Low FODMAP diet improves gastrointestinal symptoms in patients with celiac disease
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A short-term, moderately low FODMAP diet, in addition to a strict gluten-free diet, significantly reduced gastrointestinal symptoms and improved disease-specific health in celiac patients, according to a study.
“There are no recommendations or guidelines for patients with [celiac disease (CeD)] in remission with ongoing symptoms, but dietary interventions, in addition to a gluten-free diet, could be a treatment option for persistent IBS-like symptoms in CeD,” Frida van Megen, a doctoral research fellow at the department of clinical services at Oslo University Hospital Rikshospitalet in Norway, and colleagues wrote in Clinical Gastroenterology and Hepatology.
Van Megan and colleagues sought to assess the efficacy of a moderately low fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet, along with a strict gluten-free diet, on persistent GI symptoms, CeD-specific health and fatigue, compared with a gluten-free diet alone.
In a randomized, controlled study, researchers included 70 adults with biopsy-proven celiac disease and persistent GI symptoms, defined by a Gastrointestinal Symptom Rating Scale-IBS version (GSRS-IBS) score greater than or equal to 30; gluten-free diet adherence for at least 12 months; and serological and mucosal remission. Patients were randomized to either the low FODMAP-gluten-free diet intervention group or the gluten-free diet control group. GSRS-IBS was recorded at baseline and weeks 1 through 4, and Celiac Symptom Index (CSI) was recorded at baseline and week 4.
FODMAP intake during the intervention period was classified as moderately low (mean 8.1 g/day; 95% CI, 6.7-9.3).
Although GSRS-IBS total scores between the intervention group and control group were similar at baseline (39 vs. 36.8, respectively), they differed significantly after week 1 (29.5 vs. 36.3, respectively) and persisted through week 4 (27.1 vs. 36.1, respectively). CSI scores also were significantly lower in the intervention group at week 4 compared with the control group (31.9 vs. 37.1, respectively), as were recordings of pain, bloating, diarrhea and satiety (P 0.04). However, significantly lower scores were not observed for constipation.
“A low FODMAP diet should be considered [for implementation] in clinical practice for the management of persistent symptoms in treated CeD,” Van Megen and colleagues concluded. “However, patients with CeD already follow a restrictive diet, and further dietary restrictions may increase the burden of CeD by limiting food variability and make eating outside of home extremely challenging.”
Perspective
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Alberto Rubio Tapia, MD
Persistent symptoms are frequent after starting a gluten-free diet for the management of celiac disease (CeD, so-called nonresponsive CeD). The differential for persistent symptoms requires a systematic evaluation, including verification of the original diagnosis, diet review for accidental gluten contamination and investigation of other causes of persistent symptoms beyond gluten contamination, such as small bowel bacterial overgrowth, exocrine pancreatic insufficiency, microscopic colitis, irritable bowel syndrome and, rarely, true refractory CeD. The treatment for nonresponsive CeD should be directed to the specific reason for persistent symptoms (eg, antibiotic therapy for small bowel bacterial overgrowth or pancreatic enzyme supplementation for exocrine pancreatic insufficiency).
IBS is a common diagnosis in patients with nonresponsive CeD. This small, randomized control trial demonstrated efficacy for reduction of some gastrointestinal symptoms related to IBS (eg, pain, bloating and diarrhea) and modest improvement of CeD-specific health in patients with treated CeD with persistent symptoms following a short-term, moderately low FODMAP diet. Of note, inclusion criteria required strict adherence to the gluten-free diet for 12 months, negative celiac serology during follow-up and normalized duodenal biopsy. Therefore, a low FODMAP diet should be considered in clinical practice only in this subgroup of treated celiac patients on serologic and mucosal remission with persistent symptoms and strong clinical suspicion of IBS as the possible cause for their symptoms.
Diet implementation would require dietitian instruction and close clinical follow-up with symptom improvement expected as early as after only 1 week of starting the low FODMAP diet. In patients with adequate response to low FODMAP diet, shared decision-making with the patient would be needed for continuation of the diet beyond 4 weeks, as the safety and long-term consequences of following two complex diets are unknown. Patients should be followed up carefully by a physician and a dietitian if the decision is to continue the low FODMAP diet beyond 4 weeks to avoid the risk of inadequate nutritional intake. In patients without improvement on the low FODMAP diet, a systematic evaluation (as described above) for other causes of nonresponsive CeD seems very reasonable with subsequent management directed to the specific reason for persistent symptoms.
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