Chapter 5. Constipation

“Constipation was [sic] the most common digestive complaint in the United States, outnumbering all other chronic digestive conditions.”
Epidemiology of constipation in the United States[1]

“Constipation may have other serious consequences; an increased risk of colon cancer has been reported...”
The Review of Gastroenterological Disorders[2]

“Although it may be extremely bothersome, constipation itself usually is not serious.”
American Gastroenterological Association[3]

Constipation Epidemiology: One Case Of Crappy Bookkeeping

A reliable, accurate statistic on the prevalence of constipation isn’t available, because (ironically), it isn’t considered a condition serious enough to merit thorough research and analysis. According to an article in The Review of Gastroenterological Disorders, “the exact prevalence of constipation depends on the definition used; prevalence estimates range from 2% to 28%.”[4] The implications of such a considerable spread are obvious:

• There are no clear-cut diagnostic criteria for constipation, hence the majority of patients who suffer from constipation are undiagnosed. You should use the guidelines suggested in this book to evaluate your own condition.
• Constipation isn’t recognized as a health-threatening condition until it’s too late. In the words of the article cited above, “constipation is not of clinical importance until it causes physical risks or impairs quality of life.” It shouldn’t get to that point. Once “quality of life” is affected, the side effects of constipation, such as enlarged hemorrhoids, are no longer reversible.
• The “seriousness” of constipation depends on who you ask. For some doctors it’s just a nuisance, for others it’s the precursor of colorectal cancer. Obviously, you’re better off choosing a doctor who believes the latter.
• If constipation isn’t considered serious by your doctor, it means it’s not going to be treated as promptly and properly as it should be, and it’s more likely causing or worsening colorectal complications. Ask you doctors to reconsider their approach, and refer them to the sources referenced in this book.
• If constipation is considered a serious condition (as it should be), reading this book may literally “save your butt,” even though you or your doctor may believe that, thanks to fiber, you don’t have any problems, and, therefore, that fiber is safe and working for you. Study this book to understand the multifaceted perils of fiber.

According to a 1989 National Health Interview Survey[5], about 5.3 million Americans (approximately 2.5%) complained about frequent constipation. A later report from the same survey (the last time the question was asked), conducted by the Centers for Disease Control and Prevention (CDC), indicated that just 3 million people experienced chronic constipation in 1996 (over 1%), even though the overall population and the number of aging baby boomers increased substantially between those years.

Obviously, these numbers don’t add up. If, indeed, constipation outnumbers “all other chronic digestive conditions,” then the number of complainers should have been in the tens of millions, considering that over 21.3 million[6] Americans had been diagnosed with stomach ulcers, or that up to 20% of adult Americans suffer from irritable bowel syndrome, which is customarily accompanied by constipation.

There are several reasons for such a huge disparity between the actual numbers and the erroneous results of the National Health Interview Survey:

• First, assessing the disease by asking people to self-diagnose isn’t objective. That’s what is taking place during the surveys conducted via verbal interviews, like the ones mentioned above.
• Secondly, constipation isn’t technically a disease, hence it isn’t being tracked in the same way as, for example, billable conditions diagnosable by doctors, such as IBS or ulcers.
• Third, the majority of people don’t bother complaining about intermittent constipation because they rely on a variety of over-the-counter and home-brewed remedies to manage it.
• Fourth, ongoing constipation treatment doesn’t get reimbursed by most medical insurance policies, hence it doesn’t get tracked as reliably as those diseases reimbursed by state, federal, and private insurers.
• Fifth, constipation related to weight-loss diets, such as Atkins or South Beach, doesn’t get reported either, because most people simply abandon their diets, and return to regular high-fiber, high-carb fare.
• Sixth, a great number of people are embarrassed to talk to their doctors, or even spouses, about constipation.
• Finally, when dietary means such as fiber-fortified cereals, herbal teas, or prune juice are used as laxatives, people may have “regular” stools, and not consider themselves constipated. This paradox is discussed in greater depth in the Latent Constipation section later in this chapter.

When a reliable, direct statistic isn’t available, it can be determined indirectly. There is, for example, nothing uncertain about the prevalence of hemorrhoidal and diverticular diseases, two “can’t miss” side effects of chronic constipation:

The reverse analysis of this statistic is rather straightforward: If half of the adults have enlarged hemorrhoids by the age of 50, it means that most of them are straining while moving their bowels. Since only people with constipation or anorectal disorders caused by constipation (including hemorrhoids) need to strain, we can then conclude that about half of the population, by the age of 50, suffers from chronic or intermittent constipation.

According to actual “hands-on” data collected by anorectal surgeons at the Hemorrhoid Care Medical Clinic[8] in San Diego, California, enlarged hemorrhoids are detected in over two-thirds of patients during a routine physical exam. In other words, the actual occurrence of hemorrhoidal disease is even more prevalent than the NIH statistical estimate, but we’ll stay with the most conservative figures.

To corroborate the “hemorrhoidal” conclusions, let’s take a look at diverticular disease, which also results from constipation-related straining. Its equally alarming “proliferation” reconfirms the statistic on hemorrhoidal disease. According to the same NIH source:

As you can see, the causes and the numbers correspond: half the adults over 60 suffer from diverticular disease related to straining, which in turn only happens among people who are constipated. Obviously, constipation, whether chronic or intermittent, commences long before these people reach 60.

At this moment some readers may ask a reasonable and perfectly appropriate question:

• I often strain to move my bowels too, but I am not constipated. Why?

The answer depends on how you define the term “constipation.” If it is just “not having stool at regular intervals,” as most people believe, then indeed you aren’t constipated. But the classic definition of constipation is “difficult, incomplete, or infrequent evacuation of dry hardened feces from the bowels,”[10] exactly the kind of stool that not only necessitates straining, but meets the criteria for “constipation,” and eventually causes hemorrhoidal and diverticular diseases.

