Low FODMAP Diet for Functional Gastrointestinal Symptoms in Quiescent Inflammatory Bowel Disease: A Systematic Review of Randomized Controlled Trials.

Maria G Grammatikopoulou,Konstantinos Gkiouras,Alastair Forbes,Stefanos T Papageorgiou,Theodora Papamitsou,Dimitrios G Goulis,Meletios P Nigdelis,Dimitrios P Bogdanos

doi:10.3390/nu12123648

Maria G Grammatikopoulou, Konstantinos Gkiouras + Show 6 more

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https://doi.org/10.3390/nu12123648

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Abstract

A low FODMAP diet (LFD) has been hypothesized to relieve symptoms of functional gastrointestinal disorders (FGD) in patients with inflammatory bowel disease (IBD). The aim of the study was to systematically review the literature for randomized controlled trials (RCTs) assessing the effectiveness of the LFD in patients with IBD and FGD. Four databases were searched, but a meta-analysis was not performed due to methodological and outcomes heterogeneity. Four RCTs fulfilled the criteria, with three having some concerns in their risk of bias assessment. All interventions compared the LFDs against a “typical” or sham diet, spanning in duration from 21 days to 6 weeks. Quality of life was improved in two RCTs, while revealing inconsistent findings in the third trial, based on different assessment tools. The fecal assays revealed non-significant findings for most variables (fecal weight, pH, water content, gene count, and gut transit time) and inconsistent findings concerning stool frequency and short-chain fatty acids concentration. Levels of fecal calprotectin, CRP, or T-cell phenotype did not differ between intervention and comparator arms. Two RCTs reported a reduction in abdominal pain, while results concerning pain duration and bloating were inconsistent. In one trial, energy intake was considerably reduced among LFD participants. Regarding gut microbiota, no differences were noted. A considerable degree of methodological and outcome heterogeneity was observed, paired with results inconsistency. The available data are not sufficient to justify the claim that an LFD induces relief of FGD symptoms, although it may pave the way to a placebo response.

Highlights

Since the low FODMAP diet (LFD) was designed [7], its adoption has gained traction and today, it is often recommended in clinical practice [8], with evidence synthesis indicating that adoption of the LFD reduces symptoms of irritable bowel syndrome (IBS) and functional GI symptoms (FGS) in general [9,10,11,12]
The Halmos et al trial originated in Australia [23], the Cox et al randomized controlled trials (RCTs) was conducted in the UK [24,25], the Bodini and associates trial was Italian-based [26], and the Pedersen et al RCT was implemented in Denmark [27,28,29]
The trial of Halmos et al [23] reported only participant blinding in the manuscript text, while referencing a previous study performed using double-blind masking [30], the principle diagnoses of participants between the two studies failed to match

Summary

Introduction

The form and nutrient content of ingested food may trigger a variety of gastrointestinal (GI)symptoms through a matrix of different mechanisms, including bacterial fermentation altering gut microbiota, the induction of distinct osmotic load effects in the small bowel and colon, the production of gas in the GI tract, and the activation or suppression of immune responses [1,2].Putative anti-inflammatory foods and elimination diets, including the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) diet (LFD), have been proposed as complementary regimes alleviating symptoms of functional gastrointestinal disorders (FGD) [3,4,5,6].Since the LFD was designed [7], its adoption has gained traction and today, it is often recommended in clinical practice [8], with evidence synthesis indicating that adoption of the LFD reduces symptoms of irritable bowel syndrome (IBS) and functional GI symptoms (FGS) in general [9,10,11,12].FGS, are frequent among patients with inflammatory bowel diseases (IBD). Putative anti-inflammatory foods and elimination diets, including the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) diet (LFD), have been proposed as complementary regimes alleviating symptoms of functional gastrointestinal disorders (FGD) [3,4,5,6]. Since the LFD was designed [7], its adoption has gained traction and today, it is often recommended in clinical practice [8], with evidence synthesis indicating that adoption of the LFD reduces symptoms of irritable bowel syndrome (IBS) and functional GI symptoms (FGS) in general [9,10,11,12]. FGS, are frequent among patients with inflammatory bowel diseases (IBD). A few studies have examined the LFD among IBD patients with FGD, the subsequent guideline recommendations advocating the adoption of an LFD as a possible treatment appear weak and of low evidence [16,17,18]. One meta-analysis [19] of two randomized controlled trials (RCTs) and an equal number of case-control studies supported use of the LFD; since its publication, more research has emerged, the results of which have not yet been integrated into any synthesis of evidence

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