Invited Review

Nutrition in Clinical Practice

Volume 0 Number 0
Management of Irritable Bowel Syndrome: xxx 2020 1–9
© 2020 American Society for
Physician-Dietitian Collaboration Parenteral and Enteral Nutrition
DOI: 10.1002/ncp.10567
wileyonlinelibrary.com

Carol Ireton-Jones, PhD, RDN, CNSC, FASPEN1 ; and Michael F. Weisberg, MD2

Abstract
Irritable bowel syndrome (IBS) affects 10%–15% of adults in the United States and 12% of the worldwide population.
Gastroenterologists as well as primary care practitioners are likely to be the first resource for patients with gastrointestinal (GI)
symptoms. IBS is difficult to diagnose, as it is a functional GI disorder, determined after ruling out a myriad of other diagnoses. The
2016 Rome IV criteria define IBS as “a functional bowel disorder in which recurrent abdominal pain is associated with defecation
or a change in bowel habits. Disordered bowel habits are typically present (ie, constipation, diarrhea, or a mix of constipation
and diarrhea), as are symptoms of abdominal bloating/distension occurring over at least 6 months and not less than 3 months.”
Treatment of IBS historically has been through medical management; however, nutrition management of IBS using the FODMAP
(fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) elimination diet is now a recommended, first-line
therapy. FODMAPs are short-chain, poorly absorbed carbohydrates that are associated with symptoms in people with IBS. This diet
intervention can be quite challenging, and therefore, patients should meet with a qualified dietitian who can provide the complex diet
information in a practicable form. Physician-dietitian collaboration is invaluable for IBS patients to achieve a successful outcome.
(Nutr Clin Pract. 2020;0:1–9)

Keywords
FODMAP elimination diet; gastroenterology; irritable bowel syndrome; low FODMAP diet; nutrition