The term “constipation” is derived from Latin’s’ constipatio—literally, a crowding together. The “crowded together” stools become large and hard. The outcome is succinctly described by The International Foundation for Functional Gastrointestinal Disorders:

As you can see, the original meaning of the term “constipation” isn’t “lack of regularity” or “absence of stools,” as most people think, but “difficult,” “uncomfortable,” “hard,” and “large.” In other words:

You’re Constipated When You Are Not
Experiencing Easy And Complete
Stools Without Straining

There’s only one way to enjoy this kind of bathroom nirvana—a low-fiber diet and daily, or even better, twice-daily stools. But that’s the complete opposite of what countless medical authorities have been preaching all along, namely that if you eat more fiber, frequency of stools doesn’t matter, as long as it’s no less than three times a week.

Wrong! Ignoring the frequency of stools shifts the emphasis from eliminating the causes of constipation to the management of infrequent stools. And, at first glance, what can be a better remedy to accomplish this task than honest-to-goodness “natural fiber?” At “first glance,” yes, but not at second—the more fiber you add to bulk up the stools, the more damage you’ll cause to yourself, because along with more fiber, the stools are becoming larger and harder as well.

And this brings us back to the perils of dietary fiber on one’s plate, inside one’s large intestine, and, finally, inside one’s stool. To understand why fiber harms the large intestine, why fiber makes constipation more severe, and why fiber isn’t an effective treatment for constipation, you must first understand the functionality of the large intestine. Considering all the hoopla surrounding the “health” benefits of fiber, asking you to take this book’s “fiber menace” claims on faith alone wouldn’t be fair either to you or to the advocates of fiber.

The large intestine : Understand the guts, enjoy the glory

The digestive functions inside the large intestine are as essential as those inside the stomach and small intestine, because bacterial fermentation—a function exclusive to the large intestine—produces a number of vital micronutrients and immune co-factors. The large intestine completes the digestion cycle by performing these four critical functions:

• Recovery of nutrients. Water, electrolytes, and micronutrients are absorbed from chyme through the mucous membrane (mucosa). When absorption fails, the person experiences diarrhea.
• Bacterial fermentation. Chyme is mixed with colonic bacteria (intestinal flora), which ferment the remaining carbohydrates and produce a broad range of essential micronutrients, including vitamin K and certain B-complex vitamins. When the fermentation fails, the person experiences dysbacteriosis—a complex, slow-evolving syndrome of hard-to-pin down ailments related to the vitamins’ deficiencies.
• Temporary storage. Dehydrated, fermented chyme is mixed with bacteria and mucus, and formed into feces. Exemplary feces contain about 70–75% water, and traces of fat. The rest is organic solids—bacteria, dead cells, coloring pigments, and some undigested components. The feces’ cellular components (mainly bacteria) retain water and maintain the stool’s pliability. Dried out, hard stool, which is one of the symptoms of dysbacteriosis, doesn’t point to dehydration (a mistaken view), but to the lack of synergistic bacteria needed to retain water.
• Elimination. The frequency of elimination is primarily the function of diet content and physical shape—fiber and youth speeds it up. Ideally, healthy adults should move the bowels once or twice a day. The widely held view that moving the bowels from three times daily to three times weekly is normal,is incorrect.

The logic behind the large intestine’s arch-like architecture is apparent from those functions: it is inverted to keep the liquid chyme inside for as long as it takes to ferment, dehydrate and assimilate essential nutrients, and to convert them into feces. The chyme becomes “stools” by the time it reaches the descending colon. From this point on it is brownish, shaped slightly, smelly, and ready to be expelled.

The size and shape of the large intestine is determined by the species’ need to ferment fiber—the more fiber in the diet, the larger the size. Finicky carnivores, like cats, have a gut similar to humans, but much smaller; herbivores, such as sheep, goats, or cows, have a straight, large one; omnivores, like we humans, are in-between, size-wise. Not surprisingly, if we eat like cows, our gut will grow enlarged (distended) to accommodate all that fiber bulk, so even normal-weight humans may look, from the side, like chimps and monkeys, whose guts are habitually distended from chewing and fermenting fibrous leaves around the clock.

On a diet relatively free of indigestible fiber, the journey of chyme from cecum to sewer takes, give or take, 72 hours in test subjects.[12] When indigestible fiber is generously added to the diet, the transit time drops down to just 24 hours because the large intestine rushes to expel the excess fiber, in order to avoid mechanical (from too much bulk) and chemical (from too much acidity) damage to its delicate mucous lining.

If evolution intended that 72 hours are what’s needed for feces to travel to the sewer, then that’s what it takes. If you force the refuse out in 24 hours, the essential by-products of intestinal metabolism—electrolytes, vitamins, immune co-factors, and God knows what else—don’t get assimilated back into the body, and, at the very least, you experience abdominal cramps from too much peristalsis.

However, if you are chronically constipated, even when you add fiber, the trip down may take much longer than 72 hours. When this occurs, the stools are no longer small, soft, and pliable. Instead, they’re impacted—large, hard, and compressed, and not exactly in the shape desirable for the delicate anal canal, or for the even more delicate mucous layer of rectum and colon.

Lo and behold, the recommendation to use fiber in order to stimulate colonic motility—the peristaltic and mechanical movement of fecal masses through the colon—was based on experiments conducted with carefully screened healthy individuals, who were young and constipation-free. To determine transit time, participants were ingesting small metal pellets, and their stool was x-rayed to locate them.

