doi:10.1111/j.1440-1746.2009.06149.

A D VA N C E S I N C L I N I C A L P R A C T I C E jgh_6149 252..258

Evidence-based dietary management of functional

gastrointestinal symptoms: The FODMAP approach
Peter R Gibson and Susan J Shepherd
Monash University Department of Medicine, Box Hill Hospital, Box Hill, Victoria, Australia

Key words Abstract

dietary therapy, fermentable carbohydrates,
fructans, fructose, galactans, irritable bowel
Background and Aim: Functional gastrointestinal symptoms are common and their man-
syndrome, lactose, polyols. agement is often a difficult clinical problem. The link between food intake and symptom
induction is recognized. This review aims to describe the evidence base for restricting
Accepted for publication 6 October 2009. rapidly fermentable, short-chain carbohydrates (FODMAPs) in controlling such
symptoms.
Correspondence Methods: The nature of FODMAPs, their mode of action in symptom induction, results of
Professor Peter Gibson, Department of clinical trials and the implementation of the diet are described.
Medicine, Box Hill Hospital, Box Hill, Results: FODMAPs are widespread in the diet and comprise a monosaccharide (fructose),
Vic. 3128, Australia. Email: a disaccharide (lactose), oligosaccharides (fructans and galactans), and polyols. Their
[email protected] ingestion increases delivery of readily fermentable substrate and water to the distal small
intestine and proximal colon, which are likely to induce luminal distension and induction
Conflicts of interest: SJS has published five
of functional gut symptoms. The restriction of their intake globally (as opposed to indi-
cookbooks directed towards issues of celiac
vidually) reduces functional gut symptoms, an effect that is durable and can be reversed by
disease and low FODMAP diet. The authors
their reintroduction into the diet (as shown by a randomized placebo-controlled trial). The
have registered the term ‘FODMAPs’ as a
trademark.
diet has a high compliance rate. However it requires expert delivery by a dietitian trained
in the diet. Breath hydrogen tests are useful to identify individuals who can completely
absorb a load of fructose and lactose so that dietary restriction can be less stringent.
Conclusions: The low FODMAP diet provides an effective approach to the management
of patients with functional gut symptoms. The evidence base is now sufficiently strong to
recommend its widespread application.

Functional gastrointestinal disorders (FGID) are very common and Mechanistic basis for
present as major challenges for clinicians, particularly as pharma- dietary intervention
ceutical therapies offer little more than mild palliation in the vast
majority of patients. The symptoms can markedly interfere with The physiological basis for the genesis of many functional gut
quality of life and rank second in the causes of absence from work symptoms is luminal distension. Evidence for this comes from
or school.1 While the predominant underlying cause of symptoms barostat and gas infusion studies.2,3 Luminal distension not only
appears to reside in the enteric nervous system, manifesting as induces the symptoms of pain, the sensation of bloating and visible
visceral hypersensitivity and/or motility disturbances, multiple abdominal distension, but may also lead to secondary motility
other factors contribute to symptoms generation, including psy- changes. Thus, minimizing the consumption of dietary factors that
chological factors and diet. Consequently, treatment has spanned can distend the intestine would theoretically lead to improvement
multiple modalities and has involved a variety of health profes- in global symptoms that characterize FGID. In the case of two of
sionals, including medical practitioners, psychologists, hypno- the most common types of FGID involving the intestine, irritable
therapists, dietitians and naturopaths, each bringing a different bowel syndrome (IBS) and functional bloating, the distal small
perspective. A major limitation has been the limited evidence base and proximal large intestine would be the target regions of the gut.
for many therapies, not helped by the considerable placebo The intestinal lumen can be distended by solids, liquids and gas.
response seen in these disorders. However, dietary therapy, spe- Solids can be altered in the proximal large intestine by changing
cifically the low FODMAP diet (see below for explanation), has the dietary fiber content both directly and indirectly via expansion
now emerged as a key player with a well-substantiated mechanism or contraction of the bacterial mass. The liquid content in the distal
of action and evidence-based efficacy. This review will describe small intestine will be dictated by the osmotic load in the lumen,
the theoretical basis for the diet, the evidence for efficacy and its and in the proximal large intestine by the osmotic load and the
implementation, and it will address unanswered questions. absorptive ability of the epithelium. The gas content will

