Gluten-free Foods

Gluten-free Foods

Below is a selection of Q&As concerning gluten-free foods.  
If your question isn't answered here, please contact us.

What is coeliac disease?

Coeliac disease is an autoimmune disorder which affects 1 in 100 genetically susceptible people in the UK.1 Coeliac disease affects the small bowel, the lining of which is made up of tiny finger-shaped projections called villi. If sufferers of coeliac disease eat gluten, their immune system reacts causing their villi to become inflamed and flattened. The damage caused decreases the surface area of the villi, reduces the ability of the small bowel to absorb nutrients from food properly and causes much pain and discomfort. Coeliac disease is a life-long condition and adherence to a gluten-free diet is the only treatment available at present.

Symptoms of coeliac disease include bloating, diarrhoea, nausea, wind, constipation, tiredness, headaches, sudden or unexpected weight loss (but not in all cases), hair loss and anaemia.

Dermatitis herpetiformis is the skin manifestation of coeliac disease.  This is a rash, commonly found on theelbows, knees, shoulders, buttocks andface.  It affects around one in 10,000 people in the UK.2

What are the health risks of coeliac disease?

Coeliac disease is an autoimmune disorder where consumption of gluten triggers an immunological response, which causes damage to the lining of the small intestine. This results in reduced ability of the small bowel to absorb nutrients. Consequently, the only way to manage coeliac disease is by adherence to a gluten-free diet.

Untreated and poorly managed coeliac disease can lead to health risks, including gastric imbalances, malnutrition and nutritional deficiencies (iron, folate, vitamin B12 and vitamin D). This can lead to conditions such as anaemia; osteoporosis and increased risk of fractures due to a lack of calcium; the development of bowel cancer; dental problems in children; and, in women, infertility and adverse outcomes in pregnancy.

How is coeliac disease diagnosed?

Individuals who have symptoms of coeliac disease should visit their GP, who will take a simple blood test to check for coeliac antibodies. In some cases people with coeliac disease may have a negative result and require a different test. It is important that the patient continues on a gluten-containing diet whilst testing for coeliac disease is undertaken to ensure the results are accurate.

If the test is positive, or if the GP suspects coeliac disease for any other reason, he/she will refer the patient to a gastroenterologist who will conduct a full intestinal (or gut) biopsy. The biopsy is examined to determine whether characteristic changes associated with coeliac disease are present in the tissue sample.

Symptoms of coeliac disease include bloating, diarrhoea, nausea, wind, constipation, tiredness, headaches, sudden or unexpected weight loss (but not in all cases), hair loss and anaemia.

Is coeliac disease the same as a wheat or gluten allergy or intolerance/sensitivity?

Coeliac disease and gluten sensitivity are both part of a broad spectrum of gluten-related disorders.3  Although sufferers feel many of the same symptoms, the biological mechanisms underlying the two disorders are very different from each other.

Coeliac disease is an auto-immune disorder where the body’s immune system attacks itself when gluten is eaten. This causes damage to the lining of the gut and means that the body cannot properly absorb nutrients from food.

Gluten sensitivity and gluten intolerance are terms that are used interchangeably by many people, especially consumers and the media, to describe a non-allergic, non-autoimmune condition in which symptoms are triggered by gluten. Those with gluten sensitivity lack the histological damage that is a defining characteristic of coeliac disease.

Gluten sensitivity is diagnosed by a strict gluten elimination diet. Foods are reintroduced one by one over a period of two to three months to ‘test’ for any adverse reactions.

What is gluten?

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

People with coeliac disease must comply with a gluten-free diet and avoid gluten-containing foods. This may lead to a restricted and potentially unbalanced diet as many of these foods are staple products.

Are gluten-free foods completely free from gluten?

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 organisation which works to protect the health of consumers) outlines a safe threshold level of gluten.

Until July 2008 the threshold level of gluten in gluten-free foods was 200 parts per million (ppm), as set out by the Codex Standard.  This was updated following further research and the revised 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 people with gluten intolerance:

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

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

Research has shown that people with coeliac disease can consume an unlimited amount of foods containing less than 20 ppm gluten with no adverse effect.

Where can gluten-free foods be obtained?

Individuals who have been medically diagnosed with coeliac disease or dermatitis herpetiformis may be eligible to receive staple gluten-free foods on prescription.

Gluten-free foods can also be obtained from the ‘free-from’ aisle of supermarkets.

Who can receive gluten-free foods on prescription?

Only individuals who have been medically diagnosed with coeliac disease or dermatitis herpetiformis may be able to receive gluten-free foods on prescription. A strict, life-long gluten-free diet is the only way to manage either conditions, therefore access to a range of specially formulated gluten-free products on prescription has been found to aid dietary compliance. Healthcare professionals (HCPs) acknowledge that provision of a reasonable supply of basic gluten-free staple foods not only encourages adherence to the diet, but also ensures that patients maintain regular contact with expert HCPs who can monitor their health and help avoid complications. 

People who are not medically diagnosed with coeliac disease, but who may have a wheat intolerance or allergy are unable to obtain gluten-free products on prescription. This is because the Advisory Committee on Borderline Substances (ACBS), 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.

If you have been medically diagnosed with coeliac disease, you need to check your local clinical commissioning group’s (CCG) prescribing policies to find out whether you are eligible for gluten-free foods on prescription.

What foods are available on prescription?

A range of prescription gluten-free food is available for people who have been medically diagnosed with coeliac disease.  These are substitute staple foods to replace many of the staple products that have to be avoided with gluten intolerance.

