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The Role of Psyllium Fibre Supplementation
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In Treating Irritable Bowel Syndrome
LAURA E. CHOUINARD, BASc, RD, Department of Family Relations and Applied Nutrition,
University of Guelph, Guelph, ON
ABSTRACT
North American family physicians and dietitians commonly
recommend psyllium fibre supplementation for treating
symptoms of irritable bowel syndrome (IBS). In this review,
evidence on the effectiveness of psyllium supplementation for
diagnosed IBS symptoms was evaluated and summarized. A
systematic search of MEDLINE, CINAHL, and Web of Science was
conducted. Included were full-length, peer-reviewed, English-
language articles in which psyllium ingestion was tested for its
For personal use only.
effect on IBS symptoms. Quality of these articles also was
assessed. Twelve met the criteria for complete data abstraction.
Seventy-five percent of the studies examined were of weak
quality. Study designs and methods were heterogeneous.
Patient-perceived global symptoms improved significantly in six
of the nine studies measuring a global symptom outcome. In
one study, significant improvements occurred in reported
abdominal pain; in three, improvement did not occur. Quality of
life and flatulence did not improve significantly in any studies in
which these outcomes were examined. The results of this
systematic review indicate limited and conflicting evidence to
support the recommendation of psyllium supplementation for
symptomatic IBS treatment.
(Can J Diet Pract Res. 2011;72:48)
(DOI: 10.3148/72.1.2011.48)
Introduction
Irritable bowel syndrome (IBS) is a common gastrointestinal
disorder characterized by recurrent abdominal pain, bloating,
distension, cramping, constipation and/or diarrhea, and flatu-
lence (1). Diagnosis of IBS can be difficult as no biochemical,
structural, or physiological abnormalities are consistently dem-
Résumé
Il demeure assez courant pour les médecins de famille et
les diététistes de l’Amérique du Nord de recommander une
supplémentation en fibres de psyllium pour le traitement des
symptômes du syndrome du côlon irritable (SCI). L’objectif de
cette revue était d’évaluer et de résumer l’état des données
probantes relativement à l’efficacité d’une supplémentation
en psyllium sur les symptômes du SCI chez les personnes en
ayant reçu le diagnostic. Une recherche systématique dans
MEDLINE, CINAHL et Web of Science a été menée. Les articles
intégraux, en langue anglaise et révisés par des pairs ont été
inclus lorsque l’ingestion de psyllium était évaluée afin de
déterminer ses effets sur les symptômes du SCI. Une évaluation
de la qualité des articles satisfaisant aux critères ci-dessus a
été effectuée. Douze articles satisfaisaient aux critères pour une
abstraction complète des données. Soixante-quinze pour cent
des études évaluées étaient de faible qualité. De plus, les plans
et méthodologies des études étaient hétérogènes. Une amé-
lioration globale significative de l’amélioration des symptômes
perçus par les patients a été notée dans six des neuf études
mesurant un résultat relatif aux symptômes globaux. Une étude
a rapporté des améliorations significatives quant à la douleur
abdominale rapportée, tandis que trois n’ont pas fait men-
tion de ce type d’amélioration. Dans les études examinant ces
résultats, aucune amélioration significative n’a été rapportée
en matière de qualité de vie et de flatulences. Les résultats de
cette revue systématique indiquent qu’une quantité limitée de
données probantes contradictoires soutiennent la recomman-
dation d’une supplémentation en psyllium pour le traitement
des symptômes du SCI.
(Rev can prat rech diétét. 2011;72:48)
(DOI: 10.3148/72.1.2011.48)
onstrated in IBS patients. Thus the diagnosis of IBS is symptom-
based and unstandardized. As there is no standardization of di-
agnostic criteria, prevalence estimates vary from 3% to 20% of
the population (2-6). Most estimates, however, suggest a 10% to
15% prevalence.
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Dietary advice is often given for IBS management, and most
family physicians recommend an increase in total dietary fibre
intake, usually in the form of insoluble fibres such as bran (7).
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This is surprising, given the limited evidence for the role of in-
soluble fibre in alleviating IBS symptoms. Insoluble fibre under-
goes minimal change in the digestive tract and increases fecal
mass. A systematic review of 17 clinical trials of patients with
IBS indicated that insoluble fibre not only generally confers no
benefit but, in many cases, may worsen IBS symptoms (8). In
contrast, soluble fibre dissolves in water and forms a gel; it is
fermented by colonic bacteria, forming short-chain fatty acids
and gas, both of which may decrease gut transit time. Shortened
transit time may alleviate constipation and associated pain.
Psyllium fibre (also referred to as ispaghula) is derived from the
husks of the seeds of Plantago ovata, and is one such soluble fi-
bre (9). Approximately 50% of IBS patients receive some form
of drug treatment, which often includes psyllium fibre supple-
mentation (10).