252 Journal of Gastroenterology and Hepatology 25 (2010) 252–258

© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
PR Gibson and SJ Shepherd The low FODMAP diet

include a component of swallowed nitrogen, but the majority will polyols in the induction of gut symptoms has been well-described in
be locally produced by bacterial fermentation. The volume that the clinical practice; the dietary regimen for the management of lactose
gas creates will depend upon the number of molecules and its malabsorption has been comprehensively addressed18 and manda-
diffusion capacity across the epithelium and into the circulation. tory declaration of ‘excess consumption may have a laxative effect’
Dietary components that will putatively lead to luminal distension is in place for food products containing polyols. Increased flatu-
in the regions of interest will therefore be poorly absorbed in the lence and change of bowel habits after consuming ‘windy veg-
proximal small intestine, will be small molecules (i.e. osmotically etables’, such as lentils and baked beans, are common knowledge
active), will be rapidly fermented by bacteria (with the potential to although identification of galactans, in addition to resistant starch,
be fermented by small intestinal as well as cecal bacteria and to as the culprit molecules may not be. Additive effects fructose and
expand the bacterial population), and will be associated with sorbitol10,19,20 and lactose and fructans21 on abdominal symptoms
hydrogen rather than methane production. Dietary FODMAP are are also well-described.
the best fit for these principles.
The FODMAP concept in the
FODMAPs management of functional
gut symptoms
The acronym, ‘FODMAP’—Fermentable Oligo-, Di- and Mono-
saccharides and Polyols—was coined to describe a previously- There are two key components to the FODMAP concept.
unrelated group of short-chain carbohydrates and sugar alcohols • The dietary approach restricts FODMAP intake globally, not
(polyols).4 They comprise fructose, lactose, fructo- and galacto- individually. Restriction of individual FODMAPs has been used
oligosaccharides (fructans, and galactans), and polyols (such as with varying success in the management of functional gut symp-
sorbitol, mannitol, xylitol and maltitol) all of which putatively toms for a long time. The best example is restriction of dietary
have three common functional properties: lactose in patients with hypolactasia. Restriction of fructose,
• Poorly absorbed in the small intestine: Poor absorption occurs with or without sorbitol, has also been reported. However, such
by virtue of slow, low-capacity transport mechanisms across the approaches have not become widespread in their application,
epithelium (fructose), reduced activity of brush border hydro- perhaps in part related to their limited success. Restricting one
lases (lactose), lack of hydrolases (fructans, galactans), or mol- FODMAP in isolation ignores the likelihood that there is poten-
ecules being too large for simple diffusion (polyols). tially a range of FODMAPs in the diet, all of which have similar
• Small and therefore osmotically-active molecules: This effect end-effects in the bowel. The innovation in the FODMAP
has been demonstrated with, for example, a synthetic FODMAP, concept is that global restriction should have a far greater and
lactulose, which exerts a laxative effect when given in sufficient more consistent effect than limited restriction. Thus, the central
dose by increasing the liquidity of luminal contents and subse- focus is to reduce the intake of all poorly absorbed short chain
quently affecting gut motility.5 carbohydrates to be more effective in reducing luminal disten-
• Rapidly fermented by bacteria: The rapidity of fermentation by sion than merely concentrating on one of these. Such a global
bacteria is dictated by the chain length of the carbohydrate; approach to restricting carbohydrates that have similar actions
oligosaccharides and sugars are very rapidly fermented com- (high osmotic effect and rapid fermentation) should optimize
pared with polysaccharides such as soluble dietary fibre.6 symptom control in patients with IBS.
These functional properties have recently been confirmed in • FODMAPs do not cause the underlying FGID, but represent an
studies in which diets high and low in FODMAPs (rather than pure opportunity for reducing symptoms. This concept is important as
individual FODMAPs) have been fed to volunteers. In a study of 10 it steers away from the more traditional concepts of lactose
ileostomates, changes in dry-weight ileostomy effluent could be ‘intolerance’ versus ‘malabsorption’ and fructose ‘intolerance’
explained entirely on the basis of dietary FODMAPs and the versus ‘malabsorption’. The reason the symptoms are triggered
effluent volume increased by a mean of 22% on the high FODMAP by the ingestion of lactose or fructose in the individual is the
diet.7 Fermentation of FODMAPs in the small intestine was sug- response of the enteric nervous system to luminal distension
gested by the recovery of only 34% of FODMAPs consumed in the (due to visceral hypersensitivity, excessive gas production due to
ileostomy effluent, although some fermentation in the ileostomy the nature of the resident microbiota, or motility problems with
bag ex vivo also would have contributed. When the diets were fed to clearance of the fluid/gas) not because the malabsorption of the
healthy volunteers, breath hydrogen production, a marker of gas sugar is abnormal or a ‘condition’. After all, delivery of dietary
production in the intestine, was markedly elevated throughout the FODMAP to the distal small and proximal large intestine is a
day.8 Furthermore, in methane-producers, high FODMAP intake normal phenomenon, one that will generate symptoms if the
favored production of hydrogen over methane, which occupies a underlying bowel response is exaggerated or abnormal.
smaller volume per hydrogen molecule generated. Thus, all the
putative functional properties have been confirmed to occur in vivo
in association with dietary intake of FODMAPs.
FODMAPs in the diet
There is considerable evidence that individual FODMAPs in- While all FODMAPs are potentially important in the genesis of
duce abdominal symptoms. Acute provocation tests with lactose,9 symptoms (summary of food sources of FODMAP are listed in
fructose9–11 fructo-oligosaccharides (FOS)12,13 or sorbitol9,14–17 Table 1), the relative contribution of different subgroups of
cause abdominal symptoms such as bloating, pain, nausea and FODMAPs varies across ethnic and dietary groups due to the dose
disturbed bowel habit (diarrhea and/or constipation) in many delivered in the diet. In North American and Western European
people, especially those with IBS.15 The role of lactose and diets, fructose and fructans are by far the most widespread in the

