Gluten Free Works: TREATMENT GUIDE Get well and stay healthy living gluten free
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What Is Chronic Constipation?
Chronic constipation is an intestinal motility disorder characterized by abnormal stool formation, consistency, and evacuation.
Motility disorder means the normal rhythmic movement of intestinal muscles, called peristalsis, that moves food matter through the gut is hampered or dysfunctional.
Studies show that methane gas present in the colon induces constipation by delaying transit time, which is the time it takes for stool to pass through the colon.
Researchers investigating the relationship between methane and constipation found that methane positivity was detected in 75% of patients with slow transit, 44% of patients with normal transit and and 28% of the patients who were controls. However, methane positivity was not related with stool consistency.1
Other researchers investigating the total amount of methane produced found that there was significantly more methane production in patients with constipation (21.1 ppm vs. 6.1 ppm, respectively) than in controls without constipation.2
Q. How does methane get into the colon?
A. Methane is produced in the colon by intestinal methanogens (microbes) that metabolize hydrogen, one of the end products of normal anaerobic (meaning without oxygen) bacterial fermentation. Fermentation of the undigested starchy part of carbohydrates produces hydrogen in the intestine which is the substrate (food) for methane production by intestinal methanogens.
Hydrogen and methane are excreted in the flatus and in breath giving the opportunity to indirectly measure their production using breath testing. Methane is detected in 30%-50% of the healthy adult population worldwide.3
Other common causes of constipation include not getting enough exercise, not drinking enough fluids, not eating enough fiber in the diet, not eating foods that supply microbes needed by the colon (probiotics), not eating foods that nourish the good microbe population (prebiotics) and supply minerals needed for healthy movement of stool, and food sensitivities. Too much cows milk is a common cause of stool that forms into balls.
Who is Affected in the General Population? Chronic constipation is a remarkably common and costly condition that can negatively impact the quality of life and result in a major social and economic burden. Based on the definition, either self-reported or using Rome criteria, chronic constipation can affect up to 27% of the population. There is strong evidence that constipation occurs more frequently in women.4
What Is Chronic Constipation In Celiac Disease and/or Gluten Sensitivity?
- Relationship between constipation and celiac disease. Chronic constipation is an atypical symptom of celiac disease.
- Relationship between constipation and diagnosis of celiac disease. Unfortunately, constipation is often overlooked as a presenting symptom before diagnosis of celiac disease.
- Relationship between constipation and inflammation. Gluten inflames and as a consequence swells the intestinal lining. Swelling interferes with peristalsis, the normal movement of foodstuffs by muscles through the digestive tract.
- Relationship between constipation and malnutrition. Gluten causes malabsorption of nutrients necessary for normal bowel movements.
- Relationship between constipation and dysbiosis. Gluten causes dysbiosis in the majority of persons with gluten sensitivity. Dysbiosis is a major cause of constipation.
How Prevalent Is Chronic Constipation In Celiac Disease and/or Gluten Sensitivity?
- About 20% of people with celiac disease have constipation instead of diarrhea.5
- 20% of children are found to have constipation at diagnosis of celiac disease.6
- A retrospective study of children diagnosed with non-diarrheal celiac disease observed a prevalence of 48% with constipation.7
- Constipation was found in 20% of the children with gluten sensitivity. Histology revealed normal to mildly inflamed mucosa (Marsh stage 0-1) in these children with gluten sensitivity.8
What Are The Symptoms Of Constipation?
Chronic constipation is marked by these symptoms:
- Decrease in frequency of bowel movements with difficult or incomplete passage of stool and/or
- Passage of excessively dry, hard stool.
How Does Constipation in Celiac Disease Develop?
Chronic constipation in celiac disease results from any of these five conditions:
- Abnormal bowel motility causes too long transit time so that too slow movement of food matter through the digestive tract allows too much water to be removed, resulting in hard, dry stool.
- Dysbiosis causes poor formation, bulk and consistency of stool. Reduced microbe populations in the lower gut cannot perform their required functions: to keep the intestinal lining healthy and provide adequate bulk to the stool by virtue of their dead cells. That is, dead microbes by their sheer numbers normally make up about one third of stool bulk. On the other hand, abnormal microbe populations that are overgrown by feeding on excessive undigested food matter arriving from the small intestine, hamper muscle action by overproducing gas and toxins.
