Best Practice & Research Clinical Gastroenterology

Vol. 20, No. 3, pp. 575587, 2006

doi:10.1016/j.bpg.2005.11.002
available online at http://www.sciencedirect.com

9
Nutritional care of the patient with
constipation
Fernando Fernandez-Banares* MD
Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Plaza Dr Robert 5, 08221 Terrassa, Barcelona,
Spain
Chronic constipation is defined as a symptom-based disorder based on the presence for at least 3
months in the last year of unsatisfactory defecation characterized by infrequent stools, difficult
stool passage, or both. On the other hand, the presence of clinically important abdominal
discomfort or pain associated with constipation defines irritable bowel syndrome (IBS) with
constipation. Intake of dietary fibre and bulking agents (psyllium) may be effective in alleviating
chronic constipation in patients without slow colonic transit or disordered constipation. On the
other hand, fibre may improve stool consistency in patients with IBS with constipation, but it is
considered to be not effective in improving abdominal pain, distension or bloating. Probiotics may
be effective in relieving constipation; however, the effect of lactic acid bacteria ingestion may be
dependent on the bacterial strain used and the population being studied. Lactulose, which is a
substrate for lactic acid bacteria (prebiotic), is effective to treat patients with chronic
constipation.
Key words: chronic constipation; irritable bowel syndrome; dietary fibre; bulking agents;
probiotics; prebiotics.

DEFINITION
Recently the American College of Gastroenterology Chronic Constipation Task Force
defined chronic constipation as a symptom-based disorder based on the presence for at
least 3 months in the last year of unsatisfactory defecation characterized by infrequent
stools, difficult stool passage, or both. Difficult stool passage includes straining, a sense
of difficulty passing stool, incomplete evacuation, hard/lumpy stools, prolonged time to
stool, or need for manual manoeuvres to pass stool.1
Previously, a consensus definition was proposed by a group of experts to define this
heterogeneous clinical condition (Rome II) in 1998.2 The symptom-based so-called

* Corresponding author. Tel.: C34 3 7365050; fax: C34 3 7365043.

E-mail address: digestiu@mutuaterrassa.es

1521-6918/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved.

576 F. Fernandez-Banares

Rome criteria include 12 weeks or more of symptoms in the preceding 12 months,

including hard or lumpy stools, straining, a sense of incomplete evacuation, the need to
use manual manoeuvres to pass stool, or a sense of anorectal obstruction with R25%
of bowel movements, and/or !3 bowel movements/week, with no evidence of organic
disease. At least two symptoms should be present to make the diagnosis of chronic
functional constipation. This definition allows identifying uniform groups of patients for
inclusion in randomised controlled trials. However, its use is impractical in clinical
practice and most patients who refer for constipation do not fulfil the criteria. In this
sense, the constipation task force members recommended a broader definition that
encompasses the symptoms most commonly expressed by patients who self-report
constipation.
On the other hand, symptom-based criteria for chronic constipation and irritable
bowel syndrome (IBS) with constipation might overlap. IBS is characterized by
abdominal discomfort or pain, bloating, and disturbed defecation. The disturbed
defecation can take the form of constipation, diarrhoea, or mixed/alternating bowel
habits. Task force members emphasized that the presence of clinically important
abdominal discomfort or pain associated with constipation defines IBS with
constipation. Most patients with chronic constipation report minimal abdominal
bloating or discomfort. Thus, in some patients it may be difficult, if not impossible, to
differentiate chronic constipation and IBS accurately.

