The effects of psyllium hydrophilic mucilloid on diarrhea in enterally fed patients

Effects of dietary fibre on enteral feeding intolerance and clinical outcomes in critically ill patients: A meta-analysis

BACKGROUND

Although some studies have explored the relationships between dietary fibre and enteral feeding intolerance in critically ill patients, the results are equivocal.

OBJECTIVE

This study aimed to explore the effects of dietary fibre on enteral feeding intolerance and clinical outcomes in critically ill patients.

METHODS

We searched five databases from inception to July 12, 2021. Data were expressed as mean difference or odds ratio with 95% confidence interval.

RESULTS

Thirteen studies enrolled 709 critically ill patients included in the study. The results showed the dietary fibre group had a significantly decreased risk of diarrhea (OR: 0.46, 95% CI: 0.30,0.69, P < 0.001), regurgitation (OR: 0.28, 95%CI: 0.13, 0.60, P < 0.05), vomiting (OR: 0.40, 95%CI: 0.17, 0.92, P < 0.05), constipation (OR: 0.21, 95%CI: 0.09, 0.47, P < 0.001) and mortality (OR:0.34; 95%CI:-0.13, 0.91; P < 0.05) compared with the fibre free group. Besides, there was a significant decrease on time to reach full enteral nutrition (MD:-2.08; 95%CI:-4.05, -0.12; P < 0.05), the duration of the intensive care unit stay (MD:-4.62; 95%CI:-6.60, -2.64; P < 0.001) and hospital stay (MD:-6.42; 95%CI:-9.49, -3.36; P < 0.001) in the dietary fibre group.

CONCLUSIONS

Dietary fibre supplementation may significantly reduce the risk of enteral feeding intolerance and improve the clinical outcomes.

The effect of fiber supplementation on the prevention of diarrhea in hospitalized patients receiving enteral nutrition: A meta-analysis of randomized controlled trials with the GRADE assessment

Introduction

Enteral nutrition (EN) in hospitalized patients has several advantages. However, post-feeding diarrhea occurs frequently and has been linked to negative outcomes. The EN formula itself may have an impact on how diarrhea develops, and fiber supplements may theoretically help patients experience less diarrhea. This study aimed to thoroughly evaluate whether adding fiber to EN decreases the likelihood of developing diarrhea and whether different types of fibers pose different effects on diarrhea (PROSPERO CRD 42021279971).

Methods

We conducted a meta-analysis on fiber supplementation in hospitalized adult patients receiving EN. We thoroughly searched PubMed, Medline, Embase, Scopus, Web of Science, CENTRAL, and ClinicalTrials.gov databases from inception to 1 September 2022. Only randomized controlled trials (RCTs) were included. Pooled results on the incidence of diarrhea were calculated using a random-effects model. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was applied. Only fiber types from soy polysaccharides (n = 4), psyllium (n = 3), mixed soluble/insoluble fiber (mixed fiber, n = 3), pectin (n = 2), and partially hydrolyzed guar gum (PHGG, n = 2) were examined in the sensitivity analysis.

Results

Among the 4,469 titles found, a total of 16 RCTs were included. Overall, compared to fiber-free formulas, fiber supplementation reduced the occurrence of diarrhea in patients receiving EN by 36% (pooled risk ratio [RR] of 0.64 [95% confidence interval (CI): 0.49-0.82, p = 0.005; I ² = 45%]), with GRADE showing the evidence of moderate certainty. Only mixed fiber and PHGG significantly decreased the incidence of diarrhea according to the sensitivity analyses for fiber types (RR 0.54, 95%CI: 0.39-0.75, I ² = 0% and RR 0.47, 95%CI: 0.27-0.83, I ² = 0%, respectively). The results for the remaining fiber types were unclear.

Conclusion

According to a meta-analysis, fiber supplements help lessen post-feeding diarrhea in hospitalized patients receiving EN. However, not all fiber types produced successful outcomes. Diarrhea was significantly reduced by PHGG and mixed soluble/insoluble fiber.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=279971, identifier: PROSPERO CRD 42021279971.

