It’s a piece of cake
How Certified Dietary Managers can
ensure that they are serving gluten
free meals
Roberta Tripp MS RD LDN
Clinical Nutrition Manager
Sodexo at PinnacleHealth
Harrisburg PA
Objectives
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To provide more in depth knowledge to CDMs who
already have a basic knowledge of gluten intolerance
and celiac disease
To discuss which residents may be on a gluten free diet
in addition to those with diagnosed celiac disease.
To explain about the special products, cooking and
serving procedures involved
To provide a list of resources for use when working with
residents on a gluten free diet.
To help CDMs do a better job of ensuring no cross
contamination occurs in their kitchens when they must
ensure a patient receives gluten free food
Definition of Celiac Disease

An immune-mediated disease triggered by the
ingestion of gluten-containing grains (wheat, rye,
barley) in genetically susceptible individuals.
 In celiac disease gluten causes damage to the
small intestine which affects its ability to absorb
nutrients.
Gluten
 Gluten,
a protein found in wheat, barley,
and rye, forms when water is added and
the protein molecules glutanin and gliadin
combine.
 Gluten gives dough its sticky and pliable
consistency.
It Takes A Villi
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Damaged
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Healthy
Can any amount of gluten be
harmful?

As of October 2009 there is no safe level of
gluten yet established for people with celiac
disease. Sensitivity may vary but as far as food
preparation and service are concerned, even
very small amounts of gluten can be harmful.

Catassi and colleagues (Am J Clin Nutr 2007;
85:160-166) found no significant change in
villous height/crypt depth ratio in participants
consuming 10 mg gluten per day
Classic Adult Onset Symptoms
 Diarrhea
 Constipation
 Gas
and bloating
 Abdominal pain
 Nausea and vomiting
 Reflux
Atypical Adult Onset Symptoms
 Anemia
 Bone
and joint pain
 Osteoporosis/osteopenia
 Chronic hepatitis
 Infertility/recurrent miscarriages
 Mouth ulcers
Symptoms in Children
 Delayed
puberty
 Dental enamel defects
 Diarrhea/constipation
 Difficulty in learning
 Failure to thrive
 Short Stature
Autoimmune Disorders Associated
with Celiac Disease
 Autoimmune
hepatitis
 Down’s syndrome, IBD, Crohns Disease
 Rheumatoid Arthritis
 Sjogren’s Syndrome
 Thyroid Disease
 Type I diabetes
Intestinal Cancer and Celiac
Disease
A type of non Hodgkins
lymphoma that develops in the
small bowel is one of the most
common causes of death in
people with celiac disease.
“The Hidden Epidemic”
 The
title of Dr. Peter H. Green’s book
“Celiac Disease: The Hidden Epidemic”
serves as an unfortunate answer to the
question “If there are so many people with
gluten intolerance and celiac disease,
where are they?” It has been estimated
that 97% of people with celiac disease
don’t know they have it.
The average celiac goes eleven
years prior to being diagnosed
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Symptoms such as diarrhea, gas, bloating, and
abdominal pain are often wrongly diagnosed as
irritable bowel syndrome (and ironically, patients
are told to “eat more fiber”, which usually
translates to whole wheat and bran!)
Not everyone who avoids gluten
has celiac disease
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At least 1 out of every 133 people have celiac disease in
the US (3 million people)
As many as 13 million people have other forms of gluten
sensitivity
Approximately 6 million people claim to have a wheat
allergy in this country
Therefore the total number of people who need to follow
a GF diet could be as high as 22 million in the United
States (about 1 out of every 13 people).
Parents of children with Autism Spectrum Disorder may
want the child on a gluten free (and casein free) diet
even though this approach to treating ASD is unproven.
What Grains are Gluten Free?
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Amaranth
Arrowroot
Buckwheat
Corn
Flax
Millet
Montina
Potato
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Quinoa
Rice
Sorghum
Tapioca
Teff
Flours made from
nuts, seeds, and
beans (garfava, soy
flour)
What About Oats?

Oats that are uncontaminated by gluten
containing grains are usually tolerated by
individuals with celiac disease or gluten
intolerance.
 The recommendation is to introduce oats
gradually and slowly into the gluten free diet
after consulting your physician.
