Colon to Rectum
Lancet Gastroenterol Hepatol. 2025;10(6):520-536
Efficacy of dietary interventions in irritable bowel syndrome: A systematic review and network meta-analysis
Background: Patients with irritable bowel syndrome (IBS) are often interested in dietary interventions as a means of managing their symptoms. However, the relative efficacy of available diets for the management of IBS is unclear. The authors aimed to examine the relative efficacy of various dietary interventions in IBS.
Methods: For this systematic review and network meta-analysis they searched Medline, Embase, Embase Classic, and the Cochrane Central Register of Controlled Trials from database inception to February 7, 2025, to identify randomised controlled trials comparing an active dietary intervention requiring changes to the intake of more than one food in IBS with either a control intervention, such as a habitual diet, sham diet, a high fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, or alternative miscellaneous dietary advice, or any other active dietary intervention requiring changes to the intake of more than one food. The authors assessed efficacy using dichotomous assessments of improvement in global IBS symptoms or improvement in individual IBS symptoms, including abdominal pain, abdominal bloating or distension, and bowel habit. They pooled data using a random-effects model, with the efficacy of each intervention reported as pooled relative risks (RRs) with 95% confidence intervals [CIs]. They ranked interventions according to their p-score, which measures the mean extent of certainty that one intervention is better than another, averaged over all competing interventions.
Findings: The authors identified 28 eligible randomised controlled trials (comprising 2338 patients) of 11 different dietary interventions compared with 4 control interventions, of which 6 (low FODMAP diet, British Dietetic Association/National Institute for Health and Care Excellence [BDA/NICE] diet, lactose-reduced diet, starch-reduced and sucrose-reduced diet, a personalised diet, and a Mediterranean diet) were studied in more than one trial. For global IBS symptoms, assessed in 28 randomised controlled trials and when considering only the dietary interventions studied in more than one trial, a starch-reduced and sucrose-reduced diet ranked first (RR of global IBS symptoms not improving 0.41 [95% CI: 0.26–0.67]; p-score 0.84; 2 trials), a low FODMAP diet ranked fourth (0.51 [95% CI: 0.37–0.70]; p-score 0.71; 24 trials), and a BDA/NICE diet ranked tenth (0.62 [95% CI: 0.43–0.90]; p-score 0.44; 8 trials), versus a habitual diet. For abdominal pain, assessed in 26 trials and when considering only the dietary interventions studied in more than one randomised controlled trial, a starch-reduced and sucrose-reduced diet ranked second (RR of abdominal pain not improving 0.54 [95% CI: 0.33–0.90]; p-score 0.73; 2 trials), and a low FODMAP diet ranked fifth (0.61 [95% CI: 0.42–0.89]; p-score 0.64; 23 trials), versus a habitual diet. For abdominal bloating or distension, assessed in 26 trials and when considering only the dietary interventions studied in more than one randomised trial, only a low FODMAP diet (RR of abdominal bloating or distension not improving 0.55 [95% CI: 0.37–0.80]; p-score 0.64; 23 trials) was superior to a habitual diet and ranked fourth. For bowel habit, assessed in 23 randomised trials, none of the dietary interventions was superior to any of the control interventions, but a low FODMAP diet was superior to a BDA/NICE diet (RR of bowel habit not improving 0.79 [95% CI: 0.63–0.99]). All comparisons across the network were rated as low or very low confidence, except for direct comparisons between a low FODMAP diet or a starch-reduced and sucrose-reduced diet and habitual diet, both of which were rated as moderate confidence.
Interpretation: In terms of dietary interventions for irritable bowel syndrome, the most evidence exists for a low FODMAP diet, but other promising therapies are emerging and should be the subject of further study.