November 2009 Issue

’Tis the Season for Good Digestive Health
By Maggie Moon, MS, RD
Today’s Dietitian
Vol. 11 No. 11 P. 28

Don’t let constipation hinder the holidays. Educate your clients on its triggers and recommend dietary and stress management solutions to help them maintain healthy, happy insides.

With November comes the inescapable onslaught of the holiday season, which for many includes a fair amount of stress and a marathon of eating extravaganzas. People who are on the go scheduling holiday travel, handling financial concerns, and balancing work and life can get all “stopped up” during the holiday season.

Constipation, which reduces stool weight, can have serious health implications, with lower stool weight being associated with a higher risk of colon cancer.1 However, constipation isn’t normally dangerous and is usually temporary—a symptom rather than its own disease. Patients’ more immediate concern may be the everyday discomfort that constipation can cause.

Patients seek practical advice and an expert’s take on strategies that friends have recommended or that they have seen featured on TV. RDs can advise patients on how to make a higher fiber, lower fat diet suit their lifestyle (including on those special occasions such as the holidays) and fit in adequate fluids and exercise. When those guidelines aren’t enough, RDs may need to advise patients on where to turn for credible information about new products and safe laxatives. They should also educate patients about the various behaviors that may trigger constipation.

What Is Constipation?
Constipation may be the most common complaint no one is discussing. More than 4 million Americans have frequent constipation, and they spend about $725 million every year to find relief.2 Constipation can affect both younger and older people, as it’s not necessarily associated with aging, according to the American College of Gastroenterology.

What is constipation? This simple question has many answers. When their bowels aren’t moving every day, some patients may think they are constipated, but anywhere from three bowel movements per day to three per week is considered to be within the normal range. The National Institutes of Health (NIH) defines constipation as having fewer than three bowel movements per week.

It may be more meaningful, however, to reserve the term “constipation” for when certain signs and symptoms are present rather than basing it on stool frequency, according to Joanne Slavin, PhD, RD, a professor in the department of food science and nutrition at the University of Minnesota. Ask your patients if their signs and symptoms fit the bill: The stool is characterized as hard, dry, small, and difficult to pass, and the movement may be painful. Constipation is also associated with straining, bloating, and the sensation of a full bowel.

How It Occurs
Though constipation is common, patients may not know exactly what causes it. Therefore, reviewing the basics may be helpful. Once they grasp what’s going on inside their body, patients may feel more confident that behavior changes will produce real results and thus be more likely to commit to making healthful changes. The following are several key points to review:

• On the last leg of the digestion trip, food travels through the colon, where water is absorbed, and the remaining food is transformed into waste, or stool.

• If too much water is absorbed by the colon, the result is hard, dry stool: constipation.

• At the same time, muscle contractions push the remaining food toward the rectum, by which time enough water has been absorbed from the food that it’s solid.

• If the colon’s muscles are sluggish, the result is hard, dry stool.

• The most common causes of constipation are low-fiber and high-fat diets. To reverse these patterns, patients should gradually add dietary fiber over one to two weeks from a variety of sources, such as fruits, vegetables, legumes, and whole grains, and consider reducing their high intake of fatty foods such as cheese and meat.

Determining What Is “Regular”
Once patients have a basic understanding of what constipation is and how it occurs and are ready to make changes, they will be interested in achieving the goal of good digestive health: becoming “regular.” Like defining constipation, defining regular isn’t easy. A recent article in Nutrition Today discusses what makes a simple definition elusive, including a lack of samples from a large cohort of healthy people.3

Methods for assessing digestive health have often depended on self-reported, subjective, qualitative questionnaires with nonstandardized metrics (eg, characterizing symptoms as none, mild, moderate, or severe in one study and normal or more than normal in another). One tool that aims to make self-reports more accurate is the King’s Stool Chart, which is used to characterize stool and has been validated for use in free-living individuals and certain at-risk patients. The tool and instructions for use are free to download. (See the Resources section for a link to more information.)

Still, nothing beats objective lab data and, thankfully, some do exist. Grabitske and Slavin cite a United Kingdom-based meta-analysis of 11 studies that accurately measured daily fecal weight in 26 groups of people (n = 206) on controlled diets of known fiber content.3 The results showed that the level of fiber intake was significantly related to stool weight (r = 0.84) and that the range of weights varied from 72 to 470 g/day, with an average of 106 g/day in healthy British adults (men, 104 g/day; women, 99 g/day). The authors assert that the United States likely has similar average stool weights and also cite findings that optimal stool weight likely ranges from 160 to 200 g/day for adults, below which the risk of colon cancer increases.3

Slavin adds that feces need to be formed, easy to pass, and not contain undigested foods and that “digestive health is critical to quality of life, so it’s best to keep digestion and absorption in the normal range rather than be treating constipation or diarrhea.” Indeed, though it will not apply to most Americans (who consume 5 to 14 g/day of fiber compared with the recommended 20 to 35 g/day), it may be important to note that increasing fiber may not be of much additional digestive benefit to those who are already consuming enough fiber to produce healthy-weight stools.4

