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Background The low FODMAP diet (LFD) is effective in managing irritable bowel syndrome (IBS) in the short term. This study assessed the long-term effect of the LFD on symptoms, nutritional composition and socialising. Methods Patients with IBS who received dietetic-led LFD advice were approached at long term follow up (>6 months post LFD advice) from six centres across the United Kingdom. Participants completed questionnaires assessing gastrointestinal symptoms, adherence, nutritional intake, dietary acceptability and food related quality of life (QOL). Results 205 participants completed the study, with a mean follow up of 44 months (3.7 years). Adequate symptom relief was noted in 60% of individuals at long term follow up, with 76% being on the personalisation phase of the LFD (pLFD). Mean nutritional intake did not differ between individuals on the pLFD versus habitual diet, with no difference in fructan intake (2.9 g/d vs 2.9 g/d, p = 0.96). The majority (80%) of individuals on the pLFD consumed specific ‘free-from’ products at the long term, with the purchase of gluten or wheat free products being the commonest (68%). Conclusion The majority of patients follow the pLFD in the long term, with a large proportion purchasing gluten or wheat free products to manage their symptoms.

We characterised the aetiology of non-responsive coeliac disease (NRCD) and provided contemporary mortality data in refractory coeliac disease (RCD) from our centre. We also measured urine gluten immunogenic peptides (GIPs) in patients with established RCD1 to evaluate gluten exposure in these individuals. Methods: This was a longitudinal cohort study conducted in Sheffield, UK. Between 1998 and 2019, we evaluated 285 adult (≥16 years) patients with NRCD or RCD. Patients with established RCD1 and persisting mucosal inflammation and/or ongoing symptoms provided three urine samples for GIP analysis. Results: The most common cause of NRCD across the cohort was gluten exposure (72/285; 25.3%). RCD accounted for 65/285 patients (22.8%), 54/65 patients (83.1%) had RCD1 and 11/65 patients (16.9%) had RCD2. The estimated 5-year survival was 90% for RCD1 and 58% for RCD2 (p = 0.016). A total of 36/54 (66.7%) patients with RCD1 underwent urinary GIP testing and 17/36 (47.2%) had at least one positive urinary GIP test. Conclusion: The contemporary mortality data in RCD2 remains poor; patients with suspected RCD2 should be referred to a recognised national centre for consideration of novel therapies. The high frequency of urinary GIP positivity suggests that gluten exposure may be common in RCD1; further studies with matched controls are warranted to assess this further.

Background & Aims\ud \ud Various diets are proposed as first-line therapies for non-constipated irritable bowel syndrome (IBS) despite insufficient or low-quality evidence. We performed a randomized trial comparing traditional dietary advice (TDA) against the low FODMAP diet (LFD) and gluten-free diet (GFD).\ud \ud \ud \ud Methods\ud \ud Patients with Rome IV-defined non-constipated IBS were randomized to TDA, LFD, or a GFD (the latter allowing for minute gluten cross-contamination). The primary endpoint was clinical response after 4 weeks of dietary intervention, as defined by ≥50-point reduction in IBS symptom severity score (IBS-SSS). Secondary endpoints included i) changes in individual IBS-SSS items within clinical responders, ii) acceptability and food-related quality of life with dietary therapy, iii) changes in nutritional intake, iv) alterations in stool dysbiosis index, and v) baseline factors associated with clinical response.\ud \ud \ud \ud Results\ud \ud The primary endpoint of ≥50-point reduction in IBS-SSS was met by 42% (n=14/33) undertaking TDA, 55% (n=18/33) for LFD, and 58% (n=19/33) for GFD; p=0.43. Responders had similar improvements in IBS-SSS items regardless of their allocated diet. Individuals found TDA cheaper (p

Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care departmentMethods: The authors performed a retrospective chart audit of all pa...

