Review Article 1

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Influence of Dietary Restriction on Irritable Bowel

Review Article
Syndrome
Afrin Kamal, MD1 and Mark Pimentel, MD, FRCP(C)2

Up to two-thirds of patients with IBS attribute their gastrointestinal symptoms to food. The therapeutic focus of IBS
has been to alleviate gastrointestinal symptoms, approached by pharmaceutical and non-pharmaceutical treatments.
Although the most traditional approach has involved the use of medications such as bulking agents, anticholinergics,
antispasmodics, and antidiarrheals, unfortunately these are only modestly effective and patients are left with a small
menu of successful pharmacologic agents. These treatments, however, are not always enough to alleviate symptoms.
Alternative approaches have therefore been tried, including dietary manipulation. This article aims to review dietary
restrictions as a non-pharmaceutical management approach for IBS, covering literature on various dietary triggers and
the impact of dietary manipulation on gastrointestinal symptoms.
Am J Gastroenterol https://doi.org/10.1038/s41395-018-0241-2

Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI)
disorder that classically presents with symptoms of abdominal
pain, bloating, and altered bowel habits of diarrhea or consti-
pation. IBS affects ~11% of the population globally [1], with an
increased prevalence in young individuals and females [2]. Cur-
rently the diagnosis of IBS relies on the fourth version of the cri-
teria set by the Rome Foundation, encompassing symptoms of
recurrent abdominal pain and changes in stool frequency and
form, in the setting of absent alarm features or structural abnor-
malities [3–5]. Based on predominant bowel habits, IBS is further
classified into one of four subtypes: constipation-predominant
(IBS-C), diarrhea-predominant (IBS-D), predominant irregu-
lar (mixed diarrhea/constipation) bowel habits (IBS-M), and
unspecified (IBS-U) [6]. What causes these symptoms, how-
ever, is unknown. Proposed pathophysiologies for IBS include
heightened pain sensitivity or visceral hypersensitivity, abnormal
gut motility, low-grade intestinal inflammation, post-infectious
enteritis, and abnormalities in the gut–brain axis [7–9].
The therapeutic focus of IBS has been to alleviate gastrointesti-
nal symptoms, approached by two methods: pharmaceutical and
non-pharmaceutical treatments. The most traditional approach
to treating IBS has involved the use of medications such as bulk-
ing agents, anticholinergics, antispasmodics, and antidiarrheals
in efforts to specifically target gastrointestinal symptoms. How-
ever, these are only modestly effective and patients fortunately
now have a small menu of successful pharmacological treat-
ments meeting new and more objective benchmarks for US Food
and Drug Administration (FDA) approval [10]. For IBS-C these
include lubiprostone [11] and linaclotide [12] and for IBS-D,
rifaximin [13, 14] and eluxadoline [15]. For severe cases of IBS-D
in women who have failed other therapies, alosetron [16, 17]
may also be used.
Unfortunately, pharmaceutical treatments alone are not always
enough to provide adequate symptom relief [18]. In such cases,
alternative approaches are tried. Examples of these include cog-
nitive-behavioral therapy, hypnotherapy, exercise, and more com-
monly dietary manipulation [7]. The use of dietary control in IBS
management reflects the 84% of patients who attribute their symp-
toms to dietary intake. Therefore, a rising trend has been to restrict
specific foods in an effort to minimize post-prandial symptoms
[19]. This article aims to review dietary restrictions as a non-phar-
maceutical management approach for IBS, covering literature on
various dietary triggers and the impact of dietary manipulation on
gastrointestinal symptoms.
Gluten Restriction
Up to two-thirds of patients with IBS attribute their gastrointes-
tinal symptoms to food [20]. Many food components have been
proposed as contributing toward IBS symptoms, gluten being one.
Symptoms of long-standing abdominal pain and altered bowel
habits, although characteristic of IBS, are not specific for the dis-
order. A similar symptom pattern can be seen in celiac disease
and non-celiac gluten sensitivity (NCGS), two disorders charac-
terized by their intolerance to gluten, or grains that encompass
wheat, barley, rye, or triticale. Celiac disease describes a chronic
immune-mediated enteropathy instigated by the exposure to
dietary gluten in predisposed individuals carrying the genotype
HLA-DQ2 or HLA-DQ8. In these individuals, exposure to gluten
can cause symptoms of abdominal pain, bloating, diarrhea, and

1
Department of Gastroenterology and Hepatology, Digestive Diseases and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA. 2Department of
Gastroenterology and Hepatology, Digestive Diseases Center, Cedars-Sinai, Los Angeles, CA, USA. Correspondence: M.P. (email: Mark.Pimentel@cshs.org)
Received 27 February 2018; accepted 18 July 2018

© 2018 The American College of Gastroenterology The American Journal of Gastroenterology

