Learning Objectives 4/4/2011

Transcription

1 Learning Objectives Brief overview of gluten intolerances Best Practices in Food Service Find areas of cross-contamination Determine GF status Identify GF training needs Cynthia Kupper, RD Gluten Intolerance Group of NA Gluten Reactions Specific 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 Intolerances metabolic, pharmacologic, idiosyncratic. Non-celiac, fast Allergy common; immediate T-Cell Allergy + Autoimmune delayed Non-Celiac Gluten Sensitivity Wheat or Gluten Allergy Celiac Disease Gluten-Free Diet 1

2 Medical Comparison of Gluten-Related Health Conditions Reaction to: IgE Allergy Celiac Disease Gluten Intolerance Proteins IMMUNE Proteins gliadin and glutenins IMMUNE (also autoimmune) Proteins, carbohydrates, chemicals INNATE IMMUNE Medical Comparison of Gluten-Related Health Conditions IgE Allergy Celiac Disease Gluten Intolerance Reaction time Reactions FAST Immediate: Seconds, minutes, hrs Can be exercise-induced in some 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. SLOW Delayed: ~30 minutes to 24 hrs Cause known Does not cause death. Damages the intestine. 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. SLOW Delayed: up to several hrs Difficult to detect Not well understood Does not cause damage to the intestine nor death. An irritant. Detection Treatment RAST, Skin prick, Doubleblind placebo Strict avoidance of allergen food Life long or until allergen gone as shown with testing 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 Strict avoidance of gluten Life long avoidance Standard ttg or EMA IgA/IgG Differential diagnosis, rule out, elimination diet trial Avoidance or limitation of food Presentations of Celiac Disease Gluten Reactions - GI Symptoms 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 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 Silent CD Asymptomatic No external symptoms. Internal malabsorption syndromes anemia, Latent CD Asymptomatic vitamin/mineral def. **Lack of symptoms is not an indicator of disease control** NIH Consensus Conference,

3 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 Potentially million+ people use a GFD Celiac Disease 3 million+ Wheat Allergy 1 million Gluten Intolerances million Being Gluten-Free Is All About the Food Experience! 11 3

4 Lifelong Strict Avoidance Gluten-Free Diet Alternative drug therapy is years away 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 14 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 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 Celiac Disease: Its Impact on Quality of Life. J Am Diet Assoc 2003, Lee and Newman

5 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 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 Can extrapolate information to an extreme Gluten-Free Food Production Your Description Goes Here Establishing Safety Measures 5

6 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 6

7 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 Gluten-Containing Grains 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 1 minute in 2 years 1 tsp in 65 gals of milk 20 Parts per Million 1 tsp flour contains more than 100 times the gluten than allowed in proposed FDA ruling Minute amounts WHEAT Bran Bulgur Couscous Durum Einkorn Emmer Farina Faro Graham flour Kamut Matzo flour/meal Orzo Panko Seitan Semolina Spelt/Spelta Triticale Udon Wheat Wheat bran Wheat germ Wheat starch RYE BARLEY MALT OATS except GF oats 28 7

8 Gluten-Free Grains and Starches Where gluten might be Rice Corn Soy Potato Tapioca Arrowroot Beans, legumes Nut flours Sorghum Tef Millet Quinoa Amaranth Buckwheat Indian Rice Grass (Montina) Mesquite Chia Flax 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) 29 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 8

9 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 status DIST 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-PHX Cheese, Blue Crumble Roth Kase Usa Roth Kase Usa GF 2 USF-PHX Chip, Tortilla Corn White Round El Pasado El Pasado GF 2 USF-PHX Marshmallow, White Standard Jet-puffed Jet-puffed GF 2 LABATT WORCESTERSHIRE SAUCE DIAM CRYST DIAM CRYST GF 3 FSA-SEA BEEF SIRLOIN CUBE TERIYAKI THE BRUSS COMPANY BRUSS 0111MP10 Not GF 5 FSA-SEA BAGUETTE FRENCH CRESTONE BAKERY CRESTONE CHI20220 Not GF 5 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? 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 36 9

10 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 37 Best Practices - Production Control cross-contamination Your Description Goes Here Staging, prep and finished product handling Area Equipment Packaging and holding; presentation Labeling and communication to consumer 10

11 Tips for Reducing Cross-Contamination 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. 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 Tips for Reducing Cross-Contamination 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. Sources of Gluten Free Foods Major distributors Med-Diet 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 11

12 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 12

13 Station: Salad or Dessert Station Gluten-Free Best Practices: Cross-Contamination Set up salad bar to isolate GF from Nonceliac. Be sure every container has a serving utensils. Place non-gf items AFTER GF items w/ distance between Label items for clarity Monitor frequently for cross contamination Storage Allergens below non-allergens; dedicated/isolated area Open packages Bulk containers Location (prep areas) Labeling Tips for Reducing Cross-Contamination 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! 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) 13

14 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 14

15 Gluten-Free Beyond the Kitchen Gluten 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 Resources for consumers (printer friendly) Resources for health care professionals Celiac Research Centers Practical Gastro series on celiac disease 15

16 Take Away: Safe gluten-free food service is possible through critical analysis and thoughtful planning Thank You Cynthia Kupper Gluten Intolerance Group of NA