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?

 

Isn't HFCS roughly the same as sugar?

People are hearing a lot of this message lately from ads on TV and elsewhere. On the face of it, granulated sugar (sucrose) and high fructose corn syrup (HFCS) contain similar amounts of fructose and glucose. But the devil is in the details. Let's examine the question from the point of view of a FODMAPS-elimination diet for irritable bowel syndrome.

First of all, I think we can agree that fructose is absorbed best in the presence of an equal amount of glucose, in other words when the sugars present in the food or beverage are 50% fructose and 50% glucose. For more on this, see my previous post on fructose:glucose ratio. During a FODMAPS elimination diet, it is foods with excess fructose that need to be avoided. Workers in the field define free fructose in "excess" of glucose as greater than .5 grams/100 grams of the food. So a food with 50.5% fructose and 49.5% glucose has enough fructose to be considered a potential problem.

Granulated sugar (sucrose) is always 50% fructose and 50% glucose.

According to the Corn Refiners Association (www.hfcsfacts.com), HFCS is sold to the food manufacturing industry principally in two formulations: 42% fructose and 55% fructose (we will leave 90% fructose formulations out of it for now). So yeah, HFCS is in the same ballbark in terms of fructose content--close, but no cigar. In fact, the 42% fructose version of HFCS, does not have excess free fructose and would be permitted during the elimination phase of the FODMAPS elimination diet. The 55% clearly does meet the definition of excess free fructose and is capable of causing symptoms for some individuals.

Since ingredient listings on food labels don't identify which form of HFCS is in a given food or beverage, my advice is to avoid it all during the elimination phase of the diet. Feel free to include any and all HFCS during the fructose challenge phase of your diet.

By the way, "regular" corn syrup is almost 100% glucose (dextrose), so it is allowed on a FODMAPS elimination diet.

We're Jammin'

When you need a little something sweet, what jams or jellies are FODMAPS-friendly? There are three things to consider: the fruit, the sweetener, and the total grams of sugar. Check the ingredients.

The fruit should be tart: blueberries, raspberries, strawberries, lemon.

The sweetener should be sugar or regular corn syrup (not high-fructose corn syrup).

The total grams of sugar per serving should not exceed 40 grams.

Make your own, or look for upscale or imported brands such as Stonewall Kitchen, Hero or Bonne Maman; there are many varieties that might work for you! Cheaper brands tend to be sweetened with high-fructose corn syrup. As usual, read the ingredients on the label before you buy, in case the manufacturer has made last minute changes.

For more information about the FODMAPS elimination diet, see IBS--Free at Last!, by Patsy Catsos, MS, RD, LD.

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.

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.

FODMAPS--Inconsistent Facts?

If you've done much searching about on the internet or in the medical literature to learn about FODMAPS, you may have noticed some inconsistencies regarding whether certain fruits and vegetables are "allowed" or "not allowed" on a FODMAPS elimination diet.

Remember having more fructose than glucose in a food can contribute to fructose malabsorption. Some fruits and vegetables contain sugar alchohols (polyols) such as mannitol or sorbitol. These foods are "not allowed" or considered "unfavorable" during the elimination phase of the diet. Why the confusion about some fruits and vegetables?

• Sugar and polyol content of produce can vary depending on ripeness--think about your last over or under-ripe banana, and you can easily picture this.
• Sugar and polyol content of produce can vary depending on the variety--think of all the different varietals of grapes grown for wine-making or the many varieties of apples for sale in your local grocery store; other fruits and vegetables have many varieties as well.
• Growing conditions during a season vary from one to the next.
• Methodology for measuring sugars and sugar alcohols has changed over the years.

Information sources might differ for any of the above reasons. Don't drive yourself mad trying to sort this type of discrepancy--any fruits that are that close to the line aren't likely to be the worst offenders when it comes to provoking symptoms due to FODMAPS, anyway. Just remember to keep the portion sizes of fruit small, even the allowed fruits--when in doubt, less than 1/2 cup.

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.

High Performance Energy Sources

I've had several endurance athlete-clients lately looking for an appropriate energy source to use during competition that won't cause bloating and gas. During long events, a large FODMAPS load can be consumed, especially if the product used contains more fructose than glucose. Watching the Olympic games tonight, I was inspired to search for a product to recommend, and I found one: Raspberry PowerBar Gel Blasts energy chews. The web site for the product states that the ratio of glucose to fructose is 2:1--very favorable. Even so, each person has a maximum threshold for fructose absorption, so it's still possible to overdo--too much of a good thing. Do you have a favorite high-energy competition product that doesn't aggravate your IBS?