 2 A. Kamal, M. Pimentel
constipation [21]. Whereas celiac disease is the result of dietary
gluten exposure in genetically susceptible hosts, in contrast,
NCGS refers to individuals with signs, symptoms, or extra-intes-
tinal manifestations related to gluten intake or wheat proteins in
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the absence of known immune-mediated injury or genetic bio-
markers. Due to this lack of specificity, NCGS is suspected when
individuals present with diarrhea, bloating, flatulence, and/or
abdominal discomfort as well as extra-intestinal symptoms, with
subsequent symptom improvement after gluten cessation in the
setting of a negative work up for celiac disease [21–24]. Consider-
Review
ing both celiac disease and NCGS present with gastrointestinal
symptoms paralleling IBS, and ~5% of patients with IBS have con-
firmed celiac disease [24], the question arises - is there a role for
gluten-free diet as a means for IBS management?
Biesiekierski et al. measured this association in a double-blind,
randomized, placebo-controlled trial. After excluding individu-
als with celiac disease, authors designated IBS patients to receive
either placebo or gluten in the form of two bread slices and one
muffin daily for up to 6 weeks. Of the 19 patients in the gluten arm,
13 (68%) reported uncontrolled symptoms, in comparison to 6 of
15 (40%) in the placebo arm (p = 0.001). Patients exposed to glu-
ten complained of worsening pain, bloating, satisfaction with stool
consistency, and tiredness within 1 week of gluten exposure [25].
Further comparison of a 4-week trial of gluten-free diet (GFD)
to a gluten-containing diet (GCD) was performed by Vazquez-
Roque et al. Patients meeting the Rome II criteria for IBS-D and
with genotype analyses for HLA-DQ2 and HLA-DQ8 underwent
a 14-day baseline and 28-day study period. Patients recorded daily
bowel patterns including ease of passage, completeness of evacua-
tion, and date and timing of each bowel movement; while authors
measured gastric, small bowel, and colonic transit by scintigraphy,
and small bowel and colonic mucosal morphology and perme-
ability using hematoxylin and eosin (H&E) stained sections from
biopsy specimens. Following the 4-week diet intervention, authors
identified an increase in stool frequency among subjects with posi-
tive HLA-DQ2/DQ8 who were exposed to gluten. Subjects on a
GCD experienced more frequent bowel movements (p = 0.04) and
higher small bowel permeability, particularly among HLA-DQ2/
DQ8 positive subjects [26].
Despite the above-described study, there is controversy as to
the potential of gluten-free diets in managing IBS symptoms. This
stems from a double-blind, cross-over trial which tested gluten
in combination with a reduced intake of fermentable oligo-, di-,
mono-saccharides, and polyols, referred to as a low FODMAP
diet. IBS subjects were randomly assigned to a reduced FODMAP
diet plus high-gluten (16 g gluten/day), low gluten (2 g gluten/day
and 14 g whey protein/day) or control (16 g whey protein/day) for
two weeks, followed by a two-week washout period. Subsequently,
twenty-two subjects crossed over and were given either gluten
(16 g/day), whey (16 g/day), or control for 3 days. At study conclu-
sion, all participants improved with a reduced FODMAP diet, and
experienced significant worsening of symptoms with the introduc-
tion of gluten or whey protein. Gluten-specific symptoms, how-
ever, were reproduced only in 8% [27]. This study suggested the
carbohydrate component of fructans, wheat, and galacto-oligosac-
charides may be responsible for IBS symptoms, and not specifically
The American Journal of Gastroenterology
gluten [7]. Fructans being a possible cause of symptoms was seen
in a randomized, double-blind, placebo-controlled, cross-over
study aiming to assess effects of gluten and fructan on gastrointes-
tinal symptoms in patients with self-reported non-celiac sensitivity
by Skodje et al. Following exclusion of celiac disease by negative
duodenal biopsies on gluten-free diet or lack of HLA-DQ2 and
HLA-DQ8 genetic markers, individuals were challenged with a
seven-day diet rich in gluten (5.7 g), fructans (2.1 g), or placebo,
followed by a washout period, and crossed over into another diet
group. The study was complete when subjects had been chal-
lenged with all three diets. The authors measured gastrointestinal
symptoms using the Gastrointestinal Symptom Rating Scale, IBS-
version (GSRS-IBS) and among the 59 patients challenged, results
demonstrated a significantly higher symptom score after fructan
intake (p = 0.049) than after gluten [28].
Furthermore, when reviewing the structure of a gluten-free diet,
a common factor to note is the removal of foods composed of
wheat, barley, rye, and triticale. Therefore, foods that are allowed
due to their natural gluten-free properties include beans, eggs,
fresh meats, fish, and poultry, in addition to fruits, vegetables,
and most dairy products [29]. What one will notice is the limited
carbohydrates allowed, as unfortunately wheat is a common grain
used in the production of breads, pastas, and baked goods [30].
Due to this limitation in carbohydrates, the effects of a very low-
carbohydrate diet (VLCD) emerged as a possible explanation for
IBS symptom improvements, rather than the removal of gluten
from the diet. VLCD has received significant attention as means of
weight loss and consists of <20–50 g/day of carbohydrates paired
with a high fat or high protein diet [31], more commonly referred
as a ketogenic diet [32]. This has proven effective in weight loss
therapy and reducing cardiovascular risk factors [33]. Austin et
al. prospectively assessed this diet in IBS management, evaluat-
ing relief of stool frequency and abdominal pain in 13 out of 17
enrolled patients meeting Rome II criteria for IBS-D. After initially
