As a dietitian who specializes in digestive health, people often reach out about working together to follow the low FODMAP diet for IBS. While research has shown that the low FODMAP diet can be a successful form of symptom management in approximately 50-86% of patients – and I have been able to guide many patients through the three phases of the low FODMAP diet successfully in my practice - not everyone is an appropriate candidate for the elimination diet1. As a healthcare practitioner, it is important to do no harm – and knowing who is an appropriate candidate for a particular intervention is just as important as knowing how to guide a patient through each intervention.
There are many reasons low FODMAP might not be the best approach. From a clinical perspective, those who may not be suitable candidates for a full low FODMAP elimination diet can include young children, malnourished individuals, individuals with multiple dietary restrictions, individuals with limited access to low FODMAP foods (whether time, financial, or physical access), and those with an active eating disorder or disordered eating patterns. Or it might be that managing the low FODMAP diet has just gotten too challenging (we're all under a lot of stress right now!) or you'd like to try other modalities to support your health.
So, as a provider – what can you offer for individuals who are not suitable candidates for the full low FODMAP elimination diet? As a patient – how can you manage your IBS symptoms if the low FODMAP diet isn’t the best intervention for you? Keep reading to learn about different management options!Alternative Therapies
Gut-directed hypnotherapy can be performed by a therapist. Specifically, gut-directed hypnosis involves using imagery to promote a sense of calmness within the gut. Research suggests that gut-directed hypnotherapy can be an effective method of IBS symptom management, making it a wonderful option for those who do not respond to the low FODMAP diet or those who are not candidates for the low FODMAP diet2.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) involves working with a psychotherapist who can increase awareness of negative thoughts and restructure the thought process. CBT is well researched and can be used to manage a variety of conditions. Specifically, those with IBS may benefit from CBT due to its aim to restructure the experience of IBS and reduce the perception of IBS symptoms3,4.
For help finding a specialist in psychogastroenterology, the ROME Foundation has a great directory here.
Medications and/or Supplements
There are many medications indicated for use in IBS patients. The specific medication will vary based on the subtype of IBS. It is important to speak with your gastroenterologist in order to determine the best course of action for you, including whether or not management with medication is an option for you and, if so, which medication would be best for your specific needs.
Additionally, over-the-counter (OTC) supplements can be used to manage IBS symptoms, ranging from soluble fiber to peppermint oil capsules to magnesium, to name a few. Of course, different supplements can be used depending on your specific symptoms and it is always recommended to speak with your healthcare provider to determine the best option for you.
Pelvic Floor Physical Therapy
Working with a pelvic floor physical therapist can help to improve the coordination of muscles within the pelvic floor. Specifically, many patients with constipation may benefit from working with a pelvic floor physical therapist. Common techniques used within pelvic floor physical therapy include abdominal massage, breathing techniques and toileting position, to name a few.
FODMAP Gentle Approach
FODMAP Gentle is a newer term coined by the researchers at Monash University. Essentially, this is a modified version of the low FODMAP diet, as it only excludes some potential high FODMAP triggers. The aim of this approach is to manage symptoms without initiating an extensive elimination diet, which means many high FODMAP foods will still be allowed in the elimination phase. While the researchers have suggested certain foods to eliminate using this approach, the practitioner may also opt to further personalize the modified approach and cherry pick only the foods that seem to be troublesome for the individual. Of course, this approach is even more specialized than the traditional low FODMAP diet and should be carried out under the supervision and care of a qualified healthcare professional. Typically, a dietitian who specializes in digestive health would carry out the low FODMAP diet, as well as any modified version of this diet.
Utilizing companies such as Epicured can also help immensely, as the food is already prepared to be suitable for the low FODMAP diet, but the individual does not need to focus on eliminating many foods. This can help to provide convenient (and tasty) options without the stress of monitoring each specific ingredient.
Additionally, it is important to remember that there are many potential non-FODMAP dietary triggers, such as caffeine, alcohol, spicy foods, fat content and fiber content. Working with a registered dietitian can help you to determine your dietary triggers in a way that is suitable for you.
Putting It All Together
If you have been diagnosed with IBS and you are interested in the low FODMAP diet, it is so important to speak with a qualified healthcare provider in order to determine whether or not this approach is the best approach for you. Similarly, if you are reading this as a healthcare provider, I encourage you to consider the benefits and risks of dietary intervention, just as you would any other intervention, as an elimination diet should never be taken lightly. If a low FODMAP diet seems like the best approach for you, I recommend working with a dietitian to ensure that all three stages (elimination, reintroduction and maintenance/personalization) are carried out and interpreted correctly so you can ultimately enjoy the most liberalized diet that you can tolerate. And if the low FODMAP diet is not the best approach for you, rest assured that there are many other potential management options – you and your healthcare team should work together to determine the best management strategies for you.
- Hill P, Muir JG, Gibson PR. Controversies and Recent Developments of the Low-FODMAP Diet. Gastroenterol Hepatol (N Y). 2017;13(1):36-45.
- Peters SL, Muir JG, Gibson PR. Review article: gut-directed hypnotherapy in the management of irritable bowel syndrome and inflammatory bowel disease. Aliment Pharmacol Ther. 2015;41(11):1104-1115. doi:10.1111/apt.13202
- Lackner JM, Jaccard J, Radziwon CD, et al. Durability and Decay of Treatment Benefit of Cognitive Behavioral Therapy for Irritable Bowel Syndrome: 12-Month Follow-Up. Am J Gastroenterol. 2019;114(2):330-338. doi:10.1038/s41395-018-0396-x
- Shapiro J, El-Serag HB, Chan J. Durability and Effectiveness of Cognitive-Behavioral Therapy for Irritable Bowel Syndrome. Gastroenterology. 2019 Dec;157(6):1684-1686. doi: 10.1053/j.gastro.2019.10.010. Epub 2019 Oct 12. PMID: 31614122.