1
|
Pasta A, Formisano E, Calabrese F, Plaz Torres MC, Bodini G, Marabotto E, Pisciotta L, Giannini EG, Furnari M. Food Intolerances, Food Allergies and IBS: Lights and Shadows. Nutrients 2024; 16:265. [PMID: 38257158 PMCID: PMC10821155 DOI: 10.3390/nu16020265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024] Open
Abstract
This narrative review delves into the intricate relationship between irritable bowel syndrome (IBS) and food intolerances. IBS, a chronic functional gastrointestinal disorder, is characterized by symptoms like abdominal pain and altered bowel habits. The prevalence of IBS has increased globally, especially among young adults. Food and dietary habits play a crucial role in IBS management. About 85-90% of IBS patients report symptom exacerbation linked to specific food consumption, highlighting the strong connection between food intolerances and IBS. Food intolerances often exhibit a dose-dependent pattern, posing a challenge in identifying trigger foods. This issue is further complicated by the complex nature of gastrointestinal physiology and varying food compositions. This review discusses various dietary patterns and their impact on IBS, including the low-FODMAP diet, gluten-free diet, and Mediterranean diet. It highlights the importance of a personalized approach in dietary management, considering individual symptom variability and dietary history. In conclusion, this review emphasizes the need for accurate diagnosis and holistic management of IBS, considering the complex interplay between dietary factors and gastrointestinal pathophysiology. It underlines the importance of patient education and adherence to treatment plans, acknowledging the challenges posed by the variability in dietary triggers and the psychological impact of dietary restrictions.
Collapse
Affiliation(s)
- Andrea Pasta
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (A.P.); (F.C.); (M.C.P.T.); (G.B.); (E.M.); (E.G.G.)
| | - Elena Formisano
- Dietetics and Clinical Nutrition Unit, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (E.F.); (L.P.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Francesco Calabrese
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (A.P.); (F.C.); (M.C.P.T.); (G.B.); (E.M.); (E.G.G.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Maria Corina Plaz Torres
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (A.P.); (F.C.); (M.C.P.T.); (G.B.); (E.M.); (E.G.G.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (A.P.); (F.C.); (M.C.P.T.); (G.B.); (E.M.); (E.G.G.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (A.P.); (F.C.); (M.C.P.T.); (G.B.); (E.M.); (E.G.G.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Livia Pisciotta
- Dietetics and Clinical Nutrition Unit, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (E.F.); (L.P.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (A.P.); (F.C.); (M.C.P.T.); (G.B.); (E.M.); (E.G.G.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy; (A.P.); (F.C.); (M.C.P.T.); (G.B.); (E.M.); (E.G.G.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| |
Collapse
|
2
|
Vedantam S, Graff E, Khakoo NS, Khakoo NS, Pearlman M. Food as Medicine: How to Influence the Microbiome and Improve Symptoms in Patients with Irritable Bowel Syndrome. Curr Gastroenterol Rep 2023; 25:52-60. [PMID: 36763098 DOI: 10.1007/s11894-023-00861-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW This review highlights effects of dietary interventions on the gut microbiome and gastrointestinal symptoms in those with irritable bowel syndrome (IBS). RECENT FINDINGS It is hypothesized that gut dysbiosis factors into the pathophysiology of IBS. Various diets that influence the microbiome and intestinal physiology may have therapeutic properties. At present, data suggests that implementation of personalized dietary interventions have a mixed, but overall positive effect on the gut microbiome and IBS symptoms. The effect of dietary modification on the gut microbiome and GI symptoms in patients with IBS is a topic that has garnered interest due to the increasing prevalence of IBS and heightened awareness of the importance of gut health. The composition of the gut microbiome may be modulated by promoting fiber intake and implementation of exclusionary diets and dietary supplements; however, additional studies are needed to provide evidence-based guidelines in this patient population.
Collapse
Affiliation(s)
- Shyam Vedantam
- Department of Medicine, University of Miami, Miami, FL, USA
| | - Erica Graff
- Department of Medicine, University of Miami, Miami, FL, USA
| | | | | | - Michelle Pearlman
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miami, FL, USA. .,Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA.
