Cowin 1999

Eur J Clin Nutr. 1999 Nov;53(11):891-4.

The effect of missing data in the supplements to McCance and Widdowson's food tables on calculated nutrient intakes.

Cowin I1, Emmett P.

Abstract

OBJECTIVE:

To assess the degree of underestimation of nutrient intakes caused by missing data in McCance and Widdowson's food tables and supplements, the standard food tables used in the UK.

SUBJECTS:

1026 children aged 18 months.

SETTING:

A research clinic in Bristol.

INTERVENTIONS:

A 3-day dietary diary was completed for each child. These were coded and analysed using a database consisting of the unedited information in the food tables, to produce a set of 'uncorrected' nutrient intakes. 'Guesstimated' values for nutrient content were then added to our nutrient database in place of the missing values in the food tables, and the daily nutrient intakes were recalculated.

MAIN OUTCOME MEASURES:

Calculated daily nutrient intakes before and after substituting missing data in the food tables for guesstimated values.

RESULTS:

Of the 1027 foods used in the analysis, 540 had missing data for one or more nutrient content. For several of the nutrients examined adding guesstimated values altered the calculated nutrient intake of more than 90% of the subjects. However, for nutrients such as the B vitamins and the major minerals the mean percentage underestimate was very small. We calculated the underestimation of nutrient intake to be largest for vitamins E and D (13.8% and 14.7%, respectively). The effect of missing data on calculated nutrient intakes was proportionately greater at the bottom end of the nutrient intake distribution.

CONCLUSION:

Missing data has a fairly small effect on calculated mean daily intakes. However, it can result in some individuals being misranked within a nutrient intake distribution. The availability of a standard set of 'guesstimates' to use in place of missing data would reduce this problem, and would improve comparability between dietary surveys.

Oboh 1998

J Chromatogr A. 1998 Oct 9;823(1-2):307-12.

Anti-nutritional constituents of six underutilized legumes grown in Nigeria.

Oboh HA1, Muzquiz M, Burbano C, Cuadrado C, Pedrosa MM, Ayet G, Osagie AU.

Abstract

Six underutilized legume seeds grown in Nigeria namely, red and white lima beans, brown and cream pigeon pea, African yam bean and jackbean were analysed for different anti-nutritional factors Sojasapogenol B was identified as the predominant sapogenol in lima beans and jackbeans by capillary gas chromatography. The content of total inositol phosphates and individual inositol phosphates (IP6, IP5, IP4 and IP3) were analysed by ion-pair HPLC, being in the range of other legumes. Trace quantities of lupanine were identified as the alkaloid in jackbean. alpha-Galactosides were present in all the legume seeds, stachyose being the predominant galactoside in lima beans, African yam bean and jackbean, and verbascose in pigeon pea. The haemagglutinating activity was estimated as a measure of the lectin content of the samples. African yam bean was found to have the highest heamagglutinating activity. Tannins were found to be in low quantities. The presence of these anti-nutrients in relation to the nutritional value of the legume is discussed.

Martínez-Villaluenga 2005

J Food Prot. 2005 Jun;68(6):1246-52.

Raffinose family of oligosaccharides from lupin seeds as prebiotics: application in dairy products.

Martínez-Villaluenga C1, Frías J, Vidal-Valverde C, Gómez R.

Author information

Abstract

The raffinose family of oligosaccharides (RFOs) isolated from lupin seeds (Lupinus albus var. Multolupa) was evaluated for bifidogenic effects during the manufacture of probiotic fermented milk. A mixed starter inoculum was composed of Bifidobacterium lactis Bb-12 and Lactobacillus acidophilus (1:1). Lupins are a rich source of RFOs that can be used as functional food ingredients. The addition of RFOs to milk increased B. lactis Bb-12 and L. acidophilus populations at the final fermentation time compared with controls. Final fermentation products are positively affected by addition of RFOs, and time of fermentation was reduced from 12 to 10 h. When RFOs were added to milk, they were preferentially used as a carbon source (57.7%) compared with lactose (23.7%) at the end of fermentation. These results suggest that the eventual choice of B. lactis Bb-12 and L. acidophilus in a mixed culture at a 1:1 ratio and addition of RFOs to produce a fermented milk product would have the advantages of rapid growth and acidificationrate and would likely increase the probiotic effect of the final functional product.

