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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
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.
... 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.
... This could cause luminal distention and altered motility, which in turn may lead to symptoms [19]. Randomized controlled trials show that approximately 50-75% of patients with IBS experience adequate symptom relief when following a low FODMAP diet [20][21][22]. Unfortunately, this leaves 25-50% of the patients with IBS not responding. ...
... The microbiomes in these patients were depleted in Bacteroidetes species and enriched in Firmicutes and genes for amino acid and carbohydrate metabolism [30]. However, there are also studies indicating that microbial factors do not predict response to the low FODMAP diet [21,31]. Studies that investigate the prediction of response to the traditional IBS diet are lacking. ...
... Questions are scored on a 7-point Likert scale where one means 'no symptoms' and seven 'severe symptoms'. There are 5 GSRS-IBS subscales with their respective sum score ranges: pain (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14), bloating (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21), constipation (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14), diarrhea , and satiety (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14). In order have an identical score range for all subscales, the average scores were considered for all subscales in this analysis (score ranges all 1-7). ...
(1) Background: Predictors of dietary treatment response in irritable bowel syndrome (IBS) remain understudied. We aimed to investigate predictors of symptom improvement during the low FODMAP and the traditional IBS diet for four weeks. (2) Methods: Baseline measures included faecal Dysbiosis Index, food diaries with daily energy and FODMAP intake, non-gastrointestinal (GI) somatic symptoms, GI-specific anxiety, and psychological distress. Outcomes were bloating, constipation, diarrhea, and pain symptom scores treated as continuous variables in linear mixed models. (3) Results: We included 33 and 34 patients on the low FODMAP and traditional IBS diet, respectively. Less severe dysbiosis and higher energy intake predicted better pain response to both diets. Less severe dysbiosis also predicted better constipation response to both diets. More severe psychological distress predicted worse bloating response to both diets. For the different outcomes, several differential predictors were identified, indicating that baseline factors could predict better improvement in one treatment arm, but worse improvement in the other treatment arm. (4) Conclusion: Psychological, nutritional, and microbial factors predict symptom improvement when following the low FODMAP and traditional IBS diet. Findings may help individualize dietary treatment in IBS.
... 18 Subsequent studies continued to demonstrate that IBS patients on the LFD had experienced more significant improvements in overall gastrointestinal symptoms than those on controlled diets. [19][20][21][22] With the emerging evidence in the past decade, the LFD was recommended as an efficacious dietary intervention to reduce IBS symptoms. 11,23 Most recently, LFD has been recommended as a potentially helpful treatment modality for IBS by the second Asian consensus on IBS, despite the scarcity of evidence on LFD in the Asian population. ...
... Significant improvements in these gas-related symptoms post-LFD were often observed in previous studies. [19][20][21][22] In the current study, approximately 60-70% of all subjects experienced symptom improvement in "bloating" (59.7%), "burping or belching" (62.0%), and "flatulence" (70.1%). The median severity ratings of these symptoms significantly reduced post-LFD (MD = À1.0, ...
... The lack of improvement in constipation was also observed in the past. 19 Theoretically, methane production from intestinal bacterial fermentation of FODMAPs slows down gastrointestinal transit, which increases the risk of constipation. Hence, a reduction in dietary FODMAPs should lessen methanogenesis, thus alleviating constipation. ...
Background
A low–fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) diet (LFD) appeared to improve gastrointestinal symptoms in patients with Irritable Bowel Syndrome (IBS). However, evidence of its efficacy in Asia remains scarce.
Objectives
This study aims to investigate the clinical effectiveness of LFD intervention among Asian IBS patients and barriers to its adherence.
Methods
Patients with IBS who were instructed to follow LFD by dietitians at a tertiary hospital in Singapore between July 2013 and December 2014 were retrospectively reviewed. Severity scores of 19 gastrointestinal symptoms were recorded using an 11-point rating scale (0 = “no symptoms,” 10 = “extremely severe”) pre- and post-LFD intervention. Adherence to LFD was assessed based on patients’ diet history and a high-FODMAP food checklist.
Results
Eighty-two patients with a median follow-up of 5.8 weeks were investigated. The LFD adherence rate was 61.0% ( n = 50). Overall, statistically significant improvement was observed in 14 of 19 gastrointestinal symptoms (median difference = −2.0 to −0.5, p < .05). The proportion of patients who had improvement in 10 individual symptoms (defined as ≥1 point reduction in symptom severity rating) was significantly higher in LFD-adherent patients (67.5%–82.4%) than that of the non-adherent group (27.8%–55.0%). Reasons reported for non-adherence included “limited availability of low-FODMAP alternatives” ( n = 9), “limited understanding of LFD” ( n = 7), and “perceived lack of benefit” ( n = 4).
Conclusions
LFD intervention improved gastrointestinal symptoms in a cohort of Asian IBS patients. Limited access to low-FODMAP alternatives was the main barrier to adherence.
... FODMAPs are poorly absorbable carbohydrates that exert an osmotic load on the gut, and are rapidly fermented by colonic bacteria, resulting in gas production causing abdominal distention, bloating, and pain (7). A low FODMAP diet has been shown to improve IBS symptoms (8)(9)(10)(11)(12)(13)(14)(15)(16) and is currently the dietary factor with most evidence as a regimen for IBS (6). However, many FODMAP restriction studies suffer from suboptimal design, being no or single-blind (8)(9)(10)(11)(12)(13)(14)(15). ...
... A low FODMAP diet has been shown to improve IBS symptoms (8)(9)(10)(11)(12)(13)(14)(15)(16) and is currently the dietary factor with most evidence as a regimen for IBS (6). However, many FODMAP restriction studies suffer from suboptimal design, being no or single-blind (8)(9)(10)(11)(12)(13)(14)(15). In fact, only 1 double-blind study with a low FODMAP diet has been conducted and was carried out in children (16). ...
... In fact, only 1 double-blind study with a low FODMAP diet has been conducted and was carried out in children (16). Furthermore, most studies have focused on the elimination of FODMAPs from the diet, rather than provocation (8)(9)(10)(11)(12)(13)(14)(15)(16). A few studies, all single-blind, have employed provocations using all FODMAP components (12,17), though similar double-blind studies have used provocations with only a few FODMAPs (18)(19)(20)(21). ...
