On the Gluten-Free Diet But Still Feeling Unwell? Lactose, Food Intolerances and Sensitivities
This is a common scenario among my patients with celiac disease and non-celiac gluten sensitivity. Melinda Dennis, MS, RDN, is a registered dietitian specializing in celiac disease and gluten-related disorders, author, nationally acclaimed speaker, and the Nutrition Coordinator of the Celiac Center at Beth Israel Deaconess Medical Center in Boston. She offers gluten-free consulting through her private firm, Delete the Wheat, LLC.
Symptoms can include (but are not limited to) gas, bloating, cramping, abdominal pain, loose stool, diarrhea, constipation, abnormal stool patterns, fatigue, headaches, nausea, and the list goes on. So, let’s explore what might be causing these persistent symptoms.
Food Intolerances and Sensitivities Sometimes my patients tell me that after going gluten-free they notice other foods have started to bother them. Some patients have a true food allergy that can be determined through allergy testing. In some cases, the food was bothering them all along but they didn’t realize it because gluten was still in the picture, masking the symptoms. In other cases, they have developed a reaction to a food they’re now eating in greater quantities as they try to avoid gluten. Some of the most common foods I hear about are dairy, soy, eggs, corn, nuts and sugar (see FODMAPs below) but it is certainly not limited to these alone. The range of symptoms is very, very wide and can involve the gastrointestinal tract, brain, joints, skin and many other parts of the body. Let’s discuss two – lactose and the other FODMAPs (including fructose).
Lactose intolerance A high percentage of those with celiac disease and non-celiac gluten sensitivity experience the symptoms of lactose intolerance. Lactose is the sugar found in milk products from a mammal. Lactose is broken down into smaller sugars by the enzyme, lactase, which lives in the villi (fingerlike projections) that line the small intestine. If there has been damage to the small intestine, such as through a gastrointestinal infection or celiac disease (and possibly gluten sensitivity), the production of lactase is temporarily decreased.Without enough lactase enzyme, the lactose is not digested in the small intestine. It moves through to the large intestine where the bacteria ferment it leading to symptoms of gas, bloating, cramping, loose stools and diarrhea. If you are newly diagnosed, your doctor or dietitian may ask you to avoid lactose for a short period of time to give your villi a chance to heal and the enzymes to return.The degree of severity of symptoms and amount of lactose tolerated will vary greatly by person. It’s possible for many people to regain tolerance to lactose especially if they tolerated lactose in the past. Most people still produce at least a small amount of lactase and, thus, can tolerate small amounts of lactose in their diet without ill effects. Good news – in the long run, eliminating all dairy products is not the solution to lactose intolerance. If you enjoy dairy but are having some symptoms, choose gluten-free, lactose-free, or lactose-reduced products. Continue to introduce small amounts of lactose into your diet, spaced throughout the day, so that your body “remembers” to keep making the enzyme, lactase, for you.Those who cannot tolerate lactose in any amount can turn to dairy-free beverages such as soy, rice, and almond milk labeled gluten-free.
References and further reading: Lactose Intolerance. Level 3 on celiacnow.org. See https://www.bidmc.org/Centers-and-Departments/Departments/Digestive-Disease-Center/Celiac-Center/CeliacNow/NUTRAGFD/NUTRCNSDRGFD/LCTSINT/Level3.aspxDennis M, Barrett J. Malabsorption of Fructose, Lactose, and Related Carbohydrates. In Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free. AGA Press. Bethesda, MD, 2010. See https://theceliacmd.com/2012/11/top-5-reasons-for-persistent-symptoms-after-going-gluten-free
If you and your dietitian have reviewed your gluten-free diet and lifestyle and wish to pursue additional options, follow this series as we share Ms. Dennis’ insights:
• Small intestinal bacterial overgrowth (SIBO)
• Nutrient deficiencies
• FODMAP malabsortion
Other Reasons: Less common causes of continued symptoms on the gluten-free diet include, but are not limited to, microscopic colitis, pancreatic enzyme insufficiency, and refractory celiac disease (very uncommon) and can be discussed with your doctor.
Bottom line: Don’t assume it’s normal to be feeling unwell. I hear many patients say “I just assumed everyone had diarrhea twice a day and I got used to living with it.” If you are still experiencing symptoms, talk to your doctor and ask for testing. You deserve to be in excellent health.
For labeling laws in the United States and cross contamination resources, visit: www.glutenfreedietitian.com (Tricia Thompson MS, RDN)Cross Contamination: Level 3 on celiacnow.org See https://www.bidmc.org/Centers-and-Departments/Departments/Digestive-Disease-Center/Celiac-Center/CeliacNow/NUTRAGFD/NUTRCNSDRGFD/LCTSINT/Level3.aspx
Disclaimer: As Nutrition Coordinator of the Celiac Center at Beth Israel Deaconess Medical Center, I am the lead writer and editor of the website www.celiacnow.org and co-author of the book Real Life with Celiac Disease. Otherwise, I have no business/financial stake in the resources listed in my article above.Note: The References and Further Reading resources above represent only a portion of the excellent information available on these topics. I recommend PubMed, in particular, for the multiple peer-reviewed journal articles you will find.
Would you like to immerse yourself in nutrition and health at a gluten-free weekend retreat with me in New Hampshire or Santa Barbara, California? We’ll cover all of these nutrition topics and many more in great detail.Visit: https://www.deletethewheat.com/WellnessRetreatsv2.html or email me for more information: MelindaRD@DeletetheWheat.com© 2015 Melinda Dennis, MS, RDN/Delete the Wheat. LLC. All rights reserved. https://www.DeleteTheWheat.com
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