‘But bread causes my symptoms’: possible clinical scenarios

Wheat is a globally cultivated crop and staple food, valued for its adaptability, nutritional content and baking properties. Its widespread consumption, however, has been paralleled by a rise in concerns related to wheat-derived products to cause a wide range of reactions. This review explores the key wheat components—gluten, fermentable carbohydrates, amylase-trypsin inhibitors and wheat germ agglutinin—that may trigger adverse reactions in susceptible populations and the diagnostic challenges faced in clinical practice. Coeliac disease (CD) is an autoimmune disorder initiated by gluten in genetically predisposed individuals, involving both adaptive and innate immune responses. Wheat allergy, on the other hand, is mediated by immunoglobulin E antibodies against specific proteins and can present with cutaneous, respiratory or systemic symptoms. Non-coeliac gluten/wheat sensitivity is a less understood condition characterised by gastrointestinal and extraintestinal symptoms in the absence of CD or wheat allergy. It likely involves immune activation and gut-brain interaction mechanisms, with symptoms overlapping with disorders such as irritable bowel syndrome. Diagnosis of these conditions can be challenging in the clinical setting, and serological tests, skin prick tests and double-blind placebo-controlled challenges can be considered. While bread remains a nutritionally valuable food, careful diagnostic differentiation is essential to guide dietary management and avoid unnecessary restrictions. Ongoing research into molecular mechanisms and biomarkers is crucial to better understand and manage wheat-related disorders.