Introduction Studies support the use of the low FODMAP diet (LFD) in irritable bowel syndrome (IBS). Whether an optimal threshold of restriction exists is yet to be determined, but Methods A systematic review was performed of publications reporting total FODMAP and fructan intakes pre and post dietary intervention. LFD dietary trials (n=15) were identified on PubMed using MESH terms ‘low FODMAP’, ‘irritable bowel syndrome’ and ‘fructans’. From the articles identified, studies having no data on total FODMAP intake or fructan intake were excluded (n=6). Percentage change in total FODMAP intake pre- and post dietary intervention were assessed in eligible articles (n=9). All eligible articles (n=9) had data on total FODMAPs (n=7 after restriction stage and n=2 in long term) and 7 articles had data on fructan intakes (n=5 after the restriction stage and n=2 at long term). Studies assessing fructan intake in healthy participants were included for comparison (n=2). Results Total FODMAPs at baseline or in the control group was 13.0–29.6 g/d (n=7 studies) and following the LFD restriction phase 3.1–22.0 g/d (n= 7 studies), with a 24.1–85.8% reduction across studies (see graph 1). Of the 7 studies, 6 achieved the suggested threshold Conclusions The total FODMAP threshold of Reference Tuck CJ, Reed DE, Muir JG, Vanner SJ. Implementation of the low FODMAP diet in functional gastrointestinal symptoms: A real—World experience. Neurogastroenterol. Motil. 2019, 1–13

AimsThe aim of the study was to assess the provision of dietetic services for coeliac disease (CD), irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).MethodsHospitals within all National Health Service trusts in England were approached (n=209). A custom-designed web-based questionnaire was circulated via contact methods of email, post or telephone. Individuals/teams with knowledge of gastrointestinal (GI) dietetic services within their trust were invited to complete.Results76% of trusts (n=158) provided GI dietetic services, with responses received from 78% of these trusts (n=123). The median number of dietitians per 100 000 population was 3.64 (range 0.15–16.60), which differed significantly between regions (p=0.03). The most common individual consultation time for patients with CD, IBS and IBD was 15–30 min (43%, 44% and 54%, respectively). GI dietetic services were delivered both via individual and group counselling, with individual counselling being the more frequent delivery method available (93% individual vs 34% group). A significant proportion of trusts did not deliver any specialist dietetic clinics for CD, IBS and IBD (49% (n=60), 50% (n=61) and 72% (n=88), respectively).ConclusionThere is an inequity of GI dietetic services across England, with regional differences in the level of provision and extent of specialist care. Allocated time for clinics appears to be insufficient compared with time advocated in the literature. Group clinics are becoming a more common method of dietetic service delivery for CD and IBS. National guidance on GI dietetic service delivery is required to ensure equity of dietetic services across England.

Functional bowel disorders (FBDs) affect around 20% of the population worldwide and are associated with reduced quality of life and high healthcare costs. Dietary therapies are frequently implemented to assist with symptom relief in these individuals, however, there are concerns regarding their complexity, restrictiveness, nutritional adequacy, and effectiveness. Thus, to overcome these limitations, a novel approach, the 5Ad Dietary Protocol, was designed and tested for its efficacy in reducing the severity of a range of gastrointestinal symptoms in 22 subjects with FBDs. The protocol was evaluated in a repeated measures MANOVA design (baseline week and intervention week). Measures of stool consistency and frequency were subtyped based on the subject baseline status. Significant improvements were seen in all abdominal symptom measures (

Background: Many pathogens of importance, including the staphylococcal species of concern in orthopaedics, demonstrate seasonal variations influenced by environmental factors. The aim of this study was to investigate the role of humidity as a risk factor for deep prosthetic joint infection following total knee arthroplasty (TKA) in a tropical Australian hospital. Methods: A retrospective cohort study of all TKAs performed over a 13-year period was conducted at the author's institution. Univariate analysis was used to individually assess for a range of risk factors including humidity >60% and apparent temperature >30°C (86°F). Odds ratios (ORs) were reported. P-values 60% (OR 1.4; 95% confidence interval (CI) 0.68–3.04; P = 0.221); (ii) apparent temperature >30°C (86°F) (OR 2.4; 95% CI 0.56–10.1; P = 0.174); (iii) male gender (OR 2.2; 95% CI 1.02–4.81; P = 0.057); and (iv) American Society of Anesthesiologists score of III or IV (OR 2.1; 95% CI 1.00–4.49; P = 0.064). Conclusion: Humidity and apparent temperature may be potentially important risk factors for infection following TKA.