Background
Irritable bowel syndrome (IBS) has been associated with diets rich in fermentable oligo-, di-, monosaccharides and polyols (FODMAPs), and gluten. Most previous studies have been single-blind and have focused on elimination of FODMAPs or provocation with single FODMAPs. The effect of gluten is unclear, large trials isolating the effect of gluten from that of FODMAPs are needed.
Objective
The aims of this study were to ensure high intakes of a wide range of FODMAPs, gluten, or placebo, and to evaluate the effects on IBS symptoms using the IBS severity scoring system (IBS-SSS).
Methods
The study was carried out with a double-blind, placebo-controlled, randomized three-way crossover design in a clinical facility in Uppsala in September 2018—June 2019. In all, 110 participants fulfilling the IBS Rome IV criteria, with moderate to severe IBS, were randomized; 103 (90 female, 13 male) completed the trial. Throughout, IBS participants maintained a diet with minimal FODMAP content and no gluten. Participants were block-randomized to one-week interventions with FODMAPs (50 g/day), gluten (17.3 g/day), or placebo, separated by one week washout. All participants who completed at least one intervention were included in the intention-to-treat analysis.
Results
In participants with IBS (n = 103), FODMAPs caused higher IBS-SSS scores (mean 240 [95% CI 222, 257]) than placebo (198 [180, 215]; 0.00056) or gluten (208 [190, 226]; P = 0.013); no differences were found between the placebo and gluten groups (P = 1.0). There were large inter-individual differences in IBS-SSS scores associated with treatment. No adverse events were reported.
Conclusion
In participants with IBS, FODMAPs had a modest effect on typical IBS symptoms, whereas gluten had no effect. The large inter-individual differences in responses to the interventions warrant further detailed studies to identify possible underlying causes and enable individual prediction of responses.
Trial registration
www.ClinicalTrials.gov (NCT03653689).
... Although levels of beneficial bacteria have been restored by supplementing with bifidogenic oligofructose and fructo-oligosaccharides, the latter caused worsening of symptoms (Sloan et al., 2018;Hustoft et al., 2016). Changes to the microbiome may also feature during the 5Ad Protocol due to the exclusion of oligosaccharides, however, are unlikely to have occurred during the 7day study period (Staudacher et al., 2011;Staudacher et al., 2012). The long-term effects of existing approaches on the microbiome are unknown, but it has been suggested that even the reintroduction of a few prebiotic high FODMAP foods may reduce any potential alterations to the microbiome (Tuck and Barrett, 2017). ...
... Changes relating to osmotic effects or motility may occur within 24-48 hours whilst following the low FODMAP diet (Staudacher et al., 2011), with reductions in hydrogen production occurring within only 14 hours (Ong et al., 2010). Changes to the microbiota caused by dietary factors, on the other hand, may take between 2-8 weeks (Staudacher et al., 2011;Staudacher et al., 2012). ...
... Changes relating to osmotic effects or motility may occur within 24-48 hours whilst following the low FODMAP diet (Staudacher et al., 2011), with reductions in hydrogen production occurring within only 14 hours (Ong et al., 2010). Changes to the microbiota caused by dietary factors, on the other hand, may take between 2-8 weeks (Staudacher et al., 2011;Staudacher et al., 2012). Although, during this present study, significant improvements were obtained in faecal indices and in individual and overall abdominal symptoms scores in only 7 days, it is unlikely that that these improvements can be attributed to changes in gut microbiota during this time; this is an area warranting investigation in future research involving the 5Ad Protocol. ...
Functional bowel disorders (FBDs) affect around 20% of the population
worldwide and are associated with reduced quality of life and high healthcare
costs. Dietary therapies are frequently implemented to assist with symptom
relief in these individuals; however, there are concerns regarding their
complexity, restrictiveness, nutritional adequacy, and effectiveness. Thus, to
overcome these limitations, a novel approach, the 5Ad Dietary Protocol, was
designed and tested for its efficacy in reducing a range of gastrointestinal
symptoms in those with FBDs.
The 5Ad Dietary Protocol was evaluated using a repeated measures design
(baseline week and intervention week) in 15 subjects with FBDs. The Food
Intolerance Index (FII) (0-100) was used as a composite overall symptom score,
along with measures of stool consistency and frequency. The severity of
individual symptoms (abdominal pain, bloating, flatulence, bowel urgency,
straining, and incomplete defecation) was recorded by the subject using a 4-
point Likert scale.
Significant improvements occurred in FII score (39.63±16.77 to 18.99±15.54,
p=0.000), in stool consistency for baseline constipation (2.14±0.67 to 3.58±0.73,
p=0.038), and in frequency of defecation for high baseline stool frequency
(16.00±2.11 to 11.44±1.80, p=0.005). Stool consistency and frequency also
improved in the respective contrasting subtypes, and severity of all individual
symptoms was significantly reduced from baseline.
The 5Ad Dietary Protocol proved to be a promising universal approach for
varying forms and severities of FBDs; normalising bowel function in both
those with constipation and those with diarrhoea. The present study paves the
way for future research encompassing a longer study duration and the
exploration of underlying physiological mechanisms.
... 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.
... Patients with IBS often eliminate some food products from their diet. The results of numerous studies indicate that FODMAP carbohydrates (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) in the diet cause or intensify symptoms of IBS and that in contrast, a low FODMAP diet provides relief to patients with IBS [6][7][8][9][10]. It has been shown that a low FODMAP diet was effective in treating the functional symptoms of gastrointestinal conditions in comparison to a diet plan consistent with the recommendations of the UK National Institute for Health and Clinical Excellence (NICE) [9]. ...
... For a long time, it has been known that a low-FODMAP diet is effective in treating the functional symptoms of digestive tract conditions in compared to a diet plan consistent with the recommendations of the UK National Institute for Health and Clinical Excellence (NICE). [7][8][9][24][25][26]. Over 76% of patients reported improvement after introducing the low-FODMAP diet in comparison to the 54% eating according to the NICE recommendations. ...
