Talking about bowel habits is not something we often do but if constipation is affecting your life it can be quite uncomfortable and even upsetting.  Thankfully there are plenty of ways to ease the problem without resorting to pharmaceutical laxatives.  Constipation is usually defined as a change in daily bowel patterns, particularly a decrease in the number or consistency of bowel movements, or pain or difficulty passing stools

Prebiotics and probiotics
Previously (in August) I wrote extensively about prebiotics, probiotics and synbiotics with regards IBS (irritable bowel syndrome).  Unsurprisingly these same agents work very well in the prevention and treatment of constipation.  By positively changing the bacterial makeup of the gut they help to keep the digestive system functioning efficiently.  Prebiotics also act as a source of fibre, which adds bulk to stools and absorbs water to help eliminate waste efficiently and painlessly. 

As you will probably be aware, there are many yoghurts now available on the market which contain both pre-biotics and pro-biotics.  There is evidence from recent trials (1,2) to suggest they are effective in treating constipation.  A recent study (1), published in march, found that consumption of the yoghurt was associated with increased frequency of bowel movements, a reduced perception of straining effort and a reduced perception of pain associated with defecation.

Inulin, a type of prebiotic powder supplement, has been shown to increase the number of good bacteria in the gut as well as reducing constipation better than a traditionally used lactose laxative (3).  A supplement containing both prebiotics and probiotics has also shown good results in the treatment of constipation (4).   Taking a daily symbiotic supplements, those containing prebiotics and probiotics, may well be useful for the treatment and prevention of constipation and the efficient functioning of the digestive system.  There is also emerging evidence, that I have discussed previously, which indicates that a good bacterial balance in the gut may affect the immune system of the whole body, so a daily supplement may help to keep you feeling great!

Artichoke leaf extract
As well as its usefulness in treating IBS, artichoke leaf extract seems to be helpful in alleviating constipation.  One study(5) found that 71% of constipation patients experienced improvement using artichoke leaf extract for 6 weeks.  If you are suffering from this uncomfortable condition you may wish to try an ALE supplement for a few weeks to see if it brings relief and normalises daily bowel habits.

Fibre
Previously I have mentioned how, in the UK, we tend to fall short of the daily recommendations for fibre provision.  Many of us reach only 12g/day, the recommendation is for at least 18g/day with many health professionals recommending around 25g/day.  Fruit and vegetables provide lots of fibre, as well as all the other nutrients packed within them.  We would all do well to reach a minimum of five portions daily.  Fibre provides bulk in the digestive system, this then absorbs water making stools easy to pass and preventing constipation.  A recent study(6) in children found that constipated children had significantly lower intakes of dietary fibre than non-constipated counterparts which was attributable to under-consumption of plant foods.

Regularly eating the recommended portions of a variety of fruit and vegetables may prevent the occurrence of constipation.  Increasing intakes if constipation is already present may also help to ease and clear the problem.  Two studies (7,8) have found that eating a couple of kiwi fruit a day is helpful in the treatment of constipation.

You may wish to consider a supplemental source of fibre as a short term measure for treating constipation.  One source of fibre which seems to be helpful is flaxseeds (9,10).  If you want to try this form of fibre I would recommend buying a ground flaxseed, sometimes called linseed, supplement (or grinding the seeds yourself at home), these are easier on the digestive system and the grinding will also help to release essential omega 3 fatty acids within the seeds which adds to the nutritional benefits.  A table-spoonful of ground flax (about 15-25g) a day will probably help to ease constipation within a couple of days.  A teaspoon a day (around 5g) could be useful in prevention or re-occurrence of constipation and may be particularly useful if you feel your daily fibre intake is habitually low.

Water
Drinking enough (around 1.5L) water daily is important in the prevention and treatment of constipation.  Water is absorbed by fibre in the digestive system and adds bulk to the waste making it easier to pass.  One study (11) found that including 25g of fibre from food in the daily diet was very helpful in treating constipation and that the effect was significantly enhanced by increasing fluid intake to 1.5-2.0 litres/day.  Another study (12) concluded that fluid loss (via diarrhoea and laxative use), fluid restriction, poor hydration and dehydration increased constipation. It is very important to maintain hydration to prevent constipation.

