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May 23, 2005

Constipation Treatment: Fiber and Other Solutions
By Cynthia B. Sileo, MS, RD, LD
For The Record
Vol. 17 No. 11 P. 34

Acupuncture and biofeedback are among the options that could make treatment less of a gamble.

Constipation is a common problem in the United States, with treatment costing millions of dollars. Prevalence of constipation is estimated to be as high as 20% of the population,1 occurring more frequently in women, African Americans, children, and older adults.

Chronic Constipation Etiology
Most patients have chronic functional or idiopathic constipation. However, secondary causes of constipation must be ruled out, as it can be a symptom of a serious disease state or side effect of medication.2

Warning signs that a more serious condition may be present include abdominal pain, nausea, cramping, emesis, weight loss, dark tarry stools, rectal bleeding, rectal pain, and fever. In children, delayed growth is also a warning sign.3

Diagnosis
For a diagnosis of constipation, two or more of the following symptoms must be present:

• fewer than three bowel movements per week;

• excessive straining during bowel movements;

• a feeling of incomplete evacuation after bowel movements; and

• passage of hard or pellet-like stools.4

Constipation may be a sign of slow-transit constipation or pelvic floor dysfunction. Slow transit is sometimes due to colonic inertia, characterized by a decreased number of peristaltic contractions. Slow-transit constipation may also be due to a functional barrier or resistance caused by the increased, uncoordinated activity of the distal colon.

Constipation caused by pelvic floor dysfunction involves normal or slightly slow colonic transit time, but the fecal material is stored for prolonged periods of time in the rectum and not adequately evacuated. This type of constipation does not respond well to laxative treatment.

Treatment
The American Gastroenterological Association recommends fiber (dietary and supplemental) as the first course of action. This is followed by saline laxatives, stimulant laxatives, and osmotic laxatives. Enemas, suppositories, and biofeedback are options for pelvic floor dysfunction.

Finally, surgery may be required in severe cases of slow-transit constipation and pelvic floor dysfunction.5 In addition, exercise and acupuncture have been studied for effectiveness.

Diet
In general, insoluble fibers such as lignin, cellulose, and some hemicelluloses feature high water-holding capacity and fecal volume, decrease intestinal transit time, and increase the frequency of defecation. In addition to insolubility, some foods are highly fermentable by intestinal microbial proliferation, providing additional water and mass. This results in increased fecal bulk, more frequent defecation, and reduced intestinal transit time and intraluminal pressure.

One of the most effective fiber laxatives is wheat bran because it can absorb three times its weight in water, increasing fecal bulk. However, rice bran has been found to be superior to wheat bran in increasing fecal bulk and reducing intestinal transit time.6

Dukas et al studied the relationship between constipation and physical activity, fiber intake, body mass index, number of medications, aspirin intake, postmenopausal hormone use, smoking status, daily alcohol and coffee intake, and total fiber intake. The study population was 62,036 women, aged 36 to 61, chosen from the Nurse’s Health Study. Dukas et al found that moderate physical activity and higher levels of fiber intake were inversely related to constipation.7

Jenkins et al tested the effect of cocoa-bran cereal on serum lipid levels and fecal bulk on normolipidemic men (n = 13) and women (n = 12). The test cereal provided 25 grams per day of total dietary fiber vs. the control that had 5.6 grams per day of fiber.

Results from the cocoa-bran diet showed a significant increase in mean fecal output per treatment and increased flatus and frequency of bowel movements compared with the control diet. There was no significant difference in ease of bowel movement, stool consistency, abdominal distention, or abdominal pain. An unexpected significant rise in blood pressure was seen with the test diet. This may be due to the presence of caffeine, theophylline, and theobromine in cocoa.8

Older adults frequently suffer from bowel disorders such as constipation, impaction, and incontinence. Rush et al studied the laxation effect of kiwis in 13 men and 25 women at least 60 years of age. Participants continued their usual eating habits and laxative use. The test population consumed one Hayward kiwi (100 grams each) per 30 kilograms body weight each day for three weeks.

Results showed a significant increase in frequency of defecation, volume of stool produced, and softness of bowel movement as compared with the control group. Possibilities for improved laxation include the fiber content of kiwis (1.59 grams of dietary fiber per 100 grams of kiwi), the protease actinidin, high water-holding capacity of the cell walls, and/or the presence of oligosaccharides.9

Along with increasing fiber intake, increasing fluid intake is recommended to ensure that the fiber itself does not become constipating. Anti et al studied the effects of a high-fiber diet and fluid intake on functional chronic constipation. In the experiment, 107 subjects, aged 18 to 50, were divided into two treatment groups. Both groups consumed a diet providing approximately 25 grams of fiber per day. The control group drank fluids as desired and achieved a mean intake of 1.1 liters per day. The test group drank 2 liters of mineral water per day.

Results showed that a daily fiber intake of 25 grams increased stool frequency in subjects with chronic constipation. This effect can be enhanced by increasing fluid intake to 1.5 to 2 liters per day.10

Exercise
Low physical activity is a risk factor for constipation, colon cancer, cholelithiasis, and diverticular disease.11 Oettle found that moderate exercise increased colonic transit time in 10 healthy volunteers, aged 22 to 41 years. The subjects either ran on a treadmill, cycled on a bicycle ergometer, or rested in a chair for one hour daily. Whole gut transit time significantly decreased with moderate exercise (running and cycling).12

In contrast with other studies, Rao et al demonstrated that exercise decreased colonic motility in all areas measured. The researchers speculate that unlike previous studies, they did not use athletic subjects, who tend to have loose stools. In addition, the duration and intensity of exercise varied between studies.13

Acupuncture
Broide et al investigated the effects of acupuncture on chronic constipation in children. The test population consisted of 17 children, aged 3 to 13. The control population was 15 children, aged 2 to 14, without gastrointestinal complaints.