But if you are no longer young, already have a history of constipation and colorectal disorders, such as hemorrhoids, the journey of fiber to the toilet bowl may take weeks, especially when the colon is already packed with large stools waiting for their turn to be eliminated. In this case, the newly arriving fiber acts just like a plunger, and then patiently waits itself to be plunged. When there is no fiber “plunger” in the diet, constipation quickly sets in. And that, of course, describes the addiction that results from a depen­dence on fiber to move the bowels.

The colon: An epilogue to a meal

As chyme travels up the colon, water, electrolytes, and remaining nutrients are slowly absorbed through the epithelium, a mucous membrane that lines the insides of the intestines. In turn, the epithelium—more specifically, its abundant goblet cells—secretes mucus to lubricate and protect the epithelium from damage, and to bind dehydrated chyme into feces. These two actions lead to two important observations:

• First, it isn’t water that binds and forms feces, but colonic mucus. In fact, the colon does everything it can to remove the free-floating water that isn’t bound inside the cellular structure of dead cells, bacteria, and undigested fiber.
• Second, if the formed, voluminous, dried-out stool is often strong enough to tear apart the skin inside the anal canal, imagine the kind of damage it can do to the featherweight lining inside the colon. It opens up the pathway for ulcers and precancerous po­lyps to take hold there.

The movement of fecal mass through the colon (motility) is go­verned by propulsive contraction. The motility is slow, and it’s controlled by the teniae—thin, ribbon-like muscles equally spaced throughout the length of the colon, giving it the appearance of a string-tied roast with bulges of meat protruding between the coils. These pouch-like bulges in the colon are called haustrum.
Meal composition (not volume, and not fiber) influences motility more than any other factor:

This little-known fact is important for the understanding and prevention of constipation, especially age-related constipation. Low-fat or fat-free diets are more likely to cause impaction among older adults, whose colonic motility is too slow to begin with because of weak intestinal muscles—a condition known as atonic or lazy colon.

The alternating contractions and relaxation of two adjoining teniae ribbons propel stools along their way, but most often they contract in different regions in order to mix fecal mass, not move it. Several times daily a coordinated mass peristaltic movement occurs, which propels stools from the transverse to sigmoid colon. This particular movement is hard to miss, because it usually happens ten to fifteen minutes after a meal or drink. This effect of food on colonic peristalsis is called the gastrocolic reflex.

The combination of these two actions—gastrocolic reflexand massperistaltic movement—precedes the urge to defecate. The urge diminishes in people who are accustomed to suppressing it, those who are dependant on fiber and laxatives, have a long history of constipation, or are old and infirm. Nerve damage related to colorectal distention (from large stools), surgery (to fix damage caused by large stools), medication, diabetes, or a deficiency of certain vitamins may also reduce or eliminate the urge that sends healthy people running to the bathroom.

One reliable way to prevent the gastrocolic reflex from happening in the wrong place and at the wrong time is to not eat or drink if the appropriate bathroom facilities aren’t readily available, especially if you failed to relieve yourself before leaving home.

The other “reliable” way to suppress the gastrocolic reflex and cause constipation are extended low-level stress and anxiety. That’s why following the adage “don’t worry, be happy” will protect you from constipation better than fiber will. According to researchers, personality “accounted for about as much variance in stool output as did dietary fiber.”[14] And from what we already know about fiber, that’s saying a lot.

Special events, such as a honeymoon for couples who didn’t experience living together before becoming married, may represent a particular hazard to the large intestine. Sharing the same bed and bath 24/7 for the first time isn’t exactly a stress-free situation for many newlyweds. Some couples, women particularly, are likely to return from a honeymoon constipated and disappointed, rather than satisfied and happy.

Don’t contain the defecation urge for too long—the “tight ass” personality trait isn’t, at least initially, a function of character, but of a bad diet, unusual circumstances, and equally bad toilet habits.

The opposite is true in extremely stressful situations, such as an accident, tragic news, a crucial exam, or winning the lottery. Instead of constipation, these events may cause vomiting and/or diarrhea. The mechanism here is altogether different, and the main culprit behind either vomiting or diarrhea is abruptly elevated blood pressure:

• First, in response to extreme stress, the metabolic hormones (insulin and glucagon) and the stress hormones (adrenalin, noradrenalin, and cortisol) cause an almost instantaneous constriction of the blood vessels and a rapid release of glucose from the liver and muscles, where it is stored.
• Second, the combined action of constricted blood vessels and high blood sugar (glucose) causes an instant spike in blood pressure. The spike may be high enough to jam a blood pressure monitor, just like the spikes that cause strokes and heart attacks.
• Third, to prevent damage to the brain, heart, kidney, liver, and blood vessels, the body instantly takes a corrective action and li­te­rally unloads the excess blood plasma from the closed vascular loop by dumping it into the stomach and/or intestines via the cells and glands that ooze digestive juices.
• Fourth, an almost instantaneous release of so much fluid into the stomach can cause vomiting (from overloading), especially if food and digestive juices are already present there.
• Fifth, a substantial drop in blood pressure follows the release of plasma into the stomach and/or intestines. This condition (falling blood pressure and blood sugar) is made perceptible by a weakness in the knees and a relaxation of the rectal muscles that control the sphincters.
• Finally, a rapidly increasing volume of fluid in the large intestine, combined with relaxed rectal and anal sphincters, literally flushes out the entire content of the large intestine, often in profuse quantities.

So if you want someone to instantly lose lots of weight (water and feces) and relieve constipation at once, take them to a horror movie, steal their car, hire someone to simulate a hold-up, or do any other stupid thing that will scare the hell out of them.

