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The NiP/Danone digestive health survey: ‘Do as I say, not as I do!’

The NiP/Danone digestive health survey: ‘Do as I say, not as I do!’

Digestive discomfort is experienced at some point by most people. Symptoms typically include abdominal pain, altered bowel habit, flatulence and bloating, all of which are unpleasant and often embarrassing.1

Digestive discomfort can, of course, be part of normal digestive health; however, one in five women who reported experiencing digestive discomfort have an identified condition, with over 50% being diagnosed with irritable bowel syndrome (IBS).2

Peter Whorwell, Professor of Gastroenterology and Medicine at the University of Manchester, explains:
"Many people suffer from digestive discomfort at some time in their life, even if they are completely healthy. For most, the discomfort is minor and transitory, but for some, it can cause regular unpleasant symptoms, such as bloating. When it becomes more severe it often indicates the presence of irritable bowel syndrome (IBS), which can actually have a surprisingly detrimental effect on overall health and wellbeing."

How important is digestive health in primary care?
The Nursing in Practice/Danone survey on digestive health ran from 20 May to 13 July 2009 and was completed by 595 nurses.3
Of these:

  • 235/417* (56%) were practice nurses.
  • 452/527 (86%) have been qualified >10 years.
  • 513/526 (98%) were women.

*The denominator shows the number of nurses who answered each question.

The importance of digestive health in primary care was ranked by nurses as number five within a list of clinical health topics; above mental health, allergies, family planning and dermatology.

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Nurses' experience of digestive discomfort
Nearly all nurses taking part in the survey (89%) have experienced symptoms related to digestive discomfort. When asked further about these symptoms, over 70% of nurses reported abdominal bloating, while 69.5% reported that they had experienced abdominal pain or discomfort (see Figure 1).

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Of the 460 nurses who reported abdominal pain/discomfort, 80% found the symptoms very/quite bothersome (see Figure 2). Of the 457 who reported the subjective sensation of abdominal bloating, over half reported these symptoms as very/quite bothersome. A total of 364 nurses reported abdominal distension (an actual increase in girth), which was reported as very or quite bothersome by 70.4%.

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Distension, as opposed to bloating on its own, is more common in patients with constipation-predominant IBS (IBS-C) and in those with delayed GI transit, particularly of the large bowel.4
In extreme cases the patient's girth can increase by as much as 10 cm, typically being at its maximum late in the day or in the evening.

Almost three quarters of the nurses surveyed reported having to loosen clothing due to abdominal bloating in connection with digestive discomfort.

Wendy, a 44-year old part-time Nurse Prescriber from a single-handed GP practice with diagnosed IBS says:
"I often get cramping spasms and the sensation of needing to go to the loo all the time as well. It's so uncomfortable. Sometimes I don't know where to put myself. I find the distension very embarrassing. Sometimes I can look pregnant. When I have an episode of symptoms I feel very low and don't want to socialise. It's exhausting. Meal times are a real issue as I don't feel hungry but know I should eat."

Jacqueline, a 44-year-old healthcare assistant on an acute medicine and gastroenterology ward, said:
"I suffer frequently with bloating. Bloating makes me feel full and leaves me with no energy so I don't want to eat and sometimes I can't be bothered to walk the dog. A typical digestive discomfort episode for me includes a feeling of being bloated with distension and a lot of discomfort. My clothes become tight and I have to undo a button or my belt. I can also feel sick. The bloating generally starts in the middle
of the afternoon."

Nearly 80% of nurses reported that they discussed issues regarding constipation and diarrhoea with patients, followed by abdominal pain and discomfort, which was discussed during 63.1% of discussions with patients (see Figure 3).

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Digestive discomfort – an embarrassing condition
The typical symptoms of digestive discomfort (such as abdominal pain, altered bowel habit, flatulence and bloating) are often embarrassing and difficult to discuss.3

For example, recent research has shown that of over 1,000 women in the UK, 88% reported having experienced digestive discomfort from time to time, but the majority of them (70%) had never consulted a doctor or nurse.2 According to the NiP/Danone survey, four in five patients find the topic of digestive discomfort a little or very embarrassing to discuss with their nurse; and in a third of patients this actually prevents them from discussing their symptoms.

