Alimentazione, fibre, stipsi Annamaria Staiano Dipartimento di Scienze Mediche Traslazionali Università di Napoli “Federico II”

Alimentazione, fibre, stipsi

Annamaria StaianoDipartimento di Scienze Mediche

TraslazionaliUniversità di Napoli

“Federico II”

< 5%

5 - 10%

10 - 15%15 - 20%

CanadaFinland

Saudi Arabia

Japan

Brazil

USATurkey

UK

Greece

> 20%

Italy

●Hong Kong

Prevalence of constipation

van den Berg MM et al. Am J Gastroenterol 2006; 101:2401-09

Rajindrajith S. et al. J Pediatr gastr Nutr 2010; 51:472-6

Sri Lanka

Health Utilization and Cost Impact of Childhood Constipation in the United States

O Liem, J Harman, M Benninga, H Mousa, K Kelleher, C Di LorenzoJ Pediatr 2009; 154: 258-62

Children with constipation impose a significant burden on healthcare

utilization and costs

Children with constipation$ 3.430/yr

vsChildren without constipation

$ 1.099/yr

PREVALENCE AND ECONOMIC BURDEN

Journal Pediatr Gastroenterol Nutr 2014;58: 258–274

What is the definition of functional constipation?

1. Based on expert opinion, we recommend the ROME III criteria for the definition of functional constipation for all age groups.

Rasquin A et al. Gastroenterology. 2006 Apr;130(5):1527-37.Hyman PE et al. Gastroenterology. 2006 Apr;130(5):1519-26.

Suzanne M. Mugie et al. Rev. Gastroenterol. Hepatol. 8, 502–511 (2011)

Causes and risk factors for childhood constipation

Functional Constipation (90% - 95%)

Most commonly used initial interventions

Without FIWith FI

? ??

Yang CH, Punati J. JPGN 2015

Journal of Pediatric Gastroenterology and Nutrition 2003 36:329–337

LE FIBRE ALIMENTARI INSOLUBILI

CELLULOSA, LIGNINA, EMICELLULOSAsi comportano prevalentemente come

agenti di rigonfiamento in relazione alla loro

CAPACITÀ DI ASSORBIRE ACQUA

PECTINE, GOMME, MUCILLAGINI

il parametro responsabile dell’effetto

funzionale è

la FERMENTABILITÀ

LE FIBRE ALIMENTARI SOLUBILI

CELLULOSA Polimeri non ramificati del glucosio

Cereali integrali, verdura legumi, frutta

Trattiene acquaAumenta massa fecaleDiminuisce transito intestinaleLega i sali biliari

EMI-CELLULOSA

Polimeri di esosi Cereali integrali, verdura, legumi, frutta

Trattiene acquaAumenta massa fecaleDiminuisce transito intestinaleLega i sali biliari

LIGNINA Polimeri non saccaridici

Cereali integrali, verdura, legumi, frutta

AntiossidanteAumenta massa fecaleDiminuisce transito intestinaleLega i sali biliari

Es. CRUSCA DI FRUMENTOEs. CRUSCA DI FRUMENTO

FIBRA INSOLUBILE

PECTINA Polimeri di acido galatturonico

Frutta, patate, carote, fagioli

Aumenta il tempo di svuotamento gastrico e transito intestinaleAumenta SCFAAumento attività disaccarasica

GOMME Polisaccaridi di riserva

Avena, orzo, legumi

Aumenta il tempo di transito intestinaleDiminuisce colesteroloLegano i sali biliariFormano sostanze viscose

MUCILLAGINI Mucopolisaccaridi Avena, orzo, legumi

Aumenta il tempo di transito intestinaleDiminuisce colesteroloLegano i sali biliariFormano sostanze viscose

Es. GOMMA GUAR (Cyamopsis tetragonolubus), PECTINAEs. GOMMA GUAR (Cyamopsis tetragonolubus), PECTINA

FIBRA SOLUBILE

LA FIBRA SOLUBILEPREBIOTICO (COLONIC FOOD)

Alimento NON digeribile (dall’organismo umano) che influenza l’ospite stimolando selettivamente la crescita e/o l’attività di batteri residenti benefici nel colon producendo diversi metaboliti tra cui acidi grassi a corta catena (SCFA)

GIBSON E ROBERFROID, 1995

Journal of Pediatric Gastroenterology and Nutrition 36:329–337

Attalauri, et al. Aliment Pharmacol Ther 2011

The laxative effects a combination:

• sorbitol (14.7g ⁄ 100g)• dietary fiber (6g ⁄ 100)• polyphenols (184 mg ⁄ 100g) • exact mechanism has not been

established

Prunes (dried plums) are high in fibre and are perceived to promote healthy gastrointestinal (GI) function.

In constipation, prunes appear superior to psyllium for improving stool frequency and consistency, however, the evidence for other outcomes and the effects in non-constipated subjects is weak.

Although prunes may be a promising intervention for the management of constipation and increasing stool weight, this needs to be confirmed by further rigorous research.

Lever E et al. Aliment Pharmacol Ther. 2014 Oct;40(7):750-8.

