Challenges of the low FODMAP diet for managing irritable bowel syndrome and approaches to their minimisation and mitigation

Dietary restriction of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) is clinically effective and a commonly utilised approach in the management of functional symptoms in irritable bowel syndrome. Despite this, the low FODMAP diet has a number of challenges: it can alter the gut microbiota; impact nutrient intake and diet quality; is complex to understand; requires the patient to be adequately supported to follow the diet accurately and safely; and lastly, not all patients respond to the diet. The current review highlights the evidence for the clinical effectiveness of the low FODMAP diet, but focusses on the challenges associated with the diet to the patient, health professionals and the wider healthcare service. Finally, the review discusses research findings and practical guidance for how these challenges can be minimised and mitigated. The low FODMAP diet is a useful management strategy for irritable bowel syndrome, with data from clinical trials suggesting a 50–80% response rate, and when administered appropriately, the challenges to implementing the diet can be overcome so that these outcomes can be realised effectively and safely in clinical practice.

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Clinical effectiveness and economic costs of group versus one-to-one education for short-chain fermentable carbohydrate restriction (low FODMAP diet) in the management of irritable bowel syndrome

Journal of Human Nutrition and Dietetics ◽

10.1111/jhn.12318 ◽

2015 ◽

Vol 28 (6) ◽

pp. 687-696 ◽

Cited By ~ 48

Author(s):

L. Whigham ◽

T. Joyce ◽

G. Harper ◽

P. M. Irving ◽

H. M. Staudacher ◽

...

Keyword(s):

Irritable Bowel Syndrome ◽

Group Versus ◽

Clinical Effectiveness ◽

Short Chain ◽

Carbohydrate Restriction ◽

Economic Costs ◽

One To One ◽

Irritable Bowel ◽

Fodmap Diet

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Altered gastrointestinal microbiota in irritable bowel syndrome and its modification by diet: probiotics, prebiotics and the low FODMAP diet

Proceedings of The Nutrition Society ◽

10.1017/s0029665116000021 ◽

2016 ◽

Vol 75 (3) ◽

pp. 306-318 ◽

Cited By ~ 42

Author(s):

Heidi M. Staudacher ◽

Kevin Whelan

Keyword(s):

Irritable Bowel Syndrome ◽

Dietary Intervention ◽

Clinical Effectiveness ◽

Gastrointestinal Microbiota ◽

Probiotic Supplementation ◽

Symptom Profile ◽

Exciting Opportunity ◽

Fermentable Carbohydrates ◽

Irritable Bowel ◽

Fodmap Diet

Irritable bowel syndrome (IBS) is a functional bowel disorder characterised by abdominal pain or discomfort with disordered defecation. This review describes the role of the gastrointestinal (GI) microbiota in the pathogenesis of IBS and how dietary strategies to manage symptoms impact on the microbial community. Evidence suggests a dysbiosis of the luminal and mucosal colonic microbiota in IBS, frequently characterised by a reduction in species of Bifidobacteria which has been associated with worse symptom profile. Probiotic supplementation trials suggest intentional modulation of the GI microbiota may be effective in treating IBS. A smaller number of prebiotic supplementation studies have also demonstrated effectiveness in IBS whilst increasing Bifidobacteria. In contrast, a novel method of managing IBS symptoms is the restriction of short-chain fermentable carbohydrates (low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet). Studies consistently demonstrate clinical effectiveness of the low FODMAP diet in patients with IBS. However, one unintentional consequence of this dietary intervention is its impact on the microbiota. This leads to an interesting paradox; namely, increasing luminal Bifidobacteria through probiotic supplementation is associated with a reduction in IBS symptoms while in direct conflict to this, the low FODMAP diet has clinical efficacy but markedly reduces luminal Bifidobacteria concentration. Given the multifactorial aetiology of IBS, the heterogeneity of symptoms and the complex and diverse nature of the microbiome, it is probable that both interventions are effective in patient subgroups. However combination treatment has never been explored and as such, presents an exciting opportunity for optimising clinical management, whilst preventing potentially deleterious effects on the GI microbiota.

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Diarrhea Predominant-Irritable Bowel Syndrome (IBS-D): Effects of Different Nutritional Patterns on Intestinal Dysbiosis and Symptoms

Nutrients ◽

10.3390/nu13051506 ◽

2021 ◽

Vol 13 (5) ◽

pp. 1506

Author(s):

Annamaria Altomare ◽

Claudia Di Rosa ◽

Elena Imperia ◽

Sara Emerenziani ◽

Michele Cicala ◽

...

