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Functional dyspepsia (FD) is a chronic symptom complex characterized by epigastric pain or burning, bothersome postprandial fullness, or early satiation without a definitive organic cause.¹ Many patients with FD also experience other troublesome symptoms, including nausea, bloating, belching, and heartburn.² FD has been subdivided into meal-related dyspepsia, or postprandial distress syndrome (PDS), and meal-unrelated dyspepsia, or epigastric pain syndrome (EPS); however, overlap between the two conditions has been reported.³

FD is one of the more common functional disorders, with a prevalence of 10-20% of the population.⁴  

Since dyspepsia may present with a multitude of symptoms, FD is a diagnosis of exclusion. Clinicians are encouraged to look for red flags that are clinical indicators of a possible serious underlying condition.^1,5 Yet on diagnostic work-up, only 20-30% of patients with FD are found to have frank diseases that account for their symptoms.⁴ The pathogenesis of FD is unclear, but may be associated with:^6-8

• Socio-psychological factors such as stress, anxiety, depression, and stressful interpersonal relationships.
• Biological mechanisms such as gastroduodenal dysfunction and inflammation, impaired duodenal mucosal integrity, and visceral hypersensitivity.

Treatment Strategies – Modifiable Lifestyle Factors

The impaired quality of life of patients with this condition implies the need for a definitive diagnosis followed by treatment for the duration of the symptomatic interval. However, the causes of FD are varied and complex, resulting in nonstandard, limited, and potentially inefficient pharmaceutical-based therapeutic options.^3,7 Adjunctive or alternative non-pharmacologic therapies include psychotherapy, herbal supplementation, lifestyle modification, dietary interventions, acupuncture, and electrical stimulation.⁹

Consideration of a patient’s lifestyle patterns and habits is critical for a successful treatment strategy. Sleep dysfunction and disorders are common in patients with FD,^2,6 which may exacerbate other symptoms and reduce quality of life. Psychiatric comorbidities such as depression and anxiety are another feature of functional gastrointestinal (GI) disorders like dyspepsia,¹⁰ and implementing either sleeping or psychological therapies may help reduce FD symptoms.⁶

Stress and social support

Research suggests that anxiety often precedes the onset of FD, specifically PDS rather than EPS,^2,11 and that FD may lead to an increase in anxiety levels, regardless of the type of disease. A 2019 cross-sectional study compared depression and anxiety levels of patients diagnosed specifically with either PDS or EPS with healthy volunteers and found increased anxiety for both EPS and PDS patients.¹² In addition, those with PDS showed significantly lower rates of general health and social functioning as well as elevated depression levels compared to patients with EPS.¹²

In addition to anxiety, patients with FD have reportedly more depressive symptoms, more stressful life events, and less social support.^7,9 A 2019 prospective randomized controlled single-blind study with 100 patients investigated the effects of comfort care on FD symptoms, gastric motility, and mental state of patients.⁷ The study’s results suggested that comfort care reduces FD symptoms, increases gastric emptying rate, improves gastric motility, relieves patients’ depression and anxiety, and promotes the rehabilitation of the disease. In this study, comfort care was implemented as medical care that:⁷

• Identified the patient’s stressors.
• Alleviated those stress responses.
• Provided psychological and social support.

Nutrition and Exercise

Nutrition and dietary patterns are also important components when implementing treatment strategies based on modifiable lifestyle factors. A 2021 systematic review and meta-analysis found that the consumption of ultraprocessed food was associated with a range of chronic diseases, including functional dyspepsia in adults.¹³ Certain foods may trigger increased dyspeptic symptoms for some patients, and a diet low in FODMAPs may be helpful.¹ A 2018 screening of 200 patients discovered food hypersensitivity in 4% of those with a functional GI disorder,⁵ and a strong association was found between wheat sensitivity and FD in a 2018 population-based study.¹⁴ Eating small, frequent, low-fat meals may be a more accessible treatment strategy to help some patients initially find relief from dyspeptic symptoms.²

While physical activity is advocated for some patients with functional GI disorders, including FD, the evidence for increasing positive outcomes is insufficient.¹⁵ For patients with FD, normal exercise routines and physical activity may be negatively impacted. In a 2020 population-based study, subjects with FD reported significantly less walking and lower frequency of exercising; of interesting note, those with PDS reported less vigorous exercise, but not those with EPS.¹⁶ While FD was found to be associated with lower exercise levels, the cause is undetermined.¹⁶

Conclusion

The functional medicine model emphasizes the necessity for personalized treatment strategies and for considering modifiable lifestyle factors in addressing potential underlying causes of FD. Tools such as the matrix and timeline are used to map out a patient’s health journey, organize their clinical imbalances, and help develop an individualized intervention. These strategies may include identifying and reducing potential food and stress-related triggers, applying therapeutic food plans, and providing support as the patient continues on their health journey.

