Friday, June 24, 2011

Guidelines for effective dietary management of Fructose Malabsorption: The Low FODMAP Diet

  
 
Sensitivity to sugars like lactose, fructose and sorbitol are largely undiagnosed, but responsible for stomach bloating and intestinal distress to many. A group of indigestible carbohydrates or sugars, including oligosaccharides, disaccharides, monosaccharides and polyols have been shown to be osmotically active, rapidly fermenting in the gastrointestinal tract. Various studies show that these sugars are considerable triggers of gastrointestinal symptoms in patients with fructose malabsorption and IBS individually or in combination.

The low FODMAP diet has dramatically improved the gastrointestinal health of many with fructose malabsorption and irritable bowel syndrome in clinical trials.   FODMAPs represent the food types that are most prone to fermentation by the gut bacteria.  Evidence suggests that reducing global intake of FODMAPs to manage functional gut symptoms provides symptom relief for about 75% of patients with FGDs such as irritable bowel syndrome.  Functional gut symptoms vary from person to person.  The treatment of functional gut disorders varies. Modification of meal size, alcohol, fat and caffeine plays a crucial role. Consumption of adequate amounts of fiber and plenty of fresh pure water often helps dramatically in controlling and maintaining healthy digestive health. Recognition of the side effects that go along with supplements and medications is a must. Lifestyle changes that benefit digestion including relaxation, exercise, proper sleep and sunlight are also important key elements in addition to administering the Low FODMAP diet. 

This group of  poorly absorbed, short-chain carbohydrates, known as the FODMAPs was developed by  researchers from Australia, Dr Sue Shepherd and Professor Peter Gibson.  They coined the term FODMAPs as a way to categorize an otherwise unrelated group of certain types of carbohydrates.  The acronym FODMAPs stands for Fermentable Oligosaccharides, Disaccharides and Monosaccharides. It is used to define an otherwise unrelated group of short chain carbohydrate and sugar alcohols.   The FODMAPs are fermented by the bacteria of the intestines leading to flatulence, pain, bloating, reflux, diarrhea and constipation.  By reduction of dietary FODMAPs it is evident that there is success in providing relief from these symptoms to the majority of individuals with fructose malabsorption and relief to some with irritable bowel syndrome.  Fructose is only one of the many poorly absorbed, short-chain carbohydrates that cause the symptoms of fructose malabsorption. These are complex names for a collection of molecules found in food that are poorly absorbed by some people.  When these molecules are poorly absorbed in the small intestine, they act as a food source to the bacteria in the digestive tract, causing high osmotic activity and rapid fermentation which then leads to luminal distension and the potential for subsequent symptom induction in those with less adaptable bowels or visceral hypersensitivity.  In the individual fermenting short-chain carbohydrates like fructose and lactose may be malabsorbed, polyols are generally poorly absorbed and fructans and galactans are always poorly absorbed in all individuals.  Consuming foods high in FODMAPs results in increased volume of liquid and gas in the small and large intestine, resulting in distention and symptoms such as abdominal pain and gas and bloating.

Those with fructose malabsoption show great improvement by being on the Low FODMAP diet. Many people experience a greater quality of life from being on this diet. This diet does require several dietary changes.  Before starting, you should consult a registered nutritionist or dietitian to help ensure you are getting the appropriate nutrition including fiber.  It is also important and relevant to understand that FM can co-exist with intolerance to other food chemicals including additives, salicylates, amines, lactose or gluten so it is important to pay attention to these if you still are experiencing symptoms when following the diet.  Studies are still being conducted (currently at Monash University in Australia) on foods within the FODMAP diet.  This diet is still in its infancy.  New research will be revealed as time moves forward and more testing is done. 

It is up to the patient to find there own personal tolerance level to specific foods, if they can tolerate them at all.  The Low FODMAP diet acts as a guide to do just that. Until now there has been no such guide. Until now fructose malabsorption patients and IBS patients have been somewhat blindly learning what they can eat and what they cannot. Most foods do not have an immediate effect on the patient, meaning the symptoms may not show up until days later. It can be very difficult to know what is actually causing your symptoms. Symptoms can begin days later and end days later. The cycle consistently overriding itself means that patients can always be experiencing symptoms. The accumulative effect that the FODMAPs have and also the chemistry between them is a critical factor.  You are a walking science lab.  It will take some time to figure out your own personal meal plan. Many see improvement within the first week.  Also you want to buy a notebook for a food journal.  Record everything; every meal, every drink, any medications, anything consumed and of course the times. You also want to record your symptoms and those times as well too. This will help you identify a pattern. 

