The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study

Dietary fermentable carbohydrate consumption and association with cardiometabolic risk markers in college students: A cross-sectional study

Objective: Determine fermentable carbohydrates (FCs) consumption and health parameter differences between high and low FC consumers in US college students. Participants: Consented students (n = 571; 18-22 years) in a general nutrition course. Methods: Diet History Questionnaire quantified total FC plus subclasses, soluble dietary fibers (SDF), and polyols. Anthropometrics, blood pressure, and blood glucose were collected by standard measures. Median split classified FC intakes; multiple linear regression evaluated differences in health parameters between low and high FC consumers. Results: Average FC intakes for low and high FC consumers were 4.6 ± 1.4gand 10.9 ± 4.0g, with most coming from soluble dietary fibers. After controlling for confounders, low FCs showed higher diastolic blood pressure (β = 2.95, p = 0.04), blood glucose (β = 2.65 mg/dL; p = 0.02*), and BMI (β = 0.99, p = 0.050*, R2=0.04) than high consumers. Conclusions: Despite low intakes, these college students showed inverse associations between FC and diastolic blood pressure, blood glucose, and BMI. Long-term mechanistic studies are needed to evaluate potential relationships.

A service evaluation of FODMAP restriction, FODMAP reintroduction and long-term follow-up in the dietary management of irritable bowel syndrome

BACKGROUND

The dietary restriction of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs), called the low-FODMAP diet (LFD), is frequently used to manage irritable bowel syndrome (IBS). This service evaluation aimed to assess the long-term effectiveness of the LFD in managing IBS symptoms and whether symptom response and dietary adherence to the LFD were associated.

METHODS

This observational service evaluation collected data via questionnaires during clinical dietetic appointments for IBS management. Symptom severity was reported at baseline, short term (following FODMAP restriction) and long term (following FODMAP reintroduction). Additional data that captured experiences following the LFD were collected at long-term follow-up.

RESULTS

Of 184 patients, 14% reported satisfactory relief from global symptoms at baseline, which increased to 69% at short-term follow-up and 57% at long-term follow-up (p < 0.001). The most notable improvements in individual symptoms between baseline and long-term follow-up were abdominal bloating (72% baseline, 48% long term, p < 0.001), abdominal pain (61% baseline, 30% long term, p < 0.001) and flatulence (71% baseline, 40% long term, p < 0.001). High adherence with the LFD at short-term follow-up was not associated with long-term symptom improvement, but there was an association between long-term adherence and global symptom severity (p = 0.032). Completion of FODMAP reintroduction as per protocol was associated with long-term symptom improvement (p = 0.049).

CONCLUSIONS

The LFD is an effective treatment for managing IBS symptoms in the long term, particularly, when the diet is adhered to and reintroduction is completed as per dietetic education. Further randomised-controlled trials are required to explore the cause-and-effect relationship between LFD and IBS symptom management.

The Gastrointestinal Symptom Rating Scale has a Good Test-Retest Reliability in Well-Trained Athletes With and Without Previously Self-Identified Gastrointestinal Complaints

BACKGROUND

Athletes often report gastrointestinal (GI) complaints. Standardized validated tests validated in athletes are lacking.

OBJECTIVE

The objective of the current study was to investigate the test-retest reliability of the gastrointestinal symptoms rating scale (GSRS), a disease-specific instrument of 15 items to quantify the severity of various GI symptoms.

METHODS

For this purpose, a 3-week repeated measurements design was used. The mean difference (Wilcoxon signed rank test), associations (Spearman correlations), and systematic difference using Bland-Altman calculations for repeated measurements, as well as its internal consistency (Cronbach's alpha) on testing day 1 and day 2 were analyzed, with significance set at p ≤ 0.05. A total of n = 70 well-trained athletes (26.1 ± 5.4 years, of which 40% were female) were included.

RESULTS

A high Cronbach's α for GSRS was found on testing day 1 (0.825), and day 2 (0.823), suggesting a good and comparable internal consistency of the questionnaire. When assessing the multilevel temporal stability for total GSRS scores (28.0, IQR 22.0-36.3 vs 26.5, IQR 18.0-35.0), there was a small but significant difference (Z =  - 2.489, and p = 0.013), but a fair correlation between day scores (r = 0.68, p < 0.001), and a Bland-Altman reporting difference between questionnaires within 10% of the total GSRS score, without significant reporting bias (p = 0.38). In most cases, except for hunger, burping, and loose stools, the individual GSRS items were reported in line with total scores and similar for sex.

CONCLUSION

In conclusion, the GSRS is reliable when used with athletes, with good internal consistency for most symptoms independently of sex, except for hunger, burping, and loose stools.

Low-FODMAP Diet for Irritable Bowel Syndrome: Insights from Microbiome

Irritable bowel syndrome (IBS) is a prevalent gastrointestinal disorder characterized by chronic abdominal pain, bloating, and altered bowel habits. Low-FODMAP diets, which involve restricting fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, have emerged as an effective dietary intervention for alleviating IBS symptoms. This review paper aims to synthesize current insights into the impact of a low-FODMAP diet on the gut microbiome and its mechanisms of action in managing IBS. We explore the alterations in microbial composition and function associated with a low-FODMAP diet and discuss the implications of these changes for gut health and symptom relief. Additionally, we examine the balance between symptom improvement and potential negative effects on microbial diversity and long-term gut health. Emerging evidence suggests that while a low-FODMAP diet can significantly reduce IBS symptoms, it may also lead to reductions in beneficial microbial populations. Strategies to mitigate these effects, such as the reintroduction phase and the use of probiotics, are evaluated. This review highlights the importance of a personalized approach to dietary management in IBS, considering individual variations in microbiome responses. Understanding the intricate relationship between diet, the gut microbiome, and IBS symptomatology will guide the development of more effective, sustainable dietary strategies for IBS patients.

