Medical Nutrition Therapy: Fructose-Restricted Diet

What is fructose?
Fructose is a natural sugar found in many foods. As a simple sugar, fructose is found in foods
such as fruits and honey. When fructose is hooked to another sugar called glucose, it forms table
sugar or sucrose. Fructose can form a longer chain called fructans found in vegetables and
wheat. Because of the intense sweetness of fructose, the sweetness can be further concentrated
into high fructose corn syrup and used in place of table sugar in many soft drinks and sweets.
Why do I need to restrict fructose from my diet?
Some people have trouble digesting fructose. Fructose empties from the stomach more rapidly
than other sugars. Fructose is absorbed or taken in by the small intestine in a couple ways. If
glucose is present in equal amounts with the fructose, it helps the body use the fructose at the
start of the small intestine. Free fructose without matching glucose is absorbed more slowly
along the length of the small intestine. When fructose is not digested, it is fermented by bacteria.
This can cause side effects like bloating, abdominal pain, nausea, gas, and diarrhea. These side
effects can be controlled with a low fructose diet.
How do I follow a low fructose diet?
Some people can have small amounts of fructose and have no problems. Others need to avoid
even small amounts in their diet. The amount of fructose that produces GI symptoms in healthy
adults can range from less than 25 grams to 50 grams. The levels that cause discomfort in healthy
children have not been studied. It should be noted that a 16-ounce bottle of apple juice may
contain more than 30 grams of fructose and a 20 ounce bottle of soda can contain up to 40 grams
of fructose.
To get started, you will need to read food labels. Avoid foods or drinks with high fructose corn
syrup. For many people this change gets rid of their symptoms. Some people regularly drink 100
grams a day of fructose in sweetened beverages so they feel much better when these are stopped.
Some fruits and vegetables naturally have a lot of fructose. Fruits that are balanced with both
fructose and glucose will be better absorbed which will reduce gas. Use the tips below to pick
which fruits you may be better able to eat without problems.

How long do I have to follow a low fructose diet?

Some people will find relief of symptoms quickly. Others will have to eliminate more foods for
a longer period of time. Once your symptoms improve for 4-6 weeks, then you can begin to add
foods back to your diet. This will help you to see which foods you can have without side effects.
Try adding only one food back to your diet at a time. Wait 4 days before trying another food.
Fructose takes three days to pass through the gut.
What foods or food groups do I need to avoid?
Avoid foods and drinks with high fructose corn syrup (candy, sodas, sweetened juice, or
punch).
Avoid fruit juices. They are concentrated forms of fructose. It takes the juice from
multiple pieces of fruit to make one glass of juice.
Avoid commercial baked goods; most contain high fructose corn syrup.
Avoid sorbitol (a sugar alcohol) and too much of other artificial sweeteners (Splenda).
These artificial sweeteners cause symptoms in the gut similar to those caused by fructose.
The combination of fructose and sorbitol worsens symptoms.
Overall, limit all sweets to very small servings. When a sweet item is occasionally
served, give it with a meal not as a snack.
What about sweeteners?
What sweeteners should I avoid?
Agave syrup
Caramel
Fructose
High Fructose Corn Syrup
Honey
Invert Sugar
Molasses
Pancake Syrup (not real)
Palm Sugar
Sugar Alcohols: Mannitol, Sorbitol,
Xylitol
Splenda (sucralose)
Always read labels to be sure the
companies arent adding other
sweeteners, like high fructose corn
syrup.

What sweeteners are OK to use?

Avoid large amounts of allowed sweets
Barley Malt Syrup (contains about 2%
fructose, so may not be as well
tolerated)
Brown Rice Syrup (check label to make
sure High Fructose Corn Syrup wasnt
added)
Brown Sugar (small amounts)
Dextrin
Dextroseavailable in specialty stores
and online (binds free fructose in gut to
absorb) can be used in recipes
Glucose or glucose syrups
Lactose
Maltose, Isomaltose
Polycose
Raw sugar or Turbinado sugar
Real Maple Syrup (Limit 1 T)
Sucrose (Table Sugar/Cane Sugar)
Sugar substitutes: Aspartame
(Nutrasweet or Equal), Sugar
Twin, Sweet One

