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   Apr 05

Is this proof that avoiding wheat is not a pointless fad after all?

Prof. David Sanders is consultant gastroenterologist at the Royal Hallamshire Hospital, Sheffield

Says going gluten-free is seen as the height of faddy eating

Suggests many who feel this way might have a real medical problem

Going gluten-free because it ‘disagrees with you’ is seen as the height of faddy eating. But a new book by a leading gastroenterologist suggests many who feel this way might have a real medical problem…

When Novak Djokovic won at Wimbledon last year, he ate a small piece of grass as part of his celebration and joked it was OK as it was ‘gluten-free’.

Djokovic says giving up gluten has left him lighter, stronger, healthier and sharper.

Gluten-free is outselling all other diet options with 60 per cent purchasing associated gluten-free products
And by no means is he alone in his view that it is something to be avoided.

Currently, gluten-free food is outselling all other diet options. YouGov reports that 60 per cent of people purchase or consume gluten-free products. A survey my research team published in 2014 suggested as much as 13 per cent of the population believe it disagrees with them.

Yet most doctors (I used to be one of them) believe that gluten – a protein found in wheat and so in flour, bread and pasta – will only cause you problems if you have coeliac disease.

This is a condition where the immune system reacts to gluten, damaging the gut and preventing vital nutrients such as calcium being absorbed.

Coeliacs have to follow a gluten-free diet for life to prevent long-term health problems such as osteoporosis and an increased risk (albeit small) of gastrointestinal cancers.

But for many years, I have seen patients in my clinic who do not have coeliac disease, but say they have symptoms such as bloating, pain, diarrhoea, constipation and feeling sluggish when they eat gluten.

Tennis ace Novak Djokovic of Serbia says giving up gluten has left him lighter, stronger, healthier and sharper

I often wondered why, but in hindsight, I did not take this as seriously as I should have.

It has taken me a long time to overcome my early scepticism and acknowledge that something may be amiss.


Today, when I see patients who say they have a problem with gluten – but whose tests show they don’t have coeliac disease – I may advise that they have gluten sensitivity.

Gluten sensitivity – also known as non-coeliac gluten sensitivity, or wheat or gluten intolerance, depending on which term is in fashion – is something we are only beginning to understand.

Broadly speaking, it may be diagnosed when someone for whom coeliac has been ruled out finds that their symptoms improve on a gluten-free diet.

David’s medical friend said: ‘I don’t see gluten sensitivity being reported in the developing world!’

It is not something all doctors recognise – as another medical friend said to me recently: ‘I don’t see many cases of gluten sensitivity being reported in the developing world!’

The sceptical argument is that it is a lifestyle trend driven by celebrities and the food industry.

But it may be that some gluten sensitive people have what I have come to think of as ‘coeliac lite’.

It was only when I stepped away from what I was taught didactically during medical training and instead asked open questions about what I was seeing and hearing from my patients that I came around to this way of thinking.

For a seven-year period, I recorded data from all the patients I saw who said they had symptoms related to gluten, but did not have coeliac disease – the similarities were striking. They were predominantly female, in their 30s to 40s, with a high prevalence of irritable bowel type symptoms.

And almost half of them had genes we know are associated with coeliac disease – the HLA, DQ2 or DQ8 genes (virtually everyone with coeliac disease will have this gene profile).

German researchers have shown that people with this profile who have IBS (but not coeliac disease) find their symptoms improve on a gluten-free diet.

So is gluten sensitivity a lesser form of coeliac disease? There is evidence that both are down to an immune system response – just a slightly different type of response.

In patients with coeliac disease, gluten stimulates immune system cells known as T-cells, in turn stimulating attack cells which damage the finger-like projections that line the small bowel, causing them to flatten (known as villi, these help absorb nutrients from food).

The sceptical argument is that it is a lifestyle trend driven by celebrities and the food industry

The immune cells also create antibodies that ‘remember’ how to attack gluten in the future. This is known as our adaptive immune system – and it’s how the body defends against diseases.

Patients with gluten sensitivity do not have this response to eating gluten; instead, studies have shown they experience a reaction via a different part of the immune system called the innate immune system.

This, if you like, is a more basic immune response – typically against bacteria – and there is no stored memory after the event. But it does cause inflammation, which may explain symptoms in gluten sensitive people.

Recently, other researchers have used a powerful imaging technique called confocal endoscopy to look at what happens to the surface of the gut in potentially gluten sensitive patients.

The investigators, at the University Hospital Schleswig-Holstein in Germany, recruited 36 patients with IBS and suspected food intolerances. They administered diluted samples of problem foods directly on to the bowel lining. Within five minutes of exposure, the researchers saw a significant increase in immune system attack cells.

This happened for 61 per cent of people tested and the most common food to give this response? You guessed it: wheat.

So gluten seems to have a direct role in attacking the small bowel – and not just in those with coeliac disease.


Doctors would be shocked if you did not test your patients with IBS-type symptoms for coeliac disease

This idea of gluten sensitivity, or coeliac lite, is a controversial one – for now. But the fact is, our understanding of what happens in the gut is evolving rapidly.

Take the understanding, now enshrined in NICE guidelines, that people with IBS may have coeliac disease and should be tested for it. Less than 20 years ago, this was regarded as medical heresy.

It was a patient of mine who helped reverse this thinking. Betty had been referred to me by her GP for long-standing gastrointestinal symptoms. She was in her mid-40s; intelligent, articulate and polite. She told me that she wondered if she had coeliac disease.

Her family doctor had reassured her that she had irritable bowel syndrome, but she said she’d been doing some research around the subject. I smiled. It was the kind of patronising smile we have all seen on someone’s face; of course Betty had IBS, her symptoms fitted perfectly and, by the way, when did she get a medical degree?

