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A gluten-free diet (GFD) is a nutritional plan that strictly excludes gluten, which is a mixture of prolamin proteins found in wheat (and all of its species and hybrids, such as spelt, kamut, and triticale), as well as barley, rye, and oats.^[1] The inclusion of oats in a gluten-free diet remains controversial, and may depend on the oat cultivar and the frequent cross-contamination with other gluten-containing cereals.^[2]^[3]^[4]^[5]

Gluten may cause both gastrointestinal and systemic symptoms for those with gluten-related disorders, including coeliac disease (CD), non-coeliac gluten sensitivity (NCGS), gluten ataxia, dermatitis herpetiformis (DH), and wheat allergy.^[6] In these people, the gluten-free diet is demonstrated as an effective treatment,^[7]^[8]^[9] but several studies show that about 79% of the people with coeliac disease have an incomplete recovery of the small bowel, despite a strict gluten-free diet.^[10] This is mainly caused by inadvertent ingestion of gluten.^[10] People with a poor understanding of a gluten-free diet often believe that they are strictly following the diet, but are making regular errors.^[10]^[11]

In addition, a gluten-free diet may, in at least some cases, improve gastrointestinal or systemic symptoms in diseases like irritable bowel syndrome, rheumatoid arthritis, or HIV enteropathy, among others.^[12] There is no good evidence that gluten-free diets are an alternative medical treatment for people with autism.^[13]^[14]^[15]

Gluten proteins have low nutritional and biological value and the grains that contain gluten are not essential in the human diet.^[16] However, an unbalanced selection of food and an incorrect choice of gluten-free replacement products may lead to nutritional deficiencies. Replacing flour from wheat or other gluten-containing cereals with gluten-free flours in commercial products may lead to a lower intake of important nutrients, such as iron and B vitamins. Some gluten-free commercial replacement products are not as enriched or fortified as their gluten-containing counterparts, and often have greater lipid/carbohydrate content. Children especially often over-consume these products, such as snacks and biscuits. Nutritional complications can be prevented by a correct dietary education.^[4]

A gluten-free diet may be based on gluten-free foods, such as meat, fish, eggs, milk and dairy products, legumes, nuts, fruits, vegetables, potatoes, rice, and corn.^[17] Gluten-free processed foods may be used.^[4] Pseudocereals (quinoa, amaranth, and buckwheat) and some minor cereals have been found to be suitable alternative choices that can provide adequate nutrition.^[18]

Rationale behind adoption of the diet

Coeliac disease

Coeliac disease (American English: celiac) (CD) is a chronic, immune-mediated, and mainly intestinal process, that appears in genetically predisposed people of all ages. It is caused by the ingestion of gluten, which is present in wheat, barley, rye and derivatives. Coeliac disease is not only a gastrointestinal disease, because it may affect several organs and cause an extensive variety of non-gastrointestinal symptoms, and most importantly, it may often be completely asymptomatic. Added difficulties for diagnosis are the fact that serological markers (anti-tissue transglutaminase [TG2]) are not always present,^[25] and many people with coeliac may have minor mucosal lesions, without atrophy of the intestinal villi.^[26]

Coeliac disease affects approximately 1–2% of the general population all over the world^[27] and is on the increase,^[28] but most cases remain unrecognized, undiagnosed and untreated, exposing patients to the risk of long-term complications.^[29]^[30] People may develop severe disease symptoms and be subjected to extensive investigations for many years before a proper diagnosis is achieved.^[31] Untreated coeliac disease may cause malabsorption, reduced quality of life, iron deficiency, osteoporosis, obstetric complications (stillbirth, intrauterine growth restriction, preterm birth, low birthweight, and small for gestational age),^[32] an increased risk of intestinal lymphomas and greater mortality.^[33] Coeliac disease is associated with some autoimmune diseases, such as diabetes mellitus type 1, thyroiditis,^[27] gluten ataxia, psoriasis, vitiligo, autoimmune hepatitis, dermatitis herpetiformis, primary sclerosing cholangitis, and more.^[27]

Coeliac disease with "classic symptoms", which include gastrointestinal manifestations such as chronic diarrhea and abdominal distention, malabsorption, loss of appetite, and impaired growth, is currently the least common presentation of the disease and affects predominantly small children generally younger than two years of age.^[29]^[31]

Coeliac disease with "non-classic symptoms" is the most common clinical type and occurs in older children (over two years old), adolescents and adults.^[31] It is characterized by milder or even absent gastrointestinal symptoms and a wide spectrum of non-intestinal manifestations that can involve any organ of the body, and very frequently may be completely asymptomatic^[29] both in children (at least in 43% of the cases^[34]) and adults.^[29]

Following a lifelong gluten-free diet is the only medically accepted treatment for people with coeliac disease.^[16]^[35]

Non-coeliac gluten sensitivity

Non-coeliac gluten sensitivity (NCGS) is described as a condition of multiple symptoms that improves when switching to a gluten-free diet, after coeliac disease and wheat allergy are excluded.^[36]^[37] People with NCGS may develop gastrointestinal symptoms, which resemble those of irritable bowel syndrome (IBS)^[38]^[39] or a variety of nongastrointestinal symptoms.^[21]^[40]^[41]

Gastrointestinal symptoms may include any of the following: abdominal pain, bloating, bowel habit abnormalities (either diarrhea or constipation),^[21]^[41] nausea, aerophagia, gastroesophageal reflux disease, and aphthous stomatitis.^[40]^[41] A range of extra-intestinal symptoms, said to be the only manifestation of NCGS in the absence of gastrointestinal symptoms,^[21]^[40]^[41] have been suggested, but remain controversial.^[33]^[42] These include: headache, migraine, "brain fog", fatigue, fibromyalgia,^[42]^[43] joint and muscle pain, leg or arm numbness, tingling of the extremities, dermatitis (eczema or skin rash), atopic disorders such as asthma, rhinitis, other allergies, depression, anxiety, iron-deficiency anemia, folate deficiency or autoimmune diseases.^[21]^[40]^[41]^[42] NCGS has also been controversially implicated in some neuropsychiatric disorders, including schizophrenia, eating disorders, autism, peripheral neuropathy, ataxia and attention deficit hyperactivity disorder (ADHD).^[21]^[33]^[40]^[41]^[42] Above 20% of people with NCGS have IgE-mediated allergy to one or more inhalants, foods or metals, among which most common are mites, graminaceae, parietaria, cat or dog hair, shellfish and nickel.^[21] Approximately, 35% of people with NCGS have other food intolerances, mainly lactose intolerance.^[42]

The pathogenesis of NCGS is not yet well understood. For this reason, it is a controversial syndrome^[34] and some authors still question it.^[44] There is evidence that not only gliadin (the main cytotoxic antigen of gluten), but also other proteins named ATIs which are present in gluten-containing cereals (wheat, rye, barley, and their derivatives) may have a role in the development of symptoms. ATIs are potent activators of the innate immune system.^[40]^[45] FODMAPs, especially fructans, are present in small amounts in gluten-containing grains and have been identified as a possible cause of some gastrointestinal symptoms in persons with NCGS.^[40]^[46]^[45]^[47] As of 2019, reviews have concluded that although FODMAPs may play a role in NCGS, they only explain certain gastrointestinal symptoms, such as bloating, but not the extra-digestive symptoms that people with NCGS may develop, such as neurological disorders, fibromyalgia, psychological disturbances, and dermatitis.^[45]^[48]^[40]

After exclusion of coeliac disease and wheat allergy,^[49] the subsequent step for diagnosis and treatment of NCGS is to start a strict gluten-free diet to assess if symptoms improve or resolve completely. This may occur within days to weeks of starting a GFD, but improvement may also be due to a non-specific, placebo response.^[50] Recommendations may resemble those for coeliac disease, for the diet to be strict and maintained, with no transgression.^[21] The degree of gluten cross contamination tolerated by people with NCGS is not clear but there is some evidence that they can present with symptoms even after consumption of small amounts.^[21] It is not yet known whether NCGS is a permanent or a transient condition.^[21]^[34] A trial of gluten reintroduction to observe any reaction after one–two years of strict gluten-free diet might be performed.^[21]

A subgroup of people with NCGS may not improve by eating commercially available gluten-free products, which are usually rich of preservatives and additives, because chemical additives (such as sulphites, glutamates, nitrates and benzoates) might have a role in evoking functional gastrointestinal symptoms of NCGS. These people may benefit from a diet with a low content of preservatives and additives.^[46]

NCGS, which is possibly immune-mediated, now appears to be more common than coeliac disease,^[51] with prevalence rates between 0.5 and 13% in the general population.^[52]

Wheat allergy

People can also experience adverse effects of wheat as result of a wheat allergy.^[53] Gastrointestinal symptoms of wheat allergy are similar to those of coeliac disease and non-coeliac gluten sensitivity, but there is a different interval between exposure to wheat and onset of symptoms. Other symptoms such as dermal reactions like as rashes or hyperpigmentation may also occur in some people. Wheat allergy has a fast onset (from minutes to hours) after the consumption of food containing wheat and could be anaphylaxis.^[25]^[54]

The management of wheat allergy consists of complete withdrawal of any food containing wheat and other gluten-containing cereals.^[8]^[54] Nevertheless, some people with wheat allergy can tolerate barley, rye or oats.^[55]

Gluten ataxia

A male with gluten ataxia: previous situation and evolution after three months of gluten-free diet.

Gluten ataxia is an autoimmune disease triggered by the ingestion of gluten.^[56] With gluten ataxia, damage takes place in the cerebellum, the balance center of the brain that controls coordination and complex movements like walking, speaking and swallowing, with loss of Purkinje cells. People with gluten ataxia usually present gait abnormality or incoordination and tremor of the upper limbs. Gaze-evoked nystagmus and other ocular signs of cerebellar dysfunction are common. Myoclonus, palatal tremor, and opsoclonus-myoclonus may also appear.^[57]

Early diagnosis and treatment with a gluten-free diet can improve ataxia and prevent its progression. The effectiveness of the treatment depends on the elapsed time from the onset of the ataxia until diagnosis, because the death of neurons in the cerebellum as a result of gluten exposure is irreversible.^[57]^[58]

Gluten ataxia accounts for 40% of ataxias of unknown origin and 15% of all ataxias.^[57]^[59] Less than 10% of people with gluten ataxia present any gastrointestinal symptom, yet about 40% have intestinal damage.^[57]

As a popular diet

Since the beginning of the 21st century, the gluten-free diet has become the most popular fad diet in the United States and other countries.^[40] Clinicians worldwide have been challenged by an increasing number of people who do not have coeliac disease nor wheat allergy, with digestive or extra-digestive symptoms which improved removing wheat/gluten from the diet. Many of these persons began a gluten-free diet on their own, without having been previously evaluated.^[60]^[33] Another reason that contributed to this trend was the publication of several books that demonize gluten and point to it as a cause of type 2 diabetes, weight gain and obesity, and a broad list of diseases ranging from depression and anxiety to arthritis and autism.^[61]^[62] The book that has had the most impact is Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar—Your Brain's Silent Killers, by the American neurologist David Perlmutter, published in September 2013.^[61] Another book that has had great impact is Wheat Belly: Lose the Wheat, Lose the Weight, and Find Your Path Back to Health, by the cardiologist William Davis, which refers to wheat as a "chronic poison" and became a New York Times bestseller within a month of publication in 2011.^[63] The gluten-free diet has been advocated and followed by many celebrities to lose weight, such as Miley Cyrus, Gwyneth Paltrow, and Kourtney Kardashian, and are used by some professional athletes, who believe the diet can improve energy and health.^[33]^[64]^[65]^[66] It became popular in the US, as the popularity of low-carbohydrate diets faded.^[67]

Estimates suggest that in 2014, 30% of people in the US and Australia were consuming gluten-free foods, with a growing number, calculated from surveys that by 2016 approximately 100 million Americans would consume gluten-free products.^[40]^[61]^[68] Data from a 2015 Nielsen survey of 30,000 adults in 60 countries around the world conclude that 21% of people prefer to buy gluten-free foods, being the highest interest among the younger generations.^[69] In the US, it was estimated that more than half of people who buy foods labeled gluten-free do not have a clear reaction to gluten, and they do so "because they think it will help them lose weight, because they seem to feel better or because they mistakenly believe they are sensitive to gluten."^[70] Although gluten is highly immunologically reactive and humans appear not to have evolved to digest it well, a gluten-free diet is not a healthier option for the general population, other than people with gluten-related disorders or other associated conditions which improve with a gluten-free diet in some cases, such as irritable bowel syndrome and certain autoimmune and neurological disorders.^[12]^[55]^[71] There is no published experimental evidence to support that the gluten-free diet contributes to weight loss.^[71]

In a review of May 2015 published in Gastroenterology, Fasano et al. conclude that, although there is an evident "fad component" to the recent rise in popularity of the gluten-free diet, there is also growing and unquestionable evidence of the existence of non-coeliac gluten sensitivity.^[72]

In some cases, the popularity of the gluten-free diet may harm people who must eliminate gluten for medical reasons. For example, servers in restaurants may not take dietary requirements seriously, believing them to be merely a preference. This could prevent appropriate precautions in food handling to prevent gluten cross-contamination.^[73] Medical professionals may also confuse medical explanations for gluten intolerance with patient preference.^[55] On the other hand, the popularity of the gluten-free diet has increased the availability of commercial gluten-free replacement products and gluten-free grains.^[71]

Gluten-free commercial replacement products, such as gluten-free cakes, are more expensive than their gluten-containing counterparts, so their purchase adds a financial burden.^[31] They are also typically higher in calories, fat, and sugar, and lower in dietary fibre.^[67] In less developed countries, wheat can represent an important source of protein, since it is a substantial part of the diet in the form of bread, noodles, bulgur, couscous, and other products.^[16]^[74]

In the British National Health Service, gluten-free foods have been supplied on prescription. For many patients, this meant at no cost. When it was proposed to alter this in 2018, the Department of Health and Social Care made an assessment of the costs and benefits. The potential annual financial saving to the service was estimated at £5.3 million, taking into account the reduction in cost spending and the loss of income from prescription charges. The proposed scenario was actually that patients could still be prescribed gluten-free breads and mixes but would have to buy any other gluten-free products themselves. The savings would only amount to £700,000 a year. Local initiatives by clinical commissioning groups had already reduced the cost of gluten-free foods to the NHS by 39% between 2015 and 2017.^[75]

Healthcare professionals recommend against undertaking a gluten-free diet as a form of self-diagnosis,^[76] because tests for coeliac disease are reliable only if the person has been consuming gluten recently. There is a consensus in the medical community that people should consult a physician before going on a gluten-free diet, so that a medical professional can accurately test for coeliac disease or any other gluten-induced health issues.^[77]

Although popularly used as an alternative treatment for people with autism, there is no good evidence that a gluten-free diet is of benefit in reducing the symptoms of autism.^[13]^[14]^[15]

Research

In a 2013 double-blind, placebo-controlled challenge (DBPC) by Biesiekierski et al. in a few people with irritable bowel syndrome, the authors found no difference between gluten or placebo groups and the concept of non-celiac gluten sensitivity as a syndrome was questioned. Nevertheless, this study had design errors and an incorrect selection of participants, and probably the reintroduction of both gluten and whey protein had a nocebo effect similar in all people, and this could have masked the true effect of gluten/wheat reintroduction.^[30]^[42]

In a 2015 double-blind placebo cross-over trial, small amounts of purified wheat gluten triggered gastrointestinal symptoms (such as abdominal bloating and pain) and extra-intestinal manifestations (such as foggy mind, depression and aphthous stomatitis) in self-reported non-celiac gluten sensitivity. Nevertheless, it remains elusive whether these findings specifically implicate gluten or other proteins present in gluten-containing cereals.^[42]