Cow’s milk
Finally I would like to suggest that if your child (up to age 10) is suffering from regular bouts of constipation it may be a good idea to ask your GP to do a test for allergy to cow’s milk.  There are studies (13,14,15) to suggest that chronic constipation occurs as a result of cows milk allergy in some children.  There is also a lot of anecdotal evidence to back this up.  It is very important that you see your GP for the allergy test, never try elimination diets at home without the involvement of a health professional.

(1)De Paula JA et al.  2008.  Effect of the ingestion of a symbiotic yoghurt on the bowel health of women with functional constipation.  Acta Gastroenterol Latinoam.  38:16-25
(2)Sairanen U et al.  2007.  Yoghurt containing galacto-oligosaccharides, prunes and linseed reduces the severity of mild constipation in elderly subjects.  Eur J Clin Nutr.  61:1423-1428
(3) Kleessen B et al.  1997.  Effects of inulin and lactose on fecal microflora, microbial activity, and bowel habit in elderly constipated persons.  Am J Clin Nutr.  65(5):1397-1402.
(4)Amenta M et al.  2006.  Diet and chronic constipation. Benefits of oral supplementation with symbiotic zir fos (Bifidobacterium longum W11 + FOS Actilight).  Acta Biomed.  77:157-162
(5) Gebhardt R.  1996.   Antidyspeptic and lipid-lowering effects of artichoke leaf extract.  Journal for General Medicine.  2
(6)Lee WT et al.  2008.  Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant foods: A community-based study.  J Paediatr Child Health.  44:170-175
(7)Chan AO et al.  2007.  Increasing dietary fiber intake in terms of kiwifruit improves constipation in Chinese patients. World J Gastroenterol.  13(35):4771-5.
(8)Rish EC et al.  2002.  Kiwifruit promotes laxation in the elderly.  Asia Pacific Journal of Clinical Nutrition.  11(2):164.
(9)Cunnane, S. C., et al.  Nutritional attributes of traditional flaxseed in healthy young adults.  American Journal of Clinical Nutrition.  61(1):62-68, 1995.
(10)Dahl, W. J., et al.  Effects of flax fiber on laxation and glycemic response in healthy volunteers.  Journal of Medicinal Food.  8(4):508-511, 2005.
(11) Anti M et al.  1998.   Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation.  Hepatogastroenterology.  45(21):727-32
(12) Arnauld MJ.  2003.  Mild dehydration: a risk factor of constipation?  Eur J Clin Nutr.  57(Supplement 2):S88-S95.
(13)Daher S et al.  2001.  Cow's milk protein intolerance and chronic constipation in children.  Pediatr Allergy Immunol.  12(6):339-42
(14)Iacono G et al.  Intolerance of cow’s milk and chronic constipation in children.  New England Journal of Medicine.  339(16):1100-1104, 1998.
(15)Heine RG et al.  2002.  Cow's milk allergy in infancy.  Curr Opin Allergy Clin Immunol.  2(3):217-25

Written by Ani Kowal

On the 16th July I wrote about artichoke leaf extract (ALE) supplements for cholesterol lowering.  Evidence is also mounting for the usefulness of this plant supplement in the reduction of IBS symptoms (1,2).  In one study (2) 208 adults with IBS were given ALE for a two month period.  The individuals had a significant improvement whilst taking the supplement with a normalising of bowel pattern away from alternating constipation/diarrhoea toward normal.  The IBS sufferers also had a significant improvement in their total health-related quality of life scores.  The trials were small and provide preliminary evidence but it certainly seems that artichoke leaf extract is useful for an array of digestive complaints.  If you decide to try ALE supplements for the management of your IBS symptoms please follow the manufacturers dosage advice, taken in excess it may cause digestive upset.

