The Dietary Management of Patients with Irritable Bowel Syndrome: A Narrative Review of the Existing and Emerging Evidence
Abstract
:1. Introduction
2. Methodology
3. History of Dietary Management of IBS: The Bran Era and Exclusion Diets
4. IgG Elimination Diet
5. Dietary Fiber
6. The NICE Guidelines
7. FODMAPs
8. Lactose
9. Low-Fructose/Fructan Diet
10. Low-Carbohydrate Diet
11. Gluten
12. Future Directions and Recommendations
Author Contributions
Funding
Conflicts of Interest
References
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Study (Year) Country | Design, Population (n) | Interventions | Main Findings |
---|---|---|---|
Shepherd et al. (2006) Australia [58] | Single-center study, IBS patients with fructose malabsorption (n = 62) | Diet avoiding free fructose and short-chain fructans, limitation of the total dietary fructose load, encouragement of foods with balanced amount of fructose/glucose, 40 months | Seventy-four percent responded positively regarding overall abdominal symptoms. This positive response was better in the adherent group compared to the non-adherent group. |
Ong et al. (2010) Australia [46] | Single-center RCT, IBS patients and HV (n = 30) | Low FODMAP diet vs. high FODMAP diet for 2 days with 7-day wash-out period | Higher levels of breath hydrogen were found in HV and IBS patients on a high FODMAP diet. Patient following the high FODMAP diet had more GI symptoms and lethargy. HV receiving the high FODMAP diet only reported more flatulence. |
Staudacher et al. (2011) UK [59] | Single-center Clinical Observational study, IBS patients (n = 82) | Low FODMAP vs. standard dietary advice for IBS patients (based on the NICE guidelines) | Seventy-six percent of the patients on a low-FODMAP diet were satisfied with their symptom response compared to 54% receiving the standard dietary advice. Eighty-two percent reported improvement in bloating with low-FODMAP vs 49% following the NICE guidelines. For 85% and 87% of patients following the low-FODMAP diet abdominal pain and flatulence improved respectively compared to 61% and 50% on the standard diet. |
Staudacher et al. (2012) Australia [60] | Single-center RCT, IBS patients (n = 41) | Low FODMAP diet vs. habitual diet for 4 weeks | Lower intake of fermentable carbohydrates, and lower proportions/concentrations of bifidobacteria was noted in the intervention group compared to the group following their habitual diet. Sixty-eight percent of the patients in the intervention group reported adequate symptom control compared to 23% of the patients with habitual food intake. |
de Roest et al. (2013) New Zealand [61] | Single-center study, IBS patients (n = 90) | Low FODMAP diet, mean of 15.7 months follow-up | At follow-up, patients reported improvement in abdominal pain, bloating, flatulence and diarrhea. Patients with fructose intolerance experienced an even greater improvement. |
Halmos et al. (2014) Australia [50] | Single-center RCT, cross-over, IBS patients (n = 30) and healthy controls (n = 8) | Low FODMAP vs. typical Australian diet for 21 days with a washout period of at least 21 days | Patients on the low FODMAP diet reported improvement of their global IBS symptoms. Abdominal pain, bloating, and passing flatus were significantly better in the low FODMAP group. In most patients, the greatest improvement in symptoms occurred during the first week. Symptoms were minimal and unaltered by either diet among controls. |
Böhn et al. (2015) Sweden [51] | Multicenter RCT, IBS patients (n = 75) | Low FODMAP diet vs. a traditional IBS diet (based on the NICE guidelines) for 4 weeks | During the intervention, the severity of IBS symptoms was reduced in both groups. At the end of the intervention, 50% of the patients on a low-FODMAP diet had a reduction in IBS severity scores (≥50) compared with baseline vs 46% of the patients following the traditional IBS diet. |
