-IBIS-1.7.6-
tx
digestive system
constipation
Nutrition

dietary guidelines

eating principles:
Hydration: increase water consumption; make sure the patient is drinking enough water (50-60 oz/day)
Increase fiber (both water soluble and non-water soluble types)
• Increase fruit
• Increase foods rich in Sodium (Jensen, 20.)
• Elimination/rotation diet, rotation diet, rotation diet expanded, especially if alternating constipation with diarrhea

to protect against constipation:
Increase cellulose and hemi-cellulose foods in diet
note: fiber contraindicated with Qi Xu (Deficiency) constipation

therapeutic foods:
• Moistening foods, Descending foods, outward foods
• For hot constipation, foods that clear Heat
• Prunes soaked in water
Flax seed (1 Tbsp. ground on cereal or mixed with one half glass of water or juice) or flax oil: 15 ml per day.
Insoluble fiber: important sources include vegetables, beans, whole wheat, rye and brown rice. Whole grains are more beneficial than processed grains, such as white bread or white rice. (Marcus SN, Heaton KW. Gut 1986;27:893-900;.Müller-Lissner SA. Br Med J. 1988;296:615-617.)
• Whey (WHEX concentrated dried goat whey) (Jensen)
• Black Mission figs soaked in water or fig juice
• Honey
• Very ripe bananas
• Tahini, sprouted seeds, alfalfa sprouts, raw apples, apricots, asparagus, beets, bok choy cooked with beets, burdock root, bamboo shoot, figs, flaxseed, cauliflower, carob, cabbage and Chinese cabbage, sauerkraut, green beans, grapefruit, pineapple, carrots, cherry, persimmons, Jerusalem artichokes, pears, quince, squash, pomegranate, currant, sesame seeds, sunflower seeds, radishes, berries, spinach, sweet potatoes

fresh juices:
• Celery with a little sweet cream (Jensen, 50.)
• Spinach and grapefruit (Jensen, 50.)
• Grapefruit on an empty stomach in the morning (Shefi)
• Apple
• Sauerkraut (Airola,. 65.)
• Carrot, cucumber, celery, beet with small amount of watercress, spinach, nettles, garlic, onion or dandelion added (Airola, 65.)
• Mulberry (Ni, 119.)
• Honey mixed into warm water drunk on empty stomach

specific remedies:
• Eat 2-3 ripe bananas on empty stomach in the morning (Butt and Bloomfield, 127.)
• Mix 1 oz. crushed black sesame seeds with 1/2 cup hot water and drink (Butt and Bloomfield, 127.)
• Mix 2 tbsp. raw potato juice and 1 tbsp. honey with a little hot water and drink before breakfast on an empty stomach for 30 days (Butt and Bloomfield, 127.)
• Mix 10 oz. cold milk with 3 oz. mashed banana and drink (for hot constipation only) (Butt and Bloomfield, 127.)
• Add water to 3-4 dried figs and let sit several hours until absorbed, then add 1 tbsp. ground sesame seeds and eat twice daily. (Shefi)
• On empty stomach in the morning and mid-afternoon, pour 1 cup boiling water on 2-3 tsp. freshly ground flaxseed and steep 10 minutes then drink the tea at the top. (Shefi)
• Take 12 g of plum kernels and crush; add water, steam and serve. Wait for at least four hours before repeating dose (Yin-fang and Cheng-jun, 36.)
• For constipation in the aged: take 10-15 g loquat fruit stones and crush them. Cover with water and simmer 1 hour. Strain to obtain the liquid, add 30 g candied honey, mix and serve. (Yin-fang and Cheng-jun, 48.)
• Take 15 g of dried peach kernels (inner kernel removed from peach pit), crush and simmer in water until cooked. Add 30 g honey, blend and serve. (Yin-fang and Cheng-jun, 70.) Contraindicated in pregnant women.
• Take 30 g dried mulberries and 30 g candied honey, add water and simmer until cooked. Take p.r.n. (Yin-fang and Cheng-jun, 73.)
• Eat the flesh of a fresh coconut twice daily (Yin-fang and Cheng-jun, 87.)
• Eat 30 g of fresh or boiled shelled peanuts once daily, until improvement (Yin-fang and Cheng-jun, 101.)
• Simmer 500 g of daikon radish in 1 liter of water until liquid is reduced by half. Serve warm (Chao-liang, Qing-rong, Bao-zhen, 12.)
• Cook brown rice and spinach into a gruel (Chao-liang, Qing-rong, Bao-zhen, 41.)