placing subjects on a standard diet (55% calories from carbohy-
drates, 30% from fat, and 15% from protein) for 2 weeks, followed
by a VLCD limited to 20 grams per day (51% calories from fat,
45% from protein, and 4% from carbohydrates), authors noted 10
(77%) patients described adequate relief in stool frequency and
abdominal pain after all four weeks [34]. Looking further into
carbohydrate intake, specifically absorption capacity, Goldstein et
al. measured differences in absorption of lactose (18 g), fructose
(25 g), and mixture of fructose (25 g) plus sorbitol (5 g) between
94 patients meeting Rome criteria for IBS and 145 patients defined
as functional. Following administration of carbohydrate solutions
weekly, hydrogen and methane breath tests were performed. All
individuals were subsequently maintained on a 1-month restricted
diet lacking all tested sugars. Authors revealed only 7% of IBS
patients absorbed all three sugars normally compared to non-IBS
patients, with a frequency of lactose malabsorption at 16% vs. 12%,
respectively. Following dietary restriction, 56% of IBS patients
experienced marked symptom improvement (p < 0.01) [35]. These
study indicated that when carbohydrates are limited, whether due
to the limitation of wheat or sugars, patients with IBS demon-
strate improvement in symptoms. Together, these studies suggest
that although gluten can be thought of as contributing to IBS-like
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symptoms, when considering carbohydrates, we may be looking
entirely in the wrong direction?
Lactose Restriction
Lactose is an importance source of calories from all mammalian
milk, with the exception of sea lions [36]. To appropriately absorb
lactose, humans require the enzyme lactase-phlorizin hydrolase
(LPH), located in the brush-borders of the small intestine. This
enzyme, more simply referred to as lactase, functions by hydro-
lyzing the disaccharide lactose into the monosaccharides glu-
cose and galactose, facilitating intestinal absorption. When this
enzyme becomes deficient, however, the end result is lactose mal-
absorption [37].
Humans experience a rise in lactase activity starting at week
eight of gestation and increasing until week 34, with its expres-
sion peaking at birth. In up to two-thirds of the world’s popula-
tion, however, this activity decreases following first months of life
[36]. This decline in activity occurs by down-regulating lactase
expression, referred to as primary lactase deficiency. Conversely
secondary lactase deficiency, or acquired hypolactasia, refers to the
decrease in lactase activity after injury to the small bowel mucosal
brush border. This can be seen following a gastrointestinal viral
or non-viral infection, after abdominal surgery, or secondary to
a diagnosis of inflammatory bowel disease (IBD). Contrary to
individuals with primary deficiency, those with secondary lactase
deficiency can experience a drop in enzyme activity at any age and
have the potential to restore this activity following elimination of
the underlying disorder [38].
When lactase is deficient, the milk sugar fails to be absorbed
by the proximal small bowel and continues into the distal small
bowel and colon. Unabsorbed lactose is subsequently fermented
by colonic bacteria producing short chain fatty acids (SCFA) and
gas, mainly hydrogen (H2), carbon dioxide (CO2), and methane
(CH4). The non-digested contents additionally lead to an increase
in osmotic load and therefore a rise in intestinal water content.
Together, these changes contribute to symptoms of lactose intoler-
ance including diarrhea, bloating, and abdominal pain [37].
It is easy to recognize that the symptoms of lactose intoler-
ance are similar symptoms to those of IBS, and researchers have
explored whether a relationship between the two disorders exists.
In a Norwegian population of IBS patients, Farup et al. measured
variations in symptoms after intake of milk and lactose, in addition
to the presence of lactose malabsorption, as compared to healthy
volunteers. In the 187 patients [IBS (n = 82) and healthy volun-
teers (n = 105)], the authors noted that despite a high prevalence of
symptoms following milk (p < 0.001) and lactose (p < 0.01) among
IBS patients, the presence of true lactose malabsorption was low
(4.1%) [39]. When considering whether self-reported lactose
intolerance (SLI) predicted findings on lactose hydrogen breath
test, Zheng et al. took a group of patients with lower digestive tract
symptoms and assessed the presence of IBS by Rome III, the pres-
ence of SLI by questionnaires and the presence of lactose malab-
sorption by breath test. The authors revealed that although SLI was
found to be higher among those with IBS than other participants
(p < 0.001), the rise in hydrogen confirming lactose malabsorption
© 2018 The American College of Gastroenterology
influence of Dietary Restriction on irritable Bowel Syndrome 3
was found to be the same in both groups (61% vs. 54% respectively,
p = 0.14) [40]. In essence, IBS patients may more commonly report
lactose intolerance-like symptoms, however these symptoms are
not predictive of true lactose malabsorption.
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In efforts to assess whether IBS symptoms change following a lac-
tose restriction diet, Parker et al. followed 33 patients with known
IBS and lactose intolerance diagnosed by hydrogen breath test
(LHBT) in a double-blind, placebo-controlled challenge. Subjects
followed a lactose-restricted diet for three weeks, and those who
improved were subsequently placed on diets containing 5 g, 10 g,
Review
or 15 g of lactose or placebo. Applying symptom scores following
dietary changes, authors noted only moderate symptom improve-
ment (39%) in patients on a low-lactose diet [41]. Similarly Vernia
