Efficacy of a Low-FODMAP Diet in Reducing Diarrhea for Irritable Bowel Syndrome and

Beyond

Taylor Palm

NFS568

February 7, 2016

Email: Taylor.palm@yahoo.com
Abstract

Diarrhea is a common symptom associated with gastrointestinal (GI) disorders,

infections, and conditions. One condition related to diarrhea is Irritable Bowel Syndrome

(IBS). A Low-FODMAP diet (LFD) that limits intake of highly osmotic, poorly absorbed

short-chain carbohydrates, has been suggested for overall symptom management of

IBS. Due to the effects of fermentable oligosaccharides, disaccharides,

monosaccharides, and polyols (FODMAPs) on digestion, a LFD may improve diarrhea

for IBS patients as well as patient populations experiencing similar GI symptoms, such

as those with Irritable Bowel Disease (IBD), reduced intestinal length, and those

receiving enteral nutrition. The objective of this paper is to contribute not only a

consensus on whether the LFD reduces diarrhea for IBS patients, but also if it improves

diarrhea for other conditions and disease states. Previous reviews on the LFD address

its effects on overall symptom severity and individual symptoms, however, none have

focused on its efficacy for reducing diarrhea specifically. Evidence reviewed in this

paper found a LFD significantly improved stool frequency, consistency, and weight for

those with IBS-D, the diarrhea predominant IBS subcategory. Though more randomized

controlled trials are needed, results from studies evaluating a LFD for IBD, reduced

intestinal length and those receiving enteral nutrition demonstrated a positive effect on

diarrhea. Findings from this narrative literature review indicate a LFD is an effective

strategy for reducing diarrhea in at least IBS-D patients, however, due to a lack of

strong evidence as this time, a LFD should not be routinely indicated for patient

populations beyond IBS.

Introduction

Diarrhea is a common symptom associated with a variety of gastrointestinal (GI)

disorders, infections and conditions.1 When diarrhea is prolonged it can result in

dehydration, electrolyte imbalance, weight loss, malabsorption, nutrient deficiency,

and/or malnutrition.1 The optimal treatment for diarrhea is difficult to pinpoint as the

causes can be multifactorial depending on the etiology.1

One particular cause of diarrhea is Irritable Bowel Syndrome (IBS). 2 Up to 20% of

people worldwide suffer from IBS.2 Those with IBS may experience symptoms such as

aforementioned diarrhea, as well as constipation, nausea, abdominal pain, bloating, and

flatulence.3 IBS is subdivided by stool form into IBS-D for diarrhea, IBS-C for

constipation, and IBS-M for mixed.2 The causes of IBS are not well understood and

therefore, symptoms associated with reduced quality of life can be difficult to manage. 2,5

While medications and overall lifestyle changes are used to address symptoms, many

IBS patients look to their diet as a source of their ailments. 4 Up to 84% of IBS patients

believe that at least one food in particular triggers their symptoms. 5

Varying dietary advice and a number of elimination diets have been suggested to

treat or control the symptoms of IBS.2,3 One diet, in particular, the Low-FODMAP diet

(LFD), has been growing in popularity.3 The LFD, created by Monash University,

focuses on reducing the consumption of highly osmotic, short-chain carbohydrates

noted with poor absorption.3,4 The acronym, FODMAP, stands for Fermentable

Oligosaccharides, Disaccharides, Monosaccharides, and Polyols. 6 FODMAPs include:

foods with high fructose to glucose ratios like some fruits and high fructose corn syrup,

fructans found in onions, garlic and wheat, lactose in dairy products,

galactooligosaccharides like those in beans and other legumes, and sugar polyols like
sorbitol and mannitol.7 Both healthy individuals and those with functional GI disorders

can malabsorb FODMAPs.3 MRI imaging has shown fructose, a monosaccharide, draws

excess water into the small bowel which can contribute to diarrhea while inulin, an

oligosaccharide, can contribute to gas in the large bowel. 8 Based on the mechanism of

highly osmotic, poorly absorbed FODMAPs effect on the GI tract, research has sought

to determine if there is scientific-based evidence demonstrating that a LFD can reduce

GI symptoms related to IBS.9-14

The benefits of a LFD do not appear to be limited to only those patients with

IBS.11,15-19 The osmotically active and poorly absorbed FODMAPs effect on digestion

has led to the theory that a LFD may have wider applicability.11,15-19 Patients with a

variety of other conditions plagued with diarrhea and similar GI symptoms may find

relief on this diet.11,15-19 This dietary approach is being studied for its use in those with

Irritable Bowel Disease (IBD) like Crohns disease or ulcerative colitis, those with

reduced intestinal length, and those receiving enteral nutrition. 11,15-19

A number of studies have been published in the last several years that have

added to the small body of work on the topic of a LFD for the management of

diarrhea.4,9-19 The objective of this narrative is to contribute to the field not only a

consensus on if the LFD reduces diarrhea for patients with IBS, but also if this diet has

applicability for improving diarrhea for other conditions and disease states. If research

can clearly determine the efficacy of a LFD, management of diarrhea and quality of life

may be improved for a variety of patient populations.

