Is Wheat Good for Gut Health? What the Science Says

Is wheat good for gut health? Learn how whole grains provide prebiotic fibre to fuel your microbiome and why processing matters for your digestive wellbeing.

Blue Horizon Team

Introduction

It is a familiar scenario across the UK: you finish a lunchtime sandwich or a bowl of pasta, and within an hour, your stomach feels uncomfortably tight, swollen, or sluggish. In recent years, wheat has gone from being a staple of the British diet to one of the most debated foods on our supermarket shelves. Social media feeds and wellness trends frequently label wheat as inherently inflammatory, while conventional dietary guidelines continue to champion whole grains as essential for maintaining healthy digestion.

This conflicting information leaves many people wondering where the truth lies. Is wheat genuinely good for your digestive system, or is it a hidden driver of gastrointestinal discomfort?

This article explores the relationship between wheat and digestive wellbeing. We will examine what happens inside your digestive tract when you eat wheat, how different types of wheat affect the gut microbiome, why some individuals experience uncomfortable symptoms, and how to tell whether wheat is serving your body well.

At Blue Horizon, our doctor-led team has spent years helping people make sense of complex, overlapping symptoms. We believe that lasting digestive wellbeing requires a calm, methodical approach rather than sudden dietary extremes. The safest and most effective path begins with consulting your GP to rule out underlying medical conditions, followed by structured self-observation, and then—if needed—using targeted health markers to understand your overall physiological picture.

Understanding the Anatomy of Wheat

To understand how wheat influences digestion, we must first look at what a grain of wheat actually is. In its natural, unrefined state, a wheat kernel (or wheat berry) consists of three distinct anatomical sections, each offering a specific nutritional profile:

  • The Bran: This is the hard, protective outer shell of the kernel. It contains the majority of the grain's dietary fibre, alongside B vitamins, trace minerals (such as iron, zinc, and magnesium), and bioactive plant compounds known as polyphenols.
  • The Germ: The tiny embryo at the core of the seed that has the potential to sprout into a new plant. It is rich in vitamin E, essential fatty acids, B vitamins, and plant antioxidants.
  • The Endosperm: The largest part of the kernel, acting as the food storage supply for the sprouting seed. It consists predominantly of starchy carbohydrates and storage proteins, including gliadin and glutenin (which together form gluten).
   +-------------------------------------------------------+
   |                  ANATOMY OF A WHEAT KERNEL            |
   +-------------------------------------------------------+
   | 1. BRAN (Outer Shell)                                 |
   |    - High in insoluble & prebiotic fibre              |
   |    - B vitamins, trace minerals, & polyphenols        |
   |                                                       |
   | 2. ENDOSPERM (Middle Layer)                           |
   |    - Starchy carbohydrates & energy supply            |
   |    - Contains gluten proteins (gliadin & glutenin)    |
   |                                                       |
   | 3. GERM (Inner Core)                                  |
   |    - Nutrient-dense embryo                            |
   |    - Vitamin E, B vitamins, & essential healthy fats  |
   +-------------------------------------------------------+

Whole Wheat Versus Refined Wheat

The primary reason wheat causes so much confusion in gut health discussions is that "wheat" can refer to two entirely different foods: intact whole wheat and ultra-processed refined white flour.

When wheat is refined to produce white flour, modern milling techniques mechanically strip away the bran and the germ, leaving only the starchy endosperm. While this creates a soft texture and extends shelf life, it removes up to 80% of the dietary fibre and a substantial proportion of essential vitamins and minerals.

From a gut perspective, refined wheat behaves largely as a rapid source of simple starch. It is broken down quickly in the upper digestive tract, providing little nourishment for the trillions of beneficial microbes residing further down in the large intestine.

Whole wheat, by contrast, retains all three layers in their natural proportions. Because the fibre and complex carbohydrates remain intact, whole wheat moves through the digestive tract at a steadier pace, delivering valuable substrates directly to your gut bacteria. For more practical guidance, you can explore this guide to digestive wellness.

How Wheat Interacts with the Gut Microbiome

Within your large intestine lies a vast, complex ecosystem of trillions of bacteria, yeasts, and other microorganisms collectively known as the gut microbiota. A diverse and well-nourished microbiome plays a central role in human health, helping to regulate digestion, support the immune system, modulate inflammation, and even influence mood via the gut-brain axis.

