Category: Answers with Dr. Janet

**How long until I feel better after consuming gluten?**


For a more detailed answer from Dr.Janet check out our [1]

**Bowel and colon cancer**



If you would like more information on the complications of untreated coeliac disease click [here][2]

**Viruses and infections**


**Using the same cooking oil with non gluten free and gluten free products**


**Should my son who suffers from coeliac disease eat pre-packed gluten free products?**


Food packaging regulations were changed to help allergy sufferers. Take a look at the new regulations [here][3].

**Sensitive bowel after eating certain foods, is this to do with my condition?**


[1]: https://www.youtube.com/watch?v=RsNqSVr2OMI
[2]: http://www.nhs.uk/Conditions/Coeliac-disease/Pages/Complications.aspx
[3]: https://www.food.gov.uk/science/allergy-intolerance/label/labelling-changes

Some people may experience the symptoms related to gluten sensitivity that occur in Coeliac Disease but blood and biopsy tests do not confirm Coeliac Disease as a diagnosis. The main difference is the lack of damage to the small intestine, and no real indication of how the immune system may be involved. Despite a lack of diagnosis, the symptoms remain very real for the sufferer, and it’s important for healthcare professionals to support patients to help find a solution, or to ease the symptoms.
With 15% of households in the UK choosing to go ‘gluten-free’ there is certainly a great deal of interest in following a gluten free diet. Whether it is an appropriate diet for the majority is yet to be determined but there are certainly other gastrointestinal conditions where gluten is thought to be a potential trigger.

**Non Coeliac Gluten Sensitivity**

Where Coeliac Disease is ruled out through diagnostic tests, but eating gluten containing foods still continues to be an issue, this can often be referred to as Non Coeliac Gluten Sensitivity. There is still much debate around what this really means, and whether gluten really is the trigger for the symptoms experienced.

It is possible that removing gluten from the diet also removes other potentially damaging components. Interest has focussed recently on Fermentable Oligo Di Monosaccharies and Polyols (FODMAPs) or possibly the non gluten part of wheat. Further research is required to fully understand the role of gluten in non coeliac gluten sensitivity.

**Wheat or Gluten Intolerance**

Although different to Coeliac Disease in terms of the disease progression, people who are intolerant to wheat or gluten may experience similar symptoms. Interestingly, someone with wheat intolerance may continue to experience problems even if they follow a gluten free diet. This is because the remaining part of the wheat in the product may be affecting them. They may, or may not, also be able to eat barley, rye and oats without any problem, and may also be able to reintroduce wheat into the diet after a short period of elimination.

This type of intolerance is more difficult to diagnose because there is no simple test that is available. For most people, removal of gluten and wheat from the diet for a short period of time may help with symptoms. Under the advice of a Dietitian, gradual reintroduction of wheat and gluten may help to identify which foods may be problematic.

**Irritable Bowel Syndrome (IBS)**

Irritable Bowel Syndrome is a common long term condition of the gastrointestinal tract. Symptoms vary between individuals but tend to be linked to digestive comfort such as stomach cramps, diarrhoea and/or constipation.

The symptoms tend not to be continuous but can last for days or months at certain points of the individuals life. People tend to have triggers which can set off symptoms including stress or eating certain foods.

Unlike Coeliac Disease people with IBS do not suffer any damage to the small intestine, although they may experience inflammation at times. There is also no one diagnostic test, or treatment route for IBS which makes it a challenging condition.

If you experience any gastrointestinal symptoms on a regular basis, your GP should always be the first point of call. You may be referred to a Dietitian who will take a detailed dietary history, and may ask you to keep a food and symptoms diary to try and ascertain any link.

Managing the symptoms of IBS is very individual but it is thought that certain changes to the diet may help. These include:-

– Changing the amount of fibre in your diet depending on your symptoms
– Choosing a low FODMAP diet – this requires a decrease in foods
containing the FODMAP carbohydrates described above. It is a complex diet and should only be done under medical supervision.

**Moving Forward**

Whatever symptoms you are experiencing, you should always discuss this with your GP before taking any action. Although you may find symptoms improving by following a gluten or wheat free diet, for example, its important for diagnosis to keep your diet habitual. Once a diagnosis of Coeliac Disease has been ruled out (this has to be done whilst gluten is part of the diet), then your GP or gastroenterologist will advise on next steps and the best course of action.

Coeliac Disease affects 1 in 100 people in the UK, however, according to Coeliac UK (www.coeliac.org,uk) only 24% of those with the condition have been medically diagnosed meaning nearly half a million people may have the condition but not yet know it. Getting a proper diagnosis with any condition, is vital to ensure the correct advice and treatment is given. The problem for people affected by Coeliac Disease is that the symptoms can often be wide ranging making diagnosis more difficult.

