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The Role of Diet and Lifestyle Changes in the Primary Care Management of Constipation

More than 3 million people in the UK suffer from constipation once a month or more(i), and as many as 1 in 5 people experience the symptoms of constipation at some time in their lives(ii).
The new-born baby, the young child, the teenager, mothers and fathers, the elderly, the business executive, the civil servant, the postman, the farm labourer, the poor, the affluent. No-one is exempt from the risk of constipation and the stigma with which it is associated.
Constipation mostly affects children and older people, with more women than men presenting with symptoms.  One in 200 women has severe, continuous constipation and it is most common before a period and in pregnancy (iii).
Many people accept the consequences of constipation, refusing to believe there is anything that can be done about it.  In 99% of cases, however, the problem can be identified and resolved very quickly - and yet it remains one of the most poorly diagnosed and least understood disorders in primary care.
Constipation is more than just suffering from reduced bowel movements.  It can affect people in different ways, such as their bowels feeling as though they have not emptied, the need to strain, and the passage of hard or lumpy stools.  As a result of being constipated, many people can suffer from fatigue, bloating, distension, abdominal pain and even depression.
The common causes of constipation include:
• Not drinking enough fluid
• Low fibre diet
• Not enough physical exercise
• Stress and changes in an individual’s normal routine (e.g. holiday constipation)
• Putting off going to the toiletA common complaint of older people as their bowels become weaker with age is a lack of strength to push.  This can often be made worse by medication they may need to take for existing health problems that can adversely affect the bowel.  These include painkillers, antidepressants and antacids due to their calcium or aluminium content. (iv)
Food intolerance should not shoulder the blame for constipation. More often than not this is something of a red herring, and should not distract from efforts to identify the true cause of constipation in individual patients.
From the perspective of the primary health care professional, history taking is all important, and should give a very accurate impression as to the cause of an individual’s constipation – whether it be poor diet, a stressful, busy lifestyle, or even just the fear or distaste of using unfamiliar toilet facilities (e.g. in a shopping centre, at work or at school).
The digestive system is sensitive to routine, habits and lifestyle. A high fibre diet is one of the keys to achieving and maintaining digestive fitness - particularly important if an individual realises that he or she is prone to episodes or bouts of constipation.
Diet plays a very important role in the management of constipation (see Table 1). The role of fibre in the diet is to make it easier for waste matter to move through the digestive tract. Drinking between 6-8 glasses (1.5-2 litres) of fluid a day will assist this process (see Table 2). Although an intake of 18gm of dietary fibre a day is widely recommended, the average UK diet only contains about 12gm(v). Indeed, hardly anyone in the UK is achieving the optimal fibre intake goal that would be met by eating five portions of fruit and vegetables a day and a reasonable amount of whole-grain, starch-based carbohydrates.
Eating at least three regular meals during the day is a good starting point, helping to eliminate erratic eating patterns. Of all those meals, breakfast is the most important. Indeed, a typical breakfast should include half the daily requirement in terms of fibre intake. Without that, an individual is unlikely to make up the fibre shortfall later in the day.
Making breakfast doesn’t have to be a chore. Neither does a fibre-rich breakfast have to taste like a bowl of cardboard.  Many proprietary brands of whole-grain cereals contain sufficient fruit, nuts, bran and oats to supply the fibre required to combat constipation:
- For someone who doesn’t eat breakfast at all, even getting them on to a frosted whole-grain cereal is a step in the right direction
- Whole-grain cereals can be sweetened with dried fruit.
- Muesli contains a combination of soluble and insoluble fibres, as well as nutritious fruit and nuts, sources of protein and calcium.
Eating a bowl of whole-grain cereal might only take a minute-and-a-half. Compare that to the time wasted every day by feeling constipated and not being able to carry out normal activities as a result. Within 3-4 weeks of including a healthy breakfast as part of the daily routine, it soon becomes an indispensable addition to a healthy lifestyle.
The high-fibre theme should be carried over through lunch, tea and supper (see Table 1). Choose the starch option first, for example, when deciding what to eat for the evening meal. Make starch the main dietary consideration rather than the after-thought (e.g. think about wholemeal pasta before the Bolognese sauce).
If people find it difficult to manage dietary changes through diet alone, fibre-based drinks (e.g. Fybogel) are available in order to supplement dietary fibre intake. Elderly and disabled people in particular may find it difficult to shop for sufficient quantities of fruit and vegetables (both in terms of cost and the difficulty of getting them home from an out-of-town store).
Diet should not be considered in isolation, however. Exercise routines, relaxation and stress management are equally important, complementing dietary initiatives designed to prevent and relieve constipation.
Irrespective of the need to control weight, a minimum of 20 minutes brisk activity a day will reduce the risk of constipation. This might include housework, walking to the office, walking the children to school, gardening, washing the car, or even using the stairs instead of the escalator on the metro or London underground. It doesn’t mean joining a gym!
Other interventions – gentle massage, using aromatherapy oils in the bath, relaxing music, yoga, Pilates – can all help to make life less stressful.
