Looking at Special Dietary Needs Through Different Eyes Loriann Knapton, DTR, SNS, Nutrition Program Consultant November 4, 2008

Learning about the nature and severity of the childs special dietary needs and working together to provide whats best for the child should be the major focus.

Children with a Disability Schools must make substitutions of foods in the reimbursable meal for students who have a disability that restricts their diet.

What are Disabilities? Disability is defined in : Section 504 of the Rehabilitation Act of 1973 Americans with Disabilities Act of 1990 Part B of the Individuals with Disabilities Education Act (IDEA) Individual Education Plan (IEP) Explanation of these disabilities found on pages 3-5 of the USDA guidance Accommodating Children with Special Dietary Needs in the School Nutrition Programs Website link to USDA guidance:

Food Related Disabilities Some that require menu modifications: Severe Food Allergies (Food Anaphylaxis) Metabolic Diseases such as Diabetes, Celiac Disease (Gluten-free Diet) and Phenylketonuria (PKU) Prescribed diet for child with autism (one of the thirteen disability categories recognized in the Individuals with Disabilities Act)

Disability Accommodation MUST be made, based on a completed physicians statement No extra charge A disability determination can only be made by a licensed physician

Statement for Children with Disabilities What must the physicians statement include? What the disability is How it restricts diet Major life activity affected Foods to be omitted Foods to be substituted Physicians Form (for documentation) ict.doc

Under no circumstances are school food service staff to revise or change a diet prescription or medical order.

Documentation The diet orders do not need to be renewed on a yearly basis; however, schools are encouraged to ensure that the diet orders reflect the current dietary needs of the child.

Medical Requests for Children with Special Dietary Needs (not considered a disability) The school food service may make food substitutions, at their discretion, for individual children who do not have a disability, but who are medically certified as having a special medical or dietary need. Examples include: Lactose intolerance Food intolerances or allergies where there is not the concern of a life-threatening reaction

Not to be confused with…. Fluid Milk Substitutions in the School Nutrition Programs (Final Rule published September 12, 2008) Current requirements on meal variations for students with disabilities and for students with medical or other special dietary needs remain unchanged. Offering fluid milk substitutes to students under this ruling is totally at the School Food Authoritys (SFAs) discretion. Nondairy beverages offered as fluid milk substitute be nutritionally equivalent to fluid milk and provide specific levels of calcium, protein, vitamins A and D, magnesium, phosphorus, potassium, riboflavin and vitamin B-12. Website: fns.dpi.wi.gov/fns_regsfns.dpi.wi.gov/fns_regs

Goals of the Child Nutrition Program for Students with Special Dietary Needs Meet the nutritional needs, as specified by the United States Department of Agriculture (USDA) meal pattern requirements and the childs personalized diet plan. Prepare the food items exactly as the diet order specifies, including texture and consistency of the item. If the diet plan is unclear, contact the medical authority involved in prescribing the diet plan for further clarification. Ensure food safety.

Goals of the Child Nutrition Program for Students with Special Dietary Needs (continued) Be knowledgeable of the policies and procedures in place for the district/site as they pertain to children with identified special dietary needs and the role of food service personnel in the case of a medical emergency. Give appropriate feedback to the multidisciplinary team whenever applicable.

90% of foods causing food allergies Cows milk Egg Soybeans Wheat Peanut/tree nut Fish/shellfish

Celiac Disease Celiac Disease: An autoimmune disorder in which the body attacks itself. Permanent sensitivity to gluten, a protein found in wheat, rye, & barley Eating food containing gluten damages the villi (lining of the small intestine), which results in mal-absorption of nutrients Gluten Free diet for life is only treatment

Gluten Containing Grains Barley Barley malt, extract, flavoring Bran Bulgur Couscous Durum Einkorn Emmer Farina Faro Flour Graham flour, graham crackers Kamut Matzo flour, meal Malt, malt flavorings Orzo Panko Rye Seitan Semolina Spelt Triticale Udon Untested Oats Wheat berry Wheat bran Wheat germ Wheat germ oil Wheat gluten Wheat starch

Hidden sources of gluten Bouillon Breading Broth Brown Rice syrup Coating mix Communion wafers Croutons Candy Imitation Bacon/seafood Luncheon Meats Marinades, thickeners Modified food starch Processed cheese Roux Sauces Seasoning packets/mixes Self-basting poultry Soup base Soy sauce Stuffing Herbal Supplements Vitamin & mineral supplement Over the counter/prescription medications Lip-gloss, balms, lipstick Play dough

