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Randomised clinical trial:ef?cacy of Lactobacillus paracasei-enriched artichokes in the treatment of patients with functional constipation–a double-blind,controlled,crossover study

G.Riezzo*,A.Orlando?,B.D’Attoma?,V.Guerra?,F.Valerio§,https://www.wendangku.net/doc/115267582.html,vermicocca§,S.De Candia§&F.Russo?,1

*Laboratory of Experimental Pathophysiology,I.R.C.C.S.“Saverio de Bellis”,National Institute of Digestive Diseases,Castellana Grotte,Bari,Italy.?Laboratory of Experimental Biochemistry,I.R.C.C.S.“Saverio de Bellis”,National Institute of Digestive Diseases,Castellana Grotte,Bari,Italy.?Laboratory of Epidemiology and Biostatistcs,I.R.C.C.S.“Saverio de Bellis”,National Institute of Digestive Diseases,Castellana Grotte,Bari,Italy.§Institute of Sciences of Food Production,National Research Council,Bari,Italy.

Correspondence to:

Dr F.Russo,Laboratory of Experimental Biochemistry,Scienti?c Institute for Digestive Diseases,I.R.C.

C.S.“Saverio de Bellis”,I-70013 Castellana G.,Bari,Italy.

E-mail:francesco.russo@irccsdebellis.it

1These authors contributed equally to this work.

Publication data

Submitted28April2011

First decision7June2011 Resubmitted12December2011 Accepted12December2011

EV Pub Online8January2012SUMMARY

Background

The role of probiotics in the management of constipation is uncertain. Aims

To evaluate the effects of probiotic-enriched artichokes on treatment prefer-ence,symptom pro?le and short-chain fatty acid(SCFA)production in constipated subjects when compared with ordinary artichokes.

Methods

Twenty constipated patients(3M/17F;38.8±14.4years)were studied using a double-blind method and a computer-generated randomisation list.Each patient consumed180g per day of ordinary artichokes or artichokes enriched with Lactobacillus paracasei IMPC2.1for15days(daily dose of291010 CFU).Relief of symptoms was evaluated using a visual analogue scale.The stool consistency and symptom pro?le of patients were investigated using the Bristol stool form chart and the Gastrointestinal Symptom Rating Scale questionnaire (GSRS).SCFA production in faecal samples was evaluated using HPLC. Results

Eighty per cent of patients preferred probiotic-enriched artichokes to ordinary ones(P=0.011).Satisfactory relief of symptoms was signi?cantly higher (P=0.0014)during the probiotic-enriched artichoke period.Bristol chart clus-ter scores were signi?cantly higher(3.3±1.2,2.9±1.32.2±1.2,baseline, ordinary artichokes and probiotic-enriched ones,respectively;P=0.009)and GSRS constipation was signi?cantly lower(13.9±0.9,10.2±0.8,8.3±0.9; P=0.032)in the probiotic group compared with the baseline.As for SCFA production,propionic acid was signi?cantly higher(2.2±1.4, 2.1±1.53, 1.5±1.2;P=0.035)in the probiotic group compared with baseline. Conclusion

This trial shows a positive effect on symptoms in constipated patients after intake of probiotic-enriched artichokes(clinical trial NCT01212146).

Aliment Pharmacol Ther2012;35:441–450

a2012Blackwell Publishing Ltd441 doi:10.1111/j.1365-2036.2011.04970.x

Alimentary Pharmacology and Therapeutics

INTRODUCTION

Functional constipation is a common problem in western societies and is characterised by abdominal discomfort or pain,abdominal distension,headache,dizziness and poor appetite,all symptoms that can interfere heavily with patient quality of life.1

Different therapeutic strategies have been proposed ranging from the use of various laxatives to stimulant cathartics,?bre and bulking agents.A new therapeutic approach for constipation could be based on the modu-lation of intestinal micro?ora by administering prebiotics and/or probiotics.2By de?nition,prebiotics,such as inu-lin-type fructans,are nondigestible substances that when consumed provide a bene?cial physiological effect on the host by selectively stimulating the growth or activity of a limited number of favourable indigenous bacteria in healthy volunteers.3,4Prebiotics are subjected to bacte-rial metabolism in the large intestine,where they are transformed to short-chain fatty acids(SCFAs).The three major SCFAs are acetate,propionate and butyrate, with the last supposed to be the major energy source for intestinal epithelial cells.5,6In particular,butyrate is important in maintaining gut integrity and may play a role in preventing the bacterial translocation that occurs in several gastrointestinal(GI)diseases.7As a result,pre-biotics may play an active role in treatment of constipa-tion,by stimulating colonic motility.2,8

