Fructose Malabsorption & the Low-FODMAP Diet

When an apple a day no longer keeps the doctor away…

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“Isn’t fructose just fruit sugar?”
“Why can someone with fructose malabsorption eat some sweet foods, but not others?”
“How are you able to drink soft drink, but not eat an apple, when the soft drink contains far more sugar than the apple does? “Wouldn’t the soft drink have more fructose than the apple, since there’s more sugar in the soft drink overall?”
“And what do onion, garlic, chickpeas and all those other savoury foods have to do with it? They’re not even sweet, so how could they contain fructose?”
“Hang on, what do you mean I can’t have wheat, either?!”
“I can’t eat sugar-free chewing gum? Why?! It’s sugar-free!”

I know, I know.
It can all be a bit mind-boggling…

If you’re reading this, you may have already tested positive to fructose malabsorption or IBS and be in desperate need of guidance as I once was; You might be experiencing gastrointestinal symptoms and wondering if you’ve got a food intolerance and, if so, which one?; You could be interested in the human digestive system and its increasingly common gastrointestinal disorders; you might have never heard of fructose malabsorption before and now you’re curious, or, you might be wondering what all the #fructosefriendly and #lowFODMAP hashtags all over Instagram are about. No matter the reason, the purpose of this page is to put some sense into it for you.

 Before I get started, I should note early on that this page is for informational purposes only. Like any health topic, there is a lot of conflicting information about fructose malabsorption and the low FODMAP diet on the internet, and this page is no different. All the advice on here comes from my personal experience and research that I trust. I am not a qualified medical practitioner or dietitian, and my words should not be taken as sound medical advice. If you think you might have a gastrointestinal disorder such as fructose malabsorption or IBS, you should seek advice from a dietitian who specialises in food sensitivities and gastrointestinal disorders.

On this page, I will aim to shed some light on the following:

Fructose malabsorption – what is it?
Symptoms of FM
Diagnosing FM with hydrogen breath testing
The low FODMAP diet and its 3 phases
Using the low FODMAP diet to relieve the symptoms of FM and IBS
The foods you need to avoid in the beginning if you have FM
What you can eat (and in what amounts) if you have FM
Life after FM
My top tips for a happy, healthy tummy

Fructose Malabsorption

Fructose, commonly known as ‘fruit sugar’, is a naturally occurring sugar found in many foods, particularly fruit and vegetables. The word ‘sugar’ itself is a very loaded term; there are many different types of sugars found in whole and processed foods. Sucrose is the proper term for what we know as plain ol’ sugar, the granulated/powdery stuff we put in cakes and coffee and which is present in many pre-packaged foods. Sucrose is a disaccharide (di=2 sugar molecules), made up of one glucose molecule and one fructose molecule. In other words, sucrose is 50% glucose and 50% fructose.

 Fructose malabsorption (you will commonly hear me refer to it as FructMal or FM) is a type of sugar sensitivity in which the small intestine is unable to absorb excess fructose and some other carbohydrates, known as FODMAPs. I’ll go into the whole FODMAP thing a little later, but for now we will just focus on fructose. For individuals with FM, fructose is generally only a problem when a food contains more fructose than glucose (hence the term ‘excess fructose’). FM is also load-dependent, meaning that it’s the total amount of fructose and other FODMAPs you’ve consumed in the one sitting, or over a day, which determines whether you will react adversely or not. This is why FM can be very confusing; you may still have a reaction after eating a big fruit salad of ‘safe’ fruits, because the total fructose load was simply too much. Had you eaten half or even three quarters of that fruit salad, you might have been fine. Then, one day you might be able to tolerate a particular ‘unsafe’ food, such as a regular slice of bread, and the next day you may not. It all depends on what else is in your gut at the time, and what’s going on “upstairs” at the time. Your gut is known as your ‘second brain’ for a reason

The essential role of the small intestine is to chemically break down food and absorb its nutrients so that those nutrients can be used around the body. The large intestine is responsible for absorbing water and preparing undigested food for removal from the body as faeces. Glucose is a simple sugar that the body can easily digest and absorb. It also acts as a fructose carrier, meaning that each glucose molecule can transport one fructose molecule across the small intestinal wall and into the bloodstream. As such, foods containing equal amounts of glucose and fructose (such as kiwi fruit) are generally well-tolerated because there’s enough glucose to carry all the fructose across the small intestinal wall.

However, when a food containing excess fructose (such as an apple) has been eaten, sometimes the small intestine is unable to absorb the leftover fructose. Those undigested particles then make their way to the large intestine, where they are not supposed to reach, and thus begin to ferment, acting as a food source to the bacteria which naturally live there. This can result in a range of symptoms including reflux, heartburn, abdominal pain, bloating, altered bowel movements (diarrhoea and/or constipation), excessive flatulence, nausea, vomiting, and so on.

Recent studies suggest that fructose malabsorption may result in lower levels of tryptophan (an important amino acid involved in the production of the neurotransmitter serotonin, the ‘wellbeing’ chemical responsible for making us feel happy), therefore resulting in feelings of depression. Other postulated mental side effects of fructose malabsorption –which have not yet been scientifically proven– include fatigue, brain fog, concentration issues and disturbed sleeping patterns.

Essentially, so long as your gut is unhappy, the rest of your body will be unhappy.

During the 6 months I went undiagnosed with FM, I experienced every single symptom mentioned above (except for the diarrhoea part – the opposite has always been my issue). The psychological impacts of fructose malabsorption (when it’s not being treated properly) might not yet be scientifically proven, but I can confidently say from my own experience that the mental effects were worse than the physical symptoms at times.