Journal of Gastroenterology and Hepatology 25 (2010) 252–258 253

© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
The low FODMAP diet PR Gibson and SJ Shepherd

Table 1 Food sources of FODMAPs (where FODMAPs are problematic based on standard serving size) and suitable alternatives

FODMAP Excess fructose Lactose Oligosaccharides Polyols

(fructans and/or galactans)

Problem high FODMAP Fruits: apples, pears, nashi Milk: cow, goat and sheep Vegetables: artichokes, Fruits: apples, apricots,
food source pears, clingstone (regular & low-fat), Ice asparagus, beetroot, cherries, longon, lychee,
peaches, mango, sugar cream Brussels sprout, broccoli, nashi pears, nectarine,
snap peas, watermelon, cabbage, fennel, garlic, pears, peaches, plums,
tinned fruit in natural juice leeks, okra, onions, peas, prunes, watermelon
Yoghurt (regular & low-fat) shallots. Vegetables: avocado,
cauliflower, mushrooms,
Honey Cheeses: soft & fresh (e.g. Cereals: wheat & rye when
snow peas
ricotta, cottage) eaten in large amounts
Sweeteners: fructose, high (e.g. bread, pasta, Sweeteners: sorbitol(420),
fructose corn syrup couscous, crackers, mannitol(421), xylitol(967),
biscuits) maltitol (965), isomalt
Large total fructose dose: Legumes: chickpeas, lentils, (953) & others ending in
concentrated fruit red kidney beans, baked ‘-ol’
sources; large serves of beans
fruit, dried fruit, fruit juice Fruits: watermelon, custard
apple, white peaches,
rambutan, persimmon
Suitable alternative Fruit: banana, blueberry, Milk: lactose-free, rice milk Vegetables: bamboo shoots, Fruits: banana, blueberry,
low-FODMAP food carambola, durian, bok choy, carrot, celery, carambola, durian,
source grapefruit, grape, Cheese: ‘hard’ cheeses capsicum, choko, choy grapefruit, grape,
honeydew melon, including brie, camembert sum, corn, eggplant, honeydew melon,
kiwifruit, lemon, lime, green beans, lettuce, kiwifruit, lemon, lime,
mandarin, orange, chives, parsnip, pumpkin, mandarin, orange,
passionfruit, paw paw, Yoghurt: lactose-free silverbeet, spring onion passionfruit, paw paw,
raspberry, rockmelon, (green only), tomato raspberry, rockmelon
strawberry, tangelo. Ice cream substitutes: Sweeteners: sugar
gelati, sorbet (sucrose), glucose, other
Honey substitutes: maple Butter Onion/garlic substitutes: artificial sweeteners not
syrup, golden syrup garlic-infused oil ending in ‘ol’
Cereals: gluten-free & spelt
Sweeteners: any except
bread/cereal products
polyols

diet and therefore the ones to which nearly all patients with IBS are restriction of foods rich in free fructose should be unnecessary. It
exposed in their everyday diet. In addition, fructose is important is therefore desirable to identify those who completely absorb a
because its absorption in the small intestine varies widely, its load of fructose. This is effectively done by breath hydrogen
significance in dietary intervention will consequently vary widely testing, preferably with a moderately high dose of fructose (35 g),
among different people, and because it is often accompanied in although the evidence base for the dose that should be tested is
food by sorbitol. An understanding of fructose and fructans are minimal.23,24
therefore critical to appropriate implementation of the diet. Fructans are linear or branched fructose polymers and are the
Fructose is presented to the intestinal lumen as a free hexose in naturally occurring storage carbohydrates of a variety of veg-
foods or following hydrolysis of sucrose. It is present in fruits, etables, including onions, garlic and artichokes, fruits such as
honey, and high fructose corn syrup. It is absorbed across the small bananas, and in cereals.25,26 Wheat is a major source of fructans
intestinal epithelium via two mechanisms (reviewed in detail else- in the diet, and contains 1–4% fructans on solid matter.27 Addi-
where22). First, free fructose is taken up by a facultative trans- tional sources of fructans are inulin (mostly as a long-chain
porter, GLUT-5, that is present throughout the small intestine. This fructan) and FOS, which are increasingly being added to foods
is of low capacity. Secondly, when present with glucose, fructose for their putative prebiotic effects. Because the small intestine
is taken up more efficiently, a response that is believed to be lacks hydrolases capable of breaking fructose-fructose bonds,
related to the insertion of GLUT-2 into the apical membrane of the and fructans cannot be transported across the epithelium, they
enterocyte. Thus, fructose malabsorption manifests when free are not absorbed at all. Formal examination of this has confirmed
fructose (i.e. in excess of glucose) is in the lumen. This is the that 34–90% of ingested fructans can be recovered from small
reason why fructose supplied in the form of sucrose is only mal- intestinal output in subjects with an ileostomy.7,26,28–30 Lower
absorbed if sucrase activity is diminished. yields, particularly of the short-chain fructans, are likely to be
The ability to absorb free fructose varies widely across individu- due to microbial degradation by the microflora colonizing the
als. If fructose absorption is efficient in an individual, then dietary distal small intestine.7,28

