The FODMAP Diet

June 6, 2013 Written by JP       [Font too small?]

What if I told you that many seemingly healthy foods including apples, avocado, cauliflower and yogurt may be causing gastrointestinal problems in a sizable percentage of the population? If your reaction is one of disbelief, I don’t blame you. After all, these wholesome foods are a good source of dietary components (fiber, healthy fats, nutrients and probiotics) which are typically thought to benefit the digestive system and its function. However, in recent years, a group of researchers have come up with an unconventional theory that has been increasingly supported in the scientific literature. It now appears that otherwise healthful foods, which contain specific types of carbohydrates, may be largely responsible for digestive complaints that are often attributed or classified as irritable bowel syndrome (IBS). Specifically, I’m referring to foods rich in Fermentable Oligo-, Di- and Mono-saccharides and Polyols or FODMAPs.

The FODMAP Diet instructs adherents to avoid foods that contain a large proportion of short-chain carbohydrates (fructose, lactose), sugar alcohols (mannitol, sorbitol, xylitol) and fructans and/or galactans. Failing to do so can, in some people, induces bloating, cramping, diarrhea and gas. The cause of these common symptoms is three-fold: an osmotic laxative effect, poor absorption and rapid fermentation of the select carbohydrates. The primary obstacle to sticking with a low FODMAP diet is familiarizing yourself with the approved list of foods and avoiding any possible nutrient deficiencies that may occur while limiting nutritious, high FODMAP foods. Fortunately, both of these potential pitfalls can be skirted with proper education about the diet and thoughtful planning. What’s more, a low FODMAP program can usually be incorporated into other dietary philosophies including gluten free, low carb and vegetarian menu plans.

To date, there have been several studies that have sought to verify the relative effects of a low FODMAP in populations with compromised or dysfunctional digestion. The latest investigation, which followed a group of 90 patients with irritable bowel syndrome for 15.7 months, reported that over 70% of the participants successfully adhered to the diet and found symptomatic relief from abdominal pain, diarrhea and flatulence. Additionally, a previous trial, published in the October 2011 issue of the Journal of Human Nutrition and Dietetics, found that a low FODMAP diet was more effective than the “standard dietary advice” given by nutritionists and physicians treating IBS patients. Avoiding FODMAPs has also demonstrated benefits in patients without colons (due to surgery) and in those requiring enteral nutrition or tube feeding.

If you decide to embark on a low FODMAP diet, I think it’s vitally important to opt for a low glycemic, nutrient dense, whole food based version. Below are examples of what I consider a healthful, low FODMAP meal and one that is lacking.

  • Healthy FODMAP Meal: Rotisserie Chicken, Mixed Organic Greens w/ Unsweetened Vinaigrette and Mixed Berries (Blueberries, Raspberries and Strawberries) for dessert. To Drink: Iced Green Tea w/ Lemon Juice
  • Unhealthy FODMAP Meal: Cheddar Cheeseburger on a Gluten-Free Bun, French Fries and Banana Split with Lactose-Free Ice Cream. To Drink: Classic Crystal Light (a popular diet drink)

Based on the latest batch of positive studies, I’m now confident that low FODMAP diets ought to be considered in virtually all patients with chronic digestive issues. It almost certainly will not be the answer for all, but it’s worth investigating and, perhaps, combining with other modalities such as food allergy testing, stress reduction and supplemental support.

Note: Please check out the “Comments & Updates” section of this blog – at the bottom of the page. You can find the latest research about this topic there!

To learn more about the studies referenced in today’s column, please click on the following links:

Study 1 - Evidence-Based Dietary Management of Functional Gastrointestinal (link)

Study 2 - Fermentable Oligosaccharides, Disaccharides, Monosaccharides and (link)

Study 3 - The Low FODMAP Diet Improves Gastrointestinal Symptoms in Patients (link)

Study 4 – Comparison of Symptom Response Following Advice for a Diet Low in (link)

Study 5 - Manipulation of Dietary Short Chain Carbohydrates Alters the Pattern … (link)

Study 6 - Reduction of Dietary Poorly Absorbed Short-Chain Carbohydrates (link)

Study 7 - The Role of Diet in the Pathogenesis and Management of Irritable Bowel (link)

Study 8 – Dietary Poorly Absorbed, Short-Chain Carbohydrates Increase Delivery (link)

Study 9 - Pilot Study on the Effect of Reducing Dietary FODMAP Intake on Bowel (link)

Study 10 - Diarrhea During Enteral Nutrition is Predicted by the Poorly Absorbed (link)

How FODMAPs Cause Digestive Distress in Some People

Source: Aliment Pharmacol Ther. 2010 Apr;31(8):874-82. (link)

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16 Comments & Updates to “The FODMAP Diet”

  1. JP Says:

    Update: The FODMAP diet and probiotic treatment are helpful for IBS patients …

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239510/

    World J Gastroenterol. 2014 Nov 21;20(43):16215-26.

    Ehealth: low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome.