The dietary advice for the reduction of fermentation of carbohydrates in the bowel is different for each person.  By reducing the quantity of fermenting carbohydrates you will reduce symptoms.  Small amounts of these carbohydrates will often be tolerated in some cases.  In others total avoidance of a particular food, such as onions, is a must for symptoms to improve.  It is important to understand that eating foods with varying FODMAP values at the same time will add up, resulting in symptoms that you might not experience if you ate the food in isolation.  For example, fruits that contain excess fructose combined with naturally occurring polyols, such as apples and pears, will likely contribute to more severe symptoms, as the excess fructose and polyols content contributes to the total FODMAP load.

The FODMAPs
Fructose
Fructans
Lactose
Polyols (sorbitol & artificial sweeteners)
Galactans e.g. raffinose

Fructose: 
This is a single sugar found often referred to as the "fruit sugar". lt is in fruit, many vegetables along with many other foods. Fructose is a common additive in many commercial and processed products.
 
Lactose: 
This is a sugar that is in most milk and dairy products.  As FODMAPs have a collective impact on GI symptoms, limiting lactose consumption is best.  Hydrogen breath testing can be done.  Many fructmals are lactose intolerant as it is the most common intolerance among the population.  If you are unsure it is best to also avoid Lactose.  Lactose intolerance contributes to abdominal bloating, pain, gas, and diarrhea, often occurring 30 minutes to two hours following the consumption of milk and milk products.  Lactose intolerance is the inability to metabolize lactose, because of a lack of the required enzyme lactase in the digestive system. It is estimated that 75% of adults worldwide show some decrease in lactase activity during adulthood.  Tolerance to lactose varies and dietary control of lactose intolerance is dependent upon unique tolerance levels.  Lactose is present in two large food categories: conventional dairy products, and as a food additive (in dairy and non dairy products).  Lactose (also present when labels state lactoserum, whey, milk solids, modified milk ingredients, etc.) is a commercial food additive used for its flavor, texture and adhesive qualities. It is found in foods such as processed meats.
 
Fructans:
Fructans are long chains of fructose molecules 'stuck together' with a glucose molecule at the end (polymerized fructose chain with a terminal glucose).  The main dietary sources of fructans include wheat and some vegetables such as onion. They may also be called inulin or Fructo-Oligosaccarides(FOS). Fructans are food for bacteria in the digestive tract.  This causes the symptoms of fructose malabsorption and no amount of glucose will help to absorb these chains of fructose any easier.  Fructans should be strictly limited.

Polyols:
Polyols are also known as sugar alcohols. They have no calories and do not break down in the body or digest at all.  Most are too large for simple diffusion from the small intestine, creating a laxative effect on the GI tract. These include sugar alcohols that are given names such as sorbitol,mannitol, maltitol, xylitot & isomalt. Excess consumption might have a laxative effect.  If all you had to eat for three days was without any fructose at all you most likely would not experience any symptoms from polyols.  This is however very difficult to do.  Even fructose balanced with glucose will initiate the chemical reaction that polyols have within the body.  Polyols also occur naturally in some fruits and vegetables. They are often used as an artificial sweetener and added as sweeteners to sugar-free gums, mints, cough drops, and medications. Polyols actually cause fructose malabsorption when digestion is normally healthy.  In individuals who already have fructose malabsorption polyols cause FM symptoms to be much worse. This is because polyols make it even more difficult to absorb fructose.  Limiting polyols or removing them all together is advised.  Some fruits and vegetables with polyols can be consumed with an individual tolerance for different individuals.  Avocados are one example.  Apples, apricots, cherries, nectarines, pears, plums, prunes and mushrooms also have polyols.

Galactans:
Galactans are oligosaccharides containing chains of the sugar galactose that end in a fructose and a glucose. The human body lacks the enzymes to hydrolyze them into digestible components, so they are completely contributing to gas and GI distress.  Raffinose and stachyose are examples of galactans. These are found in legumes (baked beans, lentils, chickpeas) and some vegetables including peas and onions.
 
The Low FODMAP Diet
Dietary management of fructose malabsorption.
 
1.  Avoidance of foods with high levels of free fructose and “short-chain fructans”.
2.  Limited total fructose load.
3.  Recommendation of foods with balanced fructose/glucose levels.
4.  Intake of free glucose.
5.  8 – 10 weeks on the Low FODMAP diet.  If improvement takes place begin to challenge separate components one at a time.  Establish tolerance level that is personal to you.  Remember that FODMAP’s have an accumulative effect in your body. It is suggested that you seek the guidance of a dietician to ensure you are getting the appropriate nutrition and fiber requirements. 
 
