Hunting for the Missing Link Between Eczema and Food Allergies
The 1 Gut Health Issue You Might Be Mistaking For A Gluten Intolerance
It's fair to assume you have a gluten intolerance (i.E., the inability to properly digest the protein gluten) when you're left dealing with bloating, gas, and general misery after eating a piece of toast. But there's another lesser-known food sensitivity to have on your radar—and it could actually be what's behind your gut symptoms.
Ashkan Farhadigastroenterologist at MemorialCare Orange Coast Medical Center in Fountain Valley, California
It's called fructan intolerance (i.E., the inability to properly digest the sugar molecule fructose in certain carbohydrates like fruit, vegetables, and grains) and healthcare providers say most people don't even know it's a thing.1 Still, questions are swirling after fructan intolerance came up in a recent viral TikTok from Wendi LeBrett, MD, a gastroenterologist in Los Angeles, California known as @socaldoc on Instagram. In an "I wish more people knew" post, Dr. LeBrett wrote, "Most people aren't actually intolerant to gluten but instead have a fructan intolerance."
Like gluten, exposure to fructan can cause digestive issues in people who are sensitive to the carbohydrate. But these intolerances are very different, meaning their treatments are slightly different, too. We tapped two gastroenterologists and a registered dietitian to break it down.
What is fructan intolerance?Fructan is a type of complex carbohydrate that's made up of chains of fructose, a form of sugar, explains Lindsay Malone, MS, RD, an instructor in the school of medicine at Case Western Reserve University. "Fructan intolerance is an inability to digest fructans, [which are] found in wheat, onions, garlic, barley, Brussels sprouts, cabbage, broccoli, pistachios, and artichokes," she says. "It's found in other foods, too, but in high amounts in these foods."
Fructans can be hard to break down in the gut if you don't have enough of an enzyme called alpha-galactosidase, says Ashkan Farhadi, MD, a gastroenterologist at MemorialCare Orange Coast Medical Center in Fountain Valley, California.2 (For context: Enzymes speed up the rate of a specific chemical reaction in your cells. In this case, they help break down fructans in the gut.) "If you cannot break fructan down, it will remain undigested in the gut and will reach the colon," Dr. Farhadi says.
Gas is a big sign of a fructan intolerance, along with symptoms similar to irritable bowel syndrome (IBS)—a condition that causes bouts of stomach pain, diarrhea, or constipation, says Ellen Stein, MD, a gastroenterologist and associate professor at Rutgers Robert Wood Johnson Medical School. That means bloating, diarrhea, and an urgent feeling that you need to poop are on the menu, Dr. Farhadi says. "It's the exact same symptoms of a gluten sensitivity or lactose intolerance," he adds.3
A fructan intolerance could also be a sign you're dealing with another underlying gut health issue, Malone says. "Gut health conditions do tend to run together," she says. "If you think of the gut like a garden, if there is a problem with the soil, it isn't isolated to one spot in the garden." Fructan intolerance can be linked with small intestinal bacterial overgrowth (SIBO), which is an overgrowth of bacteria that colonize in the small intestine, she explains.4
But Dr. Farhadi says that experts don't usually know why someone will have a fructan intolerance.
Why does it get mistaken for gluten intolerance?You probably have some baseline familiarity with gluten intolerance, but a recap never hurt anyone. Gluten is a protein found mostly in wheat, barley, and rye. The American Academy of Allergy, Asthma & Immunology (AAAAI) notes that when you have this intolerance, you often experience gas, stomach pain, or diarrhea when you eat gluten. This is not to be confused with celiac disease, says Dr. Farhadi, which is an autoimmune disorder that damages the small intestine when gluten is ingested, per the AAAI.
So, why do gluten and fructan intolerances get confused? One reason is most people are simply more familiar with gluten, so they may just assume that's their issue, says Dr. Farhadi. And seeing that the symptoms closely overlap, this can add to the confusion, he adds. Another reason is that "gluten and fructans are in a lot of the same foods, so it's easy to get confused by the symptoms and not know if one or both of these are your issues," Malone says.
Making things even more complicated, there aren't great testing options for either condition. Providers will instead suggest elimination diets to mitigate symptoms versus giving a solid diagnosis. Because of that, Dr. Farhadi says it's hard to know for sure how many people truly have a fructan intolerance.
However, research suggests that people with IBS are especially vulnerable to fructan intolerance, with up to 51 percent of IBS cases also having food sensitivity.5
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5 ways to treat fructan intoleranceTreatment for a fructan intolerance is tied to its diagnosis. By making small changes to your diet, with the guidance and approval of your healthcare provider, you can determine the type of intolerance you might be dealing with. Here are some tips on how to do that:
1. Go on a low-FODMAP dietFODMAP is an acronym for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols.6 These are all forms of sugar molecules found in certain fruits, vegetables, legumes, and whole grains. Because FODMAPs are more likely to cause gas and bloating for certain people, a low-FODMAP diet (i.E., an eating plan that limits these foods) is recommended for a fructan intolerance.
