Dear Sir,
Restriction of Fermentable Oligosaccharide, Disaccharide, Monosaccharide, and Polyols in the diet (low FODMAP diet) has been found to be effective in management of irritable bowel syndrome (IBS), functional dyspepsia (FD), inflammatory bowel disease (IBD) and non-celiac gluten sensitivity1,2,3,4. Majority of the studies on low FODMAP diet have shown consistent symptomatic benefits. However, it has been noted that strict long-term low FODMAP diet may negatively affect the intestinal microbiota5. Implementation of low FODMAP diet in patients with IBS/functional dyspepsia is dependent on food habits and prevalent customs in the society. A recent analysis from India showed that implementing a low FODMAP diet in north-eastern India might be the easiest as rice and non-vegetarian food intake is high in the region. However, implementing the same in north India is an uphill task. Implementing a low FODMAP diet in southern and eastern India may be relatively easy, moderately easy in western India, but not easy in central India6.
Despite good evidence regarding the benefits of low FODMAP in Indian patients, the use of this intervention is limited only to a few centres across India.The aim of the present questionnaire based study was to determine the challenges faced by physicians in implementing low FODMAP diet in day to day practice, mainly from three Indian states of Gujarat, Madhya Pradesh and Maharashtra.
A questionnaire was circulated using an online survey form (Google Inc). It sought information regarding the place of practice, cases of FD / IBS seen per month and the use of low FODMAP dietary intervention for patients at their respective centres. Initially, the questionnaire was pilot tested among 10 gastroenterologists to know if the questions were easily understood or not. The data obtained was entered in a tabulated sheet (MS Excel, Microsoft Inc.) and interpreted using numbers and percentages.
The questionnaire was circulated among 100 gastroenterologists predominantly practising in Madhya Pradesh, Maharashtra and Gujarat. Response rate was 51%. Nearly all (45, 87.5%) were in private hospital setups. Majority saw >20 cases of FD (39, 76.5%) and IBS (36, 70.6%) per month. Rome IV criteria were used by 70.6% (36) regularly and nearly all (48, 94.1%) considered dietary intervention necessary for management of these disorders. Dietitian facility was available full time with 33(64.7% ) and on call with 9(17.6%) gastroenterologists. However, none used diet assessment regularly for FD and IBS patients. Twenty-seven (53%) gastroenterologists reported that dietitians at their centres were trained in administering low FODMAP diet and proper follow-up of patients. Only 9 (17.6%) respondents used low FODMAP diet regularly. Majority (82.4%, 41) noted that patients are unable to follow low FODMAP diet due to logistic reasons (62.5%) or being too restrictive (37.5%). Use of mobile applications (100%) was considered as the best option to promote low FODMAP diet among patients. Thirty-nine respondents (76.5%) believed that the use of colour coded written resources, mobile applications, online video resources, social media posts and commercial food certifications (all responses) would be useful.
The present study was done among gastroenterologists practising in Central and Western part of India. It was an online survey and noted that low FODMAP diet is seldom used in daily practice for the management of IBS and FD. Nearly one-third of respondents did not have access to dietitian facilities on a regular basis. Lack of trained dietitians for assessing and managing patients on low FODMAP diet was another concern. There was poor acceptability of low FODMAP dietary intervention among patients. Respondents felt the need of using mobile applications and online campaigns to increase awareness regarding this intervention.
As highlighted by a previous research article from India6, it was noted that acceptance of low FODMAP intervention is low in this region. This is probably related to dietary and cultural practices. The implementation of this intervention is marred by lack of trained staff as well as physicians’ reluctance to get dietary assessment for all patients. Concerted efforts are required in this regard. The study is limited by its small sample size and the focus on gastroenterology practice. Many patients with IBS and FD are managed by family physicians and may never reach specialty care in the Indian setting. It is important to educate family physicians about the important aspect of low FODMAP dietary intervention to improve the patient care.
References
- Nanayakkara WS, Skidmore PM, O’Brien L, Wilkinson TJ, Gearry RB. Efficacy of the low FODMAP diet for treating irritable bowel syndrome: the evidence to date. Clin Exp Gastroenterol. 2016;9:131-42.
- Goyal O, Batta S, Nohria S, et al. Low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol diet in patients with diarrhea-predominant irritable bowel syndrome: A prospective, randomized trial. J Gastroenterol Hepatol. 2021;36:2107–15.
- Goyal O, Nohria S, Batta S, Dhaliwal A, Goyal P, Sood A. Low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol diet versus traditional dietary advice for functional dyspepsia: a randomized controlled trial. J Gastroenterol Hepatol.2022;37(2):301-309.
- Gibson PR. Use of the low-FODMAP diet in inflammatory bowel disease. J Gastroenterol Hepatol. 2017 ;32 Suppl 1:40-42.
- Vandeputte D, Joossens M. Effects of Low and High FODMAP Diets on Human Gastrointestinal Microbiota Composition in Adults with Intestinal Diseases: A Systematic Review. Microorganisms. 2020;8(11):1638.
- Mustafa U, Ghoshal UC. The challenges of implementing low fermentable oligo-, di-, mono-saccharides and polyol diet in India: An analysis of available data. Indian J Gastroenterol. 2022;41(1):104-113.