A pharmacy guide to essential gluten-free foods

A pharmacy guide to essential gluten-free foods Advice and support on supplying essential gluten-free foods to your coeliac customers communication excellence Quality Seal 2015 in association with CIG

Contents The role of community pharmacy Introduction Coeliac disease 4 Gluten-free prescribing guidelines 6 Types of gluten-free foods available on prescription Unit allowances 7 Unit values 8 Examples of monthly allowances 9 Dispensing checklist 10 Ingredients 13 Gluten-free wheat starch Gluten-free oats Juvela product range information 14 Juvela fresh bread ordering 18 Community pharmacy is playing an increasingly important role in the diagnosis and management of coeliac disease. Often, it is community pharmacists who are the frontline healthcare professionals signposting customers with relevant symptoms to the GP for testing 1. Following diagnosis, it is the community pharmacy who has regular contact with the patient, not only dispensing their gluten-free foods, but also providing important ongoing advice and support. In some parts of the country which run gluten-free supply schemes, this role for community pharmacy is more formally acknowledged, and involves a mandatory annual review for all patients enrolled in the service. With these schemes demonstrating efficiencies and benefits for both patients and healthcare professionals, it is likely that they will become more widespread. This guide has been produced as an information resource for pharmacists and the pharmacy team on coeliac disease and dispensing and supplying essential gluten-free foods. 1 NICE Coeliac Disease: recognition, assessment and management NICE guidelines (NG20) Published date: September 2015 2 3

Coeliac disease is a life-long autoimmune condition triggered by an intolerance to gluten, a protein found in wheat, and also barley and rye. The ingestion of any amount of gluten will cause chronic inflammation and trigger an immune response, flattening the villi in the small intestine. This results in a range of symptoms in genetically predisposed people of any age. In the UK, 1 in 100 people are potentially affected; however, only 24% of those with the condition are clinically diagnosed 2. Symptoms of coeliac disease Symptoms of coeliac disease will vary from person to person and can be mild or severe. They include typical gastrointestinal symptoms such as constipation, diarrhoea, bloating, wind, abdominal pain and nausea. Other non-specific symptoms such as mouth ulcers, joint or bone pain, anaemia, headaches, skin problems and weight loss are also associated with undiagnosed coeliac disease. Diagnosing coeliac disease Coeliac disease As coeliac disease is often misdiagnosed as Irritable Bowel Syndrome, pharmacists are ideally placed to help identify people with symptoms and signpost them for further testing. TOP TIP Be alert to those customers TOP repeatedly TIP coming back for the same OTC remedies for IBS. If concerned, advise that they should be tested for coeliac disease. Testing for coeliac disease NICE 1 recommends that serological investigations and a biopsy of the small intestine provide a definitive diagnosis for adults. For some children a biopsy may not be necessary 3. Dermatitis Herpetiformis (DH) is a skin manifestation of coeliac disease, affecting around one in 10,000 people in the UK. A rash, with raised red patches, sometimes with blisters, occurs on the elbows, knees, shoulders, buttocks and face. Many DH patients will not have any gastrointestinal symptoms but damage to the villi in the small intestine will still have occurred. Treatment and management TOP TIP Advise customers of the TOP importance TIP of NOT removing gluten from their diet until they have received a confirmed diagnosis of coeliac disease. Coeliac disease and DH can be successfully treated and managed by adherence to a strict gluten-free diet. Complying with a glutenfree diet reduces the risk of long-term health complications such as osteoporosis, lymphoma and small bowel cancer. If patients maintain a strict gluten-free diet they can expect to lead a full and healthy life 1. To assist patients in adhering to a gluten-free diet, the NHS offers a range of staple gluten-free foods available from the pharmacy via a prescription or pharmacy supply. These specialist gluten-free products, including bread, all-purpose flour mixes, breakfast cereals, pasta and crackers, are often nutrient enriched, and help patients adapt to this challenging new diet. 2 West J, Fleming K, Tata LJ et al (2014). Incidence and prevalence of coeliac disease and dermatitis herpetiformis in the UK over two decades: a population based study. The American Journal of Gastroenterology 3 New guidance on diagnosis in children published by Coeliac UK and the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) https://bspghan.org.uk/guidelines 4 5