Keyword(s):

Irritable Bowel Syndrome ◽

Intestinal Microbiota ◽

Gastrointestinal Disorder ◽

Additional Energy ◽

Nutritional Advice ◽

Intestinal Dysbiosis ◽

Gi Symptoms ◽

Mutualistic Relationship ◽

Irritable Bowel ◽

Fodmap Diet

Irritable Bowel Syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by abdominal pain associated with defecation or a change in bowel habits. Gut microbiota, which acts as a real organ with well-defined functions, is in a mutualistic relationship with the host, harvesting additional energy and nutrients from the diet and protecting the host from pathogens; specific alterations in its composition seem to play a crucial role in IBS pathophysiology. It is well known that diet can significantly modulate the intestinal microbiota profile but it is less known how different nutritional approach effective in IBS patients, such as the low-FODMAP diet, could be responsible of intestinal microbiota changes, thus influencing the presence of gastrointestinal (GI) symptoms. The aim of this review was to explore the effects of different nutritional protocols (e.g., traditional nutritional advice, low-FODMAP diet, gluten-free diet, etc.) on IBS-D symptoms and on intestinal microbiota variations in both IBS-D patients and healthy subjects. To date, an ideal nutritional protocol does not exist for IBS-D patients but it seems crucial to consider the effect of the different nutritional approaches on the intestinal microbiota composition to better define an efficient strategy to manage this functional disorder.

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Irritable bowel syndrome: new insights into symptom mechanisms and advances in treatment

F1000Research ◽

10.12688/f1000research.7992.1 ◽

2016 ◽

Vol 5 ◽

pp. 780 ◽

Cited By ~ 15

Author(s):

Robin Spiller

Keyword(s):

Irritable Bowel Syndrome ◽

New Agents ◽

Enteric Nerves ◽

Inflammatory Bowel ◽

Magnetic Resonance Imaging Mri ◽

Irritable Bowel ◽

Fodmap Diet ◽

And Function ◽

The Impact

Despite being one of the most common conditions leading to gastroenterological referral, irritable bowel syndrome (IBS) is poorly understood. However, recent years have seen major advances. These include new understanding of the role of both inflammation and altered microbiota as well as the impact of dietary intolerances as illuminated by magnetic resonance imaging (MRI), which has thrown new light on IBS. This article will review new data on how excessive bile acid secretion mediates diarrhea and evidence from post infectious IBS which has shown how gut inflammation can alter gut microbiota and function. Studies of patients with inflammatory bowel disease (IBD) have also shown that even when inflammation is in remission, the altered enteric nerves and abnormal microbiota can generate IBS-like symptoms. The efficacy of the low FODMAP diet as a treatment for bloating, flatulence, and abdominal discomfort has been demonstrated by randomized controlled trials. MRI studies, which can quantify intestinal volumes, have provided new insights into how FODMAPs cause symptoms. This article will focus on these areas together with recent trials of new agents, which this author believes will alter clinical practice within the foreseeable future.

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Clinical Application of Dietary Therapies in Irritable Bowel Syndrome

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld.2014.1121.273.avy ◽

2018 ◽

Vol 27 (3) ◽

pp. 307-316 ◽

Cited By ~ 12

Author(s):

Anupam Rej ◽

Amanda Avery ◽

Alexander Charles Ford ◽

Anne Holdoway ◽

Matthew Kurien ◽

...

Keyword(s):

