Chronic Constipation (CC): Can Synbiotics Be the Ultimate Solution?

Chronic constipation (CC) is a widespread health concern where individuals find it challenging to pass stools regularly, affecting up to 14% of people worldwide, especially women and seniors ^{1 2 3}.

Symptoms include hard stools, stomach discomfort, and bloating⁴.

Diagnosis primarily involves assessing the patient’s health history and specific examinations⁵.

The widely accepted Rome criteria help differentiate constipation types.

Due to its widespread nature, prompt treatment is vital.

Options include medications, lifestyle adjustments, and dietary changes. Recently, supplements like prebiotics and probiotics have emerged as potential remedies ^{6 7 8}.

Key Points

• Understanding Chronic Constipation (CC):
  • CC affects up to 14% of the global population, especially among women and seniors.
  • It’s categorized into primary (like normal transit issues, and slow transit problems) and secondary types (often due to medications or conditions).
• Diagnosis and Classification:
  • Diagnosis requires a thorough assessment of the patient’s health history and specific examinations.
  • The Rome Criteria, established by The Rome Foundation, helps doctors categorize and diagnose different types of constipation, including functional constipation (FC), irritable bowel syndrome with constipation (IBS-C), and opioid-induced constipation (OIC).
• The Role of Prebiotics:
  • Prebiotics have evolved in definition, now understood as substances used by host microorganisms leading to health benefits.
  • Diverse animal and human studies suggest the potential benefits of prebiotics on constipation, but results are mixed, and further research is needed.
• The Potential of Probiotics:
  • Probiotics, live microorganisms beneficial to health, have shown varying degrees of success in alleviating constipation symptoms.
  • The effectiveness of probiotics depends on factors like strain, dose, duration, time of intake, and delivery method.
• Synbiotics in Combatting Constipation:
  • Synbiotics combine both probiotics and prebiotics and have shown potential in reducing symptoms of constipation.
  • While promising, research on synbiotics is still in its early stages, and further randomized control trials (RCTs) are essential to determine their effectiveness.

Demystifying Chronic Constipation

Chronic constipation (CC) is categorized into primary and secondary types. Primary CC encompasses:

1. Normal transit issues.
2. Slow transit problems.
3. Anorectal malfunctions.
4. Combined factors like pelvic floor dysfunction ⁹.

Secondary CC can arise due to medications, like opioids, or conditions like hypothyroidism and Parkinson’s disease ¹⁰.

Understanding CC’s root cause is complex. It’s believed to involve multiple systems, such as:

• The enteric nervous system (ENS) that stimulates gut movements.
• The autonomic nervous system (ANS) affecting intestinal action.
• The central nervous system (CNS) influencing gut activity through various hormonal pathways¹¹.

Moreover, other components play a part. Intestinal ion channels maintain digestive balance.

Aquaporins help transport water in the gut.

Hormones like motilin and melatonin influence gut movement.

Shifts in gut bacteria also impact digestion. Changes in diet and behavior further complicate the understanding of CC .

Chronic Constipation: Factors, Diagnosis, and Tools

Chronic constipation (CC) affects roughly 14% of adults globally ³.

This condition is more common as people age, partly due to reduced physical activity, suboptimal diets, and increased medication intake.

Women, particularly the elderly, experience CC nearly twice as much as men ¹².

Factors like hormonal changes in women, potential pelvic floor damage from childbirth, and increased healthcare visits contribute to this.

Key risk elements for CC include age, gender, socioeconomic status, medication use, and lifestyle.

Medicines like opioids can disrupt gut function.

Dietary habits, such as high fiber and water intake, significantly reduce constipation risks ¹³.

Conversely, low physical activity elevates the risk.

Because of constipation’s varied risk factors and symptoms, accurate diagnosis demands a thorough medical history and physical exam.

To assist physicians, The Rome Foundation established the Rome Criteria ¹⁴.

Initially, Rome I included four symptoms, such as hard stools and infrequent evacuations. As the criteria evolved, new symptoms and classifications, like opioid-induced constipation, were added.

By Rome IV, doctors can categorize patients into functional constipation (FC), irritable bowel syndrome with constipation (IBS-C), or opioid-induced constipation (OIC) ⁴.