Totally perplexed by my ill health despite my efforts to lead such an active and healthy lifestyle, I began researching and came across many papers on this so-called fructose malabsorption disorder which I’d never heard of before. In a way, the abundance of online information helped me to self-diagnose, but it also confused the hell out of me because the more I read, the more conflicting each piece of different information became. Regular GP’s did nothing except suggest that I cut out gluten and dairy, which I did for a while, only for my symptoms to worsen. I started digging deeper into my research, determined to get to the bottom of it, and booked myself in for hydrogen breath testing.

After undergoing the breath tests and testing positive to fructose and sorbitol malabsorption, the only way to alleviate the awful symptoms was to limit or eliminate my dietary intake of the irritants. And, as you might have gathered, it’s not as simple as cutting out a few fruits which contain more fructose than they do glucose. It’s a lot more complex than that, because fructose has other molecular derivatives that are found in a huge range of different food groups. This is where FODMAPs come into it, and the (short-term) answer to my tummy troubles was the low-FODMAP diet.

The Low FODMAP Diet

In 1999, a team at Monash University developed the Low FODMAP Diet, a specific food plan which helps fructose malabsorption and IBS (irritable bowel syndrome*) sufferers to manage their gastrointestinal symptoms. FODMAPs are a collection of carbohydrates that are poorly absorbed by individuals with FM and IBS. The low FODMAP diet involves limiting or avoiding foods which contain high amounts of such carbohydrates in order to alleviate unpleasant gastrointestinal symptoms. A diet that limits or eliminates all moderate-high FODMAP foods is obviously quite restrictive –not to mention difficult and BORING– and can lead to deficiencies in vital nutrients, so it is only to be followed for 6-8 weeks. The diet consists of three phases, and you should seek guidance from a dietitian throughout the process to ensure that you’re still getting all the nutrients you need:

1. The Elimination Phase:
Sufferers should stick to a strict low FODMAP diet for around 6 weeks. During this time, the total FODMAP load consumed at each meal and across the day is reduced to a minimum. Eliminating as many irritants as possible gives your digestive system a rest from all the stress it’s been under, and allows your gut lining to begin its natural healing process. Your progress should then be reviewed by a dietitian who will help to advise which foods (and how much of them) can be gradually re-introduced into your diet.

2. The Reintroduction Phase: 
From anywhere between 1 and 6 weeks of avoiding high FODMAP foods, your worst gastrointestinal symptoms should have subsided significantly*. After you’ve put in the hard yards and stuck to a strictly low FODMAP diet for around 6 weeks, you will be able to reintroduce moderate FODMAP foods and tiny amounts of high FODMAP foods back into to your diet. During this phase, each FODMAP is reintroduced systematically to determine which specific foods –and how much of them– you are able to tolerate comfortably, and which ones you need to limit or avoid for a little longer. You will still find yourself reacting to most high FODMAP foods, and you will figure out which particular foods you need to avoid as much as possible in future (these are mainly onion, garlic, legumes and fruits with excess fructose/sorbitol for me, but you might find otherwise). You will generally find that your tolerance levels to moderate FODMAP containing foods continue to increase over time.

*If you’re still experiencing symptoms after 6 weeks of following the strict Low FODMAP diet, seek advice from a dietitian who specialises in food intolerances to determine whether there might be another reason for your symptoms.

2. The Maintenance Phase:
After all your trial and error during the reintroduction phase, you should have a fair idea of which foods you can eat in abundance, which ones you need to be careful with and which ones you’re best to avoid for a while. From here, a dietician will help you develop an individualised meal plan which cuts out the problematic foods but still enables you to enjoy a bountiful, varied and nutritious diet. You should continue to monitor your symptoms and if you do happen to experience symptoms again, you must eliminate the FODMAP groups responsible for the reaction until your symptoms have subsided. When you are feeling better, you can reintroduce these foods again, but in smaller quanities, and continue the process.

What are FODMAPs?!

FODMAP is an acronym which stands for:

Fermentable
Oligosaccharides (fructans and galacto-oligosaccharides [GOS])
Disaccharides (eg. lactose* – for those with IBS  and/or lactose intolerance, not FructMal)
Monosaccharides (eg. excess fructose)
And
Polyols (eg. sorbitol, mannitol, maltitol, xylitol and isomalt)

Even more confused now that you know what ‘FODMAP’ stands for?
The above words are just complex names for a collection of carbohydrates found in various foods, including fructose, that can be poorly absorbed by some individuals with fructose malabsorption and IBS. As complex as the words sound, all you need to know if that ‘saccharaide’ is another word for ‘sugar’. Monosaccharides have one sugar moleule, disaccharides have two, oligosaccharides have less than ten, and a polysaccharide has many (more than ten). Polyols are sugar alcohols (sugar molecules with an alcohol side-chain).

*It is important to note that while IBS and fructose malabsorption symptoms are very similar, the actual groups of molecules, or FODMAPs, they are sensitive to are different. The full Low FODMAP Diet developed by a team of professors at Monash, which limits FODMAPs from all categories, is directed at individuals who suffer from IBS symptoms. However, if you’ve tested positive to fructose malabsorption but not to lactose intolerance, it is not medically necessary to avoid lactose unless you choose to.

Which foods contain FODMAPs and should be avoided?

When using the low FODMAP diet to alleviate symptoms of FM or IBS, the idea is to limit or restrict the amount of irritants you consume as much as possible, to allow your gut to heal. The food items below have all been found to contain certain FODMAPs. Foods labelled with an asterisk (*) are considered to contain moderate amounts of FODMAPs, and such foods are safe up to a certain amount/load. I have provided ‘safe’ recommendations in brackets as a guideline only – these foods should be eaten in careful moderation until you have determined your individual tolerance levels to each of them. Foods not labelled with an asterisk are considered to be high in the particular FODMAP they’re listed under , and should therefore be avoided altogether during the elimination phase of the low FODMAP diet.