According to FAO/WHO,probiotics are living micro-organisms,generally lactic acid bacteria(LAB)or bi?do-bacteria,which upon administration in adequate amounts confer a health bene?t on the host.9There is a great deal of evidence that probiotic bacteria supple-ments can modify,at least temporarily,the intestinal microbiota,10and recent studies indicate that they can be useful in different GI diseases such as diarrhoea,ulcera-tive colitis,pouchitis and irritable bowel syndrome (IBS).11,12

Probiotics and prebiotics are available commercially in many forms,including dietary supplements,clinical ther-apeutics with oral or non-oral delivery and,more inter-estingly,in foods.Currently,probiotic products are mainly incorporated in fermented milk-based products or concentrated probiotic preparations available as cap-sules,powders or liquids.To enlarge the range of choice and to exploit the nutritional qualities of plant matrices, an innovative line of probiotic vegetable products such as artichokes,olives and salads has been developed.13,14 It has been demonstrated that ingestion of a portion of these vegetables results in the ingestion of more than one billion live cells of the probiotic Lactobacillus paracasei strain IMPC2.1(LMGP22043).These amounts are comparable to or higher than those of milk-based probiotic products available in the market.15,16Among available vegetables,the artichoke(Cynara scolymus L.), a member of the daisy family,has been used traditionally in Europe to improve digestive and urinary tract health, and recent studies have also demonstrated its ef?cacy in both dyspepsia17and IBS.18These vegetables possess the features of prebiotics due to their high content of inulin-type fructan(approximately50–70g per kg).In such a way,probiotic-enriched artichokes can be considered as real symbiotics.

Recently,a pilot study carried out on constipated vol-unteers fed probiotic artichokes demonstrated the ability of the L.paracasei IMPC2.1to colonise the gut of all patients and indicated the potential of this symbiotic food to ameliorate constipation symptoms.19

Against this background,the aim of the present randomised double-blind controlled crossover study was to compare the effects of a15-day consumption of arti-chokes enriched with the probiotic Lactobacillus paracasei IMPC2.1(LMGP22043)with those of ordinary arti-chokes on treatment preference,on satisfactory relief of symptoms,bowel habit and the modulation of SCFA production in a group of patients suffering from func-tional constipation.

PATIENTS AND METHODS

Participants

Patients were recruited from the out-patients of the Lab-oratories of Experimental Biochemistry and Pathophysi-ology of the National Institute of Digestive Diseases,I.R.

C.C.S.‘Saverio de Bellis’,Castellana G.(Italy).They were screened by one of the investigators(G.R.)and recruited according to the inclusion criteria and their willingness to participate.

The inclusion criteria were as follows:ful?lment of the Rome Criteria III for constipation20and Constipation Scoring System(CSS);21availability of at least one GI imaging study during the last5years(colonoscopy,sig-moidoscopy,abdominal ultrasound,barium enema);aged 19–70years at the time of screening;and commitment to availability for the whole study period.Exclusion cri-teria were as follows:major abdominal surgery;the pres-ence of any concomitant diseases such as organic GI diseases,including lactose and gluten intolerance;medi-cal or psychiatric illness;alarming symptoms(rectal bleeding,weight loss,etc.);family history of peptic ulcer, colorectal cancer,or IBD;and abnormal laboratory data

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or thyroid function tests.Other tests to con?rm the diag-nosis were performed at the physicians’discretion. Pregnant and breast-feeding women and patients with major psychiatric,mental or behavioural disorders, coexisting GI and other disorders that might in?uence the symptoms or poor knowledge of language were excluded,as were those who had used probiotics more than once a week in the previous3weeks or antibiotics or laxatives in the previous5weeks.

