Saturday, October 22, 2016

"Stomaching" the food we eat-The imponderables!

We all know that food serves the twin purpose of satisfying our hunger and delivering the nutrients we need for growth and well being. Out of the three basic necessities of life, viz food, shelter and clothing the first one is most important as without food along with air and water no life can sustain in this planet. Most human beings take it for granted that when food is consumed the gastrointestinal ( GI )system automatically process these foods into usable nutrients required for the well being. But rarely any thought is given as to how complex is the GI system and what problems can arise if the normal process of digestion and absorption is hindered or adversely affected due to a host of reasons, many of them not still well known. Only people with disorders like allergies, intolerances, Crohn's disease, Celiac disease, Irritable bowel syndrome etc know what sufferings they have to endure as the present day treatment regimes are not considered absolutely satisfactory. Explosive growth of that industry sector manufacturing gluten free foods bears out the fact that all foods cannot agree with all the people. The so called well being food industry is rolling in money because the products being made by it commands a good following by those with one or the other real or imaginary problem with the foods they eat. Recent evolution of the concept of adverse effect of FODMAPS, a group of carbohydrates present in many foods, is further complicating the picture vis-a-vis tolerance of some of the foods by the GI system. Whether this is really a significant issue will emerge soon requiring attention at the hands of health pundits sooner or later. 

Take the case of Gluten-free foods which are made and marketed through out world mainly to cater to the needs of those consumers who experience disorders like Irritable Bowel Syndrome (IBS) and Celiac disease. These foods are designed based on the presumption that gluten is primarily responsible for the discomfort experienced by the patients. However over the years many consumers who do not have this disorder, rightly or wrongly, seemed to have started a feeling that gluten is a villainous food component and avoiding the same can improve their quality of life.The result was the beginning of a booming industry that caught the fancy of the consumer creating a huge market. Whether it is ethical for this industry to make a fast buck exploiting the misconception that is gaining traction during the last one decade is a difficult issue to answer because the industry is after all giving to the consumer what he wants on a platter. What may not be justified is the massive marketing blitz singing the virtues of gluten free foods attracting more and more consumers of normal health into the fold of IBS patients. The global business for gluten free foods is reported to be worth $ 3 billion which is predicted to reach about $ 5 billion within 5 years. Interestingly Europe leads in marketing these foods, more than 50% of business generated in this region. But in terms of growth, USA is on a fast galloping growth phase out pacing Europe in the near future though no one knows what is contributing to this peculiar phenomenon.

Though no reliable statistics can be cited for the extent of people affected by intestinal disorders like IBS and Celiac disease, some estimates claim that 10-15% of global population is affected. But among those patronizing gluten free foods more than 70% are not suffering from this affliction. That means the size of the current market does not reflect the ground reality vis-a-vis gluten induced GI disorders. While gluten free food market is fast growing, there is another interesting development that gives further hope to the well being industry to expand the market several fold. Based on the findings in Australia that besides gluten, there is a range of food constituents present naturally in most foods which can also create GI related disorders. These are collectively called FODMAPS, the acronym for Fermentable, Oligo-, Di--Mono-saccharides and polyols and it has been scientifically shown that reducing the levels of FODMAPS containing foods in the diet dramatically provides relief to those suffering from such GI related disorders. What does this mean to the food industry? A sign that demand for specially designed food products containing no or low levels of FODMAPS is bound to grow dramatically in the coming years.

Though Gluten cornered all the attention over many years as a causative factor for GI disorders, there have been many observations in the past that consumption of some carbohydrates does not go well with many consumers and among them a few short-chain carbohydrates that include lactose, fructose and sorbitol, fructans and galacto oligosaccharides caused IBS-like symptoms. What was more significant was that such studies also showed dramatic improvements among the affected people when there was dietary restriction to exclude short-chain carbohydrates in the diet. These carbohydrates induced symptoms similar to that caused by Gluten in the small intestine. These short-chain carbohydrates, being small molecules are either poorly absorbed or not absorbed at all and are capable of dragging water into the intestine through osmosis Further  they are easily fermented by colonic bacteria that reside in the large intestine generating gases like hydrogen, carbon dioxide and methane. Such a situation causes an expansion in volume of intestinal contents, which stretches the intestinal wall and stimulates nerves in the gut. that triggers the sensations of pain and discomfort, commonly experienced by those affected by IBS. The FODMAP concept maintains that a collective reduction in the dietary intake of all indigestible or slowly absorbed, short-chain carbohydrates would minimise stretching of the intestinal wall which in turn may reduce stimulation of the gut's nervous system and provide the best chance of reducing symptom generation in people with IBS. Later the collective term FODMAPS was evolved for designating indigestible or slowly absorbed, short-chain carbohydrates. 

Formulation of low FODMAP diet was originally developed by scientists in Australia and tested as to know whether low FODMAP diet really improved symptom control in patients with IBS. It is this pioneering work  which established the mechanism by which the diet exerted its effect. This led to efforts to evolve methodologies for measuring the FODMAPS content in foods and create a data base for foods that are consumed regularly. It is tribute to these scientists that a comprehensive and accurate database now exists describing the FODMAP content of a vast array of foods. There is now a better understanding about the mechanism by which the diet works and there is sound evidence indicating that a low FODMAP diet improves symptom control in approximately three out of every four people with IBS and other other Functional Gastric Intestinal Disorders (FGID). To day it is more or less agreed that the basis of many functional gastrointestinal disorders (FGIDs) is distension of the intestinal lumen. Such luminal distension may induce pain, a sensation of bloating, abdominal distension and motility disorders. Therapeutic approaches seek to reduce factors that lead to distension, particularly of the distal small and proximal large intestine. Food substances that can induce distension are those that are poorly absorbed in the proximal small intestine, osmotically active, and fermented by intestinal bacteria with hydrogen. 

An important question that may trouble many consumers is whether poor absorption of most FODMAP carbohydrates present in many foods can affect every body including normal healthy persons. A pertinent question that can be explained away in an understandable language.  Any FODMAPs that are not absorbed in the small intestine pass into the large intestine, where bacteria ferment them. The resultant production of gas potentially results in bloating and flatulence. Fortunately most individuals do not suffer significant symptoms but some may suffer the symptoms of IBS depending on their constitution and other biological variations. Fructose
malabsorption and lactose intolerance may produce IBS symptoms through the same mechanism but, unlike with other FODMAPs, poor absorption is found only in a minority of people. Many who 
benefit from a low FODMAP diet need not restrict fructose or lactose. It is possible to distinguish these two conditions by breath testing for the presence of hydrogen hydrogen and methane breath which will help to build into the diet only reasonable restrictions. Some of the significant sources of FODMAPS include wheat, rye, barley, onion, garlic, jerusalem  & globe artichokes, asparagus, beetroot, chicory, dandelion leaves, leek, broccoli, brussel sprouts, cabbage, fennel etc. Pulses and beans are rich in galactans while some some fruits like apples, apricots, avocado, blackberries, cherries, lychees, nectarines peaches, pears, prunes, water melon have significant concentrations of polyols. Isomalt, maltitol, mannitol, sorbitol and xylitol gets into the food when they are used as functional processing adjuncts by the industry. If such a large portfolio of foods is out of bounds for some people vulnerable to GI system malfunctioning, it is difficult to imagine how their quality of life is affected. May be this is the price humans pay for the progress of civilization as we see to it day. Ultimately the one going to be benefited is the well being food industry and the pharma sector! 


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