Efficacy and Findings of a Blinded Randomized Reintroduction Phase for the Low FODMAP Diet in Irritable Bowel Syndrome.

BACKGROUND & AIMS: The efficacy of a low fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet in irritable bowel syndrome (IBS) is well established. After the elimination period, a reintroduction phase aims to identify triggers. We studied the impact of a blinded reintroduction using FODMAP powders to objectively identify triggers and evaluated the effect on symptoms, quality of life, and psychosocial comorbidities. METHODS: Responders to a 6-week low FODMAP diet, defined by a drop in IBS symptom severity score (IBS-SSS) compared with baseline, entered a 9-week blinded randomized reintroduction phase with 6 FODMAP powders (fructans, fructose, galacto-oligosaccharides, lactose, mannitol, sorbitol) or control (glucose). A rise in IBS-SSS (≥50 points) defined a FODMAP trigger. Patients completed daily symptom diaries and questionnaires for quality of life and psychosocial comorbidities. RESULTS: In 117 recruited patients with IBS, IBS-SSS improved significantly after the elimination period compared with baseline (150 ± 116 vs 301 ± 97, P < .0001, 80% responders). Symptom recurrence was triggered in 85% of the FODMAP powders, by an average of 2.5 ± 2 FODMAPs/patient. The most prevalent triggers were fructans (56%) and mannitol (54%), followed by galacto-oligosaccharides, lactose, fructose, sorbitol, and glucose (respectively 35%, 28%, 27%, 23%, and 26%) with a significant increase in abdominal pain at day 1 for sorbitol/mannitol, day 2 for fructans/galacto-oligosaccharides, and day 3 for lactose. CONCLUSION: We confirmed the significant benefit of the low FODMAP diet in tertiary-care IBS. A blinded reintroduction revealed a personalized pattern of symptom recurrence, with fructans and mannitol as the most prevalent, and allows the most objective identification of individual FODMAP triggers. Ethical commission University hospital of Leuven reference number: s63629; Clinicaltrials.gov number: NCT04373304.

Patients' experiences of dietary changes during a structured dietary intervention for irritable bowel syndrome.

BACKGROUND: Diet plays an important role in management of gastrointestinal (GI) symptoms in patients with irritable bowel syndrome (IBS). Restrictive diets have gained popularity as treatment for IBS, but no studies have examined the patients' experiences of implementing such diets. Thus, the present study aimed to explore the experience of patients with IBS undergoing a structured dietary intervention. METHODS: Using inductive content analysis, semi-structured interviews were conducted in 19 patients with IBS, who were recruited from a randomised controlled trial evaluating two different restrictive diets for 4 weeks: a diet low in total carbohydrates; and a diet low in fermentable oligo-, di- and monosaccharides and polyols (i.e., FODMAP) combined with traditional IBS dietary advice. RESULTS: Three main themes developed from the qualitative analysis and together they describe the dietary intervention as supportive, as well as the dietary changes as challenging and contributing to reflection. Patients found the dietary support effective in both initiating and adhering to their dietary changes. Despite the support, the implementation of the diet was perceived as challenging when it interfered with other important aspects of their lives. However, going through the dietary change process, the patients began to reflect on their eating behaviours, which enabled individual dietary adjustments. The adjustments that patients maintained were not only a result of alleviation of GI symptoms, but also based on personal preferences. CONCLUSIONS: Patients with IBS undergoing restrictive diets appear to benefit from structured support. However, considering the individual patient's life situation and personal preferences, individualised dietary options should be encouraged to achieve long-term dietary changes.

[Gastrointestinal symptoms and dietary intake of patients with irritable bowel syndrome following a low FODMAP diet].