FOODS CONTAINING EXCESS FRUCTOSE
Foods that contain more fructose than glucose (or ‘excess fructose’)

Fruit:

  • Apple (all)
  • Boysenberry (eat less than 5)
  • Cherries* (eat 3 or less)
  • Dried fruits (all)
  • Figs (yes, it’s ironic that figs are the background of my blog but they’re just so pretty)
  • Fruit juice
  • Mango
  • Nashi
  • Pear
  • Sugar banana (if extra ripe – stick to 1/2 sugar banana)
  • Tamarillo
  • Watermelon

Other:

  • Agave syrup
  • High fructose corn syrup (not very common in Australia – used mainly in the States)
  • Honey

FOODS CONTAINING FRUCTANS

Individuals with fructose malabsorption find themselves reacting to some savoury foods as well as sweet, which can get very confusing because people naturally associate ‘fructose’ with sweet foods. Fructan, a chain molecule with a glucose molecule attached at the end, is formed from fructose and is a type of dietary fiber. Due to their structure, humans cannot break fructans down into their individual sugar molecules, so they are therefore malabsorbed in all of us (hence why people complain of gas after they eat baked beans and other legumes, whether they have a gastrointestinal disorder or not!). The main edible sources of fructan include wheat-based products and some fruit and vegetables. Fructan in the form of inulin/fructo-oligosaccharides (FOS) is often added to nutritional supplements and products to increase their dietary fibre content.

Fruit:

  • Apples (all)
  • Avocado* (start with 1/8th. People who malabsorb sorbitol should be careful with amounts larger than 1/8th)
  • Nectarine
  • Peach (white)
  • Persimmon
  • Tamarillo
  • Watermelon

Veggies (high fructan):

  • Artichokes
  • Cabbage, savoy* (stick to 1/2 cup or less)
  • Chicory
  • Garlic
  • Legumes & lentils (chickpeas, kidney beans etc.)
  • Leek
  • Okra
  • Onion (brown, white, Spanish & white part of spring/green onion)
  • Radicchio
  • Shallot
  • Snow peas* (eat less than 10 pods)

Veggies (moderate fructan):

  • Asparagus* (eat less than 3 spears)
  • Beetroot* (eat less than 4 slices)
  • Broccoli*(eat less than 1/2 cup)
  • Butternut pumpkin* (eat less than 1/4 cup)
  • Savoy cabbage* (eat less than 1 cup)
  • Green peas* (eat less than 1/3 cup)
  • Sweet corn* (eat less than 1 cob)

Breads and Cereals:

  • Barley
  • Rye (when it’s a major ingredient)
  • Spelt (you will find that I often use spelt in my recipes – some people are fine with it, some are not. Please test your own tolerance)
  • Wheat (modern wheat; avoid when it’s a main ingredient, such as in wheat bread, pasta, noodles, gnocchi, cous cous, wheat bran, cakes, biscuits etc.)
  • Wheat/rye/barley-based muesli bars, especially ones that contain dried fruit and/or honey

NUTS & SEEDS:

  • Cashews
  • Pistachio
  • Hazelnuts* (eat less than 10)
  • Almonds* (eat less than 10)
  • Sunflower seeds* (eat less than 2 tsp)
  • Pumpkin seeds* (pepitas – eat less than 2 tbs)

*Stick to a SMALL handful of moderate FODMAP-containing nuts and seeds at a time until you build your tolerance up (eg. less than 10 almonds, less than 2 tbs seeds etc.)

FOODS CONTAINING POLYOLS
As stated before, polyols are sugar molecules with an alcohol side-chain, and are thus called ‘sugar alcohols’. Polyols are given names such as sorbitol, mannitol, maltitol and xylitol. Isomalt also falls under this category. Such polyols occur naturally in some fruit and vegetables, but are also used in many ‘diet’ and ‘sugar free’ products as low calorie sweeteners. Reading labels and ingredients lists is very important, as sometimes polyols are identified by their number (shown below), not their name. Most products containing these sweeteners will state “excess consumption may have a laxative effect”, so look out for that too.

  • Sorbitol (420)
  • Mannitol (421)
  • Maltitol (965)
  • Xylitol (967)
  • Isomalt (953)
  • Lactitol (966)
  • Erythritol (968)

Packaged foods (read labels for the sweetener names/numbers mentioned above^):

  • Sugar-free/diet/low carb products (chewing gum, some soft drinks, chocolate, lollies)
  • Protein supplements  (powders, bars, shakes, snacks etc.)
  • Meal replacement products

 Fruit:

  • Apple
  • Apricot
  • Blackberries
  • Cherries
  • Coconut (eat less than 1 cup)
  • Lychee* (eat less than 5)
  • Nashi fruit
  • Nectarine
  • Peach (all)
  • Pear
  • Persimmon
  • Plum
  • Prune
  • Watermelon

Veggies:

  • Avocado* (most guides recommend no more than 1/8 – 1/4 avo at a time, but I’ve always been able to tolerate more)
  • Cauliflower* (a few sprigs)
  • Celery* (less than 1 stick)
  • Mushrooms
  • Snow peas
  • Sweet potato* (stick to 1/4 cup if you’re unsure. I can tolerate loads of sweet potato!)

FOODS CONTAINING LACTOSE

Only those with lactose intolerance as well as FructMal need to worry about this. Dairy products containing large amounts of lactose include cow’s milk, yoghurt, ice cream, condensed milk, custard and soft cheeses (cottage, ricotta, cream cheese).

So then, what can you eat?!

 This may seem a little hard to believe, but the answer is LOTS! It just so happens that several of the things someone with fructose malabsorption should limit or avoid are common ingredients in many prepackaged foods, restaurant dishes and home-style recipes (damn you, onion and garlic!)

