Digestive Diseases and Sciences

, Volume 60, Issue 5, pp 1169–1177 | Cite as

Low-FODMAP Diet for Irritable Bowel Syndrome: Is It Ready for Prime Time?

  • Muhammad Ali Khan
  • Salman NusratEmail author
  • Muhammad Imran Khan
  • Ali Nawras
  • Klaus Bielefeldt


Irritable bowel syndrome (IBS) is a chronic gastrointestinal disease, which adversely affects the quality of life. Its prevalence has been reported to be around 10–15 % in North America and constitutes the most common cause for gastroenterology referral. Unfortunately, the pathophysiology of IBS is not completely understood. Not surprisingly, the management strategies can leave the patients with inadequate symptom control, making IBS a debilitating gastrointestinal syndrome. Dietary interventions as a treatment strategy for IBS have been recently evaluated. One such intervention includes dietary restriction of fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs). FODMAPs define a group of short-chain carbohydrates that are incompletely absorbed in small intestine and later fermented in the colon. Evidence in the form of randomized controlled trials and observational studies have evaluated the mechanism of action and efficacy of low-FODMAP diet. This dietary intervention has showed promising results in symptom reduction in IBS patients. However, latest trials have also shown that the low-FODMAP diet is associated with marked changes in gut microbiota specifically reduction in microbiota with prebiotic properties. Implications of such changes on gastrointestinal health need to be further evaluated in future trials.


IBS FODMAP Irritable bowel syndrome Fermentable carbohydrates 


Conflict of interest

All authors have no financial disclosures or conflicts of interest to declare.


