Dietary Fructose Intolerance, Fructan Intolerance and FODMAPs

  • Amy Fedewa
  • Satish S. C. RaoEmail author
Neurogastroenterology and Motility Disorders of the Gastrointestinal Tract (S Rao, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Neurogastroenterology and Motility Disorders of the Gastrointestinal Tract


Dietary intolerances to fructose, fructans and FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are common, yet poorly recognized and managed. Over the last decade, they have come to the forefront because of new knowledge on the mechanisms and treatment of these conditions. Patients with these problems often present with unexplained bloating, belching, distension, gas, abdominal pain, or diarrhea. Here, we have examined the most up-to-date research on these food-related intolerances, discussed controversies, and have provided some guidelines for the dietary management of these conditions. Breath testing for carbohydrate intolerance appears to be standardized and essential for the diagnosis and management of these conditions, especially in the Western population. While current research shows that the FODMAP diet may be effective in treating some patients with irritable bowel syndrome, additional research is needed to identify more foods items that are high in FODMAPs, and to assess the long-term efficacy and safety of dietary interventions.


Fructose intolerance Fructose malabsorption Fructan intolerance Breath testing FODMAPS Irritable bowel syndrome Diet 



We thank Yeong Yeh Lee MD for providing assistance with the manuscript

Compliance with Ethics Guidelines

Conflict of Interest

Satish S. C. Rao declares no conflict of interest. Amy Fedewa is employed by Georgia Regents Medical Center.