Introduction pation), IBS-D (diarrhea), and IBS-M (mixed constipation

One of the most searched diagnoses by the public is
irritable bowel syndrome (IBS). A Google search of the
term “irritable bowel syndrome” brings up about 37,100,000
results, whereas “Crohn’s disease” gives 3,690,000 results
and “inflammatory bowel disease” gives 45,300,000 results
(accessed March 18, 2020). According to the American
College of Gastroenterology (ACG), ∼10%–15% of adults
in the United States suffer from IBS and IBS symptoms,
and at least 12% of the population suffer throughout the
world.1,2 This paper will review the diagnosis and treatment
of IBS and the collaborative roles of the physician and
dietitian in successful management.
Gastrointestinal (GI) symptoms associated with IBS
include gas, pain, bloating, diarrhea, and/or constipation.3,4
A patient with IBS may not receive a definitive diagnosis for
many years or ever. A family practice, primary care, or inter-
nal medicine physician may treat individual symptoms with-
out tying them all together. IBS is a challenge to diagnose, as
there are no blood tests, definitive exams, or procedures to
distinctly make the diagnosis. Evaluation for IBS is done by
excluding a multitude of other diagnoses, including inflam-
matory bowel disease, motility disorders, and celiac disease.
IBS may be further divided into subtypes—IBS-C (consti-
and diarrhea)—to better focus on management techniques;
however, symptoms may vary within the individual.4,5
The diagnosis of IBS has evolved over many years.
The initial Manning criteria proposed in 1978 used a 15-
symptom questionnaire identifying key indicators of IBS:
loose stools, relief of pain after a bowel movement, ab-
dominal distension, frequent bowel movements, mucus, and
sensation of incomplete evacuation.6 Kruis et al similarly
defined IBS using symptoms of abdominal pain, bloating,
and altered bowel habit as well as symptom duration, with
greater duration being a significant factor.7 Each of these
described symptoms are important definers of IBS but did
not separate IBS based on predominant stool type.
From 1 Good Nutrition for Good Living, Carrollton, Texas, USA;
and 2 Gastroenterologist in Private Practice, Plano, Texas, USA.
Financial disclosure: None declared.
Conflicts of interest: None declared.
This article originally appeared online on xxxx 0, 2020.
Corresponding Author:
Carol Ireton-Jones, PhD, RDN, CNSC, FASPEN, Nutrition Therapy
Specialist, Good Nutrition for Good Living, Carrollton, TX, USA.
Email: drcijrd@gmail.com
2 Nutrition in Clinical Practice 0(0)
Researchers and clinicians meeting in Rome, Italy, over
many years have outlined and revised the criteria to define
IBS. The first international meeting of experts in functional
GI disorder culminated in the development of the Rome
1 criteria using symptom-based groupings to define IBS
(1988). These criteria revealed 85% sensitivity and 71%
specificity when studied in a small number of people with
IBS-like symptoms.8 The current Rome IV criteria define
symptoms more succinctly, identify duration of symptoms,
and include bloating and distension as common symptoms.
In addition, more specific definitions of pain and discom-
fort are considered in the diagnosis. Also, classification of
IBS by subtype is based on stool consistency (not stool
frequency).9,10 The 2016 Rome IV criteria define IBS as
“a functional bowel disorder in which recurrent abdominal
pain is associated with defecation or a change in bowel
habits. Disordered bowel habits are typically present (ie,
constipation, diarrhea or a mix of constipation and diar-
rhea), as are symptoms of abdominal bloating/distension.
Symptom onset should occur at least 6 months prior to
diagnosis and symptoms should be present during the last
3 months.”9,11 Postinfectious IBS has a clearer path to
diagnosis in that a pathogen has affected the gut microbiota
and potentially carbohydrate metabolism.
Diagnosis
Diagnosis of IBS has been described by Lacy and Patel,
using modified Rome IV diagnostic criteria, as recurrent
abdominal pain on average at least 1 time per day in the
last 3 months associated with 2 or more of the following:
(1) related to defecation; (2) associated with a change in
the frequency of stool; and (3) associated with a change
in the form or appearance of the stool.2 Criteria should
be met for the past 3 months with symptoms onset at
least 6 months prior to diagnosis.1 A key characteristic of
IBS is visceral hypersensitivity. The definition of visceral
hypersensitivity is a greater recognition of pain and discom-
