Psyllium //, or ispaghula (isabgol) //, is the common name used for several members of the plant genus Plantago whose seeds are used commercially for the production of mucilage. Psyllium is mainly used as a dietary fiber to relieve symptoms of both constipation and mild diarrhea, and occasionally as a food thickener. It is commonly used as a food ingredient in manufactured breakfast cereals.
Use of psyllium in the diet for three weeks or longer often lowers blood cholesterol levels in people with elevated cholesterol, and can lower blood glucose levels in people with type 2 diabetes. Use of psyllium for a month or longer may produce a small reduction in systolic blood pressure.
The plants from which the seeds are extracted tolerate dry and cool climates and are mainly cultivated in northern India.
Psyllium has been used as a thickener in ice cream and other frozen desserts. A 1.5% weight/volume ratio of psyllium mucilage exhibits binding properties that are superior to a 10% weight/volume ratio of starch mucilage. The viscosity of psyllium mucilage dispersions are relatively unaffected between temperatures of 20 and 50 °C (68 and 122 °F), by pH from 2 to 10, and by salt (sodium chloride) concentrations up to 0.15 M.
Psyllium is mainly used as a viscous, soluble dietary fiber that is not absorbed by the small intestine. The purely mechanical action of psyllium mucilage is to absorb excess water while stimulating normal bowel elimination. Although its main use has been as a laxative, it is more accurately regarded as a dietary fiber and as such can help reduce the symptoms of both constipation and mild diarrhea. The laxative properties of psyllium are attributed to the fiber: it absorbs water and subsequently softens the stool. It increases flatulence (gas) to some degree.
High blood cholesterol
In 1998, the U.S. Food and Drug Administration approved a health claim on food labels for dietary psyllium as a soluble fiber – if consumed chronically – that would reduce the risk of heart disease by lowering blood cholesterol. Clinical research demonstrated that seven grams or more per day of soluble fiber from psyllium seed husk would sufficiently lower total cholesterol and low density lipoprotein cholesterol in people with hypercholesterolemia, two accepted biomarkers for risk of coronary heart disease. The findings were later confirmed in a meta-analysis that incorporated more evidence. To be eligible for the FDA-allowed health claim, one serving of a manufactured food or dietary supplement must contain at least 1.7 g of psyllium as soluble fiber. Whole oats, barley and foods containing beta-glucan soluble fiber were included as eligible sources for the label claim.
Type 2 diabetes
In 2014, the U.S. Food and Drug Administration approved a qualified health claim for psyllium as a possible benefit for people with diabetes, requiring FDA-approved wording on a product label: "Psyllium husk may reduce the risk of type 2 diabetes, although the FDA has concluded that there is very little scientific evidence for this claim."  A meta-analysis published after the FDA decision reported that psyllium provided before meals improved fasting blood glucose and glycated hemoglobin, but that the larger effect was seen in people diagnosed with and being treated for type 2 diabetes, and only a modest improvement for people classified as pre-diabetic.
Fiber generally has few side effects.
- Psyllium can cause bowel obstructions or bezoars, if taken without adequate amounts of water.
- Gas or stomach bloating may also occur.
- Choking is a hazard if psyllium is taken without adequate water as it thickens in the throat.
Psyllium can cause allergic reactions, including anaphylaxis. Psyllium may act as a potent inhalant allergen capable of eliciting asthma symptoms. Health care professionals at geriatric care hospitals, who are frequently exposed to psyllium in the laxatives administered to patients, are commonly IgE sensitized to psyllium (13.8%), and 8.6% have clinical allergy to psyllium. Pharmaceutical manufacturing employees who have been exposed to psyllium during the processing have developed occupational asthma and IgE sensitization. In order to protect sensitized workers, psyllium has an extremely low occupational exposure limit of 150 ng/m3.
Mechanism of action
Psyllium is produced mainly for its mucilage content. The term mucilage describes a group of clear, colorless, gelling agents derived from plants. The mucilage obtained from psyllium comes from the seed coat. Mucilage is obtained by mechanical milling (i.e. grinding) of the outer layer of the seed. Mucilage yield amounts to about 25% (by weight) of the total seed yield. Plantago-seed mucilage is often referred to as husk, or psyllium husk. The milled seed mucilage is a white fibrous material that is hydrophilic, meaning that its molecular structure causes it to attract and bind to water. Upon absorbing water, the clear, colorless, mucilaginous gel that forms increases in volume by tenfold or more.
