Samantha Boymans 12082090

Literature research /
VD-H310-08

Samantha Boymans 12082090

Jamey van Eijk 12069930

Simran Handal 12028126

Sanne Krikke 08054452

Renate Meeuwsen 12039381

Stephanie Terpstra 12077100

Rianne de Wit 12024848

Tutor: Barbara Wildeboer

Klas: VD2.C

Inhoud

Summary

Introduction

Methods

Findings

Conclusion

Literature

Appendix

Summary

This literature research is about developments in nutrition for obstipation and irritable bowel syndrome (IBS). Before the results will be discussed, there will be an explanation of the diseases.

Obstipation means constipation in the colon. When someone has obstipation, he defecates less than three times in a week and the defecation is dry and hard. Obstipation has several causes, firstly because someone has a insufficient fiber intake. Fibers stimulate the intestines to work well and provide a good bowel movement. They act like a sponge and absorb water so the defecation stays soft and flexible. Another cause of obstipation is not drinking enough. When someone doesn’t have enough exercise, the intestines won’t be stimulated. The use of some medicines, like sedatives, some painkillers, hypnotics and steel tablets can also lead to obstipation. the final reason for the development of constipation is having other diseases such as food intolerance, food allergy or IBS. (Het Voedingscentrum)

IBS is worldwide one of most recognized functional gastrointestinal disorders with the prevalence of 5% till 20%. Women are more likely to get IBS. IBS is a chronic disease in the intestinal, where the peristalsis is chronically disturbed. The movements in the intestinal go too fast or too slow. This is accompanied by abdominal pain and abnormal bowel movements. The causes of IBS are unknown and there is no deviation visible in the intestinal. Because of these unknown causes, the prevention and treatment are difficult to perform. (Vaiopoulou A)

The main question in this research is what the developments are in the area of food and obstipation and IBS. After a close look to the literature, the conclusion was that it´s hard to find a valuable nutrient to relieve (the symptoms of) IBS, but some nutriënts, like soluble fiber, 20 grams whole linseeds a day, and a diet with low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols).

Introduction

The purpose of this research is to develop a disease-specific nutritional drinkforpatients withgastro-intestinal problems, andtointroduce this intotheDutchmarket. To achieve this one literature study is completed. The literature study contains the following topics: the medical background of Irritable Bowel Syndrome and constipation, the nutritional problems and the nutritional needs for a patient who suffers from IBS and constipation, the risk/target groups andthenecessary characteristics of thedisease-specific nutritional drink.

To achieve this, a number of specificquestionsaccording to thePICO-line are formulated.

(P)PatientgroupWhich target groupsare prone toIBS/Constipationandwhy?What's the big difference withgroupsthatdo notsuffer from it?Whatare the symptoms ofConstipation/Irritable Bowel Syndrome

(I) Intervention Whichinterventions are usedwithinthe(clinical) care? Based ontheproperties, use of resources?

(C) Comparison Are therealternatives outsidethe appropriateresources?These are also usedinthe(clinical) care? Can theybe used?Combined withregular funds?

(O)Outcomeof treatmentwhatare the effectsof mainstreamand alternativetreatments?

Main question

What specific nutrient(s) can reduce the symptoms of Irritable bowel syndrome, with special attention to constipation?

Sub Questions

1. Whatare the causes andwhatare the symptoms ofIBS?
2. What are thenutritional needs for a patientwith IBS?
3. Whatare the risk factorsof IBS?
4. Whichcurrentintervention methodsare there?
5. Whatis the cause andwhatare the symptoms ofConstipation?
6. What are thenutritional needssomeonewith Constipation?
7. Whatare the risk factorsfor constipation?