"I use the low-FODMAP diet as a test for patients with symptoms," Dr. Stein says. "This helps them find a series of foods less likely to cause symptoms, and to get healthy foods into their diet that can keep them well." There are a ton of foods that fall into the low-FODMAP diet, but high-FODMAP foods to avoid include:
Need a larger breakdown? Check out our list of things to eat (or not eat) on a low-FODMAP diet.
2. Keep a food diaryKeeping a food diary for a brief time, to track what you eat and how you feel afterward, can be helpful when diagnosing an intolerance. You can keep track of how much of the food you ate and the symptoms you're dealing with, too. Using a tracking app, writing it in your phone's note section, or keeping a physical food journal are all good options. "See if you can pinpoint a food that you're suspicious about," Dr. Farhadi says. And then "share this with your doctor."
3. Reintroduce some foodsDr. Stein recommends following the low-FODMAP diet for four to six weeks before slowly starting to reintroduce some of these high-FODMAP foods. "We just monitor what happens and how they feel," she says. "Most patients can tolerate small portions of all the FODMAPs back into their diet without too much trouble. Large portions of any food can cause symptoms, so we try to keep things balanced."
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4. Tamp down on highly processed foods If gas and bloating are constants for you, Malone recommends tweaking other areas of your diet, too. "Focus on whole, minimally processed foods, since processed foods can have FODMAP-containing additives that aren't commonly known or recognized," she says. This also helps remove extra variables like preservatives, colors, and thickening agents, which could also cause gas and bloating, Malone adds.7
Of course, it's okay to eat certain processed foods now and then—it's more about enjoying everything in moderation to help balance things out.
5. Consider taking a probiotic or enzymeProbiotics help promote healthy bacteria in the gut, which can influence the types of nutrients your body uses, as well as how much gas you produce. While it won't cure a fructan intolerance, "a probiotic may help in the way of changing the bacteria population in the gut," Dr. Farhadi says.
Another option is trying an over-the-counter digestive enzyme like Beano (which contains the alpha-galactosidase enzyme) before eating high-FODMAP foods to see if it cuts down on your gas.
Ultimately, experts say that figuring out the best eating pattern for your gut is the best treatment for a fructan intolerance. "This isn't treated, really—it's about finding the balance that works for your body," Dr. Stein says.
When to see a healthcare providerThere is no standardized test for fructan intolerance, but research suggests that a hydrogen breath test may help properly diagnose you.8 This is a common test administered by your healthcare provider to determine things like lactose intolerance, as it detects the level of hydrogen gas in your breath resulting from poor digestion.
Still, if your gut health is interfering with your ability to go through your day comfortably, it's time to get checked out. "Gas, bloating, constipation, and diarrhea are not normal," Malone says. A healthcare provider can give you a full evaluation to see if your symptoms may be caused by fructan intolerance or something completely different—and set you on the path to wellness from there.
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Common Food Allergy Triggers
Dip into hot salsa or spicy Indian food, and your nose starts running. Beans give you gas, or a glass of wine means a headache later. If you're lactose intolerant, you expect diarrhea when you eat cheese or milk.
Most people have reactions to foods like these from time to time. But they're usually food sensitivities or intolerances. They aren't caused by your immune system.
A food allergy is different. Your body mistakes harmless food as something that could make you sick. When you eat something you're allergic to, your immune system responds to protect you. You might get a mild skin rash or itchy eyes, or you could have a bigger reaction that leaves you gasping for breath.
Food allergies can be serious, but you can take steps to manage them. One of the best things you can do is avoid your trigger foods.
Nine things cause more than 90% of food allergy reactions:
Almost any food can trigger an allergy, though. Less common ones include:
An allergic reaction can happen within minutes of eating, or it may happen hours later.
Mild symptoms can be hard to tie to specific foods. You could get:
Most often, peanuts, nuts, fish, and shellfish cause severe reactions, although any food can. Symptoms include:
Because young children may not know how to describe what's happening, they might say something like, "My mouth is tingling," "My tongue feels heavy," or "I've got a frog in my throat." A hoarse or squeaky voice or slurring words are also signs of an allergic reaction in kids.
Sometimes symptoms affect your whole body and are so serious that they're life-threatening. This kind of reaction is called anaphylaxis, and it's a medical emergency. It usually happens a few minutes after you've eaten. If you have asthma as well as a food allergy, you're more likely to have anaphylaxis.
