1. CELIAC DISEASE A PRIMER FOR SCHOOL NUTRITION

2. What is Celiac Disease? Inherited, Autoimmune Disorder Inherited, Autoimmune Disorder Permanent Intolerance to Gluten in WHEAT, RYE AND BARLEY Permanent Intolerance to Gluten in WHEAT, RYE AND BARLEY Also referred to as celiac sprue Also referred to as celiac sprue

3. SCOPE OF DISEASE 2.2 million Americans afflicted-over 10,000 children diagnosed annually * 2.2 million Americans afflicted-over 10,000 children diagnosed annually * Affects 1 in 133 Americans Affects 1 in 133 Americans 97% go undiagnosed. Celiacs are at greater risk of GI cancer and particularly lymphoma 97% go undiagnosed. Celiacs are at greater risk of GI cancer and particularly lymphoma * Dr. Alessio Fasano, University of Maryland-Baltimore Center for Celiac Research in A Gluten Free Solution, FoodService Director, September 15, 2008, p. 50-51. * Dr. Alessio Fasano, University of Maryland-Baltimore Center for Celiac Research in A Gluten Free Solution, FoodService Director, September 15, 2008, p. 50-51.

4. DIAGNOSIS Initial Blood Tests Initial Blood Tests If serology is positive, a biopsy of small intestine is the definitive test If serology is positive, a biopsy of small intestine is the definitive test NO CURE: person must strictly avoid food products, medicines, vitamins and even glue on envelopes that may have gluten NO CURE: person must strictly avoid food products, medicines, vitamins and even glue on envelopes that may have gluten

5. MECHANISM OF ACTION Body attacks normal tissue resulting in damage to lining of small intestinal villi, the tiny hairlike projections that line inside of small intestine. Body attacks normal tissue resulting in damage to lining of small intestinal villi, the tiny hairlike projections that line inside of small intestine. Villi contain blood vessels which absorb nutrients Villi contain blood vessels which absorb nutrients Villi increase area for absorption of nutrients Villi increase area for absorption of nutrients Digested nutrients are carried away by circulating blood Digested nutrients are carried away by circulating blood If villi are damaged, vitamins, minerals, calcium, carbohydrates, protein, and fats are not absorbed well If villi are damaged, vitamins, minerals, calcium, carbohydrates, protein, and fats are not absorbed well

6. SYMPTOMS Some may be asymptomatic Some may be asymptomatic Diarrhea Diarrhea Short Stature Short Stature Iron Deficiency Anemia Iron Deficiency Anemia Lactose Intolerance Lactose Intolerance Irritability (common in children) Irritability (common in children) Mood Swings (common in children) Mood Swings (common in children) Abdominal Pain Abdominal Pain Irritable Bowel Irritable Bowel Osteoporosis Osteoporosis Skin rash-very itchy with blisters Skin rash-very itchy with blisters

7. TREATMENT GLUTEN FREE DIET GLUTEN FREE DIET ELIMINATE ALL WHEAT, RYE, BARLEY AND THEIR DERIVATIVES ELIMINATE ALL WHEAT, RYE, BARLEY AND THEIR DERIVATIVES MAY TAKE 6-12 MONTHS FOR INTESTINE TO HEAL MAY TAKE 6-12 MONTHS FOR INTESTINE TO HEAL

8. WHAT ABOUT OATS? Oats may not be harmful to a celiac patient; however, oats may be cross- contaminated with wheat in the milling process Oats may not be harmful to a celiac patient; however, oats may be cross- contaminated with wheat in the milling process

9. FOOD LABELING LAWS Under the 2006 Food Allergen Labeling and Consumer Act, wheat protein or a derivative must be identified, even if used in small amounts Under the 2006 Food Allergen Labeling and Consumer Act, wheat protein or a derivative must be identified, even if used in small amounts The law does not address the use of barley, rye or oats The law does not address the use of barley, rye or oats Check with manufacturer if in doubt Check with manufacturer if in doubt

10. USDA has given recent clarification on a specific case for an individual child: …if the physician, in the documentation for special dietary accommodations, identifies celiac as a disability, then the school must make the accommodations for a disabled student Supt. Reg. Memo #8. October 11, 2002

11. SCHOOL NUTRITION PROGRAMS SHOULD CONSIDER THE FOLLOWING PRACTICES Determine if the student has an IEP or 504 plan Determine if the student has an IEP or 504 plan Discuss accommodations with the school division special education supervisor and/or nurse supervisor if necessary Discuss accommodations with the school division special education supervisor and/or nurse supervisor if necessary Consult with a Registered Dietitian if family is working with one through their doctor Consult with a Registered Dietitian if family is working with one through their doctor

12. Meeting Meal Requirements If following a physician’s orders, foods do not have to meet the same standard as a regular component-for example, bread doesn’t have to weigh 1 oz. If following a physician’s orders, foods do not have to meet the same standard as a regular component-for example, bread doesn’t have to weigh 1 oz.

