The Low FODMAP Diet in Alleviating Symptoms of Irritable Bowel Syndrome

Amanda Hogan

Metropolitan State University of Denver

Advanced Human Nutrition

LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 2

Abstract

Chronic functional bowel disorders, including irritable bowel syndrome (IBS), are

gastrointestinal (GI) disorders that can negatively impact a patients quality of life. The cause of

the condition is not well understood although most patients attribute certain foods as triggers to

their IBS symptoms. As such, a variety of dietary treatment protocols have been prescribed with

varied levels of success and only a limited number of controlled clinical trials supporting these

recommendations (Bhn et al., 2015). There is a growing body of evidence suggesting that short-

chain carbohydrates, which are not well absorbed, play a role in the causation of IBS symptoms.

Recently, a new dietary approach for treating IBS has gained momentum over the last several

years. This new program, coined the low-FODMAP diet, which stands for fermentable

oligosaccharides, monosaccharides, disaccharides and pololys, has shown significant

improvement in IBS symptom relief in as many as 75% of some study participants (Scarlata,

2010). While current evidence supports the use of the FODMAP diet in managing IBS, the

implementation of the diet can be complicated and, therefore, it is recommended that a

Registered Dietitian oversee delivery of the diet protocol.

LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 3

The Low FODMAP Diet in Alleviating Symptoms of Irritable Bowel Syndrome

Chronic functional bowel disorders, including irritable bowel syndrome (IBS), are

gastrointestinal (GI) disorders that negatively impact a patients quality of life. Patients

suffering from IBS often complain of a variety of symptoms including abdominal pain, gas,

bloating, and inconsistent bowel habits such as constipation and/or diarrhea (Khan, Nusrat,

Khan, Nawras, & Bielefeldt, 2014). IBS is more prevalent among women than men and the

condition typically develops before the age of 45 (Irritable Bowel Syndrome (IBS), n.d.).

Despite IBS being one of the most common GI conditions, affecting 10-15% of the U.S.

population (Fedewa & Rao, 2013), little progress has been made in understanding the root cause

of the condition, and the pathophysiology is not entirely understood (Khan et al., 2014). Many

patients report that certain foods such as dairy or grains will trigger their IBS symptoms, and

among the medical community, food intolerance has long been thought to play a contributing

role in the genesis of [IBS] (Francesca Pasqui, Carolina Poli, Antonio Colecchia, Giovanni

Marasco, & Davide Festi, 2015, p. 321).

Carbohydrates, especially short-chain carbohydrates, have been at the source of

recommended dietary modifications for alleviation of IBS symptoms (Shepherd, Lomer, &

Gibson, 2013) as they vary in their level of digestibility. There is increasing evidence suggesting

the elimination of foods from the diet containing certain short-chain carbohydrates may yield

considerable symptom relief among those affected by IBS. This theory prompted the

development of an innovative new dietary approach called the low-FODMAP diet, which

isolates IBS trigger foods and eliminates them from the diet through a two-step approach, best

managed under the care of Registered Dietitian (Whigham et al., 2015). This paper will review

the individual, social, and economic burden of functional GI disorders, specifically IBS, the role
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 4

of FODMAPs for the treatment of this condition, and best practices, through consultation with a

Registered Dietitian, for treating IBS using a low-FODMAP diet approach.

There are many diseases and conditions that can affect the GI tract. The two most

common include inflammatory bowel disease (IBD) and IBS (Michael Kerr & Kristeen Cherney,

n.d.). Many people confuse these very distinct disorders because symptoms, such as abdominal

pain, cramps, gas, bloating and irregular bowel function, are common in both conditions.

IBD is blanket term that refers to chronic intestinal inflammation (swelling) which

primarily presents itself in the form of Crohns disease, ulcerative colitis, and indeterminate

colitis (Michael Kerr & Kristeen Cherney, n.d.). These diseases cause long-lasting inflammation

to the lining of the digestive tract which can lead to the development of ulcers as seen with

ulcerative colitis, or the inflammation can spread deep into the tissues of the large and small

intestine causing severe diarrhea, fatigue, weight loss and malnutrition (Mayo Clinic Staff,

2014), not to mention a tremendous amount of abdominal pain and discomfort (Mayo Clinic

Staff, 2015).