    AIM: To investigate the effects of a low fermentable, oligosaccharides, disaccharides, monosaccharides and polyols diet (LFD) and the probiotic Lactobacillus rhamnosus GG (LGG) in irritable bowel syndrome (IBS).

    METHODS: Randomised, unblinded controlled trial on the effect of 6-wk treatment with LFD, LGG or a normal Danish/Western diet (ND) in patients with IBS fulfilling Rome III diagnostic criteria, recruited between November 2009 and April 2013. Patients were required to complete on a weekly basis the IBS severity score system (IBS-SSS) and IBS quality of life (IBS-QOL) questionnaires in a specially developed IBS web self-monitoring application. We investigated whether LFD or LGG could reduce IBS-SSS and improve QOL in IBS patients.

    RESULTS: One hundred twenty-three patients (median age 37 years, range: 18-74 years), 90 (73%) females were randomised: 42 to LFD, 41 to LGG and 40 to ND. A significant reduction in mean ± SD of IBS-SSS from baseline to week 6 between LFD vs LGG vs ND was revealed: 133 ± 122 vs 68 ± 107, 133 ± 122 vs 34 ± 95, P < 0.01. Adjusted changes of IBS-SSS for baseline covariates showed statistically significant reduction of IBS-SSS in LFD group compared to ND (IBS-SSS score 75; 95%CI: 24-126, P < 0.01), but not in LGG compared to ND (IBS-SSS score 32; 95%CI: 18-80, P = 0.20). IBS-QOL was not altered significantly in any of the three groups: mean ± SD in LFD 8 ± 18 vs LGG 7 ± 17, LFD 8 ± 18 vs ND 0.1 ± 15, P = 0.13.

    CONCLUSION: Both LFD and LGG are efficatious in patients with IBS.

    Be well!

    JP

  2. JP Says:

    Update: The latest scientific review …

    http://www.ncbi.nlm.nih.gov/pubmed/25694210

    Nutr Clin Pract. 2015 Feb 18.

    Role of FODMAPs in Patients With Irritable Bowel Syndrome: A Review.

    Irritable bowel syndrome (IBS) is a condition characterized by abdominal pain, bloating, flatus, and altered bowel habits. The role of dietary components in inducing IBS symptoms is difficult to explore. To date, foods are not considered a cause but rather symptom-triggering factors. Particular interest has been given to the so-called FODMAPs (fermentable oligo-, di-, and monosaccharides and polyols). We aimed to summarize the evidence from the most common approaches to manage suspected food intolerance in IBS, with a particular interest in the role of FODMAPs and the effects of a low FODMAP diet. We reviewed literature, consulting PubMed and Medline by using the search terms FODMAP(s), fructose, lactose, fructans, galactans, polyols (sorbitol, mannitol, maltitol, xylitol, erythritol, polydextrose, and isomalt), irritable bowel syndrome, and functional gastrointestinal symptoms. FODMAP-restricted diets have been used for a long time to manage patients with IBS. The innovation in the so-called FODMAP concept is that a global restriction should have a more consistent effect than a limited one in preventing abdominal distension. Even though all the potential low FODMAP diets provide good relief of symptoms in many patients, there is just a little relief in others. Several studies highlight the role of low FODMAP diets to improve symptoms in patients with IBS. The evidence on this dietary approach supports the hypothesis that a low FODMAP diet should be the first dietary approach. However, many points remain to be clarified, including the evaluation of possibly significant nutrition concerns.

    Be well!

    JP

  3. JP Says:

    Update: This study urges caution due to a possible shift in gut microbiota caused by adherence to a FODMAP diet …

    http://gut.bmj.com/content/64/1/93.long

    Gut. 2015 Jan;64(1):93-100.

    Diets that differ in their FODMAP content alter the colonic luminal microenvironment.

    OBJECTIVE: A low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols) diet reduces symptoms of IBS, but reduction of potential prebiotic and fermentative effects might adversely affect the colonic microenvironment. The effects of a low FODMAP diet with a typical Australian diet on biomarkers of colonic health were compared in a single-blinded, randomised, cross-over trial.

    DESIGN: Twenty-seven IBS and six healthy subjects were randomly allocated one of two 21-day provided diets, differing only in FODMAP content (mean (95% CI) low 3.05 (1.86 to 4.25) g/day vs Australian 23.7 (16.9 to 30.6) g/day), and then crossed over to the other diet with ≥21-day washout period. Faeces passed over a 5-day run-in on their habitual diet and from day 17 to day 21 of the interventional diets were pooled, and pH, short-chain fatty acid concentrations and bacterial abundance and diversity were assessed.

    RESULTS: Faecal indices were similar in IBS and healthy subjects during habitual diets. The low FODMAP diet was associated with higher faecal pH (7.37 (7.23 to 7.51) vs. 7.16 (7.02 to 7.30); p=0.001), similar short-chain fatty acid concentrations, greater microbial diversity and reduced total bacterial abundance (9.63 (9.53 to 9.73) vs. 9.83 (9.72 to 9.93) log10 copies/g; p<0.001) compared with the Australian diet. To indicate direction of change, in comparison with the habitual diet the low FODMAP diet reduced total bacterial abundance and the typical Australian diet increased relative abundance for butyrate-producing Clostridium cluster XIVa (median ratio 6.62; p<0.001) and mucus-associated Akkermansia muciniphila (19.3; p<0.001), and reduced Ruminococcus torques.

