Sensitive stomach? Investigating your diet for answers
“Could I have a gluten intolerance?” “How should I eat to feel better?” I frequently see patients who want to know if their food choices are causing chronic gastrointestinal (GI) system symptoms. Answering these questions can take time, and much of the detective-work happens outside of the office. There are a few ways you can find clues about the causes even before you get to your clinician’s office.
The gastrointestinal system is composed of a series of organs and structures that work together seamlessly to ensure proper digestion, absorption of nutrients and elimination of waste. The GI system's ability to coordinate movements, secrete digestive enzymes and sense nutrients and pathogens is essential for maintaining overall health. This complex task requires such vast networks of neurons within the GI tract that it contains more neurons than our brains!
When the GI system isn’t working perfectly, symptoms can be vague and non-specific – like constipation, diarrhea, bloating, cramping or nausea. This work of the GI system can become even more difficult depending on what is eaten. Humans have a lot of food options and knowing which foods our GI tracts are sensitive to can be tricky, from heartburn to intestinal upset. Some people have what we call intolerance to certain foods, which is different than an allergy which can be severe or life threatening. An intolerance affects only the digestive system and typically have less serious symptoms but still can be very uncomfortable.
If you have been dealing with chronic GI symptoms there are some things you can do right now to make an office visit with your clinician more effective and arrive at your answers sooner. If you have serious GI symptoms that are acute (that is, come on quickly), or are severe or unusual for you, check in with your clinician right away.
Keep track with a food journal
One of the first recommendations I give people with mild or infrequent symptoms is to continue eating the way they have been eating, but record what they are eating and how they are feeling. This is called a food journal. The idea is to write down what you eat for breakfast, lunch, dinner and any snacks throughout the day. Also record symptoms like gas, bloating or discomfort. After a few weeks, there will be enough clues to begin looking for trends. For example, vague symptoms of discomfort after eating foods with tomato or chocolate or after drinking caffeinated or alcoholic beverages could point to symptoms of reflux (heartburn).
When stomach contents reflux into the esophagus it is usually very uncomfortable. So much so that it was given the name “heartburn.” But not all reflux is experienced as a burning sensation. Sometimes it feels like pressure or vague discomfort, and that can make it difficult to diagnose right away. You can help clarify the picture by being able to relate symptoms with high-risk foods or with common activities, like lying down, that can aggravate reflux.
Food journals can help to diagnose more than reflux; they can also provide evidence of other food intolerances. For example, if your food journal shows a trend of gas and bloating after large bowls of ice cream, this could indicate some degree of lactose intolerance. Lactose is a sugar found in dairy products, and being mammals, we are born with the ability to digest lactose. However, many of us will lose some or all of this ability as we age. When that happens, the undigested lactose passes through our GI tract where it can upset our digestion. Our GI tracts are home for many healthy bacteria that help digest our food, but large amounts of lactose can be too much of a good thing for the helpful bacteria – leading to excessive gas production and bloating.
Food elimination diet
When a food journal hasn’t uncovered clues to the trigger foods or when symptoms are more than mild or occur too frequently to effectively look for what is setting it off, it may make sense to try an elimination diet. The advantage of this diet is that it makes a change in the diet and looks for a response. To improve the chances of improving symptoms, several changes are made at once. When I recommend an elimination diet to patients, I suggest stopping the three most common food intolerances – gluten, dairy and eggs.
The diet goes like this: first stop eating all the food groups that could be causing the symptoms, then wait several weeks to see a response. If symptoms improve, it is likely that one of the eliminated food groups was the source of the problem. To discover which one it was, add them back one at a time, monitoring your reactions for several weeks after each addition before moving on to the next food group. When symptoms return, we know the culprit food and can go back to avoiding it while enjoying the others. It sounds tough to some people, but a few weeks of a more restrictive diet can get the data you need to get your GI tract back on track so you can eat more of the things you love (but that don’t upset your digestion).
When gluten intolerance is suspected, clinicians can test for celiac disease – a gut allergy to gluten. However, a lack of exposure to gluten from avoiding it for a time can lead to a false negative result. Celiac disease needs to be caught “red-handed” so to speak. People who think they could have celiac disease do not need to eat extra gluten before seeing their healthcare provider, but they should let their clinician know if they have been avoiding gluten.
Low FODMAP diet
When a food journal and a food elimination diet have not given you enough information to act on, we have more of a medical mystery. Symptoms like weight loss, blood in your stool or signs of serious food allergies like swelling in the face or wheezing after exposure to a particular food, should be evaluated urgently by a healthcare professional. If you haven’t gotten to the bottom of your chronic and non-specific initial symptoms like reflux or bloating, you should seek medical advice to get a workup, review nutrition and help manage GI symptoms.
Just like a good mystery story, the next steps usually involve rounding up the usual suspects and trying to exclude them. Irritable bowel syndrome (IBS) is often what is left at the end of this process. The good news is that IBS often responds to a specific diet called “low FODMAP” that your clinician may recommend to help solve the mystery. It is a funny name, but the gist is that certain foods can aggravate IBS, so avoiding them improves symptoms. Trying this diet is usually the first recommendation when IBS is suspected. Even if you just have some but not all symptom relief, it can help to build evidence for the diagnosis of IBS, similar to a food journal or an elimination diet. When a patient tells me that a low FODMAP diet improved their symptoms I feel more confident that we are on the right track. Some people try the FODMAP diet out on their own, but it’s usually wise to seek a consultation first and work with your clinician on the diet.
The recommendations in this article can help to evaluate chronic and non-severe symptoms. They can provide additional information to help your clinician know how best to help you with your symptoms. A bit of detective work ahead of an office visit can help to solve the case of mystery GI symptoms.
Peter Barkett, MD, practices internal medicine at Kaiser Permanente Silverdale and writes a regular column for the Kitsap Sun. He lives in Bremerton.
This article originally appeared on Kitsap Sun: Sensitive stomach? Investigating your diet for answers
