Lemon – Low FODMAP


The words of the song the Lemon Tree, the words are undeniable “Lemon tree very pretty, and the lemon flower is sweet, but the fruit of the poor lemon is impossible to eat.” Many people with gastro-oesophageal reflux (GORD) and IBS avoid all citrus fruit due to reporting of them making symptoms of reflux worse. Yet, citrus fruits are allowed on the low FODMAP diet. I actually love lemon, the flavour is sharp and strong but has to be handled carefully in recipes to prevent is tasting like a popular cold remedy.

One point to mention here is that the National Institute of Health and Clinical Excellence (NICE) guidance on reflux does not specify a reduction of citrus fruit consumption as part of lifestyle GORD treatment. The reduction of coffee, chocolate, alcohol and fatty foods are the main focus of dietary lifestyle factors. Although the date of the review of this lifestyle advice is 2004 – so somewhat old data, but this is fine if no new developments have come to light. It is also worth noting that the measure of acidity, pH, is very low for stomach acid (2-3), for lemon Juice, it is 2, so not much different than the pH of gastric juices anyway. But people do report problems, so we do treat everyone as an individual and they can be reduced to a tolerable level, when needed.

Reduction of acidic foods also can reduce the amount of vitamin C in the diet, as ascorbic acid is found in higher levels in citrus fruits. Vitamin C full deficiency is rare in the UK, although arguably becoming more common due to fad diets, such as complete carnivore diets. Our bodies cannot make it, unlike other animals. Not much data is available on low vitamin C intake and GORD, but the effects of deficiency include damage to skin and likely the GI tract, which has a fast turnover of cells, not that helpful for those who have sensitive guts. The requirement for vitamin C might be increased in people who have diarrhoea – although caution is advised as vitamin C supplements above 3g/day (three times the amount of a standard over the counter supplement) will increase symptoms of abdominal pain and diarrhoea. As ever, it is better to get your nutrition from food, so once your symptoms have reduced, re-introduce those low FODMAP foods you have stopped eating, try them again, you might find that you can eat them after all.

Lemon butter drops

These little biscuits are only a mouthful – just a bite – but are a divine melt in the mouth treat. Especially nice for this time of year, Spring and Easter, (when Easter does arrive in April).


100g butter

200g rice flour

1/2g zanthan gum

Grated rind of 2 unwaxed lemons

1 egg

50g of gluten free self-raising flour plus extra for rolling out.

Filling (lemon curd)

4 wax free lemons – juice and rind

350g castor sugar

200g butter

1 1/2 tablespoons of corn flour

4 eggs


Add the butter and sugar and cream (mix) together well.

Then add the grated lemon rind and egg, mix well

Add the flour and bring together into a dough, if it doesn’t bind together add a little more flour till it does.

Roll thinly and cut out small rounds (I made 40 with the mix)

Cook for 10 minutes at gas mark 6.


Make the curd

Whisk together 4 eggs

Juice and grate the lemons and weigh out the other ingredients

Warm the eggs whilst adding the other ingredients and cook till thickened

Cool and add to the jars

(This is based on a Delia Smith recipe but with additional cornflour to make the curd thick enough to sandwich between the biscuits.)

Recipe makes enough for 20 small sandwich biscuits and enough curd to add to a litre and a half volume – more than enough to add to sterilized jam jars and they will keep for a few weeks.It does go a long way so you don’t need to use much for a sweet and sharp lemon flavour.

Prunes – natures laxative.

“I hope my tongue in prune juice smothers, If I belittle dogs and mothers”

Ogden Nash

Ogden Nash was an American poet who suffered from crohn’s disease according to Wikipedia, his unfortunate demise was after a lactobacillus infection after eating poorly prepared coleslaw as the Wikipedia site states. Interesting quote about prune juice, do you get the feeling he detested prunes? Prunes might have resulted in symptoms for him – depending on his crohn’s disease. I can only speculate, but what do these dried fruits do for us? Should we in fact include them in our diet? The following post by Compound Interest explains the chemistry behind the prune – or dried plum.


