Published online Aug 6, 2015. doi: 10.4292/wjgpt.v6.i3.84
Peer-review started: March 18, 2015
First decision: April 10, 2015
Revised: May 26, 2015
Accepted: June 9, 2015
Article in press: June 11, 2015
Published online: August 6, 2015
Processing time: 145 Days and 8.8 Hours
AIM: To examine whether non-alcoholic beverage intake preferences can guide polyethylene glycol (PEG)-based bowel laxative preparation selection for patients.
METHODS: We conducted eight public taste test sessions using commercially procured (A) unflavored PEG, (B) citrus flavored PEG and (C) PEG with ascorbate (Moviprep). We collected characteristics of volunteers including their beverage intake preferences. The volunteers tasted the laxatives in randomly assigned orders and ranked the laxatives as 1st, 2nd, and 3rd based on their taste preferences. Our primary outcome is the number of 1st place rankings for each preparation.
RESULTS: A total of 777 volunteers completed the study. Unflavored PEG was ranked as 1st by 70 (9.0%), flavored PEG by 534 (68.7%) and PEG with ascorbate by 173 (22.3%) volunteers. Demographic, lifestyle characteristics and beverage intake patterns for coffee, tea, and carbonated drinks did not predict PEG-based laxative preference.
CONCLUSION: Beverage intake pattern was not a useful guide for PEG-based laxative preference. It is important to develop more tolerable and affordable bowel preparation laxatives for colonoscopy. Also, patients should taste their PEG solution with and without flavoring before flavoring the entire gallon as this may give them more opportunity to pick a pattern that may be more tolerable.
Core tip: There is a need to improve patients’ experience with bowel preparation process in order to optimize both colonoscopy uptake. Polyethelene glycol (PEG) is the most widely used laxative but many patients do not readily tolerate it because of its taste. We evaluated whether beverage intake preference pattern can be a useful guide for predicting tolerability of bowel preparation laxative in multiple public taste tests. Our study suggested that no demographic or lifestyle factors predicted bowel preparation taste preference for PEG-based preparations. We recommend that patients should taste PEG formulation before flavoring it to assist them in choosing a more tolerable pattern of ingestion.
- Citation: Laiyemo AO, Burnside C, Laiyemo MA, Kwagyan J, Williams CD, Idowu KA, Ashktorab H, Kibreab A, Scott VF, Sanderson AK. Beverage intake preference and bowel preparation laxative taste preference for colonoscopy. World J Gastrointest Pharmacol Ther 2015; 6(3): 84-88
- URL: https://www.wjgnet.com/2150-5349/full/v6/i3/84.htm
- DOI: https://dx.doi.org/10.4292/wjgpt.v6.i3.84
Colorectal cancer (CRC) remains a leading cause of cancer-related deaths[1] despite evidence from case-control[2-4], cohort[5] and randomized control studies[6-8] that screening reduces the risk of death from the disease because a large proportion of age-eligible adults in the United States have not been screened[9,10]. This is a major public health problem. Although there are multiple acceptable options for CRC screening[11], colonoscopy is the only modality for surveillance, diagnostic and therapeutic purposes.
Colonoscopy requires a full bowel preparation using oral laxative agents. However, a substantial percentage of patients do not readily tolerate their bowel laxatives for colonoscopy. Inadequate bowel preparation wastes limited endoscopic resources in addition to patients’ and providers’ time and reduces the enthusiasm for repeat screening among patients[12]. Furthermore, inadequate endoscopy has been associated with subsequent colorectal cancer[13] underscoring the importance of achieving a high quality preparation for colonoscopy.
Given that the palatability of substances varies among people, we postulated that beverage intake preferences may be a useful guide to personalize bowel preparation recommendations for patients. We tested this hypothesis by conducting public taste tests among volunteers to correlate their beverage intake patterns to their preferred bowel preparations’ taste.