The Efficacy of the Low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) Diet in Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis

Irritable bowel syndrome (IBS) is frequently observed in clinical practice and affects people from different parts of the world. The pathogenesis and aetiology are not well-defined or fully understood; however, altered bowel movements, psychological factors, and visceral hypersensitivity may contribute to symptoms via a pathway mediated by serotonin and other enteric neurotransmitters. Altered bowel movements, including diarrhoea and constipation, abdominal pain relieved by passing flatus, and bloating are the main salient features of this condition. This systematic review and meta-analysis aimed to determine the effectiveness and efficacy of a low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (low-FODMAP) diet in these patients. Systematic searches were conducted on PubMed, Medline, Google Scholar, and Cochrane Library. Randomised controlled trials (RCTs), systematic trials and cohort studies that included keywords about IBS and a low-FODMAP diet were included. Exclusion criteria included studies that were not in the English language, not relevant to IBS, diet-related to inflammatory bowel disease, or not pertinent to the subject. A total of 41 studies were included in this systematic review and meta-analysis. There was significant heterogeneity among the RCTs; hence, a random-effects model was used. The systematic review included a total of 8460 patients across 36 studies, with follow-up durations ranging from 11 to 16 months. Specifically, the meta-analysis included 15 RCTs with 1118 participants and follow-up durations from two days to nine weeks and six cohort studies including 292 patients with follow-up durations from two weeks to two years. The risk ratio (RR) was 1.21 (95% confidence interval= 0.98-1.51), and the I2 value ​​​​​was 63% for global symptom improvement with a low-FODMAP diet using a random-effects model. There was a low risk of bias in the RCTs. Five studies were included evaluating the effect of a low-FODMAP diet on quality of life, and these studies did not show any statistically significant benefit of a low-FODMAP diet on quality of life, although a mean difference of 4.59 (95% CI 1.50-7.67) was observed. The risk of bias was moderate to severe in the observational studies included in this review. Food intolerance is increasingly recognised as a contributory factor in IBS, and its role in the pathogenesis and precipitation of symptoms is being explored. Specific mechanisms include the fermentation of FODMAPs by the gut microbiota, leading to gas production and subsequent symptoms.

Adapted Low-FODMAP Diet in IBS Patients with and without Fibromyalgia: Long-Term Adherence and Outcomes

BACKGROUND/OBJECTIVES

A low-FODMAPs Diet (LFD) is considered a "second line" dietary strategy for irritable bowel syndrome (IBS) but, after a period of strict restriction of all FODMAP foods, it has to be adapted and tailored to each patient (AdLFD). Fibromyalgia often coexists with IBS in up to 65% of cases. Our aims were to evaluate if comorbid fibromyalgia influenced the long-term clinical outcomes and adherence to an AdLFD in IBS patients.

METHODS

IBS patients with or without fibromyalgia who had started an AdLFD were enrolled. Patients had been evaluated before starting the LFD (T0). After a mean follow-up of 62.5 ± 22.7 months (T1), they were re-evaluated using questionnaires on disease severity, bowel habits, psychological status, and adherence to AdLFD.

RESULTS

In total, 51 IBS patients entered the study. Nineteen of them had comorbid fibromyalgia. Thirty patients reported a reduction in symptom severity at T1 in comparison with T0. Despite some slight differences in single IBS Symptom Severity Score items, comorbid fibromyalgia did not influence the IBS-SSS total score at T1. Patients with comorbid fibromyalgia showed a higher Hospital Anxiety and Depression Scale (HADS) score at baseline. A total of 44 patients showed good long-term adherence to the AdLFD. All patients improved their HADS score and had long-term adherence to the AdLFD.

CONCLUSIONS

Comorbid fibromyalgia showed only a slight influence on long-term outcomes of an AdLFD on IBS symptoms, without affecting the relief of global symptoms. No influence on long-term adherence to AdLFD was detected. Hence, this approach can be taken into account in fibromyalgia patients for a nonpharmacological management of IBS symptoms. However, multicentric studies on larger samples would be welcome in the future.

Patients' experiences of dietary changes during a structured dietary intervention for irritable bowel syndrome

BACKGROUND

Diet plays an important role in management of gastrointestinal (GI) symptoms in patients with irritable bowel syndrome (IBS). Restrictive diets have gained popularity as treatment for IBS, but no studies have examined the patients' experiences of implementing such diets. Thus, the present study aimed to explore the experience of patients with IBS undergoing a structured dietary intervention.

METHODS

Using inductive content analysis, semi-structured interviews were conducted in 19 patients with IBS, who were recruited from a randomised controlled trial evaluating two different restrictive diets for 4 weeks: a diet low in total carbohydrates; and a diet low in fermentable oligo-, di- and monosaccharides and polyols (i.e., FODMAP) combined with traditional IBS dietary advice.

RESULTS

Three main themes developed from the qualitative analysis and together they describe the dietary intervention as supportive, as well as the dietary changes as challenging and contributing to reflection. Patients found the dietary support effective in both initiating and adhering to their dietary changes. Despite the support, the implementation of the diet was perceived as challenging when it interfered with other important aspects of their lives. However, going through the dietary change process, the patients began to reflect on their eating behaviours, which enabled individual dietary adjustments. The adjustments that patients maintained were not only a result of alleviation of GI symptoms, but also based on personal preferences.

CONCLUSIONS

Patients with IBS undergoing restrictive diets appear to benefit from structured support. However, considering the individual patient's life situation and personal preferences, individualised dietary options should be encouraged to achieve long-term dietary changes.

The efficacy and real-world effectiveness of a diet low in fermentable oligo-, di-, monosaccharides and polyols in irritable bowel syndrome: A systematic review and meta-analysis

BACKGROUND & AIMS

A diet low in fermentable oligo-, di-, monosaccharides, and polyols (LFD) has been shown to effectively reduce irritable bowel syndrome (IBS) symptoms. Effects resulting from real-world studies may differ from those seen in efficacy studies because of the diversity of patients in real-world settings. This systematic review and meta-analysis aimed to compare the effect of the LFD on reducing IBS symptoms and improving the quality of life (QoL) in efficacy trials and real-world studies.

METHODS

Major databases, trial registries, dissertations, and journals were systematically searched for studies on the LFD in adults with IBS. Meta-analysis was conducted using a random effects model with standardized mean differences (SMD) and 95% confidence intervals (CI). Outcomes of interest were all patient-reported: stool consistency, stool frequency, abdominal pain, overall symptoms, adequate symptom relief, IBS-specific QoL and adherence to the LFD.

RESULTS

Eleven efficacy and 19 real-world studies were reviewed. The meta-analysis results for abdominal pain (SMD 0.35, 95% CI 0.16 to 0.54) and QoL (SMD 0.23, 95% CI -0.05 to 0.50) showed the LFD was beneficial in efficacy studies with no statistically significant results for stool frequency (SMD 0.71, 95% CI 0.34 to 1.07). Real-world studies found improvements in abdominal pain and QoL. Due to heterogeneity, no meta-analysis was done for stool consistency and overall symptoms. In these outcomes, results were mostly supportive of the LFD, but they were not always statistically significant.

