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

Abstract

Since its first trial showing evidence of efficacy for managing symptoms of irritable bowel syndrome, the fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet has been gaining popularity but not without criticism. Application of the diet has changed from a rigid list of “allowed” and “not allowed” foods to a structured program of initial FODMAP restriction followed by food reintroduction and finally personalization so that patients are empowered to adjust their diet themselves to achieve good predictability of symptoms. Safety concerns of the diet have centered around its initial elimination leading to compromise of nutritional and psychological health, but careful patient assessment and management, preferably through a FODMAP‐trained dietitian, will reduce the risk of such negative health outcomes. Most negative attention for the FODMAP diet has been the notion that it will ruin the microbiota. Controlled studies have indicated that reducing FODMAP intake has no effects on bacterial diversity but will reduce total bacterial abundance, and higher FODMAP intakes will increase health‐promoting bacteria, supporting the concept of the full FODMAP program, including attaining a minimal “maintenance” level of FODMAP restriction. This review addresses all these concerns in detail and how to overcome them, including the use of a “FODMAP‐gentle” diet, describing restriction of a select few foods very concentrated in FODMAPs. This version of the diet is commonly applied in practice by experienced FODMAP‐trained dietitians but is not clearly described in literature. Careful direction and assessment of response or nonresponse will decrease the risks of over‐restriction and under‐restriction of diet.

Determination of FODMAP contents of common wheat and rye breads and the effects of processing on the final contents

“…In particular sucrose and maltose are not among the most commonly discussed FODMAPs but should not left unconsidered. It was discussed in recent publications that these saccharides should be included in the concept of "new FODMAPs" [33,34]. Deficiencies of brush border hydrolases can lead to these saccharides reaching the colon, where they are rapidly fermented by the gut microorganisms.…”

The role of diet in irritable bowel syndrome: implications for dietary advice

“…More recently, a RCT from Norway noted that fructans, rather than gluten, induced gastrointestinal symptoms in patients with self‐reported gluten sensitivity These studies highlight that symptom improvement following a GFD may be due to fructans or a nocebo effect, as opposed to gluten per se. With this in regard, it could be speculated that using the term ‘GFD’ for IBS may be a misnomer and rather reflects a reduction in associated fructan intake, which some may consider as being under the realms of a ‘FODMAP‐gentle’ approach . However, irrespective of mechanism and nomenclature issues, patients are still likely to pursue a GFD for IBS given its widespread availability, popularity and symptom benefit, and it may be thought as the express route to fructan reduction.…”

Comparison of Faba Bean Protein Ingredients Produced Using Dry Fractionation and Isoelectric Precipitation: Techno-Functional, Nutritional and Environmental Performance

“…FODMAPs are poorly digestible, and are fermented and/or osmotically active in the distal small intestine and proximal colon, thus can lead to increased fluid as well as gas production [9]. Adhering to a low FODMAP diet has been shown to provide symptomatic relief to irritable bowel syndrome (IBS) sufferers [10], and such diets can be personalized depending on the individual [11]. A number of methods have been used to produce high-protein ingredients from pulses.…”