MAKING THE CASE FOR GLUTEN-FREE SENIOR 

MEALS 

November 14, 2019
MAKING THE CASE FOR GLUTEN-FREE SENIOR MEALS

Presenters: 

• Katarina Mollo, MEd, RDN, LDN, Director of Education

• Nicola Harrington, Director, Gluten-Free Food Bank

National Celiac Association, Needham, MA
DISCLAIMER

• This presentation is for informational purposes

only. It does not replace food safety and allergen

training or gluten-free (GF) certification. It is

supposed to give you an overview of what you

may need to consider when providing GF meals.

Risk levels of individual facilities will vary.
AGENDA

• Gluten 101

• Celiac Disease (CD): Symptoms, Complications, 

Diagnosis, Treatment

• Gluten-Related Disorders

• Living GF: Challenges

• National Celiac Association Resources
LEARNING OBJECTIVES

• Describe medical aspects of CD including 

symptoms, diagnosis, treatment, and 

complications.

• Identify other medical conditions that require a GF 

diet

• Recognize the importance of the GF diet in the 

treatment of celiac disease.

• Recognize the complexity of the GF diet and 

challenges (medical, nutritional, psychosocial, and 

financial) that seniors with gluten-related disorders 

are faced with.
POLL

Based on a survey of members of the Canadian 

Celiac Association what do you think was the 

average age of celiac disease diagnosis?

A. 6 years

B. 16 years

C. 36 years

D. 46 years

E. 66 years
POLL ANSWER

Answer: 46 years

Reference: 

Cranney A, Zarkadas M, Graham ID, Butzner JD, 

Rashid M, Warren R, Molloy M, Case S, Burrows V, 

Switzer C. The Canadian Celiac Health Survey. Dig Dis 

Sci. 2007 Apr;52(4):1087-95. Epub 2007 Feb 22. 

PubMed PMID: 17318390.
Gluten 101

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WHAT IS GLUTEN?

Gluten is the most common protein in the human diet. It 

can be found in these grains: 

• Wheat (gliadin)

• Barley (hordein)

• Rye (secalin)

Gluten brings elasticity and structure to baked goods. It 

is what makes them fluffy and chewy all at the same 

time. This is why gluten-free products often are crumbly. 

1
HOW MUCH GLUTEN?

• There is no official threshold for gluten 

consumption, however one study determined that 

a daily intake of 10 mg of gluten was the threshold 

that produced damage to the small intestine in 

individuals with celiac disease. 7

• How much is 10 mg?
1/350 OF SLICE OF BREAD
Celiac Disease: Symptoms, 

Complications, Diagnosis, 

Treatment

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WHAT IS CELIAC DISEASE?

• CD is a genetic, autoimmune disorder that targets 

the small intestine.

• When gluten is ingested, the body responds by 

attacking the villi (fingerlike projections in the small 

intestinal mucosa), which can lead to 

malabsorption and many other complications. 1
ANATOMY OF CD
CD MYTHS

• CD is a childhood disease/you can grow out of it

• Everyone with CD has gastrointestinal (GI) 

symptoms 

• Only people of European descent get CD

• You cannot be overweight/obese and have CD

• It is ok to eat a little bit of gluten when you have CD
CD STATISTICS

• CD affects about 3 million people in the US

• ~ 83% are still undiagnosed/misdiagnosed 2

• General population: 1 in 100

• Related symptoms: 1 in 56 

• 1

st degree relative with celiac disease: 1 in 22 

• 2

nd degree relative with celiac disease: 1 in 39 3

• 19-34% of new CD cases are aged 60 years and 

over 4
SYMPTOMS OF CD

Gastrointestinal 

• Diarrhea

• Fatty stools

• Constipation

• Cramps

• Bloating

• Flatulence

• Lactose intolerance

• Acid reflux

• Nausea

• Vomiting Over 200 

Symptoms, 

or none at all! 1
SYMPTOMS OF CD

Malabsorption

• Anemia-Iron deficiency

• Vitamin deficiencies

• Calcium malabsorption 

leading to osteopenia, 

osteoporosis

• Protein and calorie 

malnutrition 

• Weight loss or muscle 

atrophy

Non-Gastrointestinal 

• Fatigue

• Depression

• Joint pain

• Muscle aches, cramps

• Peripheral neuropathies

• Menstrual irregularities

• Dental abnormalities 1
SYMPTOMS/COMPLICATIONS IN SENIORS

• Generally less severe gastrointestinal symptoms

• Nutrient deficiencies related to malabsorption:

– Anemia

– Osteoporosis/osteopenia/osteomalacia

• Dermatitis herpetiformis

• Autoimmune thyroiditis

• Ataxia and neuropathy

• Cancers

• Celiac hepatitis 4,5
FALLS IN SENIORS & CD

• Fall from dizziness/confusion: potentially from 

electrolyte imbalance; anemia, altered blood 

pressure

• Fall from tripping: lack of muscle strength and 

atrophy and or neuropathy 

• Fall from fracture: weakened bone state from 

osteoporosis or osteomalacia

• Fall from urgently running to the bathroom 
DIAGNOSIS

• A blood test for antibodies associated with

celiac disease (also called a celiac panel)

• Endoscopy of the small intestine – is the “gold

standard” for diagnosing celiac disease 1

NOTE: Starting a GF diet before diagnosis may lead to a false negative test
BARRIERS TO DIAGNOSIS FOR SENIORS

• CD is often overlooked in seniors 

– Subtle symptoms

– Mistaken for signs of aging

– Lack of awareness in the medical community 5
TREATMENT

• The ONLY approved treatment for celiac 

disease is a STRICT gluten-free (GF) diet.
OTHER GLUTEN-RELATED DISORDERS

Dermatitis Herpetiformis (DH)

• A different manifestation of CD where the 

immune system attacks the skin creating an itchy 

blistering rash when gluten is ingested. May be 

present with or without damage to the small 

intestine. 

• DH is diagnosed via skin biopsy by a 

dermatologist.

• Treatment is a strict gluten-free diet and may 

also include medications to manage symptoms. 1
OTHER GLUTEN-RELATED DISORDERS CONT.

Non-Celiac Gluten Sensitivity (NCGS) 

• An intolerance to gluten ingestion that may show 

some immune response but little to no villi 

damage; symptoms may be similar to celiac 

disease. Affects about 6 percent of the 

population. 6

• CD and wheat allergy must be ruled out before a 

diagnosis of non-celiac gluten sensitivity is made. 

• The treatment is a GF diet. 
OTHER GLUTEN-RELATED DISORDERS CONT.

Wheat Allergy

• An allergic immune reaction (that 

involves a different branch of immune 

system than CD) to wheat ingestion. It 

may include a reaction in skin, mouth, 

lungs, and/or GI system.

• Wheat allergy should be diagnosed by 

an allergist.

• The treatment is a wheat-free diet and 

may include medications to manage 

symptoms. 1
POLL

It is ok for someone with celiac disease to eat a 

bit of gluten everyday as long as they are mostly 

gluten-free.

True/False
POLL ANSWER

Answer: False
Living Gluten-Free

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www.nationalceliac.org

Celiac Diagnosis and 

Pathophysiology

Gluten-Free Diet 

is treatment

Psychosocial Impacts

Modifications of Diet = Improvement 

in General Health

Symptoms, 

illness, and 

the search for 

an answer

Economic Burden

Complications of Celiac Disease

Limited Access to GF Food in Assisted Living 

Facilities/Hospitals/Congregate Meals/Home

Delivered Meals

Lifestyle Changes

Perceived High Treatment Burden

Delayed Healing Time

Barriers to Diagnosis

Nutrition Challenges of the Gluten-Free Diet

Hypervigilance

Confusing Ingredients/Difficult to Read Labels

THE CELIAC ICEBERG
LIVING GLUTEN-FREE

• Sharing a Kitchen

• Eating at Restaurants/Congregate Meals/Home 

Delivered Meals

• Hospitals

• Assisted Living/Nursing Homes

• Holidays & Celebrations

• Travel
PSYCHOLOGICAL AND EMOTIONAL CHALLENGES

• Anxiety

• Depression

• Isolation/avoidance

• Fear of getting sick

• Embarrassment

• Perceived annoyance factor, i.e. “they’re 

just being picky.” 1
PSYCHOLOGICAL AND EMOTIONAL CHALLENGES

• Lower Quality of Life

Recent studies show that those on a GF diet can have a lower 

quality of life due to anxiety around food. 8

• Perceived High Treatment Burden

Studies show the burden of a GF diet is comparative at levels 

with congestive heart failure (CHF) and end stage renal 

disease (ESRD). 9
CHALLENGES SPECIFIC TO SENIORS

• Change lifetime eating habits

• Adding GF to other nutritional challenges

• Limited financial resources

• Limited social resources

• Increased dependence on others for food

• Limited mobility 4
ECONOMIC BURDEN 

• A recent study found that gluten-free foods are 

overall 189% more expensive than regular 

versions of the food. 10

• A small 12 oz loaf of GF bread costs $5-$6

• Gluten-free food is rarely available at food 

pantries, leaving few options for getting 

affordable, safe hunger relief. 
NCA represents and serves individuals with celiac 

disease and gluten-related disorders. 