Review of structure and bioactivity of the Plantago (Plantaginaceae) polysaccharides

Plantago (Plantaginaceae) is an herbal plant, which is used in folk medicine, functional food, and dietary supplement products. Recent pharmacological and phytochemical studies have shown that polysaccharides isolated from Plantago have multiple medicinal and nutritional benefits, including improve intestinal health, hypoglycemic effect, immunomodulatory effect, etc. These health and pharmacological benefits are of great interest to the public, academia, and biotechnology industries. This paper provides an overview of recent advances in the physicochemical, structural features, and biological effects of Plantago polysaccharides and highlights the similarities and differences of the polysaccharides from different species and in different parts, including leaves, seeds, and husks. The scientific support for its use as a prebiotic is also addressed. The purpose of this review is to provide background as well as useful and up-to-date information for future research and applications of these polysaccharides.

Safety of Using Enteral Nutrition Formulations Containing Dietary Fiber in Hospitalized Critical Care Patients: A Systematic Review and Meta-Analysis

Enteral nutrition (EN) is the preferred route of nutrition support for patients with critical illness undergoing intensive care. Experts in the field caution against using fiber during EN because of perceived adverse patient outcomes; however, a comprehensive assessment of this topic is not evident to date. In this systematic review and meta-analysis, we searched four databases from inception to April 20, 2020, for studies on adverse events or health outcomes associated with using EN formulations containing fiber in hospitalized adults with critical illness. Nineteen articles were included. Random-effects meta-analysis models showed significantly lower diarrhea scores for fiber groups compared with nonfiber groups (pooled mean difference: -2.78; 95% CI, -4.10 to -1.47) but mixed results for risk of diarrhea between groups, depending on measures used for diarrhea (Hart and Dobb scale, pooled risk ratio [RR]: 0.68; 95% CI, 0.45-1.02; other diarrhea scales, pooled RR: 0.42; 95% CI, 0.20-0.89). Models showed 39% lower risk of gastrointestinal (GI) complications overall for fiber compared with nonfiber groups (pooled RR: 0.61; 95% CI, 0.47-0.79) but no group differences for individual GI complications, mortality, and intensive care unit or hospital length of stay. Analyses stratified by soluble- or mixed-fiber interventions reduced heterogeneity in models but showed identical conclusions. EN formulas with fiber may help reduce incidence and severity of diarrhea and GI complications overall in critically ill patients, without increased risk of other adverse events. Bias among specific GI measures indicates more high-quality studies are needed to verify these conclusions.

Saccharomyces cerevisiae Fermentation Product Did Not Attenuate Clinical Signs, but Psyllium Husk Has Protective Effects in a Murine Dextran Sulfate Sodium-Induced Colitis Model

BACKGROUND

Yeast products and psyllium husk may provide relief from clinical signs of colitis due to their ability to promote gut integrity, modulate gut microbiota, or positively affect immune responses, which have been demonstrated in several species.

OBJECTIVE

The objective of this study was to investigate the effects of a Saccharomyces cerevisiae fermentation product (SCFP) and psyllium husk (PH) on cecal and fecal microbiota, colonic gene expression and histopathology, and mesenteric lymph node (MLN) immune cells in a dextran sulfate sodium (DSS)-induced colitis model.

METHODS

Male C57BL/6J mice (n = 54) were assigned to a control, 5% SCFP, or 5% PH diet. After 2 wk of diet adaptation, mice were provided distilled water or 3% (wt:vol) DSS for 5 d ad libitum. Body weight, food and water intakes, and disease activity index (DAI) were recorded daily during the treatment period. Fresh fecal samples were collected before and during treatment for microbial analyses. After treatment, mice were killed, followed by tissue collection. Tissues were stored in proper solutions until further analyses. Data were analyzed using the Mixed Models procedure of SAS 9.4 (SAS Institute).

RESULTS

Consumption of SCFP increased (P < 0.05) species richness of the gut microbiota and relative abundance of Butyricicoccus in fecal and cecal samples compared with control or PH mice. PH mice had greater (P < 0.05) gene expression of claudin (Cldn) 2, Cldn3, Cldn8, and occludin(Ocln) compared with control mice. DAI, MLN immune cell populations, colonic histopathology, and colonic gene expression were not affected (P > 0.05) by SCFP in DSS mice. DSS mice consuming PH had lower (P < 0.05) DAI compared with control or SCFP mice.

