Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach

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.

A Critical Review on Akkermansia muciniphila: Functional Mechanisms, Technological Challenges, and Safety Issues

Due to its physiological benefits from in vitro and in vivo points of view, Akkermansia muciniphila, a common colonizer in the human gut mucous layer, has consistently been identified as an option for the next-generation probiotic. A. muciniphila is a significant bacterium that promotes host physiology. However, it also has a great deal of potential to become a probiotic due to its physiological advantages in a variety of therapeutic circumstances. Therefore, it can be established that the abundance of A. muciniphila in the gut environment, which is controlled by many genetic and dietary variables, is related to the biological behaviors of the intestinal microbiota and gut dysbiosis/eubiosis circumstances. Before A. muciniphila is widely utilized as a next-generation probiotic, regulatory obstacles, the necessity for significant clinical trials, and the sustainability of manufacturing must be eliminated. In this review, the outcomes of recent experimental and clinical reports are comprehensively reviewed, and common colonization patterns, main factors involved in the colonization of A. muciniphila in the gut milieu, their functional mechanisms in establishing homeostasis in the metabolic and energy pathways, the promising delivery role of microencapsulation, potential genetic engineering strategies, and eventually safety issues of A. muciniphila have been discussed.

Nutritional composition, in vitro carbohydrates digestibility, textural and sensory characteristics of bread as affected by ancient wheat flour type and sourdough fermentation time

This study aimed to investigate the effect of ancient wheat flour type and sourdough fermentation time on the nutritional, textural and sensorial properties of fiber-rich sourdough bread. The proximate composition, minerals, carbohydrates, organic acids, volatiles, total phenolic content, simulated gastrointestinal digestion, textural and sensorial characteristics were investigated. Bread's minerals, total phenolics, cellulose contents and radical scavenging activity variations clearly indicates an increasing trend with sourdoughs fermentation time. Compared to maltose and glucose, fructose was predominant in all bread samples. Sourdough fermentation time and wheat type had non-significant influence on fructose content from digested fraction. Excepting emmer bread, fermentation time increased in vitro digestibility values for tested samples. The crumb textural parameters (hardness, gumminess, chewiness, cohesiveness and springiness index) were positively influenced by fermentation time. The specific clustering of the analysed characteristics distinguished emmer bread from other samples in terms of volatile compounds, textural and overall acceptability, being preferred by panellists.

FODMAP Content Like-by-like Comparison in Spanish Gluten-free and Gluten-containing Cereal-based Products

Gluten-free foods (GF) availability on supermarket shelves is growing and it is expected to continue expanding in the years ahead. These foods have been linked to a lower content of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs), molecules that trigger gastrointestinal symptoms in sensitive persons. In this study, the FODMAP content of 25 cereal-based GF foods in Spain (breakfast cereals, pasta, bread, biscuits, bakery products, and dough and puff pastry) and 25 gluten-containing equivalents (GC) available in the same supermarket were analysed and compared. Lactose, fructose, glucose, sorbitol, mannitol, raffinose, stachyose and fructans were quantified. In a like-by-like analysis, GF foods were found to generally contain fewer FODMAPs than their GC counterparts. The ingredients used in the manufacture of GF cereal-based foods may contribute to this fact. When the individually wrapped size was considered, the proportion of samples classified as high-FODMAPs in GC and GF foods showed a trend towards fewer samples in the GF. However, not all the GF samples were low-FODMAP. Altogether, our findings provide essential information for FODMAP content databases of GF products in Spain.

Exploring the Nutritional Impact of Sourdough Fermentation: Its Mechanisms and Functional Potential

Sourdough fermentation is one of the oldest traditional methods in food technology and occurs as a result of fermentation of flour prepared from grains. The nutritional role of sourdough is related to the final composition of fermented foods prepared through sourdough fermentation, and recently, sourdough has become an important application to improve nutrition characteristics of bread. Thanks to lactic acid bacteria (LAB) presented in sourdough microflora and metabolites partially produced by yeasts, technological and important nutritional features of the bread improve and an increase in shelf life is achieved. In addition, sourdough bread has a low glycemic index value, high protein digestibility, high mineral and antioxidant content, and improved dietary fiber composition, making it more attractive for human nutrition compared to regular bread. When the sourdough process is applied, the chemical and physical properties of fibers vary according to the degree of fermentation, revealing the physiological importance of dietary fiber and its importance to humans' large intestine microbiota. Therefore, taking these approach frameworks into consideration, this review highlights the benefits of sourdough fermentation in increasing nutrient availability and contributing positively to support human health.

Factors Associated with Defecation Satisfaction among Japanese Adults with Chronic Constipation

Background: Constipation causes substantial morbidity worldwide. Methods: This survey assessed constipation-related factors in Japan using the Japanese version of the Irritable Bowel Syndrome Quality of Life (IBS-QOL-J) instrument. We also examined the relationship among laxative type, Bristol Stool Form Scale (BSFS) scores, and treatment cost. Finally, we examined differences in satisfaction scores according to laxative type, treatment type, treatment cost, and BSFS score. Results: IBS-QOL-J was higher among those taking salt and/or irritation laxatives. Those paying >JPY 5000 (USD 50.00) had the lowest IBS-QOL-J. IBS-QOL-J was significantly lower among those with a BSFS score of 1 or 2 (severe constipation). Conclusions: This study's findings suggest that a variety of factors, including treatment type and cost, are associated with defecation satisfaction. Those who had hard stools, used multiple laxatives, or spent more on treatment were less satisfied. Future strategies should target therapies that do not require multiple laxatives with lower treatment costs. Adequate defecation with a small number of appropriate laxatives at minimal cost appears to improve defecation satisfaction. It is desirable to identify appropriate laxatives and improve dietary habits and exercise routines. It is also necessary to stop blindly increasing laxative usage and properly diagnose constipation disorders such as anatomical abnormalities other than functional constipation.

Effects of a low FODMAP diet on the symptom management of patients with irritable bowel syndrome: a systematic umbrella review with the meta-analysis of clinical trials

A low FODMAP diet (LFD) is a common restrictive diet to manage the symptoms of irritable bowel syndrome (IBS). However, there is no consensus on the alleviating effects of this diet. Herein, a systematic umbrella review with meta-analysis was conducted to investigate the effect of an LFD on IBS symptoms and its secondary outcomes in patients, which were not reported in previous meta-analyses. We performed a systematic literature search in PubMed, Scopus, and ISI Web of Science up to December 2023. The methodological quality of systematic reviews and their included trials was evaluated using AMSTAR 2 and the Cochrane risk of bias, respectively. The certainty of the evidence tool was evaluated using the GRADE approach. The data related to IBS symptoms, quality of life (QoL), microbiome diversity, and stool short-chain fatty acids were extracted. A random-effect (if RCTs ≥ 6) or fixed-effect model (if RCTs < 5) was used to recalculate effect sizes and 95% CIs and report them in both qualitative and quantitative terms (pooled risk ratio, Hedges' g, and weighted mean difference). A total of 658 articles were initially identified, with 11 meta-analyses and 24 RCTs reporting 28 outcomes with 1646 participants included. An LFD significantly affected the clinical improvement of total symptoms according to the IBS-SSS questionnaire (RR: 1.42; 95% CI: 1.02, 1.97; P = 0.04) in all the subtypes of IBS and also had favorable effects on stool consistency (WMD: -0.48; 95% CI: -0.902, -0.07) and frequency (WMD: -0.36; 95% CI: -0.61, -0.10) and some other GI symptoms in both less and more than 4 weeks of diet intervention except for stool consistency, which needed more than 4 weeks of LFD implementation. A significant QoL improvement was observed but not in the anxiety and depression state. Furthermore, some studies showed that an LFD may increase fecal pH and dysbiosis and reduce SCFA and the abundance of Bifidobacterium. In conclusion, an LFD can alleviate symptoms and QoL in IBS patients, although dysbiosis may occur. Considering the low certainty of evidence, strong RCTs with more appropriate designs are needed.

