Residential/Health Care Facilities
Food Avoidance/Gluten Free
Success
RD’s have a leadership role in health management

Celiac Disease prevalence and awareness
 Food avoidance- Food allergy
 Menu Design/Food Service
Ronni Alicea MBA RDN CSG
 Gluten Free Diet management
rdronni@optonline.net
1 out of 3 people say they modify
their diets because they, or a loved
one, have a food intolerance/allergy
www.Niaid.nih.gov
~110,000,000 people,
70% of people over 65 can expect to
use residential care
longtermcare.gov
2
Conclusion: The prevalence of celiac
disease was high in elderly people, but the
symptoms were subtle….. Increased
alertness to the disorder is therefore
warranted.
Vilppula A et al. Undetected coeliac disease in the
elderly: a biopsy-proven population-based study.
Digestive and Liver Diseases 2008;40:809-13
§483.35 /Dietary Services
(e) Therapeutic Diet (LTC)
F325
 §483.25(i)(2) Receives a therapeutic diet
when there is a nutritional problem.
Maintains acceptable parameters of
nutritional status, such as body weight and
protein levels, unless the resident’s clinical
condition demonstrates that this is not
possible
483.35 Dietary Services
(d) Food
 F365
Food prepared in a form designed to
meet individual need
 F366
Substitutes offered of similar nutritive
value to residents who refuse food served

A food Substitute should be consistent with
the usual and ordinary food items provided
FNC Food Allergy and
Intolerance
6
Resident Choice
 See
Residents Rights at 42 CFR 483.10
(b)(3) and (4) and F 154 and F155
‘In order for a resident to exercise his/her
right appropriately to make informed
choices … consequences of refusing
treatment….. When allergies are in the
medical record, a medical note is needed
if
‘allergy
to
food’
is
to
be
served.
FNC Food Allergy and
Intolerance
8
Assess
food delivery
systems
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Facility
Training
Admin support
Tray Accuracy
Cross contamination
Kitchen training
Check your Policy: Therapeutic Diets
Therapeutic diets are prepared and served
as prescribed by the attending physician.
Therapeutic diets are planned and are on
menu extensions.
Check there is a solid policy for like
substitutions. Many with gluten/dairy
restrictions will want their favorite brand!
10
Food, personal
products and crafts
may cause reactions
Interdepartmental
F- tag
Potential
Facility Mission
Statement
Liability
Admin support
Satisfaction
Survey’s
3 Million Celiac
11
Food
Intolerances
Allergy
Non-immunologic
Sensitivity/Intolerances
Metabolic
Disorders
False food Allerg
Idiosyncratic
Lactose Intolerance
Sulfites
Inborn Errors
Gluten IIntolerance
Caffeine
Alcohol
MSG
Pharmacologic
IgE Mediated
T-cell Mediated
Big 8 Allergens
Celiac Disease
Food colors
160 foods
Cow’s Milk / soya
Allergy
Gluten Intolerance
Latex
12
Food
Avoidance
Food
Aversion
Intolerance
Allergy
(Immune)
13
No Milk
Dairy Allergy
Milk free
Lactose Free
Food Aversion
I do not like milk
I am Vegan
Intolerance
May not drink milk but
uses Lactose Free milk
eats yogurt and cheese
Allergy
No Casein, Whey
Or Lactose
An in-depth food preference interview is needed to help your kitchen be successful
Follow the most strict diet order until individualized!
14
xxxxxxxxxxxxxxxx
XXXXXXXXX
People and Professionals may use different words to describe food avoidance
Food Aversion






Phobia’s
Food Preferences
Vegan, Kosher, Halal
Food Fad’s
Clockwork orange conditioning
Disordered eating
 What’s
your most unusual one?
FNC Food Allergy and
Intolerance
16
Allergies are to proteins

Gal d 6 is the second allergen characterized from egg yolk.
Only one allergen from the egg yolk, alpha-livetin (Gal d 5) has been
described thus far. A new egg yolk allergen was detected studying 27 egg
allergic patients. 5 of the 27 patients (18%) detected a yolk allergen of an
apparent molecular weight of 35 kDa. Heating and reduction treatments did
not affect its allergenicity, although digestion with simulated gastric fluid
diminished the IgE-binding capacity of the allergen. The N-terminal amino
acid sequence corresponded with the YGP42 protein, a fragment of the
vitellogenin-1 precursor. The allergen was designated Gal d 6.

