DISACCHARIDE INTOLERANCE
Intolerance of disaccharides almost always leads to digestive-tract symptoms, such as abdominal bloating, pressure, and pain, often accompanied by diarrhea, sometimes alternating with constipation, and occasionally nausea and vomiting. The reason for the problem is an inability to digest disaccharide sugars. The most well-known and the commonest disaccharide intolerance is lactose (milk sugar) intolerance. But intolerance of other disaccharides such as sucrose (table sugar, syrup, and fruit sugar), and less frequently maltose (the sugar usually derived from grains), is experienced by some people, often as an inherited condition. This chapter will discuss the symptoms and causes of intolerance of all the disaccharides you are likely to encounter in your diet. More importantly, it will tell you how to avoid your particular “problem sugar” and give you the information you need to obtain complete, well-balanced nutrition despite your dietary restrictions.
Disaccharide intolerance may occur in a variety of conditions that damage the tissues and cells lining the digestive tract. These conditions include deficiency in digestive enzymes, for example, lactase deficiency and sucrase-isomaltase deficiency; cow’s milk and soy protein-sensitive allergy or enteropathy; gluten-sensitive enteropathy (celiac disease); infections in the digestive tract caused by parasites such as amoebae, helminths, nematodes, and microorganisms such as Giardia lamblia and viruses such as the rotavirus group. In infants, additional causes include immaturity of the digestive tract and congenital absence of enzymes or components of the transport systems needed to digest sugars. In all cases, symptoms are confined to the digestive tract.
The Cause of Disaccharide Intolerance
Sugars, starches, and complex carbohydrates in foods are broken down (digested) by enzymes produced in the body. In order to be transported across the lining of the digestive tract and into circulation to be used in body processes, carbohydrates must be broken down to monosaccharides (“single sugars”). The carbohydrate composition of the normal diet is about 60% starch, 30% sucrose, and 10% lactose. Each carbohydrate is treated slightly differently in the process of digestion.
When carbohydrates reach the small intestine, they have been largely broken down to disaccharides — sugars made up of two sugar molecules. However, these still have to be broken down to monosaccharides before they can be transported into circulation. This final degradation is carried out by disaccharidase enzymes. These enzymes are produced in cells lining the small intestine, called brush border cells. This is in contrast to other types of digestive enzymes that are produced in organs at a distance from the digestive tract, such as the pancreas, and are brought to the intestines after they are formed. However, if the cells lining the small intestine are damaged, adequate amounts of the disaccharidase enzymes cannot be produced, and the disaccharide sugars remain intact and undigested. The undigested sugars then pass into the large bowel (the colon) where bacteria act on them in a process of fermentation. The products of microbial fermentation cause the symptoms of disaccharide intolerance.
Symptoms
Fluid is drawn into the large intestine to normalize the increased osmotic pressure produced by excess sugar. Gases are produced as a result of an increase in microbial growth and fermentation in the bowel. This results in abdominal bloating, pain, and flatulence. Organic acids are produced by microbial fermentation in the bowel, which also causes a change in osmotic pressure, leading to more water being retained in the bowel. Watery diarrhea or loose stool results from the increase in fluid in the bowel.
Conditions Leading to Disaccharidase Deficiencies
There are several reasons why the cells lining the small intestine stop producing disaccharidases:
1. In many cases the cells are damaged by inflammation resulting from an intestinal infection (enteritis). The infection is often due to a virus or bacterium, or sometimes to intestinal parasites such as amoebae, Giardia lamblia, helminths, or nematode worms.
2. Inflammation may also be caused by a food allergy. The intolerance is secondary to (follows) the allergy, but will persist as long as the food allergy continues.
3. Use of strong drugs and medications taken by mouth, such as antibiotics, may cause damage to the fragile cells.
4. It may be the result of an inherited tendency. This is most commonly seen in lactose intolerance: loss of the ability to produce lactase, the disaccharidase that breaks down lactose, the sugar in milk. This usually occurs after the age of five years.
5. In rare cases, an infant inherits the condition and is disaccharidase-deficient from birth.
Duration of the Condition
If the disaccharidase deficiency is a result of damage to the intestinal cells, caused by infection, food allergy, or strong drugs, it is called a secondary deficiency and is usually temporary. When the primary cause is removed, the cells will start to heal and gradually resume production of disaccharidase enzymes. Over time, you will be able to tolerate many foods to which you are presently intolerant.
If the deficiency is a result of an inherited tendency, it is likely that the disaccharide intolerance will be lifelong: This is called a primary deficiency. The foods that cause the most problems must always be avoided. In some cases, the deficient disaccharidase enzyme can be provided in the form of medication (liquid or tablets) to be eaten with the food, or drops can be added to foods (for example, lactase in the form of Lactaid) and you will be able to tolerate a certain amount of the treated food.
