Gluten-free diets: Are you prepared?

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

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.

Nursing services. Medications will have to be checked by a pharmacist. There are several Web sites that maintain the gluten-free status of medications. The most referenced is, maintained by Steve Plogsted, PharmD, at Children’s Hospital in Columbus, Ohio.

Nurses and CNAs on all shifts will need to be comfortable with the basics of a gluten-free diet. We know that up to 10% of Type 1 diabetics have celiac disease. Appropriate snacks to manage low blood sugars will have to be available—graham crackers are off limits. Your dietitian can plan appropriate snacks (discussed above).

Ancillary services. Unlike a peanut allergy, where casual skin contact can be deadly, gluten in personal care soaps and lotions generally is not a concern unless the resident has behaviors that will cause problems—for example, eating bubbles and tasting lotions. This is also true for some of the materials used in activities. Play-Doh, some tempera paints, and papier mache all contain wheat flour. There are gluten-free substitutes and your activity aides can find them when the need arises. Low-gluten communion hosts are available at I have had tearful residents when they found that they could receive communion again.

Sample menu for a gluten-free diet

The key to success is being prepared for the diet. CareOne, LLC, a skilled nursing and assisted living company, recently trained its staff in gluten-free diets in all of its 70 facilities. Celiac is a genetic autoimmune disease and often runs in families. Being able to accommodate residents and their guests provides goodwill and positive public relations.

Care planning

What if your resident has a gluten-free diet order and does not follow it? A gluten-free diet for celiac disease is considered a therapeutic diet. The Centers for Medicare & Medicaid Services’ guidelines are available to assist in determining the facility’s obligation while respecting residents’ rights.5 Patient education that includes family and visitors is important because the social aspect of food may be contributing to noncompliance. Although gluten-free foods have vastly improved in taste and texture, there are differences between these items and their traditional wheat-based counterparts. Support groups may be available in your area to assist in identifying local resources for good-tasting food. To find the group closest to your facility, e-mail

Following a prescribed diet will make a resident feel his or her best. The care plan needs to include education to ensure that the resident understands this. After all, some of the conditions that are prompting astute physicians to look at celiac disease as its possible cause include refractory diarrhea and anemia, changes in insulin/carbohydrate ration, or dermatitis herpitaformis (the skin expression of celiac disease). If cognitive decline prevents the resident from being able to retain diet information, it is our responsibility to provide quality gluten-free products to maximize acceptance.

An icon (similar to fluid restrictions and fall risks) can be used to identify residents who cannot have gluten-containing food, medications, or communion. Such identification is particularly useful for those who cannot self-advocate and for others at risk for ingesting personal hygiene products.


Three action assignments will help your fa-cility care for residents on gluten-free diets:

  1. Ask your dietitian to give clinical and food service staff a review of celiac disease and gluten-free diets. Most professional organizations have recognized the knowledge deficit and have continuing education programs available. A comprehensive review can be found at

  2. Determine your risk of having an unannounced admission needing a gluten-free diet. To be prepared, has a meal prep and education kit that can make any kitchen ready to flawlessly deliver a safe, gluten-free meal.

  3. Review your communication process for allergies. This is an opportunity to make sure other allergens, such as latex and fish, are properly noted by other departments besides nursing and dietary, including housekeeping (for latex) and the pharmacy (for fish as found in the Omega-3 supplement).

That 86-year-old resident? After several weeks on the gluten-free diet she was no longer confused. A gluten-free diet can make a world of difference in improving quality of life. In addition to celiac disease, non-celiac gluten intolerance is now being recognized and some people are choosing a wheat-free diet as a lifestyle choice.

Ronni Alicea, RD, MBA, is a dietitian in Somerset County, New Jersey. She consults for several skilled nursing and assisted living facilities. She writes and speaks nationally on managing allergy and intolerance diets in institutional settings.

For more information, e-mail To send your comments to the author and editors e-mail


  1. American Gastroenterological Association Institute medical position statement on the diagnosis and management of celiac disease. Gastroenterology 2006; 131:1977-80.
  2. Fasano A, et al. Prevalence of celiac disease in at-risk and not-at risk groups in the United States. Archives of Internal Medicine 2003; 163 (2): 286-92.
  3. National Institute of Health. Available at
  4. Lurie Y, Landau D, Pfeffer J, Oren R. Celiac disease diagnosed early in the elderly. Journal of Clinical Gastroenterology 2008; 4 (1): 59-61.
  5. State Operations Manual Appendix PP. 483.10 Residents Rights; rev. 22, 12-15-06.
Long-Term Living 2008 December;57(12):22-24

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