constipation | The Paleo Mom

Product Review: The Squatty Potty (yes, that is what it sounds like)

February 23, 2013 in Beyond Paleo, Gut Health, Product Reviews

One of the amazing things about my blog growing so quickly is that I now get asked quite frequently to review products. I’ve learned the art of saying no and now only review products that I’m truly interested in. Yes, I was truly interested in trying out a squatty potty.

When the squatty potty PR department asked me if I was “pooping wrong” (literally, that was the subject of the e-mail), I was initially perplexed (isn’t that a bit of a personal question, and why the heck are you asking a mom paleo blogger to review a poop stool?) and then intrigued. I watched the video on their website (which had me smirking). I thought about it overnight, but by morning, my curiosity had the better of me. I responded with a “Yes, please”.

I’ve mentioned this before in other posts (like this one on constipation, which I recently updated) that prior to paleo, I had suffered Irritable Bowel Syndrome with chronic constipation for 12 years. For 12 years prior to paleo, I was on a rotating mixture of laxatives and stool softeners. Once, when I was in grad school, I spent an entire night in the emergency room where the very helpful resident diagnosed me as “full of sh*t” (yes, he literally said that like it was the funniest joke ever) and prescribed a very powerful enema (I was having severe abdominal pain because it had been 2 weeks since my last BM). I am fairly certain that I have permanent nerve damage as a result of more than a decade of chronic constipation. And I still battle the Small Intestinal Bacterial Overgrowth that likely caused it in the first place. Even now, when I give into cravings and eat starchy vegetables, coconut or too much fruit, my symptoms are bloating and constipation. So, yes, the issue of pooping is near and dear to my heart.

So, what’s the deal with the squatty potty? Well, basically the squatty potty is a very cleverly designed stool. It allows you to raise your knees high enough that your body is in a squatting position even though you’re still sitting on the toilet (you can actually properly squat and hover if you prefer). I borrowed the graphic below from the squatty potty website to show how this change in position changes the internal alignment. It means that a) gravity is working for you, and b) everything is lined up so you aren’t trying to push around a corner.

Squatting is a natural position for, well, many things. It’s actually one of the things that Mark Sisson talks about in his (completely awesome) new book: The Primal Connection. Before chairs, people would squat to relax, to eat, to chat. Squatting is a natural position for giving birth. And of course, before the invention of the toilet, squatting was the only position available. After all the natural childbirth education I went through before having my daughters, you’d think I would have drawn the connection between squatting as a birth position to help push out a baby and squatting as a poop position. Well, better late than never. Suffice it to say, squatting is a natural position for pooping.

There’s also some really convincing scientific studies supporting squatting as a healthier way to poop (of course, scientific studies use more technical terms than “poop”). For example, this study compared the Iranian-style toilet (squatting style) to the European-style toilet (what you are probably used to) and concluded:

“Use of the Iranian-style toilet seems to be a more comfortable and efficient method of bowel evacuation than the European style. Further studies are needed to ascertain the optimal approximation of the measurements to standard height of toilets for ordinary use.”

And this study concluded:

“The results of the present study suggest that the greater the hip flexion achieved by squatting, the straighter the rectoanal canal will be, and accordingly, less strain will be required for defecation.”

And this is my favorite study, which concludes:

“The present study confirmed that sensation of satisfactory bowel emptying in sitting defecation posture necessitates excessive expulsive effort compared to the squatting posture.”

The squatty potty fixes your posture while going to the bathroom. And this simple change can dramatically improve constipation, hemorrhoids, colon disease, urinary difficulty/infections, and pelvic floor issues (just in case you thought this was limited to ease of pooping). Did I mention that Mark Sisson plugs the squatty potty in his book? (I only read The Primal Connection just over a week ago, so I was feeling all proud of myself that I was already using a squatty potty when I read that chapter.)

In the paleo community, we are passionate about natural movement. We climb trees and wear vibrams. So, think of the squatty potty as MoveNat for pooping. PoopNat, if you will.