Amo A, Rodríguez-Pérez R, Blanco J, Villota J, Juste S, Moneo I, Caballero ML.
Gal d 6 is the second allergen characterized from egg yolk.
J Agric Food Chem 2010 Jun 23;58(12):7453-7.
17
FNC Food Allergy and
Intolerance
18
Metabolic intolerance
 Favism
 Trehalose
insufficiency
 Pancreatic dysfunction
 Inborn Errors of Metabolism
 Damage to enzyme producing cells can
cause secondary Intolerances
 Histamine intolerance: reduced activity of
diamine oxidase (DAO).
FNC Food Allergy and
Intolerance
19
Digestive Enzymes and source





Mouth: ∂ amylase
Stomach: pepsins
Pancreas: amylase,
lipase and Proteases
Gall Bladder: Bile
Brush Border











Lactase
∂ glucosidase
β galactosidase
Sucrase-Isomaltase
Amino-ogliopeptidase
FNC Food Allergy and
Intolerance



20
Starch ∂ 1 →4 bonds
Protein
dextrin, triglycerides
Peptides
Fat micelle formation
Lactose→glu + gal
∂ 1 →4 bonds ∂ 1→6 bonds
Sucrose → glu & fru
maltose → glu & glu
Removal of N terminal aa’s
Why is GF so popular?
Food
Avoidance
Gluten/Wheat
Food Aversion
High Protein Diet
Fad Diet
Intolerance
May limit pasta and
bread due to
digestive discomfort
Allergy/Celiac
Wheat Free is
Not Gluten Free
Population screened
13,145
Healthy Individuals
4126
Risk Groups
9019
Symptomatic subjects
3236
Positive
31
Negative
4095
Prevalence
1:132
Positive
81
Negative
3155
Prevalence
1:40
1st degree relatives
4508
Positive
205
Negative
4303
Prevalence
1:22
2nd degree relatives
1275
Positive
33
Prevalence
1:39
Projected number of celiacs in the U.S.A.: 3.3 million
Center for Celiac Research Epidemiologic Study in USA
Arch Int Med 163:286-292, 2003 Fasano et al.
Negative
1242
Celiac disease is an immune reaction to proteins found in wheat (Gliadin),
rye (secalin) and barley (hordein) collectively known as gluten. Other
grains have proteins that food scientists call gluten that are not avoided on
physician ordered gluten-free diets, important for pharmacy calls.
A. Fasano and T. Shea Donohue, Nature Clin Pract Gastroenterol Hepatol 2005 (in press)
FNC Food Allergy and
Intolerance
25
World Gastroenterology
Organization Practice Guidelines:
Celiac Disease

Associated conditions




Malignant disease
Osteoporosis
Autoimmune disorders
Such disorders include:







• Insulin-dependent type 1 diabetes
• Thyroid disease
• Sjögren’s syndrome
• Addison’s disease
• Autoimmune liver disease
• Cardiomyopathy
• Neurological disorders
Detection of Celiac Disease in Primary Care:
A Multicenter Case-Finding Study in North America
Carlo Catassi, M.D., M.P.H.,
CD was diagnosed in 22 out of 976 investigated patients
The most frequent reasons for CD screening
bloating (12/22)
thyroid disease(11/22),
irritable bowel syndrome (IBS) (7/22),
unexplained chronic diarrhea (6/22),
chronic fatigue (5/22),
and constipation(4/22).
The small bowel biopsy was available in 15 out of 22
GFD was implemented in 17 out of 22 cases.
American Journal of Gastroenterology ISSN 0002-9270
2007 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2007.01173.x
Classic GI Presentation
HF: 86 YO WF admitted to sub-acute care unit for
DX: Deconditioned post hospitalization for syncope and collapse.