INTRODUCTION: High FODMAP (fermentable oligo-, di, monosaccharides and polyols) foods have been linked with worsening symptoms of IBS patients. The aim was to compare gastrointestinal symptoms and dietary intake of patients with irritable bowel syndrome following a low FODMAP diet, with or without individual nutrition therapy. MATERIALS AND METHODS: A total of 54 patients that met Rome IV criteria for IBS were randomized into two groups, guided group (individual nutrition therapy, n=28) and self-management group (learned about low FODMAP diet online, n=26). Both groups followed low FODMAP diet for 4 weeks. Four-day food records were used to assess dietary intake. Symptoms were assessed by the IBS-severity scoring system (ISB-SSS). RESULTS: The number of subjects who did not complete the study was 13, thereof five in the nutrition therapy and eight in the self-management group, leaving 23 and 18 subjects available for analysis, respectively. Symptoms declined from baseline to endpoint in both groups, by 183±101 points on average in the group receiving nutrition therapy (p< 0.001) and 132±110 points in the self-management group (p< 0.001), with no difference between groups. At baseline, about 80% of meals in both groups contained food high in FODMAP's. The corresponding proportion was 9% and 36% in week 3 in the nutrition therapy and self-management group, respectively (p< 0.001). CONCLUSION: Both groups experienced relieve of symptoms, but compliance to the low FODMAP diet was better in the group receiving individual nutrition therapy compared with the group who only received instructions on how to learn about low FODMAP diet online.

Development and Validation of Test for "Leaky Gut" Small Intestinal and Colonic Permeability Using Sugars in Healthy Adults.

BACKGROUND: Oral monosaccharides and disaccharides are used to measure in vivo human gut permeability through urinary excretion. AIMS: The aims were as follows: (1) to obtain normative data on small intestinal and colonic permeability; (2) to assess variance on standard 16 g fiber diet performed twice; (3) to determine whether dietary fiber influences gut permeability measurements; and (4) to present pilot data using 2 selected probes in patients with diarrhea-predominant irritable bowel syndrome (IBS-D). METHODS: Sixty healthy female and male adults, age 18-70 years, participated in 3 randomized studies (2 studies on 16.25 g and 1 study on 32.5 g fiber) in otherwise standardized diets. At each test, the following sugars were ingested: 12C-mannitol, 13C-mannitol, rhamnose (monosaccharides), sucralose, and lactulose (disaccharides). Standardized meals were administered from 24 hours before and during 24 hours post-sugars with 3 urine collections: 0-2, 2-8, and 8-24 hours. Sugars were measured using high-performance liquid chromatography-tandem mass spectrometry. Eighteen patients with IBS-D underwent 24-hour excretion studies after oral 13C-mannitol and lactulose. RESULTS: Baseline sugars (>3-fold above lower limits of quantitation) were identified in the 3 studies: 12C-mannitol in all participants; sucralose in 4-8, and rhamnose in 1-3. Median excretions/24 h (percentage of administered dose) for 13C-mannitol, rhamnose, lactulose, and sucralose were ∼30%, ∼15%, 0.32%, and 2.3%, respectively. 13C-mannitol and rhamnose reflected mainly small intestinal permeability. Intraindividual saccharide excretions were consistent, with minor differences with 16.25 g vs 32.5 g fiber diets. Median interindividual coefficient of variation was 76.5% (10-90 percentile: 34.6-111.0). There were no significant effects of sex, age, or body mass index on permeability measurements in health. 13C-mannitol measurements are feasible in IBS-D. CONCLUSIONS: Baseline 12C-mannitol excretion precludes its use; 13C-mannitol is the preferred probe for small intestinal permeability.

Low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet versus traditional dietary advice for functional dyspepsia: a randomized controlled trial.

