Tag Archives: lactose intolerance

The FODMAP Diet: An IBS diet based upon peer-reviewed science

I’m extremely lactose intolerant. What this means, biologically, is that I no longer produce enough lactase to process lactose sugar. Because I can’t process lactose in my small intestine, it moves on intact to my large intestine where bacteria eat the sugar. The byproduct of their digestion, gas, causes bloating, pain, cramping and, well, you know the rest.

What is IBS and what causes it?

Irritable Bowel Syndrome (IBS) is an incredibly common malady, affecting 6-46% of the population, depending upon the study. It’s a diagnosis resulting from the lack of a diagnosis; it’s diarrhea, bloating, stomach pain, and cramping that can’t be explained by celiac disease, lactose intolerance, fructose intolerance, or other understood gut disorders.

IBS is thought to be caused by visceral hypersensitivity, or over-sensitivity to pressure on the intestines. Imagine two people eat broccoli and get a bit gassy: the person with IBS would feel pain and discomfort while the other person might be bloated but otherwise fine.

It’s often implied that IBS is psychological as much as physiological. Anxiety and depression are common in people with IBS. In my experience, the perceived psychological component, the lack of simple treatments, and the lack of life-threatening consequences can lead doctors to be blasé about IBS. They recommend fiber, exercise, and routine, and shrug if that does little. Small wonder that people might feel blue. But gut science is improving, and the FODMAP approach is a new and widely successful strategy for reducing the symptoms of IBS.

What is the FODMAP approach, and what is different about it?

The FODMAP diet is based upon known biochemistry and the hypothesis that visceral hypersensitivity causes IBS. There are many molecules that, like my undigested lactose, tend to be digested in the large intestine and produce gas. The FODMAP diet eliminates a wide range of such molecules.

FODMAP, introduced in 2005 by Monash University, is a peer-reviewed diet based upon a concrete biological hypothesis supported and improved by scientific trials. It is not a weight-loss diet. FODMAP stands for Fermentable Oligo- Di- and Mono- Saccharides And Polyols. Catchy, right? But the concept is simple—FODMAPs are short-chain sugars that we know most people digest poorly (meaning bacteria digest them), and you avoid FODMAPs on the FODMAP diet. (For the biochemists, that means avoiding fructans (oligosaccharide), lactose (disaccharide), fructose (monosaccharide), and all sugar alcohols such sorbitol (polyols).)

Many other diets have questionable scientific bases and are profit driven. The Atkins Diet was published by a cardiologist who never published any peer-reviewed work, but several books. The Paleo Diet was published by an “exercise scientist untrained in paleobiology”. This is not to say that these diets cannot be beneficial in any way. But they have not been tested and refined in the way the FODMAP diet has been, and their fundamental science is hazier. Putting the cart before the horse, they have been developed first for profit, and then researched afterwards, often with mixed results. To be fair, the scientific process is slow and contentious and doesn’t always lend itself well to studies as broad and complex as diet. But FODMAP was developed, tested, and improved using the scientific process. If you’re skeptical of diets, as I am, you can read up and convince yourself that this diet has a reasonable basis and good results.

What’s a FODMAP diet like?

If you are considering a FODMAP diet, you will have to do some research, and be able to prepare food often from scratch. The internet is a phenomenal tool, and there are even some dieticians you can consult online. FODMAP sensitivity is not the same thing as an allergy. You don’t have to absolutely eliminate FODMAP foods, you simply must aim to minimize them for a period of time.

To follow the FODMAP diet, you avoid FODMAP-laden foods for two weeks to two months (different sources vary in their recommendations, and provide rationales). After this time, you re-introduce foods in a controlled manner to identify trigger foods. Most IBS-sufferers are not sensitive to all FODMAPs. Many people report benefits within a few days of starting the diet, and 70% of IBS patients in peer-reviewed studies reported improvements following the diet. I personally had much less bloating within a few days. Following a FODMAP diet revealed that some of my symptoms are due to gastritis, which I’m now treating. I see now that I’ve had gastritis symptoms for a while, but I was unable to separate various gastrointestinal symptoms before this diet. I remain on the full FODMAP diet after three months, but I have eliminated one side issue.

What foods are and aren’t allowed?