So, what is my personal experience with the squatty potty? I’ve been using it for about 6 weeks (I wanted to give it a thorough trial run before writing this review). And, as my 6-year old would say, holly smolly guacamole. This thing is ridiculously awesome. It is not natural to love a stool as much as I do, but I can’t help it. It really is more comfortable and easier to go from a squatting position. It doesn’t feel like work (and, at least for me, it used to feel like work more often than not). And, I have overdone sugar in the last 6 weeks (wish I could say that was in order to thoroughly test out the squatty potty, but it’s really just giving into sugar cravings due to being overrun with writing the book) and had the usual response by my body. But, I didn’t have to suffer the severe discomfort of going to the bathroom after my sugar indulgence that I normally do thanks to the squatty potty. Yes, I am very impressed. Actually, I am in love.

The only downside? Less time to read.

Lest you think that any stool can do this job, let me tell you a couple of features of the squatty potty that make it worth the $10-$20 extra bucks over a regular stool. It’s wide so you can place your feet in a variety of positions depending on your hip width and what’s comfortable for you. It’s slightly angled so you can have your feet slightly angled up or down depending on the flexibility in your ankles and what’s comfortable for you. And probably best of all, it tucks right under the toilet bowl due to its shape so it is completely out of your way when you aren’t using it. I now only go to the bathroom in the one bathroom in the house than has a squatty potty… time to buy another one, I think. Actually, I think these will make great Christmas presents this year (head’s up family, you’re getting poop stools for Christmas! And a copy of The Paleo Approach. Woot!).

So, where can you get a squatty potty? You can buy them direct from www.squattypotty.com and you can buy them off amazon. The 9” squatty potty is better if you are tall, are fairly flexible, or have a higher toilet. The 7” squatty potty is better if you are shorter, less flexible or have a lower toilet. It even comes in bamboo if you think that utilitarian white won’t match your bathroom.

So, in the words of the squatty potty PR department, are you pooping wrong?

Tags: bowel, constipation, defacation, gut health, How To, IBD, IBS, Irritable Bowel Syndrome, movement, poo, poop, position, potty, squat, squatting, squatty, straining
22 Comments »

Modifying Paleo for FODMAP-Intolerance (a.k.a. Fructose Malabsorption)

August 7, 2012 in FAQ, Paleo Modifications

One of the many challenges that people face when adopting a paleo diet is dealing with the confounding factor of additional food sensitivities. Sometimes these sensitivities are known (perhaps you had allergy testing done at some point or react so violently to certain foods that it was a no-brainer). Sometimes these sensitivities are unknown and make it frustrating when we don’t experience the instant improvements to our health touted by so many paleo enthusiasts. One such sensitivity is FODMAP-intolerance (also referred to as fructose malabsorption). This isn’t a food sensitivity in the sense that there is any sort of immune reaction to these foods. Instead, it is a case of a person who cannot properly digest the fructose (and longer sugar molecules containing fructose) in these foods.

The term FODMAP is an acronym, derived from “Fermentable, Oligo-, Di-, Mono-saccharides and Polyols”. FODMAPs are short chain carbohydrates rich in fructose molecules which, even in healthy people are inefficiently absorbed in the small intestine. I know you’ve heard the limerick “beans, beans, the magical fruit…”; the punchline refers to the large amount of FODMAP carbohydrates in beans (or any of other vegetable that has a reputation for being “gassy”) that are only partially absorbed in the small intestine. When this excess fructose enters the large intestine, which is full of those wonderful beneficial bacteria we love so much, they feed the bacteria allowing for overgrowth of bacteria and excess production of gas. The presence of FODMAPs in the large intestine can also decrease water absorption (one of the main jobs of the large intestine). This causes a variety of digestive symptoms, most typically: bloating, gas, cramps, diarrhea, constipation, indigestion and sometimes excessive belching. In individuals with FODMAP-intolerance, a far greater portion of these sugars enter the large intestine unabsorbed, causing exaggerated symptoms. In fact, some researchers believe that Irritable Bowel Syndrome is purely a case of FODMAP-intolerance ^1,2.

Carbohydrates, which are just chains of sugar molecules, are broken down into individual monosaccharides (a single sugar molecule) by digestive enzymes in the small intestine (actually, this sugar digestion process begins with the salivary amylase enzyme in the mouth when you chew, but it continues all the way through the small intestine). Monosaccharides are then absorbed into the blood stream by first being transported through the cells that line the small intestine, the enterocytes. Enterocytes have specialized transporters, or carriers, embedded into the membrane that faces the inside of the gut. These carriers bind to specific sugar molecules and transport them into the cell (where the cell can either use those sugars for energy or transport those sugars to the other side of the cell where they can easily enter the blood stream). FODMAP-intolerance may be due to lack of digestive enzymes required to break longer chains of carbohydrates down to their individual monosaccharides and/or due to an insufficient amount of these carbohydrate carriers, specifically the carrier called GLUT5, which is the specific carbohydrate carrier for fructose (why this is also called fructose malabsorption).

