Can the low FODMAP diet be used in IBD?

IBD (Inflammatory Bowel Disease) and IBS (Inflammatory Bowel Syndrome) can have similar symptoms such as pain, gas, bloating, diarrhoea/constipation, and mucus in the stool. Unlike IBD, IBS does not cause inflammation, however it is possible to have both IBD and IBS. A low FODMAP diet is something that may be considered by your IBD team, Dietitian or Nutritionist if you are experiencing ongoing GI issues but your IBD is in remission and other dietary changes have not been successful in reducing these.

The FODMAP exclusion diet was developed in early 2000’s by a research team at Monash University in Melbourne, Australia in conjunction with Dieticians to help people with IBS reduce their symptoms.

What are FODMAPs?

The word FODMAP is an acronym for Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols, all of which are types of carbohydrates that are not completely digested in our intestines. When travelling through our small intestine they move slowly pulling in water as they go. They are then rapidly fermented by our gut bacteria in our large intestine, during which they produce gas. This combination of gas and excess water can cause distention  (stretching of the bowel), which can result in pain in people with sensitive guts. Other common symptoms are bloating, excessive wind, diarrhoea and/or constipation.      

Where would I find FODMAPs?

They occur naturally in some fruit and vegetables which are typically considered to be healthy for our guts, as well as dairy products, wheat and rye, legumes, sugar syrups and sweeteners. 

Examples of FODMAPs and where we can find them:-

Oligosaccarides (fructans and galacto-oligosaccharides)

  • wheat & rye (cereals, bread, cakes, pasta)

  • onions

  • garlic

  • leek

  • beetroot

  • cabbage/brussels sprouts

  • legumes & pulses (chickpeas, kidney beans, baked beans, peanuts, lentils etc.)

Disaccharides (lactose)

  • milk (cows, goats and sheep)

  • soft cheese (cottage, mascarpone, ricotta)

  • yoghurts

Monosaccharides

  • sweeteners (honey, high-fructose syrup)

  • apples

  • mango

  • dried fruit

  • fruit juices

Polyols

  • sweeteners (sorbitol, mannitol, isomalt) – typically found in low sugar drinks/products, chewing gum and confectionary.

  • avocado

  • peach/pear/plum/prunes

  • cherry/blackberry

  • green bell peppers

  • mushrooms

 

What is the low FODMAP diet?

If you have been diagnosed with IBS then your doctor may have suggested working with a Dietician. The Low FODMAP diet may be suggested if other foundational dietary changes have been implemented with little success. The low FODMAP diet should only be used for very short periods of time (usually 4-6 weeks), which is known as the elimination phase. There is evidence that long-term restriction of FODMAPs has a negative impact on gut health, which is why it is important not to self-diagnose any sensitivity to FODMAPs or exclude them without supervision. After this initial restriction phase, you will move onto the challenge or reintroduction phase, where you slowly re-introduce groups of FODMAPs to determine tolerance levels to the different groups/foods. This is a strategic and complicated process so help from a Dietician or Nutritionist who is trained in low FODMAP Diets is important so they can help to guide you through. The third phase is often called the personalisation phase. This is where you and your nutritionist or dietician will work together to create a long term diet only excluding the foods that trigger symptoms.

Does this mean I will never be able to eat FODMAPs again?

The short answer is no! It is unlikely that you will experience GI symptoms with all high FODMAP foods, which is why it is important to work out which ones are causing issues. You may also only experience symptoms when you consume in excess: -

For example, a single apple may not cause an IBS flare up, but consuming some slices of bread, half an onion, an apple, and a glass of milk during the same meal may cause the onset of IBS symptoms. This is why it can sometimes be difficult to pinpoint the exact food that is causing the issue.

Overall, the aim is to introduce as many FODMAP foods back into your diet as possible and only reduce the ones that cause symptoms but not completely cut them out. Over time many people can reintroduce all foods back into the diet but the time it takes to do this can vary from person to person. FODMAP tolerance can change over time so regularly reintroducing foods that are not tolerated as well is important and also including small amounts and working up to larger amounts over weeks or months can be helpful.

How well does it work?

The original studies carried out at Monash University found a significant reduction of IBS symptoms in 3 out of 4 people who followed the low FODMAP dietary intervention, compared to people on a standard diet. The reduction in symptoms included less pain, discomfort, bloating and distention, and improvement in bowel habits and overall quality of life.

Since the original findings this dietary intervention has been researched and implemented by gastroenterology departments across the world. A 2017 meta-analysis looking at randomised controlled trials testing FODMAP dietary intervention on IBS patients supported these original findings.

It is important to remember that FODMAP dietary intervention is not a cure for IBS, but can help you live more comfortably with the condition. Additionally, it is not the only successful treatment available for reducing IBS symptoms. There are other treatments available for IBS including yoga and cognitive behaviour therapy, which have been shown in studies to be as effective as the low FODMAP diet. There is no firm conclusion on which treatment currently has the greatest long-term impact.

Low FODMAPS and IBD

A low FODMAP dietary intervention is not currently used for treatment of gastrointestinal diseases such as IBD. There have been a number of small-scale studies demonstrating a similar benefit in terms of managing GI symptoms like pain and bloating and improving overall quality of life in people with IBD in remission. There is very little evidence that the low FODMAP diet has any influence on inflammation levels in IBD, however more research in this area is required. The low FODMAP diet reintroduction phase can be very hard to navigate during flare ups of disease as its very hard to distinguish whether symptoms are because of foods or inflammation which is another reason why, in practice, the diet is often only used in people in remission.   

Take Aways

  • The Low FODMAP diet can be helpful in reducing symptoms like bloating, pain, diarrhoea and constipation in some people with IBS.

  • The Low FODMAP diet maybe be helpful for people with IBD in remission if gastrointestinal symptoms persist and other dietary avenues have been explored with little success.

  • The Low FODMAP diet has 3 stages: elimination (for a maximum of 6 weeks), reintroduction, personalisation.

  • The diet is very restrictive, can be hard to follow and should never be done without the guidance of a nutritionist/dietician.

 

References

Monash University FODMAP site- https://www.monashfodmap.com/

Altobelli, E.; Del Negro, V.; Angeletti, P.M.; Latella, G. Low-FODMAP Diet Improves Irritable Bowel Syndrome Symptoms: A Meta-Analysis. Nutrients 2017, 9, 940. https://doi.org/10.3390/nu90909

Schumann, D, Langhorst, J, Dobos, G, Cramer, H. Randomised clinical trial: yoga vs a low-FODMAP diet in patients with irritable bowel syndrome. Aliment Pharmacol Ther. 2018; 47: 203– 211. https://doi.org/10.1111/apt.14400

Yong-le Zhan, Yong-an Zhan, Shi-xue Dai. (2018). Is a low FODMAP diet beneficial for patients with inflammatory bowel disease? A meta-analysis and systematic review. Clinical Nutrition, 37(1), 123-129, ISSN 0261-5614, https://doi.org/10.1016/j.clnu.2017.05.019.

Clemmie Macpherson