Fructose Malabsorption and Intolerance: Effects of Fructose with and without Simultaneous Glucose Ingestion

Figures & data

Table 1 Monosaccharide and net fructose content of common foods and ingredients

Serving Size
Food or Ingredient	Data Source	Measure	g	Total Sugars, g	Total Glucose, g^a	Total Fructose, g^b	Net Fructose, g^c
Sweeteners
Honey	d	1 tsp	7.0	5.8	2.6	2.9	0.3
Molasses	d	1 tsp	6.7	3.7	1.8	1.8	0.1
Sugar, table	d	1 tsp	4.2	4.2	2.1	2.1	0.0
Sugar, brown	d	1 tsp	4.6	4.5	2.2	2.2	0.0
Syrup, chocolate	g	1 tsp	6.5	3.3	2.0	1.1	0.0
Syrup, corn	g	1 tsp	7.2	5.7	5.7	0.0	0.0
Syrup, high-fructose corn (HFSC-42)	g	1 tsp	6.6	4.6	2.6	1.9	0.0
Syrup, high-fructose corn (HFSC-55)	g	1 tsp	6.7	5.1	2.2	2.8	0.6
Syrup, agave nectar	h	1 tsp	6.3	4.8	0.3	4.3	4.0
Syrup, maple	d	1 tsp	6.7	4.0	2.0	1.9	0.0
Syrup, pancake	g	1 tsp	6.7	2.8	1.8	1.0	0.0
Fruits
Agave, cooked (Southwestern)	d	—	100	20.9	2.4	18.4	16.0
Apples, raw w/ skin	d	1 med	182	18.9	6.3	12.6	6.3
Bananas	d	1 med	118	14.4	7.3	7.1	0.0
Grapes, red or green	d	1 cup	151	23.4	11.0	12.4	1.4
Oranges, navel	d	1	140	11.9	5.8	6.1	0.4
Pears	d	1 med	178	17.4	5.6	11.8	6.2
Watermelon	d	1 cup diced	152	9.4	3.4	6.0	2.6
Vegetables
Carrots, raw	d	1 large	72	3.4	1.7	1.7	0.0
Onions, raw	d	1 small	70	3.0	1.7	1.2	0.0
Sweet potatoes, boiled	d	1 med	151	8.7	6.9	1.7	0.0
Beverages
Apple juice	d	8 fl oz	248	23.9	8.1	15.8	7.7
Apple, grape, pear juice blend	d	8 fl oz	250	24.9	9.4	15.4	6.0
Cola (sucrose)	g	12 fl oz	369	40.5	20.3	20.3	0.0
Cola-type soft drink (HFCS)^i	g	12 fl oz	369	41.1	18.6	22.5	3.9
Cola-type soft drink (HFCS)^i	d	12 fl oz	369	39.0	16.5	22.5	6.0
Grape juice	d	8 fl oz	253	35.9	17.3	18.7	1.4
Lemon-lime type soft drink (sucrose)	g	12 fl oz	369	43.5	21.8	21.8	0.0
Lemon-lime type soft drink (HFCS)^i	g	12 fl oz	369	28.5	18.9	23.8	3.3
Lemon-lime type soft drink (HFCS)^i	d	12 fl oz	369	35.4	14.4	21.0	4.5
Lemon-lime sport drink 1	d	12 fl oz	366	22.4	9.5	12.2	2.6
Lemon-lime sport drink 2	f	12 fl oz	366	12.8	10.8	8.3	0.0
Orange juice	d	8 fl oz	249	20.7	10.2	10.5	0.4
Pear juice	e	8 fl oz	250	21.8	4.0	17.8	13.8
Dairy
Milk, chocolate flavored, reduced fat	d	8 fl oz	250	23.9	12.1	7.0	0.0
Ice cream, vanilla	g	4 oz	66.0	12.7	7.0	4.0	0.0
Yogurt, fruit	g	8 oz	225.0	33.1	16.0	12.8	0.0
Breakfast foods
Cereal bar, frosted and filled	g	1 bar	40.0	14.9	11.3	3.6	0.0
Cereal, ready to eat, sugared	g	1 oz	30.0	10.0	5.0	5.0	0.0
Sweets
Candies, hard, fruit flavored	g	1 oz	14.0	10.7	7.8	3.0	0.0
Chocolate, bar, milk	g	1.55 oz	43.0	24.2	12.0	9.9	0.0
Chocolate, bar, dark	d	1.55 oz	44.0	20.3	10.2	9.8	0.0
Chocolate, bar, dark	g	1.55 oz	40.0	14.8	7.3	7.3	0.0
Cookie, chocolate chip	g	1 oz	30.0	9.7	5.0	4.7	0.0
Cookie, oatmeal raisin	g	1 oz	30.0	11.4	5.7	5.7	0.1
Cookie, sandwich, peanut butter	g	1 oz	30.0	8.9	4.5	4.4	0.0
Licorice, strawberry	g	4 pieces	45.0	18.6	15.4	2.7	0.0
^aTotal glucose = 1/2 sucrose + 1/2 lactose + maltose + glucose.
^bTotal fructose = 1/2 sucrose + fructose.
^cNet fructose = total fructose – total glucose greater than 0.
^dU.S. Department of Agriculture (2009).
^eMatthews et al. (1987).
^fNutrition Data (2003).
^gManufacturer's data. For food items where only manufacturer data are presented, the USDA Standard Reference Database (2009) did not include monosaccharide information.
^hValues for agave nectar are based on the assumption of 6.3 g per tsp, 4.8 g total sugars per tsp, and LaBelle (1999), who indicates that the carbohydrate in agave nectar is 90% fructose, 8% glucose, and 2% other carbohydrates.
^iAverage of values for products with and without caffeine.

