Straining for Relief –
Damage Everywhere
Out of the Mouths of
Babes
Many years ago on one
summer evening when our daughter was 10 and our oldest son was nine, we were
enjoying a peaceful dinner when Heather asked, “Is there something wrong with
Jodi?” Heather and Patrick had spent the previous night at their best friends’
home, Jodi and Mark. Heather continued, “When Jodi is in the bathroom I hear
these strange noises, like she is in horrible pain.” She then made a long
painful grunting sound to demonstrate. Patrick interjected, “Mark makes the
same noises and he’s in there forever.” My children had never had to experience
the Herculean exertion most people require to move their bowels. In fact, for
them this daily process was accomplished effortlessly and in seconds – back out
to play before the ball stops bouncing.
Almost 30 years ago, as a
general practitioner in a small rural community on the Big Island of Hawaii, I
had a chance to learn all about the personal bowel habits of my patients. The
most upsetting stories were about the suffering children. Mothers often brought
them to see me because of lower abdominal pains and bleeding – blood on the
toilet tissue or frank blood in the toilet bowl. After detailed questioning,
the concerned mothers told me about the straining efforts their children
experienced with each bowel movement, every two to five days. No connection was
ever made between the child’s diet and this severe constipation. Nor by
patients, and nor by their concerned doctors, is there ever any connection made
between this constipation and diseases in other parts of the body.
The Fiber Man – Denis
Burkitt
All of my formal
medical-school education focused on describing and treating the signs and
symptoms of chronic illness, rather than on really important matters – cause and
cure. A turning point in my life came in the autumn of 1971, when I was a
senior medical student. During a noontime hospital conference I met the first
doctor to tell me there were causes for the common chronic diseases. Dr. Denis
Burkitt was visiting the Kellogg cereal company in Battle Creek, Michigan;
trying to convince them to add more dietary fiber to their products. He
believed the lack of fiber in our diet was at the root of our common chronic
diseases.
Dr. Burkitt, born in
Ireland in 1911, became a surgeon at Edinburgh’s Royal College of Surgeons in
1938, and was assigned to work for the colonial Medical Services in Uganda,
Africa in 1946.1 He served as the Government Surgeon of Uganda from
1946 to 1964. Here he discovered a cancer of the immune system, which carries
his name – Burkitt’s lymphoma.
In Uganda, Burkitt made
many important observations about his African patients. For example, they
produce several times more quantity of feces than people on the highly refined,
high meat Western diet. He noticed their feces were soft and passed without
pain and attributed this to the high fiber content of their foods. Westerners
have 3 to 21 bowel movements a week and the amount of stool passed is 85 to 150
grams/day (3 to 5 ounces). Africans have 30 to 60 movements a week with a stool
weight of 200 to 500 grams a day (7 to 17 ounces). Most importantly, he noticed
that the diseases he had been trained to treat in Scotland were absent among
Africans. He saw no cases of type II diabetes, obesity, appendicitis,
diverticular disease, hemorrhoids, dental caries, varicose veins, pulmonary
embolism, inflammatory bowel diseases (Crohn’s disease and ulcerative colitis)
or hiatus hernia. The only heart attack he saw was in a judge who had trained in
London, developed a taste for roast beef and Yorkshire pudding, and then
returned to Africa. “In 20 years of surgery in Africa, I had to remove exactly
one gallstone,” Dr. Burkitt claimed.
I remember only one slide
from this “medical-student, mind-changing” lecture. On one side of the slide
was pictured a large hospital building with a small bowel movement next to it;
and in the adjacent frame was a small hospital with a large stool. The message
was clear – those populations who eat a diet high in fiber have big bowel
movements and few illnesses. Denis Burkitt set out in the mid-1960s to tell the
world how important it was to add fiber back to your diet. He became known as
“The Fiber Man.” In retrospect, his focus was too narrow – simply sprinkling
bran over bacon and eggs will not solve the health problems of Western man.
Historically, similar
changes in disease patterns, as seen in Africa, have been seen as the diets of
people in England, the United States, and most recently Japan, have switched to
processed foods and animal products.2-4 There are many more important
qualities to the plant-based diet of Africans than the fact that it was high in
dietary fiber. The African diet has been traditionally a diet based on grains,
legumes, vegetable and fruits – his patients ate very little meat, dairy
products or refined foods. This means the diet was very low in animal protein,
fat and cholesterol, and high in complex carbohydrates, dietary fiber, and
healthful phytochemicals.5-6 All these ingredients go together to
define a healthy human diet – like that of Burkitt’s patients (and by no
coincidence, The McDougall Diet).
In last month’s newsletter
I explained that fiber, which is only found in plant foods, is mostly
non-digestible carbohydrate, which passes through the small intestine intact to
become the bulk of the stool. The fiber pulls in water to further expand the
volume of the stool. Americans eat very little fiber because their meals are
made of mostly fiber-free animal products and refined grains. The result is
tiny rock-hard fecal marbles – and so begins health problems throughout the
body. The following diseases are found commonly in populations of people who
consume a “rich” diet, and are essentially unknown in people, who, like Dr.