The study was approved by the Institutional Review Board of Howard University (IRB-12-MED-17). We conducted eight public taste test sessions at Howard University Hospital lobby from July 2012 to March 2013. The objective of the taste test was to determine participants’ preferences for 3 commercially procured preparations of polyethylene glycol-(PEG) 3350 used for bowel preparation for colonoscopy. These were: (1) Unflavored PEG; (2) citrus flavored PEG; and (3) PEG with sodium ascorbate and ascorbic acid (Moviprep®, Raleigh, NC).
The study was open to any volunteer (visitors, ambulatory care patients, students, and staff) if they were at least 18 years old. The study was explained to each participant and written informed consent was obtained. Each participant completed an intake form providing information on their demographic characteristics (age, sex, self identified race, highest education attained, income, marital status and self reported weight and height), lifestyle choices (smoking status and alcohol intake) and their non-alcoholic beverage intake preferences and patterns for coffee, tea and carbonated drinks (soda). Subsequently, volunteers tasted and drank 10 cc (equivalent to 2 teaspoons) of each laxative in randomly selected order (ABC, BCA, CAB) and rated the laxatives based on their preferences in an ordinal fashion with the preferred laxative rated as 1st, then 2nd for the next preferred and 3rd for the least preferred laxative. We offered confectioneries to each volunteer on completion of their participation in the study.
Information on how each volunteer prefers to drink coffee was collected with five options: (1) I do not drink coffee; (2) Without milk/cream; without sugar/sweetener; (3) Without milk/cream; with sugar/sweetener; (4) With milk/cream; without sugar/sweetener; and (5) With milk/cream; with sugar/sweetener. Similar information was obtained for tea intake. They were also asked if they drink regular carbonated drinks (soda), diet soda, and whether they prefer the taste of diet soda to regular soda. Our primary outcome was the number of 1st place ranking for each laxative preparation.
We calculated the percentages of volunteers who preferred each laxative’s taste and compared the characteristics of participants who selected each laxative as 1stvs those who did not. Missing variables were set to missing without the use of dummy variables. We used logistic regression models to compare the characteristics of volunteers who chose each laxative as 1st to the rest of the volunteers and calculated odds ratios (OR) and 95%CI. We performed similar analyses and compared the pattern of beverage intake for coffee, tea, and soda with those who did not drink these beverages. We evaluated the predictive accuracy of the models by calculating the area under the receiver operating characteristics curve (AUC). We used Stata® statistical software version 11.2 (College Station, Texas) for our analyses.
A total of 777 volunteers completed the taste test. The mean age of volunteers was 45.1 years (range 18-83 years), 432 (56.0%) women and 657 (84.6%) blacks. Seventy (9.0%) participants preferred unflavored PEG as first choice, 534 (68.7%) preferred flavored PEG while 173 (22.3%) preferred PEG with ascorbate.
Overall, no demographic or lifestyle characteristics adequately predicted the preference for any bowel laxative. Volunteers who were older than 50 years (OR = 0.69; 95%CI: 0.49-0.97) and those with hypertension (OR = 0.53; 95%CI: 0.36-0.79) were less likely to prefer PEG with ascorbate as first choice. Although those with hypertension were more likely to prefer flavored PEG (OR = 1.65; 95%CI: 1.17-2.23) but the predictive accuracy was low (AUC = 0.55). Volunteers with college education were more likely to prefer PEG with ascorbate (OR = 1.50; 95%CI: 1.06-2.12), but the predictive accuracy was also low (AUC = 0.55). Similarly, women were more likely to prefer unflavored PEG (OR = 1.90; 95%CI: 1.11-3.24), albeit with low predictive accuracy (AUC = 0.57) (Table 1). The coffee, tea and carbonated drinks intake pattern of volunteers were not associated with laxative taste preferences (Table 2).
