Fiber & Constipation: The Dirty Truth?

Since 19th century health nut Sylvester Graham (the “prophet of bran bread”) began espousing the nutritional and moral superiority of whole vs refined grains, Fiber has assumed a central role in medical lore as essential for healthy digestion and elimination.

Today, whenever issues of constipation come up, one of the first questions you get asked is "Are you eating enough fiber?" Ironically, often, the answer is "Yes!" Many people suffering from irregularity eat extremely high fiber diets. (As a former raw foodist, I myself was an excellent example of this unfortunate phenomenon.) In such cases, adding more fiber is rarely a solution. On the contrary, experience leads many people with bloating symptoms to develop a near mortal fear of fiber (think of the incredible expanding psyllium seed, and other "bulking" agents that threaten to blow your intestines up to monstrous proportions).

At any rate, in response to anecdotal evidence challenging the value of fiber for bowel health, investigators have begun asking: What if fiber isn't the constipation cure-all it's promoted to be? Research designed to answer this question, ended up with remarkable results, as evidenced by the following title:

Stopping or reducing dietary fiber intake reduces constipation and its associated symptoms.

[Ho K-S, et al. World J Gastroenterol. 2012 Sep 7; 18(33): 4593–4596]

Here's the scoop on what went down.

Sixty-three constipated adults between the ages of 20 and 80 (median age 47) were enrolled in the study referenced above. All subjects went on a 2-week fiber-free diet. Afterwards, if they had found the fiberless plan to be beneficial in terms of constipation relief (which all of them did), they were asked to remain on as low a fiber diet as possible.

Six months later, a follow-up was performed. 41 of the patients had remained on a no fiber diet, 16 on a reduced fiber diet, and 6 had resumed their high fiber diet for religious or personal reasons. And guess what? Those in the first two groups reported significant improvement in their symptoms, while the few who went back to a high fiber diet remained as constipated as ever.

A classic "zero-fiber" meal: Roast Chicken

Patients on the zero fiber diet got the best results, improving from an average of 3.75 days between bowel movements (sound familiar?) to just 1 day (the dream!) Results for the 16 low-fiber dieters were mixed, but most people in that group also started having daily poops.

To read the entire study, click here. Below are some of my favorite quotes from the paper:

"This study has confirmed that the previous strongly-held belief that the application of dietary fiber to help constipation is but a myth."

"Constipation is often mistaken by the layman as the state of not passing stool, with the subsequent false notion that making more feces will allow easier defecation. In truth, constipation refers to the difficulty in evacuating a rectum packed with feces, and easier defecation cannot possibly be affected by increasing dietary fiber which increases bulky feces."

"It is well known that increasing dietary fiber increases fecal bulk and volume. Therefore in patients where there is already difficulty in expelling large fecal boluses through the anal sphincter, it is illogical to actually expect that bigger or more feces will ameliorate this problem. More and bulkier fecal matter can only aggravate the difficulty by making the stools even bigger and bulkier. Several reviews and a meta-analysis had already shown that dietary fiber does not improve constipation in patients with irritable bowel diseases."

"The role of dietary fiber in constipation is analogous to cars in traffic congestion. The only way to alleviate slow traffic would be to decrease the number of cars and to evacuate the remaining cars quickly. Should we add more cars, the congestion would only be worsened. Similarly, in patients with idiopathic constipation and a colon packed with feces, reduction in dietary fiber would reduce fecal bulk and volume and make evacuation of the smaller and thinner feces easier. Adding dietary fiber would only add to the bulk and volume and thus make evacuation even more difficult."

  

All this is GREAT news for those of us C types following a SIBO-safe diet! (Since fiber is the Great Fermenter, there is very little of it in a good SIBO protocol.) However, everyone has a different body, and a different response to food. I get terrible bloating from whole grains, but do find that a little "bulk" can sometimes push a stool through. However, I always try to keep it in the realm of the less-fermentable starchy vegetables (carrots, winter squash), sometimes Jasmine rice, and occasionally, Lundberg rice cakes.