    CONCLUSIONS: Diets differing in FODMAP content have marked effects on gut microbiota composition. The implications of long-term reduction of intake of FODMAPs require elucidation.

    Be well!

    JP

  4. JP Says:

    Update 05/19/15:

    http://onlinelibrary.wiley.com/doi/10.1111/apt.13167/full

    Aliment Pharmacol Ther. 2015 Jun;41(12):1256-70.

    Systematic review: dietary fibre and FODMAP-restricted diet in the management of constipation and irritable bowel syndrome.

    BACKGROUND: Dietary fibre supplements have been advocated for the management of chronic constipation (CC) and irritable bowel syndrome (IBS). Recently, a fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) restricted diet has been recommended for IBS.

    AIM: To systematically examine recent evidence for dietary interventions with fibre in CC and IBS and FODMAP-restricted diet in IBS, and provide recommendations.

    METHODS: We searched PUBMED, MEDLINE, OVID and COCHRANE databases from 2004 to 2014. Published studies in adults with CC and IBS and constipation-predominant IBS (IBS-C) that compared fibre with placebo/alternative and FODMAP-restricted diet with alternative were included.

    RESULTS: Of 550 potentially eligible clinical trials on fibre, 11 studies were found and of 23 potentially eligible studies on FODMAPs, six were found. A meta-analysis was not performed due to heterogeneity and methodological quality. Fibre was beneficial in 5/7 studies in CC and 3/3 studies in IBS-C. FODMAP-restricted diet improved overall IBS symptoms in 4/4 and IBS-C symptoms in 1/3 studies and three studies did not meet inclusion criteria. There were significant disparities in subject selection, interventions and outcome assessments in both fibre and FODMAPs studies.

    CONCLUSIONS: Fibre supplementation is beneficial in mild to moderate CC and IBS-C, although larger, more rigorous and long-term RCTs are needed (Fair evidence-Level II, Grade B). Although the FODMAP-restricted diet may be effective in short-term management of selected patients with IBS (Fair evidence-Level II, Grade C) and IBS-C (Poor evidence-Level III, Grade C), more rigorous trials are needed to establish long-term efficacy and safety, particularly on colonic health and microbiome.

    Be well!

    JP

  5. JP Says:

    Update 06/02/15:

    http://link.springer.com/article/10.1007%2Fs00394-015-0922-1

    Eur J Nutr. 2015 May 17.

    Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis.

    BACKGROUND: Functional gastrointestinal symptoms such as abdominal pain, bloating, distension, constipation, diarrhea and flatulence have been noted in patients with irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD). The diversity of symptoms has meant that finding an effective treatment has been challenging with most treatments alleviating only the primary symptom. A novel treatment option for IBS and IBD currently generating much excitement is the low fermentable, oligo-, di-, mono-saccharides and polyol (FODMAP) diet. The aim of this meta-analysis was to determine the evidence of the efficacy of such a diet in the treatment of functional gastrointestinal symptoms.

    METHODS: Electronic databases were searched through to March 2015 to identify relevant studies. Pooled odds ratios (ORs) and 95 % confidence intervals were calculated for the effect of a low FODMAP diet on the reduction in IBS [Symptoms Severity Score (SSS)] score and increase in IBS quality of life (QOL) score for both randomized clinical trials (RCTs) and non-randomized interventions using a random-effects model.

    RESULTS: Six RCTs and 16 non-randomized interventions were included in the analysis. There was a significant decrease in IBS SSS scores for those individuals on a low FODMAP diet in both the RCTs (OR 0.44, 95 % CI 0.25-0.76; I 2 = 35.52, p = 0.00) and non-randomized interventions (OR 0.03, 95 % CI 0.01-0.2; I 2 = 69.1, p = 0.02). In addition, there was a significant improvement in the IBS-QOL score for RCTs (OR 1.84, 95 % CI 1.12-3.03; I 2 = 0.00, p = 0.39) and for non-randomized interventions (OR 3.18, 95 % CI 1.60-6.31; I 2 = 0.00, p = 0.89). Further, following a low FODMAP diet was found to significantly reduce symptom severity for abdominal pain (OR 1.81, 95 % CI 1.13-2.88; I 2 = 0.00, p = 0.56), bloating (OR 1.75, 95 % CI 1.07-2.87; I 2 = 0.00, p = 0.45) and overall symptoms (OR 1.81, 95 % CI 1.11-2.95; I 2 = 0.00, p = 0.4) in the RCTs. In the non-randomized interventions similar findings were observed.

    CONCLUSION: The present meta-analysis supports the efficacy of a low FODMAP diet in the treatment of functional gastrointestinal symptoms. Further research should ensure studies include dietary adherence, and more studies looking at greater number of patients and long-term adherence to a low FODMAP diet need to be conducted.

    Be well!

