Kiwis, psyllium or plums: What better helps with chronic constipation?

reference

Chey SW, Chey WD, Jackson K, Eswaran S. Exploratory comparative effectiveness study by green kiwis, psyllium or plums in US patients with chronic constipation. Am J Gastroenterol . 2021; 116 (6): 1304-1312.

draft

A partially randomized, comparative effectiveness study carried out on adults with chronic constipation in a US medical center

objective

Determination of the comparative effectiveness of psyllium, plums and kiwis in the case of symptoms of chronic constipation in a study population based in the USA

participant

The examiners recruited suitable patients from those who met the Rome IV criteria either for functional constipation (FC) or irritable bowel syndrome with constipation (IBS-C).

of the originally 247 patients addressed for the study recruitment were recorded 109 for the Baseline screening, and 79 patients met the inclusion criteria and were randomized (69 female [87%] with an average age of 42.7 years [range 18–76 years]).

The inclusion criteria included adults with chronic constipation (CC) in the past 3 months with symptoms that had occurred at least 6 months earlier; the lack of soft chair without the use of laxatives and the presence of other CC symptoms such as a daily abdominal pain score ≤ 7 (on a scale of 1–10, 10 = worst pain); ≤ 3 complete spontaneous stool passages (CSBM) per week; And with at least 2 of the following symptoms: pushing, hard/lumpy stool, incomplete intestinal emptying, use of manual maneuvers for relief and a feeling of obstruction or blockade at ≥ 25 % of the stool (BMS).

The exclusion criteria included one of the following: severe abdominal pain (> 7 on the scale of 1–10), presence of gastrointestinal (GI) bleeding, unexplained iron deficiency, unknown weight loss, active anal fissures and significant comorbid chronic illness, history of GI operations or neurological diseases. Also excluded were pregnant women and patients who take probiotics, antibiotics or opioids or react allergically to the ingredients of the study.

Study intervention

The participants were included in a 2-week basic examination phase to assess the symptoms by daily questionnaires. Those who qualified were then randomized for a 4-week treatment period into 3 low-class, followed by a 2-week observation period.

1. 2 whole green kiwis daily, peeled ( actinidia deliciosa var. Hayward), fiber = 6 g/day
2. 50 g plums (about 6 plums) twice a day (Kirkland brand), fiber = 6 g/day
3. 6 g psyllium twice a day, solved in water (Metamucil brand), fiber = 6 g/day

researchers and participants were not blinded to the assigned intervention. Due to the availability of fresh kiwis, the researchers assigned the first 30 patients taken in the KiWi arm and randomized the remaining patients through computer generation the plum or psyllium arms.

The researchers instructed all participants to eat no other foods that contain kiwi, psyllium or plums, or add their diet to fiber fruits/vegetables.

study parameters evaluated

The patients answered daily symptom questionnaires, and the researchers collected nutritional assessments by 3-day nutritional diaries after the screening period and after the treatment period.

Primary result measurement

The primary result of the result was the proportion of participants in each group who reported 1 or more CSBMS per week compared to the Baseline screening period for at least 2 of the 4 weeks of intervention. The groups were not compared.

Secondary result measurements included the effects on frequency, consistency, effort and the feeling of incomplete evacuation. Satisfaction and dissatisfaction with the treatment were also recorded.

important knowledge

For the primary end point of an increase in the BMS by at least 1 week, the proportion of responders to therapy was 45 % for the kiwi group (13/29; 95 % KI [0.27–0.63])); 67 % for the plum group (16/24; 95 % KI [0.48–0.86]); and 64 % for the psyllium group (14/22; 95 % KI [0.44–0.84]). There was no statistically significant difference in the number of responders between the groups, which indicates that everyone was equally effective when increasing the number of VSBM.

kiwis noticed in this study for another reason: the participants liked the least.

When the researchers looked at the entire 4-week treatment period, the plum group had the greatest average change in the CSBMS (+2.1; p <0.001) followed by the psyllium group in second place (+1.4; p = 0.005) and kiwi (+1; p = 0.0049).

In comparison of weeks 3 and 4,

With the starting value, there was a significant weekly CSBM rate in all 3 treatment groups ( p ≤ 0.003). Stool consistency significantly improves with kiwis ( p = 0.01) and plums ( p = 0.049). The string is significantly improved with kiwis ( p = 0.003), plums ( p <0.001) and psyllium ( p = 0.04). Patients in the KiWi group also reported a significant decrease in flatulence ( p = 0.02).

practice implications

When it comes to chronic constipation, fiber king! Ensuring sufficient fiber is a decisive component of a treatment plan for constipation, since insoluble fiber make the stool more voluminous and soluble fiber helps to hold back liquid in the stool, to make it softer and ensure that it can be easily excreted. Fillers are also necessary for a normal microbiota in the intestine, and it is known that some intestinal flora contribute to the intestinalotility. The latest Dietary Guidelines for Americans, 2020–2025, say that "over 90 % of women and 97 % of the men do not adhere to the recommended daily dose of fiber". ^{1 Almost all patients are recommended for a plant -based diet with a focus on fiber foods, and at least some patients with constipation may have to consume more fiber every day ( Table below).}

Table: Recommended fiber intake (in grams) according to age and gender 2-4

the age	male	female
1-3 years	19	19
4-8 years	25	25
9-13 years	31	26
14-19 years	38	26
20-50 years	38	25
51+	30	21

If the increase in fiber is not sufficient to solve the constipation, doctors generally recommend soft fruits or nutritional supplements such as flax, psyllium or other fiber to improve bowel movements.

In this study there were no statistically significant differences between the 3 groups in the primary target size, the VSBMS.

similar to previous studies on plums, psyllium and kiwis, all 3 active ingredients relieved the constipation to a certain extent. The only difference is that in this study the benefits of Kiwis seemed to lose weight after 2 weeks, although it remained statistically significant compared to the starting value ( p = 0.002). This contradicts previous studies that show no waste of effectiveness in Kiwis over time.

A result of this study, which was found in previous studies on Kiwis, is that Kiwis is better tolerated by people with constipation, with a lower occurrence of symptoms such as flatulence and flatulence as plums or psyllium. The authors speculate that this could be due to the sugar composition of kiwis, which contains relatively little fermentable oligosaccharides, disaccharides, monosaccharides and polyole (fodmap) compared to plums.

In this study,

kiwis noticed for another reason: the participants liked the least. The authors reported that “at Kiwis and the other groups (7 % kiwis compared to 17 % plums and 38 % psyllium, p = 0.02).”

This study was interesting because the thought of a comparable effectiveness of these fiber additives for practitioners may not be a prior consideration. There are numerous studies that compare the effectiveness of nutritional supplements, but only a few that compare food sources for fiber. ^{7 The understanding that some fiber sources can influence or tolerate other aspects of digestion can help the doctor to select the best fiber even for his most sensitive patients.}

This study is informative in that it validates the use of one of these substances in chronic constipation, with some interesting differences in their effects. The key to every effective treatment is compliance. This study validates the use of psyllium and plums in chronic constipation and offers the opportunity to use kiwis for patients who cannot tolerate psyllium or plums.