What's your experience been with fiber and constipation. I'd love to hear about it in the comments below!


NOTE: Thanks to Dr. Norm Robillard for pointing me in the direction of this groundbreaking study. To learn about Dr. Robillard's work, visit his digestivehealthinstitute.com.

 

Leaky Gut and SIBO: Are they BFFs or not?

A lot of people (like me) who end up with SIBO just started out with plain old IBS. Studies have found that anywhere from a meager 10% of IBS patients all the way up to a whopping 84% (hel-lo!) will test positive for intestinal bacterial overgrowth. Not all people with IBS get SIBO, therefore, but if you have SIBO, you pretty much are guaranteed to have IBS. SIBO and IBS go together like outlaws in love.

Lots of people with IBS also test positive for increased intestinal permeability—sometimes referred to as gut barrier dysfunction, and commonly known as "leaky gut syndrome."

A leaky gut situation results from chronic irritation, inflammation and immune activation in the GI tract. Alcohol abuse, aspirin and other drugs, toxins, trauma, synthetic food additives, food allergies and food intolerances (think gluten, casein, even potatoes) are some possible causes of leaky gut syndrome.

Anyway, the other day I was wondering if I have leaky gut. My thinking was that if both leaky gut and SIBO are common in people with IBS, leaky gut might be common in people with SIBO, too. Makes sense, right? But evidently, the association is not that straightforward.

A 2009 study titled The Relationship between Small-Intestinal Bacterial Overgrowth and Intestinal Permeability in Patients with Irritable Bowel Syndrome (Park JH, et al. Gut Liver. 2009 Sep;3(3):174-9) looked into this very question.

Researchers compared the digestive tracts of 38 people with IBS and 12 healthy controls without IBS. All subjects were tested for both SIBO and leaky gut, and the results were surprising.

Yes, incidence of leaky gut was higher in subjects with IBS, as expected. However, in those people with IBS, the presence of leaky gut was NOT correlated with the occurrence of SIBO.

The researchers stated, "no significant difference in intestinal permeability was observed among the patients with IBS-D, IBS-C and IBS-A". [Note: A=Alternating Diarrhea and Constipation, but sometimes called M for Mixed.] In other words, leaky gut was equally common in IBS of all types.

Not so with SIBO. The researchers had expected SIBO and leaky gut to go together like cheese and crackers, but contrary to expectations, no significant difference in leaky gut occurrence was observed between those IBS patients with SIBO, and those without.

Take home message: If you have SIBO, 
you may or may not have leaky gut syndrome, too.

Ha!

If you want to find out if you actually have leaky gut, you can take a test such as the famous Lactulose/Mannitol urine test—in use since the mid-1970s and available from places such as Genova Diagnostics. The test is pretty basic. You drink a pre-measured amount of two sugars, lactulose and mannitol, in solution, and then pee in a cup at 30-minute intervals over a 6 hour period. Typically, only mannitol, the molecularly smaller of the two sugars, is rapidly absorbed by villi in a healthy, intact small intestine, after which it is excreted in urine. The chunky disaccharide lactulose molecule is too large for normal villous absorption, and therefore should not show up in the urine, unless it managed to "leak" through the intestinal lining due to swelling, inflammation and weak gut barrier function. So depending on how much lactulose appears in the urine, leaky gut is there or not.

A nice cup of bone broth, with herbs.

If you DO have a leaky intestine, your next step is deciding how to address it.

It goes without saying that numero uno is maintaining your diet upgrade and continuing to avoid all the fermentable sugars and starches that feed SIBO bugs.

In addition, I suggest you consume bone broth made with marrow bones or meaty bones (not cartilaginous joint bones) and either drink a cup daily, or use the broth regularly in your cooking.

