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Reply To: Fructose Malabsorption

Blog Forums Nutrition Fructose Malabsorption Reply To: Fructose Malabsorption


Hello Dutchie,

I have not looked into PCOS extensively in the past, so please take these thoughts with great criticism.

Let me start by commenting on some stuff you may have already read or are likely to read about with some searching around. Then I’ll end with some general opinions on the approach I would take. But know that ultimately your own tinkering is likely going to be needed in order to find the cure, and most out on the web are very comfortable telling others how to do things, even when their own health sucks. (I suppose I am not that much different in that sense, since I am still fighting my own battles. So, again, take these things carefully.)

Recent trials have appeared to find fairly decent success in PCOS by supplementing inositol.

The question would be, how is inositol, which is not universally considered an essential nutrient, helping hormones and/or metabolic function in PCOS women? Well, I have some thoughts. The first possibility is the obvious, and that is that inositol actually is essential in the diet, and that for whatever reason some women have a much harder time biosynthesizing a certain minimum than others and/or have increased dietary requirements for other reasons. But considering the shear quantity being used by some women and in trials, which I find to be higher than what one could get from a reasonable diet, I think the pharmacological amount is likely partly making up for something else. And that that something else is what we should be restoring.

Inositol is known to be important as a ‘second messenger’ which just means it is an essential part of certain hormonal cascades, including insulin. An inositol deficiency could therefore mean, in theory, less efficient insulin signalling and a resultant ‘resistance’. Since PCOS women are commonly insulin resistant, inositol deficiency seems to make a nice and tidy explanation. However, not all PCOS women are insulin resistant, and even massive doses of inositol does not fully cure the PCOS or insulin resistance so I have a hard time accepting that this mechanism should be considered universally applicable.

Inositol is also important as a component in phospholipids, much like choline, though not nearly as important in scale. Choline deficiency is a huge factor in fatty liver and liver dysfunction, and in animal studies going way back, both inositol and choline can alleviate the fatty liver. What is interesting is that they appear to do this via separate mechanisms. Choline is needed to help the liver escort fat and cholesterol to peripheral tissues. And inositol appears to downregulate lipogenesis in the liver, thereby lowering the need for choline (less fat is needed to escort out of the liver).

While we’re on the subject, I would like to say that both taurine and glycine (amino acids) relieve some burden on choline by moving cholesterol into the bile-synthesis pathway, as opposed to the systemic circulation pathway. Taurine and glycine have both been shown to be highly protective in high fat diets in rats and mice in alleviating metabolic stress in the liver, and in human trials in appearing to help many serum markers that have become common to track (triglycerides, LDL-c, HDL-c, fasting glucose, etc.). Glycine and taurine have both improved insulin resistance in humans, as has choline supplementation. The liver is known to be a key intermediate of the metabolism of many nutrients, so it would not be surprising to me to find out that a major systemic illness was actually liver injury as its root.

Several other dietary factors connect to this. Fructose, for instance, can be malabsorbed and can fuel bad flora growth with the resultant endotoxemia which places big time stress on the liver. Presumably, this would drain liver stores of several nutrients, including choline, glutathione, glycine, and some B vitamins like thiamine and whatever else. But eating enough glucose or starch with the fructose would alleviate this problem, since fructose is well absorbed provided one eats as much or more glucose as fructose (which was the point of this entire fructose thread initially). However, if fructose is absorbed fine, even then it will place a small drain on choline levels in the liver, since a good portion of fructose is turned into triglycerides in the liver, which then need to be exported systemically via phosphatidylcholine. This is not me saying ‘fructose is bad’, but just that fructose requires extra choline when compared with glucose. Glucose likely requires extra thiamine, since glucose is metabolized through pathways (glycolysis and pentose phosphate shunt) that rely extensively on thiamine, so we’re even. But what this means is that fructose is going to be problematic for individuals who are already low in choline. Dietary fat, too, needs choline for its processing. So, really the best diet for SPARING choline would be a starch and protein diet. But sparing choline is only so helpful. Eating choline is how one is going to make up for a deficiency, and choline is in egg yolks and organ meats. So, adding 6 egg yolks to the daily routine should help this whole thing, and lowering fat and fructose is likely not needed provided enough yolks are eaten.

