Constipation

by Adriane Fugh-Berman, M.D.
A teacher of mine used to quiz medical students about the leading cause of constipation. After shaking his head to the list of diseases generated by the students, he would give the correct answer: ‘Lofty expectations.’
Some people move their bowels twice a day, others twice a week; whatever is normal for you is normal. Many people believe that everyone should move their bowels at least once daily, and that to do otherwise not only constitutes constipation but also leads to poor health. Some even prescribe the ‘best’ time; at one workshop, an alternative medicine practitioner recommended moving one’s bowels between 5:00 and 6:00 am! Actually, there is no evidence that moving ones bowels less than once a day (or in the afternoon!) is associated with poor health.
The belief that constipation causes disease is an ancient one. Thousands of years ago, people believed that disease was caused by intestinal waste poisoning the body. In the 19th century, the concept that toxins built up in the intestine and caused disease was very popular; the condition was called ‘intestinal autointoxication’. For prevention, Sylvester Graham and W.K. Kellogg promoted a high-fiber diet. Graham, of course, lent his name to the Graham cracker (‘graham’ is another term for whole wheat flour), and Kellogg cereal originally was a high-fiber, ready-to-eat breakfast cereal.
More drastic treatments were introduced in the 20th century. The most extreme therapy was used between 1900 and 1920, when surgery was recommended for constipation. A physician named Sir William Lane was instrumental in making the removal of part of the colon into a popular treatment for severe constipation. In the 1920s and 1930s, drugs and devices replaced surgery. Common treatments in this time included colonic irrigation, rectal dilators, abdominal massage machines, and electrical stimulators.
These treatments eventually fell out of favor, and interest in a high fiber diet returned. After spending time in Uganda, a physician named Denis Burkitt theorized that Africans’ traditional high-fiber diet was the reason the area had such a low bowel cancer rate. Burkitt believed that ‘constipation is the commonest Western disease.’
The idea that bowel cancer is a disease caused by a modern low-fiber diet had enough support in the scientific community that several clinical trials were done to test the effect of high-fiber diets on precancerous lesions in the colon. Surprisingly, adding bran or psyllium seed to the diet did not affect the progression of the precancerous condition.
Today, the popularity of ‘internal cleansers’ (a modern euphemism for laxatives) attests to the continued belief that constipation is bad for health. but there is still no solid evidence that that’s true. The fact is, you’re not constipated if you don’t move your bowels every day. You’re only constipated if you’re uncomfortable and/or have difficulty evacuating your bowels. Some people get constipated when they travel, especially if they cross time zones. And some women become constipated when they are premenstrual or pregnant. Diabetes, Parkinson’s disease, and several other conditions can cause very severe constipation.
Dietary changes can also cause constipation. Certainly, the amount of fiber in the diet can affect the size, consistency, and frequency of one’s bowel movements. Fiber is the indigestible portion of fruits, vegetables, whole grains, nuts, etc. There are two kinds of fiber: insoluble fiber, which includes wheat bran, and soluble fiber, which includes psyllium seed or husk, oat bran, and fruit pectin. Both kinds of fiber absorb water, but soluble fibers swell up into a gel.
Eating more fiber or dried fruit to treat constipation is quite safe and can be used on a regular basis. A few cautions, however. Suddenly increasing your fiber intake can cause bloating, gas, or diarrhea. Some people are allergic to psyllium and should not use it. And consuming psyllium or a high-fiber diet can reduce the absorption of some drugs; if you take chronic medication, check with your health care practitioner about this. Finally, increasing fiber without increasing fluid intake can worsen constipation.
Laxatives (whether herbal or pharmaceutical) are effective, but should not be used on a regular basis. Laxatives increase the motion of the intestinal muscles and can actually worsen constipation by making the intestine dependent on stimulation. While very occasional use of laxatives probably is not harmful, they should not be used on a regular basis.