REVIEW

CURRENT
OPINION Diet and irritable bowel syndrome
Anusha Thomas a and Eamonn M.M. Quigley a,b

Purpose of review
Those who suffer from irritable bowel syndrome (IBS) have long reported the frequent precipitation
of their symptoms in relation to food ingestion and have often been convinced that certain foods
were especially problematic. However, until very recently, research on the responses to food or
individual dietary constituents, in IBS, has been scarce. This review addresses recent literature on diet and
IBS.
Recent findings
The complexity of foodsymptom interactions in IBS is being revealed in recent and ongoing research.
Such studies have revealed the variable effects of fibre in IBS and the susceptibility of IBS individuals to the
ingestion of poorly digested and absorbed carbohydrates. The latter has led to the widespread adoption of
the low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) diet. Less
certain is the role of another widely adopted dietary strategy, gluten restriction. Dietmicrobe interactions
are critical to the homeostasis of the gut microbiome in health and may well be disturbed in disease;
enthusiasm continues, therefore, for the use of probiotics in IBS.
Summary
Food is a common precipitant of symptoms in IBS and recent research has focused on the role(s) of
individual dietary constituents in IBS and on fibre, FODMAPs, gluten and probiotics, in particular. Each
may have a role in certain IBS sufferers.
Keywords
diet, FODMAPs, gluten, irritable bowel syndrome, probiotics

INTRODUCTION gastrointestinal disorders is the rule rather than the

Irritable bowel syndrome (IBS) is a chronic func-
tional gastrointestinal disorder characterized by
abdominal pain or discomfort associated with
abnormal bowel habit in the absence of any cur-
rently detectable structural, physiological or bio-
chemical abnormalities of the gastrointestinal
tract. In the absence of a reliable or a validated
biomarker, IBS is defined on the basis of symptoms
according to one of several diagnostic systems. Most
common amongst these are the Rome criteria,
which have now gone through three iterations;
pending the outcome of the fourth set of such
deliberations, Rome III diagnostic criteria remain
the benchmark for the diagnosis of IBS in clinical
research. According to Rome III, IBS is defined by the
presence of recurrent abdominal pain or discomfort
for at least 3 days per month in the past 3 months,
associated with 2 or more of the following: improve-
ment with defecation, onset associated with a
change in the frequency of stool or onset associated
with a change in the form or appearance of stool [1].
Bloating, distension and fatigue are also commonly
featured in IBS and overlap with other functional
exception. IBS symptoms are common in the gen-
eral population and, in a minority of sufferers, exert
a significant negative impact on quality of life, work,
education and family life. Consequently, IBS is
responsible for imparting considerable morbidity
as well as a significant economic burden, through-
out the world and in Western society, in particular
[25]. Despite these costs to society and the indi-
vidual and decades of clinical and laboratory inves-
tigations into the pathophysiology of IBS, our
understanding of IBS remains incomplete and its
treatment, therefore, somewhat unsatisfactory [6].
IBS is undoubtedly a heterogeneous disorder and
a
Department of Internal Medicine and bDivision of Gastroenterology and
Hepatology, Houston Methodist Hospital, Weill Cornell Medical College,
Houston, Texas, USA
Correspondence to Eamonn M.M. Quigley, MD, FRCP, FACP, FACG,
FRCPI, Gastroenterology and Hepatology, Houston Methodist Hospital,
6550 Fannin St, SM 1001, Houston, TX 77030, USA. E-mail: equi
gley@tmhs.org
Curr Opin Gastroenterol 2015, 31:166171
DOI:10.1097/MOG.0000000000000158