    JP

  6. JP Says:

    Update 06/25/15:

    http://www.ncbi.nlm.nih.gov/pubmed/26104013

    Aliment Pharmacol Ther. 2015 Jun 24.

    Randomised clinical trial: gut microbiome biomarkers are associated with clinical response to a low FODMAP diet in children with the irritable bowel syndrome.

    BACKGROUND: A low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet can ameliorate symptoms in adult irritable bowel syndrome (IBS) within 48 h.

    AIM: To determine the efficacy of a low FODMAP diet in childhood IBS and whether gut microbial composition and/or metabolic capacity are associated with its efficacy.

    METHODS: In a double-blind, crossover trial, children with Rome III IBS completed a 1-week baseline period. They then were randomised to a low FODMAP diet or typical American childhood diet (TACD), followed by a 5-day washout period before crossing over to the other diet. GI symptoms were assessed with abdominal pain frequency being the primary outcome. Baseline gut microbial composition (16S rRNA sequencing) and metabolic capacity (PICRUSt) were determined. Metagenomic biomarker discovery (LEfSe) compared Responders (≥50% decrease in abdominal pain frequency on low FODMAP diet only) vs. Nonresponders (no improvement during either intervention).

    RESULTS: Thirty-three children completed the study. Less abdominal pain occurred during the low FODMAP diet vs. TACD [1.1 ± 0.2 (SEM) episodes/day vs. 1.7 ± 0.4, P < 0.05]. Compared to baseline (1.4 ± 0.2), children had fewer daily abdominal pain episodes during the low FODMAP diet (P < 0.01) but more episodes during the TACD (P < 0.01). Responders were enriched at baseline in taxa with known greater saccharolytic metabolic capacity (e.g. Bacteroides, Ruminococcaceae, Faecalibacterium prausnitzii) and three Kyoto Encyclopedia of Genes and Genomes orthologues, of which two relate to carbohydrate metabolism.

    CONCLUSIONS: In childhood IBS, a low FODMAP diet decreases abdominal pain frequency. Gut microbiome biomarkers may be associated with low FODMAP diet efficacy.

    Be well!

    JP

  7. JP Says:

    Updated 08/19/15:

    http://www.gastrojournal.org/article/S0016-5085%2815%2901086-0/abstract?

    Gastroenterology. 2015 Aug 5.

    Diet low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome as Well as Traditional Dietary Advice: A Randomized Controlled Trial.

    BACKGROUND & AIMS: A diet with reduced content of fermentable short chain carbohydrates (fermentable oligo-, di-, monosaccharides and polyols, FODMAPs) has been reported to be effective in the treatment of patients with irritable bowel syndrome (IBS). However, there is no evidence for its superiority to traditional dietary advice for these patients. We compared the effects a diet low in FODMAPs with traditional dietary advice in a randomized, controlled trial of patients with IBS.

    METHODS: We performed a multi-center, parallel, single-blind study of 75 patients who met the Rome III criteria for IBS, enrolled at gastroenterology outpatient clinics in Sweden. Subjects were randomly assigned to groups that ate specific diets for 4 weeks: a diet low in FODMAPs (n=38) or a diet frequently recommended for patients with IBS (a regular meal pattern; avoidance of large meals; and reduced intake of fat, insoluble fibers, caffeine and gas-producing foods such as beans, cabbage, and onions), with greater emphasis on how and when to eat rather than on what foods to ingest (n=37). Symptom severity was assessed using the IBS severity scoring system, and patients completed a 4 day food diary before and at the end of the intervention.

    RESULTS: A total of 67 patients completed the dietary intervention (33 completed the diet low in FODMAPs, 34 completed the traditional IBS diet). The severity of IBS symptoms was reduced in both groups during the intervention (P<.0001 in both groups, before vs at the end of the 4 week diet), without a significant difference between the groups (P=.62). At the end of the 4 week diet period, 19 patients (50%) in the low FODMAP group had reductions in IBS severity scores ≥50, compared with baseline, vs 17 patients (46%) in the traditional IBS diet group (P=.72). Food diaries demonstrated good adherence to the dietary advice.

    CONCLUSIONS: A diet low in FODMAPs reduces symptoms of IBS symptoms as well as traditional IBS dietary advice. Combining elements from these 2 strategies might further reduce symptoms of IBS.

    Be well!

    JP

  8. JP Says:

    Updated 1/18/16:

    http://www.cghjournal.org/article/S1542-3565%2815%2901715-2/abstract

    Clin Gastroenterol Hepatol. 2015 Dec 31.

    Efficacy of a Gluten-free Diet in Subjects With Irritable Bowel Syndrome-Diarrhea Unaware of Their HLA-DQ2/8 Genotype.

    BACKGROUND & AIMS: A gluten-containing diet alters bowel barrier function in patients with irritable bowel syndrome-diarrhea (IBS-D), particularly those who are positive for human leukocyte antigen (HLA) allele DQ2/8. We studied the effects of a gluten-free diet (GFD) in patients with IBS-D who have not previously considered the effects of gluten in their diet and were unaware of their HLA-DQ2/8 genotype.