Fructose malabsorption and fructan malabsorption are associated in patients with irritable bowel syndrome

BACKGROUND

Food malabsorption and intolerance is implicated in gastrointestinal symptoms among patients with irritable bowel syndrome (IBS). Key triggers include fructose and fructan. Prior studies examined fructose and fructan malabsorption separately in IBS patients. None have concurrently assessed both within the same patient group. We aimed to investigate the association between fructose and fructan malabsorption in the same patients with IBS using hydrogen breath testing (HBT).

METHODS

We retrospectively identified patients with IBS who underwent fructose and fructan HBTs and abstracted their results from the electronic medical record. Fructose and fructan HBTs were performed by administering a 25 g fructose solution or 10 g fructan solution, followed by breath hydrogen readings every 30 min for 3 h. Patients were positive for fructose or fructan malabsorption if breath hydrogen levels exceeded 20 ppm.

RESULTS

Of 186 IBS patients, 71 (38.2%) were positive for fructose malabsorption and 91 (48.9%) were positive for fructan malabsorption. Of these patients, 42 (22.6%) were positive for fructose malabsorption and fructan malabsorption. Positive fructose HBT readings were significantly associated with positive fructan HBT readings (p = 0.0283). Patients positive for fructose malabsorption or fructan malabsorption had 1.951 times higher odds of testing positive for the other carbohydrate.

CONCLUSIONS

Our results reveal a clinically significant association between fructose malabsorption and fructan malabsorption in patients with IBS. Fructan malabsorption should be assessed in patients with fructose malabsorption, and vice versa. Further studies are required to identify the mechanisms underlying our findings.

Assessment of dietary interventions including low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet as management for fructose intolerance

OBJECTIVES

Abdominal pain remains one of the most common referral reasons to pediatric gastroenterology. Dietary intolerances are often considered but due to various factors are hardly pursued. We observed that diet review in large number of children with abdominal pain was high in sugary foods which led to food intolerance investigation and dietary intervention.

METHODS

A retrospective review was conducted of patients presenting with abdominal pain, diarrhea, or vomiting and negative GI evaluation, who underwent fructose breath testing. Patients younger than 20 years old who were seen between June 1, 2018 and March 1, 2021 were included. Statistical analysis was performed in R.

RESULTS

There were 110 pediatric patients during the study period who underwent fructose breath testing, with 31% male and 69% female. The average age was 12.14 ± 4.01 years, and the average BMI was 21.21 ± 6.12. Abdominal pain was the most common presenting symptom (74.5%) followed by diarrhea and vomiting. Seventy-seven patients (70%) had a positive fructose breath test and were diagnosed with dietary intolerance to fructose. The 56 (67.5%) of those patients experienced symptoms during the breath test. Forty-three patients improved with dietary intervention. Twenty-seven on low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet and 16 on other diets.

CONCLUSIONS

Based on analysis of our cohort of children with abdominal pain and high incidence of fructose intolerance as well as improvement in symptoms, following dietary changes, this condition should be considered and treated. Further investigation is needed to improve diagnostic testing but also into understanding mechanisms behind symptom presentation in this population.

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.

Mechanistic Review on the Role of Gut Microbiota in the Pathology of Cardiovascular Diseases

Cardiovascular diseases (CVDs), which stand as the primary contributors to illness and death on a global scale, include vital risk factors like hyperlipidemia, hypertension, diabetes, and smoking, to name a few. However, conventional cardiovascular risk factors offer only partial insight into the complexity of CVDs. Lately, a growing body of research has illuminated that the gut microbiome and its by-products are also of paramount importance in the initiation and progression of CVDs. The gastrointestinal tract houses trillions of microorganisms, commonly known as gut microbiota, that metabolize nutrients, yielding substances like trimethylamine-N-oxide (TMAO), bile acids (BAs), short-chain fatty acids (SCFAs), indoxyl sulfate (IS), and so on. Strategies aimed at addressing these microbes and their correlated biological pathways have shown promise in the management and diagnosis of CVDs. This review offers a comprehensive examination of how the gut microbiota contributes to the pathogenesis of CVDs, particularly atherosclerosis, hypertension, heart failure (HF), and atrial fibrillation (AF), explores potential underlying mechanisms, and highlights emerging therapeutic prospects in this dynamic domain.

Effects of a low FODMAP diet on gut microbiota in individuals with treated coeliac disease having persistent gastrointestinal symptoms - a randomised controlled trial

Individuals with coeliac disease (CeD) often experience gastrointestinal symptoms despite adherence to a gluten-free diet (GFD). While we recently showed that a diet low in fermentable oligo-, di-, monosaccharides and polyols (FODMAP) successfully provided symptom relief in GFD-treated CeD patients, there have been concerns that the low FODMAP diet (LFD) could adversely affect the gut microbiota. Our main objective was therefore to investigate whether the LFD affects the faecal microbiota and related variables of gut health. In a randomised controlled trial GFD-treated CeD adults, having persistent gastrointestinal symptoms, were randomised to either consume a combined LFD and GFD (n 39) for 4 weeks or continue with GFD (controls, n 36). Compared with the control group, the LFD group displayed greater changes in the overall faecal microbiota profile (16S rRNA gene sequencing) from baseline to follow-up (within-subject β-diversity, P < 0·001), characterised by lower and higher follow-up abundances (%) of genus Anaerostipes (Pgroup < 0·001) and class Erysipelotrichia (Pgroup = 0·02), respectively. Compared with the control group, the LFD led to lower follow-up concentrations of faecal propionic and valeric acid (GC-FID) in participants with high concentrations at baseline (Pinteraction ≤ 0·009). No differences were found in faecal bacterial α-diversity (Pgroup ≥ 0·20) or in faecal neutrophil gelatinase-associated lipocalin (ELISA), a biomarker of gut integrity and inflammation (Pgroup = 0·74), between the groups at follow-up. The modest effects of the LFD on the gut microbiota and related variables in the CeD patients of the present study are encouraging given the beneficial effects of the LFD strategy to treat functional GI symptoms (Registered at clinicaltrials.gov as NCT03678935).

Association of fructose consumption with prevalence of functional gastrointestinal disorders manifestations: results from Hellenic National Nutrition and Health Survey (HNNHS)

The study aimed to assess the total prevalence of functional gastrointestinal disorders (FGID), and separately, irritable bowel syndrome (IBS) among adults and to determine their potential association with fructose consumption. Data from the Hellenic National Nutrition and Health Survey were included (3798 adults; 58·9 % females). Information regarding FGID symptomatology was assessed using self-reported physician diagnosis questionnaires the reliability of which were screened using the ROME III, in a sample of the population. Fructose intake was estimated from 24 h recalls, and the MedDiet score was used to assess adherence to the Mediterranean diet. The prevalence of FGID symptomatology was 20·2 %, while 8·2 % had IBS (representing 40·2 % of total FGID). The likelihood of FGID was 28 % higher (95 %CI: 1·03-1·6) and of IBS 49 % (95 %CI: 1·08-2·05) in individuals with higher fructose intake than with lower intake (3rd tertile compared with 1st). When area of residence was accounted for, individuals residing in the Greek islands had a significantly lower probability of FGID and IBS compared with those residing in Mainland and the main Metropolitan areas, with Islanders also achieving a higher MedDiet score and lower added sugar intake, comparatively to inhabitants of the main metropolitan areas. FGID and IBS symptomatology was most prominent among individuals with higher fructose consumption, and this was most conspicuous in areas with a lower Mediterranean diet adherence, suggesting that the dietary source of fructose rather than total fructose should be examined in relation to FGID.

