New Gut Health Research: FODMAPs, Gluten, Elemental Diet

Written by Dr. Michael Ruscio, DC on May 23, 2022

Are Rifaximin, Resistant Starch, Gluten, FODMAPs, Aspirin, or the Elemental Diet Helping or Hurting Your Gut?

There are a number of updates in gut health—and knowing about them may be able to give you an idea of what approaches may be useful for your own healing. Listen in to hear the effects that gluten, the low FODMAP diet, the elemental diet, aspirin, and long-term use of rifaximin have on your gut and overall health.

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Dr. Michael Ruscio is a DC, natural health provider, researcher, and clinician. He serves as an Adjunct Professor at the University of Bridgeport and has published numerous papers in scientific journals as well as the book Healthy Gut, Healthy You. He also founded the Ruscio Institute of Functional Health, where he helps patients with a wide range of GI conditions and serves as the Head of Research.

➕ Dr. Ruscio’s, DC Notes

AGA Clinical Practice Update on the Role of Diet in Irritable Bowel Syndrome: Expert Review
- Expert opinion review on dietary management of IBS
- “The low-FODMAP diet is currently the most evidence-based diet intervention for IBS.”
- Commentary: The AGA recommends a low FODMAP diet for IBS

Long-Term Efficacy and Safety of Rifaximin in Japanese Patients with Hepatic Encephalopathy: A Multicenter Retrospective Study
- 215 cirrhosis patients, treated w/ rifaximin long-term
- After 12 months of treatment w/ rifaximin, NO serious adverse events occurred, including no changes in:
  - Liver enzymes
  - Kidney function
  - Electrolyte balance
- 5% of patients experienced diarrhea, which improved by reducing the rifaximin dose or giving probiotics
- Commentary: Rifaximin appears to be safe long-term with minimal side effects.

Randomized study of prevention of gastrointestinal toxicities by nutritional support using an amino acid-rich elemental diet during chemotherapy in patients with esophageal cancer (KDOG 1101)
- 71 esophageal cancer patients randomized to no treatment or elemental diet
- After 9 weeks, the elemental diet group had no difference in chemotherapy side effects
- Commentary: Other studies have suggested that the elemental diet can reduce the risk of oral mucositis.

16S rRNA and metagenomic shotgun sequencing data revealed consistent patterns of gut microbiome signature in pediatric ulcerative colitis
- 19 pediatric ulcerative colitis (UC) patients, 23 healthy controls
- Microbiome analyzed by 16S rRNA sequencing
- UC patients had:
  - Lower alpha diversity
  - Greater beta diversity
  - Less abundance of Akkermansiaceae, Clostridiaceae, Eggerthellaceae, Lachnospiraceae, and Oscillospiraceae
- Commentary: Pediatric UC patients had different microbiome signatures as compared to healthy controls.

Effects of a gluten challenge in patients with irritable bowel syndrome: a randomized single-blind controlled clinical trial
- 50 IBS patients
- All patients were treated w/ low FODMAP + gluten free diet (GFD) x 6 weeks, then randomized to either:
  - Gradual gluten reintroduction x 6 weeks (with dose-escalation each 2 weeks)
  - Unrestricted gluten-containing diet
  - Continued low FODMAP + GFD x 6 weeks
- The low FODMAP + GF diet led to improvements in all symptoms
- After 3 months, all groups had similar:
  - Abdominal pain
  - Bloating
  - IBS symptom score
  - Quality of life
- Low FODMAP + GFD led to the greatest reduction in anxiety
- Commentary: While a low FODMAP and GFD was effective for improving IBS symptoms, the introduction of gluten did NOT worsen IBS symptoms.

The effect of low FODMAP diet with and without gluten on irritable bowel syndrome: A double blind, placebo controlled randomized clinical trial
- 49 IBS patients treated w/ low FODMAP diet (LFD), randomized to:
  - Placebo (gluten free rice flour)
  - Gluten powder
- After 6 weeks, both groups experienced statistically significant improvements in:
  - IBS symptom score (-32% gluten group, -49% placebo group)
  - Abdominal pain intensity (-45% vs -52%)
  - Abdominal pain frequency (-26% vs -46%)
  - Abdominal distension (-29% vs -63%)
  - Quality of life (+23% vs +32%)
- Commentary: LFD was helpful for IBS patients with or without the restriction of gluten.

