Evolution, adaptation, and new applications of the FODMAP diet.

The FODMAP diet has been a treatment of irritable bowel syndrome (IBS) for many years. Rigorous scientific evaluation and clinical application of the FODMAP diet have generated deep understanding regarding clinical efficacy, mechanisms of action, and potential adverse effects of this dietary approach. In turn, this knowledge has allowed fine-tuning of the diet to optimize treatment benefits and minimize risks, in the form of the traditional three-phase diet; the FODMAP-gentle approach, which is a less restrictive iteration; and a proposed FODMAP-modified, Mediterranean-style diet which endeavours to optimise both gastrointestinal symptoms and other health parameters. Furthermore, recognition that IBS-like symptoms feature in other conditions has seen the FODMAP diet tested in non-IBS populations, including in older adults with diarrhea and women with endometriosis. These areas represent new frontiers for the FODMAP diet and a space to watch as future research evaluates the validity of these novel clinical applications.

Higher Short-Chain Fermentable Carbohydrates Are Associated with Lower Body Fat and Higher Insulin Sensitivity in People with Prediabetes.

The quality of carbohydrates has metabolic consequences in people with prediabetes. However, the causality of short-chain fermentable carbohydrate intakes and metabolic parameters has not been explored in the prediabetic or diabetic population. We investigated associations between different types of carbohydrates, including fermentable oligosaccharides, disaccharides, monosaccharides, polyols (FODMAPs), and polysaccharides (dietary fibre), and body composition and glucose/insulin responses in subjects with prediabetes. In this prospective cross-sectional study, 177 subjects with impaired glucose tolerance (IGT) (mean age: 60 (54-62) years, 41% men) underwent an assessment of body composition and completed six-point oral glucose tolerance tests (OGTT), Homeostatic Model Assessment of Insulin Resistance (HOMA2-IR), insulin sensitivity, detailed 3-day food records, and physical activity questionnaire. Daily habitual FODMAP intake decreased progressively with increasing BMI, ranging from 7.9 (6.2-12.7) g/d in subjects with normal BMI and 6.6 (4.6-9.9) g/d in subjects with overweight to 5.8 (3.8-9.0) g/d in subjects with obesity (p = 0.038). After adjustment for age and gender, galactooligosaccharides (GOSs) were negatively correlated with body fat (Standardised Beta coefficient ß = -0.156, p = 0.006) and positively associated with insulin sensitivity (ß = 0.243, p = 0.001). This remained significant after adjustment for macronutrients, fibre, and physical activity (p = 0.035 and p = 0.010, respectively). In individuals with IGT, higher dietary GOS intake was associated with lower body fat and higher insulin sensitivity independent of macronutrients and fibre intake, calling for interventional studies to evaluate the effect of FODMAP intake in prediabetes.

Interpreting FODMAP content of foods in clinical practice.

The article by San Mauro Martin et al raises the important issue of discrepancies in the FODMAP food-composition data published by various sources. The Table compiled by Martin et al provided no indication of serving size, so it is not clear whether the discrepancies reflect true differences in FODMAP content, or simply differences in FODMAP ratings arising from differences in the selected serving size and/or cut-off criteria for high or low content.

Application of The FODMAP Diet in a Paediatric Setting.

In adults, dietary management, particularly with the FODMAP diet, is a key evidence-based part of multimodal therapy for patients with disorders of the gut-brain interaction, particularly irritable bowel syndrome. This review aims to describe the evidence for the use of this diet and how to deliver it in paediatric practice. A literature review covering studies on the FODMAP diet in adult and paediatric settings was conducted. While the evidence for the efficacy and safety of a FODMAP diet delivered in three phases, restriction, rechallenge and personalisation, is considerable, there is a lack of good-quality clinical trials exploring the efficacy of the diet in children and adolescents. Likewise, there are limited data on safety concerns associated with a restrictive diet in paediatrics, including impacts on nutrition and growth, disordered eating behaviours, psychosocial and family issues and families and the gut microbiome. The evidence suggests that the implementation of a dietary program is enhanced by a skilled dietitian when navigating a young person (and family) through healthy eating strategies and/or FODMAP restrictions to ameliorate their symptoms. Since the FODMAP diet is being prescribed globally to children, a practical guide for clinicians used to optimise efficacy and safety is provided, including the less restrictive 'FODMAP-gentle' diet.

How to Implement the 3-Phase FODMAP Diet Into Gastroenterological Practice.

Background/Aims: The 3-phase fermentable oligo-, di-, mono-saccharides, and polyols (FODMAP) diet has shown a high level of efficacy in irritable bowel syndrome, largely based on dietitian delivered education. However, access to dietitians can be limited, and challenges exist when applying the diet to a wide range of cultures, such as limited FODMAP analysis of local foods. This review aims to discuss ways to optimally use the FODMAP diet in practice in a wide range of cultures, directed at gastroenterologists from a dietitian's perspective. Methods: Recent literature was analysed via search databases including Medline, CINAHL, PubMed and Scopus. Results: The dietetic process involves detailed assessment and follow-up through the 3 stages of the FODMAP diet (restriction, re-introduction, and long-term maintenance). Emerging evidence suggests the diet can be delivered by other health professionals such as the gastroenterologist or nurse, but training on how to do so successfully would be needed. Self-guided approaches through use of technology or specialised food delivery services may be an alternative when dietitians are not available, but efficacy data is limited. Regardless of delivery mode, nutritional and psychological risks of the diet must be mitigated. Additionally, culturally appropriate education must be provided, with accommodations necessary when the FODMAP content of local foods are unknown. Conclusion: While the diet has shown improved irritable bowel syndrome outcomes across studies, it is important to acknowledge the essential role of dietitians in implementing, tailoring, and managing the diet to achieve the best outcome for each individual.

