Looking at Special Dietary Needs Through Different Eyes

1. Looking at Special Dietary Needs Through Different Eyes Loriann Knapton, DTR, SNS, Nutrition Program Consultant November 4, 2008

2. Learning about the nature and severity of the child’s special dietary needs and working together to provide what’s best for the childshould be the major focus.

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

4. 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://fns.dpi.wi.gov/fns_market1

5. 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)

6. Disability • Accommodation MUST be made, based on a completed physician’s statement • No extra charge • A disability determination can only be made by a licensed physician

7. Statement for Children with Disabilities What must the physician’s statement include? • What the disability is • How it restricts diet • Major life activity affected • Foods to be omitted • Foods to be substituted Physician’s Form(for documentation) http://fns.dpi.wi.gov/files/fns/doc/spec_diet_restrict.doc

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

10. 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.

11. 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

12. 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 Authority’s (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: fns.dpi.wi.gov/fns_regs

13. 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 child’s 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.

14. 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.

15. 90% of foods causing food allergies Cow’s milk Egg Soybeans Wheat Peanut/tree nut Fish/shellfish

16. 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

17. 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 Gluten Containing Grains

18. 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 Hidden sources of gluten

19. 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

20. 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

21. 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 Job’s 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

22. 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)

23. 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)

24. 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.

25. Acceptable foods Rice, potato, and soy products Milks Flours Fresh fruits, vegetables, meats Arrowroot Nuts Beans Tapioca Gluten and Casein Free Dietsometimes prescribed for children with Autism (recognized disability)

26. 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

27. 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

28. Diabetic Requests • Supervision of menus/meals: how many carbs are served? • What steps are taken if child doesn’t take/eat planned items: • Other selections or substitutions • Menu available for review; notify parents/nurse if there are changes

29. Phenylketonuria (PKU) • Phenylketonuria, or PKU for short, is an inherited, genetic condition in which the body can’t 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.

30. 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).

31. PKU MenuExample

32. 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.

33. 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