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Introduction
The global population has more than doubled over the past 40 years, supported by the ‘green revolution’ in agriculture producing high-yield grain varieties, including wheat, that are central to the modern diet.1 Wheat covers more than 200 million hectares of land,2 is the third most produced cereal behind rice and maize,3 and is responsible for one-fifth of the world’s calorific input.2 Wheat contains gluten proteins, predominantly made of equal parts of glutenins and gliadins, which are resistant to digestion, and their partially digested epitopes are immunogenic and central to the process that leads to coeliac disease,3 4 an autoimmune condition characterised by an aberrant immune response to ingested gluten in genetically susceptible individuals, which results in small bowel inflammation, enteropathy and potential malabsorption.5 The prevalence of coeliac disease in the past 50 years has risen to approximately 0.7%–2%, a phenomenon attributed to increased awareness and detection, as well as a true increase in prevalence.6 7 The sole and current only curative treatment, a lifelong gluten-free diet, considered central to the management of coeliac disease has also seen increasing popularity in the general population; there is a widespread underlying belief that a gluten-free diet may be ‘healthier’, despite a lack of evidence to support this notion and even evidence that it may be harmful to the non-coeliac population.8 This has seen the gluten-free food industry boom to an estimated US$6 billion per year industry.5
Non-coeliac gluten sensitivity: the current paradigm
Gluten, or more generally wheat, has also been associated with other GI disease. In the absence of coeliac disease and under the guise of the increasingly fashionable but controversial label ‘non-coeliac gluten/wheat sensitivity’ (NCG/WS), gluten has been popularised in the press as a potential cause of almost all possible conceivable physiological complaints, ranging from GI to neurological, dermatological, psychological and musculoskeletal …
Footnotes
Contributors All authors contributed to the review of literature and preparation of manuscript and figures.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests MMW: grant/research support: Prometheus Laboratories Inc (Irritable bowel syndrome (IBS Diagnostic), Commonwealth Diagnostics International (Biomarkers for FGIDs). SK: grant/research support: Cancer Institute NSW (Career Development Fellowship), National Health and Medical Research Council (Project Grant APP1128487) Commonwealth Diagnostics International (Biomarkers for FGIDs), Syntrix Biosystems (contract research, drug delivery). NJT: grant/research support: Rome Foundation; Abbott Pharmaceuticals; Datapharm; Pfizer; Salix (Irritable bowel syndrome); Prometheus Laboratories Inc (Irritable bowel syndrome (IBS Diagnostic)); Commonwealth Diagnostics International (Biomarkers for FGIDs); Janssen (Constipation). Consultant/Advisory Boards: Adelphi Values (Functional dyspepsia (patient-reported outcome measures)); GI therapies (Chronic constipation (Rhythm IC)); Allergens PLC; Napo Pharmaceutical; Outpost Medicine; Samsung Bioepis; Yuhan (IBS); Synergy (IBS); Theravance (Gastroparesis); IM Health Sciences (dyspepsia). Patent Holder: Biomarkers of irritable bowel syndrome, Licensing Questionnaires (Mayo Clinic Talley Bowel Disease Questionnaire, Mayo Dysphagia Questionnaire); Nestec European Patent (Application No. 12735358.9); Singapore ‘Provisional’ Patent (NTU Ref: TD/129/17 ‘Microbiota Modulation of BDNF Tissue Repair Pathway’).
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Provenance and peer review Commissioned; internally peer reviewed.