The genus Plantago contains over 200 species. P. ovata and P. psyllium are produced commercially in several European countries, the former Soviet Union and India. Plantago seed, known commercially as black, French, or Spanish psyllium, is obtained from P. psyllium, also known as P. arenaria. Seed produced from P. ovata is known in trading circles as white or blonde psyllium, Indian plantago, or isabgol. Isabgol is the common name in India for P. ovata. it is known as Aspaghol in Pakistan, coming from the Persian asp and gul, meaning "horse flower", which is descriptive of the shape of the seed. India dominates the world market in the production and export of psyllium.
Plantago ovata is an annual herb that grows to a height of 30–46 cm (12–18 in). Leaves are opposite, linear or linear lanceolate 1 cm × 19 cm (0.39 in × 7.48 in). The root system has a well-developed tap root with few fibrous secondary roots. A large number of flowering shoots arise from the base of the plant. Flowers are numerous, small, and white. Plants flower about 60 days after planting. The seeds are enclosed in capsules that open at maturity.
The fields are generally irrigated prior to seeding to achieve ideal soil moisture, to enhance seed soil contact, and to avoid burying the seed too deeply as a result of later irrigations or rainfall. Maximum germination occurs at a seeding depth of 6 mm (1/4 in). Emerging seedlings are frost sensitive; therefore, planting should be delayed until conditions are expected to remain frost free. Seed is broadcast at 5.5 to 8.25 kg/hectare (5 to 7.5 lb/acre) in India. In Arizonan trials, seeding rates of 22 to 27.5 kg/ha (20 to 25 lb/acre) resulted in stands of 1 plant/25mm (1 inch) in 15 cm (6 inch) rows produced excellent yields. Weed control is normally achieved by one or two hand weedings early in the growing season. Control of weeds by pre-plant irrigation that germinates weed seeds followed by shallow tillage may be effective on fields with minimal weed pressure. Psyllium is a poor competitor with most weed species.
The flower spikes turn reddish brown at ripening, the lower leaves dry and the upper leaves yellow. The crop is harvested in the morning after the dew is gone to minimize shattering and field losses. In India, mature plants are cut 15 cm above the ground and then bound, left for a few days to dry, thrashed, and winnowed.
Harvested seed must be dried to below 12% moisture to allow for cleaning, milling, and storage. Seed stored for future crops has shown a significant loss in viability after 2 years in storage.
Introduced in 1934 by G. D. Searle & Company, Metamucil was acquired by Procter & Gamble in 1985. The name is a combination of the Greek word for change (meta) and the class of fiber that it utilizes (mucilage). In its early years, Metamucil achieved sporadic drug-store distribution as a "behind the counter" brand. Since 1974, the brand was also marketed to consumers via print and TV advertising and became available in food outlets. Flavored versions were added in 1979.
The brand is sold as powdered drink mixes, capsules and wafers in a variety of flavors. Metamucil contains psyllium seed husks as the active ingredient. It is manufactured in Phoenix, Arizona by Procter & Gamble. When first marketed to consumers in 1974, Metamucil was marketed as a laxative. The advertising claim at that time was "If not nature, then Metamucil". Procter & Gamble sought to make Metamucil a household name by advertising in magazines and on television, using the claim "All fiber is not created equal".
Society and culture
This medication in the U.S. has a cost of $14 (USD) for 368 grams (3.4 g/5.8 g) 
- Slavin, Joanne (22 April 2013). "Fiber and prebiotics: Mechanisms and health benefits". Nutrients. 5 (4): 1417–1435. doi:10.3390/nu5041417. ISSN 2072-6643. PMC 3705355. PMID 23609775.
- Williams, Peter G. (1 August 2014). "The Benefits of Breakfast Cereal Consumption: A Systematic Review of the Evidence Base". Advances in Nutrition. 5 (5): 636S–673S. doi:10.3945/an.114.006247. ISSN 2156-5376. PMC 4188247. PMID 25225349.