Warren Alexander, Chief Executive of Core, the only UK charity that funds research into the entire range of gut, liver, intestinal and bowel illnesses, says:
"As a charity working in this area we are very aware of how embarrassing it is for patients to talk about their digestive discomfort. Nurses are ideally placed to help put patients at ease and provide
good advice."

What causes digestive discomfort?
A number of factors may cause digestive discomfort and gastrointestinal symptoms, including:

  • Poor diet and lifestyle changes, including irregular eating habits and a diet low in fibre, lack of physical activity and stress.5,6
  • Medical conditions, including IBS and diarrhoea.7
  • Certain medication, such as antibiotics.
  • Age-related changes in the gut microbiota, which may be related to lifestyle, dietary modification, medication or a reduction in exercise.8

Digestive discomfort may be caused by slower intestinal transit and other digestive irregularities and may lead to health issues in the long term. A balanced intestinal microbiota helps ensure optimal functioning of the digestive system.9,10 Research suggests that when the intestinal microbiota is out of balance, potentially harmful bacteria can grow, which may not only affect the digestive system, but also the individual's overall health.

Many of the intestinal microbiota exert an effect on digestive transit as a result of direct and indirect actions, for example through their metabolites. Adequate digestion is a necessary prerequisite for good health. In the absence of good digestion and absorption, even the most balanced diet may not be considered optimal for the body.

Promoting good digestive health habits
Prevention is always better than cure. As with many other conditions, digestive health and intestinal transit time may be improved by increasing physical activity and eating a balanced diet. However, for people who already have some digestive discomfort, the following steps may help.

Physical activity
Regular physical activity helps keep the digestive tract functioning normally.11 Being active appears to increase colonic activity through abdominal muscle pressure.

Regular toilet habits
Digestive comfort may be improved by encouraging bowel movement at regular times, even in the absence of real desire. The feeling of the need to defecate is stimulated by arrival of matter in the rectum, which happens most frequently in the morning or after a meal. However, an urgent need to evacuate should never be ignored, whatever time it happens.

Dietary habits
Many people will benefit from eating frequent, smaller meals. People with bloating and increased gas should avoid foods that contain oligosaccharides (eg, broad beans, broccoli and cabbage), which are digested in the large intestine.

Consumption of probiotic formulations with strains proven to improve slower digestive transit and digestive comfort is recommended, such as those containing Bifidobacterium lactis DN-173 101, which are easy for people to take as part of their normal diet when formulated into yogurts.

At least 1–1.5 litres of fluid and five portions of fruit and vegetables a day are recommended (or three portions a day for those with IBS). Specific dietary recommendations for IBS include:

  • Drink at least eight cups of fluid/day.
  • Restrict tea and coffee to three cups/day.
  • Restrict the amount of fizzy drinks.
  • Don't drink too much alcohol.
  • Consider limiting intake of high-fibre food.
  • People with diarrhoea should avoid polyols such as sorbitol, an artificial sweetener.
  • People with a lot of wind and bloating should consider increasing their intake of oats and linseeds (up to one tablespoon per day).
  • Peppermint oil may also relieve abdominal colic and distension, particularly in IBS.12

Stress management
For people with IBS, learning to manage stress in their lives may lessen the chances of future attacks. Techniques that can be used include hypnotherapy and relaxation therapy.

Nurses recommend probiotics – but do not always take their own advice
The most common advice given by nurses to patients about managing digestive health relates to:

  • Healthy diet/lifestyle.
  • Fluid intake.
  • Keep a food diary.
  • Probiotic drinks.
  • Fibre intake/constipation management.

When asked whether they had ever recommended a probiotic yogurt to patients for their digestive discomfort, 63.0% (347/551) of nurses responded positively. Of those who recommended a probiotic, 72.4% recommended that the probiotic yogurt should be eaten every day.