PATHOPHYSIOLOGY OF CHRONIC CONSTIPATION

Primary or idiopathic constipation can be broadly divided into three subtypes, including
slow transit constipation (i.e. colonic inertia), outlet delay constipation (i.e. obstructive
defecation, pelvic floor dyssnergia, pelvic floor dysfunction, defecatory dysfunction,
anismus), and functional constipation. Physiologic abnormalities in patients with slow
transit defecation include abnormal postprandial colonic motor function, autonomic
dysfunction, and reduced numbers of enterochromaffin cells and interstitial cells of
Cajal.35 Outlet delay constipation can occur as a consequence of the inability to
coordinate actions of the abdominal musculature, anorectum, and pelvic floor
musculature.6 This prevents straightening of the anorectal angle, which should precede
the normal passage of stool. The third subtype is comprised of patients with complaints
of constipation but with normal transit and normal pelvic floor function.7 However,
there is a significant overlap between these subtypes, and p.e., many patients with
dyssynergic defecation may also have prolonged colonic transit.
Secondary causes of chronic constipation are listed in Table 1. In this sense, in some
patients a careful history and physical examination can provide clues as to the etiology
of constipation.

MANAGEMENT OF CHRONIC CONSTIPATION

Lifestyle measures
The need to set aside a regular time for defecation and respond to a defecatory urge
should be stressed.

Nutrition and constipation 577

Table 1. Secondary causes of chronic constipation.

Medications
Opiates
Anticholinergics
Antidepressants
Anticonvulsants
Dopaminergics
Calcium channel blockers
Bile acid binders
Supplements (calcium and iron)
Endocrine/metabolic disorders
Diabetes mellitus
Hypothyroidism
Hypercalcemia
Pheochromocytoma
Porphyria
Neurologic disorders
Systemic
Parkinson disease
Multiple sclerosis
Autonomic neuropathy
Autonomic failure
Traumatic
Spinal cord lesions
Gastrointestinal disorders
Aganglionosis (Hirschprungs disease, Chagas disease)
Myopathy
Neuropathy
Megarectum/megacolon

It has been claimed that a sedentary life style may contribute to constipation. Several
population studies support the idea than those who are more active and perform more
physical activity have a lesser incidence of constipation.8 Physical activity affects colonic
motor function, with changes in function probably proportional to the extent of activity.
Prolonged physical inactivity in those who are normally physically active, especially in
the elderly, can reduce colonic transit, favouring constipation. However, other factors
such as cognitive function, presence of depressive symptoms, use of medications that
slow bowel motility, an inadequate diet, are likely to play a role in the elderly
constipation.
In healthy subjects, only vigorous physical activity such as running a marathon
increases gut and colonic activity and can lead to dramatic increases in large bowel
function.9 Modest physical activity may help subjects with mild constipation, but there is
no evidence that it may improve severe constipation.10
Increasing fluid intake does not have an important effect on colonic function, and it is
not recommended to treat constipation unless there is evidence of dehydration.8 In this
sense, children or adults with fever, or subjects in hot environments, should be advised
to consume sufficient fluid.

