Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. ACTA ACUST UNITED AC. 2006;106:1631-1639. [PMID: 17000196 DOI: 10.1016/j.jada.2006.07.010]

Diet, nutraceuticals, and lifestyle interventions for the treatment and management of irritable bowel syndrome

Irritable bowel syndrome (IBS) is the most common gastrointestinal (GI) disorder of the gut-brain interaction and causes significant GI distress. The etiology of IBS is multifactorial, with food intolerances being a frequent contributing factor to IBS symptoms. Diet and lifestyle interventions are key components in comprehensive IBS care. In this review, we examine the current evidence-based dietary approaches for treating IBS. The low-FODMAP diet has the most robust data for improving overall symptom burden. In conjunction with guidance from a registered dietitian, certain patients may benefit from targeted dietary elimination of specific carbohydrates such as lactose or fructose or gluten. Among the nutraceuticals used to treat IBS, peppermint oil has sufficient evidence and appropriate safety data to recommend adjunctive use to reduce IBS symptoms. Although prebiotic and probiotic food sources may be beneficial to the microbiome, there is not enough evidence to support the routine use of prebiotic or probiotic supplements. Given the complexity of IBS, a holistic approach in which clinicians address a patients' diet, culture, sleep hygiene, exercise habits, and mental health may improve patients' overall quality of life.

Demystifying Carbohydrate Maldigestion: A Clinical Review

Carbohydrate intolerance is a poorly understood and potentially overlooked cause of unexplained gastrointestinal symptoms, particularly among patients with disorders of gut-brain interaction. Symptoms related to carbohydrate intolerance arise from bacterial fermentation of unabsorbed carbohydrates leading to increased gases and osmotic load within the gastrointestinal tract. This mechanism is shared across various carbohydrates, including lactose, sucrose, maltose, fructose, and fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. Primary forms of carbohydrate maldigestion typically affect one specific type of carbohydrate and result from inherited defects in specific brush-border enzymes or transport mechanisms, whereas secondary, or acquired, forms of carbohydrate maldigestion can arise from conditions that affect the structural integrity or function of the pancreas and small intestine. Although confirmation of a disaccharidase deficiency does not imply clinical relevance, obtaining a careful patient history with appropriate use of breath testing, duodenal disaccharidase assay, and response to dietary modification can help identify patients whose symptoms are associated with carbohydrate maldigestion and who may benefit from treatment. Dietary modification remains the cornerstone of therapy for patients with carbohydrate intolerance and should focus on determining the most liberal diet for patients that allows symptom control. Given the complexity and time-consuming nature of this process, clinicians are encouraged to engage the help of dietitians with expertise in the treatment of disorders of gut-brain interaction where available. Enzyme replacement therapy can also be an important adjunct to dietary management, with sacrosidase improving symptoms in sucrase-isomaltase deficiency and helping patients to liberalize their diet.

All FODMAPs Aren't Created Equal: Results of a Randomized Reintroduction Trial in Patients With Irritable Bowel Syndrome

BACKGROUND & AIMS

A diet low in fermentable oligo, di, monosaccharides, and polyols (FODMAPs) is one of the recommended management strategies for irritable bowel syndrome (IBS). However, while effective, adherence to restricting dietary FODMAPs can be challenging and burdensome. The question remains whether limiting all FODMAPs during the restrictive phase of the diet is necessary for symptomatic improvement in the dietary treatment of IBS, or if targeting selected groups of FODMAPs for restriction is sufficient for clinical response. Our study aimed to determine which individual FODMAPs are most likely to lead to symptom generation in patients with IBS who have improved with fodmap restriction.

METHODS

Patients meeting Rome IV criteria for IBS were invited to participate in a 12-week study to identify individual FODMAP sensitivities. Those subjects who demonstrated symptom improvement after a 2- to 4-week open-label FODMAP elimination period were recruited to a 10-week blinded-phased FODMAP reintroduction phase of 7 days for each FODMAP. Throughout the study period, daily symptom severity (0-10 point numerical rating system) was recorded. A mixed effect statistical analysis model was used.

RESULTS

Between 2018 and 2020, 45 subjects were enrolled. Twenty-five subjects improved with FODMAP elimination, and 21 patients continued into the reintroduction phase of the study. Fructans and galacto-oligosaccharides (GOS) both were associated with worsened abdominal pain (P = .007 and P = .04, respectively). GOS were associated with an increase in bloating (P = 03). Both bloating and abdominal pain worsened throughout the study, regardless of the FODMAP reintroduction (P = .006).

CONCLUSION

Our results suggest that the reintroduction of select FODMAPs may be responsible for symptom generation in patients with IBS who have responded to a low FODMAP diet, and provide a strong rationale for performing a future trial comparing the treatment effects of a limited low-FODMAP diet and a standard low-FODMAP diet.

CLINICALTRIALS

GOV: NCT03052439.

Low-FODMAP Diet for Irritable Bowel Syndrome: Insights from Microbiome

Irritable bowel syndrome (IBS) is a prevalent gastrointestinal disorder characterized by chronic abdominal pain, bloating, and altered bowel habits. Low-FODMAP diets, which involve restricting fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, have emerged as an effective dietary intervention for alleviating IBS symptoms. This review paper aims to synthesize current insights into the impact of a low-FODMAP diet on the gut microbiome and its mechanisms of action in managing IBS. We explore the alterations in microbial composition and function associated with a low-FODMAP diet and discuss the implications of these changes for gut health and symptom relief. Additionally, we examine the balance between symptom improvement and potential negative effects on microbial diversity and long-term gut health. Emerging evidence suggests that while a low-FODMAP diet can significantly reduce IBS symptoms, it may also lead to reductions in beneficial microbial populations. Strategies to mitigate these effects, such as the reintroduction phase and the use of probiotics, are evaluated. This review highlights the importance of a personalized approach to dietary management in IBS, considering individual variations in microbiome responses. Understanding the intricate relationship between diet, the gut microbiome, and IBS symptomatology will guide the development of more effective, sustainable dietary strategies for IBS patients.

Adapted Low-FODMAP Diet in IBS Patients with and without Fibromyalgia: Long-Term Adherence and Outcomes

BACKGROUND/OBJECTIVES

A low-FODMAPs Diet (LFD) is considered a "second line" dietary strategy for irritable bowel syndrome (IBS) but, after a period of strict restriction of all FODMAP foods, it has to be adapted and tailored to each patient (AdLFD). Fibromyalgia often coexists with IBS in up to 65% of cases. Our aims were to evaluate if comorbid fibromyalgia influenced the long-term clinical outcomes and adherence to an AdLFD in IBS patients.

METHODS

IBS patients with or without fibromyalgia who had started an AdLFD were enrolled. Patients had been evaluated before starting the LFD (T0). After a mean follow-up of 62.5 ± 22.7 months (T1), they were re-evaluated using questionnaires on disease severity, bowel habits, psychological status, and adherence to AdLFD.

RESULTS

In total, 51 IBS patients entered the study. Nineteen of them had comorbid fibromyalgia. Thirty patients reported a reduction in symptom severity at T1 in comparison with T0. Despite some slight differences in single IBS Symptom Severity Score items, comorbid fibromyalgia did not influence the IBS-SSS total score at T1. Patients with comorbid fibromyalgia showed a higher Hospital Anxiety and Depression Scale (HADS) score at baseline. A total of 44 patients showed good long-term adherence to the AdLFD. All patients improved their HADS score and had long-term adherence to the AdLFD.

CONCLUSIONS

Comorbid fibromyalgia showed only a slight influence on long-term outcomes of an AdLFD on IBS symptoms, without affecting the relief of global symptoms. No influence on long-term adherence to AdLFD was detected. Hence, this approach can be taken into account in fibromyalgia patients for a nonpharmacological management of IBS symptoms. However, multicentric studies on larger samples would be welcome in the future.

