A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome

doi:10.1053/j.gastro.2013.09.046

Gastroenterology

Volume 146, Issue 1, January 2014, Pages 67-75.e5

https://doi.org/10.1053/j.gastro.2013.09.046 Get rights and content

Background & Aims

A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) often is used to manage functional gastrointestinal symptoms in patients with irritable bowel syndrome (IBS), yet there is limited evidence of its efficacy, compared with a normal Western diet. We investigated the effects of a diet low in FODMAPs compared with an Australian diet, in a randomized, controlled, single-blind, cross-over trial of patients with IBS.

Methods

In a study of 30 patients with IBS and 8 healthy individuals (controls, matched for demographics and diet), we collected dietary data from subjects for 1 habitual week. Participants then randomly were assigned to groups that received 21 days of either a diet low in FODMAPs or a typical Australian diet, followed by a washout period of at least 21 days, before crossing over to the alternate diet. Daily symptoms were rated using a 0- to 100-mm visual analogue scale. Almost all food was provided during the interventional diet periods, with a goal of less than 0.5 g intake of FODMAPs per meal for the low-FODMAP diet. All stools were collected from days 17–21 and assessed for frequency, weight, water content, and King's Stool Chart rating.

Results

Subjects with IBS had lower overall gastrointestinal symptom scores (22.8; 95% confidence interval, 16.7–28.8 mm) while on a diet low in FODMAPs, compared with the Australian diet (44.9; 95% confidence interval, 36.6–53.1 mm; P < .001) and the subjects' habitual diet. Bloating, pain, and passage of wind also were reduced while IBS patients were on the low-FODMAP diet. Symptoms were minimal and unaltered by either diet among controls. Patients of all IBS subtypes had greater satisfaction with stool consistency while on the low-FODMAP diet, but diarrhea-predominant IBS was the only subtype with altered fecal frequency and King's Stool Chart scores.

Conclusions

In a controlled, cross-over study of patients with IBS, a diet low in FODMAPs effectively reduced functional gastrointestinal symptoms. This high-quality evidence supports its use as a first-line therapy. Clinical Trial number: ACTRN12612001185853.

Section snippets

Participants

Patients with IBS according to Rome III criteria¹⁵ and healthy controls without gastrointestinal symptoms were recruited between April 2009 and June 2011 via advertisements in breath testing centers, community newspapers, and through word of mouth. Exclusion criteria comprised exclusion of celiac disease by duodenal biopsy and/or negative celiac serologic testing while consuming a gluten-rich diet and/or negative HLA-DQ2/DQ8 for IBS patients, previous abdominal surgery, and comorbid conditions

Participants

Forty-five participants were recruited for the study. Seven participants (3 IBS and 4 healthy controls) quit the study before commencing their second diet and were excluded from analysis. Six of these 7 participants were female, with a median age of 28 years (interquartile range [IQR], 21–29 y), body mass index of 23.6 (IQR, 20.3–25.4), and none of them had undergone previous breath testing for fructose malabsorption. Five participants exited the study because the study protocol was too

Discussion

Despite the growing popularity of the low FODMAP diet, efficacy data in unselected patients with IBS in which the effect of the diet on gastrointestinal symptoms is compared in a randomized, blinded manner with that of diet containing typical amounts of FODMAPs has been lacking. The results of the current study provide high-quality data to fill that gap. As highlighted by Figure 1, symptoms were more than halved in IBS subjects and all measured symptoms were reduced to a level that arguably is

Acknowledgments

The authors thank Gina Dimitrakopoulos and Debbie King (Monash University) for their assistance with food preparation and packaging; Kelly Liels, Ourania Rosella, and Rosemary Rose (Monash University) for analysis of FODMAP content of meals; Alicia Moltzen (Monash University) for analysis of breath samples; and Minfeng Deng and Chu Kion Yao (Monash University) for statistical analysis.