Unlike IBD, IBS is not categorized as an actual disease. Instead, IBS is referred to as a

functional disorder, meaning the condition impairs the bodys normal digestive processes, yet

the cause of the symptoms can not be identified (Kennedy, Cryan, Dinan, & Clarke, 2014). Of

all the GI disorders, IBS is the most common and it has been estimated to affect between 10-15%

of the population (Bhn et al., 2015). Among severe cases, IBS can be extremely debilitating,

causing limitations to a persons health-related quality of life (HRQOL), which speaks to the

psychological, social, and physical consequences associated with a particular disease (Gilkin

Jr, 2005, p. 1698). Some reports suggest that IBS symptoms are the second most common

reason people request sick days from school or work, and others attribute their IBS symptoms as
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 5

a chief reason they choose not to eat out or travel (Low FODMAP Diet For Irritable Bowel

Syndrome - Medibank be. magazine, 2104).

In addition to individual inconvenience and discomfort associated with IBS, there is a

substantial economic burden to society as well. After taking into consideration productivity loss,

absenteeism at work, and heath-related costs, the impact on society as a whole is staggering. A

study released in 1998 estimated that global healthcare costs associated with IBS among the 8

most industrialized nations would reach $41 billion by year 2000 (Gilkin Jr, 2005). A more

recent study, released in 2005, examined IBS-related costs in the US and Canada and estimated

$1.35 billion can be attributed to direct IBS costs (e.g. hospitalization, emergency department

visit, physician office visit, prescription medication). Furthermore, another $205 million for

indirect costs (time away from paid labor), is attributed to IBS each year (Gilkin Jr, 2005).

Given that only about 15% of patients seek medical attention for treatment of their IBS

symptoms (Khan et al., 2014) these numbers are likely underestimated.

It comes as no surprise, therefore, that frustrations are common among individuals suffering

from IBS. Patients seek concrete explanations to the source of their IBS symptoms and, more

importantly, an effective treatment protocol. Unfortunately, researchers and the medical

community remain unclear to the cause of IBS and debate the best treatment solutions (Kennedy

et al., 2014). Over the years, several theories have been presented to explain the source of IBS

symptoms. Some common theories include irregular GI motility (movement), altered brain-gut

communication and psychological issues (Hungin et al., 2015). Genetics, environmental factors,

inflammation, infections, and bacterial overgrowth may also play a role (Podovei & Kuo, 2006).

Furthermore, approximately 60% of IBS patients regard certain foods to be triggers of their

IBS symptoms (Marsh, Eslick, & Eslick, 2016). Most notably, dairy products, wheat products,
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 6

certain vegetables and legumes, caffeine, hot spices, and fried and smoked foods have been

regarded by patients as possible triggers for IBS flair-ups (El-Salhy & Gundersen, 2015). Based

on the frequency of patient-reported associations between food intake and worsening IBS

symptoms, food intolerance has been considered to be an important factor in IBS causation. As

such, many different dietary approaches have been suggested over the years despite only a

handful of controlled clinical trials supporting these recommendations (Bhn et al., 2015). In

fact, current recommendations --psychotherapy/behavioral therapy, bulking agents,

antidiarrheals, anti-spasmodics, and tricyclic antidepressants (Gilkin Jr, 2005, p. 1696)--are not

based on evidence from controlled clinical trials (Bhn et al., 2015), but rather on observational

data with unclear effectiveness (Shepherd et al., 2013). Elimination-style diets that focus on

removing specific food triggers such as wheat, dairy, caffeine and fructose, have had anecdotal

success (Marsh et al., 2016), however, few have been supported with scientific validity, due in

part to the difficulties of conducting dietary trials (Marsh et al., 2016).

Over the past several decades, there is a growing body of evidence suggesting a link

between carbohydrates and IBS symptoms [because certain] short-chain carbohydrates are

poorly absorbed in the small intestine, highly osmotic, and rapidly fermented by bacteria in the

gut, which can lead to increased gas, distention, bloating, cramping, and diarrheaall symptoms

of IBS (Marcason, 2012). Collectively these short-chain carbs are referred to as fermentable,

oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs), and are the basis for

an innovative new dietary approach for treating IBS symptoms.

