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• W2889801842 abstract "See “Effects of prebiotics vs a diet low in Fodmaps in patients with functional gut disorders,” by Huaman J-W, Mego M, Manichanh C, et al, on page 1004. See “Effects of prebiotics vs a diet low in Fodmaps in patients with functional gut disorders,” by Huaman J-W, Mego M, Manichanh C, et al, on page 1004. Recent evidence from clinical settings and research demonstrate an important role for gut microbiota in generation of symptoms in patients with functional gastrointestinal disorders (FGIDs) in general and irritable bowel syndrome (IBS) in particular.1Simren M. Barbara G. Flint H.J. et al.Intestinal microbiota in functional bowel disorders: a Rome foundation report.Gut. 2013; 62: 159-176Crossref PubMed Scopus (651) Google Scholar Clinical observations that support the involvement of gut microbiota in symptom generation in IBS and other FGIDs include (a) a substantial proportion of patients with IBS report onset of their GI symptoms after a bout of gastroenteritis (ie, postinfection IBS)2Klem F. Wadhwa A. Prokop L.J. et al.Prevalence, risk factors, and outcomes of irritable bowel syndrome after infectious enteritis: a systematic review and meta-analysis.Gastroenterology. 2017; 152: 1042-1054 e1Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar and this group of patients has abnormal gut microbiota composition,3Jalanka-Tuovinen J. Salojarvi J. Salonen A. et al.Faecal microbiota composition and host-microbe cross-talk following gastroenteritis and in postinfectious irritable bowel syndrome.Gut. 2014; 63: 1737-1745Crossref PubMed Scopus (218) Google Scholar (b) a proportion of individuals develop functional GI symptoms after receiving systemic antibiotics, presumably owing to the development of (transient) gut dysbiosis,4Maxwell P.R. Rink E. Kumar D. et al.Antibiotics increase functional abdominal symptoms.Am J Gastroenterol. 2002; 97: 104-108Crossref PubMed Google Scholar and (c) use of the nonabsorbable antibiotic rifaximin,5Lembo A. Pimentel M. Rao S.S. et al.Repeat treatment with rifaximin is safe and effective in patients with diarrhea-predominant irritable bowel syndrome.Gastroenterology. 2016; 151: 1113-1121Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar as well as the use of probiotics,6Ford A.C. Quigley E.M. Lacy B.E. et al.Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis.Am J Gastroenterol. 2014; 109 (quiz 1546, 1562): 1547-1561Crossref PubMed Scopus (508) Google Scholar improve IBS symptoms, presumably through effects on gut microbiota. Furthermore, several studies indicate that at least a subset of patients with IBS demonstrate abnormal gut microbiota composition7Rajilic-Stojanovic M. Jonkers D.M. Salonen A. et al.Intestinal microbiota and diet in IBS: causes, consequences, or epiphenomena?.Am J Gastroenterol. 2015; 110: 278-287Crossref PubMed Scopus (244) Google Scholar and that this is associated with the severity and pattern of symptoms.8Tap J. Derrien M. Tornblom H. et al.Identification of an intestinal microbiota signature associated with severity of irritable bowel syndrome.Gastroenterology. 2017; 152: 111-123 e8Abstract Full Text Full Text PDF PubMed Scopus (337) Google Scholar Taken together, these clinical and research observations implicate that modulating the gut microbiota might be a relevant treatment strategy for a substantial proportion of these patients. Dietary factors are central for patients with IBS and the majority of patients report worsening of symptoms after intake of certain food items, particularly foods containing carbohydrates and fat.9Bohn L. Storsrud S. Tornblom H. et al.Self-reported food-related gastrointestinal symptoms in IBS are common and associated with more severe symptoms and reduced quality of life.Am J Gastroenterol. 2013; 108: 634-641Crossref PubMed Scopus (390) Google Scholar Part of this finding might be explained by diet–microbiota interactions, because the gut microbes have an important role in the digestion of dietary components, resulting in metabolites that may directly or indirectly contribute to IBS symptoms.7Rajilic-Stojanovic M. Jonkers D.M. Salonen A. et al.Intestinal microbiota and diet in IBS: causes, consequences, or epiphenomena?.Am J Gastroenterol. 