Questionable ingredients Carmel color – if made in US product is safe. Food label will confirm derivation of product. Flavorings – gluten containing grains rarely used. Mostly derived from corn; exceptions include barley malt flavorings, is usually listed on the label and flavorings in meat products Dextrin – may be derived from arrowroot, corn, potato, rice, tapioca, sago or wheat Modified food starch – may be derived from corn, potato, tapioca, wheat or other starches. No requirement for the identification of plant source. Starch – FDA regulations start starch implies cornstarch; if alternative starch is used it must be listed i.e.. Wheat starch

Gluten Free Diet Any of the following words on food labels usually means that a grain containing gluten has been used: StabilizerHydrolyzed Vegetable Protein StarchFlour or Cereal Products FlavoringVegetable Protein EmulsifierMalt or Malt Flavoring Food Starch Modified Starch or Modified Vegetable Gum

Gluten-Free Grains AcornCottonseed Quinoa AlmondDal Red rice AmaranthDasheen flour Rice, rice bran, rice flour Arborio riceEnriched rice Risotto Aromatic riceFava bean Sago ArrowrootFlaxseed Sesame Basmati riceGarbanzo Sorghum Brown rice, Brown rice flourGlutinous rice Soy,soybean,tofu BuckwheatHominy Starch (made from corn or rice) CalroseInstant rice Sunflower see CanolaJobs tears Sweet rice flour CassavaMillet Tapioca ChestnutModified corn starch Taro flour ChickpeaModified tapioca starch Teff Corn, corn flour,Peanut flour Wild rice Corn gluten, Potato flour Corn Malt, cornmealPotato starch flour Cornstarch

Gluten Free School Menu Example Chicken fajitas (prepared from fresh boneless chicken breast meat and gluten free seasoning) served with corn tortillas/green peppers/onions/salsa/sour cream Steamed brown/white rice Steamed broccoli cuts Fresh fruit choice Milk (unflavored)

Gluten Free School Menu Example Cheeseburger Made with 100% lean ground beef and block cheddar cheese (not processed)/gluten free bun Oven fries prepared from fresh potatoes or gluten free French fries. Steamed green beans Chilled Peaches Flourless Peanut butter cookie Milk (unflavored)

Gluten Free Peanut Butter Cookie 1 cup creamy peanut butter or Almond Butter 1 cup white sugar 1 large egg Sugar for rolling. Combine all ingredients. Take 1 teaspoon of dough, form into a ball and roll in sugar. Place ball on baking sheet and flatten with a fork. Bake cookies at 350 degrees for 8 minutes. Watch carefully when baking as they over bake and burn easily. Yield: 1 dozen small cookies Must utilize appropriate preparation methods to avoid cross contamination.

Gluten and Casein Free Diet sometimes prescribed for children with Autism (recognized disability) Acceptable foods Rice, potato, and soy products Milks Flours Fresh fruits, vegetables, meats Arrowroot Nuts Beans Tapioca

Casein Food sources Typical dairy foods – milk, butter, cheese, yogurt Milk solids (curds) and whey Sodium caseinate – ingredient in some processed foods Natural ingredients – may contain dairy products

Gluten and Casein Free Diet Foods to avoid Milk and milk derived products Wheat, barley, oats, rye, and buckwheat flours and products Natural ingredient foods Hydrolyzed vegetable protein Carmel coloring – may contain gluten Vinegars – check label for food source Chocolates

Diabetic Requests Supervision of menus/meals: how many carbs are served? What steps are taken if child doesnt take/eat planned items: Other selections or substitutions Menu available for review; notify parents/nurse if there are changes

Phenylketonuria (PKU) Phenylketonuria, or PKU for short, is an inherited, genetic condition in which the body cant process phenylalanine (Phe), an amino acid found in many foods. Too much Phenylalanine is toxic to the brain. High Phe levels over an extended period of time can lead to vomiting, irritability, eczema, seizures, psychological and behavioral issues, and severe mental retardation.

PKU Diet Phenylalanine is found in: All protein-containing foods (eg, meat, eggs, dairy, nuts) Many other foods that are not generally thought of as containing protein (eg, most wheat products, such as pasta and bread, and some fruit, such as oranges and cherries).

PKU Menu Example

When dealing with special dietary needs remember to…. Work with the team: Parents, doctors, school nurse, teachers, administrators, school foodservice staff Keep the lines of communication open Look through the eyes of your customer… A Child who just wants to be like everyone else.

RESOURCES Diabetes The American Diabetes Association: Gluten Free diets Celiac Sprue Association: Phenylketonuria PKU support: Autism Autism Society of America: Food Allergies The Food Allergy and Anaphylaxis Network: