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2016+BDA循证实践指南：成人肠易激综合征患者的饮食管理(更新版)

PROFESSIONAL GUIDELINE

British Dietetic Association systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults(2016update)

Y.A.McKenzie,1R.K.Bowyer,2H.Leach,3P.Gulia,4J.Horobin,5N.A.O’Sullivan,6C.Pettitt,7

L.B.Reeves,8L.Seamark,9M.Williams,9J.Thompson,10M.C.E.Lomer6,11(IBS Dietetic Guideline Review Group on behalf of Gastroenterology Specialist Group of the British Dietetic Association)

1Nuf?eld Health The Manor Hospital,Oxford,UK

2Department of Nutrition and Dietetics,Great Western Hospitals NHS Foundation Trust,Swindon,UK

3Department of Nutrition and Dietetics,Southampton NHS Foundation Trust,Southampton,UK

4Dr Ashok Ayurveda Clinic,Birmingham,UK

5Department of Nutrition and Dietetics,North Middlesex University Hospital NHS Trust,London,UK

6Faculty of Life Sciences and Medicine,Diabetes and Nutritional Sciences Division,King’s College London,London,UK

7Faculty of Medicine,Imperial College London,London,UK

8Allergy Services,Oxford University Hospitals NHS Foundation Trust,Oxford,UK

9Specialist Gastroenterology Community Dietetic Service,Somerset Partnership NHS Foundation Trust,Bridgwater,UK

10Calm Gut Clinic,Todmorden,UK

11Department of Nutrition and Dietetics,St Thomas’Hospital,Guy’s and St Thomas’NHS Foundation Trust,London,UK

Keywords

alcohol,caffeine,diet,dietary?bre,dietary habits,elimination diets and food hypersensitivity, fat,fermentable carbohydrates,?uid,gluten, guidelines,healthy eating,low FODMAP diet, milk and dairy,probiotics,spicy food,systematic review.

Correspondence

Y.A.McKenzie,Nuf?eld Health The Manor Hospital,Oxford,Beech Road,Headington, Oxford OX37RP,UK.

Tel.:+447966878758

Fax:+441865307788

E-mail:yvonne@https://www.wendangku.net/doc/c2908068.html,

How to cite this article

McKenzie Y.A.,Bowyer R.K.,Leach H.,Gulia P., Horobin J.,O’Sullivan N.A.,Pettitt C.,Reeves L.B., Seamark L.,Williams M.,Thompson J.&

Lomer M.C.E.(2016)British Dietetic Association systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults(2016update).J Hum Nutr Diet.

doi:10.1111/jhn.12385Abstract

Background:The?rst British Dietetic Association(BDA)guidelines for the dietary management of irritable bowel syndrome(IBS)in adults were pub-lished in2012.Subsequently,there has been a wealth of new research.The aim of this work was to systematically review the evidence for the role of diet in the management of IBS and to update the guidelines.

Methods:Twelve questions relating to diet and IBS were de?ned based on review of the previous guideline questions,current evidence and clinical practice.Chosen topics were on healthy eating and lifestyle(alcohol,caf-feine,spicy food,elimination diets,fat and?uid intakes and dietary habits), milk and dairy,dietary?bre,fermentable carbohydrates,gluten,probiotics and elimination diets/food hypersensitivity.Data sources were CINAHL, Cochrane Register of Controlled Trials,Embase,Medline,Scopus and Web of Science up to October2015.Studies were assessed independently in duplicate using risk of bias tools speci?c to each included study based on inclusion and exclusion criteria for each question.National Health and Medical Research Council grading evidence levels were used to develop evi-dence statements and recommendations,in accordance with Practice-based Evidence in Nutrition Global protocol used by the BDA.

Results:Eighty-six studies were critically appraised to generate46evidence statements,15clinical recommendations and four research recommenda-tions.The IBS dietary algorithm was simpli?ed to?rst-line(healthy eating, provided by any healthcare professional)and second-line[low FODMAP (fermentable oligosaccharides,disaccharides,monosaccharides and polyols) to be provided by dietitian]dietary advice.

Conclusions:These guidelines provide updated comprehensive evidence-based details to achieve the successful dietary management of IBS in adults.

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Introduction

Irritable bowel syndrome (IBS)in adults is a global prob-lem,with prevalence rates of 7–21%(1).It is a chronic gas-trointestinal disorder characterised by ?uctuating abdominal pain or discomfort associated with an altered bowel habit in the absence of organic disease (2).Subtypes of IBS are classi?ed as diarrhoea-predominant (IBS-D),constipation-predominant (IBS-C),both diarrhoea and constipation (IBS-M)or unspeci?ed (IBS-U)(3).Dietary triggers are common,with up to nine out of 10individuals reporting that food generates symptoms (4,5).Two-thirds of individuals with IBS initiate dietary restrictions to improve symptoms (6),and so dietary management is an important option within medical treatment.The ?rst British Dietetic Association (BDA)guidelines for the dietary management of IBS were developed several years ago (7)but lacked com-prehensive critical appraisal for all dietary management strategies,notably within ?rst-line approaches on healthy eating and lifestyle.Evidence on the ef?cacy of a low fer-mentable oligosaccharides,disaccharides,monosaccharides and polyols (FODMAP)diet has rapidly developed (8–10),has been incorporated into other IBS guidelines (2,11),and needs further review.In addition,the potential for gluten to initiate gastrointestinal symptoms has become of interest (12,13)

and so the research on the role of gluten in IBS needs appraisal.

The aims of these BDA updated guidelines were (i)to systematically review the evidence on diet in IBS in adults (>16years),incorporating risk of bias assess-ment,in relation to symptom generation and manage-ment and (ii)to update the previous guidelines with comprehensive evidence-based guidelines and a clinical dietary pathway with international scope and applica-tion.Methods

Guideline development was in accordance with guidance from Practice-based Evidence in Nutrition (PEN)Global (Table 1)and the BDA.An IBS dietetic guideline review group (IBS-DGRG)was formed consisting of 12regis-tered dietitians belonging to the BDA Gastroenterology Specialist Group.All members developed critical appraisal skills to competently use the assessment tools described;more experienced members teamed up with less experi-enced members to develop equality in competence.

Questions were developed based on research literature,changing clinical practice and gaps in the evidence base,and included the topics:healthy eating and lifestyle (alco-hol,caffeine,spicy food,fat,?uid and dietary habits),milk and dairy,dietary ?bre,fermentable carbohydrates,gluten,probiotics and elimination diets/food

hypersensitivity.For probiotics,a systematic review of

systematic reviews was undertaken,for which details are provided elsewhere (15).

Generic and question-speci?c inclusion and exclusion criteria were based on Population,Interventions,Com-parisons,Outcome measures and Types of study (PICOT)(see Supporting information,Table S1).Search terms for each question are also described in the Supporting infor-mation (Table S2).

A systematic literature search using databases CINAHL,Cochrane Register of Controlled Trials,Embase,Medline,Scopus and Web of Science was conducted and relevant studies were identi?ed from January 1985to October 2015.Studies prior to 1985were excluded as a result of inadequate de?nitions of IBS,as well as insuf?ciently described methodology and outcomes.Only full papers (i.e.not abstracts)in the English language were eligible.Reference lists of included studies were cross-searched for other studies of potential relevance.Each title/abstract

Table 1Practice-based evidence in nutrition (PEN)evidence grading (14)answering the question addressed.The results are both clinically important and consistent with minor exceptions at most.The results are free of any signi?cant doubts about generalisability,bias,and ?aws in research design.Studies with negative results have suf?ciently large samples to have adequate statistical power Level B –the conclusion is supported by fair evidence

The evidence consists of results from studies of strong design for answering the question addressed,but there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or because of minor doubts about

generalisability,bias,research design ?aws,or adequacy of sample size.Alternatively,the evidence consists solely of results from weaker designs for the question addressed,but the results have been con?rmed in separate studies and are consistent,with minor exceptions at most

Level C –the conclusion is supported by limited evidence or expert opinion

The evidence consists of results from studies of strong design for answering the question addressed,but there is substantial

uncertainty attached to the conclusion because of inconsistencies among the results from different studies or because of serious doubts about generalisability,bias,research design ?aws,or

adequacy of sample size.Alternatively,the evidence consists solely of results from a limited number of studies of weak design for answering the question addressed.Finally,the support for a

particular opinion may consist of statement of informed,respected authorities based on their experiences,descriptive studies of reports of expert panels

Level D –evidence is limited

The evidence is limited studies that are either such poor quality or too con?icting that no conclusions can be made.No evidence from either authoritative sources or research involving humans was found

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any potentially relevant study was screened against ques-tion-speci?c inclusion and exclusion criteria by at least one member independently.Reasons for excluding studies are provided in the Supporting information(Table S3). At least two members independently critically appraised each study and assessed risk of bias methodology(16,17) (see Supporting information,Table S4).In line with the hierarchy of research evidence,PEN Global and the BDA guidance,more weighting was given to systematic reviews over randomised controlled trials(RCTs)over case–con-trol studies and?nally cross-sectional studies.Critical appraisals and risk of bias assessments were agreed by the question-speci?c members.Where applicable,measure-ment of dietary intake was considered as an important aspect of study design.

There are no biological markers to assess symptom response in IBS and so there is much reliance on patient-reported symptom assessment to measure out-comes(18).Traditional binary and50%improvement symptom assessment tools have been shown to be reli-able,valid and appropriate for use in IBS subtypes(18). Thus,for the purpose of these guidelines,interpretation of outcomes from different studies have been assumed as being comparable.

Using Australian Government National Health and Medical Research Council(NHMRC)guidance(19),an evidence statement matrix was developed for each ques-tion and included considered judgement on the evi-dence base,consistency,clinical impact and generalisability,which enabled members to link the evi-dence statements to clinical practice and research rec-ommendations.SIGN grading(2008)for evidence statements from the?rst guidelines were updated to PEN Global evidence grades(A–D)(14)(Table1).IBS-DGRG consensus agreement was used throughout the process to resolve any issues.Finally,the IBS dietary algorithm was revised.

Results

The comprehensive literature search identi?ed a potential 3170papers.Eighty-six of these met the inclusion criteria and included nine systematic reviews,67RCTs,six case–control studies and four cross-sectional cohort studies (see Supporting information,Table S5).Risk of bias assessments for all questions except probiotics are shown in Table2and probiotics are presented elsewhere(15). Forty-six evidence statements led to the development of15recommendations(Table3).A recommendation related to?uid intake was not developed as a result of insuf?cient evidence.Four research recommendations were made.The IBS algorithm for clinical practice was updated and simpli?ed to include only?rst-line and second-line advice;third-line advice was removed (Fig.1).

Healthy eating and lifestyle

Individuals with IBS often report that alcohol,caffeine, spicy food and fatty food trigger gastrointestinal symp-toms(6,20).Alcohol affects gastrointestinal motility, absorption and intestinal permeability(21,22).Caffeine increases gastric acid secretion and colonic motor activity in healthy subjects(23,24)and coffee has also been found to rapidly increase rectosigmoid motor activity(25).Cap-saicin is the active component in hot peppers and,in spicy food,this compound is responsible for accelerating gastrointestinal transit via the transient receptor potential vanilloid-1(TRPV)causing abdominal pain and burning sensations in healthy individuals(26).Increased TRPV receptors have been found in individuals with visceral hypersensitivity(27–29).Fat stimulates the gastrocolic re?ex and,when delivered directly into the duodenum, the response is prolonged and exaggerated in individuals with IBS(30,31).Moreover,fat affects small intestinal motility(32).Some of these mechanisms may explain why these food components exacerbate IBS symptoms.

The evidence for healthy eating and lifestyle was not systematically reviewed in the?rst guidelines(7)and so forms part of this update.

1a What effect does alcohol have on IBS symptoms? Included studies and evidence statements.Four level III case–control studies(33–36)and one level III cross-sectional study(37)ful?lled the inclusion criteria and were evaluated (Table4).These observational studies reported the per-ceived effects of alcohol intake with respect to symptom development in individuals with IBS compared to controls. One case–control study reported alcohol induced symp-toms(34),whereas two more noted speci?c symptom asso-ciations:loose stools(36);abdominal pain,nausea, indigestion and diarrhoea in binge drinking(more than four drinks)in women but not in men(35).The cross-sec-tional study reported that beer and wine induced symptoms (37).One case–control study did not?nd alcohol induced symptoms(33).There was a high risk of bias providing lim-ited evidence that up to one-third of patients found that alcohol induced or worsened IBS symptoms(34,36,37).

1a-i Alcohol can induce or worsen IBS symptoms(34–37)C.

Practical considerations.Assess alcohol intake in relation to symptoms to determine whether a reduction may relieve symptoms and ensure intake is within recom-mended safe limits.

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Table 2Risk of bias assessment for all studies except probiotics included in the systematic review

Topic and reference

Risk of bias*

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8

Healthy eating and lifestyle Alcohol

B?hn et al . (2013)(37)–

? + + ? ? ? +

Faresjo et al . (2010)(33)+ + ? ? – Hayes et al . (2013)(34)+ –

+ – – Reding et al . (2013)(35)– + – + + Simren et al . (2001)(36)? + – ? – Caffeine

Faresjo et al . (2010)(33)+ + ? ? – Hayes et al . (2014)(34)+ –

+ – – Reding et al . (2013)(35)– + – + + Simren et al . (2001)(36)? + –

? –

Spicy food

Agarwal et al . (2002(42)+ +

– – – B?hn et al . (2013)(37)

– ? + + ? ? ? + Bortolotti et al . (2011)(40)? ? + + – + –

Faresjo et al . (2010)(33)

+ ? ? – Gonlachanvit et al . (2009)(41)? ? + ? ? + – Hayes et al . (2014)(34)+ –

+ – – Simren et al . (2001)(36)? + – ? –

Fat

B?hn et al . (2013)(37)– ? + + ? ? ? +

Faresjo et al . (2010)(33)+ + ? ? – Hayes et al . (2014)(34)+ – + – – Serra et al . (2002)(43)? – ? + + + + Simren et al . (2001)(36)? +

– ? – Simren et al . (2007)(44)+ + – – –

Fluid

No reviewed papers Dietary habits Guo et al . (2015)(47)– – ? – ?

Kang et al . (2011)(46)

– –

– – ? ? – – Khadamolhosseini et al . (2011)(48)+ + – – – ? – – Miwa et al . (2012)(49)

+ + – –

– ? – – Milk and dairy products B?hmer et al . (1996)(55)+ + + + – ? ?

B?hmer et al . (2001)(52)+ – + + – ? ? Bozzani et al . (1986)(53)+ +

? ? ? ? – Parker et al . (2001)(54)+ + + ? – + – Vernia et al . (1995)(56)+ + – ?

– – –

Dietary fibre

Aller et al . (2004)(66)

? ? – ? ? + –

Arffmann et al . (1985)(68)? ? – – + + –

Bijkerk et al . (2009)(67)+ + + + – – + Cockerell et al . (2012)(76)+ ? – + – + – Fowlie et al . (1992)(74)– –

+ ? – + – Hebden et al . (2002)(69)+

? + + + + – Kruis et al . (1986)(70)? ?

– – + + – Lucey et al . (1987)(71)?

? + + – + – Rees et al . (2005)(72)

? ? – + + – – Snook and Shepherd (1994)(73)+ ? + + + + + Tarpila et al . (2004)(75)

? ?

+ + + + –

Fermentable carbohydrates Berg et al . (2013)(87)+ –

– ? + + – B?hn et al . (2015)(93)+

+ + + + + Olesen et al . (2010)(89)+ + + + + + –

Halmos et al . (2014)(88)+ ? ? ++ + + + Pedersen et al . (2014)(94)+

+ – + ? ? – Shepherd et al . (2008)(90)+ + + + + +

+ Silk et al . (2009)(92)

? – ? – – – Staudacher et al . (2012)(91)+ + – ? + + + Gluten

Biesiekierski et al . (2011)(104)+ + + + + + –

Biesiekierski et al . (2013)(105)+ ? + ? + ? +

Shahbazkhani et al . (2015)(103)? + – + – – – Vazquez-Roque et al . (2013)(102)+ +

? ? + + – Food hypersensitivity No reviewed papers

*The content and number of risk of bias questions are different for different study designs (see Supporting information Table S4 for details).

Not applicable

Low bias High bias –?+Unclear bias

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1b What effect does caffeine have on IBS symptoms?Included studies and evidence statements.Four level III case –control studies were included (33–36).Two related IBS symptoms to coffee and tea consumption (33,36)(Table 4),and one speci?cally to caffeine intake (34).One study noted hard stools for tea,as well as gastro-oesophageal re?ux,dyspepsia,abdominal pain,loose stools for coffee (36).Three studies with high risk of bias provided limited evidence for an association with caffeine or coffee consumption on symptoms (33,34,36)and one study with a high risk of bias found no asso-ciation with caffeine (35).

1b-i Caffeine can induce or worsen IBS symptoms (33,34,36)

C.Practical considerations.Assess caffeine intake and,if related to symptoms,consider reducing intake.Daily caf-feine intakes up to 400mg day –1do not raise any safety

concerns in the general population,apart from in preg-nancy where 200mg day –1is the current maximum (38).Behavioural changes (e.g.irritability,nervousness or anxi-ety)have been reported in caffeine intakes of 5mg day –1body weight (39).

1c What effect does spicy food have on IBS symptoms?Included studies and evidence statements.Two level II RCTs (40,41),four level III case –control studies (33,34,36,42)and one cross-sectional level III study (37)met the inclu-sion criteria and were evaluated (Table 4).Four studies relate to the ingestion of hot or spicy food (33),hot spices (36),cayenne/red pepper or chilli/Tabasco (37),spicy food,curry,chilli (34).One study compared chilli powder (2g day –1,1.87mg of capsaicin)in a meal with capsule supplementation in IBS-D (41).In two studies,supplementation was given as four enteric coated tablets per day for 6weeks (600mg of red pepper powder

per

Table 3Clinical practice recommendations 1Healthy eating &lifestyle Alcohol Assess intake and screen for signs of binge drinking.Ensure alcohol intake is in keeping with safe national limits

(2016)

C Caffeine Insuf?cient evidence to make a recommendation (2016)

D Spicy food If related to symptoms assess spicy food intake and trial restriction (2016)C Fat If related to symptoms during or after eating,assess fat intake and ensure it is in line with national healthy eating

guidelines (2016)

Fluid No evidence to make a recommendation (2016)Dietary habits Insuf?cient evidence to make a recommendation (2016)D 2Restricting milk and dairy products In individuals with IBS where sensitivity to milk is suspected and a lactose hydrogen breath test is not available or appropriate,a trial period of a low lactose diet is recommended.This is particularly useful in individuals with an

ethnic background with a high prevalence of primary lactase de?ciency (2012)

Use a low lactose diet to treat individuals with a positive lactose hydrogen breath test (2012)

D 3Dietary ?bre modi?cation Avoid using dietary supplementation of wheat bran to treat IBS.Individuals should not be advised to increase their intake of wheat bran above their usual dietary intake from (2012)

C For individuals with IBS-C,try dietary supplementation of linseeds of up to 2tablespoons/day for a 3month trial.Improvements in constipation,abdominal pain and bloating from linseed supplementation may be gradual (2016)

D 4Fermentable carbohydrates For individuals with IBS,consider a low FODMAP diet to improve abdominal pain,bloating and/or diarrhoea for a minimum of 3(88)or 4weeks (87,91).If no symptom improvement occurs within 4weeks of strict adherence to

the diet,then the intervention should be stopped and other therapeutic options considered (2016)

There may be individual tolerance levels to FODMAPs.A planned and systematic reintroduction challenge of foods high in FODMAPs will identify which foods can be reintroduced to the diet and what individual tolerance levels are (2016)

5Gluten At this time no recommendation can be made to treat IBS symptoms with a gluten-free diet (2016)D 6Probiotic products to improve IBS symptoms Advise that probiotics are unlikely to provide substantial bene?t to IBS symptoms.However,individuals choosing to try probiotics are advised to select one product at a time and monitor the effects.They should try it for a minimum of 4weeks at the dose recommended by the manufacturer (2016)

Taking a probiotic product is considered safe in IBS (2016)

B 7Elimination diets/food hypersensitivity

Non-speci?c elimination diets are no longer valid to improve IBS symptoms (2016)D

FODMAP,fermentable oligosaccharides,disaccharides,monosaccharides and polyols;IBS,irritable bowel syndrome;IBS-C,IBS –constipation-pre-dominant;PEN,Practice-based Evidence in Nutrition.

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day,2mg of capsaicin)(40)and a one-off dose of 10capsules (10g of red chilli powder,14mg of capsaicin)(42)

.One study showed positive effects of high dose chilli powder supplementation on abdominal pain threshold in IBS (40),whereas the other studies demon-strated negative effects of spicy food,hot spices and smaller quantities of chilli powder on symptom induc-tion.Two studies noted speci?c symptom onset:abdom-inal pain and oral burning (41),as well as abdominal pain and gastro-oesophageal re?ux (36).The evidence was limited with a high risk of bias.

1c-i Spicy food induced symptoms in IBS (34,36,37),speci?cally in men (33),and IBS-D (41)C.

1c-ii Oral administration of red pepper tablets (2mg day –1capsaicin)improved abdominal pain thresh-old but not abdominal pain or bloating compared to pla-cebo when taken for 6weeks (40)C.

Practical considerations.It is useful to assess other com-ponents of spicy meals that may contribute to symptoms (e.g.FODMAPs in onion and garlic).1d What effect does fat have on IBS symptoms?

Included studies and evidence statements.One level II RCT (43),four level III case –control studies (33,34,36,44)and one level III cross-sectional study (37)met the

inclusion criteria and were evaluated (Table 4).Four observational studies assessed patient perceived effects of dietary fat on symptom development in individuals with IBS,with three of these including controls (33,34,36)and one having no control (37).The effect of duodenal lipid infusion was assessed in one RCT using 6.7g of fat over 2h (43)and one case –control study using a single dose of 20g over 1h (44)on the development of symptoms in individuals with IBS versus controls.One study reported abdominal pain,dyspepsia and ?at-ulence (36).The evidence was limited with a high risk of bias.

1d-i Fat increased IBS symptoms (33,34,36,37,43,44)C.Practical considerations.A decrease in fat intake may be bene?cial in relieving IBS symptoms,in particular meal-related abdominal pain and discomfort associated with visceral hypersensitivity.

1e What effect does ?uid intake have on IBS symptoms?Included studies and evidence statements.There were no eligible studies and so no evidence statements were devel-oped.

Practical considerations.Despite the lack of evidence,a gradual increase in ?uid intake is recommended (aim for

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T a b l e 4C h a r a c t e r i s t i c s a n d s u m m a r y o f s y m p t o m o u t c o m e s o f i n c l u d e d s t u d i e s r e l a t i n g t o a l c o h o l ,c a f f e i n e ,s p i c y f o o d a n d f a t

A g a r w a l e t a l.(2002)(42)

I n d i a

R C T 29/35m a l e I B S 21/23m a l e h e a l t h y c o n t r o l s

10g o f r e d c h i l l i p o w d e r (14m g o f c a p s a i c i n ),i n a s i n g l e d o s e o f 10c a p s u l e s C h i l l i d i d n o t a l t e r s m a l l b o w e l o r c o l o n i c t r a n s i t i n I B S p a t i e n t s c o m p a r e d t o c o n t r o l s C h i l l i i n d u c e d s y m p t o m s o f n a u s e a ,a b d o m i n a l d i s t e n s i o n a n d r e c t a l d i s c o m f o r t m o r e o f t e n i n I B S t h a n c o n t r o l s C h i l l i h a d n o b e n e ?c i a l o r d e l e t e r i o u s e f f e c t o n o v e r a l l s y m p t o m s H i g h B €o h n e t a l.(2013)(37)

S w e d e n C o h o r t 197I B S

Q u e s t i o n n a i r e t o a s s e s s d i e t a r y t r i g g e r s r e l a t e d t o w i n e /b e e r ,h o t s p i c e s /T a b a s c o ,f a t t y f o o d

31%r e p o r t e d w i n e o r b e e r i n d u c e d s y m p t o m s 28%r e p o r t e d g a s t r o i n t e s t i n a l s y m p t o m s r e l a t e d t o c h i l l i /t a b a s c o F r i e d a n d f a t t y f o o d s w e r e t h e m o s t c o m m o n l y r e p o r t e d f o o d s t o i n d u c e s y m p t o m s (52.3%)H i g h

B o r t o l l o t i a n d P o r t a (2011)(40)

I t a l y

R C T 50I B S 17/23i n t e r v e n t i o n 25/27h e a l t h y c o n t r o l s

150m g o f r e d p e p p e r p o w d e r (0.50m g o f c a p s a i c i n )o r p l a c e b o i n t w o e n t e r i c c o a t e d t a b l e t s ,t w i c e a d a y f o r 6w e e k s 6w i t h d r a w n f r o m i n t e r v e n t i o n d u e t o i n t e n s e a b d o m i n a l p a i n s o d o s e r e d u c e d t o 50%50%r e d p e p p e r d o s e r e d u c e d a b d o m i n a l p a i n a n d b l o a t i n g m o r e t h a n p l a c e b o H i g h

F a r e s j o e t a l.(2010)(33)

S w e d e n

C a s e –c o n t r o l 347I B S w i t h n e w G P d i a g n o s i s 2509h e a l t h y c o n t r o l s

Q u e s t i o n n a i r e t o a s s e s s d i e t a r y t r i g g e r s r e l a t e d t o a l c o h o l ,t e a /c o f f e e ,h o t /s p i c y f o o d ,f a t t y f o o d

O u t c o m e s a r e a d j u s t e d f o r a g e N o s i g n i ?c a n t d i f f e r e n c e s f o r s y m p t o m i n d u c t i o n b e t w e e n I B S a n d c o n t r o l s i n r e l a t i o n t o a l c o h o l F e m a l e s w i t h I B S l i m i t e d c o f f e e i n t a k e .S i g n i ?c a n t l y m o r e f e m a l e s w i t h I B S r e p o r t e d t e a a n d c o f f e e i n d u c e d s y m p t o m s c o m p a r e d w i t h c o n t r o l s (21%v e r s u s 11%;P =0.004)b u t n o t f o r m a l e s (P =0.13)S i g n i ?c a n t l y m o r e m a l e s w i t h I B S r e p o r t e d h o t o r s p i c y f o o d i n d u c e d s y m p t o m s m o r e t h a n c o n t r o l s (9%v e r s u s 3%;P =0.01)b u t n o t f o r f e m a l e s (P =0.53)S i g n i ?c a n t l y m o r e I B S p a t i e n t s t h a n c o n t r o l s r e p o r t e d h i g h -f a t f o o d i n d u c e d s y m p t o m s i n m a l e s (15%v e r s u s 4%;P <0.004)a n d f e m a l e s (24%v e r s u s 9%;P <0.001)H i g h

G o n l a n c h a v i t e t a l.(2009)(41)

