Saturday, 6 February 2016

Rosacea and gluten - a coeliac connection?

It's not difficult to find stories online - usually in chat forums - of long-standing rosacea symptoms disappearing magically following a trial of a gluten-free diet.

As the culinary culprit of our times, gluten has in some corner of the web shouldered the blame for surely every disease that might conceivably be down to diet, and the association between coeliac disease and its skin manifestation - dermatitis herpetiformis - I think makes gluten a prime suspect for other skin diseases and complaints too, such as psoriasis and eczema.

But hearsay and anecdotes aside, is there any decent research that might suggest a link with rosacea?

Searching for published scientific papers on 'celiac' and 'rosacea' offers us slim pickings, and perhaps because of this vacuum, the alternative therapists have free reign to speculate on whether wheat, rye and gluten really are triggering or aggravating those red patches, flushing, pimpling, and visible capillaries that are characteristic of rosacea. I've even seen a rosacea site instruct its readers to ditch MSG on the basis that it is gluten (no, it is glutamate). Lesson: don't believe what you read online.

Rosacea charities and bodies are as quiet on the subject as the scientists: The National Rosacea Society, for instance, will only share a member anecdote, and say no more on the matter of gluten.

So a paper published in a dermatology journal recently, and covered by Healio, caught my eye. It reported an association between rosacea and several autoimmune diseases - including coeliac. In fact, women with rosacea were around twice as likely to have coeliac as the general population - an association not seen in men - which raises the possibility of autoimmune involvement in some cases.

This serves as a useful reminder that following online anecdotal advice and trying a gluten-free diet could make any potential diagnosis of coeliac disease far more difficult. So, to repeat something I regularly write on this blog, don't change your diet, and do go to your doctor to explore the possibility of underlying coeliac, in the first instance. The blood tests he or she may send you for will only work as they're designed to if you keep gluten in your diet, and if it's a positive result, you'll need the specialist support a formal diagnosis can offer - which is more than you can get from the internet.

Further reading
Acne and Rosacea: The Complete Guide - by Alison Bowser
The Rosacea Support Group - Australian group
National Rosacea Society - US group

Tuesday, 2 February 2016

Why is gluten free food so expensive?

"Supermarket gluten-free food rip-off" said the Sun. "The gluten-free food price shock" said the Mail.

The stories were based on research by Channel 4's Supershoppers, which was screened yesterday at 8.30pm.

The claim? That gluten-free shoppers are being diddled by questionable supermarket price hikes on foods suitable for coeliacs, far in reasonable excess of non free-from equivalents.

Why is free-from food so pricey?
I get asked this a lot, and I imagine there are many reasons, mostly to do with the fact that such products are manufactured in smaller quantities, therefore the usual savings involved in 'bulk' production aren't going to be available. Other reasons?

* Allergen control - this is expensive, and could involve increased costs of laboratory allergen testing, plus more rigid and careful cross-contamination protocols and checks.

* More expensive ingredients - specialist ingredients that may be required, to replace cheaper wheat or dairy ingredients, for instance, as well as dearer ingredients sourced from companies who in turn have to have more careful allergen control.

* Multiple free-from qualities - it's not just about gluten. Eliminating other allergens to assist those with additional allergies may add to costs, if further 'free from' claims are to be made.

* It's still a bit niche - despite all the talk of growth over the last decade, and that's still to come, it remains a small percentage of the market, and less competition means prices aren't squeezed downwards as quickly as we might hope.

* Other reasons that we can't know - I'm speculating here, but if you manufacture free-from you may be more at risk of product recalls and litigation. Might this add to insurance / liability cover? Possible.

Free from vs Non Free from
Let's look at two of the products considered by the show.

Tesco FreeFrom Tomato Ketchup is £1.20 and ordinary Tesco Tomato Ketchup is 65p. Both appear to be free from all 14 allergens, with no 'may contains', but the FreeFrom version makes gluten, dairy and mustard-free claims. Reason to justify almost doubling of cost? Actually, no I don't think so.

Tesco FreeFrom White Lasagne Sauce is £2 (right) and Tesco White Lasagne Sauce is 85p. The FreeFrom makes gluten / milk free claim, contains coconut (expensive), and appears to be free from all 14 allergens. The ordinary one contains milk, mustard and makes no free from claims. Reason for more than double the cost? Yes, I think that could be reasonable. (Whether you'd wish to pick it, though, is another matter: compare the fat content of the two.)

