Non-celiac gluten sensitivity is characterised by the presence of gastrointestinal and extraintestinal symptoms following gluten ingestion. Recent studies suggested an association between non-celiac gluten sensitivity and the consumption of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP). This systematic review aimed to examine literature evidence on the relationship between non-celiac gluten sensitivity and FODMAP intake. A comprehensive search was carried out for randomised clinical trials addressing gastrointestinal symptoms as the primary outcome, published between 2010 and 2020 in Portuguese, English or Spanish, and indexed in Scopus, PubMed, SciELO, Cochrane Library, CINAHL, Embase or VHL (LILACS) databases. The systematic review was performed using the population, intervention, comparison and outcome (PICO) framework. A total of 1133 articles were retrieved for further assessment. Three articles were selected for systematic review, one of which included two interventions with different periods and assessments. Quality of evidence was assessed according to the GRADE protocol. The selected articles used different instruments to measure gastrointestinal symptoms and quality of life, hindering comparison of data. Clinical trials identified an association between decreased gastrointestinal symptoms and FODMAP restriction. There are few studies on the topic, and those available used different instruments to assess gastrointestinal symptoms and quality of life. Nevertheless, current evidence supports the gluten-free diet still represents first-line therapy. However, a FODMAP restriction can decrease gastrointestinal symptoms in individuals with non-celiac gluten sensitivity. Further research is needed to confirm this finding.

Pulses are healthy and sustainable but induce gut symptoms in people with a sensitive gut. Oats, on the contrary, have no fermentable oligo- di-, monosaccharides and polyols compounds and are known for the health effects of their fibres. This 4-day cross-over trial investigated the effects of oat and rice flour ingested with pulses on gut symptoms and exhaled gases (4th day only) in subjects with a sensitive gut or IBS (n 21) and controls (n 21). The sensitive group perceived more symptoms after both meals than controls (P = 0·001, P = 0·001). Frequency, intensity or quality of the symptoms did not differ between meals during the first 3 d in either group. More breath hydrogen was produced after an oat than rice containing meal in both groups (AUC, P = 0·001, P = 0·001). No between-group difference was seen in breath gases. During day 4, both sensitive and control groups perceived more symptoms after the oat flour meal (P = 0·001, P = 0·0104, respectively) as mainly mild flatulence. No difference in moderate or severe symptoms was detected. Increased hydrogen production correlated to a higher amount of perceived flatulence after the oat flour meal in both the sensitive and the control groups (P = 0·042, P = 0·003, respectively). In summary, ingestion of oat flour with pulses increases breath hydrogen levels compared with rice flour, but gastrointestinal symptoms of subjects sensitive to pulses were not explained by breath hydrogen levels. Additionally, consumer mindsets towards pulse consumption and pulse-related gut symptoms were assessed by an online survey, which implied that perceived gut symptoms hinder the use of pulses in sensitive subjects.

The spectrum of gluten-related disorders includes coeliac disease (CD), wheat allergy (WA) and the suggested entity of non-coeliac gluten sensitivity (NCGS). An increasing number of the world’s population are avoiding gluten due to the assumption of health benefits and self-diagnosed gastrointestinal and/or extra-intestinal symptoms. Unlike CD and WA, NCGS is a relatively new entity with an unknown prevalence and mechanisms, complicated by recent literature suggesting that gluten is not the only food component that may trigger symptoms experienced by this group of patients. The term ‘non-coeliac wheat sensitivity’ has been proposed as a more accurate term, allowing inclusion of other non-gluten wheat components such as fructans and amylase–trypsin inhibitors. There is inconsistent evidence when evaluating the effects of a gluten challenge in patients with suspected NCGS and there is a need for a standardised procedure to confirm the diagnosis, ultimately enabling the optimisation of clinical care. The present review will give an overview of the different gluten-related disorders and discuss the most recent scientific evidence investigating NCGS.

