Lactose Intolerance

Those who have FM will usually find that they also have Lactose Intolerance (LI).  This falls back to what I talked about in my last entry about FODMAPs since Lactose is a Disaccharide.  Even those who do not find they have many issues with other FODMAPs foods will often find that they do still have issues with LI.  Lactose Intolerance is a common digestive problem, so it’s not surprising to find FM and LI together.  For those with FM it is a good idea to consider reducing or removing milk for ones diet for a period of time to determine whether lactose is an issue as well as FM.

LI is an inability to digest lactose which is the natural sugar in milk and other dairy products.  The cell lining of the small intestines produce an enzyme called lactase which breaks down lactose into two more simple sugars called glucose and galactose. These simple sugars are absorbed into the bloodstream.  LI occurs when the small intestine is not able to produce enough of the enzyme lactase, this means that lactose gets into the colon (large intestines) and causes various symptoms such as gas, bloating, diarrhea, abdominal cramps, nausea and sometimes vomiting

Lactose Intolerance is relatively common and usually develops later in life.  Children are generally born able to produce enough lactase and it is not until after the age of 2-3 that they begin to produce less lactase.  Most children do not experience symptoms of LI until late adolescence or adulthood.  Infants born prematurely may have reduced levels of lactase because this enzyme increases in the unborn child late in the third trimester.  Research has found that some ethnic and racial populations are more affected then others. LI is more common in people with Asian, African, Native American, or Mediterranean ancestry than it is among northern and western Europeans.  There is also research that shows that some people inherit a gene from their parents that makes it likely they will develop LI.  LI can also be developed as a result of other digestive issues that cause damage to the small intestines such a celiac disease, Crohn’s disease, severe diarrhea illness or chemotherapy.

Bear in mind that LI is a intolerance.  It is not an allergy and is very different from a milk protein allergy.  People who have LI do not have to avoid all milk but are usually able to digest small amounts of milk and items low in lactose on a regular basis.  Unlike FM it is much easier to know what foods are okay and which are not when it comes to LI.  For those who find that even the slightest amount of milk or milk products makes them ill there is a good chance that this is not LI or not just LI but an allergy to the protein in the milk.  This would be called a Type 2 milk allergy as it is not an anaphylaxis allergy but a delayed response allergy. 

Testing for LI is done similar to FM, by a Breath Hydrogen Test (BHT).  Another form of testing would be through a Lactose Tolerance Test, where one drinks a solution with a large amount of lactose and then their is tested two hours later to check the amount of glucose in the bloodstream.  If your glucose levels do not rise it means you are not properly digesting and absorbing lactose.  For infants and small children they are also able to stool acidity test.  Undigested lactose creates lactic acid that can be detected in stool samples, glucose may also be present in the stool as a result of undigested lactose.

The good news is that LI is easier to treat and manage then FM.  Most people who have LI are able to digest small amounts of lactose, especially if it is taken with a meal.  You may need to only reduce your milk and dairy product intake.  It is good to learn which foods are high in lactose and which are naturally lower in lactose.  It is best to start with removing milk from your diet in order to allow your gut time to heal.  After two weeks you can begin to reintroduce small amounts of low-lactose foods to determine what your tolerance level is.

The following gives an idea of which foods you should not eat/drink too much of as well as some ideas of what you can still try in small amounts.  It is good to remember to have dairy products in small amounts and spread it throughout your day and to drink milk with a meal and not on an empty stomach.