578 F. Fernandez-Banares

Fibre-enriched diet
In 2001, a National Academy of Sciences expert panel was appointed to define fibre.11
Dietary fibre was defined as nondigestible carbohydrates and lignin that are intrinsic
and intact in plants. Foods high in dietary fibre include whole grains, legumes, vegetables
and fruits. Another class of fibre, functional fibre was defined as nondigestible
carbohydrates extracted from foods that have beneficial physiological effects in humans.
Total fibre was then defined as the sum of dietary fibre and functional fibre. Dietary
fibre, or non-starch polysaccharide, is composed of cellulose, non-cellulose
polysaccharide, and lignin. Non-digestible (i.e. resistant) starch and oligosaccharides
(e.g. fructo-oligosaccharides -FOS-) cannot be decomposed by human digestive
enzymes in the upper alimentary tract, and thus have been recently included in a
nutritional/physiological definition of dietary fibre, as functional fibre.11 It is important
to know that fibre is neither a single substance nor an inert, indigestible, unavailable
material that simply passes through the gut.
Non-absorbed carbohydrates entering the colon suffer digestion by colonic
anaerobic bacterial flora that produce polysaccharidases and other enzymes. Because
this digestion occurs anaerobically it is known as fermentation, which is a process
characterised by a complex series of inter-related reactions resulting in the formation
of a variety of end-products including short-chain fatty acids (acetate, propionate, and
butyrate), gases (hydrogen, methane, carbon dioxide), as well as energy, which bacteria
use for growth and maintenance.12 It has been estimated that about 70 g carbohydrate/
day is required to maintain the colonic flora.
Virtually all fibres are broken down to a greater or lesser extent in the colon. The
extent of fermentation and the range and nature of the end-products depends on a
number of factors, including among others type of fibre, physical nature of the fibre (e.g.
particle size), solubility, and surface area. Different types of fibre have different effects
on stool weight.13 The cellulosic fraction of some cereal fibres has the most effect on
increasing the stool weight and decreasing transit time, since it tends to survive
digestion better than non-cellulosic polysaccharides (10% of cabbage fibre is recovered
in faeces, compared with 60% of wheat bran). Soluble fibres such as pectin or guar,
different forms of resistant starch, and fructans such as inulin or FOS are the less
effective in increasing the stool weight, and some of them are not detected in faeces
after consumption, indicating that they are completely fermented in the colon. Dietary
fibre may be classified according to their solubility, as summarised in Table 2.
Increased fibre particle size results in increased stool output. Large particles are
more slowly degraded, whereas reducing the particle size increases the available
surface area, resulting in increasing digestibility, so that the cellulose content of finely
ground bran is digested faster than that in coarse bran.14 Furthermore, it has been
shown that the particles themselves may stimulate colon motility.15
A diet poor in fibre should not be assumed to be the cause of constipation but could
be a contributing factor. There is not doubt that intake of dietary fibre, mainly insoluble
fibre, increases stool bulk and frequency, and decreases consistency in healthy people
(Grade A recommendation). A careful meta-analysis showed that in 18 of 20 studies
stool weight was increased by adequate fibre supplementation, and there was increased
faecal transit.16 In this sense an inadequate diet with a diminished intake of dietary fibre
may contribute to constipation in an important subgroup of patients. These patients
may be considered to suffer from a relative fibre deficiency, as they have not
identifiable cause of their complaints. However, there is a subgroup with more severe

Nutrition and constipation 579

Table 2. Categorisation of dietary fibre according to solubility.

Type of fibre

Examples

Insoluble fibre

Insoluble polysaccharides
Cellulose
Hemicelluloses
Soluble polysaccharides
Pectins
Beta-glucans
Plant exudates gums
Mucilages
Legume seed gums
Seaweed polysaccharides
Bacterial polysaccharides
Fructo-polysaccharides (inulin)
Fructo-oligosaccharides (oligofructose)
Resistant starch

Soluble fibre

constipation secondary to slow transit constipation and/or disordered defecation who

get worse with an increase in dietary fibre intake.8 Despite that, all constipated subjects
should be advised as an initial measure to increase their dietary fibre intake as the
simplest, most physiologic, and cheapest form of treatment.17 In those people in whom
fibre aggravates their sense of abdominal distension or in whom fibre lead to
incontinence (mainly in elderly subjects), a reduction in their fibre intake should be
recommended.
On the other hand, gas production from fibre metabolism may limit acceptance. This
is particularly true from extensively fermented fibres (usually the soluble types), which
lead to increased bulk in colon by increasing microbial mass. Less well fermented fibres
(usually the insoluble types) produce less gas and contribute to increasing bulk in the
colon by their water-holding properties. Water-holding appears to be related to
solubility and thus to rate of fermentation by colonic microflora; rapidly degraded fibres
have a less pronounced effect of stool weight than less well degraded fibres. Increased
bulk in the colon decreases transit time, which in turn results in decreased water
reabsorption, and as a consequence wetter stools and thus increased stool weight.13
It follows from these discussions, therefore, that the optimum way of improving
colonic function in most constipated patients is to prescribe a diet whose fibre content
is higher than that ingested previously. The amount of fibre that is necessary to correct
constipation varies in different people, but the effect of fibre on stool weight is dose
dependent. Whereas some subjects may require 10 g per 1000 cal, others may require
20 g per 1000 cal.18 Cummings reviewed over 100 studies of the effect of fibre intake
on stool weight and calculated the increase in weight of the stool as a function of fibre
intake.19 There was a wide range of the contribution of dietary fibre to fecal weight (p.e,
an increase of 5.7 g fecal bulk per gram of wheat bran fed compared to an increase of
1.3 g per gram of pectin in the diet). The 2005 Dietary Guidelines of the Institute of
Medicine (IOM) (USA) support a daily fibre intake of 14 g per 1000 kcal to reduce the
risk of cardiovascular disease and promote healthful laxation (for a critical daily stool
weight of 160200 g).20 In general, patients with chronic constipation require greater
doses of fibre than do healthy subjects in order to produce similar increases in stool