Metastatic Colon Cancer in an Individual Following Prolonged Daily Inulin Consumption

Studies in rodents suggest that inulin supplements may be carcinogenic. We present a case implicating that this risk extends to humans. A healthy male from a family lacking history of cancer had his first cancer-screening colonoscopy at age 56. No intestinal polyps/abnormalities were detected. A second colonoscopy, performed 7 years later, revealed a tumor in the cecum, with evidence of metastasis to lymph nodes. The only known change in patient's lifestyle during that seven-year period was the addition of 4g of inulin powder as a daily supplement during the last 2 years. Such inulin consumption is a plausible contributor to his disease.

The effect of dietary interventions on pain and quality of life in women diagnosed with endometriosis: a prospective study with control group

STUDY QUESTION

What is the influence of dietary interventions, namely the low fermentable oligo-, di-, mono-saccharides, and polyols (Low FODMAP) diet and endometriosis diet, on endometriosis-related pain and quality of life (QoL) compared to a control group?

SUMMARY ANSWER

After adhering to a dietary intervention for 6 months, women with endometriosis reported less pain and an improved QoL compared to baseline whereas, compared to the control group, they reported less bloating and a better QoL in 3 of 11 domains.

WHAT IS KNOWN ALREADY

Standard endometriosis treatment can be insufficient or may be accompanied by unacceptable side effects. This has resulted in an increasing interest in self-management strategies, including the appliance of the Low FODMAP diet and the endometriosis diet (an experience-based avoidance diet, developed by women with endometriosis). The Low FODMAP diet has previously been found effective in reducing endometriosis-related pain symptoms, whereas only limited studies are available on the efficacy of the endometriosis diet. A survey study recently found the endometriosis diet effective in improving QoL but currently no guidelines on use of the diet exist.

STUDY DESIGN, SIZE, DURATION

A prospective one-center pilot study was performed between April 2021 and December 2022. Participants could choose between adherence to a diet-the Low FODMAP diet or endometriosis diet-or no diet (control group). Women adhering to a diet received extensive guidance from a dietician in training. The follow-up period was 6 months for all three groups. For all outcomes, women adhering to the diets were compared to their baseline situation and to the control group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included women diagnosed with endometriosis (surgically and/or by radiologic imaging) who reported pain scores ≥3 cm on the visual analogue score (0-10 cm) for dysmenorrhea, deep dyspareunia, and/or chronic pelvic pain. The primary endpoint focused on pain reduction for all pain symptoms, including dysuria, bloating, and tiredness. Secondary endpoints, assessed via questionnaires, focused on QoL, gastro-intestinal health, and diet adherence.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 62 participants were included in the low FODMAP diet (n = 22), endometriosis diet (n = 21), and control group (n = 19). Compared to their baseline pain scores, participants adhering to a diet reported less pain in four of six symptoms (range P < 0.001 to P = 0.012) and better scores in 6 of 11 QoL domains (range P < 0.001 to P = 0.023) after 6 months. Compared to the control group, analyzed longitudinally over the 6-month follow-up period, participants applying a diet reported significant less bloating (P = 0.049), and better scores in 3 of 11 QoL domains (range P = 0.002 to P = 0.035).

LIMITATIONS, REASONS FOR CAUTION

No sample size was calculated since efficacy data were lacking in the literature. In order to optimize dietary adherence, randomization was not applied, possibly resulting in selection bias.

WIDER IMPLICATIONS OF THE FINDINGS

Our study suggests that women could benefit from adherence to a dietary intervention, since we found lower pain scores and better QoL after 6 months. However, caution is implied since this is a pilot study, no sample size was calculated, and data on long-term effects (>6 months) are lacking. The results of this pilot study underline the importance of further research and the drawing up of guidelines.

STUDY FUNDING/COMPETING INTEREST(S)

A.v.H. reports receiving a travel grant from Merck outside the scope of this study. J.W., S.V., J.T., and B.D.B. have no conflicts of interest to report. A.d.V. reports having received KP-register points for internship guidance of J.W., performing paid consultations with endometriosis patients outside the study and receiving reimbursements for educational lectures at the local hospital (Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands). A.S. reports having received expenses for travel and hotel costs as an invited speaker from ESHRE. This was outside the scope of this study. M.v.W. reports that she is a Co-Ed of Cochrane Gynecology and Fertility. V.M. reports receiving travel and speaker's fees from Guerbet and research grants from Guerbet, Merck and Ferring. The department of reproductive medicine (V.M.) of the Amsterdam UMC, location VUmc, has received several research and educational grants from Guerbet, Merck and Ferring not related to the submitted work.

TRIAL REGISTRATION NUMBER

N/A.

Low-level inflammation, immunity, and brain-gut axis in IBS: unraveling the complex relationships

Irritable bowel syndrome is a common functional gastrointestinal disorder, and it has been shown that the etiology of irritable bowel syndrome is a multifactorial complex of neurological, inflammatory, and immunological changes. There is growing evidence of low-grade chronic inflammation in irritable bowel patients. The peripheral action response of their intestinal immune factors is integrated into the central nervous system, while the microbiota interacts with the brain-gut axis contributing to the development of low-grade chronic inflammation. The objective of this review is to present a discussion about the impact of immune-brain-gut axis-inflammation interactions on irritable bowel syndrome, its clinical relevance in the course of irritable bowel syndrome disease, and possible therapeutic modalities.

Food contributing to fermentable oligosaccharide, disaccharide, monosaccharide, and polyols intake in Korean adults

BACKGROUND/OBJECTIVES

The dietary intake of foods with fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) is known to adversely affect patients with irritable bowel syndrome (IBS). However, the effects of FODMAP have been studied predominantly among Western populations. This study aimed to identify foods high in FODMAP content which form a part of the Korean adult diet and obtain basic data for the preparation of IBS guidelines.

SUBJECTS/METHODS

An online survey of 1,000 adults from the general population in the age group of 20 to 40 years was performed. Data from 787 participants (men, 386; women, 401) were analyzed. The general characteristics of the participants, health status, IBS diagnosis using the Rome III diagnostic criteria, semi-quantitative food frequency questionnaire findings, and food items causing symptoms were analyzed.

RESULTS

Overall, 169 participants (21.5%) had IBS. The contribution of the FODMAP nutrients in both IBS and healthy groups was as follows: fructan > lactose > excess fructose > sorbitol > mannitol > galacto-oligosaccharides (GOS). The fructan intake was 4.6 ± 2.2 g/day and 4.3 ± 2.5 g/day in the IBS and healthy groups (P = 0.014), respectively. In the IBS group, the ratio of the intake of fructan to the total FODMAP intake was 39.5%, 29.8%, and 5.8% through onions, garlic, and bananas, respectively.

CONCLUSIONS

Fructan was the FODMAP nutrient most consumed by Korean adults. Therefore, given the difference in the dietary habits of each country's population, the dietary guidelines for IBS should be country specific.

Myths and Facts about Food Intolerance: A Narrative Review

Most adverse reactions to food are patient self-reported and not based on validated tests but nevertheless lead to dietary restrictions, with patients believing that these restrictions will improve their symptoms and quality of life. We aimed to clarify the myths and reality of common food intolerances, giving clinicians a guide on diagnosing and treating these cases. We performed a narrative review of the latest evidence on the widespread food intolerances reported by our patients, giving indications on the clinical presentations, possible tests, and dietary suggestions, and underlining the myths and reality. While lactose intolerance and hereditary fructose intolerance are based on well-defined mechanisms and have validated diagnostic tests, non-coeliac gluten sensitivity and fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) intolerance are mainly based on patients' reports. Others, like non-hereditary fructose, sorbitol, and histamine intolerance, still need more evidence and often cause unnecessary dietary restrictions. Finally, the main outcome of the present review is that the medical community should work to reduce the spread of unvalidated tests, the leading cause of the problematic management of our patients.

