Poop. Everybody does it, but what happens when your body sometimes doesn’t? Constipation is something that everyone has gone through at some time in their life, and in most cases can be easily treated - if addressed quickly. Wait too long and you may end up with more than you bargained for. Having weight loss surgery, such as gastric band, gastric sleeve or gastric bypass, puts you at an increased risk of constipation, but there’s no reason to suffer in silence. Your bariatric healthcare providers have heard it all when it comes to post-op poopy problems, and waiting it out will only make matters worse. In fact, the longer you wait, the harder (literally) it becomes to treat. But enough with the jokes. Let’s get serious and learn why you  - as a bariatric patient - may be at an increased risk of constipation and what you can do to move things along in the bathroom.

How to know if you’re constipated?

Constipation is commonly defined as “a shift from one’s normal routine and frequency.” But after bariatric surgery, you’ll most likely have a new normal when it comes to going to the bathroom. Before surgery, you might have paid a trip each morning to the toilet. After surgery, you may be going only every other day. As a general rule, if you have not had bowel movement in 2 to 3 days or if going becomes painful or uncomfortable, contact your doctor. As with any medical condition, you should always consult with your doctor before beginning a specific treatment. Depending on the severity of constipation, your healthcare team may make a different recommendation so it is always important to consult with your doctor to determine appropriate treatment.

Why does constipation occur?

Our GI tract is lined with a series of muscles that work together in a synchronized fashion to mix and grind food as well as move it toward eventual excretion. Many factors influence our ability to “go". This can include illness, the types of food we eat, our activity level, nerve transmission, hydration and individual biology just to name a few. The presence of food anywhere along the GI tract acts as a stimulus for the digestive process. When things are humming along nicely it’s something we give little thought to. But when things slow to a crawl, there are many possible reasons why. Finding the right regimen to get you back on track may take some trial and error. Here are some of the main reasons why constipation is more prevalent in post-op bariatric patients.

1. Anesthesia and pain medication. Anesthesia and pain medications are two of the most common causes of acute constipation in the days immediately following bariatric surgery. Since anesthesia and certain classes of pain medication work by suppressing the nervous system, they may also block nerve signals to the GI tract resulting in a temporary shutdown of sorts. Depending on your post-op status and what stage of diet you’re following, you may want to try drinking a small cup of caffeinated coffee or tea. It could provide just enough stimulation to prevent things from getting backed up. For some patients, a simple cup of warm water with plenty of lemon squeezed in will do the trick. If not, taking an over-the-counter osmotic laxative, such as Miralax, may be necessary to wake up the nerves and muscles while also preventing a brief bout of constipation from turning into something more severe.
2. A smaller stomach means less of what your body needs to stay regular. Your new smaller stomach capacity is an important part of why bariatric surgery work so well for achieving weight loss. However, this also translates into a reduction in fluid and fiber intake. Since water and fiber are two of the main drivers for successful bowel function, even a brief reduction in supply can cause things to slow way down.
   • Water: Since approximately 20% of our daily fluid intake comes from the food we eat, such as veggies and fruit, smaller portions after bariatric surgery translates to less dietary water. And the necessary separation of solid food and liquids can complicate things further. The best approach is to drink regularly throughout the day, except for 30 minutes following a meal or snack. Aim to get as close as possible to 64 ounces of “hydrating fluids” daily, though individual needs and capacity will vary. In addition to plain water, “hydrating fluids” include protein shakes and decaffeinated beverages without sugar. Avoid caffeine and alcohol due to their diuretic effects (and the potential for empty calories).
   • Fiber: Too often, fiber is unfairly blamed for causing constipation when in truth there may be a number of different issues at work, particularly for post-operative bariatric patients. Daily fiber goals range from 25 grams to 40 grams daily, but having a gastric band, sleeve gastrectomy or gastric bypass, greatly reduces the ability to consume large amounts of fiber-containing foods.But don’t be so quick to add a fiber supplement to your daily supplement regimen, especially in the quest to combat constipation. Here’s why: There are 2 types of fiber, soluble and insoluble, and while both play a role in promoting regularity, many fiber supplements contain just one type. Fiber supplements can also worsen constipation in the absence of sufficient fluids. Most food sources contain both types and are less likely to worsen constipation, so for all these reasons I prefer to have patients start with food before incorporating fiber supplements. Start by adding high fiber foods like very soft-cooked lentils, split peas and beans during the soft food stage of your post-op diet. Typically non-starchy vegetables, nuts and seeds may be added during the solid food stage. Many of these foods contain moderate amounts of protein and are lower in digestible carbohydrates than other fiber-containing foods like fruit and grains.If your doctor or dietitian ultimately recommends a fiber supplement, be sure to add it slowly, and increase the amount gradually to minimize gas and bloating. A general rule of thumb is 1 tablespoon of fiber in 8 ounces of water. It is absolutely essential to drink adequate water when taking fiber. Choose a fiber supplement with no sugar and avoid fiber-enhanced bars, brownies, yogurts and gummies which are usually high in refined carbohydrates and sugar.
3. Increased intake of protein and other supplements. Protein supplements or shakes, a staple of many post-op bariatric diets, can be binding and contribute to constipation for some patients. Because concentrated protein sources generally contain little to no fiber on their own, one option that may help minimize their binding tendencies is to choose a protein supplement that contains added fiber. Look for products containing around 5-7 grams per serving.If you are taking additional supplements, particularly iron and calcium, talk to your doctor if you are routinely experiencing constipation. He or she may recommend less binding forms or suggest taking them in divided doses throughout the day. Pairing calcium and iron with certain forms of magnesium is another possible way to offset the constipating effects of these supplements. Good food sources of magnesium include almonds, sesame seeds, ground flax seed, cashews, lentils and broccoli. Magnesium is also available in supplement form.
4. Lactose intolerances and food sensitivity. Following weight loss surgery, patients may experience aversions or intolerances to certain foods (see Bariatric Surgery, Taste Changes and Food Sensitivities). Lactose intolerance or sensitivity to the protein in dairy may also cause interruptions to normal bowel habits. It is important to discuss any GI symptoms with your dietitian to determine which foods might need to be eliminated on a trial basis. Don’t eliminate dairy from your diet without guidance from your nutrition professional since many dairy foods are high in protein and calcium.

