Many people are relieved when they are diagnosed with fructose malabsorption. Obviously they would prefer not to suffer from it but they finally have an explanation for a long list of uncomfortable symptoms: recurrent episodes of intestinal bloating, abdominal pain, flatulence, diarrhoea and or constipation.
For some, the diagnosis resolves their gastric signs and symptoms. They learn about foods to avoid, and when they follow a fructose-friendly diet the symptoms will diminish or disappear. (An important note here, however. My thought on long term fructose friendly diets is that they do more harm than good, but that’s a topic for another article.)
For others there are some improvements but digestive function is still not quite right. Unfortunately following a low-fructose diet is not the whole answer.
As I explained in this article, there can be many causes of fructose malabsorption. Small intestinal bacterial overgrowth (SIBO) is one of the common ones (read more about that here). Quite often SIBO is overlooked as a cause of gut problems and fructose malabsorption.
SIBO occurs when the commensal bacteria (the bacteria that should be in our large bowel) migrate up into the small intestine. The small intestine should be mostly sterile and when large concentrations of bacteria move up into the ileum of the small intestine that creates digestive problems.
Treating SIBO in the fructose-intolerant individual can be difficult as the number of antimicrobials at our disposal is restricted by the person’s intolerance to high fructan containing herbs. Studies have shown that allicin (a chemical constituent of garlic) successfully eradicates SIBO in methane-breathing individuals. Allicin is a powerful anti-microbial, however ingesting garlic is problematic for most people with fructose malabsorption.
The way around this is by using anti-microbial herbs that are not going to exacerbate digestive symptoms. Berberine and tannin containing herbs, green tea extract and cinnamon all work well.
Issues with the elemental & SCD diet approach
Dietary modifications for SIBO eradication are important during the eradication stage, however so much of the information out there in the blogosphere is contentious. It’s important not to take a one size fits all approach to SIBO treatment and to work with the body to restore the gut microbiome, not starve it.
One approach is to use the elemental diet, but it can sound a bit extreme.
Dr Mark Pimentel is a gastroenterologist who has extensively studied SIBO in relation to irritable bowel syndrome. He prefers to use an elemental diet, a good explanation of which can be found in this article. By absorbing essential nutrients further up the gastrointestinal tract the bacteria never get a chance to feed on the patient’s nutrition.
It is advised that you follow the elemental diet for at least two weeks to starve bacteria in the ileum. You can use a ready-made elemental formula called Vivonex plus. Ideally you would still be eating a whole food diet while eradicating SIBO and Vivonex is a far cry from real food. Just take a look at the ingredients.
A home-made version is possible but it is not for everyone because it consists of a terrible-tasting liquid diet that contains a combination of essential amino acids, coconut oil and honey. While the Vivonex is fine to take if you are fructose intolerant, the home-made honey containing formula won’t be tolerated by people with fructose intolerance.
The elemental diet approach is very challenging to follow and impractical if you experience fructose malabsorption.
Another option that is commonly endorsed is the Specific Carbohydrate Diet (SCD). This diet involves the restriction of carbohydrates that fuel bacteria to remain inhabiting the small intestine. The SCD diet is at odds with the FODMAP friendly diet as it allows some high fructose foods but omits allowed foods from the FODMAP friendly diet leaving people on an even more restricted diet than they are already on! My major gripe with the SCD diet is it’s omission of important high fibre foods that are needed to feed beneficial bacteria and rebalance dysbiosis in the large bowel.
Therapeutic diet considerations
Some restrictions are necessary during eradication of bacterial overgrowth. A diet that has no added sugars is ideal. Eating a whole food diet, rich in prebiotic fibres and antioxidants, is going to support the growth the beneficial bacteria. It is also important to avoid a grazing style diet. Eating three main meals is a great way to ensure that gastric emptying happens in its entirety after each meal.
Finally, it is important to note that SIBO is insidious and tends to come back for many people. Ultimately, complete resolution of SIBO can be achieved for some individuals if they address the underlying cause of the SIBO and the concomitant gut issues that are often occurring at the same time.
Following a therapeutic diet that is FODMAP friendly, that starves bacteria in the small intestine and that uses anti-microbial herbs such as cinnamon, gold thread and pomegranate (which are not high in fructans or fructose) means SIBO eradication is possible. The use of prokinetic agents and correcting ileo cecal valve issues with chiropractic or osteopathy is also be beneficial.
With a combination of pre- and pro-biotic therapy, anti-microbial herbs and nutrients to assist in gut repair, there is hope for sufferers of fructose malabsorption.