**7. Dietary management strategies in functional dyspepsia**

Because of the many patients with functional dyspepsia and its serious impairment to their quality of life, this entity represents an important clinical challenge. Pharmacologic therapies are limited, leaving patients and physicians to often use dietary strategies in managing FD.

Unfortunately most of the available information concerning the role of diet and food intake in FD patients is inconclusive. Several studies fortunately have shown clear differences between FD patients and healthy persons in the ability to tolerate certain types of foods including fermentable carbohydrates (FODMAPs).

FD patients often maintain regular consumption of several foods despite these being impli‐ cated with the dyspepsia. Why these patients do not avoid the majority of food components, which they link to dyspepsia, remains unclear. Possible reasons might be ignorance of this association, a lack of alternatives to replace food items, or cultural habits such as the use of coffee in some populations. Nevertheless dietary recommendations are intrinsic for managing FD. General advice should include consuming small, frequent meals that have a low-fat content.

**Type of food HIGH in FODMAP LOW in FODMAP**

Cherries , raspberries, blackberries

Large portions of any fruit

Onion and garlic salt powders

Nectarines, white peaches, apricots, plums

Sour cream Whipping cream

Ice cream Frozen yoghurt Sherbet

Apples, pears

Watermelon

Peaches Prunes Mango, papaya Persimmon Orange fruit Canned fruit

Artichokes Asparagus Sugar snap peas Cabbage Onions Shallot Leek

Garlic Cauliflower Mushrooms Pumpkin Green peppers

Wheat Rye

Spelt

Barley-large quantities

Dairy-based condiments

Dairy-based desserts

Fruit

Vegetables

Grains

Lactose free cottage cheese

Diet in the Etiology and Management of Functional Dyspepsia

Blueberries, strawberries Cantaloupe, honeydew Grapefruit, lemon, lime

<1 tablespoon dried fruit

Bok choy , bean sprouts Red bell pepper Lettuce, spinach Carrots

Chives, spring onion

Cucumber Eggplant Green beans Tomato Potatoes Garlic infused oil Water chestnuts <1 stick celery

sprouts

Brown rice Oats , oat bran Quinoa Corn

more fructose

Consume ripe fruit ; less-ripe fruit contains

<1/2 cup sweet potato, broccoli, Brussels

Gluten-free bread, cereals , pastas and

crackers without honey Apple/pear juice , agave

Sorbet from FODMAPs friendly fruit

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105

Butter Cream cheese

Banana

Grapes Kiwi Pineapple Rhubarb Tangelos <1/4 avocado

Although such recommendations are helpful, specific strategies more commonly become necessary.

A well-trained nutritionist should direct the patient to record a 7-day food and symptom diary. It is also important to record other variables such as stress levels and activity as these factors can also impact symptomatology. The role of the dietitian is to explain the physiological basis of the diet, provide a list of suitable alternative foods and so restrict specific FODMAPs, while promoting a nutritionally adequate diet.

A low FODMAP diet is currently the first approach for many dietitians. This relatively complex diet involves the reduction, but not the complete avoidance of FODMAPs. Foods have been classified into high and low FODMAP content, and therefore knowledge of the FODMAP status of foods is an important skill for patient education (see table below). Low FODMAP foods that are suitable alternatives to foods high in FODMAP are encouraged. For example, rather than completely restricting fruit, reduce the intake of high FODMAP fruit and encourage the intake of FODMAP fruit [32]. After 6 to 8 weeks, the dietitian should undertake a review. If there is a satisfactory improvement, then a re-challenge could be done. It is important to determine the tolerance level, and also to increase variety in the diet. If the improvement is partial or absent, than additional dietary triggers should be emphasized: avoidance of some food chemicals such as salicylates, amines and glutamates, and last but not least a gluten-free diet might be initiated.

Any diet that aims to reduce one group of components will affect other dietary components with the potential to influence the same end point. This is certainly the case with a low FODMAP diet. As gluten-containing cereals also contain a high FODMAP content, any reduction of gluten intake would be accompanied by a decrease in other potentially symptominducing, cereal-related proteins. Likewise, if lactose is avoided in a proportion of patients, then the intake of dairy-associated proteins concomitantly may be reduced.



coffee in some populations. Nevertheless dietary recommendations are intrinsic for managing FD. General advice should include consuming small, frequent meals that have a low-fat

Although such recommendations are helpful, specific strategies more commonly become

A well-trained nutritionist should direct the patient to record a 7-day food and symptom diary. It is also important to record other variables such as stress levels and activity as these factors can also impact symptomatology. The role of the dietitian is to explain the physiological basis of the diet, provide a list of suitable alternative foods and so restrict specific FODMAPs, while

A low FODMAP diet is currently the first approach for many dietitians. This relatively complex diet involves the reduction, but not the complete avoidance of FODMAPs. Foods have been classified into high and low FODMAP content, and therefore knowledge of the FODMAP status of foods is an important skill for patient education (see table below). Low FODMAP foods that are suitable alternatives to foods high in FODMAP are encouraged. For example, rather than completely restricting fruit, reduce the intake of high FODMAP fruit and encourage the intake of FODMAP fruit [32]. After 6 to 8 weeks, the dietitian should undertake a review. If there is a satisfactory improvement, then a re-challenge could be done. It is important to determine the tolerance level, and also to increase variety in the diet. If the improvement is partial or absent, than additional dietary triggers should be emphasized: avoidance of some food chemicals such as salicylates, amines and glutamates, and last but not least a gluten-free

