Constipation, Hemorrhoids, Varicose Veins Most people regard a problem with this part of the body as something shameful, something to be hidden: they rarely talk openly about pain and discomfort caused by distresses in the lower bowel. In spite of this secrecy, more kinds of painful sufferings are located in this eight foot segment of writhing tubing than emanate from any other part of the body. Some of the problems are merely nuisances, while others are life threatening, but the one thing that can be said for certain is that none of them need be tolerated as a “normal part of life”. Constipation means different things to different people. I have met people who tell me that they move their bowels only once in every six to twelve days, and then only with the help of a strong laxative, and they accept this pattern as normal because they know nothing else. Would you accept this as “normal” bowel function, if you had experienced only this sequence since childhood? Bowel activity associated with good health does vary considerably among “normal people”. For some a movement once every two days may be normal, and others may have three or more stools a day and be in perfect health. The criterion I use for deciding what is normal is that the stool should be moderately soft and easy to pass without pain or strain. The accumulation of feces between movements should not reach the point where severe bloating of the intestine and discomfort occur. Constipation happens when the stool is hard, small (or “pelletized”, so to speak) and requires physical effort before it is passed. Under such demands, the abdominal muscles must contract, a deep breath must be held as the diaphragm is forced downward. This creates strong internal abdominal pressures to help force the contents out of the colon. This additional force from straining is necessary because the pressure from the contraction of the colon walls is inadequate to evacuate the compacted fecal mass. One unmistakable sign of this physical effort is that the muscles of the neck and face tense up as you strain to evacuate. If you could see it, you’d notice that your face turns red too. But most people don’t realize that permanent and destructive changes result from these powerful muscle forces, even if they don’t persist for very long. Veins in your legs are damaged by the straining created by the muscular activity needed for a difficult bowel movement. Valves are located at frequent intervals along the course of the leg veins; they help the blood to rise to the heart, in a stepladder fashion, against the forces of gravity. These valves are stretched and damaged by the high pressures that are required to move small hard dry stools. The valves soon become incapable of holding up the blood. Without valves in good working order, a four foot column of blood presses on the lower veins all day long. One result of this unrelieved pressure is varicose veins, the tortuous blue “worms” which detract so much from the appearance of a person’s legs, often causing pain, and, sometimes ulcers. Similar to varicose veins in causation if not location are hemorrhoids. All kinds of myths are associated with these painful nuisances. Probably you have heard people say they got theirs from sitting on cold toilet seats, or from having babies. The veins that become hemorrhoids are located in the very last parts of the intestinal tract, called the rectum and the anus. These veins at this terminus of the gut perform the important function of making a tight seal there, by means of blood-filled cushions to prevent feces and gas from leaking out of the intestine. The seal is actually a double one, and consists of two rows of veins. The higher row at the end of the rectum is called the internal hemorrhoidal veins, and the lower row, those in the anus are covered by skin and are called external hemorrhoidal veins. Underlying these veins is a powerful muscle which acts as the primary regulator in the passage of feces, and is therefore of great social, as well as physical, importance. The hemorrhoid veins in the rectum suffer a fate similar to the veins in the legs. After years of straining at stool, when each time veins are filled beyond their normal capacity, stretching them like over-inflated balloons, they become permanently dilated and hang out of the rectum. Now they are persistent and painful bulges, with the further troublesome symptoms of bleeding and itching. This same straining causes the anal muscles to be pushed outward. Eventually they become displaced from their normal internal position, and contribute this painful part to hemorrhoidal problems. Pregnancy can increase hemorrhoidal complications, since the uterus may lie on the veins in the pelvis and cause hemorrhoids to be enlarged. However, this temporary situation does not cause the permanent anal ruination that results from chronic constipation. The best example of the overwhelming influence of a starch based diet in preventing anal problems, even in pregnancy, is presented by African women, who often have as many as 10 babies and yet remain free of troublesome hemorrhoids throughout life. These women never have to strain at stool, because of their diet of grains, beans, and vegetables. (They do not have varicose veins troubles, either.) Yet another potentially serious problem can be caused by constipation. The natural opening in the diaphragm, through which the esophagus passes, stretches as the stomach is pushed up against it while a person strains