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Recognizing and treating sorbitol intolerance

Some of the most well-known and common food intolerances include those to the carbohydrates fructose and lactose. In addition to fructose intolerance and lactose intolerance, there is another frequently occurring sugar metabolism disorder (carbohydrate malabsorption), namely sorbitol intolerance.

Sorbitol intolerance is therefore not an allergy. Most sufferers have often dealt with it for years before a definitive diagnosis is made. Children and adults are affected equally. Often, an intolerance does not exist in isolation, but rather several different intolerances occur simultaneously.

Due to the occurrence of various intolerances, it is difficult to determine the relationship between symptoms and food intake. But what are the underlying causes, and is sorbitol intolerance curable?

Everything you need to know about sorbitol intolerance

Sorbitol is a sugar substitute used strategically by the food industry as a humectant and sweetener. Sorbitol is also known as sorbit, hexanhexol, and glucitol. Medications such as laxatives contain sorbitol, as do toothpaste, mouthwash, and naturally occurring foods. In the case of sorbitol intolerance (sorbitol malabsorption), the small intestine is unable to absorb sorbitol at all or can only absorb it in small amounts.

The sugar alcohol enters the large intestine and is broken down by intestinal bacteria into short-chain fatty acids, carbon dioxide, and hydrogen. For diabetics, the sweetener is usually well tolerated as it is metabolized independently of insulin, which causes only a minimal increase in blood sugar levels. However, the sweetening power of sorbitol is lower, which creates the risk that the body will become accustomed to sweet foods and develop an extreme craving for them.

The sweetening power of sucrose (table sugar) is about twice as high as that of sorbitol. Per gram, sorbitol has 2.4 calories, while table sugar has almost twice as much, at 4 calories.

Why is sorbitol intolerance often accompanied by fructose intolerance?

There are different types of sorbitol intolerance: the isolated form and the combined sorbitol and fructose intolerance. Isolated sorbitol malabsorption is limited only to an intolerance to sorbitol. The amount of fructose consumed therefore plays no role. In the combined form, however, those affected also suffer from a fructose intolerance.

This intestinal fructose intolerance or sorbitol-dependent fructose malabsorption occurs much more frequently. This means that fructose and sorbitol are tolerated individually, but cause discomfort when combined. People with a fructose intolerance should nevertheless avoid sorbitol, because fructose and sorbitol are metabolized via the same pathway.

This means that not only is the body's ability to absorb fructose in the small intestine limited, but the absorption capacity is further inhibited. Sorbitol can also be converted into fructose.

Symptoms of sorbitol intolerance

As with most food intolerances—including histamine intolerance, celiac disease, and fructose and lactose intolerance—people with a sorbitol intolerance may experience various complaints, particularly digestive issues.

These become noticeable within a few minutes or with a delay of up to about 48 hours. Depending on the amount of sorbitol consumed, the symptoms may be more or less severe. A combined sorbitol and fructose intolerance is primarily associated with more symptoms. The number and type of gut bacteria can also worsen symptoms, which include:

Abdominal pain
Diarrhea
Bloated abdomen
Flatulence
Feeling of fullness
Fatigue
Nausea
Bad breath
Belching
Fatty stools

Diagnosis of sorbitol intolerance

A doctor, specifically a gastroenterologist, can diagnose whether such a sugar metabolism disorder exists using an H2 breath test. On an empty stomach, the test person drinks a solution containing a maximum of 10 g of sorbitol, and their breath is then tested at 30-minute intervals. Sorbitol reaches the large intestine, where it is broken down by bacteria. This produces hydrogen (H2), which travels through the blood to the lungs and is then exhaled. The H2 content in the exhaled air provides information about whether a sorbitol intolerance exists. The likelihood of having this intolerance increases with the hydrogen content. Incidentally, such a test is also used to check for lactose and fructose intolerance.

Diet and treatment of sorbitol intolerance

Nutrition plays a major role in therapy. Once a sorbitol intolerance has been confirmed, a change in diet and the avoidance of corresponding sorbitol-containing foods should take place for about 4 weeks (elimination phase). This means consuming a maximum of 0.5 g of sorbitol daily. Other sugar alcohols should also be avoided.

