How Many Parts Per Million is Safe? Dr Kim Faulkner-Hogg, PhD qualified Dietitian

Is 20ppm safe to eat? What about shared toasters and kissing someone who ate gluten?

It is overwhelming to be told you have coeliac disease and now need to follow a gluten free diet for the rest of your life. Where do you go to for information? You have been told to get gluten out as fast as you can. Dr. Google and social media is where many people start. What you need is a specialised dietitian and joining Coeliac Australia. While social media can be a wonderful support, some of the messages put across by well-meaning people, can be really scary, do not always apply to everyone and they don’t always align with new emerging evidence.

The effects on mental health and quality of life that these messages have, greatly concern me. There is no escaping that people with coeliac disease need to be vigilant. I address my newly diagnosed clients as if they were the average person with coeliac disease and not the most sensitive person. Only time will show how sensitivity, or lack of, will evolve. Not every -one’s disease pathway or recovery pathway is the same. In a small number of people there may be medical reasons the doctors ask for extra-vigilant life-style behaviours toward gluten avoidance. These messages aren’t meant to translate to everyone with the disease.

I have been specializing in coeliac disease and gluten free eating for 30 years. Part of my PhD project was assessing possible villi, blood and symptom changes when only tiny tiny levels of gluten were in the diet. The amount of gluten only sometimes present in a food labelled gluten free at 20ppm is very very different to the quantity in a slice of bread. The body will respond very differently.

I discuss here 3 questions that come up regularly with me.

Is 20ppm safe and can I travel overseas?

The density of gluten in a food is expressed as parts per million (ppm) of that food.

·       A food labelled gluten free in Australia must contain less than 3 ppm of gluten.

·       The international gluten free standard must contain less than 20 ppm of gluten.

·       A piece of bread contains about 62 000ppm of gluten by comparison.

At the turn of this new century researchers were trying to determine what might be a safe level of gluten for people with coeliac disease. The 40 years of research before that — from food labelled under a different and no longer used food standard — suggested the average gluten intake, on a gluten free diet, was about 30mg daily. Some researchers were able to show that even 100mg a day was tolerated by some people.

It was then concluded that 10mg of gluten a day, in the background of a gluten free diet, was safe for the majority of people with coeliac disease. A 10mg quantity translates to a number of wheat bread crumbs in the butter. The closer ingestion comes to 50mg regularly each day, then villi inflammation and small amounts of damage become more likely.

The international food standard of 20ppm of gluten was then set to ensure that even if people ate large quantities of commercial gluten free products, they would not get more than 10mg of gluten in the background of their diet.

·       20ppm: Imagine standing on a beach with 1 million particles of white sand and I asked you to find 20 red particles among the 1 million.

·       3ppm: Imagine finding 3 red grains of sand in 1 million.

There is almost no difference between 3ppm and 20ppm. The International standard is safe for the majority of people and certainly the average person with coeliac disease. So you can absolutely travel overseas and eat the food labelled gluten free. Just because it is allowed to contain up to 20ppm of gluten does not mean all the food does. In fact one European study suggested that the majority of food labelled gluten free that they tested in Europe, had no detectable gluten, just like in Australia. Most large internationally known brands of gluten free food contain no detectable gluten on whatever continent they are sold., (eg Schars and Genius).

Before talking about toasters you need to appreciate that up to 20ppm is safe. Consuming foods with up to 20ppm is supported by Coeliac Australia.

Do you need 2 toasters?

Word of mouth tradition says you need to have a separate toaster when you have coeliac disease.  BUT DO YOU? Research done in 2020; toasted 20 slices of gluten free bread in an unwashed pop-up toaster, shared with wheat bread. All 20 slices had no detectable gluten.

A further 20 slices of gluten free bread were toasted in an unwashed rolling toaster along with wheat bread. 16 slices had no detectable gluten and 4 had amounts less than 20ppm, the International gluten free standard.

With everyone trying to give the ‘right message’, the ‘strict message’, the black and white message — that is not open to interpretation — this research is being ignored for the possibilities that it may bring some people.

In a forum like social media, you cannot personalise a message. This is another reason only black and white messages are offered. But research outcomes do show us that at this level of possible cross contact, there can be variation of the lifestyle behaviour with toasters. Toasters may not be as scary as they are made out to be.

This allows you to move away from a strict black and white dictate. Each of you can individualise how you want to use this research message. You may vary your choice, depending on circumstance. Your personality, your degree of healing, your sensitivity and the situation in front of you, may lead each person to make an individual and changeable choice about toasting gluten free bread and whether you travel with toastie bags or not. If you are only comfortable with a separate toaster, that’s OK too; but let others make their own decision, based on their circumstances.

Don’t kiss someone after they ate gluten. Have you been told that?

Well…..YUK…..if they dive in for a kiss with bread particles in their mouth!!! I think everyone would avoid that.

However, I recently listened to a talk from researchers at Columbia University in the United States, where dietitian Anne Lee did a study measuring gluten exposure after kissing someone who had just eaten a gluten load from wheat crackers. She reported that 2-5 minutes after eating the wheat, the gluten detected in the partners saliva after a long kiss, was less than 10ppm. By International standards this quantity is called gluten free and is thought to be safe for the majority of people.

In another scenario, the partner drank about 120ml of water after eating the wheat. When this was done there was no detectable gluten in the saliva, after kissing.

But I do get asked, what if I kiss someone who just drank beer? This was not researched.  However, compared to wheat crackers, beer contains much less gluten. So if 10ppm was detectable after wheat crackers, odds are beer gluten levels would be less, if present at all. So please don’t panic if you tasted beer from your partners mouth.

I hope you found this useful. There are a number of other ‘strict messages’ that you may hear or see in your information gathering journey. Dietitians who specialise in coeliac disease will be best equipped to address your concerns and advise you what the current research can or cannot say about your cross contact questions. In my experience, a good discussion about cross contact and background gluten goes a long way to dispel some of the anxieties that creep in about eating gluten free. It cannot stop the need for vigilance, but often helps bring you back from the edge of anxiety and hypervigilance.

My goal is to help you with the scientific information and support, it doesn’t matter where you are in your journey. Understanding why you are doing something and what the real risk to you may be, helps to relieve a lot of the worry and confusion that you are going through.

Written by Dr. Kim Faulkner-Hogg, Coeliac, Gut Health & Food Intolerance Dietitian

Website: www.glutenfreenutrition.com.au

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