In most cases, a disaccharide intolerance is dose-related. Usually the cells are producing a limited amount of disaccharidase enzyme, and small doses of foods containing disaccharides can be processed. Problems occur when the amount of disaccharide in the food exceeds the capacity of the enzymes to digest it. The important thing is to determine your own body’s capacity to handle disaccharide. As long as you remain within your personal limits, you should remain symptom-free.
The Problem Disaccharides Lactose
This is the sugar in milk. It occurs mostly in the whey (liquid) fraction of milk, although foods made mainly of casein (such as cheeses) may still contain a small amount of lactose. The enzyme that breaks down lactose is called lactase. It splits lactose into two monosaccharides: glucose and galactose. A person whose intestinal cells are producing very little lactase will not be able to break down much lactose. Lactose intolerance is quite different from milk allergy in which a person’s immune system fights the protein in milk.
Sucrose
Table sugar and syrups are examples of sucrose. Table sugar usually comes from sugar beet or sugar cane, but is also present in many plants, especially fruits, grains, and vegetables. Syrup may be made from many types of grains, or from plants such as the maple tree from which maple syrup is extracted. The enzyme that breaks down sucrose is called sucrase. It splits sucrose into two monosaccharides: glucose and fructose.
Maltose
Maltose is found mostly in grains and starchy vegetables. The enzymes that break down maltose include maltase and isomaltase: They split maltose and starches into molecules of the monosaccharide, or “single sugar,” glucose.
Starches
Starches are made up of long chains of glucose molecules. The linkages between the glucose molecules all have to be split to release the free glucose before it can be absorbed. If there is a deficiency in the enzymes that split these linkages, free glucose molecules will not be released, and the remaining undigested starch or sugar will be passed to the large bowel where bacteria will ferment it, resulting in the symptoms discussed earlier.
Identifying the Disaccharide That Is Deficient
Except in the case of a lactase deficiency, which improves dramatically when lactose is removed from the diet, it is often difficult to separate specific disaccharide intolerances from each other.
If the deficiency is due to damage to intestinal cells, loss or reduction in activity of all the disaccharidases often results. In such a case it is usually advisable to follow a diet restricting all disaccharides at first. Because this is usually a temporary situation, avoidance will lead to healing and the foods may be tolerated in increasingly large amounts the longer the diet is followed.
If the deficiency is permanent, it is often due to loss, or lack, of the ability to produce one specific disaccharidase; in this case, efforts should be made to identify the specific deficiency. In the majority of cases, it will be a lactase deficiency as this is usually an inherited tendency, often associated with certain racial groups. Eighty percent of the world’s adult population tend to lose the ability to produce lactase. Only people of northern European descent tend to retain the ability to produce lactase throughout life; 80% of this group usually can digest lactose.
Requirement for Nutritional Supplements
In general, if you are eating a wide range of the allowed foods and the disaccharide intolerance is a secondary (temporary) deficiency, you should not need a supplement. The amount of supplement that may be required will depend on individual tolerances to the disaccharide-containing food; some people will be able to tolerate a small amount of the food, so any deficiencies will be minimal. For people with primary (permanent) deficiencies, or those who need to follow the diet for an extended period of time, the following supplements may be necessary:
Lactose restricted: calcium and possibly vitamin D Sucrose restricted: vitamin C Maltose restricted: vitamin B complex
Feeding the Disaccharide-Intolerant Baby
Infant formulas that are lactose-free and sucrose-free can be given to a disaccharidase-deficient infant. If the baby is not allergic to cow’s milk proteins the milk-based formulas Enfalac (Enfamil), LactoFree (Mead Johnson), and Similac
LF (Ross), which are free from lactose and sucrose are suitable. If the infant is allergic to cow’s milk proteins, but tolerates soy, the soy-based formulas Enfalac (Enfamil) and ProSobee (Mead Johnson), which are sucrose-free, are suitable. The infant who is allergic to both cow’s milk and soy proteins may tolerate a casein hydrolysate formula such as Enfalac (Enfamil), Nutramigen (Mead Johnson), or Pregestimil (Mead Johnson), which are free from lactose and sucrose.
A breast-fed baby will ingest significant quantities of lactose in mother’s milk. The lactose composition of her milk will remain constant, regardless of whether or not the mother consumes milk and dairy products. If the baby’s lactose intolerance is secondary to a gastrointestinal tract infection or other condition that is expected to be temporary, some authorities advise continuing breast-feeding and expect the diarrhea to gradually diminish as the underlying inflammation disappears.
Alternatively, the mother can pump her breast milk, treat it with Lactaid drops (4 drops per 250 milliliters of milk), and allow the enzyme to act for 24 hours in the fridge. The baby will be fed the lactose-free milk the next day. This is continued until the diarrhea stops, when the baby can be gradually put back to the breast.
The Disaccharide-Free Diet (Table The disaccharide-free diet: foods allowed and foods restricted)
Restriction of all disaccharides is required initially.