Incidentally, abdominal cramps during critical exams, job interviews, blind dates, public performances, and similar events are all from the same causes—increased muscle tone, fear-induced elevated blood pressure, and a surge of excess electrolytes into the intestines. And the sudden lapse of memory that often accompanies the cramps results from insufficient circulation of blood in the brain because of a narrowing of cerebral blood vessels and capillaries.

I know of only a few proven recipes to combat fear—pre­pared­ness, practice, and visualization. Also, it wouldn’t hurt on these occasions to make sure that you are well rested, your digestive organs aren’t stuffed with fiber, and your large intestine isn’t packed with fiber-laden large stools.

The rectum: All’s well that ends well

The rectum is very much like an exit dock in a space station—it separates the rest of the “ship” from the perils of harsh outer space. Hence, the rectum of a healthy person is empty at all times. Its brief contact with stools and gases happens only on their final journey out to the sewer.

Unlike the colon’s circular musculature, the rectum’s is longitudinal, with strands of muscles running from top to bottom, very much like the drawings of biceps that hang in medical offices. The rectum’s muscles stretch out to accommodate the feces as they move down from the colon, and they contract back to initiate defecation. The rectum’s contraction completes an elaborate sequence of preceding events:

• The gastrocolic reflex, stimulated by eating and/or drinking, is a perceptible prologue of this process. Alas, it’s an easy reflex to suppress directly (consciously), or indirectly, through stress, lack of attention, habit, and similar factors. The more often you suppress it, the greater your chances of developing a life-long dependence on fiber to move your bowels. The gastrocolic reflex actuates the next step.
• The colonic mass peristaltic movement occurs without conscious control. It’s impossible to suppress by will, but stress, age, laxatives, and systemic muscular relaxants (such as narcoleptics, antidepressants, blood pressure and cholesterol-lowering medication) can diminish it significantly, and bring on fiber dependence. (This particular side effect is always stated on the prescription information circular for each medication.) The mass peristaltic movement propels feces into the rectum.
• The stretching of the rectum by incoming stools is, by far, the most important condition for regularity. Not surprisingly, the long-term stretching of the rectum, common among individuals who consume a great deal of fiber, eventually leads to the loss of rectal sensitivity, and inhibits natural defecation. The stretching of the rectum stimulates contraction, and…          
• At the very end of this process, following your explicit instruction to relax the external sphincter, the rectum contracts to begin the elimination of stools that are now inside the rectal ampoule. Again, the rectum’s ability to contract diminishes with age, from medication, from nerve damage related to diabetes and inadequate nutrition, muscular disorders, and also from extended periods of stretching by stool enlarged (bulked up) by fiber.
• A final, and most crucial participant in this process is the nerve plexus along the anorectal line—the juncture of rectum and anal canal. When the stools reach this intersection, the final signal is sent to the autonomous nervous system to complete elimination. All of the same factors that compromise the rectum’s ability to react and contract, desensitize the anal nerve plexus: large stools, nerve damage, hemorrhoids, anal fissures, medication, and others. Alas, as we age, these factors grow more and more pronounced.

The rectum can stretch to accommodate up to 2 liters (2 qt) of stools. This is essential to avoid incontinence, but when the stored feces becomes hard and dry, this particular ability becomes a negative, as it allows stools to accumulate into one large impacted lump that at some point may grow too big to get out.

There are three horizontal dividers that separate sigmoid colon from rectum, aptly named horizontal folds. These folds help retain stools inside the colon while allowing gases to pass through. Amazingly, evolution took into account even this anti-social contingency.

So how come Mother Nature didn’t account for fiber dependence and its prominent side effects? Because the savages didn’t depend on fiber and bathrooms the way city dwellers do:

• Just like animals in the wild, humans, until urbanization, had no shame associated with defecation, and relieved themselves as soon as they sensed the urge. (Lesson to us: avoid suppressing the defecation urge when restroom facilities are readily available.)
• Their natural world, which included pristine water and abundant meats (especially internal organs), kept their intestines continuously recharged with essential bacteria. (Lesson to us: continue to wash hands, boil water, and cook meats, but eliminate dysbacteriosis using more enlightened methods.)
• They defecated in the most natural and strain-free way—a squatting position—rather than sitting straight up on a high toilet bowl. (Lesson to us: watch out for little kids. A traditional chamber pot, not a child seat over the toilet, is the best choice for their undeveloped bodies, and will help to prevent constipation and dependence on laxatives and fiber for the rest of their lives.)
• And, of course, until very recently humans didn’t consume pro­di­gious amounts of processed dietary fiber year round, and they didn’t have anyone to tell them otherwise. (Lesson to us: use intelligent ways to navigate the sea of conflicting advice.)

Normally the rectum is empty, with stools kept out by the first of those horizontal folds inside the sigmoid and descending colons. You can verify it by adorning a preferred hand with a surgical glove, and slowly inserting a heavily lubricated forefinger (use pure petroleum jelly) inside the anal canal. If the rectum is empty, you’ll feel nothing. If it isn’t, you finger will feel the hardened stools, the kind that is usually referred to as “formed.” And that’s not normal.

If you move a small volume of loose stool regularly, there’s no point poking around inside. But if you are dependent on fiber, suffer from constipation, or your stools are hard and large, you don’t need a doctor’s license to check out the content of your own rectum. It isn’t any more gross than wiping your behind. Doctors routinely perform anal exams while checking out hemorrhoids, the male prostate gland, or the female uterus through the anus.

The Anal Canal: The weakest link in the long chain

The anal canal is shorter than Panama’s, but as treacherous to navigate, and the most prone to jams and bottlenecks. A precise coordination of the rectum and anal sphincters is required to complete defecation. The other participants are the internal obturator and levator muscles of the anus, pelvic muscles, and diaphragm, but they all play second fiddle.

