Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals?
Therap Adv Gastroenterol. 2012 Jul ;5(4):261-8. PMID: 22778791
Jacqueline S Barrett, Peter R Gibson
Eastern Health Clinical School, Monash University, Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia.
Food intolerance in irritable bowel syndrome (IBS) is increasingly being recognized, with patients convinced that diet plays a role in symptom induction. Evidence is building to implicate fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) in the onset of abdominal pain, bloating, wind and altered bowel habit through their fermentation and osmotic effects. Hypersensitivity to normal levels of luminal distension is known to occur in patients with IBS, with consideration of food chemical intolerance likely to answer many questions about this physiological process. This paper summarizes the evidence and application of the most common approaches to managing food intolerance in IBS: the low-FODMAP diet, the elimination diet for food chemical sensitivity and others including possible noncoeliac gluten intolerance.
Article Published Date : Jun 30, 2012
The role of diet in the pathogenesis and management of irritable bowel syndrome (Review).
Int J Mol Med. 2012 May ;29(5):723-31. Epub 2012 Feb 24. PMID: 22366773
M El-Salhy, H Ostgaard, D Gundersen, J G Hatlebakk, T Hausken
Most patients with irritable bowel syndrome (IBS) believe that diet plays a significant role in inducing IBS symptoms and desire to know what foods to avoid. It has been found that the intake of calories, carbohydrates, proteins and fat by IBS patients does not differ from that of the background population. IBS patients were found to avoid certain food items that are rich in fermentable oligo-, di- and monosacharides and polyols (FODMAPs), but they did have a high consumption of many other FODMAP-rich food items. The diet of IBS patients was found to consist of a low calcium, magnesium, phosphorus, vitamin B2 and vitamin A content. There is no consistent evidence that IBS patients suffer from food allergy, nor is there documented evidence that food intolerance plays a role in IBS symptoms. Abnormalities in gut hormones have been reported in IBS patients. As gut hormones control and regulate gastrointestinal motility and sensation, this may explain the abnormal gastrointestinal motility and visceral hypersensitivity reported in these patients. Guidance concerning food management which includes individually based restrictions of FODMAP-rich food items and individual evaluation of the effects ofprotein-, fat- and carbohydrate-rich/poor diets may reduce IBS symptoms.
Article Published Date : Apr 30, 2012
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 Oct ;24(5):487-95. Epub 2011 May 25. PMID: 21615553
H M Staudacher, K Whelan, P M Irving, M C E Lomer
King's College London, Nutritional Sciences Division, London, UK.
BACKGROUND: 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.
METHODS: 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.
RESULTS: 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).
CONCLUSIONS: A low FODMAP diet appears to be more effective than standard dietary advice for symptom control in IBS.
Article Published Date : Sep 30, 2011
Food intolerance in functional bowel disorders.
J Gastroenterol Hepatol. 2011 Apr ;26 Suppl 3:128-31. PMID: 21443725
Peter R Gibson
BACKGROUND AND AIM: Food-related symptoms are commonly described by patients with functional bowel disorders, but dietary change as an evidence-based therapy has not been part of routine management strategies. This reviews aims to discuss strategies commonly applied.
METHOD: Published literature was reviewed.
RESULTS: Traditional approaches involve elimination diets followed by placebo-controlled reintroduction of specific foods, which is tedious at best and not applied in routine practice. Pathogenically-based approaches include determining what food components are inducing food hypersensitivity responses using specific biomarkers, but this is probably applicable to a small proportion of patients only and has met with only limited success. Food bioactive chemicals, such as salicylates, have been targeted, but there is a paucity of quality evidence for or against this approach. In contrast, targeting poorly absorbed dietary components that might induce luminal distension via osmotic effects and rapid fermentation (FODMAPs) has been successful and the efficacy of the dietitian-delivered low FODMAP diet is now supported by high quality evidence. Improvement of all symptoms of FBD in three out of four patients has been achieved. The diet may potentially improve stool frequency in patients with an ileal pouch or a high output ileostomy, or functional symptoms in patients with inflammatory bowel disease. FODMAPs in enteral formulas may also be responsible for diarrhoea induced by enteral nutrition.
CONCLUSION: Dietary restriction of FODMAPs is an effective therapy in the majority of patients with functional bowel symptoms and, provided dietitians are trained in the technique, should be first line therapy.
Article Published Date : Mar 31, 2011
Diarrhoea during enteral nutrition is predicted by the poorly absorbed short-chain carbohydrate (FODMAP) content of the formula.
Aliment Pharmacol Ther. 2010 Oct ;32(7):925-33. PMID: 20670219
E P Halmos, J G Muir, J S Barrett, M Deng, S J Shepherd, P R Gibson
BACKGROUND: Although it is recognized that diarrhoea commonly complicates enteral nutrition, the causes remain unknown.
AIM: To identify factors associated with diarrhoea in patients receiving enteral nutrition with specific attention to formula composition.
METHODS: Medical histories of in-patients receiving enteral nutrition were identified by ICD-10-AM coding and randomly selected from the year 2003 to 2008. Clinical and demographic data were extracted. Formulas were classified according to osmolality, fibre and FODMAP (fermentable oligo-, di- and mono-saccharides and polyols) content.
