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Gluten-Free Food Service in Health Care: A Practical Guide

Many people with celiac disease have difficulty finding safe and palatable gluten-free meals and snacks in places like hospitals, long-term care facilities and retirement homes.

For those with celiac disease, eating gluten can negatively affect both mental and physical health, as well as quality of life. The longer the stay in a care facility, the greater the risk.

If you’re a Nutrition/Food Service manager working in healthcare, these guidelines are designed to help you and your staff improve safe and palatable gluten-free food service.

The guide includes comprehensive advice for leadership and teaching tools for front line staff.

Venn diagram showing person centred approach to Food Service Provision for Celiac Disease

 

Feb 2nd 2024

CBC Radio’s Andrew Coppolino reports on CCA’s new Gluten-Free Food Service in Healthcare Guide. Interviews with Doris Foster, lead author and CCA board member. and Linda Sill who’s mother got consistently glutened in long-term care. 


 

This guide was developed by dietitians at Celiac Canada with expertise in food service management, with financial support from the CCA’s Quebec Chapter. 

We encourage you to share it with your peers

We welcome your feedback. Please send comments to clientsupport@celiac.ca

Table of Contents

Brief Overview of the Gluten-free Diet

The Team Who Works Together to Provide a Safe Gluten-free Diet

  • Patient/Resident/Family or Substitute Decision Maker
  • Nutrition or Food Service Manager/Supervisor
  • Registered Dietitian/Diet Technician
  • Cook/Chef
  • Food Service Worker
  • Nursing Staff
  • Personal Support Worker

Gluten-free Food Service

  • Planning
    • Developing or customizing the gluten-free menu
    • Nutritional considerations
    • Menu Ideas
  • Procurement
    • Sourcing
    • Receiving
    • Storage
  • Preparation
    • Avoiding cross-contamination
  • Service and Delivery
    • Tray Service
    • Dining Room Service
    • Foods Brought from Home

Appendices

Appendix A – Gluten-Containing Ingredients

Appendix B – Gluten-Free Menu Planning: Foods Allowed/Foods to Question/Foods to Avoid 

Appendix C – How to Read a Food Label

Appendix D – Unexpected Sources of Gluten

Appendix E – Thickening Agents in Gluten-Free Cooking 

Appendix F – Meal and Snack Suggestions

Appendix G – Teaching Tools  

Gluten-free Diet Overview

What is gluten?

 

Gluten is a protein found in wheat, rye and barley. When mixed with a liquid it creates the elastic texture of raw dough that causes baked products to rise. Regular oats (not labelled “gluten-free”) are frequently contaminated with gluten containing grains during the growing, harvesting, transportation and milling processes. Therefore wheat, barley, rye and regular oats, and the majority of ingredients/ foods made from these grains, are NOT ALLOWED on the gluten-free diet. See Appendix A for a list of gluten containing ingredients that should be avoided.

Who Needs the Gluten-Free Diet?

 

Individuals with celiac disease must follow a strict gluten-free diet for life. People with non-celiac gluten sensitivity also benefit from a gluten-free diet.

Why do people need to follow a strict gluten-free diet?

For individuals with celiac disease, even small amounts of gluten can damage the small intestine and reduce the body’s ability to absorb nutrients. It can also cause a wide range of negative health symptoms, some of which are severe. In addition, consumption of gluten over  long periods of time can cause serious health problems.

 

For people with non-celiac gluten sensitivity, gluten does not damage the small intestine. However, eating gluten can cause various negative health symptoms.

Food Service in Health Care and Congregate Settings

 

In a health care or other congregate setting, where people with a gluten-related disorder rely on others to provide food service, the patient or resident is vulnerable to exposure to gluten, and this risk increases with the longer the length of stay. This can negatively impact both mental and physical health and quality of life.

It’s very important that health care and congregate settings make every effort to provide safe and palatable gluten-free food service.  This guide lays out all you need to know.

The Team Who Works Together to Support Gluten-free Food Service

  • Patient/Resident/Family or Substitute Decision Maker. 
  • Nutrition/Food Service Manager/Supervisor
  • Registered dietitian/Diet technician
  • Cook/Chef
  • Food Service Worker
  • Nursing Staff
  • Personal Support Worker 

Roles

Patient/Resident/Family or Substitute Decision Maker

  • The patient/resident or close family are the best source of information regarding food preferences, foods they can and cannot tolerate and health conditions which impact food consumption; their input is critical to patient satisfaction and optimizing health.
  • A new admission on a gluten-free diet should always be assessed by the Registered Dietitian as soon as possible.
  • If the Registered Dietitian is not available on or shortly after admission, someone from Nutrition/ Food Services should visit the patient as soon as possible to obtain food preferences until the Registered Dietitian is available.

