Fructose malabsorption – Clinical Alimentary

Maple Syrup

A great infographic from compound chemistry about maple syrup http://www.compoundchem.com

Maple syrup is a sweet tree sap that is high in sucrose and low in other sugars, so it is suitable for the low fodmap diet. Maple syrup may be derived from a natural source but it is still a sugar and therefore should be consumed as a treat – more important perhaps when considering the cost! The syrup has lots of health claims attached to it and has been proposed by some to be a ‘superfood’ and to be superior to table sugar in nutrients. The additional minerals and vitamins that are found in maple syrup, when compared with table sugar, are also found widely in other foods consumed in the diet at much higher levels. So a healthy balanced diet does not depend upon maple syrup to provide vitamins and minerals. Maple syrup also will usually be used in small amounts therefore will not likely contribute massively to nutrient status. There is no such thing as a ‘superfood’- I have stated this before, some of you will be fed up with me harping on about it :-). But I feel an overwhelming dietetic urge to repeat – superfood status is marketing concept to allow a high price to be attached to more unusual food items. Although maple syrup is derived in a way that might attract a higher price than other sugars, I don’t have too much of an issue with this – but please don’t call it super.

Other reported beneficial ingredients in maple syrup are Phenolic compounds, they are suggested to have an antioxidant effect – more evidence is needed to test out this hypothesis. Also, the recent proposed use of Maple syrup in prevention of Alzheimer’s disease, has only been shown in the test tube and animal models and not a randomised control trial (RCT) in humans – the gold standard method. Completing studies in the test tube is very different to the human body, which is much more complex. Therefore much more research in humans should be completed to study the benefits (or not) of the phenolic compounds found in maple syrup.

So my suggestion is – eat maple syrup if you want a low fodmap sweet flavouring and enjoy it for what it is – a flavoured liquid sugar, use it occasionally as a treat. The benefits are of course it’s low fodmap status and it does have a really nice flavour. Should you buy the pure version? Yes, using the pure version is advisable, cheaper varieties can contain fructose based sugars, so you should certainly check the label for ingredients prior to purchase.

Maple syrup is from Canada and is widely used in the United States but it is not so frequently used in the UK. Although with the development of the fodmap diet it is becoming more widely known. It can be used in recipes and goes particularly well with pecans, one of my favourite nuts! It is also commonly drizzled on pancakes and waffles.

What about other tree saps? Well birch syrup is produced from another sap that it harvested – it contains fructose as one of its main sugars (42-54%) therefore this is not suitable for individuals with fructose malabsorption or on the exclusion part of the low fodmap diet.

September 10, 2016

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Pecan and raspberry Rocky Road – Low Fodmap

Rocky road is so easy to make and a great looking snack, but not for regular consumption as it is very calorific! This version is not too sweet as dark chocolate is used and the recipe is low fodmap. I like to view this as ’emergency rations’ – what do I mean? Well, when out hiking, and particularly if the hiking is up mountains, you need to take something with you to eat if you get stuck in bad weather. This was training we received when preparing for Duke of Edinburgh’s expeditions. The food needed to be calorific and I can think of no better snack than rocky road – although we often used dark chocolate coated Kendal Mint Cake when I was younger. Now, whilst hiking I have never actually had the need to call for mountain rescue services or had to make a shelter to protect me from very severe weather. These days preparation is usually about checking the weather forecast prior to venturing out and modern forecasts are considerably more reliable than in the past – but the advice is still pertinent according to the link above. A small slice of this chocolate heaven is a very nice treat when you finish your hike though! A low fodmap diet can help with diarrhoea and IBS enabling people to be more adventurous and active so if you want to try see a registered dietitian to help you through it!

Ingredients

200g of dark chocolate (I used 70%)

a handful of raisins

70g of pecan nuts

2 tablespoons of light margarine

1 packet of raspberry marshmallow* (check for fructose based sugars)

5 gluten free digestive biscuits

Method

Chop the pecan nuts at right angles to their length (this makes them look pretty when the rocky road is sliced.) Cut the marshmallow pieces into four or eight depending on your preference, and break up the digestive biscuits into small pieces. Melt the chocolate in a bowl placed over hot water (take care not to allow any water into the bowl as this will set the chocolate solid.) When melted add the margarine and other ingredients and mix well. Stir to cool the mix a little then pour into a cling film or grease lined tray and refrigerate. Cut into 15 small slices.