CONCLUSIONS

The results of this systematic review and meta-analysis suggest the LFD improves outcomes compared to a control diet (efficacy studies) or baseline data (real-world studies). Because of diverse study designs and heterogeneity of results, a clear superiority of the LFD over control diets could not be concluded. There are no indications of an efficacy-effectiveness gap for the LFD in adults with IBS.

Effect of fibre fortification of low FODMAP pasta

Irritable bowel syndrome (IBS) is a condition affecting the digestive system and can be triggered by several different factors, including diet. To ease symptoms of IBS, a diet low in fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) is often recommended. Pasta, as a staple food in the Western World, is naturally high in FODMAPs. This study investigates the impact of insoluble and soluble dietary fibre ingredients in low-FODMAPs pasta. The assessment included physicochemical, sensory, and nutritional quality. Soluble fibre strengthened gluten network, which caused a lower cooking loss and a lower release of sugars during in vitro starch digestion. Insoluble fibre interfered with the gluten network development to a higher extent causing a higher sugar release during digestion. This study reveals the most suitable fibre ingredients for the development of pasta with elevated nutritional value and sensory characteristics compared to commercial products on the market. This type of pasta has a high potential of being suitable for IBS patients.

High fat intake sustains sorbitol intolerance after antibiotic-mediated Clostridia depletion from the gut microbiota

Carbohydrate intolerance, commonly linked to the consumption of lactose, fructose, or sorbitol, affects up to 30% of the population in high-income countries. Although sorbitol intolerance is attributed to malabsorption, the underlying mechanism remains unresolved. Here, we show that a history of antibiotic exposure combined with high fat intake triggered long-lasting sorbitol intolerance in mice by reducing Clostridia abundance, which impaired microbial sorbitol catabolism. The restoration of sorbitol catabolism by inoculation with probiotic Escherichia coli protected mice against sorbitol intolerance but did not restore Clostridia abundance. Inoculation with the butyrate producer Anaerostipes caccae restored a normal Clostridia abundance, which protected mice against sorbitol-induced diarrhea even when the probiotic was cleared. Butyrate restored Clostridia abundance by stimulating epithelial peroxisome proliferator-activated receptor-gamma (PPAR-γ) signaling to restore epithelial hypoxia in the colon. Collectively, these mechanistic insights identify microbial sorbitol catabolism as a potential target for approaches for the diagnosis, treatment, and prevention of sorbitol intolerance.

The low FODMAP diet in clinical practice: where are we and what are the long-term considerations?

A diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) improves functional bowel symptoms and is a second-line dietary management strategy for the treatment of irritable bowel syndrome (IBS). The diet is complex and involves three stages: restriction, reintroduction and personalisation and clinical effectiveness is achieved with dietitian-led education; however, this is not always available. The aim of this review is to provide an update on the evidence for using the low FODMAP diet, with a focus on the impact of FODMAP restriction and reintroduction considering long-term management of IBS in a clinical setting. Randomised controlled trials have assessed symptom response, quality of life, dietary intake and changes to the gut microbiota during FODMAP restriction. Systematic reviews and meta-analyses consistently report that FODMAP restriction has a better symptom response compared with control diets and a network analysis reports the low FODMAP diet is superior to other dietary treatments for IBS. Research focused on FODMAP reintroduction and personalisation is limited and of lower quality, however common dietary triggers include wheat, onion, garlic, pulses and milk. Dietitian-led delivery of the low FODMAP diet is not always available and alternative education delivery methods, e.g. webinars, apps and leaflets, are available but remove the personalised approach and may be less acceptable to patients and may introduce safety concerns in terms of nutritional adequacy. Predicting response to the low FODMAP diet using symptom severity or a biomarker is of great interest. More evidence on less restrictive approaches and non-dietitian-led education delivery methods are needed.

The Role of the FODMAP Diet in IBS

The low FODMAP (fermentable oligosaccharide, disaccharide, monosaccharide, and polyol) diet is a beneficial therapeutic approach for patients with irritable bowel syndrome (IBS). However, how the low FODMAP diet works is still not completely understood. These mechanisms encompass not only traditionally known factors such as luminal distension induced by gas and water but also recent evidence on the role of FOMAPs in the modulation of visceral hypersensitivity, increases in intestinal permeability, the induction of microbiota changes, and the production of short-chain fatty acids (SCFAs), as well as metabolomics and alterations in motility. Although most of the supporting evidence is of low quality, recent trials have confirmed its effectiveness, even though the majority of the evidence pertains only to the restriction phase and its effectiveness in relieving abdominal bloating and pain. This review examines potential pathophysiological mechanisms and provides an overview of the existing evidence on the effectiveness of the low FODMAP diet across various IBS subtypes. Key considerations for its use include the challenges and disadvantages associated with its practical implementation, including the need for professional guidance, variations in individual responses, concerns related to microbiota, nutritional deficiencies, the development of constipation, the necessity of excluding an eating disorder before commencing the diet, and the scarcity of long-term data. Despite its recognized efficacy in symptom management, acknowledging these limitations becomes imperative for a nuanced comprehension of the role of a low FODMAP diet in managing IBS. By investigating its potential mechanisms and evidence across IBS subtypes and addressing emerging modulations alongside limitations, this review aims to serve as a valuable resource for healthcare practitioners, researchers, and patients navigating the intricate landscape of IBS.

Astaxanthin attenuated the stress-induced intestinal motility disorder via altering the gut microbiota

Gut microbiota and short-chain fatty acids (SCFAs) are recognized as key factors in the pathophysiology of irritable bowel syndrome. Astaxanthin is a carotenoid with strong antioxidant and anti-inflammatory activities. In this study, we examined the effects of astaxanthin on gut microbiota-, SCFAs-, and corticotropin-releasing factor (CRH)-induced intestinal hypermotility. Male Wistar rats (n=12 per group) were fed a diet with or without 0. 02% (w/w) astaxanthin for four weeks and CRH or saline was administered intravenously. The number of fecal pellets was counted 2 h after injection. Then the rats were sacrificed, and the cecal content were collected 3 h after injection. The number of feces was significantly increased by CRH injection in the control group (2.0 vs. 6.5; p=0.028), but not in the astaxanthin group (1.0 vs. 2.2; p=0.229) (n=6 per group). The cecal microbiota in the astaxanthin group was significantly altered compared with that in the control group. The concentrations of acetic acid (81.1 μmol/g vs. 103.9 μmol/g; p=0.015) and butyric acid (13.4 μmol/g vs. 39.2 μmol/g; p<0.001) in the astaxanthin group were significantly lower than that in the control group (n=12 per group). Astaxanthin attenuates CRH-induced intestinal hypermotility and alters the composition of gut microbiota and SCFAs.