| |
Collapse
|
3
|
Sangiuolo K, Cheng E, Terala A, Dubrosa F, Milanaik RL. The gut microbiome: an overview of current trends and risks for paediatric populations. Curr Opin Pediatr 2022; 34:634-642. [PMID: 36226734 DOI: 10.1097/mop.0000000000001186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Gut health is an increasingly popular topic of discussion among scientists and the general population alike. As interest surrounding the gut microbiome grows, the accessibility to misinformation and unfounded gut health trends to youth is likely to emerge as a public health concern. The purpose of this review is to provide paediatricians with current information about the gut microbiome, as well as explanations and possible risks of the multitude of gut health trends that adolescents may be exposed to. RECENT FINDINGS The gut microbiome is implicated in overall health by playing roles in digestion, immunity and mental health. Novel microbiome-related therapies, such as faecal microbiota transplants, and the gut-brain link show the therapeutic potential of the gut microbiome. However, unproven dietary fads and trends on social media are rampant as well, such as ginger juice shots. In addition, paediatric supplements meant to target gut health are unregulated, yet are highly marketed. Improperly applying these trends and diets may result in risks of malnutrition and body image issues for impressionable children. SUMMARY Increased familiarity regarding the types of gut health trends and diets among young people will allow paediatricians to more effectively advise their patients about potential risks and good gut health practices. Paediatricians and caregivers serve as role models and educators with regard to children's perceptions and management of their gut and overall health.
Collapse
Affiliation(s)
- Kara Sangiuolo
- Division of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, New York, USA
| | | | | | | | | |
Collapse
|
4
|
Thomas A, Thomas A, Butler-Sanchez M. Dietary Modification for the Restoration of Gut Microbiome and Management of Symptoms in Irritable Bowel Syndrome. Am J Lifestyle Med 2022; 16:608-621. [PMID: 36072680 PMCID: PMC9442469 DOI: 10.1177/15598276211012968] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/13/2021] [Accepted: 04/08/2021] [Indexed: 08/27/2023] Open
Abstract
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder leading to chronic debilitating issues. A healthy diet plays an integral role in maintaining the gut microbiota equilibrium, thus promoting digestive health. The structure and function of gut microbiota are affected by genetics and environmental factors, such as altered dietary habits, gastroenteritis, stress, increased use of alcohol and drugs, and medication use. Whereas there are various management approaches cited in the literature to manage symptoms of IBS, the purpose of this article is to focus on dietary options that will restore the gut microbiome and help in managing IBS symptoms. Some of the diets that are discussed in this article include a low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet, gluten-free/wheat-free diet, high-fiber diet, dietary and herbal supplements (psyllium, peppermint oil), and probiotics/prebiotics/synbiotics. The clinical practice guidelines recommended by the American College of Gastroenterology outlines evidence-based dietary recommendations for patients with IBS to manage symptoms. Recent advancements in the dietary management of IBS highlighting the use of a patient-centered, personalized nutrition approach along with lifestyle changes, pharmacological therapies, and psychosocial and behavioral interventions are also reviewed and discussed.
Collapse
Affiliation(s)
- Andrew Thomas
- Bharati Vidyapeeth Medical College, Pune,
India, and University of Illinois Health Sciences System, Chicago,
Illinois
| | - Annie Thomas
- Marcella Niehoff School of Nursing, Loyola
University Chicago, Illinois
| | | |
Collapse
|
5
|
Catassi C, Verdu EF, Bai JC, Lionetti E. Coeliac disease. Lancet 2022; 399:2413-2426. [PMID: 35691302 DOI: 10.1016/s0140-6736(22)00794-2] [Citation(s) in RCA: 125] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 12/14/2022]
Abstract
Coeliac disease is an autoimmune disorder that primarily affects the small intestine, and is caused by the ingestion of gluten in genetically susceptible individuals. Prevalence in the general population ranges from 0·5% to 2%, with an average of about 1%. The development of the coeliac enteropathy depends on a complex immune response to gluten proteins, including both adaptive and innate mechanisms. Clinical presentation of coeliac disease is highly variable and includes classical and non-classical gastrointestinal symptoms, extraintestinal manifestations, and subclinical cases. The disease is associated with a risk of complications, such as osteoporosis and intestinal lymphoma. Diagnosis of coeliac disease requires a positive serology (IgA anti-transglutaminase 2 and anti-endomysial antibodies) and villous atrophy on small-intestinal biopsy. Treatment involves a gluten-free diet; however, owing to the high psychosocial burden of such a diet, research into alternative pharmacological treatments is currently very active.