Table 2 Clinical trials of fructose malabsorption and intolerance in adults

	Study Population	Test Substance and Dose						Breath Testing Regimen
Author and Year	N (M/F)	Sugar	Dose, g	Conc,%^a	Positive Breath Test,%n	Rise Above Baseline Required for Positive Result, ppm	Correlation of Symptoms With H2 Peak^b	Freq, min	Dur, h
Healthy Subjects
Beyer et al. (2005)	15 (6/9)	F	25	200 mL H2O	53	≥20	No	30	3
	15	F	50	200 mL H2O	73		No
Born et al. (1995) ^c	34 (12/22)	F	25	NR	38	≥20	No	30	2
Densupsoontorn et al. (2007)	77 (37/40)	F	25	10	14	≥20	No	30	2
	9 (0/9)	F+G	25+25	20	0		No symptoms
Hoekstra et al. (1993)	12 (5/7)	F	6 mL/kg	10	0	≥20	No symptoms	30	2.5
	12	F+Sor	6 + 0.6 mL/kg	10	0		No symptoms
Ladas et al. (2000)	32 (15/17)	F	25	250 mL H2O	19	≥20	No	15	6
	32	F	50	250 mL H2O	81		No
Madsen et al. (2006) ^d	11 (6/5)	F+Sor	25+5	10	100	≥10	No	NS	NS
	11	G	30	10	0		No
Mitsui et al. (2001)	10 (9/1)	F+rice	17.5 + 200	5	0	≥3 over 2 samples	No symptoms	15	4
Rao et al. (2007) ^d	20 (10/10)	F	15	10	0	≥20	No symptoms	30	4 to 6
	20	F	25	10	50		No symptoms
	20	F	50	10	69		No
	20	F	50	33	60		No
Ravich and Bayless (1983)	3 (NR)	F	25	10	0	≥20	No	30	4
	14 (NR)	F	37.5	10	14		No
	16 (8/8)	F	50	10	38		No
	14 (NR)	F	50	20	71		No
	15 (NR)	S	50	10	0		No symptoms
Rumessen and Gudmand-Høyer (1986)	10 (7/3)	F	15	10	10	≥20	No symptoms	15–30	4
	10	F	20	10	40		No symptoms
	10	F	25	10	50		No symptoms
	10	F	37.5	10	70		No
	10	F	50	10	80		No
	10	F+G	50+12.5	12.5	70	≥20	No
	10	F+G	50+25	15	33		No
	10	F+G	50+50	20	0		No
	10	G	50	10	0		No symptoms
	10	S	50	20	0		No symptoms
	10	S	75	20	0		No
	10	S	100	20	0		No
Truswell et al. (1988)	21 (NR)	F	25	100 g/L	11		No
	103 (31/72)	F	50	100 g/L	58	≥20	Yes	15–30	2.25
	15 (NR)	F+G	25+25	100 g/L	0		NR
	30 (NR)	F+G (as apple juice)	25+16	60 g/L	7		NR
	23 (NR)	G	50	100 g/L	0		No symptoms
	15 (NR)	S	50	100 g/L	0		No symptoms
	23 (NR)	F (as HFCS-90)	50	100 g/L	30		NR
Subjects With Functional Gut Disorders Including IBS
Barrett et al. (2009) ^e	201 (41/60)	F	35	17	45	≥10 over	NR	15	3
	71 (23/48)^g	F	35	17	34	≥2 samples	NR
	201 (41/60)	L	15	15	27		NR
	71 (23/48)^g	L	15	15	39		NR
Choi et al. (2003) ^d,f	36 (9/27)	F	25	10	39		No
	183 (50/133)	F	50	33	73	≥20 or ≥3 over 3 samples	No	30	5
	20 (9/11)	F	50	33	80		No
	33 (11/22)	F	50	20	70		No
Choi et al. (2008) ^d	80 (26/54)	F	25	10	33	≥20	Yes	30	5
Corlew-Roath and Di Palma (2009) ^d	66 (9/57)	F	25	NS	3	NR	NR	NR	NR
	55 (11/34)^g	F	25	NS	16		NR
Fernández-Bañares et al. (1993)	25 (5/20)	F	25	10	52	≥20	No	15	3
