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Low-FODMAP Diet
Definition/Introduction
FODMAP is an acronym for fermentable oligo-, di- and monosaccharides, and polyols. These short-chain carbohydrates, arranged in descending order, are associated with worsening or induction of functional gastrointestinal symptoms such as cramping, bloating, and diarrhea. Such symptoms are at least partially attributable to the non-absorbable nature of osmotic carbohydrates, which undergo bacterial fermentation in the small intestine.[1] The implementation of this diet is in three phases, with the eventual goal of eating well-tolerated foods with some FODMAP content. Up to three-quarters of patients may show a response in six weeks or less.[2]
Issues of Concern
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Issues of Concern
It is not usually advisable to continue the diet for a period longer than four to six weeks due to potentially deleterious effects on the microbiome and vitamin, mineral, and fiber intake. However, the reintroduction of small amounts of FODMAP-containing foods may aid in the gradual restoration of intestinal microflora by supplying important prebiotics to one’s diet.[3] The term prebiotic, though not exclusive to carbohydrates, refers to non-absorbable compounds beneficial to the host’s health and therefore encompasses FODMAPs. Flora native to the human gastrointestinal tract, such as Bifidobacteria, feed on these substances and are responsive to fluctuations in FODMAP intake. The concentration and/or proportion of Bifidobacteria may decrease during the diet’s restrictive phase, but this finding has not translated into health outcomes.[4][5][6]
Patients on the low-FODMAP diet should refrain from eating wheat and rye products, certain stone fruit (including apricots, cherries, peaches, and prunes), persimmons, watermelons, artichokes, beets, some cruciferous vegetables, fennel, garlic, leek, onions, peas, barley, some nuts and seeds, lentils, chickpeas, mushrooms or artificial sweeteners. The list mentioned above is not comprehensive, but instead provides an idea of the scope of limitations. Patients are, however, encouraged to eat tofu, certain nuts and legumes, and quinoa in the meanwhile.[1] Alternatively, if there is a relative contraindication to following a strict low-FODMAP diet, experienced clinicians may suggest a FODMAP-gentle diet in which avoids only certain foods rich in FODMAPs. Relative contraindications are few and include pregnancy and malnutrition.[2]
Clinical Significance
The removal of FODMAPs from a person’s diet has demonstrably improved distressing symptoms of irritable bowel syndrome (IBS) and celiac disease.[2] The worldwide prevalence of IBS alone is estimated to be between 11 and 12 percent and, among functional gastrointestinal diseases, it is also the most common.[7] Multiple studies support that the amount of FODMAPs ingested is related to symptom severity in IBS.[1]
Data from a randomized, controlled trial reveal that a low-FODMAP diet improved quality of life, psychosocial measures (including anxiety), and work performance in adults with IBS with diarrhea.[8] A low-FODMAP diet may also play a role in mitigating functional gastrointestinal symptoms in other conditions such as inflammatory bowel disease, diverticulitis, and fibromyalgia.[9][10][11][12]
Nursing, Allied Health, and Interprofessional Team Interventions
For this dietary intervention, it is optimal for patients to consult with a gastroenterologist and a nutritionist or registered dietician for instructions and symptom monitoring. Regular follow up with clinicians allows patients to incorporate the appropriate changes into their lifestyle successfully. Furthermore, advising the patient and paying close attention to his or her response to the diet will minimize potential harms associated with inadvertently extreme restrictions or the opposite. From the psychosocial perspective, one should note that a practitioner's attitude toward the diet plays an essential role in preventing a patient's poor response to it.[2]
