Fructose Malabsorption
Diagnosis
Diagnosis
Medical tests are similar as in lactose intolerance, requiring a hydrogen breath test for a clinical diagnosis. When a breath test cannot be done for some reason, reducing substances in the stool, and subsequently fructose in the stool can be checked.
It can be associated with reduced plasma tryptophan and clinical depression.
Pathophysiology
Fructose is absorbed in the small intestine without help of digestive enzymes. However, even in healthy people, only about 25-50 g of fructose per sitting can be absorbed. Persons with fructose malabsorption may absorb less than 25 g per sitting (amount is arbitrary determined according to investigation of fructose absorption is many individuals).In the large intestine the unabsorbed fructose 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. The abnormal increase in hydrogen is detected 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 patients with functional gut disorders than asymptomatic subjects. Some effects of fructose malabsorption are decreased tryptophan, folic acid and zinc in the blood. Restricting dietary intake of free fructose and/or fructans may have durable symptomatic benefits in a high proportion of patients with functional gut disorders, but high quality evidence is lacking.
Treatment
There is no known cure, but an appropriate diet will help.
Diet
Principle of diet in fructose malabsorption is in avoiding:
Fructose-rich foods or any fructose-containing food in large amount
Foods with high fructose-to-glucose ratio (Glucose enhances absorption of fructose, so fructose from foods with fructose-to-glucose ratio 1 (like apples and pears) are often problematic, regardless of actual amount of fructose in the food)
Foods with high fructose corn syrup (HFCS)
Foods rich in sorbitol
Foods rich in fructans or other FODMAPs (problematic only in some persons with FM)
Depending upon the sufferer's sensitivity to fructose, small amounts of problem foods could be eaten (especially when they are not the main ingredient of a meal).
Foods with a high glucose content actually help sufferers absorb fructose.
Symptoms
This condition is common in patients with symptoms of Irritable Bowel Syndrome and most patients with fructose malabsorption fit the profile of those with Irritable Bowel Syndrome. A small proportion of patients with both fructose malabsorption and lactose intolerance also suffer from celiac disease.
Typical symptoms of fructose malabsorption include:
Bloating (because of fermentation in the small and large intestine)
Diarrhea and / or constipation
Flatulence
Stomach pain (due to muscle spasms, which can vary from mild and chronic to acute but erratic)
Other possible symptoms of fructose malabsorption include:
Aching eyes
Fuzzy head
Fatigue
Depression as a result of absorption disorders in the small and large intestines, other substances such as amino acids are not absorbed. Because of missing substances (among others tryptophan), hormones and neurotransmitters cannot be synthesized.
Foods of concern
Foods with high fructose content
According to the USDA database, 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
55 to 90
45 to 10
There is a lot of misinformation and misconception about fruit sugar content. A common belief is that fruits contain mainly, or only, fructose sugar. The USDA food database reveals that many common fruits contain nearly equal amounts of the fructose and glucose. There is a tendency within plants to keep these sugars 50/50. Some aberrantly high fructose fruits are apple, pear, and watermelon, which have over twice as much fructose as glucose. Fructose levels in grapes varies with ripeness and variety, with unripe grapes containing more glucose.
Foods with high fructan content
Chains of fructose molecules known as fructans occur naturally in many foods. The following foods have a high fructan content:
Artichokes
Asparagus
Leeks
Onions including spring onion
Wheat including most beers, breads, cakes, biscuits, breakfast cereals, pies, pastas, pizzas, and some noodles
The role that fructans play in fructose malabsorption is still under investigation. However, it is recommended that fructan intake for fructose malabsorber should be kept to less than 0.5 grams/serving and supplements with inulin and fructooligosaccharide (FOS), fructans, intake should be avoided.
Other problem foods
In addition, the following foods can cause symptoms of fructose malabsorption:
Sodas and other beverages containing high fructose corn syrup (HFCS)
Dried fruit (including "health" bars containing dried fruit)
Tinned fruit in "natural" juice (which is often pear juice)
Sorbitol (present in some diet drinks and foods, and occurring naturally in some stone fruits)
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.
Sweet wines
Too much fruit or any food product containing fructose, sorbitol, HFCS, or polyols in a short time frame
Dietary Guidelines for the Management of Fructose Malabsorption
Dietary guidelines have been developed 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
Fruit juices
Fruit pastes - chutney, relish, plum sauce, sweet & sour sauce, BBQ sauce.