The ideal act of defecation shouldn’t take any more effort than that of urination. This may be hard to believe, but it’s true nevertheless. Just ask any healthy, constipation-free child on a low-fiber diet about his or her happy experience.

You should barely feel the movement of a stool of normal form and consistency. If you have enlarged hemorrhoids, you may feel them protruding, but this is an entirely different sensation from that of hardened feces chafing and scraping against the delicate tissues of the anal canal.

If you need to strain, it means your stool has already become enlarged and hardened, and that the rectum’s muscle tone isn’t sufficient to propel it out through the narrow opening of the anal canal. Hence the need to apply additional straining pressure on the colon and rectum to expel the large feces, bulked up by indigestible fiber. We are back again to the perils of fiber and its role in constipation.

Without fiber, remnants of food in the stool of a healthy person aren’t detectable. Even the word fecesis derived from Latin faex, or dregs—a small amount, a residue. Apparently, the ancient Romans hadn’t yet tasted bran cereal when naming it.

This profound point—that normal stools aren’t composed of food, but of physiological waste—is a mental challenge even for medical professionals, because most Westerners are accustomed to seeing primarily large, voluminous stools¾the term derived from the Anglo-Saxon stol—seat.[15]

Nonetheless, the point shines through when I highlight this undeniable fact again and again: fit, healthy people without a history of colorectal disease, constipation, and dysbacteriosis, who are placed on a liquid diet or who are starved, continue to HAVE REGULAR STOOLS the entire time. And if their preceding diet was low in fiber, the changes in stool volume are negligible. If you’re still in doubt, here’s an illuminating excerpt from a classic European medical reference:

As you can see, on the Schmidt’s diet, which is rather generous, permissive, and varied, the feces of a healthy person “doesn’t contain any food residue.” But as soon as we turn to the more typical Western fare—breads, cereals, fruits, and vegetables—represented by the Pevsner’s diet, the stool of an even healthy person “contains large amounts of undigested fiber” and “muscle tissue” from burned (grilled) meat.

Unfortunately, the no fiber/no stoolconnection is so insidiously prevalent that it’s difficult to remove even from the minds of experienced gastroenterologists and proctologists. The correct cause and effect connection is, of course, no fiber/less stool. Andthat’s exactly what happens when you switch from a high-fiber diet to a low-fiber one, such as the Atkins diet:

• Without fiber in the diet, the volume of feces in the colon drops five to ten times from its preceding volume. The receptors in the rectum, which respond to the stretching of its walls, no longer detect such a small volume of stool, and it remains unexpelled until its volume either reaches the stimulation threshold, or the person takes laxatives.
• As the fecal mass accumulates in the colon, it becomes dehydrated, compressed, and hardened. When the increased fecal volume finally stimulates elimination reflexes, its hardness requires straining in order to expel it. While passing, the hard stools da­mage the delicate tissues and blood vessels that surround the anal canal.

And when an accumulation of hardened fecal mass occurs, the grossest error one can make is to follow the prevailing advice (including Atkins’), which is to ingest “therapeutic” fiber to dislodge and expel it. In this case, the probability of injury to the colon, rectum, and anal canal is practically unavoidable, because the extra fiber behaves just like a proverbial bull in a china shop.

Constipation Treatment : Riskier Than The Disease

Whoever came up with the notion that undigested fiber is a health food was thinking about “dirty colons” and constipation:

To simple-minded quack nutritionists, the stinky stuff that comes out of the body is indeed “dirt.” So they followed an obvious cause and effect approach to problem solving:

It sounds great on paper, and, just as with most drugs, it even works for a while in healthy people who don’t have any anorectal damage. But this approach isn’t addressing several important questions:

But when these questions aren’t answered at all, or the answers are wrong, or the real causes of intestinal disorders aren’t addressed, then fiber, just like most drugs, becomes a quick fix. And drugs, no matter how innocent they may act or seem at first, have side effects, and so does fiber.

The fiber-based treatment recommendations for constipation, as proposed by the American Gastroenterological Association, serve as the basic guidelines for the gatekeepers[17] —the family physicians who hear about constipation-related problems from their patients before they can grant them a referral to the more expensive specialists (the gastroenterologists themselves). And here is what they may recommend:

Unfortunately, more fiber to bulk up the stool and more exercise to strengthen abdominal muscles are the principal reasons behind straining, even though the same document bluntly warns that “Constipation can lead to complications, such as hemorrhoids caused by extreme straining”[19] without first telling the readers that only large stools, created by fiber, require “extreme straining.”

That’s unfortunate, but easy to understand. Gastroenterologists—the principal members of the American Gastroenterological Association—are surgeons, not nutritionists. They are trained to operate on the endless complications of “extreme straining,” such as prolapsed hemorrhoids, lacerated anuses, rotting diverticula, perforated colons, and hemorrhaging ulcers. Constipation isn’t their “thing,” hence they rely on a quick and simple fiber solution for patients who don’t require surgery yet.

That fiber and straining eventually make constipation even more severe, and can cause irreversible side effects, is beside the point, because, as long as you are “regular,” all parties are happy. You’re happy because fiber delivers “regular” stools, your doctor, because you’re quickly “healed,” and your insurer, because the fiber solution is dirt cheap. and your pharmacist, because you’re hooked for life.

And that’s the reason why a recent search[20] of the well-stocked Internet pharmacy for “fiber” revealed a whopping 65 fiber-based laxatives. Why so many? Because natural fiber from the diet alone doesn’t work. Just consider these conclusions from one of the most authoritative books about functional digestive disorders published in the United States, but authored by the international consortium of the world’s leading gastroenterologists—Rome II Diagnostic Criteria For Functional Gastrointestinal Disorders.

