Systematic Review

Psyllium is a natural nonfermented gel-forming fiber that is

effective for weight loss: A comprehensive review and meta-
analysis
Roger D. Gibb, PhD1, Kyle J. Sloan, PharmD1, & Johnson W. McRorie, Jr PhD, FACG, AGAF, FACN1

ABSTRACT
Background: Psyllium is a natural, predominantly soluble fiber that forms a viscous gel when hydrated and is not
digested or fermented. In the small intestine, psyllium gel increases chyme viscosity, slowing the degradation and
absorption of nutrients. Psyllium has a significant effect in patients with metabolic syndrome and type-2 diabetes on
glycemic control, while lowering serum cholesterol in hypercholesterolemic patients. Some randomized controlled
studies have shown that psyllium also facilitates weight loss in overweight and obese participants.
Objectives: A comprehensive review and meta-analysis assessing psyllium’s impact on body weight, body mass index
(BMI), and waist circumference in overweight and obese participants.
Data sources: A comprehensive search was performed (Medline, Scopus, Cochrane Database) through March 21, 2022,
using search terms to identify randomized, controlled, clinical studies designed to assess weight loss in overweight
and obese participants over at least 2 months. Data were analyzed using the inverse variance method with random
effects models.
Conclusions: Six studies meeting inclusion criteria were identified (total n = 354). The meta-analysis showed that
psyllium, dosed just before meals (mean dose 10.8 g/day, mean duration 4.8 months), was effective for decreasing
body weight (MD = 22.1 kg [95% confidence interval [CI]: 22.6 to 21.6]; p < .001), BMI (MD = 20.8 kg/m2 [95% CI: 21.0
to 20.6]; p < .001) and waist circumference (MD = 22.2 cm [95% CI: 22.9 to 21.4]; p < .001) in overweight and obese
populations.
Implications for practice: Gel-forming nonfermented psyllium fiber, dosed just before meals, is effective in facili-
tating weight loss in overweight and obese participants.
Keywords: Body mass index; ispaghula; obese; overweight; psyllium; weight.

Journal of the American Association of Nurse Practitioners 35 (2023) 468–476, © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on
behalf of the American Association of Nurse Practitioners

DOI# 10.1097/JXX.0000000000000882

The Centers for Disease Control and Prevention (CDC) overweight/obese (73.6%; 2017–2018) (CDC Obesity and
defines “overweight” as a body mass index (BMI) of 25 Overweight, 2022d). When obesity is considered sepa-
to <30 kg/m2 and “obese” as a BMI of $30.0 kg/m2 (CDC rately, the prevalence is 41.9% of the US adult population
Defining Adult Overweight & Obesity, 2022c). Most adults (2017–2018) (CDC Adult Obesity Facts, 2022b). Epidemio-
in the United States (aged 20 years and older) are logic data suggest that dietary fiber intake is inversely
associated with body weight (Anderson et al., 2009).
1
However, it is important to note that statistical associa-
The Procter & Gamble Co., Mason, Ohio
tions do not establish causation. Epidemiologic data
This is an open access article distributed under the terms of the
Creative Commons Attribution-Non Commercial-No Derivatives cannot establish that the fiber component of a high-fiber
License 4.0 (CCBY-NC-ND), where it is permissible to download and diet is the causative agent for any observed change in
share the work provided it is properly cited. The work cannot be
changed in any way or used commercially without permission from
body weight. Furthermore, recommendations to adhere
the journal. to a high-fiber diet, which are based on a statistical as-
Correspondence: Roger D. Gibb; E-mail: [email protected] sociation between a high-fiber diet and a reduced risk of
Supplemental digital content is available for this article. Direct URL cardiovascular disease, have not led to a decrease in the
citations appear in the printed text and are provided in the HTML and
prevalence of obesity in the United States (Institute of
PDF versions of this article on the journal’s Web site (www.jaanp.com).
Received: 12 January 2023; revised: 29 March 2023; accepted 4 April
Medicine Food and Nutrition Board, 2002). From 1999 to
2023 2000 through 2017–2020, the prevalence of obesity