Functional medicine teaches clinicians the foundational background, insight, and in-depth clinical thinking to confidently work-up and treat patients who may present with conditions, signs, and symptoms indicative of GI dysfunctions such as FD. Learn to recognize and treat the most important antecedents and triggers of GI dysfunction and implement therapeutic strategies at IFM’s GI Advanced Practice Module (APM).

Related Articles:

Heal the Gut With the IFM Elimination Diet

The Microbiome, Stress Hormones, and Gut Function

References

1. Mounsey A, Barzin A, Rietz A. Functional dyspepsia: evaluation and management. Am Fam Physician. 2020;101(2):84-88.
2. Talley NJ. Functional dyspepsia: advances in diagnosis and therapy. Gut Liver. 2017;11(3):349-357. doi:10.5009/gnl16055
3. Tack J, Masuy I, Van Den Houte K, et al. Drugs under development for the treatment of functional dyspepsia and related disorders. Expert Opin Investig Drugs. 2019;28(10):871-889. doi:10.1080/13543784.2019.1673365
4. Madisch A, Andresen V, Enck P, Labenz J, Frieling T, Schemann M. The diagnosis and treatment of functional dyspepsia. Dtsch Arztebl Int. 2018;115(13):222-232. doi:10.3238/arztebl.2018.0222
5. Ramanayake RPJC, Basnayake BMTK. Evaluation of red flags minimizes missing serious diseases in primary care. J Family Med Prim Care. 2018;7(2):315-318. doi:10.4103/jfmpc.jfmpc_510_15
6. Li Y, Gong Y, Li Y, et al. Sleep disturbance and psychological distress are associated with functional dyspepsia based on Rome III criteria. BMC Psychiatry. 2018;18(1):133. doi:10.1186/s12888-018-1720-0
7. Xiong Y, Xing H, Hu L, Xie J, Liu Y, Hu D. Effects of comfort care on symptoms, gastric motility, and mental state of patients with functional dyspepsia. Medicine (Baltimore). 2019;98(25):e16110. doi:10.1097/MD.0000000000016110
8. Wauters L, Talley NJ, Walker MM, Tack J, Vanuytsel T. Novel concepts in the pathophysiology and treatment of functional dyspepsia. Gut. 2020;69(3):591-600. doi:10.1136/gutjnl-2019-318536
9. Francis P, Zavala SR. Functional Dyspepsia. StatPearls Publishing; 2021. Accessed August 2, 2021. https://www.ncbi.nlm.nih.gov/books/NBK554563/
10.  Holtmann G, Shah A, Morrison M. Pathophysiology of functional gastrointestinal disorders: a holistic overview. Dig Dis. 2017;35(Suppl 1):5-13. doi:10.1159/000485409
11.  Aro P, Talley NJ, Johansson SE, Agréus L, Ronkainen J. Anxiety is linked to new-onset dyspepsia in the Swedish population: a 10-year follow-up study. Gastroenterology. 2015;148(5):928-937. doi:10.1053/j.gastro.2015.01.039
12.  Svintsitskyy A, Solovyova G, Maliarov S, Alianova T. Peculiarities of psychological status in patients with functional dyspepsia: postprandial distress syndrome. Wiad Lek. 2019;72(10):1872-1877. doi:10.36740/WLek201910103
13.  Lane MM, Davis JA, Beattie S, et al. Ultraprocessed food and chronic noncommunicable diseases: a systematic review and meta-analysis of 43 observational studies. Obes Rev. 2021;22(3):e13146. doi:10.1111/obr.13146
14.  Potter MDE, Walker MM, Jones MP, Koloski NA, Keely S, Talley NJ. Wheat intolerance and chronic gastrointestinal symptoms in an Australian population-based study: association between wheat sensitivity, celiac disease and functional gastrointestinal disorders. Am J Gastroenterol. 2018;113(7):1036-1044. doi:10.1038/s41395-018-0095-7
15.   Matsuzaki J, Suzuki H, Masaoka T, Tanaka K, Mori H, Kanai T. Influence of regular exercise on gastric emptying in healthy men: a pilot study. J Clin Biochem Nutr. 2016;59(2):130-133. doi:10.3164/jcbn.16-29
16.  Koloski NA, Jones M, Walker MM, Holtmann G, Talley NJ. Functional dyspepsia is associated with lower exercise levels: a population-based study. United European Gastroenterol J. 2020;8(5):577-583. doi:10.1177/2050640620916680