IBS--Free at Last!

Q. 5, 6 and 7 #fodmapchat Adding glucose, conflicting info and which FODMAPs

Question 5: Can you comment on the use of glucose to improve absorption of fructose?

Question 6: Why are there so many conflicting FODMAP food lists out there?

Question 7: How do you work out which FODMAPs are a problem for you?

 

IBSDietplan.org Interviews Patsy Catsos About IBS and FODMAPs

IBSDietplan.org interviewed me on these questions:

• How to find a dietitian knowledgeable about FODMAPs
• Is  FODMAPs restriction accepted by the mainstream medical community?
• How to decide between FODMAPS, SCD and Heather Van Vorous/Help for IBS
• FODMAPs restriction v. elimination
• FM v. FODMAPs

Thanks to IBSDietplan.org for the opportunity to get the word out!

Food: The Forgotten Factor in the Irritable Bowel Syndrome

To those of us with IBS, food is rarely forgotten, but medical professionals sometimes need to be reminded that it is a factor! An excellent review article, just published in Gastroenterology Clinics of North America, will do just that.  If you love science, or if you are one of my dietitian colleagues, it will be well worth your time to read the article. Or, scroll down for my summary!

Food: The Forgotten Factor in the Irritable Bowel Syndrome
Shanti Eswaran, Jan Tack, William D. Chey
Gastroenterology Clinics of North America - March 2011 (Vol. 40, Issue 1, Pages 141-162, DOI: 10.1016/j.gtc.2010.12.012)

Short version:

• Food molecules act as chemical messengers that activate nerves, muscles and hormones, influencing digestion, fluid balance and motility in the gastrointestinal system.
• There are a variety of possible adverse reactions to food. Some are immune mediated (classic food allergy or delayed- or cell-mediated hypersensitivity) and some are not (toxins, physical irritation, lactase insufficiency, fructose malabsorption, FODMAPS in general)
• People with IBS are probably especially sensitive to all of the above.
• There are a number of specific diets for IBS, including fiber supplements (may exacerbate problems), gluten restriction (may be a subset of IBS-D patients who improve with gluten restriction), sugar/carbohydrate restriction (in IBS patients, any form of carbohydrate malabsorption is likely to result in development of symptoms) and finally FODMAPS restriction (growing body of evidence to support efficacy, impressive symptom relief with this more holistic approach)
• IBS--Free at Last! is cited as a reference for details regarding the practical implementation of the FODMAP diet! Very exciting!

Reading the Label: Major vs. Minor Ingredients

How can we judge whether something is a major or a minor ingredient in a food or supplement?

Grab a box of food from your pantry and have a look at the Nutrition Facts panel. At the bottom, you will see a list of ingredients, in descending order by weight. In other words, the product is mostly made of the ingredients at the beginning of the list. Let's say you have discovered that you need to avoid excess fructose in your food; you are trying to select a salad dressing that doesn't have too much fructose in it (let's disregard the other FODMAPS from consideration for the moment):

Salad dressing 1:

Water, High Fructose Corn Syrup, Distilled Vinegar, Salt, Garlic, Soybean Oil ( Adds A Significant Amount of Fat)Onion, Xanthan Gum, Red bell Peppers, Sorbic Acid, Sodium Benzoate, Calcium Disodium EDTA)Used to Protect Quality, Spices, Tocopheryl Acetate ( Vitamin E)Lemon Juice Concentrate, Caramel Color.

Salad dressing 2:

Water, Creole Mustard (Ground Mustard Seed, Distilled Vinegar, Salt) Cider Vinegar, Sugar, Vegetable Oil (Soybean Oil and/or Canola Oil) Maltodextrin, Honey, contains 2% or Less of: Salt, Buttermilk Solids (Milk) Spice, Xanthan Gum, Lemon Juice Concentrate, Onion (Dried) Garlic (Dried)

The major sources of fructose in the examples, above, are highlighted in pink. Dressing #1 has high fructose corn syrup as the second ingredient. Dressing #2 has honey as the 7th ingredient (not counting the "sub-"ingredients in parentheses). Therefore, Salad dressing #2 would probably be a better choice for the person trying to limit fructose in the diet.

I thought this would be a very easy post to write, but I've been looking for the right examples for almost three hours. It's complicated.

For more help with food labels, see the FDA web site How to Understand and Use the Nutrition Facts Panel.