Leaky gut or not, bone broth is deeply nourishing for the intestinal lining.

Next, consider supplements. Interestingly, some of the so-called "top supplements" for treating leaky gut syndrome are verboten, or at least highly questionable on a SIBO-friendly diet. FIBER supplements? No, thanks! PROBIOTICS? A big question mark for SIBO peeps. (We already have too many bacteria in our guts—much of which may be the right bacteria, but in the wrong place—so adding in more doesn't necessarily make a whole lot of sense.)

But there are a few SIBO-friendly supplements that I really do like for treating leaky gut syndrome. Two favorites are L-Glutamine powder and Hydrolyzed Collagen powder—supplements that can be stirred into water and taken daily to help heal your inflamed intestinal lining. I also recommend taking digestive support with meals, both to help promote proper food digestion and breakdown, and to help minimize the chances of large undigested food particles traveling too far down the digestive tract where they can interact with and irritate your gut lining.

L-Glutamine is an amino acid that directly enhances gut barrier function and protects the endothelial cells lining your small and large intestines. Glutamine has been shown to help support the rapid turnover, healthy reproduction and maintenance of these cells. Glutamine also has an anti-inflammatory effect on the gut lining, to help further promote healing.

Collagen is a short chain protein, or peptide, that occurs naturally throughout the body as a building block of connective tissue. Collagen peptides are present in hair, skin, nails, bones, joints, cartilage and the endothelial cells lining both vascular and intestinal tissues. Collagen contains high levels of the amino acids proline and glycine which, along with L-glutamine, are critical players in repairing a damaged intestinal lining.

Digestive Enzymes supplement the function of your pancreas, an organ designed to secrete digestive enzymes every time we eat. Pancreatic enzymes are required to help us break down fats, proteins and carbohydrates. However, pancreatic function decreases with stress and age, and many of us just don't produce a sufficient quantity to do the job. Taking supplemental pancreatic enzymes or plant-based digestive enzymes can make a HUGE difference in how well you digest your meals.

Betaine HCl is a form of hydrochloric acid (HCl). Hydrochloric acid is naturally produced in the stomach to initiate protein digestion and to kill pathogenic microbes every time you eat, but again, production decreases as we age, or may be impaired by medications such as proton pump inhibitors prescribed for reflux. Many people with IBS and SIBO have hypochlorhydria, a fancy term for low stomach acid production. Taking extra helps.

I have not been tested for leaky gut syndrome and don't know if I have it, but I am currently taking a few supplements to help support digestion and promote intestinal comfort. Since readers often ask what I personally am eating or taking to treat my SIBO, I'm sharing this short list with you in friendliness, not as a prescription. (For a prescription, please email me to set up an appointment!)

Pancreatin Select is a broad-spectrum digestive enzyme that contains pancreatic digestive enzymes along with extra lipase, ox bile, digestive bitters and betaine HCl. It's fantastic. I take one or two per meal. And I'll take an additional capsule or two of straight up Betaine HCl if I'm eating a large protein meal. These two supplements are fantastic for increasing digestive power and vitality.

I also just started taking a Hydrolyzed Collagen supplement which, surprisingly, tastes awesome—kind of like whey protein. I'm hoping it will help fortify my gut lining, but other researched benefits include stronger bones, stronger joints and improved skin tone and texture, so we'll see how that goes!

Finally, I've been enjoying a drink of GI Select at least a few times a week. This product combines L-glutamine with other gut healing ingredients, comes in a powder you mix with water and tastes like lemonade. I find it to have a very soothing effect on my gut while being refreshing and hydrating. (Drinking enough water is always an issue for me, so anything that makes water taste better gets two thumbs up from Sexy Sibo.)

xo

Sexy Sibo Word of the Day: Borborygmi (and some good news about erythritol)

Now here's a ten dollar word for you: Borborygmi

I'm not sure how to pronounce it, but the definition is "a rumbling or gurgling sound caused by the movement of gas in the intestines."

