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Navigating Allergies and Food Sensitivities

Fructose Intolerance

Fructose Intolerance

Fructose is a simple sugar that exists in1:

  • most fruits
  • many vegetables
  • honey
  • agave syrup
  • brown sugar
  • high fructose corn syrup, (often found as a sweetener in candies and cakes)
  • beans
  • lentils
  • legumes, (peas and peanuts)
  • medicines, vitamins, and supplements

Fructose also is a key component of Fructan which is present in some grains, (bread, flour and pasta), and vegetables.

 

Fructan Content of Various Foods 2,3,4,5
Grains
Barley kernels (very young) 22%
Rye (bran) 7%
Rye (grain) 4.6-6.6%
Wheat flour /td>1-4%/td>
Wheat pasta 1-4%
Wheat bread (white) 0.7-2.8%
Vegetables
Artichoke, Jerusalem 16.0-20.0%
Garlic 17.4%
Onion 1.1-10.1%
Artichoke, Globe 2.0-6.8%
Asparagus 1.4-4.1%

 

There are two disorders caused by fructose:

1. Fructose Malabsorption, also known as Dietary Fructose Intolerance, is a condition in which the patients small intestines are not able to absorb the fructose as they should. As a result, excess fructose remains in the large intestine, which leads to fermentation and dehydration. The undigested fructose pulls water from the intestinal walls, and creates lose stools.

Symptoms of Fructose Malabsorption may include:

  • diarrhea
  • nausea
  • vomiting
  • fatigue
  • fuzzy head
  • headaches
  • depression, (see “Fructose and Depression” below)

Some patients may be able to tolerate small amounts of fructose in their diet, but it is very unique to each individual.

Test for Dietary Fructose Intolerance is painless.  It is identified by a special breathing test ordered by your gastroenterologist.

Treatment (Fructose Intolerant Diet):
a) Removal of fructose from the diet.
b) Adding dextrose, a glucose-based sweetener, to a diet when eating a high fructose containing food is recommended by some doctors, since fructose is absorbed or digested better when glucose is present. [WARNING: Dextrose or glucose sweeteners are often derived from corn and are therefore not appropriate for individuals with Corn Allergies.]
c) Under the supervision of a doctor, while avoiding foods that are high in fructose, slowly and one food at a time, test your ability to digest low fructose foods. The University of Virginia Digestive Health Center provides the below indicated guidelines on managing Fructose Intolerance and the below food charts are based on those developed by the UVA Digestive Health Center, Mayo Clinic, Clinical Dietitian – Division of Endocrinology and the Department of Dietitians at Children’s Hospital and Clinics of Minnesota. Note the recommendations differ between these institutions, and that individuals may need to go through a “trial and error process” under the supervision of their doctor to identify their optimal diet.

Fructose Intolerance – General Guidelines

  • Eliminate products with ingredients that list fructose, crystalline fructose, and honey on the label.
  • Limit drinks with High Fructose Corn Syrup (HFCS); if used, drink less than the recommended serving size, e.g., less than 12 oz of soda (may help to drink with a meal).
  • Keep in mind the amount of fructose found in 2 apples or 2 oz of honey is the same fructose in 1 can of soda.
  • Glucose is also a naturally occurring sugar. The more glucose than fructose in a product, the more “intestinal friendly” the fruit or fruit juice may be.
  • Follow guidelines below for fruits, vegetables, and other foods that are friendlier to your intestines.

Fruits:

  • Serving size is ½ cup
  • Limit to 1 to 2 servings per day.
  • Fresh or fresh frozen fruit may be better tolerated than canned fruit.
  • Keep in mind tolerance may depend on the amount you eat at one time.
  • Limit concentrated sources such as dried fruit and fruit juices or eating large amounts of any fruit. 
Intestine Friendly Fruits Fruits to Avoid
(due to high fructose content)
Questionable Foods/limit Source
Pineapples, strawberries, raspberries, blackberries, lemons, limes, avocado, bananas*, rhubarb, orange blueberry, grapefruit, grape, honeydew melon, kiwifruit, lemon, lime, passion fruit, mandarin, papaya, tangelo Prunes, pears, cherries peaches, apples, plums, applesauce, apple juice, pear juice, apple cider, grapes, dates, mango, watermelon Other fruit juices or drinks sugar ¬free jam/jelly dried fruit, canned fruit in heavy syrup UVA8
Initially test tolerance 1 – 2 times weekly.Note tolerance may be dose dependent.Avocado – 1
Cranberries – 1/4 – 1/2 cup
Craisins – 2 tbsp
Lemons – 1
Limes – 1
Rhubarb – 1/4 – 1/2 cup.After 4 – 6 weeks test tolerance with 1/4 – 1/2 cup servings of strawberries, raspberries, orange sections.
All other fruit Fruit juices drinks, and jams and jellies. Mayo Clinic9
Avocado – 1
Lime – 1
Apricot – 1
Lemon – 1
Rhubarb – 1
Cranberries – 1 cup Cantaloupe – 1/4 cup Pineapple – 1/4 cup Nectarine – small 1/2 Strawberries – 1/4 cup Fresh, peach – small 1/2
All other fruit Children’s Hosp. and Clinics of Minnesota10