These two echo the sense of what I picked up on social media, that some comparisons were fair and others perhaps weren't.

I thought the segment on the show was poor. It was superficial, under-researched, trivialising and made no effort to answer the question of why such foods were more dear, which might have helped public understanding of the realities of food allergies, and of coeliac disease (which wasn't mentioned). It could also have been an opportunity to cover prescription cuts, although granted that may not be within the programme's remit. "Use your gluten free eyes to read the gluten free label" it concluded, fatuously.

Has the coverage been fair to supermarkets? 
They're such powerhouses that something like this is hardly going to damage or hurt them, but it can help keep them on their toes. I don't think they're necessarily taking the piss, and they're certainly not the only ones who arguably over-charge: I've been in this game long enough to have had my fill of handmade Himalayan-salted kale-scented gluten-free arnica petals bearing pricetags more typically associated with Tiffany's than Tesco's.

Things will improve, but consumers can help by wising-up on labelling issues - which are far more complicated than Supershoppers implied - by keeping their eyes peeled, shopping around (including spending longer in the non-free from aisles), and not being afraid to challenge manufacturers over their pricing. Even if this latest media coverage could have been much better, that it was covered was a positive, and it can't make matters worse, I wouldn't have thought. Make the most of Coeliac UK's food directory, which doesn't list only products found in the free-from aisle, by any means, and take advice from your dietitian too, who may be wise to local bargains and offers. Veteran freefromers and coeliacs will know all this, of course, but newbies need help negotiating the free-from maze. Give them a hand, if you can.

Tuesday, 19 January 2016

The Problem with "Free From Gluten"

I once flagged up to acquaintances from various corners of the 'free from' industry the wrapping from a paleo bar bearing the expression "Free From Gluten".

The legally permitted term, according to legislation (see clause 44), is "Gluten Free". As you can see, alternatives are "not allowed".

The party, who included a senior figure from one of the main charities, generally felt it was acceptable, a minor misdemeanour, and not worth concerning oneself with.

I disagreed. Just a few months ago, I was reminded of this when I spotted Waitrose's new free-from designs and packages in stores.



Again I thought it was a problem, still do, and so I thought I'd explain why.

The value of allergen labelling
It's not over-dramatising to say that allergy labelling law saves lives.

It is enshrined in law in order to make it compulsory. If it were optional, brands would cut corners. If the rules weren't set out precisely, manufacturers would interpret them differently. Those to suffer would be the consumers - and, incidentally, the charities, who would be fielding more resource-draining queries.

Labelling and allergy are both complicated areas, which newly diagnosed patients understandably struggle with. Legislation adherence is vital to these patients to ensure consistency. Inconsistency confuses. "Why does this food say 'gluten free' and that one say 'free from gluten'?" they might ask themselves. "Is there a difference?"

If you're thinking this example is trivial, then relative to others, I'd agree. "Free from gluten" is lesser of a labelling sin than, say, including tahini in the list of ingredients, but forgetting to point out that it contains the allergen sesame. A coeliac will not go wrong with the former; but a sesame allergic skim-reading the ingredients may be in trouble with the latter.

I'm reminded of the case several years ago of the product withdrawal of some peanuts not bearing the word 'peanuts' on the packaging, as required by law. Then chair of the RCGPs Clare Gerada called the withdrawal "madness", among other things. (I blogged about it here.) It wasn't madness: it was the correct response to a breach of labelling law which happened to risk lives.

Although I wouldn't support a recall for cases of 'free from gluten', I do consider a zero-tolerance approach to all labelling error vital because it ensures that laws are taken more seriously. As soon as we permit or excuse minor infringements, that essential high bar is lowered, but to a level which is subject to opinion, not law. Relaxing our attitude chips away at the highest standard at which allergy labelling regulations should be set, and gives a permissive amber light to other manufacturers to follow suit. It's a potentially slippery-slope scenario.

And another thing ...
Would you not expect any free-from manufacturers to at very least have read the various allergen and gluten-free labelling laws, and guidance from the Food Standards Agency?

I have read them, and I would. An error makes me wonder whether brands have, and what else they might not have read, nor understood. Perhaps nothing; perhaps any error is an isolated mistake. But it still alarms me that one error, specifically described in the guidance document to be an error, can be missed. If I were 'free from' for health reasons, my confidence would be undermined.

It was on the 4th December that I asked Waitrose why they had chosen "free from gluten" for their packaging, and - with a bit of chasing - I got a satisfactory response yesterday, albeit not an answer to the question.