254 Journal of Gastroenterology and Hepatology 25 (2010) 252–258

© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
PR Gibson and SJ Shepherd The low FODMAP diet

More than just fructose and fructans quadruple-arm placebo-controlled re-challenge trial.40 Further
evaluation of the diet in other groups with functional gut symp-
Lactose is a disaccharide naturally-occurring in mammalian milk, toms has shown consistent benefit in patients with quiescent
including that from cows, sheep and goats. Human digestion of inflammatory bowel disease and ileal pouch. An evaluation of
lactose requires the enzymic action of lactase to hydrolyse the patients who did not have a breath hydrogen test supported the
disaccharide to its constituent monosaccharides, glucose and efficacy of the diet in those with complete fructose absorption.41 Of
galactose, which are then readily absorbed. As recently reviewed,29 importance is that efficacy is not restricted to patients with
the activity of lactase is deficient in a proportion of adults and diarrhea-predominant IBS, but applies equally to any bowel habit.
children, varying with ethnicity. Malabsorption of lactose (which Thus, the evidence base for efficacy of the diet is now substantial.
can be detected by breath hydrogen testing, a lactose tolerance test, The ability of those instructed in the low FODMAP diet to
or lactase activity associated with small bowel biopsy) indicates adhere to it is remarkably good. More than 75% of patients were
that lactose should be considered a FODMAP in that individual. judged to be completely or mostly compliant with the diet in a
Legumes, including lentils, chickpeas, and red kidney beans, retrospective review median 14 months (range 2–40 months) after
are significant dietary sources of galactans. Vegetarians often implementation of the diet. In patients with inflammatory bowel
consume large amounts of galactans due to increased consumption disease, dietary compliance and efficacy of the diet were associ-
of legumes—these are commonly utilized as an important source ated with more time availability, higher education status, and the
of protein in the vegetarian diet, particularly those following vegan use of specific cookbooks. These findings suggested that an under-
vegetarian diets. Also, people consuming cuisines that are based standing of the dietary principles and allocation of time to work on
on these foods, such as dahl, many curries and soups from the applying the diet were important to ensure success. These findings
Indian sub-continent, and chilli con carne and refried beans from are not surprising.
Mexico, are also likely to have a greater intake of galactans.
Polyols are relatively underexplored as FODMAPs but are
found widely in foods. Polyols do not have associated active trans- Limitations of tables of the FODMAP
port systems in the small intestine and are probably absorbed by content of foods
passive diffusion. The rate of absorption is related to three factors. There are limitations in developing tables of FODMAP-rich and
First, the diffusion occurs through ‘pores’ in the epithelium and FODMAP-poor foods. This review paper provides a summary that
therefore depends upon molecular size.30 For example, erythritol, a is incomplete and is useful as a guide only.
4-carbon polyol, is well-absorbed in the jejunum but mannitol, a • Published lists of foods are generally limited in the description
6-carbon polyol, is not.31 Secondly, there is variation of pore size of FODMAP content. This limitation has been assisted by the
along the small intestine with larger pores proximally. Thus, eryth- development of methodologies to measure FODMAP content,
ritol is less well-absorbed in the ileum.32 The rapidity of transit together with a systematic examination of fruits, vegetables and
through the jejunum will therefore influence the degree of absorp- cereals.25,26
tion. Finally, pore size is affected by mucosal disease; pore size • The cut-off levels of FODMAP content, which dictates whether
reduces in celiac disease where erythritol is poorly absorbed.32 It is it is classified as ‘high’ or not, are not clearly defined. This is
not surprising then that limited studies performed on the absorp- further complicated by the fact that the total of FODMAPs
tion of sorbitol and mannitol have yielded considerable individual ingested (not the individual FODMAPs) at any one meal is a
variation and that the amount available for fermentation varies major factor in determining whether symptoms will be induced
with dose taken.33,34 Polyols are present in food (for example, or not. In the original description of the diet,39 cut-off values
sorbitol is often found in food rich in free fructose, mannitol is were based on careful clinical observation, which included
found in mushrooms) and are used as artificial sweeteners, being obtaining feedback from patients regarding foods that they iden-
identified by the following additive numbers on food packages: tified as triggers for symptoms. The foods reported by patients as
sorbitol (420), xylitol (967), mannitol (421), maltitol (965), and being troublesome were examined for trends in the pooled food
isomalt (953). Sorbitol has also been marketed as a laxative and composition table. Foods and beverages containing > 0.5 g fruc-
warnings have been placed on candies, especially sugarless tose in excess of glucose per 100 g, > 3 g fructose in an average
chewing gum, that polyols used as an artificial sweetener can have serving quantity regardless of glucose intake (termed a ‘high
a laxative effect. fructose load’), and > 0.2 g of fructans per serve were consid-
ered at-risk of inducing symptoms. The concept of a ‘high fruc-
Efficacy of the low FODMAP diet tose load’ has not been evaluated in terms of its importance in
Efficacy of restricting dietary fructose and/or sorbitol has been the success of the diet.
reported in several observational studies35–38 and the benefits
appeared to be durable.36 The nature of the diets used, however,
was generally poorly defined. Using a well-defined diet, restriction
The low FODMAP dietary strategy
of fructose and fructans, together with general avoidance of other The pre-dietary workup is important and is outlined in Figure 1.
FODMAPs led to impressive global symptoms response in three Breath hydrogen testing, to define who can completely absorb a
out of four patients with IBS and fructose malabsorption in a load of fructose and/or lactose is very useful as it can reduce the
retrospective study.39 Efficacy was durable and was closely related breadth of dietary restriction that is necessary. It is not strictly
to dietary compliance. That the efficacy of the low FODMAP diet necessary—the fully restricted diet can be initiated—but altering
was due to restriction of fructose and/or fructans in the diet was diet carries the risk of nutritional compromise and it is a good
convincingly shown in a subsequent double-blinded randomized principle not to restrict foods if not necessary.