Irritable bowel syndrome (IBS) is a chronic disease with recurrent abdominal pain, disturbed bowel emptying, and changes in stool consistency. We compared the effectiveness of three different dietary treatment plans (G1-FM-low FODMAP diet, G2-IP IgG based elimination-rotation-diet, and as control group, the G3-K control diet recommended by an attending gastroenterologist) in treating patients diagnosed with mixed irritable bowel syndrome. A total of seventy-three female patients diagnosed with a mixed form of irritable bowel syndrome (IBS-M) were enrolled in the study. The diet of each patient in Group 1 (G1-FM) and 2 (G2-IP) was determined individually during a meeting with a dietitian. Patients from Group 3 (G3-K) received nutrition advice from a gastroenterologist. Significant differences in the reduction of IBS symptoms were found between the groups. IBS symptoms as well as comorbid symptoms significantly improved or disappeared completely in the G2-IP group (idiopathic abdominal pain, p < 0.001; abdominal pain after a meal, p < 0.001; abdominal pain during defecation, p = 0.008), while in the G1-FM group, some of the IBS symptoms significantly improved (mucus in stool, p = 0.031; bloating, p < 0.001). In group G3-K no significant improvement was seen. Based on the results of this open-label study, it was concluded that various dietary interventions in the treatment of IBS-M patients do not uniformly affect the course and outcomes of disease management. Rotation diets based on IgG show significantly better results compared to other diets.
... One successful intervention is changing the dietary habit (Fernández-Bañares et al., 2005), especially through restriction of 'Fermentable Oligo-, Di-, Mono-saccharides And Polyols' (FODMAPs). These are short chain carbohydrates that are poorly absorbed in the small intestine (Gearry et al. 2009;Staudacher et al. 2011;Roest et al. 2013). Others include the usage of probiotic and or prebiotic (Alfredo 2004; Kim et al. 2005;McFarland and Dublin 2008;Moayyedi et al. 2010), cognitive-behavioural therapy (Boyce et al. 2000), herbs (Liu et al. 2006;Vejdani et al. 2006) and also changes in lifestyles (Foley et al. 2014;Johannesson et al. 2015). ...
... Some individuals may experience food intolerance to certain foods, like gluten, milk or soy products, which can cause bloating. For those individuals with such intolerance, it is recommended to follow a gluten-free and low FODMAP diet (Wong 2016;Zannini and Arendt 2018), especially avoiding wheat, honey, artificial sweetener, milk or legumes (Staudacher et al. 2011;Roest et al. 2013). Therefore, the promotion of healthy food intakes is needed to improve bloating cases in Malaysia. ...
Abdominal bloating is a common symptom that can affect both men and women of all ages. Although abdominal bloating is considered as a non-serious abdominal pain from a physician's perspective, it can affect patients' ability to work, participate in social or recreational activities and affects their quality of life. This chapter discusses the experience of abdominal bloating among Malaysians, which covers a few important aspects, such as social life experience exposure, symptom severity, attitudes, self-management and quality of life. There is still a lack of knowledge and awareness of the impacts of abdominal bloating on daily lives. This is because research on abdominal bloating, its impacts and management in the Malaysian context is limited. Therefore, this chapter discusses the definition of bloating from different perspectives of the population and ethnicity, the experience of bloating among Malaysians, the reasons of feeling bloated, and its management based on available literature. Future research potentials that focus on the bloating issue are also discussed.
... Estudos como o de Roest e colaboradores 9 realizado com 90 pacientes com SII, submetidos à uma dieta restrita em FODMAPs, mostram melhoras signifi cativas na maioria dos sintomas, tais como inchaço, diarreia, constipação, fl atulência, e desconforto abdominal, assim como o estudo de Staudacher et al. 13 , evidenciando a efi cácia da dieta em pacientes com SII, sendo mais efi caz que aconselhamento dietético padrão. A maioria dos pacientes também relataram satisfação quanto aos resultados dos sintomas após intervenção com a dieta 13 . ...
... Estudos como o de Roest e colaboradores 9 realizado com 90 pacientes com SII, submetidos à uma dieta restrita em FODMAPs, mostram melhoras signifi cativas na maioria dos sintomas, tais como inchaço, diarreia, constipação, fl atulência, e desconforto abdominal, assim como o estudo de Staudacher et al. 13 , evidenciando a efi cácia da dieta em pacientes com SII, sendo mais efi caz que aconselhamento dietético padrão. A maioria dos pacientes também relataram satisfação quanto aos resultados dos sintomas após intervenção com a dieta 13 . Segundo Pedersen 34 a dieta reduzida em FODMAPs tem efeito benéfi co para pacientes dinamarqueses com DII, com redução de sintomas e melhora da qualidade de vida. ...
Objetivo: reunir informações sobre o efeito da dieta com baixo teor de carboidratos fermentáveis sobre sintomas gastrointestinais, assim como sua aplicação nos transtornos do espectro autista.Método: revisão sistemática de literatura, utilizando-se descritores em inglês e português, das bases de dados Biblioteca Nacional de Medicina dos Estados Unidos, Biblioteca Virtual da Saúde e Portal de Periódicos Capes.Resultados: encontrou-se 33 artigos, dos quais dois eram coorte, 10 transversais, nove caso-controle e 12 ensaios clínicos. Os objetivos foram investigar a melhora dos sintomas gastrointestinais a partir da dieta com baixo teor de FODMAPs em pacientes com Síndrome do Intestino Irritável e Doença Inflamatória Intestinal. Na população com transtorno do espectro autista os objetivos foram avaliar a incidência de sintomas gastrointestinais e o impacto da restrição de FODMAPs nos mesmos. Os estudos mostraram melhoras de sintomas gastrointestinais, com alívio após implementação da dieta, em especial em pacientes com síndrome do intestino inflamatório e doença inflamatória intestinal.Conclusões: a dieta com baixo teor de FODMAPs mostrou melhora de sintomas gastrointestinais quando aplicada a indivíduos com alterações intestinais. Contudo são necessárias maiores evidências cientificas para indicar sua aplicação como medida de rotina no transtorno do espectro autista.
... 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.
... Various diets are increasingly implemented as treatment options not only for patients with IBS, but also for patients with functional dyspepsia [15][16][17][18]. Between studies, efficacy rates of dietary interventions generally vary from 50 to 75%, indicating that only a subset of patients responds to the dietary treatment [18][19][20][21]. Unfortunately, the specific subgroup of DGBI patients suffering from meal-related symptoms who potentially benefit from dietary intervention is currently not sufficiently characterized. ...
Background
Patients with disorders of gut-brain interaction (DGBI) report meal intake to be associated with symptoms. DGBI patients with meal-related symptoms may have more severe symptoms overall and worse health outcomes, but this subgroup has not been well characterized. We aimed to describe the global prevalence of meal-related abdominal pain and characterize this subgroup.