The study was performed in accordance with the Hel-sinki Declaration,and all participants gave written informed consent to participate before enrolment.The protocol was approved by the local Scienti?c and Ethics Committees,and the study was registered at https://www.wendangku.net/doc/115267582.html,,registration number:NCT01212146.

Study design

The study was a randomised double-blind,controlled, crossover trial with a1-week run-in period(Period1) followed by randomisation and two15-daytreatment periods(Periods2and4)separated by a4-week washout period(Period3)(Figure1).During periods2and4,the patients were instructed to consume180g per day of probiotic-enriched artichokes or ordinary ones.

A total of?ve visits were scheduled:visit no.1took place before the start of the study(clinical examination and run-in),visit no.2involved randomisation and commencement of the intervention diet,and visits nos.3–5were scheduled at the end of the?rst treatment per-iod and at the beginning and the end of the second treatment period.The participants were instructed not to change their eating habits throughout the entire study period.

All data were collected at I.R.C.C.S.‘S.de Bellis’Cas-tellana G.(Bari),Italy.The random allocation sequence was generated by means of a software package at the Laboratory of Epidemiology and Biostatistic of I.R.C.C.S.‘S.de Bellis’Castellana G.(Bari),Italy.Random alloca-tion was balanced in block with a block size of4and a numerical sequence code.Participants with satisfactory relief of symptoms in the run-in period were excluded from further participation.

During the study,participants complemented their usual lifestyles and dietary intakes with probiotic arti-chokes or ordinary artichokes supplied by Copaim Spa (Albinia,Italy).Probiotic artichokes were prepared as reported in the patented procedure by Lavermicocca et al.14This product,authorised for commercialisation

Period 1 Run in

Period 2

Treatment 1

Period 4

Treatment 2

Period 3

Wash out

1 week 4 weeks

15 days15 days

Daily intake of 180 g of artichokes enriched with L.paracasei (2x1010 CFU)

Daily intake of 180 g of ordinary artichokes

Recruitment

Clinical examination and stool sampling

Figure1|Design of the study.

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Randomised clinical trial:probiotic-enriched artichokes in functional constipation

by the Italian Ministry of Health,contained approxi-mately1.209108CFU of live probiotic cells of Lacto-bacillus paracasei IMPC 2.1(LMGP22043)per gram, which resulted in a daily dose of about291010CFU. Viable counts of the probiotic bacteria in the vegetable product were monitored throughout the study as previ-ously reported.16

Ordinary and probiotic artichokes were both lightly seasoned with olive oil and packed in identical trays with modi?ed atmosphere to obtain ready-to-eat artichoke products(about180g).Final products had identical shape,texture and appearance,and there was no way to distinguish between the two products.The participants and health care providers were blinded until data entry was complete.

Symptom assessment

Patients were evaluated with the Gastrointestinal Symp-tom Rating Scale(GSRS),a validated questionnaire for GI symptoms.22GSRS utilises a seven-level Likert scale (1–7),depending on intensity and frequency of GI symp-toms experienced during the previous week.A higher score indicates mainly inconvenient https://www.wendangku.net/doc/115267582.html,bi-nation scores among the questions can assess the follow-ing?ve domains:‘re?ux syndrome’(halitosis,heartburn, dysphagia and acid regurgitation:max.score:28),‘abdominal pain’(pain referred as epigastric,colic,con-tinuous or inde?nite pain,gastric hunger pains and nau-sea:max.score:42),‘indigestion syndrome’(postprandial fullness,early satiety,borborygmi,bloating,eructation/ belching and increased?atus,max.score:42),‘diarrhoea syndrome’(increased frequency of evacuation,loose stools and urgent need to defecate,max.score:21),and ‘constipation syndrome’(reduced frequency of evacua-tion,hard stools and feeling of incomplete evacuation, max.score:21).Maximal achievable score was154.

The stool consistency was investigated using the Bristol stool form chart.23Constipation was also self-evaluated by patients during the whole study period using a diary where the patients indicated the time of bowel movements,sense of incomplete evacuation(yes/ no),straining at defecation(yes/no),number of ineffec-tive defecation attempts,help for defecation(laxatives, suppositories,enema,digitations),associated GI symp-toms(mild,moderate,severe)and impairment of daily activities.

