My alma mater, the University of Virginia, has a fair amount of useful GI educational material on their website.
Here are a few links:
Irritable Bowel Syndrome (IBS) diet
Short Bowel Syndrome Diet (Long Version)
Nutritional Considerations for Patients with Inflammatory Bowel Disease
In a pediatric Boston cohort of 579 patients presenting for celiac evaluation but no previous diagnosis, 7.4% had previous gluten avoidance (J Pediatr 2012; 161: 471-5). In this cohort, the mean age at presentation was 8.7 years.
Independent predictors of gluten avoidance and the odds ratio (OR) included the following:
From my perspective, many families and sometimes referring physicians are convinced that their child has celiac disease before subspecialty evaluation. While a gluten-free diet may reduce some gastrointestinal symptoms even in the absence of celiac disease, it is probably helpful for families to complete diagnostic testing and to obtain dietary counseling prior to implementing a gluten-free diet.
Previous related blog entries:
Gluten free is big business. In a range of conditions, eliminating gluten has been advocated to improve symptoms. The most frequent problem in which a gluten-free diet (GFD) may be beneficial is irritable bowel syndrome (IBS). A selected summary in Gastroenterology discusses this topic (Gastroenterology 2012; 142: 664-73).
This review highlights an article that showed improvement in a double-blind randomized trial (Am J Gastroenterol 2011; 106: 508-14) & then reviews the topic more broadly. The study is the first randomized controlled trial that suggests that nonceliac IBS patients may improve with a GFD. The study looked at 34 patients with IBS who had improved with a GFD & had no evidence of celiac disease (either negative HLA-DQ2/DQ8 or duodenal biopsy). Then 19 patients had 16g of gluten per day reintroduced; control patients were offered equivalent food that was gluten-free. The gluten products in the study were free of fermentable oligo-, di-, monosaccharides and polyols to avoid confounders (What to make of FODMAPs). The patients who continued a GFD had less reported pain, bloating and tiredness. The GFD group reported good control of symptoms the previous week in 68% vs. 40% in the study group.
The commentary notes that ‘gluten sensitivity’ is big business, accounting for 1.3 billion in 2011 expenditures. Companies like General Mills, Betty Crocker, PF Chang’s, and Subway are offering gluten-free choices. Since immune activation and low-grade inflammation may be important for IBS, it is possible that some foods trigger these processes. At the same time, individuals with reported gluten sensitivity have not been shown to have increased intestinal permeability; this is in contrast to celiac disease (BMC Med 2011; 9; 23).
There may be more patients with IBS who will benefit from a GFD due to gluten sensitivity than patients with celiac disease.
Additional references:
Consumption of FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) may trigger irritable bowel syndrome (IBS) symptoms. Some research indicates that a diet low on FODMAPs may be beneficial (J Hum Nutr Diet 2011; 24: 487-95). This study tried to assess whether a low FODMAPs diet which had been reported from a single center in Australia would be effective for IBS.
In this study, consecutive patients with IBS were divided into two groups. 39 received standard dietary advice based on UK National Institute for Health and Clinical Excellence (NICE) guidelines. 43 patients were placed on a low FODMAP dietary advice. Patients were selected into each group consecutively (not randomized). This study reported a 76% satisfactory symptom response in the FODMAP group vs a 54% response in the control group (p=0.038). Overall, 86% of FODMAP group had improved composite score compared with 49% of standard treatment group. Specific improvements were noted in bloating, abdominal pain, and flatulence. The average age of the study population was 38 and 71% were females. 60% had diarrhea-predominant IBS.
NICE guidelines for IBS:
Low FODMAP diet
Of course, reading the author’s description of a low FODMAP diet is confusing. Translation:
Include more bananas, blueberries, lettuce, potatoes, gluten-free breads or cereals, rice, oats, hard cheeses, lactose-free milk, sugar, molasses, and artificial sweeteners that do not end in “ol.”
Avoid/eliminate apples, pears, canned fruits in natural juices, high-fructose corn syrup, cows’ milk (due to lactose), soft cheese, broccoli, cabbage, pasta, bread, baked goods from wheat/rye, mushrooms, and sweeteners like sorbitol or others that end in “ol.”
Since this diet has attracted more widespread attention, basic familiarity is important for all physicians who treat IBS. A useful resource to explain this diet is the Wall Street Journal:
http://online.wsj.com/article/SB10001424052970204554204577023880581820726.html
This link has a good table illustrating the recommended dietary choices.
Whether FODMAPs will be superior to other dietary advice for IBS is still uncertain. Though, given the limited number of effective treatments for IBS, this small study is a promising development.
Additional references:
With the discovery of precise serologies to identify celiac disease, the likelihood of complications of celiac disease has been changing. In addition, the presentation of celiac disease is different now. Instead of seeing children with malabsorption and abdominal distention, many children and adults are identified with mild or no symptoms. Also, the risk of severe complications including malignancy and autoimmune disease has been reevaluated based on larger cohorts. Twenty years ago, the risk of these complications did serve as a motivator for continuation of a gluten free diet (GFD). While a GFD remains important, these risks are much lower than previously reported. The most recent article to support this contention is the following:
Clinical Gastroenterology and Hepatology 2012; 10: 30-36. This study examined ~45,000 patients with either celiac disease (villous atrophy, Marsh score of 3), duodenal inflammation (Marsh 1 or 2), or latent celiac disease (normal mucosa & positive serology). After the first year, there was no significant increase risk for GI cancers. During the first year, cancers that were identified may not have been causally-related to celiac disease but due to coincident detection.
This article due to its large cohort is very useful, but other articles have come to different conclusions. Irregardless, there are still compelling reasons to continue a GFD. Many individuals feel better on a GFD & did not recognize prior symptoms. Maintaining this diet probably lowers the risk of developing certain autoimmune conditions and definitely improves bone health.
Other recent &/or related articles:
–Gastroenterology 2010; 139: 763. Mortality NOT worsened in undiagnosed celiac disease (identified by review of serology) in Olmstead County, though bone density decreased. n=129 of 16,847. (?milder cases undiagnosed)
–J Pediatrics 2010; 157: 373, 353. Even patients without villous atrophy & positive serology, benefited from GFD with regard to GI symptoms and serological markers.
–JAMA 2009; 302: 1171-78. n=29,096. Mortalitiy increased in celiac disease: 35% for latent, 72% for inflammation, 39% for celiac dz.
–Clin Gastro & Hep 2008; 6: 753. Incidence of autoimmune diseases less in those celiac patients who were compliant with GFD. n=178.
–Gastroenterology 2002; 123; 1428-1435. n=12,000. Risk for cancer 1.3 odds ratio (lower than in previous studies).
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