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What is Fructose Malabsorption?

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Fructose Malabsorption 

Is it the cause of my tummy troubles?

What is Fructose?

fructoseFructose is a sugar that is found in many foods such as fresh fruits and honey, high fructose corn syrup and many processed foods. It is also a component of plain table sugar , and some vegetables.

What is Fructose Malabsorption?

Some people cannot completely absorb fructose in their small intestine-the beginning part of the digestive tract.  The undigested fructose is then carried to the colon where our normal bacteria rapidly devour it. In the process, the bacteria produce gases which cause the intestine to swell. This is experienced by the person as bloating, cramping, gas and distention. Diarrhea may also occur due to the undigested particles of fructose.

What is Fructose Intolerance?

This is also known as hereditary fructose intolerance. It is VERY different from fructose malabsorption and we will not cover it here except to say the following:  it occurs in infants, is hereditary and can lead to severe health problems such as liver disease, seizures and mental retardation. The names are similar but the entities are VERY different. There is some confusion in that fructose malabsorption is at times referred to as DIETARY fructose intolerance.  We are discussing FRUCTOSE MALABSORPTION.

Why is it important to people with celiac disease or gluten Intolerance?

The symptoms of celiac disease and non-celiac gluten sensitivity (NCGS) can be very similar to the symptoms of fructose malabsorption . Thus, the diagnoses’ may often be confused. Fructose malabsorption can also mimic lactose/milk intolerance- a common diagnosis amongst celiac and NCGS patients.  Fructose malabsorption (FM) may also be seen with celiac disease or NCGS and should be considered in these patients who are already on a gluten free diet, yet have ongoing symptoms.

Irritable bowel syndrome (IBS)- an unfortunate co-factor for some celiac and NCGS patient- also shares symptoms with fructose malabsorption.  Recent research is indicating a large percentage of IBS patients may actually have fructose malabsorption and will see improvement of symptoms on a low fructose or Low FODMAP diet.

What are the symptoms of fructose malabsorption?

Onset of symptoms can occur at any age.  Symptoms vary depending on the person and the amount of fructose they have eaten.  Some people can tolerate much more fructose than others. The most common symptoms are bloating, gas, cramping and diarrhea. When diarrhea occurs over prolonged periods, nutrient deficiencies and their symptoms may appear. The most common nutrients affected are folic acid, zinc, iron, tryptophan, calcium, vitamin c and e.  Elevated blood levels of amylase and lipase-enzymes from the pancreas- may also be seen. Some people may also experience symptoms such as fatigue, headaches, brain fog, mood changes and constipation.

How do I test for it?

The standard test done to evaluate for fructose malabsorption is called a Hydrogen Breath Test. This is a simple test,that can be done in the office and requires no blood be drawn.  Some patients choose to start with a fructose elimination diet in lieu of the hydrogen breath test. This is best done in conjunction with a dietitian familiar with fructose malabsorption to assure the diet is initiated properly and adequate nutrition is maintained during the elimination period.  If fructose malabsorption  is the problem and the diet done correctly, it often yields good results.  If the elimination diet does not yield clear results and fructose malabsorpton is still a consideration, the breath test should be performed.

How do I treat it?

The treatment for fructose malabsorption is a low fructose diet. This is a diet that limits foods containing high amounts of fructose or with a significant amount of fructans.  Fructans are a form of fructose found in wheat and vegetables.

What foods are high in fructose?

applesSome examples of high fructose foods

Fruit: Apples ,pears, honeydew, mango, pear, peach, watermelon


Sweeteners-Fructose, High fructose corn syrup, corn syrup solids, fruit juice concentrate

There are extensive lists of foods available online if you are interested in a more detailed list.


What is the Low FODMAP diet? What does it have to do with Fructose malabsorption?

FODMAP stands for “ Fermentable, oligo-di and monosachcharides and polyols” . A low FODMAP diet eliminates:

  1. Lactose-the milk found in cow, sheep and goat milk
  2. Fructose
  3. Fructans-as mentioned above. A form of fructose found in wheat and vegetables. The most common vegetables are onions, and garlic. Other common fructans are inulin and fructooligosacharride (FOS). These are found in many probiotics and “nutrient fortified” foods.
  4. Galactans– a carbohydrate found in beans and lentils
  5. Polyols– A sugar alcohol. The most common are the artificial sweeteners sorbitol, xylitol and mannitol.