468 August 2023 · Volume 35 · Number 8 Journal of the American Association of Nurse Practitioners
 R. D. Gibb et al.

increased from 30.5% to 41.9%, and the prevalence of with other actives), at least 7 g/day in divided doses
severe obesity increased from 4.7% to 9.2% (CDC Adult before/with meals, and consistent background diet
Obesity Facts, 2022b). Childhood obesity is also a serious throughout the study. Studies designed to assess the
problem in the United States, with a 19.7% prevalence of cholesterol-lowering effects of psyllium in hypercholes-
obesity in children and adolescents aged 2–19 years (14.7 terolemia were excluded because by design, these stud-
million children and adolescents, 2017–2020) (CDC ies attempt to maintain a stable body weight throughout
Childhood Obesity Facts, 2022a). Obesity increases the the study to remove weight loss as a confounding factor
risk of serious health consequences, including all-cause for cholesterol lowering (McRorie, et al., 2021). For exam-
mortality, hypertension, dyslipidemia, type-2 diabetes, ple, “…if the weight varied by > 1 kg, the energy intake was
coronary heart disease, stroke, gallbladder disease, os- modified.”(Sola et al., 2010). Also, “The study protocol
teoarthritis, sleep apnea, many types of cancers, low specified that participants should attempt to maintain a
quality of life, clinical depression, anxiety, body pain, and stable body weight throughout the trial.” (Davidson et al.,
difficulty with physical functioning (CDC Health Effects of 1998). Study designs were independently evaluated for
Overweight and Obesity, 2022e). Modest weight loss (e.g., inclusion by two investigators (R.D.G., J.W.M.).
5–10%) can lead to significant improvement in health
outcomes (Brown et al., 2021). Data extraction and assessment of bias
To establish whether fiber plays a direct/causative Two reviewers separately extracted data from identified
role in weight loss, isolated fibers must be assessed in articles. Data extracted included population studied,
randomized controlled clinical studies that are ade- sample size, subject demographics (sex, age, BMI), study
quately designed to assess weight loss. Adequate study design, treatment duration, blinding, dose, treatment
design includes duration (e.g., multiple months), dose comparator, administration form, background diet, fund-
(e.g., 10 g/day in divided doses taken with meals), ap- ing source, and country. Efficacy data were extracted for
propriate population (overweight/obese), and a negative each treatment group in one of the following formats: 1)
control. Studies that take steps to maintain subject baseline and end-of-treatment mean and standard error
weight constant, as often done in cholesterol-lowering (SE) or SD and 2) change from baseline mean and SE, SD, or
research where weight loss is considered a confounding 95% confidence interval (CI). In some cases, data were
factor, should be excluded from consideration (McRorie, available in graph but not table format, in which case,
Gibb, et al., 2021). Although subjective measures of relevant data were extracted from figures with Un-Scan-It
satiety/hunger and single meal measures of energy in- Graph Digitizing Software Version 7.0 for Windows. In some
take might be considered suggestive of a potential for cases, authors were contacted for additional information.
weight loss, only well-controlled, multimonth, clinical The Cochrane Risk of Bias Tool (The Cochrane Col-
studies that directly assess weight loss can establish laboration, 2020) was used to assess the following five
clinical efficacy. The objective of this comprehensive re- standard domains: random sequence generation (selec-
view and meta-analysis was to assess the clinical efficacy tion bias), allocation concealment (selection bias),
of psyllium, a natural nonfermented gel-forming fiber blinding (performance bias), incomplete outcome data
supplement, on weight loss in overweight and obese (attrition bias), and selective outcome reporting (report-
participants. ing bias). Each domain was considered “low risk of bias”
when the outcome was unlikely to be affected, “unclear
Methods risk of bias” when insufficient information was provided
Data sources to make judgment, and “high risk of bias” when the out-
A comprehensive search was performed using Medline, come was likely affected.
Scopus, and Cochrane Central Register of Controlled Tri-
als. The original searches were performed on March 15–18, Data management and statistical analysis
2021, and updated on March 21, 2022. Reference lists of Summary body weight, BMI, and waist circumference data
identified studies and reviews were manually searched were extracted from each publication. When baseline and
for additional studies. Key search terms included psyl- postbaseline treatment means and corresponding SDs
lium, ispaghula, weight, body mass index, overweight, and were available, the baseline to postbaseline correlation
obese. was approximated from the reported treatment-
comparison p values. For Pal et al. (2011), it was observed
Study eligibility that postbaseline weight and BMI means were lower
Publications identified by searches were screened for compared with baseline in all treatment groups, yet waist
inclusion based on the following study design criteria: circumference means were all higher than baseline. An
randomized, concurrent negative control, inquiry was made to the first author to reconcile this
overweight/obese participants, treatment of at least unlikely finding, and she reported that the reported waist
2 months in duration, psyllium alone (not in combination circumference change from baseline magnitudes were