Phase I should be followed for a minimum of four weeks to find out if disaccharidase deficiency is the cause of the gastrointestinal symptoms, specifically diarrhea. When the diarrhea improves, loosening of these restrictions will determine each individual’s tolerance for each disaccharide.
Phase II involves introduction of one food from the “restricted” lists every other day until diarrhea recurs. Maltose tolerance is determined by introducing grains, especially “white” grains and flours. Sucrose tolerance is determined by introducing vegetables, fruits, nuts and seeds, and finally sugars. Lactose tolerance is determined by introducing dairy products and milk.
Table The disaccharide-free diet: foods allowed and foods restricted
| Type of Food | Foods Allowed | Foods Restricted |
| Milk and
Milk Products |
• Cheeses (not processed):
-Brie - Camembert - Cheddar - Gruyere - Limburger - Monterey Jack - Mozzarella - Port du Salut • Non-dairy creamers, e.g., Coffee Rich |
All except those listed at left |
| Grains, Breads,
and Cereals |
• None | Ml, including:
Flours made from grains Amaranth Barley Buckwheat Bulgur Corn Millet Oats Quinoa Rice Rye Spelt Triticale Wheat |
| Vegetables | Fresh, frozen, canned, without
added sugar or starch: • Celery • Chives • Cucumber • Endive • Garlic • Green onion • Kale • Lettuce • Mushrooms • Parsley • Parsnips • Peppers, green and red • Potatoes, french fried or hash browns • Radishes • Spinach • Swiss chard • Tomatoes • Tomato juice • Turnip • Watercress • Avocado |
Canned with additives
Added sauces Added butter or margarine Asparagus Artichokes Broccoli Cabbage, green and red Carrots Cauliflower Corn Kohlrabi Leeks Okra Onion (mature, cooking) Potatoes (boiled) Pumpkin Squash, all types Sweet potatoes Yams V-8 Vegetable Juice |
| Fruit | Fresh, frozen, canned
in own juice • Berries: - Blackberry - Blueberry - Cranberry - Gooseberry - Loganberry • Cherry • Currants, red and black • Damson plums • Figs, raw • Guava • Grapes • Grape juice • Kiwi fruit • Lemon • Lime • Passion fruit (granadilla) |
Added sugar or syrup
Apple Apricot Banana Date Grapefruit Mango Melon, all types Nectarine Orange Papaya (pawpaw) Peach Pear Pineapple, raw Plum, prune type Raspberry Strawberry Tangerine Watermelon |
| Meat, Poultry,
and Fish |
All fresh or frozen:
• Lamb • Beef • Pork • Wild game • Chicken • Duck • Turkey • Game birds • Fin fish • Shellfish |
Processed
Breaded Smoked Cured Canned Corned Beef |
| Eggs | • Cooked, plain (e.g., fried, boiled, scrambled) | With added milk, flour, or sugar |
| Legumes | • Tofu | • Bean sprouts
• Black-eyed peas • Broad beans (fava beans) • Chickpeas (garbanzos) • Green and wax beans • Kidney beans • Lentils • Navy beans • Peanut • Peas • Soybeans • Split peas |
| Nuts and Seeds | • None | All, including
• Almond • Beechnut • Brazil nut • Butternut • Cashew • Hazelnut (filbert) • Hickory • Macadam ia • Peanut • Pecan • Pistachio • Pumpkin seed • Sesame seed • Soybean (roasted) • Sunflower seed • Walnut |
| Fats and Oils | • Pure vegetable oil:
- Canola - Corn - Flaxseed - Olive - Safflower -Soy - Sunflower • Margarine without milk solids, e.g., Fleischmann’s Low Sodium, No Salt Margarine • Parkay Diet Spread • Some other diet spreads • Lard and meat drippings |
• Butter
• Margarine containing whey or milk solids |
| Sugars and
Sweeteners |
Glucose
Dextrose Fructose (fruit sugar) Levulose Honey Sugar substitutes (lactose-free and in moderation) Aspartame Cyclamate Saccharine Sugar Twin Equal Sweet ‘n’ Low |
• Sucrose (table sugar)
• Lactose (milk sugar) • Maltose (grain sugar) • Foods containing sugars • Syrups |
| Spices and
Herbs |
Allspice
Anise seed Basil Bay leaf Caraway Cayenne Celery Chervil Chili powder Cinnamon Cloves Coriander, leaf or seed Cumin seed Dill, seed or weed Fennel seed Fenugreek seed Garlic powder Ginger Mace Marjoram Mustard Nutmeg Onion powder Oregano Paprika Parsley Pepper, black and white Poppy seed Poultry seasoning Rosemary Sage Savory Tarragon Thyme Turmeric |
• Herb or spice mixes or
seasoning packets • Curry |
This post has been viewed 778 times.