Why Does My Belly Ache?

Gluten’s Bad Rap, FODMAPs, and Plant Based Eating

Let’s get this part out of the way first. There is a disease called celiac sprue, often known as just celiac, where people have an intense immune response (allergic reaction) to gluten. Gluten is a plant based protein found in barley, rye, and wheat. There is no doubt that this condition exists and that the consequences can be devastating.

There is no evidence that non-celiac gluten sensitivity exists. I thought about writing that sentence again, because it seems worth repeating and it flies in the face of conventional wisdom, where the entire country seems to be on a gluten restriction program. But non-celiac gluten sensitivity is a made up condition. It’s a cure without a disease. It’s a way to profit from ignorance where sales of gluten free products is expected to reach $15 billion this year. Yes, $15 billion. Not because it’s better for you, but because you don’t know better. Let’s explore.

A 22 year old otherwise very healthy young man came to see me because of intermittent abdominal pain. It seemed to occur predominantly after eating and was characterized by a diffuse abdominal ache, with  cramping, bloating, belching, and occasional urgent diarrhea. Many will recognize these symptoms because they either share them or know someone who does. This is classic functional abdominal pain, which also goes by the irritable bowel syndrome (IBS) label. There is no anatomic abnormality that has been identified with this syndrome. If you do an upper GI endoscopy it is normal. If you biopsy the small intestine there is no sign of celiac disease. If you do a colonoscopy, it will be normal. If you do a capsule endoscopy and look at all of the small intestine, it will look normal too. Lab tests: normal. X-ray tests: normal. Ultrasounds: normal. Normal, normal, normal. But there are very real symptoms and so people often begin to think they are crazy or that it’s all in their head. Physicians are not much better and usually of no help at all. How can they be when there is nothing to treat? There are, of course, pills to give (never forget that all drugs are poison, I learned that my first day of Pharmacology in medical school and it’s the most true thing I learned in 4 years), but they rarely help. Out of desperation, many try a gluten free diet and sometimes it helps. And suddenly, they have self-diagnosed as gluten sensitive.

The AboutIBS website estimates that 10–15% of all Americans have IBS. True? Who knows. I, and most physicians, would probably say it’s about right. I have seen an amazing number of patients with vague abdominal pain and no other findings and I’m sure they are just the tip of the iceberg, so to speak. The problem is so common that it attracts a fair amount of research and publications. An in 2011, in the American Journal of Gastroenterology, Dr. Peter Gibson from Australia published a paper that pointed a finger squarely at gluten as the culprit for a lot of people. It was a good paper and, most important, a double-randomized placebo controlled trial, almost the holy grail of medical studies. And the gluten free boom was born. Don’t get me wrong. This has been a great time for the poor people with real celiac sprue. The widespread availability of gluten free goods is a godsend for them and I’m happy they have better access to foods. But, as any physician will tell you, the number of patients with gut aches have not decreased, despite the boom market in gluten free products.

What industry fails to mention and went almost completely unreported, was Dr. Gibson is a pretty good scientist. He wasn’t completely satisfied with his results and he went back to the drawing board and designed a new study. A particularly elegant study where people who identified themselves as having non-celiac gluten sensitivity were divided into 3 groups and fed three different diets, high gluten, low gluten and gluten free. They didn’t know which diet they were eating and they kept journals of their symptoms. Then, two weeks later, they rotated diets. Two weeks later, they rotated again, until each group had eaten each diet. Then the results were tabulated. Anyone want to guess the results?

No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates.

That’s the title of Dr. Gibson’s 2013 article in Gastroenterology. And I’m pretty sure you never heard of this paper at all. Because, if you had and you believed, as Dr. Gibson does, that gluten is not the issue, well, what happens to that $15 BILLION market for gluten free goods?

As the title above suggests, Dr. Gibson has hit on a better explanation for functional abdominal pain and it’s called FODMAPS. FODMAP stands for fermentable, oligo-, di-, monosaccharides, and polyols and with a name like that, even FODMAP seems easy. I have no doubt that for many people following a low FODMAP diet will ease some of their complaints. If you are interested and want to know more, Dr. Gibson’s own site is probably the best resource and includes explanations, video, diet recommendations and even phone apps to help people feel better. But I have two problems with the whole FODMAP thing.

First, the idea is classic reductionist western medical thinking. Briefly, this is the idea that if we keep reducing the whole gut to it’s individual parts and components, we’ll eventually find something that causes this functional gut disorder. This kind of thinking works with bacterial disease because, if you look hard enough, you can often find something that causes a wide range of symptoms. Think of Borrelia burgdorferi,  the forgotten cause of Lyme’s disease. The problem with this sort of thinking, however, is that the gut is a system and it requires a systems thinking approach. For instance, the Monash University site (where Dr. Gibson practices and does reasearch) has a list of high and low FODMAP foods. You’ll notice that there are a lot of fruits and vegetables that are not recommended on a low FODMAP diet. But a Google search of “low FODMAP cookies” yields 284,000 results, which would lead one to conclude that cookies are OK, but I should avoid asparagus, artichokes, onions, leeks, legumes, celery and sweet corn as well as apples, pears, mango, watermelon, nectarines, peaches and plums. Madness.

My second issue, which is really an extension of the first, is that functional gut problems and IBS are basically non-existent in people who follow a plant based diet. Unfortunately, there is little research here, but numerous anecdotal reports of people with symptoms becoming symptom free when adopting a vegan or plant-based diet. So, perhaps, there is more to it than the FODMAPs. Maybe, just maybe, it’s the whole package. It’s the fiber, the complex carbohydrates, the phytochemicals and the nutrients that work together, naturally and in concert, to make the gut function better.

So, what happened to my 22 year old patient? Well, time for truth, it wasn’t a patient. It was my son Andrew. And he’s now a plant based eater and only has pain when he eats cheese. Go figure.

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