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Cynthia Kupper, RD

Gluten Intolerance Group of NA

Learning Objectives

� Brief overview of gluten intolerances

� Best Practices in Food Service

� Find areas of cross-contamination

� Determine GF status

� Identify GF training needs

Specific 15-33 polymer amino acid chain (gliadin and

glutenins) found in wheat, rye, barley, hybrids of these

grains; and some oat cultivars that cause a reaction in sensitive persons

Gluten

Reactions

Intolerances metabolic,

pharmacologic, idiosyncratic.

Non-celiac, fast

Non-Celiac Gluten Sensitivity

Allergycommon; immediate

Wheat or Gluten Allergy

T-Cell Allergy +

Autoimmunedelayed

Celiac Disease

Gluten-Free Diet

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Medical Comparison of Gluten-Related Health Conditions

IgE Allergy Celiac Disease Gluten Intolerance

Reaction to: Proteins

IMMUNE

Proteins – gliadin and glutenins

IMMUNE (also autoimmune)

Proteins, carbohydrates, chemicals

INNATE IMMUNE

Reaction

time

FAST

Immediate: Seconds, minutes, hrs

Can be exercise-induced in some

SLOW

Delayed: ~30 minutes to 24 hrs

Cause known

SLOW

Delayed: up to several hrs

Difficult to detect

Not well understood

Reactions Potentially deadly.

Anaphylaxis - affects several areas of the

body simultaneously: skin: flushing,

itching, or hives; airway: swelling of the

throat, difficulty talking or breathing;

intestines: nausea, vomiting, or diarrhea;

and heart – low blood pressure or

unconsciousness and possibly death.

Does not cause death.

Damages the intestine.

Does not cause damage to the

intestine nor death.

An irritant.

GI - IBS, indigestion, abdominal pain, bloating, nausea, vomiting, and diarrhea

Systemic - fever, fatigue, sweating, and chills

Lungs - food-induced bronchitis and asthma, sneezing, runny nose, and shortness of breath

Joints - food related arthritis

Muscles and connective tissue - pain, stiffness, and swelling

Skin - itching, rashes, hives, redness, swelling, and scaling as in eczema and psoriasis

Brain - disorganized, disturbed or foggy thinking, constant headaches, migraines.

Medical Comparison of Gluten-Related Health Conditions

IgE Allergy Celiac Disease Gluten Intolerance

Detection RAST, Skin prick, Double-

blind placebo

Blood Screening:

*Deaminated EMA and/or

tTG - IgA.

IgG optional

*Positive biopsy consistent

with celiac disease or DH

*Total IgA titer

*Genetic Testing – rules out

Standard tTG or EMA –

IgA/IgG

Differential diagnosis, “rule

out”, elimination diet trial

Treatment Strict avoidance of allergen

food

Life long or until allergen

gone as shown with testing

Strict avoidance of gluten

Life long avoidance

Avoidance or limitation of

food

Presentations of Celiac Disease

Class Symptoms

Classical CD GI malabsorption Gas, bloating, diarrhea, constipation, wt.

loss, cramping, chronic fatigue, nausea,

vomiting, irritability, anemia

CD w/

Atypical

Symptoms

Few GI Symptoms

Extra intestinal

symptoms

Dermatitis Herpetiformis, growth failure,

infertility, bone disease, migraines, ataxia,

chronic pain syndrome, associated

autoimmune disorders – thyroid, diabetes,

others

Silent CD Asymptomatic No external symptoms. Internal

malabsorption syndromes – anemia,

vitamin/mineral def.Latent CD Asymptomatic

NIH Consensus Conference, 2004

Gluten Reactions - GI Symptoms

� Diarrhea

� Bloating/Gas

� Cramps/Stomach Pain

� Nausea/Vomiting

� Loss of Appetite

� Constipation

� Malaise

� Steatorrhea

� Reflux/Heartburn

� Wt Gain/Wt Loss

� Pungent Flatus

� IBS- Like Symptoms

**Lack of symptoms is not an indicator

of disease control**

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Gluten Reactions – Extra Intestinal

� ‘Brain Fog’/Confusion

� Cognitive challenges

� Irritability /

Depression

� Anxiety

� Intoxication

� Headache / Migraines

� Vertigo

� Flu-like symptoms

� Hay-fever like

symptoms

� Joint or general pain /

fibromyalgia

� Bone pain

� Weakness

� Muscle spasms

� Inflammation/

swelling

� Fatigue / Lethargy

� Insomnia

� Skin irritation

� Canker sores/

cracked lips

� Asthma

� Bronchial congestion

� Bad breath

� Sore throat

� Changes in BP

� Ataxia /

Neuropathies

� Heart palpitations

� Flushing

� Visual disturbances

� Elevated liver

enzymes

� Convulsions

� Hair falling out

Who Are GF Consumers?� Celiac Disease Patients� Wheat Allergy Patients� Others

� Autism / ADHD� Fibromyalgia / Chronic Fatigue� MS� Rheumatoid Arthritis� Skin Diseases� Wheat allergic� IBS� Schizophrenia

� Food “Faddies”

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Potentially 21-25

million+ people

use a GFD

Celiac

Disease

3 million+

Wheat

Allergy

1 million

Gluten

Intolerances

18-21 million

Being Gluten-Free

Is All About the

Food Experience!