Now, estrogen helps increase choline synthesis, and so men are typically the ones with insufficient choline status. It would seem possible in this case that perhaps the low estrogen, high androgen disturbance seen in PCOS is causing the inability to synthesize as much choline as is ideal, which then results in the systemic effects. Meaning that PCOS occurs first as low estrogen, which then eventually results in low choline, which then results in insulin resistance and high cortisol, which then has its own terrible effects. In this model, eating lots of egg yolks and avoiding empty sugars and fats could save one from the systemic nightmare that effects the worse-off of PCOS women, but it wouldn’t ‘cure’ the initial problem in the first place. On the other hand, it may. Even healthy women who have genetic downregulations in PEMT will be poor choline synthesizers, which could make one choline deficient independent of bad hormones to start. Then, the choline deficiency could cause the liver dysfunction and the insulin resistance and adipose dysfunction, ultimately leading to low SHBG and high androgens? Honestly, I don’t know. But I thought it might be helpful to think outloud here.

What I would recommend for everyone is to eat a well-balanced diet, high in all the known essential nutrients, while continuing to poke and prod the details of any chronic illness. Some individual may have one chronic deficiency, and another person could have a different one, but restricting the diet in any way will ultimately lead to numerous additional deficiencies which isn’t helping anything. I think a lot of people on the 180degree threads have made a go at consuming high quantities of relative junk food in an attempt to cure their problems, and I think this is a bad approach. I think eating high quantities of nutritious foods is good, but tubers, fruits, cheese, egg yolks, organ meats, shellfish, and salts beat cookies and crackers and coco-puffs any day.

I saw you asking about salt on a recent post of yours, so allow me to share some thoughts. Low blood volume is one of the major stressors on the body. The body has, as I see it, basically only two things it views as a stress: low oxygen perfusion through the brain (which could be caused by low blood volume and/or low oxygen transport via anemia and/or low CO2 since CO2 is needed for oxygen delivery to tissues) and low glucose availability for the brain. Low blood volume is a huge stressor, and low blood volume can be causes both by low sodium and also acidosis. Salt can therefore be very helpful to keep blood volume up. However, there is a caveat, and that is that acidosis produces a volume contraction. The blood has only two major anions, chloride and bicarbonate. Chloride represents the acid and bicarb the alkaline or base in the blood. When one eats lots of NaCl, a mild acidosis can result because of displaced bicarbonate. What this means practically, is that having a little NaCl can increase blood volume, but having a lot (what ‘a lot’ means depends on the person) can decrease blood volume a little. But adding some bicarbonates to the chlorides, such as a mix of NaCl and Na-bicarb can eliminate this effect. In foods, the alkaline is typically citrate and malate and from potassium. One could make their own potassium citrate by dissolving potassium bicarb in OJ, or potassium malate by dissolving potassium bicarb with apple juice or sparkling apple cider. But a balance is important. If someone used potatoes or bananas as their staple, then I would not see any reason to use sodium or potassium bicarbonate, but I would think just lots of NaCl would be good. But if someone was eaten a lot of ‘acidic-forming’ foods (grains and animal products), then adding lots of alkaline potassium PLUS NaCl would be a good approach. (As a quick aside, I would never recommend potassium chloride. Transcellular flux of intracellular ions K and Mg into cells occurs in alkaline conditions, so Na-bicarb could cause low blood K; however, acidic conditions can increase serum K and Mg, so K-Cl can dangerously elevate serum K levels. I think K-bicarb and Na-Cl are the best ways to add each, far safer than K-Cl and Na-bicarb.)

So, how about those raw vegans? In healthy people, potassium can help the kidneys retain sodium. Here’s how: increased serum potassium stimulates aldosterone secretion by the adrenals. Aldosterone is the primary ‘mineral corticoid’ in the body, which means that aldosterone is the major ‘stress’ hormone responsible for increasing blood volume. It does this via increasing sodium retention, increasing potassium excretion, and increasing acid excretion as ammonium from breaking apart amino acids. What this means is that simply having a lot of potassium could help the body retain sodium, provided that one’s adrenals are capabale of pumping fairly high amounts of aldosterone. However, in any kind of adrenal insufficiency state such as Addisons’, the adrenals are not able to pump out aldosterone in high amounts for whatever reason. I have also seen cases of thiamine deficiency causing this in rats; and aldosterone acts via stimulating methylation in the kidneys, so theoretically a deficiency of betaine and choline and methionine could cause a sort of ‘alodteronse -resistance’ in the kidneys, which could manifest as a ‘adrenal fatigue’ type thing.