Gluten-free prescribing guidelines Gluten-free foods on prescription Prescribing of gluten-free staple foods is considered an essential NHS service provided to all patients medically diagnosed with coeliac disease and dermatitis herpitiformis. National Prescribing Guidelines 4 recommend that patients have access to a reasonable choice of staple gluten-free foods to help them maintain and manage their life-long gluten-free diet, ensuring their essential dietary and nutritional needs are met 5. Types of food available on prescription The types of staple gluten-free foods available on prescription are approved by the Advisory Committee on Borderline Substances (ACBS). Bread & Rolls - a selection of fresh andlonglife gluten-free loaves and rolls available in white andfibre varieties. All-purpose Flour Mixes - gluten-free flour substitutes in white andfibre varieties - suitable for makingbread andall general baking. Breakfast Cereals - a selection of fortifiedbreakfast cereals and pure oats *. Pasta - available in a selection of shapes in white andfibre varieties. Pizza Bases - part-baked pizza bases ready totop andbake. Crackers - a selection of savoury biscuits, crackers andcrispbread. Biscuits - a selection of plain sweet biscuits. (Biscuits are only prescribed in exceptional circumstances on clinical advice). The table below indicates the recommended number of units for different age and gender groups. Age Group Child 1-3 years 10 Child 4-6 years 11 Child 7-10 years 13 Child 11-14 years e 15 Child 15-18 1 years r 18 Male 19-59 years 18 Male 60-74 years 16 Male 75+ years 14 Female 19-74 years 14 Female 75+ years 12 3rd trimester pregnancy Breastfeeding Unit Allowances Recommended No. of units Add 1 unit Add 4 units * Pure oats - sourced from uncontaminated oats milled in a dedicated gluten-free production environment. Advise patients to check with their healthcare team should they have any concerns about including oats in their gluten-free diet. 4 Gluten-free Foods: a revised prescribing guide 2011 produced in association with the British Dietetic Association (BDA), the Primary Care Society for Gastroenterology (PCSG), and Coeliac UK. 6 5 National Prescribing Guidelines are based on information from the National Diet and Nutrition Survey. 7

Gluten-free prescribing guidelines Unit Values Typical Monthly Allowances 1unit 1.5 units 12 units = CHILD AGED 11-14 3 x loaves of White Bread 3 x packs of Fibre Rolls 1 x pack White Mix 1 x pack of Pasta (500g) 1 x pack of Breakfast Cereal 1 x pack of Pizza Bases 1 (400g) loaf /1 (5x85g) pack of rolls 1 (300-500g) pack of breakfast cereal 1 (500g) pack of all-purpose flour mix This equates to 13 units MALE AGED 19-59 8 x loaves of Fresh Bread 2 x packs of Fibre Mix 1 x pack of Pasta (250g) 1 x pack of Pizza Bases 1 x pack of Crackers 2 x packs of Breakfast Cereal 1 (250g) pack of pasta 1 (500g) pack of pasta This equates to 18 units FEMALE AGED 19-74 1 (2x180g) pack of pizza bases 2 x loaves of Fibre Bread 1 x pack of White Rolls 1 x pack of White Mix 1 x pack of Fibre Mix 1 x pack of Pasta (500g) 1 x pack of Pizza Bases 1 x pack of Crackers 2 x packs of Breakfast Cereal This equates to 14 units Gluten-free White and Fibre Mixes are an all-purpose flour substitute. Fresh loaves and rolls are supplied in cases of 8. 1 (200g) pack of crackers 4 Gluten-free Foods: a revised prescribing guide 2011 produced in association with the British Dietetic Association (BDA), 8 the Primary Care Society for Gastroenterology (PCSG), and Coeliac UK. 9

