Irritable Bowel Syndrome (IBS) is a common gastrointestinal disorder affecting about 30% of Australians and millions worldwide. While dietary management is often essential for controlling IBS symptoms, it can sometimes lead to unintended consequences, such as malnutrition. Understanding these risks is crucial to ensuring that symptom management does not come at the expense of overall health.

The Role of Diet in IBS Management

For many IBS patients, dietary adjustments are key to managing symptoms like bloating, gas, and abdominal pain. Common strategies include the Low FODMAP diet, which restricts certain fermentable carbohydrates, as well as eliminating specific food groups like gluten or dairy. While these approaches can be effective for symptom control, they also pose risks, particularly when dietary restrictions become too severe or are not properly managed.

What is Malnutrition?

Malnutrition is a serious condition with potentially adverse clinical outcomes. The World Health Organization defines malnutrition as a deficiency, excess, or imbalance in the intake of energy and/or nutrients, leading to altered body composition and cell mass. Malnutrition (undernutrition) develops when an individual does not receive an adequate amount of nutrients required for the body to function. The risk of malnutrition should be assessed using a validated screening tool, and the degree of malnutrition diagnosed by a dietitian through a comprehensive nutrition assessment.

Research on Malnutrition in IBS

Research has shown that dietary interventions, particularly those involving low levels of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs), may lead to malnutrition if strictly adhered to over a long period. [2,3] IBS patients often have an overall low intake of vitamins and minerals. [4] Studies have found that these patients tend to have lower intakes of fibres and vegetables but higher intakes of sugar and processed or ultra-processed foods compared to the general population and dietary guidelines. [5] This results in a large portion of IBS patients having insufficient micronutrient intake.

Recent research examining the nutritional adequacy of the Low FODMAP diet has revealed inconsistencies in dietary intake. The most common deficiencies occur in fibre due to reduced carbohydrate intake. [6] Excessive exclusion of dairy products can lead to decreased calcium intake, while deficiencies in vitamins such as B1, B2, B9, and D are associated with the relevant restriction of vegetables and fruits. [6] Iron deficiency has also been documented. [7] Lower energy consumption on the Low FODMAP diet could result in unintended weight loss. [8]

Strategies to Prevent Malnutrition While Following a Low FODMAP Diet

Unlike other restrictive diets that may be more permanent, the stricter low FODMAP phase lasts only 2-6 weeks and is not recommended for long-term use. To prevent malnutrition during this short-term phase, consider these strategies:

[1] Work with a Healthcare Professional: Collaborate with a dietitian or healthcare provider to create a balanced diet plan that manages IBS symptoms while ensuring nutritional needs are met. This helps prevent overly restrictive diets and potential malnutrition.

[2] Focus on Nutrient-Dense Foods: Incorporate a variety of low FODMAP nutrient-dense foods into your diet. Key options include:

• Carbohydrates: Potatoes, rice, oats, quinoa, maple syrup, and gluten-free bread/spelt sourdough
• Fats: Almonds, macadamias, nut spreads, small servings of avocado, and oily fish like salmon. Spread fat intake throughout the day to minimize IBS symptoms.
• Proteins: Eggs, chicken, beef, pork, tofu, and peanut butter, ensuring no added FODMAPs in sauces.
• Dairy: Choose full-fat, lactose-free dairy or soy-based alternatives to maintain energy, protein, and calcium intake.

[3] Consider Nutrient Supplementation: If dietary intake is insufficient, supplements may be necessary. For higher energy and protein needs, consider the following options:

[a] AdVital: Packed with 15 grams of protein and 27 vitamins and minerals, AdVital Powder supports muscle health, immune function, and bone health. It is specifically formulated for those with reduced appetites, increased nutritional needs, or conditions like IBS that affect nutrient absorption. Low GI and suitable for people with diabetes.

[b] Noisy Guts Superflora: A gut-health shake containing easily digested protein, gentle fiber, and probiotics. It supports the microbiome, maintains regularity, reduces bloating, and enhances muscle recovery. Superflora is low FODMAP and gluten-free, making it ideal for those with digestive sensitivities.

**There’s also the Superflora Daily Gut Health Boost: A daily shot of gut health support with clinically validated prebiotic fiber, probiotics, and low FODMAP superfoods.

• [i] Partially hydrolysed guar gum (PHGG) promotes regularity without causing bloating.
• [ii] Bacillus coagulans MTCC 5856 delivers live beneficial bacteria, reducing IBS discomfort and bloating.

[c] Happy Way: A natural pea protein supplement that ensures adequate protein intake. Two teaspoons are considered low FODMAP. Combine two heaped tablespoons (30 g) with water or your milk of choice for a shake or smoothie, or add it to oats, yogurt, or baked goods for a protein boost.

[4] Regular Monitoring: Regular follow-ups with a healthcare provider are crucial for monitoring nutritional status, adjusting the diet, and preventing long-term complications of malnutrition.

Conclusion

While dietary management is vital for controlling IBS symptoms, it's important to recognize and address the risks of malnutrition that can arise from overly restrictive diets. By working closely with healthcare providers and focusing on a balanced, nutrient-rich diet, IBS patients can effectively manage their symptoms without compromising their overall health.

References

[1] Elia, M. (2017) ‘Defining, recognizing, and reporting malnutrition’, The International Journal of Lower Extremity Wounds, 16(4), pp. 230–237. doi:10.1177/1534734617733902.

[2] Staudacher, H.M. et al. (2020) ‘Nutrient intake, diet quality, and diet diversity in irritable bowel syndrome and the impact of the low fodmap diet’, Journal of the Academy of Nutrition and Dietetics, 120(4), pp. 535–547. doi:10.1016/j.jand.2019.01.017.

[3] Catassi, G. et al. (2017) ‘The low fodmap diet: Many question marks for a catchy acronym’, Nutrients, 9(3), p. 292. doi:10.3390/nu9030292.

[4] Roth, B., Larsson, E. and Ohlsson, B. (2022) ‘Poor intake of vitamins and minerals is associated with symptoms among patients with irritable bowel syndrome’, Journal of Gastroenterology and Hepatology, 37(7), pp. 1253–1262. doi:10.1111/jgh.15830.

[5] Tigchelaar, E.F. et al. (2017) ‘Habitual diet and diet quality in irritable bowel syndrome: A case‐control study’, Neurogastroenterology & Motility, 29(12). doi:10.1111/nmo.13151.

[6] Whelan, K. et al. (2018) ‘The low fodmap diet in the management of Irritable Bowel Syndrome: An evidence‐based review of fodmap restriction, reintroduction and personalisation in clinical practice’, Journal of Human Nutrition and Dietetics, 31(2), pp. 239–255. doi:10.1111/jhn.12530.

[7] Eswaran, S. et al. (2020) ‘The impact of a 4-week low-fodmap and MNICE diet on nutrient intake in a sample of US adults with irritable bowel syndrome with diarrhea’, Journal of the Academy of Nutrition and Dietetics, 120(4), pp. 641–649. doi:10.1016/j.jand.2019.03.003.

[8] Morariu, I.-D. et al. (2023) ‘Effects of a low-FODMAP diet on irritable bowel syndrome in both children and adults—a narrative review’, Nutrients, 15(10), p. 2295. doi:10.3390/nu15102295.