In a 2018 double-blind, crossover research study on 59 persons on a gluten-free diet with challenges of gluten, fructans or placebo, intestinal symptoms (specifically bloating) were borderline significantly higher after challenge with fructans, in comparison with gluten proteins (P=0.049).^[45]^[48] Although the differences between the three interventions was very small, the authors concluded that fructans (the specific type of FODMAP found in wheat) are more likely to be the cause of gastrointestinal symptoms of non-celiac gluten sensitivity, rather than gluten.^[45] For this previous study, experts recommend a low FODMAP diet instead of a gluten free diet for those patients suffering of functional gastrointestinal disorders as bloating.^[78] In addition, fructans used in the study were extracted from chicory root, so it remains to be seen whether the wheat fructans produce the same effect.^[48]

Eating gluten-free

A gluten-free diet is a diet that strictly excludes gluten, proteins present in wheat (and all wheat varieties such as spelt and kamut), barley, rye, oat, and derivatives of these grains such as malt and triticale, and foods that may include them, or shared transportation or processing facilities with them.^[1]^[17] The inclusion of oats in a gluten-free diet remains controversial.^[1] Oat toxicity in people with gluten-related disorders depends on the oat cultivar consumed because the immunoreactivities of toxic prolamins are different among oat varieties.^[4]^[3] Furthermore, oats are frequently cross-contaminated with the other gluten-containing cereals.^[4] Pure oat (labelled as "pure oat" or "gluten-free oat"^[2]) refers to oats uncontaminated with any of the other gluten-containing cereals.^[3] Some cultivars of pure oat could be a safe part of a gluten-free diet, requiring knowledge of the oat variety used in food products for a gluten-free diet.^[3] Nevertheless, the long-term effects of pure oats consumption are still unclear^[79] and further studies identifying the cultivars used are needed before making final recommendations on their inclusion in the gluten-free diet.^[5]

Other grains, although gluten-free in themselves, may contain gluten by cross-contamination with gluten-containing cereals during grain harvesting, transporting, milling, storing, processing, handling or cooking.^[80]^[81]

Processed foods commonly contain gluten as an additive (as emulsifiers, thickeners, gelling agents, fillers, and coatings), so they would need specific labeling. Unexpected sources of gluten are, among others, processed meat, vegetarian meat substitutes, reconstituted seafood, stuffings, butter, seasonings, marinades, dressings, confectionary, candies, and ice cream.^[1]

Cross-contamination in the home is also a consideration for those who have gluten-related disorders.^[23]^[10] There can be many sources of cross-contamination, as for example when family members prepare gluten-free and gluten-containing foods on the same surfaces (countertops, tables, etc.) or share utensils that have not been cleaned after being used to prepare gluten-containing foods (cutting boards, colanders, cutlery, etc.), kitchen equipment (toaster, cupboards, etc.) or certain packaged foods (butter, peanut butter, etc.).^[10]

Restaurants prove to be another source of cross-contamination for those following a strict gluten-free diet. A study conducted by Columbia University Medical Center found that 32% of foods labeled gluten-free at restaurants contain above 20 parts per million of gluten, meaning that it contains enough gluten that it is no longer considered gluten-free by the Codex Alimentarius.^[82] Cross-contamination occurs in these areas frequently because of a general lack of knowledge about the needed level of caution and the prevalence of gluten in restaurant kitchens.^[83] If cooks are unaware of the severity of their guest's diet restrictions or of the important practices needed to limit cross-contamination, they can unknowingly deliver contaminated food. However, some restaurants utilize a training program for their employees to educate them about the gluten-free diet.^[84] The accuracy of the training varies. One resource to find these safer restaurants is an app and website called "Find Me Gluten Free" that allows people following a gluten-free diet to rate the safety of different restaurants from their point of view and describe their experience to help future customers.

Easily locating gluten-free items is one of the main difficulties in following a gluten-free diet. To assist in this process, many restaurants and grocery stores choose to label food items. Restaurants often add a gluten-free section to their menu, or specifically mark gluten-free items with a symbol of some kind. Grocery stores often have a gluten-free aisle, or they will attach labels on the shelf underneath gluten-free items. Though the food is labeled gluten-free in this way, it does not necessarily mean that the food is safe for those with gluten-related disorders, as a compilation of studies suggest.^[85]

Medications and dietary supplements are made using excipients that may contain gluten.^[86]

Gluten-free food

The gluten-free diet includes naturally gluten-free food, such as meat, fish, seafood, eggs, milk and dairy products, nuts, legumes, fruit, vegetables, potatoes, pseudocereals (in particular amaranth, buckwheat, chia seed, quinoa), only certain cereal grains (corn, rice, sorghum), minor cereals (including fonio, Job's tears, millet, teff, called "minor" cereals as they are "less common and are only grown in a few small regions of the world"),^[17] some other plant products (arrowroot, mesquite flour,^[87] sago,^[88] tapioca^[88]) and products made from these gluten-free foods. Many Indian cuisine options, particularly South Indian cuisine, are gluten-free.^[89]

Risks

An unbalanced selection of food and an incorrect choice of gluten-free replacement products may lead to nutritional deficiencies. Replacing flour from wheat or other gluten-containing cereals with gluten-free flours in commercial products may lead to a lower intake of important nutrients, such as iron and B vitamins and a higher intake of sugars and saturated fats. Some gluten-free commercial replacement products are not enriched or fortified as their gluten-containing counterparts, and often have greater lipid / carbohydrate content. Children especially often over-consume these products, such as snacks and biscuits. These nutritional complications can be prevented by a correct dietary education.^[4] Pseudocereals (quinoa, amaranth, and buckwheat) and some minor cereals are healthy alternatives to these prepared products and have higher biological and nutritional value.^[4]^[16] Advances towards higher nutrition-content gluten-free bakery products, improved for example in terms of fiber content and glycemic index, have been made by using not exclusively corn starch or other starches to substitute for flour. In this aim, for example the dietary fibre inulin (which acts as a prebiotic^[90]) or quinoa or amaranth wholemeal have been as substitute for part of the flour. Similarly, xanthan gum can be used in up to gram quantities per serving in some gluten-free baked goods and can be fermented by specific microbiomes in the gastrointestinal tract.^[91]^[92] Such substitution has been found to also yield improved crust and texture of bread.^[93] It is recommended that anyone embarking on a gluten-free diet check with a registered dietitian to make sure they are getting the required amount of key nutrients like iron, calcium, fiber, thiamin, riboflavin, niacin and folate. Vitamins often contain gluten as a binding agent. Experts have advised that it is important to always read the content label of any product that is intended to be swallowed.^[94]

Up to 30% of people with known coeliac disease often continue having or redeveloping symptoms.^[10]^[95] Also, a lack of symptoms or negative blood antibodies levels are not reliable indicators of intestinal recuperation. Several studies show an incomplete recovery of small bowel despite a strict gluten-free diet, and about 79% of such people have persistent villous atrophy.^[10] This lack of recovery is mainly caused by inadvertent exposure to gluten.^[10]^[95] People with poor basic education and understanding of the gluten-free diet often believe that they are strictly following the diet, but are making regular errors.^[11]^[10] In addition, some people often deliberately continue eating gluten because of limited availability, inferior taste, higher price, and inadequate labelling of gluten-free products. Poor compliance with the regimen is also influenced by age at diagnosis (adolescents), ignorance of the consequences of the lack of a strict treatment and certain psychological factors.^[10] Ongoing gluten intake can cause severe disease complications, such as various types of cancers (both intestinal and extra-intestinal) and osteoporosis.^[10]^[95]

Regulation and labels

The term gluten-free is generally used to indicate a supposed harmless level of gluten rather than a complete absence.^[19] The exact level at which gluten is harmless is uncertain and controversial. A 2008 systematic review tentatively concluded that consumption of less than 10 mg (10 ppm) of gluten per day is unlikely to cause histological abnormalities, although it noted that few reliable studies had been done.^[19]

Regulation of the label gluten-free varies by country. Most countries derive key provisions of their gluten-free labelling regulations from the Codex Alimentarius international standards for food labelling as a standard relating to the labelling of products as gluten-free. It only applies to foods that would normally contain gluten.^[96] Gluten-free is defined as 20 ppm (= 20 mg/kg) or less. It categorizes gluten-free food as:

Food that is gluten-free by composition
Food that has become gluten-free through special processing.
Reduced gluten content, food which includes food products with between 20 and 100 ppm of gluten Reduced gluten content is left up to individual nations to more specifically define.

The Codex Standard suggests the enzyme-linked Immunoassay (ELISA) R5 Mendez method for indicating the presence of gluten, but allows for other relevant methods, such as DNA. The Codex Standard specifies that the gluten-free claim must appear in the immediate proximity of the name of the product, to ensure visibility.

There is no general agreement on the analytical method used to measure gluten in ingredients and food products.^[97] The ELISA method was designed to detect w-gliadins, but it suffered from the setback that it lacked sensitivity for barley prolamins.^[98] The use of highly sensitive assays is mandatory to certify gluten-free food products. The European Union, World Health Organization, and Codex Alimentarius require reliable measurement of the wheat prolamins, gliadins rather than all-wheat proteins.^[99]

Australia

The Australian government recommends^[100] that:

food labelled gluten-free include no detectable gluten (<3ppm ^[101]) oats or their products, cereals containing gluten that have been malted or their products
food labelled low gluten claims such that the level of 20 mg gluten per 100 g of the food

Brazil

All food products must be clearly labelled whether they contain gluten or they are gluten-free.^[102] Since April 2016, the declaration of the possibility of cross-contamination is mandatory when the product does not intentionally add any allergenic food or its derivatives, but the Good Manufacturing Practices and allergen control measures adopted are not sufficient to prevent the presence of accidental trace amounts.^[103] When a product contains the warning of cross-contamination with wheat, rye, barley, oats and their hybridized strains, the warning "contains gluten" is mandatory. The law does not establish a gluten threshold for the declaration of its absence.^[102]

Canada

Health Canada considers that foods containing levels of gluten not exceeding 20 ppm as a result of contamination, meet the health and safety intent of section B.24.018 of the Food and Drug Regulations when a gluten-free claim is made.^[104] Any intentionally added gluten, even at low levels must be declared on the packaging and a gluten-free claim would be considered false and misleading. Labels for all food products sold in Canada must clearly identify the presence of gluten if it is present at a level greater than 10 ppm.^[105]

European Union

The EU European Commission delineates^[106] the categories as:

gluten-free: 20 ppm or less of gluten
very low gluten foodstuffs: 20-100ppm gluten.

All foods containing gluten as an ingredient must be labelled accordingly as gluten is defined as one of the 14 recognized EU allergens.^[107]

United States

Until 2012 anyone could use the gluten-free claim with no repercussion.^[108]^[109] In 2008, Wellshire Farms chicken nuggets labelled gluten-free were purchased and samples were sent to a food allergy laboratory^[110] where they were found to contain gluten. After this was reported in the Chicago Tribune, the products continued to be sold. The manufacturer has since replaced the batter used in its chicken nuggets.^[111] The U.S. first addressed gluten-free labelling in the 2004 Food Allergen Labeling and Consumer Protection Act (FALCPA). The Alcohol and Tobacco Tax and Trade Bureau published interim rules and proposed mandatory labelling for alcoholic products in 2006.^[112] The FDA issued their Final Rule on August 5, 2013.^[113] When a food producer voluntarily chooses to use a gluten-free claim for a product, the food bearing the claim in its labelling may not contain:

an ingredient that is a gluten-containing grain
an ingredient that is derived from a gluten-containing grain that has not been processed to remove gluten
an ingredient that is derived from a gluten-containing grain, that has been processed to remove gluten but results in the presence of 20 ppm or more gluten in the food. Any food product claiming to be gluten-free and also bearing the term "wheat" in its ingredient list or in a separate "Contains wheat" statement, must also include the language "*the wheat has been processed to allow this food to meet the FDA requirements for gluten-free foods," in close proximity to the ingredient statement.

Any food product that inherently does not contain gluten may use a gluten-free label where any unavoidable presence of gluten in the food bearing the claim in its labelling is below 20 ppm gluten.

References

^ ^a ^b ^c ^d Biesiekierski JR (March 2017). "What is gluten?". Journal of Gastroenterology and Hepatology (Review). 32 (Suppl 1): 78–81. doi:10.1111/jgh.13703. PMID 28244676. Similar proteins to the gliadin found in wheat exist as secalin in rye, hordein in barley, and avenins in oats and are collectively referred to as 'gluten.' Derivatives of these grains such as triticale and malt and other ancient wheat varieties such as spelt and kamut also contain gluten. The gluten found in all of these grains has been identified as the component capable of triggering the immune-mediated disorder, coeliac disease.
^ ^a ^b Ciacci C, Ciclitira P, Hadjivassiliou M, Kaukinen K, Ludvigsson JF, McGough N, et al. (April 2015). "The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis". United European Gastroenterology Journal (Review). 3 (2): 121–35. doi:10.1177/2050640614559263. PMC 4406897. PMID 25922672.
^ ^a ^b ^c ^d Comino I, Moreno MD, Sousa C (November 2015). "Role of oats in celiac disease". World Journal of Gastroenterology. 21 (41): 11825–31. doi:10.3748/wjg.v21.i41.11825. PMC 4631980. PMID 26557006. It is necessary to consider that oats include many varieties, containing various amino acid sequences and showing different immunoreactivities associated with toxic prolamins. As a result, several studies have shown that the immunogenicity of oats varies depending on the cultivar consumed. Thus, it is essential to thoroughly study the variety of oats used in a food ingredient before including it in a gluten-free diet.
^ ^a ^b ^c ^d ^e ^f ^g Penagini F, Dilillo D, Meneghin F, Mameli C, Fabiano V, Zuccotti GV (November 2013). "Gluten-free diet in children: an approach to a nutritionally adequate and balanced diet". Nutrients. 5 (11): 4553–65. doi:10.3390/nu5114553. PMC 3847748. PMID 24253052. For CD patients on GFD, the nutritional complications are likely to be caused by the poor nutritional quality of the GFPs mentioned above and by the incorrect alimentary choices of CD patients. (...) the limited choice of food products in the diet of children with CD induces a high consumption of packaged GFPs, such as snacks like biscuits. (..) It has been shown that some commercially available GFPs have a lower content of folates, iron and B vitamins or are not consistently enriched/fortified compared to their gluten containing counterparts. (...) Within the range of naturally GF foods, it is preferable to consume those rich in iron and folic acid, such as leafy vegetables, legumes, fish and meat.
^ ^a ^b de Souza MC, Deschênes ME, Laurencelle S, Godet P, Roy CC, Djilali-Saiah I (2016). "Pure Oats as Part of the Canadian Gluten-Free Diet in Celiac Disease: The Need to Revisit the Issue". Canadian Journal of Gastroenterology & Hepatology (Review). 2016: 1576360. doi:10.1155/2016/1576360. PMC 4904650. PMID 27446824.
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External links

Gluten-free diet by the Mayo Clinic

[Biesiekierski2017-1] Biesiekierski JR (March 2017). "What is gluten?". Journal of Gastroenterology and Hepatology (Review). 32 (Suppl 1): 78–81. doi:10.1111/jgh.13703. PMID 28244676. Similar proteins to the gliadin found in wheat exist as secalin in rye, hordein in barley, and avenins in oats and are collectively referred to as 'gluten.' Derivatives of these grains such as triticale and malt and other ancient wheat varieties such as spelt and kamut also contain gluten. The gluten found in all of these grains has been identified as the component capable of triggering the immune-mediated disorder, coeliac disease.

[CiacciCiclitira2015-2] Ciacci C, Ciclitira P, Hadjivassiliou M, Kaukinen K, Ludvigsson JF, McGough N, et al. (April 2015). "The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis". United European Gastroenterology Journal (Review). 3 (2): 121–35. doi:10.1177/2050640614559263. PMC 4406897. PMID 25922672.

[CominoMoreno2015-3] Comino I, Moreno MD, Sousa C (November 2015). "Role of oats in celiac disease". World Journal of Gastroenterology. 21 (41): 11825–31. doi:10.3748/wjg.v21.i41.11825. PMC 4631980. PMID 26557006. It is necessary to consider that oats include many varieties, containing various amino acid sequences and showing different immunoreactivities associated with toxic prolamins. As a result, several studies have shown that the immunogenicity of oats varies depending on the cultivar consumed. Thus, it is essential to thoroughly study the variety of oats used in a food ingredient before including it in a gluten-free diet.