 These certified gluten free oats are available
from 4 suppliers in North America
(www.bobsredmill.com,
www.glutenfreeoats.com,
 www.onlyoats.com and
www.creamhillestates.com)
Surprisingly gluten free
 MSG
 Corn
gluten
 Vegetable broth
 Glutinous rice
Food labels: you’re confusing
me with the facts
 In
the US, foods are either under the
jurisdiction of the Food and Drug
Administration (FDA) or the USDA FSIS
(United States Department of Agriculture
Food Safety and Inspection Service).
 The FDA regulates all foods except meat,
poultry, and egg products, which are under
FSIS jurisdiction.
 Each of these agencies has different
policies regarding food labeling.
FDA’s Food Allergens
Labeling and
Consumer Protection Act
(FALCPA)
•In 2004, the Food and Drug Administration,
which regulates most of the food supply,
enacted a new a regulation known as
FALCPA that requires that 8 known allergens,
including wheat, be declared in plain English
terms on the label of all packaged goods they
regulate.
Because of FALCPA, in FDA
regulated foods, you don’t have
to worry about…
Modified food starch
 In
the US and Canada if a food starch in
an FDA regulated food is made from
wheat the label would have to say so
 Rye
and barley are not used to make food
starch
Maltodextrin, dextrin, or hydrolyzed
vegetable protein
 If
any of these are made from wheat
the ingredient list would have to state
this fact (in the US and Canada).
Vinegar or Alcohol
Distillation proteins are too large to
pass through the distillation process
(this includes gluten).
All vinegars are distilled and are
therefore gluten free except Malt
Vinegar (has added malt from barley)
USDA Regulation
•Foods regulated by the USDA FSIS (meat,
poultry, and processed egg products) are not
covered by this regulation and therefore
could contain hidden gluten from wheat.
•Neither agency has to disclose barley, oats,
or rye on an ingredient label.
USDA Rule
 To
be consistent with FALCPA, the USDA’s
Food Safety and Inspection Service is
undertaking rulemaking to adopt the
FALCPA requirements for the products it
regulates. Currently FSIS permits
voluntary allergens labeling.
Labeling requirements for
allergens to extend to meat,
poultry, and egg products

When the USDA regulation is enacted, labels on
meat, poultry, and egg products regulated by
FSIS will be required to state if wheat is an
ingredient.
 Presently it is recommended that the
manufacturer be contacted if there are any
ingredients listed on meat, poultry, or egg
products that are questionable to make sure
they come from a gluten free source.
It’s wheat free, but is it gluten
free?
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At this time there is no universally
agreed upon definition of the term
“gluten free”.
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The FDA is working on defining this
term.
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The proposed FDA rule says that
gluten free foods must contain less
than 20 parts per million gluten.
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10 ounces of grain foods containing
20 ppm gluten would contain 5.70
mg gluten.
Foods from Europe
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Codex, the organization responsible for
regulations regarding food labeled
“gluten-free” in many European countries,
has finalized a rule that these foods,
including those made from wheat starch,
will contain no more than 20 parts per
million gluten.
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For gluten-free foods containing wheat
starch this is a much lower amount than
the previously allowed amount of 200 and
100 parts per million gluten.
Ingredients Worth
Questioning
Soup, bouillon, broth, and
soup base
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Soup and stocks (including au jus, broth, and
bouillon) may contain gluten so ingredients
should always be checked.
Some soups are USDA regulated so wheat
might not be disclosed on the label—check
with the company.
Soy Sauce
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Soy sauce usually contains wheat in addition
to soy, and therefore may contain gluten.
Check the label.
If a non-FDA regulated product contains soy
sauce (Chinese take out food, for example) it
would not have to state it contains wheat if it
did.
Spices and Seasonings
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Pure spices and herbs are gluten free
Seasoning blends may contain gluten from
anti-caking or flow agents. If these additives
are present it will be clearly labeled on the
package if they are derived from wheat and
should therefore be avoided.
Talking Turkey
 Because
fresh and frozen turkeys are
under jurisdiction of the USDA, any
injected basting solution containing gluten
would not have to be disclosed on the
label
 It is recommended to contact the company
to verify the turkey’s gluten free status.