The participants were then asked about treatment preference(the period they preferred in terms of patient’s subjective judgement)at the last visit before the un-blinding of treatment allocation by answering to the question:‘Which treatment period(period1,period2, or no preference)did you prefer in the management of your constipation concerning the stool consistency,?atu-lence and bloating?’.Possible answers were:the treat-ment1was better than treatment2;treatment2was better than treatment1;treatment1was equal to treat-ment2.Besides,the satisfactory relief of symptoms at the end of the run-in and washout periods and at the end of each treatment periods was assessed using a visual analogue scale(VAS)with grades from0(no relief)to 100(best imaginable relief of symptoms). Radiological evaluation

Before starting the study,all participants underwent the colonic transit time(CTT)examination by means of radiopaque pellets.The measurement of colonic transit time with radio-opaque markers is a simple technique that enables the objective detection of the different groups of patients with chronic idiopathic constipation. The3-day method for conducting CTT was per-formed.In this method,the patient was required to ingest20radiographic markers at a speci?c time(usually at12:00pm).A plain abdominal X-ray was then per-formed after72h.The patients were instructed not to take any form of medication or laxative that would affect bowel motility.A delayed transit time was diagnosed if the numbers of markers was more than40%(eight or more markers).24

Faecal SCFA evaluation

Faecal samples were collected at the end of the run-in and washout periods,and at the end of each treatment period.

Fresh faecal samples(about1g each)provided from each patient were placed in a sterile plastic box and fro-zen atà20°C for analysis of SCFAs.To detect the pres-ence of L.paracasei IMPC2.1in the faecal samples, bacterial DNA was isolated from colonies grown on MRS plates,and PCR reactions were performed(data not shown).

Frozen faecal samples were prepared as described by Chen and Lifschltz.25The frozen samples were thawed, and~1g was homogenised for2min in10mL of 0.15mmol H2SO4in Milli-Q-puri?ed water using a Stomacher(Seward,London,UK).A5mL portion of the homogenate was centrifuged at90009g,2°C for 20min.The supernatant?uid was then?ltered through a micro-concentrator(Ultracel-3k,Amicon,Danvers, MA,USA)with a molecular-mass cut-off of3000Da,by centrifugation(70009g,2°C,1h).Another?ltration

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was then done through a0.22-l m?lter unit(Millipore, Bedford,MA,USA)to remove bacterial cells.SCFAs were separated as recently described21with slight modi?-cations.Brie?y,SCFAs were separated on an HPLC sys-tem(AKTABasic10,P-900series pump,Amersham Biosciences AB,Uppsala,Sweden)using Rezex ROA-organic acid H+(8%)(7.809300mm,Phenomenex, Torrance,CA,USA)and a three-channel UV detector (Amersham Biosciences900)set at210nm.The mobile phase was0.005mol/L H2SO4(Fluka,Deisenhofen, Germany)pumped at a?ow rate of0.6mL/min through the column heated to70°C.SCFA amounts were deter-mined by integrating calibration curves obtained from standards and expressed as l mol/g of faecal sample. Quanti?cation limits(LOQ)of acetate,propionate,buty-rate,valerate and isovalerate were 1.825,0.147,0.380, 0.463and0.368l mol/g respectively.

Study outcomes

The primary outcome measure was treatment preference. Secondary outcomes were the score of satisfactory relief of symptoms recorded using VAS,the stool consistency recorded by the Bristol stool chart,the constipation symptom pro?le by the GSRS sum score,and modula-tion of SCFA production in faecal samples.All compari-sons were(i)between treatment with probiotic-enriched artichokes and ordinary artichokes and(ii)between treatments and baseline.Adverse events were noted. Reasons for study discontinuation

Reasons for study discontinuation were recorded in the case report form and could include one of the following categories:death,adverse event(speci?ed),insuf?cient response,patient asymptomatic/cured,ineligible to con-tinue the study,lost to follow-up,withdrew consent, noncompliant and other(including administrative clo-sure of trial).