Burkitt’s Africans, consume a diet based on unrefined plant foods.
Appendicitis:
The contents of the small
intestine empty into the large intestine. The first part of the large intestine
is called the cecum (located in the right lower part of the abdominal cavity).
A small pouch or diverticulum, called the appendix, is attached to the cecum.
When the opening of the appendix becomes blocked, fluids accumulate. These
stagnant fluids become infected creating a disease condition common to
Westerners, called appendicitis.
The cause of this blockage
is unhealthy remnants of partially digested foods, which irritate the opening of
the appendix. The observation that appendicitis is unknown in populations of
people who eat a plant-based diet must be surprising (and maybe disappointing)
to surgeons trained, like Dr. Burkitt, to treat this common condition in
Westerners.7-9 The incidence of appendicitis is increasing among
Africans as their diet changes.10
Diverticular Disease:
In Western societies, diverticulosis occurs in at least one
person in two over the age of 50 years. The frequency increases with age. Denis
Burkitt, practicing in Uganda, and doctors taking care of similar populations of
people, never see this condition among the natives.11,12
As the food moves through the small intestine the
nutrients – protein, fats, carbohydrates, vitamins, and minerals – are absorbed
through the intestinal wall into the bloodstream. Left behind are
non-digestible matters (dietary fibers), colon bacteria and a few dead cells –
these materials soon become the stool. Movement from the right side of the
large intestine to the left side is accomplished by rhythmic contractions, known
as peristalsis.
According to a law of physics (Laplace’s Law), the pressure
within a cylindrical structure with a given wall tension increases with
decreasing radius.13 In other
words, contractions at small diameters cause
high pressures. The remnants of digestion on the Western diet produce only a
small mass, and therefore, high pressures.14 Years of elevated
pressures produce ruptures in the walls of the intestine, making balloons,
called diverticula.
Blood supply of the
intestine begins on the outer surface, and then these small vessels dive through
the muscular wall to supply the inner surfaces of the intestine. The weakest
part of the wall of the intestine is where the blood vessels pass through the
wall. As a result, the most common locations of these diverticula are next to
blood vessels. Not surprisingly, one of the most common symptoms of this
disease is bleeding. I have seen the bleeding so severe that the only way to
save the person’s life was to surgically remove the bleeding portion of the
intestine.
When the diverticula become
irritated by the unhealthy remnants of digested food in the large intestine the
openings can close, allowing the fluids to become stagnant and infected – a
condition known as diverticulitis. This disease is sometimes referred to
as “left-sided appendicitis,” (remember the real appendix is located in the
right lower part of the abdomen), and is usually treated with antibiotics.
A change to a high fiber
diet will greatly reduce the risk of future bleeding and infection – in other
words, people with diverticular disease have much less trouble after they change
to a healthy, high fiber, plant-based diet.15 However, the
diverticula do not disappear with a change in diet.
The Final Act –
Defecation
Matter is further digested
and water is removed during the movement from the right to left colon. In the
final few inches of the large intestine, called the rectum, the feces
accumulate. With adequate filling the rectum becomes distended, causing reflex
contractions, which initiate the evacuation of the stool into the outside world
– properly referred to as a bowel movement. Unfortunately, life is not so
simple for those who make tiny rock-hard fecal marbles. These little guys
simply do not provide adequate filling to stimulate the rectum. Plus, because of
their slow passage almost all of the water has been removed and they become dry
and hard, thus more difficult to pass. To get them out requires enormous effort
and harmful straining.
Picture a person seated on
the toilet – grunting and groaning. The face is flushed red from blood pushed
up into the head and neck. This is not the only direction blood is forced by
straining. Blood diverted under pressure into all other body parts causes
structural damage. After many years all this translates into diseases suffered
by the majority of people living on the Western diet.
Hemorrhoids:
Diets low in fiber cause
hemorrhoids by creating high pressure in the veins found in the very last part
of the large intestine, the anus.16,17 A ring of internal veins, the
hemorrhoidal veins, provide a compressible lining which allows the anus to
completely close – sealing the intestine closed – allowing us to act sociably by
preventing release of gasses and stool at inappropriate times and places.
Straining to pass the small
stools causes retrograde pressures in the hemorrhoidal veins, dilating them.
Eventually, after years of straining they are permanently enlarged and commonly
hang out of the end of the anus. Later stages of hemorrhoid development
include the displacement of the anal muscles toward the outside.
Hemorrhoids located higher up are called internal hemorrhoids; the lower ones
are called external hemorrhoids, the latter are commonly the painful ones.
Since these are structural
changes caused by physical forces they can be expected to be permanent. Surgery
can counter some of this damage with removal of some of the stretched-out tissue
– a hemorrhoidectomy. Surgeries include sclerotherapy (injection with a caustic
substance), photocoagulation, rubber band ligation, cryotherapy (freezing) and
cutting with a knife and laser. Laser surgery is no less painful and is more
expensive.18
Surgery should be reserved
for those who fail to find comfort from less drastic means – like topical
cleansing and creams, and most importantly, better food choices. The main
symptoms from hemorrhoids are itching, pain, and bleeding. Sitting in a warm
bath (a sitz bath) can provide much relief. A change to a healthy plant-based
diet will do wonders – the itching, pain, and bleeding usually stop.