13. Rochester MN Public Schools GF menu for 5 years-on web site GF menu for 5 years-on web site Found from surveys with kids/parents that sliced bread was least liked item Found from surveys with kids/parents that sliced bread was least liked item Buy locally Buy locally Modifications include: chicken nuggets (cornflake crumbs, GF chocolate chip cookie (school made) Modifications include: chicken nuggets (cornflake crumbs, GF chocolate chip cookie (school made)

14. AVOID CROSS CONTAMINATION- RECOMMENDATIONS Separate Fryers or Clean Oil if Breaded Items are Fried in Same Vats as Non-Breaded Separate Fryers or Clean Oil if Breaded Items are Fried in Same Vats as Non-Breaded Use Separate Jars of Peanut Butter, Jelly, Mayonnaise to Avoid Wheat/Bread Crumbs in Jar Use Separate Jars of Peanut Butter, Jelly, Mayonnaise to Avoid Wheat/Bread Crumbs in Jar Clean and Sanitize Counters, Cutting Boards, Cooking Utensils, Pans after EACH use and BEFORE Cooking Gluten Free Products Clean and Sanitize Counters, Cutting Boards, Cooking Utensils, Pans after EACH use and BEFORE Cooking Gluten Free Products Use Separate Colanders for gluten free products Use Separate Colanders for gluten free products

15. GLUTEN CONTAINING GRAINS TO AVOID Barley Barley Barley malt/extract Barley malt/extract Bran Bran Bulgur Bulgur Couscous Couscous Bromated or Durum Flour Bromated or Durum Flour Einkorn Einkorn Emmer Emmer Enriched or Self Rising Flour Enriched or Self Rising Flour Farina Farina Faro Faro Graham Flour Graham Flour Kamut Kamut Matzo Flour/meal Matzo Flour/meal Orzo Orzo Panko Panko Phosphated Flour Phosphated Flour Rye Rye Seltan Seltan Semolina Semolina Spelt Spelt Triticale (cross between wheat/rye) Triticale (cross between wheat/rye) Udon Udon Wheat Wheat Wheat Bran Wheat Bran Wheat germ Wheat germ Wheat starch Wheat starch

16. OVERLOOKED GLUTEN SOURCES Ales Ales Beer and Lagers Beer and Lagers Bouillon Cubes Bouillon Cubes Breading Breading Brown Rice Syrup Brown Rice Syrup Coating Mix Coating Mix Communion Wafers Communion Wafers Croutons Croutons Candy Candy Some Chips/Potato chips Some Chips/Potato chips Luncheon Meats, hot dogs, salami, sausage Luncheon Meats, hot dogs, salami, sausage French Fries French Fries Gravy Gravy Pasta Pasta Rice Mixes Rice Mixes Seasoned Tortilla Chips Seasoned Tortilla Chips Sauces Sauces Soup Base Soup Base Stuffing Stuffing Self-basting Poultry Self-basting Poultry Imitation Bacon/Seafood Imitation Bacon/Seafood Soy Sauce Soy Sauce Marinades Thickeners Herbal Marinades Thickeners Herbal Supplements, Prescription Meds Supplements, Prescription Meds Over the Counter Meds Over the Counter Meds Vitamin and Mineral Supplements Vitamin and Mineral Supplements Lipstick Lipstick Lip Gloss and Balms Lip Gloss and Balms Play Dough* (hands must be properly washed after playing with) Play Dough* (hands must be properly washed after playing with)

17. GLUTEN FREE GRAINS AND STARCHES Amaranth Amaranth Arrowroot Arrowroot Buckwheat Buckwheat Corn Corn Flax Flax Flours made from nuts, beans and seeds Flours made from nuts, beans and seeds Millet Millet Montina Montina Potato Starch Potato Starch Potato Flour Potato Flour Quinoa Quinoa Rice Rice Rice Bran Rice Bran Sago Sago Sorghum Sorghum Soy (soya) Soy (soya) Tapioca Tapioca Teff Teff

18. TIME TO PRACTICE

19. MENU I Choose One: Whole Grain Chicken Corn Dog Bites Hamburger/Cheeseburger on Whole Wheat Bun PB&J Sandwich w/ String Cheese Yogurt w/ Graham Crackers Chef Salad/Tuna Salad (contains saltine crackers) Choose Two Steamed Whole Kernel Corn Fresh Orange Wedges Fresh Red Grapes Chilled Diced Pears Assorted Milk

20. MENU II Choose One: Chicken Drummie w/ Biscuit Grilled Cheese Sandwich on Whole Wheat Bread PB&J Sandwich w/ String Cheese Yogurt/Graham Crackers Spinach Chef (diced egg, mushrooms, onions, tomatoes) Choose Two Glazed Sweet Potatoes Chilled Applesauce Fresh Pear Dried Cranberries Assorted Milk

21. MENU III Pancakes w/Syrup OR Fat Free Yogurt OR Cereal w/ Graham Cracker OR Turkey Sausage w/ Biscuit OR PB&J Sandwich Fresh Orange Wedges or Orange Juice Assorted Milk