Methods
 A single literature search was conducted from October 2016 through January

2017. Identification of eligible articles came from several databases including: PubMed,

Rutgers Libraries, University of Rhode Island Libraries, and Google Scholar. The

following key terms were used for database searches: FODMAPs, low FODMAP diet,

diarrhea, Irritable Bowel Syndrome, and Irritable Bowel Disease. Studies were limited to

those involving a dietary intervention with a LFD. In order to assess the generalizability

and scope of a LFD as a nutritional therapy for diarrhea, any condition associated with

diarrhea that could be treated and/or managed with a LFD was included. During the

literature search, titles of articles were first screened for a focus on FODMAPs. If the

title addressed FODMAPs, the abstract was further inspected to determine if a LFD was

used as a dietary intervention. Studies read in full were excluded if they did not address

diarrhea as a dependent variable. Articles that met inclusion criteria were then sorted by

disease state/condition studied. Selection of studies focused on those published in the

last five years with all studies published within the last ten years. With the exception of

one study originally printed in Spanish, all studies reviewed were published in English.

There are a limited number of studies with high-quality designs on this topic, therefore,

a variety of study designs were included. Study designs included 3 randomized

controlled trials, 3 prospective studies, 3 retrospective studies, 1 retrospective and

prospective combination study, 2 crossover studies, 1 clinical trial and 2 literature

reviews. For this narrative review, 15 total articles were chosen that met inclusion

criteria.

Discussion

IBS
 The majority of research on a LFD for IBS compares this diet to a standard or

baseline diet.9-12 When evaluating diarrhea and stool in general, these studies focus on

stool consistency and frequency as well as LFD adherence. 9-12 LFD adherence is

significantly correlated with an improvement of diarrhea (P=0.007). 9 Though mostly

favorable, there is some inconsistency with research in regards to stool consistency.

One randomized controlled trial found when stool frequency, consistency, and weight

were evaluated using the Kings Stool Chart (KSC), there was a significant improvement

on a LFD for those with IBS-D (P=.034). 10 There was, however, no significant change in

fecal frequency or KSC scores for those with IBS-C, IBS-M or all IBS subtypes

combined.10 When stool was evaluated using a Bristol scale, one retrospective study

found the proportion of participants with normal stools increased by 41% (P<0.001).11 A

prospective study, on the other hand, found no significant change in stool form using a

Bristol scale.12 Both of these studies evaluated IBS patients without separating by

subtype.11,12 Based on the results from these studies, it appears IBS-D patients are likely

to experience improvement of diarrhea on a LFD compared to a standard or baseline

diet.10-12 Where IBS-C and IBS-M patients are included, there are conflicting results or

non-significant changes in stool.10-12

The effects of a LFD have also been studied in relation to traditional dietary

advice for IBS symptom management.4,13,14 Traditional dietary advice includes the

elimination of foods high in fat, spicy, high fiber, high in caffeine, carbonated and include

recommendations such as not overeating. 13 Three studies have compared these dietary

approaches for those with IBS.4,13,14 One randomized controlled trial found a decrease in

overall symptom severity in both interventions (P<.0001) with mixed improvement of

diarrhea.13 There was no change in stool consistency for either group, however, there

was a significant reduction in stool frequency in the LFD group (P<.001). 13 A prospective

study found a trend for the LFD group to have more improvement in diarrhea than the

traditional dietary advice group, though it was not significant (P=0.052). 4 Despite this,

they found participants were more satisfied with symptoms on a LFD (P=0.038). 4 In a

final randomized controlled trial, compared to the traditional guidelines group, there was

an improvement in stool consistency (P=0.0092), frequency (P=0.0003), and urgency

(P=0.0419) in the LFD group.14 It is important to note, this study included only patients

with IBS-D.14 Based on this evidence, compared to traditional IBS dietary advice, a LFD

may be more effective in reducing stool frequency for all subtypes of IBS, with more

significance seen in those with IBS-D. 4,13,14

Though there are some improvements for IBS patients overall, a LFD diet

appears to be most effective in reducing diarrhea for those with IBS-D. 4,9-14 Studies

evaluating all forms of IBS, including IBS-C and IBS-M, produce more conflicting or non-

significant results when evaluating diarrhea. 4,10-13 It is possible those with IBS-D,

compared to those with IBS-C and IBS-M who experience more constipation at

baseline, are more likely to respond favorably to a LFD due to the osmotic effect of