The aim of the present study was to determine if the enzyme Aspergillus niger prolyl endoprotease (ANPEP), which degrades the immunogenic proline-rich residues in gluten peptides, can be used in the development of new wheat products, suitable for gluten-sensitive (GS) individuals. We have carried out a double-blind, randomised, cross-over trial with two groups of adults; subjects, self-reporting benefits of adopting a gluten-free or low-gluten diet (GS, n 16) and a control non-GS group (n 12). For the trial, volunteers consumed four wheat breads: normal bread, bread treated with 0·8 or 1 % ANPEP and low-protein bread made from biscuit flour. Compared with controls, GS subjects had a favourable cardiovascular lipid profile – lower LDL (4·0 (sem 0·3) v. 2·8 (sem 0·2) mmol/l; P=0·008) and LDL:HDL ratio (3·2 (sem 0·4) v. 1·8 (sem 0·2); P=0·005) and modified haematological profile. The majority of the GS subjects followed a low-gluten lifestyle, which helps to reduce the gastrointestinal (GI) symptoms severity. The low-gluten lifestyle does not have any effect on the quality of life, fatigue or mental state of this population. Consumption of normal wheat bread increased GI symptoms in GS subjects compared with their habitual diet. ANPEP lowered the immunogenic gluten in the treated bread by approximately 40 %. However, when compared with the control bread for inducing GI symptoms, no treatment effects were apparent. ANPEP can be applied in the production of bread with taste, texture and appearance comparable with standard bread.

Gastrointestinal symptoms associated with milk are common. Besides lactose, milk proteins may cause symptoms in sensitive individuals. We have developed a method for mild enzymatic hydrolysation of milk proteins and studied the effects of hydrolysed milk on gastrointestinal symptoms in adults with a self-diagnosed sensitive stomach. In a double blind, randomised placebo-controlled study, 97 subjects consumed protein-hydrolysed lactose-free milk or commercially available lactose-free milk for 10 d. Frequency of gastrointestinal symptoms during the study period was reported and a symptom score was calculated. Rumbling and flatulence decreased significantly in the hydrolysed milk group (P < 0·05). Also, the total symptom score was lower in subjects who consumed hydrolysed milk (P < 0·05). No difference between groups was seen in abdominal pain (P = 0·47) or bloating (P = 0·076). The results suggest that mild enzymatic protein hydrolysation may decrease gastrointestinal symptoms in adults with a sensitive stomach.

The present study aimed to assess the adequacy of energy, macronutrients and water intakes of ultra-endurance runners (UER) competing in a 24 h ultra-marathon (distance range: 122–208 km). The ad libitum food and fluid intakes of the UER (n 25) were recorded throughout the competition and analysed using dietary analysis software. Body mass (BM), urinary ketone presence, plasma osmolality (POsmol) and volume change were determined at pre- and post-competition time points. Data were analysed using appropriate t tests, with significance set at P <0·05. The total energy intake and expenditure of the UER were 20 (sd 12) and 55 (sd 11) MJ, respectively (control (CON) (n 17): 12 (sd 1) and 14 (sd 5) MJ, respectively). The protein, carbohydrate and fat intakes of the UER were 1·1 (sd 0·4), 11·3 (sd 7·0) and 1·5 (sd 0·7) g/kg BM, respectively. The rate of carbohydrate intake during the competition was 37 (sd 24) g/h. The total water intake of the UER was 9·1 (sd 4·0) litres (CON: 2·1 (sd 1·0) litres), while the rate of water intake was 378 (sd 164) ml/h. Significant BM loss occurred at pre- to post-competition time points (P =0·001) in the UER (1·6 (sd 2·0) %). No significant changes in POsmol values were observed at pre- (285 (sd 11) mOsmol/kg) to post-competition (287 (sd 10) mOsmol/kg) time points in the UER and were lower than those recorded in the CON group (P <0·05). However, plasma volume (PV) increased at post-competition time points in the UER (10·2 (sd 9·7) %; P <0·001). Urinary ketones were evident in the post-competition samples of 90 % of the UER. Energy deficit was observed in all the UER, with only one UER achieving the benchmark recommendations for carbohydrate intake during endurance exercise. Despite the relatively low water intake rates recorded in the UER, hypohydration does not appear to be an issue, considering increases in PV values observed in the majority (80 %) of the UER. Population-specific dietary recommendations may be beneficial and warranted.