Characteristics | n | Preferred unflavored PEG (n = 70) | Preferred flavored PEG (n = 534) | Preferred moviprep (n = 173) | |||
n (%) | OR (95%CI) | n (%) | OR (95%CI) | n (%) | OR (95%CI) | ||
Age ≥ 50 yr | |||||||
No | 421 | 32 (7.6) | Reference | 283 (67.2) | Reference | 106 (25.2) | Reference |
Yes | 356 | 38 (10.6) | 1.45 (0.89-2.38) | 251 (70.5) | 1.17 (0.86-1.58) | 67 (18.8) | 0.69 (0.49-0.97) |
Sex | |||||||
Male | 340 | 21 (6.2) | Reference | 242 (71.2) | Reference | 77 (22.7) | Reference |
Female | 432 | 48 (11.1) | 1.90 (1.11-3.24) | 288 (66.7) | 0.81 (0.60-1.10) | 96 (22.2) | 0.98 (0.69-1.37) |
Race | |||||||
Non-blacks | 120 | 12 (10.0) | Reference | 83 (69.2) | Reference | 25 (20.8) | Reference |
Blacks | 657 | 58 (8.8) | 0.87 (0.45-1.68) | 451 (68.7) | 0.98 (0.64-1.49) | 148 (22.5) | 1.10 (0.69-1.78) |
Marital status | |||||||
Unmarried | 455 | 38 (8.4) | Reference | 314 (69.0) | Reference | 103 (22.6) | Reference |
Married | 169 | 13 (7.7) | 0.91 (0.47-1.76) | 110 (65.1) | 0.84 (0.57-1.22) | 46 (27.2) | 1.28 (0.85-1.91) |
College education | |||||||
No | 418 | 41 (9.8) | Reference | 299 (71.5) | Reference | 78 (18.7) | Reference |
Yes | 343 | 27 (7.9) | 0.79 (0.47-1.31) | 228 (66.5) | 0.79 (0.58-1.07) | 88 (25.7) | 1.50 (1.06-2.12) |
Yearly income < $25000 | |||||||
No | 437 | 33 (7.6) | Reference | 302 (69.1) | Reference | 102 (23.3) | Reference |
Yes | 268 | 29 (10.8) | 1.49 (0.88-2.51) | 181 (67.5) | 0.93 (0.67-1.29) | 58 (21.6) | 0.91 (0.63-1.31) |
BMI | |||||||
< 25 kg/m2 | 223 | 18 (8.1) | Reference | 150 (67.3) | Reference | 55 (24.7) | Reference |
25-29 kg/m2 | 258 | 25 (9.7) | 1.22 (0.65-2.30) | 172 (66.7) | 0.97 (0.66-1.42) | 61 (23.6) | 0.95 (0.62-1.44) |
≥ 30 kg/m2 | 275 | 26 (9.5) | 1.19 (0.63-2.23) | 199 (72.4) | 1.27 (0.87-1.87) | 50 (18.7) | 0.68 (0.44-1.05) |
History of smoking | |||||||
No | 485 | 38 (7.8) | Reference | 334 (68.9) | Reference | 113 (23.3) | Reference |
Yes | 286 | 32 (11.2) | 1.48 (0.90-2.43) | 195 (68.2) | 0.97 (0.71-1.33) | 59 (20.6) | 0.86 (0.60-1.22) |
Alcohol | |||||||
No | 311 | 26 (8.4) | Reference | 216 (69.5) | Reference | 69 (22.2) | Reference |
Yes | 457 | 42 (9.2) | 1.11 (0.66-1.85) | 312 (68.3) | 0.95 (0.69-1.29) | 103 (22.5) | 1.02 (0.72-1.44) |
Health history | |||||||
Diabetes | |||||||
No | 661 | 51 (8.8) | Reference | 453 (68.5) | Reference | 150 (22.7) | Reference |
Yes | 107 | 11 (10.3) | 1.19 (0.60-2.35) | 76 (71.0) | 1.13 (0.72-1.76) | 20 (18.7) | 0.78 (0.47-1.32) |
Hypertension | |||||||
No | 521 | 48 (9.2) | Reference | 341 (65.5) | Reference | 132 (25.3) | Reference |
Yes | 248 | 22 (8.9) | 0.96 (0.57-1.63) | 188 (75.8) | 1.65 (1.17-2.33) | 138 (15.3) | 0.53 (0.36-0.79) |
Beverage intake | n | Preferred unflavored PEG (n = 70) | Preferred flavored PEG (n = 534) | Preferred Moviprep (n = 173) | |||
