IBS--Free at Last!

Welcome to IBSFree.net

Ibsfree.net is your resource for low-FODMAPS living. Product reviews, recipes and your questions answered, by Patsy Catsos, a registered, licensed dietitian.  Your comments and questions are most welcome! Please use the comment links at the end of each post for your questions, so that everyone in our community can be part of the conversation.   Patsy's book, IBS--Free at Last!, is available on Amazon.com. In it, you'll find a step-by-step elimination diet, menus, shopping list, and label reading tips to help you learn to manage your irritable bowel syndrome. You could be feeling much better within just a week or two!

Stevia

Stevia, also known as "candyleaf", is a bush native to Central and South America. Extracts from the stevia plant are rapidly appearing in our food supply since the FDA recently recognized the "Generally Recognized as Safe" (GRAS) status of the extract, Reb A. This has raised the question of whether stevia products are allowed on the FODMAPS elimination diet.

Reb-A, the stevia derivative used in most products, is up to 300 times sweeter than sugar. It is used in very minute quantities, and has zero calories. With no sugars or fibers to be malabsorbed or fermented, it cannot be a FODMAP, therefore it is allowed on the FODMAPS elimination diet.

Be aware of what fillers are used in the stevia product, however. Many of the products are designed to be substituted for sugar on an equal volume basis. For example, you are supposed to be able to substitute 1 cup of stevia product for 1 cup of sugar. If less than one percent (1/300th) of the product is stevia, you have to ask yourself, "What is the other 99% of the white fluffy stuff in the measuring cup or packet"? Some of those fillers are definitely fermentable by gut bacteria, and shouldn't be consumed on the elimination phase of your FODMAPS elimination diet. Some manufacturers consider this a plus, and are market the stevia product as "pre-biotic", which translates to "food for gut bacteria". Although this may be fine for most people, in my opinion, IBS sufferers who are sensitive to FODMAPS could potentially experience symptoms when consuming these fillers in large quantities. I'd suggest waiting to try them during the fructans challenge phase of the diet.

If you can locate a stevia product with no fillers, such as a SweetLeaf SteviaClear, you can use it during the elimination phase. You may be able to locate stevia products that are filled with "allowed ingredients". For example, Truvía, manufactured by Cargill, can be used during the elimination phase, as it is filled with erythritol, which is not fermentable by gut bacteria.

Finally, don't forget that foods sweetened with good old-fashioned table sugar and maple syrup are allowed on the elimination phase of the FODMAPS diet. While it isn't necessary to use non-nutritive sweeteners such as stevia on the diet, it is nice to have options.

Update 9/23/09 Sun Crystals with Stevia is another product you can use during the elimination phase of the diet. It's ingredients are pure cane sugar and stevia.

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Fructose Malabsorption and Fructose:Glucose Ratio

What's up with the fructose:glucose ratio? If I experience dietary fructose intolerance, why can I tolerate fructose better if there is an equal amount of fructose in the meal?

First, let's recall the context here: the goal is to manage gastrointestinal symptoms, not to eliminate fructose, per se, from the diet. That's just not necessary (unless one has hereditary fructose intolerance, another subject entirely). Next, recall that high fructose foods include many fruits, honey, and sweetening ingredients such as high fructose corn syrup, crystalline fructose, and fruit juice concentrates.

The ability of the small intestine to absorb fructose is limited, at best. This was less of a problem years ago, when our intake of fructose was also limited! As recently as 30 years ago, the average U.S. intake of fructose was only 2/3 of what is is today, due to changes in the food supply. Imagine the distant past, when honey would have been a rare sweet treat, requiring feats of courage and strength to obtain. Cane or beet sugar and a wide variety of fruits would not have been available to most people in the world, except on rare occasions. Now, our diets contain lots of fructose, although over half of us can't fully absorb a 50 gram serving of fructose. Any time you are eating fructose faster than your personal ability to absorb it, the unabsorbed fructose will be carried on into the large intestine, where it is fermented by the resident bacteria, causing gas, bloating and altered bowel habits.