avoid:
Consider allergies, especially milk, with alternating constipation and diarrhea.
Cow's milk: While an association between dairy consumption and diarrhea has been well documented, the relation between milk connsumption and constipation or alternating diarrhea and constipation has received less attention. In a double-blind crossover study comparing cow's milk with soy milk, researchers found a significant association between the dairy intake and chronic constipation, along with a variety of related conditions such as anal fissures, perianal erythema and edema, and a range of coexistent conditions such as rhinitis, dermatitis and bronchospasm.
(Iacono G, et al. N Engl J Med 1998 Oct 15;339(16):1100-1104.)
• Food intolerances
• Salt, starchy foods, sugar, coffee, chocolate, caffeine, cheese, blackberries, fried foods, spicy foods, tea, alcohol, white flour, refined and processed foods


supplements

• Vitamin B-complex; 10 mg per day, multi-B complex orally for infants (Airola, 1980, 65; Marz, 386, 1997.)
Vitamin C: 3-10 g per day.
• Folic acid up to 60 mg per day, especially with signs of deficiency.
(Botez MI, et al. Can Med Assoc J. 1976 Aug 7;115(3):217-23..)
Magnesium 600-900 mg per day. (Marz, 1989.)
• Multimineral supplement
• Trace elements
• Chlorophyll: possible benefit for some individuals.
(Young RW, Beregi JS Jr. J Am Geriatr Soc 1980 Jan;28(1):46-47.)
• Essential fatty acids: consider if high triglycerides, blood pressure, dry skin, dermatitis, inflammation. EFAs will act both physically and through prostaglandin synthesis
HCl 5-80 grains/meal, if hypochlorhydric
Lactobacillus acidophilus (may be helpful) (Salminen S, Salminen E. Scand J Gastroenterol Suppl. 1997;222:45-48.)
Psyllium (Plantago ovata): 5 grams of husks or 7.5 grams of powdered seeds , with ample water or juice, one to two times daily; and, if cholesterol is high, add other fibers such as pectin;

» drug interaction:
• Mineral oil used as a laxative interferes with fat soluble vitamin absorption.


footnotes

Botez MI, Cadotte M, Beaulieu R, Pichette LP, Pison C. Neurologic disorders responsive to folic acid therapy. Can Med Assoc J. 1976 Aug 7;115(3):217-23.

Iacono G, Cavataio F, Montalto G, Florena A, Tumminello M, Soresi M, Notarbartolo A, Carroccio A. Intolerance of cow's milk and chronic constipation in children. N Engl J Med. 1998 Oct 15;339(16):1100-1104.
Abstract: BACKGROUND: Chronic diarrhea is the most common gastrointestinal symptom of intolerance of cow's milk among children. On the basis of a prior open study, we hypothesized that intolerance of cow's milk can also cause severe perianal lesions with pain on defecation and consequent constipation in young children. METHODS: We performed a double-blind, crossover study comparing cow's milk with soy milk in 65 children (age range, 11 to 72 months) with chronic constipation (defined as having one bowel movement every 3 to 15 days). All had been referred to a pediatric gastroenterology clinic and had previously been treated with laxatives without success; 49 had anal fissures and perianal erythema or edema. After 15 days of observation, the patients received cow's milk or soy milk for two weeks. After a one-week washout period, the feedings were reversed. A response was defined as eight or more bowel movements during a treatment period. RESULTS: Forty-four of the 65 children (68 percent) had a response while receiving soy milk. Anal fissures and pain with defecation resolved. None of the children who received cow's milk had a response. In all 44 children with a response, the response was confirmed with a double-blind challenge with cow's milk. Children with a response had a higher frequency of coexistent rhinitis, dermatitis, or bronchospasm than those with no response (11 of 44 children vs. 1 of 21, P=0.05); they were also more likely to have anal fissures and erythema or edema at base line (40 of 44 vs. 9 of 21, P<0.001), evidence of inflammation of the rectal mucosa on biopsy (26 of 44 vs. 5 of 21, P=0.008), and signs of hypersensitivity, such as specific IgE antibodies to cow's-milk antigens (31 of 44 vs. 4 of 21, P<0.001). CONCLUSIONS: In young children, chronic constipation can be a manifestation of intolerance of cow's milk.

