Controversies in constipation

  1. No-one’s to blame

    All too often, in my experience, the blame for constipation is pinned fairly and squarely on the shoulders of the sufferers themselves - for not eating the right foods or for not drinking enough liquids. But rarely, if ever, have I seen patients whose constipation is solely because of a poor diet or other lifestyle issues.

    As far as I am concerned, constipation is not substantially different to any other disorder such as diabetes, high blood pressure, asthma or even heart disease. People develop constipation for reasons almost entirely outside their own control. Yet, we continue to insist that things can be overcome by diet and exercise alone. Over many years, I have seen thousands of patients for whom this advice has been quite inadequate but who have been made to feel incredibly guilty that they are unable to control their bowels “naturally”.

    This is, perhaps, the most important myth that I encounter - the one that says that constipation shouldn’t be a problem if only you would pursue the correct lifestyle. This is nonsense! If you are constipated, the chances are very high that it has nothing to do with your lifestyle and everything to do with your own, inherent predisposition to this troublesome, at times infuriating problem. Put simply – it’s not your fault.

  2. Fibre isn’t the cure of all evil

    Following on from the knowledge that your constipation is not your fault is the simple (but politically incorrect) fact that fibre cannot and will not improve every case of constipation. In truth, fibre is a genuinely mild laxative that is unlikely to be sufficient treatment on its own in all but the mildest cases. And, at least in my experience, I have virtually never seen a patient with constipation who hasn’t already tried a high dietary fibre intake and found it wanting.

    Since fibre speeds up colonic transit only very gently, it is unlikely to provoke the sort of strong urge that is so important in improving your constipation. And since fibre results in an increase in bowel gas formation, it tends to aggravate abdominal bloating. Not only does the fibre fail to help, in some instances it can actually make things worse. In many cases my first advice to constipated patients is to reduce fibre intake – this reduces their bloating and makes way for much more effective laxative treatment.

  3. Herbal might be natural but it isn’t OK

    Of the stronger laxatives, the most readily available and the most abundant by far are those of the herbal and stimulant varieties. These include the herbal agents senna and cascara and the stimulating chemicals bisacodyl and sodium picosulfate. They are usually presented in easy-to-take tablet form which makes them very appealing, especially if you have been taking unpalatable, semi-gelatinous mixtures of fibre supplements.

    The usual thinking – herbal equates with natural and therefore must be “OK” – does not really apply to these agents. They act by chemically stimulating the intestinal muscle wall to contract. This intestinal muscle, in turn, becomes dependent upon the presence of the chemical to be able to contract at all. After regular use of herbal and stimulant laxatives, the intestines become “addicted” and require gradually increasing does to achieve the same response.

    So, while these laxatives are not poisonous or cancer-forming, they are clearly not ideal. No laxative that actually makes the bowel less responsive and ever less likely to act spontaneously can possibly be best for you. Natural or herbal does not always mean best.


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