The term FODMAP was first coined by an Australian Dietitian who noticed a reduction

in IBS symptoms among her patients following a diet low some short-chain carbohydrates

(lactose, fructose, fructans). Her initial research, a 2005 retrospective observational study of 62
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 7

patients with IBS-like symptoms, demonstrated that 74% of patients reported symptom

improvement when following the low-FODMAP dietary program. To verify these observational

findings, a double-blinded, randomized quadruple arm, placebo controlled re-challenge trial was

conducted in 2008, which found that all patients improved on a low-fructose/fructants regimen,

confirming the efficacy of the diet (Barrett, 2013). Next, a 2011 study examined the efficacy the

low-FODMAP diet in the management of IBS symptoms against standard dietary interventions

that were considered to be best practice in the UK at the time, and found the low-FODMAP

dietary approach when implementedbytraineddietitians[was]moresuccessfulinimproving

compositesymptomsandthatpatientsatisfactionwithsymptoms[was]alsogreater

(Staudacher,Whelan,Irving,&Lomer,2011).Sincetheseinitialstudies,theFODMAPs

approachhasexpandedtoincludeGOS,sorbitolandmannitol,inadditiontofructose,lactose

andfructants,andtogethertheseshortchaincarbohydratesmakeupthelowFODMAPsdietasit

standstoday(Barrett,2013).

To understand why these short-chain carbohydrates lead to absorption and digestion

issues, its helpful to examine their chemical structure. Carbohydrates, made up of carbon,

hydrogen, and oxygen molecules are arranged into small units called sugars, or

monosaccharaides (A New Way to Look at Carbohydrates, n.d.). These small carbohydrate

units are the building blocks of many foods that are regularly consumed including fruits,

vegetables, grains and legumes (Shepherd et al., 2013), and comprise about 40 45 % of the

energy to the body (A New Way to Look at Carbohydrates, n.d.). Carbohydrates are classified

according to the type of bond that exist between conjoining molecules - either or , and the

number of units linked together by the aforementioned bonds (Shepherd et al., 2013, p. 707).

Some carbohydrates are very small, consisting of only one sugar unit (monosaccharaides) or two
 LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 8

sugar units (disaccharides) while some carbohydrate compounds are quite large

(polysaccharides) and range from ten up to as many as several hundred sugar units linked

together. Oligosaccharides are a type of carbohydrate molecule with a size in-between

monosaccharides and polysaccharides, and consist of two to ten molecules bonded together. The

type of bond and length of chain is important because it impacts absorption and digestibility.

Those that are poorly absorbed in the small intestine pass through to the large intestine increasing

water volume and are rapidly fermented by bacteria resulting in gas production. These poorly

absorbed short-chain carbohydrates include (oligo-) saccharide polymers of fructose (fructans)

and galactose (galactans), disaccharides (lactose), monosaccharies (fructose), and sugar alcohols

(polys) such as sorbitor, mannitol, xylitol and maltitol) (FODMAP, 2016).

Table1.CharacteristicsandsourcesofcommonFODMAPs

F Fermentable Bycolonicbacteria

Wheat,barley,rye,onion,leek,whitepartofspringonion,
Fructans,galactooli Noabsorption(nosmall
O Oligosaccharides garlic,shallots,artichokes,beetroot,fennel,peas,chicory,
gosaccharides intestinalhydrolyzes)
pistachio,cashews,legumes,lentils,andchickpeas

Digestion,therefore
D Disaccharides Lactose Milk,custard,icecream,andyoghurt
absorptionin1095%

Freefructose(fructose Slow,activeabsorption Apples,pears,mangoes,cherries,watermelon,asparagus,sugar

M Monosaccharides
inexcessofglucose) poorin~1in3 snappeas,honey,highfructosecornsyrup,

A And

Apples,pears,apricots,cherries,nectarines,peaches,plums,
Sorbitol,mannitol,
P Polyols Slowpassiveabsorption watermelon,mushrooms,cauliflower,artificiallysweetened
maltitol,andxylitol
chewinggumandconfectionery.

FODMAP,fermentableoligosaccharides,disaccharides,monosaccharidesandpolyols.

Table source: (Shepherd et al., 2013)

LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 9

Oligosaccharides are fructans (fructo-oliogaccharides or FOS) and galacto-oligosaccharides

(GOS) (Marcason, 2012, p. 1696), which are unable to be digested because humans do not

possess the enzymes required to break them down; therefore, they are not absorbed in the small

intestine. For individuals suffering from IBS, this can be problematic. As seen in Table 1,

common foods in this category include certain wheat products, vegetables, nuts, and legumes

(Shepherd et al., 2013). Inulins, a group of naturally occurring polysaccharides found in many

plants foods (Inulin, 2016) and FOS added to processed foods should also be avoided

(Marcason, 2012, p. 1696).

Pololys are sugar alcohols whose absorption across the intestinal barrier is both incomplete and

slow. Of all polyols consumed, only about one third is actually absorbed (Marcason, 2012).