T h a i l a n d

C O R C T 20I B S -

D 38h e a l t h y c o n t r o l s

S p i c y m e a l (s t a n d a r d m e a l m i x e d w i t h 2g o f c h i l l i )2g o f c h i l l i c a p s u l e s w i t h s t a n d a r d m e a l C o n t r o l (s t a n d a r d m e a l )

I B S p a t i e n t s r e p o r t e d s i g n i ?c a n t a b d o m i n a l p a i n ,d i a r r h o e a a n d r e c t a l b u r n i n g u p t o 2h a f t e r s p i c y f o o d o r c h i l l i c a p s u l e s (P <0.05)C o n t r o l s r e p o r t e d m i l d a b d o m i n a l b u r n i n g (P <0.05)

H i g h

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Dietary management of IBS guidelines

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T a b l e 4.C o n t i n u e d

G u o e t a l.(2015)(47)

C h i n a

C a s e –c o n t r o l 78I B S 79h e a l t h y c o n t r o l s

F o o d f r e q u e n c y q u e s t i o n n a i r e i n c l u d i n g e a t i n g a n d l i f e s t y l e h a b i t s I B S p a t i e n t s c o m p a r e d t o c o n t r o l s r e p o r t e d i n c r e a s e d i r r e g u l a r m e a l s (65.4%v e r s u s 36.7%;P <0.001)b u t n o d i f f e r e n c e s i n t i m e t a k e n t o e a t o r b e i n g a p i c k y e a t e r H i g h H a y e s e t a l.(2014)(34)

I r e l a n d

C a s e –c o n t r o l 135I B S 111h e a l t h y c o n t r o l s

Q u e s t i o n n a i r e t o a s s e s s d i e t a r y t r i g g e r s r e l a t e d t o a l c o h o l ,c a f f e i n e ,s p i c y f o o d a n d f a t t y f o o d S i g n i ?c a n t l y m o r e I B S p a t i e n t s t h a n c o n t r o l s r e p o r t e d a l c o h o l (14.1%v e r s u s 2.7%P <0.01),c a f f e i n e (11.9%v e r s u s 1.8%;P <0.01),s p i c y f o o d (39.3%v e r s u s 18.9%;P <0.01)a n d f a t t y f o o d s (35.6%v e r s u s 18.9%;P <0.01)i n d u c e d s y m p t o m s H i g h

K a n g e t a l.(2011)(46)

K o r e a

C o h o r t 89I B S a r m y c a d e t s (m a l e =73)a r m y n u r s e s (n =16)L i f e s t y l e m o d i ?c a t i o n f o r 9w e e k s

63%o f I B S p a t i e n t s r e p o r t e d t h e i r s y m p t o m s i m p r o v e d w i t h l i f e s t y l e m o d i ?c a t i o n

H i g h

K h a d e m o l h o s s e i n i e t a l.(2011)(48)

I r a n

C o h o r t 215I B S p a t i e n t s 1978h e a l t h y c o n t r o l s

Q u e s t i o n n a i r e t o a s s e s s l i f e s t y l e f a c t o r s t h a t m a y b e a s s o c i a t e d w i t h I B S M o r e s u b j e c t s w i t h I B S c o n s u m e d f a s t f o o d (33%)v e r s u s s u b j e c t s w i t h o u t I B S (25%;P =0.007)a n d l e s s s u b j e c t s w i t h I B S a t e f r u i t a n d v e g e t a b l e s (92%)v e r s u s s u b j e c t s w i t h o u t I B S (96%;P =0.027)H i g h

M i w a (2012)J a p a n (49)C o h o r t 2547F D o r I B S

Q u e s t i o n n a i r e t o a s s e s s l i f e s t y l e f a c t o r s t h a t m a y b e a s s o c i a t e d w i t h I B S L e s s s u b j e c t s w i t h F D o r I B S c o m p a r e d t o h e a l t h y s u b j e c t s a t e m e a l s r e g u l a r l y (70%v e r s u s 78%;P <0.01),a l w a y s h a d a n a p p e t i t e (45%v e r s u s 28%;P <0.05),l i k e d m e a t (79%v e r s u s 84%;P <0.01),a n d t h o u g h t t h e i r v e g e t a b l e c o n s u m p t i o n w a s i n s u f ?c i e n t (52%v e r s u s 58%;P <0.01)H i g h

R e d i n g e t a l.(2013)(35)

U S A

C a s e –c o n t r o l 166f e m a l e I B S

D i a r y t o a s s e s s d i e t a r y t r i g g e r s a n d s y m p t o m s r e l a t e d t o a l c o h o l a n d c a f f e i n e B i n g e d r i n k i n g (>4d r i n k s d a y –1)i n I B S w a s

s i g n i ?c a n t l y a s s o c i a t e d w i t h n e x t d a y d i a r r h o e a (P =0.01),n a u s e a (P <0.001),s t o m a c h p a i n (P =0.002)a n d i n d i g e s t i o n (P =0.002)N o a s s o c i a t i o n f o u n d f o r l i g h t /m o d e r a t e d r i n k i n g o r c a f f e i n e i n t a k e H i g h

S e r r a e t a l.(2002)(43)

S p a i n

R C T 30I B S 45h e a l t h y c o n t r o l s ,o n l y 30i n d a t a p r e s e n t e d

D u o d e n a l f a t i n f u s i o n 6.7g i n 2h 15I B S a n d 15h e a l t h y c o n t r o l s p e r g r o u p :0k c a l m i n –1(s a l i n e )0.5k c a l m i n –1

I B S p a t i e n t s w e r e h y p e r s e n s i t i v e t o t h e s m a l l l i p i d i n f u s i o n ,r e p o r t i n g c r a m p y p a i n a n d b l o a t i n g w i t h s i g n i ?c a n t g a s r e t e n t i o n ,a b d o m i n a l s y m p t o m s ,a n d d i s t e n s i o n v e r s u s h e a l t h y c o n t r o l s (P <0.05)

H i g h

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Dietary management of IBS guidelines update

Y.A.McKenzie et

al.

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T a b l e 4.C o n t i n u e d

S i m r e n e t a l.(2001)(36)

S w e d e n

C a s e –c o n t r o l 330I B S 80h e a l t h y c o n t r o l s

Q u e s t i o n n a i r e t o a s s e s s d i e t a r y t r i g g e r s r e l a t e d t o a l c o h o l ,c o f f e e ,s p i c y a n d f a t t y f o o d A l c o h o l i n d u c e d s y m p t o m s i n 33%o f I B S s u b j e c t s A l c o h o l w a s s e c o n d m o s t c o m m o n t r i g g e r o f l o o s e s t o o l s S y m p t o m s a s s o c i a t e d w i t h t e a a n d c o f f e e w e r e r e p o r t e d i n 13%a n d 39%o f I B S p a t i e n t s ,r e s p e c t i v e l y .C o f f e e w a s s e v e n t h m o s t c o m m o n t r i g g e r o f s y m p t o m s 45%o f I B S r e p o r t e d c l i n i c a l l y s i g n i ?c a n t s y m p t o m s w i t h h o t s p i c e s I B S v e r s u s c o n t r o l s f a t t y f o o d s p r o b l e m a t i c (P <0.0001)H i g h

S i m r e n e t a l.(2007)(44)

S w e d e n C a s e –c o n t r o l 61I B S 20h e a l t h y c o n t r o l s

D u o d e n a l f a t i n f u s i o n o f C a l o g e n 120m L (1.5k c a l m L –1

a t 2m L m i n –120g o f f a t i n 1h )

D u o d e n a l f a t i n f u s i o n s i g n i ?c a n t l y i n c r e a s e d p a i n ,m e a s u r e d b y c h a n g e i n s e n s o r y p r e s s u r e t h r e s h o l d (8.6?9.1v e r s u s 1.3?5.5m m H g ;P =0.001)a n d d i s c o m f o r t (7.3?9.8v e r s u s 2.5?5.0m m H g ,P =0.006)i n I B S p a t i e n t s v e r s u s h e a l t h y c o n t r o l s

H i g h

C O ,c r o s s -o v e r ;

D B ,d o u b l e -b l i n d ;F D ,f u n c t i o n a l d y s p e p s i a ;G P ,g e n e r a l p r a c t i t i o n e r ;I B S ,i r r i t a b l e b o w e l s y n d r o m e ;I B D -D ,I B S –d i a r r h o e a -p r e d o m i n a n t ;R C T ,r a n d o m i s e d c o n t r o l l e d t r i a l.

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Dietary management of IBS guidelines

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a total intake of 1.5–3.0L day –1)to improve stool fre-quency and decrease the need for laxatives in IBS-C (45).1f What effect do dietary habits have on IBS symptoms?Included studies and evidence statements.Three level IV cross-sectional studies and one case –control study were included (Table 4)(46–49).The outcomes were not speci-?c to only IBS patients;one study included functional dyspepsia (49).Irregular meal pattern,lower consumption of fruit and vegetables and higher fast food consump-tion may be related to worsening IBS symptoms,although the studies had heterogeneous comparison groups (46–49).There was limited evidence with a high risk of bias.

1f-i There was inadequate evidence that dietary habits are associated with IBS symptoms D.