580 F. Fernandez-Banares

Table 3. Soluble and insoluble fibre contents of some common foods and supplements.18,21,22
Foods

Grams/100 g dry wt

Percentage insoluble fibre (%)

Wheat bran
Oat bran
Rye bran
Corn bran
Bran flakes
All-Bran
Corn flakes
Rice Krispies (Kellogs)
Special K (Kellogs)
Cabbage, cooked
Cauliflower, cooked
Broccoli, cooked
Pinto beans
Kidney beans
Lentils
Apple (with skin)
Guar gum
Psyllium seeds (Ispaghula husk)

35
17
39
55
19.5
30.1
1.6
1.9
2.7
1.5
1.4
2.0
14.2
13.8
7
2.8
95
7090

90
50
90
90
90
90
70
90
100
60
60
60
75
75
90
60
0
10

Most vegetables are approximately 3040% soluble and 6070% insoluble. Most legumes average from 10
to 25% soluble and 7590% insoluble. Fruits vary from 30 to 65% soluble and 3570% insoluble.

weight.16 In starting a fibre-enriched diet, the increasing levels of fibre should be

introduced slowly to tolerance, or until the patient becomes satisfied with the results.
An appropriately balanced soluble and insoluble fibre intake is likely to be the better
option. However, some patients will tolerate insoluble better than solublefibre, and
others will tolerate soluble better than insoluble. Thus, results can be obtained with
one or the other, and this will vary from patient to patient.18 Specific dietary advice is
often needed to achieve a satisfactory increase in dietary fibre. An extensive list of the
content of dietary fibre in the common foods and breakfast cereals can be obtained
from the literature.18,21,22 Table 3 lists soluble and insoluble fibre contents of some
common foods and supplements. The most important sources of fructans (inulin and
FOS) include garlic, Jerusalem artichoke, chicory, leeks, onion, wheat, asparagus, and
artichokes. Resistant starch could be found in raw potato, banana, cooked cooled
potato, bread, cornflakes, and partly milled grain and seeds. An overview of the typical
intakes of the different fibre components in the Western diet is given in Table 4.
Fibre supplements (bulking agents)
When symptoms of chronic constipation are sufficiently bothersome to impair the
patients quality of life, treatment is warranted.1 Dietary fibre supplementation can be
achieved by increasing the ingestion of fibre-rich foods (as above described), or by
providing commercially available fibre supplements. Bulk agents are a concentrated
form of non-starch polysaccharides useful for patients who cannot take adequate
dietary fibre. Available bulking agents include psyllium (Ispaghula husk), wheat bran,
calcium polycarbophil, methylcellulose, guar gum, and sterculia (Indian tragacanth or

Nutrition and constipation 581

Table 4. Estimated mean typical daily intake of the different components of dietary fibre in healthy adults
consuming a Western diet (adapted from Green23).
Components of dietary fibre

Grams/day

Total NSP

11.815.7 (aprox. 40% from cereals, 50% from vegetables, and 10%
from fruit)
6.57.0 (cellulose, 3.2; non-cellulose, 3.33.8)
5.38.7
212
1.515
1