Methods
The data analyzed originated from the Internet survey component of the population-based Rome Foundation Global Epidemiology Study, completed in 26 countries ( n = 54,127). Adult subjects were asked whether they had abdominal pain and how often this was meal-related. Respondents were categorized into “no,” “occasional,” and “frequent” meal-related abdominal pain groups based on 0%, 10–40%, and ≥50% of the pain episodes being meal-related, respectively. DGBI diagnoses, frequency of other GI symptoms, psychological distress, non-GI somatic symptoms, quality of life, and healthcare utilization were compared between groups. Mixed linear and ordinal regression was used to assess independent associations between psychological distress, non-GI somatic symptoms, quality of life, other GI symptoms, and meal-related abdominal pain.
Results
Overall, 51.9% of the respondents reported abdominal pain in the last 3 months, and 11.0% belonged to the group with frequent meal-related abdominal pain, which included more females and younger subjects. DGBI diagnoses were more common in subjects with frequent meal-related abdominal pain, and the frequency of several GI symptoms was associated with having more frequent meal-related abdominal pain. Having meal-related abdominal pain more frequently was also associated with more severe psychological distress, non-GI somatic symptoms, and a poorer quality of life. The group with frequent meal-related abdominal pain also more often consulted a doctor for bowel problems compared to the other groups of meal-related abdominal pain.
Conclusion
Reporting frequent meal-related abdominal pain is common across the globe and associated with other GI and non-GI somatic symptoms, psychological distress, healthcare utilization, and a poorer quality of life. Individuals who frequently experience meal-related abdominal pain also more frequently fulfill the diagnostic criteria for DGBI. Assessing meal-related symptoms in all DGBI patients could be of major importance to improve and individualize symptom management.
... Restricting dietary FODMAP intake reduces symptoms in patients with irritable bowel syndrome (IBS) (9)(10)(11)(12)(13). Therefore, it is reasonable to hypothesize that a low FODMAP diet (LFD) might offer clinical benefits to patients with FI, in which up to two-thirds of patients experience loose, frequent stools and urgency (2,4). ...
Introduction:
The aim of the study was to compare the effectiveness of a low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol diet (LFD) vs psyllium on the frequency and severity of fecal incontinence (FI) episodes in patients with loose stools.
Methods:
This was a single-center, randomized pilot trial of adult patients with FI (Rome III) with at least 1 weekly FI episode associated with loose stool. Eligible patients were randomized to 4 weeks of either a dietitian-led LFD or 6 g/d psyllium treatment.
Results:
Forty-three subjects were randomized from October 2014 to May 2019. Thirty-seven patients completed the study (19 LFD and 18 psyllium). There was no statistically significant difference in the proportion of treatment responders (>50% reduction in FI episodes compared with baseline) for treatment weeks 1-4 (LFD 38.9%, psyllium 50%, P = .33). Compared with baseline, mean fecal incontinence severity index score significantly improved with LFD (39.4 vs 32.6, P = .02) but not with psyllium (35.4 vs 32.1, P = .29). Compared with baseline values, the LFD group reported improvements in fecal incontinence quality of life coping/behavior, depression/self-perception, and embarrassment subscales. The psyllium group reported improvement in incontinence quality of life coping/behavior.
Discussion:
In this pilot study, there was no difference in the proportion of patients who reported a 50% reduction of FI episodes with the LFD or psyllium. Subjects in the psyllium group reported a greater reduction in overall FI episodes, whereas the LFD group reported consistent improvements in FI severity and quality of life. Further work to understand these apparently discrepant results are warranted but the LFD and psyllium seem to provide viable treatment options for patients with FI and loose stools.
... In the studied population, only 20% of the respondents adhering to the elimination diet had consulted a dietitian, and in this group, only 36 individuals had regularly visited a nutrition clinic during the entire treatment and the reintroduction phase. The skills of a dietitian in dietary assessment, knowledge of FODMAP food composition and experience with the low-FODMAP dietary approach are likely to impact on the success of the diet [2,26,30]. Experience in gastrointestinal disorder management, consideration of symptom types, severity, baseline FODMAP intake, and overall nutritional content and meal pattern are vital in the assessment. If a strict low-FODMAP diet is deemed necessary, it should only be introduced for an initial period of 4 to 6 weeks. ...
Background:
Irritable bowel syndrome (IBS) is the most common gastrointestinal disorder that is driven by the gutbrain axis and affects 1-20% of the population. Most patients note that various foods elicit abdominal symptoms, and they eliminate these products from their diets. A diet that is low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) is currently one of the mainstays in IBS treatment.
Objective:
The aim of this study was to assess the knowledge of IBS patients about the disease, treatment and the principles of the low-FODMAP diet that can alleviate gastrointestinal symptoms.
Material and methods:
The participants were adults diagnosed with IBS, the inclusion criteria were: absence of comorbidities requiring an elimination diet, age over 18 years, and consent to participate in the study. The respondents filled out an anonymous questionnaire containing questions about the IBS diagnosis, disease history and treatment, as well as 45 questions assessing the participants' knowledge about the low-FODMAP diet.
Results:
In 28% of the cases, IBS was diagnosed by a general practitioner; in nearly 40% of the cases - by a gastroenterology specialist; in 10% of the cases - by a dietitian, whereas the remaining respondents had arrived at the diagnosis independently or with the help of support groups for IBS patients. After diagnosis, only every fourth respondent sought treatment in a gastroenterology clinic. In the studied population, 237 of the respondents had followed to the low-FODMAP diet, and the differentiating factors were sex (p=0.002), place of residence (city with a population higher than 100,000 vs. rural area; p=0.0001) and education (university vs. vocational school p=0.0043). Respondents who had been recently diagnosed with IBS (less than 12 months vs. more than 12 months before the study) were more likely to follow the FODMAP diet.
Conclusions:
The surveyed population was characterized by high levels of knowledge about the low-FODMAP diet, but many respondents did not strictly comply with dietary guidelines, in particular the duration of each dietary phase. Age was significantly correlated with the respondents' knowledge, and the participants' familiarity with low-FODMAP guidelines decreased with age. Nutritional consultations did not significantly improve the respondents' knowledge about the low-FODMAP diet.
... Therefore, FODMAPs can cause gas production in the colon, along with abdominal distension [7]. This can be mainly observed in patients with irritable bowel syndrome (IBS), and there is a report that lowering the level of FODMAPs in the diet is effective for reducing GI symptoms in IBS patients [8]. In 2013, when a low-FODMAP diet was supplied to 90 patients with IBS for 15.7 months, there was a significant improvement in abdominal pain, bloating, flatulence, and diarrhea symptoms [9]. ...
