1. Accommodating Special Dietary Needs Jenny Fuller KDE

2. USDA Regulations - Disability  Require substitutions or modifications in meals for children who are considered disabled  504  IDEA  Certified by a licensed physician Regulations - Disability

3. Definition of Disability  According to Section 504, a “person with a disability” means any person who: 1. Has a physical or mental impairment that substantially limits one or more major life activities 2. Has a record of such an impairment 3. Is regarded as having such an impairment Definition of Disability

4. Definition of a Disability  According to IDEA, a “person with a disability” means 1. Having one or more of the recognized disability categories 2. Disability adversely affects educational performance 3. Child needs special education and related services Definition of Disability

5. Major Life Activities  Include: Caring for one’s self Performing manual tasks Walking Seeing Hearing Speaking Breathing Learning Working Sleeping Eating Standing Lifting Bending Reading Concentrating Thinking Communicating Major Life Activities

6. Modifications for Children with Dietary Disabilities  Require substitutions and/or modifications for children whose disability restricts their diet  Documentation from a licensed physician  Health history from school nurse is not acceptable  Documentation must identify: The child’s disability An explanation of why the disability restricts the child’s diet The major life activity affected by the disability The food or foods to be omitted from the child’s diet and the food or choice of foods that must be substituted Modifications

7. Medical Statement - Disabilities  Must be completed in its entirety  Provided before school food service can make any meal modifications  Ensures that the modified meal is reimbursable and meets nutrition standards  Can use same record from year to year if nothing has changed Medical Statement

8. Scenarios SCENARIO 1 A student’s mother brought in a medical statement signed by a licensed physician certifying a dietary disability. The medical statement is unclear and school food service in not sure they can provide the requested accommodations. What should the school do? Scenarios

9. SCENARIO 1 ANSWER: If school food service feels the medical statement is unclear or is an undue burden, then they are encouraged to convene a meeting including appropriate personnel such as: food service staff, administration, parents, school nursing staff and the physician to clarify the medical statement and determine appropriate accommodations for the student. Scenarios

10. SCENARIO 2 A licensed physician’s statement only specifies the medical disability, not the required food substitutions. Can the school food service staff decide what food should be substituted? Scenarios

11. SCENARIO 2 Answer No! An appropriate school official must receive parent or guardian permission to obtain more information from the licensed physician concerning substitutions or modifications the student requires. Scenarios

12. SCENARIO 3 A child in your school has a documented life threatening food allergy that causes an anaphylactic reaction to peanuts. The mother requests that food service staff read all food labels for peanut ingredients to ensure a safe meal for her child. Does the food service need to accommodate this request? Scenarios

13. SCENARIO 3 ANSWER YES! A life threatening food allergy that causes an anaphylactic reaction is considered a dietary disability because it can affect a major life activity, breathing. Therefore, accommodations are mandated. The request for reading food labels should be included in the medical statement signed by the licensed physician. Scenarios

14. Temporary Disabilities  Must accommodate disabilities regardless of duration  Example: A child who had major oral surgery Temporary Disability

15. Texture Modifications  Meals modified for texture will consist of regular school menu items  Unless specified by licensed physician Texture Modification

16. Specific Brands  Not required to provide a specific brand  Provide only the medically appropriate substitutions specified in medical statement Specific Brands

17. Different Portion Sizes  Must provide specified portions  Prescribed by licensed physician Portion Sizes

18. A La Carte Foods & Beverages  Required accommodations only apply to reimbursable meals  If items included in IEP, school district must provide them; may have food service handle this responsibility A La Carte

19. Meal Services Outside of USDA Meal Programs  Not required to provide meals when meal service is not available for general student body  Unless  Child has IEP that requires a meal  Child resides in a residential child care institution (RCCI) Meals Outside USDA Meal Programs

20. Carbohydrate Counts  Responsible for providing carbohydrate count to family for each food item served in one daily meal choice  NOT responsible for weighing or measuring food, or determining proper amount of carbohydrates needed or consumed  Responsibility of school nurse or other designated medical personnel Carbohydrate Counts

21. Appropriate Eating Areas  Ensure that students with disabilities participate with nondisabled students to the maximum extent appropriate  Some instances, may be to child’s benefit to be served separately  All decisions must be based on what is appropriate to meet the needs of the child Eating Areas

22. Dietary Disability Recap  Distinction between definition of ‘disability’ for Section 504 & IDEA and for the purpose of food modifications/substitutions  Modifications may include:  Food restrictions  Carbohydrate counts  Texture changes  Increased or decreased calories  Medical statement must be signed by a licensed physician and kept on file  Modifications for a Disability & documentation do not have to meet the meal pattern Recap - Disability

