Food Allergies, Dietary Disabilities and Reasonable Accommodations

1. Food Allergies, Dietary Disabilities and Reasonable Accommodations Stephanie Alsbrook, MS, RD, LD, CDE Maegan Wade, RD, LD Arkansas Department of Education Child Nutrition ZOOM Distance Learning December 2015

2. Objectives • Discuss the timeline for updates to Child Nutrition Special Dietary Needs Guidance • Learn the federal regulations which require schools to make reasonable accommodations for children with special dietary needs • Describe the responsibilities of school food service in complying with these regulations

3. Updates Coming • Estimated timeframe is 3 to 6 months • Will include updated guidance manual from USDA • Arkansas will draft a new REQUIRED Special Dietary Needs Form • Training will be available • Will not change the definition of disability as defined by ADA and ADA Amendment Act of 2008 • David Youngblood • Tentative presenter for Directors Conference 2016 • Director for the Office of Civil Rights • FNS, Headquarters

4. Laws and Regulations • The Rehabilitation Act of 1973 • Individuals with Disabilities Education Act (IDEA) • Americans with Disabilities Act (ADA) • USDA nondiscrimination regulation (7 CFR 15b) • FNS Instruction 783-2, Revision 2, Meal Substitutions for Medical or Other Special Dietary Reasons • Americans with Disabilities Act Amendments Act of 2008

5. What is considered a disability? • Any person who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such an impairment, or is regarded as having such an impairment. • Section 504 of the Rehabilitation Act of 1973 • Americans with Disabilities Act of 1990

6. What is considered a disability? • A child with a disability needs special education and related services, including school meals • To ensure appropriate accommodations, each student with a disability must have an Individualized Education Program (IEP) or Health Care Plan (504 plan) • Individuals with Disabilities Education Act

7. ADAAA of 2008 • Broadened list of “Major Life Activities” • Continues to include “caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.” • Added new list of “Major Bodily Functions” such as “functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, and reproductive functions.” • Individuals taking measures to improve or control these conditions are still considered to have a disability and require an accommodation • USDA SP 36-2013 Guidance Related to the ADA Amendments Act

8. Physician’s Statement • USDA regulations require substitutions or modifications in school meals for children whose disabilities restrict their diets • Need must be supported by a statement signed by a licensed physician • ADE Commissioner’s Memo FIN-15-122

9. Who Can Sign the Statement? • May accept statements signed by • Physicians • Including those licensed by the AR State Medical Board • The AR State Board of Chiropractic Examiners • The AR Board of Podiatric Medicine • Nurse Practitioners (APRNs in family or pediatric practice with prescriptive authority) • Physician Assistants (PAs who work in collaborative practice with a physician) • Dentists • Note: a Registered Dietitian Nutritionist (RD or RDN) may make recommendations for alternate foods, but the medical statement must be signed by one of the professionals listed above.

10. Physician’s Statement • Statement must identify: • The child’s disability (THIS IS CHANGING – NOT REQUIRED) • An explanation of why the disability restricts the child’s diet • The major life activity affected by the disability • The food or foods to be omitted from the child’s diet • The food or choice of foods that must be substituted

11. Certification of Disability • Form to be filled out by district and by licensed physician • Optional section addressing feeding, food preparation, and storage needs • Available on CN website (WILL BE UPDATED WITH THE RELEASE OF THE NEW GUIDANCE)

12. Food Allergies • An immune system response to a food that the body mistakenly believes is harmful • Can range from relatively mild to severe (anaphylaxis) • Common food allergies are peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish • Meets the definition of “disability,” and the substitutions prescribed by the licensed physician must be made

13. Food Intolerances • An adverse reaction to food that does not involve the immune system • Not typically a disability as defined under Section 504 of the Rehabilitation Act or Part B of IDEA • School food service may, but is not required to, make food substitutions for them • Follow prescribed substitutions if made by the licensed physician

14. Diabetes • Disorder in which the body is unable to produce or to respond to insulin • 2 forms of diabetes: • Type 1 • Type 2 • Meets the definition of “disability,” and the substitutions prescribed by the licensed physician must be made

15. Other Special Dietary Needs • Accommodations may be made for children with special medical or dietary needs, not considered disabilities • School food service’s discretion • Case-by-case basis • Examples: • High cholesterol • Lactose intolerance

16. Other Special Dietary Needs • Schools are not required to make modifications to meals based on food choices of a family or child regarding a healthful diet • Examples: • Low-carbohydrate diets • Vegetarianism • Religious preferences

17. Food Service Responsibilities • Must make food substitutions or modifications for students with disabilities • Substitutions and modifications must be based on prescription by licensed physician • Under NO circumstances are school food service staff to revise or change a diet prescription or medical order

18. Food Service Responsibilities • All changes to existing diet orders must be documented in writing • Schools should retain copies of special, non-meal pattern diets on file for reviews • Schools are encouraged to ensure that the diet orders reflect the current dietary needs of the child

19. Special Dietary Needs Policy • Each district needs to have a policy in place to address special dietary needs • Policy should include: • District responsibility • Parent/guardian responsibly

20. Providing Special Meals • Special meals must be provided to children with disabilities at no additional cost • Meals must be served at free or reduced price to children who qualify for these benefits even if it costs more to prepare those meals

21. Negligence • To accommodate a child with a disability, the school must ensure that both facilities and personnel are adequate to provide necessary services

22. Situation #1 • A licensed physician has prescribed portion sizes that exceed the minimum quantity requirements set forth in the regulations. Is the school required to provide these additional quantities?