FODMAPs-Unknowns for Consumers: First Survey in Serbia

According to unofficial data, every fifth person in Serbia suffers from some form of irritable bowel syndrome (IBS). Compounds classified as FODMAPs (Fermentable Oligo-, Di-, and Monosaccharides and Polyols) are newly found potential triggers of IBS and a number of associated gastrointestinal disorders. Cereals, predominantly in their wholegrain form, represent the key contributors to the high contents of FODMAPs in wholegrain (high-fiber) bakery products. The current work was structured in a way to systematically evaluate the consumer's knowledge and preferences toward wholegrain and low-FODMAP bakery products. The questionnaire was filled out by 725 respondents, aged from 18 to 86 years. They were informed about the aim of the research and management of anonymous data. The present study is the first detailed survey in this region of Europe, aiming to improve the familiarity with and attitude toward FODMAPs and a low-FODMAP diet by analyzing the different dietary habits regarding wholegrain-cereal-based products among consumers of various ages, genders, places of residence, and education. The results suggest that the respondents are, to some degree, aware of the health benefits of consuming foods with high fiber content while indicating a low level of knowledge about FODMAP compounds and connected topics. Education about contemporary scientific findings and the potentially harmful effects of consuming FODMAP compounds for a population with gastrointestinal disorders and diseases will be imperative in the future.

Investigation of the association between habitual dietary FODMAP intake, metabolic parameters, glycemic status, and anthropometric features among apparently healthy overweight and obese individuals

BACKGROUND

The predisposition of humans to metabolic syndrome is affected by many factors, including diet and lifestyle. Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) are a set of carbohydrates that are fermented by gut microbiota. In animal studies, supplementation with FODMAP-rich diets as prebiotics can alter body composition and gut microbiota. This study evaluates any relationship between FODMAP and metabolic syndrome risk factors among adults with metabolic syndrome in Iran.

METHODS

This cross-sectional study is based on sociodemographic information from 347 overweight and obese participants selected from outpatient clinics through public declaration. Participants body composition and anthropometric measures were also determined. A validated Food Frequency Questionnaire (FFQ) with 168 questions was used to collect dietary data. Biochemical parameters, including serum total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), fasting serum glucose (FSG), and insulin levels, were determined by enzymatic methods. In addition, the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and Quantitative Insulin Sensitivity Check Index (QUICKI) were calculated.

RESULTS

In moderate FODMAP and low FODMAP groups, lower waist-to-hip ratio (WHR) and higher fat-free mass (FFM) were achieved in higher tertiles. In high FODMAP groups, higher systolic blood pressure (SBP) was shown in the higher tertile (P < 0.05). Higher insulin, HOMA-IR, and lower QUICKI in the second tertile of the high FODMAP group were also observed.

CONCLUSION

Findings of this study highlight the potential role of FODMAP in managing metabolic syndrome and open a new field of research.

The Role of Bovine Kappa-Casein Glycomacropeptide in Modulating the Microbiome and Inflammatory Responses of Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder marked by chronic abdominal pain, bloating, and irregular bowel habits. Effective treatments are still actively sought. Kappa-casein glycomacropeptide (GMP), a milk-derived peptide, holds promise because it can modulate the gut microbiome, immune responses, gut motility, and barrier functions, as well as binding toxins. These properties align with the recognized pathophysiological aspects of IBS, including gut microbiota imbalances, immune system dysregulation, and altered gut barrier functions. This review delves into GMP's role in regulating the gut microbiome, accentuating its influence on bacterial populations and its potential to promote beneficial bacteria while inhibiting pathogenic varieties. It further investigates the gut microbial shifts observed in IBS patients and contemplates GMP's potential for restoring microbial equilibrium and overall gut health. The anti-inflammatory attributes of GMP, especially its impact on vital inflammatory markers and capacity to temper the low-grade inflammation present in IBS are also discussed. In addition, this review delves into current research on GMP's effects on gut motility and barrier integrity and examines the changes in gut motility and barrier function observed in IBS sufferers. The overarching goal is to assess the potential clinical utility of GMP in IBS management.

The impact of diet and ethnicity on gut microbiota variation in irritable bowel syndrome: A multi-center study

BACKGROUND AND AIM

The gut microbiota in irritable bowel syndrome (IBS) is known to vary with diet. We aim to (i) analyze the gut microbiota composition of IBS patients from a multi-ethnic population and (ii) explore the impact of a low FODMAP diet on gastrointestinal symptoms and gut microbiota composition among IBS patients.

METHODS

A multi-center study of multi-ethnic Asian patients with IBS was conducted in two phases: (i) an initial cross-sectional gut microbiota composition study of IBS patients and healthy controls, followed by (ii) a single-arm 6-week dietary interventional study of the IBS patients alone, exploring clinical and gut microbiota changes.

RESULTS

A total of 34 adult IBS patients (IBS sub-types of IBS-D 44.1%, IBS-C 32.4%, and IBS-M 23.5%) and 15 healthy controls were recruited. A greater abundance of Parabacteroides species with lower levels of bacterial fermenters and short-chain fatty acids producers were found among IBS patients compared with healthy controls. Age and ethnicity were found to be associated with gut microbiota composition. Following a low FODMAP dietary intervention, symptom and quality of life improvement were observed in 24 (70.6%) IBS patients. Symptom improvement was associated with adherence to the low FODMAP diet (46.7% poor adherence vs 92.9% good adherence, P = 0.014), and gut microbiota patterns, particularly with a greater abundance of Bifidobacterium longum, Anaerotignum propionicum, and Blautia species post-intervention.

CONCLUSION

Gut microbiota variation in multi-ethnic IBS patients may be related to dietary intake and may be helpful to identify patients who are likely to respond to a low FODMAP diet.

Revolutionizing Inflammatory Bowel Disease Management: A Comprehensive Narrative Review of Innovative Dietary Strategies and Future Directions

This comprehensive narrative review delves into the intricate interplay between diet and inflammatory bowel disease (IBD), shedding light on the potential impact of dietary interventions in disease management. By analyzing nutritional interventions, risks, challenges, and future perspectives, this review serves as a vital resource for clinicians, researchers, and patients alike. The amalgamation of evidence underscores the significance of customizing dietary strategies for individual patients, considering disease phenotype and cultural factors. Through an exploration of dietary components' effects on IBD, including exclusive enteral nutrition and omega-3 fatty acids, this review offers pragmatic implementation advice and outlines avenues for further research. Bridging the gap between research findings and clinical applications, the review facilitates informed decision-making and patient-centric care. In the face of escalating IBD prevalence, this review emerges as an indispensable guide for healthcare professionals, empowering them to navigate the complexities of dietary management while enabling patients to actively participate in their care trajectory. Ultimately, this narrative review advances the understanding of diet's pivotal role in IBD management, fostering a more integrated approach to patient care and paving the way for improved research and policy initiatives in the field of inflammatory bowel diseases.

Does sourdough bread provide clinically relevant health benefits?

During the last decade, scientific interest in and consumer attention to sourdough fermentation in bread making has increased. On the one hand, this technology may favorably impact product quality, including flavor and shelf-life of bakery products; on the other hand, some cereal components, especially in wheat and rye, which are known to cause adverse reactions in a small subset of the population, can be partially modified or degraded. The latter potentially reduces their harmful effects, but depends strongly on the composition of sourdough microbiota, processing conditions and the resulting acidification. Tolerability, nutritional composition, potential health effects and consumer acceptance of sourdough bread are often suggested to be superior compared to yeast-leavened bread. However, the advantages of sourdough fermentation claimed in many publications rely mostly on data from chemical and in vitro analyzes, which raises questions about the actual impact on human nutrition. This review focuses on grain components, which may cause adverse effects in humans and the effect of sourdough microbiota on their structure, quantity and biological properties. Furthermore, presumed benefits of secondary metabolites and reduction of contaminants are discussed. The benefits claimed deriving from in vitro and in vivo experiments will be evaluated across a broader spectrum in terms of clinically relevant effects on human health. Accordingly, this critical review aims to contribute to a better understanding of the extent to which sourdough bread may result in measurable health benefits in humans.

[Health goals amongst patients with Crohn's disease.]

