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Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with Irritable bowel syndrome
Journal of Human Nutrition and Dietetics
Abstract
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.
... The "high risk" efficacy PICOS study could only be included in the analysis of abdominal pain and overall symptoms [35] and the "high risk" realworld study only in the analysis for abdominal pain and IBS-related quality of life [36]. Studies rated with the ROBINS-I tool were largely assessed as having a serious risk rating, with one study [29] rated as low risk and one [37] with moderate risk (Figs. S3 and S4). ...
... S3 and S4). Results of the study rated as having a low risk of bias were included in the analysis for overall symptoms and IBS-related quality of life [29] and those of the study rated as moderate risk in the assessment of adequate symptom relief and adherence [37]. In the GRADE assessment, efficacy PICOS studies were found to have moderate quality of evidence (Table S2), whereas the real-world PICOS studies had very low quality of evidence (Table S3). ...
... In the real-world PICOS, most studies did not include a control group [29,51e63]. Only the RCTs and one prospective study had a control group, with control interventions being probiotics [48], a normal Danish diet [48], gut-directed hypnotherapy [50], the LFD combined with a fructooligosaccharide supplement [49], a standard IBS diet [37], or adults with IBS on a waiting-list [36]. ...
... A research group at Monash University in Australia undertook the first investigations to prove whether a low FODMAP diet could improve symptom control in IBS patients and established a mechanism by which this diet exerted its effect [69][70][71]. A retrospective study by Staudacher et al. [72] comparing standard dietary advice to the low FODPMAP diet in 82 IBS patients found a significant improvement in overall symptom response in the low FODMAP diet group (p < 0.001). However, in this study the use of other medication was not controlled for, and IBS subtypes were not distinguished. ...
... However, in this study the use of other medication was not controlled for, and IBS subtypes were not distinguished. Moreover, participants completed the questionnaire at the time of review consultation, which may have introduced bias [72]. ...
... Foods that provide a key source of micronutrients in habitual diets such as legumes and dairy products may be removed, creating a void. For instance, Staudacher et al. [72] reported a diminished calcium consumption in the 4-week restrictive diet trial. Moreover, there is a lack of studies investigating the re-introduction of FODMAP foods into the diet of IBS patients. ...
Irritable Bowel Syndrome (IBS) is the most common gastrointestinal (GI) disorder in Western populations and therefore a major public health/economic concern. However, despite extensive research, psychological and physiological factors that contribute to the aetiology of IBS remain poorly understood. Consequently, clinical management of IBS is reduced to symptom management through various suboptimal options. Recent evidence has suggested human milk oligosaccharides (HMOs) as a potential therapeutic option for IBS. Here, we review literature concerning the role of HMOs in IBS, including data from intervention and in vitro trials. HMO supplementation shows promising results in altering the gut microbiota and improving IBS symptoms, for instance by stimulating bifidobacteria. Further research in adults is required into HMO mechanisms, to confirm the preliminary results available to date and recommendations of HMO use in IBS.
... 8 IBS dietary management guidelines for clinical practice and expert review recommend a 4-week FODMAP restriction followed by reassessment with a dietitian at the 4-week time point to determine symptom response. 6,9 However in clinical practice a 4-week follow-up can be difficult to achieve 10 and 8-weeks or longer FODMAP restriction has been used in clinical practice, 11,12 randomised controlled trials 13,14 and open label studies. 15 There are benefits for the patient in restricting FODMAPs for a shorter time period versus an extended period. ...
... Currently we are without validated tools for assessing dietary adherence to a FODMAP diet. We measured adherence as has been used in previous FODMAP clinical practice individual and group studies, 11,12 which assists comparisons across studies. Asking patients to complete food diaries or use digital apps to achieve a more accurate understanding of adherence is possible in clinical practice. ...
Background
The implementation of the fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet for irritable bowel syndrome (IBS) can be effectively delivered by dietitians in group settings. The initial FODMAP restriction phase is recommended to be followed for 4 weeks; however, limited efficacy data exist for 4‐week FODMAP restriction in group education clinical practice.
Methods
We aimed to compare 4‐week versus 8‐week FODMAP group treatment pathways on clinical outcomes using a prospective service evaluation design of IBS patients attending FODMAP restriction (baseline) and reintroduction (follow‐up) group sessions (between 2015 and 2019). Clinical outcomes included global symptom question (GSQ) measuring satisfactory relief, gastrointestinal symptom rating scale (GSRS), stool frequency (SF), stool consistency using Bristol stool form scale (BSFS), diet acceptability, patient satisfaction with group sessions and dietary adherence. Logistic regression was used to test for differences in treatment effects when clinical outcomes were compared between groups.
Results
Patients (n = 284) included were aged 18 to 86 years (mean ± SD [standard deviation], 44.6 ± 15.5), 80% female, and were split into 4‐week (41%, 117/284) versus 8‐week (59%, 167/284) pathways with no differences in baseline characteristics. Mean ± SD time gap between baseline and follow‐up was 4.6 ± 0.9 weeks in the 4‐week pathway and 9.6 ± 3.3 weeks in the 8‐week pathway. When groups were compared at follow‐up, no statistical differences were observed in any measures (GSQ, GSRS, SF, BSFS, dietary adherence, diet acceptability and patient satisfaction).
Conclusion
A 4‐week dietitian‐led group FODMAP treatment pathway is as clinically effective and maintains patient acceptability when compared to 8‐weeks and should be considered as part of routine clinical practice.
... Once the reclassification was performed, it was possible to establish a significant difference between the study group and the placebo group in terms of the effect of fructans as a useful treatment in conditions such as IBS with a predominance of constipation, where constipation is the main factor associated with the symptoms of these patients (abdominal pain and inflammation, pain when defecating, and flatulence with an unpleasant smell). The use of FODMAPs (prebiotics), according to Staudacher et al. [39], is not recommended in the treatment of IBS because their fermentation in the intestine causes undesirable symptoms such as excessive flatulence and abdominal swelling. However, in this study, there was no way to differentiate between patients with IBS with diarrhea, mixed IBS, and IBS with constipation; instead, a general recommendation is provided for the reduction in FODMAPs in the diet in patients diagnosed with IBS. ...
... The daily diet of each of the patients was only monitored through daily diet reminder instruments. This finding was relevant given that there were no restrictions on the diets of the patients during the intervention, as occurs in alternative treatments, such as the low-FODMAP diet [8,12,36,39]. ...
Irritable bowel syndrome displays three different subtypes: constipation (IBS-C), diarrhea (IBS-D), and mixed (IBS-M). Treatment with dietary fiber is used, with consideration given both to the chemical composition of the fiber and to the different subtypes of IBS. The IBS-D subtype is usually treated with a low-FODMAPs diet, whereas the IBS-C subtype suggests prebiotics and probiotics to promote microbiota restoration. The aim of this study was to assess the effects of employing agave fructans as the soluble fiber of a jelly (Gelyfun®gastro) containing 8 g per serving in the IBS-C group (n = 50), using a randomized, double-blind, time-limited trial for four weeks. We evaluated changes in the frequency and types of bowel movements through the Bristol scale, and the improvement of the condition was evaluated using quality of life (IBS-QOL) and anxiety–depression (HADS) scales. The main results were that the number of bowel movements increased by more than 80%, with at least one stool per day from fifteen days onwards, without a laxative effect for the group treated. Finally, the quality of life with the prebiotic jelly was significantly improved compared to the placebo in all specific domains, in addition to significantly reducing anxiety and depression.
... Different diets and supplements have been shown to improve the symptoms of IBS patients as well as IBD patients with IBS symptoms (e.g., low-FODMAP, vitamin D, or probiotics) [13][14][15][16][17][18]. Treatment of SIBO includes antibiotics, probiotics, and prokinetics, while in recent years therapy with rifaximin is regarded as the standard of care for SIBO [12]. ...
... It is well known that, in general, patients with IBD suffer from gut dysbiosis [16] with a small intestinal bacterial overgrowth, mainly due to chronic intestinal inflammation in the small intestine, while in UC inflammation is mostly limited to the colon. In patients with IBS, small intestinal inflammation is a risk factor for SIBO [17]. ...
Background:
Small intestinal bacterial overgrowth (SIBO) is often found in patients with gut dysbiosis such as irritable bowel syndrome. Recently, the association of SIBO and inflammatory bowel disease (IBD) has been described in some cases. While clinical symptoms might be similar in IBD and SIBO, treatment is quite different for both diseases. Therefore, the differentiation between SIBO or a flare in IBD patients is key to optimizing treatment for these patients.
Methods:
We retrospectively investigated our patients with IBD receiving a glucose breath test for SIBO and correlated the results with the clinical symptoms (clinical remission or active disease).
Results:
128 patients with the diagnosis "colitis" were analyzed in our cohort. Fifty-three (41.4%) patients had Crohn's disease and 22 (17.2%) patients were suffering from ulcerative colitis. Seventy-four (57.8%) were female and 54 (42.2%) were male patients. A total of 18 (14.1%) patients had a positive testing for SIBO. Eleven (61.1%) cases were associated with CD patients and two (11.1%) with UC. IBD patients in clinical remission had a positive SIBO in six (19.4%) cases, while IBD patients with active disease were positive in nine (15.3%) cases. The proportion of positive SIBO in active IBD patients was higher; however, it did not reach significance. Older age was a risk factor for SIBO in patients with CD (p < 0.003).
Conclusions:
In our study, we could show that an increased amount of SIBO was found in IBD patients and was especially more frequent in patients with CD than in those with UC. In UC patients, SIBO rates were not different to patients with other gastrointestinal diseases investigated (e.g., infectious colitis, collagenous colitis, or irritable bowel syndrome). In active IBD, positive SIBO was detected more often numerically compared to quiescent disease; however, due to the low number of patients included, it was not significant. However, older age was a significant risk factor for SIBO in patients with CD. SIBO is of clinical relevance in the vulnerable patient cohort with IBD, and its real prevalence and impact needs to be investigated in further and larger clinical trials.
... Common FODMAPs include fructose (which is poorly absorbed in the small intestine when in excess of glucose [59]), lactose, polyols, fructans, and α-galactooligosaccharides (GOS). While for healthy individuals, FODMAPs can be a valuable source of prebiotics [60], a diet low in FODMAPs has been shown to alleviate symptoms of patients with irritable bowel syndrome (IBS) [61]. The GOS raffinose, stachyose, and verbascose are the main FODMAP in lentil [62], however, during IEP of the protein isolates from lentil flour, ...
... Common FODMAPs include fructose (which is poorly absorbed in the small intestine when in excess of glucose [59]), lactose, polyols, fructans, and α-galactooligosaccharides (GOS). While for healthy individuals, FODMAPs can be a valuable source of prebiotics [60], a diet low in FODMAPs has been shown to alleviate symptoms of patients with irritable bowel syndrome (IBS) [61]. The GOS raffinose, stachyose, and verbascose are the main FODMAP in lentil [62], however, during IEP of the protein isolates from lentil flour, the GOS content is reduced significantly [63]. ...
A milk-alternative produced from lentil protein isolate was fermented with three multifunctional strains of lactic acid bacteria, Leuconostoc citreum TR116, Leuconostoc pseudomesenteroides MP070, and Lacticaseibacillus paracasei FST 6.1. As a control, a commercial starter culture containing Streptococcus thermophilus was used. The metabolic performance of these strains and the techno-functional properties of the resulting yogurt alternatives (YA) were studied. Microbial growth was evaluated by cell counts, acidification, and carbohydrate metabolization. The structure of the YA was investigated by textural and rheological analyses and confocal laser scanning microscopy (CLSM). Production of antifungal compounds, the influence of fermentation on the content of FODMAPs, and typical metabolites were analyzed, and a sensory analysis was performed. The results revealed an exponential microbial growth in the lentil base substrate supported by typical acidification, which indicates a suitable environment for the selected strains. The resulting YA showed a gel-like texture typical for non-stirred yogurts, and high water holding capacity. The tested strains produced much higher levels of antifungal phenolic compounds than the commercial control and are therefore promising candidates as adjunct cultures for shelf-life extension. The Leuconostoc strains produced mannitol from fructose and could thus be applied in sugar-reduced YA. Preliminary sensory analysis showed high acceptance for YA produced with Lacticaseibacillus paracasei FST 6.1, and a yogurt-like flavor not statistically different to that produced by the control. Overall, each tested strain possessed promising functionalities with great potential for application in fermented plant-based dairy-alternatives.
... Recientemente se publicó en un trabajo 10 en el que los pacientes con SII, después de 15,7 (±9) meses de seguimiento la dieta libre de FODMAPs, en un 72,1% notaron mejoría, aunque sólo un 12,2% de los pacientes hizo la dieta con adherencia total. En otros trabajos 12,16 , los pacientes en un 76% experimentaron mejoría tras seguir la dieta entre 2/8 semanas. En este trabajo se compara la dieta libre de FODMAPs y la propuesta por la NICE 13 . ...
... Um estudo com 82 pacientes com SII já havia demonstrado melhorias significativas em distensão abdominal, dor abdominal e flatulência para aqueles tratados com DBTF em comparação com a mNICE. Neste estudo, 76 e 54% dos pacientes relataram melhora dos sintomas, com as DBTF e mNICE, respectivamente.27 Russo et al.19 confirmaram que a DBTF é mais eficaz para o tratamento de pacientes com SII. ...
Introdução: A síndrome do intestino irritável (SII) é um distúrbio intestinal funcional crônico, caracterizado por dor abdominal recorrente e alterações nos hábitos intestinais, sem causas orgânicas claras. Como sua etiologia ainda não é totalmente compreendida, não há um tratamento universalmente aplicável a todos os pacientes. No entanto, a exclusão de FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) da dieta tem sido estudada como potencial estratégia para tratar os sintomas da doença. Objetivo: Este estudo objetivou investigar os efeitos da dieta com baixo teor de FODMPs (DBTF) nos sintomas gastrointestinais de pacientes diagnosticados com SII. Método: Trata-se de uma revisão sistemática da literatura nas bases de dados PubMed, Lilacs, Medline, Biblioteca Virtual em Saúde (BVS), ScienceDirect e Embase, utilizando combinações de descritores com base na estratégia PICO. Foram selecionados 11 ensaios controlados randomizados publicados nos últimos dez anos (2013-2023), com adultos diagnosticados com SII. Foram excluídos estudos que utilizaram outras intervenções dietéticas além da DBTF, aqueles realizados com pacientes diagnosticados com outros distúrbios intestinais e que não avaliaram sintomas gastrointestinais. Resultados: A DBTF se mostrou eficaz na redução dos sintomas da SII, promovendo uma diminuição notável na intensidade e frequência da dor abdominal e distensão. No entanto, os pacientes seguindo a DBTF apresentaram menor ingestão de energia e fibras, sugerindo a necessidade de acompanhamento nutricional. Ademais, a adoção dessa dieta resultou na diminuição da população de Bifidobacterium, devido à exclusão de fibras. Conclusão: Este estudo sustenta que a DBTF é uma estratégia nutricional eficaz para aliviar sintomas gastrointestinais em adultos com SII.