Don’t be so crabby
 Imitation
seafood (surimi or “Sea Legs”)
contains wheat but since it is a USDA
regulated food does not need to state so
on the label.
There’s gluten in that??
 All
Kellogg’s dry ready-to-eat cereals
contain gluten in some form (either barley
malt, wheat, oats that have not been
certified gluten free, or wheat starch).
 Some
premade hamburger or turkey
burger patties contain wheat but may not
state it on the label
 Seasoned
French fries or batter dipped
fries; Rice-a-Roni
More possible hidden gluten
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Some egg substitutes
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Flourless chocolate cake (may be made in a
floured pan)
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Some shredded cheese (may be dusted with
flour)
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Some dried fruit
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Some canned beans
More ingredients to look for and
avoid
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Natural flavorings (rarely from wheat)
 Malt/Malt Extract, “barley malt”, or “barley malt
extract”
 Brown Rice Syrup (may be made with barley)
 Modified hop extract
Marinades
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Many marinades contain soy sauce or other gluten containing
ingredients
Most beer is made with barley malt so any marinade
containing beer probably contains gluten
Patients who have been on a gluten free diet may be skeptical
that they are being served food that is indeed gluten free.
They will appreciate it if after you have checked and verified
the marinade is gluten free, you reassure them that you have
done so.
Understanding the gluten free diet is
everything: the role of the CDM
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Because there is no medication
that will cure someone with
celiac disease or gluten
intolerance, the CDM, acting as
a liaison between the food
preparation area and the
patient, has a tremendous
opportunity to positively impact
the meal service experience for
the patient or resident on a
gluten free diet.
Do You Really Have a “Gluten Free
Diet”?
 If
your diet manual allows Rice Krispies or
Kellogg’s Corn Flakes on your gluten free
diet, it’s time to revise it.
 Every department in your organization
needs to understand what “gluten free”
means
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Activities Department—cookies, etc
Nursing– snacks from a pantry and med pass
Pharmacy – are the drugs and vitamins GF?
Chaplain – communion wafers
What if the resident demands
something with gluten?
 If
it is documented that they are on a GF
diet, you should not send any food
containing gluten without documentation
by Nursing of the choice to be
noncompliant
Is Your GF Diet Nutritionally
Adequate?
 Does
it provide enough calories? If you
don’t appropriately substitute when you
take a gluten containing food off the menu,
you could be deficient.
Give Your Cooks Guidance
Don’t just use your regular menu and expect
them to adjust each selection to GF. What
happens if there is “1 cookie” on the menu and
you don’t have GF cookies?
 Review products like your soup base—does it
contain gluten?
 How often do items like meatloaf, Sloppy Joes,
or meat balls come up and do you have a
substitute available?
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Gravy and bacon bits
 Make
sure your cooks know how to make
a gluten free gravy. They can use
cornstarch and gluten free soup base.
 Some “bacon bits” are not actually bacon
and may contain wheat
GF products are generally not
enriched…
 All
wheat flour in this country is enriched
with B vitamins, folate and iron
 Most GF foods are low in fiber unless they
are made with garbanzo bean flour or flax
 The GF resident is at risk of deficiencies
unless you give like substitutions with
these nutrients
What should the Activity Director
know
 Rice
Krispies Treats are NOT gluten free
 Neither is Play Doh or paper mache
 These items should be substituted with
similar nutrition
To oats or not to oats?
(with apologies to Shakespeare)
 Until
the dietitian or RN puts it in writing,
the following should not be served oats,
even if they are certified gluten free – just
in case the pt actually has celiac disease
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Wheat allergy
Gluten free
“no bread”
“wheat free”
If the resident can have oats, what
kind should I give them?
Rice cakes AGAIN??!! What residents
on a gluten free diet want
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Meals that are gluten free by substitution, not
by elimination
 Food that is good tasting, not just gluten free
 As much variety as possible
 Most importantly: residents want to trust that
the food is gluten free when you say it is
Your Kitchen Staff Needs to
Know
Patients aren’t being high maintenance or picky
when they are checking to make sure their
meals are gluten free. They are trying not to get
sick.