INTRODUCTION

Inflammatory bowel diseases, including Crohn's disease, have a significant impact on patients' lifestyle, requiring lifelong attention to health behavior.

OBJECTIVE

The aim of our study was to investigate health-related goals, emotions related to health goals, the use of infocommunication tools and their associations.

METHOD

79 patients with Crohn's disease (59.5% female, mean age 40.7 years, SD = 11.89) participated in the study. They answered demographic and health behaviour questions and completed the Personal Health Plans Questionnaire, which assessed their personal health goals, positive and negative emotions about health goal(s), support for personal health goals from their physician, negative and positive effects (barriers/support) of achieving health goals, and digital technology and internet use.

RESULTS

70% of patients had at least 1 health goal. The health goals were classified into four categories: physical activity (43.6%), stress management (25.4%), nutrition (18%) and smoking cessation (7%). 71% of participants experienced at least average levels of positive emotions related to the health goal, but about 50% also experienced negative emotions. 51% of those with a health goal regularly use the internet and apps on smartphones. Infocommunication device use showed a medium-strength correlation with perceived health goal-related barrier/support (ρ = 0.55, p<0.01), support from the person's doctor (ρ = 0.45, p<0.05) and physical activity (ρ = 0.40, p<0.01).

DISCUSSION

More than two-thirds of patients had a health goal; most of the goals were related to health behaviours that are also relevant to Crohn's disease, but few had healthy eating and smoking cessation as health goals. Half of those with a health goal regularly use the internet and apps on smartphones. Among health behaviours, physical activity was associated with infocommunication device use.

CONCLUSION

It is recommended to investigate patients' health goals and infocommunication device use in the care of patients with Crohn's disease. This would allow the development of specific interventions to improve their health behaviour, which could increase the quality of life and disease prognosis. Orv Hetil. 2023; 164(28): 1102-1110.

[Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice]

Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice Abstract: Functional dyspepsia (FD) and irritable bowel syndrome (IBS), two common gastrointestinal entities with overlapping symptoms, should be diagnosed according to Rome IV criteria. This includes one or more of the following symptoms: in FD, postprandial fullness, early satiation, epigastric pain or burning; in IBS, recurrent abdominal pain associated with defecation, change in frequency of stool or form of stool. To exclude structural diseases, attention should be paid to alarm symptoms. As far as treatment is concerned, a stepwise scheme proves to be effective for both diseases. Step 1: doctor-patient discussion with explanation of diagnosis and prognosis as well as clarification of therapy goals; lifestyle adaptations; use of phytotherapeutics; step 2: symptom-oriented medication: for FD, PPIs or prokinetics; for IBS, antispasmodics, secretagogues, laxatives, bile acid sequestrants, antidiarrheals, antibiotics, probiotics; step 3: visceral analgesics (antidepressants).

FODMAP reduction strategies for nutritionally valuable baking products: current state and future challenges

Fermentable oligo-, di- and monosaccharides and polyols (FODMAP) comprise several previously unrelated carbohydrates, such as fructans, fructo-oligosaccharides, galacto-oligosaccharides, fructose (in excess of glucose), mannitol and sorbitol, and among others. For many patients with gastro-intestinal disorders, such as irritable bowel syndrome, the ingestion of FODMAP triggers symptoms and causes discomfort. Among the main contributors to the dietary FODMAP intake are baking products, in particular bread as a major global staple food. This is primarily due to the fructan content of the cereal flours, but also process induced accumulation of FODMAP is possible. To provide low-FODMAP baking products, researchers have investigated various approaches, such as bio-process reduction by yeast, lactic acid bacteria, germination of the raw material or the use of exogenous enzymes. In addition, the selection of appropriate ingredients, which are either naturally or after pretreatment suitable for low-FODMAP products, is discussed. The sensory and nutritional quality of low-FODMAP baking products is another issue, that is addressed, with particular focus on providing sufficient dietary fiber intake. Based on this information, the current state of low-FODMAP baking and future research necessities, to establish practical strategies for low-FODMAP products, are evaluated in this article.

In Vitro Effect of Enzymes and Human Milk Oligosaccharides on FODMAP Digestion and Fecal Microbiota Composition

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) cause intestinal discomfort in patients with irritable bowel syndrome (IBS). An enzyme mix (2500 SU invertase, 2400 GalU α-galactosidase, 10,000 ALU β-galactosidase) optimized for FODMAP digestion, and/or human milk oligosaccharides (HMO) (2′-FL, DFL, and LNnT), were evaluated for effects on microbial community activity and composition in short-term colonic incubations using the fecal microbiota of four patients with IBS-D symptoms under the following test conditions: (i) FODMAP, (ii) pre-digested (with enzyme mix) FODMAP, (iii) FODMAP + HMO, and (iv) pre-digested FODMAP + HMO. Pre-digested FODMAP reduced short-chain fatty acid (SCFA) production versus FODMAP; HMO restored this. A 10-day experiment with the simulator of the human intestinal microbial ecosystem (SHIME®), using fecal samples from two patients with IBS-D, further evaluated these findings. FODMAP resulted in decreased microbial diversity versus blank. Pre-digestion with the enzyme mix restored microbial diversity, improved FODMAP digestibility, and reduced gas pressure versus undigested FODMAP; however, SCFA production decreased. HMO restored SCFA production along with an increase in gas pressure and increased abundance of Lachnospiraceae. When used in combination, the FODMAP enzyme mix and HMO may resolve FODMAP-related IBS symptoms while maintaining a healthy gut microbiome via prebiotic activity.

Strategies for Producing Low FODMAPs Foodstuffs: Challenges and Perspectives

In recent years, there has been a growing interest in a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) as a promising therapeutic approach to reduce the symptoms associated with irritable bowel syndrome (IBS). Hence, the development of low FODMAPs products is an important challenge for the food industry, and among the various foodstuffs associated with the intake of FODMAPs, cereal-based products represent an issue. In fact, even if their content in FODMAPs is limited, their large use in diet can be an important factor in developing IBS symptoms. Several useful approaches have been developed to reduce the FODMAPs content in processed food products. Accurate ingredient selection, the use of enzymes or selected yeasts, and the use of fermentation steps carried out by specific lactic bacteria associated with the use of sourdough represent the technical approaches that have been investigated, alone or in combination, to reduce the FODMAPs content in cereal-based products. This review aims to give an overview of the technological and biotechnological strategies applicable to the formulation of low-FODMAPs products, specifically formulated for consumers affected by IBS. In particular, bread has been the foodstuff mainly investigated throughout the years, but information on other raw or processed products has also been reported. Furthermore, taking into account the required holistic approach for IBS symptoms management, in this review, the use of bioactive compounds that have a positive impact on reducing IBS symptoms as added ingredients in low-FODMAPs products is also discussed.

Akkermansia muciniphila as a Next-Generation Probiotic in Modulating Human Metabolic Homeostasis and Disease Progression: A Role Mediated by Gut-Liver-Brain Axes?

Appreciation of the importance of Akkermansia muciniphila is growing, and it is becoming increasingly relevant to identify preventive and/or therapeutic solutions targeting gut-liver-brain axes for multiple diseases via Akkermansia muciniphila. In recent years, Akkermansia muciniphila and its components such as outer membrane proteins and extracellular vesicles have been known to ameliorate host metabolic health and intestinal homeostasis. However, the impacts of Akkermansia muciniphila on host health and disease are complex, as both potentially beneficial and adverse effects are mediated by Akkermansia muciniphila and its derivatives, and in some cases, these effects are dependent upon the host physiology microenvironment and the forms, genotypes, and strain sources of Akkermansia muciniphila. Therefore, this review aims to summarize the current knowledge of how Akkermansia muciniphila interacts with the host and influences host metabolic homeostasis and disease progression. Details of Akkermansia muciniphila will be discussed including its biological and genetic characteristics; biological functions including anti-obesity, anti-diabetes, anti-metabolic-syndrome, anti-inflammation, anti-aging, anti-neurodegenerative disease, and anti-cancer therapy functions; and strategies to elevate its abundance. Key events will be referred to in some specific disease states, and this knowledge should facilitate the identification of Akkermansia muciniphila-based probiotic therapy targeting multiple diseases via gut-liver-brain axes.

