New labelling legislation for gluten-free foods

Below are some of the questions you may have about the new labelling legislation and how it may affect the advice that you provide for your patients. 

When I see a newly diagnosed individual, should I recommend that they avoid the ‘very low gluten’ products and introduce later, or include them and cut them out if they experience ongoing symptoms?

The new dual legislation enables patients to distinguish between products that that are gluten-freeWhen a food has less than 20 parts per million (ppm) of gluten so it is safe for people with coeliac disease to eat. (20ppm or less) or very low gluten (21-100ppm). There isn’t enough evidence to make general recommendations and advice should be given on an individual basis. A level of gluten of 100ppm is suitable for most people with coeliac diseaseA condition where a person is unable to eat gluten as it makes their body attack itself. , whilst individuals are able to eat unlimited amounts of foods that contain 20ppm or less. We do not know of any products in the 'very low gluten' category which are currently available in the UK.

Is there a recommended number of slices of gluten-free bread which is safe for people with coeliac disease?

The amount of gluten consumed by an individual depends on the level of gluten in food and the amount of food eaten. Since the new Codex standardThe standard by which gluten-free foods are measured. All gluten-free products need to get to below a certain limit to be considered either gluten-free or very low gluten. is lower, the risk of eating a harmful amount of gluten has been reduced. There is evidence to show that people with coeliac disease are able to consume unlimited amounts of foods containing 20ppm or less. Many specialist bread products available in the supermarkets ‘Free From’ section and available on prescription will be labelled gluten-free. There is no limit to the amounts an individual can consume. A lot of the products which contain Codex wheat starchA specially manufactured kind of wheat starch that has been washed to reduce the level of gluten to a trace level within the Codex standard. will also fall within the gluten-free category.

How do I know whether to recommend the 'very low gluten' category of products to patients who are asymptomatic?

Previously, gluten-free products could contain up to 200ppm, whereas now this level has been reduced to 100ppm. The very low gluten products will be suitable for the majority of people with coeliac disease but patients should be reviewed at regular intervals. From speaking with food manufacturers, we currently do not know of any foods in this category at present, within the UK. All our feedback suggests that all manufacturers are meeting the standard of 20ppm or less.

The following checks can be used in individuals who do not show symptoms:

• review antibody levels
• monitor weight and BMI
• nutritional screening tests eg. iron, calcium, B12, folate
• other tests eg. bilirubin, liver function tests, total blood count
• endoscopyAn investigation that looks inside your gut. The endoscope is a thin flexible tube that you swallow. It has a light and a camera and is passed via the mouth and into the upper part of the gut that is affected in coeliac disease. .

Is there a recommendation for including oats in the gluten-free diet?

Oats that are guaranteed free from contamination with other grains and that contain 20ppm or less may be labelled ‘gluten-free’. There are no specific recommendations on whether to include oats in the gluten-free diet. Coeliac UK advises individuals to speak to their healthcare team for specific guidance as individual monitoring is necessary to review symptoms or other markers of care. If including oats in the gluten-free diet, the most important thing is to include pure, uncontaminated oats only, brands of which are listed in the Food and Drink DirectoryOur annual Directory of gluten-free food and drink which manufacturers voluntarily submit to. .

One option would be to wait to include uncontaminated oats in the gluten-free diet until there has been complete recovery of the gut. Another option would be to include pure, uncontaminated oats in the diet from the outset, and monitor the patient. If symptoms persist, consider removing these from the diet and monitor any improvements.