Bread – Clinical Alimentary

IBS digestive distress – is there a problem with bread?

Many people with IBS state that bread is a real issue in provoking symptoms. Is this true? What is it about bread that is the problem? This post aims to discuss the provocateurs of digestive distress in IBS (Irritable Bowel Syndrome).

Cited as sustenance – for example, the line ‘give us this day our daily bread’ in the Lord’s prayer – having access to bread was life for the poor in the past and bread is a staple food in the United Kingdom. The first piece of toast dripping in butter and a cup of tea after a period of fasting through having surgery is one time I recall, and bread was all the food I desired. How wonderful it tasted. The mouthfeel of gluten is undeniable and can be identified by those who do need to follow gluten, wheat or fructans free diet. I have identified it when I have infrequently made a mistake, as in ‘wow, this gluten-free bread tastes GREAT’ only to later realise my mistake at a cost and in fact it was the standard wheat based bread I had consumed!

In the past bread was made locally and bakers were part of the local community. When industrialisation arrived, bread, needed in large quantities as a staple food, soon was produced in factories, one of the possible reasons was because it was terrible work – bakers had to rise early and work hard to provide the daily loaf for their community. Is industrialisation the cause of bread symptoms? Many blame the Chorleywood bread making process and fast fermentation – but harking back to the bread of the past does not always leave a rosy glow. Adulterating food with cheap ingredients was commonplace in Victorian history, alum (aluminium salt) was added to the dough to improve it’s colour and was thought to be one cause of Rickets, by reducing the availability of phosphorus, leading to decreasing its absorption from the diet.

So, let’s take a look at bread more closely. There are possibly a few protagonists for digestive discomfort after eating bread, and the reason may be different for individuals – we will now discuss some of those possible causes:

Resistant starch content

‘Resistant’ starch does what its name suggests – it resists digestion and is a component of fibre. Produced by heating/cooling treatment, these resistant carbohydrates are based on wheat (and other) grains. Now for a little bit of chemistry, not too complicated, I promise. Starch is a crystalline polymer (think of a chain of a necklace containing many small beads, each small bead representing a sugar molecule, the necklace representing a polymer chain – a starch). Chains of the starch molecules closely line up on cooling, forming crystals within the bread matrix, links (imagine two or more necklace strings joined together) or bridges between the starch chains makes the structure a tightly packed area, where our digestive enzymes (amylases) can’t penetrate. The speed and repetition in cooling and heating will affect the amount of the resistance formed. Exposed to up to 20g of resistant starch per day from our diet some of the bacteria (amylolytic) in our large intestine may be able to ferment these crystalline resistant areas more successfully . IBS has alterations in the gut microbes, meaning that gut fermentation is a possible consequence and symptoms likely, in those people with IBS.

Research has shown that only certain types of bacteria are capable of digesting resistant starch of the form Bifidobacterium spp. and Clostridium butyricum but these types of study are limited. Consumption of these starches enriches the gut microbial populations with more of the microbes capable of breaking down the starch. We know that people with IBS have different populations of gut bacteria than the general public – a changing diet to improve symptoms is a possible cause of this difference.

Similar mechanism to the mechanism that causes issues from resistant starch – in other words poorly absorbed starch components causes these starches to be fermented in the large bowel resulting in symptoms when the colon is overly sensitive in IBS.

Gluten

Gluten is a different component, and it is a protein, not a starch. Different mechanisms occur with proteins. During bread mixing initially, the gluten is softened by adding water to the flour, then kneading the bread with the salt that is added strengthens the gluten bonds gives a stretchy mixture, which traps air giving a better rise. Proteins tend to solidify when heated during baking, producing the tight structure or links between the protein molecules. Some research has found by blinding during trials that it does appear to be the fructans in wheat that result in the majority of problems for people with IBS. However is it still possible for individuals to have an issue with gluten? It does make you wonder, for those people who can tolerate all other fodmaps except wheat, whether this is, in fact, a non-coeliac gluten sensitivity. In my experience, most people following a low fodmap diet will go utterly gluten-free despite the fact that small amounts of wheat are tolerated well. Or perhaps the problem is a non-IgE wheat allergic reaction, or maybe natural toxins developed by the wheat is the problem…

Wheat ATIs

Wheat amylase-trypsin inhibitors are proteins that are found naturally in wheat and are resistant to digestion and were developed by the plant to act as a defence against parasites and insects. They are activators of innate immunity and are suggested to lead to digestive symptoms by activating an immune reaction in the gut mucosa resulting in low levels of inflammation. Bioactivity of these proteins was found to be lower in spelt flour – often stated to be tolerated better for digestion. Is it possible that these ATI’s or gluten activate an immune response that then sensitises the colon leading to reactions to fodmaps?