*Possible gas forming foods may need to be avoided

Vegetables:

  • Serving size is ½ cup (most vegetables) or 1 cup (leafy green vegetables)
  • Limit to 3 servings per day.
  • Cooked vegetables may be tolerated best as cooking causes the loss of free sugars.
  • Keep in mind tolerance may depend on the amount you eat at one time.
Intestine Friendly Vegetables Vegetables to Avoid
(due to high fructose content)
Questionable Foods/limit Source
Asparagus, cauliflower*, green peppers*, broccoli*, leafy greens, celery, mushrooms, white potatoes, shallots, spinach, pea pods, cucumber*, beans*, other root vegetables Sugar snap peas Tomatoes, corn, carrot, sweet potatoes UVA8
Note tolerance may be dose dependent.Initially test tolerance with 2 -4 (1/4 cup – 1/2 cup) servings per day:Asparagus, beans, broad beans, celery, chives, dandelion greens, endive, escarole, mushrooms, mustard greens, pea pods, immature, white potatoes, shallots, spinach, swiss chard, turnip greens, snap, canned, drained, broccoli, brussels sprouts, cabbage, raw, white, cauliflower, cucumber, raw green peppers, raw leeks, cooked, iceberg lettuce, raw radishes, summer squash, watercress, zucchini Beets, Carrots, Corn, Eggplant, Onions, Peas, Sweet Potatoes, Tomatoes, Turnips, Winter Squash, all other legumes not listed in friendly vegetables. Vegetable Drinks, sundried tomatoes, tomato based sauces, catsup, salsa, pizza, spaghetti, apple cider vinegar, condiments with untolerated ingredients, soy sauce Mayo Clinic9
Low Fructose:
Spinach – 1 cup
Radish – large 1
Beets -1/2 cup
Peas – 1/2 cup
Mushroom – 1 cup
Onion – 1 tbsp
Green pepper – 1 tbsp
Raw celery – 1 stalk
Okra – 1/2 cup
Corn – 1/2 cup, green Beans – 1/2 cup canned
Romaine lettuce – 1 cup Sweet corn – 1 small ear Baby carrots – 3 each
Sweet potato – 1/2 cup bakedModerate Fructose:
Asparagus – 1/2 cup Iceberg lettuce – 1 cup chopped
Green beans – 1/2 cup frozen
Cabbage green – 1 cup raw
Carrots – 1/2 cup cooked
Cauliflower – 1 cup fresh Artichoke 1 fresh
Brussels sprouts – 1/2 cup
Cucumber – 1 cup fresh
White potato – large 1 Zucchini – 1/2 cup
Green pepper – 1/2 cup fresh
Eggplant – 1/2 cup fresh
All other vegetables Tomato sauce, Tomato juice, Tomato, Red Pepper Children’s Hosp. and Clinics of Minnesota10

*Possible gas forming foods may need to be avoided

Other:

Intestine Friendly Foods to Avoid
(due to high fructose content)
Questionable Foods/limit Source
• All meats • All fats • All dairy • All eggs • All beans* • Aspartame (Equal® and Nutrasweet®), Saccharin (Sweet ‘n Low®) • Sucrose (table sugar) • Maple or golden syrup • Honey • Flavorings with fructose • Desserts (ice cream, candy, cookies, bars) sweetened with fructose • Cereal or other processed foods fructose on the label Limit products with High Fructose Corn Syrup (HFCS); if symptoms still continue UVA8
All meats, fresh cooked
All fats
All dairy
All EggsGrains and Seeds: Amaranth, flax, millet, poppy, pumpkin, sesame, tahiniGrains: Cornmeal, buckwheat, rice, rye and products made from these grains.Gluten free breads, crackers, cereals, pastas, and bread crumbs without fructose added, are acceptable.Legumes: chic peas, lentils, lima beans, mung beansNuts: PistachiosSoy Products: soy protein isolates, and tofu.