It appears there are probably two way fructose is absorbed through the cell walls of the small intestine. The first way is a low-capacity type of diffusion, in which a fructose molecule can pass through the cell wall on its own. The second mechanism is transport system that only works when there is one glucose molecule available for every fructose molecule. If there is no glucose-fructose pair, there is no absorption.

This explains why granulated sugar, which contains an equal amount of glucose and fructose is well tolerated in moderation, even by fructose intolerant individuals. Also, fruits such as berries, certain melons, and citrus fruits, which do not have an excess of fructose compared to glucose, can be tolerated in small servings. The fructose intolerant individual could still experience symptoms if very large portions of these "allowed" foods or beverages are consumed.

If you learn that you have dietary fructose intolerance, but would still like to consume high fructose foods, you might be able to do so if  you take a glucose/dextrose tablet along with the food, to improve the fructose:glucose ratio. These inexpensive tablets are sold at your local pharmacy along with diabetic supplies.

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Timing of Symptoms

How long does it take for symptoms to appear after eating an offending food? This interesting question has many answers, depending on the type of adverse food reaction that is occurring. Symptoms of a bona fide IgE-mediated food allergy, to peanuts, for example, are immediate. Many other types of adverse food reactions are delayed for hours, or even days.

Let's talk specifically about IBS symptoms caused by consuming FODMAPS. The adverse food reaction caused by consuming these fermentable and osmotically active carbohydrates takes place in the large intestine. Everyone's "intestinal transit time" is different, but it usually takes at least a few hours, if not overnight, for the remnants of the food you eat to make it to your large intestine. Even for a single individual, transit time is affected by the composition of the meal you ate (just one example, high fat meals empty slow down stomach emptying). Also, because the FODMAPS effects are cumulative, it may be a combination of what you ate over several hours that become enough of a FODMAPS load to cause symptoms.

Given all that, you would expect to experience symptoms due to FODMAPS ingestion at least a couple of hours after the meal. An example: You ate wheat bran flakes and regular milk for breakfast. At noon you ate lunch. At 1 pm you experienced urgent diarrhea. You want to blame it on what you ate for lunch because that meal was closest in time to the symptoms. But there's a better chance your symptoms were caused by your breakfast IF FODMAPS is the type of adverse food reaction at play. Another example: You at a large bagel and a cappuccino for breakfast. So far so good. For lunch you had a 6" sandwich (big roll), an apple, and a sorbitol-sweetened bubbly water. Uh-oh. Suddenly your FODMAPS load for the day has exceeded your unique threshold, and during the afternoon you might experience symptoms that go all the way back to what you had for breakfast.

The timing of your symptoms can give important clues to help your health care provider diagnose whether you are experiencing adverse food reactions due to allergy, other immune-mediated reactions, small intestinal bacterial overgrowth, food intolerance, or even food poisoning.

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Goat's Milk and Goat Cheese

The question often comes up as to whether goat's milk might be tolerated better than cow's milk by lactose sensitive individuals. The short answer is: probably not. Goat's milk does have slightly less lactose than cow's milk, but probably not enough to make a difference for most people. (Note that the proteins in cow's milk and goat's milk are different enough so that some people with an allergy to cow's milk may be able to consume goat's milk, but that is really a separate subject.)

What about that delicious goat cheese that has become so popular? How does that fit into the FODMAPS elimination diet? Like cow's milk cheeses, there is less lactose in cheese because most of it is carried off in the whey, which is separated from the curd during the cheese making process. However, because it is not an aged (or ripened) cheese, goat cheese does have a small amount of lactose in it. It can still be eaten, even on the elimination phase of the diet, if the portion is small. Like other non-aged cheeses, the portion of goat cheese should be limited to 1 oz during the elimination phase of the diet.

Lactose, also know as milk sugar, is the predominant carbohydrate in milk of any species: cow, goat or human. People who don't produce enough of the enzyme, lactase, can't digest lactose. They experience, bloating, gas and diarrhea when they consume it.

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