Dispensing Checklist Eligibility for free prescriptions (England only) Check if your customers are eligible for free prescriptions. Provide guidance and advice on how to obtain a Prescription Prepayment Certificate (PPC). Provide a FP95 form or direct the customer to the nhsba website for more information: www.nhsbsa.nhs.uk Ordering amounts Confirm with your customers how much food they can order per month (See page 7). There is some variation around the country so please check with your Local Pharmaceutical Committee (LPC) for guidance on the gluten-free prescribing policy in your area. TOP TIP Advise your coeliac customers to keep a food diary to record how much staple food they eat in a typical month. Ask them to think about how many slices of bread, bowls of cereal, pasta, pizzas and crackers they used to eat before being diagnosed. GLUTEN-FREE STARTER PACK Advise your new coeliac customers to request a starter pack available free from gluten-free manufacturers. These contain a range of staple gluten-free products for your customer to try before setting up a regular order. Gluten-free formulary MIMS list all ACBS approved products, but your Clinical Commissioning Group Medicines Management Team may have produced its own list. Check with your LPC that you have the latest version of the glutenfree formulary, so you can advise your coeliac customers on what products are available in your area. Changing orders Please check with your coeliac customers that they understand the arrangements for repeating and amending gluten-free prescriptions in your area. Most customers prefer a monthly order. Collecting orders Check with your coeliac customers that they are aware of the specific collection days for fresh bread (see pages 18-19) Are your coeliac customers eligible for your home delivery service? TOP TIP Advise new coeliac customers of the benefits of electronic repeat prescriptions and to opt-in to EPS (if available). Direct customers to the hscic website for more information on EPS: www.hscic.gov.uk/eps 10 11

Dispensing Checklist Ingredients Annual review UK clinical management guidelines recommend that all coeliacs should receive an annual review 6. The purpose of an annual review is to monitor symptom improvement, nutritional status, dietary compliance and to check routine blood test results. In some parts of the country operating pharmacy supply schemes, pharmacists are providing an annual health check for their coeliac customers. The results of the annual health check are sent to the GP. Those customers who are symptomatic and require a full medical review are called back to their GP for re-referral to their dietitian or gastrotenterologist. TOP TIP Check with your coeliac customer that they are aware of the procedure for annual review in your area. If you should have any concerns about your coeliac customer, particularly if they have not had a review since diagnosis, please refer them back to their GP. Gluten-free wheat starch Gluten-free wheat starch (also known as Codex Wheat Starch) is a specially manufactured ingredient used in some staple gluten-free foods available on prescription, such as breads and flour mixes. This is wheat starch, in which the toxic protein (gluten), has been removed through a series of washing processes. Manufacturers choose to use this ingredient as the baking quality and texture of these products more closely resembles gluten-containing foods. This is important as it makes the diet more palatable and has been shown to improve adherence to the diet. The removal of the gluten is subject to strict quality control and rigorous testing to ensure that the finished product complies with the Codex standard for gluten-free foods of less than 20 parts per million. At this level, people with coeliac disease can safely eat these foods in unlimited amounts 7. Gluten-free oats Oats contain a similar protein to gluten called avenin. Although oats are naturally gluten-free they can be contaminated during processing. Recently, several manufacturers have produced gluten-free oats sourced from uncontaminated oats milled in a dedicated production environment. These are often referred to as pure oats. The British Society of Gastroenterology (BSG) in recent guidelines recommends that gluten-free oats can be introduced into the diet from diagnosis. However, they acknowledge that a small percentage of patients eating a diet containing gluten-free oats may continue to have symptoms and advise that these patients review their use with a healthcare professional 6. 6 British Society of Gastroenterology guidelines on the diagnosis and management 7 Codex Standard for Foods for Special Dietary Uses for Person Intolerant to Gluten. 2008 of coeliac disease Gut 2014 12 13

