Looking at Special Dietary Needs Through Different Eyes

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Looking at Special Dietary Needs Through
Different Eyes
Loriann Knapton, DTR, SNS, Nutrition Program
Consultant November 4, 2008
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Learning about the nature and severity of the
childs special dietary needs and working
together to provide whats best for the
childshould be the major focus.
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Children with a Disability

• Schools must make substitutions of foods in the
  reimbursable meal for students who have a
  disability that restricts their diet.

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What are Disabilities?

• Disability is defined in
• Section 504 of the Rehabilitation Act of 1973
• Americans with Disabilities Act of 1990
• Part B of the Individuals with Disabilities
  Education Act (IDEA)
• Individual Education Plan (IEP)
• Explanation of these disabilities found on pages
  3-5 of the USDA guidance Accommodating Children
  with Special Dietary Needs in the School
  Nutrition Programs
• Website link to USDA guidance
  http//dpi.wi.gov/fns/market1.html

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Food Related Disabilities

• Some that require menu modifications
• Severe Food Allergies (Food Anaphylaxis)
• Metabolic Diseases such as Diabetes, Celiac
  Disease (Gluten-free Diet) and Phenylketonuria
  (PKU)
• Prescribed diet for child with autism (one of the
  thirteen disability categories recognized in the
  Individuals with Disabilities Act)

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Disability

• Accommodation MUST be made, based on a completed
  physicians statement
• No extra charge
• A disability determination can only be made by a
  licensed physician

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Statement for Children with Disabilities

• What must the physicians statement include?
• What the disability is
• How it restricts diet
• Major life activity affected
• Foods to be omitted
• Foods to be substituted
• Physicians Form (for documentation)
• http//dpi.wi.gov/fns/doc/spec_diet_restrict.doc

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• Under no circumstances are school food service
  staff to revise or change a diet prescription or
  medical order.

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Documentation

• The diet orders do not need to be renewed on a
  yearly basis however, schools are encouraged to
  ensure that the diet orders reflect the current
  dietary needs of the child.

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Medical Requests for Children with Special
Dietary Needs(not considered a disability)

• The school food service may make food
  substitutions, at their discretion, for
  individual children who do not have a disability,
  but who are medically certified as having a
  special medical or dietary need.
• Examples include
• Lactose intolerance
• Food intolerances or allergies where there is not
  the concern of a life-threatening reaction

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Not to be confused with.

• Fluid Milk Substitutions in the School Nutrition
  Programs
• (Final Rule published September 12, 2008)
• Current requirements on meal variations for
  students with disabilities and for students with
  medical or other special dietary needs remain
  unchanged.
• Offering fluid milk substitutes to students under
  this ruling is totally at the School Food
  Authoritys (SFAs) discretion.
• Nondairy beverages offered as fluid milk
  substitute be nutritionally equivalent to fluid
  milk and provide specific levels of calcium,
  protein, vitamins A and D, magnesium, phosphorus,
  potassium, riboflavin and vitamin B-12.
• Website http//dpi.wi.gov/fns/regs.html

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Goals of the Child Nutrition Program for Students
with Special Dietary Needs

• Meet the nutritional needs, as specified by the
  United States Department of Agriculture (USDA)
  meal pattern requirements and the childs
  personalized diet plan.
• Prepare the food items exactly as the diet order
  specifies, including texture and consistency of
  the item. If the diet plan is unclear, contact
  the medical authority involved in prescribing the
  diet plan for further clarification.
• Ensure food safety.

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Goals of the Child Nutrition Program for Students
with Special Dietary Needs(continued)

• Be knowledgeable of the policies and procedures
  in place for the district/site as they pertain to
  children with identified special dietary needs
  and the role of food service personnel in the
  case of a medical emergency.
• Give appropriate feedback to the
  multidisciplinary team whenever applicable.

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90 of foods causing food allergies

• Cows milk
• Egg
• Soybeans
• Wheat
• Peanut/tree nut
• Fish/shellfish

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Celiac Disease

• Celiac Disease An autoimmune disorder in which
  the body attacks itself.
• Permanent sensitivity to gluten, a protein found
  in wheat, rye, barley
• Eating food containing gluten damages the villi
  (lining of the small intestine), which results in
  mal-absorption of nutrients
• Gluten Free diet for life is only treatment

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Gluten Containing Grains

• Barley
• Barley malt, extract, flavoring
• Bran
• Bulgur
• Couscous
• Durum
• Einkorn
• Emmer
• Farina
• Faro
• Flour
• Graham flour, graham crackers
• Kamut
• Matzo flour, meal
• Malt, malt flavorings

• Orzo
• Panko
• Rye
• Seitan
• Semolina
• Spelt
• Triticale
• Udon
• Untested Oats
• Wheat berry
• Wheat bran
• Wheat germ
• Wheat germ oil
• Wheat gluten
• Wheat starch

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Hidden sources of gluten

• Bouillon
• Breading
• Broth
• Brown Rice syrup
• Coating mix
• Communion wafers
• Croutons
• Candy
• Imitation Bacon/seafood
• Luncheon Meats
• Marinades, thickeners
• Modified food starch
• Processed cheese

• Roux
• Sauces
• Seasoning packets/mixes
• Self-basting poultry
• Soup base
• Soy sauce
• Stuffing
• Herbal Supplements
• Vitamin mineral supplement
• Over the counter/prescription medications
• Lip-gloss, balms, lipstick
• Play dough

