A LOT of people with brain injuries and spinal cord injuries take laxatives — one…two…or even three laxatives a day, EVERYday for years.  My question is always, why?  If someone needs laxatives every day, that usually means there is another problem going on which needs further investigation. 

It’s also worth remembering that some laxatives can have negative side effects like nausea, bloating, abdominal pain, abdominal distension, and electrolyte disturbance.1  Therefore, if there is a way to manage someone’s bowels without (or with minimal) medication that is always my preference.

What is causing the constipation? 

Common offenders include:

• Medication – certain medication (eg. Co-codamol, iron supplements, antiepileptic medication) slows down how fast food moves through the digestive tract.2  Ask the GP to review your client’s medication to see if there are any which may be contributing to the problem.

• Gut dysmobility or neurogenic bowel dysfunction – these are just fancy ways of saying the contractions which normally push food through a person’s digestive tract aren’t working correctly.  This could be from an injury to the brain or spinal cord or a side effect of medication.3  Try to rule out all other causes before accepting this is “just the way it is.”

• Being bed bound or wheelchair bound – lack of movement is known to almost double the risk of constipation.4

• Lack of fibre – Fibre is needed to “bulk” the stool, to speed up the passage of waste through the gastrointestinal tract and promote the growth of healthy bacteria in the gut.  

• Irritable Bowel Syndrome – If the constipation alternates with episodes of unexplained diarrhoea, the problem could be IBS. 

Top tips for case managers:

1.  Check how  “constipation” is being defined.  

Some people think if they do not open their bowels everyday that means they are constipated.  This isn’t necessarily the case.  In fact, the length of time between bowel movements does not define constipation – better indicators include the consistency of the stool and how difficult it is to pass (see the Rome III criteria for the official definition).  The Bristol Stool Chart can be really helpful to ensure that everyone is speaking the same language.  If stool charts are being kept, make sure the support workers are using the Bristol Stool Chart as part of it.  Stools which are Bristol Type 1 or 2 reflect constipation.

2.  Consult a GP if the constipation is accompanied by weight loss, anaemia, blood in the stools, abdominal pain, nausea or vomiting. 

This could indicate something more serious which requires attention.

3.  Make sure your clients have their medication reviewed. 

Anyone on multiple medications, should have a regular medication review.5  Use this as an opportunity to ask whether less constipating alternatives can be found.  It’s also worth mentioning that I’ve had a number of people referred for “loose stools” who are actually just on too many laxatives because their medication was not being reviewed regularly.  A Bristol Type 7 (loose, watery) stool is NEVER “normal” and this indicates that either the person is on too many laxatives or there is another gut-related problem which needs to be addressed.

4.  Introduce milled linseed (also called ground flaxseed). 

Most people need to eat more fibre and milled linseed is a great source.  You can add it to porridge, cold cereal, yogurt, smoothies or anything else with enough liquid to help it “congeal.”  Make sure to get the milled/ground variety to benefit from the soluble fibre and healthy oils inside the seed (the human body can’t break down the seed coat).  Just make sure the client is drinking enough fluid to help the fibre do its job.

5.  Ensure clients choose whole grains and get their “5-a-day”. 

The goal for adults is 30 grams of fibre per day but many people fall way below this level.6  Encourage clients to choose porridge, wholemeal bread, whole wheat pasta and brown rice whenever possible. High fibre grain products have the added bonus of providing trace nutrients which are not found in processed foods. If clients are not keen on plain vegetables and fruit, then we need to get more creative! Smoothies, mixed fruit topped with yogurt and granola, extra vegetables added to soups, tomato sauce or casseroles or even replacing traditional potatoes, rice and pasta with cauliflower “rice,” courgetti “noodles” or root vegetable mash are all excellent options.

What about bran, prune juice and/or probiotics?

Foods with a lot of “bran” in them, like Weetabix and Bran Flakes, are great sources of fibre but some people find this type of fibre (insoluble) gives them bloating and/or wind as well.7  If that happens, stick with sources of “soluble” fibre instead (the kind that get thick and gloopy when you cook them), such as peeled fruit, porridge and milled linseed (also called ground flaxseed). 

Some fruit, including prunes, are a great source of fibre and also contain a natural sugar called sorbitol which can cause stools to become softer.   If the client has Irritable Bowel Syndrome, however, the sorbitol can also cause wind and abdominal bloating/distension and so should be used with caution in these clients.

There are thousands of different types of bacteria in your gut and probiotics introduce one or more strains of “live” bacteria into the intestinal tract.  Some strains of bacteria are better for managing constipation than others, so speak to a dietitian for more information about this.

The importance of a healthy gut cannot underestimated, particularly as there is more and more research linking gut health with mood and cognitive functioning.  If your client has any type of gut-related problem – constipation, diarrhoea, abdominal pain, distension/bloating, Irritable Bowel Syndrome or Inflammatory Bowel Disease – they absolutely must see a dietitian (NHS or private) to get the problem resolved.  For more information, or to refer a client, please get in touch at info@specialistnutritionrehab.co.uk. 

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