Gutsense Header

Chapter 5. Constipation

“Constipation was [sic] the most common digestive complaint in the United States, outnumbering all other chronic digestive conditions.”
Epidemiology of constipation in the United States[1]

“Constipation may have other serious consequences; an increased risk of colon cancer has been reported...”
The Review of Gastroenterological Disorders[2]

“Although it may be extremely bothersome, constipation itself usually is not serious.”
American Gastroenterological Association[3]

Constipation Epidemiology: One Case Of Crappy Bookkeeping

A reliable, accurate statistic on the prevalence of constipation isn’t available, because (ironically), it isn’t considered a condition serious enough to merit thorough research and analysis. According to an article in The Review of Gastroenterological Disorders, “the exact prevalence of constipation depends on the definition used; prevalence estimates range from 2% to 28%.”[4] The implications of such a considerable spread are obvious:

According to a 1989 National Health Interview Survey[5], about 5.3 million Americans (approximately 2.5%) complained about frequent constipation. A later report from the same survey (the last time the question was asked), conducted by the Centers for Disease Control and Prevention (CDC), indicated that just 3 million people experienced chronic constipation in 1996 (over 1%), even though the overall population and the number of aging baby boomers increased substantially between those years.

Obviously, these numbers don’t add up. If, indeed, constipation outnumbersall other chronic digestive conditions,” then the number of complainers should have been in the tens of millions, considering that over 21.3 million[6] Americans had been diagnosed with stomach ulcers, or that up to 20% of adult Americans suffer from irritable bowel syndrome, which is customarily accompanied by constipation.

There are several reasons for such a huge disparity between the actual numbers and the erroneous results of the National Health Interview Survey:

When a reliable, direct statistic isn’t available, it can be determined indirectly. There is, for example, nothing uncertain about the prevalence of hemorrhoidal and diverticular diseases, two “can’t miss” side effects of chronic constipation:

National Institutes of Health: Hemorrhoids may result from straining to move stool. [...] About half of the population have hemorrhoids by age 50.[7]

The reverse analysis of this statistic is rather straightforward: If half of the adults have enlarged hemorrhoids by the age of 50, it means that most of them are straining while moving their bowels. Since only people with constipation or anorectal disorders caused by constipation (including hemorrhoids) need to strain, we can then conclude that about half of the population, by the age of 50, suffers from chronic or intermittent constipation.

According to actual “hands-on” data collected by anorectal surgeons at the Hemorrhoid Care Medical Clinic[8] in San Diego, California, enlarged hemorrhoids are detected in over two-thirds of patients during a routine physical exam. In other words, the actual occurrence of hemorrhoidal disease is even more prevalent than the NIH statistical estimate, but we’ll stay with the most conservative figures.

To corroborate the “hemorrhoidal” conclusions, let’s take a look at diverticular disease, which also results from constipation-related straining. Its equally alarming “proliferation” reconfirms the statistic on hemorrhoidal disease. According to the same NIH source:

About half of all people over the age of 60 have diverticulosis. [...] Constipation makes the muscles strain to move stool that is too hard. It is the main cause of increased pressure in the colon. This excess pressure might cause the weak spots in the colon to bulge out and become diverticula.[9]

As you can see, the causes and the numbers correspond: half the adults over 60 suffer from diverticular disease related to straining, which in turn only happens among people who are constipated. Obviously, constipation, whether chronic or intermittent, commences long before these people reach 60.

At this moment some readers may ask a reasonable and perfectly appropriate question:

The answer depends on how you define the term “constipation.” If it is just “not having stool at regular intervals,” as most people believe, then indeed you aren’t constipated. But the classic definition of constipation is “difficult, incomplete, or infrequent evacuation of dry hardened feces from the bowels,”[10] exactly the kind of stool that not only necessitates straining, but meets the criteria for “constipation,” and eventually causes hemorrhoidal and diverticular diseases.

The term “constipation” is derived from Latin’s’ constipatio—literally, a crowding together. The “crowded together stools become large and hard. The outcome is succinctly described by The International Foundation for Functional Gastrointestinal Disorders:

In constipation, stools become large and hard and become increasingly more difficult and uncomfortable to expel. This can lead to an enlarged rectum and colon and lead to decreased sensation. This leads to increasing difficulty in having a bowel movement.[11]

As you can see, the original meaning of the term “constipation” isn’t “lack of regularity” or “absence of stools,” as most people think, but “difficult,” “uncomfortable,” “hard,” and “large.” In other words:

You’re Constipated When You Are Not
Experiencing Easy And Complete
Stools Without Straining

There’s only one way to enjoy this kind of bathroom nirvana—a low-fiber diet and daily, or even better, twice-daily stools. But that’s the complete opposite of what countless medical authorities have been preaching all along, namely that if you eat more fiber, frequency of stools doesn’t matter, as long as it’s no less than three times a week.

Wrong! Ignoring the frequency of stools shifts the emphasis from eliminating the causes of constipation to the management of infrequent stools. And, at first glance, what can be a better remedy to accomplish this task than honest-to-goodness “natural fiber?” At “first glance,” yes, but not at second—the more fiber you add to bulk up the stools, the more damage you’ll cause to yourself, because along with more fiber, the stools are becoming larger and harder as well.

And this brings us back to the perils of dietary fiber on one’s plate, inside one’s large intestine, and, finally, inside one’s stool. To understand why fiber harms the large intestine, why fiber makes constipation more severe, and why fiber isn’t an effective treatment for constipation, you must first understand the functionality of the large intestine. Considering all the hoopla surrounding the “health” benefits of fiber, asking you to take this book’s “fiber menace” claims on faith alone wouldn’t be fair either to you or to the advocates of fiber.