The Long-Term Effects of a Low-Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols Diet for Irritable Bowel Syndrome Management

Short-term studies indicate that low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diets (LFDs) can improve symptoms for patients with irritable bowel syndrome (IBS). However, long-term (≥6 mo) effectiveness, safety, and sustainability of an LFD are not well understood and remain controversial. The primary purpose of the current review was to consider the published research on the effectiveness, safety, and sustainability of an LFD for patients with IBS. The secondary aim was to develop an infographic for dissemination to outpatient registered dietitian nutritionists and other healthcare professionals who work with patients with IBS. Three electronic databases (PubMed, Scopus, and Web of Science) were searched through December 2022, using the terms irritable bowel syndrome, FODMAP, and long-term. Following article selection, a total of 14 studies were included. Nine of 9 studies reported significant improvements in symptoms, 7 of 7 studies showed significant improvements in bowel habits, 1 of 1 study showed significantly improved disease course, and 6 of 6 studies showed significantly improved quality of life, compared to baseline. One study showed that improvement in gastrointestinal symptoms was significantly correlated with improvements in quality of life. Two of 3 studies and body composition measures indicated that nutritional adequacy was not compromised. Two of 2 studies showed that gut microbiota did not change, but 1 study showed decreased short-chain fatty acids. Adherence rates ranged from 50% to 82%, and 1 study showed that greater adherence was significantly correlated with improved IBS symptoms. Three of 3 studies showed that better adherence to an LFD was associated with improved symptom relief, and 70%-89% of participants reported satisfaction with the LFD for IBS management. The main difficulties reported were the higher expense and adhering to the diet when eating at restaurants, with family and friends, or while traveling. Overall, a long-term LFD for IBS management can be effective, safe, and sustainable.

An Exploratory Study Investigating the Prevalence of Gastrointestinal Symptoms in Collegiate Division I American Football Athletes

Gastrointestinal (GI) symptoms may limit performance, but their prevalence and impact among team sports athletes is not well-documented. The objective of this study was to examine the prevalence of GI symptoms in a small sample of collegiate DI American football athletes, using a survey including the Gastrointestinal Symptoms Ratings Scale (GSRS). Forty-six athletes responded to the survey and reported scores for the 15-question GSRS with additional questions about dietary habits and supplement use. A total of 44 athletes were included in the study (45% of the current roster, age: 20.7 ± 1.7 years, 50% Afro-American or black, 39% skill position, 18% NSAIDs use, and 41% reporting protein supplement use); approximately half of the athletes (52%) reported experiencing GI complaints during exercise. Two-thirds of the athletes (61%) reported at least one or more GI symptoms in general, and 50% reported at least four moderate complaints. Seven athletes (16%) reported ≥2 severe GI symptoms with 5-13 moderate complaints. The most reported symptom was stomach pain (39%, n = 17), followed by hunger pain (36%, n = 16). Athletes reporting the use of protein supplements reported a higher GSRS score (22.0 and interquartile range (IQR) 17.0-31.8) vs. athletes not reporting protein use (15.0 and IQR 15.0-19.3), p = 0.001. Most athletes surveyed reported experiencing GI symptoms. A small group of these athletes reported multiple, varied, and severe symptoms that were associated with self-reported protein supplement use. In conclusion, the number of complaints varied among athletes, confirming the value of integrating the GSRS for screening purposes, and the expected need for individual dietary treatment approaches.

Current evidence for dietary therapies in irritable bowel syndrome

PURPOSE OF REVIEW

Diet appears to trigger symptoms in the majority of individuals with irritable bowel syndrome (IBS) and is associated with a reduced quality of life. There has been a recent focus on the role of dietary therapies to manage individuals with IBS. The aim of this review is to discuss the utility of traditional dietary advice (TDA), low-FODMAP diet (LFD) and gluten-free diet (GFD) in IBS.

RECENT FINDINGS

Several recent randomized controlled trials (RCTs) have been published demonstrating the efficacy of the LFD and GFD in IBS, with the evidence base for TDA being predominantly based on clinical experience, with emerging RCTs evaluating TDA. Only one RCT has been published to date comparing TDA, LFD and GFD head to head, with no difference noted between diets in terms of efficacy. However, TDA has been noted to be more patient-friendly and is commonly implemented as a first-line dietary therapy.

SUMMARY

Dietary therapies have been demonstrated to improve symptoms in patients with IBS. In view of insufficient evidence to recommend one diet over another currently, specialist dietetic input in conjunction with patient preference is required to determine implementation of dietary therapies. Novel methods of dietetic delivery are required in view of the lack of dietetic provision to deliver these therapies.

The effect of starch- and sucrose-reduced diet accompanied by nutritional and culinary recommendations on the symptoms of irritable bowel syndrome patients with diarrhoea

BACKGROUND

Irritable bowel syndrome (IBS) is a common gastrointestinal condition which entails a high burden in the quality of life (QoL) of patients. Nutritional interventions have been proposed to alleviate symptoms, since still no effective treatments exist for IBS.

OBJECTIVES

Our aim is to analyse the feasibility of the use of starch- and sucrose-reduced diet (SSRD).

DESIGN

In this study, we used a SSRD accompanied by nutritional and culinary recommendations to measure the effects in IBS patients with diarrhoea.

METHODS

In all, 34 participants completed a 4-week nutritional intervention based on SSRD. Symptoms, QoL and dietary habits were assessed by several questionnaires that were completed at the beginning, daily, after 2 weeks, at the end, and after 2 months.

RESULTS

85.29% of the participants reached the primary endpoint [reduction of 50 points or more in IBS-symptom severity scale (SSS)], and 58.82% the secondary endpoint (reduction of 50% or more in IBS-SSS). The relief of symptoms and improvement of the QoL were significant after 2 weeks of intervention, at the end and after 2 months. Dietary habits were consistent with the diet and high adherence was achieved.

