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Grains and gastrointestinal symptoms

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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Grains and gastrointestinal symptoms

  1. 1. Grains and gastrointestinal symptoms [Updated May 2015] Page 1
  2. 2. 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 sometimes dismissed • On the other, 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
  3. 3. Prevalence of non-celiac ”gluten sensitivity” • According to a systematic review prevalence is 0,5-13 %. Higher figures are based on very selective populations • Prevalence figures are often based on self-reports, expert examinations and are always symptom based. NO biomarker exists for gluten sensitivity • It seems gluten free diet has not resolved symptoms in most people with sensitive stomach, because according data from UK: – 42% of IBS patients considered themselves gluten sensitive but only 11,9 % followed gluten free diet – 28% of IBD patients consider themselves as gluten sensitive but only 6,2 % followed gluten free diet Molina-Infante J1, Santolaria S, Sanders DS, Fernández-Bañares F. Systematic review: noncoeliac gluten sensitivity. Aliment Pharmacol Ther. 2015 May;41(9):807-20. Aziz I, et al. A Study Evaluating the Bidirectional Relationship Between Inflammatory Bowel Disease and Self-reported Non-celiac Gluten Sensitivity. Inflamm Bowel Dis. 2015 Apr;21(4):847-53.
  4. 4. 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 4
  5. 5. 1. Fermentable carbohydrates cause bowel symptoms The FODMAP story 5
  6. 6. 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
  7. 7. Fermentable carbohydrates, 2 classes FODMAPs • Some of fermentable carbohydrates (inulin, fructo- oligosaccharides and galacto- oligosaccharides) can be classified as soluble fiber • 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) 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
  8. 8. FODMAPs are proven cause of GI symptoms in irritable bowel syndrome *) RCT=Randomized controlled trials, non-RCT= Controlled trial, no randomization ↓↓↓=reduction ↑↑↑=increase 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. RCTs* Non-RCT* Retrospective cohorts/case- control studies ↓↓↓ in some symptoms 3 studies 1 study 6 studies No difference in any symptom None of the studies None of the studies None of the studies ↑↑↑in some symptoms None of the studies None of the studies None of the studies Effect of low-FODMAP diet on symptoms if IBS
  9. 9. 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
  10. 10. 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 10 Moshfegh AJ et al. Presence of Inulin and Oligofructose in the Diets of Americans. J. Nutr. 129: 1407S–1411S, 1999 Intake of FOS & inulin
  11. 11. 2. Wheat bran may cause GI symptoms in persons with sensitive bowel Insoluble fiber, such as cellulose in bran can cause bowel symptoms. Wheat and rye brans are are also high in FODMAPs www.pronutritionist.net11
  12. 12. 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 12 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.
  13. 13. 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 13 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
  14. 14. 3. Gluten in wheat and other grains may cause symptoms. Or may not. If low-FODMAP diet is not followed, gluten or wheat pills have caused symptoms in very selected patients (2 Italian & 1 Australian study) If low-FODMAP diet was followed, gluten pills did not cause more symptoms than whey protein (1 Australian study) 14
  15. 15. 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.net15 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
  16. 16. 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 16 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.
  17. 17. 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.net17 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.
  18. 18. Gluten caused some bowel and other symptoms in a highly selected population (no FODMAP restrictions at the same time) • One week gluten free run-in period. Gluten free diet was continued for further one week (actual test period) • Treatments: gluten pills 4.375 g/d vs placebo pills, rice starch 4.375 g/d • There was small but statistically significant difference in bloating, abdominal pain, foggy mind, depression, aphthous stomatitis favoring placebo • ” However, when we examined the individual patients’ overall scores we found that only a minority of the participants experienced a real worsening of symptoms under gluten” 18 Di Sabatino A, et al. Small Amounts of Gluten in Subjects With Suspected Nonceliac Gluten Sensitivity: A Randomized, Double-Blind, Placebo-Controlled, Cross-Over Trial. Clin Gastroenterol Hepatol. 2015 Feb 19. pii: S1542-3565(15)00153-6. N=59, cross over, 7 day-intervention
  19. 19. Gluten free diet reduces bowel movements (BM) in people with sensitive stomach and diarrhoea (IBS-D). Both intake of FODMAPs and gluten are reduced when gluten free diet is followed 19 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 • Both diets seemed to reduce bowel movements but there were significantly less bowel movements (diarrhoea) during gluten free diet (GFD) • No other symptoms were monitored! • Permeability of small intestine was reduced during GD
  20. 20. 4. Perhaps it’s the 3rd factor: α- amylase-trypsin inhibitors 20
  21. 21. Preliminary data from animal and in vitro studies: α-amylase-trypsin inhibitors are pro-inflammatory at level of intestinal epithelium 21 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. ATI family members activate the TLR4–MD2–CD14 complex and elicit strong innate immune effects not only in vitro but also in vivo after oral or systemic challenge. • Our findings have broad implications not only for celiac disease but also for other intestinal inflammatory disorders of the gastrointestinal tract”
  22. 22. Conclusions • FODMAPs, present abundantly in grains, 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 • 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 22
  23. 23. Top 3 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 • 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 23
  24. 24. Welcome aboard Reijo Laatikainen, Authorized Nutritionist, MBA, Dietitian Page 24

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  • pepeti

    May. 11, 2014
  • Miriits

    Apr. 29, 2015

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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