03 Aug 2016 Studies Support that Non-Coeliac Gluten Sensitivity is very real for some: BANT Explains

With so much information about different types of diets and their effects available to everyone from a range of ‘experts’, from qualified healthcare professionals to celebrities with a large following, it is not surprising that there is much confusion about gluten free diets, why they are popular, what they do and whether you may benefit from them or not.

BANT (British Association for Applied Nutrition and Nutritional Therapy) has been carefully monitoring reports of the varying degrees of sensitivity to gluten experienced by thousands of people in the UK and beyond.  It seems it is not just members of the public who may be uncertain as to what the effects of following a specific diet may be.  Scientists at Monash University in Australia, (a world-leading research centre for gastroenterology,) published a study in the Journal of Human Nutrition and Dietetics.  Their aim was to determine the attitudes towards diet of Inflammatory Bowel Disease patients and their clinicians. The large majority of the patients involved (71%) assumed that changes to their diet would translate into changes to their symptoms. In contrast, Monash researchers found that more gastroenterologists (44%) than dietitians (17%) agreed with their patients in that diet was a factor impacting gastrointestinal symptoms.

BANT Registered Nutritional Therapists practice within a clinical framework that uses dietary interventions as main drivers for change in symptoms (both perceived and/or biochemically measurable).

BANT can clarify the following points on gluten sensitivity

• Some recent features seem to have trivialised the severity of gastrointestinal and systemic symptoms experienced by many by labelling them as “lifestyle coeliacs” or “coeliac lite”.
• The scientific evidence documenting the effects resulting from sensitivity to gluten has increased over the last 15 years and is now solid. This evidence informs clear guidelines on the differential diagnosis of coeliac disease versus other conditions such as non-coeliac gluten sensitivity (NCGS), both within the Irritable Bowel Disease spectrum.
• From a clinical audit on BANT member clinics, BANT believes that many of those who report non-coeliac gastrointestinal symptoms may be experiencing NCGS in varying degrees of severity.
• NCGS is defined by the exclusion of coeliac disease including negative coeliac blood tests and/or normal intestinal architecture and negative immunoglobulin (Ig)E-mediated allergy tests to wheat. Additionally, to meet criteria for NCGS, the clinical symptomatology of Irritable Bowel Syndrome (IBS)-type of symptoms has to improve after gluten withdrawal and worsen after the ingestion of gluten.
• Symptoms of NCGS can include those typical of IBS, namely bloating, diarrhoea, abdominal pain (sometimes related to alternating diarrhoea and constipation), nausea and fatigue. Experience of NCGS can be highly individual. Some will experience all the symptoms and some may experience only one or two.
• Factors mediating NCGS symptoms include loss of gastrointestinal mucosal integrity, possibly driven by inflammation triggered by an immune reaction to various proteins contained in gluten-containing foods.
• Because NCGS is a relatively new condition there is still a lack of diagnostic tests that are both sensitive and specific. However, there is ample evidence that individuals with significant intestinal symptoms who have tried a gluten-free diet have experienced lessening of severity of the symptoms mentioned above.
• There is also evidence to support testing a gluten-free diet in clinical practice in people with significant intestinal symptoms which could be assessed as fitting into a NCGS diagnosis (to be issued by a gastroenterologist), and which are not solely explained by the degree of intestinal inflammation. Thus, a gluten-free diet has the potential to be a safe and highly efficient therapeutic approach.
• BANT believes that the argument that a gluten-free diet promotes the development of orthorexia is flawed. BANT understands that dietary advice provided by unqualified celebrities on social media is part of the socially prescribed perfectionism and attachment to appearance seen as characteristics in orthorexia, but there is no scientific evidence to support this claim. Indeed, a review of the literature on this argument in the databases PubMed, EMBASE, CINAHL and Cochrane retrieves zero results. As such, the correlation between the adoption of a gluten free diet and the development of orthorexia is just seen as an expert opinion, which counts as the lowest degree of evidence. Furthermore, BANT believes that to associate the development of a psychiatric disorder with a safe and therapeutically effective dietary intervention without any scientific evidence to support it is irresponsible and is seen as unfounded scaremongering.
• One of the main reasons provided by those who propose that gluten-free diets are dangerous is the potential lack of dietary fibre that may result as an effect of this dietary change. BANT sees this as incongruous advice, considering the following:
  • There is ample dietary fibre in fruit and vegetables.
  • There is no evidence to suggest that those individuals who reduce or cut gluten out of their diets also reduce and/or cut out fruit and/or vegetables.
• BANT is aware of the barriers to following a gluten-free diet, including product availability, cost and safety of gluten-free foods, as well as gluten cross-contamination.
• BANT is acutely aware of the fact that self-reported measures, most often used as sources of data in studies that assess the effect of gluten-free diets, account for the possibility of unintentional gluten ingestion and overestimate adherence to diets. Additionally, some people who believe they are following a gluten-free diet are not readily able to correctly identify foods that are gluten-free, which suggests ongoing gluten consumption may be occurring, even among those who believe they are “strictly” adherent.
• BANT Registered Nutritional Therapists follow a consultation process that puts the relationship between diet and gastrointestinal symptoms at its core, as illustrated in the BANT Consultation Process Poster. Anyone experiencing gastrointestinal symptoms such as bloating, diarrhoea, abdominal pain (sometimes related to alternating diarrhoea and constipation), nausea and fatigue would be advised to seek the advice of a BANT Registered Nutritional Therapist and gastroenterologist who can co-manage your case.
• BANT welcomes the collection and analysis of patient-generated data on the association between gluten-free diets and orthorexia that contribute towards the creation of an evidence base on this subject and is happy to talk to organisations who would like to support this research exercise.