Practical considerations.Despite the lack of evidence,assess dietary habits and provide advice on how to achieve a healthy balanced diet with a regular meal pat-tern (breakfast,lunch and evening meal with snacks as appropriate).Good eating lifestyle includes taking time over meals,sitting down to eat,chewing food thoroughly and not eating late at night (2).

What is the effectiveness of restricting milk and dairy products to improve IBS symptoms?

Many individuals with IBS restrict milk and/or dairy products resulting in low calcium intakes (50,51).To avoid unnecessary exclusion and potential dietary de?ciencies,it was important to review the evidence for restricting milk and dairy products,including lactose restriction,and to evaluate its effect on symptoms.

Included studies and evidence statements

No new studies were identi?ed and the ?ve original stud-ies from the ?rst guidelines were re-evaluated (Table 5)(52–56)

.In a minority of individuals,dairy exclusion can induce anaphylactic food hypersensitivity reactions when reintroduced (57,58)and so one previous evidence state-ment was removed.Five remaining evidence statements were still valid and have been updated.The evidence was limited with a high risk of bias.

2i Using a hydrogen breath test with a lactose load of between 25–50g,the incidence of lactose malabsorption was higher in individuals with IBS compared to individu-als without IBS from a white,Caucasian,Northern Euro-pean background (54,55)C.

2ii The incidence of lactose malabsorption was higher in individuals with IBS from ethnic groups with an increased prevalence of primary lactase de?ciency (53,56)C.

2iii In individuals with IBS and a positive diagnosis of lactose malabsorption using a hydrogen breath test,a low lactose diet improved abdominal symptoms in the short and long-term (53,55,56)C.

2iv No speci?c IBS symptom pro?les were associated with lactose intolerance or responded better to a low lac-tose diet (<9g day –1)(54,55)C.

2v Lactose intolerance is a recognised condition in itself and should be ruled out before the diagnosis of IBS is made,especially in those from an ethnic background where the incidence of primary lactase de?ciency is high (55,56)

C.Practical considerations

In individuals with IBS,lactose restriction in isolation may only provide marginal symptom bene?ts.Therefore,lactose restriction is generally considered as part of a low FODMAP diet (see section on fermentable carbohydrates further below).

If individuals wish to follow a milk-free diet,they should be informed that there is no high-quality evidence for this to improve their IBS symptoms.Cow’s milk pro-tein elimination in atopic individuals (i.e.eczema,asthma or hay-fever)should only be conducted by appropriately allergy-experienced dietitians.This is a result of the very small risk associated with dangerous anaphylactic reac-tions on food reintroduction following extended elimina-tion of foods (57,58).

Which type of dietary ?bre improves IBS symptoms?The Scienti?c Advisory Committee on Nutrition (SACN)and the European Food Safety Authority (EFSA)de?ne dietary ?bre as nonstarch polysaccharides,all resistant starches,all nondigestible oligosaccharides with three or more monomeric units and other nondigestible but quan-titatively minor components that are associated with the dietary ?bre polysaccharides,especially lignin.This incor-porates total dietary ?bre as measured using the AOAC method 2009.01and that used in EU nutritional labelling of packaged foods (59–61).The report advised that the terms insoluble and soluble ?bre are phased out because they often co-exist in intact plant cell walls and solubility does not always predict physiological function (61).

Diets rich in dietary ?bre are associated with a lower inci-dence of cardiovascular diseases,coronary events,stroke,type 2diabetes and colorectal cancers (61).Dietary ?bre has a bene?cial effect on the gastrointestinal microbiota and fer-mentation by-products (62).The SACN recommends that dietary ?bre intake should increase to 30g day –1,which is consistent with other recommendations of >3g MJ –1(25–35g day –1)and 25g day –1(women)to

30g day –1(men)

(63,64)

.High intakes of dietary ?bre have 10

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been associated with symptom generation in IBS (2,65)and so the risk factors and bene?ts of speci?c foods high in diet-ary ?bre need to be taken into consideration.

Included studies and evidence statements

One new and 10previously evaluated level II RCTs met the inclusion criteria (Table 6)(66–76).The new study was a parallel open-label,multicentre study assessing linseed (i.e.?axseed)supplementation and showed no bene?t of taking whole or ground linseeds over placebo (76).There were no new studies on other types of ?bre from food,or ?brous foods,such as oats,oat bran,corn or resistant starches.

Dietary ?bre intake was reported at baseline and post intervention in ?ve RCTs (66,72–74,76),at baseline only in three RCTs (67,71,75)and four RCTs provided no data (68–70,72)

A placebo containing potentially confounding compo-nents was used in seven RCTs (66,68,69,71–74)and the pla-cebo constituents were not described in one study (70).No placebo was used in two RCTs (75,76).

Five evidence statements were developed and/or updated.The evidence was limited with a high risk of bias.3i Wheat bran ?bre (10–40g day –1supplementation)did not improve IBS symptoms (67,69–73)C.

3ii Increasing dietary ?bre intake from cereals and fruit did not improve IBS symptoms (66,74)C.

3iii Ground linseeds (6–24g day –1)relieved constipa-tion,abdominal discomfort and bloating in IBS-C gradu-ally over 3months (75)C.

3iv Ground and whole linseeds were well tolerated in IBS as a dietary ?bre supplement (76),although there is con?icting evidence for their effectiveness on symptoms (75,76)

3v There was insuf?cient evidence for dietary supple-mentation with psyllium husk (6–24g day –1)for up to 3months to improve symptoms of IBS and IBS-C (67,75)C.Practical considerations

Evidence is lacking on whether the recommended 25–30g day –1dietary ?bre intake for the general popula-tion (61)is applicable to individuals with IBS,especially because population data demonstrate inadequate dietary ?bre intakes (77).Consider the symptom pro?le prior to assessment of dietary ?bre intake to determine whether the current intake is optimal for that individual.Check dietary ?bre intake from all potential sources (cereals,grains,fruit,vegetables,nuts,seeds,pulses and mycopro-tein).If an increase is applicable,encourage a wide variety of high ?bre starchy foods (e.g.oats and oat bran,brown rice,rice bran,wholemeal/seeded/granary bread,whole-grain pasta,wholegrain couscous,rye-based bread,pota-toes with skin,quinoa).A wide variety is important and takes into account any other dietary restrictions.

Linseeds are a useful source of dietary ?bre providing 22.8g of dietary ?bre per 100g of whole seeds.Start with 4–12g day –1linseeds and increase up to 24g day –1(1tbs =12g);the full bene?t may take up to 6months.Ensure linseeds are always consumed with ?uid (150mL ?uid tbs –1)(78).Linseeds can be added to other food

(e.g.

Table 5Characteristics and summary of symptom outcomes of included studies relating to milk B €o

hmer et al.(1996)(55)

Holland

DB non-RCT 70with IBS

Low lactose diet (<9g day –1)for 6weeks 17/70LHBT +ve 53/70LHBT àve

Symptom scores:baseline to 6weeks

LHBT +ve:13.5–4;(P <0.001)LHBT àve:13–11;(P >0.05)

High

B €o

hmer and Tuynman (2001)(52)Holland

Non-RCT 16with IBS and LHBT +ve Low lactose diet (unquanti?ed)for 5years

Symptom scores:baseline to 5years 13.5–5.1;P <0.001

High

Bozzani (1986)(53)Italy

Non-RCT 40with IBS and LHBT +ve Lactose-free diet (<9g day –1)for 4months

Symptoms assessment at 4months:3symptom-free,21improved and 16no change (P >0.05)

High

Parker et al.(2001)(54)UK

Non RCT 33with IBS and LHBT +ve

Low lactose diet (<1g day –1)for 3weeks

9improved versus 14did not improve *10withdrawals/lost to follow-up High Vernia et al.(1995)(56)Italy

Non-RCT 110with IBS and +ve LHBT

Lactose-free diet for 3months

48remission,43partial improvement and 17no improvement,two not unaccounted for *

High

CO,cross-over;DB,double-blind;IBS,irritable bowel syndrome;LHBT,lactose hydrogen breath test;RCT,randomised controlled trial;+ve,positive;àve,negative.*P value not reported.

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yoghurt,breakfast cereal,porridge,homemade bread,cas-serole,soup,salad).It does not matter whether linseeds are golden or brown,whole or ground.Individuals with co-existing diverticular disease often avoid whole seeds as they may irritate diverticulitis (79);however,there is no evidence to suggest that seeds,nuts,corn or popcorn induce diverticulosis (80).

Encourage noncaffeinated and non-alcoholic ?uids when ?bre-rich foods are consumed to enhance the bene-?cial effects of dietary ?bre on transit time.

What are the effects of altering the intake of fermentable carbohydrates to improve IBS symptoms?