23. Situation #2 • A child’s parents have requested that the school prepare a strict vegetarian diet for their child based on a statement from a health food store “nutrition advisor” who is not a licensed physician. Must the school comply with this request?

24. Situation #3 • A child has a life threatening allergy which causes an anaphylactic reaction to peanuts. The slightest contact with peanuts could be fatal. To what lengths must the food service go to accommodate the child?

25. Situation #4 • A school wishes to serve meals to children with disabilities in an area separate from the cafeteria where the majority of school children eat. May the school establish a separate facility for these children?

26. Tips From David Youngblood • Who decides if a condition is a disability? Ask yourself, “Does the condition substantially limit the student?” Who defines substantially? The new guidance will require most conditions to be reasonably accommodated. There will no longer be a distinction between disability and other special dietary need. • Take every request at face value. • Make accommodations where you can. • “Never say no – it is your duty to negotiate.” • “Reasonable” is the key word • May be different for each situation • May not say “this goes outside of our district’s policy” – that is exactly what disability law requires you to do (ex: seating children with peanut allergies separately from other students) • Some burden for the district is always expected

27. Tips From David Youngblood • Safety vs Stigma – age of the student and the severity of the allergy are the primary consideration. Sometimes separation is necessary. Always debate the issue. What is best for the student? • You can not request medical records or files. Take every request at face value. • Do what the signed form says regardless of what mom or dad tells you to do. If they believe an update is needed, ask them for an updated form from the physician. • Items do not have to be brand name – as a general rule. • The menu does not have to be “gluten-free pizza” on pizza day. • Disability law does not protect someone without a disability (ex: my child is not allergic to peanut butter)

28. Tips From David Youngblood • Procedural Safeguards • Are common in education • Are a USDA Regulation 7 CFR 15b.25 • Include a notice, examination of record, impartial hearing, and appeal • Are available for addressing special dietary needs • Always use your district as a resource • For accommodation procedures • For IEP and/or 504 Plans • “Food service staff should not fret – your district is used to handling these types of issues in other areas of education”

29. Carbohydrate Counting • Carbohydrates are NOT bad! • They provide energy for brain development, growth, and daily functions • Everyone needs carbohydrates • A student with diabetes needs to know how many carbohydrates they are consuming • The number of carbohydrates eaten determines how much insulin they should take • For example, my insulin-to-carb ratio is 1:10. So, if I eat my favorite lunch with you all (vegetable soup and grilled cheese) and consume 90 grams of carbohydrate, how much insulin do I need?

30. Carbohydrate Counting Have Carbohydrate Do Not Typically Have Carbohydrate Non-starchy vegetables Protein (meat and meat alternatives) Fats • Starches (including starchy vegetables) • Fruits • Milk • Sweets and Desserts

31. Carbohydrate Counting

32. Carbohydrate Counting • Lunch • Vegetable Soup • Look at your school’s recipe and determine amount of carbohydrate in the recipe and divide by the number of servings to find the number of carbohydrates per serving • Cheese toast • Pears • Sweet Potato Bites • Choice of Milk • Consider your serving size • Read your recipes and food labels to determine grams per serving for each item • Total the amount of carbohydrate for the meal

33. Getting Started • Start with your menu • For items that are prepackaged, read the nutrition facts label and record on your menu • As you get new items, be sure to update your records • For school recipes, look at the labels of each product that goes into the recipe. Count the carbohydrates for the total recipe and then divide by the number of servings you will get from that recipe • Record the estimated carbohydrates on your recipe and update as your recipe or ingredients change • With cycle menus, you should have this information readily available each time the menu is served

34. Tools for Carbohydrate Counting • www.calorieking.com • Calorie King book • American Diabetes Association Choose Your Foods: Exchange Lists for Diabetes • Your own recipes and food labels • Cooperative Extension Service Exchange System Tool http://www.uaex.edu/publications/pdf/FSHED-86.pdf

35. Work with your nurse • Be a part of the planning meetings to accommodate students with diabetes • Let them know you can determine the total amount of carbohydrate in each item and in the meal • Who will determine what and how much of each item the student ACTUALLY CONSUMED???