Table 2.
| Low-FODMAP diet: implementation phases25,38,48,52 | |||
|---|---|---|---|
| Preassessment and dietary counseling | Phase 1: FODMAP restriction | Phase 2: FODMAP Rechallenge/ reintroduction | Phase 3: FODMAP Maintenance /Personalization |
| Assessment | |||
| Baseline assessment Anthropometry (height, weight) and body mass index - Biochemical tests to exclude other comorbidities - Gather past medical history, family history, nutritional history Clinical assessment - Start with confirming the diagnosis Use Rome IV criteria for diagnosing IBS and Rome IV diagnostic criteria to confirm IBS subtypes 25 - Perform comprehensive symptom assessment for gastrointestinal symptoms, stool output, quality of life Some symptom assessment tools used are the following: Global symptom questions (yes/no questions), Gastrointestinal Symptom Rating Scale, Visual Analogue Scale for IBS, IBS Severity Scoring System, Bristol Stool Form Scale, Short Form 36 Health Survey, IBS Quality of Life Questionnaire 25 Dietary assessment Quantitative: assessment of current nutrients and FODMAP intake, food diary, 24-hour recall or diet history, food frequency questionnaire that includes FODMAP intake Qualitative: food that aggravates symptoms, food preferences, eating patterns, food access, availability, dietary restriction, use of nutritional supplements.12,25 Dietary counseling: a registered dietitian/nutritionist specialized in training in FODMAPs will provide counseling During initial visit: - Explain the effects of FODMAP restriction - Counsel regarding the food sources of each FODMAP category, how to incorporate FODMAP restriction into daily lifestyle, adherence to FODMAP diet, food-related social activities, day-to-day shopping, etc - Tailor counseling to specific symptoms and different IBS subgroups to evaluate the effectiveness of low-FODMAP diet - Counsel regarding the importance of maintaining quality25,48,52 |
The food items that are high in FODMAP are restricted and
substituted with small portions of moderate- or low-FODMAP
alternatives This phase is maintained for 3-6 weeks. Many people will notice improvement in symptoms by week 2. If symptoms have improved by week 4, patients move to reintroduction phase The degree of symptom improvement is variable for patients. If the symptoms have not improved, consider other treatment options22,38 One of the goals during this phase is to increase the variety of diet to ensure compliance and reduce nutritional deficiencies associated with prolonged restriction There may be situations where all the FODMAP categories need not be restricted; therefore, dietary counseling is tailored to each case25,52 Assess for clinical response. Use various symptom assessment tools and IBS Quality of Life Questionnaire 25 |
FODMAPs are slowly introduced into the patient’s diet to
test tolerance and exacerbation of symptoms This phase is usually commenced after 2-6 weeks on the restrictive phase of the low-FODMAP diet After reassessing for the symptoms and diet, counsel regarding FODMAP re-introduction Patients are instructed to remain on the strict low-FODMAP diet while completing the challenges 38 One challenge is completed at a time, and each specific food is tested every 3 days 38 For each food challenge, only 1 food from a new FODMAP category is recommended 52 Counsel patients to identify triggers and doses (quantity) that induce symptoms with each dietary challenge 25 The food groups that are frequently consumed are challenged first 11 Instruct patients to document the symptom types, symptom control, and severity of symptoms with each challenge25,38 After all the FODMAP categories have been trialed, patients can follow an individualized, modified version of the low-FODMAP diet38,52 |
After identifying the trigger foods, patients continue to
take other high-FODMAP foods that are tolerated. The
triggers are eliminated altogether during this
phase The dietitian recommends a personalized dietary plan to meet nutritional needs The personalization will focus on a diverse healthy diet that is enjoyable and not restricting the psychosocial aspects (eg, dining out, other socializing events etc)25,38 Inform that a certain degree of symptoms is normal11,52 Patients are advised to return to normal diet gradually to prevent abrupt worsening of symptoms If FODMAP restriction failed to resolve symptoms, other dietary approaches such as administration of prebiotics must be utilized 25 In the long-term, counsel on personalization with a less restrictive and diverse diet. Exclude the FODMAPs that induce symptoms 25 |
Abbreviations: FODMAP, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; IBS, irritable bowel syndrome.
a
Rome IV criteria: presence or recurrent abdominal pain (on average at least 1 day per week in past 3 months associated with 2 or more of (1) pain related to defecation; (2) a change in frequency of stool; and (3) a change in the form (appearance of stool). 25 IBS subtypes: IBS with diarrhea, IBS with constipation, IBS with mixed symptoms, IBS unclassified/unsubtyped. 25