Low-FODMAP diet in the treatment of quiescent inflammatory bowel disease

This article is part of our special May 2020 issue. Download the full issue here.

Relation

Cox SR, Lindsay JO, Fromentin S, et al. Effects of a low FODMAP diet on symptoms, fecal microbiome and inflammatory markers in patients with quiescent inflammatory bowel disease in a randomized trial.Gastroenterology. 2020;158(1):176-188.e7.

Study objective

Investigating the Effects of a Low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) Diet on Persistent Intestinal Symptoms, Gut Microbiome, and Circulating Inflammatory Markers in Patients With Quiescent Inflammatory Bowel Disease (IBD)

Draft

Multicenter, randomized, parallel, single-blind, placebo-controlled 4-week study

Participant

Fifty-two patients (27 patients in the low-FODMAP diet group and 25 patients in the control diet group) aged ≥18 years with quiescent Crohn's disease (CD) and ulcerative colitis (UC) from 2 large gastroenterology clinics in London, United Kingdom (UK). Patients were limited to patients with persistent bowel symptoms who met Rome III criteria for irritable bowel syndrome with diarrhea predominance (IBS-D), IBS with mixed bowel habits (IBS-M), or unsubtyped IBS (IBS-U), functional bloating or diarrhea, abdominal pain, bloating, and/or diarrhea on 2 or more days during the baseline screening week with inadequate relief, and the one Couldn't stick to a low-FODMAP diet. Resting IBD was determined by physician global assessment, absence of an IBD flare in the previous 6 months, fecal calprotectin <250 μg/g, and C-reactive protein (CRP) <10 mg/L.

Study parameters assessed

1. Intestinal symptoms

• IBS-Symptomschweregradskala (IBS-SSS)
• Bristol-Stuhlformskala (BSFS)
• Bewertungsskala für gastrointestinale Symptome (GSRS)

2. Health-related quality of life (HR-QoL)

• UK-spezifischer IBD-Fragebogen

3. Disease activity

• Harvey-Bradshaw-Index für CD
• Partielle Mayo-Punktzahl für UC

4. Patient perceived IBD control

• Fragebogen zur IBD-Kontrolle

5. Stool parameters, including

• Entzündungsmarker
• Calprotectin im Stuhl
• Zusammensetzung des fäkalen Mikrobioms
• Kurzkettige Fettsäuren

6. T cell phenotypes in blood

• Durchflusszytometrie

Primary outcome measures

Primary endpoint: change in IBS-SSS.

Secondary outcomes: Other measures of intestinal symptoms (IBS-SSS total score, proportion of patients achieving 50-point IBS-SSS reduction, global symptom questionnaire and GI symptom rating scale), disease-specific HR-QoL, stool frequency and consistency, clinical disease activity, inflammatory markers, dietary intake, microbiome composition and function, short-chain fatty acid and peripheral fatty acid concentrations T cell phenotype.

Key insights

The low FODMAP diet group had greater relief in gut symptoms, higher HR-QoL scores and lower abundance of gut microbes that regulate the immune response. There were no differences in microbiome diversity and inflammatory markers between the two groups.

Practice implications

The low-FODMAP diet has been found to benefit people with IBS. There is evidence that it may also help reduce persistent gastrointestinal symptoms in dormant IBD such as Crohn's disease and ulcerative colitis.^1.2IBD is characterized by periods of remission and relapse. Current treatments aim to reduce inflammation during relapse and prolong remission time. However, many patients with quiescent IBD continue to experience gastrointestinal symptoms. It is unclear why, but could possibly be due to the concurrent presence of IBS, a low-grade inflammatory process, or the psychological effects of IBD.³

The finding from this study is that a low-FODMAP diet can be used for patients with IBD at rest for persistent IBS-like gastrointestinal symptoms such as bloating, bloating, bloating, and frequent bowel movements.

The low-FODMAP diet limits foods high in certain types of sugars that are poorly absorbed by the digestive tract. These sugars are abbreviated FODMAP, which stands for fermentable oligosaccharides (fructans and galacto-oligosaccharides), disaccharides (lactose), monosaccharides (fructose), and polyols (sorbitol and mannitol). Due to limited absorption, foods high in FODMAPs move more slowly through the digestive tract and attract more water into the lumen of the small intestine. Once FODMAPs enter the colon, they are fermented by colon bacteria, a process that creates gas in the intestines. This increased amount of fluid and gas in the intestines can cause bloating, pain, and diarrhea in susceptible individuals. Eating fewer FODMAP carbohydrates can help reduce these symptoms.⁴

The low FODMAP diet limits fermentation in the colon; However, microbiome diversity did not change significantly between the low-FODMAP and control groups in this study. Patients in the low-FODMAP group had lessBifidobacterium adolescentis,Bifidobacterium longumandFaecalibacterium prausnitziiSpecies thought to regulate immune response, but this finding had no impact on inflammatory markers.

The finding from this study is that a low-FODMAP diet can be used for patients with quiescent IBD for persistent IBS-like gastrointestinal symptoms such as bloating, bloating, bloating, and frequent bowel movements. A low-FODMAP diet may improve quality of life but does not appear to have a significant effect on inflammation in patients in remission. Larger and longer-term studies are needed. Once symptomatic relief is achieved, long-term plans should be in place to address patients' continued nutritional needs.

Further considerations for treating functional gastrointestinal symptoms in IBD should include careful exclusion of underlying diseases and monitoring of inflammation. Repeated fecal calprotectin measurement to control inflammation is useful.⁵A partial list of underlying conditions to consider includes small intestinal bacterial overgrowth (SIBO),⁶increased intestinal permeability,⁷previous surgical procedures and resulting adhesions as well as the impact of underlying mental illnesses such as: B. anxiety.

Additional recommendations for the management of IBD should include exercise, as there is evidence that exercise reduces the risk of future relapses.⁸Counseling, cognitive behavioral therapy (CBT), mindfulness therapies and hypnosis have been helpful for patients to manage their condition.⁹Acupuncture and moxibustion therapy showed good results in IBD compared to oral sulfasalazine.¹⁰Aloe vera gel and curcumin have also been studied for IBD.¹¹