Sound familiar? 

I learned this fancy new borborygmi word from a study I was reading, comparing the digestive tolerance of sucrose (table sugar) with that of two polyols, xylitol and erythritol.

Xylitol (like most other polyols—sorbitol, mannitol, etc.) causes lots of gas, loose stools, borborygmi and other GI distress, as you may have found out the hard way. But erythritol, it turns out, not so much! Check it out:

"When consumed in water, 35 and 50 g xylitol was associated with significant intestinal symptom scores and watery faeces, compared to the sucrose control, whereas at all levels studied erythritol scored significantly less symptoms. Consumption of 20 and 35 g erythritol by healthy volunteers, in a liquid, is tolerated well, without any symptoms. At the highest level of erythritol intake (50 g), only a significant increase in borborygmi and nausea was observed, whereas xylitol intake at this level induced a significant increase in watery faeces."

In case you want to translate the above into practical terms, a teaspoon of erythritol (the one I've tried comes from Wholesome Sweeteners, under the brand name Zero) weighs about 6 grams. Meaning it is probably safe to use a teaspoon or two of erythritol in your tea or lemonade, for example, without it setting off your IBS/SIBO symptoms.

Sweet!

Have you tried erythritol? I'd love to hear how it worked for you. To me, it's got an interesting kind of sweetness—kind of cooling in the mouth. I think it works really well in drinks or foods containing cooling herbs like mint or cilantro, such as peppermint iced tea and cilantro vinaigrette. Still I feel a little nervous about it. I tend to stick with raw honey or a pinch of green stevia for sweetness, but I'm all for branching out. So it's nice to see some evidence suggesting that erythritol may be tolerable for SIBO.

:-)

REFERENCE

Storey D, et al. Gastrointestinal tolerance of erythritol and xylitol ingested in a liquid. 
Eur J Clin Nutr. 2007 Mar;61(3):349-54.  To read the study abstract, click here.

Article Review: SIBO Treatment Strategies by Aglaée Jacob

Aglaée Jacob, MS, RD is a French Canadian holistic dietitian specializing in the Paleo approach to digestive health. I've been following her work since 2013 when I first found out about SIBO, and have always appreciated her professionalism and attention to detail.

Today I'd like to share some highlights from an informative article by Aglaée on the Treatment and Management of SIBO, published in Today's Dietitian in December, 2012. I've underlined the parts that stand out to me for emphasis:

"SIBO and IBS symptoms are the same: abdominal distension, flatulence, cramping, diarrhea, and constipation. These digestive symptoms result from both the high osmotic activity and fermentation potential of incompletely digested and unabsorbed carbohydrates present in the small intestines."

In other words, bloating and distention are caused by accumulations of gas (the byproduct of bacterial fermentation) and water (drawn into the gut via osmotic activity) that build up in the small intestine. The presence of gas and water make your belly expand like a balloon. The reason this fermentation and osmotic activity happens is related to the presence of undigested carbohydrates in your gut.

"Both the gas produced by intestinal fermentation and the water drawn through osmosis can contribute to bloating in SIBO patients. The type of gas produced by the bacteria also seems to impact the motility of the intestines. Hydrogen-producing patients are more likely to suffer from diarrhea, while methane producers are more prone to constipation."

I'm super fascinated by the impact of bacterial gas type on motility. A C-type myself, I have long been a proud producer of odorless methane farts. Methane-producing bacteria get overgrown when slow transit time causes an overgrowth of hydrogen producing bacteria. But isn't it ironic (if not ingenious, from the microbe's point of view) that methane itself is a CAUSE of constipation. Why might this be?