The relationship between fermentable carbohydrates and post-prandial bowel symptoms in patients with functional bowel disorders

Background and aims

A low fermentable oligosaccharide, disaccharide, monosaccharide, and polyols (FODMAP) diet alleviates symptoms of irritable bowel syndrome (IBS). We aimed to investigate the relationship between habitual FODMAP intake and post-prandial bowel symptoms in adults with IBS, functional diarrhoea (FD), or constipation (FD) (functional bowel disorders), and in healthy adults (controls).

Methods

292 participants (173 with functional bowel disorders and 119 controls) completed a food and symptom times diary. Estimated meal portion sizes were entered into the Monash FODMAP Calculator to analyse FODMAP content. Wilcoxon and ANOVA tests were used to investigate the relationship between FODMAP intake and post-prandial bowel symptoms.

Results

IBS participants experienced more post-prandial bowel symptoms compared to participants with other functional bowel disorders or controls. Meals associated with abdominal pain contained on average increased excess fructose (0.31 g vs. 0.18 g, p < 0.05), sorbitol (0.27 g vs. 0.10 g, p < 0.01), and total FODMAP (3.46 g vs. 2.96 g, p < 0.05) compared to meals not associated with pain. Abdominal swelling was associated with increased sorbitol (0.33 g vs. 0.11 g, p < 0.01), and total FODMAP (3.26 g vs. 3.02 g, p < 0.05) consumption. Abdominal bloating was associated with increased galacto oligosaccharide consumption (0.18 g vs. 0.14 g, p < 0.05).

Conclusion

These findings support the role of FODMAP in post-prandial bowel symptom onset, however, the amount and type of FODMAP triggering symptoms vary between individuals. Future research should investigate the relationship between the effect of individual FODMAP consumption on post-prandial bowel symptoms for each subtype, the interaction of FODMAP with differing functional bowel disorders and whether longitudinally symptoms and dietary intake are stable.

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.

Low-FODMAP Diet for the Management of Irritable Bowel Syndrome in Remission of IBD

Approximately 30% of patients with quiescent inflammatory bowel disease (IBD) meet the diagnostic criteria for irritable bowel syndrome (IBS). The aim of this study was to evaluate the effectiveness of a low-FODMAP diet in patients who meet the diagnostic criteria for IBS whilst in IBD remission. A total of 200 patients in remission of IBD were included in the study. Sixty-five of these patients (32.5%) were diagnosed with IBS according to the R4DQ. On the patients who met the IBS diagnostic criteria, anthropometric measurements, laboratory tests and lactulose hydrogen breath tests were performed. A low-FODMAP diet was introduced for 6 weeks. Of the 59 patients with IBS diagnosed at baseline for whom data were collected at the end of follow-up, after the low-FODMAP intervention IBS-like symptoms were not present in 66.1% (n = 39) (95% CI (53.4%; 76.9%)). The difference between the two groups (with SIBO at baseline (33 of 48 patients) and without SIBO at baseline (6 of 11 patients)) in the low-FODMAP diet's effectiveness was not statistically significant (p = 0.586). The low-FODMAP diet improved the gut symptoms of flatulence and diarrhea. It had no effect on the occurrence of constipation. In IBD patients in remission who meet the IBS criteria, the dietary intervention of a low-FODMAP diet is effective for a reduction in IBS-like symptoms, regardless of the coexistence of bacterial overgrowth.

Treatments targeting the luminal gut microbiota in patients with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction affecting 4% of the world's population. Patients with IBS experience chronic or recurrent abdominal pain in combination with altered bowel habits (diarrhea and/or constipation), and have reduced quality of life. Despite the high prevalence and substantial burden of IBS, its pathophysiology is incompletely understood and remains to be elucidated. The importance of the gut microenvironment has been highlighted in IBS, as there are signs that the gut microbiota of patients differs from healthy controls. Recent studies have aimed to alter the gut microbiota and thereby, attempted to alleviate gastrointestinal symptoms in IBS patients. We highlighted recent advances in common treatments that are targeting the luminal gut microbiota in IBS.

Natural Variation in the Content and Degree of Polymerization of Fructans in Wheat: Potential for Selection of Genotypes with Beneficial Health Composition

Fructans are important biocompounds because of their health-promoting effects as dietary fiber and prebiotics and also because of their harmful effects as fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) particularly in people suffering from irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), and recently as potential triggers of non-celiac wheat/gluten sensitivity. In this work, we have analyzed the fructan contents as well as its degree of polymerization (DP) in a genetically diverse set of wheat varieties, modern and landraces, from different commonly consumed species (N = 124). A significant variation in fructan contents within and between species was observed, with the following relationship: Triticum aestivum (Landraces) > Triticum aestivum (Modern) ≥ Triticum turgidum (Modern) = T. turgidum (Landraces) ≥ Triticum spelta. In addition, a substantial part of the fructans (>50%) showed a DP ≤ 6. Considering that wheat is a major source of fructans, our results can contribute to a better nutritional management of our diets and be a basis for targeted wheat breeding to alter fructan contents.

Diet for Functional Gastrointestinal Disorders/Disorders of Gut-Brain Interaction

Dietary interventions may alleviate symptoms related to functional gastrointestinal disorders, now termed disorders of gut-brain interaction. We reviewed which interventions have high-quality data to support their use in gastroesophageal reflux disease (GERD), functional dyspepsia (FD), irritable bowel syndrome, and chronic idiopathic constipation.

Association of Diet, Body Mass Index, and Lifestyle on the Gastrointestinal Health Risk in a Sample of Adults

Gastrointestinal functional disorders are characterized by abnormalities in motility with visceral hypersensitivity, representing a global public health problem. We aimed to determine whether eating habits, lifestyle characteristics, and body mass index (BMI) are associated with gastrointestinal health risk. The Gastrointestinal Health (GIH) test of the World Gastroenterology Organization (WGO) and the Roma IV criteria were applied. We obtained information on food consumption habits and aerobic exercise, among other variables. Not exercising regularly, drinking water and eating vegetables less than recommended, having high body weight, and taking symptomatic medication were variables that explained 73% of the probabilities of not having good GIH (R² = 0.734). According to Rome IV criteria, women had a 50% higher risk than men of having functional bowel disorder (RR 1.6, 95% CI: 1.04, 2.45). Among the men studied, eating few or no vegetables and drinking less than 1 L of water daily was more frequent; however, the women had significantly more intestinal symptoms. In addition, constipation was higher among women than men (p = 0.020). All of the above explains the prognostic value of eating habits and the importance of paying attention to body weight to reduce the risk of gastrointestinal disease.

An anti-inflammatory and low fermentable oligo, di, and monosaccharides and polyols diet improved patient reported outcomes in fibromyalgia: A randomized controlled trial

Background

Fibromyalgia (FM) has been associated with dysbiosis and low-grade inflammation. Studies have reported that diet influences clinical features in FM.

Objective

To evaluate the effect of an anti-inflammatory and low fermentable oligo, di, and monosaccharides and polyols (FODMAP) diet on clinical outcomes of patients with FM.

Methods

This two arms Randomized Controlled Trial (NCT04007705) included 46 female patients with FM. The intervention group (n = 22) adopted an anti-inflammatory diet for 3 months, excluding gluten, dairy, added sugar, and ultra-processed foods, along with a low FODMAPs diet in the first month. The control group (n = 24) followed general healthy eating recommendations. Both diets were applied by a certified dietitian. Before and after the intervention, participants were assessed regarding pain, fatigue, gastrointestinal symptoms, quality of sleep, and quality of life, through the Revised Fibromyalgia Impact Questionnaire (FIQR), Visual Analogue Pain Scale (VAS), Visual Analog Scale from gastrointestinal symptoms (VAS GI), Brief Pain Inventory (BPI), Pittsburg Sleep Quality Index (PSQI), Fatigue Severity Survey (FSS), and The Short Form Health Survey (SF-36). A blood sample was collected and high-sensitive C-Reactive Protein and Erythrocyte Sedimentation Rate were quantified. Paired Samples t-test/Wilcoxon and independent samples t-test/Mann−Whitney were used to compare variables between groups.

