Gluten-free diet (GFD) is enjoying increasingly popularity, although gluten-free products are considerably more expensive. GFD is absolutely necessary for patients with celiac disease, as in this case even minor amounts of gluten can lead to the destruction of the intestinal mucosa. In addition, GFD is currently the best therapy to improve clinical symptoms of patients with non-celiac gluten sensitivity (NCGS), although the diet may not be as strict as that for patients with celiac disease. Beside gluten, other wheat components such as oligosaccharides and amylase trypsin inhibitors are discussed as triggers of NCGS in this review. An overlap between gastrointestinal symptoms in NCGS and irritable bowel syndrome (IBS) is described. Patients with NCGS attribute their symptoms to the consumption of gluten, while patients with IBS rarely describe gluten as a trigger. Recently, several studies have demonstrated that the introduction of a low FODMAP (fermentable oligo-, di-, monosaccharides, and polyols) diet reduced gastrointestinal symptoms in patients with IBS and this diet is suggested as the first choice of therapy in IBS. However, a low FODMAP diet also eliminates prebiotica and may negatively influence the gut microbiota. For this reason, the diet should be liberalized after symptom improvement. There is no evidence that a GFD is healthier than the standard diet. In contrast, GFD often is accompanied by nutritional deficiencies, mainly minerals and vitamins. Therefore, GFD and low FODMAP diets are not recommended for healthy subjects. Since wheat contains fructans belonging to FODMAPs), a GFD is not only gluten-free but also has less FODMAPs. Thus, symptom improvement cannot be correctly correlated with the reduction of either one or the other.

https://www.mdpi.com/2072-6643/11/8/1957/pdf

Gluten and FODMAPS-Sense of a Restriction/When Is Restriction Necessary?

Objective A considerable proportion of patients with irritable bowel syndrome (IBS) may be wheat-sensitive and respond to a gluten-free diet (GFD) although they do not have coeliac disease. However, a diagnostic test for wheat sensitivity (WS) is missing. Our study evaluated the diagnostic accuracy (sensitivity and specificity) of confocal laser endomicroscopy (CLE) for the identification of WS as primary outcome. Design In this prospective, double-blind diagnostic study 147 non-coeliac patients fulfilling the Rome III criteria for IBS were tested by CLE for duodenal changes after wheat (index test), soy, yeast or milk exposure. Patients with IBS responding to 2 months of GFD were classified as having WS (reference test) using response criteria recommended by regulatory bodies for pharmaceutical trials of patients with IBS. After 2 months, CLE results were unblinded and patients were advised to exclude those food components that had led to a positive CLE reaction. The clinical response was assessed at follow-up after 6 and 12 months. Results Of 130 patients who completed the study per protocol, 74 (56.9%) responded to GFD and were classified as WS after 2 months, and 38 of these 74 patients were correctly identified by CLE (sensitivity 51.4%; 97.5% CI: 38.7% to 63.9%). A total of 38 of 56 patients without WS were correctly identified by CLE (specificity 67.9%; 97.5% CI: 52.9% to 79.9%). At 6 months follow-up, CLE correctly identified 49 of 59 food-sensitive patients (sensitivity 83.1%; 97.5% CI: 69.9% to 91.3%) but specificity was only 32% (97.5% CI: 15.7% to 54.3%). Conclusion In light of the high proportion of patients with IBS responding to GFD, the diagnostic accuracy of CLE is too low to recommend widespread use of this invasive procedure. Trail registration number This study was registered as clinical trial in the German Registry for Clinical Studies (DRKS00010123).

https://gut.bmj.com/content/gutjnl/early/2021/09/20/gutjnl-2021-325181.full.pdf

Prospective, double-blind diagnostic multicentre study of confocal laser endomicroscopy for wheat sensitivity in patients with irritable bowel syndrome.

Exclusion diets for gastrointestinal symptom management have been hypothesized to be a risk factor for avoidant/restrictive food intake disorder (ARFID; a non‐body image‐based eating disorder). In a retrospective study of pediatric and adult neurogastroenterology patients, we aimed to (1) identify the prevalence and characteristics of an exclusion diet history and (2) evaluate if an exclusion diet history was concurrently associated with the presence of ARFID symptoms.