Background/objectives:
A dietary restriction on the intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has been reported to be effective in the treatment of gastrointestinal (GI) tract complications. Enteral nutrition (EN) is widely used for patients who cannot obtain their nutritional requirements orally, but many studies have reported EN complications, especially diarrhea, in up to 50% of patients.
Subjects/methods:
We performed a single-center, non-randomized, controlled trial to determine the effects of a low-FODMAP enteral formula on GI complications in patients in intensive care units (ICUs). Patients in the ICU who needed EN (n = 66) were alternately assigned to the low-FODMAP group (n = 33) or the high-FODMAP group (n = 33).
Results:
Anthropometric and biochemical parameters were measured, and stool assessment was performed using King's Stool Chart. We excluded patients who received laxatives, GI motility agents, proton pump inhibitors, antifungal agents, and antibiotics other than β-lactams. There were no differences in GI symptoms during 7 days of intervention, including bowel sound, abdominal distension, and vomiting between the 2 groups. However, diarrhea was more frequent in the high-FODMAP group (7/33 patients) than the low-FODMAP group (1/33 patients) (P = 0.044).
Conclusions:
Our results suggest that a low-FODMAP enteral formula may be a practical therapeutic approach for patients who exhibit enteral formula complications. Our study warrants further randomized clinical trials and multicenter trials.
Trial registration:
Clinical Research Information Service Identifier: KCT0005660.
... En la revisión panorámica de los estudios seleccionados y analizados se confirma que, en la mayor parte de ellos 12,[16][17][18][19][20]23,26,[30][31][32] , una dieta baja en FODMAP tiene una elevada eficacia en la gran mayoría de los pacientes con SII, al producir una mejoría evidente en la hinchazón, dolor abdominal y flatulencia, por lo que se suele apoyar su uso como terapia de primera línea. ...
REVISIÓN La dieta baja en FODMAP, ¿es realmente eficaz y segura en el síndrome del intestino irritable?: una revisión panorámica Dieta FODMAP; Síndrome del intestino irritable; Eficacia; Seguridad; Microbiota; Dietista Resumen En el momento presente, no se dispone de un tratamiento etiológico para el sín-drome del intestino irritable y la modificación de la dieta, en particular la dieta baja en FODMAP (oligosacáridos, disacáridos, monosacáridos y polioles fermentables) se utiliza cada vez más para controlar los síntomas, si bien no se conocen su eficacia y seguridad reales. El objetivo de esta revisión panorámica es conocer si la dieta baja en FODMAP es realmente eficaz y segura a largo plazo en el manejo dietético de dicho síndrome. La revisión, siguiendo una metodología adecuada, se llevó a cabo con 25 estudios, que se recuperaron a texto completo. De todos ellos, 3 eran metaanálisis, 2 revisiones sistemáticas y 3 ambos tipos de estudio. El resto de los estudios eran, en general, de baja calidad metodológica y muy heterogéneos, con poco nivel de evidencia y bajo grado de recomendación. Puede concluirse que, en el corto plazo, la dieta baja en FODMAP tiene eficacia en la mayoría de los pacientes con síndrome de intestino irritable , por lo que podría apoyarse su uso como terapia de primera línea. Sin embargo, de todos los estudios, solamente uno fue prospectivo de seguimiento a largo plazo, entre 6 y 18 meses, con buenos resultados, por lo que se precisan más estudios de seguimiento, diseñados con este propósito, en los que se investiguen los efectos a largo plazo. De aconsejarse este tipo de dieta, debería hacerse dirigida por dietistas especializados.
... Diets low in FODMAPS are reported to reduce symptoms in 50 to 80% of IBS patients (Gibson, 2017;Halmos et al., 2014;Marsh et al., 2016;Muir et al., 2019;Ong et al., 2010;Pedersen et al., 2014;Staudacher et al., 2011;Tuck et al., 2014). The diet guidelines include reduced consumption of wheat-derived and other grain products because they are significant sources fructan with a low degree of polymerization (DP) and excess fructose (Gibson & Shepherd, 2010;Verspreet et al., 2017;Whelan et al., 2011;Ziegler et al., 2016). ...
Diets low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) can help reduce symptoms in 50 to 80% of patients suffering from irritable bowel syndrome. Patients are, therefore, often advised to avoid products contributing to FODMAP intake, such as cereal grain products. However, these products are nutritious staple foods and avoiding their consumption may result in nutritional deficiencies. The development of low-FODMAP, high-fiber cereal grain products is therefore desirable. This pilot-scale study shows that Kluyveromyces marxianus CBS6014 (K. marxianus) results in more fructan hydrolysis and a significantly lower final fructan level in white and whole-grain toast bread as well as in rye sourdough bread compared to a commercial Saccharomyces cerevisiae baking strain. Moreover, combined fructan and fructose levels in white and whole-grain bread prepared with K. marxianus remained well below the threshold concentration for low-FODMAP products. In addition to reducing fructan levels, K. marxianus in rye sourdough bread also positively impacted bread height. Whereas further follow-up studies are needed to assess the potential of K. marxianus for bread production fully, our study suggests that this yeast species may open exciting novel routes for the production of low-FODMAP, high-fiber products.
... As small pore size indicates higher protein network strength [57], the CLSM results confirm the results of textural and rheological analyses. While lentils and other pulses usually contain large levels of FODMAPs and their consumption should, therefore, be limited by individuals with gastrointestinal disorders, such as IBS [58], a large proportion of these FODMAPs is removed during the process of the isoelectric precipitation isolation of the proteins from the whole lentil flour, as FODMAPs are water soluble [44]. The cut-off value for the amount of GOS per serving that does not cause gastrointestinal symptoms in IBS patients has been established below 200 mg [59]. ...