Journal of the American Association of Nurse Practitioners August 2023 · Volume 35 · Number 8 469
 Systematic Review Psyllium weight loss meta-analysis

total of 354 participants. Females comprised 57% of the

entire population. Mean age ranged from >35 to 58 years.
Abutair, et al. (2016) reported that subject age was >35
years, but not the mean age. All study populations were
either overweight or obese, with mean BMI ranging from
28.7 to 33.9 kg/m2. All studies followed a randomized,
controlled, parallel-group design and evaluated psyllium
doses ranging from 7 to 15 g/day for periods of 2–
12 months. One study was double blind, four were single
blind, and in one study participants were not blinded.
Results of the Cochrane Risk of Bias assessment are
summarized in Supplemental Digital Content 2, http://
links.lww.com/JAANP/A212. In no case was the risk of bias
considered to be high. For sequence generation, blinding,
and incomplete outcome data, the percentage of studies
Figure 1. Summary of the literature search for the effect of judged to be low risk of bias was 50%, 17%, and 67%, re-
psyllium fiber on body weight, BMI, and waist circumference. spectively. The risk of bias was unclear for all studies
regarding allocation concealment and selective outcome
reporting.
correct but that their signs were inadvertently reversed
(i.e., on average, waist circumference decreased
Effect of psyllium on body weight
postbaseline).
The mean effect of psyllium fiber on body weight relative
The standard inverse-variance method with random-
to negative control is shown in Figure 2A. In five of the six
effects model was used to perform meta-analysis calcu-
clinical studies, a statistically significant reduction in
lations for each end point. Results were reported as mean
mean weight was reported for psyllium relative to control.
difference (MD) with 95% CI and interpreted as statisti-
The overall mean effect is highly statistically significant
cally significant at p < 5%. Interstudy heterogeneity was
(MD = 22.1 kg [95% CI: 22.6 to 21.6]; p < .001). There was no
assessed and quantified with the Cochrane Q-statistic
indication of interstudy heterogeneity (I2 = 0%, p = .67),
and I2 (West et al., 2013). Publication bias for body weight,
evidenced by the consistency of results across studies
BMI, or waist circumference was not assessed with the
and overlap in CIs.
funnel plot asymmetry test because in each instance,
there were fewer than 10 studies available. Comprehen-
Effect of psyllium on body mass index
sive Meta-Analysis software version 2.2.064 was used to
The mean effect of psyllium fiber on BMI relative to
make meta-analysis calculations. Forest plots were cre-
negative control is shown in Figure 2B. Not surprisingly,
ated with SAS/GRAPH software running on SAS Enterprise
results essentially mirror those of body weight. In five of
Guide, version 7.15 HF9 for Windows 10.
the six clinical studies, a statistically significant reduction
in mean BMI was reported for psyllium relative to control.
Results The overall mean effect is highly statistically significant
Search results (MD = 20.8 kg/m2 [95% CI: 21.0 to 20.6]; p < .001). There
The results of the literature review are summarized in was no evidence of interstudy heterogeneity (I2 = 0%,
Figure 1. A total of 2,496 citations were identified in the initial p = .71).
search, with 48 reviewed in full. A total of six articles satisfied
the design criteria and were included in the final meta- Effect of psyllium on waist circumference
analysis. Body weight and BMI were reported in all six arti- The mean effect of psyllium fiber on waist circumference
cles (n = 354) (Abutair et al., 2016; Akbarzadeh et al., 2016; relative to negative control is shown in Figure 2C. The
Cicero et al., 2010; Pal et al., 2011, 2016; Soltanian & Jan- overall mean effect is highly statistically significant
ghorbani, 2019), whereas waist circumference was reported (MD = 22.2 cm [95% CI: 22.9 to 21.4]; p < .001). There was
in just five articles (n = 303) (Abutair et al., 2016; Akbarzadeh no indication of interstudy heterogeneity (I2 = 0%, p = .49).
et al., 2016; Cicero et al., 2010; Pal et al., 2011, 2016).
Discussion
Meta-analysis population characteristics The epidemic of obesity
The characteristics of the six clinical studies included in According to the CDC, obesity is an epidemic in the United
the meta-analysis are summarized in Supplemental Dig- States (CDC Adult Obesity Facts, 2022b). Nearly three of
ital Content 1, http://links.lww.com/JAANP/A211. Studies every four adults are overweight or obese (73.6%;
were conducted in four different countries and included a 2017–2018), with approximately 4 of 10 qualifying as obese

