Nutritional supplements used in weight-reduction programs increase intestinal gas in persons who malabsorb lactose.

OBJECTIVE: To determine if ingestion of 2 doses of milk-based dietary supplements produce gaseous symptoms in subjects who malabsorb lactose. DESIGN: Randomized, controlled, crossover trial. SUBJECTS/SETTING: Ten community-based subjects who malabsorb lactose. INTERVENTION: Ingestion of 2 standard servings of milk-based supplements (a powder reconstituted in fat-free milk or a ready-to-drink preparation) or low-lactose control preparations. MAIN OUTCOME MEASURES: Frequency of flatus passage and subjective impression of bloating, flatulence, and abdominal discomfort. STATISTICAL ANALYSIS: Wilcoxon signed-rank test. RESULTS: The high lactose content (27 g) of 2 servings of the powder-based supplement ingested without other food resulted in a marked increase in daily flatus passages from the basal level of 9.7+/-8.2 to 30+/-14 (mean+/-SD), and a significant increase in the subjects' perception of gas. In contrast, the lower lactose content (18.4 g) of 2 servings of a ready-to-drink supplement resulted in a flatus frequency of 17+/-10 (P=.14 vs baseline) and no significant increase in the perception of increased gas. Neither supplement resulted in a significant increase in bloating, abdominal pain, or diarrhea. The lactose content of the liquid supplement was reduced by 80% following overnight incubation with an over-the-counter lactase preparation. APPLICATIONS/CONCLUSIONS: Persons who malabsorb lactose should be aware that sizable increases in rectal gas commonly occur when milk-based powders reconstituted in milk are used as meal replacements. In contrast, gas problems probably will be minor following ingestion of 2 doses of a ready-to-drink, milk-based supplement. The lactose content of these supplements can be markedly reduced by overnight incubation with over-the-counter lactase preparations, and this manipulation should be beneficial for subjects troubled by the increased gas caused by the consumption of lactose-containing supplements.

Lactose maldigestion is not an impediment to the intake of 1500 mg calcium daily as dairy products.

BACKGROUND: A National Institutes of Health consensus conference concluded that a daily calcium intake of 1500 mg reduces the severity of osteoporosis. Because dairy products are the main natural source of dietary calcium, a diet providing 1500 mg Ca must contain large quantities of dairy products. However, it is widely believed that the lactose content of these products will not be tolerated by persons with lactose maldigestion (approximately 30% of the adult US population). OBJECTIVE: We evaluated the symptoms of lactose maldigestion and digestion when the diet was supplemented with dairy products providing 1300 mg Ca/d. DESIGN: Sixty-two women (31 with lactose maldigestion and 31 without) were studied in a double-blind, randomized protocol. Symptoms were compared during 1-wk periods when the diet was supplemented with 480 mL (2 cups) milk, 56 g cheese, and 240 mL yogurt provided as conventional products (34 g lactose/d) or as lactose-hydrolyzed products (2 g lactose/d). RESULTS: Women who digested lactose reported no significant difference in symptoms between the 2 treatment periods. Women with lactose maldigestion reported significantly increased flatus frequency and subjective impression of rectal gas during the period of high lactose intake; however, bloating, abdominal pain, diarrhea, and the global perception of overall symptom severity were not significantly different between the 2 treatment periods. CONCLUSION: The symptoms resulting from lactose maldigestion are not a major impediment to the ingestion of a dairy-rich diet supplying approximately 1500 mg Ca/d.

Fecal hydrogen sulfide production in ulcerative colitis.

OBJECTIVE: Sulfide, a product of sulfate-reducing bacteria, has been proposed to play an etiologic role in ulcerative colitis. Ulcerative colitis feces have increased numbers and activity of sulfate-reducing bacteria, but only modestly increased sulfide. However, fecal sulfide exists largely in the volatile, highly toxic H2S form that moves rapidly from feces to surrounding gas. Our aim was to quantify the fecal release of H2S and other volatiles (CO2, H2, CH4, methanethiol, and dimethylsulfide). METHODS: Fecal samples from 25 subjects with ulcerative colitis and 17 controls were incubated in 4-L containers, and gas release was assessed at intervals over 24 h. RESULTS: H2S release by ulcerative colitis feces was elevated 3-4-fold at every measurement point compared with normal feces (p < 0.003 at 24 h). The only other significant difference was increased CO2 release by ulcerative colitis feces at 1 h. Supplementation of fecal homogenates with sulfur-containing substrates showed that organic compounds (mucin, cysteine, taurocholate) provided more readily utilizable substrate for H2S production than did sulfate. CONCLUSIONS: Increased H2S release is a relatively localized metabolic aberration of ulcerative colitis feces. This increased H2S may reflect abnormalities of the fecal bacteria and/or substrate availability.

Absence of gaseous symptoms during ingestion of commercial fibre preparations.

BACKGROUND: While fibre is believed to cause gaseous symptoms, a study in healthy volunteers showed no increase in flatulence when the diet was supplemented with fermentable (psyllium) or non-fermentable (methylcellulose) fibre. However, extrapolation of this observation to subjects who use fibre is arguable since these individuals may have a propensity to gaseousness. In the present study, gaseous complaints during fibre ingestion were assessed in subjects who believed that a previous exposure to fibre induced gas. METHODS: In a double-blind protocol, subjects were randomized to one of four treatment periods, during which the regular diet was supplemented for 1-week periods with two daily doses of: placebo 10 g, psyllium 3.4 g, methylcellulose 2 g or lactulose 5 g. A symptom diary was maintained for 1-week periods on or off treatment. RESULTS: During treatment, the lactulose group passed gas significantly more often than did the psyllium or the methylcellulose group (P = 0.01). No other symptom was significantly different among the treatment groups. CONCLUSIONS: (1) psyllium and methylcellulose did not cause greater gaseous symptomatology than did placebo in subjects who believed that these preparations caused gas; and (2) subjects commonly misidentify dietary components that cause gaseous symptoms.

