Article produced in collaboration with Stop Intolleranze
With summer arriving and the uptick in social occasions—cocktails, weddings, dinners out—the number of patients presenting to their primary care physician with gastrointestinal symptoms attributed to a presumed food intolerance rises. Bloating or abdominal pain, changes in bowel habits: common signals, yet often non-specific, that complicate clinical assessment and encourage self-diagnosis.
An umbrella term that creates confusion
In everyday language, the term “food intolerances” is used as an indistinct container that includes very different conditions. This leads patients to automatically attribute symptoms to food without real clinical support. Among the foods most commonly implicated are dairy products, often self-eliminateds based on non-specific gastrointestinal symptoms. A choice that, in most cases, does not arise from a diagnosis, but from a subjective link between symptom and food.
The risk of DIY: more harm than benefit
The consequences of DIY approaches are far from negligible. Self-directed elimination diets, particularly those that involve avoiding dairy, represent one of the most widespread examples of an unsupervised approach. Beyond the risk of calcium-related nutrient deficiencies, these choices can trigger real vicious cycles. Prolonged reduction in lactose intake can indeed contribute to a decrease in lactase activity, reinforcing in the patient the belief that they are intolerant. In parallel, self-management can delay the diagnosis of underlying organic diseases, which thus remain unrecognized.
The central role of the PCP in the initial assessment
When faced with a patient who defines themselves as “intolerant,” the approach of the primary care physician must remain structured and based on history taking. It is essential to investigate systematically:
- the type and duration of symptoms
- actual dietary habits
- lifestyle
- possible temporal correlations with specific foods
In particular, it is important to verify whether the symptoms are truly associated with the intake of lactose-containing foods or whether they fit into a broader picture, frequently attributable to functional gastrointestinal disorders, such as small intestinal bacterial overgrowth (SIBO). Additionally, the review of pharmacologic therapy should not be overlooked, considering that some commonly used drugs, like proton pump inhibitors or metformin, can generate overlapping symptoms.
First-step diagnostics: what should not be missing
Before heading toward the hypothesis of intolerance, it is necessary to exclude major organic conditions. In general, basic screening represents an essential step and includes:
- breath tests for lactose, glucose, and lactulose
- celiac disease testing
- fecal calprotectin measurement
- fecal occult blood testing
Only when there are recurrent, persistent symptoms that align with a clinical suspicion is it appropriate to initiate a targeted diagnostic workup. In cases where a specific suspicion emerges, for example lactose intolerance, the pathway can be directed toward assessing malabsorption, while avoiding empiric approaches not supported by clinical evidence.
Diagnostic triggers and red flags
Not all symptoms require immediate in-depth workup. The discriminating criterion remains the repeatability and consistency of the clinical picture. At the same time, recognizing red flags (red flags) that mandate prompt referral to a specialist is essential:
- unintentional weight loss
- gastrointestinal bleeding
- nocturnal symptoms
- new onset in patients who were previously asymptomatic
In the absence of these elements, the pathway can be managed initially in primary care, with a gradual and guided approach, which can steer and support the patient away from self-diagnosis.
From suspicion to diagnosis: the value of the pathway
The summer context, with more frequent non-routine eating occasions, often marks the moment when the patient develops or reinforces the belief that they are intolerant. In reality, in most cases it is a perception not supported by a real clinical assessment. For this reason, the role of the primary care physician is central: avoid diagnostic shortcuts, counter DIY approaches, and bring the patient back into a structured care pathway. Even in the more common conditions, such as suspected lactose intolerance, the goal remains diagnostic confirmation. This is the starting point for appropriate, sustainable, and truly effective long-term management.
Abbonati a Karla Miller