Grains containing gluten – wheat (including wheat varieties like spelt, kamut, farro and durum, plus products like bulgar and semolina), barley, rye, triticale and oats* Gluten free grains – corn, millet, rice, sorghum.

Gluten free pseudo-cereals – amaranth, buckwheat, quinoa. These can be good substitutes to gluten-containing grains if you’re on a gluten free diet, but do rotate them so that your nutrient intake is varied.

*Gluten free oats are available

– Ends –

Click here to download the PDF version of this statement.

FOR FURTHER INFORMATION PLEASE CONTACT:

Daniel O’Shaughnessy

[email protected]

Tel: +44 7540  722307

NOTES TO EDITORS:

The British Association for Applied Nutrition and Nutritional Therapy (BANT) is the professional body for Registered Nutritional Therapists. Its primary function is to assist its members in attaining the highest standards of integrity, knowledge, competence and professional practice, in order to protect the client’s interests; nutritional therapy and the registered nutritional therapist.

References:

• Barnes, M. A. & Caltabiano, M. L. (2016) The interrelationship between orthorexia nervosa, perfectionism, body image and attachment style. Eat Weight Disord. [Epub ahead of print]
• Czaja-Bulsa, G. (2015) Non coeliac gluten sensitivity – A new disease with gluten intolerance. Clin Nutr, 34(2) pp. 189-94.
• Dunn, T. M., Gibbs, J., Whitney, N. & Starosta, A. (2016) Prevalence of orthorexia nervosa is less than 1 %: data from a US sample. Eat Weight Disord. [Epub ahead of print]
• Escudero-Hernandez, C., Pena, A. S. & Bernardo, D. (2016) Immunogenetic Pathogenesis of Celiac Disease and Non-celiac Gluten Sensitivity. Curr Gastroenterol Rep, 18(7) pp. 36.
• Kabbani, T. A., Vanga, R. R., Leffler, D. A., Villafuerte-Galvez, J., Pallav, K., Hansen, J., Mukherjee, R., Dennis, M. & Kelly, C. P. (2014) Celiac disease or non-celiac gluten sensitivity? An approach to clinical differential diagnosis. Am J Gastroenterol, 109(5) pp. 741-6; quiz 47.
• Herfarth, H. H., Martin, C. F., Sandler, R. S., Kappelman, M. D. & Long, M. D. (2014) Prevalence of a gluten-free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases. Inflamm Bowel Dis, 20(7) pp. 1194-7.
• Hollon, J., Puppa, E. L., Greenwald, B., Goldberg, E., Guerrerio, A. & Fasano, A. (2015) Effect of gliadin on permeability of intestinal biopsy explants from celiac disease patients and patients with non-celiac gluten sensitivity. Nutrients, 7(3) pp. 1565-76.
• Holt, D. Q., Strauss, B. J. & Moore, G. T. (2016) Patients with inflammatory bowel disease and their treating clinicians have different views regarding diet. J Hum Nutr Diet,
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• See, J. A., Kaukinen, K., Makharia, G. K., Gibson, P. R. & Murray, J. A. (2015) Practical insights into gluten-free diets. Nat Rev Gastroenterol Hepatol, 12(10) pp. 580-91.
• Silvester, J. A., Weiten, D., Graff, L. A., Walker, J. R. & Duerksen, D. R. (2016) Is it gluten-free? Relationship between self-reported gluten-free diet adherence and knowledge of gluten content of foods. Nutrition, 32(7-8) pp. 777-83.
• Thomas, L. E. (2013) How evidence-based medicine biases physicians against nutrition. Med Hypotheses, 81(6) pp. 1116-9.
• Tursi, A. & Brandimarte, G. (2003) The symptomatic and histologic response to a gluten-free diet in patients with borderline enteropathy. J Clin Gastroenterol, 36(1) pp. 13-7.
• Volta, U., Pinto-Sanchez, M. I., Boschetti, E., Caio, G. P., De Giorgio, R. & Verdu, E. F. (2016) Dietary triggers in irritable bowel syndrome: Is there a role for gluten. J Neurogastroenterol Motil [Epub ahead of print].