Journal of Gastroenterology and Hepatology 25 (2010) 252–258 255

© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
The low FODMAP diet PR Gibson and SJ Shepherd

Figure 1 A bi-disciplinary approach to the

patient with functional gastrointestinal disor-
der (FGID), especially irritable bowel syn-
drome or functional bloating. Breath hydrogen
tests determine the degree of dietary restric-
tion necessary by defining who can com-
pletely absorb fructose and/or lactose. Other
FODMAP (oligosaccharides and polyols) are
malabsorbed by all.

The low FODMAP diet has only been evaluated as a dietitian- Limitation of dietary fructose load (in the form of free fruc-
delivered diet.39,42 This has mostly been achieved in a one-to-one tose or sucrose) at any one meal; and
setting, but group education sessions have also been used with Avoidance of foods that are a substantial source of fructans
apparent success. The ability of written literature only to achieve and galactans.
efficacy has not been studied and clinicians should be cautious in Restrict lactose-containing foods, if lactose malabsorption
undertaking such an approach. Patients often only select the parts was demonstrated on breath hydrogen or lactose tolerance
of any diet that appeal to them and ignore the rest. This defeats the testing.
goals the diet is designed to achieve. Avoidance of polyols in, for example, stone fruits and
The strategy used at the first consultation is as follows: mushrooms.
• Define qualitatively the typical eating practices and style of the • Literature providing food lists and reinforcing instructions are
patient. It is important to understand the likely FODMAPs to provided.
which the patient has daily exposure. Pre-completed food • Patients are provided with positive food messages emphasizing
recording diaries and direct questioning of the patient during the suitable food alternatives. To assist in this, verbal descriptions or
consultation can be useful methods to obtain such information. visual props using packages of commercially available food
This enables individualized dietary advice to be given. For alternatives are provided, together with suggestions for their use
example, if a patient already omits lactose-containing foods or application, and information regarding retail outlets likely to
from their diet, then this potential FODMAP would not be con- stock such foods. Several suggestions are provided to cater for a
tributing to ongoing symptoms. wide spectrum of food preferences, and also to optimize variety,
• The physiological framework for the dietary approach (i.e. the and nutritional adequacy in the diet. A sample meal plan encom-
scientific basis of FODMAPs and their malabsorption and sub- passing the dietary principles is also provided.
sequent fermentation) is explained to the patient. This is perti- • Techniques for handling situations where control of food prepa-
nent as it provides the basis for a better understanding of food ration is limited, such as eating away from home (such as res-
choice and may increase the likelihood of durable adherence taurants, school camps and eating at friend’s homes) are
(although this has not been evaluated). discussed.
• Specific dietary instructions are given to the patient: As it is the total dose that will dictate the contribution to symp-
Avoid foods that contain significant free fructose in excess of toms, the accumulated intake of FODMAPs over several days is
glucose, unless complete fructose absorption was demon- critical in defining how strict an individual needs to be. In order to
strated on breath hydrogen testing; ensure symptoms are well-controlled, a strict trial of the low
Encourage choice of foods where fructose and glucose are ‘in FODMAP diet is warranted for the first 6–8 weeks. On the dietetic
balance’, or where glucose is in excess of fructose; review, assessment of symptom response will lead to discussions
Co-ingestion of free glucose to ‘balance’ excess free fructose of individual tolerance, keeping the total FODMAP load in mind.
problematic foods. In practice, many patients will manage, for example, occasional