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� Lifelong

� Strict Avoidance

� Gluten-Free Diet

Alternative drug therapy is 10-20 years away

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QOL

� Individuals with gluten intolerances are negatively impacted by the gluten-free diet

� Social and economic domains are most impacted

� Need to identify areas that intervention can make a difference

� Adolescents and the elderly are vulnerable groups

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Celiac Surveys

Adhering to GFD negatively impacts:

○ Ability to travel (82%)

○ Ability to eat out (86%)

○ Family life (67%)

○ Work/Career (41%)

○ Social activities Religious activities

�One of greatest fears is being hospitalized

�A growing need – progressive long-term care

Celiac Disease: Its Impact on Quality of Life. J Am Diet Assoc 2003, Lee and Newman

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Impact on Quality of Life

� Overall quality of life improves on diet

� Females affected more than males

� Individuals with symptoms have greatest improvement in overall quality of life rating

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Gluten Consumer Attitudes� Compulsive

� Food safety

� Cross contamination

� Suspicious & have limited trust of food industry

� Experience tells them not to trust the industry’s

knowledge and ability to safely produce GF� Consumers lack full understanding of ‘back of house’ or

mfg practices

� Perceived industry lack of understanding seriousness of

issues

� Can extrapolate information to an extreme

Gluten-Free Diners

� Are serious diners

� Ask questions

� Are appreciative of your efforts

� Praise loudly their positive experiences

“For those with gluten intolerance

- It is all about food experiences”

Gluten-Free Food Production

Establishing Safety Measures

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Best Practices for Safe

Gluten-Free Food Production

1. Established policies and procedures

2. Enforcement of policies and procedures

3. Education – all appropriate staff

4. Monitoring

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Policies and Procedures

Provides standards for practice

Quality control improves

Best Practices

Identified areas of potential problems�Identification of GF�Storage and preparation

�Cleaning

�Training�Auditing

Best Practices – GF Status

Know what you have• Raw Materials

•How do you define GF?

•How do you determine GF?

•What are the buying constraints?

Label Reading

� Allergen Labeling

� FALCPA Law

� Top 8 allergens

Wheat Milk Eggs Soy

Peanuts Tree nuts Shellfish Fin fish

� “Contains ---” or “…ingredient (wheat) …”

� Applies to FDA regulated products only

� USDA recommends voluntary use of FDA proposed guidelines

for USDA regulated products

Label Reading - FDA

� Gluten-Free Labeling� FDA proposed ruling

○ Not finalized

○ Less than 20 ppm gluten

○ No wheat, rye, barley

○ Oats ok if less than 20 ppm gluten

� 6 key words to look for on labels:

○ Wheat

○ Rye

○ Barley

○ Malt○ Oats

○ Brewers Yeast

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Label Reading - USDA

� Gluten-Free Labeling – no guidelines� Voluntary allergen statements

� Regulates meats, poultry and some egg products� Look for USDA seal on package

� 8 key words to look for on labels:

Wheat Dextrin

Rye Modified Starch

Barley

Malt

Oats

Brewers Yeast

Label Reading

� Voluntary Advisory Labeling

� “Processed (in a plant with; on the

same equipment as; etc)…”

� “May contain traces of …”

� Not Allergen Statements� Voluntary

� May not be used as intended

� May not provide useful information to consumer

� Confusing to consumers

Do not use to determine GF status of a product

Gluten-Safe Threshold

� Set at level that is safe for greatest number

� Set at level that is usually not easily reached by consumers normal consumption habits

� 3 lbs GF flour/day

20 Parts per Million� 1 minute in 2 years

� 1 tsp in 65 gals of milk

� 1 tsp flour contains more than 100 times the gluten than allowed in proposed FDA ruling

Minute amounts

Gluten-Containing Grains

Seitan

Semolina

Spelt/Spelta

Triticale

Udon

Wheat

Wheat bran

Wheat germ

Wheat starch

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RYE

BARLEY

MALT

OATS – except GF oats

WHEATBran BulgurCouscousDurumEinkornEmmerFarina FaroGraham flourKamutMatzo flour/mealOrzoPanko