Statistics

The sample size was calculated on the assumption that the preference of probiotic-enriched artichoke treatment would be declared by80%of the patients vs.20%of patients preferring the ordinary artichoke treatment.It was calculated that,with the power of80%and at a sig-ni?cance level of0.05,the difference between the groups would be statistically signi?cant with20patients per group.Altogether,30patients were recruited to allow for possible drop-outs.

Visual analogue scale values for satisfactory relief of symptoms were categorised in four classes:0–25:no or poor relief of symptoms,26–50:moderate relief of symp-toms;51–75:good relief of symptoms;and76–100:very good relief of symptoms.The difference between treat-ment periods with regard to number of patients with sat-isfactory relief of symptoms from no or poor to very good relief was tested with the marginal homogeneity test for matched ordinal variables.

The Friedman repeated measures analysis of variance on ranks was used to compare the effects of the two dietary treatments on clinical and biochemical parameters.As the sample size was small,the exact procedure for nonpara-metric test was applied.When a difference was found,non-parametric multiple comparisons were performed(Dunn’s post-test)to determine the groups between which there was a signi?cant difference.Two-sided P values<0.05were considered statistically signi?cant,and the95%con?dence interval(CI)was calculated for the main outcomes.Modi-?ed intention-to-treat analysis was performed.

To avoid the assumption of normal distribution,non-parametric tests were performed using a speci?c software package(StataCorp.2005;Stata Statistical Software: Release9,College Station,TX,USA).The con?dence interval and P value for treatment preference were calcu-lated using the Wilson(score)method.All results are given as Mean±Standard Deviation.

RESULTS

Thirty participants were included between September and December2010.Figure2shows the?ow of partici-pants through the trial.

Twenty participants(3men and17women)with a mean age of38.8±14.4years and BMI24±2kg/m2 were available for analysis.The GSRS sum score at run-in was46.7±13.5,and the duration of symptoms was 5±3years.The CTT was9.6±8.7.

Five participants that were lost to follow-up were not included in the modi?ed intention-to-treat analyses:four participants withdrew consent and one moved to another town.No adverse events were noted during the study period.

Sixteen participants preferred probiotic-enriched arti-chokes to ordinary artichokes treatment;four patients preferred control artichokes;and no patient declared no preference(80%vs.20%,CI58–92%;P=0.011respec-tively).Compliance with intake of artichokes was95%. The difference between treatment periods with regard to number of patients with satisfactory relief of symp-toms,was signi?cantly higher(P=0.0014)in the probiotic-enriched artichokes period compared with the ordinary artichokes period(Table1).

Aliment Pharmacol Ther2012;35:441-450445a2012Blackwell Publishing Ltd

Randomised clinical trial:probiotic-enriched artichokes in functional constipation

Figure 3reports the Bristol score at baseline and dur-ing consumption of the study diets.The Friedman repeated measures analysis of variance on ranks found

statistically signi ?cant differences in the Bristol score,which was higher in the probiotic-enriched artichoke group compared with the ordinary artichoke group and the baseline (3.3±1.2,2.9±1.3,and 2.2±1.2respec-tively;P =0.009).The all-pairwise multiple comparison

Included in the run-in period (n = 30)

Excluded (n = 5)

Not meeting inclusion criteria (n = 3)Withdrew consent (n = 1)Other (n = 1)

Randomized (n = 25)

Lactobacillus paracasei enriched artichokes given in the 1st treatment period (n = 13)

Allocation

Follow-up

Ordinary artichokes given in the 1st treatment period (n = 13)

Lost in follow up Withdrew consent (n = 2)

Analyzed (n = 10)

Analysis

Lost in follow up Withdrew consent (n = 2)Unable to contact (n = 1)

Analyzed (n = 10)Figure 2|Flow chart of the participants through the trial.

Table 1|Number of subjects with no/poor,moderate,good and very good satisfactory relief of symptoms in the two treatment periods

Subjects in the enriched artichoke group No/Poor Moderate Good Very good

T otal Subjects in the ordinary artichoke group

No/Poor 3312

9Moderate 11125Good 00112Very good 00224T otal 445

7

20

Visual analogue scale values for satisfactory relief of symp-toms (from 0to 100)were categorised in four classes:0–25:no or poor relief of symptoms,26–50:moderate relief of symptoms;51–75:good relief of symptoms;76–100.The differ-ence in favour of probiotic-enriched artichoke was statistically signi ?cant (P =0.0014).