    METHODS: We performed a prospective study of 41 patients with IBS-D (20 HLA-DQ2/8-positive and 21 HLA-DQ2/8-negative) at the Royal Hallamshire Hospital in Sheffield, United Kingdom, from September 2012 through July 2015. All subjects were placed on a 6 week GFD following evaluation by a dietician. Subjects completed validated questionnaires at baseline and week 6 of the GFD. The primary endpoint was mean change in IBS symptom severity score (IBS-SSS); a 50 point reduction was considered to indicate a clinical response. Secondary endpoints were changes in hospital anxiety and depression score, fatigue impact score, and short form 36 results. Clinical responders who chose to continue a GFD after the study period were evaluated on average 18 months later to assess diet durability, symptom scores, and anthropometric and biochemical status.

    RESULTS: A 6 week GFD reduced IBS-SSS by ≥50 points in 29 patients overall (71%). The mean total IBS-SSS decreased from 286 before the diet to 131 points after 6 weeks on the diet (P<.001)-the reduction was similar in each HLA-DQ group. However, HLA-DQ2/8-negative subjects had a greater reduction in abdominal distension (P=.04). Both groups had marked mean improvements in hospital anxiety and depression scores, fatigue impact score, and short form 36 results, although HLA-DQ2/8-positive subjects had a greater reduction in depression score and increase in vitality score than HLA-DQ2/8-negative subjects (P=.02 and P=.03, respectively). Twenty-one of the 29 subjects with a clinical response (72%) planned to continue the GFD long term; 18 months after the study they were still on a GFD, with maintained symptom reductions, and demonstrated similar anthropometric and biochemical features compared to baseline.

    CONCLUSION: A dietitian-led GFD provided sustained benefit to patients with IBS-D. The symptoms that improved differed in magnitude according to HLA-DQ status.

    Be well!

    JP

  9. JP Says:

    Updated 06/06/16:

    http://www.complementarytherapiesinmedicine.com/article/S0965-2299%2816%2930052-8/abstract

    Complement Ther Med. 2016 Jun;26:171-7.

    Efficacy and safety of Ayurvedic herbs in diarrhoea-predominant irritable bowel syndrome: A randomised controlled crossover trial.

    OBJECTIVE: Herbal medicines have been used widely for the treatment of irritable bowel syndrome (IBS) patients. The aim of this study is to investigate efficacy and safety of an Ayurvedic herbal compound preparation made from: Murraya koenigii (curry), Punica granatum (pomegranate) and Curcuma longa (turmeric), compared to a placebo in patients with diarrhoea predominant IBS.

    MATERIAL AND METHODS: This trial was conducted as a randomised placebo-controlled crossover trial with randomised sequence of verum and placebo for each patient. Verum and placebo were provided as ground powders and delivered in sealed containers. Patients and outcome assessors were blinded. Patients were advised to ingest the decoction twice daily for 4 weeks. The primary outcome measure was IBS symptom intensity; secondary outcomes included: quality of life, anxiety and depression, compliance and safety.

    RESULTS: 32 IBS patients were included in the trial (19 females, mean age 50.3±11.9years). Eleven people dropped out during the trial resulting in 37 complete verum and 35 complete placebo phases. No group differences were found between verum and placebo for IBS symptom intensity (difference 24.10; 95% CI: -17.12; 65.32, p=0.26). The same was true for secondary outcomes. Compliance was satisfactory to good and the preparation appeared to be safe, but one third of the patients registered at least one minor adverse event that might be related to the study interventions.

    CONCLUSION: An Ayurvedic herbal preparation made from Murraya koenigii, Punica granatum and Curcuma longa appeared to be no more effective in improving diarrhoea predominant irritable bowel symptoms than placebo.

    Be well!

    JP

  10. JP Says:

    Updated 06/26/16:

    http://www.jgld.ro/wp/y2016/n2/a6.pdf

    J Gastrointestin Liver Dis. 2016 Jun;25(2):151-7.

    Curcumin and Fennel Essential Oil Improve Symptoms and Quality of Life in Patients with Irritable Bowel Syndrome.

    BACKGROUND AND AIMS: Irritable Bowel Syndrome (IBS) patients still require effective treatment. The anti-inflammatory property of curcumin and the antispasmodic and carminative effect of fennel suggests that combination of these nutraceutical compounds would be useful in functional bowel disorders including IBS. We assessed the efficacy and tolerability of a combination of curcumin and fennel essential oil (CU-FEO) in IBS symptoms relief.

    METHODS: 121 patients with mild-to-moderate symptoms of IBS defined by an Irritable Bowel Syndrome- symptom severity score (IBS-SSS) 100-300 and abdominal pain score 30-70 on a 100 mm Visual Analogue Scale (VAS), were randomly assigned to CU-FEO or placebo (2 capsules b.d. for 30 days). Primary endpoint was the mean decrease of IBS-SSS at the end of the treatment corrected for the mean baseline score (relative decrease). The impact of the treatment on quality of life was assessed through IBS-QoL questionnaire.