Eswaran et al. (2016) US [53,54] | Single-center RCT, IBS-D patients (n = 92) | Low FODMAP diet vs. a modified diet based on the NICE guidelines (mNICE) for 4 weeks | Fifty-two percent of the low FODMAP vs. 41% of the mNICE group reported adequate relief of their IBS-D symptoms, which was not significant. The low FODMAP diet led to significantly greater improvement in individual IBS symptoms, particularly pain and bloating, and quality of life compared with the mNICE diet. |
Hustoft et al. (2017) Norway [62] | Single-center RCT, IBS-D and IBS-M patients (n = 20) | Low FODMAP diet for 3 weeks & afterwards randomization to a FODMAP supplement or maltodextrin (placebo) for 10 days with a wash-out period of 3 weeks | Patients receiving the placebo compared to the FODMAP supplement reported a significant relief of symptoms, 80% compared to 30% respectively. After following the low FODMAP diet, alterations in inflammatory cytokines, microbiota profile and SCFAs were detected. |
Staudacher et al. (2017) UK [57] | Two-center RCT, IBS patients (n = 104) | Low FODMAP diet vs. sham diet (restriction of similar amount of foods, but maintaining the FODMAP content in the diet) with randomization to a multi-strain probiotics vs. placebo for 4 weeks | The low FODMAP diet was associated with an adequate relief of symptoms and a significant reduction of symptom scores compared to placebo, 57% compared to 38% respectively. Co-administration of the probiotic increased the number of Bifidobacterium species compared to placebo. |
McIntosh et al. (2017) Canada [63] | Single-center RCT, IBS patients (n = 37) | Low FODMAP diet vs. high FODMAP diet for 3 weeks | Patients with a low FODMAP intake had a significant improvement in symptom scores and had changes in their metabolome compared to patient following the high FODMAP diet. FODMAPs modulated the microbiota and histamine levels in a subset of patients. |
Study (Year) Country | Design, Population (n) | Interventions | Main Findings |
---|---|---|---|
Dale et al. (2018) Norway [89] | RDBPC, cross-over trial NCGS patients on a GFD (n = 20) | GFD vs. GCD, 4 challenges (2 gluten, 2 placebo) 4 days per intervention, 3 days washout. (muffins with gluten 11 g/day vs. gluten-free muffins) | No significant differences in symptom severity between gluten and placebo challenges. High symptom scores during all challenges. |
Skodje et al. (2018) Norway [88] | RDBPC, cross-over trial self-reported NCGS patients on GFD >6 months (n = 59) | GFD (placebo) vs. GCD (5.7 g/day) vs. Fructans (2.1 g/day), 1 week per intervention, 1 week washout. (concealed muesli bars). | Significant differences in GI symptoms between all interventions. Fructans: overall GI symptoms and bloating significantly higher than gluten. |
Picarelli et al. (2016) Italy [90] | RDBPC trial, NCGS patients (n = 26) | GFD vs. GCD, 1 day. (croissant with 10 g of gluten vs. gluten-free croissant) | No significant difference in overall symptom severity between gluten and placebo challenge. |
Aziz et al. (2016) UK [91] | Open label, IBS-D patients (n = 41) | GFD, 6 weeks (information and advice GFD by dietician) | Decrease of symptoms in >70% of patients, significant after 2 weeks, similar results in HLA-DQ positive and negative |
Elli et al. (2016) Italy [92] | RDBPC, cross-over trial, IBS patients with NCGS (n = 98) | GFD vs. GCD, 1 week per intervention, 1 week washout (gastro-soluble capsules with 5.6 g/day gluten powder or placebo). Run-in period of 3 weeks GFD. | 14% of patients that responded to gluten withdrawal had symptomatic relapse during gluten challenge. |
