Blog entry by Rcgp Learning
It is estimated that around 17% of the UK’s population have Irritable Bowel Syndrome (IBS)1, but there is no single cure that works for all patients. April marks IBS Awareness Month, aiming to spread important information about diagnosis and management of this often uncomfortable and painful condition.
A recent development in IBS treatment is the introduction of the low FODMAP diet – standing for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides and Polyols.
The low FODMAP diet was developed in Australia by a team at Monash University in Melbourne2 after finding that foods high in certain short-chain carbohydrates can cause gastrointestinal discomfort. Short chain carbohydrates are poorly absorbed in the small intestine and are found in various foods, such as wheat, rye, pulses, lactose, fructose and some fruit and vegetables. These high FODMAP foods increase the amount of water in the small intestine which can contribute to loose stools. They start fermenting when they reach the colon, which may increase gas production and subsequently cause symptoms such as wind and bloating3. You can find examples of high and low FODMAP foods on the Monash University website here.
A 2017 review that assessed the results of published clinical studies on FODMAP, concluded that up to 86% of patients with IBS saw an improvement in overall gastrointestinal symptoms4.
As the symptoms of IBS can be similar to those of other diseases such as Inflammatory Bowel Disease (IBD) or bowel cancer, the NICE Pathway for IBS recommends looking for red flag indicators when a patient presents with IBS symptoms, to assess whether the patient should be referred to secondary care for further investigations5. More information about these red flags can be found here in the NICE Pathway.
While the efficacy of the low FODMAP diet seems impressive, patients should be referred to a dietitian before attempting it on their own, as recommended in the NICE guidance on IBS6. When a patient is referred to a dietitian, there will be three stages:
- Low FODMAP Diet - the patient will reduce their intake of high FODMAP foods for two-six weeks to establish whether the symptoms will respond to the change in diet.
- Re-challenge phase – if symptoms have improved, high FODMAP foods will be introduced for six-eight weeks so the patient can identify which FODMAPs trigger their symptoms.
- Adapted diet – the dietitian will personalise the diet to the patient, so they only avoid their ‘trigger foods’ and can resume a more normal diet2.
For further information about gastrointestinal conditions, the RCGP offers the following eLearning courses that are FREE to all healthcare professionals:
Inflammatory Bowel Disease - 0.5 CPD credits
Managing uncertainty in lower gastrointestinal tract presentations - 0.5 CPD credits
Diagnosis and Management of Coeliac Disease - 0.5 CPD credits
RCGP members can also benefit from access to the following content:
(1) Khanbhai. A and Singh Sura. D. Irritable Bowel Syndrome for Primary Care Physicians. [March 2013] Available from: http://www.bjmp.org/content/irritable-bowel-syndrome-primary-care-physicians
(2) Monash University. The Low FODMAP Diet. [Internet] Available from: https://www.monashfodmap.com/
(3) Magge. S and Lembo. A. Low-FODMAP Diet for Treatment of Irritable Bowel Syndrome. [Nov 2012] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3966170/
(4) Nanayakkara. W.S. (et al). Efficacy of the low FODMAP diet for treating irritable bowel syndrome: the evidence to date. [June 2016] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918736/
(5) NICE pathways. Irritable bowel syndrome in adults overview. Interactive flowchart. Available from: https://pathways.nice.org.uk/pathways/irritable-bowel-syndrome-in-adults
(6) NICE. Irritable bowel syndrome in adults: diagnosis and management (CG61). [April 2017] Available from: https://www.nice.org.uk/guidance/cg61/chapter/1-Recommendations#dietary-and-lifestyle-advice