The hard facts behind constipation

I’ve previously discussed the common issue of constipation and made the point that this phenomenon reveals a lot about your health, even though doctors virtually always ignore those insights. But a TV commercial this morning made the hair on the back of my neck stand up.

Putting the small TV in my kitchen on this morning, the first thing that came on was a bright and flashy ad for Linzess, a prescription drug for constipation and irritable bowel syndrome-constipation, IBS-C. At a cost of nearly $500 per month, prescriptions for this drug are handed out freely by gastroenterologists, usually with warnings about the explosive diarrhea that can result. (Take a look at the reviews of Linzess with some people saying that, while grateful for being relieved of constipation, they have to wear diapers to deal with the uncontrolled diarrheal bowel movements.)

There’s also a new drug being widely advertised to “treat” the constipation side-effect of opiates: Relistor, or methylnaltrexone, an opiate-blocker that requires injection and costs around $700 per month.

Of course, these prescriptions are typically offered after advice to hydrate, take stool softening agents and laxatives, which sometimes work but often do not. This has therefore resulted in a multi-billion dollar business to get you to move your bowels more freely.

I love constipation. I don’t love the bloating, the distended abdomen, or the hard, painful stools. I love how something as common and pedestrian as constipation perfectly illustrates so much of what is wrong with modern healthcare. Find a problem, prescribe a drug or procedure that costs a lot of money, never explore the causes. Besides only focusing on symptoms and not cause, it means that the cause could potentially lead to other health problems because it is allowed to persist unchecked. It’s like a nasty teenager who comes out every night and bashes your car’s windshield that you have to replace. Every time he breaks your windshield, you replace it, never asking how or why this is happening: costly, with limited effectiveness. Why not nab the kid doing the damage and get him to stop? An imperfect analogy, but I hope you get the point: “treating” constipation with drugs that, for instance, accelerate the propulsive activity of your gastrointestinal tract is an artificial solution that does not even begin to identify or manage the cause. Ah, but it compensates for your doctor’s indifference and ignorance, while putting plenty of revenue into the Big Pharma pocket.

The smarter doctor–or even better, YOU–instead address the factors that cause constipation in the first place. If you have struggled with constipation for an extended period, I assume that you have already engaged in all the simple, common sense strategies such as hydrating better, eating more fiber, exercising, and taking a stool softening agent like dioctyl sodium sulfosuccinate, perhaps even added a magnesium supplement as we do in the Wheat Belly and Undoctored lifestyles. What are the factors that slow intestinal transit and thereby result in struggles to evacuate the contents of your colon once or twice per day, as you should, unresponsive to basic efforts? Two of the most common causes are:

• Gliadin-derived opioid peptides—Just as prescription opiate drugs like Oxycontin result in severe constipation, so can the opioid peptides that derive from partial digestion of the gliadin protein of wheat and related grains. Gliadin-derived opioid peptides have indeed been demonstrated to bind to intestinal opiate receptors and slow intestinal transit. The effect varies from minimal effect to crippling, with the worst form of constipation labeled “obstipation.” (Early in my Wheat Belly experience, a woman shared her story of decades of unremitting constipation, repeated upper endoscopies and colonoscopies, all of which were normal, followed by advice to use laxatives and enemas. In desperation, she banished all wheat and grains after reading Wheat Belly and, within a week, lost 30 pounds by emptying out her gastrointestinal tract of stool. Two months later while her family was away, she decided to have a sandwich, thinking that one sandwich couldn’t possibly hurt. She re-experienced severe constipation that persisted for a week, lesson learned.) If gliadin-derived opioid peptides are the cause for constipation or obstipation, should you take Linzess or Relistor? Of course not—just rid your life of the source of these opioid agents and enjoy all the other health benefits that result such as weight loss, reduction in blood sugar and type 2 diabetes, drop in blood pressure, relief from many skin rashes and joint pain, marked reduction in appetite, just as we enjoy on the Wheat Belly lifestyle. I hope you also recognize the folly of advising people to eat bran-rich breakfast cereals made with wheat to bulk up stools.
• Methanogenic SIBO—Or what the Linzess commercial calls “IBS-C,” i.e., irritable bowel syndrome with constipation, as the two labels refer to the same condition. Most of the discussions I’ve posted on SIBO over the past 2 years have been about the more common variety, i.e., the type associated with excessive levels of hydrogen gas identified via formal H2-testing or the consumer AIRE device. But there is a less common form of SIBO in which the gastrointestinal tract is overpopulated with a peculiar and primitive group of organisms called Archaea, microorganisms that pre-date bacteria evolutionarily and, besides the human gastrointestinal tract, also inhabit extreme environments such as hot springs, the bottom of the ocean, and the extreme salinity of places like the Dead Sea. For unclear reasons, these creatures proliferate and produce methane that, in turn, slows intestinal transit. Our L. reuteri yogurt may provide a partial solution, as one small clinical trial showed a surprisingly favorable response. Until the AIRE device people release their consumer methane-testing device, you are left with either cumbersome formal methane breath testing or just proceeding empirically (i.e., based on your best educated guess) with some form of treatment. (I shall be discussing this issue in future, though we have had a handful of people with favorable outcomes in our Undoctored Inner Circle who have self-managed their methanogenic SIBO.) You could also take action if stool testing uncovers more methanogenic species such as Methanobrevibacter smithii or Methanobrevibacter stadtmanae than generally inhabits humans. So far, most formal success has been with prescription antibiotics such as rifaximin or neomycin. But stay tuned.

I believe that you now recognize that the sort of advice offered by most doctors for longstanding constipation—fiber, hydration, laxatives, ridiculous prescription drugs—fail to address underlying causes. By banishing all wheat and grains, you have eliminated the source of gliadin-derived opioid peptides. Perhaps by adding L. reuteri to your other basic bowel flora-cultivating efforts you will, over time, reduce (no need to eliminate) Archaea species and find relief. If not, I invite you to join our ongoing deeper explorations of such issues in our Undoctored Inner Circle.