"We are in the process of amending our packaging to say Gluten Free. We apologise for any confusion, but customers can be reassured that all 'Free From Gluten' products are Gluten Free".

Postscript 28th January 2016: I've since been rightly corrected by a commenter on Michelle Berriedale-Johnson's blog here. William Overington correctly states that the correct claim is, in fact 'gluten-free' (with hyphen) - but who uses it? Not many ... 

Friday, 1 January 2016

2015: The 10 Best and Worst in Allergy & FreeFrom

The Best!

10. #fruitisnotapudding
Demonstrating that coeliacs have a top sense of humour and exemplifying how good can come from not-good, Carly at GlutenFreeB.com runs this light-hearted annual award for the worst gluten-free dessert offering, and this year's winner is memorably, hilariously bad. See it here.

9. Dominic Teague's Samphire and Onion Buckwheat Bread
Teague is the head chef at Indigo in One Aldwych. I ate there in November with some colleagues - a meal reviewed by my pal Sue Cane - and this warm allergy-free bread was the highlight. This was the restaurant, remember, that went GF and DF ... without anybody noticing.

8. The Free From Awards
I'm biased, but the 8th Year of the FreeFrom Food Awards (winner, Voakes Pork Pie, pictured right), the 4th of the FreeFrom Skincare Awards, and the 2nd of the FreeFrom Eating Out Awards, each saw a number of terrific products and businesses rightly rewarded for continuing to provide excellent free from and allergy-friendly services to consumers.

7. Great Journalism ....
I know my business takes a deserved kicking from time to time (see below ...) but there were some terrific articles published in 2015. Try "The Real Side Effect of a Gluten-Free Diet: Scientific Illiteracy" in Vox.Com. Or "The Myth of Big Bad Gluten" in the NYT. Or "Bogus Allergy Tests Causing Real Harm" in the Guardian. Or "Diet Fads are Destroying Us" from Salon.

6. The Allergy and FreeFrom Shows
Underpinned by a dedicated and hard-working team, who want to get things right, and who take feedback on board, the events continue to be essential fixtures in the free from calendar, and in 2015 were bigger and better than ever. Expanding into Scotland for 2016 too ...

5. Bloggers
There are so many good ones covering free from, food intolerance, food allergy and gut health that I've been enjoying reading this year, but I'm going to plug two which may have gone under many people's radars - FoodConnections by Laurie Laforest and The Sensitive Gut by Dr Nick Read - both of which I think are really great.

4. Holland and Barrett
The website has not been without its teething problems, but the launches of new free from stores, and the commitment with which they've fully entered the free from market in 2015, does deserve recognition. Dedicated Twitter and Facebook social media accounts are welcome - and give them an edge over the supermarkets who have bafflingly failed to follow suit.

3. The Peanut Patch
Exciting stuff - and heading to Phase III Trials.

2. Caroline Quentin
A fantastic new ambassador for Coeliac UK - honest, funny and dedicated. Responds to coeliacs on social media. Makes fun of her bowels. She's been great.

1. The LEAP Study
Remarkable and transformative study, by a team of dedicated scientists and allergists led by Professor Gideon Lack, which will shape future allergy prevention advice. Read more here.

The Worst!

10. Boots
For appalling promotion of sugary / treat foods - including free from foods - as 'healthy snacking' products, and declining to offer a staff nutritionist for interview on the matter. Read more here.

9. CAMRA
For a silly press release trumpeting a leading-the-way approach to allergy regulations - which turned out to be literally nothing more than an upholding of the law - mixed in with some confusion about ingredients and allergens, plus careless and gross misinterpretation of statistics. The full story - and CAMRA's comments - can be read here. Disappointingly, Allergy UK reproduced the inaccurate information, and took almost a month to quietly delete the errors and correct the post - or 'update' it, as they have it on their site.

8. British Airways
For ongoing short-sightedness about peanuts on flights. Read Penny's account here.

7. UGOT
For this.

6. Genius
Sorry, Genius. Some terrific products and a trailblazing founder can't rescue you from a year of dodgy broken bread (which has inspired a Twitter account) and for a marketing policy founded on promoting the gluten-free diet as a route to fitness, health and sporting achievement - which is unproven at best, and false at worst.

5. Dr Turner
Any GP who professes to be allergic to allergies deserves their place in the top 10, surely?

4. The New York Times
For publishing this piece. For accusing those on free-from diets for wanting to feel 'special' and for trotting out the spurious 'there were no allergies in the olden days' claim to justify the author's clear disdain.