The relation of passage of gas an abdominal bloating to colonic gas production.

OBJECTIVE: To determine the relation of gas passage and abdominal bloating to the production of gas in the colon. DESIGN: Randomized, double-blind, crossover study of gaseous symptoms during a 1-week period. SETTING: A Veterans Affairs medical center. PARTICIPANTS: 25 healthy medical center employees. INTERVENTION: Participants' diets were supplemented with either a placebo (10 g of lactulose, a nonabsorbable sugar), psyllium (a fermentable fiber), or methylcellulose (a nonfermentable fiber). MEASUREMENTS: All participants were polled for gaseous symptoms (including number of gas passages, impression of increased rectal gas, and abdominal bloating), and five were examined for breath hydrogen excretion. RESULTS: Participants passed gas 10 +/- 5.0 times per day (mean +/- SD) during the placebo period. A significant increase in gas passages (to 19 +/- 12 times per day) and a subjective impression of increased rectal gas were reported with lactulose but not with either of the two fiber preparations. Breath hydrogen excretion, an indicator of hydrogen production in the colon, did not increase after ingestion of either of the fibers. However, a statistically significant (P < 0.05) increase in feelings of abdominal bloating (which the participants perceived as excessive gas in the bowel) was reported with both fiber preparations and with lactulose. CONCLUSIONS: The physician should distinguish between excessive gas (which indicates excessive gas production) and feelings of bloating (which are usually unrelated to excessive gas production). Treatment of the former consists of limiting the supply of fermentable material to the colonic bacteria. Symptoms of bloating usually indicate the irritable bowel syndrome, and therapy should be directed accordingly.

Use of metabolic inhibitors to study H2 consumption by human feces: evidence for a pathway other than methanogenesis and sulfate reduction.

Human fecal bacteria produce and consume hydrogen, and consumption rate is a critical determinant of the volume of H2 liberated into the colonic lumen. Two bacterial reactions that have been reported to be major consumers of H2 are methanogenesis and sulfate reduction. To determine the importance of each of these reactions, we measured the disappearance of exogenous H2 during incubation with human fecal homogenates treated with 20 mmol/L 2-bromoethanesulphonic acid (BES), an inhibitor of methanogenesis, and/or 20 mmol/L sodium molybdate (Mo), an inhibitor of sulfate reduction. Four methanogenic and four nonmethanogenic samples consumed an average of 99% and 85%, respectively, of the initial H2 during 22 hours of incubation. With methanogenic homogenates, 36% of the H2 consumption persisted despite inhibition of methanogenesis. Inhibition of sulfate reduction had no effect on the rate of H2 consumption by these eight fecal specimens. The importance of fecal sulfate availability was determined in fecal samples obtained from an additional 14 randomly selected volunteers. Incubation after supplementation with 20 mmol/L sulfate was associated with an increase in sulfide production in four of the samples, and three of these four samples also demonstrated an increased rate of H2 consumption. No such evidence of sulfate reduction was observed in the other 10 homogenates. We conclude that a bacterial reaction other than methanogenesis and sulfate reduction, perhaps the recently described reduction of CO2 to acetate, represents a major metabolic route of H2 disposal in nonmethanogenic feces and a minor, but appreciable, pathway in methanogenic feces.

Nutritional and therapeutic aspects of fermented dairy products.

In summary, evaluation of the nutrient composition of fermented dairy foods indicates that, like milk, they are good sources of protein, calcium, riboflavin and vitamin B12. Fermented dairy foods are also a good source of folic acid due to microbial synthesis. The absorption of lactose in yogurt is enhanced by the presence of bacterial lactase. Like their nonfermented counterparts, fermented dairy foods may be chosen within a broad range of fat and calorie levels. Fermented and low fat milk products contain only forty to sixty-three calories per 100 grams, whereas sour cream, like sweet cream, is high in fat and contains over two hundred calories per 100 grams. Some fermented dairy foods have antibiotic or antitumor activity in vitro or in laboratory rats. The relevance of these findings to the treatment of human diseases is unknown.

Factors affecting the concentration of combustible gases in the colon during colonoscopy.

The colonic concentrations of the combustible gases, H2 and CH4, were well below hazardous levels in 60 consecutive patients at the time of colonoscopy. Independent analysis of the effect of a low residue liquid diet, a 12-hr fast, and bowel cleansing on the pulmonary excretion of these gases suggest that the low colonic concentrations encountered were largely the result of our patient preparation procedure. Both ingestion of the liquid diet and fasting decreased the pulmonary excretion of H2 markedly but caused only a slight fall in CH4 excretion. Thus H2, but not CH4, production appears to depend on the delivery to the colonic bacteria of exogenous fermentable substrate. Bulk removal of bacteria from the colon resulted in about a 10-fold reduction in the excretion of both gases. The results of these studies do not support the need for routine CO2 insufflation prior to colonoscopic electrosurgical polypectomy.