens.org

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

© 2016 Beyond Celiac www.greatGFKitchens.org

Non-Celiac Gluten Sensitivity (NCGS) • 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 © COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

© 2016 Beyond Celiac www.greatGFKitchens.org

“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…

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

© 2016 Beyond Celiac www.greatGFKitchens.org

Who’s Eating Gluten-Free?

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

© 2016 Beyond Celiac www.greatGFKitchens.org

Most Difficult Lifestyle Situations

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

© 2016 Beyond Celiac www.greatGFKitchens.org

Impact on Relationships & Daily Life • “Unwanted Visibility” • Neglect and/or being “forgotten” • Risk-taking/not wanting to disclose the glutenfree diet • Constantly being “on call” and at-risk • Changes in social life

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

© 2016 Beyond Celiac www.greatGFKitchens.org

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

Creating Gluten-Free Options

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

© 2016 Beyond Celiac www.greatGFKitchens.org

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

Food Allergy Labeling 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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 crossbred hybrids (derivatives) • Voluntary labeling claim - if labeled “gluten-free” you must follow the regulation

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

20 Parts Per Million • 20 milligrams in one kilogram • One wheat seed in 5,000 sorghum seeds

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

Is it gluten-free?

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

Creating Substitutions Standard Menu Option • Soft shell beef taco on flour tortilla • Hot Dog on Bun • Cheesy Taco • Chef salad with roll Standard & Gluten-free: Refried Beans Shredded Lettuce Tomato

Plum & Grapes Peaches Low Fat Milk

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

Gluten Free Breakfast Menu Monday

Tuesday

Cereal:  Cinnamon Gluten Free Rice Chex waffles- 302798  Cheerios (GF) Syrup is gluten With Gluten free free toast (bread)302792 & jelly

Wednesday

Yogurt with Gluten free muffins (order from your central)

Lincoln Public Schools, Lincoln, NE © COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

Thursday

Gluten free English Muffin(302779 with jelly, order from your central kitchen

Friday

Cereal:  Cinnamon Rice Chex  Cheerios (GF) With Gluten free toast (bread)302792 & jelly

Controlling Gluten Hot Spots

Courtesy of www.easyeats.com

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

Cross-Contact 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

© 2016 Beyond Celiac www.greatGFKitchens.org

Cross-Contamination 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

© 2016 Beyond Celiac www.greatGFKitchens.org

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

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

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

© 2016 Beyond Celiac www.greatGFKitchens.org

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

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 Lincoln Public Schools: • K-5 - Gluten-Free Menu – August 2016

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS

Questions? Beckee Moreland, Director of GREAT Schools Beyond Celiac, Ambler, PA [email protected]

Jessie Coffey, Nutrition Specialist Lincoln Public Schools, Lincoln, NE [email protected]

© COPYRIGHT 2016 SCHOOL NUTRITION ASSOCIATION – #ANC16 – SAN ANTONIO, TEXAS