BACKGROUND AND AIM: Prospective trials evaluating efficacy of specific diet restriction in functional dyspepsia (FD) are scarce. We aimed to assess efficacy of low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet in FD, compared with traditional dietary advice (TDA). METHODS: In this prospective, single-blind trial, patients with FD (Rome IV) were randomized into low FODMAP diet (LFD) and TDA groups, for 4 weeks (phase I). In phase II (4-12 weeks), LFD group was advised systematic re-introduction of FODMAPs. Symptom severity and quality of life were assessed using "Short-Form Nepean Dyspepsia Index (SF-NDI)." Primary outcome was symptomatic response (symptom score reduction of ≥ 50%), at 4 weeks. Study was registered with CTRI (2019/06/019852). RESULTS: Of 184 patients screened, 105 were randomized to LFD (n = 54) and TDA (n = 51) groups. At 4 weeks, both groups showed significant reduction in SF-NDI symptom scores compared with baseline, with no significant difference in inter-group response rates [LFD: 66.7% (36/54); TDA: 56.9% (29/51); P = 0.32]. On sub-group analysis, patients with postprandial distress syndrome or bloating had significantly better symptomatic response with LFD (P = 0.04). SF-NDI quality of life scores improved significantly in both groups. On multivariate analysis, factors predicting response to LFD were bloating and male gender. Incidences of adverse events (minor) were similar in both groups. CONCLUSIONS: In patients with FD, LFD and TDA lead to significant symptomatic and quality of life improvement. Patients with postprandial distress syndrome or bloating respond significantly better to LFD. Therefore, dietary advice for FD should be individualized according to FD subtype.

Method Development and Validation for Simultaneous Determination of Six Flavonoids in Rat Eyes after Oral Administration of Diospyros kaki Leaves Extract by UPLC-MS/MS.

A robust ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) technique was proven effective for simultaneous characterization of six flavonoids including quercetin-3-O-beta-galactoside (Q3GAL), quercetin-3-O-beta-glucoside (Q3GLU), quercetin-3-(2-galloylglucoside) (Q3GG), kaempferol-3-O-beta-galactoside (K3GAL), kaempferol-3-O-beta-glucoside (K3GLU), and kaempferol-3-(2-galloylglucoside) (K3GG) in rat eyes. By investigation of corresponding validation parameters (linearity, selectivity, precision, accuracy, matrix effect, extraction recovery, and stability), the method was verified to be within current acceptable criteria. Thereafter, the validated method enabled quantification of the six compounds successful in rat eyes after oral administration of ethanol extract Diospyros kaki (EEDK) at 0, 3, 15, 35, 60, 120 min.

FODMAP intake in children with coeliac disease influences diet quality and health-related quality of life and has no impact on gastrointestinal symptoms.

Children with coeliac disease (CD) following the gluten-free diet may experience ongoing gastrointestinal symptoms despite strict adherence. The study objective was to evaluate the association between foods high in fermentable oligo/di/monosaccharides, and polyols (FODMAP) and gastrointestinal symptoms, and the potential implications to diet quality and health-related quality of life in CD children. Dietary intake was studied in age-sex matched children 5-18 years (CD, n = 46; non-coeliac mild chronic gastrointestinal complaints [GIC], n = 46; healthy controls [HC], n = 46). CD children consumed fewer foods high in FODMAPs compared to GIC and HC (p < .0001). FODMAP intake was not related to gastrointestinal symptoms in CD children (p > 0.05) but was positively associated with child health-related quality of life (p < 0.05). FODMAP intake from fruits and vegetables was positively associated with diet adequacy and total diet quality in CD children (p < 0.05). FODMAP intake may influence diet quality and health-related quality of life but has no impact on gastrointestinal symptoms in CD children.

Role of Mono- and Disaccharide Combination in Cryoprotective Medium for Rooster Semen to Ensure Cryoresistance of Spermatozoa.

