Can’t eat bread? Maybe you’re gluten intolerant
Non-celiac gluten intolerance causes symptoms that can include digestive problems, foggy thinking, numbness and fatigue. It is important to rule out celiac disease before going on a gluten-free diet.
If you get an upset stomach every time you eat bread, pasta or other foods containing gluten — and your doctor has already ruled out celiac disease — it’s possible you have non-celiac gluten intolerance.
Gluten is a protein found in grains, including wheat, barley, rye and triticale (a cross between wheat and rye). Celiac disease is an autoimmune disorder that can damage the lining of the small intestine. People who have celiac disease must avoid eating all foods with gluten.
Dr. Edward Lebovics, director of gastroenterology and hepatobiliary diseases at New York Medical College and Westchester Medical Center, answered a few questions about gluten sensitivity and intolerance. He is affiliated with Boston Children’s Health Physicians in Hawthorne.
What are the symptoms of non-celiac gluten intolerance?
Aside from bloating, abdominal discomfort and diarrhea, you can also have some non-GI symptoms, which include headache, numbness and tingling, so-called “foggy thinking” and fatigue. There are people who have symptoms that overlap with celiac disease, but when you test them — by doing blood tests, or with an endoscopy and biopsy — there’s no evidence of celiac disease. And they respond to a gluten-free diet. So it’s gluten intolerance but it’s not celiac disease.
How do you find out if you really can’t tolerate gluten?
There is no diagnostic test for non-celiac gluten intolerance. You can’t diagnose it with a biopsy, you can’t diagnose it with a blood test, so you’re basically relying on exclusion (ruling out other diagnoses) and the patient’s report of symptoms and response.
Are more people sensitive to gluten than ever before?
It’s certainly recognized more commonly. A generation ago, before this was recognized, these patients may have been dismissed as having either irritable bowel syndrome or just some neuroses. Famously, Novak Djokovic went from being maybe a Top 5 player to being the unequivocal number one in the world two years ago, when he had this amazing season. And he attributed that to assuming a gluten-free diet.
Is a gluten-free diet the only way to resolve symptoms from non-celiac gluten intolerance?
There’s some recent literature on the low-FODMAP (fermentable oligo-, di-, and monosaccharides and polyols) diet. This was actually developed to manage symptoms of bloating, flatulence and diarrhea that can be attributed to poorly digested carbohydrates, namely FODMAPs. And lo and behold, studies done in patients who were categorized as non-celiac gluten sensitive — and they randomized them to either a gluten-free diet or a low-FODMAP diet — I wouldn’t say it’s an open-shut case, but in some the low-FODMAP diet was more effective.
Also important, a low-FODMAP diet includes avoiding wheat, barley and rye, so there is overlap between the low-FODMPAP diet and the gluten-free diet. But it may be the FODMAPs that are causing the symptoms rather than the gluten.
Should you work with a dietitian to figure out what has FODMAPs?
It is always helpful to consult a dietitian. In the office I have a low-FODMAP diet sheet, which I give patients. And if that works, sometimes it’s very dramatic. It’s a somewhat restrictive diet, so I tell them to try to be careful about it for three, four weeks. And if they say, “Gee, this was very successful,” we try to relax it a little bit and see how much they can “cheat” and still feel well.
Can someone with celiac disease follow a low-FODMAP diet?
We strongly recommend they adhere to a gluten-free diet. Because if they eat gluten, they have small bowel inflammation and pathologic changes that may lead to more serious consequences down the line.
Is it OK to put yourself on a gluten-free or low-FODMAP diet if you have persistent stomach problems?
The best thing is to be evaluated by a gastroenterologist rather than self-manage, because this is not so straightforward. And it’s preferable to make a definitive diagnosis of celiac if it’s there. Going on a gluten-free diet can complicate that. These symptoms are very non-specific, and there’s a plethora of other considerations that have to be evaluated.