- Malabsorption causes deficiencies of thiamin and magnesium, which conditions impair tone and activity of muscle so that weak, untoned muscles fail to move food matter adequately.
- Food sensitivities irritate the gut, causing inflammation and swelling that hamper peristalsis. In the first three years of life cow milk allergy (an associated disorder of celiac disease) was the most frequent cause of constipation found in 136 children treated for constipation.9
- Insufficient fiber in the diet both before and after gluten-free diet due to poor food choices results in poor stool consistency and bulk. That is, replacing an unhealthy high starch, low fiber diet containing gluten with the same type foods made gluten-free in still not healthy for the gut. Good muscle tone in the gut needs fiber to hold moisture, give bulk and keep the normal microbe populations healthy.
Does Constipation Respond To Gluten-Free Diet?
Yes. Celiac disease-related constipation responds to gluten free diet.5
6 Steps To Improve Constipation In Celiac Disease and/or Gluten Sensitivity:
- 1Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:
- Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
- A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
- Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.
Correct Your Individual Nutritional Needs.
- Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
- Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.
Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the absorbing cells that make up the surface lining of your small intestine are better able to function.
- Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
- Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.10
- The intestinal lining may take up to a year to heal.
- 2 Reduce Inflammation. Foods to Eat and Foods Not to Eat:
Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).
- Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.11
- Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
- Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.11
- Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.11.
- Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.11
- Refined Sugars. Includes white sugar, corn fructose and high fructose corn syrup.
- Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.11
- Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.11
- Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens. Pears are especially good at resolving constipation.
- Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
- High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
- Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
- Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
- Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
- Prebiotics/ High Fiber Foods. Food with fiber keeps our population of colonic microbes healthy.
- Protective Herbs and Spices. See below #6 below for examples.
RECIPE: TANGY FETA, PEAR & BERRY DELIGHT Crumble 1 oz. sheep feta cheese into the hollow of half a ripe pear (fresh or canned), the sprinkle 6 or more blue or black berries and 5 broken pecan halves. Pears move the bowels all by themselves! Feta provides acid to better digest food for better absorption. Berries provide anti-oxidants to fight inflammation and fiber to provide bulk. Each food improves normal gut microbe populations to counter dysbiosis. 120 calories without pecans. Pecans add 70 calories.
- 3 Information Sheet You Can Take to Your Doctor or Other Health Professional:
- 4 Manage Your Medications Safely:
Certain prescription drugs cause deficiencies of magnesium and vitamin B1 (thiamin) that promote constipation. Others interefere with bowel motility by other means. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.
This is not a complete listing.
ANTACIDS / ULCER MEDICATIONS
- Pepcid®, Tagamet®, Zantac® deplete Magnesium.
- Gaviscon®, Maalox®, Mylanta®) deplete Magnesium.
- Alka Seltzer®, Baking Soda deplete Magnesium.
ANTIBIOTICS disrupt intestinal permeability.
- Tetracyclines deplete Magnesium.
ANTI-DEPRESSANTS
- Adapin®, Aventyl®, Elavil®, Pamelor®, and others promote constipation.
ANTI-HISTAMINES
- Diphenhydramine (Benadryl) promote constipation.
ANTI-INFLAMMATORIES disrupt intestinal permeability.
- Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Magnesium.
ANTICONVULSANTS
- Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Vitamin B1.
ANTIVIRAL AGENTS
- Foscanet depletes Magnesium.
CARDIOVASCULAR DRUGS
- Antihypertensives (Catapres®, Aldomet) deplete Vitamin B1.
- ACE Inhibitors (Capoten®, Vasotec®, Monopril® and others) promote constipation.
DIURETICS
- Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Magnesium.
- Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Magnesium, Vitamin B1.
FEMALE HORMONES disrupt intestinal permeability.
- 5Nutritional Supplements To Help Correct Deficiencies:
The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.
- Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications. Contains thiamin.
- Chelated magnesium as prescribed, but do not take at same time as calcium because they compete for absorption.
Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.
- 6Manage Natural Remedies:
Remember that your colon is your body’s source for water. When you do not drink enough to satisfy its need, it will draw water from your stool which will become dried as a consequence.
- Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
- If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
- Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
- What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.
Carminative Food Remedies:
- Raspberry.
- Carrot is also a cleansing digestive tonic.
- Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
- Redbeets also stimulate and improve digestion and are easily digested.
- Cabbage also stimulates and improves digestion and is also a liver decongestant.
- Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
- Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.
Carminative Herb Remedies:
- Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa. Drink as tea or use in cooking.
- Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
- Parsley also relieves indigestion.
- Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
- Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.
Carminative Spice Remedies:
- Cloves are also antispasmodic.
- Nutmeg is also useful for indigestion.
- Ginger.
Regular exercise is essential to combat constipation. Exercise improves circulation and rids the body of toxins.
- Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
- Weight training builds muscle. Read more about Exercise and Fitness.
- Stretching improves flexibilty. Read more about Exercise and Fitness.
Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal.
What Do Medical Research Studies Tell About Constipation In Celiac Disease and/or Gluten Sensitivity?
RESEARCH STUDY SUMMARIES
“Clinical, serologic, and histologic features of gluten sensitivity in children.” This study seeking to describe the clinical, serologic, and histologic characteristics of children with gluten sensitivity demonstrated findings that support the existence of gluten sensitivity in children across all ages with clinical, serologic, genetic, and histologic features similar to those of adults. Constipation was found in 20% of the children with gluten sensitivity.
Subjects were 15 children (10 males and 5 females; mean age, 9.6 ± 3.9 years) with gluten sensitivity who were diagnosed based on a clear-cut relationship between wheat consumption and development of symptoms, after excluding celiac disease and wheat allergy, along with 15 children with active celiac disease (5 males and 10 females; mean age, 9.1 ± 3.1 years) and 15 controls with a functional gastrointestinal disorder (6 males and 9 females; mean age, 8.6 ± 2.7 years). All children underwent celiac disease panel testing (native antigliadin antibodies IgG and IgA, anti-tissue transglutaminase antibody IgA and IgG, and anti-endomysial antibody IgA), hematologic assessment (hemoglobin, iron, ferritin, aspartate aminotransferase, erythrocyte sedimentation rate), HLA typing, and small intestinal biopsy (on a voluntary basis in the children with gluten sensitivity).
Abdominal pain was the most prevalent symptom in the children with gluten sensitivity (80%), followed by chronic diarrhea in (73%), tiredness (33%), bloating (26%), limb pain, vomiting, constipation, headache (20%), and failure to thrive (13%). Native antigliadin antibodies IgG was positive in 66% of the children with gluten sensitivity. No differences in nutritional, biochemical, or inflammatory markers were found between the children with gluten sensitivity and controls. HLA-DQ2 was found in 7 children with gluten sensitivity. Histology revealed normal to mildly inflamed mucosa (Marsh stage 0-1) in the children with gluten sensitivity.8
“Age-Related Patterns in Clinical Presentations and Gluten-Related Issues Among Children and Adolescents With Celiac Disease.” This study aiming to determine age-related patterns in clinical characteristics and gluten-related issues among children with confirmed Celiac Disease found that children and adolescents with Celiac Disease have age-related patterns in both the clinical presentations and gluten-related issues. More pronounced clinical and histological features were determined in younger children, whereas older children more commonly presented with solely subjective abdominal complaints or even without any GI symptoms. However, silent and atypical extraintestinal Celiac Disease presentations were comparable between age groups.