	23 (NR)	F+Sor	25+5	250 mL H2O	92		Yes
	25	S	50	250 mL H2O	68		No
	12 (6/6)^g	F	25	10	42		No
	12^g	F+Sor	25+5	250 mL H2O	83		No
	12^g	S	50	250 mL H2O	50		No symptoms
Goldstein et al. (2000) ^d	239 (NR)	F	25	NR	44	≥20 H2; ≥4 ppm CH3	Yes	30	4
	239 (NR)	F+Sor	25+5	NR	73		Yes
Gomara et al. 2008	9 (NS)	F	1	0.04	0	≥20	No	30	3
	10 (NS)	F	15	6.3	30		No
	13 (NS)	F	45	19	77		No
Johlin et al. (2004) ^d	197 (NR)	F	50	150 mL H2O	76	≥20 or ≥3 over 3 samples	NR	30	5
Rumessen and Gudmand-Høyer (1988)	25 (2/23)	F	25	250 mL H2O	52	≥10	Yes	15–30	4
Skoog et al. (2008)	30 (9/21)	F	40	330 mL H2O	70	≥20	Yes	30	3
	20 (6/14)^g	F	40	330 mL H2O	65		Yes
	30	F (as HFCS-55)	40	600 mL H2O	30		No
	20^g	F (as HFCS- 55)	40	600 mL H2O	20		No
Szilagyi et al. (2007)	90 (61/29)	F	25	100 to 150 mL H2O	32	≥10 at 2 intervals	Yes	30	3
Abbreviations: Conc, concentration; Dur, duration; F, fructose; Freq, frequency; G, glucose; F + Sor, fructose + sorbitol; HFCS, high-fructose corn syrup; L, lactulose (positive control); NR, not reported; S, sucrose.
^a Unless otherwise indicated.
^b Assessed by reported statistical correlation, apparent dose-response pattern, or subjective assessment of reported percentages by the author of this article.
^c Evaluated subjects for methane producers; included only H2 producers.
^d Evaluated subjects for methane producers.
^e Although methane production was not tested, subjects that did not increase H2 >10 ppm above baseline were considered non-H2 producers and were excluded from the analysis.
^f Eleven percent of subjects were methanogenic.
^gHealthy subjects were included as controls.

Table 3 Limitations of clinical and dietary intervention studies of fructose malabsorption and intolerance

• Optimal hydrogen breath test parameters are still under debate and reproducibility is limited.

• Fructose is usually provided in a liquid bolus dose in isolation from glucose, after fasting, in quantities not typical to foods, potentially resulting in over diagnosis.

• Most studies do not screen for or measure methane production, potentially resulting in under diagnosis.

• Testing methods vary widely in terms of test substance amount, breath testing protocol, and comparisons with other sugars.

• Poor correlation between a positive breath test and induction of symptoms limits causal attribution.

• Baseline fructose intake prior to dietary intervention is not typically assessed or reported.

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