The Impact of a 4-Week Low-FODMAP and mNICE Diet on Nutrient Intake in a Sample of US Adults with Irritable Bowel Syndrome with Diarrhea

doi:10.1016/j.jand.2019.03.003

Journal of the Academy of Nutrition and Dietetics

Volume 120, Issue 4, April 2020, Pages 641-649

https://doi.org/10.1016/j.jand.2019.03.003 Get rights and content

Abstract

Background

A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) has gained increasing acceptance for the treatment of irritable bowel syndrome but safety concerns have been raised regarding nutritional adequacy. Changes in nutrient intake during the elimination phase of the low-FODMAP diet remain predominantly unknown.

Objective

To determine changes in the mean reported daily nutrient content before and after 4 weeks of a low-FODMAP diet vs modified National Institute for Health and Clinical Excellence (mNICE) dietary intervention and to identify nutritional inadequacies based on comparison to the Dietary Reference Intakes in patients with irritable bowel syndrome-diarrhea subtype.

Design

Post hoc analysis of a randomized controlled trial entailing a 4-week trial period comparing the low-FODMAP and mNICE diets.

Participants and setting

A total of 78 patients (41 low FODMAP and 37 mNICE) meeting the Rome III criteria for irritable bowel syndrome-diarrhea subtype were consecutively recruited from gastroenterology and primary care clinics at the University of Michigan Medical Center between October 2012 and November 2015.

Methods

Participants randomized to the low-FODMAP arm were instructed to decrease their dietary intake of FODMAPs, whereas participants randomized to the mNICE intervention arm were instructed to eat small frequent meals, avoid trigger foods, and avoid excess alcohol and caffeine.

Main outcome measures

Post hoc evaluation for presence of micronutrient deficiencies per Dietary Reference Intakes when implementing low-FODMAP vs mNICE dietary interventions. Dietary intake was analyzed via 3-day food diaries at baseline and during the final week of the assigned diet.

Statistical analyses performed

A post hoc analysis utilizing either a t test or χ² analysis was conducted between before and after data.

Results

Both diets resulted in fewer daily kilocalories consumed, fewer number of daily meals consumed, and less daily carbohydrate intake. Among the patients following the low-FODMAP diet, there was a statistically significant decrease from baseline in several micronutrients, which was not observed in the mNICE cohort. However, these differences in the low-FODMAP group remained significant only for riboflavin after correcting for calorie-adjusted nutrient intake. Comparing Dietary Reference Intakes of participants pre- and postintervention, fewer patients met the Dietary Reference Intakes for thiamin and iron in the low FODMAP group, and for calcium and copper in the mNICE group.

Conclusions

During a 4-week dietary intervention, the mean daily intake of most micronutrients remained stable and within the Recommended Dietary Allowances for both diets. Although decrease in several micronutrients was observed with implementation of the low-FODMAP diet relative to the mNICE diet, most of these disappeared after adjusting for energy intake.

Section snippets

Methods

Data were collected as part of a single-center, randomized controlled trial, comparing the clinical outcomes of a low-FODMAP diet and a diet based on modified NICE guidelines (mNICE)²³ in IBS patients with diarrhea (IBS-D). The clinical results of the trial have been previously published.¹⁹ In this article, results are reported from a post hoc analysis assessing nutrient intake before and after the low-FODMAP and mNICE dietary interventions. Of 171 participants enrolled and screened between

Results

Of 78 patients who completed the study (41 in the low-FODMAP group, 37 in the mNICE group), demographic characteristics and baseline dietary intake were similar between groups, except that there were more obese patients in the mNICE group (Table 1). The mean baseline energy, nutrient, and FODMAP intake were similar between groups, but by the end of the study period, statistically significant differences were observed in nutrient intake both within and between the two groups as previously

Discussion

Although most high-quality trials examining the low-FODMAP diet in IBS include rigorous dietary analysis, few trials have reported the intake of nutrients during this dietary intervention. In this post hoc analysis of nutrient intake for participants randomized to a low-FODMAP diet, the mean daily intake of most nutrients remained stable (Table 2). Although the low-FODMAP diet is not intended to be a maintenance diet, concerns about the influence of FODMAP restriction on nutritional adequacy

Conclusions

During a 4-week dietary intervention comparing the low-FODMAP and mNICE diets, a decrease in mean intake of several micronutrients was observed with implementation of the low-FODMAP diet, although these reductions (other than for riboflavin) did not remain following adjustment for energy intake. These findings suggest that for a short-term elimination diet, the low-FODMAP diet is not associated with major micronutrient inadequacies. Subsequent studies will be required to better understand the

Acknowledgements

The authors thank Theresa Han-Markey, RD.