CONCLUSIONS

SSRD and individualized nutritional and culinary guidance improved symptoms and QoL of IBS patients with diarrhoea, with a high adherence.

Impact of Small Intestinal Bacterial Overgrowth in Patients with Inflammatory Bowel Disease and Other Gastrointestinal Disorders-A Retrospective Analysis in a Tertiary Single Center and Review of the Literature

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.

A Theory Planned Behaviour of Study on Improving Abdominal Bloating among the Malays Population: A Qualitative Study

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.

Low FODMAP diet reduces gastrointestinal symptoms in irritable bowel syndrome and clinical response could be predicted by symptom severity: A randomized crossover trial

BACKGROUND & 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 (4 g/day) or moderate (23 g/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 15 min, 4 h) 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.

The Potential Role of Human Milk Oligosaccharides in Irritable Bowel Syndrome

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.

Diet and irritable bowel syndrome: an update from a UK consensus meeting

There has been a renewed interest in the role of dietary therapies to manage irritable bowel syndrome (IBS), with diet high on the agenda for patients. Currently, interest has focussed on the use of traditional dietary advice (TDA), a gluten-free diet (GFD) and the low FODMAP diet (LFD). A consensus meeting was held to assess the role of these dietary therapies in IBS, in Sheffield, United Kingdom.Evidence for TDA is from case control studies and clinical experience. Randomised controlled trials (RCT) have demonstrated the benefit of soluble fibre in IBS. No studies have assessed TDA in comparison to a habitual or sham diet. There have been a number of RCTs demonstrating the efficacy of a GFD at short-term follow-up, with a lack of long-term outcomes. Whilst gluten may lead to symptom generation in IBS, other components of wheat may also play an important role, with recent interest in the role of fructans, wheat germ agglutinins, as well as alpha amylase trypsin inhibitors. There is good evidence for the use of a LFD at short-term follow-up, with emerging evidence demonstrating its efficacy at long-term follow-up. There is overlap between the LFD and GFD with IBS patients self-initiating gluten or wheat reduction as part of their LFD. Currently, there is a lack of evidence to suggest superiority of one diet over another, although TDA is more acceptable to patients.In view of this evidence, our consensus group recommends that dietary therapies for IBS should be offered by dietitians who first assess dietary triggers and then tailor the intervention according to patient choice. Given the lack of dietetic services, novel approaches such as employing group clinics and online webinars may maximise capacity and accessibility for patients. Further research is also required to assess the comparative efficacy of dietary therapies to other management strategies available to manage IBS.

Review article: exclude or expose? The paradox of conceptually opposite treatments for irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a heterogeneous disorder of gut-brain interaction (DGBI) maintained by interacting biological, psychological, and social processes. Interestingly, there are two contrasting yet evidence-based treatment approaches for reducing IBS symptoms: exclusion diets such as those low in fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) and exposure-based cognitive-behavioural therapy (CBT). Exclusion diets recommend patients avoid foods thought to be symptom-inducing, whereas exposure-based CBT encourages patients to expose themselves to foods.

AIMS

To address the paradox of conceptually opposite exclusion diets and exposure-based CBT for IBS.

METHODS

In this conceptual review, we describe the rationale, practical implementation, evidence base and strengths and weaknesses of each treatment. We conducted up-to-date literature search concerning the low FODMAP diet and CBT, and performed a secondary analysis of a previously conducted trial to illustrate a key point in our review.

RESULTS

The low FODMAP diet has demonstrated efficacy, but problems with adherence, nutritional compromise, and heightened gastrointestinal-specific anxiety raise caution. Exposure-based CBT has demonstrated efficacy with substantial evidence for gastrointestinal-specific anxiety as a key mechanism of action. Mediation analysis also showed that increased FODMAP intake mediated decreased symptom severity in exposure-based CBT. However, there is minimal evidence supporting which treatment "works best for whom" and how these approaches could be best integrated.

CONCLUSIONS

Even though exclusion diets and exposure-based CBT are conceptually opposite, they each have proven efficacy. Clinicians should familiarise themselves with both treatments. Further research is needed on predictors, mechanisms and moderators of treatment outcomes.

AGA Clinical Practice Update on the Role of Diet in Irritable Bowel Syndrome: Expert Review

DESCRIPTION

Irritable bowel syndrome (IBS) is a commonly diagnosed gastrointestinal disorder that can have a substantial impact on quality of life. Most patients with IBS associate their gastrointestinal symptoms with eating food. Mounting evidence supports dietary modifications, such as the low-fermentable oligo-, di-, and monosaccharides and polyols (FODMAP) diet, as a primary treatment for IBS symptoms. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the role of diet in IBS treatment.

METHODS

This expert review was commissioned and approved by the AGA CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet in treating patients with IBS. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Dietary advice is ideally prescribed to patients with IBS who have insight into their meal-related gastrointestinal symptoms and are motivated to make the necessary changes. To optimize the quality of teaching and clinical response, referral to a registered dietitian nutritionist (RDN) should be made to patients who are willing to collaborate with a RDN and patients who are not able to implement beneficial dietary changes on their own. If a gastrointestinal RDN is not available, other resources can assist with implementation of diet interventions. BEST PRACTICE ADVICE 2: Patients with IBS who are poor candidates for restrictive diet interventions include those consuming few culprit foods, those at risk for malnutrition, those who are food insecure, and those with an eating disorder or uncontrolled psychiatric disorder. Routine screening for disordered eating or eating disorders by careful dietary history is critical because they are common and often overlooked in gastrointestinal conditions. BEST PRACTICE ADVICE 3: Specific diet interventions should be attempted for a predetermined length of time. If there is no clinical response, the diet intervention should be abandoned for another treatment alternative, for example, a different diet, medication, or other form of therapy. BEST PRACTICE ADVICE 4: In preparation for a visit with a RDN, patients should provide dietary information that will assist in developing an individualized nutrition care plan. BEST PRACTICE ADVICE 5: Soluble fiber is efficacious in treating global symptoms of IBS. BEST PRACTICE ADVICE 6: The low-FODMAP diet is currently the most evidence-based diet intervention for IBS. Healthy eating advice as described by the National Institute of Health and Care Excellence Guidelines, among others, also offers benefit to a subset of patients with IBS. BEST PRACTICE ADVICE 7: The low-FODMAP diet consists of the following 3 phases: 1) restriction (lasting no more than 4-6 weeks), 2) reintroduction of FODMAP foods, and 3) personalization based on results from reintroduction. BEST PRACTICE ADVICE 8: Although observational studies found that most patients with IBS improve with a gluten-free diet, randomized controlled trials have yielded mixed results. BEST PRACTICE ADVICE 9: There are limited data showing that selected biomarkers can predict response to diet interventions in patients with IBS, but there is insufficient evidence to support their routine use in clinical practice.

