Grappling With Gluten-Free

Bread is the staff of life? It's just the opposite for some kids in your cafeteria.

By Gabriela Pacheco, RD, LD, SNS, & Kim Schwabenbauer, RD, LDN

Unless you graduated from college with a degree in nutrition or have a personal acquaintance with certain food-based medical conditions, it’s likely that you have only recently started hearing anything about “gluten-free diets” or celiac disease. But seemingly faster than a blink, many school nutrition operations now are being asked to make special menu accommodations. In addition, you may be seeing “gluten-free” labels on product packaging in your local supermarket. And references are starting to pop up in news reports.

What’s the buzz? What, exactly, is gluten and what foods contain gluten? What does it mean to have a gluten sensitivity or intolerance or to have celiac disease? And is there a reason why these medical conditions seem to be on the rise? Do school nutrition programs really have to accommodate requests for special, gluten-free diets? In this article, we’ll try to give you some of the answers.

HERE, THERE AND EVERYWHERE

Let’s start by noting that there is a reason you are hearing more about gluten today than ever before. According to a study published in Gastroenterology in July 2009, the incidence of celiac disease is more than four times higher today than it was just 50 years ago. Much of this can be attributed to advances in detection and diagnosis. But the surge in demand for gluten-free foods also is linked to a rise in consumer awareness, especially driven by celebrity references and all the other factors that fuel the latest diet or nutrition craze.

When it comes to making decisions and accommodations in your school nutrition program, it’s important to reflect separately on those children who have a medical condition that requires gluten-free accommodations versus those whose parents are making lifestyle changes. But we’re getting ahead of ourselves. Let’s get back to some underlying definitions.

Gluten is a protein that is found in wheat, rye and barley—and in any foods that include these grains as ingredients. Most bakers are familiar with gluten as the element in dough that gives it elasticity and helps it to rise. It also is credited with the chewy texture of many bread products, especially pizza crusts and bagels.

But gluten can be found far and wide throughout the food supply, because it is a part of most grain-based foods, including pasta, cereals, breads and crackers. In addition, gluten also hides in certain extracts, alcohol flavorings, hydrolyzed wheat proteins and distilled grain vinegars, which can be used as a component of condiments such as ketchup, mustard, relish, horseradish, etc. Even foods that are naturally gluten-free (such as fish, poultry and meats, as well as fruits and vegetables) can, in fact, include gluten because of additives used to preserve the item’s freshness or if the item has been further processed, such as a breaded chicken tender.

This is a significant reason why it can be very challenging to maintain a gluten-free diet—and challenging for the school nutrition professional seeking to provide gluten-free menus. Veterans have become astute label readers, recognizing that ingredients like wheat starch, wheat bran, graham flour, Kamut and hydrolyzed wheat protein all mean that gluten is present.

GLUTEN, BE GONE!

So, why do some people need to maintain a gluten-free diet? For various reasons, certain individuals are born with or develop inabilities to properly consume and process certain foods or parts of foods. You probably are familiar with some of the more well-publicized ones, like allergies to peanuts or shellfish or lactose intolerance. Scientists have found that gluten can trigger a range of adverse reactions in certain people. There are different types of gluten sensitivity, primarily celiac disease and gluten intolerance.

Celiac Disease. For people who have this chronic, genetically inherited disease, the body’s immune system responds to the presence of gluten by damaging the lining of the small intestine. Since this is where most of the nutrients in food are absorbed, the damage means that nutrients cannot be fully used by the body and pass through the digestive system without being absorbed, which can lead to nutrient deficiencies. Early diagnosis is especially important in children, since this disease can stunt their growth, due to severe calorie and vitamin/mineral insufficiencies.

But this is not the only consequence of celiac disease; other symptoms include gas, diarrhea, stomach pain, fatigue, joint pain, weight loss and an itchy skin rash. Symptoms vary from one person to another—some may show virtually no symptoms at all, while others are more debilitated. The condition is incurable, but can be managed with proper diet, allowing individuals to lead long, healthy lives. The only known treatment for celiac disease is to eat a gluten-free diet. According to the American Dietetic Association, celiac disease affects an estimated 1% of people in this country.

Gluten Intolerance. Some individuals who experience distress when eating foods containing gluten may have gluten intolerance, instead of celiac disease. In this case, although there are similar symptoms, there is no indication that gluten consumption causes damage to the small intestine. However, there are no medical tests that can confirm an intolerance to gluten; a diagnosis may be made after reducing or eliminating gluten from the diet and then gradually reintroducing gluten and carefully monitoring health status. This intolerance may be due to a variety of causes and likely will worsen over time. But it may be possible for individuals with this condition to tolerate a low-gluten diet.