Here’s a list of foods that my fellow victims of fructose can enjoy in blissful abundance, unless specified otherwise. Please note that the quantity recommendations in brackets are guides for those on strict low FODMAP diets. Some people will be able to tolerate more!

Fresh fruit (1 serve per sitting for those sticking to a strict low FODMAP diet):

  • Banana, ripe
  • Blueberries
  • Cantaloupe
  • Cherries (3 or less)
  • Coconut flesh (1/2 cup or less)
  • Dragon fruit
  • Grapefruit (1/4 – 1/2 medium)
  • Grapes
  • Kiwifruit
  • Lemon
  • Lime
  • Mandarin
  • Orange
  • Papaya
  • Passionfruit
  • Paw paw
  • Pineapple
  • Pomegranate (less than 1/4 cup seeds)
  • Raspberry
  • Rhubarb
  • Strawberries

Dried fruit:

  • Dried banana chips (1 small handful)
  • Dried shredded coconut (1/4 cup or less)

Veggies:

  • Artichoke hearts (less than 1/4 cup)
  • Asparagus (less than 3 spears)
  • Alfalfa
  • Avocado (start with 1/8th and work your way up)
  • Bamboo shoots
  • Bean sprouts
  • Beetroot (4 slices)
  • Bok Choy
  • Broccoli (less than 1/2 cup)
  • Cabbage, common
  • Cabbage, red
  • Cabbage, savoy (1/2 cup or less)
  • Carrot
  • Capsicum
  • Celery (1 stick)
  • Chili
  • Chives
  • Chinese broccoli
  • Cucumber
  • Choy sum
  • Eggplant
  • Endive (leafy green)
  • Fennel bulb (less than 1/4 cup)
  • Ginger
  • Green beans
  • Herbs, all (fresh or dried)
  • Kale
  • Lettuce
  • Olives
  • Okra (3 pods)
  • Parsnip
  • Peas, green (less than 1/4 cup)
  • Peas, snow (less than 10 pods)
  • Pickles
  • Pumpkin, Jap
  • Pumpkin, butternut (1/4 cup or less)
  • Potato, white
  • Potato, sweet (1/2 cup or less)
  • Radish
  • Rocket
  • Seaweed (nori)
  • Spinach
  • Spring onion (green part only)
  • Swede
  • Swiss chards (silberbeet)
  • Squash
  • Sweet corn (less than 1 cob)
  • Tomato (all)
  • Water chestnuts
  • Witlof
  • Zucchini

Spices:
All spices (fresh and dried) are fairly safe because they’re usually only used in small amounts. Super spicy foods (like dishes packed with chili) may irritate some people, especially those with damaged gut linings in the early days of their FM.

Protein sources:

  • Meat
  • Chicken
  • Fish
  • Eggs
  • Tofu
  • Tempeh

Dairy products (for those who eat dairy and are not lactose intolerant):

  • Milk (cow’s, sheep, goats etc.)
  • Butter
  • Ghee
  • Cheese (all)
  • Yoghurt (natural unsweetened)

Breads, Cereals & Grains:

  • Bread (gluten free*, buckwheat, oat sourdough, 100% spelt sourdough)
  • Buckwheat
  • Corn products (cornflour, maize, polenta, natural popcorn, corn cakes)
  • Oats and oat products
  • Rice (white and brown)
  • Unflavoured white & brown rice products (rice flour, noodles, pasta, puffed rice, rice crisps, rice crackers, rice cakes etc.)
  • Quinoa and quinoa products

Nuts & Seeds (no more than 1 small handful per sitting):

  • Almonds (less than 10)
  • Macadamias
  • LSA mix (1 tbs or less)
  • Peanuts
  • Pecans
  • Pine nuts
  • Pumpkin seeds/pepitas (eat less than 1 tbs)
  • Sunflower seeds (eat less than 2 tsp)
  • Sesame seeds
  • Chia seeds
  • Walnuts

Sweeteners:

  • Brown rice malt syrup
  • Pure maple syrup
  • Pure concentrated stevia extract powder/liquid drops from health food stores [must be pure & concentrated because commercial granulated and ‘baking’ stevias use fillers such as inulin (see notes on inulin in the section on fructans) to increase the volume and fibre content)].

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Life after fructose

I’m not going to sugar coat it – adapting to such a restrictive diet can be bloody difficult. No longer being able to carelessly eat some of your favourite things in the amounts you once did sucks, and if you’re anywhere near as emotionally invested in food as I am, you’ll find yourself getting a little down about it sometimes.

What does your (short-term) future look like?

Warning: there might be tears of frustration, if there hasn’t been already; You will expect your friends and family to feel sorry for you, and some genuinely will; An apple a day no longer keeps the doctor away. In fact, it only encourages him; There will be times when you don’t want anyone to enjoy a chickpea curry or date-based raw dessert in front of you ever again because if you can no longer enjoy them, why should they?; You’re an absolute nightmare to cook for and will most likely induce a nervous breakdown for dinner party hosts who have no idea what you can and cannot eat (’cause let’s face it, those lists are confusing as all hell for people who don’t have to know them); Those same hosts will secretly thank a higher power when you insist on eating before you join them; You’ll often be surrounded by an abundance of delicious food that you can’t eat, and believe me, when you know you can’t eat it, it becomes 100% MORE appealing; When you dine out, you will have to opt for plainer meals and 99% of the time you’ll be forced to order something just because it’s the only thing on the menu that won’t leave you howling in pain with tummy cramps or, um, stinking the joint out afterwards; You will endure insufferably frustrating encounters with unaccommodating waiters, but you won’t lose your cool because you don’t want them spitting in your food; If an apple or pear cider sounds delightful on a hot Summer’s arvo, you’d better think twice and opt for the vodka soda; You now have to prepare almost every snack from scratch because hardly any ‘healthy’ pre-packaged foods are fructose friendly; If you didn’t already, you must now read every single packet label before you consider putting its contents in your mouth; And now that you can’t eat plum pudding anymore (or fruit cake, or turkey stuffing, or plum sauce, or the fig paste on the cheese board), Christmas will never be the same again.

