Frequently Asked Questions

Gluten is a protein found in wheat, rye and barley. Many staple products in the UK diet contain gluten, for example, breads, rolls, pasta, flours, crackers, biscuits and cakes. In addition, there are many less obvious sources of gluten in the diet, such as sausages and ready meals, which often contain gluten in the form of cereals used as fillers or binding agents.

As people with gluten intolerance must comply with a gluten-free diet, they must avoid all of these foods. Therefore, there is the potential for these individuals to have a restricted and potentially unbalanced diet, particularly as many foods which have to be avoided are staple products.

Whilst the term ‘gluten free’ suggests that a product does not contain any gluten, in practice, it is impossible to test for a zero level of gluten. Research has shown that there is a level of gluten which is considered safe for people with coeliac disease to consume. An international standard for gluten-free foods, created by Codex Alimentarius, an international body which works to protect the health of consumers, outlines a safe threshold level of gluten.

In July 2008 the existing threshold level of 200 parts per million (ppm) of gluten in gluten-free foods, set out by the Codex Standard, was updated following further research. A new dual standard (Codex Standard for Foods for Special Dietary Uses for Persons Intolerant to Gluten. Standard 118. Revised 2008) was adopted with two labelling categories for foods suitable for individuals with gluten intolerance:

i)               Foods not exceeding 20 ppm of gluten will be labelled as ‘gluten free’

ii)              Specialist foods containing between 21-100ppm of gluten will be labelled as ‘very low gluten’

Research has shown that individuals with coeliac disease can consume an unlimited amount of products with gluten at a level of <20ppm as it has been demonstrated not to be harmful.

A range of staple gluten-free foods is available on prescription for those medically diagnosed with coeliac disease or dermatitis herpetiformis. There is also a variety of gluten-free foods available from free-from aisles in supermarkets and in health food shops. Foods include cakes, chocolate biscuits, snack products and ready meals amongst others.

Individuals medically diagnosed with coeliac disease or dermatitis herpetiformis are able to receive gluten-free foods on prescription. A strict, lifelong gluten-free diet is the only management for both conditions and easy access to a range of specially formulated gluten-free products on prescription is vital to promote strict compliance with the diet.

Individuals with a wheat intolerance or allergy are unable to obtain gluten-free products on prescription. This is because the regulatory body which approves products for prescription stipulates that gluten-free foods should only be available on prescription for individuals with gluten-sensitive enteropathies e.g. coeliac disease or dermatitis herpetiformis.

A range of specialist substitute gluten-free foods is available on prescription.  These are substitute staple foods to replace many of the staple products that have to be avoided with gluten intolerance. These specialist substitute products help individuals achieve a healthy, well-balanced diet.

In the UK, a panel of healthcare professionals developed a prescribing guide for gluten-free foods. The aim of these guidelines was to assist General Practitioners (GPs), dietitians, pharmacists and practice nurses in the decision-making process when recommending or prescribing gluten-free foods.

People with coeliac disease have varying requirements for gluten-free foods depending on their age, gender, occupation and lifestyle. The guide (Gluten-Free Foods: a prescribing guide. 2004) includes background information on coeliac disease, as well as minimum monthly recommendations and advice when prescribing the quantities and range of gluten-free foods available on prescription.

Copies can be obtained from the gluten-free manufacturers:

Nutrition Point   www.glutafin.co.uk

Juvela  www.juvela.co.uk

Guidance for the prescribing of gluten-free foods has been based on:

• Gluten-free prescribable foods providing 15% of total energy
• A review of consumption data from the National Diet and Nutrition Surveys
• Consideration of The Balance of Good Health model
• Prescribing gluten-free foods to meet 15% of total energy requirements does not increase the average expenditure on gluten-free foods

Coeliac disease is a lifelong autoimmune condition in which gluten ingestion results in the inflammation of the lining of the small intestine. It is unique amongst gastrointestinal disorders as it can be managed effectively through dietary treatment alone. Strict compliance to a gluten-free diet can help to protect individuals against the potential development of associated health complications, such as anaemia, osteoporosis and gastrointestinal malignancy.

Dermatitis herpetiformis is a skin condition caused by gluten intolerance. It can occur at any age and is managed effectively with a strict, lifelong gluten-free diet, although medication may be required in the initial stages.

A survey of 1,000 adults with coeliac disease, undertaken by gluten-free manufacturers, found that availability of gluten-free foods on prescription aids dietary compliance. Variety of and easy access to a range of gluten-free foods on prescription was considered important.

Codex wheat starch is a specially manufactured wheat starch that has been processed to remove the gluten to a trace level, which complies with the international Codex Standard for gluten-free foods. The vast majority of individuals with coeliac disease should be able to tolerate this wheat starch.

Codex wheat starch is only used in some prescribable products such as breads, rolls and flour mixes as it helps to improve the quality and texture of gluten-free foods. This helps to achieve compliance with the gluten-free diet.

It is important to note that these products are gluten free but not wheat free.

The majority of people with coeliac disease are able to follow a gluten-free diet and include products containing Codex wheat starch within the diet. However, there is a small proportion of individuals with coeliac disease who are very sensitive and are unable to tolerate Codex wheat starch. These individuals would therefore follow a gluten-free, wheat-free diet. An individual’s dietitian should advise on which diet should be followed.

It is important to be aware that products only labelled ‘wheat free’ may not be gluten free as they may contain rye or barley, both of which are dietary sources of gluten.

Specialist substitute gluten-free foods, such as bread, pasta etc, are specially formulated from ingredients that suit the special dietary requirements of the individuals they are intended for. This results in higher raw ingredient costs due to the additional processing required. To ensure that these specialist gluten-free foods are suitable for gluten-intolerant individuals the foods are manufactured in facilities dedicated to dietary foods. Additional processing and testing procedures, for example gluten analysis, are undertaken to ensure the foods meet strict compositional criteria. In some instances, some staple products are also fortified with key nutrients for these individuals, for example fibre, calcium.

In some cases gluten-free foods on prescription may be more expensive than those available in supermarkets. Manufacturers of prescribable gluten-free foods need to fund the distribution of products via wholesalers to local pharmacy shops, or, in the case of fresh bread, to deliver directly to the pharmacy. This ensures that products are available to everyone throughout the UK even in areas where the choice of gluten-free foods in supermarkets may be poor.

Specialist gluten-free manufacturers provide a wide variety of services to coeliac consumers, such as free product samples, expert advice from dietitians and careline staff, literature, recipe information and support for healthcare professionals such as dietitians and pharmacists.

Research has shown that availability of gluten-free foods on prescription aids patient compliance. The results of a survey of 1000 adults with coeliac disease revealed that of those respondents who receive gluten-free foods on prescription, 37% said they never lapse, in addition, 33% said they rarely lapse and 19% lapse occasionally.  The survey also highlighted that if patients comply with the gluten-free diet the incidence of related conditions, mainly anaemia and osteoporosis, is reduced, meaning fewer associated healthcare costs for the NHS.

Only specialist staple gluten-free foods are available on prescription. There are strict guidelines on what type of products manufacturers can supply and this does not include ‘luxuries’ such as speciality breads, cakes and chocolate biscuits. These have to be purchased from supermarkets.

Gluten intolerance only affects a small proportion of the general population- approximately 1%. It is therefore not necessary to remove gluten from the majority of individuals diets.

Reference - West JR et al. Seroprevalence, correlates and characteristics of undetected coeliac disease in England. Gut 2003;52:960-965