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Gluten-Free Grains and Starches

� Rice

� Corn

� Soy

� Potato

� Tapioca

� Arrowroot

� Beans, legumes� Nut flours� Sorghum

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• Tef• Millet• Quinoa• Amaranth• Buckwheat• Indian Rice Grass

(Montina)

• Mesquite• Chia• Flax

Where gluten might be

The Obvious

� Bread and breaded products containing wheat, rye, barley, spelt and most oats, including sandwich breads, wraps and pitas

� Pasta� Cereals and granola� Cakes, cookies, brownies� Energy Bars� Crackers� Croutons� Thickened sauces and gravies� Prepared Meats ( deli meats, hot dogs, imitation seafood)

Where gluten might be

The Less Obvious

� Soups and soup bases

� Seasonings and seasoning mixes (gravy, chili mix)

� Soy sauce

� Salad dressings

� Certain candies – licorice and chocolate bars� Beer and Ale

� Medications, supplements, vitamin/minerals – OTC and Rx

� Art and craft supplies

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Best Practices – GF Status

• Recipes•Are recipes standardized?

•Do chefs have creative recipe manipulation freedom?

•What happens if run out of raw materials during production?

•

Gluten-Free Best Practices: Identification

1. Systems for identifying GF status of materials, recipes and finished products

� In storage (receiving and after production)

� In production areas

� For consumer

2. Systems for periodic review of GF statusDIST WHS: DMA PROD NAME: MANUFACTURER

NAME_1:

DMA BRAND

NAME:

DMA MFR ITEM #: GF Status GF Risk (1=no

risk, 3= verify periodically,

5=not allowed)

USF-PHXCheese, Blue Crumble Roth Kase Usa Roth Kase Usa 33510 GF 2

USF-PHXChip, Tortilla Corn White Round El Pasado El Pasado 5810821751 GF 2

USF-PHXMarshmallow, White Standard Jet-puffed Jet-puffed 0069966116 GF 2

LABATTWORCESTERSHIRE SAUCE DIAM CRYST DIAM CRYST 4150005308 GF 3

FSA-SEA BEEF SIRLOIN CUBE TERIYAKI THE BRUSS COMPANY BRUSS 0111MP10 Not GF5

FSA-SEA BAGUETTE FRENCH CRESTONE BAKERY CRESTONE CHI20220 Not GF5

Best Practices – GF Status

• Finished products or menu label options

•How are they identified to consumer?

•How are the identified to production staff

•How are they controlled?

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Naturally Gluten-Free Diet

� Potatoes, corn, legumes, and rice

� Fresh foods: meats, eggs, vegetables, & fruits

� Milk, cheeses, yogurt

� Fats: Margarines, butter, oils, nuts, and other fats

� Spices, Herbs

� Wine, distilled spirits, GF beers

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Contamination a Serious Concern

� Small amounts cause reactions and damage

� A concern at every stage of food access –processing and handling

� Contamination may be cumulative

� Consumers want an assurance of safety

Best Practices - Storage

Control cross-contamination

•Allergen policies for storage and handling

•Storage•Raw materials storage

•Separate areas; like with like; up vs. down

•Rework or reuse product storage•Cover and label

Best Practices - Production

Control cross-contamination

•Staging, prep and finished product handling•Area•Equipment•Packaging and holding; presentation

Labeling and communication to consumer

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Common Areas of Cross-

Contamination

• Use of common equipment, utensils that cannot be adequately cleaned• Belts, cooling line systems, overhead distribution

systems

• Impinger and conveyor ovens

• Brushes, sprayers systems, tumblers, fryers,

depositors, etc

• Airborne dust

• Cleaning processes• Wet vs. dry

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Tips for Reducing Cross-Contamination

� Use clean hands, aprons, gloves

� Use clean equipment: pots, pans, cutting boards and utensils

� Create a contact barrier. Use Clean work surfaces

� Consider identification of restricted use cutting boards and other equipment.

� Labeling

� Color Coding

� Use dedicated fresh water for boiling, poaching and steaming

� Change sanitation solution frequently and use clean rags.