Intestinal permeability disturbances: causes, diseases and therapy

Nowadays, a pathological increase in the permeability of the intestinal barrier (the so-called leaky gut) is increasingly being diagnosed. This condition can be caused by various factors, mainly from the external environment. Damage to the intestinal barrier entails a number of adverse phenomena: dysbiosis, translocation of microorganisms deep into the intestinal tissue, immune response, development of chronic inflammation. These phenomena can ultimately lead to a vicious cycle that promotes the development of inflammation and further damage to the barrier. Activated immune cells in mucosal tissues with broken barriers can migrate to other organs and negatively affect their functioning. Damaged intestinal barrier can facilitate the development of local diseases such as irritable bowel disease, inflammatory bowel disease or celiac disease, but also the development of systemic inflammatory diseases such as rheumatoid arthritis, ankylosing spondylitis, hepatitis, and lupus erythematosus, neurodegenerative or psychiatric conditions, or metabolic diseases such as diabetes or obesity. However, it must be emphasized that the causal links between a leaky gut barrier and the onset of certain diseases often remain unclear and require in-depth research. In light of recent research, it becomes crucial to prevent damage to the intestinal barrier, as well as to develop therapies for the barrier when it is damaged. This paper presents the current state of knowledge on the causes, health consequences and attempts to treat excessive permeability of the intestinal barrier.

Development of a low-fructose carbohydrate gel for exercise application

This study aimed to develop a low-fructose (<3 g/serve) carbohydrate (CHO) gel for athletes. Various prototypes with 30 g CHO/serve and differing water content (12 %, 21 %, 32 %, 39 % w/v) were created and evaluated for sensory attributes. The final gel contained 62.1 ± 0.2 g CHO/100 g with 0.17 % w/w fructose. Endurance athletes (n = 20) underwent a feeding-challenge protocol, ingesting 30 g gel every 20 min during 2 h of running (60 %V ˙ O2max), followed by a 1 h self-paced distance test. Blood glucose increased significantly from baseline (4.0 ± 0.9 vs. 6.6 ± 0.6 mmol/L, p < 0.001) and remained elevated after the distance test (4.9 ± 0.7 mmol/L, p < 0.05). Breath hydrogen levels increased (5 ± 4 ppm, p < 0.05) without substantial CHO malabsorption detected. Gastrointestinal symptoms (GIS) increased during exercise but were mild. The low-fructose CHO gel demonstrated good tolerance, promoting glucose availability without severe GIS or CHO malabsorption.

Structure-function relationship of oat flour fractions when blended with wheat flour: Instrumental and nutritional quality characterization of resulting breads

The present work investigated the structure-function relationship of dry fractionated oat flour (DFOF) as a techno-functional ingredient using bread as a model system. Mechanically, DFOF fractions (F), that is, F1: <224 µm, F2: 250-280 µm, F3: 280-500 µm, F4: 500-600 µm, and whole oat flour (F5) were blended with white wheat flour at 10%, 30%, and 50% substitution levels for bread making. The blended flours, doughs, and bread samples were assessed for their techno-functional, nutritional, and structural characteristics. The results of Mixolab and the Rapid Visco Analyzer show that the 50% substituted F3 fraction exhibits the highest water absorption properties (69.53%), whereas the 50% F1 fraction exhibits the highest peak viscosity of the past slurry. Analysis of bread samples revealed a lower particle size of DFOF fractions and higher supplementation levels, increased β-glucan levels (0.13-1.29 g/100 bread (db), reduced fermentable monosaccharides, that is, glucose (1.44-0.33 g/100 g), and fructose (1.06-0.28 g/100 g). The effect of particle size surpassed the substitution level effect on bread volume reduction. The lowest hardness value for F1 is 10%, and the highest value for F2 is 50%. The total number of cells in the bread slice decreased from the control to the F4 fraction (50%). Multi-criteria analysis indicated that DFOF fractions produced breads with similar structure and higher nutritional value developed from white wheat flour. PRACTICAL APPLICATION: The use of mechanically fractionated oat flours fractions in white wheat flour breads can improve the nutritional profile without affecting the physical properties of the bread product. Based on the oat flour fractions, bakers and food processing companies can tailor the bread formulations for high β-glucan, high fiber, and low reduced sugar claims.

Factors Associated With Adherence to a Low Fermentable Carbohydrate Diet in Children With Functional Gastrointestinal Disorders

BACKGROUND

The low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet (LFD) has been associated with reduced symptomology in pediatric functional gastrointestinal disorders (FGIDs). The LFD is a complex dietary intervention that may be difficult to follow; thus, there is great interest in determining factors that contribute to adherence.

OBJECTIVE

To examine whether baseline abdominal pain, emotional/behavioral problems, or quality of life predict adherence to the LFD in children with FGIDs.

DESIGN

This was a single-group pre-post intervention design within a larger randomized controlled trial.

PARTICIPANTS/SETTING

Thirty 7- to 12-year-old children with FGIDs were recruited from pediatric gastrointestinal and primary care settings throughout Texas from 2019 to 2021. Evaluated participants were randomized to an LFD intervention as part of a larger randomized controlled trial.

INTERVENTION

Participants received dietary counseling and followed the LFD for 3 weeks.

MEASURES

Emotional or behavioral problems and quality of life were obtained via parent report, and abdominal pain was measured via child report. Adherence was assessed by using diet records and computed by a decrease in consumption of overall FODMAP intake.

STATISTICAL ANALYSES PERFORMED

A hierarchical generalized linear mixed regression model examined factors associated with adherence.

RESULTS

Greater baseline quality of life was associated with better adherence to the LFD (beta coefficient β = -.02, P = 0.03), and baseline emotional/behavioral problems and abdominal pain complaints were not significantly associated with adherence (all Ps > 0.28).

CONCLUSIONS

Higher child quality of life as reported by parents was related to increased adherence to this complex dietary intervention.

Assessment of dietary interventions including low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet as management for fructose intolerance

OBJECTIVES

Abdominal pain remains one of the most common referral reasons to pediatric gastroenterology. Dietary intolerances are often considered but due to various factors are hardly pursued. We observed that diet review in large number of children with abdominal pain was high in sugary foods which led to food intolerance investigation and dietary intervention.

METHODS

A retrospective review was conducted of patients presenting with abdominal pain, diarrhea, or vomiting and negative GI evaluation, who underwent fructose breath testing. Patients younger than 20 years old who were seen between June 1, 2018 and March 1, 2021 were included. Statistical analysis was performed in R.

RESULTS

There were 110 pediatric patients during the study period who underwent fructose breath testing, with 31% male and 69% female. The average age was 12.14 ± 4.01 years, and the average BMI was 21.21 ± 6.12. Abdominal pain was the most common presenting symptom (74.5%) followed by diarrhea and vomiting. Seventy-seven patients (70%) had a positive fructose breath test and were diagnosed with dietary intolerance to fructose. The 56 (67.5%) of those patients experienced symptoms during the breath test. Forty-three patients improved with dietary intervention. Twenty-seven on low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet and 16 on other diets.

CONCLUSIONS

Based on analysis of our cohort of children with abdominal pain and high incidence of fructose intolerance as well as improvement in symptoms, following dietary changes, this condition should be considered and treated. Further investigation is needed to improve diagnostic testing but also into understanding mechanisms behind symptom presentation in this population.

Evaluation of the effects of the FODMAP diet and probiotics on irritable bowel syndrome (IBS) symptoms, quality of life and depression in women with IBS

BACKGROUND

The present study aimed to evaluate the effects of fermented oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP) diet therapy and probiotics on irritable bowel syndrome (IBS) symptoms, quality of life and depression in women diagnosed with IBS.

METHODS

For the study, 52 female IBS patients between the ages of 20 and 55 were enrolled. Individuals were monitored for 6 weeks in two groups. A low-FODMAP diet was given to the first group and a low-FODMAP diet plus a probiotic supplement was given to the second group (Lactobacillus rhamnosus). Three-day food intake records were kept at the start of the study and continued up to its conclusion, with a weekly check-in in between. At the start and end of the trial, participants completed the Hospital Anxiety and Depression Scale, IBS Quality of Life Scale (IBS-QOL) and IBS Symptom Severity Score (IBS-SSS). The Bristol Stool Scale was also used by the subjects to record their daily stool densities.

RESULTS

At the end of the study, it was determined that the daily intake of FODMAP (lactose [g] + oligosaccharides [g] + mannitol [g] + sorbitol [g]) decreased significantly in both groups (p < 0.05). At the end of the study, it was determined that the IBS-SSS, anxiety and depression scores of the individuals in both groups decreased significantly and their IBS-QOL scores increased significantly (p < 0.05). However, the difference between these values between the groups was not statistically significant (p > 0.05).