"Research conducted by Mark Pimentel, MD, director of the gastrointestinal motility program at Cedars-Sinai Medical Center and author of A New IBS Solution, indicates that increased intestinal transit time associated with methane isn’t due to decreased motility but rather to hyperactive reverse peristalsis.[1]"

What the hell: hyperactive reverse peristalsis? Doesn't that sound a lot like "poop going in the wrong direction—with a quickness"? I need to learn more about this. According to the dictionary, "reverse peristalsis" also means "vomiting." Con-fu-sing! Note to self: further investigation warranted.

Anyway, the article continues with some basic dietary recommendations for IBS, specifically the strict avoidance of fermentable carbohydrates. This means a) following a low-FODMAP diet and b) further avoidance of all polysaccharides (grains and starchy veggies), even those which are considered lower in FODMAPs, until symptoms resolve:

"Digestive symptoms tend to significantly improve after SIBO treatment, but it’s important for patients, especially in the beginning, to avoid foods that can contribute to intestinal fermentation. Damage to the lining of the small intestines can impair secretion of brush border enzymes, such as lactase, sucrase, and maltase, according to SIBO expert Allison Siebecker, ND.[2] Undigested lactose, sucrose, and maltose (starch fragments) aren’t absorbed and can become substrates for intestinal fermentation. Restricting lactose, sugars, and starches can attenuate bloating and normalize bowel movements until the brush border is sufficiently healed to normally produce digestive enzymes again.[2]

"Foods containing FODMAPs (fermentable oligo-, di-, mono-saccharides and polyols) also can ferment in the small intestines and therefore should be limited if they induce symptoms in SIBO patients.[2] FODMAPs include fructose (eg, high-fructose corn syrup, agave syrup, honey, apples, pears); lactose (eg, milk and yogurt); fructans (eg, wheat, barley, rye, onions, garlic); galactans (eg, legumes); and polyols (eg, sugar alcohols, mushrooms, cauliflower, avocados, stone fruits)."

Beyond eating the right foods (for as long as necessary until healing has occurred) another recommendation for treating SIBO is to NOT eat between meals, also known as meal spacing. Meal spacing allows for proper functioning of the MMC (Migrating Motor Complex), a mechanical wave-like process that cleans out the small intestine between meals:

"One of the most common underlying causes of SIBO is the impairment of the migrating motor complex (MMC). The MMC corresponds to cleansing waves activated approximately every 90 minutes in the small intestines when fasting to prevent the accumulation of debris and excessive amounts of bacteria. Pimentel found that the MMC is decreased by 70% in SIBO patients.[1] Apart from snacking, stress also negatively impacts the MMC. Encourage patients to space their meals every three to five hours and better manage their stress to promote regular MMC activation and prevent SIBO from returning."

Eating too often throughout the day (the popular Graze Method) and high stress levels both impair the MMC. Meal spacing boils down to waiting at least 3 and preferably 4-5 hours after a meal before you consume any kind of caloric food or drink. This means only water (or another non-caloric beverage, such as unsweetened herbal tea) would be allowed. Such mini-fasts permit the cleansing wave of the MMC to push excess bacteria out of the small intestine.

Meal spacing is a strategy I try to apply consistently. Bonus: Meal spacing rests the digestive organs, increases energy and helps stimulate healthy appetite, adding to the pleasure and enjoyment of eating. As for stress management, consider deep breathing, meditation, yoga and exercise. A strong, metabolically active body and a calm, quiet mind are well worth cultivating, don't you agree?

Click here to read the Today's Dietitian (Vol. 14, No. 12, p.16) article, excerpted above, in its entirety.

Click here to visit the website of Aglaée Jacob, The Paleo Dietitian. (You really should. She's got sound advice, tasty recipes and great diet handouts available for free download, too!)

REFERENCES
1. Pimentel M. A New IBS Solution. Sherman Oaks, California: Health Point Press; 2005.
2. Siebecker A. Small intestine bacterial overgrowth: clinical strategies (webinar). September 17, 2011. http://ce.ncnm.edu/course/search.php?search=SIBO. Accessed September 25, 2012.