Irritable Bowel Syndrome Message Boards | Celiac / Gluten Intolerance

Celiac.com 05/14/2012 - Should gluten sensitivity be thought of as "celiac light," as just one of the milder manifestation within the wider spectrum of celiac disease? Some doctors and researchers think so.

Photo: CC--Joe MabelOver the past several years, there has been increasing discussion concerning gluten sensitivity as a possible cause of irritable bowel syndrome (IBS) symptoms in patients for whom celiac disease has been excluded.

This is undoubtedly because gluten sensitivity, like IBS, is a symptom-based condition of diverse pathogenesis. As discussed, some have argued that gluten sensitivity might be best thought of as "celiac light," representing the milder
domains of the celiac disease spectrum.

However, there are some data to suggest that a subset of patients with gluten sensitivity may actually belong to the spectrum of celiac disease.

In a recent letter to the editors of the American Journal of Gastroenterology, doctors Courtney C. Ferch and William D. Chey of the Division of Gastroenterology
at the University of Michigan Health System in Ann Arbor, Michigan, comment at length on the latest findings regarding irritable bowel syndrome and gluten sensitivity without celiac disease.

Ferch and Chey note that gluten sensitivity is one of the most rapidly growing sectors in the food industry, with gluten-free products accounting for $1.31 billion in U.S. sales alone in 2011. Those sales are expected to exceed $1.6 billion by 2015.

Major food manufacturers such as General Mills and Betty Crocker, along with popular restaurant chains like PF Chang's and Subway are busy introducing new gluten-free options, or retooling original products into gluten-free versions.

People with gluten sensitivity typically show symptoms after eating gluten, but show no evidence of celiac disease or food allergy.

Unlike celiac disease, there are no accepted biomarkers for gluten-sensitivity. Doctors diagnose the condition mainly by looking at the connection between eating gluten and the presence adverse symptoms.

Numerous studies on gluten sensitivity suffer have included small sample size, a lack of adequate controls, a lack of blinding, and the use of non-validated outcome measures. Even with these limitations, Ferch and Chey say there are several studies worthy of further consideration.

One of the studies discussed in the Ferch and Chey was a double-blind, placebo-controlled, dietary re-challenge trial performed by Biesiekierski et al. The study sought to better understand the role of gluten ingestion in the development of gastrointestinal (GI) and non-GI symptoms in patients diagnosed with IBS.

The Biesiekierski study included a sample of 34 patients diagnosed with IBS by the Rome III criteria who had experienced symptom improvement with a gluten-free diet for 6 weeks before study enrollment. Celiac disease had been excluded in all study participants by either a negative HLADQ2/HLA-DQ8 haplotype or a normal duodenal biopsy. The study excluded patients with conditions such as cirrhosis, inﬂammatory bowel disease, non-steroidal anti-inﬂammatory drug ingestion, or excessive alcohol.

Over a six week double-blind randomization phase, study participants followed either a gluten-free or gluten-containing diet that was assigned at random. Nineteen of the 34 patients ate food containing 16 g of gluten per day. The other 15 patients ate gluten-free bread and mufﬁns. Gluten used in the study was free of fermentable oligo-, di-, monosaccharides and polyols, and its protein distribution included 2.3% nongluten, 45.7% glutenin, and 52% gliadin.

The primary outcome of the study was the proportion of patients answering "no" on over half of the occasions at the end of each week to this question: "Over the past week, were your symptoms adequately controlled?"

The study team also assessed secondary outcomes including bloating, abdominal pain, satisfaction with stool consistency, nausea, and tiredness using a 100-mm visual analog scale.

Once the study period ended, the results showed that many more patients in the gluten group compared with the gluten-free group answered "no" to the primary outcome question (68% vs 40%; P .001).

Compared with the gluten-ingesting group, those who remained gluten-free also reported signiﬁcant improvements in pain (P .016), bloating (P .031), satisfaction with stool consistency (P .024), and tiredness (P .001), although they showed similar levels of wind (P .053) or nausea (P .69).

The results of celiac antibodies at baseline and after the dietary intervention were
similar. The team also found that diet had no effect on intestinal permeability as measured by urine lactuloseto-rhamnose ratio. Additionally, they found detectable fecal lactoferrin levels in just one patient during the treatment period.

Meanwhile, high-sensitivity C-reactive protein levels remained normal before and after the dietary intervention.

There was no difference in the level of symptoms experienced by those with and without HLA-DQ2 and HLA-DQ8 alleles. The authors felt that these data support the existence of non�celiac-associated gluten sensitivity. They concluded that gluten is in fact tied to overall IBS symptoms, bloating, dissatisfaction with stool consistency, abdominal pain, and fatigue in some patients.