FODMAP-intolerance means that large amounts of dietary fructose and longer carbohydrate chains that are rich in fructose are problematic. These longer, fructose-rich carbohydrate chains are called fructans (inulin, which is a type of fiber, is also rich in fructose and problematic for those with FODMAP-intolerance). Sugar alcohols, called polyols, (sorbitol is an example) are additionally problematic because these sugars have the ability to block GLUT5 carriers (and if you’re working with a deficiency, that’s really not helpful!). Why do some people develop FODMAP-intolerance? Researches don’t know yet. It may be a reaction of the body to high fructose and fructan consumption with the Standard American Diet. It may be a side effect of a very distressed and/or leaky gut. There are also very likely to be genetic factors at play. The good news is that, for many, as their gut and bodies heal, their ability to digest and absorb these sugars improves.

When it comes to modifying your diet to address a suspected FODMAP-intolerance, dose is the key. The type of FODMAP may be important for some people. Some people are more sensitive to the fructose and polyols (due to GLUT5 carrier deficiency) while some are more sensitive to fructans (due to digestive enzyme deficiency). Some people are sensitive to both. How much you can handle is very individual and is likely to change as your gut heals. There are medical tests available to diagnose fructose malabsorption, however an elimination diet approach is more reliable. Research has shown that the removal of FODMAPs from the diet is beneficial for sufferers of irritable bowel syndrome and other functional gut disorders ¹.

The following table was created by Aglaée the Paleo Dietitian, and is posted with her permission. It breaks down common foods into three categories: safe (very low to no FODMAP), be careful (low to moderate FODMAP), and avoid (high FODMAP). It also contains which kind of FODMAP is richly present in each food in parentheses (helpful for those who are more sensitive to one versus the other). (Aglaée told me that this table is likely to be updated in the near future. I will repost the edited version when it becomes available. You can see the original table here: http://www.eat-real-food-paleodietitian.com/support-files/paleo-fodmap-food-list.pdf)

As you can see from this table, many of the moderate to high FODMAP foods are foods that we typically increase consumption of when adopting a paleo diet. How frustrating for those who experience an increase in gastrointestinal symptoms when they adopt a paleo diet compared to so many who find instant alleviation of symptoms! If you suspect (or know you have) FODMAP-intolerance, I recommend eliminating all food sources of FODMAPs from your diet for a couple of weeks. If you are sensitive, you should notice a fairly dramatic effect on your digestive symptoms. You can try reintroducing some of the lower FODMAP fruits and veggies and see if your symptoms return. In many cases, following a gut-healing protocol (as outlined in this post, this post or in the book Practical Paleo) will improve digestion of FODMAPs and they can be reintroduced carefully but successfully.

It is very important to note that the symptoms of FODMAP-intolerance are virtually identical to the symptoms of Small Intestinal Bacterial Overgrowth (SIBO). The reason for this is that these two conditions are highly related. The difference is simply a matter of location, larger versus small intestine. Without testing it can be difficult to discern which of these paleo diet modifications to try first (for more information on SIBO, read this post and this post). Even more confusing, FODMAP-intolerance may or may not be linked to Small Intestinal Bacterial Overgrowth. In some cases, the unabsorbed sugars caused by FODMAP-intolerance will lead to an environment in the small intestine where bacteria will grow, thus causing SIBO. So, you may have SIBO without FODMAP-intolerance, you may have FODMAP-intolerance without SIBO, or you may also have both. If you have digestive symptoms and are unsure which condition is the problem, then, I’m sorry to say that you’ll need to either have some tests done or follow the diet restrictions for both. After a period of a couple of weeks, you can try adding in either the starchy vegetables eliminated in the modification for SIBO or some of the FODMAP fruits and veggies (choose whichever food you miss the most). It should be clear fairly quickly which foods are problematic. Also note that both of these conditions are likely to resolve completely with continued elimination of these foods (although in some cases this will take 6-12 months or even longer), so you may find that you can add everything back in and your symptoms don’t return (fingers crossed!)

¹ Gibson PR and Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010. 25(2):252-8.