FODMAPs that cause diarrhea.8,14 More studies strictly evaluating IBS-D should be

conducted to better determine the efficacy of a LFD on improvement of diarrhea for

these patients. Overall, whether compared to a standard, baseline diet or traditional

dietary advice, it appears a LFD is effective in reducing diarrhea for at least those with

IBS-D.4,10-14

IBD
 Inflammatory bowel diseases (IBD) like Crohns disease (CD) and ulcerative

colitis (UC), are plagued with symptoms like those in IBS such as diarrhea, constipation,

vomiting, and abdominal pain.11,15 Like IBS, the cause of IBD is not well understood,

making treatment and management of symptoms complicated. 15 While anti-

inflammatory therapy is often the first line of defense for those with IBD, a dietary

intervention could help patients control symptoms, specifically diarrhea. 11,15

Based on the mechanism of highly osmotic, poorly absorbed FODMAPs drawing

water into the small intestines and the success seen in those with IBS, a LFD has been

proposed as a way to manage symptoms in those with IBD. 8,11,15 In a retrospective pilot

study, improvements in diarrhea were seen in 46% of CD patients and 58% of UC

patients on a LFD.15 After 3-6 months following the LFD, diarrhea was improved for all

IBD patients (P<.001).15 In agreeance, when using a Bristol scale, another retrospective

study found 66% of IBD patients reported more normal stools following a LFD

(P<0.001).11 Though these correlations are significant, cause and effect cannot be

shown. High quality randomized controlled trials are needed to confirm these results.

However, the outcomes of these studies are promising that a LFD may result in more

normal stools and improve overall diarrhea for patients with IBD. 11,15

Reduced Intestinal Length

With a shorter GI tract, those with ileostomies and colectomies are particularly

susceptible to diarrhea.16,17 Two studies have assessed the effects of FODMAPs on

fecal output in those with reduced intestinal length. 16,17 In a cross-over study, mean

weight (P=0.01) and water content (P=0.013) of ileostomy effluent were lower on a LFD

compared to a high-FODMAP diet.16 Participants also perceived their effluent to have a

thicker consistency on the LFD (P=0.005).16 Results showed the FODMAP content of

the effluent was significantly and positively correlated to water volume (P=0.035). 16 This

supports the mechanism of osmotically active FODMAPs affecting water content of

stool.16 In a retrospective study, patients with an ileal pouch without a colon were

assessed.17 On a LFD, stool frequency was reduced from a median of 8 to 4 stools per

day (P=0.02).17 Though randomized controlled trials are needed, these studies suggest

a LFD could be beneficial in reducing diarrhea and frequency of stools for those with

reduced intestinal length.16,17

Enteral Nutrition

Enteral nutrition (EN) is indicated in patients who cannot eat by mouth or are not

meeting their needs orally, yet still have a GI system that is functional. 18,19 Diarrhea is a

common occurrence in those on tube feeds.18,19 A retrospective study found some

significant factors related to diarrhea on EN include: medications like antibiotics

(P=0.026) or PPIs (P=0.050), hospital length of stay >21 days (P<0.001), or EN for >11

days (P=<0.001).18 In this same study, adjusting for these factors, the risk for diarrhea

was reduced five-fold when patients were on an EN formula 47-71% lower in FODMAPs

(P=0.029).18 In a randomized clinical trial, compared to those on moderate and high

FODMAP EN formulas, diarrhea was improved in patients on low-FODMAP EN

(P<0.05).19 Evaluating stool using the KSC, scores were better for those on low-

FODMAP EN indicating improved stool consistency, frequency and weight (P<0.05). 19

These studies suggest a low-FODMAP formula could reduce diarrhea in tube-fed

18,19
patients, however, more studies are needed to confirm these results.

Limitations and Implications for Future Research

 Results of the studies in this review indicate a positive effect of a LFD on

diarrhea for a variety of conditions. 2-19 Though these results are encouraging, there is a

distinct lack of randomized controlled trials that provide the highest quality evidence.

More of these are needed to confirm the results of some of the retrospective,

prospective and pilot studies evaluated in this review.

