tag:theconversation.com,2011:/au/topics/glutenfree-2912/articlesGlutenfree – The Conversation2017-10-26T00:14:56Ztag:theconversation.com,2011:article/854572017-10-26T00:14:56Z2017-10-26T00:14:56ZGluten free diets aren’t easy, but if you slip up a dietary supplement could help<figure><img src="https://images.theconversation.com/files/189558/original/file-20171010-17706-btqgqq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even after many years on a gluten-free diet, many Australians with coeliac disease continue suffering persistent symptoms.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>When people with coeliac disease eat foods containing gluten, they have an abnormal immune reaction. This results in inflammation and damage to their small bowel lining. But the trouble doesn’t always go away for those coeliac sufferers who stay away from gluten. Studies show even after years on a gluten-free diet, many <a href="https://search.informit.com.au/documentSummary;dn=583396774319839;res=IELHEA">Australians with coeliac disease</a> fail to heal their bowel, or continue suffering persistent symptoms. </p>
<p>It’s hard to adhere to a lifelong gluten-free diet. It is expensive and can be be socially isolating. But even those who remain vigilant can find complete avoidance of gluten a challenge due to hidden sources of gluten. </p>
<p>Gluten is mainly found in wheat, rye and barley – some research also suggests it can be present in certain <a href="https://www.ncbi.nlm.nih.gov/pubmed/17376046">oat varieties</a>. Common <a href="https://celiac.org/live-gluten-free/glutenfreediet/sources-of-gluten/">hidden sources of gluten</a> are sauces, drugs (prescription and over the counter items, including dietary supplements), shared food preparation and processed meats. </p>
<p>Potential hidden gluten is a legitimate source of anxiety for patients, including those who have acute symptoms on minimal exposure to gluten and so remain unsure of the safety of their daily routine. </p>
<p>This is why a number of approaches in non-dietary treatments <a href="http://www.nature.com/ajg/journal/v111/n6/abs/ajg2016105a.html?foxtrotcallback=true">have been investigated</a> around the world. They include a vaccine to induce gluten tolerance, and drugs to inhibit antibodies activated by gluten during the immune response. One therapy showing good results in clinical trials is a supplement that helps break down the toxic portion of the gluten molecule. This is know as enzyme supplementation.</p>
<h2>Enzyme supplementation</h2>
<p>The part of gluten toxic to those with coeliac disease is called gliadin. A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1648798/">number of studies</a> in the 1970s showed that people with coeliac disease <a href="http://www.sciencedirect.com/science/article/pii/0009898173901265">lack an enzyme</a> known as an endopeptidase which digests gliadin into harmless fragments. </p>
<p>Without the enzyme, the immune response kicks in and results in gut inflammation.
Researchers in Melbourne proposed the idea of <a href="https://www.ncbi.nlm.nih.gov/pubmed/17013762">supplementing a digestive enzyme</a> in coeliac patients. A <a href="http://www.tandfonline.com/doi/abs/10.1080/00365520510023855?journalCode=igas20">clinical trial I supervised</a> in 2005, where coeliac patients were given supplementation with an animal-derived endopeptidase, showed promising results. But animal viruses and other pathogens potentially capable of infecting humans meant we had to abandon this type of supplement.</p>
<p>To date, two types of enzyme treatments, an American and Australian one, have been evaluated in clinical studies. The American product called ALV003 was compared with the placebo treatment. In this trial, <a href="https://www.ncbi.nlm.nih.gov/pubmed/24583059">16 Finnish patients</a> with coeliac disease were given the enzyme and 18 given a placebo. Bowel biopsies later showed gluten-induced injury in the placebo group, with no progression of damage in the group taking the enzyme. </p>
<p>The Australian product, called GluteGuard, is based on a papaya fruit enzyme called caricain. This enzyme has proven to be effective in coeliac patients before. A 2015 <a href="https://www.ncbi.nlm.nih.gov/pubmed/25306355">study showed</a> adding caricain to bread dough reduced toxicity to gluten by 90%. </p>
<p>GluteGuard was evaluated in two clinical studies in Poland. The <a href="http://pubs.sciepub.com/ijcd/4/2/2/">first study</a> was of 20 patients with coeliac disease who were in clinical remission on a gluten-free diet. All patients ingested one gram of gluten (equivalent to around one slice of bread) each day for 42 days, with 14 of them also taking GluteGuard and six taking a placebo tablet.</p>
<p>Patients recorded their symptoms and well-being each day, and intestinal tissue was examined before and after the study. Most (13 of 14) coeliac patients taking GluteGuard (93%) demonstrated no detrimental changes in clinical symptoms, biopsy results or well-being throughout the 42 days. Four of six (67%) taking placebo developed severe coeliac symptoms and withdrew from the study after 14 days, compared to one of 14 (7%) from the treatment group.</p>
<p>The second Polish study investigated the effectiveness of GluteGuard in patients with <a href="http://pubs.sciepub.com/ijcd/2/2/7/">dermatitis herpetiformis</a> (also known as Duhring disease) a skin condition in coeliac patients, also triggered by gluten components. Patients with the condition suffer an itchy, blistering and burning skin rash. </p>