Persistent Diarrhea ċ c-dif negative, anemia of
chronic disease
Admit wt 112 # family stated UBW 125
5’3
Wt loss ~13# past quarter (90% UBW)
Increased confusion, poor po of regular diet and
supplements (2Cal product 120 mL QID)
Decreased H/H, BUN 32, Cr .5, GFR WNL
GI consult ordered, admitted to the hospital
HF: 86 YO WF
Readmit new dx: Celiac Disease
DO: Regular
Facility MD resistant to diet change due to age
Family meeting: Changed to gluten-free diet order
Therapeutic vitamin (strovite plus), Iron support
Nutritional supplements (2-Cal/mL 120 mL QID)
Weight gain, increased participation in activities and
Physical therapy and resolved diarrhea
Discharged back to the Assisted Living in 15 weeks
at 120 pounds, PO 50-75%, 8 oz 1 cal/mL drink
Today’s dietitian April 2007 vol 9 no 4 Long term care concerns feature for
©2007 Becky Dorner & Associates, Inc.
LN admitted sub acute 02/2008

Diagnosis




MS
Multiple stage III & IV
Anemia
constipation

Weight Loss 30# in 3 years
5’3 admitted 97# UBW 110
 Diet History :


2000 cal daily (45cal/kg)
Labs: Hydration normal


Alb 2.7 Ca++ 8.3
H/H 8.3/2.7
LN: Cal count results
45kcal /kg 1.8 g protein/kg
WT: 98#
Requested ‘Celiac panel’,
total IGA and Vit D
Lab results:
Reticulin IgA WNL
EMA WNL,
Gliadin IgA WNL
Gliadin IgG WNL
MD concluded negative for celiac
ww.celiac.nih.gov
LN continued



Went home and was readmitted to the
hospital with respiratory distress.
Was to return to the sub-acute
53 YO with weight loss despite a hearty
appetite died of respiratory failure
Celiac panel inconclusive: no total IgA
Recommendations for practice

Call lab and ask for lab numbers for Total IgA
and tTG instead of the ‘celiac panel’


Acculab in NJ total IgA # 1029
Acculab in NJ tTG # 1506
Less expensive test ideal for screening
 With results seek GI referral. Will justify
EGD when presented with extraintestional
symptoms

LL admitted 01/2008
Nutrition Plan of Care:

Diagnosis





Diet History :





Syncope and Collapse
Pneumonia
Anemia
Celiac Disease
Gluten Free Diet 20
years
Lived with niece due
to mental deficit
Rice Krispee’s AM
Communion (regular)
Labs: As expected
1- Review GF diet with
Kitchen
2- Review facility GF
diet with resident
and Family
3- Give Activities GF
hosts for Pastor to
bless
4- Meet Nutrition needs
as assessed
Assess
food delivery
systems
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Facility
Training
Admin support
Tray Accuracy
Cross contamination
Kitchen training
Communication channels:
Dietary: Clinical and Food Service
Nursing Functions: med pass/ HS snacks
Activities: Rehab Therapies
Other: Chaplin; Pharmacy; IT department
Administration support
needed for
Interdepartmental
communication to be
successful
Religious Needs