Methods

Thisstudy is based ona literature research. To delivera goodliterature research it is important to use evidence-based literature. In order to get this literature there was searched in Google Scholar,Pubmed,MEDLINE,Scirus,OAIster,science.gov, worldwide science and the BSL vakbibliotheek. The search terms werethe causes ofIBS/Constipationand its symptoms, the nutritional needs for a patient with IBS/ Constipation ,the risk factors of IBS/Constipation, the features of the risk factors of IBS/Constipation, what kind of characterristicsthe new product should have, and the current intervention methods of IBS/Constipation. Our literature is also based on Dutch terms as Prikkelbaar darm syndroom, nerveuze dikke darm and obstipatie. With these search terms we answered our sub questions.

Findings

Whatare the causes andwhatare the symptoms ofIBS?

The causes of Irritable Bowel Syndrome are not known. It seems that it has something to do with over activity of parts of the gut, this is a long muscular tube that runs fromthemouth to theanus (Kenny). The symptoms of IBS are most likely caused by an combination of factors such asover activity of the nerves or muscles of the gut, anintestinal infection(such as food poisoning), bacteria and infections in the gut. (Maag Lever en Darmstichting)

IBS can give different complaints, such asflatulence, abdominal discomfort ,constipation with or withoutpainor cramps, painlessor frequent diarrhea and sometimeslessurge to defecate. Other symptoms that a person with IBS may havearediarrhea, nausea, dyspepsia, stinkingpeasants, anorexia andmalaise whichmay be caused by bacteria.(N.J. Wierdsma)

What are thenutritional needs for a patientwith IBS?

Dietary fiber

Dietary fibers are able to reduce the intestinal transit time, which can reduce pain for someone with constipation or IBS. A largeintake of insoluble dietary fibers of psyllium is therefore oftenrecommended for patients whereadditionalwaterbinding capacityis deemed favorable. Individual sensitivity to soluble or insoluble dietary fibers decide whether it provides a beneficial effect or not. Due to their highdegreeofindigestibility, insolublefiber excite the intestineandstimulateperistalsisand thusactivatetheintestinal tract. But thereare indications that this couldbeexperiencedas an irritating feeling. Thesepeople are morebenefited bysoluble fiber. (N.J. Wierdsma)

Probiotica

There has been much research concerning the possible beneficial effects of probiotics for people with IBS(Whorwell, 2007). Probioticsare products that containslarge amounts ofusefullactic acid bacteria, that havea beneficial effect onintestinalcomplaints. More research is needed to confirm this beneficial effect. (Maag Lever en Darmstichting)

Whatare the risk factorsof IBS?

The risk factors for Irritable Bowel Syndrome are persons over fifty years and afirst-degree relativewith inflammatorybowel disease, celiac disease or colorectaal-, ovarium- of endometriumcarcinoom among people older than 70 years. (Multidisciplinaire richtlijn diagnostiek en behandeling van het prikkelbare darmsyndroom)

Whichcurrentintervention methodsare there?

Most patients with IBS are treated with a combination of dietary management, pharmacological management and lifestyle management. It depends on the symptoms of the patients what the changes in those three groups should be. There have been recent studies for treating IBS or the symptoms of IBS,but there is not enough evidence to proof it is completely good or wrong. Results and methods of the studies can be found in the appendix. Those are also the sources on which the conclusion is based.

Whatis the cause andwhatare the symptoms ofConstipation?

Constipation can be caused by many different causes. Constipation can be caused by lack of physical exercise, insufficientfluid intake, adiet low infiber and delayinggoing to thebathroom while highlynecessary. Traveling andstress canalso contribute developing constipation. Othercauses are pregnancy, mental health disorders, colon cancer and the use of certain medications. (NIH: National Institute of Diabetes and Digestive and Kidney Diseases)

The symptoms are usually hard dry stool that is difficult to pass, the feeling that you need to defecate even if you just have done that, the feeling that your bowels are blocked and that someone defecated less than three times a week.

What are thenutritional needs forsomeonewith Constipation?

