Welcome to 2012 and 20ppm: defending the new coeliac standard for gluten free

You’ll be aware that new Codex standards concerning the labelling of gluten-free and low-gluten foods came into force on the 1st January – although in practice most manufacturers have been compliant for some time. In a nutshell, food products containing and testing at no more than 20ppm gluten (20 parts per million) can be labelled ‘gluten free’ – and those falling between 20 and 100 as ‘very low gluten’. Untested products without ‘gluten-containing ingredients’ can state as much – but no more.

Why 20ppm? I don’t have the scientific nous to dissect the studies and crunch the statistics in this post, and if I tried to it would probably induce a breakdown. But from what I can see from this study, which summarises (on page 6) findings of the few other studies in this field, there is evidence to suggest that up to 10mg of gluten a day is safe for the majority of coeliacs (but not all coeliacs – and I will come back to this later). This appears to be agreed upon by a consensus of the world’s top coeliac experts such as Alessio Fasano, whose open letter on the matter seems reasonable and well thought-out.

In order to take in 10mg daily, you would need to consume 500g of food at 20ppm every day. This is unlikely, but possible, and the Center for Celiac Research showed here how that might break down.

There is an important point to make here, though: in practice, foods’ gluten content will fall lower than 20ppm, some considerably so. This is because testing at these ultra low levels carries a margin of error, and in order to ensure a sub 20ppm result, manufacturers must in practice aim for quite a bit lower. Gluten free food often tests at 6-8ppm, thus making it unlikely you’d consume 10mg a day in this way.

Online, there’s been quite a bit of dissent about the new legislation.

Some are arguing that gluten free should mean zero gluten. We don’t have the technology to measure to 0ppm, so foods cannot be tested and confirmed to have zero gluten. Nevertheless, I’ve seen arguments put forward that only naturally gluten-free food should carry gluten-free (ie zero gluten) labelling. But that’s unworkable and seems perverse: we can’t test for it, therefore we can’t guarantee it, and it is effectively arguing against any form of testing for gluten-free food.

Wise coeliacs know – and need to know – that fruit, veg, meat, fish, dairy products, nuts and seeds are gluten free. Do you think they should be uniquely labelled as such? Would you also propose putting a nut-free label on a grapefruit or a milk-free label on a fillet of salmon? Zero-risk guarantees are impossible in the context of everyday living: an apple sitting on a shelf may carry a few microscopic particles of flour if there’s baking going on in another part of the supermarket. On the molecular level, this trace contamination is impossible to avoid.

The compromise is to have ‘gluten free’ mean ‘no detectable gluten’ – which stands at, I think, 3-5ppm according to the best detection methods. This is what Australia and New Zealand have at present – although the Australian Coeliac Society is asking to be brought in line with Europe.

The argument against this is that the threshold is needlessly strict, and difficult for many manufacturers to achieve. Just because we can measure this level – doesn’t mean our cut off point should be at this level, as Fasano argues. Manufacturers will be put off entering the gluten-free market, and as most coeliacs will tell you, they want more options, not fewer. It will probably also lead to more product recalls, not to mention increased prices and poorer quality products.

Passion vs dispassion
This is an emotional issue. Many have suffered years of non- or misdiagnosis, not to mention relapses and painful glutening episodes. Friends and family may not have always been understanding and sympathetic. There are relentless social difficulties in managing a gluten-free lifestyle. It’s bloody hard and every coeliac knows it.

But when it comes to matters of health and science, emotion cannot be allowed to dominate decision-making processes. It must be dispassionate.

As understandable as it is, a lot of the reaction against 20ppm I’ve seen has been emotional.

“I want no gluten. Coeliacs need no gluten.” Setting aside the fact that we can’t measure no gluten, specialists know that all coeliacs have a threshold and can tolerate a minute amount of gluten, which varies from person to person. As any toxicologist will tell you, it is a question of dose. Not only is zero gluten not a feasible practical option – to the best of our knowledge, it is not necessary, and disputing that is an emotional not scientific response.

“Gluten free should mean gluten free.” I think this too is an emotional argument. There is a precedent for ‘free’ to mean ‘almost but not quite free’ – alcohol-free lager can contain 0.05% alcohol, eg, and I understand it is a similar situation with cholesterol free, sugar free, calorie free, decaffeinated products and others.

To those against 20ppm, I would pose this: for whose benefit are you arguing for? It’s a sincere and genuine question. Your own benefit? The benefit of all coeliacs? The benefit of 95% of coeliacs? Which is it?

This is a very important question which anyone who disagrees with 20ppm ought to be clear about. Because, as has been pointed out, lowering the threshold will cause problems (limiting product availability, raising prices etc) which will hit many coeliacs quite hard, and may increase non-compliance with the GF diet among large sections of the coeliac population.