Nutrition/Food Service Manager with the Support of Supervisors

  • Modify menus and utilize gluten-free products that are good tasting, nutritious and which provide variety.
  • Create processes to monitor food service to ensure the medical and quality of life needs of gluten-free patients/residents are met.
  • Put in place protocols for ingredient or product substitutions and ensure they are followed.
  • Ensure all foodservice staff are trained in gluten-free food handling both in the kitchen and in dining rooms / service areas if applicable.

Registered Dietitian/Diet Technicians

  • Meet with the patient/resident on admission to obtain a diet history to understand what food items they prefer and/or usually eat.
  • Review gluten-free menu for nutritional adequacy and provide support for menu planning and staff education.
  • Communicate patient/resident nutrition care plans with the diet office / food service staff as needed.
  • Follow up to ensure patient/resident needs are being met and adjust care plan as necessary.
 

Cooks

  • Follow best practice for storage and preparation to prevent cross-contamination and ensure menu items are truly gluten-free.
  • Follow standard recipes and participate in recipe development to improve quality and variety where applicable.

Food Service Workers

  • Learn how to identify gluten-containing foods and gluten-free foods correctly with the support of the Nutrition/Food Service leadership team and the Registered Dietitian.
  • If in doubt always ask.
  • Use best practice procedures to avoid cross-contamination.
  • Report patient/resident comments and feedback about gluten-free service to Food Service leadership.

Nursing Staff

  • Document the need for a gluten-free diet in the medical record and care plan.
  • Do not provide gluten-containing foods e.g., regular cookies, other baked goods, snacks to patients requiring gluten-free food.
  • Communicate feedback from the patient/resident/family to the Registered Dietitian / Diet Office or Nutrition/Food Service leadership team as appropriate.

Personal Support Worker

  • Learn how to identify gluten-containing and gluten-free foods correctly with the support of the Nutrition/Food Service leadership team and the Registered Dietitian.
  • If in doubt always ask.
  • Share resident comments and feedback with the Nutrition/Food Service leadership team.
  • Ensure patient/resident’s chart notes include any concerns regarding gluten-free meal service.

Gluten Free Food Service – Planning

Developing or Customizing a Gluten-Free Menu

Eliminate all wheat, barley and rye and their derivatives i.e. an ingredient/food made from these sources. Identify sources of these gluten-containing grains in the table Appendix A

  • Regular oats are not allowed; however, specially produced oats labelled “gluten free” are allowed.
  • Remember “wheat free” doesn’t always mean “gluten free” – the product could contain barley, rye or regular oats.
  • See the table Appendix B for a detailed list of foods allowed / foods to question / foods to avoid by category.
  • As much as possible use naturally gluten-free foods e.g. most fruit, vegetables, meats and alternatives, milk, cheese, rice and other gluten-free grains labelled “gluten free” etc.
  • Wherever possible use products labelled “gluten free” to remove the guess work.
  • Do not serve foods with “May Contain Gluten” statements unless the product also carries a “gluten- free” claim.
  • For tips on How to Read a Food Label see table Appendix C.
  • For more in-depth information on reading food labels see Celiac Canada’s Labelling Guide 
  • For tips on How to Avoid Unexpected Sources of Gluten see table Appendix D.
  • There may be gluten-free alternatives available for many traditional gluten-containing foods. Check with your supplier. There are new products available frequently.
  • Encourage the use of gluten-free items across the board where possible to maximize menu variety, for example, use gluten-free starches/flours to thicken gluten-free products (see Appendix E), gluten-free soup and gravy bases; gluten-free soy sauce, and gluten-free salad dressings, etc.
  • A “write-in list” or list of gluten-free items that are always available, outside of the menu served that day, can help to provide variety in what can be a very restrictive diet. These items are ideally non- perishable or frozen, and wrapped individually, to easily augment the patient’s menu, for example, individually wrapped frozen gluten-free muffins. Other good choices for “write ins” include cheese slices, fresh fruit, gluten-free yogurt and puddings, etc.
  • If you really cannot control cross-contamination in your kitchen, consider using pre-packaged gluten-free meals which just need to be heated. 