Collapse
Affiliation(s)
- Carlo Catassi
- Department of Specialized Clinical Sciences and Odontostomatology, Polytechnic University of Marche, Ancona, Italy; Celiac Center and Mucosal Immunology and Biology Research, MassGeneral Hospital for Children-Harvard Medical School, Boston, MA, USA.
| | - Elena F Verdu
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Julio Cesar Bai
- Department of Medicine, Dr C Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina; Research Institutes, Universidad del Salvador, Buenos Aires, Argentina
| | - Elena Lionetti
- Department of Specialized Clinical Sciences and Odontostomatology, Polytechnic University of Marche, Ancona, Italy
| |
Collapse
|
6
|
Sun Y, Chen X, Wang S, Deng M, Xie Y, Wang X, Chen J, Hesketh T. Gluten-free Diet Reduces the Risk of Irritable Bowel Syndrome: A Mendelian Randomization Analysis. Front Genet 2021; 12:684535. [PMID: 34899821 PMCID: PMC8660079 DOI: 10.3389/fgene.2021.684535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Whether a gluten-free diet (GFD) is a cause of irritable bowel syndrome (IBS) remains controversial. We aim at exploring the causal relationship between gluten intake and IBS within Mendelian randomization (MR) design. Methods: We conducted a two-sample MR and selected single-nucleotide polymorphisms (SNPs) associated with GFD as instrumental variables (IVs). SNPs and genetic associations with GFD and IBS were obtained from the latest genome-wide association studies (GWAS) in Europeans (GFD: cases: 1,376; controls: 63,573; IBS: cases:1,121; controls: 360,073). We performed inverse variance weighting (IVW) as the primary method with several sensitivity analyses like MR-Egger and MR-PRESSO for quality control. The above analyses were re-run using another large dataset of IBS, as well as changing the p-value threshold when screening IVs, to verify the stability of the results. Results: The final estimate indicated significant causal association [per one copy of effect allele predicted log odds ratio (OR) change in GFD intake: OR = 0.97, 95% confidence interval (CI) 0.96 to 0.99, p < 0.01] without heterogeneity statistically (Q = 2.48, p = 0.78) nor horizontal pleiotropy biasing the causality (p = 0.92). Consistent results were found in validation analyses. Results of MR Steiger directionality test indicated the accuracy of our estimate of the causal direction (Steiger p < 0.001). Conclusion: GFD might be a protective factor of IBS. Therefore, we suggest taking a diet of lower gluten intake into account in IBS prevention and clinical practice.
Collapse
Affiliation(s)
- Yuhao Sun
- Centre for Global Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuejie Chen
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Shuyang Wang
- Centre for Global Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Minzi Deng
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Ying Xie
- Centre for Global Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyan Wang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Jie Chen
- Centre for Global Health, Zhejiang University School of Medicine, Hangzhou, China
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Therese Hesketh
- Centre for Global Health, Zhejiang University School of Medicine, Hangzhou, China
- Institute for Global Health, University College London, London, United Kingdom
| |
Collapse
|
7
|
Rej A, Aziz I, Sanders DS. Personalizing Dietary Therapies For Irritable Bowel Syndrome: What Is Gluten's Role? Clin Gastroenterol Hepatol 2021; 19:2270-2273. [PMID: 33069879 DOI: 10.1016/j.cgh.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Anupam Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital, NHS Foundation Trust, Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Imran Aziz
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital, NHS Foundation Trust, Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital, NHS Foundation Trust, Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
8
|
Mudryj A, Waugh A, Slater J, Duerksen DR, Bernstein CN, Riediger ND. Dietary gluten avoidance in Canada: a cross-sectional study using survey data. CMAJ Open 2021; 9:E317-E323. [PMID: 33795221 PMCID: PMC8034255 DOI: 10.9778/cmajo.20200082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND A gluten-free diet (GFD) is required for the management of some conditions, whereas some Canadians may follow a GFD for discretionary reasons. We sought to estimate the prevalence of Canadians who adhere to a GFD, identify factors associated with adherence to a GFD, and describe and compare the location of food preparation and consumption for those who follow a GFD, those who report no dietary avoidances and those reporting other dietary avoidances. METHODS We used cross-sectional data from the 2015 Canadian Community Health Survey - Nutrition (n = 20 487). Demographic variables included sex, age group, ethnicity, highest level of household education and income adequacy. The relations between respondent characteristics and report of a GFD were estimated using logistic regression. Respondents were further categorized as avoiding dietary gluten, other dietary avoidances and no dietary avoidances. RESULTS An estimated 1.9% of Canadians follow a GFD. Women had 2 times higher odds (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.32 to 3.27) of reporting a GFD than men. After adjustment for income adequacy, household education, sex, age group and ethnicity, residents of Ontario and Quebec had about half the odds (OR 0.52, 95% CI 0.31 to 0.87, and OR 0.55, 95% CI 0.32 to 0.94, respectively) of reporting a GFD compared with residents of Atlantic Canada. Canadians who followed a GFD consumed significantly fewer calories from foods prepared at restaurants than both Canadians who reported no dietary avoidances and those who reported dietary avoidances other than gluten. Canadians following a GFD reported that 2.0% (95% CI 1.1% to 2.9%) of their daily kilocalories were from foods prepared at restaurants, compared with 6.7% (95% CI 5.4% to 7.9%) for Canadians reporting 1 or more dietary avoidances other than gluten, and 6.4% (95% CI 6.0% to 6.9%) for those reporting no avoidances. INTERPRETATION The estimated 1.9% prevalence of dietary gluten avoidance likely includes individuals with celiac disease, wheat allergies and nonceliac gluten sensitivity, as well as individuals excluding gluten in the management of irritable bowel syndrome or for reasons related to dietary trends. Canadians eating GFDs consume fewer daily calories from restaurant-prepared foods than other Canadians, which may have social implications.
