One size fits all seems like a dream come true, but is just that; a dream. I recently read an article wherein a group of women tried on the same articles of clothing all touted as “one size fits most” and took pictures documenting the experience. While their bodies were different but nothing terribly extreme, the clothing looked very different on each individual. Now, can you imagine making the same claim with food, and specifically menus? We don’t: all share the same favorite foods, like the same textures, appreciate nutritional value, have the same foods available to our region, or even like the same colors on the plate in front of us. No matter how perfect the product is, there is no way to satisfy everyone; there is no such things as a perfect menu.

Though universal satisfaction isn’t possible in menu planning, great success is possible with certain considerations. According to Linda S. Eck Mills, “A number of factors impact your planning – food habits and preferences of your customers, production capability, type of service, food budget, availability of foods.” We will explore these among other factors giving you the tools and information you need to make the best choices for you and your facility.

By definition alone, facilities span a wide range of services and abilities. Just within residential care, there is: Independent living communities, Memory Care Facilities, Assisted Living Facilities, Residential Care Facilities, Continuing Care Communities, and Nursing Homes. Desirable menus for those in Independent Living Communities would differ from Nursing Home Residents even if only based on chewing ability. Can you imagine the span if you were to ask preferences between a Juvenile Group Home and a Assisted Living Facility?

Even within the same kinds of facility, size, or number of residents has to be considered. While home-made Ravioli from scratch would be labor intensive, but feasible for a small home of 10, it would be an impossibility for a 200 bed facility . Because size can vary greatly, food preparation is drastically different. In a small home, the care-taker is also the maid, activities planner, and chef. In a large facility, cooking is a full-time job and there is often chef which does nothing else. This leads us to who plans the menu.

Consider this information in an article I read titled “Who pays for science?”. In a perfect world, money wouldn’t matter — all scientific studies (regardless of funding source) would be completely objective. But of course, in the real world, funding may introduce biases — for example, when the backer has a stake in the study’s outcome. A pharmaceutical company paying for a study of a new depression medication, for example, might influence the study’s design or interpretation in ways that subtly favor the drug that they’d like to market. There is evidence that some biases like this do occur. Drug research sponsored by the pharmaceutical industry is more likely to end up favoring the drug under consideration than studies sponsored by government grants or charitable organizations. Similarly, nutrition research sponsored by the food industry is more likely to end up favoring the food under consideration than independently funded research.

While we aren’t talking about pharmaceuticals, you still have to recognize who’s agenda is being supported during meal planning. Are the menus created by the vendor being used to increase sales? Are the chef’s creating the menu as part of their job description, regardless of dietary requirements? Are dietitians writing the menu to fulfill nutritional requirements while not considering the preferences of the residents? Is it a tray card system? Did a facility owner hire their health-wise sibling who needed a job? There are good systems and program out there, but educate yourself and scrutinize who’s menu you’ll use.

Regardless of who plans your menu, frequency of menu rotations plays are roll in planning and pleasing residents. By simple mathematics, if a menu makes a complete cycle in two weeks, those recipes will be seen many more times annually than another menu perhaps on a 6 month cycle. Within the rotations, the recipes should accommodate seasonal changes as well as regional produce availabilities and cultural preferences. A warm pot of hearty squash stew with some roasted apples and a slice of pecan pie should remind you a crisp autumn day while a fresh, cool meal of melons, berries, and maybe some barbecue is desirable for summer. Additionally, regional agriculture and traditions play a role in our diets. In searching for signature dishes by state, I came across a website listing a few. You’ll likely agree as you read this selection: Chicago-style Deep-dish Pizza (Illinois), Shrimp and Grits (South Carolina), Crab Cake (Maryland), Peach Pie/Cobbler (Georgia), Gumbo (Louisiana), Key Lime Pie (Florida), Green Chili Enchiladas (New Mexico), Cedar Plank Salmon (Washington).

One factor in menu planning that debatably holds more weight than some others is controlling food costs. In a perfect world, money wouldn’t matter and we could all eat whatever meal struck our fancy, but as it is, food costs are as variable as the weather. For example, a simple pound of wholesale ground beef averages about $3.00. Beef Tenderloin runs about $10.00 per pound. If you were to serve all of one versus the other for every single dinner for one year, the difference in cost is $2,555.00. That is just for one pound; can you imagine if you needed 5 pounds per meal?