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 R. D. Gibb et al.

Figure 2. The effect of psyllium fiber on body weight (A), BMI (B), and waist circumference (C) in overweight and obese individuals
relative to negative control. Squares represent the mean treatment difference with 95% CI. Diamonds represent the overall effect
size and 95% CI, using the generic inverse-variance random-effects model. As mentioned earlier, the sign of the Pal et al. (2011) result
shown here for waist circumference is opposite that reported in the publication; this corrects an error found through
correspondence with the first author. CI = confidence interval; BMI = body mass index.

Journal of the American Association of Nurse Practitioners August 2023 · Volume 35 · Number 8 471
 Systematic Review Psyllium weight loss meta-analysis

(BMI $30 kg/m2) (CDC Adult Obesity Facts, 2022b; CDC (McRorie et al., 2021). In the Xiao et al. (2020) meta-
Obesity and Overweight, 2022d). Obesity increases the analysis of weight, three studies (Abutair et al., 2016;
risk of serious health consequences, including all-cause Soltanian & Janghorbani, 2019; Anderson, et al., 1999) were
mortality, hypertension, dyslipidemia, type-2 diabetes, included. Soltanian was incorrectly cited with the au-
coronary heart disease, stroke, gallbladder disease, os- thor’s first name, “Noureddin,” instead of the last name
teoarthritis, sleep apnea, many types of cancers, low “Soltanian.” More importantly, the treatment effect in that
quality of life, clinical depression, anxiety, body pain, and study showed statistically significant weight loss with
difficulty with physical functioning (CDC Health Effects of psyllium, yet Xiao et al. (2020) reported weight gain for the
Overweight and Obesity, 2022e). It is important that a study in the meta-analysis. In addition, Anderson et al.
relatively small decrease in body weight, such as 5–10%, (1999) conducted a cholesterol-lowering study designed
can decrease health risks/improve overall health (Brown to maintain a stable body weight, which may have mini-
et al., 2021). mized observed weight loss (“During the dietary stabili-
zation phase, participants received instruction on a
Meta-analysis findings traditional weight-maintaining diabetes exchange diet
This systematic review and meta-analysis of six, ran- ….”). These findings undermine the credibility of the body
domized, controlled, clinical studies was designed to weight meta-analysis results reported by Xiao et al., 2020.
evaluate the effects of psyllium on body weight, BMI, and The second meta-analysis by Mofrad et al. (2020) in-
waist circumference in overweight and obese partici- cluded 23 published studies, but most of the studies did
pants (Abutair et al., 2016; Akbarzadeh et al., 2016; Cicero not meet the above criteria for inclusion in a weight loss
et al., 2010; Pal et al., 2011, 2016; Soltanian & Janghorbani, meta-analysis. For example, three studies (Hylander &
2019). The three meta-analyses showed that divided Rӧssner, 1983; Wolever et al., 1994; Vuksan et al., 2008)
doses of psyllium (before meals, 7–15 g/day, mean 10.8 had a treatment duration of only 2–3 weeks, minimizing
g/day; duration 2–12 months, mean 4.8 months) resulted any potential to observe significant weight loss. One
in statistically significant reductions in body weight study (Ricklefs-Johnson et al., 2017) compared high-dose