The large intestine : Understand the guts, enjoy the glory

The digestive functions inside the large intestine are as essential as those inside the stomach and small intestine, because bacterial fermentation—a function exclusive to the large intestine—produces a number of vital micronutrients and immune co-factors. The large intestine completes the digestion cycle by performing these four critical functions:

The logic behind the large intestine’s arch-like architecture is apparent from those functions: it is inverted to keep the liquid chyme inside for as long as it takes to ferment, dehydrate and assimilate essential nutrients, and to convert them into feces. The chyme becomes “stools” by the time it reaches the descending colon. From this point on it is brownish, shaped slightly, smelly, and ready to be expelled.

The size and shape of the large intestine is determined by the species’ need to ferment fiber—the more fiber in the diet, the larger the size. Finicky carnivores, like cats, have a gut similar to humans, but much smaller; herbivores, such as sheep, goats, or cows, have a straight, large one; omnivores, like we humans, are in-between, size-wise. Not surprisingly, if we eat like cows, our gut will grow enlarged (distended) to accommodate all that fiber bulk, so even normal-weight humans may look, from the side, like chimps and monkeys, whose guts are habitually distended from chewing and fermenting fibrous leaves around the clock.

On a diet relatively free of indigestible fiber, the journey of chyme from cecum to sewer takes, give or take, 72 hours in test subjects.[12] When indigestible fiber is generously added to the diet, the transit time drops down to just 24 hours because the large intestine rushes to expel the excess fiber, in order to avoid mechanical (from too much bulk) and chemical (from too much acidity) damage to its delicate mucous lining.

If evolution intended that 72 hours are what’s needed for feces to travel to the sewer, then that’s what it takes. If you force the refuse out in 24 hours, the essential by-products of intestinal metabolism—electrolytes, vitamins, immune co-factors, and God knows what else—don’t get assimilated back into the body, and, at the very least, you experience abdominal cramps from too much peristalsis.

However, if you are chronically constipated, even when you add fiber, the trip down may take much longer than 72 hours. When this occurs, the stools are no longer small, soft, and pliable. Instead, they’re impacted—large, hard, and compressed, and not exactly in the shape desirable for the delicate anal canal, or for the even more delicate mucous layer of rectum and colon.

Lo and behold, the recommendation to use fiber in order to stimulate colonic motility—the peristaltic and mechanical movement of fecal masses through the colon—was based on experiments conducted with carefully screened healthy individuals, who were young and constipation-free. To determine transit time, participants were ingesting small metal pellets, and their stool was x-rayed to locate them.

But if you are no longer young, already have a history of constipation and colorectal disorders, such as hemorrhoids, the journey of fiber to the toilet bowl may take weeks, especially when the colon is already packed with large stools waiting for their turn to be eliminated. In this case, the newly arriving fiber acts just like a plunger, and then patiently waits itself to be plunged. When there is no fiber “plunger” in the diet, constipation quickly sets in. And that, of course, describes the addiction that results from a depen­dence on fiber to move the bowels.

The colon: An epilogue to a meal

As chyme travels up the colon, water, electrolytes, and remaining nutrients are slowly absorbed through the epithelium, a mucous membrane that lines the insides of the intestines. In turn, the epithelium—more specifically, its abundant goblet cells—secretes mucus to lubricate and protect the epithelium from damage, and to bind dehydrated chyme into feces. These two actions lead to two important observations:

The movement of fecal mass through the colon (motility) is go­verned by propulsive contraction. The motility is slow, and it’s controlled by the teniae—thin, ribbon-like muscles equally spaced throughout the length of the colon, giving it the appearance of a string-tied roast with bulges of meat protruding between the coils. These pouch-like bulges in the colon are called haustrum.
Meal composition (not volume, and not fiber) influences motility more than any other factor:

Human Physiology: Motility is influenced by the energy content and composition of the meal, but not by its volume or pH. Energy-rich meals with a high fat content increase motility; carbohydrates and proteins have no effect.[13]

This little-known fact is important for the understanding and prevention of constipation, especially age-related constipation. Low-fat or fat-free diets are more likely to cause impaction among older adults, whose colonic motility is too slow to begin with because of weak intestinal muscles—a condition known as atonic or lazy colon.

The alternating contractions and relaxation of two adjoining teniae ribbons propel stools along their way, but most often they contract in different regions in order to mix fecal mass, not move it. Several times daily a coordinated mass peristaltic movement occurs, which propels stools from the transverse to sigmoid colon. This particular movement is hard to miss, because it usually happens ten to fifteen minutes after a meal or drink. This effect of food on colonic peristalsis is called the gastrocolic reflex.

The combination of these two actions—gastrocolic reflexand massperistaltic movementprecedes the urge to defecate. The urge diminishes in people who are accustomed to suppressing it, those who are dependant on fiber and laxatives, have a long history of constipation, or are old and infirm. Nerve damage related to colorectal distention (from large stools), surgery (to fix damage caused by large stools), medication, diabetes, or a deficiency of certain vitamins may also reduce or eliminate the urge that sends healthy people running to the bathroom.

One reliable way to prevent the gastrocolic reflex from happening in the wrong place and at the wrong time is to not eat or drink if the appropriate bathroom facilities aren’t readily available, especially if you failed to relieve yourself before leaving home.