Any dietary and lifestyle advice should be tailored to suit individual circumstances, re-enforced by simple written care plans. Dietary modifications should be introduced gradually, over a period of months (one diet change, one fluid intake change and one exercise/relaxation change at each stage of the process is a realistic strategy).
Taking time to go to the toilet is extremely important for those with a sensitive bowel.  Time needs to be put aside so the experience can be relaxing, allowing the muscles in the bowel to relax.  In addition, putting off the urge to defecate can make matters worse so this should be avoided when possible.  Another useful suggestion is to advise sufferers to raise their legs, perhaps by using a footstall or piling up some books, which will encourage movement due to the increased abdominal pressure.
Make sure this kind of approach to the management of constipation becomes a part of long-term lifestyle changes. There is always the danger that as soon as an acute episode of constipation is resolved, there is a perception that the immediate danger is over. Then it occurs once more, often resulting in a vicious cycle of continuing episodes of constipation that can carry on for months, even years.
It is also important to take into account that constipation may be a symptom of something more sinister, such as Irritable Bowel Syndrome (IBS).  IBS is characterised by abdominal pain, altered bowel habit (diarrhoea or constipation), and abdominal bloating.  IBS affects up to 20% of the general population, and it is estimated that 14-24% of women and 5-19% of men have irritable bowel symptoms.(vi)
IBS is often dismissed as just being a nuisance, rather than anything more serious, but its symptoms can seriously diminish a patient’s quality of life.  Stress exacerbates IBS, so it is advisable for patients to try to avoid stressful situations.  This could be planning ahead when doing something new or perhaps when they are travelling, as well as explaining to their work place the symptoms that they suffer with as a result of the IBS.  Identifying triggers is vital to helping the patient manage their IBS, including the effect of certain foods and life events. 
Patients will respond differently to different treatments, so it is best to treat one symptom at a time, starting with the one that most bothers them.  Constipation is a frequent and distressing symptom of IBS, as is abdominal pain.  The combination of Ispaghula husk and Mebeverine (anti-spasmodic) in Fybogel Mebeverine can be extremely useful in relaxing spasms of the gut, whilst at the same time helping to restore and maintain bowel regularity.       
Suffering from constipation, especially when combined with other IBS symptoms, is far from pleasant. At worst, it can have a significantly adverse impact on quality of life, productivity at work and enjoyment at home. By adopting some of the proposals outlined in this article, much of the stress, anxiety and discomfort associated with constipation and IBS can be avoided.
Table 1:
Daily suggestions for a healthy, high-fibre diet:
Every day, try to eat the following:
- One bowl of high-fibre/whole grain cereal for breakfast or as a snack.
- At least 2 slices of high fibre/wholemeal bread.
- 5 portions of fruit/vegetables.
- Other high fibre foods:
o crisp breads
o beans and lentils (including baked beans)
o seeds and nuts (including peanuts)
Lunch on the go:
- sandwiches (made with rye, granary and wholemeal bread)
- ready-made green leaf and pasta salads
- wholemeal crackers and rolls, pitta bread
- beans on toast, jacket potato
Evening meals. Experiment with:
- wholemeal pasta, pulses e.g. peas beans and lentils (mixed into casseroles)
- new potatoes, baked potatoes, potato wedges
- couscous, bulgur wheat, pulses
- mixed beans (e.g. chick peas, kidney beans), hummus
- one extra portion of fruit and vegetables (frozen or fresh)
Avoid:
- raw bran (its action on the gut is too aggressive)
Other tips:
- replace sugary snacks with a portion of fruit or vegetable
- eat unsalted nuts instead of crisps
- keep processed foods to a minimum, as they are usually high in additives and preservatives
Finally:
- decrease intake of red meat
- increase intake of fish and poultry
- not necessarily to deal with constipation, but for good health generally.
Table 2:
What about drinks?
- Aim to drink 6-8 mugs/glasses (that’s 1½-2 litres) of non-alcoholic drinks throughout the day:
o water, fruit juices, diluted squash, herbal teas and soup
o tea and coffee in moderate quantities
People to contact:
www.digestivedisorders.org.uk
www.bda.uk.com
* Nigel Denby is a registered freelance dietitian, based in Leighton Buzzard, Bedfordshire. He works closely with the media and acts as a consultant to a number of food providers in the UK. He has previously worked in both the NHS and the private sector, managing Boots the Chemist’s nutrition and weight management service. His clinical interests include the pre-menstrual syndrome (PMS), the menopause, eating disorders, and dietetics in general.
References:
i) Digestive Fitness Information Bureau
www.prnewswire.co.uk/cgi/news/release?id=93864
Date accessed: 25/08/04
ii) MeReC Bulletin Volume 10, Number 9, 1999 The management of constipation
iii) NHS Direct Online
www.nhsdirect.nhs.uk
date accessed: 08/03/06
iv) NHS Direct Online
www.nhsdirect.nhs.uk
date accessed: 08/03/06
v) British Nutrition Foundation
www.nutrition.org.uk/information/energyandnutrients
Date accessed: 24/08/04
vi) Kennedy et al, BMJ, doi:10.1136/bmj. 2005


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