World J Gastroenterol 2017 June 7; 23(21): 3771-3783

Submit a Manuscript: http://www.f6publishing.com
DOI: 10.3748/wjg.v23.i21.3771

ISSN 1007-9327 (print) ISSN 2219-2840 (online)

REVIEW

Diet in irritable bowel syndrome: What to recommend, notwhat to forbid to patients!
Anamaria Cozma-Petruţ, Felicia Loghin, Doina Miere, Dan Lucian Dumitraşcu
Anamaria Cozma-Petruţ, Doina Miere, Department ofBromatology, Hygiene, Nutrition, “Iuliu Haţieganu” Universityof Medicine and Pharmacy, 400349 Cluj-Napoca, Romania

Published online: June 7, 2017

Felicia Loghin, Department of Toxicology, “Iuliu Haţieganu”
University of Medicine and Pharmacy, 400349 Cluj-Napoca,
Romania

Abstract
A substantial proportion of patients with irritablebowel syndrome (IBS) associate their symptoms with
the ingestion of specific foods. Therefore, in recent
years, scientific research has increasingly focusedon the role of diet in IBS and dietary management is
now considered an important tool in IBS treatment.
This article reviews the main dietary approaches in
IBS emphasizing evidence from experimental andobservational studies and summarizing the main dietand lifestyle recommendations provided by dietaryguidelines and scientific literature. Despite the limited
evidence for a beneficial role, general advice on healthyeating and lifestyle is recommended as the first-line
approach in the dietary management of IBS. Standard
recommendations include adhering to a regular meal
pattern, reducing intake of insoluble fibers, alcohol,
caffeine, spicy foods, and fat, as well as performing
regular physical activity and ensuring a good hydration.
Second-line dietary approach should be considered
where IBS symptoms persist and recommendations
include following a low FODMAP diet, to be delivered
only by a healthcare professional with expertise indietary management. The efficacy of this diet is
supported by a growing body of evidence. In contrast,
the role of lactose or gluten dietary restriction in thetreatment of IBS remains subject to ongoing researchwith a lack of high-quality evidence. Likewise, further
clinical trials are needed to conclude the efficacy ofprobiotics on IBS symptoms.

nd

Dan Lucian Dumitraşcu, 2 Medical Department, “Iuliu
Haţieganu” University of Medicine and Pharmacy, 400006 ClujNapoca, Romania
Author contributions: Cozma-Petruţ A and Dumitraşcu DL
contributed to the literature search and manuscript writing;Loghin F and Miere D contributed to the scientific content andrevision of the manuscript; Dumitraşcu DL gave the study idea,
the final revision of the article.
Conflict-of-interest statement: All authors declare no conflictof interest related to this publication.
Open-Access: This article is an open-access article which wasselected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon thiswork non-commercially, and license their derivative works on
different terms, provided the original work is properly cited andthe use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Manuscript source: Invited manuscript
Correspondence to: Dan Lucian Dumitraşcu, MD, Professor,
2 nd Medical Department, “Iuliu Haţieganu” University of
Medicine and Pharmacy, 4 Clinicilor Street, 400006 Cluj-Napoca,
Romania. ddumitrascu@umfcluj.ro
Telephone: +40-722-756475
Fax: +40-264-593355

Key words: Irritable bowel syndrome; Alcohol; Caffeine;
Spicy foods; Fat; Dietary fiber; Milk; FODMAP; Gluten;
Probiotics

Received: February 13, 2017
Peer-review started: February 14, 2017
First decision: March 16, 2017
Revised: April 8, 2017
Accepted: May 4, 2017
Article in press: May 4, 2017

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Cozma-Petruţ A et al . Dietary recommendations for IBS
Luminal distension is another mechanism by whichfood has been suggested to induce symptoms in
IBS in that short-chain carbohydrates in the diet canincrease luminal water retention and gas production,
thereby leading to bloating, pain and increased visceral[6,7]
hypersensitivity .
Furthermore, at least two thirds of patients with IBS
relate their GI symptoms to the ingestion of specificfoods, making dietary management an important tool
[7-9]
in the treatment of IBS . Nevertheless, the anxiety
about food and GI distress corroborated with the factthat typical dietary advice in IBS is focused more onwhat foods to avoid, often leaves these subjects with
unnecessarily self-restrictive diets, which could result[10,11]in nutritional deficiencies. Therefore, it is of utmost
importance for healthcare professionals to provide
detailed dietary recommendations to IBS patients.
This article reviews current evidence on the dietary
management of IBS with particular emphasis on what
to recommend to IBS patients. In the last part of thearticle, it is presented the novel “IBS Food Pyramid”,
which we developed to summarize the main dietaryand lifestyle recommendations in IBS, as identified incurrent dietary guidelines and the available literaturein the field.