The other “reliable” way to suppress the gastrocolic reflex and cause constipation are extended low-level stress and anxiety. That’s why following the adage “don’t worry, be happy” will protect you from constipation better than fiber will. According to researchers, personality “accounted for about as much variance in stool output as did dietary fiber.”[14] And from what we already know about fiber, that’s saying a lot.

Special events, such as a honeymoon for couples who didn’t experience living together before becoming married, may represent a particular hazard to the large intestine. Sharing the same bed and bath 24/7 for the first time isn’t exactly a stress-free situation for many newlyweds. Some couples, women particularly, are likely to return from a honeymoon constipated and disappointed, rather than satisfied and happy.

Don’t contain the defecation urge for too long—the “tight ass” personality trait isn’t, at least initially, a function of character, but of a bad diet, unusual circumstances, and equally bad toilet habits.

The opposite is true in extremely stressful situations, such as an accident, tragic news, a crucial exam, or winning the lottery. Instead of constipation, these events may cause vomiting and/or diarrhea. The mechanism here is altogether different, and the main culprit behind either vomiting or diarrhea is abruptly elevated blood pressure:

So if you want someone to instantly lose lots of weight (water and feces) and relieve constipation at once, take them to a horror movie, steal their car, hire someone to simulate a hold-up, or do any other stupid thing that will scare the hell out of them.

Incidentally, abdominal cramps during critical exams, job interviews, blind dates, public performances, and similar events are all from the same causes—increased muscle tone, fear-induced elevated blood pressure, and a surge of excess electrolytes into the intestines. And the sudden lapse of memory that often accompanies the cramps results from insufficient circulation of blood in the brain because of a narrowing of cerebral blood vessels and capillaries.

I know of only a few proven recipes to combat fear—pre­pared­ness, practice, and visualization. Also, it wouldn’t hurt on these occasions to make sure that you are well rested, your digestive organs aren’t stuffed with fiber, and your large intestine isn’t packed with fiber-laden large stools.

The rectum: All’s well that ends well

The rectum is very much like an exit dock in a space station—it separates the rest of the “ship” from the perils of harsh outer space. Hence, the rectum of a healthy person is empty at all times. Its brief contact with stools and gases happens only on their final journey out to the sewer.

Unlike the colon’s circular musculature, the rectum’s is longitudinal, with strands of muscles running from top to bottom, very much like the drawings of biceps that hang in medical offices. The rectum’s muscles stretch out to accommodate the feces as they move down from the colon, and they contract back to initiate defecation. The rectum’s contraction completes an elaborate sequence of preceding events:

The rectum can stretch to accommodate up to 2 liters (2 qt) of stools. This is essential to avoid incontinence, but when the stored feces becomes hard and dry, this particular ability becomes a negative, as it allows stools to accumulate into one large impacted lump that at some point may grow too big to get out.

There are three horizontal dividers that separate sigmoid colon from rectum, aptly named horizontal folds. These folds help retain stools inside the colon while allowing gases to pass through. Amazingly, evolution took into account even this anti-social contingency.

So how come Mother Nature didn’t account for fiber dependence and its prominent side effects? Because the savages didn’t depend on fiber and bathrooms the way city dwellers do:

Normally the rectum is empty, with stools kept out by the first of those horizontal folds inside the sigmoid and descending colons. You can verify it by adorning a preferred hand with a surgical glove, and slowly inserting a heavily lubricated forefinger (use pure petroleum jelly) inside the anal canal. If the rectum is empty, you’ll feel nothing. If it isn’t, you finger will feel the hardened stools, the kind that is usually referred to as “formed.” And that’s not normal.

If you move a small volume of loose stool regularly, there’s no point poking around inside. But if you are dependent on fiber, suffer from constipation, or your stools are hard and large, you don’t need a doctor’s license to check out the content of your own rectum. It isn’t any more gross than wiping your behind. Doctors routinely perform anal exams while checking out hemorrhoids, the male prostate gland, or the female uterus through the anus.

The Anal Canal: The weakest link in the long chain

The anal canal is shorter than Panama’s, but as treacherous to navigate, and the most prone to jams and bottlenecks. A precise coordination of the rectum and anal sphincters is required to complete defecation. The other participants are the internal obturator and levator muscles of the anus, pelvic muscles, and diaphragm, but they all play second fiddle.

The ideal act of defecation shouldn’t take any more effort than that of urination. This may be hard to believe, but it’s true nevertheless. Just ask any healthy, constipation-free child on a low-fiber diet about his or her happy experience.

You should barely feel the movement of a stool of normal form and consistency. If you have enlarged hemorrhoids, you may feel them protruding, but this is an entirely different sensation from that of hardened feces chafing and scraping against the delicate tissues of the anal canal.

If you need to strain, it means your stool has already become enlarged and hardened, and that the rectum’s muscle tone isn’t sufficient to propel it out through the narrow opening of the anal canal. Hence the need to apply additional straining pressure on the colon and rectum to expel the large feces, bulked up by indigestible fiber. We are back again to the perils of fiber and its role in constipation.

No Fiber, No Stool vs. No Fiber, Normal Stool

Without fiber, remnants of food in the stool of a healthy person aren’t detectable. Even the word fecesis derived from Latin faex, or dregs—a small amount, a residue. Apparently, the ancient Romans hadn’t yet tasted bran cereal when naming it.

