Alimentazione,
fibre, stipsi
Annamaria Staiano
Dipartimento di Scienze
Mediche Traslazionali
Università di Napoli
“Federico II”
Prevalence of constipation
Canada
USA
UK
Finland
Italy
Greece
Turkey
● Hong Kong
< 5%
5 - 10%
10 - 15%
15 - 20%
> 20%
Japan
Brazil
Saudi
Arabia
Sri Lanka
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
PREVALENCE AND ECONOMIC BURDEN
Health Utilization and Cost Impact of Childhood
Constipation in the United States
O Liem, J Harman, M Benninga, H Mousa, K Kelleher, C Di Lorenzo
J Pediatr 2009; 154: 258-62
Children with constipation impose a significant
burden on healthcare utilization and costs
Children with constipation
$ 3.430/yr
vs
Children without constipation
$ 1.099/yr
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.
Hyman PE et al. Gastroenterology. 2006 Apr;130(5):1519-26. Rasquin A et al. Gastroenterology. 2006 Apr;130(5):1527-37.
Causes and risk factors for childhood constipation
Functional Constipation (90% - 95%)
Suzanne M. Mugie et al. Rev. Gastroenterol. Hepatol. 8, 502–511 (2011)
Most commonly used initial interventions
?
?
?
Without FI
With FI
Yang CH, Punati J. JPGN 2015
Journal of Pediatric Gastroenterology and Nutrition 2003 36:329–337
LE FIBRE ALIMENTARI INSOLUBILI
CELLULOSA, LIGNINA, EMICELLULOSA
si comportano prevalentemente come agenti di
rigonfiamento in relazione alla loro
 CAPACITÀ DI ASSORBIRE ACQUA
LE FIBRE ALIMENTARI SOLUBILI
PECTINE, GOMME, MUCILLAGINI
il parametro responsabile dell’effetto
funzionale è
la FERMENTABILITÀ
FIBRA INSOLUBILE
CELLULOSA
Polimeri non
ramificati del
glucosio
Cereali
integrali,
verdura
legumi, frutta
Trattiene acqua
Aumenta massa fecale
Diminuisce transito
intestinale
Lega i sali biliari
EMICELLULOSA
Polimeri di esosi
Cereali
integrali,
verdura,
legumi, frutta
Trattiene acqua
Aumenta massa fecale
Diminuisce transito
intestinale
Lega i sali biliari
LIGNINA
Polimeri non
saccaridici
Cereali
integrali,
verdura,
legumi, frutta
Antiossidante
Aumenta massa fecale
Diminuisce transito
intestinale
Lega i sali biliari
Es. CRUSCA DI FRUMENTO
FIBRA SOLUBILE
PECTINA
Polimeri di acido
galatturonico
Frutta, patate, Aumenta il tempo di
carote, fagioli svuotamento gastrico e
transito intestinale
Aumenta SCFA
Aumento attività
disaccarasica
GOMME
Polisaccaridi di
riserva
Avena, orzo,
legumi
Aumenta il tempo di transito
intestinale
Diminuisce colesterolo
Legano i sali biliari
Formano sostanze viscose
MUCILLAGINI
Mucopolisaccaridi
Avena, orzo,
legumi
Aumenta il tempo di transito
intestinale
Diminuisce colesterolo
Legano i sali biliari
Formano sostanze viscose
Es. GOMMA GUAR (Cyamopsis tetragonolubus), PECTINA
LA FIBRA SOLUBILE
PREBIOTICO (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
The laxative effects a combination:
•
•
•
•
sorbitol (14.7g ⁄ 100g)
dietary fiber (6g ⁄ 100)
polyphenols (184 mg ⁄ 100g)
exact mechanism has not been
established
Attalauri, et al. Aliment Pharmacol Ther 2011
 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 nonconstipated 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
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
Lizuka N & Hamamota Y, Frontiers in Pharmacol 2015
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
• 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
Woo H-I, et al. J Cancer Prev 2015
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 (V2V5, 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
Alimentazione, fibre, stipsi
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