References (35)

F. Fernández-Bañares et al.
Sugar malabsorption in functional abdominal bloating: a pilot study on the long-term effect of dietary treatment
Clin Nutr
(2006)
S.J. Shepherd et al.
Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management
J Am Diet Assoc
(2006)
S.J. Shepherd et al.
Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence
Clin Gastroenterol Hepatol
(2008)
J.S. Barrett et al.
Development and validation of a comprehensive semi-quantitative food frequency questionnaire that includes FODMAP intake and glycemic index
J Am Diet Assoc
(2010)
M.M. Murphy et al.
Resistant starch intakes in the United States
J Am Diet Assoc
(2008)
L. Bohn et al.
Self-reported food-related gastrointestinal symptoms in ibs are common and associated with more severe symptoms and reduced quality of life
Am J Gastroenterol
(2013)
P. Hayes et al.
A dietary survey of patients with irritable bowel syndrome
J Hum Nutr Diet
(2013)
W. Atkinson et al.
Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial
Gut
(2004)
P.R. Gibson et al.
Evidence-based dietary management of functional gastrointestinal symptoms: the FODMAP approach
J Gastroenterol Hepatol
(2010)
P.R. Gibson et al.
Personal view: food for thought–western lifestyle and susceptibility to Crohn's disease. The FODMAP hypothesis
Aliment Pharmacol Ther
(2005)

R. Goldstein et al.

Carbohydrate malabsorption and the effect of dietary restriction on symptoms of irritable bowel syndrome and functional bowel complaints

Isr Med Assoc J

(2000)

C. Yao et al.

Discordant absorption of mannitol and sorbitol in patients with irritable bowel syndrome - a reflection of possible epithelial abnormalities?

J Gastroenterol Hepatol

(2010)

J.S. Barrett et al.

Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon

Aliment Pharmacol Ther

(2010)

D.K. Ong 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)

H.M. Staudacher 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

J Hum Nutr Diet

(2011)

C.K. Yao et al.

Design of clinical trials evaluating dietary interventions in patients with functional gastrointestinal disorders

Am J Gastroenterol

(2013)

Rome

Guidelines–Rome III diagnostic criteria for functional gastrointestinal disorders

J Gastrointestin Liver Dis

(2006)

Cited by (928)