The combination of saccharides in the composition of a cryopreservation medium may represent a promising method for the preservation of the reproductive cells of male birds. In the current study, cryoprotective media with a combined composition of mono- and di-saccharides were developed. The degree of penetration of reducing saccharide molecules (maltose-Mal20 medium) and non-reducing disaccharide molecules (trehalose-Treh20 medium) from the cryoprotective medium into the cytosol of rooster spermatozoa was studied. LCM control media without disaccharides were used as the control. The number of maltose molecules penetrating from the outside into the cytosol of the spermatozoon was 1.06 × 104, and the number of trehalose molecules was 3.98 × 104. Using a combination of maltose and fructose, the progressive motility of frozen/thawed semen and the fertility rates of eggs were significantly higher ((p < 0.05) 40.2% and 68.5%, respectively) than when using a combination of trehalose and fructose in a cryoprotective diluent (33.4% and 62.4%, respectively). A higher rate of chromatin integrity at the level of 92.4% was obtained when using Treh20 versus 74.5% Mal20 (p < 0.05). Maltose positively affected the preservation of frozen/thawed sperm in the genital tract of hens. On the seventh day from the last insemination when using Mal20, the fertilization of eggs was 42.6% and only 27.3% when using Treh20. Despite the same molecular weight, maltose and trehalose have different physicochemical and biological properties that determine their function and effectiveness as components of cryoprotective media.

The gut microbiome as a predictor of low fermentable oligosaccharides disaccharides monosaccharides and polyols diet efficacy in functional bowel disorders.

PURPOSE OF REVIEW: Fermentable oligosaccharides disaccharides monosaccharides and polyols (FODMAP) dietary restriction ameliorates irritable bowel syndrome (IBS) symptoms; however, not all individuals with IBS respond. Given the gut microbiome's role in carbohydrate fermentation, investigators have evaluated whether the gut microbiome may predict low FODMAP diet efficacy. RECENT FINDINGS: Gut microbiome fermentation, even to the same carbohydrate, is not uniform across all individuals with several factors (e.g. composition) playing a role. In both children and adults with IBS, studies are emerging suggesting the gut microbiome may predict low FODMAP diet efficacy. However, there is significant heterogeneity in the approaches (study population, microbiome assessment methods, statistical techniques, etc.) used amongst these studies. SUMMARY: The gut microbiome holds promise as a predictor of low FODMAP diet efficacy. However, further investigation using standardized approaches to evaluate the microbiome while concomitantly assessing other potential predictors are needed to more rigorously evaluate this area.

Tolerability of FODMAP - reduced diet in irritable bowel syndrome - efficacy, adherence, and body weight course.

BACKGROUND: FODMAP reduced diet (fermentable oligo-, di-, monosaccharide, and polyols) belongs to the established therapy strategies in irritable bowel syndrome (IBS). However, disadvantages of this diet are significant and may lead to weight loss and insufficient patient adherence. Reports from Germany are not available yet. MATERIAL AND METHODS: In a prospective study, 93 patients with IBS according to Rom III were investigated. Sixty-three patients were recruited for the study and received standardized investigation, informed consent, and structured dietary instructions about the FODMAP reduced diet. Patients complaints were documented by a validated questionnaire and a standardized Lickert scale before and 8 weeks after the start of the diet. Stool characteristics were documented by the Bristol stool form scale. RESULTS: Patients adherence was low because 30 patients (47 %) stopped the diet. Of the remaining 33 patients, 36 % (n = 12) developed significant weight loss during the FODMAP therapy. Patients completing the study reported significant global improvement of symptoms in 79 % of cases (abdominal pain 85 %, meteorism 79 %, flatulence 69 %, borbogymi 69 %, nausea 46 %, fatigue 69 %). In addition, the severity of symptoms was significantly reduced. Fourteen patients developed changes of their stool characteristics according to the Bristol stool form scale, 11 of whom improved diarrhea and 3 improved constipation. CONCLUSION: FODMAP reduced diet is an efficient therapy in IBS. However, adherence of the patients is poor and the therapy bears the risk of significant weight loss.

Nonpharmacologic options for treating irritable bowel syndrome.

Irritable bowel syndrome (IBS) is a chronic functional disorder with no organic cause. Risk factors are multifactorial and treatment typically consists of antimotility or stimulant laxatives and antidepressants. This article reviews several newer areas of interest: probiotics, fecal microbiota transplant, a low FODMAP diet, and cognitive behavioral therapy.