CONCLUSIONS

A low-FODMAP diet has been demonstrated to benefit people by lessening the severity of their IBS symptoms and enhancing their quality of life. No evidence was found, however, to indicate that the FODMAP diet would be more beneficial on these metrics if additional probiotics were used. It should be emphasised that the reaction of probiotic strains may vary depending on the IBS subtype.

The Role of the FODMAP Diet in IBS

The low FODMAP (fermentable oligosaccharide, disaccharide, monosaccharide, and polyol) diet is a beneficial therapeutic approach for patients with irritable bowel syndrome (IBS). However, how the low FODMAP diet works is still not completely understood. These mechanisms encompass not only traditionally known factors such as luminal distension induced by gas and water but also recent evidence on the role of FOMAPs in the modulation of visceral hypersensitivity, increases in intestinal permeability, the induction of microbiota changes, and the production of short-chain fatty acids (SCFAs), as well as metabolomics and alterations in motility. Although most of the supporting evidence is of low quality, recent trials have confirmed its effectiveness, even though the majority of the evidence pertains only to the restriction phase and its effectiveness in relieving abdominal bloating and pain. This review examines potential pathophysiological mechanisms and provides an overview of the existing evidence on the effectiveness of the low FODMAP diet across various IBS subtypes. Key considerations for its use include the challenges and disadvantages associated with its practical implementation, including the need for professional guidance, variations in individual responses, concerns related to microbiota, nutritional deficiencies, the development of constipation, the necessity of excluding an eating disorder before commencing the diet, and the scarcity of long-term data. Despite its recognized efficacy in symptom management, acknowledging these limitations becomes imperative for a nuanced comprehension of the role of a low FODMAP diet in managing IBS. By investigating its potential mechanisms and evidence across IBS subtypes and addressing emerging modulations alongside limitations, this review aims to serve as a valuable resource for healthcare practitioners, researchers, and patients navigating the intricate landscape of IBS.

Digesting the Impact of Diet on Irritable Bowel Syndrome (IBS): Exploring Solutions for Controlling IBS

Irritable bowel syndrome (IBS) plagues nearly a fifth of the general population. It is a chronic illness that can significantly lower quality of life (QoL) and work productivity. The relationship between diet and the functional gastrointestinal (GI) symptoms present in IBS is gaining more and more attention. In addition to being a factor in the pathophysiology of IBS, diet also has a significant impact on symptoms and overall well-being. Recent research has also shown that short-chain fermentable carbohydrates increase colonic gas production and small intestine water volume, which in turn causes functional GI symptoms in those with visceral hypersensitivity. This review article has consolidated various studies highlighting the association between certain foods and the pathophysiology of IBS. It has also talked about how restricting certain food items from the diet of affected individuals can relieve symptoms and in some cases can be more effective than pharmacotherapy. Although the low reduced fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) diet (LFD) is a well-known method of treating IBS symptoms, over a third of individuals do not benefit from it. This article has also discussed the effectiveness and applicability of the LFD compared to other dietary therapies for the long-term management of IBS.

Gastrointestinal Tract Considerations: Part II: How Should a Rheumatologist Best Manage Common Lower Gastrointestinal Tract Complaints in Systemic Sclerosis?

Lower gastrointestinal (GI) symptoms are a frequently encountered problem for clinicians managing patients with systemic sclerosis. The current management practices are focused on the treatment of symptoms with little information available on how to use GI investigations in daily practice. This review demonstrates how to integrate the objective assessment of common lower GI symptoms into clinical care with the aim of guiding clinical decision making. Understanding the type of abnormal GI function that is affecting a patient and determining which parts of the gut are impacted can help clinicians to target therapy more precisely.

Salt stress affects the biomass of industrial crop Jerusalem artichoke by affecting sugar transport and metabolism

Even though Jerusalem artichoke (Helianthus tuberosus L.) has strong resistance to abiotic stresses, salinity can still reduce the biomass of Jerusalem artichoke. The purpose of this study was to elucidate the differences in the development of Jerusalem artichoke and the dynamics of sugar throughout the growth period under high (7.23-8.15 g/kg) and low (3.20-4.32 g/kg) salinity stress in the field in Jiangsu Province, China. This study confirmed that high salinity promoted the conversion of reducing sugars to non-reducing sugars (fructans) in Jerusalem artichoke tubers, but significantly reduced the biomass of Jerusalem artichoke and advanced the peak time of the dry matter accumulation of aerial parts. In addition, in the early and late stages of tuberization, the total sugar content of tubers under low salinity conditions (786 ± 8 mg/g and 491 ± 8 mg/g) was 93.3% and 1.15 times than those under high salinity conditions, respectively. Moreover, the total sugar content in stems was consistently greater under high than low salinity conditions in the same period. The accumulation rate and the amount of dry matter were significantly higher in stems than in other tissues. Therefore, the aerial parts of "Nanyu No. 1" could be harvested before mid-to-early October, and the tubers after mid-November. This study revealed the internal reasons for the decreased yield of Jerusalem artichoke under salt stress, and provided theoretical basis and guidance for the cultivation and utilization of Jerusalem artichoke in saline-alkali soil.

Fructose malabsorption in ChREBP-deficient mice disrupts the small intestine immune microenvironment and leads to diarrhea-dominant bowel habit changes

BACKGROUND

The mechanism by which incompletely absorbed fructose causes gastrointestinal symptoms is not fully understood. In this study, we investigated the immunological mechanisms of bowel habit changes associated with fructose malabsorption by examining Chrebp-knockout mice exhibiting defective fructose absorption.

METHODS

Mice were fed a high-fructose diet (HFrD), and stool parameters were monitored. The gene expression in the small intestine was analyzed by RNA sequencing. Intestinal immune responses were assessed. The microbiota composition was determined by 16S rRNA profiling. Antibiotics were used to assess the relevance of microbes for HFrD-induced bowel habit changes.

RESULTS

Chrebp-knockout (KO) mice fed HFrD showed diarrhea. Small-intestine samples from HFrD-fed Chrebp-KO mice revealed differentially expressed genes involved in the immune pathways, including IgA production. The number of IgA-producing cells in the small intestine decreased in HFrD-fed Chrebp-KO mice. These mice showed signs of increased intestinal permeability. Chrebp-KO mice fed a control diet showed intestinal bacterial imbalance, which the HFrD exaggerated. Bacterial reduction improved diarrhea-associated stool parameters and restored the decreased IgA synthesis induced in HFrD-fed Chrebp-KO mice.

CONCLUSIONS

The collective data indicate that gut microbiome imbalance and disrupting homeostatic intestinal immune responses account for the development of gastrointestinal symptoms induced by fructose malabsorption.

Mechanisms underlying food-related symptoms in disorders of gut-brain interaction: Course ahead in research and clinical practice

A subgroup of patients with a disorder of gut-brain interaction (DGBI) report symptoms such as abdominal pain, gas-related symptoms, dyspeptic symptoms and loose stool or urgency after meal intake. Therefore, the effect of several dietary therapies including fibre-rich or restrictive diets have already been studied in patients with irritable bowel syndrome, functional abdominal bloating or distention, and functional dyspepsia. However, there is a paucity of studies in the literature on the mechanisms underlying food-related symptoms. Therefore, this review focuses on these potential mechanisms and explains the role of nutrient sensing and tasting, physical considerations, malabsorption or allergy-like reaction to food and its interaction with microbiota. In addition, it emphasizes the importance of future research and clinical practice regarding food-related symptoms in patients with a DGBI.