Sishen Wan enhances intestinal barrier function via regulating endoplasmic reticulum stress to improve mice with diarrheal irritable bowel syndrome
2024, Phytomedicine
Diarrheal irritable bowel syndrome (IBS-D), characterized primarily by the presence of diarrhea and abdominal pain, is a clinical manifestation resulting from a multitude of causative factors. Furthermore, Sishen Wan (SSW) has demonstrated efficacy in treating IBS-D. Nevertheless, its mechanism of action remains unclear.
A model of IBS-D was induced by a diet containing 45 % lactose and chronic unpredictable mild stress. Additionally, the impact of SSW was assessed by measuring body weight, visceral sensitivity, defecation parameters, intestinal transport velocity, intestinal neurotransmitter levels, immunohistochemistry, and transmission electron microscopy analysis. Immunofluorescent staining was used to detect the expression of Mucin 2 (MUC2) and Occludin in the colon. Western blotting was used to detect changes in proteins related to tight junction (TJ), autophagy, and endoplasmic reticulum (ER) stress in the colon. Finally, 16S rRNA amplicon sequencing was used to monitor the alteration of gut microbiota after SSW treatment.
Our study revealed that SSW administration resulted in reduced visceral sensitivity, improved defecation parameters, decreased intestinal transport velocity, and reduced intestinal permeability in IBS-D mice. Furthermore, SSW promotes the secretion of colonic mucus by enhancing autophagy and inhibiting ER stress. SSW treatment caused remodeling of the gut microbiome by increasing the abundance of Blautia, Muribaculum and Ruminococcus torques group.
SSW can improve intestinal barrier function by promoting autophagy and inhibiting ER stress, thus exerting a therapeutic effect on IBS-D.
Assessing ‘response’ to the low-FODMAP diet in irritable bowel syndrome: Should we be reporting harder primary endpoints?
2024, Clinical Nutrition
The low-FODMAP diet (LFD) has become almost synonymous with IBS care, yet the challenges associated with this rigorous therapeutic approach are often underacknowledged. Despite positive outcomes in RCTs, comparator groups frequently exhibit substantial response rates, raising questions about the definition of ‘response’. Whilst the assessment of response in drug trials has evolved to utilize the more stringent FDA/EMA primary clinical endpoints, trials of the LFD have not yet followed. The aim of this article is to opine whether the current approach to the measurement of clinical response to the LFD in clinical trials should be reconsidered.
A comprehensive literature review of LFD clinical trials from the past decade was conducted, focusing on recorded response metrics for primary clinical endpoints.
While response definitions vary, the 50-point IBS-SSS delta emerged as the predominant metric. Notably, no trials to date have adopted the more stringent primary clinical endpoints used in drug trials. Other response measures included binary response metrics (such as ‘adequate clinical response’), changes in visual analogue scales or stool form/output, reductions in abdominal pain, as well as changes the magnitude of the IBS-SSS delta. Whether these metrics correspond to a clinically meaningful improvement for the patient is less clear, and as such aligning patient-clinician expectations can be challenging.
A paradigm shift in the conceptualization of ‘response’ coupled with an emphasis on harder clinical endpoints in the context of clinical trials may serve to better justify the trade-off between symptom-improvement and the inherent challenges associated with this burdensome therapeutic approach.
Economic analysis of partially hydrolyzed guar gum (PHGG) for the treatment of patients receiving enteral nutrition
2024, Clinical Nutrition Open Science
Diarrhea is very common in patients receiving enteral nutrition. The principle of diarrhea treatment involves implementing dietary modifications, such as reduction of the fatty component, oral and probiotic supplementations, and increase of the fiber intake, aimed at mitigating the frequency and intensity of symptoms. In this context, partially hydrolyzed guar gum (PHGG) has emerged as a potential soluble fiber maximizing the effect against GI symptoms, particularly diarrhea. Among PHGG, NOVASOURCE® GI Control is an enteral nutrition formula indicated to improve the nutritional status and intestinal symptoms in patients with (risk of) malnutrition and intestinal barrier dysfunction, or intolerance to enteral nutrition. The objective of this economic analysis was to compare costs and effects of PHGG diet (taken with NOVASOURCE® GI Control) vs standard diet (SD, without fibers), in patients who are in need of enteral nutrition, in Italy.
Two different analyses were conducted to reflect the most typical settings where enteral nutrition is relevant: i) critically-ill patients admitted to the hospital for an acute, life-threatening condition; ii) medical or (post)surgical patients. A simple decision-tree analysis was developed, with some minor differences depending on the setting. Hospital perspective was used to evaluate PHGG cost-opportunity in the hospital for critically-ill patients setting, while the Italian National Health Service (NHS) to assess the product for medical or surgical patients, assuming they were predominantly treated in an outpatient setting. Health outcomes and costs of critically-ill hospitalized patients and medical or surgical patients treated in a healthcare facility were estimated over a time horizon of 20 (PHGG group) to 27 (SD arm) days and over 24 days, respectively.
In the critically-ill setting, the use of PHGG diet prevented ∼12 cases of diarrhea every N=100 cases treated (relative reduction: -35%). The higher acquisition costs needed for PHGG diet (+€2,992) were more than offset by savings in all the other cost items, such as costs of hospital stay, medical therapy, costs of consumables, and cost of professional care to manage diarrhea (total saving -€1,186,330). Similarly, in medical or surgical patients, the use of PHGG was found cost-saving vs SD (-€6,040), and also reduced the number of diarrhea cases (relative reduction: -60%).
The conducted economic analysis provides confidence that PHGG is a valuable and economically sustainable asset. Its utilization ensures not only adequate nutrition but also proves effective in mitigating diarrhea, thereby improving quality of life and limiting complication costs.
Dietary Interventions and Brain–Gut Disorders
2024, The Gut-Brain Axis, Second Edition
Several lines of evidence suggest that the gut microbiome may represent a valid target for new therapeutic interventions in relation to disorders of the gut–brain axis. Indeed, the concept of a microbiome–gut–brain axis has gained considerable traction in recent years. While several diseases and disorders may reflect disruption of, or dysfunction along, the microbiome–gut–brain axis this chapter will focus on one very common and challenging disorder long perceived as representing dysfunction along the gut–brain axis: irritable bowel syndrome (IBS). Recognizing the frequency with which patients report exacerbation of their IBS symptoms on eating there has been, of late considerable interest in diet in the treatment of IBS. A variety of dietary approaches have been advocated with the diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) achieving most traction. The physiological basis for its efficacy as well as evidence to support its efficacy are reviewed. While comparisons between the low FODMAP diet and other dietary approaches to IBS have yielded variable results, interest in the gluten-free diet has receded somewhat though it may be of benefit to certain select populations. Various therapeutic strategies have been employed to address gut microbial factors that may contribute to IBS and include probiotics, prebiotics, and postbiotics. With regard to prebiotics and probiotics, while a considerable volume of experimental data attests to their ability to address various pathophysiologic parameters relevant to IBS, the interpretation of clinical trials continues to pose challenges. Thus, while probiotics, in general, appear to be beneficial in IBS, less is known about ideal strain, preparation, and dosage; for prebiotics and postbiotics, data are scant but appear promising. More high-quality clinical trials are needed.
Factors influencing the quality of life in inflammatory bowel disease: A comprehensive review
2024, Disease-a-Month
Inflammatory bowel disease (IBD) is a group of chronic relapsing disorders, including Crohn's disease (CD) and ulcerative colitis (UC), which affects an increasing number of people worldwide. In the last few decades, the scientific world has witnessed many developments in IBD management by controlling debilitating symptoms and remaining in remission for more protracted periods. Even so, we still have a large population suffering from active IBD. An individual's quality of life (QoL) can be severely affected by IBD, like any other chronic illness. In this article, we have reviewed factors influencing the QoL in IBD patients, including chronic pain, diet, physical activity, and psychological factors like depression, anxiety, and stress symptoms. We also discussed the mechanisms of diet-microbial-immune system interaction, currently available dietary therapies for active CD and UC, and early psycho-social interventions that can reduce the disease burden and improve QoL in IBD patients.
Systematic review and meta-analysis of habitual intake of fermentable oligo-, di-, mono- saccharides and polyols in the general population and revisiting the low FODMAP diet concept
2024, Journal of Functional Foods
The present systematic review and meta-analysis summarized data on habitual intake of oligo-, di-, mono-saccharides and polyols from 71 studies (n = 138,653 subjects) using random-effects model. In the general population, overall habitual intake of total FODMAPs is 19.86 (95 % CI: 18.12, 21.6) g/d. No differences were observed on habitual intake of individual constituents of designated FODMAPs between healthy and those who are suffering with functional gastrointestinal disease and other GI disorders. Multiple meta-regression adjusted with macronutrient components showed that IBS-SSS score is positively correlated with lactose (R² = 77.78 %, P = 0.006) and total FODMAPs (R² = 78.48 %, P = 0.0052), but not other individual constituents of designated FODMAPs e.g. fructans, GOS, and total polyols. Macronutrient components such as fat (in 6 out of 6 models) and carbohydrate (in 5 out of 6 models) were positively associated with IBS-SSS score. Our findings add insight on current knowledge of FODMAPs habitual intake in the general population and showed that individual FODMAPs such as lactose and other macronutrient components (fat and carbohydrate) as a constituent significantly related to symptom severity.

