Chapter 79
The Problem with Laxatives
Have you ever squeezed an anti-stress ball? If so, then you know how balloon-like bubbles bulge out when you squeeze the ball. Similarly, straining on the toilet can lead to bulges in the wall of the colon, a condition called diverticulosis. The high pressure in the abdomen can cause blood to pool in the veins around the anus, which causes hemorrhoids, and can even force blood back into the legs, leading to varicose veins. But a high-fiber diet relieves this pressure, in both directions. People who eat a whole-food, plant-based diet generally have effortless bowel movements, and that means 25 times fewer “pressure diseases” such as diverticulosis, hemorrhoids, varicose veins, and hiatal hernia.
(What comes next may be a little too intimate—don’t say I didn’t warn you! Once, to my great displeasure, I discovered in the shower a … well … “rear” bump. How could I, of all people, have hemorrhoids? I had even named one of my guinea pigs after the “fiber guru” Denis Burkitt! After further examination, I realized I would have preferred hemorrhoids. The bump had legs. I’ll end the story here about how I found a huge, swollen anal crease.)
Constant straining can also disrupt heart rhythm and reduce blood flow to the heart and brain, causing fainting and, under certain circumstances, death. Just 15 seconds of straining can temporarily reduce blood flow to the brain by 21 percent; to the heart, it’s even almost 50 percent, and then the “bedpan death” mechanism kicks in. If you think it’s strenuous while sitting, then try it lying down. Straining in that position, even very briefly, can drive blood pressure up to 170/110, which explains why so many people in the hospital die suddenly and unexpectedly while using a bedpan.
If constipation isn’t adequately treated, stool builds up, which may necessitate an emergency trip to the hospital. Older people in a “half in, half out” emergency may try to relieve the impaction manually, meaning pulling the stool out with the hand, which is painful, embarrassing, and in certain cases harmful. It’s best not to let it get to constipation in the first place.
The best position for a bowel movement with constipation
Does body position matter during a bowel movement? In parts of Asia and Africa, people squat; people in Western cultures have gotten used to sitting on the toilet. But when you sit upright, the “anorectal angle” doesn’t straighten enough. This kink at the end of the rectum is what keeps us from pooping our pants. When you sit on the toilet, the stool has to negotiate almost a 90-degree bend to get around this brilliant invention. Having a bowel movement while sitting is like trying to drive a car with the parking brake on. For the research, check out the video see.nf/positioning, but it always comes down to the fact that we can change the anorectal angle by squatting or leaning forward to help unnaturally hard stool get on its way. But wouldn’t it be better to simply treat the cause and eat enough high-fiber whole plant foods so that our stool becomes so large and soft that it gets around any angle without effort?
The Problem with Laxatives
The desperation to treat constipation is embodied in medical gimmickry ranging from automated abdominal massage devices you strap on, to vibrating capsules you swallow to be massaged from the inside. But what is more dangerous: With chronic constipation, the colon is increasingly being removed. Complications occur in every fourth operation, and one out of 250 ends with the patient’s death. The most common treatments, however, are still ordinary over-the-counter products, such as laxatives, which generate sales of more than a billion US dollars per year.
Although we have more than 100 randomized clinical trials on various laxatives, we still lack reliable evidence about their safety and effectiveness in older adults. The stool softener docusate sodium, for example, sold in the US as Colace, doesn’t help constipation at all, even though it is among the best-selling products. Bowel-stimulating laxatives such as senna or bisacodyl (Dulcolax) are approved only for short-term use of less than four weeks, but unfortunately it is common for people to take them for months or years. Biopsies in long-term users show that they can “severely damage” the nerves that stimulate the colon.
The over-the-counter product with the highest safety and efficiency is probably polyethylene glycol, sold as MiraLAX or Glycolax—please do not confuse it with ethylene glycol, antifreeze, because that can kill you.
Most constipation medications currently available are generally safe when used as directed, but their effectiveness leaves much to be desired. In a survey of more than 1000 men and women with chronic constipation, most reported little or no satisfaction with over-the-counter products (62 percent), or they reported abdominal pain (78 percent). There has to be a better way!
Easy and pleasant
There are many ways to address constipation through behavior changes, such as a hot drink at breakfast intended to trigger the gastrocolic reflex, but the Holy Trinity most often preached by doctors is fiber, fluids, and exercise. Population studies don’t seem to see a clear relationship between constipation and physical activity when other factors such as fiber intake are taken into account, but you don’t know until you study it.
Inertia seems to slow things down. When active older people moved less and walked not 13,000 but only 4,000 steps a day, within two weeks the time it took for food to pass through their bodies nearly doubled. (The time it takes food to go from mouth to anus is measured via a “blue poop test” with food coloring or simply by eating a little beet.) On the other hand, even a little physical activity reduces cramps and bloating, but what about constipation?
So far, there are nine randomized controlled trials in adults on exercise and constipation. Even moderate aerobic exercise, such as 20-minute walks, can relieve mild constipation symptoms, though it has not yet been tested in severe constipation. And fluids?
I discuss all intervention studies on increased fluid intake and constipation at see.nf/mineralwater, including risks and benefits of Epsom salt (magnesium sulfate) and minerals delivered from the other end via sodium phosphate enemas. My conclusion is: Constipation is best treated by addressing the cause with sufficient fiber, the first choice against constipation.
A Fiber Deficiency Disease
You can classify constipation as a disease of nutrient deficiency—and that nutrient is fiber. Not even 3 percent of Americans consume the recommended daily minimum amount of fiber, which means they don’t eat enough whole plant foods, the only place where fiber is found in abundance. No wonder that people who eat a strictly plant-based diet are three times more likely to have a daily bowel movement. If only half of the adult US population consumed an additional 3 grams of fiber every day, for example a quarter cup of beans or a bowl of oatmeal, we could save billions in treatment costs from constipation alone, based on the estimate that the overall population would have 2 percent less constipation if everyone ate one more gram of fiber every day. It’s difficult to make a wheat-bran placebo, but cause and effect can be demonstrated through randomized placebo-controlled double-blind studies when fiber supplements are used.