Choline can be used as a methyl donor in the body to remethylate homocysteine back to methionine. Choline is turned into betaine (aka trimethylglycine, or sometimes TMG). So, a choline deficiency (which may be a piece of PCOS) would likely also manifest as a methyl donor deficiency, which could create a sort of aldosterone resistance, which could mean an inability to properly excrete acid and retain sodium, which would further increase stress hormones. Acidosis, as I have posted some about in previous posts within this thread, can have very negative effects on cortisol and other ‘stress’ hormones, which could lead to weight gain, acne, hirtuism, and whatever other terrible symptoms are common in PCOS women (and frankly many women within our society on a ‘subclinical’ level).

So, how do we approach this? Eating more choline, taurine, glycine, inositol; supplementing with enough NaCl and eating alkaline tubers and fruits as the staples; and otherwise eating a well rounded, nutrient-dense diet is, without knowing, what I would recommend.

I view a healthy diet as one that does two things:

1) provides all the essential nutrients for the body in the right ratios and amounts
2) produces a robust, healthy flora, which through mechanisms only beginning to be worked out, can mean everything for certain diseases.

Honestly, the second one is the easy one: eat foods high in resistant starch and other prebiotics, such as cooked-then-cooled potatoes and greenish bananas. Resistant starch fuels the good bugs, which produce butyrate, which itself feeds colon cells and modulates the immune system and increases Treg (regulatory T cells). For all those sports fans out there, low dose naltrexone appears to exert its anti-autoimmune effect by increasing Tregs, so butyrate is the natural way of doing this. In fact, SIBO (overgrowth of bacteria in the upper portion of the intestines) may be quickly cured by resistant starch (RS), since bacteria jump on the large RS granules but take hours to digest it. By the time they are done digesting it, the granule has long-since passed the small (upper) intestines, and is safely in the cecum (upper colon). In this way, RS effectively ‘sweeps’ the bugs down, which is presumably nice. A diet high in quickly fermenting sugars (sucrose and fructose) and small starch molecules may do the opposite by allowing the bugs to effectively climb the intestinal ladder. As long as RS is a considerable part of the diet, I don’t think sugar will give one any issues. I wish there were more clinical trials in this stuff, but there are poresently a lot of n=1 anecdotes. You can read more how to incorporate resistant starch into one’s diet by reading some of the posts at ‘Free The Animal’ and following especially ‘Tatertot’ aka Tim Steele. But long-story short, don’t eat junk food and use tubers and bananas as your staples. Don’t underestimate the power of gut health.

The first thing (getting all the essential nutrients in right ratio, etc.) is less easy, since there is far from any agreement about precisely what nutrients are essential. I have a lot of my own opinions on this, but let me just say that ratios can matter as much or more than absolute amounts, so be careful with the zinc and iron, since they can knock out copper and manganese. But following a diet with tubers and bananas, plus organ meats, yolks, yogurt/cheese, and so on to round things out, will be a good base. I personally think egg yolks are highly underrated, and I think they offer many nutrients (like choline and essential fatty acids) that will balance a tuber/fruit diet very nicely. If you need more caloric density (and may do well with extra caloric density), then try to do so with foods that are less known to cause issues to flora: so cane sugar/honey/ maple syrup not corn syrup; butter/cheese/egg yolks not vege oils. But I still think most should get their carbs from whole foods (tubers, fruit) and their fats from whole foods (yolks, cheese, organ meats, yogurt). On top of this, you can experiment around with specific supplements, but at least you’ll know you’ve got the majority of things going good with your diet.

Let me know you thoughts on all of this. This was not intended to be a full account of everything, but hopefully I have said or linked to something that you may find helpful.