    RESULTS: CU-FEO was safe, well-tolerated and induced symptom relief in patients with IBS; a significant decrease in the mean relative IBS-SSS was observed after 30 days of treatment (50.05 +/- 28.85% vs 26.12 +/- 30.62%, P<0.001). This result matched the reduction of abdominal pain and all the other symptoms of IBS-SSS. The percentage of symptom-free patients was significantly higher in the CU-FEO than in the placebo group (25.9% vs. 6.8%, P = 0.005). All domains of IBS-QoL improved consistently.

    CONCLUSION: CU-FEO significantly improved symptoms and quality of life in IBS patients over 30 days.

    Be well!

    JP

  11. JP Says:

    Updated 07/21/16:

    http://onlinelibrary.wiley.com/doi/10.1111/apt.13706/full

    Aliment Pharmacol Ther. 2016 Jul 11.

    Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome.

    BACKGROUND: A low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet is effective in treating irritable bowel syndrome (IBS).

    AIM: To compare the effects of gut-directed hypnotherapy to the low FODMAP diet on gastrointestinal symptoms and psychological indices, and assess additive effects.

    METHODS: Irritable bowel syndrome patients were randomised (computer-generated list), to receive hypnotherapy, diet or a combination. Primary end-point: change in overall gastrointestinal symptoms across the three groups from baseline to week 6. Secondary end-points: changes in psychological indices, and the durability of effects over 6 months.

    RESULTS: Of 74 participants, 25 received hypnotherapy, 24 diet and 25 combination. There were no demographic differences at baseline across groups. Improvements in overall symptoms were observed from baseline to week 6 for hypnotherapy [mean difference (95% CI): -33 (-41 to -25)], diet [-30 (-42 to -19)] and combination [-36 (-45 to -27)] with no difference across groups (P = 0.67). This represented ≥20 mm improvement on visual analogue scale in 72%, 71% and 72%, respectively. This improvement relative to baseline symptoms was maintained 6 months post-treatment in 74%, 82% and 54%. Individual gastrointestinal symptoms similarly improved. Hypnotherapy resulted in superior improvements on psychological indices with mean change from baseline to 6 months in State Trait Personality Inventory trait anxiety of -4(95% CI -6 to -2) P < 0.0001; -1(-3 to 0.3) P = ns; and 0.3(-2 to 2) P = ns, and in trait depression of -3(-5 to -0.7) P = 0.011; -0.8(-2 to 0.2) P = ns; and 0.6(-2 to 3) P = ns, respectively. Groups improved similarly for QOL (all p ≤ 0.001).

    CONCLUSIONS: Durable effects of gut-directed hypnotherapy are similar to those of the low FODMAP diet for relief of gastrointestinal symptoms. Hypnotherapy has superior efficacy to the diet on psychological indices. No additive effects were observed.

    Be well!

    JP

  12. JP Says:

    Updated 02/16/17:

    http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0172183

    PLoS One. 2017 Feb 13;12(2):e0172183.

    Vitamin D status in pediatric irritable bowel syndrome.

    IMPORTANCE: Irritable bowel syndrome (IBS) is associated with significant morbidity in children and adolescents, and the therapeutic efficacy of available treatment options is limited. The role of vitamin D supplementation in pediatric IBS is unclear as the vitamin D status of pediatric patients with IBS is unknown. Equally, the relationship of vitamin D status with psychosomatic symptoms in children and adolescents is unclear.

    AIM: To characterize the vitamin D status of pediatric patients with IBS using a case-control study design.

    HYPOTHESIS: Serum 25-hydroxyvitamin D [25(OH)D] concentration will be similar between patients with IBS and controls.

    SUBJECTS AND METHODS: A retrospective case-controlled study of 116 controls (age 14.6 ± 4.3 y), female (n = 67; 58%) and 55 subjects with IBS (age 16.5 ± 3.1y), female (n = 44; 80%). Overweight was defined as BMI of ≥85th but <95th percentile, and obesity as BMI ≥95th percentile. Vitamin D deficiency was defined as 25(OH)D of <50 nmol/L, while seasons of vitamin D draw were categorized as summer, winter, spring, and fall. Major psychosomatic manifestations included in the analysis were depression, anxiety, and migraine.

    RESULTS: More than 50% of IBS subjects had vitamin D deficiency at a cut-off point of <50 nmol/L (53% vs. 27%, p = 0.001); and >90% of IBS subjects had vitamin D deficiency at a cut-off point of <75 nmol/L (93% vs. 75%, p = 0.006). IBS subjects had significantly lower mean 25(OH)D: 53.2 ± 15.8 nmol/L vs. 65.2 ± 28.0 nmol/L, p = 0.003; and albumin: 6.2 ± 0.6 vs. 6.5 ± 0.6 μmol/L, p = 0.0.01. IBS subjects with migraine had significantly lower mean 25(OH)D concentration compared to controls (p = 0.01). BMI z-score was similar between the controls and IBS subjects (0.5 ± 1.4 vs. 1.2 ± 2.9, p = 0.11).