www.co-gastroenterology.com Volume 31  Number 2  March 2015

Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Food is a common precipitant of symptoms in IBS.
 Multiple factors may contribute to the occurrence of
symptoms in relation to food ingestion in IBS.
 Although food allergy may not be common in IBS, food
intolerance and problems with FODMAPs, in particular,
appear to be common among IBS sufferers.
 The status of gluten restriction as a therapeutic strategy,
in IBS, is unclear.
 Probiotics, in general, have been shown to ameliorate
IBS symptoms.
may, indeed, encompass a number of distinct enti-
ties. It comes as no surprise, therefore, that over the
years a number of factors have been proposed as
relevant to the etiopathogenesis of IBS and its var-
ious symptoms. Over the years, these have ranged
from genetics to gut dysmotility, visceral hypersen-
sitivity, altered brain processing of visceral signals
and abnormal psycho-neuro-endocrine and hypo-
thalamic-pituitary-adrenal responses [7,8]. Along
the way, the frequent association of IBS with anxiety
and depression has often led to the latter acting as
confounding variables in IBS research. In an attempt
to introduce some uniformity to the field, the para-
digm of the brain-gut axis emerged as a unifying
concept [9], with various manifestations and/or pre-
sentations of IBS being seen to locate themselves on
one or other point along this axis. Accordingly, in
some individuals, their symptoms may be largely of
central origin, in others, more peripheral/gut-
located factors may predominate. Indeed, of late,
research in IBS has to a significant extent focused
more on a number of putative peripheral factors,
and progress in this area has been facilitated by
advances in our understanding of the enteric nerv-
ous system, the gut microbiome, mucosal immune
responses, epithelial barrier function and epithelial
secretory mechanisms. Indeed, abnormalities in the
&
gut microbiome [10 ,11], the host immune
response, the epithelial barrier, intestinal secretion
[12], as well as systemic immune mediators [13] have
been variably identified in IBS individuals, sub-
groups thereof or experimental models, and novel
therapeutic strategies developed accordingly.
Unfortunately, few of these have, as yet, led to
effective and targeted treatment strategies for IBS
sufferers [14]. Most recently, and belatedly, the
important role of the ubiquitous interloper into
the gastrointestinal environment, food, has begun
0267-1379 Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Diet and irritable bowel syndrome Thomas and Quigley
to be recognized and serious research efforts devoted
to understanding its role in IBS and to the develop-
ment of dietary approaches to the management
of IBS.
FOOD, DIET AND IRRITABLE BOWEL
SYNDROME
IBS sufferers clearly identify that eating is one of the
most common precipitants of their symptoms
&& &
[15 ,16 ,17] and food-related symptoms impact sig-
&
nificantly on quality of life [16 ]. Indeed, the pre-
cipitation of symptoms immediately or soon after
eating is a distinguishing feature of IBS and has been
shown to permit its separation from another com-
mon functional disorder, chronic constipation [18].
In the absence of much in the way of good clinical
science, IBS sufferers have been prey to various tests
and remedies of doubtful provenance that link IBS
to any one of a host of allergies and intolerances.
Such medically unsupervised or individually con-
cocted diets may not only be of little benefit but may
also be so restrictive as to expose the individual to
the risk of serious nutritional deficiencies [19]. It is
important to note that true food allergies are
&&
uncommon in IBS [20 ]. Thus, although the preva-
lence of true food allergies in Western societies is
between 1 and 3% in adults, surveys of gastrointes-
tinal clinic patients found that 3050% believed
that their symptoms represented food allergy or
&&
food intolerance [20 ]. Immune responses to food
in IBS may be much more subtle, however. Thus,
&&
Fritscher-Ravens et al. [21 ] have thrown new light
on interactions between food antigens and IBS.
They studied 36 IBS patients with suspected food
intolerance and 10 controls using confocal laser
endomicroscopy and demonstrated, in response to
intraduodenal instillation of food antigens, ultra-
structural changes in 22 of 36 patients but none of
controls. Such changes included an increase in
intra-epithelial lymphocytes, formation of epi-
thelial leaks/gaps and widening of intervillous
spaces. These responses were rapid (within 5 min)
and also predicted a subsequent response to an
exclusion diet. These findings are reminiscent of
earlier findings in relation to gluten in IBS wherein
conventional serology was negative but celiac anti-
bodies were detected in duodenal fluid samples [22],
suggesting that food allergic responses in IBS may
be largely mucosal rather than systemic.
Are there other explanations for food-related
symptoms in IBS? A number of factors deserve con-
sideration, which are listed below:
(1) True food allergy;
