In this Australian randomized trial, continued avoidance of gluten was associated with fewer and less severe symptoms among patients with irritable bowel syndrome

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Gluten Causes Gastrointestinal
Symptoms in Subjects Without Celiac
Disease: A Double-Blind Randomized
Placebo-Controlled Trial
Biesiekierski et al. Am J Gastroenterol
advance online publication, 11 January 2011;
doi: 10.1038/ajg.2010.487
Page 1 Biesiekierski et al. Am J Gastroenterol advance online
publication, 11 January 2011

2. Page 2
Pronutritionist’s background
• Irritable Bowel Syndrome (IBS) is a common functional gastrointestinal
disorder characterized by wind, bloating, pain/discomfort and change in
bowel habits
• Three typical pathophysiological changes have been described
– Objectively measured increased visceral sensitivity, ie. lowered pain
threshold in abdominal area
– Increased tendency to produce gas after food challenge
– Change in intestinal microbiota
• Lately, indigestible carbohydrates have been linked to symptoms, and
withdrawal of these FODMAP carbohydrates relieve symptoms at least
short term (Ong et al. 2010)
• “Resistant starch” has also been linked to symptoms (NICE, UK)
• Gluten-free diet relieves symptoms among some IBS patients
according to narrative reports, but role of gluten is poorly studied
Biesiekierski et al. Am J Gastroenterol advance online
publication, 11 January 2011
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3. Methods
• A double blind randomized controlled clinical trial
• IBS patients without celiac disease (excluded with biochemical and clinical tests).
All patients had become symptomless with gluten-free diet prior entry to study,
N=34
• Primary end point: Adequate relief (subjective)
• Secondary end point: Biomarkers and gastrointestinal symptoms on VAS scale
• 14 day run in with gluten-free diet
• 6 weeks’ re-challenge:
– A) Placebo gluten-free bread, two slides a day + one gluten free muffin
– B) Gluten bread, two slices a day + one gluten muffin, including 16 grams of
gluten a day-
– Breads and muffins were identical in appearance and taste (assured with
preliminary test), only gluten and gliadin and albumin content separated
placebo and gluten products
– Both breads and muffins were also devoid of FODMAP carbohydrates
(indigestible carbohydrates)
• Symptoms were evaluated weekly and 3 weeks after protocol
Page 3 Biesiekierski et al. Am J Gastroenterol advance online
publication, 11 January 2011
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4. Results (1/3)
• All patients adhered to study and minumum 95 % of
prescribed food items were consumed in both groups
• 9 patients withdrew prematurely
– 7 in gluten group
– 2 in placebo group (continued gluten free)
• Primary outcome (Adequate Relief)
– In placebo group (continued gluten-free diet) 40 % of patients did
not receive adequate relief from continued gluten-free diet
– In gluten re-challenge group 68 % of patients did not receive
adequate relief from diet which re-introduced gluten
– p=0,001
• No anti-gliadin antibodies were induced
• Intestinal permability, CRP, fecal lactoferrin or celiac antibodies were
not different among groups
Page 4 Biesiekierski et al. Am J Gastroenterol advance online
publication, 11 January 2011
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utritionist

5. Results (2/3)
Share of IBS patients that continued to have “adequate relief”
for 6-weeks*
Page 5
*) on more than half of the symptoms for more than half of the study
Biesiekierski et al. Am J Gastroenterol advance online
publication, 11 January 2011
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utritionist

6. Results (3/3)
Symptoms (secondary outcomes) at week 1*
Page 6
*) compiled from data curves. Differences were statistically significant for all parameters depicted here but
wind. Pain and tiredness continued to be significantly different for whole study period (6 weeks)
Biesiekierski et al. Am J Gastroenterol advance online
publication, 11 January 2011
VASscore(0-100)
None=0
Worst=100
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utritionist

7. Pronutritionist’s discussion
• In the present study, the re-introduction of gluten into the diet of IBS
patients induced symptoms
• No change in biochemical markers, ie. latent celiac disease did not
explain the re-introduction of symptoms
• It’s been previously shown that elimination indigestible carbohydrates
(FODMAPs) may also alleviate symptoms among IBS patients
• Because wheat and other grains are the key sources of both FODMAPs
and gluten, an elimination of grains is emerging as feasible diet for
patients with severe IBS symptoms
• It must be kept in mind that patients included in this study were highly
selected. The results may not be extrapolated to a wider audience of IBS
patients
• Dietary counseling of IBS patients should also include (on top of
FODMAP restriction and possible gluten-free diet) introduction of a
probiotic, possibly soluble fiber and and avoidance of caffeine
• Associations of diet and IBS are still poorly studied and understood
Page 7 Biesiekierski et al. Am J Gastroenterol advance online
publication, 11 January 2011
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utritionist