Coeliac Awareness Week 2018

Coeliac disease is an autoimmune condition where the consumption of gluten (found in wheat, barley and rye) triggers the immune system to react and damage the lining of the small intestine. This lining, which is made-up of tiny finger-shaped projections called villi, becomes inflamed and flattened if sufferers of coeliac disease eat gluten. The damage caused decreases the surface area of the villi, causes much pain and discomfort for the sufferer, and reduces the ability of the small bowel to absorb nutrients from food properly.

Coeliac disease is often unrecognised and consequently under diagnosed. It is estimated that half a million people in the UK are currently suffering from coeliac disease, but are unaware of what is causing their symptoms. Coeliac UK – the UK’s main charity for coeliac patients – has reported that on average it takes 13 years for someone in the UK to be diagnosed with coeliac disease, as symptoms are commonly mistaken for other conditions, such as Irritable Bowel Syndrome (IBS).

Gluten-free foods on prescription

Prescriptions for gluten-free foods have been around since the 1960's for those who are clinically diagnosed with coeliac disease. Since then, gluten-free foods in retail have become more widely available. This led to a three month National Consultation from the Department of Health and Social Care back in March 2017 looking at the availability of gluten-free foods on prescription in primary care.

On 1 February 2018, after a through assessment of the consultation responses from a range of clinicians, patients and professional bodies, a comprehensive impact assessment and a fully costed QALY assessment,it was announced that gluten-free foods should be available for patients clinically diagnosed with coeliac disease, however these should be restricted to staple gluten-free breads and flour mixes.

The importance of a gluten-free prescription

Nutritional contribution

Gluten is found in many of the staple cereal products in the UK diet, such as bread, flour and pasta, as well as less obvious sources of gluten in the diet, such as processed foods. The National Prescribing Guidelines (NPG) for gluten-free products[1]recommend that patients with coeliac disease eat a balanced diet, which includes naturally gluten-free staple foods as well as gluten-free specialist staple foods.

Whilst patients are encouraged to consume naturally gluten-free foods such as rice and potatoes, it is not always realistic or convenient to base the diet solely on these.[2]The inclusion of gluten-free staple products, as part of a gluten-free diet, facilitates dietary modification and helps to ensure dietary balance, variety and nutritional adequacy. Cereals and cereal products, including gluten-containing cereals, make an important nutritional contribution to the UK diet. Starchy carbohydrates are the main source of energy and fibre in the UK diet and are also an important source of key micronutrients for this patient group; providing 53-55% of total iron intake for under 18’s and 39% for adults aged 19 years and over, and 24-37% of total calcium intake for under 18’s and 29-31% for adults aged 19 years and over.[3]Bread, in particular, plays an important nutritional role, providing more than 10% of iron and one fifth of dietary fibre and calcium intakes.[4]

Adherence

Following a strict gluten-free diet is challenging for patients and this provides some explanation as to why adherence rates in this patient group vary between 42-91%.[5] A serious consequence of poorly managed coeliac disease is intentional gluten consumption. Intentional gluten consumption has been shown to be significantly lower in those receiving gluten-free products on prescription.[6] Access to these products to support dietary adherence is also recognised in the NICE Clinical Knowledge Summary for coeliac disease.[7]

Long-term complications associated with non-adherence include to osteoporosis, iron deficiency anaemia, ulcerative jejunitis, malignancy (intestinal lymphoma), functional hyposplenism and vitamin D deficiency.[8] For children, non-adherence can also result in complications such as faltering growth and delayed puberty.[9] An annual review should be offered to assess adherence to treatment, symptom resolution and allow for monitoring of emerging long-term complications associated with coeliac disease.[10]

Evidence for adherence is further supported by research published last year which reported that a significantly higher proportion of patients adhere to a gluten-free diet when receiving a prescription for gluten-free foods, compared with those who did not.[11]

Access andavailability

Access to staple gluten-free foods is a vital part of successfully managing a gluten-free diet, and whilst gluten-free foods are more readily available than ever before, supermarket business models are moving towards smaller store formats carrying more limited ranges. A recent high-street survey of gluten-free food availability found that 40% of stores had no offering and patients expressed concerns on having to rely solely on retail product availability.[12]In contrast, a prescription guarantees a supply of staple gluten-free foods through every pharmacy, ensuring every coeliac patient is able to receive a foundation of nutritional support regardless of locality or socio-economic status.

The Department of Health and Social Care took all these factors into consideration and found that providing a staple supply of bread and flour mixes on prescriptionto those clinically diagnosed was the best outcome, as not only would it deliver savings to the NHS but it would also help to increase adherence and also mitigate the risk that those on lower incomes or had accessibility issues would not be able to purchase gluten-free foods, where price is often higher and availability more limited.

Coeliac Awareness Week

BSNA supports Coeliac Awareness Week 2018 and ensuring all patients with coeliac disease have access to a prescription to help them manage their lifelong condition.

Coeliac Awareness Weekis 14 to 20 May 2018.More information about the campaign can be found onCoeliac UK's websiteor on Twitter:@Coeliac_UK#CoeliacAwarenessWeek

References

[1]Coeliac UK.Gluten-Free Foods: a revised prescribing guide.2011.https://www.coeliac.org.uk/doc...Last accessed: April 2018

[2] British Dietetic Association (BDA).Policy Statement: Gluten-Free Food on Prescription. September 2015. www.bda.uk.com/improvinghealth/healthprofessionals/policy_statement_gluten_free_food_on_prescription Last accessed: April 2018

[3]National Diet and Nutrition Survey. Results from Years 1-4 (combined) of the Rolling Programme (2008/2009 – 2011/12) REVISED FEBRUARY 2017

[4]O’Conner A. An overview of the role of bread in the UK diet. Nutrition Bulletin, 2012; 37 (3): 193-212

[5] Hall NJ et al.Systematic review: adherence to a gluten-free diet in adult patients with coeliac disease.Aliment Pharmacol Ther, 2009; 30(4): 315-30

[6]Hall NJ et al. Intentional and inadvertent non-adherence in adult coeliac disease. A cross-sectional survey.Appetite, 2013; 68: 56-62

[7]NICE Clinical Knowledge Summary (CKS). Coeliac Disease. March 2016. https://cks.nice.org.uk/coeliac-disease#!scenario. Last accessed April 2018

[8]NICE. NG20. Coeliac Disease: recognition, assessment and management.2015

[9]Murch S et al.Joint BSPGHAN and Coeliac UK guidelines for the diagnosis and management of coeliac disease in children.Arch Dis Child, 2013 98(10): 806-11

[10]NICE. Quality Standard 134.Coeliac Disease QS134. October 2016

[11]Muhammad, H.; Reeves, S.; Ishaq, S.; Mayberry, J.; Jeanes, Y.M. Adherence to a Gluten Free Diet Is Associated with Receiving Gluten Free Foods on Prescription and Understanding Food Labelling.Nutrients.2017.9; 705. -http://www.mdpi.com/2072-6643/...

[12]BSNA Ltd. BSNA Survey: Department of Health Consultation: The availability of gluten-free foods on prescription. 2017.