Prunes do in fact improve constipation – but for some people at a cost – the reason they do is down, in part to the large amount of sorbitol and fructans they contain, these FODMAPs or fermentable sugars draw fluid into the small bowel and rapidly ferments in the large bowel. Sorbitol is also found in sugar free mints and gum – often a warning is given on these to avoid eating too much as a laxative effect may be the result. Not great if you have IBS and bloating and are intolerant to sorbitol. Prunes could also result in symptoms for people with active crohn’s disease too – perhaps that is the reason they are suggested by Nash to be a treatment to instill an avoidance of denigrating your mother! Or alternatively it might be just down to taste or personal preference. But to help constipation if you don’t suffer from IBS, bloating and excessive wind – they are worth a try – introduce them in your diet slowly so your bowel adjusts to the extra fibre they contain. These sugars can also have a pre-biotic (food for bacteria) action, so it is worth including some in your diet if you tolerate their effects!


Commonly malabsorbed sugar causes obesity! What? – I’m afraid its just not that simple.

What is Fructose?

Fructose is a hexose, a single unit sugar which occurs naturally in fruit and is a component of the disaccharide table sugar sucrose; it is also the building block of the long chain carbohydrate, fructans. This sugar is absorbed across the intestinal mucosa by facilitated diffusion (via GLUT 5 or GLUT 2, transporters) – a slow method of absorption, when fructose is consumed in equal amounts to glucose, by rapid active absorption. This sugar has been seen by many as a ‘healthy’ alternative to table sugar, however, recently high fructose corn syrup (HFCS) and fructose in beverages has been implicated in the rise in obesity. But fructose consumption (in excess of glucose) is often malabsorbed when consumed in large amounts, so what is going on here? It seems incongruous that a commonly malabsorbed sugar such as fructose should be implicated in increasing rates of obesity.

Fructose in foods

In recent years, availability of fructose in our diets has increased. HFCS or fructose-glucose syrup, in processed sweetened foods and beverages, and use of crystalline fructose sugar and Agave syrup seen as ‘healthier’ alternatives to table sugar, it is perhaps not surprising that fructose consumption in processed foods and drinks was reported recently by The Guardian as a current area for concern (2). A Guardian article stated that HFCS was to be re-branded to improve its image (1). A new worry is the amount of sugar contained in smoothies, promoted by beverage manufacturers as healthy drinks containing natural sugar and an easier way of increasing your fruit intake, to achieve your recommended five a day (2). Whilst the UK population average intake of HFCS sugar remains far lower than other countries, such as the USA (3),  individuals with weight management requirements may exceed these levels of intake easily, with HFCS being a component of sweet foods and beverages. High intakes are associated with obesity, type 2 diabetes and metabolic syndrome, however, Fulgoni, (4) consultant to the American food and beverage industry suggested that HFCS is no different in its metabolic obesogenic capacity than sucrose, as the structure of sucrose contains one fructose unit per molecule. Obesity is a multifactorial problem and focussing on one aspect in the diet may be misleading, anyone consuming large amounts of HFCS may also have a diet high in fats and other refined carbohydrates. These carbohydrates, when digested, may facilitate fructose absorption reducing the malabsorption effects that often result from excessive consumption.

Fructose absorption

Unpleasant gastrointestinal symptoms such as osmotic diarrhoea can result from excessive fructose intakes, as a consequence of exceeding the guts absorptive capacity. This malabsorption of fructose in excessive amounts perhaps suggests that the role fructose plays in obesity should be further studied, alongside other refined carbohydrates consumed in the diet, as fructose is not ingested in isolation. Intake of carbohydrates such as glucose and long chain refined carbohydrates may facilitate fructose absorption. Research suggests that intestinal adaptation to diets of pure fructose can occur in study animals (5, 8) to facilitate absorption, but it is not known to what extent this adjustment compensates for malabsorption in humans, who often have very varied and complex diets. Population studies have suggested a link between HFCS and fructose ingestion from beverages with obesity (3). But more needs to be known about the efficiency of absorption, degree of brush border adaptation (if this in fact does occur in humans) and a breakdown of carbohydrates consumed. In these groups it needs to be established whether correlation of fructose intake represents causation, or whether intake of HFCS represents just one of many aspects of the diet which ultimately leads to obesity.

Fructose malabsorption in functional gastrointestinal disorders

Excessive fructose intakes leading to diarrhoea perhaps should not be considered as a functional disorder per say, as most individuals will malabsorb fructose if consumed in large amounts. Intakes of 50g fructose in 250ml liquid are malabsorbed by 60-70% of individuals, when levels are reduced to 25g, 40% of people malabsorb fructose (7) Advice to reduce levels of intake in these cases would seem prudent. Individuals where visceral hypersensitivity and functional disorders (Irritable Bowel Syndrome, IBS) are an issue, fructose malabsorption should be considered as a possibility.

Individuals with functional gastrointestinal disorders can experience pain and diarrhoea with levels much less than 50g; the prevalence of fructose malabsorption in these patients can vary between 38-75% depending on which research source is viewed. A paper published by Gibson & Shepherd (6) studied the effect of a fructose modified diet in people with IBS and diagnosed with fructose malabsorption, the study reported 75% of participants had improvement in symptoms when fructose intakes were reduced. The prevalence of fructose malabsorption is higher than lactose intolerance in this patient group; however it largely remains under recognised as a factor (5). Use of the Low FODMAP diet in treatment of functional disorders has increased recognition of fructose malabsorption as a cause of symptoms.

Use of fructose breath testing for identification of fructose malabsorption has increased, to enable treatment with a low fructose diet to be utilised for those patients that need it. Gibson & Barrett recommend a diet low in FODMAPs must be consumed 24 hours prior to the breath test, to establish an accurate baseline level (5). However fructose breath testing remains a controversial test, due to variations in methodology, leading to confusion about accuracy (6) amongst health professionals. Where testing is not available, dietary fructose exclusions are effective to identify malabsorption and facilitate dietary treatment provision. For patients with Irritable Bowel Syndrome the most effective way of treatment is to exclude all Low FODMAP foods (assuming lactose malabsorption has not been excluded) and re-introduce to tolerance after 8 weeks.

For those with fructose malabsorption exclusive of IBS, reduction of the sources of fructose in excess of glucose should be advised (10.) In all patients, modifying fructose intake, rather than increasing glucose consumption to facilitate absorption, particularly where the patient is overweight is recommended (10.)

Digestive enzymes

It would be better for patients who find manipulating their diet to resolve symptoms a challenging goal to achieve, to be able to take an enzyme to facilitate conversion of fructose to glucose and facilitate absorption. Xylose Isomerase is commercially available and marketed as a solution to fructose malabsorption. It has been recognised by the FDA as safe and been found to be effective in doses of 3 capsules per 25g fructose load (9.) However the commercially available grades advise that these products should not be taken by individuals with inherited fructose malabsorption, so why is this advice given – and how would you know if someone has the condition? Also research into Xylose Isomerase has been funded by the company that market these digestive enzymes, who have a clear interest in proving this product is effective, so the advice is somewhat biased from this respect. However reducing fructose intake might be a more suitable option for individuals who are obese, as using these enzymes may facilitate an increase in energy intake. Dietetic treatment should involve assisting the individual to find a solution when individuals are having problems in following advice, such as suitable written information in an easily understandable form and helping with barriers to goal setting.