First, about the merits of consuming a fiber-rich diet for people already affected by chronic constipation:

In other words, everything you’ve heard about fiber hasn’t been true: more fiber in the diet doesn’t makes stools leave the body any faster, there is no difference in fiber consumption between healthy and constipated people, and adding more fiber doesn’t make any difference to either stool weight or transit time. (Please note again that these observations apply to patients with chronic constipation and to dietary fiber from natural foods only. Unlike fiber from the diet, supplemental fiber or fiber-fortified products do increase stool volume and do decrease transit time dramatically, especially in young, healthy subjects without any colorectal damage.) And what about the exercises?

As you can see, you can work yourself out into a stupor, but it isn’t going to make constipation go away or your colon’s health get any better.
And what about water? Here is commentary from an equally respected and credible source, The Journal of The American Dietetic Association:

Please give me a glass of water. I’m fainting...

You must be asking yourself the same question I once asked myself: how come so many experts managed to err so badly on all three counts—fiber, water, and exercise? How could these well-educated doctors, scientists, and researchers be so wrong, and wrong for so long?

Well, there are many reasons, but none of them are malicious. In an ideal world, when anyone develops constipation, doctors would investigate and quickly remedy the dysfunction(s) that caused it. But investigating the numerous causes of constipation requires an individual approach to each patient. That means an investment of time and effort and expertise on the part of family doctors, internists, and pediatricians, and that’s not what usually happens because they don’t have the time, they aren’t paid enough to devote the effort, and they lack the specialized expertise. Hence, they revert to a simple solution—more supplemental fiber, more water, more exercise.

Not surprisingly, for anyone but the very old and frail who already lack the strength to strain, adding supplemental fiber actually works for a while, because it makes stools larger, and stronger abdominal muscles indeed help to expel these large stools out. While you’re still relatively young and healthy, supplemental fiber works “as advertised” for a period of time.

But as time goes by, enlarged hemorrhoids become the most prominent result of large stools and straining. Enlarged hemorrhoids reduce the aperture of the anal canal from the already small to the very small. To overcome the resistance of a smaller opening, more fiber and straining are needed. At one point the colorectal damage becomes so severe that adding any morefiber, or straining harder,no longer works.

So how can you determine on your own that the constipation treatment isn’t causing you more damage? This is really simple. The treatment is wrong when:

• You can’t achieve defecation without a laxative, or specific foods that have laxative properties, such as prunes, herbal teas, agar-agar, and others;
• Your diet includes added fiber from supplements or fiber-fortified foods, such as cereals, crackers, muffins, etc.;
• You are consuming 400–500 grams of carbohydrates daily from the products that belong to the grain, fruit, and vegetable groups in order to ingest more natural fiber;
• You don’t have normal stools at least daily or twice daily;
• Bowel movements, even minor ones, require straining, and your stools are large.

This last characteristic—large stools—is relative. How do you determine what’s large, and what’s not? Fortunately, there is a rational method for establishing benchmarks that will help you to objectively evaluate your stools.

The Bristol Stool Form Scale: Form follows dysfunction

The British take their stools much more seriously than the Ame­ri­cans. Researchers at the Bristol Royal Infirmary—a hospital in Bristol, England—developed a visual guide for stools. This guide is called the Bristol Stool Form Scale, [24]BSF scale for short. It is a self-diagnostic tool that helps skittish patients and doctors alike discuss this delicate subject without getting embarrassed. You just look at a simple chart, point to what approximates the content of your toilet bowl, and your doctor (or this book) tells you whether the form is right or wrong.

There are seven types of stools in the chart, each with a brief annotation (in italicsbelow). The publication that features the BSF scale doesn’t provide any substantive comments beyond the brief: “The ideal stools are types 3 [wrong!] and 4, especially type 4 [correct], as they are most likely to glide out without any fuss whatsoever.”[25] The original definitions are in italics. The expanded commentaries are mine:

To avoid problems later on, check the content of the toilet bowl at every opportunity to make sure that your stool’s typeis close to optimal. Here are several additional points:

• Weight. About 80 to 100 grams (2.5–3.2 oz) per defecation is considered the norm on a low-fiber diet. Normal stools are heavier than water. Floating stools indicate an overabundance of undigested fiber and gases from fermentation. Many sources indicate that floating stool is normal. It isn’t!
• Consistency. A stool of normal consistency and frequency should be amorphous, slightly formed. This morphology assures easy, straining-free passing, and a consistent triggering of urge.
• Form. A formed stool between types 4 and 3 is bound to cause problems for people who already have colorectal disorders, such as hemorrhoids, fissures, ulcers, fistulas, abrasions, cuts, and tears, all caused by excessive mechanical pressure on the anal canal walls, and amplified by straining.
• Shape. A soft, loose stool may not be perfectly round, because it assumes the geometry of your anal canal, which in turn may be affected by internal hemorrhoids. Many people may have enlarged internal hemorrhoids without actually knowing it.
• Misconceptions. The popular scare—when the stool isn’t perfectly round, it may mean a tumor—may have validity only when the stools are large and hard (the tumor shapes the form), but not so much when they are small, thin, and pliable (the anal canal geometry shapes the form). If in doubt, it’s best to consult a physician.
• Warning signs. If the stool is formed, long, uninterrupted, and over 2 cm (0.8”) in diameter, it means that regular elimination is incomplete, and the formed stools may be extending all the way back past the descending colon.
• Danger zone. The most telltale sign of fecal impaction is that the formed stool looks just like the anatomical drawings of the colon: evenly spaced bulges on the outside repeat the anatomical pattern of haustrum inside the large intestine.
• Complications. The mechanical properties of large stools—dryness, hardness, abrasiveness, and bulk—are the primary causes of irritable bowel syndrome, ulcerative colitis, and diverticular disease.

