Glutenfri kost ved cøliaki og hva med ikke cøliakisk glutenintoleranse

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1 Glutenfri kost ved cøliaki og hva med ikke cøliakisk glutenintoleranse Primærmedisinsk uke 2018 Gry Skodje Klinisk ernæringsfysiolog OUS Rikshospitalet

2 Sammenheng mellom ernæringsmangler og grad av tynntarmsskade 700,0 600,0 500,0 400,0 300,0 200,0 100,0 Ferritin (μg/l) Hemoglobin (mmol/l) Sink (nmol/l) Vitamin D (nmol/l) Vitamin B12 (pmol/l) Folat (nmol/l) Vitamin B6 (nmol/l) Vitamin A (nmol/l) 0,0 1 og 2 3a 3b 3c Wierdsma et al 2013 Nutrients

3 Vici et al 2016 Clinical Nutrition

4 BMI og glutenfri kost Middelhavsdietten Barone et al 2016 Eur J Clinical Nutritionc

5 Cøliakere med god etterlevelse av GFK har Etterlevende ikke etterlevende Etterlevende ikke etterlevende..større vitalitet..og færre helseplager SF 36: Livskvalitet CSI: Cøliakispesifikk symptomindex Tjønsø 2012 upublisert masteroppgave

6 Gluten free diet (GFD) excludes wheat, rye and barley Coeliac disease Dermatitis herpetiformis Gluten ataxia Non coeliac gluten sensitivity LIFE LONG DIET Amaranth Quinoa Buckwheat Purified oat

7 Naturlig glutenfrie kornsorter fra Afrika Teff Nordøst Afrika Historie f.kr Rik på jern, fiber, protein Fonio Vest Afrika Rik på jern, kalsium, protein, fiber

8 Long term cohort studies as well as short term intervention studies have revealed the safe consumption of oats by celiac disease patients, provided that the products are uncontaminated with wheat, barley, or rye, or are specially produced to avoid gluten contamination above 20 ppm. None of the currently known epitopes from wheat, barley, and rye are present in oats. Two avenin specific epitopes, which can be present in all oat varieties and species, have been found to be reactive in only a very few patients. Gilissen et al 2016 Med. Sci

9 4 week GFD in 10 healthy adults Decrease of favourable: Bifidobacterium, Clostridium lituseburense, Lactobacillus TNFᾳ (pg/ml) Increase of unfavourable: Enterobacteriaceae, Escherichia coli Reduction of cytokines: TNFa, IFN Ƴ, IL 8, IL 10 Before GFD After GFD De Palma et al. British Journal of Nutrition 2009

10 4 week GFD in 21 healthy adults Abundance of Clostridiales Veillonellaceae Decrease: Veillonellaceae, Ruminococcus bromii, Roseburia faecis Increase: Slackia,Coricobacteriaceae, Clostridiaceae, Victivallaceae GFD n=74 HD n= Bonder et al. Genome Medicine 2016

11 Variations of gluten free diet Gluten free diet Low fibre High fat High sugar

12 Composition of the gluten free diet % of energy Fat Protein Carbohydr Fibre De Palma et al Bonder et al Tjønsø et al 2012 (master thesis) Skodje et al 2019 (manuscr in prep) Effect of high fat diet on gut microbiota Reduced Lactobacillus, Bifidobacteria Reduced substrate for the beneficial bacteria Singh RK et al. J. Transl Med 2017

13 Etterlevelse av GFK hos ikke cøliakisk glutensensitive Gluten exposure (in non adherent subjects) Diet adherence did not differ statistically between NCGS and CD Higher gluten exposure in NCGS but not significantly different from CD Beer, pizza, bread, spelt bread, waffles

14 Open bread challenge 52 NCGS Gastroent: Clinical assessment, exclusion of CD Dietician: Dietary assessment Foodsymptomrelation Challenge instructions Patient: Continuation of gluten free diet Symptom recording Patient: Gluten free diet + 4 slices of bread Symptom recording Dietician: Summation symptoms Evaluation Gastroent: Conclusion Diagnosis

15 Results NCGS (n=47) Baseline Non NCGS (n=9) p=0.006 Challenge Classification of NCGS and non NCGS Clinician no cut off: 85 % (47) Salerno cut off > 30 %: 63 % (35) Monash cut off >20 mm VAS: 75 % (42) Gastrointestinal Symptom Rating Scale (GSRS IBS) (score range 13 91)

16 Gluten challenge in NCGS n=59 Gluten Gastrointestinal Symptom rating scale (GSRS IBS Fructan Placebo

17 Result Statistics: Linear mixed model GSRS: Gastrointestinal Symptom Rating Scale

18 Oppsummering Glutenfri eneste behandling for cøliaki Lite tegn til mangel på mikronæringsstoffer Risiko for ubalanse i energifordeling Nydiagnostiserte henvises til klinisk ernæringsfysiolog Glutenfri kost til ikke cøliakisk glutensensitive Men grunnet reduksjon av fruktaner Glutenfri kost anbefales ikke rutinemessig ved IBS