Author:

Keywords:

Science & Technology, Life Sciences & Biomedicine, Gastroenterology & Hepatology, Pharmacology & Pharmacy, LOW-FODMAP DIET, RANDOMIZED CONTROLLED-TRIAL, GASTROINTESTINAL-SPECIFIC ANXIETY, COGNITIVE-BEHAVIORAL TREATMENT, FOOD-INTAKE DISORDER, VISCERAL SENSITIVITY, PSYCHOLOGICAL THERAPIES, EATING-DISORDERS, GAS-PRODUCTION, POLYOLS DIET, cognitive-behavioural therapy, exclusion diets, exposure-based therapy, irritable bowel syndrome, low FODMAP diet, Clinical Trials as Topic, Cognitive Behavioral Therapy, Diet, Carbohydrate-Restricted, Humans, Irritable Bowel Syndrome, Treatment Outcome, METH/15/011#53372147, AKUL/19/06#55631731, 1103 Clinical Sciences, 1115 Pharmacology and Pharmaceutical Sciences, 3202 Clinical sciences, 3214 Pharmacology and pharmaceutical sciences

Abstract:

BACKGROUND: Irritable bowel syndrome (IBS) is a heterogeneous disorder of gut-brain interaction (DGBI) maintained by interacting biological, psychological, and social processes. Interestingly, there are two contrasting yet evidence-based treatment approaches for reducing IBS symptoms: exclusion diets such as those low in fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) and exposure-based cognitive-behavioural therapy (CBT). Exclusion diets recommend patients avoid foods thought to be symptom-inducing, whereas exposure-based CBT encourages patients to expose themselves to foods. AIMS: To address the paradox of conceptually opposite exclusion diets and exposure-based CBT for IBS. METHODS: In this conceptual review, we describe the rationale, practical implementation, evidence base and strengths and weaknesses of each treatment. We conducted up-to-date literature search concerning the low FODMAP diet and CBT, and performed a secondary analysis of a previously conducted trial to illustrate a key point in our review. RESULTS: The low FODMAP diet has demonstrated efficacy, but problems with adherence, nutritional compromise, and heightened gastrointestinal-specific anxiety raise caution. Exposure-based CBT has demonstrated efficacy with substantial evidence for gastrointestinal-specific anxiety as a key mechanism of action. Mediation analysis also showed that increased FODMAP intake mediated decreased symptom severity in exposure-based CBT. However, there is minimal evidence supporting which treatment "works best for whom" and how these approaches could be best integrated. CONCLUSIONS: Even though exclusion diets and exposure-based CBT are conceptually opposite, they each have proven efficacy. Clinicians should familiarise themselves with both treatments. Further research is needed on predictors, mechanisms and moderators of treatment outcomes.