By now, you should understand why voluminous, round, well-formed stools (BSF 3)—the type most medical authorities, including the Bristol Stool Form Scale authors, would like you to have—are destructive for your colon’s health, for the normal functioning of your rectum, and for your anal canal’s structural integrity.

Unfortunately, whenever you don’t have stools like these, most Western doctors, nutritionists, and dietitians are likely to recommend more fiber, more water, and more exercise, which is the exact opposite of what you should do to protect yourself from colorectal damage related to large stools and straining. And that’s how once benign functional constipation turns into latent, and, eventually, into irreversible organic.

To better comprehend the connection between fiber dependence, constipation, and related colorectal disorders, you must first understand its progression through the functional, latent, and organic stages.

Functional constipation: Easy comes, rarely goes (away, that is)

In general, a condition is considered functional when there are no changes in the normal physiology of a particular organ. In the case of constipation it means that nothing specific, such as enlarged hemorrhoids or tumors, impedes defecation.

For otherwise healthy people, functional constipation is the initial stage of constipation. It may happen for a variety of reasons, such as a sudden change of diet, embarrassment with “toilet duties” while on a honeymoon, a shift in regular schedule while on vacation or a business trip, side effects of medication, a bout with diarrhea, extended stress, major trauma or surgery unrelated to colorectal organs, and similar circumstances.

The mainstream diagnostic criteria (by Rome II) for functional constipation are (1) straining, (2) hard or lumpy stools, (3) sensation of incomplete evacuation, (4) sensation of blockage, (5) the need for manual disimpaction, and (6) less than three defecations per week.[26] Actually, when a person experiences all of these symptoms, the constipation is way past the functional stage.

Irregular defecation is the most prominent characteristic of functional constipation. The stool’s size may increase, remain unchanged, or become smaller.

• Reduced stool size and hardness (BSF type 1) indicate an insufficiency of intestinal flora, which may be caused by preceding diarrhea, ongoing medications, or various environmental and food-born toxins.
• The increased stool size (BSF type 2 and 3) indicates an impaction of stool, and may be related to non-physiological factors, such as change of diet, business trip, vacation, and others.
• If the stool, regardless of size, becomes hard and dry, it may indicate potassium deficiency—a mineral that is responsible for moisture retention.

At this point most individuals will either visit a doctor or take matters into their own hands. What happens next depends on the remedy:

• If you address and eliminate the primary cause(s) behind functional constipation, and restore daily stools that match BSF type 4 to 6, you are back to normal. That’s what this book teaches. End of story.
• If you begin taking over-the-counter laxatives to maintain “regularity,” you’ll gradually transition to latent constipation. That’s what many people decide to do on their own, and the constipation never goes away; only “irregularity” gets chased away.
• If you add more fiber to your diet in order to increase the stool’s size and volume, you’ll also gradually transition to latent constipation. Unfortunately, that’s what most medical authorities urge people to do, and the story goes on.

As you can see, becoming “regular” doesn’t mean becoming “healthy” or “recovered.” Your goal must always be small, soft, and moist stool (BSF 4 to 6) at regular (at least daily) intervals, not just any stool regularly. When you fail to accomplish that goal, the next stage is...

Latent constipation: The hidden menace

If you have regular stools now because your diet contains lots of fiber or you’re dependent on laxatives, whether natural or synthetic, your constipation is latent—concealed, without apparent symptoms, because either your current diet is the laxative or your diet is supplemented by a laxative.

When fiber, especially supplemental, becomes a laxative, it works by increasing stools’ size. That’s why doctors refer to fiber as bulk, bulking agents, or roughage. Not surprisingly, large stool size and volume (type 2 to 3) are the most prominent characteristics of latent constipation.

The following table illustrates this connection between fiber and the resulting volume of stool. The ash content—what remains after the test sample is burned—is a reliable approximation of post-digestion remnants of fiber-free food. Here are the examples:

Indigestible content of selected food (per 100 g, ash + fiber)[27]

As you can see, legumes, nuts, peanuts, and processed, man-made foods, particularly cereals and breads, are the largest offen­ders in terms of indigestible fiber content. Natural, unprocessed vegetables in moderation are fine as long as they are themselves “low-carb”—tomatoes (4.6%), cucumbers (3.6%), squash (3.3%), cabbage (5.6%), and similar vegetables containing under 6% of carbohydrates, including fiber content.

Eventually, thanks to the ongoing impact of larger stools on the colon, rectum, and anus, latent constipation transforms into orga­nic. Hemorrhoidal disease—the irreversible enlargement of hemorrhoids—is the hallmark of encroaching organic constipation.

While the functional stage is relatively short-lived and often intermittent, latent constipation may last for decades. The actual length depends on a person’s age and treatment:

• If latent constipation starts at a relatively young age (while the internal organs are still strong and flexible) it may continue relatively unnoticed into the mid- to late thirties.
• If it starts in the late twenties or early thirties, you’ll start noticing its impact by the early forties.
• Finally, if it starts in the late thirties or early forties, you’ll see its impact in just a few years.

Obviously, the more fiber you take to treat constipation, the faster you transition to the organic stage. That’s unfortunate, but true.

You may have been led to believe that constipation is a symptom of irritable bowel syndrome, Crohn’s disease, and ulcerative colitis. This isn’t so. In fact, these conditions are the symptoms or the results of latent constipation, and the ever-increasing fiber content of your diet.

This fact—that the major disorders of the large intestine are caused by dietary fiber consumed to manage hidden constipation (not a theory, not a hypothesis, not a concept, but a hard, irrefu­table fact)—represents the core of this book and its central thesis: to prevent and eliminate chronic colorectal disorders, you must eliminate latent constipation first.