For the vast majority of people without specific medical conditions, whole-grain wheat is not merely harmless—it serves as an effective fuel source for these beneficial microbes.

Prebiotic Fibre and Bacterial Fermentation

Humans lack the digestive enzymes required to break down certain complex plant carbohydrates. These non-digestible fibres pass through the stomach and small intestine relatively untouched until they reach the colon.

When dietary fibres reach the large bowel and actively stimulate the growth or activity of beneficial bacteria, they are classified as prebiotics. Whole wheat is naturally rich in several prebiotic compounds:

  • Arabinoxylans: The primary dietary fibre found in wheat bran, making up a significant portion of its cell walls.
  • Resistant Starch: A form of starch that resists conventional enzymatic digestion in the small intestine.
  • Inulin-type Fructans: Chains of fructose molecules that beneficial bacteria can ferment rapidly.

When beneficial bacterial strains (such as Bifidobacterium and Lactobacillus) encounter these prebiotic fibres, they begin a metabolic process called fermentation.

Key Takeaway: Prebiotic fibres in whole wheat act as essential fuel for your resident gut bacteria, encouraging the growth of beneficial species and suppressing potentially harmful microbes.

The Power of Short-Chain Fatty Acids (SCFAs)

The primary byproduct of bacterial fibre fermentation is a group of compounds called Short-Chain Fatty Acids (SCFAs). The three most prominent SCFAs are acetate, propionate, and butyrate.

These small molecules have profound effects on gut integrity and overall health:

  • Butyrate: Acts as the primary energy source for the cells lining your colon (colonocytes). It helps maintain the structural integrity of the gut barrier, supports the production of protective mucus, and regulates local inflammatory pathways.
  • Propionate: Absorbed into the bloodstream and carried to the liver, where it plays a role in regulating glucose production and lipid metabolism.
  • Acetate: The most abundant SCFA, which travels to peripheral tissues and contributes to energy regulation and central appetite control.

By supporting regular SCFA production, the dietary fibre in whole wheat helps maintain a mildly acidic gut pH. This acidic environment creates ideal living conditions for friendly bacteria while making it difficult for pathogenic organisms to take hold.

+--------------------------+
|  Whole Wheat Consumption |
+-------------+------------+
              |
              v
+--------------------------+
|   Prebiotic Fibres Reach |
|   the Large Intestine    |
+-------------+------------+
              |
              v
+--------------------------+
|  Bacterial Fermentation  |
|  (Bifidobacteria, etc.)  |
+-------------+------------+
              |
              v
+--------------------------+
|  Production of SCFAs     |
| (Butyrate, Propionate)   |
+-------------+------------+
              |
              v
+-------------------------------------------------------+
|  Health Benefits:                                     |
|  - Strengthened gut lining & mucus production         |
|  - Optimised colonic pH & suppression of pathogens    |
|  - Support for normal metabolic & immune pathways     |
+-------------------------------------------------------+

Stool Bulking and Bowel Motility

Beyond microscopic microbial effects, whole wheat plays a mechanical role in digestive comfort. The insoluble fibre in wheat bran draws water into the stool, increasing its bulk and softening its texture. This promotes regular peristalsis (the wave-like muscle contractions of the bowel) and helps prevent constipation.

Large-scale observational studies consistently associate higher intakes of cereal fibre with improved bowel transit times, lower rates of diverticular disease, and a reduced long-term risk of colorectal malignancies.

The Digestive Dilemma: Why Wheat Affects People Differently

If whole wheat possesses these clear nutritional benefits, why do so many people report bloating, cramping, irregular bowel habits, and lethargy after eating it?

The answer lies in the complex composition of the grain, individual variations in gut function, and how the modern food industry processes cereal crops.

1. Fructans and Fermentable Carbohydrates (FODMAPs)

Wheat contains chains of fructose carbohydrates known as fructans. Fructans belong to a broader group of dietary compounds known as FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols).

In a healthy, resilient digestive tract, the fermentation of fructans produces beneficial SCFAs with minimal discomfort. However, in individuals with visceral hypersensitivity or Irritable Bowel Syndrome (IBS), this process can cause significant distress:

  • Fructans draw extra water into the small intestine via osmosis.
  • As they enter the large bowel, gut bacteria ferment them rapidly, producing gases such as hydrogen, carbon dioxide, and methane.
  • In someone with a sensitive nervous system in the gut, the resulting expansion of the bowel wall triggers sharp pain, bloating, and altered bowel motility (diarrhoea or constipation).