Notably, the diet itself can be a limitation in research. The LFD includes a 2-6

week elimination phase followed by a reintroduction of each FODMAP to determine

patient thresholds.6 The phases of the LFD and emphasis on individual tolerance makes

it difficult to study. Current research focuses on the elimination phase, however,

reintroduction is an important aspect of tailoring the diet that should be evaluated. 2-19

As many studies of IBS patients include all subgroups, future research should

address those with IBS-D exclusively for a better understanding of how the LFD affects

stool in these patients.4,9-14 Finally, few studies assess the long-term effects of a LFD.2

More studies with a longer follow-up should be utilized to determine if there are any

negative implications of following the diet for a longer period of time. 2

Summary

Previous reviews on low-FODMAP diet (LFD) research have addressed its

effects on overall symptom severity with mention of several individual symptoms such

as abdominal pain, bloating and bowel habits. 2,3 However, none have focused on the

efficacy of a LFD for reducing diarrhea specifically. For IBS patients, the LFD has

already been adopted around the world as a tool for overall symptom management. 6,7

According to this research, stool frequency, consistency, and weight are significantly

improved on a LFD for those with IBS-D.10,14 Compared to baseline or standard diets as
well as traditional IBS dietary advice, a LFD appears to more positively affect those with

IBS-D compared to IBS-C or IBS-M.4,9-14 Future research on the LFD specifically for IBS-

D is needed to better understand its effects on diarrhea, especially in comparison to

traditional IBS dietary advice.4,9-14 However, the evidence to date on IBS research and

particularly the results from the randomized controlled trials, demonstrate that a LFD is

an effective strategy for managing diarrhea in at least IBS-D patients. 2-14

The research supporting the LFD diet for management of diarrhea in patient

populations beyond IBS is not quite as strong.11,15-19 For those with IBD, reduced

intestinal length, and those on enteral nutrition, there are a limited number of studies on

each topic and there are very few randomized controlled trials. 11,15-19 Six articles address

a LFD and diarrhea for these three patient populations. 11,15-19 Of these studies, only one

is a randomized controlled trial.11,15-19 Results from these studies are favorable and

demonstrate a positive effect of a LFD on diarrhea, however, due to a lack of strong

evidence, a LFD should not be routinely indicated for those with IBD, reduced intestinal

length or those receiving enteral nutrition at this time. 11,15-19 Future research using more

randomized controlled trials for these patient populations are needed to ascertain the

efficacy of a LFD for reducing diarrhea in these patients.

The LFD is not intended to be lifelong.6,7 Future research is needed to evaluate

long-term changes in stool, overall GI symptoms, and patient satisfaction after

FODMAPs have been reintroduced and individual tolerances have been determined.

Few studies have evaluated the long-term effects of following a LFD. 11 This future

research could provide evidence of long-term efficacy of the diet as well as reveal any
negative impacts or common nutritional deficiencies seen while following a LFD for an

extended period of time.

The LFD is growing in popularity.6 More and more patients will likely go to

clinicians seeking assistance with implementing a LFD to relieve their GI symptoms.

Registered dietitians (RDs) are in the best position to educate patients on how to meet

their nutritional needs and guide them while following a LFD. 7 RDs are also a crucial

aide as patients reintroduce FODMAPs to determine individual thresholds. 3,7

Unfortunately, how to provide patient education on a LFD is not routinely taught to the

RDs that patients with IBS and other conditions with diarrhea turn to. It is essential that

more trainings, seminars, and workshops be designed for clinicians, specifically RDs, to

better help their patients on a LFD. After implementation, future research should

address the effectiveness of these trainings, workshops and seminars on patient

outcomes like diarrhea. The evidence assembled in this narrative review supports the

efficacy of a LFD for reducing diarrhea in at least IBS-D patients and is promising for

other patient populations such as those with IBD, reduced intestinal length and those on

enteral nutrition.2-19 Therefore, RDs have the potential to make a substantial impact on

the management of diarrhea and quality of life for these patients.

 References

1. World Health Organization(WHO). The treatment of diarrhoea: a manual for

physicians and other senior health workers. 4th rev ed. Geneva, CH: WHO
Press;2005.

2. Nanayakkara WS, Skidmore PM, OBrien L, Wilkinson TJ, Gearry RB. Efficacy of the
low FODMAP diet for treating irritable bowel syndrome: the evidence to
date. Clin Exp Gastroenterol. 2016;9:131-142.

3. Barret JS. Extending Our Knowledge of Fermentable, Short-Chain Carbohydrates

for Managing Gastrointestinal Symptoms. Nutr Clin Pract. 2013;28(3):300-306.

4. Staudacher HM, Whelan K, Irving PM, Lomer MCE. 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(5):487-495.

5. Bhn L, Strsrud S, Trnblom H, Bengtsson U, Simrn M. Self-reported food

related gastrointestinal symptoms in IBS are common and associated with more
severe symptoms and reduced quality of life. Am J
Gastroenterol. 2013;108(5):634-41.