Bristol Score

P = 0.009

6

4

2

Baseline

Control

Probiotic

a

ab

b

Figure 3|The plot representing stool consistency evaluated using Bristol score after the diet and expressed as mean with s.d.Statistical evaluations were performed using the Friedman one way repeated measures analysis of variance and Dunn ’s multiple comparison tests.For each column,values not sharing a common superscript differ signi ?cantly (P <0.05).

446

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G.Riezzo et al.

post-test assessed the signi ?cance of differences between the probiotic-enriched artichoke diet vs.baseline (P <0.05).This evidence represents an improvement in the stool consistency evaluated by Bristol score after the diet.

Symptom pro ?les showed statistically signi ?cant dif-ferences between baseline,control and probiotic-enriched artichoke diets were found in GSRS constipation cluster score (13.9±0.9,10.2±0.88.3±0.9respectively;P =0.032),as well in its single items,namely ‘reduced frequency of evacuation ’(4.0±0.3,3.2±0.4.2.5±0.5respectively P =0.005),‘hard stools ’(4.6±0.5,2.7±0.3,2.4±0.3respectively P =0.0258)and ‘feeling of incomplete evacuation ’(5.3±0.3,4.2±0.5.3.3±0.4respectively P =0.0037)(data analysed using Friedman repeated measures analysis of variance).The all-pairwise multiple comparison post-test assessed the signi ?cance of differences (P <0.05)between the probiotic-enriched artichoke diet vs.baseline.

Figure 4shows GSRS constipation cluster scores dur-ing the trial by allocation group.When taking into account the ordering of the treatments (control or probi-otic ?rst),there were no signi ?cant differences between the groups with regard to GSRS constipation cluster scores registered at the beginning of the second treat-ment period (after the wash out).Besides,score values were not signi ?cantly different compared with baseline values.

With regard to the presence of L.paracasei IMPC2.1in the faecal samples,the strain was detected in the patients receiving the probiotic-enriched artichokes at the end of the study period,whereas,it was not recov-ered in faecal samples at baseline and after wash out (data not shown).

Table 2summarises data regarding SCFA production from all patients.In general,SCFA were produced with acetic acid being found at higher levels throughout the study.Propionic,butyric and isovaleric acids increased slightly in both the probiotic and the ordinary artichoke group when compared with baseline values.In particular,the Friedman repeated measures analysis of variance on ranks showed statistically signi ?cant differences in the values for propionic acid,which were higher in the pro-biotic-enriched artichoke group compared with the base-line and ordinary artichoke group (2.2±1.4,2.1±1.53,1.5±1.2respectively P =0.035).The all-pairwise multi-ple comparison post-test assessed the signi ?cance of dif-ferences (P <0.05)between the probiotic-enriched artichoke diet vs.baseline.In contrast,a slight and not signi ?cant decrease in acetic acid was registered in the probiotic group.Finally,the total concentration of SCFA also increased in the probiotic group compared with the other two groups,although without reaching statistical signi ?cance.

DISCUSSION

In the present study,we compared the effects of Lacto-bacillus paracasei-enriched artichokes with ordinary arti-chokes in constipated patients selected according to the Rome III criteria.At the end of the study,80%of patients preferred probiotic-enriched artichokes to ordin-ary ones.For symptom pro ?le,satisfactory relief of symptoms was signi ?cantly higher during the probiotic-enriched artichoke period.In addition,signi ?cant increases in Bristol score,along with signi ?cant reduc-tions in GSRS constipation cluster score and in its single

25

20

15

10

5

Baseline

Period 1Wash-out Period 2

B1

A1

B2

A2Probiotic first Placebo first

C o n s t i p a t i o n c l u s t e r s c o r e

Figure 4|Gastrointestinal Symptom Rating Scale

constipation cluster score during the trial by allocation group.The results are given as mean with s.d.