... Consumption of FODMAPs can exacerbate gastrointestinal symptoms in IBS sufferers, influencing their quality of life and productivity (Corsetti et al., 2018;Bertin et al., 2024). The low-FODMAP diet has emerged as a cornerstone approach for managing IBS symptoms, characterized by the restriction of high-FODMAP foods and the promotion of low-FODMAP alternatives, effectively mitigating gastrointestinal distress among IBS sufferers (Gibson and Shepherd, 2010;Staudacher et al., 2011;Halmos et al., 2014;Bohn et al., 2015). ...
This study explores the development of whole-grain sourdough bread with reduced FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) content to offer dietary solutions for individuals with irritable bowel syndrome (IBS). Three sourdough breads were prepared using different lactic acid bacteria (LAB) strains including Lactiplantibacillus plantarum FST1.7 (SD-FST1.7), Lacticaseibacillus paracasei R3 (SD-R3), and Pediococcus pentosaceus RYE106 (SD-RYE106). A control sourdough bread was prepared using baker’s yeast (SD-control). In vitro digestion and in vitro colonic fermentation were employed on bread samples with cellulose (negative control) and inulin (positive control), followed by 16S rRNA sequencing and short-chain fatty acid (SCFA) analysis to evaluate the impact on gut microbiota and SCFA levels. Alpha and beta diversity did not reveal any significant differences within the groups following in vitro colonic fermentation (FDR > 0.05). Taxonomic analysis displayed Firmicutes as the predominant phylum across all fecal samples at the end of colonic fermentation. Actinobacteriota was significantly lower in cellulose fermented fecal samples compared to samples fermented with SD-Control (ANCOMBC, FDR = 0.02) and inulin (ANCOMBC, FDR = 0.0001). Fecal samples fermented with inulin had significantly higher Bacteroidota levels compared to those fermented with cellulose (ANCOMBC, FDR =0.002). Acetate levels were higher in fecal samples fermented with SD-FST1.7 compared to those fermented with SD-R3 and SD-RYE106 (p = 0.03 for both). Positive correlations between butyrate and Lachnospira, Agathobacter, and Bifidobacterium were observed, demonstrating the potential of sourdough fermentation to influence gut health and support IBS management.
... Dietary managements are among the most prescribed therapies for IBS [41] and an LFD is currently considered a "second line" dietary management for IBS [3,4]. However, some concerns have been raised regarding LFD (e.g., intestinal dysbiosis, nutri-tional inadequacy, constipation, eating disorders, etc.) [33,35,[42][43][44][45][46]. In order to overcome these possible limitations, a less restrictive diet based on the exclusion of only the food "triggers" that patients recognize can be designed. ...
Background/Objectives: A low-FODMAPs Diet (LFD) is considered a “second line” dietary strategy for irritable bowel syndrome (IBS) but, after a period of strict restriction of all FODMAP foods, it has to be adapted and tailored to each patient (AdLFD). Fibromyalgia often coexists with IBS in up to 65% of cases. Our aims were to evaluate if comorbid fibromyalgia influenced the long-term clinical outcomes and adherence to an AdLFD in IBS patients. Methods: IBS patients with or without fibromyalgia who had started an AdLFD were enrolled. Patients had been evaluated before starting the LFD (T0). After a mean follow-up of 62.5 ± 22.7 months (T1), they were re-evaluated using questionnaires on disease severity, bowel habits, psychological status, and adherence to AdLFD. Results: In total, 51 IBS patients entered the study. Nineteen of them had comorbid fibromyalgia. Thirty patients reported a reduction in symptom severity at T1 in comparison with T0. Despite some slight differences in single IBS Symptom Severity Score items, comorbid fibromyalgia did not influence the IBS-SSS total score at T1. Patients with comorbid fibromyalgia showed a higher Hospital Anxiety and Depression Scale (HADS) score at baseline. A total of 44 patients showed good long-term adherence to the AdLFD. All patients improved their HADS score and had long-term adherence to the AdLFD. Conclusions: Comorbid fibromyalgia showed only a slight influence on long-term outcomes of an AdLFD on IBS symptoms, without affecting the relief of global symptoms. No influence on long-term adherence to AdLFD was detected. Hence, this approach can be taken into account in fibromyalgia patients for a nonpharmacological management of IBS symptoms. However, multicentric studies on larger samples would be welcome in the future.
... It's important to highlight that diet plays a significant role in shaping the composition of the gut microbiome. The FODMAP diet, which involves restricting fermentable oligosaccharides, disaccharides, monosaccharides and polyols, has been shown to alleviate IBS symptoms and positively impact the overall quality of life in affected individuals (Staudacher et al. 2011). This diet operates through mechanisms such as limiting the absorption of specific FODMAPs, like fructose, in the small intestine, which can lead to water distension due to osmotic effects. ...
Exploration of the human gut microbiome has deepened the understanding of how microbial colonisation, development and imbalances contribute to different health-related ailments. The immense metabolic capabilities of gut microbes and their role in maintaining human physical condition have become increasingly evident, enabling new possibilities for using them as therapeutic agents to combat human gastrointestinal (GI) ailments. Microbiome therapeutics in different GI diseases involve interventions that aim to manipulate the gut microbiome using approaches such as adding, removing or modulating microbes and utilising antibiotics, prebiotics and postbiotics. This approach can potentially overcome traditional therapeutics’ limitations by offering personalised, coordinated, reliable and sustainable treatments. However, despite its promise, microbiome therapeutics are still in the early stages of development and face various regulatory and technical challenges that require further research, particularly in different GI disorders. This chapter provides an outline of the existing knowledge and landscape of microbiome therapeutics specifically using fecal microbiome transplantation (FMT), prebiotics, probiotics, postbiotics, antibiotics and synbiotics discussing the existing applications in different GI disorders and exploring potential future directions for modulating the microbiome-based treatments.
... It's important to highlight that diet plays a significant role in shaping the composition of the gut microbiome. The FODMAP diet, which involves restricting fermentable oligosaccharides, disaccharides, monosaccharides and polyols, has been shown to alleviate IBS symptoms and positively impact the overall quality of life in affected individuals (Staudacher et al. 2011). This diet operates through mechanisms such as limiting the absorption of specific FODMAPs, like fructose, in the small intestine, which can lead to water distension due to osmotic effects. ...
Exploration of the human gut microbiome has deepened the understanding of how microbial colonisation, development and imbalances contribute to different health-related ailments. The immense metabolic capabilities of gut microbes and their role in maintaining human physical condition have become increasingly evident, enabling new possibilities for using them as therapeutic agents to combat human gastrointestinal (GI) ailments. Microbiome therapeutics in different GI diseases involve interventions that aim to manipulate the gut microbiome using approaches such as adding, removing or modulating microbes and utilising antibiotics, prebiotics and postbiotics. This approach can potentially overcome traditional therapeutics’ limitations by offering personalised, coordinated, reliable and sustainable treatments. However, despite its promise, microbiome therapeutics are still in the early stages of development and face various regulatory and technical challenges that require further research, particularly in different GI disorders. This chapter provides an outline of the existing knowledge and landscape of microbiome therapeutics specifically using fecal microbiome transplantation (FMT), prebiotics, probiotics, postbiotics, antibiotics and synbiotics discussing the existing applications in different GI disorders and exploring potential future directions for modulating the microbiome-based treatments.
... Beyond the FODMAP content of foods, it is necessary to consider the application of these results to the diet and, in particular, to the low-FODMAP diet. The use of the low-FODMAP diet should be undertaken by dieticians [30], who for several years have had international cut-off points for the consideration of foods as low-FODMAP. Even though, as detailed in the comprehensive and well-developed review on the scientific and market perspective of FODMAP foods [28], only 19% of the products certified as low-FODMAP are marketed in Europe, and the vast majority of them do not have a certification logo [28]. ...
Gluten-free foods (GF) availability on supermarket shelves is growing and it is expected to continue expanding in the years ahead. These foods have been linked to a lower content of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs), molecules that trigger gastrointestinal symptoms in sensitive persons. In this study, the FODMAP content of 25 cereal-based GF foods in Spain (breakfast cereals, pasta, bread, biscuits, bakery products, and dough and puff pastry) and 25 gluten-containing equivalents (GC) available in the same supermarket were analysed and compared. Lactose, fructose, glucose, sorbitol, mannitol, raffinose, stachyose and fructans were quantified. In a like-by-like analysis, GF foods were found to generally contain fewer FODMAPs than their GC counterparts. The ingredients used in the manufacture of GF cereal-based foods may contribute to this fact. When the individually wrapped size was considered, the proportion of samples classified as high-FODMAPs in GC and GF foods showed a trend towards fewer samples in the GF. However, not all the GF samples were low-FODMAP. Altogether, our findings provide essential information for FODMAP content databases of GF products in Spain.
... En un estudio retrospectivo en Reino Unido de 82 pacientes con SII, los que habían recibido una dieta estándar tenían una mejoría en los síntomas generales de SII inferior (49%) respecto a los que habían recibido una dieta baja FODMAP (86%; p<0,001) (20). ...
Introducción: el síndrome de intestino irritable (SII) es el principal trastorno funcional gastrointestinal caracterizado por múltiples síntomas sin una causa orgánica clara, constituye un problema de salud por sus altos costos e impacto en la calidad de vida.Objetivo: determinar la prevalencia del síndrome de intestino irritable en los estudiantes de Medicina de la Fundación Universitaria San Martín Sabaneta a noviembre de 2016.Materiales y métodos: estudio de corte transversal, incluyó los estudiantes de Medicina de la FUSM matriculados en el programa para el periodo 2016-2. Se determinó la prevalencia del síndrome por medio de los criterios de Roma III mediante una encuesta autodiligenciada. Se realizó un análisis univariado y bivariado en búsqueda de asociaciones.Resultados: se encontró una prevalencia de SII en 17,92% de 173 encuestados, el patrón mixto fue el más frecuente (77,41%). Hubo una posible asociación entre el SII y trastorno de ansiedad generalizada, presencia de al menos un síntoma gastrointestinal, y consumo de alcohol al menos una vez al mes.Conclusiones: la prevalencia del SII es del 17,92%, la ansiedad podría asociarse al SII. La depresión mayor no se relaciona con tener SII en este estudio. Se necesitan estudios que permitan ampliar la relación de los hábitos y estilos de vida incluidos el consumo de licor y cigarrillo.
... The low FODMAP diet is effective in 52-86% of individuals with IBS, and has superior outcomes compared with following the NICE guidelines cited above (Liu et al, 2020). A retrospective study found that 76% of patients in the low FODMAP group reported satisfaction with their symptoms compared with 54% of patients in the NICE group (Staudacher et al, 2011) However, several limitations of the diet have been raised. There is a potential risk of nutrient deficiency, namely calcium and fibre and a possible reduction in gut bacteria diversity; the diet is also confusing and restrictive for those with IBS, and longterm efficacy data are limited (Horne and Missmer, 2022). ...
Irritable bowel syndrome (IBS) and endometriosis pose significant challenges to affected individuals. IBS, which is a functional gastrointestinal disorder, affects 5–10% of the population, while endometriosis affects 1 in 10 of those assigned female at birth. Despite distinct origins, symptom often overlap, which may lead to misdiagnosis. Diagnosing IBS and endometriosis requires a comprehensive approach. Nutritional management for IBS emphasises self-help strategies, nutritional changes and gut–brain axis modulation. The low FODMAP diet, which reduces the intake of foods containing specific types of carbohydrate, can be effective but requires the support of trained health professionals. For the management of endometriosis, a Mediterranean-style diet rich in antioxidants shows promise. Gastrointestinal symptoms are common with endometriosis and an individualised approach is recommended. Furthermore, vitamin D status assessment is advised. Collaboration between health professionals and dietitians is vital for tailored interventions, to enhance the wellbeing of individuals with IBS or endometriosis. A holistic approach holds promise in symptom management for both conditions.
... 16 There are studies reporting that a low-FODMAP diet has positive effects on the improvement of IBS symptoms. 17,18 Recent treatment methods for this disease include the use of probiotics and prebiotics. Although the results from many clinical studies are variable, the use of prebiotics and probiotics may theoretically have beneficial effects in the treatment of IBS through their immunomodulatory and anti-inflammatory effects. ...
Background
The present study aimed to evaluate the effects of fermented oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP) diet therapy and probiotics on irritable bowel syndrome (IBS) symptoms, quality of life and depression in women diagnosed with IBS.
Methods
For the study, 52 female IBS patients between the ages of 20 and 55 were enrolled. Individuals were monitored for 6 weeks in two groups. A low‐FODMAP diet was given to the first group and a low‐FODMAP diet plus a probiotic supplement was given to the second group (Lactobacillus rhamnosus). Three‐day food intake records were kept at the start of the study and continued up to its conclusion, with a weekly check‐in in between. At the start and end of the trial, participants completed the Hospital Anxiety and Depression Scale, IBS Quality of Life Scale (IBS‐QOL) and IBS Symptom Severity Score (IBS‐SSS). The Bristol Stool Scale was also used by the subjects to record their daily stool densities.
Results
At the end of the study, it was determined that the daily intake of FODMAP (lactose [g] + oligosaccharides [g] + mannitol [g] + sorbitol [g]) decreased significantly in both groups (p < 0.05). At the end of the study, it was determined that the IBS‐SSS, anxiety and depression scores of the individuals in both groups decreased significantly and their IBS‐QOL scores increased significantly (p < 0.05). However, the difference between these values between the groups was not statistically significant (p > 0.05).