Regular or low sodium bouillon, Gelatin, sugar free

Vinegar: rice, malt, some balsamic, distilled white,
Worcestershire Sauce

Sweeteners: Aspartame (Equal® and Nutrasweet®), corn syrup solids, (dried glucose) dextrin (corn sugar),dextrose/glucose, dextroglucose, evaporated cane sugar, glucose, glucose syrup, golden syrup, grape sugar, isomaltose, lactose, maltodextrin (form of glucose), maltose, maple sugar, maple syrup, moducal, polinculo, polycose, polydextrin, raw sugar, sucanat, • sucrose (cane or beet sugar, table sugar, sugar cane juice, turbinado, Saccharin (Sweet ‘n Low®)Sugartwin® white and brown, Stevia, sucralose (Splenda®)

Marinated meat with fructose • Desserts (ice cream, candy, cookies, bars) sweetened with fructose • Cereal or other processed foods with fructose on the label
Grains: Wheat contains fructans so limit items with wheat as the main ingredient. Wheat derived ingredients such as thickeners, maltodextrin, and dextrose are neglible amounts and are fine.Chose Cornmeal, buckwheat, rice, rye and products made from these grains
Gluten free breads, crackers, cereals, pastas, and bread crumbs without fructose added, are acceptable.Legumes: Peanuts and other than those listed in intestine friendlyNuts other than pistachiosTomato paste, sweet and sour sauces, relish, chutney, plum sauce, BBQ sauce. Limit commercial salad dressings, as many have fructose , fruit juice or high fructose corn syrupSweeteners: agave syrup, carob powder, caramel, chicory,gur, high fructose corn syrup (HFCS), high fructose glucose syrup, honey, invert sugar, isomalt, isoglucose, Karo dark corn syrup, Karo light corn syrup, lacitol, levulose, malitol, mannitol, molasses, muscovado sugar, palm sugar, panella, rapadura, reducing sugar, sorghum, sorbitol, treacle, xylitol
Products with High Fructose Corn Syrup (HFCS); Sweetened Condensed Milk, Fruited yogurt with high fructose corn syrup, Ice Cream with untolerated sugarsAvoid meat processed with honey or brown sugar, or other untolerated commercially breadedApple Cider Vinegar, Soy sauce, Tomato based sauces, catsup, salsa, pizza spaghetti sauce, condiments with untolerated ingredientsChose desserts that are wheat free, sweetened with sucrose, without added fruit or fruit juice concentrate. Choose lime or lemon sorbet or sherbert. Limit ice cream with added inulin or chicory root as they are fructans. Mayo Clinic9
All meats fresh cooked
All fats
All dairy
All EggsGrains: Wheat free corn bread or corn tortillas, rye, rice and corn crisp breads and crackers, gluten free crackers, cereals: rice, grits, oatmeal, corn flakes, puffed rice, gluten free cerealPasta: rice noodles, soba (100% buckwheat) noodles gluten free pasta, riceBreadcrumbs: cornflake and gluten free rice crumbsBeverages: choose water, carbonated water, milk, coffee, tea, diet soda, glucose-sweetened sports or energy drinks, alcoholic beverages (limit to 1 ounce): gin, rum, vodka (from grain or potato), whiskey, dry white wine or red wine, powdered drinks, sugar-free (or with allowed sweetener) and pure cranberry juice (sweetened with allowed sweeteners).Sweeteners generally tolerated: Bakers sugar, bar sugar, barley malt syrup, beet sugar berry sugar, brown sugar and brown sugar syrup, brown rice syrup, cane sugar, castor sugar, confectioners’ sugar, corn sugar, corn syrup, demerara, dextrin, dextrose, dextroglucose, evaporated cane sugar, evaporated cane juice, glucose, glucose syrup, glycogen, invert sugar, isomaltose, lactose, maltodextrin, maltose, maple sugar, maple syrup, moducal, polincillo, polycose, polydextrin raw sugar, reducing sugar, saccharose, starch sugar, sucanat, sucrose, sugar, sugar cane juice, sugar substitutes: aspartame (Equal®, NutraSweet®, NatraTaste®) saccharin (Sweet’nLow Low®, Sugartwin® white and brown) acesulfame potassium sucralose (Splenda®)
Avoid products with HFCS, honey, fruit juice concentrate, or corn syrup solids among the first 5 ingredients on the food label.Avoid sugar alcohols which include sorbitol, isomalt, lactitol, malitol, mannitol, xylitol, erythritol, and hydrogenated starch hydrosylates. (These are often found in “sugar free” and “no sugar added” gums, candies, ice creams, cookies, cough medicines/drops. Sugar alcohols are not well absorbed and create a laxative effect. Their absorption is not accelerated by consuming with glucose.Check medications for fructose or sorbitol. They are not always listed on the label, so check with the pharmacist or manufacturer. Avoid meat processed with breading from wheat, sweetened sauces, relish, tomato paste, chutney, plum sauce and BBQ sauce.Limit commercial salad dressings low fat dressings made with fructose, fruit juice or HFCS.Avoid Yogurt with added fruit, sweeteners made from fruit juice concentrate or HFCS.Limit beer, fortified wines: sherry, port. Limit all beverages, soft drinks bottled teas and coffees with fructose HFCS, or sorbitol. Limit sports drinks and juices with fructose or HFCS. Limit coconut milk or cream. Limit chicory based coffee substitute beverages. Children’s Hosp. and Clinics of Minnesota10