Nutritional Considerations

When planning a gluten-free menu, key nutrients of concern are fibre, iron, vitamin D and calcium. Ways to Improve Nutritional Content

  • Choose products made from whole grains or pulses. Pulses include dried beans, peas and lentils. Use of these items increase fibre and nutrients e.g., bread products or pasta made from whole grains like brown rice, gluten-free oats, quinoa and sorghum or pulses (e.g. chickpeas, beans, lentils) rather than white rice-based items.
  • Swap low fibre gluten-free cereals with higher fibre hot or cold cereals (e.g. gluten-free oatmeal).
  • Use tips to increase fibre on the gluten-free diet to help your planning. 
  • Protein sources like meat, poultry and fish are good sources of iron and are gluten-free.
  • Other sources of iron include leafy greens, pulses (dried beans, lentils and peas), nuts and seeds.
  • Vitamin D and calcium is found in gluten-free dairy products (milk, cheese, gluten-free yogurt).
  • Sometimes supplementation is necessary to meet nutrient needs (discuss with Registered Dietitian).

Budget-Friendly Tips

  • Gluten-free corn tortillas served as a wrap are lower cost than most gluten-free bread products.
  • Incorporate more plant sources of protein (e.g., pulses {dried beans, peas, lentils}, fruits, vegetables, nuts, seeds).
  • If you prepare food in your facility, use base ingredients which are gluten-free if possible, reducing the need to buy specialty products.
  • Where possible, buy individually wrapped gluten-free products, or individually wrap and freeze them in-house, reducing waste.

Food Quality

  • If a gluten-free menu item is not good quality i.e., you wouldn’t want to eat it, find another alternative.
  • If you can’t serve good quality safe gluten-free toast i.e., it won’t be good quality by the time it reaches the patient or you don’t have a dedicated toaster, serve gluten-free muffins, gluten-free pancakes or another alternative that is both gluten-free and of good quality.
  • Gluten free bread served cold is generally not palatable – it tends to be dry and crumble. If you are going to serve gluten-free bread it should either be warmed e.g. place it under the lid on the hot side of re-thermalization systems, wrap it in heat resistant packaging like a wax paper bag while it is warmed, or toast it in a dedicated toaster. Re-usable toaster bags are generally not acceptable in institutional food service e.g., the same bag should not be re-used in a toaster used for multiple patients.

Variety

Especially for long stay patients, it is important to offer as much variety as possible. Consider bringing in some items you don’t normally serve, perhaps from the grocery or health food store, to augment variety. The family may also be able to bring in some favourite foods to increase variety. Make sure these are labelled “gluten free” with the client’s name and date.

Menu Ideas

Meal and snack suggestions can be found in Appendix F. There should be gluten-free snacks in emergency departments and on patient care units where possible.

Diet History 

Consulting with the patient/resident on what they normally eat at home and what you can provide helps to reduce food waste and improve satisfaction. There is no point sourcing and serving items they don’t like or can’t eat.

Feedback

Ask patients and residents about the gluten-free meals you provide. Use feedback to help you continuously improve your menu. Maintain a quality improvement focus, consider feedback a gift to help you continually improve your service.

Procurement

It can be challenging to source gluten-free products in small quantities, of good quality, while at the same time providing variety. Below are some suggestions to make this easier and ways to help you ensure the product you serve is truly gluten-free.

Sourcing

  • Where possible, use a distributor or vendor who makes it easy for you to identify gluten-free products e.g. Sysco allows you to sort the order guide by “gluten-free” and the symbol for gluten free can be shown beside the product.
  • Make sure you understand how to search for gluten-free products on your distributor or supplier’s order guide. If you don’t know how, ask; if they don’t have this feature ask for it.
  • Ideally choose foods with a gluten-free claim to remove the guess work.
  • If the item does not have a “gluten-free” claim, and you think it may be gluten free, read the ingredient list and/or refer to the resources in the Appendices. When in doubt, do not serve!
  • Food products may be reformulated and what was previously gluten-free can change. Keep an eye out for notifications from the vendor, and monitor which products currently have a gluten-free claim. If a patient/resident appears to be not tolerating a product you believe to be gluten-free follow up with the vendor.

Procuring gluten-free foods may be easier than you think!

  • Procuring more naturally gluten-free foods (most protein, fruit, vegetables, dairy) is a cost-effective way to source menu items.
  • There are a growing number of gluten-free products on the market every day. Purchase gluten-free building blocks to make more in-house menu items gluten free e.g., purchase gluten-free gravy and soup base, gluten-free soy sauce, thicken with gluten-free thickeners (see Appendix D), serve gluten-free salad dressings to everyone.