Common foods in this group include fruits, fungi, brassica vegetables, and artificial sweatners

(Shepherd et al., 2013).

Freefructoseismonosaccharidethatisrapidlyabsorbedanddoesnotrequiredigestion.

Interestingly,whentheamountoffructoseexceedsthatofglucose,analternativeabsorption

mechanismensues.Inhealthyindividuals,thisalternativeabsorptionmethodoccursseamlessly,

however,forsome,therouteisimpairedwhichleadstofructosemalabsorption(Marcason,

2012).Commonfoodsincludestonefruits,certainvegetablesandsimplesugars(Shepherdetal.,

2013).

Lactoseadisaccharide,alsorequiresnodigestion.Lactoseonlypresentsabsorptionissues

whenthereisaninadequateleveloflactase(theenzymeneededforlactoseabsorptiontooccur),

whichcanbeinfluencedbyavarietyoffactorssuchasgenetics,gutdisorders,andethnicity.

PopulationsmostproneareAsian,AfricanAmerican,Hispanic,NativeAmerica,AlaskaNative,
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 10

andPacificIslanderpopulations(Marcason,2012).Commonfoodsinthisgrouparemilkand

milkproducts(Shepherdetal.,2013).

ItsimportanttonotethatnotallFODMAPswilltriggersymptomsineverypatient;only

thosethataremalabsrobedarebelievedtobeacontributingfactor.Evenamonghealthy

individuals,certainshortchaincarbohydrates,namelyfructantsandGOS,arealways

malabsrobedandthereforearefermentedbythegutmicroflora;resultingingasproductionand

associatedflatulence.Problemsarise,however,whenthegutfloraiscompromised,assuspected

inindividualswithIBS,causingintestinalmotilityissuesandguthypersensitivity(Ongetal.,

2010).TheotherFODMAPcarbohydrates(lactose,freefructose,sorbitol,mannitol,malitol,

xylitol)onlyinducesymptomsamongpatientswhoarenotabletoproperlyabsorbthem,and

newtechnologiessuchashydrogenbreathtestingprovidesareliabletooltomeasurethe

absorption(orlackthereof)ofagiventestsugar.Thosethataremalabsorbedresultinarisein

breathhydrogenwhilethosethatarecompletelyabsorbedresultinanegativebreathtest.

BecauseGOSandfructantsarealwaysmalabsorbed,theyarenotbreathtested,andshould

alwaysbeconsideredtriggersinallpatientswithIBS.Manitolisnotconsumedaspartofa

typicaldietsomalabsorbtionistypicallytestedusingelimination/rechallengeapproaches

insteadofbreathtesting(Barrett,2013).

Asindicated by numerous research studies, the low-FODMAP diet has promise to be an

effective strategy for combating undesirable IBS symptoms. However, given the complexities

and individuality of IBS triggers, the low-FODMAP diet can be complicated and confusing to

implement for many individuals.Therefore, its recommended that the low-FODMAP diet be

implemented under the management of a qualified healthcare provider. Kate Scarlata, a Boston-
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 11

based Registered Dietitian and author of The Complete Guide to Eating Well with IBS, suggests

that because The low FODMAP diet is a specialized diet[it] is best implemented by a

registered dietitian knowledgeable in the diet specifics to provide the most accurate information

about the diet and ensure that your diet is nutritionally balanced (Kate Scarlata, 2012).

Current recommendations include implementing the diet using a two-step process. First, the

patient adheres to an elimination phase, which involves removing all FODMAP foods from the

diet for a two to eight week period (or until symptom relief occurs), followed by a

reintroduction phase that introduces each FODMAP food back into the diet one by one (Riggs,

2014). If the patient experiences a recurrence of IBS symptoms upon reintroduction of a certain

food, that food should be avoided completely as it is likely an IBS symptom trigger. Given that

the elimination phase removes a lot of foods from the diet, its vital that the Registered Dietitian

educate the patients on adequate food substitutions (see Table 2) and encourage the patients to

eat a variety of low-FODMAP foods to avoid any nutrient deficiencies (Riggs, 2014).