The  Low FODMAP diet has been used in the past for inflammatory bowel disorders such as Ulcerative Colitis and Crohn’s disease. It is more recently in the press for its use in IBS. The low FODMAP diet eliminates fructose but it also eliminates other sugars in addition to fructose.

If fructose is an issue for me, do I have to follow the diet forever?

Everyone has a different tolerance level to fructose. It is recommended to follow the diet strictly for 4-6wks. and then re-introduce fructose containing foods one at a time every four days.  Each individual will find their own tolerance level for dietary fructose. If your symptoms have subsided on a low fructose diet and they return upon reintroduction of a food. You have found your sweet spot! The best news is you may have also found the answer for your digestive woes!

For additional information and resources regarding the Low FODMAP diet:


Past columns by Dr. Burkhart:

April/May 2016: Reasons People Follow a Gluten Free Diet: 7 Types of Gluten Free Dieters 

March 2016: Ten Positive Aspects of a Celiac Disease Diagnosis

February 2016: Gluten Causes Keratosis Pilaris (a.k.a. “Chicken Skin”): Fact or Myth?

January 2016: Fingernail Changes in IBS,Gluten Disorders and Celiac Disease “A window to health”

December 2015: 20 Gluten-Free Gift Ideas: From Budget to Luxury, Sentimental to Practical & More

November 2015: Cold Sores, Canker Sores and Gluten

October 2015: Celiac Disease and Gluten Sensitivity Research: Snippets from ICDS 2015 (Part 2)

September 2015: Celiac and Gluten Sensitivity Research: Ten Snippets from ICDS 2015

July/August 2015: A New Home Test To Monitor Gluten Exposure

June 2015: Six Reasons to Test for Celiac Disease Before Starting a Gluten-Free Diet

May 2015: POTS, Celiac Disease and Gluten: An Undiscovered Connection?

February/March/April 2015: Arsenic in the Gluten-Free Diet: Facts and Tips

December 2014/ January 2015: The Microbiome and Celiac Disease: A Bacterial Connection

November 2014: Celiac disease and gluten sensitivity: The doctor-patient disconnect

October 2014: Should You Trust Gluten-Free Labels?

September 2014: Triggers for celiac disease: One possible answer

July/August 2014: Ten Tips for a Healthier Gluten-Free Diet

June 2014: Back Pain and Gluten

May 2014: Self-Diagnosis of Gluten Sensitivity: Four Alarming Trends

April 2014: Update on Restaurants and Gluten-Free Dining

March 2014: Histamine Intolerance: Could it be causing your symptoms?

February 2014: Celiac Disease and Non-Celiac Gluten Sensitivity (Reprinted with permission from Sonoma Medicine)

January 2014: Four Vitamin Toxicities on a Gluten-Free Diet

December 2013: Move Over Gluten-Free, Low FODMAP is Next

November 2013: SIBO, Gluten and IBS: What Is The Connection?

October 2013: Pesticides, Wheat and Gluten Sensitivity: What is the Connection?

September 2013: Is gluten really the culprit in gluten sensitivity?

August 2013: Clarifying the Gluten-Free Labeling Rule

June/July 2013: No such thing as Mild Celiac Disease

May 2013: Magnesium Deficiency

April 2013: Six Reasons to test for celiac disease before starting a gluten-free diet

March 2013: Why am I having migraines?

February 2013: What is fructose malabsorption?

January 2013: Educating doctors about celiac disease

December 2012: Are supplements to digest gluten safe and useful?

November 2012: Top 5 reasons for persistent symptoms after Going Gluten Free


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“I have been a patient of Dr. Amy Burkhart for several years. I suffer from Crohn’s disease and was having difficulty in my daily life. After visiting many doctors, all of whom were unable to help me, Dr. Burkhart took the time and patience to create a plan which brought me back to health. I still follow her plan to this day and have been living a normal healthy life. Dr. Burkhart listened to my symptoms along with listening to me, she took her time in preparing a plan which led me to the road for recovery. I cannot thank Dr. Burkhart enough, and I would recommend her to anyone.”

8 months ago

Stone Brewing company Stone Brewing - Napa opened recently in Napa in an historic building adjacent to the river. A great venue to enjoy life! The gluten free menu options are coming (per the manager ) but please visit and inquire about GF options. The more people who show interest and discuss cross contamination the more likely they are to get it right! Wine is available. Maybe they will even consider a GF beer! . ... See MoreSee Less