This profound point—that normal stools aren’t composed of food, but of physiological waste—is a mental challenge even for medical professionals, because most Westerners are accustomed to seeing primarily large, voluminous stools¾the term derived from the Anglo-Saxon stol—seat.[15]

Nonetheless, the point shines through when I highlight this undeniable fact again and again: fit, healthy people without a history of colorectal disease, constipation, and dysbacteriosis, who are placed on a liquid diet or who are starved, continue to HAVE REGULAR STOOLS the entire time. And if their preceding diet was low in fiber, the changes in stool volume are negligible. If you’re still in doubt, here’s an illuminating excerpt from a classic European medical reference:

The sparing Schmidt’s Diet consists of 1–1.5 liters of milk, 2–3 soft-boiled eggs, white bread with butter, 125 g of ground meat, 200 g of mashed potatoes, and oatmeal with caloric value of 2250 calories. The feces of a healthy person on this diet doesn’t contain any food residue.

[…] The Pevsner’s Diet represents a heavy digestive load for a healthy person. It includes 200 g of white and 200 g of black [rye] bread, 250 g of grilled meat, 100 g of butter, 40 g of sugar, fried potatoes, carrots, salads, coleslaw, buckwheat, rice, and fresh fruits. Its caloric value is 3250 calories. The feces of healthy persons on this diet contains large amounts of undigested fiber and some muscle tissue.[16]

As you can see, on the Schmidt’s diet, which is rather generous, permissive, and varied, the feces of a healthy person “doesn’t contain any food residue.” But as soon as we turn to the more typical Western fare—breads, cereals, fruits, and vegetables—represented by the Pevsner’s diet, the stool of an even healthy person “contains large amounts of undigested fiberand “muscle tissue” from burned (grilled) meat.

Unfortunately, the no fiber/no stoolconnection is so insidiously prevalent that it’s difficult to remove even from the minds of experienced gastroenterologists and proctologists. The correct cause and effect connection is, of course, no fiber/less stool. Andthat’s exactly what happens when you switch from a high-fiber diet to a low-fiber one, such as the Atkins diet:

And when an accumulation of hardened fecal mass occurs, the grossest error one can make is to follow the prevailing advice (including Atkins’), which is to ingest “therapeutic” fiber to dislodge and expel it. In this case, the probability of injury to the colon, rectum, and anal canal is practically unavoidable, because the extra fiber behaves just like a proverbial bull in a china shop.

Constipation Treatment : Riskier Than The Disease

Whoever came up with the notion that undigested fiber is a health food was thinking about “dirty colons” and constipation:

Problem:   The colon is dirty with stools, microbes, worms, rotten food, etc. If I can get rid of “dirt” faster, I am going to be healthier.
Solution: Consume more indigestible fiber to cleanse the colon of “dirt.” Helps with constipation, too.

To simple-minded quack nutritionists, the stinky stuff that comes out of the body is indeed “dirt.” So they followed an obvious cause and effect approach to problem solving:

Cause:   Indigestible fiber causes larger stools, which stimulates and speeds up elimination.
Effect: Large, speedy stools keep the colon clean.

It sounds great on paper, and, just as with most drugs, it even works for a while in healthy people who don’t have any anorectal damage. But this approach isn’t addressing several important questions:

–   Is the colon indeed “dirty” with bad microbes, worms, and rotten food? (A: No, it isn’t. In fact, the colon becomes dysfunctional when the bacteria are wiped out. Worms are extremely rare among adults, particularly in cities. Healthy people don’t have “rotten” food in the colon, unless they consume fiber.)

–   What causes constipation in the first place? (A: Literally, the absence of “dirt” (i.e. bacteria), and the presence of undigested fiber.)

–   What can be done to eliminate those causes? (A: Restoration of the bacteria population, elimination of fiber, reduction of stool sizes.)

But when these questions aren’t answered at all, or the answers are wrong, or the real causes of intestinal disorders aren’t addressed, then fiber, just like most drugs, becomes a quick fix. And drugs, no matter how innocent they may act or seem at first, have side effects, and so does fiber.

The fiber-based treatment recommendations for constipation, as proposed by the American Gastroenterological Association, serve as the basic guidelines for the gatekeepers[17] —the family physicians who hear about constipation-related problems from their patients before they can grant them a referral to the more expensive specialists (the gastroenterologists themselves). And here is what they may recommend:

What Is The Treatment For Constipation?
A well-balanced diet that includes fiber-rich foods, such as unprocessed bran, whole-grain bread, and fresh fruits and vege­tables, is recommended. Drinking plenty of fluids and exercising regularly will help to stimulate intestinal activity. Special exercises may be necessary to tone up abdominal muscles after pregnancy or whenever abdominal muscles are lax.[18]

Unfortunately, more fiber to bulk up the stool and more exercise to strengthen abdominal muscles are the principal reasons behind straining, even though the same document bluntly warns that “Constipation can lead to complications, such as hemorrhoids caused by extreme straining”[19] without first telling the readers that only large stools, created by fiber, require “extreme straining.”

That’s unfortunate, but easy to understand. Gastroenterologists—the principal members of the American Gastroenterological Association—are surgeons, not nutritionists. They are trained to operate on the endless complications of “extreme straining,” such as prolapsed hemorrhoids, lacerated anuses, rotting diverticula, perforated colons, and hemorrhaging ulcers. Constipation isn’t their “thing,” hence they rely on a quick and simple fiber solution for patients who don’t require surgery yet.

That fiber and straining eventually make constipation even more severe, and can cause irreversible side effects, is beside the point, because, as long as you are “regular,” all parties are happy. You’re happy because fiber delivers “regular” stools, your doctor, because you’re quickly “healed,” and your insurer, because the fiber solution is dirt cheap. and your pharmacist, because you’re hooked for life.

