Before Removing Gluten, Read This

Gluten, along with lactose, is one of the most commonly avoided or eliminated food components by individuals experiencing gut issues. However, removing gluten without first testing for coeliac disease can be problematic. Moreover, for those without coeliac disease, consuming gluten-containing grains has been shown to be beneficial for gut health.

WHAT IS GLUTEN?

Gluten is an umbrella term for grain storage proteins, primarily prolamins and glutelins, found in barley, rye, wheat and oats*. These proteins are classified based on their solubility:

• Albumins - Soluble in water.

• Globulins - Soluble in sat water.

• Prolamins - Soluble in ethanol (alcohol).

• Glutelins - Soluble in acids.

*If you’ve been diagnosed with coeliac disease in Australia, please consult a dietitian for the most up-to-date advice on oats and coeliac disease.

GLUTEN’S ROLE IN TEXTURE

Gluten plays a key role in determining the texture of breads and baked goods. Its textural properties are dependent on the ratio of glutenins to gliadins and their interaction with water:

• Gliadin - Contributes to doughs extensibility (stretchiness) and ability to rise.

  • Helps bread dough to rise by expanding with trapped gas.

  • Creates a delicate and tender crumb in cakes and muffins.

  • Allows dough to spread for soft cookies and pastries.

• Glutenin - Provides strength and elasticity, contributing to structure.

  • Adds chewiness and structure to pizza dough.

  • Ensures firmness and elasticity in pasta.

  • Supports layering in croissants and puff pastry for crispy, flaky textures.

WHAT IS COELIAC DISEASE

Coeliac disease is an autoimmune condition that primarily affects the small intestine. It occurs in genetically susceptible individuals when the immune system reacts abnormally to gluten, causing the body to attack and damage the small intestine. This leads to the damage and flattening of the intestinal villi — small, finger-like projections in the small intestine that increase surface area for nutrient and water absorption. As a result, nutrient absorption is impaired, leading to various health complications.

It’s important to note that coeliac disease is an autoimmune condition, not a food intolerance or food allergy.

COELIAC DISEASE STATISTICS

In Australia, approximately 1 in 70 people have coeliac disease, yet only 20% are diagnosed. As of March 2024, with a population of 21.7 million, it is estimated that 387,143 Australians have coeliac disease. However, only around 77,429 individuals have been diagnosed, leaving approximately 309,714 Australians unaware they have the condition.

COELIAC DISEASE DIAGNOSIS

In Australia, coeliac disease is diagnosed through a positive blood test and assessment of small intestine biopsies.

For accurate results, it is necessary to consume gluten-containing foods for 4-6 weeks before testing. This is because the blood test detects specific antibodies produced by the immune system in response to gluten consumption.

Reintroducing gluten for diagnosis after experiencing symptom relief can be highly stressful and anxiety-inducing. However, obtaining an accurate diagnosis is essential, as untreated or poorly managed coeliac disease can result in long-term health complications.

Diagnosis For Those Currently Consuming Gluten:

• Step 1: Blood test (Coeliac serology). If negative, coeliac disease is unlikely but doesn’t completely exclude it. If positive:

• Step 2: A gastroscopy with small intestinal biopsy to confirm. This involves inserting a small camera on a thin tube through your mouth to your small intestine, where tissue samples are taken for testing.

Diagnosis For Those Currently Avoiding Gluten:

• Step 1: Blood test (HLA DQ2/8 genotyping). If negative coeliac disease can be excluded. If positive:

• Step 2: Gluten challenge (reintroduction of gluten for 4-6 weeks).

• Step 3: Blood test (Coeliac serology). If positive:

• Step 4: Gastroscopy with small intestinal biopsy. This involves inserting a small camera on a thin tube through your mouth to your small intestine, where tissue samples are taken for testing.

COELIAC DISEASE SYMPTOMS

Coeliac can present in two ways classical (symptomatic) or atypical (asymptomatic).

