Fructose malabsorption

Fructose Malabsorption
Classification and external resources
Fructose
ICD-10	E74.3
ICD-9	271
OMIM	138230

Fructose malabsorption, formerly named "dietary fructose intolerance," is a digestive disorder^[1] in which absorption of fructose is impaired by deficient fructose carriers in the small intestine's enterocytes. This results in an increased concentration of fructose in the entire intestine.

Fructose malabsorption is found in up to 30% of the population of Western countries and Africa.^[2] Some estimates for Asia seem to be considerably lower but are still at 10% of the population.^[2]

This condition is common in patients identified to be suffering symptoms of irritable bowel syndrome, although occurrence in these patients is not higher than occurrence in the normal population. Conversely, patients with fructose malabsorption often fit the profile of those with irritable bowel syndrome.^[3] A small proportion of patients with both fructose malabsorption and lactose intolerance also suffer from celiac disease.

Fructose malabsorption is not to be confused with hereditary fructose intolerance, a potentially fatal condition in which the liver enzymes that break up fructose are deficient.

Pathophysiology

Fructose is absorbed in the small intestine without help of digestive enzymes. Even in healthy persons, however, only about 25-50g of fructose per sitting can be properly absorbed. Persons with fructose malabsorption may absorb less than 25g per sitting (NB: Amount is arbitrarily determined according to investigation of fructose absorption in many individuals).^[4] In the large intestine, fructose that hasn't been adequately absorbed osmotically reduces the absorption of water and is metabolized by normal colonic bacteria to short chain fatty acids and the gases hydrogen, carbon dioxide and methane. This abnormal increase in hydrogen is detectable with the hydrogen breath test.

The physiological consequences of fructose malabsorption include increasing osmotic load, providing substrate for rapid bacterial fermentation, changing gastrointestinal motility, promoting mucosal biofilm and altering the profile of bacteria. These effects are additive with other short-chain poorly absorbed carbohydrates such as sorbitol. The clinical significance of these events depends upon the response of the bowel to such changes; they have a higher chance of inducing symptoms in people with functional gut disorders than asymptomatic subjects. Some effects of fructose malabsorption are decreased tryptophan, folic acid^[5] and zinc in the blood.^[6]

Restricting dietary intake of free fructose and/or fructans may provide symptom relief in a high proportion of patients with functional gut disorders.^[7]

Symptoms

• Bloating (from fermentation in the small and large intestine)
• Diarrhea and/or constipation
• Flatulence
• Stomach pain (as a result of muscle spasms, the intensity of which can vary from mild and chronic to acute but erratic)
• Vomiting (if great quantities are consumed)
• Early signs of mental depression^[8]

Other symptoms include:^[9]

• aching eyes
• fuzzy head
• fatigue

Diagnosis

The diagnostic test, when used, is similar to that used to diagnose lactose intolerance. It is called a hydrogen breath test and is the method currently used for a clinical diagnosis.

Treatment

There is no known cure, but an appropriate diet will help.

Diet

Foods that should be avoided by people with fructose malabsorption include:

• Foods and beverages containing greater than 0.5g fructose in excess of glucose per 100g and greater than 0.2g of fructans per serving should be avoided. Foods with >3g of fructose per serving are termed a ‘high fructose load’ and possibly present a risk of inducing symptoms. However, the concept of a ‘high fructose load’ has not been evaluated in terms of its importance in the success of the diet.^[10]
• Foods with high fructose-to-glucose ratio. Glucose enhances absorption of fructose, so fructose from foods with fructose-to-glucose ratio <1, like bananas, is readily absorbed, whereas foods with fructose-to-glucose ratio >1, like apples and pears, are often problematic regardless of the total amount of fructose in the food.^[11]
• Foods rich in fructans and other Fermentable Oligo-, Di- and Mono-saccharides and Polyols (FODMAPs), including artichokes, asparagus, leeks, onions , and wheat-containing products, including most beers, breads, cakes, biscuits, breakfast cereals, pies, pastas, pizzas, and some noodles.
• Foods containing sorbitol, present in some diet drinks and foods, and occurring naturally in some stone fruits, or xylitol, present in some berries, and other polyols (sugar alcohols), such as erythritol, mannitol, and other ingredients that end with -tol, commonly added as artificial sweeteners in commercial foods.