 Something may seem obvious to you (someone
who needs to avoid wheat can’t eat white bread
as well as wheat bread) that isn’t obvious to a
kitchen employee
 Have a dual person check for safest tray
accuracy
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Handling gluten free ingredients
in a non gluten free kitchen
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Food and beverage consumption should not be allowed
where the food is produced
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Clean lab coats, aprons, and gloves are important
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Equipment should be clearly marked and separate
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Storage, preparation, and serving areas should be
separate—best practice would be controlled air flow
between the two production areas
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Gluten containing foods should be stored below gluten
free foods to decrease the possibility of contamination
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Your staff should always be mindful of preventing cross
contamination.
Cross Contamination: What You
Can’t See CAN Hurt You
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Because even a miniscule
amount of gluten containing
ingredients can damage the
small intestine of a person
with celiac disease, health
care food service
departments have to be
especially diligent in not
cross contaminating gluten
free meals.
It’s as easy as sliced br…uh…
 If
it doesn’t make sense to have a
separate toaster for gluten free bread, use
foil and toast it in the oven.
 Do you use a bucket with cleaner and a
cloth to wipe tables? Do you clean a table
and then dip the rag back in the bucket
after it has cleaned up a table with wheat
crumbs on it? You have just contaminated
the surface with gluten.
Possible sources of cross
contamination
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Cutting boards; knives, spoons or ladles; butter,
peanut butter, or mayonnaise knives
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Grills, toasters, or toaster ovens used for both
gluten free and non gluten free food should be
thoroughly cleaned so no traces of gluten remain
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Deep fryer used to cook breaded or battered food
as well as French fries
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Gloved hand that has touched gluten containing
food and then touches gluten free food
More ways to avoid cross
contamination
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Work surfaces and microwaves
should be clean.
Use designated cutting boards,
knives, and toasters
Fresh, clean water for boiling,
steaming, and poaching (pasta)
If there is not a dedicated fryer for
gluten free foods, fry them in a skillet
No common prep equipment or
surfaces without appropriate
dishwashing and cleaning
You don’t bring me flours
anymore
 Even
the most well intentioned cooks can
inadvertently turn a gluten free food into a
gluten containing food simply by not
paying attention to some simple practices
in the kitchen.
 This
is particularly an issue where baking
is done from scratch (flour in the air).
An easy way to explain this to
kitchen staff is to compare gluten to
raw chicken.
Just as it’s common knowledge
that raw chicken is dangerous and
should never come in contact with
food, utensils, or plates that are
ready to be served, it should be
made absolutely clear that gluten
containing food needs to be kept
away from gluten free food at all
stages of preparation and service.
Oops—he said no croutons
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In the event an accident happens the entire
plate of food needs to be replaced
Removing the bread, wrap, breading,
croutons, etc is not acceptable once
contamination has occurred. Even a bread
stick on a plate that isn’t touching the food
can leave some gluten behind.
Garnishes that start out gluten free may
become contaminated, so any gluten
containing garnishes should be stored below
gluten free items.
Major food companies are finally
marketing to the gluten free
consumer
Gluten Free Becomes
Mainstream
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Most Chex cereals are now gluten free (with
the exception of Wheat Chex and Bran
Chex).
 Betty Crocker has recently come out with
gluten free mixes for chocolate chip cookies,
brownies, chocolate cake and yellow cake.
Some Excellent Resources
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The New Ultimate Guide
to Gluten-Free Living
 Celiac Disease Center
at Columbia University
www.celiacdiseasecenter.
org
Gluten-Free Diet: A
Comprehensive
Resource Guide,
Expanded Edition.
Shelley Case, BSc, RD
www.glutenfreediet.ca
Gluten Intolerance Group.
www.gluten.net
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Gluten-Free Living magazine
www.glutenfreeliving.com
Celiac Sprue Association
www.csaceliacs.org
National Foundation for
Celiac Awareness
www.celiaccentral.org
www.foodallergy.com
www.cfsan.fds.gov
More Resources
 www.eatright.org
Evidence based guidelines for celiac
disease
altarbreads@benedictinesisters.org
http://glutenfreeoatmatzos.com
www.glutenfreedrugs.com
Ronni Alicea, RD, MBA
Celinal Foods
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http://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”
www.glutenreview.com
Questions?