RESULTS: Formula FODMAP levels ranged from 10.6 to 36.5 g/day. Of 160 patients receiving enteral nutrition, 61% had diarrhoea. Univariate analysis showed diarrhoea was associated with length of stay>21 days (OR 4.2), enteral nutrition duration>11 days (OR 4.0) and antibiotic use (OR 2.1). After adjusting for influencing variables through a logistic regression model, a greater than five-fold reduction in risk of developing diarrhoea was seen in patients initiated on Isosource 1.5 (P = 0.029; estimated OR 0.18). The only characteristic unique to this formula was its FODMAP content, being 47-71% lower than any other formula.
CONCLUSIONS: Length of stay and enteral nutrition duration independently predicted diarrhoea development, while being initiated on a lower FODMAP formula reduced the likelihood of diarrhoea. As retrospective evaluation does not support a cause-effect relationship, an interventional study investigating FODMAPs in enteral formula is indicated.
Article Published Date : Sep 30, 2010
Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach.
J Gastroenterol Hepatol. 2010 Feb ;25(2):252-8. PMID: 20136989
Peter R Gibson, Susan J Shepherd
BACKGROUND AND AIM: Functional gastrointestinal symptoms are common and their management is often a difficult clinical problem. The link between food intake and symptom induction is recognized. This review aims to describe the evidence base for restricting rapidly fermentable, short-chain carbohydrates (FODMAPs) in controlling such symptoms.
METHODS: The nature of FODMAPs, their mode of action in symptom induction, results of clinical trials and the implementation of the diet are described.
RESULTS: FODMAPs are widespread in the diet and comprise a monosaccharide (fructose), a disaccharide (lactose), oligosaccharides (fructans and galactans), and polyols. Their ingestion increases delivery of readily fermentable substrate and water to the distal small intestine and proximal colon, which are likely to induce luminal distension and induction of functional gut symptoms. The restriction of their intake globally (as opposed to individually) reduces functional gut symptoms, an effect that is durable and can be reversed by their reintroduction into the diet (as shown by a randomized placebo-controlled trial). The diet has a high compliance rate. However it requires expert delivery by a dietitian trained in the diet. Breath hydrogen tests are useful to identify individuals who can completely absorb a load of fructose and lactose so that dietary restriction can be less stringent.
CONCLUSIONS: The low FODMAP diet provides an effective approach to the management of patients with functional gut symptoms. The evidence base is now sufficiently strong to recommend its widespread application.
Article Published Date : Jan 31, 2010
Low FODMAP in 2017: Lessons learned from clinical trials and mechanistic studies.
Neurogastroenterol Motil. 2017 Apr;29(4):
Authors: Eswaran S
Given the prevalence of irritable bowel syndrome (IBS) and the suboptimal response to most therapeutic approaches, there has been increasing interest in and adoption of dietary treatment strategies, such as the low Fermentable Oligo-, Di-, & Mono-Saccharides and Polyols (FODMAP) diet. FODMAPs are a diverse group of carbohydrates that exert effects in the gastrointestinal tract not only via fermentation but likely via alterations in the microbiota, metabolome, permeability, and intestinal immunity as well. Clinical evidence for efficacy of this diet is mounting, but there are significant questions regarding short- and long-term safety and effects on the microbiota and nutrition that remain unanswered. This review article interprets the recent findings reported in this issue of Neurogastroenterology and Motility and summarizes the mechanistic and clinical efficacy data of the low FODMAP diet in IBS patients to date.
PMID: 28345807 [PubMed - indexed for MEDLINE]
Effects of varying dietary content of fermentable short-chain carbohydrates on symptoms, fecal microenvironment, and cytokine profiles in patients with irritable bowel syndrome.
Neurogastroenterol Motil. 2017 Apr;29(4):
Authors: Hustoft TN, Hausken T, Ystad SO, Valeur J, Brokstad K, Hatlebakk JG, Lied GA
BACKGROUND: A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) is increasingly recommended for patients with irritable bowel syndrome (IBS). We aimed to investigate the effects of a blinded low-FODMAP vs high-fructo-oligosaccharides (FOS) diet on symptoms, immune activation, gut microbiota composition, and short-chain fatty acids (SCFAs).
METHODS: Twenty patients with diarrhea-predominant or mixed IBS were instructed to follow a low-FODMAP diet (LFD) throughout a 9-week study period. After 3 weeks, they were randomized and double-blindly assigned to receive a supplement of either FOS (FODMAP) or maltodextrin (placebo) for the next 10 days, followed by a 3-week washout period before crossover. Irritable bowel syndrome severity scoring system (IBS-SSS) was used to evaluate symptoms. Cytokines (interleukin [IL]-6, IL-8, and tumor necrosis factor alpha) were analyzed in blood samples, and gut microbiota composition (16S rRNA) and SCFAs were analyzed in fecal samples.
KEY RESULTS: Irritable bowel syndrome symptoms consistently improved after 3 weeks of LFD, and significantly more participants reported symptom relief in response to placebo (80%) than FOS (30%). Serum levels of proinflammatory IL-6 and IL-8, as well as levels of fecal bacteria (Actinobacteria, Bifidobacterium, and Faecalibacterium prausnitzii), total SCFAs, and n-butyric acid, decreased significantly on the LFD as compared to baseline. Ten days of FOS supplementation increased the level of these bacteria, whereas levels of cytokines and SCFAs remained unchanged.
CONCLUSIONS AND INFERENCES: Our findings support the efficacy of a LFD in alleviating IBS symptoms, and show changes in inflammatory cytokines, microbiota profile, and SCFAs, which may have consequences for gut health.
PMID: 27747984 [PubMed - indexed for MEDLINE]