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World Gastroenterology Organisation Global Guidelines: Diet and the Gut.

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The Role of Low FODMAP Diet in the Management of Irritable Bowel Syndrome

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A low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet is frequently applied to patients with irritable bowel syndrome (IBS) as a treatment to reduce functional gastrointestinal symptoms, with evidence of its efficacy mounting worldwide.1, 2 The success of the dietary therapy is now frequently applied to patients with inflammatory bowel disease (IBD) and co-existing functional symptoms. Evidence for application of a low FODMAP diet in the IBD population is limited to a retrospective study of patients with quiescent IBD and IBS-like symptoms, in which more than 50% of patients had a reduction of symptoms.3 While beneficial for symptom reduction, there is evidence suggesting that a low FODMAP diet also has negative effects on microbiota. This was first suggested in a trial where a dietitian-taught low FODMAP diet reduced relative abundance of fecal Bifidobacteria spp. in IBS subjects compared with parallel cohort of IBS subjects on their habitual diet.4 A more closely controlled trial that compared fecal bacteria of IBS and healthy subjects after being provided two diets that varied only in FODMAP content showed that a low FODMAP diet was associated with reduction of total fecal bacterial load and specific reduction of the highly butyrate-producing Clostridium cluster XIVa and Akkermansia muciniphila, a likely favorable bacteria that promotes short-chain fatty acid production and an increase in the mucus-degrading Ruminococcus torques.5 The application of a low FODMAP diet may raise concerns in the IBS population if applied long term; however, risk to an IBD population may be more significant. Literature suggests that the changes in fecal bacterial seen from a reduced FODMAP intake seem to mimic those seen in patients with Crohn's disease. Patients with Crohn's disease are more likely to have reduced butyrate-producing bacteria, Bifidobacteria spp. and A. muciniphila and increase R. torques and Ruminococcus gnavus.6-8 One bacterium of specific interest in a Crohn's Disease population is the butyrate-producing Faecalibacterium prausnitzii, as mucosal F. prausnitzii has predicted onset of active disease.9 Similarly, in vitro and animal models suggest that A. muciniphila may also predict Crohn's disease activity.8, 10 A low FODMAP diet may further impact negatively on microbiota of patients with Crohn's disease, a population already at risk of dysbiosis. With data indicating that caution should be taken in applying a low FODMAP diet, two different approaches may be used in applying an FODMAP restriction for treatment of functional gut symptoms; the ‘top-down’ or the ‘bottom-up’ approach. The more traditional top-down approach involves the patient restricting all or most foods considered to contain FODMAPs for a four-week to eight-week period. Then, if symptom benefit is seen, dietary liberalization is guided through using set food and dose challenges or general recommendations describing FODMAP dosing across restricted foods. This top-down approach is best suited to patients where the success of a low FODMAP diet or the type or amount of FODMAP tolerance is uncertain; in patients who do not normally eat a lot of FODMAPs or who are very symptomatic; or in patients who would prefer this approach. Conversely, the bottom-up approach involves reducing specific FODMAPs or a few foods that are very high in FODMAPs for a time period then further restriction of foods if necessary. Arguably, this bottom-up approach should be applied in all patients who are at risk of dysbiosis, including patients with IBD. Other indications for this more gentle restriction include patients at risk of nutritional inadequacy or who have other dietary restrictions, which may again encompass the IBD population. Because of the complex and individual nature of an FODMAP restriction, implementation should be done in guidance with a dietitian well versed in IBD, IBS, and dietary FODMAPs. In addition to appropriate FODMAP manipulation, a dietitian will assess and closely monitor nutritional adequacy with dietary restriction and manage as appropriate, including patients in whom nutrient absorption is impaired or dietary intake is altered.