While pooled results of studies examining the effectiveness
of soluble fibres (including psyllium) reveal an overall improve-
ment in global symptom indices (8), most have severe meth-
odological limitations such as inadequate outcome assessment
tools or lack of placebo controls. Despite a lack of good quality
evidence, recommendation of psyllium-based bulk laxatives re-
For personal use only.
mains quite common and is even indicated for constipation- or
diarrhea-predominant IBS in the most recent clinical practice
guidelines for Canadian dietitians (11). Recently, interest has
been renewed in re-examining the role of soluble fibres such
as psyllium in a primary care setting (as this is where most IBS
patients are treated); this group, specifically, may benefit more
from fibre therapy than do patients traditionally recruited for
clinical trials (12-14).
PURPOSE
While a number of general and systematic reviews have been
conducted on the role of different types of fibre in IBS symp-
toms (8,15,16), none has focused exclusively on the role of psyl-
lium fibre; nor has any review included the more recent studies
on primary care patients with IBS. In this paper, evidence sup-
porting the effectiveness of psyllium fibre supplementation on
symptoms in diagnosed IBS is evaluated and summarized.
METHODS
As much as possible, guidelines for reporting systematic reviews
of intervention studies were followed (17).
Search strategy
A systematic search of published literature was developed, using
both free text and/or MeSH terms. The exposure terms searched
were “psyllium,” “ispaghula,” or “Plantago ovata,” combined with
“irritable bowel” or “irritable bowel syndrome.” The computer-
ized databases MEDLINE, CINAHL, and Web of Science were
searched with no limit on publication dates. Searches took place
from September 14 to October 7, 2009. Titles and available ab-
stracts were scanned for relevance, and articles requiring further
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consideration were identified. Reference lists of relevant articles,
as well as review articles, were hand searched to identify addi-
tional publications.
Selection criteria and data extraction
Full-length, English-language primary studies in peer-reviewed
journals were included when psyllium ingestion had been tested
for its effect on IBS symptoms. Study subjects were required to
have been diagnosed with pre-existing IBS by any criteria, but
the IBS could not be medication-induced for the purposes of the
study. Medication trials were included as long as they contained
analyses of psyllium ingestion effects, independent of the medi-
cation. All study designs were considered. All searching and data
extraction were conducted by the author.
Study quality
Each study was graded for quality, using the Quality Assessment
Tool for Quantitative Studies developed by the Effective Pub-
lic Health Practice Project team (17). This tool is used to assess
quality of published quantitative studies on the basis of sample
selection methods, study design, control for confounders, blind-
ing, data collection, and withdrawals and dropouts. Studies are
ranked as weak, moderate, or strong, according to these criteria.
Primary outcome measures were also identified, and clinical/
statistical significance was noted when possible, as was whether
intention-to-treat analysis was used.
RESULTS
Overview of studies identified
The search strategy yielded 144 published articles. Of these, cop-
ies of 56 full articles were obtained for review, and after scrutiny,
12 met the criteria for complete data abstraction. An additional
article was identified through hand search of reference lists and
was eligible for data abstraction. A total of 12 articles met all
eligibility criteria and were included in this review. Figure 1 out-
lines the study selection process in detail. Quality assessment
classified one study as “strong” (8%), two as “moderate” (17%),
and nine as “weak” (75%). Many studies classified as weak did
not describe their blinding, the control of confounders, or the
reliability and/or validity of data-collection tools.
No Canadian studies were located. One study was completed
in the United States (18), and the others were conducted in Eu-
rope and India. Study designs were heterogeneous. Duration of
the studies ranged from four to 12 weeks. Study subjects’ char-
acteristics varied considerably; subject age in one study ranged
from 14 to 82 years (19), and sex distribution of the subjects
ranged from zero to 90% female. Some articles did not provide
demographics for the subjects (18,20,21). Of the 11 studies us-
ing a controlled design (randomized, controlled trial or clinical
controlled trial), four failed to describe the control substance,
four failed to report the dose of psyllium that would be tested,
and one failed to report the form of psyllium administered. Of
the studies describing the amount of psyllium tested, adminis-
tered amounts ranged from as little as 7 g per day to as much as
30 g per day.
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Figure 1
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Study selection process for systematic review of the effect of psyllium fibre supplementation on
irritable bowel syndrome symptoms