GOING WITHOUT

If a student in your school or district needs to maintain a gluten-free diet, what foods must be avoided?

  • Wheat—all varieties (including einkorn, emmer, spelt and kamut), all forms (including wheat starch, wheat bran, wheat germ, cracked wheat and hydrolyzed wheat protein) and all flours that contain wheat (including plain flour, white flour, bromated flour, enriched flour, phosphated flour, self-rising flour, durum flour, farina, semolina and graham flour)
  • Barley
  • Rye
  • Cross-bred grain varieties, such as triticale (a cross between wheat and rye)

What about oats? Many people with celiac disease can tolerate small amounts of pure oats in their diet. However, gluten can get into oats used in commercial food products through cross-contamination during growing, harvesting and processing. The safest bet is to look for the “gluten-free” claim on foods that contain oats.

“Gluten-free” labeling claims are not 100% reliable, however. There is no national standard in the United States for use of the term “gluten-free” on product packaging; even foods bearing such a label may not mean gluten is completely absent.

That said, in 2007, the U.S. Food and Drug Administration (FDA) proposed a definition for voluntary use of the term. The Codex Alimentarius allows the term “gluten-free” on products that contain wheat starch, as long as the gluten portion does not exceed 20 parts per million (ppm) in the food. Four years later, this definition is still in draft form, as FDA continues to determine a tolerable dose. In the meantime, the Food Allergen Labeling and Consumer Protection Act of 2004 requires that wheat be listed separately to further help those who seek to avoid gluten.

GRAIN STRAIN

Managing celiac disease is not just about eliminating gluten from the diet. It also involves ensuring the person gets all the vitamins and nutrients the body needs—particularly iron, calcium, fiber and the B-vitamins thiamin, riboflavin, niacin and folate—and helping to facilitate weight gain. This is especially important for school-aged children, since so many of them are often underweight due to the loss in calories and nutrients as a result of side effects of the disease.

But what about the nutritional content of gluten-free alternatives—is it sound? Many dietitians do have concerns. For the most part, gluten-free alternatives are lower in B vitamins, iron, folate and dietary fiber than their counterparts. Fortunately, many manufacturers work to supplement these elements back into the final product. In addition, greater consumption of unconventional, “well-rounded” grains might prove helpful. Amaranth, buckwheat, teff, millet, quinoa and sorghum are sometimes known as the “Super Six,” because of their high nutritional content combined with the absence of gluten.

THE MIRACLE OF SCIENCE

The rising awareness of celiac disease is helping to create demand for a greater variety of gluten-free products, and manufacturers are responding by adapting recipes and product formulations. Still, there are areas—notably baked goods—that are proving to be a greater challenge. Wheat flour has long been a staple for this category, and removing gluten from flour results in serious changes in the complex chemistry of breads and similar products; it’s not easy to find other ingredients that can provide the same structure and function.

Manufacturers have been experimenting with a number of alternative ingredients, such as corn, potato, rice, tapioca, arrowroot, millet, sorghum, sweet potato, teff, soy, taro and chickpeas—just to name a few! The problem is that many of the resulting gluten-free products just don’t taste the same; they have a reputation for being dry, bland, crumbly, powdery or “oddly textured.” In addition, such products tend to have shorter shelf lives.

More recently, food science has created some new applications and ways of preparing ingredients with proper handling and packaging to enhance the performance and acceptability of gluten alternatives. For example, a review of the ingredients list of some gluten-free products may list certain gums, starches, emulsifiers, dough conditioners and dietary fibers (like inulin and oligofructose). These additives help to improve flavor, mouth feel and texture, while enhancing shelf life.

Similarly, rice ingredients offer a lowfat, high-carbohydrate alternative that is nutritionally sound and easy to digest. Plus, rice contains a fair amount of protein (gluten-free, of course) and can add a nice crunch to many items like breakfast cereals and snack products. Even pasta can be formulated with rice ingredients, making it allergen-free, while adding vitamins B and E, as well as magnesium and phosphorous.

YOUR MISSION

Your school nutrition program probably is seeing a rise in the number of requests for a variety of different special-needs diets. This is primarily due to increased awareness and diagnosis of various conditions, as well as the rise in obesity-related conditions like diabetes. A physician certification must be submitted to the school nutrition department, but associated meal costs for special ingredients or preparation equipment must be absorbed by the foodservice operation and cannot be passed along to families. Thus, making accommodations for gluten-free meals day after day could present an even more significant challenge than other special needs requests.