Insoluble NSP
Soluble NSP
Inulin and FOS
Resistant starch
Lignin

NSP, Non-starch polysaccharides; FOS, Fructo-oligosaccharides.

karaya). There are three placebo-controlled trials of the use of psyllium in patients with
chronic constipation2426 (Table 5). These have been recently reviewed.27 They
demonstrated improvements in stool frequency and consistency at doses between 10
and 24 g/day. However, only one of these was of high quality,26 and it was the only one
lasting more than 4 wk, but only included 22 patients. Nonetheless, it appears that
psyllium improves stool frequency and consistency (Grade B recommendation).27
There were no statistically significant differences in side effects between psyllium and
placebo. In an observational study, 149 patients were treated with psyllium in the form
of Plantago ovata seeds, 1530 g daily, for a period of at least 6 weeks. There was an
improvement of 85% in patients without a pathologic finding, whereas there was a poor
response to treatment among patients diagnosed from slow colonic transit or a
disordered defecation.28 These results emphasize that patients with functional
constipation are easily treatable by modification of fibre intake.
Of note, despite the popularity of bran as a treatment of constipation, there are no
randomised trials that have shown improvements in stool frequency or consistency in
patients with chronic constipation.27 Specifically, there is only one placebo-controlled
study on the effect of wheat bran in chronic constipation, showing no differences
between therapy groups in the improvement of stool frequency or consistency.29 On
the other hand, there are no placebo-controlled trials examining the effect of the other
bulking agents above mentioned. Small trials comparing some of these agents versus
psyllium have failed to demonstrate differences in stool frequency or consistency.27
Overall, studies of bulking agents were of sub-optimal design including very small
sample sizes, short duration, or both. They were performed before the advent of what
are now generally accepted criteria for treatment trials in patients with functional
disorders.
Issues pertaining to palatability, and dose-dependent side effects (distension,
bloating, flatulence) limit compliance with fibre supplements. Although severe adverse
events with bulking agents are rare, oesophageal and colonic obstruction and
anaphylactic reactions (psyllium) have been reported.30
In conclusion, it may be considered that bulking agents may be effective in alleviating
chronic constipation in patients without slow colonic transit or outlet delayconstipation. If the patient is compliant, fibre treatment may help up to 80%. However, the same
results could be obtained by dietary means encouraging patients to eat either a
supplement of natural bran or a fibre-enriched diet.

Trial

Study type

Treatment

Dose

Duration

Cheskin
Fenn25
Ashraf26

Crossover
Parallel
Parallel

10
183
22

Psyllium
Psyllium
Psyllium

24 g/d
3.6 g t.i.d
5 g b.i.d.

NS
p!0.05
p!0.05

Badiali29

Crossover

24

Wheat Bran

6.6 g t.i.d.

Bass42

Parallel

24

Lactulose

60 mL/d

Sanders43

Parallel

47

Lactulose

30 mL/d

Wesselius-De Casparis44

Parallel

103

Lactulose

1530 mL/d

Mollenbrink39

Crossover

70

E. coli Nissle 1917

Koebnick38

Parallel

70

Banaszkiewicz41

Parallel

84a

Lactobacillus casei
Shirota
Lactobacillus GG plus
lactulose

0.55!109 viable
cells b.i.d
65 mL/d (6.5!109)

4 weeks each arm

2 weeks
8 weeks after 4
weeks placebo runin
4 weeks each arm
after 3 weeks
1 week after 1 week
baseline
12 weeks after 2
weeks baseline
3 weeks after 2
weeks baseline
4 week each arm
after 1 week
4 weeks
12 weeks

NS

24

Constipated children.

109 CFU b.i.d plus

1 mL/kg/d

NS
p!0.05
p!0.05
p!0.05
p!0.05
p!0.05

582 F. Fernandez-Banares

Table 5. Summary of trial characteristics of placebo-controlled trials in chronic constipation.