Mucosal healing is important in celiac disease (CD) for the prevention of complications. However, obtaining duodenal biopsies is invasive, and there is currently no reliable surrogate marker for histological remission in clinical practice. We aimed to assess the role of a point-of-care test (POCT) based on IgA/IgG-deamidated gliadin peptide, in detecting persistent villous atrophy (VA) in CD.We prospectively recruited patients with CD attending endoscopy for the assessment of histological remission. All patients had IgA-endomysial (EMA) antibodies, IgA-tissue transglutaminase (TTG) antibodies, and the POCT performed, and completed a validated dietary adherence questionnaire. A gastroscopy was performed in all patients, with four biopsies taken from the second part of the duodenum and one from the duodenal bulb. We compared the diagnostic performance of the surrogate markers against duodenal histology as the reference standard.A total of 217 patients with CD (70% female, age range 16-83 years, median age 53 years) on a gluten-free diet (median duration 6 years) were recruited from 2013 to 2017. Eighty-five (39.2%) patients had persistent VA. The sensitivities of the POCT, TTG, EMA, and the adherence score in detecting VA were 67.1%, 44.7%, 37.7%, and 24.7% respectively (P=0.0005). The combination of the POCT and adherence score only marginally increased the sensitivity to 70.6% (59.7-80.0%).The sensitivity of the POCT was higher than the other surrogate markers in predicting VA. A POCT may provide the additional advantage of an immediate objective assessment of mucosal healing at the time of an office-based follow-up consultation.

Introduction Non-responsive coeliac disease (NRCD) is defined by persisting symptoms or laboratory abnormalities in patients with coeliac disease (CD) despite a gluten-free diet (GFD). Causes of NRCD are heterogeneous, with refractory CD (RCD) being associated with poor prognosis. The aims of this study are to identify the aetiologies for persisting symptoms in patients with NRCD referred to a national UK centre for CD, and to assess mortality rates in each group. Methods Data on all CD patients, including those with persisting symptoms and tertiary referrals, was collected prospectively from 1998–2018. Patients were systematically investigated to establish the aetiology of their continued symptoms. They were also referred to a specialist coeliac dietitian to identify any lapses in GFD adherence or gluten cross-contamination. A repeat duodenal biopsy was performed and compared to previous biopsies where possible to check for histological remission. Colonoscopy, lactose hydrogen breath test, glucose hydrogen breath test, SeHCAT scan, CLO testing, faecal elastase, immunohistochemistry and γ-TCR clonality were performed. Results 2,356 patients with suspected CD were seen in this time period (121 were tertiary referrals). 157 were excluded from analysis due to unconfirmed diagnosis. Of the remaining 2,199 patients with confirmed CD, 2,123 had both villous atrophy and positive IgA-EMA/TTG, and 76 had seronegative CD. Of the 2,199 patients with CD (67% female, mean age at diagnosis 42.8 ± 18.5), 292 (13%) had persisting symptoms. The leading causes for persisting symptoms in patients without RCD (73% female, mean age at diagnosis 35.7 ± 19.2) were: gluten contamination (22%), functional/irritable bowel syndrome (20%), pancreatic exocrine insufficiency (7%), reflux dysmotility (5%), and microscopic colitis (5%). Of a total of 74 patients who were identified with RCD, 56 had RCD I (71% female, mean age at CD diagnosis 41.8 ± 19.0) and 18 had RCD II (33% female, mean age at CD diagnosis 55.4 ± 13.3). After a median follow up of 40.5 months (IQR 21.8–73.3), mortality was 7% in the RCD I group, compared to 39% in the RCD II group (p=0.019). Higher age at diagnosis of CD is a predictor for having RCD in patients with persisting symptoms (p Conclusions This is the largest UK study of NRCD and RCD. The contemporary mortality data in RCD II remains poor. Patients with suspected RCD should be referred to the National Centre for consideration of novel therapies such as IL-15 and Stem Cell Transplant.

Coeliac disease is a common digestive disorder that affects 1% of adults. It is characterised by mucosal damage of the small intestine caused by dietary gluten. The main treatment for coeliac disease is a lifelong gluten-free diet, which can reduce morbidity and mortality and also improve quality of life. Despite the benefits, adhering to this diet is often challenging, with patients often struggling to sustain dietary restriction. Structured follow-up for coeliac disease is recommended in international guidelines for improving adherence and for detecting complications;however, uncertainty exists concerning exactly who should be administering this follow-up care. Here, we undertake a review of the current approaches described in the literature to follow-up patients with coeliac disease, and assess the efficacy of these differing models. We also explore future directions for the care of these patients in the context of the UK National Health Service (a publicly funded healthcare system). Although the focus of this review pertains to follow-up within the UK healthcare system, these problems are recognised to be international, and so the findings of our review are likely to be of interest to all healthcare professionals seeing and managing patients with coeliac disease.