One reason is that many of the manufacturers who serve the school market have been slow to join some of their competitors in developing gluten-free alternatives in their product lines. We asked four different manufacturers about the availability of gluten-free products—particularly baked goods. The answer, for the most part, was that such products were only in early development, if at all.

As most school nutrition professionals know, districts are compelled by law to provide an appropriate meal for any student whose diagnosed medical condition or disability restricts their diet. For now, districts have managed this on a case-by-case basis, often buying separate ingredients to create special meals and menus. One Chicago-area system, Indian Prairie District 204, which contracts its foodservice operation, offers such items as gluten-free chicken nuggets, BBQ chicken, cheese nachos and cheese pizza. Served with fresh fruit or vegetables, these meals are prepared and stored separately to prevent cross-contamination.

GLUTEN-FREE GAINING GROUND?

While school nutrition operations are obliged to accommodate medically mandated special diet requests, they are not required to provide special meals or menus requested by parents for other reasons. It’s your choice to provide meals that comply with religious and cultural practices or to support lifestyle trends, like vegetarianism. In some cases, these accommodations make good business sense—they demonstrate support of a segment of the community or can help you gain new customers and boost daily participation.

So, brace yourself. Gluten-free diets are gaining some notoriety as a diet option—and you may start getting requests from parents who think that these choices should be offered with more regularity on your menu. As this article was being written, ABC News’ “Nightline” aired a segment that characterized gluten-free as a “hit diet.” A number of high-profile newsmakers have endorsed gluten-free diets, crediting them with increased energy levels, more restful nights, weight loss, better skin and so on. Chelsea Clinton’s wedding cake boasted gluten-free flour. “The View” co-host Elisabeth Hasselback, who has celiac disease, advocates a gluten-free diet for everyone, regardless of a medical diagnosis.

But doctors at Columbia University Medical Center warn that there is no medical evidence supporting the claim that eliminating gluten from the diet without a medical reason has any health benefits. Indeed, this diet can result in a deficiency of fiber and other important nutrients.

While trends come and go, gluten-free is here to stay—at least until science finds a better answer to treat celiac disease and other gluten sensitivities. It’s in your best interest to get up to speed—and fast. Keep your eye out for new research and new products. In the meantime, School Nutrition has another issue on special-needs diets planned for later this year; we invite you to share both your best practices and questions by e-mailing snmagazine@schoolnutrition.orgSN

Gabriela Pacheco is a school nutrition consultant in San Diego. Kim Schwabenbauer is a corporate dietitian for Super Bakery, Pittsburgh.


To Learn More

Check out the following websites to learn more about the complexities of celiac disease and gluten-free diets.

  • American Celiac Disease Alliance

www.americanceliac.org

  • American Dietetic Association

www.eatright.org/Public/content.aspx?id=5542

  • The Celiac Diet Series #1

www.healthsystem.virginia.edu/internet/digestive-health/nutritionarticles/sept0601.pdf

  • Gluten Intolerance Group of North America

www.gluten.net/downloads/print/glutenintoleranceflat.pdf

  • Nightline/Gluten-Free

http://abcnews.go.com/watch/nightline/SH5584743/VD5595832/nightline-gluten-free-food


Favorite Chicken Nuggets

YIELD: 25 nuggets

PER NUGGET: 60 cal., 5 g pro., 3 g carb., 0 g fiber, 3 g fat, 2 g sat. fat, 15 mg chol., 160 mg sod.

INGREDIENTS
  • Corn cereal, "Chex®"-style—3 cups
  • Parmesan cheese, grated—1/2 cup
  • Salt—1/2 tsp.
  • Salt, seasoned—1/2 tsp.
  • Paprika—1/4 tsp.
  • Garlic powder—1/8 tsp.
  • Butter or margarine, melted—3 Tbsps.
  • Milk—1 Tbsp.
  • Chicken breasts, boneless and skinless—1 lb.

DIRECTIONS

Cut the chicken breasts into 1x1-in. pieces.

Heat the oven to 400° F. Line a cookie sheet with foil.

Crush the cereal by placing it in a plastic bag or between sheets of waxed paper and mashing it with a rolling pin.

In a medium bowl, stir together the crushed cereal, cheese, salt, seasoned salt, paprika and garlic powder.

In a small bowl, stir together the melted butter and milk.

Dip the chicken into the butter mixture, then roll the chicken in the cereal mixture to coat evenly. Place on the cookie sheet.

Bake 9 minutes, then turn the nuggets over. Bake about 8 minutes longer or until the coating is light golden brown and the chicken is no longer pink in the center.

Confirm nutrient analysis to determine the portion size most appropriate for the meal, age group, etc.

Recipe & recipe analysis: General Mills,  http://liveglutenfreely.com

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