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

Peter R Gibson; Susan J Shepherd

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

Mechanistic Basis for Dietary Intervention

The physiological basis for the genesis of many functional gut symptoms is luminal distension. Evidence for this comes from barostat and gas infusion studies.^[2,3] Luminal distension not only induces the symptoms of pain, the sensation of bloating and visible abdominal distension, but may also lead to secondary motility changes. Thus, minimizing the consumption of dietary factors that can distend the intestine would theoretically lead to improvement in global symptoms that characterize FGID. In the case of two of the most common types of FGID involving the intestine, irritable bowel syndrome (IBS) and functional bloating, the distal small and proximal large intestine would be the target regions of the gut.

The intestinal lumen can be distended by solids, liquids and gas. Solids can be altered in the proximal large intestine by changing the dietary fiber content both directly and indirectly via expansion or contraction of the bacterial mass. The liquid content in the distal small intestine will be dictated by the osmotic load in the lumen, and in the proximal large intestine by the osmotic load and the absorptive ability of the epithelium. The gas content will include a component of swallowed nitrogen, but the majority will be locally produced by bacterial fermentation. The volume that the gas creates will depend upon the number of molecules and its diffusion capacity across the epithelium and into the circulation. Dietary components that will putatively lead to luminal distension in the regions of interest will therefore be poorly absorbed in the proximal small intestine, will be small molecules (i.e. osmotically active), will be rapidly fermented by bacteria (with the potential to be fermented by small intestinal as well as cecal bacteria and to expand the bacterial population), and will be associated with hydrogen rather than methane production. Dietary FODMAP are the best fit for these principles.

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Cite this: Evidence-based Dietary Management of Functional Gastrointestinal Symptoms: The FODMAP Approach - Medscape - Feb 01, 2010.

Abstract and Introduction
Mechanistic Basis for Dietary Intervention
FODMAPs
The FODMAP Concept in the Management of Functional Gut Symptoms
FODMAPs in the Diet
More Than Just Fructose and Fructans
Efficacy of the Low FODMAP Diet
Limitations of Tables of the FODMAP Content of Foods
The Low FODMAP Dietary Strategy
More Than Just FGID
Limitations and Potential Concerns
Conclusions
References

Table 1. Food sources of FODMAPs (where FODMAPs are problematic based on standard serving size) and suitable alternatives
FODMAP	Excess fructose	Lactose	Oligosaccharides (fructans and/or galactans)	Polyols
Problem high FODMAP food source	Fruits: apples, pears, nashi pears, clingstone peaches, mango, sugar snap peas, watermelon, tinned fruit in natural juice Honey Sweeteners: fructose, high fructose corn syrup Large total fructose dose: concentrated fruit sources; large serves of fruit, dried fruit, fruit juice	Milk: cow, goat and sheep (regular & low-fat), Ice cream Yoghurt (regular & low-fat) Cheeses: soft & fresh (e.g. ricotta, cottage)	Vegetables: artichokes, asparagus, beetroot, Brussels sprout, broccoli, cabbage, fennel, garlic, leeks, okra, onions, peas, shallots. Cereals: wheat & rye when eaten in large amounts (e.g. bread, pasta, couscous, crackers, biscuits) Legumes: chickpeas, lentils, red kidney beans, baked beans Fruits: watermelon, custard apple, white peaches, rambutan, persimmon	Fruits: apples, apricots, cherries, longon, lychee, nashi pears, nectarine, pears, peaches, plums, prunes, watermelon Vegetables: avocado, cauliflower, mushrooms, snow peas Sweeteners: sorbitol(420), mannitol(421), xylitol(967), maltitol (965), isomalt (953) & others ending in '-ol'
Suitable alternative low-FODMAP food source	Fruit: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passionfruit, paw paw, raspberry, rockmelon, strawberry, tangelo. Honey substitutes: maple syrup, golden syrup Sweeteners: any except polyols	Milk: lactose-free, rice milk Cheese:'hard' cheeses including brie, camembert Yoghurt: lactose-free Ice cream substitutes: gelati, sorbet Butter	Vegetables: bamboo shoots, bok choy, carrot, celery, capsicum, choko, choy sum, corn, eggplant, green beans, lettuce, chives, parsnip, pumpkin, silverbeet, spring onion (green only), tomato Onion/garlic substitutes: garlic-infused oil Cereals: gluten-free & spelt bread/cereal products	Fruits: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passionfruit, paw paw, raspberry, rockmelon Sweeteners: sugar (sucrose), glucose, other artificial sweeteners not ending in 'ol'

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