Giannoccaro 2008

Comparison of two HPLC systems and an enzymatic method for quantification of soybean sugars.

Enzo Giannoccaro, Ya-Jane Wang, Pengyin Chen

Successful breeding programs need fast and reliable methods for analyzing sugar composition in new soybean (Glycine max (L.) Merrill) lines. The efficiency to quantify the major sugars, including glucose, fructose, sucrose, raffinose, and stachyose, in fivesoybean lines with two HPLC systems and an enzymatic procedure were compared. Soluble sugars in soybean were extracted with water at a solvent-to-sample ratio of 5:1 at 50°C for 15min, and analyzed by high-performance size exclusion chromatography with refractive index detection (HPSEC-RI), high-performance anion-exchange chromatography with pulsed-amperometric detection (HPAEC-PAD), and a raffinose-series oligosaccharides assay procedure. All three methods produced comparable and reproducible results. The HPAEC-PAD method was more sensitive, faster and capable of separating all five major sugars in soybean with improved peak resolution compared with the HPSEC-RI method, and is recommended for soybeanbreeding programs. The enzymatic procedure required no expensive instrumentation and less sample preparation, but could not quantify individual raffinose and stachyose.

Richmond 1981

Analysis of simple sugars and sorbitol in fruit by high-performance liquid chromatography

Michael L. Richmond; Sebastiao C. C. Brandao; J. Ian Gray; Pericles Markakis; Charles M. Stine

Journal of Agricultural and Food Chemistry. 1981;29(1):4-7.

Scopus

Abstract

The application of a high-performance liquid chromatographic (LC) procedure for the determination of sugars and sorbitol in fresh fruits is described. This system combines the use of two bonded phase carbohydrate columns, joined in tandem; a ternary mobile phase (acetonitrile-water-ethanol) and a differential refractometer to accurately and precisely separate fructose, glucose, sorbitol, sucrose, and maltose. Total analysis time was 20 min for the five-sugar mixture. Twenty-four fruits were analyzed including eleven from the family Rosaceae, which often contain sorbitol. Sample recoveries ranged from 98% for fructose to 102% for maltose. © 1981 American Chemical Society.

Andersson 2009

J Agric Food Chem. 2009 Mar 11;57(5):2004-8. doi: 10.1021/jf801280f.

Content and molecular-weight distribution of dietary fiber components in whole-grain rye flour and bread.

Andersson R1, Fransson G, Tietjen M, Aman P.

Abstract

Content of dietary fiber and dietary fiber components in whole-grain rye (n = 18) were analyzed. The average total content, when fructan was included, was for dietary fiber 19.9% (range of 18.7-22.2%) and for extractable dietary fiber 7.4% (range of 6.9-7.9%). Arabinoxylan was the main dietary fiber component, with an average total content of 8.6%, followed by fructan (4.1%). During baking of whole-grain rye bread, only small changes in total content of arabinoxylan, arabinogalactan, and beta-glucan occurred, while the content of resistant starch increased and the content of fructan decreased in a baking-method-dependent manner. The molecular-weight distribution of extractable arabinoxylan in the flour was analyzed with a new method and ranged from 4 x 10(4) to 9 x 10(6) g/mol, with a weight average molecular weight of about 2 x 10(6) g/mol. During crisp bread making, only a limited degradation of arabinoxylan molecular weight was detected, while a notable degradation was observed in sour-dough bread. The molecular weight of extractable beta-glucan in the whole-grain rye flour ranged from 10(4) to 5 x 10(6) g/mol, with a weight average molecular weight of 0.97 x 10(6) g/mol. During bread making, the molecular weight of the beta-glucan was substantially degraded.

Sreenath 2008

Anal Bioanal Chem. 2008 May;391(2):609-15. doi: 10.1007/s00216-008-2016-x. Epub 2008 Mar 28.

Analysis of erythritol in foods by polyclonal antibody-based indirect competitive ELISA.

Sreenath K1, Venkatesh YP.Abstract

Sugar alcohols are widely used as food additives and drug excipients. Erythritol (INS 968) is an important four-carbon sugar alcohol in the food industry. Erythritol occurs naturally in certain fruits, vegetables, and fermented foods. Currently, HPLC and GC methods are in use for the quantification of erythritol in natural/processed foods. However, an immunoassay for erythritol has not been developed so far. We have utilized affinity-purified erythritol-specific antibodies generated earlier [9] to develop an indirect competitive ELISA. With erythritol–BSA conjugate (54 mol/mol; 100 ng/well) as the coating antigen, a calibration curve was prepared using known amounts of standard meso-erythritol (0.1–100,000 ng) in the immunoassay. Watermelon (Citrullus lanatus) and red wine were selected as the food sources containing meso-erythritol. The amount of meso-erythritol was calculated as 2.36 mg/100 g fresh weight of watermelon and 206.7 mg/L of red wine. The results obtained from the immunoassay are in close agreement with the reported values analyzed by HPLC and GC (22–24 mg/kg in watermelon and 130–300 mg/L in red wine). The recovery analyses showed that added amounts of meso-erythritol were recovered fairly accurately with recoveries of 86–105% (watermelon) and 85–93.3% (red wine). The method described here for erythritol is the first report of an immunoassay for a sugar alcohol.

Akin 2008

Some compositional properties of main Malatya apricot (Prunus armeniaca L.) varieties.

Department of Food Engineering, Hacettepe University, 06800 Beytepe, Ankara, Turkey

Food Chemistry (Impact Factor: 3.39). 03/2008; 116(2):939-948. DOI: 10.1016/j.foodchem.2007.08.052

ABSTRACT

Malatya apricot (Prunus armeniaca L.) varieties are among the most important agricultural products of Turkey and protected as a geographical indication. In this research, it was aimed to determine some important analytical properties (dry matter, soluble solid content, aw, ash, titratable acidity, pH, color, total phenolics, total carotenoids, β-carotene, sugars, organic acids, and mineral content) of Malatya apricots and to reveal the characteristic properties that differ these products from the similar ones. The apricot varieties, namely Hacıhaliloğlu, Hasanbey, Soğancı, Kabaaşı, Çataloğlu, Çöloğlu, and Hacıkız that are widely cultivated in Malatya region and other regions (Ereğli, İzmir, Iğdır, and Bursa) of Turkey were involved in the study. All analytical properties were found to be significantly different (p < 0.05) among different apricot varieties. The results have shown that dry matter and sugar content of Malatya apricot varieties are considerably higher than the other apricot varieties investigated in this study, as well as the data of other researches on apricots. All apricot varieties were found to be a good source of phenolic compounds (4233.70–8180.49 mg of gallic acid equiv/100 g of dry weight), carotenoids (14.83–91.89 mg of β-carotene equiv/100 g of dry weight), and β-carotene (5.74–48.69 mg/100 g of dry weight). Sucrose, glucose, and fructose were determined as the major sugars in all apricot varieties. In addition, sorbitol contents (16.91–26.84 mg/100 g of dry weight) of Malatya apricots were remarkably higher than the other apricot varieties. This was considered to be the one of the unique properties of Malatya apricots. Malic acid was the predominant organic acid in all Malatya apricot varieties. The results have also shown that the potassium content of Malatya apricots was significantly high and these apricots were important sources of Mg, Zn, and Se. This study has revealed that Malatya apricot contains functional food components with high nutritional value.

Some compositional properties of main Malatya apricot (Prunus armeniaca L.) varieties - ResearchGate. Available from: http://www.researchgate.net/publication/223101227_Some_compositional_properties_of_main_Malatya_apricot_(Prunus_armeniaca_L.)_varieties [accessed Oct 31, 2015].

L'homme C 2001 abstract

J Chromatogr A. 2001 Jun 22;920(1-2):291-7.

Evaluation of fructans in various fresh and stewed fruits by high-performance anion-exchange chromatography with pulsed amperometric detection.

L'homme C1, Peschet JL, Puigserver A, Biagini A.

