Implementation of the low FODMAP diet in functional gastrointestinal symptoms: a real-world experience

Background: The low FODMAP (fermentable oligo-, di-, monosaccharides, and polyols) diet reduces functional gastrointestinal symptoms (FGID) when implemented by dietitian-delivered education in clinical trials, but it is unknown how well the diet is followed in routine clinical care and if differences exist when implemented by physician or dietitian. This study aimed to evaluate the real-world experience of patients recommended the diet. Methods: This case-series interviewed FGID patients attending a gastroenterology clinic with previous recommendation to trial the low FODMAP diet, examining who recommended the diet and what their percentage improvement was. To evaluate implementation of the diet's 3 phases, questions were constructed based on current literature and clinical guidelines regarding length of initial restriction and food knowledge (Phase-1), number of foods re-challenged (Phase-2) and food re-introduction as tolerated (Phase-3). The comprehensive nutrition assessment questionnaire provided daily FODMAP intake. Data were analyzed using chi-squared tests. Key Results: In 80 patients (21 male), the diet was recommended by the gastroenterologist in 53%, general practitioner 22%, dietitian 9% and other 15%. 30% saw a dietitian for guidance. 55% reported a ≥50% symptom improvement. The diet was followed appropriately during Phase-1 by 78% (with vs without a dietitian, 96% vs 71%; P =.02), Phase-2 by 48% (70% vs 39%; P =.02) and Phase-3 by 40% (65% vs 29%; P <.01). A FODMAP intake of <12 g/d (considered therapeutic) was achieved by 44% (72% vs 31%; P <.01). Conclusions & inferences: Symptom improvement was reported in half of patients, but many did not reach the therapeutic FODMAP intake target, especially without dietitian education. Compliance was poor in Phase-2 and Phase-3 but improved with dietitian guidance.