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Research ArticlePractice

Low FODMAP diet

Cian Hackett and Michael R. Kolber
Canadian Family Physician August 2015, 61 (8) 691;
Cian Hackett
Associate Professor in the Department of Family Medicine, both at the University of Alberta in Edmonton.
Roles: Fourth-year medical student
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Michael R. Kolber
Associate Professor in the Department of Family Medicine, both at the University of Alberta in Edmonton.
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Clinical question

Does the low FODMAP (fermentable oligo-di-monosaccharides and polyols) diet (LFD) improve symptoms for patients with irritable bowel syndrome (IBS)?

Bottom line

The LFD might improve symptoms for those with primarily diarrhea-subtype IBS. However, most studies were of low quality; high-quality studies are needed.

Evidence

Four RCTs with mainly young female participants compared the LFD to a normal diet (ND).

  • Denmark: the largest, high-quality, 6-week, open-label RCT of 123 IBS patients receiving specialist care.1

    • -On a 500-point symptom scale (minimal clinically important difference was 50),2 LFD led to an improvement of about 150, probiotics about 80, and ND about 30 points.

    • -Subgroup analysis: only diarrhea patients improved.

    • -Limitations: pre-enrolment investigations included colonoscopy and genetic lactase deficiency testing; analysis was per protocol.

  • Australia: blinded crossover trial of LFD versus ND (each for 3 weeks, with a 3-week washout period) of 30 IBS patients and 8 controls in primary or secondary care.3

    • -Global gastrointestinal symptoms: with LFD 70% had a more than 10-point improvement on a 100-point scale.

    • -Limitations: ND results not reported; high-fibre diet included in LFD arm; authors had conflicts of interest.

  • United Kingdom: 3-week, non-blinded RCT of 41 patients with diarrhea-predominant IBS or substantial bloating, receiving specialist care.4

    • -Adequate symptom control was reported for 68% of LFD and 23% of ND patients (NNT = 3); however, symptom control at baseline was different (not significantly): 37% for LFD and 58% for ND; symptoms actually worsened in the ND arm (58% controlled at baseline, 23% at the end).

  • Fourth RCT: too short (2 days) to draw conclusions.5

  • Two systematic reviews had conflicting conclusions6,7:

    • -More research is required6 or LFD is efficacious in treating functional gastrointestinal symptoms.7

Context

  • Cohort studies demonstrate LFD benefit,6,7 but IBS patients have a high placebo response rate8 (even when told they are getting placebo).9

  • Patients who initially improve on LFD worsen with reintroduction of fructose or fructans.10

  • The LFD is restrictive, limiting many fruits, dairy products, wheat, legumes, and artificial sweeteners.11

Implementation

Approximately 7% of North Americans have symptoms of IBS12; about 4% of IBS patients actually have celiac disease.13 Testing for celiac disease is recommended for those with IBS symptoms.12 Fibre (psyllium or bran) appears beneficial for primary care IBS patients14; gluten-free15 and elimination diets16 have less convincing evidence. Antidepressants improve global symptoms of IBS (NNT = 4).17 Given side effect profiles, it is reasonable to try tricyclic antidepressants for diarrhea-subtype and selective serotonin reuptake inhibitors for constipation-subtype IBS.

Notes

Tools for Practice articles in Canadian Family Physician (CFP) are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in CFP are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Pedersen N,
    2. Andersen NN,
    3. Végh Z,
    4. Jensen L,
    5. Ankersen DV,
    6. Felding M,
    7. et al
    . Low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome. World J Gastroenterol 2014;20(43):16215-26.
    OpenUrlPubMed
  2. 2.↵
    1. Francis CY,
    2. Morris J,
    3. Whorwell PJ
    . The irritable bowel severity scoring system: a simple method of monitoring irritable bowel syndrome and its progress. Aliment Pharmacol Ther 1997;11:395-402.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Halmos EP,
    2. Power VA,
    3. Shepherd SJ,
    4. Gibson PR,
    5. Muir JG
    . A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology 2014;146:67-75.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Staudacher HS,
    2. Lomer MCE,
    3. Anderson JL,
    4. Barrett JS,
    5. Muir JG,
    6. Irving PM,
    7. et al
    . Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr 2012;142:1510-8.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Ong DK,
    2. Mitchell SB,
    3. Barrett JS,
    4. Shepherd SJ,
    5. Irving PM,
    6. Biesiekierski JR,
    7. et al
    . Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. Gastroenterol Hepatol 2010;25:1366-73.
    OpenUrl
  6. 6.↵
    1. Rao SCC,
    2. Yu S,
    3. Fedew A
    . Systematic review: dietary fibre and FODMAP-restricted diet in the management of constipation and irritable bowel syndrome. Aliment Pharmacol Ther 2015;41:1256-70.
    OpenUrlPubMed
  7. 7.↵
    1. Marsh A,
    2. Eslick EM,
    3. Eslick GD
    . Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr 2015 May 17. Epub ahead of print.
  8. 8.↵
    1. Ford AC,
    2. Moayyedi P
    . Meta-analysis: factors affecting placebo response rate in the irritable bowel syndrome. Aliment Pharmacol Ther 2010;32:144-58.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Kaptchuk TJ,
    2. Friedlander E,
    3. Kelley JM,
    4. Sanchez MN,
    5. Kokkotou E,
    6. Singer JP,
    7. et al
    . Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PLoS One 2010;(12):e15591.
  10. 10.↵
    1. Shepherd SJ,
    2. Parker FC,
    3. Muir JG,
    4. Gibson PG
    . Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized, placebo-controlled evidence. Clin Gastro Hepatol 2008;6:765-71.
    OpenUrl
  11. 11.↵
    The low FODMAP diet. Stanford, CA: Stanford Hospital and Clinics; Available from: https://stanfordhealthcare.org/content/dam/SHC/for-patients-component/programs-services/clinical-nutrition-services/docs/pdf-lowfodmapdiet.pdf. Accessed 2015 Apr 1.
  12. 12.↵
    1. American College of Gastroenterology Task Force on Irritable Bowel Syndrome
    . An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol 2009;104:S1-35.
    OpenUrl
  13. 13.↵
    1. Ford AC,
    2. Chey WD,
    3. Talley NJ,
    4. Malhotra A,
    5. Spiege BMR,
    6. Moayyedi P
    . Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome. Arch Intern Med 2009;169(7):651-8.
    OpenUrlCrossRefPubMed
  14. 14.↵
    1. Bijkerk CJ,
    2. de Wit NJ,
    3. Muris JWM,
    4. Whorwell PJ,
    5. Knottnerus JA,
    6. Hoes AW
    . Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomized placebo controlled trial. BMJ 2009;339:b3154.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. Biesiekierski JR,
    2. Newnham ED,
    3. Irving PM,
    4. Barrett JS,
    5. Haines M,
    6. Doecke JD,
    7. et al
    . Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol 2011;106:508-14.
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. Atkinson W,
    2. Sheldon TA,
    3. Shaath N,
    4. Whorwell PJ
    . Food elimination based on IgG antibodies in irritable bowel syndrome: a randomized controlled trial. Gut 2004;53:1459-64.
    OpenUrlAbstract/FREE Full Text
  17. 17.↵
    1. Ruepert L,
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    4. van der Heijden GJ,
    5. Rubin G,
    6. Muris JWM
    . Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane Database System Rev 2011;(8):CD003460.
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Canadian Family Physician: 61 (8)
Canadian Family Physician
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1 Aug 2015
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Low FODMAP diet
Cian Hackett, Michael R. Kolber
Canadian Family Physician Aug 2015, 61 (8) 691;

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