Core tip: In recent years, dietary management has
shown promise as a key tool in the treatment of
irritable bowel syndrome (IBS). This article gives a hightopical review of dietary approaches in IBS treatment
and evaluates the current evidence to support theirefficacy in the improvement of IBS symptoms. On thebasis of diet and lifestyle recommendations in IBS,
identified in dietary guidelines and scientific literature,
the article provides the “IBS Food Pyramid”, namely
a novel, visual, user-friendly tool for the dietary
counseling of IBS patients by healthcare professionals.
Cozma-Petruţ A, Loghin F, Miere D, Dumitraşcu DL. Diet in
irritable bowel syndrome: What to recommend, not what to forbid
to patients! World J Gastroenterol 2017; 23(21): 3771-3783
Available from: URL: http://www.wjgnet.com/1007-9327/full/v23/i21/3771.htm DOI: http://dx.doi.org/10.3748/wjg.v23.
i21.3771

INTRODUCTION
Irritable bowel syndrome (IBS) is a common functional
gastrointestinal (GI) disorder, with a high global
prevalence (11.2%) and a strong impact on the[1,2]
quality of life . According to the Rome IV criteria, thesyndrome is defined as recurrent abdominal pain for atleast 4 d per month over at least 2 mo, associated with
one or more of the following: related to defecation,a change in frequency of stool and/or a change in[3]
form or appearance of stool . IBS can be classified
into 4 subtypes: IBS with predominant diarrhea(IBS-D), IBS with predominant constipation (IBS-C),
IBS with mixed bowel habits (IBS-M), and IBS[3]
unclassified (IBS-U) . The pathophysiology of IBS is
not completely understood, but several abnormalities
appear to contribute to its pathogenesis, including
disruption of the brain-gut axis, gut dysmotility,vis­ceral hypersensitivity, low-grade mucosal infla­
mmation, increased intestinal permeability, and altered[4]
microbiota .
Moreover, a number of studies refer to the roleof diet in IBS, which may be explained by atypicalmodulatory mechanisms of the gut in response to[5]
stimulation of gut receptors mediated by nutrients .
Nutrients presence in the GI tract affects GI motility,[5]
sensitivity, barrier function, and gut microbiota .
Likewise, food hypersensitivity and food intolerance
have been targeted to underlie the pathogenesis of
IBS, but there is a lack of quality evidence to support[6]
this mechanisms . Hypersensitivity to certain foods
may play a role by causing low-grade intestinal
inflammation, increased epithelial barrier permeability[5]and visceral hypersensitivity . Bioactive chemicals
in foods (e.g., salicylates) also may contribute andtrigger GI symptoms in IBS, possibly by inducing[7]visceral hypersensitivity following chronic exposure .

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FIRST-LINE DIETARY APPROACH IN IBS
Currently, there is a guideline consensus that diet andlifestyle advice should be the first-line approach in[12,13]the dietary management of IBS. Healthy eating
and lifestyle advice can be provided by any healthcare
professional with interest in IBS dietary management(e.g., primary care physician, gastroenterologist,[12]
dietitian) . Typical recommendations are followinga regular eating pattern and limiting the intake ofpotential dietary triggers, such as alcohol, caffeine,[12,13]
spicy foods, and fat. Other recommendations
include ensuring a good hydration and performing a[12,13]
regular physical activity.

Eating habits[12,13]

Dietary guidelines
make recommendations ofhealthy eating habits in IBS patients, despite thelimited evidence on the association between poor
eating patterns and IBS. Several studies have reported
more irregular meal habits in IBS patients than in
healthy controls and suggested that irregular eating
may affect colonic motility and therefore contribute[14,15]to IBS symptoms. Likewise, data obtained byquestionnaire from binge and non-binge eating obese
and non-obese women showed that the relative riskof IBS was 2-4 times higher among binge eaters,suggesting that consumption of large meals may[16]
induce GI symptoms in IBS .
Recommendations on eating habits in IBS,
accor­ding to dietary guidelines and/or scientific
literature: (1) Patients with IBS should be advised

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Cozma-Petruţ A et al . Dietary recommendations for IBS
to establish a regular meal pattern (breakfast, lunch
and dinner with snacks as appropriate) and to avoid
skipping meals, leaving long gaps between eating or[12,13]eating late at night; and (2) IBS patients should
be recommended to avoid large meals as well as totake time to eat, to sit down to eat, and to chew food
[12,13,17]
thoroughly.

in IBS patients and, if related to symptoms, daily
intake should be restricted to 400 mg caffeine, which[12]is the safe limit for most adults ; and (2) sources ofcaffeine to watch for include coffee and tea, but alsoenergy drinks, soft drinks, dark chocolate, and some[24]
over-the-counter analgesics .