Leaky Gut and the Ingredients That Help Treat It: A Review

The human body is in daily contact with potentially toxic and infectious substances in the gastrointestinal tract (GIT). The GIT has the most significant load of antigens. The GIT can protect the intestinal integrity by allowing the passage of beneficial agents and blocking the path of harmful substances. Under normal conditions, a healthy intestinal barrier prevents toxic elements from entering the blood stream. However, factors such as stress, an unhealthy diet, excessive alcohol, antibiotics, and drug consumption can compromise the composition of the intestinal microbiota and the homeostasis of the intestinal barrier function of the intestine, leading to increased intestinal permeability. Intestinal hyperpermeability can allow the entry of harmful agents through the junctions of the intestinal epithelium, which pass into the bloodstream and affect various organs and systems. Thus, leaky gut syndrome and intestinal barrier dysfunction are associated with intestinal diseases, such as inflammatory bowel disease and irritable bowel syndrome, as well as extra-intestinal diseases, including heart diseases, obesity, type 1 diabetes mellitus, and celiac disease. Given the relationship between intestinal permeability and numerous conditions, it is convenient to seek an excellent strategy to avoid or reduce the increase in intestinal permeability. The impact of dietary nutrients on barrier function can be crucial for designing new strategies for patients with the pathogenesis of leaky gut-related diseases associated with epithelial barrier dysfunctions. In this review article, the role of functional ingredients is suggested as mediators of leaky gut-related disorders.

Children with functional abdominal pain disorders successfully decrease FODMAP food intake on a low FODMAP diet with modest improvements in nutritional intake and diet quality

BACKGROUND

We sought to determine how a low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) diet (LFD) affected high FODMAP food intake, nutrient intake, and diet quality in children with functional abdominal pain disorders (FAPD).

METHODS

Children (ages 7-13 years) with Rome IV FAPD began a dietitian-guided LFD. Three-day food records were captured at baseline and 2-3 weeks into the LFD. Intake of high FODMAP foods, energy, macronutrients, micronutrients, food groups, and ultra-processed foods were determined.

KEY RESULTS

Median age of participants was 11 years, and 19/31 (61%) were female. Twenty-eight (90%) decreased high FODMAP food intake on the LFD: overall median (25-75%) high FODMAP foods/day decreased from 5.7 (3.6-7.3) to 2 (0.3-3.7) (p < 0.001). A more adherent subset (n = 22/71%) of participants consumed on average ≤3 high FODMAP foods per day during the LFD. Baseline nutritional intake and quality were generally poor with several micronutrient deficiencies identified. Diet quality improved on the LFD with increased servings of vegetables and protein and decreased consumption of ultra-processed foods, trans-fatty acids, and added sugars. On the LFD, there were significant decreases in total carbohydrates and thiamin (remained within recommended intake) and significant increases in vitamin B6 (p = 0.029), vitamin C (p = 0.019), and vitamin E (p = 0.009). Children more adherent to the LFD further increased vitamin D, magnesium, potassium, and fat servings.

CONCLUSIONS AND INFERENCES

The majority of children with FAPD on a dietitian-led LFD successfully decreased high FODMAP food intake. Children with FAPD on the LFD (vs. baseline) modestly improved micronutrient intake and diet quality.

Modulating the gut microenvironment as a treatment strategy for irritable bowel syndrome: a narrative review

Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction with a complex pathophysiology. Growing evidence suggests that alterations of the gut microenvironment, including microbiota composition and function, may be involved in symptom generation. Therefore, attempts to modulate the gut microenvironment have provided promising results as an indirect approach for IBS management. Antibiotics, probiotics, prebiotics, food and faecal microbiota transplantation are the main strategies for alleviating IBS symptom severity by modulating gut microbiota composition and function (eg. metabolism), gut barrier integrity and immune activity, although with varying efficacy. In this narrative review, we aim to provide an overview of the current approaches targeting the gut microenvironment in order to indirectly manage IBS symptoms.

Therapeutic Potential of the 4 Strategies to SUlfide-REduction (4-SURE) Diet in Adults with Mild to Moderately Active Ulcerative Colitis: An Open-Label Feasibility Study

BACKGROUND

Diet therapy may bridge the therapeutic gap in ulcerative colitis (UC).

OBJECTIVES

The novel 4-SURE diet (4-strategies-to-SUlfide-REduction), designed to modulate colonic fermentation and influence production of excess hydrogen sulfide, was examined in a feasibility study for tolerability, clinical efficacy, and effects on microbial endpoints.

METHODS

Adults aged ≥18 y old with mild to moderately active UC were advised to increase intake of fermentable fibers, restrict total and sulfur-containing proteins, and avoid specific food additives for 8 wk. The primary outcome was tolerability of diet [100-mm visual analogue scale (VAS) with 100-mm being intolerable]. Secondary exploratory outcomes were self-reported adherence (always adherent ≥76-100%), clinical and endoscopic response (reduction in partial Mayo ≥2 and Mayo endoscopic subscore ≥1), modulation of fecal characteristics including markers of protein and carbohydrate fermentation, and food-related quality of life (IBD-FRQoL-29). Primary analysis was by intention to treat, performed using paired t and Wilcoxon signed-rank statistical tests.

RESULTS

Twenty-eight adults with UC [mean (range) age: 42 (22-72) y, 15 females, 3 proctitis, 14 left-sided, and 11 extensive] were studied. Prescribed dietary targets were achieved overall. The diet was well tolerated (VAS: 19 mm; 95% CI: 7, 31 mm) with 95% frequently or always adherent. Clinical response occurred in 13 of 28 (46%) and endoscopic improvement in 10 of 28 participants (36%). Two participants (7%) worsened. Fecal excretion of SCFAs increased by 69% (P < 0.0001), whereas the proportion of branched-chain fatty acids to SCFAs was suppressed by 27% (-1.34%; 95% CI: -2.28%, -0.40%; P = 0.007). The FRQoL improved by 10 points (95% CI: 4, 16; P < 0.001).

CONCLUSIONS

The 4-SURE dietary strategy is considered tolerable and an acceptable diet by adults with mild to moderately active UC. The dietary teachings achieved the prescribed dietary and fecal targets. Given signals of therapeutic efficacy, further evaluation of this diet is warranted in a placebo-controlled trial. This trial was registered at https://www.anzctr.org.au (Australian New Zealand Clinical Trials Registry) as ACTRN12619000063112.

Carbohydrate Maldigestion and Intolerance

This review summarizes dietary carbohydrate intolerance conditions and recent advances on the possible role of carbohydrate maldigestion and dietary outcomes in patients with functional bowel disease. When malabsorbed carbohydrates reach the colon, they are fermented by colonic bacteria, with the production of short-chain fatty acids and gas lowering colonic pH. The appearance of diarrhoea or symptoms of flatulence depends in part on the balance between the production and elimination of these fermentation products. Different studies have shown that there are no differences in the frequency of sugar malabsorption between patients with irritable bowel disease (IBS) and healthy controls; however, the severity of symptoms after a sugar challenge is higher in patients than in controls. A diet low in 'Fermentable, Oligo-Di- and Monosaccharides and Polyols' (FODMAPs) is an effective treatment for global symptoms and abdominal pain in IBS, but its implementation should be supervised by a trained dietitian. A 'bottom-up' approach to the low-FODMAP diet has been suggested to avoid an alteration of gut microbiota and nutritional status. Two approaches have been suggested in this regard: starting with only certain subgroups of the low-FODMAP diet based on dietary history or with a gluten-free diet.

The Effect of Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAP) Meals on Transient Lower Esophageal Relaxations (TLESR) in Gastroesophageal Reflux Disease (GERD) Patients with Overlapping Irritable Bowel Syndrome (IBS)

A randomized crossover study in eight patients (6 F, age 57 ± 13) with overlapping GERD-IBS (non-constipation) was conducted to evaluate the effects of rice noodle vs. wheat noodle meals for breakfast and lunch on postprandial TLESR, intestinal gas production, and GERD/GI symptoms. Results: Wheat ingestion was significantly associated with more frequent TLESR after lunch than rice (5.0 ± 0.7 vs. 1.9 ± 0.3 times/2 h, p = 0.01). After lunch, wheat ingestion was significantly associated with higher H2 and CH4 levels compared to rice ingestion (p < 0.05), while H2 and CH4 levels before lunch were similar (p > 0.05). The area under curve of H2 concentration until 2 h after lunch significantly correlated with the TLESR number (r = 0.69, p = 0.04). Postprandial regurgitation (2.9 ± 1.2 vs. 0.4 ± 0.2), bloating (7.0 ± 0.4 vs. 3.1 ± 0.9), satiety (7.7 ± 0.4 vs. 3.5 ± 0.9), and belching (3.8 ± 1.2 vs. 1.1 ± 0.6) symptom scores were significantly greater after wheat compared to rice noodle ingestion (p < 0.05). Conclusion: Wheat noodle meals, part of a high FODMAP diet, induced a higher frequency of TLESRs, a higher GERD, and higher upper-GI symptom scores than rice noodle meals, part of a low FODMAP diet, in patients with overlapping IBS-GERD. These effects were associated with more intestinal gas production. Thus, a low FODMAP diet may relieve GERD symptoms in GERD patients with overlapping IBS.

