New fructose malabsorption therapy 

Fructose: Why the sudden increase in the population of people with this malabsorption?

A recent study by Kyaw aet al (2011) showed that changes in the fructose/glucose ration in food may be the key to triggering fructose malabsorption.

The increased incidence of malabsorption was seen as the use of high fructose corn syrup (HFCS) as a food additive increased in the 1960s.

“These days, nearly all drinks except water, unsweetened tea and coffee contain HFCS….In food, deserts provide the highest source of calories from HFCS, 94$ more calories than the next highest sources”

The two most commonly used are HFCS-42 (42% fructose , 53% glucose) and HFCS -55 (55% fructose , 42% glucose), The latter is associated with malabsorption, the former is not, so malabsorption occurs when fructose is in excess of glucose. This concurs with data from foods likely to trigger malabsorption symptoms.

Thus fruits that usually don’t cause a problem are those with fructose content equal to or less than glucose, including berry, stone and citrus fruits, bananas and pineapples. Fruit and natural sweeteners such as honey, with higher glucose than fructose (honey, apples, pears, grapes, mangos, and watermelons) are more likely to trigger symptoms. It’s quite easy in your diet to identify fruits that cause a reaction, but reading labels to determine which HFCS is in a fizzy drink or desert can be tricky. Best to avoid anything containing HFCS until pre and probiotic therapy restores normal gut function  (see Pro and prebiotics) .

Kyaw MK et al, J Clin Gastroenterol. Vol 45, Jan 2011, 16-21


Bacopa and Shatavari

Two recent articles supported the use of these herbs.


1. Does Bacopa monnieri improve memory performance in older persons? Results of a randomized, placebo-controlled, double-blind trial.

Morgan A, Stevens J., J Altern Complement Med. 2010 Jul;16(7):753-9.

This described a randomized, double-blind, placebo-controlled trial, conducted in Lismore, NSW, Australia between February and July 2005. Ninety-eight (98) healthy participants over 55 years of age were recruited from the general population. Bacopa significantly improved memory acquisition and retention in these healthy, older Australians. This concurs with previous findings and traditional use.


2. Chemical constituents of Asparagus.

Negi JS, Singh P, Joshi GP, Rawat MS, Bisht VK. Phcog Rev 2010;4:215-20. Available from: http://www.phcogrev.com/text.asp?2010/4/8/215/70921

The roots of Asparagus racemosus (Shatavari) are bitter, sweet oleaginous, cooling, and indigestible, appetizer, and are useful in dysentery, tumors, inflammation, biliousness, leprosy, epilepsy, and night blindness. The roots are used as laxatives, tonic, aphrodisiac, galactogogue, and in disease of kidney and liver. …The bark exhibited antibacterial and antifungal activity. …..In India, it is used to promote fertility, reduce menstrual cramping, and increase milk production in nursing mothers. Asparagus acts to increase cellular activity in the kidneys and thus increases the rate of urine production.


Fructose (fruit sugar): What happens when you are attacked by a piece of fruit?

from Google: Monty Pythons picture page: what to do when attacked by a piece of fruit

There are two basic types of reaction to fructose, inherited and acquired.

Hereditary Fructose Intolerance (HFI)

This shows up in infancy when a child starts to eat baby food containing fruit and sugar. The symptoms include severe abdominal pain, failure to thrive (weight loss), increased or prolonged neonatal jaundice, vomiting, convulsions and excessive sleepiness. It can lead to fatal liver and kidney failure if untreated.


It ranges from mild to severe and infant health improves rapidly when sugars and fruit are excluded from the diet. It is a relatively rare recessive genetic disorder, due to a deficiency of the enzyme, aldolase B, resulting in the accumulation of fructose-1-phosphate in the liver, kidneys and intestine. This inhibits glycogen breakdown and glucose synthesis, thereby causing severe hypoglycaemia (low sugar levels) following ingestion of fructose. There is no cure and the only treatment is a strict fructose-free diet. Probiotics can be useful (see below). http://www.foodreactions.org


Fructose Malabsorption.

Unlike HFI, where fructose is absorbed from the intestine but not processed correctly, in fructose malabsorption the fruit sugar accumulates in the large intestine due to lack of fructose transporter systems in the gut. Fructose accumulation causes overgrowth of aerobic intestinal bacteria and excess hydrogen and hydrogen sulphide (rotten egg gas!) production, resulting in pain, flatulence, bloating and fatigue. The condition is usually diagnosed in adults and the incidence increases with age. http://www.foodreactions.org


Diagnosis and treatment 

Although patients may report the above symptoms, diagnosis is difficult because patients often fail to find any relationship between foods ingested and symptom onset, even when a diet diary is kept. This is because most foods contain both fructose and glucose. Tests for hydrogen in the breath can be inconclusive. The most common treatment is a diet with low levels of both sucrose and fructose (http://www.foodreactions.org). However, new data has indicated that a diet that includes pre and probiotics can restore gut bacteria and increase fructose absorption, thus relieving symptoms.


The importance of gut bacteria in fructose absorption.

Living in harmony with your resident gut bacteria provides good immune protection and vital nutrition: you couldn’t survive without them. The human intestine is host to an estimated 100 trillion bacteria, 70–80% of which cannot yet be grown outside the gut, so we don’t yet know precisely what their role is in food processing. The bacteria are classified as Firmicutes species. (eg Clostridium, Enterococcus and Lactobacillus ) or Bacteroidetes species. The gut population changes rapidly with a change of diet (Gourbeyre, Denery et al. 2011).