Foods with a high glucose content ingested with foods containing excess fructose may help sufferers absorb the excess fructose.^[12]

The role that fructans play in fructose malabsorption is still under investigation. However, it is recommended that fructan intake for fructose malabsorbers should be kept to less than 0.5 grams/serving,^[13] and supplements with inulin and fructooligosaccharide (FOS), both fructans, should be avoided.^[13]

Foods with high fructose content

According to the USDA database,^[14] foods with more fructose than glucose include:

Food	Fructose (grams / 100 grams)	Glucose (grams / 100 grams)
Sucrose (for reference)	50	50
Apples	5.9	2.4
Pears	6.2	2.8
Fruit juice e.g. Apples, Pears	5 to 7	2 to 3
Watermelon	3.4	1.6
Raisins	29.8	27.8
Honey	40.9	35.7
High fructose corn syrup	42 to 55	45 to 58

The USDA food database reveals that many common fruits contain nearly equal amounts of the fructose and glucose, and they do not present problems for those individuals with fructose malabsorption.^[15] Some fruits with a greater ratio of fructose than glucose are apples, pears and watermelon, which contain more than twice as much fructose as glucose. Fructose levels in grapes varies depending on ripeness and variety, where unripe grapes contain more glucose.

Dietary guidelines for the management of fructose malabsorption

Researchers at Monash University in Australia developed dietary guidelines^[13] for managing fructose malabsorption, particularly for individuals with IBS.

Unfavorable foods (i.e. more fructose than glucose)

• Fruit — apple, pear, guava, honeydew melon, nashi fruit, pawpaw, papaya, quince, star fruit, watermelon;
• Dried fruit - apple, currant, date, fig, pear, raisin, sultana;
• Fortified wines
• Foods containing added sugars, such as agave nectar, some corn syrups, and fruit juice concentrates.

Favorable foods (i.e. fructose equal to or less than glucose)

• Stone fruit: apricot, nectarine, peach, plum (caution - these fruits contain sorbitol);
• Berry fruit: blueberry, blackberry, boysenberry, cranberry, raspberry, strawberry, loganberry;
• Citrus fruit: kumquat, grapefruit, lemon, lime, mandarin, orange, tangelo;
• Other fruits: ripe banana, jackfruit, kiwi fruit, passion fruit, pineapple, rhubarb, tamarillo.

United States Food-labeling laws

Producers of processed food in the USA are not currently required by law to mark foods containing "fructose in excess of glucose." This can cause some surprises and pitfalls for fructose malabsorbers.

Foods (such as bread) marked "gluten-free" are usually suitable for fructose malabsorbers, though sufferers need to be careful of gluten-free foods that contain dried fruit or high fructose corn syrup or fructose itself in sugar form. However, fructose malabsorbers do not need to avoid gluten, as those with celiac disease must.

Many fructose malabsorbers can eat breads made from rye and corn flour. However, these may contain wheat unless marked "wheat-free" (or "gluten-free") (Note: Rye bread is not gluten-free.) Although often assumed to be an acceptable alternative to wheat, spelt flour is not suitable for sufferers of fructose malabsorption^{[citation needed]}, just as it is not appropriate for those with wheat allergies or celiac disease. However, some fructose malabsorbers do not have difficulty with fructans from wheat products while they may have problems with foods that contain excess free fructose.^[7]

There are many breads on the market that boast having no high fructose corn syrup. In lieu of high fructose corn syrup, however, one may find the production of special breads with a high inulin content, where inulin is a replacement in the baking process for the following: high fructose corn syrup, flour and fat. Because of the caloric reduction, lower fat content, dramatic fiber increase and prebiotic tendencies of the replacement inulin, these breads are considered a healthier alternative to traditionally prepared leavening breads. Though the touted health benefits may exist, sufferers of fructose malabsorption will likely find no difference between these new breads and traditionally prepared breads in alleviating their symptoms because inulin is a fructan, and, again, consumption of fructans should be reduced dramatically in those with fructose malabsorption in an effort to appease symptoms.

