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Exploration of differential responses to FODMAPs and gluten in people with irritable bowel syndrome- a double-blind randomized cross-over challenge study.
Nordin, E, Landberg, R, Hellström, PM, Brunius, C
Metabolomics : Official journal of the Metabolomic Society. 2024;20(2):21
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Irritable bowel syndrome (IBS) is a complex condition characterized by recurrent abdominal pain associated with abnormal bowel habits. Diet is considered a main cause of symptoms in IBS, and fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs) are of major concern. The aim of this study was to unravel determinants of differential IBS responses to FODMAP and gluten provocation interventions from molecular data. This study was a randomised, double-blind, placebo-controlled three-way crossover study. Participants were randomised in blocks of 12 into the sequences CBA, ACB, and BAC (A=FODMAPs, B=Gluten, and C=Placebo). Results showed that despite a comprehensive set of methods applied to explore IBS responses, including both regression and classification, predictors of differential response could not be established. Authors concluded by encouraging the application of molecular subtyping methodologies in future studies due to the differential responses to treatment.
Abstract
INTRODUCTION There is large variation in response to diet in irritable bowel syndrome (IBS) and determinants for differential response are poorly understood. OBJECTIVES Our aim was to investigate differential clinical and molecular responses to provocation with fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs) and gluten in individuals with IBS. METHODS Data were used from a crossover study with week-long interventions with either FODMAPs, gluten or placebo. The study also included a rapid provocation test. Molecular data consisted of fecal microbiota, short chain fatty acids, and untargeted plasma metabolomics. IBS symptoms were evaluated with the IBS severity scoring system. IBS symptoms were modelled against molecular and baseline questionnaire data, using Random Forest (RF; regression and clustering), Parallel Factor Analysis (PARAFAC), and univariate methods. RESULTS Regression and classification RF models were in general of low predictive power (Q2 ≤ 0.22, classification rate < 0.73). Out of 864 clustering models, only 2 had significant associations to clusters (0.69 < CR < 0.73, p < 0.05), but with no associations to baseline clinical measures. Similarly, PARAFAC revealed no clear association between metabolome data and IBS symptoms. CONCLUSION Differential IBS responses to FODMAPs or gluten exposures could not be explained from clinical and molecular data despite extensive exploration with different data analytical approaches. The trial is registered at www. CLINICALTRIALS gov as NCT03653689 31/08/2018.
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Effects of FODMAPs and Gluten on Gut Microbiota and Their Association with the Metabolome in Irritable Bowel Syndrome: A Double-Blind, Randomized, Cross-Over Intervention Study.
Nordin, E, Hellström, PM, Dicksved, J, Pelve, E, Landberg, R, Brunius, C
Nutrients. 2023;15(13)
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Irritable bowel syndrome (IBS) is defined as recurring abdominal pain in relation to stool irregularities. The mechanisms behind IBS are poorly understood, but changes in gut microbiota composition, intestinal barrier function, enteroendocrine cell population, low-grade inflammation and gut–brain axis modulations are believed to play a role. The aim of this study was to investigate how fermentable oligo-, di-, mono-saccharides, and polyols (FODMAPs) and gluten affected gut microbiota and circulating metabolite profiles, as well as to investigate potential links between gut microbiota, metabolites, and IBS symptoms. This study was a double-blind, placebo-controlled three-way crossover study. Both the study personnel and participants were blinded. Results showed that consumption of high FODMAP foods, but not gluten, altered the gut microbiota composition, in particular causing changes to microbiota and metabolites, previously associated with improved metabolic health and reduced inflammation. There were also minor effects of FODMAPs and gluten on short-chain fatty acids. Authors conclude that the intake of FODMAP, but not gluten, over one week altered the gut microbiota composition, with only weak associations with IBS symptoms. Healthcare practitioners working with IBS should consider the impacts on the gut microbiome when advising the use of a low-FODMAP diet.
Abstract
BACKGROUND A mechanistic understanding of the effects of dietary treatment in irritable bowel syndrome (IBS) is lacking. Our aim was therefore to investigate how fermentable oligo- di-, monosaccharides, and polyols (FODMAPs) and gluten affected gut microbiota and circulating metabolite profiles, as well as to investigate potential links between gut microbiota, metabolites, and IBS symptoms. METHODS We used data from a double-blind, randomized, crossover study with week-long provocations of FODMAPs, gluten, and placebo in participants with IBS. To study the effects of the provocations on fecal microbiota, fecal and plasma short-chain fatty acids, the untargeted plasma metabolome, and IBS symptoms, we used Random Forest, linear mixed model and Spearman correlation analysis. RESULTS FODMAPs increased fecal saccharolytic bacteria, plasma phenolic-derived metabolites, 3-indolepropionate, and decreased isobutyrate and bile acids. Gluten decreased fecal isovalerate and altered carnitine derivatives, CoA, and fatty acids in plasma. For FODMAPs, modest correlations were observed between microbiota and phenolic-derived metabolites and 3-indolepropionate, previously associated with improved metabolic health, and reduced inflammation. Correlations between molecular data and IBS symptoms were weak. CONCLUSIONS FODMAPs, but not gluten, altered microbiota composition and correlated with phenolic-derived metabolites and 3-indolepropionate, with only weak associations with IBS symptoms. Thus, the minor effect of FODMAPs on IBS symptoms must be weighed against the effect on microbiota and metabolites related to positive health factors.
