COMMENTARY

Gluten Sensitivity Aftershock! Is a Low-FODMAP Diet the Next Big Thing?

William F. Balistreri, MD

Disclosures

September 20, 2017

In This Article

One Size Will Not Fit All

In my opinion, a low-FODMAP diet is one more tool to add to our armamentarium for the management of patients with IBS. However, the reception of this recommendation by our patients will be variable. On the plus side, a dietary approach has intuitive appeal, and many patients have already identified a correlation of symptoms with certain foods. Yet, the long-term effectiveness is unknown, and stringent restriction of FODMAPs may bring unintended consequences, such as inadequate nutrient intake and adverse effects from altered gut microbiota. For example, it is well recognized that adhering to a gluten-free diet puts one at risk for reduced intake of fiber, iron, zinc, calcium, folate, other B-group vitamins, and natural antioxidants.[13] In addition, although dietary interventions are considered low-risk, the long-term effects of the rapid and marked alterations in the colonic microbiome are unknown.[37]

In my opinion, a low-FODMAP diet is one more tool to add to our armamentarium for the management of patients with IBS.

In a recent review of IBS, Ford and colleagues[37] recommended, as an initial approach to affected persons, increased exercise and stress reduction, as well as dietary modifications. They suggested a slow increase in the content of dietary soluble fiber if the patient has IBS with constipation, or instituting a low-FODMAP diet temporarily if the patient has IBS with diarrhea or the mixed subtype of IBS.

When implementing a low-FODMAP diet, it is important to first inform patients and their families about what is not known about the role of dietary components in exacerbating or alleviating the symptoms of IBS. Then, in view of the highly restrictive nature of the diet, patients may be advised to use a "selective restriction" approach, which may be best accomplished with a registered dietician.

There are no scientifically validated guidelines, but during the induction phase, all FODMAP groups are restricted. It may be effective to individualize the recommended dietary strategy by eliminating certain components of the FODMAPs class, wheat products, and/or gluten sequentially.

After 4-6 weeks, consider reducing the level of restriction with a step-wise reintroduction of the restricted foods, focusing on specific FODMAP groups.[11] Patients will need to pay attention to food labels in search of FODMAP content.

Next Steps

Our hope is that future clinical trials will determine which component of the spectrum of FODMAPs may be responsible for the symptoms in a given patient.

Dissecting the list of restricted foods into component parts will help to determine whether a less restrictive dietary approach could be effective for that specific patient.[15] Identification of specific dietary triggers for each individual patient will allow a more personalized, and possibly more effective, strategy for the management of IBS symptoms.

Emerging data regarding the individual "intolerance or sensitivity" profile of patients with IBS will allow a rational basis for a restricted diet, whether that involves gluten, wheat, FODMAPs, or any other substance—instead of riding the crest of the latest dietary wave.

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