A Comparison of the Low-FODMAPs Diet and a Tritordeum-Based Diet on the Gastrointestinal Symptom Profile of Patients Suffering from Irritable Bowel Syndrome-Diarrhea Variant (IBS-D): A Randomized Controlled Trial

The dietary approach low in oligosaccharides, disaccharides, monosaccharides, and fermentable polyols (FODMAPs-LFD) is a good strategy for treating irritable bowel syndrome (IBS). Beyond the LFD, other dietary approaches with beneficial effects may be hypothesized. Among them, consumption of Tritordeum-based foods (TBD, bread, bakery products, and pasta) in substitution of other cereals seem to achieve promising results. In a randomized controlled trial, we compared the effects of 12 weeks of LFD to TBD in improving the symptom profile of IBS-diarrhea (IBS-D) patients. The two diets equally improved gastrointestinal symptoms and QoL, measured by the IBS Severity Scoring System (IBS-SSS) questionnaire, reducing the total score after four weeks and maintaining this range until the end of treatment (IBS-SSS total score change: −132.1; 95% CI: −74.9 to −189.4 and −130.5; 95% CI: −73.2 to −187.7; p < 0.0001 after LFD and TBD, respectively). The two diets did not modify the micronutrients content when extended for 12 weeks. LFD could be regarded as a first-line dietary approach for IBS-D patients. However, TBD may represent a valid alternative, with high palatability, especially among Italian patients, for whom pasta is considered one of the main assets of dietetic culture, and would be easier to manage in their daily habits.

The Effect of Rice vs. Wheat Ingestion on Postprandial Gastroesophageal Reflux (GER) Symptoms in Patients with Overlapping GERD-Irritable Bowel Syndrome (IBS)

A randomized crossover study in twenty-one patients (18F, age 50 ± 13 years) with overlapping GERD-IBS was conducted to evaluate the effects of rice noodles (low FODMAPs) vs. wheat noodles (high FODMAPs) on typical GER symptoms, and the correlation between GERD symptoms and intestinal gas production. Results: Heartburn and regurgitation scores were highest in most patients (19/21) during the first 15 min after meals. At 15 min after lunch, wheat was significantly associated with more regurgitation and heartburn than rice. Also, at 15 min after breakfast, wheat aggravated more regurgitation than rice. Wheat ingestion was significantly associated with higher H₂ and CH₄ levels after lunch compared to rice, whereas gas levels before lunch were similar (p > 0.05). The area under the curve of H₂ and CH₄ concentration 15 min after a lunch of wheat moderately correlated with the regurgitation severity at 15-min (r = 0.56, p < 0.05). Conclusion: Wheat induced more GERD symptoms than rice in patients with overlapping GERD-IBS. This effect, immediately developed after lunch, was associated with more intestinal gas production. Thus, a low FODMAPs diet may relieve postprandial GERD symptoms in GERD patients with overlapping IBS. Wheat inducing more regurgitation than rice after breakfast suggests other mechanism(s) besides gut fermentation.

The efficacy of the traditional Korean herbal medicine Tongsayobang for the treatment of irritable bowel syndrome: A protocol for a systematic review and meta-analysis

BACKGROUND

Irritable bowel syndrome (IBS) is a functional bowel disorder with symptoms of recurrent abdominal pain associated with a change in stool frequency or appearance that decreases patient quality of life. Conventional Western medicine has limited efficacy in treating IBS. Tongsayobang (TSYB) is a traditional Korean medicine that has been used to treat lower intestinal problems. This study provides a procedure for conducting a systematic review of the efficacy and safety of TSYB for IBS.

METHODS AND ANALYSIS

The main electronic databases will be searched up to May 2021 for randomized controlled trials and quasi-randomized controlled trials evaluating the effect of TSYB or modified TSYB on patients with IBS. The primary outcome will be the overall efficacy rate. The secondary outcome will be data such as IBS-related quality of life, global symptom scores, and adverse events. This study will adopt the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and will involve a meta-analysis, if possible. The methodological quality of the included studies will be assessed using the Risk of Bias tool from the Cochrane Handbook, version 6.1.0.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study does not include any participants' personal information.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/M32BK (https://osf.io/m32bk).

Epigastric symptom response to low FODMAP dietary advice compared with standard dietetic advice in individuals with functional dyspepsia

BACKGROUND

Certain dietary constituents may provoke symptoms of functional dyspepsia (FD); however, there is an absence of dietary trials testing specific dietary interventions. Empirically derived dietary strategies and the low FODMAP diet are frequently used in practice. This study aimed to compare the effectiveness of low FODMAP dietary advice with standard dietary advice for reducing epigastric and overall gastrointestinal symptoms in individuals with FD.

METHODS

Data were collected from 59 consecutive eligible individuals with FD attending an initial and review outpatient dietetic consultation at Princess Alexandra Hospital. Of these, 40 received low FODMAP advice and 19 received standard dietary advice. As part of usual care, the Structured Assessment of Gastrointestinal Symptom Scale (SAGIS) was used to assess epigastric (maximum score = 28) and overall gastrointestinal symptoms (maximum score = 88). Dietary adherence data were collected, and change in symptom score and proportion of responders (defined as a ≥30% reduction in score) for epigastric and total symptoms was calculated.

KEY RESULTS

Most individuals (48/59, 81%) had FD and coexisting irritable bowel syndrome. There was a greater reduction in epigastric score in those receiving low FODMAP dietary advice compared with those receiving standard advice (est. marginal mean [95% CI]: -3.6 [-4.9, -2.2] vs. -0.9 [-2.9, 1.1], p = 0.032) and total symptom score (-9.4 [-12.4, -6.4] vs. -3.3 [-7.7, 1.1] p = 0.026). A greater proportion receiving low FODMAP dietary advice were responders versus those receiving standard advice (50% vs. 16%, p = 0.012). Dietary adherence did not differ between groups (p = 0.497).

CONCLUSIONS & INFERENCES

The low FODMAP diet appears more effective for improving epigastric symptoms in people with FD compared with standard advice. A randomized controlled trial is required to substantiate these findings.

Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (FODMAPs) and cancer risk in the prospective NutriNet-Santé cohort

BACKGROUND

Fermentable Oligosaccharides, Disaccharides and Monosaccharides And Polyols (FODMAPs) have been shown to be involved in gastrointestinal disorders. In view of their pro-inflammatory potential and their interactions with the gut microbiota, their contribution to the etiology of other chronic diseases such as cancer has been postulated. However, no epidemiological study has investigated this hypothesis so far.

OBJECTIVE

Our objective was to investigate the associations between FODMAP intake (total and by type) and cancer risk (overall, breast, prostate and colorectal) in a large prospective cohort.

DESIGN

The study was based on the NutriNet-Santé cohort (2009-2020); 104,909 adult participants without cancer at baseline were included in our analyses (median follow-up time = 7.7y, 78.7% women, mean age at baseline 42.1y (SD = 14.5)). Baseline dietary intakes were obtained from repeated 24h-dietary records linked to a detailed food composition table. Associations between FODMAP intake (expressed in quintiles, Q) and cancer risks were assessed by Cox proportional hazard models adjusted for a large range of lifestyle, sociodemographic and anthropometric variables.

RESULTS

Total FODMAP intake was associated with increased overall cancer risk (n = 3374 incident cases, HR for sex-specific Quintile 5 versus Quintile 1: 1.21; 95%CI: 1.02, 1.44; P-trend = 0.04). In particular, oligosaccharides were associated with cancer risk: a trend was observed for overall cancer (HR Q5 vs. Q1: 1.10; 95%CI: 0.97, 1.25; P-trend = 0.04) and colorectal cancer (n = 272, HR Q5 vs. Q1: 1.78; 95%CI: 1.13-2.79; P-trend = 0.02).