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Questionable ingredients

• Carmel color if made in US product is safe.
  Food label will confirm derivation of product.
• Flavorings gluten containing grains rarely
  used. Mostly derived from corn exceptions
  include barley malt flavorings, is usually listed
  on the label and flavorings in meat products
• Dextrin may be derived from arrowroot, corn,
  potato, rice, tapioca, sago or wheat
• Modified food starch may be derived from corn,
  potato, tapioca, wheat or other starches. No
  requirement for the identification of plant
  source.
• Starch FDA regulations start starch implies
  cornstarch if alternative starch is used it must
  be listed i.e.. Wheat starch

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Gluten Free Diet

• Any of the following words on food labels usually
  means that a grain containing gluten has been
  used
• Stabilizer Hydrolyzed Vegetable Protein
• Starch Flour or Cereal Products
• Flavoring Vegetable Protein
• Emulsifier Malt or Malt Flavoring
• Food Starch
• Modified Starch or Modified Vegetable Gum

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Gluten-Free Grains

• Acorn Cottonseed Quinoa
• Almond Dal Red rice
• Amaranth Dasheen flour Rice, rice bran, rice
  flour
• Arborio rice Enriched rice Risotto
• Aromatic rice Fava bean Sago
• Arrowroot Flaxseed Sesame
• Basmati rice Garbanzo Sorghum
• Brown rice, Brown rice flour Glutinous rice
  Soy,soybean,tofu
• Buckwheat Hominy Starch (made from corn or
  rice)
• Calrose Instant rice Sunflower see
• Canola Jobs tears Sweet rice flour
• Cassava Millet Tapioca
• Chestnut Modified corn starch Taro flour
• Chickpea Modified tapioca starch Teff
• Corn, corn flour, Peanut flour Wild rice
• Corn gluten, Potato flour
• Corn Malt, cornmeal Potato starch flour
• Cornstarch

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Gluten Free School MenuExample

• Chicken fajitas (prepared from fresh boneless
  chicken breast meat and gluten free seasoning)
  served with corn tortillas/green
  peppers/onions/salsa/sour cream
• Steamed brown/white rice
• Steamed broccoli cuts
• Fresh fruit choice
• Milk (unflavored)

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Gluten Free School MenuExample

• Cheeseburger Made with 100 lean ground beef and
  block cheddar cheese (not processed)/gluten free
  bun
• Oven fries prepared from fresh potatoes or gluten
  free French fries.
• Steamed green beans
• Chilled Peaches
• Flourless Peanut butter cookie
• Milk (unflavored)

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Gluten Free Peanut Butter Cookie

• 1 cup creamy peanut butter or Almond Butter
• 1 cup white sugar
• 1 large egg
• Sugar for rolling.
• Combine all ingredients. Take 1 teaspoon of
  dough,
• form into a ball and roll in sugar. Place ball on
  baking
• sheet and flatten with a fork. Bake cookies at
  350
• degrees for 8 minutes.
• Watch carefully when baking as they over bake and
  burn easily.
• Yield 1 dozen small cookies
• Must utilize appropriate preparation methods to
  avoid cross
• contamination.

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Gluten and Casein Free Dietsometimes prescribed
for children with Autism (recognized disability)

• Acceptable foods
• Rice, potato, and soy products
• Milks
• Flours
• Fresh fruits, vegetables, meats

• Arrowroot
• Nuts
• Beans
• Tapioca

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Casein

• Food sources
• Typical dairy foods milk, butter, cheese,
  yogurt
• Milk solids (curds) and whey
• Sodium caseinate ingredient in some processed
  foods
• Natural ingredients may contain dairy products

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Gluten and Casein Free Diet

• Foods to avoid
• Milk and milk derived products
• Wheat, barley, oats, rye, and buckwheat flours
  and products
• Natural ingredient foods
• Hydrolyzed vegetable protein
• Carmel coloring may contain gluten
• Vinegars check label for food source
• Chocolates

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Diabetic Requests

• Supervision of menus/meals how many carbs are
  served?
• What steps are taken if child doesnt take/eat
  planned items
• Other selections or substitutions
• Menu available for review notify parents/nurse
  if there are changes

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Phenylketonuria (PKU)

• Phenylketonuria, or PKU for short, is an
  inherited, genetic condition in which the body
  cant process phenylalanine (Phe), an amino acid
  found in many foods.
• Too much Phenylalanine is toxic to the brain.
  High Phe levels over an extended period of time
  can lead to vomiting, irritability, eczema,
  seizures, psychological and behavioral issues,
  and severe mental retardation.

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PKU Diet

• Phenylalanine is found in
• All protein-containing foods (eg, meat, eggs,
  dairy, nuts)
• Many other foods that are not generally thought
  of as containing protein (eg, most wheat
  products, such as pasta and bread, and some
  fruit, such as oranges and cherries).

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PKU MenuExample
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When dealing with special dietary needs remember
to.

• Work with the team Parents, doctors, school
  nurse, teachers, administrators, school
  foodservice staff
• Keep the lines of communication open
• Look through the eyes of your customer
• A Child who just wants to be like
• everyone else.

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RESOURCES

• Diabetes
• The American Diabetes Association
• http//www.diabetes.org
• Gluten Free diets
• Celiac Sprue Association
• http//www.csaceliacs.org
• Phenylketonuria
• PKU support
• http//www.pku.com
• Autism
• Autism Society of America
• http//www.autism-society.org
• Food Allergies
• The Food Allergy and Anaphylaxis Network
• http//www.foodallergy.org