Alcohol intake

Many IBS patients report that the ingestion of spicy
foods triggers GI symptoms, such as abdominal pain
[8,9,26]
and gastroesophageal reflux. Recently, a large
cross-sectional study in Iranian adults reported thatthe consumption of spicy foods at least ten times per
week substantially increased the likelihood of suffering[27]
from IBS in women but not in men . However, thisstudy was performed in an Asian country, where theaverage daily chili consumption is 2.5-8 g/person,
which is much higher than that of 0.05-0.5 g/person in[28]
Europe and America .
Capsaicin is considered the active component in
red chili responsible for the effects of spicy foods on[29,30]the GI tract. Capsaicin accelerates GI transit via
the transient receptor potential vanilloid type-1 (TRPV1)
causing a sensation of burning and pain in healthy[28]
individuals . Increases in the number of TRPV1
receptors have been found in subjects with disorders
characterized by visceral hypersensitivity, including in[31,32]
patients with IBS. Several studies have shown that
supplementation of capsaicin exacerbates abdominal[33,34]
pain and burning in IBS patients. It is to be notedthat these studies have used high doses of spices as atreatment, whereas there is no reported data on therole of habitual consumption of spicy foods in IBS.
Furthermore, there are studies to demonstrate abeneficial effect of red pepper in IBS, under conditions[35]
of chronic consumption . Nevertheless, in thesestudies, the analgesic effect of red pepper was obtainedat the expense of an initial, although transitory,
exacerbation of pain in the first weeks of treatment in[35]
some patients .

Spicy foods intake

Alcohol is known to affect the GI tract motility,[18]
absorption, and permeability . However, the[17]evidence relating alcohol to IBS is limited . Studies
on self-reported food intolerance have indicated arole of alcoholic beverages in GI symptoms among[8-10]IBS patients. In contrast, alcohol intake was not[19,20]correlated with IBS in population-based studies.
Moreover, in women with IBS, GI symptoms likeabdominal pain and diarrhea have been associatedonly with binge drinking (more than 4 drinks per day)and not with moderate (2-3 drinks per day) or light[18]
drinking (1 drink per day) . These conflicting resultson alcohol and IBS emphasize the need for conducting
randomized controlled trials (RCTs) to evaluate theeffect of low alcohol intake on IBS symptoms.
Recommendations on alcohol intake in IBS,
accor­ding to dietary guidelines and/or scientific
literature: (1) alcohol intake should be assessed inrelation to GI symptoms to determine if a reduction[12]
may alleviate them ; and (2) IBS patients should
be advised to consume alcohol in compliance withrecommended safe limits, while having at least two[12,21]alcohol free days a week
. Generally, safe alcohol
limits are described as no more than 1 drink per day
for women and no more than 2 drinks per day for[22]
men . A drink is defined as 12 oz of regular beer
(5% alcohol), 5 oz of wine (12% alcohol), or 1.5 oz of[22]
80-proof distilled spirits (40% alcohol) .

Caffeine intake

Coffee, particularly caffeinated coffee, has been
demonstrated to increase gastric acid secretion and[23,24]colonic motor activity in healthy individuals. Coffee
has also been reported to stimulate rectosigmoid
motor activity and lead to laxative effect in susceptible[12]people . Nevertheless, the role of caffeine in IBS is[17]
less clear . Several studies have indicated coffee andtea among the foods associated with symptoms by[8,10,25]
IBS patients. On the other hand, habits of coffee
drinking have not been noted to be more common[18,19]among IBS patients than among healthy controls.
Moreover, there have been no RCTs to determine
whether a low caffeine intake would lead to better
clinical outcomes for patients with IBS.

Recommendations on spicy foods intake in IBS,
according to dietary guidelines and/or scientific
literature: (1) spicy food intake should be assessedin IBS patients and, if related to IBS symptoms, the[12]intake should be restricted ; (2) IBS triggers in spicy
foods other than hot spices (e.g., fructans in onion and[12]garlic) should also be assessed .

Fat intake

An important proportion of patients with IBS relate[8,25,26]
symptoms to foods rich in fat. As a consequence,
the avoidance of fatty foods is one of the mostfrequent dietary approaches considered by IBS[36]
patients for symptoms improvement . Indeed,laboratory-based studies have shown that duodenal
lipids inhibit small bowel motility and impair intestinal[37,38]gas clearance, inducing gas retention and bloating.

Recommendations on caffeine intake in IBS,
according to dietary guidelines and/or scientific
literature: (1) caffeine intake should be assessed

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Cozma-Petruţ A et al . Dietary recommendations for IBS
This mechanism is up-regulated in patients with[38]
IBS . Duodenal lipids also enhance colorectal
hypersensitivity with increased perception of rectal[39,40]distension in IBS patients. Despite such complex
laboratory studies, the evidence associating dietary
fat intake to IBS is limited. In particular, there are noreported RCTs to support that a reduction in fat intake
would lead to symptoms improvement in IBS.
A series of studies failed to identify differences in the[11,41]
intake of fat between IBS patients and controls.
Furthermore, recent findings suggest even a putative[42,43]
positive effect of dietary fat in IBS. Polyunsaturated
fatty acids and their metabolites can exhibit beneficial[42]
effects on intestinal inflammation . Given that lowgrade inflammation has been recently revealed as a
[43]
mechanism involved in IBS , the supplementation ofpolyunsaturated fatty acids in IBS patients warrants
further research.

