Question:

I have been gluten-free and dairy free for over a year now, and I have never felt better until recently. Now when I eat, especially alcohol or soda pop (which is rare for me) in any size amount I get painful symptoms in my stomach and intestines.  I have discontinued eating them the last few days, but the symptoms are continuing whenever I eat.

From, 

Sarah

Answer:

Hi Sarah,
What you describe may be an issue with poorly absorbed sugars (carbohydrates), known as FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols). Please see the other entry on FODMAPs for more details on them and the testing that can be done to assess one’s ability to absorb them. Fructose is one type of poorly absorbed carbohydrate that is getting a lot of attention lately, especially in the celiac literature.

It is interesting to note that if fructose is eaten at the same time as glucose (a type of sugar that is very well absorbed by the human body), it can improve fructose absorption. For example, if you eat an orange (which has relatively equal amounts of fructose and glucose), it is better tolerated than a fruit or vegetable that has a high fructose load, such as an apple or asparagus. 

Regular soda often contains high amounts of fructose, corn syrup, or high fructose corn syrup, three ingredients which commonly cause GI problems in people, especially those with sensitive gastrointestinal (GI) tracts. Diet soda contains polyol sweeteners (sugar free ingredients such as sorbitol, xylitol, mannitol, and isomalt) which are another category of FODMAPs. Grapes, the main ingredient in wine, are a type of FODMAPs called fructans, another type of poorly absorbed sugar. Some wines contain mannitol. Although wines have not been extensively tested for their fructose content, it seems likely that they could be poorly tolerated by some people. Of note, distilled alcohol has not been tested either but, per the experts, they seem better tolerated. Be careful of any mixers or added flavorings which could contain sugar and are obviously a potential problem. And be sure to drink alcohol with food to help offset the sugar load.

If your symptoms don’t clear after you remove these two beverages, it might mean that you have other problematic FODMAPs in your diet. It is recommended that you speak to a dietitian who can help you find possible additional FODMAPs that you might remove for a trial period.

Another possibility is small intestinal bacterial overgrowth (SIBO), a common complication of many different types of gastrointestinal disorders and diseases, such as celiac disease. Although there are between 300 and 500 different types of bacterial species in the human gastrointestinal tract, most of them are in the middle and last parts of the small intestine and in the colon. Abnormal intestinal motion and lowered immune defense are two likely reasons why large numbers of bacteria may grow in the upper small intestine which normally contain few bacteria. This can result in injury to the intestinal lining causing malabsorption of vitamin and minerals, as well as gas, bloating and other symptoms that mimic celiac disease. Talk to your doctor about SIBO; the standard test is the lactulose or glucose breath test and the standard therapy is a course of antibiotics. Probiotics may be recommended to help reestablish friendly bacteria in the gut.

And, as always, share your symptoms with your doctor so that further investigation can be done, as needed, for your best health. 

Sincerely,

Melinda Dennis, MS, RD, LDN

References:

Melinda Dennis, MS, RD, LDN and Daniel Leffler, MD, MS. Small Intestinal Bacterial Overgrowth in Real Life with Celiac Disease. American Gastroenterology Advisory Press, Bethesda, MD, 2010.  

Quigley EM, Quera R. Small intestinal bacterial overgrowth: roles of antibiotics, prebiotics, and probiotics. Gastroenterology 2006;130:S78-90.