  1. 1.
    Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006;130:1480–1491.CrossRefPubMedGoogle Scholar
  2. 2.
    Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ 3rd. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology. 1991;101:927–934.PubMedGoogle Scholar
  3. 3.
    Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38:1569–1580.CrossRefPubMedGoogle Scholar
  4. 4.
    Hahn BA, Saunders WB, Maier WC. Differences between individuals with self-reported irritable bowel syndrome (IBS) and IBS-like symptoms. Dig Dis Sci. 1997;42:2585–2590.CrossRefPubMedGoogle Scholar
  5. 5.
    Thompson WG, Irvine EJ, Pare P, Ferrazzi S, Rance L. Functional gastrointestinal disorders in Canada: first population-based survey using Rome II criteria with suggestions for improving the questionnaire. Dig Dis Sci. 2002;47:225–235.CrossRefPubMedGoogle Scholar
  6. 6.
    Saito YA, Locke GR, Talley NJ, Zinsmeister AR, Fett SL, Melton LJ 3rd. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol. 2000;95:2816–2824.CrossRefPubMedGoogle Scholar
  7. 7.
    Halder SL, Locke GR 3rd, Schleck CD, Zinsmeister AR, Melton LJ 3rd, Talley NJ. Natural history of functional gastrointestinal disorders: a 12-year longitudinal population-based study. Gastroenterology. 2007;133:799–807.CrossRefPubMedGoogle Scholar
  8. 8.
    Drossman DA, Morris CB, Schneck S, et al. International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit. J Clin Gastroenterol. 2009;43:541–550.CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Agarwal N, Spiegel BM. The effect of irritable bowel syndrome on health-related quality of life and health care expenditures. Gastroenterol Clin North Am. 2011;40:11–19.CrossRefPubMedGoogle Scholar
  10. 10.
    Schuster MM. Diagnostic evaluation of the irritable bowel syndrome. Gastroenterol Clin North Am. 1991;20:269–278.PubMedGoogle Scholar
  11. 11.
    Jones R, Lydeard S. Irritable bowel syndrome in the general population. BMJ. 1992;304:87–90.CrossRefPubMedCentralPubMedGoogle Scholar
  12. 12.
    Ford AC, Forman D, Bailey AG, Axon AT, Moayyedi P. Irritable bowel syndrome: a 10-yr natural history of symptoms and factors that influence consultation behavior. Am J Gastroenterol. 2008;103:1229–1239.; quiz 40.CrossRefPubMedGoogle Scholar
  13. 13.
    Everhart JE, Renault PF. Irritable bowel syndrome in office-based practice in the United States. Gastroenterology. 1991;100:998–1005.PubMedGoogle Scholar
  14. 14.
    Talley NJ, Gabriel SE, Harmsen WS, Zinsmeister AR, Evans RW. Medical costs in community subjects with irritable bowel syndrome. Gastroenterology. 1995;109:1736–1741.CrossRefPubMedGoogle Scholar
  15. 15.
    Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500–1511.CrossRefPubMedGoogle Scholar
  16. 16.
    Ludidi S, Conchillo JM, Keszthelyi D, et al. Rectal hypersensitivity as hallmark for irritable bowel syndrome: defining the optimal cutoff. Neurogastroenterol Motil. 2012;24:729–733, e345–346.Google Scholar
  17. 17.
    Chey WY, Jin HO, Lee MH, Sun SW, Lee KY. Colonic motility abnormality in patients with irritable bowel syndrome exhibiting abdominal pain and diarrhea. Am J Gastroenterol. 2001;96:1499–1506.CrossRefPubMedGoogle Scholar
  18. 18.
    King TS, Elia M, Hunter JO. Abnormal colonic fermentation in irritable bowel syndrome. Lancet. 1998;352:1187–1189.CrossRefPubMedGoogle Scholar
  19. 19.
    Camilleri M, Di Lorenzo C. Brain-gut axis: from basic understanding to treatment of IBS and related disorders. J Pediatr Gastroenterol Nutr. 2012;54:446–453.CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Simren M, Barbara G, Flint HJ, et al. Intestinal microbiota in functional bowel disorders: a Rome foundation report. Gut. 2013;62:159–176.CrossRefPubMedCentralPubMedGoogle Scholar
  21. 21.
    Monsbakken KW, Vandvik PO, Farup PG. Perceived food intolerance in subjects with irritable bowel syndrome–etiology, prevalence and consequences. Eur J Clin Nutr. 2006;60:667–672.CrossRefPubMedGoogle Scholar
  22. 22.
    Jones HF, Butler RN, Brooks DA. Intestinal fructose transport and malabsorption in humans. Am J Physiol Gastrointest Liver Physiol. 2011;300:G202–G206.CrossRefPubMedGoogle Scholar
  23. 23.
    Blakemore SJ, Aledo JC, James J, Campbell FC, Lucocq JM, Hundal HS. The GLUT5 hexose transporter is also localized to the basolateral membrane of the human jejunum. Biochem J. 1995;309:7–12.PubMedCentralPubMedGoogle Scholar
  24. 24.
    Choi YK, Johlin FC Jr, Summers RW, Jackson M, Rao SS. Fructose intolerance: an under-recognized problem. Am J Gastroenterol. 2003;98:1348–1353.CrossRefPubMedGoogle Scholar
  25. 25.
    Barrett JS, Irving PM, Shepherd SJ, Muir JG, Gibson PR. Comparison of the prevalence of fructose and lactose malabsorption across chronic intestinal disorders. Aliment Pharmacol Ther. 2009;30:165–174.CrossRefPubMedGoogle Scholar
  26. 26.
    Bailey RK, Fileti CP, Keith J, Tropez-Sims S, Price W, Allison-Ottey SD. Lactose intolerance and health disparities among African Americans and Hispanic Americans: an updated consensus statement. J Natl Med Assoc. 2013;105:112–127.PubMedGoogle Scholar
  27. 27.
    Yang J, Deng Y, Chu H, et al. Prevalence and presentation of lactose intolerance and effects on dairy product intake in healthy subjects and patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 2013;11:262–268.Google Scholar
  28. 28.
    Reddy BS. Possible mechanisms by which pro- and prebiotics influence colon carcinogenesis and tumor growth. J Nutr. 1999;129:1478S–1482S.PubMedGoogle Scholar
  29. 29.
    Topping DL, Clifton PM. Short-chain fatty acids and human colonic function: roles of resistant starch and nonstarch polysaccharides. Physiol Rev. 2001;81:1031–1064.PubMedGoogle Scholar
  30. 30.