Author information

Abstract

Fructans are food-grade non-digestible carbohydrates that exert beneficial nutritional effects. Their characterization and quantification is required for food-labeling purposes. We describe the suitability of high-performance anion-exchange chromatography coupled with pulsed amperometric detection for the identification and quantification of fructans in fresh fruits (various apple and pear cultivars, plum, banana) as well as in commercial stewed fruits obtained from a local manufacturer. After extraction with water and appropriate filtration, inulobiose [beta-D-Fru-(2-->1)-beta-D-fructofuranoside; F2], 1-kestose [beta-D-Fru-(2-->1)2-alpha-D-glucopyranoside; GF2] and nystose [beta-D-Fru-(2-->1)3-alpha-D-glucopyranoside; GF3] were completely separated in a single 36-min run using a Dionex CarboPac PA 100 column and the new quadruple-potential waveform, originally tailored for oligosaccharide separation. No measurable amounts of F3 and GF4 were detected within the group of studied fruit products. Peak identification was realized using standards. The method is easy, reproducible, and sensitive since as little as 28 microg of sugar per gram dry matter can be quantified. Banana and plum are the varieties containing the highest levels of fructans (about 6000 microg per gram dry matter). The maturity of the fruit appears to have a great influence on the level of GF2. Samples of apple-banana stewed fruits contained the highest total fructan concentration (about 700 microg per gram dry matter). Accurate quantification of fructans will allow more precise nutritional formulation and diet selection for higher fructan consumption.

Fodmap Links

A FODMAP Diet Update: Craze or Credible? http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/Parrish_Dec_12.pdf
Heidi M. Staudacher. Fermentable Carbohydrate Restriction Reduces Luminal Bifidobacteria and Gastrointestinal Symptoms in Patients with Irritable Bowel Syndrome http://jn.nutrition.org/content/142/8/1510.full
van Loo J. On the presence of inulin and oligofructose as natural ingredients in the western diet. http://www.ncbi.nlm.nih.gov/pubmed/8777017
M. C. E. Lomer. Review article: the aetiology, diagnosis, mechanisms and clinical evidence for food intolerance. http://onlinelibrary.wiley.com/doi/10.1111/apt.13041/abstract
Jacqueline S. Barrett. Extending Our Knowledge of Fermentable, Short-Chain Carbohydrates for Managing Gastrointestinal Symptoms. http://www.clinicaleducation.org/documents/NutrClin-Pract-2013-Barrett-0884533613485790.pdf
Peter R Gibson. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1746.2009.06149.x/abstract 
M. C. E. LOMER. Review article: lactose intolerance in clinical practice – myths and realities. http://onlinelibrary.wiley.com/store/10.1111/j.1365-2036.2007.03557.x/asset/j.1365-2036.2007.03557.x.pdf?v=1&t=igfff2hl&s=054ddf83b5c76dd94fcc52755d6541cb8fcbc701 
Bernadette P. Marriott. National Estimates of Dietary Fructose Intake Increased from 1977 to 2004 in the United States. http://jn.nutrition.org/content/139/6/1228S
P. R. Gibson. Functional bowel symptoms and diet. http://onlinelibrary.wiley.com/doi/10.1111/imj.12266/abstract
C. K. Yao. Dietary sorbitol and mannitol: food content and distinct absorption patterns between healthy individuals and patients with irritable bowel syndrome. http://onlinelibrary.wiley.com/doi/10.1111/jhn.12144/abstract
Heidi M. Staudacher. Mechanisms and efficacy of dietary FODMAP restriction in IBS. http://www.nature.com/nrgastro/journal/v11/n4/full/nrgastro.2013.259.html
Emma P. Halmos. A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome. http://www.gastrojournal.org/article/S0016-5085(13)01407-8/abstract?referrer=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%2F24076059
Jane G. Muir. Fructan and Free Fructose Content of Common Australian Vegetables and Fruit.

Extra:
Kathy R. Niness. Inulin and Oligofructose: What Are They? http://jn.nutrition.org/content/129/7/1402S.full

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FODMAP Diet basics

Carbohydrate Absorption 

Carbohydrate absorption takes place in the small intestine. Here the carbohydrates undergo hydrolysis by luminal and brush border hydrolyses to monosaccharides: glucose, galactose, and fructose. These molecules are A FODMAP Diet Update then transported across the epithelium. There are 3 main transporters involved in this process:

1. SGLT1 is the sodium/glucose-galactose co-transporter that is present in the apical membrane of the small intestinal epithelium. When luminal concentrations of glucose are low, SGLT1 can transport glucose and galactose against a concentration gradient. 
2. GLUT5 is a facultative transporter that is specific to fructose. This transporter is found in the apical membrane along the length of the small intestine. 
3. GLUT2 is a low affinity facultative transporter that will carry glucose, fructose, and galactose.8 Unlike GLUT5, GLUT2 is present on the basolateral membrane and it transports hexoses down a concentration gradient out of the cell. This transporter is inserted into the apical membrane when SGLT1 transports glucose. It allows for a high capacity, low affinity pathway for absorption of glucose, galactose, and fructose. The glucose uptake with this transporter activates a system that can efficiently take up all hexoses. This is a diffusional pathway that explains why fructose uptake is increased by glucose and sucrose. This mechanism appears to be highly adaptive to wide variations of luminal glucose concentrations and ensures maximal nutrient utilisation proximally in order to protect distal regions of the intestine from the presence of hexoses. 