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Effects of a low FODMAP diet on gut microbiota in individuals with treated coeliac disease having persistent gastrointestinal symptoms - a randomised controlled trial.
Herfindal, AM, van Megen, F, Gilde, MKO, Valeur, J, Rudi, K, Skodje, GI, Lundin, KEA, Henriksen, C, Bøhn, SK
The British journal of nutrition. 2023;130(12):2061-2075
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Coeliac disease (CeD) is a common immune-mediated disease where intolerance to gluten can lead to severe health problems with a wide range of gastrointestinal (GI) and extra-intestinal symptoms. Research shows that a diet low in fermentable oligo-, di-, mono-saccharides and polyols (FODMAP) helps to reduce GI symptoms in irritable-bowel syndrome and gluten-free diet treated CeD. The aim of this study was to investigate whether a low FODMAP diet (LFD) in this patient group affects (i) the faecal microbiota, (ii) the concentrations of faecal short-chain fatty acids (SCFA) and (iii) the concentrations of faecal human neutrophil gelatinase-associated lipocalin (a biomarker of gut inflammation). This study is part of a clinical trial which followed a nonblinded, parallel randomised design. The participants were randomised to either an LFD group or a control group. Results showed that after four weeks, certain differences in gut microbiota were detected between the control and LFD group. The SCFA results indicated that the LFD resulted in lower concentrations of propionic and valeric acid in participants with initially high concentrations. Biomarker of gut inflammation was, however, unaffected by the LFD. Authors conclude that the LFD led to changes in overall community structure of the faecal microbiota, with a possible unfavourable low faecal abundance of Anaerostipes, and low concentrations of the faecal SCFA propionic and valeric acid in participants with high concentrations of these acids at baseline.
Abstract
Individuals with coeliac disease (CeD) often experience gastrointestinal symptoms despite adherence to a gluten-free diet (GFD). While we recently showed that a diet low in fermentable oligo-, di-, monosaccharides and polyols (FODMAP) successfully provided symptom relief in GFD-treated CeD patients, there have been concerns that the low FODMAP diet (LFD) could adversely affect the gut microbiota. Our main objective was therefore to investigate whether the LFD affects the faecal microbiota and related variables of gut health. In a randomised controlled trial GFD-treated CeD adults, having persistent gastrointestinal symptoms, were randomised to either consume a combined LFD and GFD (n 39) for 4 weeks or continue with GFD (controls, n 36). Compared with the control group, the LFD group displayed greater changes in the overall faecal microbiota profile (16S rRNA gene sequencing) from baseline to follow-up (within-subject β-diversity, P < 0·001), characterised by lower and higher follow-up abundances (%) of genus Anaerostipes (Pgroup < 0·001) and class Erysipelotrichia (Pgroup = 0·02), respectively. Compared with the control group, the LFD led to lower follow-up concentrations of faecal propionic and valeric acid (GC-FID) in participants with high concentrations at baseline (Pinteraction ≤ 0·009). No differences were found in faecal bacterial α-diversity (Pgroup ≥ 0·20) or in faecal neutrophil gelatinase-associated lipocalin (ELISA), a biomarker of gut integrity and inflammation (Pgroup = 0·74), between the groups at follow-up. The modest effects of the LFD on the gut microbiota and related variables in the CeD patients of the present study are encouraging given the beneficial effects of the LFD strategy to treat functional GI symptoms (Registered at clinicaltrials.gov as NCT03678935).
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Efficacy and Acceptability of Dietary Therapies in Non-Constipated Irritable Bowel Syndrome: A Randomized Trial of Traditional Dietary Advice, the Low FODMAP Diet, and the Gluten-Free Diet.
Rej, A, Sanders, DS, Shaw, CC, Buckle, R, Trott, N, Agrawal, A, Aziz, I
Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2022;20(12):2876-2887.e15
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Irritable bowel syndrome (IBS) is a common disorder characterised by stomach pain, bloating, and altered bowel movements. Dietary therapy is a way to manage IBS, with 3 diets becoming popular amongst health care professionals and those who suffer from IBS. Traditional dietary advice (TD), which involves adopting healthy, sensible eating patterns with adequate hydration, is the first line recommendation in the UK. The low-FODMAP diet (LFD) is the avoidance of carbohydrates, which tend to ferment in the stomach and are found in certain fruits and vegetables. The gluten free diet (GFD) is the avoidance of foods which contain gluten such as bread and pasta. All three diets have little evidence to support their use in IBS and this randomised control trial of 101 individuals with IBS aimed to determine whether the GFD and LFD are superior in relieving IBS symptoms compared to TD. The results showed that GFD, LFD and TD were all effective in the management of non-constipated IBS, but that TD was easier to follow and cheaper compared to the other two diets. It was concluded that TD should be used as first-line therapy for people with non-constipated IBS and that GFD and LFD should be reserved for specific patients under the care of a health care professional.