Table 2|Concentrations of short-chain fatty acids (SCFAs)in faecal samples

Baseline

Control Probiotic P Acetic 10,42±5.4110.82±6.9310.94±7.04N.S.Propionic 1.53±1.24a 2.08±1.53ab 2.20±1.36b 0.035Butyric 0.77±0.49 1.02±0.60 1.20±0.79N.S.Isovaleric 0.56±0.380.53±0.180.62±0.33N.S.Valeric 2.09±2.580.86±0.52 1.16±0.98N.S.T otal

13.76±7.58

15.19±7.76

15.66±8.71

N.S.

Data (l mol/g of faeces)are reported as mean ±s.d.Statistical evaluations were performed using the Friedman one way repeated measures analysis of variance and Dunn ’s multiple comparison test.For each row,values not sharing a common superscript differ signi ?cantly (P <0.05).

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items(frequency of evacuation,hard stools and feeling of incomplete evacuation),were observed.

The primary goal in the treatment of constipation is to improve the patient’s quality of life by relieving symp-toms and normalising GI motility.

Nearly one-half of constipated patients are unsatis?ed with their treatment,mostly because they consider it unsuccessful.26Currently,the dietary management of constipation is commonly begun by increasing the intake of?bre,27especially soluble?bres.28A daily intake of 25g of?bre seems to be effective26although,in spite of the wide use of?bre supplementation for treatment of constipation,evidence from clinical trials of the real ef?-cacy in chronic constipation is limited.Another thera-peutic nonpharmacological option for treating constipation is represented by the use of probiotics. There are several reasons why probiotics might have therapeutic potential for the treatment of this disorder. First,differences in the intestinal microbiota between healthy individuals and patients with chronic constipa-tion have been recorded.

Secondly,studies involving the administration of some particular probiotics(e.g. https://www.wendangku.net/doc/115267582.html,ctis DN-173010)have shown improved colonic transit times in both a healthy population29and constipated patients.30Finally,probiot-ics alone or in combination with prebiotics,are able to lower the intracolonic pH,mainly as a direct conse-quence of bacterial SCFA production.In turn,a lower pH enhances peristalsis in the colon and might subse-quently decrease the colonic transit time.31However,in this?eld,there are also a few well-planned investigations showing signi?cant bene?cial effects on IBS32or chronic constipation.28

A variety of factors,including bacterial strain,treat-ment duration,form of administration and dose may affect therapeutic outcome in the management of consti-pation when administering probiotics.All of the above items are extremely important,as they can heavily affect probiotic treatments in terms of customer satisfaction, costs and above all,therapeutic outcomes.

One of the?rst questions that need to be answered is the duration of administration.As reported in literature, the duration of probiotic administration generally varies from2–6weeks or even more,at least in IBS patients.33 Naturally,administration for longer periods of time could heavily in?uence patient compliance,and thus shorter periods of treatment should be more attractive. In the present study,administration of Lactobacillus paracasei-enriched artichokes was limited to15days and none of the patients complained of side effects,showing a good compliance with treatment.With regard to the symptom pro?le,Lactobacillus paracasei-enriched arti-choke consumption alleviated constipation by easing def-ecation and softening faeces.It also resulted in an average increase in bowel movements per week.This result is generally achieved by faecal mass-increasing lax-atives,although,according to the clinical history of our patients,laxatives had previously been demonstrated not to be effective in relieving their constipation.

Another issue is the appropriate means of administer-ing probiotics.At present,probiotics can be administered in the form of capsules or sachets,or,more interestingly, can be added to the food supply.Some data show that adequate colonisation may be achieved at a lower dose, if probiotics are administered in food(usually a dairy product).34This may not always represent the best way to administer probiotics for therapeutic purposes. Beyond the limitation for those patients who suffer from lactose intolerance or do not wish to drink milk deri-vates,it has been found that the addition of probiotic bacteria to yoghurt after the fermentation process causes the counts to decrease signi?cantly during the storage period.An alternative appealing possibility is the use of those vegetables in which the live probiotic strains can take advantage of some peculiar feature for growth and improved survival.3Artichokes,in particular,with their high content of inulin-type fructans,have already been proven to be a reliable vehicle for carrying probiotics, allowing the ingestion of more than one billion live cells of a probiotic Lactobacillus paracasei strain.16These veg-etables can therefore work as valid‘active’vehicles for the transport and release of adequate amounts of bacte-rial populations.However,in opposition with other pro-biotic formulations(such as tablets,caps etc.)that can be administered for long periods of time,treatments with probiotic-enriched vegetables must be necessarily short because of a consequential lack of variety in the daily diet.