Any diet that aims to reduce one group of components will affect other dietary components with the potential to influence the same end point. This is certainly the case with a low FODMAP diet. As gluten-containing cereals also contain a high FODMAP content, any reduction of gluten intake would be accompanied by a decrease in other potentially symptominducing, cereal-related proteins. Likewise, if lactose is avoided in a proportion of patients,

Soy yoghurt Coconut milk yoghurt

Milk : almond, coconut, hazelnut, rice

Hard cheeses : cheddar, Swiss, brie, blue cheese, mozzarella, parmesan, feta No more than 2 tablespoons ricotta or

Lactose free cow's milk Lactose free ice cream

cottage cheese

then the intake of dairy-associated proteins concomitantly may be reduced.

**Type of food HIGH in FODMAP LOW in FODMAP**

Milk : cow, sheep, goat, soy Creamy soups with milk Evaporated milk

Sweetened condensed milk

Cottage cheese Ricotta cheese Mascarpone cheese

Yoghurt Cow's milk yoghurt

content.

necessary.

promoting a nutritionally adequate diet.

104 Dyspepsia - Advances in Understanding and Management

diet might be initiated.

Milk

Cheese


**References**

G13

1346-1352

[1] Tack J., Bisschops R.: Mechanisms underlying meal-induced symptoms in functional

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107

[2] Miwa H. Why dyspepsia can occur without organic disease: pathogenesis and man‐ agement of functional dyspepsia. J. Gastroenterology, 2012, Aug, 47 (8): 862-871

[3] Karamanolis G., Tack J. Nutrition and motility disorders. Best Practice and Research

[4] Feinle-Bisset C., Horowitz M. Dietary factors in functional dyspepsia. Neurogas‐

[5] Feinle-Bisset C., Vozzo R., Horowitz M., Talley N. Diet, food intake and disturbed physiology in the pathogenesis of symptoms in functional dyspepsia. Am J Gastroen‐

[6] Wood S.C. Gastrointestinal satiety signals. An overview of gastrointestinal signals that influences food intake. Am J Physiol Gastrointest Liver Physiol. 2004, 286: G7-

[7] Thumshirm M. Pathophysiology of functional dyspepsia. Gut 2002, 51 (Suppl 1): 3-66

[8] Tack J.,Piessevaux H., Coulie B., Caenepeel P.,Janssens J. Role of impaired gastric ac‐ commodation to a meal in functional dyspepsia. Gastroenterology 1998, 115:

[9] Tack J. Functional dyspepsia: impaired fundic accommodation. Curr Treat Options

[10] Quartero A.O., de Wit N.J., Lodder A.C., Numans M.E., Smout A.J., Hoes A.W. Dis‐ turbed solid-phase gastric emptuying in non functional dyspepsia: a meta analysis.

[11] Lemann M., Dederding J.P., Flourie B., Franchisseur C., Rambaud J.C., Jian R. Abnor‐ mal perception of visceral pain in response to gastric distention in chronic idiopathic

[12] Marciani L., Gowland P.A., Spiller P.C., Manoy P., Moore R.J., Young P., Fillery-Travis A.J. Effect of meal viscosity and nutrients on satiety, intragastric dilation and emptying assessed by MRI. Am J Gastrointest Liver Physiol 2001, 280: G1227-G1233

[13] Hill A.J., Blundell J.E. Macro-nutrients and satiety:the effects of a high protein or a high carbohydrate meal on subjective motivation to eat and food preferences. Nutr

dyspepsia. The irritable stomach syndrome. Dig Dis Sci 1991, 36: 1241-1254

dyspepsia. Gastroenterology, 2204, Dec 127 (6): 1844-1847

Clin. Gastroenterol., 2006 ; 20 (3): 485-505

troenterology. Motility, 2006, 18: 608-618

terol 2004, Jan 99 (1): 170-181

Gastroenterol, 2000, 3: 287-294

Dig Dis Sci 1998, 43: 2028-2033

Behav 1986, 3: 133-144

**Table 3.** FODMAP status of food

#### **8. Summary**

Functional dyspepsia is a clinical problem of considerable magnitude for the health care system due to its high prevalence and the chronic or recurrent nature of symptoms. The manifestation of FD symptoms is directly caused by physiological abnormalities: abnormal gastroduodenal motility and/or visceral hypersensitivity. The therapeutic options for a clinician are limited and far from optimal: pharmacological therapies often fail. As food ingestion commonly triggers gastrointestinal symptoms, a dietary approach would seem most effective. There is reasonable evidence to suggest that a low FODMAP diet is beneficial, while gluten sensitivity may benefit others particularly in patients with IBS features. Gastroenterologists should no longer ignore specific dietary intervention for patients with functional dyspepsia.
