Let’s Talk About Poop!

Tummy troubles can be bothersome, sometimes to the point of diminishing quality of life. The subject can also feel taboo, but it shouldn’t be. I sat down with a local expert in GI health to address the top questions we get about common digestive issues – including some interesting thoughts on kiwi!

 

Though it’s often the subject of jokes, bathroom issues are a day-to-day reality for many people. The topic can also be embarrassing to broach. But it shouldn’t be, and good information can help.  

In that spirit, I reached out to Dr. Kaci Christian, MD, a board certified gastroenterologist who specializes in the treatment of inflammatory bowel disease in Lancaster, Pennsylvania. We discussed the ins and outs of everyday tummy troubles and how to manage them at home.

What follows is our responses to frequently asked questions. Our goal is to minimize confusion around the trendy treatments, tonics, and supplements, and focus on the facts we know to be true about bowel health. 

First, how do you talk about poop?
Dr. Christian: I use the Bristol Stool Scale (see the feature image) when asking patients about their bowel habits. But I take much more stock in a patient reporting a change in stool consistency or frequency, because we all have our own unique stool patterns at baseline.

While this discussion can be uncomfortable or embarrassing for some patients, chronic constipation or diarrhea can be even more uncomfortable. Getting a good history with all the details is often times all that is needed to understand the root the problem and get the patient on their way to feeling better.

Emily: I probably tend to use the slang term more than I should! But beyond consistency (loose, liquid, little rocks, for example), I occasionally discusses color (brown, black, grey, red or green, for example), smell (sometimes health professionals can identify an infectious smell), or other descriptors such as oily or floating. 

How does diet impact bowel health?
Emily: Changes in what we eat, how much we eat, when we eat, and how quickly or slowly we eat can impact stool. More specifically, a decrease in fluids and/or fiber can make stool harder to pass, while a sharp increase can have the opposite effect. Food dyes (including in sports drinks) and brightly colored foods (liked blueberries) and even supplements can impact the color.

Dr. Christian: I agree. In my experience, a change in fiber and/or fluid intake is the most common reason why stools change. I also find that those who eat a diet high in processed or packaged foods are more prone to constipation. Lactose, found in dairy products, and sugar substitutes are also a common cause of diarrhea in adults.

Talking about change in color… this can be due to medications or food. For example, beets will turn the stool a maroon color and lots of spinach or kale will turn it green. Medicines that contain bismuth, like Pepto Bismol, often turn the stool black. So, there are lots of colors that are normal!

Can stress impact bowel changes?
Emily: Yes! Feelings of stress and anxiety can cause either constipation and diarrhea, depending on the person, I skew to the latter. (Sorry if TMI!)

Dr Christian: This is definitely a big topic in our profession, and amongst our patients. Despite the fact that the brain and gut are housed in different locations in our body, they remain intricately connected physically and through chemical signaling. The same chemicals that influence our mood and emotions — serotonin, epinephrine, cortisol, estrogen/progesterone to name a few — also have direct influence over our gut.  

What are the best ways to manage constipation at home without meds?
Dr. Christian: Limiting highly processed foods and getting enough water as well as both soluble and insoluble fiber (see links for sources) is the best way to stay regular. 

In our family, we always have a few green kiwis on hand. A recent study (small, but informative) indicated two kiwi fruit a day (the fruit is quite high in actinidin, a protein which plays a role in digestion) can be just as effective in helping to resolve constipation compared with both 10 prunes daily or even Metamucil. For me, eating kiwi is much more appealing! Hot tip: slice the kiwi lengthwise and scoop out the flesh with a spoon – much easier than peeling and slicing!

Oh! And warm beverages, especially in the morning, can be effective.

Emily: Water, water, water, and coffee! Increase fluid and fiber – but don’t increase fiber without fluid because it will have the opposite effect. Walking around the block, stretching, or any kind of movement can help too!

How about diarrhea?
Emily: The BRAT diet (banana, rice, applesauce, toast), essentially a low fiber diet, can be a helpful tool to not to exacerbate diarrhea, while feeling crummy. 

Dr. Christian: BRAT is a reasonable approach, but I find that people stay on a low fiber, all white food diet for too long. It’s important to get back to incorporating high fiber foods within a day or two. Also stay away from greasy or “rich” foods, as this can increase bile production and have a laxative effect.

Why does travel throw a wrench in things?
Dr. Christian: Diets change due to access and timing of meals, and we typically don’t get in as much fresh produce. When natural circadian rhythms are off (especially if we usually have a bowel movement in the morning), that can impact us more than we think. For example, if you don’t typically wake up at 4am (like you may on a travel day), this can confuse the normal flow of things.

Emily: Thanks Dr. Christian, I’m never taking an early flight again! But seriously, I think people often don’t get enough fluids during air travel, which can lead to constipation. 

What is Dr. Christian’s favorite OCT cocktail for constipation?

• Daily soluble fiber boost in the form of Citrucel powder because it is made of methylcellulose (typically better tolerated than psyllium, commonly known as Metamucil)
• For motility (or movement through the intestines), a cap of daily Miralax. Patients can safely continue taking it long term, but it’s not “addicting” as some people fear. Think of it like blood pressure medication — if it’s working, you keep taking it. That doesn’t mean it’s “addicting.”
• Magnesium oxide, specifically before bed. This also has an added benefit of helping with sleep and restless leg syndrome.

I seldom recommend enemas, but will suggest a mineral oil enema as a one-off treatment for someone who has not had a bowel movement in over a week. Stores stock small bottles of mineral oil next to the enema kits!

How about probiotics?
Dr. Christian: Probiotics are a multibillion dollar industry, and there isn’t strong evidence they work for most people. In very specific situations, such as patients who have had intestinal surgery to create a J-pouch, they have been shown to have adjunct benefit in treating inflammation of the pouch and I use them. I don’t recommend them otherwise. 

Emily: I like to use probiotics, short-term, after a GI bug when I want to restore good bacteria. I give my kids Culturelle in their morning beverage for about a week as they recover. For more information on probiotics, check out my article Should I Take Probiotics?

When to see a doctor?
Dr. Christian says these are the red flags to pick up the phone and make an appointment:

• Blood in stool
• Diarrhea longer than 2 weeks
• Unintentional weight loss
• Sudden change in bowel habits without other obvious explanation

What about cleanses?
Emily: There are no high quality research studies indicating that cleanses of any kind are warranted or helpful in any circumstance. Luckily, humans have a built in detoxification system, including our liver, kidneys, GI tract, and lungs, to expel what we don’t need, 24 hours a day!

Dr. Christian: Agreed! Also be aware that there are a lot of companies out there offering products that promise improved gut health that are eager to take your money.

Any last comments, Dr. Christian?
Yes, commercially available “food sensitivity” tests, including IgG and ALCAT tests, have not been validated and often lead to confusing results. There is no sound evidence to prove their efficacy. Save your time and money and see your doctor if you’re struggling!

Emily: I agree – and will do!

KEY TAKEAWAYS
A diet rich in fiber and fluids, such as fruits, vegetables, legumes, and whole grains, is the building block for overall bowel health. By making small dietary changes, sometimes we can make a big impact on our stool and our overall health.

There are some helpful OTC regimens for constipation, but make sure to understand side effects of the medications first. Many other trendy treatments or testing is not evidence-based and can be a waste of money.

Speak with your physician if you see blood in stool, diarrhea longer than two weeks, have unintentional weight loss, or a sudden change in bowel habits without other obvious explanation.

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