CONCLUSIONS

Results suggest that, despite the modest changes it had on cecal and fecal microbiota, SCFP did not attenuate clinical signs associated with DSS-induced colitis in mice, while PH showed protective effects.

Modulations in the offspring gut microbiome are refractory to postnatal synbiotic supplementation among juvenile primates

Background

We and others have previously shown that alterations in the mammalian gut microbiome are associated with diet, notably early life exposure to a maternal high fat diet (HFD). Here, we aimed to further these studies by examining alterations in the gut microbiome of juvenile Japanese macaques (Macaca fuscata) that were exposed to a maternal HFD, weaned onto a control diet, and later supplemented with a synbiotic comprised of psyllium seed and Enterococcus and Lactobacillus species.

Results

Eighteen month old offspring (n = 7) of 36% HFD fed dams were fed a control (14% fat) diet post weaning, then were synbiotic supplemented for 75 days and longitudinal stool and serum samples were obtained. All stool samples were subjected to 16S rRNA metagenomic sequencing, and microbiome profiles and serum lipids and triglycerides were compared to untreated, healthy age matched and diet matched controls (n = 7). Overall, 16S-based metagenomic analysis revealed that supplementation exerted minimal alterations to the gut microbiome including transient increased abundance of Lactobacillus species and decreased abundance of few bacterial genera, including Faecalibacterium and Anaerovibrio. However, serum lipid analysis revealed significant decreases in triglycerides, cholesterol, and LDL (p < 0.05). Nevertheless, supplemented juveniles challenged 4 months later were not protected from HFD-induced gut dysbiosis.

Conclusions

Synbiotic supplementation is temporally associated with alterations in the gut microbiome and host lipid profiles of juvenile Japanese macaques that were previously exposed to a maternal HFD. Despite these presumptive temporal benefits, a protective effect against later HFD-challenge gut dysbiosis was not observed.

Electronic supplementary material

The online version of this article (10.1186/s12866-018-1169-9) contains supplementary material, which is available to authorized users.

Fiber and prebiotic supplementation in enteral nutrition: A systematic review and meta-analysis

AIM: To investigate fiber and prebiotic supplementation of enteral nutrition (EN) for diarrhea, fecal microbiota and short-chain fatty acids (SCFAs).

METHODS: MEDLINE, EMBASE, Cochrane Library, CINAHL, Academic Search Premier, and Web of Science databases were searched for human experimental and observational cohort studies conducted between January 1990 and June 2014. The keywords used for the literature search were fiber, prebiotics and enteral nutrition. English language studies with adult patient populations on exclusive EN were selected. Abstracts and/or full texts of selected studies were reviewed and agreed upon by two independent researchers for inclusion in the meta-analysis. Tools used for the quality assessment were Jadad Scale and the Scottish Intercollegiate Guidelines Network Critical Appraisal of the Medical Literature.

RESULTS: A total of 456 possible articles were retrieved, and 430 were excluded due to lack of appropriate data. Of the 26 remaining studies, only eight investigated the effects of prebiotics. Results of the meta-analysis indicated that overall, fiber reduces diarrhea in patients receiving EN (OR = 0.47; 95%CI: 0.29-0.77; P = 0.02). Subgroup analysis revealed a positive effect of fiber supplementation in EN towards diarrhea in stable patients (OR = 0.31; 95%CI: 0.19-0.51; P < 0.01), but not in critically ill patients (OR = 0.89; 95%CI: 0.41-1.92; P = 0.77). Prebiotic supplementation in EN does not improve the incidence of diarrhea despite its manipulative effect on bifidobacteria concentrations and SCFA in healthy humans. In addition, the effect of fiber and/or prebiotic supplementation towards fecal microbiota and SCFA remain disputable.

CONCLUSION: Fiber helps minimize diarrhea in patients receiving EN, particularly in non-critically ill patients. However, the effect of prebiotics in moderating diarrhea is inconclusive.

Treatment of chronic diarrhoea

The treatment of chronic diarrhoea can be challenging. While Oral Rehydration Solution is an important step in treating diarrhoeal illnesses, various medications can be used to alleviate the symptoms while the patient is undergoing diagnostic work up or to target the underlying mechanism responsible for their diarrhoea. Medications are also being prescribed in cases when there is a strong suspicious about a diagnosis or when there is no specific treatment for an underlying aetiology. This chapter discusses the treatment options for diarrhoeal disorders.

