Medical Nutrition Therapy: Fructose-Restricted Diet HF#376

  

What is fructose?

Fructose is a natural sugar found in many foods.  As a simple sugar, fructose is found in foods such as fruits and honey. When fructose is hooked to another sugar called glucose, it form stable sugar or sucrose.  Fructose can form a longer chain called fructans found in vegetables and wheat.  Because of the intense sweetness of fructose, the sweetness can be further concentrated into high fructose corn syrup and used in place of table sugar in many soft drinks and sweets.

 

Why do I need to restrict fructose from my diet?

Some people have trouble digesting fructose. Fructose empties from the stomach more rapidly than other sugars. Fructose is absorbed or taken in by the small intestine in a couple ways.  If glucose is present in equal amounts with the fructose, it helps the body use the fructose at the start of the small intestine.  Free fructose without matching glucose is absorbed more slowly along the length of the small intestine.  When fructose is not digested, it is fermented by bacteria.  This can cause side effects like bloating, abdominal pain, nausea, gas, and diarrhea.  These side effects can be controlled with a low fructose diet.

 

How do I follow a low fructose diet?

Some people can have small amounts of fructose and have no problems.  Others need to avoid even small amounts in their diet.  The amount of fructose that produces GI symptoms in healthy adults can range from less than 25 grams to 50 grams.  The levels that cause discomfort in healthy children have not been studied.  It should be noted that a 16-ounce bottle of apple juice may contain more than 30 grams of fructose and a 20 ounce bottle of soda can contain up to 40 grams of fructose.

 

To get started, you will need to read food labels.  Avoid foods or drinks with high fructose corn syrup. For many people this change gets rid of their symptoms.  Some people regularly drink 100 grams a day of fructose in sweetened beverages so they feel much better when these are stopped.  Some fruits and vegetables naturally have a lot of fructose.  Fruits that are balanced with both fructose and glucose will be better absorbed which will reduce gas.  Use the tips below to pick which fruits you maybe better able to eat without problems.

How long do I have to follow a low fructose diet?

Some people will find relief of symptoms quickly.  Others will have to eliminate more foods for a longer period of time. Once your symptoms improve for 4 to 6 weeks, then you can begin to add foods back to your diet. This will help you to see which foods you can have without side effects.  Try adding only one food back to your diet at a time.  Wait 4 days before trying another food.  Fructose takes three days to pass through the gut.

 

What foods or food groups do I need to avoid?

• Avoid foods and drinks with high fructose corn syrup (candy, sodas, sweetened juice, or punch).
• Avoid fruit juices.  They are concentrated forms of fructose.  It takes the juice from multiple pieces of fruit to make one glass of juice.
• Avoid commercial baked goods; most contain high fructose corn syrup.
• Avoid sorbitol (a sugar alcohol) and too much of other artificial sweeteners (Splenda®).  These artificial sweeteners cause symptoms in the gut similar to those caused by fructose.  The combination of fructose and sorbitol worsens symptoms.
• Overall, limit all sweets to very small servings. When a sweet item is occasionally served, give it with a meal not as a snack.  

What about sweeteners?

What sweeteners should I avoid?

What sweeteners are OK to use?

Agave syrup Caramel Fructose High Fructose Corn Syrup Honey Invert Sugar Molasses Pancake Syrup (not real) Palm Sugar Sugar Alcohols: Mannitol, Sorbitol, Xylitol Splenda® (sucralose) Always read labels to be sure the companies aren’t adding other sweeteners, like high fructose corn syrup.

Avoid large amounts of allowed sweets Barley Malt Syrup (contains about 2% fructose, so may not be as well tolerated) Brown Rice Syrup (check label to make sure High Fructose Corn Syrup wasn’t added) Brown Sugar (small amounts) Dextrin Dextrose—available in specialty stores and online (binds free fructose in gut to absorb) can be used in recipes Glucose or glucose syrups Lactose Maltose, Isomaltose Polycose Raw sugar or Turbinado sugar Real Maple Syrup (Limit 1 T) Sucrose (Table Sugar/Cane Sugar) Sugar substitutes: Aspartame (Nutrasweet® or Equal®), Sugar Twin®, Sweet One®

Helpful Hints:

Fruits

• Eat fruit in moderation as part of a meal.  Do not eat fruit separately as a snack.
• Avoid fruit drinks, juices, jams, jellies, and chutneys.

 

Fructose Content of Common Fruits 

Note: “Glucose” means this fruit has more glucose than fructose)

Easier to Tolerate

FRUIT	SERVING SIZE	FRUCTOSE (GRAMS)	Grams Excess Fructose
Apricot	1 fruit	.33	Glucose*
Cantaloupe	1/2 cup diced	1.5	0.27
Raspberries	½ cup sliced	1.5	0.31
Plums	1 fruit	2	Glucose*
Peach	1 medium	2	Glucose*
Nectarine	1 medium	2	Glucose*
Blackberries	1/2 cup sliced	2	0.07
Grapefruit	½ fruit	2	0.2
Pineapple	½ cup chunks	2	0.32
Strawberries	1/2 cup sliced	2	0.38
Honeydew	1/2 cup diced	2.5	0.24
Orange	1 fruit	3	0.39
Cherries	½  cup	4	Glucose*
Blueberries	½  cup	4	0.07