et al. designed a prospective trial measuring lactose malabsorption
prevalence in 230 Italian patients with suspected IBS, in addition
to clinical effects of long-term lactose-free diets. Applying hydro-
gen breath tests, 157 patients (68.2%) were identified with lactose
malabsorption. Of the 110 patients compliant with diet restric-
tions, 48 (43.6%) reported symptom cessation, 43 (39%) noted
reduced symptoms, and 17 (15.5%) described unchanged symp-
toms [42]. Prospectively, in a 5-year follow up study quantifying
effects of lactose-restriction in patients with IBS and lactose mal-
absorption, the latter confirmed by hydrogen breath testing and
blood-glucose measurements, Böhmer et al. demonstrated that
at 6 weeks, patients reported marked improvement in symptoms
(p < 0.001). Subsequently at 5 years, the majority continued to
report symptom improvement (88%). Unique to this study was the
author’s ability to express cost and change in number of outpatient
visits as a result of diet restriction. In 16 patients, a mean of 2.4
visits/year/person (range 1–7 visits) was seen before diet initiation,
significantly decreasing at 5 years to a mean of 0.6 visits/year/per-
son (range 0–6 visits). Hence, the authors not only demonstrated
short and long-term GI symptom improvement after following a
lactose-restricted diet, but an additional decline in cost and time
spent on outpatient visits [43].
Although some studies have demonstrated improvement in GI
symptoms with lactose-restriction in IBS, authors have questioned
the accuracy of lactose malabsorption diagnosis following breath
testing. To review, a rise in H2 occurs following colonic fermenta-
tion of unabsorbed lactose. This is excreted into expired air, and is
detectable on breath testing [44]. Therefore hydrogen breath tests
have become a common means to detect lactase deficiency, meas-
ured after ingesting 25 g of lactose mixed with or following one cup
of water and observing a rise of ≥20 parts per million (ppm) from
baseline hydrogen [45].
The difficulty occurs when subjects with IBS have underlying
small intestinal bacterial overgrowth (SIBO), which is present in
>50% of these patients [44]. When the milk sugar is incompletely
digested, it reaches the distal small bowel as lactose residue. In
patients with bacterial overgrowth, the lactose is fermented before
it has time to be broken down and absorbed, resulting in a false
increase in hydrogen on a lactose breath test [45]. This concept that
the presence of bacterial overgrowth can lead to early fermenta-
tion and elevation of exhaled hydrogen was proposed by Pimentel
et al. when observing diarrhea-predominant IBS subjects after a
lactulose breath test and lactose tolerance test. Nineteen subjects
The American Journal of Gastroenterology
 4 A. Kamal, M. Pimentel
underwent an initial lactulose breath test, and within 7 days,
patients returned for a fasting lactose breath test and blood glucose
measurement. The authors demonstrated a significant relationship
between hydrogen production on lactulose and lactose breath test-
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ing (r = 0.56, p = 0.01), suggesting that lactose breath testing in the
IBS population may be reflective of bacterial overgrowth, rather
than a reflector of true lactose malabsorption [46]. This lead to the
consensus that using breath testing to rule out lactose malabsorp-
tion necessitated the need to first rule out SIBO [45].
Review
Low Fructose, Lactose, Fructo- and Galacto-
oligosaccharides and Polyols (FODMAP)
In efforts to define an improved diet therapy for IBS, a global
restriction of fructose, lactose, fructo-, and galacto-oligosaccha-
rides (fructans galactans), and polyols (sorbitol, mannitol, xylitol,
and malitol), termed fermentable oligo-, di-, monosaccharides,
and polyols or “FODMAP” was designed. The logic behind
restricting FODMAPs was two-fold. First, short-chain carbohy-
drates were found to be poorly absorbed in the small intestine,
particularly under conditions of low or absent brush border
enzymes (e.g., lactase) and the presence of low-capacity epithe-
lial transporters. When poorly absorbed, FODMAPs create an
osmotic load and consequently draw fluid into the small intestine,
leading to symptoms of abdominal distention and an increased
colonic delivery of fluid [7]. This physiologic change was dem-
onstrated in a randomized, cross-over, single-blinded interven-
tion study of 12 ileostomates consuming two diets differing in
FODMAP content. By measuring the 14 h ileal effluents on day
4 of each diet, authors demonstrated an increased mean effluent
weight, water content, and dry weight on a high versus low FOD-
MAP diet. These results suggest that FODMAPs augment colonic
delivery of water and fermentable substrates [47].
The second logic behind restricting FODMAPs is the feature of
rapid fermentation of the short-chain carbohydrates by colonic
microbiota, resulting in increased gas production (H2, CO2, and
CH4) and colonic distention. In the setting of underlying gut dys-
motility and visceral sensation, symptoms can manifest as pain,
cramping, and bloating [48, 49]. This hypothesis was tested by
comparing patterns of breath hydrogen and methane with symp-
toms in response to differing diets of FODMAP content. In a sin-
gle-blind, crossover intervention study involving 15 individuals
with IBS and 15 controls, subjects maintained food and symptom
diaries after consuming either a low (9 g/day) or high (50 g/day)
FODMAP diet. Those with IBS consuming high FODMAP diets
produced higher levels of breath hydrogen than healthy volunteers,
suggesting FODMAPs induce increased intestinal fermentation
and hydrogen production in IBS [49].
Subtypes within FODMAP exist based on carbohydrate length,
as seen in Table 1. Oligosaccharides are the longest chain and com-
