CD: Provide Resources and Education on Label Reading 2009
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CD: Provide Resources and Education on Label Reading
The registered dietitian (RD) should provide resources and educate individuals with celiac disease about reviewing the ingredients on labels of food and supplements, using current publications, including those from the United States Food and Drug Administration, for identification and avoidance of sources of gluten, namely wheat, rye, barley, malt and oats (unless oats are gluten-free). Education about the disease is optimal to integrate MNT for individuals with celiac disease into overall disease management.
Risks/Harms of Implementing This Recommendation
- Careful attention must be given to label-reading education. Incomplete or absence of detailed label reading education could result in consumption of products that may contain gluten-containing ingredients
- Individuals need to be instructed on continued monitoring of product labels and ingredients, as manufacturers may periodically change ingredients
- Incomplete implementation of this recommendation may result in liability issues.
Conditions of Application
- FDA mandates allergen labeling for the eight major allergens, including wheat, but not for oats, rye, barley and malt. If an ingredient in an FDA-regulated food contains protein from wheat, the word "wheat" must be included on the food label either in the ingredient list or “Contains” statement. For the purposes of this regulation, “food” also includes medical foods, dietary supplements and infant formula. However, the term “food” does not include any medications, either prescription or over-the-counter drugs. The gluten-free status of medications has to be verified.
- Allergen labeling of USDA-regulated foods (egg products, poultry products, meat products) is voluntary. Potential ingredients of concern that may be derived from wheat include modified food starch and dextrin.
- Under the proposed FDA rule, labeling foods with the term "gluten-free" continues to be voluntary. Foods labeled gluten-free must contain less than 20 parts per million of gluten. A food labeled gluten-free may contain wheat starch if the food contains less than 20 parts per million of gluten. Food containing wheat starch that is not labeled gluten-free should not be eaten. Oats and products containing oats may be labeled gluten-free if they contain less than 20 parts per million of gluten. Oats and products containing oats should not be eaten unless they are labeled gluten-free.
Potential Costs Associated with Application
Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT sessions are essential for improved outcomes.
The National Institutes of Health Consensus Development Conference Statement identified six elements required for the management of celiac disease:
- Consultation with a skilled dietitian
- Education about the disease
- Lifelong adherence to a gluten-free diet
- Identification and treatment of nutritional deficiencies
- Access to an advocacy group
- Continuous long-term follow-up by a multi-disciplinary team.
Dietitians should be aware of current FDA and USDA labeling regulations and check for future updates.
Recommendation Strength Rationale
The ADA Celiac Disease Work Group concurs with the National Institutes of Health Consensus Development Conference Statement.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
- National Institutes of Health Consensus Development Conference on Celiac Disease. Consensus Development Conference Statement. Available at http://consensus.nih.gov/2004/2004CeliacDisease118html.htm.
- Food and Drug Administration. Food Allergen Labeling and Consumer Protection Act of 2004. Available at http://www.cfsan.fda.gov/~dms/alrgact.html
- Food and Drug Administration. Proposed Rule on Food Labeling: Gluten-Free Labeling of Foods. Available at http://www.fda.gov/OHRMS/DOCKETS/98fr/E7-843.pdf or http://www.cfsan.fda.gov/~dms/lab-cat.html#gluten
- United States Department of Agriculture. A Guide to Federal Food Labeling Requirements for Meat and Poultry Products. Available at http://www.fsis.usda.gov/pdf/labeling_requirements_guide.pdf and www.glutenfreedrugs.com.