 

Low Lactose	High Lactose
lactose-free milk	cows milk
lactose-free ice cream	sheeps milk
lactose-free yogurt	goats milk
cheddar cheese	custard
swiss cheese	ice cream
parmesan cheese	yogurt
brie cheese	evaporated milk
feta cheese	cottage cheese
mozzarella cheese	ricotta cheese
camembert cheese	mascarpone
lactose-free cottage cheese	cream cheese
sour cream	condensed milk
butter	buttermilk
almond milk
coconut milk
rice milk
kefir
sorbet

For those who have more severe LI you are able to purchase Lactose Free Milk which allows you to still gain the other benefits of milk without the lactose.  A cheaper option is to purchase Lactaid drops.  These drops are the liquid form of lactase which can be added to milk, or liquid dairy products to reduce the lactose in the milk.  The only thing with these drops is that you have to pre-treat your milk 24 hours before using it.  It just takes a bit to train oneself to make sure there is always pre-treated milk in the fridge to use for drinking or preparing recipes/meals.

Many people have success with taking lactase pills.  These are pills or chewable tablets that you can take just before eating foods with lactose in them.  These are fast acting pills that will help you to digest the lactose in the food.  Not everyone is able to tolerate these pills (I feel worse if I take them), but they are definitely worth a try to see if they can help assist in keeping down symptoms.

The other important thing to remember is that if you are decreasing the amount of milk you intake then you are also decreasing the amount of calcium and vitamin D that your body takes in and you will need to find other ways to get the appropriate amount of these.

 

Further Information on Lactose Intolerance:

• Mayo Clinic - http://www.mayoclinic.com/health/lactose-intolerance/DS00530
• National Digest Disease Information Clearinghouse http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance/
• PubMed Health - http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001321/
• MedicineNet - http://www.medicinenet.com/lactose_intolerance/article.htm

FODMAPs

If you find that after removing the fructose and fructans from your diet you are still having issues then it is time to consider whether FODMAPs is an issue. You may have already naturally eliminated these foods not realizing why they did not work for you and now as you look at this list the missing information comes together.

FODMAPs is an acronym referring to Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols.  These are a family of carbohydrates (or short-chain sugars) found in certain foods that are poorly absorbed by some people, especially those with IBS.

FODMAPs are poorly absorbed in the small intestine and this can cause increased water to be drawn into the gut, resulting in diarrhea for some people. For others, these carbohydrates move along into the large intestine without being appropriately digested, and they are fermented by the bacteria (good and bad bacteria) to produce unwanted gas.   This gas can lead to bloating and distension, flatulence, loud digestive noises, abdominal pain and nausea or can cause constipation.

Many people with IBS find that limiting their overall FODMAP intake is an effective treatment plan.

-----------------------------------------------------

What does it mean to limit FODMAP intake?  What do all those big words mean?  I will try to break it down

• Oligosaccharides  - A sugar (carbohydrate) that consists of a relatively small number (three to six) of monosaccharides (the simplest form of sugar, such as fructose and glucose, that cannot be broken down to a simplier sugar and constitutes as a building block for more complex sugars)
• Disaccharides - A sugar (carbohydrate) composed of two monosaccharides
• Monosaccharides - the simplest form of sugar that cannot be broken down to a simplier sugar and constitutes as a building block for more complex sugars
• Polyols – sugar alcohols, which are a type of sugar where part of their chemical structure resembles sugar, and part of it resembles alcohol

 

So if you’re like me you’re probably thinking that those definitions do not really help you any further.  So let’s see if I can break it down a bit further yet and give examples of each of these sugars

• Oligosaccharides – fructans,  glactans, Fructo-oligosaccharides (FOS), glactooligosaccharides (GOS),
• Disaccharides – Lactose, sucrose, maltose
• Monosaccharides – fructose, glucose, glactose, xylose, ribose
• Polyols – Sorbitol, Mannitol, Maltitol, Xylitol, Isomalt

Some examples of foods that have these FODMAPs and should be avoided and/or trialed properly would be:

• Excess Fructose: Honey, Apples, Mango, Pear, Watermelon, High Fructose Corn Syrup, Corn Syrup Solids, fruit juices
• Fructans: Artichokes (Globe), Artichokes(Jerusalem), Asparagus, Beetroot, Chicory, Dandelion leaves, Garlic (in large amounts), Leek, Onion (brown, white, Spanish, onion powder), Raddicio lettuce, Spring Onion (white part), Wheat (in large amounts), Rye (in large amounts), Inulin, Fructo-oligosaccharides (FOS).
• Lactose: Milk, icecream, custard, dairy desserts, condensed and evaporated milk, milk powder, yoghurt, margarine, soft unripened cheeses (eg. ricotta, cottage, cream, marscarpone).
• Galacto-Oligosaccharides (GOS): Legume beans (eg. baked beans, kidney beans, bortolotti beans), Lentils, Chickpeas
• Polyols: Apples, Apricots, Avocado, Cherries, Longon, Lychee, Nectarines, Pears , Plums, Prunes, Mushrooms, and artificial sweeteners such as: sorbitol, mannitol, xylitol, maltitol and isomalt which are usually found in diabetic foods.

 

I’ve previously talked about fructose, fructans and foods high in these.  I’ve also talked about lactose.  Fructose and lactose are sugars that you can be tested for via breath hydrogen testing with regards to your absorption tolerance.  The other sugars do not have a test to let you know if you are malabsorbing them.  This means that the only way to truly know that you have problems with FODMAPs is to do an elimination diet.  The Elimination Diet I posted is low FODMAP.

Be careful not to assume that because you can’t eat wheat you can’t eat all fructans or because you cannot tolerate lactose that means you cannot tolerate all disaccharides.  It is still a very individual things, just like when trying to figure out the foods with fructose that you can tolerate.  While there may be some relationship, you may just as well find that there is not a connection.  Remember that serving sizes should remain small and not to eat the same foods too many days in a row.

 

Further readings about FODMAP

• Diet Solutions - http://dietsolutions.net.au/index.php/specialities/fodmap-intolerance/
• IBS Diet - http://ibsdietplan.org/the-low-fodmap-diet/
• Shepherd Works - http://shepherdworks.com.au/disease-information/low-fodmap-diet
• Cassandra Forsythe FODMAP List - http://www.cassandraforsythe.com/blog/Complete+FODMAP+List+For+a+Happy+Gut
• Low FODMAP - http://www.lowfodmap.com/fodmaps-explained/
• Foods on FODMAP Diet - http://ibs.about.com/od/ibsfood/a/The-FODMAP-Diet.htm
• University of Arizona  - http://www.health.arizona.edu/health_topics/nutrition/handouts/FODMAPs%20diet.pdf

Breath Hydrogen Test

The only test for Fructose Malabsorption is a breath hydrogen test.  At this time there is no other way to see if a person has FM, other then by an elimination diet.  While an elimination diet is ultimately going to decide if you are on the right track, sometimes it helps to just know that you have a confirmed diagnosis.  During the beginning of our FM journey it was good to know that there was positive tests for each of us.  When we were confused or frustrated or just wanted to throw out he whole idea of a low fructose diet as we weren’t getting the results we had hoped for a quick as we had hoped for it helped to know that the tests had come back positive and we had to work through these down times.  There were times where we questioned if it was truly a FM problem, but knowing the test was positive meant we had to buckle down and be faithful to a low-fructose diet in order to determine if there were other issues as well.

In Canada there is not an issue over the cost of having the test done since we are covered by the government for such tests.  The issue is usually where to get such a test done.  Our family had the testing done at the GI Investigation Clinic in the McMaster University Hospital in Hamilton.  It would be great if those who have had testing done, whether Canadian or elsewhere, would leave a comment stating where you had it done so others are able to find a lo cation near them to get the testing done. 