A diet low in poorly absorbed, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) is now considered as an effective strategy for symptoms control in patients with irritable bowel syndrome (IBS). The low FODMAP diet is administered in three phases, namely restriction of all dietary FODMAPs followed by rechallenge and then reintroduction of specific FODMAPs according to the tolerance of patients. A dietician should be involved in patients in whom a low FODMAP diet is planned. While restricting high FODMAPs, it is pertinent that patients are advised a well-balanced diet and suitable alternatives with low FODMAP contents in each food groups are prescribed. Strict adherence to a low FODMAP diet has been shown to improve symptoms, stool output, quality of life, and the overall well-being of patients with IBS. For those who do not respond to this dietary approach, a normal diet may be initiated and other treatment strategies (dietary or nondietary) should be considered. Interestingly, the low FODMAP diet has also been tried in other functional disorders, nonceliac gluten sensitivity, and even inflammatory bowel disease. Since the concept of FODMAP is relatively new, there is only limited data on the content of FODMAP in the Indian food items and there is a need to address this question. There is also a need for well-designed and adequately powered studies to explore the efficacy of low FODMAP diet in patients with IBS. In the present review article, we have compiled all the relevant information about FODMAPs with an objective to provide comprehensive information on FODMAPs to a physician.

Background and Aim: To evaluate the usefulness of a low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) diet on patients with irritable bowel syndrome (IBS), non-active inflammatory bowel diseases (IBD), and celiac disease (CD) on a gluten-free diet (GFD). Methods: Dietetic interventional prospective study. IBS, IBD, and CD subjects were evaluated to check if they fulfilled the Rome III criteria. Each subject was educated to follow a low FODMAP diet after being evaluated by filling out questionnaires that assessed the quality of life (QoL) and symptoms experienced (IBS-SSS and SF-36), and was reevaluated after 1 and 3 months. Results: One hundred twenty-seven subjects were enrolled: 56 with IBS, 30 with IBD, and 41 with CD. IBS-SSS showed that abdominal symptoms improved after 1 and 3 months of diet in all subjects, with significant difference among the 3 groups at T0 (average scores IBS: 293 ± 137, IBD: 206 ± 86, CD: 222 ± 65, p < 0.001), but no difference at T3 (IBS: 88 ± 54, IBD: 73 ± 45, CD: 77 ± 49, p = ns). By analyzing the SF-36 questionnaire, we did not observe any difference between the 3 groups, in terms of response to diet (p = ns), we observed a clinical improvement from T0 to T3 for most of the questionnaire’s domains. Conclusions: A low FODMAP diet could be a valid option to counter ­abdominal symptoms in patients with IBS, non-active IBD, or CD on a GFD, and thus, improve their QoL and social ­relations.

A child's diet has an important impact on their quality of life, and with functional gastrointestinal disorders becoming an increasing issue, a child's diet has become recognised as an area to be investigated in how to treat such disorders. Katarzyna Miroslawa Boradyn and Katarzyna Eufemia Przybylowicz from the University of Warmia and Mazury explore the potential of a low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet as an effective treatment for these disorders.Functional gastrointestinal disorders (FGID) are one of the most prevalent disorders diagnosed by paediatricians.[1] Within this wide range, functional abdominal pain (FAP) is a disorder particularly common among school-age children and it can substantially affect their quality of life.[2] A child's diet has a significant influence on the occurrence of symptoms.[1] So far, previously tested therapies have not provided an effective treatment that would alleviate the symptoms and improve the microbiota.[2] Researchers from Monash University in Australia developed a diet based on the elimination, or at least a reduction, of foods high in FODMAP. These compounds are characterised by high resistance to digestion, low level of absorption in the gastrointestinal tract and long fermentation in the gut.[1],[3] Depending on the type of sugar, FODMAPs are found in various foods. Fructo-oligosaccharides are contained among others in wheat, rye, onions, garlic and artichokes and galacto-oligosaccharides are a component of legumes. Lactose is mainly found in milk and other dairy products. The richest food sources of fructose are honey, apples, pears, watermelon and mango; and of sorbitol are: stone fruits, apples, pears and sugar-free mints/gum. Mannitol is found in sugar-free mints/gum and is also one of the components in mushrooms and cauliflower.[4]Existing evidence suggests that the use of a low FODMAP diet is associated with the reduction of the symptoms of irritable bowel syndrome (IBS), Crohn's disease and coexisting functional symptoms.[3],[4] Moreover, an experimental study in children confirmed that a low FODMAP diet reduced abdominal pain in children with IBS by 50%.[1] Interestingly, to our knowledge, no previous studies have investigated the impact of low FODMAP diet in children with FAP.Currently, two approaches have been suggested in planning a low FODMAP diet: bottom-up and top-down. The bottom-up method allows you to specify the patient's limit of FODMAP and is a gradual elimination of single products (or groups of products) from the diet until the symptoms have been alleviated. This progressive method can be applied in (1) patients who have not been diagnosed with IBS, but experience symptoms affecting their life quality; (2) patients who have already started elimination of other components from their diet; or (3) patients who struggle to follow a diet low in FODMAP. …