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What else can I do to move things along?

• Avoid these foods. Other foods known to bind up stools include bananas, rice and potatoes. In general, these foods should be excluded from the post-operative diet due to their high starch/low protein content. Avoiding them for constipation prevention is just one more good reason to do so.
• But not these. Adding some healthy fat may encourage things to move along more smoothly, especially for bulky, hard stools that are difficult to pass. Try one-fourth of an avocado sliced on top of a turkey burger or mashed into tuna. Another good choice is 1 tablespoon of flax oil mixed into yogurt or drizzled over cooked veggies and salad. (Don’t cooking with flax oil because heat easily turns its good fats into harmful ones.)
• Don’t hold it in! Something I hear quite frequently from patients is how often they ignore the urge to go when they have to, or worse, fight against it because they are not comfortable using a public or workplace restroom. On occasion, this type of behavior may not be detrimental beyond a few hours of discomfort. But ignoring urges regularly can lead to chronic, severe constipation coupled with painful gas and bloating. In cases where forcing or straining to go becomes the norm, fissures (tears) and hemorrhoids can result. So go when you need to go! Whatever embarrassment or temporary unpleasantness you might feel is fleeting compared to the potential for bigger and more complex problems.
• Squat. Once you’ve mastered the art of going when nature calls, it might also be beneficial to consider the position of your body. Most of us just sit and don’t give it a second thought. You might be surprised to know that historically (and still in many parts of the world) squatting is actually the way to go. If you have a history of prolonged bowel movements or feelings of inadequate emptying (also called incomplete evacuation), you may benefit from adopting a more squatted position. Believe it or not, there are actually stools designed to raise your feet to a higher level than the floor. This can result in shorter bathroom visits and less straining.
• Exercise. You know how a lot of sitting around and doing nothing can make you feel like, well, sitting around and doing nothing? It’s like that for our digestive systems, too. As soon after surgery as your doctor permits, start walking. Studies show that a regular exercise routine, even if it’s just walking for just 10-15 minutes once or twice each day, can significantly improve symptoms of constipation and help normalize bowel habits. Once you are able to return to more rigorous physical activity, consider adding higher-intensity cardiovascular exercises and even yoga to your routine. Many yoga poses, particularly poses involving twisting and squatting, are believed to stimulate bowel activity and encourage regularity. Be sure to always check with your doctor before beginning a new exercise program after bariatric surgery.

There you have it, the dos and don'ts of postoperative constipation. I hope this article has armed you with the knowledge and courage to talk with your healthcare team instead of suffering in silence. Be well and happy going!