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Family Health Magazine
DIABETES

Constipation
A manageable problem

As many as one in four Canadians and up to half of people with diabetes say they are troubled by constipation. Although it is common, many of us feel uncomfortable discussing it with a doctor. Symptoms include irregular bowel movements, straining, and passing hard bowel waste (stool). Fortunately, constipation is not a disease. With the right information and tools, you can learn to manage what is often a preventable problem.

Understanding the system

To understand how the bowels work, we must look at the whole digestive system. The process begins when you put something in your mouth. Swallowing moves food and liquid down a narrow tube called the esophagus and into the stomach. Once in the stomach, digestive juices help break food into a more liquid state.
From the stomach, it moves into the small bowel. In the small bowel, useful parts of the food are absorbed into the body.

Leftover waste then moves into the large bowel. Here, fluid is absorbed back into the body. Stool is stored at the end of the large bowel, in the rectum. It takes one to three days for food to be processed. Up to 90 per cent of that time is spent moving food through the large bowel or rectum, until it passes out of the body through the anus.

Muscles in the rectum, called sphincters, open as the bowel pushes stool forward. Sphincter muscles can also close off, preventing stool from passing if it is not a good time for a bowel movement. A well functioning pelvic floor is essential to this process.

What is constipation?

Normal bowel patterns vary from having a bowel movement three times a day to once every three days. Having less than three bowel movements in a week is considered one sign of constipation. Others include straining with a bowel movement, a feeling of not completely emptying the bowel, and hard or lumpy stool.

Sometimes a solid ball of hard, putty-like stool can build up in the rectum. Despite this, diarrhea may appear, as liquid stool can still make its way out. This form of constipation is called fecal impaction.

Straining during a bowel movement is not normal. Physical manipulation is sometimes required in order to remove the stool. Over time, straining can stretch the sphincter muscle and surrounding rectal tissue, resulting in conditions such as hemorrhoids (swellings near the anus, also called piles).

Repetitive bearing down and straining can cause other problems. Urinary incontinence (loss of bladder control) and pelvic organ prolapse (where the rectum, uterus or bladder drops down or extends out of the body) are also possible.

What causes constipation?

Constipation may be caused by any of the following.

• Poor toilet habits
  • Ignoring or delaying the need to go to the bathroom can allow the bowel to absorb too much fluid. This makes stools harder and more difficult to pass.
• Poor diet
  • Lack of food, fibre and fluid in the diet can lead to constipation. Skipping meals, especially breakfast, can lead to sluggish or irregular bowel movements.
• Lack of exercise
  • Exercise helps prevent constipation by encouraging intestinal muscles to contract and move bowel contents along.
• Lifestyle
  • Influences including travel, stress, depression and anxiety can all have a major effect on the bowels.
• Medication
  • Many medications can contribute to constipation, including antacids, antidepressants, blood pressure and pain medications.
• Medical conditions
  • Many medical conditions involving the nervous system, such as multiple sclerosis (MS), Parkinson’s disease and diabetes, can affect the bowels and lead to chronic constipation.
  • Childbirth or persistent straining during bowel movements can lead to poor muscle control in the pelvic floor. This can contribute to difficulty with bowel movements.
  • Fear of pain in the area of the rectum, such as a fissure (crack) or hemorrhoids, can delay bowel movements and lead to constipation.
  • Poor circulation and nerve supply to the bowel can contribute to constipation.
• Medical procedures
  • Surgery and special bowel tests using barium can lead to constipation.

Preventing constipation

It is always better to prevent a problem than try to treat it once it has happened. The following suggestions may help.

• Stay physically active. Tailor your activity to your abilities and health condition. To begin, try walking 15 to 20 minutes once or twice a day.
• Drink six to eight cups of fluid each day, unless your doctor advises otherwise. Fluid works with fibre in your diet to promote good bowel habits.
• Include 25 to 30 grams of fibre in your diet daily.