3. The Daily Mail
For the Gluten Free Prescription fiasco - right - and for their too-little, too-late correction.

2. 100 Chefs / Business for Britain
Loathsome anti-EU body gathers ninety-odd unknowns and a few celebrity foodies to dub life-saving food allergen legislation a "bureaucratic nightmare". Comments by Prue Leith and Thomasina Miers merely highlighted their ignorance. A shameful episode, all round, which made fools of all signatories, and whose backsides will one day be bitten by it, I'll bet. More here.

1. Duncan Bannatyne
Unpleasant of character, clueless of glutenological knowledge - as demonstrated by the events that transpired in July. It takes some ego to dismiss the pleas of qualified dietitians to correct his deeply misguided and mistaken comments made on Twitter on the supposed dangers of gluten - and promotion of GF for weight loss - but that's just what he did this year, even claiming they (the dietitians) "want to be paid for advice". An arse. And my choice for low of the year.

What were your highs and lows from 2015? 

Sunday, 13 December 2015

Marketing Genius? (Part II)

Genius are no stranger to this blog, and my criticism of their pursuit of a marketing strategy which seems to involve aligning themselves - and the gluten-free diet (GFD) - with fitness, sport and sporting excellence was covered in a previous blog, a couple of years ago.

Promoting a myth that switching to a GFD in the absence of a medically prescribed reason to do so is beneficial to fitness is one which obviously benefits them, and it is one which, to my knowledge, they have never supplied any good evidence for. Possibly because there is none. The last I read on the subject can be seen here, from Time - albeit drawn from a small study.

I'm late to it, but this appears to be the latest marketing initiative, involving long jumper and Sports Personality of the Year nominee Greg Rutherford, and which is hosted by MumsNet.

Five members have been awarded £100 vouchers to spend on Genius GF products, and asked to post their experiences following both the GF diet for a week and fitness tips from Rutherford. Those not lucky enough are encouraged also to give their thoughts on GF products and going GF - with the carrot of a voucher dangled before them as incentive.

The quote from Genius founder Lucinda Bruce-Gardyne (for whom I have a lot of admiration) is concerning. She talks of "easier to digest dishes" (no real evidence that this is necessarily true) and going "gluten-free as a positive lifestyle choice" - implying that it is necessarily a positive move, when for most it may be the opposite.

Targeting mothers, many of them possibly new mothers, seems irresponsible. As Carly (gfreeb) has already pointed out on Twitter, nutrition is vital when breastfeeding, and to suggest dietary experimentation for the sake of winning a prize surely implies it is risk-free, when it may not be.

One voucher-receiving commenter talks about her need to lose weight - reinforcing another of the popular gluten myths - and apparently ignorant to the fact that, for example, Genius pain au chocolate has 388 calories and Tesco's non-GF one 260. I can see no mention of the importance of remaining on a gluten-containing diet before coeliac testing, or indeed any mention of coeliac testing at all, which would have been a responsible thing to do.

I find all of this frustrating - mostly because nothing ever seems to be done to address it. The thing I'm most disappointed about this time is Rutherford's involvement. He's a terrific athlete, seems a genuinely sincere and likeable guy, has taken a lot of crap over the SPOTY nomination controversy (read this astonishing article by his wife if you need to be briefed) and it's a pity that he too, like Novak Djokovic, has apparently fallen for the 'evil gluten' nonsense that has now bedded into society's health consciousness, and which some of those who stand to benefit from it persisting seem determined to espouse.

You can comment below or on Facebook.

Sunday, 6 December 2015

Onion allergy, kiwi allergy, garlic allergy, spice allergy, banana allergy ...

When it comes to food allergies and intolerances, most of the talk is about gluten and the top 14 allergens - mainly milk, eggs, nuts, peanuts, soya, gluten grains and sesame. Labelling legislation requires manufacturers to emphasise (typically in bold) these allergens in their ingredients. All well and good if your allergens are among the 14 - but what if they're not?

There are no figures I know of for allergies to beans, to exotic fruits, to alliums, to spices, but they exist. Allergies to hundreds of foods have been recorded. Even bland ones: cases of anaphylaxis to lettuce are on record.

Tom-uch for some .... 
Although they should not emphasise them, manufacturers are obliged to list these ingredients on their packaging, so that if they include onion in a product, they must accordingly add 'onion' to their list of ingredients.