Izzo AA, Gaginella TS, Capasso F. The osmotic and intrinsic mechanisms of the pharmacological laxative action of oral high doses of magnesium sulphate. Importance of the release of digestive polypeptides and nitric oxide. Magnes Res. 1996 Jun;9(2):133-138. (Review)

Marcus SN, Heaton KW. Effects of a new, concentrated wheat fibre preparation on intestinal transit, deoxycholic acid metabolism and the composition of bile. Gut 1986 Aug;27(8):893-900.
Abstract: When the cholesterol saturation index of bile is reduced by wheat bran there is generally a fall in the deoxycholic acid content of bile. As the same effects occur with senna, bran might act on bile simply via its accelerating effect on colonic transit. We have studied the effects of a new, concentrated, wheat fibre preparation (Testa Triticum Tricum, Trifyba, which is 80% dietary fibre) upon bile composition, deoxycholic acid metabolism and intestinal transit time, and have assessed whether these effects are related. Twenty constipated volunteers were prescribed Testa Triticum Tricum in doses (10-32 g/day) sufficient to relieve their symptoms for at least six weeks. Before and at the end of this period, duodenal bile was sampled to enable measurement of deoxycholic acid pool (by isotope dilution), total bile acid pool, bile acid composition and cholesterol saturation index. Whole gut transit time fell from 120 +/- SD35 to 68 +/- 35 hours. At the same time, biliary % deoxycholic acid fell from 26.6 +/- 12.0 to 23.0 +/- 11.8 (p = 0.002), the total bile acid pool expanded from 2.36 +/- 0.88 to 2.75 +/- 0.90 g (p = 0.008) and cholesterol saturation index fell from 1.13 +/- 0.32 to 1.07 +/- 0.29 (p = 0.04). In subjects with initial cholesterol saturation index over 1.0 (n = 12), it fell from 1.33 +/- 0.25 to 1.22 +/- 0.21 (p = 0.008). There was no significant correlation between change in saturation index and change in % deoxycholic acid or deoxycholic acid pool, nor between any of these parameters and change in transit time.

Muller-Lissner SA. Effect of wheat bran on weight of stool and gastrointestinal transit time: a meta analysis. Br Med J (Clin Res Ed). 1988 Feb 27;296(6622):615-617.
Abstract: Twenty original papers that reported on the effect of wheat bran on large bowel function were analysed. Bran increased the stool weight and decreased the transit time in each study in healthy controls and in patients with the irritable bowel syndrome, with diverticula, and with chronic constipation. Statistical evaluation of the data showed, however, that constipated patients had lower stool output and slower transit whether or not they had taken bran, and they responded less well to bran treatment than controls. From these data it is concluded that bran can be expected to be only partially effective in restoring normal stool weight and transit time in patients who are constipated.

Passmore AP, Wilson-Davies K, Stoker C, Scott ME. Chronic constipation in long stay elderly patients: A comparison of lactulose and senna-fiber combination. Br Med J. 1993 Sep 25;307(6907):769-771.
Abstract: OBJECTIVES--To compare the efficacy and cost effectiveness of a senna-fibre combination and lactulose in treating constipation in long stay elderly patients. DESIGN--Randomised, double blind, cross over study. SETTING--Four hospitals in Northern Ireland, one hospital in England, and two nursing homes in England. SUBJECTS--77 elderly patients with a history of chronic constipation in long term hospital or nursing home care. INTERVENTION--A senna-fibre combination (10 ml daily) or lactulose (15 ml twice daily) with matching placebo for two 14 day periods, with 3-5 days before and between treatments. MAIN OUTCOME MEASURES--Stool frequency, stool consistency, and ease of evacuation; deviation from recommended dose; daily dose and cost per stool; adverse effects. RESULTS--Mean daily bowel frequency was greater with the senna-fibre combination (0.8, 95% confidence interval 0.7 to 0.9) than lactulose (0.6, 0.5 to 0.7; t = 3.51 p < or = 0.001). Scores for stool consistency and ease of evacuation were significantly higher for the senna-fibre combination than for lactulose. The recommended dose was exceeded more frequently with lactulose than the senna-fibre combination (chi 2 = 8.38, p or = 0.01). As an index of the standard daily dose, the dose per stool was 1.52 for lactulose and 0.97 for the senna-fibre combination, at a cost per stool of 39.7p for lactulose and 10.3p for senna-fibre. Adverse effects were no different for the two treatments. CONCLUSIONS--Both treatments were effective and well tolerated for chronic constipation in long stay elderly patients. The senna-fibre combination was significantly more effective than lactulose at a lower cost.