- Jovanovski, Elena; Yashpal, Shahen; Komishon, Allison; Zurbau, Andreea; Blanco Mejia, Sonia; Ho, Hoang Vi Thanh; Li, Dandan; Sievenpiper, John; Duvnjak, Lea; Vuksan, Vladimir (15 September 2018). "Effect of psyllium (Plantago ovata) fiber on LDL cholesterol and alternative lipid targets, non-HDL cholesterol and apolipoprotein B: a systematic review and meta-analysis of randomized controlled trials". The American Journal of Clinical Nutrition. 108 (5): 922–932. doi:10.1093/ajcn/nqy115. ISSN 0002-9165. PMID 30239559.
- Gibb RD, McRorie JW, Russell DA, Hasselblad V, D'Alessio DA (December 2015). "Psyllium fiber improves glycemic control proportional to loss of glycemic control: a meta-analysis of data in euglycemic subjects, patients at risk of type 2 diabetes mellitus, and patients being treated for type 2 diabetes mellitus". Am. J. Clin. Nutr. 102 (6): 1604–14. doi:10.3945/ajcn.115.106989. PMID 26561625.
- Khan, K.; Jovanovski, E.; Ho, H.V.T.; Marques, A.C.R.; Zurbau, A.; Mejia, S.B.; Sievenpiper, J.L.; Vuksan, V. (2018). "The effect of viscous soluble fiber on blood pressure: A systematic review and meta-analysis of randomized controlled trials". Nutrition, Metabolism and Cardiovascular Diseases. 28 (1): 3–13. doi:10.1016/j.numecd.2017.09.007. ISSN 0939-4753. PMID 29153856.
- Darooghegi Mofrad, Manije; Mozaffari, Hadis; Mousavi, Seyed Mohammad; Sheikhi, Ali; Milajerdi, Alireza (2019-03-18). "The effects of psyllium supplementation on body weight, body mass index and waist circumference in adults: A systematic review and dose-response meta-analysis of randomized controlled trials". Critical Reviews in Food Science and Nutrition. 60 (5): 859–872. doi:10.1080/10408398.2018.1553140. ISSN 1040-8398. PMID 30880409. S2CID 81983941.
- McRorie, Johnson W.; McKeown, Nicola M. (2017). "Understanding the Physics of Functional Fibers in the Gastrointestinal Tract: An Evidence-Based Approach to Resolving Enduring Misconceptions about Insoluble and Soluble Fiber". Journal of the Academy of Nutrition and Dietetics. 117 (2): 251–264. doi:10.1016/j.jand.2016.09.021. ISSN 2212-2672. PMID 27863994.
- Christodoulides, S.; Dimidi, E.; Fragkos, K. C.; Farmer, A. D.; Whelan, K.; Scott, S. M. (2016-07-01). "Systematic review with meta-analysis: effect of fibre supplementation on chronic idiopathic constipation in adults". Alimentary Pharmacology & Therapeutics. 44 (2): 103–116. doi:10.1111/apt.13662. ISSN 1365-2036. PMID 27170558. S2CID 34178677.
- Sec. 101.81 Health claims: Soluble fiber from certain foods and risk of coronary heart disease (CHD) Archived 2019-05-23 at the Wayback Machine U.S. Food and Drug Administration, Code of Federal Regulations Title 21.
- Olson BH, Anderson SM, Becker MP, Anderson JW, Hunninghake DB, Jenkins DJ, LaRosa JC, Rippe JM, Roberts DC, Stoy DB, Summerbell CD, Truswell AS, Wolever TM, Morris DH, Fulgoni VL (October 1997). "Psyllium-enriched cereals lower blood total cholesterol and LDL cholesterol, but not HDL cholesterol, in hypercholesterolemic adults: results of a meta-analysis". J. Nutr. 127 (10): 1973–80. doi:10.1093/jn/127.10.1973. PMID 9311953.
- Wei ZH, Wang H, Chen XY, Wang BS, Rong ZX, Wang BS, Su BH, Chen HZ (July 2009). "Time- and dose-dependent effect of psyllium on serum lipids in mild-to-moderate hypercholesterolemia: a meta-analysis of controlled clinical trials". Eur J Clin Nutr. 63 (7): 821–827. doi:10.1038/ejcn.2008.49. PMID 18985059. S2CID 205129609.