History of trying exclusion diets and association with avoidant/restrictive food intake disorder in neurogastroenterology patients: A retrospective chart review

http://www.clinicalnutritionjournal.com/article/S0261561423001024/pdf

Practical guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline.

During the last 30 y, a gluten-free diet has been classified among the most popular fad diets mainly due to the ambiguous notion that gluten avoidance promotes health. Gluten intolerance has been implicated in non-celiac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS), 2 disorders with overlapping symptoms and increasing trend. Together with gluten, other wheat components; fermentable oligo-, di-, monosaccharide, and polyols (FODMAPs); and amylase trypsin inhibitors (ATIs), are implicated in the pathogenesis of both disorders. Gut microflora alterations in IBS and NCGS have been described, while microbiota manipulations have been shown to be promising in some IBS cases. This literature review summarizes our current knowledge on the impact of wheat ingredients (gluten, FODMAPs, and ATIs) in IBS and NCGS. In both disorders, FODMAPs and ATIs trigger gut dysbiosis, suggesting that gluten may not be the culprit, and microbiota manipulations can be applied in diagnostic and intervention approaches.

Non-Celiac Gluten Sensitivity and Irritable Bowel Disease: Looking for the Culprits.

Background FODMAP reduced diet (fermentable oligo-, di-, monosaccharide, and polyols) belongs to the established therapy strategies in irritable bowel syndrome (IBS). However, disadvantages of this diet are significant and may lead to weight loss and insufficient patient adherence. Reports from Germany are not available yet. Material and methods In a prospective study, 93 patients with IBS according to Rom III were investigated. Sixty-three patients were recruited for the study and received standardized investigation, informed consent, and structured dietary instructions about the FODMAP reduced diet. Patients complaints were documented by a validated questionnaire and a standardized Lickert scale before and 8 weeks after the start of the diet. Stool characteristics were documented by the Bristol stool form scale. Results Patients adherence was low because 30 patients (47 %) stopped the diet. Of the remaining 33 patients, 36 % (n = 12) developed significant weight loss during the FODMAP therapy. Patients completing the study reported significant global improvement of symptoms in 79 % of cases (abdominal pain 85 %, meteorism 79 %, flatulence 69 %, borbogymi 69 %, nausea 46 %, fatigue 69 %). In addition, the severity of symptoms was significantly reduced. Fourteen patients developed changes of their stool characteristics according to the Bristol stool form scale, 11 of whom improved diarrhea and 3 improved constipation. Conclusion FODMAP reduced diet is an efficient therapy in IBS. However, adherence of the patients is poor and the therapy bears the risk of significant weight loss.

Tolerability of FODMAP - reduced diet in irritable bowel syndrome - efficacy, adherence, and body weight course.

Viele Patienten mit gastrointestinalen Funktionsstorungen bzw. funktionellen gastrointestinalen
 Erkrankungen geben nahrungsassoziierte Beschwerden an. Die Bewertung der Symptome ist subjektiv und kann
 nur in wenigen Fallen objektiviert werden. Die wesentlichen Differenzialdiagnosen (u. a. chologene
 Diarrho, Zoliakie) sollten beachtet werden. Nach Standardisierung (leichte Vollkost) mit Berucksichtigung
 der Zeit, Menge und Frequenz der Nahrungszufuhr kann eine Diagnostik und Therapie durch ein
 Ernahrungstagebuch mit individueller Nahrungsanpassung erfolgen. Diatetische Strategien sind die
 laktose-, fruktose- bzw. sorbitarme Ernahrung bei Nachweis einer entsprechenden Unvertraglichkeit im
 Wasserstoffatemtest, die gluten- bzw. weizenarme Kost, die FODMAP-reduzierte Kost bzw. die 6-Food-Diat
 bei eosinophiler Osophagitis. Eine dogmatische, auf bestimmte Ernahrungsgewohnheiten fixierte Diat sollte
 vermieden werden.

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Tolerability of FODMAP - reduced diet in irritable bowel syndrome - efficacy, adherence, and body weight course.

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