If you want a sweeter version add 3 tablespoons of golden syrup.

Some people with IBS have an exaggerated gastro-colic reflex, too much chocolate can result in immediate diarrhoea, so remember portion size is important – don’t eat too much at once.

* I used Art of Mallow marshmallows purchased specifically for the recipe.

August 29, 2016

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Wheat free couscous stuffed peppers and Living well with IBS

Please watch and share ‘Living well with IBS’ (irritable bowel syndrome), a film made by Vicky Grant, a researcher at the University of Sheffield, and Gemma Thorpe, a professional filmmaker. Vicky has lived with IBS for over 30 years; here she talks about her experiences and the experiences of others, as portrayed through the storytelling workshops she runs through the Knowing as Healing project.

One of the recipes developed for the video is the one below – a perfect choice for meatless Monday!

Ingredients

150g of wheat free couscous
200ml of boiling water
60g of green olives
60g of hazelnuts*
2 teaspoons cumin
1 teaspoon of cinnamon
1 teaspoon of mild paprika
10-12 strands of fresh coriander
Grated rind and juice of 1 lemon
4 slices of wheat free seeded bread
4 teaspoons of garlic infused oil
Five orange peppers.
Salt to taste.

Weigh out the maize couscous and add the boiling water and cover – leave to stand for 5 minutes.

Add the oil to a pan and add chopped hazelnuts and add cumin, cinnamon and mild paprika and toast the nuts.

Mix the nuts and spices with the couscous and add chopped olives.

Wash and cut the peppers in half fill each with the couscous.

Crumb the bread and add lemon and fresh coriander and sprinkle this mix on the top of each pepper.

Use aluminium foil to cover the peppers while they cook and cook till pepper is soft 20-10 minutes at gas mark 5 or 190°C. Remove aluminium foil for the last 5 minutes to toast the breadcrumbs. Watch out for other recipes soon!

*Hazelnuts do contain some FODMAP but are used in very small amounts in the recipe – if you wish you can omit them if problematic or if you are on the exclusion part of the diet.

Serves 10 – serve with some Low FODMAP salad as a light lunch

December 1, 2014December 21, 2014

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Commonly malabsorbed sugar causes obesity! What? – I’m afraid its just not that simple.

What is Fructose?

Fructose is a hexose, a single unit sugar which occurs naturally in fruit and is a component of the disaccharide table sugar sucrose; it is also the building block of the long chain carbohydrate, fructans. This sugar is absorbed across the intestinal mucosa by facilitated diffusion (via GLUT 5 or GLUT 2, transporters) – a slow method of absorption, when fructose is consumed in equal amounts to glucose, by rapid active absorption. This sugar has been seen by many as a ‘healthy’ alternative to table sugar, however, recently high fructose corn syrup (HFCS) and fructose in beverages has been implicated in the rise in obesity. But fructose consumption (in excess of glucose) is often malabsorbed when consumed in large amounts, so what is going on here? It seems incongruous that a commonly malabsorbed sugar such as fructose should be implicated in increasing rates of obesity.

Fructose in foods

In recent years, availability of fructose in our diets has increased. HFCS or fructose-glucose syrup, in processed sweetened foods and beverages, and use of crystalline fructose sugar and Agave syrup seen as ‘healthier’ alternatives to table sugar, it is perhaps not surprising that fructose consumption in processed foods and drinks was reported recently by The Guardian as a current area for concern (2). A Guardian article stated that HFCS was to be re-branded to improve its image (1). A new worry is the amount of sugar contained in smoothies, promoted by beverage manufacturers as healthy drinks containing natural sugar and an easier way of increasing your fruit intake, to achieve your recommended five a day (2). Whilst the UK population average intake of HFCS sugar remains far lower than other countries, such as the USA (3), individuals with weight management requirements may exceed these levels of intake easily, with HFCS being a component of sweet foods and beverages. High intakes are associated with obesity, type 2 diabetes and metabolic syndrome, however, Fulgoni, (4) consultant to the American food and beverage industry suggested that HFCS is no different in its metabolic obesogenic capacity than sucrose, as the structure of sucrose contains one fructose unit per molecule. Obesity is a multifactorial problem and focussing on one aspect in the diet may be misleading, anyone consuming large amounts of HFCS may also have a diet high in fats and other refined carbohydrates. These carbohydrates, when digested, may facilitate fructose absorption reducing the malabsorption effects that often result from excessive consumption.