INTRODUCTION: \ud \ud Celiac disease (CD) is common, affecting approximately 1% of the population. The cornerstone of management is a gluten-free diet, with dietetic advice being the key to aiding implementation. The aim of the study was to assess group clinics in comparison with traditional individual appointments.\ud \ud METHODS: \ud \ud Patients with a new diagnosis of CD, confirmed histologically, were prospectively recruited over 18 months in Sheffield, United Kingdom. Patients received either a group clinic or traditional one-to-one appointment, led by a dietitian. Quality-of-life questionnaires were completed at baseline, as well as biochemical parameters being recorded. Patients were followed up at 3 months, where adherence scores were assessed as well as biochemical parameters and quality of life questionnaires being completed.\ud \ud RESULTS: \ud \ud Sixty patients with CD were prospectively recruited and received either an individual (n = 30) or group clinic (n = 30). A statistically significant reduction in tissue transglutaminase was noted following group clinics (mean 58.5, SD 43.4 U/mL vs mean 13.2, SD 5.7 U/mL, P < 0.01). No significant differences in baseline and follow-up biochemical parameters between one-to-one and group clinics were noted. At follow-up, there was no statistically significant difference between mean gluten-free diet adherence scores (mean 3.1, SD 0.4 vs mean 3.1, SD 0.7, P = 0.66) between one-to-one and group clinics.\ud \ud DISCUSSION: \ud \ud This first study assessing group clinics in CD demonstrates they are as effective as traditional one-to-one clinics, with the added benefits of peer support and greater efficiency, with an estimated 54% reduction of dietetic resources.

Background & Aims: Diet appears to play a pivotal role in symptom generation in Irritable Bowel Syndrome (IBS). First line dietary therapy for IBS has focused on advice concerning healthy eating and lifestyle management. Research recently has focused on the role of a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs), gluten free (GFD) and wheat free (WFD) diets for the relief of symptoms in IBS.Methods: A round table discussion with gastroenterologists and dietitians with a specialist interest in dietary therapies in IBS was held in Sheffield, United Kingdom in May 2017. Existing literature was reviewed. PubMed and EMBASE were searched with the MeSH terms irritable bowel syndrome/diet/diet therapy/gluten/low FODMAP in different combinations to identify relevant articles. A consensus on the application of these dietary therapies into day-to-day practice was developed. Results: Fourteen randomized trials in IBS evaluating the low FODMAP diet (n studies = 9), GFD (n = 4) and WFD (n = 1) were included in this review. The total number of patients recruited from randomized trials reviewed was: n=580 low FODMAP diet (female, n=430), n=203 GFD (female, n=139), n=276 WFD (female, n=215). There was no significant difference in the gender of patients recruited for both the low FODMAP and GFD randomized studies (p=0.12). The response rate in the literature to a low FODMAP diet ranged between 50-76%, and to GFD ranged between 34-71%. Percentage of IBS patients identified as wheat sensitive was reported as 30% in the literature. Conclusion: There are no head-to-head trials to date utilizing the low FODMAP diet, GFD and WFD for dietary treatment of IBS and still a number of concerns for diets, including nutritional inadequacy and alteration of the gut microbiota. The consensus suggests that there is evidence for the use of the low FODMAP diet, GFD and WFD as dietary therapies for IBS; the decision-making process for using each individual therapy should be directed by a detailed history by the dietitian, involving the patient in the process.