High Fructose Foods:
High fructose foods that have a higher fructose percentage than glucose percentage can cause many negative reactions to those with fructose malabsorption.  They should be avoided or strictly limited.  Consumption of free glucose will help absorb excess fructose but there is still a limit as to how much fructose the small intestine can handle.  Fructose is generally only a problem when there is more fructose than glucose present or too much fructose is eaten at once, such as eating two or three pieces of fruit in one sitting. Some high fructose foods are:
Honey
Apples (all varieties)
Pears
Dried fruit
Fruit juice
Coconut in any form
Peaches
Honeydew melon
High fructose corn syrup
Watermelon
Star fruit
Lychee
Nashi fruit
Canned fruit
Corn syrup
 
Fructans:
Wheat (in large amounts) Unlike celiac disease trace amounts of wheat are okay and well tolerated usually in FM. 
Rye (in large amounts)
Onions (all varieties) Onion is a MAJOR problem, even when eaten in small amounts.
Brown rice:  Many report having difficulty with brown rice.  It may be suitable in small amounts.
Leeks
Zucchini
Chicory
Inulin (artificial fiber added to foods etc.  Check labels.)
Artichokes
Fructo-oligo saccharides (FOS) (artificial fiber added to some foods)
Dandelion tea

Sorbitol:
Artificially sweetened gum, candy and soft drinks
Artificial sweeteners: Sorbitol, Mannitol. Xylitol, Isomalt
Apples
Apricots
Peaches
Apricots
Nectarines
Pears
Cherries

Raffinose:
Cabbage
Brussel sprouts
Baked beans
Asparagus
Red kidney beans, Green beans
Legumes        
Lentils
Chickpeas
 
Lactose:
Most dairy foods have lactose, some more than others. The following are on the higher end of the spectrum.
Ice cream
Condensed milk
Milk
Soft cheeses

 
Closing Notes:

If you have any questions or comments please feel free to post them. Please feel free to post your fructose malabsorption experiences or irritable bowel experiences. I look forward to hearing from you.
 

10 comments:

  1. Nice post, Maria! you summed it up very well!

    ReplyDelete
  2. Your blog is informative and well written. Unfortunately, it is also the story of my life. If you succeeded and feel better that gives hope for those like me.
    I do have one question, though. Did you ever find as the condition got worse that you were unable to metabolize substances like vitamins for instance? I don't take them anymore as they leave a constant taste in the mouth that simply doesn't go away and even oozes through the skin.
    All the best, CJ

    ReplyDelete
  3. Hello CJ

    Thank you for your kind words.

    I used to have a very difficult time metabolizing vitamin supplements and vitamins from food as well. Can you explain what you mean by vitamins oozing through your skin? Is it something you could see? What kinds of vitamins were they? Please tell me a little more about your diet, if you feel comfortable.

    Best,

    Maria

    ReplyDelete
  4. So grateful I found your blog! I was just diagnosed 2 days ago and feeling rather hopeless until I found your site. Thank you & I will read more!!

    ReplyDelete
  5. I have fructose, lactose and Celiac disease. What can I eat? Can fructose intolerance effect your health like bone problems, spasms etc.? I already have mild coronary spasms, secondary hyperparathroidism, osteoporosis, malabsorption, arcuate ligament problem (MAL) sjogrens, hiatal hernia, and osteoarthritis in the hip. I am very active, run, weight train and swim. Only on Nitro for chest pain and I do take vitamins gluten sugar free. Can this fructose and celiac cause all of these health problems. I am having a hard time with the fructose diet. It seems like all food is like poison going thru my system. Any ideas?

    ReplyDelete
  6. Hello,

    I am so glad you found my blog.

    I also have difficulty with lactose and gluten, along with fructose. I must admit that my diet is very limited but I do feel healthier than I have ever felt in my entire life.

    The gluten free section of the grocery store has all sorts of choices; rice noodles, rice cookies, rice crackers and white rice. White rice is usually safe, but I have heard that some people cannot tolerate it. There are a lot of gluten free options available now. You want to try to eat small portions when you do eat. Keep a food diary also. Different people can eat differently. For example you may or may not be able to eat mushrooms, spinach, tomatoes potatoes or corn. Check the lists in my blog titled Guidelines for effective dietary management of Fructose Malabsorption: The Low FODMAP Diet. What are you eating now?