<p>All participants in this trial were in clinical remission. They consumed around six grams of gluten daily for seven days, with ten concurrently taking GluteGuard tablets and ten placebo. Those taking GluteGuard fared much better with 81% being protected from increasing areas of skin lesions and a substantial 71% reduction in the appearance of skin lesions. There was also a large 38% reduction in the emergence of a troublesome itch. </p>
<p>Of the seven patients who withdrew from the study due to gluten symptoms, six were taking placebo.</p>
<h2>So, can enzyme supplementation help gluten intolerance?</h2>
<p>These clinical trials met high standards. They were randomised, meaning participants were randomly allocated to receive the treatment or placebo. They were double blind, so neither the participants nor the researchers knew which patient was receiving which intervention. </p>
<p>Based on these trials, enzyme supplementation promises to be a useful adjunct for coeliac patients anticipating unavoidable exposure to gluten – such as when travelling or eating food prepared outside their direct control.</p>
<p>It’s important to note enzyme supplementation won’t cure coeliac disease, and sufferers still need to avoid gluten. But the evidence suggests it helps in digesting hidden dietary gluten and could make life much easier for many coeliac sufferers.</p><img src="https://counter.theconversation.com/content/85457/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Finlay Alistair Macrae is part of a clinical research team that has been supported by Glutagen (makers of GluteGuard) to run randomised controlled trials on their product.</span></em></p>Enzyme supplementation won’t cure those with coeliac disease, but it could make life much easier for many sufferers.Finlay Alistair Macrae, Head of Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/49282012-05-06T20:49:02Z2012-05-06T20:49:02ZEverything you need to know about coeliac disease (and whether you really have it)<figure><img src="https://images.theconversation.com/files/10100/original/t33f2bp8-1335761395.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Thinking of jumping on the gluten-free bandwagon? Better think again.</span> <span class="attribution"><span class="source">GlutenFreeChops/Flickr</span></span></figcaption></figure><p>The <a href="http://history-world.org/neolithic.htm">Neolithic Revolution</a> introduced a whole range of new foods and proteins into the human digestive tract. But this phenomenal change created the perfect conditions for the rise of coeliac disease. </p>
<p>While most proteins were readily consumed, some people’s immune systems struggled to tolerate others. Wheat was the first cereal to be widely domesticated, and in the case of the gluten protein from wheat, the result of this struggle was coeliac disease. </p>
<p>When people with coeliac disease consume gluten, an abnormal immune reaction occurs causing inflammation and damage to the small bowel lining. This impairs absorption of nutrients and can lead to a wide range of symptoms and medical complications.</p>
<h2>Ancient condition, 20th century treatment</h2>
<p>The second century Greek physician Arateus is credited with coining the term coeliac disease, or “koiliakos”, after the Greek word koelia (abdomen), to describe patients suffering typical symptoms of diarrhoea, weight loss and anaemia. </p>
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<img alt="" src="https://images.theconversation.com/files/10092/original/nw4mrfhq-1335759356.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/10092/original/nw4mrfhq-1335759356.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/10092/original/nw4mrfhq-1335759356.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/10092/original/nw4mrfhq-1335759356.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/10092/original/nw4mrfhq-1335759356.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/10092/original/nw4mrfhq-1335759356.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/10092/original/nw4mrfhq-1335759356.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Wheat was finally identified as the culprit of the reoccurring health problems.</span>
<span class="attribution"><span class="source">Joana Hard</span></span>
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<p>Reports from the 19th and 20th century reveal considerable suffering and mortality associated with coeliac disease, particularly in infants. An effective treatment didn’t arise until the middle of the 20th century, when gluten was identified as the culprit. </p>
<p>The discovery was fortuitous – a wartime bread shortage led Dutch paediatrician Willem Dicke to observe improved health in children with coeliac disease, and note their relapse shortly after food drops of bread returned wheat back into their diet. </p>
<p>The work of Australian physician Charlotte Anderson established it was the gluten component of wheat (and also rye, barley and oats) that caused coeliac disease. It was the 1950s and the age of treatment with a gluten-free diet had begun.</p>
<h2>Prevalence and the reasons why</h2>
<p>Far from being a medical rarity, coeliac disease is very common today, affecting more than one in 100 Australians. And in the last half century, it has become approximately <a href="http://www.ncbi.nlm.nih.gov/pubmed/17944736">twice as common every two decades</a>, similar to the rise in other immune diseases, such as type 1 diabetes. </p>
