Celiac disease affects about 1% of the general population, or approximately 3 million Americans. Beyond Celiac estimates that another 18 million Americans have gluten sensitivity. Celiac disease is not a fad, and although there are individuals who choose to be gluten-free, their actions are distinct from those who must eat gluten-free.
In this course, we will discuss the FDA's guidelines regarding food labeling and gluten-free products, how celiac disease and gluten-free needs affect patient care, and the rapidly growing market for gluten-free products.
Celiac, Coeliac, and Sprue (non-tropical) are all the same disease. It is defined as the permanent intolerance to the gliadin fraction of wheat protein and related alcohol-soluble proteins (called prolamines) found in rye and barley. It is a genetic autoimmune disorder that damages the small intestine and interferes with the digestion and absorption of nutrients from food when gluten is present.
A cornerstone of treatment is strict avoidance of dietary gluten. Sometimes, the symptoms of celiac disease do not respond to a gluten-free diet. This condition is called refractory celiac disease.
The body processes involved in celiac disease are not the same as those of gluten intolerance or wheat allergy. A gluten intolerance or sensitivity is a non-genetic and non-specific immune response that has been clinically recognized as less severe than celiac disease.
A wheat allergy is an immunologic response to the protein in wheat. It, too, is non-genetic. However, only about .01% of the population has a documented wheat allergy.
It’s estimated the 6% of the population has gluten sensitivity. At the same time, 41% of Americans believe that gluten-free foods are beneficial to everyone, as reported in U.S. News & World Report. Capannolo and colleagues investigated patients who followed a gluten-free diet. They found that less than 7% had celiac disease and another <7% had gluten sensitivity. The majority, though—86%—did not experience any changes in symptoms after following a gluten-free diet. They concluded that self-diagnosis for gluten sensitivity is most often inaccurate. Symptoms commonly attributed to gluten sensitivity could turn out to be the result of FODMAPs, a group of carbohydrates that do not digest easily.1
1. Beyond Celiac. Non-celiac gluten sensitivity.
Classic signs and symptoms of celiac disease include: abdominal distention, abdominal pain, chronic diarrhea, anorexia, weight loss, and muscle wasting.
Additional signs and symptoms include: bulky or loose stools, fatigue, itchy skin rash, discolored teeth or loss of enamel, canker sores, joint pain, irritability, poor weight gain, delayed growth, missed menstrual cycles, and fractures or thinning bones.
A proper medical history and family history is extremely important when diagnosing celiac disease, as it is genetic. Diagnosing celiac disease early is imperative, since the disease can lead to other complications such as osteoporosis, infertility, other autoimmune conditions, and cancer.
Testing for celiac disease includes a blood test, tissue transglutaminase (tTG), and an intestinal biopsy. There isn't any particular testing done to rule in or out gluten sensitivity, although both conditions require complete elimination of gluten-containing foods. Traditional food allergy testing is performed to diagnose a wheat allergy.
Regarding drug treatments, Sheila Crowe, MD, a gastroenterologist at the University of California, San Diego School of Medicine, told celiac.org that “most of these approaches would not replace the gluten-free diet. The enzymes, for example, can only stop the effects of a few grams of gluten at a time. The average diet contains 10 to 50 grams of gluten per day.”
As of August 5, 2014, a new FDA regulation, the Gluten-Free Food Labeling Final Rule, went into effect, stating that a food must contain less than 20 parts per million (ppm) of gluten in order to bear a "gluten-free" label. According to the FDA, research supports that less than 20ppm is a safe threshold for a product to be consumed by individuals with celiac disease and other gluten-related disorders.
The final rule applies to all FDA-regulated packaged foods, including dietary supplements. The rule excludes those foods whose labeling is regulated by the U.S. Department of Agriculture (USDA) and the Alcohol and Tobacco Tax and Trade Bureau (TTB). Generally, the USDA regulates the labeling of meats, poultry, and certain egg products. (The FDA regulates the labeling of shell eggs.) The TTB regulates the labeling of most alcoholic beverages, including all distilled spirits, wines that contain 7% or more alcohol by volume, and malted beverages that are made with both malted barley and hops.
The final rule does not require or recommend that manufacturers include any particular symbol on a food label to indicate that the food meets the FDA's definition of gluten-free. The FDA defines the term "gluten-free" in this final rule and does not require the use of a symbol alone or in combination with this term.
When thinking of the healthcare requirements of those with celiac disease or gluten intolerance, most people think only of managing the symptoms. However, there are multiple components to the healthcare system involved with managing celiac disease and gluten-free needs.
Gluten in medications is a huge area of concern. The Food Allergy Labeling and Consumer Protection Act (FALCPA) has done a tremendous job in recognizing the top 8 allergens, including wheat. However, there aren't any current laws requiring that wheat or gluten derivatives be labeled on medications. Therefore, it is up to consumers to be well educated and to communicate with their doctor and pharmacist about their gluten-free requirements and the medications they have been prescribed.
There are guidelines available on the most common medications. However, formularies can change, and a different manufacturer may be used each time a prescription is filled, depending on availability. The main areas of concern include starches, starch derivatives (dextrates, dextrin), and other excipients (caramel coloring, dextrimaltose).
All hospital guests—be they inpatient, outpatient, or visitor—may visit a retail operation in the facility. This may include a gift shop, a vending machine, or a cafeteria. In these areas the facility is still responsible for getting accurate food safety information to guests.
Guests, especially elderly guests, may not ask or tell about their allergy, which is why it's so important to have the information already available for them.
Protocols for special dietary restrictions can help in the care of a patient with celiac disease or gluten-free needs.