You may wonder why other
forms of straining such as lifting or straining to deliver a baby don’t cause
permanent dilation of the hemorrhoid veins. In all forms of straining, except
those associated with bowel movements, there is a reflex contraction of the anal
muscles (sphincter), and this compensates for the raised pressures in these
veins.1
Although hemorrhoids may
have been rare in rural Africa before modernization of the diet, that is not the
case today. Approximately one-fifth of modern black Africans now have these
dilated veins – a direct result of their switch to a modern diet.19
Varicose Veins:
Straining to push out small
stools causes great retrograde pressures into the veins of the legs. This
pressure is even higher and more damaging because of our custom of sitting to
defecate on high-seated toilets. If you have traveled to less developed
countries, you may have been shocked to find their toilets are simply holes
flush with the ground. To relieve yourself, you squat. This position bends the
legs at the hips and knees cutting off the veins and preventing pressures
created by straining from being transmitted down into the leg veins – thus
protecting them.
Notice that when you are
standing, the distance from the feet to your heart is about four to five feet.
A column of blood this tall would place tremendous pressures due to the weight
of the blood on the veins in the lower leg and feet. To prevent this, the large
veins in the legs have valves that shut closed to prevent flow of the blood in
the direction of the feet. When we walk the muscles in the legs contract,
pushing blood past open valves towards the heart. However, the valves are one
way, preventing the blood from falling back down toward the feet.
When a person strains to
move those stubborn fecal marbles, the high pressures dilate the leg veins and
stretch out the valves. After years of such damaging forces, the valves become
distorted and incompetent – producing those well-recognized “blue worms,” that
we call varicose veins.16,19
Varicose veins occur
elsewhere: Varicose veins in the scrotum of men are called varicoceles. In
women, this dilation of veins can occur in their vulva and around their
ovaries.
Hiatus Hernia:
The action of defecation
raises the pressures in the abdominal cavity above those that are in the chest.
The result is that the contents of the abdomen are pushed up into the chest.
The chest and the abdomen are separated anatomically by a large muscle used for
breathing, called the diaphragm. Three structures pass though the diaphragm –
the aorta, vena cava and esophagus. Only the esophagus is moveable. Straining
pushes the stomach into the natural opening for the esophagus causing the
muscular opening to dilate. A dilated muscle is known as a hernia. This
condition is called a hiatus (or hiatal) hernia.21-22 Eventually the
top portion of the stomach may actually sit in the chest cavity. Each breath
creates negative pressures in the chest that draw acid up into the esophagus.
With the stomach out of its natural position, the sphincter (lower esophageal
sphincter) that functions to close the opening between the esophagus and stomach
when we are not swallowing becomes incompetent. The result is acids from the
stomach can reflux into the esophagus and up into the mouth and lungs causing
esophagitis, loss of dental enamel, sinusitis, and asthma (see the February 2002
McDougall Newsletter). This condition is referred to as Gastroesophageal Reflux
Disease (GERD).
Surgical repair can move
the stomach back into the abdominal cavity and close the hernia. However, this
operation should be reserved for those who cannot find relief from a healthy
diet, raising the head of their bed and/or antacids.
Other Possible
Conditions from Straining:
I believe the following
conditions are also due to straining to defecate: prolapse of the female
uterus, spermatocele (dilation of the spermatic cord), cystocele (prolapse of
the female bladder), and rectocele (prolapse of the rectum).
Treatment of Damaged
Tissues:
Unfortunately, the
conditions that are caused by straining are not returned to normal with a change
in diet. But diet will relieve most of the problems associated with
diverticulosis (bleeding and infection), hemorrhoids (bleeding, pain and
itching) and hiatus hernia (heartburn). Surgery for these conditions and the
others discussed (diverticulosis, varicose veins, and prolapsed uterus) should
be reserved for those who cannot find relief with less drastic measures. I
would expect that changing to a healthy high-fiber, plant-food based diet will
slow the progression of all these conditions, preventing them from becoming
worse.
Rather than wonder why so
much disease is caused by the simple act of moving your bowels, you should
marvel at the strength of your body to withstand these tissue-wrenching forces
for so many years. Today would be a great day to start reducing the wear and
tear on your body – you will be amazed by how quickly it responds.
References:
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2) Taylor R. Management
of constipation. 1. High fibre diets work.
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3) Burkitt D. Effect of
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disease. Lancet. 1972 Dec 30;2(7792):1408-12.
4) Walker A. Epidemiology
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Review.
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veins, deep vein thrombosis, and haemorrhoids: epidemiology and Suggested aetiology. Br Med J. 1972 Jun 3;2(813):556-61.
17) Haas P. The
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treat haemorrhoids. Prevention is best; haemorrhoidectomy needs skilled
operators. BMJ. 2000 Sep 9;321(7261):582-3.
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