Dietary practices and FODMAPs in South Asia: Applicability of the low FODMAP diet to patients with irritable bowel syndrome.

The low Fermentable Oligosaccharides, Disaccharides, and Monosaccharides And Polyols (FODMAP) diet has been described, evaluated, and found efficacious for the treatment of patients with irritable bowel syndrome primarily in Western countries. The aim of this review was to address the applicability of this diet to South Asia. The high prevalence of irritable bowel syndrome in South Asia and its associated effects of quality of life and economics warrant the introduction of efficacious therapies. The considerable heterogeneity of dietary patterns and methods of food preparation across South Asian countries and a paucity of food analysis limit precision in defining foods that are high or low in FODMAPs. Spices and condiments are commonly consumed and mostly have a low FODMAP content. However, major high FODMAP sources are frequently used and include onion, garlic, shallots, legumes/pulses, and wheat-based products, as well as coconut and milk products, offering an opportunity for dietary management to reduce the symptom load. The feasibility of instituting a restrictive diet in which foods with a high FODMAP content are replaced by foods low in FODMAPs must be addressed as a substantial proportion of the nutritional intake including energy, proteins, and micronutrients, is often obtained from FODMAP-rich food. Furthermore, limited knowledge of health professionals together with a paucity of dietitians further challenge the practicality of introducing the diet. Thus, while the use of the low FODMAP diet in South Asia may be more limited than in westernized countries, it does offer potential therapeutic opportunities, the efficacy, and impact of which require further investigation.

Low fermentable oligo-di-mono-saccharides and polyols diet versus general dietary advice in patients with diarrhea-predominant irritable bowel syndrome: A randomized controlled trial.

BACKGROUND AND AIM: Recent evidence indicates that new approach of the diet with low fermentable oligo-di-mono-saccharides and polyols (FODMAPs) may have an effective role in management of the patients with irritable bowel syndrome (IBS). We compared the results of low FODMAP diet with current dietary treatment, general dietary advices (GDA), on the clinical response in patients with diarrhea subtype of IBS (IBS-D). METHODS: In this randomized, controlled, single-blind trial, we included 110 patients with IBS-D in two intervention groups. Participants were randomly assigned to the low FODMAP diet (n = 55) and GDA (n = 55) for 6 weeks after a 10-day screening period. Gastrointestinal symptoms and bowel habit status were evaluated using a symptom severity scoring system and Bristol stool form scale pre-intervention and post-intervention. Patients completed 3-day food diary before and after the intervention. RESULTS: Of 110 patients, 101 completed the dietary interventions. At the baseline, the nutrient intake, severity of symptoms, and demographic data were similar between two groups. After 6 weeks, the low FODMAP diet improves significantly overall gastrointestinal symptoms scores, stool frequency, and consistency versus GDA group (P < 0.001, P < 0.001, and P = 0.003, respectively). Compared with the baseline, both intervention groups expressed a significant reduction in overall scores of symptom severity scoring system, abdominal pain, distension, consistency, and frequency, but this reduction is greater in low FODMAP diet group. CONCLUSIONS: Both low FODMAP diet and GDA in patients with IBS-D led to adequate improvement of gastrointestinal symptoms for 6 weeks. However, the low FODMAP diet has greater benefits in IBS improvement.

Exploring Gut Microbiota Composition as an Indicator of Clinical Response to Dietary FODMAP Restriction in Patients with Irritable Bowel Syndrome.