Expert Review
Conflicts of interest:
None
Take Home Message:
- TDA, LFD and GFD can all lead to significant improvements in non-constipation IBS with no statistically significant difference in effectiveness between the diets.
- Most patients find a TDA easier and cheaper to implement than a LFD or GFD.
- TDA is therefore recommended as a first line approach in non-constipation IBS.
Evidence Category:
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A: Meta-analyses, position-stands, randomized-controlled trials (RCTs)
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B: Systematic reviews including RCTs of limited number
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C: Non-randomized trials, observational studies, narrative reviews
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D: Case-reports, evidence-based clinical findings
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E: Opinion piece, other
Summary Review:
Introduction
The aim of this study was to compare the effectiveness and patient acceptability of traditional dietary advice (TDA) vs a low FODMAP diet (LFD) vs a gluten-free diet (GFD, cross-contamination allowed) in patients with non-constipation irritable bowel syndrome (IBS).
TDA definition: healthy, sensible eating pattern, including regular meals, not eating too little/too much, adequate hydration, and reducing the intake of: alcohol/caffeine/fizzydrinks/fatty/spicy/ processed foods; fresh fruit (maximum of 3 per day); fibre/gas-producing foods and perceived food intolerances.
Methods
This was a randomised dietary trial over 4 weeks. Dietary advice was provided by a specialist dietitian in a session lasting 45-60 minutes. 99 patients completed the study (33 in each group). Stool analysis was performed in “around half“ (study authors terminology) of participants due to disruption of trial caused by COVID-19.
Results:
- Primary endpoint (reduction of 50 points or more on IBS symptom severity score) was met by 42% of patients on the TDA, 55% on LFD and 58% on GFD. The differences between groups were not statistically significant, p=0.43.
- Patients on the LFD had greater improvements in mood compared to the other diets under examination, reaching statistical significance (p=0.03) for Hospital Anxiety and Depression scale and (p<0.01) for dysphoria score on IBS-QOL scale.
- Patients on TDA found their diet cheaper (p<0.01), less time consuming to shop (p<0.01) and easier to follow when eating out with family and friends (p=0.03), whilst TDA and GFD were considered easier to incorporate into daily diet than LFD (p=0.02).
- No significant differences were found between groups in changes to macro- and micronutrient composition, except a trend to lower fibre intake with LFD (p=0.06).
- There was a significant reduction in intake of FODMAPs in all groups, with greatest reduction in LFD (27.7 to 7.6 g/day, p<0.01), followed by TDA (24.9 to 15.2 g/day, p<0.01) and GFD (27.4 to 22.4 g/day, p=0.03). Differences between groups were statistically significant (p<0.01).
- No differences were noted in change to the dysbiosis index between groups.
- Neither clinical characteristics nor dysbiosis index predicted response to any of the diets.
Conclusion
- TDA, LFD and GFD are all effective approaches for non-constipation IBS.
- TDA should be first-line dietary advice due to being the most patient-friendly.
Clinical practice applications:
- When working with clients with non-constipation IBS, a TDA approach may be favoured over LFD and GFD as a first line intervention if the patient has not already tried a TDA diet.
- Patient preferences, budget, time and living situation should be taken into account when deciding on best dietary advice for IBS.
Considerations for future research:
- As all 3 approaches led to reduction in FODMAPs, trials comparing different levels of FODMAP exclusion could lead to valuable information, as a strict FODMAP exclusion, which is commonly recommended in IBS, is difficult and may not be necessary.
- Studies of longer duration would be valuable to confirm that benefits observed with the 3 approaches are not short-term only.
- Comparing individual approaches to appropriate control group would ensure that improvements are not due to a placebo effect.
Abstract
BACKGROUND & AIMS Various diets are proposed as first-line therapies for non-constipated irritable bowel syndrome (IBS) despite insufficient or low-quality evidence. We performed a randomized trial comparing traditional dietary advice (TDA) against the low FODMAP diet (LFD) and gluten-free diet (GFD). METHODS Patients with Rome IV-defined non-constipated IBS were randomized to TDA, LFD, or GFD (the latter allowing for minute gluten cross-contamination). The primary end point was clinical response after 4 weeks of dietary intervention, as defined by ≥50-point reduction in IBS symptom severity score (IBS-SSS). Secondary end points included (1) changes in individual IBS-SSS items within clinical responders, (2) acceptability and food-related quality of life with dietary therapy, (3) changes in nutritional intake, (4) alterations in stool dysbiosis index, and (5) baseline factors associated with clinical response. RESULTS The primary end point of ≥50-point reduction in IBS-SSS was met by 42% (n = 14/33) undertaking TDA, 55% (n = 18/33) for LFD, and 58% (n = 19/33) for GFD (P = .43). Responders had similar improvements in IBS-SSS items regardless of their allocated diet. Individuals found TDA cheaper (P < .01), less time-consuming to shop (P < .01), and easier to follow when eating out (P = .03) than the GFD and LFD. TDA was also easier to incorporate into daily life than the LFD (P = .02). Overall reductions in micronutrient and macronutrient intake did not significantly differ across the diets. However, the LFD group had the greatest reduction in total FODMAP content (27.7 g/day before intervention to 7.6 g/day at week 4) compared with the GFD (27.4 g/day to 22.4 g/day) and TDA (24.9 g/day to 15.2 g/day) (P < .01). Alterations in stool dysbiosis index were similar across the diets, with 22%-29% showing reduced dysbiosis, 35%-39% no change, and 35%-40% increased dysbiosis (P = .99). Baseline clinical characteristics and stool dysbiosis index did not predict response to dietary therapy. CONCLUSIONS TDA, LFD, and GFD are effective approaches in non-constipated IBS, but TDA is the most patient-friendly in terms of cost and convenience. We recommend TDA as the first-choice dietary therapy in non-constipated IBS, with LFD and GFD reserved according to specific patient preferences and specialist dietetic input. CLINICALTRIALS gov: NCT04072991.