contradictory data. A systematic review evaluated 12
RCTs involving 621 patients and found no beneficial
effect with either soluble fibers or insoluble fibers
over placebo for improving abdominal pain, global[49]
assessment or symptom scores . In contrast, amore recent systematic review and meta-analysis
based on 14 RCTs including 906 patients concluded
that soluble fibers, such as psyllium, may have somebeneficial effects in IBS, whereas insoluble fibers,
such as bran, do not appear to be beneficial and may[46]
even worsen symptoms . These data corroborated
with the information on the fermentability of fibers,suggest that soluble viscous fibers with low rate offermentation (e.g., psyllium) would be the mostappropriate for both constipation and diarrhea in IBS[24]
patients . The addition of linseeds in the diet may
also help in the management of constipation. Linseeds
are a rich source of dietary fibers and, according
to prior studies, ground linseed (6-24 g/d) relieved
constipation, abdominal pain and bloating in IBS-C[12]
gradually over 3 mo .

Recommendations on fat intake in IBS, according
to dietary guidelines and/or scientific literature:(1) if related to IBS symptoms during or after eating,fat intake should be assessed, while ensuring the[12]
intake is in line with healthy eating guidelines .
According to FAO/WHO dietary recommendations, thetotal fat intake for an adult should range from 30% to
35% of total energy, without being under 15% of total[44]
energy ; and (2) patients with IBS should be advised[17]
to limit fat intake to no more than 40-50 g/d .

Recommendations on dietary fiber intake in IBS,
according to dietary guidelines and/or scientific
literature: (1) evidence is lacking on the optimaldose of fibers in IBS, but a gradual increase in total
dietary fiber (naturally occurring and supplemented) to[50]
a target dose of 20-30 g/d should be suitable . IBS
patients should however not be advised to increase
their intake of wheat bran above their usual dietary[12]
intake ; and (2) patients with IBS-C should berecommended to try dietary supplementation of linseedsof up to 2 tablespoons per day, consumed with fluid (150[12]mL/tablespoon), for a 3 mo trial . Improvements in GI
symptoms from linseed supplementation may take up[12]
to 6 mo .

Dietary fiber intake

Although an increase in the intake of dietary fiber was[45]
long believed to improve IBS, particularly IBS-C ,this view has largely been revised. In some patientswith IBS, the use of fiber may actually exacerbate
symptoms and increase abdominal pain, bloating and[46,47]distension.
The efficacy of fibers in IBS has often been
discussed in terms of soluble and insoluble fibers,
with the recommendation to increase the intake ofsoluble fibers and decrease the intake of insoluble[46]
fibers, respectively . However, this approach may[12]
no longer be suitable . Fibrous foods such as
psyllium or oats have both attributes and most plantbased foods contain mixtures of soluble and insoluble[24]
fibers . A more appropriate approach relies on theclassification of fibers not only by solubility, but also by
fermentability, viscosity, and gel formation, as follows:
insoluble, poorly fermented (e.g., wheat bran), soluble,
nonviscous, readily fermented (e.g., inulin), soluble
viscous/gel forming, readily fermented (e.g., β-glucan),and soluble viscous/gel forming, nonfermented (e.g.,[48]
psyllium) . The readily fermented fibers can lead to
rapid gas formation, while the poorly fermented and[48]
nonfermented fibers often result in less flatulence .
The role of fibers in IBS remains subject to ongoingdebate with a lack of high-quality evidence and

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Milk and dairy products intake

Milk and dairy products contain lactose, a disaccharide
that is not well digested by an important proportion[7]of adults worldwide . This phenomenon is attributed
to low levels of the enzyme lactase in the intestinal[17]
mucosa of these people . Undigested lactose iscleaved by gut flora into short-chain fatty acids andgas (e.g., hydrogen), products that are likely to lead[51]
to GI symptoms in case of milk ingestion . Typical GI
complaints of lactose intolerance are similar to thosein IBS and include abdominal discomfort, bloating, and[7]loose stools .
Furthermore, many patients with IBS attribute
symptoms to consumption of milk and dairy pro­
[10,52-54]
ducts, but this self-reported intolerance does
not always correlate with results from objective[52,53]
investigations, such as the hydrogen breath test.
Some trials have noted an improvement in IBS
symptoms in response to a lactose-free diet among[55,56]a substantial proportion of patients. Despite

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Cozma-Petruţ A et al . Dietary recommendations for IBS[61]

such findings, all these trials were not blinded orcontrolled. The improvement of symptoms may be[17]because some IBS patients have lactase deficiency .
However, lactase supplementation did not alleviate
IBS symptoms in one small double-blind, placebo[57]
controlled study .
It is also plausible to hypothesize that other milk
components rather than lactose may play a role in IBS.
For instance, it has been suggested that milk intolerance
could in some cases be related to the ingestion of the[58]
protein A1 β-casein . During digestion, this protein
releases β-casomorphin 7, which is known to exhibit GI[58]
effects . Indeed, further research studies are needed
to elucidate the role of milk and dairy products in IBS.