Collapse
Affiliation(s)
- Adriana Mudryj
- Department of Food and Human Nutritional Sciences (Mudryj, Waugh, Slater, Riediger), Faculty of Agricultural and Food Sciences, University of Manitoba; Department of Internal Medicine (Duerksen, Bernstein), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Department of Community Health Sciences (Slater, Riediger), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man
| | - Anne Waugh
- Department of Food and Human Nutritional Sciences (Mudryj, Waugh, Slater, Riediger), Faculty of Agricultural and Food Sciences, University of Manitoba; Department of Internal Medicine (Duerksen, Bernstein), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Department of Community Health Sciences (Slater, Riediger), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man
| | - Joyce Slater
- Department of Food and Human Nutritional Sciences (Mudryj, Waugh, Slater, Riediger), Faculty of Agricultural and Food Sciences, University of Manitoba; Department of Internal Medicine (Duerksen, Bernstein), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Department of Community Health Sciences (Slater, Riediger), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man
| | - Donald R Duerksen
- Department of Food and Human Nutritional Sciences (Mudryj, Waugh, Slater, Riediger), Faculty of Agricultural and Food Sciences, University of Manitoba; Department of Internal Medicine (Duerksen, Bernstein), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Department of Community Health Sciences (Slater, Riediger), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man
| | - Charles N Bernstein
- Department of Food and Human Nutritional Sciences (Mudryj, Waugh, Slater, Riediger), Faculty of Agricultural and Food Sciences, University of Manitoba; Department of Internal Medicine (Duerksen, Bernstein), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Department of Community Health Sciences (Slater, Riediger), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man
| | - Natalie D Riediger
- Department of Food and Human Nutritional Sciences (Mudryj, Waugh, Slater, Riediger), Faculty of Agricultural and Food Sciences, University of Manitoba; Department of Internal Medicine (Duerksen, Bernstein), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Department of Community Health Sciences (Slater, Riediger), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.
| |
Collapse
|
9
|
Seamark L, Barclay Y, Marchant C, Williams M, Hickson M. Long-term symptom severity in people with irritable bowel syndrome following dietetic treatment in primary care: A service evaluation. J Hum Nutr Diet 2021; 34:890-900. [PMID: 33761153 DOI: 10.1111/jhn.12860] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Evidence suggests that dietary interventions can improve symptoms in people with irritable bowel syndrome (IBS), although most data explore the short-term (immediate) impact. Data on long-term (>6 months) impact are limited, especially from primary care settings. The present study aimed to investigate the long-term effect of dietetic-led interventions for IBS delivered in primary care. METHODS A service evaluation of a dietetic-led IBS clinic was completed, analysing data on symptom severity, stool frequency and consistency, and healthcare input. Data were collected before and immediately after dietary intervention as part of patients' routine clinical appointments. Long-term data were collected via a postal questionnaire at least 11 months later. RESULTS In total, 211 patients responded to the long-term follow-up questionnaire at a median of 13 months (interquartile range 12-16 months) post follow-up appointment. Of these, 84% had been advised to follow a low FODMAP (i.e., fermentable oligosaccharides, disaccharides, monosaccharides and polyols carbohydrates) diet. All symptoms were reported significantly less frequently short term, and all except heartburn and acid regurgitation remained so over the long term. The four most commonly reported bowel symptoms reduced in frequency were abdominal pain (62%), bloating (50%), increased wind (48%) and urgency to open bowels (49%) (p < 0.001). The percentage of patients reporting satisfactory relief of gut symptoms was 10% at baseline and 55% at long-term follow-up (p < 0.001). Visits to a general practitioner were reduced (from 96% to 34%; p < 0.001), as were those to the gastroenterologist (from 37% to 12%; p = 0.002), during the year prior to long-term follow-up compared to the year prior to dietary intervention. CONCLUSIONS Patients with IBS who received dietetic-led interventions in primary care reported long-term symptoms improvements that may result in reduced healthcare usage.