But such transparency only applies with 'wholefood' ingredients. So as I understand it, there are two problems for those with more unusual or less recognised allergies:

1/ The source of ingredients need only be declared when it is one of the 14 allergens. So, a 'flavouring' has to be described as 'barley malt flavouring', for example, if derived from barley, or 'flavouring (from milk)' if derived from milk - but can be described as nothing more than 'flavouring' if it's onion-derived (or tomato-derived, or mushroom-derived ...).

2/ The ingredients of compound ingredients - such as mayonnaise in a tuna pate - must be declared if constituting over 2% of the final product. But if constituting under 2%, they need only be declared if they are one of the top 14. If you have an allergy to a spice, typically used as mixtures, and in tiny amounts, you'll commonly find - to your frustration - the expression 'spices' on ingredients, with no further elucidation. (Here's Ruth at What Allergy almost getting caught out with coriander in a soup.)

Fungis to be with - unless you have a mushroom allergy
This is tough for sufferers, because all ingredients must be read individually, and every non-explicit or non-wholefood ingredient that could be 'concealing' the trigger allergen needs to be assessed or investigated. Often, this will require a phone call to the manufacturer - inconvenient, especially if you're at a supermarket and in a rush.

I have no evidence for it, but it would not surprise me to learn that the intense focus on the 14 allergens in the food industry since the allergen regulations were introduced had deflected attention even further away from other ingredients. Let's face it, how many chefs will check whether there's fenugreek in their spice mix, or chives in their dried herb mix? How many investigate compound or generic ingredients listed in stock cubes or bouillon powders that they use?

Then there's the risk from cross-contamination. Product recalls are unlikely to be instigated for corn flour, for example; I don't know of one on record due to a non-14 allergen that didn't constitute a non-allergy health risk. Precautionary labelling - 'may contain traces of' - is unheard of with regard to allergens outside the 14.

No food allergy is nice to have - but the unusual food allergies come with a particular set of challenges which slip under the radar of most. How can we change that?

Further Information / Resources
The Anaphylaxis Campaign - Onion and Garlic Allergy
The Anaphylaxis Campaign - Kiwi Allergy
The Anaphylaxis Campaign - Banana Allergy

Anila's Sauces - onion / gluten free.

Thursday, 3 December 2015

Hipsters, gluten and food snobbery

I'm not 100% sure what a hipster is, but it appears to involve multiple tattoos and skinny jeans and possibly an unruly beard and maybe implanting one of those black Polo-mint-shaped earrings through which you can see daylight into a stretched lobe and drinking the limited edition output of microbreweries.

Hipsters appear to irritate normally level-minded people, and sneering at them has become socially acceptable; from my seat, the more right-on and left-wing you are, the more sneering you do, which seems strange.

Apparently many of them now hate gluten as much as they do shaving and regular ear shapes, which makes them sitting ducks for everything from actual abuse to jokes and pisstakery galore. (Examples of the latter only.)




Coeliacs are playing along too. Increasing numbers are taking to disclaiming hipsterdom to reinforce their medical intolerance to gluten.




With all the anti-glutenising self-proclaimed wellness experts opining on the interweb these days, it seems odd to me that a relatively harmless assortment of young people appear to be on the receiving end of the flak, and even blame, for GF's trendy status. But we live in a time when it is acceptable to criticise others for what they put into their mouths, and I guess it's much more fun to mock a hipster than to take the mick out of a nutritional therapist with an anti-wheat detox fixation or indeed the more typical average lifestyle gluten-dodger of today, who's a thirty-something woman watching her waistline.

The following popped up on my stream the other day.


Is it only in this country that this might be considered funny? Only the British apply class to food. Quinoa and kale - and much of 'free from' - is middle class (or 'hipster class'). Chips are working class. Don't go getting ideas above your station, laddy, is the message here. Don't try to climb the social ladder by changing what you eat, or we will pull you back to where you belong.

Here's Britain's food problem in a nutshell of inverse snobbery. Eat 'differently'? Show an interest in a non-traditional food - food that's perhaps on an upward trajectory and therefore been dubbed 'fashionable'? Then it's time to take you down a peg or two. If the increase in gluten-free menus and allergy-aware dining irritates you - and some appear to be inexplicably offended by it - then channelling your fury towards people you irrationally dislike is now the norm - no matter that they are only responsible for a tiny fraction of the phenomenon.