to move the bowels. Eventually a tear in the muscular diaphragm happens, and the stomach sits forever above the diaphragm, part way up into the chest in the condition that is called a hiatal hernia. Constipation is not a consequence of an emotional disorder, at least not initially. However, a lifetime of bowel problems could make anyone question his sanity, and lose his stability. If you eat mostly fiber-free foods, such as animal products (e.g. fish, pork, beef, chicken, lobster, cheese, milk, etc.), visible fats (e.g. butter and corn oil), alcohol, and grains that are highly refined (e.g. white bread and white rice), then little will be left to make feces with adequate bulk. Your BM will resemble hard rabbit pellets. Fibers are the prime requirement for healthy bowel function. Plant foods contain fibers, a variety of non-digestible complex carbohydrates. After all the soluble components derived from digested fats, proteins, and carbohydrates, along with the vitamins and minerals are absorbed from the small intestine, then non-digestible fibers remain (along with a huge number of friendly microorganisms) to form the bulk of the remnant stool. These fibers have the capacity to hold water, thereby increasing the stool volume further. Also, the more foods and beverages that are consumed, the greater will be the intestinal content, and therefore the frequency and amount of the bowel movement. A starch-based diet along with vegetables and fruits is a sure cure for constipation. Certain foods, like fruits, contain generous amounts of water and fibers, and therefore contribute to a bulkier, softer stool. Prunes are famous for their beneficial effect on constipation, due to the helpful changes they promote in the lower bowel. Grains contain many kinds of fibers, two of which – cellulose and hemicellulose – are very water absorbent. African natives living on a grain based diet have, on the average, have three large, unformed bowel movements a day. So might you too, with a healthier vegetarian diet. Avoiding proteins from milk and milk products is very important. I have seen some people who have made nearly a complete change to a health supporting diet. But they couldn’t give up the little bit of skimmed milk in the morning on their dry cereal–and their bowels didn’t work very well. A little dairy protein can literally jam up the works for most people who are sensitive to it. People who have had intestinal troubles for years, and are labeled as laxative abusers, may have stretched out their colons to twice the normal length and have developed redundant coils of bowel tubing that sort of loop back and forth in the abdominal cavity like a roller coaster. These people need a little extra help. First of all, the colon of a chronic laxative user is accustomed to receiving from a drug the message to contract. The colon has not recently responded to the body’s natural message to contract that should be provided by the stretching of the colon wall as the segment fills with remnants of yesterday’s meals. A person with such a laxative dependency must be encouraged first to renounce his laxatives, and then to wait patiently while the elongated colon fills enough to provide the natural stimulation to evacuate. Initially several days may be needed to fill a very large, stretched out colon; but eventually the muscles in the bowel wall will contract as they should and a movement will follow. Once a natural cycle of filling and emptying is started with high fiber foods, the process continues unaided by anything except the correct choices of foods. Recommendations A starch-based diet, frequent meals, a little extra water (10 glasses per day instead of the usual 4 or 5) and fruits. Prunes should be eaten as the next step, and following this, for extra help, add flax seeds and bran. Add two to four tablespoons of flax seeds to each cup of a grain, such as rice, before cooking. As a last resort, I will recommend a non-absorbable sugar, called lactulose (Chronulac, Granulac), this draws water into the colon and helps to end constipation in even the toughest cases. Lactulose is available only with a doctor’s prescription. How to Help the Volume Eater—The Person with a Binge Eating Disorder Possibly disproving my usual preaching that people following our diet always lose weight and become healthier are a few extraordinary people I call “volume eaters.” They eat very large amounts of McDougall approved foods, and their weight remains stubbornly fixed at a point too high for excellent health—although they all lost initially after giving up the high-fat, high-calorie Western diet. I can vividly recall several men and a few woman who exemplify this behavior—and I know there are many more out there (in fact, I am guilty of a tinge of this behavior at times myself—“it takes one to know one”). In my experience, a “big eater” might consume 2 plates filled 2 inches high with salad, potatoes, pasta, beans, and vegetables. The volume eater will put down three to five such plates—often in less than 20 minutes—a pattern repeated for breakfast, lunch and dinner. Their conveyor belt style of ingesting allows no time for the body and brain to register that they have eaten. By the time their abdomen is noticeably (and sometimes painfully) distended they will have consumed 2,000 calories at a single meal, which could mean 4,000 to 6,000 calories for the day. In the medical world a person with this pattern of eating is thought to suffer from a binge eating disorder. Binge