Juvela Product Range Information Juvela Products Pack Size Gluten Free Wheat Free Milk FRESH LOAVES & ROLLS Soya Egg Unit Value PIP Code Fresh White Loaf 8x400g X* X X 8 322-0217 Fresh Fibre Loaf 8x400g X* X X 8 339-9789 Fresh White Rolls 8x5x85g X* X X 8 355-8871 Fresh Fibre Rolls 8x5x85g X* X X 8 355-6800 LONG-LIFE AND PART-BAKED LOAVES & ROLLS White Loaf sliced 400g X* X X 1 074-8590 White Loaf unsliced 400g X* X X 1 031-4781 Fibre Loaf sliced 400g X* X X 1 074-8632 Fibre Loaf unsliced 400g X* X X 1 010-1675 White Part Baked Loaf 400g X* X X 1 273-6882 Fibre Part Baked Loaf 400g X* X X 1 273-6890 White Rolls 5x85g X* X X 1 010-5916 Fibre Rolls 5x85g X* X X 1 080-3668 White Part Baked Rolls 5x75g X* X X 1 243-7267 Fibre Part Baked Rolls 5x75g X* X X 1 262-9020 MIXES White Mix 500g X* X X 2 035-2161 Fibre Mix 500g X* X X 2 023-6042 Harvest Mix 500g X X X 2 247-7875 * this product is made from gluten-free wheat starch which complies with the Codex Alimentarius standard for gluten-free foods and is suitable for a gluten-free diet. Useful Information FRESH LOAVES & ROLLS Freshly baked bread ready to eat straight from the pack (6 days shelf life from day of receipt). Suitable for freezing for up to one month. For Fresh Bread ordering information, see page 18. Portion sizes: Loaves - approx 14 slices, 3-4 slices per serving; Rolls - 5 rolls per pack, 1-2 rolls per serving. LONG-LIFE AND PART-BAKED LOAVES & ROLLS Specially packaged to give an extended shelf life; 13 weeks unopened from date of baking. Once opened, reseal and store in a cool dry place and use within 2-3 days. Long life loaves and rolls are all quickly and easily refreshed back to oven baked freshness in a microwave or oven; Part baked loaves and rolls are suitable for oven baking for fresh warm crusty bread Suitable for freezing - to freeze, pierce a hole in outer packaging or remove bread from packaging and place in freezer bag. Can be frozen for up to one month. Portion sizes: Loaves - approx 14 slices per loaf, 3-4 slices per serving; Rolls - 5 rolls per pack, 1-2 rolls per serving MIXES Versatile all-purpose flour substitutes suitable for making bread and all general baking. Each box contains a sachet of yeast for breadmaking. Mixes are enriched with B vitamins and milk powder for added calcium. Portion sizes: Each 500g pack can make either: 2 loaves of bread (approx 14 slices per loaf), OR 12 bread rolls OR 2x8 sandwich cakes OR 24 fairy cakes, OR enough pastry to line 2 large quiche tins. It can also be used to thicken soups, sauces and gravies. 14 15