2015; 110: 278-287Crossref PubMed Scopus (244) Google Scholar Food items rich in indigestible carbohydrates (ie, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [FODMAPs]) seem to be particularly relevant, because they can provoke IBS symptoms in susceptible individuals through osmosis and fermentation by gut microbes.10Staudacher H.M. Irving P.M. Lomer M.C. et al.Mechanisms and efficacy of dietary FODMAP restriction in IBS.Nat Rev Gastroenterol Hepatol. 2014; 11: 256-266Crossref PubMed Scopus (167) Google Scholar Several studies have demonstrated the clinical efficacy of a low FODMAP diet in IBS,10Staudacher H.M. Irving P.M. Lomer M.C. et al.Mechanisms and efficacy of dietary FODMAP restriction in IBS.Nat Rev Gastroenterol Hepatol. 2014; 11: 256-266Crossref PubMed Scopus (167) Google Scholar an effect that goes beyond the placebo response frequently reported in patients with IBS,11Staudacher H.M. Lomer M.C.E. Farquharson F.M. et al.A diet low in FODMAPs Reduces symptoms in patients with irritable bowel syndrome and a probiotic restores Bifidobacterium species: a randomized controlled trial.Gastroenterology. 2017; 153: 936-947Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar but not clearly superior to traditional IBS dietary advice.12Bohn L. Storsrud S. Liljebo T. et al.Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial.Gastroenterology. 2015; 149: 1399-1407 e2Abstract Full Text Full Text PDF PubMed Scopus (405) Google Scholar The clinical effect of a low FODMAP diet is partly mediated through diet–microbiota interactions; a reduction of carbohydrates, that is, the substrate for bacterial fermentation in the colon, leads to lowered gas production and thereby reduced intestinal distension. However, the physiologic responses to FODMAP intake, that is, the effect on luminal water content, gas production, and degree of luminal distension, do not seem to differ between patients with IBS and healthy controls, but colonic hypersensitivity to distension, rather than excessive gas production, seems to be the main cause of carbohydrate-related symptoms in patients with IBS.13Major G. Pritchard S. Murray K. et al.Colon hypersensitivity to distension, rather than excessive gas production, produces carbohydrate-related symptoms in individuals with irritable bowel syndrome.Gastroenterology. 2017; 152: 124-133 e2Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar Regarding gut microbiota, a low FODMAP diet leads to substantial changes in gut microbiota composition with a decrease in gut microbes putatively associated with health, such as bifidobacteria, which may seem counterintuitive.14Bennet S.M.P. Bohn L. Storsrud S. et al.Multivariate modelling of faecal bacterial profiles of patients with IBS predicts responsiveness to a diet low in FODMAPs.Gut. 2018; 67: 872-881Crossref PubMed Scopus (135) Google Scholar However, the relevance of changes in the gut luminal microenvironment and changes in symptoms remain unclear. Furthermore, gut microbiota composition before starting a low FODMAP diet seems to be a predictor for the symptom response, highlighting the relevance of diet–microbiota interactions for efficacy.14Bennet S.M.P. Bohn L. Storsrud S. et al.Multivariate modelling of faecal bacterial profiles of patients with IBS predicts responsiveness to a diet low in FODMAPs.Gut. 2018; 67: 872-881Crossref PubMed Scopus (135) Google Scholar Prebiotics and probiotics can also improve symptoms in IBS through modulation of the gut microbiota6Ford A.C. Quigley E.M. Lacy B.E. et al.Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis.Am J Gastroenterol. 2014; 109 (quiz 1546, 1562): 1547-1561Crossref PubMed Scopus (508) Google Scholar and, as stated, this is also true for nonabsorbable antibiotics.5Lembo A. Pimentel M. Rao S.S. et al.Repeat treatment with rifaximin is safe and effective in patients with diarrhea-predominant irritable bowel syndrome.Gastroenterology. 