posed of fructans and galacto-oligosaccharides (GOS). These are
naturally found in wheat, rye products, legumes, nuts, artichokes,
onions, and garlic. As humans we lack enzymes to break down
fructans and GOS (hydrolase), illustrated in Table 1, the higher the
intake, the greater the increase in fermentation and gas produc-
tion. This leads to bloating, abdominal pain, and excessive flatus.
The American Journal of Gastroenterology
Table 1  Carbohydrates based on length composing fermentable
oligosaccharides, disaccharides, monosaccharides, and polyols
(FODMAP)
Oligosaccharides Fructans
galacto-oligosacharides (GOS)
Disaccharides Lactose
Monosaccharides Fructose in excess of glucose
Polyols Sorbitol
Mannitol
Maltitol
Xylitol
Isomalt
FODMAPS partially Fructose
absorbed Lactose
Polyols
FODMAPS incompletely Fructans
absorbed Galacto-oligosaccharides
Disaccharides such as lactose, as mentioned previously, require
lactase activity for absorption. By assessing lactose absorptive
capacity through hydrogen breath testing, individuals can tai-
lor dietary lactose intake. Monosaccharides include fructose, the
smallest chain subtype, found naturally in apples, pears, mango,
watermelon, honey, and a few vegetables including sugar snap
peas. Commercially, fructose is found in sweeteners and corn
syrup. Due to its size, fructose leads to a high osmotic effect, lead-
ing to increased small bowel water content. The larger fructose
load parallels the increased risk of diarrhea and altered intestinal
motility. Lastly, polyols comprise mannitol and sorbitol, naturally
found in apples, pears, cauliflower, mushroom, and snow peas.
Similar to fructose, this group exhibits slow absorption and high
osmotic effects along the small bowel length [50].
Studies exploring the effect of dietary FODMAP restriction in
IBS have generally been positive and support overall improve-
ments GI symptoms. Previous studies suggested restricting lactose
alone, or fructose with or without sorbitol, as a dietary approach
in managing IBS. The latter worked well in patients with fructose
malabsorption. However as mentioned above, fructans are poorly
absorbed in humans due to lack of hydrolase. Prior to the con-
cept of FODMAP, dietary fructan restriction was not standard.
Based on the hypothesis that dietary FODMAP restriction opti-
mized symptom control in IBS, in particular fructans, fructose,
and foods with free fructose exceeding free glucose, Shepherd et
al. measured daily dietary symptoms after graded introduction of
fructose, fructans, alone or in combination, or glucose taken in
drinks, followed by a 10-day washout period. The authors revealed
that symptom triggers in the IBS population included not only
fructose, but also fructans. This was the first evidence suggesting
dietary FODMAP reduction specifically of fructose and fructans,
could lead to symptom improvement [51].
To compare the effects of a reduced FODMAP diet to tradi-
tional dietary advice in IBS such as avoiding larger meals, reduced
fat intake, and reduced excessive fiber and gas-producing foods,
Böhn et al. performed a multi-center, randomized trial comparing
symptoms. The results demonstrated that IBS symptoms severity
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reduced significantly in both dietary groups (p < 0.0001), however
no significant difference was found between the two diets [52]. In
contrast, Eswaran et al. compared a low FODMAP diet to a diet
based upon the modified National Institute for Health and Care
Excellence (mNICE) guidelines in individuals with IBS-D in a
randomized, controlled trial. After 4-weeks of either diet, indi-
viduals reported relief of IBS-D symptoms including change in
abdominal pain and stool consistency based on the Bristol Stool
Form. The authors demonstrated that individuals following a low
FODMAP diet reported greater improvements in abdominal pain,
stool consistency, frequency, and urgency compared to those fol-
lowing the mNICE diet [53]. Furthermore, parallel to the hypoth-
esis that symptoms associated with IBS relate to intraluminal gas
production, Ong et al. sought to measure a similar pattern relating
breath hydrogen and methane to changes in FODMAP content.
In this randomized, single-blinded, crossover intervention study,
the authors compared two FODMAP diets: either low (9 g/day) or
high (50 g/day), between healthy volunteers and subjects with IBS.
Not only was higher breath hydrogen production seen in the high
FODMAP group, but increased gastrointestinal symptoms and
lethargy were also significantly induced among IBS patients [49].
The degree of malabsorption with FODMAPs differs with
each individual, therefore is not considered a “one-size-fits-all”
approach. The recommendation of a restricted FODMAP diet is
short-term, initiating a full elimination for 2–6 weeks with aid of
a licensed dietician. Understanding individuals’ tolerance level to
FODMAPs differ, with tailored dietary counseling foods contain-
ing FODMAPs are gradually re-introduced, arriving at an indi-
vidualized and less restricted “low FODMAP” diet [50]. When
a low FODMAP diet does not work, or demonstrates no clinical
efficacy, it is recommended to transition towards other therapeutic
interventions [54].
Long term implications are to be considered when apply-
ing FODMAPs. The fermentable carbohydrates in FODMAPs
provide substrates for healthy bacteria. Studies have compared
low FODMAP to the traditional IBS diet, revealing a reduction
in proportion and concentration of Bifidobacteria while other
studies have demonstrated a decrease in total bacteria [55, 56].
Additionally, fermentation by natural colonic microbiota gener-
ates products including short-chain fatty acids, which provide
nutrients to the colonic mucosa (butyrate) and are used as sub-
strates for lipogenesis and gluconeogenesis (acetate, propionate).