Low-Gluten Hosts


1-800-223-2772
www.benedictinesisters.org
Matzo


www.glutenfreematzo.com
Made from GF Oats
CMS INTENT: §483.25(i) 325
Nutritional Status uses Celiac
Disease example:
A
resident with known celiac disease
(damage to the small intestine related to
gluten allergy) develops persistent
gastrointestinal symptoms including weight
loss, chronic diarrhea, and vomiting, due
to the facility's failure to provide a glutenfree diet (i.e., one free of wheat, barley,
and rye products) as prescribed by the
physician.
Standardize
diet orders
Admin support
Check the Diet Manual!!!!!
misinformation
‘ Read all labels carefully. Many ingredients contain gluten but
may not list it as such. Avoid: commercial products or
mixes containing malt or malt flavorings, textured
vegetable protein, hydrolyzed vegetable protein, cereal
products, flour, starch, wheat, rye, barley, oat, farina,
semolina, durum, triticale, gums, emulsifier ….
MENU PLANNING GUIDELINES:
stabilizers, vinegar, artificial colors or flavors, some
monosodium glutamate, vanilla.
What’s up with this statement in the manual guidelines?
Use of soy products should be individually evaluated. Millet and
buckwheat may not be tolerated by some.
Standard
All DO’s
Gluten Free
Celiac, wheat allergy, wheat No Wheat, rye, barley aka
free, no bread
malt, spelt or oats
Dairy Free
No Milk, Milk or diary
allergy, Casein Free
Lactose Free
Lactose Intolerance, lactose Food preferences may have
free, low Lactose
milk protein (casein & whey)
e.g. coffee creamers
Egg Free
Egg allergy, no Eggs
No egg ingredients
No egg substitutes
Peanut/tree nut free
Peanut allergy, nut allergy,
no seeds or nuts
No nuts/peanuts including
their oils
Soy-Free
Soy allergy, no soy
No soy ingredients. Soy oil
and lecithin allowed unless
specified
Additive-Free
Feingold diet, sulfite, MAO
MSG, asthma diet
No additives: low sulfite,
Salicylates, tyramine
Latex Free
Any diet with latex allergy
Identified in chart
No latex gloves around food
or tray, no banana, kiwi,
avocado, chestnuts
Policy until individualized
No animal milk: Lactose,
Casein, whey ingredients
Worcestershire Sauce
 Ingredients:
distilled white
vinegar, molasses, water, sugar,
onions, anchovies, salt, garlic,
cloves, tamarind extract, natural
flavorings, chili pepper extract.
Contains anchovies.
45
Dairy allergy Diets Eliminate

Casein
Whey
lactose








Fluid Milk
Ingredient Milk
Cream
Butter
Check All processed foods
Cream Soup
Cheese
Yogurt
Check non-dairy creamer
(sodium caseinates)
46
FDA definition gluten free
< less then 20 PPM in finished goods
One slice of regular bread has 124,000 PPM
One slice of gluten free bread usually < 5 PPM
Claims for food service are encouraged to
follow FDA regulation for manufacturers
TIP: Use ‘ Gluten-restricted’ as term
Use gluten-free ingredients or TEST.
Daily intake of Carbs and ppm of
gluten in food for celiacs
50 g
100 g
200 g
300 g
200 ppm
10 mg
20 mg
40 mg
60 mg
100 ppm
5 mg
10 mg
20 mg
30 mg
50 ppm
2.5 mg
5 mg
10 mg
15 mg
20 ppm
1 mg
2 mg
4 mg
6 mg
www.tastelikerealfood.com

NET WT 14.7 oz. (417g) Makes 1 loaf.
Mix contains less than 20 ppm total
gluten content, which is considered
gluten-free according to the Codex
Alimentarius, the European food safety
standard.
Ingredients SPECIALLY
FORMULATED WHEAT STARCH*,
BUCKWHEAT (WHOLE GRAIN AND
FLOUR), PRECOOKED RICE FLOUR,
GLUCOSE, BEET FIBER, POTATO
FIBER, SESAME SEEDS, POTATO
STARCH, STABILIZER (E464), SALT,
RICE STARCH, VEGETABLE FAT
(PALM OIL), RAISING AGENT
(CALCIUM PHOSPHATE, SODIUM
HYDROGEN CARBONATE),
THICKENING AGENT (XANTHAN
GUM).
Meal Service
system
Standardize
diet orders
Admin support
Assess Food Service Systems
 Review



your system and risks
Tray Line Plate
Buffet Style
Room Service cook to order
 Snack
carts, Floor Stock and Activities
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Standardize
diet orders
Admin support
§483.35 Dietary Services
(c) Standard Menus/Adequacy

F 363 Probe (c) (1)
If a food group is missing from the resident’s daily diet, does
the facility have an alternative means of satisfying the
resident’s nutrient needs.

