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Recommendations Summary

CD: FODMAP (2021)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

  • Recommendation(s)

    CD: FODMAP Dietary Pattern

    In adults with celiac disease and refractory abdominal symptoms, there is insufficient evidence to suggest a low-FODMAP restriction in addition to gluten-free dietary pattern.

    Rating: Level 2(C)

    • Risks/Harms of Implementing This Recommendation

      The FODMAP diet may be a challenging diet to correctly implement from patient, caregiver, and provider perspectives due to the number and type of foods restricted and the need to continually evaluate individual diet efficacy in relation to gastrointestinal symptoms. The dietary modifications may increase the risk of nutritional inadequacy for some individuals, especially those with insufficient nutritional literacy. Further, the implications of the FODMAP diet on the intestinal microbiome in the context of Celiac Disease are unknown. Lastly, the potential harms may include diminished quality of life as a result of the additional dietary restrictions that reduce food enjoyment, increase food apprehension at home and eating out, and increase the time needed to procure and prepare foods according to FODMAP recommendations.

    • Conditions of Application

      Implementation Considerations
      Please ensure that all patients with refractory gastrointestinal (GI) symptoms receive adequate clinical investigations for comorbidities that may be the source of the GI symptoms (e.g. SIBO, altered transit time) as appropriate by the GI providers. In refractory cases, ongoing nutrition support by registered dietian nutritionist is appropriate to ensure compliance with the gluten-free diet.

      Refer to the Nutrition Care Manual for Client Education documents for Education on Gluten-Free Nutrition Therapy, Label reading tips, and healthy eating tips:   https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=422

      Other available resources such as beyondceliac.org, celiac.org (Celiac Disease Foundation), and Academy's Celiac Disease Toolkit are also available.

    • Potential Costs Associated with Application

      Specialized foods are not needed to implement the FODMAP diet. Therefore, the financial costs are not anticipated to be greater than a standard diet. However, the additional time cost associated with learning or teaching, implementing or monitoring and evaluating the ongoing efficacy of the FODMAP diet in the context of evolving gastrointestinal symptoms should be considered by the patient and the provider. 

    • Recommendation Narrative

      One neutral-quality study (Roncoroni et al, 2018) examined the effects of a low-FODMAP diet, compared to a control, on nutrition-related outcomes in patients with celiac disease. The study was conducted in Italy and included adults with celiac disease who followed a gluten-free diet for at least one year and reported persistent gastrointestinal symptoms. Sample sizes of participants analyzed ranged from 21-23 per group. 

      Results Overview
      Roncoroni et al, 2018 reported on indicators of quality of life and indicators of gastrointestinal health and gastrointestinal symptoms. They reported no significant difference in the self-reported general health between the group randomly assigned to receive a low-FODMAP gluten-free diet in comparison to the group receiving a standard gluten-free diet. The authors reported on gastrointestinal symptoms, including abdominal pain, fecal consistency and general functional gastrointestinal symptoms. While a significant decrease in the visual analog scale score for abdominal pain was observed in the low-FODMAP gluten-free diet group in comparison to the standard gluten-free diet group, there were no significant differences in other gastrointestinal symptoms between groups. 

      Roncoroni et al, 2018: Fifty adults (mean age 41.1 ±10.1) on a gluten-free diet for at least 12 months were randomized to either continue a regular gluten-free diet or consume a low-FODMAP gluten-free diet for 21 days. These diets were personalized to meet individual energy, macro- and micronutrient daily requirements. Both groups received an in-depth diet review and food education related to their individual diets. 

      Indicators of Quality of Life
      Quality of life was measured via the Short Form-36 Health Survey at baseline and after the intervention. After 21 days, there was no significant difference in the general health reported between groups (P=0.98). 

      Indicators of Gastrointestinal Health and Gastrointestinal Symptoms
      Visual analog scales were used to assess gastrointestinal symptoms before and after the intervention. Participants in the low-FODMAP gluten-free diet group reported significant decreases in abdominal pain in comparison to those in the regular gluten-free diet group (P < 0.01). Differences in visual analog scale scores for other gastrointestinal symptoms, including post-prandial fullness, fecal consistency and non-specific symptoms were not significant between groups. 

    • Recommendation Strength Rationale

      The evidence supporting the recommendation is based on Grade III /Grade C evidence. 

    • Minority Opinions

      Consensus reached.