Constipation Triggers and Solutions
The following are factors that can influence the digestive process and possible ways to help patients avoid a sluggish system this holiday season:

Diet
Slavin points out that low-fiber diets, especially high-protein, low-carbohydrate diets, are problematic. As RDs, we know that a well-rounded, high-fiber diet leads to good digestive health, which is important for extracting essential nutrients from our food.
Suggesting specific solutions for specific circumstances, such as the holiday season, may be helpful. The following are several solutions you can offer patients to improve the “go factor” of some traditional Thanksgiving dishes:

• Instead of bread crumb stuffing, try a more fiber-packed version made with a mix of wild and brown rice, dried cranberries, and pistachios.

• Opt for a freshly prepared cranberry-orange relish, made by combining uncooked cranberries, orange slices, and walnuts in a blender, instead of canned cranberry sauce.

• Add fresh sweet corn kernels and wheat bran to a plain corn bread mix.

• Instead of plain, cooked string beans, make a colorful legume dish of lightly seasoned cooked edamame and black beans.

Is it all about fiber? Interestingly, the answer may be yes and no. We know that fiber is related to stool weight and stool weight is related to digestive health. However, in a 1985 study by Slavin et al in the Journal of Parenteral and Enteral Nutrition, solid food also played an important role. Participants who ate a usual diet (not especially high in fiber, at an estimated 20 g/day) had a higher average daily stool weight (145 g/day) compared with participants on a liquid diet who were given 0 or 30 g of soy fiber (stool weights of 67 g/day and 100 g/day, respectively). There was also a group on the liquid diet getting 60 g/day of soy fiber whose average daily stool weight was greater than those on their usual diets but only minimally so at 150 g/day.

Patients looking to the NIH fact sheet on constipation will see that caffeinated drinks such as coffee are implicated in constipation because they are dehydrating. Yet, Jo Ann Hattner, MPH, RD, author of Gut Insight: Probiotics and Prebiotics for Digestive Health and Well-Being, notes that she has “often advised clients with constipation who only drink decaf to try regular coffee in the morning as a colonic stimulate.”

Hattner continues: “Caffeine is a central nervous system stimulant. It can stimulate the colon, and many people use that ‘morning cup’ just for this purpose.” Furthermore, 2003 research by Maughan et al in the Journal of Human Nutrition and Dietetics suggests that the level of caffeine in one to three daily cups may not be all that dehydrating.

What about plum juice? Hattner notes that some plum juice is made from the same type of plum used to make prune juice and that “prunes have a well-known reputation for a laxative effect, which is not well understood but may relate to its sugar alcohol content.” Sorbitol is the naturally occurring sugar alcohol that may stimulate gastrointestinal muscle contractions, but because even small doses can be effective, too much may lead to diarrhea.

Exercise
Slavin notes that “exercise probably speeds transit, but … studies are inconclusive.” For example, a small, controlled 1989 study by Bingham and Cummings in Gastroenterology found that a nine-week exercise program actually slowed transit time for nine participants while speeding it up for five. Still, Slavin notes that inactivity is not without its risks and that “being bedridden typically causes more problems with constipation.”

Despite conflicting research findings on the topic of constipation, there are certainly plenty of good reasons to recommend adequate physical activity.

Stress
Surprisingly, some types of stress (eg, exams, competitions, public speaking) have been linked to faster intestinal transit.2 However, the kind of stress associated with holiday errands and increased demands on time often pushes patients to ignore the urge to “go,” and the time that passes due to ignoring these cues allows more water to be absorbed away from stool, resulting in drier, harder feces that are more difficult to pass.

The American Psychological Association acknowledges that many people feel overwhelmed during the holiday season. In addition to dietary advice, we can share the association’s tips for preventing holiday stress, which include taking personal time, volunteering, having realistic expectations, focusing on what’s important, and seeking support. Making practical recommendations for healthier holiday meal planning is also bound to relieve some stress.

Nonmodifiable Triggers
Keep in mind that there are plenty of factors that contribute to constipation over which patients have little to no control, such as age, sex, genes, digestive enzymes, food intolerances, and gastrointestinal conditions such as celiac disease and some semimodifiable factors such as medications and personality. (When healthy participants followed controlled diets, Tucker et al found that the more outgoing ones were more likely to produce higher weight stool, as reported in a 1981 Gastroenterology study.) RDs can help patients focus on the behaviors they can modify and arm them with the simple truth that despite a variety of contributing factors, poor diet remains the No. 1 trigger of constipation.

A Little Extra Help
Because patients may have questions about specific brand-name products, it’s important to round out general knowledge of whole foods to recommend with some digging into the research (or lack thereof) supporting the claims of commonly available products.

