Issue 30 / 12 August 2013

THE push to make the Australian definition of “gluten-free” food less restrictive is continuing despite some criticism that it could endanger the wellbeing of patients with coeliac disease.

A letter published online today on the MJA website was critical of the move, saying increasing “permissible” gluten in food from undetectable to < 20 parts per million (ppm) would increase overall gluten ingestion in a gluten-free diet. (1)

“For an undetermined proportion of patients with CD [coeliac disease], this will lead to adverse health outcomes and generate additional health care costs”, Dr Geoffrey Forbes, a gastroenterologist at Royal Perth Hospital, wrote.

Earlier this month the in the US, where the term “gluten-free” has previously not been consistently defined, the Food and Drug Administration set its gluten-free definition at < 20 ppm in a move it said would “help people with this condition make food choices with confidence and allow them to better manage their health”. (2)

It also brings the US in line with the European standard.

The Australian Food and Grocery Council (AFGC) and Coeliac Australia (CA) are backing the move to < 20 ppm, although an application is yet to be lodged with Food Standards Australia New Zealand (FSANZ).

Dr Jason Tye-Din, chairman of CA’s medical advisory committee and head of the CD research team at the Walter and Eliza Hall Institute of Medical Research in Melbourne, said he was fully supportive of the move to < 20ppm.

Improvements in technology meant more sensitive detection methods for gluten were becoming available, which was reducing the number of foods which could be labelled as gluten free, Dr Tye-Din told MJA InSight.

“The CSIRO, for example, is working on detecting gluten in the parts-per-billion range”, he said.

“In the end it will [not be feasible] to produce gluten-free food affordably if we leave the definition at < 3 ppm or no detectable gluten. It will become much harder to find gluten-free food and it will be much more expensive.”

Dr Tye-Din said the current medical evidence suggested that < 20 ppm was a safe level but conceded that there were “no robust data” on the effects of low levels of gluten in patients with CD.

“A gluten-free diet is essential for the treatment of CD. Gluten-free food needs to be available and affordable”, he said.

“Obviously the best treatment is to be as strict as possible and have absolutely no gluten in the diet, but there needs to be a degree of balance. We are trying to do the best for the most … people as possible.”

A spokesman for the AFGC said people would be able to see exactly how much gluten was in food products as it would be mandatory to have exact amounts on the nutrient panel of the packaging.

He said plans were going ahead for an application to the FSANZ and the process was “very collaborative”.

“Our aim is to establish a safe level of gluten, not a zero level”, he said.

In his MJA letter, Dr Forbes wrote that one of the few high-quality studies determining safe gluten intake in CD had been misinterpreted. (3)

“The study concluded that, in patients with CD, daily contaminating of food with gluten should be < 50 mg”, he wrote. “This study has been interpreted as suggesting 10 mg gluten daily is safe.

“Regrettably, study patients were a selective group possibly less sensitive to gluten and, of those receiving 10 mg gluten, one had symptomatic relapse and several had worsening histology on bowel biopsy.”

Dr Tye-Din said although the 2007 study was not “definitive”, it was “reassuring”.

“If new data emerge that suggest that < 20 ppm is not safe then we will change our position”, he

1. MJA 2013; Online 12 August
2. US FDA 2013; 2 August news release
3. Am J Clin Nutr 2007; 85: 160-166

11 thoughts on “Gluten-free definition concerns

  1. Beverley Walker says:

    My gut has been damaged for most of my life my mother died from what I beleive was this allergy and one of my sons refuses to recognise the damage.

    I ws on medical taablets and potions until a GP homeopath told me to get off gluten.  I now live a better diet life and lost a lot of  overweight – I used to feed the pain.

    When companies stop calling wheat flour corn flour and when they stop propping up things like cocoa powder with wheat flour – I cannot have this sprinkled on cappaccuino – when I have soy sauce with wheat, when icecream was puffed up with wheat. We are finding out there are a lot of foods that have gluten products in the – ICECREAM, for goodness sake. 

