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A Systematic Review and Meta-Analysis Evaluating the Efficacy of a Gluten-Free Diet and a Low FODMAPS Diet in Treating Symptoms of Irritable Bowel Syndrome

Dionne, Joanna, MD, MSc, FRCP, PhD1; Ford, Alexander C., MB, ChB, FRCP2,3; Yuan, Yuhong, MD1; Chey, William D., MD, FACG4; Lacy, Brian E., MD, PhD, FACG5; Saito, Yuri A., MD, MPH6; Quigley, Eamonn M. M., MD, FRCP, FACP, MACG, FRCPI7; Moayyedi, Paul, MB, ChB, PhD, FACG1,8

American Journal of Gastroenterology: September 2018 - Volume 113 - Issue 9 - p 1290–1300
doi: 10.1038/s41395-018-0195-4

OBJECTIVE: Dietary triggers such as gluten and highly fermentable oligo-, di- and monosaccharides and polyols (FODMAP)-containing foods have been associated with worsening irritable bowel syndrome (IBS) symptoms. However, the true impact of dietary restriction on IBS symptoms has remained unclear. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) examining the efficacy of exclusion diets (we focused on low FODMAP and gluten-free diets (GFD)) in IBS.

METHODS: We conducted a search of the literature using the electronic databases MEDLINE (1946 to November 2017), EMBASE (1974 to November 2017), Cochrane Central Register of Controlled Trials (November 2017), and Cochrane Database of Systematic Reviews (2005 to November, 2017) for RCTs of exclusion diets in IBS. Two independent reviewers screened citations and a third reviewer resolved disagreement. Two independent reviewers performed eligibility assessment and data abstraction. For inclusion, RCTs that evaluated an exclusion diet versus an alternative or usual diet and assessed improvement in either global IBS symptoms or abdominal pain were required. Data were synthesized as relative risk of symptoms remaining using a random effects model. Quality of evidence was assessed using GRADE methodology.

RESULTS: A total of 1726 citations were identified. After full-text screening a total of nine studies were eligible for the systematic review. There were two RCTs of a GFD, involving 111 participants. Both selected patients who responded to a GFD and then randomized them to continue the diet or have the diet “spiked” with gluten. A GFD was associated with reduced global symptoms compared with a control diet (RR = 0.42; 95% CI 0.11 to 1.55;I2 = 88%), although this was not statistically significant. There were seven RCTs comparing a low FODMAP diet with various control interventions in 397 participants. A low FODMAP diet was associated with reduced global symptoms compared with control interventions (RR = 0.69; 95% CI 0.54 to 0.88;I2 = 25%). The three RCTS that compared low FODMAP diet with rigorous control diets had the least heterogeneity between studies, but also the least magnitude of effect. The overall quality of the data was “very low” according to GRADE criteria.

CONCLUSIONS: There is insufficient evidence to recommend a GFD to reduce IBS symptoms. There is very low quality evidence that a low FODMAP diet is effective in reducing symptoms in IBS patients.

1Division of Gastroenterology, McMaster University, Hamilton, ON, Canada. 2Leeds Gastroenterology institute, St. James's University Hospital, Leeds, UK. 3Leeds institute of Biomedical and clinical sciences, university of leeds, leeds, UK. 4Division of Gastroenterology, university of Michigan health system, Ann Arbor, MI, USA. 5Mayo clinic, jacksonville, FL, USA. 6Mayo clinic, Rochester, MN, USA. 7Division of Gastroenterology and hepatology, department of Medicine, houston Methodist hospital, houston, TX, USA. 8Farncombe Family digestive health Research institute, McMaster university, hamilton, ON, canada.

Correspondence: P.M. (email:

Received 10 April 2018; accepted 18 June 2018; Published online 26 July 2018

© The American College of Gastroenterology 2018. All Rights Reserved.
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