(22.1 kg, p < .001), BMI (20.8 kg/m2, p < .001), and waist flaxseed (28 g/day) to a lower dose of psyllium (9 g/day)
circumference (22.2 cm, p < .001). These meta-analyses without a negative control. Mofrad et al. (2020) presented
strengthen the existing clinical evidence that psyllium, this disparate comparison as “weight gain” for psyllium in
dosed before meals as a dietary supplement, provides an the forest plot. However, a review of the original study
effective modality for reducing body weight, BMI, and data showed that psyllium 9 g/day resulted in weight loss
waist circumference in overweight and obese pop- versus baseline. Seven of the publications included were
ulations. An average weight loss of 2.1 kg over an average cholesterol-lowering studies, which consider weight
of 4.8 months translates to 20.44 kg/month. Over a 12- loss a confounding factor to be avoided to show that the
month period, this would translate to a weight loss of fiber, not weight loss, yielded the observed changes in
5.3 kg, which is 6.1% of the average body weight of the serum cholesterol concentration. Most of the
participants in the six clinical studies (86.6 kg). This cholesterol-lowering publications provided statements
weight loss falls within the 5–10% weight loss range in the methods section that a stable weight was main-
shown to improve overall health (Brown et al., 2021). tained throughout the study (e.g., Sola et al., 2010 “…if the
weight varied by > 1 kg, the energy intake was modified.”).
Apparent contradiction of other meta-analysis findings Removing the publications with inappropriate study de-
Two previous meta-analyses concluded that psyllium had signs from the Mofrad et al. (2020) and Xiao et al. (2020)
no significant effect on weight loss, but both online meta-analyses, as was done in the current meta-analysis,
publications had significant methodological flaws showed significant weight loss for psyllium.
(Mofrad et al., 2020; Xiao et al., 2020). As discussed in the
methods section, a meta-analysis of the effects of a Psyllium weight loss mechanism of action
specific fiber on weight loss should focus on studies with Despite decades of research, the cause of the obesity
1) a sufficient dose of the specific fiber (e.g., 10–15 g/day epidemic in the United States remains open to debate.
for psyllium) delivered just before/with meals; 2) a suf- The conventional mantra, “energy balance,” asserts that
ficient duration of treatment for significant weight loss to all calories are equal, and obesity is a matter of balancing
occur (e.g., multiple months); 3) an overweight/obese “calories in versus calories out.” As concluded in a 2017
population (significant weight loss does not occur in publication entitled “Obesity Pathogenesis: An Endocrine
normal or underweight participants with fiber consump- Society Scientific Statement,” “a calorie is a calorie,” and
tion); and 4) does not preclude the potential for weight “A major area of emphasis is the science of energy ho-
loss to occur as part of the study design (e.g., cholesterol- meostasis, the biological process that maintains weight
lowering studies typically specify that weight loss is a stability by actively matching energy intake to energy
confounding factor and is controlled/minimized) expenditure over time.” (Schwartz et al., 2017). The

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 R. D. Gibb et al.

Endocrine Society also acknowledged, “However, growing glycemic control. A meta-analysis of patients with type-2
evidence indicates that obesity pathogenesis involves diabetes found that psyllium lowered fasting glucose by
processes far more complex than the passive accumula- 37 mg/dl (p < .001) and HbA1c by 0.97% (p = .048) on av-
tion of excess calories. It is this complexity that lies at the erage compared with placebo (Gibb et al., 2015). Taken
heart of why obesity is so difficult to treat.” (Schwartz together, it is plausible that the mechanism by which
et al., 2017). psyllium caused a reduction in body weight was
A competing theory asserts that it is not the number of primarily a decrease in serum insulin concentration and
calories consumed, but the composition of the food (e.g., insulin resistance. As further evidence, a statistically
100 calories of spinach produce a completely different significant (p # .01) reduction in fasting insulin and in-
metabolic response than 100 calories of bacon or 100 sulin resistance was reported in two of the studies
calories of candy) (Fung, 2016). The fact that the inflection assessed in the current meta-analyses (Abutair et al.,
point of the US obesity epidemic coincides with the US 2016; Cicero et al., 2010). A reduction in insulin resistance
Federal Government’s publication of The Dietary Goals for has also been proposed as the mechanism of action by
the United States in 1977 (Select Committee on Nutrition which psyllium lowers blood pressure (Schulman & Zhou,
and Human Needs, 1977) is often cited as supportive ev- 2009). All things considered, the most plausible evidence-
idence. The government’s dietary guidelines, built on the based explanation for the weight loss observed in this
“calories in versus calories out” theory, caused an over- meta-analysis for psyllium is a combination of reduced
haul of the American diet away from fat and toward re- insulin resistance through improved glycemic control
fined carbohydrates. According to the “insulin imbalance” and caloric reduction from increased satiety, the former
model, increased consumption of refined carbohydrates likely being more substantial than the latter.
results in elevated insulin levels, which then drive calo-
ries into adipose tissue (Fung, 2016). Therefore, obesity is Hierarchy of evidence-based scientific research
not a problem of caloric imbalance but rather hormonal Evidence-based clinical practice has a hierarchy of sci-
imbalance, where the primary hormone is insulin. Fur- entific evidence. Meta-analyses are the highest order of
thermore, chronic hyperinsulinemia fueled by chronic clinical evidence (Figure 3; Duke University, 2022). The
overconsumption of sugar and refined carbohydrates lowest order is nonhuman studies (animal studies and
results in insulin resistance in liver and muscle tissues. in vitro studies), whereas the next four levels are obser-
Insulin resistance forces the pancreas to drive insulin vational studies (not randomized or placebo controlled),
levels even higher, thus accelerating the body’s slide to- which cannot establish cause and effect (Figure 3). The
ward obesity (Bikman, 2020; Fung, 2016). This poses a third highest level is composed of prospective, random-
question: which model of weight gain, “calories in versus ized, controlled clinical studies, the gold standard for
calories out” or “insulin imbalance,” best explains the individual clinical studies. The top two levels are con-
weight loss observed in the current meta-analysis? sidered “synthesized evidence,” combining available
All six of the studies were randomized and designed to randomized/controlled clinical studies into a systemic
balance caloric intake across treatment groups. However, review or meta-analysis of randomized, controlled, clin-
psyllium does provide a modest satiety effect (Brum et al., ical studies. Individual randomized controlled clinical
2016), and this could have resulted in small unobserved studies can vary significantly in their outcomes, so it is
reductions in caloric intake for psyllium treatment important to rigorously/statistically evaluate the totality
groups. However, it should be noted that two clinical of clinical evidence from randomized controlled clinical
studies assessed the effects of psyllium on macronutrient studies. A statistically significant outcome in meta-
and micronutrient absorption and found that psyllium analysis of randomized, controlled, clinical studies
had no significant effect on either (Kawasakia et al., 2010; supports a conclusion of “clinically proven.”
Pal et al., 2022). Therefore, the satiety effect of psyllium Figure 3 shows the hierarchy of scientific evidence for
might help explain some of the weight loss observed for evidence-based clinical practice (reprinted with permis-
psyllium, but it seems an unlikely explanation for the sion from Duke University Medical Center Library and
entire effect observed in this meta-analysis. Archives (2022)). Meta-analyses of randomized controlled
All participants in the current meta-analysis were clinical studies represent the highest order of clinical
overweight/obese and, per the “insulin imbalance” evidence. A statistically significant outcome supports a
model, they should have experienced some degree from conclusion of “clinically proven.”
insulin resistance. Two of the six studies were comprised
patients with type-2 diabetes (Abutair et al., 2016; Sol- Health benefits of psyllium
tanian & Janghorbani, 2019), whereas one study In addition to the current meta-analysis showing that
assessed a population with metabolic syndrome (Cicero psyllium provided significant reductions in body weight,
et al., 2010). Psyllium has been shown to provide signifi- BMI, and waist circumference, other published meta-
cant glycemic benefits in patients with compromised analyses have shown psyllium to be clinically proven for

