The study by Somvanapanich et al¹ in this issue of Journal of Neurogastroenterology and Motility is a timely reminder regarding the practical usefulness of spot hydrogen breath test for predicting response to low fermentable oligo-, di-, mono-saccharides, and polyols (FODMAPs) diet in patients with bloating, because it is not a panacea. The authors have provided the evidence for the recommendation to encourage performance of the spot hydrogen breath test to identify good candidate to low FODMAPs dietary intervention. In their study, patients with bloating were diagnosed as having irritable bowel syndrome (IBS), functional constipation, functional dyspepsia, and functional diarrhea. The spot breath samples were collected 2 hours after the patient’s usual lunch. In the study, the severity of abdominal bloating recorded and assessed using a 0-10 cm visual analog scale at baseline, and the average of 7 days of those symptoms before the end of the study. Responders were defined as those with at least a 30% decrease in its severity during the fourth week compared to the baseline. The baseline spot hydrogen level in responders was 9.5 (3.3-17.3) vs 4.5 (3.3-6.3) in non-responders (P < 0.05). The area under the curve for predicting low FODMAPs dietary advice responsiveness using baseline hydrogen level was 0.692 (95% CI, 0.51-0.86; P < 0.05) with the best cutoff at 8 parts per million (ppm) (sensitivity 66.7% and specificity 82.4%). The good candidate for a low FODMAPs diet were patients with spot postprandial hydrogen level > 8 ppm. Traditional dietary advice (TDA) is effective like the low FODMAPs and gluten-free diet but is more IBS patient friendly with regard to cost, time to shop, and ease of implementation.² Given together, TDA is considered the first-choice dietary intervention in IBS. In a network meta-analysis, a low FODMAPs diet was superior to TDA dietary advice for abdominal bloating or distension (relative risk, 0.72; 95% CI, 0.55-0.94).³ Low FODMAPs should be considered for patients who have poor response to TDA. The most effective low FODMAPs diet service require specialist dietetic care. There appears to be poor availability of gastrointestinal dietetic service in the world. In England, many patients are failing to receive specialist dietetic care, likely leading to patients self-implementing or not implementing dietary interventions.⁴ Somvanapanich et al¹ emphasize that the implementation of a low FODMAPs diet is associated with higher healthcare utilization and a high level of patient cooperation, the prediction of low FODMAPs responsive patients is therefore essential to treatment success by increasing physicians’ confidence in recommending a low FODMAPs diet for suitable patients and enhancing patients’ compliance. We agree with their opinion the spot postprandial hydrogen breath test is a simple point-of-care test possibly helpful in managing patients with bloating. However, some limitations of this study should be resolved by further studies with a larger sample size and standardized method in postprandial breath test. Accumulating evidence for the practical utility of spot hydrogen breath test should be needed. A great hockey player plays where the puck is going to be. We hope that most physicians accept the belief that a good doctor recommends low FODMAPs diet in patients with bothersome bloating and higher postprandial hydrogen levels.

This work was supported by the Soonchunhyang University Research Fund.

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