Author Contributions

S. Eswaran was a principal investigator, and was responsible for study design, acquisition of data, analysis and interpretation of data, drafting of manuscript, statistical analysis, obtaining the funding. R. D. Dolan and S. C. Ball were responsible for interpretation of data and drafting the manuscript. K. Jackson was responsible for statistical analysis. W. Chey was a principal investigator and was responsible for study concept and design, analysis and

S. Eswaran is an associate professor in gastroenterology, Division of Gastroenterology, University of Michigan Medicine, Ann Arbor.

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Systematic review and meta-analysis of habitual intake of fermentable oligo-, di-, mono- saccharides and polyols in the general population and revisiting the low FODMAP diet concept
2024, Journal of Functional Foods
The present systematic review and meta-analysis summarized data on habitual intake of oligo-, di-, mono-saccharides and polyols from 71 studies (n = 138,653 subjects) using random-effects model. In the general population, overall habitual intake of total FODMAPs is 19.86 (95 % CI: 18.12, 21.6) g/d. No differences were observed on habitual intake of individual constituents of designated FODMAPs between healthy and those who are suffering with functional gastrointestinal disease and other GI disorders. Multiple meta-regression adjusted with macronutrient components showed that IBS-SSS score is positively correlated with lactose (R² = 77.78 %, P = 0.006) and total FODMAPs (R² = 78.48 %, P = 0.0052), but not other individual constituents of designated FODMAPs e.g. fructans, GOS, and total polyols. Macronutrient components such as fat (in 6 out of 6 models) and carbohydrate (in 5 out of 6 models) were positively associated with IBS-SSS score. Our findings add insight on current knowledge of FODMAPs habitual intake in the general population and showed that individual FODMAPs such as lactose and other macronutrient components (fat and carbohydrate) as a constituent significantly related to symptom severity.
AGA Clinical Practice Update on the Role of Diet in Irritable Bowel Syndrome: Expert Review
2022, Gastroenterology
Irritable bowel syndrome (IBS) is a commonly diagnosed gastrointestinal disorder that can have a substantial impact on quality of life. Most patients with IBS associate their gastrointestinal symptoms with eating food. Mounting evidence supports dietary modifications, such as the low–fermentable oligo-, di-, and monosaccharides and polyols (FODMAP) diet, as a primary treatment for IBS symptoms. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the role of diet in IBS treatment.
This expert review was commissioned and approved by the AGA CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet in treating patients with IBS. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed.
Best Practice Advice Statements
Dietary advice is ideally prescribed to patients with IBS who have insight into their meal-related gastrointestinal symptoms and are motivated to make the necessary changes. To optimize the quality of teaching and clinical response, referral to a registered dietitian nutritionist (RDN) should be made to patients who are willing to collaborate with a RDN and patients who are not able to implement beneficial dietary changes on their own. If a gastrointestinal RDN is not available, other resources can assist with implementation of diet interventions.
Patients with IBS who are poor candidates for restrictive diet interventions include those consuming few culprit foods, those at risk for malnutrition, those who are food insecure, and those with an eating disorder or uncontrolled psychiatric disorder. Routine screening for disordered eating or eating disorders by careful dietary history is critical because they are common and often overlooked in gastrointestinal conditions.
Specific diet interventions should be attempted for a predetermined length of time. If there is no clinical response, the diet intervention should be abandoned for another treatment alternative, for example, a different diet, medication, or other form of therapy.
In preparation for a visit with a RDN, patients should provide dietary information that will assist in developing an individualized nutrition care plan.
Soluble fiber is efficacious in treating global symptoms of IBS.
The low-FODMAP diet is currently the most evidence-based diet intervention for IBS. Healthy eating advice as described by the National Institute of Health and Care Excellence Guidelines, among others, also offers benefit to a subset of patients with IBS.
The low-FODMAP diet consists of the following 3 phases: 1) restriction (lasting no more than 4–6 weeks), 2) reintroduction of FODMAP foods, and 3) personalization based on results from reintroduction.
Although observational studies found that most patients with IBS improve with a gluten-free diet, randomized controlled trials have yielded mixed results.
There are limited data showing that selected biomarkers can predict response to diet interventions in patients with IBS, but there is insufficient evidence to support their routine use in clinical practice.
The low FODMAP diet for IBS; A multicentre UK study assessing long term follow up
2021, Digestive and Liver Disease
Citation Excerpt :