Fermentable carbohydrates include FODMAPs,resistant starch and prebiotics.There is some overlap between pre-biotics and FODMAPs because some can be considered to meet both de?nitions.FODMAPs can lead to increased small intestinal luminal ?uid and gas production via colonic microbial fermentation (81–83).Both of these mechanisms can result in functional bowel symptoms in susceptible individuals.Prebiotics are nondigestible,fer-mentable food components that result in the ‘selective stimulation of growth and/or activity of one or a limited number of microbial genera/species in the gastrointestinal microbiota that confer health bene?ts to the host’(84).The restriction of individual FODMAPs (https://www.wendangku.net/doc/c2908068.html,ctose,fructose and sorbitol)has been of interest for a long time;however,reducing their dietary intake has only had a mar-ginal effect on gastrointestinal symptoms,as reviewed else-where (85,86).In recent years,there has been increasing evidence that a diet low in FODMAPs improves IBS symp-toms (8,9,85,86).This update has broadened its scope to appraise dietary restriction of FODMAPs and supplemen-tation of prebiotics on all IBS symptoms,and is not just limited to abdominal bloating as in the previous guidelines.Included studies and evidence statements

Eight level II RCTs (87–94)were included and summarised in Table 7.One study from the previous guidelines was excluded because it only had 15IBS patients (95).

One study compared a fructose restricted diet contain-ing less than 2g of fructose per meal with an ‘IBS’diet (details not provided);however,fructose intake was not measured in either arm (87).One study assessed the low FODMAP diet (3.05g FODMAPs day –1)versus a typical Australian diet (23.7g FODMAPs day –1)in a feeding study (88).Two studies assessed the low FODMAP diet versus habitual diet (91,94):one reported FODMAP intakes of 17.7g day –1(low FODMAP diet)versus 29.6g day –1(habitual diet)(91),whereas the other did not measure FODMAP intake (94).The latter also compared the low FODMAP diet with a probiotic Lactobacillus rhamnosus

GG (94),although this was not part of the criteria for comparison in these guidelines.One study assessed the low FODMAP diet (3.8g FODMAPs day –1)versus tradi-tional National Institute for Health and Care Excellence (NICE)/BDA dietary advice (15.8g FODMAPs day –1).Two studies assessed the symptom effect of challenging with 10–20g day –1FOS (89)or 14–50g day –1fructose and 7–19g day –1fructans (90).One study assessed 3.5–7g day –1trans -galacto-oligosaccharide (b -GOS)supple-mentation (92).These guidelines include six new and two updated evidence statements,with good evidence from three RCTs with low or unclear risk of bias indictating that dietitian-led low FODMAP education with up to 6weeks of FODMAP restriction improves symptoms in IBS,IBS-D and IBS-M.There is currently no evidence to support the low FODMAP diet being nondietitian deliv-ered (88,91,93,94).

4i A low FODMAP diet for 3(88),4(91,93)or 6(94)weeks improved overall symptoms in IBS and the sub-types IBS-D and IBS-M (88,91,93,94)but not IBS-C (94),abdominal pain (88,93),bloating (88,91,93),?atulence,satis-faction with stool consistency (88),borborygmi,urgency (91)

and life interference (93)in IBS B.

4ii A fructose restricted diet for 4weeks improved abdominal pain,bloating and stool frequency in IBS (87)C.4iii A low FODMAP diet improved overall symptoms for the subtypes IBS-D and IBS-M (88,91,93,94)but not IBS-C (94)B.

4iv A low FODMAP diet reduced dissatisfaction in stool consistency and reduced bowel frequency in IBS-D (88)

4v A low FODMAP diet reduced dissatisfaction in stool consistency in IBS-C (88)C.

4vi A low FODMAP diet had similar ef?cacy as NICE/BDA dietary advice for overall symptoms in IBS (93).Symptom improvement was similar for all IBS subtypes for a low FODMAP diet but less for IBS-C than IBS-D or IBS-M for NICE/BDA dietary advice (93)C.

4vii A low FODMAP diet had similar ef?cacy as a pro-biotic L.rhamnosus GG for overall symptoms in IBS,IBS-D and IBS-M (94)C.

4viii A high dose of fructans (>19g day –1)and fructose (>14g day –1)in IBS with fructose malabsorption (90),and trans-GOS (7g day –1)in IBS (92),induced abdominal pain,bloating and ?atulence C.

4vix Trans-GOS at 3.5g day –1for 4weeks improved bloating and ?atulence but not pain in IBS.At 7.0g day –1,bloating worsened,whereas ?atulence improved (92)C.

Practical considerations

A low FODMAP diet with a restriction phase for 3–6weeks is ef?cacious in the treatment of IBS when

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T a b l e 6C h a r a c t e r i s t i c s a n d s u m m a r y o f s y m p t o m o u t c o m e s o f i n c l u d e d r a n d o m i s e d c o n t r o l l e d t r i a l s r e l a t i n g t o d i e t a r y ?b r e

A l l e r e t a l.(2004)(66)

S p a i n

S B R C T 56I B S

30.5g ?a s h i g h ?b r e d i e t (28/28)v e r s u s c o n t r o l :10.4g ?a s l o w ?b r e d i e t (28/28)

3m o n t h s N o s i g n i ?c a n t d i f f e r e n c e f o r s y m p t o m s b e t w e e n g r o u p s .P a i n ,b o w e l a n d b l o a t i n g i m p r o v e d i n b o t h g r o u p s (P <0.05)

H i g h A r f f m a n n e t a l.(1985)(68)

D e n m a r k D B C O R C T 20I B S -C o r I B S -M 30g ?o f w h e a t b r a n v e r s u s p l a c e b o :30g ?

c o l o u r e

d b r

e a d c r u m b s (n =18/20p e r g r o u p )6w e e k s w a s h o u t n o t s t a t e d N o s i g n i ?c a n t d i

f f e r e n c e f o r s y m p t o m s b e t w e e n

g r o u p s W

h e a t b r a n s

i g n i ?c a n t l y i n c r e a s e d s t o o l m a s s (P <0.02)a n d r e d u c e d t r a n s i t t i m e (P <0.01)H i g h

B i j k e r k e t a l.(2009)(67)

H o l l a n d

D B R C T 3a r m 275I B S

4g ?o f w h e a t b r a n (n =54/97)v e r s u s 4g ?o f p s y l l i u m

(n =54/85)v e r s u s p l a c e b o :w h i t e r i c e (n =56/93)12w e e k s S y m p t o m s e v e r i t y w a s s i g n i ?c a n t l y l e s s f o r p s y l l i u m t h a n p l a c e b o :(à34%v e r s u s à18%,P =0.03).N o s i g n i ?c a n t d i f f e r e n c e f o r s y m p t o m s b e t w e e n w h e a t b r a n a n d p l a c e b o H i g h

C o c k e r e l e t a l.(2012)(76)

U K

O p e n l a b e l R C T 40I B S

W h o l e l i n s e e d s [m e a n 21g d a y –1,u p t o 7g o f N S P ?](10/14)v e r s u s g r o u n d l i n s e e d s [m e a n 18g d a y –1,u p t o 6g o f N S P ?](12/13)

v e r s u s c o n t r o l :n o s u p p l e m e n t t o d i e t 4w e e k s (9/13)N o s i g n i ?c a n t d i f f e r e n c e s f o r o v e r a l l s y m p t o m s b e t w e e n g r o u p s .A b d o m i n a l p a i n s e v e r i t y (P =0.011)a n d d a y s o f p a i n (P =0.042)i m p r o v e d f o r w h o l e l i n s e e d s b u t n o t g r o u n d l i n s e e d s o r c o n t r o l.B l o a t i n g s e v e r i t y i m p r o v e d f o r g r o u n d l i n s e e d s (P =0.028)a n d c o n t r o l (P =0.018)b u t n o t w h o l e l i n s e e d s (P =0.138)H i g h

F o w l i e e t a l.(1992)(74)

U K

N o n -R C T 49I B S -C

4.1g ?o f c e r e a l a n d f r u i t ?b r e i n 5t a b l e t s (n =15/25)v e r s u s p l a c e b o :s t a r c h ?,C a P O 4,

l a c t o s e i n 5t a b l e t s (n =17/24)3m o n t h s N o s i g n i ?c a n t d i f f e r e n c e f o r s y m p t o m s b e t w e e n g r o u p s

H i g h

H e b d e n e t a l.(2002)(69)

U K D B C O R C T 12I B S 30g ?o f w h e a t b r a n v e r s u s p l a c e b o :30g ?

o f p l a i n b i s c u i t s (12/12p e r g r o u p )2w e e k s T h e w h e a t b r a n i n c r e a s e d p a i n a n d b l o a t i n g c o m p a r e d t o p l a c e b o (P <0.02)

H i g h

K r u i s e t a l.(1986)(70)

G e r m a n y D B R C T 80I B S 15g (7.95g )?o f w h e a t b r a n v e r s u s p l a c e b o ?