Helpful Hints:
Eat foods with fructose in small amounts and spread them over the day.
Your body may be able to digest foods with fructose when eaten with other foods.
Check medicines and vitamins for hidden fructose and/or Sorbitol.
Keep a food journal of what was eaten and your symptoms. You may see trends.
You may need to use a daily vitamin if you find you must cut back on most fruits and
vegetables. Talk with your doctor or a dietitian for vitamin recommendations.
Fruits
Eat fruit in moderation as part of a meal. Do not eat fruit separately as a snack.
Avoid fruit drinks, juices, jams, jellies, and chutneys.
Fructose Content of Common Fruits
Note: Glucose means this fruit has more glucose than fructose)

Easier to Tolerate
FRUIT

SERVING
SIZE

FRUCTOSE (GRAMS)

Apricot
Cantaloupe
Raspberries
Plums
Peach
Nectarine
Blackberries
Grapefruit
Pineapple
Strawberries
Honeydew
Orange
Cherries
Blueberries

1 fruit
1/2 cup diced
cup sliced
1 fruit
1 medium
1 medium
1/2 cup sliced
fruit
cup chunks
1/2 cup sliced
1/2 cup diced
1 fruit
cup
cup

.33
1.5
1.5
2
2
2
2
2
2
2
2.5
3
4
4

Grams
Excess
Fructose
Glucose*
0.27
0.31
Glucose*
Glucose*
Glucose*
0.07
0.2
0.32
0.38
0.24
0.39
Glucose*
0.07

Harder to Tolerate
FRUIT

SERVING
SIZE

FRUCTOSE (GRAMS)

Kiwi
Raisins

1 fruit
1 miniature box
(1 oz or 30
raisins)
1 cup diced
1 medium
cup
1 whole
1 cup

4
4

Grams
Excess
Fructose
0.22
0.28

5
6
6
6
6.4

2.7
Glucose*
0.7
4.1
0.54

9.3

0.2

10
11
11
14
14
17

4.48
Glucose*
6.18
7.69
Glucose*
Glucose*

Watermelon
Banana
Grapes
Mango
Orange
Juice
Persimmons
Apples
Prunes
Pears
Apple Juice
Dates
Figs, dry

1 whole 2
inch diameter
1 medium
cup
1 medium
1 cup
cup
cup

Adapted from USDA National Nutrient Database for Standard Reference, Release 20

Start with small portions of Easier to Tolerate fruits at meals. See table on previous page.
They have a lower number of grams of fructose and are lower in Excess Fructose so
will cause less gas and other symptoms.

When the Excess Fructose column says Glucose, the fruit has a good balance of
glucose and fructose to help the body take in the fructose. For example, apricots are low
in fructose and are balanced with glucose to help with absorption. Apricots usually do
not cause problems. Bananas and mangos are equally high in fructose, but mangos cause
more digestive problems because of their excess fructose which ferments in the gut.

Avoid Harder to Tolerate fruits until you are feeling better. See box above. Once you
are symptom free, you may be able to gradually add 1-2 new fruits weekly. If side
effects return, decrease the amount of fruit in your diet. (Continue to avoid juices.)

Tomatoes
Tomatoes are a fruit, but are eaten like a vegetable.
FRUIT

Fresh Tomato
Tomato Sauce
Canned Tomatoes
Tomato Paste

SERVING SIZE

1 whole
cup
cup
1 Tablespoon

FRUCTOSE (GRAMS)

1.7 grams
2.03 grams
1.52 grams
0.48 grams

Excess
Fructose

0.15 grams
Glucose
0.2 grams
0.01 grams

Many people have problems eating tomato products. Dishes like spaghetti with marinara sauce
have a larger portion of sauce. Traditional spaghetti sauce made with tomato paste is bitter from
the skin so a sweetener is normally added. Commercial spaghetti sauce has a total of 11 grams
of sugars which is twice plain tomato sauce. After you are symptom free, if you want spaghetti
sauce, try making your own sauce using this simple recipe. You will still need to limit your
portion.
Spaghetti with Meat Sauce:
pound hamburger, browned and drained
2 cloves fresh garlic, minced
16 ounces tomato sauce

1 teaspoon Oregano, or to taste

1 teaspoon Basil, or to taste
Salt and pepper to taste

After meat is browned and drained, add garlic, oregano, and basil. Add tomato sauce, salt and
pepper to taste and simmer for about 20-30 minutes while pasta cooking. Do not eat more than
cup serving try with gluten-free noodles. Note: other herbs or spices may be added.
Vegetables
Some vegetables contain fructose, but are well balanced with glucose. Half cup portions
are not a problem.
Eat vegetables as part of a meal for better tolerance.
If you have issues with diarrhea, avoid whole kernel corn. It is not well digested and goes
right through the gut.
Fructan Content
Most Problems
Asparagus
Leeks
Onions
Jerusalem artichoke

