With more and more gluten-free foods appearing on supermarket shelves, we investigate what’s driving the trend

For 32-year old Preeti Gurung, feeling bloated and tired after eating pasta and bread was something she put down to overeating. But last year she had a stronger reaction than normal – swollen joints on one hand and pains around her kidney. She persevered with her GP in getting a diagnosis and, eventually, found that she was gluten intolerant.

Preeti is now one of a growing number of people with non-coeliac gluten sensitivity (NCGS). While around one per cent of the population have coeliac disease, published data suggest that around seven per cent may have NCGS, says Coeliac UK. To manage her symptoms, Preeti has switched to a gluten-free diet, and is one of the many people who have contributed to this market growing by 90 per cent between 2007 and 2012, according to Mintel data.

In fact, the wider visibility of gluten-free foods may in itself be fuelling growth. “This drives the market as people see more products on the shelves and more information in the media, increasing their awareness of gluten-free products,” says Wimbledon nutritionist and former pharmacist Dr Sharon Pitt. “Also some people think that cutting out wheat helps with weight loss and it’s currently trendy. I see patients who choose gluten-free foods because they think it’s a healthy option. However, they can still be full of sugar – choosing a gluten-free brownie doesn’t make it a healthy brownie.”

Gastroenterology dietitian and diet advisor to the IBS Network Julie Thompson says her patients are often influenced by sports professionals and celebrities touting a gluten-free lifestyle. “Going gluten-free is very fashionable, but it’s an important issue as we have people restricting their diet when wheat ‘bloats’ them, without seeking a medical diagnosis for their symptoms.”

The gluten lowdown

Gluten is the main protein complex in wheat and is also found in other cereals, such as barley and rye. Fragments of the gluten protein, called gliadins, can cause a lifelong autoimmune reaction in some people, resulting in inflammation of the avoiding gluten. Obvious glutencontaining products include bread, pasta, flours, cereals, cakes and biscuits, but it is also present in fish fingers, sausages, gravies, sauces and stock cubes.

Diagnosed coeliacs can supplement their diet with gluten-free products available on prescription (usually staples such as bread and pasta, rather than ‘treat’ products). Around 70 per cent of adults switching to a gluten-free diet see improvements within days or weeks.

Gluten sensitivity

NCGS is a relatively recent phenomenon and is defined as symptoms that are related to eating gluten-containing foods in those who are neither wheat allergic nor coeliac. According to some researchers, coeliac disease is part of a wider range of wheatrelated disorders. Dr Pitt agrees: “At one end of the spectrum, there are those who can tolerate gluten and at the other end, the coeliacs. However, there is a whole range of people in between. Previously those ‘in-betweens’ were ignored.”

For patients like Preeti, NCGS affects their everyday life, just like people with coeliac disease. “I find it extremely difficult to stay on a gluten-free diet as taste is very important to me and the texture is not great,” says Preeti. “On-the-go is definitely where I really find it difficult. It’s frustrating as I now can’t easily pop out for lunch and, inevitably, I end up not sticking to a strict diet when socialising, and then I feel awful.”

The existence of NCGS is contentious, however. Authors of one of the key papers that identified it as a condition have done further research and found the same symptoms in people being given a gluten-free diet. Instead, they conclude that the culprit may be another type of dietary product – the fermentable oligo-, di-, mono- and polysaccharides, also known as FODMAPs (such as fruit, vegetables, pulses and beans).

Dr Stevens thinks the jury is still out on NCGS. “My own feeling is that cutting out gluten means you are cutting out bread and so reducing your fibre intake, which helps with loose stools and bloating. This is independent of gluten sensitivity; it is just altering your diet,” he says.

Julie believes that while there is debate over certain aspects of NCGS, it does exist. “But,” she says, “it is very difficult to distinguish from IBS without a clinical marker. As we don’t have an NHS-approved test for NCGS, it is unclear whether someone is reacting to the carbohydrate component of wheat – fructans, the protein component – gluten, or in fact, another component of which we are not aware.”

Coeliac UK concurs: “Currently there is no specific biomarker to diagnose NCGS and diagnosis is reached following exclusion of coeliac disease, IBS and wheat allergy.”

Long-term effect

For coeliacs who fail to stick to a gluten-free diet, there are consequences. Short-term, it can trigger symptoms such as severe diarrhoea and vomiting within hours of eating gluten; longerterm, malnutrition, osteoporosis, cancer of the small bowel and infertility problems can occur.

New research also suggests that people who eat a gluten-free diet may also be at risk of developing new food intolerances. But others are highly dismissive of this theory. “Although it is possible to have additional food intolerances alongside coeliac disease, there is currently no strong evidence to conclude that following a glutenfree diet would result in developing additional food intolerances,” says Coeliac UK.

Another area of interest is the impact of a gluten-free diet on the friendly bacteria in the gut (the gut microbiota). Each of us has a unique gut microbiota that helps with digestion and acts as an immune defence system. Data suggest that those with a glutenfree diet have lower levels of bifidobacteria in their gut.

“The gut microbiota is certainly influenced by diet and is highly dependent on macronutrient intake,” says Julie. She adds that more research is needed as too little is known about the consequences on long-term gut health.

Some people think that cutting out wheat helps with weight loss and it’s currently trendy

Pharmacy’s role

Helping patients manage coeliac disease and NCGS provides an opportunity for pharmacy to identify sufferers, signpost to the GP and support patients with access to gluten-free foods on prescription. Coeliac UK has created a support package, along with the Centre for Pharmacy Postgraduate Education, whichincludes information on recognising the disease, designing a poster for a health promotion campaign and building a business case to bid for a gluten-free food service. Dr Stevens adds that pharmacy staff can encourage and remind people with coeliac disease to have an annual review.

For those experiencing gluten-induced symptoms, Julie advises they see their GP, without excluding foods from their diet beforehand. “My role as a gastroenterology dietitian would be to first check that coeliac disease and other conditions have been ruled out and then to identify which component of the diet is problematic, so only eliminating what is required,” she says. “I would also advise on how to increase knowledge about what is safe to eat and how to live well with a food intolerance.”

Dr Pitt adds that cutting gluten from their diet won’t result in patients becoming malnourished. “We make carbohydrates the focus of the meal, but we should be eating more vegetables, a good protein source and just a little of the starchy carbohydrates,” he says. “Gluten grains can easily be replaced with non-gluten grains, such as quinoa, brown rice and buckwheat, or even with pulses.”

 

 

Further information

• Coeliac UK
• Coeliac UK and CPPE training platform 
• The IBS Network
• Primary Care Society for Gastroenterology