Collapse
Affiliation(s)
- Leah Seamark
- Community Dietetics, Somerset NHS Foundation Trust, Bridgwater, Somerset, UK
| | - Yvonne Barclay
- Community Dietetics, Somerset NHS Foundation Trust, Bridgwater, Somerset, UK
| | - Ceri Marchant
- Community Dietetics, Somerset NHS Foundation Trust, Bridgwater, Somerset, UK
| | - Marianne Williams
- Community Dietetics, Somerset NHS Foundation Trust, Bridgwater, Somerset, UK
| | - Mary Hickson
- Plymouth Institute of Health Research, University of Plymouth, Plymouth, UK
| |
Collapse
|
10
|
Abstract
Gluten is a common dietary component with a complex protein structure. It forms incomplete products of digestion, which have the potential to mount an immune response in genetically predisposed individuals, resulting in celiac disease. It also has been linked with nonceliac gluten sensitivity and irritable bowel syndrome due to wheat allergy. A gluten-free diet is an effective treatment of these conditions; however, it can lead to micronutrient and mineral deficiencies and a macronutrient imbalance with higher sugar and lipid intake. Recent popularity has led to greater availability, but increasing cost, of commercially available gluten-free products.
Collapse
Affiliation(s)
- Naueen A Chaudhry
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Florida, 1329 Southwest 16th Street, Suite 5251, Gainesville, FL 32608, USA
| | - Chelsea Jacobs
- Department of Medicine, University of Florida, 1329 Southwest 16th Street, Suite 5251, Gainesville, FL 32608, USA
| | - Peter H R Green
- Celiac Disease Center at Columbia University, 180 Fort Washington Avenue, New York, NY 10032, USA
| | - S Devi Rampertab
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Florida, 1329 Southwest 16th Street, Suite 5251, Gainesville, FL 32608, USA.
| |
Collapse
|
11
|
Low Fermentable Oligo- Di- and Mono-Saccharides and Polyols (FODMAPs) or Gluten Free Diet: What Is Best for Irritable Bowel Syndrome? Nutrients 2020; 12:nu12113368. [PMID: 33139629 PMCID: PMC7692077 DOI: 10.3390/nu12113368] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/22/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
Irritable Bowel Syndrome (IBS) is a very common functional gastrointestinal disease. Its pathogenesis is multifactorial and not yet clearly defined, and hence, its therapy mainly relies on symptomatic treatments. Changes in lifestyle and dietary behavior are usually the first step, but unfortunately, there is little high-quality scientific evidence regarding a dietary approach. This is due to the difficulty in setting up randomized double-blind controlled trials which objectively evaluate efficacy without the risk of a placebo effect. However, a Low Fermentable Oligo-, Di- and Mono-saccharides And Polyols (FODMAP) Diet (LFD) and Gluten Free Diet (GFD) are among the most frequently suggested diets. This paper aims to evaluate their possible role in IBS management. A GFD is less restrictive and easier to implement in everyday life and can be suggested for patients who clearly recognize gluten as a trigger of their symptoms. An LFD, being more restrictive and less easy to learn and to follow, needs the close supervision of a skilled nutritionist and should be reserved for patients who recognize that the trigger of their symptoms is not, or not only, gluten. Even if the evidence is of very low-quality for both diets, the LFD is the most effective among the dietary interventions suggested for treating IBS, and it is included in the most updated guidelines.
Collapse
|
12
|
Abstract
Wheat-based foods have been staple foods since about 10,000 years and constitute a major source of energy, dietary fiber, and micronutrients for the world population. The role of wheat in our diet, however, has recently been scrutinized by pseudoscientific books and media reports promoting the overall impression that wheat consumption makes people sick, stupid, fat, and addicted. Consequently, numerous consumers in Western countries have started to question their dietary habits related to wheat consumption and voluntarily decided to adopt a wheat-free diet without a medical diagnosis of any wheat-related disorder (WRD), such as celiac disease, wheat allergy, or non-celiac gluten sensitivity. The aim of this review is to achieve an objective judgment of the positive aspects of wheat consumption as well as adverse effects for individuals suffering from WRDs. The first part presents wheat constituents and their positive nutritional value, in particular, the consumption of products from whole-grain flours. The second part is focused on WRDs that affect predisposed individuals and can be treated with a gluten-free or -reduced diet. Based on all available scientific knowledge, wheat consumption is safe and healthy for the vast majority of people. There is no scientific evidence to support that the general population would benefit from a wheat-free diet.