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A Low-FODMAP Diet Provides Benefits for Functional Gastrointestinal Symptoms but Not for Improving Stool Consistency and Mucosal Inflammation in IBD: A Systematic Review and Meta-Analysis.
Peng, Z, Yi, J, Liu, X
Nutrients. 2022;14(10)
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The low-FODMAP diet eliminates carbohydrates that cannot be easily digested in order to reduce functional gastrointestinal symptoms associated with irritable bowel disease (IBD). The symptoms of irritable bowel disease include abdominal pain and bloating. This systematic review and meta-analysis aimed to evaluate whether a low-FODMAP diet can alleviate functional gastrointestinal symptoms in individuals with inflammatory bowel disease. In comparison with a regular diet, a low-FODMAP diet significantly reduced symptoms of bloating, wind, flatulence, abdominal pain, fatigue, and lethargy in patients with IBD. In addition, patients with Crohn's disease have achieved remission or reduced symptoms after following a low-FODMAP diet. Healthcare professionals can use this study to understand better the effects of a low-FODMAP diet on patients with IBD who have functional gastrointestinal symptoms. Further robust studies are, however, required to evaluate the evidence's robustness and identify the mechanism behind the improvement of symptoms.
Expert Review
Conflicts of interest:
None
Take Home Message:
- LFD use in IBD improved symptoms of bloating, wind or flatulence, borborygmi, abdominal pain, and fatigue or lethargy, but not nausea and vomiting.
Evidence Category:
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A: Meta-analyses, position-stands, randomized-controlled trials (RCTs)
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B: Systematic reviews including RCTs of limited number
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C: Non-randomized trials, observational studies, narrative reviews
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D: Case-reports, evidence-based clinical findings
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E: Opinion piece, other
Summary Review:
Introduction
This meta-analysis assesses the efficacy of a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet (LFD) in inflammatory bowel disease [IBD: ulcerative colitis (UC) and Crohn’s disease (UC)] participants with functional gastrointestinal symptoms (FGSs).
Methods
A search was performed on PubMed, Web of Science, EMBASE, Cochrane Central Register of Controlled Trials, Chinese National Knowledge Infrastructure (CNKI), WanFang (Chinese) Database up to March 2022. Quality assessment of all included studies was performed.
Results
9 studies (4 randomised controlled trials, 5 non-randomised studies) with a total of 351 participants diagnosed with IBD were included, and compared LFD with a placebo diet or normal diet (ND), overall and individual
LFD Effects of FGS:
- Overall 9 studies: an improvement (0.47, 0.33–0.66, p = 0.0000)
- No difference in the subgroup classified by disease type
- CD and UC: no improvement
Individual improvement:
- Bloating (0.37, 0,24-0,57, p=0.0000); wind or flatulence (0.38, 0,28-0,51, p=0.0000); borborygmi (0.48, 0,26-0,89, p=0.0000), abdominal pain (0.5, 0,37-0,68, p=0.0000), fatigue/lethargy (0.71, 0,61-0,82, p=0.0000)
- No difference in nausea and vomiting (0.54, 0,22-1,32, p=018)
IBS Quality of Life Score:
- 2 studies: reduced Short IBD Questionnaire (SIBDQ) score (11.24, 6.61-15.87, p=0.0000)
Bristol Stool Form Chart:
- 2 studies: normal stool consistency (type 3-4); no difference (5.99, 0.17-216.51, p=0.33)
- 2 other studies: no difference (-0.17, 0.48 - 0.15, p=0.30)
Diseases activity (Harvey-Bradshaw index):
- 2 studies using the Mayo score: no difference (-32, -1,09-0.45, p=0.41)
- 3 studies using BHi score: reduction (-1.09, -1,77-0.42, p=0.002)
Faecal calprotectin:
- 2 studies: no change (-16.03, -36,78-4.73, p=0.13)
Limitations
- Comparison diets were not standardised, suggesting the potential of different dietary habits to bias results..
- Heterogeneity of included studies, and the relatively small sample size of the studies can reduce the reliability of the results.
Conclusion
While the study found inconsistent definition standards for FGS, all the nine studies showed that LFD was associated with an improvement in some symptoms.