If you have a severe food allergy, always carry at least two doses of epinephrine (adrenaline) in case you have a reaction. Don't hesitate to use your epinephrine auto-injector or nasal spray even if you're unsure whether your symptoms are caused by an allergy. The epinephrine won't hurt you and could save your life. If your symptoms don't ease quickly and completely after you use epinephrine, if they're severe, or if you don't have a second dose on hand, call 911.
For highly allergic people, even tiny amounts of a food (for example, 1/44,000 of a peanut kernel) can set off a reaction. Less sensitive people may be able to eat small amounts of their trigger food.
The key to controlling a food allergy? Avoid the problem food. That isn't always easy, though. It may be hidden as an ingredient in something else.
So, be sure to read food labels. That's a good place to start.
Still, labels don't always tell the whole story. For example, pineapple, milk casein, or hydrolyzed soy protein may be used in microwave popcorn -- yet you won't see them on the ingredient list. You'll see the catch-all terms "flavoring" or "natural flavoring" instead. Words like "emulsifier" or "binder" can signal soy or egg in the product.
When you have a food allergy, you need to get familiar with these general terms and what specific things they can include. If you have questions about any product, check with the manufacturer. The customer service department or the quality assurance officer should be able to help you figure out if the food is safe for you.
You'll need to read menus at restaurants carefully, too. Ask about how food is prepared before you order if you have any concerns.
How The Low Histamine Diet Works And What To Eat
The low histamine diet may help people who develop symptoms, such as sneezing, itching, or hives, in response to foods that contain histamine.
Histamine is a chemical that occurs naturally in the body and in some foods. The low histamine diet can help a person find out which foods cause their symptoms. By avoiding those foods, they may see an improvement. A nutrition professional can guide someone through this process.
This article looks at how histamine affects the body, what histamine intolerance is, and the foods people may wish to avoid. It also provides an example meal plan and tips for grocery shopping and food preparation.
Histamine is a chemical that regulates the body's response to foreign substances and injury.
When the body reacts to a substance it perceives as harmful, it releases histamine. This causes inflammation and dilates a person's blood vessels, leading to symptoms such as:
Despite the discomfort these symptoms can cause, histamine plays an important and complex role in the body's defenses. A 2018 review describes histamine as having a 'paradoxical nature', as it can both increase and decrease inflammation levels.
Some people develop symptoms in response to foods that contain or release histamine. Doctors call this condition histamine intolerance.
The symptoms of histamine intolerance are similar to that of an allergic reaction and can affect multiple systems in the body.
Diamine oxidase (DAO) is the enzyme that breaks down histamine in the body. People with lower levels of DAO have higher histamine levels and, therefore, may be more likely to develop allergies.
The impact of histamine varies depending on age, sex, and genetics. The gut lining and gut flora also seem to play a role in histamine intolerance. For example, a 2018 study compared people with histamine intolerance to those with food intolerances, and others with no intolerances at all. The group with histamine intolerance had lower bacterial diversity in their gut and an impaired gut lining.
The low histamine diet aims to reduce the symptoms of histamine intolerance and allergies. There is limited evidence to suggest the diet may be helpful for some people.
A small 2018 study showed that a 4-week low-histamine diet helped reduce symptoms in adults with hives.
However, more high quality studies on histamine intolerance to better understand the condition and the best treatments.
Alternatives
There is no one-size-fits-all approach to nutrition, and an individualized approach to diet is often best for people with intolerances, including histamine intolerances.
Factors such as medication, stress levels, and overall health affect what works for them.
Research in 2017 recommended a phased approach to the diet. This entails 10 to 14 days of avoiding histamine foods, followed by up to 6 weeks of reintroducing foods. This allows someone to determine their histamine tolerance.
Before trying any type of restrictive diet, people should seek expert nutritional counseling to ensure they are getting adequate nutrients, and to avoid an unnecessary reduction in their quality of life.
Freshness impacts the amount of histamine in food. It is a good idea to learn how different methods of production and storage impact histamine levels in food.
How a person shops for and prepares food is also important.
A person with histamine intolerance can monitor and potentially reduce their symptoms by:
Some medications and supplements also influence histamine levels. If a person suspects something they are taking is exacerbating their symptoms, they should speak to their doctor.
A low histamine diet may benefit someone with histamine intolerance. Planning varied meals, avoiding high histamine foods, and allocating time to prepare fresh foods may help a person manage their symptoms.
If someone suspects they may have histamine intolerance, it is essential that they consult their doctor for advice.
People need to ensure that they do not miss out on essential nutrients when following a limited diet. People should not follow long-term exclusion diets without seeking advice from a registered dietitian or nutritionist.
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