However, it is important to note that individuals on the pLFD had a similar nutritional intake to those on a habitual diet at long term follow up, which highlights that this may be a result of dietary behaviours in IBS as a whole, rather than the LFD itself. This has been previously shown, with many individuals with IBS having been shown to fail to meet DRVs [29,30]. Whilst a validated food frequency questionnaire was used to assess nutritional and FODMAP intake, and currently the most validated tool available, potential limitations remain, including potential underreporting of total energy intakes using food frequency questionnaires [39].
The low FODMAP diet (LFD) is effective in managing irritable bowel syndrome (IBS) in the short term. This study assessed the long-term effect of the LFD on symptoms, nutritional composition and socialising.
Patients with IBS who received dietetic-led LFD advice were approached at long term follow up (>6 months post LFD advice) from six centres across the United Kingdom. Participants completed questionnaires assessing gastrointestinal symptoms, adherence, nutritional intake, dietary acceptability and food related quality of life (QOL).
205 participants completed the study, with a mean follow up of 44 months (3.7 years). Adequate symptom relief was noted in 60% of individuals at long term follow up, with 76% being on the personalisation phase of the LFD (pLFD). Mean nutritional intake did not differ between individuals on the pLFD versus habitual diet, with no difference in fructan intake (2.9 g/d vs 2.9 g/d, p = 0.96). The majority (80%) of individuals on the pLFD consumed specific ‘free-from’ products at the long term, with the purchase of gluten or wheat free products being the commonest (68%).
The majority of patients follow the pLFD in the long term, with a large proportion purchasing gluten or wheat free products to manage their symptoms.
Irritable Bowel Syndrome: Food as a Friend or Foe?
2021, Gastroenterology Clinics of North America
Citation Excerpt :
Questions of nutritional adequacy also have been raised, with some studies reporting a decrease in calcium and fiber intake during the elimination phase. After correcting for calorie-adjusted nutrient intake, however, this decrease was not found to be significant.52 It should be emphasized that the elimination phase is not meant to extend longer than 4 weeks to 6 weeks, thus any detrimental change to the microbiome or nutritional intake should be transient.
Update on the FODMAPs-less diet: What place in the treatment of intestinal functional disorders?
2021, Revue Francaise d'Allergologie
Les FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) sont des sucres ayant la caractéristique commune d’être peu absorbés par l’intestin grêle, hautement fermentescibles et abondants dans l’alimentation occidentale. Leur éviction (régime sans FODMAPs, RSF) pourrait, en théorie, représenter une opportunité pour réduire les symptômes des patients(es) souffrant de troubles fonctionnels intestinaux (TFI), une pathologie pour laquelle il existe pour l’heure peu de thérapeutiques efficaces et où l’alimentation joue un rôle prépondérant dans l’apparition des symptômes. Les méta-analyses récentes sont contradictoires au sujet de l’efficacité du RSF pour la prise en charge des TFI : ce régime semble apporter un confort digestif aux patients(es) mais avec un faible niveau de preuve et au prix d’effets indésirables sur lesquels il manque de recul (modifications du microbiote digestif, carences nutritionnelles et en fibres). Il n’est pas non plus prouvé que ce régime soit plus efficace que les recommandations diététiques classiques actuellement prodiguées à ces patients(es). L’hétérogénéité des études rend difficile leur généralisation. Pour l’heure, ce régime n’est pas recommandé en première intention. Il peut s’envisager au cas par cas et en cas d’échec des mesures diététiques classiques. Un suivi diététique global est nécessaire, car il s’agit d’un régime d’exclusion large, à risque de carences et de dérives vers des troubles du comportement alimentaire. De plus amples travaux semblent nécessaires pour cibler et mieux définir le ou les profils des patients(es) qui pourraient être répondeurs à ce type de régime.
FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are short chain carbohydrates that are poorly absorbed in the small intestine, highly fermentable and abundant in the Western diet. A low FODMAP diet (LFD) could, in theory, be an opportunity to reduce the symptoms of patients suffering from irritable bowel symptoms (IBS), a pathology for which there are currently few effective therapeutics and where food is a major trigger. Recent meta-analyses are contradictory about the effectiveness of LFD in the management of IBS: this diet seems to improve digestive comfort but with a low level of evidence and at the cost of undesirable effects on which there is a lack of perspective (disruption in the intestinal microbiome, nutritional and fiber deficiencies). There is also no evidence that this diet is more effective than the conventional dietary recommendations currently provided to these patients. The heterogeneity of the studies makes their wider application difficult. For the time being, LFD is not recommended as a first line. It can be considered on a case-by-case basis and in the event of failure of conventional dietetic measures. Dietary and comprehensive monitoring is necessary because it is a wide exclusion diet, at risk of deficiencies and drifts towards eating disorders. More work seems necessary to target and better define the patient profile(s) who could possibly be responders to this diet.
Conference on Diet and digestive disease Symposium 1: Nutrition, inflammation and pathobiology: Challenges of the low FODMAP diet for managing irritable bowel syndrome and approaches to their minimisation and mitigation
2021, Proceedings of the Nutrition Society