Those who are experimenting, those who are curious, those who want to eat a way contrary to the embedded junk- and processed-food culture, those who want to support the food service outlets who are trying to cater with originality, are not permitted to simply get on with it and do so.

Until that changes, I don't hold out much hope for our much publicised issues with food, diet and obesity.

But meanwhile, sod it: here's a bloody good recipe from Michelle at Foods Matter with kale, quinoa and - good grief - fresh beetroot and coriander seeds too. Hipsters in body or soul, enjoy.

Tuesday, 1 December 2015

Christmas Gifts for Coeliacs and Allergy Folk: an alternative guide

It's December! If you've not yet done your Christmas shopping for coeliac or allergic loved ones - or dropped hints about what you'd like if you're the one with allergies or intolerances - then you'll want to take every word of what follows with a fistful of salt ...

Kicking us off, what lover of fine art could possibly be disappointed to find a Canvas Print of False-colour SEM of intestinal villi (right) in their stocking? Ready to hang, and yours for a penny shy of £70, the rendering in various shades of brown doesn't remind the viewer whatsoever of what one's bowels normally get up to, and would gracefully adorn (or fuel) any living room fireplace.

If that doesn't do it for you, surely David Gifford's Artist's Depiction of Coeliac Disease is a must-have for the gluten intolerant in your life? Let's face it - who wouldn't want a rendering of a swollen-bellied man grim-faced at having carelessly wandered naked into a wheat field on a hot summer's day on their wall? Splash out on a 91x122 cm print, with frame, and it'll only set you back £234.99!

If that tops your budget, then perhaps an Artist's Depiction of Coeliac Disease Keepsake Box, at £22.50, might appeal? (NB. Other Gluten Enteropathy Keepsake Boxes are available.)

Still not convinced? Then Artist's Depiction of Coeliac Disease Flip Flops (left) will surely do the job. A snip at £13. Who needs Havaianas?

Puzzle-loving loved one to buy for? This 300-piece 'Home Made Jam on Toast Made From Gluten Free Bread with Silver Spoon' Jigsaw will keep them fully occupied till at least 9.30am on Christmas morning.

Ladies! Why not accessorise with this Intestinal Villi Wristlet Clutch Bag? It's not at all gross, and could serve as a useful educational prop when engaging with food service providers about cross-contamination.

Let's not forget those with allergy.

Something for the home? An 'Asthma is Sexy' Inhaler Throw Pillow will brighten up the dullest of living quarters, while a Round Dust Mite Ornament will serve both a decorative purpose and a practical one - as a handy reminder to run a vacuum about the place periodically.

Meanwhile, the Allergens in Trachea Pillow Case (above) will surely help you doze off while gently recalling the day's wheezing highlights.

Clothing is perennially popular too. Some No Peanut Earrings would nicely offset a Japanese Hay Fever Hat. Sexy underwear for your anaphylactic partner? Nothing says 'I need you, baby' like a Food Allergies Classic Thong. It's only a tenner! The boys need not feel sidelined in the style wars: a Penicillin Allergy Alert Tie is perhaps second only to an Innate Immune System Cells tie when it comes to matters sartorial, but either will bring him out in a smile (or rash?).

Fans of the Bristol Stool Chart are amply catered for this season. I'm not quite sure what to make of a Bristol Stool Chart Service Tray (other than FORTY TWO POUNDS?), but a Bristol Stool Chart Wall Clock could come in handy should you wish to time your evacuations as well as accurately grade them.

Continuing the theme, this Bristol Stool Chart Coaster is an affordable £4.99 - good job it's a "wipe clean" item, just in case anyone should leave a deposit.

And surely there's nothing finer than Bristol Stool Chart Wrapping Paper to parcel up your crappy gifts this year?

Finally, greeting cards. None are Christmas-themed, per se, but on the plus side, should you have any left over you can use them to bring joy to recipients' lives after December 25th too - even next Christmas, should you have any friends left.

You may first like to marvel at the very existence of the Epipen Adrenaline Syringe and Peanuts Greetings Card, or the Small Intestinal Villi Greetings Card, or indeed the Mast Cell Releasing Histamine Greeting Card, or (not for the squeamish) Dermatitis Herpetiformis Vintage Greeting Card.

But ultimately I'm confident you'll settle for the following for your yuletide greetings. Because, ahem, trumping them all is this exquisite Endoscopy Greeting Card (right) - which is without doubt the ultimate means through which to send ... seasanal greetings.

Bottoms up!