Clinical practice applications:
- This study suggests that IBD patients with FGSs may benefit from LFD treatment with the assistance of a healthcare professional.
Considerations for future research:
- This study has shown that LFD can improve FGSs in IBD, but further research with a larger sample size and more comprehensive analysis is warranted to replicate the results.
- The description of the findings and Quality of Life data are a little unclear. The impact on Quality of Life warrants further investigation, as clinicians need to consider the impact of following a restrictive diet on Quality of Life.
Abstract
BACKGROUND A low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet (LFD) is claimed to improve functional gastrointestinal symptoms (FGSs). However, the role of LFD in inflammatory bowel disease (IBD) patients with FGSs remains unclear. OBJECTIVE To systematically assess the efficacy of LFD in IBD patients with FGSs. METHODS Six databases were searched from inception to 1 January 2022. Data were synthesized as the relative risk of symptoms improvement and normal stool consistency, mean difference of Bristol Stool Form Scale (BSFS), Short IBD Questionnaire (SIBDQ), IBS Quality of Life (IBS-QoL), Harvey-Bradshaw index (HBi), Mayo score, and fecal calprotectin (FC). Risk of bias was assessed based on study types. A funnel plot and Egger's test were used to analyze publication bias. RESULTS This review screened and included nine eligible studies, including four randomized controlled trials (RCTs) and five before-after studies, involving a total of 446 participants (351 patients with LFD vs. 95 controls). LFD alleviated overall FGSs (RR: 0.47, 95% CI: 0.33-0.66, p = 0.0000) and obtained higher SIBDQ scores (MD = 11.24, 95% CI 6.61 to 15.87, p = 0.0000) and lower HBi score of Crohn's disease (MD = -1.09, 95% CI -1.77 to -0.42, p = 0.002). However, there were no statistically significant differences in normal stool consistency, BSFS, IBS-QoL, Mayo score of ulcerative colitis, and FC. No publication bias was found. CONCLUSIONS LFD provides a benefit in FGSs and QoL but not for improving stool consistency and mucosal inflammation in IBD patients. Further well-designed RCTs are needed to develop the optimal LFD strategy for IBD.
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Igg Food Antibody Guided Elimination-Rotation Diet Was More Effective than FODMAP Diet and Control Diet in the Treatment of Women with Mixed IBS-Results from an Open Label Study.
Ostrowska, L, Wasiluk, D, Lieners, CFJ, Gałęcka, M, Bartnicka, A, Tveiten, D
Journal of clinical medicine. 2021;10(19)
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IBS, also known as irritable bowel syndrome, is a debilitating condition characterised by abdominal pain, irregular bowel movements, and changes in the consistency of stool. Symptoms of IBS may appear shortly after eating a meal. Excluding foods high in FODMAP carbohydrates, such as fermentable oligo- and di-saccharides, mono- and disaccharides, and polyols, or following an elimination rotation diet to reduce IgG-dependent food hypersensitivity, which has been shown to improve IBS symptoms previously. The purpose of this open-label study is to investigate the effectiveness of a low-FODMAPS diet and an elimination rotation diet based on IgG as well as a control diet in reducing symptoms of IBS. During the eight-week study, 73 female subjects with a mix of IBS were assigned to either of the three dietary treatments. Compared to the other diet groups, the IgG based elimination rotation diet group showed a significant improvement in the IBS symptoms and comorbid symptoms after the intervention period. In order to determine whether IgG-mediated food hypersensitivity plays a role in IBS and the efficacy of an IgG-dependent elimination rotation diet in the general population, further robust research is required. Healthcare professionals, however, can make use of these results to gain a better understanding of how an IgG based elimination diet tailored to each individual can improve IBS symptoms.
Expert Review
Conflicts of interest:
None
Take Home Message:
- After implementing the three diets, among patients with IBS-M, a statistically significant reduction of the frequency of the idiopathic abdominal pain, abdominal pain after a meal, abdominal pain during defecation, and sensation of incomplete defecation before and after the diet plans, were only found in Group 2.
- Significantly, only in the Group 2 IgG based elimination-rotation-diet was there a high decrease or complete disappearance of dyspeptic IBS symptoms and co-morbidities together with IBS symptoms.
- This study shows that a personalised dietary approach is more effective in treating IBS than generalised diet recommendations, with elimination diets focused on IgG antibodies providing the best results.
Evidence Category:
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A: Meta-analyses, position-stands, randomized-controlled trials (RCTs)
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B: Systematic reviews including RCTs of limited number
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X
C: Non-randomized trials, observational studies, narrative reviews
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D: Case-reports, evidence-based clinical findings
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E: Opinion piece, other
Summary Review:
Science supports the use of a low-FODMAP diet for symptom relief of IBS. However, more recently evidence suggests that IBS is a low-grade inflammatory disease that may result from or lead to IgG-dependent food hyper-sensitivities.
This study compared the effectiveness of three dietary treatment plans in 73 female patients diagnosed with mixed-form IBS based on Rome III criteria and no other gastrointestinal condition over 8 weeks.
The 3 dietary groups were:
- Group 1-low FODMAP diet
- Group 2- IgG based elimination-rotation-diet
- Group 3-control diet (control group)
Diets of G1 and G2 were determined individually by a dietitian, based on low-FODMAP dietary information and results from IgG food sensitivity testing respectively. Group 3 received nutrition advice from a gastroenterologist.
In G1, some of the IBS symptoms significantly improved (mucus in stool, p = 0.031; bloating, p < 0.001). Gurgling sensation and gastric fullness also reach statistical significance in G1.
IBS symptoms as well as co-morbid symptoms significantly improved or disappeared completely in G2 (idiopathic abdominal pain, p < 0.001; abdominal pain after a meal, p < 0.001; abdominal pain during defecation, p = 0.008; sensation of incomplete defecation p = 0.001; difficulty to defecate (constipation) p = 0.002; bloating p = < 0.001; gurgling sensation < 0.001; gastric fullness p = < 0.001. However, blood and mucus in the stool were impossible to test because the symptoms were not reported by any patient during the 2nd examination). (p-values less than 0.05 were considered statistically significant).
In group G3 no statistically significant improvements were seen in any measure.
Based on the results of this open-label study, it was concluded that personalised dietary interventions were more effective in the treatment of IBS-M patients than generalised diet recommendations. Dietary elimination based on IgG food sensitivity test results had the greatest impact on IBS and related symptoms.This study supports results from other studies showing an IgG-guided diet as an effective strategy in co-morbid conditions such as fatigue, headache/migraine, and skin conditions.
Conflicts of Interest
C.F.J.L., M.G. and A.B. are employees of the Institute of Microecology in Poznan ,where the ImuPro tests were determined. D.T. is the Head of Laboratory and shareholder of Lab1, offering ImuPro tests in Norway.
Clinical practice applications:
- Low FODMAP diets studies (NICE) showed GI improvements for abdominal pain, abdominal cramps, diarrhoea, gas, and bloating, largely because FODMAPs mainly cause an excessive production of gas, leading to discomfort and pain and an increased osmotic effect leading to increased bowel movement and diarrhoea. However 30% of patients still suffered from bloating on the FODMAP diet. Gurgling sensation decreased from 65% to 15%, and gastric fullness decreased from 58% to 11% in the patients on the low FODMAP diet.
- A potential new approach to resolve functional symptoms of gastrointestinal conditions could be to start with an IgG-guided elimination diet, as it was proven to be the more effective diet in this open study, and in cases of persistent symptoms, it could be combined with a low-FODMAP diet.
- Calprotectin is currently one of the best-known diagnostic markers indicating mucosa inflammation and changes in the inflammation intensity. In this study serious intestinal inflammation was diagnosed at the faecal calprotectin concentration of >50 mg/kg of stool. During the first examination, no statistically significant differences were found in calprotectin concentrations between the compared groups of patients, and the values were low, suggesting that the included patients suffered from low-grade inflammation and were suitable for diet alteration as the best choice of treatment.
Limitations:
- The main limitations of this study are the open-labeled nature, the low number of participants and the bias of only including female participants with only the patients in the G2 group tested for IgG food antibodies.
- Foods consumed by the patients before they entered the study were not ascertained.
Considerations for future research:
- Claims that IgG food antibodies only reveal exposure to food and not intolerance should be reinvestigated in larger double-blinded studies.
Abstract
Irritable bowel syndrome (IBS) is a chronic disease with recurrent abdominal pain, disturbed bowel emptying, and changes in stool consistency. We compared the effectiveness of three different dietary treatment plans (G1-FM-low FODMAP diet, G2-IP IgG based elimination-rotation-diet, and as control group, the G3-K control diet recommended by an attending gastroenterologist) in treating patients diagnosed with mixed irritable bowel syndrome. A total of seventy-three female patients diagnosed with a mixed form of irritable bowel syndrome (IBS-M) were enrolled in the study. The diet of each patient in Group 1 (G1-FM) and 2 (G2-IP) was determined individually during a meeting with a dietitian. Patients from Group 3 (G3-K) received nutrition advice from a gastroenterologist. Significant differences in the reduction of IBS symptoms were found between the groups. IBS symptoms as well as comorbid symptoms significantly improved or disappeared completely in the G2-IP group (idiopathic abdominal pain, p < 0.001; abdominal pain after a meal, p < 0.001; abdominal pain during defecation, p = 0.008), while in the G1-FM group, some of the IBS symptoms significantly improved (mucus in stool, p = 0.031; bloating, p < 0.001). In group G3-K no significant improvement was seen. Based on the results of this open-label study, it was concluded that various dietary interventions in the treatment of IBS-M patients do not uniformly affect the course and outcomes of disease management. Rotation diets based on IgG show significantly better results compared to other diets.
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An algorithm for differentiating food antigen-related gastrointestinal symptoms.
Rostami, K, Bold, J, Ismail Ali, J, Parr, A, Dieterich, W, Zopf, Y, Htoo, A, Rostami-Nejad, M, Danciu, M
Gastroenterology and hepatology from bed to bench. 2021;14(1):8-16
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Irritable bowel syndrome (IBS) is a collection of gastrointestinal symptoms. Due to multiple etiologies, the pathogenesis of IBS is poorly understood. The aim of this audit was to assess the outcomes achieved using a lactose and gluten-free diet clinical intervention in patients traditionally diagnosed with IBS. This study was an audit of outcomes from the records of 149 patients presenting with IBS symptoms at secondary and tertiary Gastroenterology outpatients in two UK hospitals. This audit has demonstrated that more than 70% of patients presenting with IBS symptoms improved by following a diet eliminating lactose and gluten containing grains (improvement for >30% in their symptoms). The success of the elimination diet did not seem to be correlated with the body mass index (BMI). The best outcome was recorded in patients with normal BMI and also in the overweight group. Patients with higher BMI >30 or low below 18 also responded well to nutrition therapy. In conclusion, multidisciplinary team management and implementation of detailed nutrition therapy using the audit algorithm might prove to be both cost effective and efficacious a treatment option in IBS.
Abstract
AIM: The aim of this clinical audit was to assess patient-reported outcomes on the effect of dietary intervention, to enhance our understanding of possible treatment options in irritable bowel syndrome (IBS). BACKGROUND A large number of food-related gastro-intestinal disorders have been attributed to IBS for decades. METHODS Patient-reported outcomes from the records of 149 IBS patients treated at secondary and tertiary Gastroenterology outpatients in two UK hospitals between January 2014 and July 2016 were audited. Patients all presented with symptoms fulfilling Rome III-IV criteria for IBS had negative coeliac serology and did not have other gastrointestinal (GI) conditions. A modified version of a low FODMAP diet had been recommended (gluten and lactose free diet (G/LFD)) and was implemented for 6 weeks. Outcomes and dietary adherence were recorded during outpatient's consultations. RESULTS A total of 134 patients complied with the diet optimally. The majority had an improvement rate >70% and continued with the diet. Fifty-three percent became completely or almost asymptomatic, while 27.6% had a poor response to the diet (scoring < 30%) to G/LFD. The improvement was excellent in patients with normal BMI and good in overweight and obese and where BMI <18. Over 50% did not require any follow-up within 12 months. CONCLUSION Although it is unclear whether symptoms are triggered by gluten, fructans or lactose, elimination of gluten and lactose proved to be an effective treatment in patients with IBS. Multidisciplinary team management and implementation of detailed nutrition therapy using the audit algorithm might prove to be both cost effective and efficacious a treatment option in IBS.
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Nutritional Interventions in the Management of Fibromyalgia Syndrome.
Pagliai, G, Giangrandi, I, Dinu, M, Sofi, F, Colombini, B
Nutrients. 2020;12(9)
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Fibromyalgia (FM) is a chronic pain condition, often presenting with widespread body pain, joint stiffness, sleep disorders, depression, anxiety, gastrointestinal and cognitive complaints. Despite being common, the cause of FM is not well understood. In the absence of effective treatments, the current management of FM involves a multidisciplinary approach utilizing pharmacological and non-pharmacological interventions. Growing evidence suggests a role for nutrition as a complementary strategy for FM management. This brief review summarises the possible impact of nutritional supplements and dietary interventions on FM. Previous reviews concluded that vitamin and mineral deficiencies themselves are unlikely to be significant in the development of FM. Yet, a few interventional studies investigating the use of Vitamin D, magnesium, iron and probiotics showed promising results. To date, there is no or limited evidence for the use of Vitamin C, E, selected amino acids, botanical or antioxidant supplements. Food-wise the inclusion of quality olive oil and the grain Khorasan proved helpful on FM presentation, whilst findings around the role of dietary monosodium glutamate and aspartame seem mixed. Regarding diet patterns, gluten-free, low-calorie, vegetarian, vegan, raw food or Mediterranean diets were all associated with improvement of symptoms. Equally a FODMAP diet can aid FM associated digestive complaints due to the significant overlap of Irritable Bowel Syndrome with FM. The authors concluded that the clinical application of dietary supplements in the management of FM remains controversial. Yet, dietary interventions appear to be an effective tool in the management of FM. Since various diet interventions demonstrated benefits, dietary adequacy and weight loss may be most critical from a clinical perspective.
Abstract
Fibromyalgia (FM) is a multifactorial syndrome of unknown etiology, characterized by widespread chronic pain and various somatic and psychological manifestations. The management of FM requires a multidisciplinary approach combining both pharmacological and nonpharmacological strategies. Among nonpharmacological strategies, growing evidence suggests a potential beneficial role for nutrition. This review summarizes the possible relationship between FM and nutrition, exploring the available evidence on the effect of dietary supplements and dietary interventions in these patients. Analysis of the literature has shown that the role of dietary supplements remains controversial, although clinical trials with vitamin D, magnesium, iron and probiotics' supplementation show promising results. With regard to dietary interventions, the administration of olive oil, the replacement diet with ancient grains, low-calorie diets, the low FODMAPs diet, the gluten-free diet, the monosodium glutamate and aspartame-free diet, vegetarian diets as well as the Mediterranean diet all appear to be effective in reducing the FM symptoms. These results may suggest that weight loss, together with the psychosomatic component of the disease, should be taken into account. Therefore, although dietary aspects appear to be a promising complementary approach to the treatment of FM, further research is needed to provide the most effective strategies for the management of FM.