fort in the bowel, including allodynia and hyperalgesia.12
Abdominal distension activates nociceptors and enteric
reflexes, leading to increased symptoms, worsened for those
with visceral hypersensitivity.13,14 The gut-brain connection
is highlighted in that the nerves in the GI tract send the
sensation of pain to the brain.
When patients present to the gastroenterologist, patients’
symptoms vary widely and rarely are only specific for IBS.
There is a huge overlay of other symptoms, often including
nausea and vomiting, specific food triggers, blood in the
stool, and others. First the gastroenterologist must look for
the “red flag” signs that could portend different diagnoses.
Weight loss, fever, blood in the stool, and male sex are just
a few of the important elements in the history that point
away from the diagnosis of IBS. In the United States, the
female to male ratio of IBS is 6:1. Not only gender but
also the age of the patient is important in reaching the
diagnosis of IBS. IBS usually occurs in women in their
teens and 20s. When a woman in her 50s presents with IBS
symptoms for the first time, a full diagnostic workup should
be undertaken, including radiologic and endoscopic testing.
Because IBS is a diagnosis of exclusion, the amount of
testing the gastroenterologist does depends on the patient’s
history, a complete physical exam, and baseline laboratory
tests. Often, even with negative results of the preliminary
evaluation, it is important to do further workup both to sat-
isfy the patient’s anxiety and to resolve extraneous findings.
Further workup may include a sonogram or computed to-
mography scan of the abdomen and pelvis, upper endoscopy
with biopsies for celiac disease, colonoscopy, and possibly
a small-bowel series. Testing for small-intestinal bacterial
overgrowth (SIBO) and a lactose tolerance test may also
be indicated.15,16 This extensive testing not only is useful in
ruling out a myriad of other diagnoses but often is very com-
forting to the patient to know that they did not have a more
dire process going on, and this starts the healing process.
Treatment
Medications/supplements. Typically, treatment of IBS
symptoms has been through medications. The medications
used are associated with the symptom they are to treat
(Table 1). Diarrhea is treated with standard antidiarrheals,
but most do not have any effect on the other symptoms
of gas, bloating, or pain. Supplements to treat IBS are not
well researched other than the few listed in Table 1. There
is a plethora of supplements for IBS that can be purchased.
Many times, patients come with the belief that digestive
enzymes will alleviate symptoms. Over-the-counter (OTC)
digestive enzymes for IBS are generally not useful, as the
enzymes are deactivated in the stomach and rendered inef-
fective in the GI tract. An exception is OTC lactase enzymes
in tablet or liquid form (ie, Lactaid), that may be taken
with lactose-containing foods to break down lactose. Foods
treated with the lactase enzyme may be rendered lactose-
free, such as lactose-free milk or cottage cheese, and these
may be helpful for patients with diagnosed lactase deficiency
by allowing these valuable calcium sources to be tolerated
in larger quantities. α-Galactosidase has been proposed
as an OTC enzyme that may be effective specifically for
galactans (beans, legumes) in some individuals in reducing
gas and bloating.17 Treatment of individual symptoms may
benefit some individuals but does not get to the core of the
problem in IBS, which is likely related to >1 food.
Diet and IBS. The nutrition management of IBS requires a
physician to make the diagnosis and a well-skilled dietitian
to provide the nutrition intervention. Given that IBS is
a functional GI disorder, the patient should come to the
Ireton-Jones and Weisberg
Table 1. Medications and Supplements to Treat Irritable
a
Bowel Syndrome .
Category of Agent Medication or Supplement
Anti-diarrheal agents loperamide, rifaximin, eluxadoline,
cholestyramine (off label),
serum-derived bovine
immunoglobulin
Anti-spasmodic dicyclomine, hyoscyamine,
agents enteric-coated peppermint oil, etc.
Laxatives linaclotide, polyethylene glycol,
lubiprostone, prucalopride,
plecanatide
b
Selective Serotonin amitriptyline and others
Reuptake Inhibitor
Antidepressants
Fiber psyllium husk, partially hydrolyzed
guar gum
Herbal supplements IBGard (contains peppermint
microspheres, fiber, and amino acids;
IM Health Science, Boca Raton,
FL), Iberogast (herbal supplement
made from 9 plants; Bayer Global,
Leverkusen, Germany)
a Notall-inclusive.