The impact of oligofructose (OF) intake on stool frequency has not been clearly substantiated, while significant gastrointestinal (GI) symptoms have been reported in some individuals. The aim of the present study was to determine the effects of OF on stool frequency and GI symptoms in healthy adults. In an 8-week, randomised, double-blind, parallel-arm study, ninety-eight participants were provided with 16 g OF in yogurt and snack bars (twenty male and thirty female) or matching control foods (seventeen male and thirty-one female), to incorporate, by replacement, into their usual diets. Participants completed a daily online questionnaire recording stool frequency and rating four symptoms: bloating, flatulence, abdominal cramping and noise, each on a Likert scale from ‘0’ for none (no symptoms) to ‘6’ for very severe, with a maximum symptom intensity score of 24 (sum of severities from all four symptoms). Online 24 h dietary recalls were completed during pre-baseline and weeks 4, 6 and 8 to determine fibre intake. When provided with OF foods, fibre intake increased to 24·3 (sem 0·5) g/d from pre-baseline (12·1 (sem 0·5) g/d; P < 0·001). Stool frequency increased with OF from 1·3 (sem 0·2) to 1·8 (sem 0·2) stools per d in males and 1·0 (sem 0·1) to 1·4 (sem 0·1) stools per d in females during intervention weeks compared with pre-baseline (P < 0·05),but did not change for control participants (males: 1·6 (sem 0·2) to 1·8 (sem 0·2); females: 1·3 (sem 0·1) to 1·4 (sem 0·1)). Flatulence was the most commonly reported symptom. Mean GI symptom intensity score was higher for the OF group (3·2 (sem 0·3)) v. control (1·7 (sem 0·1)) (P < 0·01), with few participants reporting above moderate symptoms. No change in symptom intensity occurred over time. Consuming yogurt and snack bars with 16 g OF improves regularity in young healthy adults. However, GI symptoms, resulting from an increase in oligofructose intake, may not diminish with time.

On March 11, 2011, a 9.1 magnitude earthquake occurred in the eastern Pacific Ocean off the coast of northern Japan. A resulting tsunami struck the Japan Pacific coast, causing >20,000 deaths, injuries and missing persons.

Survivors’ post-tsunami health and nutritional status were surveyed one month after the disaster in a school shelter in Ishinomaki City. Hyogo College of Medicine's disaster relief team observations and survivors’ questionnaires were used to assess the disaster's effects on survivors’ lifestyles and gastrointestinal symptoms while residing in temporary shelters. Of 236 disaster evacuees 9-88 years of age (mean age 52 years), 23% lost weight and 28% reported decreased food intake one month after the earthquake. Up to 25% of the participants presented with gastrointestinal symptoms, including constipation (10%), appetite loss (6.4%), vomiting (6.4%), and nausea (2.1%). Although the victims preferred more vegetables (44%) or fruit (33%), most food aid received, such as rice balls or bread, was carbohydrate-based, possibly because of easy provision and abundance in emergency food pantries. The authors asked the volunteers and the Japan Self-Defense Forces to provide a more balanced diet, including vegetables and fruit. Consumption of imbalanced diets may have caused more gastrointestinal symptoms for the survivors. Because of the victims’ hesitation to request more balanced diets, and because of poorly controlled existing chronic disease and mental stress, professional public health providers should assure emergency food nutrition after disasters.

Inoue T, Nakao A, Kuboyama K, Hashimoto A, Masutani M, Ueda T, Kotani J. Gastrointestinal Symptoms and Food/Nutrition Concerns after the Great East Japan Earthquake in March 2011: Survey of Evacuees in a Temporary Shelter. Prehosp Disaster Med. 2014;29(3):1-4.