The purpose of this study is to evaluate the efficacy of a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) in adolescents with irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) in a non-guided setting, resembling clinical practice. This prospective multicenter cohort study conducted in 13 centers included patients aged 12–18 years diagnosed with IBS or FAP-NOS. Patients received educational material on FODMAPs, including extensive lists of high and low FODMAP foods and additional online information. They were instructed to replace high FODMAP foods with low FODMAP alternatives for the duration of 4 weeks. No dietician was consulted. The primary end point was the proportion of patients with treatment success (≥ 30% reduction of abdominal pain intensity) at 4 weeks. The key secondary outcome was adequate relief of IBS/FAP-NOS symptoms. Of the 325 included patients, 81 patients (24.9%) achieved treatment success (≥ 30% reduction of abdominal pain intensity) after 4 weeks, with higher rates in patients with IBS (29.3%) than FAP-NOS (16.8%, OR 2.16 (1.04–4.48)). Adequate relief was reported in 51 patients (15.7%). There was a significant decrease in abdominal pain intensity (2.2 (1.1) vs. 2.5 (1.0), P < 0.001), daily bloating (2.4 (2.1) vs. 2.8 (2.3), P < 0.001), and flatulence (2.4 (2.1) vs. 2.8 (2.3), P = 0.001). Adverse events were mild and infrequent.Conclusion: The low FODMAP diet in a non-guided setting, mimicking clinical practice, yielded treatment success in almost 30% adolescents with IBS and 17% in FAP-NOS, suggesting it may not be the first treatment option for these patients.Trial registration: EUCTR2015-003293–32-NL.What is Known:• Irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) are common disorders in children which negatively impact quality of life.• While a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has demonstrated effectiveness in adult IBS, its efficacy in pediatric IBS and FAP-NOS remains uncertain.• Clinical application of the low FODMAP diet often occurs without dietician consultation, contrary to controlled trial settings.What is New:• The low FODMAP diet, without dietician guidance, resulted in treatment success in almost 30% of adolescents with IBS and only 17% with FAP-NOS.• With only 15.7% of participants achieving adequate relief of IBS/FAP-NOS symptoms, the non-guided low FODMAP diet may not be the first treatment option for pediatric IBS and FAP-NOS.

Emerging evidence indicates that the consumption of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) may result in symptoms in some patients with irritable bowel syndrome (IBS). The present study aimed to determine whether a low FODMAP diet is effective for symptom control in patients with IBS and to compare its effects with those of standard dietary advice based on the UK National Institute for Health and Clinical Excellence (NICE) guidelines. Consecutive patients with IBS who attended a follow-up dietetic outpatient visit for dietary management of their symptoms were included. Questionnaires were completed for patients who received standard (n = 39) or low FODMAP dietary advice (n = 43). Data were recorded on symptom change and comparisons were made between groups. In total, more patients in the low FODMAP group reported satisfaction with their symptom response (76%) compared to the standard group (54%, P = 0.038). Composite symptom score data showed better overall symptom response in the low FODMAP group (86%) compared to the standard group (49%, P < 0.001). Significantly more patients in the low FODMAP group compared to the standard group reported improvements in bloating (low FODMAP 82% versus standard 49%, P = 0.002), abdominal pain (low FODMAP 85% versus standard 61%, P = 0.023) and flatulence (low FODMAP 87% versus standard 50%, P = 0.001). A low FODMAP diet appears to be more effective than standard dietary advice for symptom control in IBS.

