Patient discussions

As soon as the patient is diagnosed with coeliac disease, they should be advised to avoid all products containing wheat, rye, barley, and spelt. National Digestive Diseases Information Clearinghouse: celiac disease Opens in new window National Celiac Association Opens in new window​ Although not technically a trigger for coeliac disease, many oat products are contaminated with wheat, and a minority of patients with coeliac disease may be oat-intolerant. There is substantial evidence that oats that are not contaminated by wheat or barley are safe for the vast majority of patients with coeliac disease.[148][149][150]​ Some patients may, however, be sensitive.[151] The American College of Gastroenterology guidelines recommend inclusion of gluten-free oats in diets of patients with coeliac disease.[73]​ In North America, some food manufacturers operate under a 'Purity Protocol' which involves harvesting, transporting, storing, processing and manufacturing oats using processes that minimise the presence of gluten.[152] Oats are not recommended as part of a gluten-free diet in some countries, and local guidance should be consulted before recommending them.

The gluten-free diet is demanding, especially at the outset, and referral to both a dietitian skilled in coeliac disease and a local support/advocacy group is strongly recommended. Patients should be reassured that adopting the diet is a challenge and mistakes and difficulties adjusting early on are common. Factors improving overall adherence to a gluten-free diet include improving knowledge about the diet, becoming a member of a coeliac association, increased education, and increased self-regulatory efficacy.[195]​ Counselling with a therapist may be recommended, as people with coeliac disease may be at risk of disordered eating patterns.[196]

Hidden sources of gluten

Under ideal circumstances, a 'gluten-free diet' should exclude all gluten-containing foods. However, despite adopting strict dietary modifications, at least one third of patients with coeliac disease are exposed to gluten.[197]​ Many natural and certified gluten-free foods are prone to contamination and have gluten levels above the 20 mg/kg threshold set by Codex Alimentarius 118-1979.[198][199][200][201]​​ Improper labelling, social constraints, and ubiquity of gluten proteins in raw or cooked food and medicines can also lead to accidental encounters with gluten. Further, inadvertent exposure to gluten can happen through restaurant meals, consumption of composite foods, and use of oral hygiene and cosmetic products containing hidden gluten.[202]​​​​[203][204]​ Using separate manufacturing and processing areas for gluten-containing and gluten-free products may be one possible solution to this problem.[205]​​

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