b FordAC, Lacy BE, Harris LA, Quigley EMM, Moayyedi P. Effect
of Antidepressants and Psychological Therapies in Irritable Bowel
Syndrome: An Updated Systematic Review and Meta-Analysis.
Am J Gastroenterol. 2019;114(1):21-39.
dietitian with a workup that excludes other diagnoses in-
cluding and specifically celiac disease.
It is logical to surmise that food entering the GI tract
would be associated with and therefore cause symptoms.
However, because of the nonlinearity of the symptoms
and the often related psychosocial aspects noted by these
individuals, diet is frequently not addressed. Oral intake or
“the daily diet” has been implicated in IBS but was not
fully understood until Shepherd and colleagues identified
common foods associated with symptoms.18 Although not
defined with IBS, some foods have been recognized as “gas
producers” or causing diarrhea. Lactose intolerance is char-
acterized by diarrhea and cramping associated with milk
product intake. Fruit juice diarrhea was reported in relation
to fructose intake, and sorbitol- and mannitol-containing
foods were associated with similar symptoms. Upon fur-
ther study, the common characteristics of foods associated
with symptoms were short-chain, poorly absorbed, rapidly
fermentable carbohydrates.19,20 In 2004, Monash University
in Australia coined “Fermentable, Oligosaccharides, Disac-
charides, Monosaccharides and Polyols” as FODMAPs in
association with the low-FODMAP diet (LFD) developed
and investigated by researchers such as Sue Shepherd, RD;
Peter Gibson, MD; and others.19 Since the early description
of FODMAPs, there have been numerous studies con-
firming the biological feasibility and well-defined modes
3
of action of these carbohydrates with evidence-based and
efficacious diet interventions.20–24 Over time and through
meticulous food analysis, primarily by Monash University,
levels of FODMAPs in many foods have been defined.
Table 2 lists examples of high-FODMAP foods and low-
FODMAP alternatives.
There have been many well-done investigations that
have proven the efficacy of the FODMAP elimination diet
in treating IBS. Researchers and clinicians have observed
an overall ∼70%–75% response rate (that is, decrease in
symptoms) to an LFD.23,25 In a controlled, single-blind
study of patients with IBS who were randomized to 3 weeks
of LFD (19 patients) or high-FODMAP diet (18 patients),
the symptom severity improved in 72% of patients given
the LFD.14 Decreased abdominal pain, distension, and
improved diet satisfaction were noted.
Mansueto identified 31 original studies and 9 reviews
that substantiated the role of poorly absorbed, short-chain
carbohydrates and polyols and an increase in GI symptoms
on a high-FODMAP diet.22 In a double-blind, randomized
crossover trial of 30 adults with IBS randomized to 21 days
of an LFD or a typical diet, improvement in symptoms
regardless of IBS subtypes (C, D, M) were seen.23 In 33
children aged 7–17 years, an LFD vs typical American child-
hood diet was evaluated in a double-blind crossover trial.26
Children reported less abdominal pain with the LFD and a
decrease in pain severity and symptoms (bloating gas, nau-
sea, heartburn). Of special interest, gut microbiome markers
were measured and showed that responders to the LFD had
a different microbiome composition at baseline and after
LFD. Responders had more microbiota with saccharolytic
capacity (Bacteroides, Ruminococcaceae, and Faecalibac-
terium prausnitzii).26 The authors surmise that this may be
a predictor or response to the LFD. Many other studies
corroborate the beneficial application of the FODMAP
elimination diet in managing IBS.4,14,27,25 It should be noted
that the benefits and positive outcomes of the FODMAP
elimination diet may not be achieved by all patients with
IBS, requiring communication by the dietitian and physician
in reporting those patients who need further workup.28,29
What are FODMAPs
FODMAPs are short-chain, poorly absorbed
carbohydrates.4,13 They are small in molecular size and
rapidly fermentable, meaning they distend the GI lumen,
increase gas production, and are associated with increased
pain in the GI tract due to visceral hypersensitivity
and increased fluid delivery to the GI tract.4,23,30,31 The
carbohydrates in each of these categories are further defined
as oligosaccharides, including certain fructans and galac-
tans (galacto-oligosaccharides); disaccharides or lactose;
monosaccharides such as fructose; and polyols or sugar
alcohols. The modes of actions of digestion and absorption
4 Nutrition in Clinical Practice 0(0)

