JANE VARNEY, JANE MUIR
Monash University, Department of Gastroenterology, Melbourne, Australia

Abstract

The gluten free diet has surged in popularity in recent years, and none more so than among people without conditions for which the diet is clinically indicated. Despite the many and varied motivations for gluten avoidance, most remain scientifically unfounded and the phenomenon of non-coeliac gluten sensitivity (NCGS) remains shrouded in controversy. Instead, mounting evidence suggests that in the majority of cases, symptomatic responses to gluten ingestion and/or gluten removal are attributable to the presence of undiagnosed coeliac disease; strong nocebo responses; and/or the incidental removal of a group of fermentable carbohydrates (known as FODMAPs) in people with co-existing (possibly undiagnosed) functional gastrointestinal disorders (FGIDs). This evidence is gaining traction in the scientific literature and lay press, leading to growing awareness of- and interest in the low FODMAP diet. 

As awareness of the low FODMAP diet grows, it will be responsibility of scientists, clinicians and food industry professionals to translate the science of FODMAPs in a responsible way; to balance commercial interests with clinical best practice. Widespread uptake of the low FODMAP diet and availability of low FODMAP food products will only be seen as a win if this is coupled with appropriate diagnosis and management of conditions for which the diet is clinically indicated. The challenge will be to ensure that the low FODMAP diet does not suffer the same fate as the gluten free diet; that the diet is used, but not abused.

BACKGROUND / HISTORICAL CONTEXT

Wheat cultivation first emerged over 10,000 years ago, and cereal grains have long since been staple components of the human diet (1). Nowadays, grain and cereal products (particularly those based on wheat) make major contributions to daily energy intake (2, 3). However, this scenario appears to be changing, with declines in human wheat consumption observed in many developed nations. In the US for instance, per capita wheat consumption declined from a peak of 67kg per capita in 1997, to 60kg per capita in 2015 (4). This trend is predicted to continue, driven in part by popular dietary trends that restrict intake of carbohydrates (e.g. the Atkins diet), grains (e.g. the Paleolithic diet), and increasingly, wheat and/or gluten (5).

Diagnoses that require the dietary restriction/removal of wheat and/or gluten

Uptake of gluten and/or wheat free diets has been substantial in recent years, and none more so than among people without an identifiable clinical need. A finite number of clinical disorders require the dietary restriction of gluten and/or wheat, namely coeliac disease (CD) and wheat allergy ...