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IBS: When FODMAP is Not the Solution
Congenital Sucrase-Isomaltase Deficiency (CSID)
Congenital sucrase-isomaltase deficiency (CSID) is a genetic disorder that occurs when the body cannot produce the enzyme sucrase-isomaltase which is needed to digest sucrose and maltose, which are two types of sugars. Sucrose is contained in fruit, cane sugar (table sugar), maple syrup, and many foods containing added sugars, while maltose is found in starchy foods. Historically, it was believed to be a rare condition affecting about 0.2% of the population, but new studies suggest that it could rather affect between 2 and 9% of the population. Sucrose malabsorption typically causes symptoms of gas, bloating, and diarrhea that occurs about 90 minutes to eight hours after the ingestion of foods containing sucrose. Often, digestive symptoms can worsen if you follow a low-FODMAP diet.
The gold standard for detecting this condition is a biopsy of the small intestin with a special testing to measure enzyme activity. There is a hydrogen breath test available that is not reliable, but also a radio-labelled carbon-13 breath test, which is less invasive and relatively reliable for detecting a deficiency of the enzyme sucrase. It is also possible to do an oral sucrose challenge test at home, which can give an idea of whether or not a sucrose intolerance may be the problem. Treatment for this condition is a dietary restriction (which is very difficult to follow) or taking an enzyme supplement called sacrosidase (Sucraid®) with meals. It should be noted that the replacement of the enzyme sucrase helps digest sucrose, but not starch.
Bile Acid Malabsorption
Bile acid malabsorption, also known as bile acid diarrhea, causes several gastrointestinal symptoms, the main one being chronic diarrhea. It affects about 1% of the population. This condition can be a secondary effect to the removal of the gallbladder, certain diseases (Crohn’s disease, chronic pancreatitis, bowel resections) or taking certain medications such as Metformin. Symptoms can occur at any time (including at night) and may include gas, abdominal pain, urgency to defecate, light-colored diarrhea, vitamin B12 deficiency, and unexplained weight loss. Diarrhea can occur more severely several hours after ingesting a high-fat meal, and symptoms usually worsen if people decide to follow a ketogenic diet. Up to 25% of people diagnosed with diarrhea-component IBS (IBS-D) suffer rather from bile acid malabsorption. Treatment for this condition is a bile acid sequestering drug. Note that this medication must be taken with meals to be effective, and that trials should be done to customize the dose to regulate diarrhea while avoiding constipation.
Alpha-Gal Syndrome
Alpha-gal (galactose-α-1,3-galactose) is a sugar molecule found in most mammals excluding humans. Alpha-gal is transmitted to humans through a tick bite where the tick has previously fed on another type of mammal, such as a deer. The body reacts to the foreign substance with an influx of IgE antibodies, causing symptoms of an allergic reaction the next time alpha-gal enters the body following the ingestion of foods, drugs, or supplements that contain it. Thus, the allergic response can be triggered when eating red meat (including pork), dairy products, or products that contain collagen or gelatin. Symptoms usually appear about two to six hours after eating meat or other mammalian products. Symptoms can present as gastrointestinal disorders such as abdominal pain, nausea, and diarrhea, but can also be very varied: skin reactions, swelling affecting the airways or areas of the face, headache, shortness of breath, cough, runny nose, sneezing, low blood pressure, and even symptoms of anaphylaxis, indicating a serious and life-threatening allergic reaction. Sensitivity to this allergy is varied. In some patients, leaner meat or dairy products will not trigger a reaction, while in others, the mere fact of being in the presence of meat that is being cooked can cause symptoms. Some affected patients may not have a reaction every time they consume products containing alpha-gal.
Author
Kathryn holds a Bachelor Degree in Nutrition as well as a Bachelor and a Master Degree in Kinesiology, all from Laval University. She is a Registered Dietitian and active member of the Ordre professionnel des Diététistes Nutritionnistes du Québec (ODNQ) and of the American Academy of Nutrition and Dietetics. She holds the Monash University's certification for the FODMAP diet and IBS, and has considerable clinical experience in that area. She is also an accomplished athlete, having ran track and cross-country at a national level. Kathryn specializes in sports nutrition, weight loss, diabetes, as well as heart and gastrointestinal health.
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