The Academy of Nutrition and Dietetics advices to consume25to 35 gramsdietary fibers aday. Drinking enough water and eating enoughvegetables and fruits, makes the fiber intake easier and more effective. The following tips are recommended.Drink eight to ten glasses of fluid each day. Consume high-fiber cereals such as bread, pasta and crackers made with whole grains. Vegetables such as broccoli, corn and potatoes will help ease the constipation. Fruits such as berries, prunes and plums increase the dietary fiber intake. Legumes such as kidney beans, soy beans, walnuts and almonds also supply fiber to the diet.

Conclusion

The question of this research was ‘What specific nutrient(s) can reduce the symptoms of Irritable bowel syndrome, with special attention to constipation?’. After having a close look at the recent studies that have been done for improvement in symptoms of IBS or constipation, there are several nutrients found which can alleviate the symptoms or improve them. The soluble fibers are helpful for constipation according to the Dutch article ‘Vezels zijn maar weinig effectief bij het prikkelbaredarmsyndroom: een systematische review’.They do not help with relieving the symptoms of IBS, but there are also no negative effects. Next to soluble fibers, linseeds seems to be effective when taken about 20 grams a day. Both whole and ground linseeds are able to improve the symptoms of IBS. In previous studies it was also shown that whole linseeds improvethe bowel habit and stool consistency. Another research showed that a low FODMAP(fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet also improves the symptoms of IBS. Unfortunately it doesn’t show any improvement on stool consistency, so it doesn’t help for constipation, but there are also no negative effects. This diet is based on a total restriction of FODMAP’s, which can’t be achieved by only a nutritional drink, but keeping them low in the drink, might also give effect.

Literature

Cockerell KM, W. A. (sd). Effects of linseeds on the symptoms of irritable bowel syndrome. Opgeroepen op maart 15, 2014, van PubMed:

Het Voedingscentrum. (sd). voedingscentrum. Opgeroepen op maart 2014, van Prikkelbare Darm Syndroom:

Kenny, D. T. (sd). abdominal pain. Opgeroepen op maart 3, 2014, van

Lesley M Roberts, D. M. (sd). A Randomised Controlled Trial of a Probiotic 'Functional Food' in the Management of Irritable Bowel Syndrome. Opgeroepen op maart 11, 2014, van medscape:

Maag Lever en Darmstichting. (sd). Opgeroepen op maart 5, 2014, van

Multidisciplinaire richtlijn diagnostiek en behandeling van het prikkelbare darmsyndroom. (sd). Opgeroepen op maart 10, 2014, van NHG:

N.J. Wierdsma, D. A. (sd). Opgeroepen op maart 5, 2014, van BSL springer link:

NIH: National Institute of Diabetes and Digestive and Kidney Diseases. (sd). obstipation. Opgeroepen op maart 11, 2014, van Medline plus:

René Bijkerk, J. M. (sd). Vezels zijn maar weinig effectief bij prikkelbare darm syndroom: een systematische review. Opgeroepen op maart 12, 2014, van huisartsenopleidingutrecht:

Staudacher HM, W. K. (sd). Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome.Opgeroepen op maart 12, 2014, van PubMed:

Vaiopoulou A, K. G. (sd). Molecular basis of the irritable bowel syndrome.Opgeroepen op februari 26, 2014, van PubMed:

Appendix

Resources

Name of the research / Vezels zijn maar weinig effectief bij het prikkelbaredarmsyndroom: een systematische review.(René Bijkerk)
Source / Huisarts en Wetenschap (2005) 48: 754-761
Characteristicsof the study / None of the reviews analyzed the outcomes of the soluble and insoluble fibers separated.
The main goal in this mata-analyse is to quantify the effectivity of the different types of fibers by different outcome measures.
Through a search strategy of useful english artikels a bibliography was created.
Through a checklist (with items about blinding of randomization and blinding of patients and clinicians) the quality of the research was scored.
Only RCT’s were used in this analyse.The next outcomeparameters were used: General IBS-symptons, IBS-related stomach ache and
IBS-related constipation. Researches that had a combination of fibers and midcation or took any other kind of treatment in practice were ruled out.
The data of the selected artikels was collected and the results pf individuel research of succesful patients out of the artikels where placed in the Cochrane Collaboration Review Manager.
During this analyse Metaview was used.
De analyses were executed together for all the individual studies. For the studies regarding insoluble fiber and soluble fiber the analyzes were executed on individual base.
.
Results / General IBS-symptoms
In five of the 12 researches a signification error was found (the relative risk was 1,28).
There was no signification error found in three of the eight studies of the effect of soluble fibers.
The proportion of succesful treated patients with fibertreatment was 64%.
Unsoluble fibers were never as effective as in the Placebo research.The IBS-symptoms even went from bad to worse.
The one and only research of the effectivity of psylliamseed had no signification error.
IBS-related stomach ache.
Fibers turned out not to be effective bu treatment.
IBS-related constipation
Soluble and insoluble fibers seemed to be effective in this treatment.
Strengths
Weaknesses / The quality of life, an important measure, was in none of the studies included.
Inthree studies the treatment was to short, whereby a high placebo response has a higher chance. This could have had a negative influence on the results.
In study group was most likely to small, whereby all the study’s results showed heterogenic results.
Intwo studies the intervention was blinded for patients and theaters (This is very hard when a fiber rich diet is used).
None of the treatments showed a positive effect in the results of the studies.
Conclusion / Soluble fibers do not accure to have any effect on general IBS-symptoms. The advice to use more soluble fibers instead of insoluble fibers in a diet, could lead to less general IBS-symptoms and constipation for some patients.
Conclusion
Level of evidence / Valid clinic research with IBS-patients are necessary for the development of evidence-based treatment guide lines.
Name of the research / A randomized controlled trial of a probiotic “functional food” in the management
of irritable bowel syndrome.(Lesley M Roberts)
English study to Probiotic effect on IBS and Constipation
Source / Biomedcentral
Characteristicsof the study / -Examinesresponse toother publications en investigate the effect ofprobiotics oncomplaints due to IBS and constipation
-Target group: adults (18-65 years) with mild to severe symptoms
-Starting point: What changes occur after 4 weeks during the use of beverage probiotics
-Reason: People with IBS experience a reduction in the quality of life. Often theyseek(easilyaccessible) alternativesto diminish the symptoms. Forobviousproducts, whichareeasily available (For example, in the supermarket)and which could contribute to the reduction of symptoms, such as fortified beverages Probiotics.
-Other, lessreliable,studies have shown thatthere has beenimprovementof the quality of life. Their efforts are of publication bias.
-The aim isto establish whether thereisa reductionofsymptomsas shown in other studies.
-The added ingredient was a bifidobacterium
Results / The improvements madeafter4,8and 12weeks inthe intervention groupand the placebo group do not differ. Thatisthe conclusiondrawn that there is no ETP for the attention of these probiotics products.
Strengths / Research with a high level of evidence
Weaknesses / Highfailure ofpatients (>50%) duringthe study periodin particular on placebo.
Conclusion / There is no differenceinthe reduction ofsymptoms
between the group that received probiotic-enriched beverageand the group that received a placebo.
Conclusion
Level of evidence / Double-blind studyin whichthe distribution :
50% of milk a substance with a probiotic product
and about 50% with a placebo.
Research meets the ROME III criteria
Name of the research / Guidelines for constipation of children by the age of 0-18 years old. Studies initiated by the Dutch association of pediatrics (NVK) and the Dutch general practitioner association (NHG). Studies from a research group show if there is any constipation and which medical or nonmedical treatment would be effective.
Source / The Dutch association of pediatrics.
Characteristicsof the study / -Target group: 0-18 years old with constipation
