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  • Review
  • Open Access

Low-FODMAP diet in the management of irritable bowel syndrome

Nutrire201843:17

https://doi.org/10.1186/s41110-018-0076-z

  • Received: 13 April 2018
  • Accepted: 15 June 2018
  • Published:

Abstract

Background

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) are short-chain carbohydrates poorly absorbed by humans due to their small size, high osmotic activity, and the speed with which they are fermented by the microbiota. This causes abdominal pain, diarrhea and or constipation, and bloating. Studies about low-FODMAP diet to reduce the symptoms presented by patients with irritable bowel syndrome (IBS) have recently grown. This study aims to identify the characteristics and the risks of low-FODMAP diet to irritable bowel syndrome patients.

Methods

Electronic databases were used to search for the following words and/or expressions: “FODMAP Diet,” “Low FODMAP diet,” “irritable bowel syndrome,” and “Diet in IBS.” The study was carried out between February and September 2017.

Results

The low-FODMAP diet consists of two phases: in the first phase, carbohydrates associated with symptom induction in IBS patients and with the evaluation of the improvement conditions are eliminated or reduced; in the second phase, the eliminated groups are gradually reintroduced according to the presented symptomatology.

Conclusions

The low-FODMAP diet restrains the intake of certain food, and it leads to significant improvement in the symptoms of irritable bowel syndrome patients. However, some nutritional deficiencies may occur, if there is inadequate nutritional guidance, highlighting the need for adequate dietary management.

Keywords

  • FODMAPs
  • Low-FODMAP diet
  • Irritable bowel syndrome
  • Carbohydrates

Background

FODMAP is an acronym for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, which are known as short-chain carbohydrates poorly absorbed by humans. Such characteristic is related to their small size, high osmotic activity, and the speed with which they are fermented by the microbiota. This process produces gases and osmotically active byproducts [13]. This causes abdominal pain, diarrhea and or constipation, and bloating.

FODMAPs have low digestibility in the gastrointestinal tract and fermentation capacity in the bowel [4]. They have three possible common functional properties, as follows [5]:
  • Low absorption in the small intestine—which is generated by lack of enzymes capable of hydrolyzing glycosidic bonds, lack or low activity of border enzymes in intestinal brush border, and low capacity of epithelial transporters, and is related to the polyols, due to their large size for simple diffusion [1, 57];

  • FODMAPs small size and high osmotic activity fosters water mobilization in the intestine, thus increasing the amount of fluids. It alters the intestinal function, causing abdominal distension and the exacerbation of symptoms [1, 57];

  • Quick fermentation by bacteria—FODMAPs are substrates for gut bacteria in both healthy flora and dysbiosis. They increase gas production, which results in distension, pain, and swelling [1, 57].

The induction of symptoms related to FODMAPs in irritable bowel syndrome (IBS) patients remains unclear. However, it may occur due to the interaction of certain factors, such as [8]:
  • Increased amount of water in the small intestine;

  • Increased gas production;

  • Increased intestinal motility which, in addition to the retention of gases, would lead to a change in the bowel movement. It affects defecation;

  • Shift in the number and composition of these patients’ gut microbiota.

FODMAPs are fermented by the local microbiota in the large intestine, and it increases the amount of hydrogen gas, carbon dioxide, methane, and short-chain fatty acids in the lumen. Such process results in abdominal distension, bloating, flatulence, and pain [4, 9].

FODMAPs and the irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional disorder of the intestine, defined from diagnoses primarily based on the presence of symptoms and on lack of organic causes. It is usually characterized by changes in the bowel habit in association with abdominal pain and/or abdominal discomfort, distension, bloating, and flatulence [10].

Treatment of IBS consists of pharmacological and non-pharmacological measures. Among the non-pharmacological measures, it is possibly highlighting the actions taken to reduce stress (a factor strongly associated with crises) and food adequacy through the restriction of certain food (i.e., FODMAPs) associated with the onset of symptoms [1013]. The distension caused by unabsorbed and/or fermented FODMAPs can be the basis for the most common symptoms in IBS [1, 14]. Table 1 [15] presents the main sources and maximum intake dose of FODMAPs not associated with the onset of symptoms in individuals with IBS.
Table 1

FODMAP types, sources, and maximum intake doses

FODMAP

Main sources

Maximum dose (portion)

Fructans

Onion, garlic, artichoke and wheat

0.2 g

Galactans

Grain legumes (bean, lentil, chickpea)

0.3 g

Lactose

Milk and milk products

< 1.0 g

Fructose

Apple, peach, honey, corn syrup

< 0.15 ga

Polyols

Blackberry, apricot, apple, sorbitol, xylitol, mannitol

< 0.4 g

aFructose in excess of glucose

Regarding the relevance of dietary treatment in IBS, the aim of the present review was to identify the characteristics and the risks of the low-FODMAP diet.