The Advisory Committee on Borderline Substances (ACBS), an independent body advising the Department of Health, approves a list of products that can be prescribed to patients medically diagnosed with coeliac disease. The ACBS only approves items that are considered to be “dietary staples”, including:

  • fresh and long life breads and rolls
  • crackers and crispbreads
  • flour mixes
  • pastas
  • pizza bases
  • xanthan gum

The availability of these prescribable gluten-free foods aims to help people with coeliac disease and dermatitis herpetiformis to comply with a lifelong strictly gluten-free diet.  Many of these foods are fortified with key nutrients such as calcium and fibre, which may be lacking in gluten-free diets.

A full list of the prescribable products currently available can be found here.

What are the National Prescribing Guidelines for gluten-free products?

In the UK, a prescribing guide for gluten-free foods has been developed by the patient charity Coeliac UK, the Primary Care Society of Gastroenterology and the British Dietetic Association following consultations involving professional organisations and patients. The aim of these guidelines is to assist General Practitioners (GPs), dietitians, pharmacists and practice nurses in the decision-making process when recommending or prescribing the quantities of gluten-free foods on prescription.

People with coeliac disease have varying requirements for gluten-free foods depending on their age, gender, occupation and lifestyle. The guide recommends that the amounts of gluten-free food prescribed should be in conjunction with a dietary assessment and advice from a registered dietitian. ‘Gluten-free foods: a revised prescribing guide 2011’ includes background information on coeliac disease, as well as recommendations and advice for healthcare professionals on the quantities and range of gluten-free foods available for prescription purposes.

Gluten-Free Foods: The National Prescribing Guidelines, which were last updated in 2012, is available on the Coeliac UK website here.

Why is it necessary for individuals with gluten intolerance to follow a lifelong gluten-free diet?

Coeliac disease is a lifelong autoimmune condition; therefore a lifelong gluten-free diet is vital for good health.  Coeliac disease is unique amongst gastrointestinal disorders as it can be managed effectively through dietary treatment alone. Strict compliance to a gluten-free diet is essential to help to protect people with coeliac disease from developing associated health complications, such as anaemia, osteoporosis and gastrointestinal malignancy.

Dermatitis herpetiformis is a skin condition linked to coeliac disease. The main way to manage dermatitis herpetiformis is also by following a lifelong gluten-free diet.  

In a 2013 survey commissioned by the BSNA, 86% of respondents agreed that access to gluten-free foods on prescription was important in aiding adherence. Those in lower social grades were found to rely more heavily on their prescriptions to manage their condition.4

What is Codex wheat starch?

Codex wheat starch, also known as gluten-free wheat starch, is a specially manufactured wheat starch that has been processed to remove the wheat protein (gluten) to a trace level, which complies with the international Codex Standard for gluten-free foods.

Following the changes to the Codex Standard in 2008, all specialist substitute foods that are labelled as ‘gluten free’ have to have a level of gluten of 20ppm or less. At this level, people with coeliac disease can consume these foods in unlimited amounts. Gluten-free foods that contain Codex wheat starch should no longer cause a problem for sensitive patients.

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

It is important to note that products which contain Codex wheat starch are gluten-free but not wheat-free.

What is the difference between a gluten-free and a gluten-free, wheat-free diet?

The majority of people with coeliac disease are able to include gluten-free foods containing Codex wheat starch (also known as gluten-free wheat starch) within a gluten-free diet. These products are gluten-free but not wheat-free and should not cause a problem for people with coeliac disease. 

It is important to bear in mind that sensitivity to gluten may vary and should be considered on an individual basis. For some individuals with ongoing symptoms a gluten-free, wheat-free diet may be required. People with coeliac disease should consult their individual healthcare professional for advice on which diet should be followed.  It is important to be aware that products labelled ‘wheat-free’ may not be gluten-free as they may contain rye or barley, both of which are dietary sources of gluten.

Why are specialist gluten-free foods more expensive than normal foods?

Specialist substitute gluten-free foods, such as bread and flour, are specially formulated from ingredients which do not contain gluten or have had the gluten removed from them. To ensure that these specialist gluten-free foods are suitable for patients with coeliac disease, BSNA’s members’ foods are manufactured in specialist facilities to reduce any risk of cross-contamination with other products; undergo rigorous testing procedures at each level resulting in higher costs; and are fortified with key nutrients such as calcium, iron, folate and B vitamins. Prices are higher because specialist gluten-free products are produced in lower volumes than mainstream products.

Is there a difference in cost between gluten-free foods available on prescription and in retail?

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 pharmacies, 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 also 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 survey4 of 1,000 adults with coeliac disease revealed that of those respondents who receive gluten-free foods on prescription, 37% said they never lapse, 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.

Why should the NHS pay for gluten-free luxuries?

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.

The Advisory Committee on Borderline Substances (ACBS), an independent body advising the Department of Health, approves a list of products that can be prescribed to patients.  The ACBS will only approve items that are considered to be “dietary staples”. These foods, typically, form the basis of a nutritionally balanced diet and include: plain breakfast cereals containing no added sugar, breads and rolls, crackers and crispbreads, flours and bread mixes, pastry mixes, pastas, pizza bases, xanthan gum.

What products do BSNA member companies manufacture?

BSNA’s members develop and produce prescribable gluten-free products for individuals who are medically diagnosed with coeliac disease. These include fresh and long-life breads, rolls, cereals, pasta, pizza bases, flours, crackers and biscuits.