Release behaviour of propranolol HCl from hydrophilic matrix tablets containing psyllium powder in combination with hydrophilic polymers

The objective of this study was to investigate the release behaviour of propranolol hydrochloride from psyllium matrices in the presence hydrophilic polymers. The dissolution test was carried out at pH 1.2 and pH 6.8. Binary mixtures of psyllium and hydroxypropyl methylcellulose (HPMC) used showed that an increase in the percentage of HPMC in the binary mixtures caused a significant decrease in the release rate of propranolol. Psyllium-alginate matrices produced lower drug release as compared to when the alginate was the matrix former alone. When sodium carboxy methyl cellulose (NaCMC) was incorporated into the psyllium, the results showed that matrices containing the ratio of psyllium-NaCMC in the 1:1 ratio are able to slow down the drug release significantly as compared to matrices made from only psyllium or NaCMC as retardant agent suggesting that there could be a synergistic effect between psyllium and NaCMC. The double-layered tablets showed that the psyllium and HPMC in the outer shell of an inner formulation of psyllium alone had the greatest effect of protecting the inner core and thus producing the lowest drug release (DE = 38%, MDT = 93 min). A significant decrease in the value of n in Q = kt(n) from 0.70 to 0.51 as the psyllium content was increased from 50 to 150 mg suggests that the presence of psyllium in HPMC matrices affected the release mechanism. Psyllium powder had the ability in the combination with other hydrophilic polymers to produce controlled release profiles. Care and consideration should as such be taken when formulating hydrophilic matrices in different combinations.

Mechanisms, prevention, and management of diarrhea in enteral nutrition

PURPOSE OF REVIEW

Diarrhea is a common and problematic complication of enteral nutrition, about which there has been considerable recent research. This article briefly reviews the mechanisms of diarrhea during enteral nutrition and then critically appraises the recent and emerging evidence for the prevention and management of this distressing complication.

RECENT FINDINGS

For many years, fiber was extensively investigated for its role in preventing diarrhea; however, a more recent focus has been the investigation of specific fiber blends, including soluble fibers and prebiotics, for which there is now considerable quality evidence. Enteral nutrition may result in deleterious effects on the gastrointestinal microbiota, including reductions in bifidobacteria and key butyrate producers. Their modulation by prebiotics has been confirmed in studies on healthy individuals, but convincing evidence in acutely ill patients is required. Probiotics have undergone extensive recent research and their effect on preventing diarrhea in enteral nutrition would seemingly be strain dependent. Further research is required on systematic approaches to treating diarrhea during enteral nutrition.

SUMMARY

A number of factors contribute to the pathogenesis of diarrhea in enteral nutrition, meaning that approaches to its prevention and management are necessarily multifaceted. Approaches to prevent diarrhea during enteral nutrition, and a clinical algorithm to manage it, are now presented.

Systematic review and meta-analysis: the clinical and physiological effects of fibre-containing enteral formulae

BACKGROUND

Enteral nutrition can be associated with gastrointestinal side effects and fibre supplementation has been proposed as a means to normalize bowel function.

AIM

To evaluate systematically the effects of fibre supplementation of enteral feeds in healthy volunteers and patients both in the hospital and community settings.

METHODS

Electronic and manual bibliographic searches were conducted. Controlled studies in adults or children, comparing fibre-supplemented vs. fibre-free formulae given as the sole source of nutrition for at least 3 days, were included.

RESULTS

Fifty-one studies (including 43 randomized-controlled trials), enrolling 1762 subjects (1591 patients and 171 healthy volunteers) met the inclusion criteria. Fibre supplementation was generally well tolerated. In the hospital setting, the incidence of diarrhoea was reduced as a result of fibre administration (OR 0.68, 95% CI: 0.48-0.96; 13 randomized-controlled trials). Meta-regression showed a more pronounced effect when the baseline incidence of diarrhoea was high. In both patients and healthy subjects, fibre significantly reduced bowel frequency when baseline frequency was high and increased it when it was low, revealing a significant moderating effect of fibre.