When asked about their own digestive health, over 70% (388/549) of nurses reported that they had taken a probiotic product to relieve digestive discomfort, the majority having taken the probiotic as a yogurt (73%) or a yogurt drink (67%). When asked specifically if they had ever eaten Activia yogurt, 73% (405/555) replied positively. However, most nurses had only eaten it occasionally (216/401, 53.9%), once a week (26/401, 6.5%) or every other day (64/401, 16.0%). Only 23.7% (95/401) of those who had eaten Activia yogurt had eaten it every day as recommended.

Understanding probiotics

  • Probiotics – live micro-organisms, including bacteria, which confer a health benefit on the host.
  • Prebiotics – non-digestible foods (typically carbohydrates) that selectively stimulate the growth of certain bacteria within the microbiota (ie, Bifidobacteria).

According to the Food and Agriculture Organization of the United Nations (FAO)/World Healh Organization (WHO) definition, probiotics are "live micro-organisms which when administered in adequate amounts, confer a health benefit on the host".13 As this is a rare property among micro-organisms, the demonstration of the health benefit and the qualification as a probiotic is only valid for the specific strain tested.
Most commonly used probiotics strains belong to lactic acid-producing bacteria such as Bifidobacteria and Lactobacilli.

Lactic acid-producing bacteria convert sugars into lactic acid and have been used for many years in the food industry as they lower pH and reduce the growth of "spoilage" organisms.
There is evidence of a correlation between improved colonic movement and the quantity of Bifidobacterium present in faeces.7 Certain Bifidobacterium strains are able to produce a number of important vitamins eg, folic acid.14 However, it should be noted that probiotics in yogurt format are a food intended for the general population and are not medicines.

How can probiotics help support digestive comfort?
It is still not understood how the intestinal microbiota stimulates intestinal transit and digestive comfort. There are a number of mechanisms being researched including:
The effects on transit of by-products from bacterial fermentation, such as short chain fatty acids (SCFAs).

The effects of physiochemical modifications, such as stool formation and gas production.Whether probiotics can interfere with substances that affect colonic motility.15

Nevertheless, increasing the proportion of beneficial bacteria in the gut through the regular consumption of probiotics may help support digestive comfort. Regular daily consumption of certain probiotic formulations (or food) can help to regulate slow intestinal transit time.15-18 Transit time and bowel function can be associated with digestive comfort and health. Research has shown that probiotics have an excellent safety profile and offer an easily available and convenient option as they can be consumed as live cultures in foods such as yogurt.10

Effects of fermented milk containing Bifidobacterium lactis DN-173 010 on digestive comfort
A number of studies have provided clinical evidence of benefits in digestive health from regular eating of probiotics. For example, in a study involving 371 adults which was designed to reflect real life, consumption of the test products containing Bifidobacterium lactis DN-173 010 (Activia), led to a significant improvement in almost all digestive symptom scores (eg, feeling bloated, excessive/trapped wind) (P<0.001).20

A randomised, double-blind, parallel, controlled study of 197 women aged 18–60 with minor digestive symptoms but without gastrointestinal diseases, also showed improvements in digestive wellbeing. In this study, 2x125 g servings of either a fermented milk containing Bifidobacterium lactis DN-173 010 (Activia) or a non-fermented dairy product with low content of lactose were consumed for over four weeks with the following benefits being reported (see Figure 4):

  • A significantly more pronounced decrease in the composite score of digestive symptoms* (P=0.044) in the Activia group compared to the control group.
  • The decrease in flatulence frequency was significantly higher in the Activia group than in the control group at weeks 1, 2 and 4 (P<0.05).
  • A significant (P=0.02) improvement in stool consistency was observed in the Activia group vs the control group.21

*Digestive symptoms including abdominal pain/discomfort, bloating, flatulence/passage of gas, borborygmi/rumbling stomach.