Methods

PUBMED electronic database was used to search for the following words and/or expressions: “FODMAP Diet,” “Low FODMAP diet,” “Irritable Bowel Syndrome,” and “Diet in IBS,” between February and September 2017.

Articles related to bowel inflammatory disease were excluded, as well as articles related to celiac disease and food allergy. Only studies performed in humans were included. The search resulted in 90 articles.

Results

The low-FODMAP diet

The benefits of restricting FODMAP-rich food for individuals with IBS have been reported by several authors. Shepherd et al. (2008) noticed the improvement of symptoms related to diet restrictions in 74% of IBS patients; treatment efficacy was directly associated with the patient’s commitment to the diet [16]. Whelan et al. [17] remarked that the low-FODMAP diet, delivered through dietitian-led dietary counseling, is effective in the management of functional gastrointestinal symptoms in IBS.

FODMAP-rich food is eliminated or restricted in the low-FODMAP diet in order to detect the groups exacerbating the symptoms in each individual. As a result, the diet encompasses two phases; the first one is the withdrawal of these carbohydrates from the diet, which should contain less than 0.5 g per meal or less than 3 g per day [7, 18, 19].

Based on the current literature, it is not possible to assume that only a specific food group causes symptoms related with FODMAPs. Also, it is possible that individual characteristics (i.e., genetics and intestinal function) related to the ingestion of FODMAPs imply in a threshold to each food type.

Phase 1 of the diet lasts 4 to 8 weeks, on average, during which the FODMAP-rich food undergo full exclusion. Table 2 presents the food to be avoided and consumed in the first phase [3, 5, 7, 20].
Table 2

High and low FODMAP foods

FODMAP

Examples of high-FODMAP foods

Examples of low-FODMAP foods

Oligosaccharides (fructans and galactans)

Vegetables: artichoke, asparagus, beet, broccoli, Brussels sprouts, cabbage, cauliflower, garlic, leek, okra, onion

Cereals: wheat, barley and rye and their derivatives (bread, noodles, cookies)

Legumes: bean, chickpea, lentil, red bean, pea, soybean

Fruits: persimmon, custard apple, watermelon, peach

Chestnuts: walnut, hazelnut, pistachio

Vegetables: carrot, lettuce, zucchini, pumpkin, bamboo shoots, pepper, celery, scallion, chard, tomato

Cereals: rice, corn, tapioca, quinoa, oat and its derivatives

An option to replace garlic and onion: garlic infusion in olive oil

Lactose

Cow, goat and sheep milk, fluid or powdered, condensed milk

Ice cream

Yogurt

Cheeses: soft and fresh cheeses (for instance, cottage, ricotta and mascarpone)

Milk: low-lactose milk

Ice cream replacers: sorbets

Yogurts: low-lactose yogurts

Cheeses: ripened cheese, brie, camembert, cheddar, feta, parmesan

Fructose

Fruits: apple, peach, mango, pear, watermelon, fruit syrup

Honey sweeteners: fructose, high fructose corn syrup

Vegetables: asparagus, artichoke

Sweet wines

Large total fructose dose: concentrated fruit sources, large servings of fruit, dried fruit, fruit juice

Fruits: banana, blueberry, melon, star fruit, grape, melon, kiwi, lemon, orange, passion fruit, papaya, raspberry, strawberry, tangerine

Sweeteners: any sweetener, except for polyols

Polyols

Fruits: apple, apricot, avocado, cherry, lychee, nectarine, peach, pear, plum, prune, watermelon

Vegetables: cauliflower, mushroom

Sweeteners: isomalt, maltitol, mannitol, sorbitol, xylitol and other sweeteners ending with “-ol”

Fruits: banana, blueberry, melon, star fruit, grape, kiwi, lemon, lime, orange, passion fruit, papaya, raspberry

Sweeteners: glucose, sugar (sucrose), other artificial sweeteners not ending with “-ol”

At the beginning of diet implementation, the dietitian should conduct a detailed questionnaire on the symptoms presented, including type, frequency, and pattern, and whether there is a perception that some food causes discomfort, as well as it should be asked about associated psychological factors. Also, the dietitian should investigate the frequency of food intake, especially those “rich in FODMAPs” [4, 19].

The dietitian should explain to the patient, qualitatively and quantitatively, how the diet will be implemented, taking into account their lifestyle and eating habits, advise on foods with high and low content of FODMAPs. An important point is to emphasize that each person is unique and responds in a way to approach, that is, each one will have a level of tolerance to each type of food, emphasizing the importance of having control and monitoring the symptoms and having a food diary [7].

The knowledge of the composition of industrialized foods is relevant to avoid the ingestion of large quantities of high FODMAP foods. In this sense, the reading of labels should be part of the routine of individuals who follow the diet with low content of FODMAP.