basic complement to the diet . Regular exercise
is beneficial to health in general and recent data
[62,63]highlights its positive effects also for IBS patients.
In several studies, mild physical activity has beenreported to reduce IBS symptoms and enhance
intestinal gas clearance, reduce bloating and relieve[64-67]
constipation. The practice of yoga has also been
demonstrated to improve IBS symptoms in both adults[68,69]and adolescents.
Mechanisms suggested to underlie the benefitsof physical activity in IBS are decreased splanchnic
blood flow, neuroimmuno-endocrine alternations,increased GI motility and mechanical bouncing during[70]
movement . The impact of exercise on psychologicalsymptoms has also been postulated as a potential
mechanism and studies have reported positive effects
on quality of life, fatigue, anxiety, and depression after
moderate increase in physical activity in patients with
[67]
IBS .
Nevertheless, it should be taken into considerationthat increased physical activity, particularly strenuous
exercise, may actually worsen IBS symptoms. For
example, moderate physical activity (e.g., brisk
walking) has been reported to improve gut transit
time, whereas vigorous physical activity (e.g., running)
may act on the intestines as a stressor and result in[71,72]“runners trots”.

Recommendations on milk and dairy products
intake in IBS, according to dietary guidelines
and/or scientific literature: (1) IBS patients should
be advised to use a low-lactose diet only if they have[12]
a positive lactose hydrogen breath test ; (2) If theywish to follow a milk-free diet, IBS patients should be
informed that there is no high-quality evidence for[12]this diet to improve their symptoms . In addition,
patients should be informed that a milk-free diet could
result in low calcium intakes and increase the risk of[11,12]
not meeting the daily calcium requirements; and(3) In patients with IBS where sensitivity to milk issuspected and a lactose hydrogen breath test is notavailable or appropriate, a trial period of a low lactose[12]
diet is recommended .

Recommendations on physical activity in IBS,
according to dietary guidelines and/or scientific
literature: (1) The physical activity levels of patientswith IBS should be assessed, ideally using the[13]
General Practice Physical Activity Questionnaire .
IBS patients with low activity levels should be advised
to increase their activity levels, while taking into
account the needs, preferences and circumstances[13]
of each patient ; and (2) IBS patients should berecommended to perform moderate physical activity,
such as yoga, walking, cycling, or swimming, for at[13,21]
least 30 min a day, on 5 d of the week or more.

Fluid intake

Despite no evidence from scientific research on theeffect of fluid intake in IBS, current dietary guidelines
recommend the daily consumption of up to 1.5-3 L[12]of fluids . In particular, an adequate fluid intake issuggested to improve stool frequency and decrease[12]
the need for laxatives in IBS-C .
Water and other non-caffeinated drinks, for example
herbal teas, are recommended as a beverage for[13,59,60]
patients with IBS. In contrast, carbonated waterand other carbonated beverages should be avoided by[59,60]
IBS patients, because they may cause symptoms.
One study reported more GI symptoms fromcarbonated beverages among IBS patients compared[25]
with controls .

SECOND-LINE DIETARY APPROACH IN
IBS: THE LOW FOODMAP DIET
There is a guideline consensus that in case IBS
symptoms persist while following general diet andlifestyle advice, the second-line intervention in IBS
dietary management should include advanced dietary
manipulations to alleviate symptoms, such as the low
FODMAP (fermentable oligosaccharides, disaccharides,[12,13]monosaccharides and polyols) diet.
The term FODMAP reunites a collection of poorly
absorbed short-chain fermentable carbohydrates
that are naturally present in many foods, including
fructans and fructo-oligosaccharides in garlic andwheat, galacto-oligosaccharides in legumes, lactose indairy products, excess fructose in apples, and polyols

Recommendations on fluid intake in IBS,
according to dietary guidelines and/or scientific
literature: IBS patients should be advised to drink
up to 1.5-3 L/d of fluids (about 35 ml/kg), especiallywater or other caffeine-free and alcohol-free non[12,13]
carbonated drinks (e.g., herbal teas).

Physical activity[13,21]

Current dietary guidelines for IBS management
include recommendations on physical activity. Thisis due to the fact that physical activity serves as a

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Table 1 High FODMAP foods and alternative low FODMAP foods
FODMAP[24,79,80]