Collapse
Affiliation(s)
| | | | - Katharina A. Scherf
- Department of Bioactive and Functional Food Chemistry, Institute of Applied Biosciences, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| |
Collapse
|
13
|
Mast Cell Regulation and Irritable Bowel Syndrome: Effects of Food Components with Potential Nutraceutical Use. Molecules 2020; 25:molecules25184314. [PMID: 32962285 PMCID: PMC7570512 DOI: 10.3390/molecules25184314] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/12/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022] Open
Abstract
Mast cells are key actors in inflammatory reactions. Upon activation, they release histamine, heparin and nerve growth factor, among many other mediators that modulate immune response and neuron sensitization. One important feature of mast cells is that their population is usually increased in animal models and biopsies from patients with irritable bowel syndrome (IBS). Therefore, mast cells and mast cell mediators are regarded as key components in IBS pathophysiology. IBS is a common functional gastrointestinal disorder affecting the quality of life of up to 20% of the population worldwide. It is characterized by abdominal pain and altered bowel habits, with heterogeneous phenotypes ranging from constipation to diarrhea, with a mixed subtype and even an unclassified form. Nutrient intake is one of the triggering factors of IBS. In this respect, certain components of the daily food, such as fatty acids, amino acids or plant-derived substances like flavonoids, have been described to modulate mast cells' activity. In this review, we will focus on the effect of these molecules, either stimulatory or inhibitory, on mast cell degranulation, looking for a nutraceutical capable of decreasing IBS symptoms.
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW Noncoeliac gluten sensitivity (NCGS) can be suspected after exclusion of coeliac disease and wheat allergy. However, poorly understood pathogenesis of the NCGS, lack of gold standard for diagnosis and agreement in the definition for the NCGS condition, open the space for future investigation. This review aims to give an overview on the diagnosis and effective diet composition in the treatment of NCGS symptoms. RECENT FINDINGS It appears that a diet low in fermentable oligo, di, and monosaccharides and polyols (FODMAPs) and gluten-free diet play a prominent role in the strategy of NCGS management. Considering available evidence with respect to diagnostic tools, it is challenging to prepare a standard guideline for NCGS diagnosis and treatment with clear cut-offs for symptom reduction/improvement that could directly be translated into test results. Nutritional support, including the use of pre/probiotics, has to be tailored to the individual situation of NCGS patients. SUMMARY The exclusion of such components of wheat as amylase/trypsin inhibitors, wheat-germ agglutinins, or free of FODMAPs diet can reduce clinical symptoms of NCGS. The further investigation on microbiota changes may strengthen the knowledge in this area, where the major challenge is to develop biomarkers for NCGS investigation.
Collapse
|
15
|
Rej A, Buckle RL, Shaw CC, Trott N, Urwin H, McGough N, Aziz I, Sanders DS. National survey evaluating the provision of gastroenterology dietetic services in England. Frontline Gastroenterol 2020; 12:380-384. [PMID: 35401953 PMCID: PMC8989012 DOI: 10.1136/flgastro-2020-101493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/12/2020] [Accepted: 05/20/2020] [Indexed: 02/04/2023] Open
Abstract
AIMS The aim of the study was to assess the provision of dietetic services for coeliac disease (CD), irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). METHODS Hospitals within all National Health Service trusts in England were approached (n=209). A custom-designed web-based questionnaire was circulated via contact methods of email, post or telephone. Individuals/teams with knowledge of gastrointestinal (GI) dietetic services within their trust were invited to complete. RESULTS 76% of trusts (n=158) provided GI dietetic services, with responses received from 78% of these trusts (n=123). The median number of dietitians per 100 000 population was 3.64 (range 0.15-16.60), which differed significantly between regions (p=0.03). The most common individual consultation time for patients with CD, IBS and IBD was 15-30 min (43%, 44% and 54%, respectively). GI dietetic services were delivered both via individual and group counselling, with individual counselling being the more frequent delivery method available (93% individual vs 34% group). A significant proportion of trusts did not deliver any specialist dietetic clinics for CD, IBS and IBD (49% (n=60), 50% (n=61) and 72% (n=88), respectively). CONCLUSION There is an inequity of GI dietetic services across England, with regional differences in the level of provision and extent of specialist care. Allocated time for clinics appears to be insufficient compared with time advocated in the literature. Group clinics are becoming a more common method of dietetic service delivery for CD and IBS. National guidance on GI dietetic service delivery is required to ensure equity of dietetic services across England.