The Department of Health and Social Care has recently published their consultation outcome regarding the availability of gluten-free foods (GFF) on NHS prescriptions.1 Following an unprecedented number of responses from patients, healthcare professionals, and professional bodies, the Government has decided to continue to provide GFF on prescription but restrict the products available to breads and mixes. This favoured option by the majority of consultation responders has now proceeded to formal ratification, through an amendment to the NHS Regulations 2004, Schedule 1. In this editorial, we discuss the controversies that have existed regarding prescription of GFF in coeliac disease where the gluten-free diet is the treatment, and discuss the future implications that this decision may have on both patients and the NHS. GFF products have been available in the UK via prescription for those medically diagnosed with coeliac disease for >50 years, with the aim of supporting dietary adherence and reducing complications. In recent years, these prescriptions were restricted to staple foods, approved by the Advisory Committee on Borderline Substances (ACBS). The National Prescribing Guidelines endorsed by both the Primary Care Society for Gastroenterology and the British Dietetic Association set out recommendations to healthcare professionals on the quantity of gluten-free staple foods that may be prescribed.2 These allowances (in units) were determined by an individual’s age and sex (for example, male 19–59 years = 18 units, female 19–74 years = 14 units) and based upon

Introduction A gluten free diet (GFD) is essential in the management of coeliac disease, as well as several studies demonstrating its utility as a dietary therapy in patients with irritable bowel syndrome. The aim of this double-blind placebo-controlled study was to assess the role of a GFD in a healthy population who take a GFD as a lifestyle choice (‘lifestylers’). Methods Subjects were recruited via an advert, following exclusion criteria including coeliac disease. Following selection, subjects were commenced on a 2 week GFD following evaluation by a dietitian. Participants were then randomised to receive either organic gluten (Group A, Vital Gluten 14 g gluten protein/day) or gluten free flour (Group B) in pre-made bags, over a 2 week period. These were sprinkled on their food twice daily. Gastrointestinal Symptom Rating Scale (GSRS) scores were assessed at baseline (following 2 weeks GFD) and after 2 weeks of randomization. Data was analysed using SPSS version 22. Results 45 subjects were identified with 28 participants recruited into the trial (Group A; n≥14, Group B; n≥14) following exclusion criteria. Median age was 36.5 years (range: 19–63) and 21 (75%) were female. There was no significant difference in baseline demographics between both groups (p≥0.54). Over a 2 week period there was no significant difference in gastrointestinal symptoms or fatigue in either group, as seen in table 1. Conclusion This study demonstrates that gluten is unlikely to be the culprit agent for gastrointestinal symptoms or fatigue in healthy individuals. A GFD has no evidence base in individuals who do not have coeliac disease or IBS. The public should be discouraged from considering a GFD of their own volition.

Introduction In recent years there has been a renewed interest in dietitian-led nutritional treatments for Irritable Bowel Syndrome (IBS)-specifically the Low FODMAP (LFD) and Gluten Free Diets (GFD). Increases in diagnosis and a lack of suitably trained dietitians to deliver these modalities mean many patients only receive nutritional information from General Practitioners (GP’s) and Gastroenterologists (GE’s). Since the LFD and GFD are dietitian-led, the aim of this research was to qualitatively explore how people with IBS use and apply dietary information from GP’s and GE’s in IBS self management. Methods An initially sample of 33 people (7 male) responded to a research request from the staff and student body of Sheffield University. 10 participants with a median age of 45 years (range 24–64, 2 male) matched the inclusion criteria-diagnosed with IBS (ROME IV) and used diet as their primary treatment. There were no differences in baseline demographics between patients who participated in the study and those who did not (gender p=1.0, age p=0.9). All participants had received dietary information from GP’s and GE’s for self managing their IBS symptoms; primarily advice on the LFD. Semi-structured interviews were conducted (minimum an r duration) and evaluated using Interpretive Phenomenological Analysis (IPA). IPA is a qualitative research method that employs phenomenological, and idiographic techniques to explore and explain participants lived experience. IPA is particularly suited to examine and understand how people with IBS make sense of the dietary information they are given and how this relates to the self-management of their symptoms. Findings The providence of nutritional information was important for the participants, information from GP’s and GE’s was valued as evidenced based. However, the information was seen as very simplistic, often just ‘food lists’ with little or no personalisation to meet individual needs of the participants (figure 1). Digital online and resources were used to supplement the dietary information received form GP’s and GE’s, however this required additional interpretation and personalisation and led to negative effects on both the participants social and food-related quality of life. Conclusion The participants found much of the nutritional information provide by GPS’ and GE’s to be overly generic and incomplete; in that it was difficult to apply in ‘real life’. The findings in this study support the current clinical guidelines proposed by the both by NICE and the BDA that LFD and GFD’s should still be considered second-line dietitian-led only interventions.