Is the FODMAPS Elimination Diet Useful for People With Fructose Malabsorption (FM)?

There is a limit to how much fructose a body can absorb over a given time period. Each person's limit is different. An individual who can absorb very little fructose per meal or per day is said to have fructose malabsorption (FM). The collection of symptoms that occur when fructose is malabsorbed, such as gas, bloating, and watery diarrhea, are referred to as dietary fructose intolerance (to distinguish it from another medical problem called hereditary fructose intolerance). Malabsorption is one possible reason for intolerance. I know this all sounds like splitting hairs, but I just want to make sure we're all talking the same language.

FM is being tested for, and diagnosed, more often these days. In the US, a person is usually given a 25 gram dose of fructose to test for malabsorption. 

Studies in Australia have shown that 70% of individuals who have tested positive for fructose malabsorption and have a diagnosis of IBS experience significant improvement on a FODMAPS elimination diet such as the one described in IBS--Free at Last! This makes the answer to the question posed in the title of this posting "YES" for many people! Many people with FM, but not all, will be helped with the FODMAPS elimination diet.

My next post will explore why some people with FM may not be helped enough by the FODMAPS elimination diet as written in IBS--Free at Last! and what can be done about it.

Clear Liquids

Has your health care provider asked you to drink clear liquids to prepare for a procedure or for bowel rest? Here is a list of some clear liquids that are FODMAPS/FM-friendly.

• sugar-sweetened, carbonated soft drinks (bottled)
• homemade or commercial lemonade made with lemon juice concentrate (no pulp) and sugar or real maple syrup
• tea, regular or herbal
  
• gelatin dessert (like Jello) made from powdered mix (double check label--dextrose is OK)
• soft drink (like Kool-Aid) made from powdered mix (double check label--dextrose is OK)
• diluted white grape juice
• chicken or beef broth
• water, of course
• Frozen lemonade or limeade, sugar sweetened (single serving section of freezer), such as Minute Maid
• lemon sorbet sweetened with sugar or corn syrup (not high-fructose), such as Haagen-Dazs
• pulp-free orange juice (w/OK from physician--sometimes this is not considered a clear liquid)

Now, if the next step to get ready for your procedure is to consume laxatives, there is nothing I can do to save you from diarrhea, since that is pretty much the point. But at least the first day of your prep might be reasonably comfortable if you stick to the above liquids. Remember, if you are preparing for a colonoscopy, you should avoid products with red or purple food dye in them.

Does (Portion) Size Matter?

On a FODMAPS- (or fructose-intolerance-) friendly diet, does portion size matter? You bet. But only for foods that contain FODMAPS. Foods that do not contain FODMAPS can be eaten in the portions that are appropriate for your calorie needs and appetite, for example:

• allowed grains and starches
• allowed vegetables
• oils
• meat, fish, poultry, eggs
• lactose-free milk products

There are some foods allowed on the elimination phase of a FODMAPS elimination diet that do contain small amounts of FODMAPS. For these foods, portion size does matter. Examples include:

• allowed fruits
• sour cream or half-n-half or whipped cream
• sugar-sweetened foods

In my book, IBS--Free at Last! you can recognize these foods because they are in bold-face type. I recommend limiting these foods to one serving per sitting. The servings are small. For example, blueberries are allowed, and the portion is 3/4 cup (corrected 4/22/10).

What would be the harm in having a whole cup of blueberries in one meal? Or adding a serving of whipped cream to the blueberries? Simply, you might not be able to absorb that much fructose fast enough to avoid "overflowing"--some fructose might end up unabsorbed, and might continue on to the large intestine where it could cause gas, bloating, and diarrhea.

For fruits and milk products, see the portion sizes listed in the book for a guideline. For sugar-sweetened foods, the rule of thumb is that your portion should contain less than 40 grams of sugar according to the Nutrition Facts on the food label.

Update to What about Vinegar?

Sprinkling your own oil and vinegar on salad is the FODMAPS-friendly way to dress it, since most commercial salad dressings have one or more ingredients that are not allowed during the elimination phase of the diet. I am often asked which vinegars are OK to use? The answer is that any filtered vinegar will do, in a 1 tablespoon portion. Filtered vinegars include white vinegar, white or red wine vinegar, champagne vinegar, rice or rice wine vinegar, and most flavored vinegars.

