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Complex carbohydrates are an excellent energy source rich in vitamins, minerals and
fiber. But many people are intolerant to such foods, including fruits and vegetables,
whole grains, nuts and seeds, breads, cereals, beans, lentils and dried peas. This
intolerance can lead to uncomfortable and embarrassing symptoms such as flatulence,
abdominal pain, cramping, diarrhea, and/or constipation.1
Many patients are unsure if their gastrointestinal symptoms are within normal limits
and often hesitate to seek treatment. There is a need to facilitate awareness and
discussion about bowel gas and gastrointestinal distress caused by carbohydrate
intolerance. As such, Complex Carbohydrate Intolerance (CCI) becomes a broad term
to encompass the range of symptoms associated with carbohydrate intolerance. By
linking common symptoms of carbohydrate intolerance with the term CCI, patients
will be able to more easily open discussion with physicians, pharmacists, and other
healthcare professionals about the embarrassing symptoms associated with this
condition and make appropriate choices to treat rather than merely mask symptoms.1
With an understanding of complex carbohydrates that may cause varying degrees of
gastrointestinal distress and available treatment alternatives for CCI, people will
be able to better tolerate healthy, balanced diets rich in complex carbohydrates.1
Complex carbohydrates consist of oligosaccharides, long chains of monosaccharides
(small sugar units that cannot be further broken down) held together by alpha-galactosidic
linkages. Oligosaccharide digestion is necessary because the gastrointestinal tract can
only absorb monosaccharides, including glucose and galactose, in the small intestine.
Following this digestion, the glucose, galactose, and other simple sugars are transported
by an enzyme to specialized cells in the small intestine where they are absorbed and
transferred to other cells and used by the body for energy.
The inability of the small intestine to adequately transport and absorb glucose, galactose,
and other monosaccharides is caused by a lack of a sufficient number of enzymes required to
digest oligosaccharide bonds. In particular, all humans lack the intestinal enzyme
alpha-galactosidase, which is required to hydrolyze alpha-galactosidic linkages present
in complex carbohydrates.2 Such a deficiency of enzymes results in incomplete
digestion of complex carbohydrates, allowing unabsorbed undigested sugars to move into the
large intestine. As a result of fermentation by native microbial flora in the large
intestines, the undigested carbohydrates produce hydrogen, carbon dioxide, and short
chain fatty acids2, resulting in bloating, pain and gastrointestinal discomfort.
Diet and Lifestyle
People who are carbohydrate intolerant should follow a low-carbohydrate diet with low intake
of legumes, starches, sorbitol, fructose, fiber and lactose. This type of diet will help
reduce the amount of substrate for bacterial fermentation during digestion that results in
uncomfortable bloating.3
Gas may also be reduced by a variety of simple lifestyle changes. Throughout the day, small
quantities of air are swallowed. To decrease excessive air swallowing and the associated
flatulence, patients may be benefit from various techniques, including chewing food rather
than gulping it, eating and drinking slowly, and avoidance of gum, hard candy, and tobacco
products.3
Exercise may help gas move more quickly through one's digestive tract, thus reducing the
discomfort associated with CCI.
Drug Products
There are a variety of prescription and over-the-counter medications available to address
various symptoms associated with carbohydrate intolerance.
Prescription drugs. Tetracycline, an antibiotic, is often recommended for patients with
bacterial overgrowth of the small intestine.3 Metoclopramide, a gastrointestinal
stimulant, is also used for treatment of gastrointestinal discomfort; however, there are
limited data to support its use in decreasing distention and bloating.3 While
these drugs may target specific symptoms associated with CCI, they do not allow the body
to more easily digest complex carbohydrates, thus preventing occurrence of CCI symptoms.
Over-the-counter drugs. Simethicone, an agent that results in less residual gas to cause
uncomfortable cramping, is often used for treatment of excess gas. Simethicone may cause
gas bubbles in the stomach to combine, forming larger bubbles thereby allowing the patient
to excrete a greater volume of gas at one time. Alternatively, simethicone may facilitate
the passage of gas through the bowel lumen.4 Simethicone treatment, however,
does not reduce the actual amount of gas in the intestinal lumen. In fact, some studies
suggest that simethicone does not exhibit any beneficial effect on symptoms of intestinal
gas.5 Simethicone is available as a single agent or in combination with
antacids.
Antacid/anti-diarrhea products, such as bismuth subsalicylate, are often used to help
reduce indigestion, nausea, and diarrhea, and to reduce fecal and flatus odor.3
However, these products do not prevent the formation of gas.
Dietary Supplements
In addition to antacids, dietary supplements are available for over-the-counter treatment
of CCI symptoms. Activated charcoal tablets can be taken after meals or at the first sign
of gas discomfort. Although there are limited data to support efficacy,3
charcoal may decrease odor from gas in the colon. Importantly, however, charcoal does
not prevent gas from forming. In addition, charcoal can be associated with unpleasant side
effects, including black, tarry stools.