Also, it should be emphasized that the provision of adequate food alternatives considering the nutritional value of the food and the acceptance of the patient is fundamental to avoid possible nutritional deficiencies [5, 7].

The food of each subgroup should be progressively and exclusively reintroduced in phase 2 of the diet: at first, certain food with significant quantities of only one FODMAP should be selected, such as milk, which contains a large proportion of lactose, but has no other subgroup. This fragmentation happens due to the different effects FODMAPs cause in the gastrointestinal tract. Regarding the quantities, it is recommended to start reinsertion with reduced portions for approximately 3 days, thereby checking the patient’s acceptance to a particular category [7, 21].

In case of significant worsening of the symptoms or of their intensity, it is recommended to interrupt the approach of a particular group. If there is no worsening, the individual is encouraged to increase the intake dose of the group in question in order to reach the usual consumption portion. Subsequently, the process for the next subgroup is initiated; 2 to 3 days of washout shall be performed between procedures to assure no cross-effects between categories. Given the reestablishment of tolerance to each group, the patient should be encouraged to increase the doses, the frequency and the combination of high-FODMAP food. In this context, it is possible to improve the diet from the nutritional point of view [21].

Potential limitations and risks of low-FODMAP diet implementation

Alteration in the gut microbiota composition and the reduction of beneficial bacteria are likely to occur when fructans and galactans are eliminated [8, 15, 18]. Consequently, there is short-term risk associated with insufficient carbohydrate, dietary fiber, B group vitamins, and calcium intake. In addition, if the restricted diet goes on, these inadequacies may extend for longer periods. It is also possible that patients face weight loss due to the dietary restriction [7, 8, 22, 23].

Lack of clear tolerance values to groups covered by the FODMAP’s acronym, and also to values of these subgroups in food and the numbers reporting individual and population consumption are other points of extreme relevance. Currently, there are food composition databases with limited descriptions of these carbohydrates contents [5, 6, 8, 23, 24].

The existence of tolerance values of the FODMPAS intake would allow improvement of nutritional guidance. However, the scarcity of data regarding the values of such oligosaccharides in foods compromises the indication of their use, which contributes to limit the food intake of this group of FODMAP. Also, it should be mentioned that not all food analysis laboratories are capable of identifying FODMAP content in food.

It should be pointed out that there is a need for a global standardization of the methods used to analyze the content of FODMAPS in food so that several laboratories around the world can analyze the products in the same way. This topic gains more pertinence with the lack of composition tables and local lists for each region that bring this information [5, 6, 8, 23, 24]. In this way, the existence of more reliable regional data will contribute to a more effective treatment as it will bring more qualitative and quantitative information. Also, different eating habits around the world should be considered in the prescription of a diet with low content of FODMAP, thus emphasizing the need to individualize the diet, respecting habits and their own culinary practices.

Conclusion

The low-FODMAP diet restricts the intake of some food, such as certain fruits, dairy products, grain legumes, and wheat. Adherence to this diet provides remarkable improvement of symptoms in irritable bowel syndrome patients, besides reducing bloating, abdominal pain, and diarrhea. Nevertheless, it is advisable to follow suitable meal plans conducted by skilled dietitians to avoid possible nutritional deficiencies as the consequence of adopting a low-FODMAP diet.

Abbreviations

FODMAP: 

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols

IBS: 

Irritable bowel syndrome

Declarations

Authors’ contributions

The authors contributed equally to this work. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
Department of Nutrition, School of Public Health - University of São Paulo, São Paulo, Brazil