Key terms searched Excluded

n=144 n=88
Review articles 30
Not peer reviewed 10
Subjects not diagnosed
with irritable bowel
syndrome (IBS) 25
Psyllium not tested as a

Articles requiring full treatment 12

Additional studies
identified by hand text review Article not in English 6
review of reference lists n=57 Medication-induced IBS 5
n=1
For personal use only.

Excluded
n=45
Articles meeting criteria No report of effectiveness
for complete data of psyllium independent of
abstraction medication 1
n=12 Not primary sources 2
Duplication 41
Published as abstract only 1

Study outcomes Three of the 12 studies (25%) showed no benefit of psyllium

Table 1 details interventions and outcomes (14,18,19-28). In nine
(75%) studies, patient-perceived symptom improvement was
measured (14,19-23,26-28), while in two (17%), quality-of-life
outcomes were examined (14,18). In six (50%), improvements in
specific symptoms such as abdominal pain, gas, or bowel actions
were investigated (14,18,24,25,28). In several studies, objective
measures were used alone or in combination with the measures
above. Physician assessment was performed in one study (8%)
(24), gut transit time was measured in two studies (17%)(21,22),
and stool weight was measured in one (8%)(21).
Numbers of subjects completing the studies ranged from 10
to 168 over the 12 studies. The mean number of subjects per
study was 82.3.
administration for any outcomes measured (18,25,29). In six of
the nine studies measuring a global symptom outcome, patient-
perceived global symptoms improved significantly (p<0.05) with
psyllium ingestion (14,19,20,22,23,26). One study indicated sig-
nificant improvements in reported abdominal pain (24), while
three did not (14,18,22). Quality of life and flatulence symptoms
did not improve in any of the studies in which those outcomes
were examined specifically. Bowel movement characteristics and
subjective bowel function improved significantly in three studies
(25%) and not in one (8%)(18). Gut transit time was not im-
proved significantly in either study in which it was measured. Of
the studies classified as being of “strong” or “moderate” quality
(n=3), two described significant improvements in well-being or

