Clinical Gastroenterology and Hepatology 2022;-:-–-
LETTER TO THE EDITOR
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Traditional Dietary Advice, Low FODMAP
Diet, or Gluten-Free Diet for IBS: Growing
Understanding but Uncertainties Remain
Dear Editor:
We read the article by Rej et al1 with great interest
and commend them on conducting the first head-to-head
comparison of the low FODMAP diet, the gluten-free diet
(GFD), and traditional dietary advice (TDA) over 4 weeks
in patients with nonconstipation irritable bowel syn-
drome. They not only examined the effect on global
symptoms, but also on psychological aspects, and food-
related quality of life and acceptability, for which we
applaud. However, we wish to raise 4 issues about the
authors’ interpretation of the findings.
First, the authors conclude that there is no difference
in efficacy across the diets. This is shown by a per-
protocol responder analysis, but summary and individ-
ual patient data are not shared with the reader to
examine this in more detail. Power calculations were
based on assumptions that are at odds with published
data and with the authors’ own arguments. Efficacy of
TDA was underestimated at 40%, given published
response rates of 46%–51% in well-conducted trials
with a modified TDA2 or a TDA in which gas-producing
foods were restricted.3 The authors argue appropriately
that inclusion of such restriction of gas-producing foods
may well improve the efficacy of the TDA. On top of this,
the responder rate for the low FODMAP diet was set at
75%, yet this is higher than in these same randomized
controlled trials (50%–52%). Furthermore, the authors
later justified their power calculation with data from this
study despite overlooking it in their power calculation.
Hence, we caution regarding the conclusion that the
responder rate for the TDA was equivalent to that of the
other 2 diets.
Second, we believe there is a misunderstanding of
the TDA. It is an empirical approach not designed to be
rigid, but to be individualized based on patient symptom
profile and habitual diet. Variable implementation is to
be expected. Variability in TDA response rates across
trials may therefore be caused by differences in the
populations studied (and therefore the advice provided),
or because of the level of dietetic expertise, or both.
Furthermore, we would suggest the claim that 4 of
the 5 previous trials of TDA did not lead to reduction in
intake of gas-producing foods is unsubstantiated
without a scientifically sound finite list of “gas-produc-
ing” foods (which we do not believe exists) and detailed
food intake data (vs nutrient data) extracted from food
diaries.
Third, the authors implied in their discussion of the
results that the GFD exerts its efficacy by eliminating
gluten from the diet. However, the diet also reduces
FODMAP intake as does the TDA (both measured). The
basis for the benefits of a GFD are controversial and
rechallenge investigations have provided evidence that
gluten has no greater effect on gastrointestinal symp-
toms compared with placebo.4,5 It may, therefore, be
premature to suggest that gluten reintroduction strate-
gies need to be investigated.
Finally, the recommendation that TDA be the first-line
dietary approach seems appropriate on first glance given
the greater psychological and financial burden that the
other diets place on the patients and the need for a
specialized dietitian. However, a specialized dietitian
delivered the TDA in this trial and previously2,3 and it is
not known whether efficacy is comparable if delivered by
a nondietitian or written information alone. There was
also no difference in food-related quality of life outcomes
between diet groups and no difference in the proportion
of individuals who would choose to continue their allo-
cated diet. When managing patients with irritable bowel
syndrome, decisions should be made for their long-term
benefit, not for a 4-week window. The TDA (or indeed
GFD) has no step-down process and does not empower
the patients to manage their symptoms. This is in
contrast to the 3-phase FODMAP approach that em-
powers the patient to increase or reduce FODMAP intake
as dictated by their symptoms.6,7
Thus, we commend the authors on a thoughtful study
and agree that, in many instances, TDA or other dietary
approaches (eg, fiber modification) could be considered
as first-choice therapy, as recommended in UK dietetic
guidelines.8 However, their findings should be inter-
preted in light of the fact that the trial was underpow-
ered, that evidence for a TDA is based only on trials in
which it was dietitian-delivered, and that there are
ongoing uncertainties with regards to long-term TDA
implementation. Thus, the study has provided important
new information, but uncertainties remain.
2 Letter to the Editor Clinical Gastroenterology and Hepatology Vol. -, No. -

HEIDI M. STAUDACHER, B App Sci, M Nutr Diet, 2. Eswaran SL, et al. Am J Gastroenterol 2016;111:1824–
PhD 1832.
Deakin University 3. Bohn L, et al. Gastroenterology 2015;49:1399–1407.
Institute for Mental and Physical Health and Clinical 4. Nordin E, et al. Am J Clin Nutr 2022;115:344–352.
Translation 5. Skodje GI, et al. Gastroenterology 2018;54:529–539.
Food & Mood Centre 6. Whelan K, et al. J Hum Nutr Diet 2018;31:239–255.
Geelong, Victoria, Australia 7. Gibson PR, et al. J Gastroenterol Hepatol 2022;37:644–652.
8. McKenzie YA, et al. J Hum Nutr Diet 2016;29:549–575.
PETER R. GIBSON, MBBS(Hons), MD, FRACP
Department of Gastroenterology
Central Clinical School Conflicts of interest
This author discloses the following: Peter R. Gibson has served as a consultant
Monash University or advisory board member for Anatara, Atmo Biosciences, Immunic Thera-
Melbourne, Victoria, Australia peutics, Novozymes, Novoviah, and Comvita; has received research grants for
investigator-driven studies from Atmo Biosciences; and holds shares in Atmo
Biosciences. His department financially benefits from the sales of a digital
References application, booklets, and online courses on the FODMAP diet. Heidi M.
Staudacher discloses no conflicts.
1. Rej A, et al. Clin Gastroenterol Hepatol 2022. https://doi.org/10.
1016/j.cgh.2022.02.045. https://doi.org/10.1016/j.cgh.2022.05.051