Coeliac Disease is an autoimmune condition where the body reacts in an adverse way to the presence of an element of gluten, known as gliadin, in the diet. Gluten is a protein found in cereals such as wheat, barley and rye. This adverse reaction causes damage to the lining of the small intestine.

It’s not known exactly what causes Coeliac Disease, or why some people have more severe symptoms than others. Risk appears to increase within families with a risk of about 10% for those with a relative who has Coeliac Disease. Developing an infection such as rotavirus in early life may also play a role in the development of the condition, but this is not the only factor involved. Early weaning with gluten containing food, before 3 months of life, is also thought to be a risk factor. Current advice states that gluten should not be introduced to a baby’s diet until at least 6 months of age.

Other conditions such as ulcerative colitis, type 1 diabetes and neurological conditions such as epilepsy also appear to be linked to Coeliac Disease but it is not yet known whether these are independent risk factors for developing Coeliac Disease, or whether they maybe just have the same underlying cause, which is as yet unknown.

**What happens inside to someone with untreated Coeliac Disease?**

In a healthy person the gastrointestinal tract, sometimes referred to as the gut, consists of different sections. One of the most biologically active areas is the small intestine. Here, there are finger like projections all over the surface of the intestines called villi. These villi, and microscopic hairs covering the surface of the villi (known as micro-villi) increase the surface area of the small intestine which results in a very efficient surface for the absorption of nutrients from the intestine into the bloodstream.
In fact, the simple small intestine tube has a surface area of about 2 square feet in area, but if the total surface area including the villi and micro-villi was included this would increase to cover an entire tennis court in size!

Not only do the villi increase the surface area required for absorption – they also tend to store and hold the important enzymes we need to break down foods into the right size nutrients to be absorbed.


When an individual has Coeliac Disease, gluten causes an immune reaction – firstly the white blood cells in the villi increase in number and this eventually causes an inflammation in the villi. As this inflammation continues, damage occurs which leads to a flattening of the villi reducing the surface area of the small intestine dramatically. In some cases, the villi can be completely lost from the small intestine.

**What effect does this have?**

Severe inflammation of the small intestine resulting in damage to the villi can have severe effects on an individual. If you can imagine the surface area of the small intestine reducing in size, but at the same time being inflamed and damaged this can partly explain some of the symptoms that individuals with Coeliac Disease experience including abdominal pain, difficulty digesting and absorbing food resulting in vomiting and/or diarrhoea, nutrient deficiencies and poor growth patterns in children.

**Is there a treatment?**

The human body is amazing, and despite the severe damage caused to the small intestine in individuals with Coeliac Disease, the villi and microvilli are able to recover. In most cases avoiding the root cause of the inflammation, allows the regeneration of the small intestine, and in many cases a complete recovery. The only possible way to do this is through the complete avoidance of gluten – the cause of the problem. Following a lifelong gluten-free diet allows individuals with Coeliac Disease to manage their condition, however even a trace amount of ingested gluten can lead to a flare up of unpleasant symptoms.

Coeliac Disease is an autoimmune condition which results in severe inflammation and damage to the small intestine. The small intestine, also known as the ileum, is the main organ in the body concerned with the absorption of nutrients so any damage can have serious repercussions for the individual.

The symptoms of Coeliac Disease can range from mild to very severe, and can often come and go which can cause confusion both for the individual and also for medical professionals. In very mild cases of Coeliac Disease the symptoms may not be noticeable and diagnosis may occur during routine tests for other issues.

For those affected more severely, symptoms can be very unpleasant with the most common problem being diarrhoea. As the small intestine becomes damaged, the nutrients are not absorbed properly leading to release of the food through the intestinal system. In addition, the lack of nutrient absorption can lead to very high levels of fat in the stools (a condition known as steatorrhea) which can lead to very foul smelling, pale coloured and greasy stools.

Diarrhoea is not the only problem for people with Coeliac Disease, and a whole range of other symptoms may occur including:-

– Bloating
– Severe abdominal pain
– Flatulence
– Weight loss
– Tiredness and fatigue (which can be a sign of iron or folate deficiency anaemia)
– Tingling and numbness in the hands and feet (peripheral neuropathy)
– Vomiting
– Swelling of hands, feet, arms of legs caused by a build up of fluid
– Hair loss
– Liver abnormalities
– Repeated miscarriages

Coeliac Disease is known as a ‘multi system’ disorder because it can affect so many different aspects of the body.
In children with undiagnosed or untreated Coeliac Disease, a lack of nutrient absorption can also affect growth and development, as well as delayed puberty in older children.
Although not a classic symptom of Coeliac Disease some people suffer from severe skin rashes and blistering skin known as dermatitis herpetiformis which can clear up following a gluten-free diet intervention.