F 363 Probe (c) (3)
Is food served as planned?
Specifics help the
production staff
Facility
Knowledge:
FSD first GF
resident was
from the UK.
They requested
Rice Krispees…
on the UK list of
‘allowed’ prior to
2008.
56
Menu Analysis: Food Allergy
extension
Recipe #
Menu item
name
Do Not
Serve
Do not serve
Do not serve
Do not serve
Do not serve
Dairy
allergy
Egg Allergy
Fin Fish allergy
gluten reduced
Lactose reduced peanut/nut free
Do no serve
Do not serve
Do not serve
Seafood Free
Shellfish allergy
Juice of
1 Choice
2Cold Cereal
(Chex Cereal only)
3Oatmeal
? Made with milk?
(Cream rice only)
? Made with milk?
4Farina
? Made with milk?
(Cream rice only)
? Made with milk?
5Cream of Rice ? Made with milk?
Scrambled
6 Egg
? Made with milk?
? Made
with milk? ( Greek yogurt or
other 7 gram protein
7Bacon
8Toast
? Made with milk? Made with
egg?
9Milk
Soy, almond milk
Tuna Salad
10 Sandwich
11 beef Pot Pie
? Milk in
dressing
? Mayo
(Gluten Free bread)
lactose reduced
Ham salad
(gluten free bread
Serve Beef stew if
flour not used or
Worchester sauce? beef stir fry on rice
ham salad
57
Foods that contain:
_____Gluten/wheat__________________
Recipe # Sub with:
1.__white/rye/toast/rolls__________ Sub_ gluten-free bread or fruit cup_
2.__Muffins/croissants____________ Sub__gluten-free muffin or fruit cup
3. _pancake/waffle _______________ Sub __gluten-free pancake
4.__blintz__________________
_ Sub ___omelet_______
5._______________________ Sub ____________________
6.______________________ Sub____________________
7.______________________ Sub____________________
8. ______________________ Sub ____________________
9.______________________ Sub ____________________
Cheat sheets can assist departments
58
Oven Fried chicken
Baked Chicken Breast
- GF gravy
Rice Pilaf
Buttered Beets
White Rice
- GF Soy Sauce
Buttered Beets
Dinner Roll
GF Microwave Cornbread
Margarine
Margarine
Lemon Meringue Pie
Lemon Pudding on
GF Microwave Biscuit
Whipped Cream
CONTAINS BARLEY
Rice Chex are Gluten Free
The barley has been
replaced with Molasses!
60
Watch Gravy and bacon bits

Gluten Free Stock
Certified:




Limit Cross Contamination!
Make GF gravy
portion, label and freeze
Celinal Foods
Cuisine Santé (HACO)
RC Fine Foods
Read all labels for
ingredients: recipes
can change on noncertified food.
All Wheat Flour is Enriched

Thiamin

Riboflavin

Niacin

Iron

Folate

GF products usually are
not fortified
Field to Plate: 0ats
64
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Admin support

Ingredients: Enriched flour (wheat flour,
malted barley, niacin, reduced iron, thiamin
mononitrate, riboflavin, folic acid), sugar,
partially hydrogenated soybean oil, and/or
cottonseed oil, high fructose corn syrup, whey
(milk), eggs, vanilla, natural and artificial
flavoring) salt, leavening (sodium acid
pyrophosphate, monocalcium phosphate),
lecithin (soy), mono-and diglycerides
(emulsifier)
 OR
Contains wheat, milk, egg and soy ingredients
FALCPA
 FDA advised
that advisory labeling such
as "may contain [allergen]" should not be
used as a substitute for adherence to
current Good Manufacturing Practices
(cGMPs). In addition, any advisory
statement such as "may contain [allergen]"
must be truthful and not misleading.
 Fines
attached for non-compliance
WHEAT FREE
IS NOT GLUTEN FREE!
 Made
in plant with Wheat- GMP
 Shared
Equipment : GMP more difficult
CONTAINS BARLEY
Rice Chex are Gluten Free
The barley has been
replaced with Molasses!
Certification/ Dedicated
Plants
Recognized by
Ingredients on lists to Question
Modified Food
Starch*
 Citric Acid*





need to ask if using
imported
Caramel Coloring*
 Flavoring*
 Dextrin*
Soy Sauce
often contains wheat
Mono and Diglycerides
may have a wheat carrier
when used in dry
ingredients but it should
be declared
Brown Rice Syrup
 may be made from
barley