Tips for Reducing Cross-Contamination

� Control airborne flour dust� Use dedicated utensils and cooking surfaces for

GF � Have dedicated equipment if adequate cleaning

is not assured:� Brushes and wooden equipment� Serving baskets if not properly cleaned

� Baking racks with direct food contact

� Toasters� Baking pans – is muffin tins, etc

� Avoid using the same preparation equipment and surfaces without appropriate dishwashing and cleaning

� Use clean aprons after handling flour

� Set up work and serving stations to minimize cross contact from share utensils, hand-service, etc

� Avoid shared fryers with breaded items

� Store gluten-containing foods BELOW GF foods

� Clearly and properly label all stored foods

� Consider PC or squeeze or pump bottles to dispense condiments. Double dipping is not acceptable

� In the event an error occurs - replace the entire plate of food. Just removing the gluten-containing food is not acceptable.

Tips for Reducing Cross-Contamination Sources of Gluten Free Foods

� Major distributors

� Med-Diet

○ http://www.800-45-sysco.com/index.html

○ use Sysco SUPC seven digit code via eSysco or from the Med-

Diet website

○ Ships direct to customer

� Sysco, UNFI, etc

� Direct Order Gluten Free Products

� Local retailer

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Stations: Sandwich Station

Store GF bread above gluten-bread

Consider cross contamination from condiments

Can GF sandwiches be safely prepared on main line

Dedicated equipment for hot sandwiches

Create a contact barrier

Stations: Grill Station

•Isolate section of grill for GF items

•Use separate utensils

•How are starches (buns, pancakes, etc) handled?

•Are Sauces GF? What is the cross contamination procedure?

Station: Fryers

GF and gluten-containing products cannot share a common fryer oil well

Can GF fryer remain such in high peak production times?

Station: Coolers

Store gluten-containing items below GF items or in dedicated areas

Remember:

Cover. Date. Label

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Station: Salad or Dessert Station

Place non-GF items AFTER GF items w/ distance between

Label items for clarity

Monitor frequently for cross contamination

Set up salad bar to isolate GF from Non-celiac.

Be sure every container has a serving utensils.

Gluten-Free Best Practices: Cross-Contamination

� Storage

� Allergens below non-allergens; dedicated/isolated area

� Open packages

� Bulk containers

� Location (prep areas)

� Labeling

� Avoid using condiments like mayonnaise that may be contaminated with breadcrumbs, or a common spreading utensil is used between GF and gluten-containing foods.

� In the event an error occurs - replace the entire plate of food. Just removing the gluten-containing food is not acceptable for these people once contamination has occurred.

� Create a Contact Barrier� Think of Kosher food preparation

� Separation and cleanliness are key!

Tips for Reducing Cross-Contamination Common Mistakes

� Cross Contamination (service)� Pulling gluten-containing items off a plate

� Sharing Utensils

� Unclean surfaces

� Failing to change gloves

� Placement of food components items in prep area

(i.e.. Croutons over salad items; breads over deli meats or plates)

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Best Practices – Quality Control

Established QC processes and training• Allergen policies

•Production schedules•Identification process

•Dedicated vs. non-dedicated production lines and

facilities•Staff education and routine guidelines

•Clothing, gloves, etc

•Break room policies•Frequent & ongoing training

•Testing

•Raw materials•Equipment

•Finished product

Gluten-Free Best Practices: Training and QC

� Staff Education� General

○ What, why, who

� Job Specific

○ Prep stations, servers

� Non-food service staff

○ Nursing, Speech therapy, PT/OT, Pharmacy, Aides

� Quality Control� Record keeping

� Corrective action

� Monitoring – internal vs. external

Front of house (servers, meal delivery, retail outlets)

� Be familiar with the GF options and/or menu� Know what GF foods are available, how they are

labeled and where they are stored

� Guide Customers to GF options� Do not prescribe – Know your role

� When in doubt – call for a manager to assist. � Don’t guess

� Don’t fake it

Quality Control

� Record, record, record!

� Policies

� Procedures

� Internal and external auditing

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Gluten-Free Beyond the KitchenGluten in Supplements, OTC

and Rx Drugs� Inactive vs. active ingredient� Binders

� Pills, capsules, powders

Gluten-Free� Inhalants� Injections

� IV’s� Patches� Elixirs

Non-food service staff

� Be familiar with how a GF diet impacts their job

� Nursing and Pharmacy

○Medications

○ Administering meds

� OT/PT and Speech

○ Food related therapy or testing

� Aides

○Nourishments

Resources for Dietitians

� ADA – Evidence Analysis Library

� Guidelines based on evidence

� Toolkits for Dietitians

� www.Gluten.net

� Resources for consumers (printer friendly)

� Resources for health care professionals

� Celiac Research Centers

� Practical Gastro series on celiac disease

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Take Away:

Safe gluten-free food service is

possible through critical analysis and

thoughtful planning …

Thank You

Cynthia Kupper

Gluten Intolerance Group of NA

www.Gluten.net

Cynthia.Kupper@gluten.net253-833-6655