Introduction Patients with coeliac disease (CD) symptoms usually respond to a gluten free diet (GFD). However up to a quarter of adults with CD have persistent gastrointestinal (GI) symptoms despite strict adherence to a GFD and complete intestinal healing. Overlap between CD and irritable bowel syndrome (IBS) may explain this symptomology. Over the last decade there has been a renewed interest in dietary treatments in IBS particularly the low FODMAP diet (LFD) which temporally restricts fermentable carbohydrates. The aim of this prospective study was to investigate the efficacy of the LFD in patients with CD and IBS. Methods We conducted a prospective study of the LFD as an intervention in patients with treated-CD and persisting IBS symptoms. All CD patients met the ROME IV criteria, had negative coeliac serology and normal duodenal biopsy. All patients were reviewed by a specialist GI dietitian with experience in delivering the LFD. Symptom response was assessed using the validated Gastrointestinal Symptom Rating Scale (GSRS) from base-line to follow up. Results 24 patients with a mean age of 44 years (SD=15.2) met the inclusion criteria. 8 patients chose not to pursue treatment and 2 were unable to complete the minimum treatment period. 14 patients (2 males) completed four weeks of a LFD. There were no differences in baseline demographics between patients who chose to participate in the study and those who did not, or who were unable to complete the study protocol (p=0.7). Global symptom relief of gut symptoms was reported by 8/14 patients (57% p=0.007 figure 1). A sub-group analysis demonstrated a significant reduction in both abdominal pain (p=0.001 figure 2) and distension (p=0.02 figure 3) respectively. There were no significant differences to anthropometric and biochemical features at follow up compared with baseline. Conclusion This is the first study to demonstrate that a LFD is an effective dietary treatment for patients with biopsy confirmed treated-CD and on going GI symptomology. Such patients should be seen by a specialist dietitian to improve adherence, ensure nutritional adequacy and appropriate reintroduction of FODMAP containing foods. Disclosure of interest: None Declared

Gluten-related disorders have recently been reclassified with an emerging scientific literature supporting the concept of non-celiac gluten sensitivity (NCGS). New research has specifically addressed prevalence, immune mechanisms, the recognition of non-immunoglobulin E (non-IgE) wheat allergy and overlap of NCGS with irritable bowel syndrome (IBS)-type symptoms. This review article will provide clinicians with an update that directly impacts on the management of a subgroup of their IBS patients whose symptoms are triggered by wheat ingestion.

There is a lack of dietitians trained to deliver the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet (LFD) for irritable bowel syndrome (IBS). Many patients receive nutritional information from general practitioners (GPs) or gastroenterologists (GEs). Since the LFD is dietitian-led, the aim of this research was to qualitatively explore the effects of GP- and GE-delivered LFD information, in IBS self-management. Semi-structured interviews were conducted in a purposive sample of 8 people with IBS (6 female), who used the LFD as their primary treatment. Interpretive Phenomenological Analysis (IPA) was used to develop themes on the lived experience of the participant&rsquo, s use of LFD information from GPs and GEs. This information was perceived as trustworthy but simplistic, often just &rdquo, food lists&rdquo, with little personalisation to meet individual needs and difficult to apply in &rdquo, real life&rdquo, The information required substantial interpretation and the familial and social effects of implementation were not addressed in the materials provided. Supplementary digital resources were regarded as more practical but the participants expressed concern in relation to the validity of these materials. The findings in this study support current clinical guidelines proposed by both the National Institute for Health and Care Excellence and the British Dietetic Association that the LFD should be considered a dietitian-led only intervention.