Diet as a therapeutic tool in chronic gastrointestinal disorders: Lessons from the FODMAP journey

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 nonceliac 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 randomized 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 optimize outcomes as they can target and tailor the therapy and to mitigate the key risks of compromising nutritional adequacy and precipitating disordered eating behaviors, skills outside the gastroenterologist's standard tool kit. While concurrent probiotics are ineffective, specific fiber supplements may improve short-term 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.

Belgian consensus on irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is characterised by recurrent abdominal pain related to defaecation or associated with altered stool frequency or consistency. Despite its prevalence, major uncertainties in the diagnostic and therapeutic management persist in clinical practice.

METHODS

A Delphi consensus was conducted by 20 experts from Belgium, and consisted of literature review and voting process on 78 statements. Grading of recommendations, assessment, development and evaluation criteria were applied to evaluate the quality of evidence. Consensus was defined as > 80 % agreement.

RESULTS

Consensus was reached for 50 statements. The Belgian consensus agreed as to the multifactorial aetiology of IBS. According to the consensus abdominal discomfort also represents a cardinal symptom, while bloating and abdominal distension often coexist. IBS needs subtyping based on stool pattern. The importance of a positive diagnosis, relying on history and clinical examination is underlined, while additional testing should remain limited, except when alarm features are present. Explanation of IBS represents a crucial part of patient management. Lifestyle modification, spasmolytics and water-solube fibres are considered first-line agents. The low FODMAP diet, selected probiotics, cognitive behavioural therapy and specific treatments targeting diarrhoea and constipation are considered appropriate. There is a consensus to restrict faecal microbiota transplantation and gluten-free diet, while other treatments are strongly discouraged.

CONCLUSIONS

A panel of Belgian gastroenterologists summarised the current evidence on the aetiology, symptoms, diagnosis and treatment of IBS with attention for the specificities of the Belgian healthcare system.

Long-term personalized low FODMAP diet in IBS

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.

Global prevalence and burden of meal-related abdominal pain

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.

A systematic review and meta-analysis on the prevalence of non-malignant, organic gastrointestinal disorders misdiagnosed as irritable bowel syndrome

Treatable gastrointestinal disorders in patients with symptoms typical for irritable bowel syndrome (IBS) may be overlooked. The prevalence of five gastrointestinal conditions-bile acid diarrhoea (BAD), carbohydrate malabsorption (CM), microscopic colitis (MC), pancreatic exocrine insufficiency (PEI) and small intestinal bacterial overgrowth (SIBO) was systematically assessed from studies including consecutive patients meeting diagnostic criteria for IBS. 4 databases were searched from 1978 to 2020. Studies were included if they evaluated the prevalence of these conditions in secondary healthcare setting. Estimated pooled rates were calculated and statistical heterogeneity between studies was evaluated using Q and I2 statistics. Seven studies (n = 597) estimated the pooled prevalence for BAD as 41% (95% CI 29-54). 17 studies (n = 5068) estimated that of MC as 3% (95% CI 2-4%). Two studies (n = 478) suggested a rate of 4.6% (range: 1.8-6.1%) for PEI. Using breath testing, 26 studies (n = 6700) and 13 studies (n = 3415) estimated the prevalence of lactose and fructose malabsorption as 54% (95% CI 44-64%) and 43% (95% CI 23-62%); 36 studies (n = 4630) and 22 studies (n = 2149) estimated that of SIBO as 49% (95% CI 40-57%) with lactulose and 19% (95% CI 13-27%) with glucose. Rates of all conditions were significantly higher than in healthy controls. A significant proportion of patients presenting to secondary care with IBS have an organic condition which may account for their symptoms. Failure to exclude such conditions will deny patients effective treatment.

Beneficial Effects on Abdominal Bloating with an Innovative Food-Grade Formulation of Curcuma longa and Boswellia serrata Extracts in Subjects with Irritable Bowel Syndrome and Small Bowel Dysbiosis

Bloating is a symptom frequently reported by subjects with irritable bowel syndrome (IBS) and small bowel dysbiosis, and Low FODMAP’s diet (LFD) has been used to treat them. Extracts of Curcumalonga and Boswelliaserrata share anti-inflammatory and antimicrobial effects that could be useful in the management of these clinical conditions. The aim of this study was to evaluate the efficacy of curcumin and boswellia extracts (as Curcumin Boswellia Phytosome, CBP) and LFD on the relief of abdominal bloating in IBS subjects with small bowel dysbiosis, in comparison to LFD alone, in a 30-day supplementation, randomized trial. IBS participants were randomized to either the intervention (500 mg bid of CBP and LFD) or control arm (LFD). Small bowel dysbiosis has been defined by an increase of urinary indican with normal urinary skatole. A total of 67 subjects were recruited. The intervention group (33 subjects) showed a significant decrease (p < 0.0001) of bloating, abdominal pain, and indican values at the end of the study, when compared to the control group (34 subjects). Moreover, the subjects of the intervention group showed a significantly better (p < 0.0001) global assessment of efficacy (GAE) as compared to controls. In conclusion, in subjects with IBS and small bowel dysbiosis, abdominal bloating can be successfully reduced with a supplementation with CBP and LFD.

Predictors of Symptom-Specific Treatment Response to Dietary Interventions in Irritable Bowel Syndrome

(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) Conclusions: 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.

SEVERITY OF IRRITABLE BOWEL SYNDROME SYMPTOMS AND FODMAPS INTAKE IN UNIVERSITY STUDENTS

BACKGROUND

Irritable bowel syndrome (IBS) symptoms such as diarrhea, bloating and abdominal pain can reduce University student's productivity and learning ability. One of the possible treatments for IBS is the temporarily exclusion of foods that have a high content of short-chain fermentable carbohydrates, the fermentable, oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs).