    Docotrs refuse to admit that this is a problem – it is a matter of the right eating habits. They cannot prescibe a pill which hurts the pharmaceutical companies and the lack of use of wheat hurts the wheat industyr.

    i am a health scientist and bioethicist  – generally speaking doctors do not mention diet. 

    Stop thinking you can put a small amount in if  the amount in cocoa sprinkeld on cappacino gives me pain.


  2. David Liberali says:

    As a dietitian who has been counselling patients on a gluten free diet for many years, the doubt created by doing the best you can with a gluten restricted diet seems a little confusing for health professionals and patients/clients alike.

    The message , “avoid all detectable gluten” in the diet , should mean just that.

    A mixed message based on “no detectable harm” is not likely to be helpful to anyone, potentially permitting the consumption of gluten in small amounts every now and then.

    The optimal way to minimise risk in this patient group is to equally have the most cost effective and thorough testing processes available for patients who must follow a lifelong gluten restricted diet .



  3. Amanda says:

    I have a gluten intolerance. From experience I can report that the only safe level of gluten for someone with CD is ZERO.  To suggest otherwise is misinformed at best, and ignorant at worst. I hope that common sense prevails on this issue. It is already challenging negotiating my way around foods I can safely eat without making the challenge even any more difficult. 

  4. Dr Matthew Long says:

    Wow, what an emotional area for a lot of people. As a GP who also has coeliac disease I feel it is very important that we get the science correct. The increased sensitivity of testing means that for years foods that were labelled gluten free may no longer fit this criteria. I know that my favourite beer was withdrawan from sale because it no longer complied with labelling laws despite being <20 parts per million. I think there will need to be 2 categories, 1. Gluten Free and 2. a safe for coeliacs label of <20 PPM. Obviously if the science changes we re visit the issue. WIth 2 labels then people with coeliac disease still have the choice.

  5. Martin Vdmolen says:

    I have coeliac disease (CD) and this move to increase the limit in classification is very disappointing. Those with CD don’t have an allergy, its a disease – we don’t practice a gluten free (GF) diet as a ‘life style choice’, or a fad diet, or because we mentally think it makes us better. We do it because we have too, to stay well.  

    While GF food is currently a bit pricey, the price is quickly reducing in the Australian market as more players get onboard, including Coles and Woolworths. And now it seems you want to move the maker?! After a recent 10wk trip to Europe I’d say the Australian market for GF products is currently much better/bigger. 

    My concerns are:

    1) the increase > than 6 times the current acceptable level (< 3 ppm to < 20 ppm). That seems like a pretty extreme jump.

    2) levels build up in a day over the various foods consumed. For example after 3 meals I might total < 100 ppm.

    3) Creep. Restaurants and food providers will start forming the notion that they can pass GF food if there is low gluten rather than it truly being GF. So ultimately those with CD will have to interpret the tiny numbers on the back of packs for traces of gluten to work it out if they don’t want to get sick? This being the opposite of the intention of labeling things gluten free in the first place. PLUS, coeliacs wont be able to confidently eat out, because any chef or cook is unlikely to read the numbers on the back of packs.

    If your a coeliac or are concerned for anyone that has it I encourage you to write to the federal minister for health (noting contact may change after election).

  6. Ross Drewe says:

    Not enough emphasis is being put on the wide variation in gluten sensitivity.  Some people do seem to be very sensitive. These people are happy to accept very restricted choice if it makes their gut comfortable, and for them it is important that a “gluten free” label means what it says.   Bear in mind that dishonesty is a long tradition in the food industry:  Even with legal restrictions, some companies will lie.  We need a regulation with some teeth to protect the seriously intolerant people.   For a wider group of people, small amounts are tolerable and we should define a government-mandated level for a low gluten label, choosing a level which will not cause symptoms in most people and will allow wider choice of diet.   Useless marketing ploy labels (eg, “reduced wheat”) can be left unregulated.  Two government-mandated labels based on fixed levels would cover the more serious intolerances nicely, and the argument about choosing the lower limit would become irrelevant..   The “gluten free” label should mean undetectable.  The level for the other label (“low gluten”) can be debated but should be kept quite low.  It’s only this end of spectrum where the labelling is important.