Recent studies have shown a vital link between the Bacteroidetes species and fructose metabolism. In studies in germ-free mice, gut inflammation could be treated by adding protective Bacteroidetes species (bifidobacteria). The protective bacteria have fructose transporters and can consume fructose, producing short chain fatty acid (acetate) that is taken up into the blood stream (Fukuda, Toh et al. 2011). Acetate is anti-inflammatory and helps to protect the lining of the gut from infection and irritation. High levels of acetate have been shown to reduce chronic inflammation in arthritis and colitis (Maslowski and Mackay 2011).


Lack of bifidobacteria in the gut in human populations may be due to a Western diet that is low in fibre and complex carbohydrates, and where antibiotics are frequently used (Maslowski and Mackay 2011). Only bifidobacteria can break down complex carbohydrates to produce short chain fatty acids. In the upper gastric tract bifidobacteria use glucose as food, but in the lower part of the colon, where glucose has been exhausted, only the bifidobacteria that have fructose transporters can survive and produce protective acetate, removing the fructose from the gut (Fukuda, Toh et al. 2011).

Lack of these bacteria changes the gut microenvironment, allowing a build-up of fructose, resulting in conditions that encourage yeast growth, fermentation and hydrogen and hydrogen sulphide release. Lack of short chain fatty acids also increases the risk of inflammation in the bowel. Thus fructose malabsorption may be due primarily to lack of Bacteriodetes in the colon.


How to cultivate your own fructose-eating bacteria

Just eating “probiotics” cannot guarantee survival of these bacteria in the large intestine. Firstly, the probiotic must contain the right species of bacteria. Many contain a variety of Lactobacilli and these are very useful in treating allergy, and in maintaining general gut health (Maslowski and Mackay 2011), but Bacteriodetes must be included to treat fructose malabsorption, and the species required for humans are not clearly know as yet. Secondly, only 5-15% of ingested probiotics survive passage through the stomach and small intestine to reach the large intestine, and this varies from person to person, so enough bacteria need to be eaten regularly to allow gut repopulation.


Finally, the gut environment must allow the survival of the bacteria once they arrive there. Maintenance of Bacteroidetes in humans seems to require a diet high in complex carbohydrates. This is a common factor in the populations were fructose malabsorption and allergies are rare, for example in Asia and Africa, where the diet typically includes little red meat, large amounts of rice, beans and green vegetables (which yield high amounts of short chain fatty acids) and also includes pickled and fermented foods that provide live cultures of Lactobacilli and Bacteroidetes. These diets do not include large amounts of fruit or fruit concentrates.


So guidelines for those with known fructose malabsorption are:

1. Avoid foods with a high fructose content, particularly avoid fruit juices and concentrated forms of fructose (dried fruit, tinned fruit, sorbitol, present in some diet drinks, sweet wines).

Foods to avoid/moderate:

• apples

• coconut milk

• guavas

• high fructose corn syrup (present in some soft drinks),

• honey

• lychees

• mangos

• melons

• pawpaw

• pears

• persimmons

• quince



2. Take probiotics regularly

Probiotics are dietary supplements containing potentially beneficial bacteria and yeast. Biodynamic yoghurts, specially formulated powders, supplement pills or probiotic drinks may contain one or more strains of these bacteria.

However, treatments for fructose malabsorption require probiotics that contain specific bifidobacteria strains, and these are not generally specified. Vibrant Vitality Products,  sells SELF that contains bifidobacteria.


3. Eat plenty of prebiotics

Prebiotics are defined as nutrients and constituents of food which our gut flora feed upon and are broadly classified as dietary fibre. Each species of bacteria is nourished by different food, and the bifidobacteria require dietary fibre to increasing their numbers. Dietary fibre is provided by carbohydrates found naturally in many plants (eg all leafy greens: see the salad article, leeks, onions, wheat, garlic, chicory root and artichokes). These carbohydrates are not broken down significantly by the digestive processes in the stomach and small intestine. They are only processed by the bacteria in the large intestine, and broken down into short chain fatty acids. Prebiotics thus help digestion and the immune system by increasing “good” bacterial levels.


Vegan and vegetarian diets can help, as they provide many of the prebiotic foods without the inflammatory effects of red meat and refined foods. Supplements, such as BioMedica's Pro-Flora that has bacteria plus prebiotics, and Bacto-C and GI from Mediherb (practitioner products available from me and from herbalists and naturopaths) can provide added high quality fibre to help in maintaining fructose-eating bacteria. In conclusion, these new advances give hope to sufferers of fructose malabsorption, that a change of diet and supplements may restore gut bacteria and function to normal levels so that they can again eat fruit without it attacking them later!




Fukuda, S., H. Toh, et al. (2011). "Bifidobacteria can protect from enteropathogenic infection through production of acetate." Nature 469(7331): 543-547.

Gourbeyre, P., S. Denery, et al. (2011). "Probiotics, prebiotics, and synbiotics: impact on the gut immune system and allergic reactions." J Leukoc Biol 89(5): 685-695.

Maslowski, K. M. and C. R. Mackay (2011). "Diet, gut microbiota and immune responses." Nat Immunol 12(1): 5-9.




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