OBJECTIVE

This study aimed to assess University student's intake of foods that are rich in FODMAPs, looking for possible associations with the severity of IBS symptoms.

METHODS

A cross-sectional study was carried out, with undergraduate students from a private University in the city of São Paulo, Brazil, aged between 19 and 46 years old and that were enrolled in different courses and stages. Students were invited to participate and those who gave their formal consent were included in this research. A sociodemographic and lifestyle questionnaire was applied, in addition to the Gastrointestinal Symptom Rating Scale - GSRS. Students also responded a short Food Frequency Questionnaire, developed to investigate habitual FODMAPs intake of Brazilian adult population. Spearman's correlation analysis between the student's GSRS scores and the frequency of foods rich in FODMAPs intake were performed in SPSS v.21.

RESULTS

Fifty-six students were interviewed, with mean age of 21.4 years old (SD=4.41), with a predominance of women (76.8%). The GSRS results showed that 58.9% of students felt minimal to moderate abdominal discomfort and 14.3% had moderately severe to very severe abdominal pain during the prior week to the interview. Besides abdominal pain, the gastrointestinal symptoms that were most reported by students were flatulence (98.2%), stomach rumbling (89.3%) and eructations (85.7%). Greater symptom severity was observed in women (P=0.004) and sedentary students (P=0.003). Regarding FODMAPs consumption, honey (P=0.04), chocolate (P=0.03) and milk table cream (P=0.001) intakes were positively correlated with the greater severity of symptoms.

CONCLUSION

Although clinical diagnosis is necessary to establish IBS, 73.2% of the students presented minimal to very severe abdominal pain during the prior week. Female had sedentary students had greater severity of gastrointestinal symptoms. A low FODMAP diet, well oriented, could bring some symptoms relief to these University students.

Effects of a low-FODMAP enteral formula on diarrhea on patients in the intensive care unit

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

The low FODMAP diet for IBS; A multicentre UK study assessing long term follow up

BACKGROUND

The low FODMAP diet (LFD) is effective in managing irritable bowel syndrome (IBS) in the short term. This study assessed the long-term effect of the LFD on symptoms, nutritional composition and socialising.

METHODS

Patients with IBS who received dietetic-led LFD advice were approached at long term follow up (>6 months post LFD advice) from six centres across the United Kingdom. Participants completed questionnaires assessing gastrointestinal symptoms, adherence, nutritional intake, dietary acceptability and food related quality of life (QOL).

RESULTS

205 participants completed the study, with a mean follow up of 44 months (3.7 years). Adequate symptom relief was noted in 60% of individuals at long term follow up, with 76% being on the personalisation phase of the LFD (pLFD). Mean nutritional intake did not differ between individuals on the pLFD versus habitual diet, with no difference in fructan intake (2.9 g/d vs 2.9 g/d, p = 0.96). The majority (80%) of individuals on the pLFD consumed specific 'free-from' products at the long term, with the purchase of gluten or wheat free products being the commonest (68%).

CONCLUSION

The majority of patients follow the pLFD in the long term, with a large proportion purchasing gluten or wheat free products to manage their symptoms.

Investigating the Role of Low-FODMAP Diet in Improving Gastrointestinal Symptoms in Irritable Bowel Syndrome

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.

Igg Food Antibody Guided Elimination-Rotation Diet Was More Effective than FODMAP Diet and Control Diet in the Treatment of Women with Mixed IBS-Results from an Open Label Study

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.

Clinical effectiveness of adding probiotics to a low FODMAP diet: Randomized double-blind placebo-controlled study

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.

No Correlation between Positive Fructose Hydrogen Breath Test and Clinical Symptoms in Children with Functional Gastrointestinal Disorders: A Retrospective Single-Centre Study

Fructose malabsorption is regarded as one of the most common types of sugar intolerance. However, the correlation between gastrointestinal symptoms and positive results in fructose hydrogen breath tests (HBTs) remains unclear. The aim of this study was to assess the clinical importance of positive fructose HBT by correlating the HBT results with clinical features in children with various gastrointestinal symptoms. Clinical features and fructose HBT results were obtained from 323 consecutive children (2-18 years old, mean 10.7 ± 4.3 years) that were referred to the Tertiary Paediatric Gastroenterology Centre and diagnosed as having functional gastrointestinal disorders. A total of 114 out of 323 children (35.3%) had positive HBT results, of which 61 patients were females (53.5%) and 53 were males (46.5%). Children with positive HBT were significantly younger than children with negative HBT (9.0 vs. 11.6 years old; p < 0.001). The most frequent symptom among children with fructose malabsorption was recurrent abdominal pain (89.5%). Other important symptoms were diarrhoea, nausea, vomiting, and flatulence. However, no correlation between positive fructose HBT results and any of the reported symptoms or general clinical features was found. In conclusion, positive fructose HBT in children with functional gastrointestinal disorders can be attributed to their younger age but not to some peculiar clinical feature of the disease.

Expression of the fructose transporter GLUT5 in patients with fructose malabsorption

BACKGROUND

 Patients with abdominal symptoms are frequently diagnosed with fructose malabsorption (FM). Fructose is absorbed by monosaccharide transporters located in the brush border of the human small intestine. The aim of this study was to investigate the histoanatomical distribution of the main fructose transporter GLUT5.

MATERIALS AND METHODS

 We studied 223 patients diagnosed with FM by a hydrogen breath test and grouped according to their response to a fructose-free diet. The control group were 42 healthy individuals and 29 patients with celiac disease (CD). The fructose breath test was done with 50 g fructose. The expression of Glut5 in duodenal biopsy specimens was studied by immunohistochemistry. The Kruskal-Wallis-test and Mann-Whitney U-test were used to carry out the statistical analysis.

RESULTS

 The histoanatomical expression pattern of GLUT5 did not differ significantly between those patients with FM who responded completely to a fructose-free diet (n = 183) and healthy individuals (n = 42); nor did it correlate to H2 production measured in fructose breath testing. In patients with FM, the GLUT5 expression pattern did not differ between those individuals responding to a fructose-free diet and those who did not. However, GLUT5 expression pattern was significantly different in patients with CD (n = 29) compared to patients with FM and to healthy individuals (p = 0.009).

CONCLUSION

 GLUT5 expression patterns are not be related to adult patients with FM. However, in secondary malabsorption, a decreased GLUT5 expression was found. Further investigation is needed to understand the essential factors in FM and the influence on functional gastrointestinal disorders.

