OBJECTIVE: Dietary triggers such as gluten and highly fermentable oligo-, di- and monosaccharides and polyols (FODMAP)-containing foods have been associated with worsening irritable bowel syndrome (IBS) symptoms. However, the true impact of dietary restriction on IBS symptoms has remained unclear. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) examining the efficacy of exclusion diets (we focused on low FODMAP and gluten-free diets (GFD)) in IBS.
METHODS: We conducted a search of the literature using the electronic databases MEDLINE (1946 to November 2017), EMBASE (1974 to November 2017), Cochrane Central Register of Controlled Trials (November 2017), and Cochrane Database of Systematic Reviews (2005 to November, 2017) for RCTs of exclusion diets in IBS. Two independent reviewers screened citations and a third reviewer resolved disagreement. Two independent reviewers performed eligibility assessment and data abstraction. For inclusion, RCTs that evaluated an exclusion diet versus an alternative or usual diet and assessed improvement in either global IBS symptoms or abdominal pain were required. Data were synthesized as relative risk of symptoms remaining using a random effects model. Quality of evidence was assessed using GRADE methodology.
RESULTS: A total of 1726 citations were identified. After full-text screening a total of nine studies were eligible for the systematic review. There were two RCTs of a GFD, involving 111 participants. Both selected patients who responded to a GFD and then randomized them to continue the diet or have the diet "spiked" with gluten. A GFD was associated with reduced global symptoms compared with a control diet (RR = 0.42; 95% CI 0.11 to 1.55; I2 = 88%), although this was not statistically significant. There were seven RCTs comparing a low FODMAP diet with various control interventions in 397 participants. A low FODMAP diet was associated with reduced global symptoms compared with control interventions (RR = 0.69; 95% CI 0.54 to 0.88; I2 = 25%). The three RCTS that compared low FODMAP diet with rigorous control diets had the least heterogeneity between studies, but also the least magnitude of effect. The overall quality of the data was "very low" according to GRADE criteria.
CONCLUSIONS: There is insufficient evidence to recommend a GFD to reduce IBS symptoms. There is very low quality evidence that a low FODMAP diet is effective in reducing symptoms in IBS patients.
As a gastroenterologist who looks after patients with IBS, I am often asked about dietary interventions. This systematic review and meta-analysis from an expert group explains the quality of the evidence in detail. Physicians and patients should understand that there is no rationale for recommending a gluten-free diet for IBS patients in the absence of coeliac disease (or documented non-coeliac gluten sensitivity). Furthermore, the widely popular low FODMAPs diet appear to be based on very weak evidence. Since this diet is cumbersome and needs the participation of an expert dietitian, it is probably not something that most gastroenterologists should be routinely recommending.
This is a meta analysis of the effect of restriction of gluten and fermentable sugars on symptoms of IBS. They felt the evidence was of very low quality with small number of patients but it suggested some benefit.
Gluten free or low FODMAP diets would seem plausibly helpful for IBS patients but, as this review demonstrates, the evidence remains limited. While there is low quality evidence for low FODMAP diets, the resources required to institute such a diet are significant and seem best to be deferred until there is better evidence to support such an effort.