IBS--Free at Last!

My Comment to the FDA on the Corn Sugar Petition

Some of you may have heard that the Corn Refiner's Association has submitted a petition to the Food And Drug Administration requesting that the term "corn sugar" be approved for use on food labels instead of high fructose corn syrup. Read the petition for yourself if you like. There is a "submit comment" link on the upper right had side of the document details page. Please use the form to let the FDA know what you think fo the petition; it is an easy process. There is a limit on the number of characters one can use in the comment. As you can imagine, I could have gone on at much greater length, but here is the text of my comment:

"I am a registered, licensed dietitian. I help patients with gastrointestinal diseases and disorders, including those with fructose malabsorption. I object to the reasoning presented by the Corn Refiners Association in their petition for the FDA to approve the use of the term corn sugar to describe high-fructose corn syrup, and I urge the FDA to turn down this petition. Fructose is absorbed into the bloodstream from the small intestine at a slow rate. Fructose absorption is more complete when the ratio of fructose to glucose is exactly 50/50 for biochemical reasons, and the rate at which individuals absorb fructose varies a great deal. Individuals with fructose malabsorption may experience gas, bloating and diarrhea when they consume foods containing as little as .5 grams/100 grams of food excess fructose relative to glucose (.5% difference).

In Section B. 1. of the petition, the Corn Refiners Association alleges that high fructose corn syrup and sugar have equivalent ratios of glucose and fructose, and that they are equivalent by every parameter of relevance to consumers. Both of these statements are patently false. The percentage of fructose in sugar (sucrose) is exactly 50%. The percentage of fructose in commercially available high fructose corn syrups varies from 45% to 55% to 90%. The 45% fructose high fructose corn syrup would not pose a problem for my patients. However, corn syrup products over 50.5% fructose have the potential to trigger symptoms in patients with fructose malabsorption. 55%-90% fructose in high fructose corn syrup is NOT equal, and NOT equivalent to the ratio in sucrose. For consumers with fructose malabsorbtion, this is a highly relevant difference between sucrose and high fructose corn syrup. Consumers with fructose malabsorption need to see the word fructose on the food label to help them avoid foods they cannot tolerate. On their behalf I urge the FDA to deny the petition.  Please call 207-318-7629 for more references.

 

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.

Sucrose, By Any Other Name...

Sucrose--good old table sugar--is one of the few allowed sweeteners on the elimination phase of the FODMAPS diet. In an effort to be more specific, more exotic or healthier-sounding, manufacturers use a great many different words on the food label that all mean essentially the same thing: sucrose. Here is a list of allowed sugar names you might see in recipes or the ingredients section of a food label:

• sugar
• cane sugar
• confectioner's sugar
• granulated sugar
• superfine sugar
• naturally milled organic sugar
• sugar syrup
• cane syrup
• evaporated milled cane juice
• organic cane syrup
• organic sugar
• beet sugar
• bar sugar
• berry sugar
• castor sugar
• icing sugar
• refined sugar
• cane juice crystals
• invert sugar

Raw, unmilled, unrefined or darker colors of sugar have not had the molasses removed, and have an excess of fructose, so should be avoided on the elimination phase of the diet.

Remember, even if sweetened with sucrose, your treat shouldn't have more than 40 grams of sugar per serving during the elimination phase of the diet.

To learn more about the sweeteners named above, start with one of my favorite sites, Cook's Thesaurus.

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?

What If I've Tested Negative for Lactose Malabsorption?

If you've tested negative for lactose intolerance, how does that fit into the FODMAPS picture?

First of all, let's review the test for lactose intolerance. The patient consumes a known amount of lactose. If the lactose is poorly digested and absorbed in the small intestine, it continues "down the line" to the large intestine, where it is fermented by the resident bacteria. They produce hydrogen gas as they ferment the lactose. Some of this gas is absorbed into the patients blood stream, where it travels to the lungs and is exhaled. If there is a sharp rise in the amount of hydrogen exhaled after the patient consumes the lactose, that is considered "positive" for lactose malabsorption. One thing to keep in mind is the fact that approximately 20% of us are not colonized by hydrogen-producing bacteria; instead, our resident bacteria many produce other types of gas such as methane or hydrogen sulfide (bad breath, anyone?).  Lactose-malabsorbing individuals in this category will falsely test negative for lactose intolerance on a hydrogen breath test alone, but might be positive if tested for both hydrogen and methane exhalation. The results of the lactose test really need to be viewed together with the patient's history of symptoms after consuming lactose, both during the test and at other times.

If someone has tested negative for lactose malabsorption AND doesn't particularly have a history of symptoms after ingesting milk products, it is pretty safe to say that individual is not lactose-intolerant.

However, even adults who tolerate lactose well in general do have limits to how much lactose they can handle. Because the effects of FODMAPS carbohydrates are additive, excessive lactose intake could put you over the top, and contribute to symptoms mostly caused by the other FODMAPS.

How much lactose is "excessive"? The answer to that question varies from one person to the next, but to put things in perspective, check out these generalizations about the lactose content of milk products:

Fluid milk: 11-14 grams per cup

Lactose-free milk: 0 grams per cup

Evaporated milk: 24 grams per cup

Yogurt: 5 grams per cup

Ice cream: 12 grams per cup

Butter: trace per 1 tsp

Most cheeses: 0-2 grams per ounce

Whey protein concentrate: varies

Whey protein isolate: trace per serving

Click here for more complete info on lactose content of foods and beverages.

To learn more about lactose intolerance and the FODMAPS elimination diet, visit www.ibsfree.net

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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Cough Drops

What if you have a cough while on the FODMAPS elimination diet? Can you use cough drops? To answer that question, I bought a selection of cough drops at the local pharmacy the other day, so I could study the list of ingredients in detail. I found several good options.

Halls Mentho-Lyptus Strawberry:  Active ingredient: Menthol. Inactive ingredients: FD&C red no. 40, flavors, glucose syrup, sucrose, water. These sweeteners are not FODMAPS, so this one is OK, although I wish they wouldn't put food dyes in the product.

Halls Naturals Wild Cherry: Active ingredient: Menthol. Inactive ingredients: citric acid, elderberry juice, flavors, ginger, glucose syrup, lemon grass, sage, sucrose, water, white thyme.

Ricola Natural Lemon Mint: Active ingredient: Menthol. Inactive ingredients: citric acid, extract of lemon balm and Ricola's herb mixture (elder, horehound, hyssop, lemon balm, linden flowers, mallow, peppermint, sage, thyme, wild thyme), natural color (beta-carotene), natural flavors (lemon oil, peppermint oil), starch syrup, sugar. Starch syrup = glucose syrup, so no FODMAPS here.

If you are considering different flavors of the above brands, be sure to check the ingredients, as each one is a little different. For example, the Halls sugar free product I checked was sweetened with isomalt, which is a FODMAP. Ingredients to avoid: honey, high fructose corn syrup, isomalt and sugar alcohols (sorbitol, mannitol, xylitol, maltitol, or lactitol), maybe pectin (I am still looking into this one).

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