256 Journal of Gastroenterology and Hepatology 25 (2010) 252–258

© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
PR Gibson and SJ Shepherd The low FODMAP diet

ingestion of wheat or rye breads, garlic as a minor ingredient and they do provide a reminder that this dietary intervention is estab-
small serves of broccoli or cauliflower. Testing of tolerance is a lished for those with functional gut symptoms and is not a diet for
vital stage of the dietetic process to ensure maximum variety in the otherwise healthy people.
diet.
If the symptomatic response is inadequate, specific questioning
is required to determine the adherence to the dietary principles and Conclusions
any deficiencies corrected. If adherence was strict, attention may The low FODMAP diet provides an effective approach to the
be needed to modify intake of resistant starch and insoluble and management of patients with functional gut symptoms, with an
soluble fiber. Other dietary triggers such as food chemicals may increasing evidence base. It is a dietitian-delivered diet that
need to be considered, as should potential factors such as caffeine, achieves a high degree of compliance. It provides relief of global
fat, meal size and regularity. symptoms in the majority of patients with IBS and offers improve-
ment in functional gut symptoms in patients with inflammatory
More than just FGID bowel disease. It warrants widespread application.

There is considerable evidence to point to a strong association of

functional gut disorders with inflammatory bowel disease; FGID Acknowledgments
appears to be about two- to threefold more common in than in the Studies presented in this review were supported by National
general community.43,44 Functional gut symptoms in patients with Health & Medical Research Council of Australia via a project
quiescent inflammatory bowel disease appear to respond just as grant and scholarship for SJS, the Eva and Les Erdi Foundation,
well to the low FODMAP diet.45 Other applications include patients Sir Robert Menzies Memorial Research Scholarship in the Allied
with troublesome frequency of bowel actions in the presence of an Health Sciences.
ileal pouch. In a pilot study, the frequency of pouch emptying was
reduced when the low FODMAP diet was instituted, particularly in
those who had a high dietary intake of FODMAPs, although there References
was little evidence of any benefit in those with pouchitis.46 Like- 1 Drossman DA, Li Z, Andruzzi E et al. U.S. householder survey of
wise, high ileostomy output might respond to reducing dietary functional gastrointestinal disorders. Prevalence, sociodemography,
FODMAP intake, although the study was not performed in patients and health impact. Dig. Dis. Sci. 1993; 38: 1569–80.
who considered their ileostomy output troublesome.7 2 Mertz H. Regional cerebral activation in irritable bowel syndrome
and control subjects with painful and non painful rectal distension.
Gastroenterology 2000; 118: 842–8.
Limitations and potential concerns 3 Salvioli B, Serra J, Azpiroz F, Malagelada JR. Impaired small bowel
The diet is not a panacea for patients with FGID.47 It provides good gas propulsion in patients with bloating during intestinal lipid
relief of symptoms in about 75% of patients, but has little benefit infusion. Am. J. Gastroenterol. 2006; 101: 1853–7.
4 Gibson PR, Shepherd SJ. Personal view: food for thought—western
in some. Studies have yet to identify predictive factors of benefit
lifestyle and susceptibility to Crohn’s disease. The FODMAP
apart from dietary adherence. Intermittent symptoms remain, hypothesis. Aliment. Pharmacol. Ther. 2005; 21: 1399–409.
albeit at a now tolerable level, in many patients since the under- 5 Clausen MR, Jorgensen J, Mortensen PB. Comparison of diarrhea
lying FGID is not directly addressed by the diet. Patients should induced by ingestion of fructooligosaccharide Idolax and
not be given expectations of a ‘cure’. Symptomatic hyperrespon- disaccharide lactulose: role of osmolarity versus fermentation of
siveness to the reintroduction of FODMAPs in the diet has been malabsorbed carbohydrate. Dig. Dis. Sci. 1998; 43: 2696–707.
anecdotally described, although this aspect has not been formally 6 Rumessen JJ, Gudmand-Hoyer E. Fructans of chicory: intestinal
studied. The mechanism for this has also not been evaluated. transport and fermentation of different chain lengths and relation to
However, in rats fed fructose-poor diets, GLUT-5 expression falls fructose and sorbitol malabsorption. Am. J. Clin. Nutr. 1998; 68:
as does the ability to absorb fructose from the small intestine.48 357–64.
7 Barrett JS, Gearry RB, Irving PM et al. Dietary poorly absorbed
Whether this occurs in humans warrants further investigation.
short-chain carbohydrates (FODMAPs) increase the volume and
Restriction of FODMAP intake might potentially have a down fermentable substrate content of ileal output. Gastroenterology 2009;
side. It does mean restriction of dietary components with prebiotic 136 (Suppl. 1): A876.
effects.49 This might potentially be detrimental to large bowel 8 Ong DK, Mitchell SB, Smith S et al. The intestinal fermentative
health (such as the promotion of colorectal carcinogenesis), response to dietary FODMAPs: failure to switch to methane
although no studies have addressed this issue to date. The restric- production in patients with irritable bowel syndrome. J.
tion of wheat-based products may lead to reduced fiber intake, but Gastroenterol. Hepatol. 2008; 23 (Suppl. 4): A219.
part of dietary counseling is to ensure continuing adequate intake 9 Ladas SD, Grammenos I, Tassios PS, Raptis SA. Coincidental
of resistant starch and non-starch polysaccharides. This should be malabsorption of lactose, fructose, and sorbitol ingested at low doses
addressed during the dietary consultation. One study vaguely sug- is not common in normal adults. Dig. Dis. Sci. 2000; 45: 2357–62.
10 Ravich WJ, Bayless TM. Carbohydrate absorption and
gested that restricting FODMAPs in patients with ileal pouch, to
malabsorption. Clin. Gastroenterol. 1983; 12: 335–56.
reduce the frequency of pouch emptying, might increase the risk of 11 Truswell AS, Seach JM, Thorburn AW. Incomplete absorption of
pouchitis.46 Ileostomates who have a low output from the ileo- pure fructose in healthy subjects and the facilitating effect of
stomy might depend upon the osmotic effects of FODMAPs and glucose. Am. J. Clin. Nutr. 1988; 48: 1424–30.
such patients may risk functional bowel obstruction if these are 12 Davidson MH, Maki KC. Effects of dietary inulin on serum lipids. J.
strictly reduced.7 While these suggestions are all unsubstantiated, Nutr. 1999; 129: 1474S–14747S.