View all citing articles on Scopus

: Author names in bold designate shared co-first authorship.

: Conflicts of interest These authors disclose the following: Susan Shepherd has published a book on food intolerances and several cookbooks related to the topic of the article, and Peter Gibson has published a book on food intolerances. The remaining authors disclose no conflicts.

: Funding This study was supported by the National Health and Medical Research Council of Australia, the Eva and Les Erdi Foundation, and by a scholarship from the Faculty of Medicine, Nursing and Health Sciences, Monash University (E.P.H.).

View full text

Original ResearchFull Report: Clinical—Alimentary TractA Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome

Background & Aims

Methods

Results

Conclusions

Section snippets

Participants

Participants

Discussion

Acknowledgments

Clin Nutr

J Am Diet Assoc

Clin Gastroenterol Hepatol

J Am Diet Assoc

J Am Diet Assoc

Self-reported food-related gastrointestinal symptoms in ibs are common and associated with more severe symptoms and reduced quality of life

Am J Gastroenterol

A dietary survey of patients with irritable bowel syndrome

J Hum Nutr Diet

Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial

Gut

Evidence-based dietary management of functional gastrointestinal symptoms: the FODMAP approach

J Gastroenterol Hepatol

Personal view: food for thought–western lifestyle and susceptibility to Crohn's disease. The FODMAP hypothesis

Aliment Pharmacol Ther

Carbohydrate malabsorption and the effect of dietary restriction on symptoms of irritable bowel syndrome and functional bowel complaints

Isr Med Assoc J

Discordant absorption of mannitol and sorbitol in patients with irritable bowel syndrome - a reflection of possible epithelial abnormalities?

J Gastroenterol Hepatol

Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon

Aliment Pharmacol Ther

Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome

J Gastroenterol Hepatol

Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome

J Hum Nutr Diet

Design of clinical trials evaluating dietary interventions in patients with functional gastrointestinal disorders

Am J Gastroenterol

Guidelines–Rome III diagnostic criteria for functional gastrointestinal disorders

J Gastrointestin Liver Dis

Original Research
Full Report: Clinical—Alimentary Tract
A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome