Long-term irritable bowel syndrome symptom control with reintroduction of selected FODMAPs

Ruth M Harvie, Alexandra W Chisholm, Jordan E Bisanz, Jeremy P Burton, Peter Herbison, Kim Schultz, Michael Schultz, Ruth M Harvie, Alexandra W Chisholm, Jordan E Bisanz, Jeremy P Burton, Peter Herbison, Kim Schultz, Michael Schultz

Abstract

Aim: To investigate the long-term effect of dietary education on a low fermentable oligosaccharide, disaccharide and polyol (FODMAP) diet on irritable bowel syndrome (IBS) symptoms and quality of life (QoL).

Methods: Participants with IBS (Rome III) were randomized to two groups. Group I commenced a low FODMAP diet at baseline. At three months, group II, so far a comparator group, crossed over to a low FODMAP diet while group I started re-challenging foods. All patients completed the IBS SSS (IBS symptom severity scoring system, 0-500 points increasing with severity), IBS QoL questionnaire (0-100 increasing with QoL), a FODMAP specific food frequency questionnaire and provided a stool sample at baseline, three and six months for microbiome analysis.

Results: Fifty participants were enrolled into group I (n = 23) or group II (n = 27). Participants in both groups were similar in baseline values but with more men in group I. There was a significantly lower IBS SSS (275.6 ± 63.6 to 128.8 ± 82.5 vs 246.8 ± 71.1 to 203.6 ± 70.1) (P < 0.0002) and increased QoL (68.5 ± 18.0 to 83 ± 13.4 vs 72.9 ± 12.8 to 73.3 ± 14.4) (P < 0.0001) in group I vs group II at 3 mo. The reduced IBS SSS was sustained at 6 mo in group I (160 ± 102) and replicated in group II (124 ± 76). Fiber intake decreased on the low FODMAP diet (33 ± 17 g/d to 21 ± 8 g/d) (P < 0.01) and after re-introducing FODMAP containing foods increased again to 27 ± 9 g/d. There was no change seen in the intestinal microbiome when participants adopted a low FODMAP diet.

Conclusion: This study demonstrated that a reduction in FODMAPs improves symptoms in IBS and this improvement can be maintained while reintroducing FODMAPs.

Keywords: Diet; FODMAP; Irritable bowel syndrome; Microbiome; Microbiota; Short chain fermentable carbohydrates.

Conflict of interest statement

Conflict-of-interest statement: All authors report no conflicts of interest.

Figures

Figure 1
Figure 1
Participant flow.
Figure 2
Figure 2
Comparison of total FODMAP intake between group I who received dietary education immediately after randomisation and began reintroducing FODMAP at three months and group II who received dietary education after the collection of the 3-mo data. Total FODMAP is the sum of galacto-oligosaccharides, fructo-oligosacchardies, lactose, fructose in excess of glucose, sorbitol and mannitol in grams as measured on a FODMAP specific food frequency questionnaire[34]. aP < 0.05, bP < 0.01.
Figure 3
Figure 3
Change in IBS severity scoring system[35] by group and time period. Participants in Group I received dietary education immediately after baseline measures and started reintroductions to tolerance at 3 mo. Participants in group II received dietary education after collection of data at 3 mo. Scores > 300 indicate severe IBS, 175-300 indicate moderate IBS, 50-175 indicate mild IBS and scores aP < 0.05, bP < 0.01.
Figure 4
Figure 4
Maximum number of bowel motions reported per day by participants by time period and group. Group I received their dietary education after the collection of baseline measures and started reintroducing FODMAP to tolerance at 3 mo. Group II received their dietary education after the collection of data at 3 mo. bP < 0.01.
Figure 5
Figure 5
Days in ten when participants were experiencing pain by time period and group. Participants in Group I received dietary education after collection of baseline measures and at 3 mo were encouraged to reintroduce FODMAP foods to tolerance. Participants in Group II received dietary education after the collection of data at 3 mo. bP < 0.01.
Figure 6
Figure 6
Change in severity of pain (A) and abdominal distension (B) by group and time period. Increasing scores represent increasing severity. This is a subscale of the irritable bowel syndrome symptom severity scoring system[34]. Participants in group I received dietary education immediately after collecting baseline measures and after 3 mo were reintroducing FODMAPs to tolerance. Participants in Group II received dietary education after the data collection at 3 mo.
Figure 7
Figure 7
Change in irritable bowel syndrome related quality of life[36] by time period and group. Participants in group I received dietary education after the collection of baseline measures and started reintroducing FODMAP to tolerance after collecting of data at 3 mo. Group II received their dietary education after the collection of data at 3 mo. aP < 0.05, bP < 0.01.
Figure 8
Figure 8
Comparison of total fiber intake between group I who received dietary education immediately after randomisation and began reintroducing FODMAP at three months and group II who received dietary education after the collection of the 3-mo data. Fiber intake was measured on a food frequency questionnaire[34] previously validated for estimating fibre intakes. Recommended fiber intakes for NZ adult males are 30 g per day and for adult NZ females are 25 g per day as represented by the horizontal lines, bP < 0.01.
Figure 9
Figure 9
Diversity of samples measured by the Shannon index. Participants in Group I commenced the low FODMAP diet after collection of the baseline measures and in Group II after the collection of data at three months. Each sample is represented by one dot.

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