Conclusions
A low‐FODMAP diet has been demonstrated to benefit people by lessening the severity of their IBS symptoms and enhancing their quality of life. No evidence was found, however, to indicate that the FODMAP diet would be more beneficial on these metrics if additional probiotics were used. It should be emphasised that the reaction of probiotic strains may vary depending on the IBS subtype.
... Although associated with issues such as nutritional inadequacy, complexity, and restrictiveness [102], adherence to the low FOD-MAP diet results in a 50e80% response rate regarding reduction of IBS symptoms [103]. It has also shown similar [104] or greater [101,105] efficacy in reducing IBS symptoms, such as abdominal pain, bloating, and flatulence than first-line advice. Additionally, when compared with a typical Australian diet, lower overall GI symptoms were witnessed on a low FODMAP diet, as well as bloating, pain, and flatulence [106]. ...
Low molecular weight (LMW) non-digestible carbohydrates (namely, oligosaccharides and inulin) are accepted as dietary fibre in many countries worldwide. The inclusion of oligosaccharides as dietary fibre was made optional within the Codex Alimentarius definition in 2009, which has caused great controversy. Inulin is accepted as dietary fibre by default, due to being a non-digestible carbohydrate polymer. Oligosaccharides and inulin occur naturally in numerous foods and are frequently incorporated into commonly consumed food products for a variety of purposes, such as to increase dietary fibre content. LMW non-digestible carbohydrates, due to their rapid fermentation in the proximal colon, may cause deleterious effects in individuals with functional bowel disorders (FBDs) and, as such, are excluded on the low FODMAP (fermentable oligosaccharides, disaccharides, and polyols) diet and similar protocols. Their addition to food products as dietary fibre allows the use of associated nutrition/health claims, causing a paradox for those with FBDs, which is further complicated by lack of clarity on food labelling. Therefore, this review aimed to discuss whether the inclusion of LMW non-digestible carbohydrates within the Codex definition of dietary fibre is warranted. This review provides justification for the exclusion of oligosaccharides and inulin from the Codex definition of dietary fibre. LMW non-digestible carbohydrates could, instead, be placed in their own category as prebiotics, recognised for their specific functional properties, or considered food additives, whereby they are not promoted for being beneficial for health. This would preserve the concept of dietary fibre being a universally beneficial dietary component for all individuals.
... Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction that affects about 4%-11% of the general population. 1 [5][6][7][8][9] but it is restrictive and meant for short-term use because it can be associated with nutritional deficiencies and changes in the gut microbiota. [10][11][12] The diet starts with the elimination of high FODMAP foods, ideally under the guidance of a dietitian. ...
Background
Limited data exist to guide FODMAP (fermentable oligo‐, di‐, monosaccharides, and polyols) reintroduction to assess tolerance following a low FODMAP diet (LFD). Fructose reintroduction is often stepwise up to 7.5 g fructose (e.g., three tsp of honey). We aimed to determine the fructose tolerance threshold in non‐constipated, LFD‐responsive patients with irritable bowel syndrome (IBS) and assess whether stool microbiome predicted LFD response or fructose tolerance.
Methods
Thirty‐nine non‐constipated IBS patients (51% women, mean age 33.7 years) completed a 4‐week LFD. LFD responders were defined as those who reported adequate relief of IBS symptoms following the LFD. Responders were randomized to one of the three solution groups (100% fructose, 56% fructose/44% glucose, or 100% glucose) and received four doses (2.5, 5, 10, 15 g) for 3 days each. Patients reached their tolerance dose if their mean daily IBS symptom severity (visual analog scale [VAS], 0–100 mm) was >20 mm higher than post‐LFD VAS. Stool samples before and after LFD were analyzed using shotgun metagenomics.
Results
Seventy‐nine percent of patients were LFD responders. Most responders tolerated the 15 g sugar dose. There was no significant difference in mean dose tolerated between solution groups (p = 0.56). Compared to baseline, microbiome composition (beta diversity) significantly shifted and six bacterial genes in fructose and mannose metabolism pathways decreased after LFD, irrespective of LFD response or the solution group.
Conclusions
Non‐constipated, LFD‐responsive IBS patients should be reintroduced to fructose in higher doses than 15 g to assess tolerance. LFD is associated with significant changes in microbial composition and bacterial genes involved in FODMAP metabolism.
... Moreover, AB has been found to be a significant predictor of the severity of IBS (30). Given that it has been reported to be the third most important reason for seeking medical care, prior studies have examined different aspects of interventions designed to treat the symptoms of AB in an effort to find a cure for it (33)(34)(35)(36). The findings of the present study suggested lifestyle management to be a possible alternative treatment for AB. ...
Background:
Abdominal bloating (AB) is a common medical complaint known to diminish patients' quality of life. However, lifestyle and behavioural changes could mitigate its expression and severity. This study sought to explore the health beliefs, intentions and health-promoting behaviours among people with AB in Kelantan, Malaysia.
Methods:
The theory of planned behaviour (TPB) was employed to explore the factors that influence the management of adults with AB, namely health beliefs and intentions. An interview guide was developed by adapting the TPB and the findings of prior studies concerning the factors associated with AB management. All eligible participants took part in in-depth interviews.
Results:
The mean age of the participants was 32.5 years old (standard deviation [SD] = 14.19 years old) and the majority of participants were female (58.3%). The themes and sub-themes that emerged following the application of the TPB framework represented the qualitative results of this study, which indicated that the health beliefs, intentions and health-promoting behaviours observed among people with AB were closely related.
Conclusion:
The findings of this study suggest that the adoption of a healthy lifestyle could be an effective means of improving AB. Thus, it is vital to implement a health education programme that promotes health-related beliefs and intentions in order to trigger health-promoting behaviour among people with AB.
... The low FODMAP diet is effective in reducing the symptoms of irritable bowel syndrome. Studies have shown that the low FODMAP diet can reduce symptoms in up to 70% of IBS patients [99,100]. In our literature survey, we were unable to identify any studies suggesting the lack of efficacy of the low FODMAP diet in terms of reducing the IBS symptoms, with only the study by Bohn et al. pointing to the efficacy of the low FODMAP diet being comparable to that of standard diets used in IBS patients [101]. ...
Inflammatory bowel disease has become a global health problem at the turn of the 21st century. The pathogenesis of this disorder has not been fully explained. In addition to non-modifiable genetic factors, a number of modifiable factors such as diet or gut microbiota have been identified. In this paper, the authors focus on the role of nutrition in the prevention of inflammatory bowel disease as well as on the available options to induce disease remission by means of dietary interventions such as exclusive and partial enteral nutrition in Crohn’s disease, the efficacy of which is reported to be comparable to that of steroid therapy. Diet is also important in patients with inflammatory bowel disease in the remission stage, during which some patients report irritable bowel disease-like symptoms. In these patients, the effectiveness of diets restricting the intake of oligo-, di-, monosaccharides, and polyols is reported.
... Studies that compared the low FODMAP diet to sham or habitual diets found clear results supporting the efficacy of the low FODMAP diet [26,27], but placebo responses, which are common in IBS, may influence the outcome due to the methodology of these studies [28]. Other studies compared the low FODMAP diet with an active comparator, traditional IBS dietary advice, and in general, these studies found that both diet interventions were equally effective in reducing GI symptoms in IBS or with only modest differences between the diet interventions [29][30][31][32][33]. To date, few studies [13][14][15] have assessed effects of diets low and moderate/high in FODMAPs, and the present study demonstrates a modest effect of a FODMAP challenge on GI symptoms, which is largely in line with previous studies [13][14][15]. ...
Background and aims
Fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) can provoke symptoms in patients with irritable bowel syndrome (IBS). We aimed to compare the effects of diets with low vs. moderate FODMAP content on gastrointestinal (GI) symptoms and bowel habits, and to identify possible predictors of clinical response to a low FODMAP diet and FODMAP sensitivity in IBS.
Methods
Adult participants with IBS (Rome IV criteria, n=29) were included and adhered to two 7-day diet periods, with either low (4g/day) or moderate (23g/day) amounts of FODMAPs, in this randomized, double-blind, crossover study. The periods were separated by a wash-out period (≥14 days). IBS-Severity Scoring System (IBS-SSS) and a stool diary (Bristol Stool Form) were completed before and after the diet periods. At baseline, severity of GI symptoms and gut microbial fermentation were assessed (every 15min, 4h) during the Lactulose Nutrient Challenge Test (LNCT). Clinical response and FODMAP sensitivity were defined by reduction after low FODMAP period, and increase after moderate FODMAP period in IBS-SSS (≥50 points), respectively.
Results
Severity of GI symptoms (P=0.04), stool consistency (P=0.01), and stool frequency (P=0.01) differed between the interventions, with reduced overall GI symptom severity, abdominal pain intensity and frequency, bowel habits dissatisfaction, and daily life interference (P<0.05 for all), as well as more firm (P=0.03) and less frequent (P<0.01) stools after low FODMAP intervention, but not after moderate FODMAP intervention. A third (34%) responded clinically to the low FODMAP diet, and the response could be predicted by higher IBS-SSS at baseline (P=0.02). Although modest associations between FODMAP sensitivity (22%) and GI symptoms during LNCT were observed, no independent predictors could be identified.
Conclusions
A diet low in FODMAPs reduces GI symptoms and affects bowel habits in IBS, compared with a moderate FODMAP diet. Assessment of IBS severity before the intervention may be used to predict clinical response to a low FODMAP diet.
Trial registry (http://www.clinicaltrials.gov): Registered under Clinical Trial number NCT05182593.
... Several disorders affecting the gastrointestinal tract, such as food intolerances, irritable bowel syndrome (IBS) or celiac disease, can be managed by following highly restrictive diets (7)(8)(9)(10)(11). However, over time, these diets can have a negative impact on the composition of the intestinal microbiota, although this is a more complex relationship (11-15). ...
Restrictive diets for the treatment of different gastrointestinal disorders are reported to change the composition of intestinal microbiota. Recently, it has been proposed that individuals with histamine intolerance suffer from intestinal dysbiosis, having an overabundance of histamine-secreting bacteria, but how it is still unknown this state is affected by the usual dietary treatment of histamine intolerance [i.e., low-histamine diet and the supplementation with diamine oxidase (DAO) enzyme]. Thus, a preliminary study was carried out aiming to evaluate the potential changes on the composition of the intestinal microbiota in a group of five women diagnosed with histamine intolerance undergoing 9 months of the dietary treatment of histamine intolerance. After sequencing bacterial 16S rRNA genes (V3-V4 region) and analyzing the data using the EzBioCloud Database, we observed a reduction in certain histamine-secreting bacteria, including the genera Proteus and Raoultella and the specie Proteus mirabilis. Moreover, it was also observed an increase in Roseburia spp., a bacterial group frequently related to gut health. These changes could help to explain the clinical improvement experienced by histamine intolerant women underwent a dietary treatment.
... During the process, hydrogen gas and methane gas are generated, and they draw water into the intestinal tract due to their high osmotic pressure. In clinical trials, it has been reported that IBS patients who ate a low-FODMAP diet had fewer IBS symptoms than those who ate a normal diet [34,35,[39][40][41][42][43]. ...
Irritable bowel syndrome (IBS) causes abdominal pain during bowel movements and is diagnosed according to the Rome IV international diagnostic criteria. Patients diagnosed as having IBS experience abdominal pain at least 1 day/week, on average, over a 3-month period and not 3 days per month. A diagnosis of IBS is confirmed if symptoms have persisted for more than 6 months. IBS symptoms negatively affect daily life. First, improving daily habits are important to ameliorating IBS symptoms. IBS symptoms can be alleviated by staying active, sleeping, resting and staying stress-free. In addition, it is important to eat three, balanced meals a day on a regular basis and avoid overeating, especially at night. Spicy foods, high-fat foods, and alcohol can exacerbate symptoms. Researchers found, in a literature review, that IBS symptoms can be ameliorated by improving daily habits, thus relieving abdominal pain and the defecation symptoms of IBS.
... For some, increased motility occurs, leading to diarrhoea and fermentation in the large bowel, the result of which is wind, bloating and abdominal pain [39]. The low FODMAP diet has consistently been shown to effectively manage symptoms in those with IBS [40][41][42][43][44][45]. However, these intervention studies have been conducted in adults with a mean age of 50 years or younger. ...
Chronic diarrhoea affects up to 10% of older adults, impacts quality of life and has potential adverse medical outcomes. Dietary changes can be effective but, if not managed correctly, could negatively impact health. This review summarises the prevalence, potential causes, and complications of chronic diarrhoea in older people. The evidence for dietary treatments, and the nutritional implications, are described.
... No significant change was observed in the levels of Bacteriodetes and Enterococcus compared to the control group [82]. Studies have shown that a diet containing low levels of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) reduces symptom severity in IBS patients [83][84][85][86]. In a study investigating the efficacy of the FOD-MAP diet on microbiota in childhood IBS, it was determined that the diet-responsive group had higher rates of Bacteroidaceae, Erysipilotrichaceae, and Clostridiales species, which have a higher saccharolytic metabolic capacity and carbohydrate metabolism. ...
Recent studies have shown that the microbiota, which is rich in variety and amount of nutrients, lives in the intestines and is thought to act as an organ, plays a significant role in the pathogenesis of health and diseases, and its composition is personal. Tailoring the diet, one of the most effective factors in the modulation of microbiota, for the promotion of health, the treatment of obesity, diabetes mellitus, cardiovascular and gastrointestinal system diseases are accepted as a potential therapeutic approach. In addition to practical methods such as anthropometric measurements used in the routine evaluation of nutrition, evaluation of food consumption records, and physical activity, some technological methods have been developed recently after the technology 4.0 revolution, which analyzes the host-microbiome with various methods. Although these next-generation technologies are promising for the evaluation of data on the individual microbiome and dietary interactions and the development of recommendations in this direction, there are several problems in data processing and analysis. Considering the impact of diet-microbiota interaction on health and disease, microbiota-based personalized dietary recommendations are promising, but still, there seems to be some way to go. In this mini-review, the diet-microbiota relationship in a personalized diet approach was evaluated and the potential use or usability of diet planning based on this approach was discussed.