[PenaginiDilillo-4] ^ ^a ^b ^c ^d ^e ^f ^g Penagini F, Dilillo D, Meneghin F, Mameli C, Fabiano V, Zuccotti GV (November 2013). "Gluten-free diet in children: an approach to a nutritionally adequate and balanced diet". Nutrients. 5 (11): 4553–65. doi:10.3390/nu5114553. PMC 3847748. PMID 24253052. For CD patients on GFD, the nutritional complications are likely to be caused by the poor nutritional quality of the GFPs mentioned above and by the incorrect alimentary choices of CD patients. (...) the limited choice of food products in the diet of children with CD induces a high consumption of packaged GFPs, such as snacks like biscuits. (..) It has been shown that some commercially available GFPs have a lower content of folates, iron and B vitamins or are not consistently enriched/fortified compared to their gluten containing counterparts. (...) Within the range of naturally GF foods, it is preferable to consume those rich in iron and folic acid, such as leafy vegetables, legumes, fish and meat.

[DeSouzaDeschenes2016-5] Souza MC, Deschênes ME, Laurencelle S, Godet P, Roy CC, Djilali-Saiah I (2016). "Pure Oats as Part of the Canadian Gluten-Free Diet in Celiac Disease: The Need to Revisit the Issue". Canadian Journal of Gastroenterology & Hepatology (Review). 2016: 1576360. doi:10.1155/2016/1576360. PMC 4904650. PMID 27446824.

[LudvigssonLeffler-6] Ludvigsson JF, Leffler DA, Bai JC, Biagi F, Fasano A, Green PH, et al. (January 2013). "The Oslo definitions for coeliac disease and related terms". Gut. 62 (1): 43–52. doi:10.1136/gutjnl-2011-301346. PMC 3440559. PMID 22345659.

[MulderWanrooijQuotation-7] Mulder CJ, van Wanrooij RL, Bakker SF, Wierdsma N, Bouma G (2013). "Gluten-free diet in gluten-related disorders". Digestive Diseases (Review). 31 (1): 57–62. doi:10.1159/000347180. PMID 23797124. S2CID 14124370. The only treatment for CD, dermatitis herpetiformis (DH) and gluten ataxia is lifelong adherence to a GFD.

[HischenhuberCrevelQuotation-8] Hischenhuber C, Crevel R, Jarry B, Mäki M, Moneret-Vautrin DA, Romano A, et al. (March 2006). "Review article: safe amounts of gluten for patients with wheat allergy or coeliac disease". Alimentary Pharmacology & Therapeutics. 23 (5): 559–75. doi:10.1111/j.1365-2036.2006.02768.x. PMID 16480395. S2CID 9970042. For both wheat allergy and coeliac disease the dietary avoidance of wheat and other gluten-containing cereals is the only effective treatment.

[VoltaCaio2015Quotation-9] Volta U, Caio G, De Giorgio R, Henriksen C, Skodje G, Lundin KE (June 2015). "Non-celiac gluten sensitivity: a work-in-progress entity in the spectrum of wheat-related disorders". Best Practice & Research. Clinical Gastroenterology. 29 (3): 477–91. doi:10.1016/j.bpg.2015.04.006. PMID 26060112. A recently proposed approach to NCGS diagnosis is an objective improvement of gastrointestinal symptoms and extra-intestinal manifestations assessed through a rating scale before and after GFD. Although a standardized symptom rating scale is not yet applied worldwide, a recent study indicated that a decrease of the global symptom score higher than 50% after GFD can be regarded as confirmatory of NCGS (Table 1) [53]. (…) After the confirmation of NCGS diagnosis, according to the previously mentioned work-up, patients are advized to start with a GFD [49].

[SeeKaukinen2015-10] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l See JA, Kaukinen K, Makharia GK, Gibson PR, Murray JA (October 2015). "Practical insights into gluten-free diets". Nature Reviews. Gastroenterology & Hepatology (Review). 12 (10): 580–91. doi:10.1038/nrgastro.2015.156. PMID 26392070. S2CID 20270743.

[MulderWanrooij-11] Mulder CJ, van Wanrooij RL, Bakker SF, Wierdsma N, Bouma G (2013). "Gluten-free diet in gluten-related disorders". Digestive Diseases (Review). 31 (1): 57–62. doi:10.1159/000347180. PMID 23797124. S2CID 14124370.

[ElChammasDanner2011Quotation-12] El-Chammas K, Danner E (June 2011). "Gluten-free diet in nonceliac disease". Nutrition in Clinical Practice (Review). 26 (3): 294–9. doi:10.1177/0884533611405538. PMID 21586414. The prescription of a GFD has been recommended for patients with IBS-like symptoms without histologic evidence of CD and who have positive IgA tTG antibodies or have the at-risk haplotypes DQ2 or DQ8.46 (...) Historically, a GFD was occasionally used in the management of multiple sclerosis (MS), because anecdotal reports indicated a positive effect (reversal of symptoms) of a GFD in MS patients. (…) what has been demonstrated so far is that a glutenfree vegan diet for 1 year significantly reduced disease activity and levels of antibodies to β-lactoglobulin and gliadin in patients with RA. (...) The beneficial effect of a GFD on diarrhea and weight gain in patients with HIV enteropathy has been demonstrated in a few case series. Treatment with a GFD has been observed to decrease the frequency of diarrhea and thus allow weight gain.84 (IBS=irritable bowel syndrome; RA=rheumatoid arthritis; GFD=gluten-free diet)

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[Buie2013-14] Buie T (May 2013). "The relationship of autism and gluten". Clinical Therapeutics (Review). 35 (5): 578–83. doi:10.1016/j.clinthera.2013.04.011. PMID 23688532. At this time, the studies attempting to treat symptoms of autism with diet have not been sufficient to support the general institution of a gluten-free or other diet for all children with autism. ...There may be a subgroup of patients who might benefit from a gluten-free diet, but the symptom or testing profile of these candidates remains unclear.

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[LamacchiaCamarca2014-16] Lamacchia C, Camarca A, Picascia S, Di Luccia A, Gianfrani C (January 2014). "Cereal-based gluten-free food: how to reconcile nutritional and technological properties of wheat proteins with safety for celiac disease patients". Nutrients (Review). 6 (2): 575–90. doi:10.3390/nu6020575. PMC 3942718. PMID 24481131.

[Saturni-etal-2010-table2-p21-17] Saturni L, Ferretti G, Bacchetti T (January 2010). "The gluten-free diet: safety and nutritional quality". Nutrients (Review). 2 (1): 16–34. doi:10.3390/nu2010016. PMC 3257612. PMID 22253989.. See Table 2 and page 21.

[18] Caeiro, Carolina; Pragosa, Caroline; Cruz, Marisa Carreira; Pereira, Cidália Daniela; Pereira, Sónia Gonçalves (2022). Huerta, José María (ed.). "The Role of Pseudocereals in Celiac Disease: Reducing Nutritional Deficiencies to Improve Well-Being and Health". Journal of Nutrition and Metabolism. 2022: 1–8. doi:10.1155/2022/8502169. ISSN 2090-0732. PMC 8850039. PMID 35186332.

[Akobeng2008-19] Akobeng AK, Thomas AG (June 2008). "Systematic review: tolerable amount of gluten for people with coeliac disease". Alimentary Pharmacology & Therapeutics. 27 (11): 1044–52. doi:10.1111/j.1365-2036.2008.03669.x. PMID 18315587. S2CID 20539463.

[MorenoRodriguezHerrera2017-20] Moreno ML, Rodríguez-Herrera A, Sousa C, Comino I (January 2017). "Biomarkers to Monitor Gluten-Free Diet Compliance in Celiac Patients". Nutrients (Review). 9 (1): 46. doi:10.3390/nu9010046. PMC 5295090. PMID 28067823.

[VoltaCaio2015-21] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k Volta U, Caio G, De Giorgio R, Henriksen C, Skodje G, Lundin KE (June 2015). "Non-celiac gluten sensitivity: a work-in-progress entity in the spectrum of wheat-related disorders". Best Practice & Research. Clinical Gastroenterology. 29 (3): 477–91. doi:10.1016/j.bpg.2015.04.006. PMID 26060112.

[HadjivassiliouGrünewald2002-22] Hadjivassiliou M, Grünewald RA, Davies-Jones GA (May 2002). "Gluten sensitivity as a neurological illness". Journal of Neurology, Neurosurgery, and Psychiatry (Review). 72 (5): 560–3. doi:10.1136/jnnp.72.5.560. PMC 1737870. PMID 11971034. Incomplete elimination of gluten from the diet may be enough to abolish gastrointestinal symptoms with recovery of the small bowel mucosa but is insufficient to arrest the state of heightened immunological responsiveness resulting in neuronal injury. There is a group of patients with CD 'resistant' to gluten-free diet. This may reflect hypersensitivity to the minute amounts of gluten present in most 'gluten-free' products.

[FrancavillaCristofori2014-23] Francavilla R, Cristofori F, Stella M, Borrelli G, Naspi G, Castellaneta S (October 2014). "Treatment of celiac disease: from gluten-free diet to novel therapies". Minerva Pediatrica (Review). 66 (5): 501–16. PMID 24938882.

[Antiga_E,_Caproni2015-24] Antiga E, Caproni M (2015). "The diagnosis and treatment of dermatitis herpetiformis". Clinical, Cosmetic and Investigational Dermatology (Review). 8: 257–65. doi:10.2147/CCID.S69127. PMC 4435051. PMID 25999753.

[NEJM2012-25] Fasano A, Catassi C (December 2012). "Clinical practice. Celiac disease". The New England Journal of Medicine. 367 (25): 2419–26. doi:10.1056/NEJMcp1113994. PMID 23252527.

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[LundinWijmenga2015-27] Lundin KE, Wijmenga C (September 2015). "Coeliac disease and autoimmune disease-genetic overlap and screening". Nature Reviews. Gastroenterology & Hepatology. 12 (9): 507–15. doi:10.1038/nrgastro.2015.136. PMID 26303674. S2CID 24533103.

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[Fasano2005Pediatric-29] Fasano A (April 2005). "Clinical presentation of celiac disease in the pediatric population". Gastroenterology. 128 (4 Suppl 1): S68-73. doi:10.1053/j.gastro.2005.02.015. PMID 15825129.

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[LebwoholLudvigsson-quotation-33] Lebwohl B, Ludvigsson JF, Green PH (October 2015). "Celiac disease and non-celiac gluten sensitivity". BMJ (Review). 351: h4347. doi:10.1136/bmj.h4347. PMC 4596973. PMID 26438584. Some population groups seem to be especially wed to the gluten-free diet, with nearly 50% of 910 athletes (including world class and Olympic medalists) adhering to a gluten-free diet, mainly because of the perceived health and energy benefits.

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[RossiDiLollo-43] Rossi A, Di Lollo AC, Guzzo MP, Giacomelli C, Atzeni F, Bazzichi L, Di Franco M (2015). "Fibromyalgia and nutrition: what news?". Clinical and Experimental Rheumatology (Review). 33 (1 Suppl 88): S117-25. PMID 25786053.

[FasanoSapone2015Quotation2-44] Fasano A, Sapone A, Zevallos V, Schuppan D (May 2015). "Nonceliac gluten sensitivity". Gastroenterology (Review). 148 (6): 1195–204. doi:10.1053/j.gastro.2014.12.049. PMID 25583468. One of the most controversial and highly debated discussions concerns the role of gluten in causing NCGS. Recent reports have indicated that gluten might not be the cause of NCGS, and some investigators still question whether NCGS as a real clinical entity. (...) Cereals such as wheat and rye, when consumed in normal quantities, are only minor sources of FODMAPs in the daily diet (Table 1). Therefore, gluten-containing grains are not likely to induce IBS exclusively via FODMAPs. In contrast, there is growing evidence that other proteins that are unique to gluten-containing cereals can elicit an innate immune response that leads to NCGS, raising a nomenclature issue. For this reason, wheat sensitivity, rather than gluten sensitivity, seems to be a more appropriate term, keeping in mind that other gluten-containing grains such as barley and rye also can trigger the symptoms.

[Verbeke2018-45] Verbeke K (February 2018). "Nonceliac Gluten Sensitivity: What Is the Culprit?". Gastroenterology. 154 (3): 471–473. doi:10.1053/j.gastro.2018.01.013. PMID 29337156. Although intolerance to fructans and other FODMAPs may contribute to NCGS, they may only explain gastrointestinal symptoms and not the extraintestinal symptoms observed in NCGS patients, such as neurologic dysfunction, psychological disturbances, fibromyalgia, and skin rash.15 Therefore, it is unlikely that they are the sole cause of NCGS.

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[VoltaDeGiorgio2019-48] Volta U, De Giorgio R, Caio G, Uhde M, Manfredini R, Alaedini A (March 2019). "Nonceliac Wheat Sensitivity: An Immune-Mediated Condition with Systemic Manifestations". Gastroenterology Clinics of North America (Review). 48 (1): 165–182. doi:10.1016/j.gtc.2018.09.012. PMC 6364564. PMID 30711208. Furthermore, a role for the FODMAP (eg, fructans) component of wheat as the sole trigger for symptoms is somewhat doubtful, because many patients with NCWS report resolution of symptoms after the withdrawal of wheat and related cereals, while continuing to ingest vegetables and fruits with high FODMAP content in their diets.59 On the whole, it is conceivable that more than one culprit may be involved in symptoms of NCWS (as they are currently defined), including gluten, other wheat proteins, and FODMAPs.60–62

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[113] 78 FR 47154 (5 August 2013). Codified at 21 CFR 101.91.