The last thing we would like to emphasize is that a good menu should include compliance, customization, and feedback. About half of the states in America require a dietitian approved menu which meets with state standards and regulations. Wherever a facility may be, the menu must be within given guidelines and meet respective standards. Whomever writes the menu must understand this principle. Customization is something we have touched on previously. To recap, menus need to be written to accommodate, traditions, preferences, location, and season. Within these parameters, creativity is essential. As this is achieved, satisfaction will increase. Lastly, feedback not only from residents, but from professionals as well will help in your “recipe” for success. It is good to know what recipes do and don’t please, what the chefs think will work on a large scale and what wont, how well recipes convert for size, what pinches a budget and what doesn’t, just to name a few.

It would be easy to feel overwhelmed by the variables to a good menu, but you will have the most success if you try to do right by the residents. A CEO of an assisted living company wrote, “I still remember walking into the very first assisted living facility I owned, on the first week of opening and hearing a resident loudly proclaim for all to hear, “This food tastes like $#!&”. Regardless of the delivery, the message is clear; food is important to people. Often, the highlight of the residents day, and even our own, is meal-time. Louise Fresco said, “Food, in the end, in our own tradition, is something holy. It’s not about nutrients and calories. It’s about sharing. It’s about honesty. It’s about identity.”

As you consider all the moving parts to this big picture hopefully you feel better direction as you think of what goes into your menus. Recognize that no matter how good a product looks, be it a shirt, or the best menu you have planned in your life, it will not please everybody. One size does not fit all. However, focus on what you can control, consider all the factors and make it about the residents. When you do these things, you will please most, and with that you can take pride in your menus and have fulfillment in the product.

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One specific gluten related symptom piqued my interest: Several non-celiac individuals attempting a gluten-free diet claimed stomach pains after re-introducing foods containing wheat into their diet. I have experienced the same thing and wondered if I was affected by a gluten intolerance. Every now and again after I eat wheat based cereals, my stomach becomes upset.

Jessica Bruso, a writer for SFgate, has a Masters of Science in food policy and applied nutrition. She states in an article on digesting grains, “Eating more fiber can cause digestive complaints, including bloating, gas and constipation, until your system gets used to it” (Bruso. Healthyeating). Whole grains contain gluten, along with fiber, so which is to blame?

Consider this: When January 1^st comes around, many people make resolutions to hit the gym and lose that extra weight they have been lugging around. A common complaint is how sore they feel the morning after. Does this mean anyone who feels sore after working out is allergic to it? Certainly not. The body is simply not accustomed to exerting that kind of effort and needs time to adjust. Likewise, a diet including fiber is proven to be healthy and beneficial, but the body needs an adjustment period.

Regarding any food topic or trend there is the money to be made. Frequently, diets that spread by word of mouth rather than credible, evidence driven sources, are more about marketing than improving health. The gluten-free diet has revolutionized the food industry. “Sales of gluten-free products are estimated to hit $15 billion by 2016 — that’s a 50% jump over 2013’s numbers!” (Pomeroy).

I have noticed at stores and restaurants that gluten-free labels are proliferating. At a recent business convention I attended there was a non-gluten section in the buffet. Companies are starting to capitalize on this trend. In fact, “The Food and Drug Administration clarified its rules on what qualifies as gluten-free, which could lead more marketers to start labeling products that way — including those that have never contained gluten” (Schultz). Later in this article, the author E.J Schultz stated that “Betty Crocker gluten-free chocolate- brownie mix costs 38¢ per ounce, compared with 16¢ per ounce for regular fudge-brownie mix, according to prices posted on NetGrocer.com” (Schultz). Clearly, promoting gluten-free products is very lucrative right now.

Journalist Kiera Butler described a visit to her chiropractor, “A few months ago, I visited a well-meaning but ineffective chiropractor: I was seeking relief for pain in my hip, but she seemed much more interested in my mental health. ‘Do you ever feel stressed?’ she asked. ‘Uh, yeah,’ I said. ‘Doesn’t everyone?’ ‘Well, I think you should try a gluten-free diet for that,’ she said. She then pulled out a prescription pad and wrote down the names of a few specialty food manufacturers” (Butler).