eating disorder is characterized by ingestion of very large meals without purging (throwing up) afterwards and is found in a subset of overweight individuals. These people are different for several reasons. They have been found to have larger stomachs than the average person of comparable physical size.1 Hormones governing eating and fat storage compound their troubles—they have higher levels of insulin (a hormone which forces fat into the fat cells) and lower levels of appetite suppressing hormones, like ghrelin.1 Volume eaters seem to derive a heightened sense of pleasure from eating, akin to that experienced by drug addicts using heroin.2,3 These “opioid-mediated rewards” play an important role in this form of hedonistic eating behavior. Thinking back on the people I know who are volume eaters, I would characterize their personalities as “driven,” and by no coincidence all have been financially successful in their individual businesses. Possible Solutions Binge eating disorder is a nearly impossible condition to treat by standard medical care. Many programs attempt psychological and behavior change with little success. More drastic treatments with gastric surgery (gastric banding and bypass) and drugs such as the anti-epilepsy medication, topiramate, are also used—unfortunately, the results are poor here too.4 Serious changes in eating behavior are the only real hope for these extreme personalities. The most successful program for the treatment of people with serious eating disorders is the Kempner Rice Diet.5 This is a diet of rice, fruit, and sugar, plus vitamin and iron supplements, devised by Walter Kempner, MD, of Duke University in the 1940s to treat hypertension. The regular diet consists of about 2,000 calories daily and contains 5 gm or less of fat, about 20 gm of protein, and not more than 150 mg of sodium. However, the initial diet prescribed for weight loss is even more restricted in calories (400 to 800 per day). In a study of the results published in the Annals of Internal Medicine, one hundred and six massively obese patients were treated as outpatients with the rice/reduction diet, exercise, and motivational enhancement under daily supervision. The average weight loss was 63.9 kg. (141 pounds). Forty-three patients achieved normal weight. Men lost weight at a greater rate than women. Along with the weight loss there were significant reductions in blood pressure, blood sugar, triglycerides, and uric acid levels. Heart sizes decreased, EKGs improved and blood vessels in the eyes appeared healthier. (For more information please contact: The Rice Diet Clinic, 3543 Rose of Sharon Road, Durham, NC 27712; Phone: (919) 383-7276 ext. 1; Fax: (919) 309-4695; ricediet@ricediet.com.) From the Bulletin of the Walter Kempner Foundation (June 1972) What I Have Learned So Far Volume eaters (people with binge eating disorder) possess strong personalities, are very hard-working, demanding, driven, are not prone to take advice, and are used to being in control of everything around them. Unfortunately, even though they are strong individuals, they are out of control of their eating behavior—and most of them are well aware of their problem. In addition to the obvious excess body weight they carry, they can see their health failing—often with diabetes and heart failure. Only when they are imminently faced with death and disability does their powerful drive for self-preservation take over and they attempt to save themselves from their equally strong self-destructive binge eating disorder. This is the advice I give to volume eaters: They must slow down their intake and give the food they eat time to register. The stomach needs to tell the brain that food has been consumed. A pause must be taken so that hormones signaling that calories have been consumed can deliver their messages throughout the body. In essence, the binge-eater must change from a gorger to a nibbler and a grazer. In practical terms, they are to consume a medium-size plate of food and then go work on some other project—to return to the dinner table a half-hour later and have another similar-sized plate. This slowed pattern sends signals of satiety to the brain before over-consumption occurs. Consumption of all calorie-dense foods must be strongly discouraged. Therefore, dried fruits, nuts, seeds, avocados, olives, and flour products (especially breads and bagels) are off limits. And I MEAN off-limits, because a volume eater does not understand “eat only a little bit.” Very calorie-dilute foods, like green and yellow vegetables, are encouraged—especially to be consumed at the beginning of the meals. But there is a limit to this advice—it is easy to overdo the very low-calorie foods and be unsatisfied. There must be sufficient starch (potatoes, rice, corn, sweet potatoes, etc.) in the meals to provide a healthy sense of satiety. (See the January 2005 McDougall Newsletter article: Pushing Your Set Point to the Limits – The McDougall Program for Maximum Weight Loss, for more help.) Exercise is hard for people to fit into their lives and I have found this especially true for driven people who are binge-eaters. Exercise burns calories and resets the appetite—something these people need desperately. Since they are typically obsessive in their behaviors, directing some of that energy toward exercise is a big part of the solution. Obviously, solving the binge eating disorder has not been easy for patients, the medical profession or for me. However, the stakes are great, so every effort must be made. Those who fail on the McDougall Program are encouraged to take a long vacation in Durham, North Carolina for a diet of rice and fruit (The Rice Diet)—which should serve as strong motivation to make the McDougall Program work. References: 1) Geliebter A, Yahav EK, Gluck ME, Hashim SA. Gastric capacity, test meal intake, and appetitive hormones in binge eating disorder. Physiol Behav. 