... Over the last decade, research has shown that the FODMAPrestricted diet may be a safe and effective dietary intervention (56). Several studies have been conducted to conclude that an LFD is effective in relieving overall IBS symptoms and behaves either with non-inferiority or superiority with respect to other comparators (27,57,58). The consumption of an LFD has been found to improve symptoms in more than half of IBS patients (59). ...
Background
There are about 10–23% of adults worldwide suffering from irritable bowel syndrome (IBS). Over the past few decades, there are many aspects of uncertainty regarding IBS leading to an ongoing interest in the topic as reflected by a vast number of publications, whose heterogeneity and variable quality may challenge researchers to measure their scientific impact, to identify collaborative networks, and to grasp actively researched themes. Accordingly, with help from bibliometric approaches, our goal is to assess the structure, evolution, and trends of IBS research between 2007 and 2022.
Methods
The documents exclusively focusing on IBS from 2007 to 2022 were retrieved from the Science Citation Index Expanded of the Web of Science Core Collection. The annual productivity of IBS research, and the most prolific countries or regions, authors, journals and resource-, intellectual- and knowledge-sharing in IBS research, as well as co-citation analysis of references and keywords were analyzed through Microsoft Office Excel 2019, CiteSpace, and VOSviewer.
Results
In total, 4,092 publications were reviewed. The USA led the list of countries with the most publications (1,226, 29.96%). Mayo Clinic contributed more publications than any other institution (193, 4.71%). MAGNUS SIMREN stood out as the most active and impactful scholar with the highest number of publications and the greatest betweenness centrality value. The most high-yield journal in this field was Neurogastroenterology and motility: the official journal of the European Gastrointestinal Motility Society (275, 6.72%). Gastroenterology had the most co-citations (3,721, 3.60%). Keywords with the ongoing strong citation bursts were chromogranin A, rat model, peptide YY, gut microbiota, and low-FODMAP diet, etc.
Conclusion
Through bibliometric analysis, we gleaned deep insight into the current status of literature investigating IBS for the first time. These findings will be useful to scholars interested in understanding the key information in the field, as well as identifying possible research frontiers.
... bean meal) have thus been shown to increase intestinal gas production (volume, frequency of evacuations) and abdominal symptoms in patients with DGBI complaining of GRS (12)(13)(14)(15) . Moreover, dietary restriction strategies like the low fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet are currently used to relieve IBS symptoms (16)(17)(18) . ...
This study evaluated the association between dietary patterns, Gas-Related Symptoms (GRS) and their impact on quality of life (QoL) in a representative sample (n=936) of the French adult population. During the 2018-2019 “Comportements et Consommations Alimentaires en France” (CCAF) survey (Behaviors and Food Consumption in France), online evaluation of GRS in adult participants was performed using the validated Intestinal Gas Questionnaire (IGQ), which captures the perception of GRS and their impact on QoL via 6 symptom dimensions scores (range 0-100; 100=worse) and a global score (mean of the sum of the 6 symptom dimensions scores). Socio-demographics, lifestyle parameters and dietary habits (7-day e-food diary) were also collected online. Quality of diet was determined using the NRF9.3 score (range 0-900; 900=best). Univariate and multivariate linear regression models were applied to identify factors associated with IGQ global score. K-means was used to identify clusters of subjects based on their dietary records. Data from 936 adults who completed both the IGQ and the food diary showed a mean (SD) IGQ global score of 11.9 (11.2). Younger age and female gender were associated with a higher IGQ global score. Only 7% of subjects reported no symptom at all and nearly 30% of study participants reported a high impact of GRS on their QoL. Two dietary clusters were identified: cluster1, characterized by a higher consumption of fruits and vegetables, lower sugars intake and higher NRF9.3 score and cluster 2, characterized by higher intake of sugars, lower intake in dietary fibers and lower NRF9.3 score. The IGQ global score was lower in cluster1 and higher in cluster2 vs. the total sample average (p<0.001). Prevalence of GRS in the French adult population is high and is associated with impaired QoL and dietary patterns. A change in food habits towards healthier patterns could help reducing the burden of GRS.
... advice. 17,18 Further, a study by Böhn and colleagues also showed statistically significant improvements in abdominal distension in patients with IBS treated with a low-FODMAP diet compared with pre-diet intervention baseline. 19 However, a recent meta-analysis of 13 randomized controlled trials (RCTs) assessing a low-FODMAP diet for the treatment of IBS demonstrated that a low-FODMAP diet was superior to British Dietetic Association/National Institute for Health and Care Excellence dietary advice with respect to improving symptoms of bloating or distension but was not found to be superior to other dietary strategies, including a high-FODMAP diet. ...
Abdominal bloating and distension are highly prevalent symptoms that can negatively impact quality of life and lead to medical consultation. Despite their prevalence, symptoms of bloating and distension pose a unique diagnostic and therapeutic challenge, as they are inherently nonspecific symptoms with a complex etiology, and no uniform diagnostic or treatment algorithm currently exists. Additionally, bloating is common among disorders of gut-brain interaction, which can be difficult to treat. This article offers a practical approach for evaluating and treating symptoms of bloating and distension through discussion of 5 common etiologies: diet, small intestinal bacterial over-growth, constipation, visceral hypersensitivity, and abdomino-phrenic dyssynergia. An effective personalized evaluation and treatment plan can be established to address symptoms of bloating and distension through consideration of these etiologies in the context of the patient's individual characteristics and presentation.
... 3 Indeed, an MRI study revealed that IBS patients have a greater small bowel water content after ingestion of lactulose than healthy controls, 16 which might be caused either by increased fluid secretion, mediated for example by mast cells, or altered motor activity of the small intestine. 16 Some of the first evidence that restricting poorly absorbed carbohydrates could relieve IBS symptoms came from studies carried on in Australia, 17 supported shortly after by a study conducted in the United Kingdom, 18 Multiple studies have focused on predictors of treatment response to identify those patients that are more likely to respond to the low FODMAP diet. Among those, a good adherence to the diet, a lower intake of fermentable carbohydrates before starting the diet, as well as older age, female sex, and psychological status have been identified. ...
Irritable bowel syndrome (IBS) patients often resort to dietary interventions to manage their symptoms, as these are frequently exacerbated by various food items. A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) is now considered by many a first‐line treatment option for IBS, as it has been found to be superior to alternative dietary interventions. However, concerns have been raised as restricting fermentable carbohydrates might result in nutritional deficits or alter composition and function of the gut microbiome in the long term. The study by Staudacher et al., published in this issue of the journal, is the first prospective study to follow IBS patients after completing all three phases of the low FODMAPs diet (restriction, reintroduction, and personalization), demonstrating that this is safe and effective in long‐term, when patients are supervised by a dietician. This mini‐review provides an up‐to‐date overview of the use of fermentable carbohydrate's restrictions for symptom management in IBS patients, while summarizing the current knowledge on the possible mechanisms of action behind low fermentable carbohydrate diet efficacy.
It is now well-established that exercise can disturb various aspects of gastrointestinal integrity and function. The pathophysiology of these perturbations, termed “exercise-induced gastrointestinal syndrome (EIGS),” can lead to exercise-associated gastrointestinal symptom (Ex-GIS) inconveniences. EIGS outcomes can impact physical performance and may lead to clinical manifestation warranting medical intervention, as well as systemic responses leading to fatality. Athlete support practitioners seek prevention and management strategies for EIGS and Ex-GIS. This current position statement aimed to critically appraise the role of EIGS and Ex-GIS prevention and management strategies to inform effective evidence-based practice and establish translational application. Intervention strategies with mostly consistent beneficial outcomes include macronutrient (i.e., carbohydrate and protein) intake and euhydration before and during exercise, dietary manipulation of fermentable oligo-, di-, and mono-saccharides and polyols (FODMAP), and gut training or feeding tolerance adjustments for the specific management of Ex-GIS from gastrointestinal functional issues. Strategies that may provide benefit and/or promising outcomes, but warrant further explorations include heat mitigating strategies and certain nutritional supplementation (i.e., prebiotics and phenols). Interventions that have reported negative outcomes included low-carbohydrate high-fat diets, probiotic supplementation, pharmaceutical administration, and feeding intolerances. Owing to individual variability in EIGS and Ex-GIS outcomes, athletes suffering from EIGS and/or support practitioners that guide athletes through managing EIGS, are encouraged to undertake gastrointestinal assessment during exercise to identify underlying causal and exacerbation factor/s, and adopt evidence-based strategies that provide individualized beneficial outcomes. In addition, abstaining from prevention and management strategies that present unclear and/or adverse outcomes is recommended.
Context
The efficacy of probiotics and diet management in irritable bowel syndrome (IBS) is controversial, and their relative effectiveness remains unclear.
Objective
This study aimed to evaluate the effects of probiotics, diet management, and their combination on IBS.
Data Sources
PubMed, Embase, Cochrane, and Web of Science were searched from inception to July 10, 2023, for relevant studies, including symptom relief, IBS–symptom severity score (-SSS), and IBS–quality of life measure (-QOL).
Data Extraction
Two investigators independently performed the data extraction and quality assessment.
Data Analysis
A network meta-analysis was performed using a frequentist approach and a random-effects model to estimate the relative risk (RR) and 95% CI.
Results
Forty-four articles were eligible for this study. In relieving IBS symptoms, compared with a sham diet, a low–fermentable oligosaccharide, disaccharide, monosaccharide, and polyols (low-FODMAP) diet (RR: 3.22; 95% CI: 1.70–6.26) and low-FODMAP diet combined with probiotics (RR: 17.79; 95% CI: 3.27–112.54) significantly relieved IBS symptoms. The control group showed significantly lower effectiveness than the probiotics group (RR: 0.47; 95% CI: 0.32–0.69). According to the surface under the cumulative rank curve (SUCRA), a low-FODMAP diet combined with probiotics (80.4%) had the best effect in relieving IBS symptoms, followed by a low-FODMAP diet (70.8%), probiotics (65.1%), and a gluten-free diet (54.3%). In reducing the total IBS-SSS, the low-FODMAP diet (90.5%) was the most effective, followed by the low-FODMAP diet combined with probiotics (76.6%), probiotics alone (62.3%), and gluten-free diet (28.3%). In reducing total IBS-QOL, probiotics (72.1%) ranked first, followed by gluten-free (57.0%) and low-FODMAP (56.9%) diets. Probiotics (34.9%) were associated with the lowest risk of adverse effects.
Conclusion
A low-FODMAP diet combined with probiotics is most effective in relieving IBS symptoms. A low-FODMAP diet is the most recommended diet for alleviating IBS severity, and probiotics were associated with improving the QOL of patients with IBS, with the fewest adverse events.
Systematic Review Registration
PROSPERO registration no. CRD42024499113.
Irritable bowel syndrome (IBS) is a very common functional gastrointestinal disease, and it is likely various factors contribute to the causation of IBS symptoms. The prevalence of IBS are greatly affected by the IBS diagnostic criteria such as Manning, Rome III, and Rome IV. The worldwide prevalence of IBS ranges from 8% to 20% of the general population before the Rome IV criteria publication in 2016, whereas a recent study reported a 3.8% IBS prevalence with the Rome IV criteria. The Rome IV IBS criteria are thought to be more restrictive and severe than the Rome III and other criteria.
Numerous studies have reported that IBS is more prevalent in women than in men. Additionally, IBS is the most prevalent in patients with less than 50 years old, and this prevalence decrease with age. Several other factors including races, geographic location, eating habits, and body mass index influence the epidemiology of IBS.
A síndrome do intestino irritável (SII) é uma condição gastrointestinal comum que afeta significativamente a qualidade de vida dos pacientes. Esta revisão sistemática visa avaliar a eficácia de dietas específicas no manejo da SII, com foco em dietas como a baixa em FODMAPs, nutrição enteral exclusiva e estratégias de modulação da microbiota intestinal. Foram revisados estudos publicados entre 2010 e 2023, extraídos de bases de dados como PubMed, Scopus, Web of Science e Cochrane Library. Os resultados indicam que a dieta baixa em FODMAPs é particularmente eficaz na redução dos sintomas da SII, enquanto outras intervenções, como a nutrição enteral e o transplante de microbiota fecal, também mostram benefícios promissores. A personalização das dietas e a orientação nutricional contínua são essenciais para maximizar os benefícios terapêuticos. A revisão destaca a importância de abordagens dietéticas personalizadas e sugere direções para pesquisas futuras.
FODMAP, diyeti içerisinde “fermente edilebilir oligosakkaritler, disakkaritler, monosakkaritler ve polyolleri bulunduran bir terimdir. FODMAP içeren besinlerin tüketimi şişkinlik, karın ağrısı, diyare gibi bazı gastrointestinal semptomların ortaya çıkmasına neden olabilmektedir. Bu nedenle fermente edilebilir monosakkaritler, disakkaritler, oligosakkaritler ve poliolleri içeren besinlerin diyette alımının azaltılması olarak tanımlanan düşük FODMAP diyetinin; gastrointestinal semptomlarla karakterize olan irritabl bağırsak sendromu (İBS), Crohn hastalığı, ülseratif kolit ve çölyak tanısı olmayan gluten duyarlılığı hastalıklarının seyrinin iyileşmesinde fayda sağlayabildiği görülmüştür. Çalışmalar, vücut ağırlığı artışının gastrointestinal sistem motilitesi ile ilişkili olduğunu göstermektedir. Obez bireylerde değişen ince bağırsak ve kolon geçişi, İBS semptomlarına benzer semptomların ortaya çıkmasına neden olabilmektedir. Düşük FODMAP diyetinin İBS hastalarının gastrointestinal sistem semptomlarını düzeltmede etkili olduğu, hastalığın şiddetini ve seyrini değiştirebildiği vurgulanmıştır. Bu nedenle düşük FODMAP diyetinin obez bireylerde bozulan bağırsak motilitesini, bağırsak mikrobiyotasını ve İBS semptonlarına benzer şikayetleri olumlu yönde değiştirebileceği belirtilmiştir. Ayrıca düşük FODMAP diyeti bağırsak motilitesini düzenleyerek ve gastrointestinal endokrin hücrelerin dansitelerinin normale yaklaşma eğilimini artırarak obez bireylerde vücut ağırlığı kaybına da katkı sağlayabilmektedir. Ancak FODMAP içeren besinler, olumsuz etkilerinin yanı sıra; dışkı hacmini arttırırlar, serum kolesterol ve triasilgliseroller seviyelerini azaltırlar. Ayrıca kolonda hücre proliferasyonunu uyararak kolonu kansere karşı korurlar. Bu olumlu etkilerin tümü düşük FODMAP diyetiyle kaybolmaktadır. Düşük FODMAP diyetinin gastrointestinal şikayetlerin iyileşmesinde, obezite riskinin azalmasında, vücut ağırlığı yönetiminin sağlanmasında olumlu sonuçları olmasına karşın, diyetin bağırsaktaki yararlı bakteriler için prebiyotik özellik gösteren besinlerden yoksun olması nedeniyle mikrobiyata üzerinde olumsuz etkileri olduğu, diyetin kontrollü olarak uygulanmasının ve kısa süreli diyet denemelerinin hasta sağlığı açısından önemli olduğu unutulmamalıdır.