Diet as a therapeutic tool in chronic gastrointestinal disorders: Lessons from the FODMAP journey.

BACKGROUND AND AIM: Diet is a powerful tool in the management of gastrointestinal disorders, but developing diet therapies is fraught with challenge. This review discusses key lessons from the FODMAP diet journey. METHODS: Published literature and clinical experience were reviewed. RESULTS: Key to designing a varied, nutritionally adequate low-FODMAP diet was our accurate and comprehensive database of FODMAP composition, made universally accessible via our user-friendly, digital application. Our discovery that FODMAPs coexist with gluten in cereal products and subsequent gluten/fructan challenge studies in nonceliac gluten-sensitive populations highlighted issues of collinearity in the nutrient composition of food and confirmation bias in the interpretation of dietary studies. Despite numerous challenges in designing, funding, and executing dietary randomized controlled trials, efficacy of the low-FODMAP diet has been repeatedly demonstrated, and confirmed by real-world experience, giving this therapy credibility in the eyes of clinicians and researchers. Furthermore, real-world application of this diet saw the evolution of a safe and effective three-phased approach. Specialist dietitians must deliver this diet to optimize outcomes as they can target and tailor the therapy and to mitigate the key risks of compromising nutritional adequacy and precipitating disordered eating behaviors, skills outside the gastroenterologist's standard tool kit. While concurrent probiotics are ineffective, specific fiber supplements may improve short-term and long-term outcomes. CONCLUSIONS: The FODMAP diet is highly effective, but optimal outcomes are contingent on the involvement of a gastroenterological dietitian who can assess, educate, and monitor patients and manage risks associated with implementation of this restrictive diet.

FODMAPs: food composition, defining cutoff values and international application.

The low-FODMAP diet is a new dietary therapy for the management of irritable bowel syndrome that is gaining in popularity around the world. Developing the low-FODMAP diet required not only extensive food composition data but also the establishment of "cutoff values" to classify foods as low-FODMAP. These cutoff values relate to each particular FODMAP present in a food, including oligosaccharides (fructans and galacto-oligosaccharides), sugar polyols (mannitol and sorbitol), lactose, and fructose in excess of glucose. Cutoff values were derived by considering the FODMAP levels in typical serving sizes of foods that commonly trigger symptoms in individuals with irritable bowel syndrome, as well as foods that were generally well tolerated. The reliability of these FODMAP cutoff values has been tested in a number of dietary studies. The development of the techniques to quantify the FODMAP content of foods has greatly advanced our understanding of food composition. FODMAP composition is affected by food processing techniques and ingredient selection. In the USA, the use of high-fructose corn syrups may contribute to the higher FODMAP levels detected (via excess fructose) in some processed foods. Because food processing techniques and ingredients can vary between countries, more comprehensive food composition data are needed for this diet to be more easily implemented internationally.

Food components and irritable bowel syndrome.

Ingestion of food has long been linked with gut symptoms, and there is increasing interest in using diet in the management of patients with irritable bowel syndrome (IBS). The West has developed an intense interest in specialized, restrictive diets, such as those that target multiple food groups, avoid gluten, or reduce fermentable oligo-, di-, and mono-saccharides and polyols. However, most gastroenterologists are not well educated about diets or their effects on the gut. It is important to understand the various dietary approaches, their putative mechanisms, the evidence that supports their use, and the benefits or harm they might produce. The concepts behind, and delivery of, specialized diets differ from those of pharmacologic agents. High-quality research is needed to determine the efficacy of different dietary approaches and the place of specific strategies.

Efficacy of hospital in the home services providing care for patients admitted from emergency departments: an integrative review.

INTRODUCTION: Increases in emergency department (ED) demand may compromise patient outcomes, leading not only to overcrowding in the ED, increased ED waiting times and increased ED length of stay, but also compromising patient safety; the risk of adverse events is known to rise in the presence of overcrowding. Hospital in the home (HiTH) services may offer one means of reducing ED demand. AIM: This integrative review sought to assess the efficacy of admission-avoidance HiTH services that admit patients directly from the ED. METHODS: Papers published between 1995 and 2013 were identified through searches of Medline, CINAHL and Google. English-language studies that assessed the efficacy of a HiTH service and that recruited at least one-third of the participants directly from the ED were included in the review. A HiTH service was considered one that provided health professional support to patients at home for a time-limited period, thus avoiding the need for hospitalization. RESULTS: Twenty-two articles met the inclusion criteria for this review. The interventions were diverse in terms of the clinical interventions delivered, the range and intensity of health professional input and the conditions treated. The studies included in the review found no effect on clinical outcomes, rates of adverse events or complications, although patient satisfaction and costs were consistently and favourably affected by HiTH treatment. CONCLUSION: Given evidence suggesting that HiTH services which recruit patients directly from the ED contribute to cost-savings, greater patient satisfaction and safety and efficacy outcomes that are at least equivalent to those associated with hospital-based care, the expansion of such programmes might therefore be considered a priority for policy makers.