Table 2. Examples of High-FODMAP Foods and Low-FODMAP Alternatives.

Foods High-FODMAP foods Low-FODMAP foods

Vegetables Artichoke, asparagus, cauliflower, garlic, green Eggplant, bok choy, bell pepper, carrot,
peas, mushrooms, onion, sugar snap peas cucumber, lettuce, potato, tomato, zucchini
Fruits Apple, apple juice, cherries, dried fruit, mango, Cantaloupe, grapes, kiwi fruit (green),
peaches, pears, plums, watermelon mandarin, orange, pineapple, strawberries
Dairy and Cow’s milk, custard, evaporated milk, ice Lactose-free milk, almond milk,
alternatives cream, soy milk (made from whole brie/camembert cheese, feta cheese, hard
soybeans), sweetened condensed milk, yogurt cheese, soy milk (made from soy protein)
Protein sources Most legumes/pulses (beans and peas), some Eggs, firm tofu, plain cooked meats, poultry,
marinated meats, poultry, seafood, some seafood, tempeh
processed meats
Breads and cereal Wheat-, rye-, and barley-based breads, Corn flakes, oats, quinoa flakes,
products breakfast cereals, biscuits, and snack quinoa/rice/corn pasta, rice cakes (plain),
products sour dough, spelt bread, wheat, rye, barley
free breads
Sugars, sweeteners, High-fructose corn syrup, honey, sugar-free Dark chocolate, maple syrup, rice malt syrup,
a
and confectionery sweetened confectionery table sugar
Nuts and seeds Cashews, pistachios Macadamias, peanuts, pumpkin seeds, walnuts

FODMAP, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols.