CONCLUSION

Results from this large population-based study on French adults from the NutriNet-Santé cohort show a significant association between FODMAP intake and the risk of cancer development. Further epidemiological and experimental studies are needed to confirm these results and provide data on the potential underlying mechanisms.

Investigating the Role of Low-FODMAP Diet in Improving Gastrointestinal Symptoms in Irritable Bowel Syndrome

Background

A low–fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) diet (LFD) appeared to improve gastrointestinal symptoms in patients with Irritable Bowel Syndrome (IBS). However, evidence of its efficacy in Asia remains scarce.

Objectives

This study aims to investigate the clinical effectiveness of LFD intervention among Asian IBS patients and barriers to its adherence.

Methods

Patients with IBS who were instructed to follow LFD by dietitians at a tertiary hospital in Singapore between July 2013 and December 2014 were retrospectively reviewed. Severity scores of 19 gastrointestinal symptoms were recorded using an 11-point rating scale (0 = “no symptoms,” 10 = “extremely severe”) pre- and post-LFD intervention. Adherence to LFD was assessed based on patients’ diet history and a high-FODMAP food checklist.

Results

Eighty-two patients with a median follow-up of 5.8 weeks were investigated. The LFD adherence rate was 61.0% ( n = 50). Overall, statistically significant improvement was observed in 14 of 19 gastrointestinal symptoms (median difference = −2.0 to −0.5, p < .05). The proportion of patients who had improvement in 10 individual symptoms (defined as ≥1 point reduction in symptom severity rating) was significantly higher in LFD-adherent patients (67.5%–82.4%) than that of the non-adherent group (27.8%–55.0%). Reasons reported for non-adherence included “limited availability of low-FODMAP alternatives” ( n = 9), “limited understanding of LFD” ( n = 7), and “perceived lack of benefit” ( n = 4).

Conclusions

LFD intervention improved gastrointestinal symptoms in a cohort of Asian IBS patients. Limited access to low-FODMAP alternatives was the main barrier to adherence.

FODMAP Consumption by Adults from the French Population-Based NutriNet-Santé Cohort

BACKGROUND

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) are increasingly studied because they are suspected unfavorably to impact health (irritable bowel syndrome in particular). However, little is known about FODMAP intake in the general population, or which groups are more likely to consume them, because their intakes are usually assessed in inpatient settings.

OBJECTIVES

This study aimed to describe FODMAP consumption in a large French cohort and its association with sociodemographic and lifestyle characteristics.

METHODS

This cross-sectional study described FODMAP intakes in 109,362 volunteers (78.0% female, mean age 43.8 ± 14.7 y) from the French NutriNet-Santé cohort, using an ad hoc FODMAP composition table. Associations between FODMAP intakes and sociodemographic characteristics were investigated using χ2 tests or Kruskal-Wallis tests according to the qualitative or quantitative status of the variable, and multinomial logistic regressions were performed after adjusting for energy intake in sensitivity analyses. Eligible participants had completed ≥3 detailed 24-h food records.

RESULTS

We observed a mean intake of 18.9 ± 9.5 g/d FODMAPs in this French cohort, and 11.7% of participants had intakes <9 g/d (i.e., low-FODMAP diets). Participants with FODMAP intakes <9 g/d were more likely to have lower caloric intakes (Δ = 383 kcal/d compared with participants with FODMAP intakes ≥16 g/d), to be smokers, to have lower incomes, and to have lower levels of physical activity. Total FODMAPs accounted for a mean intake of 18.9 ± 9.5 g/d, which was 3.7 ± 2.0% of total energy intake. The highest intake of FODMAPs was represented by lactose followed by excess fructose, fructans, polyols, and galacto-oligo-saccharides.

CONCLUSIONS

FODMAP consumption by a large sample of adults from the general population is ∼19 g/d, with half of the population having a FODMAP intake >16 g/d.This trial was registered at www.clinicaltrials.gov as NCT03335644.

Clinical effectiveness of adding probiotics to a low FODMAP diet: Randomized double-blind placebo-controlled study

BACKGROUND

There are various studies showing the relationship between irritable bowel syndrome (IBS) and diet, and some dietary adjustments are recommended to reduce symptoms. In recent years, there is a growing number of studies that show a 4-8 wk low fermentable oligo, di- and mono-saccharides and polyols (FODMAP) diet has a 50%-80% significant effect on symptoms in IBS patients. There is strong evidence suggesting that changes in fecal microbiota have an impact on IBS pathogenesis. Based on this argument, probiotics have been used in IBS treatment for a long time. As is seen, the FODMAP diet and probiotics are used separately in IBS treatment.

AIM

To evaluate the effectiveness of adding probiotics to a low FODMAP diet to control the symptoms in patients with IBS.

METHODS

The patients who were admitted to the Gastroenterology Clinic of Dokuz Eylul University Hospital and diagnosed with IBS according to Rome IV criteria were enrolled into the study. They were randomized into 2 groups each of which consisted of 50 patients. All patients were referred to a dietitian to receive dietary recommendations for the low FODMAP diet with a daily intake of 9 g. The patients were asked to keep a diary of foods and beverages they consumed. The patients in Group 1 were given supplementary food containing probiotics (2 g) once a day in addition to their low FODMAP diet, while the patients in Group 2 were given a placebo once a day in addition to their low FODMAP diet. Visual analogue scale (VAS), the Bristol Stool Scale and IBS Symptom Severity Scale (IBS-SSS) scores were evaluated before and after the 21 d treatment.

RESULTS

The rate of adherence of 85 patients, who completed the study, to the FODMAP restricted diet was 92%, being 90% in Group 1 and 94% in Group 2. The mean scores of VAS and IBS-SSS of the patients in Group 1 before treatment were 4.6 ± 2.7 and 310.0 ± 78.4, respectively, and these scores decreased to 2.0 ± 1.9 and 172.0 ± 93.0 after treatment (both P < 0.001). The mean VAS and IBS-SSS scores of the patients in Group 2 before treatment were 4.7 ± 2.7 and 317.0 ± 87.5, respectively, and these scores decreased to 1.8 ± 2.0 and 175.0 ± 97.7 after treatment (both P < 0.001). The IBS-SSS score of 37 patients (86.04%) in Group 1 and 36 patients (85.71%) in Group 2 decreased by more than 50 points. Group 1 and Group 2 were similar in terms of differences in VAS and IBS-SSS scores before and after treatment. When changes in stool shape after treatment were compared using the Bristol Stool Scale, both groups showed significant change.

CONCLUSION

This study is the randomized controlled study to examine the efficiency of probiotic supplementation to a low FODMAP diet in all subtypes of IBS. The low FODMAP diet has highly positive effects on symptoms of all subtypes of IBS. It was seen that adding probiotics to a low FODMAP diet does not make an additional contribution to symptom response and adherence to the diet.

Dietary modulation of gut microbiota for the relief of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a frequently diagnosed gastrointestinal (GI) disorder characterized by recurrent abdominal pain, bloating, and changes in the stool form or frequency without any structural changes and overt inflammation. It is not a life-threatening condition but causes a considerable level of discomfort and distress. Among the many pathophysiologic factors, such as altered GI motility, visceral hypersensitivity, and low-grade mucosal inflammation, as well as other immunologic, psychologic, and genetic factors, gut microbiota imbalance (dysbiosis), which is frequently found in IBS, has been highlighted as an etiology of IBS. Dysbiosis may affect gut mucosal homeostasis, immune function, metabolic regulation, and even visceral motor function. As diet is shown to play a fundamental role in the gut microbiota profile, this review discusses the influence of diet on IBS occurring through the modulation of gut microbiota. Based on previous studies, it appears that dietary modulation of the gut microbiota may be effective for the alleviation of IBS symptoms and, also an effective IBS management strategy based on the underlying mechanism; especially because, IBS currently has no specific treatment owing to its uncertain etiology.