Back in the dark ages when we had little to offer the patient with irritable bowel syndrome (IBS) other than a pat on the head (the origin of the problem; as in ‘it's all in your head’) and an anti-spasmodic that made your mouth dry, fibre assumed significant status in the gastroenterologist's therapeutic armamentarium. This was a time when the many benefits of fibre intake to health maintenance and disease prevention had come to be appreciated and it was assumed, given its physiological effects on gut function, that IBS sufferers should benefit. Clinical trials revealed a more complex picture; yes, some did achieve benefit but many did not appreciate the exacerbation of bloating and flatulence that ensued as their fibre intake was increased.1 Within the constraints imposed by the quality of many of the original trials, a recent systematic review has clarified the picture to some extent by indicating that, in IBS, soluble but not insoluble fibre is of benefit and that constipation is the symptom that is most likely to improve with supplementation.2 Now, we enter a new phase in the dietary management of IBS with the appreciation of the negative impact of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) on symptoms and the demonstration of symptomatic benefits from the institution of a low-FODMAP diet.3 As foods that contain FODMAPs (fruits, vegetables and grains) represent a major source of dietary fibre for many, the institution of a low-FODMAP diet would appear at first flush to fly in the face of conventional wisdom, both in terms of the management of IBS and general health. Allied to the latter are concerns regarding the long-term impact of a low-FODMAP diet, which inevitably removes an important substrate for bacterial metabolism, on the integrity of the gut microbiome4; are we literally robbing Peter to pay Paul? Laatikainen and colleagues have developed an ingenious solution to the fibre/FODMAPs dichotomy.5 Using a specially prepared rye bread that was low in FODMAPs, they still managed to deliver the same amount of dietary fibre as regular bread, yet drastically reduced the amounts of fructans, mannitol and resistant starch. Those who were randomized to the low-FODMAP bread experienced, in comparison to those who consumed regular rye bread, modestly lower scores in several key IBS symptoms, although without any significant impact on the IBS symptom severity score (IBS-SSS) or quality of life. As expected, colonic fermentation, assessed by breath hydrogen excretion, was lower among those randomized to the low-FODMAP bread. This clever study has demonstrated that you can go low-FODMAP and high fibre and still experience improvements in symptoms such as flatulence, cramps, pain and ‘stomach rumbling’; unfortunately, while distension is a component of the IBS-SSS, bloating and distension, so prevalent in IBS, and so frequently exacerbated by fibre, were not reported individually. It is also noteworthy that constipation-predominant IBS subjects were excluded, a group expected to benefit most from fibre. Not surprisingly, therefore, no change in stool symptomatology was evident. Parenthetically, given the debate that surrounds the impact of a gluten-free diet in IBS,6 it should be noted that, although rye is contraindicated for those who have coeliac disease and would be expected to exacerbate symptoms, if a gluten-type response was operative in IBS, those who ingested the low-FODMAP rye bread still derived benefit. This observation supports the contention that it is the removal of fructans (an important FODMAP in rye as well as wheat), and not gluten equivalents, that mediate the benefits of a gluten-free diet in IBS.6 A few words of caution. The study did not meet its primary endpoint and individual symptom benefits were selective and modest. Changes from baseline in individual symptoms are not presented; were they simply less severely exacerbated in the low-FODMAP rye bread group. Furthermore, long-term effects on symptoms and the microbiota are unknown. Are we on the verge of a culinary revolution where the low-FODMAP kitchen and bakery will rival the gluten-free industry? Perhaps not yet, but this innovative study does provide a novel approach to the dietary management of IBS, an approach so dearly sought by its sufferers. Declaration of personal and funding interests: EMMQ has served as an advisory board member for Alimentary Health, Allergan, Biocodex, Rhythm, Salix, Vibrant and served as a speaker for Procter and Gamble, Biocodex and has Research Support from Rhythm, Theravance, Vibrant.