While I am sure this chiropractor was well meaning, could it be possible she was getting paid to recommend certain food brands? That extra money on the side would certainly be an ulterior motive for prescribing a NCGS diagnosis. Overall, it is wise to be cautious about spending the extra money on gluten-free products if there is no hard evidence backing the claims.

I am very sympathetic to those who believe they are non-celiac gluten sensitive. I have yet to meet someone who likes having diarrhea, low energy, or joint pain. But after researching and looking at the facts, I am skeptical. To me the answer to the question, “Does gluten adversely affect those without celiac’s disease?” The answer is no. If you choose to follow the gluten-free diet, just know that the claims are unsubstantiated and you and your wallet might need to look elsewhere for answers. Hopefully these blogs of given you food for thought. Pardon the pun, I couldn’t help myself!  

Ben Fager

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We all want to understand why there are conflicting views of gluten and as a result, doctors and scientists have set out to clear the air.

In 2011, Peter Gibson, Professor and Director of Gastroenterology at Alfred and Moash Univeristy and a team of other doctors performed a study, concluding that Gluten causes gastrointestinal symptoms in subjects without celiac disease. 34 subjects, with irritable bowel syndrome, but without celiac disease, were selected for the study. 19 of the patients were given two slices of bread, and one muffin containing gluten. The other 13 subjects were given gluten-free foods. This trial was double-blind, meaning none of the participants knew which group they were in. After six weeks on these diets, the results were significant enough to show an increase in stomach issues for those individuals consuming the gluten-laden muffins and bread. However, the evidence was far from decisive. The doctors came to the conclusion that, “’Non-celiac gluten sensitivity’ (NCGS) may exist, but no clues to the mechanism were elucidated” (Gibson 2011 study). This means the process which leads to these gastrointestinal problems was not revealed by the study, leaving room for question. As a result, two years later, Gibson conducted another experiment.

Gibson had noticed that, “reports of NCGS have not taken into account the presence of other components of wheat, particularly fructans, that might have been pathogenically responsible for the symptoms” (Biesiekierski JR). These fructans are referred to as “FODMAPs”, or in layman terms: sugars, more specifically carbohydrates, found in foods such as pastries, sodas, and other foods with high sugar content. “These types of carbohydrate are rapidly fermented but poorly absorbed in the small intestine, leading to functional gastrointestinal symptoms in sensitive individuals. Evidence suggests that a reduction in high FODMAP foods leads to an improvement in GI symptoms (Zubek, J).

This second study found that when pills containing gluten, but devoid of FODMAP’s were consumed under the pretense they were gluten-free, patients showed no significant signs of gluten sensitivity. Interestingly enough, the patients complained they had symptoms of gluten sensitivity when they were given pills with no gluten, but were under the pretense gluten was included. As a result, Gibson found that gluten sensitivity was a “nocebo” effect. The “nocebo” effect is the negative counterpart to the placebo effect, “The same reaction that prompts some people to get sick from wind turbines and wireless signals, was at work here” (Pomeroy).

Even with this new found evidence, many doctors, dietitians, and parents still blame gluten for ADHD, headaches, and even depression. However, after looking at many different government sponsored and academically based articles on the symptoms of celiac disease, none mention headaches, depression, or behavior related issues such as ADHD. For example, eatright.org, the world’s largest organization of food and nutrition professionals, includes a list of symptoms of those with a gluten intolerance on their website. Mentioned are: “Diarrhea, stomach pain, fatigue, joint pain, weight loss, and itchy skin rash” (eatright.org). If these are symptoms for those with an intolerance, a list for those with reported non-celiac gluten sensitivity should be close to identical. Because of this, I am skeptical when gluten is pegged for causing behavior issues, amongst other villainous claims.

Though logic may be faulty, it is hard to dispute anecdotal “evidence” that people have experienced. Sometimes personal experiences seem like empirical data when truly, we might not understand the science or process behind it. Conflict, specifically regarding gluten is due to misinformation and lack of knowledge.

Ben Fager

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Jimmy Kimmel, a late night television show host, also noticed the trending gluten-free craze. Curious about people’s understanding, he did a street poll by randomly stopping strangers to ask them about gluten. The vast majority did not know what it was, or what specifically it was in. A select few could place it in “breads and cereals”.

For being such a buzz word – what is gluten? Celiac.org defines it as, “a general name for the proteins found in wheat… rye, barley and triticale. Gluten helps foods maintain their shape, acting as a glue that holds food together” (Celiac.org). The name gluten comes from the base word “glu”, simply meaning a glue-like substance that creates and maintains form. So what about this glue-like protein causes so much pain for those with celiac disease?

Gluten is made up of two proteins, gliadin and glutenin (livescience.com). Gliadin is the main culprit for the adverse reaction in individuals with celiac’s. The damaged villi in the small intestines are unable to absorb crucial nutrients, but “symptoms may vary among different people:” One person might have diarrhea and abdominal pain, while another person has irritability or depression. Some patients develop celiac symptoms early in life, while others feel healthy far into adulthood” (celiaccentral.org).

Thus, a diagnosis of gluten intolerance can happen at any time of life. If a person is consistently feeling sick from eating food containing gluten (and does not mistake it for the bellyache after a half-pound, double bacon cheeseburger), he or she should be tested for Celiacs’s.

Emilee, a young girl, tells her true story of being diagnosed with Celiac’s: “I am 13 and I was diagnosed 2 years ago (2012). I am currently living a gluten-free life….Two years ago I got a stomach virus. All the symptoms went away except my stomach pains. I was on the couch almost every night curled up in a ball clenching my stomach. It was to the point I could put nothing in my stomach. Not even water. After more trips to the hospital, I went to a different one. They took my gluten count and the numbers were through the roof. So I went through more testing and a biopsy. After my biopsy results came back it was confirmed. I had celiac disease. We suspect my stomach virus kick started my dormant gene. I was put on a gluten-free diet right away.” (celiaccentral.org).

The number of reported gluten related problems is skyrocketing. Until just recently, diagnosis of celiac disease was about 1 in 133 people (niddk.hig.gov) but now gluten has become a house hold term. I find this perplexing – with better science and technology, testing for gluten intolerance has become easier, however, if gluten sensitivity is an actual condition, why was it not nearly as prominent a few decades ago, as it is now? Why is gluten a hot-button topic? In my research, I noticed that genetically modified organisms (GMO), are a very popular scape-goat amongst all the finger pointing.

Layla Katiraee, a Doctor in Molecular Genetics from the University of Toronto, noticed the same pattern, and stated, “The Internet is exploding with stories about the supposed dangerous link between gluten allergies and genetically modified foods” (Katiraee). An obscure essay, written by Stephanie Seneff and Anthony Samsel, scientists from MIT, attributes to this new found blame on GMO’s. The essay focused on the correlation between glyphosateand rise in modern disease. Glyphosate the proper name for berbicides like Round-up, is sprayed on many crops that are sold commercially.

Dr. Katiraee noted that, “Anti-GMO campaigners postulate two primary hypotheses as to how GMOs cause gluten sensitivity. The first is that glyphosate may kill the healthy bacteria in the gut, leading to a bacterial imbalance. The second is that the Bt-toxin, found in Bt-resistant GM crop, punctures holes in human cells (in this case, the gut), leading to a leaky gut” (Katiraee). The Celiac Disease Foundation (CDF) challenged these hypotheses, calling them pure speculation: “The scientists at CDF pointed out that patients with Celiac Disease or gluten-sensitivity feel better when they cut gluten out of their diets. If the cause of their sensitivity were GMOs or glyphosate, then they’d have to cut out a lot more than just gluten.” Glyphosate is used on a wide spectrum of crops reaching much further than just wheat, barley, or rye.

Katiraee goes on to point out that the most convincing evidence against these hypotheses is that genetically modified wheat is not even on the market. Wheat is not glyphosate resistant, and is being tested to become so, but GM wheat is currently not commercially available (Katiraee). Katiraee states that the essay written by Seneff and Samsel, “cherry-pick data from global statistics to support their claims…Neither has any known expertise in genetics or toxicology” (Katiraee). 

In the world of increasing “gluten sensitive” individuals, Doctor Stefano Guandalini, director of the University of Chicago Celiac Disease Center, concludes, “These patients absolutely do exist… They do have real symptoms” (webmd.com). Many doctors and even registered dietitians will gladly prescribe a gluten-free diet for those who have what is known as non-celiac’s gluten sensitivity (NCGS). However, there is a very real conflict in the medical and dietary world on the topic. Why?