In their letter, Ferch and Chey also comment on several side issues.

First, they note that a recent global meta-analyses of studies showed that patients with IBS symptoms had signiﬁcantly higher rates of celiac disease than controls. As such, they point out that the American College of Gastroenterology Task Force now recommends routine celiac blood screens for patients with diarrhea-predominant IBS and IBS with a mixed bowel pattern (grade 1B recommendation).

Secondly, they note that there has been much recent discussion around the potential role of food in IBS symptoms that has focused on celiac disease. However, they point out that much has been made over the possible role of food, and possibly celiac disease, in IBS symptoms. However, they note that data from US studies show no higher risk for celiac disease among patients with IBS symptoms and no warning signs.

Although these results are certainly intriguing and hypothesis generating, they require validation in larger, randomized, controlled trials in other parts of the world.

What is clear and important for providers to understand is that gluten sensitivity is here to stay and signiﬁcantly more likely for them to encounter in day-to-day practice than celiac disease.

Read the full letter by Ferch and Chey at the website for the American Journal of Gastroenterology.

Source:

Am J Gastroenterol 2011;106:508 �514

http://www.celiac.com/articles/22889/1/Irritable-Bowel-Syndrome-and-Gluten-Sensitivity-Without-Celiac-Disease-Notes-from-the-Front-Lines/Page1.html

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Heather is the Administrator of the IBS Message Boards. She is the author of Eating for IBS and The First Year: IBS, and the CEO of Heather's Tummy Care. Join her IBS Newsletter. Meet Heather on Facebook!

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The Gluten-Free Vegetarian � Not to Worry, the Food Options Are Plentiful

By Cheryl Harris, MPH, RD

Today's Dietitian
Vol. 15 No. 4 P. 20

When Nancy became a vegetarian as a teenager, she found it easy to balance her diet with an active lifestyle. After she was diagnosed with celiac disease in her 40s, however, suddenly she couldn't eat the variety of foods she once enjoyed. Whole wheat bread, granola, and many of her beloved high-protein meals and snacks, including seitan, veggie burgers, falafel, and barley-based miso, now were off limits.

Like all people with celiac disease, Nancy must avoid foods containing gluten, a protein found in wheat, barley, rye, and in oats that aren't specifically grown and processed without gluten. Individuals who don't have celiac disease but have been diagnosed with gluten sensitivity, a condition that causes similar gastrointestinal (GI) symptoms, such as diarrhea, constipation, bloating, and gas, in response to gluten, also are unable to eat gluten-containing foods.1

The different types of vegetarians, from people who avoid all meat, fish, and poultry to vegans who avoid all foods of animal origin, including eggs and dairy products, especially find it difficult to eat healthfully and obtain the nutrients they need while following a gluten-free diet.

This article will discuss the types of vegetarian foods containing hidden gluten and the nutrient deficiencies common in vegetarian clients with celiac disease and provide meal and snack options RDs can share with clients.

Gluten's Hiding Place
It's no secret that gluten is ubiquitous in the typical American diet, yet vegetarian dishes tend to rely more heavily on wheat, barley, rye, and oats, either as a source of protein or as a binder or filler. Many commercially available veggie burgers, veggie sausage links, or textured vegetable protein crumbles contain gluten. Seitan, also known as "wheat meat," often is used in vegetarian Asian fare. Tempeh may be made with wheat or barley, and tofu may be breaded or flavored with wheat-derived soy sauce. In addition, gluten frequently appears in processed foods, including sauces, candy, beer, soups, and supplements.

Cross-contamination also is a concern, both at home and restaurants. Even though foods such as French fries are made from only potatoes, restaurants often fry them in the same oil used for other breaded products, making them unsafe for anyone with celiac disease.

A Balanced Diet
The first step RDs should take when counseling vegetarian clients with celiac disease or gluten sensitivity is to teach them basic label-reading skills to identify hidden sources of gluten, ways to avoid cross-contamination when preparing foods at home, and strategies for dining out. They also should provide support to balance nutritional needs, which is critical.

"A combined gluten-free and vegetarian diet should be very well planned," says Tricia Thompson, MS, RD, founder of Gluten-Free Watchdog, a subscriber service that independently tests products for the presence of gluten. "Gluten-free diets, as typically followed, may be high in fat and low in carbohydrates, fiber, calcium, iron, phosphate, zinc, folate, niacin, and B12, and some of these nutrients are especially concerning for vegetarians."