* By definition may contain wheat but US manufactures
say they are not using gluten containing grains
Other Concerns
 Where


to purchase?
Distributor: May stock or Special Order
Local Grocery: Keep Receipts!
 Check
Labels Each Time!
 Store
High if possible
 Label
book for reference
Plan meals and snacks
Assess production ability: make or buy
Assess product availability: Distributor
Nutritionally Adequate
Assess Other Departments Food Needs
Include all Therapeutic and Consistency
Don’t forget the disaster menu
F 371
 Store,
prepare distribute and serve food
under sanitary conditions;


Reduce the practices which result in food
contamination
Store GF foods higher then flour bins and
away from mixes
- Wrap, date and Identify clearly
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Admin support
Cross contamination
Kitchen training
LL admitted 01/2008 2 weeks later

Diagnosis



Add persistent
diarrhea
Benign pancreatic
mass
Diet



Facility Gluten Free
Diet
No Outside snacks
Communion (lowgluten)
Plan of Care:
1- Review GF diet with
Kitchen
2- MD to evaluate
Pancreatic Mass
for change
3- R/O C- Diff
4- Nurses to check
medications with
pharmacy
Crumbs Count
Double Dipping
Trouble hot spots
Flour and rice scoop stored
together
No Ingredient
statement
The Kitchen
There are no scientific studies to evaluate cleaning
practices or methods
Food Allergy News suggestions
1- Warm soapy water
2- Fresh cloth or paper towel to wipe
3- Prep the special diet foods first
4- Wrap and Identify clearly
Ongoing Inservice
Education
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Admin support
Tray Accuracy
Cross contamination
Kitchen training
Right Tray, Right Person

Visual cues



Tray color
napkin color
Icon

Tray ticket color

Privacy rights
XXXXX
What if Everything was perfect:
except the roll?
Prepare for Kitchen Training
Rewrite inservices to include an allergy
component for continued reinforcement
Topics to update:
Sanitation, Inventory storage, Food preparation
Tray line Services, Therapeutic Diets, Food Safety
Mechanically Altered, Residents Rights
Food Allergy Kitchen Protocol
Follow Recipes
Allergen trays prepared first
Equipment and work surfaces will be cleaned before use
with a fresh cloth or paper towel.
Clean and Sanitized utensils to be used in food
production and portioning.
Label read every time unless specific claim made on the
label
Food can not be fixed…. start over
Meal delivery
system
Plan Menu
Plan Nourishments
Plan Snacks
Buy and
store food
Standardize
diet orders
Admin support
Tray delivery
feeding assts
Therapists
Tray Accuracy
Cross contamination
Kitchen training
October 31, 2008
By DAVID GIALANELLA Staff Writer
Prosecutors said Thursday they are reviewing the case of an Elgin Mental
Health Center patient who died months ago
after two facility employees allegedly gave him
a meal containing fish despite a severe fish
allergy.
Morris Howard, 58, formerly of Chicago, died on June 20 after the employees gave him the meal, which
A coroner's jury on
Wednesday ruled the death a reckless homicide.
investigators said sent him into anaphylactic shock.
Illinois State Police investigators earlier this week handed the case off to the Kane County State's Attorney's Office, and
criminal charges against the employees could be announced in the coming days, according to State's Attorney John Barsanti
.
Barriers to Compliance
 Daily
Lifestyle Challenges
 Quality of Life Issues
 Limited Cooking availability and/or skill
 Not Convenient
 Costly
 Misinformation
 Psych-Social Challenges
 Knowledge Deficit of suitable substitutions
LB CCRC DNR DNH resident in Skilled Nursing