Of course, I’m exaggerating. It’s not all doom and gloom.
It’s only as bad as ^^that^^ if you allow it to be, but for a while, it felt that extreme at times. But then I realised that feeling sorry for myself and restricting myself from touching anything high-FODMAP would leave me miserable, so I stopped taking it so seriously and relaxed a little bit. The only really hard part about low FODMAP living should be the elimination phase, because that is, technically, the only time in which you should be truly restricting yourself. After that, you should be able to enjoy small amounts of even high-FODMAP foods, depending on your load at the time.

Where’s the silver lining?

We live in a modern age where humans eat for reasons more complex than merely maintaining survival. Food is the essence of so many social settings, from the mundane everyday lunch dates to our most celebrated food-fuelled festivities. For a lot of people, food is also a source of comfort – it’s familiar, a great distraction, and a void filler when things are less than perfect.
There’s nothing wonderful about not being able to eat a lot of your favourite foods in abundance, or having to be cautious every time you go to put something in your mouth.
So, no, fructose malabsorption isn’t a delight to live with, BUT the good news is that it DOES get easier with time. I promise.

You’ll learn to create delicious meals with the foods you can eat (which is still A LOT, by the way!), and you’ll stop missing particular things once you’ve replaced them with tasty alternatives. You’ll also find that you start appreciating and even LOVING foods you didn’t eat before. Believe it or not, I wouldn’t touch eggplant, zucchini, capsicum or pumpkin before I developed FM. I hated their textures and tastes, and I’d avoid them at all costs. Still, I needed to increase the variety of my veggie intake, and once I started incorporating them into my meals, I quickly learned to genuinely enjoy them. They’re now among my absolute favourite things to eat!

 It’s important to remember that the super strict version of the low FODMAP diet shouldn’t last for more than 6-8 weeks. It is, afterall, a “low FODMAP” diet, not a “NO FODMAP” diet, and it should not be treated as a lifelong meal plan. Once you’ve figured out what (and how much) of FODMAP-containing foods you can tolerate through systematic trial and error, you will be able to develop a long-term plan that ensures you are avoiding the foods that are most problematic for you, whilst still enjoying a varied diet full of nutritious and delicious foods. Down the track when you are symptom free and your digestive system is functioning ‘normally’, you can try reintroducing small amounts of the foods you reacted to even during the reintroduction phase! For instance, I can now gobble up whole sweet potatoes, however much avocado I want, the odd dollop of apple sauce with my roast pork, a few squares of agave-sweetened raw choccie, and even dishes that have small amounts of (very well-cooked) garlic and onion in them, so long as my overall FODMAP load hasn’t been too high that day.
See, I told you it gets better!

My blessing in disguise

I was at a total loss when I first developed FM. I already had a blog on the way, but like most other blogging health-foodies, my recipes were crawling with FODMAPs (dates, cashews, chickpeas, lentils etc. etc. etc). Like anyone trying to adapt to living with FM, I found it extremely difficult to come to terms with the fact that I couldn’t eat half the things I’d been enjoying for 20 years. When I first started hunting for fructose friendly and low FODMAP recipes, one fact was alarmingly obvious: there was a serious lack of recipes out there that were both genuinely healthy and suitable for people with FM. Sure, cyberspace is brimming with fantastic websites full of clean and wholesome recipes, and the majority of those sites accommodate for all the common dietary needs and preferences, such gluten free, lactose free, vego, pesco, vegan, paleo, blah, blah, blah. That’s all good and well for most people, but the problem for people like me is that those recipes often contain a myriad of no-go high FODMAP ingredients.  And at the other end of the spectrum, while the number of fructose friendly and low FODMAP recipes are on the rise as the demand for them increases, it’s difficult to find ones that are honestly healthy.
I didn’t know where to turn.

The lack of healthy fructose friendly recipes out there was totally deflating and got quite stressful at times. Mum didn’t know how to cook without onion or garlic, and I didn’t know how to make healthy sweets without using copious amounts of dates and nuts. I quickly stopped feeling sorry for myself and decided to be active about it.

And so Nourish By Ashlyn was born.
I want to bring you recipes that are fructose friendly, FODMAP conscious, super nourishing, nutritionally balanced AND tasty as hell. I adapted to my new low FODMAP lifestyle reasonably well, not because I found it easy to farewell many of the foods I once ate on a daily basis, but because I was so desperate to enjoy a meal that tasted great but was honestly healthy and didn’t leave me bed-ridden in pain. Bridging this gap  wouldn’t be possible if I hadn’t experience it all myself.

My aim is to take a bit of the frustration out of living with fructose absorption for you. You deserve to eat a tasty meal without being house-bound with offensive gastrointestinal symptoms afterwards; You deserve to not feel like you’re missing out on delicious food, no matter how restricted your diet seems and, above all, you deserve to feel healthy and live symptom-free!

My top tips for a tip-top tummy

How to add flavour without using onion and garlic

Garlic-infused Extra Virgin olive oil
Asafoetida powder (use a tiny pinch for onion flavour. Available from Indian spice markets and online)
Spring onion (green part)
Chives
Herbs (fresh and dried)
Spices
Chili
Ginger
Lemon juice
Lime juice
Maple syrup
Rice malt syrup
Tamari
Bragg’s All Purpose Seasoning

Stock
As you are no doubt aware, most pre-made stocks contain onion and/or garlic. The best option is to make your own in big batches, dividing into 500mL portions and and freezing until needed. However, for someone with FM who wants to eat healthily and already has to spend so much time in the kitchen preparing food from scratch, sometimes it’s simply inconvenient to make your own stock. For this reason, I have found Massels 7’s Stock Cubes to be invaluable. They come in ‘chicken’ or ‘beef’ flavour (both gluten free and vegan), and are the only pre-packaged stock product I’ve come across that doesn’t contain garlic or onion. The ingredients are not 100% clean, (chicken stock cube ingredients: Sea Salt, Maltodextrin (Maize), Sugar, Canola Oil, Yeast Extract, Natural Vegetable Flavours, Extra Virgin Olive Oil, Turmeric Ground Madras, Chilli), but considering the small amount that is used and how much effort they take out of cooking, I think they’re pretty great. Besides, if a few grains of salt and sugar and a drop of canola oil are the worst things in your meal, then I think you’re doing alright!

