Original article—alimentary tract
Dietary Triggers of Abdominal Symptoms in Patients With Irritable Bowel Syndrome: Randomized Placebo-Controlled Evidence

Findings in this article have been presented at the Australian Gastroenterology Week, October 2006 and an abstract published as follows: Shepherd S, Gibson PR. Role of dietary fructose and fructans in initiating symptoms of IBS in fructose malabsorbers. J Gastroenterol Hepatol 2006;18(Suppl):B102.
https://doi.org/10.1016/j.cgh.2008.02.058Get rights and content

Background & Aims: Observational studies suggest dietary fructose restriction might lead to sustained symptomatic response in patients with irritable bowel syndrome (IBS) and fructose malabsorption. The aims of this study were first to determine whether the efficacy of this dietary change is due to dietary fructose restriction and second to define whether symptom relief was specific to free fructose or to poorly absorbed short-chain carbohydrates in general. Methods: The double-blinded, randomized, quadruple arm, placebo-controlled rechallenge trial took place in the general community. The 25 patients who had responded to dietary change were provided all food, low in free fructose and fructans, for the duration of the study. Patients were randomly challenged by graded dose introduction of fructose, fructans, alone or in combination, or glucose taken as drinks with meals for maximum test period of 2 weeks, with at least 10-day washout period between. For the main outcome measures, symptoms were monitored by daily diary entries and responses to a global symptom question. Results: Seventy percent of patients receiving fructose, 77% receiving fructans, and 79% receiving a mixture reported symptoms were not adequately controlled, compared with 14% receiving glucose (P ≤ 0.002, McNemar test). Similarly, the severity of overall and individual symptoms was significantly and markedly less for glucose than other substances. Symptoms were induced in a dose-dependent manner and mimicked previous IBS symptoms. Conclusions: In patients with IBS and fructose malabsorption, dietary restriction of fructose and/or fructans is likely to be responsible for symptomatic improvement, suggesting efficacy is due to restriction of poorly absorbed short-chain carbohydrates in general.

Section snippets

Patient Selection

Twenty-six patients with IBS and FM were recruited during a 5-month period from a hospital-based dietetic practice serving the community. Inclusion criteria comprised diagnosis of IBS fulfilling Rome II criteria,26 positive fructose breath hydrogen test following a 35-g load of fructose, instruction at least 3 months before recruitment in the low FODMAP diet (as outlined in detail elsewere22, 23), and marked and sustained global improvement in gastrointestinal symptoms on the diet. Patients

Patients

One of the 26 patients recruited was excluded from all analyses because she withdrew before completing the first test drink arm. No data were collected for some test arms in 3 patients; one withdrew after 2 test arms because of family tragedy; one developed acute cholecystitis during the third arm, underwent cholecystectomy, and was withdrawn from the study; and one failed to complete records for 1 arm, such that end points could not be assessed. Five patients did not follow protocol in 1 test

Discussion

Providing high level evidence in support of therapeutic dietary interventions is difficult because of complexity of diet, heterogeneity of dietary intake across the community, and difficulty in successfully instituting change in dietary patterns. It is for these reasons that a placebo-controlled “rechallenge” design was used on the background of controlled dietary intake. The results of the study represent the first high-level evidence that dietary FODMAPs, in the form of fructose and fructans,

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    Susan J. Shepherd was supported by a National Health & Medical Research Council postgraduate biomedical scholarship. Foods were donated by the following organizations: ACI packaging, Advanced Brockerage Australia (Liddell's), Bundaberg Sugar, Cerebos Foods, Coles supermarket, Confoil Pty Ltd, Country Life, Duncan Davis Smallgoods, Findus, Freedom Foods (Aust) Pty Ltd, Goodman Fielder Pty Ltd, Greens General Foods Pty Ltd, Heinz, Ingham chicken, Lactos Pty Ltd, Massel Australia Pty Ltd, McCormick Foods Australia Pty Ltd, National Foods, Orgran (Roma Foods), Pace Farm Pty Ltd, Pakval, Purewater, Riviana Foods, Silly Yaks, Simplot Australia Pty Ltd, Sunrice, The Smiths Snackfood Company Ltd, Trialia Foods, Uncle Rick's, Virgona Fruit and Vegetables.

    Susan J. Shepherd has published three cookbooks directed toward issues of fructose malabsorption and celiac disease. The term FODMAPs has been registered by Susan Shepherd and Peter Gibson.

    We thank Lance Schiapulus for developing and formulating the test drinks, Nia Rosella and Rosemary Rose for technical support, and Paul Rose, Kathryn Stephens, and Martin Shepherd for logistical support.

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