Beano revisited: could enzyme treatment ever replace the low FODMAP diet?
In 1783, Benjamin Franklin wrote ‘it is universally well known, that in digesting our common food, there is created or produced in the bowels of human creatures, a great quantity of wind. Franklin also suggested that scientists work to develop a drug, which can be mixed with “common Food or Sauces” with the effect of rendering flatulence “not only inoffensive, but agreeable”.
It was another 200 years before the enzyme preparation, Beano, was marketed to reduce the symptoms of bloating and flatulence. Beano contains an enzyme, alpha galactosidase, which is purified from the fungus, Aspergillus niger. It reduces the gas generated by the fermentation of galacto-oligosaccharides (GOS) the complex chains of sugars found in lentils, peas and beans, soy products, beetroot, peanuts and cashews, by breaking them down to galactose and glucose, which are easily absorbed.
Although I could not quite rid myself of associations with Dennis the Menace, Lord Snooty, the Bash Street Kids and other characters in the comic of the same name, I recommended Beano for my gassy patients. Some did well, but it received little attention from my colleagues in gastroenterology and its efficacy in reducing symptoms of IBS was not supported by any major study. Since then, several different brands have been marketed, but none have achieved mainstream status as treatment for IBS.
Then just this last month, I read of a study from the research group at Monash University, which investigated whether another brand of ‘alpha-galactosidase’ (Vitacost Gas Enzyme, Florida USA) could help people with IBS to tolerate foods containing GOS. After stabilisation on a low FODMAP diet, 31people with IBS undertook a series of 3-day randomised ‘tests’, during which they added GOS to their diet plus either a full-dose, half-dose or placebo (dummy) enzyme treatment. Participants were instructed to take ½ the enzyme treatment immediately before their meal and half during the meal to optimise access to the GOS that enters the gut. Between each test period they followed their low FODMAP diet for up to 2 weeks.
The results showed that addition of GOS to a diet that was low in other FODMAPs only induced symptoms in 2/3 of participants, suggesting that approximately 1/3 of people with IBS are not sensitive to pulses (beans, peas and lentils) and highlighting the importance of establishing tolerance to different groups of FODMAPs. Secondly, only the full-dose enzyme treatment improved IBS symptoms in GOS-sensitive individuals. Nevertheless, drilling down into individual responses, 90% patients said their symptoms were adequately controlled on full does enzyme compared with 74% on placebo – not a fantastic difference.
Thirdly, there were no differences in breath hydrogen excretion between control and test limbs irrespective of the dose of alpha-galactosidase. This might suggest that the results are unrelated to changes in gas production, although gas measurements were conducted hourly through the day and not timed to ingestion of a particular meal. Recent studies have shown that intestinal capsules are a much more sensitive means of measuring gas production. If gas was not implicated, it is possible that fluid distension, microbial changes or even a placebo effect (subjects may have guessed when they were taking high dose enzyme by the taste and the amount) may have been responsible for changes in symptoms.
The results from this study indicate if upon FODMAP re-introduction, people find that they react to nuts, legumes, lentils and some soy-products, then alpha-galactosidase may be beneficial to take with meals containing these foods. This is particularly relevant for vegetarians and vegans since nuts and legumes are important sources of protein and improving tolerance to them may help to minimise dietary restrictions and ensure nutritional adequacy.
I wonder if there is a similar enzyme that could break down chains of fructo-oligosaccharides (FOS). It might leave IBS patients with a surfeit of slowly absorbed fructose, but if that wasn’t too much of a problem, patients, who are intolerant of FODMAPs, could respond to ‘combined enzyme therapy’ instead of having to subject themselves to the rigours of low FODMAP diet?
Finally, Benjamin Franklin was not necessarily advocating something to reduce the production and explosion of gas. He was more looking to find some perfume to disguise the smell. But we might already have that. At around the same time as Beano was released, capsules of Colpermin that released peppermint oil when they reached the colon were marketed as new antispasmodics for IBS. I must admit that I was never completely convinced as to their efficacy as antispasmodics, but many patients told me that when they farted, their gas smelt sweetly of peppermint.
The Sensitive Gut 