For example, getting enough iron can be tricky on a gluten-free vegetarian diet. Approximately one-half of the people newly diagnosed with celiac disease have iron-deficiency anemia. Many gluten-free cereal products lack the iron fortification of their standard counterparts, and vegetarians don't consume heme iron found in animal sources, which is more bioavailable. Nonheme iron is found in beans, lentils, seeds, quinoa, and nuts, but pairing these foods with vitamin C can significantly increase iron absorption. In many cases, iron supplements are necessary to replenish iron stores.2

Research indicates that fewer than one-third of women with celiac disease consume the recommended amount of calcium daily, and this is presumably lower among people who avoid dairy.3 The intestinal damage resulting from celiac disease temporarily can hinder the digestion of lactose in some individuals shortly after diagnosis. This lactose intolerance causes GI symptoms, such as bloating, gas, and diarrhea, after eating dairy foods. Subsequently, clients may avoid all dairy products, not realizing they can choose foods low in lactose, such as hard cheeses, or lactose-free milk and yogurts to obtain the calcium they need without experiencing GI symptoms.

Supplemental lactase drops can help clients digest lactose, enabling them to enjoy a wider range of dairy products. However, dietitians also should recommend other nutrient-dense calcium sources, such as firm tofu, leafy greens, nuts, seeds, a range of fortified nondairy milks, or calcium supplements, for clients struggling to meet calcium requirements.4

Moreover, many gluten-free diets are low in B vitamins, and B12 is of particular concern for vegans. "Many fortified foods may not be gluten free, and many gluten-free foods are not fortified," Thompson says. Fortunately, whole grains contain a range of B vitamins (except B12) and some protein. While quinoa has long enjoyed elite status in the vegetarian world as a complete protein, other options include buckwheat, millet, amaranth, sorghum, and teff in addition to the more familiar whole grains, such as gluten-free oats, wild rice, brown rice, and corn.

Zinc is a nutrient of concern for vegetarians with celiac disease, since it's mostly absorbed from animal sources. Pumpkin seeds, navy beans, wild rice, and teff are the best vegetarian sources of zinc. A variety of legumes, nuts, and grains have smaller amounts.4

Educating Clients
Vegetarian clients with celiac disease or gluten sensitivity may miss their favorite foods initially, but once RDs identify all the gluten-free vegetarian options available, clients can enjoy a wide variety of nutritious foods once again. There are many gluten-free recipes that include protein sources, such as beans, lentils, soy, whole grains, seeds, nuts, dairy, and eggs.

According to Rachel Begun, MS, RD, a spokesperson for the Academy of Nutrition and Dietetics, "Egg dishes such as omelets, frittatas, and Spanish tortillas pair well with greens and salads. Eggs and greens are one of my personal favorites."
Begun also recommends bean dishes, such as bean chili, lentil soup, black bean soup, or split pea soup. Beans are nutrient-dense sources of protein, iron, and calcium, and a great source of fiber.

Gluten-free whole grains lend themselves well to quick and easy meals. Clients can microwave quinoa in minutes to make a pilaf; they can pair 100% buckwheat soba noodles, which cook in fewer than 10 minutes, with veggies and peanut sauce; and they can top whole grain gluten-free pasta with sauce and serve with steamed veggies. Precooked wild rice tossed with feta, cucumbers, tomatoes, and olive oil is another simple but tasty meal. For customer convenience, precooked brown rice, wild rice, and quinoa are sold frozen or in pouches, but urge clients to read labels, as these ready-to-heat processed foods may contain gluten.

Naturally gluten-free snack options include fruits and vegetables that clients can serve with hummus, salsa, guacamole, or another type of dip. Clients can eat a variety of nuts, seeds, popcorn, yogurt, cheese, hard-boiled eggs, edamame, roasted garbanzo beans, or soynuts, or they can make their own trail mix. Fruit or vegetable smoothies with yogurt or tofu for protein are a quick and easy snack or light meal.

For many vegetarians with celiac disease, following a gluten-free diet can be a challenging transition. But with careful planning and by focusing on the available nutritious food options they can eat, RDs can help make their journey a smooth one.

� Cheryl Harris, MPH, RD, is a dietitian in private practice in Alexandria and Fairfax, Virginia, specializing in helping people follow a gluten-free diet. She's also a nutrition advisor for the DC Metro Area Celiac Support Group and speaks locally and nationally on celiac disease.

http://www.todaysdietitian.com/newarchives/040113p20.shtml

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Heather is the Administrator of the IBS Message Boards. She is the author of Eating for IBS and The First Year: IBS, and the CEO of Heather's Tummy Care. Join her IBS Newsletter. Meet Heather on Facebook!

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