2016; 151: 1113-1121Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar Probiotics, which are live microorganisms that, when administered in adequate amounts, confer a health benefit on the host, are effective in IBS, but the mechanism behind symptom improvement is not altogether clear.6Ford A.C. Quigley E.M. Lacy B.E. et al.Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis.Am J Gastroenterol. 2014; 109 (quiz 1546, 1562): 1547-1561Crossref PubMed Scopus (508) Google Scholar, 15Hill C. Guarner F. Reid G. et al.Expert consensus document. The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic.Nat Rev Gastroenterol Hepatol. 2014; 11: 506-514Crossref PubMed Scopus (4195) Google Scholar Prebiotics are defined as a substrate that is selectively used by host microorganisms conferring a health benefit and they selectively stimulate beneficial gut microbes, such as bifidobacteria. Most of the currently established prebiotics are carbohydrate based and the dietary prebiotics most extensively documented in humans are nondigestible oligosaccharides.16Gibson G.R. Hutkins R. Sanders M.E. et al.Expert consensus document: The International Scientific Association for Probiotics and Prebiotics (ISAPP) consensus statement on the definition and scope of prebiotics.Nat Rev Gastroenterol Hepatol. 2017; 14: 491-502Crossref PubMed Scopus (2314) Google Scholar In IBS, some studies have suggested a positive effect of prebiotics on symptoms, but the results are mixed and the mechanisms behind symptom improvement is unclear.6Ford A.C. Quigley E.M. Lacy B.E. et al.Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis.Am J Gastroenterol. 2014; 109 (quiz 1546, 1562): 1547-1561Crossref PubMed Scopus (508) Google Scholar, 17Dimidi E. Rossi M. Whelan K. Irritable bowel syndrome and diet: where are we in 2018?.Curr Opin Clin Nutr Metab Care. 2017; 20: 456-463Crossref PubMed Scopus (17) Google Scholar However, the fact that several studies have demonstrated reduction of bifidobacteria in IBS7Rajilic-Stojanovic M. Jonkers D.M. Salonen A. et al.Intestinal microbiota and diet in IBS: causes, consequences, or epiphenomena?.Am J Gastroenterol. 2015; 110: 278-287Crossref PubMed Scopus (244) Google Scholar and the finding of an inverse association between bifidobacteria and abdominal pain18Jalanka-Tuovinen J. Salonen A. Nikkila J. et al.Intestinal microbiota in healthy adults: temporal analysis reveals individual and common core and relation to intestinal symptoms.PLoS One. 2011; 6: e23035Crossref PubMed Scopus (245) Google Scholar suggest that stimulating bifidobacteria in the gut with prebiotics may be of relevance for symptom improvement in IBS. However, because prebiotics are nonabsorbable and fermentable (ie, FODMAPs), there are also concerns that they may lead to a worsening of GI symptoms, particularly gas-related symptoms.17Dimidi E. Rossi M. Whelan K. Irritable bowel syndrome and diet: where are we in 2018?.Curr Opin Clin Nutr Metab Care. 2017; 20: 456-463Crossref PubMed Scopus (17) Google Scholar In the current issue of Gastroenterology, Huaman et al19Huaman J.-W. Mego M. Manichanh C. et al.Effects of prebiotics vs a diet low in Fodmaps in patients with functional gut disorders.Gastroenterology. 2018; 155: 1004-1007Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar present a very interesting randomized controlled trial addressing some of these apparent inconsistencies. Specifically, they asked the question whether treatment strategies that affect the gut microbiota composition and gas production in opposite directions, that is, a low FODMAP diet and a prebiotic (galacto-oligosaccharide), may lead to similar symptom reduction.19Huaman J.-W. Mego M. Manichanh C. et al.Effects of prebiotics vs a diet low in Fodmaps in patients with functional gut disorders.Gastroenterology. 