Journal of Gastroenterology and Hepatology 25 (2010) 252–258 257

© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
The low FODMAP diet PR Gibson and SJ Shepherd

13 Pedersen A, Sandstrom B, van Amelsvoort JMM. The effect of 33 Würsch P, Koellreutter B, Schweizer TF. Hydrogen excretion after
ingestion of inulin on blood lipids and gastrointestinal symptoms in ingestion of five different sugar alcohols and lactulose. Eur. J. Clin.
healthy females. Br. J. Nutr. 1997; 78: 215–22. Nutr. 1989; 43: 819–25.
14 Hyams JS. Sorbitol intolerance: an unappreciated cause of functional 34 Langkilde AM, Andersson H, Schweizer TF, Würsch P. Digestion
gastrointestinal complaints. Gastroenterology 1983; 84: 30–3. and absorption of sorbitol, maltitol and isomalt from the small
15 Goldstein R, Braverman D, Stankiewicz H. Carbohydrate bowel. A study in ileostomy subjects. Eur. J. Clin. Nutr. 1994; 48:
malabsorption and the effect of dietary restriction on symptoms of 768–75.
irritable bowel syndrome and functional bowel complaints. Isr. Med. 35 Andersson DE, Nygren A. Four cases of long-standing diarrhoea and
Assoc. J. 2000; 2: 583–7. colic pains cured by fructose-free diet: a pathogenetic discussion.
16 Rumessen JJ, Gudmand-Hoyer E. Absorption capacity of fructose Acta Med. Scand. 1978; 203: 87–92.
in healthy adults. Comparison with sucrose and its constituent 36 Johlin FC Jr, Panther M, Kraft N. Dietary fructose intolerance: diet
monosaccharides. Gut 1986; 27: 1161–8. modification can impact self-rated health and symptom control. Nutr.
17 Kneepkens CM, Vonk RJ, Fernandes J. Incomplete intestinal Clin. Care. 2004; 7: 92–7.
absorption of fructose. Arch. Dis. Child. 1984; 59: 735–8. 37 Ledochowski M, Widner B, Bair H, Probst T, Fuchs D. Fructose-
18 McBean LD, Miller GD. Allaying fears and fallacies about lactose and sorbitol reduced diet improves mood and gastrointestinal
intolerance. J. Am. Diet. Assoc. 1998; 98: 671–6. disturbances in fructose malabsorbers. Scand. J. Gastroenterol. 2000;
19 Nelis GF, Vermeeren MA, Jansen W. Role of fructose-sorbitol 35: 1048–52.
malabsorption in the irritable bowel syndrome. Gastroenterology 38 Fernandez-Banares F, Esteve-Pardo M, Humbert P, de Leon R,
1990; 99: 1016–20. Llovet JM, Gassull MA. Role of fructose-sorbitol malabsorption in
20 Rumessen JJ, Gudmand-Hoyer E. Functional bowel disease: the irritable bowel syndrome. Gastroenterology 1991; 101: 1453–4.
malabsorption and abdominal distress after ingestion of fructose, 39 Shepherd SJ, Gibson PR. Fructose malabsorption and symptoms of
sorbitol, and fructose-sorbitol mixtures. Gastroenterology 1988; 95: irritable bowel syndrome: guidelines for effective dietary
694–700. management. J. Am. Diet. Assoc. 2006; 106: 1631–9.
21 Teuri U, Vapaatalo H, Korpela R. Fructooligosaccharides and 40 Shepherd SJ, Parker FJ, Muir JG, Gibson PR. Dietary triggers of
lactulose cause more symptoms in lactose maldigesters and subjects abdominal symptoms in patients with irritable bowel syndrome:
with pseudohypolactasia than in control lactose digesters. Am. J. randomised placebo-controlled evidence. Clin. Gastroenterol.
Clin. Nutr. 1999; 69: 973–9. Hepatol. 2008; 6: 765–71.
22 Gibson PR, Newnham E, Barrett JS, Shepherd SJ, Muir JG. Review 41 Shepherd S, Willet I, Fone D et al. The value of the ‘fructose
article: fructose malabsorption and the bigger picture. Aliment. malabsorption’ (FM) diet and the fructose breath hydrogen test in
Pharmacol. Ther. 2007; 25: 349–63. patients with irritable bowel syndrome (IBS). J. Gastroenterol.
23 Bate JP, Irving PM, Barrett JS, Gibson PR. Benefits of breath Hepatol. 2003; 18 (Suppl.): B126.