Inherited fructose intolerance

This condition occurs as a result of an in-borne error of fructose metabolism, and therefore acts by a different mechanism to fructose malabsorption. The deficiency is of Fructose 1, 6 biphosphate aldolase (Aldose B.) Ingestion of fructose results in post prandial hypoglycaemia and abdominal pain, diarrhoea and vomiting, the ingestion of fructose, sucrose, and sorbitol is problematic for these individuals (12). If consumption is continued hepatic injury, renal injury, coma and death can result (12). This condition is often identified in childhood as consumption of fructose can produce severe symptoms; it is recognised when these carbohydrates are introduced into the child’s diet. However some children have survived to adulthood without the condition being recognised, by self excluding sugar from their diet. Patients have to inherit the deficiency from both parents, who carry the gene but do not exhibit symptoms. Its prevalence is one person in every 20,000 to 30,000 so it is a rare condition, but should be considered if post prandial hypoglycaemia and other gastrointestinal symptoms are reported (11). Born (7) suggests that blood glucose levels should be checked in individuals referred for fructose breath tests, to identify these individuals. It would be prudent to consider this condition with symptomatic individuals who report that ‘sugar’ is a problem and have taken steps to exclude it from their diet.

Clearly fructose malabsorption, digestion and metabolism is a very complex situation and more studies are required to improve knowledge of fructose’s’ dietary effects. Focussing on fructose provides one example of how complex human nutrition and metabolism is, and how improved knowledge is vital to help patients to manage their symptoms. High fructose corn syrup/fructose will be digested to some degree depending on the proportion of glucose it contains, and the individuals levels of GLUT transporters, but despite this many individuals with functional bowel symptoms struggle to digest even low doses. This brief look at fructose digestion also suggests that obesity is a multifactorial public health problem and blaming one nutrient or food may do little to resolve the problem in the general population. In fact publicly concentrating on one minutiae of the causes of obesity beclouds, possibly resulting in confusion for the general population which could cause apathy around lifestyle change. As always, research into digestion should involve a complete food intake analysis facilitated by a research dietitian, including a review of confounding variables. A review of total energy consumption and it’s implications on fructose absorption in the case of HFCS’s relationship to obesity would be advisable, but this will only add a little information to the whole question of the causes of obesity in our society.

 1) Boseley, S (7th September 2013) Smoothies and fruit juices are a new risk to health, US scientists warn Scientists say potential damage from naturally occurring fructose in apparently healthy drinks is being overlooked The Guardian available from http://www.theguardian.com/society/2013/sep/07/smoothies-fruit-juices-new-health-risk

2) Clark, A. (15th September 2010) Manufacturers petition regulator to change name to ‘corn sugar’ as consumer backlash grows against the food and drink sweetener in the US The Guardian available from http://www.theguardian.com/business/2010/sep/15/high-fructose-corn-syrup-rename

3) Bazian (2012) Sugar substitute sparks global diabetes epidemic NHS Choices available from http://www.nhs.uk/news/2012/11November/Pages/Sugar-substitute-sparking-global-diabetes-epidemic.aspx

4) High-fructose corn syrup: everything you wanted to know, but were

afraid to ask1,2 Victor Fulgoni III Am J Clin Nutr 2008;88(suppl):1715S.

 5) Barrett J Gibson, PR,( 2012) Fructose and lactose testing Australian Family Physician Vol. 41, No. 5

 6) Shepherd SJ, Gibson PR. (2006) Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. J Am Diet Assoc 2006; 106: 1631-1639

 7) Peter Born (2007) Carbohydrate malabsorption in patients with non-specific abdominal complaints World J Gastroenterol 2007 November 21; 13(43): 5687-5691

 8) Levin RJ (1994) Digestion & absorption of carbohydrates from molecules to membranes to humans American Journal of Clinical Nutrition 1994;59 (supple) 690S-8S

 9) Putkonan L, Yao CK, Gibson PR (2013) Fructose Malabsorption syndrome A review Current Opinion in Clinical Nutrition & Metabolic Care. 16:473-477

10) Marie E. Latulippe and Suzanne M. Skoog (2011) Fructose Malabsorption and Intolerance: Effects of Fructose with and without Simultaneous Glucose Ingestion Critical Reviews in Food Science and Nutrition, 51:583–592

 11) Genetic fructose malabsorption – http://ghr.nlm.nih.gov/condition/hereditary-fructose-intolerance

 12) Ali, M Rellos, P Cox TM (1998) Hereditary Fructose Intolerance J Med Gen 35: 353-365



Exploits in English preserves – rhubarb and ginger.