The Breath Hydrogen Test (BHT) for Fructose Malabsorption is done the same way as a BHT for lactose intolerance, SIBO and sucrose intolerance.  This test measures the amount of hydrogen in your breath.  Hydrogen gas is produced from intestinal bacteria.  The bacteria produce hydrogen when they are exposed to unabsorbed food, particularly sugars and carbohydrates.  Large amounts of hydrogen may be produced when a person has a problem with the digestion or absorption of food in the small intestine, which in turn allows unabsorbed food to reach the colon.  Some of this hydrogen is absorbed into the blood flowing through the wall of the small intestine and colon. This hydrogen containing blood travels to the lungs when the hydrogen is released and exhaled in normal breathing.  There are studies suggesting that some patients do not produce hydrogen but methane and so some tests are now testing for both hydrogen and methane. I have not read much about this so I cannot comment further on this.

When a person goes for a BHT they will be required to follow a strict diet the day before coming in for the test and fast for 12 hours before the test.  I do not remember the details of the diet the day before but I believe it had to do with not eating whole grains or high fiber foods.  The test involved blowing into a bag every 15 minutes for 2-3 hours. 

When you arrive for the test they will first take a breath sample to determine your base line.  You will then be required to drink a solution of fructose.  After that your breath sample will be taken every 15 minutes.  The picture shows a sample of how the breath is taken.  You will put the blue part to your mouth and blow hard into the bag.  The sample is removed from the bag with the syringe, allowing the bag to be used again for the next sample.  During the test it is important to write down or report any symptoms you have that are typical to the reason you came for the test. 

A diagnosis is made by evaluating the pattern the hydrogen takes after the sugar is digested.  The amount of gas produced determines how well the sugar was absorbed.  The more gas produced the less sugar absorbed.  If the level of hydrogen rises higher then 20 ppm (parts per million) from the baseline test a person is considered to have FM.  (For methane producersif the number rises 12ppm then you are considered to have FM)

BHTing can also be done on young children.  Our son, Matthew, was sixteen months old when he had his test done.  The thing I dreaded most for his test was getting him through the fasting stage.  He did surprisingly well. The other challenge is to get a child to drink the solution, and to drink it all quickly.  For Matthew it worked out fine that he was not particular about what was in his bottle as long as he could have something to drink.  So we pour the solution in his bottle and it went down quickly. 

Because young children can not blow hard enough into the bag for collecting samples, they instead place a mask over their face and have them breath into this mask.  You can see Matthew having a collection taken in this picture.  I was amazed how well he cooperated that day.  I did not expect things to go that well.  It’s difficult to put your child through a test but in the end we had a positive result and knew what we were working with.  It’s also very difficult to play guessing games with a small child.  In his case we would have given up on the FM idea if we did not have a positive test at the time.  It took us another 8 months before we were able to figure out that Matthew is also intolerant to rice.  We persevered with the low-fructose diet because we knew that he had tested positive and that initially he had done better once fructose was removed.  At 16 months Matthew did not eat any solids but strictly drank a bottle … he refused to eat.  We removed him from the formula he was on when we found out he had FM.  He was on a hypo-allergenic formula because he did not tolerate milk or soy.  We started with trying to put him back on milk, which failed, next we tried soy, which failed.  So we moved on to rice milk. He had a diet filled with rice – rice milk, rice for meals, rice flour – (he had been on a gluten free diet since young) – no wonder his poor tummy was so upset.  Matthew was two years old before he began to truly eat solid foods, that was after we removed rice from his diet.  Over the next few months his tummy began to heal and his eating took off.  Hard to believe now that we had so much trouble in the beginning.

What it means to be Wheat-Free

When one is wheat-free one is reading labels all the time.  When one has FM they do not technically have to be completely wheat-free but to maintain a low wheat intake diet in order to reduce the intake of fructans.  For our family that means we are pretty much wheat-free in what we eat from day to day, but if we go out we may dismiss the diet for a bit and eat a bit of wheat. 