Eating out

There’s no other way to put it: dining out when you have fructose malabsorption is just as much a pain in the ass as it is in the tummy. During my first year of FM, eating out went from being one of my favourite pastimes to a dreaded nightmare. I quickly learnt how heavily restaurants rely on onion and garlic, and how unaccommodating chefs can be if they a) don’t understand your condition or b) are intimidated by it and don’t have the creativity –nor the willingness– to cook something you can eat without onion and garlic in it. If my blog does anything for you, I hope it proves that super tasty meals can EASILY be created without touching onion or garlic. And I’m certainly no chef.

Once you’ve got your symptoms under control and can tolerate small amounts of FODMAPs, dining out with FM is absolutely possible. I’ll soon be blogging a separate guide on “eating out with fructose malabsorption”. I definitely haven’t got it mastered, but I can now walk into (almost) any restaurant and know that if I word things in a certain way, and if I’ve been watching my FODMAP load that day, I’ll be able to get them to cook me something yummy that will leave me symptom free, whilst still being nutritious. While you do have to accept the fact that dining out with FM requires a lot of effort, patience and compromise, you shouldn’t have to feel like you’re totally missing out. My guide will show you ways to help achieve that.

Guides & Cookbooks

The Monash University Low FODMAP diet App. (approx. $12 from the App store).
I could not recommend purchasing this app more! Since it’s an app and thus continually updated, its recommendations are supported by the latest research.

‘Food Intolerance Management Plan’ by Dr. Sue Shepherd & Dr.Peter Gibson ($35 AUD from Dymocks).
This book is a must if you’ve just found out that you’ve got FM or are about to start the low FODMAP diet. It’s a fantastic all-round info guide and lifestyle plan based on the low FODMAP diet which answers a lot of questions in a straightforward, uncomplicated way. While I wouldn’t say that all the recipes in this book are clean (some are clean, but a lot call for things like refined gluten free pasta and sugar), they spark your imagination and give you ideas on the types of things you can cook.

‘Low FODMAP Recipes’ by Dr. Sue Shepherd ($35 AUD from Dymocks)
This is purely a low FODMAP recipe book, and most of the recipes that aren’t already ‘clean’ can be easily altered to be so, especially the savoury dishes.

General Tips 

  • First and foremost, get hydrogen breath testing done and SEE A DIETITIAN! Do not do it alone, especially if your symptoms are impacting your quality of life. You might have self-diagnosed (as I did before getting tested) and think you’ve got things under control, but a dietitian will monitor your progress and enable you to reintroduce certain foods more effectively than you can. They’ll also ensure that you’re consuming the right type and amount of nutrients, specific to your individual needs.
  • Make sure your diet is full of (natural) bright colours and lots of variation. Please remember that the low FODMAP diet is a “low FODMAP” diet, NOT a “no FODMAP” diet. Many FODMAP containing foods are highly nutritious and cutting FODMAPs out completely would mean depriving your body of vital nutrients. Plus, your sensitivities may worsen without moderate exposure to certain foods.
  • Avoid overeating. Devouring large amounts of food at the one time will increase your FODMAP load, so the best thing to do is eat small meals every 3 or so hours so that you’re spacing the FODMAP load out. Eat slowly and consciously and enjoy each mouthful.
  • When you’re first starting out, stick to one piece of ‘safe’ fruit or less per sitting, and aim for no more than 2-3 servings of fruit a day (like normal eating guidelines). It can be very easy to eat more than one serving of fruit at the one time, particularly in things like fruit salads and smoothies, but just be careful until you know exactly how much fructose you can tolerate at a time.
  • If you’re trying to work up your garlic/onion tolerance, make sure you cook the bejeezus out of it. The more you cook your onion and garlic, the less pungent –and more friendly for you– they become. During my 12 week European trip in 2014, I only experienced a few bad reactions, despite eating dishes that contained considerable amounts garlic and onion in them on a near-daily basis. I later realised that this was because a) I was more relaxed while I was eating (see next point), and b) the onion and garlic had been cooked out so much. Still, tread with caution until you know your tolerance levels.
  • Physical and mental stress will exacerbate your symptoms. Such stresses include alcohol, caffeine, excess fat and mental and physical stress. When you’re eating a meal, your mental state in that moment can impact how well you digest your food. Avoid eating when you’re stressed or in stressful surroundings. Take time out to enjoy your meal in a relaxed environment, and eat slowly and consciously. The mind is an amazing thing, and what it’s capable of doing to your physical body is scary – if you were highly stressed or depressed for a period before you started ‘developing’ your FM or IBS symptoms, the chances of there being a correlation between the two are high. Many people have found guided meditation and hypnosis to be great for aiding their symptoms, and it might come down to the fact that they are simply living in a more relaxed body and state of mind thereafter. Ask your dietitian about therapists who specialise in helping people with stress-related gastrointestinal issues.
  • Be mindful of FODMAP combining. The more DIFFERENT types of FODMAPs you have on your plate, the larger your ‘load’ gets. For instance, one bowl of sultanas (excess fructose) will not affect you as badly as a same size bowl of foods containing different FODMAPs, such as a mix of sultanas, (excess fructose), onion (fructan) and watermelon (polyol). If you want to combine FODMAPs, make sure you’re closely moderating your intake of each type. It’s also impossible to determine the FODMAP you’ve reacted to if you’re combining FODMAPS, which is why it’s important to follow the steps of the low FODMAP diet so that you know exactly what you can and can’t tolerate, and so that you can enjoy a variety of ingredients in your meals without fearing that you’ll get sick from them.
  • Healthy flora = happy gut = happy YOU. Flora refers to gut microorganisms that inhabit the digestive tracts of animalsHealthy intestinal flora is crucial for forming stools, supporting the immune system and metabolic activity, preventing allergies, synthesizing essential vitamins, and protecting from colorectal cancers. If you have FM or IBS, there’s a good chance that your gut flora has been seriously disrupted, and you may have an overgrowth of bad bacteria. To restore healthy flora balance, you might benefit from taking a probiotic (friendly bacteria) supplement. In recent times, I have also been trying to incorporate more fermented foods into my diet, such as kimichi, sauerkraut, keffir and kombucha. Eating naturally fermented foods introduces friendly bacteria into your gut to help restore flora balance. The fermentation process also produces beneficial digestive enzymes, which enable you to absorb the nutrients in your food more effectively, leading to better overall digestion and health.

