Do you need to exclude gluten when you have IBD?

Gluten is a common topic that comes up in our clinic. We often get asked “Do I need to remove gluten for my IBD?”. The short answer is generally no but lets look into this further…..

What is gluten?

Gluten is a general name for the proteins found in wheat, rye, and barley. Gluten helps foods maintain their shape, acting as a glue that holds food together. Gluten can be found in many types of foods, even ones that would not be expected such as soy sauce and some processed meats.

Some common foods that contain gluten

  • Wheat

  • Barley

  • Rye

  • Spelt

  • Wheat pasta (white and wholegrain)

  • Bread

  • Cakes

  • Biscuits

  • Many breakfast cereals

  • Many sauces and marinades (including gravy)

  • Some flavourings

  • Many ready meals

  • Some sausages and other processed meats

  • Baking powder (if it uses wheat starch)

  • Some readymade soups

  • Some salad dressings

  • Soy sauce

  • Beer

Problems with wheat and gluten

  • Coeliac disease - this affects around 1% of the population and is an autoimmune condition where the immune system attacks and damages the lining of the small intestine when gluten is eaten. It is possible to have IBD and Coeliac disease together. Having Crohns or Ulcerative Colitis may slightly increase a persons risk of developing coeliac disease (1). The prevalence of coeliac disease is higher in people with Microscopic Colitis and coeliac disease should always been screened for in these patients (2).

  • Wheat allergy - an allergic reaction to foods containing wheat. If someone with a wheat allergy eats wheat a reaction usually happens within minutes. The person may experience symptoms including swelling, itching or irritation of the mouth or throat, hives, headache, difficulty breathing, cramps, nausea or vomiting and sometimes anaphylaxis.

  • Gluten intolerance/non coeliac gluten sensitivity (NCGS) – intolerance and NCGS is less clear cut and there is some controversy around their existence. NCGS is generally defined as a “clinical entity induced by the ingestion of wheat leading to intestinal and/or extraintestinal symptoms that improve once the wheat-containing foodstuff is removed from the diet, and celiac disease and wheat allergy have been excluded”. There is some argument and evidence to suggest that it is not the gluten in wheat products that can cause gastrointestinal symptoms like bloating but instead something called fructans. Gluten-containing foods also contain fructans, a type of carbohydrate that falls into the FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) category. Reducing FODMAP containing foods has been shown to improve gastrointestinal symptoms in IBS.

We can test for coeliac disease and wheat allergy but currently there is no evidence-based way to test for gluten intolerance/NCGS.


Gluten and IBD

Statistics show that a gluten free diet is tried by around 20% of patients with IBD (without coeliac disease). A study of 1,647 people with IBD which asked patients, through a questionnaire, about their experience of a gluten free diet, found that 65.6% of people who attempted a gluten-free diet, described an improvement of their gastrointestinal symptoms and 38.3% reported fewer or less severe flare-ups between periods of remission (3). However, there have been no prospective studies looking at the role of gluten in the induction and maintenance of IBD so currently the data we have does not support the universal use of a gluten free diet in IBD (4, 5). In fact, research in healthy adults has shown that unnecessary removal of gluten may have a negative impact on microbial diversity which may have a negative impact on our gut health (6).


What to do

If you think you may experience symptoms when eating gluten containing foods the first and most important thing to do is to be tested for Coeliac Disease.

Anyone who suspects they have an issue with gluten should first get tested for coeliac disease, which is a blood test that can be done via your GP/IBD team. This must be done before attempting to remove gluten from the diet because, for a coeliac blood test to be accurate, the person must have been exposed to gluten for at least 2-4 weeks prior to the test. 1.5 slices of bread or equivalent (3g of gluten) should be consumed every day for 2 weeks or more in the lead up to the test (7). It is important to determine whether you have coeliac disease or not as this will determine how strict you would need to be on a gluten free diet.

If this comes back negative, there are still some really important things to consider before removing gluten;

  1. Going gluten free might not be necessary – if you are experiencing symptoms when eating gluten containing foods we may be able to adapt these foods to help you tolerate them better, avoiding the need to remove gluten completely.