Breads and pastas are the most common wheat items, but to be wheat-free does not mean bread and pasta free.  Wheat is in far more items then bread and pastas.  To be wheat-free you will be required to read labels and look for a variety of words that refer to wheat and wheat products.  Some of these would be:

• all purpose flour
• enriched flour
• cake flour
• pastry flour
• self-rising flour
• unbleached flour
• stone-ground wheat flour
• graham flour
• semolina flour
• durum wheat flour
• whole wheat flour
• white wheat flour
• sprouted wheat
• cracked wheat
• spelt
• kamut
• couscous
• matzo
• einkorn
• bulgar

Someone with FM also does not have to watch for every tiny little bit of wheat in items, as someone who is gluten free does.  Small amounts of wheat at the bottom of an ingredients list should be okay, if they aren’t then consider that you may have gluten intolernace (which is different then celiac disease).  People with FM should be able to eat gluten products, although they do use gluten-free items alot in their diet in order to maintain the wheat-free aspect of their diet. 

So small amounts of wheat should be okay as well as oats which are not okay for someone with gluten intolerance.  Barley is not allowed on a gluten-free diet and is said to be high in fructans so it should also be avoided or limited for those with FM.

Don’t despair, there are other grains that you can eat and with time you will find what works for you.  Some of these grains are:

• sorghum
• tapioca
• amaranth
• rice
• millet
• buckwheat
• oats

It is a difficult change, I think for our family leaving wheat behind was the biggest hurdle, but with time you will find substitutes and foods that you enjoy again and it will get easier.  I admit, nothing is quite the same a wheat, but it does teach one to be creative.  I sure miss my fresh out of the oven bread tho!

Fructans

Many of those who start on a low fructose diet are insistent that they can still eat wheat.  I know I was one of them and I’ve heard many others say the same at first and later realize that they needed to remove wheat from their diet.   The problem is that wheat contains fructans and since wheat is so largely consumed today it is considered the largest contributor to our fructan ingestion. 

How do fructans fit in with Fructose Malabsorption?  Fructans are a chain molecule, formed from fructose, with glucose as the final molecule.  Fructans are a food fiber which humans do not have the enzymes to break down and absorb in the small intestine.  The bacteria in the large intestine is able to digest them, in the process producing gas.  For many people this is not a problem, but for those with IBS the gas can cause painful bloating, diarrhea or constipation. 

The largest amount of fructans are consumed in wheat, and the second largest would be in onions, followed by garlic and unripe bananas.

Excess Fructan  Foods:

• Artichokes (Globe & Jerusalem)
• Asparagus
• Banana’s (green) – can eat well ripened bananas
• Beet
• Brussel Sprouts
• Cabbage
• Chocolate
• Chicory
• Dandelion leaves
• Fennel
• Garlic
• Leek
• Legumes
• Okra
• Onion (brown, white, & Spanish)
• Peach
• Peas
• Persimmon
• Radicchio lettuce
• Shallot
• Spring/Green onion (white section) – green section is okay to eat.
• Watermelon
• wheat
• rye
• inulin
• FOS

 

It seems that fructans and fructose can cause different symptoms in individuals.  It is certainly so for myself.  Fructose creates excess gas for me.  When we first began on our low FM diet we worked on fructose only and reduced our wheat intake to one serving every other day.  While the gas symptoms did reduce I was still having episodes that I couldn’t explain and was not able to get my constipation under control as well as I had hoped.  Matthew continued to have his bright green loose stools inconsistenly without being able to put a trigger on what was causing it.  Rebecca was struggling emotionally and we didn’t know if it was because of something she was eating.  The final straw came when I became so tired all the time.  At first I tried to dismiss it as needing more rest, but soon it became apparent that something was not right.  After a decent nights sleep I would be exhausted by 9am and need to lay down.  My mind couldn’t focus and I wasn’t able to process things.  It was slowly getting worse and I was getting more and more frustrated.  For a period of time I suspected wheat but I didn’t want to take it out of my diet.  I like food, I love food, food is such a social aspect of our lives.  I guess I just had to get bad enough to realize that wheat wasn’t worth feeling like crap and that’s the point I hit.  I was determined to go a month without wheat.  My first attempt made it to not quite two weeks, a family tragedy found me at the hospital quite a bit and receiving meals from people and it was just too difficult to stick to the diet change at that time when it was all so new to me.  I gave up saying the two weeks hadn’t made a different so wheat must not be the issues.  But a couple months later I found myself thinking it was time to do another trial and that this time I was going to stick it out for a month.  We made it through the month (and let me say it wasn’t easy at times) and it became apparent that wheat (or fructans) was the cause of some of my unlying issues.  While it didn’t cause the immediate obvious symptoms that fructose was, it did make me groggy, tired, fatigued, brain fogged … and constipated. 