23. Scenarios SCENARIO 1 A student with celiac disease has a medical statement signed by a licensed physician that prescribes a gluten-free diet. Does the school food service need to accommodate this request? Scenarios

24. SCENARIO 1 ANSWER YES! The student’s physician has determined that the medical condition affects a major life activity and rises to the level of a disability. Therefore, school food service must accommodate the physician’s diet prescription. Scenarios

25. SCENARIO 2 Occupational therapy staff is requesting that a disabled student eat their meals outside the cafeteria in order to work on feeding skills. Is this acceptable? Scenarios

26. SCENARIO 2 ANSWER Federal civil rights legislation requires that “in providing for or arranging for the provision of nonacademic services and extracurricular activities, including meals, school districts must ensure that students with disabilities participate with nondisabled students to the maximum extent appropriate to the needs of students with disabilities”. In rare instances, however, it may be to a child’s benefit to be served separately. Scenarios

27. SCENARIO 2 cont’d For instance, a child with severe motor disabilities may be able to receive individualized attention in handling eating utensils if a special education staff member is able to work with the student outside the cafeteria. In all cases, the decision to feed disabled children must always be based on what is appropriate to meet the needs of the children. Scenarios

28. SCENARIO 3 A student has type 1 diabetes. The Individual Education Plan states that carbohydrate counting will be used as part of the medical treatment. Is food service staff required to count the carbohydrates this student eats? Scenarios

29. SCENARIO 3 ANSWER The school district is responsible for providing a carbohydrate count to the family of a diabetic child for each food item served in one daily reimbursable meal choice. Food service personnel are not responsible for weighing or measuring leftover food or determining the proper amount of carbohydrates needed or consumed. This is the responsibility of the school nurse or other designated medical personnel if requested. Scenarios

30. USDA Regulations – Non Disability  Permit substitutions or modifications in meals for children without dietary disabilities, but with medical or other special dietary needs  School may choose to make these accommodations Regulations

31. Modifications for Children Without Disabilities  Schools encouraged, but not required to make modifications  Documentation from a recognized medical authority  Documentation must identify:  Medical or other special dietary condition which restricts the child’s diet  The food or foods to be omitted from the child’s diet  The food or choice of foods to be substituted Modifications – Without Disability

32. Examples of Medical Conditions  Food intolerance  Food allergies (not affecting a major life activity)  Elevated blood cholesterol  Overweight (not morbidly obese) Medical Conditions

33. Meal Modifications for Students Without a Disability  Children without food allergies that do not affect a major life activity are not considered to have a dietary disability  A meal that is modified must still meet the meal pattern requirements to be reimbursable Meal Modifications – Without Disability

34. Offer vs. Serve  Allows students to decline a certain number off food items in the meal  Can assist in accommodating students with special dietary needs Offer vs. Serve

35. Scenarios SCENARIO 1 If the school food service does decide to make food substitutions and/or modifications for students without a dietary disability, what documents are required? Scenarios

36. SCENARIO 1 Answer Each special dietary request must be supported by a statement, which explains the food substitution that is requested. It must be signed by a recognized medical authority. The medical statement must include: An identification of the medical or other dietary condition that restricts the child’s diet, the food or foods to be omitted from the child’s diet, and the food or choice of foods to be substituted. Scenarios

37. SCENARIO 2 Are schools required to provide a modified meal to a child whose parents are strict vegetarians and want their child to be provided with vegetarian meals? Scenarios

38. SCENARIO 2 ANSWER NO! A school food service is not required to make accommodations based on food preferences of a family or child. Scenarios

39. Non-Disability Recap  Schools have the option of providing accommodations  Medical statement must be signed by a recognized medical authority and kept on file  Offer vs. Serve may help to provide meal solutions to non-disability requests Recap – Non-Disability

40. Lactose-Free Milk  Creditable as the milk component for meals  Must be low-fat (1%) or fat-free (skim)  May be substituted without written statement  May not charge more Lactose-Free Milk

41. Non Dairy Milk Substitutions  May provide non dairy substitutes when requested by parent/guardian  Must be nutritionally equivalent to fluid milk  If make milk substitutions available, must be available for all children when request made  At the expense of the school food service program Non Dairy Milk Substitutions

42. USDA Nutritional Standards for Non Dairy Milk Substitutions Nutrients Per Cup (8 fluid ounces) Calcium: 276 mg Protein: 8 g Vitamin A: 500 IU Vitamin D: 100 IU Magnesium: 24 mg Phosphorus: 222 mg Potassium: 349 mg Riboflavin: 0.44 mg Vitamin B12: 1.1 mcg Non Dairy Milk Substitutions

