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Efficacy of a Reintroduction Phase for the Low FODMAP Diet in Patients With IBS
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND AND AIMS
The efficacy of a low fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet in Irritable Bowel Syndrome (IBS) is well established. After the elimination period, a reintroduction phase aims to identify triggers. We studied the impact of a blinded reintroduction using FODMAP-powders to objectively identify triggers and evaluated the effect on symptoms, quality of life (QoL), and psychosocial co-morbidities.
METHODS
Responders to a 6-week low-FODMAP diet, defined by a drop in IBS-symptom severity score (IBS-SSS) compared to baseline, entered a 9-week blinded randomized reintroduction phase with 6 FODMAP powders (fructans, fructose, galacto-oligosaccharides, lactose, mannitol, sorbitol) or control (glucose). A rise in IBS-SSS (≥50 points) defined a FODMAP-trigger. Patients completed daily symptom diaries and questionnaires for QoL and psychosocial co-morbidities.
RESULTS
In 117 recruited IBS patients, IBS-SSS improved significantly after the elimination period compared to baseline (150±116 vs 301±97, P < .0001, 80% responders). Symptom recurrence was triggered in 85% of the FODMAP powders, by an average of 2.5±2 FODMAPs/patient. The most prevalent triggers were fructans (56%) and mannitol (54%), followed by galacto-oligosaccharides, lactose, fructose, sorbitol, and glucose (respectively 35%, 28%, 27%, 23%, and 26%) with a significant increase in abdominal pain at day 1 for sorbitol/mannitol, day 2 for fructans/galacto-oligosaccharides and day 3 for lactose.
CONCLUSION
We confirmed the significant benefit of the low-FODMAP diet in tertiary care IBS. A blinded reintroduction revealed a personalized pattern of symptom recurrence, with fructans and mannitol as the most prevalent, and allows the most objective identification of individual FODMAP-triggers; Clinicaltrial.gov number: NCT04373304.
Additional Info
Disclosure statements are available on the authors' profiles:
Efficacy and findings of a blinded randomized reintroduction phase for the low FODMAP diet in Irritable Bowel Syndrome
Gastroenterology 2024 Feb 22;[EPub Ahead of Print], K Van den Houte, E Colomier, K Routhiaux, Z Mariën, J Schol, J Van den Bergh, J Vanderstappen, N Pauwels, A Joos, J Arts, P Caenepeel, F De Clerck, C Matthys, A Meulemans, M Jones, T Vanuytsel, F Carbone, J TackFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Van den Houte et al present a relatively large study of a blinded reintroduction phase of fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs) in patients with IBS. The efficacy of a low FODMAP diet in IBS is well-established, and the current dietary strategy involving FODMAPs consists of three phases. First, FODMAPs are excluded from the diet in the elimination phase; this phase should last approximately 4 weeks. Second, FODMAPs should be gradually reintroduced during the reintroduction phase, and, third, dietary habits should be individualized during the individualized phase, excluding solely the FODMAPs that provoked symptoms during the reintroduction phase. Previous studies have mainly focused on the elimination phase, and studies have shown that a substantial number of patients with IBS do not reintroduce or individualize after the initial elimination phase. These patients are on a so-called long-term low-FODMAP diet, which can have negative impacts on the gut microbiota, as well as negative impacts on eating habits, and induce eating disorders, as the low-FODMAP diet is very restrictive.
Van den Houte et al assessed the effect of a blinded FODMAP reintroduction phase in patients who responded to the low-FODMAP diet. The authors aimed to determine which FODMAPs were most likely to trigger gastrointestinal symptoms. In total, 105 patients followed a 6-week low-FODMAP diet, and 94 patients responded to the low-FODMAP diet and entered a 9-week blinded reintroduction phase. Here, the patients were challenged with powders of fructans (20 g), fructose (60 g), galacto-oligosaccharides (12 g), glucose (30 g), lactose (60 g), mannitol (15 g), and sorbitol (15 g) in a randomized order. Note that these FODMAP concentrations are very high and considerably higher than the habitual FODMAP intake in patients with IBS or the general population. Symptoms are to be expected during the provocation with high amounts of FODMAPs, which is not representative of dietary habits in patients with IBS. In total, 77 patients completed the study and were analyzed.
The results show that the low-FODMAP diet effectively reduced gastrointestinal symptoms, with a response rate of 80%. Symptoms were triggered by 85% of the FODMAP powders, with an average of 2.5 FODMAPs per patient. Especially fructans and mannitol triggered symptoms; of note, 26% of the patients had a recurrence of symptoms owing to glucose, which is not a FODMAP. Nocebo responses are most likely involved during reintroductions of all powders. The study was randomized and meticulously designed, and this is the first study that used a blinded reintroduction phase and found objective individual FODMAP triggers. Future clinical practice could use these FODMAP powders during the reintroduction phase; however, more studies are needed to determine the concentrations of these powders.