Cancer patients receiving chemotherapy have a high risk of malnutrition secondary to the disease and treatment, and 40–80 % of cancer patients suffer from different degrees of malnutrition, depending on tumour subtype, location, staging and treatment strategy. Malnutrition in cancer patients affects the patient's overall condition, and it increases the number of complications, the adverse effects of chemotherapy and reduces the quality of life. The aim of the present study was to evaluate weight-loss prevalence depending on the tumour site and the gastrointestinal (GI) symptoms of oncology patients receiving chemotherapy. We included 191 cancer patients receiving chemotherapy. Files of all patients were reviewed to identify symptoms that might potentially influence weight loss. The nutritional status of all patients was also determined. The cancer sites in the patients were as follows: breast (31·9 %); non-colorectal GI (18·3 %); colorectal (10·4 %); lung (5·8 %); haematological (13·1 %); others (20·5 %). Of these patients, 58 % experienced some degree of weight loss, and its prevalence was higher among the non-colorectal GI and lung cancer patients. Common symptoms included nausea (59·6 %), anorexia (46 %) and constipation (31·9 %). A higher proportion of patients with ≥ 5 % weight loss experienced anorexia, nausea and vomiting (OR 9·5, 2·15 and 6·1, respectively). In conclusion, these results indicate that GI symptoms can influence weight loss in cancer patients, and they should be included in early nutritional evaluations.

Dientamoeba fragilis is a pathogenic protozoan parasite that is implicated as a cause of human diarrhoea. A case-controlled study was conducted to determine the clinical signs associated with D. fragilis infection in children presenting to a Sydney Hospital. Treatment options are also discussed. Stool specimens were collected from children aged 15 years or younger and analysed for the presence of D. fragilis. In total, 41 children were included in the study along with a control group. Laboratory diagnosis was performed by microscopy of permanently stained, fixed faecal smears and by real-time PCR. Gastrointestinal symptoms were present in 40/41 (98%) of these children with dientamoebiasis, with diarrhoea (71%) and abdominal pain (29%) the most common clinical signs. Chronic gastrointestinal symptoms were present in 2% of cases. The most common anti-microbial used for treatment was metronidazole (n=41), with complete resolution of symptoms and clearance of parasite occurring in 85% of cases. A treatment failure rate occurred in 15% of those treated with metronidazole. Follow-up treatment comprised of an additional course of metronidazole or iodoquinol was needed in order to achieve complete resolution of infection and symptoms in this group. This study demonstrates the pathogenic potential of D. fragilis in children and as such it is recommended that all laboratories must routinely test for this organism and treat if detected.

We investigated the effects of a probiotic fermented milk and inulin on gastrointestinal function and microecology. The study was double-blinded and comprised 66 healthy adults (22 male, 44 female), mean age 40 years (range, 22–60 years). After a 12-d baseline period the subjects were randomized to consume, for 3 weeks, 3×200 ml daily of either (1) a fermented milk with probiotics (Bifidobacterium longum BB536, Bifidobacterium spp. 420 and Lactobacillus acidophilus 145), (2) a fermented milk with the same probiotics plus 4 g inulin, or (3) a control fermented milk. During the last 7 d of the baseline and the intervention periods, the subjects kept a record of their defaecation frequency and gastrointestinal symptoms, and collected all their faeces. Intestinal transit time, stool weight and faecal enzyme activities were measured. Thirty-nine subjects were randomized to give faecal samples for analysis of pH and microbes, including lactobacilli, bifidobacteria, coliforms, Escherichia coli, Bacteroides and Clostridium perfringens. Consumption of fermented milk with probiotics or with probiotics and inulin increased the faecal number of lactobacilli (P=0·009, P=0·003) and bifidobacteria (P=0·046, P=0·038) compared with the baseline. Compared with the control fermented milk, both active products increased lactobacilli (P=0·005, ANCOVA). Subjects consuming fermented milk with probiotics and inulin suffered from gastrointestinal symptoms, especially flatulence, more than the others (P<0·001). In conclusion, the probiotic fermented milk product had a positive effect by increasing the number of lactobacilli and bifidobacteria in the colon. Inulin did not alter this effect but it increased gastrointestinal symptoms.