And that’s the reason why a recent search[20] of the well-stocked Internet pharmacy for “fiber” revealed a whopping 65 fiber-based laxatives. Why so many? Because natural fiber from the diet alone doesn’t work. Just consider these conclusions from one of the most authoritative books about functional digestive disorders published in the United States, but authored by the international consortium of the world’s leading gastroenterologists—Rome II Diagnostic Criteria For Functional Gastrointestinal Disorders.

First, about the merits of consuming a fiber-rich diet for people already affected by chronic constipation:

Rome II: ...there is little or no relationship between dietary fiber intake and whole gut transit time; (2) constipated patients on the average do not eat less fiber than controls; and (3) patients have lower stool weights and longer transit times than controls whether treated with wheat bran or not.[21]

In other words, everything you’ve heard about fiber hasn’t been true: more fiber in the diet doesn’t makes stools leave the body any faster, there is no difference in fiber consumption between healthy and constipated people, and adding more fiber doesn’t make any difference to either stool weight or transit time. (Please note again that these observations apply to patients with chronic constipation and to dietary fiber from natural foods only. Unlike fiber from the diet, supplemental fiber or fiber-fortified products do increase stool volume and do decrease transit time dramatically, especially in young, healthy subjects without any colorectal damage.) And what about the exercises?

Rome II: Active or chronic physical exercise has probably no major effect on the functions of healthy colons.[22]

As you can see, you can work yourself out into a stupor, but it isn’t going to make constipation go away or your colon’s health get any better.
And what about water? Here is commentary from an equally respected and credible source, The Journal of The American Dietetic Association:

It is a common but erroneous belief that the increased weight [of stool] is due primarily to water. The moisture content of human stool is 70% to 75% and this does not change when more fiber is consumed. In other words, fiber in the colon is not more effective at holding water in the lumen [intestinal cavity] than the other components of stool.[23]

Please give me a glass of water. I’m fainting...

You must be asking yourself the same question I once asked myself: how come so many experts managed to err so badly on all three counts—fiber, water, and exercise? How could these well-educated doctors, scientists, and researchers be so wrong, and wrong for so long?

Well, there are many reasons, but none of them are malicious. In an ideal world, when anyone develops constipation, doctors would investigate and quickly remedy the dysfunction(s) that caused it. But investigating the numerous causes of constipation requires an individual approach to each patient. That means an investment of time and effort and expertise on the part of family doctors, internists, and pediatricians, and that’s not what usually happens because they don’t have the time, they aren’t paid enough to devote the effort, and they lack the specialized expertise. Hence, they revert to a simple solution—more supplemental fiber, more water, more exercise.

Not surprisingly, for anyone but the very old and frail who already lack the strength to strain, adding supplemental fiber actually works for a while, because it makes stools larger, and stronger abdominal muscles indeed help to expel these large stools out. While you’re still relatively young and healthy, supplemental fiber works “as advertised” for a period of time.

But as time goes by, enlarged hemorrhoids become the most prominent result of large stools and straining. Enlarged hemorrhoids reduce the aperture of the anal canal from the already small to the very small. To overcome the resistance of a smaller opening, more fiber and straining are needed. At one point the colorectal damage becomes so severe that adding any morefiber, or straining harder,no longer works.

So how can you determine on your own that the constipation treatment isn’t causing you more damage? This is really simple. The treatment is wrong when:

This last characteristic—large stools—is relative. How do you determine what’s large, and what’s not? Fortunately, there is a rational method for establishing benchmarks that will help you to objectively evaluate your stools.

The Bristol Stool Form Scale: Form follows dysfunction

The British take their stools much more seriously than the Ame­ri­cans. Researchers at the Bristol Royal Infirmary—a hospital in Bristol, England—developed a visual guide for stools. This guide is called the Bristol Stool Form Scale, [24]BSF scale for short. It is a self-diagnostic tool that helps skittish patients and doctors alike discuss this delicate subject without getting embarrassed. You just look at a simple chart, point to what approximates the content of your toilet bowl, and your doctor (or this book) tells you whether the form is right or wrong.

There are seven types of stools in the chart, each with a brief annotation (in italicsbelow). The publication that features the BSF scale doesn’t provide any substantive comments beyond the brief: “The ideal stools are types 3 [wrong!] and 4, especially type 4 [correct], as they are most likely to glide out without any fuss whatsoever.”[25] The original definitions are in italics. The expanded commentaries are mine:

Type 1: Separate hard lumps, like nuts—Typical for acute dysbacteriosis. These stools lack a normal amorphous quality, because bacteria are missing and there is nothing to retain water. The lumps are hard and abrasive, the typical diameter ranges from 1 to 2 cm (0.4–0.8”), and they’re painful to pass, because the lumps are hard and scratchy. There is a high likelihood of anorectal bleeding from mechanical la­ceration of the anal canal. Typical for post-antibiotic treatments and for people attempting fiber-free (low-carb) diets. Flatulence isn’t likely, because fermentation of fiber isn’t taking place.
Type 2: Sausage-like but lumpy—Represents a combination of Type 1 stools impacted into a single mass and lumped together by fiber components and some bacteria. Typical for organic constipation. The diameter is 3 to 4 cm (1.2–1.6”). This type is the most destructive by far because its size is near or exceeds the maximum opening of the anal canal’s aperture (3.5 cm). It’s bound to cause extreme straining during elimination, and most likely to cause anal canal la­ceration, hemorrhoidal prolapse, or diverticulosis. To attain this form, the stools must be in the colon for at least seve­ral weeks instead of the normal 72 hours. Anorectal pain, hemorrhoidal disease, anal fissures, withholding or delaying of defecation, and a history of chronic constipation are the most likely causes. Minor flatulence is probable. A person experiencing these stools is most likely to suffer from irritable bowel syndrome because of continuous pressure of large stools on the intestinal walls. The possibility of obstruction of the small intestine is high, because the large intestine is filled to capacity with stools. Adding supple­mental fiber to expel these stools is dangerous, because the expanded fiber has no place to go, and may cause hernia, obstruction, or perforation of the small and large intestine alike.
Type 3: Like a sausage but with cracks in the surface—This form has all of the characteristics of Type 2 stools, but the transit time is faster, between one and two weeks. Typical for latent constipation. The diameter is 2 to 3.5 cm (0.8–1.4”). Irritable bowel syndrome is likely. Flatulence is minor, because of dysbacteriosis. The fact that it hasn’t become as enlarged as Type 2 suggests that the defecations are regular. Straining is required. All of the adverse effects typical for Type 2 stools are likely for type 3, especially the rapid deterioration of hemorrhoidal disease.
Type 4: Like a sausage or snake, smooth and soft—This form is normal for someone defecating once daily. The diameter is 1 to 2 cm (0.4–0.8”). The larger diameter suggests a longer transit time or a large amount of dietary fiber in the diet.
Type 5: Soft blobs with clear-cut edges—I consider this form ideal. It is typical for a person who has stools twice or three times daily, after major meals. The diameter is 1 to 1.5 cm (0.4–0.6”).
Type 6: Fluffy pieces with ragged edges, a mushy stool—This form is close to the margins of comfort in several respects. First, it may be difficult to control the urge, especially when you don’t have immediate access to a bathroom. Second, it is a rather messy affair to manage with toilet paper alone, unless you have access to a flexible shower or bidet. Otherwise, I consider it borderline normal. These kind of stools may suggest a slightly hyperactive colon (fast motility), excess dietary potassium, or sudden dehydration or spike in blood pressure related to stress (both cause the rapid release of water and potassium from blood plasma into the intestinal ca­vity). It can also indicate a hypersensitive personality prone to stress, too many spices, drinking water with a high mi­neral content, or the use of osmotic (mineral salts) laxatives.
Type 7: Watery, no solid pieces—This, of course, is diarrhea, a subject outside the scope of this chapter with just one important and notable exception—so-called paradoxical diarrhea. It’s typical for people (especially young children and infirm or convalescing adults) affected by fecal impaction—a condition that follows or accompanies type 1 stools. During paradoxical diarrhea the liquid contents of the small intestine (up to 1.5–2 liters/quarts daily) have no place to go but down, because the large intestine is stuffed with impacted stools throughout its entire length. Some water gets absorbed, the rest accumulates in the rectum. The reason this type of diarrhea is called paradoxical isnot because its nature isn’t known or understood, but because being severely constipated and experiencing diarrhea all at once, is, indeed, a paradoxical situation. Unfortunately, it’s all too common.

To avoid problems later on, check the content of the toilet bowl at every opportunity to make sure that your stool’s typeis close to optimal. Here are several additional points:

By now, you should understand why voluminous, round, well-formed stools (BSF 3)—the type most medical authorities, including the Bristol Stool Form Scale authors, would like you to have—are destructive for your colon’s health, for the normal functioning of your rectum, and for your anal canal’s structural integrity.

Unfortunately, whenever you don’t have stools like these, most Western doctors, nutritionists, and dietitians are likely to recommend more fiber, more water, and more exercise, which is the exact opposite of what you should do to protect yourself from colorectal damage related to large stools and straining. And that’s how once benign functional constipation turns into latent, and, eventually, into irreversible organic.

The Three Stages Of Constipation

To better comprehend the connection between fiber dependence, constipation, and related colorectal disorders, you must first understand its progression through the functional, latent, and organic stages.

Functional constipation: Easy comes, rarely goes (away, that is)

In general, a condition is considered functional when there are no changes in the normal physiology of a particular organ. In the case of constipation it means that nothing specific, such as enlarged hemorrhoids or tumors, impedes defecation.

For otherwise healthy people, functional constipation is the initial stage of constipation. It may happen for a variety of reasons, such as a sudden change of diet, embarrassment with “toilet duties” while on a honeymoon, a shift in regular schedule while on vacation or a business trip, side effects of medication, a bout with diarrhea, extended stress, major trauma or surgery unrelated to colorectal organs, and similar circumstances.

The mainstream diagnostic criteria (by Rome II) for functional constipation are (1) straining, (2) hard or lumpy stools, (3) sensation of incomplete evacuation, (4) sensation of blockage, (5) the need for manual disimpaction, and (6) less than three defecations per week.[26] Actually, when a person experiences all of these symptoms, the constipation is way past the functional stage.

Irregular defecation is the most prominent characteristic of functional constipation. The stool’s size may increase, remain unchanged, or become smaller.

At this point most individuals will either visit a doctor or take matters into their own hands. What happens next depends on the remedy:

As you can see, becoming “regular” doesn’t mean becoming “healthy” or “recovered.” Your goal must always be small, soft, and moist stool (BSF 4 to 6) at regular (at least daily) intervals, not just any stool regularly. When you fail to accomplish that goal, the next stage is...

Latent constipation: The hidden menace

If you have regular stools now because your diet contains lots of fiber or you’re dependent on laxatives, whether natural or synthetic, your constipation is latent—concealed, without apparent symptoms, because either your current diet is the laxative or your diet is supplemented by a laxative.