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Table 1
Summary of studies on irritable bowel syndrome and psyllium fibre included in the literature review
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Design
(quality Participants and
Study assessment) intervention Results Comments
Arthurs and Fielding, Randomized, Target: patients newly diagnosed with No significant difference Subjects were 61 females,
1983, Ireland (27) controlled trial irritable bowel syndrome (IBS) between groups; p values not 17 males, aged 15-50 years
(weak) described
Intervention: ispaghula/poloxamer
granules, dose not specified Subjects completing study:
78
Control: not specified
Duration: 4 weeks
Outcome measures: Patient report
of general symptoms as either mild,
moderate, or severe
Bijkerk et al., 2009, Randomized, Target: patients aged 18-65 years Significant improvement in Subjects were 94% white,
Netherlands (14) controlled trial diagnosed with IBS in last 2 years adequate symptom relief 78% female, mean age 34.4
(strong) with psyllium in 1st and 2nd years
Intervention: 10 g psyllium (form not month only (p<0.05); severity
identified) BID of symptoms was significantly Used intention-to-treat (ITT)
decreased (p<0.05); no change analyses
Control: bran or rice flour
in quality of life or abdominal
Duration: 12 weeks pain
Outcome measures: patient- Subjects completing study:
determined adequate symptom relief 164
(primary), quality of life, severity of
symptoms, abdominal pain (secondary)
Chapman et al., 1990, Controlled clinical Target: patients aged 18-75 years with No difference between Parallel group study, subjects
For personal use only.

England (25) trial (weak) IBS groups (p=0.499); both treated with ispaghula +
groups improved significantly mebeverine or dietary advice
Intervention: ispaghula 3.5 g BID (p<0.001) + mebeverine
Control: high-fibre dietary advice Subjects completing study: Open study due to nature of
Duration: 8 weeks 103 control
Outcome measures: number and Unpalatability of ispaghula
severity of pain attacks, number of bowel described by many subjects
actions with stool consistency Subjects were aged 18-74
years; 76% female
Dettmar and Sykes, Controlled clinical Target: patients with IBS >1 year duration Significant reduction in Parallel group study, similar to
1999, United Kingdom trial (weak) physician-assessed abdominal Chapman et al.’s design (25);
(24) Intervention: ispaghula husk 3.5 g pain (p<0.01), as well as open study due to nature of
BID-TID physician-assessed (p<0.01) control
Control: high-fibre dietary advice and patient-assessed (p<0.05)
bowel function Subjects were 71% female;
Duration: 4 weeks ages ranged from 18-40
Subjects completing study: years; mean age 34 years
Outcome measures: physician and 110
patient assessments of number and
severity of episodes of pain and bowel
function
Golechha et al., 1982, Randomized, Target: IBS patients 13/26 reported improvement No description of data
India (20) controlled trial— with ispaghula versus 6/26 collection or assessment tools;
placebo- controlled Intervention: ispaghula husk powder, with placebo (p<0.05) no demographic information
crossover design no dose specified available
(weak) Subjects completing study:
Control: wheat flour 26
Duration: 3 weeks for each intervention,
6 weeks total
Outcome measures: patient-described
overall symptom improvement
Jalihal and Kurian, Controlled clinical Target: IBS >2 years Significant improvement in Subjects: 16 male, 4 female;
1990, India (22) trial— placebo- satisfaction with BMs with age range 17-56 years;
controlled crossover Intervention: 30 g ispaghula husk OD ispaghula (p<0.05); no change median age 38 years
design (weak) Control: not specified in pain, flatulence, number of
BMs, consistency of BMs, gut
Duration: 4 weeks treatment, 4 weeks transit time (p>0.05)
alternate therapy
Subjects completing study:
Outcome measures: patient reports 20
of pain, flatulence, number of bowel
movements (BMs), average consistency
of BMs, satisfaction with BMs, %
symptom improvement, gut transit time

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Table 1 (cont’d.)
Summary of studies on irritable bowel syndrome and psyllium fibre included in the literature review
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Design
(quality Participants and
Study assessment) intervention Results Comments