The processing of wheat to produce bread, however, reduced ATI’s bioactivity up to 30-50%. But some people state bread is explicitly a problem so we should look at the manufacturing process specifically.

Chorleywood bread making process – the case for fructans?

All the above are commonly found in all wheat-based food, but bread is processed, what effects does this have? The Chorleywood process was developed in 1961 and improves production time reducing costs of bread production. This production method can also use a lower protein content flour, which was the type of flour available in the UK, to reduce costs of having to import flour with higher protein. The protein content in UK wheat has increased since this development, but this process is still used and widely disparaged as a cause of digestive distress.

One fascinating study looked at the differences in symptoms between the general population and those with IBS and whether a longer fermentation would lead to lower gut fermentation and gas (1). Now, this study was tiny and was completed in vitro (it was not a controlled trial in human subjects, although human stool from volunteers was used) so, the conclusions would need further study. The Chorleywood process produced more gas more quickly, after simulated digestion. The more prolonged fermentation process also led to a higher level of bifidobacteria in the stool, the levels of these microbes are reduced in IBS. Bifidobacteria also produce less fermentation in the gut, suggesting increasing numbers compared with others may help reduce symptoms.

So, the combination of less gas delivered more slowly and increasing commensal bacteria that produce less gas anyway, was suggested to equal better tolerance, which is perhaps a leap of faith to suggest that this reduction will reduce symptoms without it being tested in humans. Voila, testing in humans has been done (2)! A more extensive study in humans also looked at Chorleywood process compared with sourdough and showed that a more extended fermentation leads to the breakdown of ATI components and reduced fodmap levels BUT NO DIFFERENCE IN SYMPTOMS OF IBS. Both studies used constipated volunteers, so no difference there, the symptom production in the second study was reported to possibly be a nocebo effect – expecting symptoms due to previous experience. Which is possible, six slices per day is a considerable amount to consume for people who have an intolerance to wheat. Diet was excluded as a confounding factor but what is not clear is how the bread was eaten and whether this was different in the two groups – toasted, fresh, or frozen, perhaps taking us back to resistant starches? Also, about a third of people with constipation based IBS will have pelvic floor dyssynergia, which in theory could elicit symptoms that might not necessarily be helped by changes in the diet, if symptoms are severe. Both these studies were pilot studies and need further investigation on a broader population of people with IBS.

Yeast

For many people with IBS yeast is anecdotally reported to result in symptoms. We do not have any evidence that this is a problem and this has been dismissed by the medical establishment as a cause. No evidence means precisely that, we don’t know, so would it be an issue? Saccharomyces cerevisiae, a yeast, has been studied in improving IBS symptoms, so we have another situation of modulating the gut microbiota to improve symptoms. While we have absolutely no evidence that a low yeast diet is useful, in IBS treatment, it might lead to altering the microbiome and should not be advised, but this is an area indeed worthy of further study.

I think in conclusion, symptom inducement in IBS with bread is complicated and needs further study – with this detail of research required for one food item – is it any wonder that we have not got a cure for this medical condition?

Adele Costabile, Sara Santarelli, Sandrine P. Claus, Jeremy Sanderson, Barry N. Hudspith, Jonathan Brostoff Alison Lovegrove, P R. Shewry, Hannah E. Jones, Andrew M. Whitley, Glenn R. Gibson (2014) Effect of Breadmaking Process on In Vitro Gut Microbiota Parameters in Irritable Bowel Syndrome PLOS one Volume 9 Issue 10 e111225
Laatikainen R, Koskenpato J, Hongisto SM, Loponen J, Poussa T, Huang X, Sontag-Strohm T, Salmenkari H, Korpela R (2017) Pilot Study: Comparison of Sourdough Wheat Bread and Yeast-Fermented Wheat Bread in Individuals with Wheat Sensitivity and Irritable Bowel Syndrome. Nutrients. 2017 Nov 4;9(11). pii: E1215. doi: 10.3390/nu9111215.