When fiber, especially supplemental, becomes a laxative, it works by increasing stools’ size. That’s why doctors refer to fiber as bulk, bulking agents, or roughage. Not surprisingly, large stool size and volume (type 2 to 3) are the most prominent characteristics of latent constipation.

The following table illustrates this connection between fiber and the resulting volume of stool. The ash content—what remains after the test sample is burned—is a reliable approximation of post-digestion remnants of fiber-free food. Here are the examples:

Indigestible content of selected food (per 100 g, ash + fiber)[27]

Food Dietary fiber
Indigestible content (g) Ratio
Kellogg’s All-Bran With Extra Fiber 51.1 5.30 56.40 56.40%
Fiber One (cereal) 47.5 4.09 51.59 51.59%
Wheat bran, crude 42.8 5.79 48.59 48.59%
Rice bran, crude 21.0 9.98 30.98 30.98%
Split peas 22.5 2.66 25.16 25.16%
Almonds 11.8 3.11 14.91 14.9%
Quaker oatmeal 9.0 3.50 12.50 12.50%
Raisin Nut Bran (cereal) 9.2 2.66 11.86 11.86%
Pecans 9.6 1.49 11.09 11.09%
Peanuts 8.5 2.33 10.83 10.83%
Whole wheat bread 6.6 2.30 8.90 8.90%
Rye bread 5.8 2.50 8.30 8.30%
Spinach 2.7 1.70 4.40 4.40%
Bread (bleached wheat) 2.3 1.90 4.20 4.20%
Broccoli 3.0 0.92 3.92 3.92%
Carrots 3.0 0.87 3.87 3.87%
Cabbage 2.3 0.72 3.02 3.02%
Apples 2.7 0.26 2.96 2.96%
Salmon 0 1.53 1.53 1.53%
Eggs 0 1.36 1.36 1.36%
Pork 0 1.29 1.29 1.29%
Beef 0 0.90 0.90 0.90%
Whole milk 0 0.72 0.72 0.72%
Breast milk 0 0.20 0.20 0.20%

As you can see, legumes, nuts, peanuts, and processed, man-made foods, particularly cereals and breads, are the largest offen­ders in terms of indigestible fiber content. Natural, unprocessed vegetables in moderation are fine as long as they are themselves “low-carb”—tomatoes (4.6%), cucumbers (3.6%), squash (3.3%), cabbage (5.6%), and similar vegetables containing under 6% of carbohydrates, including fiber content.

Nutrients Reference Lookup

  • Fiber
    • Protein
    • Fat
    • Cholesterol
    • Carbohydrates
    • Sugars
    • Fiber
    • Water
    • Calories
    • Ash

  • All food groups
    • All food groups
    • American Indian/Alaska Native Foods
    • Baby Foods
    • Baked Products
    • Beef Products
    • Beverages
    • Breakfast Cereals
    • Cereal Grains and Pasta
    • Dairy and Egg Products
    • Fast Foods
    • Fats and Oils
    • Finfish and Shellfish Products
    • Fruits and Fruit Juices
    • Lamb, Veal, and Game Products
    • Legumes and Legume Products
    • Meals, Entrees, and Side Dishes
    • Nut and Seed Products
    • Pork Products
    • Poultry Products
    • Restaurant Foods
    • Sausages and Luncheon Meats
    • Snacks
    • Soups, Sauces, and Gravies
    • Spices and Herbs
    • Sweets
    • Vegetables and Vegetable Products

  • Highest to lowest
    • Highest to lowest
    • Lowest to highest

Go to expanded search

Eventually, thanks to the ongoing impact of larger stools on the colon, rectum, and anus, latent constipation transforms into orga­nic. Hemorrhoidal disease—the irreversible enlargement of hemorrhoids—is the hallmark of encroaching organic constipation.

While the functional stage is relatively short-lived and often intermittent, latent constipation may last for decades. The actual length depends on a person’s age and treatment:

Obviously, the more fiber you take to treat constipation, the faster you transition to the organic stage. That’s unfortunate, but true.

You may have been led to believe that constipation is a symptom of irritable bowel syndrome, Crohn’s disease, and ulcerative colitis. This isn’t so. In fact, these conditions are the symptoms or the results of latent constipation, and the ever-increasing fiber content of your diet.

This fact—that the major disorders of the large intestine are caused by dietary fiber consumed to manage hidden constipation (not a theory, not a hypothesis, not a concept, but a hard, irrefu­table fact)—represents the core of this book and its central thesis: to prevent and eliminate chronic colorectal disorders, you must eliminate latent constipation first.

You may have also been led to believe that constipation is one of the “side effects” of low-carb diets such as the Atkins and South Beach diets. This isn’t true, either. Diet-related constipation is a symptom of latent constipation, too. If low-carb diets suddenly make you constipated, it simply means that your current diet is no longer providing enough bulk from fiber to stimulate defecation. If you suddenly dropped a laxative, the situation would be identical, because the fiber in your preceding diet was the laxative.

Again, this fact, that low-carb diet-related constipation is a symptom of latent constipation caused by the withdrawal of fiber (not a theory, not a hypothesis, not a concept, but a hard, irrefutable fact) also represents the core of this book and its key thesis: to enjoy a low-carb, low-fiber diet, you must first eliminate latent consti­pation.

And if you don’t eliminate latent constipation, it turns into the next phase as inevitably as winter follows autumn.

