Celiac disease and wheat allergy: how to distinguish between the two diseases

Coeliac disease and wheat allergy are two distinct diseases that are wrongly associated, in some cases causing alarm among the population. All too often, when even fatal accidents occur to allergic patients, the diseases are confused: only a widespread and correct knowledge of these pathologies can guarantee the protection of the health of patients who, although in different ways, are equally exposed to very serious risks and complications. In addition, it is important that food business operators, especially restaurateurs, are also adequately trained on how to handle the reception of a coeliac or allergic person.

Coeliac disease is a chronic inflammation of the small intestine triggered by the ingestion of gluten in genetically predisposed individuals and is characterised by a highly variable clinical picture ranging from profuse diarrhoea with marked weight loss, to extra-intestinal symptoms, to association with other autoimmune diseases. Wheat allergy is a different pathological condition that can be triggered by a complex of wheat molecules even other than gluten, and involves response times and reactions quite distinct from those of coeliac disease, including rash and anaphylactic shock. In coeliac disease, the gluten exposure capable of activating the disease is in the intestine, so a coeliac can only develop symptoms of the disease by consuming gluten with food, whereas the pathways for triggering wheat allergy also include the respiratory system, skin and mucous membranes. The pathogenetic mechanism of coeliac disease is also different from that of food allergies, so the ingestion of gluten in coeliacs does not cause anaphylactic shock. In fact, coeliac disease has a toxic effect of gluten that is triggered and amplified by continuous and prolonged exposure, even to very small doses, unlike allergies, where a single exposure, even to very small doses, of wheat may be enough to lead to the trigger mechanism of the allergic reaction.

Next to correct information and education, a key issue when it comes to coeliac disease and wheat allergy is the labelling of food, in particular food allergens. The current European Union legislation on precautionary labelling of allergens (Article 36 of Regulation 1169/2011) is in fact still incomplete, as the necessary implementing acts to regulate its use have never been issued: today, the wording "May contain..." is subject to different interpretations, with great uncertainty for consumers.

It is therefore absolutely necessary that the Italian and European institutions commit themselves to adopting clear and reliable rules for food labels with the regulation of the precautionary writing of Pal allergens: the objective is that the writing should be part of the mandatory information on labels, based on the quantitative and qualitative risk management of allergens. Both Associations, through their European federations, are contributing to the ongoing work of the Codex Alimentarius (FAO's internal body, competent for the subject), the results of which are awaited by the European Commission to take action to complete the regulations.

While waiting for institutional interventions, the two associations, inspired by the principle of utmost caution, have defined specific recommendations to protect the health of coeliac and allergic patients: The Italian Coeliac Disease Association advises coeliac sufferers to always rely on the wording 'gluten-free' for food products and beverages that may contain gluten. This wording, designed especially for coeliacs, guarantees by law (EU Regulation 828/2014) compliance with the maximum gluten threshold allowed for them (20ppm, i.e. 20 mg per kg). This wording is not intended for wheat allergy sufferers and should not be sought in foods that are naturally gluten-free and for which the regulation itself prohibits its use, as it could be misleading and confusing for patient-consumers.