Symptoms of FGID can result from the malabsorption of fructose and sucrose that occurs when the activity of one of these transporters is altered. As stated above, fructose absorption is highly dependent on GLUT 5 activity, and GLUT 5 expression appears to be influenced by dietary fructose and sucrose load. GLUT 2 expression can be inhibited by stress, glucocorticosteroids, or a diet with a low glycemic index. When the small intestine is unable to absorb fructose, it is transported into the large intestine where it is fermented by colonic flora. During fermentation, hydrogen, carbon dioxide, short-chain fatty acids, and other trace gases are produced, which are thought to lead to symptoms of bloating. The delivery of fructose to the distal small bowel and colon also exerts an osmotic effect causing an increased resorption of water from the gut mucosa into the lumen. This increased water accelerates gut motility, and can cause the symptom of diarrhoea.

Oligosaccharides 

An oligosaccharide is simply a carbohydrate whose molecules are composed of a relatively small number of monosaccharide units. For example, chains of fructose with one glucose molecule on the end are oligosaccharides known as fructans. The small intestine lacks hydrolase capable of breaking fructose-fructose bonds; therefore, fructans are not transported across the epithelium or absorbed at all. Studies have shown that 50-90% of ingested fructans can be recovered from stool output of patients with an ileostomy. Wheat is a major source of fructans in the diet, which means most breads, pasta, and pastries contain large amounts of fructans. Other sources are vegetables such as onions, garlic, and artichokes. Galactans are chains of galactose with one fructose molecule on the end and act similarly to fructans. Foods rich in galactans are legumes (soy, beans, chickpeas, lentils), cabbage, and brussels sprouts.

Disaccharides and Monosaccharides 

Fructose exists as a monosaccharide (free fructose) or a disaccharide (sucrose). Fructose is absorbed directly from the small intestine. When ingested as sucrose the molecule is cleaved to one glucose unit and one fructose unit by sucrase, which is then absorbed into the bloodstream. The capacity at which fructose is absorbed ranges from about 15-50g per day with greatest absorption occurring when glucose and fructose are administered in equal quantities. This is because fructose exists with glucose in a 1:1 ratio. The facultative transporter GLUT5 is present throughout the small intestine and takes up free fructose. When present with glucose, fructose is taken up more efficiently due to the insertion of GLUT-2 into the apical membrane of the enterocyte. Therefore malabsorption of fructose occurs when fructose is present in excess of glucose. Some foods rich in fructose are honey, prunes, dates, apples, pears, and papaya. It is also often added to commercial foods and drinks as high fructose corn syrup. Disaccharides such as lactose are found in dairy products, but may also be found in most beers or prepared soups and sauces.

Polyols 

Sorbitol is the most common polyol in the diet. Unlike some others in the FODMAP group, the absorption of polyols are not accelerated by co-ingestion with glucose. A few studies have found that sorbitol and fructose ingested together cause worsening IBS symptoms. Most artificial sweetners contain polyols such as mannitol, xylitol, or sorbitol. Interestingly, symptoms from polyols not only come from foods, but also other ingested substances such as toothpastes, mints, sugar-free chewing gum, and many liquid cough/cold and pain relief preparations. Patients with small bowel bacterial overgrowth appear to be even more sensitive to polyol containing foods.

