Community Question – Celiac, Food Allergies, and Fatigue (part two of two)

elimination diets

This is such a common question and I wish I had an easy answer, but I don’t.  To get to the bottom of the problem, experimentation and patience is so, so key.

Before we get into potential elimination diets, it is best to re-read part one, which you can access by clicking here.

I think point #4 is commonly overlooked and is one of the most common nutritional issues I see that pop in client food diaries.  Sometimes, individuals jump feet first into an elimination diet and tend to think it must be another food that is causing the grief, without taking the time to, honestly, assess the health and nutrition of their current dietary patterns.

That and point #2 is also a very, very common reason why celiacs do not feel better.  So, focusing on the strategies presented in part one of this two part series is an extremely good starting point for anyone that is still experiencing digestive health complaints.

Whenever you continually feel unwell (especially when you already have a celiac diagnosis), it is ALWAYS important to go back to your health care provider to ensure that there are not more serious issues going on.  Hopefully, you have a good care team on your side, including a GP and gastroenterologist.

Starting an elimination diet requires professional expert dietitian support.  They can be highly restrictive in nature and can potentially end up making you feel worse energy wise, so, if you are considering it, I highly suggest embarking on one with a knowledgable health professional in your back pocket.  Here are common elimination diets that may be helpful when still not feeling well on a strict, gluten free diet.

Common Elimination Diets to Consider When You Also Have a Celiac Diagnosis:

1.  The low FODMAP diet:  Irritable bowel syndrome (IBS) is a common condition that can coincide with celiac disease.  Diagnosis of IBS follow what is called the Rome III criteria which includes the following:

Recurrent abdominal pain or discomfort, 3 days per month in the last 3 months (12 weeks), associated with ≥2 of the criteria below. The criteria are fulfilled with symptoms onset 6 months prior to diagnosis.

  • Improvement with defecation
  •  Onset associated with a change in stool frequency
  • Onset associated with a change in stool form (appearance)

If you meet the criteria above, the low FODMAP diet may improve your digestive health as it has been studied extensively within the IBS population.  It is very important to enlist a dietitian specializing in this diet to support you as you go through it as it can be quite restrictive, difficult to manage nutritionally, and labor intensive.  Most importantly, this is NOT a long-term diet!! I repeat, this is not a long term diet!

This is a short term exclusion diet, anywhere from 2-6 weeks on average.  Following this diet long term can have negative implications on your good gut bacteria as it cuts out many health promoting foods.  You must embark on the reintroduction phase to identify your specific food sensitivities, improve your good gut bacteria over the long term, and, most importantly, improve your quality of life and nutrition by increasing the variety of food in your diet.

2.  Food intolerance – Lactose free diet:  A food intolerance is when you lack a specific enzyme to break down a food component.  A common example is lactose intolerance.  This is common in celiac disease as the damaged villi in celiac disease are what make the enzyme ‘lactase’ which is used to digest lactose.

If you are newly diagnosed with celiac, the damaged villi due to celiac disease may result in inadequate production of lactase and it can result in lactose intolerance.  Overtime, as the villi heal on a strict gluten free diet, it is common to be able to digest lactose again.  However, at the onset of your diagnosis, a lactose free diet (in addition to the gluten free diet) may be needed.

Symptoms of a lactose intolerance include gurgly stomach, bloat, gas, abdominal pain, diarrhea, nausea and sometimes vomiting.  Typically, symptoms show up anywhere from 30 min-2 hours after eating lactose containing foods.

Lactose intolerance is not synonymous with a dairy intolerance.  Those with lactose intolerance can still have dairy, but they must be mindful to choose products that are ‘lactose free’ or ‘lactose reduced.’  There are many lactose free foods on the market such as lactose free yogurt that be substituted for regular yogurt.  In addition, all hard cheese is naturally very low in lactose and is appropriate for a lactose free diet.

3.  Low Fructose Diet: 

It is somewhat common for celiacs to have problems digesting fructose (called fructose malabsorption) and may benefit from a low fructose diet.  A great overview of the low fructose diet is here.