In these instances, the discomfort is not caused by permanent tissue damage or toxic effects; rather, it is a functional reaction to rapid gas production and fluid shifts.

2. Gluten and Complex Protein Digestion

Gluten is the composite name for the storage proteins found in wheat, barley, and rye. It gives bread dough its elasticity and chewiness.

Gluten is unusually rich in the amino acids proline and glutamine. The human digestive tract does not possess the specific enzymes needed to completely cleave these tight peptide bonds. As a result, gluten is broken down into smaller protein fragments (peptides) rather than individual amino acids.

In the vast majority of individuals, these undigested peptides pass through the digestive tract harmlessly and are excreted. However, in genetically predisposed individuals, these fragments can interact with the immune system or the intestinal lining in unexpected ways.

3. Naturally Occurring Plant Compounds: Lectins and Phytates

Like all plants, grains contain natural defensive compounds designed to protect the seed from insects and microbial pests:

  • Wheat Germ Agglutinin (WGA): A type of lectin found predominantly in the germ. In experimental laboratory settings using isolated, raw cells, high concentrations of lectins can irritate cell membranes. In real-world human diets, however, cooking, baking, boiling, and commercial processing deactivate the vast majority of lectins, making them of negligible concern for most people.
  • Phytic Acid (Phytate): An antioxidant storage form of phosphorus in the bran that can bind to minerals like iron, zinc, and calcium, mildly reducing their absorption. While this is sometimes termed an "anti-nutrient", phytates also exert beneficial antioxidant and anti-inflammatory actions within the colon. Traditional grain preparation methods—such as long sourdough fermentation, soaking, and sprouting—naturally break down phytic acid, making the underlying minerals more bioavailable.

4. Modern Processing and Additives

Much of the wheat consumed in the UK is found in ultra-processed commercial breads, pastries, and convenience foods. These products are often made using accelerated industrial baking methods (such as the Chorleywood Bread Process) that bypass traditional long fermentation times.

Furthermore, processed wheat products frequently contain added sugars, emulsifiers, preservatives, and saturated fats. In many cases, digestive distress attributed to "wheat" may actually be a reaction to the high fat content, emulsifiers, or rapid transit of ultra-processed food formulations, rather than the wheat grain itself.

+-------------------------------------------------------------------------+
|                WHY WHEAT AFFECTS INDIVIDUALS DIFFERENTLY                |
+-------------------------------------------------------------------------+
| Factor                | Mechanism                   | Typical Symptom   |
+-----------------------+-----------------------------+-------------------+
| Fructans (FODMAPs)    | Rapid bacterial             | Bloating, gas,    |
|                       | fermentation & water draw   | abdominal pain    |
+-----------------------+-----------------------------+-------------------+
| Gluten Peptides       | Incomplete enzymatic        | Variable; immune  |
|                       | breakdown                   | triggers in some  |
+-----------------------+-----------------------------+-------------------+
| Processing Style      | Ultra-processed recipes     | Sluggish transit, |
|                       | with additives/emulsifiers  | general discomfort|
+-----------------------+-----------------------------+-------------------+
| Sourdough vs Fast Bake| Lack of fermentation to     | Increased heavy   |
|                       | pre-digest starches/phytates| sensation in gut  |
+-------------------------------------------------------------------------+

Clinical Distinctions: Medical Reasons to Avoid or Limit Wheat

When evaluating whether wheat is good for your personal digestive health, it is essential to distinguish between general functional tolerance and distinct medical conditions.

Coeliac Disease

Coeliac disease is a serious, lifelong autoimmune condition that affects roughly 1 in 100 people in the UK. In people with coeliac disease, consuming gluten triggers an abnormal immune response that causes the immune system to attack and damage the delicate, finger-like lining of the small intestine (the villi).