You may have also been led to believe that constipation is one of the “side effects” of low-carb diets such as the Atkins and South Beach diets. This isn’t true, either. Diet-related constipation is a symptom of latent constipation, too. If low-carb diets suddenly make you constipated, it simply means that your current diet is no longer providing enough bulk from fiber to stimulate defecation. If you suddenly dropped a laxative, the situation would be identical, because the fiber in your preceding diet was the laxative.

Again, this fact, that low-carb diet-related constipation is a symptom of latent constipation caused by the withdrawal of fiber (not a theory, not a hypothesis, not a concept, but a hard, irrefutable fact) also represents the core of this book and its key thesis: to enjoy a low-carb, low-fiber diet, you must first eliminate latent consti­pation.

And if you don’t eliminate latent constipation, it turns into the next phase as inevitably as winter follows autumn.

Organic constipation: No turning back, but not entirely hopeless

If functional constipation is distinguished by irregularity and latent by large stools, organic is distinguished by all of the above plus the ongoing difficulty to attain not just “regular” stool, but any stool. And the reasons are:

• Permanent organ changes. The stool gets stalled because of enlarged hemorrhoids, because of a stretching of the colon and rectum, because of anal fissures, because of nerve damage to the anal receptors and loss of sensitivity, and similar factors.
• Irreversible loss of natural function. It means there is slow go or no go even when the circumstances are ideal and the stool morphology is perfect.
• Continuing dependence on laxatives. It means that you can no longer “get regular” by just fixing up circumstances and the stool’s shape and form, and may require some form of external assistance to move your bowels for the rest of your life.

Organic constipation speeds up aging and chronic disease, unless luck intervenes and you get the chance to read this or a similar book in time to manage it by means safer than adding an ever-increasing amount of fiber, or ever harsher and more addictive laxatives.

Fortunately, there are natural ways of managing organic constipation without the use of fiber or stimulant laxatives, and ways to make sure the side effects won’t get worse, and will remain nothing more than a manageable nuisance. Considering all the other indignities of aging—reading glasses, enlarged prostate, sagging breasts, receding gums—a few more minor nuisances here and there isn’t such a big deal, especially when visiting the bathroom is no longer such a dreaded event.

So, as you can see, the operative word for organic constipation is “manage,” not “fully recover.” That’s why reading this book is imperative while you can still “fully recover,” because functional constipation is preventable, avoidable, and reversible. It will not turn into latent if it’s handled right and early. Latent constipation is completely or partially reversible, meaning it will not cause further damage to the colon, rectum, and anus, or become chronic.

There is, however, some “icing on the cake” even for organicconstipation. While it may be too late to undo the existing damage, you can always halt further erosion and complications, which are discussed in greater depth throughout this book.

Colorectal disorders: The domino effect of fiber

Nature prescribes a gradual decline and eventual death for us, but it doesn’t presume that hemorrhoidal disease, diverticulosis, irritable bowel syndrome, ulcerative colitis or Crohn’s disease will inevitably accompany normal aging. Those “lucky” ones who die from old age without experiencing any of these disorders are the proof of God’s intent to keep our large intestines fit and sound until our last breath.

Thus, it isn’t God’s will to make you suffer from constipation, hemorrhoidal disease, or ulcerative colitis, but it’s the actions of your parents (first), and, later, your own actions (or lack thereof), that bring the punishment. The next five chapters continue to investigate the connection between fiber, constipation, and major colorectal disorders.
Summary

Chapter summary

• Constipation is a poorly recognized medical condition. It isn’t considered serious by most medical authorities, and is mostly noted after it’s already caused irreversible colorectal disorders.
• The prevalence of constipation in the population is significantly underreported, because different research venues use different criteria to define constipation.
• Constipation is a primary causative factor behind major colorectal disorders, such as irritable bowel syndrome, hemorrhoidal and diverticular diseases, ulcerative colitis, Crohn’s disease, colon cancer, and others.
• Chronic, late-stage constipation seriously affects the quality of life, and is difficult to treat because of irreversible changes in the anatomy and physiology of the large intestine.
• There are three types of constipation—functional, latent, and organic. The length of transition from one type to another is determined by age, constipation severity, and form of treatment.
• Dietary and supplemental fiber has become the primary form of constipation treatment because it produces large stools and, presumably, speeds up elimination (motility).
• Dietary (natural) fiber doesn’t materially affect the progression of constipation, stool size, and motility in healthy individuals. (Supplemental fiber does!)
• Physical exercise doesn’t improve the outcome of constipation treatment, while the development of strong abdominal muscles to enable straining is likely to cause significant anorectal damage.
• Additional water consumption doesn’t improve the constipation outcome regardless of the amount of added fiber.
• The treatment of constipation by encouraging “large stools” is the primary reason behind its worsening and progression to the organic stage.
• Latent constipation is difficult to recognize because a fiber-rich diet is a de facto laxative, and regular stools obscure the underlining problem.
• The straining required to move large stools is the primary reason behind colorectal disorders related to constipation. Small normal stools don’t require any effort to eliminate.
• The Bristol Stool Form Scale classifies stools by form, size, and consistency into seven types. Each particular type of stool helps determine the health and integrity of the colorectal organs.
• The stools that match the Bristol Stool Form Scale type 4 to 6 are considered normal, while type 4 to 5 are ideal.
• Fiber, whether dietary or supplemental, is clearly not a proper preventive or solution for constipation treatment, because it causes stools to be larger and more voluminous, than the optimal (BSF type 4 or 5).
• Specific recommendations to treat constipation, fiber depen­dence, and related colorectal disorders are presented in Part III.