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Effects of fermented milk containing Bifidobacterium lactis DN-173 010 on IBS
In a randomised, double-blind, controlled trial involving 34 women aged 20–69 with IBS-C, daily consumption of a fermented milk containing Bifidobacterium lactis DN-173 010 (Activia) (2x125 g servings daily) for four weeks had the following benefits compared with a non-fermented dairy product control (see Figure 5):

  • Significantly reduced percentage change in maximal distension by an average of 39% (P=0.02).
  • Reduced maximal distension by up to 78%.
  • Significantly reduced overall severity of IBS symptoms (P=0.032), and abdominal pain/discomfort (P=0.044).
  • Significantly reduced transit time:
    – Orocaecal transit reduced by 1.2 hours (P=0.049)
    – Colonic transit reduced by 12.2 hours (P=0.026).23

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How to discuss an embarrassing problem
As previously reported, four in five patients find the topic of digestive discomfort a little or very embarrassing to discuss and this actually prevents approximately one third from discussing their symptoms.

Nurses reported that the most common methods used to engage patients in talking about digestive health are verbal communication (used by 426/574, 74.2% of nurses) and leaflets (used by 349/574, 60.8% of nurses); websites were only recommended by 17.8% of nurses (102/574).

Educational resources for nurses
Nearly 90% (472/530) of nurses felt that they had not received adequate training in digestive health management, with the majority preferring to access such training via professional journals (336/503, 66.8%), training courses (317/503, 63.0%) or professional leaflets/documents (290/503, 57.7%).

The most widely read professional journal is Nursing in Practice. The Royal College of Nursing (RCN) was ranked as the most influential organisation in making decisions related to digestive health management by 62.7% (286/456) of nurses. The British Nutrition Foundation (156/456, 34.2%), British Dietetic Association (166/456, 36.4%) and British Society of Gastroenterology (94/456, 20.6%) were also indicated as influential.

Other recognised authorities include the Primary Care Society for Gastroenterology and Core, the research charity. The most frequently used websites were Nursing in Practice, listed by 75.4% (361/479) of nurses and the RCN, listed by 69.5% (333/479) of nurses.

Joycelyn Gage, a Specialist Nurse in Adult Chronic Abdominal Pain at the University of Manchester, says:
"Nurses would welcome more formal training on digestive health. It is an extremely common condition that affects both nurses themselves and many of their patients. The symptoms are often embarrassing to live with and discuss. However, there are some simple steps that people can take to improve their digestive health and nurses are in an ideal situation to be able to give such advice."

Conclusions
The NiP/Danone Survey confirmed the widespread occurrence of digestive discomfort among the population (including nurses and patients).2 The symptoms are generally quite or very bothersome, with many patients feeling embarrassed to discuss their symptoms with the nurse. In general, nurses are providing very good advice to patients about digestive health, although most of them feel that they have not received sufficient education on the topic.

Alongside other advice commonly given, nurses usually recommend patients with digestive discomfort to eat probiotic yogurts and, of the total number surveyed, 48% said they advised their patients to eat probiotic yogurts every day. Unfortunately, they are not always following this advice for their own digestive discomfort.