CONCLUSIONS

The review indicates that the fibre-supplemented enteral formulae have important physiological effects and clinical benefits. There is a need to use a consistent approach to undertake more studies on this issue in the community setting.

Managing diarrhoea in intensive care

OBJECTIVE

To assess the incidence of diarrhoea in intensive care patients with a length of stay (LOS) greater than 3 days who were receiving any type of enteral tube feeding, and to measure the effect of implementing a bowel management protocol.

DESIGN

A 2-year prospective audit, with an intervention after 12 months. Diarrhoea was defined as bowel activity exceeding three stools of any consistency per day, or three or more unformed stools (or 300 mL) per day, for two consecutive days.

SETTING

A tertiary referral intensive care unit (ICU) in a large public hospital.

SAMPLE

Six hundred fifty-six consecutive patients admitted to ICU with a LOS >3 days.

INTERVENTION

A bowel management protocol was implemented to address both diarrhoea and constipation.

MAIN OUTCOME MEASURES

Number of patients who experienced diarrhoea during their ICU stay; number of ICU patient-days on which diarrhoea occurred.

RESULTS

After the protocol was implemented, diarrhoea was experienced by 13% fewer patients (p = 0.0002) and occurred on 8% fewer ICU days (p < 0.0001).

CONCLUSION

Use of an evidence-based protocol, and improved monitoring and reporting of bowel activity, can decrease the incidence of diarrhoea in ICU patients.

Enteral feeding in the critically ill: are nursing practices contributing to hypocaloric feeding?

INTRODUCTION

Enteral feeding is the preferred method of nutritional support for the critically ill; however, a significant number of these patients are under-fed. It is possible that common nursing practices associated with the delivery of enteral feeding may contribute to under-feeding although there is little data available describing nursing practice in this area.

METHOD

A descriptive survey-based design was used to explore the enteral feeding practices of 376 critical care nurses (response rate 50.5%). Participants completed a 57-item survey that focused on general enteral feeding practice and the management of feeding intolerance and complications.

RESULTS

The enteral feeding practice of critical care nurses varied widely and included some practices that could contribute to under-feeding in the critically ill. Practices associated with the measurement of gastric residual volumes (GRV) were identified as the most significant potential contributor to under-feeding. GRV measurements were commonly used to assess feeding tolerance (n = 338; 89.9%) and identified as a reason to delay feeding (n = 246; 65.4%). Delayed gastric emptying was frequently managed by prokinetic agents (n = 237; 63%) and decreasing the rate of feeding (n = 247; 65.7%) while nursing measures, such as changing patient position (n = 81; 21.5%) or checking tube placement (n = 94; 25%) were less frequently reported.

CONCLUSION

The findings of this survey support the contention that nursing practices associated with the delivery of enteral feeds may contribute to under-feeding in the critically ill patient population.

What's new on defining diarrhea in tube-feeding studies?

Nurses who are involved in studies of tube feeding tolerance or who review the literature on this topic are confronted with a myriad of definitions and methods of reporting diarrhea. In a 1992 study, the authors reported that these definition differences influenced results. In a review of the current literature, they determined that little progress had been made toward standardizing definitions and reports of diarrhea in studies of tube feeding. A secondary analysis of stool characteristics of hospitalized patients using various definitions of diarrhea showed there was a positive association between stool frequency and consistency. Criteria for stool consistency in the definitions of diarrhea appeared to have a greater influence on diarrhea outcomes when stool frequency was low. The authors suggest recognition of a taxonomy of definitions of diarrhea in the absence of consensus, which will help guide the design of future investigations and facilitate the evaluation and utilization of research.

An overview of diarrhea in the patient receiving enteral nutrition

Many healthcare providers associate enteral tube feedings with diarrhea. Research suggests an incidence of diarrhea in patients receiving enteral tube feedings of 2% to 63%. This wide variation in incidence is due, in part, to the lack of a universal definition of diarrhea and other suspected factors that influence stool output such as malabsorption, infection, bacterial contamination of the feeding, medical diagnosis of the patient, medication therapy, or formula-related causes. An understanding of digestion, the role of fiber and fat in the diet, and the control for other influences will aid nurses in identifying interventions that promote a normal stool consistency in patients receiving enteral tube feedings. The need for further research regarding the causes and management of diarrhea is also supported.