**After a Gluten Free Diet Intervention**

Because Coeliac Disease is caused by an auto immune reaction to gluten, removing gluten from the diet can result in a complete recovery from symptoms.

Following diagnosis, you will be advised to follow a completely gluten free diet immediately. Some people report improvements in symptoms within a few days, and usually classic symptoms like bloating, diarrhoea and nausea will clear up with a few weeks.

Complete healing of the damage to the small intestine will take time, and it may take between 6 months and 2 years before a biopsy of the gut will show complete recovery. That said, the removal of gluten from the diet will enable the healing of the gut that is required for it to perform its normal function of the absorption of nutrients. Once this healing has begun, all the symptoms associated with Coeliac Disease will gradually subside.

Whilst following a gluten free diet both symptoms and the biological damage caused by gluten will be eliminated, therefore testing for Coeliac Disease whilst following a gluten free diet will not show up the condition. Testing for Coeliac Disease must therefore always take place whilst gluten is part of the diet.

**What if Gluten is reintroduced?**

Despite the best efforts of an individual with Coeliac Disease it is not always possible to remain completely gluten free. Accidental ingestion of gluten, often referred to as ‘being glutened’ by individuals with the condition, can lead to a return to some or all symptoms.

This can be an immediate and severe reaction with diarrhoea and/ or vomiting, or may be a longer term reaction with abdominal pain and other symptoms. Most people recognise when gluten has been ingested, and may feel unwell for several days subsequently.

Once again recovery is dependent on the removal of gluten from the diet to return to a symptom free lifestyle.

Coeliac Disease is a multi-system condition often resulting in lengthy and challenging roads to diagnosis. With wide ranging, and diverse symptoms often mimicking other medical conditions such as irritable bowel syndrome (IBS), colitis and other forms of inflammatory bowel disease, getting the right diagnosis can take time.

**What to do if you have concerns?**

If you are suffering from any of the symptoms of Coeliac Disease discussed in our last article, then it is vital that you discuss them with your GP as soon as possible. Your GP will take a detailed history to enable them to make a judgement about whether your condition could be Coeliac Disease.

**Screening and Diagnosis**

Screening for Coeliac Disease is a two stage process which includes:-
– A blood test
– A biopsy of the small intestine

*Blood test*

Your GP will be able to arrange for the blood test as the first screening. At this stage it is vital that gluten is still part of your diet as the blood test is specifically looking for antibodies to gluten that are usually present in the bloodstream of people with Coeliac Disease. If you are avoiding gluten when the blood test it taken this could lead to an inaccurate result.

If the result of the bloodtest is positive for Coeliac Disease antibodies, your GP will then refer you for a biopsy to confirm the diagnosis. This stage of diagnosis will be carried out by a consultant Gastroenterologist in a hospital.

*Biopsy*

A biopsy is a medical procedure where a small sample of tissue is taken from the body so that it can be examined under a microscope to look for the presence of a disease or condition. If you are referred for a biopsy to test for Coeliac Disease, the gastroenterologist will be taking a small piece of tissue from the small intestine – the area of the gut known to be affected in Coeliac Disease.

When someone has Coeliac Disease, the surface area of the small intestine will be inflamed and damaged. The tissue biopsy can highlight this damage and confirm a diagnosis.

To gain access to the tissue in your small intestine, a small thin tube called an Endoscope will be inserted into your mouth, and gently passed through to the small intestine. The gastroenterologist will then pass a small biopsy tool through the endoscope which will take very small tissue samples from your small intestine. The biopsy samples will then be sent away to be examined under a microscope.

*Other tests*

If blood tests and biopsy results come back as positive for Coeliac Disease, your GP or gastroenterologist may also want to perform some additional tests to ascertain how much the condition has affected your health. These additional tests might include:-

– Blood tests to check for nutrient deficiencies such as iron or folate anaemia
– A skin biopsy if dermatitis herpetiformis is an issue
– Bone scans – if malabsorption has been an issue for a long period of time, it can cause bone density to be weaker than normal. A bone scan will check the strength of the bones and allow for treatment, if required.

**Post Diagnosis – What now?**

A diagnosis of Coeliac Disease can be very daunting, but, for some, can also be a relief. Knowing how to manage the symptoms you may have been experiencing for months, or even years, can provide some comfort.

The only treatment for Coeliac Disease is to follow a lifelong gluten free diet. Removing gluten from your diet should be attempted in conjunction with support from your healthcare professional team which may include a Dietitian.