Effect of Inoculated Lactic Acid Fermentation on the Fermentable Saccharides and Polyols, Polyphenols and Antioxidant Activity Changes in Wheat Sourdough

Inoculation of sourdough allows the fermentation medium to be dominated by desired microorganisms, which enables determining the kinetics of the conversion of chemical compounds by individual microorganisms. This knowledge may allow the design of functional food products with health features dedicated to consumers with special needs. The aim of the study was to assess the dynamics of transformations of fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) compounds from wheat flour as well as their antioxidant activity during inoculated and spontaneous sourdough fermentation. The FODMAP content in grain products was determined by the fructan content with negligible amounts of sugars and polyols. To produce a low-FODMAP cereal product, the fermentation time is essential. The 72 h fermentation time of L. plantarum-inoculated sourdough reduced the FODMAP content by 91%. The sourdough fermentation time of at least 72 h also positively influenced the content of polyphenols and antioxidant activity, regardless of the type of fermentation. The inoculation of both L. plantarum and L. casei contributed to a similar degree to the reduction in FODMAP in sourdough compared to spontaneous fermentation.

The diagnosis of avoidant restrictive food intake disorder in the presence of gastrointestinal disorders: Opportunities to define shared mechanisms of symptom expression

OBJECTIVE

Individuals with a gastrointestinal (GI) disorder often alter their diet to manage GI symptoms, adding complexity to understanding the diverse motivations contributing to food avoidance/restriction. When a GI disorder is present, the DSM-5 states that Avoidant/Restrictive Food Intake Disorder (ARFID) can be diagnosed only when eating disturbance exceeds that expected. There is limited guidance to make this determination. This study attempts to address this gap by characterizing the presentation of ARFID in adults with and without a self-reported GI disorder.

METHOD

Participants were 2,610 adults ages 18-44 who self-identified as "picky eaters." Participants reported on motivations for food avoidance, affective experiences towards food, and perceived impairment. Responses were compared across four groups: GI issues and likely ARFID (L-ARFID/GI), L-ARFID-only, GI-only, and No-ARFID/No-GI.

RESULTS

Groups with a GI disorder (L-ARFID/GI, GI-only) reported more fear of aversive consequences of eating than those without a GI disorder, while groups with L-ARFID (L-ARFID, L-ARFID/GI) evidenced significantly greater sensory aversion to food and indifference to food or eating, negative emotional reactions to food and overall disgust sensitivity, and eating related impairment.

DISCUSSION

Consideration of the interplay of a GI disorder with ARFID can add precision to case conceptualization. Food avoidance may be attempts to manage fears of aversive consequences that are augmented by a history of GI symptoms, while sensory aversions and negative emotional reactions towards foods may be more elevated in ARFID. These findings emphasize the need to consider an ARFID diagnosis in patients with GI disorders to optimize care.

A Low-FODMAP Diet in the Management of Children With Functional Abdominal Pain Disorders: A Protocol of a Systematic Review

The available interventions for the management of children with functional abdominal pain disorders (FAPD) are limited. A diet low in fermentable oligosaccharides, disaccharides monosaccharides, and polyols (FODMAPs) is widely used in adults and children with FAPD, despite limited available evidence. We aim to systematically review evidence on the efficacy and safety of using a low-FODMAP diet for the management of children with FAPD.

Methods

The Cochrane Library, EMBASE, and MEDLINE databases will be searched for randomized controlled trials (RCTs) that compare the use a low-FODMAP diet (preferably a 3-step low-FODMAP diet but also only a strict low-FODMAP diet or restriction of individual FODMAPs) with any comparator (i.e., standardized [i.e., average national] or other diet or no intervention) in children with FAPD (regardless of the definition). Each FAPD and each low-FODMAP diet or individual FODMAP restriction will be assessed separately. The Cochrane Collaboration's tool for assessing the risk of bias will be used. The primary outcome will be the abdominal pain intensity. The secondary outcomes will be abdominal pain frequency, stool consistency, other gastrointestinal symptoms, school performance, and psychological functioning associated with FAPD, parent's work absenteeism associated with FAPD of a child, health-related quality of life, compliance, growth, and adverse events. The findings will be published in a peer-reviewed journal and submitted to relevant conferences.

Conclusion

This systematic review of rigorous methodological design will update current evidence on the efficacy and safety of using a low-FODMAP diet. However, it may be limited by the quality of the included studies.

Diarrhea Predominant-Irritable Bowel Syndrome (IBS-D): Effects of Different Nutritional Patterns on Intestinal Dysbiosis and Symptoms

Irritable Bowel Syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by abdominal pain associated with defecation or a change in bowel habits. Gut microbiota, which acts as a real organ with well-defined functions, is in a mutualistic relationship with the host, harvesting additional energy and nutrients from the diet and protecting the host from pathogens; specific alterations in its composition seem to play a crucial role in IBS pathophysiology. It is well known that diet can significantly modulate the intestinal microbiota profile but it is less known how different nutritional approach effective in IBS patients, such as the low-FODMAP diet, could be responsible of intestinal microbiota changes, thus influencing the presence of gastrointestinal (GI) symptoms. The aim of this review was to explore the effects of different nutritional protocols (e.g., traditional nutritional advice, low-FODMAP diet, gluten-free diet, etc.) on IBS-D symptoms and on intestinal microbiota variations in both IBS-D patients and healthy subjects. To date, an ideal nutritional protocol does not exist for IBS-D patients but it seems crucial to consider the effect of the different nutritional approaches on the intestinal microbiota composition to better define an efficient strategy to manage this functional disorder.

What Are the Pearls and Pitfalls of the Dietary Management for Chronic Diarrhoea?

Chronic diarrhoea affects up to 14% of adults, it impacts on quality of life and its cause can be variable. Patients with chronic diarrhoea are presented with a plethora of dietary recommendations, often sought from the internet or provided by those who are untrained or inexperienced. In this review, we summarise the possible causes of chronic diarrhoea that can be managed by diet, the symptom improvement and quality of life benefits but also the potential risks of such dietary treatments. Clinicians need to consider both the benefits and risks of dietary treatments before making dietary recommendations to manage chronic diarrhoea. The pivotal role that dietitians have in ensuring optimal symptom improvement without jeopardising nutritional and overall health is discussed.

Event Surrogate from Clinical Pathway Completion to Daily Meal for Availability Extension Using Standard Electronic Medical Records: a Retrospective Cohort Study

This study aimed to improve generalizability of our previous study that analyzed clinical pathway (CP) completion. Although our previous study demonstrated that CP completion can reduce the length of hospital stay, it is possible for few medical organizations to extract the implementation of treatment registered on CP from typical electronic medical records. Therefore, we have defined a prospective event for event substitution, called meal completion (MC), in which patients can take their meal daily. Data were collected from April 2013 to March 2018 from the electronic medical records of the University of Miyazaki Hospital. We used propensity score matching to extract records from 8033 patients. Patients were further divided into the MC and non-MC groups; 2577 patients in each group were available for data analysis. The numbers of patients with CP completion were 646 (28.1%) in the MC group and 411 (18.2%) in the non-MC group. The P value of the chi-square test was <0.001. According to this result, there was the causation from MC to increase in CP completion. Additionally, it was possible to consider the inclusion relationship in all treatments (universal set), treatments registered on CP (subset of all treatments), and meals (subset of treatments registered on CP). In conclusion, MC can substitute for CP completion because the demonstration is appropriate for the Prentice criterion, which is often used for the evaluation of a surrogate endpoint.

Gut microbiota associations with diet in irritable bowel syndrome and the effect of low FODMAP diet and probiotics

BACKGROUND AND AIMS

Diet is both a modulator of the gastrointestinal microbiota and an important therapy in irritable bowel syndrome (IBS). We aimed to comprehensively (i) identify diet-microbiota associations in adults with IBS consuming habitual diet; (ii) assess the impact of two nutritional interventions on the microbiota; and (iii) determine whether baseline microbiota can predict clinical response to diet or probiotic intervention.

METHODS

Data were analyzed from 95 individuals with IBS participating in a previously published 4-week 2x2 factorial design randomized controlled trial investigating the impact of the low FODMAP diet (LFD) and co-administration of a probiotic. Diet was assessed at four hierarchical levels and partial 16S rRNA gene sequencing was used to profile the microbiota.