Evidence Behind the Diet 

Before examining the evidence, it is important to understand that high level, large study evidence in support of therapeutic dietary intervention is hard to come by because of the complexity of the diet and the difficulty in making changes to ones dietary routine. Dietary studies cannot be compared with the same objectives used in analyzing pharmacologic therapy. In the last few years there have been more studies supporting the ideas behind the FODMAP diet, as well as evaluating carbohydrate malabsorption and its clinical role in the symptoms of FGID. Early studies of dietary therapy in FGID seemed to focus mainly on fructose restriction or lactose restriction rather than global FODMAP restriction. A pilot study then showed a low FODMAP diet led to sustained improvement in all gut symptoms in 77% of 62 patients with IBS and fructose malabsorption. There were no placebo-controlled trials evaluating this subject until 2008. At that time Shepherd et al studied 25 patients with IBS in a double-blinded, randomized, quadruple arm, placebo-controlled rechallenge trial.16 The aim of this study was to determine whether dietary restriction was the likely mechanism for symptomatic benefit as well as to define whether the efficacy resided in the restriction of free fructose specifically, or whether it reflected a restriction of poorly absorbed, shortchain carbohydrates in general. The study used test substances (fructose, fructans, glucose) in different phases on patients who were already on a diet low in FODMAPS. Seventy-seven percent of patients who received fructose and fructans and 79% receiving a mixture of fructose, fructans, and glucose reported their symptoms were not adequately controlled; however, only 14% of patients who received just glucose reported that symptoms were not controlled low FODMAP diet in patients with IBS. Most recently, Staudacher and colleagues evaluated 82 patients who attended a follow up dietetic outpatient visit for IBS symptoms.19 They found that more patients in the low FODMAP group reported satisfaction with their symptom response to the diet compared to the standard group. Statistically significant symptomatic improvement was seen with respect to bloating, abdominal pain, and flatulence.

Patient Populations Benefitting from a Low FODMAP Diet 

The low FODMAP diet will benefit most patients with FGID. One study showed improvement of symptoms in 75% of patients. The majority of patients with functional GI disorders complain that certain foods make their symptoms worse. A combined approach is likely to yield the greatest treatment success and improvement in symptoms. This article has focused on the use of the FODMAP diet in treating patients with FGID but there is also evidence that a low FODMAP diet may help symptoms in patients with IBD. Other studies have been done using the FODMAP diet on patients with an ileostomy or ileal pouch to decrease high output. Initial research is promising but more studies are needed in both of these areas before the diet will be routinely recommended for those conditions. Recent research has also linked enteral nutrition–associated diarrhoea to the FODMAP content of the enteral formula; therefore, some patients may benefit from low FODMAP enteral nutrition. Researchers at Monash University found that the liquid nutritional supplements are 3-7 times more concentrated in FODMAPs than an average Australian diet and this cannot be predicted by ingredient lists. Also reviewing enteral nutrition, an earlier study from the same institution retrospectively studied 160 patients to determine the source of developing diarrhea in hospitalized patients. The patient’s length of stay and enteral nutrition duration were found to be independent predictors of developing diarrhea. Interestingly, starting an enteral nutrition formula with the lowest FODMAP content seemed to decrease the likelihood of diarrhea and this was statistically significant.

How Should the FODMAP Diet be Used? 

The short answer to this question is easy, with a dietician’s assistance. It is the physician’s responsibility to accurately diagnose the patient with a FGID, order breath tests if available, and investigate any alarm symptoms that may be present. It is essential for primary care physicians and gastroenterologists to understand the science behind FODMAPS, carbohydrate digestion, and the role of the FODMAP diet; however, in clinical practice today, especially in the primary care setting, most physicians are unable to dedicate 20 to 30 minutes to educate patients regarding their nutrition needs, Teaming up with a local nutritionist is the key to treating these patients. Physicians must start the process, but specific education will be done in detail at the nutritionist visit. In general, the following approach, suggested by Dr. Gibson, can be implemented in initiating this diet:

1. Hydrogen breath testing if readily available as this could potentially limit what foods need to be restricted. 
2. Referral to a dietitian who is comfortable with the low FODMAP approach for examination of the patient’s current diet to determine potential triggers, education regarding malabsorption, and education regarding portion control of fructose containing foods. 
3. Complete FODMAP restriction for 6 weeks. This is an important concept behind the diet, understanding that an initial global restriction is indicated rather than avoiding only fructose or lactose containing foods. 
4. A slow controlled reintroduction of FODMAPs to determine the level that will be tolerated. 

CONCLUSION 

The above evidence indicates that the FODMAP diet provides an effective approach to managing patients with FGID. Drug therapy is often necessary as well, but long-term success is likely to take place only after the addition of dietary changes. More research is needed to determine the FODMAP content of all foods and to determine the legitimacy of applying a low FODMAP diet to patients with IBD. Many gastroenterologist and dietitians are now starting to apply this diet in clinical practice. The FODMAP diet may have once been a craze, but now with an increasing body of evidence behind it, is definitely a credible and valuable tool in the management of patients with FGID.

