Studies show that there is reason to be sceptical about the significance of gluten in non-coeliac gluten sensitivity. It is now time to evaluate the right of patients with such symptoms to basic benefit.
The basic benefit scheme is intended for people who have unavoidable extra expenses due to long-term illness, injury or disability (1). In recent years, additional food expenses due to dietary restrictions have been the main reason for granting basic benefit according to a NAV report (2). A total of 74 % of new benefit recipients in the last three years were registered as having coeliac disease or other gluten sensitivity (2). This report does not indicate how many have non-coeliac gluten sensitivity. In contrast to coeliac disease and wheat allergy, this is a controversial diagnosis composed of several possible causal relationships and diagnostic challenges (3, 4).
The number of individuals on a gluten-free diet appears to be much higher than the estimated number of patients with coeliac disease, gluten ataxia, wheat allergy and non-coeliac gluten sensitivity (3–5). It is likely that the growth in the number of benefit recipients in the latter group is related to the increased interest in the media and the population at large in health and diet over the last few years, and not least the increased interest in a ‘healthy’ diet (2). A gluten-free diet seems to be becoming more and more established, especially in view of the fact that the alternative medicine industry is actively engaged in marketing this (5).
The National Insurance Act stipulates that the necessity for a special diet for the diagnosis in question must be scientifically documented and generally accepted in medical practice (1). Furthermore, NAV’s circular states that in the case of confirmed non-coeliac gluten sensitivity or gluten intolerance, the treatment prescribed will be the same as for coeliac disease – a gluten-free diet. Basic benefit is granted without an individual assessment of the associated expenses in line with the rates given in the coeliac disease table (1). This practical approach seems sensible since the treatment is the same, i.e. a gluten-free diet. However, there is debate as to whether there is scientific proof and general acceptance for following a gluten-free diet in the case of non-coeliac gluten sensitivity (3, 4).
From 2003 onwards, scientific proof of the necessity for a special diet for the diagnosis in question has been required (1, 2). In recent years, the significance of gluten in the case of non-coeliac gluten sensitivity has been the subject of evidence-based scepticism. It is open to question whether it is gluten or other food components that give rise to this condition (3–5).
An Australian study shows no clear association between the intake of gluten and the participants’ gastrointestinal problems
Several reputable clinical studies, mostly of adults, indicate that fermentable carbohydrates (FODMAPs) are the cause of irritable bowel symptoms in patients with self-reported non-coeliac gluten sensitivity (6–8). An Australian study shows no clear association between the intake of gluten and the participants’ gastrointestinal problems (6). In this randomised, double-blind, placebo-controlled study, symptoms following the intake of a placebo and the intake of gluten were generally the same. Similar findings were reported in a Norwegian study in which the majority of patients with suspected non-coeliac gluten sensitivity were unable to identify in a double-blind, placebo-controlled provocation test when the test involved a gluten challenge, thus indicating that gluten was not the cause of their symptoms (7).
Another randomised crossover study showed that fructans, which are part of the FODMAP group, appear to induce symptoms in individuals with self-reported non-coeliac gluten sensitivity (8). In light of fresh knowledge, patients with self-reported non-coeliac gluten sensitivity should presumably start avoiding FODMAP foodstuffs.
Gluten provocation test
The legislation stipulates that specialist assessment and a controlled provocation test are therefore essential to determine the diagnosis (1). The reason is that laboratory tests cannot confirm non-coeliac gluten sensitivity. Double-blind, placebo-controlled provocation with gluten is the gold standard for diagnosing non-coeliac gluten sensitivity (3–8). Nevertheless, provocation tests are conducted less frequently than is desirable (9) and in a less satisfactory manner (2–5). An erroneous diagnosis will mean that the patient will experience physical effects in the form of nutritional deficiencies caused by a gluten-free diet, and psychological effects in the form of being labelled as ‘sick’ when this is not the case (4).
It is a well-known fact that gluten plays a key role in coeliac disease and wheat allergy. However, randomised, double-blind, placebo-controlled trials provide little proof that gluten-containing food induces symptoms in individuals with non-coeliac gluten sensitivity. Fresh knowledge acquired over recent decades may perhaps justify a reassessment of the basic benefit scheme for those with this condition.