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Introduction
Patients with colorectal or anorectal problems are generally
unaware of how their own bowel habits may vary from normal.
Since their problems usually stem from childhood, representing
lifelong habits, and since they have no standards for comparison,
most patients assume that their function is normal.
Most patients who develop colon cancer, diverticulosis, diverticulitis,
hemorrhoids, fistula and fissure have had a lifelong history
of difficulty with their bowels. In most instances, they suffer
from chronic habit constipation.
The usual cause of chronic constipation is a lack of adequate
dietary fiber. Dietary fiber is generally obtained from plant
foods, and consists of that portion of the plant which is
not digested by man. While the sugars, starches and vitamins
are broken down into nutrients and are absorbed by our intestines,
the cell walls are not digested and go on to form an important
component of the stool, the bulk or roughage. An example of
dietary fiber is cellulose, and a food which is high in fiber
is wheat bran.
Correcting the fiber inadequacy in one's diet will help one
to achieve normal bowel movements and normal bowel habits.
If damage has taken place, as in the development of diverticulitis,
the adjustment of one's dietary fiber intake may prevent further
deterioration of the damage over time. The decision as to
how much fiber to use in the face of pre-existing conditions
should be made in consultation with your doctor.
For the bowels to work properly, a lifelong daily intake
of 25-30 grams, or about one ounce of dietary fiber daily,
is required. After the digestion of all proteins, fats and
carbohydrates, and the absorption of water and other nutrients
in the small intestine, the colon (the last five feet of the
intestine) receives approximately one pint of liquid stool
together with the undigested fiber.
Under normal circumstances, the colon gradually removes the
remaining water, and forms a shaped stool, which moves toward
the rectum as a result of gentle pressure waves. In people
who eat too little of fiber-containing foods, the stool becomes
hard, dry and small. Whereas the soft, bulky stool can move
easily along the passage of the colon, the hard, dry stool
sticks to the dry wall of the colon and requires that the
colon develop high-pressure waves to be moved. Years pass,
and the colon is no longer capable of generating such high
pressure waves. The colon now requires assistance to push
along the hard, dry stool, and the abdominal muscles begin
to contribute the necessary force. This we call "straining."
The straining produces pressure on all of the abdominal wall,
forcing the development of hernias, varicose veins (due to
pressure on the long veins of the legs), hiatus hernia (upward
pressure forcing the stomach into the chest), diverticulitis
and diverticulosis (weakening and infection of the colon wall),
hemorrhoids, anal fissures and fistulae. Colorectal cancers
may also be more common in patients with lifelong habit constipation.
This may be due to the concentrated exposure of carcinogens
to the colonic surface, as a result of the hard dry stool
and its slow movement or evacuation.
Normal
Bowel Habits
It is normal for one to have one or two soft, formed easily
passed bowel movements a day, without any effort or straining.
The British term is a "bowel action," and literally
one should be able to evacuate promptly and easily. This is
not the case for most Americans, some of whom have the best
"bathroom libraries" in the world, and some of whom
actually reserve this time for reading the daily newspaper-cover
to cover. The habit of reading in the bathroom is simply a
reflection of inadequate function.
It is not normal to miss moving one's bowels on any given
day. It is not normal to solve the problem by taking a laxative.
If your bowels move daily, but with difficulty or straining,
if your stool is dry or hard, or if you don't move your bowels
daily, you need to adjust your diet for the right amount of
fiber intake.
Normal
Physiology
When there is adequate fiber in the diet, the fiber (viewed
as millions of tiny water attracting particles) mixes with
the stool. Each particle soaks up available liquid, and enlarges
into a minute gel bead. These particles give the stool size
shape and moisture, making it easy for the colon to move along
easily.
To work properly two other circumstances must also be right;
adequate water for absorption, and adequate lubrication of
the colon lining. We require 8-10 (8 or 10 ounce) large glasses
of water daily. Water can be any liquid, whether it is tea,
coffee, milk, fruit juices, soft drinks, or other beverages
that agree with you. Milk products may be particularly gassy,
due to the fermentation of milk sugar, i.e., lactose, in the
colon.
