Coeliac Awareness Week is all about raising awareness of Coeliac Disease.
Being a gut health dietitian, I ask every client I see if they have been tested for coeliac disease. This is because the symptoms of coeliac disease can overlap with many other gut disorders (such as IBS) and if left undiagnosed/untreated, coeliac disease can lead to many complications and health issues.
So if you’re wondering what coeliac disease even is, read along to find out all about coeliac disease, the gluten free diet (how it is different to a low FODMAP diet) and how coeliac disease and IBS overlap.
This year for Coeliac Awareness Week, I have teamed up with the wonderful Free From + Allergy community to present at the virtual Coeliac Awareness Show on the topic “Is it coeliac disease or IBS…or both?)”. I’m discussing the differences (and similarities) between Coeliac Disease and IBS. I delve into the details of coeliac disease testing (ie. how to get an accurate diagnosis) and highlight the differences between eating gluten free and eating low FODMAP (one of the most common questions I get in clinic).
You can register for this FREE virtual show on the Free From + Allergy website.
So, let’s get into coeliac disease…
What is coeliac disease?
Coeliac disease is not an allergy or an intolerance. It’s an autoimmune disorder where the immune system reacts abnormally to dietary gluten, results in damage to the small intestine. This typically leads to malabsorption of nutrients and gastrointestinal symptoms. Coeliac disease affects 1.5% of Australians, however around 80% are undiagnosed.
The symptoms of coeliac disease may include:
- Abdominal pain
- Weight loss
- Nutrient deficiencies
- Mouth ulcers
- Dermatitis herpetiformis (skin rash)
Coeliac disease can also be asymptomatic.
Treatment of coeliac disease:
A strict gluten free diet is the only way to treat and manage the condition. This means having no traces of gluten in the diet (no cross-contamination). In Australian, gluten free is defined as having <3 parts per million of gluten present in food or drinks, essentially this means almost no gluten at all (not even crumbs of bread).
What is gluten?
Gluten is a protein, found in wheat, rye, barley and oats as well as food products made from these grains. Regular wheat products (bread, pasta, biscuits, crackers, pastries, wraps) all contain gluten and must be avoided on a gluten free diet. It’s also really important for people with coeliac disease to avoid tiny portions of gluten as even small amounts can be enough to damage the small intestine and lead to long term health complications. People with coeliac disease must be careful of gluten cross contamination, ie. using the same preparation utensils, cooking in the same pot/pan and using the same knife to spread button on regular bread as gluten free bread.
Oats and Coeliac Disease:
In Australia, oats are considered to be a gluten-containing grain, however in other countries, you may hear the term ‘gluten free oats’ thrown around more. To get specific, the gluten protein in oats is slightly different to the protein in wheat, rye and barley. The Australian food standard to define gluten free food is different to the standards in other parts of the world, such as Europe and America. In Australia, oats can be labelled as ‘wheat free’, meaning they are uncontaminated and have not been produced or processed in the presence of wheat, rye or barley.
There is evidence to show that some people with coeliac disease can tolerate these uncontaminated, wheat-free oats, however in some people oats can trigger reactions in the body. Damage to the small intestine can still occur at a microscopic level, even if you don’t have any symptoms with coeliac disease, so it’s important to use accurate testing (not symptoms) to assess for damage to the gut. For those looking to introduce oats as part of a gluten free diet, it is strongly recommended (by Coeliac Australia) to do so under the guidance of a health professional- and it is not a simple process. This involves undertaking a gastroscopy and small bowel biopsy before and after 3 months of regular ingestion of uncontaminated oats, then following up the results with a health care professional (gastroenterologist and dietitian) to determine the safest diet plan going forward.
What are the complications of untreated coeliac disease?
If a strict gluten free diet is not followed to manage coeliac disease, this can put an individual at risk of:
- Chronic inflammation
- Infertility & miscarriage
- Nutrient deficiencies
- Intestinal lymphomas
- Dermatitis herpetiformis
- Other autoimmune diseases
These complications can occur even if you do not have symptoms when eating gluten.
Coeliac disease diagnosis:
Coeliac disease can only be accurately diagnosed by having a gastroscopy procedure with small bowel biopsy (tiny sample of the small bowel) which is examined from damage under a microscope. This procedure is done by a gastroenterologist (GI specialist).
In practice, it’s common to have a blood test to check for coeliac genes and/or coeliac antibodies (called coeliac serology test). It’s important to note that a gene test cannot diagnose coeliac disease.
Gene Test: Tests for certain genes via a blood test or buccal (cheek) swab. This can be useful in understanding your risk of coeliac disease. Over 99% of people with coeliac disease have the HLA genes DQ2 or DQ8 or parts of these genes. A negative test result can rule out coeliac disease. However, a positive test result alone cannot be used to diagnose coeliac disease, as not all people with the genes will develop coeliac disease.
The gene test is not dependent on gluten intake, so it can be used for people who have already removed gluten from their diet. However, if the gene test is positive, then a gluten challenge (reintroducing gluten back into your diet at around 6-10g per day or 4 slices wheat bread) will be commenced to ensure the next stages of testing are accurate.
Blood test for antibodies: This blood test measures the levels of antibodies in the blood that are associated with coeliac disease. A positive test result should be followed by a gastroscopy and small bowel biopsy.
Small bowel biopsy: A gastroscopy procedure (a camera looking into your small intestine, through the mouth and down the digestive tract) is undertaken to collect a tiny sample (biopsy) of the small bowel. The biopsy will be examined under a microscope to detect signs of damage (villous atrophy).
If coeliac disease is negative, could there be something else in wheat, rye or barley that is upsetting your gut?
Yes! It could in fact be that you have a fructan sensitivity or intolerance. Fructans are a FODMAP, meaning they are short-chain carbohydrates. They can be fermented in the large intestine which can trigger symptoms of bloating, abdominal pain and altered bowel habits in people with IBS. Fructans are found in wheat, rye, barley, onion, garlic and some fruit and vegetables. See the overlap with gluten!?
Wheat, rye and barley contain both fructans AND gluten. In many cases, reactions to these grains may actually be a fructan intolerance not a gluten intolerance.
How do you know if you have a fructan intolerance?
A gut health dietitian can help to determine this. We can assess your diet, symptoms, medical history and test you have had and then guide you to trial food “challenges” to understand your individual tolerance of fructans (and other FODMAP foods can can trigger IBS symptoms).
What if you do have coeliac disease?
A coeliac disease diagnosis can be overwhelming and you might feel like all your favourite foods are taken away from you. However- it can be very well managed and you can STILL enjoy delicious food (trust me, I’ve cooked this way for many years living in a coeliac-friendly household). One of the best things to do to get started is to see a gut health dietitian. They will be able to talk you through all the fine details of gluten in food and how to manage eating both at home as well as eating out with coeliac disease.
If you’re looking for individualised dietetic support for a gluten free diet, coeliac disease and IBS, you can book an appointment here.