While the low-FODMAP diet may feel very restricting to patients, especially in the

beginning, its helpful for patients to realize that the diet is not designed to be everlasting. As

Riggs points out, the low-FODMAP approach is not a regimented avoidance diet, where

patients must forever avoid all high-FODMAP foods to find relief. Rather, this diet tests the

patient's tolerance to many high-FODMAP foods, allowing the patient to target which specific

foods cause IBS symptoms and, thus, eliminate those particular foods from the diet (Riggs,

2014, p. 309). Along with dietary education, Registered Dietitians can also play a central role in

providing organizational support using tools like a food/symptom diary prior to the rechallenge

phase to help patients track foods that may cause IBS flairs. Furthermore, Registered Dietitians
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 12

are qualified healthcare professionals trained in providing emotional support when implanting

dietary programs.

Table 2

Table Source: (Monash University.webmed, n.d.)

Functional GI disorders, especially IBS, are conditions that negatively impact individuals

across the globe, causing symptoms such as diarrhea, constipation, abdominal pain, bloating, and

gas. Traditional dietary approaches have yielded mixed but mainly unsatisfactory results (Santos

& Whorwell, 2014). The low-FODMAP diet has been shown to be an effective strategy for

identifying food-related triggers and reducing symptoms in many individuals. While a low-

FODMAP diet does not cure IBS, it can be an effective strategy for controlling symptoms,

especially when administered under the supervision of a knowledgeable Registered Dietitian.

LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 13

References

A New Way to Look at Carbohydrates. (n.d.). Retrieved April 5, 2016, from

http://www.whfoods.com/genpage.php?tname=george&dbid=115

Barrett, J. S. (2013). Extending Our Knowledge of Fermentable, Short-Chain Carbohydrates for

Managing Gastrointestinal Symptoms. Nutrition in Clinical Practice, 28(3), 300306.

http://doi.org/10.1177/0884533613485790

Bhn, L., Strsrud, S., Liljebo, T., Collin, L., Lindfors, P., Trnblom, H., & Simrn, M. (2015).

Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome as Well as

Traditional Dietary Advice: A Randomized Controlled Trial. Gastroenterology, 149(6),

13991407.e2. http://doi.org/10.1053/j.gastro.2015.07.054

El-Salhy, M., & Gundersen, D. (2015). Diet in irritable bowel syndrome. Nutrition Journal,

14(1), 3646. http://doi.org/10.1186/s12937-015-0022-3

Fedewa, A., & Rao, S. S. C. (2013). Dietary Fructose Intolerance, Fructan Intolerance and

FODMAPs. Current Gastroenterology Reports, 16(1), 18.

http://doi.org/10.1007/s11894-013-0370-0

FODMAP. (2016, March 29). In Wikipedia, the free encyclopedia. Retrieved from

https://en.wikipedia.org/w/index.php?title=FODMAP&oldid=712498359

Francesca Pasqui, Carolina Poli, Antonio Colecchia, Giovanni Marasco, & Davide Festi. (2015).

Adverse food reaction and functional gastrointestinal disorders: role of the dietetic
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 14

approach. Journal of Gastrointestinal and Liver Diseases, 24(3).

http://doi.org/10.15403/jgld.2014.1121.243.paq

Gilkin Jr, R. J. (2005). The spectrum of irritable bowel syndrome: A clinical review. Clinical

Therapeutics, 27(11), 16961709. http://doi.org/10.1016/j.clinthera.2005.11.012

Hungin, A. P. S., Becher, A., Cayley, B., Heidelbaugh, J. J., Muris, J. W. M., Rubin, G., De

Wit, N. J. (2015). Irritable bowel syndrome: an integrated explanatory model for clinical

practice. Neurogastroenterology & Motility, 27(6), 750763.

http://doi.org/10.1111/nmo.12524

Inulin. (2016, April 7). In Wikipedia, the free encyclopedia. Retrieved from

https://en.wikipedia.org/w/index.php?title=Inulin&oldid=714061538

Irritable Bowel Syndrome (IBS). (n.d.). Retrieved April 1, 2016, from

https://www.innerbody.com/diseases-conditions/ibs

Kate Scarlata, G. B. (2012, November 9). Got IBS? Try the Low FODMAP Diet | Fooducate.

Retrieved from http://blog.fooducate.com/2012/11/09/got-ibs-try-the-low-fodmap-diet/

Kennedy, P. J., Cryan, J. F., Dinan, T. G., & Clarke, G. (2014). Irritable bowel syndrome: A

microbiome-gut-brain axis disorder? World Journal of Gastroenterology: WJG, 20(39),

1410514125. http://doi.org/10.3748/wjg.v20.i39.14105

Khan, M. A., Nusrat, S., Khan, M. I., Nawras, A., & Bielefeldt, K. (2014). Low-FODMAP Diet

for Irritable Bowel Syndrome: Is It Ready for Prime Time? Digestive Diseases and

Sciences, 60(5), 11691177. http://doi.org/10.1007/s10620-014-3436-4

Low FODMAP Diet For Irritable Bowel Syndrome - Medibank be. magazine. (2104, June 24).