-Target: Optimization of the diagnosis and treatment of children with constipation.
-On the one hand laxatives (medical research)
-On the other hand (intestinal rinse with water and salt)
-Alternative: Fiber research
Results / - Extra fiber intake has no effect.
- Extra moisture, no conclusions can be made due to the quality of the research.
- Extra physical activity has no positive effect.
- No experiments with probiotics means, because the lack of research around probiotics.
- Less than five years of toilet training gives a positive result.
- In some cases behavioral training helps and supports.
- So called “biofeedback training” gives no result at all.
- Physiotherapy could work in an additional way with children older than four years old.
- Recommendations are made for further research.
Strengths / -EVB guidelines will be followed
-The group is big enough
-Multidisciplinary work group
Weaknesses / Rome- III criteria is probably not applicable for different patient groups
Conclusion / The interventions have none too little positive effect on the complains. Recommendations are being made to provide further research
Conclusion
Level of evidence / - Use ROME-III criteria
- Cross-over study (with placebo groups)
- Systematic review of at least two different studies A2 (double blind compared clinic research) EVB guidelines are followed.
- The search strategies are evidence based.
Name of the research / Effects of linseeds on the symptoms of irritable bowel
syndrome: a pilot randomised controlled trial (Cockerell KM)
Source / Journal of Human Nutrition and Dietetics
Characteristicsof the study / -40 participants
-Open randomized controlled study
- They compared the results of taking two spoons of whole linseeds a day, two spoons of ground linseeds a day or no linseeds at all. Two spoons of linseed is approximately 24 grams.
- participants were in the age of 18-70
Results / -The intake of whole linseeds did have effect on the symptom severity. The pain and days with pain were less and the satisfaction with bowel habit was improved.
-The intake of ground linseeds did also have effect on the symptom severity. It had possitive effects on the days with pain and bloating.
-both of the linseeds did not have any effect on the bowel habit and stool consistency.
-earlier studies, however, found that the regular use of ground linseeds over 2-3 months did have effect on the bowel habit and stool consistency
Strengths
Weaknesses / -The amount of participants is (too) low for good results. The study itself also refers to the fact that there were too less participants.
-The study only last for four weeks, which is actually too short for a good research
-The amount of intake of whole linseeds or ground linseeds did differ about 2-4 grams, depending on the weight of one spoon linseed.
Conclusion / Although this study shows us that linseeds do not change anything of the bowel habit or stool consistency, it does alleviate some of the other symptoms occurring with IBS. Earlier studies showed effect of ground linseeds on bowel habit and stool consistency.
Conclusion
Level of evidence / -All the participants met the ROME 3 criteria for IBS
-It’ s an open randomized controlled study
-No control group
Classification of medical articles (English) Level B
Name of the research / Comparison of symptom response following advice for a
diet low in fermentable carbohydrates (FODMAPs) versus
standard dietary advice in patients with irritable bowel
syndrome. (Staudacher HM)
Source / Journal of Human Nutrition and Dietetics
Characteristicsof the study / -82 patiënts were participating on the research. They were first diagnosed with IBS by their primary care physician, second they were referred for dietary advice and third they had been seen by a dietician for the last 2-6 months for management of their symptoms.
-39 patients received standard dietary advice according to the NICE guidance, and 42 patients received a low FODMAP dietary advice. By the last group Fructooligosaccharides, galactooligosaccharides and polyols were restricted.
Results / -To determine whether the symptoms had changed, the participants were asked to fill in a questionnaire, answering the questions with ‘no change, or worse’, ‘slightly improved’, ‘moderately improved’, ‘substantially improved’. In general the low FODMAP group had a score of 86% improvement of symptoms score, against only 49% in the standard group.
Strengths / -the patients had gone through the same procedure of screening
-the patients were seen by a dietitian 2-6 months before the research
Weaknesses / -The patients knew whether they were having a standard diet or a low FODMAP diet. This can affect the answers they give on the questionnaire.
Conclusion / The symptoms of IBS are reducing with a low FODMAP diet compared to a standard diet. This is good, although there’s still no evidence that a low FODMAP diet also effects on constipation in patients with IBS.
Conclusion
Level of evidence / Level of evidence 2. It’s a comparing study, without double blind placebo control, the patients knew whether they had the low FODMAP diet or the standard diet.

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