Evidence-based Dietary Management of Functional Gastrointestinal Symptoms: The FODMAP Approach

Peter R Gibson; Susan J Shepherd

Disclosures

J Gastroenterol Hepatol. 2010;25(2):252-258. 

In This Article

Limitations and Potential Concerns

The diet is not a panacea for patients with FGID.[47] It provides good relief of symptoms in about 75% of patients, but has little benefit in some. Studies have yet to identify predictive factors of benefit apart from dietary adherence. Intermittent symptoms remain, albeit at a now tolerable level, in many patients since the underlying FGID is not directly addressed by the diet. Patients should not be given expectations of a 'cure'. Symptomatic hyperresponsiveness to the reintroduction of FODMAPs in the diet has been anecdotally described, although this aspect has not been formally studied. The mechanism for this has also not been evaluated. However, in rats fed fructose-poor diets, GLUT-5 expression falls as does the ability to absorb fructose from the small intestine.[48] Whether this occurs in humans warrants further investigation.

Restriction of FODMAP intake might potentially have a down side. It does mean restriction of dietary components with prebiotic effects.[49] This might potentially be detrimental to large bowel health (such as the promotion of colorectal carcinogenesis), although no studies have addressed this issue to date. The restriction of wheat-based products may lead to reduced fiber intake, but part of dietary counseling is to ensure continuing adequate intake of resistant starch and non-starch polysaccharides. This should be addressed during the dietary consultation. One study vaguely suggested that restricting FODMAPs in patients with ileal pouch, to reduce the frequency of pouch emptying, might increase the risk of pouchitis.[46] Ileostomates who have a low output from the ileostomy might depend upon the osmotic effects of FODMAPs and such patients may risk functional bowel obstruction if these are strictly reduced.[7] While these suggestions are all unsubstantiated, they do provide a reminder that this dietary intervention is established for those with functional gut symptoms and is not a diet for otherwise healthy people.

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