Retrieved April 9, 2016, from https://www.medibank.com.au/bemagazine/post/food/low-

fodmap-diet-for-irritable-bowel-syndrome/
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 15

Marcason, W. (2012). What Is the FODMAP Diet? Journal of the Academy of Nutrition and

Dietetics, 112(10), 1696. http://doi.org/10.1016/j.jand.2012.08.005

Marsh, A., Eslick, E. M., & Eslick, G. D. (2016). Does a diet low in FODMAPs reduce

symptoms associated with functional gastrointestinal disorders? A comprehensive

systematic review and meta-analysis. European Journal of Nutrition, 55(3), 897906.

http://doi.org/10.1007/s00394-015-0922-1

Mayo Clinic Staff. (2014, August 13). Crohns disease - Mayo Clinic. Retrieved April 6, 2016,

from http://www.mayoclinic.org/diseases-conditions/crohns-

disease/basics/definition/con-20032061

Mayo Clinic Staff. (2015, February 18). Inflammatory bowel disease (IBD) - Mayo Clinic.

Retrieved April 6, 2016, from http://www.mayoclinic.org/diseases-

conditions/inflammatory-bowel-disease/basics/definition/con-20034908

Michael Kerr, & Kristeen Cherney. (n.d.). Irritable Bowel Syndrome vs. Inflammatory Bowel

Disease. Retrieved April 6, 2016, from http://www.healthline.com/health/crohns-

disease/ibs-vs-ibd

Ong, D. K., Mitchell, S. B., Barrett, J. S., Shepherd, S. J., Irving, P. M., Biesiekierski, J. R.,

Muir, J. G. (2010). Manipulation of dietary short chain carbohydrates alters the pattern of

gas production and genesis of symptoms in irritable bowel syndrome. Journal of

Gastroenterology & Hepatology, 25(8), 13661373. http://doi.org/10.1111/j.1440-

1746.2010.06370.x

Podovei, M., & Kuo, B. (2006, November). Irritable bowel syndrome: a practical review.

Southern Medical Journal, 99(11), 1235+.

LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 16

Riggs, S. (2014). The Low-FODMAP Diet: An Approach for Controlling Irritable Bowel

Syndrome. Topics in Clinical Nutrition, 29(4), 304312.

http://doi.org/10.1097/TIN.0000000000000015

Santos, A. R., & Whorwell, P. J. (2014). Irritable bowel syndrome: the problem and the problem

of treating it - is there a role for probiotics? The Proceedings of the Nutrition Society,

73(4), 470476. http://doi.org/10.1017/S0029665114000706

Scarlata, K. (2010, August). The FODMAPs Approach Minimize Consumption of

Fermentable Carbs to Manage Functional Gut Disorder Symptoms. Todays Dietitian,

12(8), 30.

Shepherd, S. J., Lomer, M. C. E., & Gibson, P. R. (2013). Short-Chain Carbohydrates and

Functional Gastrointestinal Disorders. The American Journal of Gastroenterology,

108(5), 707717. http://doi.org/10.1038/ajg.2013.96

Staudacher, H. M., Whelan, K., Irving, P. M., & Lomer, M. C. E. (2011). Comparison of

symptom response following advice for a diet low in fermentable carbohydrates

(FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome.

Journal of Human Nutrition and Dietetics, 24(5), 487495. http://doi.org/10.1111/j.1365-

277X.2011.01162.x

webmed. (n.d.). The Monash University Low FODMAP diet. Retrieved April 13, 2016, from

http://www.med.monash.edu/cecs/gastro/fodmap/low-high.html

Whigham, L., Joyce, T., Harper, G., Irving, P. M., Staudacher, H. M., Whelan, K., & Lomer, M.

C. E. (2015). Clinical effectiveness and economic costs of group versus one-to-one

education for short-chain fermentable carbohydrate restriction (low FODMAP diet) in the
LOW-FODMAP DIET IN THE ALLEVIATION OF IBS SYMPTOMS 17

management of irritable bowel syndrome. Journal of Human Nutrition and Dietetics,

28(6), 687696. http://doi.org/10.1111/jhn.12318