16w e e k s N o s i g n i ?c a n t d i f f e r e n c e f o r s y m p t o m s b e t w e e n g r o u p s

H i g h

L u c e y e t a l.(1987)(71)

U K

D B C O R C T 38I B S

12(15.6g )§o f w h e a t b r a n b i s c u i t s v e r s u s p l a c e b o :12(2.76g )§p l a i n b i s c u i t s (28/38p e r g r o u p )

16w e e k s N o s i g n i ?c a n t d i f f e r e n c e f o r s y m p t o m s b e t w e e n g r o u p s .G l o b a l s y m p t o m s i m p r o v e d f o r b o t h g r o u p s (P <0.01)

H i g h

R e e s e t a l.(2005)(72)

U K

S B R C T 28I B S -C o r I B S -M 10–20g (3.64–7.28g )?o f w h e a t b r a n (12/14)v e r s u s p l a c e b o :l o w ?b r e c r i s p b r e a d (0.22–0.44g )?(10/14)

12w e e k s N o s i g n i ?c a n t d i f f e r e n c e f o r s y m p t o m s b e t w e e n g r o u p s .S t o o l w e i g h t i n c r e a s e d f r o m 95g t o 123g f o r w h e a t b r a n a n d d e c r e a s e d f r o m 135g t o 125g f o r p l a c e b o (P <0.02)H i g h

S n o o k a n d S h e p h e r d (1994)(73)

U K D B C O R C T 80I B S 40g o f w h e a t b r a n (12g )§(71/80)v e r s u s p l a c e b o :w h e a t a n d r i c e ?o u r (n e g l i g i b l e )§(71/80)

7w e e k s w i t h 2-w e e k w a s h o u t N o s i g n i ?c a n t d i f f e r e n c e f o r s y m p t o m s b e t w e e n g r o u p s .F l a t u l e n c e i n c r e a s e d f o r w h e a t b r a n c o m p a r e d t o p l a c e b o (P <0.001)

U n c l e a r

T a r p i l a e t a l.(2004)(75)

F i n l a n d

S B R C T 55I B S -C

G r o u n d l i n s e e d s (≤24g ,10.6g )?(26/26)v e r s u s p s y l l i u m (≤24g ,13.5g )?(29/29)

3m o n t h s

G r o u n d l i n s e e d s i m p r o v e d c o n s t i p a t i o n (P =0.05,N N T =2.1)a n d a b d o m i n a l s y m p t o m s (P =0.001,N N T 2.4)c o m p a r e d t o p s y l l i u m

H i g h

C O ,c r o s s -o v e r ;

D B ,d o u b l e -b l i n d ;N N T ,n u m b e r n e e d t o t r e a t ;R C T ,r a n d o m i s e d c o n t r o l l e d t r i a l.?

U n d e ?n e d d i e t a r y ?b r e m e a s u r e m e n t .?E n g l y s t d i e t a r y ?b r e m e a s u r e m e n t .§S o u t h g a t e d i e t a r y ?b r e m e a s u r e m e n t .B o l d s i g n i ?e s a n i n a p p r o p r i a t e c o n t r o l /p l a c e b o .

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delivered by a dietitian with expertise in FODMAP edu-cation (88,90,91,96).Successful adherence and symptom management are achieved by the provision of detailed verbal and written information on avoidance of high FODMAP foods and the inclusion of suitable alterna-tives to ensure a nutritionally adequate diet (97).Two studies showed that the low FODMAP diet has similar ef?cacy as traditional dietary advice based on NICE/BDA (93)or a probiotic L.rhamnosus GG (94),without any speci?c symptom pro?ling.Thus,where adherence may be compromised,it may be applicable to consider other treatment options.

Restriction of FODMAPs reduces the short-chain oligosaccharide components of dietary ?bre by 4g day –1compared to habitual diet (91).An increase in low FODMAP high ?bre foods may be warranted to meet dietary ?bre healthy eating recommendations.From a safety perspective,evidence shows that a low FODMAP diet alters the microbiota (91,98)and reduces calcium intake (91)in the short-term.Therefore,following satis-factory symptom improvement (3–6weeks)(87,88,91),reintroduction of individual FODMAPs to personal tol-erance using dietitian-delivered systematic food chal-lenges is necessary.Recent long-term data indicate that calcium intakes meet nutrient recommendations using the above described dietitan-led delivery (99).However,there are no long-term microbiota data.FODMAP rein-troduction veri?es effective treatment and individual tolerance to speci?c foods at the same time as increas-ing dietary variety and enabling long-term self-manage-ment.

What effect does gluten have on IBS symptoms?Gluten is the main structural protein complex of wheat,rye and barley and a gluten-free diet is the primary treatment for coeliac disease (100).There is increasing research suggesting a possible link between the inges-tion of gluten and the development of functional bowel symptoms in noncoeliac individuals.However,many of the gluten-responsive individuals in these studies are positive for the human leucocyte antigens (HLA)DQ2or DQ8,which are present in 98%of coeliac disease and 25%of the normal population (100),and so it is unclear whether a proportion of these individuals may actually be exhibiting sero-negative coeliac disease.Furthermore,a gluten-free diet reduces fructan intake,FODMAPs and potentially toxic compo-nents within grains such as wheat amylase trypsin inhibitors,which may be responsible for symptom improvement (101).Therefore,whether gluten is directly involved in the exacerbation of IBS-type symptoms is unclear.

Included studies and evidence statements

Four level II RCTs with con?icting evidence met the inclu-sion criteria and are summarised in Table 8(102–105).One RCT included only IBS-D patients and compared a gluten containing diet (amount not speci?ed)with a gluten-free diet for 4weeks (102).The other studies included all IBS subtypes.One study assessed a gluten-free diet with 100g of gluten-containing powder (52%gluten)compared to a gluten-free diet with 100g of gluten-free powder in patients whose symptoms had responded to a gluten-free diet (103).One feeding study assessed a gluten containing diet (16g gluten day –1)compared to a gluten-free diet (0g gluten day –1)(104).All of these studies showed that symptoms did increase in response to gluten (102–104).A second cross-over feeding study controlled for FODMAP intake and compared high gluten (16g gluten day –1)with low gluten (2g gluten day –1)and a control (0g gluten day –1)for 1week with a 2-week washout but showed no gluten-speci?c response (105).The evidence is limited with an unclear risk of bias for one RCT (105)and a high risk of bias for the other three (102–104).

5i A gluten-free diet improved some IBS symptoms;speci?cally,abdominal pain,satisfaction with stool consistency and tiredness at 6weeks (104)and stool frequency in IBS-D at 4weeks (102),which was more pronounced in individuals with a positive HLA-DQ2or HLA-DQ8.C.

5ii When dietary confounders (e.g.FODMAPs)were controlled for,there was insuf?cient evidence that gluten induced IBS symptoms (105).C.

Practical considerations

If individuals wish to follow a gluten-free diet,they should be informed that the current evidence for its use is con?icting.The diet should be assessed for nutri-tional adequacy in line with healthy eating recommen-dations.The long-term effects of a gluten-free diet in IBS are unknown.In coeliac disease,a gluten-free diet is used as a life-long treatment and impairs quality of life (106).

Which strain-speci?c probiotic products improve IBS symptoms?

Probiotics are one of the most investigated treatment options for IBS and have generated great interest amongst individuals with IBS and healthcare professionals.There are many probiotics available as single or multi-strain products in a variety of formulations (e.g.capsules,pow-ders,fermented milks and yoghurts).None have had their health claims approved by European Food &Health Safety Authority (EFSA)(107).

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Dietary management of IBS guidelines update Y.A.McKenzie et

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T a b l e 7C h a r a c t e r i s t i c s a n d s u m m a r y o f s y m p t o m o u t c o m e s o f i n c l u d e d s t u d i e s r e l a t i n g t o f e r m e n t a b l e c a r b o h y d r a t e s

F e r m e n t a b l e c a r b o h y d r a t e r e d u c t i o n B e r g e t a l.(2013)(87)N o r w a y R C T

202I B S 88/101i n t e r v e n t i o n 94/101c o n t r o l 2-w e e k r u n -i n :I B S d i e t I n t e r v e n t i o n :f r u c t o s e r e d u c e d d i e t +I B S d i e t C o n t r o l :I B S d i e t 4w e e k s F r u c t o s e r e d u c e d d i e t s i g n i ?c a n t l y r e d u c e d b l o a t i n g (P <0.0005),a b d o m i n a l p a i n (P <0.0005),s t o o l f r e q u e n c y (P =0.001)b u t n o t s t o o l c o n s i s t e n c y (n s )c o m p a r e d t o I B S d i e t a l o n e .N o I B S s u b t y p e a n a l y s i s H i g h

B €o h n e t a l.(2015)(93)S w e d e n R

C T 75I B S 33/38i n t e r v e n t i o n 34/37c o n t r o l

D i e t a r y a d v i c e s t u d y .P r o b i o t i c s a t s a m e d o s e a l l o w e d .L o w l a c t o s e a l l o w e d I n t e r v e n t i o n :l o w F O D M A P C o n t r o l :N I C

E /B D A (a v o i d o n i o n ,c a b b a g e ,b e a n s ),g o o d e a t i n g b e h a v i o u r ,s m a l l m e a l s 4w e e k s

C h a n g e i n I B S -S S S 77(110)l o w F O

D M A P i n a p p r o p r i a t e 65(84)N I C

E /B D A w a s s i m i l a r b e t w e e n g r o u p s (P =0.62)19(50%)r e s p o n d e r s i n l o w