Human and Animal Rights and Informed Consent

This article does contains studies with human subjects performed by the authors that were approved by ethics boards.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Hungin AP, Chang L, Locke GR, Dennis EH, Barghout V. Irritable bowel syndrome in the United States: prevalence, symptom patterns and impact. Aliment Pharmacol Ther. 2005;21:1365–75.CrossRefPubMedGoogle Scholar
  2. 2.
    Chang L. Review article: epidemiology and quality of life in functional gastrointestinal disorders. Aliment Pharmacol Ther. 2004;20 Suppl 7:31–9.CrossRefPubMedGoogle Scholar
  3. 3.•
    Böhn L, Störsrud S, Törnblom H, Bengtsson U, Simrén M. Self-reported food-related gastrointestinal symptoms of IBS are common and associated with more severe symptoms and reduced quality of life. Am J Gastroenterol. 2013;108:634–41. This study investigates dietary food triggers using a food questionnaire in patients with IBS and their effects on gastrointestinal and psychological symptoms and quality of life.CrossRefPubMedGoogle Scholar
  4. 4.
    Heizer WD, Southern S, McGovern S. The role of diet in symptoms of irritable bowel syndrome in adults: a narrative review. J Am Diet Assoc. 2009;109:1204–14.CrossRefPubMedGoogle Scholar
  5. 5.
    Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am Clin Nutr. 2004;79:537–43.Google Scholar
  6. 6.
    Economic Research Service, USDA. Table 49–US total estimated deliveries of caloric sweeteners for domestic food and beverage use, by calendar year. 2003.Google Scholar
  7. 7.
    Choi YK, Johlin Jr FC, Summers RW, Jackson M, Rao SS. Fructose intolerance: an under-recognized problem. Am J Gastroenterol. 2003;98:1348–53.CrossRefPubMedGoogle Scholar
  8. 8.••
    Choi YK, Kraft N, Zimmerman B, Jackson M, Rao SS. Fructose intolerance in IBS and utility of fructose-restricted diet. J Clin Gastroenterol. 2008;42:233–8. This study provides evidence that fructose intolerance is prevalent in patients with IBS and showed that, with compliance to fructose-restricted diet, symptoms improved despite only moderate impact on lifestyle.CrossRefPubMedGoogle Scholar
  9. 9.
    Wilder-Smith CH, Li X, Ho SSY, Leong SM, Wong RK, Koay ESC, et al. Fructose transporters GLUT5 and GLUT2 expression in adult patients with fructose intolerance. United Eur Gastroenterol J. 2013. doi: 10.1177/2050640613505279.Google Scholar
  10. 10.
    Riby JE, Fujisawa T, Kretchmer N. Fructose absorption. Am J Clin Nutr. 1993;58:748S–53S.PubMedGoogle Scholar
  11. 11.
    Putkonen L, Yao CK, Gibson PR. Fructose malabsorption syndrome. Curr Opin Clin Nutr Metab Care. 2013;16:473–7.PubMedGoogle Scholar
  12. 12.
    DeBosch BJ, Chi M, Moley KH. Glucose transporter 8 (GLUT8) regulates enterocyte fructose transport and global mammalian fructose utilization. Endocrinology. 2012;153:4181–91.CrossRefPubMedGoogle Scholar
  13. 13.
    Barrett JS, Gearry RB, Muir JG, Irving PM, Rose R, Rosella O, et al. Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment Pharmacol Ther. 2010;31:874–82.PubMedGoogle Scholar
  14. 14.••
    Rao SS, Attaluri A, Anderson L, Stumbo P. Ability of the normal human intestine to absorb fructose: evaluation by breath testing. Clin Gastroenterol Hepatol. 2007;5:959–63. The dose for breath testing of fructose malabsorption is determined in this dose-response study in normal volunteers.CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Jones HF, Butler RN, Moore DJ, Brooks DA. Developmental changes and fructose absorption in children: effect on malabsorption testing and dietary management. Nutr Rev. 2013;71:300–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Gibson PR, Newnham E, Barrett JS, Shepherd SJ, Muir JG. Review article: fructose malabsorption and the bigger picture. Aliment Pharmacol Ther. 2007;25:349–63.CrossRefPubMedGoogle Scholar
  17. 17.
    Barrett JS, Gibson PR. Fructose and lactose testing. Aust Fam Physician. 2012;41:293–6.PubMedGoogle Scholar
  18. 18.
    Shepherd SJ, Gibson PR. Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. J Am Diet Assoc. 2006;106:1631–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Kim Y, Park SC, Wolf BW, Hertzler SR. Combination of erythritol and fructose increases gastrointestinal symptoms in healthy adults. Nutr Res. 2011;31:836–41.CrossRefPubMedGoogle Scholar
  20. 20.
    Komericki P, Akkilic-Materna M, Strimitzer T, Weyermair K, Hammer HF, Aberer W. Oral xylose isomerase decreases breath hydrogen excretion and improves gastrointestinal symptoms in fructose malabsorption-a double-blind, placebo-controlled study. Aliment Pharmacol Ther. 2012;36:980–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Roberfroid MB. Introducing inulin-type fructans. Br J Nutr. 2005;93 Suppl 1:S13–25.CrossRefPubMedGoogle Scholar
  22. 22.
    Marcason W. What is the FODMAP diet? J Acad Nutr Diet. 2012;112:1696.CrossRefPubMedGoogle Scholar
  23. 23.•
    Donahue R, Attaluri A, Schneider M, Valestin J, Rao SS. Absorptive capacity of fructans in healthy humans: a dose response study. Gastroenterology. 2010;138:S709. This preliminary study provides the dose appropriate for fructan breath testing.Google Scholar
  24. 24.
    Muir JG, Shepherd SJ, Rosella O, Rose R, Barrett JS, Gibson PR. Fructan and free fructose content of common Australian vegetables and fruit. J Agric Food Chem. 2007;55:6619–27.CrossRefPubMedGoogle Scholar
  25. 25.
    Moshfegh AJ, Friday JE, Goldman JP, Ahuja JK. Presence of inulin and oligofructose in the diets of Americans. J Nutr. 1999;129:14707S–11S.Google Scholar
  26. 26.
    Biesiekierski JR, Rosella O, Rose R, Liels K, Barrett JS, Shepherd SJ, et al. Quantification of fructans, galacto-oligosaccharides and other short-chain carbohydrates in processed grains and cereals. J Hum Nutr Diet. 2011;24:154–76.CrossRefPubMedGoogle Scholar
  27. 27.
    Shepherd SJ, Parker FC, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence. Clin Gastroenterol Hepatol. 2008;6:765–71.CrossRefPubMedGoogle Scholar
  28. 28.
    Attaluri A, Paulson J, Jackson M, Donahue R, Rao SS. Dietary Fructan intolerance: a new recognized problem in IBS. Neurogastroenterol Motil. 2009;57:150.Google Scholar
  29. 29.
    Barrett JS, Gibson PR. Clinical ramifications of malabsorption of fructose and other short-chain carbohydrates. Pract Gastroenterol. 2007;31:51–65.Google Scholar
  30. 30.••
    Shepherd SJ, Lomer MC, Gibson PR. Short-chain carbohydrates and functional gastrointestinal disorders. Am J Gastroenterol. 2013;108:707–17. This review provides comprehensive evaluation of FODMAPs in functional gastrointestinal disorders.CrossRefPubMedGoogle Scholar
  31. 31.
    Fernández-Bañares F, Esteve M, Viver JM. Fructose-sorbitol malabsorption. Curr Gastroenterol Rep. 2009;11:368–74.CrossRefPubMedGoogle Scholar
  32. 32.
    Staudacher HM, Whelan K, Irving PM, Lomer MC. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPS) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet. 2011;24:487–95.CrossRefPubMedGoogle Scholar
  33. 33.
    de Roest RH, Dobbs BR, Chapman BA, Batman B, O’Brien LA, Leeper JA, et al. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. Int J Clin Pract. 2013;67:895–903.CrossRefPubMedGoogle Scholar
  34. 34.•
    Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2013;pii: S0016-5085(13):01407–8. doi: 10.1053/j.gastro.2013.09.046. This randomized controlled trial provides evidence on the efficacy of FODMAPs in IBS.
  35. 35.
    Ong DK, Mitchell SB, Barrett JS, Shepherd SJ, Irving PM, Biesiekierski JR, et al. Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. J Gastroenterol Hepatol. 2010;25:1366–73.CrossRefPubMedGoogle Scholar
  36. 36.
    Halmos EP, Muir JG, Barrett JS, Deng M, Shepherd SJ, Gibson PR. Diarrhoea during enteral nutrition is predicted by the poorly absorbed short-chain carbohydrate (FODMAP) content of the formula. Aliment Pharmacol Ther. 2010;32:952–33.Google Scholar
  37. 37.
    Gearry RB, Irving PM, Barrett JS, Nathan DM, Shepherd SJ, Gibson PR. Reduction of dietary poorly absorbed carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease-a pilot study. J Crohns Colitis. 2009;3:8–14.CrossRefPubMedGoogle Scholar
  38. 38.
    Barrett JS. Expanding our knowledge of fermentable, short-chain carbohydrates for managing gastrointestinal symptoms. Nutr Clin Pract. 2013;28:300–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Barrett JS, Gibson PR. Fermentable oligosaccharides disaccharides, monosaccharides and polyols (FODMAPS) and nonallergic food intolerance: FODMAPs or food chemicals? Ther Adv Gastroenterol. 2012;5:261–8.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Food and Nutrition DepartmentGeorgia Regents UniversityAugustaUSA
  2. 2.Department of Medicine, Section of Gastroenterology and HepatologyGeorgia Regents UniversityAugustaUSA

Personalised recommendations