2018; 155: 1004-1007Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar The primary outcome was the effect of the low FODMAP diet versus the prebiotic on gut microbiota composition. As expected, the microbiota composition differed between the treatment groups after the 4-week treatment period, particularly in relation to bifidobacteria (increase in the prebiotic group and decrease in the low FODMAP group) and Bilophila wadsworthia (the opposite pattern). Despite the opposite effect on gut microbiota composition, the effects on symptoms were very similar during the treatment, with significant reductions of most GI symptoms in both groups (Figure 1). The only exception was anal gas evacuations, where only the low FODMAP group had a positive effect. However, of interest, the decrease in symptoms persisted during the 2-week follow-up after cessation of the prebiotic, but reappeared immediately after the patients discontinued the low FODMAP diet, which may indicate that the effect of the prebiotic is mediated through its effects on gut microbiota composition, whereas the effect of the low FODMAP diet is more related to the meal composition per se and diet–microbiota interactions than to its effects on gut microbiota composition. This finding relates well to the current view on the pathophysiology in IBS, where different abnormalities and mechanisms may lead to similar symptoms.20Enck P. Aziz Q. Barbara G. et al.Irritable bowel syndrome.Nat Rev Dis Primers. 2016; 2: 16014Crossref PubMed Scopus (528) Google Scholar Moreover, as the authors rightly point out, intermittent prebiotic administration may be a valid alternative to restrictive diets. Alternatively, based on the current study findings, (semi-)restrictive diets in combination with intermittent prebiotic treatment may be an attractive alternative to avoid unwanted microbiota alterations. Furthermore, another recent study suggested that the coadministration of a multi- probiotic might be given to restore bacterial alterations in patients on a low FODMAP diet.11Staudacher H.M. Lomer M.C.E. Farquharson F.M. et al.A diet low in FODMAPs Reduces symptoms in patients with irritable bowel syndrome and a probiotic restores Bifidobacterium species: a randomized controlled trial.Gastroenterology. 2017; 153: 936-947Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar More studies in this area are now needed to optimize dietary treatment for the large IBS population in relation to both efficacy and long-term safety. Specifically, studies addressing combinations of various interventions such as diet and prebiotics or probiotics and the ability to predict treatment response to personalize dietary treatments, as well an assessment of the durability of the response and long-term safety are needed. Effects on microbiota composition and function needs to be included, given the relevance of gut microbiota not only for gut health but also for general health.1Simren M. Barbara G. Flint H.J. et al.Intestinal microbiota in functional bowel disorders: a Rome foundation report.Gut. 2013; 62: 159-176Crossref PubMed Scopus (651) Google Scholar Modulation of gut microbiota as a treatment strategy for IBS and other FGIDs seems promising, but additional methodologically rigorous studies are needed and long-term safety aspects need to be taken into account so we do not offer patients diets that reduce symptoms, but deteriorate gut health and general health in the long term. Effects of Prebiotics vs a Diet Low in FODMAPs in Patients With Functional Gut DisordersGastroenterologyVol. 155Issue 4PreviewPrebiotics and diets low in fermentable oligo-, di-, mono-saccharides and polyols (low-FODMAP diet) might reduce symptoms in patients with functional gastrointestinal disorders, despite reports that some nonabsorbable, fermentable meal products (prebiotics) provide substrates for colonic bacteria and thereby increase gas production. We performed a randomized, parallel, double-blind study of patients with functional gastrointestinal disorders with flatulence. We compared the effects of a prebiotic supplement (2.8 g/d Bimuno containing 1.37 g beta-galactooligosaccharide) plus a placebo (Mediterranean-type diet (prebiotic group, n = 19) vs a placebo supplement (2.8 g xylose) plus a diet low in FODMAP (low-FODMAP group, n = 21) for 4 weeks; patients were then followed for 2 weeks. Full-Text PDF" @default.
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• W2889801842 title "Manipulating the Gut Microbiome as a Treatment Strategy for Functional Gastrointestinal Disorders" @default.
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