March 31, 2018

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Gluten free, low lactose rosemary and olive bread

The seat in the wood has intrigued me since I stumbled across it, looks home made, old – it has certainly seen its fare share of winters, I guess. It doesn’t overlook a repose worthy view and the valley’s features are obscured by the wall when seated, but is certainly a welcome resting place from the steep climb of the valley side. A haunting melancholy spot in an old oak forest – to come home to a meal of rosemary and olive bread is certainly what’s needed to cheer up the spirit after today’s walk! Check out the recipe below.

Ingredients

450g gluten free self raising flour

1 teaspoon of xanthan gum

3 tablespoons of olive oil

15 green olives

salt

350 mls of lactose free milk

5g of rosemary leaves

Spray olive oil

2 eggs

50g of Parmesan cheese

Method

Wash your hands

Measure out the lactose free milk, add eggs and olive oil mix well, add salt to season.

Weigh out the gluten free flour and add the xanthan gum, and mix well.

Grate the Parmesan cheese and add 2/3 to the flour leaving the remainder to sprinkle on the finished bread.

Chop the rosemary finely and add to the flour.

Slice the olives and add 2/3 to the flour leaving the remainder to decorate the top of the bread mix before cooking.

Mix the Parmesan and olives into the flour, make a well in the centre of the flour mix and add the liquid ingredients.

Incorporate the liquid into the flour till everything is blended in.

The finished mix has a slightly sticky texture.

Oil a tray well and add the mix, wet your hands and smooth the surface and add a thumb print in lines down the bread as a decoration.

Spray the surface of the mix with olive oil

Add the remaining olives and cheese.

Cook for 40 minutes or until a skewer inserted into the bread comes out clean at gas mark 6 or 220 degree centigrade.

Serves 8-10

For a low fodmap diet xanthan gum is possibly fermentable but is in the bread in very low levels (less than 0.5%) so most people should be OK to have a portion.

September 14, 2015September 14, 2015

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A dietitian’s reflection on following a gluten free diet

Marsh grading for diagnosis of coeliac disease — Copyright (c) 2012 Jules_GastroRD.
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When I initially became involved in treating people with coeliac disease I decided that it would be good to try to follow the gluten-free diet to see what the problems were, this post is a copy of my reflection and was originally written in 2009 – some of the issues I experienced will not have been made any easier in the current economic climate. I feel the need to share this with you – I may try to persuade you to continue following your gluten-free diet to ensure optimum health, but I do appreciate this is no mean feat to achieve!

I REALLY like bread and my favourite meal of the day is breakfast when I have a bowl of cornflakes (what??? a dietitian not eating a fibre based breakkie? – let me assure you, I do eat plenty of fibre :-).) I have some experience of changing my breakfast cereal for unnamed brands to try to save money and I have to say I failed miserably, as many brands fail to keep their texture once in milk and often taste very bland. I therefore eat a certain very well-known brand of cornflakes. As such I was not looking forward to the experience of having to change, but I felt it was worthwhile.

I began by purchasing the prescription breads, rolls, pitta breads and some breakfast cereal. I cut the rolls without refreshing them and they just crumbled and were unusable, so I learned very quickly to refresh bread before doing anything with it. The homemade bread in the bread maker was significantly better than pre made bread (as the latter was powdery and not helped by the fact that I do not generally use any spread on my bread.) I could also add seeds and dried fruit to this to increase the fibre content, as I have also learned that despite the flour being marketed as fibre based the levels are still lower than the equivalent wholemeal bread I normally consume. Regardless of consuming in excess of five portions of fruit & vegetables a day and plenty of fluids, this diet resulted in constipation, so as you can probably imagine – I was not a happy bunny (with stools to match!)

I decided to purchase everything that I used to see what difference it made, the diet is very expensive and Coeliac UK surveys suggest that it adds ten pounds to a shopping bill (don’t forget this was written in 2009) despite foods being available on prescription, as food prices have increased since then, this data is probably now a conservative estimate. This may result in people with coeliac disease not purchasing gluten free foods and this is particularly relevant at the moment, as many people are managing on very tight budgets. One issue that did vex was that many foods in the dietary allergy section of the supermarkets are expensive, often ORGANIC (this is a luxury lifestyle choice in my view, and might pander to those who manipulate their diet by choice, and not medically evidenced/diagnosed as required, often these individuals can afford to spend more on their diet. Although – why shouldn’t people with Coeliac Disease have a choice of organic you may ask? – that’s fine, as long as there are also standard alternatives available.) The problem is, when newly diagnosed coeliac, and not used to using the Coeliac UK food directory, people will obviously choose foods that are easily identifiable, as they must have something to eat. This may well be in these specialist sections in the supermarket where 1/ not everything may well be gluten-free, as the section is for all food intolerances (still need to use the gluten free food directory) and 2/ cheaper gluten free versions might be available in the rest of the store (again looking at the directory will help.) I found the most time effective way of doing this is to write the usually consumed foods on a list and to either do a search on the Coeliac UK online food directory, or match the foods from the directory in the store that is used, prior to visiting the supermarket.