Coconut
Dried fruit bars
Honey
Fortified wines
High Fructose Corn Syrup - many processed products contain this
Corn syrup solids
Fruit juice concentrates
Agave nectar
Red Ripe Tomato
Favorable foods (i.e. fructose equal to or less than glucose)
Stone fruit: apricot, nectarine, peach, plum (caution - these fruit 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
Food labelling laws
Producers of processed food 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.
Note that 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 do those with celiac disease.
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, just as it is not appropriate for those with wheat-allergies or celiac disease (while bread made from spelt sprouts may be tolerated by the latter). 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.
Note that there are many breads on the market that advertise themselves with phrases like: "No High Fructose Corn Syrup". Many bakeries now produce special breads with a high-inulin content, where inulin is a replacement in the baking process for all three: 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. Inulin breads may even highlight the absence of high fructose corn syrup in the bread. However significant these health advances may be, sufferers of fructose malabsorption will likely find no difference between these new breads and traditionally prepared breads in the areas of flatulence or stool, because inulin is a fructan.
See also
Gastroenterology
Hydrogen breath test
Invisible disability
Glucose-galactose malabsorption
German Wikipedia article on fructose malabsorption -- Google Translate
References
^ MayoClinic.com
^ Tryptophan, Serotonin, and Melatonin: Basic Aspects and applications, By Gerald Huether
^ http://allergyadvisor.com/Educational/sept2002.htm
^ Ledochowski M, Widner B, Murr C, Sperner-Unterweger B, Fuchs D (2001). "Fructose malabsorption is associated with decreased plasma tryptophan". Scand. J. Gastroenterol. 36 (4): 36771. doi:10.1080/003655201300051135. PMID 11336160.
^ http://www.uihealthcare.com/kxic/2008/06/fructose.html
^ Maximilian Ledochowski, Florian berall, 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.
^ 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): 20134. PMID 10545075. http://www.clinchem.org/cgi/content/full/45/11/2013.
^ 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): 34963. doi:10.1111/j.1365-2036.2006.03186.x (inactive 2008-06-21). PMID 17217453.
^ http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/BarrettArticle.pdf
^ Skoog SM, Bharucha AE (2004). "Dietary fructose and gastrointestinal symptoms: a review". Am. J. Gastroenterol. 99 (10): 204650. doi:10.1111/j.1572-0241.2004.40266.x. PMID 15447771. http://www.bashaar.org.il/files/101022005111814.pdf.
^ Ledochowski M et al.: Fruktosemalabsorption. Journal fr Ernhrungsmedizin, 2001 (German)
^ Ledochowski M, Sperner-Unterweger B, Widner B, Fuchs D (1998). "Fructose malabsorption is associated with early signs of mental depression". Eur. J. Med. Res. 3 (6): 2958. PMID 9620891.
^ USDA National Nutrient Database Release 20, September 2007
^ Sugar Content of Selected Foods: Individual and Total Sugars Ruth H. Matthews, Pamela R. Pehrsson, and Mojgan Farhat-Sabet, (1987) U.S.D.A.
^ 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): 16319. doi:10.1016/j.jada.2006.07.010. PMID 17000196.
^ Template:"http://www.auntmillies.com/
External links
Fructose Malabsorption -- Practical Gastroenterology
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): 104852. 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): 20134. PMID 10545075. http://www.clinchem.org/cgi/content/full/45/11/2013.