 

Harder to Tolerate

FRUIT	SERVING SIZE	FRUCTOSE (GRAMS)	Grams Excess Fructose
Kiwi	1 fruit	4	0.22
Raisins	1 miniature box (1 oz or 30 raisins)	4	0.28
Watermelon	1 cup diced	5	2.7
Banana	1 medium	6	Glucose*
Grapes	½ cup	6	0.7
Mango	1 whole	6	4.1
Orange Juice	1 cup	6.4	0.54
Persimmons	1 whole 2 ½ inch diameter	9.3	0.2
Apples	1 medium	10	4.48
Prunes	½ cup	11	Glucose*
Pears	1 medium	11	6.18
Apple Juice	1 cup	14	7.69
Dates	½ cup	14	Glucose*
Figs, dry	½ cup	17	Glucose*

Adapted from USDA National Nutrient Database for Standard Reference, Release 20

• Start with small portions of Easier to Tolerate fruits at meals.  See table on previous page.  They have a lower number of grams of fructose and are lower in “Excess Fructose” so will cause less gas and other symptoms.  
• When the “Excess Fructose” column says “Glucose”, the fruit has a good balance of glucose and fructose to help the body take in the fructose. For example, apricots are low in fructose and are balanced with glucose to help with absorption.  Apricots usually do not cause problems.  Bananas and mangos are equally high in fructose, but mangos cause more digestive problems because of their excess fructose which ferments in the gut.
• Avoid Harder to Tolerate fruits until you are feeling better.  See box above.  Once you are symptom free, you may be able to gradually add 1-2 new fruits weekly.  If side effects return, decrease the amount of fruit in your diet. (Continue to avoid juices.)
  
  

Tomatoes

If you are having problems with gas, try limiting these vegetables

Broccoli

Dairy Products to Avoid

• Flavored or sweetened milks (chocolate and others).
• Flavored or sweetened yogurts
• Sweetened condensed milk

Beverages to Avoid

• Carbonated sweetened beverages, particularly citrus flavors and certain diet beverages containing Splenda ®.
• Fruit and vegetable juices. Lemonade and other sweetened juice drinks.
• Milk shakes and malts
• Beer, Sherry, Port and other fortified wines

Allowed Beverages

• Water, carbonated water.
• Milk.
• Glucose-sweetened energy and sports drinks.
• Powdered drink, sugar-free (or with allowed sweetener).
• Coffee or tea.
• Alcoholic Beverages (limit to 1 ounce): gin, rum, vodka (from grain or potato), whiskey, dry white wine, or red wine.

 

Other Foods to Avoid or Modify

• Avoid chewing gum (both sugar and sugar-free).
• Avoid chocolate andmost other desserts.  Cocoa powder with allowed sweeteners is okay.
• Avoid condiments sweetened with fructose: catsup and soy sauce.
• Avoid coconut, coconut milk, coconut cream.  These are high in sugars.
• For sandwiches and salads, chop up dill pickles instead of using sweet pickle relish.

Constipation

If you are having issues with constipation, talk to your doctor about a bowel management program. If you are constipated, the bacteria in the gut have longer to feed and ferment on the sugars in the gut from the foods you eat. As the sugars feed those bacteria, the bacteria grow and which causes gas and abdominal pain.

Breads and Starches

If removinghigh fructose corn syrup and watch how much fruit you eatdoes not control your symptoms, you may need to watch your intake of fructans in breads and starches. Wheat-based foods contain fructans and/or high fructose corn syrup which can increase symptoms. Most people just need to eliminate breads with honey or high fructose corn syrup.  Then, they can eat breads as desired.

 

Breads and Starches

Breads/Starches to Avoid (Fructan Content/Serving)		Alternatives (Better Choices)
Limit whole wheat breads	(1.8 grams/2 slices), whole grain cereals (1.9 grams/1 cup) and graham crackers (1.2 grams/2 crackers). Note: Flour provides (4 grams/ 3.3 ounces of flour).	Rye Bread Gluten-free Breads, Pasta, Cereals Rice Noodles Rye, Corn or Rice-Crispbreads Gluten-free Cookies and Cakes Brown Rice (for fiber) or White Rice
Avoid wheat pasta	(2.5 grams/1cup serving).
Avoid commercial cookies, cakes, or muffins	(1.4 grams/1 small muffin).
Avoid products with dried fruits, fruits, honey, coconut or added sugars
Avoid instant flavored cereals &granola.

 

References:

 

Barrett JS. Clinical Ramification of Malabsorption of Fructose and Other Short-chain Carbohydrates. Practical Gastroenterology. 2007(Aug);53:51-65.

Shepherd S. Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management. J Am Diet Assoc. 2006;106:1631-1639.

USDA National Nutrient Database for Standard Reference, Release 20

 

 

If you have more questions please contact UW Health at one of the phone numbers listed below.

 

 

 

The Spanish version is PI 417.

 

The information provided should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Any duplication or distribution of the information contained herein is strictly prohibited.

Last Updated: 12/28/2012

Copyright © 12/28/2012 University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#376

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