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:

• There are no clear-cut diagnostic criteria for constipation, hence the majority of patients who suffer from constipation are undiagnosed. You should use the guidelines suggested in this book to evaluate your own condition.
• Constipation isn’t recognized as a health-threatening condition until it’s too late. In the words of the article cited above, “constipation is not of clinical importance until it causes physical risks or impairs quality of life.” It shouldn’t get to that point. Once “quality of life” is affected, the side effects of constipation, such as enlarged hemorrhoids, are no longer reversible.
• The “seriousness” of constipation depends on who you ask. For some doctors it’s just a nuisance, for others it’s the precursor of colorectal cancer. Obviously, you’re better off choosing a doctor who believes the latter.
• If constipation isn’t considered serious by your doctor, it means it’s not going to be treated as promptly and properly as it should be, and it’s more likely causing or worsening colorectal complications. Ask you doctors to reconsider their approach, and refer them to the sources referenced in this book.
• If constipation is considered a serious condition (as it should be), reading this book may literally “save your butt,” even though you or your doctor may believe that, thanks to fiber, you don’t have any problems, and, therefore, that fiber is safe and working for you. Study this book to understand the multifaceted perils of fiber.

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 outnumbers “all 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:

• First, assessing the disease by asking people to self-diagnose isn’t objective. That’s what is taking place during the surveys conducted via verbal interviews, like the ones mentioned above.
• Secondly, constipation isn’t technically a disease, hence it isn’t being tracked in the same way as, for example, billable conditions diagnosable by doctors, such as IBS or ulcers.
• Third, the majority of people don’t bother complaining about intermittent constipation because they rely on a variety of over-the-counter and home-brewed remedies to manage it.
• Fourth, ongoing constipation treatment doesn’t get reimbursed by most medical insurance policies, hence it doesn’t get tracked as reliably as those diseases reimbursed by state, federal, and private insurers.
• Fifth, constipation related to weight-loss diets, such as Atkins or South Beach, doesn’t get reported either, because most people simply abandon their diets, and return to regular high-fiber, high-carb fare.
• Sixth, a great number of people are embarrassed to talk to their doctors, or even spouses, about constipation.
• Finally, when dietary means such as fiber-fortified cereals, herbal teas, or prune juice are used as laxatives, people may have “regular” stools, and not consider themselves constipated. This paradox is discussed in greater depth in the Latent Constipation section later in this chapter.

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:

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:

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:

• I often strain to move my bowels too, but I am not constipated. Why?

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:

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.