Journal of the American Association of Nurse Practitioners August 2023 · Volume 35 · Number 8 473
 Systematic Review Psyllium weight loss meta-analysis

Figure 3. Hierarchy of scientific evidence for evidence-based clinical practice (reprinted with permission from Duke University
Medical Center Library and Archives34). Meta-analyses of randomized, controlled, clinical studies represent the highest order of
clinical evidence. A statistically significant outcome supports a conclusion of “clinically proven.”

additional health benefits (Table 1). These include de- in patients with hypertension (Khan et al., 2018). A recent
creasing fasting blood glucose and HbA1c in patients with meta-analysis also showed that nonfermenting gel-
metabolic syndrome and type 2 diabetes (Gibb et al., 2015), forming psyllium is more effective than wheat bran for
lowering elevated low-density lipoprotein (LDL) and total increasing stool output in patients with chronic idiopathic
cholesterol in patients with hypercholesterolemia (Jova- constipation (McRorie et al., 2020). The water-holding ca-
novski et al., 2018), providing a cholesterol-lowering benefit pacity of the psyllium gel acts as a stool normalizer, soft-
equivalent to doubling the dose of a statin drug in patients ening hard stool in constipation, firming loose/liquid
already being treated for hypercholesterolemia with a stools in diarrhea, and normalizing stool form/reducing
statin drug (Brum et al., 2018) and lowering blood pressure symptoms in irritable bowel syndrome (IBS) (McRorie et al.,

Table 1. Summary of clinically proven health benefits for Psyllium

Health Benefit Treatment Population Meta-Analysis Reference
Weight loss Overweight/obese Current study

Improved glycemic control Metabolic syndrome, type-2 diabetes Gibb et al., 2015
mellitus, prediabetes

Cholesterol lowering Hypercholesterolemia Jovanovski et al., 2018

Lower blood pressure Hypertension Khan et al., 2018

Increased stool output/softer stools Chronic idiopathic constipation McRorie et al., 2020

Normalize stool form/decrease Irritable bowel syndrome Ford et al., 2008

symptoms Moayyedi et al., 2014

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 R. D. Gibb et al.