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 [[File:Triticum monococcum0.jpg|thumb|200px|Wheat]]
-Gluten free diets mean that one must drink marinara sauce once weekly in order to avoid getting COVID-19. A '''gluten-free diet''' ('''GFD''') is a [[diet (nutrition)|nutritional plan]] that strictly excludes [[gluten]], which is a mixture of [[prolamin]] [[protein]]s found in [[wheat]] (and all of its species and hybrids, such as [[spelt]], [[Khorasan wheat|kamut]], and [[triticale]]), as well as [[barley]], [[rye]], and [[oats]].<ref name=Biesiekierski2017>{{cite journal | vauthors = Biesiekierski JR | title = What is gluten? | journal = Journal of Gastroenterology and Hepatology | volume = 32 | pages = 78–81 | date = March 2017 | issue = Suppl 1 | pmid = 28244676 | doi = 10.1111/jgh.13703 | quote = Similar proteins to the gliadin found in wheat exist as secalin in rye, hordein in barley, and avenins in oats and are collectively referred to as 'gluten.' Derivatives of these grains such as triticale and malt and other ancient wheat varieties such as spelt and kamut also contain gluten. The gluten found in all of these grains has been identified as the component capable of triggering the immune-mediated disorder, coeliac disease. | doi-access = free | type = Review }}{{open access}}</ref> The inclusion of [[oats]] in a gluten-free diet remains controversial, and may depend on the oat [[cultivar]] and the frequent cross-contamination with other gluten-containing cereals.<ref name=CiacciCiclitira2015>{{cite journal | vauthors = Ciacci C, Ciclitira P, Hadjivassiliou M, Kaukinen K, Ludvigsson JF, McGough N, Sanders DS, Woodward J, Leonard JN, Swift GL | display-authors = 6 | title = The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis | journal = United European Gastroenterology Journal | volume = 3 | issue = 2 | pages = 121–35 | date = April 2015 | pmid = 25922672 | pmc = 4406897 | doi = 10.1177/2050640614559263 | type = Review }}</ref><ref name=CominoMoreno2015 /><ref name=PenaginiDilillo /><ref name=DeSouzaDeschenes2016>{{cite journal | vauthors = de Souza MC, Deschênes ME, Laurencelle S, Godet P, Roy CC, Djilali-Saiah I | title = Pure Oats as Part of the Canadian Gluten-Free Diet in Celiac Disease: The Need to Revisit the Issue | journal = Canadian Journal of Gastroenterology & Hepatology | volume = 2016 | pages = 1576360 | year = 2016 | pmid = 27446824 | pmc = 4904650 | doi = 10.1155/2016/1576360 | type = Review | doi-access = free }}</ref>
+A '''gluten-free diet''' ('''GFD''') is a [[diet (nutrition)|nutritional plan]] that strictly excludes [[gluten]], which is a mixture of [[prolamin]] [[protein]]s found in [[wheat]] (and all of its species and hybrids, such as [[spelt]], [[Khorasan wheat|kamut]], and [[triticale]]), as well as [[barley]], [[rye]], and [[oats]].<ref name=Biesiekierski2017>{{cite journal | vauthors = Biesiekierski JR | title = What is gluten? | journal = Journal of Gastroenterology and Hepatology | volume = 32 | pages = 78–81 | date = March 2017 | issue = Suppl 1 | pmid = 28244676 | doi = 10.1111/jgh.13703 | quote = Similar proteins to the gliadin found in wheat exist as secalin in rye, hordein in barley, and avenins in oats and are collectively referred to as 'gluten.' Derivatives of these grains such as triticale and malt and other ancient wheat varieties such as spelt and kamut also contain gluten. The gluten found in all of these grains has been identified as the component capable of triggering the immune-mediated disorder, coeliac disease. | doi-access = free | type = Review }}{{open access}}</ref> The inclusion of [[oats]] in a gluten-free diet remains controversial, and may depend on the oat [[cultivar]] and the frequent cross-contamination with other gluten-containing cereals.<ref name=CiacciCiclitira2015>{{cite journal | vauthors = Ciacci C, Ciclitira P, Hadjivassiliou M, Kaukinen K, Ludvigsson JF, McGough N, Sanders DS, Woodward J, Leonard JN, Swift GL | display-authors = 6 | title = The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis | journal = United European Gastroenterology Journal | volume = 3 | issue = 2 | pages = 121–35 | date = April 2015 | pmid = 25922672 | pmc = 4406897 | doi = 10.1177/2050640614559263 | type = Review }}</ref><ref name=CominoMoreno2015 /><ref name=PenaginiDilillo /><ref name=DeSouzaDeschenes2016>{{cite journal | vauthors = de Souza MC, Deschênes ME, Laurencelle S, Godet P, Roy CC, Djilali-Saiah I | title = Pure Oats as Part of the Canadian Gluten-Free Diet in Celiac Disease: The Need to Revisit the Issue | journal = Canadian Journal of Gastroenterology & Hepatology | volume = 2016 | pages = 1576360 | year = 2016 | pmid = 27446824 | pmc = 4904650 | doi = 10.1155/2016/1576360 | type = Review | doi-access = free }}</ref>
 Gluten may cause both [[gastrointestinal]] and [[systemic disease|systemic]] symptoms for those with [[gluten-related disorders]], including [[coeliac disease]] (CD), [[non-celiac gluten sensitivity|non-coeliac gluten sensitivity]] (NCGS), [[gluten ataxia]], [[dermatitis herpetiformis]] (DH), and [[wheat allergy]].<ref name=LudvigssonLeffler>{{cite journal | vauthors = Ludvigsson JF, Leffler DA, Bai JC, Biagi F, Fasano A, Green PH, Hadjivassiliou M, Kaukinen K, Kelly CP, Leonard JN, Lundin KE, Murray JA, Sanders DS, Walker MM, Zingone F, Ciacci C | display-authors = 6 | title = The Oslo definitions for coeliac disease and related terms | journal = Gut | volume = 62 | issue = 1 | pages = 43–52 | date = January 2013 | pmid = 22345659 | pmc = 3440559 | doi = 10.1136/gutjnl-2011-301346 }}</ref> In these people, the gluten-free diet is demonstrated as an effective treatment,<ref name=MulderWanrooijQuotation>{{cite journal | vauthors = Mulder CJ, van Wanrooij RL, Bakker SF, Wierdsma N, Bouma G | title = Gluten-free diet in gluten-related disorders | journal = Digestive Diseases | volume = 31 | issue = 1 | pages = 57–62 | date = 2013 | pmid = 23797124 | doi = 10.1159/000347180 | type = Review | s2cid = 14124370 | quote = The only treatment for CD, dermatitis herpetiformis (DH) and gluten ataxia is lifelong adherence to a GFD. }}</ref><ref name=HischenhuberCrevelQuotation>{{cite journal | vauthors = Hischenhuber C, Crevel R, Jarry B, Mäki M, Moneret-Vautrin DA, Romano A, Troncone R, Ward R | display-authors = 6 | title = Review article: safe amounts of gluten for patients with wheat allergy or coeliac disease | journal = Alimentary Pharmacology & Therapeutics | volume = 23 | issue = 5 | pages = 559–75 | date = March 2006 | pmid = 16480395 | doi = 10.1111/j.1365-2036.2006.02768.x | quote = For both wheat allergy and coeliac disease the dietary avoidance of wheat and other gluten-containing cereals is the only effective treatment. | s2cid = 9970042 | doi-access = free }}</ref><ref name=VoltaCaio2015Quotation>{{cite journal | vauthors = Volta U, Caio G, De Giorgio R, Henriksen C, Skodje G, Lundin KE | title = Non-celiac gluten sensitivity: a work-in-progress entity in the spectrum of wheat-related disorders | journal = Best Practice & Research. Clinical Gastroenterology | volume = 29 | issue = 3 | pages = 477–91 | date = June 2015 | pmid = 26060112 | doi = 10.1016/j.bpg.2015.04.006 | quote = A recently proposed approach to NCGS diagnosis is an objective improvement of gastrointestinal symptoms and extra-intestinal manifestations assessed through a rating scale before and after GFD. Although a standardized symptom rating scale is not yet applied worldwide, a recent study indicated that a decrease of the global symptom score higher than 50% after GFD can be regarded as confirmatory of NCGS (Table 1) [53]. (…) After the confirmation of NCGS diagnosis, according to the previously mentioned work-up, patients are advized to start with a GFD [49]. }}</ref> but several studies show that about 79% of the people with coeliac disease have an incomplete recovery of the small bowel, despite a strict gluten-free diet.<ref name=SeeKaukinen2015 /> This is mainly caused by inadvertent ingestion of gluten.<ref name=SeeKaukinen2015 /> People with a poor understanding of a gluten-free diet often believe that they are strictly following the diet, but are making regular errors.<ref name="SeeKaukinen2015"/><ref name=MulderWanrooij />
@@ Line 11: / Line 11: @@
 Gluten proteins have low [[nutrition]]al and biological value and the grains that contain gluten are not essential in the human diet.<ref name=LamacchiaCamarca2014>{{cite journal | vauthors = Lamacchia C, Camarca A, Picascia S, Di Luccia A, Gianfrani C | title = Cereal-based gluten-free food: how to reconcile nutritional and technological properties of wheat proteins with safety for celiac disease patients | journal = Nutrients | volume = 6 | issue = 2 | pages = 575–90 | date = January 2014 | pmid = 24481131 | pmc = 3942718 | doi = 10.3390/nu6020575 | type = Review | doi-access = free }}</ref> However, an unbalanced selection of food and an incorrect choice of gluten-free replacement products may lead to nutritional deficiencies. Replacing flour from wheat or other gluten-containing cereals with gluten-free flours in commercial products may lead to a lower intake of important nutrients, such as [[iron]] and [[B vitamins]]. Some gluten-free commercial replacement products are not as enriched or fortified as their gluten-containing counterparts, and often have greater [[lipid]]/[[carbohydrate]] content. Children especially often over-consume these products, such as snacks and biscuits. Nutritional complications can be prevented by a correct dietary education.<ref name=PenaginiDilillo />
-A gluten-free diet may be based on gluten-free foods, such as meat, fish, eggs, milk and dairy products, legumes, nuts, fruits, vegetables, potatoes, rice, and corn.<ref name="Saturni-etal-2010-table2-p21" /> Gluten-free [[Food processing|processed foods]] may be used.<ref name=PenaginiDilillo>{{cite journal | vauthors = Penagini F, Dilillo D, Meneghin F, Mameli C, Fabiano V, Zuccotti GV | title = Gluten-free diet in children: an approach to a nutritionally adequate and balanced diet | journal = Nutrients | volume = 5 | issue = 11 | pages = 4553–65 | date = November 2013 | pmid = 24253052 | pmc = 3847748 | doi = 10.3390/nu5114553 | quote = For CD patients on GFD, the nutritional complications are likely to be caused by the poor nutritional quality of the GFPs mentioned above and by the incorrect alimentary choices of CD patients. (...) the limited choice of food products in the diet of children with CD induces a high consumption of packaged GFPs, such as snacks like biscuits. (..) It has been shown that some commercially available GFPs have a lower content of folates, iron and B vitamins or are not consistently enriched/fortified compared to their gluten containing counterparts. (...) Within the range of naturally GF foods, it is preferable to consume those rich in iron and folic acid, such as leafy vegetables, legumes, fish and meat. | doi-access = free }}</ref> [[Pseudocereal]]s ([[quinoa]], [[amaranth]], and [[buckwheat]]) and some minor cereals have been labelled commercially as alternative choices but have since been found to be problematic among [[Non-celiac gluten sensitivity|gluten intolerant]] and [[Coeliac disease|coeliac]] individuals depending on the quantity consumed.<ref name=PenaginiDilillo /><ref name=LamacchiaCamarca2014 />
+A gluten-free diet may be based on gluten-free foods, such as meat, fish, eggs, milk and dairy products, legumes, nuts, fruits, vegetables, potatoes, rice, and corn.<ref name="Saturni-etal-2010-table2-p21" /> Gluten-free [[Food processing|processed foods]] may be used.<ref name=PenaginiDilillo>{{cite journal | vauthors = Penagini F, Dilillo D, Meneghin F, Mameli C, Fabiano V, Zuccotti GV | title = Gluten-free diet in children: an approach to a nutritionally adequate and balanced diet | journal = Nutrients | volume = 5 | issue = 11 | pages = 4553–65 | date = November 2013 | pmid = 24253052 | pmc = 3847748 | doi = 10.3390/nu5114553 | quote = For CD patients on GFD, the nutritional complications are likely to be caused by the poor nutritional quality of the GFPs mentioned above and by the incorrect alimentary choices of CD patients. (...) the limited choice of food products in the diet of children with CD induces a high consumption of packaged GFPs, such as snacks like biscuits. (..) It has been shown that some commercially available GFPs have a lower content of folates, iron and B vitamins or are not consistently enriched/fortified compared to their gluten containing counterparts. (...) Within the range of naturally GF foods, it is preferable to consume those rich in iron and folic acid, such as leafy vegetables, legumes, fish and meat. | doi-access = free }}</ref> [[Pseudocereal]]s ([[quinoa]], [[amaranth]], and [[buckwheat]]) and some minor cereals have been found to be suitable alternative choices that can provide adequate nutrition.<ref>{{Cite journal |last1=Caeiro |first1=Carolina |last2=Pragosa |first2=Caroline |last3=Cruz |first3=Marisa Carreira |last4=Pereira |first4=Cidália Daniela |last5=Pereira |first5=Sónia Gonçalves |date=2022 |editor-last=Huerta |editor-first=José María |title=The Role of Pseudocereals in Celiac Disease: Reducing Nutritional Deficiencies to Improve Well-Being and Health |journal=Journal of Nutrition and Metabolism |language=en |volume=2022 |pages=1–8 |doi=10.1155/2022/8502169 |doi-access=free |issn=2090-0732 |pmc=8850039 |pmid=35186332}}</ref>
 ==Rationale behind adoption of the diet==
@@ Line 21: / Line 21: @@
 [[Coeliac disease]] ([[American and British English spelling differences|American English]]: celiac) (CD) is a chronic, immune-mediated, and mainly intestinal process, that appears in [[genetic predisposition|genetically predisposed]] people of all ages. It is caused by the ingestion of [[gluten]], which is present in wheat, barley, rye and derivatives. Coeliac disease is not only a gastrointestinal disease, because it may affect several organs and cause an extensive variety of non-gastrointestinal symptoms, and most importantly, it may often be completely asymptomatic. Added difficulties for diagnosis are the fact that serological markers ([[Anti-transglutaminase antibodies#Anti-tissue transglutaminase|anti-tissue transglutaminase]] [TG2]) are not always present,<ref name=NEJM2012>{{cite journal | vauthors = Fasano A, Catassi C | title = Clinical practice. Celiac disease | journal = The New England Journal of Medicine | volume = 367 | issue = 25 | pages = 2419–26 | date = December 2012 | pmid = 23252527 | doi = 10.1056/NEJMcp1113994 }}</ref> and many people with coeliac may have minor mucosal lesions, without atrophy of the [[intestinal villi]].<ref name=BoldRostami>{{cite journal | vauthors = Bold J, Rostami K | title = Gluten tolerance; potential challenges in treatment strategies | journal = Gastroenterology and Hepatology from Bed to Bench | volume = 4 | issue = 2 | pages = 53–7 | date = 2011 | pmid = 24834157 | pmc = 4017406 }}</ref>
-Coeliac disease affects approximately 1–2% of the general population all over the world<ref name=LundinWijmenga2015>{{cite journal | vauthors = Lundin KE, Wijmenga C | title = Coeliac disease and autoimmune disease-genetic overlap and screening | journal = Nature Reviews. Gastroenterology & Hepatology | volume = 12 | issue = 9 | pages = 507–15 | date = September 2015 | pmid = 26303674 | doi = 10.1038/nrgastro.2015.136 | s2cid = 24533103 }}</ref> and is on the increase,<ref name=LionettiGatti2015>{{cite journal | vauthors = Lionetti E, Gatti S, Pulvirenti A, Catassi C | title = Celiac disease from a global perspective | journal = Best Practice & Research. Clinical Gastroenterology | volume = 29 | issue = 3 | pages = 365–79 | date = June 2015 | pmid = 26060103 | doi = 10.1016/j.bpg.2015.05.004 | type = Review }}</ref> but most cases remain unrecognized, undiagnosed and untreated, exposing patients to the risk of long-term complications.<ref name=Fasano2005Pediatric>{{cite journal | vauthors = Fasano A | title = Clinical presentation of celiac disease in the pediatric population | journal = Gastroenterology | volume = 128 | issue = 4 Suppl 1 | pages = S68-73 | date = April 2005 | pmid = 15825129 | doi = 10.1053/j.gastro.2005.02.015 }}</ref><ref name=ElliBranchi>{{cite journal | vauthors = Elli L, Branchi F, Tomba C, Villalta D, Norsa L, Ferretti F, Roncoroni L, Bardella MT | display-authors = 6 | title = Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity | journal = World Journal of Gastroenterology | volume = 21 | issue = 23 | pages = 7110–9 | date = June 2015 | pmid = 26109797 | pmc = 4476872 | doi = 10.3748/wjg.v21.i23.7110 | doi-access = free }}</ref> People may develop severe disease symptoms and be subjected to extensive investigations for many years before a proper diagnosis is achieved.<ref name="LudvigssonCard">{{cite journal | vauthors = Ludvigsson JF, Card T, Ciclitira PJ, Swift GL, Nasr I, Sanders DS, Ciacci C | title = Support for patients with celiac disease: A literature review | journal = United European Gastroenterology Journal | volume = 3 | issue = 2 | pages = 146–59 | date = April 2015 | pmid = 25922674 | pmc = 4406900 | doi = 10.1177/2050640614562599 | type = Review }}</ref> Untreated coeliac disease may cause [[malabsorption]], reduced [[quality of life]], [[iron deficiency]], [[osteoporosis]], obstetric complications ([[stillbirth]], [[intrauterine growth restriction]], [[preterm birth]], low [[birth weight|birthweight]], and [[small for gestational age]]),<ref name=SacconeBerghella2015>{{cite journal | vauthors = Saccone G, Berghella V, Sarno L, Maruotti GM, Cetin I, Greco L, Khashan AS, McCarthy F, Martinelli D, Fortunato F, Martinelli P | display-authors = 6 | title = Celiac disease and obstetric complications: a systematic review and metaanalysis | journal = American Journal of Obstetrics and Gynecology | volume = 214 | issue = 2 | pages = 225–234 | date = February 2016 | pmid = 26432464 | doi = 10.1016/j.ajog.2015.09.080 }}</ref> an increased risk of intestinal [[lymphoma]]s and greater mortality.<ref name="LebwoholLudvigsson-quotation"/> Coeliac disease is associated with some autoimmune diseases, such as [[diabetes mellitus type 1]], [[thyroiditis]],<ref name="LundinWijmenga2015"/> [[ataxia|gluten ataxia]], [[psoriasis]], [[vitiligo]], [[autoimmune hepatitis]], [[dermatitis herpetiformis]], [[primary sclerosing cholangitis]], and more.<ref name="LundinWijmenga2015"/>