vde
Digestive system Digestive disease Gastroenterology (primarily K2093, 530579)
Upper GI tract
Esophagus
Esophagitis(Candidal) rupture(Boerhaave syndrome, Mallory-Weiss syndrome) UES(Zenker's diverticulum) LES(Barrett's esophagus) Esophageal motility disorder(Nutcracker esophagus, Achalasia, Diffuse esophageal spasm, GERD) Esophageal stricture Megaesophagus
Stomach
Gastritis(Atrophic, Mntrier's disease, Gastroenteritis) Peptic (gastric) ulcer(Cushing ulcer, Dieulafoy's lesion) Dyspepsia Pyloric stenosis Achlorhydria Gastroparesis Gastroptosis Portal hypertensive gastropathy Gastric antral vascular ectasia Gastric dumping syndrome Gastric volvulus
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Intestinal/
enteropathy
Small intestine/
(duodenum/jejunum/ileum)
Enteritis(Duodenitis, Jejunitis, Ileitis) Peptic (duodenal) ulcer(Curling's ulcer) Malabsorption: Coeliac Tropical sprue Blind loop syndrome Whipple's Short bowel syndrome Steatorrhea Milroy disease
Large intestine
(appendix/colon)
Appendicitis Colitis(Pseudomembranous, Ulcerative, Ischemic, Microscopic, Collagenous, Lymphocytic) Functional colonic disease(IBS, Intestinal pseudoobstruction/Ogilvie syndrome) Megacolon/Toxic megacolon Diverticulitis/Diverticulosis
Large and/or small
Enterocolitis(Necrotizing) IBD(Crohn's disease) vascular: Abdominal angina Mesenteric ischemia Angiodysplasia Bowel obstruction: Ileus Intussusception Volvulus Fecal impaction Constipation Diarrhea(Infectious)
Rectum
Proctitis(Radiation proctitis) Proctalgia fugax Rectal prolapse
Anus
Anal fissure/Anal fistula Anal abscess Anal dysplasia Pruritus ani
GI bleeding/BIS
Upper(Hematemesis, Melena) Lower(Hematochezia)
Accessory
Liver
Hepatitis(Viral hepatitis, Autoimmune hepatitis, Alcoholic hepatitis) Cirrhosis(PBC) Fatty liver(NASH) vascular(Hepatic veno-occlusive disease, Portal hypertension, Nutmeg liver) Alcoholic liver disease Liver failure(Hepatic encephalopathy, Acute liver failure) Liver abscess(Pyogenic, Amoebic) Hepatorenal syndrome Peliosis hepatis
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Cholecystitis Gallstones/Cholecystolithiasis Cholesterolosis Rokitansky-Aschoff sinuses Postcholecystectomy syndrome Porcelain gallbladder
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other biliary tree
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digestive system navs: anat of tract,glands,perit,diaphragm/physio/dev, noncongen/congen/congen of d+w/neoplasia, symptoms+signs/eponymous, proc
vde
Genetic disorder: Membrane transport protein disorders
ABC-transporter
ABCA1 (Tangier disease) ABCC2 (Dubin-Johnson syndrome)
Solute carrier
1-10
SLC1A3 (Episodic ataxia 6) SLC2A5 (Fructose malabsorption) SLC3A1 (Cystinuria) SLC4A1 (Hereditary spherocytosis) SLC5A1 (Glucose-galactose malabsorption) SLC5A2 (Renal glycosuria) SLC5A5 (Thyroid dyshormonogenesis type 1) SLC6A19 (Hartnup disease) SLC7A7 (Lysinuric protein intolerance) SLC7A9 (Cystinuria)
11-20
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21-40
SLC26A4 (Pendred syndrome) SLC40A1 (African iron overload)
vde
Inborn error of carbohydrate metabolism: monosaccharide metabolism disorders (including glycogen storage diseases) (E73-74, 271)
Sucrose, transport
(extracellular)
Disaccharide catabolism
Lactose intolerance Sucrose intolerance
Monosaccharide transport
Glucose-galactose malabsorption Inborn errors of renal tubular transport (Renal glycosuria) Fructose malabsorption
Hexose glucose
Monosaccharide catabolism
fructose: Essential fructosuria Fructose intolerance
galactose/galactosemia: GALK deficiency GALT deficiency/GALE deficiency
Glucose glycogen
Glycogenesis
GSD type 0, glycogen synthase GSD type IV, Andersen's, branching
Glycogenolysis
extralysosomal: GSD type V, McArdle, muscle glycogen phosphorylase/GSD type VI, Hers', liver glycogen phosphorylase GSD type III, Cori's, debranching
lysosomal/LSD: GSD type II, Pompe's, glucosidase
Glucose CAC
Glycolysis
MODY 2 GSD type VII, Tarui's, phosphofructokinase Triosephosphate isomerase deficiency Pyruvate kinase deficiency
Pyruvate catabolism
PDHA Fumarase deficiency
Gluconeogenesis
PCD Fructose bisphosphatase deficiency GSD type I, von Gierke, glucose 6-phosphatase
Pentose phosphate pathway
Glucose-6-phosphate dehydrogenase deficiency Pentosuria
Other
Hyperoxaluria (Primary hyperoxaluria)
see also fructose and galactose metabolism enzymes, intermediates; see also glycolysis enzymes, intermediates
see also glycogenesis and glycogenolysis enzymes, intermediates; see also pentose phosphate pathway enzymes, intermediates
Categor
by: gaga
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