(2) The physiological response to food ingestion;
www.co-gastroenterology.com 167
Nutrition
(3) Impact of certain molecules contained in the
diet;
(4) Intolerance to food(s);
(5) Interactions with the microbiota;
(6) Psychological reactions.
Of these, an exaggerated physiological response
to food is the most time honoured with an abnormal/
accentuated gastro-colonic motor response to food
ingestion described several decades go. Although
there is experimental evidence to suggest that dietary
levels of individual molecules, such as tryptophan,
may influence both central and peripheral symptoms
& serving as attractive options in the therapy of con-
in IBS and related disorders [23 ], the relevance of
such findings to the dietary management of IBS is
unclear. Recent data would suggest that, although
only 1127% of patients can accurately identify the
presumed offending food when re-challenged in a
double-blind manner, many food-related IBS symp-
toms appear to represent food intolerance rather than
&&
allergy [24 ].
Although a tremendous range and variety of
foods have been incriminated in dietary surveys,
some culprits have emerged with some consist-
ency and include wheat, fruit and vegetables
[19,25], findings that may come as somewhat of
a surprise given our traditional insistence on the
inclusion of these foods in dietary recommen-
dations for IBS. Indeed, diet and lifestyle modifi-
cation, which included fibre supplementation
along with symptomatic pharmacological agents
and, where appropriate, psychological interven-
tions, have been the bulwark of IBS management.
It is now abundantly evident that diet, in both the
short-term and long-term, is a significant modifier
of the microbiome [26,27]. Metabolic interactions
between components of the diet and products of
digestion will alter the luminal environment
through changes in short-chain fatty acids, gases
and bile acids, for example; each of these can alter
gut function and generate symptoms. Finally, food
ingestion has profound psychological and social
implications. Thus, the individual who, on a
previous occasion, experienced profound and
embarrassing urgency in a restaurant will forever
be gripped with fear when confronted with a
similar situation and may, therefore, forego all
such social activities.
It is abundantly evident that the role(s) of food, in
general, and of food components, in particular, is
complex and may vary considerably in various IBS
populations and even between individual IBS patients.
At this stage, it does not seem possible to clinically
define those who are food sensitive/intolerant and are
likely to respond to a particular strategy. Several have,
168 www.co-gastroenterology.com
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
nevertheless, been introduced into the management of
IBS sufferers and will be assessed in the remaining
sections of this manuscript.
FIBRE AND BULKING AGENTS
For decades, fibre and fibre supplements (bulking
agents) were the mantra in the management of IBS.
Synthetic and naturally occurring fibre supplements
such as psyllium, calcium polycarbophil, bran and
ispaghula husk have been examined extensively and
were found to increase stool frequency, improve
stool consistency and accelerate transit, thereby
stipation-predominant IBS. Interpreting the clinical
benefits of fibre has been more challenging.
Although fibre and fibre supplements, in general,
seem to help constipation, some studies reported
the exacerbation of symptoms, and bloating, in
particular, in response to fibre. However, most of
the studies involving these agents have been small
and have contributed to conflicting results in a
number of meta-analyses. In general, and, as con-
firmed in the most recent systematic review and
&&
meta-analysis [24 ,28], soluble fibres (psyllium,
calcium polycarbophil, ispaghula) are effective in
IBS, whereas bran does not appear to be of benefit.
Despite earlier claims to the contrary, this latest
review did not uncover any evidence of harm from
this intervention [28]. Fibre appears therefore to
have a limited and formulation-dependent role
in IBS.
FODMAPS (FERMENTABLE
OLIGOSACCHARIDES, DISACCHARIDES,
MONOSACCHARIDES AND POLYOLS)
Short-chain carbohydrates are poorly absorbed by
the gastrointestinal tract. Via their osmotic effects in
the intestinal lumen, rapid fermentation by gut
bacteria to short-chain fatty acids (SCFAs) and
associated gas production, these molecules can
impact significantly on colonic function [29,30].
By stimulating the release of serotonin from the
intestinal mucosa, high-amplitude, propagated
colonic contractions are initiated leading to accel-
erated intestinal transit, further contributing to the
exacerbation of symptoms in patients with IBS. IBS
patients and some clinical studies, indeed, noted
that foods that are now included in the FODMAP
category exacerbated their symptoms, but as many
of these foods included fruits and vegetables,
regarded as essential constituents of a healthy diet,
they persisted to ingest the offending items. On
the basis of evidence that the restriction of such
Volume 31  Number 2  March 2015

