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There’s no disagreement on one thing: people with coeliac disease must keep off gluten for life. In these individuals, gluten inflicts serious damage.

A growing number of people who don’t have coeliac disease say they don’t
tolerate gluten well either, believing it to be the cause of their bloating, gas, constipation or diarrhoea. They’ll head for health-food stores and specialty aisles
in supermarkets, forking out extra dollars for products labelled gluten-free.
(There’s even gluten-free beer now.) And when they reintroduce foods containing gluten, their symptoms return.  So who should go gluten-free?

The risk of coeliac disease

One major cause of the ‘gluten-free’ trend has been the increase of coeliac disease.
Coeliac disease is an auto-immune disease, whereby the body’s immune system
reacts abnormally to gluten and produces antibodies that attack its own tissues.
This causes inflammation and damage to the small intestine.

If gluten is not removed from the diet, the small intestine becomes unable to
process nutrients properly, which can result in nutrient deficiencies.
Left untreated, coeliac disease is associated with many conditions, including
infertility, osteoporosis and depression.

Sufferers also have a slightly higher risk of cancer and if undiagnosed long-term, appear to have four times greater risk of early death. People with coeliac disease
are born with a genetic predisposition, so it’s hereditary – although environmental factors also play a role in ‘switching on’ the disease gene.
According to The Coeliac Society of Australia, a first-degree relative of someone
with coeliac disease – such as a parent, brother, sister or child – has about a 10 per cent chance of having the disease. In Australia, coeliac disease affects approximately 1 in 100 people

Could I have coeliac disease?

The nature of coeliac disease makes it very difficult to diagnose. In some people, it’s obvious that food is causing trouble. For example, children may be irritable from stomach pain, have delayed growth, poor weight gain and smelly bowel movements. But in others, few, if any, symptoms may be apparent.

Some people put up with regular discomfort and tiredness, thinking this is ‘normal’. Alarmingly, 75 per cent of sufferers in Australia don’t know they have it. Gill Keuskamp, member of the Coeliac Research Fund Medical Advisory Board and a coeliac herself, says members often comment that diagnosis has come after many years of problems.

Inability to put on weight is a classic symptom, she says, although other common symptoms can include fatty bowel movements, abdominal cramps, bloating and weight loss. See ‘do you have these symptoms?
 

Ruling out coeliac disease

Diagnosis of coeliac disease includes several steps.

Step 1: The initial screening is a blood test for the presence of antibodies, which are typically elevated in those with untreated coeliac disease. The two most commonly used investigations are for two types of IgA antibodies: endomysial antibody (eMA) and tissue transglutaminase (tTG). The total IgA antibody test should also be performed, as 2 per cent of people with coeliac disease have IgA deficiency, rendering the tTG test unreliable in these people. In this case, tests for the IgG antibody are used.

step 2: If your blood tests return positive results, you will be referred to a gastroenterologist, as blood test results are not definitive. Confirmation of coeliac disease requires a gastroscopy, where an endoscope is passed through the mouth into the small intestine to collect a biopsy of the distal duodenum (part of the  small intestine). For an accurate result, blood tests and biopsies need to be done when gluten has been eaten for the previous six to eight weeks, says dr Richard Steele, prominent immunologist and clinical advisor to the Coeliac Research Fund.When the blood test is negative, coeliac disease can be ruled out in most cases, except for ‘high-risk’ patients – those suffering from diarrhoea, weight loss or anaemia. If you’re a high-risk patient, you’ll be referred to a gastroenterologist for a gastroscopy regardless of your tTG result.

Step 3: You may also undergo gene testing, where blood test or a cheek swab look for the “if coeliac disease isn’t present, you should look hard at the cost and inconvenience of gluten-free eating … And you should also work closely with an Accredited Practising dietitian specialising in food-intolerances.” Anna Richards agrees. “There is a risk that a gluten-free diet will be low in B vitamins and fibre, particularly if most wheat products are replaced with rice,” she explains. “Carbohydrate intake may also be insufficient, especially for children’s high needs,” she adds, “and eating rice cakes instead of bread could leave some people short of fuel.” For this reason, she says, a gluten-free diet should include peas, beans, lentils, chickpeas, baked stuffed potatoes and kumara. It should also include alternative grains such as quinoa and amaranth; and brown rice.
 

Going gluten-free:  how to get an accurate diagnosis
 

Could I have a sensitivity  to gluten?

If you’ve ruled out coeliac disease but your symptoms remain, it’s possible you may have a sensitivity to gluten, says noted paediatric gastroenterologist and allergist dr Rodney Ford. Having seen a large number of patients who don’t have coeliac disease, but whose symptoms have been alleviated by eliminating gluten from their diet, he believes going gluten-free may still be an option. “you may have symptoms and yet not have coeliac disease,” he states. Controversially, Dr Ford argues that gluten ‘injures’ the nervous system and directly affects brain function in approximately 10 per cent of the population. This, he says, results in a range of reactions including gastrointestinal, brain and behavioural disorders, irritability and tiredness, skin problems, muscle aches and pains, and joint problems. But don’t be too hasty to blame gluten, says dietitian Anna Richards. If these symptoms sound familiar, you should see your doctor – “but gluten might not  be the issue.” 

Gluten, or something  else?

If you’ve removed gluten from your diet and you’re feeling better, it’s worthwhile noting that other factors might be of influence. Richards believes that once people remove gluten from their diet, the results of their ‘improved "health’ are often due to the increased amounts of fruit and vegetables that have replaced the processed, gluten-containing foods previously in the diet. Alternatively, she says, gluten may be to blame when it’s actually another ingredient at fault. Indeed, dr Ford admits that digestive problems may alternatively be caused by a reaction to fructooligosaccharides or the structure of the carbohydrate being eaten.  “Or it may be other food intolerances that show up in irritable bowel syndrome … in children, these [intolerances] are most commonly peanuts, eggs, dairy and soy,” he says. 

Similarly, “Some people’s difficulties may also be caused by an allergy or intolerance to wheat, rather than gluten,” explains Richards. She also cites an example of one of her clients, whose reaction to the salicylates in marmalade had her believing she was having an intolerant reaction to toast. “Too many people see gluten-free as a panacea for all ills,” she says. To rule out allergies (to foods, animals, insects, pollens, grasses, etc), The Australasian Society of Clinical Immunology and Allergy (ASCIA) advises people to see an experienced GP or allergy specialist for an allergy test, which may involve a skin-prick test or RAST blood test (Medicare rebates are available for these tests).After that, you may be prescribed an elimination diet which, like any special diet, is  not a journey you should take without professional guidance.

Going  Gluten-free

If you’ve consulted with a GP  and medical experts, ruled out coeliac disease, ruled out other allergies and intolerances and gluten still appears to be the culprit, then a gluten-free diet might be worth trying.
“It’s important to respect  people who report feeling better without gluten,” says dr Ford. But before going gluten-free, you should absolutely discuss the pros and cons with your doctor first, he advises. dr Steele adds, “if coeliac disease isn’t present, you should look hard at the cost and inconvenience of gluten-free eating … And you should also work closely with an Accredited Practising dietitian specialising in food-intolerances.”

Anna Richards agrees. “There is a risk that a gluten-free diet will be low in B vitamins and fibre, particularly if most wheat products are replaced with rice,” she explains. “Carbohydrate intake may also be insufficient, especially for children’s high needs,” she adds, “and eating rice cakes instead of bread could leave some people short of fuel.” For this reason, she says, a gluten-free diet should include peas, beans, lentils, chickpeas, baked stuffed potatoes and kumara. It should also include alternative grains such as quinoa and amaranth; and brown rice.
Check out this great Gluten free recipe, bacon, beet root and Green Lentil Salad.

The Verdict

The decision to go gluten-free should not be taken lightly. If you have the symptoms outlined on page 39, then you need to see a GP or allergy specialist to commence the process of getting an accurate diagnosis. If you decide to eliminate gluten or wheat because it makes you feel better, then see a dietitian to ensure you include all the necessary foods in your diet, to avoid nutrient deficiencies.

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