High FODMAP foods

Low FODMAP foods

Oligosaccharides:
Vegetables: artichokes, asparagus, beetroot, Brussels sprouts,
Vegetables: carrot, cucumber, potato, bell pepper, eggplant,
fructans and/or galacto- broccoli, cabbage, fennel, garlic, leeks, shallots, okra, onions,green beans, lettuce, spinach, chives, parsnip, pumpkin,oligosaccharides
peas
silverbeet, spring onion (green only), tomato, zucchini, bamboo
shoots, bok choy, choko, choy sum
Cereals: wheat & rye when eaten in large amounts (e.g.,
Cereals: wheat-free grains or wheat-free flours and products
bread, pasta, crackers)
made with these (e.g., bread, pasta, crackers), spelt and spelt
products, oats, corn, rice, quinoa
Legumes: chickpeas, lentils, red kidney beans, baked beans
Legumes: canned chickpeas
Fruits: watermelon, custard apple, white peaches, rambutan,kakiDisaccharides: Lactose
Milk (cow, goat, sheep), yoghurt, soft & fresh cheeses (e.g., Lactose-free milk, rice milk, almond milk, lactose-free yoghurt,
Ricotta, Cottage), ice cream
hard cheeses (e.g., Cheddar, Parmesan, Swiss, Brie, Camembert),
butter, ice-cream substitutes (e.g., dairy-free gelato, sorbet)
Monosaccharides:
Fruits: apples, pears, nashi pears, clingstone peaches, mango, Fruits: banana, blueberry, grapefruit, grape, honeydew melon,
Fructosesugar snap peas, watermelon, tinned fruit in natural juice,kiwifruit, lemon, lime, mandarin, orange, tangelo, raspberry,
dried fruits
strawberry, pawpaw, star fruit, passion fruit, rockmelon,
carambola, durian
Honey
Honey substitutes: maple syrup
Sweeteners: fructose, high fructose corn syrup
Sweeteners: sugar, glucose, artificial sweeteners not ending in“-ol”
Polyols
Fruits: apples, apricots, cherries, longon, lychee, nashi pears, Fruits: banana, blueberry, grapefruit, grape, honeydew melon,
nectarines, pears, peaches, plums, prunes, watermelon
kiwifruit, lemon, lime, mandarin, orange, raspberry, pawpaw,
star fruit, passion fruit, rockmelon, carambola, durian
Vegetables: avocado, cauliflower, mushrooms, snow peas
Sweeteners: sorbitol, mannitol, xylitol & others ending in
Sweeteners: sugar, glucose, artificial sweeteners not ending in“-ol”, isomalt“-ol” (e.g., sucralose, aspartame)[73]

in stone fruits . FODMAPs can pass unabsorbed tothe colon, where they increase luminal water throughosmotic activity and induce gas production due tofermentation by colonic bacteria, which can result in
luminal distension and GI symptoms in patients with
[74-77]IBS. Moreover, recent studies show that the byproducts of the interaction between FODMAPs andgut microbiota act on intestinal stem cells, resulting
in aberrant differentiation of these cells into endocrine
cells and leading to an abnormal density of endocrine[78]
cells in the gut . GI endocrine cells regulate GI sen­sitivity, motility, secretion, absorption, local immune[47]
defense, and appetite . Therefore, abnormalities in
the GI endocrine cells may play a major role in thedevelopment of visceral hypersensitivity, dysmotility,
and abnormal intestinal secretion, all being features[47,78]observed in patients with IBS.
Relying on the role of FODMAPs in IBS pathogenesis,
the low FODMAP diet restricts the dietary intake ofthese carbohydrates with the overall aim to improve IBS
symptoms. Foods are classified into “high FODMAP” and“low FODMAP” and the consumption of the latter foods
is recommended within this dietary approach (Table[24,79,80]
1).
There is a growing body of evidence supporting
the efficacy of the low FODMAP diet. Observational
studies and RCTs have indicated that the low FODMAP
dietary approach leads to symptom improvement in[81-83]up to two-thirds of patients with IBS. Many IBS
patients will respond within 1-2 wk of initiating the[84]
diet, whereas some can take 3-4 wk to respond .

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Reducing the intake of FODMAPs may be beneficial
for patients suffering of abdominal pain, bloating,[85]
flatulence, or diarrhea . Although the low FODMAP
dietary approach appears to benefit many IBS
patients, a recent RCT reported similar efficacy withthe low FODMAP diet and a diet based on traditional
dietary advice for IBS (e.g., regular meal pattern,[86]
limiting intake of fat, caffeine, alcohol) . This provides
support for further studies aiming to define the role of
low FODMAP diet in the management of IBS.
Furthermore, implementing low FODMAP diet canbe challenging. One major challenge with this diet
[12,87,88]
concerns adequate intake of fibers and calcium.
Likewise, restricting the dietary intake of prebiotic
fructans and galacto-oligosaccharides can alter[88,89]luminal microbiota. Dietary counseling through aspecialized dietitian is a key towards success of this[12]
fairly complex dietary approach . An experienced
specialized dietitian can provide a detailed dietary planthat will ensure the low FODMAP diet is nutritionally[87]
adequate . Additionally, after good symptomatic
response is achieved, the dietitian can help patients
gradually reintroduce FODMAPs using a systematic
food-challenge process to determine personal tolerance[12]
thresholds to individual foods .
Recommendations on low FODMAP diet in IBS,
according to dietary guidelines and/or scientific
literature: (1) Low FODMAP diet needs to be provided
by a healthcare professional with training in medical
nutrition therapy and knowledge of food composition,

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Cozma-Petruţ A et al . Dietary recommendations for IBS[12,13][101]such as a specialized dietitian; (2) Low FODMAP
diet should not be strictly followed over the long
[84,89]term. A restriction phase of minimum 3 or 4 wk
[12,84]is usually sufficient to obtain a clinical response.
Then, FODMAP foods should be reintegrated in thediet to find the level of food restriction that the patient[12,90]requires to properly control symptoms; and (3)
If no symptom improvement occurs within 4 wk ofstrict adherence to the low FODMAP diet, then theintervention should be stopped and other therapeutic[12]
options considered .

