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Melanie Cole (Host): A number of gastrointestinal conditions involve allergic reactions or intolerances to various foods. And these can pose serious problems for the millions who suffer from them. My guest today is Dr. Robert Shmuts. He’s a gastroenterologist with Lourdes Medical Center of Burlington County. Dr. Shmuts what is the difference between a food intolerance and an allergy?

Robert Shmuts, DO (Guest): Sure, well an allergy in terms of a food allergy is when there is an actual antibody, when there is an actual reaction that someone’s body is forming against a particle or food whereas an intolerance is different in the sense that if someone does not produce an antibody where their body actually has a quantifiable, measurable reaction to a substance but where for sometimes reasons that we haven’t completely discovered; that their body whether it’s because of the bacteria makeup of their digestive tract, whether it’s some type of genetic either marker or intolerance that we have yet to be able to identify, they are unable to tolerate that substance.

Melanie: So, then what do people feel? What are the symptoms? Because we all get bloated from time to time and we all feel full or have some of these nauseous feelings, but how do you know if it’s an intolerance or an allergy or something more severe?

Dr. Shmuts: Exactly. And that can be very difficult and that’s why presenting to a gastroenterologist could be a very important step in trying to flush this out. Because like you said, bloating, nausea, sometimes diarrhea, sometimes feeling fatigued, a vague rash. A lot of times, people may have one of those things and sometimes people present to their gastroenterologist and they are surprised when we start asking questions about those types of manifestations of a problem, because sometimes we don’t even think that that’s linked to what’s going on. And that’s why presenting to a gastroenterologist for these kinds of issues is important because when you sit down with a gastroenterologist and they are able to parse out along with you what particular foods might be bothering you, what particular symptoms you might be having. That kind of helps narrow it down and then sometimes that coupled either with things like food journals, bloodwork, biopsies of the digestive tract to really flush out what is the issue. Is it an allergy? Is it an intolerance? Is there maybe something else going on? Sometimes it isn’t the digestive tract but oftentimes that needs to be excluded before you could start thinking about other areas.

Melanie: So, let’s talk about some of the specific conditions. We have all heard about lactose intolerance. We are hearing so much in the media about gluten and even the word celiac pops ups. Tell us what these are and what are some of the specifics of them and then we will get into some of the treatments.

Dr. Shmuts: Sure. So, lactose intolerance has been around for quite a while, it’s very well known and it’s out there. Lactose intolerance you can either be a primary lactose intolerant person, you could be a secondary lactose intolerant person. Some folks are born lactose intolerant which is not the same as when you hear about infants who have like a milk intolerance. Milk intolerance in infants oftentimes they will outgrow, not always, but most often. But there are some folks even from an early age who are not able to handle dairy products and those people who are secondary lactose intolerant folks, people who develop it over a period of time; those are the folks who lose their lactase, their brush border enzyme which is by far and away, the more common lactose intolerance and those are – like I said, those are people who lose their ability to tolerate lactose coming into their system. Now something like lactose intolerance oftentimes can be diagnosed multiple different ways. Sometimes folks will come in already saying listen, I looked into this and when I had all these symptoms of bloating or nauseousness or diarrhea and then I cut dairy out of my diet and then I felt better. Sometimes that’s enough to say, you know what, it seems like it’s lactose intolerance. Sometimes people need further testing. They can have what we call breath testing where we do that in an office setting where we are trying to see if the patient develops symptoms to a lactose load that they drink. Sometimes we will do biopsies where we are looking at the brush border in the small intestine. So, once that is established, once you go through the gastroenterologist; then you can talk about ways to deal with that. Sometimes folks who are secondary lactose intolerant individuals can handle certain dairies. They might be able to handle hard cheeses but not soft cheeses. They might be able to handle frozen yogurt but not ice cream. But that’s something that needs to get flushed out in collaboration with the doctor.