Irritable Bowel Syndrome ◽

Randomized Trials ◽

Individual Therapy ◽

Dietary Therapy ◽

Round Table Discussion ◽

Mesh Terms ◽

Number Of Patients ◽

Significant Difference ◽

Irritable Bowel ◽

Fodmap Diet

Background & Aims: Diet appears to play a pivotal role in symptom generation in Irritable Bowel Syndrome (IBS). First line dietary therapy for IBS has focused on advice concerning healthy eating and lifestyle management. Research recently has focused on the role of a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs), gluten free (GFD) and wheat free (WFD) diets for the relief of symptoms in IBS.Methods: A round table discussion with gastroenterologists and dietitians with a specialist interest in dietary therapies in IBS was held in Sheffield, United Kingdom in May 2017. Existing literature was reviewed. PubMed and EMBASE were searched with the MeSH terms irritable bowel syndrome/diet/diet therapy/gluten/low FODMAP in different combinations to identify relevant articles. A consensus on the application of these dietary therapies into day-to-day practice was developed. Results: Fourteen randomized trials in IBS evaluating the low FODMAP diet (n studies = 9), GFD (n = 4) and WFD (n = 1) were included in this review. The total number of patients recruited from randomized trials reviewed was: n=580 low FODMAP diet (female, n=430), n=203 GFD (female, n=139), n=276 WFD (female, n=215). There was no significant difference in the gender of patients recruited for both the low FODMAP and GFD randomized studies (p=0.12). The response rate in the literature to a low FODMAP diet ranged between 50-76%, and to GFD ranged between 34-71%. Percentage of IBS patients identified as wheat sensitive was reported as 30% in the literature. Conclusion: There are no head-to-head trials to date utilizing the low FODMAP diet, GFD and WFD for dietary treatment of IBS and still a number of concerns for diets, including nutritional inadequacy and alteration of the gut microbiota. The consensus suggests that there is evidence for the use of the low FODMAP diet, GFD and WFD as dietary therapies for IBS; the decision-making process for using each individual therapy should be directed by a detailed history by the dietitian, involving the patient in the process.

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Letter: bias in clinical trials of the symptomatic effects of the low FODMAP diet for irritable bowel syndrome-getting the facts right

Alimentary Pharmacology & Therapeutics ◽

10.1111/apt.14150 ◽

2017 ◽

Vol 46 (3) ◽

pp. 385-386 ◽

Cited By ~ 3

Author(s):

P. R. Gibson ◽

E. P. Halmos ◽

J. G. Muir

Keyword(s):

Clinical Trials ◽

Irritable Bowel Syndrome ◽

Irritable Bowel ◽

Fodmap Diet

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Applying a Low-FODMAP Dietary Intervention to a Female Ultraendurance Runner With Irritable Bowel Syndrome During a Multistage Ultramarathon

International Journal of Sport Nutrition and Exercise Metabolism ◽

10.1123/ijsnem.2017-0398 ◽

2019 ◽

Vol 29 (1) ◽

pp. 61-67 ◽

Cited By ~ 5

Author(s):

Stephanie K. Gaskell ◽

Ricardo J.S. Costa

Keyword(s):

Irritable Bowel Syndrome ◽

Dietary Intervention ◽

Gastrointestinal Symptoms ◽

Irritable Bowel Syndrome Symptom ◽

Carbohydrate Intake ◽

Severe Nausea ◽

Dietary Analysis ◽

Irritable Bowel ◽

Fodmap Diet ◽

The Impact

Malabsorption of fermentable oligo-, di-, mono-saccharides and polyols (FODMAPs) in response to prolonged exercise may increase incidence of upper and lower gastrointestinal symptoms (GIS), which are known to impair exercise performance. This case study aimed to explore the impact of a low-FODMAP diet on exercise-associated GIS in a female ultraendurance runner diagnosed with irritable bowel syndrome, competing in a 6-day 186.7-km mountainous multistage ultramarathon (MSUM). Irritable bowel syndrome symptom severity score at diagnosis was 410 and following a low-FODMAP diet (3.9 g FODMAPs/day) it reduced to 70. The diet was applied 6 days before (i.e., lead-in diet), and maintained during (5.1 g FODMAPs/day) the MSUM. Nutrition intake was analyzed through dietary analysis software. A validated 100-mm visual analog scale quantified GIS incidence and severity. GIS were modest during the MSUM (overall mean ± SD: bloating 27 ± 5 mm and flatulence 23 ± 8 mm), except severe nausea (67 ± 14 mm) experienced throughout. Total daily energy (11.7 ± 1.6 MJ/day) intake did not meet estimated energy requirements (range: 13.9–17.9 MJ/day). Total daily protein [1.4 ± 0.3 g·kg body weight (BW)−1·day−1], carbohydrate (9.1 ± 1.3 g·kg BW−1·day−1), fat (1.1 ± 0.2 g·kg BW−1·day−1), and water (78.7 ± 6.4 ml·kg BW−1·day−1) intakes satisfied current consensus guidelines, except for carbohydrates. Carbohydrate intake during running failed to meet recommendations (43 ± 9 g/hr). The runner successfully implemented a low-FODMAP diet and completed the MSUM with minimal GIS. However, suboptimal energy and carbohydrate intake occurred, potentially exacerbated by nausea associated with running at altitude.

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