In the Byron shire we have a fabulous local comedian called Mandy Nolan who makes a lot of fun of the health and food fads that regularly sweep this area and one of her favourite catch-cries is “I’m gluten intolerant-intolerant, if I meet another person who tells me they’re gluten intolerant I’m going to scream!” Although I take genuine gluten reactions very seriously I do get where she’s coming from and it stems primarily from pervasive misunderstandings & misuse of terms in the community. The problems with this are multiple: firstly those people who are walking around with an exaggerated sense of their problem will unnecessarily limit their diet (and perhaps the diets of their loved ones) at significant financial, nutritional & even psychological cost and then we have people who have the most extreme gluten reactions not receiving the serious attention that they absolutely need in all sorts of settings like restaurants, childcare centres and schools…because seemingly everyone has some sort of ‘gluten issue’ & therefore it has become dangerously ‘normalised’.
So let’s just recap the possibilities and try to clear the confusion. When people walk through our door and tell us they ‘can’t eat bread’ or ‘pasta makes them bloat’ or ‘I don’t think wheat agrees with me’, that’s where our work just begins in terms of needing to clarify what the nature of their reaction is. Putting them immediately on a gluten free diet is a mistake because it doesn’t tell us which one of the below issues is at play and therefore fails to give us clear guidance about what is an appropriate course of treatment & dietary intervention.
- Coeliac disease – while there are a multitude of testing options for CD the first place to start is the genotype. If you don’t have the gene it is extremely unlikely that you have CD. If you have the gene then there’s about a 1/3 chance you might & specific tailored antibody testing or jejunal investigations are necessary.
- A genuine wheat allergy (not CD) is rare but is more common in infants & toddlers. It can be diagnosed by blood antibody tests (IgE RAST) or skin prick testing (SPT) for wheat
- Non-coeliac disease gluten sensitivity – may not involve the immune system at all, however, raised anti-gliadin antibodies are frequently seen in these patients
- FODMAPS – is not an allergy but a type of intolerance due to impaired digestion of the fructans found in wheat. We must rule this out as a possible explanation for someone’s reaction and I would start with a good checklist of other FODMAP foods to check tolerance e.g. soy, dairy, increased fruit intake and check for other conditions that can lead to this via disruption or destruction of the small intestinal brush border
- Carbohydrate digestion issues other than (or in addition to) FODMAPs i.e. underfunctioning of the pancreas
- Red herring! And don’t forget this old pearl… it could of course be a total red herring. Perhaps the reaction is due to another component in bread (yeasts, preservatives etc.), or the other foods they always eat with the pasta (tomato etc.) or their general poor diet quality and speed of eating, lack of relaxation around meals etc. etc.
My one exception would be in children diagnosed on the spectrum for autism. I think going gluten free where possible is appropriate from the get-go in ASD. For everyone else, a correct diagnosis is the essential first step to effective & proportionate treatment so keep your wits about you my fabulous fellow diet detectives! 