Transcript Slide 1

Gluten-free Food Service
A Systems Approach
Lacey Wilson MPH, RD
www.TheGlutenFreeNutritionist.blogspot.com
About me
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My perspective – big and small picture
Wellness Coach
Gluten-free consultant & Advocate
Celiac Disease
New Mom
Blogger
Angry Runner
Devoted member of Netflix
Presentation Objective
Introduce you to the gluten-free lifestyle and
provide insight going forward with
labeling to protect the consumer
Presentation Outline
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Gluten and gluten-free
Gluten & Celiac Disease
What it really means to live GF
GF discourse & common misconceptions
Policies (labeling, protocols, inspections)
Gluten
• Protein network in grains
– Wheat (durum, einkron, faro, semolina, spelt,
graham, kamut, triticale, farina) Rye, Barely
– Gliadin and Glutenin
• Provides structure/shape/stabilizer, texture
– Frozen poultry, luncheon meats, dressings/sauces
– hair products, makeup
• Acts as a preservative
– Microwave meals, packaged products
Gluten is a concern for:
• Gluten Intolerance
• Gluten Sensitivity
• Celiac Disease
All considered a
gluten Special
Dietary Need
(SDN)
Medical
Necessity
• Anecdotally: other diseases, disorders &
‘weight loss’
Celiac Disease
Celiac Disease (CD) is a lifelong inherited
autoimmune condition affecting children and
adults. When people with CD eat foods that contain
gluten, it creates an immune-mediated toxic
reaction that causes damage to the small
intestine and does not allow food [vital
nutrients] to be properly absorbed. Even
small amounts [20 ppm] of gluten in foods can
affect those with CD and cause health problems.
Damage can occur to the small bowel even when
there are no symptoms present.
- Celiac Disease Foundation
Internal Manifestations of CD
• Flattening of the villi1
– Villi “capture” nutrients,
amino acids, etc.
– no absorption leads to
nutrient deficiencies
• sickness and disease
• T cell regulated Immune
response results in chronic
inflammation2
• Comorbidities &
sickness (‘immunocompromised)
– T cell lymphoma
– GI cancers
Examples of macroscopic features of villous atrophy detected by wireless
capsule endoscopy in celiac disease: A) Normal villi, B) scalloping of the
mucosa on circular folds, C) fissuring of the mucosa, D) mosaic pattern
Image: http://discoverysedge.mayo.edu/celiac-disease/index.cfm
Symptoms/Consequences of
Unmanaged CD1,2,3,4,5
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GI Symptoms
– Diarrhea/constipation
– Bloating
– Cramping
– Fatty stool
– Vomiting
– Loss of villi
– Nutrient Deficiency
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Humoral symptoms
– Arthritis
– Bone loss
(osteoporosis/osteoarthritis)
– Loss of tooth enamel
– Hair loss
– Anxiety, depression, mood
– Memory loss
– Neuropathy (peripheral nerve
cell damage)
– Chronic fatigue
– Unregulated body temperature
– “brain fog”
– Infertility
– Anemia
– Heart burn
– Dermatitis herpetiformis
– Stunted growth
– Blurred vision
*While a CD ‘reaction’ may not be an acute, visibly noticeable one, chronic
exposure leads to comorbidities and cancer.
Early Statistics and Estimates
2,3,4
• 1 in ~100 people have CD
– 1.8 million people, yet 1.4 are unaware
• Estimated that 1/3 of the population
carries the gene(s)
• 4.5 times higher mortality rate in the
undiagnosed CD
Individual Management of CD
• GF lifestyle
– FDA – “prohibited grains” and other products
– *Oats
– Life-long GF
– Continued: awareness, education, label
reading, transparency in food system
• Pharmaceuticals
– Food testing (ex: GlutenTox)
– Deamidation pill (ex: Gluten Ease)
Gluten Intolerance & Sensitivity6
• Medical necessity
• Symptoms
• Diagnosis
– Elimination diet
• Tolerate different amounts
Gluten-free by Choice
• Personal choice
– No research to support health benefits
– A “re-portioning” of the plate
• Online information not always reputable
• Unlike any other ‘medical treatment’
– Major source of confusion amongst the public
• Poses difficulties for those with CD
– Gluten-free is becoming a “punch-line”
Language & Misconceptions
• Special Dietary Needs (SDNs)
– Sensitivity ≠ Intolerance ≠ Allergy ≠ CD
• Wheat Allergy v. CD
– Acute (immediate danger) v. Progressive
(sustained damage)
CD & GF Specific Language &
Misconceptions
• GF is a lifestyle, not a diet
– Environment, food, care products,
pharmaceuticals
• Wheat-free ≠ Gluten-free
• Cross-contamination
– Occurs when gluten comes in contact with an
otherwise GF item or product
– Salad bar, buffet line, fryers, toasters
• Can a person with CD have a ‘little’ gluten?
– No. 6
Specific Language &
Misconceptions4,7
• Gluten cannot be “cooked out”
• Are some people with CD more ‘sensitive’
than others?
– Symptoms v. autoimmune reaction
• Can one ‘out-grow’ CD?
– lifelong disease that requires diligent
management with a GF lifestyle.
• Can health status improve with proper
management?