- Qualified Health Claim for Diabetes Archived 2017-05-08 at the Wayback Machine US Food and Drug Administration (June 24, 2014).
- Niinistö, K.E.; Ruohoniemi, M.O.; Freccero, F.; Raekallio, M.R. (August 2018). "Investigation of the treatment of sand accumulations in the equine large colon with psyllium and magnesium sulphate". The Veterinary Journal. 238: 22–26. doi:10.1016/j.tvjl.2018.06.005. PMID 30103912.
- Dahl, WJ; Stewart, ML (November 2015). "Position of the Academy of Nutrition and Dietetics: Health Implications of Dietary Fiber". Journal of the Academy of Nutrition and Dietetics. 115 (11): 1861–70. doi:10.1016/j.jand.2015.09.003. PMID 26514720.
- Stack PE, Thomas E (1995). "Pharmacobezoar: an evolving new entity". Dig Dis. 13 (6): 356–64. doi:10.1159/000171515. PMID 8590522.
- Abou Azar S, Wehbe MR, Jamali S, Hallal A (2017). "Small Bowel Obstruction Secondary to a Metamucil Bezoar: Case Report and Review of the Literature". Case Rep Surg. 2017: 2702896. doi:10.1155/2017/2702896. PMC 5632449. PMID 29085697.
- "Metamucil oral : Uses, Side Effects, Interactions, Pictures, Warnings & Dosing – WebMD". WebMD. Archived from the original on 2016-11-18. Retrieved 2016-11-17.
- Khalili, B.; Bardana, EJ.; Yunginger, JW. (Dec 2003). "Psyllium-associated anaphylaxis and death: a case report and review of the literature". Ann Allergy Asthma Immunol. 91 (6): 579–84. doi:10.1016/S1081-1206(10)61538-4. PMID 14700444.
- Alemán AM, Quirce S, Bombín C, Sastre J (2001). "[Asthma related to inhalation of Plantago ovata]". Med Clin (Barc) (in español). 116 (1): 20–2. doi:10.1016/S0025-7753(01)71705-8. PMID 11181258.
- Bernedo N, García M, Gastaminza G, Fernández E, Bartolomé B, Algorta J, Muñoz D (2008). "Allergy to laxative compound (Plantago ovata seed) among health care professionals". J Investig Allergol Clin Immunol. 18 (3): 181–9. PMID 18564629.
- Bardy, J-D.; Malo, J-L.; Seguin, P.; Ghezzo, H.; Desjardins, J.; Dolovich, J.; Cartier, A. (1987). "Occupational Asthma and IgE Sensitization in a Pharmaceutical Company Processing Psyllium". The American Review of Respiratory Disease. 135 (5): 1033–1038. doi:10.1164/arrd.19184.108.40.2063 (inactive 2021-01-18). PMID 3579003.CS1 maint: DOI inactive as of January 2021 (link)
- "Metamucil Orange Coarse Milled Original Texture MSDS" (PDF). Procter & Gamble. Archived (PDF) from the original on July 22, 2019. Retrieved July 22, 2019.
- Fischer MH, Yu N, Gray GR, Ralph J, Anderson L, Marlett JA. (2004) The gel-forming polysaccharide of psyllium husk (Plantago ovata Forsk). Carbohydr Res. 2004 Aug 2;339(11):2009–17.
- Carilla, Christina (Jan 25, 2019). "Made In Arizona: Valley factory makes Metamucil for shipping around the world". Fox10. Retrieved 2020-01-21.
- Zabin, Jeff (2004). Precision Marketing: The New Rules for Attracting, Retaining, and Leveraging Profitable Customers. John Wiley & Sons. pp. 58–59.
- "Metamucil - Trademark Details". trademarks.justia.com. Retrieved 21 January 2020.
- "Metamucil - Trademark Details". trademarks.justia.com. Retrieved 21 January 2020.
- "Psyllium Prices, Coupons & Patient Assistance Programs". Drugs.com. Retrieved 7 April 2021. CS1 maint: discouraged parameter (link)