F O D M A P 17r e s p o n d e r s i n N I C E d i e t P =0.72L o w F O D M A P d i e t i m p r o v e d o v e r a l l s y m p t o m s (P <0.001)a b d o m i n a l p a i n f r e q u e n c y (P =0.008),s e v e r i t y o f d i s t e n s i o n (P <0.001)L i f e i n t e r f e r e n c e i m p r o v e d (P <0.001).N I C E /B D A d i e t i m p r o v e d o v e r a l l s y m p t o m s (P <0.001)a b d o m i n a l p a i n f r e q u e n c y (P <0.001),s e v e r i t y o f d i s t e n s i o n (P =0.003),d i s s a t i s f a c t i o n w i t h b o w e l h a b i t (P =0.01).L i f e i n t e r f e r e n c e i m p r o v e d (P =0.002).I B S s u b t y p e a n a l y s i s f o r r e d u c t i o n i n I B S -S S S w a s s i m i l a r f o r l o w F O D M A P d i e t (P =0.76)b u t I B S -C d i d n o t r e s p o n d a s w e l l a s I B S -D o r I B S -M f o r N I C E /B D A (P =0.03)L o w

H a l m o s e t a l.(2014)(88)

A u s t r a l i a S

C O R C T 30I B S 8h e a l t h y c o n t r o l s

F e e d i n g s t u d y :I n t e r v e n t i o n :L o w F O D M A P C o n t r o l :t y p i c a l A u s t r a l i a n d i e t 3w e e k s o f e a c h d i e t w i t h ≥3-w e e k w a s h o u t

L o w F O D M A P d i e t h a d s i g n i ?c a n t i m p r o v e m e n t s i n g l o b a l s y m p t o m s ,a b d o m i n a l p a i n ,b l o a t i n g a n d d i s s a t i s f a c t i o n w i t h s t o o l c o n s i s t e n c y c o m p a r e d t o c o n t r o l d i e t f o r I B S (a l l P <0.001).F o r I B S s u b t y p e s s i g n i ?c a n t i m p r o v e m e n t s i n d i s s a t i s f a c t i o n w i t h s t o o l c o n s i s t e n c y w e r e o b s e r v e d f o r I B S -D (P =0.038)a n d I B S -C (P =0.037)c o m p a r e d t o c o n t r o l b u t s a m p l e s i z e w a s t o o s m a l l t o s h o w a n y d i f f e r e n c e f o r I B S -M U n c l e a r

P e d e r s e n e t a l.(2014)(94)

D e n m a r k

R C T 108/123I B S L o w F O D M A P 34/42L G G 37/4137/40c o n t r o l (d e l a y e d l o w F O D M A P d i e t )

D i e t a r y a d v i c e o r p r o b i o t i c s s t u d y :I n t e r v e n t i o n 1:L o w F O D M A P I n t e r v e n t i o n 2:p r o b i o t i c s (L G G )?

C o n t r o l :n o r m a l

D a n i s h d i e t 6w e e k s

A d j u s t e d c h a n g e s i n I

B S -S S S f o r b a s e l i n e c o v a r i a t e s s h o w e d s t a t i s t i c a l l y s i g n i ?c a n t r e d u c t i o n o f I B S -S S S f o r l o w F O D M A P d i e t v e r s u s c o n t r o l a t 6w e e k s (75;95%

C I 24–126;P <0.01)b u t n o t f o r L G G v e r s u s c o n t r o l (32;95%C I 18–80P =0.2).T h e m e a n d i f f e r e n c e i n I B S -S S S b e t w e e n l o w F O

D M A P a n d L G G d i d n o t r e a c h s i g n i ?c a n c e (43.8;95%C I 8.1–95.8;P =0.09)F o r I B S s u b t y p e s I B S -D i m p r o v e d f o r a l l t r e a t m e n t g r o u p s ,l o w F O D M A P d i e t (P <0.01),L G G a n d c o n t r o l (P =0.01)a n d I B S -M i m p r o v e d f o r l o w F O D M A P d i e t (P =0.01)a n d L G G (P =0.04)b u t n o t f o r c o n t r o l (P =0.12).I B S -C d i d n o t i m p r o v e f o r a n y t r e a t m e n t

H i g h

a2016The British Dietetic Association Ltd.

Y.A.McKenzie et al.

Dietary management of IBS guidelines

update

https://www.wendangku.net/doc/c2908068.html,

T a b l e 7.C o n t i n u e d

S t a u d a c h e r e t a l.(2012)(91)

U K

R C T 41I B S w i t h d i a r r h o e a a n d /o r b l o a t i n g 16/19i n t e r v e n t i o n 19/22c o n t r o l I T T a n a l y s i s D i e t a r y a d v i c e s t u d y :I n t e r v e n t i o n :l o w F O D M A P C o n t r o l :h a b i t u a l d i e t 4w e e k s I T T :L o w F O D M A P d i e t h a d s i g n i ?c a n t i m p r o v e m e n t s i n g l o b a l s y m p t o m s (P =0.006),b l o a t i n g (P =0.007),b o r b o r y g m i (P =0.04),u r g e n c y (P =0.047)c o m p a r e d t o c o n t r o l d i e t b u t n o t P P f o r s t o o l c o n s i s t e n c y (P =0.56)o r i n c i d e n c e (P =0.24)o r s e v e r i t y (P =0.34)o f d i a r r h o e a

H i g h

F e r m e n t a b l e c a r b o h y d r a t e c h a l l e n g e o r s u p p l e m e n t a t i o n O l e s e n a n d

G u d m a n d -

H o y e r (2000)(89)D e n m a r k D B R C T 96

I B S 38/50i n t e r v e n t i o n 37/46c o n t r o l

2-w e e k r u n -i n w i t h p l a c e b o I n t e r v e n t i o n :10g d a y –1f r u c t o -o l i g o s a c c h a r i d e (F O S )2w e e k s t h e n 20g d a y –1F O S 10w e e k s C o n t r o l :10g d a y –1p l a c e b o (g l u c o s e s y r u p )2w e e k s t h e n 20g d a y –1p l a c e b o 10w e e k s

N o s i g n i ?c a n t d i f f e r e n c e f o u n d H i g h

S h e p h e r d e t a l.(2008)(90)

A u s t r a l i a

D B C O R C T 25/26I B S

F e e d i n g s t u d y o f l o w F O D M A P d i e t w i t h i n t e r v e n t i o n s :14–50g o f f r u c t o s e ;7–19g o f f r u c t a n s ;14–50g o f f r u c t o s e +7–19g o f f r u c t a n s C o n t r o l :20g o f g l u c o s e 9d a y s i n c r e a s i n g d o s e w i t h a t l e a s t 10d a y s w a s h o u t i n b e t w e e n O v e r a l l s y m p t o m s (P <0.02)a n d b l o a t i n g (P ≤0.0046)w e r e s i g n i ?c a n t l y i n c r e a s e d w i t h f r u c t o s e ,f r u c t a n s o r f r u c t o s e -f r u c t a n m i x v e r s u s c o n t r o l L o w

S i l k e t a l.(2009)(92)

U K

S B R C T 3a r m s 60I B S

L o w d o s e :3.5g d a y –114d a y s p l a c e b o (m a l t o d e x t r i n )+3.5g d a y –1t r a n s -G O S ?28d a y s H i g h d o s e :7g d a y –1p l a c e b o 14d a y s +7g d a y –1

t r a n s -G O S 28d a y s C o n t r o l :7g d a y –1p l a c e b o 14d a y s +28d a y s

P P 44/60s u b j e c t i v e g l o b a l a s s e s s m e n t i m p r o v e d m o r e i n l o w d o s e t r a n s -G O S v e r s u s p l a c e b o (P <0.05)b u t n o t f o r h i g h d o s e v e r s u s p l a c e b o H i g h

B D A ,B r i t i s h D i e t e t i c A s s o c i a t i o n ;

C O ,c r o s s -o v e r ;

D B ,d o u b l e -b l i n d ;F O D M A P ,f e r m e n t a b l e o l i g o s a c c h a r i d e s ,d i s a c c h a r i d e s ,m o n o s a c c h a r i d e s a n d p o l y o l s ;I B S ,i r r i t a b l e b o w e l s y n d r o m e ;I B S -C ,I B S –c o n s t i p a t i o n -p r e d o m i n a n t ;I B S -D ,I B S –d i a r r h o e a -p r e d o m i n a n t ;I B S -M ,I B S i n v o l v i n g b o t h d i a r r h o e a a n d c o n s t i p a t i o n ;I B S -S S S ,I B S -S y m p t o m S e v e r i t y S c o r e ;I T T ,i n t e n t i o n t o t r e a t ;L G G ,L a c t o b a -c i l l u s r h a m n o s u s G G ;N I C

E ,N a t i o n a l I n s t i t u t e f o r H e a l t h a n d C a r e E x c e l l e n c e ;P P ,p e r p r o t o c o l ;R C T ,r a n d o m i s e d c o n t r o l l e d t r i a l.?L a c t o b a c i l l u s r h a m n o s u s G G (1.291010C

F U i n 2c a p s u l e s d a y –1).?T r a n s -g a l a c t o -o l i g o s a c c h a r i d e p o w d e r ,m a d e f r o m B i ?d o b a c t e r i u m b i ?d u m N C I M D 41171c o n t a i n i n g 22%l a c t o s e m a d e u p w i t h w a t e r a s a b a n a n a o r c h o c o l a t e ?a v o u r e d d r i n k .

a2016The British Dietetic Association Ltd.

Dietary management of IBS guidelines update

Y.A.McKenzie et

al.

https://www.wendangku.net/doc/c2908068.html,