While FC mainly involves challenging evacuations, IBS-C adds abdominal pain. OIC, on the other hand, arises due to opioids affecting the digestive system.

Besides the Rome Criteria, other tools like the Bristol Stool Form (BSF) scale help evaluate stool consistency.

Specialized questionnaires like the Cleveland Clinic Constipation Score (CCCS) and Patient Assessment of Constipation Symptom (PAC-SYM) gauge constipation severity ^{15 16}.

These instruments, chosen based on the study’s goal, are pivotal for understanding and addressing constipation.

Prebiotics: A Potential Solution for Chronic Constipation?

Prebiotics have evolved in definition over the years.

Originally, they were understood as non-digestible food ingredients that promote the growth of specific beneficial gut bacteria, thereby enhancing the host’s health ¹⁷.

However, a more recent consensus by the International Scientific Association for Probiotics and Prebiotics (ISAPP) in 2017 defines prebiotics as substances used by host microorganisms that lead to health benefits¹⁸ .

In exploring the impact of prebiotics on constipation, diverse animal studies have been conducted.

These studies utilized various prebiotics such as lactulose, inulin, and different oligosaccharides, often testing them at multiple doses ^{19 20 21}.

Common metrics for assessing their efficacy included stool frequency, gastrointestinal (GI) transit time, and stool water content.

Promising results were found, especially in medium (0.6-0.85 g/kg) and high doses (1.70-2.49 g/kg), with these doses improving GI transit rates ²².

Furthermore, while most doses improved defecation frequency, some exceptions were noted, particularly with certain doses of D-tagatose.

A study that combined prebiotics (galactooligosaccharides + lactulose) revealed an increase in defecation frequency and a decrease in colonic transit time ²³.

However, a broader spectrum of studies is needed to confirm these findings.

Human studies mainly focused on inulin, either in isolation or combination ^{24 25}.

While some found that inulin supplementation improved defecation frequency, other results were more mixed, especially concerning stool consistency or other constipation-related symptoms ²⁶ .

One of the potential benefits of inulin is its ability to modify the gut microbiota, promoting beneficial bacterial species, which is linked to a better quality of life in healthy individuals ²⁷.

But when paired with other agents like lactitol or aloe vera, the benefits seemed to diminish ²⁸.

While some prebiotics show potential benefits against constipation, the evidence remains mixed, necessitating further research.

Probiotics and Constipation: What We Know So Far

Probiotics, defined as live microorganisms beneficial to our health when taken in appropriate amounts, have been an exciting subject of research for their potential benefits in alleviating constipation ²⁹.

The International Scientific Association of Probiotics and Prebiotics (ISAPP) redefined them in 2014, drawing from an earlier 2001 definition by FAO/WHO ³⁰.

While many animal and human studies suggest probiotics’ positive impact on constipation, results are inconsistent due to varied methodologies ^{31 32}.

For instance, in animal studies, mice were the predominant test subjects, with a focus on the Lactobacillus and Bifidobacterium probiotic strains ^{33 34 35}.

These studies primarily aimed to understand the gastrointestinal (GI) transit rate.

Notably, L. plantarum showed conflicting results across different researches, suggesting that dosage, duration, and combined strains play roles in its effectiveness ^{36 37}.

In human studies, single-strain probiotics like Bifidobacterium lactis and Lactobacillus Casei Shirota were predominantly studied ^{38 39}.

These studies have shown some promising effects on defecation frequency and stool consistency, though the results are still debated ^{40 41}.

Interestingly, while single-strain probiotics seemed more effective for certain symptoms, the combination or “multistrain” probiotics showed mixed results ^{42 43}.

Dosage is another area of exploration. Some studies focused on high doses (≥ 10¹⁰ CFU), others on low doses (< 10¹⁰ CFU), with a few comparing the two ^{44 45}.

Both dosage groups showed positive impacts, yet a recent systematic review suggests no significant difference between the two in alleviating constipation symptoms ⁴⁶.

The duration of taking probiotics is also under scrutiny.