Nutrition and constipation 583

On the other hand, fibre supplements may improve stool consistency in patients
with IBS with constipation (constipation with abdominal pain), but they are not
considered to be effective in improving abdominal pain, distension or bloating (Grade A
recommendation). In a recent meta-analysis about treatment of IBS,31 the odds ratio in
the high-quality studies on the effect of fibre treatment was not significant (OR of global
symptom relief, 1.4; 95% CI, 0.992; pZ0.06). Another meta-analysis showed a benefit
of fibre treatment in the relief of global IBS symptoms (relative risk, 1.33; 95% CI, 1.2
1.5). However, when IBS symptoms were analysed separately, fibre was shown to be
ineffective in the relief of abdominal pain.32 Supplemental bran may even worsen
symptoms as abdominal pain or bloating compared to a normal diet.33
Fibre additives in enteral formulas for tube feeding
Patients receiving enteral nutrition in the chronic care setting often suffer from
constipation, necessitating laxative use. Multiple studies have examined the effects on
bowel function of adding fibre to enteral diets compared with fibre-free and selected
diets, showing only marginal benefits of questionable clinical significance.34 It is possible
that the particle size of fibre incorporated into liquid diets may be too small to retain its
expected water holding capacity. On the other hand, most studies employed the use of
rapidly degradable fibre, which is completely fermented in the colon, losing the
possibility to hold water. Certain fibres, e.g. the cellulosic fraction, tend to survive
digestion better than non-cellulosic polysaccharides, and have a more pronounced
effect on stool weight than the later. However, it may be impossible to manufacture a
formula that is of sufficiently low viscosity to pass through a fine nasogastric tube, and
that contains sufficiently large fibre particles to exert the expected effects on bowel
function.
Probiotics and prebiotics
Probiotics are defined as live micro-organisms which when administered in adequate
amounts confer a health benefit on the host.35 There is some evidence suggesting that
probiotics might relieve constipation. Some studies have shown that milk or yoghurt
fermented with different types of probiotics may reduce intestinal transit time and
increase the daily stool number in constipated patients. In a double-blind, randomised,
crossover design, Bifidobacterium animalis reduced the colonic transit time in a group of
healthy women aged 1845 years.36 Likewise, B. animalis intake led to a significant
reduction in oro-cecal gut transit time in a group of elderly subjects free of any
gastrointestinal pathology.37 In a double-blind, placebo-controlled study performed in
70 patients with chronic constipation, a probiotic beverage containing Lactobacillus casei
Shirota administered for a 4-week period was significantly better than placebo in
improving severity of constipation and stool consistency38 (Table 5). Likewise, a
preparation containing Escherichia coli Nissle 1917 strain was compared to placebo in a
double-blind clinical trial in 70 patients with chronic constipation, showing that the E.
coli preparation was significantly better than placebo in increasing stool frequency39
(Table 5). In an open trial in elderly subjects, a commercial mixture of Lactobacillus
rhamnosus and Propionibacterium freudenreichii improved defecation frequency in a 24%,
but no reduction in laxative use was observed.40 Finally, in a double-blind, placebocontrolled trial, Lactobacillus GG was ineffective as an adjunct to lactulose for the
treatment of constipation in children41 (Table 5). Thus, probiotics may be effective in

584 F. Fernandez-Banares

patients with mild to moderate constipation (Grade B recommendation). However, the