The substitution of animal protein with proteins of plant origin is a viable way to decrease the negative impact caused by animal husbandry on the environment. Pulse consumption has been widely promoted as a nutritious contribution to protein supplementation. In this study, an emulsion of lentil (Lens culinaris) protein isolate is fermented with lactic acid bacteria (LAB) to manufacture a yoghurt alternative and the techno-functional properties compared to a dairy- and a soy-based product with similar protein contents. The yoghurt-like products are subjected to large and small deformation analysis, quantification of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP), water holding capacity tests, protein profile analysis and the gel structure is visualised by confocal laser scanning microscopy (CLSM). The lentil yoghurt alternative shows good water holding capacity, high firmness and consistency values in large deformation analysis, with cohesiveness and viscosity not significantly different from that of dairy yoghurt. The high gel strength and rigidity of the lentil yoghurt gels measured by small deformation analysis is well-reflected in the dense protein matrix in the CLSM graphs. FODMAP content of the lentil yoghurt is very low, making it suitable for consumption by irritable bowel syndrome (IBS) patients. Our results show that lentil protein isolate is an excellent base material for producing a plant-based yoghurt alternative.
... When combined, despite the symptomatic improvement of an LFD in the majority of IBS patients, further research is still required to examine the long-term effects on gut health as many IBS sufferers are reluctant to re-introduce trigger foods. If patients do not manage to replace high FODMAP foods with suitable low-FODMAP alternatives, they may also be reducing fibre intake simultaneously [23,32]. Therefore, in this scoping review, the low-FODMAP diet is regarded as a dietary fibre-related intervention. ...
Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder affecting 4-5% of the global population. This disorder is associated with gut microbiota, diet, sleep, and mental health. This scoping review therefore aims to map existing research that has administrated fibre-related dietary intervention to IBS individuals and reported outcomes on at least two of the three following themes: gut microbiota, sleep, and mental health. Five digital databases were searched to identify and select papers as per the inclusion and exclusion criteria. Five articles were included in the assessment, where none reported on all three themes or the combination of gut microbiota and sleep. Two studies identified alterations in gut microbiota and mental health with fibre supplemen-tation. The other three studies reported on mental health and sleep outcomes using subjective questionnaires. IBS-related research lacks system biology-type studies targeting gut microbiota, sleep, and mental health in patients undergoing diet intervention. Further IBS research is required to explore how human gut microbiota functions (such as short-chain fatty acids) in sleep and mental health, following the implementation of dietary pattern alteration or component supplementation. Additionally, the application of objective sleep assessments is required in order to detect sleep change with more accuracy and less bias.
... Currently, the lectin-free diet regimen is gaining popularity among IBS patients 34 . Food rich in IACs often causes bloating, abdominal pain, and diarrhea, and a diet with low amounts of FODMAPs has been widely investigated in the attempt to alleviate IBS symptoms 35 . Just under half of the interviewed patients indicated IACs as IBS triggers, although it has been documented that up to 70% of IBS patients report gastrointestinal symptoms after the intake of food rich in IACs 10 . ...
Objective:
Diet, visceral sensitivity, and psychological distress play an important role in Irritable Bowel Syndrome (IBS). This study focused on the relation between IBS severity, foods, visceral sensitivity, and anxiety/depression.
Patients and methods:
Patients with IBS were investigated through (1) IBS-symptoms severity score (SSS), (2) self-reported food intolerance, (3) visceral sensitivity index (VSI), and (4) Hospital Anxiety and Depression Scale (HADS). Seventy-seven patients agreed to participate in the survey. Of them, 64 (83%) showed IBS according to Rome IV criteria and were included in the final analysis. Patients with IBS-D were 30 (47%), with IBS-C 27 (42%), and with IBS-M 7 (11%).
Results:
Fifty-eight patients (90%) considered at least one foodstuff as IBS trigger. Amine-rich foods represented a symptom trigger for 77% of patients, those with lectin for 70%, IACs by 48%, and capsaicin by 37%. Overweight was significantly associated with amine-rich foods (p=0.015), age >45 years (p=0.001) and non-smoking condition (p=0.033) with lectin-rich foods, male gender (p=0.005) and overweight (p=0.027) with capsaicin-containing foods. A positive VSI score was found in 59% of patients, and non-smoking condition was significantly associated (OR 10.03; p=0.009). No factors were associated with a positive HADS score, shown by 80% of patients. Severe IBS was shown by 63% of patients, being amine-rich foods (p=0.024), overweight (p=0.020), and female gender (p=0.029) independent risk factors while marriage/cohabiting a protective one (p=0.038). Amine-rich foods are an independent risk factor for severe IBS, along with overweight and female gender.
Conclusions:
Clinicians should pay more attention to self-reported food intolerance in IBS patients. A personalized therapy including dietary advice as part of treatment could be of great benefit.
... 22 Dietary interventions, such as a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols, may improve bloating in some patients, although large RCTs have not been carried out specifically in IBS-C populations. 23,24 Finally, some behavioural interventions, such as biofeedback, may be beneficial for abdominal bloating. 25 There are currently five Food and Drug Administration (FDA)licensed drugs available for the treatment of IBS-C. ...
Background
Although bloating is a highly prevalent and troublesome symptom in irritable bowel syndrome with constipation (IBS-C), treatment is empirical with no specific guidelines for its management.
Aim
To conduct a pairwise and network meta-analysis, using a frequentist approach, of Food and Drug Administration-licensed drugs for IBS-C comparing their efficacy for abdominal bloating as a specific endpoint.
Methods
We searched the medical literature through December 2020 to identify randomised controlled trials (RCTs) in IBS-C, with abdominal bloating reported as a dichotomous assessment. Efficacy of each drug was reported as a pooled relative risk (RR) with 95% confidence intervals (CIs) to summarise effect of each comparison tested. Treatments were ranked according to their P-score.
Results
We identified 13 eligible RCTs, containing 10 091 patients. Linaclotide 290 µg o.d., lubiprostone 8 µg b.d., tenapanor 50 mg b.d. and tegaserod 6 mg b.d. were all superior to placebo for abdominal bloating in patients with IBS-C, in both pairwise and the network meta-analyses. Linaclotide demonstrated the greatest improvement in abdominal bloating in both pairwise and network meta-analysis (RR of failure to achieve an improvement in abdominal bloating = 0.78; 95% CI 0.74-0.83, number needed to treat = 7, P-score 0.97). Indirect comparison revealed no significant differences between individual drugs.
Conclusions
We found all licensed drugs for IBS-C to be superior to placebo for abdominal bloating. Linaclotide appeared to be the most efficacious at relieving abdominal bloating. Further research is needed to assess long-term efficacy of these agents and to better understand the precise mechanism of improving bloating.
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.
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.
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.