When discussing IBS it is difficult not to mention the issue of food sensitivities or intolerances.  Some studies indicate that a large proportion of people afflicted with IBS have food sensitivities, very few have true food allergies, and that gas production and other IBS symptoms diminish when the sensitivities are discovered and the offending food(s) eliminated (3,4,5,6).  Assessing sensitivities can be quite subjective and therefore difficult to assess properly in a clinical-trial setting. 

Research suggests that some people with IBS may malabsorb the sugars lactose (found in milk), fructose (found in high concentrations in fruit juice and dried fruit) and sorbitol (found in diabetic and sugar-free products) (7).   Research shows that in a large majority of IBS patients with lactose malabsorption, a lactose-restricted diet can improve symptoms markedly both in the short term and the long term (8).  Fructose- and sorbitol-reduced diets in subjects with fructose malabsorption reduce gastrointestinal symptoms such as bloating, cramps, osmotic diarrhoea and other IBS symptoms (9).  Hence, individuals with IBS attempting to uncover food sensitivities should consider the possibility that milk, fruit juice, dried fruit and products containing sorbitol might cause worsening of their symptoms.

A note of caution – please do not attempt elimination diets without supervision from your GP or a fully qualified professional.  Many ‘food sensitivity tests’ are advertised at very high cost and, in my opinion, can often be unhelpful.  Working with a professional and keeping food diaries and symptom scores may uncover specific triggers for your personal symptoms.  Stress, emotions and psychology may also be playing a major role in your IBS symptoms so assessing how you feel could also prove helpful.  Foods may be triggering symptoms in conjunction with stressful/emotional periods but less-so at other times.

Finally I would like to briefly mention aloe vera juice.  Many individuals with digestive complaints report that their symptoms diminish greatly with the regular ingestion of an aloe vera juice drink or supplemental aloe capsules.  Most of the evidence so far is anecdotal (but that does not lessen personal experiences).  A few animal studies have started to provide weight to the evidence but very few human studies have occurred to date.  A test tube study(10) using human colon cells has shown that aloe vera did appear to work as a potent anti-inflammatory.  You may find it useful to try the juice yourself to see if it is helpful in reducing your personal symptoms.  Remember to follow the dosage guidance and try and keep note of your symptoms for about a week.  If the juice works for you then it is worth continuing with. 

That ends my posts on IBS, I do hope that the information presented over the last few days has been of help?!

(1)Walker AF et al.  2001.  Artichoke leaf extract reduces symptoms of irritable bowel syndrome in post-marketing surveillance study.  Phytotherapy Research.  15:58-61
(2)Bundy R et al.  Artichoke leaf extract reduces symptoms of irritable bowel syndrome and improves quality of life in otherwise healthy volunteers suffering from concomitant dyspepsia: a subset analysis.  J Altern Complement Med.  10:667-669
(3) King TS et al.  1998.  Abnormal colonic fermentation in irritable bowel syndrome.  Lancet.  352:1187-1189
(4) Jones AV et al.  1982.  Food intolerance: a major factor in the pathogenesis of irritable bowel syndrome.  Lancet.  ii:1115-1117
(5) Smith MA et al.  1985.  Food intolerance, atopy, and irritable bowel syndrome.  Lancet.  ii:1064
(6) Parker TJ et al.  1995.  Management of patients with food intolerance in irritable bowel syndrome: the development and use of an exclusion diet.  J Human Nutr Diet.  8:159-166
(7) Fernandez-Banares F et al.  1993.  Sugar malabsorption in functional bowel disease: clinical implications.  Am J Gastroenterol.  88:2044-2050.
(8) Bohmer CJ, Tuynman HA.  2001.  The effect of a lactose-restricted diet in patients with a positive lactose tolerance test, earlier diagnosed as irritable bowel syndrome: a 5-year follow-up study.  Eur J Gastroenterol Hepatol.  13(8):941-944
(9)Ledochowski M et al.  2000.  Fructose- and sorbitol-reduced diet improves mood and gastrointestinal disturbances in fructose malabsorbers.  Scand J Gastroenterol.  35(10):1048-52
(10)Langmead L et al.  2004.  Anti-inflammatory effects of aloe vera gel in human colorectal mucosa in vitro.  Aliment Pharmacol Ther.  19:521-527

Written by Ani Kowal

Last weekend I had the most delicious artichoke and broad bean salad and it spurred me into thinking about the health benefits of artichoke.  More and more people are taking a supplement of artichoke leaf extract for a variety of reasons.  Artichoke leaf extract is made from the thistle-like leaves at the base of the stem of the Globe Artichoke (botanical name Cynara scolymus) and not from the (very tasty!) artichoke heart that we use in cooking.

