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Reuniting with Wheat

November 2,2018

For the last 8 years I have assumed that I had coeliac disease and followed a strict gluten free diet. I had my own toaster, I freaked out with cross contamination and I wouldn’t go near anything with a “may contain” statement. I missed out on chocolate, hot cross buns and cheesecake. However, if I had been encouraged to undertake a gluten challenge I would have discovered that it wasn’t the gluten after all. Let’s explore the difference between coeliac disease and IBS, and how to get diagnosed properly.

What is Coeliac disease and how does it differ from IBS?

Coeliac disease is an autoimmune condition where the body acts abnormally in response to the protein found naturally in wheat, barley, rye and oats. In the one in 70 Australians who have coeliac disease, eating gluten will trigger a release of antibodies that attack the lining of the small bowel. The resulting damage affects nutrient absorption and potentially leads to abdominal symptoms (e.g. diarrhoea, cramping or nausea), iron deficiency, osteoporosis, fertility problems and even lymphoma. As you can imagine, coeliac disease is a serious condition. If a person has coeliac disease, the only treatment is a strict gluten free diet for life, including care to avoid cross contamination.

Irritable bowel syndrome (IBS), on the other hand, does not cause damage to the bowel nor does it lead to long term health complications. It does cause rather nasty symptoms. The treatment for IBS is focused on minimising symptoms. This is done by limiting your trigger foods enough that you stay under your symptom threshold. There is no need to be concerned with cross contamination, and if you do choose to eat something that triggers your IBS, the worst part is the symptoms.

My story

It was two weeks before Christmas that I found myself getting blood taken to test for coeliac antibodies. The result came back elevated and I was told I would need to stop eating gluten and see a gastroenterologist. At this point I was still nursing and only at the beginning of my nutrition studies. My knowledge was limited, so I booked into the specialist and did what I was told. Being Christmas and all, it was three months later that I found myself in the specialist’s office, only to be told that I would need to start eating gluten again to have a gastroscopy and confirm I had coeliac disease. I was devastated, I had never felt so good in my entire life, my gut was settled and I had my energy levels back, I also had an energetic toddler, so feeling sick again was the last thing I wanted or needed at that point in my life.

After some discussion, it was decided that I would have to assume I had coeliac disease and when I was ready to go back and do a “gluten challenge”, I would make contact with the specialist again.

Fast forward 8 years, I was a fully qualified dietitian and working exclusively in gut health. Every time I discussed the importance of testing for coeliac disease with a patient I felt like a fraud. I was telling them how important it was to do what I hadn’t done myself. It was in the winter of 2017, when I was working with Bakers Delight to launch their high protein Lo Fo loaf, that I eventually worked up the courage to address my conscience. I held my breath and started with a nibble of bread, and oh boy was it delicious. Surprisingly I actually felt ok as well. The next day I had a little more and eventually I worked up to the recommended amount of wheat per day for my gluten challenge, always being careful to choose low FODMAP options.

I survived the 6 week “gluten challenge” and even got a pleasant surprise with the results coming back negative for coeliac.

What I learnt

I now know for sure that I have IBS and not coeliac disease. I am able to eat low FODMAP amounts of wheat products. My diet is more varied and my supermarket bill is cheaper, but most of all, it has allowed me to get a better grasp of my real triggers.

How Coeliac disease is assessed

Coeliac disease is a genetic condition that is environmentally triggered. About 30% of the population are born with genes that predisposes them to coeliac disease. The most common genes being HLA DQ2 and HLA DQ8. Just having theses genes does not mean you have coeliac disease and most cases for all intensive purposes they remain dormant. If you are already gluten free, you can have a blood test for these genes. If the gene test is positive, it doesn’t mean you have coeliac disease just that you are predisposed to it. If the gene test is negative coeliac disease can be excluded.

In about 1 in 70 people, a stressful life event occurs and these genes “wake up” and become active. If this happens, when the person eats gluten antibodies will be released, triggering a chain of events that results in damage to the lining of the small bowel. These antibodies are known as tTG-IgA and DGP.

Diagnosing coeliac disease is a two step process:

  1. A blood test to screen for the likelihood of coeliac disease. This blood test looks for the presence of tTG-IgA and DGP antibodies.
  2. If the blood test is positive a gastroscopy is performed and a biopsy taken from the small bowel. This biopsy is examined under a microscope to assess for damage.

Since both of these tests are looking for either antibodies or damage caused when someone with coeliac disease eats gluten, it is important to be tested before going on a gluten free diet. If you are already gluten free, the tests will always be negative, regardless of if you have coeliac disease or not. In this case you will have to do a “gluten challenge” to know for sure if you have coeliac disease or not.

Low FODMAP gluten challenge:

Coeliac Australia recommend eating the equivalent of four slices of wheat bread per day for six weeks prior to coeliac testing. Its important to note here, that gluten is the protein in wheat, barley, rye and oats, while FODMAPs are the carbohydrate in wheat, barley and rye. They are different molecules that sometimes occur in the same foods. The great thing about this is that it means you can do a gluten challenge within the confines of a low FODMAP diet.

Low FODMAP serves of wheat:

  • 2 slices of FODMAP Friendly certified wheat breads (Alpine Bread or Bakers Delight Lo Fo loaf)
  • 1 slice of regular wheat bread
  • ½ cup of regular wheat pasta (equivalent of 1 slice of wheat bread)

During the low FODMAP diet it is recommended to leave a 3-hour break between each serve of wheat. This means you can have multiple serves per day as long as you space your serves through the day. For example, to achieve the equivalent of 4 slices of wheat bread per day, you could have:

Breakfast – 7am: 2 slices of Alpine or Bakers Delight bread
Lunch – 12:00: 1 slice of wheat bread
Dinner – 6pm: ½ cup wheat pasta

Alternatively, Vital Wheat Gluten is a low FODMAP flour that is almost pure gluten. It can be added to baking or used to make “Seitan” which is a type of vegetarian meat alternative. Vital wheat gluten can be bought online or from some bakeries. You would meet the requirements of a gluten challenge by eating approximately 8g of vital wheat gluten per day.

Check out this recipe from The Expat Dietitian for instructions on how to make Seitan. Of course to make this recipe low FODMAP, omit the garlic powder and replace with Italian Herbs.