Gastrointestinal tract involvement in systemic sclerosis: The roles of diet and the microbiome

A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) is a promising therapeutic approach to reduce gastrointestinal symptoms associated with irritable bowel syndrome (IBS). However, a shift toward a more sustainable, healthy diet with higher inclusion of whole-grain cereals (i.e., wheat, rye, barley) and pulses, naturally rich in FODMAPs, poses a severe challenge for susceptible individuals. Dietary restriction of fermentable carbohydrates (commonly called the "low FODMAP diet") has received significant consideration. Hence, the development of functional low FODMAP products is emerging in food science and the food industry. In this review, we evaluate the most promising yet neglected (bio)-technological strategies adopted for modulating the FODMAP contents in complex food systems and the extent of their uptake in the global food market. We extensively investigated the global low FODMAP market, contrasted with the status quo in food science and discussed the key principles and concomitant challenges of targeted FODMAP reduction strategies. Powerful tools are available which are based either on the use of ingredients where FODMAPs have been physically removed (e.g., by membrane filtration) or biotechnologically reduced during the food processing, mediated by added enzymes, microbial enzymes during a fermentation process, and seed endogenous enzymes. However,<10% of the small market of functional products with a low FODMAP claim (total ∼800 products) used any of the targeted FODMAP reduction techniques. The global market is currently dominated by gluten-free products, which are naturally low in FODMAPs and characterized by inferior sensory attributes.

The low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet is an effective dietitian-led treatment for irritable bowel syndrome (IBS). An increasing demand of IBS patient referrals has warranted group FODMAP education led by specialist dietitians. Psychological co-morbidities are common in IBS, although how the low FODMAP diet influences psychological outcomes is not understood. The present study aimed to evaluate symptom related outcomes of the diet following group education and assess its effect on psychological profiles. An observational, prospective study was conducted in 55 IBS patients who attended FODMAP Restriction and FODMAP Reintroduction group sessions. Data were collected at baseline and follow-up after FODMAP Restriction and analysed using descriptive and McNemar's tests. Primary outcome was evaluated by IBS Symptom Severity Score (IBS-SSS). Secondary psychological outcomes included anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and risk of eating disorder questionnaire (SCOFF). After FODMAP Restriction, 27 of 55 (54%) patients reported clinically relevant symptom improvement, as defined by a reduction in the IBS-SSS ≥50points, whereas no differences were recorded in the proportion of patients identified with clinical anxiety (p = 1.000) or clinical depression (p = 0.375). Positively, no increased risk of an eating disorder was observed. The present study provides data supporting the efficacy of the low FODMAP diet in IBS patients who attended dietitian led group education settings in tertiary care. Clinically significant improvements in gastrointestinal symptoms were observed, although with no impact on clinical levels of anxiety, depression or the risk of an eating disorder.

Objectives:Altering FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) intake has substantial effects on gut microbiota. This study aimed to investigate effects of altering FODMAP intake on markers of colonic health in patients with Crohn's disease.Methods:After evaluation of their habitual diet, 9 patients with clinically quiescent Crohn's disease were randomised to 21 days of provided low or typical (“Australian”) FODMAP diets with ≥21-day washout in between. Five-day fecal samples were collected at the end of each diet and analyzed for calprotectin, pH, short-chain fatty acids (SCFA) and bacterial abundance. Gastrointestinal symptoms were recorded daily.Results:Eight participants collected feces and were adherent to the diets. FODMAP intake differed across the three dietary periods with low<habitual<Australian diet. SCFA, pH and total bacterial abundance remained unaltered, but relative abundance was higher for butyrate-producing Clostridium cluster XIVa (P=0.008) and mucus-associated Akkermansia muciniphila (P=0.016), and lower for Ruminococcus torques (P=0.034) during the Australian compared with low FODMAP diet. Results during habitual diet were similar to the low FODMAP intervention, but significantly different to the Australian diet. The diets had no effects on calprotectin, but symptoms doubled in severity with the Australian diet (n=9; P<0.001).Conclusions:In clinically quiescent Crohn's disease, altering dietary FODMAP intake is associated with marked changes in fecal microbiota, most consistent with a prebiotic effect of increasing FODMAPs as shown in an irritable bowel/healthy cohort. This strategy might be favorable for gut health in Crohn's disease, but at the cost of inducing symptoms.