Research
Perspectives in Practice
Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management

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Abstract

Dietary fructose induces abdominal symptoms in patients with fructose malabsorption, but there are no published guidelines on its dietary management. The objective was to retrospectively evaluate a potentially successful diet therapy in patients with irritable bowel syndrome and fructose malabsorption. Tables detailing the content of fructose and fructans in foods were constructed. A dietary strategy comprising avoidance of foods containing substantial free fructose and short-chain fructans, limitation of the total dietary fructose load, encouragement of foods in which glucose was balanced with fructose, and co-ingestion of free glucose to balance excess free fructose was devised. Sixty-two consecutively referred patients with irritable bowel syndrome and fructose malabsorption on breath hydrogen testing underwent dietary instruction. Dietary adherence and effect on abdominal symptoms were evaluated via telephone interview 2 to 40 months (median 14 months) later. Response to the diet was defined as improvement of all symptoms by at least 5 points on a −10- to 10-point scale. Forty-eight patients (77%) adhered to the diet always or frequently. Forty-six (74%) of all patients responded positively in all abdominal symptoms. Positive response overall was significantly better in those adherent than nonadherent (85% vs 36%; P<0.01), as was improvement in individual symptoms (P<0.01 for all symptoms). This comprehensive fructose malabsorption dietary therapy achieves a high level of sustained adherence and good symptomatic response.

Section snippets

Patient Selection

Sixty-two consecutive patients with IBS and proven fructose malabsorption were referred in a private practice setting by physicians for dietary management. Age range of subjects was 17 to 81 years (median, 50 years).

Fifteen were men (17 to 77 years, median 61 years) and 47 were women (23 to 81 years, median 46). Inclusion criteria comprised a diagnosis of IBS (made by the referring physician and fulfilling the Rome II criteria [26]). Patients with predominant diarrhea or constipation and those

Results

From tables of fructose, glucose, and fructan content of foods, detailed lists of problematic and favorable foods related to fructose and glucose were compiled and are shown in Figure 2. For fructans, published detailed data are more limited (12, 36, 37, 38, 39). Problematic foods have been grouped according to the likelihood of inducing symptoms and are outlined in the Table. The majority of fructan intake in a typical Western diet derives from wheat-based products (pasta, bread, breakfast

Discussion

The potential importance of malabsorbed fructose and fructans as a trigger for symptoms in patients with IBS has been generally underappreciated. The evidence that a fructose or fructan load can provoke acute gastrointestinal symptoms is substantial (3, 4, 5, 8, 13, 14, 19).

There is also support for the view that chronic symptoms of IBS can be effectively reduced in patients with fructose malabsorption by restricting dietary fructose ingestion (6, 7). During the last few decades, reports

S. J. Shepherd is an accredited practicing dietitian and P. R. Gibson is a professor and director of Medicine, Department of Gastroenterology and Monash University Department of Medicine, Box Hill Hospital, Box Hill, Victoria, Australia.

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    S. J. Shepherd is an accredited practicing dietitian and P. R. Gibson is a professor and director of Medicine, Department of Gastroenterology and Monash University Department of Medicine, Box Hill Hospital, Box Hill, Victoria, Australia.

    Australian credentials for Master of Nutrition and Dietetics (M Nut Diet) and Accredited Practising Dietitian (APD).

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