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- Gluten, wheat and FODMAPs
Gluten, wheat and FODMAPs
Professor Umberto Volta gained his degree in Medicine with honours, July 1976 from the University of Bologna and from 1986 to date he is the Professor of Diagnostic Immunopathology, University of Bologna. From 1999 to 2012 he was the Director of the Celiac Disease Centre of St. Orsola-Malpighi Hospital, Bologna. Prof. Volta’s research interests include immunology and clinical aspects of coeliac disease; acute and chronic liver diseases; immunological abnormalities and cardiovascular involvement in connective tissue diseases; organ specific and non organ specific autoimmunity in type 1 diabetes. Prof. Volta was President of the Scientific Board of the Italian Association for Celiac Disease (AIC) (2006-2014) and Member of AIC Scientific Board (2014 to date). He is also a member of the Board of the European Society for the Study of Celiac Disease (ESSCD) from 2015 to date and vice president of the Ethical Committee of St. Orsola-Malpighi Hospital from 2013 to date.
Irritable bowel syndrome (IBS) can be regarded as the prototype of all functional bowel disorders for its high prevalence worldwide and impact on patients’ quality of life. Patients with IBS suffer from abdominal pain associated with bowel habit changes. In recent years growing attention has been paid to the causative role of food in IBS. Wheat is regarded as one of the most relevant IBS triggers, although which component(s) of this cereal is/are involved remain(s) unknown. Gluten, other wheat proteins, eg amylase-trypsin inhibitors (ATIs), and fructans (which belong to fermentable oligo-di-mono-saccharides and polyols [FODMAPs]) have been identified as possible factors for symptom generation. These dietary triggers precipitate or exacerbate symptoms in patients with IBS by evoking luminal distension/changing intestinal permeability, microbiota composition/inducing mast cell degranulation and finally by altering the gut brain axis likely via their opioid like activity.
The awareness that gluten can be one of the IBS triggers has expanded the spectrum of gluten related disorders by adding a new entity referred to as non-coeliac gluten sensitivity (NCGS). NCGS has been defined as a syndrome characterised by symptoms occurring a few hours or days after the ingestion of gluten and wheat in patients testing negative for coeliac disease and wheat allergy. The pathogenesis of NCGS is still unclear, but innate immunity seems to exert a pivotal role, together with factors similar to those mentioned for IBS (ie low grade intestinal inflammation, increased intestinal permeability and changes in intestinal microbiota). The epidemiology of NCGS is far from being established with a highly variable prevalence in the general population ranging from 0.6% to 6%. From a clinical stand point NCGS is characterised by a wide array of gastrointestinal (IBS like) and extra intestinal manifestations (mainly involving peripheral/central nervous systems, as well as skin and joint/muscle).
Although no routine test has been identified so far, the combined use of serum markers of intestinal cell damage and systemic immune activation (FABP-2, AGA, LBP, sCD14 and antimicrobial antibodies) might become useful for NCGS diagnosis. The double blind, placebo controlled, crossover trial using gluten and rice starch confirmed NCGS diagnosis only in a small percentage of cases, supporting the hypothesis that also ATIs and FODMAPs, contained in wheat, can have a role in generating NCGS/IBS overlapping symptoms. FODMAPs, which are also present in many foods, including vegetables, dairy products and fruits, display a relevant role in eliciting intestinal symptoms observed in both IBS and NCGS patients. A better knowledge of the relationship between IBS and NCGS is expected to promote standardisation in dietary strategies (gluten wheat free and low FODMAP) as effective measures for the management of IBS and NCGS patients.