Diagnosis








Alzheimer’s Disease
Osteoporosis
Depression
Hypercholestermia
4/2009 WT 122 BMI 19.5
DO: Gluten-Free POS: allergy:
wheat
5/2009 WT 120 RD selected
menu for resident for GF status
6/2009 WT 115 (new MDS
significant change) Supplement
2cal/mL and magic cups
Vitamin not ordered after call to
pharmacy no GF guarantee.
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7/2009 WT 113
8/2009 WT 114 (husband admitted
to share room)
9/2009 WT 115-118
10/2009 WT 120
11/2009 WT 118-120
12/2009 weight gain started 124
7/2010 Wt 133- nurses are
concerned due to acute decrease
in PO. No GI distress reported.
Resident states: ‘I eat gluten-free
foods: no bread or pasta’
Strovite Plus Vitamin ordered
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Celiac panel ordered
LB CCRC DNR DNH resident in Skilled Nursing
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Reticulin IgA WNL
 Endomysial IgA WNL
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Gliadin IgG 15.8 H
 Gliadin IgA 13.2 H

Labs inconclusive
would need an EGD
to confirm celiac
disease at this time.
LB CCRC DNR DNH resident in Skilled Nursing
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Diagnosis
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Alzheimer’s Disease
Osteoporosis
Depression
Hypercholestermia
4/2009 WT 122 BMI 19.5
DO: Gluten-Free POS:
allergy: wheat
8/2010 WT 136. RD/RN
charting on overt intake of
gluten containing food
between meals. (husbands
PB&J HS snack). PO
improving, seeking food
items. No GI distress
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9/2010 134
10/2010 135
11/2010 supplement d/c'd
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DO continued Gluten-Free.
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Recommend to change to
regular diet with RD selecting
gluten-free meals as
preference 2° to behavior
and clinical presentation.

www.glutenfreedrugs.com to
review medications as
needed.
GF resident admitted
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Review diet management with kitchen
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Review diet order rational with nursing/caregivers
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Review religious needs with activities. Review
with other departments as needed: speech
therapy screens no crackers.
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Request baseline tTG for monitoring on
admission with known celiac residents.
Management Musts
All therapeutic diets should be in the diet
manuals. Road map for staff success.
Policy for purchasing foods for ‘free-of’ diet
requests. (Therapeutic diet vs preferences)
If allergen food requested (Resident Rights)
written medical approval is required.
98
Resources & Web Sites

Gluten-Free Diet: A Comprehensive Resource Guide - Shelley Case

The Celiac Diet, Series 1-7 Carol Rees Parshi MS RD

http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/resources.cfm

Evidence Based Standards of Practice
http://celiac.nih.gov
www.eatright.org manual of clinical dietetics
AGA Institute Medical Position Statement on the DX and Mngt of Celiac Disease:
Gastroenterology 2006;131:1977-1980

Center for Celiac Research

www.celiaccenter.org

Steve Plogsted’s medication list

www.glutenfreedrugs.com

Local Support Groups: CSA, GIG,CDF, Independents

rdronni@optonline.net

Religious resource


www.glutenfreediet.ca
altarbreads@benedictinesisters.org, http://glutenfreematzo.com
Allergen Food for Institutions mailorder

www.celinalfoods.com (also available thru Gordon Food Service)
www.med-diet.com
Celiac Disease and the aged: limited clinical studies
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Murray JA. Et al. Morbidity and mortality among older
individuals with undiagnosed celiac disease.
Gastroenterology. 2010 Sep;139(3):763-9
Collin P et al. Increasing Prevalence and high incidence of celiac
disease in elderly people: A population-based study. BMC
Gastroenterology 2009; 9:49
Vilppula A et al. Undetected coeliac disease in the elderly: a biopsyproven population-based study. Digestive and Liver Diseases
2008;40:809-13.
Lurie Y et al. Celiac disease diagnosed in the elderly. Journal of
Clinical Gastroenterology 2008;42:59-61
Hu WT et al. Cognitive impairment and celiac disease. Archives of
Neurology 2006;63:1440-46.
Hankey GL, Holmes GK. Coeliac disease in the elderly. Gut
1994;35:65-67.