n (%) | OR (95%CI) | n (%) | OR (95%CI) | n (%) | OR (95%CI) | ||
Coffee intake pattern | |||||||
Don't drink coffee | 265 | 22 (8.3) | Reference | 183 (69.1) | Reference | 60 (22.6) | Reference |
No milk, no sugar | 41 | 4 (9.8) | 1.19 (0.39-3.66) | 27 (65.9) | 0.86 (0.43-1.73) | 10 (24.4) | 1.10 (0.51-2.38) |
With sugar, no milk | 42 | 2 (4.8) | 0.55 (0.13-2.44) | 34 (81.0) | 1.90 (0.84-4.29) | 6 (14.3) | 0.57 (0.23-1.42) |
With milk, no sugar | 65 | 9 (13.9) | 1.78 (0.78-4.06) | 42 (64.6) | 0.82 (0.46-1.45) | 14 (21.5) | 0.94 (0.49-1.81) |
With milk, with sugar | 336 | 31 (9.2) | 1.12 (0.63-1.99) | 230 (68.5) | 0.97 (0.69-1.38) | 75 (22.3) | 0.98 (0.67-1.44) |
Tea intake pattern | |||||||
Don't drink tea | 138 | 14 (10.1) | Reference | 96 (69.6) | Reference | 28 (20.3) | Reference |
No milk, no sugar | 89 | 6 (6.7) | 0.64 (0.24-1.73) | 63 (70.8) | 1.06 (0.59-1.90) | 20 (22.5) | 1.14 (0.60-2.18) |
With sugar, no milk | 336 | 30 (8.9) | 0.87 (0.44-1.69) | 240 (71.4) | 1.09 (0.71-1.69) | 66 (19.6) | 0.96 (0.59-1.57) |
With milk, no sugar | 25 | 2 (8.0) | 0.77 (0.16-3.62) | 16 (64.0) | 0.78 (0.32-1.90) | 7 (28.0) | 1.53 (0.58-4.02) |
With milk, with sugar | 153 | 14 (9.2) | 0.89 (0.41-1.94) | 96 (62.8) | 0.74 (0.45-1.20) | 43 (28.1) | 1.54 (0.89-2.65) |
Carbonated drinks | |||||||
Regular soda intake | |||||||
No | 269 | 27 (10.0) | Reference | 180 (66.9) | Reference | 62 (23.1) | Reference |
Yes | 482 | 41 (8.5) | 0.83 (0.50-1.39) | 336 (69.7) | 1.14 (0.83-1.57) | 105 (21.8) | 0.93 (0.65-1.33) |
Diet soda intake | |||||||
No | 493 | 43 (8.7) | Reference | 336 (68.2) | Reference | 114 (23.1) | Reference |
Yes | 218 | 19 (8.7) | 1.00 (0.57-1.76) | 155 (71.1) | 1.15 (0.81-1.63) | 44 (20.2) | 0.84 (0.57-1.24) |
Prefers the taste of diet soda to regular soda | |||||||
No | 582 | 47 (8.1) | Reference | 402 (69.1) | Reference | 133 (22.9) | Reference |
Yes | 111 | 13 (11.7) | 1.51 (0.79-2.89) | 76 (68.5) | 0.97 (0.63-1.51) | 22 (19.8) | 0.83 (0.50-1.38) |
In this large study of volunteers in public taste tests, demographic, lifestyle and beverage intake patterns of volunteers did not predict their taste preferences for the studied bowel laxatives commonly used in the preparation process for colonoscopy. This suggests that these characteristics are not clinically useful to guide the selection of laxatives for colonoscopy. It is unclear why beverage intake patterns of our participants did not predict their preferences for bowel laxatives examined in this study. However, we speculate that beverage intake patterns are probably more unique to the individuals and can be varied in composition more readily than the limited taste range of the bowel laxatives. It will be important to develop better tasting and more acceptable bowel preparation laxatives and make them available and affordable to all patients.