More likely than not, patients interested in digestive health will have questions about widely advertised probiotic-containing products such as Dannon’s Activia yogurt or Yakult’s minidrink. Activia’s Web site includes a section specifically for healthcare professionals, including a research summary of clinical trials. Yakult’s Web site promises that a healthcare professional site is coming soon and offers e-mail notification for those who are interested. Both sites promote everyday use of the products. Hattner adds that it is advisable to always check the stamped date prior to purchase to ensure the cultures are still active. Given the recent questions about the reliability of some probiotic health claims, it’s also a wise idea to keep an eye out for news of stricter industry regulation.

Those interested in temporary, targeted assistance may have questions about over-the-counter laxatives. “Sometimes when traveling, people are without their normal foods that keep them regular, [and] they like to take a laxative,” says Hattner. She suggests that patients “look for the most natural and mild preparation” and do a test run at home to determine whether it works well with the individual. One example is Senokot, which is a senna plant laxative that falls into the stimulant category. The company’s Web site offers diet and lifestyle solutions first and its product as a secondary solution. The site also includes a concise overview of efficacy results from clinical trials.

Fiber supplements also fall into the laxative category (in the bulk-forming subcategory), but Hattner asserts that since “natural fiber sources are abundant, why not use natural foods?” An overview of laxatives by mechanism and with examples of brand names is included in the NIH National Digestive Diseases Information Clearinghouse fact sheet on constipation. (See the Resources sidebar.)

In the world of cookbooks, the recently published The Un-Constipated Gourmet: Secrets to a Moveable Feast — 125 Recipes for the Regularity Challenged by Danielle Svetcov may be of particular interest to patients who are looking for ways to prepare holiday meals that will promote digestive health.

The Bottom Line
The promise of constipation relief, during the holidays and beyond, can be a strong motivator for patients to make the well-founded dietary behavior changes RDs have long supported. Slavin says, “RDs know about foods and the importance of eating real foods for normal digestion and absorption. They are able to devise diets rich in dietary fibers and can also stress the importance of regular eating patterns and bathroom patterns to maintain digestive health.”

In conclusion, recommend food first, additional help (like additional helpings) second, and always be ready with practical advice.

— Maggie Moon, MS, RD, is a nutrition writer and registered dietitian based in New York City.

 

References
1. Cumming JH, Bingham SA, Heaton KW, Eastwood MA. Fecal weight, colon cancer risk, and dietary intake of nonstarch polysaccharides (dietary fiber). Gastroenterology. 1992;103(6):1783-1789.

2. National Digestive Diseases Information Clearinghouse. Constipation. July 2007. NIH Publication No. 07-2754. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/constipation

3. Grabitske HA, Slavin JL. Laxation and the like: Assessing digestive health. Nutrition Today. 2008;43(5):193-198.

4. National Center for Health Statistics. Dietary intake of macronutrients, micronutrients, and other dietary constituents: United States, 1988-94. Vital and Health Statistics. 2002;11(245).

 

Resources
• American Gastroenterological Association: www.gastro.org

• Gut Insight: Probiotics and Prebiotics for Digestive Health and Well-Being by Jo Ann Hattner, MPH, RD, with Susan Anderes, MLIS: www.gutinsight.com

• International Foundation for Functional Gastrointestinal Disorders: www.iffgd.org

• King’s Stool Chart: www.kcl.ac.uk/schools/biohealth/research/nutritional/stoolchart

• National Digestive Diseases Information Clearinghouse Fact Sheet on Constipation: http://digestive.niddk.nih.gov/ddiseases/pubs/constipation

• The Un-Constipated Gourmet: Secrets to a Moveable Feast — 125 Recipes for the Regularity Challenged by Danielle Svetcov: www.theunconstipatedgourmet.com

Select Foods and Their Fiber Content

	Fiber (g)		Fiber (g)
Fruits		Vegetables
Apple, with skin (1 medium)	4.4	Peas, cooked (1/2 cup)	4.4
Raspberries, fresh (1/2 cup)	4	Corn, cooked (1 medium)	2.9
Cranberries, dried (1/3 cup )	2.3	Broccoli, boiled (1/2 cup)	2.6
Grains		Nuts
Quinoa, cooked (1 cup)	5.2	Almonds (1 oz, 22 nuts)	3.3
Brown rice, cooked (1 cup)	3.5	Pistachios (1 oz, 49 nuts)	2.9
Popcorn, air popped (3 cups)	3.5	Walnuts (1 oz, 14 halves)	1.9
Beans
Lentils, cooked (1/2 cup)	7.8
Black beans, cooked (1/2 cup)	7.5
Edamame, cooked (1/2 cup)	4

— Source: U.S. Department of Agriculture Agricultural Research Service. USDA National Nutrient Database for Standard Reference, Release 21. Last modified August 13, 2009. Available at: http://www.ars.usda.gov/services/docs.htm?docid=8964