+Coeliac disease affects approximately 1–2% of the general population all over the world<ref name=LundinWijmenga2015>{{cite journal | vauthors = Lundin KE, Wijmenga C | title = Coeliac disease and autoimmune disease-genetic overlap and screening | journal = Nature Reviews. Gastroenterology & Hepatology | volume = 12 | issue = 9 | pages = 507–15 | date = September 2015 | pmid = 26303674 | doi = 10.1038/nrgastro.2015.136 | s2cid = 24533103 }}</ref> and is on the increase,<ref name=LionettiGatti2015>{{cite journal | vauthors = Lionetti E, Gatti S, Pulvirenti A, Catassi C | title = Celiac disease from a global perspective | journal = Best Practice & Research. Clinical Gastroenterology | volume = 29 | issue = 3 | pages = 365–79 | date = June 2015 | pmid = 26060103 | doi = 10.1016/j.bpg.2015.05.004 | type = Review }}</ref> but most cases remain unrecognized, undiagnosed and untreated, exposing patients to the risk of long-term complications.<ref name=Fasano2005Pediatric>{{cite journal | vauthors = Fasano A | title = Clinical presentation of celiac disease in the pediatric population | journal = Gastroenterology | volume = 128 | issue = 4 Suppl 1 | pages = S68-73 | date = April 2005 | pmid = 15825129 | doi = 10.1053/j.gastro.2005.02.015 }}</ref><ref name=ElliBranchi>{{cite journal | vauthors = Elli L, Branchi F, Tomba C, Villalta D, Norsa L, Ferretti F, Roncoroni L, Bardella MT | display-authors = 6 | title = Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity | journal = World Journal of Gastroenterology | volume = 21 | issue = 23 | pages = 7110–9 | date = June 2015 | pmid = 26109797 | pmc = 4476872 | doi = 10.3748/wjg.v21.i23.7110 | doi-access = free }}</ref> People may develop severe disease symptoms and be subjected to extensive investigations for many years before a proper diagnosis is achieved.<ref name="LudvigssonCard">{{cite journal | vauthors = Ludvigsson JF, Card T, Ciclitira PJ, Swift GL, Nasr I, Sanders DS, Ciacci C | title = Support for patients with celiac disease: A literature review | journal = United European Gastroenterology Journal | volume = 3 | issue = 2 | pages = 146–59 | date = April 2015 | pmid = 25922674 | pmc = 4406900 | doi = 10.1177/2050640614562599 | type = Review }}</ref> Untreated coeliac disease may cause [[malabsorption]], reduced [[quality of life]], [[iron deficiency]], [[osteoporosis]], obstetric complications ([[stillbirth]], [[intrauterine growth restriction]], [[preterm birth]], low [[birth weight|birthweight]], and [[small for gestational age]]),<ref name=SacconeBerghella2015>{{cite journal | vauthors = Saccone G, Berghella V, Sarno L, Maruotti GM, Cetin I, Greco L, Khashan AS, McCarthy F, Martinelli D, Fortunato F, Martinelli P | display-authors = 6 | title = Celiac disease and obstetric complications: a systematic review and metaanalysis | journal = American Journal of Obstetrics and Gynecology | volume = 214 | issue = 2 | pages = 225–234 | date = February 2016 | pmid = 26432464 | doi = 10.1016/j.ajog.2015.09.080 | hdl = 11369/330101 | hdl-access = free }}</ref> an increased risk of intestinal [[lymphoma]]s and greater mortality.<ref name="LebwoholLudvigsson-quotation"/> Coeliac disease is associated with some autoimmune diseases, such as [[diabetes mellitus type 1]], [[thyroiditis]],<ref name="LundinWijmenga2015"/> [[ataxia|gluten ataxia]], [[psoriasis]], [[vitiligo]], [[autoimmune hepatitis]], [[dermatitis herpetiformis]], [[primary sclerosing cholangitis]], and more.<ref name="LundinWijmenga2015"/>
-Coeliac disease with "classic symptoms", which include gastrointestinal manifestations such as chronic diarrhea and abdominal distention, malabsorption, loss of appetite, and impaired growth, is currently the least common presentation form of the disease and affects predominantly to small children generally younger than two years of age.<ref name=Fasano2005Pediatric /><ref name=LudvigssonCard />
+Coeliac disease with "classic symptoms", which include gastrointestinal manifestations such as chronic diarrhea and abdominal distention, malabsorption, loss of appetite, and impaired growth, is currently the least common presentation of the disease and affects predominantly small children generally younger than two years of age.<ref name=Fasano2005Pediatric /><ref name=LudvigssonCard />
 Coeliac disease with "non-classic symptoms" is the most common clinical type and occurs in older children (over two years old), adolescents and adults.<ref name=LudvigssonCard /> It is characterized by milder or even absent gastrointestinal symptoms and a wide spectrum of non-intestinal manifestations that can involve any organ of the body, and very frequently may be completely asymptomatic<ref name=Fasano2005Pediatric /> both in children (at least in 43% of the cases<ref name="VriezingaSchweizer2015">{{cite journal | vauthors = Vriezinga SL, Schweizer JJ, Koning F, Mearin ML | title = Coeliac disease and gluten-related disorders in childhood | journal = Nature Reviews. Gastroenterology & Hepatology | volume = 12 | issue = 9 | pages = 527–36 | date = September 2015 | pmid = 26100369 | doi = 10.1038/nrgastro.2015.98 | type = Review | s2cid = 2023530 }}</ref>) and adults.<ref name=Fasano2005Pediatric />
-Following a lifelong gluten-free diet is the only medically-accepted treatment for people with coeliac disease.<ref name=LamacchiaCamarca2014 /><ref name="De Palma">{{cite journal | vauthors = De Palma G, Nadal I, Collado MC, Sanz Y | title = Effects of a gluten-free diet on gut microbiota and immune function in healthy adult human subjects | journal = The British Journal of Nutrition | volume = 102 | issue = 8 | pages = 1154–60 | date = October 2009 | pmid = 19445821 | doi = 10.1017/S0007114509371767 | doi-access = free | hdl = 10261/15885 | hdl-access = free }}</ref>
+Following a lifelong gluten-free diet is the only medically accepted treatment for people with coeliac disease.<ref name=LamacchiaCamarca2014 /><ref name="De Palma">{{cite journal | vauthors = De Palma G, Nadal I, Collado MC, Sanz Y | title = Effects of a gluten-free diet on gut microbiota and immune function in healthy adult human subjects | journal = The British Journal of Nutrition | volume = 102 | issue = 8 | pages = 1154–60 | date = October 2009 | pmid = 19445821 | doi = 10.1017/S0007114509371767 | doi-access = free | hdl = 10261/15885 | hdl-access = free }}</ref>
 ===Non-coeliac gluten sensitivity===
@@ Line 33: / Line 33: @@
 Non-coeliac gluten sensitivity (NCGS) is described as a condition of multiple symptoms that improves when switching to a gluten-free diet, after coeliac disease and wheat allergy are excluded.<ref>{{cite journal | vauthors = Mooney PD, Aziz I, Sanders DS | title = Non-celiac gluten sensitivity: clinical relevance and recommendations for future research | journal = Neurogastroenterology and Motility | volume = 25 | issue = 11 | pages = 864–71 | date = November 2013 | pmid = 23937528 | doi = 10.1111/nmo.12216 | s2cid = 9277897 }}</ref><ref>{{cite journal | vauthors = Nijeboer P, Bontkes HJ, Mulder CJ, Bouma G | title = Non-celiac gluten sensitivity. Is it in the gluten or the grain? | journal = Journal of Gastrointestinal and Liver Diseases | volume = 22 | issue = 4 | pages = 435–40 | date = December 2013 | pmid = 24369326 }}</ref> People with NCGS may develop gastrointestinal symptoms, which resemble those of [[irritable bowel syndrome]] (IBS)<ref name=ElliRoncorni>{{cite journal | vauthors = Elli L, Roncoroni L, Bardella MT | title = Non-celiac gluten sensitivity: Time for sifting the grain | journal = World Journal of Gastroenterology | volume = 21 | issue = 27 | pages = 8221–6 | date = July 2015 | pmid = 26217073 | pmc = 4507091 | doi = 10.3748/wjg.v21.i27.8221 | type = Review | doi-access = free }}</ref><ref name=CatassiBai>{{cite journal | vauthors = Catassi C, Bai JC, Bonaz B, Bouma G, Calabrò A, Carroccio A, Castillejo G, Ciacci C, Cristofori F, Dolinsek J, Francavilla R, Elli L, Green P, Holtmeier W, Koehler P, Koletzko S, Meinhold C, Sanders D, Schumann M, Schuppan D, Ullrich R, Vécsei A, Volta U, Zevallos V, Sapone A, Fasano A | display-authors = 6 | title = Non-Celiac Gluten sensitivity: the new frontier of gluten related disorders | journal = Nutrients | volume = 5 | issue = 10 | pages = 3839–53 | date = September 2013 | pmid = 24077239 | pmc = 3820047 | doi = 10.3390/nu5103839 | doi-access = free }}</ref> or a variety of nongastrointestinal symptoms.<ref name=VoltaCaio2015>{{cite journal | vauthors = Volta U, Caio G, De Giorgio R, Henriksen C, Skodje G, Lundin KE | title = Non-celiac gluten sensitivity: a work-in-progress entity in the spectrum of wheat-related disorders | journal = Best Practice & Research. Clinical Gastroenterology | volume = 29 | issue = 3 | pages = 477–91 | date = June 2015 | pmid = 26060112 | doi = 10.1016/j.bpg.2015.04.006 }}</ref><ref name=FasanoSapone2015 /><ref name="CatassiBai2013">{{cite journal | vauthors = Catassi C, Bai JC, Bonaz B, Bouma G, Calabrò A, Carroccio A, Castillejo G, Ciacci C, Cristofori F, Dolinsek J, Francavilla R, Elli L, Green P, Holtmeier W, Koehler P, Koletzko S, Meinhold C, Sanders D, Schumann M, Schuppan D, Ullrich R, Vécsei A, Volta U, Zevallos V, Sapone A, Fasano A | display-authors = 6 | title = Non-Celiac Gluten sensitivity: the new frontier of gluten related disorders | journal = Nutrients | volume = 5 | issue = 10 | pages = 3839–53 | date = September 2013 | pmid = 24077239 | pmc = 3820047 | doi = 10.3390/nu5103839 | type = Review | doi-access = free }}</ref>
-Gastrointestinal symptoms may include any of the following: [[abdominal pain]], [[bloating]], bowel habit abnormalities (either [[diarrhea|diarrhoea]] or [[constipation]]),<ref name=VoltaCaio2015 /><ref name="CatassiBai2013" /> [[nausea]], [[aerophagia]], [[gastroesophageal reflux disease]], and [[aphthous stomatitis]].<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /> A range of extra-intestinal symptoms, said to be the only manifestation of NCGS in the absence of gastrointestinal symptoms,<ref name=VoltaCaio2015 /><ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /> have been suggested, but remain controversial.<ref name="LebwoholLudvigsson-quotation"/><ref name=AzizHadjivassiliou2015>{{cite journal | vauthors = Aziz I, Hadjivassiliou M, Sanders DS | title = The spectrum of noncoeliac gluten sensitivity | journal = Nature Reviews. Gastroenterology & Hepatology | volume = 12 | issue = 9 | pages = 516–26 | date = September 2015 | pmid = 26122473 | doi = 10.1038/nrgastro.2015.107 | type = Review | s2cid = 2867448 }}</ref> These include: [[headache]], [[migraine]], "[[Clouding of consciousness|brain fog]]", [[fatigue (medical)|fatigue]], [[fibromyalgia]],<ref name=AzizHadjivassiliou2015 /><ref name=RossiDiLollo>{{cite journal | vauthors = Rossi A, Di Lollo AC, Guzzo MP, Giacomelli C, Atzeni F, Bazzichi L, Di Franco M | title = Fibromyalgia and nutrition: what news? | journal = Clinical and Experimental Rheumatology | volume = 33 | issue = 1 Suppl 88 | pages = S117-25 | date = 2015 | pmid = 25786053 | type = Review }}</ref> joint and muscle pain, leg or arm [[hypoesthesia|numbness]], [[paresthesia|tingling]] of the extremities, dermatitis ([[dermatitis|eczema]] or [[rash|skin rash]]), [[atopy|atopic disorders]] such as [[asthma]], [[rhinitis]], other [[allergy|allergies]], [[depression (mood)|depression]], [[anxiety]], [[iron-deficiency anemia]], [[folate deficiency]] or [[autoimmune disease]]s.<ref name=VoltaCaio2015 /><ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=AzizHadjivassiliou2015 />  NCGS has also been controversially implicated in some [[neuropsychiatric disorder]]s, including [[schizophrenia]], [[eating disorder]]s, [[autism]], [[peripheral neuropathy]], [[ataxia]] and [[attention deficit hyperactivity disorder]] (ADHD).<ref name=VoltaCaio2015 /><ref name="LebwoholLudvigsson-quotation"/><ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=AzizHadjivassiliou2015 /> Above 20% of people with NCGS have IgE-mediated allergy to one or more inhalants, foods or metals, among which most common are [[mite]]s, [[poaceae|graminaceae]], [[parietaria]], cat or dog hair, [[shellfish]] and [[nickel]].<ref name=VoltaCaio2015 />  Approximately, 35% of people with NCGS have other [[food intolerance]]s, mainly [[lactose intolerance]].<ref name=AzizHadjivassiliou2015 />
+Gastrointestinal symptoms may include any of the following: [[abdominal pain]], [[bloating]], bowel habit abnormalities (either [[diarrhea]] or [[constipation]]),<ref name=VoltaCaio2015 /><ref name="CatassiBai2013" /> [[nausea]], [[aerophagia]], [[gastroesophageal reflux disease]], and [[aphthous stomatitis]].<ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /> A range of extra-intestinal symptoms, said to be the only manifestation of NCGS in the absence of gastrointestinal symptoms,<ref name=VoltaCaio2015 /><ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /> have been suggested, but remain controversial.<ref name="LebwoholLudvigsson-quotation"/><ref name=AzizHadjivassiliou2015>{{cite journal | vauthors = Aziz I, Hadjivassiliou M, Sanders DS | title = The spectrum of noncoeliac gluten sensitivity | journal = Nature Reviews. Gastroenterology & Hepatology | volume = 12 | issue = 9 | pages = 516–26 | date = September 2015 | pmid = 26122473 | doi = 10.1038/nrgastro.2015.107 | type = Review | s2cid = 2867448 }}</ref> These include: [[headache]], [[migraine]], "[[Clouding of consciousness|brain fog]]", [[fatigue (medical)|fatigue]], [[fibromyalgia]],<ref name=AzizHadjivassiliou2015 /><ref name=RossiDiLollo>{{cite journal | vauthors = Rossi A, Di Lollo AC, Guzzo MP, Giacomelli C, Atzeni F, Bazzichi L, Di Franco M | title = Fibromyalgia and nutrition: what news? | journal = Clinical and Experimental Rheumatology | volume = 33 | issue = 1 Suppl 88 | pages = S117-25 | date = 2015 | pmid = 25786053 | type = Review }}</ref> joint and muscle pain, leg or arm [[hypoesthesia|numbness]], [[paresthesia|tingling]] of the extremities, dermatitis ([[dermatitis|eczema]] or [[rash|skin rash]]), [[atopy|atopic disorders]] such as [[asthma]], [[rhinitis]], other [[allergy|allergies]], [[depression (mood)|depression]], [[anxiety]], [[iron-deficiency anemia]], [[folate deficiency]] or [[autoimmune disease]]s.<ref name=VoltaCaio2015 /><ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=AzizHadjivassiliou2015 />  NCGS has also been controversially implicated in some [[neuropsychiatric disorder]]s, including [[schizophrenia]], [[eating disorder]]s, [[autism]], [[peripheral neuropathy]], [[ataxia]] and [[attention deficit hyperactivity disorder]] (ADHD).<ref name=VoltaCaio2015 /><ref name="LebwoholLudvigsson-quotation"/><ref name=FasanoSapone2015 /><ref name="CatassiBai2013" /><ref name=AzizHadjivassiliou2015 /> Above 20% of people with NCGS have IgE-mediated allergy to one or more inhalants, foods or metals, among which most common are [[mite]]s, [[poaceae|graminaceae]], [[parietaria]], cat or dog hair, [[shellfish]] and [[nickel]].<ref name=VoltaCaio2015 />  Approximately, 35% of people with NCGS have other [[food intolerance]]s, mainly [[lactose intolerance]].<ref name=AzizHadjivassiliou2015 />
 The pathogenesis of NCGS is not yet well understood. For this reason, it is a controversial syndrome<ref name=VriezingaSchweizer2015/> and some authors still question it.<ref name=FasanoSapone2015Quotation2>{{cite journal | vauthors = Fasano A, Sapone A, Zevallos V, Schuppan D | title = Nonceliac gluten sensitivity | journal = Gastroenterology | volume = 148 | issue = 6 | pages = 1195–204 | date = May 2015 | pmid = 25583468 | doi = 10.1053/j.gastro.2014.12.049 | type = Review | quote = One of the most controversial and highly debated discussions concerns the role of gluten in causing NCGS. Recent reports have indicated that gluten might not be the cause of NCGS, and some investigators still question whether NCGS as a real clinical entity. (...) Cereals such as wheat and rye, when consumed in normal quantities, are only minor sources of FODMAPs in the daily diet (Table 1). Therefore, gluten-containing grains are not likely to induce IBS exclusively via FODMAPs. In contrast, there is growing evidence that other proteins that are unique to gluten-containing cereals can elicit an innate immune response that leads to NCGS, raising a nomenclature issue. For this reason, wheat sensitivity, rather than gluten sensitivity, seems to be a more appropriate term, keeping in mind that other gluten-containing grains such as barley and rye also can trigger the symptoms. | doi-access = free }}</ref> There is evidence that not only [[gliadin]] (the main cytotoxic antigen of gluten), but also other proteins named ATIs which are present in gluten-containing cereals ([[wheat]], [[rye]], [[barley]], and their derivatives) may have a role in the development of symptoms. ATIs are potent activators of the [[innate immune system]].<ref name="FasanoSapone2015">{{cite journal | vauthors = Fasano A, Sapone A, Zevallos V, Schuppan D | title = Nonceliac gluten sensitivity | journal = Gastroenterology | volume = 148 | issue = 6 | pages = 1195–204 | date = May 2015 | pmid = 25583468 | doi = 10.1053/j.gastro.2014.12.049 | type = Review | doi-access = free }}</ref><ref name=Verbeke2018 /> [[FODMAP]]s, especially [[fructans]], are present in small amounts in gluten-containing grains and have been identified as a possible cause of some gastrointestinal symptoms in persons with NCGS.<ref name=FasanoSapone2015 /><ref name="VoltaCaioQuestions" /><ref name=Verbeke2018 /><ref name=OntiverosHardy>{{cite journal | vauthors = Ontiveros N, Hardy MY, Cabrera-Chavez F | title = Assessing of Celiac Disease and Nonceliac Gluten Sensitivity | journal = Gastroenterology Research and Practice | volume = 2015 | pages = 723954 | year = 2015 | pmid = 26064097 | pmc = 4429206 | doi = 10.1155/2015/723954 | type = Review | doi-access = free }}</ref> As of 2019, reviews have concluded that although FODMAPs may play a role in NCGS, they only explain certain gastrointestinal symptoms, such as [[bloating]], but not the [[#Extraintestinal|extra-digestive symptoms]] that people with NCGS may develop, such as [[neurological disorder]]s, [[fibromyalgia]], psychological disturbances, and [[dermatitis]].<ref name=Verbeke2018 /><ref name=VoltaDeGiorgio2019 /><ref name="FasanoSapone2015" />
-After exclusion of coeliac disease and wheat allergy,<ref name="mansueto-etal-2014">{{cite journal | vauthors = Mansueto P, Seidita A, D'Alcamo A, Carroccio A | title = Non-celiac gluten sensitivity: literature review | journal = Journal of the American College of Nutrition | volume = 33 | issue = 1 | pages = 39–54 | year = 2014 | pmid = 24533607 | doi = 10.1080/07315724.2014.869996 | hdl-access = free | type = Review | s2cid = 22521576 | hdl = 10447/90208 }}</ref> the subsequent step for diagnosis and treatment of NCGS is to start a strict gluten-free diet to assess if symptoms improve or resolve completely. This may occur within days to weeks of starting a GFD, but improvement may also be due to a non-specific, placebo response.<ref name="GenuisLobo2014">{{cite journal | vauthors = Genuis SJ, Lobo RA | title = Gluten sensitivity presenting as a neuropsychiatric disorder | journal = Gastroenterology Research and Practice | volume = 2014 | pages = 293206 | year = 2014 | pmid = 24693281 | pmc = 3944951 | doi = 10.1155/2014/293206 | type = Review | doi-access = free }}</ref> Recommendations may resemble those for coeliac disease, for the diet to be strict and maintained, with no transgression.<ref name=VoltaCaio2015 /> The degree of gluten [[cross contamination]] tolerated by people with NCGS is not clear but there is some evidence that they can present with symptoms even after consumption of small amounts.<ref name=VoltaCaio2015 /> It is not yet known whether NCGS is a permanent or a transient condition.<ref name=VoltaCaio2015 /><ref name=VriezingaSchweizer2015 /> A trial of gluten reintroduction to observe any reaction after 1–2 years of strict gluten-free diet might be performed.<ref name=VoltaCaio2015 />