Improving bowel preparation experience of patients is an important step to enhance uptake of CRC screening using colonoscopy. Previous interventions have involved reduction in the salt content and flavoring of the solutions by manufacturers. For those with low socio-economic status, these newer products are often not accessible because they are generally not considered to be “preferred brands” and are either not covered by their third party payers or covered with substantially higher co-pays. Bowel preparations containing PEG is the predominant laxative used in the preparation process for colonoscopy but salty taste and large volume of these solutions limit their tolerability. PEG is generally covered by health insurance and is relatively inexpensive. The effect of flavoring of PEG on patients’ tolerability is uncertain. In a taste test involving 5 PEG preparations tasted by 100 subjects, Diab et al[14] reported that the majority of subjects preferred the flavored products while 22% rated unflavored PEG as their first choice. Furthermore, Hayes et al[15] reported that flavoring PEG (Colyte®) solution did not improve bowel preparation as compared to unflavored PEG.
An approach to ameliorate this challenge will be for manufacturers to provide free samples of their laxatives for patients to try at their endoscopists’ offices. However, this may not be a viable option particularly as the relationship of pharmaceutical industries with care providers is under close scrutiny in many institutions and provision of free “test” samples medications has been abolished in many institutions. Therefore, it is imperative to develop palatable bowel preparation laxatives and make them affordable.
A notable strength of our study is that we studied the taste preference of a large number of volunteers. However, a limitation of our study is that we drew our inference from preferences that were based on tasting a small volume of laxatives by participants. However, if a small volume of a solution tastes really bad, it is highly unlikely that a large volume of it will be tolerable. Nonetheless, we acknowledge that it is conceivable that the sheer volume of solution to actually consume for colonoscopy preparation may further influence the overall experience of patients. Although our study was open to the general public, it was conducted at a single institution. Furthermore, the majority of our participants were black and the experience of other race-ethnicities may be different since beverage intake patterns and preferences may vary based on social characteristics.
In conclusion, the demographic characteristics, lifestyle choices and beverage intake preferences of volunteers in this large taste test did not predict preferences for PEG-based bowel preparation laxatives to be a clinically useful guide to improve the experience of patients undergoing CRC screening. There is a need to develop palatable and affordable bowel preparation laxatives.
Abstracts from this study were presented at the Digestive Diseases Week in May 2013 in Orlando, Florida and at the American College of Gastroenterology meeting in San Diego in October 2013.
There is a great need to improve the bowel preparation process in order to increase colon cancer screening uptake. The current study evaluated whether the beverage intake pattern for coffee, tea and carbonated drinks can guide the preference of volunteers for polyethylene glycol (PEG)-based bowel preparation for colonoscopy.
Adequacy of bowel preparation for screening colonoscopy is a quality measure. This underscores the need to improve bowel preparation quality during colonoscopy, and overall bowel preparation experience of the population when undergoing colonoscopy.
The current study examined whether personalized uniqueness of beverage intake of coffee, tea and carbonated drinks can be useful to guide the selection of PEG-based bowel preparation laxative for patients. This has not been investigated previously.
To summarize the practical applications of their research findings, so that readers may understand the perspectives by which this study will affect the field and future research. Beverage intake preferences for coffee, tea and carbonated drinks did not predict the preferences for PEG-based bowel preparation laxative among volunteers. This suggests that taste preference is probably too unique and individuals should probably taste the unflavored PEG-based laxative prior to flavoring during the bowel preparation process.
Bowel preparation is the process of ensuring that the colon is free of stool during colonoscopy and involves the consumption of laxatives. It is important to tolerate the laxatives, which of often consumed in large volumes, to achieve optimal bowel cleansing.
Better tolerable bowel preparation would increase the rates of screening colonoscopy and therefore benefit the public.
P- Reviewer: Greenspan M, Katsoulis IE S- Editor: Ji FF L- Editor: A E- Editor: Liu SQ
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