Now, celiac disease which is like you were saying very much out there right now and everyone is talking about it. Really, when we talk about celiac disease, we should talk about celiac disease and also gluten sensitivity. Celiac disease is the recognized disease where folks develop antibodies to gluten. And these can be measured in the bloodwork. So when individuals come in with symptoms where I’m concerned about celiac disease we are sending off bloodwork, testing for these antibodies. These can then be followed up with biopsies of the small intestines looking for specific things in the biopsies that supported a diagnosis of celiac disease. Likewise, these individuals will respond to gluten free diet, however, sometimes what you will come across is an individual will come in, you will go through let’s say a food journal with them and it will seem like gluten seems to play a big role in their symptoms. But you might do bloodwork and they don’t come back positive for celiac antibodies. You may even do biopsies and they don’t show evidence of celiac disease on the biopsies, but they respond to this gluten free diet and in the GI literature, we are recognizing that there is something called gluten insensitivity and part of this is that maybe we don’t have all the information yet. Maybe there is some type of genetic material abnormality that science has gotten to the point where we are able to test and quantify that. Maybe there is something genetic going on in the individual but what we do recognize is there are a lot of people out there that will respond to a gluten free diet who may not come back as a celiac patient.

Melanie: So, then let’s talk about treatment options. As you have said, gluten avoidance or certain dairies, I mean knowing your triggers would certainly seem to be the most important part of this. But it can often be very difficult to go out to dinner, to parties. What do you tell patients about these treatment options and managing whatever it is that they have got as far as food intolerance or sensitivity or celiac?

Dr. Shmuts: In terms of trying to counsel patients on that. The first and most important thing that I can do as a provider is be empathetic. Because I totally get this question and I deal with it probably on a daily basis. It can be sometimes very cumbersome. It can be very difficult. Someone’s having a graduation party, or you are going to a wedding and you are worried that you are going to show up and are you going to need to know where all the bathrooms are, you are going to have to take an Imodium or something before you go and it can be very difficult. The first and second job I probably have is as a treating physician to these individuals is to be empathetic. I understand. The best thing we can try and do is to try and modify the diet, to make arrangements where and how you can. When you cannot, to try and have contingency plans, back up plans. In terms of something like lactose intolerance; I mean it’s a little bit easier because if you have a secondary lactose intolerant person, they are the individual who might respond to lactose replacement, the lactase enzyme replacement that you can pick up even over the counter at the pharmacy. A lot of individuals will be able to do that including some of my family members. You want to have some ice cream, you pop one of those pills and oftentimes you can enjoy that and not have to have any problems afterwards. Gluten is tougher. Gluten is in a lot of things. I think as a society, even in the last five, ten years, we have gotten a lot better about having gluten free options. But it is difficult. I’m not going to lie.

Melanie: Wow, well it certainly is and it’s something that people are learning to live and manage with and new products on the market and foods that are gluten free and such, but wrap it up for us Dr. Shmuts with your best advice about what life is like for patients and what you tell them about the symptoms and symptom management, getting the proper diagnoses which is certainly very important and what you would like them to know about seeing a gastroenterologist to get this all figured out.

Dr. Shmuts: Of course. What I will tell you is you definitely need to make sure that you find a partner in your care. Oftentimes, when I’m seeing patients it’s a little bit down the road in their journey, oftentimes, I have patients who are coming in who are just fatigued on dealing with their symptoms. They are fatigued on dealing with any stigma and they are tired. And they want someone to understand and they would like some answers. A lot of times, they are frustrated, and I would say that more than half the time, getting the answer, saying to someone this is the problem, now this is where we focus. I have had that conversation with individuals where you can see stress melting away from them and if there is one thing I could say, it’s you got to make sure that you establish a good relationship and that you got to stay on top of things. I mean one of the biggest things I always stress with individuals who come in to see me when they are coming in with these symptoms that we said that can sometimes be nonspecific is keeping journals of the symptoms and what is going on. Because we are saying some of these symptoms are nonspecific nausea, bloating. I mean sometimes you think someone has a food intolerance, sometimes people have irritable bowel syndrome. Sometimes there could be rarer other things going on. So, you need to parse that out. Once that diagnosis is established though, I tend to see that a lot of folks are a lot happier and they are a lot more willing to go about that treatment because if they are seeing that response, if they are doing well and they are feeling well; that fuels them to keep going. What I would say is it’s really important when you are dealing with these symptoms to get in to see a gastroenterologist and myself and the other docs here at Lourdes, we try to have that open dialogue and for patients to feel that they can come in, they can have a real conversation with the doc and we can work together as a team to try and get them answers and get them on to the road feeling better and doing better.

Melanie: Great information and so important. It’s such a big topic in the media today Dr. Shmuts. Thank you so much for sharing your expertise and explaining these food intolerances and sensitivities to us and what treatment options are out there. This is Lourdes Health Talk. For more information please visit www.lourdesnet.org, that’s www.lourdesnet.org. This is Melanie Cole. Thanks so much for listening.