When the villi become flattened and inflamed, the body cannot absorb nutrients efficiently, which can lead to complications such as:

  • Iron-deficiency anaemia
  • Osteoporosis and poor calcium absorption
  • Unexplained weight loss and chronic fatigue
  • Persistent diarrhoea, malabsorption, or steatorrhoea (pale, foul-smelling stools)
  • Peripheral nerve tingling or neurological symptoms

For anyone with coeliac disease, wheat is directly harmful to gut health and must be strictly and permanently avoided across all food sources, preparation surfaces, and cooking utensils.

Important Clinical Rule: If you suspect you have coeliac disease, it is critical that you do not remove wheat or gluten from your diet before speaking with your GP. Standard diagnostic blood tests (which look for specific antibodies) rely on the ongoing presence of gluten to produce an accurate result.

Non-Coeliac Wheat Sensitivity

Some individuals experience noticeable gastrointestinal symptoms (such as bloating, abdominal pain, and bowel changes) alongside extra-intestinal symptoms (like brain fog, joint aching, or fatigue) when eating wheat, despite testing negative for coeliac disease.

Research into this area is ongoing. While previously assumed to be purely a reaction to gluten, recent scientific evidence suggests that other wheat components—such as amylase-trypsin inhibitors (ATIs) or fructans—may trigger low-grade mucosal immune responses or functional sensitivity in certain people.

Red Flag Symptoms Requiring Urgent Review

While occasional mild bloating after a heavy meal is common, digestive symptoms should never be ignored if they are persistent, progressive, or accompanied by warning signs.

Consult your GP promptly if you experience:

  • Unintentional, unexplained weight loss
  • Visible blood in your stool or black, tarry stools
  • A persistent change in your bowel habit lasting more than four to six weeks (especially if aged 50 or older)
  • Unexplained, severe fatigue or pale complexion (signs of potential anaemia)
  • A palpable lump or persistent pain in your abdomen
  • Difficulty swallowing or persistent vomiting

Safety Note: If you ever experience sudden, severe symptoms such as swelling of the lips, tongue, or throat, difficulty breathing, or collapse, seek emergency medical attention immediately via 999 or your nearest A&E department.

The Broader Health Picture: Nutrient Absorption and Systemic Balance

Gut health does not exist in isolation. The state of your digestive lining and the efficiency of your digestion directly influence your systemic health, metabolic vitality, and nutritional reserves.

When your digestive tract is inflamed, overburdened, or unable to absorb nutrients properly, you may experience symptoms that seem entirely unrelated to the gut, such as lethargy, low mood, poor exercise recovery, or brittle hair and nails.

+-----------------------------------------------------------------+
|                  THE SYSTEMIC GUT CONNECTION                    |
+-----------------------------------------------------------------+
|   Digestive Tract Function & Microbial Health                   |
|   |                                                             |
|   +--> Nutrient Absorption (Iron, B12, Folate, Vitamin D)       |
|   |                                                             |
|   +--> Systemic Inflammation Regulation (Immune Balance)        |
|   |                                                             |
|   +--> Metabolic & Hormonal Modulation (Thyroid & Energy)       |
+-----------------------------------------------------------------+

Key Micronutrients and Blood Markers

If you have been experiencing ongoing digestive discomfort or lingering fatigue, evaluating specific blood markers with your healthcare provider can provide objective insight into how well your body is absorbing and utilising essential nutrients:

  • Ferritin: The primary storage protein for iron in the body. Low ferritin levels often point to poor absorption in the upper small intestine or insufficient dietary intake, resulting in fatigue and breathlessness before full anaemia appears on a standard blood count.
  • Active Vitamin B12 and Folate: Essential water-soluble B vitamins responsible for red blood cell production, cellular repair, and neurological health. They require healthy stomach acid and a functional intestinal lining to be absorbed effectively.
  • Vitamin D (25-OH): A fat-soluble vitamin and immune-modulating hormone. Adequate vitamin D levels are important for maintaining intestinal epithelial barrier integrity and regulating mucosal immune responses.
  • C-Reactive Protein (CRP): A sensitive protein produced by the liver that rises in response to systemic inflammation. While non-specific, it helps doctors evaluate whether an inflammatory process is occurring in the body.
  • Magnesium: An essential mineral cofactor involved in over 300 biochemical reactions, including muscle contraction, nerve transmission, and bowel regularity.

Hormonal and Metabolic Overlap

Persistent digestive symptoms can sometimes overlap with or be exacerbated by systemic endocrine imbalances. For example, an underactive thyroid gland (hypothyroidism) significantly slows down gastrointestinal motility, frequently causing chronic constipation, sluggish digestion, weight gain, and profound fatigue.

