Grains and gastrointestinal symptoms
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Grains and gastrointestinal symptoms

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This deck describes why grains may cause bowel symptoms in people with sensitive bowel. It's not only about gluten, but FODMAPs and even bran.

This deck describes why grains may cause bowel symptoms in people with sensitive bowel. It's not only about gluten, but FODMAPs and even bran.

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  • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2525476/ <br /> USA:ssa fruktoosin saanti n. 54 g/pv <br /> The largest source of fructose was sugar-sweetened beverages (30%) followed by grains (22%) and fruit or fruit juice (19%). <br /> Sorbitoli <br /> http://www.medscape.com/viewarticle/568700 <br /> Nicotette: 0,4 mg ksylitolia/purukumi, Nicotinelle: 0,2 mg sorbitolia/purukumi <br />

Grains and gastrointestinal symptoms Grains and gastrointestinal symptoms Presentation Transcript

  • Grains and gastrointestinal symptoms [Updated May 2014] Page 1
  • Background • There are myriad blog posts and “expert” opinions on gluten and on its possible detrimental role in non-celiac disorders • In these opinions the role of fermentable carbohydrates (FODMAPs) and insoluble bran is often dismissed • On the other hand, medical doctors and even gastroenterologists have been slow and reluctant to recognise the role of gluten or grains per se in non-celiac disorders • What does the evidence say about grains and gastrointestinal symptoms? 2 28 days
  • Gastrointestinal symptoms can be caused by at least 3 factors of gluten containing grains • Fermentable carbohydrates , ie. FODMAPs are shown to cause gastrointestinal symptoms in irritable bowel syndrome • Wheat bran can cause bloating and pain in irritable bowel syndrome (even if helps in constipation) • Gluten can cause symptoms in a fragment of patients. Non- celiac gluten sensitivity is recognised as own disease entity 3
  • 1. Fermentable carbohydrates cause bowel symptoms The FODMAP story 4
  • FODMAP* Galactans Oligosaccharides Inulin GOS* RaffinoseFructans FOS* Disaccharides Lactose Monosaccharides Fructose Polyols Isomalt Maltitol Lactitol Xylitol (Lactulose) Mannitol *) FOS= Fructo-oligosaccharide *) GOS= Galacto-oligosaccharide Sorbitol FODMAP: Fermentable oligosaccharides, disaccharides, monosaccharides and polyols Jacqueline S. Barrett and Peter R. Gibson Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals? Ther Adv Gastroenterol(2012) 0(0) 1–8
  • Fermentable carbohydrates, 2 classes FODMAPs • Poorly absorbed short chain carbohydrates undergo rapid and extensive fermentation in colon which causes bloating, gas formation, water retention, urge to defecate and diarrhea (or constipation in some cases) • Some of fermentable carbohydrates (inulin, fructo- oligosaccharides and galacto- oligosaccharides) can be classified as soluble fiber Non-FODMAPs • Poorly absorbed carbohydrates with longer chains are less likely to cause extensive symptoms because they undergo slower and incomplete fermentation (still can cause minor symptoms) – Resistant starch, beta-glucan, pectin, gums & polydextrose
  • FODMAPs are proven cause of GI symptoms in clinical studies Staudacher H, Irving P, Lomer M, Whelan K. Mechanisms and efficacy of dietary FODMAP restriction in IBS. Nat Rev Gastroenterol Hepatol. 2014 Apr;11(4):256-66.
  • Main sources of FODMAPs Jacqueline S. Barrett and Peter R. Gibson Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals? Ther Adv Gastroenterol(2012) 0(0) 1–8
  • In US wheat is a key source of inulin and FOS • Oligosaccharides inulin and FOS are major causes of GI symptoms in irritable bowel syndrome • Wheat is a key source of fructans in American and Western diets 9 Moshfegh AJ et al. Presence of Inulin and Oligofructose in the Diets of Americans. J. Nutr. 129: 1407S–1411S, 1999 Intake of FOS & inulin
  • 2. Wheat bran may cause GI symptoms in persons with sensitive bowel Insoluble fiber, such as cellulose in bran can cause bowel symptoms but wheat and rye brans are are also high in FODMAPs www.pronutritionist.net10
  • Wheat bran causes symptoms • In an American randomized trial wheat bran increased abdominal bloating (30 g/d) and did not ease any IBS-related symptom • In a German randomized trial psyllium (10 g/d) relived bloating ,where as wheat bran (21 g/d) worsened bloating in two weeks’ follow up • 12 g grams of wheat bran daily was equally effective as placebo in global score of IBS symptoms but increased wind and bloating in a 4 week randomized trial • Not all randomized trials have shown deleterious effects in sensitive bowel 11 Hebden JM et al. Abnormalities of GI transit in bloated irritable bowel syndrome: effect of bran on transit and symptoms. Am J Gastroenterol. 2002 Sep;97(9):2315-20. Effectiveness of plantago seed husks in comparison with wheat brain on stool frequency and manifestations of irritable colon syndrome with constipation. Med Klin (Munich). 1994 Dec 15;89(12):645-51. Hotz J, Plein K.Snook J, Shepherd HA. Bran supplementation in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 1994 Oct;8(5):511-4.