RESULTS

There were numerous diet-microbiota associations especially at the nutrient level, including a negative association between protein and Bifidobacterium abundance (r_s = -0.358, p < 0.001). After correction for multiple testing, the significance for this association (q = 0.237) and all others was lost. Low FODMAP diet led to changes in abundance of major saccharolytic genera compared with sham diet, including higher Bacteroides (LFD 34.1% (15.7%) vs sham 23.3% (15.2%), q = 0.01) and lower Bifidobacterium (0.9% (1.0%) vs 2.1%, (2.5%) q = 0.029). Compared with placebo, probiotic supplementation led to higher Lactobacillus (probiotic 0.08% (0.1%) vs placebo 0.03% (0.2%), q < 0.001), and Streptococcus abundance (2.0% (2.2%) vs 0.6% (1.2%), q = 0.001). The probiotic treatment buffered the impact of the low FODMAP diet on Bifidobacterium. Baseline microbiota did not predict clinical response to either intervention.

CONCLUSIONS

Although diet modifies the gut microbiota, bivariate correlation analysis may only provide a limited explanation of the complex diet interactions with individual gut bacteria in IBS. Some diet interventions modify the microbiota in IBS.

TRIAL REGISTRY

ISRCTN (http://www.isrctn.com) Registered under ISRCTN registry identifier no.ISRCTN02275221.

Review article: the impact of diet on ileoanal pouch function and on the pathogenesis of pouchitis

BACKGROUND

There is expanding interest in the role that diet plays in ileoanal pouch function and in the pathogenesis of pouchitis.

AIMS

To present a narrative review of published literature regarding the relationship of diet with pouch function and the pathogenesis of pouchitis, and to provide potentially beneficial dietary strategies.

METHODS

Current relevant literature was summarised and critically examined.

RESULTS

Dietary components influence pouch function via their effect on upper gastrointestinal transit, small bowel water content and the structure and fermentative activity of the pouch microbiota. FODMAPs in fruits and vegetables appear to affect pouch function the most, with intake positively associated with increased stool frequency and reduced consistency. Dietary factors that influence the pathogenesis of pouchitis appear different and, at times, opposite to those better for optimising function. For example, risk of pouchitis appears to be inversely associated with intake of fruits. The food components mechanistically responsible for this observation are not known, but a rich supply of fermentable fibres and micronutrients in such foods might play a beneficial role via modulation of microbial community structure (such as increasing diversity and/or changing microbial communities to favour 'protective' over 'pathogenic' bacteria) and function and/or anti-inflammatory effects.

CONCLUSION

Available data are weak but suggest tailoring dietary recommendations according to pouch phenotype/behaviour and pouchitis risk might improve outcomes. More sophisticated dietary strategies that utilise the physiological and pathophysiological effects of dietary components on ileoanal pouches have potential to further improve outcomes. Well designed, adequately powered studies are required.

A Low FODMAP Diet May Reduce Symptoms in Patients With Fecal Incontinence

Fecal incontinence (FI) is a common complaint and is often associated with diarrhea and urgency. Foods high in fermentable oligo-, di-, and mono-saccharides and polyols (FODMAP) cause symptoms of diarrhea and urgency. Therefore, this study assesses the impact of a low FODMAP diet on the occurrence of FI due to loose stool.

Wheat Sensitivity and Functional Dyspepsia: A Pilot, Double-Blind, Randomized, Placebo-Controlled Dietary Crossover Trial with Novel Challenge Protocol

Introduction: Functional dyspepsia (FD), characterised by symptoms of epigastric pain or early satiety and post prandial distress, has been associated with duodenal eosinophilia, raising the possibility that it is driven by an environmental allergen. Non-coeliac gluten or wheat sensitivity (NCG/WS) has also been associated with both dyspeptic symptoms and duodenal eosinophilia, suggesting an overlap between these two conditions. The aim of this study was to evaluate the role of wheat (specifically gluten and fructans) in symptom reduction in participants with FD in a pilot randomized double-blind, placebo controlled, dietary crossover trial. Methods: Patients with Rome III criteria FD were recruited from a single tertiary centre in Newcastle, Australia. All were individually counselled on a diet low in both gluten and fermentable oligo-, di-, mono-saccharides, and polyols (FODMAPs) by a clinical dietitian, which was followed for four weeks (elimination diet phase). Those who had a ≥30% response to the run-in diet, as measured by the Nepean Dyspepsia Index, were then re-challenged with ‘muesli’ bars containing either gluten, fructan, or placebo in randomised order. Those with symptoms which significantly reduced during the elimination diet, but reliably reappeared (a mean change in overall dyspeptic symptoms of ≥30%) with gluten or fructan re-challenge were deemed to have wheat induced FD. Results: Eleven participants were enrolled in the study (75% female, mean age 43 years). Of the initial cohort, nine participants completed the elimination diet phase of whom four qualified for the rechallenge phase. The gluten-free, low FODMAP diet led to an overall (albeit non-significant) improvement in symptoms of functional dyspepsia in the diet elimination phase (mean NDI symptom score 71.2 vs. 47.1, p = 0.087). A specific food trigger could not be reliably demonstrated. Conclusions: Although a gluten-free, low-FODMAP diet led to a modest overall reduction in symptoms in this cohort of FD patients, a specific trigger could not be identified. The modified Salerno criteria for NCG/WS identification trialled in this dietary rechallenge protocol was fit-for-purpose. However, larger trials are required to determine whether particular components of wheat induce symptoms in functional dyspepsia.

Changes in gut microbial metagenomic pathways associated with clinical outcomes after the elimination of malabsorbed sugars in an IBS cohort

Specific diets to manage sugar malabsorption are reported to reduce clinical symptoms of irritable bowel syndrome (IBS). However, the effects of diets for malabsorbed sugars on gut microbiota signatures have not been studied, and associations with clinical outcomes in IBS have not been characterized. 22 IBS patients positively tested for either lactose-, fructose-, sorbitol- or combined malabsorptions were subjected to 2-weeks sugar elimination and subsequent 4-weeks re-introduction. 7 IBS patients tested negative for sugar malabsorption were used as controls. Nutrition and clinical symptoms were recorded throughout the study. Fecal samples were serially collected for 16S rRNA amplicon and shotgun-metagenome sequencing. Dietary intervention supervised by nutrition counseling reduced IBS symptoms during the elimination and tolerance phases. Varying clinical response rates were observed between subjects, and used to dichotomize our cohort into visual analogue scale (VAS) responders and non-responders. Alpha -and beta-diversity analyzes revealed only minor differences regarding 16S rRNA-based fecal microbiota compositions between responder and non-responder patients during baseline or tolerance phase. In shotgun-metagenome analyzes, however, we analyzed microbial metabolic pathways and found significant differences in pathways encoding starch degradation and complex amino acid biosynthesis at baseline between IBS controls and malabsorbers, and notably, between diet responder and non-responders. Faecalibacterium prausnitzii, Ruminococcus spp. and Bifidobacterium longum largely informed these metabolic pathways. Our study demonstrates that diet interventions for specific, malabsorbed carbohydrates reshaped the metagenomic composition of the gut microbiota, with a small community of bacterial taxa contributing to these changes rather than a single species.

Gut Microbial Metabolites and Biochemical Pathways Involved in Irritable Bowel Syndrome: Effects of Diet and Nutrition on the Microbiome

The food we consume and its interactions with the host and their gut microbiota affect normal gut function and health. Functional gut disorders (FGDs), including irritable bowel syndrome (IBS), can result from negative effects of these interactions, leading to a reduced quality of life. Certain foods exacerbate or reduce the severity and prevalence of FGD symptoms. IBS can be used as a model of perturbation from normal gut function with which to study the impact of foods and diets on the severity and symptoms of FGDs and understand how critical processes and biochemical mechanisms contribute to this impact. Analyzing the complex interactions between food, host, and microbial metabolites gives insights into the pathways and processes occurring in the gut which contribute to FGDs. The following review is a critical discussion of the literature regarding metabolic pathways and dietary interventions relevant to FGDs. Many metabolites, for example bile acids, SCFAs, vitamins, amino acids, and neurotransmitters, can be altered by dietary intake, and could be valuable for identifying perturbations in metabolic pathways that distinguish a "normal, healthy" gut from a "dysfunctional, unhealthy" gut. Dietary interventions for reducing symptoms of FGDs are becoming more prevalent, but studies investigating the underlying mechanisms linked to host, microbiome, and metabolite interactions are less common. Therefore, we aim to evaluate the recent literature to assist with further progression of research in this field.