Nursing staff must have an understanding of food allergy and special dietary needs for their patients, as it is not just the responsibility of the dietary department. If the wrong meal is delivered without being double checked, for some patients, there could be disastrous results.
Food trays should be delivered in a separate meal cart, if available. Alluserv, for example, supplies allergy-friendly healthcare meal delivery equipment options. If a separate cart is not available, food trays should be completely covered and marked accordingly to ensure there is no cross contamination during transport.
Most meal options are limited for those with gluten dietary restrictions, which often leads to eating frequent small meals. Many healthcare facilities have switched over to a 24-hour room-service model for their patients and have found it works quite well, as everyone gets what they want with less food waste.
According to Howard Waxman in the Packaged Facts January 2015 Gluten-Free Foods in the US Report, "Sales of Gluten free grew 34% annually in the five years leading up to 2014, when they reached $973 million. In 2017, Forbes reported that the total number of Americans following a gluten-free diet tripled from 2009 to 2014. Their most recent estimate was that 2.4% of Americans eat gluten-free.
Statista says the U.S. market for gluten-free foods will reach $23.9 billion by 2020.
Although the gluten-free pre-packaged industry has grown, it is extremely important for affected individuals to be vigilant and maintain a strictly gluten-free diet, including eating nothing with wheat, barley, or rye. Fortunately, there are a variety of naturally occurring gluten-free foods—such as meat, fish, fruits, and vegetables. Additionally, many breads and pastas are created with gluten alternatives such as potato, rice, soy, or bean flour. Further alternatives include almond flour, amaranth, brown rice, buckwheat, corn flour, corn starch, guar gum, lentils, potato flour, potato starch, soy flour, sweet rice, tapioca pudding, teff, and xanthan gum.
As with all food allergies, strict avoidance of the allergen (dietary gluten in the case of celiac disease) is the prescription. Therefore, everyday events in life become much more complex—like going to school or work, attending social gatherings, traveling, and dining out. Fortunately, there are a few great programs and resources to assist with these categories, which we'll explore specifically.
When a dietary restriction occurs because of food allergy, not only can a food allergy directly affect a person's line of work, but it can also affect that person's coworkers. Breakrooms and other eating areas may become health hazards. Suddenly lunch or dinner breaks aren't social calls, but risks.
In a school environment, being a kid is hard enough. Kids may be teased for any number of reasons. A child may be forced to sit at one table alone the entire school year, because it may be the only table in the entire lunchroom that is "somewhat guaranteed to be safe" or free from the offending food allergy. Without proper protocols, this may seem to be the only option for a foodservice director.
Additionally, never assume that everyone attending a foodservice event will volunteer information about food allergies or celiac disease. Having a food allergy is awkward, and regardless of the risk involved, sometimes, people would rather just pretend the allergy doesn't exist and attend without mentioning the allergy. It's always better to ask ahead of time and make everyone feel welcome.
Traveling with celiac disease or gluten-free needs also presents numerous challenges. One is completely bombarded at all times with potential threats. Furthermore, when a family, couple, or individual with food allergies travels, they must plan every meal, snack, and late night craving down to the finest detail.
A hungry child or spouse is certainly not a fun companion on a vacation, especially when they watch you eat that delicious double cheeseburger, fries, and milkshake! Fortunately, there are a few great blogs catering specifically to gluten-free travel, such as Gluten-Free Globetrotter and Gluten Free Jetset. A person with dietary limitations can take advantage of the vast knowledge these blogs offer.
Dining out is one of the hardest areas for an individual with special dietary needs, especially a food allergy or celiac disease. Celiac and gluten-free individuals too often hear things like, "Can't you just pick the croutons off?" Without specific training in the handling of special dietary requests, it is almost impossible to ensure the safety of foodservice guests.
The National Foundation for Celiac Awareness has developed a program called GREAT Kitchens for the hospitality industry. GREAT Kitchens is an online multimedia course for chefs, foodservice managers, and waitstaff. Included with the program are tools to educate front-of-the-house and back-of-the-house staff on safe gluten-free food handling.
Eggs, which are naturally gluten-free, can help replicate the texture of traditional baked goods. Gluten is a protein, and the American Egg Board states that it "entraps and holds air bubbles. A leavening agent causes the gluten network to expand; the heat causes the bubbles to rise, and then the structure sets, forming a combination of expansion, elasticity and rigidity."
Gluten-free flour has about half the protein of traditional wheat flour. The lack of protein can hamper this expansion process. Adding more eggs to the recipe adds protein to make up for gluten-free flour's lower protein content. Research at Kansas State University, led by Fadi Aramouni, PhD, revealed that adding eggs to gluten-free baking yields rolls with better crumb, deeper color, and greater volume, with "better overall quality."
Another naturally gluten-free ingredient is potatoes, which can offer satisfaction and satiety to patients avoiding gluten.
Lesley University also agreed to pay $50,000 in compensatory damages to previously identified students who have celiac disease or other food allergies.
"Gluten-free" isn't just a diet buzzword. Society is increasingly aware how they can accommodate food-allergic people. Just as avoiding allergens is crucial for food-allergic people, avoiding gluten is important for people with celiac disease.
Foodservice operators must be aware of how celiac disease and gluten intolerance affect their guests. It is important to understand the symptoms and complications people with celiac disease or gluten intolerance experience and to realize that, with most therapeutic options being in trial at best, strict avoidance of gluten is currently their only practical option.
With greater understanding of this issue and increased attention to the needs of those it affects, foodservice professionals can better serve their guests and their communities.
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If you would like to submit your evaluation and comments to the Commission on Dietetic Registration, you may do so at http://www.cdrnet.org.