BACKGROUND: A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) may relieve symptoms of irritable bowel syndrome (IBS). However, nutritional counseling is resource-demanding and not all patients will benefit. AIMS: To explore whether gut microbial composition may identify symptom response to a low-FODMAP diet in patients with IBS. METHODS: Patients were recruited consecutively to participate in a 4-week FODMAP-restricted diet. Response to diet was defined as ≥ 50% decrease in IBS symptom severity scores (IBS-SSS) compared to baseline. Fecal microbiota were analyzed by a commercially available method (the GA-map™ Dysbiosis Test), assessing 54 bacterial markers targeting more than 300 bacteria at different taxonomic levels. RESULTS: Sixty-one patients (54 F; 7 M) were included: 32 (29 F; 3 M) classified as responders and 29 (25 F; 4 M) as non-responders. Ten of the 54 bacterial markers differed significantly between responders and non-responders. Based on median values (used as cutoff) of responders for these 10 bacterial markers, we constructed a Response Index (RI): Each patient was given a point when the value for each selected bacterial marker differed from the cutoff. These points were summed up, giving an RI from 0 to 10. Patients with RI > 3 were 5 times more likely to respond (OR = 5.05, 95% CI [1.58; 16.10]), and the probability to respond was 83.4%, 95% CI [61.2-94%]. CONCLUSIONS: Gut microbial composition, assessed by using a new RI, may constitute a tool to identify patients that are likely to respond to dietary FODMAP restriction.

High-monosaccharide intake inhibits anorexigenic hypothalamic insulin response in male rats.

OBJECTIVE: The aim of this research is to evaluate if intake of 20% fructose solution is able to change the anorexigenic hypothalamic insulin action. METHODS: Thirty day-old male Wistar rats were randomly assigned to one of the following groups: standard chow and water for the rats (Control group, C) and standard chow and 20% fructose solution for the rats (Fructose group, F).These treatments lasted 8 weeks. Three-month-old rats from group C and F received insulin or saline intracerebroventricular injections for evaluation of 24 h food intake, phosphorylated forms of the IR (p-IR) and Akt (p-Akt) proteins and quantified hypothalamic insulin receptor (IR) and insulin receptor substrate 1 (IRS-1) proteins. RESULTS: Insulin injection was able to decrease food intake in group C compared to 0.9% saline. However, insulin infusion failed to inhibit 24 h food intake in group F compared to 0.9% saline. The hypothalamic content of the IRS-1 was 37% higher in group F as well as p-Akt protein was significant higher vs. group C. CONCLUSION: We concluded that the 20% fructose solution compromised insulin signaling considering that it inhibited the anorexigenic hypothalamic response to acute injection of this hormone and increase of IRS-1 and p-Akt content.

Irritable bowel syndrome and diet: where are we in 2018?

PURPOSE OF REVIEW: The aim is to review the most recent advances in the evidence supporting the use of various dietary interventions for the management of irritable bowel syndrome (IBS). RECENT FINDINGS: There is insufficient evidence of the effect of fibres other than psyllium in IBS, whereas the recent studies on prebiotics suggest a limited effect in IBS. Recent probiotic trials continue to provide varying results, with some probiotic strains exhibiting beneficial effects, whereas others show no effect. Recent trials have also confirmed the clinical effectiveness of a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (i.e. low FODMAP diet) in IBS. Although gluten sensitivity has also been recently investigated, its presence cannot be confirmed yet because of the presence of other potential contributing compounds in wheat. Studies also suggest a potential beneficial effect of peppermint oil, which warrants further research. SUMMARY: It is clear that a low FODMAP diet has a beneficial effect in a majority of patients with IBS. Probiotics also have great potential in the management of IBS; however, it is still unclear which strains and doses are the most beneficial. Further research is needed on the effect of different fibres, or combinations of fibres, in IBS.

Who should deliver the low FODMAP diet and what educational methods are optimal: a review.

Dietary management is being hailed as an effective strategy for the management of irritable bowel syndrome. Specifically, a diet low in fermentable carbohydrates (FODMAPs) has demonstrated efficacy in approximately 70% of patients. As evidence in support of the low FODMAP diet continues to emerge, there is increasing debate regarding implementation of the diet particularly concerning who should educate patients and how to educate them. Registered dieticians have largely pioneered the evidence that supports the effectiveness of the low FODMAP diet in irritable bowel syndrome, and the diet is recognized as a dietician-led therapy. However, there is an increasing trend for non-dietician-led implementation of the diet despite an absence of evidence on both the clinical or cost-effectiveness of such. Additionally, there is a growing requirement for dietetic services to increase capacity in response to increasing referrals, and consequently, there is a need to investigate innovative ways to educate patients whilst maintaining dietician-led intervention. Herein, we review the evidence for delivery of the low FODMAP diet and discuss potentially effective methods for service delivery.