Fructose absorption

Unpleasant gastrointestinal symptoms such as osmotic diarrhoea can result from excessive fructose intakes, as a consequence of exceeding the guts absorptive capacity. This malabsorption of fructose in excessive amounts perhaps suggests that the role fructose plays in obesity should be further studied, alongside other refined carbohydrates consumed in the diet, as fructose is not ingested in isolation. Intake of carbohydrates such as glucose and long chain refined carbohydrates may facilitate fructose absorption. Research suggests that intestinal adaptation to diets of pure fructose can occur in study animals (5, 8) to facilitate absorption, but it is not known to what extent this adjustment compensates for malabsorption in humans, who often have very varied and complex diets. Population studies have suggested a link between HFCS and fructose ingestion from beverages with obesity (3). But more needs to be known about the efficiency of absorption, degree of brush border adaptation (if this in fact does occur in humans) and a breakdown of carbohydrates consumed. In these groups it needs to be established whether correlation of fructose intake represents causation, or whether intake of HFCS represents just one of many aspects of the diet which ultimately leads to obesity.

Fructose malabsorption in functional gastrointestinal disorders

Excessive fructose intakes leading to diarrhoea perhaps should not be considered as a functional disorder per say, as most individuals will malabsorb fructose if consumed in large amounts. Intakes of 50g fructose in 250ml liquid are malabsorbed by 60-70% of individuals, when levels are reduced to 25g, 40% of people malabsorb fructose (7) Advice to reduce levels of intake in these cases would seem prudent. Individuals where visceral hypersensitivity and functional disorders (Irritable Bowel Syndrome, IBS) are an issue, fructose malabsorption should be considered as a possibility.

Individuals with functional gastrointestinal disorders can experience pain and diarrhoea with levels much less than 50g; the prevalence of fructose malabsorption in these patients can vary between 38-75% depending on which research source is viewed. A paper published by Gibson & Shepherd (6) studied the effect of a fructose modified diet in people with IBS and diagnosed with fructose malabsorption, the study reported 75% of participants had improvement in symptoms when fructose intakes were reduced. The prevalence of fructose malabsorption is higher than lactose intolerance in this patient group; however it largely remains under recognised as a factor (5). Use of the Low FODMAP diet in treatment of functional disorders has increased recognition of fructose malabsorption as a cause of symptoms.

Use of fructose breath testing for identification of fructose malabsorption has increased, to enable treatment with a low fructose diet to be utilised for those patients that need it. Gibson & Barrett recommend a diet low in FODMAPs must be consumed 24 hours prior to the breath test, to establish an accurate baseline level (5). However fructose breath testing remains a controversial test, due to variations in methodology, leading to confusion about accuracy (6) amongst health professionals. Where testing is not available, dietary fructose exclusions are effective to identify malabsorption and facilitate dietary treatment provision. For patients with Irritable Bowel Syndrome the most effective way of treatment is to exclude all Low FODMAP foods (assuming lactose malabsorption has not been excluded) and re-introduce to tolerance after 8 weeks.

For those with fructose malabsorption exclusive of IBS, reduction of the sources of fructose in excess of glucose should be advised (10.) In all patients, modifying fructose intake, rather than increasing glucose consumption to facilitate absorption, particularly where the patient is overweight is recommended (10.)