It is advisable to keep a food and symptom diary. Once your stomach and intestines have recovered, you can slowly begin to eat sorbitol-containing foods again after this period to check whether they are tolerated (reintroduction phase). This is exactly the same approach taken when diagnosing histamine intolerance. After a 4-week elimination phase and the avoidance of histamine-containing foods, you can slowly reintroduce histamine-containing foods into your diet, depending on your tolerance.

It is best to start with one food per day and test your way through. Keep in mind that symptoms can sometimes occur only after 48 hours. If you notice symptoms again, remove that food from your diet. In this way, you can find out what amount of sorbitol (and histamine) your body can tolerate. Always remember that the tolerance threshold, and thus the level of tolerance, is individual for every intolerance, including sorbitol intolerance.

Food intolerances often arise due to dysbiosis or a leaky gut in the intestine. If the root causes are not treated, the consequences can include further complaints such as bacterial overgrowth, diverticula, and diseases of the rectum.

Which foods contain high levels of sorbitol?

What should you avoid eating if you have a sorbitol intolerance? Sorbitol is contained as a food additive in industrially processed foods, especially in ready-made products. You should definitely avoid these if you have a sorbitol intolerance. Pay attention to the information on the ingredients list, where sorbitol is declared as E 420, E 432, E 433, E 434, E 435, and E 436. Baked goods such as bread or sugar-free, calorie-reduced light products and confectionery such as candy or chewing gum contain sorbitol as an additive and preservative.

Chocolate itself does not contain sorbitol, but chocolate and praline fillings often do to protect the food from drying out. Certain natural foods also have a very high sorbitol content, which is why it is important to avoid them during the elimination phase. These primarily include various types of vegetables, fruits such as stone fruit, and alcohol:

Dried fruit
Bell peppers
Brussels sprouts
Tomatoes
Pears
Apples
Plums
Cherries
Apricots
Damsons
Mirabelle plums
Grapes
Raisins
Rowan berries
Red wine
White wine
Beer

In addition to sorbitol, other sugar substitutes can also lead to problems, for example, xylitol (birch sugar or E 967), palatinit or isomalt (E 953), mannitol (E 421), and lactitol (E 966).

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Low-sorbitol foods: What you can eat with sorbitol intolerance

Meat and sausage products, as well as fish without preservatives, are generally well tolerated. However, if you also suffer from a histamine intolerance, you should be careful with meat. Pay attention to freshness when consuming it. Fresh poultry, along with beef, is suitable for someone with histaminosis. The following fruits and vegetables are not only low in sorbitol but also low in histamine:

(White) onions
Asparagus
Lettuce
Broccoli
Fennel
Parsnip
Pasta (e.g., spelt)
Potatoes
Rice
Grains (e.g., oats)
Yogurt
Young Gouda
Blackberries
Persimmon
Currants
Dates
Melon
Zucchini
Pumpkin
Coconut
Carrots
Blueberries

Is there a connection between sorbitol and histamine?

There is no direct link between a sorbitol and histamine intolerance, but many people suffer from multi-intolerances, meaning several intolerances at the same time. Out of fear of discomfort, those affected restrict themselves more and more, eventually having only a limited number of foods on their menu. This leads to a disturbed intestinal microbiome, as our gut and our gut bacteria require a variety of foods.

Tips for dealing with sorbitol intolerance

To avoid severe symptoms, the following helpful tips can support you:

Consuming sorbitol in combination with fat and protein can prolong the retention time of food in the small intestine, which increases the utilization of sorbitol. This in turn reduces discomfort.
Natural vegetables are more digestible than processed vegetables such as pickled peppers.
During the elimination phase, it can help to switch to a gentle, bland diet, as hard-to-digest foods can also inhibit sorbitol tolerance. Therefore, avoid gas-inducing vegetables such as onions, cabbage, or broccoli, as well as whole grain products. Furthermore, chew all food thoroughly, eat smaller but more frequent meals, and drink plenty of water.
A complete avoidance of sorbitol can further impair the intestine's ability to break it down. Additionally, ensure an adequate nutrient intake.
Sugar substitutes that are generally better tolerated are birch sugar (E 967) and erythritol (E 986).
Be alert when you see labels like "suitable for diabetics" or "sugar-free." These products usually contain sorbitol.
It is best to always cook fresh, as ready-made products contain high amounts of sorbitol.

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