References
1. Guyonnet D, Woodcock A, Stefani B, Trevisan C, Hall C. Fermented milk containing Bifidobacterium lactis DN-173 010 improved self-reported digestive comfort amongst a general population of adults. A randomized, open-label, controlled, pilot study. J Dig Dis 2009;10:61–70.
2. TNS internet omnibus survey (OnLineBus). Survey of Digestive health in the UK. Conducted between 24 April - 1 May 2008.
3. Nursing in Practice/Danone Digestive Discomfort Survey. Conducted with Nurses between 20 May - 13 July 2009.
4. Houghton LA, Lea R, Agrawal A, Reilly B, Whorwell PJ. Relationship of abdominal bloating to distension in irritable bowel syndrome and effect of bowel habit. Gastroenterology 2006;131:1003-10.
5. Vikha GV, Lizko NN, Stebeneva SA. Monitoring of faecal sIgA in the evaluation of resistance of organism to stress situation. Microb Ecol Health Dis 2000;12:118.
6. Holdeman LV, Good IJ, Moore WEC. Human fecal flora: variation in bacterial composition within individuals and a possible effect of emotional stress. Appl Environ Microbiol 1976;31:359-75.
7. Salminen S, Isolauri E, Onnela T. Gut flora in normal and disordered states. Chemotherapy 1995;41(Suppl 1):5-15.
8. Woodmansey EJ. Intestinal bacteria and ageing. J Appl Microbiol 2007;102:1178–86.
9. Macfarlane GT, Macfarlane S. Human colonic microbiata: ecology, physiology and metabolic potential of intestinal bacteria. Scand J Gastroenterol Suppl 1997;222:3-9.
10. Naidu AS, Bidlack WR, Clemens RA. Probiotic spectra of lactic acid bacteria (LAB). Crit Rev Food Sci Nutr 1999;39:13-126.
11. The Merck Manual of Medical Information. Second Home Edition. Irritable Bowel Syndrome (IBS). Available from: www.merck.com/mmhe/print/sec09/ch129/ch129a.html
12. Patient UK. Irritable Bowel Syndrome. Available from: www.patient.co.uk/showdoc/23068776
13. World Health Organisation (WHO). Guidelines for the Evaluation of Probiotics in Food. Report of a Joint FAO/WHO Working Group on Drafting Guidelines for the Evaluation of Probiotics in Food. Available from: www.who.int/foodsafety/fs_ management/en/probiotic_guidelines.pdf
14. Strozzi GP, Mogna L. Quantification of folic acid in human feces after administration of Bifidobacterium probiotic strains. Journal of Clinical Gastroenterology 2008;42:S179–84.
15. Marteau P, Cuillerier E, Meance S et al. Bifidobacterium animalis strain DN-173 010 shortens the colonic transit time in healthy women: a double-blind, randomized, controlled study. Aliment Pharmacol Ther 2002;16:587–93.
16. Bouvier M, Meance S, Bouley C, Berta JL, Grimaud JC. Effects of consumption of a milk fermented by the probiotic strain Bifidobacterium animalis DN-173 010 on colonic transit times in healthy humans. Bioscience and Microflora 2001;20:43–8.
17. Meance S, Cayuela C, Turchet P, Raimondi A, Lucas C, Antoine JM. A fermented milk with a bifidobacterium probiotic strain DN-173 010 shortened oro-fecal gut transit time in elderly. Microb Ecol Health Dis 2001;13:217–22.
18. Meance S, Cayuela C, Raimondi A, Turchet P, Lucas C, Antoine JM. Recent advances in the use of functional foods: effects of the commercial fermented milk with Bifidobacterium animalis strain DN-173 010 and yogurt strains on gut transit time in the elderly. Microb Ecol Health Dis 2003;15:15-22.
19. National Institute for Health and Clinical Excellence (NICE). Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care. London: NICE; 2008. Available from: www.nice.org.uk/Guidance/CG61/Guidance/pdf/English
20. Guyonnet D, Woodcock A, Stefani B, Trevisan C, Hall C. Fermented milk containing Bifidobacterium lactis DN-173 010 improved self-reported digestive comfort amongst a general population of adults. A randomized, open-label, controlled, pilot study. J Dig Dis 2009;10:61–70.
21. Guyonnet D, Schlumberger A, Mhamdi L, Jakob S, Chassany O. Fermented milk containing Bifidobacterium lactis DN-173 010 improves gastrointestinal well-being and digestive symptoms in women reporting minor digestive symptoms: a randomised, double-blind, parallel, controlled study. Br J Nutr 2009;22:1–9.
22. Guyonnet D, Chassany O, Ducrotte P et al. Effect of fermented milk containing Bifidobacterium animalis DN-173 010 on the health-related quality of life and symptoms in irritable bowel syndrome in adults in primary care: a multicentre, randomised, double-blind, controlled trial. Aliment Pharmacol Ther 2007;26:475-86.
23. Agrawal A, Houghton LA, Morris J et al. Clinical trial: the effects of a fermented milk product containing Bifidobacterium lactis DN-173010 on abdominal distension and gastrointestinal transit in irritable bowel syndrome with constipation. Aliment Pharmacol Ther 2009;29:104–14.

 

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