No one wants to talk about constipation. But it’s a chronic problem that undermines the health of millions of Americans. Are you one of them?
This is not the most appealing topic for a magazine article. And that’s part of the problem: Because most of us are uncomfortable talking about our bathroom habits, much less writing about them, they don’t get a lot of air time. As a result, most of us don’t know nearly as much as we should about the topic, which happens to be critical to our health.
Given that 63 million Americans have sluggish bowels, and that constipation can undermine our energy, digestion and detoxification, that it can fuel inflammation and create the breeding grounds for chronic disease, it’s definitely time to throw open the bathroom door and shed some much-needed light on the condition.
“Because we don’t talk about bowel movements, a lot of people don’t know what’s normal and what’s not,” says Carolyn Dean, MD, ND, and coauthor of IBS Cookbook for Dummies (Wiley, 2009). Our modesty around bowel habits is, she points out, a relatively recent development. In the 1600s, she notes, King Louis XIII had a toilet bowl built directly into his throne.
You may not be ready to hold court from the can, but chronic constipation is not something you can afford to either hide or ignore, because it’s both a symptom and a triggering health offender in its own right.
And if you’re suffering from it, you know how much of a toll it can take on your quality of life, says Cynthia Yoshida, MD, an associate professor of gastroenterology at the University of Virginia in Charlottesville and author of No More Digestive Problems (Random House, 2005). “Being constipated,” she says, “just doesn’t feel good.”
But beyond common symptoms like cramping and bloating, many integrative and naturopathic practitioners see a connection between chronic constipation and a host of unexpected maladies, from bad breath and headaches to fatigue and a weakened immune system. And the more you know about the topic, the less constipated you want to be.”
In his book The New Detox Diet: The Complete Guide for Lifelong Vitality (Celestial Arts, 2004), Elson Haas, MD, connects the dots between a stagnant bowel and bad breath. Methane gas, he writes, is the smelly result of an overgrowth in the gut of bad bacteria — which bloom when bowel habits are slow — and eventually it can rise up and waft right out of your mouth.
Horrible, yes. And that, gentle reader, is just the beginning.
How Slow is Too Slow?
When it comes to defining constipation, everyone’s answer is a little different. According to the National Institutes of Health, among others, one of the main symptoms of chronic constipation is having fewer than three bowel movements (BMs) a week for a minimum of 12 weeks (not necessarily consecutive) in the past year.
But many integrative practitioners think that number is far too low. “Optimal bowel transit time is 12 to 24 hours,” says Liz Lipski, PhD, CCN, author of Digestive Wellness: How to Strengthen the Immune System and Prevent Disease Through Healthy Digestion (McGraw-Hill, 2005). “Three bowel movements a week amounts to a transit time of 56 hours, which is way too long.”
Americans eat a mere 5 to 14 grams of fiber a day, which is a pittance compared with the 20 to 35 grams of fiber many nutritionists say we need to keep the trains running on time. Compared with what our hunter-gatherer ancestors ate, today’s recommended daily allowance for fiber is outright laughable. “Our guts used to be scrubbed clean with 100 grams of fiber per day,” says Kathie Swift, MS, RD, coauthor with Gerard Mullin, MD, of The Inside Tract: Your Good Gut Guide to Great Digestive Health (Rodale, 2011).
Because fiber can’t be patented, no one invests much money in studying exactly how fiber supports dietary health, but a study published in the 1970s found that people on a low-fiber diet sent an average of 51 grams (almost 2 ounces) of poop on its way daily and had a BM every 33 hours. When they switched to a high-fiber diet, their daily “outpoop” jumped to 157 grams (5.5 ounces) and a BM arrived every 19 hours on average.
Fiber, Water and Activity
Many integrative practitioners suggest that a “normal” schedule would include two or three bowel movements a day — one for each significant, fiber-rich meal. The problem, though, is that Americans don’t eat nearly enough fiber-rich whole foods, such as vegetables, legumes and fruits. As a result, our low-fiber diet leads directly to constipation.
“Most fiber is a matrix of both soluble and insoluble fiber,” says Swift, and both are key to maintaining healthy bowel movements. “The soluble fiber feeds the flora (good bacteria in the gut); the insoluble fiber helps move things through.”
The gut’s good bacteria, such as lactobacillus and bifidobacteria, help the body digest food, absorb nutrients and facilitate the elimination process. When the bacterial balance is out of whack, due to poor nutrition, stress, illness or antibiotic use, bad bacteria can proliferate and gum up the works. Too many bad guys in the gut can lead to bloating, flatulence and constipation. Long-term health implications include yeast overgrowth (often referred to as candida) and leaky gut syndrome.
Another reason to eat fiber? Bile. A gastrointestinal slush of acids, cholesterol, lecithin and other ingredients, bile plays a key role in degunking your body and keeping inflammation at bay.
Every day, Lipski explains, the liver doles out roughly a quart of soaplike bile that the body uses as a solvent to break food down into digestible particles. Bile also absorbs toxins from fats, drugs, heavy metals and other wastes. And fiber is what moves that polluted bile out of the body.
The longer waste sits in the colon, the more concentrated the bile acids become, she says. Concentrated bile irritates the colon’s lining. And the longer it takes to move through your system, the more irritation that occurs. Additionally, hormones broken down by the body are excreted in the stool. “As feces sit in your colon, those hormones are reabsorbed into the bloodstream,” she says, “which can increase the risk of estrogen-fueled cancers, like breast cancer.”
So, a lack of fiber engenders not just a sluggish system, but a toxic one as well. (For more on the fiber-bile connection, read “Fiber: Why It Matters More Than You Think”.)
In addition to fiber-rich whole foods, the next essential factor in keeping the trains moving on time is water, which works in conjunction with fiber and bile, to dilute waste and move it out of your body.
The body is good at conserving water, though — sometimes too good. The walls of the colon normally absorb excess water from the material that has passed through your digestive system. But if water is in short supply, the colon can resort to sucking too much moisture out of the stool. The stool then dries and hardens, which can lead to pebble-like poop and constipation.
Drinking more water and other liquids during the day (aim for eight 8-ounce glasses) can make your BMs softer and easier to expel. Water also speeds transit time, which is the time food and waste products require to travel through the gastrointestinal (GI) tract.
What you don’t want to drink is soda. “Soda causes electrolyte imbalances, which can upset the gut’s water balance,” says Dean. “Plus, it has a ton of sugar, which feeds bad bacteria and yeast in the gut and can exacerbate constipation.”
The third key factor in proper elimination is exercise. A sedentary lifestyle is a setup for a sluggish gut.
Some experts posit that exercise stimulates the gut’s blood flow, which ups gastrointestinal motility, or movement. “There is a certain amount of musculature in the gut that isn’t under our conscious influence,” says Victor Sierpina, MD, a professor of integrative medicine at the University of Texas Medical School in Galveston, Texas, and author of The Healthy Gut Workbook (New Harbinger, 2010). You can’t command your colon to move, he says, but regular exercise can help encourage it.
The Laxative Factor
Americans spend roughly $725 million a year on over-the-counter laxatives. But most health practitioners consider laxatives a last-resort solution. It appears that chronic use of laxatives, even herbal options such as senna, dried aloe and buckthorn, can cause the bowels to become lazy. Eventually, the muscles of the GI tract become reliant on laxatives to move, says Lipski. “People often find they need more and more laxatives to have the same effect.”
There are times, though, when the judicious use of laxatives makes sense. For instance, painkillers, like those given after surgery, often cause heavy-duty constipation, which can exacerbate discomfort and impede healing. And, anyone who has traveled knows that transit time can slow considerably when one is on the road, away from home and life’s daily routines.
