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Yes, Where Do I Start?

Are You Gluten or FODMAP Sensitive?

Gluten free diets can certainly be helpful, no question.  However, there are some people who go gluten free and don’t feel fully improved.  There is a well identified and somewhat simple answer that may help these people, a low FODMAP diet. Let’s discuss a recent study that found that FODMAP avoidance was more effective for those with self-diagnosed non-celiac gluten sensitivity than was gluten avoidance.

Dr. R’s Fast Facts

If a gluten-free diet didn’t resolve your symptoms, a low FODMAP (LF) diet may help.

Fructan, Rather Than Gluten, Induces Symptoms in Patients With Self-Reported Non-Celiac Gluten Sensitivity

  • This study compared gluten-free diet to LF diet in patients with non-celiac gluten sensitivity.
    • A double-blind crossover challenge of 59 individuals on a self-instituted gluten-free diet for whom celiac disease had been excluded.
    • Participants were randomly assigned to groups placed on diets containing gluten (5.7g), fructans (2.7g), or placebo.
    • There were greater symptomatic reactions to fructan than gluten and placebo.
      • 13 had an increase in symptoms after gluten ingestion
      • 24 had an increase in symptoms after fructan ingestion
      • 22 had an increase in symptoms after placebo ingestion
  • The placebo effect can be very powerful when it comes to digestive health.
    • Some studies estimate a 45% impact from placebo effect in controlled studies.
  • If you think you are non-celiac gluten sensitive, you may also be sensitive to FODMAPs if eliminating gluten does not resolve your symptoms.
    • Try a low FODMAP diet.
    • Give yourself 2-4 weeks on the low FODMAP diet and you should notice if this is the right diet for you.
    • If you do not see improvement, you may want to look into bacterial overgrowth and fungal overgrowth, or other inflammatory issues in the book.
    • If you do, continue that diet for 1-2 months, then try reintroducing foods you were avoiding.
      • You’ll likely find that many of the foods are okay, but some may still cause symptoms.
    • It is definitely possible to have non-celiac gluten sensitivity and sensitivity to FODMAPs.
    • The low FODMAP diet is an easy, 2-4 week way to evaluate if you have issues with fructans.

If you are still struggling, you can find a plan for different things you can try in Dr. Ruscio’s new book, Healthy Gut Healthy You.

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Are You Gluten or FODMAP Sensitive?

Dr. Michael Ruscio: Hi, this is Dr. Ruscio, and let’s discuss what to do if you’ve gone gluten-free, but you’re not fully feeling better from doing that. And good news, essentially, there may be a different diet, the low FODMAP diet, that can help improve the symptoms that may not have improved from going on a gluten-free diet.

And a group of researchers recently wanted to assess what type of benefit this type of diet, this low FODMAP diet, may have compared to going gluten-free in patients with non-celiac gluten sensitivity, or more plainly termed, gluten sensitivity, those who were not documented as celiac. So, let’s talk about the study and some of the important findings that it illustrates.

The study title—I’ll put the abstract up here on the screen—“Fructan,” which is a food component that is restricted on the low FODMAP diet, “Fructan, Rather Than Gluten, Induces Symptoms in Patient with Self-Reported Non-Celiac Gluten Sensitivity.”

This was a study in 59 individuals who had elected to put themselves on a gluten-free diet. And these researchers wanted to see, if we give them in a randomized controlled fashion… So no one knows what the subjects are taking, so it’s devoid of placebo effect. What will happen if we give participants either gluten, fructan, or placebo? And as you see here, the overall symptom scores differed significantly during gluten, fructan, and placebo challenges.

And to continue, there are significantly greater symptomatic reactions to fructans than to gluten or to placebo. And if you see here from the data table in the study, 13 participants had an increase in symptoms after gluten ingestion, 24 after fructan ingestion, and 22 after consuming placebo.

So, one, this shows you how important placebo effect is and why we should be careful when someone says, “Oh, something helped me.” We have to be careful—and that thing may have helped that person—but we want to be careful not to get overly wrapped up in anecdote, because placebo, especially when it pertains to digestive symptoms, is a powerful force. Some studies estimate a 45% impact from the placebo effect in controlled studies, so much higher if you’re doing this in a non-controlled fashion. But here, what we’re seeing is clearly a higher amount of reactivity to the fructans than to the gluten.

And so they continue, “There was no difference in symptom scores between gluten and placebo groups.” And so they conclude, and I’ll quote for you, “In a randomized double-blind placebo controlled cross-over study of individuals with self-reported non-celiac gluten sensitivity, we found that fructans do induce symptoms.” Okay.

So, what do you do with this? Well, firstly, if you think you’re non-celiac gluten sensitive, you very well may be, but you also might actually be sensitive to FODMAPs. So try a low FODMAP diet to determine this. A low FODMAP diet will remove the fructans that was noted in this study that can be problematic and that can aggravate the gut. And give yourself about two to four weeks on the low FODMAP diet. And if you don’t see any improvement, then move on. If you do see improvement, ride that wave for one to two months, and then try to reintroduce some of the foods that you were avoiding on the low FODMAP diet. You will likely find that many of these foods are okay, but there may be a few that you have to be careful with.

And finally, you might also be gluten sensitive, so listen to your body. It’s possible that someone may have both of these. We discussed in other videos in the past how there is legitimacy to non-celiac gluten sensitivity even though it has been attacked. Now, I understand why it has been attacked, because there is certainly overzealousness with recommendations for gluten-free diets, which can be damaging. It’s, on the one hand, helpful to get someone to a gluten-free diet who needs it, great. But, when we try to make everyone eat as if they had celiac disease, that creates an overzealous recommendation that does have social and psychological implications to it.

And I see with my patients in the clinic every week, some people are afraid to go out, afraid to eat off plan, they’re withdrawing from social activities because they’ve been indoctrinated into thinking that they have to live like they have celiac disease. And for many of these patients—not for all, but for many—they’re actually able to eat some gluten without any problems, especially after we clean up their gut and repair problems like FODMAP sensitivities.

And then they can get back to going out and having some fun. It’s not to say we would want to make gluten a dietary staple in these folks. But certainly, giving someone the freedom to be able to eat off plan without some severe repercussions is very nice, or get them to the point where, psychologically, they understand that they can eat off plan without having to be fearful of any repercussions.

So, the gluten-free diet can definitely be helpful. There are some people who are very sensitive, yes, and they should avoid gluten very strictly, especially if you’re a celiac. There are many who can tolerate some gluten and there are some that have no problem with gluten at all. And in some of these cases, the underlying provocating factor may actually be fructans, which can be avoided in a low FODMAP diet.

So, remember, if you’ve gone gluten-free and that’s either not helping you at all or it’s only partially helping, another dietary consideration that is easy to do and you can evaluate in a two-to-four-week experiment will be a low FODMAP diet. Now, if the low FODMAP diet doesn’t help, there are other things you may want to look into, like bacterial overgrowths, fungal overgrowths, other inflammatory issues in the gut. And I’m happy to say that in my new book, Healthy Gut, Healthy You, a plan for going through all of this will be laid out. So, if you go to the low FODMAP diet and you’re still kind of struggling, just look up the book Healthy Gut, Healthy You. You can go to to learn more about that.

But in any case, remember, if you’re going gluten-free and it’s only partially helping, there’s another dietary step of a few potentials, but another one that is definitely worth a primary consideration, which would be the low FODMAP diet.

Okay, this is Dr. Ruscio. And I hope this information helps you get healthy and get back to your life. Thanks.

What do you think? I would like to hear your thoughts or experience with this.

Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.


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