years .
A particular interest has been given to probiotics.
Evidence exists to suggest that probiotics may exert aneffect in IBS through various mechanisms which target
visceral hypersensitivity, GI dysmotility, intestinal
barrier function, intestinal microbiota, and intestinal[102]
immune function. Several systematic reviews andmeta-analyses have screened RCTs conducted on theeffects of probiotics in IBS patients and demonstrated
a beneficial effect of these organisms in the treatment[103-105]of IBS. However, it should be noted that the
RCTs in these meta-analyses are somewhat difficult
to compare. They are highly heterogeneous, show
differences in the study design (size of the study,
duration of the treatment) and use different probiotic
species, strains, and preparations, some of whichappear to be more effective for specific symptoms. For
example, certain probiotics mainly reduce abdominal[106,107]pain and flatulence, some reduce bowel move­
[108]
ments
, whereas others have a positive effect on[109,110]global symptoms.
Despite these findings, in terms of type of probiotic
to use (single species, strains, or mixtures), dosage
to use and treatment duration, the optimal approach[111]
in IBS remains unknown. Thus, there is a clear
need for further high-quality RCTs to provide additional
information on the efficacy of probiotics as a therapeutic
tool in the management of IBS symptoms.

GLUTEN/WHEAT INTAKE IN IBS
The role of gluten in IBS is still unclear. A considerable
proportion of IBS patients report symptoms in
response to ingestion of gluten, despite no evidenceof having either celiac disease or wheat allergy, aphenomenon that received the nomenclature of “non[91]celiac gluten sensitivity” (NCGS) . Some of thesepatients may respond to a gluten-free diet. Several
interventions have reported that gluten restriction for
4 to 8 wk improved IBS symptoms and reduced bowel[92-94]movements per day and intestinal permeability.
However, the mechanisms underlying the beneficial
effect of the gluten-free diet in IBS require further
research. Wheat contains short-chain fructans as the[73]
main carbohydrate component . Therefore, there
are reports suggesting that FODMAPs in wheat, rather
than gluten, induce the GI symptoms in patients with
[91]
IBS . Amylase trypsin inhibitors and wheat germ
agglutinins have also been reported as components[95,96]
in wheat that may contribute to IBS symptoms.
In this context, is has been recently suggested that
“NCGS” is a misnomer, as this term gives to understandthat all symptoms patients experience following wheat[97]
ingestion are from gluten . It has also been indicatedthat a nomenclature more appropriate than NCGS
[ 97]
would be “wheat intolerance” or “wheat sensitivity” .

Recommendations on probiotics use in IBS,
according to dietary guidelines and/or scientific
literature: (1) Although probiotics seem to offersome benefit in IBS as a whole, the optimal approachin terms of which individual species, strains, or
combinations to use, and at what dose and for what[111]
duration, remains unknown; and (2) IBS patients
who choose to try probiotics should be advised to[12]select one product at a time and monitor the effects .
They should try it for a minimum of 4 wk at the dose[12]
recommended by the manufacturer . If within the 4
wk treatment, the probiotic proves to be beneficial, theadministration may be continued, although the long[12]term effects are not known .

Recommendations on gluten intake in IBS,
according to dietary guidelines and/or scientific
literature: (1) If IBS patients wish to follow agluten-free diet, they should be informed that the[12]current evidence for its use is conflicting ; and (2)If IBS patients decide to restrict gluten, they should
be warned that an inappropriate gluten-free diet[98]
may be detrimental . Gluten-rich cereals are avaluable source of nutrients in the general diet, so
their exclusion could potentially lead to nutritional[98]
deficiencies .

IBS FOOD PYRAMID[12,13,21]

Based on the current guidelines
and the existing
literature on dietary and lifestyle recommendations[17,24,79,80]
in IBS, we developed the novel “IBS Food
Pyramid” (Figure 1). It is a visual and user-friendly
tool, to be used by healthcare professionals for the
dietary counseling of IBS patients. The pyramid
consists of nine levels. Within the pyramid, foods
are arranged on the basis of recommended intake
frequency in ascending order, from the most to theleast frequent.
At the base of the pyramid, on the first level,
regular physical activity and good hydration are
considered. Moderate physical activity is recommended,

PROBIOTICS SUPPLEMENTATION IN IBS
Gut microbiota in IBS patients may differ from those inhealthy individuals, suggesting an association between[99,100]
microbiota and the pathophysiology of IBS. In thiscontext, strategies aimed at modifying the microbiota in
IBS patients have been increasingly explored in recent

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Cozma-Petruţ A et al . Dietary recommendations for IBS