  • Wheat and rye brans are also rich sources of inulin and fructo- oligosaccharide (=fructans) • Wheat, barley and especially rye are rich in fructans (FODMAPs) but oats is low • Wheat is also rich in cellulose and and lignin, insoluble fiber components 12 Fructans = inulin and fructo-oligosaccharide (FOS) Frølich W, Aman P, Tetens I. Whole grain foods and health – a Scandinavian perspective. Food Nutr Res. 2013;57
  • 3. Gluten in wheat and other grains may cause symptoms. Or may not. Work by Biesiekierski Jessica et at. (Melbourne, Australia) 13
  • Gluten caused bowel symptoms in a highly selected population (no FODMAP restrictions at the same time) • A highly selective sample of patients with subjective feeling of gluten intolerance was exposed to blinded gluten challenge • 60 % of patients reported improvement in symptoms • Symptoms didn’t improve in 32 % patients • The test was done on purified gluten (no extra FODMAPs and bran on top of gluten) www.pronutritionist.net14 Biesiekierski et al. Gluten Causes Gastrointestinal Symptoms in Subjects Without Celiac Disease: A Double-Blind Randomized Placebo-Controlled Trial. Am J Gastroenterol. 2011 Mar;106(3):508-14
  • Later study from the same investigators: gluten caused no symptoms when low-FODMAP diet was followed at the same time • When IBS patients with self- reported gluten sensitivity were re-challenged with gluten pills they experienced no more (any) symptoms than on placebo • The study differs from the previous study in that the participants followed low FODMAP diet at the time of re- challenge 15 Biesiekierski J et al. Effects of Gluten in Patients With Self-Reported Non-Celiac Gluten Sensitivity After Dietary Reduction of Fermentable, Poorly Absorbed, Short-Chain Carbohydrates. Gastroenterology 2013; 145, 320–328.
  • Wheat challenge in a highly selected population • 30 % IBS patients with subjective wheat sensitivity actually show wheat sensitivity in blinded wheat challenge test (12 g/d) • In those who proved to be wheat intolerant, a dramatic increase in pain, bloating and stool consistency was observed during wheat period • Bran and FODMAPs may contribute to symptoms as they were not controlled in this trial www.pronutritionist.net16 Changes in symptom severity over baseline during the double- blind placebo-controlled wheat challenge: 2 weeks on wheat- containing diet and 2 weeks on placebo. Carroccio A et al. Non-Celiac Wheat Sensitivity Diagnosed by Double-Blind Placebo-Controlled Challenge: Exploring a New Clinical Entity, Am J Gastroenterol. 2012 Jul 24. doi: 10.1038/ajg.2012.236.
  • Gluten free diet reduces bowel movements (diarrhoea) in people with sensitive stomach and diarrhoea (IBS-D). Both consumption of FODMAPs and gluten is reduced when gluten free diet is followed 17 Vazquez-Roque MI, et al. . Association of HLA-DQ gene with bowel transit, barrier function, and inflammation in irritable bowel syndrome with diarrhea. Am J Physiol Gastrointest Liver Physiol. 2012 Dec 1;303(11):G1262 28 days 28 days
  • 4. Perhaps it’s the 4th factor: α- amylase-trypsin inhibitors 18
  • Preliminary data from animal and in vitro studies: α-amylase-trypsin inhibitors are pro-inflammatory at level of intestinal epithelium 19 Junker Y et al. Wheat amylase trypsin inhibitors drive intestinal inflammation via activation of toll-like receptor 4. Journal of Experimental Medicine 2012; 209:2395-408 • “In this study, we show that members of the nongluten α- amylase/trypsin inhibitor (ATI) family contained in wheat and related cereals are strong inducers of innate immune responses in human and murine macrophages, monocytes, and DCs. • Our findings have broad implications not only for celiac disease but also for other intestinal inflammatory disorders of the gastrointestinal tract”
  • Conclusions • FODMAPs do cause gastro-intestinal symptoms in patients with sensitive stomach (irritable bowel syndrome). • Wheat bran may cause bloating and pain in some occasions • Gluten can cause bowel symptoms in a fragment of patients but its role in triggering symptoms is still highly controversial • Prevalence of wheat, grain or gluten sensitivity is not known. Estimations are basing on highly selected populations • Role of α-amylase/trypsin inhibitors is fully open because no randomized trials/clinical studies are available • Oats is more or less devoid of FODMAPs and gluten, and is therefore better tolerated 20
  • Top 4 readings • Jacqueline S. Barrett and Peter R. Gibson Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals? Ther Adv Gastroenterol (2012) 0(0) 1–8, open access • Staudacher H, Irving P, Lomer M, Whelan K. Mechanisms and efficacy of dietary FODMAP restriction in IBS. Nat Rev Gastroenterol Hepatol. 2014 Apr;11(4):256-66 • Grabitske H & Slavin J. Low-Digestible Carbohydrates in Practice. J Am Diet Assoc. 2008;108:1677-1681 • Sapone et al. Proposed new nomenclature and classification of gluten-related disorders. BMC Medicine 2012, 10:13 21
  • Welcome aboard http://twitter.com/pronutritionist http://www.facebook.com/pronutritionist http://www.pronutritionistblog.com http://www.pronutritionist.net Reijo Laatikainen, Authorized Nutritionist, MBA, Dietitian Page 22