Emptying the bowel properly

Knowing how to empty the bowel correctly is very important. Your position on the toilet helps avoid straining and problems that come from repetitive bearing down. Try these simple steps:

When and how to use laxative medications

If you have tried prevention methods and are still constipated, you may consider using laxatives for a short time for very occasional constipation. They may also be a good choice in certain situations. These include:

• counteracting a short-term medication that causes constipation
• avoiding straining (for instance, those with angina should not strain)
• when emptying the bowel to prepare for special bowel tests or surgery
• to keep stool soft during healing from surgery to the rectum, rectal prolapse (where the inner lining of the bowel turns inside out and sticks out of the rectum), or an overstretched rectum
• and for the severely or terminally ill.

Laxatives come in liquid, powder and pill form. Some laxatives are in suppository form. All are available over-the-counter at pharmacies. Check with your pharmacist about the one best for you.

Laxatives are not a cure for constipation. They are not always necessary and can be habit forming. Since it is common to become dependent on laxatives, heavy or long-term use is not recommended. Users often feel they must increase the dose to continue the effect, but eventually the laxative stops working altogether.
Using some types of laxatives too much can be harmful. They can cause diarrhea, resulting in dehydration and loss of sodium and potassium. They may also cause some vitamins and minerals to be poorly absorbed.

Laxatives can damage nerves in the bowel. This interferes with the bowel’s natural ability to push the bowel contents along to the rectum. It is important to stop taking laxatives to allow the bowel to do the work on its own. Your doctor, dietitian, nurse or pharmacist can help guide this process.

Types of laxatives

Several types of laxatives are taken by mouth. Keep in mind that an estimated 85 per cent of constipation-related visits to the doctor result in prescriptions for laxatives.

• Stool softeners moisten bowel contents and prevent stool dehydration. They allow fluid to penetrate, producing a semi-solid stool. Their use may cause a chemical and electrolyte imbalance in the body. Stool softeners include Colace™ (docusate sodium) and Surfak™ (docusate calcium).
• Lubricants grease stool to allow easy passage through the intestines, working in six to eight hours. They may interfere with the absorption of blood thinner medications and vitamins. Lubricants include mineral oil and glycerine.
• Laxatives in liquid form (osmotic/saline laxatives) retain water and cause fluid to flow into the bowel. They act like a sponge, softening bowel contents and moving them along to the rectum. The process usually takes three to six hours. Such laxatives may affect absorption of medications or cause dehydration and muscle cramps, bloating and gas. Osmotic/saline laxatives include lactulose, sorbitol and Milk of Magnesia™ as well as GoLytely™ and Colyte™(polyethylene, glycol and electrolytes) which do not raise or lower sodium levels. When using these laxatives, people with diabetes should ensure they are drinking sufficient fluids, up to one-half ounce per pound of body weight unless this is not recommended due to kidney or heart disease.
• Bulk forming Laxatives raise stool weight and consistency thus increasing bowel movement frequency. An example is Psyllium (Metamucil™, Prodiem™ Plain) which should be taken with at least eight ounces of water.

A caution – people with diabetes should also be monitored for electrolyte imbalances. Repeated use of these laxatives can alter fluid and electrolyte balance. If you have kidney problems, avoid magnesium-containing laxatives. If you have swelling in your legs, abdomen or hands, heart problems, high blood pressure or megacolon, avoid sodium-containing laxatives.

• Stimulant laxatives – Senokot™ and Dulcolax™ both help increase movement of the bowel. They can cause cramping due to increased muscle activity. They should be used sparingly and only when osmotic laxatives are not effective. Some laxatives are placed in the rectum.
• Rectal suppositories – Glycerin, bisacodyl and Dulcolax™ work only in direct contact with the lining of the rectum. They must be inserted far enough up into the rectum to make contact with the lining. They will not work if inserted into stool. These may help in attempting to regain a regular bowel routine.
• Rectal enemas
  • Mineral oil enemas lubricate stool in the rectum, helping it to slide out. These are mild and can be used for occasional constipation.
  • Microlax™ Micro Enemas make stool disintegrate

It is important to consult a pharmacist or doctor if you are considering using a laxative. For many, changes to diet, exercise and lifestyle habits may solve problems with constipation. Medication may occasionally be a short-term solution.