In order to lubricate the passage, the colon manufactures
mucous. If the colon is dry, i.e., one has too little mucous,
or drinks too little water, the stool will be hard and dry
and will stick to the colon requiring that one strain to eliminate.
A Proper
Diet
A proper diet is conscious of calories, balanced nutrition,
vitamins, avoidance of dangerous foods such as saturated fats,
and attention to all sources of fiber.
A typical diet of meats, dairy products, breads made from
enriched or refined flours, and other starches such as potatoes,
pasta and rice are all very low in fiber.
| The typical
American diet: |
Breakfast
Cereal (Corn flakes)
Coffee
Juice
Eggs
Toast (White)
Bagel
Meat |
Lunch
Sandwich (Meat,
Chicken, Tuna)
White bread
Pizza
Hamburger
French fries |
Dinner
Fish or chicken
Starch
Vegetable (Corn) |
Virtually all such meals contain a minimum
of fiber, leading to a daily total of 5-8 grams.
| An optimal
diet would typically include: |
Breakfast
Bran cereal
(All-Bran 13 gm;
Fiber One 18 gm) |
Lunch
A large salad (Dinner Plate) |
Dinner
Two one cup servings of vegetables (broccoli, etc)
Starch
4-5 oz chicken or fish
Salad |
Learning how to change one's eating habits takes deliberate
work over many months. When shopping, one must be familiar
with the calorie and fiber content of all foods, and plan
and purchase with menus in mind. One must read the content
information on the package. This process can take six or more
months to master.
Supplements
and Substitutes
While one is learning to eat properly, or if one is "too
old" or "too set in their ways" to make a major
change, one can substitute commercial sources of fiber in
one's diet. Psyllium seeds are ground up water absorbing particles
which substitute for dietary fiber. Products such as Metamucil,
Hydrocil, Konsyl, etc. or other products such as Citrucel
(methylcellulose) are perfectly good substitute sources of
fiber. One tablespoon a day provides 15 grams of the recommended
25-30 grams daily. Most people take such products at night,
generally after completing one's meal. No matter what the
label says, these products are not laxatives, but fiber substitutes.
Taking them daily provides the fiber which allows the bowels
to function normally. Taking them only when one is constipated
means that one doesn't understand their proper role and use.
Mineral oil is the best and the most consistent lubricant.
Colace, a pill, is easier to take or swallow, however, its
result is more erratic. Mineral oil, one tablespoon by mouth
daily, from the refrigerator will serve as an excellent lubricant.
Lubrication should be considered if one is taking the prescribed
amounts of fiber and water, and one is still straining, or
the stool remains hard.
Some people, when they hear of the importance of fiber in
their diet, overdo the fiber intake. This can be harmful too.
Fiber, especially in the absence of adequate water intake,
can be so binding, as to cause severe constipation. If that
happens, enemas and mineral oil may be needed to eliminate
the hard, dry impassable stool before resuming a normal schedule.
An occasional fiber abuser will have diarrhea.
Remember, there is a necessary balance between fiber content
of the diet, water intake and lubrication. Give each one some
thought before figuring that reasonable bowel function is
a hopeless pursuit. Do not expect immediate or day-by-day
results. If you have had sluggish bowels and constipation
all of your life, expect to see the effects of your new fiber
intake over the weeks that follow. All changes will be gradual,
and any adjustments that you make will require days to weeks
before the results may be noticeable.
Laxative
Abuse
Some people have had chronic habit constipation for as long
as they can remember. It is possible that they were born with
a sluggish bowel that does not function easily. Furthermore,
if they were not taught to eat properly at a young age, their
underlying problem may be aggravated by a diet that lacks
the correct amount of fiber.
To people who are not aware of fiber's importance, years
may have been spent experimenting with laxatives or natural
substances that act as laxatives obtained through health food
stores, such as powders, teas and other supplements.
Taking laxatives (or other unknown remedies) as a lifelong
solution to constipation is extremely dangerous. The fatigued
colon becomes so reliant on the laxatives for emptying, that
after decades of "bowel abuse" older people become
completely dependent upon these products. It is as much an
addiction as are other types of dependencies, and people become
afraid to try the proper solution. Do not get "hooked"
on products containing senna leaves, or other "natural"
laxatives. Most laxatives come from natural sources, and all
can be dangerous except when prescribed for specific uses.