    CONCLUSIONS: Pediatric patients with IBS had significantly lower 25(OH)D concentration compared to controls despite having similar mean BMI values as controls. Only 7% of the children and adolescents with IBS were vitamin D sufficient, and >50% of the subjects with IBS had vitamin D deficiency. This is a much higher prevalence of vitamin D deficiency compared to IBD and other malabsorption syndromes. Monitoring for vitamin D deficiency should be part of the routine care for patients with IBS. Randomized control trials are warranted to determine the role of adjunctive vitamin D therapy in pediatric IBS.

    Be well!

    JP

  13. JP Says:

    Updated 07/03/17:

    https://www.ncbi.nlm.nih.gov/pubmed/28668539

    Clin Gastroenterol Hepatol. 2017 Jun 28.

    A Diet Low in Fermentable Oligo-, Di-, and Mono-saccharides and Polyols Improves Quality of Life and Reduces Activity Impairment in Patients with Irritable Bowel Syndrome and Diarrhea.

    BACKGROUND & AIMS: We investigated the effects of a diet low in fermentable oligo-, di-, and mono-saccharides and polyols (FODMAPs) vs traditional dietary recommendations, on health-related quality of life (QOL), anxiety and depression, work productivity, and sleep quality in patients with IBS and diarrhea (IBS-D).

    METHODS: We conducted a prospective, single-center, single-blind trial of 92 adult patients with IBS-D (65 women; median age, 42.6 years) randomly assigned to groups placed on a diet low in FODMAPs or a modified diet recommended by the National Institute for Health and Care Excellence (mNICE) for 4 weeks. IBS-associated QOL (IBS-QOL), psycho-social distress (based on the Hospital Anxiety and Depression Scale), work productivity (based on the Workplace Activity Impairment Questionnaire), and sleep quality were assessed before and after diet periods.

    RESULTS: Eighty-four patients completed the study (45 in the low-FODMAP group and 39 in the mNICE group). At 4 weeks, patients on the diet low in FODMAPs had a larger mean increase in IBS-QOL score than patients on the mNICE diet (15 v 5; 95% CI, -17.4 to -4.3). A significantly higher proportion of patients in the low-FODMAP diet group had a meaningful clinical response, based on IBS-QOL score, than in the mNICE group (52% v 21%; 95% CI, -.52 to -08). Anxiety scores decreased in the low-FODMAP diet group compared to the mNICE group (95% CI, 0.46- 2.80). Activity impairment was significantly reduced with the low-FODMAP diet (-22.89) compared to the mNICE diet (-9.44; 95% CI, 2.72-24.2).

    CONCLUSION: In a randomized, controlled trial, a diet low in FODMAPs led to significantly greater improvements in HRQOL, anxiety, and activity impairment compared with a diet based on traditional recommendations for patients with IBS-D.

    Be well!

    JP

  14. JP Says:

    Updated 08/30/17:

    https://www.ncbi.nlm.nih.gov/pubmed/28850525

    Scand J Pain. 2016 Oct;13:166-172.

    A low fermentable oligo-di-mono saccharides and polyols (FODMAP) diet reduced pain and improved daily life in fibromyalgia patients.

    BACKGROUND AND AIMS: Fibromyalgia (FM) is a chronic, rheumatic disease characterized by widespread myofascial pain, of unknown aetiology, having a major impact on quality of life (QOL). Available pharmacotherapy for FM is marginally effective. FM is associated with co-morbidities of gastrointestinal (GI) disorders and Irritable Bowel Syndrome (IBS). There is growing evidence that diets low in FODMAPs, “fermentable oligo-, di- or mono-saccharides and polyols” [Low FODMAP Diet (LFD)], are effective in treating IBS. The aim of this pilot study was to examine the effects of LFDs on symptoms of FM, especially with regard to pain, QOL and GI disorders.

    METHODS: A longitudinal study using LFD intervention was performed on 38, 51±10 year-old, female patients diagnosed with FM for an average of 10 years, based on ACR (American College of Rheumatology) 2010 criteria. The study was conducted from January through May, 2015, using a four-week, repeated-assessment model, as follows: Moment 0 – introduction of the protocol to participants; Moment 1 – first assessment and delivery of individual LFD dietary plans; Moment 2 – second assessment and reintroduction of FODMAPs; Moment 3 – last assessment and final nutritional counselling. Assessment tools used were the following: RFIQ (Revised Fibromyalgia Impact Questionnaire), FSQ (Fibromyalgia Survey Questionnaire), IBS-SSS (Severity Score System), EQ-5D (Euro-QOL quality of life instrument), and VAS (Visual Analogue Scale). Daily consumption of FODMAPs was quantified based on published food content analyses. Statistical analyses included ANOVA, non-parametric Friedman, t-student and Chi-square tests, using SPSS 22 software.