Investigation of different dietary-fibre-ingredients for the design of a fibre enriched bread formulation low in FODMAPs based on wheat starch and vital gluten

Consumption of fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) often induces symptoms of irritable bowel syndrome (IBS). Since FODMAPs and dietary fibre (DF) share certain characteristics, IBS-patients have a limited intake of DF. Therefore, enrichment of a low FODMAP model bread (based on 84% wheat starch and 16% vital gluten) with various fibres (bamboo, cellulose, psyllium, guar gum) in two different concentrations (3 g/100 g and 6 g/100 g) was investigated. Physico-chemical properties of doughs and breads were analysed (fermentation quality, gluten development, specific volume and hardness), as well as the release of reducing sugars during in vitro digestion. High performance anion exchange chromatography with coupled pulsed amperometric detection (HPAEC-PAD) was used to determine the FODMAP levels (contents of mannitol, sorbitol, fructose in excess of glucose, fructans and α-galactooligosaccharides) of both dough and bread. Prototypes were compared with wheat flour-based breads (bakers’ flour with and without wheat bran addition) to assess the performance of these prototypes. Prototypes showed a decreased quality compared to a baker’s flour control, however, a quality comparable to commercial wheat bran breads was found. This in combination with a lower release of reducing sugars during in vitro digestion underline the potential of fibre enriched breads as part of a healthier and more palateable low FODMAP diet. Furthermore, this study highlights the importance of the type (viscous and insoluble) and the concentration of fibres used. Application of psyllium in a concentration of 3 g/100 g showed the most beneficial impact on both physical (specific volume, hardness after 0 h and 24 h) and nutritional aspects of bread.

What Are the Pearls and Pitfalls of the Dietary Management for Chronic Diarrhoea?

Chronic diarrhoea affects up to 14% of adults, it impacts on quality of life and its cause can be variable. Patients with chronic diarrhoea are presented with a plethora of dietary recommendations, often sought from the internet or provided by those who are untrained or inexperienced. In this review, we summarise the possible causes of chronic diarrhoea that can be managed by diet, the symptom improvement and quality of life benefits but also the potential risks of such dietary treatments. Clinicians need to consider both the benefits and risks of dietary treatments before making dietary recommendations to manage chronic diarrhoea. The pivotal role that dietitians have in ensuring optimal symptom improvement without jeopardising nutritional and overall health is discussed.

Management of irritable bowel syndrome with diarrhea: focus on eluxadoline

OBJECTIVE

We sought to summarize current recommendations for the diagnosis of diarrhea-predominant irritable bowel syndrome (IBS-D) and describe available management options, highlighting a newer US Food and Drug Administration (FDA)-approved agent, eluxadoline.

METHODS

Literature on IBS-D was assessed up to January 2020 using PubMed, with key search terms including "IBS-D diagnosis", "IBS-D management", and "eluxadoline".

RESULTS

IBS is a common gastrointestinal disorder affecting up to 14% of US adults and is particularly prevalent in women and those aged under 50. Symptoms include abdominal pain associated with altered bowel habits (i.e. diarrhea and/or constipation subtyped based on the predominant stool pattern). As IBS-D is challenging to manage with varying symptom severity, effective treatment requires a personalized management approach. Evidence-based therapeutic options endorsed by the American Gastroenterological Association and the American College of Gastroenterology can be used to effectively guide treatment. Dietary and lifestyle modifications, including adequate hydration, reducing caffeine and alcohol intake, and increasing soluble fiber intake may lead to symptom improvement. Over-the-counter medications such as loperamide are frequently recommended and may improve stool frequency and rectal urgency; however, for the outcome of abdominal pain, mixed results have been observed. Several off-label prescription medications are useful in IBS-D management, including tricyclic antidepressants, bile acid sequestrants, and antispasmodics. Three prescription medications have been approved by the FDA for IBS-D: alosetron, eluxadoline, and rifaximin.

CONCLUSIONS

IBS-D can be effectively managed in the primary care setting in the absence of alarm features. Benefits and risks of pharmacologic interventions should be weighed during treatment selection.

Nutrition Tools for the Practicing Gastroenterologist

There are several online tools, books, and applications available to enhance the application of nutrition interventions for gastroenterologists and patients with gastrointestinal (GI) disorders. Nutritional health may be compromised in GI patients because of the nature of the disease impacting use of nutritional substrates or reducing oral intake. Protein-calorie malnutrition can result from insufficient intake, malabsorption of nutrients, and increased energy expenditure, all of which can occur in certain GI conditions. Eating disorders and disordered eating, and food insecurity, also impact nutritional status. Therapeutic nutrition interventions should be implemented with guidance of a registered dietitian with expertise in their application.

Role of diet and nutrition in inflammatory bowel disease

Inflammatory bowel diseases (IBDs) are closely linked to nutrition. The latest research indicates that diet and nutrition are significantly involved in the etiopathogenesis of the disease, although their specific role throughout its clinical course still remains unclear. This study reviewed how diet and nutrition are associated with IBD development and management. Even though specific diets have been shown to bring about positive outcomes, there is currently no scientific consensus regarding an appropriate diet that would benefit all IBD patients. We suggest that individualized dietary recommendations are of the greatest importance and that diets should be planned to provide individual IBD patients with specific nutrient requirements while keeping all the clinical aspects of the patients in mind. Further research is clearly necessary to investigate nutritional factors involved in IBD development and, especially, to evaluate the applications of the diets during the course of the disease.

Low-FODMAP Diet for Irritable Bowel Syndrome: What We Know and What We Have Yet to Learn

Irritable bowel syndrome (IBS) is the most prevalent of gastrointestinal (GI) conditions, affecting millions of people worldwide. Given that most IBS patients associate their GI symptoms with eating food, specific dietary manipulation has become an attractive treatment strategy. A diet low in FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) has generated the greatest level of scientific and clinical interest. Overall, 52-86% of patients report significant improvement of their IBS symptoms with elimination of dietary FODMAPs. Patients who experience symptom improvement with FODMAP elimination should undergo a structured reintroduction of foods containing individual FODMAPs to determine sensitivities and allow for personalization of the diet plan. This review discusses the literature surrounding the administration of the low-FODMAP diet and its efficacy in the treatment of IBS.