  2. Gluten free is not always healthy - many processed gluten-free products can contain higher levels of trans fat and additives, compared to gluten-containing foods, which may have a negative impact on our health and gut health so just switching over to these may not be beneficial to our health.

  3. Gluten free products can be expensive – if you opt for lots of gluten free alternative products this can make the weekly shop more expensive so its important to get guidance on how to best follow a gluten free diet so its better for your health and your wallet!

  4. Restrictive diets can decrease quality of life in IBD – gluten is found is so many everyday foods and removing it may reduce our food related quality of life (which research shows is already low in people with IBD and gets lower the more restrictive our diet is). This can cause unnecessary stress and anxiety which we know has a negative impact on our IBD (read more about that here).

  5. Get help - you should only remove gluten under the guidance of a qualified nutrition professional as there are risks associated with a gluten free diet including an increased nutrient deficiency risk, and a reduced fibre intake which may have a negative impact on the health of our gut microbes.

If you want support with your diet, nutrition and IBD journey we can help.

At The NALM Clinic we have me (Clemmie), an IBD specialist Nutritional Therapist, and specialist gastroenterology Dietician (Jess) and and we are here to support you. We both have IBD too so we ‘get it’ and are so passionate about helping others.

If you would like support with your IBD please book a call with me via the button below.

I have also written a free e-book to help you find a way forward for your everyday life with Inflammatory Bowel Disease. Whether you are right at the beginning of your journey with IBD or have been living with your condition for years and feel like you have tried almost everything, there are things you can do everyday, beyond the medication you are taking, to help you take back control.

Disclaimer: All content found on the nalmclinic.com website, including: text, video, or other formats have been created for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor, consultant or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

We are all wonderfully unique and what works for one person may not work for another so please seek help and advice before changing your diet to work out the right way forward for you.

References

1.       Shah A, Walker M, Burger D, Martin N, von Wulffen M, Koloski N, Jones M, Talley NJ, Holtmann GJ. Link Between Celiac Disease and Inflammatory Bowel Disease. J Clin Gastroenterol. 2019 Aug;53(7):514-522. doi: 10.1097/MCG.0000000000001033. PMID: 29762265.

2.       Nimri FM, Muhanna A, Almomani Z, Khazaaleh S, Alomari M, Almomani L, Likhitsup A. The association between microscopic colitis and celiac disease: a systematic review and meta-analysis. Ann Gastroenterol. 2022 May-Jun;35(3):281-289. doi: 10.20524/aog.2022.0714. Epub 2022 Apr 8. PMID: 35599929; PMCID: PMC9062845.

3.       Herfarth HH, Martin CF, Sandler RS, Kappelman MD, Long MD. Prevalence of a gluten-free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases. Inflamm Bowel Dis. 2014 Jul;20(7):1194-7. doi: 10.1097/MIB.0000000000000077. PMID: 24865778; PMCID: PMC4331053.

4.       Weaver KN, Herfarth H. Gluten-Free Diet in IBD: Time for a Recommendation? Mol Nutr Food Res. 2021 Mar;65(5):e1901274. doi: 10.1002/mnfr.201901274. Epub 2020 Jun 28. PMID: 32558265.

5.       Sasson AN, Ingram RJM, Zhang Z, Taylor LM, Ananthakrishnan AN, Kaplan GG, Ng SC, Ghosh S, Raman M. The role of precision nutrition in the modulation of microbial composition and function in people with inflammatory bowel disease. Lancet Gastroenterol Hepatol. 2021 Sep;6(9):754-769. doi: 10.1016/S2468-1253(21)00097-2. Epub 2021 Jul 14. PMID: 34270915.

6.       Hansen, L.B.S., Roager, H.M., Søndertoft, N.B. et al. A low-gluten diet induces changes in the intestinal microbiome of healthy Danish adults. Nat Commun 9, 4630 (2018). https://doi.org/10.1038/s41467-018-07019-x

7.       https://www.celiac.ca/healthcare-professionals/diagnosis/gluten-challenge/

 

Clemmie Macpherson