• Kivia powder containing Zyactinase™ is a freeze-dried powder from kiwifruit (Actinidia deliciosa var. Deliciosa) containing the enzyme actinidin, plant polyphenols, dietary fiber, carbohydrates, and oligosaccharides.

Pediatrics 1962

Udani JK1, Bloom DW. Nutr J. 2013 Jun 8;12:78

Udani JK1, Bloom DW. Nutr J. 2013 Jun 8;12:78

• In this randomized, doubleblind, placebo-controlled study, we examined the effects of Actazin and Gold, kiwifruit derived nutritional ingredients, on stool frequency, stool form, and gastrointestinal comfort in healthy and functionally constipated (Rome III criteria for C3 functional constipation) individuals

• In the healthy cohort the Actazin-H and Gold interventions significantly increased the mean daily bowel movements compared with the washout.

• In a subgroup analysis of responders in the healthy cohort, Actazin-L, Actazin-H, and Gold consumption significantly increased the number of daily bowel movements by greater than 1 bowel movement per week.

• This study demonstrated that Actazin and Gold produced clinically meaningful increases in bowel movements in healthy individuals.

Ansell J et al. Nutr Res. 2015 Apr 11.

• Rhei rhizoma-based Japanese herbal medicines (JHMs) including Daiokanzoto and Mashiningan, and Kenchuto-based JHMs including Keishikashakuyakuto and Daikenchuto, which coordinate the motility of the alimentary tract.

Shimoyama T, et al. J Gastroenterol Hepatol 2015

Lizuka N & Hamamota Y, Frontiers in Pharmacol 2015

Rhei Rhizoma (rhubarb)•Dianthrone glucosides (sennosides A to F) and anthraquinones

Daikenchuto•Ginger, Ginseng Radix Rubra, Zanthoxyli Fructus and Saccharum Granorum (maltose powder derived from rice)

•Has been successfully used to treat postoperative ileus since it stimulates peristalsis of the gastrointestinal tract

Effect of Vegetables and Whole Grain Powder That Is Rich in Dietary Fibers on Bowel Functions and Defecation in

Constipated Young Adults

• 51 subjects were supplied with rice flakes-powder (RFP)

• 45 subjects in the VP group (whole grain, chicory (inulin↑), and broccoli) were provided with 30 g of VP twice daily for 4 weeks

Woo H-I, et al. J Cancer Prev 2015

• In addition, significant differences between RFP and VP groups in stool hardness, amount, sensation of incomplete evacuation, and straining to defecate at day 14 and 28 of experimental diet

A Randomized, Prospective, Comparison Study of a Mixture of Acacia Fiber, Psyllium Fiber and Fructose (AFPFF) versus Polyethylene Glycol

3350 with Electrolytes (PEG+E) for the Treatment of Chronic Functional Constipation in Childhood

No significant difference were found between the efficacy of AFPFF and PEG+E in the treatment of children with CFC.

Both medications were proved to be safe for CFC treatment, but PEG+E was better accepted by children.

Quitadamo P. et al. J Pediatr. 2012

“Prospective evaluation of dietary treatment in childhood constipation: high dietary fiber (DF) and wheat bran intake are associated with

constipation amelioration”

High DF and bran intake are feasible in constipated children and contribute to amelioration of constipation

• BH and dietary data of 28 children with functional constipation defined by the "Boston criteria" were obtained at visit 1 (V1,n = 28) and at 4 follow-up visits (V2-V5, n = 80)

•At V1, median DF intake was 29.9% below the minimum recommended and at the last visit 49.9% above it

•At the last visit 21 children presented RECOVERY (REC) (improved, no complications; asymptomatic) (75%); 20 of them were asymptomatic and 18 were off washout/laxatives

Maffei HV et al. JPGN 2011 Jan;52(1):55-9

• Low fibre intake is associated with constipation. We found insufficient evidence from RCTs showing that extra fibre reduces constipation compared with placebo. We found insufficient evidence on the effects of increased fibre intake compared with lactulose.

• We found insufficient evidence from RCTs on the effects of probiotics versus placebo or versus osmotic laxatives at improving symptoms of constipation.

• Overall, many of the studies we found used different definitions and outcomes measures, and the quality of evidence was low. There is a need for further large high-quality RCTs in this condition.

Tabbers MM, Benninga MA. BMJ Clin Evid. 2015 Mar 10;2015

Tabbers MM, Benninga MA. BMJ Clin Evid. 2015 Mar 10;2015

What is the additional effect of nonpharmacological treatments in children with functional constipation?

We recommend a normal fiber intake in children with constipation.

We recommend a normal fluid intake in children with constipation.

We recommend a normal physical activity in children with constipation.

We do not recommend the routine use of prebiotics or probiotics in the treatment of childhood constipation.

Journal Pediatr Gastroenterol Nutr 2014;58: 258–274

CONCLUSIONI

Si raccomanda una normale assunzione di fibre (5g+anni d’eta’ al giorno)

Si raccomanda una normale assunzione di fluidi

Al momento mancano studi RCT che provino l’efficacia terapeutica delle fibre nella stipsi cronica funzionale

Alimentazione, fibre, stipsi