Introduction
The low fermentable oligosaccharide, disaccharide, monosaccharide and polyol diet (LFD) has been purported as a first line therapeutic treatment for the management of irritable bowel syndrome (IBS)1,2. Despite the extensive research supporting the efficacy of the LFD3 4, there are few studies exploring the lived experience of people with IBS undertaking a dietitian-led three-phase LFD.
Aims & Methods
This study aimed to explore people’s expectations of and experience with each phase of the LFD, and identify barriers and enablers to successfully completing each phase. A descriptive, qualitative design employed semi-structured interviews with adults with IBS who undertook all or part of a dietitian-led research study on predictors of response to a LFD. Participants underwent LFD restriction, reintroduction and personalisation between October 2020 and April 2022. Interviews examined expectations and experiences of the LFD process, and barriers and enablers to undertaking and completing each phase. Sociodemographic and IBS characteristics were also collected. Thematic analysis summarised key themes.
Results
Seventeen people (32%, 17/53 response rate) aged 37.5 ± 14 years (88% female) completed interviews, of whom 76% (13/17) completed all three phases of the LFD. Duration of experiencing IBS symptoms ranged from one to 40 years with 76% experiencing diarrhoea as the most predominant symptom. Four themes emerged from the data. Firstly, people presented with different IBS and healthcare experiences, and expectations of what the LFD would provide. Previous unsuccessful treatments (pre- and probiotics, gluten elimination, herbal medicine) motivated people to undertake the LFD. Secondly, people’s expectations of outcomes within each phase varied and was related to their symptom response. People expected symptom resolution during the restriction phase and were disappointed that symptoms were not entirely alleviated. Symptoms during the reintroduction phase were a barrier to continuing challenges for some but others felt that symptoms assisted in identifying trigger foods. Despite overall reductions in symptoms during each phase, a residual frustration was felt as symptoms were not eliminated on completion of personalisation. Thirdly, the three-phase process required significant planning, effort and self-efficacy. Ability to adhere to personal tolerance levels of fermentable carbohydrates was an enabler to successful completion of the reintroduction and personalisation phase. Environmental barriers included eating out, multi-person households and altering meals to suit family mealtimes. Personal barriers included perceptions of food triggers, apprehension to try foods that had long been avoided and experiencing symptoms during the reintroduction phase. Lastly, most people incorporated learning and experiences from the LFD into daily life after reintroduction. Those with symptom improvement identified strategies to circumvent FODMAP intake in daily life and were understanding of the interplay between food, the environment and psychological factors on symptoms. Some used the LFD restriction to manage symptom exacerbations.
Conclusion
The LFD process is complex, and personal beliefs, experiences and expectations impact on adherence and completion of each phase. Further personalisation of the LFD to individual circumstances is fundamental to improving the experience and outcome of this therapeutic management strategy in people with IBS. These findings will be used to inform improved implementation to optimise peoples experience and success with the LFD.
References
1 Clinical Decision Support Tool: IBS Treatment. (2022). Gastroenterology 163(1): 152-152 http://doi.org./10.1053/S0016-5085(22)00536-4
2 Vasant, D.H., Paine, P.A., Black, C.J., Houghton, L.A., Everitt, H.A., Corsetti, M., Agrawal, A., Aziz, I., Farmer, A.D., Eugenicos, M.P, Moss-Morris, R., Yiannakou, Y & Ford, A, C. (2021). British Society of Gastroenterology guidelines on the management of irritable bowel syndrome Gut, 70(7), 1214-1240.http://doi.org/10.1136/gutjn-2021-324598
3 Black, C.J., Staudacher, H.M & Ford, A.C. (2022). Efficacy of a low FODMAP diet in irritable bowel syndrome: systematic review and network meta-analysis. Gut, 71(6), 1117-1126. doi:10.1136/gutjnl-2021-325214
4 Wang, J., Yang, P., Zhang, L and Hou, X. (2021). A low FODMAP diet improves the global symptoms and bowel habits of adult IBS patients: A systematic review and meta-analysis. Frontiers in nutrition, 8. http://doi.org/10.3389/fnut2021.683191