• Chapters, Local Partners, Resource People (40+

groups and growing)

• Gluten-Free Food Bank (GFFB)

• Semi-Annual Symposium

• Phone hotline 5 days/week

– 1-888-4-CELIAC

• Check out NCA’s website for more resources:

https://nationalceliac.org/

RESOURCES
TAKE HOME MESSAGES

• CD is a serious medical condition.

• A strict GF diet is the only treatment for CD. 

• There are several other gluten-related disorders 

that also require a GF diet. 

• Being on a GF diet can be cumbersome and a 

psychosocial burden. 

• The GF diet can be an economic burden preventing 

those living with food insecurity from getting 

access to safe and nutritious meals. 
CALL TO ACTION

• Find out who needs GF meals among the 

population you serve.

• Let your population know that GF meals are 

available for those with a medical need. 

• Explore the possibility of offering GF meals.

• Participate in our upcoming webinar on November 

19! 
REFERENCES

1. National Celiac Association. Gluten-Free, Off To A Fresh Start. Presentation. May

4, 2018.

2. Beyond Celiac. Celiac Disease Fast Facts. Beyond Celiac

Website:https://www.beyondceliac.org/celiac-disease/facts-and-figures/

Updated 2019. Accessed April 27, 2019.

3. Fasano A, Berti I, Gerarduzzi T, Not T, Colletti RB, Drago S, Elitsur Y, Green PH,

Guandalini S, Hill ID, Pietzak M, Ventura A, Thorpe M, Kryszak D, Fornaroli F,

Wasserman SS, Murray JA, Horvath K. Prevalence of celiac disease in at-risk and

not-at-risk groups in the United States: a large multicenter study. Arch Intern

Med. 2003 Feb 10;163(3):286-92.

4. Rashtak S, Murray JA. Celiac disease in the elderly. Gastroenterol Clin North Am.

2009;38(3):433–446. doi:10.1016/j.gtc.2009.06.005

5. Cappello M, Morreale GC, Licata A. Elderly Onset Celiac Disease: A Narrative

Review. Clin Med Insights Gastroenterol. 2016;9:41–49. Published 2016 Jul 27.

doi:10.4137/CGast.S38454
REFERENCES

6. Igbinedion SO, Ansari J, Vasikaran A, et al. Non-celiac gluten sensitivity: All wheat

attack is not celiac. World J Gastroenterol. 2017;23(40):7201–7210.

7. Catassi C, Fabiani E, Iacono G, D'Agate C, Francavilla R, Biagi F, Volta U,

Accomando S, Picarelli A, De Vitis I, Pianelli G, Gesuita R, Carle F, Mandolesi A,

Bearzi I, Fasano A. A prospective, double-blind, placebo-controlled trial to

establish a safe gluten threshold for patients with celiac disease. Am J Clin Nutr.

2007;85(1):160-6.

8. Wolf RL, Lebwohl B, Lee AR, Zybert P, Reilly NR, Cadenhead J, Amengual C, Green

PHR. Hypervigilance to a gluten-free diet and decreased quality of life in

teenagers and adults with celiac disease. Dig Dis Sci. 2018 Jun;63(6):1438-1448.

9. Shah S, Akbari M, Vanga R, et al. Patient perception of treatment burden is high in

celiac disease compared with other common conditions. Am J Gastroenterol.

2014;109(9):1304–1311. doi:10.1038/ajg.2014.29.

10. Lee AR, Wolf RL, Lebwohl B, Ciaccio EJ, Green PHR. Persistent economic burden

of the gluten free diet. Nutrients. 2019 Feb 14;11(2).

* Pictures from Pixabay, no attribution required.
Upcoming Trainings /

New Resources

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UPCOMING EVENT

• Operational Considerations for 

Providing Gluten-Free Meals.

• What: Webinar

• When: Tuesday, November 19, 2019

• To Register: Online
NEW RESOURCE!

• Check out a new 

resource on CD 

Facts, developed by 

NCA focused on 

seniors.

• You can access it on 

our social 

networking 

platform, 

NRCNAengage.
NRCNAengage

• Visit: https://nrcna.mn.co to sign up today!
Thank You

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