Kumar et al., 1987, Cohort (weak) Target: male patients with IBS Significant improvement in Study trying to determine
India (21) symptom score (p<0.01); optimum dosage of ispaghula
Intervention: processed ispaghula husk, significant increase in stool
10 g/20 g/30 g a day for each of 17 days weight (p<0.001) with best Subjects all male; no age
results at 20 g; no change to information provided
Control: N/A
transit time (p>0.05)
Duration: 51 days
Subjects completing study:
Outcome measures: patient reports of 10
symptoms, gut transit time by radio-
opaque markers, stool weight
Longstreth et al., Randomized, Target: Patients >18 years with IBS No significant improvement No descriptive statistics of
1981, United States controlled trial with intervention (p>0.05); study subjects
(18) (moderate) Intervention: Metamucil 6.4 g TID significant improvement with
Control: cornstarch, dextrose, and control substance
polyvinylpyrrolidone Subjects completing study:
Duration: 8 weeks 60
Outcome measures: stool consistency,
abdominal pain, gas, interference of
symptoms with activities of daily living
Nigam et al., 1984, Controlled clinical Target: IBS patients aged 16-68 years Significant improvement in No description of data
India (23) trial (weak) patient-described symptoms collection or assessment tools
Intervention: ispaghula husk, dose not
For personal use only.

with ispaghula (p<0.02)

specified Subjects: 55% male; average
Subjects completing study: age 34.5 years
Control: not specified 168
Duration: 12 weeks
Outcome measures: patient-described
overall symptom improvement
Prior and Whorwell, Randomized, Target: patients with IBS, aged 18-63 Significant decrease in number Subjects were 90% female
1987, England (28) controlled trial years of days with no BM (p=0.026);
(moderate) significant increase in reported Used ITT analysis
Intervention: ispaghula husk (Regulan) well-being (p=0.02); significant
3.6 g TID, with patient discretion to decrease in transit time
change dose as desired (p=0.001); no difference in
Control: Regulan with no ispaghula pain, bloating, days with >3
BMs (p>0.05)
Duration: 12 weeks
Subjects completing study:
Outcome measures: patient report of 57
improvement in well-being; days with no
or >3 BMs; pain, bloating, measured gut
transit time
Ritchie and Truelove, Randomized, Target: not described 23/48 reported improvement Factorial design, along with
1979, England (26) controlled trial with ispaghula versus 13/48 lorazepam (Ativan) and
(weak) Intervention: ispaghula husk (Fybogel); with placebo (p>0.05) butylscopolamine (Buscopan)
no dose described
Subjects completing study: Authors describe likely
Control: not described 96 synergy between treatments
Duration: 12 weeks No description of data
Outcome measures: patient-described collection or assessment tools
overall symptom improvement Subjects: mean age 38 years;
range 16-69 years; 77%
female

Ritchie and Truelove, Randomized, Target: not described 33/48 patients reported Factorial design, along
1980, England (19) controlled trial improvement with ispagula vs. with muscle relaxants and
(weak) Intervention: ispaghula husk (Fybogel) 23/48 with bran (p<0.05) psychotropic drugs
3.5 g BID
Subjects completing study: Authors describe likely
Control: coarse natural bran 96 synergy between treatments
Duration: 12 weeks No description of data
Outcome measures: patient-described collection or assessment tools
overall symptom improvement Subjects: mean age 39 years;
range 14-82 years; 74%
female