It’s a tough, harsh fact of life that we can’t please everyone, everytime. I was at a talk at Leatherhead recently on food allergens (the write-up is on the FoodsMatter.com site) at which the Food Standards Agency’s Dr Chun-Han Chan pointed out that thresholds for other allergens (nuts and peanuts, perhaps most importantly, but others too) were being developed. None of these will be zero. As Dr Chan said, the aim is not to protect every individual on every occasion against any possible reaction, but to manage overall public health as best possible. ‘Free from’ will translate to ‘no mild reaction in the vast majority of individuals’ – vast majority being 95-99% of people.

Tough decisions have to be made in order to move forward in healthcare – for instance, on the value and cost of certain drugs in relation to NHS budgets and the economy. We simply cannot do everything, for everybody, in every conceivable situation. Therefore, decisions must be made to benefit the most people – and on that apparent basis 20ppm has been agreed upon.

The ultra sensitive
Upstream I said I’d come back to the issue of acute sensitivity to gluten. The first thing I’d say is that unless confirmed by your gastro, I’d urge ultra-sensitive coeliacs to be open to the possibility that they could be reacting to another ingredient or substance, if only because it’s impossible to know the precise level of gluten in any food. I don’t know of any coeliacs who have a scientifically tested numerical value on their threshold, and while coeliacs doubtlessly understand their bodies very well indeed, there remain other possibilities (such as sugars in wheat starch, other intolerances, IBS) which I examined a little in my book and which could potentially mimic glutening symptoms.

The second thing is that, if you are or feel you are acutely sensitive to gluten at extremely trace levels, then it must be bloody tough and I can’t imagine the difficulties of it at all. I’m aware it seems heartless of any pro-20ppm’ers to be supporting this figure if you literally and metaphorically cannot stomach it – but I hope that you’ll understand from what I’ve said above why it seems this level has been set.

I expect it will feel a harsh decision to some, hence the emotion: ‘But what about me?’ Yet the further tough reality is that if we indulged in endless ‘whataboutery’, then we’d end up with no labelling regulations at all – and that would put us back to the sixties and seventies. For instance, what about people with mushroom or kiwi or strawberry allergy, for whom an allergy alert box is useless and whose allergy is not covered in the alerts the allergy charities send out? What about people with other dietary needs? Those with PKU, or favism, or gout? Or who avoid certain foods due to religious reasons?

As the experts acknowledge, we could do with more studies to better understand the picture of safe gluten thresholds. But there are ethical concerns here. Let’s face it, would you be happy to submit to gluten micro-challenges every day? That’s what science needs to get that clearer picture, and giving coeliacs measured quantities of gluten isn’t without its obvious problems.

If only in the interests of balance, there is what seems to be a very well thought-out and dispassionate counter-argument which you may like to read. I’ve briefly looked at it and not yet unpicked it, but I hope to find the time to do so in the future, and I may repost when I’ve done so, and taken on board any comments that follow here. It’s on the Ultimate Gluten Free site here.

In summary…
Perhaps ultimately it just comes down to who you trust, and I guess I trust the scientists and the coeliac bodies.

Here’s a concern. I fear for newly or recently diagnosed coeliacs. I’m worried that all the impassioned and occasionally alarmist talk on Twitter and blogs and forums about the need to eliminate every last trace of gluten and recommendations to avoid wheat-based glucose syrup and other gluten-free ingredients and the dangers of Codex is merely confusing already struggling new coeliacs, and potentially restricting their diets to detrimental levels. They are the most vulnerable.

It seems to me – and I admit this is just my own experience – that the loudest voices in this debate appear to be well-informed and often highly gluten-sensitive coeliacs who largely cook for themselves from scratch, maintain a high degree of health, and don’t rely much, if at all, on rendered gluten-free ‘free from’ foods.

I’d like to hear from others, from those for whom these foods represent a literal lifeline – including parents of coeliac children. Sometimes coeliacs write to me directly as they’re too shy or nervous of posting a comment publically on this or another blog: some are wary of challenging fundamentalist views and no longer know what to believe. We need to bear this in mind: not everyone is using their voice, and some of the stuff out there in webland (an alarmist video which I refuse to link to springs to mind) cannot, I’m sure, be helping the people who most need sane and evidence-based advice.

The best allergy-related food labelling there is in the world is for gluten. It beats nut, peanut, milk, egg and fish (which, remember, can kill) hands down. It’s remarkable we’ve got this far in a relatively short period – be aware that African and Asian countries don’t have anything that comes close – and it’s worth remembering too that the way we do it is not set in stone: if evidence is found to support a need for a lower gluten-free threshold, it will surely be considered.

You may not agree with it, but at the very least, a move from 200ppm to 20ppm is an enormous step in the right direction. That, at a minimum, cannot be denied.

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