Let’s Talk About Constipation

As a practicing General Surgeon in a rural community, my practice also involved a good bit of upper GI endoscopy and colonoscopy. As such, I have spent many years talking with patients about their GI complaints and one of the most common, by far, is constipation. In light of my current efforts to promote a plant based diet, I thought it might be time to have a few words about this common problem. It’s also an interesting study in where the medical practice in the US has gone so wrong.

I refer the interested readers to a new article, published in the Journal of the American Medical Association (JAMA) on January 12, 2016 entitled “Constipation, Advances in Diagnosis and Treatment“. The article was written by Arnold Wald, MD from the University of Wisconsin’s Gastroenterology Division. Dr. Wald was recommended as a “Best Doctor in America” for 2011, 2013, 2014 and 2015 (no mention of what happened in 2012). I’m not here to pick on Dr. Wald, who I’m sure is very learned and an excellent physician. I am here to pick on his article.

As background, you have to understand the role that JAMA plays in American medicine. There are basically two journals that most primary care doctors read. One is JAMA and the other is The New England Journal of Medicine. After that, it’s hit or miss depending upon the specialty and interest of the physician (i.e. Family Practice, Internal Medicine, Peds, etc.). So having a review article in JAMA, which is likely to have wide readership among primary care physicians, is a big deal. And, equally important, it’s a big deal to get the information right so these busy primary care docs know what to do when a patient presents complaining of constipation. In the section of the article headed Clinical Presentation and Assessment Dr. Wald is informing his readers what he recommends they do to assess patients with constipation. He says: “The clinical evaluation should include the duration of symptoms, frequency and consistency of stools, presence of excessive straining, feeling of incomplete evacuation, or use of manual maneuvers during defecation. Clinical evaluation should also focus on excluding organic causes and medications (box) and identifying the presence of “alarm” symptoms that suggest further workup is required for colon cancer (such as sudden change in bowel habits, blood mixed in the stool, unexpected weight loss, or a strong family history of colon cancer).” The (box) notation then goes on to a graphic that illustrates the other “common” causes of constipation that the clinician should consider. It includes: Mechanical, Neurologic Disease, Metabolic Disturbances, Medications (Partial List), and Miscellaneous causes.

OK, I know that most of you are not physicians, but I’m hoping, at this point, you don’t need to be to spot the huge gap here. What did our esteemed colleague Dr. Wald miss? Well, how about diet? How in the world can you expect to work up constipation if you don’t ask about the diet? According to Journal of Academy of Nutrition and Dietetics article in May 2012 the average fiber intake for someone living in the US was 15 grams. 15 grams! Even the lame guidelines recommend a minimum of 25 grams. As a plant based eater, my daily intake varies between 45 and 100 grams and I can assure you that it makes a serious impact on colon function.

Bottom line (so to speak): if you’re a physician, ask patients what they eat. If they have any GI problems (and so many do) think about recommending a plant based diet. The naturally occurring high fiber is excellent for IBS, constipation, diverticular disease and hemorrhoids. And if you are interested in taking an active role in your own health, consider being more plant based to get you back to “normal”.

Add-on bonus! The second most important thing that Dr. Wald forgot to advise physicians to ask is what position do you assume for defecation (i.e. going #2, pooping, etc.). There has been some very good research done on the effect of position on ease of passing stool. The bottom line here is it is super important to get your hips flexed (i.e. get your feet off the floor). A commercial Squatty Potty  will do the trick. If that’s too difficult or inconvenient, Doctors Takano and Sands from the colorectal division of the Cleveland Clinic recommend “The Thinker” position. Food for thought?the-thinker-by-rodin-1233081-639x852

5 thoughts on “Let’s Talk About Constipation”

  1. I want to know if you currently believe what we eat has relevance to colon cancer? Do you think it is “genetic”? Do you think the family history is because you eat what your family ate?

    1. Tammy, I don’t think it’s ever that simple. I think, like most things, it’s complicated (multifactorial in doctor speak). It seems clear that there is genetic predisposition to colon cancer (like many cancers). It seems also clear that your risk can be greatly changed by what you eat. I don’t know that someone with a high genetic risk of cancer (like Lynch Syndrome) can get their risk down to “normal” levels just through diet, but why not try? It’s the one part of the equation you control!

  2. Your criticism here is completely ill-founded and either born of a.) agenda or b.) incomplete review of the available data and discussion by Wald. http://well.blogs.nytimes.com/2016/02/08/simple-remedies-for-constipation/ Is but one example of a discussion in which he articulates the importance of diet.
    I find such simplistic interpretations of anothers position to be, in this case, writing for the sake of writing and not to articulate a meaningful lack of thoroughness or error. If you’re going to suggest it was a methodological failure that’s another point entirely since your criticism was, and remains, outside of the scope of the paper to whit you refer and not a methodological one.

    1. I thank you for your interest and comment. I will stand by my criticism of Dr. Wald’s JAMA article. While you do, correctly, point out that in his discussion with The New York Times author Jane Brody Dr. Wald did confirm the importance of diet and fiber, he did not do so in his JAMA article. As I pointed out, primary care physicians are far more likely to read the JAMA article than a lay piece about constipation in the New York Times.
      Do I have an agenda. Yes, of course I do. I want the world to quit eating animals and drinking cows milk. Will following a Whole Food Plant Based Diet fix everyone with constipation. Of course not and I never claimed that it would. But would a WFPB diet, rather than the SAD (standard American diet) cut down on the estimated 8 million physician visits for constipation? I have no doubt.

  3. Dr. Clayton is completely correct that an optimal review article on constipation in a medical journal such as JAMA in the discussion of clinical assessment should include a review of diet. A medical journal review article does not defer to a newspaper to complete the information that was missed. The physicians that read the journal expect the review article to stand on its own.

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