Figure 1 Irritable bowel syndrome food pyramid. The pyramid was built upon the current dietary guidelines[12,13,21] and the existing literature[17,24,79,80] on diet andlifestyle recommendations in IBS. The pyramid consists of nine levels. At the base of the pyramid, it is emphasized the importance of regular physical activity, good
hydration and healthy eating habits. Then, foods are arranged on the basis of recommended intake frequency in ascending order, from the most to the least frequent.
Each food level also contains examples of what the patient can consume within a low FODMAP diet. A pictogram on the left side of the pyramid highlights theimportance of seeking specialized dietary advice in case considering the low FODMAP dietary approach. The other pictograms on the left side are accompanied byrecommendations on the intake of dietary fiber and administration of probiotics in IBS. Recommendations have associated superscript letters symbolizing the level ofscientific evidence that supports them. IBS: Irritable bowel syndrome.
[13,21]such as yoga, walking, cycling, and swimming.
Recommendations related to frequency and duration,
are at least 150 min per week, split into 30 min periods[13]
5 times per week . Moreover, the consumption of
1.5-3 L per day of water and other non‑caffeinated,
non-carbonated fluids is recommended and water is[12,13]represented in the pyramid.
On the next step, at the second level, areemphasized good eating habits that may favor thehealth status in IBS. The pictogram states the im­[12,13]
portance of regular eating patterns.
At the third level, cereals and cereal derivatives(e.g., bread, pasta) are shown. This group of foods
provides a significant amount of the energy throughout[62]
the day . The recommended intake is 6 servings perday (1 serving = 40-60 g of bread or 60-70 g of pasta[ 62]
or rice) .
Vegetables occupy the next level. This food groupis an important source of nutrients and bioactive[61]
compounds . The consumption of 3-5 servings per[62]
day (1 serving = 100-150 g) is recommended .
At the fifth level, fruits are considered. Like vege­
tables, fruits are valuable sources of nutrients and[61]
bioactive compounds . The recommended intake is[13]
2-3 servings per day (1 serving = 80 g) .
The sixth level shows high-protein foods, of either
animal or non-animal origin, namely meat, fish, eggs,

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legumes, soy, nuts, and seeds. The recommended
intake is 2-3 servings per day (1 serving = 100-125
g of meat or 125-150 g of fish or 60-80 g of eggs or[62]
60-80 g of legumes or 20-30 g of nuts and seeds) .
At the next level, the seventh level, the consumptionof 2-3 servings per day of milk and dairy products is
recommended (1 serving = 200-250 mL of milk or
200-250 g of yogurt or 80-100 g of fresh cheese or[62]
30-50 g of hard cheese) . This group of food provides
many nutrients, including important amounts of[11]
calcium .
The eighth level is marked with the “consume inmoderation” recommendation. This level includes
potential IBS dietary triggers, namely fats, sweets,
spicy foods, caffeine, and alcohol. The total fat intake
should be limited to no more than 50 g/d, while[17,62]choosing healthy fats, like olive oil. Healthy sweets
should be chosen and consumed sparingly (e.g.,dark chocolate at 30 g per serving). Alcohol, caffeine,
spicy foods should be restricted if they are related to[12]
symptoms . In the case of alcohol and caffeine, thereis the recommendation to ensure the consumption is[12]
within the safe limits for the general adult population .
The top of the pyramid, the ninth level, includes
fried and processed foods, which should be removed[21]
from the IBS diet .
Furthermore, each food level contains examples

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Cozma-Petruţ A et al . Dietary recommendations for IBS
of what the patient can consume if deciding to follow[24,79]a low FODMAP diet
. A pictogram on the left sideof the pyramid highlights the importance of seeking
specialized dietary advice in case considering the low[12]
FODMAP diet .
The other pictograms on the left side are referringto the intake of fibers and administration of probiotics,
respectively. The intake of fiber is recommended,with emphasis on the intake of soluble fibers (e.g.,[12,24]psyllium). Also, for IBS patients that decide totry probiotics, there is the recommendation to takethe probiotic supplements daily, for at least 4 wk, atthe dose recommended by the manufacturer, to see if[12]
symptoms improve .
Recommendations included in the pyramid areaccompanied by superscript letters symbolizing thelevel of scientific evidence supporting them, as gradedin the recently updated British Dietetic Association
evidence-based practice guidelines for the dietary[12]
management of IBS in adults . The evidence
reviewed within these guidelines was graded using
the Practice-based evidence in nutrition (PEN) grading
criteria, as follows: level A - supported by goodevidence; level B - supported by fair evidence; levelC - supported by limited evidence or expert opinion;[12]level D - evidence is limited .

5

6
7

8

9

10

11

12

CONCLUSION
In recent years, dietary management has shownpromise as a key tool in the treatment of IBS. A
growing body of evidence exists to support theuse of interventions such as the low FODMAP diet,although further well-designed, adequately powered,randomized controlled trials from around the world areneeded to validate the efficacy of this dietary approachand assess its long-term benefits and safety. Thereis also ample room for improving the knowledge onother dietary approaches available to date, notably the
first-line intervention on healthy eating and lifestyle,but also approaches such as the dietary restriction ofgluten or the use of probiotics. Valuable data can only
be obtained by future large, randomized controlled
trials with rigorous end points.

13

14

15

16
17

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