“Oops, I think there was garlic in that!”

All these low FODMAP guidelines and symptom-prevention tips all good and well, but what happens when you do eat something you’re not supposed to, whether by accident or you just couldn’t help yourself? Did the waiter fail to mention that there was onion powder all over that marinated chicken? Did that garlicky hummus just look too good? Could you not resist eating half the tub of fig & pear paste on that cheese platter? Did you have a few too many mouthfuls of your friend’s cold-pressed watermelon juice?

I’m not saying you won’t feel any discomfort, but in many cases, your symptoms can be lessened if you act quickly. Foods with excess fructose are the easiest to combat. Think about it: you’ve eaten a bit too much pear paste (not to mention all the wheat crackers) at a dinner party, and you’re worried that your gut will hate the excess fructose and that you’ll be stinking the joint out in no time. How can you balance some of the excess fructose out? With glucose, of course (remember that glucose helps to carry fructose across the small intestinal wall for absorption!). Keep a snap-lock baggie of pure glucose powder on you for EMERGENCIES, and make sure you have a jar of rice malt syrup (glucose) in your pantry at home. Now, I must emphasise that this strategy is for emergencies only – you should not be stuffing your face with high-fructose foods and then combating them with half a jar of rice malt syrup just because you can, because glucose is still a simple sugar and does’t possess nutritional value. I’ve also found that this tactic works just as well after I’ve accidentally eaten foods with other irritants such as fructans and polyols.

Get minty: For those of you who can tolerate sorbitol – I love Mintec peppermint oil tablets, and I always try to keep a packet close by. They’re great to take 30 minutes BEFORE a meal, and I typically take them before I dine out when I know I’ll be picking at high-FODMAP foods. The tablets have a special coating which enables them to pass through the stomach intact, delaying the release of the peppermint oil until it reaches the intestinal tract where it effectively targets the site of the pain. Mintec causes the bowel muscle to relax, which helps restore normal contractions and relieves discomfort and pain. Please note that if you are highly sensitive to SORBITOL or polyols in general, Mintec is not a good idea because the coating contains some sorbitol.
I also love to sip on peppermint tea after meals.

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79 thoughts on “Fructose Malabsorption & the Low-FODMAP Diet

  1. Thank you so much for this blog! Being FM is not easy that is for sure and I am going on 10 years. I look forward to fresh ideas. I love your humour about stinking the place up. Lol 😂 FMs and their families can relate. Ha… Let’s just say I know how to clear a room. Hehehe… Thanks again!

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  2. Hi Ashlyn. What a wonderful informative blog. Thank you. I was diagnosed with FM 5 years ago (hydrogen breath test) but was not given any other info by my doctor except a list of foods to avoid. No explanation of how FM works. No mention of fructose loading, so I assumed I could eat a bucket of pineapple etc. I am going to find a dietician that specialises in FM and try and get my gastric problems resolved. Look forward to your recipe e book greatly!!

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  3. Thank you! I learned a great deal from your post. I haven’t had a breath test but, now, I plan on finding one or asking my doctor if they have this test available.

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  4. Hi. My son was recently diagnosed with FM and lactose intolerance and he has been on a strict FODMAP – no lactose diet for 3 weeks and is still doubled-over in pain – in bed most of the day. I suspect something else is going on, too. For those of you with fructose malabsorption – is your pain something you can live with? Does it ebb and flow? His is constant and he hasn’t been able to go to school in MONTHS. He does not have SIBO or Celiac. Signed – Desperate Mom

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  5. This is so helpful! Thank you so much!

    I didn’t see it on this list, but I live in Mexico and tamarind is very common here; anything to do with it gives me the worst stomach aches. 😦

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  6. Hello Ashley,so delighted in finding your blog. I can relate to everything you have written.Dining out a disaster.So many more tasty foods that you have suggested is exciting.Agree that feeling stressed before a meal is definitely a bad combo. You are so kind and helpful in so much information you have written.A million Thankyous.

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  7. Oh, dear Ashlyn! This page is a life saver! I was unexpectedly diagnosed with FM before a endoscope for an unrelated health problem. I now have a whole pinterest board dedicated to my lowFODMAP diet. The posts and recommendations are, just as you said, all different!! This is probably the best and most comprehensive explanation of FM and diet recommendations I’ve found!! I am your newest fan! In a world and internet where it is overwhelming to the newly diagnosed, thank you for taking the time to research this relatively unknown food intolerance.