Ben Fager

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As a young boy, I  remember countless dinner conversations where my mother, a registered dietitian, would playfully quiz my siblings and me on the vitamins and nutrients in our meal. I quickly became aware of the need to treat my body with respect and to eat the right foods. I have always trusted my health to my mom because she loves me, continues her education thoughtfully and meticulously, and applies those principles in our family life.

Like everyone else, I’ve faced the revolving door of diets.  Every time a new way of eating came my way, I would process it and then share what I had heard with my mother. Without fail she would break down the faulty reasoning behind each fad diet. The latest fad  I have encountered is the gluten-free diet.  It is trendy and it is  catching on quickly. I am sensitive to the fact that many people are afflicted by celiac disease or gluten intolerance.  It is a real condition.  One of our family members died because of it. So what is the difference between gluten intolerance and gluten sensitivity?  Does gluten sensitivity even exist?

According to celiac.org, “When people with celiac disease eat gluten, their body mounts an immune response that attacks the small intestine. These attacks lead to damage on the villi, small finger-like projections that line the small intestine, that promote nutrient absorption. When the villi get damaged, nutrients cannot be absorbed properly into the body”.

Celiac disease is the most common form of a gluten intolerance, affecting nearly one in every 141 Americans. Whereas, “A diagnosis of gluten sensitivity is confirmed when you are not diagnosed with celiac disease…, and your symptoms diminish after starting a gluten-free diet, followed by a return of symptoms when gluten is reintroduced into your diet” (celiac.org). Scientifically it seems the only difference between celiac disease and gluten sensitivity is that the body does not attack the villi in the small intestines when gluten is consumed by someone who is gluten sensitive. Interestingly enough, “Research estimates that 18 million Americans have gluten sensitivity. That’s 6 times the amount of Americans who have celiac disease” (celiaccentral.org). It seems that gluten is causing millions of people significant discomfort.

Despite the emphatic testimonials and anecdotes, I am a little wary of gluten-free fad for two reasons. First, gluten is pegged with causing symptoms such as “foggy mind”, depression, ADHD-like behavior, abdominal pain, bloating, diarrhea, constipation, headaches, bone or joint pain, and chronic fatigue” (celiac.org). These symptoms seem far too wide-spread to be attributed to substance that is primarily dealt with in the gut.  Second, from ages 2 to 7 my parents believed that I had a gluten intolerance. I never had a biopsy, but I was showing a few of the tell-tale symptoms.  For years I sporadically ate gluten-free. I ate rice bread, and avoided many of my favorite treats, pretzels being the main sacrifice. In the end, my family and I discovered that gluten was not the culprit.  My discomfort was simply an over sensitive stomach which I still have.

I have an aunt who has celiac disease as a standard against which to compare my experience. When I was taken off gluten, symptoms did not change dramatically for me.  When my aunt began eating gulten-free, she left behind constant gut pain and relentless diarrhea.

Based on this experience, I feel that gluten does not harm the general population only those afflicted with celiac’s disease. While this is empirical data for myself, I do recognize my own personal experience is far from conclusive for society.   In future blogs, I will show the science to substantiate my claims.

Ben Fager

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In many cases these team players are bright, opinionated and very protective of their turf.  At the top of list of those “Proud and Protective” of what they do are the food service group.  There is no one more proud, proprietary and protective than a chef!  I include foodservice managers, dietary department managers, and head cooks, to boot.

It is easy to see why. Where else does a person’s work get scrutinized and evaluated openly and candidly three times a day, every day, every week. Even if you do your job very well, you will never satisfy everyone.

I still remember walking into the very first assisted living facility I owned, on the first week of opening and hearing a resident loudly proclaim for all to hear, “This food tastes like #%)+&!”.

So many things factor into our perception of “good food”:  personal preferences, past experiences, memories, mood.  In short, it is not an easy job to feed large groups of people and have everyone satisfied with the results.

It is not an easy job, but is an important one.  Effective managers and food service professionals must insure food preparation is consistent with the vision and expectations of their health care organization.

I have seen cooks run management out of the kitchen, but inevitably this doesn’t work.  Managers need to allow “the artist” in the kitchen the freedom to work, but we all should remember that we eat because many people have contributed work and skill.  Good food is the goal; teamwork is needed to get it right.

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