Evaluating thyroid function markers—such as Thyroid Stimulating Hormone (TSH), Free T4, and Free T3—can help clarify whether low energy and slow bowels stem from a primary digestive issue or a wider metabolic slowdown. You can read more about what thyroid blood tests are used for.

Navigating Wheat in Your Diet: The Blue Horizon Method

Determining whether wheat is beneficial for your individual gut health does not require guessing or jumping straight to restrictive diets. We recommend following a structured, clinically responsible four-step pathway.

+-------------------------------------------------------------+
|                 THE BLUE HORIZON METHOD                     |
+-------------------------------------------------------------+
|  Step 1: Consult Your GP                                    |
|          Rule out coeliac disease and underlying pathology. |
|                                                             |
|  Step 2: Structured Self-Tracking                           |
|          Keep a 14-day symptom, food, and lifestyle diary.  |
|                                                             |
|  Step 3: Mindful Dietary Optimisation                       |
|          Prioritise traditional, high-fibre, unrefined grain.|
|                                                             |
|  Step 4: Targeted Pathology Snapshot                        |
|          Use blood markers to check systemic nutrient stores.|
+-------------------------------------------------------------+

Step 1: Consult Your GP First

The foundation of any health journey must always be professional clinical assessment. If you are experiencing persistent digestive issues, schedule an appointment with your GP.

Your GP can perform essential clinical rule-outs, conduct a physical examination, and arrange standard NHS screening tests—such as a coeliac serology panel—before any dietary modifications are introduced. This ensures that serious conditions are not missed or obscured.

Step 2: Structured Self-Tracking

If clinical investigations do not identify a specific disease, the next step is to observe your everyday habits carefully. Keep a detailed food, lifestyle, and symptom diary for 14 days, noting:

  • What you ate, including the specific type of wheat (e.g., commercial white sliced bread, authentic sourdough, wholemeal pasta, or bulgur wheat)
  • The timing of your meals
  • Any symptoms experienced (bloating, wind, cramping, energy slumps, headaches), noting the severity and how many hours after eating they occurred
  • Lifestyle factors, including your sleep duration, fluid intake, and daily stress levels

Stress has a powerful, direct effect on gut motility and digestive enzyme secretion via the nervous system. Often, symptoms that appear to be caused by a specific food only occur when eating rapidly or under high stress.

Step 3: Mindful Dietary Optimisation

If you and your doctor establish that wheat is safe for you to consume, you can make simple adjustments to help your gut digest it comfortably:

  • Choose Whole and Ancient Grains: Opt for 100% whole-grain wheat, spelt, farro, or bulgur wheat over refined white flour to maximise prebiotic fibre intake.
  • Explore Traditional Sourdough: Authentic sourdough undergoes a slow, natural fermentation process using wild yeasts and lactobacilli. This pre-digests some of the starches, reduces fructan levels, and breaks down phytic acid, often making it much gentler on sensitive digestive systems.
  • Build Dietary Diversity: Avoid relying solely on wheat for your carbohydrate intake. Incorporate a wide variety of other fibre-rich plants and grains—such as oats, brown rice, quinoa, buckwheat, lentils, and root vegetables—to feed different families of beneficial gut bacteria.
  • Increase Fibre Gradually: If your current diet is low in fibre, introduce whole-grain wheat slowly over several weeks while drinking plenty of water to give your microbiome time to adapt.

Step 4: Targeted Pathology Testing

If you have addressed basic lifestyle factors, ruled out conditions with your GP, but still feel fatigued, run down, or uncertain about your nutritional status, an objective blood test panel can provide a helpful physiological snapshot.

At Blue Horizon, we provide doctor-led, private blood testing to help you gather clear information for discussion with your GP or healthcare specialist.