*Possible gas forming foods may need to be avoided

Fructose Intolerant Recipes: The University of Iowa provides an impressive list of recipes of beverages, meals, appetizers and desserts (!) for the Fructose Intolerant at: http://www.uihealthcare.com/topics/medicaldepartments/foodandnutrition/dfi/recipes.html

Prognosis: Very good, symptoms may begin to dissipate relatively quickly but can take up to a few weeks, after removal of the offending foods.11

Fructose and Depression: According to the Fructose Intolerance Network, Fructose Intolerance can be responsible for depression on two different levels. Firstly, if the regular symptoms of fructose intolerance persist for quite some time, they can “lead to the deterioration of the psychological and social situation.” In other words, the fructose intolerance symptoms make life difficult and less pleasurable.

Secondly, it is believed that fructose intolerance can upset the balance in the biochemistry of the brain. The neurotransmitter serotonin, which is responsible for making us “feel good,” is produced from Tryptophan, an essential amino acid. The body needs to get tryptophan from ingested food. Tryptophan will form a stable complex (or naturally combine) with the fructose in the gut and thus, in a fructose intolerant person, will not be absorbed when there is too much fructose. Too little tryptophan equals too little serotonin, which results in depression. If the depression is strictly caused by the fructose malabsorption, then the depression should leave if the diet is strictly followed. However, if it does not leave, then the patient should still see a physician for further evaluation of this symptom. 12

2.  Fructosemia, can also be called Hereditary Fructose Intolerance-adolase B-deficiency or Fructose 1, 6 bisphosphate aldolase deficiency.  This is a genetically inherited condition in which the patient lacks the correct enzyme, Adolase B to properly digest fructose.  The symptoms can include:

  • Convulsions
  • Excessive sleepiness
  • Irritability
  • Jaundice
  • Poor feeding as a baby
  • Problems after eating fruits and fructose/sucrose-containing foods
  • Vomiting
  • Hypoglycemia
  • Hemorrhage
  • Enlarged Liver
  • Kidney Failure
  • Dislike for sweets

Children are usually diagnosed at an early age, however, it is possible to go undiagnosed until adulthood.13

Tests that confirm the diagnosis include:

  • Blood clotting tests
  • Blood sugar test
  • Enzyme studies
  • Genetic testing
  • Kidney function tests
  • Liver function tests
  • Liver biopsy
  • Uric acid blood test
  • Urinalysis

Treatment for these patients is complete abstinence from all Fructose.  Prognosis depends upon how early the condition is detected.14

Complications may include:

  • Bleeding
  • Seizures
  • Gout
  • Illness from eating foods containing fructose or sucrose
  • Liver failure
  • Low blood sugar (hypoglycemia)
  • Death

It is essential that you immediately contact your physician if any of these symptoms occur after feeding starts with your infant. According to The University of Iowa Health Care, a clinic that specializes in Fructose Intolerance, it is recommended that the patient see a doctor who specializes in biochemical genetics or metabolism.15