Following the most basic level of the FODMAP diet, one avoids all garlic, onion, and gluten-containing foods. It is not a gluten-free diet, but grains containing gluten overlap almost perfectly with grains containing the FODMAP fructan. Beer happily is the major exception; it is FODMAP-free due to the fermentation process.

I consider the FODMAP approach an alternative way of categorizing foods. There is a common perception that vegetables and fruit are healthful, and grains and meat are less healthful. At least from the perspective of IBS, that is not a useful framework. On the FODMAP diet, meats are okay. Roughly half of grains, dairy, vegetables and fruit contain FODMAPs, and these are avoided on the diet. Specifically, greens and squash are okay, but broccoli, leeks, and  brussels sprouts aren’t. Citrus and melon are okay, but peaches, cherries, and figs aren’t. Lactose-free milk and hard cheeses are okay, and ice cream, fresh cheeses, and sour cream aren’t.

For those considering the diet, this is my favorite exhaustive list of allowed and disallowed foods.

TL;DR

In short, the FODMAP diet requires research and it’s a pain to follow, but it offers real promise to the numerous people suffering from IBS. If you’re considering the diet yourself, good luck. I hope this provided a better explanation of the topic than the sources I encountered when trying to understand this diet. To others, maybe this will help explain why your friend has such a fiddly diet, and why you should support them.

Food and science: understanding and cheating lactose intolerance

A person is lactose intolerant when they no longer makes sufficient quantities of the enzyme lactase. Because the enzyme no longer breaks the lactose sugar down, bacteria in the large intestine do instead. The bacteria release a lot of gas when they do this, which irritates the large intestine and causes the symptoms we observe. 

Below is a quick run down to understanding lactose content in foods, and what I’ve done to continue eating awesome dairy food despite my own very inconvenient sensitivity.

What contains lactose?

As a short answer, more than you would think. Obviously ice cream and milk do. Hard cheeses contain very little. I often read that yogurt is well-tolerated by lactose-intolerants due to the bacterial culture, but I do not tolerate yogurt. Sour cream made by traditional methods is low in lactose, but many manufacturers add milk solids.

It gets more complicated. Many foods contain milk powder or whey. Milk powder is 50% lactose by weight, and whey is 10%-70% lactose. Pastries, hot chocolate mixes, pudding mixes, and even Doritos can contain milk powder and whey. Most annoyingly, products do not list the quantity of lactose contained.

Fortunately, several websites tabulate the lactose content of various foods (at least dairy– if you find one for prepared foods, I would love to hear about it). Steve Carper’s Super Guide to Dairy gives a great explanation of the lactose content of a wide variety of dairy products. This link has a decent list.

Circumventing lactose intolerance

Thanks to modern science, we can synthesize the lactase enzyme. The enzyme can be taken as pills and eaten with food, or added to the food as a liquid. I used to take the pills, but as my symptoms progressed, that method became insufficient. The stomach is a mixing chamber, and mixing is imperfect, so enough lactose still got through to cause issues.

After going a year without ice cream or yogurt, I decided to investigate my options. Online, I found the lactase liquid drops, which can be added to any liquid. In 24 hours, these drops reduce the lactose content of a product roughly 70%. I usually add more than the recommended quantity and wait three days to be extra sure. (A side note: I read in the amazon comments that some batches of the enzyme didn’t work; you can test the enzyme’s effectiveness using diabetic glucose test strips. Lactose splits into glucose and galactose, but food doesn’t normally contain glucose; a test strip indicating its presence in a treated food means the enzyme worked. I bought my enzyme in August, and did the test because heat can de-activate enzymes; it was super easy.)

Then I made lactose-free yogurt. I made lactose-free fresh mozzarella cheese (although I wasn’t very good at it). I bought an ice cream maker and made ice cream in any flavor I wanted. I made chocolate mousse. For Thanksgiving, I made ice cream and pumpkin pie with sweetened condense milk and mashed potatoes with sour cream.

Basically, you can add the enzyme to the cream or starting dairy product, let it be for a couple of days, and then cook as you normally would. In milk, the treatment slightly changes the flavor of the milk (it becomes a little cloying, because glucose tastes different than lactose), but in prepared foods I can’t tell the difference. Below are a couple pics of some projects I enjoyed very much. Hopefully this brief run down helps a few of you, or a least gives a picture of our complicated food science lives.

photo1

Green tea ice cream, made with matcha green tea.

photo2

Chocolate mousse.