Collapse
Affiliation(s)
- Anupam Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel Louise Buckle
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Christian Charles Shaw
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nick Trott
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Heidi Urwin
- Coeliac UK, High Wycombe, Buckinghamshire, UK
| | | | - Imran Aziz
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK,Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - David Surendran Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK,Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| |
Collapse
|
16
|
Schiepatti A, Savioli J, Vernero M, Borrelli de Andreis F, Perfetti L, Meriggi A, Biagi F. Pitfalls in the Diagnosis of Coeliac Disease and Gluten-Related Disorders. Nutrients 2020; 12:nu12061711. [PMID: 32517378 PMCID: PMC7352902 DOI: 10.3390/nu12061711] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 02/07/2023] Open
Abstract
The spectrum of gluten-related disorders (GRD) has emerged as a relevant phenomenon possibly impacting on health care procedures and costs worldwide. Current classification of GRD is mainly based on their pathophysiology, and the following categories can be distinguished: immune-mediated disorders that include coeliac disease (CD), dermatitis herpetiformis (DH), and gluten ataxia (GA); allergic reactions such as wheat allergy (WA); and non-coeliac gluten sensitivity (NCGS), a condition characterized by both gastrointestinal and extra-intestinal symptoms subjectively believed to be induced by the ingestion of gluten/wheat that has recently gained popularity. Although CD, DH, and WA are well-defined clinical entities, whose diagnosis is based on specific diagnostic criteria, a diagnosis of NCGS may on the contrary be considered only after the exclusion of other organic disorders. Neither allergic nor autoimmune mechanisms have been found to be involved in NCGS. Mistakes in the diagnosis of GRD are still a relevant clinical problem that may result in overtreatment of patients being unnecessary started on a gluten-free diet and waste of health-care resources. On the basis of our clinical experience and literature, we aim to identify the main pitfalls in the diagnosis of CD and its complications, DH, and WA. We provide a practical methodological approach to guide clinicians on how to recognize and avoid them.
Collapse
Affiliation(s)
- Annalisa Schiepatti
- Gastroenterology Unit of IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, 27100 Pavia, Italy; (M.V.); (F.B.d.A.); (F.B.)
- Correspondence: ; Tel.: +39-0382-592331
| | - Jessica Savioli
- Allergy and Immunology Unit of Pavia IRCCS Institute, Istituti Clinici Scientifici Maugeri, 27100 Pavia, Italy; (J.S.); (L.P.); (A.M.)
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, 27100 Pavia, Italy
| | - Marta Vernero
- Gastroenterology Unit of IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, 27100 Pavia, Italy; (M.V.); (F.B.d.A.); (F.B.)
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, 27100 Pavia, Italy
| | - Federica Borrelli de Andreis
- Gastroenterology Unit of IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, 27100 Pavia, Italy; (M.V.); (F.B.d.A.); (F.B.)
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, 27100 Pavia, Italy
| | - Luca Perfetti
- Allergy and Immunology Unit of Pavia IRCCS Institute, Istituti Clinici Scientifici Maugeri, 27100 Pavia, Italy; (J.S.); (L.P.); (A.M.)
| | - Antonio Meriggi
- Allergy and Immunology Unit of Pavia IRCCS Institute, Istituti Clinici Scientifici Maugeri, 27100 Pavia, Italy; (J.S.); (L.P.); (A.M.)
| | - Federico Biagi
- Gastroenterology Unit of IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, 27100 Pavia, Italy; (M.V.); (F.B.d.A.); (F.B.)
| |
Collapse
|
17
|
The Evolving Role of Gut Microbiota in the Management of Irritable Bowel Syndrome: An Overview of the Current Knowledge. J Clin Med 2020; 9:jcm9030685. [PMID: 32143424 PMCID: PMC7141230 DOI: 10.3390/jcm9030685] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 12/12/2022] Open
Abstract
The intestinal microbiota is one of the most rapidly evolving areas in biology and medicine. Extensive research in the last decade has escalated our understanding of the role of the microbiota in the pathogenesis of several intestinal and extra-intestinal disorders. Marked by high prevalence, substantial morbidity, and enormous costs, irritable bowel syndrome (IBS) is an important chronic gastrointestinal disorder that is widely encountered by gastroenterologists. Despite advances in our understanding of its pathophysiology, curative interventions have yet to be discovered, and therapeutic approaches remain symptom-driven. Recently, accumulating evidence has enlightened the possible impact of an imbalanced gut microbiome in the pathogenesis of IBS. In fact, several studies have documented altered microbiota in patients, while others have shown that IBS severity was associated with a distinct microbiota signature. These findings may pave the way for the use of microbiota manipulation strategies as an attractive option for IBS management, and may have an essential role in efforts to reduce the societal and economic effects of this ever-growing disorder. In this review, we have outlined the results of the latest research on the association between microbiota and IBS and their implications for the clinical management of affected patients.