References

1. Drossman, DA. The functional gastrointestinal disorders and the Rome II process. Gut 1999;45(suppl 2):1-5.

2. Nanda, R, James, R, Smith H et al. Food intolerance and the irritable bowel syndrome. Gut 1989;30:1099-104.

3. Bentley, SJ, Pearson, DJ, Rix KJ. Food hypersensitivity in irritable bowel syndrome. Lancet 1983;2:295-7.

4. Gibson, PR, Newnham, E, Barrett JS, et al. Review article: fructose malabsorption and the bigger picture. Aliment. Pharmacol There. 2007;25:349-63.

5. Nussey, S, Whitehead, S. Endocrinology: An Integrated Approach. Oxford: BIOS Scientific Publishers; 2001. Box 2.3. Absorption of monosaccharides in the small intestine.

6. Ferraris, RP. Dietary and developmental regulation of intestinal sugar transport. Biochem J. 2001;360:265-6.

7. Pessin, JE, Bell GI. Mammalian facilitative glucose transporter family: structure and molecular regulation. Annu Rev Physiol. 1992;54:911-30.

8. Thorens, B, Cheng, ZQ, Brown D. et al. Liver glucose transporter: a basolateral protein in hepatocytes and intestine and kidney cells. Am J Physiol. 1990;259:C279-85.

9. Cheeseman CI. Intestinal hexose absorption: transcellular or paracellular fluxes. J Physiol. 2002;544:336.

10. Castello, A, Guma, A, Sevilla L, et al. Regulation of GLUT5 gene expression in rate intestinal mucosa: regional distribution, circadian rhythm, perinatal development and effect of diabetes. Biochem J. 1995;309:271-7.

11. Croagh, C, Shepherd SJ, et al. Pilot study on the effect of reducing dietary FODMAP intake on bowel function in patients without a colon. Inflammatory Bowel Diseases 2007;13(12):1522-8.

12. Gibson, PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology & Hepatology 2010;25(2):252-8.

13. Choi, YK, Johlin, FC, Summers RW et al. Fructose intolerance: an under recognized problem. Am J Gastroenterol. 2003;98:1348-1353.

14. Symons, P, Jones, MP, Kellow JE. Symptoms provocation in irritable bowel syndrome. Effects of differing doses of fructosesorbitol. Scan J Gastroenterol. 1992;27:940-944.

15. 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.

16. Shepherd, SJ, Parker, FC, Muir JG et al. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo controlled evidence. Clin. Gastroenterol. Hepatol 2008;6:765-71.

17. Barrett, JS, Gearry, RB, Muir JG et al. Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment. Pharmacol. There. 2010;31:874-82.

18. Ong, DK, Mitchell, SB, Barrett JS 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;25:1366-72.

19. Staudacher, HM, Whelan, K, Irving PM et al. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. Journal of Human Nutrition & Dietetics 2011;24(5):487-95.

20. Barrett, JS, Irving, PM, Shepherd SJ et al. Comparison of the prevalence of fructose and lactose malabsorption across chronic intestinal disorders. Aliment. Pharmacol There. 2009;30:165-74.

21. Gearry, RB, Irving, PM, Barrett JS et al. Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPS) improves abdominal symptoms in patients with inflammatory bowel disease- a pilot study. J. Crohns Colitis 2009;3:8-14.

22. Gibson, PR, Shepherd SJ. Personal view: food for thought- -western lifestyle and susceptibility to Crohn’s disease. The FODMAP hypothesis. Aliment Pharmacol & Therap. 2005;21(12):1399-409.

23. Halmos, EP, Liels, KL, Rosella O. Enteral and oral nutritional supplement formulas deliver laxative doses of FODMAPs which cannot be predicted by ingredients lists. Journal of Gastroenterology and Hepatology 2011;26(suppl 4):73.

24. Halmos, EP, Muir, JG, Barrett JS et al. Diarrhoea during enteral nutrition is predicted by the poorly absorbed short-chain carbohydrate (FODMAP) content of the formula. Aliment Pharmacol Ther. 2010;32(7):925-933.

25. Gibson, PR. Food intolerance in functional bowel disorders. Journal of Gastroenterology & Hepatology 2011;26(suppl 3):128-31.