 

Why I cook: food and science series

I cook a lot. I cook because it’s cheaper, but mostly I cook because I am absurdly lactose-intolerant, with a generally fussy tummy. As a kid, cooking seemed like something girly and irrelevant; food simply appeared. Now I see that eating is something we do every day and it can be either drudgery or exquisite.

This post is the first of a series I will post each Friday. Other posts will talk about specifics: science, recipes, and methods. Today I will talk more about how cooking became something I spend time on, and why cooking matters.

In college, I picked up some kind of food poisoning, probably on dorm food. I started to get sick a lot. I lost weight. I drank bulk-up drinks like body builders do. I became sensitive to milk products; I switched to lactose-free milk, and started drinking whole milk. I couldn’t move after meals, or else I’d get sick. If I ate even a bite too much, I got sick. If I got too hungry, I got sick. My lunches were often half a pizza slice. I bottomed out with a BMI below 18. Doctors seemed disinterested my inability to keep food, but they couldn’t explain the weight loss.

Finally, I started taking probiotics, which seemed to help. Now, seven years after my minimum weight, I’m at my high school weight, with gain more of a concern than loss. I cook most meals for myself, where I have control over my intake. Eating out with others isn’t easy, because I must be picky and inflexible about where and when I eat. I can’t wing it. If I deviate from the rules too much, I will get sick, which directly affects me for up to a day, and destabilizes me for the future. It’s manageable; some people with IBS get sick a dozen times a day, and digestive illnesses like Crohn’s disease can be life threatening.

The gut is understood very poorly, despite its importance. The enteric nervous system, or gut brain, is the site of 90% of serotonin and 50% of dopamine. With my ups and downs, I know well the relationship between gut health and mood. The digestive system is second in neurons only to the brain, and contains more neurons than the spinal cord. It is the engine of our body, and it functions in tandem with more bacteria than there are stars in the galaxy. Yet Americans spend the least time cooking of any country on Earth.

Loads of scientific evidence and my own personal evidence shows that a happy tummy goes a long ways towards a happy person, even in cases less extreme than mine. Good food can be a blissful experience, and in these posts I’ll talk about some methods toward good food. I don’t believe in diets or supplements or shortcuts, just making food that works. Good food can be made in a small kitchen on a limited budget with limited time. The primary ingredient is our own interest and curiosity, which I intend to share here.

Fun Science: Enzymes

An enzyme. Spirals and sheets and strands indicate different kinds of structures. (from Wikipedia)

Enzymes are the catalysts of the body, helping to facilitate chemical reactions that would be very slow or unfavorable in their absence. In a previous post, I discussed how platinum lowers the activation energy barrier for desirable chemical reactions in a car engine, among other places. Enzymes do the same thing, but they are much more selective. Platinum can act on millions of molecules. Enzymes are shaped so specifically that they act only on one molecule. Because of this, enzyme catalysis is often compared to a lock and key–only one chemical is so perfectly shaped as to fit into the active site of the enzyme.

Enzymes are mostly proteins, which are made of hundreds of amino acids with several layers of structure. Our DNA is coded so that enzymes can be assembled from the instructions. The “primary structure” is the sequence of amino acids strung together. The shape of local groups of amino acids gives the “secondary structure”; some combinations tend to coil, others tend to be flat (see the picture at the top of this post). This is due to interactions between the amino acid groups; for example, ionic groups might attract or repel each other. The “tertiary structure” is the structure of the overall molecule, also called the “folding”. We can reproduce the primary and secondary structures in the lab; the folding is harder, because for most sequences of amino acids, there are several possible structures. In the body, the protein is assembled in such a way that it conforms properly. We are mostly still unable to synthesize proteins and enzymes. We usually use bacteria and fungi to make them, when possible.

Enzymes are essential to life. They aid in digestion. Many diseases are caused by the lack of a single enzyme. People with lactose intolerance lack lactase; the deadly Tay-Sachs disease is caused by the lack of hexosaminidase A. In Tay-Sachs, a waste product of cellular metabolism builds up in the brain. Without the enzyme to accelerate its break-down, the waste product builds up to intolerable levels. We can obtain hexosaminidase A, but we can’t therapeutically deliver it to where it is needed in the brain.

You probably already knew that the human body is a remarkable machine. But I hope this brief overview of enzymes gives an appreciation for this one small aspect. Happy digesting.