During the last decade, scientific interest in and consumer attention to sourdough fermentation in bread making has increased. On the one hand, this technology may favorably impact product quality, including flavor and shelf-life of bakery products; on the other hand, some cereal components, especially in wheat and rye, which are known to cause adverse reactions in a small subset of the population, can be partially modified or degraded. The latter potentially reduces their harmful effects, but depends strongly on the composition of sourdough microbiota, processing conditions and the resulting acidification. Tolerability, nutritional composition, potential health effects and consumer acceptance of sourdough bread are often suggested to be superior compared to yeast-leavened bread. However, the advantages of sourdough fermentation claimed in many publications rely mostly on data from chemical and in vitro analyzes, which raises questions about the actual impact on human nutrition. This review focuses on grain components, which may cause adverse effects in humans and the effect of sourdough microbiota on their structure, quantity and biological properties. Furthermore, presumed benefits of secondary metabolites and reduction of contaminants are discussed. The benefits claimed deriving from in vitro and in vivo experiments will be evaluated across a broader spectrum in terms of clinically relevant effects on human health. Accordingly, this critical review aims to contribute to a better understanding of the extent to which sourdough bread may result in measurable health benefits in humans.
Background
A diet low in fermentable oligo‐saccharides, di‐saccharides, mono‐saccharides and polyols (low FODMAP diet) is complex and clinical effectiveness is achieved with dietitian‐led education, although dietitian availability in clinical practice varies. This study aimed to assess the feasibility of undertaking a trial to investigate the clinical and cost‐effectiveness of different education delivery methods of the low FODMAP diet in patients with disorders of gut–brain interaction (DGBI).
Methods
In this feasibility randomized controlled trial, patients with DGBI requiring the low FODMAP diet were randomized to receive one of the following education delivery methods: booklet, app, or dietitian. Recruitment and retention rates, acceptability, symptoms, stool output, quality of life, and dietary intake were assessed.
Key Results
Fifty‐one patients were randomized with a recruitment rate of 2.4 patients/month and retention of 48 of 51 (94%). Nobody in the booklet group strongly agreed that this education delivery method enabled them to self‐manage symptoms without further support, compared to 7 of 14 (50%) in the dietitian group (p = 0.013). More patients reported adequate relief of symptoms in the dietitian group (12, 80%) compared with the booklet group (7, 39%; p = 0.026), but not when compared to the app group (10, 63%, p > 0.05). There was a greater decrease in the IBS‐SSS score in the dietitian group (mean −153, SD 90) compared with the booklet group (mean −90, SD 56; p = 0.043), but not when compared with the app group (mean −120, SD 62; p = 0.595).
Conclusions & Inferences
Booklets were the least acceptable education delivery methods. Dietitian‐led consultations led to high levels of clinical effectiveness, followed by the app, while the dietitian was superior to booklets alone. However, an adequately powered clinical trial is needed to confirm clinical effectiveness of these education delivery methods.
Irritable bowel syndrome (IBS) is characterized by abdominal pain and altered bowel habits in the absence of an identifiable structural abnormality. Abdominal bloating, loose stools, urgency associated with bowel movements, and feelings of incomplete evacuation are common symptoms. Since there are no diagnostic laboratory tests to confirm the diagnosis, IBS is usually a clinical diagnosis, and symptom-based diagnostic criteria have been proposed. Unlike adults, there are few published studies in pediatric age group, especially in young children, validating these criteria. It is generally thought that IBS symptoms result from the convergence of multiple factors, including a genetic predisposition, an infectious or inflammatory injury to the gastrointestinal (GI) tract leading to altered sensory perception by the brain, and an underlying bowel dysmotility. Children with inflammatory bowel disease are prone to developing visceral hypersensitivity due to chronic GI tract inflammation. Abdominal pain and loose stools in the absence of detectable and clinically significant gut mucosal inflammation should prompt one to consider this diagnosis in patients with IBD. Judicious use of endoscopic examination in addition to laboratory test to screen for bowel mucosal inflammation can be helpful in differentiating symptoms due to relapse of IBD for visceral hypersensitivity and IBS. Symptom relief is the primary goal of management in IBS; targeting the most distressing symptom is recommended. Current treatment includes diet modification, antibiotics for small bowel bacterial overgrowth and probiotics, cognitive behavioral therapy (CBT) to empower the patient to cope with chronic illness and learn to control their symptoms, and drugs for neuropathic pain.
Inflammatory bowel disease (IBD), a non-specific chronic idiopathic inflammatory condition of the digestive system, requires lifelong treatment in which drugs are the mainstay, along with surgery when necessary. In adjuvant therapies, the diet is considered to be an essential, controllable, and economical component. However, the majority of recent nutrition research has focused on the general effects of nutrients on IBD, with little attention given to the advantages and negative aspects of individual foods and dietary combinations. To cover these shortcomings, we surveyed the benefits and drawbacks of typical foods and their chemical compositions on intestinal pathophysiology by comparing nutrients existing in the foods in Eastern and Western countries. Moreover, for Eastern and Western patients with IBD, we innovatively propose a 3-step dietary recommendation based on modified customary eating habits, including lowering the triggering foods, modifying dietary advice to control disease progression, and improving surgery prognosis.
The irritable bowel syndrome (IBS) is a chronic disorder of gut-brain interaction. IBS is still associated with areas of uncertainties, especially regarding the optimal diagnostic work-up and the more appropriate management. Experts from 7 Italian Societies conducted a Delphi consensus with literature summary and voting process on 27 statements. Recommendations and quality of evidence were evaluated using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus was defined as >80% agreement and reached for all statements. In terms of diagnosis, the consensus supports a positive diagnostic strategy with a symptom-based approach, including the psychological comorbidities assessment and the exclusion of alarm symptoms, together with the digital rectal examination, full blood count, C-reactive protein, serology for coeliac disease, and fecal calprotectin assessment. Colonoscopy should be recommended in patients with alarm features. Regarding treatment, the consensus strongly supports a dietary approach for patients with IBS, the use of soluble fiber, secretagogues, tricyclic antidepressants, psychologically directed therapies and, only in specific IBS subtypes, rifaximin. A conditional recommendation was achieved for probiotics, polyethylene glycol, antispasmodics, selective serotonin reuptake inhibitors and, only in specific IBS subtypes, 5-HT3 antagonists, 5-HT4 agonists, bile acid sequestrants.
Kap. 4 befasst sich ausschließlich mit dem Management der EDS durch eine Kombination aus verschiedenen Behandlungsmethoden. Unter anderem werden den Leser*innen in diesem Zusammenhang verschiedene physiotherapeutische Konzepte näher gebracht. Des Weiteren wird aufgezeigt, welche Vorsorgeuntersuchungen regelmäßig stattfinden müssen, welche allgemeinen Anpassungen der Lebensumstände, z. B. Verbesserung der Schlafhygiene oder die Veränderung der Ernährung, hilfreich sein können. Auch auf die Schmerztherapie unter Einsatz verschiedener Schmerzmedikamente wird detailliert eingegangen und zusätzlich wird aufgezeigt, welche verschiedenen Hilfsmittel die Lebensqualität verbessern können. Anschließend wird auf die möglichen Komplikationen bei Operationen sowie bei Geburt und Schwangerschaft verwiesen und zum Schluss hin erfahren die Betroffenen, welche Mechanismen im Alltag zur besseren Bewältigung der Erkrankung beitragen können.
Background:
Irritable bowel syndrome (IBS) is characterised by recurrent abdominal pain related to defaecation or associated with altered stool frequency or consistency. Despite its prevalence, major uncertainties in the diagnostic and therapeutic management persist in clinical practice.
Methods:
A Delphi consensus was conducted by 20 experts from Belgium, and consisted of literature review and voting process on 78 statements. Grading of recommendations, assessment, development and evaluation criteria were applied to evaluate the quality of evidence. Consensus was defined as > 80 % agreement.
Results:
Consensus was reached for 50 statements. The Belgian consensus agreed as to the multifactorial aetiology of IBS. According to the consensus abdominal discomfort also represents a cardinal symptom, while bloating and abdominal distension often coexist. IBS needs subtyping based on stool pattern. The importance of a positive diagnosis, relying on history and clinical examination is underlined, while additional testing should remain limited, except when alarm features are present. Explanation of IBS represents a crucial part of patient management. Lifestyle modification, spasmolytics and water-solube fibres are considered first-line agents. The low FODMAP diet, selected probiotics, cognitive behavioural therapy and specific treatments targeting diarrhoea and constipation are considered appropriate. There is a consensus to restrict faecal microbiota transplantation and gluten-free diet, while other treatments are strongly discouraged.
Conclusions:
A panel of Belgian gastroenterologists summarised the current evidence on the aetiology, symptoms, diagnosis and treatment of IBS with attention for the specificities of the Belgian healthcare system.
Excluding oligo-, di-, monosaccharides and polyols (FODMAPs) from the diet is increasingly being used to treat children with gastrointestinal complaints. The aim of this position paper is to review the available evidence on the safety and efficacy of its use in children and provide expert guidance regarding practical aspects in case its use is considered . Members of the Gastroenterology Committee, the Nutrition Committee and the Allied Health Professionals Committee of the European Society for Pediatric Gastroenterology Hepatology and Nutrition contributed to this position paper. Clinical questions regarding initiation, introduction, duration, weaning, monitoring, professional guidance, safety and risks of the diet are addressed. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. The systematic literature search revealed that the low-FODMAP diet has not been comprehensively studied in children. Indications and contraindications of the use of the diet in different pediatric gastroenterological conditions are discussed and practical recommendations are formulated. There is scarce evidence to support the use of a low-FODMAP diet in children with Irritable Bowel Syndrome and no evidence to recommend its use in other gastrointestinal diseases and complaints in children. Awareness of how and when to use the diet is crucial, as a restrictive diet may impact nutritional adequacy and/or promote distorted eating in vulnerable subjects. The present article provides practical safety tips to be applied when the low-FODMAP diet is considered in children.
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain and altered defecation, usually accompanied by abdominal bloating or distension. The integrated model of bidirectional interaction between the central, autonomic, enteric nervous system, the microbiome, and the gut barrier allows a better understanding of the pathophysiology of IBS, as well as consideration of potential therapeutic strategies. IBS with predominant diarrhea (IBS-D) represents a therapeutic challenge. Dietary changes or restrictions are most commonly used by patients in an attempt at symptom control. Therefore, a number of diets, especially low-FODMAP diet, have increasingly gained interest as a therapy for IBS-D or mixed IBS. However, this kind of diet, while effective, is not exempt of problems. It is therefore necessary that other therapeutic options be considered while bearing pathophysiological mechanisms and general symptom management in mind.
We studied in an investigator-blinded trial the efficacy of roughly ground partly defatted flaxseed on constipation in 55 patients suffering from constipation predominant irritable bowel syndrome. Fifty-five patients were randomised to receive 6-24 g/d either flaxseed or psyllium for 3 months. During the blinded treatment period 26 patients received flaxseed and 29 received psyllium. In flaxseed group, constipation and abdominal symptoms were decreased significantly (p=0.002) whereas in psyllium group the reduction was not statistically significant. After the blinded treatment period, the difference between groups was statistically significant in constipation (p=0.05) and in bloating and pain (p=0.001). Forty patients continued to the open period with flaxseed treatment only, 18 from flaxseed group and 22 from psyllium group. After the open period of 3 months, constipation and abdominal symptoms were further significantly reduced (p=0.001). Safety laboratory values were unchanged with exception of serum thiocyanate that increased from 40.9 to 153.7 μmol/l in flaxseed group. After additional 3 months' treatment with flaxseed this value was decreased to 104 mmol/l. Blood cadmium was normal (3.4 nmol/l) after six months' flaxseed treatment.
Symptoms of pain, bloating, wind, constipation and/or diarrhea are commonly present in various gastrointestinal disorders and are often attributed to a functional gut disturbance. Dealing with such symptoms is currently unsatisfactory and is minimally featured in conventional medical literature. Fructose is receiving increasing attention as a factor in the diet that, when malabsorbed, may induce these symptoms. However, fructose is only one of many poorly absorbed, short-chain carbohydrates (Fermentable Oligo-, Di- and Mono-saccharides And Polyols or FODMAPs) in the diet. Others include fructans, lactose (in hypolactasic individuals), polyols and galactans. FODMAPs are theoretically attractive targets for dietary change due to their high osmotic activity and rapid fermentability, leading to luminal distension and the potential for subsequent symptom induction in those with less adaptable bowels and/or visceral hypersensitivity. A global approach to the reduction of dietary FODMAPs is proposed and current evidence supports its efficacy in relieving symptoms in the majority of patients with functional gut disorders.
Despite increased prescription of a gluten-free diet for gastrointestinal symptoms in individuals who do not have celiac disease, there is minimal evidence that suggests that gluten is a trigger. The aims of this study were to determine whether gluten ingestion can induce symptoms in non-celiac individuals and to examine the mechanism.
A double-blind, randomized, placebo-controlled rechallenge trial was undertaken in patients with irritable bowel syndrome in whom celiac disease was excluded and who were symptomatically controlled on a gluten-free diet. Participants received either gluten or placebo in the form of two bread slices plus one muffin per day with a gluten-free diet for up to 6 weeks. Symptoms were evaluated using a visual analog scale and markers of intestinal inflammation, injury, and immune activation were monitored.
A total of 34 patients (aged 29-59 years, 4 men) completed the study as per protocol. Overall, 56% had human leukocyte antigen (HLA)-DQ2 and/or HLA-DQ8. Adherence to diet and supplements was very high. Of 19 patients (68%) in the gluten group, 13 reported that symptoms were not adequately controlled compared with 6 of 15 (40%) on placebo (P=0.0001; generalized estimating equation). On a visual analog scale, patients were significantly worse with gluten within 1 week for overall symptoms (P=0.047), pain (P=0.016), bloating (P=0.031), satisfaction with stool consistency (P=0.024), and tiredness (P=0.001). Anti-gliadin antibodies were not induced. There were no significant changes in fecal lactoferrin, levels of celiac antibodies, highly sensitive C-reactive protein, or intestinal permeability. There were no differences in any end point in individuals with or without DQ2/DQ8.
"Non-celiac gluten intolerance" may exist, but no clues to the mechanism were elucidated.
Reduction of short-chain poorly absorbed carbohydrates (FODMAPs) in the diet reduces symptoms of irritable bowel syndrome (IBS). In the present study, we aimed to compare the patterns of breath hydrogen and methane and symptoms produced in response to diets that differed only in FODMAP content.
Fifteen healthy subjects and 15 with IBS (Rome III criteria) undertook a single-blind, crossover intervention trial involving consuming provided diets that were either low (9 g/day) or high (50 g/day) in FODMAPs for 2 days. Food and gastrointestinal symptom diaries were kept and breath samples collected hourly over 14 h on day 2 of each diet.
Higher levels of breath hydrogen were produced over the entire day with the high FODMAP diet for healthy volunteers (181 +/- 77 ppm.14 h vs 43 +/- 18; mean +/- SD P < 0.0001) and patients with IBS (242 +/- 79 vs 62 +/- 23; P < 0.0001), who had higher levels during each dietary period than the controls (P < 0.05). Breath methane, produced by 10 subjects within each group, was reduced with the high FODMAP intake in healthy subjects (47 +/- 29 vs 109 +/- 77; P = 0.043), but was not different in patients with IBS (126 +/- 153 vs 86 +/- 72). Gastrointestinal symptoms and lethargy were significantly induced by the high FODMAP diet in patients with IBS, while only increased flatus production was reported by healthy volunteers.
Dietary FODMAPs induce prolonged hydrogen production in the intestine that is greater in IBS, influence the amount of methane produced, and induce gastrointestinal and systemic symptoms experienced by patients with IBS. The results offer mechanisms underlying the efficacy of the low FODMAP diet in IBS.
Irritable bowel syndrome (IBS) is a disorder of chronic abdominal pain, altered bowel habit and abdominal distension. It is the commonest cause of referral to gastroenterologists in the developed world and yet current therapeutic strategies are often unsatisfactory. There is now increasing evidence linking alterations in the gastrointestinal (GI) microbiota and IBS. Changes in faecal and mucosa-associated microbiota, post-infectious IBS, a link with small intestinal bacterial overgrowth and an up-regulation of the GI mucosal immune system all suggest a role for the GI microbiota in the pathogenesis of IBS. Given this evidence, therapeutic alteration of the GI microbiota by probiotic bacteria could be beneficial. The present paper establishes an aetiological framework for the use of probiotics in IBS and comprehensively reviews randomised placebo-controlled trials of probiotics in IBS using multiple electronic databases. It highlights safety concerns over the use of probiotics and attempts to establish guidelines for their use in IBS in both primary and secondary care.
To determine the effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome.
Systematic review and meta-analysis of randomised controlled trials.
Medline, Embase, and the Cochrane controlled trials register up to April 2008. Review methods Randomised controlled trials comparing fibre, antispasmodics, and peppermint oil with placebo or no treatment in adults with irritable bowel syndrome were eligible for inclusion. The minimum duration of therapy considered was one week, and studies had to report either a global assessment of cure or improvement in symptoms, or cure of or improvement in abdominal pain, after treatment. A random effects model was used to pool data on symptoms, and the effect of therapy compared with placebo or no treatment was reported as the relative risk (95% confidence interval) of symptoms persisting.
12 studies compared fibre with placebo or no treatment in 591 patients (relative risk of persistent symptoms 0.87, 95% confidence interval 0.76 to 1.00). This effect was limited to ispaghula (0.78, 0.63 to 0.96). Twenty two trials compared antispasmodics with placebo in 1778 patients (0.68, 0.57 to 0.81). Various antispasmodics were studied, but otilonium (four trials, 435 patients, relative risk of persistent symptoms 0.55, 0.31 to 0.97) and hyoscine (three trials, 426 patients, 0.63, 0.51 to 0.78) showed consistent evidence of efficacy. Four trials compared peppermint oil with placebo in 392 patients (0.43, 0.32 to 0.59).
Fibre, antispasmodics, and peppermint oil were all more effective than placebo in the treatment of irritable bowel syndrome.
Background:
Both high-fibre dietary advice and the prescription of fibre as a bulking agent are very common in primary and secondary care management of irritable bowel syndrome. Irritable bowel syndrome patients with constipation may have delayed intestinal transit. Therefore, fibres that accelerate intestinal transit may be beneficial in these patients. The uncertain benefits reported in several clinical studies, however, have led us to reappraise the value of fibre in irritable bowel syndrome management.
Aim:
To quantify the effect of different types of fibre on global and symptom relief from irritable bowel syndrome.
Methods:
Using a structured literature search in MEDLINE (1966-2002), we selected randomized controlled trials involving irritable bowel syndrome patients treated with fibre. Analyses were performed for the total group and for trials using soluble and insoluble fibre separately.
Results:
Seventeen studies were included in the analysis. None investigated primary care irritable bowel syndrome patients. Fibre, in general, was effective in the relief of global irritable bowel syndrome symptoms [relative risk, 1.33; 95% confidence interval (CI), 1.19-1.50]. Irritable bowel syndrome patients with constipation may receive benefit from fibre treatment (relative risk, 1.56; 95% CI, 1.21-2.02), but there was no evidence that fibre was effective in the relief of abdominal pain in irritable bowel syndrome. Soluble and insoluble fibre, separately, had different effects on global irritable bowel syndrome symptoms. Soluble fibre (psyllium, ispaghula, calcium polycarbophil) showed significant improvement (relative risk, 1.55; 95% CI, 1.35-1.78), whereas insoluble fibre (corn, wheat bran), in some cases, worsened the clinical outcome, but there was no significant difference compared with placebo (relative risk, 0.89; 95% CI, 0.72-1.11).
Conclusions:
The benefits of fibre in the treatment of irritable bowel syndrome are marginal for global irritable bowel syndrome symptom improvement and irritable bowel syndrome-related constipation. Soluble and insoluble fibres have different effects on global irritable bowel syndrome symptoms. Indeed, in some cases, insoluble fibres may worsen the clinical outcome. Future clinical studies evaluating the effect and tolerability of fibre therapy are needed in primary care.
This study estimates the prevalence of perceived food intolerance and its consequences in subjects with irritable bowel syndrome (IBS), evaluates the utility of common tests for food intolerance, studies the relation between perceived food intolerance and other disorders, and discusses the etiology.
Cross-sectional study.
National health survey.
A selection of the population (n=11,078) in Oppland county, Norway, was invited to a health screening, and a sample of subjects with IBS were included in the study.
A medical history of food intolerance, musculoskeletal pain, mood disorders and abdominal complaints was taken, and tests were performed for food allergy and malabsorption. A dietician evaluated the dietary habits of the subjects.
Out of 4,622 subjects with adequately filled-in questionnaires, 84 were included in the study, 59 (70%) had symptoms related to intake of food, 62% limited or excluded food items from the diet and 12% had an inadequate diet. The mean numbers of food items related to symptoms and the number of foods limited or excluded from the diet were 4.8 and 2.5, respectively. There were no associations between the tests for food allergy and malabsorption and perceived food intolerance. Perceived food intolerance was unrelated to musculoskeletal pain and mood disorders.
Perceived food intolerance is a common problem with significant nutritional consequences in a population with IBS. The uselessness of current antibody tests and tests for malabsorption and the lack of correlation to psychiatric co-morbidity make the etiology obscure.
Design:
Study part 1 was executed as a randomized double-blind placebo-controlled crossover study and study part 2 as a longitudinal study.
Subjects:
Forty-one healthy adult volunteers aged 18-24 years were recruited from the student population of the University of Salford. All subjects enrolled and completed study part 1 and 39 subjects enrolled and completed study part 2.
Interventions:
In study part 1, individuals consumed, in random order 0, 20, 40, 60, 80, 100 or 120 g of a RRM containing starch product incorporated in pre-prepared foods on individual test days. Assuming a minimum content of 50% RRM in the starch product this delivered respectively 0, 10, 20, 30, 40, 50 or 60 g of RRM. All foods were prepared and coded by personnel not involved in carrying out the tests. Test days were separated by 7 day washout periods. In study part 2, consumption of RRM was increased from 3.6 g at day 1 in incremental doses up to each subject's MNED as determined in study 1, to be achieved at day 14. Subsequently, RRM intake was from day 15-21 in a way that the final intake at day 21 was at least 10 g above the individual MNED. In both parts of the study, subjects reported the prevalence and magnitude of GI symptoms.
Results:
No significant change was observed in either defecation frequency and faecal consistency or the number of subjects experiencing any GI symptoms, following consumption of foods containing 0-60 g RRM. The individual MNED at which an increase in symptoms did not occur was determined as 60 g RRM for 71% of the subjects who participated in study part 1. Regression analysis showed that consumption of gradually increasing doses of RRM in food products over 21 days was associated with a significant increase in the mean symptom score for flatulence (P=1.5 x 10(-4)), total bowel movement frequency (P=0.023) and bowel movement frequency to pass watery faeces (P=0.0157). Increasing the ingested dose of RRM by 10 g above the predetermined MNED, however, did not provoke significant increases in GI symptoms. In both studies, the majority of symptom responses were classified by the subjects as 'little more than usual'.
Conclusions:
Consumption of up to 60 g RRM is tolerated well by most individuals with no evidence of any significant dose-dependent increase in the magnitude of symptoms or the occurrence of multiple GI symptoms. However, a mild laxative effect when consuming >60 g RRM is suggested. Although there was no change in GI responses following consumption of increasing doses of RRM over 21 days, generally a dose of 10 g RRM above the MNED level was tolerated well during medium term intake.
Patient education improves clinical outcomes in patients with chronic illness, but little is known about the education needs of patients with IBS.
The objective of this study was to identify: (1) patients perceptions about IBS; (2) the content areas where patients feel insufficiently informed, i.e., "knowledge gaps" about diagnosis, treatment options, etiology, triggers, prognosis, and role of stress; and (3) whether there are differences related to items 1 and 2 among clinically significant subgroups.
The IBS-Patient Education Questionnaire (IBS-PEQ) was developed using patient focus groups and cognitive item reduction of items. The IBS-PEQ was administered to a national sample of IBS patients via mail and online.
Frequencies of item endorsements were obtained. Clinically relevant groups, (a) health care seekers or nonhealth care seekers and (b) users or nonusers of the Web, were identified and grouped as MD/Web, MD/non-Web, and non-MD/Web.
1,242 patients completed the survey (371 via mail and 871 online), mean age was 39.3 +/- 12.5 yr, educational attainment 15 +/- 2.6 yr, 85% female, IBS duration 6.9 +/- 4.2 yr, 79% have seen an MD for IBS in the last 6 months, and 92.6% have used the Web for health information. The most prevalent IBS misconceptions included (% of subjects agreeing with the statement): IBS is caused by lack of digestive enzymes (52%), is a form of colitis (42.8%), will worsen with age (47.9%), and can develop into colitis (43%) or malnutrition (37.7%) or cancer (21.4%). IBS patients were interested in learning about (% of subjects choosing an item): (1) foods to avoid (63.3%), (2) causes of IBS (62%), (3) coping strategies (59.4%), (4) medications (55.2%), (5) will they have to live with IBS for life (51.6%), and (6) research studies (48.6%). Patients using the Web were better informed about IBS.
(1) Many patients hold misconceptions about IBS being caused by dietary habits, developing into cancer, colitis, causing malnutrition, or worsening with age; (2) patients most often seek information about dietary changes; and (3) educational needs may be different for persons using the internet for medical information.
Objective: To determine the effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome. Design: Systematic review and meta-analysis of randomised controlled trials. Data sources: Medline, Embase, and the Cochrane controlled trials register up to April 2008. Review methods: Randomised controlled trials comparing fibre, antispasmodics, and peppermint oil with placebo or no treatment in adults with irritable bowel syndrome were eligible for inclusion. The minimum duration of therapy considered was one week, and studies had to report either a global assessment of cure or improvement in symptoms, or cure of or improvement in abdominal pain, after treatment. A random effects model was used to pool data on symptoms, and the effect of therapy compared with placebo or no treatment was reported as the relative risk (95% confidence interval) of symptoms persisting. Results: 12 studies compared fibre with placebo or no treatment in 591 patients (relative risk of persistent symptoms 0.87, 95% confidence interval 0.76 to 1.00). This effect was limited to ispaghula (0.78, 0.63 to 0.96). Twenty two trials compared antispasmodics with placebo in 1778 patients (0.68, 0.57 to 0.81). Various antispasmodics were studied, but otilonium (four trials, 435 patients, relative risk of persistent symptoms 0.55, 0.31 to 0.97) and hyoscine (three trials, 426 patients, 0.63, 0.51 to 0.78) showed consistent evidence of efficacy. Four trials compared peppermint oil with placebo in 392 patients (0.43, 0.32 to 0.59). Conclusion: Fibre, antispasmodics, and peppermint oil were all more effective than placebo in the treatment of irritable bowel syndrome.
Aim : To determine the prevalence, symptom pattern and impact of the irritable bowel syndrome, across eight European countries, using a standardized methodology.
Methods : A community survey of 41 984 individuals was performed using quota sampling and random digit telephone dialling to identify those with diagnosed irritable bowel syndrome or those meeting diagnostic criteria, followed by in-depth interviews.
Results : The overall prevalence was 11.5% (6.2–12%); 9.6% had current symptoms, 4.8% had been formally diagnosed and a further 2.9%, 4.2% and 6.5% met the Rome II, Rome I or Manning criteria, respectively. Bowel habit classification varied by criteria: 63% had an ‘alternating’ bowel habit by Rome II vs. 21% by self-report. On average, 69% reported symptoms lasting for 1 h, twice daily, for 7 days a month. Irritable bowel syndrome sufferers reported more peptic ulcer (13% vs. 6%), reflux (21% vs. 7%) and appendectomy (17% vs. 11%), but not hysterectomy, cholecystectomy or bladder procedures. Ninety per cent had consulted in primary care and 17% in hospital; 69% had used medication. Irritable bowel syndrome substantially interfered with lifestyle and caused absenteeism.
Conclusions : Irritable bowel syndrome is common with major effects on lifestyle and health care. The majority of cases are undiagnosed and the prevalence varies strikingly between countries. Diagnostic criteria are associated with varying prevalences and bowel habit sub-types. This limits their utility in clinical practice and the transferability of research findings using them.
Functional gut symptoms are common in patients with inflammatory bowel disease (IBD). Since poorly absorbed, short-chain carbohydrates (FODMAPs) appear to play an important role in the induction of functional gut symptoms, we aimed to determine the effect of their dietary restriction on abdominal symptoms in patients with stable IBD and to examine factors associated with success of and adherence to the diet.
52 consecutive patients with Crohn's disease and 20 with ulcerative colitis who received dietary advice at least 3 months prior at a gastrointestinal dietetic service in Victoria, Australia, underwent a retrospective telephone questionnaire. Information gathered included patient demographics, recall of dietary advice, dietary adherence, and change in gastrointestinal symptoms.
Up to 70% of patients were adherent to the diet. Approximately one in two patients responded (defined as improvement of at least 5 out of 10 in overall symptoms). Overall abdominal symptoms, abdominal pain, bloating, wind and diarrhoea improved in patients with Crohn's disease and ulcerative colitis (p<0.02 for all), but constipation did not. For Crohn's disease, efficacy was associated with dietary adherence (p= 0.033) and inefficacy with non-adherence (p=0.013). Sustained response was associated with post-secondary education and working 35 h per week or less (p<0.03).
These data suggest that reduction of FODMAP intake offers an efficacious strategy for patients with IBD who have concurrent functional gut symptoms. A controlled dietary intervention trial is indicated.
Functional gut symptoms are induced by inclusion and reduced by dietary restriction of poorly absorbed short-chain carbohydrates (FODMAPs), but the mechanisms of action remain untested.
To determine the effect of dietary FODMAPs on the content of water and fermentable substrates of ileal effluent.
Twelve ileostomates without evidence of small intestinal disease undertook two 4-day dietary periods, comprising diets differing only in FODMAP content in a randomized, cross-over, single-blinded intervention study. Daytime (14 h) ileal effluent was collected on day four of each diet. Patients rated effluent volume and consistency on a 10-cm visual analogue scale. The FODMAP content of the diet and effluent was measured.
Ingested FODMAPs of 32% (range 6-73%) was recovered in the high FODMAP diet effluent. Effluent collection weight increased by a mean of 22% (95% CI, 5-39), water content by 20% (2-38%) and dry weight by 24% (4-43%) with the high compared to low FODMAP diet arm. Output increased by 95 (28-161) mL. Volunteers perceived effluent consistency was thicker (95% CI, 0.6-1.9) with the low FODMAP diet than with the high FODMAP diet (3.5-6.1; P = 0.006).
These data support the hypothetical mechanism; FODMAPs increase delivery of water and fermentable substrates to the proximal colon.
About 35% of humans have methane-producing gut flora. Methane-producing irritable bowel syndrome (IBS) subjects are generally constipated. In animal models, methane infusion slows intestinal transit. Whether methanogenic flora alters colonic transit or stool characteristics and its relationship to constipation is unclear. The aim of this study was to examine the prevalence and association of methanogenic flora in patients with slow transit (ST) constipation and normal transit (NT) constipation and non-constipated controls.
Ninety-six consecutive subjects with chronic constipation (CC) (Rome III) were evaluated with radio-opaque marker (ROM) transit studies and were classified as ST (>20% ROM retention) or NT. All constipated subjects and 106 non-constipated controls underwent breath tests to assess methane production. Baseline CH4 of >or=3 p.p.m. was used to define presence of methanogenic flora. Stool frequency and consistency were assessed using a prospective stool diary. Correlation analyses were performed.
Forty-eight subjects had ST and 48 had NT. Prevalence of methanogenic flora was higher (P<0.05) in ST (75%) compared to NT (44%) or controls (28%). ST patients had higher methane production compared to NT and controls (P<0.05). NT patients also produced more methane compared to controls (P<0.05). There was moderate(P<0.05) correlation among baseline, peak, and area under the curve (AUC) of methane response with colonic transit but not with stool characteristics.
Presence of methanogenic flora is associated with CC. Methane production after carbohydrate challenge and its prevalence were higher in ST than NT, although stool characteristics were similar in both groups. Methane production correlated with colonic transit, suggesting an association with stool transport but not with stool characteristics.
The pathophysiology of IBS is complex and still incompletely known. Both central and peripheral factors are thought to contribute to the symptoms of IBS, including psychosocial factors, abnormal GI motility and secretion, and visceral hypersensitivity. In this review the involvement of peripheral factors in the pathophysiology in IBS is reviewed. Altered GI motility is commonly found in this patient group, even though a specific motor pattern has been hard to find. Colonic transit has been found to be of relevance for the bowel habit of the patient. Abnormal gas handling within the gut is also commonly seen, and seems to be one, but not the only factor responsive for bloating. There is also limited evidence supporting the presence of abnormal GI secretion in IBS, but its relevance for symptoms remains unclear. Visceral hypersensitivity is currently considered to be one of the most important pathophysiological factors in IBS. It can be modulated by several external and internal factors and recent studies support an association between colorectal sensitivity and the symptoms reported by the patients, especially pain.
This review summarizes what is known about the effect of diet on irritable bowel syndrome (IBS) symptoms emphasizing data from randomized, controlled clinical trials. Studies suggest that IBS symptoms in one quarter of patients may be caused or exacerbated by one or more dietary components. Recent studies indicate that a diet restricted in fermentable, poorly absorbed carbohydrates, including fructose, fructans (present in wheat and onions), sorbitol, and other sugar alcohols is beneficial, but confirmatory studies are needed. Despite a long history of enthusiastic use, fiber is marginally beneficial. Insoluble fiber may worsen symptoms. Some patients with IBS, especially those with constipation, will improve with increased intake of soluble fiber. Prebiotic fibers have not been adequately tested. Daily use of peppermint oil is effective in relieving IBS symptoms. The usefulness of probiotics in the form of foods such as live-culture yogurt and buttermilk for IBS symptoms is not established. In clinical practice, it is very difficult to establish that a patient's symptoms result from an adverse reaction to food. A double blind placebo-controlled food challenge is the most reliable method, but it is not suitable for routine clinical use. A modified exclusion diet and stepwise reintroduction of foods or trials of eliminating classes of food may be useful.
Fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) are short-chain carbohydrates that can be poorly absorbed by the small intestine and may have a wide range of effects on gastrointestinal processes. FODMAPs include lactose, fructose in excess of glucose, fructans and fructooligosaccharides (FOS, nystose, kestose), galactooligosaccharides (GOS, raffinose, stachyose), and sugar polyols (sorbitol, mannitol). This paper describes an analytical approach based on HPLC with ELSD that quantifies the major FODMAPs in 45 vegetables and 41 fruits. Sorbitol and/or mannitol were measured in 18 vegetables (range = 0.09-2.96 g/100 g of fw), raffinose and/or stachyose in 7 vegetables (0.08-0.68 g/100 g of fw), and nystose and/or kestose in 19 vegetables (0.02-0.71 g/100 g of fw). Apple, pear, mango, clingstone peach, and watermelon all contained fructose in excess of glucose. Sorbitol was measured in 15 fruits (0.53-5.99 g/100 g of fw), mannitol was found in 2 fruits, and nystose or kestose was measured in 8 fruits. Understanding the importance of dietary FODMAPs will be greatly assisted by comprehensive food composition data.
Flatulence can cause discomfort and distress but there are few published data of normal patterns and volumes. Twenty four hour collections were made using a rectal catheter in 10 normal volunteers taking their normal diet plus 200 g baked beans. Total daily volume ranged from 476 to 1491 ml (median 705 ml). Women and men (both n = 5) expelled equivalent amounts. The median daily flatus hydrogen volume was 361 ml/24 h (range 42-1060) and the carbon dioxide volume 68 ml/24 h (range 25-116), three volunteers produced methane (3, 26, and 120 ml/24 h), and the remaining unidentified gas (presumably nitrogen) or gases contributed a median 213 ml/24 h (range 61-476). Larger volumes of flatus were produced after meals than at other times. Flatus produced at a faster rate tended to contain more fermentation gases. Flatus was produced during the sleeping period, but the rate was significantly lower than the daytime rate (median 16 and 34 ml/h respectively). Ingestion of a 'fibre free' diet (Fortisip) for 48 hours significantly reduced the total volume collected in 24 hours (median 214 ml/24 h), reduced the carbon dioxide volume (median 6 ml/24 h), and practically eradicated hydrogen production. The volume of unidentified gas was not significantly affected (median 207 ml/24 h). Thus fermentation gases make the highest contribution to normal flatus volume. A 'fibre free' diet eliminates these without changing residual gas release of around 200 ml/24 h.
Twenty-five patients with functional bowel disease were given fructose, sorbitol, fructose-sorbitol mixtures, and sucrose. The occurrence of malabsorption was evaluated by means of hydrogen breath tests and the gastrointestinal symptoms, if any, were recorded. One patient could not be evaluated because of lack of H2 production. Based on a cut-off level of 10 ppm rise of H2 concentration, malabsorption was apparent in 13 patients, in 7 of which the calculated absorption capacities were below 15 g. In contrast, in patients given 50 g of sucrose, malabsorption could not be detected. Ingestion of fructose caused marked abdominal distress in patients with demonstrable malabsorption. Ingestion of sucrose in these patients gave less pronounced symptoms of abdominal distress. Malabsorption of a 5-g dose of sorbitol could be detected in 8 of 13 patients. Mixtures of 25 g of fructose and 5 g of sorbitol caused significantly increased abdominal distress, and more than additive malabsorption was found in several cases. The present study shows that pronounced gastrointestinal distress may be provoked by malabsorption of small amounts of fructose, sorbitol, and fructose-sorbitol mixtures in patients with functional bowel disease. The findings may have direct influence on the dietary guidance given to a major group of patients with functional bowel disease and may make it possible to define separate entities in this disease complex.
Sorbitol is a commonly used sugar substitute in "sugar-free" food products. Although sorbitol intolerance manifested by abdominal pain, bloating, and diarrhea has been observed in children, it has not been well documented in adults. Forty-two healthy adults (23 whites, 19 nonwhites) participated in this study. After ingestion of 10 g of sorbitol solution, end expiratory breath samples were collected at 15-min intervals for 4 h and analyzed for H2 concentration. Clinical sorbitol intolerance was detected in 43% of the whites and 55% of the nonwhites, the difference not being statistically significant. However, severe clinical sorbitol intolerance was significantly more prevalent in nonwhites (32%) as compared to whites (4%). There was a good correlation between the severity of symptoms and the amount of hydrogen exhaled. Dietetic foods, many of them containing sorbitol, are very popular with diabetics and "weight watchers." Based on our observations, we believe that a large number of adults could be suffering from sorbitol-induced nonspecific abdominal symptoms and diarrhea. These symptoms could lead to an extensive diagnostic work-up and lifelong diagnosis of irritable bowel syndrome.
Symptoms of irritable bowel syndrome (IBS) are reported by 10% of the general population; however, evaluation of traditional risk factors has not provided any insight into the pathogenesis of this condition. The objective of this study was to identify additional risk factors for irritable bowel syndrome.
A valid self-report questionnaire that records the gastrointestinal (GI) symptoms required for a diagnosis of IBS, self-reported measures of potential risk factors, and a psychosomatic symptom checklist was mailed to an age-and gender-stratified random sample of Olmsted County, Minnesota residents aged 30-64 yr. A logistic regression model that adjusted for age, gender, and psychosomatic symptom score was used to identify factors significantly associated with IBS.
A total of 643 (72%) of 892 eligible subjects returned the survey. IBS symptoms were reported by 12% of the respondents. IBS was significantly associated with use of analgesics (acetaminophen, aspirin, or nonaspirin nonsteroidal antiinflammatory drugs) for reasons other than IBS, reporting a food allergy or sensitivity, and ratings of somatic symptoms. No association was detected for age, gender, body mass index, smoking history, alcohol use, educational level, exposure to pets in the household, or water supply. Among subjects reporting the use of just one type of analgesic, IBS was associated with acetaminophen but not aspirin or nonaspirin nonsteroidal antiinflammatory drugs used alone. The odds of having IBS were higher among subjects reporting more reasons for taking analgesics and intolerance to a higher number of foods.
IBS is significantly associated with analgesic use. However, this is confounded by other somatic pain complaints. IBS symptoms are associated with the reporting of many food allergies or sensitivities. The role of food-induced symptoms in IBS requires further investigation.
To determine the prevalence, symptom pattern and impact of the irritable bowel syndrome, across eight European countries, using a standardized methodology.
A community survey of 41 984 individuals was performed using quota sampling and random digit telephone dialing to identify those with diagnosed irritable bowel syndrome or those meeting diagnostic criteria, followed by in-depth interviews.
The overall prevalence was 11.5% (6.2-12%); 9.6% had current symptoms, 4.8% had been formally diagnosed and a further 2.9%, 4.2% and 6.5% met the Rome II, Rome I or Manning criteria, respectively. Bowel habit classification varied by criteria: 63% had an 'alternating' bowel habit by Rome II vs. 21% by self-report. On average, 69% reported symptoms lasting for 1 h, twice daily, for 7 days a month. Irritable bowel syndrome sufferers reported more peptic ulcer (13% vs. 6%), reflux (21% vs. 7%) and appendectomy (17% vs. 11%), but not hysterectomy, cholecystectomy or bladder procedures. Ninety per cent had consulted in primary care and 17% in hospital; 69% had used medication. Irritable bowel syndrome substantially interfered with lifestyle and caused absenteeism.