The low FODMAP diet would address a low fructose diet because fructose is part of the ‘fodmap’ gang.  However, if you are not quite ready for a full, low FODMAP diet, you may be able to just start with a low fructose elimination diet to see if your symptoms improve.   You would follow the low fructose diet for 4-6 weeks and then embark on the challenge phase.

Symptoms of a fructose malabsorption may include bloating, gas, cramping, diarrhea, fatigue, headaches, brain fog, mood changes and constipation.

4.  Food Allergies:

Food allergies are very easy to pinpoint because they are consistent every time you eat the food and always show up within 30 minutes to 2 hours after eating the food culprit.  Completing a food diary for 2-4 weeks should pinpoint the potential food culprit.

A food allergy is an immune response to the protein in the food.  For example, if it was a dairy allergy, the immune system would be reacting to casein, the protein found in all milk products.

Common symptoms of a food allergy are wheezing or breathing difficulties, vomiting, diarrhea, skin rashes or hives.

The most common food allergens include:

  • Peanuts
  • Tree Nuts (e.g., walnuts, almonds, hazelnuts, cashews)
  • Milk
  • Eggs
  • Fish
  • Shellfish (e.g., shrimp, crab, lobster, mussels)
  • Soy
  • Sesame Seeds
  • Wheat
  • Mustard

It is important to note that food allergies are much more rare in those with celiac disease and not as common as food sensitivities.

5.  Food Sensitivities – Top 8 Elimination Diet:

This is, by far, the trickiest ones to pinpoint.  Food sensitivities are different from food allergies.  They can show up anytime after ingesting the potential culprit food, typically up to 72 hours after.  They also tend to be dose dependent.  So, a little bit of the food may not be bothersome, but 2-3 servings of the food may cause symptoms.  Although not impossible, it is very difficult to pinpoint food sensitivities on a food journal.  If you think you may be dealing with food sensitivities, enlist the help of an expert digestive health dietitian.

Common food sensitivities symptoms can effect the whole body and include bloat, gas, abdominal pain, constipation, diarrhea, migraines/headaches, consistent fatigue, consistent low energy.

There are various forms of the top eight elimination diet.  However, they typically include avoiding:

  • Wheat and/or Gluten (gluten should already be gone if you’re celiac!)
  • Egg
  • Soy
  • Peanut
  • Dairy/Milk
  • Shellfish
  • Tree nuts
  • Fish
  • Optional: caffeine/alcohol

By working with a dietitian, she/he may alter the elimination diet to be suited to your lifestyle, motivation to change, medical history and preferences.  For example, as a starting point, you may only remove dairy in addition to gluten and see if that is enough to get you back on the road to wellness.

6.  Modified Paleo:

This is a diet that I came up with in practice as a beginner strategy to improve digestive health in those with celiac disease.  This would be a potential next step for an individual after consistently following step #4 in part one, but still feeling minor digestive complaints.

Individuals who may benefit from this diet may be those who are not ready to embark on a full elimination diet, or who have mild symptoms but still not feeling 100 percent despite following step #4 in part one.  They are ready to make minor adjustments to their already gluten free diet.  Their symptoms would not be classified as significant or having a significant impact on your day to day life.

Modified Paleo includes:

  • Plain yogurt or kefir as the only dairy choice.
  • No more than one serving beans/legumes per day.  Sprouted lentils being a preferred choice.
  • No more than one serving GF whole grains per day.
  • No servings of purchased and pre-packaged GF food products.  This means, for a limited time, purchased and pre-packaged GF bread/cereals/bars/baked goods are not consumed.
  • Limited added sugars (take home point – no/limited intake of ‘paleo’ desserts)
  • Small amount of whole nuts/seeds with nut/seed butters being the preferred choice.
  • Majority of intake comes from lean proteins (fish, wild game, and poultry) and easy to digest fresh fruit and vegetables
  • Liberal intake of water and herbal teas including peppermint, ginger, fennel, slippery elm, dandelion root, nettle and marshmallow root.

A full paleo diet can also be quite helpful for certain individuals.

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Real Life Advice from a Dietitian Living with Celiac Disease