2020). Psyllium is the only isolated fiber recommended for Akbarzadeh, Z., Nourian, M., Askari, G., & Maracy, M. (2016). The effect of
Psyllium on body composition measurements and liver enzymes
treatment of IBS by the American College of Gastroenter-
in overweight or obese adults with nonalcoholic fatty liver disease
ology (Ford et al., 2018) and chronic idiopathic constipation (NAFLD). International Journal of Advanced Biotechnology Re-
by the American Gastroenterological Association (Bhar- search, 7(3), 1545–1554. https://www.researchgate.net/pu-
blication/290527713_The_effect_of_psyllium_on_anthropomet-
ucha et al., 2013).
ric_measurements_and_liver_enzymes_in_overweight_or_
A limitation on this meta-analysis is the relatively small obese_adults_with_nonalcoholic_fatty_liver_disease_NAFLD
number of clinical studies. Although the meta-analysis Anderson, J., Allgood, L., Turner, J., Oeltgen, P., & Daggy, B. (1999). Ef-
fects of psyllium on glucose and serum lipid responses in men
included data from three continents, a broader represen-
with type 2 diabetes and hypercholesterolemia. The American
tation from other populations, including the United States, Journal of Clinical Nutrition, 70(4), 466–473. https://doi.org/10.
would have provided a more robust picture of psyllium 1093/ajcn/70.4.466
Anderson, J., Baird, P., Davis, R. H. Jr, Ferreri, S., Knudtson, M., Koraym,
efficacy. In addition, four of the six studies were just 2–
A., Waters, V., & Williams, C. (2009). Health benefits of dietary fiber.
3 months in duration and thus afford limited information Nutrition Reviews, 67(4), 188–205. https://doi.org/10.1111/j.
on the long-term weight loss potential of psyllium fiber in 1753-4887.2009.00189.x
Bharucha, A., Pemberton, J., & Locke, G. (2013). American gastroen-
overweight and obese individuals. Finally, the majority of
terological association technical review on constipation. Gastro-
Cochrane Risk of Bias assessments (Supplemental Digital enterology, 144(1), 218–238. https://doi.org/10.1053/j.gastro.2012.
Content 2, http://links.lww.com/JAANP/A212) resulted in 10.028
Bikman, B. (2020). Why we get sick: The hidden epidemic at the root of
“unclear risk of bias” owing to the lack of complete in-
most chronic disease: And how to fight it. BenBella Books.
formation provided in published results. Brown, J., Buscemi, J., Milsom, V., Malcolm, R., & O’Neil, P. (2016). Effects
on cardiovascular risk factors of weight losses limited to 5–10%.
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Conclusions org/10.1007/s13142-015-0353-9
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In conclusion, the present meta-analysis showed that
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Data sharing: All data used to conduct the reported meta- sion, while guar gum reduces body weight more rapidly in patients
affected by metabolic syndrome following an AHA Step 2 diet.
analysis are shared in this article.
Mediterranean Journal of Nutrition and Metabolism, 3(1), 47–54.
https://doi.org/10.1007/s12349-009-0056-1
Authors’ contributions: J. W. McRorie conceived the idea Darooghegi Mofrad, M., Mozaffari, H., Mousavi, S., Sheikhi, A., & Mila-
jerdi, A. (2020). The effects of psyllium supplementation on body
of conducting the meta-analysis. R. D. Gibb conducted the
weight, body mass index and waist circumference in adults: A
meta-analysis. J. W. McRorie and R. D. Gibb wrote the systematic review and dose-response meta-analysis of random-
manuscript and had primary responsibility for final con- ized controlled trials. Critical Reviews in Food Science and Nutri-
tion, 60(5), 859–872. https://doi.org/10.1080/10408398.2018.
tent. All authors read and approved the final manuscript.
1553140
Davidson, M., Maki, K., Kong, J., Dugan, L., Torri, S., Hall, H., Drennan, K.,
Competing interests: The authors are employees of Anderson, S., Fulgoni, V., Saldanha, L., & Olson, B. (1998). Long-term
effects of consuming foods containing psyllium seed husk on
Proctor and Gamble, the manufacturer of Metamucil, a
serum lipids in subjects with hypercholesterolemia. The American
psyllium-containing product. Journal of Clinical Nutrition, 67(3), 367–376. https://doi.org/10.
1093/ajcn/67.3.367
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