Who said you can’t have a fun free from Easter?

DSCF1315aThese are dairy free, wheat free, gluten-free easter nests just the job if you have to avoid dairy and want to have at least a small amount of chocolate.

Ingredients

100g milk free chocolate

60g of gluten-free corn flakes

30g sultanas

Gluten wheat & milk free yellow sprinkles

Gluten, milk and wheat free jelly beans

A few kitsch chicks!

Method

Weigh out the cornflakes and sultanas into a bowl.

Crush the cornflakes a little.

Melt the chocolate in a bowl over hot water.

Add to the cornflakes ans sultanas and mix till coated thoroughly.

Put the mix into a bun tin and flatten the middle to make a nest.

Place in the fridge to set then sprinkle the middle with sprinkles and add some jelly bean ‘eggs’.

Have a happy easter! :-)

 

 

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Saffron Simnel Cake

Saffron Simnel Cake

This recipe can also be downloaded from the IBS Network website

http://www.theibsnetwork.org/what-we-offer/recipes/

It is a different take on the traditional simnel cake – without marzipan as this might provoke symptoms if you have IBS. A small slice of this is nice to have on Easter Sunday, many people may find that Easter eggs are too much to tolerate, particularly if you suffer from lactose intolerance. Saffron can be excluded if you don’t like the taste.

Ingredients

240g of self-raising wheat free/gluten-free flour
1 flat tsp of cinnamon
1 flat tsp ginger
2 tbsp ginger syrup
50g of sultanas
4 eggs
200g of milk free margarine
Large pinch of saffron
150g of golden castor sugar

Method
Pour approximately 1 tablespoon of boiling water on to the saffron and set aside to cool.
Weigh all other ingredients into a mixing bowl, add saffron and liquid mix, mix well.
Place in a paper lined seven-inch baking tin and bake at gas mark 6 220ºC for 45 minutes – 1 hour until a cake skewer comes out clean, when inserted into the centre of the cake.
Decorate.

DSCF1294modOther posts that you might find useful at Easter:

http://clinicalalimentary.wordpress.com/2014/04/17/easter-hot-cross-buns/

http://clinicalalimentary.wordpress.com/2013/03/31/easter-meal-roast-spring-lamb/

If you can tolerate marzipan you might want to try this recipe instead

http://clinicalalimentary.wordpress.com/2013/03/30/easter-with-food-intolerance/

 

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Easter Hot Cross Buns

Hot cross buns are an integral part of the Easter festivities – being on a wheat free diet shouldn’t exclude you from enjoying them.

DSCF1295modaIngredients
350g Brown Wheat/Gluten Free bread flour
2¼ Teaspoons xanthan gum
4½ Tablespoons castor sugar
1½ Teaspoons cinnamon
1¼ Fresh grated nutmeg
¼ Teaspoon of salt
3 Eggs
3 Tablespoons of olive oil based spread
1 Teaspoon vinegar
280 ml warm water
¾ Teaspoon sugar
3½ Teaspoons of dried fast acting yeast
125g Sultanas

To make the cross

Wheat free brown bread flour

1/2 egg (use the other half to glaze the buns.)

Method

This mix produces a very stiff dough so a powerful mixer with a kneader tool attachment is needed

Weight out the flour, xanthan gum, castor sugar, cinnamon, freshly grated nutmeg and salt into a bowl, mix the dried ingredients well.
In another bowl add the warm water, and sugar – dissolve and add fast acting yeast and leave till a foam forms on the surface.
Add the eggs, butter and vinegar to another bowl and beat and add the yeast mixture
Set the mixer to a slow speed to start and begin to add the dry ingredients to the wet and when all the ingredients are added mix well.
Add the sultanas and mix well with a spoon.
Quickly drop about 60g of mix into a greased bun tray and leave in a warm place for 30 minutes to rise.

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Best consumed within 24 hours of baking – I am sure you won’t have a problem with this bit! I have not added any candid peel to the recipe as I don’t like it but you could add some if you do.

 

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Another AGM and buckwheat slaw salad

I am preparing for another IBS Network AGM tomorrow, I can’t believe its three years since I attended the first one – we have achieved lots of things since then, the Self Care Plan and now free access to all, new website, two Wellbeing days and lots of meetings. Now for the next 12 months!

Buckwheat slaw salad
170g buckwheat grain
½ courgette
1 carrot
1 bag of rocket
1 bag of radish
2 tablespoons of light mayonnaise
3 dessert spoons of pine nuts
Salt & pepper

Method
Cook the buckwheat in water for 20 minutes, rinse with cold water.
Grate carrot, radish and courgette and squeeze out any excess water.
Mix the mayonnaise with the carrot, radish, courgette, pine nuts, rocket and add salt + pepper to taste.

Simple!

 

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Would Renaming Irritable Bowel Syndrome (IBS) Make a Real Difference?

