Sixty-four per cent of the UK adult population has suffered from digestive distress in the past six months, according to experts at Rennie, writes Sarah Clark. Heartburn, acid reflux and indigestion are the most commonly experienced digestive issues.
Although one in four adults tries to live ‘cleanly’, specifically to benefit their digestive health, many agree that it is easier to take over-the-counter remedies than to make lifestyle changes – which provides a continued need for easy access to OTC digestive health remedies.
Despite help and advice being readily available, half the adult population don’t seek treatment, often because they don’t understand the options available; 49 per cent of consumers say they find it difficult to know what treatment is best for them.
Coeliac disease affects one in 100 people in the UK. Only 30 per cent of sufferers are diagnosed and about 500,000 people remain undiagnosed, according to Ruth Passmore, Coeliac UK health policy officer. Pharmacists can play an important role in identifying individuals in need of testing by recognising key symptoms, associated conditions and/or other risk factors.
“If coeliac disease is suspected, pharmacists should refer the individual to their GP for serological testing and it is essential that people are advised to keep eating foods that contain gluten until all testing is complete,” says Ms Passmore.
The symptoms of coeliac disease can include ongoing gut symptoms such as diarrhoea, constipation, nausea and vomiting, severe or persistent mouth ulcers, nutritional deficiencies and unexpected weight loss. Other signs include unexplained neurological symptoms, particularly peripheral neuropathy or ataxia, subfertility and recurrent miscarriage. In children, faltering growth and delayed puberty can indicate coeliac disease.
People with undiagnosed coeliac disease may sometimes present with prescriptions for, or buy, over-the-counter medicines for irritable bowel syndrome or for iron, B12 or folate deficiency anaemias. Pharmacists should also look out for people who present with autoimmune diseases often associated with coeliac disease. NICE recommends serological testing for coeliac disease should also be offered to people with type 1 diabetes and autoimmune thyroid disease at diagnosis.
Once diagnosed, community pharmacy can support people with coeliac disease in managing their condition with advice and, in some cases, suitable products. People may not be aware that extra vaccinations are recommended for people with coeliac disease, too.
In 2017 the Department of Health and Social Care held a consultation on the future of gluten-free prescribing in England. The decision was made to retain access to gluten-free bread and flour mixes on prescription, but to blacklist other products. Despite this, many clinical commissioning groups continue to recommend that GPs do not prescribe any gluten-free foods, other than in exceptional circumstances. This has led to inequality in England as the availability of gluten-free foods varies from one CCG to another.
Access to prescriptions is important for a number of reasons, according to Coeliac UK. “Despite gluten-free staples being more widely available today, they are still not readily available in budget supermarkets or convenience stores,” says Ms Passmore. “Where they are available, they can be prohibitively expensive, costing three to four times more than gluten-containing equivalents. For bread, the cost difference is even greater. On average, gluten-free bread is six times more expensive gram for gram. Without access to prescriptions, those on a limited income, the elderly or people living in remote rural areas can be left struggling to maintain a gluten-free diet.”
Extra vaccinations are recommended for people with coeliac disease
Scotland has a Gluten Free Foods Service, a national opt-in pharmacy service that aims to improve access to gluten-free foods for people who need them.
“Patients who are referred onto the service by their GP or dietitian are able to order foods from a select list each month,” says Adam Osprey, policy and development pharmacist at Community Pharmacy Scotland. “Depending on their age and other factors, patients are allocated an allowance of points, which can be spent each calendar month on staple gluten-free foods. Each health board draws up its own list of foods that can be prescribed and pharmacy teams process monthly orders using an electronic prescribing system and provide advice on health matters.”
Crucially, pharmacy also offers annual health checks and provides information and support for following a gluten-free diet as well as risk-assessing any symptoms and referring back to the dietitian or consultant if there are any concerns.
According to NICE statistics, the incidence and prevalence of IBS in the UK is between 10 and 20 per cent and it is more common in women and older people.
The first line option to avoid IBS symptoms is lifestyle change, but to manage symptoms, products such as Silicolgel may be useful, especially during the festive season when food choices and a lack of routine can exacerbate symptoms.
“The IBS category is growing by 10 per cent year on year,” says Jill Stuart, Silicolgel sales and marketing manager. “We’re committed to supporting Silicolgel with an annual PR, marketing and advertising campaign that has delivered sales growth of 51 per cent year on year and demonstrates the increased demand for an effective OTC treatment that manages the uncomfortable symptoms of gastrointestinal disorders.”
Probiotics may be another option for supporting gut health. NICE recommends that anyone deciding to try probiotics for IBS management should take the product for at least four weeks, at the dose recommended by the manufacturer, and monitor the effects.
“Immunity starts in the gut,” says Gail Robertson, nutritionist at Annandale Clinic and co-founder of Bellygoodness. “Research indicates that the bacteria in our gastrointestinal tract can play a major role in immunity. It is imperative that we help consumers look after their gut health, especially during winter months.”
Consumers may not know the difference between a prebiotic and probiotic and how both can help. Prebiotics contain no bacteria, but provide fuel to help bacteria multiply. Probiotics are live micro-organisms with proven health benefits.
Bellygoodness’s recommendations for gut health include:
One more tip pharmacy staff can give people who present with prescriptions for antibiotics is that probiotics can be useful for supporting gut health.
Lila Thakerar, Shaftesbury Pharmacy Harrow
“This is one of our biggest categories. Customers ask about upset stomachs, diarrhoea and indigestion. Constipation, indigestion and diarrhoea are common areas of concern. Popular products are Pepto Bismol and Gaviscon for indigestion, Imodium for diarrhoea. Make customers aware that we should be the first place they go to for minor concerns and we will refer them if necessary. Lots of the products are P lines, so it’s important customers can see dummy packs or leaflets so they can read about the products.”
Mital Thakrar, Well Pharmacy, Birmingham
“Constipation, diarrhoea, bloating and reflux are all common and can all be treated with OTC medicines and lifestyle advice. The skills of our pharmacy teams mean we can make important interventions around diet, exercise and lifestyle and provide the best advice to support healthy changes to reduce the number of occurrences of gastro complaints. Popular products are those that are well advertised in the media, but an understanding of the basic action of these products can help us explain to patients how they work.”
Melissa Liew, Ellacombe Pharmacy, South Gloucestershire
“Common complaints in this category are constipation, heartburn and bloating. We stock a range of brands, but we also try to give plenty of dietary advice depending on the issue, such as drink peppermint tea, increase fibre intake, eat regular meals. It’s important to look out for red-flag symptoms – dysphagia, unexplained weight loss and blood in the stools – which should be a priority and the patient must be referred. There is scope to improve the category and add more variety. We have added probiotics and herbal teas to our range.”