Research suggests that bacteria may be an effective therapy for prevention or treatment of
some gastrointestinal conditions. Probiotics and prebiotics, therefore, may relieve gas,
bloating, and other conditions caused by gut flora.6
Peppermint and other herbs that soothe the digestive tract may also be beneficial in
preventing belching and decreasing bloating after large meals. Evidence suggests that
enteric-coated peppermint oil capsules may reduce abdominal pain, distention, flatulence,
and bowel movements in 70% to 80% of patients 8 years of age and older with irritable bowel
syndrome.7-10 Despite its efficacy, it should be noted that peppermint and other
herbs do not target the enzyme deficiency responsible for CCI discomfort.
Enzyme Replacement
Nonprescription enzyme replacement/anti-gas products are available to relieve flatulence,
burping, bloating, and abdominal discomfort associated with CCI. Unlike lifestyle/diet changes,
drug treatments, and dietary supplements, enzyme replacement helps the body break down complex
carbohydrates thereby preventing the formation of gas and associated discomfort.
The enzyme alpha-galactosidase, which is derived from the mold Aspergillus niger, has been
shown to diminish intestinal gas production by enhancing the breakdown of oligosaccharides
before they reach the lower intestine.11-14 Although further study is warranted,
the available data suggest that alpha-galactosidase added to high-fiber foods decreases gas,
bloating, and flatulence. A variety of studies,
demonstrate the efficacy of alpha-galactosidase (available under the Beano® trade name)
in treatment of CCI symptoms.
Based on the available safety information, alpha-galactosidase should be considered safe for
use in adults and children over age 12. Individuals with known medical conditions, including
galactosemia (a rare autosomal recessive inborn error of galactose metabolism) and diabetes
should use alpha-galactosidase under the supervision of a doctor. In addition, pregnant and
lactating women should be advised to consult a physician before taking this, or any, dietary
supplement.
So, while there are a variety of measures that can be taken to help patients manage bloating
and flatulence, effective treatments for CCI target the root cause of the problem, rather
than just the symptoms. Enzyme replacement therapy with alpha-galactosidase, such as Beano®,
is the only treatment alternative that treats the deficiency in enzymes necessary to digest
complex carbohydrate, thus preventing formation of gas and CCI symptoms. To prevent gas
before it starts, alpha-galactosidase preparations (one tablet or 5 drops liquid)†
should be taken at the same time as ingestion of each half-cup serving of complex carbohydrate
foods. There is significant scientific agreement that the symptoms associated with CCI are
related to insufficient quantities of the alpha-galactosidase enzyme. As such, most
authoritative bodies and sources of healthcare information recognize enzyme replacement
as the only option for preventing symptoms in patients who should not, or choose not, to
avoid foods rich in complex carbohydrates.
References:
1 Levine B, Weisman S. Enzyme Replacement as an Effective Treatment for the Common Symptoms of Complex Carbohydrate Intolerance. Nutrition in Clinical Care. 2004.
2 Worthington RE, Beuchat LR. Alpha-galactosidase activity of fungi on intestinal gas-forming peanut oligosaccharides. J Agric Food Chcm. 1974;22:1063-1066.
3 Fink RN, Lembo AJ. Intestinal gas. Curr Treat Options Gastroenterol2001;4:333-337.
4 Pray SW. Consult your pharmacist. Excessive gas: what can be done? US Pharmacist. 1998;23 (6).
5 Friis H, Bode S, Rumessen JJ, Gudmand-Hoyer E. Effect of simethicone on lactulose-induced H2 production and gastrointestinal symptoms. Digestion. 1991;49:227-230.
6 Teitelbaum JE, Walker WA. Nutritional impact of pre- and probiotics as protective gastrointestinal organisms. Annu Rev Nutr. 2002;22:107-138.
7 Liu JH, Chen GH, Yeh HZ, Huang CK, Poon SK. Enteric-coated peppermint-oil capsules in the treatment of irritable bowel syndrome: a prospective, randomized trial. J Gastroenterol. 1997;32:765-768.
8 Pittler MH, Ernst E. Peppermint oil for irritable bowel syndrome: a critical review and metaanalysis. Am J Gastroenterol. 1998;93:1131-1135.
9 Tate S. Peppermint oil: a treatment for postoperative nausea. J Adv Nurs. 1997;26:543-549.
10 Kline RM, Kline JJ, Di Palma J, Barbero GJ. Enteric-coated, pH-dependent peppermint oil capsules for the treatment of irritable bowel syndrome in children. J Pediatr. 2001;138:125-128.
11 Solomons NW, Guerrero AM, Zepada E, Grazioso C. The efficacy of an oral alpha-galactosidase to promote oligosaccharide hydrolysis and to reduce intolerance symptoms after ingestion of beans: a dose response trial. Clin Res. 1991;39:655A.
12 Solomons NW, Vettorazzi L, and Grazioso C. Use of an oral alpha-galactosidase to control gastrointestinal symptoms from legume oligosaccharides in bean-intolerant subjects: a doubly masked, controlled therapeutic trial. Clin Res. 1991;39:428A.
13 Ganiats TG, Norcross WA, Halverson AL, Burford PA, Palinkas LA. Does Beano prevent gas? A double-blind crossover study of oral alpha- galactosidase to treat dietary oligosaccharide intolerance. J Fam Pract. 1994;39:441-445.
14 Lettieri JT, Dain B. Effects of beano on the tolerability and pharmacodynamics of acarbose. Clin Ther. 1998;20:497-504.
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