Jules_GastroRD:

This is a thought provoking piece about renaming IBS – we certainly need more IBS advocates would a name change increase advocacy?

Originally posted on IBS IMPACT:

Over the years, the symptom cluster currently known as irritable bowel syndrome or IBS has been called various other terms that are now outdated. These range from, among others, the extremely vague “nervous stomach” to the inaccurate “spastic colitis,” “irritable colitis” “mucous colitis” (IBS, as currently understood scientifically, is not a form of colitis.) to “spastic colon,” as an apparent attempt to acknowledge the unpredictable motility found in IBS. “Irritable bowel syndrome” is the most recent name choice, as physicians and researchers began to realize that the symptoms of IBS form distinct patterns. “Syndrome,” in a medical context, means “a group of signs and symptoms that occur together and characterize a particular abnormality.” This part of the present name is more consistent with the symptom-based Rome criteria that functional gastrointestinal disorder experts have advocated as the international diagnostic standard for over two decades. Rome III is the current version. (See page 889.)…

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Gluten Free, Low FODMAP, Low Fibre, tea scones

Afternoon tea is an English tradition that is now only consumed for a birthday or other celebrations and one of my favourites for a treat. It should contain sliced sandwiches, a scone with jam and small cakes. The following is a recipe for plain scones.

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Ingredients

250g of gluten-free self-raising flour

50g of olive oil based spread

50g of castor sugar

1 pinch of salt

40mls of milk

1 egg

(1 egg to use for an egg wash and sugar for coating the scone.)

Method

1. Weigh out the flour and add the olive oil based spread, sugar and salt to the bowl

2. Rub the margarine into the flour until you have a small crumb

3. Add the egg and milk and bring the mix together – remember the more work you put into this the better the mix will stay together, it really is not like working with wheat flour!

4. Roll out to a 1.5 cm thickness and cut out scones.

5. Wash with egg and sprinkle with sugar and bake in an oven for 15-20 minutes at gas mark 6 22o°C.     

You could add a teaspoon of gluten-free baking powder to increase the rise of the scone – I didn’t – as I tend to feel that you can taste baking powder in scones if you use too much.

 

 

 

 

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Adventures with Quinoa Flour

Due to a fortuitous reduction in the price of Quinoa flour at a local health shop I have purchased some to try baking with it, for you. I decided to bake some blondies – ginger ones, or may be I should call them gingies! I love the flavour ginger – in fact ALL things ginger. Now THIS particular quinoa flour, according to the packet, is sugar-free, saturated fat-free, cholesterol free, trans fat-free, sodium free, low-fat, (as is all flour – nothing new here, then ) non-gmo, gluten-free AND ‘caution extremely organic’ – but not that funny – or clever! What they forgot to tell me was wheat free, milk free, egg free but unfortunately no mention of nuts. Really great then? The protein content of the flour is not really that high at 4g /100g but quinoa has a good amino acid profile as a grain, although the flour is a fine milled white flour (- contains some fibre though at 3.5g/100g,) so it cannot be assumed that the amino acid profile is exactly the same as the raw grain. It has not been tested for fermentable carbohydrate content although quinoa grain itself is completely suitable for people following a low FODMAP diet.

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So how easy was it to use? My first attempt was a bit of a culinary disaster. I added some zanthan gum and 2 teaspoons of ginger and a small amount of chopped stem ginger. This resulted in a very gloopy texture and after baking, on tasting, the slice was really strongly flavoured, not that pleasant in fact. The taste reminded me of the taste of chickpea flour, again this is fine to use, but I would suggest that as both these flours impart a very strong flavour to baked items it might be better to use them for very strongly flavoured dishes. My second attempt was better and as I increased the ginger flavouring the taste was very much improved.

IMG_1570As part of a flour mix this flour would be suitable, as other free from flours, such as rice or teff as these should reduce the flavour. So was it worth the purchase – at full cost, or even discounted? I feel that the ‘benefits’ of this type of flour should not command such a high cost. Most people will not be able to afford to purchase and include it in their diet on a regular basis, so nutritionally you are not likely to see the benefits of the amino acids; gut ‘calmness’ wise – there are other options to choose, which do not impart strong taste or flavour. So I will not be buying this flour on a regular basis. However for your enjoyment I have included the recipe for you – you could try it with other flour mixes! Also as this recipe is high in fats and sugars the gingie is really just suitable for an occasional treat. The random images in the post are my whistful desire for summer – it’s really cold today.

 

Ingredients

135 g Quinoa Flour (or other free from flour)

120 g dairy free margarine

2 eggs

100 g of dark muscovado sugar

1 tablespoon of crystallised ginger liquor

3 teaspoons of powdered ginger

40 g of chopped crystallised ginger

Pinch of salt

Chopped dried ginger to decorate

Melted dark chocolate with ginger to decorate (milk free if needed.)