Safety and effectiveness of low-dose aspirin for the prevention of gastrointestinal cancer in adults without atherosclerotic cardiovascular disease: a population-based cohort study
- Matched cohort of 49,679 aspirin and non-aspirin users
- After an average of 10.4 years, the low-dose aspirin group had:
  - Lower colorectal cancer rate (HR 0.83)
  - Lower gastric cancer rate (HR 0.77)
  - No change in esophageal cancer rates
  - More GI bleeds (HR 1.15)
- Commentary: Aspirin use was correlated with less colon and gastric cancer rates, but more GI bleeding risk.

Low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet versus traditional dietary advice for functional dyspepsia: a randomized controlled trial
- 184 patients w/ functional dyspepsia
- Randomized to low FODMAP or traditional diet advice x4 weeks
- After 4 weeks, the low FODMAP diet had:
  - Similar symptom response rate (67% vs 57%)
    - Those w/ bloating had statistically significant better response to low FODMAP
- Commentary: This study showed a trend towards better improvement w/ low FODMAP diet for functional dyspepsia.

Quality of life and sleep in individuals with irritable bowel syndrome according to different diagnostic criteria and inflammatory bowel diseases: A comparison using data from a population-based survey
- Cross-sectional study of 4,420 participants:
  - 3.5% had IBS
  - 0.8% had IBD
- Individuals w/ IBS had:
  - Lower mental quality of life
  - More sleep problems (OR 1.74)
- Commentary: IBS is associated w/ worse quality of life and sleep.

Beneficial Effects on Abdominal Bloating with an Innovative Food-Grade Formulation of Curcuma longa and Boswellia serrata Extracts in Subjects with Irritable Bowel Syndrome and Small Bowel Dysbiosis
- 67 IBS patients randomized to:
  - Low FODMAP diet (LFD)
  - Combo of LFD + Curcumin (500 mg BID) + Boswellia
- After 30 days of supplementation, the combo group had:
  - Greater improvement of bloating, abdominal pain
  - Greater global symptom improvement
- Commentary: Addition of curcumin and Boswellia led to greater improvements to a LFD compared to a LFD alone.

Evaluating tolerability of resistant starch 2, alone and in combination with minimally fermented fibre for patients with irritable bowel syndrome: a pilot randomised controlled cross-over trial
- Cross-over study of 6 IBS patients, 5 healthy controls
- Participants consumed fibers in escalating doses lasting 3 d each:
  - Resistant starch (10, 15 and 20 g/d)
  - Sugarcane bagasse (5, 10 and 15 g/d)
  - And combo of both (20, 25 and 30 g/d)
- For IBS patients, all resistant starch doses led to increased bloating
- Commentary: IBS patients may be particularly sensitive to resistant starch.

Effectiveness of diet, psychological, and exercise therapies for the management of bile acid diarrhoea in adults: a systematic review
- 8 prospective studies, 192 patients w/ bile acid diarrhea (BAD)
- Benefit found for:
  - Carbohydrate modification (1 study, n=2)
  - Dietary fat intake reductions (5 studies, n=181)
  - Exclusive elemental diet therapy (2 studies, n=9)
- Commentary: Dietary modification, including an elemental diet, may improve BAD.

Efficacy of Fecal Microbiota Transplantation in Irritable Bowel Syndrome: A Meta-Analysis of Randomized Controlled Trials
- 7 RCTs, 472 participants w/ IBS
- After 12 weeks, FMT had:
  - NO improvement in global symptoms (RR 0.75)
  - Improved quality of life (RR 9.4)
  - No difference in adverse effects
- FMT did NOT significantly improve global symptom in IBS at 1-year follow-up compared with placebo
- Commentary: There is weak evidence to support FMT for IBS.

New Gut Health Research: FODMAPs, Gluten, Elemental Diet

Are Rifaximin, Resistant Starch, Gluten, FODMAPs, Aspirin, or the Elemental Diet Helping or Hurting Your Gut?

➕ Dr. Ruscio’s, DC Notes

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