Management of irritable bowel syndrome in primary care

Sarah L Alderson; Christopher J Black; Alexander C Ford; Hazel A Everitt

doi:10.3399/BJGP.2025.0190

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Management of irritable bowel syndrome in primary care
Alex Ford and Hazel Everitt

Published on: 04 December 2025
Management of irritable bowel syndrome in primary care
Kevork Hopayian

Published on: 01 December 2025

Published on: (4 December 2025)
Page navigation anchor for Management of irritable bowel syndrome in primary care
Management of irritable bowel syndrome in primary care
Alex Ford, Professor of Gastroenterology and Honorary Consultant Gastroenterologist, Leeds Institute of Medical Research at St. James's, University of Leeds and Leeds Gastroenterology Institute
Other Contributors:
Hazel Everitt, Professor of Primary Care Research and General Practitioner, Primary Care Research Centre, University of Southampton
We thank Dr. Hopayian for his thoughtful letter discussing our recent article dealing with the management of irritable bowel syndrome (IBS).¹ In the network meta-analysis he refers to, there were 24 randomised controlled trials (RCTs), containing 1803 patients, comparing a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) with either habitual diet, sham dietary intervention, or another active whole dietary intervention.² This compares with only two trials of a Mediterranean diet, recruiting 85 patients, although another RCT of a Mediterranean diet in 139 patients with IBS has been published since the network meta-analysis was conducted.³

In the network meta-analysis,² in terms of global symptom improvement, a starch- and sucrose-reduced diet ranked first, a gluten-free diet second, and a tritordeum-based diet third, but these interventions were each studied in only one or two RCTs. A low FODMAP diet ranked fourth in the network (relative risk of IBS symptoms not improving = 0.51; 95% confidence interval 0.37 to 0.70). The Mediterranean diet was not superior to any of the control interventions or any of the other active dietary interventions in this analysis. Finally, there were no data on the effect on quality of life scores reported in this network meta-analysis.

In terms of endpoints studied in dietary intervention trials in IBS, all RCTs in the network meta-analysis reported the eff...
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We thank Dr. Hopayian for his thoughtful letter discussing our recent article dealing with the management of irritable bowel syndrome (IBS).¹ In the network meta-analysis he refers to, there were 24 randomised controlled trials (RCTs), containing 1803 patients, comparing a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) with either habitual diet, sham dietary intervention, or another active whole dietary intervention.² This compares with only two trials of a Mediterranean diet, recruiting 85 patients, although another RCT of a Mediterranean diet in 139 patients with IBS has been published since the network meta-analysis was conducted.³

In the network meta-analysis,² in terms of global symptom improvement, a starch- and sucrose-reduced diet ranked first, a gluten-free diet second, and a tritordeum-based diet third, but these interventions were each studied in only one or two RCTs. A low FODMAP diet ranked fourth in the network (relative risk of IBS symptoms not improving = 0.51; 95% confidence interval 0.37 to 0.70). The Mediterranean diet was not superior to any of the control interventions or any of the other active dietary interventions in this analysis. Finally, there were no data on the effect on quality of life scores reported in this network meta-analysis.

In terms of endpoints studied in dietary intervention trials in IBS, all RCTs in the network meta-analysis reported the effect of the intervention on global symptoms rather than on constipation, pain, or bloating separately.² Most trials used either adequate relief of symptoms or an improvement on the IBS severity scoring system,⁴ a validated questionnaire. Both are widely accepted as endpoints in treatment trials in IBS. In terms of the bowel habit of participants in these RCTs, 17 of the 28 eligible trials recruited patients with a mixed bowel habit among their participants, although the effect of dietary interventions by specific bowel habit was not reported by many.

In terms of the evidence, there was moderate certainty in the network meta-analysis that a low FODMAP diet was superior to habitual diet for global IBS symptoms.² All other comparisons across the network were rated low or very low confidence. Hence, the best evidence exists for the use of a low FODMAP diet, although care is needed with its implementation due to the high levels of restrictive eating behaviours seen in patients with IBS.⁵ It should, therefore, only be implemented by a FODMAP-accredited dietitian who can assess for red flags, in the context of restrictive diets, and monitor nutritional adequacy.