Rao SS, Beaty J, Chamberlain M, Lambert PG, Gisolfi C Effects of acute graded exercise on human colonic motility. Am J Physiol. 1999 May;276(5 Pt 1):G1221-1226.
Abstract: Whether physical exercise stimulates colonic motility is unclear. Our aim was to determine the immediate effects of graded exercise on colonic motility. Colonic motility was recorded at six sites in 11 untrained subjects, by colonoscopically placing a solid-state probe. Subjects were free to ambulate. The next day, subjects exercised on a bicycle at 25, 50, and 75% of peak oxygen uptake for 15 min, with each followed by a 15-min rest. Motor patterns, motility indexes, and regional variations before, during exercise, during rest, and during postexercise periods were compared. During exercise, there was an intensity-dependent decrease (P < 0.001) in the number and area under the curve of pressure waves. The incidence of propagated or simultaneous pressure waves and cyclical events also decreased (P < 0.05). After exercise, the pressure activity reverted to baseline, but the number and amplitude of propagated waves increased (P < 0.01), whereas the simultaneous waves and cyclical events remained lower. Acute graded exercise decreases colonic phasic activity. This may offer less resistance to colonic flow, whereas the postexercise increase in propagated activity may enhance colonic propulsion.

Salminen S, Salminen E. Lactulose, lactic acid bacteria, intestinal microecology and mucosal protection. Scand J Gastroenterol Suppl. 1997;222:45-48. (Review)
Abstract: During the fermentation of lactulose, short-chain fatty acids are formed with consequent lowering of the colon pH and modification of the microflora. Lactulose promotes the growth of lactic acid bacteria and bifidobacteria and, more specifically, Lactobacillus acidophilus in the colon. Lactulose and lactulose-containing products fermented with lactic acid bacteria lower colonic pH balancing intestinal microecology and normalizing intestinal transit. In animal studies, lactulose promotes a mainly Gram-positive faecal microflora, but large doses of lactulose may be associated with transient diarrhoea. Our studies indicate that lactulose with lactic acid bacteria effectively relieves constipation in human volunteers. Lactulose with lactic acid bacteria in a fermented diary product can balance and prevent radiotherapy-associated diarrhoea and intestinal side effects. Normalizing the intestinal flora and stabilizing mucosal integrity with lactulose has beneficial effects in intestinal disorders. Lactulose and lactic acid bacteria offer a promising ingredient combination for future functional and special dietary foods in treating intestinal disturbances.

Schindlbeck NE, Muller-Lissner SA. [Dietary fiber. Indigestible dietary plant constituents and colon function]. Med Monatsschr Pharm. 1988 Oct;11(10):331-6. Review) [Article in German]

Voderholzer WA, Schatke W, Muhldorfer BE, Klauser AG, Birkner B, Muller-Lissner SA. Clinical response to dietary fiber treatment of chronic constipation. Am J Gastroenterol. 1997 Jan;92(1):95-98.
Abstract: OBJECTIVES: To determine the clinical outcome of dietary fiber therapy in patients with chronic constipation. METHODS: One hundred, forty-nine patients with chronic constipation (age 53 yr, range 18-81 yr, 84% women) at two gastroenterology departments in Munich, Germany, were treated with Plantago ovata seeds, 15-30 g/day, for a period of at least 6 wk. Repeated symptom evaluation, oroanal transit time measurement (radiopaque markers), and functional rectoanal evaluation (proctoscopy, manometry, defecography) were performed. Patients were classified on the basis of the result of dietary fiber treatment: no effect, n = 84; improved, n = 33; and symptom free, n = 32. RESULTS: Eighty percent of patients with slow transit and 63% of patients with a disorder of defecation did not respond to dietary fiber treatment, whereas 85% of patients without a pathological finding improved or became symptom free. CONCLUSION: Slow GI transit and/or a disorder of defecation may explain a poor outcome of dietary fiber therapy in patients with chronic constipation. A dietary fiber trial should be conducted before technical investigations, which are indicated only if the dietary fiber trial fails.

Wilson JA. Constipation in the elderly. Clin Geriatr Med. 1999 Aug;15(3):499-510. (Review)

Young RW, Beregi JS Jr. Use of chlorophyllin in the care of geriatric patients. J Am Geriatr Soc 1980 Jan;28(1):46-47.
Abstract: In a test group of 62 geriatric nursing home patients, the administration of chlorophyllin tablets was found to be helpful in controlling body and fecal odors. It aided also in easing chronic constipation, served at times as a useful and morale-building placebo, and assisted in abating excessive flatus. No toxic or other ill effects were observed. Bacteriologic studies failed to confirm reports in the literature of antibacterial properties for chlorophyllin. Further investigation of this possibility is recommended.