² Born P Carbohydrate malabsorption in patients with non-specific abdominal complaints World Journal of Gastroenterology, 2007, 13(43): 5687-5691

Tags: ancestral, bloating, constipation, diarrhea, Diet, digestion, fermentable, FODMAP, Fructose, gas, IBS, intolerence, malabsorbtion, oligosaccharide, paleo, Paleolithic, primal, sensitivity, Sugar, symptom
39 Comments »

Treating Constipation without Destroying Your Gut

May 29, 2012 in Beyond Paleo, Gut Health

Perhaps you are wondering how on earth I am going to address this topic delicately. The answer is: I can’t. It’s an impossible task and I’m just plain old going to be frank, cross over into TMI territory, and talk about poop. Although, I will spare you the drawing of a constipated stick figure. Perhaps you are wondering exactly why this is even a worthy topic for my blog. Well, constipation is a relatively common complaint during the adjustment period when people first transition to a paleo diet (as is diarrhea, but that’s a topic for another day). And even the best of us can suffer constipation on occasion as a result of stress, eating foods we shouldn’t, and traveling. But perhaps more relevant, you may be interested in how to treat constipation if you have some type of gut pathology than lends itself to constipation or if you suffered nerve damage caused by years of chronic constipation like I have.

Before discovering paleo, I had chronic constipation for about as long as I can remember. I was officially diagnosed with Irritable Bowel Syndrome in my early twenties and prescribed daily doses of stool softeners and laxatives. As a result of 12 years of irregular bowel movements, constipation and laxative use, I have nerve damage that may never fully heal. Transitioning to a paleo diet allowed me to stop taking these medications; however, I do need to be constantly vigilant. And, because I have a (thankfully, fairly minor) case of Small Intestinal Bacterial Overgrowth, the two chief symptoms that I get when I consume sugary or starchy foods is bloating and constipation. The first time after transitioning to a paleo diet that I was faced with the need to take something to help me poop, I did a little research into what was safe to take. I was shocked to find out that most of the commonly used laxatives and stool softeners available are gut irritants and can directly damage the lining of the gut (in fact, for many of them that is actually how they work!). Since my diet and lifestyle choices now prioritize gut health, I needed to know what is safe to take for constipation!

I will spare you the long exhaustive list of what not to take (except perhaps to make sure to tell you that I include natural, senna-based laxatives, including teas, in the gut irritant list as well as fiber supplements of any kind). Here are the ONLY treatments that I recommend:

Use a squatty potty every day. The better angle for pooping decreases straining, and makes pooping easier and more comfortable.
Milk of Magnesia (or another high dose magnesium supplement like Natural Calm), taken at bedtime in conjunction with LOTS of water.
Glycerin Suppositories
In extreme cases, you may wish to try a Saline Enema in addition to milk of magnesia.

But there are a few other tricks that are helpful as a preventative and also for minor constipation. This may seem obvious, but make sure that your diet includes plenty of plant matter and make sure that you are drinking sufficient water (this is the most common cause of constipation in individuals following a paleo diet who do not have a history of digestive problems). It’s also very important to make sure that you have a source of probiotics in your diet, whether it’s from fermented foods or a supplement. Taking 1-2 Tbsp of Lemon Juice or Raw Apple Cider Vinegar 10-15 minutes before each meal can help with the secretion of digestive enzymes and decrease transit time. Avoiding starches and sugary foods that feed bacteria and contribute to hunger hormone disregulation can be very helpful for some people (especially those who suspect they have Small Intestinal Bacterial Overgrowth). Sauerkraut can be very helpful in regulating stomach acidity as well as providing probiotics. Ginger is a miracle. It helps regulate stomach acidity, stimulates peristalsis, and decreases transit time. I drink several cups of ginger tea daily (my favorite brand is Yogi), and when I need a little extra, I like to eat alot of homemade honey-candied ginger (especially because the honey doesn’t aggravate my SIBO due to its monosaccharide content). Exercise can be very helpful, especially something like going for a nice long walk. Doing alot of spinal twist yoga poses can help too. For a simple one, lie on your back with your legs bent and your arms out in a T position. Drop your legs to the left, leaving your shoulders on the floor, and look to the right. Hold for a good five minutes and then do the other side.