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overall symptom relief with psyllium administration (14,28), while
one showed no significant improvement in any symptoms, but
rather an advantage with the control substance over psyllium (18).
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DISCUSSION
The results of this systematic review indicate limited and con-
flicting evidence exists to support the recommendation of psyl-
lium supplementation for symptomatic IBS treatment. The het-
erogeneity of the 12 studies included in this review precluded the
collation of results as a meta-analysis. Psyllium fibre supplemen-
tation may be effective for patient-reported global symptom re-
lief and constipation-related symptoms, but does not appear to
be effective for abdominal pain, flatulence, or patient-reported
quality-of-life measures.
Variable outcome measurements
Outcomes measured in the 12 studies varied considerably, with
most employing a general patient report of overall symptom
improvement, and secondary outcomes of reported or mea-
sured improvement in specific IBS-related symptoms. While
these measures may have face validity, many have not been
tested in the IBS population. Moreover, a recent meta-analysis
indicates that the outcome measure of “global improvement in
For personal use only.
IBS symptoms,” employed by the majority of studies in this re-
view, is associated with a greater placebo response rate than is
measured improvement in individual symptoms (29). This may
in part explain the inability to detect significant difference be-
tween treatment groups for this outcome in some of the studies
reviewed. A number of the studies were classified as “weak” in
quality partly because of the lack of evidence for reliability and/
or validity of the outcome measures used.
Adequate relief
Before 1998, no accepted or widely used measures were avail-
able for outcome assessment in IBS treatment trials. In 1998,
the measure of “adequate relief” was validated as a clinically
meaningful outcome measure. “Adequate relief” is defined as a
patient’s report of adequate relief of abdominal pain and dis-
comfort (30). Patients are considered responders to treatment
if they report adequate relief during at least 50% of the weeks
of the treatment trial. The Design of Treatment Trials Commit-
tee (DTTC) of the American Gastroenterological Association
has since endorsed this outcome (31). Physician assessment of
symptom improvement was employed as an outcome measure
in one study (24), but has since been associated with greater
measurement error than is patient report (32). The DTTC now
exclusively endorses the use of patient-reported measures (31).
Quality of life
Quality-of-life assessments are considered important outcome
measures but should be secondary to patient-reported physical
symptom outcomes because they are considered more respon-
sive to treatment (31). While not as easily measured in the set-
ting of a treatment trial, quality-of-life assessments are likely to
be clinically relevant and important to individuals living with
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IBS. Negative impacts of IBS on quality of life have been report-
ed in numerous studies (33-36). Further, research teams in the
United Kingdom and the United States have recently demon-
strated financial and social impacts of IBS. Lost productivity is
often noted, and an employee with IBS is estimated to cost the
employer six hours of lost productivity each week (36), which is
50% more than an employee without IBS costs employers (37).
When exploring these secondary outcomes in treatment
trials, investigators should employ disease-specific quality-of-
life instruments (31), such the Work Productivity and Activity
Impairment questionnaire, which was developed and validated
specifically for use in IBS-affected individuals (37). As with the
primary outcome measures outlined above, these validated sec-
ondary outcome measures were not available when many of the
studies in this review were published.
Study design, outcomes, and duration
Study design and reporting of methods were quite variable
among the studies reviewed. While a number of randomized
and clinical controlled trials were included, many did not de-
scribe the method of randomization or whether blinding was
used. While the double-blind, randomized, placebo-controlled
trial is now considered the gold standard in IBS treatment tri-
als (31), blinding may be difficult in trials including dietary in-
terventions. When a placebo is chosen, it must be one believed
to lack any specific effect that would change the outcome being
measured. In some studies, bran or wheat flour was used as a
control substance, which may not be appropriate as increased
insoluble fibre may worsen IBS symptoms in some patients (8).
Factorial designs were employed in three of the 12 studies
reviewed (19,25,26). These studies were considered appropriate
for inclusion in this review because all treatments had distinct
mechanisms of action and treatments were assigned so that
simple effects of each treatment, as well as possible synergies be-
tween treatments, could be detected (31).
Sample size was variable (10 to 168 subjects) among stud-
ies, and methods for determining sample size were not routinely
outlined. Smaller sample sizes have less power than larger ones
to reveal significant outcomes, and can result in type II statistical
error (38). For clinical trials with multiple outcome measures,
a sample size that can provide at least 90% power for each end
point should be employed (39).
Intention-to-treat analysis was used in only two of the 12
studies. This type of analysis is now considered the standard for
the transparent reporting of clinical trial results (40), and it is
recommended for use in IBS treatment trials specifically (31).
As with study design and outcome measures, study duration
and psyllium doses were variable. Psyllium doses ranged from 7
g a day to as much as 30 g a day in the seven studies detailing the
dose. In only one small study (n=10) did the investigators at-
tempt to determine the optimal dose of psyllium effective in im-
proving symptoms and increasing stool weight. They concluded
that 20 g of psyllium a day is likely the preferred dose (21). The
remaining study groups that outlined intervention doses did not
publish the justifications for the dose chosen. This is a signifi-