    Sengupta S, Muir JG, Gibson PR. Does butyrate protect from colorectal cancer? J Gastroenterol Hepatol. 2006;21:209–218.CrossRefPubMedGoogle Scholar
  31. 31.
    Gibson GR, Probert HM, Loo JV, Rastall RA, Roberfroid MB. Dietary modulation of the human colonic microbiota: updating the concept of prebiotics. Nutr Res Rev. 2004;17:259–275.CrossRefPubMedGoogle Scholar
  32. 32.
    Staudacher HM, Irving PM, Lomer MC, Whelan K. Mechanisms and efficacy of dietary FODMAP restriction in IBS. Nat Rev Gastroenterol Hepatol. 2014;11:256–266.CrossRefPubMedGoogle Scholar
  33. 33.
    Ong DK, Mitchell SB, Barrett JS, et al. Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. J Gastroenterol Hepatol. 2010;25:1366–1373.CrossRefPubMedGoogle Scholar
  34. 34.
    Murray K, Wilkinson-Smith V, Hoad C, et al. Differential effects of FODMAPs (fermentable oligo-, di-, mono-saccharides and polyols) on small and large intestinal contents in healthy subjects shown by MRI. Am J Gastroenterol. 2014;109:110–119.CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.
    Barrett JS, Gearry RB, Muir JG, et al. Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment Pharmacol Ther. 2010;31:874–882.PubMedGoogle Scholar
  36. 36.
    Marciani L, Cox EF, Hoad CL, et al. Postprandial changes in small bowel water content in healthy subjects and patients with irritable bowel syndrome. Gastroenterology. 2010;138:469–477.Google Scholar
  37. 37.
    Madsen JL, Linnet J, Rumessen JJ. Effect of nonabsorbed amounts of a fructose-sorbitol mixture on small intestinal transit in healthy volunteers. Dig Dis Sci. 2006;51:147–153.CrossRefPubMedGoogle Scholar
  38. 38.
    Barbara G, Cremon C, De Giorgio R, et al. Mechanisms underlying visceral hypersensitivity in irritable bowel syndrome. Curr Gastroenterol Rep. 2011;13:308–315.CrossRefPubMedGoogle Scholar
  39. 39.
    Larsson MB, Tillisch K, Craig AD, et al. Brain responses to visceral stimuli reflect visceral sensitivity thresholds in patients with irritable bowel syndrome. Gastroenterology. 2012;142:463–472.Google Scholar
  40. 40.
    Shepherd SJ, Gibson PR. Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. J Am Diet Assoc. 2006;106:1631–1639.CrossRefPubMedGoogle Scholar
  41. 41.
    Ostgaard H, Hausken T, Gundersen D, El-Salhy M. Diet and effects of diet management on quality of life and symptoms in patients with irritable bowel syndrome. Mol Med Rep. 2012;5:1382–1390.PubMedGoogle Scholar
  42. 42.
    de Roest RH, Dobbs BR, Chapman BA, et al. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. Int J Clin Pract. 2013;67:895–903.CrossRefPubMedGoogle Scholar
  43. 43.
    Mazzawi T, Hausken T, Gundersen D, El-Salhy M. Effects of dietary guidance on the symptoms, quality of life and habitual dietary intake of patients with irritable bowel syndrome. Mol Med Rep. 2013;8:845–852.PubMedGoogle Scholar
  44. 44.
    Pedersen N, Vegh Z, Burisch J, et al. Ehealth monitoring in irritable bowel syndrome patients treated with low fermentable oligo-, di-, mono-saccharides and polyols diet. World J Gastroenterol. 2014;20:6680–6684.CrossRefPubMedCentralPubMedGoogle Scholar
  45. 45.
    Shepherd SJ, Parker FC, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence. Clin Gastroenterol Hepatol. 2008;6:765–771.CrossRefPubMedGoogle Scholar
  46. 46.
    Staudacher HM, Lomer MC, Anderson JL, et al. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr. 2012;142:1510–1518.CrossRefPubMedGoogle Scholar
  47. 47.
    Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014;146:67–75.Google Scholar
  48. 48.
    Biesiekierski JR, Newnham ED, Irving PM, et al. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011;106:508–514.; quiz 15.CrossRefPubMedGoogle Scholar
  49. 49.
    Biesiekierski JR, Peters SL, Newnham ED, Rosella O, Muir JG, Gibson PR. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterology. 2013;145:320–328.Google Scholar
  50. 50.
    Bouhnik Y, Flourie B, Riottot M, et al. Effects of fructo-oligosaccharides ingestion on fecal bifidobacteria and selected metabolic indexes of colon carcinogenesis in healthy humans. Nutr Cancer. 1996;26:21–29.CrossRefPubMedGoogle Scholar
  51. 51.
    Silk DB, Davis A, Vulevic J, Tzortzis G, Gibson GR. Clinical trial: the effects of a trans-galactooligosaccharide prebiotic on faecal microbiota and symptoms in irritable bowel syndrome. Aliment Pharmacol Ther. 2009;29:508–518.CrossRefPubMedGoogle Scholar
  52. 52.
    Davis LM, Martinez I, Walter J, Hutkins R. A dose dependent impact of prebiotic galactooligosaccharides on the intestinal microbiota of healthy adults. Int J Food Microbiol. 2010;144:285–292.CrossRefPubMedGoogle Scholar
  53. 53.
    Halmos EP, Christophersen CT, Bird AR, Shepherd SJ, Gibson PR, Muir JG. Diets that differ in their FODMAP content alter the colonic luminal microenvironment. Gut. 2014. doi: 10.1136/gutjnl-2014-307264.
  54. 54.
    Ford AC, Quigley EM, Lacy BE, et al. Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: systematic review and meta-analysis. Am J Gastroenterol. 2014;109:1350–1365.; quiz 66.CrossRefPubMedGoogle Scholar
  55. 55.
    Gibson PR, Barrett JS, Muir JG. Functional bowel symptoms and diet. Int Med J. 2013;43:1067–1074.CrossRefGoogle Scholar
  56. 56.
    Staudacher HM, Whelan K, Irving PM, Lomer MC. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet. 2011;24:487–495.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Muhammad Ali Khan
    • 1
  • Salman Nusrat
    • 2
    Email author
  • Muhammad Imran Khan
    • 1
  • Ali Nawras
    • 1
  • Klaus Bielefeldt
    • 3
  1. 1.Department of GastroenterologyUniversity of ToledoToledoUSA
  2. 2.Department of GastroenterologyUniversity of Oklahoma Health Sciences CenterOklahoma CityUSA
  3. 3.Department of GastroenterologyUniversity of PittsburghPittsburghUSA

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