Recently,our group conducted a pretest/post-test study design by administering Lactobacillus paracasei-enriched artichokes to a small number of constipated patients.19The results clearly showed that this probiotic strain transiently colonised the gut of all patients after the test period(15days),resulting in a modulation of micro?ora,mainly at individual level.In particular,a slight decrease in potentially harmful bacteria(Entero-bacteriaceae,Clostridium)with a concomitant increase in total anaerobes and LAB population was observed.In addition,some SCFAs(namely,butyric and valeric) increased signi?cantly at the end of the test period.In

448Aliment Pharmacol Ther2012;35:441-450

a2012Blackwell Publishing Ltd G.Riezzo et al.

this connection,prebiotics and probiotics generally also in?uence faecal biochemical parameters such as SCFA production.These acids are implicated in colonic physi-ology and,of these,butyrate arising from microbial fer-mentation is important for the energy metabolism and normal development of colonic epithelial cells and has a mainly protective role in relation to colonic diseases.7It is noteworthy that in the present study,a general increase in SCFAs production was registered in the pro-biotic-enriched artichoke group and,in particular,a sig-ni?cant increase in the faecal amount of propionic acid was observed.Interestingly,the concomitant reduction of acetic acid and increase of butyric acid observed in the probiotic-artichoke group could be related to the conver-sion of acetate to butyrate by intestinal microorganisms, even if a considerable part of SCFAs could also be absorbed from the human colon.5

Taking into account the limitation of any study tack-ling the issue of treating a chronic constipation popula-tion,it would appear that the consumption of a symbiotic food such as probiotic artichokes can result in a useful and safe tool for managing constipation.How-ever,compared with other similar investigations,35,36 our study was carried out with a stricter clinical selec-tion,which excluded concomitant lactose intolerance for a short time period.

In this study,a signi?cant improvement in total and single items GSRS scores,as well as in the Bristol score was observed.In particular,the Bristol score showed a small but clinically relevant https://www.wendangku.net/doc/115267582.html,e of the Bristol Stool Scale can offer patients a visual and numeric refer-ence,and caretakers a rough estimate of stool consis-tency.Low scale numbers(#1,2)mean harder stool, whereas higher values(#3,4)support a normal stool con-sistency.Therefore,a little improvement in the Bristol values from2to3may represent a signi?cant improve-ment in the clinical condition of these patients.23

The intervention with probiotics was limited to 15days.Undoubtedly,a longer period of intervention would have strengthened the internal validity,but increased the drop-out rates.The use of a cross-over design provided some practical advantages as the study was performed mainly by evaluating subjective outcomes. Therefore,the between-patient variations could be effec-tively reduced along with a lower number of patients compared with that requested in a parallel group study design.For ethical reasons,the number of participants and the study period should be reduced as much as pos-sible in a phase II study like this one.The design was?t-ted for stable chronic diseases.37

Both the primary outcome(treatment preference)and the secondary outcomes(satisfactory relief of symptoms, stool consistency and constipation symptom pro?le) showed the same positive result for treatment with pro-biotics.This strengthens the internal validity,but a type I error cannot be excluded.Overall,it could be assumed from these results that some selected constipated patients could receive substantial bene?t from symbiotics,but the treatment may need to be tentatively given on a cyclical schedule,because of the temporary modi?cation of the faecal?ora.Present preliminary results allow us to sup-pose that the introduction of some vegetables enriched with probiotics such as artichokes,but also salads and olives,could increase the choices for patients/consumers on a modi?ed dietary regimen by contemporarily ampli-fying therapeutic effects in a synergistic manner. ACKNOWLEDGEMENTS

The authors thank Prof B.I.Carr for his help in the English language revision of the manuscript.Declaration of personal interests:None.Declaration of funding inter-ests:This study was funded in part by Copaim(Albinia, GR,Italy),grant no.271,May28,2009.This trial is registered with https://www.wendangku.net/doc/115267582.html,,number NCT01212146.

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