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FEATURE The rise of the gluten free diet What does this mean for Australian <strong>doctor</strong>s? While it is tempting to view the extraordinary rise in popularity of the gluten free diet as just a fascinating social phenomenon, there are important medical implications that should not be missed by <strong>doctor</strong>s at the front line of patient care. An astonishing 10% of Australians now remove wheat or gluten from their diet to some extent. While this is often a consequence of perceived adverse symptoms to eating gluten, the conviction it can help with weight loss, a range of diseases or is a ‘healthy’ lifestyle choice is frequently propagated by a number of non-medical sources, such as celebrities and enthusiastic proponents on social media. While a strict gluten free diet (GFD) is essential for the treatment of coeliac disease, an autoimmune illness caused by disordered immunity to gluten, there is little to support its role for other reasons outside anecdote. A clinically perverse aspect of this phenomenon is that the majority of Australians with coeliac disease – who have a compelling reason to follow a GFD – remain undiagnosed, while many of those following a GFD don’t have a medically supported reason to do so. As the accuracy of both serology and small intestinal histology required to diagnose coeliac disease require active gluten consumption, definitive diagnosis is a major challenge for the many Australians who have already removed dietary gluten. Clinicians need to be confident dealing with this increasingly common and frustrating challenge. Coeliac disease is one of Australia’s most common autoimmune illnesses, affecting 1 in 70 of the population, and its prevalence is increasing. Lack of awareness and its broad clinical presentation means that detection is poor, with only 20% of affected Australians diagnosed. Delayed diagnosis is concerning, as the immune-mediated inflammatory response to gluten is associated with nutrient deficiencies and a range of systemic complications including osteoporosis, other autoimmune disease (3-fold higher), and elevated mortality (2-4-fold higher), often due to sepsis or malignancies such as lymphoma. The negative impact on quality of life, education and work performance often goes unappreciated. A mean of 11 to 13 years from first presentation to diagnosis signifies missed opportunities to break the cycle of chronic symptoms that can generate healthcare costs comparable to those incurred by patients with diabetes. Diagnosing coeliac disease is the first critical step towards combating its burden on health, quality of life and resources. While population screening has its proponents, current guidelines recommend an active-case finding strategy – seeking those at higher-risk for screening serology. With casefinding applied in primary care 1:50-1:30 tests typically return a positive case of coeliac disease. Here the most frequent presentations are bloating, thyroid disease, ‘irritable bowel syndrome’, diarrhoea, chronic fatigue and constipation. Screening people with highrisk features such as first-degree relatives of patients with coeliac disease, type 1 diabetes and irritable bowel syndrome is important and cost-effective. An algorithm to guide the appropriate use of serology, HLA-DQ2/DQ8 genotyping, and gastroscopy is accessible here: www.coeliac.org.au/ health-professionals. A care plan and chronic disease management template can also be downloaded to guide the next critical step for GPs: systematic follow-up. Making a clear diagnosis of coeliac disease is often life-changing. Fortunately, a positive effect of the expanding market for gluten free foods is their improved palatability, affordability and availability, making the GFD as a medical treatment now more effective than ever for our patients. dr. Dr Jason Tye-Din is a guest speaker at the MJA Professional Development ‘Emerging Trends in Gastroenterology for GPs’ seminar in Melbourne on Saturday 12 March. Coeliac Awareness Week will be held 13-20 March. A video for GPs on the diagnosis and new facts sheets are available on www.coeliac.org.au/health-professionals/ 26 I THE NSW DOCTOR I MARCH/APRIL 2016
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