The low FODMAP diet in the management of irritable bowel syndrome: an evidence‐based review of FODMAP restriction, reintroduction and personalisation in clinical practice

Abstract

Dietary restriction of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) is effective in the management of functional gastrointestinal symptoms that occur in irritable bowel syndrome (IBS). Numerous reviews have been published regarding the evidence for their restriction in the low FODMAP diet; however, few reviews discuss the implementation of the low FODMAP diet in practice. The aim of this review is to provide practical guidance on patient assessment and the implementation and monitoring of the low FODMAP diet. Broadly speaking, the low FODMAP diet consists of three stages: FODMAP restriction; FODMAP reintroduction; and FODMAP personalisation. These stages can be covered in at least two dietetic appointments. The first appointment focuses on confirmation of diagnosis, comprehensive symptom and dietary assessment, detailed description of FODMAPs and their association with symptom induction, followed by counselling regarding FODMAP restriction. Dietary counselling should be tailored to individual needs and appropriate resources provided. At the second appointment, symptoms and diet are re-assessed and, if restriction has successfully reduced IBS symptoms, education is provided on FODMAP reintroduction to identify foods triggering symptoms. Following this, the patient can follow FODMAP personalisation for which a less restrictive diet is consumed that excludes their personal FODMAP triggers and enables a more diverse dietary intake. This review provides evidence and practice guidance to assist in delivering high-quality clinical service in relation to the low FODMAP diet.

Controversies and reality of the FODMAP diet for patients with irritable bowel syndrome

“…Since then, knowledge of its possible negative associations and the observation that tolerances to foods differed across individuals led to the current three‐step FODMAP diet. This protocol details how to initially restrict, then reintroduce foods, and finally personalize a diet for long‐term IBS management and has been described in detail elsewhere . This protocol has not been formally assessed in randomized controlled trials, but several studies of the longer‐term efficacy when individualization of the diet is achieved have now been published.…”

Low-FODMAP diet in the management of irritable bowel syndrome

“…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.…”

Review article: biological mechanisms for symptom causation by individual FODMAP subgroups ‐ the case for a more personalised approach to dietary restriction

“…5 While dietitian-taught therapy is believed to be associated with success of the diet, poor access to dietitians may impact patients' ability to receive individualised dietary guidance. 5 While dietitian-taught therapy is believed to be associated with success of the diet, poor access to dietitians may impact patients' ability to receive individualised dietary guidance.…”

“…A dietitian with time and expertise to evaluate usual dietary intake and potential triggers is likely to be very important to the ultimate impact of such an approach. Dietitians can play an important role to ensure the patient appropriately navigates dietary modifications and avoids over-restriction of the diet 5. Currently, no evidence exists to know which patients may respond best to each type of treatment plan.While it is possible that the microbiome, VOCs or genetic variants may allow clinicians to predict response, further data are needed prior to implementation into clinical practice.…”