On Passover, Jewish families around the world will gather around the Seder table to remember the exodus from Egypt. Central to this meal is matzo: We are taught that when we eat this unleavened bread we should remember the rush out of Egypt, during which there was no time to waste waiting for bread to rise. But when I eat matzo, I also think about my patients.
Giving up bread, even for eight days, is to leave behind staple foods that have been with us for as long as civilization itself. But while those observing Passover can choose to do so with varying degrees of stringency, patients with celiac disease do not have such flexibility, as they are advised to go completely gluten-free forever — or face serious medical consequences.
For all patients with celiac disease who observe Passover, this can be a trying season. People with this autoimmune condition are advised to strictly avoid eating even minute amounts of gluten, which is present in wheat, rye and barley. For some, even taking a few bites of matzo can trigger severe physical discomfort. For others, gluten does not cause symptoms but induces intestinal damage, with downstream consequences for cancer risk and other adverse outcomes.
Giving up products containing gluten may be rational and medically advisable, but it is also a major adjustment. As a physician and researcher who specializes in the treatment of celiac disease, I have seen how difficult the gluten-free diet can be for some patients. In our recently published study of teenagers and adults with celiac disease, my colleague Randi Wolf and I found that people who avoid gluten exposure most vigilantly also tend to have a lower quality of life compared to those with less vigilance.
Observant Jews who have been diagnosed with celiac disease can now fulfill the ritual of eating matzo at the Seder with matzo made from oats, the only one of the five grains which is gluten-free. Previously occupying a small shelf in specialty food shops, gluten-free food is now showcased in supermarkets and appearing on menus in major restaurant chains year-round. Today there is also an unprecedented selection of gluten-free cakes, breads and cereals available during Passover. In part, this is due to the dramatic and unexplained rise in rates of celiac disease in the United States over the past 50 years; the condition is now present in approximately 1 percent of the United States population.
Despite this progress, sticking to a gluten-free diet remains difficult. Gluten can be found everywhere, including such unlikely sources as soy sauce and nutritional supplements. So being on a gluten-free diet requires constant vigilance. People with celiac disease by necessity become experts at reading food labels and making inquiries regarding ingredients. It’s a similar kind of vigilance with which observant Jews avoid leavened products during Passover, but it’s not a holiday — it’s a necessary lifestyle overhaul.
In the Torah, matzo is referred to as “lechem oni,” a pauper’s bread. Eating matzo during this time of celebration and grandeur brings us back to earth, and teaches us to be humble. I have to change what I eat for an eight days, the length of this festival. But when patients are diagnosed with celiac disease, they are prescribed a restricted diet for life, or until a cure is developed. Those observing this festival should use the experience to empathize with those for whom a dietary change is a medical necessity all year round.