carbohydrates could alleviate symptoms [31], for-
mal controlled trials of low FODMAP diets, albeit
involving small patient numbers, went on to docu-
ment their beneficial impact on many of the cardi-
nal symptoms of IBS, including that most resistant
&&
of symptoms, bloating [32 ]. This dietary approach
to IBS has been widely employed, but it must be
stressed that this diet is not easy to implement and
proves difficult to maintain, for some. Given the role
of SCFAs and other products of FODMAPs in colonic
homeostasis, defining the long-term consequences
of this diet on the microbiome and colonic integrity
will be important [30,33].
Diets based on the exclusion of individual FOD-
MAPs have received less attention of late despite
past enthusiasm for the exclusion of lactose, fruc-
tose and sorbitol in IBS. One recent study confirmed
the benefits of fructose exclusion for some patients
and also the lack of predictability of a fructose
tolerance test [34].
GLUTEN
On the basis of patient reports, as well as clinical
studies, there has been a suspicion for some time
that some individuals with IBS who clearly did not
have celiac disease appeared to be sensitive to or
intolerant of gluten-containing food and the term
nonceliac gluten sensitivity has been acknowledged
by experts in the field [35,36]. That gluten might
play a role in IBS-like syndromes is supported by the
symptomatic overlap between IBS and celiac disease
[3741] as well as the precipitation of their typical
symptoms in IBS individuals when exposed, in a
&&
blinded fashion, to gluten [42,43,44 ]. In one of
these studies, gluten-related disturbances in gastro-
intestinal function were also documented and
those IBS individuals harbouring the human leuko-
cyte antigen (HLA) haplotypes associated with cel-
iac disease were more susceptible to the effects of
&&
gluten [44 ]. The pathogenesis of gluten-related (or
more correctly, perhaps, wheat-induced) symptoms
in IBS and the benefits of a gluten-free diet remain
unclear. Although some studies suggest benefits
from gluten restriction [45], other studies found
little additive benefit for gluten restriction over
and above that conferred by a low FODMAP diet
&&
[46 ]. The latter finding suggests that it is the
fructan component of wheat (a FODMAP) and
not gluten that is the guilty party in wheat sensi-
tivity in IBS. Limited results from formal testing of
the immune response to gluten in IBS would sup-
port a nonimmune basis for nonceliac gluten sen-
sitivity [47]. The role of a gluten-free diet in IBS
remains unclear.
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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Diet and irritable bowel syndrome Thomas and Quigley
PROBIOTICS, PREBIOTICS AND
SYNBIOTICS
As the role of the microbiota in IBS has come to be
explored and changes in microbial composition
described, in IBS [48], enthusiasm for therapeutic
interventions that could beneficially modulate the
&
microbiota has increased [49,50 ]. Among these, the
food supplements probiotics, prebiotics and synbi-
otics are of relevance to this review. Data from
animal models, as well as clinical research in
humans, have revealed a number of properties of
probiotics that could be of value in the management
of IBS. These include antipathogenic and anti-
inflammatory effects, modulation of gut motility
and visceral hypersensitivity, restoration of epi-
thelial integrity, as well as altering the microbiome
&
and its metabolic activity [49,50 ,51]. Prebiotics,
such as fructo-oligosaccharides and inulin and syn-
biotics (combinations of prebiotics and probiotics),
though less studied, could, by stimulating either the
growth or the activity of bacteria that are beneficial
to human health, exert similar effects.
Numerous individual studies have attested to
the beneficial impact of probiotics (particularly Lac-
tobacillus or Bifidobacterium species) on IBS symp-
toms and, especially, on bloating, and flatulence
[52]; more global effects on overall symptomatology
and quality of life have been less frequently docu-
mented [49]. That probiotics, in general, are
beneficial in IBS was confirmed by a recent meta-
analysis [53]; similar benefits could not be con-
firmed in this study for prebiotics and synbiotics.
However, despite the reported benefits of probiotics
in IBS, there are many aspects of this approach that
remain to be resolved, such as the optimal strain,
dosage and treatment duration. The small size and
less than optimal study design of many studies to
date precludes, in large part, the development of
very specific advice on probiotics, prebiotics and
synbiotics in IBS.
PEPPERMINT OIL
This antispasmodic, available over-the-counter and
in health food stores, acts primarily as a calcium
channel blocker, thereby facilitating gastrointesti-
nal smooth muscle relaxation. Shown to be superior
to the placebo in a recent meta-analysis, peppermint
oil provides short-term relief of discomfort and
&&
abdominal pain in IBS [24 ]. It can, however,
exacerbate gastroesophageal reflux, a disorder com-
monly associated with IBS. Furthermore, it needs to
be stressed that the trials demonstrating the benefits
of peppermint oil were performed using very specific
formulations that may have little in common with
www.co-gastroenterology.com 169
Nutrition
preparations on the shelves of supermarkets or
health food stores.
CONCLUSION
Formal studies of the role of food and dietary com-
ponents in IBS have been long overdue and have
revealed the complexities of interactions between
food, food constituents, the gut and the gut-brain
axis, which may lead to symptoms in IBS. Progress
has been made and new approaches, such as the low
FODMAP diet, offer real benefits to some IBS
&&
patients [54 ]. Studies of food effects and the impact
of dietary manipulations in humans are challenging
but need to be done to fully reveal the nature of
food-related effects in IBS.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
None.
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