hydrogen testing following lactulose administration in analyzing 42 Barrett JS, Gibson PR. Clinical ramifications of malabsorption of
carbohydrate malabsorption. Eur. J. Gastroenterol. Hepatol. 2009; fructose and other short-chain carbohydrates. Pract. Gastroenterol.
[Epub July 24]. 2007; 31: 51–65.
24 Barrett JS, Irving PM, Shepherd SJ, Muir JG, Gibson PR. 43 Farrokhyar F, Marshall JK, Easterbrook B, Irvine EJ. Functional
Comparison of the prevalence of fructose and lactose malabsorption gastrointestinal disorders and mood disorders in patients with
across chronic intestinal disorders. Aliment. Pharmacol. Ther. 2009; inactive inflammatory bowel disease: prevalence and impact on
30: 165–74. health. Inflamm. Bowel. Dis. 2006; 12: 38–46.
25 Muir J, Shepherd SJ, Rosella O, Rose R, Barrett J, Gibson P. 44 Mikocka-Walus AA, Turnbull DA, Andrews JM, Moulding NT,
Fructan and free fructose content of common Australian vegetables Holtmann GJ. The effect of functional gastrointestinal disorders on
and fruit. J. Agric. Food Chem. 2007; 55: 6619–27. psychological comorbidity and quality of life in patients with
26 Muir JG, Rose R, Rosella O et al. Measurement of short-chain inflammatory bowel disease. Aliment. Pharmacol. Ther. 2008; 28:
carbohydrates (FODMAPs) in common Australian vegetables and 475–83.
fruit by high performance liquid chromatography (HPLC) with 45 Gearry RB, Irving PM, Barrett JS, Nathan D, Shepherd SJ,
evaporative light-scattering detection (ELSD). J. Agric. Food Chem. Gibson PR. Reduction of dietary FODMAPs improves abdominal
2009; 57: 554–65. symptoms in patients with inflammatory bowel disease. J. Crohns
27 Nilsson U, Dahlqvist A. Cereal fructosans: Part 2—characterisation Colitis 2009; 3: 8–14.
and structure of wheat fructosans. Food Chem. 1986; 22: 95–106. 46 Croagh C, Shepherd SJ, Berryman M, Muir JG, Gibson PR. A pilot
28 Bach Knudsen KE, Hessov I. Recovery of inulin from Jerusalem study on the effect of reducing dietary FODMAP intake on bowel
artichoke (Helianthus tuberosus L.) in the small intestine of man. Br. function in patients without a colon. Inflamm. Bowel Dis. 2007; 13:
J. Nutr. 1995; 74: 101–13. 1522–8.
29 Lomer MC, Parkes GC, Sanderson JD. Review article: lactose 47 Rangnekar AS, Chey WD. The FODMAP diet for IBS: food fad or
intolerance in clinical practice—myths and realities. Aliment. roadmap to a new treatment paradigm? Gastroenterology 2009; 137:
Pharmacol. Ther. 2008; 27: 93–103. 383–6.
30 Munro IC, Berndt WO, Borzelleca JF et al. Erythritol: an 48 Kishi K, Tanaka T, Igawa M et al. Sucrase-isomaltase and hexose
interpretive summary of biochemical, metabolic, toxicological and transporter gene expressions are coordinately enhanced by dietary
clinical data. Food Chem. Toxicol. 1998; 36: 1139–74. fructose in rat jejunum. J. Nutr. 1999; 129: 953–6.
31 Fordtran JS, Rector FC Jr, Ewton MF, Soter N, Kinney J. 49 Hopkins MJ, Cummings JH, Macfarlane GT. Inter-species
Permeability characteristics of the human small intestine. J. Clin. differences in maximum specific growth rates and cell yields of
Invest. 1965; 44: 1935–44. bifidobacteria cultured on oligosaccharides and other simple
32 Fordtran JS, Rector FC, Locklear TW, Ewton MF. Water and solute carbohydrate sources. Selective stimulation of bifidobacteria in the
movement in the small intestine of patients with sprue. J. Clin. human colon by oligofructose and inulin. J. Appl. Microbiol. 1998;
Invest. 1967; 46: 287–98. 85: 381–6.

258 Journal of Gastroenterology and Hepatology 25 (2010) 252–258

© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd