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Gluten-free diets: Are you prepared?

December 1, 2008
by Ronni Alicea, RD, MBA
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Providing special diets for residents with celiac disease is a growing concern

An 86-year-old resident comes back from the hospital with a diagnosis of celiac disease. A family is looking for a facility that can assure safe gluten-free meal service for their active senior. Group homes have gluten-free diets for autism spectrum residents and people with Downs syndrome are now routinely screened for celiac disease.

Gluten-free meal

Gluten-free meal

Subacute facilities are expected to manage complex patients and receive no warning when a gluten-free diet is needed. Are you prepared to handle these cases?

What is gluten?

Gluten is a protein complex found in wheat, barley, and rye as well as any oats not certified to be gluten-free. Wheat and oats are used in many products from tomato soup to lip gloss to shampoo. Gluten-containing ingredients may be found in medications, art supplies, and is in communion hosts.

What is celiac disease?

Celiac disease is an autoimmune response to gluten. A person's immune system recognizes gluten as a toxin and produces antibodies that damage the small intestine's ability to absorb nutrients, which can lead to weight loss and vitamin and mineral deficiencies unless corrected. Historically, people with celiac disease are not properly diagnosed and are treated for persistent symptoms.

The American Gastroenterology Association's September 2006 celiac position paper recommended expanding celiac disease testing consideration beyond the usual symptoms of weight loss and diarrhea. Many physicians are now exploring options when the C. dificile panel is negative. Other high-risk populations include those with medical concerns that appear on many diagnosis sheets, including unexplained iron deficiency anemia, cerebellar ataxia, recurrent migraine, Sjögren's syndrome, and Type 1 diabetes mellitus.1

The prevalence of celiac disease in the American population is quite high, with the benchmark study done in 2003 by the University of Maryland2 showing the prevalence as 1 in 133, or 1% of the population. Unfortunately, celiac disease is underdiagnosed, resulting in needless suffering. To help reverse this trend, the National Institutes of Health (NIH) has developed and implemented an education campaign.3

This physician awareness has led to an increase in people over 60 years of age being diagnosed, according to a January 2008 article in the Journal of Clinical Gastroenterology4 and the only treatment is the elimination of even causal exposure to gluten. This population will be seeking healthcare and residential services.

Facility commitment

Managing gluten-free diets, like other food allergies, depends on facility-wide awareness. While your dietitian will assist with menu design and nutrition assessment, other department heads will need to be aware of this diet order. Ancillary departments such as speech therapy, occupational therapy, pastoral services, and food-related activities are equally important. This article will explore demographics, facility preparedness, and care planning.

Facility preparedness

The kitchen. Ensuring that your kitchen is prepared to flawlessly execute a gluten-free diet order is not difficult. The Food Service Director (FSD) already includes food allergy preparedness with the annual food safety in-service. Your dietitian can do an in-service for the staff on what gluten-free diets are. Key concepts for the kitchen include:

  • Use fresh cleaning cloths. Sanitized crumbs are still allergenic!

  • Read labels of all processed foods carefully. The Dietary Managers Association has several online articles for continuing education at

  • Prepare gluten-free trays first to ensure that serving utensils are clean. The baked chicken cannot be picked up with the tongs that served the baked breaded poultry, but both dishes can be baked in the same oven provided there is no physical contact.

  • If a mistake is made, make a new tray. It is tempting to pick off the salad croutons or remove a roll from a plate, but remember that crumbs count.

  • A HIPAA-compliant way to identify the tray as “special attention” is advised. A colored tray liner, napkin, or color code on the tray ticket will help ensure that it is delivered to the proper resident.

Your kitchen already manages fish allergies, the most prevalent adult food allergy. Ask and you'll find that the kitchen staff uses a clean cutting board and knife to make the egg salad sandwich when tuna is on the menu. The same care is needed for gluten-free food preparation. Toast is one of the most challenging gluten-free favorites to execute in an institutional kitchen. Your cook knows how to make safe toast in an oven for gluten-free bread. It may make sense for a facility to purchase a dedicated toaster, used solely for gluten-free breads since even the small amounts of gluten found in a crumb can be toxic.

It is wise to have a default menu available, similar to your disaster menu. This will help ensure that safe meals can be provided until your (FSD) can order the special food needed. A sample three-day menu is available at Your menu company may have already planned a gluten-free extension for your cycle menu, too.