– Yes, if diligent on a gfree diet, villi will regenerate.
Vulnerable CD Populations
• Those that are unable to control their food choices.
– “captive” populations
– Children, adolescents, college students
• Those that utilize food programs as primary source
of food.
– Meals On Wheels, Communal-site meals
• Those displaced from their homes during
emergencies
– Food banks, shelters
• …Anyone with CD
Chronic exposure
FDA & GF7
“Food Allergen Labeling and Consumer
Protection
Act of 20041, Title II of Public Law 108-282,
enacted on August 2, 2004, which directs the
Secretary of Health and Human Services to
propose and later make final a rule that defines
and permits the use of the food labeling term
"gluten-free.“”
-FDA
*A voluntary process
FDA’s Proposed Definition of
GF7
• “[A] food bearing this claim in its labeling
does not contain any one of the following:
– An ingredient that is a prohibited grain
– An ingredient that is derived from a prohibited
grain and that has not been processed to remove
gluten
– An ingredient that is derived from a prohibited
grain and that has been processed to remove
gluten, if the use of that ingredient results in the
presence of 20 parts per million (ppm) or more
gluten in the food or
– 20 ppm or more gluten”
FDA’s Allowable GF
Synonyms7
– "free of gluten"
– "without gluten"
– "no gluten“
– Naturally GF
• The wording of the claim clearly indicates that all
foods of the same type, not just the brand bearing
this labeling claim, are gluten-free (e.g., "milk, a
gluten-free food," "all milk is gluten-free"); and
• The food does not contain 20 ppm or more gluten.
CD Community Celebrates7
• August 2, 2013 FDA final rule
• Includes “cross-contact”
– Final product
GF labeling concerns
• Cross-contamination8
• Price Gouging
– Cost often shifts to the consumer
• GF foods = billion dollar industry
– Ethics of price increases
• Uniformity in labeling
– Communication to consumer
– Education component, transparency
• Consistency in labeling, label placement, ease for
consumer
– Safety of consumer
Third Party GF Labeling
• Gluten Intolerance Group (GIG)
– Certifying arm – Gluten-Free Certification
Organization
• Celiac Sprue Association (CSA)
• National Foundation for Celiac Awareness
(NFCA)
GF labeling and Dining Out7
• Restaurants are encouraged to comply
• Not mandatory at this time
• State and local governments
Massachusetts State Model
“An Act relative to restaurant
training”
“By Mr. Fennell of Lynn, a petition
(accompanied by bill, House, No. 1876) of
Robert F. Fennell relative to food allergy
awareness training for restaurant
employees. Consumer Protection and
Professional Licensure.”
1. Take part in an allergens training or
watch training video
2. Menus must instruct customer to make
associate aware of any SDN
3. Display Health Department approved
poster
4. A manager is deemed “protection
manager”
5. Disciplinary action taking under the state
sanitary code
Additional GF Dining-Out
Challenges
• HACCP concept
• Points of potential “contamination”
– Ordering
– Preparation
– Service
• Control
• Transparency
Foodservice SDNs Best
Practices
• Much more than individual
education/training
– Staff turnover, food prep., etc.
• Systems changes in addition to individual
training is necessary to ensure safety
• Transparency in menu labeling, ordering,
prep and service
• Knowledgeable & honest staff
• Systems approach to GF food service
– Food environment to the individual
• Awareness, Policy Development,
Manufacturing, Labeling, Education,
Enforcement
Protect the consumer
Support laws and uniformity
Succinctly communicate
References
1. Miśkiewicz P, Kępczyńska-Nyk A, Bednarczuk T (2012). Coeliac disease in endocrine
diseases of autoimmune origin. Endokrynol Pol. 63(3):240-9.
2. Sharaiha RZ, Lebwohl B, Reimers L, Bhagat G, Green PH, Neugut AI (2012).
Increasing incidence of enteropathy-associated T-cell lymphoma in the United States,
1973-2008. Cancer. 118(15):3786-92.
3. The Celiac Disease Foundation www.celiac.org
4. Rubio-Tapia A, Murray JA (2010). Celiac disease. Curr Opin Gastroenterol. (2):11622.
5. Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE (2012). The
Prevalence of Celiac Disease in the United States. Am J Gastroenterol. doi:
10.1038/ajg.2012.219.
6. Catassi C, Bai JC, Bonaz B, Bouma G, Calabrò A, Carroccio A, Castillejo G, Ciacci C,
Cristofori F, Dolinsek J, Francavilla R, Elli L, Green P, Holtmeier W, Koehler P,
Koletzko S, Meinhold C, Sanders D, Schumann M, Schuppan D, Ullrich R, Vécsei A,
Volta U, Zevallos V, Sapone A, Fasano A. (2013). Non-Celiac Gluten sensitivity: the
new frontier of gluten related disorders. Nutrients. 26;5(10):3839-53.
7. The Food and Drug Administration (2013). Questions and Answers: Gluten-free Food
Labeling Final Rule.
8. Hollon JR, Cureton PA, Martin ML, Puppa EL, Fasano A (2013). Trace gluten
contamination may play a role in mucosal and clinical recovery in a subgroup of dietadherent non-responsive celiac disease patients. BMC Gastroenterol. 13:40.