Unfiltered cider vinegar does retain some sugar in it, and it has an excess of fructose, so it is probably not appropriate during the elimination phase unless it is a minuscule portion. You can recognize unfiltered cider vinegar because it is cloudy in appearance, not transparent, like filtered or distilled vinegars are.

Balsamic vinegar has a 2 grams of sugar in a 1 Tb. portion, but luckily for us balsamic lovers, there is more glucose than fructose in it, so it is allowed on the elimination phase. For more information about the role of the fructose to glucose ratio, click here.

Update on 1/20/2010: Remember, even if a person has a verified problem with FODMAPS, other kinds of adverse food reactions can occur. Please read my post entitled: One of My Problem Foods is Allowed on the Elimination Diet. Vinegar is complicated. A person could be sensitive to the food the vinegar was made from. Vinegars vary in their degree of acidity. Aged vinegars like balsamic may contain phenylethylamine. Flavored vinegars may have additives; for example some commercially seasoned sushi vinegars contain high fructose corn syrup. Some stray yeasts can be present in raw vinegars. Malt vinegar contains gluten. And so on. All of these factors might influence a body's experience with consuming vinegar.

Polyols 101

Many of my clients tell me that even a few small pieces of sugar-free candy or gum cause diarrhea. Ditto for the well-know effect of prunes or cherries. What do these foods have in common? They contain polyols, also known as "sugar alcohols".

Technically, they are FODMAPS carbohydrates, and they are sweet! Most polyols are poorly absorbed, and wind up in the large intestine when they are consumed. In the large intestine, polyols are fermented by gut bacteria. They are also capable of drawing water into the large intestine. Together, the excess gas and excess fluid can cause distension of the colon, which cause bloating, flatulence and looser stools for the IBS sufferer. In a double whammy, eating or drinking sugar alcohols worsens fructose intolerance!

Some sugar alcohols, such as sorbitol, occur naturally in fruits such as apples, pears, and the "stone fruits," which include plums, prunes, apricots, peaches, cherries and so on. Sugar alcohols are often used to sweeten "sugar-free" foods (such as candy, gum, low-carb items, and bubbly water) and liquid medications. They can be recognized on the food label's list of ingredients by the ending "-ol". Examples are xylitol and maltitol.

Note that erythritol seems to be an exception. Studies have shown it is well absorbed and unlikely to cause GI symptoms.

Fructose 101

Fructose is known as "fruit sugar". It is present in fruits, some vegetables, honey, granulated sugar, agave syrup and high-fructose corn syrup. In the past, the human diet was lower in fructose than it is today--think of how hard it was to get honey in the wild, for example, or what a treat it would have been in the past to have fruit out of season, much less a never-ending supply of ketchup, cookies, candy and other sweets. Now it seems as though fructose is everywhere in our food supply.

Our capacity to absorb fructose is easily overwhelmed; it is almost considered normal to experience abdominal pain, flatulence, bloating or diarrhea when we overdo the amount of fruit or fruit juice we consume--many people have experienced this phenomenon. But some of us experience symptoms with much smaller intakes of fructose. And most of us overlook the impact that large portions of sugary sweets, baked goods and soft drinks can have. And what about those honey or fruit juice concentrate-sweetened energy bars? Interestingly, apples are part of the traditional BRAT diet sometimes recommended to fight diarrhea. Umm...maybe apples and apple juice aren't such a good idea for some people with diarrhea.

Diagnostic dietary fructose intolerance tests are available, but are not ordered as frequently in the US as they are elsewhere. If you suspect you don't tolerate fructose very well, try cutting back on soft drink and other sweets. Limit tomato paste. Choose small portions of fruits that are lower in fructose, such as kiwi, berries, citrus fruits, and bananas. Read labels, and avoid or limit portion sizes of foods sweetened with honey, fructose, high-fructose corn syrup, agave syrup and fruit juice concentrates.  See if you feel better!

Fructose malabsorption can occur on its own, or it can be part of the larger IBS picture.The FODMAPS elimination diet in IBS--Free at Last! can help you figure out how fructose fits into your IBS scenario.

It is important to distinguish dietary fructose intolerance, described in this posting, from hereditary fructose intolerance, which is a serious, hereditary disorder requiring a truly fructose-free diet.

Click here for more details about dietary fructose intolerance and how it causes GI symptoms.

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