 

Method

Add the flour, ginger & salt to a mixing bowl

Melt the margarine in a pan with the sugar, and chopped crystalline ginger and ginger liquor, warm slowly do not boil.

Cool the melted mixture slightly, add the two eggs and mix well.

Add the liquid ingredients to the dry ingredients then add the mix to a paste. Add this to a tray and bake at gas mark 5 for 25 minutes. Cool on a cooling rack and melt the chocolate and pour this over and sprinkle with finely chopped dried ginger pieces.

IMG_1759

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Haddock Florentine with mustard roasted carrots (gluten free, low lactose, Low FODMAP)

IMG_1776It’s grim ‘up north’ today, the weather is grey and dismal at February’s threshold, still winter then? Few frosty mornings have occurred to evidence winters grasp on the landscape, just sodden foliage and waterlogged boggy moor – a relentless morass. The trees are coated in a thin layer of moss and everything is damp and dismal – great weather for ducks, but pretty uninspiring to everyone else! The ‘mood’ of the woods brings to mind one of my favourite poems by Rudyard Kipling, evoking feelings of nostalgia at its reading. It’s haunting theme I feel is more about sadness and loss, and I am often reminded of it whilst wandering in the woods around West Yorkshire -

The Way Through the Woods

They shut the road through the woods
Seventy years ago.
Weather and rain have undone it again,
And now you would never know
There was once a road through the woods
Before they planted the trees.
It is underneath the coppice and heath
And the thin anemones.
Only the keeper sees
That, where the ring-dove broods,
And the badgers roll at ease,
There was once a road through the woods.

Yet, if you enter the woods
Of a summer evening late,
When the night-air cools on the trout-ringed pools
Where the otter whistles his mate,
(They fear not men in the woods,
Because they see so few.)
You will hear the beat of a horse’s feet,
And the swish of a skirt in the dew,
Steadily cantering through
The misty solitudes,
As though they perfectly knew
The old lost road through the woods …
But there is no road through the woods.

http://www.kiplingsociety.co.uk/bookmart_fra.htm

Summer is some way off – need something warm and tasty bring comfort and lift the mood? This is a really nice fish recipe for using up any stale or spare gluten-free bread (if you have any that is!) Otherwise you could use shop bought gluten-free or rice crumbs, which is more easily available to you. It is warm and filling and not too hard on delicate malfunctioning digestive systems. Fish is not cheap these days but this dish works well with smoked river cobbler too which will help with the cost, tinned spinach is also a useful standby to use. If you suffer from bloating from resistant starches you could make the dish without the breadcrumbs if you wish.

 IMG_0858

Ingredients

1/2 packet of gluten-free/wheat free bread crumbs

2 smoked haddock or river cobbler fillets

1/2 pint of lactose free skimmed milk

3 teaspoons of corn flour

10 g of margarine

1 teaspoon of freshly grated nutmeg

25 g Gruyère

12 g of parmesan

1 tin of spinach

Method

Make the sauce, melt the margarine and add cornflour mix to a paste and slowly add milk till all the flour has been incorporated and add grated nutmeg, Gruyère and salt to taste. Mix till thickened, cool.

Wash the spinach and layer in the bottom of an oven proof dish, cut the skin off the fish and add a layer on the top of the spinach. Coat the fisn layer with the cooled sauce. Add salt and pepper to the dish.

Sprinkle breadcrumbs on the top of the sauce and cover with the grated parmesan.

Cook in a preheated oven at gas mark 5 or 180ºC. Serve with mustard carrots (roast carrots with a small amount of garlic infused oil and grained mustard.)

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Rectal Bleeding – A discussion about possible causes

Jules_GastroRD:

A nice post about the causes and investigations of rectal bleeding.

Originally posted on Doctor Rennie's Blog:

Colon-Endoscopes
anat_colon_1.0

 

 

 

 

 

 

 

 

 

Photo credit:  http://www.naturalhealingsolutionsllc.com/learn-about-colon-hydrotherapy.html

Photo credit:  http://www.thenurseslockerroom.com/2013/03/sigmoidoscopy-screening-test-for.html

One of the more common problems that bring patients into the doctor believe it or not is seeing blood in the toilet, on the stool or on the toilet paper after having a bowl movement.  Since I’ve had a few patients recently who have come in because of this problem, I thought I’d discuss some possible causes.

Healthcare providers take this issue seriously because sometimes blood noticed after having a bowl movement can be a sign of colon or rectal cancer.  Fortunately, most of the time the causes of rectal bleeding is not cancer however.

Causes of rectal bleeding:

1)  Hemorrhoids:  Swollen blood vessels can occur in the rectum or anus and cause itching and/or pain and can sometimes bleed.  Usually hemorrhoids produce a blood that is described by patients as being a…

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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

 

 

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