New research

Fructose and fructans which are polymers of fructose are FODMAPs (Fermentable Oligo-, Di- and Mono-saccharides and Polyols) known to cause GI discomfort in susceptible individuals. A low FODMAP diet has widespread application for managing functional GI disorders such as IBS and IBD.^[16]

See also

• Gastroenterology
• Hydrogen breath test
• Invisible disability
• Food intolerance
• Irritable bowel syndrome
• Malabsorption

References

1. ^ MayoClinic.com
2. ^ ^{a b} Peter Born: Carbohydrate malabsorption in patients with non-specific abdominal complaints World Journal of Gastroenterology, 2007, ISSN 1007-9327.
3. ^ Ledochowski M et al.: Fruktosemalabsorption. Journal für Ernährungsmedizin, 2001 (German)
4. ^ http://www.uihealthcare.com/kxic/2008/06/fructose.html
5. ^ Maximilian Ledochowski, Florian Überall, Theresia Propst, and Dietmar Fuchs Fructose Malabsorption Is Associated with Lower Plasma Folic Acid Concentrations in Middle-Aged Subjects, Clin. Chem., Nov 1999; 45: 2013 - 2014.
6. ^ Ledochowski M, Uberall F, Propst T, Fuchs D (1999). "Fructose malabsorption is associated with lower plasma folic acid concentrations in middle-aged subjects". Clin. Chem. 45 (11): 2013–4. PMID 10545075. http://www.clinchem.org/cgi/content/full/45/11/2013. 
7. ^ ^{a b} Gibson PR, Newnham E, Barrett JS, Shepherd SJ, Muir JG (2007). "Review article: fructose malabsorption and the bigger picture". Aliment. Pharmacol. Ther. 25 (4): 349–63. doi:10.1111/j.1365-2036.2006.03186.x. PMID 17217453. 
8. ^ Ledochowski M, Sperner-Unterweger B, Widner B, Fuchs D. (2010). "Fructose malabsorption is associated with early signs of mental depression.". European journal of medical research 3 (6): 295–8. PMID 9620891. 
9. ^ ^{[author missing]} (2011 [last update]). "foodreactions.org:: Fructose Malabsorption". foodreactions.org. http://www.foodreactions.org/intolerance/fructose/malabsorption.html. Retrieved May 5, 2011. 
10. ^ Gibson PR, Shepherd SJ (2010). "Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach". Advances in Clinical Practice 25 (2): 252–258. doi:10.1111/j.1440-1746.2009.06149.x. PMID 20136989. http://www3.interscience.wiley.com/journal/122650565/abstract. 
11. ^ http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/BarrettArticle.pdf
12. ^ Skoog SM, Bharucha AE (2004). "Dietary fructose and gastrointestinal symptoms: a review". Am. J. Gastroenterol. 99 (10): 2046–50. doi:10.1111/j.1572-0241.2004.40266.x. PMID 15447771. http://www.bashaar.org.il/files/101022005111814.pdf. 
13. ^ ^{a b c} Shepherd SJ, Gibson PR (2006). "Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management". Journal of the American Dietetic Association 106 (10): 1631–9. doi:10.1016/j.jada.2006.07.010. PMID 17000196. http://sacfs.asn.au/download/SueShepherd_sarticle.pdf. 
14. ^ USDA National Nutrient Database Release 20, September 2007
15. ^ Sugar Content of Selected Foods: Individual and Total Sugars Ruth H. Matthews, Pamela R. Pehrsson, and Mojgan Farhat-Sabet, (1987) U.S.D.A.
16. ^ Gibson PR, Shepherd SJ. (Feb 2010). "Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach". J Gastroenterol Hepatol. 25 (2): 252–8.. doi:10.1111/j.1440-1746.2009.06149.x. PMID 20136989. 

External links

• Fructose Malabsorption at the food intolerance network -- Society for Public Health
• Fructose Malabsorption -- Practical Gastroenterology
• Low FODMAP Diet
• Excess Fructose Content of American Foods
• Ledochowski M, Widner B, Bair H, Probst T, Fuchs D (2000). "Fructose- and sorbitol-reduced diet improves mood and gastrointestinal disturbances in fructose malabsorbers". Scand. J. Gastroenterol. 35 (10): 1048–52. doi:10.1080/003655200451162. PMID 11099057. 
• Ledochowski M, Uberall F, Propst T, Fuchs D (1999). "Fructose malabsorption is associated with lower plasma folic acid concentrations in middle-aged subjects". Clin. Chem. 45 (11): 2013–4. PMID 10545075. http://www.clinchem.org/cgi/content/full/45/11/2013.