Table 2 reproduced with permission from FODMAPs and Irritable Bowel Syndrome. Monash University. Accessed July 12, 2020.
https://www.monashfodmap.com/about-fodmap-and-ibs/
a Sugar alcohols (sorbitol, mannitol, xylitol, erythritol).

of these carbohydrates are associated with the symptoms.
Lactose causes colonic distension due to fermentation of
unabsorbed lactose and, therefore, diarrhea and bloating.
Fructose, in excess, increases water content in the small
bowel, which leads to diarrhea. Oligosaccharides, including
both fructans and galactans, increase colonic gas and in-
crease symptoms related to visceral hypersensitivity. Polyols
are large molecules that cannot be absorbed through simple
diffusion and, therefore, have limited absorptive capacity,
leading to changes in stool consistency and frequency.
Implementing the LFD. The FODMAP elimination diet has
been identified as “first-line therapy in managing IBS” when
education on the diet is provided by a skilled dietitian
trained on the FODMAP elimination diet principles and
nuances.23,25,30 Implementation of the FODMAP elimina-
tion diet is illustrated in Figure 1. Although it may be
referred to as an LFD, the goal of the elimination diet is,
first, to avoid higher-FODMAP foods to reduce or eliminate
symptoms over a period of time; second, to reintroduce
higher-FODMAP foods in a methodical manner to de-
termine the foods that cause symptoms; and finally, to
liberalize or “personalize” the diet as much as possible.
The dietitian plays a pivotal role in suggesting alternative
foods and assuring nutrient needs are met initially and in
the successful reintroduction and personalization of the
nutrition plan.30–32
Prior to initiating the LFD, a thorough nutrition as-
sessment should be completed by the dietitian. Nutrition
assessment is an important component of the initial nu-
trition plan. Nutrition assessment should include a review
of symptoms, presence of other diagnoses, and physical
assessment. Previous diet interventions, history of intake,
and nontraditional therapies as well as current medication
history should be evaluated. A thorough nutrition history
is needed to evaluate intake of high- and low-FODMAP
foods. In some cases, this may be adequate in identifying
key symptom-causing foods and providing substitutions,
therefore alleviating the symptoms.
Patients may have had weight loss due to an inability to
tolerate certain foods, fear of eating, or non–evidence-based
diet plans that they have attempted. In practice, significant
weight loss should be addressed; however, overweight or
obese patients may want to tackle their GI problems first
and then begin to manage their caloric intake. Both can be
incorporated. In addition, a relatively new concept called
avoidant or restrictive food intake disorder (AFRID) should
be considered.28 Although not specific to IBS, because food
is associated with symptom management, it can become
devasting to some individuals and result in food avoidance
and fear of eating.28 In this case, nutrition implementation
of any kind may need to be modified to obviate the further
exacerbation of AFRID.
The first “phase” of the FODMAP elimination diet
focuses on identifying high- and low-FODMAP–containing
foods. Although Table 2 provides a sample of high- and
low-FODMAP foods, there are many other foods in each
category. It is important to explain the rationale for the
diet, describing the types of carbohydrates and their effects
on the GI tract. In this phase, the patient will need many
Ireton-Jones and Weisberg 5

I. Patient presents to primary care physician, nurse practitioner, or

gastroenterologist with complaints of gas, bloating diarrhea, constipation. If
patient meets Rome IV criteria, IBS diagnosis may be made if the following have
been ruled out:
a. Celiac disease has been ruled out by serum transglutaminase testing with
confirmed small bowel biopsy.
b. Chronic idiopathic constipation
c. GI bleeding, IBD
d. Small intestine bacterial overgrowth (SIBO)
e. Disordered Eating
II. Referral to a qualified RDN
a. Nutrition Assessment
b. Confirm diagnosis/nutrition intervention
III. FODMAP Elimination Diet (provided by skilled RDN)
a. Elimination pf highest FODMAP containing foods
b. Re-Introduction, systematically and by category of higher FODMAP foods
to assess for tolerance of food and amount
c. Personalization of the diet for the individual’s learned tolerance and
making appropriate nutrient equivalent substitutions.
d. FODMAP Diet evaluation
i. Adequate symptom control/food tolerance
ii. In inadequate symptom control:
1. Rule out: SIBO, Sucrase-isomaltase deficiency
2. Go to additional considerations
IV. Additional Considerations
a. Gut-Directed Psychotherapy
b. Yoga, Meditation
c. Exercise
d. Nutraceuticals, e.g., peppermint oil, Iberogast (Bayer Global, Leverkusen,
Germany)