Results

After intervention, there was an improvement in intervention group scores of FIQR (p = 0.001), VAS (p = 0.002), BPI (p = 0.011), FSS (p = 0.042), VAS_GI (p = 0.002), PSQI (p = 0.048), and SF36 (p = 0.045) compared to control group. Inflammatory biomarkers (hs-CRP, ESR) did not change in both groups. The intervention was beneficial in the intervention group, regardless of age, disease duration, body mass index variation, and body fat change between baseline and post-intervention.

Conclusion

An anti-inflammatory and low-FODMAP diet improved clinical features in patients with FM and may be useful as a complement to pharmacological therapy.

Clinical Trial Registration

[https://clinicaltrials.gov/ct2/show/NCT04007705], identifier [NCT04007705].

Feeding Our Microbiota: Stimulation of the Immune/Semiochemical System and the Potential Amelioration of Non-Communicable Diseases

Non-communicable diseases are those conditions to which causative infectious agents cannot readily be assigned. It is increasingly likely that at least some of these conditions are due to the breakdown of the previously mutualistic intestinal microbiota under the influence of a polluted, biocide-rich, environment. Following the mid-20th century African studies of Denis Burkitt, the environmental cause of conditions such as obesity has been ascribed to the absence of sufficient fibre in the modern diet, however in itself that is insufficient to explain the parallel rise of problems with both the immune system and of mental health. Conversely, Burkitt himself noted that the Maasai, a cattle herding people, remained healthy even with their relatively low intake of dietary fibre. Interestingly, however, Burkitt also emphasised that levels of non-communicable disease within a population rose as faecal weight decreased significantly, to about one third of the levels found in healthy populations. Accordingly, a more cogent explanation for all the available facts is that the fully functioning, adequately diverse microbiome, communicating through what has been termed the microbiota-gut-brain axis, helps to control the passage of food through the digestive tract to provide itself with the nutrition it needs. The method of communication is via the production of semiochemicals, interkingdom signalling molecules, potentially including dopamine. In turn, the microbiome aids the immune system of both adult and, most importantly, the neonate. In this article we consider the role of probiotics and prebiotics, including fermented foods and dietary fibre, in the stimulation of the immune system and of semiochemical production in the gut lumen. Finally, we reprise our suggestion of an ingestible sensor, calibrated to the detection of such semiochemicals, to assess both the effectiveness of individual microbiomes and methods of amelioration of the associated non-communicable diseases.

A therapeutic guide on pediatric irritable bowel syndrome and functional abdominal pain-not otherwise specified

Disorders of the gut-brain interaction negatively impact quality of life and carry a substantial socioeconomic burden. Irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) are common functional abdominal pain disorders in childhood. The pathophysiology is not fully understood, and high-quality intervention trials and international guidelines are missing. Therefore, the management of these disorders remains challenging. This review aims to provide an up-to-date overview of therapeutic possibilities for pediatric IBS or FAP-NOS and recommends management strategies. To prevent unnecessary referrals and extensive costs, it is fundamental to make a positive diagnosis of IBS or FAP-NOS in children with chronic abdominal pain with only minimal investigations. A tailor-made approach for each patient, based on the accompanying physical and psychological symptoms, is proposed to date.

CONCLUSION

Shared decision-making including non-pharmacological and pharmacological interventions should be considered and discussed with the family.

WHAT IS KNOWN

• Irritable bowel syndrome and functional abdominal pain-not otherwise specified are common in childhood. • Although the number of treatment options has grown recently, managing these disorders can be challenging and unsatisfactory, and no evidence-based international management guidelines are available.

WHAT IS NEW

• We suggest using a stepwise individualized approach to management, where after first-line management, both non-pharmacological and pharmacological interventions should be discussed.

Microbiome–Gut Dissociation in the Neonate: Obesity and Coeliac Disease as Examples of Microbiome Function Deficiency Disorder

The purpose of this article is to provide a direction for translational research based on an analysis of the nature of complex, immune-related conditions such as obesity and coeliac disease. In essence, it seems that the prevalence of these non-communicable diseases is related to the degradation of the microbiome during the industrialisation of society, and that their nature can be used to infer the functions of the “pre-industrial” microbiome. Based on this analysis, the key point is the necessity for the fully functioning microbiome, acting alongside the parental genetic inheritance of the child, to be in place immediately after birth. In our view, this is achieved by the seemingly accidental process of maternal microbial inheritance during normal birth. Note, however, that this is not possible if the microbiome of the mother is itself degraded following previous problems. Under these conditions the health of a child may be affected from the moment of birth, although, with the exception of atopic diseases, such as eczema and food allergy, the consequences may not become apparent until late childhood or as an adult. In this way, this microbiome function deficiency hypothesis incorporates the epidemiological observations of David Strachan and David Barker in that their onset can be traced to early childhood. Coeliac disease has been chosen as an illustrative example of a multifactorial disorder due to the fact that, in addition to a series of immune system manifestations and a potential problem with food absorption, there is also a significant psychological component. Finally, it is worth noting that an ingestible sensor calibrated to the detection of interkingdom communication molecules (semiochemicals) within the intestine may offer a practical way of assessment and, perhaps, amelioration of at least some of the consequences of non-communicable disease.

Increased fermentable carbohydrate intake alters colonic mucus barrier function through glycation processes and increased mast cell counts

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder for which dietary interventions can be a useful treatment. In recent years, the low-FODMAP approach is gaining traction in this regard. The fermentation of these non-absorbed carbohydrates by the gut microbiota can generate toxic glycating metabolites, such as methylglyoxal. These metabolites can have harmful effects by their role in the generation of advanced glycation end products (AGEs), which activates Receptor for AGEs (AGER). Mast cells can be stimulated by AGEs and play a role in IBS. We have treated mice with lactose or fructo-oligosaccharides (FOS), with or without co-administration of pyridoxamine and investigated the colonic mucus barrier. We have found that an increased intake of lactose and fructo-oligosaccharides induces a dysregulation of the colonic mucus barrier, increasing mucus discharge in empty colon, while increasing variability and decreasing average thickness mucus layer covering the fecal pellet. Changes were correlated with increased mast cell counts, pointing to a role for the crosstalk between these and goblet cells. Additionally, AGE levels in colonic epithelium were increased by treatment with the selected fermentable carbohydrates. Observed effects were prevented by co-treatment with anti-glycation agent pyridoxamine, implicating glycation processes in the negative impact of fermentable carbohydrate ingestion. This study shows that excessive intake of fermentable carbohydrates can cause colonic mucus barrier dysregulation in mice, by a process that involves glycating agents and increased mucosal mast cell counts.

Functional gastrointestinal symptoms and increased risk for orthorexia nervosa

PURPOSE

Recent guidelines point out the possible risk for orthorexia nervosa in functional gastrointestinal disorders, however, to date, no study has investigated this association. The present study aimed to explore the potential relationship between irritable bowel syndrome-related functional gastrointestinal symptoms and certain maladaptive eating behaviours, such as symptoms of orthorexia nervosa and emotional eating.

METHODS

A sample of 644 Hungarian volunteers (M_age = 22.37; SD_age = 3.95) completed a survey with the following questionnaires: the Rome IV Diagnostic Questionnaire (R4DQ) for adults-Irritable bowel syndrome module for the measurement of functional gastrointestinal symptoms, the Hungarian version of the ORTO-15 questionnaire (ORTO-11-Hu) to assess symptoms of orthorexia nervosa, the Three-Factor Eating Questionnaire (TFEQ) Emotional Eating subscale to measure symptoms of emotional eating and the Short Health Anxiety Inventory (SHAI) for the assessment of health anxiety. Spearman's rank correlation was used to explore the associations between the measured variables, and structural equation modeling was used to test the proposed mediation models.