References

1. Alderson SL, Black CJ, Ford AC, Everitt HA. Management of irritable bowel syndrome in primary care. Br J Gen Pract 2025;75:429.
2. Cuffe MS, Staudacher HM, Aziz I et al. Efficacy of dietary interventions in irritable bowel syndrome: A systematic review and network meta-analysis. Lancet Gastroenterol Hepatol 2025;10:520-536.
3. Bamidele JO, Brownlow GM, Flack RM, et al. The Mediterranean diet for irritable bowel syndrome : A randomized clinical trial. Ann Intern Med 2025; doi: 10.7326/ANNALS-25-01519.
4. Francis CY, Morris J, Whorwell PJ. The irritable bowel severity scoring system: A simple method of monitoring irritable bowel syndrome and its progress. Aliment Pharmacol Ther 1997;11:395-402.
5. Flack R, Brownlow G, Burton-Murray H, Palsson O, Aziz I. The prevalence and burden of avoidant/restrictive food intake disorder symptoms in adults with disorders of gut-brain interaction: A population-based study. Gastroenterology 2025; doi: 10.1053/j.gastro.2025.07.043.
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Competing Interests: None declared.
Published on: (1 December 2025)
Page navigation anchor for Management of irritable bowel syndrome in primary care
Management of irritable bowel syndrome in primary care
Kevork Hopayian, General practitioner, University of Nicosia Medical School and Suffolk GP Federation
Alderson SL et al. are to be congratulated on a clear and pragmatic presentation of the management of IBS.¹ They based their recommendations for the dietary management of IBS on the best evidence we have. But caution is needed when considering the implications of the best evidence for dietary manipulation because the results are not clear cut. A meta-analysis found that both a low FODMAP diet, LFD, and the Mediterranean diet improve overall symptoms and quality of life.² The review found several studies of LFD but only one for the Mediterranean diet. Thus we have more evidence for the effectiveness of LFD. On the other hand, the Mediterranean diet had a greater effect. Of the two, the LFD is harder to apply. So far, it would seem sensible to recommend the Mediterranean diet first in primary care and that LFD be reserved for non-responsive or more severe cases. A clear plan for dietary management? I am not sure. There seems to be a contradiction. The Mediterranean diet replete with pulses, wheat products, fruit, onions and brassicas is high in FODMAPs. How can both it and an LFD be effective? Another review found that soluble fibre (as found in oats and products like ispaghula) is effective for global symptoms but insoluble fibre (Mediterranean) may worsen some symptoms.³ However, the review had several shortcomings. It did not fully describe the inclusion criteria and there was no risk of bias assessment.

There is another prob...
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Alderson SL et al. are to be congratulated on a clear and pragmatic presentation of the management of IBS.¹ They based their recommendations for the dietary management of IBS on the best evidence we have. But caution is needed when considering the implications of the best evidence for dietary manipulation because the results are not clear cut. A meta-analysis found that both a low FODMAP diet, LFD, and the Mediterranean diet improve overall symptoms and quality of life.² The review found several studies of LFD but only one for the Mediterranean diet. Thus we have more evidence for the effectiveness of LFD. On the other hand, the Mediterranean diet had a greater effect. Of the two, the LFD is harder to apply. So far, it would seem sensible to recommend the Mediterranean diet first in primary care and that LFD be reserved for non-responsive or more severe cases. A clear plan for dietary management? I am not sure. There seems to be a contradiction. The Mediterranean diet replete with pulses, wheat products, fruit, onions and brassicas is high in FODMAPs. How can both it and an LFD be effective? Another review found that soluble fibre (as found in oats and products like ispaghula) is effective for global symptoms but insoluble fibre (Mediterranean) may worsen some symptoms.³ However, the review had several shortcomings. It did not fully describe the inclusion criteria and there was no risk of bias assessment.

There is another problem when it comes to translating research into practice: research on dietary management has focused on constipation, pain, and bloating. But what are we to suggest for patients with mixed constipation and diarrhoea (IBS-M)?

For me, the message is that we should share the uncertainty about diet with patients then guide them to explore the effects of different diets over a suitable period with the warning that they may not find an answer. Future research should look further into the

Mediterranean diet, include IBS-M, and explore better the difference between soluble and insoluble fibre. We might then be able to give our patients more accurate guidance.

References

1. Alderson SL, Black CJ, Ford AC, Everitt HA. Management of irritable bowel syndrome in primary care. Br J Gen Pract 2025;75:429.
2. Cuffe MS, Staudacher HM, Aziz I et al. Efficacy of dietary interventions in irritable bowel syndrome: a systematic review and network meta-analysis. The Lancet Gastroenterology & Hepatology 2025;10:520-536.
3. Bijkerk CJ, Muris JWM, Knottnerus JA, Hoes AW, De Wit NJ. Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome. Alimentary Pharmacology & Therapeutics 2004;19:245-251.

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Competing Interests: None declared.

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