Figure 1. Suggested IBS Management Protocol Featuring Physician and Dietitian Collaboration. © Ireton-Jones & Weisberg. GI,
gastrointestinal; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome; RDN, registered dietitian nutritionist

helpful resources, including printed materials (Table 3).
The dietitian should be able to provide the most up-to-
date listing of the higher- and lower-FODMAP foods. As
research continues to evolve on the foods, it is imperative
that the materials provided are current. Often, patients
will come to their first nutrition appointment with diet
information either obtained from the internet or provided
as a handout from their practitioner. There are various
sources of information, and although many may have been
accurate when printed a year ago, the content may no longer
be correct. Monash University has created the Monash
FODMAP app, which has the largest low-FODMAP food
database available and uses a “stop light” version of rating
the foods as either green, yellow, or red. The rating includes
serving size considerations as well as types of foods. It is
from Australia, but many foods from different countries
have been analyzed and are included. The app is available for
smart phones at a nominal fee and includes recipes and re-
sources for patients (https://www.monashfodmap.com/ibs-
central/i-have-ibs/get-the-app/).
The first phase, “elimination,” usually lasts 3–5 weeks.
The goal is to select foods that provide a balance of nutrients
while eliminating high-FODMAP foods. Food choices will
be different; however, they should be comparable to pa-
tients’ usual intake to generate success during this period. A
modification of the FODMAP elimination diet can be used
if the total elimination will be too restrictive or difficult.
This “simple” LFD includes 3–5 of the most common
6 Nutrition in Clinical Practice 0(0)
Table 3. Evidence-Based Resources for IBS.
Description
Monash FODMAP; recipes, education, training; for consumer and
clinician
Monash University FODMAP Diet app; look up foods and FODMAP
content
Patsy Catsos, MS, RDN; IBS Free; recipes, current diet materials, books
Products/resources/food resources
Monash; International Directory of Qualified Dietitians; dietitians who
have taken the Monash FODMAP course
Digestive Nutrition Group; dietitians, resources
Kate Scarlata, MPH, RDN; recipes, current diet materials, books
University of Michigan Health Systems, Division of Gastroenterology
and Hepatology; education, recipes
Meal delivery service
Behavioral intervention resources
FODMAP, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; IBS, irritable bowel syndrome.
and highest-FODMAP foods in each category and may be
adequate to achieve acceptable results.
Following elimination, the next phase is to begin the
reintroduction of higher-FODMAP foods. This may also be
called the “challenge” phase.33 The best way to accomplish
an understanding of the foods that are associated with
symptoms is to evaluate these systematically. Foods in each
FODMAP category are added back individually and in
increasing quantities. As reintroduction is occurring, the
individual should maintain a log of food, quantity, and
any symptoms noticed. It is recommended to start at a
smaller serving size and increase to a usual serving size
before heading to another category to determine the dose
response. Not every food within a group (all fructans, for
example) must be evaluated, and excess size servings are
not necessary. Introducing individual foods rather than
mixed foods will allow for a better understanding of the
amounts tolerated. Reintroduction may be done by category
or by certain foods that are desired to add back into the
diet. When foods have multiple categories of FODMAPs
(fructose and polyols, for example), it may be difficult to
understand which one is causing more symptoms; therefore,
single food categories are best for this phase. In between
each category that is reintroduced, it is recommended to
have a 3- to 4-day low-FODMAP washout to assure that
symptoms are elucidated more clearly. The challenge phase
is a “trial and error” approach that leads to a personalized
diet for each individual.
The goal of the FODMAP elimination diet is to un-
derstand the higher-FODMAP–containing foods that cause
symptoms and to modify the overall diet accordingly. It
should be noted that higher-FODMAP ingredients may be
present in unknown or unrecognized food combinations
when eating out or at events. This may cause symptoms and
Website/contact
www.monashfodmap.com/
www.monashfodmap.com/ibs-central/i-have-ibs/get-
the-app/
www.ibsfree.net/about-patsy-catsos
www.fodyfoods.comwww.fodmapfriendly.com/
www.monashfodmap.com/online-training/fodmap-
dietitians-
directory/www.digestivenutritiongroup.com
www.katescarlata.com/
www.myginutrition.com/
www.modifyhealth.com/www.epicured.com/
www.romegipsych.org/www.psychologytoday.com/
us
be a concern for a setback. Although symptom relief is the
primary goal of the FODMAP elimination diet, a singular
event does not mean failure. In fact, some individuals
realize they have a food or foods that they now know cause
symptoms upon eating, but they take that risk to enjoy
the food on an occasional basis. In a study of the long-
term effect of the FODMAP elimination diet in 103 IBS
patients, 82% reported that a personalized nutrition plan for
IBS symptom management was well tolerated and deemed
to be nutritionally adequate.34 Two key nutrients that may
be deficient are calcium (because of lactose avoidance)
and fiber, which is fairly common in the population.35
Recognizing that all nutrients can and should be met on the
personalized diet is important with supplementation used
where necessary.
Foods. Research related to amounts of FODMAPs in the
foods in each category continues to advance. Examples
of fructans or fructo-oligosaccharides (FOSs) are wheat,
rye, and barley, which are recognized as gluten-containing
grains. IBS patients are often told to “try a gluten-free
diet.” Although this gets at the grains that are commonly
consumed in the diet, gluten-free flours and grains may
contain fructans such as coconut flour, amaranth flour, and
nut flours, which can be found on the Monash FODMAP
app. Other fructans that are often associated with symptoms
include garlic, leeks, onions, onion or garlic powder, and
some vegetables and fruits (artichokes, asparagus, nec-
tarines, and watermelon). Galacto-oligosaccharides, which
are a galactose chain with fructose and glucose at the
end, are found in legumes, kidney beans, and black beans.
Foods that are supplemented to enhance the fiber content
may contain FOSs or inulin. Individuals with IBS-C may
have been told to increase fiber in their diet—increasing
Ireton-Jones and Weisberg
fiber using these sources may only further exacerbate the
symptoms.
The disaccharide in the FODMAP is lactose, which oc-
curs in milk from cows, sheep, and goats—that is, mammals.
Lactose intolerance and lactase deficiency are different from
lactose maldigestion, as a small amount of lactose may be
tolerated. In addition, this is not a dairy intolerance, which
describes whey or casein allergy. Fructose is found in excess
