• diet
• irritable bowel syndrome

The introduction and adoption of the FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols) diet has been a major change in the management of patients with irritable bowel syndrome (IBS) towards integrated care.1 The diet has been seen as an effective symptomatic therapy, but one that carries risks associated with exacerbating disordered eating, challenging nutritional adequacy and putatively inducing dysbiotic gut microbiota. The concept that FODMAPs are involved in pathogenic mechanisms that underlie visceral hypersensitivity2 might explain ongoing symptom control in patients after reintroducing dietary FODMAPs up to a level taken before FODMAP restriction.3 The report by Vervier et al in Gut goes one step further.4 Their study has suggested that initial FODMAP restriction might actually correct dysbiosis in a proportion of patients with IBS with consequent durable symptomatic benefit without the need for major FODMAP restriction. Furthermore, they may have provided another mechanism by which we can explain the wide variation of responses to FODMAP restriction from complete symptom resolution to worsening in a very small minority.

Reasons behind such heterogeneity of outcomes need to be defined so that the diet can be directed to the candidates more likely to respond or, more importantly, away from those highly likely not to respond. Dietary non-adherence, poor food selection, sometimes directed by misinformation on websites,5 or …