Happiness, I think you make some very important observations. Dr. Robillard is the first one to suggest looking at gluten and he responded to some of these concerns you raise in a response to one of the amazon book reviews. I will excerpt it here and provid a link. The thing about this diet, is we are talking about 4-8 million people with IC, all being told to follow a low acid diet by their urologists with very mixed results. From a public health perspective, the Fast Track Diet could have a huge impact on reducing symptoms for many, many people that for whatever reason are not going to go the holistic route and pay for Cyrex Assay tests, etc… This diet is SO easy to implement, and if it provides dramatic relief for many people in a matter of weeks (in terms of reduction in burping, heartburn, gas, bloating, and other digestive concerns) then it is a huge step in the right direction. With taking out a large amount of the undigested, unabsorbed food, the bad microbes can’t thrive, and the body, via cleansing waves can start to move some of this bad stuff out of the small intestine.
Dr. Robillard: (The full exchange can be found in the link I provided at the bottom of this post.
I appreciate your ideas and perspectives on the challenges of addressing SIBO and IBS. I would like to make a few clarifications and share my perspective on low GI foods as well as cross-reactivity with gluten and food elimination based on immune-reactive foods in general, so that others might also benefit.
The Fast Tract Diet (FTD) is not an elimination diet, but a systematic approach to limit fermentation potential (FP). The overall carb-count for the recipes in the book is approximately 75 grams per day, significantly lower than what is recommended by the ADA for diabetics. However, my recommendation for people with diabetes or other carb-driven metabolic conditions is a ketogenic diet. I do not recommend lower GI foods if they have high carb counts, because those foods would have a high FP, potentially driving symptoms. There is a significant amount of literature out there recommending high carb, low GI foods, but I am convinced those very foods cause and perpetuate SIBO.
While I believe that limiting difficult-to-digest, but fermentable carbs will be enough to address most people’s IBS symptoms, for certain individuals, there may be other underlying causes contributing to SIBO and IBS for. Chapter 8 addresses these potential underlying causes including motility issues, antibiotics usage, loss of stomach acidity, immune dysfunction, and specific carbohydrate malabsorption issues, such as fructose or lactose intolerance. I am convinced that both leaky gut and digestive malabsorption will be improved by the Fast Tract Diet as long as these other underlying causes are identified and addressed when they exist.
Cross-reactivity of gluten with other foods and foods that elicit their own antibody response are interesting topics. My approach is to control inflammation and leaky gut by the Fast Tract Diet first, instead of trying to limit every food possible that might exhibit cross reactivity or elicit an antibody response. If we have rabbits getting into our garden, we could choose to eliminate them, or we could fix the fence.
Food elimination diets for IBS based on IgG testing may be an interesting area of study, but at the writing of my book, the evidence wasn’t there to justify highlighting this approach. Food elimination diets based on antibody testing was not a very effective means of controlling symptoms in a randomized study of 150 patients with IBS. Only 10% showed symptomatic improvement (http://www.ncbi.nlm.nih.gov/pubmed/15361495). I agree with the commentary of J.O. Hunter http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774875/#r8) on the problems with this study and the likelihood that this approach won’t help most people with IBS. Even the author’s (P.J. Whorwell) rebuttel stated that “it is likely that only a subset of patients have an immuno-inflammatory basis to their condition and these might be the very individuals who respond to dietary exclusion based on IgG antibodies. This would fit with our results where only a proportion of patients responded despite all having antibodies.”
Regarding the Cyrex Labs list of foods that cross react with gluten, they have a tough case to make for celiac disease. In the study supporting the tests (http://www.scirp.org/Journal/PaperInformation.aspx?paperID=26626), polyclonal rabbit anti-α-gliadin antibodies were evaluated for cross-reactivity against milk, yeast, casein, coffee bean extract, instant coffee, millet, corn, and rice. In most cases, whole foods were used presenting a huge number of molecular targets to a huge array of polyclonal rabbit antibodies. It would be surprising if there was not some level of cross-reactivity detected. The authors also noted that a significant amount of cross-reactivity was caused by the presence of gluten contaminating the test foods. Another important point the authors don’t address is what their results mean in terms of invoking symptoms in celiac patients. There is no work that I am aware of that shows that avoiding foods that cross-react with α-gliadin results in symptomatic improvement in celiac disease or people with other digestive diseases. This work may exist, but I have not found it. If you know of this work, please share it with me and I will take a look.
There is another Ocam’s razor explanation that may better explain the persistence of symptoms in 30% of celiac patients on a gluten free diet – resistant starch (RS) and other difficult-to-digest carbohydrates. Though gluten free diets have less resistant starch than the standard American diet (SAD) because three specific grains are removed, gluten-free diets do allow non-gluten grains and other foods including a variety of rice, potatoes, legumes, millet, tapioca, fruits including higher fructose fruits, high RS bananas, table sugar, and a number of other baked goods. Thus, gluten free diets still contain large quantities of the five carbohydrates the Fast Tract Diet limits in order to control bacterial overgrowth. The presence of too many of these carbs may continue to drive inflammation, leaky gut and villus destruction on a gluten-free diet precisely because they are high FP.
On a personal note, I wish you the best in finding the solution that works best for you.”