cant oversight, as suboptimal doses may lead to underestimated
treatment effects and inflated doses may be detrimental.
Study duration ranged from four to 12 weeks. While all 12
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studies lasted longer than the four weeks Bijkerk et al. determined
to be the minimum required to show benefit, not all lasted long
enough to detect the absence of benefit after eight weeks, which
these authors also noted (14). Further, some of the longer stud-
ies tested effects only at baseline and 12 weeks, potentially miss-
ing the key time frame for the most significant improvements
in symptoms outlined in Bijkerk et al. (14). Moreover, if the
most significant improvement in IBS symptoms continues to be
found in the first two months of treatment, the next step should
be proposing mechanisms for this time-dependent response, as
well as further treatment options for practitioners dealing with
IBS patients no longer responding to psyllium therapy.
Broad study populations and rigorous sampling procedures
increase external validity of clinical trials and support the gener-
alizability of findings to patients outside the trial. While the ma-
jority of patients receive IBS management in primary care (41),
only one study group (14) in the current review examined this
population. Generalizing the results of the remaining studies to
patients seeking primary care is therefore difficult, and drawing
conclusions about the impacts on IBS sufferers who do not seek
medical attention is even more challenging. Of note is the wide
For personal use only.
demographic variability of study participants included in this
review. Although female IBS sufferers predominate in the gen-
eral population (42), female subjects represented between zero
to 90% of the sample in the studies reviewed.
Therapeutic acceptability and tolerance
Poor acceptability and tolerance of psyllium therapy were re-
ported to be a significant issue in only one study (25). Interest-
ingly, this study employed the smallest dose of psyllium, only
3.5 g twice a day. This is in contrast to a more recent lipid study
employing a similar dose of psyllium, in which no difference was
found between the acceptability of psyllium and placebo (43).
Further, Bijkerk et al. found no differences in tolerance with a
larger 10-g dose of psyllium versus placebo (14). More work is
needed to assess tolerance and acceptability of psyllium therapy
in IBS patients.
Review limitations
While this review has several strengths, such as its systematic and
exhaustive nature and the broad inclusion criteria, it has some
limitations in terms of the strength of the conclusions that could
be reached. Although a valid, modern quality-assessment tool
was employed (17), studies may have been given weaker ratings
than were merited owing to dated or foreign reporting norms
and standards. Because of the diverse populations, interven-
tions, and outcomes in the studies reviewed, much still remains
to be learned about the role of psyllium supplementation for
IBS symptoms. More investigation is required to determine the
optimal effective dose of psyllium in IBS patients, and rigorously
controlled, blinded trials with validated outcomes are needed to
test its usefulness.
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RELEVANCE TO PRACTICE
Currently, the therapeutic norm is a recommendation of psylli-
um fibre supplementation in IBS patients’ diets (11), but this re-
view has shown only limited support for this recommendation.
The British Society of Gastroenterology (42) clinical practice
guidelines acknowledge the limited availability of high-quality
research on the effects of psyllium fibre, especially in primary
care settings. The society advises that, if fibre supplementation
is needed, it should be in the form of soluble (as opposed to
insoluble) fibres such as psyllium fibre. Similarly, Dietitians of
Canada practice guidelines indicate that, because of inconsis-
tent results and poorly designed studies, evidence is controver-
sial for fibre supplementation in those with IBS (44). Psyllium
fibre may provide modest global symptom relief, especially in
constipation-predominant IBS; however, clinicians may wish to
exercise caution when recommending supplementation, as the
evidence for the effectiveness of psyllium fibre remains limited
and conflicting.
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