Quite a lot of recent research into artichoke leaf extract in the UK has come from the University of Reading and has mostly concentrated on the positive effects of the herb on the digestive system.  Studies have indicated that it may alleviate irritable bowel syndrome(1, 2) and indigestion(3,4). 

However, the latest research, published online last month, has found that artichoke leaf extract is also very effective at reducing cholesterol levels(5).  Many people are now taking statins in order to try and reduce their high cholesterol levels.  Taking steps through diet, exercise and perhaps supplements, before cholesterol levels reach a high could help to reduce the need for drugs (it is my personal opinion that prevention is always better than cure).  This piece of research is important because the study involved healthy people who had only moderately raised blood plasma cholesterol levels (not yet needing drugs) and it was found that the artichoke leaf extract was helpful in reducing their blood cholesterol concentrations.

The trial involved 75 individuals with total plasma cholesterol in the range 6.0–8.0 mmol/l and lasted 12 weeks.  The participants took 1280 mg of a standardised artichoke leaf extract (4 capsules), or a placebo each day.  Plasma total cholesterol decreased significantly in the treatment group (compared to the placebo) by an average of 4.2%.  This may seem like a modest change but it is favourable and certainly significant.

Dr Rafe Bundy, the lead study scientist, is quoted as saying “Reducing cholesterol levels can reduce the risk of developing cardiovascular disease. Our research investigated whether ALE [artichoke leaf extract] could be beneficial to otherwise healthy people who had raised levels of cholesterol but were not yet at a stage where they needed standard medical intervention. ALE may provide another option which people could try over and above a healthy diet in order to help lower plasma cholesterol.”

Artichoke leaf extract may be having an effect via antioxidant action, though the exact mechanism is not clear.  The extract contains a variety of polyphenols/flavonoids (bio-active plant chemicals) such as Caffeic Acid, Chlorogenic Acid and a group of compounds collectively called Caffeoylquiinic Acids (e.g. Cynarin), these are probably the active substances responsible for the beneficial health effects.

Artichoke leaf extract is widely available as a supplement and often supplements are standardised to contain around 15% Chlorogenic Acid and 2-5% Cynarin.  Typically around 600mg-900mg per day is recommended (check the recommended dose on the label) for improved digestion and cholesterol lowering.

(1) Walker AF et al.  2001.  Artichoke leaf extract reduces symptoms of irritable bowel syndrome in a post-marketing surveillance study.  Phytotherapy Research.  15(1):58-61.
(2)Bundy R et al.  2004.  Artichoke leaf extract reduces symptoms of irritable bowel syndrome and improves quality of life in otherwise healthy volunteers suffering from concomitant dyspepsia: a subset analysis.  J Altern Complement Med.  10(4):667-669.
(3)Marakis G et al.  2002.  Artichoke leaf extract reduces mild dyspepsia in an open study.  Phytomedicine.  9(8):694-699.
(4) Holtmann G et al.  2003.  Efficacy of artichoke leaf extract in the treatment of patients with functional dyspepsia: a six-week placebo-controlled, double-
blind, multicentre trial.  Aliment Pharmacol Ther.  18(11-12):1099-1105.
(5)Bundy R et al.  2008.  Artichoke leaf extract (Cynara scolymus) reduces plasma cholesterol in otherwise healthy hypercholesterolemic adults: a randomised double-blind placebo controlled trial. Phytomedicine [Epub ahead of print DOI: 10.1016/j.phymed.2008.03.001 doi:10.1016/j.phymed.2008.03.001]    

Written by Ani Kowal