The evidence base for efficacy of the low FODMAP diet in irritable bowel syndrome: is it ready for prime time as a first-line therapy?

Six randomized controlled trials comparing low FODMAP diet with placebo approaches have all indicated efficacy in patients with irritable bowel syndrome (IBS). The studies have provided all the food (n = 3) or utilized dietitian-led education (n = 3). They have variably met criticisms regarding issues such as the choice of placebo, the number of patients studied, the success of blinding, and the duration of the interventions, but the results are uniformly positive for the diet. Real-world experience of the low FODMAP diet has confirmed the findings of the randomized studies, in that about 70% of patients respond. Difficulty in delivering the diet has not been an issue, and the majority of patients find the diet easy to follow when dietitian led. Observational studies have suggested durability of efficacy, even in association with reintroduction of FODMAPs as recommended. Three studies comparing institution of standard dietary guidelines for IBS with the low FODMAP diet have found either similar or improved outcomes with the latter. Low FODMAP diet also has similar efficacy to that of gut-directed hypnotherapy, another strategy with broad benefit in IBS. There are currently no clinically applicable indices that predict response to the diet. In conclusion, clinical trials and observational studies support the notion that a dietitian-led low FODMAP diet is ready for primetime and should be considered as a first-line therapy for patients with IBS where the use of a restrictive diet is appropriate.

How to institute the low-FODMAP diet.

A diet low in poorly absorbed, fermentable, short chain carbohydrates (FODMAPs) is an effective strategy to manage symptoms of irritable bowel syndrome (IBS). The diet has gained traction since its original description in Australia 10 years ago and is now an internationally accepted dietary management strategy for IBS. Randomized controlled trials have raised the profile of the low-FODMAP diet to become a viable first-line therapy for IBS, when implemented under a dietitian's guidance. Importantly, the diagnosis of IBS should be confirmed before commencement of the dietary approach. The skill set of the dietitian is then paramount to the success of the diet. Experience in gastrointestinal disorder management, consideration of symptom types, severity, baseline FODMAP intake, and overall nutritional content and meal pattern are vital in the assessment of the patient. If a strict low-FODMAP diet is deemed necessary, it should only be for an initial period of 4 to 6 weeks. Research suggests that a strict long-term, low-FODMAP diet may negatively impact intestinal microbiome. After the initial strict period, follow up with the dietitian should be conducted to achieve the overall goal-a relaxed FODMAP restriction that enables inclusion of prebiotic FODMAPs while still maintaining symptom relief. The diet will be effective in the vast majority of patients. For those in which it fails, FODMAPs should be reintroduced to the diet, and other dietary (or non-dietary) approaches should be considered.

The low-FODMAP diet in the management of functional dyspepsia in East and Southeast Asia.

Functional dyspepsia (FD) is a common disorder in East and Southeast Asia where subjects experience post prandial fullness/bloating, early satiety, belching, epigastric pain, and/or burning. A subset of patients with FD experience triggers exclusively related to meals, defined as the post prandial distress syndrome in the Rome IV guidelines. There is significant overlap of symptoms and implicated pathogenic factors with another common functional gastrointestinal disorder, irritable bowel syndrome (IBS) and in fact, a significant proportion of subjects have FD/IBS overlap. The introduction of the low-FODMAP diet has changed the paradigm of treatment for IBS. Like IBS, dietary management appears to be important to patients with FD and clinicians treating the condition. This review aims to examine the current role of diet in the management of FD in East and Southeast Asia, with an exploration of the likely efficacy and mechanisms of action of the low-FODMAP diet in this region.