  7. Maxine Szramka says:

    wow. its breath taking to consider how conveniently language is intended to be bastardised for the sake of the convenient profits of the suppliers. No means no- no gluten means exactly that. And things labelled gluten free, need to be exactly that. People are incredibly sensitive to gluten- even the smallest trace amount in a sensitive person can create an enormous state of unwellness. profits are here being placed ahead of the true health of the consumer. What is being said here is that that near enough is good enough, as long as the suppliers make a profit. There is no point in making ‘affordable’ gluten free products, if those said products are in fact not gluten free. This is a major public health issue and need to be publicly debated. Trace of gluten is unacceptable in a gluten free product. Lets get real and demand absolute honesty.

  8. A Harris says:

    Congratulations on raising awareness of an important issue.

    Work remains to upskill docotors about Coeliac and it’s diagnosis, especially those presenting with nonclassical symptoms and what a ‘gluten free’ diet actually involves. Coeliac disease is the new ‘great imitator’. It is a systemic autoimmune disease with a cytokinine cascade response triggered at the molecular level when offending peptides traverse the gut mucosa. The GF diet works at a celluar level, traces of gluten are important.

    An important public health issue is the presence of gluten contamination in food products without the GF label, but without any of the guilty grains on the ingredient label. Education about all sources of gluten that coeliacs can be exposed to and the risks involved is under-recognised in persistent patient morbidity.

    Australia has the best GF food labelling standards much to the envy of coeliacs overseas. Whilst expensive, there is a wide range of GF foods currently available. It is extraordinary that any raise in the level of gluten should be advocated. Evidence does not support it’s safety. How does a doctor know who is a ‘sensitive’ patient? 

    Today the influence that industry has when entangled with medical policy makers is topical. The patient is disserviced and the profession tarnished. Sadly, it appears the interests of those wishing to profit from what is a very large GF food industry are muddying the scientific waters. Sound medical evidence and professional adherence to the ethics of maleficence and skill maximisation must prevail in the medical community.

    Finally, it is possible to adhere to a strict GF diet, have good health outcomes and have a charmed life!


  9. Genevieve Freer says:

    One problem with parts per million is the batching of food with higher levels, as we have seen with Cadmium in imported peanuts. One presumes that the batching is mixed, however, what if it is not -20 tonnes per million tonnes batched may not be mixed, so some of the million tonnes may have less, some may have more. As rice  is more expensive than wheat, batching with gluten is a means of reducing cost and increasing profit.

    I prefer to eat  not one cadmium-containing peanut in a pack of 100 , just as I expect a bag of rice to contain no wheat.

    Tthere are plenty of natural foods that contain no gluten, so it is false to claim that zero gluten is too expensive for the consumer-rather it means less profit for the seller.


  10. Melanie King says:

    Why shouldn’t gluten free mean zero gluten? Clearly these doctors and those bureaucrats making the decisions do not have CD and are not gluten intolerant. This is a very stupid and inconsiderate move

  11. Amy Williams says:

    this absolutely disgusts me.  I feel like Coeliac Australia are doing a complete backflip from the advice they have been handing out for years.

    No robust data ?

    ““If new data emerge that suggest that < 20 ppm is not safe then we will change our position”, he”so shouldn’t that tell everyone that this should NOT happen?

    Why can’t they just set the detectable level to 3ppm and be done with it ?  Woudln’t that be far safer ?

    My coeliac daughter is nearly 7.  She has her entire life ahead of her.  20+ years of consuming greater than 3ppm of gluten on a daily basis could adversely affect her health. I know that we will have a choice, with levels on packaging, but I feel that this will lead to a reduction in manufacturers producing GF food at the current 3ppm level, so it will infact be a bad thing overall and choice will eventually be taken away from those who are easily sticking to a completely strict gluten free diet.

    My child’s gut had complete healing upon her last scope.  That was 2 years after diagnosis.  I do not want her going backwards with her health or for anything to affect her behaviour/schooling etc.

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