    Food allergies and food intolerances cause a variety of illnesses. It is very possible that food is the culprit with some or all of the problems that you are experiencing.

    You have to be careful with the fillers, additives and added fiber in vitamins. Check labels for the artificial fibers inulin and
    Fructo-oligo saccharides (FOS). These fructans are very difficult to break down if you are sensitive to glucose.

    What kind of vitamins are you taking? Is the sugar replaced with an alternative to sugar, such as splenda or nutrasweet?

    If you are just getting started on the diet try rice noodles in the gluten free section. Cook them up with fresh steamed spinach. Add sea salt and extra virgin olive oil. If you like lemon add some fresh lemon juice also. Please let me know if you enjoy this meal. It is quick and easy and tastes delicious.

    ReplyDelete
  7. Hello,

    I am so glad you found my blog.

    I also have difficulty with lactose and gluten, along with fructose. I must admit that my diet is very limited but I do feel healthier than I have ever felt in my entire life.

    The gluten free section of the grocery store has all sorts of choices; rice noodles, rice cookies, rice crackers and white rice. White rice is usually safe, but I have heard that some people cannot tolerate it. There are a lot of gluten free options available now. You want to try to eat small portions when you do eat. Keep a food diary also. Different people can eat differently. For example you may or may not be able to eat mushrooms, spinach, tomatoes potatoes or corn. Check the lists in my blog titled Guidelines for effective dietary management of Fructose Malabsorption: The Low FODMAP Diet. What are you eating now?

    Food allergies and food intolerances cause a variety of illnesses. It is very possible that food is the culprit with some or all of the problems that you are experiencing.

    You have to be careful with the fillers, additives and added fiber in vitamins. Check labels for the artificial fibers inulin and
    Fructo-oligo saccharides (FOS). These fructans are very difficult to break down if you are sensitive to glucose.

    What kind of vitamins are you taking? Is the sugar replaced with an alternative to sugar, such as splenda or nutrasweet?

    If you are just getting started on the diet try rice noodles in the gluten free section. Cook them up with fresh steamed spinach. Add sea salt and extra virgin olive oil. If you like lemon add some fresh lemon juice also. Please let me know if you enjoy this meal. It is quick and easy and tastes delicious.

    ReplyDelete
  8. Help!!! My child was just diagnosed with fructose and lactose intolerance. He has only been eating meat and potatoes french fries potatoe chips. Still bloating diarreah feels weak stomach pain. Do you have any ideas for the food he should be eating to ease his symptoms? What were doing is not working. Also do you have a brand of vitamin he could take? Im very concerned about his vitamin and calcium levels. Ty

    ReplyDelete
  9. Hello.

    Sensitivities to lactose and fructose often go undiagnosed. It is very good news that you now have this diagnosis to go by for your child.

    I can only offer here, to you, my own experience and am in no way an expert, especially when it comes to children. I highly suggest visiting http://shepherdworks.com.au/
    Shepherd Works is the website of dietician Sue Shepherd. She is an expert and a pioneer in the debilitating troubles that come along with malabsorption of fructose. You can make appointments via Skype and get your child the proper care needed. Nutrition is very important, especially when young and developing. Sue is widely known and respected.

    My own experience with potatoes has been that I cannot eat many. One serving, once or twice a week. If I eat too much potato I get very sick with shooting pain that I can feel piercing through my body. Try to limit potato for the time being, until you can get to a dietician experienced with food intolerance.

    I myself eat very little meat, although I have found that I can digest some meat very well. A small piece of meat might do more for your child than too much.

    Be aware that fatty food is difficult for anyone to digest. Some meat is very fatty. French fries and chips are also often fatty foods.

    Ketchup can be a big problem. Ketchup often contains large amounts of high fructose corn syrup. Tomatoes in general can cause a reaction in fructmals.

    Limit your child's portions of everything.

    Try some white rice, rather than potatoes all the time. Fresh steamed spinach can be very addicting. My mom used to feed it to my sibling and I when we were very young and now we love it.

    The gluten free section of the grocery can be a much needed life saver. Much of the food I eat is made fresh from scratch at home, nothing processed. You could try to make some fresh bread for your child made of gluten and fructose free flour. My favorite flour in white rice flour.

    A half of a banana once a week or twice a week might be tolerable.

    Water with lemon to drink. (Very healthy)

    I hope this gives you a nice start, until you can get to a dietician. Please let me know if this helps or if you have any other questions.

    Best wishes!

    Love and light,

    Maria

    ReplyDelete