A structured medical record review of biopsy-proven celiac disease patients, aged 0–19 years, between 2000 and 2010 at a large Boston teaching hospital. Data collection included demographics, medical history, gluten-related issues, and diagnostic investigations. The first positive duodenal biopsy with Marsh III classification defined age of diagnosis. Patients were divided into three age groups for comparisons of the aforementioned characteristics: infant-preschool group (0–5 years), school-aged group (6–11 years), and adolescence group (12–19 years). Two-thirds of the school-aged group had complaints of subjective abdominal complaints (pain, discomfort, gas, and bloating) at the initial presentation, which was more common than the other two groups. Generally, females more frequently had abdominal pain compared with males with borderline significance (48% vs. 38%, P=0.051). More pronounced GI presentations such as abdominal distention, vomiting, bowel movement changes, or weight issues (weight loss or poor weight gain) were more common in the younger age group.12
“Celiac disease presentation in a tertiary referral centre in India: current scenario.” This facility-based retrospective observational study compared the clinical spectrum of nondiarrheal celiac disease (NDCD) with that of diarrheal/classical celiac disease (CCD) included consecutive patients diagnosed with celiac disease (as per modified ESPGHAN criteria) from October 2009 to August 2011. A total of 381 patients were diagnosed with celiac disease during the study period. NDCD was present in 192 (51.8 %). NDCD had higher mean age at presentation (5.8 vs. 6.9 years respectively) and longer duration of symptoms prior to diagnosis (2.9 years vs. 3.6 years as compared to CCD.
In the NDCD group, the most frequent gastrointestinal symptoms were recurrent abdominal pain in 122 (63.5 %) and abdominal distension in 102 (53.1 %) followed by constipation in 48 (25 %), vomiting in 76 (39.6 %) and recurrent oral ulcers in 89 (46.4 %). Vomiting and constipation were more frequently seen in NDCD as compared to CCD. The number of patients with a Marsh score IIIb and above of duodenal biopsy was significantly more in the CCD group.13
- Triantafyllou K, Chang C, Pimentel M. Methanogens, Methane and Gastrointestinal Motility. J Neurogastroenterol Motil. 2014 Jan;20(1):31-40. Epub 2013 Dec 30. [↩]
- Triantafyllou K, Chang C, Pimentel M. Methanogens, Methane and Gastrointestinal Motility. J Neurogastroenterol Motil. 2014 Jan;20(1):31-40. Epub 2013 Dec 30. [↩]
- Triantafyllou K, Chang C, Pimentel M. Methanogens, Methane and Gastrointestinal Motility. J Neurogastroenterol Motil. 2014 Jan;20(1):31-40. Epub 2013 Dec 30. [↩]
- Sanchez MI, Bercik P. Epidemiology and burden of chronic constipation. Can J Gastroenterol. 2011 Oct;25 Suppl B:11B-15B. [↩]
- Murray JA, Watson T, Clearman B, Mitros F. Effect of a gluten-free diet on gastrointestinal symptoms in celiac disease. American Journal of Clinical Nutrition. Apr 2004;79(4):669-73. [↩] [↩]
- Tanpowpong P, Broder-Fingert S, Katz AJ, Camargo, Jr CA. Age-Related Patterns in Clinical Presentations and Gluten-Related Issues Among Children and Adolescents With Celiac Disease. Clin Transl Gastroenterol. 2012 February; 3(2): e9. Published online 2012 February 16. [↩]
- Bhattacharya M, Kapoor S, Dubey AP. Celiac disease presentation in a tertiary referral centre in India: current scenario. Indian J Gastroenterol. 2013 Mar;32(2):98-102. doi: 10.1007/s12664-012-0240-y. Epub 2012 Aug 19. [↩]
- Francavilla R, Cristofori F, Castellaneta S, Polloni C, Albano V, Dellatte S, Indrio F, Cavallo L, Catassi C. Clinical, serologic, and histologic features of gluten sensitivity in children. J Pediatr. 2014 Mar;164(3):463-7.e1. doi: 10.1016/j.jpeds.2013.10.007. [↩] [↩]
- Kamer B, Dóka E, Pyziak K, Blomberg A. Food allergy as a cause of constipation in children in the first three years of life – own observations. Med Wieku Rozwoj. 2011 Apr-Jun;15(2):157-61. [↩]
- Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
- Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
- Tanpowpong P, Broder-Fingert S, Katz AJ, Camargo, Jr CA. Age-Related Patterns in Clinical Presentations and Gluten-Related Issues Among Children and Adolescents With Celiac Disease. Clin Transl Gastroenterol. 2012 February; 3(2): e9. [↩]
- Bhattacharya M, Kapoor S, Dubey AP. Celiac disease presentation in a tertiary referral centre in India: current scenario. Indian J Gastroenterol. 2013 Mar;32(2):98-102. doi: 10.1007/s12664-012-0240-y. [↩]