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Dietary Interventions in the Management of Fibromyalgia: A Systematic Review and Best-Evidence Synthesis.
Lowry, E, Marley, J, McVeigh, JG, McSorley, E, Allsopp, P, Kerr, D
Nutrients. 2020;12(9)
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Fibromyalgia syndrome (FMS) is a complex multifaceted condition with chronic widespread pain as the most common symptom. Currently there is no standard diagnostic process nor treatment protocol for individuals diagnosed with FMS as symptoms and co-morbidities vary widely among individuals. Since most dietary advice regarding FMS has been anecdotal, this review evaluates the impact of dietary changes on symptoms related to fibromyalgia and discusses the potential mechanisms by which nutrition could help reduce symptoms. This review included 22 studies that found pain to be significantly improved after the consumption of chlorella green algae, a vegan diet, a low FODMAP diet, coenzyme Q10 and acetyl-L-carnitine. Outcome measures aside from pain were inconclusive. Overall, the authors found insufficient evidence to soundly recommend a specific nutritional intervention for the management of fibromyalgia. They suggest further research is needed that include improved study design, larger sample sizes and measurements of oxidative stress and inflammatory biomarkers.
Abstract
Fibromyalgia syndrome (FMS) is characterised by chronic widespread pain alongside fatigue, poor sleep quality and numerous comorbidities. It is estimated to have a worldwide prevalence of 1.78%, with a predominance in females. Treatment interventions for fibromyalgia have limited success, leading to many patients seeking alternative forms of treatment, including modifications to their diet and lifestyle. The effectiveness of dietary changes in fibromyalgia has not been widely researched or evaluated. This systematic review identified twenty-two studies, including 18 randomised control trials (RCTs) and four cohort studies which were eligible for inclusion. In total these studies investigated 17 different nutritional interventions. Significant improvements in reported pain were observed for those following a vegan diet, as well as with the low fermentable oligo di-mono-saccharides and polyols (FODMAP) diets. Supplementation with Chlorella green algae, coenzyme Q10, acetyl-l-carnitine or a combination of vitamin C and E significantly improved measures of pain. Interpretation of these studies was limited due to the frequent poor quality of the study design, the wide heterogeneity between studies, the small sample size and a high degree of bias. Therefore, there is insufficient evidence to recommend any one particular nutritional intervention for the management of fibromyalgia and further research is needed.
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Dietary Patterns and Interventions to Alleviate Chronic Pain.
Dragan, S, Șerban, MC, Damian, G, Buleu, F, Valcovici, M, Christodorescu, R
Nutrients. 2020;12(9)
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A common symptom of many conditions is pain, with chronic pain being a significant cause of emotional distress and disability. Chronic pain is associated with a pro-inflammatory state. Diet interventions can be a helpful tool for the management of chronic pain and its associated inflammation. The increase of nutrient-dense, antioxidant-rich foods and the reduction of pro-inflammatory foods, as well as correcting nutrient deficiencies, all appear to have a positive effect on pain. Whilst previous research on the impact of diet therapy in chronic pain yielded varied results, the authors of this article sought to analyse the most important literature to gain more clarity and direction for future research. After a detailed introduction on the different types of pain, the article summarises the outcome of a range of dietary interventions for chronic pain management. These include calorie restriction and fasting, polyunsaturated fatty acids, low-fat plant-based diets, high protein diet, elimination diet, antioxidants and vitamins including vitamin D, fruits and fibres, prebiotics and probiotics. In the discussion, a helpful table presents the key results organised by type of pain (chronic musculoskeletal pain, chronic headache, neuropathic pain, chronic abdominal pain) and the clinical interventions that showed positive outcomes. In conclusion, diet interventions could be part of a multidisciplinary approach in the management of chronic pain. This article yields an oversight of the possible interventions to consider when supporting people with different types of chronic pain.
Abstract
Pain is one of the main problems for modern society and medicine, being the most common symptom described by almost all patients. When pain becomes chronic, the life of the patients is dramatically affected, being associated with significant emotional distress and/or functional disability. A complex biopsychosocial evaluation is necessary to better understand chronic pain, where good results can be obtained through interconnected biological, psychological, and social factors. The aim of this study was to find the most relevant articles existent in the PubMed database, one of the most comprehensive databases for medical literature, comprising dietary patterns to alleviate chronic pain. Through a combined search using the keywords "chronic pain" and "diet" limited to the last 10 years we obtained 272 results containing the types of diets used for chronic pain published in the PubMed database. Besides classical and alternative methods of treatment described in literature, it was observed that different diets are also a valid solution, due to many components with antioxidant and anti-inflammatory qualities capable to influence chronic pain and to improve the quality of life. Thirty-eight clinical studies and randomized controlled trials are analyzed, in an attempt to characterize present-day dietary patterns and interventions to alleviate chronic pain.