Receiving

  • Check that items delivered are the correct products and have not been substituted – NEVER assume a replacement product or the same product in a different sized pack will have the same gluten-free status as the original.
  • If you determine that a replacement product is not gluten-free, communicate this via communication tools at your site and choose a replacement product. Lack of clear communication for substitutions is a common way that a gluten-containing product may be served inadvertently.
  • If ever in doubt about a product:
    • Ask the supplier or Registered Dietitian;
    • Contact the manufacturer;
    • Or leave it off the menu for gluten-free diets.

Storage

  • Gluten-free ingredients/foods are ideally stored in a segregated dedicated area. If this is not possible, then they need to be in well-labelled containers and stored on the highest shelves (to avoid gluten-containing foods from falling on them). Gluten-free flours keep best in a dark, cool area. For long-term storage, they can be placed in a refrigerator or freezer in well-sealed and labelled containers.
  • Gluten-free meals, bread products and desserts may be individually frozen, in well-labelled and dated, air-tight packaging to make it easier to provide a small number of servings.

Preparation

Avoiding Cross-Contamination

During food preparation, cross-contamination can occur when gluten-free foods or ingredients come into contact with gluten-containing items. It is important to prevent cross-contamination as even small amounts of gluten can negatively affect the health of those requiring a gluten-free diet e.g., triggering a variety of symptoms and causing damage to the digestive system. Persons with gluten-related disorders who are admitted to health care and congregate facilities put the safety of their food, and therefore their health, in the hands of the Nutrition/Food Service and broader health care team.

Cross-contamination can be reduced by:

  • Storing gluten-free foods separately from gluten-containing foods where possible.
  • Labeling all containers of gluten-free products clearly.
  • Cooking gluten-free foods separately from gluten-containing foods.
  • When baking, ideally prepare gluten-free items on separate days from other products, or at least prior to gluten-containing.
  • Using clean utensils and equipment for gluten-free food preparation.
  • Using a separate toaster for gluten-free foods. Reusable toaster bags are not generally acceptable from a public health perspective.
  • Using squeezable containers of condiments or individual condiments to eliminate the chance of double dipping.
  • Wooden cutting boards and utensils are not recommended in institutional settings and they should not be used in gluten-free food preparation. If plastic cutting boards are badly scored they should be replaced or ground down so they can be cleaned properly.
  • Using a separate pot and pasta strainer for gluten-free pasta.
  • Tightly covering and labelling gluten-free products.
  • Not using the same oil to fry gluten-containing and gluten-free food.

Meal Preparation

  • Double check gluten-free ingredients to confirm they are still safe.
  • Ensure meals/snacks are covered and labeled gluten-free once completed.
  • Use standard recipes where possible.

Service and Delivery

It is important that prepared gluten-free food is delivered and served to the patient/resident without error or cross-contamination.

Tray Service

  • Gluten-free meals should be checked by a Supervisor.
  • The diet should be clearly visible on the tray ticket or menu.
  • When staff provide the tray to the patient, they should state the tray is gluten-free to give the patient confidence the diet is accurate.
  • Never add or change items on a gluten-free meal after it has been plated or left the kitchen unless you are absolutely sure the substitution or addition is also gluten-free.

Dining Room Service

There can be a greater chance for error in dining rooms as frontline staff interact with residents and may have to make decisions. The below are suggestions to minimize the chance of error.

  • Staff should clean their hands with soap and water. Alcohol-based sanitizers are not recommended and do not eliminate gluten. Also the use of gloves is discouraged as they often gives staff a false sense of security.
  • If residents can select from more than one menu item, ensure you offer only menu items that are gluten-free, if in doubt ask.
  • Where possible serve gluten-free meals first using clean or designated utensils.
  • Deliver meals directly to the individual and state the meal is gluten free.
  • If there are self-service food bars, give the gluten-free resident the option of having their meal served to reduce cross-contamination.
  • If the resident wishes to use the self-service, utilize squeeze containers for condiments or individual condiments.
  • Clearly label the gluten-free items on the self-service food bar.

Foods from Home

  • Foods brought from home should contain a label with the following information: gluten-free status, patient/resident name and the date.
  • Ensure proper storage e.g. sealed packaging or containers and handling to minimize the risk of cross-contamination.
  • Perishable food brought from home should be discarded within a specific timeframe e.g., three days to minimize the chance of food-borne illness.

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