6. Shepard, S. Low FODMAP Diet. Shepherd Works Web site.

http://shepherdworks.com.au/disease-information/low-fodmap-diet/. Accessed
January 11, 2017.

7. The Monash University Low FODMAP Diet booklet. Monash University Web site.
http://www.med.monash.edu/cecs/gastro/index.html. Published 2013. Accessed
January 13, 2017.

8. 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(1):110-119.

9. 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.

10. Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A Diet Low in
FODMAPs Reduces Symptoms of Irritable Bowel Syndrome. Gastroenterol.
2014;146:67-75.
11. Maagaard L, Ankersen DV, Vegh Z, et al. Follow-up of patients with functional
bowel symptoms treated with a low FODMAP diet. World J Gastroenterol. 2016;
22(15):4009-4019.

12. Perez N, Torres-Lopez E, Zamarripa-Dorsey F. Mexican clinical response in

patients with irritable bowel syndrome treated with diet low in fermentable
carbohydrates (FODMAP). Rev Gastroenterol Mex. 2015; 80(3):180-185.

13. Bhn L, Strsrud S, Liljebo T, et al. Diet Low in FODMAPs Reduces Symptoms of
Irritable Bowel Syndrome as Well as Traditional Dietary Advice: A Randomized
Controlled Trial. Gastroenterol. 2015;149(6):1399-1407e1392.

14. Eswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K. A Randomized

Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines
in US Adults with IBS-D. Am J Gastroenterol. 2016;111:1824-1832.

15. Gearry RB, Irving PM, Barrett JS, Nathan DM, Shepherd SJ, Gibson PR. Reduction
of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves
abdominal symptoms in patients with inflammatory bowel disease-a pilot study. J
Crohns Colitis. 2009;3(1):8-14.

16. 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(8):874-82.

17. Croagh C, Shepherd SJ, Berryman M, Muir JG, Gibson PR. Pilot study on the effect
of reducing dietary FODMAP intake on bowel function in patients without a colon.
Inflamm Bowel Dis. 2007;13(12):1522-1528.

18. Halmos EP, Muir JG, Barrett JS, Shepherd SJ, Gibson PR. Diarrhoea during enteral
nutrition is predicted by the poorly absorbed short-chain carbohydrate (FODMAP)
content of the formula. Aliment Pharmacol Ther. 2010;32(7):925-933.

19. Yoon SR, Lee JH, Lee JH, Na GY, Lee K, Lee Y, Jung G, Kim OY. Low-FODMAP
formula improves diarrhea and nutritional status in hospitalized patients receiving
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 Letter to the Editor

Dear Dr. Jessica Monroe,

Thank you for your time and consideration in reviewing my Narrative Literature

Review entitled Efficacy of a Low-FODMAP Diet in Reducing Diarrhea for Irritable

Bowel Syndrome and Beyond. Thank you also for your constructive feedback. Please

see my comments below for an explanation of how your feedback was handled.

Introduction

1) Citations need to be after the period .1 Make changes throughout paper.

o All in text citations have been revised throughout the length of the paper.

The super script numbers can be seen following the period in all cases.

Thank you for your comment.

2) Citation needed- there will be very few statements that dont require a citation

make the necessary change throughout paper.

o Citations have been added to any statement missing one that is not 100%

original thought in order to give appropriate credit to the referenced authors.

Thank you for your comment.

Methods

o No comments were made in this section. Thank you for your review.

Discussion

1) Condensing this whole section and including it in the introduction would be

more beneficial.

o This section has been condensed and added into the introduction. Thank

you for your comment.

 2) Clarify what you are referring to here a LFD generates improvement in

diarrhea or only including patients with IBS-D?

o This section has been given more detail and clarification in order to make it

more clear to the reader. Thank you for your comment.

3) This would be a good place to relate these results back to your overall

topic/research question. Maybe mention a possible reason why LFD may help

alleviate IBD symptoms?

o A concluding statement relating the results of IBD studies to the topic of

diarrhea and a LFD has been included. Another statement has been added

to the paragraph to pose why a LFD can alleviate IBD symptoms. Thank

you for your comment.

Summary

1) Based on the feedback received from a peer review by Erin Sheridan, a brief

note regarding how future research should address the efficacy of Low-

FODMAP diet trainings and workshops for registered dietitians on patient

outcomes such as diarrhea has been added. Additionally, for a stronger

opening sentence, Low-FODMAP diet has been written out instead of

abbreviating to LFD. I have thanked Ms. Sheridan for her comments.

Thank you again,

Taylor Palm