A gluten-containing diet alters bowel barrier function in patients with irritable bowel syndrome with diarrhea (IBS-D), particularly those who are positive for HLA allele DQ2/8. We studied the effects of a gluten-free diet (GFD) in patients with IBS-D who have not previously considered the effects of gluten in their diet and were unaware of their HLA-DQ2/8 genotype.We performed a prospective study of 41 patients with IBS-D (20 HLA-DQ2/8-positive and 21 HLA-DQ2/8-negative) at the Royal Hallamshire Hospital in Sheffield, United Kingdom, from September 2012 through July 2015. All subjects were placed on a 6-week GFD following evaluation by a dietician. Subjects completed validated questionnaires at baseline and Week 6 of the GFD. The primary endpoint was mean change in IBS Symptom Severity Score; a 50-point reduction was considered to indicate a clinical response. Secondary endpoints were changes in hospital anxiety and depression score, fatigue impact score, and Short Form-36 results. Clinical responders who chose to continue a GFD after the study period were evaluated on average 18 months later to assess diet durability, symptom scores, and anthropometric and biochemical status.A 6-week GFD reduced IBS Symptom Severity Score by ≥50 points in 29 patients overall (71%). The mean total IBS Symptom Severity Score decreased from 286 before the diet to 131 points after 6 weeks on the diet (P.001); the reduction was similar in each HLA-DQ group. However, HLA-DQ2/8-negative subjects had a greater reduction in abdominal distention (P = .04). Both groups had marked mean improvements in hospital anxiety and depression scores, fatigue impact score, and Short Form-36 results, although HLA-DQ2/8-positive subjects had a greater reduction in depression score and increase in vitality score than HLA-DQ2/8-negative subjects (P = .02 and P = .03, respectively). Twenty-one of the 29 subjects with a clinical response (72%) planned to continue the GFD long term; 18 months after the study they were still on a GFD, with maintained symptom reductions, and demonstrated similar anthropometric and biochemical features compared with baseline.A dietitian-led GFD provided sustained benefit to patients with IBS-D. The symptoms that improved differed in magnitude according to HLA-DQ status. Clinical trials.gov no: NCT02528929.

Introduction A gluten-free diet (GFD) is the mainstay of treatment for coeliac disease (CD). Since the late 1960 s prescriptions for gluten-free foods have been widely available, helping CD patients maintain dietary adherence and reduce complications. In Scotland and Wales GF foods are widely prescribed in accordance with the National Prescribing Guidelines. In England however, whilst the vast majority of Clinical Commissioning Groups (CCGs) are following this guidance some have chosen not to. This has lead to the reduction or removal of prescriptions in certain parts of England. This cohort study examines the influence restriction or removal of GF prescriptions may have on CD patients. Methods Between September and October 2015, CD patients and carers of CD patients were approached from 4 differing CCG areas (North Norfolk, West Suffolk, Oxfordshire, Vale of York). These CCG areas were specifically selected as areas where CCGs had either restricted or removed GF prescriptions. All participants were asked to complete an online questionnaire, with information requested pertaining to prescriptions, availability of GF foods, costs incurred and what influence changes to prescriptions have had on health. Findings from this work were then compared to a previous study assessing primary care trusts, undertaken in 2013 (n = 1000).1 Statistical analyses was performed using SPSS version 20.0, with X2 statistics used to compare categorical data. Results 25.0% (894/3586) of invited individuals completed the online questionnaire (632 F: 262 M, mean age of 59.2 years). Compared to the 2013 cohort, there was a significant reduction in the number of patients receiving gluten-free prescriptions (63% versus 70%, p Conclusion Although this study is confined to only 2% (4/209) of all CCGs in England, it raises concerns as to how the restriction and removal of gluten-free prescriptions can affect patients with CD. Given these findings, further work should now aim to establish whether prescription restriction is a false economy, as detriment may ensue due to poor dietary adherence and the development of serious long-term complications. Reference 1 The impact of the restrictions to gluten-free prescription foods on people with Coeliac Disease. BSNA. 2013. Disclosure of Interest None Declared

Introduction Newly diagnosed CD patients should have a nutritional assessment and gluten-free diet (GFD) education by registered dietitians, in accordance with guidelines. Achieving these standards is problematic due to increased CD diagnosis and limited trained dietitians available to deliver these services. Locally, we have shown that patients often wait four to six weeks for a dietetic consultation following CD diagnosis, with patient feedback suggesting this is unacceptably long. This study aimed to address this concern by comparing whether dietetic consultations provided in group clinics was non-inferior to an individual appointment for newly diagnosed CD patients. Methods Between January 2015 and December 2015 newly diagnosed CD patients were seen either by a dietitian in a group clinic or in an individual appointment as part of a local service evaluation project. Group clinics were defined as having a minimum of 6 individuals, and covered the same topics as individual appointments (education on gluten-free diets, prescriptions, travelling and information on Coeliac UK). All patients had nutritional assessments at baseline and bloods performed in accordance with BSG guidelines. These were reassessed at 3 month follow-up appointments, alongside evaluation forms for clinics and assessment of GFD adherence using the Biagi score (A validated 5 point adherence score (0–4), with the highest score indicating strict GFD adherence). Comparisons between groups were made using a student t-test, with a p-value Results 56 new CD patients were initially referred for a dietetic consultation. Eight patients (14%) did not attend first appointments and 8 failed to attend follow-up. Of the remaining 40 patients (25 F:15 M, mean age 48 years), 30 were seen in group clinics and 10 had individual appointments. There was no statistically significant difference in baseline BMI (p = 0.57), age (p = 0.10) or tissue transglutaminase antibody levels (p = 0.54) between group patients and individual clinic patients. At follow-up mean GFD adherence scores were similar in both groups (3.3 vs 3.1, p = 0.51), with paired t-tests showing significant reduction in both groups in serological markers and haematinics (p Conclusion This study demonstrates how group dietetic clinics for newly diagnosed patients may be a resource saving intervention, which derives no detriment to patient education and GFD adherence. Findings from this work provide proof of concept for undertaking a future randomised controlled trial in this area, including health economic analysis. Disclosure of Interest None Declared