For those looking to assess nutritional foundations, inflammatory markers, and systemic balance, our thyroid blood test collection offers clear, tiered options:

  • Bronze: Covers base thyroid hormones (TSH, Free T4, Free T3) alongside our unique Blue Horizon Extra markers (cortisol and magnesium) to evaluate stress and metabolic baseline.
  • Silver: Includes everything in Bronze, adding thyroid antibody markers (TPOAb and TgAb) to check for autoimmune thyroid patterns.
  • Gold: Combines the comprehensive Silver panel with essential nutritional and inflammatory markers, including Ferritin, Folate, Active Vitamin B12, Vitamin D, and CRP. This tier provides a detailed snapshot of both metabolic regulation and key micronutrient absorption.
  • Platinum: Our most comprehensive metabolic panel, combining the Gold markers with Reverse T3, HbA1c, and a full iron panel (Total Iron, Transferrin Saturation, TIBC, UIBC).

For a focused starting point, you can review the Thyroid Premium Bronze profile. For the most comprehensive option, explore the Thyroid Premium Platinum profile.

Bronze, Silver, and Gold tests can be completed conveniently at home using a fingerprick sample kit or a Tasso device, or via a phlebotomy clinic visit. Platinum profiles require a professional venous blood draw due to the advanced panel size. We generally recommend taking thyroid and metabolic blood samples around 9am to ensure consistency with your body's natural diurnal hormone rhythms.

Clinical Reminder: Blood test results from Blue Horizon provide an objective snapshot to guide constructive conversations with your GP or registered specialist. They are not a standalone diagnosis or a substitute for medical care.

Conclusion

So, is wheat good for gut health? From a biological and nutritional perspective, the answer for most people is yes—provided it is consumed as intact whole grain rather than ultra-processed white flour.

Whole-grain wheat delivers essential prebiotic fibres, including arabinoxylans and resistant starches, that feed beneficial gut bacteria and stimulate the production of health-promoting Short-Chain Fatty Acids like butyrate. These compounds support the intestinal barrier, promote regular bowel motility, and contribute to long-term metabolic health.

However, wheat is not universally tolerated. For individuals with coeliac disease, it causes autoimmune intestinal damage and must be strictly avoided. For those with Irritable Bowel Syndrome or functional sensitivities, the rapid fermentation of fructans can trigger uncomfortable bloating and pain.

If you are struggling to make sense of your digestive health, avoid extreme elimination diets that risk compromising your nutritional intake. Instead, follow a calm, structured approach: speak with your GP first to rule out underlying medical conditions, maintain a lifestyle diary to identify functional triggers, choose unrefined and traditionally prepared grains, and consider targeted pathology testing if you need a clearer picture of your internal health.

FAQ

Does eating wheat cause a "leaky gut"?

In healthy individuals without coeliac disease, there is no strong clinical evidence that consuming whole-grain wheat as part of a balanced diet causes permanent intestinal permeability (often referred to as leaky gut). While gluten contains gliadin—a protein fragment that can temporarily interact with zonulin pathways in the gut lining—a resilient digestive tract regulates this process naturally. For people with coeliac disease, however, gluten triggers an autoimmune reaction that actively damages the intestinal lining.

Why can I digest sourdough bread better than standard supermarket bread?

Traditional sourdough bread is made using a slow fermentation process that relies on wild yeasts and lactic acid bacteria over many hours. This extended fermentation allows natural enzymes to partially break down gluten proteins, ferment a portion of the hard-to-digest fructans (FODMAPs), and degrade phytic acid. In contrast, mass-produced commercial bread uses rapid chemical raising agents and short proving times, leaving these components intact and potentially harder for sensitive digestive systems to process.

Is whole-wheat pasta better for gut health than white pasta?

Yes, whole-wheat pasta is generally much better for supporting gut microbiota health. Whole-wheat pasta contains the bran and germ of the grain, providing significantly higher amounts of dietary fibre, B vitamins, and trace minerals. The insoluble and prebiotic fibres in whole-wheat pasta slow down digestion, support smooth bowel transit, and serve as valuable fuel for beneficial colonic bacteria, whereas refined white pasta acts primarily as a rapid source of simple starch.

Should I cut out wheat completely if I suffer from daily bloating?

You should not cut out wheat completely before speaking to your GP. Bloating can be caused by many different factors, including meal pacing, stress, swallowing air, hormonal fluctuations, or specific medical conditions. It is essential to keep wheat in your diet while your doctor tests for conditions like coeliac disease, as eliminating gluten beforehand can cause false-negative test results. If medical causes are ruled out, a structured approach with a healthcare professional can help you identify whether specific portion sizes, preparation styles, or high-FODMAP foods are contributing to your symptoms.