Irritable bowel syndrome is common with major effects on lifestyle and health care. The majority of cases are undiagnosed and the prevalence varies strikingly between countries. Diagnostic criteria are associated with varying prevalences and bowel habit sub-types. This limits their utility in clinical practice and the transferability of research findings using them.
The Global Improvement Scale (GIS) assesses multiple irritable bowel syndrome (IBS) symptoms using a patient-defined 7-point Likert scale ranging from symptoms substantially worse to substantially improved. To evaluate the scale as an efficacy end point, data were collected from two 12-week randomized, double-blind, placebo-controlled studies of female nonconstipated IBS patients. GIS responders were defined as having substantial or moderate improvement in IBS symptoms. GIS responders had more days with satisfactory control of urgency, firmer stools, fewer stools per day, and fewer days with incomplete evacuation compared to nonresponders. Substantially more GIS responders (90% and 89% in studies 1 and 2, respectively) were satisfied or very satisfied with their treatment overall compared to nonresponders (13% and 11%) (r = 0.8 in both studies). GIS responders had greater satisfaction with medication relief of pain and discomfort and the time needed to return to usual activities. Favorable correlations between GIS and work and nonwork productivity losses were observed. Correlation of the GIS measure with IBS clinical end points establishes the validity of the GIS for measuring improvement in IBS symptoms. The GIS may be useful in assessing the efficacy of IBS interventions in future clinical trials.
Wheat bran (WB) increases fecal bulk and hastens colonic transit, whereas resistant starch (RS) has effects on colonic fermentation, including increasing concentrations of butyrate.
We hypothesized that a diet combining WB with RS would produce more favorable changes in fecal variables (eg, fecal bulk, rapid transit time, lower pH, and higher butyrate) than would WB alone.
This was a randomized crossover block-design study for which 20 volunteers with a family history of colorectal cancer were recruited. The study included 3 diets: control, WB (12 g fiber/d), and WBRS (12 g WB fiber/d plus 22 g RS/d), each continued for 3 wk. In each diet, the major source of protein was lean red meat. During 5 consecutive days (days 15-19) of each dietary period, the subjects collected their total fecal output for analysis.
The WB diet resulted in greater fecal output (by 23% and 21% for wet and dry weights, respectively) and a lesser transit time (-11 h) than did the control diet but did not have major effects on fermentation variables. Compared with the control diet, the WBRS diet resulted in greater fecal output (by 56%) and a shorter transit time (-10 h), lower fecal pH (-0.15 units), higher fecal concentration (by 14%) and daily excretion (by 101%) of acetate, higher fecal concentration (by 79%) and daily excretion (by 162%) of butyrate, a higher fecal ratio of butyrate to total short-chain fatty acids (by 45%), and lower concentrations of total phenols (-34%) and ammonia (-27%).
Combining WB with RS had more benefits than did WB alone. This finding may have important implications for the dietary modulation of luminal contents, especially in the distal colon (the most common site of tumor formation).
Abnormal fermentation may be an important factor in irritable bowel syndrome (IBS). Gastroenteritis or antibiotic therapy may damage the colonic microflora, leading to increased fermentation and the accumulation of gas. Gas excretion may be measured by whole-body calorimetry but there has only been one such study on IBS to date. We aimed to assess the relationship between IBS symptoms and fermentation rates in IBS. A purpose-built, 1.4-m3, whole-body calorimeter was used to assess excretion of H2 and CH4 in IBS subjects while consuming a standard diet and, again, after open randomization on either the standard diet together with the antibiotic metronidazole or a fiber-free diet to reduce fermentation. Metronidazole significantly reduced the 24-hr excretion of hydrogen (median value compared to the control group, 397 vs 230 ml/24 hr) and total gas (H2 + CH4; 671 vs 422 ml/min) and the maximum rate of gas excretion (1.6 vs 0.8 ml/min), as did a no-fiber polymeric diet (hydrogen, 418 vs 176 ml/min; total gas, 564 vs 205 ml/min; maximum rate of gas excretion, 1.35 vs 0.45 ml/min), with a significant improvement in abdominal symptoms. IBS may be associated with rapid excretion of gaseous products of fermentation, whose reduction may improve symptoms.
The presence of methane on lactulose breath test among irritable bowel syndrome (IBS) subjects is highly associated with the constipation-predominant form. Therefore, we set out to determine whether methane gas can alter small intestinal motor function. In dogs, small intestinal fistulae were created to permit measurement of intestinal transit. Using a radiolabel, we evaluated transit during infusion of room air and subsequently methane. In this model, small intestinal infusion of methane produced a slowing of transit in all dogs by an average of 59%. In a second experiment, guinea pig ileum was pinned into an organ bath for the study of contractile activity in response to brush strokes applied to the mucosa. The force of contraction was measured both orad and aborad to the stimulus. The experiment was repeated while the bath was gassed with methane. Contractile activities orad and aborad to the stimulus were significantly augmented by methane compared with room air (P < 0.05). In a third experiment, humans with IBS who had undergone a small bowel motility study were compared such that subjects who produced methane on lactulose breath test were compared with those producing hydrogen. The motility index was significantly higher in methane-producing IBS patients (1,851 +/- 861) compared with hydrogen producers (1,199 +/- 301) (P < 0.05). Therefore, methane, a gaseous by-product of intestinal bacteria, slows small intestinal transit and appears to do so by augmenting small bowel contractile activity.
Functional abdominal bloating is a functional bowel disorder dominated by a feeling of abdominal fullness without sufficient criteria for another functional gastrointestinal disorder. Gas-related complaints (i.e., passage of flatus), which are present in a subgroup of these patients, might be associated with carbohydrate malabsorption.
To evaluate the presence of lactose and/or fructose plus sorbitol malabsorption, and the long-term efficacy of malabsorbed sugar-free diets, in patients with Rome II criteria of functional abdominal bloating and gas-related symptoms.
Thirty-six consecutive patients (age, 51+/-3.1 years; sex, 12 M, 24 W) with Rome II criteria of functional abdominal bloating and gas-related symptoms were included in a pilot study. In all cases, the presence of malabsorption of both lactose (20 g) and fructose plus sorbitol (20+3.5 g) was assessed by means of hydrogen breath test. Patients with sugar malabsorption were put on a malabsorbed sugar-free diet. Follow-up visits were scheduled at both 1 and 12 months after starting the diet. Global rating scales of change as compared to the beginning of the study were used to assess symptom changes.
Twenty-six of 36 patients (72.2%) presented sugar malabsorption (six lactose, 12 fructose plus sorbitol, and eight both). Seventeen of the 26 (65%) patients with malabsorption had symptoms of sugar intolerance during the 3-h breath testing period. All 26 were put on malabsorbed sugar-free diets. Eighty-one per cent of patients referred clinical improvement at 1-month visit, which was maintained at 12 months in 67% of them (complete improvement in 50% and partial improvement in 16.7%).
Sugar malabsorption and intolerance seem to be frequent in patients with functional abdominal bloating and gas-related complaints. A malabsorbed sugar-free diet might be a long-term effective therapy in a high percentage of patients. Further controlled clinical trials are warranted.
Dietary fructose induces abdominal symptoms in patients with fructose malabsorption, but there are no published guidelines on its dietary management. The objective was to retrospectively evaluate a potentially successful diet therapy in patients with irritable bowel syndrome and fructose malabsorption. Tables detailing the content of fructose and fructans in foods were constructed. A dietary strategy comprising avoidance of foods containing substantial free fructose and short-chain fructans, limitation of the total dietary fructose load, encouragement of foods in which glucose was balanced with fructose, and co-ingestion of free glucose to balance excess free fructose was devised. Sixty-two consecutively referred patients with irritable bowel syndrome and fructose malabsorption on breath hydrogen testing underwent dietary instruction. Dietary adherence and effect on abdominal symptoms were evaluated via telephone interview 2 to 40 months (median 14 months) later. Response to the diet was defined as improvement of all symptoms by at least 5 points on a -10- to 10-point scale. Forty-eight patients (77%) adhered to the diet always or frequently. Forty-six (74%) of all patients responded positively in all abdominal symptoms. Positive response overall was significantly better in those adherent than nonadherent (85% vs 36%; P<0.01), as was improvement in individual symptoms (P<0.01 for all symptoms). This comprehensive fructose malabsorption dietary therapy achieves a high level of sustained adherence and good symptomatic response.
The relationship between the sensation of bloating, often ranked as the most bothersome symptom by patients with irritable bowel syndrome (IBS), and actual distention manifest as an increase in abdominal girth is controversial. Investigation of this problem has been hampered by the lack of a reliable ambulatory technique to measure abdominal girth. The aim of this study was to use the technique of abdominal inductance plethysmography to compare diurnal variation in girth in IBS patients and healthy volunteers, relating these changes to the sensation of bloating.
Abdominal girth was recorded for 24 hours in 20 IBS-constipation (age, 18-73 y), 20 IBS-diarrhea (age, 25-62 y) and 10 IBS-alternating (age, 21-59 y) female patients meeting Rome II criteria and 20 healthy female controls (age, 18-67 y). All subjects pursued normal daily activities, recording their symptoms of bloating and pain together with bowel habit.
All patients with IBS, irrespective of bowel habit, reported significantly greater bloating than controls (P < .0001). Forty-eight percent of patients also showed distention beyond the 90% control range, with this being most prominent in IBS-constipation. Bloating correlated strongly only with distention in IBS-constipation (r > or = 0.48; P < or = .02). Neither bloating nor distention in IBS was related to body mass index, age, parity, or psychologic status.
Abdominal distention is a clearly definable phenomenon in IBS that can reach 12 cm. However, it only occurs in half of patients reporting bloating, and the 2 only correlate in IBS-constipation. Bloating and distention may differ pathophysiologically and this appears to be reflected in the bowel habit subtype.
Fructans are not digested in the small intestines of humans. While many health benefits have been attributed to these carbohydrates, they can cause gastrointestinal symptoms in some individuals. We measured the total fructans in 60 vegetables and 43 fruits using the Megazyme fructan assay. Vegetables with the highest quantity of fructans included garlic, artichoke, shallots, leek bulb, and onions (range, 1.2-17.4 g/100 g fw). Fruits with low, but detectable, fructans included longon, white peach, persimmon, and melon (range, 0.21-0.46 g/100 g fw). The fructan assay was modified to provide an estimate of the average chain length (degree of polymerization) for high fructan vegetables. d-Fructose can also be malabsorbed in the small intestine of humans, so the d-fructose content in some foods was measured to supplement the current food tables. Research in this area will be facilitated through the availability of more comprehensive food composition data.
Whether dietary fructose intolerance causes symptoms of irritable bowel syndrome (IBS) is unclear. We examined the prevalence of fructose intolerance in IBS and long-term outcome of fructose-restricted diet.
Two hundred and nine patients with suspected IBS were retrospectively evaluated for organic illnesses. Patients with IBS (Rome II) and positive fructose breath test received instructions regarding fructose-restricted diet. One year later, their symptoms, compliance with, and effects of dietary modification on lifestyle were assessed using a structured interview.
Eighty patients (m/f=26/54) fulfilled Rome II criteria. Of 80 patients, 31 (38%) had positive breath test. Of 31 patients, 26 (84%) participated in follow-up (mean=13 mo) evaluation. Of 26 patients, 14 (53%) were compliant with diet; mean compliance=71%. In this group, pain, belching, bloating, fullness, indigestion, and diarrhea improved (P<0.02). Of 26 patients, 12 (46%) were noncompliant, and their symptoms were unchanged, except belching. The mean impact on lifestyle, compliant versus noncompliant groups was 2.93 versus 2.57 (P>0.05).
About one-third of patients with suspected IBS had fructose intolerance. When compliant, symptoms improved on fructose-restricted diet despite moderate impact on lifestyle; noncompliance was associated with persistent symptoms. Fructose intolerance is another jigsaw piece of the IBS puzzle that may respond to dietary modification.
Observational studies suggest dietary fructose restriction might lead to sustained symptomatic response in patients with irritable bowel syndrome (IBS) and fructose malabsorption. The aims of this study were first to determine whether the efficacy of this dietary change is due to dietary fructose restriction and second to define whether symptom relief was specific to free fructose or to poorly absorbed short-chain carbohydrates in general.
The double-blinded, randomized, quadruple arm, placebo-controlled rechallenge trial took place in the general community. The 25 patients who had responded to dietary change were provided all food, low in free fructose and fructans, for the duration of the study. Patients were randomly challenged by graded dose introduction of fructose, fructans, alone or in combination, or glucose taken as drinks with meals for maximum test period of 2 weeks, with at least 10-day washout period between. For the main outcome measures, symptoms were monitored by daily diary entries and responses to a global symptom question.
Seventy percent of patients receiving fructose, 77% receiving fructans, and 79% receiving a mixture reported symptoms were not adequately controlled, compared with 14% receiving glucose (P < or = 0.002, McNemar test). Similarly, the severity of overall and individual symptoms was significantly and markedly less for glucose than other substances. Symptoms were induced in a dose-dependent manner and mimicked previous IBS symptoms.
In patients with IBS and fructose malabsorption, dietary restriction of fructose and/or fructans is likely to be responsible for symptomatic improvement, suggesting efficacy is due to restriction of poorly absorbed short-chain carbohydrates in general.
Irritable bowel syndrome (IBS) is a chronic disorder characterized by abdominal pain, change in bowel habit, and bloating. It has traditionally been viewed as a disorder of visceral hypersensitivity heavily influenced by stress, and therefore therapeutic strategies to date have largely reflected this. However, more recently, there is good evidence for a role of the gastrointestinal (GI) microbiota in its pathogenesis. Changes in fecal microbiota, the use of probiotics, the phenomenon of postinfectious IBS, and the recognition of an upregulated host immune system response suggest that an interaction between the host and GI microbiota may be important in the pathogenesis of IBS. This article explores the role of the GI microbiota in IBS and how their modification might lead to therapeutic benefit.
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Appendix S1. IBS satisfaction survey.
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content or functionality of any supporting materials supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding author
for the article.