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Gluten-Free But Still Having Symptoms?

April 12, 2010

Gluten-Free But Still Having Symptoms?

Research Suggests that 9% of Unresponsive Celiac Disease May Be Attributed to Disaccharide Intolerance, and 4% to Co-Existing IBS

Last fall Kristin Voorhees, NFCA Program Associate, began experiencing symptoms reminiscent of her pre-celiac diagnosis days. Having been diagnosed with Irritable Bowel Syndrome (IBS) in addition to celiac disease, she knew that abdominal pain and bloating would be occasional occurrences. But when the complaints became daily, Kristin scheduled a visit with her dietitian to learn whether anything could be done to improve her symptoms.

After evaluating Kristin’s diet to ensure that she wasn’t accidentally ingesting gluten, the dietitian scheduled her for a fructose intolerance* test, a procedure similar to checking a patient for lactose intolerance. The results were positive for fructose intolerance, and the dietitian proposed that Kristin try eliminating all dietary FODMAPs – an acronym that stands for Fermentable Oligosaccharides, Monosaccharides, and Polyols.

Australian researchers have found that a low FODMAPs diet is beneficial for patients with IBS and fructose malabsorption (FM). FODMAPs are dietary, inadequately absorbed, short-chain carbohydrates. Common foods restricted on the low FODMAPs diet include:

  • Fruits whose fructose content exceeds glucose such as apples, pears and watermelon
  • Fructan-containing vegetables such as broccoli, asparagus, onion, and artichokes
  • Sorbitol-containing foods such as peaches, nectarines and other stone fruits
  • Wheat-based products such as bread, pasta and cereals
  • Raffinose-containing foods such as lentils, legumes and cabbage

A 2008 study conducted by Australian researchers Shepherd, Parker, Muir, and Gibson has contributed significantly to the field of FODMAPs, IBS and FM. They identified that fructose and fructans act as dietary triggers for causing IBS symptoms when FM is present. Additionally, their work suggests that it is the interaction between the FODMAPs and the small bowel and colon that trigger abdominal symptoms – not the FODMAPs themselves.

Although therapeutic approaches for IBS currently exist, new approaches are needed given the condition’s significant impact on an individual’s quality of life. Research has also indicated that patients with IBS report an extensive financial burden. A dietary approach such as restricting FODMAPs provides patients with a unique opportunity: the ability to take control of their symptoms using nutrition as medicine. Interestingly, patients with celiac disease experience this same opportunity.

Kristin admits that the low-FODMAPS diet was initially frustrating as it further restricted her choice of food and beverage. Her dietitian had initially recommended that she follow a low-FODMAPs diet for six weeks and then slowly re-introduce the restricted items back into her diet. However, because the results were almost immediate and her symptoms had significantly decreased, she has since remained committed to limiting the amount of fructose and fructan-containing foods she consumes.

Individuals who continue to experience abdominal symptoms despite living gluten-free may find it worthwhile to schedule an appointment with their gastroenterologist or dietitian to discuss whether a low-FODMAPs diet would prove beneficial for them.

*Please note that this is different than hereditary fructose intolerance

Suggested reading/reference:

Shepherd, S.J., Parker, F.C., Muir, J.G., & Gibson, P.R. (2008). Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: Randomized placebo-controlled evidence. Clinical Gastroenterology and Hepatology, 6, 765-771.

Leffler, D.A., Dennis, M., Hyett, B., Kelly, E. Schuppan, D., & Kelly, C.P. (2007). Etiologies and predictors of diagnosis in nonresponsive celiac disease. Clinical Gastroenterology and Hepatology, 5(4), 445-450.

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