These paleo-friendly strategies work well if you are proactive and take some action after skipping just a couple of days of bowel movements (my rule of thumb is if I skip two days, but I have to be very careful, so depending on who you are, you may consider anywhere from 2 to 4 days as your metric). Here is the important caveat though: whether you are dealing with constipation as part of a greater pathology or the occasional reaction to traveling, food, or stress, you need to know when the gentle paleo-friendly strategies are not working. There comes a point where problems caused by severe constipation are far worse than the gut irritation caused by taking a laxative. Constipation can even be life threatening. Please, do not hesitate to see a doctor if your attempts to get your bowels moving again are not working. And don’t do what I did in grad school and wait two full weeks and then have to spend a night in the ER (where the very helpful resident diagnosed me as “full of shit”, his exact words). I am still paying for the nerve damage that caused now.

Tags: ancestral, bowel, constipation, Diet, gut irritation, laxative, movement, paleo, Paleolithic, primal, safe, stool softener
27 Comments »

Challenge #2 Update: My Still Spirited but Much Healthier Kids

May 5, 2012 in 2012, About Sarah's Family

Over the past 6 months, I have successfully transitioned my daughters to a lacto-paleo diet. I tackled this transition by finding great paleo substitutes for their favorites, gradually introducing new foods, and slowly phasing out the foods that we don’t eat anymore. You can read about various aspects of my children’s transition to paleo in these posts:

and also about my general approach to the transition in this post:

Getting Your Kids On Board–Toddlers & Preschoolers

How has going paleo improved their health? Both girls had small patches of eczema that cleared up once their diet was gluten-free. My youngest still gets very mild rashes from time to time, which I think might indicate a dairy sensitivity and I am also growing suspicious of strawberries (she got a very obvious rash after eating birthday cake so we know she is for sure gluten-sensitive). I love that I don’t have to slather my girls in cortisone cream anymore! I have also noticed that, since going gluten-free, both my daughters’ immune systems seem to be much stronger. The last few colds that passed through our house were so minor as to be barely noticed. We used to be sick all the time and catch absolutely everything that was going around. Now, I’ve even started to not worry about exposure to other sick kids because for I finally have some confidence in their immune systems actually doing their job! The most amazing accomplishment is that we were able to wean my oldest off of Miralax, which she had been on for the last three years (since she was 2!) for chronic constipation. And this is saving a noticeable amount of money! My oldest also seems to be sleeping a bit better and has better energy, but still seems lower energy than other kids her age. We’ve had her tested for various deficiencies, all of which she doesn’t have, so it seems to be simply caused by not eating enough, or at least, not regulating her blood sugar well with what she is eating.

Unfortunately, my youngest still has nighttime breathing issues which continue to be not fully diagnosed (and actually even less clear than they were before because now they continue after she awakes, so it doesn’t look like sleep apnea anymore). We have taken her off the acid reflux medicine (it never did anything anyway!), which I think is progress in terms of ruling that out as a potential cause (I also disliked that she was on proton-pump inhibitors at all, so I am very pleased to have her off of them!). We do know that she still has a laryngomalacia (a floppy epiglottis) and that her vocal cord bands are tight. This may be the root cause of her breathing issues (in which case, she may grow out of it, but surgery is an option), which would be unrelated to diet. We have another sleep study booked (her third!) to see whether or not she is still experiencing any obstructive sleep apnea and will proceed from there.

So, what are my goals with my kids? I am proud of my girls (and myself) for making and accepting so many changes to their diets. However, I have decided that I want to remove dairy products from their diet after all. For my youngest, I am hoping it will fix whatever is causing her to gasp for air at night and hopefully put an end to the occasional rashes she gets. For my oldest, I am hoping that removing these insulinogenic foods from her diet will help balance her blood sugar and hence her energy levels during the day. I have actually already started the process. We got my youngest used to drinking water instead of milk throughout the day (this was never an issue with my oldest who never did like to drink straight milk). We no longer have cow’s milk in the house so that if they do want milk, it’s coconut milk. And I have been experimenting with flavoring my own homemade coconut milk yogurt so that the girls will eat it. I haven’t quite figured out what to do about cheese, except try to get used to not eating it. My youngest doesn’t eat much, so this is mostly an issue for my oldest.

When I think back to how my kids ate just 6 months ago, I am completely amazed at how much progress we have made. I still have challenges ahead of me; but I can now say that I feel confident that I am feeding my children optimal nutrition and teaching them how to eat to stay healthy for their entire lives. And that feels pretty good!