Digestive enzymes

It would be better for patients who find manipulating their diet to resolve symptoms a challenging goal to achieve, to be able to take an enzyme to facilitate conversion of fructose to glucose and facilitate absorption. Xylose Isomerase is commercially available and marketed as a solution to fructose malabsorption. It has been recognised by the FDA as safe and been found to be effective in doses of 3 capsules per 25g fructose load (9.) However the commercially available grades advise that these products should not be taken by individuals with inherited fructose malabsorption, so why is this advice given – and how would you know if someone has the condition? Also research into Xylose Isomerase has been funded by the company that market these digestive enzymes, who have a clear interest in proving this product is effective, so the advice is somewhat biased from this respect. However reducing fructose intake might be a more suitable option for individuals who are obese, as using these enzymes may facilitate an increase in energy intake. Dietetic treatment should involve assisting the individual to find a solution when individuals are having problems in following advice, such as suitable written information in an easily understandable form and helping with barriers to goal setting.

Inherited fructose intolerance

This condition occurs as a result of an in-borne error of fructose metabolism, and therefore acts by a different mechanism to fructose malabsorption. The deficiency is of Fructose 1, 6 biphosphate aldolase (Aldose B.) Ingestion of fructose results in post prandial hypoglycaemia and abdominal pain, diarrhoea and vomiting, the ingestion of fructose, sucrose, and sorbitol is problematic for these individuals (12). If consumption is continued hepatic injury, renal injury, coma and death can result (12). This condition is often identified in childhood as consumption of fructose can produce severe symptoms; it is recognised when these carbohydrates are introduced into the child’s diet. However some children have survived to adulthood without the condition being recognised, by self excluding sugar from their diet. Patients have to inherit the deficiency from both parents, who carry the gene but do not exhibit symptoms. Its prevalence is one person in every 20,000 to 30,000 so it is a rare condition, but should be considered if post prandial hypoglycaemia and other gastrointestinal symptoms are reported (11). Born (7) suggests that blood glucose levels should be checked in individuals referred for fructose breath tests, to identify these individuals. It would be prudent to consider this condition with symptomatic individuals who report that ‘sugar’ is a problem and have taken steps to exclude it from their diet.

Clearly fructose malabsorption, digestion and metabolism is a very complex situation and more studies are required to improve knowledge of fructose’s’ dietary effects. Focussing on fructose provides one example of how complex human nutrition and metabolism is, and how improved knowledge is vital to help patients to manage their symptoms. High fructose corn syrup/fructose will be digested to some degree depending on the proportion of glucose it contains, and the individuals levels of GLUT transporters, but despite this many individuals with functional bowel symptoms struggle to digest even low doses. This brief look at fructose digestion also suggests that obesity is a multifactorial public health problem and blaming one nutrient or food may do little to resolve the problem in the general population. In fact publicly concentrating on one minutiae of the causes of obesity beclouds, possibly resulting in confusion for the general population which could cause apathy around lifestyle change. As always, research into digestion should involve a complete food intake analysis facilitated by a research dietitian, including a review of confounding variables. A review of total energy consumption and it’s implications on fructose absorption in the case of HFCS’s relationship to obesity would be advisable, but this will only add a little information to the whole question of the causes of obesity in our society.

1) Boseley, S (7^th September 2013) Smoothies and fruit juices are a new risk to health, US scientists warn Scientists say potential damage from naturally occurring fructose in apparently healthy drinks is being overlooked The Guardian available from http://www.theguardian.com/society/2013/sep/07/smoothies-fruit-juices-new-health-risk

2) Clark, A. (15^th September 2010) Manufacturers petition regulator to change name to ‘corn sugar’ as consumer backlash grows against the food and drink sweetener in the US The Guardian available from http://www.theguardian.com/business/2010/sep/15/high-fructose-corn-syrup-rename

3) Bazian (2012) Sugar substitute sparks global diabetes epidemic NHS Choices available from http://www.nhs.uk/news/2012/11November/Pages/Sugar-substitute-sparking-global-diabetes-epidemic.aspx

4) High-fructose corn syrup: everything you wanted to know, but were

afraid to ask1,2 Victor Fulgoni III Am J Clin Nutr 2008;88(suppl):1715S.