Juvela Product Range Information Juvela Products Pack Size Gluten Free Wheat Free Milk BREAKFAST CEREALS Soya Egg Unit Value PIP Code Flakes 300g X X X 1.5 371-1652 Fibre Flakes 300g X X X 1.5 371-1660 Crispy Rice 375g X X X 1.5 388-2982 Corn Flakes 375g X X X 1.5 388-2990 Pure Oats 500g X X X 1.5 371-1678 PASTA & PIZZA BASES Fusilli 500g X X 2 280-7980 Spaghetti 500g X X 2 280-7998 Macaroni 500g X X 2 280-8004 Lasagne Sheets 250g X X 1 280-7972 Tagliatelle 250g X X 1 319-3497 Fibre Penne 500g X X 2 332-8010 Fibre Linguine 500g X X 2 332-8002 Pizza Bases 2x180g X* X X 1 265-4390 CRACKERS Crispbread 200g X X X 1 236-6136 Savoury Biscuits 150g X* X X 1 310-7893 BISCUITS Digestive Biscuits 150g X* X 1 210-0923 Tea Biscuits 150g X* X 1 210-0915 Sweet Biscuits 150g X X X 1 276-4959 Useful Information BREAKFAST CEREALS Breakfast cereals: fortified with vitamins and minerals; Fibre Flakes are also high in fibre Portion sizes: approx 8-10 servings per box. Pure Oats - sourced from uncontaminated oats milled in a dedicated production environment. Portion sizes: approx 10 servings per box. PASTA & PIZZA BASES Pasta: High quality and versatile pasta shapes which retain shape and texture during cooking. Portion sizes: 500g pack = 6-7 servings; 250g pack = 3-4 servings. Pizza Bases: Light textured part-baked pizza bases ready to be topped and baked. 13 week shelf life from date of baking; once opened, use within 3 days. Suitable for freezing - place in a sealed freezer bag; can be frozen for up to 1 month. Portion sizes: 2 per pack - 1 as a main meal or 1/2 as a base for a snack. CRACKERS Portable snacks to provide versatility and convenience. Once opened, will stay fresh for several weeks if stored in an airtight container. Portion sizes: 3-4 crackers per serving (14 crispbread per box; 18 savoury biscuits per box). BISCUITS Portable snacks to provide versatility and convenience. Once opened, will stay fresh for several weeks if stored in an airtight container. Portion sizes: 1-2 biscuits. (18 Tea/Digestive per box; 14 Sweet biscuits per box). Biscuits available on healthcare advice in exceptional circumstances only. *this product is made from gluten-free wheat starch which complies with the Codex Alimentarius standard for gluten-free foods 16 and is suitable for a gluten-free diet. 17

Ordering Juvela Fresh Bread Juvela Fresh White and Fibre Loaves and Rolls are available in standard and mixed case options. The minimum order is 1 case 1 case is made up of 8 units (either 1x8 or 2x4) How to order 0871 872 1872 Northern Ireland: 028 9079 7458 If you do not have an account set up, please call 0844 854 4998 www.juvela.co.uk/fresh-bread-ordering via your pharmacy PMR system Some pharmacists MAY need to use the phone line for mixed cases When to order Standard cases are made up of 8 units: 8 Fresh White Loaves Wednesday & Friday delivery Northern Ireland: Thursday delivery 8 pkts Fresh White Rolls* Mixed cases are made up of 2 x 4 units: 4 Fresh White Loaves OR 8 Fresh Fibre Loaves Wednesday & Friday delivery Northern Ireland: Thursday delivery 8 pkts Fresh Fibre Rolls* 4 Fresh Fibre Loaves The standard cases of 8 Juvela Fresh Loaves are available twice a week and are delivered directly to the pharmacy on a Wednesday or Friday before 5.30pm. For a Wednesday delivery, please place the order before 10am on the preceding Monday. For a Friday delivery, please place the order before 10am on the preceding Wednesday. The mixed* Fresh cases and standard cases of 8 packets of Juvela Fresh Rolls* are available once a week and are delivered directly to the pharmacy before 5.30pm on a Friday only. For a Friday delivery, please place the order before 10am on the preceding Wednesday. 4 pkts Fresh White Rolls* AND 4 pkts Fresh Fibre Rolls* Northern Ireland: the Fresh Bread is delivered once a week on a Thursday. Please place the order before 10am on the preceding Monday. *Fresh Rolls and mixed cases are available in mainland UK only. 18 19

Health & wellbeing resources to support your coeliac customers As the healthcare professionals at the centre of the coeliac pathway we have put together a range of useful resources for you to use and share with your coeliac customers. Guide to Gluten-Free Foods from the Pharmacy Juvela Product Guide Customer Food Diary Customer Information & Recipe Resources essential gluten-free foods from the pharmacy 0800 783 1992 hcp@juvela.co.uk www.juvela.co.uk/hcp communication excellence Quality Seal 2015 in association with CIG This communication has been approved by the NPA* *The NPA will have no liability to any person or entity with liability, loss or damage caused or alleged to have been caused directly or indirectly by information therein. The NPA is not responsible for the content of any non-npa websites mentioned in this programme or for the accuracy of any information found there. The fact that a website, organisation or product is mentioned in the programme does not mean that the NPA either approves of it or endorses it. APRIL 2015