I will not say that I never had wheat.  The first months I gave in more often, usually on the weekend.  I stuck to the wheat-free diet at home but had a harder time when we went out.  I struggled to accept that there was one more odd thing about me.  I just wanted to fit in and enjoy my food.  I wasn’t ready to give up the wheat all the time.  We’ve been wheat-free for over a year now.  Again, I cannot say I never have wheat, but I would say it’s usually about once every three weeks or so.  I notice the different and don’t like the after effects of having wheat.  I can’t stand that brain fogged feeling, walking around in a haze unable to think and the headache that comes with it.  Often if I give in to having some wheat it will be later in the day or in the evening when I know I don’t have much more to do for the day and can relax and sleep it off later. I will have to deal with slight constipation the next day or so, but as long as I don’t eat too much or do it several days in a row it’s okay.  After a year I have had the time to learn more ideas to replace wheat and this had made being wheat-free easier, we have simply learned to pack along food whenever we go out. 

Marietta is not so fortunate to be able to sleep of her brain fog, she has actually had episodes of brain fog in her sleep/dreams.  She is the most sensitive in the house to fructans and also the most dedicated to staying away from them.  She knows it makes her feel unwell with almost instant brain fog and she also hates feeling that way.  I will give her credit, she has much more willpower then I to reject food and stick to the diet.  Rebecca’s willpower is not quite so strong, but neither are her symptoms.  She does not get immediate symptoms nor the excess gas the Marietta and I get.  It’s often hard to tell where to draw the line with Rebecca so she has to stick to the same diet as the rest of us.  While Rebecca will give in much easier when we are out, she will also faithful eat the appropriate food if it is provided.  As long as I pack a lunch or snack for her she sticks to that and might only have a nibble of something else.  It’s not easy being 10 or 11 and having to always explain why you can’t eat what others are eating.

Similar to our situation I have also heard of others that withdrew fructans from their diet later on when they realize they had not gotten rid of all their symptoms and could be feeling even better then they were.  I wish I could say that I am symptom free now, but that would be a lie.  I do have occasional bouts of diarrhea that I haven’t pinpointed yet and then there are just the days where something is off or not right and I can’t figure it out.  But overall I’m happy with where I am.  It’s a bit of a balancing act to find a point that you are content with. I’m not 100% but I am so much better then I was that I’m happy with being 80% there.  Maybe someday I’ll figure out the rest of it, but for the time being I can still eat a good variety and can better enjoy the life God has given me.

 

More information on Fructans

• A List of Foods with Fructans  http://www.livestrong.com/article/440357-a-list-of-foods-with-fructan/
• Fructans 101 http://www.ibsfree.net/ibsfree_at_last/2010/02/fructans-101.html
• Kitchen Therapy http://blog.kitchentherapy.us/2010/01/wheat-free-gluten-free-fodmaps-free-ibs-free-at-last-book-giveaway/
• Food Info http://www.food-info.net/uk/carbs/fructans.htm
• Maybe It`s Something you Ate - http://foodworksblog.wordpress.com/2012/03/22/maybe-it-is-something-you-ate-fructans/
• Fructose Friendly Foodie http://www.fructosefriendlyfoodie.com/fructose-friendly-food-guides/fructan-content-food-guide