Collapse
|
18
|
Ibrahim F, Stribling P. Reply to “A Gluten Reduction Is the Patients’ Choice for a Dietary ‘Bottom Up’ Approach in IBS—A Comment on “A 5Ad Dietary Protocol for Functional Bowel Disorders” Nutrients 2019, 11, 1938”. Nutrients 2020; 12:nu12010140. [PMID: 31947828 PMCID: PMC7019583 DOI: 10.3390/nu12010140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/20/2019] [Indexed: 11/17/2022] Open
|
19
|
Chen Y, Wu G, Zhao Y. Gut Microbiota and Alimentary Tract Injury. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1238:11-22. [PMID: 32323177 DOI: 10.1007/978-981-15-2385-4_2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The gastrointestinal (GI) tract is inhabited by a diverse array of microbes, which play crucial roles in health and disease. Dysbiosis of microbiota has been tightly linked to gastrointestinal inflammatory and malignant diseases. Here we highlight the role of Helicobacter pylori alongside gastric microbiota associated with gastric inflammation and cancer. We summarize the taxonomic and functional aspects of intestinal microbiota linked to inflammatory bowel diseases (IBD), irritable bowel syndrome (IBS), and colorectal cancer in clinical investigations. We also discuss microbiome-related animal models. Nevertheless, there are tremendous opportunities to reveal the causality of microbiota in health and disease and detailed microbe-host interaction mechanisms by which how dysbiosis is causally linked to inflammatory disease and cancer, in turn, potentializing clinical interventions with a personalized high efficacy.
Collapse
Affiliation(s)
- Ye Chen
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Guangyan Wu
- Department of Pathophysiology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Yongzhong Zhao
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
20
|
Guerreiro M, Sousa Guerreiro C, Cravo M. Irritable bowel syndrome: how can symptoms and quality of life be improved with diet? Curr Opin Clin Nutr Metab Care 2019; 22:377-382. [PMID: 31313689 DOI: 10.1097/mco.0000000000000589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This article aims to review the current scientific evidence of dietary approaches to control the symptoms of irritable bowel syndrome (IBS). RECENT FINDINGS In the last decade, there was an important evolution in the study of the low fermentable oligo, di, mono-saccharides and polyols (FODMAP) diet (LFD). Current scientific evidence suggests a significant efficacy in the overall control of symptoms. LFD seems to be effective in improving quality of life. Recent studies suggest that LFD is effective and nutritionally well tolerated also in the long term, and longer adherence may contribute to greater effectiveness in improving depression. There is insufficient scientific evidence for the recommendation of gluten exclusion in IBS therapy, and some authors still suggest that the efficacy of this approach results from the limited ingestion of fructans. There is a promising efficacy of pre, pro, and symbiotic supplements, but there is no consensus on the most appropriate and effective strains in each case. SUMMARY Given the poor evidence and the pathophysiological variability of IBS, the interest of each therapeutic option should be always evaluated individually. Nevertheless, LFD is currently the dietary approach with a higher degree of scientific evidence.
Collapse
Affiliation(s)
| | - Catarina Sousa Guerreiro
- Faculdade de Medicina
- Laboratório de Nutrição
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisboa
| | - Marília Cravo
- Faculdade de Medicina
- Hospital Beatriz Ângelo - Serviço de Gastrenterologia, Loures, Portugal
| |
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW There has been significant interest in gluten over the last decade, with an increase in interest of gluten-related disorders outside coeliac disease. Particularly, there has been a focus on the role of gluten in noncoeliac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS). There is significant overlap between both of these conditions, with the aim of this review to explore their complex relationship. RECENT FINDINGS Gluten has been demonstrated to generate symptoms in individuals with NCGS. However, there appears to be an increasing role for gluten in symptom generation in patients with IBS also. Other components of wheat, other than gluten, are now also thought to be contributing factors in symptom generation. SUMMARY There appears to be significant overlap between IBS and NCGS. It is likely that a subset of patients presenting with IBS actually have NCGS. In addition, it is likely that individuals with IBS may also have symptoms triggered by gluten. With the pathophysiology of both conditions not fully understood, as well as increasing knowledge of wheat components in symptom generation, further research is required to help distinguish between both.
Collapse
|
22
|
Rej A, Trott N, Sanders DS, Aziz I. Letter: the low FODMAP diet is not the only diet for IBS. Aliment Pharmacol Ther 2019; 49:1108-1109. [PMID: 30920037 DOI: 10.1111/apt.15176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Anupam Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Nick Trott
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK.,Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Imran Aziz
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK.,Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| |
Collapse
|
23
|
Affiliation(s)
- Luca Elli
- Center for the Prevention and Diagnosis of Coeliac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy.
| | - Beatrice Marinoni
- Center for the Prevention and Diagnosis of Coeliac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy.
| |
Collapse
|