5) Barrett J Gibson, PR,( 2012) Fructose and lactose testing Australian Family Physician Vol. 41, No. 5

6) Shepherd SJ, Gibson PR. (2006) Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. J Am Diet Assoc 2006; 106: 1631-1639

7) Peter Born (2007) Carbohydrate malabsorption in patients with non-specific abdominal complaints World J Gastroenterol 2007 November 21; 13(43): 5687-5691

8) Levin RJ (1994) Digestion & absorption of carbohydrates from molecules to membranes to humans American Journal of Clinical Nutrition 1994;59 (supple) 690S-8S

9) Putkonan L, Yao CK, Gibson PR (2013) Fructose Malabsorption syndrome A review Current Opinion in Clinical Nutrition & Metabolic Care. 16:473-477

10) Marie E. Latulippe and Suzanne M. Skoog (2011) Fructose Malabsorption and Intolerance: Effects of Fructose with and without Simultaneous Glucose Ingestion Critical Reviews in Food Science and Nutrition, 51:583–592

11) Genetic fructose malabsorption – http://ghr.nlm.nih.gov/condition/hereditary-fructose-intolerance

12) Ali, M Rellos, P Cox TM (1998) Hereditary Fructose Intolerance J Med Gen 35: 353-365

January 23, 2014January 24, 2014

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Tapas

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This recipe is inspired by tapas dishes, usually filled with lots of garlic and onion – not great for people who are avoiding these ingredients. I hope you enjoy the recipe and the views of Barcelona!

DSCF1207mod

1) Spanish omelette.

This is a layered egg and potato omelette – minus the onions, but no worse because of it. It is probably best eaten warm, although if you don’t have a problem with resistant starches you could have it cold with a green leaf salad perhaps.

Ingredients

4 large eggs

4 potatoes

1 teaspoon of paprika

Oil/margarine to grease the dish, to prevent the omelette sticking to it.

Salt + Pepper

Method

Slice the potatoes thinly leaving the skins on for a little extra fibre!

Beat the eggs and add salt + Pepper

Rub margarine around your cooking dish and sprinkle around the paprika.

Par boil the potatoes and cool (don’t allow them to go too cold if you have a problem with resistant starch)

Add layers of potato and egg.

Weight the dish as it cooks so the egg penetrates all the layers.

Cook in a moderate oven till the potatoes and egg are cooked through.

2) Roasted paprika peppers

Ingredients

3 peppers – I like to use yellow and orange peppers as they look so nice but you can use any colour of pepper you feel like.

1 tablespoon of garlic infused olive oil

1 Teaspoon of smoked paprika (I used hot, but you can choose the heat of your paprika depending on your symptoms)

Salt + Pepper to taste

Method

Slice the top off the pepper and remove the stalk, slice the pepper. For the main body of the pepper again slice it but remove any white pithy material from the inside.

Add the oil paprika and seasoning and roast till soft – really couldn’t be simpler!

Low FODMAP, gluten free (check paprika contains no contamination) milk, lactose and fructose free.

January 19, 2014

Jules_GastroRD1 Comment

Valentines Day approaches – love me, love my gut – even if it misbehaves sometimes.

Now, I’m not a counsellor or psychologist but I am able to give you some advice around dining out and reducing the anxiety this can cause around safe foods to eat. If you are going out with a new partner Dr Barbara Bolen has some really useful advice around dating and functional bowel problems (IBS.) She advises that you should be open about having digestion problems and it is OK to describe them as such, you don’t need—and probably

A little flippant perhaps – but also some truth, love me love my GUT!