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S. Eswaran is an associate professor in gastroenterology, Division of Gastroenterology, University of Michigan Medicine, Ann Arbor.

R. D. Dolan is a resident in internal medicine, Division of Gastroenterology, University of Michigan Medicine, Ann Arbor.

K. Jackson is a statistician and study coordinator, Division of Gastroenterology, University of Michigan Medicine, Ann Arbor.

W. Chey is a professor in gastroenterology, Division of Gastroenterology, University of Michigan Medicine, Ann Arbor.

S. C. Ball is a trained dietitian nutritionist, Nutrition Obesity Research Center, University of Michigan Medicine, Ann Arbor.

: STATEMENT OF POTENTIAL CONFLICT OF INTEREST W. Chey is a consultant and has received grant funding from Nestlé S.A., Sweden. No potential conflict of interest was reported by the other authors.

: FUNDING/SUPPORT Research reported in this article was supported by a Michigan Nutrition Obesity Research Center Grant (P30 DK089503), a Clinical and Translational Science Award Grant (2UL1TR000433-06), as well as Prometheus Therapeutics and Diagnostics (San Diego, CA).

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ResearchOriginal Research: BriefThe Impact of a 4-Week Low-FODMAP and mNICE Diet on Nutrient Intake in a Sample of US Adults with Irritable Bowel Syndrome with Diarrhea

Abstract

Background

Objective

Design

Participants and setting

Methods

Main outcome measures

Statistical analyses performed

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgements

Author Contributions

Gastroenterology

Clin Ther

Am J Gastroenterol

Am J Gastroenterol

Gastroenterol Clin North Am

J Nutr

Gastroenterology

Clin Nutr

Gastroenterology

J Nutr

J Am Diet Assoc

Functional gastrointestinal disorders: History, pathophysiology, clinical features and Rome IV [published online ahead of print February 19, 2016]

Gastroenterology

Association between constipation and colorectal cancer: Systematic review and meta-analysis of observational studies

Am J Gastroenterol

Health-related quality of life among persons with irritable bowel syndrome: A systematic review

Aliment Pharmacol Ther

The burden of IBS: Looking at metrics

Curr Gastroenterol Rep

The burden of illness of irritable bowel syndrome: Current challenges and hope for the future

J Manage Care Pharm

Food-related gastrointestinal symptoms in the irritable bowel syndrome

Digestion

Pain is temporally related to eating but not to defaecation in the irritable bowel syndrome (IBS). Patients' description of diarrhea, constipation and symptom variation during a prospective 6-week study

Eur J Gastroenterol Hepatol

Perceived food intolerance in subjects with irritable bowel syndrome: Etiology, prevalence and consequences

Eur J Clin Nutr

What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ)

Am J Gastroenterol

Research
Original Research: Brief
The Impact of a 4-Week Low-FODMAP and mNICE Diet on Nutrient Intake in a Sample of US Adults with Irritable Bowel Syndrome with Diarrhea