Initially my breakfast was a huge disappointment, the first cereal I purchased was an organic gluten free cereal flakes that was at the allergy section of the supermarket, it was extremely expensive, and as I normally consume a large bowl it only lasted five days. Reducing the portion size resulted in hunger so I then had to add a slice of gluten free toast and jam. This cereal tasted good, but I obviously couldn’t afford to continue using this. The same supermarket had cornflakes available in their own brand range, in the directory, and much cheaper, but only available in the cereal section – not the free from section, clearly to the supermarkets advantage. Another organic and expensive (arrgh!) cereal was then used (larger packet for same price as the first option), this did not go soggy, but tasted like cardboard, and it went straight in the bin. I sometimes eat porridge, so my next foray into trying to find a suitable breakfast was to make some GF porridge (not made with gluten-free oats – remember people newly diagnosed are asked to avoid GF oats initially,) the really weird thing was that the rice based cereal smelled and looked like porridge when it was being prepared and the rice flakes kept their texture well. It was just a bit disappointing as the porridge didn’t quite have the mouth feel of normal porridge, (I also HAD (??) to add some maple syrup as a treat, as by this stage I felt mildly irritated that I was not able to eat my usual diet, resulting in an increase in calories!). The most agreeable breakfast solution was toast and jam, but this obviously reduced my milk consumption, an important source of calcium and a good learning point.

Another thing I have learned was when I ran out of bread and did not have enough for my lunch I resorted to unhealthy snacks (crisps) that I knew were suitable, as the salad I had prepared did not satisfy my appetite. The options to choose when eating out are less. I also incorrectly assumed that I would lose weight as the portions of the gluten free foods were smaller, I had assumed that weight gain post diagnosis was as a result of better absorption of nutrients. But shock, horror, the smaller portion sizes OFTEN CONTAIN THE SAME CALORIES!!! People might eat more portions of the bread, increasing calories consumed and need to be informed of this. This realisation was more than a bit of a shock and was one of the causes of my relapse into eating a gluten based diet. I lasted on the diet about three weeks, it was a very emotional time, I felt deprived, was constipated, poor, possibly gaining weight (didn’t weight myself) and generally very, very grumpy. I now know that it can take time to get used to the diet and the free samples are very useful to identify which foods are tolerated best. The emotions involved cannot be underestimated and as this diet needs to be permanently adhered to it is probably one of the most difficult life changes to make. Even more difficult than weight reduction, as a few changes at a time can make a difference with managing weight, I’m not suggesting that managing ones weight is EASY, far from it. More difficult than stopping smoking or drinking alcohol, as this can be stopped completely and again I’m not underestimating the problems people have changing these aspects of their lifestyle – but coeliacs still need to EAT! Patients that are symptom free will not feel a strong compulsion to change, and if young, slight increased risk of cancer and osteoporosis, may not be a strong a enough deterrent. I also realised it is very important to help people in clinic to identify their own symptoms to help them to move to a position of making changes some symptoms are sometimes unrecognised, such as tiredness and bloating. I have now gained so much respect for those people who follow the diet and following the diet placed me in a much better position to help by improving my knowledge. I am still going to continue to try foods, it is important that I do, as I have found good bread and cereal, but not follow the diet 100%, as not being diagnosed as Coeliac, I am extremely fortunate to be able to choose!

How my practice has changed – I have now increased my knowledge of the gluten-free diet and probably just as important I have some idea of the difficulties experienced by patients that are newly diagnosed, this has informed my practice and I can now give more detailed information to patients. I have joined Coeliac UK and find their website very useful to have on the screen in clinic and I can download information for patients directly. This also gives them the idea that joining would be useful as all the information is available to them.

I hope you appreciate my honesty in this reflection and I would also strongly advise any new gastro Dietitian to follow the diet as there is no better learning experience.