Professor Nicholas Kennedy:

That could take a while, but I will try to address a number of them. Deputy Kelleher's comments were first. He asked why we did not have 1% of people diagnosed in Ireland.

The 1% I referred to are people who are likely to have coeliac disease. I do not think there are very many countries in which they are all diagnosed. In Europe, probably the country with the highest rate of diagnosis is Finland. I accept that we have a poor diagnosis rate here. The most important reason for this is probably low awareness of the variety of symptoms and signs that can be manifested by coeliac disease. This applies to the general population not being very aware, to GPs perhaps not being aware enough and to specialists who may not be aware enough, in some cases, to screen for coeliac disease, for instance, in all cases suggesting the possibility through IBS. This is one of the biggest categories of patient attending gastroenterology outpatient clinics. I agree that training is needed for quite a few categories of health care staff. There should also be an improvement with a greater public awareness campaign. The Coeliac Society of Ireland gets involved in a coeliac awareness day every year. It is very difficult to reach everyone without spending a lot of money on expensive media campaigns. However, that could be a way of improving awareness.

Deputy Kelleher also asked about vitamin absorption in women of child-bearing age. This probably goes back to the same point on awareness. Improved awareness is a key issue. Everyone here is probably aware of the recommended need to take folic acid supplements when considering pregnancy to reduce the risk of neuro-tube defects. If a person has active coeliac disease, the absorption rate of these folic acid supplements will be lower. That is something else people need to know. People with undiagnosed coeliac disease think they are doing their best by taking 400 mg folic acid a day, but it is not going to be absorbed properly and it is not going to have the desired effect. In undiagnosed coeliac disease, there has been research in a number of countries showing an increased rate of neuro-tube defects occurring in people with undiagnosed coeliac disease who do become pregnant.

Deputy Kelleher asked about the need for inspection and whether training was needed for people working in restaurants. Training is required. The Food Safety Authority of Ireland does offer training for HACCP and it includes a certain amount in that training about gluten. However, it is not a specific training programme about gluten and its importance to people on a gluten-free diet. The focus of such training programmes on coeliac disease could be improved. The Coeliac Society of Ireland met the Food Safety Authority of Ireland with that hope in mind two years ago but has not made much progress in getting a better training programme designed. In the UK, the coeliac society has developed a training programme for caterers and those involved in food service. It is possible to take this online. It issues a certificate of completion for online completion. There are other models that could be used in Ireland. The UK coeliac training programme is not entirely suitable for Ireland because of some of the different ways of doing things here but it could be adapted.

I am not sure if there were any other issues which Deputy Kelleher raised which I could answer.