Wissenswertes

Recognizing and treating sorbitol intolerance

Among the best-known and most common food intolerances are those to the carbohydrates fructose and lactose . Besides fructose and lactose intolerance, there is another frequently occurring sugar malabsorption disorder , namely sorbitol intolerance .

Sorbitol intolerance is therefore not an allergy. Those affected often suffer for years before receiving a definitive diagnosis. Children and adults are equally affected. Frequently, one intolerance does not occur in isolation, but rather several intolerances occur simultaneously.

Due to the occurrence of various intolerances, it can be difficult to establish a connection 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 by the food industry as a humectant and sweetener . It is also known as sorbitol, hexanhexol, and glucitol. Sorbitol is found in medications such as laxatives, as well as in toothpaste, mouthwash, and naturally occurring foods. In cases of sorbitol intolerance (sorbitol malabsorption), the small intestine cannot absorb sorbitol at all or only in very small amounts.

The sugar alcohol reaches 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 because it is metabolized independently of insulin, resulting in only a minimal rise in blood sugar levels. However, sorbitol's sweetening power is lower, which increases the risk of the body becoming accustomed to sweet foods and developing an extreme craving for them.

Sucrose (table sugar) is about twice as sweet as sorbitol. Sorbitol has 2.4 calories per gram, while table sugar has almost twice as many at 4 calories.

Why is sorbitol intolerance often accompanied by fructose intolerance?

There are different types of sorbitol intolerance: isolated sorbitol intolerance and combined sorbitol and fructose intolerance. Isolated sorbitol malabsorption is limited to an intolerance to sorbitol alone. Therefore, the amount of fructose ingested is irrelevant. In the combined form, however, those affected also suffer from fructose intolerance.

This intestinal fructose intolerance, or sorbitol-dependent fructose malabsorption, is far more common. This means that fructose and sorbitol are tolerated individually, but their combination causes symptoms. People with fructose intolerance should still avoid sorbitol, as fructose and sorbitol are metabolized via the same pathway.

This means that the body's ability to absorb fructose in the small intestine is not only 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, fructose and lactose intolerance, people with sorbitol intolerance may also experience various symptoms, especially digestive problems.

These symptoms can appear within minutes or be delayed by about 48 hours. The severity of the symptoms depends on the amount of sorbitol ingested. A combined sorbitol and fructose intolerance is generally associated with more pronounced symptoms. The number and type of gut bacteria can also worsen the symptoms, which include:

Abdominal pain
Diarrhea
Bloating
Flatulence
Feeling of fullness
fatigue
nausea
Bad breath
Belching
Fatty stools

Diagnosis of sorbitol intolerance

A hydrogen breath test can be used by a doctor, specifically in the field of gastroenterology, to diagnose a sugar metabolism disorder. On an empty stomach, the test subject drinks a maximum of 10 g of sorbitol solution, and their breath is then tested every 30 minutes. Sorbitol reaches the large intestine, where it is broken down by bacteria. This process produces hydrogen (H2), which travels through the bloodstream to the lungs and is exhaled. The H2 content in the breath indicates whether a sorbitol intolerance is present. The likelihood of suffering from this intolerance increases with the hydrogen content. Incidentally, a similar test is also available to check for lactose and fructose intolerance.

Diet and treatment of sorbitol intolerance

Diet plays a major role in therapy. If sorbitol intolerance is diagnosed, a dietary change and avoidance of the corresponding sorbitol-containing foods should be implemented for approximately four weeks (elimination phase). This means a maximum daily intake of 0.5 g of sorbitol. Other sugar alcohols should also be avoided.

It is recommended to keep a food and symptom diary. Once your stomach and intestines have recovered, you can slowly reintroduce sorbitol-containing foods and check whether they are tolerated (test phase). The same applies to a histamine intolerance diagnosis. After a four-week elimination phase and abstaining from histamine-containing foods, you can gradually reintroduce them into your diet, depending on your tolerance.

It's best to start with one food per day and test it out. Keep in mind that symptoms may not appear for up to 48 hours. If you experience symptoms again, remove that food from your diet. This way, you can find out how much sorbitol (and histamine) your body can tolerate. Always remember that the tolerance threshold, and therefore the tolerability, is individual for every intolerance, including sorbitol intolerance.

Food intolerances often arise from dysbiosis or leaky gut syndrome. If these underlying causes are not treated, further problems such as bacterial overgrowth, diverticula, and rectal diseases can result.

Which foods contain a lot of sorbitol?

What should you avoid if you have a sorbitol intolerance? Sorbitol is found as a food additive in industrially processed foods, especially convenience foods. If you have a sorbitol intolerance, you should definitely avoid these. Pay attention to the ingredient list, where sorbitol is declared as E 420, E 432, E 433, E 434, E 435, and E 436. Baked goods such as bread , sugar-free, reduced-calorie "light" products, and sweets like candy or chewing gum contain sorbitol as an additive and preservative.

Chocolate itself contains no sorbitol, but chocolate and praline fillings do, to protect the food from drying out. Certain natural foods also have a very high sorbitol content, which is why it's important to avoid them during the elimination phase. These include, above all, various vegetables, fruits such as stone fruits, and alcohol .

dried fruit
paprika
Brussels sprouts
tomatoes
pears
apples
plums
Cherries
apricots
plums
apricots
grapes
raisins
Rowan berries
red wine
white wine
Beer

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

Low-sorbitol foods: What you can eat if you have a sorbitol intolerance

Meat and sausage products, as well as fish without preservatives, are generally well tolerated. However, if you also suffer from histamine intolerance, you should be careful with meat. When consuming meat, pay attention to its freshness. Fresh poultry, along with beef, is a good choice for those with histamine intolerance. 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
blackberry
Khaki
currant
Dates
melon
zucchini
pumpkin
coconut
carrots
blueberries

Is there a connection between sorbitol and histamine?

There is no direct link between sorbitol and histamine intolerance; however, many people suffer from multiple intolerances , meaning several intolerances simultaneously. Out of fear of symptoms, those affected increasingly restrict their diets, eventually limiting themselves to a very small number of foods. This leads to a disrupted gut microbiome, as our gut and gut bacteria require a diverse range of foods.

Tips for dealing with sorbitol intolerance

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

Consuming sorbitol in combination with fat and protein can prolong the transit time of ingested food in the small intestine, thereby increasing the bioavailability of sorbitol. This also reduces discomfort.
Natural, unprocessed vegetables are more easily digestible than processed vegetables such as pickled peppers.
During the elimination phase, switching to a light, whole-food diet can be helpful, as foods that are difficult to digest can also impair sorbitol tolerance. Therefore, avoid gas-producing vegetables such as onions, cabbage, or broccoli, as well as whole-grain products. Also, chew all food thoroughly, eat smaller, more frequent meals, and drink plenty of water.
Completely avoiding sorbitol can further impair the intestines' ability to break down waste. It is also important to ensure an adequate intake of nutrients.
Sugar substitutes that are usually better tolerated are birch sugar (E 967) and erythritol (E 986).
Be wary of products labeled “suitable for diabetics” or “sugar-free.” These products usually contain sorbitol.
It's best to always cook from scratch, because ready-made products contain a lot of sorbitol.