Introduction Gluten is a ubiquitous part of a western diet. It is implicated for causing an array of disorders, which have both intestinal and/or extraintestinal manifestations. Our understanding of this heterogeneous group of gluten-related disorders is advancing, however uncertainty exists as to how much gluten the general population is consuming. This study aims to address this knowledge gap and also assess the prevalence of self-reported gluten sensitivity within the general population. Methods Between September and October 2015 a population-based survey was undertaken in Sheffield, UK. Members of the general public, all over the age of 16 years, were invited to complete a modified version of a previously validated written questionnaire. This questionnaire assessed demographic information, GI conditions and also determined the presence of gluten sensitivity (GS). In addition, total gluten consumption was calculated using a food frequency questionnaire. Participants were asked about their use of a gluten free diet (GFD), and whether they had seen a healthcare professional for their symptoms. A diagnosis of coeliac disease (CD) was determined if individuals had a doctor diagnosis of CD, and were also taking a GFD. Results 1003 adults completed the population-based survey (59% female, median age 31 years (16–86 years). The mean consumption of gluten per day for this group was 13.2 g (s.d =9.2 g). The self-reported prevalence of GS was 32.5% (326/1003, female 70% [P Conclusion This is the first study assessing gluten consumption in a UK population. Findings from our work highlight that sensitivity to gluten-based products is common, and that affected individuals have a higher prevalence of IBS. Although only a minority of individuals maintained a gluten-free diet, individuals with gluten related symptoms evidently were electing to reduce their gluten consumption. Disclosure of Interest None Declared

Introduction Gluten has been shown to alter bowel barrier function in patients with diarrhoea-predominant irritable bowel syndrome (D-IBS), particularly those who are HLA-DQ positive. Aims To assess the clinical response to a gluten-free diet (GFD) in D-IBS patients previously naive to the effects of gluten and blinded to HLA-DQ status. Method Between May 2012 to December 2014 we enrolled 48 D-IBS patients (24 HLA-DQ positive and 24 HLA-DQ negative) to undertake a six-week GFD. Patients commenced a GFD after seeing an expert dietitian. Both patients and dietitian were blinded to HLA-DQ status. Questionnaires were self-completed at baseline and at week 6. The primary end-point was change in IBS-symptom severity score (IBS-SSS), with a 50 point reduction conferring clinical benefit. Secondary end-points were change in IBS-quality of life (IBS-QOL), short form-36 (SF-36), hospital anxiety and depression score (HADS) and fatigue impact score (FIS). Results Data from 41 patients (74.4% women, mean-age 40.3 yrs) was available for per protocol analysis. Of these, 21 were HLA-DQ positive and 20 HLA-DQ negative; baseline characteristics were similar other than worse physical-fatigue (0.04) and vitality (0.05) in the HLA-DQ positive group. Overall, a GFD reduced IBS-SSS ≥50 points in 76% (n = 31). In fact, the mean-total IBS-SSS decreased from 286 to 131 (change –155, p Conclusion A GFD is a therapeutic option for the management of D-IBS. A clinical improvement was seen in 76% of patients undertaking a six-week GFD, with 61% opting to continue with a GFD for the foreseeable future. The pathophysiological mechanism may differ according to HLA-DQ status. Disclosure of interest None Declared.