43. Summary of Allowable Milk Substitutions (non disability) ScenarioIs This a Reimbursable Meal? The school provides whole milk or reduced fat (2%) milk. No. The USDA requires that schools serve only low-fat (1%) or fat-free (skim) milk. The school provides lactose-free milk. Yes, if the lactose free milk is low fat (1%) or fat free (Skim). The school provides a nondairy milk substitute that does not meet the USDA nutrition standards. No. All nondairy milk must meet the USDA nutrition standards. The school provides juice or water instead of milk. No. Juice or milk can never be offered as milk substitutes. All substitutions must be either lactose-free milk or a nondairy beverage that meets the nutrition standards. Non Dairy Milk Substitutions

44. Scenarios SCENARIO 1 When a student has a non-disabling milk allergy, can juice or water be substituted for milk? Scenarios

45. SCENARIO 1 ANSWER No. Children with non-disabling milk allergies may only be offered a nondairy beverage that is nutritionally equivalent to fluid milk a specified by USDA. However, if the milk allergy is a dietary disability, a juice or water substitution prescribed by a licensed physician must be followed. Scenarios

46. SCENARIO 2 If a student pays full price for their lunch, but has a request from a parent to provide lactose-free milk, is the school food service responsible for providing that accommodation? Scenarios

47. SCENARIO 2 Answer The USDA requirements for accommodating special dietary needs apply to all children regardless of their eligibility for paid, free, or reduced-price meals. School food service is encouraged, but not required, to provide food substitutions or modifications for children without disabilities. Lactose-free milk is creditable as the milk component for reimbursable meals and can be provided without written request. Scenarios

48. Requirements For All Special Dietary Accommodations Documentation  Required to have documentation on file  Regardless of disabled or nondisabled  All changes to diet order must be in writing  Food service personnel should never revise or change diet prescription  Recommend schools develop a plan for ensuring current information on file Documentation

49. Requirements For All Special Dietary Accommodations Price of Meals  Cannot charge more for modified meals  Accommodating special dietary needs apply regardless of eligibility for paid, free, or reduced-price meals Price of Meals

50. Requirements For All Special Dietary Accommodations Reimbursement  Claimed at same reimbursement rate as standard meals  For children with and without disabilities  No additional reimbursement is available  Additional costs for food is an allowable food service program cost Reimbursement

51. Best Practices for Accommodating Special Dietary Needs  Provide clear guidelines for students, families and school staff  Ensure consistent practices  Document compliance with federal and state requirements  Educate families regarding school policies and procedures  Monitor to ensure meal modifications are appropriate and meet individual and meet individual dietary needs Best Practices

52. Frequently Asked Questions: 1. What must a licensed physician’s statement for children with a dietary disability identify? The child’s disability An explanation of why the disability restricts the child’s diet The major life activity affected by the disability The food or foods to be omitted from the child’s diet, and the food or choice of foods that must be substituted Frequently Asked Questions

53. 2. Are schools required to provide a modified meal to a student without a dietary disability? No. School food service is encouraged, but not required to provide food substitutions or modifications for children without dietary disabilities. The school food service is responsible for determining if and for what cases modifications will be made. Keep in mind that substitutions and/or modifications must be based on a statement provided by a recognized medical authority. Frequently Asked Questions

54. 3. What is the difference between a licensed physician and a recognized medical authority? A licensed physician is a doctor of medicine (MD) or osteopathy (DO). A recognized medical authority is a professional recognized by the state of Kentucky who is a physician (MD or DO), physician assistant, or advanced practice registered nurse (APRN). Frequently Asked Questions

55. 4. Is the school food service able to charge more for a meal that requires modification? No. Schools may not charge children with dietary disabilities or with certified special dietary needs who require food substitutions or modifications more than they charge any other children for program meals or snacks. Frequently Asked Questions

56. Additional Resources  USDA – Accommodating Children with Special Dietary Needs  http://origin.www.fns.usda.gov/cnd/Guidance/ special_dietary_needs.pdf http://origin.www.fns.usda.gov/cnd/Guidance/ special_dietary_needs.pdf  NFSMI Handbook for Children with Special Food and Nutrition Needs  http://nfsmi- web01.nfsmi.olemiss.edu/documentlibraryfiles/P DF/20111103084132.pdf http://nfsmi- web01.nfsmi.olemiss.edu/documentlibraryfiles/P DF/20111103084132.pdf  Q&As: Milk Substitutions:  http://www.fns.usda.gov/cnd/Governance/Poli cy-Memos/2009/SP_35-2009_os.pdf http://www.fns.usda.gov/cnd/Governance/Poli cy-Memos/2009/SP_35-2009_os.pdf Resources

57. Questions? Questions