Purpose of review:
Irritable bowel syndrome (IBS) is a highly prevalent functional gastrointestinal disorder (FGID) characterized by chronic abdominal pain and altered bowel habits. The diagnosis of IBS is based on the presence of defined clinical Rome IV criteria in the absence of alarm features. The majority of patients with IBS report of food triggers eliciting typical IBS symptoms and trying to modify their dietary intake.
Recent findings:
FGID including IBS are defined as disorders of the gut-brain interaction. A large proportion of individuals with IBS link their symptoms to dietary factors, and recent clinical studies have shown benefits of a diet low in FODMAPs (Fermentable Oligo-, Di-, and Monosaccharides and Polyols) on IBS symptoms and quality of life. Dietary interventions mediate directly changes of luminal gut contents affecting chemosensing-enteroendocrine cells in the modulation of the gut brain microbiome axis in IBS patients. Long-term assessment of clinical outcomes in patients on a low FODMAP diet is needed. Professional guidelines have incorporated the suggestion to offer IBS patients a diet low in FODMAPs.
Summary:
The FGIDs, including IBS, are defined as gut-brain disorders. Low FODMAP diet has been shown in clinical trials to reduce IBS symptoms but long-term efficacy and nutritional side-effects remain uncertain.
Background and Aim
Diet is a powerful tool in the management of gastrointestinal disorders, but developing diet therapies is fraught with challenge. This review discusses key lessons from the FODMAP diet journey.
Methods
Published literature and clinical experience were reviewed.
Results
Key to designing a varied, nutritionally adequate low FODMAP diet was our accurate and comprehensive database of FODMAP composition, made universally accessible via our user-friendly, digital application. Our discovery that FODMAPs coexist with gluten in cereal products, and subsequent gluten/fructan challenge studies in non-celiac gluten sensitive populations highlighted issues of collinearity in the nutrient composition of food and confirmation bias in the interpretation of dietary studies. Despite numerous challenges in designing, funding and executing dietary randomised controlled trials, efficacy of the low FODMAP diet has been repeatedly demonstrated, and confirmed by real-world experience, giving this therapy credibility in the eyes of clinicians and researchers. Furthermore, real-world application of this diet saw the evolution of a safe and effective three-phased approach. Specialist dietitians must deliver this diet to optimise outcomes as they can target and tailor the therapy, and mitigate the key risks of compromising nutritional adequacy and precipitating disordered eating behaviours, skills outside the gastroenterologist’s standard tool kit. While concurrent probiotics are ineffective, specific fiber supplements may improve short- and long-term outcomes.
Conclusions
The FODMAP diet is highly effective, but optimal outcomes are contingent on the involvement of a gastroenterological dietitian who can assess, educate and monitor patients and manage risks associated with implementation of this restrictive diet.
Die individuelle Herangehensweise der integrativen Ernährungstherapie bietet bei vielen Gesundheitsthemen eine gute Unterstützung. Ob Darmgesundheit, Allergien oder Unverträglichkeiten: Ziel ist, ein Gleichgewicht im Körper herzustellen bzw. den Körper mit dem täglichen Essen so zu unterstützen, dass seine Verdauungsfähigkeit, die Resorption von Nährstoffen und damit die bessere Versorgung mit Nährstoffen einen Beitrag zur Gesundung leistet. Dieses Kapitel gibt einen Überblick über die individuelle Herangehensweise bei Reizdarm, Allergien und Intoleranzen unter Berücksichtigung der neuesten ernährungsmedizinischen Erkenntnisse und der Rolle von Stress im Alltag. Ergänzend wird der Einsatz der FODMAP-Methode inklusive Rezepten dargestellt.
Background
The long-term management of irritable bowel syndrome (IBS) poses many challenges. In short-term studies, eHealth interventions have been demonstrated to be safe and practical for at-home monitoring of the effects of probiotic treatments and a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs). IBS has been linked to alterations in the microbiota.
Objective
The aim of this study was to determine whether a web-based low-FODMAP diet (LFD) intervention and probiotic treatment were equally good at reducing IBS symptoms, and whether the response to treatments could be explained by patients’ microbiota.
Methods
Adult IBS patients were enrolled in an open-label, randomized crossover trial (for nonresponders) with 1 year of follow-up using the web application IBS Constant Care (IBS CC). Patients were recruited from the outpatient clinic at the Department of Gastroenterology, North Zealand University Hospital, Denmark. Patients received either VSL#3 for 4 weeks (2 × 450 billion colony-forming units per day) or were placed on an LFD for 4 weeks. Patients responding to the LFD were reintroduced to foods high in FODMAPs, and probiotic responders received treatments whenever they experienced a flare-up of symptoms. Treatment response and symptom flare-ups were defined as a reduction or increase, respectively, of at least 50 points on the IBS Severity Scoring System (IBS-SSS). Web-based ward rounds were performed daily by the study investigator. Fecal microbiota were analyzed by shotgun metagenomic sequencing (at least 10 million 2 × 100 bp paired-end sequencing reads per sample).
Results
A total of 34 IBS patients without comorbidities and 6 healthy controls were enrolled in the study. Taken from participating subjects, 180 fecal samples were analyzed for their microbiota composition. Out of 21 IBS patients, 12 (57%) responded to the LFD and 8 (38%) completed the reintroduction of FODMAPs. Out of 21 patients, 13 (62%) responded to their first treatment of VSL#3 and 7 (33%) responded to multiple VSL#3 treatments. A median of 3 (IQR 2.25-3.75) probiotic treatments were needed for sustained symptom control. LFD responders were reintroduced to a median of 14.50 (IQR 7.25-21.75) high-FODMAP items. No significant difference in the median reduction of IBS-SSS for LFD versus probiotic responders was observed, where for LFD it was –126.50 (IQR –196.75 to –76.75) and for VSL#3 it was –130.00 (IQR –211.00 to –70.50; P>.99). Responses to either of the two treatments were not able to be predicted using patients’ microbiota.
Conclusions
The web-based LFD intervention and probiotic treatment were equally efficacious in managing IBS symptoms. The response to treatments could not be explained by the composition of the microbiota. The IBS CC web application was shown to be practical, safe, and useful for clinical decision making in the long-term management of IBS. Although this study was underpowered, findings from this study warrant further research in a larger sample of patients with IBS to confirm these long-term outcomes.