RESULTS

Functional gastrointestinal symptoms were positively related to symptoms of orthorexia nervosa and emotional eating. The relationship between functional gastrointestinal symptoms and symptoms of orthorexia nervosa was partially mediated by health anxiety, while the association between functional gastrointestinal symptoms and symptoms of emotional eating was partially mediated by symptoms of orthorexia nervosa.

CONCLUSION

Our findings highlight the possible risk for developing orthorexic symptoms in functional gastrointestinal symptoms, which could lead to other types of disordered eating patterns, such as emotional eating. The results also underscore the potential role of health anxiety in these relationships.

LEVEL OF EVIDENCE

Level V (descriptive cross-sectional study).

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.

FODMAPs, inflammatory bowel disease and gut microbiota: updated overview on the current evidence

PURPOSE

Based on the fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) hypothesis, the low-FODMAP diet has been suggested as a potential therapeutic approach for inflammatory bowel disease (IBD) with promising results on disease management. However, this diet implies a specific broad food restriction, which potentially increases the risk of nutritional deficiencies and may aggravate gut microbiota dysbiosis of IBD patients. The aim of the present study is to review the effect of individual FODMAPs on the human gut microbiota. In addition, this narrative review provides an updated overview of the use of the low-FODMAP diet in IBD, namely the implementation, advantages, limitations, and the impact on the gut microbiota.

METHODS

The literature search strategy was applied to PubMed and Web of Science using relevant keywords, IBD, FODMAPs, Fructose, Lactose, Polyols, FOS, GOS, low-FODMAP diet and gut microbiota.

RESULTS

Current data suggest that the low-FODMAP diet may effectively improve clinical outcomes in the management of IBD and ensure better quality of life for IBD patients. However, there is evidence highlighting some issues of concern, particularly the adequacy of the diet and the impact on the gut microbiota. The various FODMAP types differently modulate the gut microbiota.

CONCLUSION

IBD management should be achieved with the least possible dietary restriction to avoid detrimental consequences, particularly on nutritional adequacy and gut microbiota. Thus, it is important to individualize and monitor the nutrition intervention. Further studies are required to better characterize the relationship between diet, the gut microbiota, and IBD to support the generalization of this approach for clinical practice in IBD therapy and management.

Dietary interventions for functional abdominal pain disorders in children: a systematic review and meta-analysis

BACKGROUND

Functional abdominal pain disorders (FAPDs) are common among children and are associated with decreased quality of life and school attendance. Several dietary interventions have been suggested to improve symptoms of FAPDs. This systematic review assessed the efficacy and safety of dietary interventions for pediatric FAPDs.

DESIGN AND METHODS

Electronic databases were searched (inception-October 2021). Systematic reviews or RCTs were included if children (4-18 years) with FAPDs were treated with dietary interventions and compared to placebo, no diet or any other diet. Data extraction and assessment of quality of evidence based on GRADE system was independently performed by two review authors. Outcomes were treatment success, pain intensity and frequency, and withdrawal due to adverse events.

RESULTS

Twelve articles were included, representing data of 819 pediatric FAPD patients. Trials investigating fibers, FODMAP diet, fructans, fructose-restricted diet, prebiotic (inulin), serum-derived bovine immunoglobulin, and vitamin D supplementation were included. We found very low-certainty evidence that the use of fibers leads to higher treatment success (NNT = 5).

CONCLUSION

Based on current evidence, the use of fibers can be discussed in daily practice. High-quality intervention trials are highly needed to investigate if other dietary interventions are effective in the treatment of pediatric FAPD.

Online Mindfulness Intervention for Inflammatory Bowel Disease: Adherence and Efficacy

The impact of stress and other psychological variables on Inflammatory Bowel Disease (IBD) prognosis, treatment response, and functional level is well-established; however, typical IBD treatment focuses on the physiological pathology of the disease and neglects complementary stress-reducing interventions. Recent pilot studies report the benefits of mindfulness-based interventions (MBIs) in people living with IBD, but are limited by small sample sizes. Recruitment challenges to in-person studies may be in part due to the difficulty IBD patients often have adhering to fixed schedules and travel as a result of IBD symptoms such as pain, fatigue, and incontinence. The current study aimed to address this barrier by offering participants access to online mindfulness training, allowing individuals to engage with intervention materials to fit their own schedule. Online mindfulness programs have gained popularity in recent years, as they increase access and flexibility and decrease cost to the user; however, the dropout rate tends to be high. The current study compared the rate of adherence and efficacy of mindfulness training as a function of level of support: self-guided versus supported. Analysis revealed no significant difference in the benefits received between participants in the two groups; however, a significant difference group (χ2 = 15.75; p = 0.000, r = 0.38) was found in terms of rate of completion, with 44.1% of the supportive group completing the protocol compared to 11.7% of the self-guided. Common challenges to meditation were measured, but did not significantly predict adherence to the intervention, and experience of these challenges did not significantly change (increase or decrease) over the duration of the study. Implications of the current research, future directions for the use of MBI for IBD patients, and a discussion of methodological considerations are provided.

Evaluating tolerability of resistant starch 2, alone and in combination with minimally fermented fibre for patients with irritable bowel syndrome: a pilot randomised controlled cross-over trial

Resistant starch 2 (RS2) may offer therapeutic value to irritable bowel syndrome (IBS) patients particularly in combination with minimally fermented fibre, but tolerability data are lacking. The present study evaluated the tolerability of RS2, sugarcane bagasse and their combination in IBS patients and healthy controls. Following baseline, participants consumed the fibres in escalating doses lasting 3 d each: RS2 (10, 15 and 20 g/d); sugarcane bagasse (5, 10 and 15 g/d); and their combination (20, 25 and 30 g/d). Gastrointestinal symptoms were assessed daily. Six IBS patients and five controls were recruited. No differences in overall symptoms from baseline were found across the fibre doses (IBS, P = 0⋅586; controls, P = 0⋅687). For IBS patients, all RS2 doses led to increased bloating. One IBS patient did not tolerate the low combination dose and another the high sugarcane bagasse dose. Supplementation of RS2 ≤ 20 g/d caused mild symptoms and was generally tolerated in IBS patients even when combined with minimally fermented fibre.

FODMAP modulation as a dietary therapy for IBS: Scientific and market perspective

A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) is a promising therapeutic approach to reduce gastrointestinal symptoms associated with irritable bowel syndrome (IBS). However, a shift toward a more sustainable, healthy diet with higher inclusion of whole-grain cereals (i.e., wheat, rye, barley) and pulses, naturally rich in FODMAPs, poses a severe challenge for susceptible individuals. Dietary restriction of fermentable carbohydrates (commonly called the "low FODMAP diet") has received significant consideration. Hence, the development of functional low FODMAP products is emerging in food science and the food industry. In this review, we evaluate the most promising yet neglected (bio)-technological strategies adopted for modulating the FODMAP contents in complex food systems and the extent of their uptake in the global food market. We extensively investigated the global low FODMAP market, contrasted with the status quo in food science and discussed the key principles and concomitant challenges of targeted FODMAP reduction strategies. Powerful tools are available which are based either on the use of ingredients where FODMAPs have been physically removed (e.g., by membrane filtration) or biotechnologically reduced during the food processing, mediated by added enzymes, microbial enzymes during a fermentation process, and seed endogenous enzymes. However, <10% of the small market of functional products with a low FODMAP claim (total ∼800 products) used any of the targeted FODMAP reduction techniques. The global market is currently dominated by gluten-free products, which are naturally low in FODMAPs and characterized by inferior sensory attributes.