While most human studies recommend longer durations (≥ 28 days), some evidence suggests short-term usage might be more effective, though it may vary depending on the strain ⁴⁶.

Other critical factors influencing probiotic efficiency include the time of day they’re taken and the method of consumption.

For instance, some studies suggest that taking probiotics after meals might reduce their effectiveness due to the stomach’s acidic environment ⁴⁷.

However, the optimal time remains uncertain.

Furthermore, how probiotics are consumed—be it with a beverage, food, or on their own—may also influence their effect.

The matrix, or substance in which probiotics are delivered, varies from dairy products to capsules, which might affect their overall impact^{48 49}.

For example, while no significant difference was observed between yogurt and capsule-based probiotics, cheese as a probiotic delivery method seemed less effective ⁵⁰.

While probiotics show promise in treating constipation, more refined research is required.

Factors like the probiotic strain, dose, duration, time of intake, and delivery method all play a role in their efficacy.

As the scientific community delves deeper into this area, it is hoped that clearer guidelines will emerge, benefiting those seeking natural remedies for constipation.

Future randomized control trials (RCT) will be crucial in offering more definitive answers.

LEARN MORE:

Power of Prebiotics, Probiotics, and Synbiotics Against Constipation

Probiotics vs. Plant-Derived Products: A Battle for IBS-D Relief

How Fiber Prebiotics Can Combat Antibiotic-induced Gut Dysbiosis

Gut-Skin Axis: The Probiotic Connection You Need to Know

The Power of Synbiotics in Combatting Constipation

Synbiotics, a combination of probiotics and prebiotics, are defined as mixtures that bring health benefits to the host by utilizing specific live microorganisms and their preferred growth substrates⁵¹.

While research on synbiotics and constipation is limited compared to probiotics, with 10 human and 2 animal studies, certain trends emerge.

The predominant prebiotics in synbiotic products are inulin ^{52 53}, FOS⁵⁴, and psyllium ⁵⁵ .

Few of these products contained single probiotic strains like B. coagulant ⁵⁶ or B. animals ⁵⁷.

Findings show synbiotics can reduce Colonic Transit Time (CTT) ^{58 59}, enhance defecation frequency ⁶⁰, and better stool consistency ⁵⁴.

However, their impact on constipation symptoms, such as bloating and abdominal discomfort, remains debatable.

Consequently, further randomized control trials (RCTs) are essential to decipher synbiotics’ role in treating constipation.

Discussion

• Chronic Constipation (CC) Prevalence and Complexity:
  • Affects up to 14% of the global population with a higher incidence among women and the elderly.
  • Diagnosis requires multifaceted approaches, including the Rome Criteria and various assessment tools.
• Potential of Prebiotics:
  • Historically understood as non-digestible food ingredients, now redefined by the ISAPP.
  • Animal studies suggest benefits, especially in medium and high doses, but human studies present mixed results.
• Promising Findings on Probiotics:
  • While results are inconsistent due to varied methodologies, certain strains have shown potential benefits in human and animal studies.
  • Factors like strain type, dose, and consumption method influence probiotic efficiency.
• Synbiotics’ Emerging Role:
  • Combining probiotics and prebiotics, synbiotics are researched less but have presented potential in improving defecation frequency and stool consistency.
  • However, the impact on other symptoms like bloating and abdominal discomfort remains uncertain.

Conclusion

• Interplay of Prebiotics, Probiotics, and Synbiotics:
  • The research indicates a potential interplay where the combined use might present synergistic benefits for CC patients.
• Need for More Comprehensive Research:
  • Despite promising findings, there’s a clear need for more comprehensive, randomized control trials to establish definitive benefits and guidelines.
• Personalized Approaches:
  • Given the varied responses to treatments across individuals, personalized approaches considering factors like age, gender, and specific symptoms might be more effective.
• Natural Remedies Gaining Traction:
  • With increasing awareness and demand for natural remedies, the research into prebiotics, probiotics, and synbiotics is timely and essential.
• Final Takeaway:
  • While prebiotics, probiotics, and synbiotics present promising avenues for CC treatment, patients and practitioners should be cautious, awaiting more conclusive evidence before making them primary treatments.

Review date not set.