A gluten-free diet is one that removes all sources of gluten including wheat, barley and rye. Foods such as semolina, durum, couscous and spelt all contain gluten and must be avoided. Some newly diagnosed Coeliac individuals are also advised to remove oats from the diet, however gluten-free oats do not cause a problem for most people. This should be discussed on a case by case basis to ensure you are getting the best advice. As a protein gluten is not an essential part of the diet and therefore can be replaced by other foods.

Naturally gluten free foods can be eaten freely, and these include:-

– Meat
– Vegetables
– Fruits
– Most dairy product including milk, cheese and butter
– Potatoes
– Rice

In addition, gluten-free versions of staple food ingredients are available on prescription and this should be discussed with your GP. Prescribable gluten free foods include flour, bread, breakfast cereals, pasta, pizza base mixes, crackers, crispbreads, cakes and biscuits although the product lists tends to change each year so your GP will be able to help with your requirements.

Gluten free products are also available to buy both in stores and online. By law foods can only be labelled as gluten free if they have less than 20 parts per million (ppm) of gluten. For most people this trace amount won’t cause any adverse effects, however for a small minority of people with Coeliac Disease they will have to avoid such products altogether and have a diet completely free of cereals.

The range of gluten free foods has increased extensively in recent years allowing more choice for people with Coeliac Disease. Any concerns over the suitability of a food for a gluten free diet should be discussed with your healthcare professional.

**Where to go for more advice?**

Diagnosis with Coeliac Disease can be daunting but there is good support available both from your local healthcare professional team but also through information organisations such as Coeliac UK (www.coeliac.org.uk). Their website contains a whole range of information on how to manage Coeliac Disease from symptoms to diagnosis, and how to eat gluten free.

Following a gluten free diet isn’t easy, so it’s important to get symptoms checked out by a doctor, and to secure the right advice. Today we thought we’d start at the beginning, and delve a bit deeper into the science of gluten.

**An Introduction to Gluten**

With gluten-free foods becoming more widely available, and the popularity of following gluten- free diets growing exponentially, there is no doubt that gluten is something that many people will have heard about – but what really is it? And why are people so keen to take it out of their diets?

In simple terms, gluten is a protein that is found in the cereals wheat, barley and rye. Meaning ‘glue’ from its Latin origin, this is exactly what gluten does in our food – it gives elasticity to dough, helping it to rise and to maintain a certain texture.

As an ingredient the two sub proteins of gluten – gliadin and glutenin – form strands which strengthen dough, and trap the air released from raising agents such as yeast. Gluten, through baking, stabilises the final structure of bread so it is an important ingredient for manufacturers. Gluten, on its own doesn’t enhance the flavour of a food – in fact, it has a chalky taste and can be quite stringy – a bit like a very ‘unsticky’ bubble gum! For the majority of people, including gluten within the diet will cause no adverse effect.

**Gluten in our food**

Gluten is naturally occurring in the cereals wheat, barley and rye, and because of this is found in many staple foods within our diet including:-

– Bread
– Pasta
– Cakes
– Breakfast cereals

Gluten may also be extracted and used as an added ingredient in other foods – either through the use of wheat derivatives, or as a single ingredient. In this form it may appear in other non-cereal based foods such as soy sauce, gravies and beer which may be more unexpected.

Although gluten, itself, isn’t classified as one of the 14 major allergens highlighted by the EU for labelling purposes, manufacturers do have to highlight the presence of cereals containing gluten on pre-packed foods. New legislation in the catering industry means that this information should also be readily available in any restaurant or café providing food and drink.

**Avoiding Gluten**

Around 1 in 100 people in the UK have been diagnosed with Coeliac Disease, and it is thought that this might just be the tip of the iceberg in terms of people who are either misdiagnosed with other conditions, or who remain undiagnosed. Coeliac Disease is a lifelong autoimmune disease caused by intolerance to gluten. For people with Coeliac Disease the only solution is to avoid gluten completely from the diet – going gluten-free is not a choice.

The gluten-free market is growing – with a reported 15% of households in the UK avoiding wheat and gluten (Mintel 2014), many of whom do so due to lifestyle choices rather than a medical reason. In addition 1 in 10 new food products launched in 2014 were gluten-free highlighting the expansion of this market.

For people with Coeliac Disease, the increase in gluten-free products is good news meaning more choice, and a heightened understanding of the requirements of a gluten-free diet. At the same time, the rise in people choosing a gluten-free diet for lifestyle reasons – less bloating, weight loss, detoxing, feeling less tired – may be having an effect on how seriously the needs of Coeliacs are taken.

For those with Coeliac Disease following a diet completely free from gluten is essential. Proper diagnosis is vital to ensure that the health and dietary needs of the individual are met – just removing gluten from the diet after symptoms can extend the time to diagnosis, and more importantly delay appropriate treatment, advice and recovery.