Gluten-free Food ServiceA Systems Approach

Lacey Wilson MPH, RDwww.TheGlutenFreeNutritionist.blogspot.com

About me• My perspective – big and small

picture• Wellness Coach• Gluten-free consultant & Advocate• Celiac Disease• New Mom• Blogger• Angry Runner• Devoted member of Netflix

Presentation ObjectiveIntroduce you to the gluten-free lifestyle and provide insight going

forward with labeling to protect the consumer

Presentation Outline• 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

• Anecdotally: other diseases, disorders & ‘weight loss’

All considered a gluten Special

Dietary Need (SDN)

Medical Necessity

Celiac DiseaseCeliac 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 (‘immuno-compromised)

– 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

• 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

• GI Symptoms– Diarrhea/constipation– Bloating– Cramping– Fatty stool– Vomiting– Loss of villi– Nutrient Deficiency

*While a CD ‘reaction’ may not be an acute, visibly noticeable one, chronic exposure leads to comorbidities and cancer.

Early Statistics and Estimates2,3,4

• 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 ProtectionAct of 20041, Title II of Public Law 108-282,enacted on August 2, 2004, which directs theSecretary of Health and Human Services topropose and later make final a rule that definesand 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 Awar

eness (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 consumerSupport laws and uniformity

Succinctly communicate

References1. 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.org4. Rubio-Tapia A, Murray JA (2010). Celiac disease. Curr Opin Gastroenterol.

(2):116-22.5. 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 diet-adherent non-responsive celiac disease patients. BMC Gastroenterol. 13:40.