2004 Jul;81(5):735-40. 2) de Zwaan M, Mitchell JE. Opiate antagonists and eating behavior in humans: a review. J Clin Pharmacol. 1992 Dec;32(12):1060-72. 3) Yeomans MR, Gray RW. Opioid peptides and the control of human ingestive behaviour. Neurosci Biobehav Rev. 2002 Oct;26(6):713-28. 4) McElroy SL, Shapira NA, Arnold LM, Keck PE, Rosenthal NR, Wu SC, Capece JA, Fazzio L, Hudson JI. Topiramate in the long-term treatment of binge-eating disorder associated with obesity. J Clin Psychiatry. 2004 Nov;65(11):1463-9. 5) Kempner W, Newborg BC, Peschel RL, Skyler JS. Treatment of massive obesity with rice/reduction diet program. An analysis of 106 patients with at least a 45-kg weight loss. Arch Intern Med. 1975 Dec;135(12):1575-84. <<< Return to Newsletter Home Page Email this page to a friend or coworker You may subscribe to this free McDougall Newsletter at https://www.drmcdougall.com How Do I Gain Weight on the McDougall Diet? I’m Not Joking! (Please do the opposite of the advice below to lose weight faster) One common question I get from people who seriously follow my instructions is, “How do I stop losing weight?” For example, this e-mail letter from a woman says, “I was a 100% raw foodist for almost 2 years and this past 10 days I came off that diet and went on your plan. My question is this: your plan is definitely the ONE; however, I was only 105 pounds as a raw foodist (usually high in fat with nuts, seeds, avocados, etc. and sugars from fruits and juices) and since eating your cooked low-fat plan, I am losing weight and only weigh 100 pounds now. How do I increase my body weight?” Maybe the Problem is One of Perception? You and your friends are used to looking at you at one size and now the change is difficult to adjust to and uncomfortable for many. Fortunately, people when they first meet folks who follow a healthy diet will likely think how exceptional they look – they are not burdened by past perceptions. There is also the problem of envy from those who wish they could lose weight so easily and were as thin. They may say, “You look so thin. Have you been ill?” A participant in one of our recent live-in programs in Santa Rosa asked me, “Don’t you think Mary (McDougall) is a little too thin?” My reply was, “Have you noticed our dietitian, Jill, our psychologist, Doug, and our administrator, Heather (McDougall)?” “Yes, they’re thin, too,” she replied. My response was clear, “Our staff members are trim, vigorous, and young looking for a simple reason; they follow the McDougall diet and exercise program. You should be so lucky.” (By the way, no one ever accuse me of being too thin – possibly because I have no hesitation in eating large amounts of food and strenuously exercising while windsurfing on the water off Northern California.) The Kempner Rice Diet Program Knows about Trim Weight I have used a chart from the Kempner Foundation for more than 20 years to help people who think they are becoming too thin to realize that their new weight may actually be an ideal weight when it comes to good health. Walter Kempner, MD, established the Rice Diet Program in the 1940s at Duke University and until very recently this program was an important part of Duke’s medical department. The Rice Diet begins with mostly rice and fruit and then expands to other foods as people become healthier and thinner. Again, the purpose of showing these figures is to help reassure you that you are not becoming too thin on the McDougall Diet – you should not look at these as goal weights. This chart records what Kempner considered to be reasonable adult weight in proportion to height. He also recommended that people with diabetes, heart, kidney, or blood vessel diseases should weigh l0-l5% less than the optimum figures presented in this chart. Women Height Wt. Should Be Below* lbs. 4ft 11in 91 5ft 94 5ft 1in 97 5ft 2in 100 5ft 3in 104 5ft 4in 108 5ft 5in 112 5ft 6in 117 5ft 7in 122 5ft 8in 127 5ft 9in 132 5ft 10in 137 5ft 11in 142 6ft 147 *Fully Dressed Men Height Wt. Should Be Below* lbs. 5ft 2in 110 5ft 3in 115 5ft 4in 120 5ft 5in 125 5ft 6in 130 5ft 7in 135 5ft 8in 140 5ft 9in 145 5ft 10in 150 5ft 11in 155 6ft 160 6ft 1in 165 6ft 2in 170 6ft 3in 175 6ft 4in 180 6ft 5in 185 *Fully Dressed Even though you will not look at these figures as your goal weight, if you follow a starch centered meal plan, as I recommend, and exercise, you could easily end up at a weight close to Dr. Kempner's figures. So be reassured you are not too thin. How Do You Tell If You’re the Right Weight? Take off all of your clothes and stand in front of the mirror. Do you like what you see? All the weight charts in the world pale in importance to your own perceptions. One Important Precaution. If you are too thin and have any concern that this might be a health issue then please check with your doctor. Illnesses, like cancer, infectious diseases (AIDS), liver and thyroid disease can also cause excessive weight loss. So can some serious psychological problems, like anorexia and depression. How to Gain Weight in a Healthful Manner I have known people