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<img alt="" src="https://images.theconversation.com/files/10093/original/qqhzzm5n-1335759870.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/10093/original/qqhzzm5n-1335759870.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/10093/original/qqhzzm5n-1335759870.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/10093/original/qqhzzm5n-1335759870.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/10093/original/qqhzzm5n-1335759870.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/10093/original/qqhzzm5n-1335759870.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/10093/original/qqhzzm5n-1335759870.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The increased prevalence of the disease may be due to hyper-conscious hygiene practices.</span>
<span class="attribution"><span class="source">sydeen/Flickr</span></span>
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<p>Why the prevalence is increasing remains unknown, but a variety of environmental factors and the “<a href="https://theconversation.com/how-clean-is-too-clean-trust-your-gut-instincts-855">hygiene hypothesis</a>” have been proposed. </p>
<p>Today, people are typically diagnosed in adulthood and are mostly female. Alarmingly, <a href="http://www.ncbi.nlm.nih.gov/pubmed/21426277">80% of Australians with coeliac disease remain undiagnosed</a>. This is because symptoms are wide-ranging and largely non-specific. And coeliac disease still remains “off the radar” for many doctors.</p>
<h2>Many symptoms but simple diagnosis</h2>
<p>In people with coeliac disease, gluten causes widespread inflammation not limited to the bowel. Patients are commonly troubled by gut upset (such as bloating, abdominal pain, diarrhoea and/or constipation), lethargy, anaemia, and nutrient deficiencies, such as low iron. They can also suffer loss of fertility, migraine headaches, abnormal liver function, arthritis and autoimmune diseases, such as type 1 diabetes and autoimmune thyroid disease. </p>
<p>Bones are more likely to be thinned out (osteoporosis) and patients can develop certain cancers, such as lymphoma. The good news is that early diagnosis and treatment can greatly reduce the chances of these complications.</p>
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<img alt="" src="https://images.theconversation.com/files/10094/original/w9jpcx6b-1335760316.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/10094/original/w9jpcx6b-1335760316.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=425&fit=crop&dpr=1 600w, https://images.theconversation.com/files/10094/original/w9jpcx6b-1335760316.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=425&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/10094/original/w9jpcx6b-1335760316.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=425&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/10094/original/w9jpcx6b-1335760316.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=533&fit=crop&dpr=1 754w, https://images.theconversation.com/files/10094/original/w9jpcx6b-1335760316.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=533&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/10094/original/w9jpcx6b-1335760316.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=533&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A blood test is a simple way to indicate whether you may have coeliac disease.</span>
<span class="attribution"><span class="source">Healthcare Experts/Flickr</span></span>
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<p>A simple blood test is used to screen for coeliac disease, although making a definite diagnosis requires demonstrating the characteristic small bowel changes of flattened and inflamed lining (“villous atrophy”) under the microscope. Small bowel samples are readily obtained by gastroscopy, a ten-minute procedure performed under sedation that introduces a flexible instrument via the mouth into the small bowel to allow samples to be taken. </p>
<p>It’s vital that a gluten-free diet isn’t started before testing for coeliac disease, as this can cause false negative results.</p>
<h2>Genes and the environment</h2>
<p>Coeliac disease shares certain predisposing genes with autoimmune diseases, such as type 1 diabetes (which explains why these conditions often occur together). These genes control how the immune system “recognises” and responds to foreign proteins and are fundamental for disease to develop. </p>
<p>But genes alone are not enough to cause coeliac disease and environmental factors are thought to play an important role in “triggering” disease in those with genetic susceptibility. Some factors appear to increase coeliac disease risk (such as <a href="http://www.ncbi.nlm.nih.gov/pubmed/17032199">rotavirus infection</a> in infancy) while some may reduce the risk. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11976167">Breastfeeding at the time gluten is introduced</a> to an infant, for instance, may protect against developing disease. </p>
<h2>The challenge of gluten-free diets</h2>
<p>Excluding all dietary sources of gluten from wheat, rye, barley and oats allows the small bowel damage to heal and symptoms to resolve – but it’s far from easy. Wheat flour, the most common and significant source of gluten, is found in many foods, such as bread, breakfast cereals, cakes, biscuits, pasta, pastries and pizzas. </p>
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<span class="caption">People with coeliac disease have to learn how to pass up the pastries.</span>
<span class="attribution"><span class="source">pastryfusion/Flickr</span></span>