(2.6 gram/6 spears)

( 5.6 grams/ cup)
(May cook with but remove
chunks - 2.1 gram/2T)
(15 grams/ cup)

May be a problem
Globe artichoke
(5.5 gram/ 1 globe)
Dandelion greens
Chicory roots

(3.1 gram/ cup)

(15 grams/ cup)

If you are having problems with gas, try limiting these vegetables
Broccoli
Cauliflower
Peppers (raw)
Brussels sprouts
Cucumbers (raw)
Radishes (raw)
Cabbage
Legumes/Baked Beans
Scallions
Dairy Products to Avoid
Flavored or sweetened milks (chocolate and others).
Flavored or sweetened yogurts
Sweetened condensed milk
Beverages to Avoid
Carbonated sweetened beverages, particularly citrus flavors and certain diet beverages
containing Splenda .
Fruit and vegetable juices. Lemonade and other sweetened juice drinks.
Milkshakes and malts
Beer, Sherry, Port and other fortified wines
Allowed Beverages
Water, carbonated water.
Milk.
Glucose-sweetened energy and sports drinks.
Powdered drink, sugar-free (or with allowed sweetener).
Coffee or tea.
Alcoholic Beverages (limit to 1 ounce): gin, rum, vodka (from grain or potato), whiskey,
dry white wine, or red wine.
Other Foods to Avoid or Modify
Avoid chewing gum (both sugar and sugar-free).
Avoid chocolate and most other desserts. Cocoa powder with allowed sweeteners is
okay.
Avoid condiments sweetened with fructose: catsup and soy sauce.
Avoid coconut, coconut milk, coconut cream. These are high in sugars.
For sandwiches and salads, chop up dill pickles instead of using sweet pickle relish.
Constipation
If you are having issues with constipation, talk to your doctor about a bowel management
program. If you are constipated, the bacteria in the gut have longer to feed and ferment on the
sugars in the gut from the foods you eat. As the sugars feed those bacteria, the bacteria grow and
which causes gas and abdominal pain.
Breads and Starches
If removing high fructose corn syrup and watch how much fruit you eat does not control your
symptoms, you may need to watch your intake of fructans in breads and starches. Wheat-based
foods contain fructans and/or high fructose corn syrup which can increase symptoms. Most
people just need to eliminate breads with honey or high fructose corn syrup. Then, they can eat
breads as desired.

Breads and Starches

Breads/Starches to Avoid (Fructan Content/Serving)

Limit whole
wheat breads

(1.8 grams/2 slices), whole

grain cereals (1.9 grams/1
cup) and graham crackers
(1.2 grams/2 crackers).
Note: Flour provides (4
grams/ 3.3 ounces of flour).
(2.5 grams/1cup serving).

Avoid wheat
pasta
(1.4 grams/1 small muffin).
Avoid
commercial
cookies, cakes, or
muffins
Avoid products
with dried fruits,
fruits, honey,
coconut or added
sugars
Avoid instant
flavored cereals &
granola.

Alternatives (Better Choices)

Rye Bread
Gluten-free Breads, Pasta,
Cereals
Rice Noodles
Rye, Corn or RiceCrispbreads
Gluten-free Cookies and
Cakes
Brown Rice (for fiber) or
White Rice

References:
Barrett JS. Clinical Ramification of Malabsorption of Fructose and Other Short-chain
Carbohydrates. Practical Gastroenterology. 2007(Aug);53:51-65.
Shepherd S. Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for
Effective Dietary Management. J Am Diet Assoc. 2006;106:1631-1639.
USDA National Nutrient Database for Standard Reference, Release 20
If you have more questions please contact UW Health at one of the phone numbers listed below.
University Station
Nutrition Clinic Room L33
2880 University Avenue
Madison, WI 53705
(608) 263-4360 appointments
(608) 263-5012

UW Health West Clinic

Nutrition Clinic Room 1296
451 Junction Road
Madison, WI 53717
(608) 262-9181 appointments
(608) 265-7526

UW Health East Clinic

Nutrition Clinic Room 2106
5249 East Terrace Drive
Madison, WI 53718
(608) 265-7405 appointments
(608) 265-0963

American Family Childrens Hospital, 1675 Highland Ave, Madison, WI 53792

Pediatric Specialty Clinics - Nutrition (608) 890-8298 or 263-6420 Appointments
The Spanish version is HF#417
Copyright 12/2012. University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by
the Clinical Nutrition Services Department. HF#376