Shahbazkhani et al. (2015) Iran [93] | DB RCT, IBS patients (n = 148) | GFD vs. GCD, 6 weeks (packages with 52 g/day gluten powder, or rice starch as placebo). Run-in period of 6 weeks. | Significant improvement in overall symptom severity GFD (83.8%) vs. GCD (25.7%). |
Di Sabatino et al. (2015) Italy [94] | RDBPC, cross-over trial, suspected NCGS patients (n = 61) | GFD vs. GCD, 1 week per intervention, 1 week washout. (gastro-soluble capsules with 4.4 g/day gluten vs. rice starch) | Significant increase in overall symptom severity during gluten compared to placebo. Abdominal bloating, pain and (extra)-intestinal symptoms significantly more severe during gluten-period. |
Peters et al. (2014) Australia [95] | RDBPC, cross-over trial NCGS patients (n = 22) | Gluten (16 g/day) vs. Whey (16 g/day) vs. Placebo, 3 days per intervention, at least 3 days washout. (provided meals with 16 g/day whey protein vs. placebo) | No significant differences in GI symptoms between interventions. Significant more feelings of depression due to short-term exposure to gluten. |
Vazquez-Roque et al. (2013) USA [96] | RCT, IBS-D patients (n = 45) | GFD vs. GCD, 4 weeks (standardized meals provided by metabolic kitchen, with or without gluten) | Significant increase in stool frequency GCD vs. GFD. Greater difference in HLA-DQ positive patients. |
Biesiekierski et al. (2013) Australia [86] | (1) RDBPC, cross-over trial, IBS patients with NCGS (n = 40) (2) Rechallenge, IBS patients with NCGS (n = 22) | (1) High gluten (16 g/day) vs. Low gluten (2 g/day) vs. Whey (16 g/day), 1 week per intervention. (2) Gluten (16 g/day) vs. Whey (16 g/day) vs. Placebo (no additional protein), 3 days. Run-in period of 2 weeks, GFD and low FODMAP diet | Symptom improvement in all patients during run-in period (low FODMAP, gluten-free). Symptom deterioration in all groups, no specific gluten dose response. |
Carroccio et al. (2012) Italy [97] | RDBPC, cross-over trial, suspected NCGS patients (n = 920) | Wheat (20 g/day) vs. Xylose (placebo), 2 weeks per intervention, at least 1 week washout. (gastro-soluble capsules). Elimination diet of 4 weeks prior to challenge. | Symptom improvement of at least 30% in wheat-free period (Salerno experts’ criteria): NCGS diagnosis was confirmed in 30% (n = 276) of subjects. |
Biesiekierski et al. (2011) Australia [98] | RCT, IBS patients (n = 39) | GFD vs. GCD, 6 weeks (Muffin and bread with or without gluten, 16 g/day) | GCD baseline vs. 1 week: significant increase in overall symptom severity, as well as bloating, abdominal pain, tiredness, dissatisfaction with stool. GCD vs. GFD, 6 weeks: significant increase in severity of abdominal pain, tiredness and dissatisfaction with stool. |
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Algera, J.; Colomier, E.; Simrén, M. The Dietary Management of Patients with Irritable Bowel Syndrome: A Narrative Review of the Existing and Emerging Evidence. Nutrients 2019, 11, 2162. https://doi.org/10.3390/nu11092162
Algera J, Colomier E, Simrén M. The Dietary Management of Patients with Irritable Bowel Syndrome: A Narrative Review of the Existing and Emerging Evidence. Nutrients. 2019; 11(9):2162. https://doi.org/10.3390/nu11092162
Chicago/Turabian StyleAlgera, Joost, Esther Colomier, and Magnus Simrén. 2019. "The Dietary Management of Patients with Irritable Bowel Syndrome: A Narrative Review of the Existing and Emerging Evidence" Nutrients 11, no. 9: 2162. https://doi.org/10.3390/nu11092162
APA StyleAlgera, J., Colomier, E., & Simrén, M. (2019). The Dietary Management of Patients with Irritable Bowel Syndrome: A Narrative Review of the Existing and Emerging Evidence. Nutrients, 11(9), 2162. https://doi.org/10.3390/nu11092162