Organic constipation: No turning back, but not entirely hopeless

If functional constipation is distinguished by irregularity and latent by large stools, organic is distinguished by all of the above plus the ongoing difficulty to attain not just “regular” stool, but any stool. And the reasons are:

Organic constipation speeds up aging and chronic disease, unless luck intervenes and you get the chance to read this or a similar book in time to manage it by means safer than adding an ever-increasing amount of fiber, or ever harsher and more addictive laxatives.

Fortunately, there are natural ways of managing organic constipation without the use of fiber or stimulant laxatives, and ways to make sure the side effects won’t get worse, and will remain nothing more than a manageable nuisance. Considering all the other indignities of aging—reading glasses, enlarged prostate, sagging breasts, receding gums—a few more minor nuisances here and there isn’t such a big deal, especially when visiting the bathroom is no longer such a dreaded event.

So, as you can see, the operative word for organic constipation is “manage,” not “fully recover.” That’s why reading this book is imperative while you can still “fully recover,” because functional constipation is preventable, avoidable, and reversible. It will not turn into latent if it’s handled right and early. Latent constipation is completely or partially reversible, meaning it will not cause further damage to the colon, rectum, and anus, or become chronic.

There is, however, some “icing on the cake” even for organicconstipation. While it may be too late to undo the existing damage, you can always halt further erosion and complications, which are discussed in greater depth throughout this book.

Colorectal disorders: The domino effect of fiber

Nature prescribes a gradual decline and eventual death for us, but it doesn’t presume that hemorrhoidal disease, diverticulosis, irritable bowel syndrome, ulcerative colitis or Crohn’s disease will inevitably accompany normal aging. Those “lucky” ones who die from old age without experiencing any of these disorders are the proof of God’s intent to keep our large intestines fit and sound until our last breath.

Thus, it isn’t God’s will to make you suffer from constipation, hemorrhoidal disease, or ulcerative colitis, but it’s the actions of your parents (first), and, later, your own actions (or lack thereof), that bring the punishment. The next five chapters continue to investigate the connection between fiber, constipation, and major colorectal disorders.

Chapter summary


1Epidemiology of constipation in the United States. Sonnenberg A. Koch TR., Dis Colon Rectum. 1989 Jan;32(1):1–8.

2Definitions, epidemiology, and impact of chronic constipation; Rev Gastro-enterol Disord. 2004;4 Suppl 2:S3-S10. PMID: 15184814.

3Constipation; American Gastroenterological Association; on-line brochure;

4Definitions, epidemiology, and impact of chronic constipation; Rev Gastro­enterol Disord. 2004;4 Suppl 2:S3-S10. PMID: 15184814.

5Prevalence of Major Digestive Disorders and Bowel Symptoms, 1989; National Center for Health Statistics, #212, March 24, 1992.

6Digestive Disorders, Fast Stats A-to-Z; National Center for Health Statistics; [link]

7Hemorrhoids; NIH Publication No. 02–3021; February 2002; [link]

8What are hemorrhoids?, a web site of Hemorrhoid Care Medical Clinic; [link]

9Diverticulosis and Diverticulitis; NIH Publication No. 04–1163; April 2004; [link]

10Constipation; The American Heritage® Dictionary of the English Language, Fourth Edition Copyright © 2000 by Houghton Mifflin Company;
on-line edition: [link]

11About Kids GI Health; Constipation; International Foundation for Functional Gastrointestinal [link]

12R.F. Schmidt, G. Thews. Colonic Motility. Human Physiology, 2nd edition. 29.7:730.

13Ibid. 29.7:731.

14Tucker DM, et al; Dietary fiber and personality factors as determinants of stool output; Gastroenterology. 1981 Nov;81(5):879–83.

15A commode is a piece of furniture with a compartment for a chamber pot. Depending on the owner’s social status, upscale commodes—the progenies of contemporary bathrooms—had a seat concealed by the flip-up cover. The less fortunate had to rely on the outhouse or ditch. Most of the underdeve­loped world still does, and, actually, this is to their advantage, as the squatting position over a ditch is far more natural and superior to the higher-up toilet bowl, and less likely to cause constipation and hemorrhoids.

16Concise Medical Encyclopedia in six volumes, Volume 2, page 364, article “Feces.” (Russian language, 1991, Publishing House Soviet Encyclopedia.)

17Gatekeeper is the term used in the managed medical care industry (HMO). It describes the role of primary care physicians to limit patients’ access to expensive specialists. The gatekeepers, on average, allot less than 10 minutes to each patient.

18Constipation; American Gastroenterological Association; on-line brochure; [link]


20Site search on keyword “Fiber.” July 2, 2004.

21Functional Constipation; Rome II: The Functional Gastrointestinal Disorders by Douglas A. Drossman (editor); 3:386.


23Health implications of dietary fiber; J Am Diet Assoc 2002;102:993–1000; [link]

24Information about the Bristol Stool Form Scale is available on the Family Doctor Books’ web site (, which “are published by Family Doctor Publications in association with the British Medical Association.” Information is excerpted from the book entitled “Understanding your Bowels” by Dr. Ken Heaton. The actual preview chapter contains a number of egregious errors, particularly in the Passage times through the gut chart. While the rest of the information is mostly accurate and useful, some of the information will differ from this book in similar ways as most medical and popular literature related to this subject. The suggestion that Type 3 stool is “ideal” is incorrect, because this form is typical of latent constipation. [link]


26Functional Constipation; Rome II: The Functional Gastrointestinal Disorders by Douglas A. Drossman (editor); 3:384;

27USDA Nutrient Database for Standard Reference; [link]