In these cases, mild, bulk-forming natural laxatives, such as psyllium supplements, are considered by many docs to be the first choice because they are generally safe and have fewer side effects — as opposed to stimulant-type laxatives, which cause the muscles that line the digestive tract to contract rhythmically and push out the poop. “These can really cause the bowel to go crazy,” says gastroenterologist Saad Habba, MD. He doesn’t recommend them because they can cause cramping as well as upset the body’s electrolyte balance.
Ultimately, it all comes down to what ends up in the toilet bowl. So what do you want to see there? A soft, but well-formed, relatively continuous stool, probably at least 6 inches long, and about 150 grams in weight (not that you’re going to weigh it, but for comparison, that’s about the weight of an average apple).
The ideal stool is sausage-shaped with a smooth or slightly cracked surface. If you see hard “rabbit pellets,” that’s a definite sign of constipation. A too-liquidy or unformed bowel movement, meanwhile, could indicate that you ate something that does not agree with you.
And what if there’s nothing at all? First, relax. Seriously, to properly propel poop from the body, the external anal sphincter and puborectalis muscle must voluntarily relax, allowing the pelvic-floor muscles to descend (thus lengthening the rectum and allowing the stool to exit).
Second, keep in mind that stress, physical trauma, childbirth, or a variance in schedule or routine (often caused by travel) can result in temporary constipation. Typically, regular bowel movements will resume once the situational stressors resolve. In the meantime, fiber, water and exercise can all help move things along. Obsessing about your bowel movements (or lack thereof) generally will not.
“We are a product of biological and environmental components,” says Habba. Meaning that certain emotional and physical stars must align for most of us to feel comfortable answering nature’s call. It’s our job to do what we can to create the right conditions for regularity (see sidebar), then get out of the way — and let nature’s wisdom take over.
Yes, you’ve been sitting on the john since you were a tot, but, if constipation is an issue, you might want to reconsider your technique. Many experts recommend a “semi-squatting” position. There is a very good reason why so many people around the world squat to poop, says Carolyn Dean, MD, ND. And it’s not just about primitive plumbing.
More specifically, the puborectalis muscle supports the rectum and enables us to control when we poop. The muscle acts as a safety valve. When we sit or stand, the muscle is taut. When we squat, the muscle relaxes, like a hammock, and that slack encourages bowel evacuation. That relaxation of the muscle, plus sheer convenience, is why many cultures continue to squat and poop. “The anal sphincter ties things off so you won’t lose anything,” says Dean, “but a good squat or semi-squat stretches the sphincter so you can have a good bowel movement.”
While Dean doesn’t recommend you rip out your toilet, she does suggest getting your knees a few inches above your hips to better enable the muscles of the pelvic floor to relax. The easiest way is to get a small footstool, place it in the bathroom near the toilet, and put your feet on it when you sit down. If you share a bathroom with small children, you might have a stepstool handy. If not you can just take all the “books and magazines you’ve been reading during your constipated sessions on the toilet and pile them into a makeshift stool,” she says. “You won’t need to keep reading material in the john anymore because your sessions will fly by!”
If just propping up your feet doesn’t do the trick, Dean recommends leaning forward on the toilet seat until your chest touches your knees. Then wrap your arms around your thighs. Then inhale deeply. Then exhale as you push down on your pelvic muscles. If you are away from home and don’t have access to your footstool, just do the hug part of this exercise with a long deep breath.
Constipation: What NOT to Eat
One of the major reasons so many Americans suffer chronic constipation is that they don’t eat enough colorful, whole-food sources of fiber, such as veggies, fruit, whole grains and legumes. Adding to the problem, they eat a variety of foods that actually promote constipation. According to Carolyn Dean, MD, ND, and coauthor of IBS Cookbook for Dummies (Wiley, 2009), the foods that most promote constipation are high-starch foods, dairy products, sugar products, dehydrated foods and low-fiber foods, in general. Below is a quick list, from Dean, of some constipation-inducing foods:
• Bread, Crackers
• Ice cream
• Dehydrated foods
• Sugary foods such as pies, cakes and cookies
• Fast Food (hamburgers, hotdogs, pizza, etc.)
• Processed foods in general