+After exclusion of coeliac disease and wheat allergy,<ref name="mansueto-etal-2014">{{cite journal | vauthors = Mansueto P, Seidita A, D'Alcamo A, Carroccio A | title = Non-celiac gluten sensitivity: literature review | journal = Journal of the American College of Nutrition | volume = 33 | issue = 1 | pages = 39–54 | year = 2014 | pmid = 24533607 | doi = 10.1080/07315724.2014.869996 | hdl-access = free | type = Review | s2cid = 22521576 | hdl = 10447/90208 }}</ref> the subsequent step for diagnosis and treatment of NCGS is to start a strict gluten-free diet to assess if symptoms improve or resolve completely. This may occur within days to weeks of starting a GFD, but improvement may also be due to a non-specific, placebo response.<ref name="GenuisLobo2014">{{cite journal | vauthors = Genuis SJ, Lobo RA | title = Gluten sensitivity presenting as a neuropsychiatric disorder | journal = Gastroenterology Research and Practice | volume = 2014 | pages = 293206 | year = 2014 | pmid = 24693281 | pmc = 3944951 | doi = 10.1155/2014/293206 | type = Review | doi-access = free }}</ref> Recommendations may resemble those for coeliac disease, for the diet to be strict and maintained, with no transgression.<ref name=VoltaCaio2015 /> The degree of gluten [[cross contamination]] tolerated by people with NCGS is not clear but there is some evidence that they can present with symptoms even after consumption of small amounts.<ref name=VoltaCaio2015 /> It is not yet known whether NCGS is a permanent or a transient condition.<ref name=VoltaCaio2015 /><ref name=VriezingaSchweizer2015 /> A trial of gluten reintroduction to observe any reaction after one–two years of strict gluten-free diet might be performed.<ref name=VoltaCaio2015 />
 A subgroup of people with NCGS may not improve by eating commercially available gluten-free products, which are usually rich of preservatives and additives, because chemical [[food additive|additives]] (such as [[sulphite]]s, [[glutamic acid|glutamates]], [[nitrate]]s and [[benzoic acid|benzoates]]) might have a role in evoking functional gastrointestinal symptoms of NCGS. These people may benefit from a diet with a low content of preservatives and additives.<ref name="VoltaCaioQuestions">{{cite journal | vauthors = Volta U, Caio G, Tovoli F, De Giorgio R | title = Non-celiac gluten sensitivity: questions still to be answered despite increasing awareness | journal = Cellular & Molecular Immunology | volume = 10 | issue = 5 | pages = 383–92 | date = September 2013 | pmid = 23934026 | pmc = 4003198 | doi = 10.1038/cmi.2013.28 | type = Review }}</ref>
@@ Line 60: / Line 60: @@
 ===As a popular diet===
-Since the beginning of the 21st century, the gluten-free diet has become the most popular [[fad diet]] in the United States and other countries.<ref name="FasanoSapone2015" /> Clinicians worldwide have been challenged by an increasing number of people who do not have coeliac disease nor wheat allergy, with digestive or extra-digestive symptoms which improved removing wheat/gluten from the diet. Many of these persons began a gluten-free diet on their own, without having been previously evaluated.<ref name=VoltaCaio2017>{{cite journal | vauthors = Volta U, Caio G, Karunaratne TB, Alaedini A, De Giorgio R | title = Non-coeliac gluten/wheat sensitivity: advances in knowledge and relevant questions | journal = Expert Review of Gastroenterology & Hepatology | volume = 11 | issue = 1 | pages = 9–18 | date = January 2017 | pmid = 27852116 | doi = 10.1080/17474124.2017.1260003 | type = Review | s2cid = 34881689 }}</ref><ref name="LebwoholLudvigsson-quotation"/> Another reason that contributed to this trend was the publication of several books that demonize gluten and point to it as a cause of type 2 diabetes, weight gain and obesity, and a broad list of diseases ranging from depression and anxiety to arthritis and autism.<ref name="NashSlutzky2014" /><ref name="ShewryHey2016">{{cite journal | vauthors = Shewry PR, Hey SJ | title = Do we need to worry about eating wheat? | journal = Nutrition Bulletin | volume = 41 | issue = 1 | pages = 6–13 | date = March 2016 | pmid = 26941586 | pmc = 4760426 | doi = 10.1111/nbu.12186 }}</ref> The book that has had the most impact is ''Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar—Your Brain's Silent Killers'', by the American neurologist [[David Perlmutter]], published in September 2013.<ref name="NashSlutzky2014" /> Another book that has had great impact is [[William Davis (cardiologist)#Wheat Belly in the public forum|''Wheat Belly: Lose the Wheat, Lose the Weight, and Find Your Path Back to Health'']], by the cardiologist William Davis, which refers to wheat as a "chronic poison" and became a [[The New York Times Best Seller list|''New York Times'' bestseller]] within a month of publication in 2011.<ref>{{cite web | author=David Quick | url=http://www.postandcourier.com/article/20120911/PC1211/120919931/1020/quick-column-wheat-belly-continues-its-run-on-nyt-best-seller-list-but-is-demonizing-wheat-and-gluten-justified | title='Wheat Belly' continues its run on NYT Best Seller list, but is demonizing wheat and gluten justified? | work=The Post and Courier | date= September 11, 2012 | access-date=December 16, 2012}}</ref> The gluten-free diet has been advocated and followed by many celebrities to lose weight, such as [[Miley Cyrus]], [[Gwyneth Paltrow]], and [[Kourtney Kardashian]], and are used by some professional athletes, who believe the diet can improve energy and health.<ref name="LebwoholLudvigsson-quotation">{{cite journal | vauthors = Lebwohl B, Ludvigsson JF, Green PH | title = Celiac disease and non-celiac gluten sensitivity | journal = BMJ | volume = 351 | pages = h4347 | date = October 2015 | pmid = 26438584 | pmc = 4596973 | doi = 10.1136/bmj.h4347 | quote = Some population groups seem to be especially wed to the gluten-free diet, with nearly 50% of 910 athletes (including world class and Olympic medalists) adhering to a gluten-free diet, mainly because of the perceived health and energy benefits. | type = Review }}</ref><ref name="Jones2017">{{cite journal | vauthors = Jones AL | title = The Gluten-Free Diet: Fad or Necessity? | journal = Diabetes Spectrum | volume = 30 | issue = 2 | pages = 118–123 | date = May 2017 | pmid = 28588378 | pmc = 5439366 | doi = 10.2337/ds16-0022 }}</ref><ref name="USAToday2013">{{cite news|title=Is gluten-free a lifestyle or a diet craze?|url=https://www.usatoday.com/story/news/nation/2013/03/05/gluten-free-diet-popularity/1963715/|work=[[USA Today]]|date=5 March 2013|access-date=4 April 2018}}</ref><ref>{{Cite web|url=http://www.instyle.com/celebrity/gluten-free-stars|title=Celebrities Who Are Gluten-Free|website=InStyle}}</ref> It became popular in the US, as the popularity of low-carbohydrate diets faded.<ref name=":0">{{Cite news |url=http://freakonomics.com/podcast/demonization-gluten/ |title=The Demonization of Gluten | vauthors = Dubner SJ |date=18 October 2017 |work=Freakonomics |access-date=2017-11-06|archive-url=https://web.archive.org/web/20171019055039/http://freakonomics.com/podcast/demonization-gluten/|archive-date=2017-10-19|url-status=dead|language=en-US}}</ref>
+Since the beginning of the 21st century, the gluten-free diet has become the most popular [[fad diet]] in the United States and other countries.<ref name="FasanoSapone2015" /> Clinicians worldwide have been challenged by an increasing number of people who do not have coeliac disease nor wheat allergy, with digestive or extra-digestive symptoms which improved removing wheat/gluten from the diet. Many of these persons began a gluten-free diet on their own, without having been previously evaluated.<ref name=VoltaCaio2017>{{cite journal | vauthors = Volta U, Caio G, Karunaratne TB, Alaedini A, De Giorgio R | title = Non-coeliac gluten/wheat sensitivity: advances in knowledge and relevant questions | journal = Expert Review of Gastroenterology & Hepatology | volume = 11 | issue = 1 | pages = 9–18 | date = January 2017 | pmid = 27852116 | doi = 10.1080/17474124.2017.1260003 | type = Review | s2cid = 34881689 }}</ref><ref name="LebwoholLudvigsson-quotation"/> Another reason that contributed to this trend was the publication of several books that demonize gluten and point to it as a cause of type 2 diabetes, weight gain and obesity, and a broad list of diseases ranging from depression and anxiety to arthritis and autism.<ref name="NashSlutzky2014" /><ref name="ShewryHey2016">{{cite journal | vauthors = Shewry PR, Hey SJ | title = Do we need to worry about eating wheat? | journal = Nutrition Bulletin | volume = 41 | issue = 1 | pages = 6–13 | date = March 2016 | pmid = 26941586 | pmc = 4760426 | doi = 10.1111/nbu.12186 }}</ref> The book that has had the most impact is ''Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar—Your Brain's Silent Killers'', by the American neurologist [[David Perlmutter]], published in September 2013.<ref name="NashSlutzky2014" /> Another book that has had great impact is [[William Davis (cardiologist)#Wheat Belly in the public forum|''Wheat Belly: Lose the Wheat, Lose the Weight, and Find Your Path Back to Health'']], by the cardiologist William Davis, which refers to wheat as a "chronic poison" and became a [[The New York Times Best Seller list|''New York Times'' bestseller]] within a month of publication in 2011.<ref>{{cite web | author=David Quick | url=http://www.postandcourier.com/article/20120911/PC1211/120919931/1020/quick-column-wheat-belly-continues-its-run-on-nyt-best-seller-list-but-is-demonizing-wheat-and-gluten-justified | title='Wheat Belly' continues its run on NYT Best Seller list, but is demonizing wheat and gluten justified? | work=The Post and Courier | date= September 11, 2012 | access-date=December 16, 2012}}</ref> The gluten-free diet has been advocated and followed by many celebrities to lose weight, such as [[Miley Cyrus]], [[Gwyneth Paltrow]], and [[Kourtney Kardashian]], and are used by some professional athletes, who believe the diet can improve energy and health.<ref name="LebwoholLudvigsson-quotation">{{cite journal | vauthors = Lebwohl B, Ludvigsson JF, Green PH | title = Celiac disease and non-celiac gluten sensitivity | journal = BMJ | volume = 351 | pages = h4347 | date = October 2015 | pmid = 26438584 | pmc = 4596973 | doi = 10.1136/bmj.h4347 | quote = Some population groups seem to be especially wed to the gluten-free diet, with nearly 50% of 910 athletes (including world class and Olympic medalists) adhering to a gluten-free diet, mainly because of the perceived health and energy benefits. | type = Review }}</ref><ref name="Jones2017">{{cite journal | vauthors = Jones AL | title = The Gluten-Free Diet: Fad or Necessity? | journal = Diabetes Spectrum | volume = 30 | issue = 2 | pages = 118–123 | date = May 2017 | pmid = 28588378 | pmc = 5439366 | doi = 10.2337/ds16-0022 }}</ref><ref name="USAToday2013">{{cite news|title=Is gluten-free a lifestyle or a diet craze?|url=https://www.usatoday.com/story/news/nation/2013/03/05/gluten-free-diet-popularity/1963715/|work=[[USA Today]]|date=5 March 2013|access-date=4 April 2018}}</ref><ref>{{Cite web|url=http://www.instyle.com/celebrity/gluten-free-stars|title=Celebrities Who Are Gluten-Free|website=InStyle|access-date=April 6, 2018|archive-date=April 6, 2018|archive-url=https://web.archive.org/web/20180406102411/http://www.instyle.com/celebrity/gluten-free-stars|url-status=dead}}</ref> It became popular in the US, as the popularity of low-carbohydrate diets faded.<ref name=":0">{{Cite news |url=http://freakonomics.com/podcast/demonization-gluten/ |title=The Demonization of Gluten | vauthors = Dubner SJ |date=18 October 2017 |work=Freakonomics |access-date=2017-11-06|archive-url=https://web.archive.org/web/20171019055039/http://freakonomics.com/podcast/demonization-gluten/|archive-date=2017-10-19|url-status=dead|language=en-US}}</ref>
-Estimates suggest that in 2014, 30% of people in the US and Australia were consuming gluten-free foods, with a growing number, calculated from surveys that by 2016 approximately 100 million Americans would consume gluten-free products.<ref name=FasanoSapone2015 /><ref name="NashSlutzky2014">{{cite journal | vauthors = Nash DT, Slutzky AR | title = Gluten sensitivity: new epidemic or new myth? | journal = Proceedings | volume = 27 | issue = 4 | pages = 377–8 | date = October 2014 | pmid = 25484517 | pmc = 4255872 | doi = 10.1080/08998280.2014.11929164 }}</ref><ref name="HeraldSun2014">{{cite news|title=An increasing number of Australians are choosing a gluten-free diet |url=http://www.heraldsun.com.au/news/national/an-increasing-number-of-australians-are-choosing-a-glutenfree-diet/news-story/55fe0b30277e721cc69f1eeb6191c130 |work=[[Herald Sun]] |date=18 November 2014|access-date=4 April 2018}}</ref> Data from a 2015 Nielsen survey of 30,000 adults in 60 countries around the world conclude that 21% of people prefer to buy gluten-free foods, being the highest interest among the younger generations.<ref name="Reilly2016">{{cite journal | vauthors = Reilly NR | title = The Gluten-Free Diet: Recognizing Fact, Fiction, and Fad | journal = The Journal of Pediatrics | volume = 175 | pages = 206–10 | date = August 2016 | pmid = 27185419 | doi = 10.1016/j.jpeds.2016.04.014 | doi-access = free }}</ref> In the US, it was estimated that more than half of people who buy foods labeled gluten-free do not have a clear reaction to gluten, and they do so "because they think it will help them lose weight, because they seem to feel better or because they mistakenly believe they are sensitive to gluten."<ref name=CBS>{{cite web |url=http://www.cbsnews.com/8301-504763_162-57483789-10391704/gluten-free-diet-fad-are-celiac-disease-rates-actually-rising/ |title=Gluten-free diet fad: Are celiac disease rates actually rising? |publisher=[[CBS News]] |date=2012-07-31 |access-date=2013-12-06}}</ref> Although gluten is highly immunologically reactive and humans appear not to have evolved to digest it well, a gluten-free diet is not a healthier option for the general population, other than people with [[gluten#Disorders|gluten-related disorders]] or other associated conditions which improve with a gluten-free diet in some cases, such as irritable bowel syndrome and certain autoimmune and neurological disorders.<ref name="ElChammasDanner2011Quotation" /><ref name="Pietzak2012"/><ref name="GaesserAngadi2012">{{cite journal | vauthors = Gaesser GA, Angadi SS | title = Gluten-free diet: imprudent dietary advice for the general population? | journal = Journal of the Academy of Nutrition and Dietetics | volume = 112 | issue = 9 | pages = 1330–1333 | date = September 2012 | pmid = 22939437 | doi = 10.1016/j.jand.2012.06.009 | doi-access = free }}</ref> There is no published experimental evidence to support that the gluten-free diet contributes to weight loss.<ref name="GaesserAngadi2012" />
+Estimates suggest that in 2014, 30% of people in the US and Australia were consuming gluten-free foods, with a growing number, calculated from surveys that by 2016 approximately 100 million Americans would consume gluten-free products.<ref name=FasanoSapone2015 /><ref name="NashSlutzky2014">{{cite journal | vauthors = Nash DT, Slutzky AR | title = Gluten sensitivity: new epidemic or new myth? | journal = Proceedings | volume = 27 | issue = 4 | pages = 377–8 | date = October 2014 | pmid = 25484517 | pmc = 4255872 | doi = 10.1080/08998280.2014.11929164 }}</ref><ref name="HeraldSun2014">{{cite news|title=An increasing number of Australians are choosing a gluten-free diet |url=http://www.heraldsun.com.au/news/national/an-increasing-number-of-australians-are-choosing-a-glutenfree-diet/news-story/55fe0b30277e721cc69f1eeb6191c130 |work=[[Herald Sun]] |date=18 November 2014|access-date=4 April 2018}}</ref> Data from a 2015 Nielsen survey of 30,000 adults in 60 countries around the world conclude that 21% of people prefer to buy gluten-free foods, being the highest interest among the younger generations.<ref name="Reilly2016">{{cite journal | vauthors = Reilly NR | title = The Gluten-Free Diet: Recognizing Fact, Fiction, and Fad | journal = The Journal of Pediatrics | volume = 175 | pages = 206–10 | date = August 2016 | pmid = 27185419 | doi = 10.1016/j.jpeds.2016.04.014 | doi-access = free }}</ref> In the US, it was estimated that more than half of people who buy foods labeled gluten-free do not have a clear reaction to gluten, and they do so "because they think it will help them lose weight, because they seem to feel better or because they mistakenly believe they are sensitive to gluten."<ref name=CBS>{{cite web |url=https://www.cbsnews.com/news/gluten-free-diet-fad-are-celiac-disease-rates-actually-rising/ |title=Gluten-free diet fad: Are celiac disease rates actually rising? |publisher=[[CBS News]] |date=2012-07-31 |access-date=2013-12-06}}</ref> Although gluten is highly immunologically reactive and humans appear not to have evolved to digest it well, a gluten-free diet is not a healthier option for the general population, other than people with [[gluten#Disorders|gluten-related disorders]] or other associated conditions which improve with a gluten-free diet in some cases, such as irritable bowel syndrome and certain autoimmune and neurological disorders.<ref name="ElChammasDanner2011Quotation" /><ref name="Pietzak2012"/><ref name="GaesserAngadi2012">{{cite journal | vauthors = Gaesser GA, Angadi SS | title = Gluten-free diet: imprudent dietary advice for the general population? | journal = Journal of the Academy of Nutrition and Dietetics | volume = 112 | issue = 9 | pages = 1330–1333 | date = September 2012 | pmid = 22939437 | doi = 10.1016/j.jand.2012.06.009 | doi-access = free }}</ref> There is no published experimental evidence to support that the gluten-free diet contributes to weight loss.<ref name="GaesserAngadi2012" />
 In a review of May 2015 published in ''[[Gastroenterology (journal)|Gastroenterology]]'', Fasano et al. conclude that, although there is an evident "fad component" to the recent rise in popularity of the gluten-free diet, there is also growing and unquestionable evidence of the existence of non-coeliac gluten sensitivity.<ref name="FasanoSapone2015-quotation">{{cite journal | vauthors = Fasano A, Sapone A, Zevallos V, Schuppan D | title = Nonceliac gluten sensitivity | journal = Gastroenterology | volume = 148 | issue = 6 | pages = 1195–204 | date = May 2015 | pmid = 25583468 | doi = 10.1053/j.gastro.2014.12.049 | quote = Although there is clearly a fad component to the popularity of the GFD, there is also undisputable and increasing evidence for NCGS. | doi-access = free }}</ref>
@@ Line 70: / Line 70: @@
