ABSTRACT

Functional dyspepsia (FD) is a disorder of gut–brain interaction affecting approximately 7% of the global population under Rome IV criteria, characterised by postprandial fullness, early satiation, epigastric pain, and/or epigastric burning in the absence of identifiable organic disease. Meal ingestion is the dominant symptom trigger in the majority of patients, yet the relationship between diet and FD is bidirectional: dietary exposures drive symptoms through established pathophysiological mechanisms, while FD itself can promote maladaptive eating behaviours and progressive dietary restriction with nutritional and psychological consequences. The pathophysiological substrate linking diet to symptom generation encompasses impaired gastric accommodation and emptying, visceral hypersensitivity to mechanical and chemical stimuli, low-grade duodenal mucosal immune activation and epithelial barrier impairment, alterations of the small intestinal microbiota, and gut–brain axis dysregulation. Dietary fat is the macronutrient most consistently implicated, acting through cholecystokinin-mediated chemosensory and mechanosensory pathways. Cross-sectional population data suggest that a high protein intake may also be associated with epigastric pain, although this association did not persist after multivariable adjustment, while the evidence linking total carbohydrate intake to symptoms remains sparse and inconsistent, so that no recommendation on total carbohydrate intake can currently be made. Cognitive factors, including learned food beliefs, expectancy, and nocebo effects, further modulate symptom perception independently of actual nutrient content. Among dietary patterns, Mediterranean-style eating offers the most coherent mechanistic rationale and the strongest observational support, while a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) shows selective benefit in patients with postprandial distress syndrome features or prominent bloating. Common triggers including spicy foods, coffee, and alcohol show heterogeneous evidence driven by individual sensitivity rather than dose-related effects. Nutritional concerns are substantial: clinically significant weight loss affects approximately 35% of tertiary-care patients, and nearly 40% screen positive for avoidant/restrictive food intake behaviour using validated screening tools. Dietary management should therefore be individualised, nutritionally adequate, and integrated within a broader biopsychosocial framework, with screening for disordered eating before any elimination strategy is initiated.

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