in some fruits and vegetables but also in honey, molasses,
dried fruit, and high-fructose corn syrup. Sucrose (granu-
lated sugar) has equal amounts of fructose and glucose and
so is not considered a FODMAP food. Polyols are sugar
alcohols, primarily sorbitol and mannitol found in some
fruits and vegetables. Many contain polyols and fructose,
such as apples, apricots, pears, blackberries, cauliflower, and
snow peas. Artificial sweeteners containing sorbitol, manni-
tol, maltitol, xylitol, and isomalt are also high FODMAP.
Aspartame, saccharine, and stevia are acceptable, as they are
not polyols. The challenge with understanding FODMAP
foods is that they cross all food groups, but not all foods in
a food group are high in FODMAPs or restricted.
Other considerations
Stress is a major factor in IBS, and ways to relieve stress
are important in treatment. In a study, yoga was found to
be equally as effective as the LFD in relieving symptoms.36
This takes a serious commitment. However, stress reduction
of any kind can be an adjunct therapy for IBS treatment.
Exercise (walking, aerobic exercise, strength training) and
meditation can also help relieve stress and provide not
only health benefits but also psychological benefits. Gut-
directed psychotherapy for managing IBS has been found
to be effective in improving symptom management.37,38
Specially trained psychotherapists provide therapy to help
reduce stress and feelings of anxiety using a number of
techniques.39
Probiotics are currently being studied for application in
IBS, although data are variable.40,41 The use of probiotics
or prebiotics in phase 1 of the FODMAP elimination diet is
generally not recommended. The most recent ACG guide-
lines do not recommend probiotics for IBS management.42
Beyond IBS. SIBO is most often associated with motility
changes in the GI tract. It is unclear if changes in motility
affect the bacteria or the bacteria cause motility changes in
the GI tract.15 SIBO occurs when bacteria from the large
intestine enter the small intestine. Lack of an ileocecal valve,
impaired motility, and long-term usage of proton-pump
inhibitors have been implicated in the development of SIBO.
The origin of SIBO in IBS is not fully understood. Pa-
tients with IBS may complain of symptoms associated with
SIBO—bloating, gas, abdominal pain, and diarrhea—not
relieved adequately by the LFD. SIBO may be the primary
7
culprit or may be an additional part of the symptoms seen
in patients with IBS. As mentioned previously, hydrogen
and or methane breath tests may be used to diagnose SIBO,
although sensitivity and specificity are low.15 Since current
treatment for SIBO is with antibiotics, empiric treatment
with antibiotics is commonly used even without breath
testing.
Rifaxamin is often used for SIBO, although amoxicillin,
metronidazole, and ciprofloxacin have also been used.3 The
goal of the antibiotic therapy is to eliminate the excessive
bacteria in the small intestine. During antibiotic therapy,
probiotic therapy is not recommended. There are no diet
recommendations for SIBO, although anecdotally, the LFD
has been suggested because it reduces fermentable products
in the GI tract. Some patients need to be treated more than
once for SIBO, and in the most recalcitrant cases, patients
may need to be treated on a monthly basis for 1 week
at a time with a rotation of antibiotics. Fecal microbiota
transplant has been hypothesized as a treatment for SIBO
but has not been properly studied.43,44
When symptoms of bloating, gas, and diarrhea are
present and not fully managed by medical and nutrition
therapies for IBS, sucrase-isomaltase deficiency (SID)
should be considered.45,46 Genetic mutations in the SI gene
affects sucrose and disaccharide digestion in congenital SID
or SID when found in adulthood and may cause symptoms
similar to IBS.46 Diagnosis of SID may be made through
symptom development with sucrose ingestion, a carbon 13
(13 C-sucrose) breath test, or endoscopic biopsy. In this case,
the breath test has been shown to be accurate and does
not cause symptoms as would occur with actual sucrose
ingestion. Although rare, the authors suggest that clinicians
consider this evaluation in refractory IBS cases.
It is important to note that IBS symptoms and perhaps
IBS may be seen in patients with celiac disease, inflamma-
tory bowel disease, and short-bowel syndrome. Application
of some level of high-FODMAP food evaluation for toler-
ance could be helpful.
What Is Not Recommended. Because the time from symp-
toms to diagnosis may be protracted, many people with
IBS may seek out non–evidence-based therapies or tests.
Patients feel that their symptoms must be related to “some-
thing they ate”; therefore, a test that relates to food “sensi-
tivities” or intolerances sounds plausible. Food allergies are
determined by testing for food-mediated immunoglobulin
E (IgE) changes.47 However, there is no evidence-based test
for food sensitivities. Tests for food-related adverse reactions
typically test serum IgG or IgG4 antibodies to foods or
white blood cell reactions to food using flow cryptography,
which is not relatable to a food reaction.47 Other tests
used to evaluate food-related symptoms include hair anal-
ysis, electrodermal testing, and applied kinesiology. Two
commonly purported tests that are not evidence based or
8 Nutrition in Clinical Practice 0(0)
clinically correlated with disease include antigen leukocyte
antibody test (ALCAT) testing and IgG antibodies testing
(Mediator Release Test (MRT) for example).47
Stool sample testing is not useful in diagnosing or
treating IBS unless searching for the presence of a parasite,
the presence of Clostridium difficile in intractable diarrhea,
or increased fat due to malabsorption. New data on fecal
calprotectin as a stool biomarker for inflammatory bowel
disease are promising but not yet applied to IBS.48 Because
there are millions of bacteria not only in the stool but in the
intestinal wall, a stool sample does not define the bacteria
milieu in the GI tract.48 Although IBS is associated with
gut microbial dysbiosis, attempting to make a nutrition or
probiotic recommendation based on the stool data is not
evidence based.42
Summary
Management of IBS requires, first, a physician to make the
diagnosis within a reasonable time period and referral to a
dietitian with expertise in nutrition and GI disorders. The
dietitian can work with the patient to design the appropriate
nutrition plan. Treatment of IBS is complex, combining nu-
trition interventions as well as medical therapy to facilitate
remission and improvement in quality of life. The dietitian
and physician working together will provide the patient with
comprehensive care. As IBS is multifactorial, exercise, re-
laxation, yoga, and other entities may be important adjunct
therapies.
Statement of Authorship
C. Ireton-Jones and M. F. Weisberg equally contributed to the
conception and design of the manuscript and interpretation of
the data and drafted the manuscript. Both authors critically re-
vised the manuscript, agree to be fully accountable for ensuring
the integrity and accuracy of the work, and read and approved
the final manuscript.
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