 Gluten-free commercial replacement products, such as gluten-free cakes, are more expensive than their gluten-containing counterparts, so their purchase adds a financial burden.<ref name="LudvigssonCard" /> They are also typically higher in calories, fat, and sugar, and lower in [[dietary fiber|dietary fibre]].<ref name=":0" /> In less developed countries, wheat can represent an important source of protein, since it is a substantial part of the diet in the form of bread, noodles, bulgur, couscous, and other products.<ref name=LamacchiaCamarca2014 /><ref>Shewry P.R. "Seed Proteins". In: Black M., Bewley J.D., editors. ''Seed Technology and Its Biological Basis''. Sheffield Academic Press; Sheffield, UK: 2000. pp. 42–84.</ref>
-In the British [[National Health Service]], gluten-free foods have been supplied on prescription. For many patients, this meant at no cost.  When it was proposed to alter this in 2018, the [[Department of Health and Social Care]] made an assessment of the costs and benefits. The potential annual financial saving to the service was estimated at £5.3 million, taking into account the reduction in cost spending and the loss of income from prescription charges. The proposed scenario was actually that patients could still be prescribed gluten-free breads and mixes but would have to buy any other gluten-free products themselves. The savings would only amount to £700,000 a year. Local initiatives by [[clinical commissioning group]]s had already reduced the cost of gluten-free foods to the NHS by 39% between 2015 and 2017.<ref>{{cite journal |title=Ending gluten-free prescribing entirely would have more health benefits and save more money, government assessment finds |url=https://www.pharmaceutical-journal.com/20205712.article |access-date=16 December 2018 |journal=Pharmaceutical Journal |date=8 November 2018}}</ref>
+In the British [[National Health Service]], gluten-free foods have been supplied on prescription. For many patients, this meant at no cost.  When it was proposed to alter this in 2018, the [[Department of Health and Social Care]] made an assessment of the costs and benefits. The potential annual financial saving to the service was estimated at £5.3 million, taking into account the reduction in cost spending and the loss of income from prescription charges. The proposed scenario was actually that patients could still be prescribed gluten-free breads and mixes but would have to buy any other gluten-free products themselves. The savings would only amount to £700,000 a year. Local initiatives by [[clinical commissioning group]]s had already reduced the cost of gluten-free foods to the NHS by 39% between 2015 and 2017.<ref>{{cite journal |title=Ending gluten-free prescribing entirely would have more health benefits and save more money, government assessment finds |url=https://www.pharmaceutical-journal.com/20205712.article |access-date=16 December 2018 |journal=Pharmaceutical Journal |date=8 November 2018 }}{{Dead link|date=June 2024 |bot=InternetArchiveBot |fix-attempted=yes }}</ref>
 Healthcare professionals recommend against undertaking a gluten-free diet as a form of [[self-diagnosis]],<ref name="slewis">{{cite web |url=http://oregon.providence.org/our-services/p/providence-nutrition-services/forms-and-information/three-reasons-to-go-gluten-free-and-three-reasons-not-to|title=Three Reasons to Go Gluten Free and Three Reasons Not to| vauthors = Lewis S |work=Related Forms & Information |publisher=Province Health & Services|access-date=30 March 2014}}</ref> because tests for coeliac disease are reliable only if the person has been consuming gluten recently. There is a consensus in the medical community that people should consult a physician before going on a gluten-free diet, so that a medical professional can accurately test for coeliac disease or any other [[gluten-related disorders|gluten-induced health issues]].<ref name="ElliBranchi2015">{{cite journal | vauthors = Elli L, Branchi F, Tomba C, Villalta D, Norsa L, Ferretti F, Roncoroni L, Bardella MT | display-authors = 6 | title = Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity | journal = World Journal of Gastroenterology | volume = 21 | issue = 23 | pages = 7110–9 | date = June 2015 | pmid = 26109797 | pmc = 4476872 | doi = 10.3748/wjg.v21.i23.7110 | type = Review | doi-access = free }}</ref>
@@ Line 104: / Line 104: @@
 ===Risks===
-An unbalanced selection of food and an incorrect choice of gluten-free replacement products may lead to nutritional deficiencies. Replacing flour from wheat or other gluten-containing cereals with gluten-free flours in commercial products may lead to a lower intake of important nutrients, such as [[iron]] and [[B vitamins]] and a higher intake of sugars and saturated fats. Some gluten-free commercial replacement products are not enriched or fortified as their gluten-containing counterparts, and often have greater [[lipid]] / [[carbohydrate]] content. Children especially often over-consume these products, such as snacks and biscuits. These nutritional complications can be prevented by a correct dietary education.<ref name=PenaginiDilillo /> [[Pseudocereal]]s ([[quinoa]], [[amaranth]], and [[buckwheat]]) and some minor cereals are healthy alternatives to these prepared products and have higher biological and nutritional value.<ref name=PenaginiDilillo /><ref name=LamacchiaCamarca2014 /> Advances towards higher nutrition-content gluten-free bakery products, improved for example in terms of fiber content and glycemic index, have been made by using not exclusively [[corn starch]] or other starches to substitute for flour. In this aim, for example the dietary fibre [[inulin]] (which acts as a [[Prebiotic (nutrition)|prebiotic]]<ref>{{cite journal | vauthors = Gibson GR, Roberfroid MB | title = Dietary modulation of the human colonic microbiota: introducing the concept of prebiotics | journal = The Journal of Nutrition | volume = 125 | issue = 6 | pages = 1401–12 | date = June 1995 | pmid = 7782892 | doi = 10.1093/jn/125.6.1401 | type = Review }}</ref>) or quinoa or amaranth wholemeal have been as substitute for part of the flour. Similarly, [[xanthan gum]] can be used in up to gram quantities per serving in some gluten-free baked goods and can be fermented by specific microbiomes in the gastrointestinal tract.<ref>{{cite web |title=Bob's Red Mill |url=https://www.bobsredmill.com/recipes/how-to-make/easy-gluten-free-pizza |website=Easy Gluten Free Pizza Recipe |access-date=9 April 2022}}</ref><ref>{{cite journal |last1=Ostrowski |first1=Matthew P. |last2=La Rosa |first2=Sabina Leanti |last3=Kunath |first3=Benoit J. |last4=Robertson |first4=Andrew |last5=Pereira |first5=Gabriel |last6=Hagen |first6=Live H. |last7=Varghese |first7=Neha J. |last8=Qiu |first8=Ling |last9=Yao |first9=Tianming |last10=Flint |first10=Gabrielle |last11=Li |first11=James |last12=McDonald |first12=Sean P. |last13=Buttner |first13=Duna |last14=Pudlo |first14=Nicholas A. |last15=Schnizlein |first15=Matthew K. |last16=Young |first16=Vincent B. |last17=Brumer |first17=Harry |last18=Schmidt |first18=Thomas M. |last19=Terrapon |first19=Nicolas |last20=Lombard |first20=Vincent |last21=Henrissat |first21=Bernard |last22=Hamaker |first22=Bruce |last23=Eloe-Fadrosh |first23=Emiley A. |last24=Tripathi |first24=Ashootosh |last25=Pope |first25=Phillip B. |last26=Martens |first26=Eric C. |title=Mechanistic insights into consumption of the food additive xanthan gum by the human gut microbiota |journal=Nature Microbiology |date=April 2022 |volume=7 |issue=4 |pages=556–569 |doi=10.1038/s41564-022-01093-0| pmid=35365790|s2cid=247866305 |hdl=11250/3003739 |hdl-access=free }}</ref> Such substitution has been found to also yield improved crust and texture of bread.<ref name="GallagherGormley2004">{{cite journal|vauthors=Gallagher E, Gormley TR, Arendt EK|title=Recent advances in the formulation of gluten-free cereal-based products|journal=Trends in Food Science & Technology|volume=15|issue=3–4|year=2004|pages=143–152|issn=0924-2244|doi=10.1016/j.tifs.2003.09.012}}</ref> It is recommended that anyone embarking on a gluten-free diet check with a registered dietitian to make sure they are getting the required amount of key nutrients like iron, calcium, fiber, thiamin, riboflavin, niacin and folate. Vitamins often contain gluten as a binding agent.  Experts have advised that it is important to always read the content label of any product that is intended to be swallowed.<ref>{{cite web|title=Gluten-free Diet|website=[[Mayo Clinic]]|url=http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gluten-free-diet/art-20048530|access-date=11 December 2016}}</ref>
+An unbalanced selection of food and an incorrect choice of gluten-free replacement products may lead to nutritional deficiencies. Replacing flour from wheat or other gluten-containing cereals with gluten-free flours in commercial products may lead to a lower intake of important nutrients, such as [[iron]] and [[B vitamins]] and a higher intake of sugars and saturated fats. Some gluten-free commercial replacement products are not enriched or fortified as their gluten-containing counterparts, and often have greater [[lipid]] / [[carbohydrate]] content. Children especially often over-consume these products, such as snacks and biscuits. These nutritional complications can be prevented by a correct dietary education.<ref name=PenaginiDilillo /> [[Pseudocereal]]s ([[quinoa]], [[amaranth]], and [[buckwheat]]) and some minor cereals are healthy alternatives to these prepared products and have higher biological and nutritional value.<ref name=PenaginiDilillo /><ref name=LamacchiaCamarca2014 /> Advances towards higher nutrition-content gluten-free bakery products, improved for example in terms of fiber content and glycemic index, have been made by using not exclusively [[corn starch]] or other starches to substitute for flour. In this aim, for example the dietary fibre [[inulin]] (which acts as a [[Prebiotic (nutrition)|prebiotic]]<ref>{{cite journal | vauthors = Gibson GR, Roberfroid MB | title = Dietary modulation of the human colonic microbiota: introducing the concept of prebiotics | journal = The Journal of Nutrition | volume = 125 | issue = 6 | pages = 1401–12 | date = June 1995 | pmid = 7782892 | doi = 10.1093/jn/125.6.1401 | type = Review }}</ref>) or quinoa or amaranth wholemeal have been as substitute for part of the flour. Similarly, [[xanthan gum]] can be used in up to gram quantities per serving in some gluten-free baked goods and can be fermented by specific microbiomes in the gastrointestinal tract.<ref>{{cite web |title=Bob's Red Mill |url=https://www.bobsredmill.com/recipes/how-to-make/easy-gluten-free-pizza |website=Easy Gluten Free Pizza Recipe |access-date=9 April 2022}}</ref><ref>{{cite journal |last1=Ostrowski |first1=Matthew P. |last2=La Rosa |first2=Sabina Leanti |last3=Kunath |first3=Benoit J. |last4=Robertson |first4=Andrew |last5=Pereira |first5=Gabriel |last6=Hagen |first6=Live H. |last7=Varghese |first7=Neha J. |last8=Qiu |first8=Ling |last9=Yao |first9=Tianming |last10=Flint |first10=Gabrielle |last11=Li |first11=James |last12=McDonald |first12=Sean P. |last13=Buttner |first13=Duna |last14=Pudlo |first14=Nicholas A. |last15=Schnizlein |first15=Matthew K. |last16=Young |first16=Vincent B. |last17=Brumer |first17=Harry |last18=Schmidt |first18=Thomas M. |last19=Terrapon |first19=Nicolas |last20=Lombard |first20=Vincent |last21=Henrissat |first21=Bernard |last22=Hamaker |first22=Bruce |last23=Eloe-Fadrosh |first23=Emiley A. |last24=Tripathi |first24=Ashootosh |last25=Pope |first25=Phillip B. |last26=Martens |first26=Eric C. |title=Mechanistic insights into consumption of the food additive xanthan gum by the human gut microbiota |journal=Nature Microbiology |date=April 2022 |volume=7 |issue=4 |pages=556–569 |doi=10.1038/s41564-022-01093-0| pmid=35365790|pmc=11537241 |s2cid=247866305 |hdl=11250/3003739 |hdl-access=free }}</ref> Such substitution has been found to also yield improved crust and texture of bread.<ref name="GallagherGormley2004">{{cite journal|vauthors=Gallagher E, Gormley TR, Arendt EK|title=Recent advances in the formulation of gluten-free cereal-based products|journal=Trends in Food Science & Technology|volume=15|issue=3–4|year=2004|pages=143–152|issn=0924-2244|doi=10.1016/j.tifs.2003.09.012}}</ref> It is recommended that anyone embarking on a gluten-free diet check with a registered dietitian to make sure they are getting the required amount of key nutrients like iron, calcium, fiber, thiamin, riboflavin, niacin and folate. Vitamins often contain gluten as a binding agent.  Experts have advised that it is important to always read the content label of any product that is intended to be swallowed.<ref>{{cite web|title=Gluten-free Diet|website=[[Mayo Clinic]]|url=http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gluten-free-diet/art-20048530|access-date=11 December 2016}}</ref>
 Up to 30% of people with known coeliac disease often continue having or redeveloping symptoms.<ref name=SeeKaukinen2015 /><ref name=AGA2006>{{cite journal | vauthors = Rostom A, Murray JA, Kagnoff MF | title = American Gastroenterological Association (AGA) Institute technical review on the diagnosis and management of celiac disease | journal = Gastroenterology | volume = 131 | issue = 6 | pages = 1981–2002 | date = December 2006 | pmid = 17087937 | doi = 10.1053/j.gastro.2006.10.004 | url = http://www.gastrojournal.org/article/S0016-5085%2806%2902227-X/fulltext | type = Review | doi-access = free }}</ref> Also, a lack of symptoms or negative [[Coeliac disease#Blood tests|blood antibodies]] levels are not reliable indicators of intestinal recuperation. Several studies show an incomplete recovery of small bowel despite a strict gluten-free diet, and about 79% of such people have persistent [[villous atrophy]].<ref name=SeeKaukinen2015 /> This lack of recovery is mainly caused by inadvertent exposure to gluten.<ref name=SeeKaukinen2015 /><ref name=AGA2006 /> People with poor basic education and understanding of the gluten-free diet often believe that they are strictly following the diet, but are making regular errors.<ref name=MulderWanrooij /><ref name="SeeKaukinen2015"/> In addition, some people often deliberately continue eating gluten because of limited availability, inferior taste, higher price, and inadequate labelling of gluten-free products. Poor compliance with the regimen is also influenced by age at diagnosis (adolescents), ignorance of the consequences of the lack of a strict treatment and certain psychological factors.<ref name=SeeKaukinen2015 /> Ongoing gluten intake can cause severe disease complications, such as various types of cancers (both intestinal and extra-intestinal) and [[osteoporosis]].<ref name=SeeKaukinen2015 /><ref name=AGA2006 />
@@ Line 128: / Line 128: @@
 ===Brazil===
-All food products must be clearly labelled whether they contain gluten or they are gluten-free.<ref name='"ANVISA2017"'>{{cite web|title=Rotulagem de alimentos Alergênicos|url=http://portal.anvisa.gov.br/documents/33916/2810640/Rotulagem+de+Alerg%C3%AAnicos/283b1a22-d923-4eb1-84fa-cb1a662b7846|publisher=Agência Nacional de Vigilância Sanitária (ANVISA)|date=7 June 2017|access-date=7 April 2018|language=pt}}</ref> Since April 2016, the declaration of the possibility of cross-contamination is mandatory when the product does not intentionally add any allergenic food or its derivatives, but the Good Manufacturing Practices and allergen control measures adopted are not sufficient to prevent the presence of accidental trace amounts.<ref name="ANVISA2016">{{cite web|title=Agência Nacional de Vigilância Sanitária Guia sobre Programa de Controle de Alergênicos|url=https://www.saude.rj.gov.br/comum/code/MostrarArquivo.php?C=MzIxOQ%2C%2C|publisher=Agência Nacional de Vigilância Sanitária (ANVISA)|date=2016|access-date=7 April 2018|language=pt|archive-url=https://web.archive.org/web/20180429222652/https://www.saude.rj.gov.br/comum/code/MostrarArquivo.php?C=MzIxOQ,,|archive-date=April 29, 2018|url-status=dead}}</ref> When a product contains the warning of cross-contamination with wheat, rye, barley, oats and their hybridised strains, the warning  "contains gluten" is mandatory. The law does not establish a gluten threshold for the declaration of its absence.<ref name='"ANVISA2017"' />
+All food products must be clearly labelled whether they contain gluten or they are gluten-free.<ref name='"ANVISA2017"'>{{cite web|title=Rotulagem de alimentos Alergênicos|url=http://portal.anvisa.gov.br/documents/33916/2810640/Rotulagem+de+Alerg%C3%AAnicos/283b1a22-d923-4eb1-84fa-cb1a662b7846|publisher=Agência Nacional de Vigilância Sanitária (ANVISA)|date=7 June 2017|access-date=7 April 2018|language=pt}}</ref> Since April 2016, the declaration of the possibility of cross-contamination is mandatory when the product does not intentionally add any allergenic food or its derivatives, but the Good Manufacturing Practices and allergen control measures adopted are not sufficient to prevent the presence of accidental trace amounts.<ref name="ANVISA2016">{{cite web|title=Agência Nacional de Vigilância Sanitária Guia sobre Programa de Controle de Alergênicos|url=https://www.saude.rj.gov.br/comum/code/MostrarArquivo.php?C=MzIxOQ%2C%2C|publisher=Agência Nacional de Vigilância Sanitária (ANVISA)|date=2016|access-date=7 April 2018|language=pt|archive-url=https://web.archive.org/web/20180429222652/https://www.saude.rj.gov.br/comum/code/MostrarArquivo.php?C=MzIxOQ,,|archive-date=April 29, 2018|url-status=dead}}</ref> When a product contains the warning of cross-contamination with wheat, rye, barley, oats and their hybridized strains, the warning  "contains gluten" is mandatory. The law does not establish a gluten threshold for the declaration of its absence.<ref name='"ANVISA2017"' />
 ===Canada===
@@ Line 141: / Line 141: @@
 * very low gluten foodstuffs: 20-100ppm gluten.
-All foods containing gluten as an ingredient must be labelled accordingly as gluten is defined as one of the 14 recognised EU allergens.<ref>{{cite web|url=https://www.food.gov.uk/science/allergy-intolerance/label/labelling-changes|title=EU Food Information for Consumers Regulation (EU FIC) |date=March 2016|publisher=[[Food Standards Agency]]|format=link}}</ref>
+All foods containing gluten as an ingredient must be labelled accordingly as gluten is defined as one of the 14 recognized EU allergens.<ref>{{cite web|url=https://www.food.gov.uk/science/allergy-intolerance/label/labelling-changes|title=EU Food Information for Consumers Regulation (EU FIC) |date=March 2016|publisher=[[Food Standards Agency]]|format=link}}</ref>
 ===United States===
@@ Line 154: / Line 154: @@
 == See also ==
 {{Portal|Food|Medicine}}
-{{div col|colwidth=20em}}
 * [[2010s in food]]
 * [[Gluten-free, casein-free diet]]
@@ Line 160: / Line 159: @@
 * [[Paleolithic diet]]
 * [[Specific carbohydrate diet]]
-{{div col end}}
+{{-}}
 == References ==
@@ Line 168: / Line 167: @@
 {{Wiktionary|Gluten-Free}}
 {{Cookbook|Gluten-Free}}
+*[https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gluten-free-diet/art-20048530 Gluten-free diet] by the [[Mayo Clinic]]
 {{Gluten sensitivity|state=expanded}}
@@ Line 174: / Line 174: @@
 {{Diets}}
 {{Authority control}}
 [[Category:Gluten-free diet| ]]
 [[Category:2010s in food]]
-[[Category:Diets]]
 [[Category:Fad diets]]