A saturday in September, a real autumnal feeling in the air. I love this time of year, it’s the time of year I chose to get married and we have some lovely pictures of our day amongst trees adorned with yellow, orange and red leaves. Anyway I digress, or reminisce or whatever! Back to the Saturday.


– I woke early with the cat pawing and purring for his breakfast, a real feline bon viveur. Much to my consternation he was back asleep within half an hour of scoffing his breakfast chow. Slightly embarrassing for a dietitian to have such a portly cat, but despite our efforts if we cut his food intake he goes and gets his own outside. He has arrived home with ham, battered fish and his favourite – sausages, which I suppose is slightly better than mauled dead wildlife.

What to cook today, I mused – after a trip to the supermarket, where I purchased 2 packs of rhubarb for the price of one, I decided to make some jam. I have some preserve jars and before coming home I also bought a packet of jam sugar. This is sugar with added citrus and pectin (apple pectin to those who need have problems digesting apples) this assists setting. In the past, exploits in jam making have resulted in disappointment, my last attempt was to make LOFFLEX pear preserve. This was probably a little too much to start with, as obviously, use of citrus fruit to enhance the preservation was out of the question. The jam was fine initially but crystallised over time, I’m not sure why.

Rhubarb and Ginger Jam

800g of washed sliced rhubarb (don’t eat the leaves!!!)

200 mls water

700g of jam sugar (for strawberries)

100g table sugar

2 inch (5cm) piece of peeled ginger chopped finely

Put the sliced rhubarb and ginger in a bowl and place in the microwave cook till soft, smaller pieces will reduce the time needed

Add the fruit mix to a pan with the water and heat, mash with a potato masher

Add sugar and warm till the sugar has dissolved (do not boil at this stage)

Bring the jam to a rolling boil and boil for four minutes.

Check the set by dropping a small amount of jam onto a plate, allow to cool and push the jam with your finger – it should wrinkle up, then its ready.

Put the jam in a sterilised preserve jar and allow to cool.

This took no more than 30 minutes – wow, easy!!! Apparently this is a jam not a preserve according to Wiki, something to do with the sugar content, oh well never mind  – it’s still a slightly sharp, but sweet jam and rhubarb is one of my favourite fruits. Yum, fine to have occasionally – our two jars are in the store cupboard, think I will open one at Christmas.

Six good reasons to increase your fibre intake?

Fibre (or roughage) is a term you may have heard of, but what is it, you may be wondering? Why am I asked to increase, or decrease the amount of fibre I am eating? This is the one area that I give advice about most often.

Fibre is the residue of carbohydrates (starchy foods) that are left in our bowel after we have digested the food that we eat. So it’s waste then? Well not really, it is food for the good bacteria in our bowel and it’s useful for our health to have a good intake of wholegrain starchy foods. Fibre is found in wholegrain and bran based cereals, oats and oat flour, pulses (peas & beans,) lentils, wholemeal, brown & seeded breads, wholemeal pasta, brown rice, nuts, seeds, dried and fresh fruit and vegetables for example.

Two different kinds of fibre are

Soluble fibre – found in oats, golden linseeds, pulses and certain fruit pulps, and vegetables such as Jerusalem artichokes, this fibre is soluble in water. Soluble fibre is food for our gut bacteria and helps lower cholesterol levels.

Insoluble fibre – this is found in wheat bran, rye and other grains and is also the tough outer coatings on fruits, nuts & seeds, this fibre is not soluble in water. Insoluble fibre reduces constipation and promotes gut health.

We are all aware that we need to have at least 5 portions of fruit and vegetables per day, but little is said about wholegrain foods (2-3 servings per day are advised) – to be healthy we should include these in our diet where we can. The UK Committee On the Medical Aspects of food (1999) say that adults should aim for at least 18g up to 24g of fibre per day, this is rather old advice, however we are still as a population not achieving these levels and we have no reason to change this advice. (Levels may be different in other countries and children also have different requirements.)