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  8. I am finding things getting worse as the years are going on. I now can’t seem to have anything with any sugars in. I am intolerant to preservatives and additives, so gluten free bread a no no!!! Is this normal or do I have something else wrong with th stupid gut??

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  9. Wow, I’m glad i found this site was diagnosed 3 months ago and just given a piece of outdated paper with foods on to eat and avoid. Look forward to this as had many problems with my stomach in the past few years with H pylori, gluten lactose and now this fructose malabsorption. Love from Dubai UAE xxxx

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  10. Hi there Greg, my apologies – I’ve fixed it up now, but it was supposed to say that SAVOY cabbage is to be avoided in amounts larger than 1/2 cup, however red and common cabbage should be tolerated quite well in abundance. Thanks for bringing this to my attention!

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  11. I recently did t b e breath test and found I’m lactose. ..fructose & sorbitol intolerant… …he elp…..don’t know what to eat….what to do?

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  12. Hi Ashlyn, I was diagnosed with severe Fructose Intolerance yesterday and have been lactose intolerant all my life so not adverse to living by a strict diet. The FODMAP explained to me why I could eat some foods one day without an issue and the same food the next and i would have issues. I really enjoyed your blog and have a query. I must be misreading something as I think its states that cabbage is a veggie to avoid however further down it states that you can eat both common and savoy in abundance. what am a missing ?
    Thanks Regards
    Greg

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  13. Hi Joan, I only just came across this comment as I was reviewing the page – so sorry! It sounds like all your digestive issues are symptoms of a much larger problem, and hence why you’re reacting to so-called safe things like meat and veggies. Have you been to a naturopath? It’s always a controversial thing to say and I’m not qualified to give you specific advice but if I were you I’d be steering clear of western-style doctors and dietitians (since they clearly haven’t worked for you) and find a great naturopath who will try to find the root and cause of your problem, not just treat the myriad of symptoms. Also, ask the naturopath if they think water fasting would help for you (you can do your own research on this as well). Finding a great naturopath is key – ask around and do research. Hope that helps x

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  14. Ashlyn…
    I would definitely be interested in your e-book. Once it’s in the making, I can let a group of fellow FMers know.

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  15. Hi there! No idea how I missed this comment as it’s so large and wonderful, but sorry that I did! Your symptoms sound awful and you absolutely shouldn’t have to live like that. I’d seriously suggest finding a great naturopath who will help you understand that Frucmal and similar “intolerances” are mere symptoms of a larger problem, and that’s why it’s so hard to treat or “cure”, because everyone’s reasons behind developing it vary. When I’ve finished Uni next year and have more time on my hands, I really want to write an eBook with lots of new (strictly) low FODMAP recipes and a bit of a “how to deal” plan with helpful resources etc. Do you think you’d be interested in purchasing it if I were to do it? I need to ensure that it’s sell-able before I pour months of hard work into it haha! I’ll also be writing a blog post to gauge interest levels on this and to ask if there’s anything in particular people would like to see in it, so I’ll be very open to suggestions! Xxx

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  16. Thank you for sharing your story and helpful advice. I was finally diagnosed 2 years ago with FM (and a long history of reflux and diverticulitis and all the listed problems for many years With countless gastroscopies and colonoscopies which diagnosed inflammation)and gleaned more from your site than everything else I have been told and read. That includes 2 dietitians and several doctors ( most doctors I have been to refuse to admit that FM exists)
    Sometimes I just need someone to “talk ” to about a problem without going to a dietician or being misunderstood by yet another doctor.
    Thank you for making the complex problem somewhat more simplified and humorous

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  17. Hi Jacky, it sounds like your daughter’s body is completely burnt out – I doubt whether a low fructose diet alone will be the sole answer as it sounds to me like her food intolerances and leaky gut are a mere symptom of a bigger problem. Stress can wreck havoc on the entire body and especially the digestive system, and it’s a vicious cycle because the digestive system in turn when unhappy impacts hormones and other organ function – I’m sure the naturopath went through this with you? I sincerely hope you’re closer to finding an answer and getting your daughter’s health back on track. I will ask you this – before all these symptoms, was your daughter a natural stress-head, perfectionist, have a tendency to get worked up/highly strung or a poor sleeper due to restlessness/overthinking/can’t shut off? If so, I’d be looking into yoga, meditation and counselling because those personality traits (= STRESS + nervous system over-working) are a recipe for the issues you’ve mentioned above, and thus need to be addressed before her digestive issues have any chance of getting better… XXX

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  18. Hi Wendy, thanks for your comments! Wow, I haven’t heard of those methods of cooking and freezing onion/garlic before – amazing! I’ll have to give it a go. Thanks again 🙂

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  19. Thank you for your lovely comments, Emma! Means a lot. I hope your daughter’s body is beginning to heal. You’ve no doubt done this already, but if you haven’t, I’d recommend finding a really good naturopath who specialises in digestive disorders. They can work wonders when dietary intervention alone doesn’t fix things xxx

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  20. Hi Jo, very sorry to hear that. I would highly recommend getting onto a good naturopath and dietitian. Have you tried/entertained the idea of water fasting? If not, do some research on it, it might benefit you tremendously xx

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  21. Gosh thanks so much for that info Catherine, I had no idea Mintec contained sorbitol, I wouldn’t have tried it in the first place if I saw that! Can’t believe I didn’t react to it because I still react to sugar free chewy! I’ll take this recommendation off straight away. Thanks again x

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  22. Hi Ashlyn,
    Love your writing style, so good to hear your perspective on this issue! I have had FM for 5 years and have been going along ok until a few months ago I started getting symptoms really badly again, and led to feeling super low. I’ve gone back to a fairly strict diet and slowly feeling better. I have lost a lot of weight though, but can’t find any info on how to gain weight – any ideas? Thanks for your great insights cheers Jo 🙂

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