Sources
of Fiber in One's Diet
Without guidance, most people don't know where to find fiber
in their diet. Reading materials are available on the diet
and nutrition shelves of your local libraries. Any such book
can be a good guide to getting started. On the attached pages,
you will find two lists with fiber content information. Both
are taken from a book called the "F" Plan Diet by
Audrey Eyton. It was first published in the early 1980s, and
is now out of print.
The first table can serve as a general guide. It lists the
foods that are the richest sources of dietary fiber. The second
table provides more specific calorie and fiber content information
for a large variety of foods. This table can help you estimate
your daily and weekly fiber intake.
General
Guidelines
For people who have developed hemorrhoids, fissures, or fistulae,
benign anal conditions associated with straining, hard stool
and chronic constipation, the above information is intended
to help you get the dietary requirements that you will need
for your lifetime. Fiber is not a temporary remedy, to be
stopped whenever you've temporarily overcome the problem.
For patients who have experienced complications of chronic
fiber shortage, such as diverticulitis, getting started with
a normal fiber intake can be more difficult, and may have
to be very gradual. The same may be true for patients who
have undergone colorectal surgery. Nevertheless, the goal
remains the same. Only the steps to achieve it, or the final
amounts of fiber for each person, may differ.
Good luck with your lifelong adventure to normal bowel function.
If after reading this information and working on your own
you still have questions, please bring your concerns to the
attention of your clinician.
Understanding
Your Own Fiber Intake
As an exercise, we recommend that you list each item that
you eat for breakfast, lunch, dinner and snacks. Include all
representative foods. Look up the calories and fiber content
in the tables and see how close your daily diet comes to providing
you with the daily requirement of 25-30 grams of fiber. Always
ask yourself, out of a seven-day week, how many days do I
really eat each item.
The Top
Twenty Fiber Foods
| This list can serve as a general guide.
For more specific calorie and fiber content of particular
foods, to estimate your daily and weekly quotas, refer
to the alphabetical chart that follows: |
| 1. |
Dried beans, peas, and other legumes
This includes baked beans, kidney beans, split peas, dried
limas, garbanzos, pinto beans and black beans. |
| 2. |
Bran cereals
Topping this list are Bran Buds and All-Bran, but 100%
Bran, Raisin Bran, Most and Cracklin' Bran are also excellent
sources. |
| 3. |
Fresh or frozen lima beans, both Fordhook and baby limas |
| 4. |
Fresh or frozen green peas |
| 5. |
Dried fruit, topped by figs, apricots and dates |
| 6. |
Raspberries, blackberries and strawberries |
| 7. |
Sweet corn, whether on the cob or cut off in kernels |
| 8. |
Whole-wheat and other whole-grain cereal products.
Rye, oats, buckwheat and stone-ground cornmeal are all
high in fiber. Bread, pastas, pizzas, pancakes and muffins
made with whole-grain flours. |
| 9. |
Broccoli-very high in fiber! |
| 10. |
Baked potato with the skin
(The skin when crisp is the best part for fiber.) Mashed
and boiled potatoes are good, too-but not french fries,
which contain a high percentage of fat. |
| 11. |
Green snap beans, pole beans, and broad beans
(These are packaged frozen as Italian beans, in Europe
they are known as haricot or french beans.) |
| 12. |
Plums, pears, and apples
The skin is edible, and are all high in pectin. |
| 13. |
Raisins and prunes
Not as high on the list as other dried fruits (see #5)
but very valuable. |
| 14. |
Greens
Including spinach, beet greens, kale, collards, swiss
chard and turnip greens. |
| 15. |
Nuts
Especially almonds, Brazil nuts, peanuts, and walnuts
(Consume these sparingly, because of their high fat content.). |
| 16. |
Cherries |
| 17. |
Bananas |
| 18. |
Carrots |
| 19. |
Coconut
(dried or fresh-but both are high in fat content). |
| 20. |
Brussels sprouts |
Fiber Content
Chart
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