So, why is this advice so important? Well we all know that those people who have a low intake get constipated, but longer term, low intake of fibre can be more problematic. But rather than focus on negatives, lets discuss the positive aspects. Six good reasons to increase your fibre intake:

1. High fibre foods take longer to leave our stomach, therefore making us feel fuller for longer, good food then, if you are aiming to manage your weight. This idea may be more complex than just adding fibre to processed food or supplements for example; high fibre foods take longer to eat also, which also may have additional effects on satiety.

2. Foods that contain fibre take longer for the available component to pass into our bodies and this can help to achieve a lower blood sugar level after meals, compared with low fibre food, for people who have type 2 diabetes.

3. Some fibre also provides prebiotic action, giving homes and food for the bacteria that live in our large bowel. Helping increases in numbers of ‘friendly bacteria’ is beneficial, these bacteria produce vitamin K and also make short chain fatty acids, which feeds our gut and keeps it healthy. High numbers of good bacteria also reduce the levels of harmful bacteria in our bowel, the ones that result in illness.

4. Having a higher intake of fibre also protects against bowel cancer (which type of fibre is more protective is disputed – Parkin & Boyd 2011.)

5. Fibre also decreases the time it takes for food to pass through our digestive system, reducing constipation (along with a good fluid intake.)

6. Total and ‘bad’ cholesterol levels are reduced with higher fibre diets, by reducing the amount of cholesterol that is reabsorbed into your body, reducing your risk of heart attacks and stroke.

Therefore, as you can see – lots of good reasons to ensure you eat plenty of sources.

All good advice – so why is it I sometimes give advice to reduce the amount of fibre people eat, isn’t this going to be harmful in the future? People who have bowel conditions that may need to reduce fibre intake are often advised to go on a low fibre or low residue diets because fibre stretches the bowel wall, causing bloating and increased pain, also if the bowel is narrowed high fibre residues may cause a blockage. These may be people with crohn’s disease, colitis, cancer, stricturing (narrowing of the bowel) or adhesions from past surgery. Sometimes the type of fibre may be problematic, such as for people with irritable bowel syndrome and advice is provided to eat fibre that does not result in as much bloating, such as following the Low FODMAP diet for example. All these situations need changes to the amount or type of fibre in the diet, but this is usually a short-term measure, and people are advised to increase their fibre intake back to healthy levels post illness or after surgery. They then need to increase the amount slowly initially, starting with fruits without skins or pith & well cooked vegetables, increasing to foods higher in fibre such as wholegrain breads and pulses when tolerated.

So why not try some sources of fibre if you don’t eat it often? It is always advisable to increase the amount you eat slowly, particularly if you are not used to eating large amounts. Start by including one more portion of fruit (about a handful) or vegetables (2-3 tablespoons or a small salad) per day, till you are eating recommended levels or start with a bowl of wholegrain cereal (30g,) then include wholegrain breads, oats, wholegrain pasta/rice – increase by one item per day and see how tasty it is!

http://summaries.cochrane.org/CD002128/dietary-advice-for-reducing-cardiovascular-risk Free article

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252068/?tool=pubmed Parkin DM, Boyd, L. (2011) Cancers attributable to dietary factors in the UK in 2010 111 – low consumption of fibre British Journal of Cancer 105 (S27-S30) Free article

Click to access revision1.pdf

N. Babio1,2, R. Balanza1,2, J. Basulto1, M. Bulló1,2 and J. Salas-Salvadó1,2 (2010) Dietary fibre: influence on body weight, glycemic control and plasma cholesterol profile Nutr Hosp. 2010;25(3):327-340 Free article

http://www.diabetes.org.uk/Documents/Reports/Nutritional_guidelines200911.pdf Evidence-based nutrition guidelines for the prevention and management of diabetes
May 2011 diabetes UK Free article