v t e Irritable bowel syndrome (IBS)
Management	Low-FODMAP diet Gluten-free diet Soluble fiber Laxatives Antispasmodics Psychotherapy Tricyclic antidepressants SSRIs Probiotics Eluxadoline
Related topics	Gut–brain axis Hypothalamic–pituitary–adrenal axis Sympathetic nervous system

v t e Fad diets
Food-specific diets	Alkaline diet Banana and skimmed milk diet Cabbage soup diet Carnivore diet Clean eating Cookie diet Egg and wine diet Food combining Beverly Hills Diet Hay diet Fit for Life Fruitarianism Gluten-free diet Grape diet Grapefruit diet High-protein diet Lamb chop and pineapple diet Lectin-free diet Macrobiotic diet Milk diet Monotrophic diet Morning banana diet Mucusless Diet Mushroom diet No-Aging Diet Paleolithic diet Pegan diet Potato diet Raw foodism Raw veganism Rhubarb diet Superfood Uric-acid free diet Whole30
Low-carbohydrate / high-fat diets	Atkins diet Banting diet Bulletproof diet Calories Don't Count Drinking Man's Diet Dukan Diet Eat and Grow Thin Hal Huggins diet Hamptons Diet Kimkins Kordel diet Montignac diet Salisbury diet Scarsdale diet Slimming for the Million South Beach Diet Pioppi Diet Protein Power Rosedale diet Stillman diet Strong Medicine Sugar Busters! The 4-Hour Body The Cruise Control Diet Wahls Protocol Diet Wheat Belly diet Zone diet
High-carbohydrate / low-fat diets	Engine 2 Diet F-plan McDougall diet Ornish diet Nutritarian diet Pritikin diet Rice diet The Good Carbohydrate Revolution The Thrive Diet
Detoxification / fasting	5:2 diet Activated charcoal cleanse Breatharianism Breuss diet Celery juice diet Chase Dietary Method Detox diet Dubrow Diet Eliminating Diet Enzyme-Catalyst Diet Fasting mimicking diet Fat Flush Plan Hippocrates Diet Intermittent fasting Time-restricted feeding Juice fasting KE diet Master Cleanse No Breakfast Plan Orthopathy Protein-sparing modified fast The Fast Way To Health The Last Chance Diet Wheatgrass diet Wigmore diet
Other	Blood type diet Budwig diet Cotton ball diet Fletcherism Hallelujah Diet Hip and Thigh Diet Immune Power Diet Maker's Diet Seed cycling Sensa diet Swank diet Tongue Patch Diet The Cambridge Diet Very-low-calorie diet Werewolf diet
Related	List of fad diets List of food faddists Pseudoscience Quackery Seed oil misinformation
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