References

  1. Hayes PA, Fraher MH, Quigley EM. Irritable bowel syndrome: the role of food in pathogenesis and management. Gastroenterol Hepatol. 2014;10(3):164–74.Google Scholar
  2. Andrade VLA, Fonseca TN, Gouveia CA, Kobayashi TG, Leite RGS, Mattar RA, Silva FAA. Dieta restrita de FODMEPs como opção terapêutica na síndrome do intestino irritável: revisão sistemática. GED Gastroenterol Endosc Dig. 2014;34(1):34–41.Google Scholar
  3. Magge S, Lembo A. Low-FODMAP diet for treatment of irritable bowel syndrome. Gastroenterol Hepatol. 2012;8(11):739–45.Google Scholar
  4. Staudacher HM, Irving PM, Lomer MCE, Whelan K. Mechanisms and efficacy of dietary FODMAP restriction in IBS. Nat Rev Gastroenterol Hepatol. 2014;11(4):256–66.View ArticlePubMedGoogle Scholar
  5. Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: the FODMAP approach. J Gastroenterol Hepatol. 2010;25(2):252–8.View ArticlePubMedGoogle Scholar
  6. Nanayakkara WS, Skidmore PML, O’Brien L, Wilkinson TJ, Gearry RB. Efficacy of the low FODMAP diet for treating irritable bowel syndrome: the evidence to date. Clin Exp Gastroenterol. 2016;17(9):131–42.Google Scholar
  7. Murillo AZ, Arévalo FE, Jáuregui EP. Diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) in the treatment of irritable bowel syndrome: indications and design. Endocrinol Nutr. 2016;63(3):132–8.View ArticleGoogle Scholar
  8. Infante JM, Serra J, Banares FF, Mearine F. The low-FODMAP diet for irritable bowel syndrome: lights and shadows. Gastroenterol Hepatol. 2016;39(2):55–65.View ArticleGoogle Scholar
  9. Kortlever T, Hebblethwaite C, Leeper J, O’Brien L, Mulder C, Gearry RB. Low FODMAP diet efficacy in IBS patients—what is the evidence and what else do we need to know? N Z Med J. 2016;129(1442):75–83.PubMedGoogle Scholar
  10. WGO - World Gastroenterology Organization, Global Guidelines. Síndrome do intestino irritável: uma perspectiva mundial. 2009. http://www.worldgastroenterology.org/UserFiles/WGO_2015_IrritablebowelsyndromeIBS_Portuguese_Final.pdf. Accessed 16 Feb 2017.Google Scholar
  11. Jones J, Boorman J, Cann P, Forbes A, Gomborone J, Heaton K, Hungin P, Kumar D, Libby G, Spiller R, Read N, Silk D, Whorwell P. British Society of Gastroenterology guidelines for the management of the irritable bowel syndrome. Gut. 2000;47(Suppl II):ii1–ii19.PubMedPubMed CentralGoogle Scholar
  12. Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, Jones R, Kumar D, Rubin G, Trudgill N, Whorwell P. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut. 2007;56(12):1770–98.View ArticlePubMedPubMed CentralGoogle Scholar
  13. Chehter L, Domingues SS. Síndrome do Intestino Irritável. Revista Brasileira de Medicina 2009. http://www.moreirajr.com.br/revistas.asp?id_materia=4006&fase=imprime. Accessed 16 July 2017.
  14. Laatikainen R, Koskempato J, Hongistos M, Loponens J, Poussa T, Hilila M, Korpela R. Randomised clinical trial: low-FODMAP rye bread vs. regular rye bread to relieve the symptoms of irritable bowel syndrome. Aliment Pharmacol Ther. 2016;44(5):460–70.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Varney J, Barrett J, Scarlata K, Catsos P, Gibson PR, Muir JG. FODMAPs: food composition, defining cutoff values and international application. J Gastroenterol Hepatol. 2017;32(Suppl 1):53–61.View ArticlePubMedGoogle Scholar
  16. Shepherd SJ, Parker FJ, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomised placebo-controlled evidence. Clin Gastroenterol Hepatol. 2008;6(7):765–71.View ArticlePubMedGoogle Scholar
  17. Whelan K, Martin LD, Staudacher HM, Lomer MCE. The low FODMAP diet in the management of irritable bowel syndrome: an evidence-based review of FODMAP restriction, reintroduction and personalisation in clinical practice. J Hum Nutr Diet. 2018;31(2):239–55.View ArticlePubMedGoogle Scholar
  18. Hill P, Muir JG, Controversies GPR. Recent developments of the low-FODMAP diet. Gastroenterol Hepatol. 2017;13(1):36–45.Google Scholar
  19. Barret JS. How to institute the low-FODMAP diet. J Gastroenterol Hepatol. 2017;32(Suppl 1):8–10.View ArticleGoogle Scholar
  20. Mullin GE, Shepherd SJ, Roland BC, Ireton-Jones C, Matarese LE. Irritable bowel syndrome: contemporary nutrition management strategies. JPEN J Parenter Enteral Nutr. 2014;38(7):781–99.View ArticlePubMedGoogle Scholar
  21. Tuck C, Barrett J. Re-challenging FODMAPs: the low FODMAP diet phase two. J Gastroenterol Hepatol. 2017;32(Suppl. 1):11–5.View ArticlePubMedGoogle Scholar
  22. Staudacher HM. Nutritional, microbiological and psychosocial implications of the low FODMAP diet. J Gastroenterol Hepatol. 2017;32(Suppl. 1):16–9.View ArticlePubMedGoogle Scholar
  23. Mansueto P, Seidita A, D’Alcamo A, Corroccio A. Role of FODMAPs in patients with irritable bowel syndrome. Nutr Clin Pract. 2015;30(5):665–82.View ArticlePubMedGoogle Scholar
  24. Méance S, Giordano J, Chuang E, Schneider H. Food regulations: low FODMAP labeling and communication goals. J Gastroenterol Hepatol. 2017;32(Suppl. 1):62–3.View ArticlePubMedGoogle Scholar

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