A senior academic gastroenterologist said: ‘I have been undertaking research in IBS for years and I have never seen a case of coeliac disease’

Though after some discussion I reluctantly agreed to test her.

Six weeks later Betty had a cast iron diagnosis of coeliac disease – both a blood test and a gut biopsy confirmed it. What an idiot I felt.

This was in 1998. Now, doctors would be shocked if you did not test your patients with IBS-type symptoms for coeliac disease.

To find out if Betty was just a one-off, my colleagues and I undertook a study to see if there was an association between coeliac disease and IBS. Of the IBS patients we tested for coeliac disease, 4.7 per cent of them had it. This was seven times more than in our healthy controls, and four times what you’d expect to see in the general population.

Though when I presented our findings, a senior academic gastroenterologist stood up and said: ‘I have been undertaking research in IBS for years and I have never seen a case of coeliac disease. I am not sure I believe there is an association.’ The Lancet write-up of our study was accompanied by a similarly damning editorial.

Since then, many other studies have backed us up, but it was a ten-to-15-year journey to change medical practice. I wonder if we are now on the same journey for gluten sensitivity.


Prof. David says: ‘Some with coeliac disease get a skin rash, known as dermatitis herpetiformis’ (file photo)

But back to our study and the 12 apparently healthy individuals we’d found had coeliac disease – they commenced a gluten-free diet.

The vast majority said they felt better, which was surprising as so many at the start of the study said they felt completely well.

It taught me that many accept their pre-diagnosis state as normal.

One volunteer, a policeman, said: ‘I’d accepted I needed a nap after a busy day at work. We have two kids and I thought that life is just busier and more tiring. Now I realise it was coeliac disease. I have much more energy. I wish I’d been tested sooner.’

The symptoms of coeliac disease may be subtle – perhaps more subtle than conventional thinking allows for. People with undiagnosed coeliac disease do not always have gut symptoms – fatigue, anaemia, mouth ulcers, ‘brain fog’ and joint pain are all common. Some with coeliac disease also get a skin rash, known as dermatitis herpetiformis.

So I now consider the gut to be the point through which gluten ‘breaks and enters’; but after that, it may be that the reaction it causes is about us as individuals.

Perhaps different individuals trigger different immune responses which determine whether you present with gut symptoms, anaemia, a skin rash or in another way.


Undiagnosed coeliac disease can lead to neurological symptoms such as ‘brain fog’

Undiagnosed coeliac disease can lead to neurological symptoms such as headaches and ‘brain fog’ – this has generally been considered a knock-on effect of nutritional deficiencies caused by damage to the gut.

However, it may be that gluten itself can have an effect on the brain.

A seminal 1996 paper by Professor Marios Hadjivassiliou showed that up to 54 per cent of neurology patients had antibodies to gluten in their blood compared with only 12 per cent of the healthy population. Gut biopsies later revealed that 16 per cent of neurology patients had coeliac disease.

A lot of these patients had unexplained ataxia – problems with balance, walking and co-ordination of the arms and legs.

It happens when part of the brain called the cerebellum is damaged. The connection between ataxia and coeliac disease led Professor Hadjivassiliou to coin the term ‘gluten ataxia’.

He has since shown that a gluten-free diet has improved ataxia in coeliac and non-coeliac patients.


It’s generally accepted that coeliac disease affects about one in 100 people in the UK. But in 1950 it was one in 8,000.

A 2000 study from Finland found the percentage of the population with coeliac disease had jumped from 1 per cent to 2 per cent in just two decades. So what’s going on?

One possibility is our increasing exposure to gluten. Historically, doctors from China and the Indian sub-continent have never reported coeliac disease as a significant problem – until recently.

Previously these have been predominantly rice-based cultures, but with increasing westernisation, they are now eating more bread, pizza and pasta – where wheat goes, it seems coeliac follows.

With increasing westernisation, China and the Indian sub-continent, predominantly rice-based cultures, are now eating more bread, pizza and pasta – where wheat goes, it seems coeliac follows (file photo)

There is also a suggestion that wheat grown today contains more gluten – dubbed ‘Frankenwheat’.

There is no doubt that modern wheat tends to be short and stocky, with a high grain yield; however, there is no published research to support the assertion that this means it is more gluten rich.

It may also be that industrial bread-making processes – using high-speed mixers and additives so it rises quickly – has led to higher gluten content.

But this is not reported on food labels, so it’s hard to know. The estimate is that a typical slice of bread contains 2.5g to 3 g.

It may be that we are unwittingly eating industrial quantities of gluten. It is thought we eat 15g to 20 g per day – gluten is in instant soups, breakfast cereals, stock cubes, gravy granules, soya sauce, ready meals, meat substitutes (the sort of stuff you will get on a takeaway pizza without realising it), energy drinks and, my favourite, the Mars bar. It’s even in some medication.


I keep wondering if gluten is a public health problem. Should we all only have 5 g or 10 g per day?

Should it just be those who have identified problems? Or should it be preventative? Time (and further research) will tell.

I don’t believe – yet – there is a need for everyone to go gluten-free. Neither should you just stop eating gluten if you think it gives you symptoms – please do visit a doctor.

‘When it comes to gluten, the evidence suggests it’s a lot more complicated than we know’

A diagnosis can only be made while you are still eating gluten, and if you don’t have a medical diagnosis, you will never really know what it is you are suffering from.

So seek medical advice and be persuasive!

There is one sentence I have heard many times over when listening to doctors: ‘I don’t believe in…’.

But medicine is not theology: it is not for us to believe or not believe. We simply need to study the evidence – and when it comes to gluten, the evidence suggests it’s a lot more complicated than we know.

Source: Daily Mail

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