wouldn’t wish to go into detail. She also provides some good examples of how to describe your GUT problems so check out her website. An explanation will also help to reduce your anxiety about needing to go to the loo frequently during a meal and this might help reduce the actual visits required. Dr Bolen also has some really good information on her website about how to tell someone about your IBS, relationships and how to enjoy a healthy sex life with functional bowel problems, check out her site here –

http://ibs.about.com/od/livingwithibs/tp/IBSandDating.htm

Dr Bolen has also posted a link about this post and she does also appreciate Valentines Day is not a day that everyone celebrates and it can be a time that can be difficult psychologically – see the link here:-

http://ibs.about.com/b/2013/02/14/ibs-and-valentines-day.htm

If you are going on a date you may want to go to an establishment that you know well and ask for a table to be reserved in a good position, making it easier should you need to visit the toilet. Making a suggestion about where to go on a date shouldn’t cause a problem, just be a little assertive and ensure that you explain about your IBS at some point—if someone wishes to go out with you this really shouldn’t be an issue. You could also a look at the menu before your visit and telephone the chef to ask if they can cook your food without ingredients that may cause problems if this helps. See if your partner also wishes to look at the menu before arriving, this will leave more time for conversation and getting to know each other. Looking at the menu is easier to do these days as most restaurants post menus on-line.

Eating out on the Low FODMAP diet can be challenging, as onion and garlic are widely used, don’t forget to ask about sauces and stock. Having dietary intolerances shouldn’t stop you going out – some ideas for choosing food are grilled chicken breast, fish fillets, steak—in other words plain meat or fish without sauce. Egg dishes are also a possibility, omelette or frittata, check the dishes are onion and garlic free, if they are a problem for you. Choices for the starchy component are plain rice, freshly cooked potato or you could ask for wheat or gluten-free dishes (depending on your intolerance,) but again check for other FODMAPs. Establishments are now better at labelling their menus, or providing separate gluten-free menus, since a recent change in regulations. Or you could try sushi, if you like it but again check any vegetables for FODMAPs. Always remember that it might not be the food you have just eaten that causes symptoms. If you are through the exclusion phase stick to your known low FODMAP foods for the day and possibly the evening before your date depending on your GUT motility (knowing the time it takes food to pass through your digestive system.)

If foods high in fat are a problem for your digestion then ask for the meat grilled or cooked on a griddle which will allow the majority of the fat to drain away. Vegan options are a little more challenging as they often contain foods high in fermentable carbohydrates, but a risotto based on Low FODMAP vegetables or rice stuffed peppers would be an option here, not forgetting to ask about use of onion and garlic in the dish, should you need too.

Some people find alcohol is a problem, if you want to have alcohol and it does give you symptoms, limit the amount that you have. You could have a glass of wine, for example with your main meal, or ask for a spritzer to make a longer drink. Order a spritzer with your starter and allow it to go a little flat before drinking it, if you suffer from bloating. Using an implement such as a straw or cocktail stirrer to mix your drink will help to disperse the gas it contains, but don’t be tempted to drink from the straw. You could try a little seduction and gaze into your partners eyes, whilst stirring your drink! Watch the amount of fruit cocktails you have, if you have fructose intolerance—one small glass (100 ml) of pure fruit juice containing low FODMAP fruits is usually the maximum advised. So ensure your cocktail has no more than this amount and drink it with the main dish or sweet.

Check out The IBS Network Self-Care Plan for medications that are helpful.

I would really encourage you to eat out this Valentines Day if you are invited, you may have some symptoms because it can be difficult to avoid all FODMAPs, but the most important factor is that you go out and enjoy the experience. You might find a life partner by going on the date, what more could you wish for? If you don’t have a partner, you could plan to do something special with friends or family for the day.

Most of the advice has been about functional gut problems (IBS) but if you have inflammatory bowel disease IBD, some of the advice posted may be useful but I would strongly advise you to go on-line and check out Crohns & Colitis website (link to the main site is found to the right) as they have some really useful advice on relationships and IBD, or the link for The Ileostomy and Internal Pouch Association for advice.

Check out the living with IBD leaflet here

http://www.nacc.org.uk/content/services/infoSheets.asp

Now for the bah humbug ;-), this advice also applies to the rest of the year! Valentines Day is very commercialised, expensive and anticipation of events occasionally can prove to be disappointing if you spend lots of money on the day. You could always suggest going out at another time, if you wish and there are other ways of showing your affection than an expensive card and some petrol station bought carnations! If you know what your partner likes, try making your own gifts, some baking perhaps (and I do include you gentlemen readers here too)—invest some time and personalise your gift, this will be really appreciated as it shows your love and understanding.