The change in micronutrient intake with a low FODMAP diet was
recently measured by Farida et al. in a single-center, randomized-
controlled study of individuals with IBS-D on a low FODMAP
diet compared to mNICE guidelines, or standard dietary recom-
mendations. Among 78 patients, 41 were randomized to follow
a low FODMAP diet whereas 37 patients followed the mNICE
diet. At 4-weeks, a statistically significant decrease in retinol
(p = 0.03), thiamin (p = 0.009), riboflavin (p = 0.045), and calcium
(p = 0.009) were observed in the low FODMAP group, compared
to a significant decrease in polyunsaturated fatty acids (p = 0.04)
seen in the standard diet group [57]. Therefore, while low FOD-
MAPs may improve symptoms of abdominal bloating, gas, and
diarrhea/constipation in IBS, avoidance of long-term use may
need to be considered [58].
© 2018 The American College of Gastroenterology
influence of Dietary Restriction on irritable Bowel Syndrome 5
“Spicy foods” Restriction
In addition to gluten, lactose, and short-chain carbohydrates,
spicy foods have received attention in IBS. Foods are categorized
as “spicy” when they create a hot sensation, produced by capsai-
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cin. The degree of heat is measured by Scoville heat units (SHU)
and any pepper marked as ≥1 SHU is regarded as spicy [59]. The
term “spicy foods” encompasses many ingredients, the most com-
mon of which are onion, black and white pepper, chili pepper,
garlic, and ginger [60–62]. In efforts to make food tastier and
more colorful, spices are an integral part of cooking around the
Review
world. In fact, chili peppers are considered the most popular spice
in Chinese culture [63]. Interestingly, it is estimated 5–10% of the
adult Asian population is affected by IBS [60], and the impact of
spicy foods in contributing to IBS has been questioned [63].
The Asian diet is characterized by high consumption of carbo-
hydrates and fiber, but is less balanced in fat and meat protein. A
common flavor in this diet is chili, averaging 2.5–8 g/person daily,
a huge increase when compared to European and American coun-
terparts at 0.005–0.5 g/person. The downstream effects of chili are
a direct consequence of capsaicin, the active ingredient in chili
peppers. Through modulation of gastrointestinal sensation via the
effects of transient receptor potential vanilloid-1 (TRPV1) expres-
sion on sensory nerve fibers, capsaicin is the reason humans feel
a burning, painful sensation in their digestive system after chili
ingestion [61]. This effect is thought to be enhanced in IBS due
to an increased number of colonic TRPV1 receptors, as seen in
rectosigmoid biopsies from patients with IBS [64].
The correlation with the generation of IBS symptoms, however,
is the subject of mixed reviews. The effects of chili-containing diet
on postprandial gastrointestinal symptoms was measured in IBS-D
subjects by Gonlachanvit et al., who randomized subjects to either
a standard meal, standard meal mixed with 2 g chili, or standard
meal with 2 g chili in capsules. By measuring postprandial symp-
toms every 15 min by a 2-hour visual analogue scale, the authors
demonstrated a significant degree of abdominal pain and burning
in IBS-D subjects compared to healthy controls (p < 0.05) [65].
Although we know short-term capsaicin exposure can aggra-
vate abdominal pain and bloating via TRPV1 expression, chronic
intake has been proposed to actually decrease visceral hypersen-
sitivity by TRPV1 desensitization. A preliminary study tested this
theory in 42 patients diagnosed with IBS using the Rome II criteria
– 17 received 4 pills/day for six weeks containing 150 mg of red
pepper powder, while 25 patients unknowingly received placebo
pills. Abdominal pain and bloating intensity were scored follow-
ing the 5-point Likert scale. Interestingly, intra-group comparisons
revealed groups receiving red pepper improved their abdominal
pain and bloating, with lower mean values [66].
Even though chronic ingestion of red pepper resulted in improved
GI symptoms, the question lingers whether the broad category of
spicy foods may contribute to symptoms, particularly for foods
beyond chilies and therefore not solely limited to capsaicin effects.
To answer this question, Esmailzadeh et al. explored the associa-
tion between IBS and spicy foods in an Iranian population, whose
prevalence of IBS is estimated at 1.1–25% of the population, and
whose diet included large amounts of turmeric, saffron, and gin-
ger. In a sample of adults working in 50 various healthcare centers
The American Journal of Gastroenterology
 6 A. Kamal, M. Pimentel
across the province of Isfahan, 8691 subjects returned completed
questionnaires on dietary habits and symptoms in addition to a
modified Persian version of the Rome III questionnaire. Authors
assessed dietary habits by measuring meal frequencies, regularity of
Article
Review Article
meals, drinks before meals, and regularity of spicy foods (chili pep-
per, curry, ginger, cinnamon, and turmeric) during the study week.
The authors determined that study subjects consuming spicy foods
≥10 times/week were not only more likely to be young and women,
but also had an increased prevalence of IBS. After adjusting for age
and gender, a significant association between consumption of spicy
Review
foods ≥10 times/week and IBS remained (p < 0.001) [60].
As we know consumption of spicy foods is highest among East-
ern countries. In the United States, the intake of spicy ingredients
has doubled since 1980 - the result of a rising appeal of spicy and
hot flavors [59]. Despite this, Europeans and Americans still con-
sume spicy foods to a lesser extent than their Eastern counterparts.
Curcumin Supplement
Herbal remedies are a traditional means of treating a variety of
conditions. Recently curcumin, the main active ingredient in
turmeric, has demonstrated effectiveness in the management of
chronic inflammatory conditions including rheumatoid arthritis,
ulcerative colitis (UC), as well as IBS. Turmeric is a curry spice used
throughout Asia and in certain regions consumption is as high as
2500 mg/day. Native to the Eastern World, the spice was introduced
to Europe in the 13th century by Marco Palo and only recently
received attention for its anti-inflammatory properties [67].
First isolated in 1815, curcumin has been noted to affect several
inflammatory pathways including down-regulating the activity
of COX-2, inhibiting production of tumor necrosis factor (TNF)
alpha, and down-regulating mitogen-activating and Janus kinases,
in addition to affecting anti-neoplastic cell cycle arrest and induc-
tion of apoptotic signals. Today curcumin has been approved by
the United States Food and Drug Administration (FDA) as a “Gen-
erally Recognized as Safe” (GRAS) supplement, recognizing it as a
safe food additive [67].
Curcumin is used in traditional Chinese, Indian, and West-
ern herbal remedies for the management of gastrointestinal
symptoms, particularly abdominal pain and bloating [67]. More
recently, curcumin has been shown to improve bowel symptoms
in patients with UC by inhibiting pro-inflammatory cytokines
and their signaling pathways, resulting in improvements in Clini-
cal Activity Index (CAI) and endoscopic scores, and reduction in
flares [68]. This therapeutic potential of curcumin, however, goes
beyond inflammatory bowel disease and may extend to functional
bowel diseases. As a compound with a vanilloid ring moiety simi-
lar to that of capsaicin, curcumin has been shown to competitively
inhibit activation of TRPV1 expression on sensory nerve fibers,
and therefore modify the body’s response to various stimulants. In
contrast to capsaicin, which aggravated abdominal pain and bloat-
ing via TRPV1 expression, curcumin had been found to reverse
gut hypersensitivity [69].
In a pilot study, Bundy et al. randomized 207 volunteers meeting
the Rome II criteria for IBS and assessed the effects of turmeric
consumption after 8 weeks. Patients who took one or two tab-
lets of turmeric daily reported reductions in abdominal pain and
The American Journal of Gastroenterology
discomfort of 22 and 25%, respectively. Findings, however, fell
short of statistical significance (p = 0.071) [70]. Portincasa et al.
randomized 121 patients with mild to moderate IBS based on the
Irritable Bowel Syndrome Symptom Severity Score (IBS-SSS) to
receive 30 days of either a combination of curcumin and fennel
essential oil (CU-FEO) or placebo. Anethole, the active ingredient
in fennel oil seeds, acts as an intestinal smooth muscle relaxant.
Patients receiving CU-FEO experienced a significant drop in symp-
tom severity from baseline scores (p < 0.001), including abdomi-
nal pain (p < 0.001), higher complete symptom-free rates at day
30 (p = 0.005), and a greater IBS-quality of life score (p = 0.003).
The use of curcumin led to no serious adverse effects [68]. There-
fore, curcumin has shown promising effects in mediating IBS
symptoms.
Dietary Fiber
It has been suggested that IBS is directly related to a lack of die-
tary fiber, non-digestible carbohydrates intrinsic to plants. Die-
tary fiber can be separated into soluble fibers (pectins, gums, and
mucilages) and insoluble fibers (cellulose, hemicelluloses, and
lignins), or characterized based on carbohydrate length (short-
chain and long-chain) and fermentability [71]. Soluble fibers can
form a viscous gel that delays gastric emptying and impedes small
intestinal absorption, and is ultimately fermented by bacteria in
the large intestine. Fermentation results in production of gas and
short-chain fatty acids which increase stool mass, and changes in
oro-anal transit time [71]. In contrast, insoluble fibers are poorly
fermented, influence the viscosity of intestinal contents less, and
retain water. These processes increase the volume and bulk of
stool, in addition to increasing colon transit time [72].
The proposed mechanisms by which dietary fiber benefits those
with IBS are: (1) increased stool bulk through fermentation of
byproducts (as with soluble fiber) or accelerated colonic transit
by mechanical stimulation (as with insoluble fiber); (2) influences
on the microbiota - the production of short-chain fatty acids and
the decrease in colonic pH support the growth of bacteria such
as lactobacilli and bifidobacteria; and (3) influences on the neu-
roendocrine system (NES) of the gastrointestinal tract through the
release of hormones including serotonin, which impacts visceral
sensitivity, and peptide YY (PYY) which increases colonic absorp-
tion of water and electrolytes [71]. These effects of dietary fiber
were first noted by Manning et al., who compared 26 IBS patients
receiving either a high or low wheat-fiber diet. After 6 weeks, those
receiving the high-fiber diet reported more significant improve-
ments in IBS symptoms [73]. In a meta-analysis, 14 randomized
controlled trials on dietary fiber in IBS were reviewed. By compar-
ing fiber to placebo, control treatment, or standard management
in a total of 906 patients, the authors noted a significant overall
benefit in IBS (RR = 0.86; 95% CI 0.80–0.94, number needed to
treat (NNT) = 10; 95% CI 6–33) and when stratifying for type of
fiber, authors revealed a more prominent response with soluble
fiber versus bran, an insoluble fiber (RR = 0.83; 95% CI 0.73–0.94
and RR = 0.90; 95% CI 0.79–1.03, respectively) [74].
As IBS patients do not all have the same presentation, but are
categorized into subtypes based on the predominant symptom of
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 influence of Dietary Restriction on irritable Bowel Syndrome 7

Table 2  Advantages and disadvantages of dietary restriction in Irritable Bowel Syndrome (IBS)

Dietary manipulation Advantage Disadvantage

Lactose restriction •Reduces IBS symptoms in short and long-term •Formal diagnosis requires hydrogen breath test or blood-glucose

Gluten restriction
Low Fermentable Oligosaccharides,
Disaccharides, Monosaccharides,
trials
•Reduces number of outpatient visits at 5 years
•Affects abdominal symptoms, bowel movement
frequency, and small bowel permeability
•Reduces abdominal pain and stool consistency
after comparing to the modified National Insti-
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ReviewArticle
measurement
•Diagnosis requires ruling out small intestinal bacterial overgrowth
(SIBO) before interpreting hydrogen breath testing
•Symptom response may not be specific to gluten (i.e. fructans,
very low carbohydrate diet)
•Restrictive diet
•Not a “one-size-fits-all” approach, tailored dietician counseling

Review
and Polyols (FODMAP) tute for Health and Care Excellence (mNICE) recommended
guidelines •No difference in symptoms seen after comparing to traditional
dietary advice
•Potential change in microbiome and nutrient deficiency with long-
term restriction
“Spicy foods” restriction •Affects abdominal pain and burning •Bland diet
•Abdominal pain and bloating may improve with
chronic ingestion
Curcumin supplement •Reduces symptom severity including •Randomized study data in combination with fennel essential oil
abdominal pain seeds
•Improves symptom free rates and quality of life
Dietary soluble fiber •Reduces IBS symptoms, specifically relieving •No difference in abdominal symptoms
constipation
•Increases whole gut transit time

diarrhea or constipation, Cann et al. assessed which category of
fiber is more beneficial. In a double-blind, crossover trial, patients
with IBS received either a course of wheat bran or placebo. The use
of bran resulted in a significant improvement in constipation, with
increases in whole gut transit time (p < 0.05) and daily stool weight
(p < 0.01). Abdominal pain, however, was increased with the use
of bran and demonstrated limited efficacy in patients with diar-
rhea [75]. Similarly, in a double-blind placebo-controlled trial of
ispaghula husk (a soluble fiber commonly referred to as psyllium)
versus placebo in 80 IBS patients, Prior et al. assessed changes in
bowel habits, whole gut transit time, and abdominal pain. The
study revealed patients felt better overall after receiving ispaghula
husk (p < 0.02), with particular benefits for relief of constipation
(p = 0.026) and increased whole gut transit time (p = 0.001). In
contrast, no improvements in abdominal pain or distention were
seen between the two treatment groups [76]. Therefore, authors
concluded the use of soluble fiber (psyllium/ispaghula husk) and
not insoluble fiber (bran) should be considered as a dietary option
in management of IBS symptoms, particularly for those with
constipation-predominant IBS, but not for the management of
abdominal symptoms [5, 77].
Conclusions
Up to two-thirds of IBS patients attribute their abdominal symp-
toms and changes in bowel habits to their dietary intake, and as
a result there is a rising trend towards restricting specific foods
in an effort to minimize post-prandial symptoms. A review of
the literature on various dietary manipulations, however, yields
mixed results (Table 2). This is particularly notable for literature
on patients with gluten intolerance, whether due to celiac disease
or NCGS. For example, Biesiekierski et al. demonstrated posi-
tive symptom correlation with gluten exposure in the form of
bread slices and muffins in IBS individuals compared to controls,
reporting worsening abdominal pain, bloating, satisfaction with
stool consistency, and tiredness within 1 week of gluten exposure.
However, following a cross-over trial in which a similar subject
population to reduced FODMAP and gluten, the same authors
concluded that the carbohydrate components of wheat, fructans,
and galacto-oligosaccharides had more pronounced effects on
IBS symptoms than gluten itself. Further, questions arise as to
whether gluten restricted diets are functioning similarly to a very
low carbohydrate diet, and whether symptom response could in
fact be a reflection of reduced carbohydrate intake.
Despite positive evidence supporting lactose restriction in IBS,
questions arise as to the validity of applying hydrogen breath
testing in the diagnosis of lactose intolerance. Are patients truly
lactose intolerant producing hydrogen due to underlying small
intestinal bacterial overgrowth? Trials of this diet in IBS using the
low FODMAP have produced mixed results. When compared to
mNICE guidelines in IBS-D, a low FODMAP diet was found to
be favorable in reducing abdominal pain, improving stool consist-
ency, frequency, and urgency. Interestingly, low FODMAP diet
was not superior to traditional dietary advice, such as reducing
excessive fiber, fat intake, and avoiding larger meals. Despite these
findings, the low FODMAP diet has gained popularity in IBS treat-
ment, leading to concerns for potential long-term ramifications.
Our review also identified mixed results in the literature on spicy
foods, as trials have revealed worsening abdominal pain after iso-
lated capsaicin exposure, even in an Iranian diet containing large
amounts of turmeric, saffron, and ginger, whereas another trial
found improved symptoms following chronic red pepper exposure.

© 2018 The American College of Gastroenterology The American Journal of Gastroenterology

 8 A. Kamal, M. Pimentel
The latter result suggested that chronic intake of capsaicin could in
fact decrease visceral hypersensitivity. Further, turmeric has dem-
onstrated promising effects in improving IBS symptoms, with sig-
nificant improvements reported when paired with fennel essential
Article
Review Article
oils. Lastly, although dietary fiber appears to play a beneficial role
in IBS, the use of soluble fibers (psyllium, ispaghula husk) in con-
stipation-predominant IBS has shown the most promising results.
Fiber did not significantly improve abdominal symptoms.
Overall, we have found mixed results regarding various dietary
triggers and the impacts of dietary manipulations on GI symp-
Review
toms. Although there are data to support dietary restrictions in
the management of IBS, further and better controlled trials will be
required to provide definitive recommendations.
Conflict of interest
Guarantor of the article: Mark Pimentel.
Specific author contributions: AK drafted and revised the manu-
script. MP reviewed and revised the manuscript. Both AK and MP
have approved the final draft submitted.
Financial support: None.
Potential competing interests: Cedars-Sinai has licensing agree-
ments with Valeant Pharmaceuticals International Inc., Common-
wealth Laboratories Inc., and Synthetic Biologics Inc. Mark Pimentel
is a consultant for Valeant Pharmaceuticals, Commonwealth Labo-
ratories Inc., Synthetic Biologics Inc., Micropharma Inc., and Naia
Pharmaceuticals and is on the advisory boards for Valeant Pharma-
ceuticals and Commonwealth Laboratories. The remaining authors
declare that they have no conflict of interest.
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