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<p>There are also “hidden” sources of gluten found in sauces and processed foods and less obvious items, such as malted foods and beer. While gluten-free alternatives are increasingly available, they’re much more expensive and generally much less palatable – anyone who has ever tried gluten free bread will know how dense and crumbly it is! </p>
<p>Compounding its complexity, cost and poor palatability, the gluten-free diet needs to be very strict to work - even <a href="http://www.ncbi.nlm.nih.gov/pubmed/17209192">small amounts of gluten</a> (about 50 milligrams – less than 1/100th of a slice of bread) can cause bowel damage. </p>
<p>That’s why patients need to be obsessive about excluding gluten – for people with coeliac disease the gluten free diet is not a fad but a serious medical treatment.</p>
<h2>Is gluten free for everyone?</h2>
<p>It’s hard to miss the ever-expanding sections of supermarkets dedicated to selling gluten-free food and many restaurant menus list gluten-free options. The gluten-free food industry is booming, with a global market projected to well exceed US$4 billion over the next three years. </p>
<p>Interestingly, a recent market survey commissioned by <a href="http://www.coeliac.org.au/">Coeliac Australia</a> indicates that approximately 10% of Australians are currently following a strict or significantly reduced gluten diet. This is ten times greater than the total number of Australians thought to have coeliac disease.</p>
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<img alt="" src="https://images.theconversation.com/files/10099/original/qh39m5s9-1335761035.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/10099/original/qh39m5s9-1335761035.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/10099/original/qh39m5s9-1335761035.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/10099/original/qh39m5s9-1335761035.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/10099/original/qh39m5s9-1335761035.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/10099/original/qh39m5s9-1335761035.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/10099/original/qh39m5s9-1335761035.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A gluten-free diet isn’t all that tasty, and not necessarily the healthiest option.</span>
<span class="attribution"><span class="source">simply..gluten-free/Flickr</span></span>
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<p>It’s likely that alternative health practitioners, disease advocacy groups, proliferating internet blogs and forums, and the gluten-free food industry are directly or indirectly fuelling the mounting public perception that a gluten-free diet is intrinsically “healthy” or suitable to treat a variety of symptoms and illnesses. </p>
<p>But medical evidence to support undertaking a strict gluten-free diet outside of coeliac disease is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22237879">minimal</a>. If people do choose to follow a gluten free diet, it’s medically important that coeliac disease is excluded first so that testing isn’t compromised - a missed diagnosis of coeliac disease can be disastrous for long-term health. </p>
<p>While many people feel their symptoms might improve on a gluten-free diet, this doesn’t necessarily mean they have coeliac disease. Nor does it mean a gluten-free diet is the most appropriate treatment for them. </p>
<p>Many cases of perceived wheat or gluten intolerance reported by patients is not due to gluten itself but intolerance to the wheat’s carbohydrate component (fructans). For some, a diet reducing fructans and other fermentable carbohydrates, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/20136989">low FODMAP (fermentable oligo-, di-, mono-saccharides and polyols) diet</a> can be a more effective and appropriate treatment than going gluten free. </p>
<h2>Awareness, diagnosis and management</h2>
<p>Inadequate and delayed diagnosis of coeliac disease remains a major problem in our community so improving awareness and testing is a major goal to reduce the burden of this disease. </p>
<p>Excitingly, there’s been significant progress in understanding the <a href="http://www.ncbi.nlm.nih.gov/pubmed/21219178">genetic and immunological basis</a> for why gluten is toxic in people with coeliac disease. Immune cells called T cells are the key mediators of damage in coeliac disease. These T cells are stimulated to cause damage by <a href="http://www.ncbi.nlm.nih.gov/pubmed/20650871">specific gluten fragments</a>, which have now been identified. </p>
<p>Such insights are allowing a variety of <a href="http://www.ncbi.nlm.nih.gov/pubmed/21401739">potential treatments</a> for coeliac disease to be explored, some of which will supplement and some of which could one day replace the gluten-free diet altogether.</p><img src="https://counter.theconversation.com/content/4928/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Tye-Din is affiliated with The Walter and Eliza Hall Institute and The Royal Melbourne Hospital. He receives funding from the NHMRC. He consults for ImmusanT Inc. and is co-inventor of patents related to the use of gluten peptides in diagnostics and therapies for coeliac disease.</span></em></p>The Neolithic Revolution introduced a whole range of new foods and proteins into the human digestive tract. But this phenomenal change created the perfect conditions for the rise of coeliac disease. While…Jason Tye-Din, Postdoctoral Scientist, Walter and Eliza Hall InstituteLicensed as Creative Commons – attribution, no derivatives.