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Don't Just Do Something, Sit There!
You Can Treat Constipation in Many Ways, but First Find Out if You've Really Got a Problem
By Kathleen F. Phalen

Many people believe that a daily regimen of waste elimination is a sign of good health. Wrong. And failing to meet this standard, they self-medicate. Wrong again. "Fixing" your plumbing when it's not broken is asking for trouble.

(Before we go on, we should note that writing about certain topics, especially those rarely discussed in public or in tasteful company, can present challenges for writers and readers alike. And be advised that some of the details that follow may not make for suitable dinner conversation -- but might well provoke amazed or alarmed discussion elsewhere. So: You've been warned. Back to the action.)

Before reaching for a laxative, find out if you really have constipation, which is defined as having bowel movements that are uncomfortable or infrequent. "People are very focused on defecating every day and end up with rigid ideas of what is normal," says Henry C. Lin, director of the GI Motility Program at Cedars-Sinai Medical Center in Los Angeles. In fact, "normal" can be three times a day or three times a week, depending on the person. And "normal" can change significantly over time, based on age and other factors.

Some simple questions can help determine if you are actually constipated: Do you feel bloated? Are your stools harder or bulkier than normal? When you feel the urge, is it difficult or painful to use the toilet? If not, your rate of elimination is probably just fine.

But if you are constipated, it's important to find out why. Inadequate dietary fiber and insufficient exercise are common causes of constipation, and they can often be corrected with modest lifestyle changes. But a sudden change in bowel habits may indicate a serious condition, such as colon cancer. Also, certain drugs -- including antihistamines, anti-hypertensives and pain medications -- can cause temporary bouts of constipation.

Most commonly treated with stool softeners, laxatives and nutritional changes, constipation can also be addressed with biofeedback, behavior modification and increased exercise. Before resorting to prescription laxatives, some progressive mainstream doctors explore home remedies and natural supplements. Alternative practitioners generally view constipation as an intestinal imbalance and use a combination of diet, herbs, homeopathy and sometimes acupuncture.

In and Around the Mainstream

Walk down any drugstore's laxative aisle and you'll find a broad variety of potential solutions: natural fiber of all descriptions; stool softeners; "new, improved, more gentle" laxatives; enema kits. The choices can be confounding, but effective treatment may be as simple as spending 25 cents for the newspaper and reading it while sitting on the toilet.

That's what Lin prescribes. "When somebody tells me they are constipated, I ask, 'How long do you sit there?' " he says. The way he explains it, elimination is a staged process. Initially we receive a cue that tells us nature is calling. If we choose to respond to the cue, we must consciously bear down to pass the first stool. This may sound like a no-brainer, but Lin says many patients believe they are constipated if they merely have to help things along.

The process is fairly automatic once it has begun, but it can take a while. As a behavior modification technique, Lin advises sitting on the toilet for 15 minutes at a regular time each day.

The chronically bound-up might have anal sphincter sensory problems -- feeling like they always have to go, or never feeling the cue. In other cases, people inadvertently prevent voiding by squeezing the anus instead of pushing to clear the colon. Such problems can be treated with biofeedback sessions, in which the patient is able to see, on a computer monitor linked to sensors attached to the body, the effect of muscular contractions. The monitor can reveal, for example, if the patient is squeezing instead of pushing. When the patient begins to push, the change becomes evident on the computer screen.

In addition to products available in stores, home remedies are an option. Craig Rubin, a professor of internal medicine and chief of the geriatric section at University of Texas Southwestern Medical Center in Dallas, offers this one: Mix and then refrigerate a half-cup of unprocessed bran and a half-cup of applesauce with a third of a cup of prune juice. Take two tablespoons after dinner followed by a glass of water; increase to three to four tablespoons if needed.

Speaking of water, Rubin says there's no scientific evidence that drinking more keeps bowels regular, though a diet of fresh vegetables, fruit and fiber is important.

Starting a high-fiber diet should be gradual, Rubin advises, to give the body time to adjust. He suggests the herb epazote if an increased diet of beans, grains and other high-fiber foods creates an excess of gas. And a word of caution on fiber: If you are bedridden or not mobile, additional fiber can make constipation worse.

Over-the-counter stool softeners like Colace and prescription formulas like MiraLax can help because they add water to the stool, which allows it to move through the colon more easily.

There is nothing wrong with occasionally taking a stimulant laxative, which prompts the colon to contract. But daily use is not advised, because over time the colon can become numb and unable to do its job. This can leave a person reliant on laxatives for routine bowel movements.

As for enemas? They're available, traditional and affordable. But they're rarely used and better choices abound.

Alternatives Include Herbs

To practitioners of alternative medicine, constipation is often a sign that the bowel is imbalanced; long-term resolution requires lifestyle and dietary changes, along with herbs to tone bowel function and other supplements to restore normal flora to the intestinal tract. Multiple studies in Europe, Asia and the United States have shown probiotic bacteria such as acidophilus to to be effective in restoring or maintaining healthy intestinal flora.

The elimination of refined foods and sugar, a decrease in animal fats and an increase in essential fatty acids (abundantly found in nuts, seeds and cold-water fish), fresh vegetables, fruit and grains is a good start, these practitioners say. Getting more exercise, sitting while eating, drinking a cup of warm lemon water before meals and eating a few stewed prunes each day can improve digestive hygiene.

Herbs such as licorice root, yellow dock, fennel seed, flaxseed, aloe latex and psyllium are believed to help constipation. Many of these have been studied, especially in Europe, and have been shown to be effective for constipation. But again, a few words of caution: Aloe latex is powerful and can cause uterine cramping; pregnant and nursing women should not take it. It may also aggravate ulcers, hemorrhoids or irritable bowel syndrome. Chronic use may lead to potassium deficiency. Flaxseed may slow down absorption of oral medications. Psyllium should always be taken with a full glass of water and shouldn't be taken within an hour of other medications because it can interfere with their effectiveness.

Before suggesting remedies, issues like the color, shape and size of stools and the amount of gas are important to assess, says Lynn Shumake, a pharmacist who specializes in natural medicine at the Riverhill Wellness Center in Clarksville. "Constipation can lead to inflammatory conditions of the bowel," says Shumake. "And we often find an imbalance of bacteria within the gut."

Shumake's remedies may include taking bitters before meals, which is thought to improve digestive efficiency. He says these herbs reduce gas and discourage the growth of yeast in the intestine, which can lead to imbalances in the colon. To restore healthy flora, probiotics like acidophilus and natural digestive enzymes are helpful. Megadoses of vitamin C (3 to 5 grams) for a few days can moisturize the digestive system, and herbal teas, such as Smooth Move, can also help.

Both alternative and mainstream practitioners advise against self-medication, saying proper treatment of constipation takes individual attention by an informed professional.


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