Trial Registration
ClinicalTrials.gov NCT03586622; https://clinicaltrials.gov/ct2/show/NCT03586622
Background and aims:
Efficiency of a low FODMAPs diet (LFD) to relieve symptoms in patients with irritable bowel syndrome (IBS) has been proved in several studies. Our study aimed to evaluate the management of IBS-patients when explanations about LFD are given by the physician without dietician intervention.
Patients and methods:
Patients with IBS were evaluated prospectively after explanations about the LFD were given with the help of a leaflet. A first questionnaire evaluating trigger foods and diet acceptability was submitted to the patient after the consultation. Six weeks later, a second questionnaire evaluated patient's understanding and adherence to the diet, the evolution of symptoms, and the need for a specific dietetic support.
Results:
Thirty-five patients were included (69% female; mean age 45±15). Seventy-four percent of the patients thought that their symptoms were related to food ingestion, and 97% were ready to go on a diet to improve their symptoms. During the second visit, 91% of the patients reported understanding correctly the explanations, 52% followed LFD regularly, 28% sometimes and 20% did not follow LFD at all or barely. Multiple non-adherence factors were reported. All symptoms, except constipation, decreased significantly six weeks after starting LFD. Finally, 77% of the patients reported satisfaction with care and 69% were willing to be supported by a dietician.
Conclusions:
Most IBS patients understood explanations given by GI physicians, but low compliance to the diet and a wish for dietician support was highlighted, suggesting that a dietician intervention should be scheduled when LFD is implemented.
The 100 trillion microbes that make up our gut microbiota interact with the host on an ongoing basis. This complex ecosystem is shaped by a variety of materials such as host derived glycans, non-digestible dietary components and host secreted bile acids. The broad metabolic capacity within the microbiome produces a variety of bioactive compounds from these resources. Short chain fatty acids (SCFAs) are the best-known bioactive compounds, however, other compounds such as molecular hydrogen play an underreported role in the gut. Redox balances throughout the microbiome are often maintained by producing molecular hydrogen, creating a hydrogen cycle between gut microbes. This bioactive compound negatively affects Irritable Bowel Syndrome (IBS) patients, distending the gut lumen and causing pain and bloating. IBS therapies targeting gut microbes, such as antibiotics and dietary control, are effective by reducing fermentation within the gut, in turn reducing the volume of hydrogen present. We discuss the various IBS therapies and their mechanisms of action, how hydrogen is cycled during the carbohydrate fermentation process and how specific probiotics may have potential for reducing hydrogen derived IBS symptoms.
Background:
There are various studies showing the relationship between irritable bowel syndrome (IBS) and diet, and some dietary adjustments are recommended to reduce symptoms. In recent years, there is a growing number of studies that show a 4-8 wk low fermentable oligo, di- and mono-saccharides and polyols (FODMAP) diet has a 50%-80% significant effect on symptoms in IBS patients. There is strong evidence suggesting that changes in fecal microbiota have an impact on IBS pathogenesis. Based on this argument, probiotics have been used in IBS treatment for a long time. As is seen, the FODMAP diet and probiotics are used separately in IBS treatment.
Aim:
To evaluate the effectiveness of adding probiotics to a low FODMAP diet to control the symptoms in patients with IBS.
Methods:
The patients who were admitted to the Gastroenterology Clinic of Dokuz Eylul University Hospital and diagnosed with IBS according to Rome IV criteria were enrolled into the study. They were randomized into 2 groups each of which consisted of 50 patients. All patients were referred to a dietitian to receive dietary recommendations for the low FODMAP diet with a daily intake of 9 g. The patients were asked to keep a diary of foods and beverages they consumed. The patients in Group 1 were given supplementary food containing probiotics (2 g) once a day in addition to their low FODMAP diet, while the patients in Group 2 were given a placebo once a day in addition to their low FODMAP diet. Visual analogue scale (VAS), the Bristol Stool Scale and IBS Symptom Severity Scale (IBS-SSS) scores were evaluated before and after the 21 d treatment.
Results:
The rate of adherence of 85 patients, who completed the study, to the FODMAP restricted diet was 92%, being 90% in Group 1 and 94% in Group 2. The mean scores of VAS and IBS-SSS of the patients in Group 1 before treatment were 4.6 ± 2.7 and 310.0 ± 78.4, respectively, and these scores decreased to 2.0 ± 1.9 and 172.0 ± 93.0 after treatment (both P < 0.001). The mean VAS and IBS-SSS scores of the patients in Group 2 before treatment were 4.7 ± 2.7 and 317.0 ± 87.5, respectively, and these scores decreased to 1.8 ± 2.0 and 175.0 ± 97.7 after treatment (both P < 0.001). The IBS-SSS score of 37 patients (86.04%) in Group 1 and 36 patients (85.71%) in Group 2 decreased by more than 50 points. Group 1 and Group 2 were similar in terms of differences in VAS and IBS-SSS scores before and after treatment. When changes in stool shape after treatment were compared using the Bristol Stool Scale, both groups showed significant change.
Conclusion:
This study is the randomized controlled study to examine the efficiency of probiotic supplementation to a low FODMAP diet in all subtypes of IBS. The low FODMAP diet has highly positive effects on symptoms of all subtypes of IBS. It was seen that adding probiotics to a low FODMAP diet does not make an additional contribution to symptom response and adherence to the diet.
We conducted a meta-analysis exploring the effect of a low fermentable oligo-, di-, monosaccharides, and polyols diet (LFD) on the overall symptoms, quality of life, and stool habits of irritable bowel syndrome (IBS) patients. The meta-analysis was performed using a random-effects method. The effect size was presented as weighted standardized mean difference (SMD) and 95% confidence interval (CI). Subgroup analyses were conducted to determine the potential effects of covariates on the outcome. Twenty-two papers were included. The LFD group showed a moderate reduction in symptom severity and a slight improvement in quality of life compared to the control group (SMD, −0.53 and 0.24; 95% CI, −0.68, −0.38 and 0.02, 0.47, respectively). IBS symptom improvement was consistent between subgroups stratified according to proportions of female patients, study durations, IBS subtypes, assessment methods, and control interventions. Three studies regarding stool habits change in IBS-D patients showed a significant decrease in stool frequency (mean differences [MD], −5.56/week; 95% CI, −7.40, −3.72) and a significant improvement in stool consistency (MD, −0.86; 95% CI, −1.52, −0.19) in the LFD group compared to the control group. This is the most updated meta-analysis including studies that adopted diverse control interventions such as dietary interventions, supplementation, habitual diets, and lifestyle changes.
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.
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.
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.