    RESULTS: The mean scores of the 38 participants at the beginning of the study were: FSQ (severity of FM, 0-31) – 22±4.4; RFIQ (0-100) – 65±17; IBS-SSS (0-500) – 275±101; and EQ-5D (0-100) – 48±19. Mean adherence to dietary regimens was 86%, confirmed by significant difference in FODMAP intakes (25g/day vs. 2.5g/day; p<0.01). Comparisons between the three moments of assessment showed significant (p<0.01) declines in scores in VAS, FSQ, and RFIQ scores, in all domains measured. An important improvement was observed with a reduction in the severity of GI symptoms, with 50% reduction in IBS scores to 138±117, following LFD therapy. A significant correlation (r=0.36; p<0.05) was found between improvements in FM impact (declined scores) and gastrointestinal scores. There was also a significant correlation (r=0.65; p<0.01) between “satisfaction with improvement” after introduction of LFDs and “diet adherence”, with satisfaction of the diet achieving 77% among participants. A significant difference was observed between patients who improved as compared to those that did not improve (Chi-square χ2=6.16; p<.05), showing that the probability of improvement, depends on the severity of the RFIQ score.

    CONCLUSIONS: Implementation of diet therapy involving FODMAP restrictions, in this cohort of FM patients, resulted in a significant reduction in GI disorders and FM symptoms, including pain scores. These results need to be extended in future larger studies on dietary therapy for treatment of FM.

    IMPLICATIONS: According to current scientific knowledge, these are the first relevant results found in an intervention with LFD therapy in FM and must be reproduced looking for a future dietetic approach in FM.

    Be well!

    JP

  15. JP Says:

    Updated 10/28/17:

    https://www.ncbi.nlm.nih.gov/pubmed/29076171

    Aliment Pharmacol Ther. 2017 Oct 27.

    Randomised clinical trial: yoga vs a low-FODMAP diet in patients with irritable bowel syndrome.

    BACKGROUND: Irritable bowel syndrome is the most frequent gastrointestinal disorder. It is assumed that lifestyle interventions might be a rational treatment approach.

    AIM: To examine the effect of a yoga-based intervention vs a low-FODMAP diet on patients with irritable bowel syndrome.

    METHODS: Fifty-nine patients with irritable bowel syndrome undertook a single-blind, randomised controlled trial involving yoga or a low-FODMAP diet for 12 weeks. Patients in the yoga group received two sessions weekly, while patients in the low-FODMAP group received a total of three sessions of nutritional counselling. The primary outcome was a change in gastrointestinal symptoms (IBS-SSS). Secondary outcomes explored changes in quality of life (IBS-QOL), health (SF-36), perceived stress (CPSS, PSQ), body awareness (BAQ), body responsiveness (BRS) and safety of the interventions. Outcomes were examined in weeks 12 and 24 by assessors “blinded” to patients’ group allocation.

    RESULTS: No statistically significant difference was found between the intervention groups, with regard to IBS-SSS score, at either 12 (Δ = 31.80; 95%CI = -11.90, 75.50; P = .151) or 24 weeks (Δ = 33.41; 95%CI = -4.21, 71.04; P = .081). Within-group comparisons showed statistically significant effects for yoga and low-FODMAP diet at both 12 and 24 weeks (all P < .001). Comparable within-group effects occurred for the other outcomes. One patient in each intervention group experienced serious adverse events (P = 1.00) and another, also in each group, experienced nonserious adverse events (P = 1.00).

    CONCLUSIONS: Patients with irritable bowel syndrome might benefit from yoga and a low-FODMAP diet, as both groups showed a reduction in gastrointestinal symptoms. More research on the underlying mechanisms of both interventions is warranted, as well as exploration of potential benefits from their combined use.

    Be well!

    JP

  16. JP Says:

    Updated 11/06/17:

    http://www.mdpi.com/2072-6643/9/11/1215/htm

    Nutrients 2017, 9(11), 1215

    Pilot Study: Comparison of Sourdough Wheat Bread and Yeast-Fermented Wheat Bread in Individuals with Wheat Sensitivity and Irritable Bowel Syndrome

    Abstract: Many patients suspect wheat as being a major trigger of their irritable bowel syndrome (IBS) symptoms. Our aim was to evaluate whether sourdough wheat bread baked without baking improvers and using a long dough fermentation time (>12 h), would result in lower quantities of alpha-amylase/trypsin inhibitors (ATIs) and Fermentable, Oligo-, Di-, Mono-saccharides and Polyols (FODMAPs), and would be better tolerated than yeast-fermented wheat bread for subjects with IBS who have a poor subjective tolerance to wheat. The study was conducted as a randomised double-blind controlled 7-day study (n = 26). Tetrameric ATI structures were unravelled in both breads vs. baking flour, but the overall reduction in ATIs to their monomeric form was higher in the sourdough bread group. Sourdough bread was also lower in FODMAPs. However, no significant differences in gastrointestinal symptoms and markers of low-grade inflammation were found between the study breads. There were significantly more feelings of tiredness, joint symptoms, and decreased alertness when the participants ate the sourdough bread (p ≤ 0.03), but these results should be interpreted with caution. Our novel finding was that sourdough baking reduces the quantities of both ATIs and FODMAPs found in wheat. Nonetheless, the sourdough bread was not tolerated better than the yeast-fermented bread.

    Be well!

    JP

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