The CREST Guidelines state that the objectives of dietary advice are to ensure that people with coeliac disease:

1. Exclude all dietary sources of gluten
2. Know which foods and ingredients are naturally free from gluten
3. Substitute gluten-containing foods and ingredients with gluten-free alternatives to improve dietary acceptability and nutritional adequacy
4. Have nutritional deficiencies identified and treated, e.g. iron/folate/ vitamin B12 deficiency, osteoporosis
5. Have appropriate management of associated conditions which require dietary intervention, e.g. type 1 diabetes mellitus, lactose intolerance and pancreatic insufficiency
6. Consume a balanced diet which helps to maintain health and protect against disease
7. Have ongoing life-long dietetic support

Oats

The World Gastroenterology Organisation (2007) states that the inclusion one serving per day of pure, uncontaminated oats in the gluten-free diet is safe in the majority of coeliacs (95%) with only a small proportion (5%) having a sensitivity to the protein found in oats.

However, oats produced in Ireland are likely to be contaminated with gluten from other grains during the growing, transport or milling processes and are, therefore, not suitable on the gluten-free diet. The Food List provides a list of 3 brands of pure, uncontaminated oats suitable for consumption by the majority of coeliacs; conventional oats should not be included in the gluten-free diet.

Pure, uncontaminated oats should not be included in the diets of newly diagnosed coeliacs, should only be introduced to the diet when the client is symptom-free and serology is negative, and should be avoided during episodes of gastroenteritis. Clients should receive regular follow-up when introducing oats into the gluten-free diet, ideally including small bowel biospy.

Codex Standard for Gluten-Free Labelling

The WHO/FAO international Codex Alimentarius set the standard for gluten-free labelling. This standard was previously set at 200mg gluten/kg or 200ppm. This level was suitable for the majority of coeliacs; however, a minority were sensitive to a gluten content of this level. In a bid to offer better protection to coeliacs these guidelines have been reduced and two standards for gluten-free foods now exist:

1. Foods containing <20ppm gluten are labelled 'gluten-free'
2. Foods containing 20-100ppm gluten are labelled ‘very low gluten’

(See Codex Standard for more information on new labelling guidelines.)

A large amount of manufacturers have already adhered to these new labelling guidelines, however, they will not become mandatory until 1st January 2012.

As there is currently a lack of evidence-based clinical guidelines on dietary education involving these new standards, the Gastrointestinal Interest Group (GIG) of the Irish Nutrition and Dietetic Institute (INDI) has produced the following guidelines:

• Newly diagnosed coeliacs should commence on a strict gluten-free diet, i.e. containing only ‘gluten-free’ foods (< 20ppm), to facilitate as rapid a recovery as possible. They should not be ‘titrated up’ to the old standard subsequently.
• Coeliacs who were established on the old gluten-free diet (<200ppm) may include ‘very low gluten’ foods initially. If, however, they demonstrate signs of gluten sensitivity they should be advised to adhere to a strict ‘gluten-free’ diet.
• Asymptomatic coeliacs who do not have regular objective tests such as serology or biopsy should be advised on a ‘gluten-free’ diet, as monitoring of this patient group is impossible.
• All advice should be provided on an individual basis./li>

More information on the gluten-free diet is available from the Gluten-Free Living section of this website and the Gluten-Free Diet factsheet available from the Irish Nutrition and Dietetic Institute (INDI).