effect of lactic acid bacteria ingestion may be dependent on the bacterial strain used and
the population being studied. On the other hand, there are no studies evaluating the
effect of probiotics as compared to fibre supplements (psyllium). Further controlled
and well-designed studies in this type of patients are warranted.
Prebiotics such as FOS, galacto-oligosaccharides (GOS), lactulose, and inulin can act
as being substrates for lactic acid bacteria, thus encouraging their growth in the
intestine (see Chapter 3).The widely used laxative lactulose is not digested by human
disaccharidases, and is a substrate for the bifidobacteria in the colonic flora. Three
placebo-controlled trial have shown that lactulose (1530 ml twice a day) is effective at
increasing stool frequency and stool consistency in patients with mild to moderate
chronic constipation4244 (Table 5). These have been recently reviewed (Grade A
recommendation).27 Other prebiotics would be a promising therapy of chronic
constipation.4547
On the other hand, a small number of studies have evaluated the response of IBS to
probiotic preparations.4852 The results between studies are difficult to compare
because of differences in study design, type of IBS evaluated, probiotic dose, and strain.
Overall there is, however, some evidence of symptom improvement, mainly in
symptoms related to altered handling or perception of intestinal gas (abdominal
distension, bloating). This improvement is observed independent of any change in stool
frequency or consistency, and cannot therefore be attributed to either a laxative or an
antidiarrhoeal effect. In fact, it seems that there is no effect of probiotics on stool
frequency and consistency in patients with constipation-predominant IBS.50,52
Discordance between the results of some studies support the concept of specific
probiotic strains being more effective than others. Further controlled and welldesigned trials are required to evaluate the effect of probiotics in the different subtypes
of IBS, and to assess if they are effective in the treatment of IBS with constipation.
A review outlining the safety of current probiotic compounds has been published.53
Cases of infection by Lactobacillus and Bifidobacterium organisms are extremely rare and
are estimated to occur at a rate of approximately 0.050.4% of all cases of infective
endocarditis and bacteraemia.

SUMMARY
Chronic constipation is defined as a symptom-based disorder based on the presence
for at least 3 months in the last year of unsatisfactory defecation characterized by
infrequent stools, difficult stool passage, or both. The presence of clinically important
abdominal discomfort or pain associated with constipation defines IBS with
constipation. A diet poor in fibre should not be assumed to be the cause of
constipation but could be a contributing factor. Intake of dietary fibre, mainly insoluble
fibre, increases stool bulk and frequency, and decreases consistency in healthy people
(Grade A recommendation). Likewise, bulking agents (psyllium) may be effective in
alleviating chronic constipation (Grade B recommendation). However, there is a
subgroup of patients with severe constipation secondary to slow transit constipation
and/or disordered defecation who get worse with an increase in dietary fibre. On the
other hand, fibre may improve stool consistency in patients with IBS with constipation,
but it is considered to be not effective in improving abdominal pain, distension or
bloating (Grade A recommendation). Probiotics may be effective in relieving chronic

Nutrition and constipation 585

constipation (Grade B recommendation); however, the effect of lactic acid bacteria

ingestion may be dependent on the bacterial strain used and the population being
studied. Lactulose, which is a substrate for lactic acid bacteria (prebiotic), is effective to
treat patients with chronic constipation (Grade A recommendation). Dose-dependent
side effects (distension, bloating, flatulence) limit compliance with both fibre
supplements and prebiotics (lactulose). Although severe adverse events with bulking
agents are rare, oesophageal and colonic obstruction and anaphylactic reactions
(psyllium) have been reported. Cases of infection after supplementation with
Lactobacillus and Bifidobacterium organisms are extremely rare.

Practice points
a diet poor in fibre may contribute to constipation in an important subgroup of
patients
as an initial measure, increasing the dietary fibre intake is the simplest, most
physiologic, and cheapest form of treatment of mild to moderate constipation
there is a subgroup of patients with severe constipation due to slow transit
time and/or disordered defecation who get worse with dietary fibre or bulking
agents
although fibre may improve stool consistency in patients with IBS with
constipation, it is not effective in improving abdominal pain or distension
probiotics may be useful to relieve constipation, but the effect may be
dependent on the probiotic dose, bacterial strain used, and the population
being studied
a prebiotic such as lactulose is effective at improving stool frequency and
consistency in patients with chronic constipation

Research agenda
well-designed controlled trials are necessary to define further the efficacy of
bulking agents in patients with functional chronic constipation
well-designed placebo- and fibre-controlled trials are necessary to define the
efficacy of the different probiotics and prebiotics in patients with functional
chronic constipation
the role of probiotics and prebiotics in the treatment of patients with IBS with
constipation has to be defined

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