Initially, treatment subjects received five weekly placebo acupuncture treatments, where the needle was superficially inserted into the skin. This was followed by 10 weekly true acupuncture treatments, where the needle was inserted subdermally.

Results showed that acupuncture significantly improved the frequency of defecation. Girls received maximal response after only five true acupuncture sessions, while boys required 10 true acupuncture sessions. The authors suggest that acupuncture may be an adjunctive or alternative treatment option for constipation.14

Biofeedback
Van der Plas et al tested the effectiveness of biofeedback on chronically constipated children, aged 5 to 16. In the study, 94 patients were randomized to conventional treatment, which consisted of laxative use, encouragement of a high-fiber diet, toileting for five minutes after each meal, and enemas if no bowel movement in three days. The treatment group (conventional treatment + biofeedback), which consisted of 98 patients, received the above interventions plus five biofeedback training sessions.

At six weeks, significantly more children in the treatment group achieved normal defecation patterns than the conventional group. However, one year later, there was no significant difference between groups.

The researchers concluded that biofeedback does not provide additional benefit and is too expensive to consider in treating chronic constipation. Instead, intensive laxative therapy is recommended.15

Ferrara et al confirm the above results with regard to decay of biofeedback benefits over time. The researchers concluded that patients may need reevaluation after one year and may benefit from additional biofeedback treatment.16

Chiotakakou-Faliakou et al conducted a study on 100 subjects who completed biofeedback sessions at least 12 months prior to the study. These subjects were followed up 12 to 44 months after treatment.

Fifty percent or more felt improvement both immediately and after long-term follow-up. Significant reduction in the use of laxatives, suppositories, and enemas was maintained for all three medications at long-term follow-up. Immediately after and at long-term follow-up, there was a significant reduction in symptoms associated with constipation such as bloating, pain, and need to strain. It was concluded that for a majority of patients, there is a long-term benefit to biofeedback treatment for idiopathic constipation.17

Overall, studies indicate that biofeedback initially provides significant improvement in bowel function. Still, at this time there is no consensus as to biofeedback’s long-term efficacy and cost-effectiveness.

Summary
It is widely agreed that the addition of fiber in the diet is the first course of treatment for constipation. This is best achieved from food sources due to the additional nutritional benefits provided. Along with increasing fiber, fluid intake, especially water, should be increased to prevent the fiber itself from becoming constipating.

Exercise may provide benefit as well by increasing colonic motility. However, based on the studies cited, this seems to be inconclusive at the moment. Still, exercise provides well-documented benefits in the treatment of several disease states and should be recommended for overall health.

Studies on the effectiveness of acupuncture in the treatment of chronic constipation are limited. More long-term studies are needed before its use may be recommended.

Biofeedback bears consideration as a course of action as its short-term efficacy has been proven in various studies. It remains controversial as an efficacious and cost-effective long-term treatment.

— Cynthia Sileo, MS, RD, LD, has been a clinical dietitian for more than 15 years, specializing in geriatrics.

References
1. American Gastroenterological Association. American Gastroenterological Association medical position statement: Guidelines on constipation. Gastroenterology. 2000;119(6):1761-1766.

2. Arce DA, Ermocilla CA, Costa, H. Evaluation of constipation. Am Fam Physician. 2002;65(11):2283-2290,2293,2295-2296.

3. American Gastroenterological Association. American Gastroenterological Association medical position statement: Guidelines on constipation. Gastroenterology. 2000;119(6):1761-1766.

4. Stanford, EK. Constipation. Available at: http://www.medical-library.org.

5. American Gastroenterological Association. American Gastroenterological Association medical position statement: Guidelines on constipation. Gastroenterology. 2000;119(6):1761-1766.

6. Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd edition. United States: Wadsworth; 2000;108-114.

7. Dukas L, Willett WC, Giovannucci EL. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. Am J Gastroenterology. 2003;98(8):1790-1796.

8. Jenkins DJA, Kendall CWC, Vuksan V, et al. Effect of cocoa bran on low-density lipoprotein oxidation and fecal bulking. Arch Intern Med. 2000;160(15):2374-2379.

9. Rush EC, Patel M, Plank LD, Ferguson LR. Kiwifruit promotes laxation in the elderly. Asia Pacific J Clin Nutr. 2002;11(2):164-168.

10. Anti M, Pignataro G, Armuzzi A, et al. Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology. 1998;45(21):727-732.

11. Simren M. Physical activity and the gastrointestinal tract. Eur J Gastroenterol Hepatol. 2002;14(10):1053-1056.

12. Oettle GJ. Effect of moderate exercise on bowel habit. Gut. 1991;32(8):941-944.

13. Rao SSC, Beaty J, Chamberlain M, et al. Effects of acute graded exercise on human colonic motility. Am J Physiol. 1999;276:G1221-1226.

14. Broide E, Pintov S, Portnoy S, et al. Effectiveness of acupuncture for treatment of childhood constipation. Dig Dis Sci. 2001;46(6):1270-1275.

15. Van der Plas RN, Bennings MA, Buller HA, et al. Biofeedback training in treatment of childhood constipation: a randomized controlled study. Lancet. 1996;348:776-780.

16. Ferrara A, De Jesus S, Gallacher JT, et al. Time-related decay of the benefits of biofeedback therapy. Tech Coloproctol. 2001;5(3):131-135.

17. Chiotakakou-Faliakou E, Kamm MA, et al. Biofeedback provides long-term benefit for patients with intractable, slow and normal transit constipation. Gut. 1998;42(4):517-521.

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