Classical

• Abdominal distension and bloating

• Abdominal pain

• Diarrhoea or constipation

• Vomiting and nausea

• Heartburn

• Mouth ulcers

• Weight loss

• Iron deficiency

• Fatty stool

Atypical

Minor gastrointestinal symptoms

Extra-intestinal manifestations:

• Headaches

• Fatigue

• Anaemia

• Osteoporosis

• Arthritis

• Tooth enamel defects

• Infertility

• Neurological symptoms

• Autoimmune diseases

COELIAC DISEASE TREATMENT

Currently, the only treatment for coeliac disease is a strict lifelong gluten-free diet.

GLUTEN-RELATED CONDITIONS

Wheat Allergy

Wheat allergy is an allergic reaction to one or more of the proteins found in wheat.

Symptoms: Itching and swelling in the nose and throat, sneezing, hives or skin rash, nausea, stomach cramps, indigestion, vomiting, diarrhoea, asthma, wheezing and/or anaphylaxis.

Diagnosis: By an allergist with allergen specific immunoglobulin E (IgE) antibody skin prick or blood tests.

Irritable Bowel Syndrome (IBS)

Irritable Bowel Syndrome (IBS) is a common gastrointestinal disorder characterised by altered gut motility, visceral hypersensitivity, dysregulation of the brain-gut axis and the influence of psychosocial factors.

Symptoms: Bloating, abdominal pain, diarrhoea, wind, and altered bowel habits.

Diagnosis: Assessment by your GP or gastroenterologist to exclude organic causes (e.g., blood tests, stool tests) and meeting Rome IV Criteria.

Non-Coeliac Gluten Sensitivity (NCGS)

Non-coeliac gluten sensitivity is controversial condition in which individuals experience symptoms after consuming gluten-containing foods, in the absence of coeliac disease or wheat allergy. There are other components found in gluten-containing grains that are currently being researched for their potential role in triggering symptoms. These include, fructans (carbohydrate), amylase/trypsin inhibitors (protein), and wheat germ agglutinin (carbohydrate-binding protein).

Symptoms: IBS-like symptoms, fatigue, headache, fibromyalgia-like joint or muscle pain, leg or arm numbness, foggy mind, skin rash, anaemia, depression, anxiety.

Diagnosis: There are no tests for diagnosing NCGS, therefore, its diagnosis relies on excluding coeliac disease and wheat allergy.

IF NOT GLUTEN, THEN WHAT?

Just like overall health, gastrointestinal function can be influenced by various factors, including:

• Diet: Fibre, fat, FODMAPs, food additives, bioactive food chemicals, gut irritants, and allergens.

• Dietary pattern: Food restriction, adequate intake, meal skipping, and elimination diets.

• Mental health: Stress, anxiety, depression, and the gut-brain axis.

• Sleep: Sleep duration, insomnia, snoring, sleep hygiene, and daytime fatigue.

If you're struggling to understand your gut issues and need support, feel free to reach out for guidance.

REFERENCES

Biesiekierski, J. R. (2017). What is gluten? Journal of Gastroenterology and Hepatology, 32(S1), 78–81. https://onlinelibrary.wiley.com/doi/full/10.1111/jgh.13703

Cárdenas-Torres, F. I., Cabrera-Chávez, F., Figueroa-Salcido, O. G., & Ontiveros, N. (2021). Non-celiac gluten sensitivity: An update. Medicina, 57(6), 526. https://www.mdpi.com/1648-9144/57/6/526

Coeliac Australia (n.d). Coeliac Disease. https://coeliac.org.au/learn/coeliac-disease/

Tuck, C. J., Biesiekierski, J. R., Schmid-Grendelmeier, P., & Pohl, D. (2019). Food intolerances. Nutrients, 11(7), 1684. https://pmc.ncbi.nlm.nih.gov/articles/PMC6682924/pdf/nutrients-11-01684.pdf

Mumolo, M. G., Rettura, F., Melissari, S., Costa, F., Ricchiuti, A., Ceccarelli, L., de Bortoli, N., Marchi, S., & Bellini, M. (2020). Is Gluten the Only Culprit for Non-Celiac Gluten/Wheat Sensitivity? Nutrients, 12(12), 3785. https://www.mdpi.com/2072-6643/12/12/3785