who stop eating our diet with the excuse that they became too thin. This was almost always just an excuse to go back to burgers and fries – an excuse like inconvenience, difficulty, pressure from a spouse, longing for cake and cookies, etc. – to stop my recommendations. Never use too much weight loss as a reason to stop a healthy diet and exercise program. Many times people become “too thin” on our diet because they don’t like the food – and that is simply because they don’t take the time to make interesting dishes. A plain baked potato and three stalks of broccoli will not make a successful long-term diet for many people. If you want this for a lifestyle then you must take the effort to find 4 to 8 dishes that you like to eat and are willing to find the time to prepare. For example, oatmeal for breakfast, a soup and bread for lunch, and bean burritos or spaghetti for dinner. Another common mistake is to think that our food plan is a diet of green and yellow vegetables. These foods – like broccoli, cauliflower, pea pods, and sprouts – are too low in calories to get you through the day. You would have to eat bushel baskets full to get your 2000 to 3000 calories. Our diet is centered on delicious higher calorie vegetable foods commonly referred to as starches – foods like rice, corn, potatoes, beans, pastas, and breads, are also called “comfort foods” because of the way they make us feel. To this higher calorie centerpiece are added green and yellow vegetable dishes and fruits. When I say “higher calorie” this is relative to the low calorie concentration found in green and yellow vegetables. (Higher calorie does not mean these choices will make you fat – becoming fat would be very difficult to accomplish on a starch-based diet – consider there are billions of people, like rural Chinese, who live on a starch-based diet (rice) and no one is fat – until they change to the Western diet. There are a few people running around swearing they follow the McDougall Diet and they look to be 50 to a hundred pounds overweight. The truth is they are following their interpretation of my recommendations – you can learn about unhealthy, overweight vegans – people eating no animal products – in my October 2002 Newsletter). Gaining weight is usually a matter of more calories in than calories out of your body. Fats are the most easily stored of all three kinds of calories (protein, carbohydrates and fats). Any change in diet that raises insulin levels will make weight gain easier – insulin is the hormone that pushes fat into fat cells and prevents the release of fat. Make the Following Changes in this Order to Regain Weight in a Healthful Manner 1) Eat more whole grain flour products like breads and bagels. Flour is more fattening than the whole grain because the change in physical properties that comes with milling causes faster and more complete absorption of the calories and a great rise in insulin response. 2) Eat more simple sugars in the form of fruits, dried fruits and fruit juices. This will cause a greater rise in insulin in your body. 3) Eat more high-fat plant foods, like nuts (and nut butters), seeds (and seed spreads), avocados, and olives. Fats are concentrated calories. 4) Add high-fat soy milks and tofu products. These are higher in fats. 5) Eat more high-fat soy foods. However, in general, these fake foods (like burgers, hot dogs, lunch meats, and cheeses) should be kept to a minimum because they are not very nutritious. 6) Eat more food – this is often difficult because most people already eat to the full satisfaction of their appetite. Making more delicious meals and taking more time to eat may help accomplish this. 7) Eat a greater variety of foods – new kinds of foods stimulate interest, which increases food intake. 8) Add salt, sugar and favorite spices to the surface of your foods. If they taste better to you then you will eat more. Plus sugar adds calories (empty calories). 9) Use salad dressing, barbecue and steak sauces (made without oils and animal products) over your dishes to make them taste better so you eat more. Many sauces also contain simple sugars that provide calories and raise insulin levels. 10) Exercise less. We all know people who are exercise fanatics and they burn 3000 to 5000 extra calories a day – making it very difficult for them to eat enough food to fully replenish the expenditure. One simple way to gain more weight, and in some ways improve your overall health, may be to exercise more moderately. I have never seen any otherwise healthy person “starve to death” when there were adequate amounts of nutritious foods available to them. Your hunger drive is there to guarantee your personal survival by making sure you consume sufficient calories and nutrients. It works just fine when the correct foods are present – unprocessed starches, vegetables and fruits. With the wrong foods – meats, dairy products and refined and packaged foods – all bets are off and you are struggling for survival in this artificial world. The McDougall Program is the easiest and surest method of achieving trim body weight, and much better than fighting your hunger drive and losing the "lifelong battle of the bulge" – it works because the qualities of food match the size of the stomach, the strengths of the hunger drive, and the needs of the body – how could it not be this way in a perfectly created world that works so well for all other matters? You may subscribe to this free McDougall Newsletter at http://www.drmcdougall.com