Additionally, clinic visits are an opportunity to disseminate written material to patients, which improves understanding and has been demonstrated to enhance diet adherence.[2][13] [Level 5] If there are relative contraindications or significant patient concerns, an experienced dietician may opt to initiate patients on the aforementioned FODMAP-gentle diet. However, there is not yet substantive research on this version of the diet.[2]
References
Mansueto P, Seidita A, D'Alcamo A, Carroccio A. Role of FODMAPs in Patients With Irritable Bowel Syndrome. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2015 Oct:30(5):665-82. doi: 10.1177/0884533615569886. Epub 2015 Feb 18 [PubMed PMID: 25694210]
Halmos EP, Gibson PR. Controversies and reality of the FODMAP diet for patients with irritable bowel syndrome. Journal of gastroenterology and hepatology. 2019 Jul:34(7):1134-1142. doi: 10.1111/jgh.14650. Epub 2019 Apr 4 [PubMed PMID: 30945376]
Davani-Davari D, Negahdaripour M, Karimzadeh I, Seifan M, Mohkam M, Masoumi SJ, Berenjian A, Ghasemi Y. Prebiotics: Definition, Types, Sources, Mechanisms, and Clinical Applications. Foods (Basel, Switzerland). 2019 Mar 9:8(3):. doi: 10.3390/foods8030092. Epub 2019 Mar 9 [PubMed PMID: 30857316]
Staudacher HM, Lomer MC, Anderson JL, Barrett JS, Muir JG, Irving PM, Whelan K. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. The Journal of nutrition. 2012 Aug:142(8):1510-8. doi: 10.3945/jn.112.159285. Epub 2012 Jun 27 [PubMed PMID: 22739368]
Level 1 (high-level) evidenceHalmos EP, Christophersen CT, Bird AR, Shepherd SJ, Gibson PR, Muir JG. Diets that differ in their FODMAP content alter the colonic luminal microenvironment. Gut. 2015 Jan:64(1):93-100. doi: 10.1136/gutjnl-2014-307264. Epub 2014 Jul 12 [PubMed PMID: 25016597]
Level 1 (high-level) evidenceBarrett JS. How to institute the low-FODMAP diet. Journal of gastroenterology and hepatology. 2017 Mar:32 Suppl 1():8-10. doi: 10.1111/jgh.13686. Epub [PubMed PMID: 28244669]
Chatila R, Merhi M, Hariri E, Sabbah N, Deeb ME. Irritable bowel syndrome: prevalence, risk factors in an adult Lebanese population. BMC gastroenterology. 2017 Dec 2:17(1):137. doi: 10.1186/s12876-017-0698-2. Epub 2017 Dec 2 [PubMed PMID: 29197339]
Eswaran S, Chey WD, Jackson K, Pillai S, Chey SW, Han-Markey T. A Diet Low in Fermentable Oligo-, Di-, and Monosaccharides and Polyols Improves Quality of Life and Reduces Activity Impairment in Patients With Irritable Bowel Syndrome and Diarrhea. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2017 Dec:15(12):1890-1899.e3. doi: 10.1016/j.cgh.2017.06.044. Epub 2017 Jun 28 [PubMed PMID: 28668539]
Level 2 (mid-level) evidenceGibson PR. Use of the low-FODMAP diet in inflammatory bowel disease. Journal of gastroenterology and hepatology. 2017 Mar:32 Suppl 1():40-42. doi: 10.1111/jgh.13695. Epub [PubMed PMID: 28244679]
Bellini M, Tonarelli S, Nagy AG, Pancetti A, Costa F, Ricchiuti A, de Bortoli N, Mosca M, Marchi S, Rossi A. Low FODMAP Diet: Evidence, Doubts, and Hopes. Nutrients. 2020 Jan 4:12(1):. doi: 10.3390/nu12010148. Epub 2020 Jan 4 [PubMed PMID: 31947991]
Gibson PR, Shepherd SJ. Food choice as a key management strategy for functional gastrointestinal symptoms. The American journal of gastroenterology. 2012 May:107(5):657-66; quiz 667. doi: 10.1038/ajg.2012.49. Epub 2012 Apr 10 [PubMed PMID: 22488077]
Uno Y, van Velkinburgh JC. Logical hypothesis: Low FODMAP diet to prevent diverticulitis. World journal of gastrointestinal pharmacology and therapeutics. 2016 Nov 6:7(4):503-512 [PubMed PMID: 27867683]
de Roest RH, Dobbs BR, Chapman BA, Batman B, O'Brien LA, Leeper JA, Hebblethwaite CR, Gearry RB. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. International journal of clinical practice. 2013 Sep:67(9):895-903. doi: 10.1111/ijcp.12128. Epub 2013 May 23 [PubMed PMID: 23701141]
Level 2 (mid-level) evidence